The Effect of Cardiopulmonary Physiotherapy and Sports Physiotherapy on Asthma Control: Case Study

Theeb Naif S Alsalem^1*, Faisal Saadoon F Alenzy² and Turki Menwer J Almuhaid³

¹Physiotherapist, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia

²Physiotherapist, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

³Physiotherapist, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia

^*Corresponding author: Theeb Naif S Alsalem, Physiotherapist, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia.

Citation: Alsalem TNS, Alenzy FSF, Almuhaid TMJ. (2022) The Effect of Cardiopulmonary Physiotherapy and Sports Physiotherapy on Asthma Control: Case Study. J Neurol Sci Res. 2(2):1-26.

Received: June 02, 2022 | Published: June 20, 2022

Copyright ^©️ 2022 genesis pub by Alsalem TNS, et al.  CC BY-NC-ND 4.0 DEED. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives 4.0  International License. This allows others distribute, remix, tweak, and build upon the work, even commercially, as long as they credit the authors for the original creation.

DOI: http://doi.org/10.52793/JNSR.2022.2(2)-16

Abstract

Introduction: The World Health Organization estimations show 235 million people who currently suffer from asthma, and the numbers of asthma deaths are increasing in the next 10 years. Asthma is a chronic disease characterized by intermittent attacks of breathlessness that is triggered by the allergies and cold air commonly. Asthma is well known disease to restrict physical activity, although exercising is one of the ways to manage the disease and minimize the symptoms and attacks.
Methods: Twelve weeks program and each week consist of aerobic training twice, a swimming session, Inspiratory Muscle Training session, breathing exercises and Yoga session in every second week, the patient was introduced to Buteyko Technique as home exercises. The patient was asked to avoid all the allergies (Triggers). The patient was assessed on baseline and on the end of the program using the lung function test and Asthma Control Questionnaires (ACQ).
Discussion: The patient completed the entire program chosen for him and the baseline assessment showed that the patient suffered from symptoms such as coughing and chest tightness especially at night. The lung function test showed improvement on the FEV1 predicted from the baseline (85%) and after the program assessment (92%) with an increase of 7%. The asthma control questionnaires showed also an improvement as the score at the baseline was 2.28 and after the program it is 1.14, which considered as borderline of adequate asthma control.
Conclusion: Twelve-week supervised program of interventions can lead to improvement of lung function test parameter, control and quality of life in asthmatic motivated patients. From the findings a well-structured program influenced from the patient hobbies will keep the patient motivated and will increase the patient physical activities without any restrictions.

Introduction

Asthma is very common disease and the idea of helping patient to manage it and push away as far as possible all the restriction on physical activity and sport is by itself the biggest motivation for me, imagining the patient life with limited sports activity motivate me as well. And by educating the patient to the view of physiotherapy to this disease and the ability to manage it by training programs is my goal. By managing the disease the patient productivity will increase in the levels of work, his or her favorite sports or even simple task of the day like using the stairs. And to give an example there are athletes who have asthma like the American football star player named Jerome Bettis. If they can do it so any patient can. First of all the asthma as defined on WHO (World Health Organization) is “a disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. In an individual, they may occur from hour to hour and day to day”. Asthma is a widely common disease among almost every society and the numbers are getting higher every year, internationally an estimated 300 million patient who suffer of asthma with an annual 25000 deaths, and by 2025 the number will increase 100 million, And studies shows the increase in the incidence of asthma over the last 20-30 years.  And as far as I was growing up in my hometown the majority of the people think the treatment is only by inhalers. The risk factors of asthma are Genetics or environmental and the Causes of the symptoms are facing the patient in everyday life and the patient need to manage it to provide the patient much easier, happy and symptoms free life. To achieve that we as physiotherapist have to convince the patient that by exercising (which is a trigger) will improve controlling the symptoms.

The topic is physiotherapy management of asthmatic patients in an adult age, physiotherapy approach to the lung diseases is sufficient by all level and it can manage and decrease the symptoms such as coughing, wheezing, shortness of breath, chest tightening and trouble in sleeping. The leading causes of symptoms are the infections, allergies, smoking (primary of even secondary), air pollutions and Exercises. By controlling asthma the patient should have few or no symptoms and minimal usage of medications.

The objectives are to achieve well-controlled asthma the patient has to go through training program and control by spirometer it every week for 10 supervised weeks and 2 unsupervised weeks. By the end of the program my patient should have the characteristics of the well-controlled asthma. And gradually returns to his favorite hobbies and sports. Respiratory diseases are common because of the higher rates of pollutions in the air. Asthma and heart disease have a relationship according to a study found that a patients who have to take daily medications are 60% more likely to have a heart attack in 10 years. So by treating and managing asthmatic patients it is already preventing the patients from having heart problems in the future. In this research these question will answered precisely and detailed:

1. What is asthma?
2. What is the different between asthmatic lung and healthy lung?
3. What is the pathophysiology of the asthma?
4. What are the signs and symptoms of asthma?
5. What are the diagnostic methods?
6. What are the classifications between the asthmatic patients?
7. What are the risk factors and the triggers?
8. Is there relationship between asthma and other disease?
9. What are the pharmacological treatment options for the patients?
10. How can the physiotherapist help the patient reduce the symptoms?

The levels of asthma control are less than what it should, a research was done on 12 weeks showed that there is a significant effect on the patients symptoms, as measured and controlled by the Asthma Control Questionnaire (ACQ) in the beginning and at the end of the program, and it led to improve the quality of life and motivate even more patients to control their symptoms. I will follow up this research on a patient who has a mild asthma done by the same methods and questionnaires and hopefully it will have the same results [1].

Theoretical Background

The thoracic wall is formed from the spinal column and twelve thoracic vertebrae from the posterior side and from the anterior side the sternum and twelve pairs of ribs and costal cartilages. From the anterior side the first seven pairs of ribs are connected to sternum, and from the 8^th to the 10^th are connected to each other by the costal cartilage, and the 11^th and 12^th ribs are floating ribs to allow the full chest expansion.

Figure 1: The thoracic wall [2].

The main blood supply to the sternum it supplied from the superior side by pair internal thoracic arteries that connecter with the lateral thoracic, the acromio-thoracic and the transverse cervical arteries. The internal thoracic artery is branched from the sub clavian artery and it goes posterior to the costal cartilage with the sternum. Ventral skin and muscles are supplied from the superior side by sub claivian vessels.

Figure 2: The main blood supply [2].

There is to mail groups of muscles in the chest wall, inspiratory and expiratory, and that classification comes from the functions. The inspiratory muscles (e.g. sternocleidomastoid and scalene muscles) expand the chest volume by pulling up the superior side of the rib cage. The Expiratory Muscles (e.g. rectus abdominis, internal oblique and external oblique muscles) decrease lung volumes pulling or narrowing the rib cage by downward motion. 

Figure 3: Muscles in the chest wall, Inspiratory and Expiratory [2].

 The diaphragm divides the thoracic and the abdominal cavities and it has a dome shape and supplied by the phrenic nerve. Pass through it the aorta, inferior vena cava, esophagus, vagus nerve and the gastric vessels. The diaphragm movements are concentric (by deep and slow inspiration) and controlled eccentric (exhaling “speaking”).

There are other muscles, which help the breathing and they are attached to the clavicle, scapula and the humarus such as pectoralis major, latissimus dorsi, serratus anterior and trapezius muscle. The movements of the thorax go on 3 planes: antero-posterior, supero-inferior and transversal. During the Inspiration there is trunk extension and during Expiration there is trunk flexion. During rest the diaphragm works (75%) and the intercostal (25%). The movements of the chest cavity seen in breathing during the inspiration and expiration. In inspiration, the inspiratory muscles contract and the diaphragm descends and that makes the rib cage elevate. Elevation of the rib cage increases the volume of thoracic cavity. With that the lung gets stretched and the intrapulmonary volume increases that makes the pressure drops to -1 mmHg. With that the air flows into the lungs until the intrapulmonary pressure equals to the atmospheric pressure, and that is the end of the inspiration and the start of the expiration which the muscles will act the opposite and relax so the diaphragm will raise and the rib cage will descend due the recoil of the costal cartilages. That will lead decreasing of the thoracic cavity volume and due that the intrapulmonary pressure raises to +1 mmHg. Then the air flow out of the lung until the intrapulmonary pressure is zero.

Upper and lower airways (23 generations). The upper starts from the nose until the larynx, and it consist of the nose (which warms and filters and humidifies the air) and sinuses, glottis, pharynx and larynx. The lower airways starts from the Trachea which is 16-20 cartilaginous c-shaped rings opened from the posterior side then 2 main bronchi then it branches more to 5 labor bronchi the top 10 segmental bronchi then to primary and terminal bronchioles which does not have cartilage, so far all the above is called the conducting system (1-16 generation) which has no gas exchange at all. After that comes the exchange surfaces (17-23 generations) which is the respiratory bronchioles and alveolar ducts and the alveolar sacs, and what connects the alveoli to another alveoli is called pores of kohn, and from alveoli to bronchioles is channels of Lambert. And a section of the airway walls consist of the epithelium, goblet cells, ciliated cells, glands, hyaline cartilage, smooth muscles and elastic fibers.

Figure 4: The lower airways [2].

The chest cavity consists of two lungs one on each side. The right lung has three lobes (upper, lower and middle) and the left lung has two lobes (upper and lower). The bronchopulmonary segments of the upper lobe (apical, posterior and anterior), the Right middles lobe (lateral and medial) and the left Lingular lobe (superior and inferior) and the Lower lobe (apical, anterior basal, posterior basal, lateral basal and subapical). The lungs are covered by the pleural cavity, which are two layers (visceral and parietal) to allow the negative pressure of breathing stay with no friction [2]. The respiratory system is where the exchange of the O₂ and CO₂ between the air lungs and blood in the pulmonary circulation (external respiration) and between the blood, cells and tissues (internal respiration) Figure 1 to Figure 4 [1-25].

Disorders of the Respiratory System

Restrictive Disorders: which means the restriction of the lung expansion resulting in decreasing of the lungs volumes (FVC, FEV₁, TLC, VC, RV). And it localization is extrapulmonary (rib fracture, kyphoscoliosis and neuromuscular diseases) or Pleural (pleuritis and pleural disorder and effusion) or Parenchymal (pulmonary fibrosis, alveolar oedema and rheumatic diseases). Obstructive Disorders: it is characterized by abnormal low airflow. The airflow decreased always and volumes decreased frequently (FEV₁ and FEF25-75). Some examples of the disorders (Asthma, COPD, Bronchiolitis).

Asthma

Is a chronic disease, which the pulmonary airways and the bronchioles are inflamed that lead to obstruction and usually the obstruction is reversible. The decreased bronchial flow after the bronchoprovocation is called bronchial hyperresponsiveness. And there is other triggers which provoke the airway obstruction such as cold air, exercise, infection, cigarette smoke and allergies. The pathology of asthmatic airways displays lung hyperinflation, smooth muscles hypertrophy and lamina reticularis thickening, mucosal edema, epithelial cell sloughing, cilia cell disruption and mucus glands hypersecretion [3]. Most attacks are short, without any symptoms between episodes. But airway inflammation is present in asymptomatic individuals. Asthma occurs in all ages, which nearly half of the patients develop asthma from childhood and the other third before the age 40, it has been estimated that 5% of adults have asthma and 7-10% of children in United states have asthma. Asthma Morbidity and mortality have risen in last two decades despite the increase number of antiasthma drugs. The etiology of asthma is believed to be genetic because asthma considered as familial disorder and that is strong evidence. Environmental factors also play a major role with the inherited factors to increase the risk of asthma and to cause bronchospasm attacks.

Childhood exposure to environment which has high levels of allergens, cigarette smoke, air pollution or respiratory viruses has increased chance to develop asthma, especially those children who has family history with asthma. The severity of the asthma acute attack is different from a patient to another, over time and the amount of exposure to inciting factors [4]. Asthma has two major components. When the immune system becomes sensitized to an allergen, usually through big exposure in childhood. The lungs became hyper reactive and this cause the muscles to contract making it very difficult to the patient to breath. The second component is inflammation, which makes the airway narrow, and swell and the cells produce more mucus. Asthma may be categorized as conventional asthma, occupational asthma, or exercise induced asthma. But the pathophysiology is the same; since the triggers and allergens are vary from a patient to another, each person react differently.

Asthma Classification

The classification of asthma is based on the severity, which can be seen in symptoms and the functional tests. Which are?

1. Intermittent mild asthma: without treatment the symptoms are (difficulty in breathing, wheezing, chest tightness and coughing), and occur less than two days a week and the symptoms do not interference the day activity life, and nighttime symptoms comes less than two days a month.
2. Mild persistence asthma: without treatment the symptoms occur more than 2 days a week but not every day, the attacks happen in the daily life activity, nighttime symptoms happen 3-4 times a month.
3. Moderate persistence asthma: without treatment the symptoms happen every day, nighttime symptom happen more than once a week but not every night.
4. Sever persistence asthma: without treatment the symptoms happen every day and there is severing limitation of the daily physical activity, the nighttime symptoms happen often and some cases every night [5].

Diagnosis

Asthma is a complex disease it comes with airway inflammation, hyper-responsiveness and variable obstructions of the airflow that may not all co-exist in many patients. The lung function test is done by Spirometry, which is a simple device can be used in the physician office and it provides the very important information about the relationship between the flow and volume. The test accuracy depends highly on the patient effort. The patient must listen and do exactly as the assessor coach and in the other hand the assessor must coach the patient with the correct understandable language and can identify the unacceptable effort as poorly performed maneuvers can lead to several of diseases patterns. There are more possible ways for diagnosis of asthma but the recommended approach in spirometry device is measuring the improvement in forced expiratory volume in 1s (FEV₁) of 12% and 200 ml after taking the bronchodilator challenge. The spirometry shows the increase of FEV₁ then it is a positive diagnosis, and if there is no increase it is a negative diagnosis.

Measurement of the peak expiratory flow rate (PEFR) is simple and convenient the patient can do it in the clinic or even in the house. PEFR has been linked with airway hyper-reactivity and it is useful diagnostic method. There are other methods such as Methacholine challenge, which is recommended for patient who has all the clinical features of asthma but normal spirometric testing measurements. Methacholine challenge testing (MCT) is in the beginning a safe test even on sever obstructed patients, MCT starts with inhaling methacholine, a substance that induce bronchoconstriction in susceptible airways, to their knowledge there were no deaths reported from MCT. And then measure the lung functions if the FEV₁ is decreased > 10% that’s a positive diagnosis. And in the other hand if there is no limitation (airflow limitation: FEV₁<80%, FEV₁/FVC<65%) after inhaling the bronchospasm provocation then it is a negative diagnosis.

Peak flow can be measured by the Peak flow meter and it is used to monitor the disease. It shows the peak expiratory flow (L/sec) and it should be used 2-3 times a day. It is not expensive and portable that makes it easier to check up everywhere and ever time. The diagnostic testing for patient who is over six years old is the same as adults, which is the lung function test and allergy tests. And for patients less than six years old it is difficult because they are not able to perform conventional lung function test [5].

Signs and Symptoms

Asthma signs and symptoms may vary from a patient to another but the most common ones are:

1. Shortness of breath
2. Coughing
3. Chest tightness
4. Wheezing
5. Trouble of sleeping

And there are causes to the symptoms (triggers) such as:

1. Viral infections
2. Allergens: dust mites, pet dander and pollen
3. Tobacco smoke

Exercises

Weather changes or cold air to monitor the patient severity the patient usually uses a timetable to check whenever he had the symptoms on each day in day or night. That helps with the management and check if the treatment option is suitable for the patient or the physician should change it to other option. And especially it is very helpful for the physiotherapist during the physical training treatment plan. Trying to avoid these causes is part from the treatment [6].

Treatment

The goal is controlling the asthma. A well-controlled asthma must have minimal or no symptoms, few or no asthma flare-ups, no limitations in physical activity, minimal usage of medications and few or no side effects of medications. Drugs that are used as preventive medications or long-term medications (Long acting beta-agonists, immune modulator) are used for reducing the inflammation. Then the quick-relief (short acting beta-agonists, systemic corticosteroids) or rescue medication to quickly open the airways during the attacks (2-5 min). Allergy-desensitization or immunotherapy diminishes the symptoms in 3-5 years.

The physicians confuse often asthma control with asthma severity. The concept of asthma control has been always used in the treatment guidelines. There was a thought that the well-controlled asthma was the same concept as mild asthma, and the poorly controlled asthma like the severe asthma this concept is not correct. Severity is the intensity of the disease process before the treatment takes a place. For example patient with severe asthma if they were treated and managed appropriately can be controlled, and the opposite is true, patients with mild asthma if they did not follow the treatment plan they will have a poorly controlled asthma. The goals of treating and managing all levels of asthma are the same, but patients with severe asthma the treatment will be more difficult to achieve a controlled asthma. The meaning of controlled asthma requires the patient to have no symptoms in the daytime or the night-time, also a very infrequent rescue beta2-agonist use, and have no limitation in physical activity and lung function values close to normal. The Global Initiative for Asthma (GINA) suggests 5 steps for treatment. For each step there is a preffered option and other alternetive. Step 1 is rapid-acting inhaled beta2-agonist. The other 4 steps has other controlled options with the low-dose inhaled corticosteriods (ICSs) as the preffered option in Step 2 to long-acting inhaled beta2-agonist and high-dose of ICSs together and oral corticosteriods at Step 5. If the asthma is controlled the treattment should be reduced and consider other treatments to manage the disease. If the controling of asthma has not been established then the treatment advance to the next step. And the study suggest that the most effective control therapy for asthma is ICSs in low-doses in both children and adults.

Figure 5: The Global Initiative for Asthma [7].

     Other Therapy control options are well known such as:

• Breathing Exercises: the aim of these exercises is to normalize the breathing pattern by teaching the patient slower respiratory rate and longer expiration and reducing of hyperventilation and hyperinflation. And with the assumption that the asthmatic patients have an abnormal breathing pattern the physio should encourage the nasal breathing and diaphragmic breathing pattern.
• Inspiratory Muscle Training: the inspiratory muscles can be trained by external device to achieve strength and endurance. The reason for suggesting that exercising these muscles may reduce the intensity of the dyspnea and increase the exercise tolerance. It is possible that the effect of the corticosteroid treatment is to loss some muscles mass including the respiratory muscles.
• Physical Training: the fear of physical aerobic training as a treatment and the same time symptoms provocator inhibits many patients from taking part of this treatment option. The aim of the physical training programmes to improve physical fitness and neuromuscular coordination and self-confidence and it is the important component for a better management of asthma [8].

As a study shows which specific exercise is preferred for the asthmatic patients, between the fallowing (swimming, cycling, running). All the functional values were monitored, especially FEV₁- FVC- FEV_T%. This study confirms that the best results are seen in swimming. Because exercise-induced asthma present in swimming is less than running or cycling [9]. Therefore another study states that there are huge influences in the temperature of the air and also on the high interval exercises. The study results suggest that patients should avoid high intensity exercises (95% of Maximal heart rate) in the extremely low temperature (winter) and in extremely high temperature (summer) as a preventive option of exercise-induced asthma [10]. The study results suggest that patients should avoid high intensity exercises (95% of Maximal heart rate) in the extremely low temperature (winter) and in extremely high temperature (summer) as a preventive option of exercise-induced asthma [10]. The program was once in a week training on moderate intensity for 60 minutes. And doing the assessment before and after the 12 months by using questionnaires. The results showed that moderate intensity for long-term program could show clinical relevant improvements in exercise capability and the quality of life in the motivated adult patients [10]. As my opinion, every patient is different from another, by the age, gender, life-style, and even psychological factors are important. The physiotherapist should choose the best program depending on all the factors seen in the patient. 

For example asthmatic patient who loves swimming will be always motivated for the program that involve swimming, and in the other hand we must introduce new treatment exercise methods and without any restriction we prepare the patient for any sport the patient desires. After giving the program for patient and after adding his interests in it to keep him always motivated, the physiotherapists should explain always to carry his or her inhaler and when and how to use it. The period of the treatment is an important factor; if it’s a long periods the program should be moderate intensity and increasing gradually the intensity first and session time. The physiotherapist should encourage the patient to increase the quality and intensity of the exercises gradually, in order to adapt the body for the new training load. By doing all of that and making the preferred program for each patient and encouraging for higher intensity the patient can reach the well managed asthma with fewer asthma attacks and better life quality.

Physiotherapy Interventions 

Breathing Techniques

By using a big number of asthmatic patients to experiment the breathing techniques, a study had been done on the interventions of the physiotherapy in asthma. It was a systematic review to try the effectiveness of these interventions.  The study used interventions such as slow deep breathing with the Pink City Lung Exerciser 15 min a session and twice a week for the mild conditioned asthma patients. And another physiotherapy intervention for patient with acute sever cases which are hospitalized to establish chest physiotherapy after 6-24 the admission patients given the inhaled salbutamol comes after it physiotherapy breathing exercises. And some other stable conditioned patient with different intervention such as, a 16 weeks program strengthening the respiratory muscles to maximize the efficiency of the lung capacity, yoga breathing exercises; physiotherapy breathing exercises both of them 15 sessions of 3 hours over 3 weeks. The patients were monitored by lung function tests and spirometry values were taken before and after the programs for all the groups. And the results advice that on sever cases of acute asthma may not profit from physiotherapeutic breathing techniques. But in the other hand cases with mild-to-moderate may offer some assistance to the patient life. the breathing exercises and the strengthening of the respiratory muscles showed a significant result on mild-to-moderate asthmatic patients [10].

Swimming

Swimming can improve the aerobic capacity to patients with asthma. That’s the results of several study on of them was done on Two groups. One group consists of eight patients, was training with 125% of the lactate threshold (LT), and monitored using a swimming ergometer. Another group with the same number of patients served as a control group subjects. As a result of the six weeks swimming training program, the patients showed a beneficial effect on the aerobic capacity (Matsumoto I. 2001). In this study they analyzed the effect of swimming on lung functions and (BHR) Bronchial hyperresponsiveness in mild asthmatic patients. The study was done on 70 mild persistent asthmatic patients selected according to GINA. The method was to have two sessions a week for one hour, for the following 6 months. There were two groups one had the asthma education and the swimming sessions and the other had drugs. The sessions were held on an indoor pool with natural warm water without chlorination. For assessment they measured the lung functions with spirometry, broncho provocative test and skin tests. The Conclusion was that patients with mild persistent asthma going to swim in non-chlorinated pools combined with asthma regular medicine and asthma education can cause better improvements of their parameters of the lung functional test. And more significant decrease of their airway hyperresponsiveness compared to traditionally treated patients with medicine [11].

Cart and Slow

Study experimenting on the raising of Pco2 level compared with slow breathing is linked with improvements in asthma control. The method of the study was testing one hundred twenty patients with asthma. With assigning the patients to Capnometry-Assisted Respiratory Training (CART) for raising Pco2 or Slow Breathing and Awareness Training (SLOW). Patients received five sessions a week and completed the home exercises over 4 weeks. Post-treatment and baseline assessments were made with monthly follow ups and measuring the pulmonary function tests such as spirometry, forced oscillations and quality of life and symptoms and drugs use. As a result improvements are seen in the lung function tests and quality of life and drugs use. The improvements were persistent on the 6^th month follow up [12]. This study was done on 33 patients between the ages of 17-65 years, with diagnosis of asthma and had at least one prescription for an inhaler or oral bronchodilator. They were managed by Nijmengen questionnaires and hit the score less than or equal to 23 to be diagnosed with dysfunctional breathing. The interventions of the physiotherapists were on groups of 4-5 patients for 45 minutes a session once or twice a week. In these sessions the physiotherapists explained the several symptoms such as breathlessness could be produced. The physiotherapists taught the patients diaphragmatic breathing exercise by using physiotherapy methodology. Emphasizing the slow and regular breathing is the main use of the diaphragmatic respiratory effort. The results and the data analyzing and the questionnaires showed that over the half of the asthmatic patients treated for dysfunctional breathing are clinically significant improvements in quality of life following the brief physiotherapy intervention. And this increased improvement is sustained in over 25% after 6 months of the interventions [13].

Pulmonary Rehabilitation

Patients with lung diseases are closer to present decreasing in the exercise tolerance and muscle strength, and the cause is the pulmonary limitations and the systematic repercussions of the pulmonary disease. The goals of this study are to evaluate and increase the physical capacity, peripheral muscle function, physical activity in daily life and the inflammatory markers after pulmonary rehabilitation. The study involved visits: the 1^st was Evaluation, in this visits they asked quality of life and asthma control questionnaires, lung function tests, blood inflammation, cardiopulmonary exercise test. The 2^nd visit was skeletal muscle function assessment. On the 3^rd visit they did incremental shuttle walk test and physical activity (accelerometer) and then divided and randomization to two groups on was intervention group, which was supervised rehabilitation program. The program was twice a week and the duration of each session was 60 minutes for 8 weeks. Each session includes of three parts: aerobic exercise (10 minutes warm up 20 minutes on target load and 5 minutes cool down), strength muscles exercises (40-70% of maximal repetition), and chest physiotherapy (Flutter will be used for 5 minutes). The second group is Control group. This program includes chest physiotherapy (Flutter for 10 minutes) and stretching exercises (for upper and lower limbs for 40 minutes) twice a week. Each session will be held for 60 minutes for 8 weeks. And after 8 weeks the study reevaluated the patients as the same method on the 1^st visit. And the results were both groups had controlled the asthma and with the evaluation and reassessment it can be seen in quality of life and the usage of drugs. Pulmonary rehabilitation is recommended for patients with chronic diseases with increased aerobic capacity [14].

Buteyko Technique

It is the most effective approach to management of asthma without using any drug, it can be applied to any age and any severity and it will give up quick and consistent results. Which emphasize the importance of nasal breathing? Nasal breathing humidify, warm, and clean the air which enters the lung. By encouraging the nasal breathing the night symptoms can improve. In that fact a study was made on the Buteyko technique to assess the effectiveness in asthmatic patient. A randomized controlled group of adult asthmatic patient did the buteyko technique, and other group was trained by physiotherapists to perform breathing and relaxing techniques. The measurements were composed by a score based on the Canadian asthma consensus reporting after six months of the intervention. And the results show both groups showed significant and similar improvements. And the Buteyko group the proportion with controlling the asthma increases from 40% to 70%. And in addition to the Buteyko group they showed a substantially reduced in their inhaled corticosteroid therapy comparing to the controlled group. As a conclusion of this study, after six months completing the intervention, a large majority of both groups showed control on their asthma with an additional benefit of reduction of the inhaled corticosteroids use in the Buteyko group. Therefore we may say that the Buteyko technique appear to provide benefits on adult asthmatic patient along with the chest physiotherapy in patients who are being treated with corticosteroid inhaled therapy [15].

Yoga

Yoga treatment to improve the quality of life in asthmatic patients has its own popularity. Therefore a study was made to determine the effectiveness of yoga in patients with asthma. The study included 120 patients diagnosed with asthma. The patients were randomized to follow two groups. Group A was Yoga training group and group B was the control group. Group A included deep breathing exercises, Kapalabhati (cleaning breath), Bhastrika (rapid and deep respiratory movements), Ujjayi (loud sound producing pranayama) and sukha purvaka pranryama (easy comfortable breathing). The Yoga sessions were 24 minutes duration per week under supervision. And the patients were instructed to practice at home. Both groups had to answer the asthma quality of life Questionnaires (AQLQ) at baseline and 8 weeks after the baseline. The results were based on the (AQLQ), scores of Group B showed no significant changes from the baseline after eight weeks. Group A score showed an increase in the QOL after eight weeks. Means that the score of Group A was significantly higher than Group B score. From the results we know that Yoga may be beneficial for patients with asthma after practicing Yoga exercises [16].

Aerobic Exercises vs Breathing Exercises

Both of the exercises has major rule on management of asthmatic patients conditions. Therefore a study was done to compare the effectiveness of these treatments. The method was to choose randomly, comparative, blinded clinical trials with two groups will receive different interventions. Forty-eight patients with diagnosed asthma will be divided into two groups, Group A was the aerobic and Group B was the breathing exercises. First they evaluated the two groups on two visits; the first had clinical control, anxiety evaluation, hyperventilation syndrome, pulmonary and systematic inflammations and daily life physical activity. The second visit had the pulmonary function tests, maximal exercise capacity, thoracoabdominal kinematics and autonomic control. After their two visits the groups had two educational programs, which included pathophysiology, medical skills, medications skills, self-monitoring techniques, environmental control, avidness strategies and the use of the peak flow meter. After the educational programs the study randomized the two groups into aerobic training and breathing exercises. The aerobic training has been done on the treadmill with 60% of the maximum intensity and reaching to 80%. The breathing exercise group has been done yoga breathing techniques, nasal and diaphragmic breathing, increasing the expiratory time and slowing the respiratory flow. Breathing exercises had been divided into 3 phases lasting each phase one month. The study has showed a significant improvement on both groups in the functional respiratory. The aerobic exercises showed improvements in the daily life activity. And breathing exercises showed improvements in the peak expiratory flow and decrease anxiety and depressing and medical consumption. The study is undergoing and the data in being analyzed with encouraging improvements from the baseline tests. The results will show us the benefits of each intervention to optimize its effect to the asthmatic patients [17].

Inspiratory Muscles Trainings

A study was done to evaluate the effectiveness of Inspiratory Muscle Training (IMT) and respiratory exercises on the strength of muscles. The study was done on a randomized analytical including 50 patients of asthma. They were put in two groups: an IMT group, involving of 25 patients with a program includes an IMT and both education about asthma, treatment programs. The second group called a control group that includes also 25 patients, which had the usual monthly medical visits and education about asthma. The IMT was done by using a pressure threshold of 40% of the maximal inspiratory pressure. IMT was performed using of the threshold IMT (Respironics, Cedar Grove). The respiratory therapy includes IMT and breathing exercises, twice a week for a 50 minutes session, for 7 consecutive weeks. 25 minutes of it was IMT, during the first 20 minutes the IMT threshold used for sixty seconds of practice separated by sixty seconds of rest, in order to develop muscle strength. And on the last 5 minute, the equipment was used uninterruptedly to gain and develop the endurance.Both groups compared in terms of PEF and respiratory muscles strength and as well as the severity variables, by using equipment like Peak Flow device. The Conclusion of the study was: the program that involved IMT and respiratory exercises (IMT group) showed increase of the efficiency of the respiratory muscles, and in addition to improving of PEF and severity variables [18].

Discussion

Objectives

The estimates of the global burden of asthma of 2014 are rising to 334 million people suffer from asthma. An estimated 14% of the world’s children have symptoms of asthma and 8.6% of adults (18-45 years old) experience asthma symptoms. Asthma is the 14^th most important disorder in the world in terms of extent and duration of disability. As a result of that, it is highly recommended to do research, interventions and managing to decrease the asthma burden in the world [19]. Objectives of the research:

1. Better understanding of management of asthma.
2. Describe the Physiotherapy interventions towards asthmatic patients in details and the benefits.
3. Improving the lung function measurements.
4. Achieve the well-controlled asthma.
5. Prevent asthma attacks or at least minimize it.
6. Minimal usage of Medicine.
7. Increase the quality of life and the physical activity of the patient so he/she can do whatever sport they like with no limitation.

In order to reach these objectives, the patients needs in the beginning the education about asthma and in most cases the physiotherapy approach about management of asthma and the variety of interventions it has to help the patient health and quality of life. After that the patient has to learn how to use the medicine giving as an inhaled substance in case the patient needs to use it during the physiotherapy interventions. Then the patient must do a lung function test (spirometry) and fill Questionnaires to assess how the interventions improving. To choose the best intervention for the patient is a matter of evidence-based treatment, although of that we should also choose the best intervention method to keep the patient motivated and encouraged to do more. Then we prepare the perfect specified program for the patient and in end of it we assess the same way as the baseline and we compare the results and hopefully we will reach all the objectives that we set with the patient.

Subject

There is no cure for asthma, in another hand pharmacological interventions showed a good improvement in symptoms. The physiotherapy interventions showed also substantial improvements in managing asthma. Poorly managed asthmatic patient have a very restrictive life, and with the physiotherapy interventions the patient will be free of the restrictions and can practice all the physical activities symptoms-free. Physical activity is widely known as the enemy of the asthmatic patients and by this research I will be able to prove that with physical activity the asthmatic patients well have a better life quality. So the physical activity is the subject I chose.

Hypotheses

The literature review I have made about asthma and the different intervention and from all the articles I listed above that:

• I assume that the aerobic training will improve the lung functions parameters [20].
• I assume that with the swimming session the lung function parameter will increase [11,9].
• I assume that Yoga sessions will improve the quality of life to asthmatic patient.
• I assume that the Inspiratory Muscle Training (IMT) will improve the efficiency of the respiratory muscles and the PEF value.
• I assume by the breathing exercises the patient quality of life will improve.
• I assume that the breathing exercises will improve the patient’s anxiety.
• I assume that the Buteyko technique will help the patient to control the asthma and it will help also the patient’s night symptoms.
• I assume that every patient needs unique program depending on his hobbies to keep him motivated.

And to prove my hypotheses I will make a scientific-based program to an adult asthmatic patient.

Patient’s Clinical Findings

The patient is 29 years old and diagnosed with mild asthma through his physician. The lung function test showed a mild obstruction, and the patient did an allergy test as well to determine the triggers. He suffers from variety of symptoms. Symptoms seen in the patient:

• Cough, more than 2 days per week.
• Wheezing.
• Chest tightness especially at night, awakening symptoms 3 to 5 times per month.
• Minor limitation of daily activities.
• Anxiety.

The patient also did an allergy test that showed the inhaled triggers. The physician gave the patient the suitable medication and the patient has been advised to stay away from the triggers as much as possible to avoid the attacks. The patient has been educated about the relation between the triggers and the attacks [Appendix 3]. Patient’s triggers (Allergies):

• Cold air.
• Dust mites, mugwort and ragweed.
• Pet dander specially dogs and cats.

The patient complained about tobacco smoke also leads to the attack.

Medications

The patient used for two years a medication (inhaler) named Seretide, twice a day.

Assessments

Before the patient starts the Treatment plan. I did a baseline assessment using the lung function test and Asthma Control Questionnaire 7 (ACQ-7).

Lung Functional (Spitometry) Test

The most important parameter of the spirometry for asthmatic patients is the FEV₁ expressed as percent of the predicted value [21]. Baseline assessment (appendix 1).

Appendix 1: Before treatment lung functional (Spitometry) baseline test.

Asthma Control Questionnaire 7 (ACQ-7)

All the guidelines in the world to treat asthma share the same goal of asthma management that is the patient will obtain control on asthma. That is why Asthma Control Questionnaire 7 (ACQ-7) was established to evaluate if the patient has a well-controlled asthma or poor-controlled asthma. It measures both capability of asthma control and the change of asthma control, which happens unexpectedly or a result of treatment program. The patient asked these questions and sum up the points and divide it on 7 and the score will determine if the patient has a controlled asthma or not. The patients who have score less than 1.0 will have a well-controlled asthma and the patients who have above 1.0 will have poor-controlled asthma. However there is a grey area between 0.75-1.25 where the patients are in the borderline of adequate control [22]. The patient had answered these questionnaires weekly. And the score for his baseline assessment (before the program started) was 2.28 which means poor-controlled asthma (Appendix 2).

Treatment Plan

Swimming

Yoga

Inspiratory Muscle Training

The patient had the breathing exercises once on every second week. The duration was 45 minutes per session. During this session I taught the patient the diaphragmatic breathing and why is it important to us. Emphasizing the main use of the diaphragmatic breathing is the slow and regular use [14].

Buteyko Technique

Results

Conclusion

Patients with asthma suffer daily and my goal to prevent that with the help of the patient. The patient was diagnosed with mild asthma and his symptoms were coughing, wheezing, sleeping difficulties with chest tightness in the nighttime and these symptoms wakes him up, and anxiety. An allergy test was done to determine the triggers of the patient, which are ragweed, cold air, pet dander specially dogs and cats, tobacco smoke. The patent was asked to avoid all the triggers. And then I did program influenced on the patient hobbies to keep him motivated, which is 12 weeks program scientifically based interventions to improve his control of asthma. The patient was educated on asthma generally and his condition specially and knowing the importance of the intervention. The patient was educated on the different of well-controlled asthma and poor-controlled asthma, so with tests and questionnaires we established that the patient suffer from poor-control asthma. 

References