PULMONARY REHABILITATION

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       DEFINITION OF PULMONARY REHABILITATION

As defined by the 2013 ATS/ERS Statement on Pulmonary Rehabilitation, PR 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.”

ROLE OF PULMONARY REHABILITATION



1-Patients with chronic obstructive pulmonary disease (COPD) should be administered pulmonary rehabilitation in an effort to increase exercise capacity by a clinically significant amount.

2-Patients with COPD should be provided with pulmonary rehabilitation in an effort to significantly improve their health and dyspnea.

3-Various elements of a pulmonary rehabilitation programme, such as resistance training, might affect quadriceps strength.

4-To enhance psychological wellbeing, COPD patients should be provided with pulmonary rehabilitation. 

5-The effectiveness of pulmonary rehabilitation programmes should at the very least be frequently evaluated by presenting clinically significant improvements in exercise capacity, dyspnea, and health status.

6-Regular evaluations should include asking about patient satisfaction and feedback.

GENERAL PRINCIPLES OF PATIENT SELECTION FOR PR

INDICATION

1-People with COPD and other chronic respiratory disorders who, despite receiving the best possible medical care, including non-invasive ventilation and oxygen,:

2-Continue to experience dyspnea, tiredness, exercise intolerance, or trouble accomplishing ADL

3-Are struggling to control or cope with their sickness

ABSOULTE CONTRAINDICATION

1-Angina or an irregular heartbeat

2-Unstable fracture of the bone

3-A contagious illness that could spread and endanger others

4-Unstable mental health problems that put a person at risk of harming themselves or others

RELATIVE CONTRAINDICATION

1-Extreme brain impairment

2-Progressive illness of the muscles

3-Pignificant uncontrolled anaemia

4-A lack of drive

5-A severe exhaustion that makes it impossible for the patient to participate in PR sessions, such as that caused by advanced congestive heart failure, chemotherapy, etc.

6-Severely impaired vision

7-A relatively short lifespan, such as six months or less

ADDITIONAL CONSIDERATIONS FOR PATIENT SELECTION FOR PR

1-Patient age 

2- Severity of lung function impairments 

3-Smoking status 

4-Medical co-morbidities

5-Ventilatory impairment 

6-Skeletal muscle dysfunction


PATIENT ASSESSMENT AND OUTCOME MEASUREMENT IN PR

Core Programme assessment and outcome measurement domains

1-Exercise capacity

2-Exercise ability in relation to strength and endurance (lower and upper extremities)

3-Balance

4-Measures relevant to activities of daily living (such as sit-to-stand, timed up-and-go-testing and dowel lifting)

5-Symptoms: dyspnea and leg fatigue

6-Quality of life

Additional domains to enhance patient assessment

1-Anxiety and Depression

2-Cognition

3-Generalized fatigue

4-Physical activity

5-Nutritional status

6-Smoking status

7-Exacerbations

8-Patient knowledge, self-efficacy and coping style

Other important outcomes


1-Hospitalizations and urgent healthcare visits

2-Patient satisfaction with PR programme

3-Programme metrics

TEST FOR PULMONARY REHABILITATION PLAN

Healthcare team will first develop your pulmonary rehabilitation plan by performing the tests listed below:
1-Breathing Test : It helps determine how well your lungs are working overall.

2-Exercise Stress Test: This measures your ability to exercise while monitoring your blood pressure, heart rate, and oxygen level. 

3-Six-Minute Walk Test: This measures your ability to walk for six minutes.


STRUCTURE OF PULMONARY REHABILITATION

A great way to design a program to help you safely achieve your goals is the FITT Principle

FREQUENCY


1-Programs for pulmonary rehabilitation should include at least twice-weekly supervised sessions. 

2- A third session of the prescribed exercise is advised in accordance with the results of published pulmonary rehabilitation research. This can be done without supervision. 

3-In accordance with general recommendations for healthy living, moderate physical activity is suggested five days a week for 30 minutes each time.

INTENSITY

The intensity of PR was determined by cardiopulmonary exercise testing as follows: 
1-≥70% of maximal oxygen uptake, which was defined as high-intensity PR exercise

2-50~70% was defined as moderate-intensity PR exercise

3-<50% was defined as low-intensity PR exercise.

TYPE

1-Walking

2-Strength program

3-Stretching.

TIME

1-Programs for pulmonary rehabilitation lasting 6 to 12 weeks are advised. 

2-Although individual patients can benefit from less sessions, it is advised that participants in pulmonary rehabilitation programmes attend at least 12 supervised sessions.

EXERCISE PLAN 

There are several breathing techniques that you can use when you exercise to help you control your breathing.

• Blow as you go: breathe out when you are making a big effort, such as standing up, stretching or bending.
 
• Pursed-lips breathing: breathe out with your lips pursed as if you were whistling 

There are certain positions that you might find helpful to reduce breathlessness if you get so short of breath when you are physically active or exercising that you need a breather (see the diagrams below). For instance:

1-Standing with a forward lean: With your elbows resting on a railing, a wall, a windowsill, or the back of a chair, lean forward.

2-Leaning forward while seated: Sit with your knees supporting your elbows and leaning forward. Make your hands and wrists go numb.If you are really short of breath, you can rest your head and arms on a pillow on a table.

3-Standing with a sideways or backward lean: With your feet slightly apart and about a foot (30 cm) from the wall, lean back or sideways against the wall. Place your hands in your pockets or let them hang free by your sides. You might like to rest your hands or thumbs on the waistband, belt loops, or across your handbag's shoulder strap.


1-Warm Up

2-Aerobic Exercises 

3-Strengthening Exercises

4-Cool Down And Stretching Exercises 


WARM UP 

In order to avoid injury, warming up helps your body become ready for exercise. You should warm up for about five minutes. You should feel a little out of breath at the conclusion.You can perform the exercises while sitting or standing. 2-4 times for each movement.

1-Shoulder Elevation 


2-Shoulder Circling 


3-Head Rotations


4-Trunk Rotations 


5-Side Bends  


6-Heel Digs


7-Knee Lifts


8-Toe tap at the side 


9-Mraching on the spot 


10-Step Up 


AEROBIC EXERCISES

You should try to engage in aerobic activity for 20 to 30 minutes five days per week.
You should Aim to feel slightly out of breath. By timing your aerobic activity, you can gradually increase the duration you can handle. Smaller increments, such as an extra 30 seconds or minute of activity, may constitute this.

1-Walking 


2-Cycling 


3- Swimming 


STRENGTHENING EXERCISES 

Exercises that build muscle will strengthen muscles that have weakened as a result of your disease. Three sessions of strengthening exercises each week should be your goal.Aim to perform each exercise for three sets of ten repetitions.You will be guided to the ideal starting weight by your physiotherapist. Every set should be followed by a brief break. Use heavier weights to make your muscles work harder until you can perform three sets of ten reps with ease

Breathe out on the hardest part of the exercise = ‘Blow as you go technique’

For the Front of the Thighs 

1-Leg Extension 


2-Knee lifts


For the Back of the Thighs

1-Knee bend 


2-Leg lift


 For the Ankles 

1-Heel Lift


2-Toe lift 


For the Back 

1-Arm Extension


For the Chest 

1-Standing Push-ups


For the Shoulders

1- Side Arm Lift


2-Front Arm Lift


For the Arms 

1-Front Elbow Bend


2-Back Elbow Bend




For the Abdomen

1- Abdominal Contractions

2-Upper Body Rotation



For the Neck 

1-Chin Pull



2-Chin Drop



3-Head Rotation



COOL DOWN AND STRETCHING EXERCISES

Exercises for cooling down help your body go back to normal before you stop. Your five-minute cool down period should result in your breathing returning to normal.
• 2 minutes of slower walking are required.
Stretching your muscles will aid in easing any discomfort you might have the days following an exercise session. You should gently extend each stretch and hold it for 15 to 20 seconds.

1-Back Thigh Stretch



2-Front Thigh Stretch



3-Buttock Stretch



4-Shoulder Stretch 



5-Chest Stretch



6-Palm Down Forearm Stretch



7-Palm Up Forearm Stretch



8-Neck Stretch



                                    

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