Postural and Musculoskeletal Impairments Contributing to Increased Work of Breathing

Transcription

1 Postural and Musculoskeletal Impairments Contributing to Increased Work of Breathing Jordon Metcalf, Tiffany Sheffield, Katherine Sullivan, Ashley Williams

2 Objectives Review the normal mechanics of breathing Understand the correlation between posture and the musculoskeletal system on the work of breathing Provide examples of postural and musculoskeletal impairments and their symptoms Provide interventions to address postural and musculoskeletal impairments

3 Normal Mechanics of Inspiration During normal tidal breathing: first the inspiratory muscles are activated which causes an increase in thorax volume and a decrease in intrathoracic pressure which results in air being drawn into the lungs. Bucket-handle effect Water pump effect

4 Normal Mechanics of Exhalation Inspiratory muscles relax Passive elastic recoil Increase in alveolar pressure Air flows out of the lungs nt=safari&hl=enus&prmd=vsin&source=lnms&tbm=isch&sa=x&ved=0ahukew jlskk4warxahuc0ymkhxhbbmqq_auifcgd&biw=1024 &bih=666#imgrc=wrx9onpsknllim:

5 Posture vs. Musculoskeletal Impairments Posture directly influences the musculoskeletal system The musculoskeletal system directly influences posture For example: Trunk muscle activity will change to maintain certain postures which has an affect on ribcage and abdominal compliance.

6 Postural Impairments Posture can have a direct effect on respiratory cycle Subtle changes in posture, even in just one plane, changes the configuration of all three dimensions of the chest wall. This directly affects distribution of lung volume and breathing mechanisms Thoracic kyphosis has been associated with a lower FVC, FEV1, and FEV1/FVC

7 Postural Impairments When there are changes in postural alignment it can affect position, range of motion and coupling patterns of the spinal and rib articulations. Influencing compliance by changing the articular range of motion that is available for respiration. Some postures reduce compliance in one region that will increase motion elsewhere in the chest wall Individual variations in the chest wall shape and kinematics can be attributed to uncontrolled posture. Chest wall adaptations

8 Musculoskeletal Impairments Trunk musculature directly influences pressure changes within the chest and abdomen necessary for normal breathing.

9 Musculoskeletal Impairments Examples: Weakness (pathological/aging process), paralysis, neuromuscular tone of intercostal muscles Symptoms: Increased work of breathing, sensation of dyspnea, compensatory breathing patterns including paradoxical breathing, upper accessory breathing, asymmetrical breathing, and shallow breathing

10 Interventions for Postural and Musculoskeletal Impairments Breathing control maneuvers: Pursed lip breathing, paced breathing, inspiratory hold technique, stacked breathing, diaphragmatic, lateral costal breathing, sniffing Medical intervention: Prescription of oxygen Inspiratory Muscle Strength Training (IMST): Strengthening Endurance CCEP- Comprehensive Corrective exercise program - Seidi, et al using Kendall s theory and exercises however emphasizing the simultaneous correction of the abnormalities related to the postural hyper kyphosis

11 Inspiratory Muscle Strength Training Intervention consists of 4 sets of 6 training breaths (High intensity-low Repetition) Completed 5x/week for 6 weeks 3x with PT 2x independently Training breaths utilized basic strengthening ideals, using 75% of inspiratory max (Reassessed weekly)

12 Interventions Effects on BDI and 6MWD *Significant Improvements in BDI in Both Training Groups *Significant Improvements in 6MWD in Training Non-COPD Group Basic Dyspnea Index and 6MWT BDI: Self-report looking at breathlessness 6MWD: Dyspnea measured with Visual Analog Scale. SaO 2 and HR measured at start and finish

13 Interventions Effects on PImax PI max=maximal Inspiratory Pressure 1. Subjects seated upright with nose clips 2. Exhale to residual volume 3. Inspire as forcefully as possible at least 5x with sec rest 4. 3 measures within 10% and then averaged *Significant Increases in PImax Only in Treatment Groups

14 Comprehensive Corrective Exercise Program CCEP should be used as an intervention to help kyphosis CCEP uses Kendall s theories however emphasizes the simultaneous correction of abnormalities related to the postural hyper kyphosis. CCEP was shown to be more effective than LCEP(local comprehensive corrective exercise) which just uses kendall s theories and exercises alone.

15 CCEP The patient is asked to perform exercises aimed at stretching the pectoral muscles and strengthening the back extensor muscles of the thoracic spine while performing a chin tuck, erecting the thoracic spine and adducting the scapulae. The subjects performed two stretching exercises, one self mobilization, and two strengthening exercises. 12 weeks- three sessions per week.

16 Clinical Significance Posture and musculoskeletal impairments effects the work of breathing IMST is beneficial for relieving dyspnea, improving quality of life, and improving treatment tolerance CCEP has been shown to improve kyphosis Treatment of kyphosis could help with dyspnea, ventilatory dysfunction, and respiratory morbidity/mortality in elderly Physical Therapists should use IMST and CCEP to address posture and musculoskeletal impairments that effect the work of breathing

17 References 1) De Bari M, Chiarlone M, Marchionni N, et al. Thoracic kyphosis and ventilatory dysfunction in unselected older persons: an epidemiological study in Dicomano, Italy. Journal Of The American Geriatrics Society [serial online]. June 2004;52(6): Available from: CINAHL, Ipswich, MA. Accessed September 26, ) Hillegass E. Essentials of Cardiopulmonary Physical Therapy. 4th ed. Saint Louis, Missouri: Elsevier, ) Huang C-H, Yang G-G, Wu Y-T, Lee C-W. Comparison of Inspiratory Muscle Strength Training Effects Between Older Subjects With and Without Chronic Obstructive Pulmonary Disease. Journal of the Formosan Medical Association. 2011;110(8): doi: /s (11) ) Lee, Linda-Joy; Chang, Angela; Coppieters, Michel; Hodges, Paul. Changes in Sitting Posture Induce Multiplanar Changes in Chest Wall Shape and Motion with Breathing. Respiratory Physiology & Neurobiology 170 (2010) ) Massery, Mary. Multisystem Clinical Implications of Impaired Breathing Mechanics and Postural Control. In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical Therapy: Evidence to Practice 5th edition. St. Louis, MO: Elsevier- Mosby; 2012: ) Seidi F, Rajabi R, Ebrahimi I, Alizadeh M, Minooneiad H. Thee efficiency of corrective exercise interventions on thoracic hyper-kyphosis angle. Journal Of Back & Musculoskeletal Rehabilitation[Serial Online]. January 2014;27(1):7-16. Available from: SPORTdiscus with Full Text, Ipswich, MA. Accessed November 8, 2017.