Renaissance physiotherapy

Physio-led breathing exercises are making a comeback underpinned by positive research, reports Colleen Shannon

Two decades ago, when Lesley Rimington was working on the wards as a respiratory physiotherapist, teaching breathing and relaxation exercises to asthma patients was a routine part of the job. Today she is a lecturer at Keele University, and students there still learn about basic breathing and relaxation techniques. However, they are unlikely to use these skills to help patients with asthma. Nurses mostly manage the condition now and their main tool is medication. ‘Physiotherapists don’t get as involved as they used to,’ Dr Rimington says.  Julia Bott, a consultant physiotherapist in respiratory care, agrees. ‘Since the advent of the asthma nurse specialist, people stopped referring patients to physiotherapists.  So the patient is getting very good nursing care and very good advice on medication, but they are not getting the holistic care we would give, which would involve breathing, body movements, posture and exercises.’ That may soon change. New guidelines from the Association for Chartered Physiotherapists in Respiratory Care and the British Thoracic Society, on the role of physiotherapy in respiratory care, are due to be published soon in Thorax (Ms Bott chaired the steering group developing the guidelines). The guidelines are likely to recommend physiotherapy breathing exercises for asthma, in light of evidence emerging in recent months.

Positive Papworth studies

The research findings come as no surprise to Elizabeth Holloway.  She has been using the Papworth method (see panel: The Papworth method) since the 1970s and still teaches it to patients. She is also an author on two pivotal studies and a Cochrane review. ‘Patients and physiotherapists acknowledge the benefits but there is little evidence to substantiate these claims,’ says Ms Holloway. ‘Therefore when I retired from my practice I decided I should attempt to provide some evidence.’ She approached a GP practice to recruit patients for a randomized controlled trial, which was published in 2007 in the journal Thorax. Patients who received five sessions of the Papworth method showed significant improvements in quality of life, anxiety and depression, and symptoms from dysfunctional breathing. Ms Holloway participated in another study published this year comparing physiotherapy breathing exercises and nurse-led education. Patients in the physiotherapy group had greater and enduring improvements in quality of life, anxiety and depression. With this increasing evidence base and the upcoming guidelines, there could be more demand for physiotherapists with these skills. For those who want to brush up, Dr Rimington recommends a refresher course. Keele University is developing one now, which will be offered as a continuing professional development package. The Buteyko system of breathing exercises is another technique in physiotherapists’ respiratory tool kit with an expanding evidence base (see panel: All about Buteyko). A 2008 Canadian study compared Buteyko with conventional physiotherapy breathing and relaxation exercises for asthma, and found patients benefited from both methods. In the Buteyko group the proportion with asthma control increased from 40 per cent to 79 per cent and in the physiotherapy (control) group from 44 per cent to 72 per cent. In addition, patients in the Buteyko group reduced their inhaled corticosteroid therapy significantly.

Tailor your approach

One of the important messages to get across is both Buteyko and physiotherapy breathing exercises can work for patients. Ruth Brown, a senior physiotherapist in respiratory care at Bangor hospital, uses both methods in her practice. Because she has trained in both Buteyko and the Papworth method, she can tailor the best approach for each individual patient. ‘It’s a case of choosing the approach and technique that best fits a patient’s personality, as well as their diagnosis,’ she says. For example, teenagers respond well to the structured nature of Buteyko and it is easier to see how well they are keeping up with their exercises.  The Papworth method, on the other hand, could be a better choice for people who are anxious. Ms Brown also considers the underlying pathology and co-morbidities. In her experience, Buteyko works well for straightforward asthma and some people with hyperventilation syndrome. Where the picture is more complex and additional pathologies may be at work, the Papworth method might be more suitable. She would like all patients to have access to the range of techniques, and worries that Buteyko practitioners without a physiotherapy background provide a limited offering.  ‘A skilled therapist is the best person to treat these patients,’ she comments. ‘If you get a good respiratory therapist who knows the Buteyko technique, knows the Papworth technique, and has other knowledge and skills at their disposal, they have a tool box.’  She is concerned physiotherapists ‘do not shout loud enough’ about what they can offer. Her hope is that more physios will start learning Buteyko so the profession is not ‘cut out of the equation’. In the future, perhaps, more physiotherapists will be in a position to give their patients the best of both worlds. Buteyko has already received a boost from its recommendation in the definitive BTS/SIGN guidelines for asthma. With the new ACPRC and BTS guidelines also on the horizon, awareness of both methods should increase not only among physiotherapists but also among other professionals. One day soon, doing a few breathing exercises every day may come just as naturally for an asthma patient as reaching for their inhaler.  FL


British Thoracic Society and Scottish Intercollegiate Guidelines Network. 2008 British guidelines on the management of asthma.  and Buteyko Breathing Association Cowie et al. ‘A randomised controlled trial of the Buteyko technique as an adjunct to conventional management of asthma’, Respiratory Medicine (2008), 102(5):726 Holloway et al. ‘Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial. Thorax (2007), 62(12):1039 Thomas et al. ‘Breathing exercises for asthma: a randomised controlled trial’, Thorax (2009), 64(1):55

The Papworth method

Most physiotherapists have been trained in at least some elements of the Papworth method, which was developed in the 1960s and integrates breathing exercises and relaxation techniques.  The method focuses on appropriate breathing for the metabolic rate and psychological state of the individual at a given time. The aim is to slow and regularise the breathing pattern, avoiding mouth breathing and habits such as coughing, sighing and sniffing. Recent studies of this approach appeared after cut-off deadlines for the 2008 asthma guidelines from the BTS and the Scottish Intercollegiate Guidelines Network, so physiotherapy exercises for asthma receive short shrift in the current version. It is anticipated Papworth-type breathing exercises, as an adjunct to medication, will be recommended for asthma in the new joint BTS/ACPRC guidelines on respiratory physiotherapy.

All about Buteyko

Buteyko (pronounced Bu-tay-ko) was developed in Russia in the 1950s by a physician, Konstantin Buteyko. Patients are taught to breathe through the nose and not the mouth, to monitor their pulse and regulate the depth of their breathing. Practitioners may advise dietary changes and a more active lifestyle. Buteyko is recognised as a potentially helpful intervention in definitive asthma management guidelines from the BTS and the SIGN. Buteyko is likely to receive similar treatment in the upcoming physiotherapy guidelines from the ACPRC and the BTS.

The patient’s perspective

Jacky Angelo-Gizzi is a paediatric diabetes nurse – and a person with asthma. She participated in Elizabeth Holloway’s trial and was randomised to the Papworth method treatment group. She noticed an improvement in her asthma control and symptoms. ‘I tended to mouth breathe quite a lot, and the techniques we learned enabled me to focus on breathing properly instead of gulping down air.’ Ms Angelo-Gizzi had a few sessions with Ms Holloway and received a CD so she could practise at home. The exercises also helped her to de-stress and now they are second nature. Today her dose of inhaled steroids is very small and stops in the summer. She only needs her rescue inhaler when she has a cold – down from four or five times a week.

Teaching good habits

When she is off duty from her NHS job as a learning disabilities physiotherapist, Libby Davies goes to school. Working with a local nurse researcher, she is taking Butyeko lessons into Glasgow classrooms as part of a health education programme for children with asthma. The aim is to teach children how to control their breathing and generally take charge of their asthma, Ms Davies says. Recently, some of the children gave a presentation to local councillors, Scottish MPs and doctors, about their experience with the programme. ‘We’re finding that we get great results,’ Ms Davies says. Asthma symptoms have improved and so has attendance, which is often a problem for this group. Teachers have also noticed an improvement in concentration. Teaching Butyeko to children is very different from working with adults, and there is a special technique, Ms Davies explains. The emphasis is more practical, with fun exercises and not too much theory. Children have not built up bad habits over many years so their improvement is more rapid, she adds. ‘With children you see a dramatic change very quickly.’
Colleen Shannon

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