CASE PRESENTATION

Presented By: Karishma Lalwani (Fy MPT )

Guided By : Dr. Rachana Shah
(MPT In Cardiopulmonary )

05/21/2025 CASE PRESENTATION 1

 SUBJECTIVE ASSESSMENT
DEMOGRAPHIC DETAILS :

 Name: Gyaneshbhai Vyas

 Age: 60 Years
 Gender: Male
 Address: 979/2, Sector 2/C , Gandhinagar
 Occupation: Retried Railway Officer (Retired From June 2024)
 Height: 167 Cm
 Weight: 86.10 Kg
 BMI: 30.97 (Obese class 1)
 Ref. No.: 348/25
 Referred By : relatives
05/21/2025 CASE PRESENTATION 2
 Date of hospital admission:
 Date of surgery: Not present
 Date of discharge :

 Date of assessment: 22 February 2025

05/21/2025 CASE PRESENTATION 3

 Chief complaints:
The patient has complained of breathlessness while doing ordinary activities { walking,
stair climbing, and stair descending}, for the last 15 years. And it was come under
control by medicines but in the last 5-6 days breathlessness increased and is present
even in standing (> 2-3 minutes), walking(> 500 meters) and sometimes it is present
even at rest now.
The patient has complained of left knee pain on the superior-medial side of the knee
joint line for the last 2-3 days with no history of falls/ trauma/jerks.

05/21/2025 CASE PRESENTATION 4

 HISTORY
• History of present illness:
The patient has genetic asthma which is diagnosed approx. 4 years of
age after that patient continue to take medicine for that . Patient starts
using asthma pump. Patient do check up on every 2-3 months regularly ,
he was doing job in railway and his more work is on standing but patient
does not have much difficulty and asthma attack frequency was also not
much but from last 15 years patient starts dyspnea in between attack
also but mostly it comes under control with the help of medicines.
Patient did check up in many hospitals like sterling , AIIMS , apollo etc .
Patient did various reports like CT scan , chest x ray , PFT reports, echo
cardiogram , USG abdomen and other lab findings. His reports suggest
high number of eosinophilis, so dr concluded that eosinophils are
present in respi system also so it is eosinophilic asthma.

05/21/2025 CASE PRESENTATION 5

 • Then in apollo hospital they suggest 6 doses of benralizumab
injection to control the asthma on 2021 so patient took 3 doses of this
injection . (one dose is for 2 lakh cost). But patient didn’t see any
changes in the symptoms of asthma. After took this injection his
weight increase up to 3 to 5 kg. In 2024 patient starts having knee
pain , so he took physiotherapy treatment in Aastha clinic for a week
but he didn’t find any changes , so he took Ayurvedic treatment for
knee pain. But in the last month his knee pain aggravate, he comes
CMPP MS OPD in the evening time , on seeing his breathless so
DR.avdhi mam suggest to go cardio OPD , SO from next day on
18/2/2025 patient comes to cardio OPD for some days .

05/21/2025 CASE PRESENTATION 6

 Medical history: present
diabetes mellitus type II (from last 5 years)
 Past surgical history: not present
 Personal history:
• Diet: vegetarian
• Appetite: Normal
sufficient
3 meals/day
• Sleep: normal
sufficient (not disturbed)
6- 7 hours at night
1-2 hours in afternoon

05/21/2025 CASE PRESENTATION 7

• Bowel: Normal
• Bladder: Normal
 Personal history:
• Alcohol history – not present
• Smocking history – 10 years
12 -13 cigarette/ day
Pack/year 120-130
• Nicotine history: not present
• Family history: Present (grandfather)
• Covid history: not present

05/21/2025 CASE PRESENTATION 8

 socioeconomic history :
By modified kuppuswami scale

05/21/2025 CASE PRESENTATION 9

Interpretation - total score 24
So patient belongs to the upper middle-class family.

05/21/2025 CASE PRESENTATION 10

 Occupational history: retired railway officer
Retired from June 2024
Work posture: standing
Working hours: 10-12 years
 Environmental history :
 Patient living in a tenement on the ground floor
 He has to climb no stairs in his routine life
 He is retired now (from June 2024), so he didn’t go outside much on a daily base
 He uses Western toilet
 He is not using AC on daily base right now(neither in day time or in night time)
 He has windows in his room. He keeps the window open at night time specially.

05/21/2025 CASE PRESENTATION 11

 Rehabilitation history:
o Patient not taken any physiotherapy treatment for asthma
o For knee pain patient go Aastha physiotherapy center for one week but patient
didn’t feel much more relief so he took ayurved treatment.
 Recreational history: not relevant
 History of COVID–19: not present
 History of an asthma attack: the patient has an asthma attack once in every 1.5- 2
months on approx. but during seasonal changes its frequency increases once in 15
days . Rather than this asthma attack present when it comes in contact with
allergens.

05/21/2025 CASE PRESENTATION 12

Drug history:
31/12/2024
Tablet Concor 2.5 For High BP OD

Tablet Ecosprin 75 For Angina OD

Tablet Aldachone 25 Diuretic OD

Tablet Prostogard –D(8) Prostatic Hyperplasia OD

Seroflo 250 Inhaler For Asthma & COPD TD

Tiova Inhaler For Asthma & COPD BD

Tablet Pregason For Neuropathic Pain OD

Tablet Febutaz 40 To Prevent Gout OD

Tablet Montac LC For Allergic Rhinitis OD

AB Phyline Capsule For Asthma & COPD BD

05/21/2025 CASE PRESENTATION 13

• INVESTIGATION
CT Scan chest – 23/2/2022

05/21/2025 CASE PRESENTATION 14

• USG abdomen
8/10/2024

05/21/2025 CASE PRESENTATION 15

• ECHO cardiogram
5/9/2024

05/21/2025 CASE PRESENTATION 16

• ECHO cardiogram
27/9/2023

05/21/2025 CASE PRESENTATION 17

• Pulmonary function test
23/2/2022

05/21/2025 CASE PRESENTATION 18

• Pulmonary function test
9/10/2023

05/21/2025 CASE PRESENTATION 19

• Impulse oscillometry
9/10/2023

05/21/2025 CASE PRESENTATION 20

• Chest X-ray
23/3/2022
PA view

05/21/2025 CASE PRESENTATION 21

 • Interpretation
 CT scan suggests – bronchial asthma
 PFT suggests – airway obstruction with severe small airway disease
 Impulse oscillometry suggests severe central airway obstruction
 Chest x-ray-

Other
 USG abdomen suggests fatty liver
 Echo cardiogram shows normal findings.

05/21/2025 CASE PRESENTATION 22

 PROVISIONAL DIAGNOSIS

Severe breathlessness with MMRC grade 4

05/21/2025 CASE PRESENTATION 23

 CLINICAL DIAGNOSIS

Severe eosinophilic asthma

05/21/2025 CASE PRESENTATION 24

 SUBJECTIVE
ASSESSMENT

05/21/2025 CASE PRESENTATION 25

 COUGH
o Onset: gradual
o Duration: chronic
o Nature: dry at normal days but productive during asthma attack
o Severity: intermittent
o Aggravating Factor: seasonal changes , allergens , during attack of
asthma
o Relieving Factor: medicines
o Cough Complication : Muscular Pain( intercostal muscle)

05/21/2025 CASE PRESENTATION 26

 SPUTUM

o Not present right now but it is mostly present during seasonal changes ,
allergens and during asthmatic attack

o Colour : White watery in starting after few days it become yellowish

o Quantity: 3-4 TS /day
o Odour : odourless
o Consistency: mucoid
o Grade: I
o Time of maximum Secretion: Early morning
o Aggravating Factor: seasonal changes , allergens , during attack of asthma
o Relieving Factor: medicines

05/21/2025 CASE PRESENTATION 27

 DYSPNEA
o Onset: gradual
o Duration: patient feels dyspnea from approx. last 15 years but from5-6 days
it becomes more

o Frequency of attack : regularly

o Time : no time specific

o Related body position: dyspnoea on exertion

o Aggravating factor: standing (> 2-3 minutes), walking(> 500 meters) and
sometimes it is present even at rest now.

o Relieving factor : dyspnea relieving positions

05/21/2025 CASE PRESENTATION 28
o Severity
Modified MMRC GRADE - 4

05/21/2025 CASE PRESENTATION 29

Modified BORG DYSPNEA SCALE = GRADE 7-8

05/21/2025 CASE PRESENTATION 30

 CHEST PAIN

NOT PRESENT

05/21/2025 CASE PRESENTATION 31

 Fever: not present

 Diaphoresis: present (mostly in foot >palm)-B/L

 Headache: present

 Syncope attack: not present

 Palpitation: not present

 Hoarseness of voice: present

05/21/2025 CASE PRESENTATION 32

 Other accompanying symptoms:
o Light headache - present
o Fatigue- present
o Weakness- present
o Hypotension – not present
o Possible wheezing- present
o Positional variation
Orthopnea-
Treponea- not present
Platypnea-

05/21/2025 CASE PRESENTATION 33

 OBJECTIVE ASSESSMENT
 ON OBSERVATION

 Consciousness: alert
 Level of distress: light headache (sometimes )
 Supportive equipment: asthma pump/ inhaler
 Body type: endomorphic

05/21/2025 CASE PRESENTATION 34

 Body posture: Upper quadrant
STANDING – ANTERIOR VIEW

 Head: left side flexed

 Earlobe: not at the same level
 Chin not aligned with the manubrium
 Chest: pectus excavatum
 Shoulder: not at the same level- left side
depressed, both shoulders adducted
 Cubital fossa: not at the same level

05/21/2025 CASE PRESENTATION 35

 STANDING –RIGHT SIDE LATERAL
VIEW

 Head: left side flexed,

Forward head
 Face: right side puffiness present
 Cervical: increase lordosis
 Thoracic curve: normal kyphotic
 Lumbar curve: can not comment
 Scapula: lest side protracted
 Shoulder : Extended
 Elbow: flexed
05/21/2025 CASE PRESENTATION 36
 STANDING –POSTERIOR VIEW

 Head: left side flexed,

 Earlobe: not at the same level
 Neckline: Present
 Shoulder: not at the same level
 Scapula: normal aligned
 Olecranon process: not at the same level
 Wrist: not at same level
 Trunk: neutral
 PSIS: can not comment
05/21/2025 CASE PRESENTATION 37
 SITTING –ANTERIOR VIEW

 Head: left side flexed

 Earlobe: not at the same level
 Chin not aligned with the manubrium
 Chest: pectus excavatum
 Shoulder: not at the same level- both
shoulders supported on the leg
 Cubital fossa: not at the same level
 Hip: flexed

05/21/2025 CASE PRESENTATION 38

 HEAD & NECK

1. Head:
o Facial expression: anxious
o Nasal flaring: normal
o Cyanosis: not present
o Pursed lip breathing: not present
o Pallor: not present
o Edema: present
o Puffiness: present(RT>LT) over face
and below eyes

05/21/2025 CASE PRESENTATION 39

2. NECK:

o Use of accessory muscle:

present(B/L scalene and
sternocleidomastoid muscle
o Jugular venous distension- not
present
o Tracheal position: Midline

05/21/2025 CASE PRESENTATION 40

 3. THORAX

o Thoracic configuration:
• AP Diameter- 11.5 CM
• Transverse diameter – 12.7 CM
• Transverse diameter >AP diameter
• Common abnormalities – Not present
o Deformities: present- pectus excavatum
o Breathing pattern: thoraco –abdomen
o Symmetry : present at rest and at activity
o Incision: not present

05/21/2025 CASE PRESENTATION 41

 EXTREMITIES

o Cyanosis: not present o Schamorth sign: positive

o Clubbing: present – grade 3 o Tremors: not present
o Nicotine stains: present o Wasting: not present
• On lips- darker lips o weakness: present
• On teeth- yellowish-brown o Peripheral edema: absent
teeth o Pedal edema: present
• On nails- yellowish brittle
o Presence of varicose vein:
nails
present
• On tongue- yellowish-brown
Grade- 1
tongue
o Presence of equipment: not
• On hands- dark discoloration
present
hand

05/21/2025 CASE PRESENTATION 42

 ON EXAMINATION
 ON PALPATION

o Tracheal position: midline

o Respiratory muscle activity: normal
o Chest wall excursion: normal and B/L symmetrical at upper lobe ,
middle lobe and lower lobe
o Chest wall pain: not present

05/21/2025 CASE PRESENTATION 43

o Tactile fremitus: anterior , posterior and lateral side

location Right side Left side

1 st intercostal space Normal Decrease than right side
2 nd intercostal space Normal Decrease than right side

3 rd intercostal space Normal Decrease than right side

4 th intercostal space Normal Decrease than right side
5 th intercostal space Normal More Decrease than right side
6 th intercostal space Normal More Decrease than right side
7 th intercostal space Normal More Decrease than right side
8 th intercostal space Normal More Decrease than right side
9 th intercostal space Normal More Decrease than right side
10 th intercostal space Normal More Decrease than right side
11 th intercostal space Normal More Decrease than right side

05/21/2025 CASE PRESENTATION 44

05/21/2025 CASE PRESENTATION 45
o Cardiac impulse: brief, localized impulse is present
o Peripheral pulse: 17 beats per minute, regular, strong, and B/L
symmetric radial and dorsalis pedis pulse
o Capillary perfusion: normal (within 2 second)
o Edema: present (pedal)

05/21/2025 CASE PRESENTATION 46

 On percussion:
Resonance-

Left Lung Right Lung

Upper lobe Hyperresonance Normal

Middle lobe Hyperresonance Normal

Lower lobe Hyperresonance Hyporesonance

05/21/2025 CASE PRESENTATION 47

 On auscultation:

 Air entry: decrease B/L lower lobes (left > right)

 Normal breath sounds: present
 Abnormal breath sounds: present
 Adventitious sound: wheeze present in expiration in left lingula> right middle
lobes

 Heart sound: present normal -S1,S2

05/21/2025 CASE PRESENTATION 48

Chest expansion measurements:
Expiration (cm) Inspiration (cm) Difference
(cm)

At axilla level 93 cm 94.5 cm 1.5 cm

At nipple level 93 cm 95 cm 2 cm

At xiphisternum 91.5 cm 94.5 cm 3 cm

Scar examination: any kind of surgery is not done.

05/21/2025 CASE PRESENTATION 49

 OUTCOME MEASURES:

 ASTHMA QUALITY OF LIFE QUESTIONNAIRE (AQLQ-MEDAN)

Total score: 32/80
Patient quality of life was affected moderately due to asthma

 Level of asthma control – GINA scale

Interpretation: uncontrolled asthma

05/21/2025 CASE PRESENTATION 50

05/21/2025 CASE PRESENTATION 51
05/21/2025 CASE PRESENTATION 52
 Other system examination
Musculoskeletal system
 Left knee pain:
History
o History: no history of fall or trauma is present
o Pain: dull aching starts gradually

On observation:
o Patellar malalignment – not present
o Swelling: not present
o Tropical changes : present in B/L CALF(RT=LT side)

05/21/2025 CASE PRESENTATION 53

On palpation:
o Tenderness: grade 2 over the superior-medial side of the knee joint line
o Crepitus: present
On examination:
o Knee ROM: Normal
o End feel: normal firm in flexion and normal hard in extension
o Joint play: patellar mobility: grade 3 normal
o Spasm: not present
o Tightness: calf (B/L)
o Diagnosis: patellofemoral OA knee

Neurological system:
no abnormality detected

05/21/2025 CASE PRESENTATION 54

 INVESTIGATION
• CT Scan
• PFT
• Impulse Oscillometry
• USG abdomen
• Chest x-ray
• Echo cardiogram

05/21/2025 CASE PRESENTATION 55

• Lab findings

Normal findings Abnormal findings

 IgE  Postprandial blood glucose -219.4

 Absolute eosinophils count (increase)-9/10/2024
 Hb  Fasting insulin -36.2
 S. Creatinine (increase )- 9/10/2024
 S.G.P.T  Vit D – 26.68 (deficit)
 Urine analysis
 HBa1c
 Testosterone
 Vit B12
 T3,T4,TSH
 Calcium
 Uric acid
 Creatinine
 Glomerular filtration rate
 All CBC reports

05/21/2025 CASE PRESENTATION 56

 PHYSICAL AND FUNCTIONAL DIAGNOSIS
 A 60-year-old retired railway officer male patient with grade 1 obese class, presents with
a complaint of breathing difficulty while doing ordinary activities { walking, stair
climbing, and stair descending}, for the last 15 years. And it was come under
control by medicines but in the last 5-6 days breathlessness increased and is
present even in standing (> 2-3 minutes), walking(> 500 meters) and sometimes it
is present even at rest now with the history of 120-130 cigarette pack/ year with a
genetic history of asthma(grandfather).On assessment, dry cough is present and
aggravates during seasonal changes, allergens, and during asthmatic attacks. Presence of
dyspnea with MMRC grade 4, borg scale grade 7, with no chest pain. The patient is having
diaphoresis (foot>palm)with mild headache sometimes &hoarseness of voice, fatigue, and
generalized weakness. On examination patient has altered posture with pectus excavatum
deformity, anxious facial expression &puffiness on the face(RT>LT) patient is using an
accessory muscle in breathing with midline trachea, and normal thoracic configuration.

05/21/2025 CASE PRESENTATION 57

 Patient is breathing with thoracic-abdomen pattern with 1:2 -I:E ratio. chest symmetry is
present in all the lobes and during rest and activity also. On extremities examination, the
patient is having grade 3 clubbing with nicotine stains over teeth, lips, tongue, hands, and
nails, positive schmorth sign , Prescence of pedal edema & grade 1 varicose vein ingreat
saphenous vein (GSV) and the small saphenous vein (SSV).patient has decrease TVF in left
side , more increase in lower intercostal space in all anterior, posterior and lateral side
with hyper resonance on left lung in all the lobes and hypo on right lower lobes.
Auscultation findings suggest decreased air entry in B/L lower lobes(LT>RT)and
presence of wheeze in in expiration in left lingula> right middle lobes. With decrease
chest expansion. So all the findings suggest a patient has asthma and due to asthma his life
is affected moderate by AQLQ score of 32/80 and the asthma is uncontrolled or severe
from GINA scale. From lab finding, we can conclude that patient has severe eosinophilic
asthma with obstruction in PFT reports . Patient also having left knee pain with grade 2
tenderness over the superior-medial side of the left knee joint line with the Presence of
Crepitus in the left knee and tightness of bilateral calf muscle with no other findings
which suggest early degenerative changes in left knee joint

05/21/2025 CASE PRESENTATION 58

 ICF
• Structural impairment:  Knee joint
 Right and left lungs  Cartilage of knee
 Alveoli
 Thorax
 Face
 Legs
 great saphenous vein (GSV) and
the small saphenous vein (SSV)
 Calf muscle

05/21/2025 CASE PRESENTATION 59

 Functional impairment
 Presence of Dry cough  Presence of pedal edema
 Presence of Dyspnea  Presence of varicose vein in both lower legs
 Wheeze in the middle lobe  Pain in left knee joint
 Decrease air entry in lower lobes  Presence of grade 2 tenderness over the
 Alteration in posture superior-medial side of the left knee joint
line
 Deformity of chest wall
 Presence of Crepitus in left knee
 Presence of nicotine stains
 Tightness of bilateral calf
 Presence of clubbing
 Hoarseness of voice
 Decrease TVF in left side
 Hyper resonance on left side all lobes
 Hypo resonance on right lower lobe
 Presence of facial puffiness

05/21/2025 CASE PRESENTATION 60

Activity limitation Participation limitation
 standing (> 2-3 minutes)  Travelling
 walking(> 500 meters)  Not as such
 Stair climbing
 Stair descending

Facilitators Barriers
 Asthma pump  Pollens
 Lift  Dust
 Areas with more  Stairs
ventilation
 Mask

05/21/2025 CASE PRESENTATION 61

 PROBLEM LIST

 Presence of Dry cough  Presence of facial puffiness

 Presence of Dyspnea  Presence of pedal edema
 Wheeze in the middle lobe  Presence of varicose vein in both lower legs
 Decrease air entry in lower lobes  Pain in left knee joint
 Alteration in posture  Presence of grade 2 tenderness over the
 Deformity of chest wall superior-medial side of the left knee joint
line
 Presence of nicotine stains
 Presence of Crepitus in left knee
 Presence of clubbing
 Tightness of bilateral calf
 Hoarseness of voice
 Decrease TVF in left side
 Hyper resonance on left side all lobes
 Hypo resonance on right lower lobe

05/21/2025 CASE PRESENTATION 62

 PHYSIOTHERAPY
MANAGEMENT

05/21/2025 CASE PRESENTATION 63

 1. IN BETWEEN ATTACK DURING ATTACK

1. To gain confidence 1) To relieve bronchospasm

2. To reduce dyspnea 2) To remove secretion
3. To assist in the removal of excess bronchial 3) To improve breathing pattern
secretion
4. Increase lung volume & capacities
5. Improve chest mobility
6. Improve respiratory muscle strength
7. Improve and maintain exercise tolerance and quality
of life
8. Reduce the pain of left knee
9. To treat and prevent progression of varicose vein
10.Postural correction
11.Home advice

05/21/2025 CASE PRESENTATION 64

 IN BETWEEN ATTACK
1)To gain confidence:
o Explain about the condition, risk
of complications, and
management strategies.
o To provide psychological support.
o Explain the proper use of inhaler .
Check than correct him by
demonstration

05/21/2025 CASE PRESENTATION 65

 oDyspnea relieving positions

2)To reduce dyspnea

o Dyspnea relieving
positions
o Counted breathing
o Relaxation technique
o Diaphragmatic
breathing exercise

05/21/2025 CASE PRESENTATION 66

o Counted breathing
In sitting or supine position give counted breathing

1-2 inhale

1-2-3-4 exhale

Slow steady control breath

• It can progress in standing, walking and stair climbing to make habit

05/21/2025 CASE PRESENTATION 67

Deep breathing exercise Relaxation technique
oJacobson relaxation

05/21/2025 CASE PRESENTATION 68

3) To assist in the removal of excess
bronchial secretion

Bronchial hygiene therapy/techniques or

airway clearance techniques is a variety of
non-invasive techniques designed to improve
gas exchange by helping to mobilize and
remove secretions.

i)COUGHING
• A cough can either be a reflex or a voluntary
action.
Stages:
1) Adequate inspiration
2) Closure of glottis
3) Increase intrathoracic pressure
4) Expulsion (forceful expiration)

05/21/2025 CASE PRESENTATION 69

ii)BREATHING EXERCISES
 Diaphragmatic breathing
 Segmental breathing

05/21/2025 CASE PRESENTATION 70

iii)POSTURAL DRAINAGE

iv) chest physiotherapy

 Percussion

 Vibration

 Shaking

05/21/2025 CASE PRESENTATION 71

v) ACBT
The active cycle of breathing involves
three phases repeated in cycles
1 breathing control
2 thoracic expansion
3 forced expiratory technique
Dosage: 2 or 3 times in one session

05/21/2025 CASE PRESENTATION 72

1) Breathing control:
The patient is instructed to breathe in a relaxed manner using normal tidal volume
Upper chest and shoulders should remain relaxed
Lower chest and abdomen should be active
Period of breath control between other phases is essential to prevent bronchospasm.
2)Thoracic expansion exercise:
The emphasis during this phase is on inspiration
The patient is instructed to take 3-4 deep breathe to inspiratory reserve volume

Expansion of lung

Decrease collapse of lung tissue

05/21/2025 CASE PRESENTATION 73

The expiration is passive and relaxed.
Chest percussion, shaking or vibration can be performed in combination with
thoracic expansion

3) Forced expiratory technique:

This phase consists of huffing
A huff is a rapid, forced exhalation but not with maximal effort
1 or 2 huffs performed at mid to low lung volume.
Abdominal muscle contraction to produce forced exhalation

05/21/2025 CASE PRESENTATION 74

2) Autogenic drainage:

05/21/2025 CASE PRESENTATION 75

4)Increase lung volume & capacities

• spirometer

05/21/2025 CASE PRESENTATION 76

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.
 The therapist then slows the audible breathing pattern and the facilitation of
shoulder movement to encourage an increased tidal volume and decreased
respiratory rate.

05/21/2025 CASE PRESENTATION 77

5)Improve chest mobility
• Thoracic expansion exercise

To mobilize one side of the chest.

o While sitting, have the patient bend away from the
tight side to lengthen tight structures and expand that
side of the chest during inspiration.
o 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.
o 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.

05/21/2025 CASE PRESENTATION 78

To mobilize the upper chest and stretch To mobilize the upper chest and
the pectoralis muscles. shoulders
o while the patient is sitting in a chair o With patient sitting in a chair, have
with hands clasped behind the head, him or her reach with both arms over
have him or her horizontally abduct the head (180 degrees bilateral shoulder
arms (elongating the pectoralis flexion and slight abduction) during
muscles) during a deep inspiration. inspiration. Then have the patient
bend forward at

05/21/2025 CASE PRESENTATION 79

6)Improve respiratory muscle strength

05/21/2025 CASE PRESENTATION 80

7)Improve and maintain exercise tolerance and quality of life

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.
 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.

after dyspnea relives start with

AEROBIC EXERCISE PROTOCOL:
Warm-Up(5 to 10 minutes )
Conditioning (FITT)
Cool down (5-10 minutes)
05/21/2025 CASE PRESENTATION 81
8)Reduce the pain of left knee
• Quadriceps Strengthening Exercise
SQE
SLR
VMO
HSKE
• Ultrasound On Tenderpoint , Pulse Mode , 1mhz For 7 Min With 1 W/Cm2
Intensity
• Hot Pack
• Stretching Of Calf

05/21/2025 CASE PRESENTATION 82

10)To treat and prevent progression of varicose vein

 Ankle pump exercise

 Calf stretching
 Leg elevation
 Other hip and knee
mobility exercise
Exercise with 10 time 2
sets of esch thrice a day
Stretching 3 times 3o sec
hold twice a day

05/21/2025 CASE PRESENTATION 83

10)Postural correction
• Patient having forward head & rounded shoulder

05/21/2025 CASE PRESENTATION 84

11)Home advice

o Maintain hygiene
o Avoid allergen
o do regular exercise
o Maintain weight
o Work modification
o Wear mask
o See correct use of inhaler
(by demo)- if needed

05/21/2025 CASE PRESENTATION 85

 DURING ATTACK
1) To relieve
bronchospasm • salbutamol
For longer airway • Tibutalin
• Use inhaler
• Bronchodilators
For smaller • ipratropiumdromid
airway

In chronic stage • corticosteroid

05/21/2025 CASE PRESENTATION 86

2) To remove secretions
Postural drainage
• It is a technique that involves
positioning a patient in specific
ways to assist in the
mobilization and removal of
secretions from different
segments of the lungs.
• It utilizes gravity to aid in the
drainage process

05/21/2025 CASE PRESENTATION 87

Chest physiotherapy
Percussion and vibration
• Percussion and vibration are manual
techniques used in respiratory therapy to
help clear airways by mobilizing secretions,
with percussion involving rhythmic clapping
and vibration involving fine oscillations
during expiration.
• Percussion: Performed with a cupped hand,
the therapist rhythmically claps on the chest
or back over the affected area.
• Vibration: Fine oscillatory movements are
applied to the chest wall by the therapist's
hands during expiration after a deep
inspiration.

05/21/2025 CASE PRESENTATION 88

• ACBT with more breath control phase
DOSAGE : 10 mins ideally until chest feels clear of sputum , once or twice a day.

05/21/2025 CASE PRESENTATION 89

3) To improve breathing pattern:
In sitting or supine position give counted breathing

1-2 inhale

1-2-3-4 exhale

Slow steady control breath

• It can progress in standing, walking and stair climbing to make habit

05/21/2025 CASE PRESENTATION 90

05/21/2025 CASE PRESENTATION 91
05/21/2025 CASE PRESENTATION 92
05/21/2025 CASE PRESENTATION 93