Nawrin Jahan

EFFECTIVENESS OF INTER COSTAL STRETCH TECHNIQUES
AMONG COPD PATIENTS AT NIDCH
Nawrin Jahan
DU Roll: 182
Reg No: 5271
Session: 2012-2013
BHPI, CRP, Savar, Dhaka
Bangladesh Health Professions Institute (BHPI)
Department of Physiotherapy
CRP, Savar, Dhaka-1343, Bangladesh
February, 2017
CONTENTS
Content point (s) Page no.
Acknowledgement I
Acronym II
List of tables III
List of figures IV
Abstract V
CHAPTER I: INTRODUCTION 1-10
1.1 Background 1
1.2 Justification of the study 6
1.3 Research Question 7
1.4 Aim 8
1.5 Objectives 8
1.6 Conceptual framework 9
1.7 Operational definition 10
CHAPTER II: LITERATURE REVIEW 11-21
CHAPTER III: METHODOLOGY 22-28
3.1 Study Design 22
3.2 Sampling 22
3.3 Study Population 22
3.4 Flow chart 23
3.5 Sampling 24
3.6 Selection Criteria 24
3.7 Treatment protocol 25
3.8 Data Collection Procedure 25
3.9 Data Collection Tool 25
3.10 Questionnaire 25
3.11 Significant level 26
3.12 Ethical consideration 27
3.12 Informed consent 28
3.13 Rigor 29
CHAPTER IV: RESULT 30-52
30
4.1 Socio demographic Information
[
32
4.1.1 Gender Distribution of the Participants
33
4.1.2 Education level of the participants
34
4.1.3 Occupation of the Participants
35
4.1.4 Living area of the participants
37
4.2 Respiratory Rate measurement
40
4.3 Heart Rate measurement
43
4.4 Inhale volume measurement
46
4.5 Exhale volume measurement
49
4.6 Interpretation of the results
52
CHAPTER V: DISCUSSION 53-54
CHAPTER VI: CONCLUSION AND RECOMMENDATION 55-57
REFERENCES 58-63
APPENDIX 64-79
Acknowledgment
First of all, I express my gratitude to Almighty Allah who has given me the ability to
complete this dissertation in time with great success. When I started the study I didn’t
know whether I could complete it or not but I was believed ―Fortune favors the brave‖.
So, I was determined to try my best to make it successful and I am most grateful to
almighty Allah. After that I must go to my family who inspired me always and provide
necessary support. I would like to pay my deepest thanks and highest gratitude to my
honorable supervisor.
Ehsanur Rahman, Assistant professor of Department of Physiotherapy, BHPI, for his

constructive suggestion, guidelines and optimistic and courageous attitude that have
inspired me throughout the project.
I would like to express my gratitude to my respected teacher Md. Shofiqul Islam,

Assistant Professor, BHPI, Department of Physiotherapy, for his tireless effort with
excellent guidance.
I am also indebted to Mohammad Anwar Hossain, Associate professor, BHPI & Head
of the Department of Physiotherapy, CRP for his valuable suggestion.
I am also indebted to Md. Obaidul Haque, Associate Professor and Head of the
Department of Physiotherapy for inspiration and encouragement advice.
And lastly Mohammad Habibur Rahman, Department of Physiotherapy and with all of
honorable teachers for sharing their precious knowledge that enabled me to fine-tune
various aspects concerning this study.
I like to state few names whom I express my hearty gratitude. I extend my gratitude to
Mrs. Mohsina is librarian of Bangladesh Health Professions Institute (BHPI)
Above all I would like to give thanks to the participants of this study. Finally thanks to all
who always are my well-wisher and besides me as friend without any expectation.
i
ABBREVIATIONS
BHPI Bangladesh Health Professional Institute

BMRC Bangladesh Medical and Research Council.
COPD Chronic Obstructive Pulmonary Disease
HR Heart Rate
IC Inter Costal
IRB Institutional Review Board
NIDCH National Institute of Disease of the Chest & Hospital.
RR Respiratory Rate
SPSS Statistical package for Social Sciences
WHO World Health Organization
ii
LIST OF TABLES
Table No. Title Page no

1 Treatment Protocol. 25
2 Mean age of the participants. 29
3 Comparisons of changes of Respiratory rate 42
4 Mean Difference Respiratory rate 42
5 Comparisons of changes of heart rate 44
6 Mean Difference heart rate 44
7 Comparisons of changes of inhale volume 46
8 Mean Difference inhale volume 48
9 Comparisons of changes of exhale volume 49
10 Mean Difference exhale volume 49
11 Comparison through paired t test for variables of RR, 50
HR, Inhale volume and Exhale volume in statistically significance at the
following level of significance
iii
List of figures
Figure No page no
1 Gender Distribution of participants 30
2 Educational level of participants 30
3 Occupation of COPD patients 31
4 Living area of the participants 31
5 Compare pretest and post test score of 1st patient 32
6 Compare pretest and post test score of 2nd patient 33
7 Compare pretest and post test score of 3rd patient 34
8 Compare pretest and post test score of 4th patient 35
th
14 Compare pretest and post test score of 10 patient 41
15 Respiratory rate of COPD patients 43
16 Heart rate reduction of COPD patients 45
17 Inhale volume of COPD patients 47
18 Exhale volume of COPD patients 49
iv
ABSTRACTS
Purpose: COPD is a most common pulmonary disease in our country. But physical
therapy is not common for the COPD patients. So the purpose of this study is evaluate the
effectiveness of inter costal stretch technique as a physical therapy.
Objective: Find out the effect of Inter costal stretch techniques among COPD patients at
NIDCH.
Methodology: It was quazi experimental study. Data was collected by questionnaire and
confidentiality of information and voluntarily participation were ensured by the
researcher. Data were numerically coded and captured in Microsoft Excel 10, using an
SPSS 16.0 version program.
Result: In this study 10 patients were participated. After providing the inter costal stretch
techniques I had found that reduce dyspnea by decreasing respiratory rate, decrease heart
rate or improve cardiovascular status, improve pulmonary function by increasing inhale
and exhale volume.
Conclusion: There is a paucity of population-based data on COPD prevalence and its

determinants in Bangladesh. COPD prevalence and socioeconomic and lifestyle
determinants among > 40 years Bangladeshi adults. Worsening this symptom day after
day. In this study found that inter costal stretch technique reduce its symptom.
Key words: Intercostals stretch techniques, Chronic Obstructive Pulmonary Disease.
v
CHAPTER: I INTRODUCTION
1.1 Background
Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by
chronic obstruction of lung airflow that interferes with normal breathing and is not fully
reversible. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer
used, but are now included within the COPD diagnosis. COPD is not simply a "smoker's
cough" but an under-diagnosed, life-threatening lung disease founded by (WHO, 2015).
Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease

that makes it difficult to empty air out of the lungs. This difficulty in emptying air out of
the lungs (airflow obstruction) can lead to shortness of breath or feeling tired because you
are working harder to breathe. COPD is a term that is used to include chronic bronchitis,
emphysema, or a combination of both conditions. It is not uncommon, however for a
patient with COPD to also have some degree of asthma declared by (American thoracic
society, 2011).
Chronic obstructive pulmonary disease (COPD) is a condition which is common treatable

disorder and it is also progressive, partially its main character is reversible airflow
limitation declared by (Barnes, 2002). COPD is also a gradual worsening disease of lung
functions and health status of a person health founded by (Sharker, 2008).
Globally COPD is associated with considerable morbidity and mortality proportion, it is

the fifth leading cause of death in the world, with its mortality rate is expected to increase
more than 30% during the next 10 years declared by (WHO, 2010).
The goal of treatment for COPD is to control symptoms to a degree that allows people
with the disease to breathe easier and live as normally and actively as possible for as long
as possible. COPD patients most commonly and main features are exercise and activity
intolerance Pulmonary; cardiovascular as well as skeletal muscles dysfunctions are the
main underlying elements in limiting exercise capacity of COPD patients declared by
(Mohamed & Mousa, 2012). Pulmonary functional abnormalities, COPD is also
associated with significant effects outside the lungs, such as malnutrition, pulmonary
1
hypertension and peripheral muscle weakness, the so-called systemic effects of COPD
founded by (Mahler, D.A et al., 2007). Mucous hyper secretion results in a chronic
productive cough. This is characteristic of chronic bronchitis but not necessarily
associated with airflow obstruction, and not all patients with COPD have symptomatic
mucous hyper secretion. The hyper secretion is due to squamous metaplasia, increased
numbers of goblet cells, and increased size of bronchial submucosal glands in response to
chronic irritation by noxious particles and gases; ciliary dysfunction is due to squamous
metaplasia of epithelial cells and results in an abnormal mucociliary escalator and
difficulty in expectorating founded by (Burgel, 2009).
The main site of airflow obstruction occurs in the small conducting airways that are < 2
mm in diameter; this is because of inflammation and narrowing (airway remodeling) and
inflammatory exudates in the small airways. Other factors contributing to airflow
obstruction include loss of the lung elastic recoil (due to destruction of alveolar walls)
and destruction of alveolar support; the airway obstruction progressively traps air during
expiration, resulting in hyperinflation at rest and dynamic hyperinflation during exercise.
Hyperinflation reduces the inspiratory capacity and therefore the functional residual
capacity during exercise declared by (Macnee, 2006). These features result in
breathlessness and limited exercise capacity typical of COPD. The airflow obstruction in
COPD is best measured by spirometry and is a prerequisite for its diagnosis founded by
(Macnee, 2006). These occur in advanced disease and are characterized by arterial
hypoxemia with or without hypercapnia. An abnormal distribution of ventilation:
perfusion ratios—due to the anatomical changes found in COPD—is the main
mechanism for abnormal gas exchange. The extent of impairment of diffusing capacity
for carbon monoxide per liter of alveolar volume correlates well with the severity of
emphysema declared by (Macnee, 2006).
This develops late in COPD, at the time of severe gas exchange abnormalities;
Contributing factors include pulmonary arterial constriction (as a result of hypoxia),
endothelial dysfunction, remodeling of the pulmonary arteries (smooth muscle
hypertrophy and hyperplasia), and destruction of the pulmonary capillary bed. Structural
changes in the pulmonary arterioles result in persistent pulmonary hypertension and right
2
ventricular hypertrophy or enlargement and dysfunction (cor-pulmonale) founded by
(Anderson, 2003). COPD patients aimed to relieve symptoms, prevent the progression of
disease, prevent and treat secondary infections or complications, prevent and treat
exacerbation, improve health status, reduce mortality, and increase quality of life. Non-
pharmacological method consists of using breathing exercises, energy conservation,
exercise, environmental adjustment, nutritional management, relaxation techniques,
education and behavioral approaches declared by (Parveen, 2014). The causes of dyspnea
in COPD patients included progressive airway obstruction, pulmonary hyperinflation,
hypoxemia, hypercapnia, pulmonary hypertension, pulmonary embolism, respiratory
infection, anxiety and depression, as well declared by (Jantarakupt & Porock, 2005).
We know that diaphragm is the main muscle for respiration; There are mainly two type of
inter costals muscle and these are internal Inter costal muscles and external Inter costal
muscles. These muscles are mainly working together when inspiration-expiration process
occurs. This muscle of respiration may undergo atrophy in physical inactivity. This may
affect chest wall mobility and Chest expansion and reduce lung compliance founded by
(Kenneth Saladin, 2009).
Neuro physiological facilitation of respiration said that the proprioception and tactile
stimuli that alter the depth and rate of breathing. Inter costal stretching is a technique
which is effective PNF technique helps in improving breathing pattern and respiratory
muscle activity declared by (Mohan et al., 2012).
The Inter costal stretch technique enhances the chest wall for elevation, increasing chest
expansion and diaphragm excursion to improve intra-thoracic lung volume. Inter costal
(IC) muscles are different and widely spread throughout the rib cage. These muscles are
morphologically and functionally one kind of skeletal muscles and it helps in upward and
outward movement of the ribs which results in increase in anterior-posterior diameter of
the thoracic cavity declared by (De Troyer, 2005).
Various research studies demonstrated that IC stretching improved expired tidal volume
decreased the level of dyspnea (increase respiratory rate) level and increased chest
expansion clinically which results in better gaseous exchange in human subjects. IC
3
stretch is performed actively by thoracic mobility exercises. Passively IC stretch can be
performed by thoracic rotation, mid sternum rotation, lateral thoracic stretching, through
thoracic mobility exercises as well as through manual stretching of IC spaces discovered
by (Leelarungrayub et al., 2009). The IC muscles are work for both in inspiration and
forced expiration. Even though these muscles engage in respiration, their activities are
less common during active contraction among normal healthy adults and respiratory
suppressive patient declared by (Mohan et al., 2012).
In Bangladesh, COPD is a common clinical problem. It is difficult to manage dyspnea

among these COPD patients because treatment facilities are not always available. There
is only one tertiary level referral hospital for COPD patients. This hospital can serve for a
limited number of patients among the increased prevalence of COPD, with health
professional shortage, and inadequate supply of medicine declared by (Robinson et al.,
2013).
Dyspnea management is important for the COPD patients to relieve their symptoms as it
can prevent complication and slow the progression of the disease. Currently, no existing
study examined physical therapy like inter costal stretch technique for management of
COPD patients in Bangladesh. Although COPD cannot be cured, optimal management
provides symptom control, slows progression of the disease, and may improve the quality
of life founded by (Kaplan & Ries, 2005).
Chronic obstructive pulmonary disease (COPD) is characterized by poorly reversible

airflow obstruction and its symptom produce due to abnormal inflammatory response in
the lungs; the latter represents the innate and adaptive immune responses to long term
exposure to noxious particles and gases, particularly cigarette smoke; all cigarette
smokers have some inflammation in their lungs, but those who develop COPD have an
enhanced or abnormal response to inhaling toxic agents; this amplified response may
result in mucous hyper secretion (chronic bronchitis), tissue destruction (emphysema),
and disruption of normal repair and defense mechanisms causing small airway
inflammation and fibrosis (bronchiolitis) declared by (Macnee, 2006). These pathological
changes result in increased resistance to airflow in the small conducting airways,
increased compliance of the lungs, air trapping, and progressive airflow obstruction all
4
characteristic features of COPD. We have good understanding of the cellular and
molecular mechanisms underlying the pathological changes found in COPD. The
pathogenic mechanisms result in the pathological changes found in COPD; these in turn
result in physiological abnormalities—mucous hyper secretion and ciliary dysfunction,
airflow obstruction and hyperinflation, gas exchange abnormalities, pulmonary
hypertension, and systemic effects declared by (Macnee., 2006).
Physical examination is not usually diagnostic of COPD but is an important part of

patient care; diagnosing COPD in an early stage is relevant because early and appropriate
management, especially smoking cessation interventions but also vaccination against
influenza and medication, reduces the number and severity of exacerbations of COPD
and improves quality of life of patients declared by (Broekhuizen et al.,2009).
Physical signs of airflow limitation and air trapping (barrel chest, loss of cardiac and
liver dullness, prolonged expiration, reduced breath sounds) are not usually present until
the disease is already at an advanced stage; physical examination may detect co-
morbidities or other illnesses and detect the development of complications of COPD such
as malnourishment and core pulmonale declared by (Kelly et al., 2007).
5
1.2 Justification of the study
The percentage of COPD is increasing day by day worldwide. In Bangladesh COPD is a

most common pulmonary disease. So, various systems of medicine are trying their best to
give maximum recovery within short time. Bangladesh is a developing country with
massive population though there is very limited resources and opportunities to get proper
medical care due to insufficient skilled professionals and expensive services. Who are not
capable of taking treatment like operation, more medication they are poor. They have no
much time to take a long procedure treatment as they are day labor. Inter costal stretch
technique is more effective for COPD patients because it is stretching may have activated
the stretch receptors in the chest wall. Inter costal stretch technique has been successfully
used by respiratory physiotherapist in management of reducing breathlessness and
improving pulmonary function in many developed and developing countries. But in our
country few physiotherapist have known this technique. But for evidence based
physiotherapy there is absolutely needed some guideline in which COPD patients will get
proper treatment. It has been suggested that this technique can be used to treat diseases
like chronic bronchitis, emphysema however there is a lack of evidence.
That does why researcher was choosing this topic to show the efficacy of inter costal
stretch technique. In Bangladesh the field of research in physiotherapy this type research
are limited, this is my wish to develop physiotherapy treatment for pulmonary conditions.
So, evidence based physiotherapy intervention is the important to build up the liability to
the patients also professionals. This topic is more interesting to researcher because of
challenge. If the researcher can show that there is an efficacy of intercostals stretch
technique as a new treatment may develop in Bangladesh and that may helpful for
physiotherapy profession and the COPD patients. The results of this study may help to
guide physiotherapist to give evidence based treatment in patient with COPD.
The study is designed to investigate the efficacy intercostals stretch techniques for the
treatment of COPD patients and the study will help to other physiotherapist to know the
actual effectiveness of this treatment approach.
6
1.3 Research question
Is intercostals stretch technique effective to improve pulmonary function for COPD
patients?
7
1.4 Aim
The aim of the study was find out the effect of intercostal stretch technique along with
conventional Physiotherapy for patients with COPD.
1.5 Study objectives
General objectives
To find out the effect of inter costals stretch technique along with conventional
physiotherapy patient with COPD.
Specific objectives
 To assess the effectiveness of inter costal stretch technique on
respiratory rate of the patients.
 To identify the effectiveness of inter costal stretch technique on
heart rate for the patient.
 To evaluate the level of pulmonary functioning of the patients
after applying inter costal stretch technique.
 To find out socio demographic factors for patient with COPD.
8
1.6 Conceptual Framework
Independent variables Dependent variable
Inter costal stretch techniques COPD
Conventional
Physiotherpy Respiratory rate
Age Heart rate
Sex Inhale volume
Exhale volume
9
1.7 Operational definition
Inter costal stretch
Innermost inter costal muscle, the deep layers of the internal inter costal muscles which
are separated from them by a neurovascular bundle. Procedure: This is provided by
applying pressure to upper border of a rib in order to stretch the inter costal muscle in a
downward direction (not inward). Application of stretch should be timed with exhalation.
COPD
Chronic obstructive pulmonary disease (COPD) is a type of obstructive lung diseases

which characterized by long-term poor air flow or air flow limitation. The main
symptoms include shortness of breath and cough with sputum production. COPD is a
progressive disease meaning it typically worsens over time. COPD is a common
preventable and treatable disease, characterized by persistent airflow limitation that is
usually progressive and associated with enhanced chronic inflammatory responses in the
airways and the lungs to noxious particles or gases. Exacerbations and co morbidities
contribute to the overall severity in individual patients (GOLD, 2014).Chronic
obstructive pulmonary disease (COPD) is defined independently of exacerbations, which
are largely a feature of moderate-to-severe disease.
Effectiveness
The capability of producing desired results. When something is deemed effective, it
Means it has an intended or expected outcome, or produces a deep, vivid impression.
Pulmonary Disease
Any abnormal condition of the respiratory system, characterized by cough, chest pain,
dyspnea, hemoptysis, sputum production, stridor, or adventitious sounds.
Pulmonary Function
Pulmonary function tests are a broad range of tests that measure how well the lungs take
in and exhale air and how efficiently they transfer oxygen into the blood.
10
CHAPTER: II LITERATURE REVIEW
Chronic Obstructive Pulmonary Disease (COPD) is an important public health problem

and it is the major cause of chronic morbidity and mortality in the world declared by
(GOLD., 2013). Approximately, 210 million people suffer from COPD and 3 million
people die every year because of COPD, which will become the third leading cause of
death in the world by 2030 declared by (WHO, 2008).
In Bangladesh, formal reports on the prevalence of disease are limited for assessing, one
study conducted in Bangladesh reported the prevalence of COPD among patients
attending at the outpatient department (OPD) was 0.7% and among the inpatient
department (IPD) was about 5.9% said by (Ilias, et al., 2009). Factors associated with
increase prevalence of COPD in Bangladesh may relate to smoking habit declared by
(Alam, et al., 2013).
Occupational dust and chemicals, outdoor and indoor air pollution, and environmental
change founded by (Ilias, et al., 2009). Many people suffer from the disease for years and
die too early from its complications. It is the fourth leading cause of death in adults of
United States and also projected to be the third by 2020 declared by (Gold,2008).
COPD is a preventable and treatable disease, however once developed this disease along
with its co morbidities cannot be cured, though its progression and morbidity can be
reduced which makes the pulmonary component of COPD is characterized by airflow
limitation which is not fully reversible and usually progressive and chronic airflow
limitation in COPD is caused by mixture introduction mortality throughout the world in
where many people suffer from the disease for years and die too early from its
complications and it is the fourth leading cause of death in adults of United States and
also projected to be the third by 2020 (Gold,2008). (Buist et al., 2003) aimed to measure
the prevalence of COPD and its risk factors and investigate variation across countries by
age, sex, and smoking status. Participants from 12 sites (n=9425) completed post
bronchodilator spirometry testing plus questionnaires about respiratory symptoms, health
status, and exposure to COPD risk factors which helps to assurance the COPD prevalence
11
estimates based on the Global Initiative for Chronic Obstructive Lung Disease staging
criteria were adjusted for the target population. Logistic regression was used to estimate
adjusted odds ratios (ORs) for COPD associated with 10-year age increments and 10-
pack-year (defined as the number of cigarettes smoked per day divided by 20 and
multiplied by the number of years that the participant smoked) increments. Meta-analyses
provided pooled estimates for these risk factors. The prevalence of stage II or higher
COPD was 10·1% .Overall, 11·8% (7·9) for men, and 8·5% (5·8) for women. The ORs
for 10year age increments were much the same across sites and for women and men
declared by (Buist et al., 2007).
The overall pooled estimate was 1·9 per 10-year increment. Site-specific pack-year ORs
varied significantly in women, but not in men; this worldwide study showed higher levels
and more advanced staging of spirometrically confirmed COPD than had typically been
reported. However, although age and smoking were strong contributors to COPD, they
did not fully explain variations in disease prevalence other factors also seemed to be
important. Although smoking cessation is becoming an increasingly urgent objective for
an ageing worldwide population, a better understanding of other factors that contribute to
COPD is crucial to assist local public-health officials in developing the best possible
primary and secondary prevention policies for their regions said by (Buist et al., 2007).
There is currently no consensus on the criteria for the diagnosis of chronic obstructive
pulmonary disease. This study evaluated the impact of different definitions of airway
obstruction on the estimated prevalence of obstruction in a population-based sample in
needed references founded by (Celli et al., 2003).
On November 19th this year, World Chronic Obstructive Pulmonary Disease (COPD)
Day 2003, people worldwide will be encouraged to review their not only health but also
respiratory health status and consult a doctor in case of certain symptoms are exposed
showed by (Schermer et al., 2003).
WHO- FCTC (2015) stated that other risk factors of this disease is including exposure to
indoor and outdoor air pollution and occupational dusts and fumes. Some cases of COPD
are due to try to cope up with long-term asthma. COPD is likely to increase in coming
years due to higher smoking prevalence and aging populations in many countries such as
12
ours. Many cases of COPD are preventable by the avoidance or early cessation of
smoking, who is smoked and who is secondarily smoked. Hence, it is important that
countries adopt the WHO Framework Convention on Tobacco Control and implement the
MPOWER package of measures so that non-smoking becomes the norm globally for
reducing the change of chronic obstructive disease. COPD is not curable, but some
treatments can relieve symptoms, improve quality of life and may reduce the risk of
death. From 37472 publications a total of 123 studies depended on a spirometry result
which is defined as the prevalence of retained for the review. From the Meta regression
epidemiological model, we estimated about 227.3 million COPD cases in the year 1990
among people aged 30 years or more than it, corresponding to a global prevalence of
10.7% (95%) confidence interval (CI) 7.3%–14.0%) in this age difference group. The
number of COPD cases is increased to 384 million in 2010, with a global prevalence the
percentage of 11.7% (8.4%–15.0%). This number of increase of 68.9% was mainly
driven by global demographic changes. (WHO., 2015) stated that, the highest prevalence
was estimated in the Americas (13.3% in 1990 and 15.2% in 2010), and the lowest in
South East Asia (7.9% in 1990 and 9.7% in 2010). The percentage is so much increased
in COPD cases between 1990 to 2010 was the highest in the Eastern Mediterranean
region (118.7%), followed by the African region (102.1%), while the European region
recorded the lowest increase (22.5%). In 1990, we studied the estimated about 120.9
million COPD cases among urban dwellers (prevalence of 13.2%) and 106.3 million
cases among rural dwellers (prevalence of 8.8%). In 2010, there were more than 230
million COPD cases among urban dwellers (prevalence of 13.6%) and 153.7 million
among rural dwellers (prevalence of 9.7%). The overall prevalence in men aged 30 years
or more was 14.3% (95% CI 13.3%–15.3%) compared to 7.6% (95% CI 7.0%–8.2%) in
women founded by (Adeloye et al., 2015).
Epidemiologic studies examining the incidence of respiratory symptoms show that COPD
is a major health problem in not only Europe but also the whole world. However, it is
very hard to have an exact figure of COPD prevalence in the Europe due to the
heterogeneity of studied populations (general, ―targeted‖, selected age groups). The
heterogeneity means a term of methods that depends on (symptom-based, medical
diagnosis & expert opinion, spirometry based). Underestimations of the disease
13
severity by the patients who report their smoking with a sense of guilt, anxiety and
depression that alter the perception of the disease and quality of life with fewer
adherences to treatment, more exacerbations, and more reaction time when the symptoms
are being worsen. As a consequence, COPD is often under-diagnosed; not the false
prevalence rates and the burden of disease may be much higher than the currently
available data suggest showed by (Halbert et al., 2003) it should to understand not to
realize. In 2005, about one in 20 deaths in the United States had COPD as the remarkable
because Smoking is manning to be responsible for at least 75% of COPD deaths. Excess
health-care expenditures are estimated is near about $6,000 annually for every COPD
patient in the United States (Centers for Disease Control and Prevention founded by
(Cdc,2008).
The COPD prevalence rates projected by the model reflect at high prevalence of the risk
factors for the disease in not only Asia but also near about Asia. The combined
prevalence of 6.3% for these countries is considerably higher than the overall rate of
3.8% as extrapolated from WHO data for only this region. These estimates highlight the
need for further epidemiological studies to support appropriate allocation of resources for
the evaluation, prevention and management of COPD. The total number of moderate to
severe COPD cases in the 12 countries of this region, as projected by the model, is 56.6
million with an overall prevalence rate of 6.3%. The COPD prevalence rates for the
individual countries range from 3.5% (Hong Kong and Singapore) to 6.7% (Vietnam)
founded by (WHO, 2003). The survey showed that 76.1% of the respondents used the
pulmonary function test as assessment which is higher when compared to the extent to
which this test is employed in countries like Australia and New Zealand (42.8%).
According to the World Health Organization (WHO) published, currently 210 million
people have COPD and 3 million people died of COPD in 2005. The WHO assuming that
COPD will become the fourth leading cause of death worldwide in 2030 researched by
(COPD., 2007). The burden of COPD assessed by disability-adjusted life years (DALYs)
ranks 10th worldwide founded by (WHO 2008).
Total deaths from COPD are projected to increase by more than 30% in the next 10 years
unless urgent preventive measures are in place said by (COPD, 2007). Even with recent
14
treatment advances; COPD continues as a severely debilitating condition or disease that
is usually undiagnosed until clinical symptoms become apparent. COPD is a leading
cause of morbidity and mortality and results in an economic and social burden that is
both substantial and increasing. COPD prevalence, morbidity, mortality vary across
countries and across different groups within countries. It is the result of cumulative
exposures over decades. Often the prevalence of COPD is directly is directly related to
the prevalence of tobacco smoking. Although in many countries outdoor, occupational,
indoor air pollution- the latter resulting from burning of wood and other biomass fuels are
the major risk factors. A systematic review and Meta-analysis of 2 studies carried out in
28 countries between 1990 and 2004 which provide evidence that COPD is appreciably
higher in smokers and ex-smokers than in non-smokers, in those over 40 years of age
than those under 40 and in men than in women declared by (Gold, 2013).
The development of successful preventive strategies requires better elucidation of the

untraditional risk factors for COPD besides smoking. In addition, it is likely that other
risk factors biologically interact with cigarette smoking and potentiate the development
of airflow obstruction. Consequently, there is an urgent need to evaluate the contribution
of novel risk factors for COPD at the population level, both in our country and
worldwide. Although COPD cannot be cured, the optimal management can provides for
symptom control, slows progression of the disease, and may improve the quality of life
showed by (Kaplan & Ries .,2005; Rodriguez-Roisin., 2005).
Breathing exercises are used to improve the efficiency of ventilation and gas exchange,
increasing the excursion of the diaphragm and easing the mobilization of secretions
founded by (Caroline et al., (2007). Breathing exercises like localized breathing
exercises, diaphragmatic breathing exercises, lateral basal expansion, upper lateral
expansion, and apical pectoral expansion exercises are important for treating thoracic
surgery patients. These exercises help to counteract an abnormal breathing pattern in the
postoperative period founded by (Shields, 2010).
15
In 2005, an estimated 22.2 million Americans had asthma: 6.5 million children and 15.7
million adults. The public health impact of asthma is significant and 2003, asthma
accounted for 1.4 deaths/100,000 persons in the USA founded by (Ahmed, 2016).
According to the National Center for Health Statistics, in 2003, children between the ages
of 5 and 17 years with a history of at least one asthma attack in the previous year
accounted for 12.8 million missed school days, and adults with a history of at least one
asthma attack in the previous year accounted for 10.1 million missed workdays. Gina
estimates that the prevalence of asthma is 300 million persons worldwide. The World
Health Organization estimates that 1% of the global disease burden, 15 million disability-
adjusted life years, is attributable to asthma. Asthma accounts for 250,000 deaths
annually worldwide declared by (Gina, 2015).
Mortality does not correlate with prevalence since countries such as Wales and New
Zealand have the lowest asthma related mortality rate, despite a high prevalence of
disease (Gina, 2015).
The epidemiology of asthma differs from that of COPD in that asthma usually presents
early in childhood, and atrophy is much more prevalent in asthma than in COPD. Asthma
is usually not progressive, although exacerbations can be intermittent and variable.
Eosinophils and lymphocytes are the major inflammatory cells in asthma. With
appropriate therapy, asthma is completely reversible in most patients declared by (Wise
et al., 2007).
COPD is the fourth leading cause of death in the USA recommended by (Wise et al.,
2007). In 2001, the World Health Organization reported that COPD was the fifth leading
cause of 4 deaths in high-income countries and the sixth leading cause of death in low-
and middle-income countries and COPD usually presents in middle age, is slowly
progressive and is associated with history of cigarette smoking in 80-90% of patients
declared by (Taussig et al., 2003).
Patients usually present with a chronic productive cough, and atrophy is not a frequent
finding with these clinical symptoms are slowly progressive, and airflow limitation is
only partially reversible after tobacco cessation and with bronchodilator use T
16
lymphocytes, with macrophages and neutrophils, are the predominant inflammatory cell
types declared by (Rabe et al., 2005).
COPD is more likely to be reported as a contributory rather than underlying cause of

death or morbidity, or may not be reported at all declared by (Holguin et al., 2001). In
Asia Pacific countries where tobacco smoking and indoor air pollution are highly
prevalent the rise of COPD incidence is particularly dramatic contributing to a significant
disease burden data from a WHO World Bank study were used to extrapolate a COPD
prevalence figure of 3.8% for the entire Asian population, but recent studies suggest that
COPD is a more significant problem in the region than has been previously realized. Two
major studies conducted in Japan said by (Takemura et al., 2005). More recently showed
a COPD prevalence of 8.55% and 7.5% respectively (Kim et al., 2005).
Consistent with the findings of WHO Global Burden of Disease study said by
(Whiteford,2013) both mortality and morbidity rates for COPD in the Asia-Pacific region
were reported to be higher in men than in women and increased with increasing age.
(NIH, 2004) said that COPD-related illness was higher in men, with rates of 32.6 to 334
per 10,000 people, compared with rates of 21.2 to 129 per 10,000 for women declared by
(Whiteford., 2013).
Prevalence of COPD in >40 years population was 21.24%.The total number of COPD
patients in Bangladesh is assumed to be 5947200. The overall prevalence of COPD in
total population of Bangladesh is estimated to be 4.32%. The prevalence of COPD was
found to be highest for rural population 23.15%, followed by urban 22.62% and was
lowest for metropolitan population 17.77% of the patients were suffering from moderate-
COPD, the prevalence of which in rural areas (48.55%) was higher than that of urban and
metropolitan areas (44.30% and 42.53% ). In general, males suffer more than females
(62.83% vs. 37.17%) declared by (Biswas et al., 2016).
Day by day prevalence of Asthma and COPD is increasing in the whole world as well as
in Bangladesh; the morbidity and mortality rate also has been increased. Asthma affects
both children and adults. Using conservative definitions, it is estimated that as many as
300 million people of all ages and all ethnic backgrounds suffer from asthma. For the past
17
40 years, the prevalence of asthma has increased in all countries in parallel with that of
allergy. It is estimated that asthma accounts for about 250 000 annual deaths worldwide.
Chronic obstructive pulmonary disease (COPD) affects 210 million people. It was the
fifth cause of death in 2002 and it is projected to be the fourth cause of mortality by 2030.
Tobacco smoking is the major risk factor, but the use indoors of solid fuels for cooking
and heating also presents major risks declared by ( Mannino et al., 2007).
Several cross sectional studies have been conducted over past 20-30 years that indicate
prevalence of allergic respiratory diseases worldwide declared by (Anderson et al., 2007).
In this study we will try to find out the prevalence of Asthma and COPD in a region for
the better understanding of the present situation and to aware people about the diseases
and to reduce mortality rate, to reduce severity and increase patient’s compliance and to
improve management of asthma and COPD. Asthma and COPD are common diseases of
the airways which are mainly diagnosed and treated in general practice. Various studies
have reported an increase in the morbidity of asthma and COPD declared by (Vestbo et
al., 2007). Another has conducted a study on a sample of 2328 adults from the general
population were screened for asthma and COPD. Those screened were then divided into
five sub-groups (grades 1-5), according to severity of: (1) respiratory symptoms; and (2)
loss in FEV1. The number of patients who were not known to the general practitioner
prior to the screening as having asthma or COPD grades 1-5 was also assessed
(Tirimanna et al., 2003).
In 1992, they studied a different sample of 1184 adults of the general population in the
same area. They used the same criteria as in 1977 to analyze their results. The number of
patients not known to the general practitioner prior to the screening was also studied. The
result was overall prevalence (grades 1-5) of asthma and COPD has increased from +/-
19% in 1977 to +/- 31% in 1992 (range 21-42). The main reason for this is an increase in
prevalence of very mild to moderate asthma and COPD (grades 1-3) from 17% in 1977 to
27% in 1992. The prevalence of severe cases (grades 4-5) increased from 2% in 1977 to
4% in 1992. In 1992, around 65% of the patients were not known to the general
practitioner as having any grade of asthma or COPD. This was only slightly lower than
the 72% in 1977. All patients with a severe disease (grade 5) were known to the general
18
practitioner. There is a real increase in the prevalence of asthma and COPD, caused
predominantly by an increase in the number of mild cases declared by (Tirimanna et al.,
2001). According to our study, more than 95% of physiotherapists employ breathing
exercises postoperatively and this is more than the response rate reported by
physiotherapists in Australia and New Zealand (90%) founded by (Reeve et al., 2007).
Exercise and activity intolerance are the two main characteristic features or treatment of
COPD patients. Pulmonary, cardiovascular as well as skeletal muscles dysfunctions are
the main underlying elements in limiting or reducing exercise capacity of COPD patients.
Pulmonary function test is used to determine the degree to which the preexisting
obstructive and restrictive components of pulmonary function may compromise the
ability to ventilate adequately and to maintain clear lungs after thoracic surgery.
Pulmonary function abnormalities in thoracic region has including a decrease enforced
expiratory volume, increased airway resistance, a decreased inspiratory capacity, and also
a decrease in maximum voluntary ventilation (MVV) and also founded that neglect of
skeletal muscle from a low level of physical activity is also a factor that may have
detraining effect on muscle mass or muscle fiber. This will have an impact or effect on
the oxidative capacity of the skeletal muscles and it will decrease or reduce the
proportion of muscle fibers from type I to type II declared by (Gosker et al., 2000).
Hence, it can be hypothesized inter costal muscles which aids in the mechanical future or
aspects of breathing may undergo atrophy when there is a poor physical activity.
Therefore, this could have an impact on chest wall mobility to upward or downward and
expansion in turn to ventilation on normal healthy body adults; various research studies
or finds demonstrated that IC stretching improved expired tidal volume decreased the
level of dysponea level and increased chest expansion clinically which results in better
gaseous exchange in human subjects found by (Leelarungrayub et al., 2009).
IC stretch is performed actively by thoracic mobility exercises by the help of the

therapists. Passively IC stretch can be performed by thoracic rotation, mid sternum
rotation, lateral thoracic stretching, through thoracic mobility exercises as well as through
manual stretching of IC spaces found by (Leelarungrayub et al., 2009). The external IC
muscles which are helpful during inspiration period showed a higher discharge activity
19
during forcible inhalation for a individuals. Similarly, a stretch of 15 micrometers applied
to IC spaces showed an increase or enhance in muscle activity and also said that the
increase in muscle activity or such as muscle work of the IC muscles could lead to
increase in lung volume, capacities and also in function. According to (Puckree et
al.,2002). IC stretching is effective in improving or enhancing the breathing pattern and
respiratory muscle activity among healthy conscious adults. However; none of the
research studies examined the effect of IC stretching on dynamic pulmonary function
parameters among healthy subjects who are normal and morphologically inter costal
muscles displayed a variation in fiber size and atrophy among obstructive lung disease
subjects. Puckree et al. (2002) studied with the effect of IC stretch on third and the eighth
IC space in which they were proved there were a number of decreases in breathing
frequency when a stretch performed on third and eighth IC spaces. This study did not
have statistically significant values between the groups on respiratory rate although
another. However, the rate of respiration lessened only in the experimental group not in
control group, which showed here there were impacts on respiratory rate also when an IC
stretch was performed; although there is a lack of evidence that supports the use or
applies of this technique, the results showed or exposed improvements in dynamic
ventilator parameters (FEV1%). A previous study reported or said that localized stretch
in the third and eighth IC space showed a deeper breathing pattern, greater activities on
para sternal ICs, electro myographic activities which resulted in an increase or enhance in
tidal volume and a decrease in breathing frequency among healthy subjects found by
(Puckree et al., 2002).
In addition, Threlkeld (2002) reported that applying manual techniques such as IC stretch
may produce a suitable amount of plastic deformation of connective tissue to enhance
mobility at joints that helps to move body parts easily. Therefore, the results of this study
provide preliminary evidence whereby IC stretch was an effective treatment parameter
which works shown in before study. Hence, future studies on a larger sample size may
corroborate the findings in detail for better result. A possible limitation of our study was
quantification of stretch pressure was not performed and it is uncertain that how far these
stretch receptors stimulated to evoke response. The respiratory rate measurement which
was used in our study did not provide or help a sensitive measure of change in the group
20
and therefore, future design of stretching protocol and its measured quantities in cardio
respiratory physiotherapy may be considered or envisaged in order to promote ventilation
declared by (Parveen et al., 2014).
21
CHAPTER: III METHODOLOGY
3.1 Study Design

This study was conducted using experimental study under a quantitative study design.
Here this study included the single group under the pre-test and post-test design because
here the one group of patient is tested under one condition, take the data before (pre-test
score) and after (post-test score) giving 6 session physiotherapy treatment. Thus two
scores were compared to see if there were any differences between them. Quasi
experimental design differs from a true experimental design in that, although it contains
an independent variable that was manipulated in order to look for an effect on a
dependent variable, either control group or randomization was lacking. These designs
were useful to researcher looking for validation of treatment method and techniques.
A pre-test (before intervention) and post-test (after intervention) were administered with
each subject of the selected group to compare the respiratory rate, heart rate ,pulmonary
function of the subject before and after the treatment.
3.2 Study area

The researcher is a fourth year B.Sc. in Physiotherapy student of Bangladesh Health
Professions Institute (BHPI) and the research is a part of the course curriculum. Data
were taking from those patients who were admitted in Bangladesh National Institute of
Diseases of the Chest & Hospital (NIDCH) for the condition of COPD.
3.3 Study population

The populations were selected by me. The study populations were taken from National
Institute of Disease of the Chest & Hospital (NIDCH) patients with COPD who attended
for treatment.
22
3.4 Flow chart of phages of Pre-test & Post-test design
Assessed for eligibility
Indoor COPD patients
Conveniently selected 10 COPD patients from NIDCH
Measure the pretest result (respiratory rate, heart rate, lung

volume)
Provide intercostal stretch techniques with conventional

physiotherapy.
Follow up six sessions
Measure the post test result (respiratory rate, heart rate, lung
volume)
Analysis the data
23
3.5 Sample size
The number of items to be selected from the population is the sample size. Sample a
group of subjects were selected from population, who are used in a piece of research
(Hicks, 1999).
10 participants (COPD patients) were selected for my dissertation.
3.6 Sampling procedure

Searching a appropriate number and kind of people who are a part of this study is called
―Sampling‖ (Hicks 1999, p. 24).
A total ten sample with COPD patients were selected conveniently as sample group. The
samples were regularly taking hospitals treatment. Establishes inclusion and exclusion
criteria and selected those individuals who fit these factors and volunteer to participate in
the study. The samples had been collected on the basis of some inclusion and exclusion
criteria. I was provided treatment for 2 weeks totally. Three session per week. That’s
mean every selective patient was received three sessions on this dissertation. When
qualified physiotherapist was give therapy firstly I was check that patient’s respiratory
rate, heart rate, inhale volume and exhale volume. After complete the session I was again
check that patient’s respiratory rate, heart rate, inhale volume and exhale volume.
3.7 Selection criteria

3.7.1 Inclusion criteria
 Medically diagnosed Chronic Obstructive Pulmonary Disease patient.
 Male and Female patient.
 Willing to participate.
 Admitted into National Institute Of Disease of the Chest & Hospital (NIDCH).
3.7.2 Exclusion criteria
 Any heart disease patient.
 Depressed patient.
 Any tumor
 Sternum fracture
 Intercostals muscle strain
24
3.8 Treatment protocol
Treatment option Duration/Repetation

Diaphragmatic breathing 5 rep. per session
Pulse lip breathing 10 rep. per session
Incentive Spirometry 3 times per session
Thoracic expansion exercise 5 rep. per session
Intercostals stretch techniques 4 rep. per costal space per session
Table-1: Treatment Protocol
Procedure of Inter costal stretch techniques
Patients positioning were standardized to supine flat, limbs positioned in neutral. The
position of the therapist is behind the patient. First palpate the supra sternal notch. Then
goes downward about 5cm and palpate the angle of Louis. 2nd rib lies at the level of
angle of Louis. From the angle of Louis trace the finger laterally. The Inter-costal stretch
technique is applied over 2nd and 3rd rib bilaterally. The technique is given with the help
of index finger. The direction of the pressure is downward towards the next rib.
Technique is applied during expiration phase. Therapist was providing intercostals stretch
technique in 2nd and 3rd intercostals space by four repetitions per set. Three set per
session where therapist giving 1 minute rest between two set.
3.9 Data collection tools

The researcher organized the materials to successfully complete the interview session.
The organized material was a written questionnaire, pen, paper, pencil, laptop, automatic
blood pressure monitor, spirometry, stop watch were use as data collection tools in this
study.
3.9.1 Questionnaire
The questionnaire was developed under the advice and permission of the supervisor
following certain guidelines. There were two parts a socio-demographic and a medical
25
information part. Data was gathered through a pre test, intervention and post test and the
data was collected by using a written questionnaire from which is formulated by the
researcher.
3.9.2 Incentive Spirometer

Incentive Spirometer is a machine which is commonly used for test and assess how well
your lungs work by measuring how much air you inhale, how much you exhale and how
quickly you exhale. Spirometer was used to diagnose asthma, chronic obstructive
pulmonary disease (COPD) and other conditions that affect breathing. In this study
researcher used spirometer to measure lung volume, expiratory volume.
3.9.3 Digital blood pressure machine

In this study the researcher use digital blood pressure machine for measuring heart rate.
This was a simple and accurate way of objective assessment of heart rate.
3.10 Data collection procedure
The study procedures were conducted through assessing the patient, initial recording,
treatment and final recording. After screening the patient at ward, the patients were
assessed by qualified physiotherapist. Six sessions of treatment was provide for every
patient. 10 subjects were choosing for data collection according to the inclusion criteria.
A qualified physiotherapist was providing inter costal stretch techniques along with
conventional physiotherapy. Data was gathering through a pre-test, intervention and post-
test and the data will collected by using a written questionnaire form which was
formatted by the researcher. Pretest will performed before beginning the treatment and
measure the respiratory rate, heart rate and pulmonary function. Post test result record
after finishing the last session.
26
3.10.1 Data Analysis
In order to ensure that the research have some value, the meaning of collecting data has
to be presented in ways that other research worker can understand. In other words the
researcher has to make sense of the results. As the result of a quasi-experimental study I
was analyzed my data by using of SPSS 20 software, Microsoft Office Excel and
scientific calculator.
Probability & Pair t-test
No. Variables Observed Observed Significant/Not
“t” value “P” value Significant
01 Respiratory rate 1.464 .004 Significant
02 Heart Rate 3.943 .000 Significant
03 Inhale volume 2.283 .001 Significant
04 Exhale volume .688 .001 Significant
Interpretation of data
In this way respiratory rate (p=.004), heart rate (.000), inhale volume (p=.001) and the
last one is exhale volume (p=.001) was significant. It indicates that intercostal stretch
technique was effective for those variables this technique was significant.
27
3.10.2 Significant level
In order to find out the significance of the study, the researcher calculated the ―p‖ value.
The p values refer the probability of the results for experimental study. The word
probability refers to the accuracy of the findings. A p value is called level of significance
for an experiment and a p value of <0.05 was accepted as significant result for health
service research. If the p value is equal or smaller than the significant level, the results are
said to be significant.
3.11 Ethical consideration

The research proposal was submitted to Institute Review Board (IRB) of Bangladesh
Health Professions Institute (BHPI) for oral presentation and defense was done in front of
the IRB. Then IRB was approved the proposal. A research proposal was submitted to the
physiotherapy department of BHPI for approval and the proposal was approved by the
faculty members. For data collection purposes, it was also taken permission from the
director of National Institute of Disease of the Chest & Hospital (NIDCH).Data
collection was started and completed within the allocate time frame. All information was
kept in secure. World Health Organization (WHO) and Bangladesh Medical and
Research Council (BMRC) rules were followed to conduct the study.
3.12 Informed Consider

Written consent (appendix) was given to all participants prior to completion of the
questionnaire. The researcher explained to the participants about his or her role in this
study. The researcher received a written consent form every participants including
signature or finger trip (who were not able to give signature). So the participant assured
that they could understand about the consent form and their participation were on
voluntary basis. The researcher was obtained consent to participate from every subject. A
signed informed consent form was received from each participant. The participants are
informing that they have the right to meet with outdoor doctor if they think that the
treatment is not enough to control the condition or if the condition become worsens. The
participants are also inform that they are completely free to decline answering any
question during the study and were free to withdraw their consent and terminate
28
participation at any time. Withdrawal of participation from the study would not affect
their treatment in the hospital authorities and they would still get the same facilities.
3.13 Rigor
During the data collection and data analysis the author was always tried not to influence
the process by his own perspectives, values and biases. No leading questions were asked
and judgments were avoided. When conduct the study the researcher was taken help from
the supervisor when needed. The other researchers could use the results in their related
area.
29
CHAPTER: IV RESULTS
In this study 10 patients with COPD were taken as sample from National COPD who
attended in National Institute of Disease of the Chest & Hospital (NIDCH) for the
condition of COPD.
This study works to explore the effectiveness of Intercostal stretch techniques among
COPD patients.
In this study the results which were found have been shown in different bar diagrams, pie
charts and tables.
4.1 Socio demographic Information:

Table 2: Mean age of the participants
Subjects Age (years)

p1 27
p2 70
p3 70
p4 50
p5 55
p6 56
p7 39
p8 62
P9 60
p10 35
Mean age =52.4 years
From the above mentioned table, it is obvious that mean age of participant was 52.4
years.
30
4.1.2 Gender Distribution of the Participants
In this study 10 Patients with COPD are included as sample, among them 30% (n=3) are
Female and 70% (n=7) were Male.
Female
30%
Male
70%
Figure – 1: Gender Distribution
4.1.2 Education Level of the participants

Among the 10 participants 30% (n=3) was Illiterate, 50% (n= 5) was Primary, 10% (n=1)
was Secondary, 10% (n=1) was Higher secondary.
Higher
secondary
Secondary 10% Illiterate
10%
30%
Primary
50%
Figure – 2: Educational level of the participants.
31
4.1.3 Occupation of the Participants
Among the total 10 sample 30% (n=3) were housewife, 30% (n=6), 10% (n=2) were Farmer and
20% (n=4) were others.
Housewife Service Holder Day lauber Businessmen
Housewife
30%
30%
Businessmen
Day lauber Service Holder

20% 20%
Fig-3: Occupation of the Participants
4.1.4 Living area of the participants

This study done with 10 patients among them 30% (n=3) came from urban living area
10% (n=1) came from semi urban area and 70% (n=7) came from rural living area.
Urban
27%
Rural Semi urban

64% 9%
Fig -4: Living area of the participants
32
Individual Patient Status in Chart
7
6 6 6
6
5 5
5
4 4
4
Pre test
3 Post test
2
2
0
Respiratory rate Heart rate Inhale volume Exhale volume
Fig-5: Compare pretest and post test score of 1st patient (according to questionnaire
coding )
In this study 1st patient 27 years old male his pretest RR was 6 (41-45)/min after six
session found that post test result was 4 (31-35)/min. that means his respiratory rate
decrease or reduce dyspnea level. Then pretest HR was 6 (96-100)/min after six session
measure post test score was 2 (76-80)/min. So his cardio vascular was improved. His
inhale pretest volume was 6(1800cc) and posttest is same. His exhale pretest volume was
4(1200cc) and six sessions posttest value was 5 (1200-1800). So intercostals stretch
technique has improved lung volume.
33
5
5
4 4
4
3
3 Pre test
Post test
2
2
1 1 1
1
0
Fig-6: Compare pretest and post test score of 2nd patient (according to
questionnaire coding)
In this study 2nd patient 70 years old female her pre-test RR was 2 (21-15)/min after six
session found that post-test result was 1(15-20)/min. that means her respiratory rate
measure post test score was 1 (71-75)/min. So her cardio vascular function was
improved. His inhale pretest volume was 1 (<600cc) and post-test 3 (600-1200cc). Her
exhale pretest volume was 4 (1200cc) and six sessions post-test value was 5 (1200-
1800cc). So intercostals stretch technique has improved lung volume.
34
5
5
4
4
3
3 Pre test
Post test
2 2 2
2
1 1
1
0
Fig-7: Compare pretest and post test score of 3rd patient (according to
In this study 3rd patient 70 years old male his pre test RR was 3 (26-30)/min after six
decrease or reduce dyspnea level. Then pre test HR was 2 (76-80)/min after six session
inhale pretest volume was 4 (1200cc) and post test was (1200-1800cc). His exhale pretest
volume was 1(<600cc) and six sessions post test value was 2 (600cc). So intercostals
stretch technique was improving lung volume.
35
5 5
5
4
4
3 3
3 Pre test
Post test
2 2
2
1
1
0
Fig-8: Compare pre-test and post-test score of 4th patient (according to

In this study 4th patient 50 years old female her pre-test RR was 5 (36-40)/min after six
session found that post test result was 2 (21-25)/min. that means her respiratory rate
decrease or reduce dyspnea level. Then pre-test HR was 5 (91-95)/min after six session
measure post test score was 1 (71-75)/min. So her cardio vascular is improved. Now his
inhale pretest volume was 3 (600-1200cc) and post-test 4 (1200cc). Her exhale pretest
volume was 2 (600cc) and six sessions post-test value was 3 (600-1200). So intercostals
stretch technique has improved lung volume.
36
5
5
4 4 4
4
3 3
3 Pre test
Post test
2 2
2
0
Fig-9: Compare pretest and post test score of 5th patient (according to
In this study 5th patient 55 years old male his pre-test RR was 3 (26-30)/min after six
measure post test score was 2 (76-80)/min. So his cardio vascular is improved. His inhale
pretest volume was 4 (1200cc) and post test was 5 (1200-1800cc). His exhale pretest
volume was 3 (600-1200cc) and six sessions post test value was 4 (1200cc). So
intercostals stretch technique was improving lung volume.
37
5 5
5
4
4
3 3 3
3 Pre test
Post test
2
1 1
1
0

measure post test score was 3 (81-85)/min. So his cardio vascular is improved. Now his
inhale pretest volume was 4 (1200cc) and post-test was 5 (1200-1800cc). His exhale
pretest volume was 1 (<600) and six sessions post test value was 3 (600-1200cc). So
intercostals stretch technique has improved lung volume.
38
5
5
4
4
3 3
3 Pre test
Post test
2 2
2
1 1
1
0

In this study 7th patient 39 years old male his pre test RR was 5 (36-40)/min after six
inhale pretest volume was 3 (600-1200cc) and post test is 4 (1200cc). His exhale pretest
volume was 1 (<600cc) and six sessions post test value was 2 (600cc). So intercostals
stretch technique has improved lung volume.
39
7
6
6
5
4 4
4
Pre test
3 3
3 Post test
2
2
1 1
1
0

inhale pretest volume was 2 (600cc) and post test is 4 (1200cc). His exhale pretest
volume was 1 (<600cc) and six sessions post test value was 3 (600-1200cc). So
40
4.5
4 4
4
3.5
3 3 3
3
2.5
2 Pre test
2 Post test
1.5
1 1
1
0.5
0

measure post test score was 1 (71-75)/min. So his cardio vascular was improved.
Hisinhale pretest volume was 2 (600cc) and post test is 3 (600-1200cc). His exhale
pretest volume was 1 (<600cc) and six sessions post test value was 3 (600-1200). So
41
4.5
4 4
4
3.5
3 3 3
3
2.5
2 2 Pre test
2
Post test
1.5
1
1
0.5
0

inhale pretest volume was 2 (600cc) and post test was 4 (1200cc). His exhale pretest
volume was 1 (<600cc) and six sessions post test value was 3 (600-1200cc). So
42
4.2 Respiratory Rate measurement:
Respiratory rate reduction of COPD patients
Reduction of Respiratory rate is shown in the table.
Table –3 Comparisons of changes of Respiratory rate
Subjects Pre-test Post-test Subject defferance
P1 6 4 2
P2 2 1 1
P3 3 2 1
P4 5 3 2
P5 3 2 1
P6 3 1 2
P7 5 3 2
P8 6 3 3
P9 4 3 1
P10 4 3 1
Table-4: Mean difference of Respiratory rate
Pre test Post test
Mean 4.10 2.40

Mean difference 1.70
43
Statistical difference of respiratory rate
Respiratory rate
50
45
40
35
30
25
20
15
10
5
0
P1 P2 P3 P4 P5 P6 P7 P8 P9 P 10
Pre test 45 21 30 36 30 30 36 42 32 33
Post Test 31 15 24 30 22 20 28 30 26 26
Figure – 15: Respiratory rate of COPD patients
Result of respiratory rate for ten patients pre-test and post-test scores were shown at
figure-15. It indicates that there have differences between pre-test and post-test scores.
Pre-test scores were higher than post-test score. So Intercostals stretch techniques have
great role on respiratory rate.
44
4.4 Heart Rate measurement
Table-5: Heart rate of COPD patients
Subjects Pre-test Post-test Subject defferance
P1 6 2 4
P2 4 1 3
P3 2 1 1
P4 5 2 3
P5 4 2 2
P6 5 3 2
P7 2 1 1
P8 4 1 3
P9 4 1 2
P10 3 2 3
Table-6: Mean difference of Heart rate
Pre test Post test
Mean 3.9 1.5
Mean difference 2.4
45
Statistical difference of Heart rate
Heart rate
120
100
80
60
40
20
0
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10
Pretest 100 88 79 92 88 91 78 87 86 85
Posttest 79 73 68 75 78 82 71 72 75 76
Figure16- Heart rate of COPD patients
Result of Heart rate for ten patients pre-test and post-test scores were shown at figure-16.
It indicates that there have differences between pre-test and post-test scores. Pre-test
scores were higher than post-test score. So Intercostals stretch techniques have great role
on Heart rate.
46
4.5 Inhale volume measurement:
Table-7: Comparisons of changes of Inhale volume

Subjects Pre test Post test Subject difference
P1 5 6 1
P2 4 5 1
P3 4 5 1
P4 3 4 1
P5 4 5 1
P6 4 5 1
P7 3 4 1
P8 2 4 2
P9 2 3 1
P10 2 4 2
Table 8: Mean Difference Inhale volume increase
Table of mean difference:
Pre test Post test
Mean 1.6 3.00
Mean difference 1.4
47
Statistical difference of Inhale volume
6
6
5 5 5 5 5
5
4 4 4 4 4 4 4
4
Pre test
3 3 3 Post test
3
2 2 2
2
0
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10
Figure – 17: Inhale volume of COPD patients
Result of Inhale volume for ten patients pre-test and post-test scores were shown at
Post-test scores were higher than pre-test score. So Intercostals stretch techniques have
improve pulmonary function for COPD patients.
48
4.6 Exhale volume measurement:
Table- 9: Comparisons of changes of respiratory rate:
Subjects Pre test Post test Subject difference

P1 4 5 1
P2 1 3 2
P3 1 2 1
P4 2 3 1
P5 3 4 1
P6 1 3 2
P7 1 2 1
P8 1 3 2
P9 1 2 1
P10 1 3 2
Table 10: Mean Difference Exhale volume
Pre test Post test
Mean 3.3 4.5
Mean difference 1.2
49
Statistical difference of Exhale volume
5
5
4 4
4
3 3 3 3 3 3
3 Pre test
Post test
2 2 2 2
2
1 1 1 1 1 1 1
1
0
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10
Figure – 18: Exhale volume of COPD patients
Result of Inhale volume for ten patients pre-test and post-test scores were shown at
Post-test scores were higher than pre-test score. So Intercostals stretch techniques have
improve pulmonary function for COPD patients.
50
Table 11: Within Participant age and Post-test comparison through paired t
test for variables of RR, HR, Inhale volume and Exhale volume in statistically
significance at the following level of significance
No. Variables Observed Observed Significant/Not
―t‖ value ―P‖ value Significant
01 Respiratory rate 1.464 .004 Significant
02 Heart Rate 3.943 .000 Significant
03 Inhale volume 2.283 .001 Significant
04 Exhale volume .688 .001 Significant
In this way respiratory rate (p=.004), heart rate (.000), inhale volume (p=.001) and the last one is
exhale volume (p=.001) was significant. It indicates that intercostal stretch technique was
effective for those variables this technique was significant.
51
Interpretation of results:
Respiratory rate:
10 patients are receiving Inter costal stretch techniques in 6 sessions. Mean difference of
respiratory rate between pre-test and post-test 1.7
Following application of treatment the study found that the intercostals stretch techniques
showed a significant improvement (p<.004) in case of COPD patients.
Heart rate:
Mean difference of heart rate between pre-test and post-test 2.4

Following application of treatment the study found that the intercostals stretch
techniques showed a significant improvement (p<.005) in case of COPD patients.
After completing 6 sessions of treatment named Inter costal stretch techniques. It could
indicate that this techniques improve the cardiac function.
Inhale volume:
Mean difference of inhale volume between pre-test & post test 1.4.
Here 10 patients are received the intercostals stretch techniques by researcher.
Exhale volume:
Mean difference of inhale volume between pre-test & post-test 1.2.

In this study found that Inter costal stretch techniques reduce dyspnea, decrease heart rate
or improve cardiovascular function, improve lung volume.
52
CHAPTER – V DISCUSSION
The study was indicated a process that could be continuing to establish the result. Here
the aim of this study could be achieved if the researcher could show effective support.
The purpose of this study was to evaluate the effectiveness of intercostals stretch
techniques among COPD patients.
The situation of COPD is severe in Bangladesh among the aged people. The majorities of
the patients were adult male, diagnosed with COPD within 5 years, and had history of
smoking. It is possible that smoking habit increase among male in Bangladesh (WHO,
2009).
This finding indicated that people with older age and smoking were likely to be
diagnosed with COPD more than younger people. Similar to another study which
reported smokers were at two or three times higher risk of developing dyspnea in their
life time compared to non-smokers. It is possible that smoking can damage sensory nerve
and increase the risk of dyspnea said by (Rosi & Scano, 2004).
The prevalence of COPD was 13.5% by Gold criteria. The purpose of this study was to
evaluate the effectiveness of the Inter costal stretch techniques among COPD patients at
NIDCH. In this quazi experimental study 10 patients were received Inter costal stretch
techniques Each patient attended for 6 sessions in every alternative day before giving
treatment record pre test result and after giving 6 session record the post test result in
order to demonstrate the improvement.
From this study it is obvious that mean age of participant was 52.4 years.
In this study 10 Patients with COPD are included as sample, among them 30% (n=3) are
Female and 70% (n=7) were Male. In general, males suffer more than females (62.83%
vs. 37.17%) said by (Biswas, et al., 2016).
The mean of respiratory rate reducing in COPD patients between pre-test and post-test
are 4.1 and 2.4. Mean difference of respiratory rate is 1.7 and the intercostals stretch
techniques showed a significant improvement (p<.004) in case of COPD patients. The
results of the present study is similar to a previous study which reported that pulmonary
53
condition physical therapy along with medication acting a good result in the
management of dyspnea (Parveen, 2014).
The mean of Heart rate reducing in COPD patients between pre-test and post-test are 3.9
and 1.5. And mean difference of heart rate is 2.4 and showed a significant improvement
(p<.005). The mean of inhale volume increasing in COPD patients between pre-test and
post-test are 1.6 and 3. Mean difference of inhale volume is 1.4 and found a significant
improvement (p<.001) in case of COPD patients. The mean of exhale volume increasing
in COPD patients between pre-test and post-test are 3.3 and 4.5. Mean difference of
exhale volume is 1.2 i also found significant improvement (p<.001).
In this study showed that Inter costal stretch techniques reduce respiratory rate that’s
means reduce dyspnea and heart rate that reduce COPD symptom.
There are many research said that IC stretching improved many pulmonary diseases
condition like decreased the level of dysphonic level and increased chest expansion
clinically which results in better gaseous exchange in human subjects founded by
(Leelarungrayub , 2009).
Finding of the study supported by it has been found that IC stretch is more effective in
reduction of respiratory rate and heart rate .The present study is in accordance with an
earlier study in which IC stretch was given as one of the sets of unsupported arm
exercises (Mohan et al., 2010).
The results of the present study is similar to a previous study which reported intercostals
stretch techniques could lead to increase in lung volume, capacities and also in function
(Puckree et al., 2002).
In this study intercostals stretch techniques was reduce respiratory and heart rate in
similarly found by (Gupta et al., 2014) advantage of application of IC stretch technique is
it helps in lowering the raised RR and HR.
54
Limitation of the study:
The study was conducted with 10 patients with COPD, which was a very small number of
samples was not sufficient enough for the study to generalize the wider population of this
condition.
There was no available research done in this area in Bangladesh. So, relevant
information about COPD with specific intervention for Bangladesh was very limited in
this study.
It is limited by the fact daily activities of the subject were not monitored which could
have influenced like they all are taking drugs. Researcher only explored the effect of inter
costal stretch techniques after 6 sessions of treatments, so the long term effect of inter
costal stretch techniques was not explored in this study.
As the study was quasi-experimental and one group data is used so there is no
comparison group and so there is no comparison. This research project was a part of 4th
year physiotherapy course and this type of work is first at this level, so there may have
some problems in techniques and short out in term of practical aspect.
55
CHAPTER- VI CONCLUSION AND RECOMMENDATION
6.1 Conclusion
COPD is the most common pulmonary disease in Bangladesh and major cause of
disability and morbidity. The environment condition is poor here which aggravates the
diseases more rapidly. COPD control is the most important factor, in the current situation
these diseases can be reduced by giving proper guidelines, physical exercise and
monitoring the conditions of these patients especially in remote areas by forming multi-
disciplinary team which should be initiated by the government. There is need to identify
the effective physiotherapy interventions that will reducing and relieving symptom of
patients Bangladeshi people are not fully concerned about basic health care. Health
services in government and non-government sector are not sufficient. Physiotherapy is
considered as an important treatment process in the develop countries. So this
physiotherapy technique is improving the condition. The result of the study had identified
that the effectiveness of inter costal stretch techniques was better inter costal stretch
technique for COPD patients which was a Quantitative experimental study. The result of
the current study indicates that inter costal stretch techniques is an effective therapeutic
approach for patient with COPD. It may be helpful for patient with COPD to increase
return to normal daily activities, worsening symptom, work and to measure longer term
effects for determining cost effectiveness of inter costal stretch techniques for COPD
patients. By conducting the study the researcher found effectiveness of the Inter costal
stretch techniques among COPD patients at NIDCH. But it is not always possible to gain
complete achievement from every work. Same things happened in the study, what the
researcher wanted to gain from the study not achieved fully. So, some further steps that
might be taken for better accomplishment for further research. A much large subject
should be chosen randomly because it will be more significant. In the study participant
were taken only from indoor patient of NIDCH but the participant also can be taken from
the outdoor patient. A further study could be done with longer duration of time and with
good combination of the assessment and treatment. Sample should collect from different
hospital, clinic, institute and organization in different area of Bangladesh to generate the
result.
56
6.2 Recommendation
As a consequence of this researcher it is recommended to do further study include

combined intercostals stretch techniques along with conventional physiotherapy.
As a consequence of this researcher it is recommended that further research on large

group of population and different hospital and different area.
I got a limited time that’s why i couldn’t fulfill the all requirement what i had needed. So
i want to recommend the next research on start early so that they can fulfill the all
requirement as they can provide more session for more effectiveness result.
And also increase the treatment session more than 6 session and time increase the
significance of results.
57
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63
঳ম্মতত঩ত্র (ফাাংরা)
(অাং঱গ্র঴নকাযীকক ঩কে শ঱ানাকত ঴কফ )
আ঳ারাভু আরাইকুভ / নভস্কায, আভায নাভ নওতযন জা঴ান , আতভ এই গকফলণাটি ফাাংরাকে঱ শ঴ল্থ
প্রকপ঱নার ইতিটিউকে ( তফ এইচ ত঩ আই ), ঢাকা তফশ্বতফেযারকেয তচতকৎ঳া অনুলকেয অধীকন কযতি মা
আভায তপতজওকথযা঩ী স্নাতক শকাক঳েয আাংত঱ক অতধবূ ক্ত মায ত঱কযানাভ ঴র “শ্বাসতন্ত্রে বাধাগ্রস্ত
দীর্ঘ স্থায়ী রুগীন্ত্রদর ঩াাঁজন্ত্ররর মধযবতী স্থান্ত্রনর প্রসাররত করার ঩দ্ধরতর কার্ঘ কাররতা”।
পযকভ উকেতিত তকিু প্রকেয উত্তয শেোয জনয আন্ততযকবাকফ অনুকযাধ জানাতি মা আনুভাতনক ২০ –
৩০ তভতনে ঳ভে তনকফ ।
আতভ আ঩নাকক অফগত কযতি শম, এো শকফরভাত্র আভায অধযেকনয ঳াকথ ঳ম্পকে মুক্ত এফাং অনয শকান
উকেক঱য ফযফ঴ায ঴কফ না । আতভ আ঩নাকক আকযা তনশ্চেতা প্রোন কযতি শম ঳কর তথয প্রোন কযকফন
তায শগা঩নীেতা ফজাে থাককফ এফাং এই তকথযয উৎ঳ অপ্রকাত঱ত থাককফ । এভনতক গকফলণাটিয শ঱কল
এই ঳কর তথয নষ্ট ককয শপরা ঴কফ ।এই অধযেকন আ঩নায অাং঱গ্র঴ন শেিাপ্রকণােীত এফাং আ঩তন শম
শকান ঳ভে এই অধযেন শথকক শকান শনততফাচক এফাং পরাপর শকান তফব্রতকফাধ িাোই তনকজকক
প্রতযা঴ায কযকত ঩াযকফন । এিাোও শকান তনতেষ্ট প্রে অ঩িন্দ ঴কর উত্তয না শেোয এফাং ঳াক্ষাৎকাকযয
঳ভে শকান উত্তয না তেকত চাওোয অতধকায আ঩নায আকি ।
মতে আ঩নায এই গকফলণা ঳ম্পককে তকিু প্রে কযায থাকক অথফা একজন অাং঱গ্র঴নকাযী ত঴ক঳কফ এো
আ঩নায অতধকায , তা঴কর আ঩তন গকফলক নওতযন জা঴ান , ঳াকথ শমাগাকমাগ কযকত ঩াকযন ।
তপতজওকথযা঩ী তফবাগ , তফ এইচ ত঩ আই , ঳াবায , ঢাকা – ১৩৪৩ এই ঠিকানাে ।
এই ঳াক্ষাৎকায শুরু কযায আকগ আ঩নায তক শকান প্রে আকি ?
আতভ আ঩নায অনুভতত তনকে এই ঳াক্ষাৎকায শুরু কযকত মাতি ?
঴যা না
঳াক্ষাৎকায প্রোনকাযীয োক্ষয........................................... তাতযি ..............................
঳াক্ষাৎকায গ্র঴নকাযীয োক্ষয............................................. তাতযি ...............................
঳াক্ষীয োক্ষয. ....................................................তাতযি .................................
64
APPENDIX-II: INFORMED CONSENT (English)
Title: Effectiveness of Intercostal stretch techniques among COPD patients at
NIDCH
Thanks in advance for being a part of my study. My name is Nawrin jahan. I am a

student of Bangladesh Health Professions Institute (BHPI), CRP. As a part of my
academic course requirement I need to conduct a research work. The aim of my research
topic is to find out the effectiveness of intercostals stretch techniques for COPD patients
at NIDCH. This will be a experimental type of study. I assure you that all data will be
kept confidential. In report information will be presented in the form of group. No name
will be mentioned. For your information Bangladesh Health Professions Institute
(BHPI), CRP has permitted me to do the research.
Your co-operation in answering a few questions will be highly appreciated. If you
kindly permitted then only shall I start.
So, may I have your consent to proceed with the interview?
Yes ☐ No ☐
Signature of the Participant and date ______________________________
Signature of the Interviewer and date _____________________________
Witness signature and date ____________________________
Date of interview:
Address of participant:
65
-ক ( ক কত )
ক্রতভক নাং
১ আ঩নায ফে঳ কত ফিয ত঴ক঳কফ? ২১-৩০ বছর=১
৩১-৪০ বছর =২
৪১-৫০ বছর=৩
৫১-৬০বছর=৪
৬১-৭০ বছর=৫
২ =১
=২
৩ র বব ব ? বব =১
বব =২
৪ র ? র =১
র =২
এ এ র =৩
এ এ র =৪
=৫
৫ র ? গৃত঴ণী=১
চাকুতযতজতফ=২
তেন ভজুয=৩
অনযানয=৪
৬ আ঩নায ঩তযফাকযয ভাত঳ক আে কত? ১০০০০>=১
১০০০০-২০০০০=২
২০০০০>=৩
৭ জীফকনয শফত঱যবাগ ঳ভে আ঩তন কথাে ফা঳ ককযকিন? ঱঴য অঞ্ছর=১
গ্রাা্ভয ঱঴য=২
গ্রাভ অঞ্ছর=৩
66
খ- ক ত
ব র র
র ব র র
১. এ বর ১=১৫-২০/ ১=১৫-২০/
র ? ২=২১-২৫/ ২=২১-২৫/
৩=২৬-৩০/ ৩=২৬-৩০/
৪=৩১-৩৫/ ৪=৩১-৩৫/
৫=৩৫-৪০/ ৫=৩৫-৪০/
৬=৪১-৪৫/ ৬=৪১-৪৫/
২. র ? ১=৭১-৭৫/ ১=৭১-৭৫/
২=৭৬-৮০/ ২=৭৬-৮০/
৩=৮১-৮৫/ ৩=৮১-৮৫/
৪=৮৬-৯০/ ৪=৮৬-৯০/
৫=৯১-৯৫/ ৫=৯১-৯৫/
৬=৯৬-১০০/ ৬=৯৬-১০০/
৩. র য় র ? ১=<৬০০ ১=<৬০০
২=৬০০ ২=৬০০
৩=>৬০০-১২০০ ৩=>৬০০-১২০০
৪=১২০০-১৮০০ ৪=১২০০-১৮০০
৫=>১২০০-১৮০০ ৫=>১২০০-১৮০০
৬=১৮০০ ৬=১৮০০
৪. বর বর র ? ১=<৬০০ ১=<৬০০
২=৬০০ ২=৬০০
৩=>৬০০-১২০০ ৩=>৬০০-১২০০
৪=১২০০-১৮০০ ৪=১২০০-১৮০০
৫=>১২০০-১৮০০ ৫=>১২০০-১৮০০
৬=১৮০০ ৬=১৮০০
67
ENGLISH QUESTIONAIRRE
Title: Effectiveness of Intercostal stretch techniques among COPD patients at

NIDCH
Data collection instrument: Questionnaire
A: Socio-demographical Questions
Serial Questions Coding category

1 What is your current age?(Years) 1=20-30
2=31-40
3=41-50
4=51-60
5=61-70
2 Sex 1 = Male
2 = Female
3 What is your marital status? 1 = Married
2 = Unmarried
4 What is your educational qualification? 1 = Illiterate
2=Primary
3=Secondary
4=Higher secondary
5=Graduation
5 What is your occupation? 1 = Housewife
2 = Service holder
3 = Day laborer
4 = Business
6 What is your total family income per 1=<10000
month?(Taka) 2=10000-20000
3=>20000
7 Where you spent most of the time in your life? 1=urban area
2=Semi urban area
3=Rural area.
68
Part B Medical information:
Serial Questions Coding Coding

category category
Pretest Post test
1 How many breath do you take per 1=15-20/min 1=15-20/min

minute?(Respiratory rate ) 2=21-25/min 2=21-25/min
3=26-30/min 3=26-30/min
4=31-35/min 4=31-35/min
5=36-40/min 5=36-40/min
6=41-45/min 6=41-45/min
2 What is your heart beat per 1=71-75/min 1=71-75/min
minute?(Heart rate) 2=76-80/min 2=76-80/min
3=81-85/min 3=81-85/min
4=86-90/min 4=86-90/min
5=91-95/min 5=91-95/min
6=96-100/min 6=96-100/min
3 What is the volume of lung?(CC) 1=<600 1=<600
2=600 2=600
3=>600-1200 3=>600-1200
4=1200 4=1200
5=>1200-1800 5=>1200-1800
6=1800 6=1800
4 How much air exhale in once a 1=<600 1=<600
time?(CC) 2=600 2=600
3=600-1200 3=600-1200
4=1200 4=1200
5=1200-1800 5=1200-1800
6=1800 6=1800
69
70
71

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EFFECTIVENESS OF INTER COSTAL STRETCH TECHNIQUES

AMONG COPD PATIENTS AT NIDCH

Bangladesh Health Professions Institute (BHPI)

CRP, Savar, Dhaka-1343, Bangladesh

Content point (s) Page no.

List of tables III

CHAPTER I: INTRODUCTION 1-10

1.2 Justification of the study 6

1.3 Research Question 7

1.6 Conceptual framework 9

1.7 Operational definition 10

CHAPTER II: LITERATURE REVIEW 11-21

CHAPTER III: METHODOLOGY 22-28

3.1 Study Design 22

3.3 Study Population 22

3.4 Flow chart 23

3.7 Treatment protocol 25

3.8 Data Collection Procedure 25

3.9 Data Collection Tool 25

3.11 Significant level 26

3.12 Ethical consideration 27

3.12 Informed consent 28

CHAPTER IV: RESULT 30-52

CHAPTER VI: CONCLUSION AND RECOMMENDATION 55-57

Ehsanur Rahman, Assistant professor of Department of Physiotherapy, BHPI, for his

I would like to express my gratitude to my respected teacher Md. Shofiqul Islam,

BHPI Bangladesh Health Professional Institute

Table No. Title Page no

HR, Inhale volume and Exhale volume in statistically significance at the

following level of significance

Conclusion: There is a paucity of population-based data on COPD prevalence and its

Key words: Intercostals stretch techniques, Chronic Obstructive Pulmonary Disease.

Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease

Chronic obstructive pulmonary disease (COPD) is a condition which is common treatable

Globally COPD is associated with considerable morbidity and mortality proportion, it is

In Bangladesh, COPD is a common clinical problem. It is difficult to manage dyspnea

Chronic obstructive pulmonary disease (COPD) is characterized by poorly reversible

Physical examination is not usually diagnostic of COPD but is an important part of

The percentage of COPD is increasing day by day worldwide. In Bangladesh COPD is a

1.5 Study objectives

Independent variables Dependent variable

Inter costal stretch techniques COPD

Age Heart rate

Sex Inhale volume

Inter costal stretch

Chronic obstructive pulmonary disease (COPD) is a type of obstructive lung diseases

Chronic Obstructive Pulmonary Disease (COPD) is an important public health problem

The development of successful preventive strategies requires better elucidation of the

COPD is more likely to be reported as a contributory rather than underlying cause of

IC stretch is performed actively by thoracic mobility exercises by the help of the

3.1 Study Design

3.2 Study area

3.3 Study population

Assessed for eligibility

Indoor COPD patients

Conveniently selected 10 COPD patients from NIDCH

Measure the pretest result (respiratory rate, heart rate, lung

Provide intercostal stretch techniques with conventional

Follow up six sessions