Case Study using ICF : COPD

Original Editor - Sonal Joshi Top Contributors - Sonal Joshi and Ewa Jaraczewska

Abstract[edit | edit source]

This article will cover a case study of Mr.S, who has been recently diagnosed with COPD. He has been recommended physiotherapy for the same. The article follows the journey of the physiotherapist assessing Mr.S using ICF format.

Please note: the below case study is imaginary but inspired by actual COPD patients. Therefore, it may not include all symptoms or signs of the disease condition. Remember that the assessment findings, in reality, will vary slightly from patient to patient, changing the treatment protocol accordingly.

Client Characteristics[edit | edit source]

A 40-year-old male, Mr.S, has had difficulty breathing on stair climbing to his office on 2nd floor for almost a year. He complains of persistent cough with expectoration for the last 3-4 years, which increases every 2-3 months & then goes away for some time. He had to be admitted for exacerbation of his symptoms & was on medication with oxygen therapy for a week. He was diagnosed as suffering from COPD in the hospital. It has been two weeks since his discharge has come for pulmonary rehabilitation after the recommendation of his pulmonologist. Mr.S works as a manager in the marketing department of his company. His job sometimes requires sitting in a meeting for hours together or travelling around the city on his two-wheeler for a full day. He was a smoker for eight years & has quit on regular counselling and treatment for the last two years. He also complains of getting very tired till the end of the day & does not want to go to any social event in the evening with family or friends. Mr. & Mrs S stay on the 4th floor with a lift in the building in an urban city in India. His wife & college-going son have accompanied him for his first physiotherapy consultation.

Examination Findings[edit | edit source]

It consists of Mr.S's history, investigations and objective examination. This will primarily focus on respiratory assessment along with other systems.

History[edit | edit source]

Mr.S has a history of

  • Smoking for eight years, consuming about 1 1/2 packs per day (approx. 30 cigarettes per day).
  • Persistent cough with expectoration for 3-4 years(i.e. sign of repeated chest infection). It typically lasts up to 3-4 months and reduces on over-the-counter symptomatic medication.
  • Dyspnea (MMRC scale - Gr.3)
  • Breathlessness & wheezing on moderate exertion (RPE –2 to 4 on Mod. Borg scale)
  • Fatigue on the moderate activity of between 3-5.9 METs

Investigations[edit | edit source]

Chest X-ray[edit | edit source]

This radiological investigation of the chest helps us understand the areas of lung involved and is also an outcome measure post physiotherapy treatment.

  • widening of intercoastal spaces
  • flattened diaphragm
  • bullae present in the middle & lower zone on the right side
  • increased bronchovascular markings

Spirometry[edit | edit source]

Spirometry is the gold standard tool which can be used in the patients for diagnostic, prognostic & treatment montoring.

  • FEV1/FVC & FVC are reduced and obstructive abnormality is present [1]  

Objective Examination[edit | edit source]

On Inspection[edit | edit source]

Mr.S was assessed in standing and sitting positions. He was found to have

  • barrel chest appearance of the chest
  • forward head posture
  • use of accessory muscles (sternocleidomastoid muscle) on minimal exertion
  • breathing pattern is thoraco-abdominal, I: E ratio is 1:1
  • Height: 170cm
  • Weight: 90Kg
  • BMI: 31.1 Kg/m2 (i.e. Obesity Class I)[2]

On Palpation[edit | edit source]

Mr.S assessed in standing position had,

  • Anterior-Posterior: transverse diameter is 1:1
  • Chest expansion
    • Supramammary-0.5 cm
    • Mammary-0.5cm
    • Inframammary -0 cm

On percussion[edit | edit source]

  • Percussion was performed to mark ascend of the diaphragm on exhalation
  • Diaphragmatic excursion is reduced to 2 cm

On auscultation[edit | edit source]

  • Diminished vesicular breath sounds B/L middle & lower zone
  • Wheeze present B/L on expiration

Six min walk test[edit | edit source]

In order to improve exercise capacity in Mr.S, we need to assess it using a sub-maximal exercise test such as six minute walk test.

The results after patient assessment were as follows,

  • Distance achieved by Mr S is 280 m
  • Ideal for Indian Male: 486.4 m[3]

Summarizing Assessment using ICF[edit | edit source]

Structural and Functional Impairments[4][edit | edit source]

Sr.No. Structural & Functional Impairement Clinical Reasoning

(due to)

Correlate on Examination
1. Cough with expectoration due to hyperplasia of goblet cells from H/O indicating chief complaints & smoking for 8 years
2. Hyperinflation of lungs due to abnormal & permanent enlargement of airways in middle & lower zone of lung seen on X-ray,H/O indicating emphysema & palpation
3. Bronchial wall thickening due to inflammation of airway & presence of irritant from H/O of smoking & repeated bouts of chest infection
3. Increased bronchovascular markings due to thickening of walls of airways seen on X-ray
4. Reduced chest expansion due to lack of proper elastic recoil of lung seen on inspection & palpation
5. Barrel shaped chest due to hyperinflation of chest seen on inspection, palpation & X-ray
6. Presence of bullae due to extensive damage to lung tissue seen on x-ray & cough with expectoration H/O
7. Abdominothoracic breathing pattern due to hyperinflation of chest seen on inspection
8. Shoulder protracted with forward neck posture due to use of accessory muscles & increased work of breathing (WOB) seen on inspection & H/O
9. Dyspnea Gr.3 on MMRC due to airflow limitation & reduced elastic recoil of lungs seen on inspection & H/O
10. RPE –2 to 4 on Mod. Borg scale due to increased WOB, abnormal breathing pattern & hyperinflation of chest seen on H/O
11. Fatigue on the moderate activity of between METs 3-5.9 due to increased WOB dyspnea on exertion seen on H/O
12. Six minute walk distance is reduced due to dyspnea on exertion & peripheral muscle weakness secondary to chronic fatigue seen on 6MWT

Activity Limitation[edit | edit source]

  • Mr S has difficulty riding on two wheeler due to dyspnea
  • He is unable to sit in a meeting for a long time due to frequent cough with expectoration about which he is not comfortable & also fatigue
  • He is not able to do household chores/ activities in the evening as he is too tired

Participation Restriction[edit | edit source]

  • Mr S has difficulty continuing his marketing job
  • He does not feel comfortable going to any social function with family or friends

Contextual Factors[edit | edit source]

Environmental[edit | edit source]

Sr. No. Barrier Facilitator
1. Works on 2nd floor Good family support
2. Travels to work on a two-wheeler stays in a building with a lift
3. Has better access to physiotherapy set-up due to living in an urban city

Personal[edit | edit source]

Sr. No. Barrier Facilitator
1. He is the primary earning member of the family Quit smoking two years ago
2. Has H/O of smoking for eight years, thus a major risk factor Motivated to start a pulmonary rehabilitation program
3. He is obese

Management[edit | edit source]

So based on the ICF summary of Mr. S, the physiotherapy treatment can be divided into short term & long term goals.

Short Term Goals[edit | edit source]

Long Term Goals[edit | edit source]

References[edit | edit source]

  1. Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, Chen R, Decramer M, Fabbri LM, Frith P. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary. American journal of respiratory and critical care medicine. 2017 Mar 1;195(5):557-82.
  2. Weir CB, Jan A. BMI classification percentile and cut off points. (accessed on 22.11.2022)
  3. Ramanathan RP, Chandrasekaran B. Reference equations for 6-min walk test in healthy Indian subjects (25-80 years). Lung India: official organ of Indian Chest Society. 2014 Jan;31(1):35.
  4. Agarwal AK, Raja A, Brown BD. Chronic obstructive pulmonary disease (COPD). StatPearls [Internet]. 2020 Jun 7. 22.11.2022)