1st International Conference on Health Sciences

October 28-29, Yogyakarta Indonesia

EFFECTS OF WORKOUT COMBINATION OF THE UPPER BODY PARTS

WITH BREATHING EXERCISE AND CHEST PHYSIOTHERAPY TO LUNG FUNCTION, QUALITY
OF LIFE AND FUNCTIONAL CAPACITY IN STABLE COPD PATIENT

Amira Permatasari Tarigan1, P.Pandia1, Sahdra1, Hapsah1, Andrean1, Dewi Agustina2,

Maryaningsih2, Miarel2, Ika Rahman3

1. Department Pulmonology and Respiratory Medicine, Medical Faculty, University of Sumatera

Utara, Indonesia
2. Academic of Physioterapy, STIKes Siti Hajar Medan, Indonesia
3. Physiotherapy Clinic, Siti Hajar Hospital, Medan, Indonesia

Amira Permatasari Tarigan, amira@usu.ac.id

Introduction.COPD results in inability to perform daily activities, loss of productivity, and decreased quality
of life of the patient, all of which deteriorate along with the increased severity of the disease.
Aim.To look at the effects of upper bodypart training method on a combination of breathing exercises and
chest physiotherapy to lung function, functional capacity and quality of life of COPD patients by assessing
FEV1, FVC, the six minute walk test and CAT questionnaire (COPD Assesment Test).
Method.Chest physiotherapy and upper body workout with the combination of breathing exercises were
done to patients with COPD GOLD III-IV with or without comorbid for 8 times with the frequency 2 times a
week for a month. Spirometry test, CAT interview questionaires and six minute walk test were performed
before and after the research. The subjects were given 4 puffs of salbutamol inhaler by using MDI with
spacer eachtime before performing any test.
Results.Of all 26 patients, 22 patients completed the program and 4 patients dropped out. A significant
increase was found ( p < 0.001 ) in FEV1 where the mean was 0.41 0.14 and post-intervention was 0.61
0.65. A significant increase was found ( p < 0.001 ) in the quality of life of patients where the mean of CAT
score pre-intervention was 23.91 5:50 and post-intervention was 18,32 5,21. A significant increase was
also found in functional capacity ( p < 001 ) with the average mileage pre-intervention was 277.30 80.78m
rising to 319.11 78.30m.
Conclusion. Workout combination of the upper body parts with breathing exercises and chest
physiotherapy can increase lung function, quality of life and functional capacity in stable COPD patients.

Keywords
COPD, lung function, functional capacity, quality of life, chest physiotherapy, upper body workout.

1. Introduction

A newer projection estimated COPD will be the fourth leading cause of death in 2030 . As a result
of the condition of shortness of breath and persistent airway obstruction in COPD patients will result in
inability to perform daily activities, loss of productivity, and decreased quality of life, all of which deteriorated
with the increased severity of the disease1,2.
 Respiratory muscle training can increase ventilation, improve quality of life and reduce
breathlessness, thus will cut the spiral inactivity. Previous studies of pulmonary rehabilitation programs in
COPD patients, Incorvaia et al. reported value of lung function (Force Expiration Volume per one
second/FEV1) statistically significant increases from 1240 ml to 1252.4 ml, Yves Lacasse et al. reported a
mean increase of functional capacity (6-minute walking distance/6mwd test) of 55.7 m, and Kon et al.
reported the improvement of quality of life (COPD Assesment Test/CAT) as much as 3 point 3,4,5.
There are several kinds of exercise that can be given to COPD patients with persistent airflow
limitation, breathlessness and often followed by comorbid. This study aimed to examine the effect of chest
physiotherapy and upper body exercises combined with breathing exercises on lung function, functional
capacity and quality of life in COPD patients which evaluated with spirometry, the 6-minute test and
questionnaire CAT (COPD Assessment Test) before and after training for 8 times in 4 weeks. We expected
outputs of this study to be a model of proper exercise for patients with severe breathlessness and
comorbid.

2. Materials and methods

2.1 Materials
The study population was all patients with stable COPD as outpatient in COPD clinic in Adam Malik
Hospital, Medan, Indonesia. The subjects were taken by consecutive sampling who meets the criteria of
inclusion-exclusion. The intervention was done at the Clinic Physiotherapy Siti Hajar Medan, Indonesia.

2.2. Methods
An experimental study was conducted to COPD patients with all degrees of obstruction. The
exclusion criteria were osteoarthritis, exacerbation and uncooperative patient. Subjects were patients who
all signed informed consent and completed the study. The Intervention were chest physiotherapy and
followed by upper body exercises combined with breathing exercises for 1 month with a frequency of 2
times a week with a duration of about 45-60 minutes persesion. All subjects were measured by spirometry,
6-minute walk, CAT questionnaire, mMRC, blood test for CRP and uric acid level pre and post intervention.

2.3. Data Analysis

Univariate analysis to identify the characteristics of COPD patients based on age, sex, lung function,
quality of life and functional capacity before the interventions presented in the form of distribution frequency
table. Bivariate analysis were calculated by mean difference test (t-test) followed by t-test dependent
regarding the effect of exercise on lung function, functional capacity and quality of life.

3. Results
Of all 26 patients who participated at the beginning of the study, 22 patients were completed the study,
caused by personal reasons for 2 patients, while the other two were due to the worsening of comorbid
disorders. Table 3.1 is the characteristic of patients using the mean value.

Table 3.1 Patient Characteristics with mean value

Mean value
Parameters
( n=22)
BMI 24,6
Age 63,31
Brikmans Index 1209,08
FEV1 0,36
FVC 0,47
mMRC 2,50
Sat O2 97,38
6mwd 286,75
CAT 24,46
Uric acid level 7,44
CRP level 1,68

The predominant sex in this study was male; as many as 19 patients (86.0%) and women 3 patients (14%)
(Figure 3.1.)

Woman: 14%
Man: 86%

Figure 3.1. The proportion of patients with COPD by sex

Of 22 patients included in this study, the predominant age ranges were age> 60 years as many as
18 patients (68%) and the least one was <50 years as many as 1 patient (3%), (Table 3.2).

Table 3.2. Proportion of patients with COPD by age

Age N %
< 50 years old 1 4
50-60 years old 6 27
>60 years old 15 69
 Total 22 100,0

Of 22 patients, 20 patients (91%) had a severe degree of Brinkman index (history of smoking) and
moderate degree of Brinkman index were 2 patients (9%) and no patient in mild degree (0.0%). The
distribution of patients with COPD based on the degree Brinkman index can be seen in table 3.3

Table 3.3 Proportion of patients with COPD based on Brinkman Index

Brinkman Index N %
Mild 0 0
Moderate 2 9
Severe 20 91
Total 22 100,0
Note: Multiplication of the number of cigaret per day by the long years of smoking

Of 22 patients enrolled in this study, most patients were in severe degree of obstruction in 13 patients (59%)
and moderate were 7 patients (31%) while 2 patients were in very severe (10%). The distribution of
patients with COPD based on the degree of obstruction can be seen in table 3.4.

Tabel 3.4 Proportion of patients based on the degree of airflow limitation of COPD
Airflow Limitation N %
Mild 0 0

Moderate 7 31
Severe 13 59

Very severe 2 10
Total 22 100

There was an increase of FVC before and after chest physiotherapy and exercise which average
increase was 0.54 0.15, but the increases was not statistically significant (p = 0,207). FVC value
difference before and after intervention can be seen in Table 3.5

Table 3.5 Difference Value of FVC before and after Chest Physiotherapy and exercise
n Mean s.b. Difference Mean P
FVC pre 22 0.51 0.14 0.03 0.12 0.207
FVC post 22 0.54 0.15
An increase of average score of FEV 1 before and after chest physiotherapy and exercise, was from 0,37
(0.20 - 0.65) increased to 0:43 (0:27 to 3:47) and the increase was statistically significant (p <0.001). FEV 1
value difference before and after can be seen in Table 3.6.
Table 3.6 Differences FEV1 value before and after exercise and chest physiotherapy
Median
n (min - max) Mean s.d. P
FEV1 pre 22 0.37 (0.20 - 0.65) 0.41 0.14 0.001
FEV1 post 22 0.43 (0.27 - 3.47) 0.61 0.65

There was no increase in mMRC value before and after chest physiotherapy and exercise (p = 0.371).
mMRC value difference before and after intervention can be seen in table 3.7
Table 3.7 Difference mMRC value before and after chest physiotherapy and exercise
mMRC post
Tot
0 1 2 3 4 al P
mMRC 0.37
pre 0 1 0 0 0 0 1
1 0 2 1 2 0
2 0 1 5 0 0
3 0 0 3 2 0
4 0 0 1 3 1
1
Total 1 3 0 7 1 22

There was impaired oxygen saturation before and after chest physiotherapy and exercise. Mean level of
saturation pre-intervention 97.23 1.85 decreased to 96.86 1.64, but the decline was not statistically
significant (p = 0.308). Differences in oxygen saturation values before and after the intervention can be
seen in Table 3.8

Table 3.8 Difference Oxygen Saturation value before and after exercise and chest physiotherapy
n median (min - maks) Mean s.d. P
2 97.23
SatO2 pre 2 98 (91 - 99) 1.85 0.308
2 96.86
SatO2 post 2 97 (93 - 99) 1.64

The average CAT score increased after the intervention from 23.91 5,50 rising to 18,32 5.21 and the
increase was statistically significant (p <0.001). CAT score difference before and after intervention can be
seen in Table 3.9.
Table 3.9 Difference CAT value before and after exercise and Chest Physiotherapy
N Mean s.d. Mean difference P
CAT pre 22 23.91 5.50 5.59 2.79 < 0.001
 CAT post 22 18.32 5.21

The average six-minute walk (6MWD) increased after intervention from 277.30 80.78 increased to 319.11
78.30 and the mean increase was statistically significant (p <0.001). Differences in 6MWD values before
and after intervention can be seen in Table 3:10

Tabel 3.10 Differences Values Six-minute walk (6MWD) before and after exercise
and Chest Physiotherapy
N Rerata s.b. Perbedaan rerata P
6MWD pre 22 277.30 80.78 41.81 48.07 0.001
6MWD post 22 319.11 78.30

4. Discussion
Of 22 patients who completed the study, most patients were male (86.0%), simillar to Yunus et al,
male (86.2%) more than female (13.6%). This may be caused by risk factors such as smoking, which
males were more commonly smokers.
Distribution of subjects according to age the majority were aged > 60 years and the mean age was
63,31 y.o . This is consistent with Yunus et al who found the largest age between 61-80 years. Wihastuti get
a mean age of patients with COPD was 65.4 years old. 6 Siregar et al on his research on breathing
exercises to get the distribution of subjects according to the mean age is 64,94.9. Abidin et al get COPD
patients mean age of 66.2 and Tarigan et al get age 67,44. 7,8,9 Onset of COPD usually begins at age > 40
years and with increasing age, the symptom became appear. In addition, increased age also resulted in a
decrease in lung function.
Many reports state that smoking is a risk factor of COPD Patients. The longer history of smoking
can increase morbidity and mortality in COPD. Similarly, the highest count of cigarette also influence
morbidity and mortality of COPD. Brinkman index is the most frequently used instrument to assess the
degree of smoker, which is obtained from the multiplication results of average cigarettes smoked in a day
to length of smoking in year. In this study, the predominant Brinkman Index Values was severe (91% ). This
is similar to Ikalius et al reported that COPD patients tend to have a Brinkman index medium to severe
caused by high consumption of cigarette on patients.10 Smoking influence the important defense
mechanism of lungs. The macrophages in the lungs are known to have important functions as particles
cleaners that enter the body through the airway. Under normal circumstances, the macrophages have the
endogenous metabolism with high activity and high level of enzyme.
 Cigarette smoke and nicotine can decrease the function of macrophages in the lung. Specific
enzymes that serve as energy for fagosistosis can be suppressed by cigarette smoke. Besides cigarette
smoke can inhibit mucociliary transport that causes the sufferer more vulnerable to infection. Cigarette
smoke also induce oxidant that can activate alpha 1 protease inhibitor so that it can no longer prevent the
damage caused by elastase enzymes derived from neutrophils cells.
Smoking is known to have strong relationships with COPD, 98% of patients with COPD have
history of smooking. Smoking can increase the risk of developing COPD among others by reducing the
maximum lung function that can be achieved, leading to the onset of accelerated decline in lung function
and causes more rapid reduction in lung physiology.1,2 Based on the degree of COPD, most subjects in this
study suffered severe obstruction (59%) . This is likely due to the high history of smoking in these subjects
as well as the effect of age. Lung function changes occur gradually in accordance with age. Around the age
of above 30 years lung function FEV1 begins to decline about 25-30 ml per year and a smoker will
experience a faster decline of around 125 ml per year. 11,12
In elderly there is a change in the form of the chest wall stiffness due to changes in the spine and
joints costovertebral thus reduced chest wall compliance. There is a decrease in the elasticity of the lung
parenchyma, increased mucous glands of the bronchi and thickening of the bronchial mucosa. The result is
an increase in airway resistence, decrease in lung function, as forced vital capacity (FVC), forced
expiratory volume in the first second (FEV 1), Force expiratory flow, midexpiratory phase (FEF 25% -75%).
There is an increase in the residual volume due to loss of lung elastic recoil. However, the severity of
obstruction degree in patients with COPD has not matched the age of patient. As in this study, very severe
degree of obstruction was found in the age range 50-60 years 1 patient (4.5%) and age> 60 years 1 patient
(4.5%). COPD patients with severe obstruction degree (59%) were found in all age groups. This is caused
by many factors that can accelerate the decline in lung function among other recurrent lung infections,
genetic factors that make a faster decline in lung function, another disease that can aggravate pulmonary
conditions, and patients with COPD who continue smoking. Donaldson et al. reported that COPD patients
who suffered infections and exacerbations more frequently (> 2.92 times / year) decreased FEV1 more
around 40 ml / year and PEF 0.9 liters / year. While those who experience exacerbations more rarely (<2.92
/ year) get decline in FEV1, around 32 ml / year and PEF 0.7 liters / year. 13,14
In this study, there was an increase in lung function after exercise FEV 1 of 0.41 to 0.61, specific exercises in
breathing muscles will result in increased maximum ventilation, improve the quality of life and reduce
breathlessness. In patients who are unable to do the endurance exercise, respiratory muscle training will be
beneficial. If both forms of exercise can be carried by the patient results will be better. This is consistent with
Incorvaia et al who provide rehabilitation program in 257 COPD patients in which FEV 1 vaue increased
significantly from 1240 ml to 1252.4 ml.
 Functional capacity is the ability to perform activities of daily life. An objective assessment of the
functional capacity in this study was the 6-minute test. There was significant change in the mean 6-minute
walking distance after the intervention (p <0.001). The mean distance of the 6-minute test preintervention
was 277.30 80.78 meters and after given exercises for 4 weeks there was an increase in distance up to
319.11 78.30 meters. There is an increase in the distance of 41.81 48.07 meters at the end of the
exercise (p <0.001).
Finnerty et al reported the increase in 6-minute test in the group receiving 6 weeks of pulmonary
rehabilitation increase the distance of 59 meters compared to controls. 15 Bendstrup et al reported the the
increase in 6-minute walking distance of 79.8 m in the treatment group and 21.6 m in the control group (p
<0.001) .16 Lacase et al conducted a meta-analysis of patients with COPD who received pulmonary
rehabilitation, the mean difference in the 6 minute increase in distance of 55.7 meters. In this study
concluded that the minimum clinically important differnce (MICD) is 50 M. 4 Britsh Thoracic Society (BTS)
recommends a minimum increase in clinically significant distance is 54 m. 17 Regular exercise, intensive and
specific period of time in patients with COPD as in this study with Stationary Cycling and chest
physiotherapy will be a change of biochemical tissue, cardiorespiratory, and hormonal. Increased
concentrations of myoglobin is oxygen-binding pigment that helps the diffusion of oxygen from the cell
membrane into the mitochondria. Myoglobin increased in skeletal muscle associated with changes in the
dominant type I muscle as a result of exercise. Exercise will increase the capacity of skeletal muscle to
perform aerobic metabolism so that energy is formed larger and increase the anaerobic threshold. Exercise
can occur changes in the cardiorespiratory, especially induced oxygen transport system, that is the system
of circulation, respiration and body tissues.This system works in an integrated manner, causing changes in
heart size, decreased pulse rate, increased stroke volume, increased blood volume, hemoglobin levels,
increased VO2 max and changes in breathing patterns. Improved aerobic capacity is the basis for
determining the capacity of the cardiorespiratory system. Rate aerobic threshold can be determined by
measuring blood levels of lactic acid, patients who get regular exercise, and in a certain period of intensive
blood lactic acid levels will decrease.10 In this study, the increase in distances that are less than 54 m
possible causes include comorbid disease, duration and the type of exercise. Where in this study almost
all patients have a comorbid, duration of training was only 4 weeks and the type of exercise only the upper
body and breathing exercise where the patient carry out the exercise while seated on a couch without lower
body exercise.
Assessment of quality of life in these patients also showed significant differences after the
intervention. Each patient felt quite good results at the end stages of the exercise. It can be seen from the
CAT at the beginning of the exercise amounted to 23.91 5:50 and at the end of the exercise at 18:32
5:21 (p <0.001). A multicenter study conducted by James W Dodd in 2011 that connects the CAT response
assessment in pulmonary rehabilitation showed significant differences after training for 8 weeks in which
162 patients feel better after pulmonary rehabalitation programe. 18 Thomas Ring Baek also compared the
response assessment SGRQ , CCQ, CAT in a pulmonary rehabilitation programe conducted for 7 weeks.
CAT and CCQ represent the quality of life assessment in patients with COPD and has more advantages
because it is easy and can be done in a short time than SGRQ. 19 Paul Jones on his research in 2010 also
stated that CAT responsive to pulmonary rehabilitation where there is an equivalent value of 5,5 SGRQ
unit.20 Lacasse et al. reported from meta-analysis that pulmonary rehabilitation will reduce the symptoms of
breathlessness and improve the activity of patients with COPD so that the functional capacity and quality of
life also increase.3 Berry et al. also explained that pulmonary rehabilitation will increase the maximum
oxygen consumption and maximum work capacity thus increasing the functional capacity and quality life. 21
From the CAT questionnaire we can also assess changes in each patient complaints. There is a reduction
in patient sputum at each stage of the exercise. This is consistent with the objective of chest physical
therapy on pulmonary rehabilitation program is to aid the move of secretions and also prevent the
accumulation of secretions. Rachel Garrod assessing several studies that examined the effectiveness of
chest physical therapy in patients with chronic obstructive pulmonary disease and came to the conclusion
that effective chest physical therapy to clear the airways.22 Exacerbations incident did not occur during the 4
weeks of study and training, and other complications not found. Finally, suggestions for further research to
be given exercise is a combination of breathing exercises with upper body exercises and lower, and with a
longer duration is 8 weeks.

5. Conclusions
Workout combination of the upper body parts with breathing exercises and chest physiotherapy can
increase lung function, quality of life and functional capacity in stable COPD patients.

Acknowledgements
USU research institutions, staff and resident of Department of Pulmonology and Respiratory Medicine.
Physiotherapist at Physiotherapy Clinic Siti Hajar and STIKes Siti Hajar and all those who participated in
this study so could be completed and published.

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