What's bronchial asthma?y Bronchial asthma is a disease caused by increased

responsiveness of the tracheobronchial tree to various stimuli. The result is paroxysmal constriction of the bronchial airways.

What's bronchial asthma?y Asthma is a variable chronic disease of the respiratory system

characterised by the constriction of the smaller bronchi and bronchioles (three to five millimetre diameter), increased bronchial secretions or mucus and mucosa swelling or inflammation, often in response to one or more triggers. y Asthma is characterised by paroxysmal attacks of dyspnea, chest tightness, coughing and wheezing due to airway obstruction. Due to the high and ever-increasing incidence and cost of asthma, this disease has become a new so-called epidemic with approximately 150 million individuals diagnosed with asthma world-wide. In this regard, sustained and extensive efforts have been made by epidemiologists in recent years to propose some treatment measures that will hopefully limit the morbidity and mortality of this disease.

PATHOGENESISIn the initial stage, the patient can be totally symptom-free for long periods of time in the intervals between the attacks. As the disease progresses, increased mucus is secreted between attacks as well, which in part builds up in the airways and can then lead to secondary bacterial infections. Bronchial asthma is usually intrinsic (no cause can be demonstrated), but is occasionally caused by a specific allergy (such as allergy to mold, dander, dust). Although most individuals with asthma will have some positive allergy tests, the allergy is not necessarily the cause of the asthma symptoms.

SYMPTOMSy Symptoms can occur spontaneously or can be

triggered by respiratory infections, exercise, cold air, tobacco smoke or other pollutants, stress or anxiety, or by food allergies or drug allergies. The muscles of the bronchial tree become tight and the lining of the air passages become swollen, reducing airflow and producing the wheezing sound. Mucus production is increased.

RISK FACTORSy Typically, the individual usually breathes relatively normally, and

will have periodic attacks of wheezing. Asthma attacks can last minutes to days, and can become dangerous if the airflow becomes severely restricted. Asthma affects 1 in 20 of the overall population, but the incidence is 1 in 10 in children. Asthma can develop at any age, but some children seem to outgrow the illness. Risk factors include self or family history of eczema, allergies or family history of asthma. Bronchial asthma causes cough, shortness of breath, and wheezing. Bronchial asthma is an allergic condition, in which the airways (bronchi) are hyperreactive and constrict abnormally when exposed to allergens, cold or exercise.

TREATMENTy Treatment is aimed at avoiding known allergens and controlling symptoms through medication. A variety of medications for treatment of asthma are available. People with mild asthma (infrequent attacks) may use inhalers on an as-needed basis. y Persons with significant asthma (symptoms occur at least every week) should be treated with anti-inflammatory medications, preferably inhaled corticosteroids, and then with bronchodilators such as inhaled Alupent or Vanceril. Acute severe asthma may require hospitalization, oxygen, and intravenous medications.

PREVENTIONy Decrease or control exposure to known allergens by

staying away from cigarette smoke, removing animals from bedrooms or entire houses, and avoiding foods that cause symptoms. Allergy desensitization is rarely successful in reducing symptoms

WHY PHYSICAL REHABILITATION?y Improved exercise capacity y Improved health-related quality of life y Reduced hospitalisations and length of stay y Reduced anxiety and depression associated with

bronchial asthma y Increased survival y Benefits probably extend well beyond the period of rehab, especially if exercise training is maintained at home.

AIMS OF PHYSICAL REHABILITATIONy To restore balance of stimulative and inhibitory y y y y y

processes in the thorax of bigger cerebral hemispheres. To decrease corticovisceral reflexes To reduce bronchospasm and improve lung ventilation To activate trophic processes in tissues Prevent lung emphysema To improve the ability of the patient to expire for a long time.

PHYSICAL REHABILITATIONy Physical rehabilitation in hospitals comprises of 3

periods. y 1. sparing- this is aimed at bringing the patient to his functional capacity, the duration depends on how serious the patient s state and it involves breathing exercises, massage of peripheral muscle group.

PHYSICAL REHABILITATIONy Stage 2. In the second stage, the training is done in the

sitting position, walking, vibratory massage and the classic chest massage. y Stage 3. The same medical physical training is done but in local sanatoriums or polyclinics. y Medical physical training tones up the central nervous system, it improves of functional state of the patient and mobilizations of compensatory mechanisms. It gives positive effect on neuro-regulatory mechanisms of blood circulatory system.

PHYSICAL REHABILITATIONy These exercises focus on special breathing exercises

with prolonged exhalation y Sound exercises which help reflex decrease of bronchospasm y Exercises that promote muscle relaxation of the upper shoulder girdle, diaphragmatic respiration y Exercises to strengthen the abdominal wall

Callisthenic Trainingy callisthenics before exercise training results in

maximal expiratory flow rate diminishment. This diminishment is significant in that it can act as a preventative method in the development of exercise induced asthma and as such allows the asthmatic to optimally benefit from training.

Postural Retrainingy Postural exercises have been recommended since the

posture of an asthmatic is typically pronounced by thoracic kyphosis and the flattening of the sacrolumbar portion. These postural misalignments can lead to a decrease respiratory capacity and can severely affect visceral functioning. However, these postural abnormalities have been found to be improved following postural retraining that includes postural, breathing and abdominal strengthening exercises

Postural Retrainingy Postural retraining can correct thoracic kyphosis and

improve breathing in asthmatics especially in severe asthmatics that are more likely to suffer from such postural abnormalities when the pectoral and intercostal muscles are stretched. Postural retraining in asthmatics should focus on the facilitation of correcting righting, equilibrium and protective reactions with normal tactile, proprioceptive and kinesthetic input.

Breathing Trainingy Diaphragmatic breathing exercises could benefit an

asthmatic s condition since they compress the abdominal contents which increase intra-abdominal pressure that causes lateral transmission of pressure to the lower ribs laterally, upward and outward motion of the lower ribs and anterior/posterior motion of the upper ribs. This then results in an increase in thoracic volume that decreases intra thoracic pressure which facilitates inspiration.

Breathing Trainingy Breathing training is essential to an asthmatic since,

breathing in an asthmatic is of the thoracic type and since dyspnea can cause the asthmatic to increase inspiration further leading to further overextension of the already over-inflated lungs.

Breathing Trainingy y y y y y y y y y y

The purpose of breathing exercises is to empty the lungs by prolonging the expiratory phase, retrain normal breathing patterns, increase expansile forces in hypo-ventilated areas, increase lung volume, dilate airways, force mucus into larger airways, re-educate the autonomic diaphragmatic movements reduce the thoracic type breathing, relax spasmodic muscle contractions, mobilise the ribs and chest wall and correct kyphosis

Breathing Trainingy These benefits are achieved by shortening inspiration and y y

y y

lengthening expiration, by performing expiration via the pulling in of the abdominal muscles dorsally towards the spine while relaxing the abdominal, intercostals and neck musculature. This is achieved by using special weights or belts to increase intra-abdominal pressure, by applying compression to the lower ribs to facilitate expiratory ascent of the diaphragm during expiration which can increase the movement of secretions from the small bronchi into the respiratory passages, by exhaling through a resistive breathing device by breathing while creating a hissing noise in order to reduce bronchial constriction.

Breathing Trainingy Diaphragmatic breathing exercises have also been proven to reduce patients anxiety levels and to alter their attitude towards work while breathing retraining has been shown to decrease bronchodilator use and acute exacerbations and to improve quality of life. y Breathing exercises have been found to decrease anxiety during an asthma attack and also prevent the onset of an attack. y Breathing exercises have resulted in clinical improvements which translated into improved school attendance, exercise tolerance, asthma control and self-confidence.

Inspiratory Resistive Breathing Trainingy The purpose of inspiratory resistive breathing training is to enhance

respiratory muscle function and in doing so possibly reduce the severity of breathlessness and improve exercise tolerance. y This may benefit the asthmatic patients, especially those with severe asthma, since asthmatics could suffer from respiratory muscle dysfunction due to the loss in respiratory muscle bulk and resultant respiratory muscle strength. y The use of inspiratory resistive breathing training in asthmatic patients could possibly result in improvements in inspiratory muscle coordination, improvements in inspiratory muscle strength and endurance and the correction of inappropriate respiratory muscle effort. y These improvements and corrections then possibly result in improvements in spirometry variables, a desensitisation to dyspnea, lessening of asthma symptoms, reduced hospitalisations, less emergency room contacts, absences from school and work and/or the decreased use of medication

Aerobic Exercise Trainingy Aerobic training has become the prominent mode of

exercise treatment for asthmatics. This is probably justified since aerobic exercise training has been found to cause a decrease in ventilatory demand for a given workload, thus blunting the exercise-induced asthmatic response

Aerobic Exercise Trainingy Aerobic training can decrease airway sensitivity despite no change in

airway reactivity and has been found to enhance exercise-induced bronchodilation. Bronchodilation can be promoted, bronchospasm threshold increased and bronchoconstriction response blunted at higher workloads by increasing the number of Beta 2 (2) receptors, by directly increasing 2 adrenoceptor sensitivity and by increasing catecholamine release and thereby 2 adrenoceptor stimulation. y In addition to the general benefits of exercise training, aerobic training has also been found to reduce medication use and air trapping in the asthmatic individual, which effectively places the diaphragm in a more advantageous position mechanically. If the diaphragm is placed in a more advantageous position mechanically, an improved excursion of the diaphragm will occur and the diaphragm s contractions will be less spasmodic which will ultimately improve airway reserve, vital capacity VC and alveolar gas exchange, all of which serve to improve inspiration.

Lactate Threshold Trainingy The anaerobic component of physical conditioning

may be important in the overall physiologic profile of the individual with asthma. It has been proposed that asthmatics should participate in brief, intense bouts of y muscle work alternating with rest periods since this mode of training is less likely to induce EIA and reduces the risk of asthma exacerbations while allowing the asthmatic patient to train optimally for longer periods.

Lactate Threshold Trainingy The importance of improving lactic acid metabolism

and tolerance in Exercise Induced Asthma patients and exercising at or above lactate threshold is of critical importance since, this intensity is not only less likely to induce EIA, it is sufficient to increase aerobic capacity while minimising the amount of water loss from hyperventilation during exercise thus suppressing the onset of EIA. A benefit of lactate threshold training is that this training can increase the anaerobic threshold, reduce the onset of EIA and reduce hyperpnoea which often occurs when lactate threshold is passed

CONTRAINDICATIONSy Patients with respiratory and cardiac insufficiency in

the stage of decompensation.

CONCLUSIONy Exercise therapy has become increasingly important in the treatment of asthma

as it is commonly recommended and widely applied in asthmatic patients. Research has traditionally focused on traditional outcome measures such as mortality and physiologic indexes of lung and exercise function as well as psychosocial measures, health-related quality of life and economic analyses of costs and benefits. Although aerobic exercise training has been and continues to be the gold standard for the treatment of asthma since the mid-19th century [50], there is an increasing need to unequivocally determine the effects of alternative modes of exercise (such as a combination of aerobic exercise combined with diaphragmatic breathing combined with inspiratory resistive breathing) on asthma. y These studies need to be well-designed prospective, placebo- controlled, clinical trials to be of any value in asthmatic rehabilitation. In conclusion, the present authors recommend the continued use of aerobic exercise training in addition to making concurrent use of additional modes of exercise such as inspiratory resistive breathing training. This is because the sole use or inclusion of alternative modes of exercise along with aerobic exercise may be warranted not only for its favourable effects on asthma, but also for the additional benefits to be gained from alternative modes of exercise.

CONCLUSIONy Regular exercise training can increase an asthmatic

patient s sense of well-being, decrease exertional breathlessness by desensitising the patient to the uncomfortable breathless sensation and decrease the patient s ventilatory requirements through the increases in aerobic capacity and exercise efficiency. y It is also important to note that less fit subjects can gain the most benefits from exercise training due to their initially low level of exercise acceptance, social and disease adjustment and self-care due to their negative attitudes towards disease and exertion.

REFERENCESy Gibbs RA, Seal RME. Atlas of pulmonary pathology.

Volume 3. Lancaster, England: MTP Press Limited. 1982 y Sarinho E, Schor D, Veloso MA, Rizzo JA. There are more asthmatics in homes with high cockroach infestation. Braz J Med Biol Res 2004; 37(4): 503-510 y Bungaard A. Exercise and the asthmatic. Sports Med 1985; 2: 254-266 y Jenkinson SG. Obstructive Lung Disease. New York: Churchill Livingstone. 1992