Introduction

The aims of respiratory physiotherapy include mobilization and aid in expectoration of bronchopulmonary secretions, improving the efficiency of ventilation and maintaining or improving exercise tolerance. Physiotherapy has a key role to play in the prevention and treatment of respiratory complications after cardiac surgery.

This chapter starts by detailing the possible effects of cardiac surgery and general anaesthesia on the respiratory system. It then discusses the physiological basis and current evidence for the most commonly used physiotherapy techniques in the cardiac critical care unit. The management of both the spontaneously ventilating and intubated patient is considered.

Respiratory complications after cardiac surgery

It is well recognized that left lower lobe collapse occurs in the majority of patients after cardiac surgery. Reasons for this include:

1. • perioperative compression of the lobe;

2. • occasional injury to the phrenic nerve; and

3. • postoperative pain.

Other contributory factors leading postoperative atelectasis include:

1. • the effects of the median sternotomy/thoracotomy incision;

2. • internal mammary artery dissection;

3. • the use of cardiopulmonary bypass; and

4. • prolonged recumbency.

A certain amount of micro-atelectasis after surgery is inevitable, partly due to a reduction in functional residual capacity (FRC) secondary to general anaesthesia. If FRC falls below closing volume, then atelectasis occurs in the dependent lung. The efficiency of the mucociliary escalator (composed of mucus-secreting goblet cells, cilia and a viscous mucus gel layer) is also reduced.

Introduction

The physiotherapist has a range of responsibilities in functional psychiatric disorders. In addition to treating the physical conditions encountered in an aging population and those more specific to this group of patients, the physiotherapist is responsible for the education of patients, their family, carers and fellow staff members. As a member of the multidisciplinary team, the physiotherapist contributes a sophisticated understanding of normal and abnormal movement and the means of therapeutic intervention for movement problems to the treatment program.

Role of the physiotherapist

In the management of all psychiatric disorders a mature approach is required to assist patients with lack of motivation, cognitive problems and a variety of functional deficits. Physiotherapists undertaking the management of patients with functional psychiatric disorders should possess comprehensive knowledge and skills in cardiothoracic, neurological and musculoskeletal physiotherapy and in techniques of behavioral management. They must understand the normal psychophysiology of aging and the effects of superimposed pathology.

Patients are seen in the context of all the factors impinging on their lives and all health professionals should be aware of the integration between mind and body. Moon (1988) argues that the increasing knowledge in mental health should be absorbed into physiotherapy so that ‘all treatment approaches acknowledge the intrinsic unity between the mind and the body’. This is supported by Katona (1991) who reports that depression is found more often in the elderly with poor physical health than in the physically healthy.

Introduction

Physiotherapy is a movement and rehabilitation based profession. It is impossible to define a generic role for physiotherapists as they are engaged in all major areas of medical practice. Physiotherapists/physical therapists from all backgrounds have frequent contact with patients in pain; it is estimated that over 90% of all patients seen by physical therapists have pain at presentation.

The original aim of the profession was to return people to function. However, during the period from the 1970s to the early 1990s musculoskeletal therapists shifted from rehabilitation to tissue-specific, modality-focused approaches that were heavily dependent on passive interventions. This trend has recently reversed and resulted in the profession receiving growing attention as a valuable tool in the management of pain.

The various modalities used to treat and manage pain can be broadly divided into passive and active therapies. The evidence base for specific modalities remains weak. The problem in the clinic is that therapists tailor concurrent therapeutic inputs and interventions/exercises to the individual, making it difficult to evaluate the efficacy of the intervention and/or a given dosage/regimen.

Introduction

Tasks and professions change over time, and theorists of professions such as Abbott (1988) emphasise that the development of a profession always takes place both through interaction and in conflict with adjacent professions. The tasks and fields of responsibility of a profession are the result of negotiations, struggles and border disputes with other professions. In the case of healthcare providers, the needs of different client groups and the state's wish for control and management are also part of the picture. In order to understand the development of a profession, it must be studied within an interacting system of professions. Task control – jurisdiction, according to Abbott – is in this connection the key to understanding.

In this chapter, we discuss the history of physiotherapy in Norway, which is a case that illustrates the significance of Abbott's perspective. It is first and foremost characterised by disputes related to the division of work and responsibility between physicians and physiotherapists, that is, jurisdictional borders concerning physiotherapists’ practice and knowledge base. These disputes are closely connected to the struggle for acceptance by society, primarily expressed in the physiotherapist group's efforts to become part of the country's health services and to achieve public authorisation. A central concern with regard to physiotherapists’ practice and knowledge base has been to have the state – not the medical profession – take control of the education of physiotherapists.

From the very beginning, in the early 20th century, physiotherapists – working in private institutes and with home visits – depended on physicians’ acceptance and goodwill for a secure livelihood. Moreover, for 70 years physicians owned and ran the education of physiotherapists. As time passed, and as physiotherapists struggled for permanent positions in what became the country's welfare project, physiotherapy gradually developed as part of the state apparatus. Thus, and as we will show, the state should be regarded as a partner in strengthening the autonomy of Norwegian physiotherapists. This is the case with respect to crucial formalities, via legislation, as well as therapists’ freedom at the workplace, for example, to choose new and relevant tasks and to broaden their client base. As to their training, the education of physiotherapists has for several decades been organised by the state.

Introduction

A primary motor disorder, such as Parkinson's disease (PD), appears to be an ideal target for physiotherapy intervention. Referral to physiotherapy is recommended in the early stages of the disease (Dobbs et al. 1992) and there is evidence of the clinical effectiveness of physiotherapy at this time (Comella et al. 1994). Unfortunately it is still more common for referral to be delayed until the disease is advanced (Oxtoby 1982), when the opportunity to initiate a preventative treatment strategy has passed.

Physiotherapy has a significant role to play in the short and long-term management of PD. Physiotherapy must be integrated with other therapies. This will maximize the benefits of therapy for the patient and carer by ensuring consistency of approach, reinforcement of treatment aims, and by developing appropriate compensatory strategies (Kauser and Powell 1996).

The pathophysiology of the motor disorder in PD

Due to a deficiency of dopamine in the basal ganglia motor control is impaired in PD. Patients experience this in terms of difficulties with initiating, maintaining, and changing from one sequence of voluntary movement to another. Excess abnormal involuntary movement, such as tremor, may also be present. Balance is often impaired in elderly patients with PD. Clinical examination defines these difficulties in terms of akinesia, bradykinesia, tremor, rigidity and impaired postural reflexes. Impaired integration of normal control may contribute to these problems and a sense of increased effort of movement may result (Lövgreen and Cody 1997).