Respiratory rehabilitation with abdominal weights: a prospective case study

doi:10.4236/health.2010.25061

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Vol.2, No.5, 407-411 (2010)

doi:10.4236/health.2010.25061

Health

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Respiratory rehabilitation with abdominal weights:

a prospective case study

Stanley John Winser1, Priya Stanley1, George Tarion2*

1Department of Physiotherapy Masterskill University college of Health Science (MUCH), Cheras, Malaysia;

2Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, India; *Corresponding Author:

[email protected], stanjw_pt@ yahoo.com, [email protected]

Received 6 January 2010; revised 21 January 2010; accepted 24 January 2010.

ABSTRACT

Objective: Abdominal weights was used to

strengthen the diaphragm of a C6 ASIA (A)

tetraplegic subject with the aim of studying the

long term effect of the technique as a part of

respiratory rehabilitation. Setting: Department

of Physical Medicine and Rehabilitation, Chris-

tian Medical College, Vellore, Tamil Nadu, India.

Study Design: Prospective case study. Material

and methods: The peak EMG amplitude of the

diaphragm (DIA), intercostals (INT) and sterno-

clidomastiod (SCM) were assessed using a

surface EMG and inspired lung volume (ILV)

was assessed using an adjustable portable

spirometer. The measurements were repeated

after 3, 6, 9 and 12 months of inspiratory muscle

training for a period of 15 minutes daily, 6 days a

week for 12 months. Results and discussion:

Peak amplitudes recorded by the EMG of DIA

and SCM muscles showed a progressive in-

crease, INT muscle did not show a consistent

change. INV showed a gradual rise from 1772ml

to 2760 ml over the study period. These values

have the following significance: 1) Use of ab-

dominal weights as a part of respiratory reha-

bilitation has beneficial long term effects; 2) In

patients with tetraplegia, respiratory muscles in

particular the diaphragm, are trainable in terms

of muscle efficiency; 3) The improvement in the

muscle efficiency obtained during the early re-

habilitation can be maintained or improved us-

ing simple non sophisticated exercises like

abdominal weights post discharge. Conclusions:

Abdominal weights can be used as an effective

adjunct to pulmonary rehabilitation in improving

the efficiency of diaphragm on a long term basis,

thereby reducing the risks associated with

pulmonary complications.

Keywords: Tetraplegia; Abdominal Weights; EMG

1. INTRODUCTION

Complete lesions of the spinal cord affect the respiratory

inspiratory and expiratory muscles. The degree of im-

pairment in respiratory function is related to the level of

the lesion [1]. If the lesion is below the C3–C4 level, the

diaphragm is intact but the loss of other respiratory mus-

cles decreases the vital capacity (VC) to approximately

50% [2,3] and total lung capacity (TLC) to approxi-

mately 70% [3-5] of predicted normal values. Paralysis

of the expiratory muscles reduces the ability to force

expiration leading to an increased residual volume and

reduced ability to huff (forcefully exhale) and cough.

This may cause secretion to accumulate in the airways.

In complete lesions above the Th6 level, the autonomic

nervous system is injured, and bronchial hypersecretions

occur, which further aggravates problems regarding se-

cretions [6].

Currently a complete retrival of the muscle efficiency

following spinal cord injury (SCI) is not known. Cases

in which patients are unable to maintain adequate venti-

lation, long-term mechanical ventilator support is indi-

cated [7]. Although this treatment is effective, it can also

lead to serious medical complications such as infection,

pneumonia, atelectasis, and even death [8-10]. In fact,

the primary cause of death after SCI, regardless of the level

of injury, is caused by respiratory insufficiency and

complications associated with impaired respiratory func-

tion.

Training of these muscles may improve the daily ac-

tivities. Respiratory muscle training in healthy subjects,

COPD (Chronic Obstructive Pulmonary Disease) and

other pulmonary patients has shown positive effects

[11-17]. In individuals with tetraplegia, training of the

inspiratory muscles has been applied by Gross et al. [18]

Biering-Sorensen et al. [19] and Derrickson et al. [20].

Use of abdominal weights, resistive inspiratory muscle

training, Abdominal binders [21], Trendlenbergs posi-

tion and Incentive spirometry [22] have been reported in

literature to have useful effects in improving the effi-

S. J. Winser et al. / HEALTH 2 (2010) 407-411

408

ciency of diaphragm among the target population. In the

survey done we found a paucity of literature on the long

term effects of these therapeutic modalites on the respi-

ratory status of tetraplegic patients, thus we intended to

observe the influence of abdominal weights on the effi-

ciency of the available respiratory muscle on a tetraple-

gic patient over a period of 1 year.

2. CASE REPORT

A 30-yr-old male patient presented with complaints of

weakness of arms and legs, with fecal and urinary incon-

tinence, in March 2004. The patient’s history revealed

that a C5 vertebrate fracture caused SCI after a fall from

height (mango tree) in December 2003. He had applied

to a clinic and had been managed conservatively with

bed rest for 3 months.

The patient's history included an internal fixator at his

femur because of a fracture that occurred in another ve-

hicle accident before 6 yrs. The patient's medical status

was stable. He had no pressure ulcers, range of motion

(ROM) of all four limbs were full and free. On clinical

neurologic examination, he had spastic tetraplegia with

loss of motor function below the C6 level and loss of all

sensation below C7 dermatome. Spasticity was found to

have grade 1+ in Modified Asworth scale (MAS) in all 4

limbs. Deep tendon reflexes were hyperactive, and plan-

tar response was extensor bilaterally. The patient was

classified as C6 American Spinal Injury Association

grade A and admitted to a rehabilitation program. The

rehabilitation program involves concurrent sessions of

physiotherapy, occupational therapy, vocational training,

prosthetics and orthostics and recreation classes. In the

department of physiotherapy the patient was undergoing

re-education exercises for the upperlimbs, progressive

orientation to erect stance using tilt table to counteract

postural hypotension, passive movement for the lower-

limbs, passive stretching for hamstrings and tendo achil-

les. In addition to this the patient was given strengthen-

ing to the diaphragm muscle using Abdominal weights

as a part of respiratory rehabilitation.

3. RESPIRATORY ASSESSMENT

Patient had no history of COPD, TB or other chronic

respiratory illnesses. Patient demonstrated a diaphrag-

matic breathing pattern. Chest expansion was 2 cms at

the level of xiphisternum and nil at nipple and axilla.

Cough was weak functional. Auscultatory findings re-

vealed a good air entry in all lobes and no added sounds

were recorded. Muscle strength of the Diaphragm was

good. The strength of the diaphragm involves interpreta-

tion of the total neurological involvement, complete res-

piratory evaluation and observational techniques. It is

best done in supine lying. “Poor power” is being graded

if the subject is not able to expand his/her epigastric re-

gion fully on deep inspiration. “Fair power”, if the sub-

ject is able to expand his/her epigastric region fully on

deep inspiration. “Good power” the therapist’s hands are

placed over the epigastric region with fingers spread,

and the subject is asked to inhale, while maximum man-

ual resistance is applied. If the subject is able to com-

plete a full epigastric raise against resistance then he\she

can be graded as Good. The subjects who are able to

take resistance but not able to hold can be graded as

“Fair plus” [23]. Subjects with diaphragmatic power of

fair plus and above are candidates for progressive re-

sisted exercises.

4. MATERIALS AND METHODS

A prospective case study of a 30 year-old tetraplegic

patient, with complete spinal cord section at C6 level,

was considered. The subject gave written consent to par-

ticipate in the trial, the study was approved by the re-

search board of Christian Medical College, Vellore, In-

dia. Initial assessment was done in march 2004 and sub-

sequent assessments were planned at an interval of three

months for the next one year. The 2 outcome measures

which were considered are peak amplitude of Electro-

myographic (EMG) readings of diaphragm, intercostals

and sternocliedomastoid muscles and Inspired Lung

Volume (ILV). The investigator who performed these

tests was blind to the situation.

4.1. EMG Analysis

The EMG activity was measured using 3 pairs of Silver

chloride bipolar surface electrode. The active electrodes

were placed over T7 & T8 intercostal space, T4 & T5

intercostal space and mid portion of sternocleidomastoid

to get the electrical activity of diaphragm (DIA), inter-

costals (INT) and sternocleidomastoid (SCM) muscles

respectively as shown in Figure 1. Readings of all three

groups of muscles were taken simultaneously [24]. Elec-

trodes were secured to the skin using adhesive plaster

after skin preparation. While taking the readings the

subject was instructed to take 3 consecutive deep inspi-

rations followed by expiration, readings were recorded

for 10 seconds and the mean of peak amplititudes in the

EMG were recorded. Three trials were done and the best

response of peak amplitude was noted.

Figure 1. Placement of surface electrodes.

S. J. Winser et al. / HEALTH 2 (2010) 407-411

409

4.2. ILV Analysis

The ILV was assessed using a volume adjustable port-

able spirometer (Spectra SpirometerTM) The spirometer

has calibrations for adjusting the flow rate (100 cc, 200

cc,…800 cc) The device has a single chamber with 1 ball

inside. Air flows into this channel on inspiration and

raises the ball depending on the flow inhaled per second.

This upward movement of the ball during inspiration

provides the patient with visual feedback i.e. an indirect

indicator of the inspired volume. The patient was in-

structed to perform a deep inspiration through the mouth

piece and while inspiring he was required to keep the

ball inflated for the maximum seconds possible. As

shown in Figure 2.

ILV was measured using the formula: ILV = Flowrate

× seconds

Flow rate: was kept constant at 400 cc. Seconds: was

a measure of patients ability to keep the spirometer ball

inflated during inspiration and was calculated using a

stop watch.

4.3. Treatment Protocol

Diaphragm was strengthened using abdominal weights

for 15 minutes/day for six days/week for a period of 1

year. An initial evaluation of weight to be placed over

the abdomen was done. The subject was positioned in

supine lying, then a minimal weight was placed over the

epigastric region (weights starts with half a kilogram)

and then the subject was allowed to breath (the weight

should come up fully with each inspiration). If the sub-

ject showed any signs of fatigue or started using his ac-

cessory muscles, the weights were taken off immediately.

Adequate rest was given, then the procedure was re-

peated using a lesser weight. If the patient is able to take

up the weight comfortably for 15 minutes, a short break

was given and the procedure was repeated by increasing

the weight by half a kilogram, thus the appropriate

weight for training the diaphragm was determined by

trial and error method [23]. The evaluated weight was

placed over the epigastric region with an isosceles tri-

angular board. The board was placed in such a way that

one of the corners touches the xiphisternum and the

other two corners touching the anterior borders of the

ribcage. Cushioning is provided with the under surface

of the triangular board in order to prevent skin irritation,

as shown in Figure 3. Evaluated weights were added to

the triangular board using dish weights. During the

training period the subject was instructed to perform the

exercise in supine lying and do normal breathing with

the weights on for 15 minutes. Progression in weights

was done during each review. Subsequent assessments

were planned during the routine medical screening and

checkups of the client.

Figure 2. Analysis of ILV using spirometer.

Figure 3. Placement of abdominal weights.

5. RESULTS

Weights were progressively increased during each visit.

Initial weight was 5 kgs and the patient progressed to 12

kgs by the end of the trial, as shown in Table 1.

Increment in the mean of peak amplitudes of EMG

values were noted in DIA and SCM muscles, progress in

the INT muscle did not show a consistent change (shown

in Figure 4). Similarly the INV showed a gradual rise

from 1772 ml to 2760 ml over the study period (shown

in Figure 5).

6. DISCUSSION

The efficiency of respiratory muscles were studied over

a period of 1 year, following administration of abdomi-

nal weighted training with the aim to determine the long

term effects of the examined respiratory muscle training.

The subjects respiratory muscle efficiency was assessed

using recordings made over key respiratory muscles with

the help of surface EMG. EMG was chosen because it

captures the electrical activity happening within the mus-

cle which is a direct measure of maximal contraction of

the assessed muscle. Work done by Jennifer Beck et al on

healthy individuals states there is no artifactual effect of

lung volume on the diaphragm EMG signal strength dur-

ing voluntary contractions [25]. Thus the EMG readings

S. J. Winser et al. / HEALTH 2 (2010) 407-411

410

Table 1. Progress of the study.

DATE Weights used

in Kgs

EMG in milli

volts INV in ml

DIA 1.2453

INT 0.7237

Day 1 3

SCM 1.5234

1772

DIA 1.4356

INT 0.5634 3 months 5

SCM 1.5735

2080

DIA 1.5643

INT 0.8675 6 months 8

SCM 1.6876

2280

DIA 1.7536

INT 0.7457 9 months 10

SCM 1.7453

2440

DIA 1.9675

INT 0.9656

12 months 12

SCM 1.8758

2760

Figure 4. Peak amplitude of the analyzed muscles.

Figure 5. ILV over the study period.

can be considered as an objective measure of respiratory

muscle efficiency. ILV was considered as the secondary

outcome measure because of the ease of administration.

Though the objectivity of the test has not been tested, the

results obtained are directly related to strength of the

respiratory muscles and pulmonary compliance.

Our study shows the following findings:

1) Measures of EMG of the DIA and SCM muscles as

well as the ILV have showed a gradual rise which im-

plies: Use of abdominal weights as a part of respiratory

rehabilitation has beneficial long term effects; 2) In pa-

tients with tetraplegia, respiratory muscles in particular,

the diaphragm is trainable in terms of muscle efficiency,

provided that the muscle performance is not severely

compromised as in cases of ultra high lesions who re-

quire ventilator assistance; 3) The improvement in the

muscle efficiency obtained during the early rehabilita-

tion can be maintained or improved using simple non

sophisticated exercises like abdominal weights. Clini-

cally we did not observe any deterioration in the patients

respiratory as well as functional status which is a good

sign for a tetraplegic.

We hypothesized a reduction in the EMG activity of

the sternocleidomastoid muscle following training, due

to an improvement in the efficiency of diaphragm, which

is the primary respiratory muscle. We found an increase

in the activity of sternocleidomastoid muscle on the

subject along with the increase in activity of the dia-

phragm. However we could not explain the reason for

this phenomenon.

There were few limitations in our study which in-

cludes spasticity and adherence of the subject to the

training program. There are possibilities that distur-

bances from the abnormally activated trunk muscles

could have reduced the accuracy of EMG activity of the

diaphragm and other respiratory muscles. Outcome

demonstrated by the ILV has shown a consistent rise

which can be considered to overcome the limitation of

misleading values from the EMG if any. Though we

used a log book for tracking the adherence to the treat-

ment protocol a direct supervision of the subject on a

regular basis at community level can be considered for

upcoming studies, for more accurate results.

7. CONCLUSIONS

The peak EMG amplitude and ILV showed a consistent

rise on the subject who was trained using abdominal

weights. This is an apparent indication of improved per-

formance of the target muscle with regards to strength

and pulmonary function. The improvement of the muscle

efficiency was maintained throughout the study period

which is a positive sign of long term effects of the tech-

nique. Cost effectiveness, ease of administration of this

technique ensures its frequent usage by clinical practi-

S. J. Winser et al. / HEALTH 2 (2010) 407-411

411

tioners. With adequate instructions and proper training,

this technique does not require direct supervision by a

therapist and so is useful for community based rehabili-

tation. Thus we conclude stating Abdominal weights can

be used as an effective adjunct to pulmonary rehabilita-

tion in improving the efficiency of diaphragm on a long

term basis, thereby reducing the risks associated with

pulmonary complications.

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