Effect of diaphragmatic stretch technique on thoracic excursion and pulmonary function in COPD patients: Study protocol for randomized controlled trial.

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is a diverse lung illness that is typified by persistent respiratory symptoms (such as coughing, sputum production, dyspnoea, and/or exacerbations) brought on by abnormalities of the alveoli (emphysema) and/or airways (bronchitis, bronchiolitis) that result in persistent, frequently progressive airflow obstruction.¹ Air entrapment and lung hyperinflation are two prominent indicators of COPD.¹

As the lung volume can be considered the respiratory muscle’s length index, the diaphragm’s contraction force, lung volumes, and lung capacities can all be impacted by shortening it.² The diaphragm’s ability to function is compromised by these two prominent COPD features. They result in a mechanical disadvantage because they shorten its operational length and alter the mechanical interaction between its numerous elements. These pathological alterations result in the diaphragm’s inability to expand and elevate the lower rib cage, which causes the lower ribs’ transverse diameter to contract during inspiration. While functional capability decreases, these changes result in an increase in breathing effort.^3,4

Diaphragm and rib cage movements gradually become lessened in patients with respiratory disorders due to alternate cyclical usage of the chest wall or diaphragm, which creates resistance to the chest wall and increases effort of breathing since it puts more strain on the respiratory muscles. Stretching muscle fibres encourages the growth of sarcomeres, which in turn lengthens shortened muscles. The ability of the respiratory muscles to contract would generally improve with appropriate length, leading to an increase in thoracic expansion and improved respiratory mechanics performance.^2,3

Numerous manual therapies have been suggested for the treatment of COPD symptoms because of the relationship between the musculoskeletal and respiratory systems. Increasing the thoracic structures’ range of motion is a common goal in respiratory mechanics. A respiratory muscle stretch aims to extend both the muscles that contract during inspiration and expiration, which are found in the chest wall. By relaxing and strengthening diaphragmatic contraction, the diaphragmatic stretch technique seeks to increase the pressure gradient between the thorax and abdomen.⁷

The healing process in manual therapy involves manipulating the hands for therapeutic purposes, which eventually impacts the body’s ability to heal itself. Both the individual’s general behaviour and the level of local repairs may change. Despite the benefits of manual treatment for the respiratory system, studies utilizing this approach are uncommon.⁴ The immediate effects of diaphragmatic stretch technique on improving thoracic excursion have been seen in a cross-over trial with washout period of three hours and can be safely recommended in clinically stable COPD patients.⁴ It is also discovered that diaphragmatic stretching along with conventional chest physiotherapy significantly improves pulmonary function (FEV₁/FVC) and thoracic excursion in COPD patients.² Other parameters of pulmonary function (FEF_25%-75%, PEFR) are also important as they are sensitive measure of small airway obstruction and to know about the complications related to COPD.^5,6 The effect of diaphragmatic stretch in addition to conventional chest physiotherapy on these parameters of pulmonary function are not known. Therefore, the goal of the current study is to determine how the diaphragmatic stretch technique along with conventional chest physiotherapy helps in improving thoracic excursion and pulmonary function in COPD patients.

Duration: 1 year

Discussion

Chronic obstructive pulmonary disease (COPD) is defined by an abnormality of the alveoli (emphysema) and/or airways (bronchitis, bronchiolitis) that produces a continuous restriction of airflow that regularly worsens. COPD is characterized by chronic respiratory symptoms such as dyspnoea, coughing up mucus, and/or exacerbations. One of the main characteristics of COPD is restricted airflow, which frequently results in changes in lung capacity and limited thoracic movement. For those with this illness, diaphragmatic stretching therapy has shown promising results in terms of thoracic excursion and lung function. The major objective of this study is to assess the impact of diaphragmatic stretching on individuals with COPD, specifically in relation to enhanced thoracic excursion and lung function.

Bonnie E. Ronish et al. in their research reported that beyond FEV₁, %predFEF_25%-75% offers further insights into the manifestation of a disease and helps to link the anatomic pathology and deranged physiology of COPD.⁹

Diaphragmatic stretching exercises can be incorporated into traditional physiotherapy to help patients with COPD improve their thoracic expansion and pulmonary function, as demonstrated by G. Swathi et al. (2021). The results of this study shed light on the most effective methods for managing COPD symptoms and, ultimately, improving patient outcomes.²

A team of researchers looked into how senior population chest expansion and pulmonary function were affected by chest mobility exercises and respiratory muscle stretching in 2020. Fascinatingly, respiratory muscle stretching was found to be significantly more helpful than chest mobility exercises, even though FVC, FEV₁, and chest expansion improved with both exercises.¹¹

In a recent study, Anusree Sreejith and her colleagues assessed the efficacy of respiratory muscle stretches and chest mobility exercises for older adults. Group A stretched their respiratory muscles while Group B concentrated on thoracic mobility exercises over a two-week period. Stretching the respiratory muscles was more advantageous than chest mobility exercises for increasing chest expansion, FVC, and FEV₁. In the elderly population, both forms of physical activity enhanced chest expansion and lung function.¹²

A study by Do Sun Kwon et al concluded that careful monitoring should be done with COPD patients who present with low FEF_25-75% values, even after having normal lung function.⁵

A 2019 study by Aishwarya Nair and colleagues found that diaphragmatic excursion and chest expansion can be improved in COPD patients by using manual diaphragm release techniques and diaphragmatic stretch. Twenty patients took part in the trial, and they were split into two groups at random. Both methods were successful.⁴

According to a study by Islam, Rofiqul et al. (2017), when combined with traditional physiotherapy, diaphragmatic and costal manipulations improve lung function, chest mobility, and total functional capacity in patients with chronic obstructive pulmonary disease (COPD).¹³

A 2017 study by Dangi Ashwini et al. found that in people with stable COPD, diaphragmatic breathing and the intercostal stretch technique both improve chest expansion and functional capacity while reducing dyspnoea. The study concluded that there was no appreciable difference in the effectiveness of the two strategies.¹⁰

Studies show that stretching the diaphragm, especially for people with COPD, can improve respiratory function. The act of ribcage extension and contraction improves thoracic excursion and mobility, enabling greater lung expansion and ventilation, and eventually improving respiratory function. Exercises that stretch the diaphragm can relieve tension, improve muscular coordination and strength, and improve breathing efficiency.

Dissemination: I’ve decided to present my study protocol at the last meeting.

Study status: Yet to be started.