Case studies

The following case studies provide examples of how to formulate a patient problem list. The reasoning for identifying each problem and the considerations for patient intervention are given. Assessment of the patient may reveal many features. The clinical features reported in these case studies include only those considered to be important in formulating the problem list for each case.

Table 6.1 Pulmonary function tests, case study 1

FVC, forced vital capacity; FEV_1, forced expiratory volume in 1 second; FRC, functional residual capacity; RV, residual volume; TLC, total lung capacity; TLCO, transfer factor of the lung for carbon monoxide

Table 6.2 Analysis of problems from case study 1

Current cardiopulmonary problems	Evidence for each problem based on clinical features	Most likely pathophysiological basis for each problem
Impaired airway clearance	Increased sputum production which has changed in colour and is now purulent; coarse inspiratory crackles in lower lobes Significant difficulty expectorating sputum Patient is febrile Sputum culture grew Pseudomonas aeruginosa	Increased production of mucus with altered composition due to colonization with pathogen
Dyspnoea	On conversation, on lying flat, mobilizing to toilet and around the bed	Increased work of breathing due to an increase in airways resistance: increased expiratory muscle work to effect airflow through narrow airways and increased inspiratory muscle work due to lung hyperinflation Increase in ventilatory requirements due to fever and hypoxaemia
Airflow limitation	FEV1/FVC indicates airflow obstruction, FEV1 indicates severe airflow obstruction Evidence of hyperinflation: chest X-ray findings, chest shape (barrel), poor chest expansion, increased TLC and FRC Adaptive breathing pattern: increased expiratory phase, PLB, increased abdominal effort, intercostal recession Expiratory wheeze on auscultation Tight cough	Loss of radial traction to airways due to a decrease in elastic recoil Mucus causing partial occlusion of airway lumen
Impaired gas exchange	Respiratory acidosis with CO2 retention. 28% oxygen required to maintain adequate PaO2 Reduced TLCO	Mixed causes for hypoxaemia, including / mismatch, diffusion limitation, wasted perfusion (intrapulmonary shunt) and hypoventilation Mixed causes for hypercapnia, including added load on the mechanics of breathing resulting in hypoventilation, increased CO2 and increased dead space as a fraction of VT
Decreased exercise tolerance	Reports needing significant help going to the toilet. Further assessment is recommended
Considerations for treatment	GORD and orthopnoea – a head-up position should be maintained during all interventions Patient thin and frail – consideration required in selection of intervention and implementation of treatment (e.g. care with patient handling) Patient acutely unwell – treatments should be short and interspersed with sufficient rest periods

Note: respiratory muscle dysfunction may be present (clinical features include orthopnoea, CO₂ retention and altered breathing pattern) and further assessment may be warranted

FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; TLC, total lung capacity; FRC, functional residual capacity; PLB, pursed-lip breathing; TLCO, transfer factor of the lung for carbon monoxide; GORD, gastro-oesophageal reflux disorder; /, ventilation/perfusion ratio; V_T, tidal volume

Table 6.3 Analysis of problems from case study 2

Current cardiopulmonary problems	Evidence for each problem based on clinical features	Most likely pathophysiological basis for each problem
Reduced lung volume	Chest radiograph reveals collapse and consolidation Decreased breath sounds on auscultation Reduced chest expansion Abnormal breathing pattern – rapid shallow breathing	Atelectasis resulting from marked decrease in FRC, postoperative diaphragmatic dysfunction, reduced function of surfactant, airway obstruction from mucus plugging and abdominal incisional pain
Impaired gas exchange	Acute hypoxaemia: PaO2 7.8 kPa (59 mmHg) and SaO2 91% on room air	Mixed causes for hypoxaemia including / mismatch caused by a decrease in FRC
Impaired airway clearance	Patient is febrile, elevated WCC, moist cough	Possible colonization of sputum, possible systemic dehydration, impaired MCC from opioid, ineffective cough
Considerations for treatment	Reduced mobility further increases risk factors for PPC, a reduction of oxygen transport and risk of a deep vein thrombosis – mobilization of patient is a major goal of treatment IHD, hypertension and diabetes – careful monitoring required during treatment Incisional pain – patient needing encouragement to use PCA Patient feeling ill – consideration required during treatments (e.g. ensure optimal use of anti-emetic medication before treatment, short treatments)

FRC, functional residual capacity; MCC, mucociliary clearance; WCC, white blood cell count; PPC, postoperative pulmonary complication; IHD, ischaemic heart disease; PCA, patient-controlled analgesia, /, ventilation/perfusion ratio; PaO₂, partial pressure of oxygen in arterial blood; SaO₂, arterial oxygen saturation

The problem-solving approach to determining patient management not only assists with the identification of existing problems but also enables recognition of potential patient problems. For example, a high-risk surgical patient will develop reduced lung volume and has the added potential to develop problems of impaired airway clearance but if active treatment, such as early ambulation, is started during the at-risk period, these problems may be prevented. Some problems are not amenable to physiotherapy intervention or physiotherapy intervention may be detrimental.

For the patient with more than one problem, it is essential to prioritize the problem list and to establish the short and long-term goals of the patient and, where appropriate, their relatives and/or caregiver and any other service providers (e.g. other allied health professionals, nurses and medical practitioners). Some problems may only be short term, for example, reduced lung volume in the immediate postoperative period. Developing and prioritizing the problem list and developing the intervention should, whenever possible, take place in consultation with the patient. Some interventions may be determined by taking into consideration other factors such as the availability of resources and the model of service delivery.

Once the short- and long-term goals of the patient and, where appropriate, their relatives and/or caregiver and any other service providers have been established, the next stage is to identify the means of achieving these goals through physiotherapy intervention and the time frame over which they are to be achieved. The appropriate intervention requires selecting the optimal physiotherapy management strategy and this should be evidence based where possible. When a patient has several physiotherapy problems, the physiotherapy techniques selected should ideally address more than one of the high-priority problems. When selecting a treatment approach, the potential risks to the patient (e.g. the possibility of causing adverse physiological responses) and methods to minimize such risks must be taken into consideration. Other factors to be considered include ensuring that the intervention is appropriate for the patient’s age, occupation, ability to communicate, cultural beliefs, level of understanding and motivation and the presence of any psychosocial factors which may interfere with the treatment approach (e.g. fear, anxiety or depression). It is important also to determine the patient’s likes and dislikes; for example, patient preferences for types of activities are vital considerations when developing an exercise programme.

Common to the management of most problems is the education of the patient by the physiotherapist. This is essential to ensure that the patient takes responsibility for their own management and becomes actively involved in the management of their problem and the prevention of associated problems. If the problem is amenable to physiotherapy, treatment should be started. Conditions that are not amenable to physiotherapy intervention or that require the expertise of a specialist physiotherapist (e.g. a physiotherapist specializing in continence problems) should be referred appropriately. With some problems, a stage will be reached when the natural rate of recovery will no longer be augmented by physiotherapy intervention and treatment should then be discontinued.

The selection and use of appropriate outcome measures are fundamental to the evaluation of physiotherapy intervention. Healthcare fundholders increasingly require data demonstrating the effects of physiotherapy intervention, using instruments that are reliable and valid. Other parties requiring outcome data include the patient, the patient’s relatives and caregivers, employers of physiotherapists, clinicians, patient support groups and associations of patients with particular conditions (e.g. cystic fibrosis, heart failure), members of other healthcare professions and insurers. Thus, when selecting which outcome data to monitor it is important to consider the relevant stakeholders.

In this chapter the problems commonly encountered by the physiotherapist when managing patients with respiratory or cardiovascular dysfunction are discussed. The underlying pathophysiology for each problem is outlined and the clinical features that assist in the identification of the problem are described. The physiotherapy management is listed alongside each problem and discussed in greater detail in other chapters. The discussion of each problem concludes with guidelines for the choice of clinical outcome measures to be used to evaluate physiotherapy intervention.

Clinical features

The clinical features of impaired airway clearance are usually those resulting from excess or retained secretions. The history of usual daily sputum production obtained from the patient may reveal a chronic productive cough. Changes in the normal pattern of sputum production, such as an increase in the amount or a change in the colour or consistency of the sputum, are likely. Some patients report difficulty expectorating secretions. Further questioning may reveal an increase in the number of chest infections or hospitalizations for their illness compared with previous years. Patients with chronic lung disease may report signs of stress incontinence on coughing.

Examination of the patient may reveal an altered breathing pattern due to increased work of breathing (WOB). The presence of infection may produce fever and tachycardia. When the secretions cause marked airflow limitation, wheezing may be audible (see Problem - airflow limitation). Auscultatory findings include diminished or absent breath sounds, bronchial breath sounds, crackles or wheezes. The cough may be moist or dry and hacking, effective and productive or ineffective and weak. Some patients have a paroxysmal cough with associated adverse effects such as dizziness, syncope or exhaustion. The examination of any sputum expectorated may reveal an increase in the volume or weight compared with the patient’s normal expectorant. The colour of the sputum may have changed to yellow, green or brown and there may be blood present (haemoptysis). Also the consistency of the sputum may have altered and microculture may reveal colonization (e.g. with bacteria) (Chapter 1).

Chest radiographs sometimes show signs of lung collapse and/or consolidation or abnormalities reflecting the underlying disease process; for example bronchiectatic changes.

The clinical features of impaired airway clearance in the postoperative patient may include an increased volume of sputum expectorated compared with the patient’s usual expectorant; a weak, ineffective moist cough; possible bacterial contamination of expectorated sputum; fever; and chest radiographic changes consistent with atelectasis or pneumonia (Chapter 12).

Physiotherapy management

Physiotherapy is an integral part of the management of patients with impaired airway clearance but bronchial secretions only become a physiotherapy problem when they are excessive, retained or difficult to eliminate. Some patients expectorate a small amount of foul-smelling, tenacious sputum postoperatively but this is not a problem if the patient is conscious, able to cough effectively and self-ambulating.

Airway clearance techniques comprise a range of physiotherapy interventions used for the management of impaired airway clearance (Chapter 5). These techniques aim to promote clearance of excessive secretions from the distal airways and thereby prevent the consequences of obstruction and thus improve ventilation homogeneity and gas exchange. Airway clearance techniques may incorporate positive pressure or oscillation applied at the mouth or chest wall (manual or mechanical) and/or breathing strategies to aid the movement of secretions to the central airways. From the central airways, forced expiratory manoeuvres such as coughing or huffing are used to facilitate expectoration. Such manoeuvres aim to use high expiratory flow rates to shear secretions from the airway walls.

The physiotherapy management of impaired airway clearance is influenced by the underlying cause and acuity of the patient’s condition. For patients with chronic hypersecretory lung disease who regularly produce excess bronchial secretions, the use of daily airway clearance techniques is recommended (Jones & Rowe 1998, van der Schans et al 2000). The rationale for daily treatment is to reduce stagnation of secretions in an attempt to avoid contamination with pathogens and thereby reduce the destruction of airway walls caused by the inflammatory response. This may slow the cycle of progressive tissue damage. The physiotherapist’s role in this case is to prescribe and teach a daily airway clearance regimen that is individually tailored and acceptable to the patient. Factors to be considered when choosing an airway clearance technique include:

evidence supporting the technique

patient age and ability to learn the technique

patient motivation

patient preference and comfort

physiotherapist’s skill in teaching the technique.

The physiotherapist’s role may change in a patient with hypersecretory lung disease when the patient experiences a worsening of their condition such as during a chest infection. During a hospital admission for an acute illness the physiotherapist may take a more active role and the frequency and duration of treatments may increase. It may be that a change of technique is indicated and it is the physiotherapist’s role, in consultation with the patient, to select a technique that addresses the changing condition.

A number of additional measures are available that have been shown to enhance or improve airway clearance. Table 6.5 outlines these measures (Conway et al 1992, Elkins et al 2006, Houtmeyers et al 1999b, Jones et al 2003, Wark et al 2005, Wills & Greenstone 2006).

Table 6.5 Additional measures to enhance airway clearance

NIV, non-invasive ventilation; MCC, mucociliary clearance; V_T, tidal volume

In the postoperative patient it is essential to establish whether the patient has excess secretions and whether they have difficulty managing their own airway clearance. This is one of the factors influencing the risk of the patient developing PPCs. The techniques to assist sputum clearance in the postoperative patient aim to increase alveolar ventilation and expiratory flow rates using, for example, upright positioning and ambulation at an adequate intensity with encouragement to take deep breaths. Expectoration of secretions can be facilitated by supported coughing or huffing (Chapter 12). If the patient has large amounts of secretions, techniques such as the active cycle of breathing techniques (ACBT) and vibrations may be used.

For patients who are reluctant or unable to cough, a spontaneous cough may be elicited by physical activity or a change of position. The cough reflex may be elicited using a tracheal rub or suctioning. Strengthening of the abdominal muscles and assisted cough techniques (e.g. abdominal support with an upward pressure) or a mechanical insufflation- exsufflation device may be helpful for patients with impaired cough due to weakness of the abdominal muscles (Chapter 16). For the intubated and ventilated patient, improved alveolar ventilation and increased expiratory flow rates can be achieved by positioning and manual hyperinflation, and secretions cleared by suctioning (Chapter 8).

Outcome measures

Short-term outcomes can be monitored by a change in sputum expectorated, as measured by weight, volume or rate of expectoration. Ease of sputum expectoration can be measured using a categorical scale or visual analogue scale (VAS). In acute conditions, chest radiographs and auscultatory findings may provide evidence for a change in the patient’s condition. Radio-aerosol clearance may be used as an outcome measure in studies of airway clearance techniques (van der Schans et al 1999).

Long-term outcomes in patients with hypersecretory lung disease may be assessed by the number of exacerbations, courses of antibiotics, hospitalizations and days lost from work/study per year. Quality of life scales, such as the St George’s Respiratory Disease Questionnaire (SGRQ), include a section that quantifies symptoms of cough and sputum (Jones et al 1992). Pulmonary function, in particular spirometry, has been used to evaluate the effects of airway clearance techniques but may be relatively insensitive to the intervention (van der Schans et al 1999).

In the high-risk postoperative patient with excess bronchial secretions, outcomes from physiotherapy intervention may be measured by the prevention of PPCs.

Improved cough or huff technique may be associated with a reduction in associated problems such as fatigue, dyspnoea, syncope, airflow limitation, arterial oxygen desaturation or stress incontinence.

Clinical features

The time course for the onset of dyspnoea (e.g. acute vs insidious) gives important information as to the likely aetiology and is obtained from the subjective assessment. Most commonly, the patient’s account will reveal that dyspnoea is elicited by physical activity, for example during ADL or when walking on the flat or up inclines. The patient may also report that adopting certain body positions causes dyspnoea, for example, when attempting to lie flat to sleep. Many patients with chronic lung disease will report day-to-day variability in dyspnoea intensity and this may include variation depending on the time of day and climatic conditions. Extremes of temperature and humidity and high levels of atmospheric pollution tend to heighten the perception of dyspnoea in most individuals. In chronic hyperventilation disorder, dyspnoea may occur at rest and is often accompanied by an excessive frequency of sighs (Chapter 17).

Some patients may seek medical care when they become very breathless playing sports, for example golf or bowls, but many individuals attribute breathlessness to ageing or a poor level of fitness and fail to seek help until breathlessness occurs during ADL. Patients with respiratory disease or heart failure may also report feeling fatigued; this may be a generalized symptom or felt predominantly in the legs during physical activity.

On examination, the patient may display an altered breathing pattern. Abnormalities in the rate and depth of breathing, inspiratory to expiratory ratio and symmetry of chest movements are often observed. Clinical features indicative of an increase in the WOB associated with airflow limitation include the adoption of an upper chest breathing pattern with shoulder girdle fixation to enable the accessory muscles to assist with inspiration. Other signs commonly seen in patients with severe airflow limitation who report dyspnoea include an increase in abdominal effort during expiration, paradoxical breathing and PLB. Characteristically, expiratory time will be prolonged in the presence of airflow limitation (see Problem - airflow limitation). The patient may complain of feeling hot and appear sweaty if the WOB is excessive and dyspnoea is associated with fear or panic.

Assessment may reveal signs and symptoms of other problems, most commonly airflow limitation, impaired gas exchange and, in patients with cardiovascular disease, angina may accompany dyspnoea. Exercise tolerance will usually be reduced as a result of dyspnoea on exertion. The chest radiograph will often show signs consistent with the underlying pathology (e.g. lung hyperinflation, effusion, pneumothorax, areas of collapse or consolidation). A laboratory-based incremental exercise test with continuous measurement of ventilatory and cardiovascular variables can be used to differentiate between dyspnoea arising from cardiovascular or respiratory origin. If respiratory muscle weakness is suspected to be a contributing factor this can be confirmed by measuring maximum inspiratory and expiratory mouth pressures (PiMax and PeMax) (Chapter 3 and see Problem - respiratory muscle dysfunction).

Physiotherapy management

In patients with airflow limitation, bronchodilators may reduce dyspnoea and improve exercise tolerance; therefore, inhaler technique and timing of bronchodilators should be optimized.

Positioning, breathing control and relaxation techniques are used in an attempt to decrease the WOB and eliminate unnecessary muscular activity (Gosselink 2004, O’Neill & McCarthy 1983). Positions such as the forward lean position with the arms supported or high side lying may be useful for patients who are severely distressed, especially when the cause of their breathlessness is COPD. In these patients, the forward lean position increases transdiaphragmatic pressure, improves thoraco-abdominal movements and reduces activity of the scalenes and sternomastoid muscles. In addition, the forward lean position with the arms supported allows the pectoral muscles to significantly contribute to rib cage elevation (Gosselink 2004). Relaxation techniques that do not involve breath holding or the contraction of large muscle groups may be useful for relieving dyspnoea in those who are anxious (Gosselink 2004). Symptomatic relief may be achieved by increasing the movement of cold air onto the patient’s face (e.g. sitting by an open window, use of a fan). This stimulates mechanoreceptors on the face and the decrease in skin temperature may alter afferent feedback to the brain and the perception of dyspnoea (ATS 1999).

Pursed-lip breathing is often spontaneously adopted by patients with COPD and may be very effective in reducing the discomfort associated with dyspnoea. This breathing strategy aims to prevent airway closure and increase expiratory time. This may lead to a decrease in respiratory rate, an increase in tidal volume (V_T) and, in turn, may improve gas exchange at rest. Pursed-lip breathing appears to be most effective when used by patients with COPD who adopt the technique spontaneously (Gosselink 2004). Recovery from dyspnoea following physical activity can be assisted with positioning (e.g. forward lean with the arms supported) together with breathing strategies such as breathing control or PLB. Some patients have a tendency to breath-hold when performing physical tasks and encouraging exhalation during effort is another breathing strategy that may be helpful. For selected patients with severe dyspnoea, education on energy conservation techniques during ADL is important. Conversely, many patients with respiratory or cardiovascular disease adopt a very sedentary lifestyle and, in addition to starting an exercise programme, such patients require encouragement to participate in a greater range of ADL with adequate rests as required to recover from breathlessness. Exercise training is an effective method of relieving dyspnoea in patients with stable chronic lung disease and in those with cardiac failure (ATS /European Respiratory Society (ERS) 2006, Lacasse et al 2006, Rees et al 2004). The underlying mechanisms responsible for the reduction in dyspnoea following exercise training are varied and for the individual may include:

Physiologic training effect with an increased aerobic capacity of the peripheral muscles associated with decreased lactate production and decreased ventilation at a given submaximal workload

Decreased oxygen consumption (VO₂) and ventilation for a given level of physical activity as a result of improved mechanical efficiency (e.g. increased stride length when walking)

Reduced anxiety as a result of improved self-confidence and desensitization to the intensity of dyspnoea from repeated controlled exposure to a stimulus (e.g. as may occur with regular participation in supervised exercise classes).

Walking aids (e.g. rollator/wheeled walker, gutter frame/pulpit frame) that facilitate the forward lean position and arm support may reduce dyspnoea, increase exercise tolerance and may limit the extent of oxygen desaturation in some patients with COPD (Probst et al 2004, Solway et al 2002). Ambulatory oxygen may be beneficial for patients who are dyspnoeic on exercise and demonstrate oxygen desaturation. Oxygen therapy is only indicated if shown to produce benefit in terms of increased exercise tolerance and reduced breathlessness. The application of non-invasive ventilation (NIV) during exercise may reduce dyspnoea and improve exercise endurance and has been shown to be effective in patients with COPD (van’t Hul et al 2002). However, the use of NIV during exercise is cumbersome and often difficult in clinical practice.

For patients with COPD, high-intensity inspiratory muscle training (IMT) has been shown to reduce dyspnoea but the effects of such training on measures of whole body exercise capacity are less convincing (Geddes et al 2005, Hill et al 2006, Lotters et al 2002). Indications for IMT in COPD patients include the presence of severe musculoskeletal problems that prevent participation in a whole body exercise training programme and severe intractable dyspnoea persisting following whole body exercise training.

Outcome measures

The relevant outcome measures include assessment of dyspnoea intensity at rest, during ADL and when exercising. Dyspnoea intensity is most easily quantified using the modified Borg (0-10) Category Ratio Scale (Borg 1982). Changes in exercise tolerance are usually assessed in the clinical setting using a field walking test (Chapter 3). Scales that quantify the functional limitation due to dyspnoea are useful outcome measures of physiotherapy intervention and include the Medical Research Council (MRC) Scale and the New York Heart Association (NYHA) Scale, the University of California San Diego Shortness of Breath Questionnaire, the London Chest Activity of Daily Living Scale and the Pulmonary Functional Status and Dyspnea Questionnaire (Meek 2004). A health-related QoL questionnaire that includes quantification of dyspnoea during ADL is a useful outcome measure for patients who present with dyspnoea and participate in a pulmonary or heart failure rehabilitation programme (Chapters 13 and 14).

Clinical features

Subjectively the patient with reduced exercise tolerance will report that their performance of ADL or the ability to exercise is limited as a result of breathlessness, fatigue or pain. Patients with EIA will report that respiratory symptoms, i.e. cough, chest tightness or wheeze, occur during or immediately following exercise. If peripheral arterial disease is present, the patient will report pain in the calf and often also in the buttock limiting their ability to walk. The intensity of pain will be increased when walking up inclines, hurrying and walking on uneven ground and barefoot.

On examination, functional exercise capacity, which is most commonly assessed in the clinical setting with a field walking test, will be reduced, abnormal physiological responses (e.g. oxygen desaturation, blunted or increased HR response) may be present and the patient will report symptoms limiting exercise (i.e. dyspnoea, fatigue or pain). When EIA is present, there will be a reduction in FEV₁ and peak expiratory flow rate (PEFR) measured immediately following exercise. In patients with claudication pain, a marked limp may be noticeable prior to the patient terminating a walking test. In the obese individual, exercise tolerance is usually limited due to breathlessness occurring with low-intensity exercise.

A cardiopulmonary exercise test, including assessment of the physiologic responses, is required to identify the pathophysiological limitation to exercise (Chapters 3, 13 and 14 on assessment, pulmonary rehabilitation and cardiac rehabilitation). The physiologic variables measured usually include VO₂, carbon dioxide output (VCO₂), V_E, V_T, and respiratory rate, oxygenation (measured via oximetry, SpO₂), HR and rhythm (electrocardiogram (ECG)) and systemic blood pressure. In many clinical settings, a full cardiopulmonary exercise test may not be available; however, when a cardiopulmonary exercise test is performed, the data obtained can assist with exercise prescription.

On examination of the patient there may be signs of peripheral muscle wasting and a reduction in muscle strength found on testing. In some patients, respiratory muscle strength may be reduced compared with normal values (Chapter 3).

For the patient with acute cardiopulmonary dysfunction an exercise test is inappropriate. Information regarding the likely responses to interventions aimed at improving oxygen transport (e.g. transferring from bed to chair, standing, ambulating) will be obtained from knowledge of responses to nursing and medical interventions and observation of subjective and objective data over time. Chapter 4 details the therapeutic effects of positioning and mobilization for the patient with acute cardiopulmonary dysfunction.

Physiotherapy management

Identification and optimal medical management of the underlying cause of reduced exercise tolerance (e.g. COPD, IHD, valvular heart disease, CHF) and of comorbid conditions (e.g. osteoarthritis, diabetes, obesity, malnutrition) are essential before starting an exercise programme. Individuals with known or suspected EIA should use an inhaled short-acting β₂−agonist or non-steroidal anti-inflammatory medication before exercise.

There is strong evidence to support the benefits of exercise training for people with respiratory and cardiovascular disease (Lacasse et al 2006, Leng et al 2001, Rees et al 2004, Smart & Marwick 2004). Regular physical activity is also effective in preventing cardiovascular disease (Thompson et al 2003). The following section outlines the broad principles of exercise training. The reader is also referred to Chapters 4, 8, 12-14 for further information on the physiotherapy management of specific patient populations.

An exercise programme should be designed to meet the specific requirements of the patient. Supervised exercise training, involving a group of patients with the same or similar condition, can be very helpful. Such training provides peer support that may assist patients to overcome anxiety and improve their motivation to exercise. Further, the supervised setting ensures that the exercise prescription is safe and enables the physiotherapist to adjust the prescription on a regular basis. Concurrent with starting an exercise programme, many patients need encouragement to engage in more physical activity during their everyday life.

The frequency, intensity, duration and modes of exercise should be individually selected for each patient based on assessment findings and established goals. In general, the programme should consist of a warm-up, stretches, an aerobic component, resistive training, when appropriate, and a cool-down. Postural correction is also important (Chapter 5 and see Problem - musculoskeletal dysfunction: postural abnormalities, decreased compliance or deformity of the chest wall). Unsupported upper limb exercises are especially important for patients who have respiratory disease and complain of dyspnoea during ADL that involve the upper limbs. Although it is recognized that endurance training is beneficial for most patients, it may be more important for some patients to improve their speed of ambulation over a short distance (e.g. to cross a road or to improve their ability to reach the toilet because of urinary urgency) rather than focusing on improving the distance the patient can walk. Resistance training is an important component of a programme for many patients, as weakness of the peripheral muscles is commonly found in patients with respiratory or cardiovascular disease and may contribute to exercise intolerance (Chapters 13 and 14).

Intermittent exercise and interval training are useful to improve the exercise endurance of patients who are severely deconditioned, extremely dyspnoeic, excessively fatigued or have claudication pain, and are essential when rehabilitating patients in the acute care setting. When marked oxygen desaturation occurs with exercise, the inclusion of frequent rests can assist in maintaining oxygen saturation at an acceptable level.

An adequate warm-up before exercise and including intermittent exercise to provide and make use of the refractory period is very important for those with EIA (Storms 2005).

In the dyspnoeic patient, the use of breathing strategies may assist with improving exercise tolerance and may accelerate the rate of recovery following exercise (see Problem - dyspnoea). Walking endurance may be increased with the use of a walking aid that provides arm support and facilitates a forward lean position (see Problem - dyspnoea). Ambulatory oxygen therapy during exercise is essential for patients who are receiving long-term oxygen therapy and should be provided in accordance with local guidelines. The flow rate may need to be increased especially during exercise that involves large muscle groups (i.e. walking, step-ups); however, care must be taken to monitor signs of carbon dioxide retention in susceptible patients. In patients who markedly desaturate on exercise but have adequate oxygen saturation levels at rest, formal assessment of the benefits of ambulatory oxygen for exercise is required. A walking test (field test or treadmill test) should be used in preference to a cycle ergometry test to identify exercise-induced hypoxaemia as oxygen desaturation is more marked with walking than cycling (Poulain et al 2003, Turner et al 2004).

In selected patients, the application of non-invasive ventilation (NIV) during exercise may enable exercise to be performed at a greater intensity or duration.

Patients should, whenever possible, exercise in an appropriate environment. Extremes of temperature, very high humidity, very windy conditions and environments with high levels of airborne irritants or pollutants should be avoided. These recommendations are especially important for individuals with EIA.

Outcome measures

Commonly used measures for evaluating the effects of an exercise programme include the assessment of anthropometric variables (e.g. weight, body mass index, waist : hip ratio) in selected patients, resting blood pressure, peripheral muscle strength, functional exercise capacity including assessment of HR response to exercise and symptoms (dyspnoea, fatigue, pain) and QoL using disease-specific questionnaires where available. The ability to perform ADL may be assessed via patient self-report or quantified using validated questionnaires. The economic benefits of an exercise programme for people with CHF or COPD may be evaluated by recording hospital admissions and length of stay before and following rehabilitation.

Chapters 13 and 14 detail specific outcome measures for patients participating in pulmonary or cardiac rehabilitation programmes.

Clinical features

Subjectively the patient may report that breathing requires effort. On examination there will be an adaptive breathing pattern characterized by a small V_T and increased respiratory rate. In the presence of pain, or fear of pain (e.g. in the patient with a surgical incision, fractured ribs or pleuritic pain), there will be an absence of periodic sighs. Chest expansion will be reduced overall such as with ILD or may be a localized finding, for example in the area overlying a collapsed lobe.

On auscultation there will be absent, diminished or bronchial breath sounds. The cough will be weak, due mainly to the inability to achieve an adequate inhaled volume and expiratory airflow (e.g. in spinal cord injury, quadriplegia). Chest radiograph findings may identify the cause of the reduction in lung volumes such as a pleural disorder, ILD, lobar or lung collapse.

Clinical features resulting from acute lobar collapse depend on the extent of the collapse, the abruptness of onset and the underlying respiratory impairment. A slowly developing segmental or lobar collapse may produce few symptoms if the patient has otherwise normal lungs. If a similar magnitude of lung collapse occurs acutely in a patient with chronic lung disease, severe respiratory distress may develop in which case the clinical features of hypoxaemia will be present (see Problem - impaired gas exchange). If however, there is a decrease in perfusion to the collapsed lung as a result of hypoxic pulmonary vasoconstriction, hypoxaemia may be minimal or absent.

Lung function test results show a decrease in lung volumes (RV) and capacities (FRC, VC and TLC). Hypoxaemia may be present, particularly when there is an inability to expand a large portion of lung tissue, primarily as a result of V/Q mismatching arising from changes in the FRC/closing volume relationship. Hypercapnia is often absent but will occur if there is associated hypoventilation or chronic lung disease.

Physiotherapy management

When gas exchange is reduced or WOB is increased, physiotherapy management is largely focused on the optimization of lung volumes achieved by upright positioning. As upright positions increase FRC and therefore alveolar inflation, high sitting, sitting out of bed and ambulation are encouraged. The side-lying position is preferred to slumped or supine positions and may be modified by tilting the patient towards prone to further decrease compression on lung tissue. This is especially so in patients with abdominal distension (Jenkins et al 1988). Functional residual capacity may also be increased with the use of continuous positive airway pressure (CPAP).

Short-lived increases in V_T and inspiratory capacity may occur with the use of breathing techniques (e.g. thoracic expansion exercises, sustained maximal inspirations with or without the use of an incentive spirometer, intermittent positive airway pressure (IPPB)) and manual hyperinflation in the intubated patient. These breathing techniques assist in re-expansion of lung tissue and will be more efficient if performed in upright positions. In addition, upright positioning will assist patients to increase inhaled volume sufficiently to generate adequate expiratory airflow and produce an effective cough.

For patients with fixed and irreversible chest wall or lung pathology (e.g. kyphoscoliosis, ILD), physiotherapy is unable to influence lung volume; however, the associated problems of dyspnoea and reduced exercise tolerance can be treated (see Problem - dyspnoea and Problem - decreased exercise tolerance).

Ambulation increases V_E (Chapter 4) and when ambulating, patients should be encouraged to take frequent deep breaths to ensure that the increased V_E is not solely due to an increase in respiratory rate (Orfanos et al 1999, Zafiropoulos et al 2004) and to assist in lung re-expansion.

Patients at increased risk of developing clinically significant atelectasis following surgery should be identified and prophylactic physiotherapy started (Chapter 12).

Obese patients may benefit from exercise programmes designed to achieve weight reduction provided that exercise is accompanied by dietary control (see Problem - decreased exercise tolerance).

Outcome measures

Following physiotherapy intervention there may be a change in cough effectiveness. Auscultatory findings may reflect changes in lung volume. Chest radiographs may reflect resolution of the underlying problem but are not always good indicators of clinical progress; for example, following coronary artery surgery, small pleural effusions or atelectasis may persist for a considerable time after the patient has recovered clinically. Pulmonary function tests will reflect changes in lung volume if the underlying lung pathology is reversible. Improvements in associated problems such as impaired gas exchange, reduced exercise tolerance and dyspnoea may be evident. In the high-risk surgical patient, the outcome will be prevention of PPCs and reduced length of hospitalization.

Clinical features

Patients may adapt to chronic changes in arterial blood gas tensions whereas acute hypoxaemia and hypercapnia are less well tolerated.

There are few clinical features associated with mild hypoxaemia; however, if associated with severe anaemia or impaired cardiac output, mild hypoxaemia may be poorly tolerated. At moderate degrees of hypoxaemia (PaO₂ between 4.5 and 8 kPa (34 and 60 mmHg) ventilation may be increased to twice the normal level (Schwartzstein & Parker 2006). The features of moderate or severe hypoxaemia that develop acutely are tachypnoea, restlessness, confusion, sweating, tachycardia, hypertension, skin pallor and cyanosis. With severe hypoxaemia, bradycardia, arrhythmias and hypotension may develop. Worsening neurologic signs associated with acute severe hypoxaemia include blurred vision, tunnel vision, loss of coordination, impaired judgement, convulsions, coma and permanent brain damage. Hypoxaemia exacerbates cardiac arrhythmias and angina in patients with IHD and may predispose to heart failure. The long-term cardiovascular consequences of chronic hypoxaemia are pulmonary hypertension and cor pulmonale.

The clinical features of hypercapnia are determined more by the onset of the raised PaCO₂ rather than the severity. Chronic hypercapnia may not be clinically manifest until a more rapid rise is induced by infection, sedation, or oxygen administration. Signs and symptoms associated with hypercapnia include those consistent with vasodilatation, for example warm peripheries, the appearance of flushed skin and a full and bounding pulse. The cardiac system may respond with episodes of extrasystoles. The resulting increase in cerebral blood flow is responsible for headache (this occurs especially on waking and can occur during exercise), a raised cerebrospinal fluid pressure and sometimes papilloedema (oedema of the optic disc). Impaired concentration and drowsiness may also be present. Rapid accumulation of CO₂ and the accompanying acidosis may quickly lead to convulsions and coma. The clinical features of hypercapnia may be less obvious in patients with COPD who have chronic respiratory failure because metabolic adaptations may occur in response to chronically elevated PaCO₂.

The signs and symptoms of hypocapnia are many and varied (Gardner 2003). They include paraesthesia in the hands, face and trunk and tetany. A reduction in central nervous system and cerebral blood flow may be responsible for dizziness, loss of consciousness, visual disturbances, headache, tinnitus, ataxia and tremor. With acute hypocapnia, systemic blood pressure falls and HR increases. Peripheral vasoconstriction is thought to be responsible for the complaint of cold hands.

Impaired gas exchange will be reflected in abnormalities in arterial blood gases, pulse oximetry and transcutaneous measures of PaCO_2.

Physiotherapy management

Physiotherapy management is determined by the underlying pathophysiological cause(s) and may be limited. Oxygen therapy is indicated whenever tissue oxygenation is impaired and should be prescribed by the medical practitioner in accordance with established guidelines. Physiotherapists should ensure the correct application of oxygen therapy including the delivery device and flow rate/concentration (Chapter 5). For patients with type II respiratory failure susceptible to oxygen-induced respiratory depression, controlled oxygen therapy should be administered via a fixed performance device (Chapter 5). For these patients, careful administration of oxygen therapy is required when a nebulizer is used (Chapter 5).

Gas exchange may by optimized by positioning patients in an upright position to increase FRC. In spontaneously breathing adults with unilateral lung pathology, V/Q matching may be improved by positioning in side lying with the unaffected lung dependent. However, hypoxaemia due to hypoventilation may be worsened by positioning in supine lying due to the increased load on the respiratory muscles.

Physical activity may improve gas exchange by enhancing oxygen transport or may result in further impairment in gas transfer (i.e. identified by a fall in oxygen saturation) in some patients with severe cardiopulmonary dysfunction. Oxygen therapy during ambulation may be indicated in some patients and this should be assessed using a walking test (Chapter 3) (Poulain et al 2003, Turner et al 2004). In other patients, NIV applied during ambulation may improve gas exchange. Non-invasive ventilation is also a useful treatment for exacerbations of COPD, some causes of acute respiratory failure and nocturnal hypoventilation (Mehta & Hill 2001). Specifically, CPAP may improve oxygenation in patients with acute cardiogenic pulmonary oedema (Cooper 2004).

Outcome measures

Arterial blood gases, oximetry and transcutaneous end-tidal measures of PaCO₂ will reflect changes in gas exchange. Short-term changes in cognitive function and symptoms such as headache may be evident when abnormalities in gas exchange are corrected.

In patients with long-term abnormalities in gas exchange, changes in QoL may occur in response to interventions such as NIV or long-term oxygen therapy. In this patient group, a reduction in healthcare utilization and improved survival may also occur.

Clinical features

The patient with airflow limitation may report chest tightness or wheeze, cough and breathlessness, limiting their ability to undertake ADL and exercise. In asthma, cough and breathlessness may be particularly evident at night or early morning and may lead to sleep disruption. Patients may report that their cough is ‘tight’ and they have difficulty clearing secretions.

On examination, patients may display signs of an increased WOB to overcome the increase in airway resistance. Respiratory rate may be increased and expiration may be active, with contraction of the abdominal muscles, and prolonged expiration (increased I : E ratio). Recruitment of the accessory respiratory muscles may be evident and indrawing of the intercostal spaces and supraclavicular fossae visible. Pursed-lip breathing is adopted by some patients with severe airflow limitation (e.g. COPD).

With long-standing disease, examination of the chest may reveal signs of hyperinflation such as a barrel-shaped chest with an increase in the anteroposterior diameter and a raised shoulder girdle. Paradoxical movement of the lower chest wall can occur in patients with severe hyperinflation as the diaphragm is unable to descend and contraction of the diaphragm during inspiration leads to indrawing of the lower ribs (Hoover’s sign).

Wheezing may be audible. Auscultatory findings often reveal widespread, polyphonic wheezes; however, patients with hyperinflation may have reduced breath sounds.

The chest radiograph may show signs of hyperinflation as well as signs consistent with the underlying condition; for example, the presence of emphysematous bullae or bronchiectatic changes.

Abnormalities in pulmonary function indicative of airflow limitation comprise a reduction in FEV₁, FEV₁/FVC, PEFR and forced expiratory flow at 25-75% of forced expiratory flow (FEF_25–75). Characteristic patterns can be seen in the flow-volume loop and may help with identifying the cause and site of the airflow limitation (Chapter 3). Functional residual capacity, RV and TLC are often increased and the ratio of RV to TLC may be elevated.

Physiotherapy management

Where airflow limitation is reversible, optimal medical management with medication is essential. Patient education is an important aspect of the management of airflow limitation, particularly in asthma, and may be undertaken by a physiotherapist in some settings. A simple explanation about the mechanism(s) of airflow limitation, the importance of avoiding trigger factors including cigarette smoke and allergens, and the use and effects of medications are essential. Self-management should be encouraged and, in particular for patients with asthma, the physiotherapist’s role includes reinforcing the patient’s action plan that has been developed by a medical officer to manage their changing symptoms (Gibson et al 2002).

Education and instruction in the correct method of using inhaled medications to reduce airflow limitation is necessary to ensure maximal deposition of the medication. A large range of devices is available for the delivery of inhaled respiratory medications and the physiotherapist should be familiar with these (Chapter 5). Airway clearance techniques with prior, effective delivery of an inhaled bronchodilator may help to overcome airflow limitation due to retained bronchial secretions and bronchospasm. Where necessary airway clearance techniques should be adapted to ensure that no increase in airflow limitation occurs. Increasing the length of periods of breathing control between huffs in the forced expiration technique (FET) may help to prevent an increase in airflow limitation. For patients with COPD it may be necessary to modify the huff to prevent dynamic airway collapse by decreasing expiratory force or increasing inspiratory volume (van der Schans 1997). Alternatively, positive expiratory pressure (PEP) therapy has been suggested as an appropriate airway clearance technique for patients with COPD as it provides positive mouth pressure to splint open collapsible airways (Holland & Button 2006). Further details on these airway clearance techniques are provided in Chapter 5 on physiotherapy techniques.

Breathing strategies such as PLB may be encouraged in patients who spontaneously adopt the technique (Gosselink 2004). This technique aims to splint the airways open and increase expiratory time, thereby reducing dyspnoea. Other breathing strategies may be directed towards the management of dyspnoea associated with airflow limitation (see physiotherapy management in Problem - dyspnoea). For patients with asthma a number of breathing ‘retraining’ strategies (such as the Buteyko technique; Chapter 17) have been advocated although there is no consistent evidence for improved asthma control (Holloway & Ram 2004).

For the management of EIA, see Problem - decreased exercise tolerance.

Where the cause of airflow limitation is a tumour or enlarged lymph nodes, physiotherapy management is not indicated.

Outcome measures

Changes in symptoms related to airflow limitation, particularly in asthma, can be measured with a health-related QoL questionnaire. A number of widely used questionnaires exist, including:

Asthma Quality of Life Questionnaire (AQLQ) (Juniper et al 1993)

Mini AQLQ (Juniper et al 1999a)

Marks Asthma Quality of Life Questionnaire (AQLQ-M) (Marks et al 1993)

Modified AQLQ-M (Adams et al 2000)

Asthma Control Questionnaire (Juniper et al 1999b).

For patients with COPD, the SGRQ includes a section that quantifies symptoms of wheeze/chest tightness (Jones et al 1992).

Short-term changes in airflow limitation, as reflected by wheeze, may be evident on auscultation.

Pulmonary function tests may reflect changes in the degree of airflow limitation depending upon the underlying aetiology and whether the condition is reversible.

Clinical features

Mild respiratory muscle dysfunction is often difficult to detect using simple clinical measures. Weakness of the respiratory muscles is often advanced before clinical symptoms are present because the pressure required to initiate inspiratory flow represents only a small proportion of the maximum force-generating capacity of the inspiratory muscles (Troosters et al 2005). The main clinical features and patient problems associated with respiratory muscle weakness are an unexplained reduction in VC, abnormal breathing pattern, nocturnal hypoxaemia and hypercapnia in the absence of chronic lung disease, dyspnoea, decreased exercise tolerance and impaired airway clearance.

Subjectively, the patient may report breathlessness, especially when supine or standing in water up to their chest, for example when entering the sea or a swimming pool. The weight of water causes pressure on the chest and the abdominal wall and thus the load on the inspiratory muscles, especially the diaphragm, is increased. Marked breathlessness during ADL that involve unsupported upper limb activities may be reported by patients with diaphragm weakness or bilateral phrenic nerve palsy. Daytime somnolence, early morning headaches and impaired mental function may be present if hypoxaemia and hypercapnia occur during sleep. Abnormalities in breathing pattern may be present and include increased respiratory rate, decreased V_T, reduced chest expansion, use of accessory muscles and respiratory alternans (periods of breathing using only chest wall muscles alternating with periods of breathing using the diaphragm). Profound diaphragm weakness or paralysis gives rise to paradoxical movement of the abdomen occurring during inspiration and is most easily seen with the patient supine (Moxham 1999). This occurs when the diaphragm is unable to match the negative intrapleural pressure generated by the other inspiratory muscles, resulting in passive transmission of this pressure during inspiration and causing the abdominal contents to be pulled upwards. When upright, recruitment of the abdominal muscles may occur during expiration in order to elevate the diaphragm so that gravity and chest wall and lung recoil pressure can assist diaphragm descent during inspiration. The patient may have a weak cough due to an inadequate inspired volume or weakness of the expiratory muscles resulting in a reduction in expiratory airflow. The weak cough may in turn lead to the problem of impaired airway clearance.

The plain chest radiograph is a useful diagnostic tool in unilateral diaphragm paralysis as the affected dome is elevated. In addition to respiratory muscle weakness there may also be signs of generalized muscle wasting and assessment may reveal a reduction in peripheral muscle strength. The ability to perform ADL and participate in exercise will be impaired as a result of dyspnoea reflecting the difficulties of the inspiratory muscles to cope with the required increase in ventila- tion. Depending on the underlying pathological process, peripheral muscle dysfunction may also contribute to exercise intolerance.

Physiotherapy management

Targeted respiratory muscle training may be an effective means of increasing the strength and endurance of the respiratory muscles (Chapter 5). Most of the evidence for the benefits of respiratory muscle training has been gained from studies of IMT in patients with COPD. In this patient population, IMT performed using a threshold loading device or a target-flow resistive device has been shown to increase inspiratory muscle strength and endurance and reduce dyspnoea (Geddes et al 2005, Lotters et al 2002). The optimal IMT protocol has not been determined; however, high-intensity interval-based protocols, which include regular rest periods, appear to be more efficient at improving respiratory muscle function than protocols that do not permit rest periods (Hill et al 2004, 2006).

Although unsupported upper limb exercise training increases the reliance on the diaphragm to generate inspiratory flow, such training does not appear to improve diaphragm function. Patients may benefit from whole body exercise training as a result of improvements in peripheral muscle function. For patients with excess bronchial secretions, assistance with airway clearance including the use of assisted coughing techniques is often required (Chapters 5 and 16).

Non-invasive ventilation provided during sleep may be required to rest the respiratory muscles and correct blood gas abnormalities. Some patients may also require periods of NIV during the daytime.

In some patients, the underlying cause of respiratory muscle dysfunction is progressive and the main role of physiotherapy is the successful management of associated and potential problems (e.g. impaired airway clearance).

Outcome measures

The following outcome measures should be considered when evaluating the response to physiotherapy intervention. The patient’s perception of dyspnoea during ADL and exercise can be assessed using the Borg Category Ratio Scale or a VAS (see Problem - dyspnoea). Perception of dyspnoea during ADL can also be quantified using standardized questionnaires, for example, the dyspnoea domain of the Chronic Respiratory Disease Questionnaire (Guyatt et al 1987). Measurement of PiMax and PeMax will determine whether changes in respiratory muscle strength have occurred. Observation of breathing pattern and evaluation of cough effective- ness are important outcomes to evaluate. Measurement of VC is a useful outcome measure and simple to perform clinically. Changes in exercise tolerance can be assessed using a field walking test (Chapter 3).

In the mechanically ventilated patient who is having problems weaning, changes in respiratory muscle function may be associated with changes in the tolerance to periods of spontaneous breathing (i.e. duration of periods, arterial blood gas tensions).

In situations where the cause of respiratory muscle dysfunction is a progressive condition, the outcome measures for evaluating physiotherapy intervention often relate to the management of associated problems (such as Problem - impaired airway clearance) and may include such measures as the frequency of chest infection.

Clinical features

These include abnormalities in respiratory rate and depth, including excessive sighing or breath holding, and changes in the I : E ratio. Observation and palpation may reveal asymmetrical chest wall movement, paradoxical chest wall movement, asynchronous movements or respiratory alternans. The patient may overuse their accessory respiratory muscles, and may actively elevate their shoulders during inspiration. Associated excessive muscle activity (e.g. facial grimacing, gripping objects) may also occur.

Arterial blood gas analysis may demonstrate abnormalities consistent with an underlying problem (e.g. hypocapnia in hyperventilation syndrome or hypoxaemia and hypercapnia in spinal cord injury). Diagnostic tests may be used to assess hyperventilation including the voluntary hyperventilation provocation test, Nijmegen questionnaire and breath-holding time (Chapter 17).

Physiotherapy management

Breathing pattern retraining is focused on changing dysfunctional breathing patterns when they are not associated with strategies employed by the patient to reduce other problems such as dyspnoea or airflow limitation. Thus, physiotherapy generally aims to eliminate the exaggerated muscle activity associated with increased WOB or associated responses. Retraining may focus on changing V_T, flow rate and strategies such as relaxation and breathing control are encouraged (Chapter 17).

Dysfunctional breathing patterns associated with abnormalities of the chest wall or spinal cord injury may be managed with positive pressure ventilation if these are associated with abnormal gas exchange.

Outcome measures

Physiotherapy intervention can be evaluated using the Nijmegen questionnaire, breath-holding time, diaries recording disability/distress/symptoms and QoL measures (Thomas et al 2003) (Chapter 17).

Arterial blood gas analysis, transcutaneous CO₂ and oximetry may reflect concomitant changes in gas exchange.

Clinical features

The clinical features associated with pain of respiratory or cardiovascular origin are outlined in Tables 6.11 and 6.12. Subjective assessment will identify the clinical features of the pain and factors that elicit pain or increase the intensity of the pain.

Quantification of the pain intensity can be made using a VAS, a verbal rating of pain severity on a 0-10 or 0-5 scale. On examination of the patient there may be signs of an abnormal breathing pattern and systemic signs such as sweating, pallor and tachycardia. Chest expansion may be reduced over the painful area and there may be an associated reduction in breath sounds on auscultation and pleural rub.

Physiotherapy management

Diagnosis and management of the underlying cause are essential. Anti-inflammatory agents or analgesics are used for musculoskeletal, pleuritic and pericardial pain.

Direct methods of pain management used by physiotherapists include heat modalities, interferential, transcutaneous electrical nerve stimulation, Entonox, acupuncture and manual therapy. Knowledge of pain management, for example medications and their onset and duration of action, route of administration, is required so that physiotherapy interventions can be provided when pain management is optimal.

The physiotherapy management of patients with stable angina is described in Chapter 14.

Outcome measures

These may include assessment of pain and function obtained via subjective questioning and objectively using a VAS or other pain scale. The dose and frequency of analgesics or anti-inflammatory medications required by the patient should be recorded. Outcome measures for evaluating the effects of physiotherapy for the patient with angina are given in Chapter 14.

Clinical features

The patient may present with an abnormal posture, reduced range of movement of the cervical spine, thoracic spine and glenohumeral joint and may report pain or stiffness resulting in decreased function. The assessment of pain, associated functional limitation, posture, muscle length, strength and endurance and joint range of movement are covered elsewhere (Chapter 5).

Physiotherapy management

Physiotherapy management should include, where appropriate, postural correction, stretching techniques (for example, hold-relax), of tight muscles, mobilizations to the cervical spine and thoracic spine, costotransverse, costochondral and sternochondral joints, to the ribs and to the glenohumeral joint (Bray et al 1995, Vibekk 1991) and muscle strengthening exercises. Postural correction and stretches to improve chest wall mobility should be incorporated into other active exercises and ADL. Where possible, especially when chronic lung disease is present, patients should be taught to manage their own condition with clear instructions on appropriate stretches and exercises to carry out daily at home (Chapter 5).

The patient’s position during treatment will need to be carefully selected as many patients will not be able to lie prone or supine due to dyspnoea and mobilizations will have to be performed in sitting or forward lean sitting.

Following a sternotomy or thoracotomy, advice should be given on postural correction and upper limb exercises (Chapter 12).

For patients with neuromuscular disorders, physiotherapy management is targeted to the underlying condition.

Clinical outcomes

Range of movement of the cervical spine, thoracic spine and glenohumeral joints can be measured before and following physiotherapy intervention. Muscle length and strength can also be measured where appropriate. Short-term changes in pain can be measured on a VAS. Longer-term changes can be measured with a generic QoL scale such as the Short Form-36 Health Survey (SF-36) (Ware & Gandek 1998).