Effect of Chest Proprioceptive Neuromuscular Facilitation Combined with Abdominal Muscle Stimulation on Respiratory Function in Tetraplegia
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International Journal of Research and Review
Vol.7; Issue: 5; May 2020
Website: www.ijrrjournal.com
Original Research Article E-ISSN: 2349-9788; P-ISSN: 2454-2237
Effect of Chest Proprioceptive Neuromuscular
Facilitation Combined with Abdominal Muscle
Stimulation on Respiratory Function in Tetraplegia
Apurva Chatterjee1, Jyoti2, Mohit Kumar Dahiya3
1
Post Graduate Research Scholar, ISIC Institute of Rehabilitation Science, New Delhi
2
Assistant Professor, Sharda University, Noida.
3
Assistant Professor, Sharda University, Noida.
Corresponding Author: Apurva Chatterjee
ABSTRACT Key words: Chest PNF, Abdominal muscle
stimulation, breathing exercise, tetraplegia,
Purpose: The purpose of this study was to respiratory function.
determine whether there was an effect of chest
proprioceptive neuromuscular facilitation 1. INTRODUCTION
combined with abdominal muscle stimulation on Spinal cord injury (SCI) can be one
respiratory function in tetraplegia of the most catastrophic experiences for the
Subjects and Methods: Twenty- seven individual who sustains it. It is a life
tetraplegic subjects were randomly assigned to a
changing event that can have a profound
PNF+ AS group (n=15) or a BRE+AS group
(n=12). The PNF+ AS group received chest effort on personal, social as well as
PNF along with abdominal muscle stimulation economical aspect of a person’s life. Injury
for 30 minutes, 4 times a week. Subjects were to the cervical cord has an adverse effect to
assessed pre-test and post- test by measurement the respiratory function. As SCI results in
of respiratory function (Forced vital capacity, muscle paralysis that is determined by the
Forced expiratory volume in 1 second and peak neurologic level and completeness of the
expiratory flow rate), respiratory muscle injury, higher neurologic level and more
strength (Maximum inspiratory pressure and complete injury will result in a greater
Maximum expiratory pressure) and dyspnoea degree of respiratory muscle dysfunction
(modified Borg Scale). (P,2003).1
Results: After 3 weeks of intervention, pre and
Respiratory complications are the
post intervention analysis for both groups
showed a significant improvement in scores of most frequent cause of morbidity and
FVC (% pred), FEV1 (% pred), PEF (% pred), mortality in patients with tetraplegia ((H,
MIP, MEP and modified Borg scale. Between 2008).2
group analysis showed significant improvement Tetraplegics have an alteration in
in FVC (% pred) at (p = .01), FEV1 (% pred) at their breathing mechanics because of the
(p = .04), PEF (% pred) at (p = .04), MIP at (p = abnormally high extra pulmonary work of
.001), MEP at (p = .001) and modified Borg breathing.
scale at (p = .001) People with tetraplegia who have a
Conclusion: This study concludes that there lesion at a lower level are typically able to
was a significant improvement in respiratory breathe voluntarily and are mostly
function, respiratory muscle strength and
independent from mechanical ventilation.
dyspnoea using chest proprioceptive
neuromuscular facilitation combined with Their breathing capacity is still
abdominal muscle stimulation for tetraplegia. compromised due to paralysis of inspiratory
and expiratory muscles. Because the
paralysis also affects the abdominal wall
International Journal of Research and Review (ijrrjournal.com) 332
Vol.7; Issue: 5; May 2020Apurva Chatterjee et.al. Effect of chest proprioceptive neuromuscular facilitation combined with abdominal
muscle stimulation on respiratory function in tetraplegia
muscles which are the main expiratory resistive exercises through the PNF
muscles, their capacity to forcefully expire respiration pattern.
air, e.g. during cough, is also reduced. Newer studies showed that PNF
Electrical Stimulation (ES) is the respiration exercise can increase pulmonary
application of a train of electrical pulses to a functions in normal adults, elderly
motor nerve, causing contraction of the population and stroke patients.
associated muscle. ES can be used in health The purpose of this study is to
care for one of three purposes: to aid evaluate the effect of chest PNF along with
diagnosis, as a therapeutic tool, and/or to abdominal stimulation on pulmonary
restore lost or damaged function. (Rushton, functions, cough, respiratory muscle
1997) 3 strength and dyspnoea in tetraplegia.
It has been shown that stimulation of
abdominal muscles during expiration can 2. MATERIALS & METHODS
improve respiratory function. This This study was conducted in Indian
technique can enhanced cough since the Spinal Injuries centre, located in New Delhi,
contraction of the stimulated abdominal India. The average age of the subjects was
muscles leads directly to an increase in 32 years. All of the protocols used in this
respiratory pressure and consequently to study were approved by the Ethical
improved expiratory flow. It also causes a Committee of Indian Spinal Injuries Centre,
reduction of lung volume below the New Delhi. Before participation, the
functional residual capacity, and the procedure, risks, and benefits were
subsequent passive recoil during inspiration explained to all the subjects, who gave their
can result in an increase of tidal volume. informed consent. All the subjects were
Stimulation of the abdominal muscles is randomly allocated using an online
typically used in tetraplegic individuals with randomiser, to the Chest PNF combined
spontaneous breathing, although this with abdominal stimulation group
technique has been applied in individuals (PNF+AS, n = 15) or breathing exercise
who are unable to breathe spontaneously. combined with abdominal stimulation group
The abdominal muscles are typically (BRE+AS, n = 12).
stimulated through surface electrodes which The criteria for the subject selection
are easy to apply, and stimulation results in included complete and incomplete
a uniform, well defined muscle response. tetraplegics with level of injury between C5-
Proprioceptive Neuromuscular C8; subjects between the age of 18-60
Facilitation (PNF) is a stretching technique years; subjects with upper motor neuron
that employs to improve muscle elasticity paralysis of abdominal muscles; subjects
and has been shown to have a positive effect who were medically stable and willing to
on active and passive range of motions. participate. The exclusion criteria were any
Recent research has been focused on the recent complication associated with SCI
efficiency of the intervention on certain such as autonomic dysreflexia, orthostatic
outcome counts, such as passive range of hypotension, bed sores, etc, which might
motion (PROM), active range of motion interfere with the treatment; subjects with
(AROM), peak torque and muscular premorbid respiratory conditions such as
strength. (Hindle, 2012) 4 asthma, COPD, restrictive disease of the
A study conducted by Dietz et al lungs; subjects with ventilator support or
indicated that muscle strength can be tracheostomy; subjects who were current
improved through three dimensional spiral smoker i.e. those who currently smoked
large scale resistive exercises using PNF. cigarettes, cigars, and/or pipes or those who
(Kim, 2015)5 Studies have also examined had quit for ≤ 1 year; history of any other
the improvement of respiratory functions neurological condition (seizures, brain
induced by direct respiratory muscle injury or stroke) and psychiatric conditions
International Journal of Research and Review (ijrrjournal.com) 333
Vol.7; Issue: 5; May 2020Apurva Chatterjee et.al. Effect of chest proprioceptive neuromuscular facilitation combined with abdominal
muscle stimulation on respiratory function in tetraplegia
(dementia, Alzheimer disease), which may The intensity of the stimulation was
interfere with the treatment and any increased till a visible contraction was seen
musculoskeletal conditions like rib fracture in the abdominal musculature. The pulse
which might interfere with the treatment and duration was adjusted manually throughout
any other contraindications to ES such as the experiment to avoid progressive muscle
cardiac pacemaker, local skin infection, etc. fatigue. The subjects were told that they
The instruments needed were a 4 might feel a tingling sensation or a
channel stimulation unit with 8 carbon squeezing of abdominal muscles. They were
electrodes, spirometer and a manometer. asked to immediately report, in case they
Modified Borg Scale was used to measure felt any abnormal sensation and in those
dyspnoea. cases the treatment was terminated.
Procedure for Group A (PNF+AS) Procedure for Group B (BRE+AS)
consisted of chest PNF and abdominal consisted of breathing exercise and
stimulation. Chest PNF was administered abdominal muscle stimulation. Breathing
simultaneously along with abdominal exercise was administered simultaneously
muscle stimulation. The subjects were made along with abdominal muscle stimulation.
to lie down in supine and the entire The subjects were instructed to breathe in
procedure was explained. The therapist slowly and deeply through the nose, while
placed his hands on the lateral surface on keeping the shoulders relaxed and the upper
both side of the 8th, 9th, 10th and 11th ribs chest quiet, allowing the abdomen to rise.
of the subject. For inspiration, the subjects At the end of inspiration, the subjects had to
were instructed to “take a deep breath”. As hold the breath for five seconds and exhales
the subjects’ ribs moved upward and slowly through the mouth.
laterally, the therapist assisted the The spirometry was performed for
movement of the ribs. A maximum FVC, FEV1 and PEF with KoKo® Legend
inspiration, the subjects were instructed to Portable spirometer using American
hold their breath for 5 seconds. At Thoracic Society standards. The MIP and
maximum expiration the therapist applied MEP were checked with a manometer using
pressure on the lower ribs diagonally in a the Black and Hyatt model. Each subject
caudal and medial direction, with both the was seated and made to wear a nose-clip.
hands. As the subjects breathed out, the The MEP was measured near total lung
therapist shook the region to discharge the capacity (TLC) after a maximal inspiration.
remaining air from the lungs (SeoJ, 2014).6 The MIP was measured near residual
Abdominal muscle stimulation was given to volume (RV) after a maximal expiration.
subjects in the supine position. Abdominal The pressures measured were maintained
hair was shaved off and the area was for at least 1 second. The determination was
cleaned with water and cotton to remove repeated three times and the average value
dust and oil. Four pair of electrodes were was used in the subsequent calculations.
applied around the umbilicus, where two The dyspnoea was quantified before training
channels were used to stimulate the rectus and at the end of 3 weeks using the
abdominals and the other two channels were Modified Borg Scale. Values of FVC, FEV1
used to stimulate the internal and the and PEF were recorded as percentage
external oblique on both sides of the predicted (% pred) and the values of MIP,
abdomen. MEP were recorded in cm H20.
Parameters for stimulation were 2: DATA ANALYSIS
Frequency – 50 Hz Data was analysed using SPSS
Intensity – constant current between 30 and version 21 for Windows (SPSS Inc.,
100 mA Chicago, Illinois). Out of 30 subjects there
Pulse duration – 100-400 µs were 3 drop outs therefore analysis was
done for 27 subjects who completed the
International Journal of Research and Review (ijrrjournal.com) 334
Vol.7; Issue: 5; May 2020Apurva Chatterjee et.al. Effect of chest proprioceptive neuromuscular facilitation combined with abdominal
muscle stimulation on respiratory function in tetraplegia
study. Sample size was determined through Group A and 12 in Group B) at 0.05 level of
power calculation based on previous studies significance was calculated. 30 subjects
for abdominal muscle stimulation in SCI were recruited to allow 10% dropouts. The
with an estimated effect size of 0.08. An demographic details of Group A and Group
overall sample size of 27 participants (15 in B are given in Table 2.1.
Table2.1: Demographic details of Group A and Group B
The physical characteristics of the Group A and Group B were analysed by unpaired t test
(table 2.2).
Table 2.2: Comparison of pre-intervention scores between Group A and Group B
The mean change scores were calculated as There were statistically significant
the difference between post and pre test difference between pre and post results
scores and an independent t test was used to within both groups. Mean and standard
test the difference in the changed scores deviations are mentioned for each group in
between two groups. Paired t test was used table 3.1, table 3.2, respectively. The mean
to analyse within group difference. A level change of scores of Group A and Group B
of significance was set at 0.05. revealed significant changes for FVC (p =
0.01), FEV1 (p = 0.04), PEF (p = 0.04), MIP
3. RESULT
International Journal of Research and Review (ijrrjournal.com) 335
Vol.7; Issue: 5; May 2020Apurva Chatterjee et.al. Effect of chest proprioceptive neuromuscular facilitation combined with abdominal
muscle stimulation on respiratory function in tetraplegia
(p = 0.001), MEP (p = 0.001) and MBS (p = 0.001) as shown in table 3.3
Table 3.1: Comparison of pre – intervention and post – intervention scores of Group A
Table3.2: Comparison of pre – intervention and post -intervention scores of Group B
Table3.3: Comparison of post – intervention mean change scores of Group A and Group B
4. DISCUSSION respiratory functions, respiratory muscle
Respiratory dysfunction due to strength and dyspnoea.
paresis or paralysis of respiratory muscles is Cervical spinal cord injury patients
common among tetraplegics. In this study, from neurological level C5 to C8 were
chest PNF combined with abdominal recruited post 3 months after injury, to
muscle stimulation was used to improve
International Journal of Research and Review (ijrrjournal.com) 336
Vol.7; Issue: 5; May 2020Apurva Chatterjee et.al. Effect of chest proprioceptive neuromuscular facilitation combined with abdominal
muscle stimulation on respiratory function in tetraplegia
minimize changed due to spontaneous resistance in order to induce irradiation can
recovery in the acute phase of injury. result in facilitation.
A total of 30 subjects consented to Gellhorn and Loofbourroe showed
participate in the study. Out of these, there that a muscle’s response to cortical
were 3 drop outs, 2 subjects dropped out stimulation increases with resisted muscle
because of illness and 1 subject could not contraction. Studies in the past explained
continue the 3 week protocol. about the neuromuscular mechanism in
With technical advancement and detail, whereby it was observed that sensory
improved care, survival rates for tetraplegic inputs from the periphery leads to stronger
patients have increased. In tetraplegics, excitation of the cortical areas. This caused
respiratory insufficiency due to paresis or a variation in the threshold of the motor
paralysis of respiratory muscles is neuron activation (D,2013).9
commonly seen. Factors such as Respiratory muscle strength and
concomitant trauma of lung tissue and endurance is seen to be improved after
thorax, spasticity of the trunk muscles and resistive training and it could be a result of
the degree of preservation of expiratory change in the individual muscle fibre’s
muscles may play an important role. In oxidative capacity of the diaphragm. The
addition, over time the inability to inspire easily fatigable fibres change to more
deeply (due to weak inspiratory muscle fatigue resistant fibres (A, 1998).10 Increase
strength) may lead to a cascade of reduced in FVC, MIP and MEP are attributable to
compliance of lung and thorax, lowered the fact that when the subject was breathing
reserve capacity of the respiratory pump, in, the activity of the diaphragm and other
increased susceptibility for medical assistant inspiratory muscles was promoted
complications recurrent respiratory by the therapist. Pushing both sides of the
infections and gradual deterioration of lung subjects’ chest wall towards the head creates
tissue (J., 2010).8 a spiral movement which increases the intra
According to Mateus et al (SRM, - abdominal pressure. This leads to resisted
2007) 7, the most important pulmonary inspiration. When the subjects breathe out,
function change is a nonparenchymatous the chest wall mobility was increased as
pulmonary restriction, owing to weakness or much as possible by giving assistive
paralysis of respiratory muscles, hence the movements with the medial gathering of the
aforementioned factors of inspiratory lower chest wall.
muscle function, lung volumes and cough Resisted training causes an
flow may have a complex and cumulative improvement in respiratory muscle strength
nature. which reduces dyspnoea.
To maintain adequate gas exchange Troyer et al, states that intercostal
during quite breathing and in situations of muscles have an important function in
increased respiratory demand, preserved stabilizing the chest wall as these muscles
inspiratory muscle strength is essential. prevent the inward collapse of a passive rib
It is possible that chest PNF could cage(SeoJ, 2014).6
had affected the chest wall compliance Pink et al showed that unexercised
which is reduced in tetraplegics. Chest PNF muscles become active during resisted
could have worked by stimulating the upper extremity PNF patterns in normal
proprioceptors by facilitating the subjects. Loverdige et al also showed
neuromuscular mechanism. Kabat reported improvement in MIP after ventilator muscle
that when employing facilitating techniques endurance training.
with resistance, a greater motor response All the findings are in accordance
can be achieved. A number of factors such with the previous work done on abdominal
as application of stretch, use of particular muscle stimulation (Zupan, 1997) (Jaeger,
movement patterns and use of maximal 1993) (Linder, 1993) 2, 11-13. They stated that
International Journal of Research and Review (ijrrjournal.com) 337
Vol.7; Issue: 5; May 2020Apurva Chatterjee et.al. Effect of chest proprioceptive neuromuscular facilitation combined with abdominal
muscle stimulation on respiratory function in tetraplegia
there are effects of abdominal muscle leading to large inter- subject variability.
stimulation on pulmonary function test Despite this complex mix, the results show
results. that FVC, FEV1, PEF, MIP, MEP and MBS
A possible explanation for the improved in all patients.
increases may be due to increased The results have shown that both
abdominal muscle mass and tone which has chest PNF combined with abdominal
shown to be reduced in tetraplegia. muscle stimulation and breathing exercises
Abdominal muscles are powerful with abdominal muscle stimulation are
muscles for expiration which plays an effective in improving respiratory function,
important role in functions such as forced respiratory strength, and dyspnoea. More
expiration and coughing. Exhalation is a significant improvement was seen in MIP,
passive process occurring in the absence of MEP and dyspnoea in the group which
thoracic or abdominal muscle contraction. received chest PNF combined with
However, as minute ventilation increases, abdominal muscle stimulation.
the abdominal muscles contract during
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