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Abstract

Background: Respiratory muscular weakness and associated changes in thoracoabdominal motion have been poorly studied in stroke subjects, since the individuals' functional levels were not previously considered in the investigations. Aim: To investigate the breathing patterns, thoracoabdominal motion, and respiratory muscular strength in chronic stroke subjects, who were stratified into two groups, according to their walking speeds. Design: Cross-sectional, observational study. Setting: University laboratory. Population: Eighty-nine community-dwelling chronic stroke subjects Methods: The subjects, according to their gait speeds, were stratified into community (gait speed ≥0.8 m/s) and non-community ambulators (gait speed <0.8 m/s). Variables related to pulmonary function, breathing patterns, and thoracoabdominal motions were assessed. Measures of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were obtained and were compared with the reference values for the Brazilian population. The MIP and MEP values were expressed as percentages of the predicted values. Mann-Whitney-U or independent Student t-tests were employed to compare the differences between the two groups for the selected variables. Results: No significant between-group differences were found for the variables related to the breathing patterns and thoracoabdominal motions (0.01 < z/t < 1.51; 0.14<P<0.99). Compared to the predicted values, the stroke subjects demonstrated decreases of 26.5 and 20% of the MIP and MEP, respectively. Non-community ambulators showed significant lower predicted MIP values than those from the community ambulators (t=2.10; P=0.04). However, no significant between-group differences were found for the predicted MEP measures (t = -1.10; P=0.25). Conclusion: Stroke subjects demonstrated weakness of the respiratory muscles and lower predicted MIP values were found for the non-community ambulators. Clinical rehabilitation impact: Evaluations and interventions involving respiratory muscular training could be included in stroke rehabilitation, especially for individuals with lower functional levels.
Vol. 50 - 2014 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 1
Inspiratory muscular weakness is most evident in
chronic stroke survivors with lower walking speeds
ambulators (t=2.10; P=0.04). However, no signicant
between-group differences were found for the predict-
ed MEP measures (t=-1.10; P=0.25).
Conclusion. Stroke subjects demonstrated weakness
of the respiratory muscles and lower predicted MIP
values were found for the non-community ambulators.
Clinical rehabilitation impact. Evaluations and in-
terventions involving respiratory muscular training
could be included in stroke rehabilitation, especially
for individuals with lower functional levels.
Key words: Stroke - Hemiplegia - Respiratory muscles -
Muscular weakness.
Stroke is considered a public health problem,
because it is the third highest leading cause of
chronic disability and one of the most devastating
neurological conditions, which lead to serious dis-
abilities.1, 2 Among the most frequently observed
decits in post-stroke individuals, muscular weak-
ness stands out, which was also observed in the re-
1UniversidadeFederaldeMinasGerais
BeloHorizonte, MinasGerais, Brazil
2UniversidadeFederaldeMinasGerais
BeloHorizonte, MinasGerais, Brazil
3DepartmentofPhysicalTherapy
UniversidadeFederaldeMinasGerais
BeloHorizonte, MinasGerais, Brazil
4UniversidadeFederaldeMinasGerais
BeloHorizonte, MinasGerais, Brazil
5DepartmentofPhysicalTherapy
UniversidadeFederaldeMinasGerais
BeloHorizonte, MinasGerais, Brazil
6DepartmentofPhysicalTherapy
UniversidadeFederaldeMinasGerais,
BeloHorizonte, MinasGerais, Brazil
EUR J PHYS REHABIL MED 2013;49
M. B. PINHEIRO 1, J. C. POLESE 2, C. D. C. M. FARIA 3, G. C. MACHADO 4
V. F. PARREIRA 5, R. R. BRITTO 5, L. F. TEIXEIRA-SALMELA 6
Background. Respiratory muscular weakness and as-
sociated changes in thoracoabdominal motion have
been poorly studied in stroke subjects, since the indi-
viduals’ functional levels were not previously consid-
ered in the investigations.
Aim. To investigate the breathing patterns, thoracoab-
dominal motion, and respiratory muscular strength in
chronic stroke subjects, who were stratied into two
groups, according to their walking speeds.
Design. Cross-sectional, observational study.
Setting. University laboratory.
Population. Eighty-nine community-dwelling chronic
stroke subjects
Methods. The subjects, according to their gait speeds,
were stratied into community (gait speed ≥0.8 m/s)
and non-community ambulators (gait speed <0.8 m/s).
Variables related to pulmonary function, breathing
patterns, and thoracoabdominal motions were as-
sessed. Measures of maximal inspiratory pressure
(MIP) and maximal expiratory pressure (MEP) were
obtained and were compared with the reference val-
ues for the Brazilian population. The MIP and MEP
values were expressed as percentages of the predict-
ed values. Mann-Whitney-U or independent Student
t-tests were employed to compare the differences be-
tween the two groups for the selected variables.
Results. No signicant between-group differences
were found for the variables related to the breath-
ing patterns and thoracoabdominal motions (0.01<z/
t<1.51; 0.14<P<0.99). Compared to the predicted
values, the stroke subjects demonstrated decreases
of 26.5 and 20% of the MIP and MEP, respectively.
Non-community ambulators showed signicant lower
predicted MIP values than those from the community
Corresponding author: L. Fuscaldi Teixeira-Salmela, PhD, De-
partamento de Fisioterapia, Universidade Federal de Minas Gerais,
Avenida Antônio Carlos, 6627, Campus Pampulha, 31270-901 Belo
Horizonte, Minas Gerais, Brazil. E-mail: lfts@ufmg.br
Anno: 2013
Mese: ??
Volume: 49
No: 1
Rivista: EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE
Cod Rivista: EUR J PHYS REHABIL MED
Lavoro: 3280-EJPRM
titolo breve: Inspiratory muscular weakness
primo autore: PINHEIRO
pagine: 1-2
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PINHEIRO INSPIRATORY MUSCULAR WEAKNESS
2 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE Vol. 50 - 2014
spiratory muscles 3 and may compromise the respi-
ratory function of these individuals.4
Declines in respiratory function have been shown
to be independent predictors of coronary and car-
diovascular mortality and morbidity.5 In addition,
respiratory muscular weaknesses, when associated
with changes of the thoracoabdominal motions,
could be related to decreased tidal volumes (VT)
and exercise tolerance.6
Studies have reported the importance of maintain-
ing the strength of respiratory muscles and have al-
ready demonstrated the relationships between the
respiratory strength and the perceptions of efforts in
individuals with Parkinson’s Disease 7 and with the
functional capacity of various populations, such as
the elderly,8 individuals with chronic obstructive pul-
monary diseases,9 as well as in healthy individuals.10
Weaknesses and strengthening of the peripheral
muscles have been often investigated in stroke sub-
jects.11-13 However, few studies have addressed the
strength of the respiratory muscles. A systematic re-
view, which included four studies related to respi-
ratory strength, demonstrated that, when compared
to controls, stroke subjects showed lower values of
maximal inspiratory pressure (MIP) and maximal
expiratory pressure (MEP).14 However, these stud-
ies included few individuals (n≤18) and people at
both the acute 15-17 and chronic phases after stroke.3
Furthermore, few studies have investigated the pa-
rameters related to breathing patterns and thoraco-
abdominal motions of stroke subjects.3, 15-17
Despite the lack of studies that investigated the
cardiopulmonary parameters in stroke survivors, the
impact and consequences of any health conditions,
such as stroke, can be differentially manifested with
various subjects.18 Therefore, to better understand the
consequences of stroke on the cardiopulmonary sys-
tem, it is important to consider the subject´s function-
al levels. Gait speed has been reported as a powerful
indicator of functioning after stroke, since gait ability
is related to functional independence,19 and higher
speeds are associated with more complex commu-
nity participation and better quality of life.20 In this
sense, Perry et al.21 proposed a stratication of stroke
individuals into two clinically functional groups:
Non-community (gait speed <0.8 m/s) and commu-
nity ambulators (≥0.8 m/s). Community ambulation
has been broadly defined as locomotion outdoors to
encompass activities, such as visits to the supermar-
ket, shopping malls, social outings, and others.21
The identication of respiratory impairments and
their possible relationships with functional capacity
in stroke patients is important to better identify the
group of patients to whom assessments and perhaps
specic interventions should be emphasized. There-
fore, the main purpose of this study was to investigate
breathing patterns, thoracoabdominal motions, and
respiratory muscular strength of chronic stroke sur-
vivors, who were stratied into two groups (commu-
nity and non-community ambulators), according to
their functional levels. It was hypothesized that sub-
jects with lower functional levels would demonstrate
decreases of respiratory strength and changes in the
breathing patterns and thoracoabdominal motion.
Materials and methods
Participants
One-hundred subjects were recruited from the gen-
eral community of the city of Belo Horizonte, Brazil,
according to the following criteria: Were older than
20 years; had the time since the onset of a unilateral
stroke of at least six months; demonstrated residual
weakness and/or increased tonus of the paretic low-
er limb, determined by strength decits above 10%
and/or scores on the modied Ashworth scale dif-
ferent from zero, respectively; could independently
walk with or without assistive devices; had no facial
palsy, which could prevent proper labial occlusion;
and had no cognitive impairments, as assessed by
the Mini Mental State Examination,22 according to the
cut-off scores, recommended by Brucki et al.23 They
also should be able to understand and perform the
test procedures. Eligible participants provided con-
sent prior to screening, based upon approval from
the university ethical review board.
Measurement instruments and procedures
The assessments were carried out over two con-
secutive days and the same measurement orders
were employed. During the rst day, the participants
underwent a physical examination and interviews to
obtain their demographic, anthropometric, and clini-
cal information related to age, gender, body mass,
height, paretic side, time since the onset of stroke, use
of medications, and smoking habits. For characteriza-
tion purposes, pulmonary function tests were also
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This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
or other proprietary information of the Publisher.
INSPIRATORY MUSCULAR WEAKNESS PINHEIRO
Vol. 50 - 2014 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 3
ing inspiration and expiration, respectively, whereas
the PhaseAng reected the delay between the rib
cage and abdomen excursions.31
Then, measures of MIP and MEP were obtained
with a previously calibrated manovacuometer
(GeRar®, Brazil), with operating intervals of ±300
cm H2O. Assessments of MIP and MEP have been
used as indirect measures of strength of the inspira-
tory and expiratory musculature, respectively.3 This
test has shown appropriate psychometric proper-
ties.32, 33
All MIP and MEP measures were performed with
the participants comfortably seated on a chair with-
out trunk support, with their feet on the ground and
their trunk positioned at an angle of 90° in relation
to their hips. A nose clip was used and a mouthpiece
was tightly held between the lips during all maneu-
vers, to avoid leaks. To record the MIP, participants
were instructed to exhale into the mouthpiece to re-
sidual volume and, then, perform a maximal inspir-
atory effort against an obstructed airway.34, 35 The
MEP was recorded in a similar way, and the subjects
were instructed to breathe from the mouthpiece to
total lung capacity and, then, perform a maximal
expiratory effort. One-minute rest intervals were al-
lowed between the trials and immediately after two
familiarization trials,34 the participants were asked
to perform the tests until three acceptable measures
were obtained without an air leak for at least a one
second of duration.34 Two reproducible maneuvers
with a maximum 10% variation, were retained and
the highest value was selected for analysis.34,35 The
MIP and MEP values were compared with the pre-
dicted ones, by employing the following equations
proposed by Neder et al.:34
MIP: Women: y = −0.49 (age) + 110.4; standard
error of the estimate =9.1
Men: y = −0.80 (age) + 155.3, standard error of the
estimate =17.3
MEP: Women: y = −0.61 (age) + 115.6; standard
error of the estimate =11.2
Men: y = −0.81 (age) + 165.3; standard error of the
estimate =15.6
Statistical analyses
Descriptive statistics, test for normality (Shapiro-
Wilk or Kolmogorov-Smirnov tests) and for equal-
ity of variances (Levene) were carried out for all of
the investigated variables. The MIP and MEP values
performed using a spirometer (Vitalograph® 2120, Vi-
talograph Ltd, UK), following the recommendations
for data acquisition, quality, and reproducibility.24
Gait speed was assessed to determine the partici-
pants’ functional levels. The subjects were instructed
to walk at self-selected comfortable speeds along a
28m hallway wearing their usual shoes and assistive
devices. The time spent to cover the central 24m was
recorded with a digital stopwatch and the speed (m/s)
was calculated. Three trials were collected and the
average values were stored for analyses.3 Based upon
the gait speed values, the subjects were stratied into
two clinically functional groups: Non-community
(speed <0.8 m/s) and community (≥0.8 m/s) ambula-
tors.21 A time break of at least one hour was ensured
for all subjects between the spirometry and gait speed
tests, to guarantee that they were fully recovered.
During the second day, the breathing patterns and
thoracoabdominal motions were assessed with the
respiratory inductive plethysmography (Respitrace®
204, Nims, USA), which has shown to be a simple
and accurate method to identify the tidal volume,
respiratory frequencies, and time of inspiration
and expiration during the respiratory cycle.25-27 The
breathing patterns and thoracoabdominal motion
components were obtained by the changes in the
cross-sectional areas of the rib cage and abdominal
compartments.28
The participants were asked to comfortably lie
down in the supine position on an examination
table with inclination of 30° for 30 minutes 3, 29
and were instructed not to talk, sleep, or move
any part of their body during data collection. The
equipment calibration was performed, following
standardized procedures.3, 30 The signals were ob-
tained using specic software (RespiEvents, Nims,
USA) for 10 minutes. To analyze the data, inter-
vals of at least 30 seconds of stable respiratory
cycle tracings were selected. In addition, the sum
of these intervals should reach a minimum of ve
minutes.30
The following variables were obtained from the
respiratory cycle: Tidal volume (VT), respiratory rate
(RR), minute ventilation (VE), inspiratory duty cycle
(TI/Ttot), mean inspiratory ow (VT/TI), percentage
of rib cage motion (%RC), phase relation in inspira-
tion (PhRIB), phase relation in expiration (PhREB),
and phase angle (PhaseAng). The PhRIB and PhREB
reected the percentage of the time that the rib cage
and the abdomen moved in opposite directions dur-
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This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
or other proprietary information of the Publisher.
PINHEIRO INSPIRATORY MUSCULAR WEAKNESS
4 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE Vol. 50 - 2014
mass, height, body mass index, time since the onset
of the stroke, use of medication, and spirometric
variables (0.33<t<1.54; 0.07<P< 0.75). All individ-
uals of both groups did not have any respiratory
complaints.
As seen in Table II, no signicant between-group
differences were found for any of the variables relat-
ed to the breathing patterns and thoracoabdominal
motions (0.01<z/t<1.51; 0.14<P<0.99).
Table III provides the data related to the meas-
ures of maximal respiratory pressures stratied into
the two functional levels. Compared to the predicted
values, decreases of 26.5 and 20% were found for
the MIP and MEP, respectively. The non-community
ambulators showed signicant lower predicted MIP
values than those of the community ambulators
(t=-2.10; P=0.04). However, no signicant between-
group differences were found for the predicted MEP
measures (t=-1.10; P=0.25).
Discussion
To the best of our knowledge, this is the rst study
that investigated the parameters of respiratory func-
were expressed as percentages of the predicted val-
ues, according to the following formula: (observed
value/predicted value * 100). Mann-Whitney-U or in-
dependent Student t-tests were employed to inves-
tigate the differences between the community and
non-community ambulatory groups for all selected
variables. All analyses were carried out with the
SPSS version 17.0 for Windows with a signicance
level of 5%.
Results
Eleven subjects, ve from the community and six
from the non-community ambulation group, were
excluded either because the subjects were not
able to complete the tests or due to the inductive
plethysmography measurement artifacts. Therefore,
out of the 89 individuals who completed all the
tests (48 men and 41 women), 57 (64%) were classi-
ed as community and 32 (36%) as non-community
ambulators. Table I shows the participants’ demo-
graphic, clinical, anthropometric, and spirometric
characteristics. No signicant differences between
the groups were found regarding their ages, body
Table I.—Demographic, clinical, anthropometric, and spirometric characteristics of the participants.
Characteristic
Community
ambulators
(N.=57)
Non-community
ambulators
(N.=32)
Total
(N.=89)
Age (years), mean ± SD
range: min-max
54.8±11.9
(24-82)
57.9±12.1
(31-79)
56.2±12.0
(24-82)
Gender, male (%) 35 (61.4) 14 (43.8) 48 (53.9)
Body Mass (kg), mean ± SD
range: min-max
70.3±13.4
(40-101)
65.5±15.5
(44-106)
68.1±13.9
(40-106)
Height (m), mean ± SD
range: min-max
1.63±0.08
(1.45-1.79)
1.60±0.11
(1.44-1.86)
1.62±0.09
(1.44-1.86)
BMI (kg/m2), mean ± SD
range: min-max
26.3±4.0
(15.2-36.5)
25.1±3.6
(19.0-32.9)
25.8±4.0
(15.2-36.5)
Paretic side, right (%) 37 (64.9) 14 (43.8) 51 (57.3)
Time since onset of the stroke (months), mean ± SD
range: min-max
60.7±52.8
(6-228)
70.3±56.4
(6-240)
64.2±54.0
(6-240)
Use of medications (number), mean ± SD
range: min-max
3.0±1.8
(0-8)
2.9 ±1.6
(0-6)
2.9±1.7
(0-8)
Smokers, number (%)
Non-smokers, number (%)
Ex-smokers, number (%)
9 (15.8)
16 (28.1)
32 (56.1)
2 (6.3)
19 (59.4)
11 (34.4)
11 (12.4)
35 (39.3)
43 (48.3)
FEV1 (% predicted), mean ± SD
range: min-max
86.7±20.0
(46.8-159.0)
80.5±16.5
(46.9-111.8)
84.6±19.0
(46.8-159)
FVC (% predicted), mean ± SD
range: min-max
89.7±18.6
(46.7-159)
82.0 ±15.7
(45.8-109.5)
87.3±17.9
(45.8-159)
FEV1/FVC (% predicted), mean ± SD
range: min-max
97.8±8.3
(72.9-111.1)
98.4±7.8
(80.5-114.8)
98.0±8.1
(72.9-114.8)
BMI: body mass index; FEV1: forced expiratory volume in the rst second; FVC: forced vital capacity.
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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
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INSPIRATORY MUSCULAR WEAKNESS PINHEIRO
Vol. 50 - 2014 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 5
to reduced tolerance to exercise,6, 37 which restricts
social participation of these individuals.37 However,
there were not found statistical differences regarding
these variables between the community and non-
community ambulators. It appears that these param-
eters are not easily affected by changes at the func-
tional levels.
The participants of the present study demonstrated
reduced maximal respiratory pressure values, which
were similar to those found by Teixeira-Salmela et
al.,3 who reported MIP values of 73 cmH2O and MEP
of 89 cmH2O. However, lower values were found by
Lanini et al.15 (MIP of 55 cmH2O and MEP of 61
cmH2O). Harraf et al.16 and Ward et al.17 also found
lower MEP values (62 cmH2O and 50 cmH2O, re-
spectively) than those observed in the present study.
These differences could be partially explained by
the fact that the above studies investigated stroke
subjects during the acute stages,15-17 and employed
different methodological procedures, which could
also justify these differences.
Despite the reduction in respiratory pressure val-
ues, the participants did not have either respiratory
symptoms nor complaints. According to the ndings
of Hautmann et al.,38 MIP has to be approximately
tion in a large group of stroke subjects at chronic
stages, stratied according to their functional lev-
els. Regarding the breathing patterns and thoraco-
abdominal motions, no between-groups differences
were found. The stroke subjects showed respiratory
muscular weaknesses and signicantly lower pre-
dicted MIP values were observed for the non-com-
munity ambulators, who had lower functional levels.
The only previous study, which analyzed data on
breathing pattern characteristics with a similar sam-
ple, was Teixeira-Salmela et al.,3 who observed simi-
lar values to those found in this study, despite their
reduced sample size. Parreira et al.30 investigated the
breathing patterns and thoracoabdominal motions
of healthy Brazilian individuals, recruited from the
same community as this study. Although the posi-
tioning adopted by the subjects during data collec-
tion was different (supine at 0o) from that of the
present study, all of the other procedures were simi-
lar. Overall, the stroke subjects showed lower values
of VT, VE and VT/TI, higher values of fR, PhRIB,
%CT and similar values for the remaining variables,
when compared to healthy subjects.30, 36 Although
statistical analyses were not performed, the appar-
ent volume reductions in stroke subjects may lead
Table II.—Descriptive data and comparisons of the variables related to the breathing patterns and thoracoabdominal motions
between the community and non-community ambulators.
Variable Community ambulators
(N.=57)
Non-community ambulators
(N.=32)
Total
(N.=89) t or z; P values
VT (mL) 270 (224-341) 261 (195-365) 269 (207-345) 0.36; 0.72
fR (bpm) 17 (15-19) 16 (15-19) 17 (15-19) 0.01; 0.99
VE (L/min) 4.62 (3.98-5.69) 4.51 (3.69-5.56) 4.62 (3.77-5.66) 0.60; 0.55
TI/Tot (%) 0.40 (0.38-0.43) 0.39 (0.36-0.42) 0.40 (0.37-0.42) 1.51; 0.14
VT/TI (mL/s) 195 (165-244) 194 (152-240) 196 (162-239) 0.23; 0.82
%RC 38 (29-49) 43 (34-50) 40 (31-49) 1.32; 0.19
PhRIB (%) 9 (6-13) 8 (6-14) 9 (6-14) 0.35; 0.73
PhREB (%) 12 (8-19) 15 (9-21) 13 (9-19) 0.41; 0.68
PhaseAng (o) 13 (9-19) 12 (7-19) 13 (7-20) 0.17; 0.87
Data were expressed as medians and interquartile intervals. VT: Tidal volume; fR: Respiratory rate; VE: Minute ventilation; TI/Tot: inspiratory duty cycle;
VT/TI: mean inspiratory ow; %RC: rib cage motion; PhRIB: phase relation in inspiration; PhREB: phase relation in expiration; PhaseAng: phase angle.
Table III.—Descriptive data and comparisons of the respiratory pressures between the community and non-community ambula-
tors.
Variable Community ambulators
(N.=57)
Non-community ambulators
(N.=32)
Total
(N.=89) t, P values
MIP (cmH2O) 79.5±30.6 62.8±24.1 73.5±29.5 NA
MIP (% predicted) 79.9±30.8 66.1±23.4 74.4±28.4 -2.10, 0.04
MEP (cmH2O) 87.7±40.1 73.0±31.1 82.4±37.6 NA
MEP (% predicted) 82.8±34.5 75.0±27.7 80.0±32.3 -1.10, 0.25
Data were expressed as means±SD. MIP: maximal inspiratory pressure; MEP: maximal expiratory pressure; NA: not applicable.
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PINHEIRO INSPIRATORY MUSCULAR WEAKNESS
6 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE Vol. 50 - 2014
lationships between the studied variables cannot be
determined. Additionally, low gait speed could be
a consequence of a low cardiorespiratory function,
but this was not assessed. The participants were also
not uniformly stratied into the groups, which may
have inuenced the results. It is important to point
out that only individuals with chronic hemiparesis,
who demonstrated ability to walk independently
were included. Thus, the present ndings cannot be
generalized to subjects with different characteristics,
such as being in the acute or sub-acute stages or
unable to walk.
Conclusions
No signicant differences between the commu-
nity and non-community ambulators were found for
any of the variables related to the breathing pat-
terns and thoracoabdominal motions. Lower respira-
tory strength values were demonstrated by chronic
stroke subjects. When the subjects were stratied
into two functional levels, lower predicted MIP val-
ues were found for the non-community ambulators.
It is possible that interventions involving respiratory
muscular training should be included in stroke reha-
bilitation, especially for individuals with lower func-
tional levels.
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their interventions. In addition, indirect assessments
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when compared with other direct assessments.
Limitations of the study
This study had some limitations. The main limita-
tion is that due to the nature of the study, causal re-
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INSPIRATORY MUSCULAR WEAKNESS PINHEIRO
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One abstract of the present paper was presented at the 8th World
Stroke Congress held in Brasilia, Brazil, October 10-13, 2012.
Funding.—Brazilian National funding agencies: Coordena-
ção de Aperfeiçoamento de Pessoal de Nível Superior (grant
#NF2322/2008), Conselho Nacional de pesquisa (CNPq grant #
501645/2010-1), and Fundação de Apoio a Pesquisa do Estado
de Minas Gerais (FAPEMIG (grant # PPM-00023-10).
Conicts of interest.—The authors certify that there is no conict
of interest with any nancial organization regarding the material
discussed in the manuscript.
Ethical approval.—This study was approved by the ethical re-
view board of the Universidade Federal de Minas Gerais (UFMG),
under the protocol number: ETIC 05380.0.203.000-09.
Received on May 27, 2013.
Accepted for publication on September 25, 2013.
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... Whereas, Lista et al. reported these values as 55.5% and 60.6% 7 ) , respectively. Respiratory muscle strength is also related with cough capacity, which is linked with aspiration pneumonia, walking speed, walking tolerance, and physical activity [7][8][9][10][11][12] . Additionally, respiratory muscle strength has been associated with sarcopenia in older adults 13) ; hence, it may also be associated with stroke. ...
... We found a positive correlation between ΔMIP and Δ6MWT, which implies that the recovery of inspiratory muscle strength may be related to walking ability. For chronic patients with stroke, 6MWT was positively correlated to MIP 7 ) , and non-community ambulators ( walking speed < 0.8 m/s) had lower predicted MIP values than community ambulators ( " 0.8 m / s ) 11 ) . Moreover, inspiratory training can improve cardiopulmonary functions, such as FVC, FEV1.0, vital capacity, forced expiratory flow rate 25-75%, and maximum voluntary ventilation; it could also lead to higher peak oxygen consumption (!O2 peak) in patients with stroke (time since stroke: 5 month) 30) . ...
... Our study suggested that moderate stroke patients recover approximately 70% of the respiratory muscle strength of healthy subjects during the 3 months after stroke onset. Respiratory muscle strength has also been shown to be related to walking speed, walking tolerance, and physical activity 7,11,12 ) . Although it is highly possible that the reduction in respiratory muscle may cause limitations in daily living of stroke patients, the influence on daily living may be alleviated due to the recovery of respiratory muscle strength at 3 months from stroke onset. ...
Article
Objective: To determine the recovery process of respiratory muscle strength during 3 months following stroke, and to investigate the association of change in respiratory muscle strength and physical functions. Additionally, we compared respiratory muscle strength with those of healthy subjects. Method: In this prospective, observational study, 19 stroke patients and 19 healthy subjects were enrolled. Maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), motricity index, trunk control test, 6-minute walk test (6MWT) and functional independence measure were assessed at 1, 2, and 3 months from stroke onset in stroke patients. MIP and MEP were assessed at arbitrary times in healthy subjects. Repeated one-way analysis of variance with Bonferroni post-hoc test was used to compare the change in respiratory muscle strength in each period in stroke patients. Pearson's correlation coefficient was computed for changes in respiratory muscle strength and physical functions. Student's t-test was used to compare respiratory muscle strength between stroke patients at 3 months from onset and healthy subjects. Results: MIP was significantly increased at 3 months compared to 1 month. MEP was significantly increased in 2 months and 3 months, compared to 1 month. MIP changes associated with 6MWT changes. Compared to healthy subjects, MIP and MEP at 3 months were significantly lower in stroke patients. Conclusion: Respiratory muscle strength significantly increased during 3 months following stroke. However, the trend of recovery may be different. MIP changes may associated with walking endurance changes. During 3 months following stroke, respiratory muscle strength did not recover to healthy subjects.
... This condition may interfere with their performances in daily living activities and quality of life (Britto et al., 2011). Previous studies indicated that inspiratory muscle weakness was associated with walking limitations in individuals with stroke (Pinheiro et al., 2014;Lista Paz et al., 2016), so that those, who had greater inspiratory muscle weakness, were non-community ambulators (Pinheiro et al., 2014). ...
... This condition may interfere with their performances in daily living activities and quality of life (Britto et al., 2011). Previous studies indicated that inspiratory muscle weakness was associated with walking limitations in individuals with stroke (Pinheiro et al., 2014;Lista Paz et al., 2016), so that those, who had greater inspiratory muscle weakness, were non-community ambulators (Pinheiro et al., 2014). ...
... In the present study, there was not found a significant correlation between measures of inspiratory strength and walking capacity. This finding differs from that of a previous study (Pinheiro et al., 2014), which found a significant correlation, of moderate magnitude, between inspiratory strength and walking capacity (r = 0.43; P < 0.05) with 30 post-stroke individuals (Pinheiro et al., 2014). However, this study included participants with low-walking capacity and, thus, the observed difference may be explained by the levels of disability of the included participants. ...
Article
Full-text available
The objective of the present study was to investigate if different levels of inspiratory muscle strength would be associated with dyspnea, walking capacity, and quality of life after stroke. For this exploratory study, the dependent outcome was strength of the inspiratory muscles, measured by maximal inspiratory pressure. Individuals with maximal inspiratory pressure ≥80 cmH2O were classified as non-weak, those with maximal inspiratory pressure between 45 and 80 cmH2O were classified as weak, and those with maximal inspiratory pressure ≤45 cmH2O were classified as very weak. Related outcomes included dyspnea, measured by the modified Medical Research Council scale; walking capacity, measured by the 6-minute walk test; and quality of life, measured by the Stroke-Specific Quality of Life scale. Fifty-three participants, who had a mean age of 62 years (SD 12) and a mean time since the onset of the stroke of 20 (SD 17) months were included. Significant differences were found only between the weak/very weak and non-weak groups. The mean differences between the non-weak and weak/very weak participants were -1.8 points (95% confidence interval -2.7 to -0.9) for dyspnea and 55 points (95% confidence interval 22-88) for quality of life. Significant correlations were found between measures of inspiratory strength and dyspnea (r = -0.54; P < 0.01) and quality of life (r = 0.56; P < 0.01). There were not found any significant differences or correlations regarding walking capacity. The findings demonstrated that individuals with stroke, who had weakness of the inspiratory muscles, reported greater dyspnea and worse quality of life, compared with those, who did not have weakness. The results regarding walking capacity remain unclear.
... The sample sizes ranged from 20 to 98 patients with Stroke distributed in two main designs: patients with stroke compared to healthy controls [47,51,57,65,66] and comparisons among clinical profiles in relation to the stroke side [51] and severity related to the ambulation capacity [67], duration from onset (acute vs chronic) [68][69][70], age [71], gender [72] or activity level [73]. ...
... Maximal inspiratory and expiratory pressures were used in seven of the included studies [47,52,66,67,70,71,73]. Spirometric variables like FEV 1 , FVC, VC, FEV 1 /FVC were used in eight studies [51,52,57,65,67,68,70,71], with FEV 1 as the most reported one. ...
... Maximal inspiratory and expiratory pressures were used in seven of the included studies [47,52,66,67,70,71,73]. Spirometric variables like FEV 1 , FVC, VC, FEV 1 /FVC were used in eight studies [51,52,57,65,67,68,70,71], with FEV 1 as the most reported one. MVV was used in only two studies [51,68]. ...
Article
Introduction: The high incidence of respiratory impairments in patients with neurological diseases is recognized, but the design, dosage and effectiveness of interventions to manage them is seen as an ongoing challenge. Areas covered: This article summarizes the evidence regarding the respiratory impairments in major neurological diseases, and how to best manage them. Expert opinion: On the balance of available evidence, respiratory impairments are part of the clinical profile of neurological diseases including Multiple Sclerosis, Stroke and Parkinson Disease, acquiring more importance as the pathologies progress. It is recognized that knowledge gaps remain in some areas of relevance related to respiratory function and further research is required. When considering the therapeutic options, the respiratory training emerges as the approach with most evidence. However, important questions remain unsolved: what kind, how much, and how to best include respiratory interventions is uncertain. At present, respiratory programs also fail to include clinical relevant factors such as ambulation and trunk stability.
... In the case of patients with stroke, respiratory rehabilitation is necessary for the inhalation muscles because the more difficult it is for a patient to walk, the worse the effect on inhalation muscles is [7,8]. Threshold inspiratory muscle training was used as a method to improve inspiratory function in stroke patients [9]. ...
Article
Full-text available
Background and Objectives: Patients with stroke have a forward neck posture due to neurological damage and often have impaired pulmonary function. This study investigated the effect of diaphragmatic breathing with cervical mobilization to improve pulmonary function cervical alignments. Materials and Methods: This study used a one-group pre-test–post-test design including 20 patients with stroke. Two types of cervical joint mobilization techniques, consisting of left and right lateral glide mobilization and posterior–anterior mobilization, were utilized. During joint mobilization, the patients performed diaphragmatic breathing. The measurements were performed immediately after the intervention. Pulmonary function was evaluated using a spirometer to measure the forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF). The craniovertebral angle (CVA) was measured using lateral photographs. Results: After diaphragm breathing with cervical joint mobilization, subjects had significantly increased FEV1, FVC, PEF and CVA. Conclusion: Diaphragm breathing with cervical joint mobilization are possible interventions to increase pulmonary function and improve the craniovertebral angle in patients with stroke. However, a complete conclusion can be reached only after a follow-up study has been conducted with a comparison of more subjects and controls.
... These measurements are taken noninvasively and can be performed conveniently at the patient bedside in any clinical or community setting (Laveneziana et al., 2019). The validity of MIP, MEP, and SNIP measurements as indicators of respiratory muscle function (or impairment) has been established in detailed physiological studies of acute stroke patients and matched healthy control participants (Harraf et al., 2008;Ward et al., 2010) and in observational studies of chronic stroke survivors with differing levels of physical ability (e.g., Pinheiro et al., 2014). Longitudinal MIP and MEP measurements are often required to adjust the intensity of respiratory muscle training to individuals' baseline levels and any incremental improvements during the training period (McConnell, 2013). ...
Article
Full-text available
Background and Purpose Many stroke trials include maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and sniff nasal inspiratory pressure (SNIP) outcome measurements. However, data on agreement and reliability of repeated MIP, MEP, and SNIP measurements in acute and subacute stroke patients are scarce. Methods This study employed a test–retest design. Eighteen patients (seven female) with mean (SD) age 59 (14.5) years were recruited from neurological wards. Median (range) time since first stroke was 50.5 (21–128) days. MIP, MEP, and SNIP were measured repeatedly in three testing sessions (S1–3) conducted within 24 h and following international standards. Intra‐rater agreement between testing sessions was analyzed using the Bland–Altman method. Test–retest reliability was analyzed using intra‐class correlation coefficient (ICC). Association between individual measurement variability, time poststroke, and level of stroke impairment was analyzed using Spearman's rho. Results Mean difference and 95% limits of agreement for MIP were −0.40 (−23.02, 22.22) cmH2O between S1 and S2, and 2.14 (−12.79, 16.99) cmH2O between S2 and S3; for MEP, −4.56 (−29.01, 19.90) cmH2O between S1 and S2, and 0.29 (−24.28, 24.87) cmH2O between S2 and S3; and for SNIP, −10.56 (−38.48, 17.37) cmH2O between S1 and S2, and −6.06 (−27.32, 15.20) cmH2O between S2 and S3. ICCs for MIP, MEP, and SNIP were ≥0.9 throughout. There were no strong correlations between individual measurement variability and time poststroke or level of stroke impairment. Discussion MIP, MEP, and SNIP in acute and subacute stroke patients show good test–retest reliability for group averages; however, absolute agreement can vary considerably for some individuals.
... Stroke patients usually exhibit a decrease in the chest wall movements on the paretic side [5], reduced respiratory muscle activity [6], and decreased pulmonary function [7]. Particularly, lower functional levels in stroke patients lead to inspiratory muscle weakness more frequently than expiratory muscle weakness [8]. Since the decrease in the inspiratory capacity in the chronic stage occurs due to rib cage contracture [9], intervention methods to address restrictive respiratory dysfunction in stroke patients should be designed to increase the total volume of the ribcage [10] and to strengthen the inspiratory muscles [11]. ...
Article
Full-text available
After stroke, limited ribcage movement may lead to impaired respiratory function. Combining threshold inspiratory muscle training with rib cage joint mobilization has been shown to enhance the recovery of respiratory function in patients with stroke. The present study investigated whether the combination of rib cage joint mobilization and inspiratory muscle training would improve chest expansion, inspiratory muscle activity, and pulmonary function after stroke. Thirty stroke patients were recruited and randomly assigned to one of the two groups, namely 6-week rib cage joint mobilization with inspiratory muscle training (experimental group) or inspiratory muscle training alone (control group). Outcome measures included upper and lower chest expansion, activity of accessory inspiratory muscles (latissimus dorsi (LD) and upper trapezius (UT)), and pulmonary function (forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and peak expiratory flow (PEF)). All evaluations were conducted at baseline and after 6 weeks of inspiratory muscle training. Significant increases were observed in upper and lower chest expansion, LD and UT muscle activity, FVC, FEV1, and PEF in both the groups. Upper and lower chest expansion and muscle activity of UT and LD were significantly higher in the experimental group than in the control group. No significant differences were observed in FVC, FEV1, and PEF between the groups. Inspiratory muscle training is effective in improving chest expansion, inspiratory muscle activity, and pulmonary function after stroke. The addition of rib cage joint mobilization further increases chest expansion and inspiratory muscle activity.
... 3 Inspiratory muscle training has been used for stroke respiratory rehabilitation because non-community dwelling stroke survivors show weaker inspiratory muscles than expiratory muscles. [4][5][6] Inspiratory muscle training can improve dynamic balance ability. 7 Recently taping methods have been introduced in the respiratory rehabilitation of stroke patients. ...
... Studies evaluating muscle respiratory strength in sedentary and physically active elderly women [22,23], verified by MIP and MEP, were higher in the participants-a fact also observed in the literature where it was related that physical exercises in general, even if not oriented to the respiratory muscles and/or pulmonary function, resulted in better respiratory muscle performance [22,24,25]. This allows us to explain in our study that the 64-year-old patient, who regularly practices short walks, reaches the predicted values according to age. ...
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The International Classification of Functioning, Disability and Health (ICF) was published by the World Health Organization in 2001 to provide a standardized description of health and health-related states (WHO 2001). The ICF classifies functioning and disability associated with health conditions at the levels of body/body parts, the whole person and the person in their environmental context. The ICF is a multipurpose classification that can be used by different disciplines and sectors to provide a scientific basis and common language for the description of health and health related states, outcomes and determinants. ICF data enables comparison across countries, disciplines and time, and provides a coding system for health information (WHO 2001). The ICF is not a tool for assessment, but rather it provides the basis for such tools as well as a framework to which these tools can be related, thus building up a more complete picture of how a person lives. This paper will provide an overview of this international classification, give examples of its use in national data collections as well as detail its relevance to ergonomic research and practice.
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A variety of methods for subject selection and test procedures have been used for the determination of normal values and reference equations for maximal inspiratory pressure (MIP). In the cross-sectional study described here, we made MIP measurements on 668 men and women in the Baltimore Longitudinal Study of Aging (BLSA), using a standardized electronic procedure. Results were combined with spirometric and anthropometric measurements. After subjecting them to rigorous health screening, we analyzed a well-defined, healthy subgroup of 139 men and 128 women with a wide age range (20 to 90 yr), using multiple linear regression, for the purpose of determining the effect of age, other correlates, normal values, and gender-specific reference equations for MIP. The gender effect was strong, with the average MIP values of the men being about 30% higher than those of the women (101 cm H2O and 72 cm H2O, respectively). The reference equation for men is: MIP ± standard error of the estimate (SEE) = 126 − 1.028 × age + 0.343 × weight (kg) ± (22.4); and for women: MIP ± SEE = 171 − 0.694 × age + 0.861 × weight (kg) − 0.743 × height (cm) ± (18.5). These equations may be used for the assessment of inspiratory muscle strength.
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Study objectives To quantify thoracoabdominal asynchrony (TAA) in children during anesthesia, and to measure the effect of continuous positive airway pressure (CPAP) on TAA, tidal volume (Vt), and minute ventilation ( V˙e). Design Prospective, nonrandomized, controlled study. Setting Operating room of a university children's hospital. Participants Ninety children aged 2 to 9 years scheduled for elective outpatient day surgery who were enrolled prospectively. Methods Each subject was anesthetized with sevoflurane 3% in equal parts O2 and N2O while breathing spontaneously through a facemask. Respiratory impedance plethysmography was used to calculate TAA indexes (phase angle [PA], phase relation in inspiration [PhRIB], phase relation in expiration, phase relation in total breath [PhRTB], and ratio of the inspiratory time to the total duration of the respiratory cycle [Ti/Ttot]), Vt, and V˙e. Tidal gas flows were measured with a dual-hotwire anemometer with the sensor inserted between the facemask and the Y-piece of the anesthetic breathing circuit. This enabled the volume calibration of the respiratory impedance plethysmography equipment. The following conditions were compared: (1) no CPAP, (2) CPAP of 5 cm H2O, and (3) CPAP of 10 cm H2O. Results Eighty-one children completed the study protocol. All measurements of TAA with an inspiratory component (PA, PhRIB, PhRTB, and Ti/Ttot) decreased significantly from baseline with the addition of CPAP to the circuit. Application of CPAP of 10 cm H2O decreased significantly mean Vts and V˙es compared with CPAP of 5 cm H2O and no CPAP. There were no differences in TAA for all conditions when comparing children scheduled for adenoidectomy with other surgical procedures. Conclusions With spontaneously breathing anesthetized children, TAA decreases with the application of CPAP. CPAP of 5 cm H2O was as effective as CPAP of 10 cm H2O in reducing PA, PhRIB, PhRTB, and Ti/Ttot. However, CPAP of 10 cm H2O also caused a significant decrease in Vt and V˙e.