II-Introduction:
Chronic obstructive pulmonary disease (COPD) is considered as the fourth leading cause of death globally. COPD is defined as a lung disease which obstructs the air flow entry as a result of emphysema and chronic bronchitis. The occurrence of this disease is increased by cigarette smoking, second-hand smoking, exposure to occupational dust and genetic factors. As for this disorder, cigarette smoking is the main factor held for 90 % of developing COPD. In addition, a deficiency in alpha 1-antitrypsin is also known to be associated with the development of COPD. The longer the individual is exposed to dusts and chemicals, the higher the risk of developing this disease. Adults in 40's and older are considered to be at higher risk.
Cessation of cigarette smoking is the first step a patient should take in the treatment. Further-more, the treatment should consist of certain medication and oxygen supplements for severe cases. The application of a pulmonary rehabilitation (PR) program is also considered to be an effective management method for COPD patients. The COPD patient will be able to control symptoms and enhance the quality of life with the administration of a PR program. In 1981 the American thoracic society defined the PR as an effective medical program, which is established by accurate diagnosis, emotional support and education. Also this program generally reverses both the physiology and the psychopathology of pulmonary diseases. In order to be successful the PR is designed separately for each patient specific needs (1). The national institute of health consensus described PR as a course provided by the health care specialists for the pulmonary disease patients. Their goal is to make the patient dependent on him or herself and participate in the society (2). A COPD patient with PR program administration is expected to increase his quality of life, by limiting the risk factors. These disease limiting factors can be physical and psychological such as: dyspnea, chronic cough, fatigue, anxiety and depression etc. The PR program utilization improves the life of a COPD patient in a several ways. First the hospitalization rate and the use of health care resources are decreased. Also it encourages the patient to be more active in performing his daily activities. The PR program has a major effect in decreasing the physical symptoms (dyspnea) as well as the psychological symptoms (anxiety and depression). Furthermore, it lowers the mortality & morbidity rate in some patients. In addition, it assists the patient to return to his work as soon as possible. Finally, as a result of this program application the patient awareness and knowledge about his condition increases. The physiotherapist plays a major role in decreasing the COPD patient's symptom. The treatment techniques proved to be effective with this population. The purpose of this paper is to prove the effect of PR in terms of psychological effects as well as quality of life in COPD patients.
III-Body of knowledge:
A-COPD:
COPD is a life-threatening disease and could be the limiting cause of having a normal quality of life for the affected subjects. It occurs in different types and range in its severity according to each patient condition; however, all of the cases share in the airway irritant that leads to its development. The patient may experience shortness of breath when he performs an activity. Besides, the patient will experience fatigue episodes easily; As a result of that the patient sedentary life-style will be increased. The patient shortness of breath (dyspnea) may progress into dyspnea at rest. This may influence the patient psychological well-being in a bad way. Likewise, a raise in the anxiety and depression levels as well as impaired memory and concentration performance. In severe cases, a chronic cough may occur to the patient in which he performs it with difficulty. The patient respiratory muscles may be weakened with time, so the patient uses his accessory muscles to compensate. These symptoms may progress rapidly and lead to a sudden acute exacerbation. Severe COPD patients utilize more medical resources, more primary care services and more emergency care. As I mentioned earlier, the PR is an effective way in improving the related symptoms. Recently, the awareness of the PR need for the COPD cases was significantly increased. Accordingly, the treatment plan can not be completed without the PR intervention.
B-General rehabilitation:
General rehabilitation program was established and meant to people experiencing limited functional abilities as a result of impairment. This process aims to regain their optimal functional level. Additionally, it enhances the level of independence in this population by providing the necessary tools of rehab. The impairment could be the consequence of an external trauma or internal illness. External trauma could be traumatic head injury, any joint fracture and burn .As for the, the internal illness could include diabetes, cardiac problems, cancer, pulmonary disease, stroke, and multiple sclerosis. The rehabilitation program can be directed toward different cases; such as, drug and alcohol addicted individuals, cardiac problems patients, or pulmonary problems patients. Any person suffering from drug and alcohol abuse is referred to the specialized drug and alcohol rehabilitation centers. On the other hand, the cardiac rehab is designed to improve the quality of life and to increase the survival rate in patient with heart disease. The cardiac rehab is delivered to patient in phases. First is the in-hospital phase where the physiotherapist will encourage the patient to ambulate and do low-level exercises. In addition they will educate both the patient and his family about the disease and management techniques. The most intensive phase begins two weeks after discharge from the hospital. This phase is the early post-hospitalization program and it's supervised by physician. The physician is present in the exercise area and monitors the patient performance. The patient in this phase will be able to reach the optimal level in his daily functions. Also, the patient will have an excessive session to provide him with the required skills and information. Theses skills and information will assist him with the life-style change activities. Finally, the third phase is the maintenance rehabilitation program and it's held out side the hospital. This phase proceed with the phase II objective which is the life-style change activities education. Also, this phase will offer to the participant a prevention program.Similarly; the pulmonary rehab is concerned with the same objectives to patients suffering from chronic pulmonary diseases. The last type of the general rehab is the occupational rehabilitation. This type of rehab focuses on the patient ability to work and doing his daily live task.
The sudden need for the rehabilitation services emerged during World War II (3). After that, several organizations were established to emphasis on the urgent need of the rehabilitation. The international rehabilitation medicine association (IRMA) is the most famous among them. The IRMA is an institution that is established by doctors and surgeon from different medical specialties. The IRMA goal is to instruct the society about the importance of the rehabilitation in treating the disabilities (4).
The rehab program requires the participation of several health care members. The rehab program team may vary according to the patient injury and the facility resources of the rehab team. This team includes patient, caregiver, physicians, physiotherapist, occupational therapist, nurse, speech language pathologists, respiratory therapist, dietitian, psychologist, social worker, vocational therapist and much more. In order for the team to be successful they must share the same goal which is promoting the patient health. Each of the health care members will work in his/her area of expertise. For example, physiotherapist will work on the patient's range of motion and muscle strength .while the speech language pathologists will be concerned with the patient's neurological communication problems. The rehabilitation assessment is available to discover the physical, mental, socail deficit that occurs as a result of the disease. A reliable and valid assessment must be done in order to identify the patient's problems. The patient case will determine the required assessment tools and tests. First of all, the rehab team will take the patient's history that includes: present, past, social, personal and family. After that, they will examine him/her in different methods; such as, functional level, musculoskeletal, cardiopulmonary, and neurological. Eventually, a proper treatment plan will be set to meet the patient's desired goals.
Furthermore, the rehabilitation service will differ according to the patient's post-injury situation and location. The rehab services that are offered to the resident individuals in the hospital are called inpatient rehabilitation. The patient in this medical environment will have the advantage of several health-care services. The health care member will have an easy access to the patient and provide him/her with the maximum level of services. The physiotherapist, occupational therapist and the speech language will participate in this patient rehab as well. The duration of this rehab service is directly related to the length of stay in the hospital. The rehab for a stroke patient can be considered in this type of rehab. However, the stroke rehab can be useful for certain type of people, while in contrast it might not for other people. The conventional treatment is one of the rehab techniques offered to a stroke patient. In this treatment, the physiotherapist will do a range of motion exercises, strengthening exercises and mobilization exercises. The outpatient rehabilitation is the other type of the rehab procedure .This rehab service is meant to ambulatory individuals in which they can attend the rehab session. The rehab is provided to any sport-related injuries for example: athlete is classified in this rehab category. There are several points to be taken in consideration in this treatment plan; such as, the athlete age, the type of sport, the anticipated level of function. Yet, in any sport injury case the treatment plan should include improvement for the muscle strength as well as the endurance. The duration of this rehab service in Kuwait can range between 6 to 8 sessions maximum. The physical and medicine rehabilitation (PMR) in Kuwait is a special hospital concerning with the post-injury rehabilitation. The PMR provide rehab services to both in and outpatient equally.
C-Pulmonary rehabilitation:
As I mentioned earlier, the pulmonary rehabilitation program (PR) consists of multidisciplinary health care specialties, who work to improve the life of COPD patients. The multidisciplinary team includes: respiratory therapist, pulmonary physician, physical therapist, occupational therapist, dietitian, pharmacist, pulmonary laboratory technologist, nurse, speech therapist, and much more. The participation of these health care specialties will be determined by each patient's specific case. In addition, the PR can be a very effective program to the post-operative patient complaining of secretion and shortness of breath as a result of the general anesthesia. Furthermore, there are several conditions that can benefit of this program likewise: lung cancer, neuromuscular and neurological disorder and primary pulmonary hypertension. Nevertheless, there are certain requirements a subject must fulfill to be a qualified subject for this program. For instance, if dyspnea contributes to a decrease in the physical activity and impair the quality of life, or if the patient's consumption of the medical services increased. All of these will make the patient a good candidate for the PR program. In contrast, there are several conditions are considered as contraindications to this program such as: metastatic cancer, disabling stroke, severe cognitive deficit, severe psychiatric disease, congestive heart failure and acute cor pulmonale.
The PR program must include assessment, treatment and follow up program as assessing the patient is the first step in the PR program. The important part of the assessment is the patient's interview, in which the therapist extracts the related information from the patient. The patient's interview helps in building the trust and confident between the therapist and his patient. In this interview there are several important question are raised; such as, what is your occupation, the frequency of hospitalization due lung problems, do you complain of any medical problems, did you attend any past rehabilitation program, the family history of respiratory disease, did the disease limit your functional activities and what is your main goal of attending this program. This interview will give the therapist an idea about the patient's main concern and his most limited functional activities. In addition to that, the therapist must be more interested and look at the patient's medical record. This will allow him to be more confident about this particular case and set the appropriate treatment plan that is suitable for the patient's condition. For example, if the patient is complaining from diabetes mellitus the therapist must be sure that the patient took his medication prior to the treatment in two hours. Besides, there are diagnostic test must be running out. These diagnostic tests will identify the patient's condition that is used as an evaluation tool after the program duration. Lung volumes, resting arterial blood gas, arterial oxygen saturation, chest radiograph are some of diagnostic tests. Dyspnea, cough, wheeze, chest pain and sputum (color, volume, smell, consistency). All of these are some of the symptoms that are observed in a COPD patient. Assessing these symptoms is helpful in terms of confirming the patient's disease. The physiotherapist role is observed in doing the physical assessment; such as, taking vital sign, breathing pattern and the usage of accessory muscles while respiration. The physical assessment can help in monitoring the patient progress.
Once the assessment is done and the patient main problems are identified a proper treatment plan is set. The treatment plan will vary according to each deficit and the available medical recourse. Breathing exercises are the first in the treatment plan. Diaphragmatic and pursed-lip breathing exercises are there to teach the patient how to breathe properly. A patient complaining from an excess secretion will suffer from decreased air flow entry. That kind of patient will follow the bronchial hygiene program. This program aims to release all the secretion and allow the lung to breathe without any limitation. The program includes: postural drainage along with percussion or vibration techniques and cough techniques. In order for this population to live their life with their maximal independence, they are taught certain daily live activities exercise. Energy conservation, relaxation technique and panic control are some of these exercises. The usage of certain respiratory modalities is necessary for the severe pulmonary cases. Nebulizers, positive airway pressure, peak flow meters, sleep assessment equipment, ventilator management in home, suctioning in home. Finally, the treatment plan must contain training for the upper and lower extremity. The upper extremity training includes: arm ergometry, wall pulleys, therabands and posture-specific exercises. While the lower extremity training includes: walking, stationary bike and stairs.
The PR is ongoing processes that keep following the patient progress with his/her daily life activities. The follow up helps to maintain the achieved level of goals and prevent the upcoming symptoms. First, the patients are obligated to keep doing their home program that the therapist administered. Then, the patients are advised to see their physician annually for checkups. Once the PR program ends, the patients are advised to engage in educational group that is concerned of their condition and teach them how they can cope with it. This will allow the patients to be more familiar with their disease and how they can manage symptoms. The patient's family must know how to deal with the patient's emergency cases. For that they must know how to handle with the respiratory modalities. Another follow up option is the home care, which allows patients to use the medical equipment if they need them. At first the rehabilitation team must evaluate the patients' need for that medical equipment. After that they will provide them with most required medical equipment for example: IV therapy, home ventilator management and wound care.
D-literature review:
The treatment for COPD patient showed to be correlated with an improvement in the quality of life; as well as the psychological aspects. Wijkstra et al study was concerned in measuring the correlation between an extensive rehab program and the quality of life (QOL), lung function and the exercise tolerance. The study was done in home settings and for forty three subjects with history of severe airflow limitation. The inclusion criteria were patient with forced expiratory volume in one second (FEV) lower than 60% predicted and FEV/inspiratory vital capacity (IVC) lower than 50% .Whereas, any patient suffers from ischemic heart disease, intermittent claudication and musculoskeletal disorder were excluded. For this reason, the subjects were hospitalized for two days to assess and categorize them either to experimental or control group. After that thirty patients entered the 12 week rehab program, while fifteen patients entered the control group. To be specific, the subjects were measured before and after the 12 week rehab by chronic respiratory questionnaire (CRQ), spirometry and cycle ergometer test. The CRQ which measures the QOL is separated to four dimensions: dyspnea, fatigue, emotion and mastery. After the completion of all the measurement the results were obtained. The result showed a significant improvement in the four dimensions of the CRQ. In conclusion, the result of the study is that the improvement of quality of life at the end of the rehabilitation team (5).
Similar to the previous study, this study was done in a home setting. The study purpose was to examine the long term effects of quality of life and exercise tolerance in COPD patients after 18 months of rehabilitation. The study examined forty five patients diagnosed with COPD. The inclusion criteria were: forced expiratory volume in one second (FEV) lower than 60% predicted, FEV/inspiratory vital capacity (IVC) lower than 50%, patient experiencing severe airflow obstruction and little reversibility. The exclusion criteria were patients with disabling diseases such as: ischemic heart disease, intermittent claudication and musculoskeletal disorder. Furthermore, the participants were assessed and divided randomly into three groups each group includes 15 patients. To explain more, Group A and B are alike in receiving rehabilitation program for 18 months. In contrast, group C didn't receive any rehabilitation program. The rehab program is monitored by a multidisciplinary team that includes: pulmonary physician, physiotherapist, nurse and general practitioner. At the first 12 weeks both group A and B were obligated to visit their local physiotherapist twice a week for 0.5 hours session duration. After that, group A and B will differ in the number of visited session to the physiotherapist. Group A will have a schedule to visit the physiotherapist once a week for 0.5 hours session duration; on the other hand, group B will go to the physiotherapist once a month for 0.5 hours session duration. The subjects will go through an outcome measurement at the first, after three months, six months, 12 months, and 18 months. Lung function, quality of life and six minute walk test were the implanted measurement in this study. For the quality of life they used the chronic respiratory questionnaire. The result showed that both group A and B showed an improvement in the quality of life. Nevertheless, group B demonstrated a higher improvement than group A this may relate to the intensive exercise performed by group B. While group A patients depends more on their weekly session. On the contrary, group C did not show a major improvement in the quality of life as other groups. There was no increase in the exercise tolerance and it's not associated with the quality of life (6).
Garuti et al study was the first study recording that a twelve daily session of in -patient pulmonary rehabilitation (iPR) may improve the level of anxiety and depression in patient with moderate or severe COPD after an acute exacerbation. In addition, this study combined the effect of iPR on symptoms, exercise capacity and health related quality of life. The number of patients participated in this study were 149. The inclusion criteria were: persisting symptomatic disease after exacerbation, FEV lower than 80% of predicted, FEV/FVC ratio below 70%, arterial PO2 ≥60 mmHg breathing room air at rest, sufficient endurance and motivation to join the rehab session daily. On the other hand, they excluded any patient with history of unstable disease such as: severe left ventricular dysfunction, resting hypoxemia and cancer. Then several outcome measurements were applied on the COPD patients like : the hospital anxiety and depression(HAD) scale, 6 minute walking test ( 6MWD), spirometer and the St George's respiratory questionnaire (SGRO). The patient were supervised and trained by a multidisciplinary iPR team, in which their aim is to discharge the patient with optimal function level. After the completion of the twelve daily sessions the subjects were re-assessed and the results were obtained. The conclusion of the results is a significant improvement in the level of anxiety and depression. Besides, there is improvement in the symptoms, exercise capacity and health related quality of life (7).
Another study was concerned with observing the effect of an out-patient pulmonary exercise rehabilitation program on physiological, psychological and cognitive functioning. Sixty-one subjects from both genders where voluntarily participated. In order to be included in this study your age must be more than 50 years old. Also, you should have been experiencing the COPD symptoms more than six months and your FEV/FVC ratio must be below 0.70. The program duration is 30 days and consists of respiratory therapy, warm-up exercises, aerobic exercises, upper limb, exercises, pool exercises, psychosocial counseling and stress management sessions. All subjects went through physiological, psychological and cognitive functioning evaluations before starting the program and after the 30 days. The data of the evaluation process indicated the major effect of the rehab program on the pulmonary function and the physical function and endurance. Hence, at the end of the program the patients experienced a reduction in depression and anxiety as well as improved well-being. In addition, the researcher observed enhancement in the cognitive function in terms of psychomotor speed, mental flexibility, memory and concentration (8).
A recent study done by Kahayan et al, examined the result of an outpatient pulmonary rehabilitation on the psychological symptoms (anxiety, depression) in patients with COPD. The study was done on 45 patients who were diagnosed with COPD according to the global initiative for chronic obstructive lung disease (GOLD). For the subject to be included in this study, age must be between 50 and 75 years old. Also, he must been experiencing a history of smoking over 20 years and no smoking for at least 1 year. The most important criterion is that he must be in a stable condition in which he did not experience any exacerbations within the last eight weeks. The exclusion criteria includes: patient with severe heart disease, malignant disease, acute respiratory infection, musculoskeletal disorders, and peripheral vascular disease. Moreover, patients were divided into two groups: rehabilitation and control group. The rehabilitation group contained 26 patients, where as the control group contained 19 patients. Patients in both groups were evaluated and assessed physiologically and psychologically. The physiologically assessment consisted of: Lung function testing, vertical visual analogue scale (VVAS), 6-min walk test (SMWT), St George respiratory questionnaire (SGRQ). While the psychologically assessment composed of the Hamilton depression rating scale (HAM-D) and the Hamilton anxiety rating scale (HAM-A). The rehabilitation program designed with a variable treatment methods like: education, relaxation exercises, bronchial hygiene program, breathing retraining. The result showed that there is a significant improvement in the anxiety symptoms in patients with COPD because of the rehab program. This study proved the effect of an outpatient pulmonary rehab program in the psychological symptoms (anxiety, depression) in patients with COPD (9).
A furthermore recent systematic review and meta-analysis study was done on 2007. This study discussed the effect of a comprehensive pulmonary rehabilitation for anxiety and depression in adults with COPD. They did a systematic review on randomized controlled trail (RCT). The RCT discussed about the effectiveness of the pulmonary rehabilitation for the treatment of anxiety and depression in out-patient environments. First the investigator searched for relevant articles from inception to august 2006. A primary study included clinically stable out-patients and aged ≥ 18 years and eighty percent of these patients diagnosed with moderate to severe COPD. All of these characteristics must be in the primary study to be included in the systematic review. On the other hand, any study with patients complains from chronic physical or neurological disease is excluded from this review. These studies designed as a comprehensive program in which it contains exercise training, strength training, nutritional support, education and smoking cessation. Also these studies must be for out-patient populations and lasts for ≥ four weeks that included two weekly sessions of low intensity and incremental high-intensity. The result of the search comes out with six randomized controlled trail (RCT) were included in the review. The result of the review confirmed that the comprehensive pulmonary rehabilitation is more effective for the reduction of anxiety and depression than the standard care. The review suggested that the program must includes three sessions per week of incremental exercise in order to reduce the mild to moderate symptoms of anxiety and depression (10).
VI-Conclusion:
COPD is a disease that affects the patient physical and psychological well-being. The associated symptoms are responsible for the obvious life-style limitation. The treatment plan can contain different approaches. Pulmonary rehabilitation was proved to be an effective intervention method in order to control the related symptoms. The PR multidisciplinary team work together to promote the patient's health to the maximum level. The PR program is suitable for only certain kind of patients. Besides, there are certain requirements that the patient must achieve to be engaged in the program. On the other hand, it's considered to be a contraindication for another kind of patients. The PR program consists of assessment, treatment and follows up. One of the disease effects is the decline in the patient quality of life. Also, the impact of COPD is tremendous on the psychological well-being. The impact can be obvious in the increased levels of anxiety and depression. The PR program proved to be providing a major influence in the patient quality of life and psychological aspects. The PR program aids in improving the patient quality of life by increasing his functional capacity coupled with lower the levels of anxiety and depression
