Asthma

Definition & Description

Asthma airways.png

Asthma, also known as a reactive airway disease, is a chronic lung disease and a very common respiratory condition which is inconvenient most of the time but, in most cases, manageable. Asthma attacks all age groups but often starts in childhood. It is a disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. In an individual, they may occur from hour to hour and day to day.This condition is due to inflammation of the air passages in the lungs and affects the sensitivity of the nerve endings in the airways so they become easily irritated. In an attack, the lining of the passages swell causing the airways to narrow and reducing the flow of air in and out of the lungs[1].


Asthma is caused by inflammation and constriction of bronchial walls due to hyper-reactivity of their smooth muscle, thereby leading to a series of spasmodic attacks of wheezing and shortness of breath (SOB). Various factors can contribute to the cause of asthma: exposure to cigarette smoke, climate change, physical exertion or emotional stress. It normally begins during childhood and the disease is commonly triggered by viral infection.

Asthma can be diagnosed by the presence of the various signs and symptoms. Diagnosis is normally confirmed by presenting a response to a inhaled bronchodialator. In addition, pulmonary function tests, chest x-rays and blood tests can also be carried out to confirm the diagnosis.

In childhood, the first symptoms may appear before the age of five years. However, diagnosing asthma in young children under 5 years is difficult due to the fact that other childhood conditions may have similar symptoms. Therefore, the doctor is reliant upon the child's medical history, their symptoms and physical examinations in order to confirm a diagnosis. Moreover, the doctor could also carry out a 4-6 week asthma medication trial and monitor the child's response (US department of health and human services 2009).

Epidemiology

Currently 8.4% of persons in the United States have asthma as compared with 4.3% of the population worldwide, and both numbers are on the rise[2]. The average annual asthma prevalence is higher in children (9.5%) than adults (7.7%). The prevalence of asthma is higher in black persons than white persons, and the ethnicity most affected is the Puerto Rican population.[2] Asthma prevalence increases with each successive lower poverty level group. There are interesting relationships between asthma and certain otolatyngologic diseases. The impact of asthma on both morbidity and mortality is particularly noteworthy.

800px-Asthma world map - DALY - WHO2004.svg.png

The Global Asthma Report 2018 gives an account that Asthma kills around 1000 people every day and affects as manyas 339 million people and prevalence is rising. low and middle-income countries disproportionally suffer the most severe cases[3]. On average, 3 people a day die from asthma. Although the UK still has some of the highest asthma prevalence rates in Europe, its prevalence is thought to have plateaued since the late 1990s. In Scotland, approximately 368,000 (1 in 14) people are currently receiving treatment for asthma: 72,000 children and 296,000 adults. The UK NHS spends in excess of £1 billion a year treating and caring for people with asthma, whilst in Scotland the spend is in excess of £130 million [4].

Aetiology

Asthma has many possible causes but the exact mechanism of onset is still unknown. This is due to asthma not being defined as a single disease, but a variety of multiple diseases with similar clinical features, resulting from different genetic and environmental causes [5] mainly developing at an early age, The complex interplay between hereditary and environmental factors which are occurring at this critical time in development, lead to the onset of the disease [6][7].

Patients who are atopic have a genetic predisposition for developing the disease due to a hypersensitivity of the airways to environmental triggers. An allergic reaction to antigens that normally do not cause a response, predisposes to asthma onset demonstrating the genetic component of the disease. Asthmatics can commonly suffer from other allergies including food, drug and skin allergies[8]. The increased prevalence of asthma in developed countries and urbanized areas [9] supports the theory of environmental exposure contributing to the disease. Sufferers are chronically-exposed to substances when inhaled lead to an allergic response in the airways[10].

Risk Factors

The following risk factors increase possibility of disease development

Hereditary

  • Family History
  • Susceptibility to Allergic Reactions

Environmental[11]

  • Tobacco Smoke/Passive Smoking
  • Prenatal Smoking
  • Dust, Dust Mites
  • Damp Homes
  • Carpets
  • Upholstered Furniture
  • Pet Hair
  • Pollens
  • Pollutants
  • Occupation (Chemical Exposure)
  • Urbanisation

Other Causes

  • Premature Birth with Ventilation Use
  • Low Birth Weight[12]
  • Early Age Antibiotic Use
  • Bronchiolitis as a Child[13][14]
  • Viral Infection [15]
  • Diet [16]

Triggers for an Asthma Attack

Many substances can trigger allergies and the same applies to asthma. Common allergens that triggers asthma are pollen, mold, dust mites and pet dander. Other irritants are smoke, pollution fumes, sprays and cleaning chemicals. Asthma symptoms can therefore be reduced by avoiding exposure to known respiratory irritants and allergens. There are many intrinsic and extrinsic triggers for an asthma attack, the most common are:[17]
Triggers.png
  • Exercise
  • Cold Air
  • Climate Change
  • Emotions
  • Medications (aspirin, NSAIDs, beta-blockers)
  • Respiratory Infection
  • Irritant Inhalation - being a smoker, living or working with a smoker are examples of irritant inhalation
  • Dust Mites - having mats or carpets that can easily trap dust particles
  • Pollen
  • Environmental Pollutants -for example, the closeness of home or work to airports, industries and shopping centers(environmental irritants), as well as the use of spray insecticides or insect oils. Even the dampness level of home or work
  • Stress
  • Allergic Reaction for example pollen or having pets at home

Prevention of an attack or an episode is better in the case of asthma because it cannot be cured. Sharing the following information can assist in reducing the risk

  • education on the disease and medication that is used
  • follow the doctor's instructions on how to use medicine and how to keep symptoms under control
  • identify the aggravating factors e.g. smoke, dust, etc.
  • keep record of recurrent symptoms and try and maintain control
  • go to doctor for regular checkups

Pathophysiology

In asthma, airway constriction is caused by a combination of bronchial constriction (bronchoconstriction) and bronchial inflammation. This leads to chronic lung pathology in which the bronchial airways are prone to narrowing, causing episodes of wheezing, chest tightness, coughing and breathlessness (SOB) that range in severity from mild to potentially life threatening[18].

Entrance of allergens through the oral or nasal cavity results in swelling of an already compromised and highly sensitive airway [19]. As a result, constriction of smooth muscle in the walls of the airway and excessive release of mucus into the area causes airway narrowing and ultimately reduces the amount of air circulating in and out of the lungs [19]. Due to these differences in airway flow rate, the lungs become hyperinflated.

                                        Pathology.jpg

                                           
When the tidal volume (VT) of the lungs reaches a capacity similar to that of the pulmonary dead space, it is termed alveolar hypoventilation and results in a ventilation-perfusion (Va/Q) mismatch. This Va/Q mismatch is ultimately worsened by vasoconstriction [20]

A reduction in arterial oxygen supply (hypoxia) can result from the Va/Q mismatch. Diffusion of carbon dioxide (CO2) across the alveolar capillary membranes prevents high levels of carbon dioxide in the blood (hypercapnia) during the early stages of an acute asthmatic exacerbation/attack. Therefore, although these patients have hypoxia, the low levels of oxygen (low PaO2) trigger hyperventilation and therefore decrease PaCO2 to prevent hypercapnia and the retention of carbon dioxide. During the first stages of an acute episode, alveolar hyperventilation can result in respiratory alkalosis. However, if airway obstruction worsens and there is a further increase in Va/Q mismatch, it can lead to CO2 retention, hypercapnia and compensatory metabolic acidosis.

In asthmatic patients, chronic airway inflammation is associated with:

  • Increased in heart rate
  • Bronchospasms
  • Increased work of breathing (WOB)
  • Wheezing
  • Shortness of breath (SOB)
  • Coughing due to exposure to allergens, environmental irritants, exercise, cold air or viruses.

Types of Asthma

Because of the different triggers and symptoms of asthma there are different terms used to describe the many types of asthma[21]

Allergic Asthma

There is often a tie between allergies and asthma. not everyone who has allergies has asthma, and everyone with asthma has allergies. but allergens such as pollen, dust and pet dander can trigger asthma symptoms and asthma attacks in certain people.

Non-allergic Asthma

It is also called intrinsic asthma and it usually develops after the age of 30 years where allergies do not play any role.Non-Allergic (intrinsic) asthma is triggered by factors not related to allergies, it is likely triggered by respiratory irritation substances (e.g cleaning agents, perfume and smoking). Like allergic asthma, non-allergic asthma is characterized by airway obstruction and inflammation that is at least partially reversible with medication, however symptoms in this type of asthma are not associated with an allergic reaction. Many of the symptoms of allergic and non-allergic asthma are the same, but non-allergic asthma is triggered by other factors such as anxiety, stress, exercise, cold air, dry air, hyperventilation, smoke, viruses or other irritants. In non-allergic asthma, the immune system is not involved in the reaction.

Exercise Induced Asthma

Exercise induced asthma is a type of asthma triggered by exercise or physical exertion.It affects anyone and at any age. It is caused by lack of heat and moisture in the lungs which occurs during strenuous exercises. Many people with asthma experience some degree of symptoms with exercise. However, there are many people without asthma, including Olympic athletes, who develop symptoms only during exercise. With exercise-induced asthma, airway narrowing peaks 5 to 20 minutes after exercise begins, making it difficult to catch your breath. The symptoms begin within few minutes of exercise and peak or worsen a few minutes after stopping exercise. Symptoms of an asthma attack which is wheezing and coughing may be present.

Nocturnal Asthma

It is also called nighttime asthma and it is the type of asthma that attacks people when they are asleep. The victims tend to sleep earlier and they wake up in the middle of the night (1-4am) due to difficulties with breathing and they will drink a glass of water to try to relieve the symptoms.[22] Symptoms include chest tightness, shortness of breath, cough, and wheezing at night and can make sleep impossible and leave the victim tired and irritable during the day. These problems may affect the overall quality of life and make it more difficult to control the daytime asthma symptoms. Nocturnal or nighttime asthma is very serious. It needs a proper asthma diagnosis and effective asthma treatment. The exact reason that asthma is worse during sleep is not known, but there are explanations that include increased exposure to allergens; cooling of the airways; being in a reclining position; and hormone secretions that follow a circadian pattern. Sleep itself may even cause changes in bronchial function

Occupational Asthma

People with this condition usually work around chemical fumes, dust or other irritants in the air. if you have been diagnosed with asthma that has another cause, it can be worsened by air borne irritants at work

Steroids Resistance Asthma

Overuse of asthma medications which leads to status asthmatic and severe asthma that does not respond with any medication. Such patients are considered to have severe, steroid-resistant asthma, which is associated with more frequent exacerbations, greater likelihood of hospitalizations, and worse quality of life compared with other patients with asthma. In clinical practice, they are often treated with high-dose steroids and bronchodilators, but they do not respond well to these therapies,

Signs and Symptoms

Symptoms may vary between individuals and can also be dependent on the type of Asthma, but the most common symptoms are:[23][24]

  • Wheeze
  • Dry Cough 
    • Increased with Exercise
    • Worse Early Morning/Night
  • Chest Tightness
  • Sputum (stringy, thick)
  • Fatigue
  • Itchy Throat
  • Runny Nose
  • Headache
  • Dyspnoea

[25]These symptoms occur due to the pathophysiology of the disease. Bronchoconstriction causes an audible wheeze and subsequent cough. Chest tightness can be felt and a shortness of breath (dyspnoea) from a constriction of the bronchial walls. Sputum is produced due an inflammatory response in the airways [26] adding to the difficulty of breathing.

Clinical Features

Asthma is an obstructive lung disease. Narrowing of the airways (bronchospasm) due to constriction of the bronchial muscles in the wall, lead to decreased air flow and difficulty with breathing. Bronchospasm causes decreased peak expiratory flow rate, which in turn leads to decreased PaO2 and increased PaCO2 of the blood. Heart rate increases to compensate for a lack of oxygen being transported in the blood. To increase oxygen during inspiration, hyperventilation will occur in the patient. However work of breathing will be increased due to the narrowed bronchi which make it more difficult to breathe [27].

  • Hyperventilation/Increased Respiratory Rate
  • Increased Work of Breathing
  • Decreased Peak Expiratory Flow Rate
    • FEV1
    • FEV1/FVC
  • Decreased PaO2 (partial pressure of oxygen in blood)
  • Increased PaCO2 (partial pressure of carbon dioxide in blood)
  • Increased Heart Rate

When does asthma become life threatening?

  • Difficulty to catch a breath
  • Difficulty talking and concentrating
  • Difficulty talking and walking
  • Cyanosis of skin especially around the mouth and finger areas
  • Nasal flaring and constant wheeze

When these signs and symptoms presents, a person should be aware and are advice to consult with your general practitioner as soon as possible.

Investigations and Diagnosis

Diagnosis of asthma is dependent on many factors. The following aspects of assessment and diagnostics are used in combination to determine the presence of Asthma.[28]

Medical History

The patient is initially asked to explain their various symptoms, including their description, frequency, duration and aggravating factors. Substance exposure may have also lead to the onset of asthmatic symptoms, in which case exposure to tobacco smoke, chemical fumes, dust or other airborne irritants is determined. Additional questioning may include relevant health problems, the patient’s occupation and medications that may cause airway irritation.

Family History

If the patient has a family history of asthma or allergies, they are more likely to also suffer from asthmatic symptoms.

Physical Assessment

Firstly, the patient’s nose, throat and upper airways will be examined for signs of asthma or allergies. Assessment of the patient’s respiratory rate and breathing pattern will be carried out in conjunction with auscultation (using a stethoscope) in order to listen for signs of asthma or allergies that may aid diagnosis. These signs include:

  • Wheezing (high-pitched whistling sounds when the patient exhales)
  • Coughing, chest tightness
  • Shortness of breath (SOB)
  • A runny nose
  • Swollen nasal passages.

The patient’s skin will also be examined for signs of allergic skin conditions (e.g. eczema and hives)[29].

Diagnostic Tests

The following tests are used to assess the patient’s breathing as well as to monitor the effectiveness of asthma treatment.

Lung function tests[30]

  • Spirometry
    Spirometry may be used to assess lung function by measuring the amount of expired air as well as the speed of expiration. It is used to confirm the presence of airway obstruction and can accurately measure the degree of lung function impairment. Spirometry is used to measure the sensitivity of the airways and lung function during physical activity, or following the inspiration of increasing doses of cold air or a special chemical However, it is only recommended for adults and children over the age of 5.
  • Peak flow testing
    Peak flow testing is a self-assessment lung function test using a peak flow meter to provide an objective measure of airway function based upon peak expiratory flow rate (PEFR). Peak flow is described as the highest airflow velocity that can be achieved, with any drop in the peak flow measurement indicating airway obstruction.

Other tests:

  • Allergy testing
  • Bronchoprovocation
  • Tests to rule out other conditions with similar asthmatic symptoms (reflux disease, vocal cord dysfunction, sleep apnea)
  • Chest X-ray
  • Electrocardiogram (ECG)
  • Asthma in older adults is frequently underdiagnosed and has higher morbidity and mortality rates compared to their younger counterparts. A detailed history and physical examination as well as judicious testing are essential to establish the asthma diagnosis and exclude alternative ones. Medical comorbidities, such as cardiovascular disease, cognitive impairment, depression, arthritis, gastroesophageal reflux disease (GERD), rhinitis, and sinusitis are common in this population and should also be assessed and treated. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital.[31]

Medical Management

Various medication exists that help the control of asthma by reducing inflammation of the airway and bronchial constriction, these medications are administered orally, via aerosol or an inhaler. (Cleveland Clinic. 2009). Pharmacologic management includes standard asthma therapies such as inhaled corticosteroids (ICS), inhaled corticosteroid-long acting β-agonist combinations (ICS-LABA), leukotriene antagonists, long acting muscarinic antagonists (LAMA), and short acting bronchodilators (SABA). Newly approved biologic agents may also be utilized. Older adults are more vulnerable to polypharmacy and medication adverse events, and this should be taken into account when selecting the appropriate asthma treatment. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital.[31]

One form of an inhaler is a bronchodilator, which allows dilatation of the bronchioles and in turn relieves some of the symptoms. It also aids in mucus removal from lungs. There are two forms of bronchodilators:

  1. Short-acting beta 2-agonists (quick acting or rescue medicine): these drugs are used best to treat sudden and severe or new asthma symptoms as they open the airways and relieve symptoms within 20 minutes and lasts four to six hours. It can also be used before physical activity about 15-20 minutes before the time to prevent exercise-induced asthma.
  2. Long-acting beta 2-agonists: these drugs are not used to for a quick relief of asthma symptoms, instead they are used to control symptoms and their effect lasts 12 hours.

Physiotherapy Management

Unfortunately, there is no cure for this illness but there are ways of effectively managing the disease. However, this should involve the active participation of both the person suffering from the disease and his/her doctor. The majority of patients suffering from asthma will seek physiotherapy for dyspnoea and hyperventilation [32]. Physiotherapists treat asthma in a variety of ways with the aim to improve breathing technique. Physiotherapy techniques for asthma are in addition to medication and should never be used as a replacement to prescribed medication, however may reduce the dosage required.

Breathing Techniques

Breathing pattern retraining and relaxed breathing techniques are two approaches to physiotherapy management of asthma. The aim of breathing pattern retraining is to develop a more efficient pattern of respiration, thereby reducing breathlessness. This is usually accomplished by slowing the breathing rate, and encouraging relaxed, ‘abdominal’ breathing (Bruton, 2006). Another potential mechanism for breathing pattern retraining is that by encouraging a longer expiratory time, the effects of any static/ dynamic hyperinflation may be reduced.

Mild asthmatics can hold their breath for up to twenty seconds, moderate asthmatics for fifteen seconds and severe asthmatics for up to ten seconds. The aim of this method is to increase the control pause to 60 seconds and the maximum pause to 2 minutes. It is practiced twice a day, with the practitioner there to help with breath holding and ensure safety. Its aim is to reduce minute volume through reduction of respiratory rate, and increasing carbon dioxide levels through breath holding, reducing bronchospasm caused by hyperventilation in the asthmatic patient.

1. Breathing Retraining Techniques [33]

Breathing techniques may have more benefit on mild – moderate asthma [34]. The aim of breathing retraining is to normalise breathing patterns by stabilising respiratory rate and increasing expiratory airflow. Instructions are given from the physiotherapist on how to complete this technique, with the following components:

  • Decreasing Breaths Taken (Reducing Respiratory Rate)
  • Taking Smaller Breaths (Reducing Tidal Volume)
  • Deep Breathing (Diaphragmatic breathing through use of abdominal muscles and lower thoracic chest movement)
  • Breathing through the Nose (Nasal Breathing)
  • Relaxation (Relaxed, controlled breathing)
  • Decreasing Air Leaving (Decreased expiratory flow through pursed lip breathing)
  • These retraining techniques help control breathing and reduce airflow turbulence, hyperinflation, variable breathing pattern and anxiety.

2. Buteyko Breathing Technique[35]

The Buteyko breathing technique is another breathing retraining technique; however it is specific to reducing hyperinflation. It was developed based on the theory that asthmatic bronchospasm is caused by hyperventilation, leading to a low PaCO2 and therefore all asthmatic symptoms are due to this. The narrowed airways induce an “air hunger” causing a switch to mouth-breathing and an increased respiratory rate leading to hyperinflation. Buteyko believes that this hyperinflation then also contributes to bronchoconstriction. The Buteyko technique aims to reduce ventilation and subsequently lung volume, as a treatment for asthma and other respiratory diseases. A qualified practitioner is necessary to train the patient [36].

The Buteyko Technique[37]
Buteyko.png
  • Breathe normally through the nose for 2-3 mins
  • Breathe out normally, close nose with fingers, and hold
  • Record number of seconds
  • On first need to breathe, release nose and return to nasal breathing (Control Pause)
  • Wait 3 minutes
  • Repeat and hold breath for as long as possible (Maximum Pause)

Physical Training


Physical training with asthma is advised when taking the proper precautions, and should not be avoided. The American College of Sports Medicine (ACSM) Guidelines provide tips and safety precautions for asthmatics to exercise safely[38].


Physical training should be prescribed by physiotherapists for asthmatics to increase fitness and cardiorespiratory performance, reduce symptoms such as breathlessness and improve quality of life [39]. Breathlessness, chest tightness and wheezing can occur when exercising, deterring patients from physical exertion [40]. Fear avoidance can contribute to a further deterioration of physical health and quality of life, leading to anxiety and depression. It has been shown [41] that maintaining physical training in asthmatics improves disease symptoms and quality of life, therefore making it a crucial management strategy.

Respiratory Muscle Training


Hyperinflation in asthma causes increased lung volume, leading to altered inspiratory muscle mechanics. Inspiratory muscles are shortened resulting in a sub-optimal length-tension relationship for contraction. There is a decreased capacity for tension generation when breathing, resulting in accessory muscles of inspiration being utilised [42]


Breathing exercises are carried out using an external device to make breathing more difficult. This helps to strengthen the inspiratory muscles, making it easier to breathe in everyday life.
A breathing device is used which sets up a load to breathe against. During inspiration air is only released if enough effort is used to force open the valves of the device. Respiratory muscles are forced to work harder, increasing their strength, leading to diaphragmatic breathing becoming easier, reducing hyperinflation.[43]

The following physiotherapy techniques are also beneficial in managing the symptoms of Asthma:

Removal of secretions

  • Percussions
  • Shaking
  • Vibrations,
  • Postural drainage and
  • Effective coughing

Range of motion exercises for patients who need hospitalisation.

Education

  • About condition
  • On use of a bronchodilator and any other medication
  • How to prevent chest infection from occurring
  • Correct posture in standing and sitting which assists in the management of asthma attacks by allowing the chest to expand appropriately and the lungs to function optimally

Evidenced Based Physiotherapy Management

Due to the high prevalence of asthma and associated healthcare costs, it is important to identify low-cost alternatives to traditional pharmacotherapy. One of these low cost alternatives is the use of inspiratory muscle training (IMT), which is a technique aimed at increasing the strength and endurance of the diaphragm and accessory muscles of respiration. IMT typically consists of taking voluntary inspirations against a resistive load across the entire range of vital capacity while at rest. In healthy individuals, the most notable benefits of IMT are an increase in diaphragm thickness and strength, a decrease in exertional dyspnea, and a decrease in the oxygen cost of breathing. IMT has been shown to decrease dyspnea, increase inspiratory muscle strength, and improve exercise capacity in asthmatic individuals.[44]

Also, in a systematic review done by Vera et al.(2012),it was found out that exercise can provoke asthma symptoms, such as dyspnoea, in children with asthma. Exercise-induced bronchoconstriction (EIB) is prevalent in 40–90% of children with asthma. and it was concluded physical exercise is safe and can be recommended in children with asthma. A training programme should have a minimum duration of 3 months, with at least two 60 min training sessions per week, and a training intensity set at the (personalised) ventilatory threshold.[45] Another systematic review by Cristina et al (2018) demonstrated that aerobic physical exercise may improve nocturnal asthma in children and adults by reducing the prevalence and frequency of nocturnal symptoms.[46]

Other Health Professional Management

Asthma patients will be involved with a multidisciplinary team to manage their condition. Other health professionals treating the patient include:

  • Doctor
    • Initial diagnosis and treatment.
  • Consultant
    • Specialised in asthma, to help with reducing symptoms and recognising triggers.
  • Specialised Nurse
    • To provide help, education, medication advice and general information.
  • Pharmacist
    • Medication distribution.
  • Dietitian
    • Advice on proper to diet to not induce symptoms.
  • Health Psychologist
    • To help with anxiety/depression associated with symptoms

Prevention and Physiotherapist Role In Prevention

Asthma may not be fully preventable due to the pathology progression and the differing possible causes of onset. However, there are ways of avoiding triggers for the disease and reducing symptoms. Being aware of triggers is vital on an individual basis as these will differ amongst sufferers.

Before the onset of disease, a child should avoid causes of asthma such as passive smoking, damp and dusty living environment and allergen exposure, as well as all possible causes for the disease. However, development can be hereditary and may not be preventable.

Some triggers to be avoided include:

  • Cold Air
  • Allergens
  • Tobacco smoke

To prevent asthma attacks, precautions should be made to avoid exacerbations of symptoms and to be aware of the signs of an attack.[47]

  • Vaccination against flu and pneumonia
  • Learn to recognise warning signs of an attack
  • Identify signs of attack and treat early
  • Use medication as prescribed

A physiotherapist works with the patient to promote a healthy lifestyle benefiting the patient in identifying triggers, reducing symptoms and preventing disease progression. Education, advice and physiotherapy techniques help in the overall outcome of the disease.

Educate on:

Advice on:

  • Appropriate living environment
  • For family members to stop smoking, or not smoke around children
  • Promoting a healthy lifestyle, free of air pollution and inhalation irritants

Disease Progression:

  • Identifying triggers
  • Medication management
  • Physiotherapy techniques to manage disease

Resources

References

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