| Author: | Tsui, Ying Yu |
| Title: | Effectiveness of chest wall mobilization program in improving respiratory function in patients with severe chronic obstructive pulmonary disease : a randomized controlled trial |
| Advisors: | Cheing, Gladys (RS) Tsang, Sharon (RS) |
| Degree: | DHSc |
| Year: | 2023 |
| Subject: | Lungs -- Diseases, Obstructive Respiratory organs -- Diseases -- Treatment Chest -- Physical therapy Respiratory muscles -- Physiology Hong Kong Polytechnic University -- Dissertations |
| Department: | Faculty of Health and Social Sciences |
| Pages: | xx, 183 pages : color illustrations |
| Language: | English |
| Abstract: | Introduction Accelerated decline in pulmonary function is a hallmark of chronic obstructive pulmonary disease (COPD). Clinical trials have reported a positive correlation between pulmonary function and chest expansion in patients with COPD (Kaneko et al., 2016; Reddy et al., 2019). A decrease in chest expansion compromises rib cage mobility and functional length of the respiratory muscles, which ultimately impairs the efficiency and function of the respiratory system (Aliverti, 2008; McKenzie et al., 2009). Chest wall mobilization techniques have been demonstrated to be effective in producing immediate and short-term effects on chest expansion and in improving respiratory function (de Sá et al., 2017; Engel et al., 2013; Rehman et al., 2020; Yelvar et al., 2016). Temporary improvements following a single treatment session have confirmed that these techniques target the regions of musculoskeletal dysfunction. Given the interdependent relationship between the respiratory and musculoskeletal system, the addition of an intervention for improving musculoskeletal performance in order to promote respiratory function may be crucial for enhancing the rehabilitation of patients with COPD. Objectives The objectives of this randomized controlled trial (RCT) were (i) to investigate the cumulative and 3-month post-intervention maintenance effects of chest wall mobilization program on respiratory function and musculoskeletal performance in patients with severe COPD; (ii) to investigate the cumulative and 3-month post-intervention maintenance effects of chest wall mobilization program on respiratory efficiency during exercise, functional exercise capacity, and quality of life in patients with severe COPD; and (iii) to determine the association of musculoskeletal performance with respiratory function and functional exercise capacity in patients with severe COPD. Methods The study was a two-arm parallel RCT that included two groups of patients with COPD. Thirty male patients with severe COPD participated in this study. They were randomly allocated to two groups: the chest wall mobilization group (CWMG) and control group (CG). Both groups received standardized educational sessions and walking exercise training. In addition, therapist-assisted chest wall mobilization techniques and thoracic stretching home exercise program were included in CWMG. The chest wall mobilization intervention was administered in a total of 12 sessions conducted twice a week for 6 weeks. Respiratory function, musculoskeletal performance, respiratory efficiency, functional exercise capacity, and quality of life were evaluated pre-intervention, post-intervention, and at the 3-month follow-up. Results Regarding respiratory function, there was a significant increase in maximum inspiratory pressure (MIP) (p < 0.001) and maximum expiratory pressure (MEP) (p < 0.001) in the CWMG compared with in the CG. However, there was no significant difference in forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) between the two groups in the pulmonary function test conducted during the post-intervention evaluation. Regarding musculoskeletal performance, there was a significant increase in thoracic extension (p < 0.001), bilateral thoracic rotation (p < 0.001), and side flexion (p < 0.001) in the CWMG compared with in the CG. In addition, there was a significant post-intervention increase in thoracic excursion in the CWMG compared with in the CG; the increase (upper thoracic: p = 0.003, lower thoracic: p < 0.001) was especially marked in the lower thoracic region. As for functional exercise capacity, the patients in the CWMG exhibited a significant increase in the distance achieved (6MWD) during the 6-min walk test (6MWT) and an increase in the work rate and metabolic equivalent (MET) level during the incremental cycling exercise test (ICET). The average increase of 96.2 m in the 6MWD after chest wall mobilization was well above the MCID for evaluating interventional outcomes in patients with COPD (Holland et al., 2010). Moreover, in terms of respiratory efficiency, patients in the CWMG exhibited a decrease of 12.75% and 14.75% in scalene and sternocleidomastoid muscle activities respectively during the ICET. Intercostal muscle activities also decreased during the first quarter of the ICET in the CWMG compared with in the CG, and the response was similar to that in healthy individuals during incremental exercise testing (Duiverman et al., 2009). Furthermore, after the intervention, there was a significant increase in oxygen delivery to the intercostal muscles, as reflected by the steeper decline of the tissue oxygen saturation slope in response to increasing workload. The patients in the CWMG were able to progress from light activities (< 3 MET) to moderately intense activities (4-6 MET) with a significantly lower rate of perceived dyspnea. Regarding quality of life, the scores in the symptom, activity, and impact domains of St. George’s Respiratory Questionnaire (SGRQ), as well as the total SGRQ score, were significantly lower in the CWMG than in the CG. The improvements in respiratory function, musculoskeletal performance, functional exercise capacity, and quality of life were well maintained, as assessed during the 3-month follow-up session. There was a strong positive relationship between the increase in MIP and MEP and increase in lower thoracic excursion (MIP: F (1,28) = 132.954, p < 0.001, adjusted R2 = 0.820; MEP: F (1,28) = 77.679, p < 0.001, adjusted R2 = 0.726). Moreover, the increase in lower thoracic excursion was positively and strongly associated with the increase in thoracic extension and rotation (F (2,27) = 103.055, p < 0.001, adjusted R2 = 0.876). As for functional exercise capacity, 6MWD exhibited a significant positive association with MIP and MEP (F (2,27) = 78.949, p < 0.001, adjusted R2 = 0.843), and similar results were obtained in the case of the MET level (F (2,27) = 100.571, p < 0.001, adjusted R2 = 0.873). Conclusion Chest wall mobilization involving chest wall stretching and thoracic joint mobilization was an effective means of remedying musculoskeletal dysfunction, thus enhancing thoracic mobility, thoracic excursion, and respiratory function in patients with severe COPD. The increase in respiratory muscle strength and functional exercise capacity along with an increase in chest expansion was the most clinically significant development after chest wall mobilization. More importantly, patients in the CWMG exhibited an increase in exercise capacity and were less dyspneic. As exercise capacity is a strong predictor of survival in COPD, an increase in exercise capacity after chest wall mobilization would improve the prognosis of the disease. Based on the results of this RCT, it would be beneficial to include chest wall mobilization techniques in the rehabilitation for COPD patients. |
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