This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.Hemiparesis caused by a stroke leads to decreased efficiency in posture control and movement coordination due to asymmetry and abnormal alignment of the chest wall and torso. This directly or indirectly diminishes the motor function of respiratory muscles, ultimately resulting in reduced respiratory muscle strength and endurance. Consequently, these changes contribute to alterations in the breathing cycle[1]. For patients with compromised respiratory function, addressing the decline in respiratory efficiency and respiratory mechanics requires maintaining sufficient expansion of the chest wall, adequate ventilation, and appropriate lung capacity[2]. To address these issues, the use of passive methods such as spinal joint mobilization exercises has been reported to have physiological and functional benefits. Physiologically, through spinal movement, these exercises stimulate the autonomic nervous system response and lymphatic circulation. Functionally, they enhance flexibility in the posterior joints of the spine and mobility of the chest wall. This can lead to improved cardiopulmonary function and reduced respiratory distress symptoms[3]. In the study by Seo et al.[4], joint mobilization applied around the spine was reported to enhance symmetry in the muscles of the trunk. Additionally, the research by Jang and Bang, Jang[5]. indicated that in stroke patients, decreased mobility of the trunk led to reduced respiratory function due to diminished chest space. Their observations revealed that the application of joint mobilization to both the cervical and thoracic spine led to significant improvements in mobility, inducing chest expansion and enhancing respiratory function. Kim[6] reported improvements in dynamic balance and walking ability in hemiparetic patients through spinal segmental joint mobilization. This technique resulted in effective trunk movement, leading to uniform weight distribution in the lower extremities, wider range of motion, and stable gait, subsequently reducing the risk of falls and increasing walking time. Jung[7] stated that a comprehensive respiratory training including chest expansion exercises was efficient in increasing walking endurance among stroke patients. Watchie[8] uggested that mobilization of the chest and thoracic spine could address inefficient ventilation caused by impaired pumping function of the chest. Additionally, the utilization of chest expansion exercises among stroke patients resulted in a noteworthy rise in the maximal expiratory flow rate, prompting the endorsement of respiratory exercises that incorporate chest wall expansion[9]. In light of this, the primary objective of this study is to explore the impacts of thoracic joint mobilization and breathing exercises targeting the chest wall in individuals who have experienced hemiparesis due to a stroke. The study aims to investigate changes in diaphragm thickness, expansion of the chest wall, respiratory functionality, and endurance. The goal is to propose effective rehabilitation training methods for stroke patients based on these findings.
This study was conducted on 29 inpatient and outpatient stroke patients who checked the notice posted on the bulletin board at Hospital B located in Bundang-gu, Seongnam-si, Gyeonggi-do and expressed their intention to voluntarily participate. The selection criteria included individuals diagnosed with a stroke for at least 6 months, with forced vital capacity (FVC) measuring below 80% of the predicted normal value without receiving specific treatment. comprised individuals without congestive heart failure, unstable angina, peripheral arterial disease, orthopedic conditions, depression, and with a Mini-Mental State Examination-Korean (MMSE-K) score of 24 or higher. Eligible participants were those capable of walking for at least 6 minutes, regardless of the presence of assistive devices, and who comprehended the study's purpose and agreed to participate, both the patient and caregiver. Individuals taking medications that could impede neuromuscular control during testing, unable to sustain a prone position necessary for joint mobilization, or having congenital chest deformities, rib fractures, or conditions such as pulmonary renal endocrine disorders due to orthopedic or rheumatic diseases that would render respiratory mechanics impossible, individuals who had experienced chest or abdominal surgery were not included in the selection criteria. The sample size of the experimental subjects was determined using the sample size calculation program(G*Power,3.1; Universitat Kiel, Germany), based on the results of a previous study by Cho et al[10]. regarding skinfold thickness. An effect size of 1.051 was set. Based on a power of 80% and a significance level of 0.05, the initial estimation indicated the need for 24 participants. Anticipating a dropout rate of 20%, the final sample size was determined to be 29 participants. Subjects were informed of their right to withdraw from the study at any time, after which they provided informed consent. This study was conducted with the approval of the Institutional Review Board of Shamyook University (Approval No. 2-1040781-A-N-012020075HR).
A total of 29 participants were selected. In order to randomly assign research subjects to each group, a lottery was conducted by placing 29 pieces of paper with ‘A’ or ‘B’ written on them in a box. The patients were divided into 14 patients in the thoracic joint mobilization and breathing exercise group (A) and 15 patients in the conservative physical therapy and breathing exercise group (B). Research subjects who signed a consent form to participate in the experiment received a pre-test one week before the start of the experiment and a post-test within one week from the day after the end of the six-week experiment. In pre- and post-examination, changes in diaphragm thickness were measured using rehabilitation imaging ultrasound, and upper and lower chest circumferences were measured using a tape measure (Baseline 12-1201 Gulick, USA) to measure chest cage expansion ability. Respiratory function was measured using a diagnostic spirometer (Pony FX, Italy) to measure forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and peak expiratory velocity (PEF). To measure endurance, a 6-minute walk test was performed. All tests were conducted in the rehabilitation treatment room where the study subjects performed the experiments. All study subjects performed the exercise for 30 minutes, 3 times a week, during the 6-week experiment period. During the experiment, a total of 2 people were dropped from the thoracic joint mobilization and breathing exercise group, including 1 person who was discharged midway and 1 person who discontinued the experiment due to COVID-19. In the conservative physical therapy and breathing exercise group, 3 people were eliminated due to discontinuation of the experiment due to COVID-19. Therefore, ultimately, 12 people in the thoracic joint mobilization and breathing exercise group and 12 people in the conservative physical therapy and breathing exercise group successfully completed the experiment, and statistical analysis was performed by combining the research results(Figure 1).
In this study, the thoracic joint mobilization and breathing exercise group and the conservative physical therapy and breathing exercise group progressed the program according to a set schedule, and the thoracic joint mobilization and breathing exercise group performed joint mobilization. Both groups, the thoracic joint mobilization and breathing exercise group and the conservative physical therapy and breathing exercise group, performed the same breathing exercise program. To ensure smooth progress of the study, two physical therapists with more than 5 years of experience were appointed as research assistants. The researcher shared the program and related matters with the research assistant to ensure uniformity in training, and reported any necessary information about the researcher's content.
Thoracic joint mobilization was performed for 15 minutes with the subject lying prone and turning his or her head to a comfortable direction. The patient was placed in a comfortable prone position and the table top was lowered so that the spine was slightly forwardly bent. The therapist stands next to the patient and moves the metacarpals. Place the lateral or conical bone on the patient's spinous process. Standing right next to the patient, arms were stretched out straight, shoulders were directly above the spine, and 2-3 stages of joint mobilization were applied while transferring body weight from the arms to the hands[10]. Joint mobilization surgery is a method suggested by Maitland[11]. Grade Ⅰ is low-amplitude vibration at the starting point of the range of motion, grade Ⅱ is high-amplitude vibration at the midpoint of the range of motion, and grade Ⅲ is high-amplitude vibration at the end of the range of motion. Vibration, grade Ⅳ, is low amplitude vibration at the end of the range of motion and is applied depending on pain and movement limitations. Central vertebral postero-anterior joint mobilization, transverse vertebra joint mobilization, and unilateral postero-anterior joint mobilization were applied to spinal segments with reduced mobility. Chest wall joint mobilization was performed with the subjects lying face down, gently turning their head to one side for a duration of 15 minutes. The patients assumed a comfortable position by lowering the upper part of the treatment table while lying prone, allowing a slight anterior flexion of the thoracic spine. The therapist positioned themselves beside the patient, aligning their metacarpals, lateral aspects, or knuckles with the patient's spinous process. Standing next to the patient, the therapist extended their arm straight and aligned their shoulder directly above the patient's spine, transmitting body weight through the arm to the hand. This was done while applying joint mobilization techniques in 2-3 stages[10](Figure 2).
Breathing exercises were performed using the Positive Expiratory Pressure (PEP) device (Philips Respironics, UK). The training intensity was typically set at 40-70% of maximum expiratory pressure (PEmax), and some studies have suggested levels below 22%[12-15]. However, in this study, considering the participants' age and overall decline in physical function after stroke, the exercises were conducted at an intensity of 15% of maximum inspiratory pressure for a duration of 15 minutes[16]. The first stage breathing exercise was performed 4 times with the respiratory rate of 15 times/min during exhalation, and a 1-minute break was given to each number in consideration of the subject's fatigue during training, and a 1-minute break was given after the first stage training. In the second stage breathing exercise, exhalation was maintained for 4 seconds, repeated 5 times every 20 seconds, and training was conducted for 15 minutes. The total number of breaths was not to exceed 65, and sufficient explanations and demonstrations were made for smooth progress for each item at each stage(Figure 3).
Conservative physical therapy includes exercises aimed at joint exercise, muscle strengthening, and aerobic control, all aimed at improving the functional capabilities of stroke patients[17]. This treatment approach was performed on the control group for 15 minutes.
From the perspective of rehabilitation, RUSI can be used to directly evaluate muscle atrophy and hypertrophy, and can also be used as a method to test differences in functional changes in muscles through training[18]. Therefore, To measure diaphragm thickness changes, ultrasound images using Rehabilitative Ultrasound Imaging (RUSI) were collected with real-time ultrasound imaging equipment MYSONO U5(Samsung Medison, Korea). A linear transducer with a frequency of 7.5 MHz was used, with a frequency modulation range spanning from 6 to 8.5 MHz and a gain range spanning from 20 to 80, consistently applied for all tests. The subject was placed in a comfortable supine position, Subsequently, the 8th to 9th intercostal spaces were delineated along the right axillary line. Subsequently, with the participants in a supine position, the transducer was vertically maneuvered along the chest wall to assess diaphragm thickness within a 2D coronal plane. This process entailed three repetitions of maximal inhalation and exhalation to ensure accurate diaphragm visualization. Diaphragm thickness was gauged during both maximal exhalation (resting state) and maximal inhalation (contracted state). The alteration in thickness rate was computed. A total of three measurements were taken and the average value was used, and the affected side and non-affected sides were measured(Figure 4).
To measure chest expansion, the upper and lower chest circumferences were measured using a Gulick Baseline 12-1201 tape measure (USA). This measurement method was developed to measure chest expansion during respiration in individuals without respiratory abnormalities, as well as those with conditions such as thoracic hyperkyphosis and scoliosis that involve structural changes in the chest. The agreement between different raters was extremely strong, as indicated by an intraclass correlation coefficient of .99[19]. Measurements of chest circumferences were taken while participants were in an upright position. The measurement for the upper chest circumference was derived from the third intercostal space along the mid-clavicular line and the fifth vertebral spinous process. For the lower chest circumference, the measurement was based on the tip of the xiphoid process and the tenth vertebral spinous process.
The tape measure was positioned horizontally during the measurement. The measurement method involved measuring the distance (cm) the tape measure extended after the subject's maximum inhalation and the distance the tape measure retracted after the subject's maximum exhalation. Both upper and lower measurements followed the same procedure. The result value was calculated by measuring the difference in chest circumference at maximum inspiration and maximum expiration three times and calculating the average value, and was calculated as the difference in circumference formed at maximum inspiration and maximum expiration.
To measure respiratory function, a diagnostic spirometer (Pony FX, Italy) was used. To ensure accurate pulmonary function measurements, after providing participants with thorough explanations and demonstrations, the examination took place while they were seated on a bed with their hip joint flexed at a 90° angle. Pulmonary function testing was conducted according to the "2016 Pulmonary Function Test Guidelines" published as stipulated by the 2016 guidelines from the Korean Academy of Tuberculosis and Respiratory Diseases (Korean Academy of Tuberculosis and Respiratory Diseases, 2016). In order to prevent air from coming out of the nose, participants were seated in a relaxed position on a bed, they held a nose plug and a personal mouthpiece between their teeth, tightly sealing their lips around it for measurement. Following three calm breaths at rest, they were instructed to inhale maximally, followed by a forceful and rapid exhalation through the spirometer turbine. Additionally, participants were prompted to hold their breath for a duration of 7 seconds. For measurement, one demonstration and practice was performed, and a total of three measurements were taken, and the average value was used. The measured variables for this study were FEV1 (forced expiratory volume in 1 second), FVC (forced vital capacity), and PEF (peak expiratory flow rate).
For the assessment of endurance, a 6-minute walking test was conducted. The 6-minute walking test is a method used to evaluate the endurance of stroke patients, measuring the maximum distance they can walk in 6 minutes. This test has shown high reliability in stroke patients (ICC=0.94)[20]. The assessment involved walking back and forth on a 20-meter long path marked with markers at 1-meter intervals for 6 minutes without any assistance. Time elapsed was indicated at 1, 3, 5 minutes, and the last 10 seconds to inform the subjects. The walking pace was adjusted to the patient's ability for self-paced walking. Additionally, to account for the subject's condition during walking, breaks were allowed for rest, and when ready, walking was resumed. Considering the patient's condition, the results of one measurement were used.
All statistical procedures and analyses in this study were performed using SPSS (Ver. 21, SPSS Inc., Chicago, IL, USA). The homogeneity of general characteristics such as gender, cause of onset, and affected side was examined through chi-square tests. Homogeneity of variables including height, weight, age, duration of illness, baseline dependent variables was tested using independent t-tests. Paired t-tests were employed to scrutinize intra-group variances pre and post training, while independent t-tests were utilized to investigate inter-group differences. The effects of training were evaluated by analyzing alterations in means using the change score. A significance threshold of α=0.05 was established for all statistical analyses.
A total of 29 participants were involved in this study, with 2 dropouts in the experimental group due to COVID-19 and discharge, and 3 dropouts in the control group due to COVID-19. Therefore, data from a total of 24 individuals were collected. The general characteristics of the participants and the homogeneity testing for pre-tests are as follows(Table 1)(Table 2).
The pre-post changes in the thickness of the affected side of the diaphragm are as follows (Table 3). In all groups, there was no significant difference in the thickness of the affected side of the diaphragm at rest before and after intervention. During contraction, both groups showed significant differences in diaphragm thickness and rate of change (p<0.05), but there was no significant difference between the groups.
The pre-post changes in the thickness of the non-affected side of the diaphragm are as follows (Table 4). In all groups, there was no significant difference in the thickness of the non-affected side of the diaphragm at rest before and after intervention. During contraction, both groups showed significant differences in diaphragm thickness and rate of change (p<0.05), and the experimental group exhibited a significant difference in diaphragm thickness change during contraction compared to the control group (p<0.05).
The pre-post changes in upper and lower chest wall expansion are as follows (Table 5). In all groups, significant differences were found in both upper and lower chest wall expansion before and after intervention (p<0.05). The experimental group showed a significant difference in the change of upper and lower chest wall expansion compared to the control group (p<0.05).
The pre-post changes in respiratory function are as follows (Table 6). In all groups, significant differences were found in FVC, FEV1, and PEF before and after intervention (p<0.05), but there was no significant difference between the two groups.
The pre-post changes in endurance are as follows (Table 7). In all groups, there was a significant difference in endurance change before and after intervention (p<0.05), but there was no difference between the two groups.
In the present study, no noteworthy distinctions in diaphragm thickness at rest were found between the affected and unaffected sides within the experimental group. Similarly, no significant variances were noted in the diaphragm thickness at rest for both the affected and unaffected sides within the control group. These outcomes align with the findings reported by Enright et al.[21], who conducted an 8-week respiratory exercise intervention on a group of 20 healthy adults and reported no significant differences in resting diaphragm thickness. Furthermore, The outcomes of this study align with the discoveries made by Jung[22], who conducted a 6-week intervention involving chest mobility breathing exercises and inspiratory training on a group of 40 stroke patients. Their study revealed no significant differences in resting diaphragm thickness before and after the training on both affected and unaffected sides. Based on these results, it can be inferred that chest wall mobilization and breathing exercises may not have a significant impact on the resting diaphragm thickness of both affected and unaffected sides. Regarding the contraction phase, significant differences in diaphragm thickness were Significant findings were identified in both the experimental and control groups, pertaining to both the affected and unaffected sides. The diaphragm thickness change rate also showed significant differences for both the affected and unaffected sides in both the experimental and control groups. However, when comparing the changes between groups based on the training methods, Only the diaphragm thickness on the unaffected side during contraction exhibited statistically significant distinctions. In a study conducted by Jo[10] involving 30 patients with chronic stroke, it was reported that inspiratory training resulted in significant changes in diaphragm thickness during contraction for on both the impaired and unimpaired sides. This finding was consistent with reports indicating significant changes in the diaphragm thickness change rate. In stroke patients, not only muscle paralysis of the respiratory muscles but also reduced chest wall mobility due to rigidity and inactivity can contribute to impaired respiratory function, Frownfelter and Dean[23] highlighted that compromised chest wall mobility and differing levels of respiratory muscle paralysis can result in diminished respiratory effectiveness and alterations in the respiratory process. In this study, a marked increase in the thickness of the diaphragm on the non-affected side in comparison to the affected side was identified. This result is believed that the non-affected side was more active to the extent that the chest wall movement of the affected side and respiratory muscle paralysis.
Regarding chest wall expansion, noteworthy disparities were noted in upper chest wall expansion for both the experimental group and the control group. However, in the evaluation of pre and post intervention alterations between the two groups, the experimental group displayed a more substantial variance. Likewise, significant variances were identified in lower chest wall expansion for both the experimental and control groups. Nevertheless, when comparing pre- and post intervention adjustments between the groups, the experimental group exhibited a more prominent variance. These findings align with the results of a prior study by Park[11] where chest wall mobilization and threshold inspiratory muscle training were applied to 36 stroke patients for 6 weeks. That study demonstrated significant changes in the range of upper and lower chest wall expansion, corroborating the current outcomes. In a study conducted by Gu[16] involving 26 chronic stroke patients, spinal mobilization and respiratory exercises were administered for a duration of 6 weeks. The results were consistent with the findings of significant differences in upper and lower chest wall expansion compared to the group that underwent only respiratory exercises. In the context of this study, noticeable variations in chest wall expansion were identified within the experimental group when contrasted with the control group. This is believed to be due to the application of chest wall mobilization prior to active respiratory exercises, leading to an increased passive chest wall mobility in stroke patients. Subsequently, active respiratory exercises were carried out, resulting in significant differences in chest wall expansion.
For evaluating pulmonary function, FVC, FEV1 are commonly used indicators[24], and an elevation in PEF is indicative of enhanced respiratory muscle strength[25]. Along with chest wall mobility, these indicators, including FVC, FEV1, and PEF, have been used to estimate respiratory function levels and chest wall volumes[26]. In this study, we assessed FVC, FEV1, and PEF as measures of respiratory function.
In relation to respiratory function, significant disparities in FVC were observed in both the experimental group and the control group according to the study results. The FEV1 exhibited significant differences in both the experimental and control groups, also, PEF displayed significant distinctions in both the experimental group and the control group, as indicated by the study findings. Nonetheless, no statistically significant variations were identified when comparing pre and post training alterations between the two groups, categorized by their respective training methods. In a previous study by Park[27] chronic stroke patients were subjected to 6 weeks of Maitland spinal mobilization exercises, and the results indicated improvements in FVC, FEV1, and PEF. These findings align with the findings from this study. Additionally, in a study conducted by Sutbeyaz et al,[28], in a study centered on acute stroke patients, who were divided into a diaphragmatic muscle training group, a respiratory retraining group, and a control group for a 6-week period, significant outcomes were evident. Notably, the diaphragmatic muscle training group demonstrated considerable improvements in FVC and FEV1 when compared to their baseline values. However, no significant changes were found in PEF. This variance can be attributed to the fact that in our investigation, respiratory muscle training was conducted using an inspiratory training device, whereas the measurement parameter, peak expiratory flow, is directly influenced by the expiratory phase. The respiratory muscle training implemented in our study is recommended to which specifically targeted the expiratory phase, had a greater impact on the measured variable of peak expiratory flow. Furthermore, the reasons why chest wall mobilization and respiratory exercises did not yield significantly increased respiratory function results compared to conservative physical therapy and respiratory exercise groups might stem from the fact that while chest wall mobilization ensures the appropriate length for respiratory muscle contraction and promotes muscle activation to enhance ventilation[29], The relatively short duration of intervention in this study might have contributed to the inability to significantly enhance the participants' respiratory function. However, despite not showing statistically significant improvements in respiratory function, both chest wall mobilization and respiratory exercises led to increased results in respiratory function. This suggests that with interventions lasting over 6 weeks in the future, there could potentially be more effective enhancements in respiratory function. Regarding the results of this study, significant differences were observed in endurance as assessed by the 6-minute walking test for both the experimental group and the control group. However, Upon comparing the pre and post intervention alterations between the two groups based on the training methods, no statistically significant disparities were observed. In a study by Jung et al.[7], the application of comprehensive respiratory training, including chest wall expansion, on 30 stroke patients for 6 weeks resulted in a significant increase in the 6-minute walking test values. Similarly, Sezer et al.[30], in a study examining cardiovascular and metabolic responses to maximal exercise in 15 hemiplegic patients, it was observed that diminished respiratory function in stroke patients was associated with a decrease in their walking ability. Considering the results of this current study and the aforementioned studies indicating improved endurance through chest wall expansion and respiratory exercises, in spite of the absence of a substantial difference between the two groups, the increased values observed before and after training suggest that the enhanced endurance is likely attributed to improved respiratory function due to chest wall expansion. Furthermore, it can be inferred that with interventions lasting over 6 weeks, more effective improvements in endurance could potentially be achieved.
This study's limitations encompass the recruitment of participants exclusively from a particular hospital environment, including both inpatients and outpatients, which could pose challenges in generalizing the findings to all stroke patients residing in the community. Additionally, the study was unable to control for potential interference from other treatments and variables beyond the intervention variables for all subjects. Everyday life and psychological factors that could influence the assessments were not adequately controlled. Moreover, the study did not observe the duration of the effects after the research period and lacked insight into the sustainability of the outcomes. Therefore, future research should consider follow-up assessments to determine the maintenance of the effects. Furthermore, while this study demonstrated the effectiveness of chest wall expansion and respiratory exercises on non-affected side diaphragm thickness and chest wall expansion, more objective and conclusive validation might necessitate the need for repetitive studies.
A limitation of this study is that it was conducted on patients hospitalized and outpatients at a specific hospital, so it may be difficult to generalize to all stroke patients living in the community. In addition, the intervention of other treatments and variables other than the intervention variables for all subjects could not be ruled out, and daily life and psychological factors that could affect the evaluation could not be controlled. Additionally, it was not observed how long the effect lasted after the study, and its sustainability was unknown. Therefore, it is believed that follow-up studies will need to investigate the maintenance of the effect through follow-up evaluation. In addition, it has been shown that thoracic joint mobilization and breathing exercises are effective in increasing the thickness of the diaphragm on the non-affected side and expanding the thoracic cage, but repeated research is needed for more objective and reliable verification.
The primary objective of this research was to explore the impact of thoracic joint mobilization and respiratory exercises on diaphragm thickness, chest wall expansion, respiratory function, and endurance in individuals diagnosed with chronic stroke. According to the results of the study, chest wall mobilization and respiratory exercises were found to have positive effects on diaphragm thickness, chest wall expansion, respiratory function, and endurance in chronic stroke patients. Particularly, the group receiving chest wall mobilization and respiratory exercises demonstrated significant differences in non-affected side diaphragm thickness and chest wall expansion compared to the conservative physical therapy and respiratory exercise group. Therefore, it is suggested that chest wall mobilization and respiratory exercises could be more effective than conservative physical therapy and respiratory exercises in terms of non-affected side diaphragm thickness and chest wall expansion, making them a potential approach for respiratory exercise methods in the future.
The author has no potential conflicts of interest in relation to the authorship and/or publication of this article.
The general characteristics of the subjects
| Variable | EG (n=12) | CG (n=12) | χ2/t(p) |
|---|---|---|---|
| Sex (female/male) | 5/7 | 7/5 | 0.040(0.841) |
| Age (y) | 55.38±12.51a | 53.33±11.45a | 0.426(0.674) |
| Height (㎝) | 166.31±8.30a | 165.08±6.05a | 0.424(0.676) |
| weight (kg) | 59.73±8.41a | 58.75±5.52a | 0.347(0.732) |
| Diagnosis (Infarc./hemo.) | 7/5 | 9/3 | 1.960(0.162) |
| Affected side (left/right) | 5/7 | 4/8 | 1.000(0.317) |
| Onset (mo) | 38.92±14.16a | 34.58±8.50a | 0.937(0.360) |
| MMSE-K (score) | 27.08±1.15a | 27.58±1.56a | -0.938(0.350) |
EG: Experimental group; CG: Control group
a Values are expressed as mean ± Standard deviation
The subject's diaphragmatic thickness, thoracic expansion, respiratory function and endurance
| Variable | EG (n=12) | CG (n=12) | t(p) |
|---|---|---|---|
| diaphragm thickness | |||
| ADR (cm) | 0.16±0.05a | 0.14±0.16a | 1.645(0.114) |
| NDR (cm) | 0.19±0.05 | 0.16±0.02 | 1.660(0.111) |
| ADC (cm) | 0.28±0.06 | 0.25±0.02 | 1.280(0.214) |
| NDC (cm) | 0.38±0.05 | 0.35±0.4 | 1.491(0.150) |
| APC (%) | 74.56±14.31 | 83.89±12.30 -1.712(0.101) | |
| NPC (%) | 107.75±33.37 | 118.36±22.34 -0.907(0.374) | |
| chest expansion | |||
| UCE (cm) | 1.58±0.39 | 1.45±0.16 | 1.013(0.327) |
| LCE (cm) | 2.13±0.35 | 1.92±0.16 | 1.893(0.077) |
| respiratory function | |||
| FVC (ℓ) | 2.11±0.82 | 1.96±0.66 | 0.469(0.644) |
| FEV1 (ℓ) | 1.73±0.51 | 1.55±0.19 | 1.116(0.277) |
| PEF (ℓ) | 2.84±1.47 | 2.45±1.48 | 0.656(0.519) |
| Endurance | |||
| 6MW (m) | 164.08±14.18 | 168.00±10.33 -0.757(0.457) | |
Note. ADR=affected diaphragm rest; NDR=nonaffected diaphragm rest; ADC=affected diaphragm contraction; NDC=nonaffected diaphragm contraction; APC= affected percent change; NDC=nonaffected percent change; UCE=upper chest expansion; LCE=lower chest expansion; FVC=forced vital capacity; FEV1=forced expiratory volume in the one second; PEF=peak expiratory flow; 6MW=six-minute walk test. EG: Experimental group; CG: Control group. a Values are expressed as mean ± Standard deviation
Affected diaphragm thickness
| Variable | EG (n=12) | CG (n=12) | HT (p) | t(p) |
|---|---|---|---|---|
| ADR (cm) | ||||
| Pre | 0.16±0.05a | 0.14±0.16a | 0.114 | |
| Post | 0.16±0.04 | 0.14±0.18 | ||
| Change | 0.0006±0.13 | 0.005±0.01 | -0.971(0.344) | |
| t(p) | 0.187(0.889) | -1.732(0.111) | ||
| ADC (cm) | ||||
| Pre | 0.28±0.06 | 0.25±0.02 | 0.214 | |
| Post | 0.38±0.07 | 0.36±0.01 | ||
| Change | 0.10±0.02 | 0.10±0.04 | -0.058(0.955) | |
| t(p) | -13.041(0.001) | -8.308(0.001) | ||
| APC (%) | ||||
| Pre | 74.56±14.31 | 83.89±12.30 | 0.101 | |
| Post | 135.04±26.11 | 150.92±44.36 | ||
| Change | 60.47±19.86 | 67.02±42.98 | -0.479(0.636) | |
| t(p) | -10.549(0.001) | -5.042(0.001) | ||
Note. ADR=affected diaphragm rest; ADC=affected diaphragm contraction; APC=affected percent change
EG: experimental group; CG: control group; HT; homogeneity test
a Values are expressed as mean ± Standard deviation
Non-affected diaphragm thickness
| Variable | EG (n=12) | CG (n=12) | HT (p) | t(p) |
|---|---|---|---|---|
| NDR (cm) | ||||
| Pre | 0.19±0.05a | 0.16±0.02a | 0.111 | |
| Post | 0.19±0.05 | 0.16±0.02 | ||
| Change | 0.002±0.006 | 0.01±0.05 | 0.340(0.737) | |
| t(p) | -1.393(0.191) | -1.000(0.399) | ||
| NDC (cm) | ||||
| Pre | 0.38±0.05 | 0.35±0.04 | 0.150 | |
| Post | 0.45±0.04 | 0.40±0.03 | ||
| Change | 0.06±0.01 | 0.05±0.01 | 2.103(0.047) | |
| t(p) | -11.388(0.001) | -14.200(0.001) | ||
| NPC (%) | ||||
| Pre | 107.70±33.37 | 118.36±23.34 | 0.374 | |
| Post | 140.05±42.44 | 147.51±24.69 | ||
| Change | 32.35±13.23 | 29.14±14.03 | 0.576(0.571) | |
| t(p) | -8.466(0.001) | -7.192(0.001) | ||
Note. NDR=non-affected diaphragm rest; NDC=non-affected diaphragm contraction; NPC=non-affected percent change
EG: experimental group; CG: control group; HT; homogeneity test
a Values are expressed as mean ± Standard deviation
Chest expansion
| Variable | EG (n=12) | CG (n=12) | HT (p) | t(p) |
|---|---|---|---|---|
| UCE (cm) | ||||
| Pre | 1.58±0.39a | 1.45±0.16a | 0.327 | |
| Post | 2.01±0.41 | 1.69±0.32 | ||
| Change | 0.43±0.15 | 0.23±0.20 | 2.681(0.014) | |
| t(p) | -9.918(0.001) | -4.002(0.002) | ||
| LCE (cm) | ||||
| Pre | 2.13±0.33 | 1.92±0.16 | 0.077 | |
| Post | 2.75±0.34 | 2.26±0.16 | ||
| chang | 0.61±0.14 | 0.33±0.06 | 5.855(0.001) | |
| t(p) | -14.265(0.001) | -16.776(0.001) | ||
Note. UCE=upper chest expansion; LCE=lower chest expansion
EG: experimental group; CG: control group; HT; homogeneity test
a Values are expressed as mean ± Standard deviation
Respiratory function
| Variable | EG (n=12) | CG (n=12) | HT (p) | t(p) |
|---|---|---|---|---|
| FVC (ℓ) | ||||
| Pre | 2.11±0.82a | 1.96±0.66a | 0.644 | |
| Post | 2.43±0.67 | 2.15±0.63 | ||
| Change | 0.32±0.26 | 0.19±0.26 | 1.230(0.232) | |
| t(p) | -4.174(0.002) | -2.455(0.032) | ||
| FEV1 (ℓ) | ||||
| Pre | 1.73±0.51 | 1.55±0.19 | 0.277 | |
| Post | 2.23±0.66 | 1.94±0.36 | ||
| change | 0.50±0.19 | 0.39±0.24 | 1.232(0.232) | |
| t(p) | -8.947(0.001) | -5.494(0.001) | ||
| PEF (ℓ) | ||||
| Pre | 2.84±1.47 | 2.45±1.48 | 0.519 | |
| Post | 3.54±1.73 | 3.32±1.76 | ||
| Change | 0.69±0.70 | 0.86±0.66 | -0.626(0.538) | |
| t(p) | -3.402(0.006) | -4.518(0.001) | ||
Note. FVC=forced vital capacity; FEV1=forced expiratory volume in the one second; PEF=peak expiratory flow
EG: experimental group; CG: control group; HT; homogeneity test
a Values are expressed as mean ± Standard deviation.
Endurance
| Variable | EG (n=12) | CG (n=12) | HT (p) | t(p) |
|---|---|---|---|---|
| 6MW (m) | ||||
| Pre | 164.08±14.64a | 168.00±10.33a | 0.457 | |
| Post | 181.74±14.73 | 184.66±10.69 | ||
| Change | 17.65±6.4 | 16.66±4.77 | 0.429(0.672) | |
| t(p) | -9.519(0.001) | -12.094(0.001) | ||
Note. 6MW=six-minute walk test
EG: experimental group; CG: control group; HT; homogeneity test
a Values are expressed as mean ± Standard deviation.
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