Page 8 P H Y S I O T H E R A P Y September, 1960 Physiotherapy in the Treatm ent of the Asthmatic and Emphysematous Patient Bv M A R G A R E T R. W H I T E , M . C . S . P . , L e c t u r e r D e p a r t m e n t o f P h y s i o t h e r a p y , U n i v e r s i t y o f C a p e T o w n . In th e t r e a t m e n t o f M e d i c a l C h e s t c o n d i t i o n s by P h y s i o ­ t h e r a p y , t h e need f o r e x p i r a t o r y b r e a t h i n g is b e c o m i n g m o r e a n d m o r e wid ely r ec o g n i se d . P a r t i c u l a r l y is thi s so in the t r e a t m e n t o f t h e a s t h m a t i c , e m p h y s e m a t o u s a n d b r o n c h i t i c g r o u p , a n d it is this ty p e o f p a t i e n t t h a t I w o u l d like to di sc uss . O u r a i m s o f t r e a t m e n t fall i n t o 3 m a i n h e a d i n g s : 1. T o o b t a i n r e l a x a t i o n 2. T o p r o m o t e b r e a t h i n g c o n t r o l 3. T o d e v e l o p g o o d p o s t u r e a n d b a l a n c e A s we k n o w t h e c a u s e s o f a s t h m a a r e o f t e n m o s t c o m p l e x a n d f o r t h a t r e a s o n t h e w h o l e p e r s o n a n d p e r s o n a l i t y m u s t be c o n s i d e r e d , n o t j u s t th e p a t i e n t ' s ches t. O u r a p p r o a c h m u s t , th e r e f o r e , b e a r thi s in m i n d . T h e p at i en t s h o u l d be t r e a t e d in a c a l m , u n h u r r i e d a t ­ m o s p h e r e a n d the P h y s i o t h e r a p i s t r e q u i r e s i m m e n s e p a t i e n c e , re al isi n g t h a t it m a y t a k e w e e k s fo r t h e p a t i e n t t o l ea r n to use his l o w e r ch e s t a n d d i a p h r a g m c o r r e c t ly . T h e b ad b r e a t h i n g h a b i t s o f y e a r s c a n n o t be c o r r e c t e d in a few ea s y lessons. T h e first few t r e a t m e n t s s h o u l d be i n d i v i d u a l w h e n e v e r po ss ib le, as t h o r o u g h n e s s in t e a c h i n g t h e f u n d a m e n t a l s o f c o r r e c t b r e a t h i n g a r e o f th e u t m o s t i m p o r t a n c e . A g r ea t p a r t o f t h e su cc ess ful t r e a t m e n t o f a s t h m a a ls o d e p e n d s on g a i n i n g the c o n f i d e n c e a n d c o - o p e r a t i o n o f t h e p a t i e n t . T o this e n d t h e p a t i e n t s h o u l d be e n c o u r a g e d t o tal k t o his P h y s i o t h e r a p i s t , a n d in t hi s w a y he c a n get s o m e o f his f r u s t r a t i o n s a n d t r o u b l e s a i r e d , a n d o u t o f his s y s te m , w h i c h is o f t e n o f th e g r e a t e s t a s s i s t a n c e in g e t t i n g h i m to relax. T i m e m u s t a l s o be t a k e n in e x p l a i n i n g th e c o r r e c t m e t h o d o f u s i n g his ch e s t a n d d i a p h r a g m a n d in g e t t i n g to u n d e r ­ s t a n d t he p u r p o s e o f t h e exercises. S o in th e first lesson, i f o n e o n l y m a n a g e s t o e x p l a i n D i a p h r a g m a t i c B r e a t h i n g a n d e m p h a s i s e t h a t w h e n he m a s t e r s th i s c o n t r o l he has th e r e m e d y f o r h e l p i n g his b r e a t h l e s s n e s s in his o w n h a n d s , o n e h a s a c h i e v e d a lot. I n n o r m a l r e s p i r a t i o n t he ac t i v e p h a s e is t h e in s p ira to ry o n e , b u t in a b n o rm a l r e s p ir a to r y f u n c t i o n — as in a s t h m a — o n e m u s t m a k e e x p ir a tio n th e a c t i v e p h a s e — to c o u n t e r a c t the a s t h m a t i c ' s t e n d e n c y t o o v e r b r e a t h in. T h i s in v ol ve s m a k i n g th e p a t i e n t c o n s c i o u s o f u s i n g his l o w e r ch es t a n d as si st i n g in th e p i s t o n a c t i o n o f th e d i a p h r a g m , a n d l e a r n i n g to c o n t r o l his u p p e r che st . O n X - r a y s c r e e n i n g in a n u n t r a i n e d a s t h m a t i c t h e d i a ­ p h r a g m is u s u a l ly c o n t r a c t e d , ( f l a t t e n e d ) lo w in th e che st , a n d m o v i n g little. In a t r a i n e d a s t h m a t i c th e d i a p h r a g m will be f o u n d t o be m o v i n g freely at a h i g h e r level in the che st . T h e p a t i e n t m u s t , t h e r e f o r e , be t a u g h t t o realise t h a t t h o u g h we t e a c h h i m ex e r c i se s— a n d see t h a t he u n d e r s t a n d s t h e m — it is u p t o h im t o p r a c t i s e t h e m u n ti l he h a s m a s t e r e d th e m , a n d be a w a r e t h a t by so d o i n g he h a s t h e r e m e d y in his o w n h a n d s . H e m u s t a l s o be m a d e a w a r e t h a t he m a y h av e to d o a little p r a c t i c e d a i l y f o r th e rest o f his life. It is best fo r th e p a t i e n t t o p r a c t i s e w h e n he is free o f w h ee z in e ss , a n d a l w a y s b e f o r e he g o e s to sle ep a n d , if p o ss ib le, first t h i n g in t h e m o r n in g s . O c c a s i o n a l l y t h e n ew p a t i e n t get s d e p r e s s e d a s he se em s t o be m o r e w h e e z y a n d c o u g h s m o r e at th e s t a r t o f his exe rcise s. It s h o u l d be e x p l a i n e d t o h i m t h a t th i s is n a t u r a l a s he is u s i n g his ch e s t m o r e a n d , t h e r e f o r e , l o o s e n i n g the m u c u s in t h e b r o n c h i a l t u b e s . O n c e thi s is c l e a r e d he will feel b e t t e r a n d m a k e pr o g re s s. T h e es se n t i al p o i n t s t o be c o n s i d e r e d in th e t r e a t m e n t o f t h e a s t h m a t i c a n d e m p h y s e m a t o u s p a t i e n t a r e a s f o l lo w s : 1. T h e N a s a l P a s s a g e s s h o u l d be k ep t cl ear , th e as s i s t a n c e o f t h e E .N .T . s u r g e o n s b e i n g calle d in if ne ce s sa ry . 2. C o n tro l o f th e C h e st s h o u l d be t a u g h t w i t h t h o r o u g h ­ ness, p a t i e n c e a n d a t t e n t i o n t o det ail . T h e p a t i e n t m u s t n o t be m a d e t o feel s t u p i d if he is sl ow t o g r a s p w h a t is r e q u i r e d — a f t e r all t h a t is w h y he ha s c o m e fo r t r e a t m e n t t o be t a u g h t h o w t o use his ch es t c o rre ct ly . E v e n t o o b t a i n " d r o p p i n g ” o f t he u p p e r p a r t o f t he ch es t o n e x p i r a t i o n m a y be difficult, a s so o f t e n t h e s h o u l d e r s a r e held high a n d th e a c c e s s o ry m u s c le s o f i n s p i r a t i o n ar e ti g h t e n e d . J f thi s is t a u g h t wit h a sigh o u t to be gi n wi th, it c a n help t h e p a t i e n t t o re alise w h a t is r e q u i r e d . T h e s id e -ly in g p o s i t i o n w i t h t he b o d y well r o t a t e d f o r w a r d is a ls o o f g r e a t benefit in t e a c h i n g s r e l a x a t i o n o f t h e u p p e r ches t — a n d c o n t r o l o f t h e l o w e r c h e s t — e m p h a s i s i n g t h r o u g h o u t th e a c ti vi ty o f t h e e x p i r a t o r y p h a s e a n d a l l o w i n g gr a v i t y to as sist in th e r e l a x a t i o n o f th e a b d o m i n a l m u s c le s o n i n s p i r ­ a t i o n . IN S P IR A T IO N E X P IR A T IO N 3. G e n e r a l R e l a x a t i o n s h o u l d be t a u g h t t o ev er y p a t i e n t i n d i v i d u a l l y so t h a t th ey really u n d e r s t a n d w h a t R e l a x a t i o n is; th es e p a t i e n t s a r e o f t e n so ten s e t h a t th e y c a n n o t a p p r e c i a t e t r u e r e l a x a t i o n . T h e P h y s i o t h e r a p i s t s h o u l d , t h e r e f o r e ' d e m o n s t r a t e t h e d if fe r en ce b e t w e e n t e n s io n a n d relaxation*,, O n e w a y t o d o thi s is t o al l o w t he p a t i e n t t o s u p p o r t the o p e r a t o r ' s a r m w h i c h is held stiffly a t first, b u t t h e n g r a d u a l l y r el ax ed so th a t th e p a t i e n t b e c o m e s a w a r e o f th e in cr ea se o f w ei gh t o f t h e a r m as it is re lax ed . T h e p a t i e n t s h o u l d be in lying, w i t h a pi ll o w u n d e r t h e h e a d , o n e u n d e r ea c h a r m wit h e l b o w flexed a n d fingers o v e r e d g e o f pillow a n d a n o t h e r p illow u n d e r t h e knee s. T h u s t he b o d y is e n t i r e l y s u p p o r t e d . T h e p a t i e n t is t h e n e n c o u r a g e d to c o n c e n t r a t e o n t h e l ar ge m u s c l e g r o u p s in t u r n — t h i n k i n g d o w n t o t h e m a n d tell ing t h e m t o “ let g o ” a l w a y s a s th e p a t i e n t b r e a t h e s o u t . T h e p a t i e n t s h o u l d try t o ha v e h a l f a n h o u r ' s r e l a x a t i o n pr a c t i c e ev e r y d a y at a c o n v e n i e n t a n d r e g u l a r ti m e, u n ti l g r a d u a l l y a h a b i t o f c o n t r o l l e d r e l a x a t i o n is m a s te r e d . 4. W h e n D ia p h r a g m a tic C o n tro l is u n d e r s t o o d a n d the p a t i e n t is b e g i n n i n g t o d o it p r o p e r l y , t h e n local ise d o n e side d B a sa l B r e a t h i n g c a n be s t a r t e d , th e a i m in th i s case b e i n g t o gel m a x i m u m u se a n d m o b i l i t y o f e a c h lu n g base a n d so e v e n t u a l l y d e v e l o p t h e fullest use o f t h e b as es o f b o t h lu ngs . L a t e r a belt c a n be u se d w h e n p r a c t i s i n g , as this a l l o w s g r e a t e r r e l a x a t i o n o f t he m u s c le s o f t h e s h o u l d e r gir dle, a n d t h e p a t i e n t c a n assess his o w n p r o g r e s s as he p e r f o r m s his l o cal ise d b r e a t h i n g ex er cis es s i t t i n g in f r o n t o f a m i r r o r . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) September, 1960 P H Y S I O T H E R A P Y Page 9 I n a n y s c h e m e o f e x e rc ise s f o r th is ty p e o f p a t i e n t , sim p le sw in g in g , m o b ilis in g a n d r e la x in g e x e rc ise s s h o u ld b e in ­ c lu d e d . O n c e t h e a c tu a l f u n c t i o n o f c o r r e c t b r e a th in g c o n tr o l h a s b e e n m a s te re d , it is th e n i m p o r t a n t to p ro c e e d to e n c o u r a g e t h e p a t i e n t t o g r e a te r a c tiv ity , w h ile still m a in ta in in g c o n t r o l o f h is b r e a t h i n g a t a ll tim e s. T h e first s te p is in p o s t u r e c o r r e c t io n , in s e e in g t h a t th e p a tie n t d o e s n o t s ta n d s lu m p e d d o w n in to h is p elv is w ith his w e ig h t h e a v ily o n h is h e e ls , b u t r a t h e r t h a t t h e w e ig h t o f his b o d y is c a r r ie d slig h tly f o r w a r d f r o m h is a n k le s , th e m a in w e ig h t b e in g ta k e n to w a r d s th e f o re p a r t o f th e feet. T h e b a c k s tr a ig h t a n d a p lu m b lin e d r o p p e d f r o m th e sh o u ld e rs s h o u ld fall c e n tr a lly t h r o u g h th e h ip j o i n t s . T h e sh o u ld e rs s h o u ld b e h e ld lo o s e ly w ith th e s c a p u la e c o m f o r t ­ a b ly c o n tr o lle d . T h is p o s itio n a llo w s t h e f re e u s e o f t h e p a tie n t’s lo w e r c h e s t a n d d ia p h r a g m . T h e n e x t s te p is t o te a c h t h e p a t i e n t t o c o - o r d i n a t e h is b re a th in g w ith t h e a c tu a l s te p s h e ta k e s w h ile w a lk in g . T h is is sta rte d slo w ly , t h e p a t i e n t b r e a th e s o u t a s h e d r o p s h is chest a n d tig h te n s h is a b d o m i n a l m u s c le s t o a slo w c o u n t o f 2. H e th e n r e la x e s t h e lo w e r c h e s t a n d a b d o m e n o n 1 c o u n t a s h e a llo w s t h e a i r t o c o m e in , th u s m a k in g th e e x p ira to ry p h a s e d o u b l e t h e le n g th o f t h e i n s p i r a t o r y o n e . T h e p a tie n t th e n s t a r t s m a r k in g tim e , 2 s te p s t o b r e a t h e o u t an d I t o b r e a th e in . T h is is p ro g re s s e d t o w a lk in g t o t h e sa m e r h y th m a n d fin a lly t o s t a ir c lim b in g o r w a lk in g u p h ill. It is im p o r t a n t t o s u p e rv is e t h e c h e s t m o v e m e n ts a t th is sta g e, a s s o o f te n t h e p a t i e n t te n d s t o r e t u r n t o t h e o ld h a b it o f u p p e r c h e s t b r e a th in g w h e n a n y e x tr a e x e r tio n is r e q u ire d . It is b est f o r th e P h y s io th e r a p is t t o w a lk b e s id e t h e p a t i e n t w ith h e r h a n d s p la c e d lig h tly o n t h e p a t i e n t ’s lo w e r r ib s , w hile s h e a s c e r ta in s t h a t t h e p a t i e n t is c a r r y in g o u t h e r in stru c tio n s c o r re c tly , a n d d e v e lo p in g t h e c o r r e c t b r e a t h i n g rh y th m . T h is q u e s tio n o f r h y th m p la y s a g r e a t p a r t in t h e life o f every o n e o f u s, a n d o n e w o n d e r s i f t h e d i s t u r b a n c e o f rh y th m is n o t t h e r o o t c a u s e o f m a n y o f o u r tr o u b le s . In th e a s th m a tic a n d e m p h y s e m a to u s p a t i e n t th e b r e a t h i n g r h y th m h as b een lo s t, a n d w ith th is lo s s o f r h y th m t h e p a t i e n t b e c o m e s m o re a n d m o r e te n s e a n d less a b le t o re la x . S o w ith th e se p a tie n ts it is m o s t i m p o r t a n t t o c o n c e n t r a t e o n r e sto rin g th e ir se n se o f r h y t h m b y w h a te v e r m e a n s is a v a ila b le . R h y th m ic a l e x e rc ise s s h o u ld a lw a y s b e u se d , a n d w h e n a v a ila b le m u s ic h a s b e e n f o u n d t o b e o f t h e g r e a te s t benefit. O n c e th e p a tie n t r e a lis e s w h a t is r e q u ire d o f h im a n d as h e b e c o m e s a b le t o s y n c h ro n is e h is b r e a th in g w ith h is w a lk in g th e n , a s lo n g as h is b r e a th in g a n d r h y th m a r e m a in ta in e d , th e a c tu a l n u m b e r o f s te p s h e ta k e s c a n b e in c re a s e d t o s u it th e in d iv id u a l. T h is c a n b e 3 s te p s t o b r e a t h e o u t , a n d 2 ste p s t o b r e a th e in, o r 4 s te p s t o b r e a th e o u t a n d 3 ste p s to b re a th e in, a c c o r d n g t o t h e in d iv id u a l a n d his n o r m a l w a lk in g p a c e . I t is w ise r t o k e e p t o t h e o r ig in a l p a t t e r n o f 2 o u t a n d I in, w h e n t h e p a t i e n t h a s t o m a k e e x tr a e ffo rt as in s ta ir c lim b in g a n d w a lk in g u p hills. In th e c a s e o f th e y o u n g e r p a t i e n t o r o n e less s e rio u s ly affected h e c a n be p r o g re s s e d t o r u n n i n g s k ip p in g , e tc ., a t first w ith c o n s c io u s ly c o n tr o lle d b r e a th in g , b u t g r a d u a lly th e c o n tro l s h o u ld b e c o m e a u t o m a t i c a n d t h e p a t i e n t sh o u ld b e a b le t o r e t u r n t o a life o f n o r m a l a c tiv ity . A ll th e p a tie n ts s h o u ld b e e n c o u r a g e d t o t r y t o A B O R T a n y a tta c k s o f b re a th le s s n e s s b y p r a c t i s i n g th e ir c o n tr o lle d b r e a th in g a s s o o n as th e y h a v e th e slig h te s t fe e lin g o f t i g h t ­ ness o r s h o r tn e s s o f b r e a th . O n c e a n a t t a c k h a s b e e n su c cessfu lly p r e v e n te d it is m o s t e n c o u r a g in g t o se e h o w th e p a tie n t’s o u tlo o k is im p ro v e d , h is s e lf-c o n fid e n c e r e tu r n s , a n d h o w m u c h m o r e re la x e d h e b e c o m e s . References: " R e le a s e f ro m N e r v o u s T e n s io n ” b y F in k . " P h y s io th e r a p y f o r C h e s t D is e a s e s ” b y J . M . R e e d , m .c .s .p . Illustrations: “ P h y s io th e ra p y fo r M e d ic a l & S u rg ic a l T h o r a c i c C o n ­ d itio n s ” — fro m B r o m p to n H o s p ita l B o o k le t. This hygienic Physiotherapist Uniform has so many good points! Sa nfo rise d, M e rc e ris e d w h ite tw ill A d ju sta b le ne c klin e — t o the specification o f the U n iv e rs it y P h y sio th e ra p y S e ction B re a st p o c k e t - - - ''' L o n g s le e v e s -------------- D e ta ch a b le b e l t .......... T w o hip p o cke ts, o n e w ith con ce a le d insid e p o c k e t . . . Button front ... DELILAH GARMENT OF QUALITY AND STYLE by THE HOUSE OF E N S I G N M a n u fa c tu r e d by The AFRICAN CLOTHING FACTORY P.O. B O X 1098 CAPE T O W N a n d obtainable fr o m good clothing stores ev eryw h e re R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )