Download - Razi's Dissertation
A STUDY TO EVALUATE THE EFFECTIVENESS OF
DIAPHRAGMATIC BREATHING AND PURSEDLIP BREATHING
EXERCISE FOR IMPROVING FLOW RATE AND FUNCTIONAL
EXERCISE TOLERANCE IN PATIENTS WITH STABLE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE AWARD OF MASTER’S DEGREE
IN PHYSIOTHERAPY WITH SPECIALISATION
IN CARDIOPULMONARY AND INTENSIVECARE PHYSIOTHERAPY
SUBMITTED BY
MUHAMMED RAZI. C. K
REG. NO: ASAH MPT 011
UNDER THE GUIDANCE OF
Mr. PREM KUMAR, MPT
EXTERNAL EXAMINER INTERNAL EXAMINER
DEPARTMENT OF PHYSIOTHERAPY
A W H SPECIAL COLLEGE
(AFFILIATED TO UNIVERSITY OF CALICUT)
KALLAI, CALICUT -673003, KERALA.
2007-2009
DECLERATION BY THE STUDENT
I hereby declare that this dissertation entitled “A STUDY TO EVALUATE THE
EFFECTIVENESS OF DIAPHRAGMATIC BREATHING EXERCISE AND
PURSEDLIP BREATHING EXERCISE FOR IMPROVING FLOW RATE AND
FUNCTIONAL EXERCISE TOLERANCE IN PATIENTS WITH STABLE CHRONIC
OBSTRUCTIVE PULMONARY DISEASE ” is a bonafide and genuine research work
carried out by me under the guidance of Mr. Prem Kumar.
Place: Mr. MUHAMMED RAZI. C. K
Date:
CERTIFICATE
This is to certify that Mr. MUHAMMED RAZI. C. K is a bonafide student of Master
of Physiotherapy Course with specialization CARDIO PULMONARY AND
INTENSIVECARE PHYSIOTHERAPY at AWH Special College, Calicut. This
dissertation entitled “ A STUDY TO EVALUATE THE EFFECTIVENESS OF
DIAPHRAGMATIC BREATHING EXERCISE AND PURSEDLIP BREATHING
EXERCISE FOR IMPROVING FLOW RATE AND FUNCTIONAL EXERCISE
TOLERANCE IN PATIENTS WITH STABLE CHRONIC OBSTRUCTIVE
PULMONARY DISEASE” is submitted in partial fulfilment of the requirements for the
degree of Master of Physiotherapy from University of Calicut. This bonafide work has
been carried our under my guidance and supervision.
Place: MR.PREM KUMAR
Date MPT (CARDIORESPIRATORY PHYSIOTHERAPY)
Senior Lecturer
Department of Physiotherapy
AWH Special College
Calicut.
CERTIFICATE
This is to certify that Mr. MUHAMMED RAZI is a bonafide student of Master of
Physiotherapy Course with specialization in CARDIO PULMONARY AND
INTENSIVECARE PHYSIOTHERAPY at AWH Special College, Calicut. This
dissertation entitled “A STUDY TO EVALUATE THE EFFECTIVENESS OF
DIAPHRAGMATIC BREATHING EXERCISE AND PURSEDLIP BREATHING
EXERCISE FOR IMPROVING FLOW RATE AND FUNCTIONAL EXERCISE
TOLERANCE IN PATIENTS WITH STABLE CHRONIC OBSTRUCTIVE
PULMONARY DISEASE” is submitted in partial fulfilment of the requirements for the
degree of Master of Physiotherapy from University of Calicut.
Place: Mr. RASHIJ. M
Date: MPT (Neurology and Psychosomatic disorder)
Assistant Professor
Head of the Department
Dept of Physiotherapy
AWH Special College
Calicut.
CERTIFICATE
This is to certify that Mr. MUHAMMED RAZI is a bonafide student of
Master of Physiotherapy course with specialization in CARDIO PULMONARY
INTENSIVECARE PHYSIOTHERAPY at AWH Special College, Calicut. This
dissertation is submitted in partial fulfilment of the requirements for the degree of Master
of Physiotherapy from university of Calicut.
Place: Dr. P. K. ABDUL KADER
Date: Principal
AWH Special College,
Calicut
ADVISORS OF THE STUDY
DR. ANIL JOSEPH. MD, DTCD
Pulmonologist.
Chest Hospital,
Kozhikode.
Mr. ROSHITH. C
MPT (Rehabilitation)
Assistant Professor
Department of Physiotherapy
AWH Special College
Mr. RASHIJ. M
MPT (Neurology and Psychosomatic disorder)
Assistant Professor
Head of the Department
Dept of Physiotherapy
AWH Special College
ACKNOWLEDGEMENT
First and foremost I would like to thank my parents whose valuable support gave
me Courage and Confidence throughout the study.
I would like to express my deep sense of gratitude to Mr. Prem Kumar, Associate
Professor, Department of Physiotherapy, AWH Special College, Calicut, for being my
guide and bringing out the best in me and marking this study perfect with his valuable
guidance. I am extremely thankful for his constant encouragement and inspiration during
the course of this study.
I wish to express my thanks to our co-ordinator Mr. Bhuvanesh Babu, Assistant
Professor, Department of Physiotherapy, AWH Special College for his valuable help and
guidance throughout the study that enlighten my courage in completing this dissertation
successfully.
I am outmost thankful to Mr. Rashij. C, MPT, Head of the department,
Department of Physiotherapy, for the scholarly guidance and support in the fulfilment of
my task.
I am thankful to our respected Principal Mr. Abdul Kader and respected Vice
Principal Mr. Prabakaran Nambiar and the Management of AWH Special College for all
the facilities extended to me for the study.
I express my thanks to Mr. Roshith. C, M.P.T, Mr. Deepak. T. V, M.P.T and
MR. Suhas.K.P for helping me in this study. I extend my sincere thanks to Dr. V. Raju,
senior professor, Dept. of Statistics, University of Calicut for helping me in statistical
analysis.
I express my thanks to all staff members Dept. of Physiotherapy in AWH Special
College for helping with their valuable suggestions.
I am thankful to my friends Mr. Abhishek , Mr. Benson Baby, Mr. David
Thomas, Mr. Linto Varghese, Mr. Akheel Ahammed.M. M, Mr. Ratheesh Kumar,
Mr.Sajeevan T, Mr. Akheel M, Dr. Deepthi, Mr. Ibrahim and my colleagues who were
always there to help me with my research study. My Sincere thanks to all the
contributors whose name I have not mentioned but though they all deserve my gratitude.
Last but not the least I would like to thank all the subjects of my study without whom
this task would not have been possible.
MUHAMMED RAZI. C. K.
Dedicated to my loving parents
LIST OF ABBREVIATION
COPD: Chronic Obstructive Pulmonary Disease
VT: Tidal Volume
FEV1: Forced Expiratory Volume in 1 Second
FVC: Forced Vital Capacity
6MWT: Six Minute Walk Test
DB: Diaphragmatic Breathing
PLB: Pursed Lip Breathing
WOB: Work of Breathing
ATS: American Thoracic Society
GOLD: Global Initiative for Chronic Obstructive Lung Disease
RR: Respiratory Rate
MRC: Medical Research Council
HR: Heart Rate
ADL: Activity of Daily Living
ABSTRACT
Objective:
To evaluate the effectiveness of diaphragmatic breathing and pursed lip breathing
exercise in stable COPD patients
Methods:
30 Subjects were selected on the basis of inclusion and exclusion criteria. All the
Subjects were divided equally into two groups, Group A and Group B based on
convenience Sampling Technique. Before starting the training, pre-test scores are
measured by using pulmonary function test and six minute walk test. Group A received
diaphragmatic breathing and Group B received pursed lip breathing. At the end of sixth
week, post-test scores of both groups were taken.
Results:
Pursed lip breathing group showed better improvements in pulmonary function test and
six minute walk test, when compared to the diaphragmatic breathing group.
Conclusion:
Improvement of the flow rate and exercise performance in moderate COPD patients is
associated with pursed lip breathing.
Key words:
Diaphragmatic breathing exercise, pursed lip breathing, stable COPD.
CONTENTS
CHAPTER Page no
1. INTRODUCTION 1
1.1. Introduction
1.2. Need for the study
2. REVIEW OF LITERATURE 8
3. METHODOLOGY 16
3.1. Aim of the study
3.2. Objectives of the study
3.3. Research Design
3.4. Hypotheses
3.5. Population
3.6. Study settings
3.7. Samples and Sampling Method
3.8. Selection Criteria
3.9. Variables of the study
3.10. Research Tool
3.11. Duration of the study
3.12. Data collection procedure
4. DATA ANALYSIS 21
5. RESULTS 23
CHAPTER Page no
6. DISCUSSION 25
6.1. Discussion
6.2. Limitations and Suggestions
7. CONCLUSION 35
8. REFERENCES 37
APPENDICES
1. Assessment form
2. Data collection form
3. Results tables
4. Graphs
5. Protocols
6. Informed consent form
7. Master chart
CHAPTER 1
INTRODUCTION
1.1 INTRODUCTION
Chronic obstructive pulmonary disease (COPD) has been defined by the Global
initiative for chronic obstructive pulmonary disease (GOLD) as a disease characterized
by air flow limitation that is not fully reversible. The airflow limitation is usually both
progressive and associated with an abnormal inflammatory response of the lungs to
noxious particles or gases.(www . GOLD COPD .com) 1
The chronic airflow limitation characteristic of COPD is caused by a mixture of
small airway disease and paranchymal destruction, the relative contribution of which
varies from person to person. Chronic inflammation causes remodelling and narrowing
of the small airways. Destruction of the lung parenchyma, also by inflammatory process,
leads to the loss of alveolar attachments to the small airways and decreases lung elastic
recoil, inturn these changes diminish the ability of the airways to remain open during
expiration. Air flow limitation is measured by spirometry, as this is most widely
available, reproducible test of lung function.2
COPD is a global health concern, and is a major cause of chronic morbidity and
mortality worldwide. Many people suffer from this disease for years and die prematurely
from it or its complications. The global burden of COPD is projected to be the fifth
leading cause of death and GOLD estimates and suggests that the COPD will rise from
the sixth to third most common cause of the death world wide by 2020. The burden of
COPD in Asia is currently greater than that in developed Western countries.3
Worldwide cigarette smoking is the most commonly encountered risk factor for
COPD, although in many countries, air pollution resulting from the bumming of wood
and other biomass fuels also been identified as a COPD risk factor .The second most
significant documented risk factor for COPD IS alpha-1 antitrypsin deficiency .Certain
occupational exposures like dusts and chemicals (vapours, irritants, fumes) and indoor
and outdoor air pollutions are also associated with increased risk of COPD.
The characteristic symptoms of COPD are cough, sputum production and dyspnoea
on exertion. Chronic cough and sputum production often precede the development of
airflow limitation by many years; although not all individuals with cough and sputum
production go on to develop COPD. The natural course of COPD is characterized by
occasional sudden worsening of symptoms called acute exacerbations, most of which are
caused by infections or air pollution. This pattern offers a unique opportunity to identify
those at risk for COPD and intervene when the disease is not yet a health problem. A
major objective of GOLD is to increase awareness among health care providers and the
general public of the significance of these symptoms and decrease morbidity and
mortality from the disease .GOLD aims to improve prevention and management of
COPD through a concerted world wide effort of people involved in all facets of health
care and health care policy, and to encourage an expanded level of research interest in
this highly prevalent disease.5
All population based studies in developed countries showed a markedly greater
prevalence and mortality of COPD among men compared to woman .gender related
differences in exposure to risk factors mostly cigarette smoking probably explain this
pattern. 6
The goals of the global initiative for COPD are to increase awareness of COPD and
decrease morbidity and mortality from the disease. GOLD aims to improve prevention
and management of COPD through a concerted world wide effort of people involved in
all facets of health care and health care policy, and to encourage an expanded level of
research interest in this highly prevalent disease.7
Dyspnoea limiting physical activity is a common complaint in COPD patients with
moderate to severe airflow obstruction and usually arises during the sixth or seventh
decade of life. The onset of dyspnoea is often insidious and may be attributed incorrectly
to the effects of ageing. Avoidance of activity as a strategy to limit the experience of
dyspnoea leads to a sedentary lifestyle. Accompanying this lifestyle is locomotor muscle
de condition pounds the effects of pulmonary dysfunction on dyspnoea. The reduction of
maximum expiratory flow rate and slow forced emptying of lung are common problems
seen in COPD that leads to dyspnoea and reduction in exercise tolerance. The COPD
patients are reluctant to do exercises because of dyspnoea. In severe cases of COPD
accessory muscles may required for respiration. 8
The four stage classification COPD severity provides an educational tool and a
general indication of the approach to management.
Stage 1: Mild COPD –Mild airflow limitation (FEV1/FVC <70%; FEV1>_80%
predicted.), and sometimes, but not always chronic cough and sputum production.
Stage 2: Moderate COPD –Worsening airflow limitation (FEV1/FVC <70%, 50 %<
_FEV1<80% predicted.), with shortness of breath typically developing on exertion.
Stage 3: Severe COPD –Further Worsening airflow limitation (FEV1/FVC <70%, 30
%< _FEV1<50% predicted.), with greater shortness of breath, reduced exercise capacity,
and repeated exacerbations which have an impact on patients quality of life.
Stage 4: Very Severe COPD - : Severe airflow limitation (FEV1/FVC <70%,
FEV1<30% predicted.), or FEV1<50% Predicted plus chronic respiratory failure
.patients may have very severe COPD even if the FEV1 is >30%predicted when ever this
complications are present.9
This conceptual frame work also emphasizes that COPD is usually progressive if
exposure to the noxious agent is continued. The staging is based on airflow limitation as
measured by spirometry which is essential for diagnosis and provides a useful
description of severity of pathological changes in COPD.
The overall approach to managing stable COPD should be characterized by a step
wise increase in treatment, depending on the severity of the disease. The classification of
severity of stable COPD incorporates an individualized assessment of disease severity
and therapeutic response in to the management strategy.11
While disease prevention is the ultimate goal, once COPD has been diagnosed,
effective management should be aimed at the following goals:
-prevent disease progression
-relieve symptoms
-improve exercise tolerance
-improve health status
-prevent and treat complications
-prevent and treat exacerbations
-reduce mortality.
The benefits of pulmonary rehabilitation program include improved exercise
capacity, an enhanced sense of wellbeing and a reduced need for hospitalization.
Pulmonary rehabilitation has been demonstrated to improve the health related quality of
life, dyspnoea, and exercise tolerancecapacity.12
The goal of pulmonary rehabilitation program are to reduce symptoms, improve
activity and daily function, and restore the highest level of independent function in
patient with respiratory disease.
Diaphragmatic breathing is an exercise to better use and to strengthen the
diaphragm, the major and most efficient muscle of breathing. Regular practice of
diaphragmatic breathing can help restore function of diaphragm and return to a more
efficient breathing pattern. Practicing a deeper diaphragmatic style of breathing can help
ease of work of breathing and expect more stale air.14
Pursed lip breathing is performed as expiratory blowing against pursed lips, is a
pulmonary rehabilitation strategy instinctively or voluntarily employed in patients with
COPD to relieve or control dyspnoea.
Six minute walk test is simple, easy reproducible and requires no apparatus. It is
a self paced exercise that patients could perform this test alone. It can be carried out at
same time of the day at any time.
Management of stable COPD involves the avoidance of risk factors to prevent
disease progression and pharmacotherapy as needed to control symptoms. In addition to
patient education, health advise and pharmacotherapy, these patients require specific
counselling about smoking cessation, instruction in physical exercise, nutritional advise
and continued nursing support. Not all approaches are needed for every patient and
assessing the potential benefit of each approach at each stage of the illness is a crucial
aspect of effective disease management. An effective COPD management plan includes
four components .assess and monitors the disease, reduce risk factors, manage stable
COPD and manage exacerbations.
The treatment programme includes preventive and general care management. It
includes pharmacological and non pharmacological treatment. Pharmacological
treatment includes medications like B-2 agonists, ancholinergics, methylxanthines, and
bronchodilators. Other pharmacological treatment includes vaccines, antibiotics,
mucolytic agents, antioxidant agents, immuno regulators, antitussives, vasodilators, and
narcotics. non pharmacological treatment includes rehabilitation, education, oxygen
therapy.
1.2 NEED FOR THE STUDY.
Reduction of maximum expiratory rate, slow forced emptying of lung and
breathlessness are common problems seen in COPD. In severe cases of COPD, the use of
accessory muscles was increased. Diaphragmatic breathing exercise and PLB are
effective to relieve the symptoms.
In other studies functional performance of the COPD patients are not evaluated.
Hence the need of this study is to improve exercise tolerance along with the flow rates
and rate of perceived exertion.
CHAPTER 2
REVIEW OF LITERATURE
REVIEW OF LITERATURE
American thoracic society has defined COPD as`` a disease state characterized by
the presence of airflow limitation due to Chronic Bronchitis or Emphysema; the airflow
obstruction is generally progressive, may be accompanied by airway hyper reactivity,
and may be partially reversible. 15
Hyper inflation of lungs affects not only the bony components of the chest wall,
but also the muscles of the thorax .the resting position of the diaphragm changes to a
more flattened configuration .The angle of pull of diaphragm fibers becomes more
horizontal with a decreased zone of apposition and decreased strength and range of
contraction. In severe cases of hyperinflation the fibers of diaphragm will be aligned
horizontally. Contraction of this much flattened diaphragm will pull the lower ribcage
inward actually working against lung inflation.16
Dyspnoea is a subjective experience of breathing discomfort that consists of
qualitatively distinct sensations that vary in intensity. The experience derives from
interactions among multiple physiological, psychological, social and environmental
factors and may induce secondary physiological and behavioural responses. (American
thoracic society 1999)17
A scale such as the MRC breathlessness scale suggests five different grades of
dyspnoea based on the circumstances in which it arises.
Grade 1 - no dyspnoea except with strenuous exercise.
Grade 2 - dyspnoea when walking up an incline or hurrying on the level.
Grade 3 -walks slower than most on the level, or stops after 15 minutes of walking on
the level.
Grade 4 -stops after a few minutes of walking on the level.
Grade 5 - dyspnoea with minimal activity such as getting dressed, too dyspnoea to leave
the house.18
COPD patients frequently develop nocturnal oxygen destruction because of
alveolar hypoventilation, worsening of ventilation-perfusion mismatch, and sometimes
obstructive sleep apneas. In contrast, little is known about their oxygen status during the
various activities of daily life.19
The diagnosis of COPD confirmed by spirometry, a test that measures breathing,
it measures the forced expiratory volume in one second (FEV1) which is the greatest
volume of air that can be breathed out in the first second of a large breath. Spirometry
also measures the Forced vital capacity (FVC) which is the greatest volume of air that
can be breathed out in a whole large breath. Normally at least 70% of the FVC comes out
in the 1st second, ie, FEV1/FVC ratio is >70%.In COPD this ratio is less than normal,
i.e., FEV1/FVC ratio is <70% even after a bronchodilator medication has been given.
Spirometry helps to determine the severity of COPD. The FEV1 is expressed as a
percent of a predicted normal value based on a person’s age , gender ,height and weight.
Pulmonary function test provides greater information regarding illness and serving that
may not be otherwise obtainable. For the purpose of clinical research spirometry has
significant advantages including reliability, validity, reproductively, quality control,
maintenance of records and values that are more physiologically specific.20
Diaphragmatic breathing facilitates outward motion of the abdominal wall while
reducing upper ribcage motion during inspiration. Accordingly, individual skill in
performing diaphragmatic breathing is assessed by observation or measurement of
abdominal excursion during the respiratory cycle. It increase the tidal volume and no
change in minute ventilation, which indicate a substantial slowing of respiratory
frequency.21
Diaphragmatic breathing changes the breathing pattern and it is most helpful in
reducing respiratory rate, minute ventilation and it also increases tidal volume in severe
chronic obstructive pulmonary disease patients.
The study of Levine et al. provides the first evidence that appropriate adaptive
response occur in the inspiratory intercostals muscles of patients with chronic
obstructive pulmonary disease. Levenson et al. states that abdominal muscle contraction
should be encouraged to lengthen the diaphragm and increase its force generating
capacity. In severe COPD patients with hypercapneoa and reduced inspiratory muscle
strength recovering from an episode of acute respiratory failure, deep diaphragmatic
breathing is able to improve blood gases whereas inspiratory muscle effort increases and
dyspnoea worsens. Diaphragmatic breathing (DB) has been claimed, but not
demonstrated, to correct abnormal chest motion, decrease the work of breathing (WOB)
and dyspnoea.
Ambrosino et al. reported improvement in maximal exercise tolerance in mild
COPD patients undergoing deep DB. Campbell and friend postulated that the increased
abdominal motion during DB may shift ventilation towards the base of the lungs. Brach
et al. found that DB did not alter regional ventilation for the group as a whole. Two
people , however, increased ventilation to the base of one lung by more than 20%.
Unfortunately; the authors were not able to explain this finding. The study by Sackner et
al. demonstrated that half of the subjects had minimal abdominal displacement during
DB. Another study by Sackner et al. Showed that DB was associated with distorted chest
wall motion. Diaphragmatic breathing caused increased paradoxical and asynchronous
movements of the rib cage. The amount of asynchrony was not correlated with disease
severity. Gosselink et al. report increased VO2 and work of breathing in people with
severe COPD who performed DB with no spontaneous changes in respiratory frequency.
The work of breathing was calculated according to the method of Collett et al. which
relates changes in mechanical work to changes in VO2 during loaded breathing.
Gosselink et al. found that during resting breathing, DB increased VO2 (by an
average of 17 ml/min) but had no effect on Vt, breathing frequency, duty cycle (
inspiratory time divided by total respiratory cycle time). When compared with natural
breathing, DB during load breathing was associated with a lower mechanical efficiency,
increased paradoxical rib cage motions and no change in VO2 or dyspnoea.
Diaphragmatic breathing improves the ventilation, decreases work of breathing,
decreases dyspnoea and normalize breathing pattern in patients with chronic obstructive
pulmonary disease.
Breathing techniques are included in the rehabilitation program of patients with
chronic pulmonary disease (COPD). In patients with COPD, breathing techniques aim to
relieve symptoms and ameliorate adverse physiological effects by increasing strength
and endurance of the respiratory muscles, optimizing the pattern of thoraco-abdominal
motion; and reducing dynamic hyperinflation of the rib cage and improving the gas
exchange. Evidence exists to support the effectiveness of purse-lip breathing, forward
leaning position, active expiration and inspiratory muscle training but not for
diaphragmatic breathing.
Diaphragmatic breathing exercises attempts to enhance diaphragmatic exertion
throughout the respiratory cycle for the purpose of reducing accessory muscle use and
providing a more normalized breathing pattern. DB exercises allegedly enhance
diaphragmatic descent during inspiration and diaphragmatic ascent during expiration.
Diaphragmatic breathing exercises are designed to improve the efficiency of ventilation,
decreases work of breathing, increase the excursion of diaphragm, improve gas exchange
and oxygenation. Diaphragmatic breathing exercises are also used to mobilize secretions
during postural drainage. Diaphragmatic and PLB reveals that the use of PLB appears
tobe an effective way to decrease dyspnoea and improve gas exchange in stable COPD.
Sackner et al –reported the effects of DB on VT and respiratory frequency in
patients with COPD respiratory inductance plethysmography was used to measure chest
wall movements, and these changes were calibrated using spirometric measurements to
indicate actual volume change. Gosselink et al found that during resting breathing, DB
increased Vo2, but had no effect on VT, breathing frequency, duty cycle or VE.
Pursed lip breathing is often used in patients with severe airway disease. By
opposing the lips during expiration the airway pressure inside the chest is maintained,
preventing the floppy airways from collapsing. Thus overall air flow is increased.22
Falling described PLB as easiest breathing technique and often employed
instinctively. Patients inhale through the nose over several seconds with the mouth
closed and then exhale slowly over 4-6 seconds. Through pursed lips held in a whistling
or kissing position. This is done with or without the contraction of abdominal muscles.23
PLB is thought to keep airways open by creating a backpressure in the airways. It
is thought to help a patient with COPD with repeated attacks of shortness of breath
.studies suggest that PLB decreases the respiratory rate ,increases the tidal volume and
improves the exercise tolerance.24
PLB leads to reduced diaphragmatic and increased ribcage and accessory muscle
recruitment. It provides a perception of control over breathing. PLB is performed as
expiratory blowing against pursed lips ,is a pulmonary rehabilitation strategy
instinctively or voluntarily employed in patient with COPD to relieve or control
dyspnoea.24
Thoman and colleagues reported on comparison of spontaneous breathing.PLB
and slow breathing was done in an attempt to clarify whether the effect of PLB were due
to slowing of respiratory rate. The investigators reported that PLB slow breathing
frequency and that both slow, deep breathing and PLB result in a similar increase in tidal
volume. 25
The 6MWT has first been introduced as a functional exercise test by Lipkin in
1986. Its results are highly correlated with those of the 12 minutes’ walk test from which
it was derived and with those of cycle ergo meter or treadmill based exercise tests . The
6MWT is also a valuable instrument to assess progression of functional exercise capacity
in different clinical intervention studies. The reliability of the test in healthy elderly
persons is high and it is considered as a valid and reliable test to assess the exercise
capacity of elderly patients with chronic obstructive pulmonary disease. Several authors
studied the determining factors of the 6MWT-distance in healthy adults and propose
either reference equations or normative data for the 6MWT-outcome. Troosters et al.
found that age, gender, height and weight explained 66% of the 6MWT-distance
variability in 51 healthy adults aged 50–85 years.
6MWT is used for the objective evaluation of the functional exercise capacity.
The strongest indication for the 6 MWT is for measuring the response to therapeutic
interventions for pulmonary disease. The self paced 6 MWT asses the sub maximal level
of functional capacity. The 6 MWT is easy to administer, better tolerated and more
reflective of ADL than the other walk test.26
6MWT is a simple test to evaluate the functional capacity by measuring the
distance walked during a defined period of time. In an attempt to accommodate patients
with respiratory disease for whom walking 12 minute was too exhausting. It elevates
global and integrated response of organ involved during exertion like cardiovascular
system, pulmonary system etc.27
The six-minute walk test is an objective method, to measure the ability to
perform daily living activities. It is more often performed, to evaluate the functional
status, monitor therapy, or assess the prognosis in patients with cardiac and pulmonary
diseases. In comparison to traditional pulmonary exercise test, 6MWT needs less
technical support or equipment, making it a simple and inexpensive method to measure
functional capacity. The validity and the reliability of 6MWT was studied in different
conditions, including obstructive lung diseases, interstitial lung diseases, pulmonary
hypertension, heart failure and peripheral arterial diseases.
The improvement in health related quality of life after pulmonary rehabilitation
clearly exceeds the minimal clinically important difference. When disease specific
instruments were used, the lower limit of the 95% confidence interval exceeded the
minimal clinically important difference.28
CHAPTER 3
METHODOLOGY
3.1 AIM OF THE STUDY
To evaluate the effectiveness of diaphragmatic breathing exercise and pursed lip
breathing exercise in stable COPD patients.
3.2 OBJECTIVES OF THE STUDY
� To evaluate the effectiveness of diaphragmatic breathing exercise in stable
COPD patients.
� To evaluate the effectiveness of Pursed lip breathing exercise in stable COPD
patients.
3.3 RESEARCH DESIGN
Pre-test and post-test experimental design.
3.4 HYPOTHESES
Null hypothesis
There is no significant difference between diaphragmatic breathing exercise and pursed
lip breathing exercise in stable COPD patients.
Alternate hypothesis
There is significant difference between diaphragmatic breathing exercise and pursed lip
breathing exercise in stable COPD patients.
3.5 POPULATION
Patients who are diagnosed as stable COPD, referred by pulmonologist were taken as
population of the study.
3.6 STUDY SETTINGS
1. Department of physiotherapy, Chest Hospital, Kozhikode.
3.7 SAMPLES AND SAMPLING METHOD
30 Patients who are diagnosed as stable COPD, referred by Pulmonologist were
selected as samples for the study from the population using convenience sampling
method.
3.8 SELECTION CRITERIA
Inclusion criteria
1. Patients diagnosed as Stable COPD.
2. Haemodynamically stable COPD patients
3. Both male and female patients
4. Patients with 50 to 70 yr old
5. Moderate COPD patients.
6. FEV1 with 50-80%
Exclusion Criteria
1. Patients with cardiac, metabolic, or endocrine disorders
2. Acute exacerbation of COPD
3. Thoracic or abdominal surgery within last 2 months
4. Patients with unstable vital sign
5. Patient with pleural disorder
6. Mentally retarded patients and un co operative patients
7. Patients with unstable cardiac disease
8. Subjects who are not able to do spirometry
9. Patients like infectious diseases like tuberculosis and pneumonia
10. Any orthopaedic deformities of the chest
3.9 VARIABLES OF THE STUDY
Independent variables
� Diaphragmatic breathing exercise
� Pursed lip breathing exercise
Dependent variables
� FEV1,FVC
� Six minute walk test
3.10 RESEARCH TOOLS
1. Sphygmomanometer.
2. Spirometer.
3. Respiratory assessment form.
4. Borgs scale for rate of perceived exertion.
5. Stethoscope.
6. Inch tape.
7. Stop watch.
3.11 DURATION OF THE STUDY
Total duration of study was six weeks.
3.12 DATA COLLECTION PROCEDURE
30 Subjects were selected on the basics of inclusion and exclusion criteria. All the
subjects were divided equally into two groups, Group A and Group B. Each group
consisted of 15 subjects, the study procedures were explained to the subjects and
informed consent was obtained prior to study. Before starting the training, pre-test scores
were measured by using Pulmonary function test and six minute walk test.
Group A- Subjects in Group A (n=15) received Diaphragmatic breathing exercises as
per the appendix
Group B- Subjects in Group B (n=15) received Pursed lip breathing exercise as per the
appendix
At the end of sixth week post test scores of both groups were taken by using
pulmonary function test and six minute walk test.
CHAPER 4
DATA ANALYSIS
DATA ANALYSIS
Data was analysed using a paired T test to find out within group difference of
dependent variable and a univariate analysis of variance to find out between group
differences. There was one within group factor which was time and a between subject
factor which was group. All data was analysed using SPSS version 12.O with
significance level kept at 0.05.
CHAPTER 5
RESULTS
RESULTS
Six minute walk test.
A t-test was done to analyse the within group difference of six minute walk test.
There was a significant improvement for six minute walk test in group A from pre to
post. T value (14, 0.05) = -10.088, P<0.000. Group B also showed a significant
improvement from pre to post for six minute walk test. T value (14, 0.05) = -6.859,
P<0.000. Univariate analysis of variance was done to analyse the between group
difference of six minute walk test and showed a significant difference between groups, F
value (1, 27, 0.05) = 45.645, P<0.000.
FEV 1
A t-test was done to analyse the within group difference of FEV1.There was no
significant difference for FEV1 in group A from pre to post. T value(14,0.05) = -0.866,
P<0.401.But Group B showed a significant difference from pre to post for FEV 1,T
value(14,0.05)= 6.144,P<0.000. Univariate analysis of variance was done to analyse the
between group difference of FEV1 and showed a significant difference between groups,
F value (1, 27, 0.05) = 29.25, P<0.000.
FVC
A t-test was done to analyse the within group difference of FVC. There was no
significant difference for FVC in group A from pre to post. T value(14,0.05) = -1.684,
P<0.114.But Group B showed a significant difference from pre to post for FVC,T
value(14,0.05) = -4.971, P<0.000. Univariate analysis of variance was done to analyse
the between group difference of FVC and showed a significant difference between
groups, F value (1, 27, 0.05) = 24.681, P<0.000.
CHAPTER 6
DISCUSSION
6.1 DISCUSSION
The study is an experimental comparative study to find out the effectiveness of
DB & PLB exercise in patients with stable COPD. The patients are divided in two group
A and group B comprising of 15 patients each. Both groups were trained twice daily for
15 minutes for 6 days per week for 6 weeks. The Outcome measurement of the study was
6MWT, spirometry of measurement of FEV1 and FVC. Group A received DBE and
group B received PLB exercises.
Group which received DBE showed significant improvement in 6 MWT than the
PLB exercises group and PLB group showed significant improvement in FEV1 and FVC
compared with DBE group. But there was no significant improvement in FEV1 and FVC
in DBE group from pre to post. In both groups there was significant improvement in
6MWT from pre to post.
Pursed lip breathing results in a positive expiatory pressure and is thought to have
similarities with continuous positive airway pressure and positive end expiratory
pressure. By creating an obstruction at the lip, this active expiration may be intensified
and the resulting greater increase in positive expiratory pressure may increase bronchial
pressure and thus “tansmural” pressure, leading to a diminution of airway collapse: In
various studies there was a linear relationship between the effectiveness of PEP
breathing in decreasing the nonelectric resistance across the lung and airway and the
collapsibility of airways
Bianchi R et al assessed the volumes of chest wall compartments using an
optoelectronic plethysmograph and concluded that by decreasing respiratory frequency
and lengthening expiratory time, pursed lip breathing decreases end expiratory volume of
chest wall, which is mostly at the abdominal level et al. decrease in end expiratory
volume of abdomen and modulates the breathlessness. Changes in end expiratory volume
of chest wall are related to baseline airway obstruction (FEV1) but not due to
hyperinflation. So, improvement in dyspnoea observed after breathing exercises can be
attributed to the decrease in respiratory rate, increase in tidal volume, decreased
physiological dead space to tidal volume ratio, improved blood gases and decrease the
work of breathing by decreasing or preventing airway collapse and promoting more
homogenous ventilation as observed in various clinical trials of breathing exercises.
Esteve et al found that breathing pattern training, enhanced with visual feedback
increased the FEV1, and FVC in patients with COPD following pulmonary rehabilitation
having breathing exercises as a component and this area needs further evaluation by
more clinical trials.
Thoman R, proposed that those segments of lungs with greatest fall or greater
increase in flow resistance will receive disproportionately less of the tidal volume.
Therefore, the abnormal and uneven distribution of gases in emphysema will be
accentuated with increased respiratory rate. So the slowing of respiration alone would be
expected to enhance the ventilation of those subdivisions of the lung which normally are
under ventilated. They found that tidal volume increases while respiratory rate decreases
and CO2 elimination improves without significant change in forced residual capacity and
volume of slow space by pulsed lip breathing. They found that indeed there was an
increase in ventilatory rates of those most slowly ventilated lung components, when
respiratory rate slowed down with pursed lip breathing. Mueller et al also observed that
pursed lip breathing was accompanied by both increased tidal volume and decreased
respiratory rate, more so in subjects who claimed benefit from pursed lip breathing in
comparison to the subjects who did not feel improvement with pursed lip breathing. An
improvement in PO2 was observed in both groups during rest, but not during exercise
and he concluded that benefits of pursed lip breathing were due to decreased airway
collapse, decreased respiratory rate, and increased tidal volume but found no relationship
between symptomatic benefit from pursed lip breathing and improvement in ABG.
Mueller as well as other investigators found that although pursed lip breathing
was more effective in the sense that less air exchange was required to absorb a given
amount of oxygen, there was no increase in oxygen uptake This suggests that PLB does
not significantly alter the work of breathing. It is known that hyperactivity of the
inspiratory muscles is a cause for the sensation of dyspnoea. Their assumption that
decrease in dyspnoea sensation which is often thought to be related to pursed lip
breathing might be caused by reduced activity of respiratory muscle is still a matter of
debate. Through encouraging the use of diaphragm, the principal and efficient muscle of
inspiration, the oxygen cost of breathing can be decreased. Decreasing the use of
accessory muscles also decreases the work of breathing. The bio feed can be used to
discourage accessory muscle firing during the ventilatory cycles. Because use of the
diaphragm as in diaphragmatic breathing was found to increase rather than decrease the
level of dyspnea at present routine use of diaphragmatic breathing in pulmonary
rehabilitation is not recommended.
Killian and co workers showed that exercise capacity in COPD patient is mainly
limited by subjective symptoms such as muscle fatigue and dyspnoea without the patient
reaching their physiological limitations. Now as this is well known that a “vicious cycle”
of exertional dyspnoea, exercise and activity limitation, psychosocial illness are the
major causes of poor health related quality of life in COPD patients, there are increasing
evidence that physical reconditioning which is most essential component of pulmonary
rehabilitation can improve the exercise capacity and health related quality of lives.
Casciari RJ et al found in their study that breathing retraining increases exercise
performance in subjects with severe chronic obstructive pulmonary disease.
Schans et al observed that positive expiratory pressure breathing which is in
range of mouth pressure reached during expiration with pursed lip in patients with COPD
increases the efficiency of ventilation at rest and during exercise, since same work load is
achieved with less ventilation. So the improvement in exercise tolerance seems to be due
to the decrease in the sensation of dyspnoea. That’s why these patients do not feel panic
at the time of respiratory distress. Their self-confidence could be improved, which
progressively increases activities of daily living that mimics exercise of physical
reconditioning that can ultimately restore the patient to the highest level of functional
capacity and improved health related quality of life. However, the effect on quality of
life has not been evaluated by other workers.
Evidence suggests that diaphragmatic breathing does not change regional
ventilation in people with COPD. This technique increase total ventilation but if so ,this
suggest this may due to the slower ,deeper breathing patterns that may occur during DB
rather than an exaggeration of abdominal motion. Some authors noted an increase in the
work of breathing; this may be due to increased paradoxical rib motion during DB. The
relaxed expiration effects of less air tapping, results in reduction of hyperinflation, which
turns into reduced respiratory rate, dyspnoea and improved tidal volume and oxygen
saturation in resting condition. A study by Gosse link proved deep breathing exercise
which includes diaphragmatic breathing immediate decrease respiratory rate, dyspnea
and anxiety. Jones et al confirmed that DB results lower oxygen cost and respiratory rate.
The pursed-lip breathing shifts a major portion of the inspiratory work of breathing from
the diaphragm to the ribcage muscles, resting the diaphragm and reducing dyspnoea.
Techniques such as PLB help to reduce respirations while improving the expiratory
phase. Slow controlled expiration postpones small airway collapse, thereby reducing air
trapping that occurs with forced expiration.
Some patients may benefit from Diaphragmatic breathing technique. The patient
is taught to employ only the diaphragm during inspiration and to maximize abdominal
protrusion. During expiration, the patient may contract the abdominal wall muscles to
displace the diaphragm more cephalic. Not all patients with COPD benefit from this
technique; therefore, close clinical monitoring to ascertain efficacy is required.
The study of Levine et al. provides the first evidence that appropriate adaptive
response occur in the inspiratory intercostals muscles of patients with chronic
obstructive pulmonary disease. Levenson et al. states that abdominal muscle contraction
should be encouraged to lengthen the diaphragm and increase its force generating
capacity.
Ambrosino et al. reported improvement in maximal exercise tolerance in mild
COPD patients undergoing deep DB. Campbell and friend postulated that the increased
abdominal motion during DB may shift ventilation towards the base of the lungs. Brach
et al. found that DB did not alter regional ventilation for the group as a whole.
Unfortunately; the authors were not able to explain this finding. The study by Sackner et
al. demonstrated that half of the subjects had minimal abdominal displacement during
DB. Another study by Sackner et al. Showed that DB was associated with distorted chest
wall motion. Diaphragmatic breathing caused increased paradoxical and asynchronous
movements of the rib cage. The amount of asynchrony was not correlated with disease
severity. Gosselink et al. report increased VO2 and work of breathing in people with
severe COPD who performed DB with no spontaneous changes in respiratory frequency.
The work of breathing was calculated according to the method of Collette et al. which
relates changes in mechanical work to changes in VO2 during loaded breathing.
Dechman G reported that Diaphragmatic breathing improves the ventilation,
decreases work of breathing, decreases dyspnoea and normalize breathing pattern in
patients with chronic obstructive pulmonary disease.
Breathing techniques are included in the rehabilitation program of patients with
chronic pulmonary disease (COPD). In patients with COPD, breathing techniques aim to
relieve symptoms and ameliorate adverse physiological effects by increasing strength
and endurance of the respiratory muscles, optimizing the pattern of thoraco abdominal
motion; and reducing dynamic hyperinflation of the rib cage and improving the gas
exchange. Evidence exists to support the effectiveness of purse-lip breathing, forward
leaning position, active expiration and inspiratory muscle training but not for
diaphragmatic breathing.
Diaphragmatic breathing exercises attempts to enhance diaphragmatic exertion
throughout the respiratory cycle for the purpose of reducing accessory muscle use and
providing a more normalized breathing pattern. DB exercises allegedly enhance
diaphragmatic descent during inspiration and diaphragmatic ascent during expiration.
Diaphragmatic breathing exercises are designed to improve the efficiency of ventilation,
decreases work of breathing, increase the excursion of diaphragm, improve gas
exchange and oxygenation.
The PLB group patients showed markedly reduced RR stable COPD after
performing the breathing exercises. The reduced rate was associated with commensurate
the reduction of COPD .Motley reported that the effect of PLB on ventilatory parameters
and arterial blood gases in people with COPD. They uniformly reported that the
technique decreases respiratory rate, minute ventilation and increases tidal volume
pursed-lip breathing also has been documented to increases partial pressure of oxygen in
arterial blood, and the percentage of haemoglobin sites that are bound to oxygen in
arterial blood, changes in oxygen consumption are less consistent. Pursed-lip breathing
has been reported to decrease dyspnoea, and therefore, may improve exercise tolerance,
and reduce limitations in activities of daily living.
Breslin reported that, during PLB, decreased diaphragm activity during
inspiration was accompanied by increased use of rib cage muscles. Both abdominal and
rib cage accessory muscle activity increased during expiration. Respiratory rate
decreased as did the duty cycle. In addition, Breslin’s estimate of the resting diaphragm
tension-time index indicates that, as a group, the subjects were above the diaphragm
fatigue threshold described by Bellemare and Grassino. A breathing pattern above this
threshold purportedly leads to imminent respiratory failure. These data are surprising
because all of the subjects lived in the community and were medically stable.
There is a clinical improvement of the six minute walk test after breathing
exercises from pre to post test. The ability to walk for a distance is an easy way to
measure exercise capacity in patients with pulmonary diseases. A variety of walk tests,
including self-paced walk tests, controlled-pacing incremental walk tests and time- paced
tests, are considered to be objective measurements of functional capacity. Six minute
walk test is found to be an effective way of assessing exercise tolerance. Its validity,
reliability and reproducibility, were studied in several populations.
The 6MWD had no significant correlation with the level of borg-scale or oxygen
saturation at baseline, or at the end of the test. There were no significant differences in
FEV1, FVC between female and male patients. Spirometric values correlate modestly
with 6MWD. FVC had a stronger positive correlation with distance walk than FEV1.
The 6MWD had no significant correlation with volumetric lung measurements. There
was a significant correlation between 6MWD in patients with respiratory diseases.
O’Donnell and colleagues proposed that people with COPD have “a very fine
control of expiratory flow whereby intrathocic pressure is continuously adjusted to a
level that is just enough to attain maximal flow”. Furthermore, they proposed that this
active control develops with the disease process, suggesting that imposing retraining
techniques is not uniformly helpful in this population.
6.2 LIMITATIONS AND SUGGESTIONS
Limitations:
1. The study was performed for a short duration.
2. The study was done on a Small sample size, which decreases the power to detect
treatment effects.
3. The study did not include long term follow up.
4. As the measurements were taken manually, there may be a chance of error
Suggestions
1. To establish the efficacy of the treatment, a large sample sized study is required.
2. For more valid result, a long term study must be carried out.
3. Follow up programmes can be included to assess the long term effects of
treatment.
4. Further study can be done to check the effects of these techniques on other
conditions.
5. Effects of these techniques on other stages of COPD can be studied.
6. Further study should include more measurement tools.
CHAPTER 7
CONCLUSION
CONCLUSION
Results indicates that PLB are effective for alleviating the symptoms like
dyspnoea and airflow limitations and both exercises are effective in improving the
exercise tolerance in the management of COPD. This was shown by improvement in
FEV1, FVC and six minute walk test.
PLB help to reduce respiratory rate while improving the expiratory phase. Slow
controlled expiration postpones small airway collapse, thereby reducing air trapping that
occurs with forced expiration. Diaphragmatic breathing improves the ventilation,
decreases work of breathing, decreases dyspnoea and normalize breathing pattern in
patients with chronic obstructive pulmonary disease. The effectiveness of DB and PLB is
increasingly being called in to question. In addition, the negative effects of these
procedures have been reported. Interventions that focus on optimizing respiratory
mechanics may result in a better therapeutic outcome rather than a focus on breathing
patterns that primarily may be the result of impaired respiratory mechanics.
CHAPTER 8
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APPENDICES
APPENDIX – 1
ASSESSMENT FORM
Subjective Assessment
Name : Date of admission :
Age : Date of assessment :
Sex :
Occupation :
Weight :
Height :
Chief complaints :
HISTORY
Present medical history :
Past medical history :
Personal History :
Associated Problems :
H/O Allergens :
Family History :
Occupational History :
Socioeconomic status :
Psychological History :
EVALUATION OF CARDINAL SYMPTOMS
Chest Wall Pain
� Musculoskeletal
� Neuralgic
� Angina
� Pleuritic
Cough
� Nocturnal cough
� Productive cough
� Prolonged cough
� Early morning productive cough
� Short cough
� Cough syncope
Sputum
� Consistency
� Smell
� Colour
Haemoptysis
Dyspnoea Grade
� Orthopnea
� Trepopnea
� Paroxismal nocturnal dyspnea
� Platypnea
MODIFIED BORG SCALE: score:
Wheeze
Clubbing grade:
Cyanosis
OBJECTIVE ASSESSMENT
Vital signs
� Heart rate :
� Blood pressure :
� Respiratory rate :
� Temperature :
ON OBSERVATION
Built :
Posture :
Face evaluation
Colour
Distress
Puffiness
Neck evaluation
Use of accessory muscles:
Distension of veins :
Chest wall
Expansion:
Movement:
Deformities:
Pattern of breathing
Rate :
Depth :
Rhythm :
Spinal deformities
Scoliosis :
Kyphosis :
Kyphoscoliosis :
Ankylosing spondylosis :
External Appliances :
ON PALPATION
Trachial shift :
Tenderness over chest wall :
Accessory muscle spasm :
Trachial fremitus :
Movement of Diaphragm :
ON PERCUSSION
Resonant :
Hyper resonant :
Hypo resonant :
Dull :
ON AUSCULTATION
Wheeze :
Crepitation :
Breath sounds
Tracheal :
Bronchial :
Diaphragmatic :
Vocal Resonance:
Pleural rub :
Pericardial rub :
Heart sounds
Mitral :
Tricuspid :
Aortic :
Pulmonary:
ON EXAMINATION
Chest Expansion
Axillary (…….cm) Nipple (……cm) Xiphoid process(…….cm)
ECG :
Echocardiogram:
Chest X ray :
ABG :
PFT :
Bronchoscopy :
Clinical Diagnosis:
APPENDIX – 2
DATA COLLECTION FORM
NAME
AGE
SEX
Group
APPENDIX 3
Serial
number
Outcome
Measures
Pre Test Score Post Test Score
1 6 Minute walk
test
2 FEV1
3 FVC
RESULT TABLES
T-Test 6 Minute Walk Test (Group A)
Paired samples statistics
Mean N Std. Deviation Std. Error
Mean
PairgrpA_6MWT_pre &
1. grpA_6MWT _post
280.6667
301.6667
15
15
44.59607
43.36995
11.51466
11.19807
Paired samples correlations
N Correlation Sig.
Pair grpA_6MWT_pre &
1. grpA_6MWT _post
15 .984 .000
Paired sample test
Paired difference t df Sig. (2-tailed)
mean Std.
deviation
Std.
Error
mean
95% confidence
interval of the
difference
Lower Upper
Pair grpA_6MWT_pre
1. grpA_6MWT_post
-21.00 8.06226 2.08167 -25.4647 -16.53527 -10.088 14 .000
T-Test of FEV1
Paired samples statistics
Mean N Std. Deviation Std. Error
Mean
PairgrpA_FEV1_pre &
1. grpA_ FEV1_post
1.4533
1.4587
15
15
.15235
.14347
.03934
.03704
Paired samples correlations
N Correlation Sig.
Pair grpA_ FEV1_pre &
1. grpA_ FEV1_post
15 .989 .000
Paired sample test
Paired difference t df Sig. (2-tailed)
mean Std.
deviation
Std.
Error
mean
95% confidence
interval of the
difference
Lower Upper
Pair grpA_ FEV1_pre
1. grpA_ FEV1_post
-
.00053
.02386 .00616 -.0185 .00078 -.866 14 .401
T-Test of FVC
Paired samples statistics
Mean N Std. Deviation Std. Error
Mean
PairgrpA_FVC_pre &
1. grpA_ FVC _post
2.1707
2.1900
15
15
.17702
.15996
.04571
.04130
Paired samples correlations
N Correlation Sig.
Pair grpA_ FVC _pre &
1. grpA_ FVC _post
15 .970 .000
Paired sample test
Paired difference T df Sig. (2-tailed)
mean Std.
Deviation
Std.
Error
mean
95% confidence
interval of the
difference
Lower Upper
Pair grpA_ FVC _pre
1. grpA_ FVC _post
-
.01933
.04448 .01148 -.04396 .00530 -1.684 14 .114
T-Test 6 Minute Walk Test (Group B)
Paired samples statistics
Mean N Std. Deviation Std. Error
Mean
PairgrpB_6MWT_pre &
1. grpB_6MWT _post
287.00
292.6667
15
15
39.9016
39.6352
10.3025
10.2337
Paired samples correlations
N Correlation Sig.
Pair grpB_6MWT_pre &
1. grpB_6MWT _post
15 .997 .000
Paired sample test
Paired difference t df Sig. (2-tailed)
mean Std.
Deviation
Std.
Error
mean
95% confidence
interval of the
difference
Lower Upper
Pair grpB_6MWT_pre
1. grpB_6MWT_post
-5.666 3.1997 .82616 -7.4386 -3.8947 -6.859 14 .000
T-Test of FEV1
Paired samples statistics
Mean N Std. Deviation Std. Error
Mean
Pairgrp B_FEV1_pre &
1. grp B_ FEV1_post
1.500
1.5720
15
15
.2426
.2334
.0626
.0602
Paired samples correlations
N Correlation Sig.
Pair grpB_ FEV1_pre &
1. grpB_ FEV1_post
15 .983 .000
Paired sample test
Paired difference T df Sig. (2-tailed)
mean Std.
deviation
Std.
Error
mean
95% confidence
interval of the
difference
Lower Upper
Pair grpB_ FEV1_pre
1. grpB_ FEV1_post
-.072 .0453 .01172 -.0971 -.0468 -6.144 14 .000
T-Test of FVC
Paired samples statistics
Mean N Std. Deviation Std. Error
Mean
PairgrpB_FVC_pre &
1. grpB_ FVC _post
2.283
2.383
15
15
.3127
.2713
.08074
.07007
Paired samples correlations
N Correlation Sig.
Pair grpB_ FVC _pre &
1. grpB_ FVC _post
15 .974 .000
Paired sample test
Paired difference T df Sig. (2-tailed)
mean Std.
Deviation
Std.
Error
mean
95% confidence
interval of the
difference
Lower Upper
Pair grpB_ FVC _pre
1. grpB_ FVC _post
-.100 .0779 .0201 -.1431 -.0568 -4.971 14 .000
Univariate Analysis of Variance- 6 MINUTE WALK TEST (6MWT)
Descriptive statistics
Dependant Variable 6MWT post
Group Mean Std. Deviation N
Group A
Group B
Total
301.6667
292.6667
297.1667
43.3699
39.6352
41.0777
15
15
30
Tests of Between-Subjects Effects
Dependant Variable 6MWT post
Source Type III Sum of
Squares
Df Mean
Squares
F Sig.
Corrected Model
Intercept
Group
6MWT-pre
Error
Total
Corrected total
47921.623a
279.964
1711.757
47314.123
1012.544
2698175
48934.167
2
1
1
1
27
30
29
23960.811
279.964
1711.757
47314.123
37.502
638.927
7.465
45.645
1261.655
.000
.011
.000
.000
Pair-wise Comparison
Dependant Variable 6MWT post
Group Group Mean Difference Std.
Error
Sig. 95% Confidence Interval for
Difference
Lower Bound Upper Bound
GroupA GroupB 15.153 2.243 .000 10.551 19.755
Univariate Tests
Dependant Variable 6MWT post
Sum of Squares Df Mean Square F Sig.
Contract Error 1711.757
1012.544
1
27
1711.757
37.502
45.645 .000
Univariate Analysis of Variance- FEV1
Descriptive statistics
Dependant Variable FEVI post
Group Mean Std. Deviation N
Group A
Group B
Total
1.4587
1.5720
1.5153
.14347
.23346
.19892
15
15
30
Tests of Between-Subjects Effects
Dependant Variable FEV1 post
Source Type III Sum of
Squares
Df Mean
Squares
F Sig.
Corrected Model
Intercept
Group
FEV1-pre
Error
Total
Corrected total
1.115a
.008
.036
1.018
.033
70.035
1.148
2
1
1
1
27
30
29
.557
.008
.036
1.018
.001
457.735
6.658
29.25
836.352
.000
.016
.000
.000
Pair-wise Comparison
Dependant Variable FEV1 post
Group Group Mean Difference Std.
Error
Sig. 95% Confidence Interval for
Difference
Lower Bound Upper Bound
GroupA GroupB -.069 .013 .000 -.096 -.043
Univariate Tests
Dependant Variable FEV1 post
Sum of Squares Df Mean Square F Sig.
Contract Error .036
.033
1
27
.036
.001
29.25 .000
Univariate Analysis of Variance- FVC
Descriptive statistics
Dependant Variable FVC post
Group Mean Std. Deviation N
Group A
Group B
Total
2.190
2.3833
2.2867
.1599
.2713
.2399
15
15
30
Tests of Between-Subjects Effects
Dependant Variable FVC post
Source Type III Sum of
Squares
Df Mean
Squares
F Sig.
Corrected Model
Intercept
Group
FVC-pre
Error
Total
Corrected total
1.596a
.054
.067
1.315
.074
158.535
1.669
2
1
1
1
27
30
29
.798
.054
.067
1.315
.003
292.43
19.754
24.681
482.117
.000
.000
.000
.000
Pair-wise Comparison
Dependant Variable FVC post
Group Group Mean Difference Std.
Error
Sig. 95% Confidence Interval for
Difference
Lower Bound Upper Bound
GroupA GroupB -.097 .020 .000 -.137 -.057
Univariate Tests
Dependant Variable FVC post
Sum of Squares Df Mean Square F Sig.
Contract Error .067
.074
1
27
.067
.003
24.681 .000
APPENDIX 4
GRAPH FOR 6 MINUTE WALK TEST
GRAPH FOR FEV1
GRAPH FOR FVC
APPENDIX 5
EXERCISE PROTOCOLS
APPENDIX 5
EXERCISE PROTOCOLS
Diaphragmatic Breathing Exercise:
� The patient is asked to get relaxed and comfortable position in which gravity
assists the diaphragm such as a semi –fowler’s position.
� Hands placed on the rectus abdominus just below the anterior costal margin with
elbows supported and keeping the shoulder relaxed.
� Ask the patient to breathe in slowly and deeply through the nose and keep the
shoulder and upper chest relaxed allowing the abdomen to rise.
� Tell the patient to slowly let all the air out using controlled expiration.
� Ask the patient to keep his hand over the rectus abdominis and feel the
movement.
� The patients hands should rise during inspiration and fall during expiration
� Patient should feel the contraction of the abdominal muscle.
� Practice diaphragmatic breathing in a variety of positions
Pursed-Lip Breathing Exercise
� Make the patient in a comfortable position and relax as much as possible
� It is performed by inhaling through the nose and exhaling through pursed lips.
� Abdominal muscles may or may not be used for exhalation.
� Instruct the patient to breathe in slowly and deeply.
� The expiration must be relaxed, have the patient loosely purse the lips and exhale.
APPENDIX – 6
INFORMED CONSENT FORM
Institute’s name & address: - Department of physiotherapy
A.W.H Special collage
Kallai
Calicut
Name of the researcher: MUHAMMED RAZI C. K
Title of the study: “ A Study To Evaluate The Effectiveness Of
Diaphragmatic Breathing And Pursed
lip Breathing Exercise For Improving
Flow Rate And Functional Exercise
Tolerance In Patients With Stable
Chronic Obstructive Pulmonary
Disease”
Phone number: 09895419487
I ---------------------------------------------- agree to participate in the research
conducted by Mr. Muhammed Razi. C. K for the partial fulfilment of his Masters in
Physiotherapy program of the Department of Physiotherapy of A.W.H Special Collage,
Kallai, under Calicut University. The project is under supervision of Mr. Premkumar.
The purpose is to find out the effectiveness of diaphragmatic breathing and pursed lip
breathing exercise for improving flow rate and functional exercise tolerance in patients
with stable chronic obstructive pulmonary disease.
My participation will consist essentially of attending once daily 6 days in a week
for 6 weeks and each session approximately 30 minutes. I will be either treated with
diaphragmatic breathing exercises and pursed lip breathing exercises.
I understand that diaphragmatic breathing and pursed lip breathing exercise has
no any side effects or danger. I am free to withdrawn from the project at any time before
or during the interventions, refuse to participate and refuse to answer questions.
I have received assurance from the researcher that the information’s, I share will
remain strictly confidential. Anonymity will be assured not using name and any type of
publications or Non participation will not affect on service that I or my family members
may receive from the physiotherapy department of this institution.
These are 2 copies of the consent form one of which I may keep. If I have any
questions about the conduct of the research project I may contact the researcher.
Researcher name: MUHAMMED RAZI. C.K Respondent’s signature
Official address: Department of Physiotherapy
A.W.H special collage
Kallai.
Date: Researchers signature
Appendix 7
MASTER CHART
Sl no group Age
Pre
6MWT
Post
6MWT
Pre
FEV1
Pre
FVC
Post
FEV1
Post
FVC
1 A 57 310 325 1.27 2.22 1.29 2.23
2 A 61 300 340 1.53 2.3 1.57 2.33
3 A 63 325 340 1.42 2.1 1.44 2.15
4 A 69 290 320 1.33 2 1.34 2.1
5 A 66 250 280 1.2 1.98 1.23 2
6 A 67 260 275 1,67 2.44 1.69 2.45
7 A 62 300 320 1.66 2.42 1.63 2.4
8 A 58 270 300 1.42 2.1 1.43 2.1
9 A 64 340 350 1.32 1.95 1.35 2
10 A 67 285 300 1.52 2.23 1.49 2.16
11 A 59 360 375 1.4 2.1 1.42 2.13
12 A 65 250 270 1.67 2.43 1.67 2.42
13 A 63 260 280 1.63 2.31 1.6 2.32
14 A 65 200 220 1.37 1.98 1.35 1.96
15 A 58 210 230 1.39 2 1.38 2.1
16 B 68 220 225 0.92 1.73 1.03 1.96
17 B 59 280 285 1.43 2.1 1.62 2.3
18 B 68 350 350 1.52 2.2 1.58 2.28
19 B 53 330 330 1.67 2.44 1.7 2.52
20 B 65 310 320 1.81 2.85 1.9 2.95
21 B 66 320 325 1.87 2.85 1.9 2.9
22 B 62 280 290 1.32 2 1.4 2.2
23 B 58 320 330 1.62 2.4 1.75 2.43
24 B 66 310 315 1.23 2.2 1.3 2.22
25 B 62 260 265 1.63 2.39 1.72 2.44
26 B 58 300 310 1.57 2.29 1.6 2.3
27 B 59 305 310 1.43 2.1 1.47 2.32
28 B 66 220 225 1.32 1.98 1.38 2.1
29 B 58 240 245 1.46 2.13 1.5 2.23
30 B 64 260 265 1.7 2.59 1.73 2.6