V-03/2008

KNGF-Guideline for physical therapy in patients with

chronic obstructive pulmonary disease

Problem solving

Dysnea
Impaired mucus clearance
Impaired exercise performance
Infections
PA
Screening Referral

Pulmonary function tests

Pulmonary function tests
and exercise test

Exertional dyspnea
Recurrent respiratory infections Poor physical activity in daily
Case
exacerbations with hypersecretion life (MRC 2), < 30 min/day
history
Adherence to treatment Comorbid conditions
(cardiovascular disease)

Exercise performance and

Mucus quality and quantity
physical activity
Physical Impaired cough:
Respiratory and peripheral
assessment - airway collapse,
muscle function
- muscleweakness
Quality of life

Causes of exercise limitation / inactivity

Causes of impaired cough
Motivation / self-management
Analysis

Optimal medical treatment no

Referral physician
Sufficient referral data

Health education
Self-management

Treatment
Forced expiration Excercise training
Cough Muscle training
Adjuncts (PEP, PD) Breathing exercises

Exercise performance, physi-

Number of respiratory infections
Outcome cal activity, Muscle strength,
with mucus retention - Symptoms
Quality of life

PA = physical activity; PEP = positive expiratory pressure; PD = postural drainage.

Royal Dutch Society for Physical Therapy

 V-03/2008

KNGF-Guideline for physical therapy in patients with

chronic obstructive pulmonary disease

Dyspnea, impaired physical activity and physical fitness

Spirometry / MRC-score / Physical activity (< 30 min./day)

FEV1 50% pred. FEV1 50% pred. FEV1 < 50% pred.
MRC-score <2 MRC-score 2 MRC-score 2

Multidisciplinary
No physical therapy Cycly ergometry*
Assessment
Advice:
Increase physical activity
Adapted sports activity
Wmax 70% pred. Wmax < 70% pred.
Regular sports activity
VO2max 80% pred. VO2max < 80% pred.

Advice: Multidisciplinary
Increase physical activity Rehabilitation
PT intake physical activity programme

Physical activity programme

Adapted sports activities

* The Primary care physicians guideline and Transmural guideline for COPD only recommend exercise testing in patients
with increased cardiovascular risk. The ACSM guideline recommends exercise testing in any elderly subject, while the Physical
therapy in COPD guideline recommends exercise testing in any COPD patient.
MRC = Medical Research Council dyspnea score
FEV = positive expiratory pressure

no physical therapy / advice to increase physical activity

treatment in primary care (physical activity program)
treatment in secondary/tertiary care (rehabilitation)

Royal Dutch Society for Physical Therapy

 V-03/2008

KNGF-Guideline for physical therapy in patients with

chronic obstructive pulmonary disease

Impaired exercise performance/dyspnea

Peripheral Anxiety
Cardio- Oxygen transport
Ventilatory muscle Motivation
circulatory in the lungs
strength Self-esteem

Respiratory
muscle weakness
Hyperinflation

Hypoxemia/Hypercapnia
during exercise?

IMT
Body positioning
Rollator Muscle training Counseling
Endurance Interval training NIV EMS Relaxation
training ev. suppl. O2 Active expiration Nutrition Education
PLB

IMT = inspiratory muscle training; NIV = non-invasive ventilation; EMS = electrical muscle stimulation;
PLB = pursed lips breathing; ev. = eventually.

Royal Dutch Society for Physical Therapy

 V-03/2008

KNGF-Guideline for physical therapy in patients with

chronic obstructive pulmonary disease

Impaired Mucus Clearance

Yes Hypersecretion? No

Yes
Cough/Huff effective?
Physically active?
Treatment compliance?

No Yes

No

See Flow Chart No indication for physical

Impaired Exercise Performance therapy
(see figure 3)

Inadequate technique?
Airway collapse?
Non-compliance?

Yes Yes

Teach coughing/huffing/breathing exercise dependent on severity and

causes of obstruction
Education - improve compliance

Re-assessment Evaluation: treatment effective?

Confirm indication with
referring physician Yes
No

Stop treatment

Other treatments:
Postural drainage, PEP
Flutter
Report to referring physician
Percussion/Vibration

PEP = positive expiratory pressure.

Royal Dutch Society for Physical Therapy