Volume 4, Issue 3, March – 2019 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Efficacy of Retraining Diaphragm by Proprioceptive

Neuromuscular Facilitation versus Diaphragmatic
Breathing Exercises in Reducing Dyspnoea in the
Copd Patients
Premkumar. k JUI Giri
HOD & Professor Formerly Professor
College of Paramedical Sciences Laxmi & Shree Devi College of Physiotherapy
EMCHRC, Perinthalmanna Mangalore

Abstract:- expectoration, wheezing, worsen shortness of breath

(SOB), fatigue, chest tightness and mood disturbances.
 Background and Purpose These changes contribute to a decrease in health-related
Chronic Obstructive Pulmonary Disease (COPD) quality of life (HRQL) and in daily physical activities 4–6.
is major cause of morbidity and mortality in globally Repeated exacerbations are a risk factor for increased
and disease process is characterized by dyspnoea and mortality and contribute to the health care burden
limited exercise tolerance. Pulmonary rehabilitation associated with COPD disease, especially when they result
improves the health-related quality of life and exercise in hospitalization 7–9.
tolerance capacity. This study was evaluated the
efficacy of retraining diaphragm muscle in the COPD The management of patients with COPD is to
patients before and after performing PNF techniques minimize frequency and impact of acute exacerbations
and DB exercises. because COPD results primary impairments of the
respiratory system and secondary impairments including
 Method skeletal muscle dysfunction10.
selected 30 COPD patients into two groups were
being treated with PNF & DB and who had been Disease prevention is the ultimate goal of COPD once
referred to a pulmonary rehabilitation program; the disease is diagnosed the effective management should
patients evaluated severity of the dyspnoea by using be carried on. The management of mild to moderate
Borg’s scale ratio 3(moderate) and 4 (somewhat severe). involves the avoidance of risk factors to prevent the disease
progression and pharmacotherapy as needed to control the
 Results symptoms. Severe disease often requires the integration of
Upon completion of pulmonary rehabilitation, a a variety of treatment approaches like pharmacotherapy,
significant improvement dyspnea score in PNF ventilatory support and counseling11-12.
techniques shows the retraining in diaphragm muscle of
COPD patients. Pulmonary rehabilitation a group of exercise and
education programme to reduce symptoms, improve
 Conclusion exercise performance and prevent exacerbations. PR has
High quality studies are required to identify PNF been demonstrated to improve the health-related quality of
group or DB group clinically effective. life, dyspnoea and exercise tolerance capacity15.

Keywords:- COPD, dyspnoea, Physiotherapy, PNF, DB The diaphragm is the main respiratory muscle in
humans which accounts for 70% of the resting ventilation
I. INTRODUCTION so the pulmonary rehabilitation mainly focused to retrain
the diaphragm muscle thereby improve the physical
Chronic Obstructive Pulmonary Disease (COPD) is efficiency of the COPD patients14.
progressive disease and leading cause of morbidity and
mortality world, especially in India (1-2). COPD mainly Pulmonary rehabilitation consists of chest
caused by cigarette smoke, occupational dusts, chemicals, physiotherapy technique like breathing exercise, postural
infections, socio-economic status, indoor and outdoor drainage, spirometry, clapping, vibration and
pollution3. proprioceptive neuromuscular facilitation of respiration
(PNF) and breathing techniques are shown to improve the
The abnormal inflammatory response develops air ventilatory capacity and decrease dyspnoea15-16.
flow limitation of the lungs which produces an obstruction
of mechanical function and the gas exchanging capability Neurophysiological facilitation of respiration is also
of the lungs. The symptoms of COPD is cough with known as controlled breathing techniques the use of

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Volume 4, Issue 3, March – 2019 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
selective external proprioceptive and tactile stimuli that Rhythmic stabilization performed as stimulate
produce the reflexive movement response to assist diaphragm by using the thumbs .the fingers are placed
respiration. These procedures have been employed in the contact with the lower chest walls. The patient is instructed
physiotherapy chest care more than 25 years17. “breathe in, and hold it”. The patient sustains breath while
physiotherapist applies pressure and stretch alternatively
PNF techniques with autogenic stretching give the chest wall and diaphragm .After 2 or 3 alterations, the
respiratory muscle relaxation and improve inspiration and patients instructed, “Breathe in again, again and again”
expiration in next inspiration –expiration cycle by reflex while the therapist repeats with increasing and decreasing
stretching. This way inspiration-expiration graph shows pressure to the diaphragmatic area.
improvement with active initiation or more participation in
respiration. As inspiration-expiration improves chest B. Diaphragmatic Breathing Exercise
expansion occurs effectively due to contractions of a 15 COPD patients received diaphragmatic breathing
stretched muscle are 18- 19. exercise, treatment 30 minute two times daily for 6 days in
a week for 3 consecutive weeks. Diaphragmatic breathing
The application of PNF techniques alter the rate and occurs when there is a conscious appreciation of inspiring
depth of breathing thereby changes of the respiratory rate, air to the lung bases with slight forward abdominal
improved respiratory muscle integrity &chest stability, displacement and passive relaxed expiration. The
which improves the breathing pattern of the diaphragm and instruction given to the patient was “breathe slowly through
increase tidal volume.. Airflow changes more slowly in the your nose and aim to getting air to the lower parts of your
COPD patients than the other patients, so COPD patients part of your lungs”, remember to relax your tummy and
require more repetition of PNF stretch in each session to allow the air to go under here (The investigator put his
get result while patients with active initiation of breathing hand on the subjects epigastric /sub costal region).Then
20
. relax and let all air out through your mouth, allowing your
tummy to sink gently”
Diaphragmatic breathing (DB) increases the
asynchronous and the paradoxical ribcage motion, which  Inclusive Criteria
may account for the work of breathing. Researchers have 1. Level of dyspnoea- patients with Borg’s scale rate of 3
examined DB affects overall ventilation, improves the gas (moderate) and 4(some what severe) on the 10 point
exchange and decrease the respiratory rate21. scale
2. Haemodynamically stable patients
Diaphragmatic breathing exercise reduces breathing
efficiency in people with severe COPD. Diaphragmatic  Exclusive Criteria
breathing contributes to appropriate chest wall motion and 1. Patients with pleural disorders.
decreased mechanical efficiency in patient with dyspnoea 2. Active lung infection like tuberculosis, typhoid,
and hypoxemia, which reduce the mechanical work of pneumonia.
breathing and improve ventilatory efficiency23. 3. Broncho-pulmonary fistula, Bronchial carcinoma.
4. Subjects with orthopedic deformity and trauma to chest
II. METHODOLOGY wall.
5. History of unstable cardiovascular condition.
Studied 30 COPD patient into two sub groups 6. Spinal cord injuries involved the phrenic nerve.

A. Proprioceptive Neuromuscular Facilitation of III. RESULTS

Respiration Techniques
15 patients received Proprioceptive Neuromuscular
Facilitation of Respiration techniques to stimulate
diaphragm muscle for 30 minute two times daily for 6 days
in a week of 3 consecutive weeks.

Techniques of stimulating response and strengthening

diaphragm muscle related to respiration by placing the
thumbs and palms of the hand along the costal cartilages of
the lower ribs. Pressure and stretch is applied with the
thumbs pushed up under the rib cage as far possible
without producing pain. The tips of the thumbs are pointed Table 1
toward the xiphoid process. Repeated contractions may be
performed to both sides simultaneously, or one side may  The mean difference of Borg scale pre scale Group A is
emphasize with sustained pressure to the other side. 3.6667 SD ± .48795 and Group B: 3.5333 SD ± .51640
Resistance applied to forced expiration in this area by and p value = .464 ns
resisting the downward motion of ribcage so as to prevent  Post scale Group A: 1.0000 SD ± .56695 and Group B:
the diameter of the lower chest as exhales. 14000 SD ± .80623 with a p= .11 ns

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Volume 4, Issue 3, March – 2019 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
functional method to retrain the diaphragm muscle in the
pulmonary rehabilitation.

Evidence suggests that Diaphragmatic breathing does

not change regional ventilation in people with COPD but
techniques increase total ventilation due to the slower,
deeper breathing patterns that may occur during DB rather
than an exaggeration of abdominal motion .review of the
articles on diaphragmatic breathing in stable COPD
patients increased in the work of breathing due to increased
paradoxical rib motion. The relaxed breath out results less
Table 2
air trapping and reduction of hyperinflation, which turns
into reduced respiratory rate, dyspnoea and improved tidal
 The mean difference pre total score of clinical COPD
volume and oxygen saturation in resting condition. A study
questionnaire group A is 5.1000 SD ± .42426 and
by Gosselink proved deep breathing exercise which
group B 5.0333 SD ± .51223 and p value = .611 ns
includes diaphragmatic breathing immediate decrease
 Post total score clinical of COPD group A: 1.5733 SD ± respiratory rate, dyspnoea and anxiety. Jones et al
.41484 and group B 1.8733 SD ± .43006 and p value = confirmed that DB results lower oxygen cost and
.092 ns respiratory rate Jones et al confirmed that diaphragmatic
breathing exercise reduce the oxygen cost and reduce the
IV. DISCUSSION respiratory rate.
Goals of pulmonary rehabilitation is minimization of
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