PHYSICAL THERAPY

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Contents:

  • Chest Percussion and Postural Drainage
  • High Frequency Chest Compression (vest)
  • Flutter
  • Positive Expiratory Pressure (PEP) Mask
  • Autogenic Drainage
  • Exercise
  • Chest physiotherapy (CPT) is a vital part of the treatment regimen for people with Cystic Fibrosis (CF). CPT is used to remove secretions from the lungs thereby reducing airway obstructions. The thick, viscous secretions are difficult to expectorate and are very damaging to the airways. New methods of performing CPT have been created in recent years offering people with CF quite a few alternatives. There is also much discussion taking place about the benefits of exercise. It used to be that many doctors told their patients not to exercise or to “take it easy.” Today, doctors are more apt to encourage their patients to maintain an exercise program.

    The following methods of CPT will be discussed below: Chest Percussion and Postural Drainage, High Frequency Chest Compression (the vest), the Flutter, Positive Expiratory Pressure Mask (PEP Mask), Autogenic Drainage, and Exercise. As always, consult your doctor before switching regimens.

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    Chest Percussion and Postural Drainage

    The conventional method of CPT is chest percussion, which is often accompanied by postural drainage. Chest percussion is the manual pounding or clapping to loosen secretions. Postural drainage relates to the positioning of a person to drain and remove secretions from particular areas of the lungs. The specific positions involved in postural drainage allow different lobes to drain. Manual chest percussion is very time consuming and also requires another person. The patients feeling of independence and freedom is drastically reduced because they must rely on someone else in order to have CPT completed. The patient is also not actively involved and, for the most part, does very little in the way of special breathing techniques. This method of CPT is often difficult to comply with especially when you have a child who resists every therapy session. See also: FAQ PART TWO, item 11. EQUIPMENT, Aids to Positioning a CFer During CPT and Postural Drainage.

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    High Frequency Chest Compression (vest)

    High frequency chest compression uses an inflatable vest (ThAIRaphy vest) with hoses connected to a high frequency pulse generator. The pulse generator delivers air to the vest, which vibrates the chest. The high frequency air waves clear all lobes of the lungs. The vest has been found to be more effective than conventional CPT in clearing mucus, and it can be done without the aid of another person. The new model is smaller, quieter, and cheaper than the previous model. The unit only weighs 30 lbs. and is so quiet you may not realize it is running. It comes in it’s own suitcase and is perfect for traveling. The cost is $15,000. See APPENDIX A, item 4, CYSTIC-L LENDING LIBRARY for information on borrowing a video tape on the vest.

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    Flutter

    The flutter is a hand-held device shaped like a small, fat pipe. It helps loosen mucus in the airways making it easier to cough up secretions. The flutter has a mouthpiece, a high-density stainless steel ball, and a cone that holds the ball. When the patient exhales through the flutter, the steel ball moves, which causes vibrations in the lungs thereby loosening mucus. It has proven to be the most successful form of airway clearance for some patients. Once the patient is shown the proper way to use the flutter, he or she is totally independent with this technique. See APPENDIX A, item 4, CYSTIC-L LENDING LIBRARY for information on borrowing a video tape on the Flutter.

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    Positive Expiratory Pressure (PEP) Mask

    The Positive Expiratory Pressure (PEP) mask is another alternative to airway clearance. The PEP mask consists of a rubber mask which is connected to a one-way breathing valve and tube adaptor, which creates resistance. The patient presses the mask against his/her face and slowly inhales through the inspiratory port and then exhales against the expiratory resistance. The PEP mask keeps the airways open allowing mucus to be secreted. The PEP mask theory has been related to a bottle of ketchup. A new bottle of ketchup turned upside down and pounded on doesn’t move much ketchup out of the bottle; but as soon as a knife is put in the bottle, the ketchup flows freely. The idea is that once there is air in the bottle, the air helps push the ketchup. With the PEP mask, the valves allow the airways to stay open longer causing air to help push out the secretions. It takes some training to learn how to use the PEP mask, and the mask has different size valves that can be used to fit the specific needs of each patient. The mask is done without the aid of another person. The patient is actively involved with this type of therapy, and it takes much discipline to comply with this therapy regimen.

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    Autogenic Drainage

    Autogenic Drainage clears secretions further down the airways than can be reached by a cough. This method of airway clearance keeps the airways open, similar to the PEP mask theory. Autogenic Drainage uses a combination of breathing techniques at different levels to move the secretions up to where they can be “huff” coughed out. The first level is unsticking the mucus with a low-lung volume breathing, then collecting the secretions with mid-volume breathing, and finally removing the secretions with “huff” coughing at a higher level. This method of airway clearance needs to be taught to the patient and requires much discipline and concentration when performing. It has the advantage of allowing total independence; no equipment or other people are necessary to complete this form of airway clearance. It is a very gentle procedure; if you are doing AD correctly you will not cough violently. This gentler form of therapy is wonderful for people who are prone to hemoptysis.

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    Exercise

    One person says: “My mom did cpt on me when I was little, usually only when I was sick. I cannot remember doing it on a regular basis since I was a child, but I was always running and dancing around, despite my parents’ warnings that I was “too sick to play like the other kids.” Through high school, I danced professionally, but a ski accident ended that, For the first time, my PFTs went down once I had to stop dancing. Three surgeries (two for my knee, one abdominal), two tune-ups, a bout of kidney stones, all within five years after stopping my dancing, left me with little cardio outlet. Not to mention hemoptysis”.

    “So last November, almost a year after emergency abdominal surgery, I bit the bullet, jumped on a stationary bike, and rode my heart out. Bled for two days, coughed up more gunk than I had ever seen (a quart a day), and within six months, my PFTs went from 82% to 117%. All the antibiotics and inhalers couldn’t do for me what exercise did. I never realized it til I wasn’t able to do it, and my lungs really paid the price. I also went from needing 5-6 breathing treatments a day to ONE (unless I’m sick), but also haven’t been on antibiotics in FOUR MONTHS- the longest EVER IN MY LIFE”.

    “If you don’t do CPT, do SOMETHING. Run, jump, dance, laugh, whatever gets you moving. Who cares if you cough all over. And if all else fails, and you’re too tired to exercise, make yourself cough. It’s a great technique if you can master it, and can really pull stuff out. Just don’t hemoptysize”.

    Exercise has proven very beneficial for people with Cystic Fibrosis. It helps loosen mucus and decreases shortness of breath and muscle deterioration. Exercise also gives the person a sense of well-being and independence. People with CF who exercise regularly find increased stamina and often times, less congestion.

    Exercise is one of the most important factors in controlling cystic fibrosis (CF). With much of the focus on medications, treatments, hospital stays, and transplant issues, it can be easy to view CF in purely reactionary terms. But a more proactive approach, one involving a comprehensive exercise program, can, as the old saying goes, quite literally add years to your life, and life to your years.

    There are two basic types of exercise: aerobic (with oxygen), and anaerobic (without oxygen). For people with cystic fibrosis (PWCF), aerobic exercise is the primary concern, since it has the greatest impact on lung function. A steady course of aerobic activity, followed from an early age, can help stave off lung damage associated with CF.

    This is accomplished in a number of ways. First, vigorous exercise helps promote the clearing of mucus from the lungs by moving high volumes of air through partially clogged passages. And, of course, that same air movement can help prevent any new passages from becoming clogged. Second, vigorous exercise helps to preserve the elasticity of the lung walls, further promoting the ability to clear mucus in the long term. Third, many of the organisms that grow in PWCF’s lungs prefer an environment that is moist, with low air movement. Exercise helps to create an environment that is less conducive to organism growth. Finally, consistent aerobic exercise forces the body to use oxygen more efficiently (this is, of course, true for anyone, CF or not). Getting “in shape” has benefits which extend beyond those that are measurable. Many PWCF report an improvement in their attitude and outlook when they undertake a program of exercise.

    A “good” aerobic exercise is probably one that a PWCF will stick to. It is very important that the exercise be challenging, i.e. inducing deep breathing. Depending on the initial level of fitness, this could be anything from a slow walk around the block to running a 15K road race. Other popular aerobic exercises include swimming, bicycling, jumping on trampolines, and sports from basketball to tennis to soccer. The consistency of the exercise is important. Try to do SOME exercise every day. It will extend your life, period. DO IT! Many PWCF begin a program of aerobic exercise, only to stop a short period of time later, because the exercise induces coughing. Sometimes this is uncomfortable, and even embarrassing. However, the fact that the exercise is causing coughing is the exact reason that the program MUST be continued. The exercise is simply shaking that “gunk” up, and the long term result will be clearer lungs and easier breathing. People who have complications from asthma should talk to their doctor about a safe way to exercise aerobically.

    The second type of exercise, anaerobic exercise, can be of great benefit to PWCF. When speaking of anaerobic exercise, I am referring primarily to weight bearing, or weight lifting exercises (“pumping iron”). A concern of many PWCF is that they have trouble gaining or maintaining bodyweight. This is especially true during times of illness, when bodyweight can potentially drop to perilously low levels. So, again, a better approach may be to take a proactive course of action, by building muscle through a weight training regimen. Assuming that a PWCF is receiving adequate levels of nutrition (tips for achieving OPTIMAL nutrition are found elsewhere in this FAQ), he or she can build lean body mass (muscle) by following a program which stimulates hypertrophy (muscle growth). A program to build muscle should consist of using heavy weights, which allow the person in question to perform 8-12 repetitions of a given exercise before reaching muscle failure. This repetition range ensures that the “Creatine-P” energy system is being utilized in the muscle. The action by which muscle hypertrophy occurs is still not completely understood, but it appears that the suggested range of repetitions and no more than two sets of those reps per bodypart are sufficient. There are a range of differing opinions on this issue, but this FAQ is not the forum for their complete discussion. There are many excellent books on the market (as well as periodicals) that can direct a beginning weightlifter to the proper path. The important issue is that a PWCF embarks on a disciplined program of weight training to increase bodyweight and overall physical condition. A good weight training program may look something like the following (with 1 warm up set of 15-20 reps, and 1 “all-out” set of 8-12 reps):

    MONDAY Dumbbell Flies (Chest) Incline Bench Press (Chest) Side Laterals (Deltoids-Shoulders) Tricep Pushdowns (Triceps) Dips (Chest/Shoulders/Triceps)

    WEDNESDAY Lat Pulldowns (Latissimus Dorsi-Back) Seated Rows (Back) Hyperextensions (Lower Back) Bicep Curls (Biceps)

    FRIDAY Leg Extensions (Quadriceps) Leg Press (Quads/Hamstrings/Buttocks) Leg Curls (Hamstrings/Buttocks) Calf Raises (Calves) Sit-Ups (Abdominals)

    This program stimulates every major muscle group, and since only one “all-out” set is being performed, your body will have ample recuperative ability. Aerobic exercises can be performed on days you are not weight training. Again, this anaerobic exercise program is only an example. Reading the available literature can only serve to bolster your knowledge, and will help you design a program which is ideal for you.

    Anyone, but especially a PWCF, can benefit from an exercise program which combines both aerobic and anaerobic elements. These elements work synergistically to promote total physical (and mental) well-being. Fewer health complications, shorter hospital stays, and resistance to fewer antibiotics are just a few of the benefits of a dedicated exercise program. Should you have any further questions, feel free to e-mail Buck Bell at [email protected]

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