Treatment of Cystic Fibrosis in Patients

NHS Lothian - University Hospitals Division – Children’s Services

PHYSIOTHERAPY EXERCISE IN CF

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1. Purpose of this document Guidelines for exercise treatment for in patients with Cystic Fibrosis.

2. Who should use this document Physiotherapy, nursing and medical staff

3. To whom this document applies Physiotherapy staff

4. Contact point Physiotherapy department

5. Further reference ACPCF Standards of Care CF Out Patient Guidelines Association of Chartered Physiotherapist in Cystic Fibrosis treatment booklet. Relevant articles in Physiotherapy Dept NHS Lothian hand hygiene policy NHS Lothian PPE policy

6. Review Group Senior Respiratory Physiotherapists

7. Review September 2013

BACKGROUND

Ref No: Issue Date: June 2010 Review Date: July 2013 Published by:Elaine Dhouieb Level:     Ratified By: CMT CD  CN Issuing Officer: Fiona Gardner Signature: Signature: Page 1 of 2 Filename & path (inserted by FG) NHS Lothian - University Hospitals Division – Children’s Services

Within Scotland, the Scottish Executive and Health Education Board for Scotland (HEBS) are increasingly encouraging young people to exercise.

Recent figures show that only 55.5% of 11 year old boys, and 41.2% of 11 year old girls are accumulating the recommended level of five 60-minute periods of moderate physical activity per week, described as the equivalent of a brisk walk. This further decreases to 38.6% of boys and 23.5% of girls aged 15 years.

There is overwhelming evidence for the benefits of exercise and the importance of physical activity in maintaining good health in the general population. In people with Cystic Fibrosis (CF) it is generally accepted that physical training contributes to a reduction in dyspnoea and reduced exercise tolerance (Bradley & Moran, 2005). Additionally there are benefits of pulmonary function, sputum clearance (O’Neill, 1987), improved body image (Peebles, 1998), delay to the onset of osteoporotic changes and bone mineral density (Wolman, 1995).

Within the Physiotherapy Treatment of Cystic Fibrosis In Patient Guidelines is the recommendation that “Where appropriate, ie if the patient is not too breathless and unwell, they should be encouraged to have exercise sessions in the Physiotherapy Dept at least three times a week.” These sessions should comply with an aim of increasing a patient’s awareness of appropriate exercise, and encourage independent exercise on return to the home setting. A variety of body systems should be targeted including cardiovascular, musculoskeletal strengthening and flexibility, and multi-angled weight bearing activities to encourage increased bone density.

In addition it is appropriate to consider the following points. Exercise should be:

Focused to the individual needs of the child. Challenging Controlled Timed to suit the patient, in terms of IV’s, feeds and visiting Enjoyable Encouraging Weight bearing Cardiovascular Strengthening Increasing flexibility (and decreasing kyphosis) Improving posture

ASSESSMENT

Prior to attending the Physiotherapy Department for an exercise session, assessment should be made of the clinical condition of the child, to assess their suitability for an exercise programme on the current admission. This, where

PHYSIOTHERAPY EXERCISE IN CF appropriate, should include measures of breathlessness, oxygen saturation, heart rate and other scores of exercise tolerance e.g. Borg Scale. A formalised exercise tolerance test can be requested from the respiratory technician. If there is doubt around a patient’s ability to participate in an exercise program, liaison with medical staff may be appropriate.

PRECAUTIONS

The following should be considered as possible contraindications to an exercise programme:

Distal intestinal obstruction syndrome Acute exacerbation Arthropathy Hypoxia Pneumothorax Haemoptysis Pyrexia Contact sports (beware of liver problems and osteoporosis)

EXERCISE LOCATIONS

Physiotherapy Gym – Booking procedure as standard, use rooms one and four if available.

Patient Cubicle/bed space – this area can be utilised to allow the patient to perform an independent weights program, exercise bike or trampette, remembering the safety of others in the ward area.

The Meadows – this excellent resource can be used in good weather, for activities utilising far greater space, and provides a welcome break from indoors during an admission.

EXERCISE

The physiotherapist should utilise a wide knowledge base of exercises to provide a varied, targeted exercise program for children with CF attending the gym.

Only one patient with CF should exercise in the department at once, they should bring a sputum pot, as exercise may act as an airway clearance technique. If successive patients are attending the department, consideration should be taken of their bacteriology eg B Cepacia patients seen last. A time gap of as at least an hour should be left between CF patients using the same physiotherapy room for exercise. Mats and equipment must be cleaned as per guidelines between patients.

Constant assessment of the child should be performed to progress or modify treatment as appropriate. Monitoring of oxygen saturation before, during and after exercise can provide evidence of the response to exercise.

It might be appropriate for the Physiotherapy Assistant to carry out an individual exercise programme. Guidance should be given as to the aims of the treatment, assessment of change and regular monitoring in order to progress the patient’s ability appropriately. The physiotherapy assistant should document the contents of the treatment session on a recording form (See Appendix) so as to demonstrate the exercises completed in the treatment session.

Following exercise it is especially important that children with Cystic Fibrosis are encouraged to drink fluids, therefore the physiotherapist should encourage use of the water cooler in the department or consumption of high calorie drinks on return to the ward. (Remember that additional enzymes may be required by some children). Additionally, in hot weather it may be appropriate for the child to replace lost salt, clarification of this can be made with their dietician.

DOCUMENTATION

Exercise sessions must be documented within the Physiotherapy Section of the patients’ notes. This must comply with the departmental and professional notes standards. Inclusion of the individual exercise sheet will allow other members of the multidisciplinary team to assess the level of activity.

REFERENCES Association of Chartered Physiotherapists in Cystic Fibrosis: Physiotherapy National Standards of Care for people with Cystic Fibrosis 2009.

O'Neill PA, Dodds M, Phillips B, Poole J, Webb AK. Regular exercise and reduction of breathlessness in patients with cystic fibrosis. British Journal of Diseases of the Chest 1987;81(1):62-9.

Peebles AD. Physiotherapy (Chapter 5). In: Hill CM, editor(s). Practical Guidelines for Cystic Fibrosis Care. 1st Edition. London: Churchill Livingstone, 1998.

Wolman RL. Osteoporosis and exercise. In: McLatchie G, Harris M, King J, Williams C, editor(s). ABC of Sports Medicine. 4th Edition. BMJ Publishing, 1999.

Ref No: Issue Date: June 2010 Review Date: July 2013 Published by:Elaine Dhouieb Level:     Ratified By: CMT CD  CN Issuing Officer: Fiona Gardner Signature: Signature: Page 5 of 2 Filename & path (inserted by FG) NHS Lothian - University Hospitals Division – Children’s Services NHS Lothian – University Hospital Division PHYSIOTHERAPY EXERCISE IN CF Paediatric Physiotherapy Service

Patient Name ______DOB______

Exercise Recording Chart

Date Exercise/Activity Repetitions/Comments Signature/Print

Exercise Ideas

Exercise/Activity Variation Strengthenin g UL Biceps with/without weights Triceps with/without weights Deltoid with/without weights Pectoralis with/without weights Lats with/without weights

LL Sit to stand with/without weights Knee extesions in sitting with/without weights Knee curls in prone lying with/without weights Lunges (Static or dynamic) with/without weights Knee bends in standing (bilat, single leg) with/without weights Step ups (leading with each leg) with/without weights Abduction in standing with/without weights Hip extension in standing or prone lying with/without weights Calf raises (single or bilat) with/without weights Bridging (bilateral/ single leg)

Cardio Bench, leading with different Step ups feet first with/without weights Stepping machine Football Crab football Shuttle runs upto cones Picking up objects and Hopping returning Jumping (on dots, over lines) Thowing Catching, Single leg, Trampette two legs Standing - squat - pressup- squat standing Exercise bike Circuit Stations (combining above) Running on Meadows Ref No: Issue Date: June 2010 Review Date: July 2013 Published by:Elaine Dhouieb Level:     Ratified By: CMT CD  CN Issuing Officer: Fiona Gardner Signature: Signature: Page 7 of 2 Filename & path (inserted by FG) NHS Lothian - University Hospitals Division – Children’s Services

Please add additional ideas to this sheet, to assist others in improving their exercise sessions.

Ref No: Issue Date: June 2010 Review Date: July 2013 Published by:Elaine Dhouieb Level:     Ratified By: CMT CD  CN Issuing Officer: Fiona Gardner Signature: Signature: Page 8 of 2 Filename & path (inserted by FG)