Magic Allum

Respiratory conditions are a very common presentation in community and hospital settings, with a wide variety of diagnoses being assessed and treated by physiotherapy. Conditions which can present include pneumonia, chronic bronchitis, asthma, bronchiectasis, cystic fibrosis, hyperventilation and chronic obstructive pulmonary disease. Physiotherapists are trained to assess respiratory conditions and manage, treat and advise on them. Respiratory skills are an important part of every physiotherapist’s training and early work, if they have a job in an acute area of practice. It is a difficult skill to learn and physiotherapists have a lot of responsibility for managing acutely unwell patients in hospitals.

The patient’s notes and observation charts are first reviewed by the physiotherapist before going to see the patient, so as to be clear about the medical diagnosis, opinion and treatment. The blood test results will be important and the physiotherapist should have a good understanding of these. The physiotherapist will introduce themselves to the patient and whilst questioning the patient about their illness will be observing their condition at the same time, looking for the rate of respiration, hand, nose and lip colour, oxygen or nebuliser treatments, the overall wellness of the patient, their weight, the effort of breathing they are making and if they are using arm and neck muscles to help breathing.

The observation gives the physiotherapist a lot of information very quickly about the patient’s condition and what they need to concentrate on in the examination. They can then move on to the objective examination, starting with assessing the lung expansion and air entry. By holding the chest on both sides, the physiotherapist can assess how well the expansion is occurring and whether it is symmetrical. Auscultation, listening to the chest with a stethoscope, tells the examiner about how well the air is entering the lungs, whether there is a blockage, collapse, consolidation or wheeze. The results of this will determine any further examination and the type of treatments suggested.

The physiotherapist initially looks at the patient’s oxygen concentration as the correct level is critical for the patient’s respiratory and overall status. If the blood oxygen saturations are below normal then the doctors will prescribe oxygen at a specific percentage such as 24 percent or 28 percent via a venturi type administration device which maintains a constant oxygen concentration as variations in concentration would be damaging. Continuous gas delivery can dry the airways and the secretions, making treatments more difficult, so oxygen should always be administered humidified and heated to body temperature by the appropriate gas delivery circuit.

The next clinical aspect for the physiotherapist to address is the air entry to the peripheral airways of the lungs. The airways can collapse or become occluded by swelling or sputum, blocking air entry and reducing the lungs’ ability to maintain oxygen concentrations. Physiotherapists initially use breathing exercises to attempt to re-inflate the collapsed areas, instructing the patient to attempt to breathe deeply every hour or so. If this is not sufficient then intermittent positive pressure breathing may be attempted, using a pressure device to deliver gas at varying pressures into the lungs to re-inflate the desired areas passively.

Sputum retention in the lungs occurs when the patient is unable to expectorate the secretions which are formed by infections and worsened by lying in bed in hospital. Active cycle of breathing is a typical physiotherapy technique taught to patients, allowing them to move secretions from peripheral airways to the central airways where they can be removed by huffing or coughing. The technique involves steadily increasing depth of inspiration with longer expirations under slight pressure, avoiding the tendency to increase the bronchospasm of the airways. Patients can become very good at practicing this technique, allowing them to self treat effectively.

Physiotherapists can also apply manual techniques directly to the chest, using vibration or clapping to mechanically disturb the secretions and make coughing and expectoration more likely. Flutter devices are useful to mechanically disturb the sputum as the patient breathes in the vibrating air, again promoting coughing. Surgery to the thorax or abdomen or fractured ribs can inhibit deep breathing and coughing and physiotherapists will encourage patients to take regular pain control medication and to support the wound or painful part whilst practicing their inspiration and huffing.

By: Jonathan Blood-Smyth

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Total hip replacement has matured into a routine operation for the relief of hip pain and disability due to hip arthritis, giving some of the greatest quality of life increases of all medical procedures. Typically performed in older people, many get a good result from their hip replacement surgery but many do not reach their greatest potential due to lack of follow up rehabilitation in the post-operative period.

An osteoarthritic hip joint is likely to cause a degree of pain and disability for a year or more before the person comes to operation. This period of difficulty can cause influential changes in the tissues around the hip which can be relevant in the postoperative period. Pain and weakness can make us use our joints less, avoiding pushing them to the ends of their movement, a process which gradually reduces the joint’s range of motion. Adaptive shortening occurs in the hip’s ligaments, as the structures shorten in response to the fact that the joint is not being put through its full range any more in the normal daily pattern.

When a hip joint is not used in the normal way or through its full range the muscles which power it will lose some of their strength. The hip joint is designed to bear weight and to move the body around which involves high levels of power, provided by the largest muscles in the body, the gluteal muscles. The ability to run, walk, get up from a chair, climb stairs and go uphill is facilitated by the power of the gluteal muscles to a great extent. If these muscles weaken they can reduce a person’s independence to an important degree.

The hip abductors, a smaller muscle group of the gluteal muscles, are important in controlling the side to side stability of the pelvic girdle in gait, with weakness of these muscles interfering with walking. Standing on one leg in walking we hold the opposite side of the pelvis up to avoid it dropping and make bringing through the moving leg more difficult. The hip abductor muscles do this and if weak we feel unstable in walking and tend to lurch towards the weak side, making us lean our trunk towards the other side to restore balance. This is described as a positive Trendelenberg sign.

The abnormal Trendelberg gait imposes unnatural forces on the hip and requires side flexion of the spine to hold balance on each step. The abnormal gait which results fails to strengthen the hip abductors and remedy the problem. With hip problems we tend not to extend our hips fully so the gait cycle is shortened as the hip extensor muscles fail to attain full movement and power. A restriction in hip joint movement and the presence of muscular weakness makes mobility more difficult and can make the outcome of the operation less satisfactory in the absence of rehabilitation.

Patients typically have impaired balance and coordination even before they have their joint replacement operation, with some improvement occurring as the hip’s function moves more towards normal after the joint has been replaced and the mechanical function of the hip is restored towards normal. Other impairments usually include the sense of joint position sense, an important ability the lack of which compromises balance and makes falling more likely.

Physiotherapists assess a patient’s hip function and ability to get through their normal daily work, looking at the deficiencies in the joint so they can plan the rehabilitation. Noting the gait of the patient will be the first thing in the assessment, moving on to checking movements of the hip, knee and spine to check for any restrictions due to joint stiffness. An abnormal gait can be habitual and the physiotherapist will analyse and correct the gait pattern towards normal.

Excessive range is not encouraged in hip replacements due to the risk of dislocation. Next the muscle power in all the surrounding muscles will be tested and then the person’s balance reactions and joint position sense. Once the assessment is complete the physiotherapist will give the patient a programme including joint mobility, strengthening, and balance and gait correction. Many with hip arthroplasty do not reach their best potential due to a lack of rehabilitation care after the operation.

By: Jonathan Blood-Smyth

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