Chest mobilization exercises, Butterfly Technique

CHEST MOBILIZATION EXERCISES, COUNTER-ROTATION TECHNIQUE, BUTTERFLY TECHNIQUE, BREATH CONTROL DURING WALKING. These Mobilization Techniques are useful to improve Chest Wall Mobility and Expansion in Patients with Restricted Chest wall movements and also Postoperative patients

1. Chest Mobilization Techniques Dr. T. Sunil Kumar Dept. of Physiotherapy

2. Introduction Chest mobilization is one of many techniques and very important in conventional chest physical therapy for increasing chest wall mobility and improving ventilation. Either passive or active chest mobilizations help to increase chest wall mobility, flexibility, and thoracic compliance. The mechanism of this technique increases the length of the intercostal muscles and therefore helps in performing effective muscle contraction.

3. The techniques of chest mobilization are composed of rib torsion, latera stretching, back extension, lateral bending, trunk rotation, etc. This improves the biomechanics of chest movement by enhancing direction of anterior-upward of upper costal and later outward of lower costal movement, including downward of diaphragm directions.

4. Maximal relaxed recoiling of the chest wall helps in achieving effective contraction of each intercostal muscle. Thus, chest mobilization using breathing, respiratory muscle exercise or function training allows clinical benefit in chronic lung disease, especially COPD with lung hyperinflation or barrel-shaped chest.

5. Therefore, the technique of chest mobilization helps in chest wall flexibility, respiratory muscle function and ventilatory pumping, and results from this relieve both dyspnea symptoms and accessory muscle use.

6. Goals Maintain or improve mobility of the chest wall trunk and shoulders when it affects respiration. For example, a patient with tightness of the trunk muscles on one side of the body will not expand that part of the chest fully during inspiration. Exercises that combine stretching of these muscles with deep breathing will improve ventilation on that side of the chest.

7. Reinforce or emphasize the depth of inspiration or controlled expiration. For example, a patient can improve expiration by leaning forward at the hips or flexing the spine as he or she breathes out. This pushes the viscera superiorly into the diaphragm and further reinforces expiration.

8. Thoracic Mobilization Techniques If mobility of the thorax is restricted, it may be difficult for a patient to improve his or her breathing pattern through controlled breathing alone. It may be necessary to incorporate simple thoracic mobilization techniques to increase the ability of the thorax to expand during breathing. Simple positioning can be used to increase thoracic mobility. Placing a towel roll vertically down the thoracic spine while the patient is in a supine position can improve anterior chest wall mobility.

9. Similarly, placing the patient in side lying over a towel roll can increase lateral chest wall mobility. Upper extremity movement can be paired with each position to increase mobility. The upper extremity is either actively or passively elevated to further stretch the affected areas. This technique can be progressed to sitting or standing positions.

10. Indications Patients with limited chest movements; either structurally or physiologically. However, This technique can be used for various conditions such as COPD, prolonged bed rest, abnormal spine, deconditioning and aging.

11. Contraindications Severe and unstable rib fracture Metastasis bone cancer Tuberculosis spondylitis Severe osteoporosis Herination Severe pain Unstable vital signs

12. Functional movements in sitting position 1. Flexion and extension 2. Lateral flexion 3. Trunk rotation

13. Specific Exercises 1. To mobilize one side of the chest . While sitting, have the patient bend away from the tight side to lengthen tight structures and expand that side of the chest during inspiration. Then, have the patient push the fisted hand into the lateral aspect of the chest, as he or she bends toward the tight side and breathes out. Progress by the patient raise the arm on the tight side of the chest over the head and side bend away from the tight side, This will place an additional stretch on the tight tissues.

14. 2. To mobilize the upper chest and stretch the pectoralis muscles . while the patient is sitting in a chair with hands clasped behind the head, have him or her horizontally abduct the arms (elongating the pectoralis muscles) during a deep inspiration.

15. 3. To mobilize the upper chest and shoulders With patient sitting in a chair, have him or her reach with both arms over head (180 degrees bilateral shoulder flexion and slight abduction) during inspiration. Then have the patient bend forward at the hips and reach for the floor during expiration.

16. 4. To increase expiration during deep breathing Have the patient breathe in while in a hook lying position (hips and knees are slightly flexed) Then instruct the patient to pull both knees to the chest (one at a time to protect the low back) during expiration (picture). This pushes the abdominal contents superiorly into the diaphragm to assist with expiration.

17. COUNTERROTATION TECHNIQUE Counterrotation technique can increase tidal volume and decrease respiratory rate by reducing neuromuscular tone and increasing thoracic mobility. It is effective for (1) Patients with impaired cognitive functioning after neurologic insult, (2) Young children who are unable to follow verbal cues, and (3) Patients with high neuromuscular tone. Briefly, this technique incorporates rotating the upper trunk to one side while the lower trunk is rotated in the opposite direction

18. The patient is positioned in side-lying with knees bent and arms resting in front. The patient should be in a comfortable position to facilitate relaxation. The therapist stands behind the patient, perpendicular to the patient’s trunk. With one hand on the patient’s shoulder and one hand on the patient’s hip, the therapist assesses the patient’s breathing cycle. Next, the patient is log-rolled gently from the side-lying position toward prone. At the same time, the therapist is audibly breathing with the patient. As the technique progresses, the therapist gradually slows audible cuing for a decreased respiratory rate.

19. In phase two, the therapist moves to stand behind the patient near his or her hips and faces the patient’s head, and then the therapist changes hand position. If the patient is lying on the left side, the therapist slides the left hand to the patient’s shoulder and the right hand to the patient’s right gluteal fossa at the beginning of expiration. Then, the therapist can facilitate more complete exhalation, compressing the rib cage manually at the end of exhalation by pulling the shoulder back and down and the hip up and forward.

20. The opposite occurs during inhalation. The therapist slides the left hand to the patient’s right scapula and the left hand to the patient’s right iliac crest. During inhalation, the therapist stretches the chest by pulling the pelvis back and down and the scapula up and away from the spine. Initially, this is done along with the patient’s breathing cycle and respiratory rate but slows as the treatment progresses. Audible breathing cues slow along with the manual facilitation. The technique progresses by gradually decreasing manual input and then by eliminating verbal cues.

21. BUTTERFLY TECHNIQUE The butterfly technique is an upright version of the counterrotation technique and can be used if the patient has good motor control. The patient sits unsupported, and the therapist stands either in front of or behind the patient. The therapist assists the patient with bringing his or her arms up into a butterfly position. The therapist breathes audibly with the patient. With inhalation, the therapist brings the patient’s arms into increased shoulder flexion and lowers the arms during exhalation.

22. The therapist then slows the audible breathing pattern and the facilitation of shoulder movement to encourage an increased tidal volume and decreased respiratory rate. The therapist can incorporate diagonal movement into the technique to facilitate increased intercostal and oblique abdominal muscle contractions.

23. BREATHING CONTROL ON WALKING When the patient is able to control his breathing in the necessary relaxed positions, progression can be made to the control of breathing while walking on the level, up stairs and on hills. Many patients tend to hold their breath and find it difficult to breathe economically when taking exercise. The tendency to hold the breath only increases the feeling of breathlessness.

24. Breathing in rhythm with their steps can be helpful; for example, breathing out for two steps and in for one step, out for three steps and in for two steps, or out for one step and in for one step. The correct breathing pattern will vary with each individual. The physiotherapist can help to find the optimum pattern by walking with the patient and helping him, initially, by counting the synchronized walking-breathing pattern with the patient.

25. THANK YOU