Peter Anderson MCSP
All people with cystic fibrosis (PWCF) have a physiotherapy regime, in fact it’s one of the first things PWCF or their parents are taught following diagnosis and it is accepted as a cornerstone of the management of the disease. Of course, everyone knows why they do physiotherapy, don’t they? Well, to clear mucus from their lungs, that much is obvious, but why do they have to do physiotherapy to achieve this? Why can’t they just cough and clear it like anyone else and what practical benefits does it provide?
“…the benefits may not be immediately clear…”
The bacteria that colonise the lungs of most PWCF live and breed in the mucus produced by their lungs. The dark, moist, warm conditions are an ideal environment for them. People without lung disease breathe in the same bacteria but their lungs deal with this and clear them without much of a problem, however if you have a lung condition which causes an excess of mucus to build up in the lungs (to even a small degree) the bacteria gets trapped in the mucus and begins to multiply very quickly and unfortunately often, as with the Pseudomonas aeruginosa bacteria you may never get completely clear of it. It then becomes a battle to keep them under control. Part of this battle is the use of antibiotics, but unless you clear the mucus from your lungs and keep it clear, then the bacteria will quickly begin to multiply again and cause infections. The gradual worsening of lung disease in CF is largely due to the trauma caused to the lungs by these repeated infections. Keeping infections at a minimum is consequently of extreme importance. Those PWCF who become unwell when they don’t do their physiotherapy are aware of how important it is in combating infection only too well. It is a process which can occur over a long time, so the benefits may not be immediately clear, especially to those who don’t feel any obvious deterioration when they don’t do their chest physiotherapy. For those people who produce little or no sputum and who do not have infections, the goal is to keep them that way as long as possible.
“…deep seated secretions.”
Coughing is something that is used after physiotherapy to clear the mucus from the throat and upper airways, but if the mucus has not been moved high enough from the lungs in the first place then coughing will not move it there. If mucus is left lying in the lungs it will very easily trigger a cough. In normal lungs this is usually enough to get rid of it, but unfortunately even in mild CF there is a tendency for the airways to be collapsible and narrowed. Therefore the force of a cough can be so high that the airways (especially the smaller ones), may close, making the movement of mucus inefficient. Mucus can usually be coughed up from the larger airways but because of the sharp deep breaths taken before a cough it’s more likely to force the mucus deeper down, making it even harder to clear and even huffing alone won’t move these deep seated secretions.
“It should be part of your lifestyle…”
In preparing this article I asked one of our adults who attends the centre where I’m based, “why is it important that you do your physiotherapy”. The reply was, “Because the physio will hound you if you don’t”. Now obviously this was light-hearted, but I see patients with CF regularly for whom this thought, or something like it, is their main motivation for carrying out their treatment. Physiotherapy has developed that kind of “Secret Police” attitude to it and I suppose anything to get people to do their physiotherapy helps. But by adopting this outlook it’s unlikely that PWCF will be motivated sufficiently to carry out their treatment effectively. Then the object of treatment becomes less to do with the beneficial effects on your lung problems and more to do with just getting your physio over with so you can say you’ve done it. Physiotherapy should be really only just one of a great number of things that can be done every day; some connected with CF, but most not. It should be part of a PWCF’s lifestyle, but more importantly something which helps them maintain their lifestyle and it is up to physiotherapists to make sure this approach is taken from the beginning.
“…there is a much wider spectrum of physiotherapy techniques and devices to choose from.”
In times gone by chest physiotherapy universally meant “Postural Drainage” and “Chest Clappings” and indeed these remain widely and effectively used techniques in some parts of the world. But increasingly nowadays there is a much wider spectrum of physiotherapy techniques and devices to choose from. Techniques such as: Autogenic Drainage; The Active Cycle Of Breathing and devices like: The Flutter © and Positive Expiratory Pressure (PEP). These devices and techniques as well as traditional chest physiotherapy have been extensively researched to find out how effective they are and comparing them against each other. Unfortunately physiotherapy is not something which lends itself well to scientific research. It’s not like giving someone a drug and seeing what effect it has. The main thing so far to come out of all this research is that it is important to do physiotherapy and that it leads to much more positive outcomes compared with not doing any physiotherapy and helps maintain lung function and keep infections at bay. Beyond that it gets a bit greyer and other techniques and devices have been shown to be: better; worse; or as good as traditional techniques depending on what research you read and how it’s been carried out. That is why it is important that each person is assessed by their physiotherapist as an individual and suggests the best approach for him or her. The patient is obviously the most important part of this process and often it includes an element of “try and see”.
PEP and Flutter devices augment mucus clearance, but in different ways. Put simply, The Flutter works by causing a vibration in the chest helping to loosen mucus. It also helps overcome wheeze during chest physio. PEP devices work partly by opening up small collapsed airways deep in the lungs. Whether any of them would be helpful depends on each individuals particular problems.
As well as treatment to clear your chest another area your physiotherapist can give you advice on is exercise. The research carried out in exercise has demonstrated quite clearly the important beneficial effects it has on lung disease in CF. Higher levels of aerobic fitness produces the same positive changes that it has for the rest of the population. PWCF who are more limited by their shortness of breath may need more help and advice, but they can achieve the same positive benefits. Breathlessness can develop independent of the condition of your lungs.
“…consequently they may try to avoid any exertion which makes them breathless.”
The breathless episodes that some PWCF experience can be quite frightening, consequently they may try to avoid any exertion which makes them breathless. This avoidance can lead to a gradual deterioration in their level of general fitness and it is this loss of fitness that will become the main cause of breathlessness. It is important therefore that a therapist shows each PWCF how to improve their exercise tolerance in a controlled way and how to avoid this breathlessness becoming too excessive during exercise. Even with relatively poor lung function, each PWCF can achieve exercise to a high level if they get the right advice from their physiotherapist and, crucially, if they are determined to do it. Getting started with an exercise programme can and should be an important part of the management of CF.
“That’s what we’re here for.”
So if you have CF and have a physiotherapy regime that you manage well and keeps your lung problems under control, then you should obviously continue with it. But if you don’t feel you are doing the best you can, or require advice, your physiotherapist will be happy to work with you on this. That’s what we’re here for. Education is not just for when you first start using physiotherapy. Throughout your life you may need time to learn techniques taught a long time ago, especially if you’re beginning to take more personal control of your treatment, or you may need to learn new techniques. I personally continue to work in physiotherapy because I know it can make such a dramatic positive impact on the lives of PWCF and help keep their condition under some sort of control.
“…all people with cystic fibrosis need physiotherapy…”
Therefore to answer the question set out in the title of this article, all people with cystic fibrosis need physiotherapy and I’m sure that comes as no surprise to any of you.
Peter Anderson MCSP
Senior Physiotherapist
West Of Scotland Adult CF Unit
Gartnavel General Hospital
Great Western Road
Glasgow
UNITED KINGDOM
p.anderson2 @ ukonline.co.uk
