DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

By
MARVANIA GUNJAN JAMNADAS
UNDER THE GUIDANCE OF
S. NATARAJAN

VIKAS COLLEGE OF PHYSIOTHERAPY

MARYHILL, KONCHADY, MANGALORE-575006
2011-2013

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

1.

Name of the Candidate

and Address

MARVANIA GUNJAN JAMNADAS

VIKAS COLLEGE OF PHYSIOTHERAPY
AIRPORT ROAD
MARYHILL, KONCHADY
MANGALORE 575008

2.

Name of the Institution

VIKAS COLLEGE OF PHYSIOTHERAPY

Mangalore.

3.

Course of study and subject

Master of Physiotherapy in Cardiorespiratory

Disorders and Intensive care

4.

Date of admission to Course

24-06-2011

5.

Title of the Topic

EFFECT OF THORACIC MOBILITY AND STRENGTH ON DYSPNEA,
CHEST EXPANSION AND EXERCISE CAPACITY IN PATIENTS WITH
CHRONIC OBSTRUCTIVE PULMONARY DISORDERS.

BRIEF RESUME OF THE INTENDED WORK

6.1) Need for the study
COPD, which stands for chronic obstructive pulmonary disease, by definition is
stated as a disease state characterized by airflow limitation that is not fully
reversible. The airflow limitation is usually both progressive and associated with an
abnormal inflammatory response of the lungs to noxious particles or gases.1
It is second most common lung disorder following pulmonary tuberculosis and
constitutes 25-30% of cases in non-tubercular chest clinics in India2. It has been even
predicted to become the third leading cause of death and fifth commonest cause of
disability by 2020 in the world.3 Even prevalence rates vary a lot being 5% in males
and 2.7% in females of over 30 years of age. 4 The disease affects function of other
organs of body besides lung even leading to dysfunction of respiratory muscles.3
Patients with COPD often develop changes in chest wall configuration. These
changes have been related to airway obstruction, hyperinflation, and mechanical
disadvantage of respiratory muscles. In addition, disuse resulting from reduced
upper limb activity may lead to muscle tightening and stiffness around the muscle
quadrant, thereby further increasing chest wall resistance and the work of breathing.5
In COPD marked postural changes are observed which includes elevated, protracted
or abducted scapulae with medially rotated humerus, and kyphotic spinal
deformities.6,7 The hyperinflated lungs places the pectoralis major in a shortened
position, which leads to increase in resistance of chest wall to expand this causes a
decrease in exercise capacity and pulmonary function.8
Gooselink R. et al studied Peripheral muscle weakness contributes to exercise
limitation in COPD pts.18 Also Victor D. et al studied relation of thoracic muscle
strength to exercise capacity in copd pts and concluded that skeletal muscle
strengthening should be emphasized.20
Pulmonary rehabilitation plays a fundamental role in management of patients with

COPD. It is multi dimensional and various components include chest physiotherapy

(bronchial drainage, breathing exercise, coughing technique), aerobic exercise,
strengthening exercise, functional training & psychosocial training.26
Efficacy of pulmonary rehabilitation have been demonstrated in many studies.27
However very few studies has been done to find the effects of thoracic muscle
strengthening and stretching on dyspnea, chest expansion and exercise capacity in
COPD pts. Thus, the major aim of this study is to find the effects of thoracic muscle
strengthening and stretching on dyspnea, chest expansion and exercise capacity in
copd pts.
Hypothesis :
Null hypothesis:
There is no significant difference between the effects of thoracic muscle
strengthening and stretching on dyspnea, chest expansion and exercise capacity in
copd pts.
Alternate hypothesis:
There is significant difference between the effects of thoracic muscle strengthening
and stretching on dyspnea, chest expansion and exercise capacity in copd pts.
6.2 Review of literature:
Carla M et al (2009) in their research regarding reliability of chest wall mobility
and its correlation with pulmonary function in patients with COPD concluded that
there was an association between inspiratory capacity and

measurement at

abdominal level, chest wall mobility did not correlate with pulmonary function.5
Donrawee L et al (2009) studied acute benefits of chest wall stretching exercise on
expired tidal volume, dyspnea and chest expansion in a patient with COPD. The
results showed a significant clinical improvement ofexpired tidal volume, reduction
in dyspnea level and increase in chest expansion.23

Michael T. Putt et al (2008) in their research regarding the effect of pectoralis

muscle stretching technique in COPD to improve vital capacity concluded that hold
and relax stretching technique increases vital capacity significantly. Also it provided
evidence that hold and relax technique can improve the restrictive component of
COPD and possibly overcome some of the postural changes of COPD.8
Victor Z. et al (2006) investigated the influence of thoracic and upper limb muscle
function on 6 min walk distance in copd patients. This study showed the importance
of skeletal musculature of the thorax and upper limbs in submaximal exercise
tolerance and could open new perspectives for training programs designed to
improve functional activity in copd pts.20
Kriel, Achmat (2005) did considerable research on chest wall expansion and lung
function found that if chest wall movements are restricted in anyway, decrements in
pulmonary function and exercise capacity are seen. Furthermore, there is significant
increase in oxygen cost associated with external chest wall restriction.9
Roger E. et al (2011) studied the role of spinal manipulation, soft tissue therapy, and
exercise in copd and concluded that applying these interventions to the chest wall in
copd could reduce chest wall rigidty, thereby improving breathing mechanics, thus
reducing the work of respiratory musclesand delays the onset of dyspnea and
improving exercise capacity in copd.22
Elaine Pauline, Antonio Brunetto, Celso Carvalho (2003) studied 30 moderate to
severe COPD patients and found that exercises aimed at increasing thoracic
expansion in COPD patients improve thoracic expansion, quality of life and
submaximal exercise capacity, as well as reducing dyspnea and depression.11
Hightower et al. (1999) tested the effects of rib cage mobilization and respiratory
muscle stretching on vital capacity and chest wall expansion in fourteen elderly
adults aged 58 to 83. Although the results indicated that the experimental group
showed an improvement in xiphoid and axillary chest wall expansion measurements
following manual stretching and rib mobilization compared to a control group.12

Caro et al. (1959) the effects of restricting chest cage expansion on pulmonary
function in man was tested. The results of this study showed that restricting chest
wall expansion in normal man reduced the total lung capacity and its subdivisions.
Following the release of chest restriction, the mechanical changes in the lungs were
reversed. Thus, any abnormality that affects the muscles of respiration or rib
biomechanics will have an effect on the optimal functioning of the lungs and
respiratory system as a whole.13
Gonzalez et al. (1999) makes mention of the fact that chest wall
restriction, whether it be caused by disease or mechanical constraints,
can cause decrements in pulmonary function and exercise capacity. Thus,
any abnormality e.g. hypertonicity affecting the muscles of respiration,
especially the intercostal muscles, or rib biomechanics will have an effect
on the optimal functioning of the lungs and the respiratory system as a
whole. Gonzalez et al. (1999) also stated that there is a significant
increase in oxygen cost associated with external chest wall restriction,
which is directly related to the level of chest wall restriction. 15

6.3 Objectives of the study:

1. To determine the effects of thoracic muscle strengthening and stretching on
dyspnea, chest expansion and exercise capacity in copd pts.
2. To design a new rehabilitation program to emphasis the importance of
thoracic muscle strengthening and stretching along with chest physiotherapy
& breathing exercises.

7.

Materials and methods:

7.1 Source of data: opd of vikas college of physiotherapy & govt. wenlock hospital.
7.2 Method of collection of data

Population

:-stable COPD patients.

Sample design

:- random sampling

Sample size

:- 30

Type of Study

:- experimental comparative study

Duration of study

:-3 months

Materials required:

Measuring tape

Chair

Plinth

Stopwatch, sphygmomanometer, markers(to mark 6 minute walk distance)

St. George respiratory questionnaire

American thoracic scale to measure dyspnea grade.

Inclusion criteria :

Patients diagnosed as having COPD by physician

Patients who have not had any episodes of acute exacerbation of COPD in
the past two months(stable COPD patients)

Both male and female

Not involved in any upper limb exercises from past one month

Predicted FEV1 should be mild to moderate

Exclusion criteria:

Acute exacerbation during or before study

Pain in shoulder

Periarthritis of shoulder

Disability preventing mobility of thorax

Back pain

Unstable cardiac disease

Cor pulmonale

Acute illness

Respiratory muscle fatigue

Any other spinal deformity, soft tissue lesion around chest wall.

Outcome measures:

Chest girth measurement.

6 minute walk performance.

St. George respiratory questionnaire

American thoracic scale to measure dyspnea grade.

7.3 Methodology:
A total of 30 subjects fulfilling inclusion criteria will be selected for the study. All
the subjects will be informed of the objectives of the study. Informed consent will be
taken from the subjects prior to participation. The Subjects will then be randomly
assigned to one of the two groups: group A (n=15) and group B (n=15). Patients will
be blinded to the group allocation. Each subject will undergo formal evaluation
including chest girth measurement, 6 minute walk test, subject will grade their
dyspnea levels on American thoracic scale and fill st.georges respiratory
questionnaire. 8 Weeks of training program will be done where subjects will be
called 3 times in a week for exercise session. Total of 24 sessions wil be conducted

for both the groups.

GROUP A:
Subjects of this group will receive thoracic mobility and stretching exercise like
thoracic rotations and lateral stretching in sitting position, stretching of pectoralis
major, scalenes and trapezius muscle groups.30,31 and thoracic strengthening exercise
like back extensors, latissimus dorsi, rhomboids, serratus anterior along with
breathing exercise and other chest physiotherapy techniques.30,31
GROUP B:
Subjects of this group will receive chest physiotherapy techniques and breathing
exercises.
After 8 weeks of exercise session, chest girth measurements (at 3 levels), American
thoracic scale to assess dyspnea, 6 min walk test, St George respiratory questionnaire
will be assessed.
Statistics:

Unpaired t-test will be used to test for difference among the demographic
variable and base line variable.

Chi Square test will be used to analyse the gender difference between groups.

Paired t test will be used to compare chest girth, spirometric value, 6 min
walk performance, questionnaire score pre and post treatment in intra group
comparison.

Unpaired t-test will be used to compare in between groups.

7.4 Ethical Clearance:As this study involve human subjects, the ethical clearance has been obtained from
the ethical committee of our institute, to carry out necessary investigation and
interventions on pts necessary for the study.

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2. Guleria JS. Chronic Obstructive Pulmonary Disease In: API Textbook of
Medicine, 5th ed. National book Depot, Bombay. 1992
3. Lopez AD, Murray CC. The global burden of disease, 1990-2002. Nat Med
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5. Carla M et al, Reliability of chest wall mobility& its correlation with pulmonary
function in pts with copd. Respiratory care. 2009; 54(12).
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8. Michael TP, Michelle W, Helen S, Paratz JD. Muscle stretching techniques
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Pulmonary Disease. Arch Phys Med Rehab 2008; 89:1103-1107.
9. Kriel. Achmat. An investigation into the immediate effect of rib mobilization and

sham laser application on chest wall expansion and lung function in healthy
asymptomatic males: a pilot study. Dept. of chiropractic, Durban institute of
technology, 2005. Available from: URL: http://hdl.handle.net/10321/189
10. Sibuya M. Yamada M, Kanamaru A, Tanaka K, Suzuki H, Noguchi E, Altose
MD, Humma I. Effect of chest wall vibration on dyspnea in patients with chronic
respiratory disease. Am J Respir Crit Care Med 1994; 149(5):123.5-1240
11. MacIntyre NR. Muscle dysfunction associated with chronic obstructive
pulmonary disease. Respir Care 2006; 51:840-8.
12. Elaine P, Antonio FB, Celso RFD. Effects of a physical exercise program
designed to increase thoracic expansion in chronic obstructive pulmonary disease
patients. J.Pneumologia vol.29 no.5 So Paulo Sept./Oct. 2003
13. Hightower, M., Nguyen, T., Long, K., Pollock, M., Ngan, G. and Wetzel,G.
1999. The Effects of Respiratory Muscle Stretching and Rib Cage Mobilization
on Vital Capacity and Chest wall Expansion in the Older Adult. Abstracts
presented at the 1999 Pennsylvania Physical Therapy Association
14. Caro, C.G., Butler, J. and Dubois, A.B. 1959. Some Effects of Restriction of
Chest Cage Expansion on Pulmonary Function in Man: An Experimental Study.
The Journal for Clinical Investigation 39 (4):573-583.
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Preliminary report on the effects of respiratory muscle stretch gymnastics on
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Respir Care 1999; 44:409-14.
16. Gonzalez J. et al 1999, a chest wall restrictor to study effects on pulmonary
function and exercise. Respiration. Internal journal of thoracic medicine, 66 (2).
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Am j respire crit care med 1999;159.
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20. Wegner r, factor analysis of exercise capacity, dyspnea ratings, and lung function
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walk distance in copd patients. Chest 2006;129
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volume, dyspnea, and chest expansion in a copd pt. journal of bodywork and
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25. Donald r, immediate effects of osteopathic manipulative treatment in elderly
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copd. Eur respire j 2003;22(46)
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9.

Signature of the candidate

10. Remarks of the Guide

11. Name and Designation of

11.1 Guide

11.2 Signature

11.3 Co-Guide

11.4 Signature

11.5 Head of the Department

11.6 Signature