Respiratory muscle weakness and respiratory muscle training in severely disabled multiple sclerosis patients

Effects of home-based respiratory muscle training in children and adolescents with chronic lung disease

OBJECTIVE

Respiratory muscle weakness is a functional repercussion of chronic lung disease (CLD). The objective of this study was to assess the effects of home-based respiratory muscle training (RMT) in children and adolescents with CLD or neuromuscular disease (NMD).

METHODS

This was a quasi-experimental study involving children and adolescents with CLD or NMD. Before and after 6 months of home-based RMT, we measured respiratory muscle strength (MIP and MEP), PEF, and peak cough flow (PCF). We made statistical comparisons between the pre-RMT and post-RMT values, as well as evaluating the correlation between the duration and effect of RMT.

RESULTS

The study included 29 patients, with a mean age of 12 years (range, 5-17 years), of whom 18 (62.1%) were male. The CLD group comprised 11 patients (37.9%), and the NMD group comprised 18 (62.1%). The mean duration of the RMT was 60 weeks (range, 46-90 weeks) in the CLD group and 39 weeks (range, 24-89 weeks) in the NMD group. In comparison with the pre-RMT values, the post-RMT values for MIP and MEP were significantly higher in both groups, whereas those for PEF and PCF were significantly higher only in the NMD group. We found no correlation between the duration and the effect of RMT.

CONCLUSIONS

Home-based RMT appears to be an effective strategy for increasing respiratory muscle strength in children and adolescents with CLD or NMD, although it increased the ability to cough effectively only in those with NMD.

Treatment of progressive multiple sclerosis: what works, what does not, and what is needed

Disease-modifying drugs have mostly failed as treatments for progressive multiple sclerosis. Management of the disease therefore solely aims to minimise symptoms and, if possible, improve function. The degree to which this approach is based on empirical data derived from studies of progressive disease or whether treatment decisions are based on what is known about relapsing-remitting disease remains unclear. Symptoms rated as important by patients with multiple sclerosis include balance and mobility impairments, weakness, reduced cardiovascular fitness, ataxia, fatigue, bladder dysfunction, spasticity, pain, cognitive deficits, depression, and pseudobulbar affect; a comprehensive literature search shows a notable paucity of studies devoted solely to these symptoms in progressive multiple sclerosis, which translates to few proven therapeutic options in the clinic. A new strategy that can be used in future rehabilitation trials is therefore needed, with the adoption of approaches that look beyond single interventions to concurrent, potentially synergistic, treatments that maximise what remains of neural plasticity in patients with progressive multiple sclerosis.

Functional outcomes associated with expiratory muscle strength training: narrative review

This review presents the available evidence for the effects of expiratory muscle strength training (EMST) with the use of a pressure threshold device. The investigators used computerized database searches for studies reporting the outcomes of pressure threshold EMST published after 1994. A total of 24 selected articles presented outcomes related but not limited to respiratory function, such as speech, swallow, voice, and cough function in persons with neurologic conditions such as Parkinson disease, multiple sclerosis, and Lance-Adams syndrome; in persons with respiratory diseases, such as chronic obstructive pulmonary disease; and in healthy young adults and sedentary and active elderly. Several studies demonstrated promising outcomes of EMST as a non-task-specific training for airway protection in persons with dysphagia secondary to neuromuscular impairments; however, further research is needed to confirm and generalize the reported findings.

Measures of respiratory function correlate with fatigue in ambulatory persons with multiple sclerosis

PURPOSE

This article examines the association between measures of respiratory muscle function and fatigue in individuals with mild-to-moderate disability multiple sclerosis (MS).

METHODS

This was a cross-sectional study of 37 ambulatory volunteers with MS (28 F/9 M, 52.7 ± 10.2 years, Expanded Disability Status Scale [EDSS] = 3.5 ± 1.9). No patients withdrew from the study. Primary outcome variables included measures of respiratory function: maximal inspiratory (MIP) and expiratory pressures (MEP), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), maximal voluntary ventilation (MVV₁₂); and a self-reported measure of fatigue: the Modified Fatigue Impact Scale (MFIS). Secondary measures included 6-min walking test (6MWT), a timed stair climb, the Short Form (SF)-36, the Epworth Sleepiness Scale and the Physical Activity and Disability Scale (PADS).

RESULTS

Significant correlations were shown between expiratory muscle strength (MEP) and the MFIS total (p < 0.03, r = -0.362) and between MEP and physical fatigue scores (p < 0.03, r = -0.360), as well as between MVV₁₂ percent predicted (respiratory muscle endurance) and both the 6MWT (p = 0.045, r = 0.346) and the Epworth Sleepiness Scale (p = 0.006, r = 0.447).

CONCLUSIONS

Respiratory muscle performance is correlated with perceived fatigue (MFIS), whereas respiratory endurance correlated to reductions in physical function and sleep quality among individuals with mild-to-moderate severity MS. Implications for Rehabilitation Multiple sclerosis (MS) results in peripheral and respiratory muscle weakness and affected individuals report fatigue as one of their most disabling symptoms. Expiratory muscle strength was correlated with self-reported physical fatigue, while respiratory muscle endurance was correlated with functional performance and sleepiness. Respiratory muscle strength was not correlated with lung spirometry testing. These findings highlight the importance of considering the effects of respiratory muscle weakness when evaluating causes of fatigue among individuals with mild-to-moderate MS.

Respiratory dysfunction in multiple sclerosis

Respiratory dysfunction frequently occurs in patients with advanced multiple sclerosis (MS), and may manifest as acute or chronic respiratory failure, disordered control of breathing, respiratory muscle weakness, sleep disordered breathing, or neurogenic pulmonary edema. The underlying pathophysiology is related to demyelinating plaques involving the brain stem or spinal cord. Respiratory complications such as aspiration, lung infections and respiratory failure are typically seen in patients with long-standing MS. Acute respiratory failure is uncommon and due to newly appearing demyelinating plaques extensively involving areas of the brain stem or spinal cord. Early recognition of MS patients at risk for respiratory complications allows for the timely implementation of care and measures to decrease disease associated morbidity and mortality.

Respiratory muscle training on pulmonary and swallowing function in patients with Huntington's disease: a pilot randomised controlled trial

OBJECTIVE

To examine the effects of 4-month of respiratory muscle training on pulmonary and swallowing function, exercise capacity and dyspnoea in manifest patients with Huntington's disease.

DESIGN

A pilot randomised controlled trial.

SETTING

Home based training program.

PARTICIPANTS

Eighteen manifest Huntington's disease patients with a positive genetic test and clinically verified disease expression, were randomly assigned to control group (n=9) and training group (n=9).

INTERVENTION

Both groups received home-based inspiratory (5 sets of 5 repetitions) and expiratory (5 sets of 5 repetitions) muscle training 6 times a week for 4 months. The control group used a fixed resistance of 9 centimeters of water, and the training group used a progressively increased resistance from 30% to 75% of each patient's maximum respiratory pressure.

MAIN MEASURES

Spirometric indices, maximum inspiratory pressure, maximum expiratory pressure, six minutes walk test, dyspnoea, water-swallowing test and swallow quality of life questionnaire were assessed before, at 2 and 4 months after training.

RESULTS

The magnitude of increases in maximum inspiratory (d=2.9) and expiratory pressures (d=1.5), forced vital capacity (d=0.8), forced expiratory volume in 1 second (d=0.9) and peak expiratory flow (d=0.8) was substantially greater for the training group in comparison to the control group. Changes in swallowing function, dyspnoea and exercise capacity were small (d ≤ 0.5) for both groups without substantial differences between groups.

CONCLUSIONS

A home-based respiratory muscle training program appeared to be beneficial to improve pulmonary function in manifest Huntington's disease patients but provided small effects on swallowing function, dyspnoea and exercise capacity.

Association between peripheral muscle strength and daily physical activity in patients with COPD: a systematic literature review and meta-analysis

BACKGROUND

Patients with chronic obstructive pulmonary disease have skeletal muscle dysfunction and reduced daily physical activity (PA). Whether the reduction in quadriceps strength (QS) is directly linked to physical inactivity remains to be elucidated.

METHODS

A systematic review and a meta-analysis were conducted to determine the potential relationship between QS and the level of PA. The overall estimate of the correlation coefficient (r*) was calculated, and a subgroup analysis was conducted to analyze the association between QS and indices of PA separately.

RESULTS

A total of 8 studies were included in the meta-analysis. The overall association between QS and PA was low but highly significant (r * = 0.288, 95% CI = 0.180-0.389; P < .001). In the subgroup analysis, the association between QS and the number of steps per day was low (r = 0.260; 95% CI = 0.060-0.440) and the association between QS and the time spent walking was moderate (r = 0.418; 95% CI = 0.229-0.576).

CONCLUSIONS

Peripheral muscle strength is associated with PA as assessed by the number of steps per day and the time spent walking in patients with chronic obstructive pulmonary disease. The overall association between QS and PA was low to moderate and highly significant.

Inspiratory high frequency airway oscillation attenuates resistive loaded dyspnea and modulates respiratory function in young healthy individuals

Direct chest-wall percussion can reduce breathlessness in Chronic Obstructive Pulmonary Disease and respiratory function may be improved, in health and disease, by respiratory muscle training (RMT). We tested whether high-frequency airway oscillation (HFAO), a novel form of airflow oscillation generation can modulate induced dyspnoea and respiratory strength and/or patterns following 5 weeks of HFAO training (n = 20) compared to a SHAM-RMT (conventional flow-resistive RMT) device (n = 15) in healthy volunteers (13 males; aged 20–36 yrs). HFAO causes oscillations with peak-to-peak amplitude of 1 cm H₂O, whereas the SHAM-RMT device was identical but created no pressure oscillation. Respiratory function, dyspnoea and ventilation during 3 minutes of spontaneous resting ventilation, 1 minute of maximal voluntary hyperventilation and 1 minute breathing against a moderate inspiratory resistance, were compared PRE and POST 5-weeks of training (2×30 breaths at 70% peak flow, 5 days a week). Training significantly reduced NRS dyspnoea scores during resistive loaded ventilation, both in the HFAO (p = 0.003) and SHAM-RMT (p = 0.005) groups. Maximum inspiratory static pressure (cm H₂O) was significantly increased by HFAO training (vs. PRE; p<0.001). Maximum inspiratory dynamic pressure was increased by training in both the HFAO (vs. PRE; p<0.001) and SHAM-RMT (vs. PRE; p = 0.021) groups. Peak inspiratory flow rate (L.s⁻¹) achieved during the maximum inspiratory dynamic pressure manoeuvre increased significantly POST (vs. PRE; p = 0.001) in the HFAO group only. HFAO reduced inspiratory resistive loading–induced dyspnoea and augments static and dynamic maximal respiratory manoeuvre performance in excess of flow-resistive IMT (SHAM-RMT) in healthy individuals without the respiratory discomfort associated with RMT.

Effect of expiratory resistive loading in expiratory muscle strength training on orbicularis oris muscle activity

[Purpose] The purpose of this study was to elucidate the effect of expiratory resistive loading on orbicularis oris muscle activity. [Subjects] Subjects were 23 healthy individuals (11 males, mean age 25.5±4.3 years; 12 females, mean age 25.0±3.0 years). [Methods] Surface electromyography was performed to measure the activity of the orbicularis oris muscle during maximum lip closure and resistive loading at different expiratory pressures. Measurement was performed at 10%, 30%, 50%, and 100% of maximum expiratory pressure (MEP) for all subjects. The t-test was used to compare muscle activity between maximum lip closure and 100% MEP, and analysis of variance followed by multiple comparisons was used to compare the muscle activities observed at different expiratory pressures. [Results] No significant difference in muscle activity was observed between maximum lip closure and 100% MEP. Analysis of variance with multiple comparisons revealed significant differences among the different expiratory pressures. [Conclusion] Orbicularis oris muscle activity increased with increasing expiratory resistive loading.

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

Respiratory muscle training for respiratory deficits in neurodegenerative disorders: a systematic review

BACKGROUND

Studies of the impact of respiratory muscle training (RMT) on central neurodegenerative pathologies have been aimed at improving pulmonary function. However, there is no certainty about the effectiveness of RMT in patients affected by these groups of disorders. The purpose of this review was to assess the evidence regarding the efficacy of inspiratory muscle training (IMT) and expiratory muscle training (EMT) on respiratory function in patients with neurodegenerative disorders of the CNS.

METHODS

A comprehensive search from 1990 to September 2012 on MEDLINE, Physiotherapy Evidence Database (PEDro), PubMed, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases was made. Studies reporting on IMT and EMT in patients with neurodegenerative diseases were included. The selected studies were abstracted using a standardized data collection instrument and were assessed by a quality checklist created and adapted from CONSORT (Consolidated Standards for Reporting Trials) and TREND (Transparent Reporting of Evaluation with Nonrandomized Designs).

RESULTS

Twenty-four studies were identified by the search strategy. Only 19 studies met the criteria for full review. Ten studies met all the inclusion criteria and were included in the final analysis. Of the 16 parameters present in the quality assessment checklist, only six were achieved for the studies analyzed.

CONCLUSIONS

There is some evidence that RMT improves a number of respiratory function parameters in patients with Parkinson disease and multiple sclerosis; however, the number of studies and their quality are not sufficient to conclude whether IMT or EMT is effective in improving respiratory function in patients with neurodegenerative disorders of the CNS.

Change in tongue morphology in response to expiratory resistance loading investigated by magnetic resonance imaging

[Purpose] The purpose of this study was to investigate the effect of expiratory resistance load on the tongue area encompassing the suprahyoid and genioglossus muscles. [Subjects] The subjects were 30 healthy individuals (15 males, 15 females, mean age: 28.9 years). [Methods] Magnetic resonance imaging was used to investigate morphological changes in response to resistive expiratory pressure loading in the area encompassing the suprahyoid and genioglossus muscles. Images were taken when water pressure was sustained at 0%, 10%, 30%, and 50% of maximum resistive expiratory pressure. We then measured tongue area using image analysis software, and the morphological changes were analyzed using repeated measures analysis of variance followed by post hoc comparisons. [Results] A significant change in the tongue area was detected in both sexes upon loading. Multiple comparison analysis revealed further significant differences in tongue area as well as changes in tongue area in response to the different expiratory pressures. [Conclusion] The findings demonstrate that higher expiratory pressure facilitates greater reduction in tongue area.

Early respiratory evaluation should be carried out systematically in patients with multiple sclerosis

The present study aimed at evaluating respiratory parameters in multiple sclerosis (MS). The sample comprised 30 patients with MS diagnosis and 30 healthy subjects, matched by gender and age. Neurological assessment, expanded disability status scale (EDSS), manovacuometry, and peak flow (PEF) were performed. Patients with MS had lower values of maximum inspiratory (MIP) and expiratory (MEP) pressures and PEF compared to healthy controls. It was shown that respiratory impairment may be present in MS patients with low functional disability by EDSS. The data suggest that manovacuometry and PEF determination should be carried out systematically in patients with MS, and may be a reliable tool for the early detection of respiratory impairment allowing early respiratory rehabilitation.

Effect of training frequency on maximum expiratory pressure

PURPOSE

To determine the effects of expiratory muscle strength training (EMST) frequency on maximum expiratory pressure (MEP).

METHOD

We assigned 12 healthy participants to 2 groups of training frequency (3 days per week and 5 days per week). They completed a 4-week training program on an EMST trainer (Aspire Products, LLC). MEP was the primary outcome measure used to determine the effect of training frequency.

RESULTS

Participants who trained 3 days per week produced equivalent amounts of improvement in MEP compared with participants who trained 5 days per week. An overall improvement in MEP over the 4-week training period indicated a 33% increase when the data was collapsed across the 2 training groups.

CONCLUSION

The effects occurring with respiratory muscle strength training in healthy young adults are likely to be different from those occurring in patient populations. Therefore, the results of the present study suggest exploring the variable of training frequency in patient populations. Such knowledge will be informative for designing clinical protocols that are effective and may result in improved treatment compliance for those suffering from expiratory muscle weakness.

Validation of the comprehensive ICF core set for multiple sclerosis from the perspective of physical therapists

BACKGROUND

The Comprehensive ICF Core Set for Multiple Sclerosis (MS) is an application of the International Classification of Functioning, Disability and Health (ICF) and represents the typical spectrum of problems in the functioning of people with MS.

OBJECTIVES

The objective of this study was to validate the Comprehensive ICF Core Set for MS from the perspective of physical therapists.

DESIGN

A 3-round survey based on the Delphi technique was used.

METHODS

Physical therapists experienced in the management of MS were asked about problems and resources of people with MS as well as environmental aspects treated by physical therapists (eg, use of assistive devices, support). Statements were linked to the ICF and compared with the Comprehensive ICF Core Set for MS.

RESULTS

Eighty physical therapists from 23 countries mentioned 2,133 issues that covered all of the ICF components. Two hundred thirty-eight ICF categories were linked to the statements. Forty-six categories in the Comprehensive ICF Core Set for MS were confirmed by physical therapists at the same level or a more specific level of classification. Nineteen additional ICF categories were reported by at least 75% of the participants.

CONCLUSIONS

The results of this study support the content and face validity of the Comprehensive ICF Core Set for MS. Areas of functioning and health that physical therapists believe should be assessed were identified. The findings of this study as well as the results of completed and ongoing validation studies will further elucidate the validity of the Comprehensive ICF Core Set for MS from different perspectives.

Respiratory muscle strength and training in stroke and neurology: a systematic review

We undertook two systematic reviews to determine the levels of respiratory muscle weakness and effects of respiratory muscle training in stroke patients. Two systematic reviews were conducted in June 2011 using a number of electronic databases. Review 1 compared respiratory muscle strength in stroke and healthy controls. Review 2 was expanded to include randomized controlled trials assessing the effects of respiratory muscle training on stroke and other neurological conditions. The primary outcomes of interest were maximum inspiratory and expiratory mouth pressure (maximum inspiratory pressure and maximum expiratory pressure, respectively). Meta-analysis of four studies revealed that the maximum inspiratory pressure and maximum expiratory pressure were significantly lower (P < 0·00001) in stroke patients compared with healthy individuals (weighted mean difference -41·39 and -54·62 cmH(2) O, respectively). Nine randomized controlled trials indicate a significantly (P = 0·0009) greater effect of respiratory muscle training on maximum inspiratory pressure in neurological patients compared with control subjects (weighted mean difference 6·94 cmH(2) O) while no effect on maximum expiratory pressure. Respiratory muscle strength appears to be impaired after stroke, possibly contributing to increased incidence of chest infection. Respiratory muscle training can improve inspiratory but not expiratory muscle strength in neurological conditions, although the paucity of studies in the area and considerable variability between them is a limiting factor. Respiratory muscle training may improve respiratory muscle function in neurological conditions, but its clinical benefit remains unknown.

Initial effect of an elastic chest band during inspiratory exercise on chest function improvement in people with limited rib mobility: a randomized controlled pilot trial

BACKGROUND AND PURPOSE

While performing respiratory training, an elastic chest band has great benefits for clinical use due to its safety and easy application. However, to our knowledge, there is no published data on the clinical use of an elastic chest band into inspiratory training for people with limited rib mobility. This study aimed to investigate the effects of an elastic chest band integrated into inspiratory exercise for people with decreased chest function.

METHOD

Sixteen subjects with limited rib mobility were randomly assigned to either experimental group (EG) or control group (CG), with eight subjects in each group. All subjects received an inspiratory exercise using incentive spirometer for 30 minutes. For the subjects of the EG, an elastic chest band was incorporated into the inspiratory exercises to provide compressive resistance to the chest. The chest function was measured using an electronic spirometer to determine the vital capacity (VC), tidal volume (TV), inspiratory reserve volume (IRV), expiratory reserve volume, forced vital capacity (FVC), forced expiratory volume (FEV), FEV in 1-second (FEV₁) and the ratio of FEV₁ to FVC (FEV₁ %).

RESULTS

Significant differences were found for the VC, TV, IRV, FVC and FEV₁ between pre-test and post-test in the two groups (p < 0.05). Further, the changes in the values of VC (0.47 L vs. 0.22 L), FVC (0.55 L vs. 0.25 L) and FEV₁ (0.65% vs. 0.21%) in the EG subjects were significantly greater than those in the CG subjects (p < 0.05).

CONCLUSIONS

These findings suggest that an elastic chest band combined with inspiratory exercise produces additional positive effect on improving chest function in people with limited rib mobility.

Painful and involuntary multiple sclerosis

INTRODUCTION

Pain, dysphagia, respiratory problems, sexual and cardiovascular dysfunctions may occur in patients with MS.

AREAS COVERED

In the present review, we attempt to summarize the current knowledge on the impact pain, dysphagia, respiratory problems, sexual and cardiovascular dysfunctions have in patients with MS.

EXPERT OPINION

To effectively manage MS, it is essential that these symptoms are recognized as early as possible and treated by a rehabilitative multidisciplinary approach, based on proven scientific evidence.

Effects of a 10-week inspiratory muscle training program on lower-extremity mobility in people with multiple sclerosis: a randomized controlled trial

Pulmonary muscle weakness is common in ambulatory people with multiple sclerosis (MS) and may lead to deficits in mobility function. The purpose of this study was to examine the effect of a 10-week home-based exercise program using an inspiratory muscle threshold trainer (IMT) on the results of four lower-extremity physical performance tests in people with MS. The study design was a two-group (experimental-control), pretest-posttest study. Outcome measures consisted of pulmonary function measures including maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and maximal voluntary ventilation (MVV), and the following lower-extremity physical performance measures: the 6-Minute Walk (6MW) distance, gait velocity (GV), the Sit-to-Stand Test (SST), the Functional Stair Test (FST), and a balance test (BAL). A total of 46 ambulatory participants (Expanded Disability Status Scale [EDSS] score, 2.0-6.5) with MS were randomly assigned to an intervention group (mean EDSS score, 4.1) that received 10 weeks of home-based inspiratory muscle training or a nontreatment control group (mean EDSS score, 3.2). Of the original 46 participants, 20 intervention group participants and 19 control group participants completed the study. Compared with the control group, the intervention group made significantly greater gains in inspiratory muscle strength (P = .003) and timed balance scores (P = .008). A nonsignificant improvement in 6MW distance (P = .086) was also noted in the IMT-trained group as compared with the control group. This is the first study directly linking improvement in respiratory function to improvement in physical performance function in people with mild-to-moderate disability due to MS.

Correlation between trunk control, respiratory muscle strength and spirometry in patients with stroke: an observational study

INTRODUCTION

 Stroke is the main cause of chronic disability in adults, and the effect of a stroke on the respiratory system depends on the structures affected by the lesion. 

OBJECTIVES

 To evaluate the correlation between trunk control, respiratory muscle strength and pulmonary function in individuals who suffered stroke. 

METHODS

 Observational, quantitative and descriptive study. Twenty-three patients who had a clinical diagnosis of ischaemic or haemorrhagic stroke. The trunk control was assessed through the Trunk Impairment Scale (TIS), and the respiratory muscle strength was assessed by manovacuometry by measuring the maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). For pulmonary function analysis, we measured forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), peak expiratory flow (PEF) and the Tiffeneau index (TIFF) through spirometry. 

RESULTS

 A consistent and statistically significant correlation was found between TIS and PEF (r = 0.489, p = 0.024) and between TIS and EPmax (r = 0.517, p = 0.016). No relation was found between the other variables of pulmonary function and TIS. 

CONCLUSION

 This study demonstrated that there is a relation between trunk control and respiratory muscular strength, especially concerning the expiratory muscles. However, there seems to be no relation between trunk control and pulmonary function in this series of individuals who suffered stroke.

Respiratory Dysfunction in Chronic Neck Pain Patients. A Pilot Study

The aim of this pilot study was to add weight to a hypothesis according to which patients presenting with chronic neck pain could have a predisposition towards respiratory dysfunction. Twelve patients with chronic neck pain and 12 matched controls participated in this study. Spirometric values, maximal static pressures, forward head posture and functional tests were examined in all subjects. According to the results, chronic neck patients presented with a statistically significant decreased maximal voluntary ventilation ( P = 0.042) and respiratory muscle strength (Pimax and Pemax), ( P = 0.001 and P = 0.002, respectively). Furthermore, the current study demonstrated a strong association between an increased forward head posture and decreased respiratory muscle strength in neck pateits. The connection of neck pain and respiratory function could be an important consideration in relation to patient assessment, rehabilitation and consumption of pharmacological agents.

Physiotherapy and related activities in multiple sclerosis

There are now about 50 randomized controlled trials into rehabilitation packages, physiotherapy or related specific and non-specific techniques in multiple sclerosis (MS). Generally these, and related systematic reviews, report benefits. Particular problems arise, however, with the blinding of assessment, determination of what is the active or beneficial input by the therapist, the use of multiple domains of assessment of quality of life and function without, sometimes, a clear statement of a trial hypothesis or primary outcome and the short-term nature of many studies. Therapy inputs can be broadly broken down into verbal interactions with the patient, physical inputs and referral/recommendation processes. Each may be relevant to the outcome. ‘Response-shift’ may be an important internal mechanism of mind whereby changes in ‘quality of life’ may not always parallel function emphasizing the case for clearly separating quality of life from functional assessment and attempting to make the latter as objective as possible. Trials of such complex interventions will need to randomize specified components of therapy against appropriate placebos or active treatment arms rather than no therapy, which will be ethically harder to sustain. Classification of physiotherapy inputs by type and ‘dosage’, a primary hypothesis under test and attention to concealed allocation of treatment, assessor blinding and intention to treat analysis together with improved measurements of function will assist in the consolidation of the evidence base for physiotherapy as an important component of management for MS patients.

Randomized control trial of effects of a 10-week inspiratory muscle training program on measures of pulmonary function in persons with multiple sclerosis

Pulmonary impairments have long been recognized as major causes of morbidity and mortality in individuals with advanced multiple sclerosis (MS). This study was designed to determine if a 10-week home exercise inspiratory training program in community-dwelling persons with MS improves pulmonary muscle strength and endurance. Forty-six ambulatory individuals with clinically diagnosed MS [Expanded Disability Status Scale (EDSS) 2.0-6.5, intervention group mean = 3.96 and control group mean = 3.36] were randomly assigned to an intervention group that received 10 weeks of inspiratory muscle strength training (IMT) or a nontreatment control group. Twenty-one subjects in the control group and 20 subjects in the intervention group completed the study. The intervention group demonstrated significantly greater improvement than the control group in maximal inspiratory pressure (P < 0.001). When compared to the control group, no significant differences were noted for maximal expiratory pressure or maximal ventilation volume after training in the intervention group. Baseline and postexercise training comparison of secondary pulmonary expiratory outcomes were significant in the intervention group for forced expiratory volume at one second (FEV1) (P = 0.014), forced vital capacity (FVC) (P = 0.041), and midexpiratory flow rate(FEF(25-75%)) (P = 0.011). No significant changes were noted for the control group. Thus, IMT significantly increased inspiratory muscle strength and resulted in generalized improvements in expiratory pulmonary function in persons with MS who have minimal to moderate disability. Future studies are needed that focus on the long-term effects of IMT with increased resistance and the impact it has on increasing pulmonary function and functional performance.

Treatment Outcomes for Professional Voice Users

Professional voice users comprise 25% to 35% of the U.S. working population. Their voice problems may interfere with job performance and impact costs for both employers and employees. The purpose of this study was to examine treatment outcomes of two specific rehabilitation programs for a group of professional voice users. Eighteen professional voice users participated in this study; half had complaints of throat pain or vocal fatigue (Dysphonia Group), and half were found to have benign vocal fold lesions (Lesion Group). One group received 5 weeks of expiratory muscle strength training followed by six sessions of traditional voice therapy. Treatment order was reversed for the second group. The study was designed as a repeated measures study with independent variables of treatment order, laryngeal diagnosis (lesion vs non-lesion), gender, and time. Dependent variables included maximum expiratory pressure (MEP), Voice Handicap Index (VHI) score, Vocal Rating Scale (VRS) score, Voice Effort Scale score, phonetogram measures, subglottal pressures, and acoustic and perceptual measures. Results showed significant improvements in MEP, VHI scores, and VRS scores, subglottal pressure for loud intensity, phonetogram area, and dynamic range. No significant difference was found between laryngeal diagnosis groups. A significant difference was not observed for treatment order. It was concluded that the combined treatment was responsible for the improvements observed. The results indicate that a combined modality treatment may be successful in the remediation of vocal problems for professional voice users.

Rééducation fonctionnelle et sclérose en plaques : une vue d’ensemble

Multiple sclerosis (MS) is a chronic progressive disease which is the leading cause, after road traffic accidents, of handicap in young subjects. The large range of symptoms associated with MS lead to continuing decline in mood and quality of life. Despite therapeutic advances, functional impairments have significant consequences. Neurorehabilitation can be highly contributive in this disease with the goals of increasing independence and quality-of-life and improving functional capacities. Individualized programs elaborated by a multidisciplinary team of experts are the key to success of rehabilitation. Assessment is difficult because of the underlying conflict between the philosophies of rehabilitation and evidence-based medicine. The aim of this paper is to provide an overview of MS rehabilitation. Physical exercise is safe and should be encouraged for people with MS. Some studies have shown that supervised exercises have a beneficial effect on MS disability and quality of life. Inpatient rehabilitation for MS yields short-term benefits in function, mobility and quality of life; periodic hospitalization may be needed. In the future, rehabilitation professionals will have to learn how to anticipate patient needs and lay the groundwork for services and equipment in advance. Rehabilitation is one of the treatments of MS patients and should be viewed as an ongoing process to maintain and restore maximum function and quality of life.

Pulmonary function in multiple sclerosis without any respiratory complaints

OBJECTIVES

Pulmonary complications in severe multiple sclerosis (MS) are often seen secondary to respiratory muscle dysfunction. The development of respiratory muscle dysfunction and its association with disability during the course of MS is unknown. In our study, we investigated the predictive value of respiratory muscle functions and the change in forced vital capacity (Delta forced vital capacity [FVC]; FVC upright-FVC supine) to detect deterioration of respiratory muscle functions in the early phase of MS.

PATIENTS AND METHODS

Twenty-one MS patients with a median age of 34.5+/-9.45 years were enrolled. Fourteen cases were relapsing-remitting, six were secondary progressive, one was primary progressive type. The mean duration of disease was 10.76+/-6.6 years. Seventeen healthy subjects with a median age of 40.7+/-7.6 years were chosen as a control group. Smoking habit was similar in both groups. Pulmonary function tests (PFT), lung volumes, diffusion, respiratory muscle function ( P(Imax) , P(Emax)), mouth occlusion pressure, and indirect sign of respiratory center function (P(0.1)) tests were performed. PFT were repeated in supine and upright positions.

RESULTS

Our results in the MS group and the control group, respectively, were: diffusion (DL(CO): 18.8+/-4.2 vs. 26.4+/-7.3 mL/mmHg/min), P(I(max) (82.1+/-26.3 vs. 109.1+/-23.3 cm H(2)O), P(E(max) (119.2+/-42 vs. 171.8+/-50.2 cm H(2)O), P(0.1) (2.6+/-0.7 vs. 4.2+/-0.7). All parameters were lower in the MS group compared with the control group (p<0.05). In the MS group, FVC values in the upright position were higher than FVC values in the supine position. The difference in FVC values in MS patients between the upright and supine positions (Delta FVC) was also found to be significantly higher than in the control group (Delta FVC 262.3+/-247.6 (MS), 98.8+/-179.1 mL (CONTROL)) (p<0.01).

CONCLUSION

Our results indicate the presence of pulmonary dysfunction in MS even in the absence of any respiratory symptoms.

Expiratory Muscle Strength Training

Purpose. This study investigated the effect of expiratory muscle strength training (EMST) on voice production, dysarthria, and voice-related quality-of-life issues in persons with multiple sclerosis (PwMS). It was hypothesized that PwMS would have improved voice production and reduced voice-related quality-of-life issues following EMST. Participants and Methods. Seventeen participants with MS and 14 healthy (H) controls completed 8 weeks of EMST, followed by 4 weeks of no training. Analyzed outcomes as a function of EMST were maximal expiratory pressure (MEP), sustained vowel prolongation (SVP), words per minute (WPM) measured from connected speech, and quality-of-life indices related to the presence of the dysarthria and dysphonia. Results. PwMS had lower MEPs, shorter SVP, and less WPM than the controls prior to training. Following EMST, both groups had significant improvement in MEPs that stayed above baseline after training halted. EMST did not improve voice production or voice-related quality of life for PwMS. Conclusion. Respiratory muscle weakness is present in PwMS having mild- to moderate-level disability. EMST improved expiratory muscle strength but did not statistically change objective and subjective components of voice/speech production in PwMS.

Cardiopulmonary and metabolic functions, aerobic capacity, fatigue and quality of life in patients with multiple sclerosis

OBJECTIVES

The objectives of this study were to evaluate cardiopulmonary and metabolic functions in patients with multiple sclerosis (MS) and to clarify the relationship between these functions and neurological deficits, respiratory involvement, fatigue and quality of life.

MATERIALS AND METHODS

Twenty-five patients with MS and 15 healthy controls were included in the study. Cardiopulmonary and metabolic responses to maximum exercise were investigated with an electronically braked arm crank ergometer. A computerized gas analysis system collected and analysed expired gases during exercise.

RESULTS

In the present study, significant respiratory muscle weakness, and decreased aerobic performance and cardiopulmonary and metabolic responses to maximum exercise were determined in patients with MS.

CONCLUSIONS

As respiratory muscle function plays a strong role in aerobic capacity and in most of the cardiopulmonary and metabolic responses to exercise, measurement of respiratory muscle strength and endurance should also be carried out in the MS population.

Expiratory muscle strength training in persons with multiple sclerosis having mild to moderate disability: effect on maximal expiratory pressure, pulmonary function, and maximal voluntary cough

OBJECTIVE

To determine the effect of expiratory muscle strength training (EMST) on maximal expiratory strength, pulmonary function, and maximal voluntary cough in persons with multiple sclerosis (MS) having mild to moderate disability.

DESIGN

Before-after trial.

SETTING

Assessments were completed in the privacy of the subject's home or exercise physiology laboratory.

PARTICIPANTS

Seventeen persons with MS were age- and sex-matched to 14 healthy controls.

INTERVENTION

Eight weeks of EMST and 4 weeks of detraining.

MAIN OUTCOME MEASURES

Maximal respiratory pressures, pulmonary function, and maximal voluntary cough were assessed 3 times (pretraining, posttraining, detraining). Maximal expiratory pressure (MEP) was assessed weekly and training intensity adjusted based on the new measurement.

RESULTS

Subjects with MS had lower MEP, decreased pulmonary function, and weaker maximal voluntary cough at each assessment. EMST increased MEP and peak expiratory flow. However, improvement in maximal voluntary cough only occurred in subjects with a moderate level of disability when the MS group was subdivided into mild and moderate disability levels based on the Expanded Disability Status Scale.

CONCLUSIONS

EMST is a viable tool to enhance the strength of the respiratory muscles. However, further work is needed to determine the best parameters to assess change in cough following EMST.

Six-minute walk distance as a measure of functional exercise capacity in multiple sclerosis

PURPOSE

We hypothesised that six-minute walk (6MWT) distance of patients with ambulatory multiple sclerosis (MS)would differ from age-matched healthy control subjects. We also investigated the contribution of demographic, physical and physiological factors to impaired functional capacity in MS.

METHOD

Thirty MS patients and 30 healthy subjects participated in this study. Respiratory muscle strength was measured. Pulmonary function test and 6MWT were performed. The Barthel Index (BI) was used to assess activities of daily living, and the Modified Ashworth Scale was used to determine spasticity. Symptomatic fatigue was measured using the Fatigue Severity Scale (FSS).

RESULTS

Pulmonary function and respiratory muscle strength of ambulatory MS patients were significantly lower, and baseline heart rate and fatigue perception were significantly higher than were healthy controls (p < 0.05). MS patients reached a significantly higher exercise heart rate, and walked significantly shorter distance than did healthy subjects (p < 0.05). The BI score, baseline heart rate and FSS score together accounted for 81 percent variance in 6MWT distance of MS patients (p < 0.05).

CONCLUSION

The shorter distance covered during a 6MWT is determined by the limitations in activities of daily living,resting heart rate and subjective symptomatic fatigue in ambulatory patients with MS. Respiratory muscle weakness, lung function and level of neurological impairment do not contribute to impaired functional exercise capacity in these patients.

Examination of strength training and detraining effects in expiratory muscles

PURPOSE

The purpose of this study was to determine strength gains following expiratory muscle strength training (EMST) and to determine detraining effects when the training stimulus is removed.

METHOD

Thirty-two healthy participants were enrolled in an EMST program. Sixteen participants trained for 4 weeks (Group 1) and 16 participants trained for 8 weeks (Group 2). All 32 participants were detrained for 8 weeks. Maximum expiratory pressure (MEP) was used to document change in expiratory muscle strength throughout the study.

RESULTS

Group 1 had a 41% increase and Group 2 had a 51% increase in MEP following the training. Mean MEP, for both groups, was significantly greater than baseline at the end of the training period (p = .0001), at the 4th week of detraining (p = .0001), and at the 8th week of detraining (p = .0001). The results also indicated that there was no significant difference in mean MEP between the groups at baseline, end of training, or throughout the detraining period (p = .960).

DISCUSSION

The results suggest that expiratory muscle strength gains following a 4- and 8-week EMST program do not differ significantly. Additionally, detraining rates do not appear to be dependent on length of training time.

Symptomatic therapy and neurorehabilitation in multiple sclerosis

Multiple sclerosis (MS) is associated with a variety of symptoms and functional deficits that result in a range of progressive impairments and handicap. Symptoms that contribute to loss of independence and restrictions in social activities lead to continuing decline in quality of life. Our aim is to give an updated overview on the management of symptoms and rehabilitation measures in MS. Appropriate use of these treatment options might help to reduce long-term consequences of MS in daily life. First, we review treatment of the main symptoms of MS: fatigue, bladder and bowel disturbances, sexual dysfunction, cognitive and affective disorders, and spasticity. Even though these symptomatic therapies have benefits, their use is limited by possible side-effects. Moreover, many common disabling symptoms, such as weakness, are not amenable to drug treatment. However, neurorehabilitation has been shown to ease the burden of these symptoms by improving self-performance and independence. Second, we discuss comprehensive multidisciplinary rehabilitation and specific treatment options. Even though rehabilitation has no direct influence on disease progression, studies to date have shown that this type of intervention improves personal activities and ability to participate in social activities, thereby improving quality of life. Treatment should be adapted depending on: the individual patient's needs, demands of their surrounding environment, type and degree of disability, and treatment goals. Improvement commonly persists for several months beyond the treatment period, mostly as a result of reconditioning and adaptation and appropriate use of medical and social support at home. These findings suggest that quality of life is determined by disability and handicap more than by functional deficits and disease progression.

Spiroergometric and spirometric parameters in patients with multiple sclerosis: are there any links between these parameters and fatigue, depression, neurological impairment, disability, handicap and quality of life in multiple sclerosis?

One-hundred and twelve patients with multiple sclerosis were selected as population-based sample and examined on impairment (Expanded Disability Status Scale), disability (Barthel Index), handicap (Environment Status Scale), the quality of life (Multiple Sclerosis Quality of Life), fatigue (Modified Fatigue Impact Scale), depression (Beck Depression Inventory Score), respiratory function (spirometric parameters on spirometry) and physical fitness (spiroergometric parameters on a bicycle ergometer). The aim of the study was to examine and analyse (descriptive statistics) spiroergometric and spirometric parameters in patients with multiple sclerosis. Firstly, we tested the hypothesis whether spiroergometric and spirometric parameters are decreased and whether there are any correlations between these parameters and measures of impairment, depression, disability, handicap and quality of life. Secondly, we tested the hypothesis whether there is any correlation between a possible deconditioning and fatigue, and between a possible respiratory dysfunction and fatigue in multiple sclerosis. It results from this study that many spiroergometric parameters in patients with multiple sclerosis are significantly lowered in comparison to the population norm. A link can be found between some spiroergometric parameters and neurological impairment, disability, handicap and quality of life. It is not possible to prove any correlation between spiroergometric parameters and depression. From the spirometric parameters, these are expiratory flows that are significantly lowered in MS patients. It is not possible to prove any correlation between spirometric parameters and fatigue, depression, neurological impairment, duration of the disease, disability, handicap and quality of life in multiple sclerosis.

Exercise and Multiple Sclerosis

The pathophysiology of multiple sclerosis (MS) is characterised by fatigue, motor weakness, spasticity, poor balance, heat sensitivity and mental depression. Also, MS symptoms may lead to physical inactivity associated with the development of secondary diseases. Persons with MS are thus challenged by their disability when attempting to pursue an active lifestyle compatible with health-related fitness. Although exercise prescription is gaining favour as a therapeutic strategy to minimise the loss of functional capacity in chronic diseases, it remains under-utilised as an intervention strategy in the MS population. However, a growing number of studies indicate that exercise in patients with mild-to-moderate MS provides similar fitness and psychological benefits as it does in healthy controls. We reviewed numerous studies describing the responses of selected MS patients to acute and chronic exercise compared with healthy controls. All training studies reported positive outcomes that outweighed potential adverse effects of the exercise intervention. Based on our review, this article highlights the role of exercise prescription in the multidisciplinary approach to MS disease management for improving and maintaining functional capacity. Despite the often unpredictable clinical course of MS, exercise programmes designed to increase cardiorespiratory fitness, muscle strength and mobility provide benefits that enhance lifestyle activity and quality of life while reducing risk of secondary disorders. Recommendations for the evaluation of cardiorespiratory fitness, muscle performance and flexibility are presented as well as basic guidelines for individualised exercise testing and training in MS. Special considerations for exercise, including medical management concerns, programme modifications and supervision, in the MS population are discussed.

Effect of inspiratory muscle training in patients with multiple sclerosis

OBJECTIVE

To evaluate whether inspiratory muscle training (IMT) improves inspiratory muscle strength, respiratory capacity, fatigue, and subjective perception of physical endurance in patients with advanced multiple sclerosis (MS).

DESIGN

Randomized controlled trial.

SETTING

Outpatient clinic in Sweden.

PARTICIPANTS

Fifteen severely disabled patients with MS, randomized to a training or control group.

INTERVENTION

Seven patients trained with a Threshold inspiratory muscle trainer, twice every other day, with 3 sets of 10 loaded inspirations (40%-60% of patients' maximal inspiratory pressure [Pimax]) over a 10-week period.

MAIN OUTCOME MEASURES

Spirometry, Pimax, maximal expiratory pressure (Pemax), clinical assessments, and questionnaires on the patients' fatigue severity and physical endurance were evaluated.

RESULTS

After training, the Pimax (P<.008) and Pemax (P<.02) increased in the training group. The improvement in Pimax after 10 weeks of training was higher than the improvement in the control group (P<.01) and was maintained 1 month after the training period ended. The training affected neither respiratory function nor the patients' symptoms.

CONCLUSIONS

IMT had a beneficial effect on inspiratory muscle strength in patients with MS and is recommended as a complement to ordinary physical training.

Disorders of the respiratory muscles

The act of breathing depends on coordinated activity of the respiratory muscles to generate subatmospheric pressure. This action is compromised by disease states affecting anatomical sites ranging from the cerebral cortex to the alveolar sac. Weakness of the respiratory muscles can dominate the clinical manifestations in the later stages of several primary neurologic and neuromuscular disorders in a manner unique to each disease state. Structural abnormalities of the thoracic cage, such as scoliosis or flail chest, interfere with the action of the respiratory muscles-again in a manner unique to each disease state. The hyperinflation that accompanies diseases of the airways interferes with the ability of the respiratory muscles to generate subatmospheric pressure and it increases the load on the respiratory muscles. Impaired respiratory muscle function is the most severe consequence of several newly described syndromes affecting critically ill patients. Research on the respiratory muscles embraces techniques of molecular biology, integrative physiology, and controlled clinical trials. A detailed understanding of disease states affecting the respiratory muscles is necessary for every physician who practices pulmonary medicine or critical care medicine.

Locomotor-respiratory coupling during axillary crutch ambulation

OBJECTIVE

To test the hypotheses that locomotor-respiratory coupling occurs in humans using axillary crutches in a swing-through ambulation pattern and that expiration occurs during crutch-stance phase during locomotor-respiratory coupling.

DESIGN

Eighteen able-bodied persons were trained in one-footed swing-through gait with axillary crutches. Then, as subjects walked at "somewhat hard" speeds (Borg) on a motorized treadmill for 5 min, we recorded signals from a crutch pressure switch and a mouthpiece-mounted thermocouple. Coupling was defined as being present when the onset of inspiration varied by < or = 5% with respect to the onset of the crutch gait cycle for a minimum of 10 consecutive gait cycles and when there was no drift on a raster plot of the respiratory phases relative to the onset of the gait cycle.

RESULTS

Ten (56%) of the 18 subjects exhibited locomotor-respiratory coupling on 1-4 occasions each, with episodes lasting 11.3-148 sec. In 17 (89%) of the 19 episodes of 1:1 locomotor-respiratory coupling, expiration occurred during the crutch-stance phase of the gait cycle and inspiration occurred during crutch swing.

CONCLUSIONS

Transient 1:1 locomotor-respiratory coupling occurs in many able-bodied subjects ambulating with axillary crutches and a swing-through gait. Expiration is most often associated with the crutch-stance phase of the gait cycle. This study may have implications for training axillary crutch users.