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Diaphragmatic breathing training and walking performance in chronic airways obstruction
Br. 3.. Dis. Chest (1982) 76, 164
DIAPHRAGMATIC BREATHING TRAINING AND WALKING PERFORMANCE IN CHRONIC AIRWAYS OBSTRUCTION ISOBEL
P.
WILLIAMS,
Department
CATHERINE
M. SMITH
of Thoracic Medicine,
AND
CLIVE
St James’ Hospital,
R.
MCGAVIN
London
Summary Eight patients with chronic obstructive bronchitis and moderate disability entered a pilot study of the effects of controlled diaphragmatic breathing. They received three weeks of placebo physiotherapy (shoulder exercises) followed by three weeks of instruction on controlled diaphragmatic breathing. No beneficial effects were observed on exercise performance or the perceived strain of exercise.
INTRODUCTION
Accepted physical methods for helping patients with chronic airways obstruction include exercise training (Cockroft et al. 1980) and measures to aid the removal of sputum. ‘Breathing exercises’ are widely prescribed and practised but their effects on exercise performance have never to our knowledge been assessed. Objective evaluation of physical treatment in chronic lung disease has recently been called for (Committee on Thoracic Medicine 1981). The stated aims of breathing exercises are to make more efficient use of the lungs by improving the method of breathing and to enable the patient to control his breathing during attacks of breathlessness. ‘Diaphragmatic breathing’ is an important component of such breathing exercises, the rationale of which appears to be to improve ventilation to the bases of the lungs and reduce ineffectual movements of the upper rib cage. If effective, the instructions should either improve exercise performance or reduce the strain of exercise, or both. We carried out a pilot study to test this hypothesis. Materials and Methods Patients with stable chronic airways obstruction were studied. All had exercise performance limited by breathlessness of at least grade II on the MRC scale (Fletcher et al. 1959). Laboratory tests were carried out on three occasions at intervals of three weeks and at approximately the same time of day. The test consisted of forced expiratory volume in one second (FEVl), forced vital capacity (FVC) and a 12-minute walking test (12 MD) (McGavin et al. 1976), before and after inhalation of 200 pg of salbutamol aerosol. The strain experienced during the exercise test was assessed by Borg’s rating of perceived exertion (RPE) (Borg 1970). After the first visit patients underwent a three-week course of placebo exercises. They attended the physiotherapy department thrice weekly and carried out 35 minutes of rope and pulley shoulder exercises. The laboratory tests were repeated and the patients then underwent a threeweek instruction course of diaphragmatic breathing and breathing control exercises. These were essentially as described by Gaskell(l980) to encourage movement of the lower chest and abdomen.
Diaphragmatic
Breathing Training and Walking Performance
165
One of us (C.M.S.) gave instruction initially at rest but then supervised the patients during increasing activity, checking during exercise that they were breathing as instructed. The patients were asked to practise these exercises at home. They were advised to avoid exercise dyspnoea by adjusting the rate of exercise but were asked to keep the level of their general activities constant during the trial. The diaphragmatic breathing exercises were checked by thrice weekly attendances in the physiotherapy department and again before the final laboratory test. The results were analysed by the t test for paired observations. RESULTS
The group consisted of eight patients (six male) with a mean age (+ SD) of 67 f 6 years. The mean FEVJFVC ratio was 34+ 8%. The mean values for FEV1, FVC, 12 MD and RPE, before and after placebo (shoulder exercise) therapy and after active (diaphragmatic breathing) therapy, are given in Table I. The changes in spirometry and walking performance are expressed as percentage difference from the previous test; change in RPE has been expressed in absolute terms. The results of the paired t-test are also shown. No significant changes were recorded in any measurement at any stage. Table
I. Mean values ( + SD) of FEVl, FVC, 12-MD placebo therapy and after active therapy
I?zitiuZ
FEVl (ml) FVC (ml) 12-MD RPE
950 + 270 2790+610 936 2 82 10.7k1.6
After
shoulder exercises
940 + 290 285Ort580 928+111 11.2k2.3
and RPE before
t
-0.37 0.86 -0.25 0
The t-values are obtained by comparing percentage in the case of FEV1, FVC and 12-MD and absolute
After diaphragmatic breathing
900 k 270 29OOk 510 945 + 145 10.6~2.7
and after
t
-1.69 2.1 1.62 -1.96
changes from the previous test changes in the case of RPE.
DISCUSSION
The design of this study was suboptimal in that it was a single-blind and there was no randomization of order. The technician would therefore be aware of the treatment and there may have been a systematic change in the placebo effect. This design was adopted because the persistence of any benefit from active physiotherapy was unknown; indeed the benefit might have been permanent. The exercises were intended to make more efficient use of the lungs by diaphragmatic movement and to enable the patient to control his breathlesssness during exercise. If effective they should either have enabled the patient to walk further or have reduced the strain of exercise. However, no change either in walking distance or in perceived strain of exercise was observed. Borg’s scale of rating of perceived exertion has been investigated by several groups of workers and the score has been found to correlate with physiological indicators of physical stress during exercise (Edwards et al. 1972). We have found no indication that patients with airways obstruction and a 1Zminute walking distance of around 930 m benefit from diaphragmatic breathing exercises.
Isabel P. Williams, Catherine M. Smith and Clive R. MeGavin
166
Furthermore there is no trend suggesting that some patients walked as far for less perceived stress while others walked faster for the same amount of stress. It is possible, however, that more disabled patients might derive some benefit. ACKNOWLEDGEMENTS
We thank Dr F. J. C. Millard Alison
Humberstone
for
C.M.S. was supported
for allowing
laboratory
help
us to study patients under his care, Mrs and
Miss
Julie
Cox
for
secretarial
help.
by a grant from the Chest, Heart and Stroke Association. REFERENCES
BORG, G. COCKROFT,
as an indicator of somatic stress. &and. J, Rehab. Med. 2, 92. G. (1980) Rehabilitation in chronic respiratory disability: A control study. Thorax 35, 233. COMMITTEE ON THORACIC MEDICINE (1981) Disabling chest disease: prevention and care. J. R. Coil. Physns Lond. 15, 69. EDWARDS, R. H. T., MELCHER, A., HESSER, C. M., WIGERTZ, 0. & EKELUND, L. G. (1972) Physiological coordinates of perceived exertion in continuous and intermittent exercise with the same average power output. Europ. J. clin. Invest. 2, 108. FLETCHER, C. M., ELMES, P. C., FAIRBAIRN, A. S. & WOOD, C. H. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Br. med. J. 2, 257. GASKELL, D. V. (1980) Breathing Exercises for Chronic Bronchitis and Emphysema. London. Chest,
Heart MCGAVIN,
(1970) Perceived A.,
SAUNDERS,
exertion
M.
& BERRY,
and Stroke Association. C. R., GUPTA, S. P. & MCHARDY,
assessing disability
in chronic
bronchitis.
G.
J. R.
(1976)
Br. med. J. 1, 822.
Twelve
minute
walking
test
for
DIAPHRAGMATIC BREATHING TRAINING AND WALKING PERFORMANCE IN CHRONIC AIRWAYS OBSTRUCTION ISOBEL
P.
WILLIAMS,
Department
CATHERINE
M. SMITH
of Thoracic Medicine,
AND
CLIVE
St James’ Hospital,
R.
MCGAVIN
London
Summary Eight patients with chronic obstructive bronchitis and moderate disability entered a pilot study of the effects of controlled diaphragmatic breathing. They received three weeks of placebo physiotherapy (shoulder exercises) followed by three weeks of instruction on controlled diaphragmatic breathing. No beneficial effects were observed on exercise performance or the perceived strain of exercise.
INTRODUCTION
Accepted physical methods for helping patients with chronic airways obstruction include exercise training (Cockroft et al. 1980) and measures to aid the removal of sputum. ‘Breathing exercises’ are widely prescribed and practised but their effects on exercise performance have never to our knowledge been assessed. Objective evaluation of physical treatment in chronic lung disease has recently been called for (Committee on Thoracic Medicine 1981). The stated aims of breathing exercises are to make more efficient use of the lungs by improving the method of breathing and to enable the patient to control his breathing during attacks of breathlessness. ‘Diaphragmatic breathing’ is an important component of such breathing exercises, the rationale of which appears to be to improve ventilation to the bases of the lungs and reduce ineffectual movements of the upper rib cage. If effective, the instructions should either improve exercise performance or reduce the strain of exercise, or both. We carried out a pilot study to test this hypothesis. Materials and Methods Patients with stable chronic airways obstruction were studied. All had exercise performance limited by breathlessness of at least grade II on the MRC scale (Fletcher et al. 1959). Laboratory tests were carried out on three occasions at intervals of three weeks and at approximately the same time of day. The test consisted of forced expiratory volume in one second (FEVl), forced vital capacity (FVC) and a 12-minute walking test (12 MD) (McGavin et al. 1976), before and after inhalation of 200 pg of salbutamol aerosol. The strain experienced during the exercise test was assessed by Borg’s rating of perceived exertion (RPE) (Borg 1970). After the first visit patients underwent a three-week course of placebo exercises. They attended the physiotherapy department thrice weekly and carried out 35 minutes of rope and pulley shoulder exercises. The laboratory tests were repeated and the patients then underwent a threeweek instruction course of diaphragmatic breathing and breathing control exercises. These were essentially as described by Gaskell(l980) to encourage movement of the lower chest and abdomen.
Diaphragmatic
Breathing Training and Walking Performance
165
One of us (C.M.S.) gave instruction initially at rest but then supervised the patients during increasing activity, checking during exercise that they were breathing as instructed. The patients were asked to practise these exercises at home. They were advised to avoid exercise dyspnoea by adjusting the rate of exercise but were asked to keep the level of their general activities constant during the trial. The diaphragmatic breathing exercises were checked by thrice weekly attendances in the physiotherapy department and again before the final laboratory test. The results were analysed by the t test for paired observations. RESULTS
The group consisted of eight patients (six male) with a mean age (+ SD) of 67 f 6 years. The mean FEVJFVC ratio was 34+ 8%. The mean values for FEV1, FVC, 12 MD and RPE, before and after placebo (shoulder exercise) therapy and after active (diaphragmatic breathing) therapy, are given in Table I. The changes in spirometry and walking performance are expressed as percentage difference from the previous test; change in RPE has been expressed in absolute terms. The results of the paired t-test are also shown. No significant changes were recorded in any measurement at any stage. Table
I. Mean values ( + SD) of FEVl, FVC, 12-MD placebo therapy and after active therapy
I?zitiuZ
FEVl (ml) FVC (ml) 12-MD RPE
950 + 270 2790+610 936 2 82 10.7k1.6
After
shoulder exercises
940 + 290 285Ort580 928+111 11.2k2.3
and RPE before
t
-0.37 0.86 -0.25 0
The t-values are obtained by comparing percentage in the case of FEV1, FVC and 12-MD and absolute
After diaphragmatic breathing
900 k 270 29OOk 510 945 + 145 10.6~2.7
and after
t
-1.69 2.1 1.62 -1.96
changes from the previous test changes in the case of RPE.
DISCUSSION
The design of this study was suboptimal in that it was a single-blind and there was no randomization of order. The technician would therefore be aware of the treatment and there may have been a systematic change in the placebo effect. This design was adopted because the persistence of any benefit from active physiotherapy was unknown; indeed the benefit might have been permanent. The exercises were intended to make more efficient use of the lungs by diaphragmatic movement and to enable the patient to control his breathlesssness during exercise. If effective they should either have enabled the patient to walk further or have reduced the strain of exercise. However, no change either in walking distance or in perceived strain of exercise was observed. Borg’s scale of rating of perceived exertion has been investigated by several groups of workers and the score has been found to correlate with physiological indicators of physical stress during exercise (Edwards et al. 1972). We have found no indication that patients with airways obstruction and a 1Zminute walking distance of around 930 m benefit from diaphragmatic breathing exercises.
Isabel P. Williams, Catherine M. Smith and Clive R. MeGavin
166
Furthermore there is no trend suggesting that some patients walked as far for less perceived stress while others walked faster for the same amount of stress. It is possible, however, that more disabled patients might derive some benefit. ACKNOWLEDGEMENTS
We thank Dr F. J. C. Millard Alison
Humberstone
for
C.M.S. was supported
for allowing
laboratory
help
us to study patients under his care, Mrs and
Miss
Julie
Cox
for
secretarial
help.
by a grant from the Chest, Heart and Stroke Association. REFERENCES
BORG, G. COCKROFT,
as an indicator of somatic stress. &and. J, Rehab. Med. 2, 92. G. (1980) Rehabilitation in chronic respiratory disability: A control study. Thorax 35, 233. COMMITTEE ON THORACIC MEDICINE (1981) Disabling chest disease: prevention and care. J. R. Coil. Physns Lond. 15, 69. EDWARDS, R. H. T., MELCHER, A., HESSER, C. M., WIGERTZ, 0. & EKELUND, L. G. (1972) Physiological coordinates of perceived exertion in continuous and intermittent exercise with the same average power output. Europ. J. clin. Invest. 2, 108. FLETCHER, C. M., ELMES, P. C., FAIRBAIRN, A. S. & WOOD, C. H. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Br. med. J. 2, 257. GASKELL, D. V. (1980) Breathing Exercises for Chronic Bronchitis and Emphysema. London. Chest,
Heart MCGAVIN,
(1970) Perceived A.,
SAUNDERS,
exertion
M.
& BERRY,
and Stroke Association. C. R., GUPTA, S. P. & MCHARDY,
assessing disability
in chronic
bronchitis.
G.
J. R.
(1976)
Br. med. J. 1, 822.
Twelve
minute
walking
test
for