Dr.

Prerana Chittal
Assistant Professor,
DVVPF College of
Physiotherapy,
Ahmednagar 414111
 OBJECTIVES
• Introduction
• Definition
• Basis for pulmonary rehabilitation
• Indications and contraindications
• Goals
• Team
• Assessment
• Components
 ATS-ERS statement, 2013

• “ Pulmonary rehabilitation is a comprehensive

intervention based on a thorough patient
assessment followed by patient tailored
therapies that include, but are not limited to,
exercise training, education, and behavior
change, designed to improve the physical and
psychological condition of people with chronic
respiratory disease and to promote the long-
term adherence to health-enhancing behaviors”
RATIONALE
Ventilatory
impairments

Lower limb Gas

muscle exchange
dysfunction abnormality

Exercise
limitations

Respiratory
Psychological
muscle
impact
problem

Cardiac
abnormalities
4
• Exercise intolerance is one of the main
factors limiting participation in activities of
daily living among individuals with chronic
respiratory disease.

• The cardinal symptoms that limit ex in pts

with respiratory ds. are -dyspnea
-fatigue
Common indications for referral to
pulmonary rehabilitation
Respiratory disease resulting in
• Anxiety engaging in activities
• Breathlessness with activity
• Limitations with:-social activities
-leisure activities
-indoor and/or outdoor chores
-basic ADL or instrumental ADL
• Loss of independence
 Indications for pulmonary
rehabilitation
• It is indicated for those individuals with
chronic respiratory disease who have
decreased exercise tolerance, exertional
dyspnea or fatigue, and/or impairment of
activities of daily living.
Obstructive pulmonary disease:
• Chronic obstructive pulmonary diseases
• Asthma
• Bronchiectasis

Restrictive pulmonary disease

• Interstitial fibrosis
• Collagen vascular lung disorders
• Pneumoconiosis
• Sarcoidosis
Restrictive chest wall disease
• Kyphoscoliosis
• Severe obesity
• Poliomyelitis

Other conditions
• Pulmonary vascular disease
• Lung resection
• Lung transplantation
• Occupational and environmental lung disease
 Contraindications
• Conditions that might interfere with the
patient undergoing the rehabilitative
process.
E.g. advanced arthritis, inability to learn,
disruptive behavior
• Conditions that might place the patient at
undue risk during ex training.
e.g.. Severe pulmonary HTN, unstable
angina, recent MI.
 Alleviate
symptoms

Increase
Decision exercise
making capacity

GOALS

Behavioral Increase
change ADL

Improve
11
QoL
Benefits of pulmonary rehabilitation

• Improvements in exercise tolerance

• Reduction in the sensation of dyspnea
• Improvement in health related quality of life
(HRQoL)
• Improvement in peripheral muscle strength and
mass
• Reductions in number of days spent in hospital
• Pulmonary rehabilitation is a cost effective
intervention
• Improvement in the ability to perform
routine activities of daily living
• Reductions in exacerbations
• Reduction in anxiety and depression
• Improvements in exercise tolerance are
maintained between 6 - 12 months
• Improvements in HRQoL may be
maintained for longer
 Program Setting

Inpatient

Outpatient

Home based rehabilitation

Assessment
 ASSESSMENT
• Necessary to determine severity of the
respiratory impairment

Clinical history
Review of pertinent records
Educational assessment
Physical examination
Other assessments:
• Measurements of respiratory muscle
strength
• Measures of peripheral muscle strength
• Assessments of ADL
• Health status, cognitive function
• Level of anxiety or depression
• Nutritional status/ body composition
 Assessment…

• Stress testing:-
physical performance test to measure
activity limitation; e.g. 6minute walk test
 Assessment …

• Quality of Life:-
Chronic resp
ds quest
Disease (CRDQ)
specific
questionnaires
St. george’
quest

Genre specific
 The major components of
pulmonary rehabilitation are:-

1. Dyspnea management
2. Exercise training
3. Nutrition and body composition
4. Patient education
5. Cognitive Behavioral Therapy
DYSPNEA MANAGEMENT

Dyspnea

Aggravation
of Fear of
pulmonary activity
disease

Decreased
CVS and Decreased
muscular activity
fitness
1. Reduce ventilatory demand

2. Reduce ventilatory impedance

3. Improve inspiratory muscle function

4. Alter central perception

Points to be considered in exercise
prescription
Frequency

Intensity

Time

Type
Program duration and frequency
• 20 sessions more effective than 10
• Short term intensive programs- 20
sessions in 3-4 wk found to be more
effective
• Outpatient rehabilitation 2-3 times/wk for 4
wks less effect than 7 wks
• One supervised session is ineffective
(ATS 2006)
• Training respiratory patients at 60 to 75%
of maximal work rate results in substantial
increases in maximal exercise capacity
and reductions in ventilation and lactate
levels at identical exercise work rates
 Training Specificity
• Training effects have been found to be
specific to trained muscles

• Traditionally focused on lower extremity

training

• Many ADL involve UE. So UE training

should be incorporated
 Strength and endurance
• Traditionally endurance training is used in
form of cycle/walking ex.

• Relatively longer durations of higher

intensity(>60% of max. work rate) are
adopted in endurance training

• Total effective training time should exceed

30min.-but difficult to achieve in some
patients
• Interval training:
• results in significantly lower symptom
scores despite high training loads,
thus maintaining the training effects
• Strength training has greater potential to
improve muscle mass and strength

• Session includes: 2-4 sets of 6-12 reps

with intensity of 50 to 85% of the one-
repetition maximum

• The combination of endurance and

strength training is probably the best
strategy
 Lower extremity
• Walking and cycling are the
most common exercise
prescribed
• Intensity:
• <12yrs,elderly,ds patients-
mild to moderate
• Normals- progress from
moderate to severe
• Prescribed on basis of
HR,VO2max, RPE, MET
• Duration:
• Minimum of 30 min with or without breaks

• Frequency:
• 3-4 sessions a week
 Upper extremity
• Increase strength
training with or without
weights
• Without weights-
preferred
• Free weights like
theraband etc.
• Type: pulling/pushing
• Upper extremity exercises along with the
other benefits help in increasing thoracic
cage mobility

• Cross training:
• Both UL and LL ex. done together
 Ventilatory Muscle Training
• Inspiratory muscle function may be
compromised in COPD.

• Respiratory muscle strength is commonly

estimated by measuring maximal negative
inspiratory pressure (PImax), although this
is a highly effort-dependent test.
 VMT

• 3 types
 Inspiratory resistive training
 Threshold loading
 Normocapnic hyperpnoea
Exercise prescription guidelines for
VMT
• Frequency: at least 5 times per week
• Intensity: >30% PImax
• Duration: 30 min per day(continuous or 15
min twice a day).
• Training device:
• Breathing frequency of 12-15 breaths per
minute is recommended.
Respiratory training
Pulm ms
performance

dyspnea

Ventilatory
efficiency

endurance
 Oxygen therapy
• Hypoxemic and non-hypoxemic patients:
• Allows for higher training intensity and/or
reduced symptoms in the research setting.

• Long term O2 therapy

 Self management education
• Prevention of exacerbations
• Breathing strategies
• Bronchial hygiene
• Medications
• symptom management
• Self-assessment
• Exercise training and benefits
• Activities of daily living and energy
conservation
 Smoking cessation

• Smoking cessation is the single most

effective and cost-effective way to reduce
the risk of developing COPD and stop its
progression.
SUMMARY
• Aims

• Settings

• Patients included

• Components

• Dyspnea

• Patient education

• Lifestyle modification
 EX prescription in brief
• Frequency : 3-4 times/wk
• Intensity: high intensity training
– 60-80% max. work capacity for LE
– 60% of max. work cap. For UE
• Duration: 25-30 minutes/ as tolerated
• Mode: continuous/interval, combination of
strength and endurance
• 20 sessions within 6-8 weeks
• At least 2 supervised session
• Monitor: HR, dyspnea, fatigue
THANK
YOU