PHYSICAL REHABILITATION

FOR ASTHMATIC PATIENTS

What's bronchial asthma?

Bronchial asthma is a disease caused by increased

responsiveness of the tracheobronchial tree to various
stimuli. The result is paroxysmal constriction of the
bronchial airways.
What's bronchial asthma?
Asthma is a variable chronic disease of the respiratory system
characterised by the constriction of the smaller bronchi and
bronchioles (three to five millimetre diameter), increased bronchial
secretions or mucus and mucosa swelling or inflammation, often in
response to one or more triggers.
Asthma is characterised by paroxysmal attacks of dyspnea, chest
tightness, coughing and wheezing due to airway obstruction. Due to
the high and ever-increasing incidence and cost of asthma, this
disease has become a new so-called epidemic with approximately 150
million individuals diagnosed with asthma world-wide. In this
regard, sustained and extensive efforts have been made by
epidemiologists in recent years to propose some treatment measures
that will hopefully limit the morbidity and mortality of this disease.
PATHOGENESIS
In the initial stage, the patient can be totally symptom-free
for long periods of time in the intervals between the attacks.
As the disease progresses, increased mucus is secreted
between attacks as well, which in part builds up in the
airways and can then lead to secondary bacterial infections.
Bronchial asthma is usually intrinsic (no cause can be
demonstrated), but is occasionally caused by a specific
allergy (such as allergy to mold, dander, dust). Although
most individuals with asthma will have some positive allergy
tests, the allergy is not necessarily the cause of the asthma
symptoms.
SYMPTOMS
Symptoms can occur spontaneously or can be
triggered by respiratory infections, exercise, cold air,
tobacco smoke or other pollutants, stress or anxiety, or
by food allergies or drug allergies. The muscles of the
bronchial tree become tight and the lining of the air
passages become swollen, reducing airflow and
producing the wheezing sound. Mucus production is
increased.
RISK FACTORS
Typically, the individual usually breathes relatively normally, and
will have periodic attacks of wheezing. Asthma attacks can last
minutes to days, and can become dangerous if the airflow becomes
severely restricted. Asthma affects 1 in 20 of the overall population,
but the incidence is 1 in 10 in children. Asthma can develop at any
age, but some children seem to outgrow the illness. Risk factors
include self or family history of eczema, allergies or family history of
asthma. Bronchial asthma causes cough, shortness of breath, and
wheezing. Bronchial asthma is an allergic condition, in which the
airways (bronchi) are hyper-reactive and constrict abnormally when
exposed to allergens, cold or exercise.
TREATMENT
Treatment is aimed at avoiding known allergens and controlling
symptoms through medication. A variety of medications for
treatment of asthma are available. People with mild asthma
(infrequent attacks) may use inhalers on an as-needed basis.
Persons with significant asthma (symptoms occur at least every
week) should be treated with anti-inflammatory medications,
preferably inhaled corticosteroids, and then with
bronchodilators such as inhaled Alupent or Vanceril. Acute
severe asthma may require hospitalization, oxygen, and
intravenous medications.
PREVENTION
Decrease or control exposure to known allergens by
staying away from cigarette smoke, removing animals
from bedrooms or entire houses, and avoiding foods
that cause symptoms. Allergy desensitization is rarely
successful in reducing symptoms
WHY PHYSICAL REHABILITATION?
Improved exercise capacity
Improved health-related quality of life
Reduced hospitalisations and length of stay
Reduced anxiety and depression associated with
bronchial asthma
 Increased survival
Benefits probably extend well beyond the period of
rehab, especially if exercise training is maintained at
home.
AIMS OF PHYSICAL REHABILITATION
To restore balance of stimulative and inhibitory
processes in the thorax of bigger cerebral hemispheres.
To decrease corticovisceral reflexes
To reduce bronchospasm and improve lung
ventilation
To activate trophic processes in tissues
Prevent lung emphysema
To improve the ability of the patient to expire for a
long time.
PHYSICAL REHABILITATION
Physical rehabilitation in hospitals comprises of 3
periods.
1. sparing- this is aimed at bringing the patient to his
functional capacity, the duration depends on how
serious the patient’s state and it involves breathing
exercises, massage of peripheral muscle group.
PHYSICAL REHABILITATION
Stage 2. In the second stage, the training is done in the
sitting position, walking, vibratory massage and the
classic chest massage.
Stage 3. The same medical physical training is done
but in local sanatoriums or polyclinics.
Medical physical training tones up the central nervous
system, it improves of functional state of the patient
and mobilizations of compensatory mechanisms. It
gives positive effect on neuro-regulatory mechanisms
of blood circulatory system.
PHYSICAL REHABILITATION
These exercises focus on special breathing exercises
with prolonged exhalation
Sound exercises which help reflex decrease of
bronchospasm
Exercises that promote muscle relaxation of the upper
shoulder girdle, diaphragmatic respiration
Exercises to strengthen the abdominal wall
Callisthenic Training
callisthenics before exercise training results in
maximal expiratory flow rate diminishment. This
diminishment is significant in that it can act as a
preventative method in the development of exercise
induced asthma and as such allows the asthmatic to
optimally benefit from training.
Postural Retraining
Postural exercises have been recommended since the
posture of an asthmatic is typically pronounced by
thoracic kyphosis and the flattening of the
sacrolumbar portion. These postural misalignments
can lead to a decrease respiratory capacity and can
severely affect visceral functioning. However, these
postural abnormalities have been found to be
improved following postural retraining that includes
postural, breathing and abdominal strengthening
exercises
Postural Retraining
Postural retraining can correct thoracic kyphosis and
improve breathing in asthmatics especially in severe
asthmatics that are more likely to suffer from such
postural abnormalities when the pectoral and
intercostal muscles are stretched. Postural retraining
in asthmatics should focus on the facilitation of
correcting righting, equilibrium and protective
reactions with normal tactile, proprioceptive and
kinesthetic input.
Breathing Training
Diaphragmatic breathing exercises could benefit an
asthmatic’s condition since they compress the
abdominal contents which increase intra-abdominal
pressure that causes lateral transmission of pressure to
the lower ribs laterally, upward and outward motion of
the lower ribs and anterior/posterior motion of the
upper ribs. This then results in an increase in thoracic
volume that decreases intra thoracic pressure which
facilitates inspiration.
Breathing Training
Breathing training is essential to an asthmatic since,
breathing in an asthmatic is of the thoracic type and
since dyspnea can cause the asthmatic to increase
inspiration further leading to further overextension of
the already over-inflated lungs.
Breathing Training
The purpose of breathing exercises is to
empty the lungs by prolonging the expiratory phase,
retrain normal breathing patterns,
 increase expansile forces in hypo-ventilated areas,
increase lung volume,
dilate airways,
force mucus into larger airways,
re-educate the autonomic diaphragmatic movements
reduce the thoracic type breathing,
relax spasmodic muscle contractions,
mobilise the ribs and chest wall and correct kyphosis
Breathing Training
These benefits are achieved by shortening inspiration and
lengthening expiration, by performing expiration via the pulling in of
the abdominal muscles dorsally towards the spine while relaxing the
abdominal, intercostals and neck musculature.
This is achieved by using special weights or belts to increase intra-
abdominal pressure,
by applying compression to the lower ribs to facilitate expiratory
ascent of the diaphragm during expiration which can increase the
movement of secretions from the small bronchi into the respiratory
passages,
by exhaling through a resistive breathing device
by breathing while creating a hissing noise in order to reduce
bronchial constriction.
Breathing Training
Diaphragmatic breathing exercises have also been proven
to reduce patients’ anxiety levels and to alter their attitude
towards work while breathing retraining has been shown
to decrease bronchodilator use and acute exacerbations
and to improve quality of life.
Breathing exercises have been found to decrease anxiety
during an asthma attack and also prevent the onset of an
attack.
Breathing exercises have resulted in clinical improvements
which translated into improved school attendance,
exercise tolerance, asthma control and self-confidence.
Inspiratory Resistive Breathing
Training
The purpose of inspiratory resistive breathing training is to enhance
respiratory muscle function and in doing so possibly reduce the severity of
breathlessness and improve exercise tolerance.
This may benefit the asthmatic patients, especially those with severe
asthma, since asthmatics could suffer from respiratory muscle dysfunction
due to the loss in respiratory muscle bulk and resultant respiratory muscle
strength.
The use of inspiratory resistive breathing training in asthmatic patients
could possibly result in improvements in inspiratory muscle coordination,
improvements in inspiratory muscle strength and endurance and the
correction of inappropriate respiratory muscle effort.
These improvements and corrections then possibly result in improvements
in spirometry variables, a desensitisation to dyspnea, lessening of asthma
symptoms, reduced hospitalisations, less emergency room contacts,
absences from school and work and/or the decreased use of medication
Aerobic Exercise Training
Aerobic training has become the prominent mode of
exercise treatment for asthmatics. This is probably
justified since aerobic exercise training has been found
to cause a decrease in ventilatory demand for a given
workload, thus blunting the exercise-induced
asthmatic response
Aerobic Exercise Training
Aerobic training can decrease airway sensitivity despite no change in
airway reactivity and has been found to enhance exercise-induced
bronchodilation. Bronchodilation can be promoted, bronchospasm
threshold increased and bronchoconstriction response blunted at higher
workloads by increasing the number of Beta 2 (ß2) receptors, by directly
increasing ß2 adrenoceptor sensitivity and by increasing catecholamine
release and thereby ß2 adrenoceptor stimulation.
In addition to the general benefits of exercise training, aerobic training has
also been found to reduce medication use and air trapping in the asthmatic
individual, which effectively places the diaphragm in a more advantageous
position mechanically. If the diaphragm is placed in a more advantageous
position mechanically, an improved excursion of the diaphragm will occur
and the diaphragm’s contractions will be less spasmodic which will
ultimately improve airway reserve, vital capacity VC and alveolar gas
exchange, all of which serve to improve inspiration.
Lactate Threshold Training
The anaerobic component of physical conditioning
may be important in the overall physiologic profile of
the individual with asthma. It has been proposed that
asthmatics should participate in brief, intense bouts of
muscle work alternating with rest periods since this
mode of training is less likely to induce EIA and
reduces the risk of asthma exacerbations while
allowing the asthmatic patient to train optimally for
longer periods.
Lactate Threshold Training
The importance of improving lactic acid metabolism
and tolerance in Exercise Induced Asthma patients and
exercising at or above lactate threshold is of critical
importance since, this intensity is not only less likely to
induce EIA, it is sufficient to increase aerobic capacity
while minimising the amount of water loss from
hyperventilation during exercise thus suppressing the
onset of EIA. A benefit of lactate threshold training is
that this training can increase the anaerobic threshold,
reduce the onset of EIA and reduce hyperpnoea which
often occurs when lactate threshold is passed
CONTRAINDICATIONS
Patients with respiratory and cardiac insufficiency in
the stage of decompensation.
CONCLUSION
Exercise therapy has become increasingly important in the treatment of asthma as
it is commonly recommended and widely applied in asthmatic patients. Research
has traditionally focused on traditional outcome measures such as mortality and
physiologic indexes of lung and exercise function as well as psychosocial measures,
health-related quality of life and economic analyses of costs and benefits.
Although aerobic exercise training has been and continues to be the gold standard
for the treatment of asthma since the mid-19th century [50], there is an increasing
need to unequivocally determine the effects of alternative modes of exercise (such
as a combination of aerobic exercise combined with diaphragmatic breathing
combined with inspiratory resistive breathing) on asthma.
These studies need to be well-designed prospective, placebo- controlled, clinical
trials to be of any value in asthmatic rehabilitation. In conclusion, the present
authors recommend the continued use of aerobic exercise training in addition to
making concurrent use of additional modes of exercise such as inspiratory resistive
breathing training. This is because the sole use or inclusion of alternative modes of
exercise along with aerobic exercise may be warranted not only for its favourable
effects on asthma, but also for the additional benefits to be gained from alternative
modes of exercise.
CONCLUSION
Regular exercise training can increase an asthmatic
patient’s sense of well-being, decrease exertional
breathlessness by desensitising the patient to the
uncomfortable breathless sensation and decrease the
patient’s ventilatory requirements through the increases
in aerobic capacity and exercise efficiency.
It is also important to note that less fit subjects can gain
the most benefits from exercise training due to their
initially low level of exercise acceptance, social and
disease adjustment and self-care due to their negative
attitudes towards disease and exertion.
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 Sarinho E, Schor D, Veloso MA, Rizzo JA. There are
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Bungaard A. Exercise and the asthmatic. Sports Med
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Jenkinson SG. Obstructive Lung Disease. New York:
Churchill Livingstone. 1992