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

Effects of cardiorespiratory physiotherapy on lung function in stroke: a network meta-analysis

BACKGROUND

The efficacy of various physiotherapy interventions for improving lung function has not been compared.

OBJECTIVES

To evaluate cardiorespiratory physiotherapy interventions on lung function in patients with stroke, prioritize intervention types, and establish hierarchy.

METHODS

Twelve randomized controlled trials published during 2000-2022 in PubMed, EMBASE, Cochrane Library, and Web of Science were selected. Interventions included aerobic training (AT), combined inspiratory and expiratory training (CIET), inspiratory training (IT), combined aerobic and breadth training (CABT), and conventional training (CT). Outcome variables were forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC.

RESULTS

CIET and IT were more effective than CT for FEV1 and FVC. CIET and IT showed larger effect sizes compared to AT for FEV1. The intervention rankings were as follows: IT (86.62%), CIET (63.31%), CABT (50.79%), AT (28.72%), and CT (20.55%) for FEV1; IT (93.89%), CIET (75.06%), CT (42.38%), CABT (37.73%), and AT (0.94%) for FVC; and IT (78.30%), CT (54.14%), CABT (42.62%), CIET (41.65%), and AT (33.29%) for FEV1/FVC. CIET and IT were more effective than CT for FVC in patients with stroke aged ≥60 years.

CONCLUSIONS

Besides FEV1/FVC, IT and CIET inhalation exercises improved lung function more effectively than other therapies, with IT or CIET being more effective than AT or CT. CIET and IT were more effective than CT for FVC in patients with stroke aged ≥60 years than in those <60 years. These findings highlight the significance of breathing training for patients with stroke and support clinical decision-making.

Investigating the relationship of trunk and postural control with pulmonary functions in subacute stroke patients

Stroke is a disease with high mortality and morbidity that not only causes weakness in the extremities, loss of balance, and disturbances in trunk and postural control, but also affects respiratory function. The aim of this study was to investigate the relationship between trunk and postural control and pulmonary function in subacute stroke patients. Herein, 32 volunteer patients who were diagnosed with hemiplegia by a competent physician after unilateral hemorrhagic or ischemic stroke and who met the inclusion criteria participated in the study. Functional independence of the participants was evaluated using the Modified Rankin Scale (mRS) and their cognitive function was assessed with the Standardized Mini Mental State Examination. Respiratory function was evaluated with spirometric measurements, inspiratory muscle strength was evaluated with intraoral pressure measurements, trunk control was evaluated using the Trunk Impairment Scale (TIS), postural control was evaluated using the Postural Assessment Scale for Stroke Patients (PASS-T), computerized postural sway evaluation, and static posture analysis. A significant correlation was found between the TIS scores and inspiratory muscle strength (p < 0.05). A significant correlation was also found between the PASS-T scores and inspiratory muscle strength and pulmonary function (p < 0.05). All of the COP parameters measured were significantly correlated with the PEF(L/s) and FEF25-75 (L/s) (p < 0.05). In conclusion, this study showed that trunk and postural control are associated with inspiratory muscle strength and pulmonary function. It is recommended that evaluation of trunk and postural control and respiratory functions, as well as exercise training to improve these parameters, should be included in rehabilitation programs for individuals with stroke.

Respiratory muscle strength in stroke: a case-control study

AIM

The aim of the study was to determine the respiratory muscle strength of stroke patients and compare them with healthy individuals.

METHOD

The study was conducted with 171 patients who had a stroke between 2017 and 2021 and 32 healthy controls. Respiratory muscle strength and inspiratory and expiratory mouth pressure (MIP and MEP) were measured using the portable MicroRPM device (Micro Medical, Basingstoke, UK).

RESULTS

The stroke group exhibited significantly lower values in both MIP for men (p<0.001) and women (p=0.013) and maximal expiratory pressure for men (p<0.001) and women (p=0.042), compared with the healthy control group. Notably, there was a significant difference in the MIPmen (p=0.026) and MEPmen (p=0.026) values when comparing the reference values, which were calculated based on age and sex, with those of the healthy group. The baseline values calculated according to age for stroke patients were as follows: MIPmen 31.68%, MIPwomen 63.58%, MEPmen 22.54%, and MEPwomen 42.30%.

CONCLUSION

This study highlights the significant respiratory muscle weakness experienced by stroke patients, with gender-specific differences. It highlights the importance of incorporating respiratory assessments and interventions into stroke rehabilitation protocols to improve the overall health and well-being of stroke patients.

Effects of respiratory muscle training on post-stroke rehabilitation: A systematic review and meta-analysis

BACKGROUND

Stroke often results in significant respiratory dysfunction in patients. Respiratory muscle training (RMT) has been proposed as a rehabilitative intervention to address these challenges, but its effectiveness compared to routine training remains debated. This systematic review and meta-analysis aim to evaluate the effects of RMT on exercise tolerance, muscle strength, and pulmonary function in post-stroke patients.

AIM

To systematically assess the efficacy of RMT in improving exercise tolerance, respiratory muscle strength, and pulmonary function in patients recovering from a stroke, and to evaluate whether RMT offers a significant advantage over routine training modalities in enhancing these critical health outcomes in the post-stroke population.

METHODS

Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, a comprehensive search across PubMed, Embase, Web of Science, and the Cochrane Library was conducted on October 19, 2023, without temporal restrictions. Studies were selected based on the predefined inclusion and exclusion criteria focusing on various forms of RMT, control groups, and outcome measures [including forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), maximal voluntary ventilation (MVV), peak expiratory flow (PEF), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and 6-min walking test (6MWT)]. Only randomized controlled trials (RCTs) were included. Data extraction and quality assessment were conducted independently by two reviewers using the Cochrane Collaboration's risk of bias tool. Statistical analyses, including those using the fixed-effect and random-effects models, sensitivity analysis, and publication bias assessment, were performed using Review Manager software.

RESULTS

A total of 15 RCTs were included. Results indicated significant improvements in MIP (12.51 cmH2O increase), MEP (6.24 cmH2O increase), and various pulmonary function parameters (including FEV1, FVC, MVV, and PEF). A substantial increase in 6MWT distance (22.26 meters) was also noted. However, the heterogeneity among studies was variable, and no significant publication bias was detected.

CONCLUSION

RMT significantly enhances walking ability, respiratory muscle strength (MIP and MEP), and key pulmonary function parameters (FEV1, FVC, MVV, and PEF) in post-stroke patients. These findings support the incorporation of RMT into post-stroke rehabilitative protocols.

Effects of Upper Limb Control on the Less-Affected Side on Upper Limb Function, Respiration, Balance, and Activities of Daily Living in Stroke

Background and Objectives: This study aimed to investigate the effects of upper limb control exercises on upper limb function, respiration, balance, and activities of daily living in patients with stroke. Materials and Methods: The 28 patients who met the selection criteria were randomly assigned to two groups of 14 patients each. Subsequently, upper limb control exercises using real-time feedback were applied. The same interventional exercise was applied to both the less-affected and affected limbs of the study participants, who were classified into a less-affected side upper limb control group and an affected side upper limb control exercise group. Interventional exercises, 30 min each, were performed five times weekly for 4 weeks, and follow-up examinations were performed 2 weeks after the end of exercise. Electronic muscle strength measurements and an electronic goniometer were used to evaluate upper limb function. A spirometer was used to measure respiration. Balance ability was evaluated using a force plate pressure distribution measuring system with a sensor that detects the movement of the body center on the ground. Daily life movements were evaluated using the Korean version of the modified Barthel index. Results: When examining the results, the upper limb function on the paralyzed side showed an increase in the electromyographic strength of shoulder joint depression and flexion angle. Improvements were also observed in respiration (forced vital capacity [L] and forced expiratory volume in 1 s [L]), balance (95% confidence ellipse area [mm2] and center of pressure displacement [mm]), and daily life activities, all of which showed statistically significant differences in the time × group interaction effect (p < 0.05). Conclusions: Thus, it was found that the upper limb control exercise on the less-affected side had a significant effect when the exercise was performed together with treatment on the affected side in patients with stroke. It is anticipated that this study will provide basic data for evaluating both the trunk and upper limbs of the less-affected and affected sides.

Structured different exercise protocols improve lung function, respiratory muscle strength, and thickness in stroke patients. A randomized controlled trial

BACKGROUND

The effect of core stabilization exercises (CSE) alone, or in combination with neuromuscular electrical stimulation (NMES) and Kinesio taping (KT) on lung function, respiratory muscle strength, and thickness in patients with stroke is not fully known.

OBJECTIVE

To compare the efficacy of NMES and KT applied with CSE on lung functions, respiratory muscle strength, and thickness in patients with stroke.

METHODS

A total of 45 stroke patients were randomly assigned to the core stabilization exercises (CSE) group, CSE+KT group or CSE+NMES group, respectively. All groups received the training protocol for 30-45 minutes, 3 days a week, for 6 weeks. Lung functions were measured using portable spirometry. Respiratory muscle strength was assessed using an analog manometer to measure maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). Peak cough flow (PCF) was measured with a peak flow meter. Respiratory muscles thickness were determined using ultrasonography.

RESULTS

Except for FVC (%pred) (F=4.432, p=0.018, np2=0.174), FEV1(%pred) (F=3.725, p=0.032, np2=0.151), and MEP (F=3.861, p=0.029, np2=0.155), the overall group by time interaction for rmANOVA showed that there was no statistically significant difference between groups (p>0.05). After post hoc analysis, it was determined that there was no statistically significant difference between the groups in terms of FVC (%pred), FEV1(%pred) and MEP (p>0.025).

CONCLUSIONS

The addition of NMES or KT to core stabilization exercises did not appear to provide additional benefit in improving lung function, respiratory muscle strength, and thickness in stroke patients.

The effects of respiratory muscle training on respiratory function and functional capacity in patients with early stroke: a meta-analysis

BACKGROUND

Respiratory muscle training is a continuous and standardized training of respiratory muscles, but the evidence of the effects on early stroke patients is not clear. This meta-analysis aimed to investigate the effects of respiratory muscle training on respiratory function and functional capacity in patients with early stroke.

METHODS

PubMed, Embase, PEDro, ScienceDirect, AMED, CINAHL, and China National Knowledge Infrastructure databases were searched from inception to December 8, 2023 for articles about studies that 1) stroke patients with age ≥ 18 years old. Early stroke < 3 months at the time of diagnosis, 2) respiratory muscle training, including inspiratory and expiratory muscle training, 3) the following measurements are the outcomes: respiratory muscle strength, respiratory muscle endurance, pulmonary function testing, dyspnea fatigue score, and functional capacity, 4) randomized controlled trials. Studies that met the inclusion criteria were extracted data and appraised the methodological quality and risk of bias using the Physiotherapy Evidence Database scale and the Cochrane Risk of Bias tool by two independent reviewers. RevMan 5.4 with a random effect model was used for data synthesis and analysis. Mean differences (MD) or standard mean differences (SMD), and 95% confidence interval were calculated (95%CI).

RESULTS

Nine studies met inclusion criteria, recruiting 526 participants (mean age 61.6 years). Respiratory muscle training produced a statistically significant effect on improving maximal inspiratory pressure (MD = 10.93, 95%CI: 8.51-13.36), maximal expiratory pressure (MD = 9.01, 95%CI: 5.34-12.69), forced vital capacity (MD = 0.82, 95%CI: 0.54-1.10), peak expiratory flow (MD = 1.28, 95%CI: 0.94-1.63), forced expiratory volume in 1 s (MD = 1.36, 95%CI: 1.13-1.59), functional capacity (SMD = 0.51, 95%CI: 0.05-0.98) in patients with early stroke. Subgroup analysis showed that inspiratory muscle training combined with expiratory muscle training was beneficial to the recovery of maximal inspiratory pressure (MD = 9.78, 95%CI: 5.96-13.60), maximal expiratory pressure (MD = 11.62, 95%CI: 3.80-19.43), forced vital capacity (MD = 0.87, 95%CI: 0.47-1.27), peak expiratory flow (MD = 1.51, 95%CI: 1.22-1.80), forced expiratory volume in 1 s (MD = 0.76, 95%CI: 0.41-1.11), functional capacity (SMD = 0.61, 95%CI: 0.08-1.13), while inspiratory muscle training could improve maximal inspiratory pressure (MD = 11.60, 95%CI: 8.15-15.05), maximal expiratory pressure (MD = 7.06, 95%CI: 3.50-10.62), forced vital capacity (MD = 0.71, 95%CI: 0.21-1.21), peak expiratory flow (MD = 0.84, 95%CI: 0.37-1.31), forced expiratory volume in 1 s (MD = 0.40, 95%CI: 0.08-0.72).

CONCLUSIONS

This study provides good-quality evidence that respiratory muscle training is effective in improving respiratory muscle strength, pulmonary function, and functional capacity for patients with early stroke. Inspiratory muscle training combined with expiratory muscle training seems to promote functional recovery in patients with early stroke more than inspiratory muscle training alone.

TRIAL REGISTRATION

Prospero registration number: CRD42021291918.

Relationship between motor dysfunction, the respiratory muscles and pulmonary function in stroke patients with hemiplegia: a retrospective study

BACKGROUND

The interaction between motor dysfunction and respiratory functions in stroke patients with hemiplegia are not fully understood, particularly with regard to the relationship between changes in trunk control, balance, and daily activities, and changes in respiratory muscle strength and pulmonary volume. Investigating this relationship will facilitate the optimization of stroke rehabilitation strategies.

METHODS

Clinical history data were collected from 134 patients to analyze the relationship between motor function scales scores and spirometric data. The data from 60 patients' data were used to evaluate the relationship between motor function scales scores and spirometric data at baseline and after 3-weeks rehabilitation.

RESULTS

(1) Patients with lower scores on Trunk impairment Scale (TIS), Berg Balance Scale (BBS) and Barthel Index (BI) had weaker respiratory muscle strength and pulmonary function. (2) Stroke patients' BBS and BI scores showed differences between normal and unnormal maximal inspiratory pressure (MIP), but not in TIS. (3) Improvements in motor function led to promotion of enhanced respiratory function. Patient exhibited less MIP improvement at the severe level of TIS and BBS.

CONCLUSIONS

Patients with hemiplegia exhibited diminished respiratory muscle strength and pulmonary function at a more severe motor dysfunction level. Impaired inspiratory muscle strength was associated with reduced balance ability and limitations in activities required for daily living. Enhanced motor function improved respiration and rehabilitation programs should prioritize the activation of diaphragm function to improve overall outcomes.

Pulmonary Function Tests Post-Stroke. Correlation between Lung Function, Severity of Stroke, and Improvement after Respiratory Muscle Training

Stroke is a significant cause of mortality and chronic morbidity caused by cardiovascular disease. Respiratory muscles can be affected in stroke survivors, leading to stroke complications, such as respiratory infections. Respiratory function can be assessed using pulmonary function tests (PFTs). Data regarding PFTs in stroke survivors are limited. We reviewed the correlation between PFTs and stroke severity or degree of disability. Furthermore, we reviewed the PFT change in stroke patients undergoing a respiratory muscle training program. We searched PubMed until September 2023 using inclusion and exclusion criteria in order to identify studies reporting PFTs post-stroke and their change after a respiratory muscle training program. Outcomes included lung function parameters (FEV1, FVC, PEF, MIP and MEP) were measured in acute or chronic stroke survivors. We identified 22 studies of stroke patients, who had undergone PFTs and 24 randomised controlled trials in stroke patients having PFTs after respiratory muscle training. The number of patients included was limited and studies were characterised by great heterogeneity regarding the studied population and the applied intervention. In general, PFTs were significantly reduced compared to healthy controls and predicted normal values and associated with stroke severity. Furthermore, we found that respiratory muscle training was associated with significant improvement in various PFT parameters and functional stroke parameters. PFTs are associated with stroke severity and are improved after respiratory muscle training.

Respiratory Parameters as Predictors of Balance and Gait Ability in Patients with Stroke at Discharge

Pulmonary complications are frequent in stroke, contributing to both mortality and morbidity rates. Respiratory parameters in such patients encompass both pulmonary function and respiratory muscle strength. Identifying respiratory function variables that influence the balance and gait ability of patients with stroke is crucial for enhancing their recovery in these aspects. However, no study has assessed predictions for a comprehensive array of balance and gait abilities in such patients. We aimed to examine whether initial respiratory muscle strength and pulmonary function can predict balance and gait ability at discharge from a rehabilitation program. Thirty-one patients with stroke were included in this prospective observational study. Multiple regression models with a forward selection procedure were employed to identify respiratory parameters (including peak expiratory flow and maximal expiratory pressure) that contributed to the results of balance assessments and gait evaluations at the time of discharge. The peak expiratory flow (PEF) served as a predictor explaining 42.0% of the variance. Similarly, the maximal expiratory pressure (MEP) was a predictor variable explaining 32.0% of the variance. PEF and MEP assessments at the initial stage as predictive factors for both balance and gait ability are important in stroke management.

Pulmonary function in patients with chronic stroke compared with a control group of healthy people matched by age and sex

BACKGROUND

Effects of chronic stroke on pulmonary function are largely unknown.

AIM

To compare lung volumes in people with chronic stroke with a control group of healthy people matched by age and sex, as well as to investigate the relationship between the lung volumes and functional capacity.

METHODS

A cross-sectional study involving people with chronic stroke. Cases were matched to a control group of healthy people. Lung function and the distance walked during the Six-Minute Walk Test (6MWD) were the main outcomes. Independent t-tests were used to compare pulmonary function between groups and the Pearson correlation coefficient was used to assess any relationship between lung volumes and the 6MWD in the stroke group.

RESULTS

Sixty-six participants (24 males in each group; 56.5 ± 15.5 years) were included. People with stroke presented significantly lower lung volumes when compared to the control group. The median of forced vital capacity (FVC) was 79% and peak expiratory flow was 64% of the reference value. The 6MWD was found to be weakly correlated with inspiratory reserve volume (r = 0.39, p = .03) and peak inspiratory flow (r = 0.35, p = .05).

CONCLUSIONS

People with chronic stroke show decreased lung volumes when compared with healthy people and this likely impacts on their functional capacity.

Respiratory muscle ultrasonography evaluation and its clinical application in stroke patients: A review

Background

Respiratory muscle ultrasound is a widely available, highly feasible technique that can be used to study the contribution of the individual respiratory muscles related to respiratory dysfunction. Stroke disrupts multiple functions, and the respiratory function is often significantly decreased in stroke patients.

Method

A search of the MEDLINE, Web of Science, and PubMed databases was conducted. We identified studies measuring respiratory muscles in healthy and patients by ultrasonography. Two reviewers independently extracted and documented data regarding to the criteria. Data were extracted including participant demographics, ultrasonography evaluation protocol, subject population, reference values, etc.

Result

A total of 1954 participants from 39 studies were included. Among them, there were 1,135 participants from 19 studies on diaphragm, 259 participants from 6 studies on extra-diaphragmatic inspiratory muscles, and 560 participants from 14 studies on abdominal expiratory muscles. The ultrasonic evaluation of diaphragm and abdominal expiratory muscle thickness had a relatively typically approach, while, extra-diaphragmatic inspiratory muscles were mainly used in ICU that lack of a consistent paradigm.

Conclusion

Diaphragm and expiratory muscle ultrasound has been widely used in the assessment of respiratory muscle function. On the contrary, there is not enough evidence to assess extra-diaphragmatic inspiratory muscles by ultrasound. In addition, the thickness of the diaphragm on the hemiplegic side was lower than that on the non-hemiplegic side in stroke patients. For internal oblique muscle (IO), rectus abdominis muscle (RA), transversus abdominis muscle (TrA), and external oblique muscle (EO), most studies showed that the thickness on the hemiplegic side was lower than that on the non-hemiplegic side.Clinical Trial Registration: The protocol of this review was registered in the PROSPERO database (CRD42022352901).

Correlation between trunk rotation and lateral flexion range of motion, peak cough flow, and chest expansion in stroke patients

INTRODUCTION

Stroke patients have problems with voluntary movement and trunk control. Moreover, the respiratory function in stroke patients is affected by neurological impairment, which increases the incidence of respiratory complications.

OBJECTIVES

To determine the correlation between trunk rotation range of motion (TRROM) and trunk lateral flexion range of motion (TLFROM), peak cough flow (PCF), and chest expansion in stroke patients.

METHODS

This was an observational study involving 21 patients with a clinical diagnosis of stroke from October 2021 to January 2022. TRROM and TLFROM were assessed using smartphone applications (Compass and Clinometer), respectively, PCF was assessed using a peak flow meter, and chest expansion was assessed using a tape measure. Pearson's correlation was used to analyze the relationships between the variables.

RESULTS

Statistically significant correlations were found between TRROM and TLFROM (r = 0.91, p < 0.01) and between upper chest expansion and PCF (r = 0.59, p < 0.01). There were significant correlations between lower chest expansion and TRROM (r = 0.50, p < 0.05) and between lower chest expansion and TLFROM (r = 0.51, p < 0.05).

CONCLUSION

This study demonstrates the relationship between upper chest expansion and PCF. Upper chest expansion exercises should be considered to improve the PCF in stroke patients. In addition, a very strong positive correlation between TRROM and TLFROM was demonstrated. TRROM and TLFROM exercises should be considered to improve the lower chest expansion in stroke patients.

Assessment of Diaphragm in Hemiplegic Patients after Stroke with Ultrasound and Its Correlation of Extremity Motor and Balance Function

Background: A variety of functional disorders can be caused after stroke, among which impairment of respiratory function is a frequent and serious complication of stroke patients. The aim of this study was to examine diaphragmatic function after stroke by diaphragm ultrasonography and then to apply to explore its correlation with extremity motor function and balance function of the hemiplegia patients. Methods: This cross-sectional observational study recruited 48 hemiplegic patients after stroke and 20 matched healthy participants. The data of demographic and ultrasonographic assessment of all healthy subjects were recorded, and 45 patients successfully underwent baseline data assessment in the first 48 h following admission, including post-stroke duration, stroke type, hemiplegia side, pipeline feeding, pulmonary infection, ultrasonographic assessment for diaphragm, Fugl−Meyer Motor Function Assessment Scale (FMA Scale), and Berg Balance Scale assessment. Ultrasonographic assessment parameters included diaphragm mobility under quiet and deep breathing, diaphragm thickness at end-inspiratory and end-expiratory, and calculated thickening fraction of the diaphragm. The aim was to analyze the diaphragm function of hemiplegic patients after stroke and to explore its correlation with extremity motor function and balance function. Results: The incidence of diaphragmatic dysfunction under deep breath was 46.67% in 45 hemiplegia patients after stroke at the convalescent phase. The paralyzed hemidiaphragm had major impairments, and the mobility of the hemiplegic diaphragm was significantly reduced during deep breathing (p < 0.05). Moreover, the thickness fraction of hemiplegic side was extremely diminished when contrasted with the healthy control and non-hemiplegic side (p < 0.05). We respectively compared the diaphragm mobility under deep breath on the hemiplegic and non-hemiplegic side of patients with left and right hemiplegia and found there was no significant difference between the hemiplegic side of right and left hemiplegia (p > 0.05), but the non-hemiplegic side of right hemiplegia was significantly weaker than that of left hemiplegia patients (p < 0.05). The diaphragm mobility of stroke patients under quiet breath was positively correlated with age and FMA Scale score (R2 = 0.296, p < 0.05), and significant positive correlations were found between the diaphragm mobility under deep breath and Berg Balance Scale score (R2 = 0.11, p < 0.05), diaphragm thickness at end-inspiratory and FMA Scale score (R2 = 0.152, p < 0.05), and end-expiratory thickness and FMA Scale score (R2 = 0.204, p < 0.05). Conclusions: The mobility and thickness fraction of the hemiplegic diaphragm after stroke by diaphragm ultrasonography were significantly reduced during deep breathing. Diaphragm mobility on bilateral sides of the right hemiplegia patients were reduced during deep breathing. Moreover, the hemiplegic diaphragmatic function was positively correlated with extremity motor and balance function of the hemiplegia patients.

Breathing Exercises for Improving Cognitive Function in Patients with Stroke

Patients with stroke may experience a certain degree of cognitive decline during the period of recovery, and a considerable number of such patients have been reported to show permanent cognitive damage. Therefore, the period of recovery and rehabilitation following stroke is critical for rapid cognitive functional improvements. As dysfunctional breathing has been reported as one of the factors affecting the quality of life post stroke, a number of studies have focused on the need for improving the breathing function in these patients. Numerous breathing exercises have been reported to enhance the respiratory, pulmonary, cognitive, and psychological functions. However, scientific evidence on the underlying mechanisms by which these exercises improve cognitive function is scattered at best. Therefore, it has been difficult to establish a protocol of breathing exercises for patients with stroke. In this review, we summarize the psychological, vascular, sleep-related, and biochemical factors influencing cognition in patients and highlight the need for breathing exercises based on existing studies. Breathing exercises are expected to contribute to improvements in cognitive function in stroke based on a diverse array of supporting evidence. With relevant follow-up studies, a protocol of breathing exercises can be developed for improving the cognitive function in patients with stroke.

Comparing the Effects of Short-Term Liuzijue Exercise and Core Stability Training on Balance Function in Patients Recovering From Stroke: A Pilot Randomized Controlled Trial

Aims

Liuzijue Qigong (LQG) exercise is a traditional Chinese exercise method in which breathing and pronunciation are combined with movement guidance. Breathing is closely related to balance, and LQG, as a special breathing exercise, can be applied to balance dysfunction after stroke. The purpose of this study was to observe the clinical effects of short-term LQG exercise on balance function in patients recovering from stroke.

Methods

Stroke patients were randomly divided into an Intervention Group (IG) (n = 80) and a Control Group (CG) (n = 80). The IG received conventional rehabilitation training plus LQG and the CG received conventional rehabilitation training plus Core Stability Training (CST). All patients received treatment once a day, 5 times a week for 2 weeks. The primary outcome was Berg Balance Scale (BBS). Secondary outcome measures were static standing and sitting balance with eyes open and closed, Fugl-Meyer Assessment (FMA), Maximum Phonation Time (MPT), Modified Barthel Index (MBI) and diaphragm thickness and mobility during quiet breath (QB) and deep breath (DB).

Results

Compared with the CG, the IG showed significant improvement in the BBS (10.55 ± 3.78 vs. 9.06 ± 4.50, P = 0.039), MPT (5.41 ± 4.70 vs. 5.89 ± 5.24, P = 0.001), MBI (12.88 ± 6.45 vs. 10.00 ± 4.84, P = 0.003), diaphragmatic mobility during QB (0.54 ± 0.73 vs. 0.33 ± 0.40, P = 0.01) and diaphragmatic mobility during DB (0.99 ± 1.32 vs. 0.52 ± 0.77, P = 0.003), Cop trajectory in the standing position with eyes open (−108.34 ± 108.60 vs. −89.00 ± 140.11, P = 0.034) and Cop area in the standing positions with eyes open (−143.79 ± 431.55 vs. −93.29 ± 223.15, P = 0.015), Cop trajectory in the seating position with eyes open (−19.95 ± 23.35 vs. −12.83 ± 26.64, P = 0.001) and Cop area in the seating position with eyes open (−15.83 ± 9.61 vs. −11.29 ± 9.17, P = 0.002).

Conclusions

The short-term LQG combined with conventional rehabilitation training significantly improved the balance functions of stroke patients. It also improved static standing and sitting balance with the eyes open, diaphragm functions, maximum phonation time and the quality of daily life for stroke patients.

Clinical Trial Registration

http://www.chictr.org.cn/edit.aspx?pid=25313&amp;htm=4, Identifier: ChiCTR1800014864.

Stroke and breathing

Stroke remains a leading cause of neurologic disability with wide ranging effects, including a variety of respiratory abnormalities. Stroke may influence the central control of the respiratory drive and breathing pattern, airway protection and maintenance, and the respiratory mechanics of inspiration and expiration. In the acute phase of stroke, the central control of breathing is affected by changes in consciousness, cerebral edema, and direct damage to brainstem respiratory centers, resulting in abnormalities in respiratory pattern and loss of airway protection. Common acute complications related to respiratory dysfunction include dysphagia, aspiration, and pneumonia. Respiratory control centers are located in the brainstem, and brainstem stroke causes specific patterns of respiratory dysfunction. Depending on the exact location and extent of stroke, respiratory failure may occur. While major respiratory abnormalities often improve over time, sleep-disordered breathing remains common in the subacute and chronic phases and worsens outcomes. Respiratory mechanics are impaired in hemiplegic or hemiparetic stroke, contributing to worse cardiopulmonary health in stroke survivors. Interventions to address the respiratory complications are under researched, and further investigation in this area is critical to improving outcomes among stroke survivors.

Efficacy of chest expansion resistance exercise on respiratory function, trunk control and dynamic balance in patients with chronic stroke: A Comparative study

Background

Motor impairments caused by stroke result in impaired diaphragmatic and respiratory muscle function, changes in thoracic biomechanics on the hemiparetic side ultimately resulting in decreased efficiency of lung ventilation. This study aimed to examine the efficacy of chest expansion resistance exercise (CERE) on respiratory function, trunk control ability, and balance in patients with chronic stoke. Following a purposive sampling, thirty-five patients with chronic stroke were randomly allocated into two groups, i.e., the experimental group receiving CERE with conventional therapy and the control group receiving conventional therapy alone. Both the groups received therapy four times per week for a period of four weeks (total 16 sessions). Following assessments were done before and after treatment in both the groups: chest expansion ( axillary, nipple, xiphisternal levels) using measure tape, respiratory muscle strength using micro-respiratory pressure meter, trunk control using the Trunk Impairment Scale, and balance using mini-Balance Evaluation Systems Test.

Results

Both groups had 17 participants each (n = 34, drop-outs = 1) consisting of 12 males and 5 females having a mean age of 56.5 ± 12.98 years and 59.7 ± 10.2 years, respectively. Intra-group analysis showed a statistically significant increase in mean values of chest expansion, respiratory muscle strength, trunk control ability, and balance in the experimental group whereas the control group showed improvement only in trunk control ability and balance. Inter-group comparison revealed a better improvement in all the outcome variables in experimental group compared to the control group.

Conclusions

Based on these results, this study proved that CERE was more effective in improving respiratory function, trunk control, and balance in patients with chronic stroke.

The effect of trunk training on trunk control, upper extremity, and pulmonary function in children with Duchenne muscular dystrophy: A randomized clinical trial

OBJECTIVES

To investigate the effect of trunk training on trunk control, arm, and pulmonary function in children with Duchenne muscular dystrophy.

DESIGN

A randomised controlled trial.

SETTINGS

Neuromuscular diseases clinic of university hospital.

SUBJECTS

Twenty-six children with Duchenne muscular dystrophy aged 5-16 were included in the study.

INTERVENTION

Participants were randomly allocated into two groups. The study group (N = 13) exercised with the trunk-oriented exercise program and the conventional exercise program, whereas the control group (N = 13) underwent the conventional exercise program for eight weeks.

MAIN MEASURES

The primary outcomes were trunk control was assessed using the Trunk Control Measurement Scale, the arm function was assessed using Performance of Upper Limb, and respiratory function using the pulmonary function test. Data collection was conducted at baseline, and eighth week. The differences in trunk control scores, arm function scores, and respiratory function values before and after the training were calculated for the intergroup comparison.

RESULTS

The mean age of the participants was 11.6 (2.6) in the study group and 10.6 (3.4) in the control group. The changes between trunk control score, arm function score (total and distal level score), and respiratory function value (Forced Vital Capacity, Forced Expiratory Volume in one second, and Peak Expiratory Flow Volume percentage values) were compared and significant differences were found after eight week periods in the study and control groups.

CONCLUSIONS

Trunk-oriented exercise program in Duchenne muscular dystrophy might be effective for trunk control, arm, and respiratory function.

Investigating the correlation between pulmonary function tests and ultrasonographic diaphragm measurements and the effects of respiratory exercises on these parameters in hemiplegic patients

Objective: To investigate the correlation of DUS and pulmonary function tests (PFTs), and investigate the effects of respiratory exercises on the above parameters.Methods: For the treatment group (n=20), neurological rehabilitation and respiratory exercise program, and for the control group (n=21), only a neurological rehabilitation program was implemented for 30 sessions. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), end-inspiration diaphragm thickness (IDT), end-expiratory diaphragm thickness (EDT), and diaphragm thickening ratio (DTR) were measured pre- and post-treatment.Results: IDTs and EDTs as well as DTRs of affected side (p < .001, .001, and .03, respectively) and intact side (p < .001, .001, and .02, respectively) were found to improve post-treatment than before treatment in the treatment group. Similarly, FVC, FEV1, and FEV1/FVC, were better post-treatment than before treatment in the treatment group. Moreover, the affected side IDT was positively correlated with FVC and FEV1 before treatment (r = .38, p = .03 and r = .35, p = .02) and post-treatment (r = .46, p = .02 and r = .39, p = .03). The affected side DTR was positively correlated with FVC and FEV1 before treatment (r = .44, p = .01 and r = .40, p = .02) and post-treatment (r = .32, p = .03 and r = .40, p = .04).Conclusion: DUS can be used for the evaluation of respiratory problems in stroke patients. Moreover, breathing exercises improve these parameters in stroke patients, and they can be followed up by DUS.

Prestroke VO2max by the Jurca prediction index as a predictor of functional outcomes in stroke patients

BACKGROUND

Prestroke cardiopulmonary fitness (CPF) levels can affect post-stroke respiratory function and functional status, including gait and activities of daily living (ADL).

OBJECTIVES

To investigate the prestroke CPF level measured by the Jurca prediction index as a predictor of functional outcomes after stroke and to evaluate the association between estimated prestroke CPF and respiratory function after stroke.

METHODS

This was a prospective observational study involving 71 inpatients with first-time subacute stroke between June 2017 and July 2019. The prestroke VO₂max was assessed using the Jurca prediction index, which was calculated from age, sex, resting heart rate, body mass index, and physical activity level. Linear regression analysis was performed to determine the relationship between the Jurca prediction index, functional outcomes, pulmonary functions, and cough strength variables.

RESULTS

The estimated prestroke VO₂max was significantly associated with the post-stroke Berg Balance Scale (β=1.199, P<0.001), Trunk Impairment Scale (β=0.308, P=0.006), and Functional Independence Measure score (β=1.102, P=0.004) at admission, and these relationships remained significant at the follow-up evaluation after 1 month of conventional rehabilitation (P<0.001). Among the respiratory function variables, only peak cough flow (PCF) (β=0.696, P=0.037) was significantly associated with the estimated prestroke VO₂max.

CONCLUSIONS

Prestroke CPF likely affects the stability of core muscles that are related to PCF and the functional status, including balance function and ADL after stroke. Regular exercise to increase the CPF level should be encouraged in patients with risk factors for stroke, not only for primary prevention but also for functional improvement after stroke.

The effects of dynamic core-postural chain stabilization on respiratory function, fatigue and activities of daily living in subacute stroke patients: A randomized control trial

BACKGROUND

Neurodevelopmental treatment (NDT) and dynamic core-postural chain stabilization (DCS)- based exercise is effective for improving core stability and postural control in stroke patients. However, no study has reported respiratory function, increased fatigue and ADL function in subacute stroke patients by training using NDT and DCS exercises.

OBJECTIVE

To compare the effects of DCS and NDT exercises on respiratory function, fatigue and activities of daily living in individuals with hemiparetic stroke.

METHODS

Thirty-one participants with hemiparetic stroke (17 male, 14 female; mean age 60.4±14.58 years; post-stroke duration, 7.2±2.2 weeks) participated in this study. The participants were randomly allocated into DCS (n = 16) and NDT (n = 15). Respiratory function was determined using forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP). The fatigue severity scale (FSS) and functional independent measure (FIM) were used to evaluate fatigue severity and activities of daily living (ADL). Analysis of covariance (ANCOVA) was used to evaluate post-test differences in the DCS and NDT exercise groups.

RESULTS

ANCOVA revealed the superior effects of DCS in respiratory function, as well as clinical FSS and FIM tests, compared with those of NDT (p < 0.05).

CONCLUSIONS

The results suggest that DCS training was more effective than NDT training at improving respiratory function, fatigue severity and ADL via balanced co-activation of the diaphragm and increased diaphragm movement in individuals with hemiparetic stroke.

Effects of inspiratory muscle training on walking capacity of individuals after stroke: A double-blind randomized trial

OBJECTIVES

Identify the effects of inspiratory muscle training (IMT) on walking capacity, strength and inspiratory muscle endurance, activities of daily living, and quality of life poststroke.

DESIGN

Double-blind randomized trial.

SETTING

The Sarah Network of Rehabilitation Hospitals.

SUBJECTS

Adult poststroke inpatients with inspiratory muscle weakness.

INTERVENTIONS

The Experimental Group (EG) (n = 23) underwent IMT for 30 minutes/day, five times/week over six weeks. The Control Group (CG) (n = 27) performed sham IMT. Both groups underwent standard rehabilitation.

MAIN MEASURES

Primary outcome was post-intervention six-minute walking test (6MWT) distance. We also measured maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), inspiratory muscle endurance, activities of daily living (functional independence measure - FIM), and quality of life at baseline and post-intervention. Three months after intervention, we measured MIP, walking capacity and quality of life.

RESULTS

Baseline characteristics were similar, with mean age 53 ± 11 years and FIM 74 ± 10p. Both groups similarly increased the walking capacity at six weeks (63 vs 67 m, P = 0.803). Compared to the CG, the EG increased the inspiratory endurance (22 vs 7 cmH₂O, P = 0.034) but there was no variation in MEP (14 vs 5 cmH₂O, P = 0.102), MIP (27 vs 19 cmH₂O, P = 0.164), FIM (6 vs 6, P = 0.966) or quality of life (0 vs 0.19, P = 0.493). Gains in both groups were sustained at three months.

CONCLUSION

Adding IMT to a rehabilitation program improves inspiratory muscle endurance, but does not further improve MIP, 6-MWT distance, activities of daily living or quality of life of individuals after stroke beyond rehabilitation alone.Registered in Clinical Trials, NCT03171272.

Recovery process of respiratory muscle strength in patients following stroke: A Pilot Study

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.

Stroke Severity and Maximum Inspiratory Pressure are Independently Associated with Functional Mobility in Individuals After Stroke

BACKGROUND

Clinical changes after stroke can contribute to reduced mobility and negatively affect the survival of these individuals. The objective of this study was to verify factors associated with functional mobility in stroke individuals.

METHODS

Crosssectional study carried out with stroke individuals in an outpatient clinic. Demographic and clinical data were collected and the following measures were applied: National Institute of Health Stroke Scale (NIHSS), modified Barthel Index, Trunk Impairment Scale, Functional Reach Test, Timed Up and Go Test, and the International Physical Activity Questionnaire. Respiratory muscle strength was assessed by measuring the maximum inspiratory pressure (MIP) and the maximum expiratory pressure (MEP).Variables with p < .05 in univariate logistic regression analysis were included in the multivariate logistic regression model, using the backward stepwise method.

RESULTS

53 individuals were enrolled with a mean age of 55 years (±13.43). 51% were male and the median NIHSS score was 2.25 (0-13). The final multivariate model included NIHSS (OR = 1.872; 95% CI 1.167-3.006; p = 0.009), physical therapy treatment (OR = 15.467; 95% CI 1.838-130.178; p = 0.012) and MIP (OR = 1.078; 95% CI 1.024-1.135; p = 0.004).

CONCLUSION

Stroke severity and inspiratory muscle strength were factros associated with functional mobility in individuals after stroke, regardless stroke time.

Comparative Effect of Liuzijue Qigong and Conventional Respiratory Training on Trunk Control Ability and Respiratory Muscle Function in Patients at an Early Recovery Stage From Stroke: A Randomized Controlled Trial

OBJECTIVES

To compare the effects of Liuzijue Qigong and conventional respiratory training on trunk control ability and respiratory muscle functions in patients at an early recovery stage from stroke.

DESIGN

A single-blind, randomized controlled trial.

SETTING

A hospital.

PARTICIPANTS

Patients (N=60) within 2 months poststroke.

INTERVENTIONS

The experimental group (n=30) received conventional rehabilitation training combined with Liuzijue exercise, and the control group (n=30) received conventional rehabilitation training combined with conventional respiration training. The training in the 2 groups was conducted 5 times per week for 3 weeks.

MAIN OUTCOME MEASURES

Trunk Impairment Scale (TIS), maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF), maximum expiratory mid-flow (MMEF), diaphragmatic movement, the change of intra-abdominal pressure (IAP), Berg Balance Scale (BBS), and Modified Barthel Index (MBI). All outcome measures were assessed twice (at baseline and 3 weeks).

RESULTS

Both groups significantly improved in TIS, MIP, FVC, PEF, and the change of IAP, BBS, and MBI when pre- and postassessments (P<.05) were compared. Compared with the control group, there was a significant difference in the experimental group in the static sitting balance subscale (P=.014), dynamic balance subscale (P=.001), coordination subscale (P<.001), TIS total scores (P<.001; effect size [ES]=0.9), MIP (P=.012; 95% confidence interval [CI], 2.23-17.69; ES=0.67), MEP (P=.015; 95% CI, 1.85-16.57; ES=0.65), change of IAP (P=.001), and MBI (P=.016; 95% CI, 1.51-14.16; ES=0.64). No significant differences were found between the 2 groups in FEV1 (P=.24), FVC (P=.43), PEF (P=.202), MMEF (P=.277), the diaphragmatic movement of quiet breathing (P=.146), deep breathing (P=.102), and BBS (P=.124).

CONCLUSIONS

Liuzijue exercise showed more changes than conventional respiratory training in improving trunk control ability, respiratory muscle functions, and activities of daily living ability in patients at an early recovery stage from stroke.

Effectiveness of Respiratory Muscle Training for Pulmonary Function and Walking Ability in Patients with Stroke: A Systematic Review with Meta-Analysis

Background: Neurological dysfunction due to stroke affects not only the extremities and trunk muscles but also the respiratory muscles. Aim: to synthesise the evidence available about the effectiveness of respiratory muscle training (RMT) to improve respiratory function parameters and functional capacity in poststroke patients. Methods: a systematic electronic search was performed in the MEDLINE, EMBASE, SPORTDiscus, PEDro and Web of Science databases, from inception to May 2020. Study selection and data extraction: randomised controlled trials (RCTs) that examined the effects of RMT versus non-RMT or sham RMT in poststroke patients. We extracted data about respiratory function, respiratory muscle strength and functional capacity (walking ability, dyspnea, balance, activities of daily life), characteristics of studies and features of RMT interventions (a type of RMT exercise, frequency, intensity and duration). Two reviewers performed study selection and data extraction independently. Results: nineteen RCTs met the study criteria. RMT improved the first second forced expiratory volume (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF), maximal expiratory pressure (MEP), maximal inspiratory pressure (MIP) and walking ability (6 min walking test), but not Barthel index, Berg balance scale, and dyspnea. Conclusions: RMT interventions are effective to improve respiratory function and walking ability in poststroke patients.

Comparison of Diaphragmatic Breathing Exercises, Volume, and Flow-Oriented Incentive Spirometry on Respiratory Function in Stroke Subjects: A Non-randomized Study

Abstract.

BACKGROUND

Reduced respiratory muscle strength leads to reduced pulmonary function, chest wall movements in the affected side, and increased chest infections, which thereby reduces oxygenation and ventilation. Respiratory muscle training can be used in acute stroke subjects to increase their pulmonary function.

PURPOSE

To compare the short-term effects of diaphragmatic breathing exercise, flow, and volume-oriented incentive spirometry on respiratory function following stroke.

METHODS

A non-randomized hospital-based study was conducted at Kasturba Medical College Hospitals, Mangalore, India. Forty-two sub-acute subjects of either gender, with the first episode of stroke within six months, were assigned to three groups by the consultant, i.e., diaphragmatic breathing group (DBE), Flow oriented-incentive spirometry group (FIS), and volume oriented-incentive spirometry group (VIS; N = 14) each. All subjects received intervention thrice daily, along with conventional stroke rehabilitation protocols throughout the study period. Pre- and post-intervention values were taken on alternate days until day 5 for all the three groups.

RESULTS

The pulmonary function and maximal respiratory pressures were found to be significantly increased by the end of intervention in all three groups, but FIS and DBE groups had better results than VIS (FVC = FIS group, 13.71%; VIS group, 14.89%; DBE group, 21.27%, FEV1 = FIS group, 25.97%; VIS group, 22.52%; DBE group, 19.38%, PEFR = FIS group, 38.76%; VIS group,9.75%; DBE group, 33.16%, MIP = FIS group, 28.23%; VIS group, 19.36%; DBE group, 52.14%, MEP = FIS group, 43.00%; VIS group, 22.80%; DBE group, 28.68%).

CONCLUSION

Even though all interventions had positive outcomes in all variables, flow incentive spirometry had better results across all outcomes (pulmonary function and maximal respiratory pressures) when compared to the other two interventions making it a valuable tool for stroke rehabilitation.

Can Pulmonary Function Testing Predict the Functional Outcomes of Poststroke Patients?: An Observational Study

OBJECTIVE

Patients with stroke may experience pulmonary dysfunction that reduces movement of the muscles involved in postural control and respiration. This study aimed to evaluate the relationship between postural control and respiratory muscle strength using pulmonary function testing. We sought to identify the respiratory function parameters that predict the functional outcomes patients with stroke at discharge.

DESIGN

We prospectively recruited 52 patients with first-ever stroke within 6 mos of onset. Peak cough flow, maximal inspired pressure, maximal expired pressure, forced vital capacity, and forced expiratory volume in 1 sec were measured at baseline and after 4 wks of rehabilitation. The primary outcomes were trunk balance measured using the Trunk Impairment Scale and functional outcomes measured using the Berg Balance Scale and functional independence measure.

RESULTS

The initial peak cough flow, forced vital capacity, and forced expiratory volume in 1 sec values correlated with the Trunk Impairment Scale scores at admission; only the initial peak cough flow and forced vital capacity were predictive factors for the final Trunk Impairment Scale score. Multivariable linear regression analysis showed that the initial peak cough flow was a significant predictive factor for follow-up test scores at discharge: Berg Balance Scale (P < 0.001) and functional independence measure (P < 0.025).

CONCLUSION

Initial respiratory function was significantly correlated with trunk balance and the functional outcomes.

Respiratory Muscle Training Improves Strength and Decreases the Risk of Respiratory Complications in Stroke Survivors: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the effects of respiratory muscle training in a population of stroke patients.

DATA SOURCES

The following databases were searched for clinical trials through December 2019: PubMed, EMBASE, Cochrane Library, CINAHL, and China National Knowledge Infrastructure.

STUDY SELECTION

Randomized controlled trials (N=9) published in English met the inclusion criteria.

DATA EXTRACTION

Data were extracted and assessed for accuracy by 2 reviewers. Any disagreements were resolved after discussions with an independent third reviewer. The quality of the included randomized controlled trials was assessed using the Cochrane bias tool.

DATA SYNTHESIS

The meta-analysis showed increased maximal inspiratory pressure (standardized mean difference [SMD], 0.88; 95% confidence interval [CI], 0.62-1.15; P<.001; 12-wk follow-up period: SMD, 0.94; 95% CI, 0.42-1.45; P<.001), maximal expiratory pressure (SMD, 0.83; 95% CI, 0.15-1.52; P=.017; 12-wk follow-up period: SMD, 0.99; 95% CI, 0.47-1.51; P<.001), forced expiratory volume in 1 second (SMD, 1.41; 95% CI, 0.57-2.24; P=.001), forced vital capacity (SMD, 1.36; 95% CI, 0.55-2.16; P<.001), peak expiratory flow (SMD, 0.74; 95% CI, 0.16-1.32; P=.013), 6-minute walk test (SMD, 0.67; 95% CI, 0.11-1.23; P=.020), and decreased respiratory complications (odds ratio, 0.55; 95% CI, 0.30-1.00; P=.050) compared with no respiratory intervention or a sham intervention.

CONCLUSIONS

Respiratory muscle training improved poststroke muscle strength and the benefits were carried over for up to 12 weeks, including improved lung function, walking capacity, and a reduced risk of respiratory impediments.

Effectiveness of LiuZiJue Qigong versus traditional core stability training for poststroke patients complicated with abnormal trunk postural control: study protocol for a single-center randomized controlled trial

BACKGROUND

Trunk function in stroke patients with hemiplegia is associated with respiration and core stability and is also found to be associated with balance and postural control and activities of daily living. LiuZiJue Qigong (LQG) is a traditional Chinese method of fitness based on breath pronunciation. The purpose of this study is to compare the clinical efficacy of LQG and traditional core stability training in the treatment of stroke patients with abnormal trunk posture. This protocol is written according to the SPIRIT 2013 statement.

METHODS/DESIGN

This study is a single-center randomized controlled trial in which 160 stroke patients are randomly divided into a study group and a control group. Patients in the study group will receive LQG combined with conventional rehabilitation therapy, and patients in the control group will receive traditional core stability training combined with conventional rehabilitation therapy. All treatments will be done for 45 min/day, five times per week, for 2 weeks. The primary outcome (Trunk Impairment Scale) and secondary outcomes (Berg Balance Scale, Fugl-Meyer Assessment, Modified Barthel Index, Maximum Phonation Time, Dynamic and Static balance testing, and thickness and the mobile degrees of diaphragm) will be measured at baseline, 2 weeks, and the end of the rehabilitation course.

DISCUSSION

The aim purpose of this research study is to compare the clinical efficacy of LQG and traditional core stability exercise in the treatment of stroke patients with abnormal trunk posture.

TRIAL REGISTRATION

Chinese Clinical Trial Register, ChiCTR1800014864. Registered on 24 November 2018.

Incidence and predictive factors of diaphragmatic dysfunction in acute stroke

Background

The most characteristic clinical signs of stroke are motor and/or sensory involvement of one side of the body. Respiratory involvement has also been described, which could be related to diaphragmatic dysfunction contralateral to the brain injury. Our objective is to establish the incidence of diaphragmatic dysfunction in ischaemic stroke and analyse the relationship between this and the main prognostic markers.

Methods

A prospective study of 60 patients with supratentorial ischaemic stroke in the first 48 h. Demographic and clinical factors were recorded. A diaphragmatic ultrasound was performed for the diagnosis of diaphragmatic dysfunction by means of the thickening fraction, during normal breathing and after forced inspiration. Diaphragmatic dysfunction was considered as a thickening fraction lower than 20%. The appearance of respiratory symptoms, clinical outcomes and mortality were recorded for 6 months. A bivariate and multivariate statistical analysis was designed to relate the incidence of respiratory involvement with the diagnosis of diaphragmatic dysfunction and with the main clinical determinants.

Results

An incidence of diaphragmatic dysfunction of 51.7% was observed. 70% (23 cases) of these patients developed symptoms of severe respiratory compromise during follow-up. Independent predictors were diaphragmatic dysfunction in basal respiration (p = 0.026), hemiparesis (p = 0.002) and female sex (p = 0.002). The cut-off point of the thickening fraction with greater sensitivity (75.75%) and specificity (62.9%) was 24% (p = 0.003).

Conclusions

There is a high incidence of diaphragmatic dysfunction in patients with supratentorial ischaemic stroke which can be studied by calculating the thickening fraction on ultrasound. Among these patients we have detected a higher incidence of severe respiratory involvement.

Evaluation of Respiratory Muscular Strength Compared to Predicted Values in Patients with Stroke

The purpose of this study was to evaluate the inspiratory and expiratory muscle strength of individuals affected by stroke and to compare it with the predicted values in the literature considering their corresponding age. Respiratory muscle strength was evaluated in 22 elderly people who had sequels of stroke, four with right hemiparesis, 16 with left hemiparesis and two with bilateral, of ages ranging from 34 to 82 years. The collected data were submitted to statistical analysis using a Mann–Whitney test to evaluate if there was a significant difference in the average data collected when compared with a mean of the predicted data in the literature. Fourteen men and eight women were evaluated, who obtained mean values of 71.85 cmH₂O and 57.75 cmH₂O, respectively, for a maximal inspiratory pressure (MIP), and when compared to the predicted values for men and women, 105.41 cmH₂O (p-value 0.0019) and 80.57 cmH₂O (p-value 0.00464) were significantly lower. For a maximal expiratory pressure (MEP), the mean value obtained for men was 62.28 cmH₂O and 49.5 cmH₂O for women, whereas the predicted values in the literature were 114.79 cmH₂O (p-value < 0.0001) and 78, 46 cmH₂O (p-value 0.0059), respectively. In the statistical analysis, it was possible to notice that the studied population did not reach the predicted age indexes and that there was a significant difference between the median columns. In conclusion, there is a weakness in the respiratory muscles of hemiparetic men and women due to stroke.

Respiratory Function and Grip Strength in the Acute Phase of Stroke Are Associated with Stroke Severity and Disability at Hospital Discharge

Introduction. Stroke can lead to musculoskeletal and respiratory dysfunction, chronic deconditioning, and functional limitations, as well as long-term complications.

Respiratory repercussions of neurological diseases and how best to manage them

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 are 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's 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 clinically relevant factors such as ambulation and trunk stability.

Feasibility and trend of pulmonary function in a pilot trial of aerobic walking exercise in non-ambulatory stroke survivors

Background: Lung function is compromised in stroke survivors, which may cause fatigue and exercise intolerance. Furthermore, past studies of aerobic exercise have involved only stroke survivors who could walk independently. Stroke survivors who were unable to walk were not included in the previous research-investigating changes in lung function from walking exercise interventions. In this pilot study, the feasibility and the effect of aerobic walking exercise on lung function was examined in non-ambulatory stroke survivors using a treadmill, bodyweight support system, and a gait training device.Methods: This study was a single group trial. Eight non-ambulatory stroke survivors (five males, mean age 63.3 ± 13.7 years, seven with ischemic stroke) completed a low intensity walking exercise program (30 min/session; three sessions/week for 8 weeks) and lung function test. Before and after the intervention, vital capacity (VC) and forced vital capacity (FVC) using a spirometer were measured according to the guideline from American Thoracic Society/European Respiratory Society.Results: The rates of compliance and attrition were 100% and 10%; respectively, and no adverse events were reported. There were significant differences between pre- and post-intervention assessments in FVC (p = .09), percentage of predicted VC (p = .08), and percentage of predicted FVC (p = .08).Conclusions: In non-ambulatory stroke survivors, aerobic walking exercise is feasible and safe. Also, the results are promising and suggest that aerobic walking exercise may improve lung function; more data are needed.

Immediate effects of the respiratory stimulation on ventilation parameters in ischemic stroke survivors: A randomized interventional study (CONSORT)

BACKGROUND

Post-stroke brain damage, which affects the central control of respiration, leads to various respiratory disorders. They can be caused by the weakening of the respiratory muscles and chest movements, which can indirectly contribute to an impairment of the ventilation function. The aim of the study is an objective assessment of the effect of a single-session intervention of respiratory stimulation through Proprioceptive Neuromuscular Facilitation (PNF) on chosen respiratory parameters and the following comparison of these changes with a group in which positioning was used (intra- and intergroup comparison).

METHODS

This was a randomized interventional study evaluating the respiratory parameters depending on the applied respiratory stimulation in patients after ischemic stroke. The patients qualified to participate in the study were randomly assigned to 1 of 2 groups: PNF-treated group - in which respiratory stimulation through PNF was used, PNF untreated group - in which positioning was used. The research procedure consisted of several stages. First, an interview was conducted with each participant and basic data was collected. Then, spirometry was conducted, after which each patient underwent a single-session intervention according to their assigned group. Finally, the patients were given another spirometry examination. The main outcomes will be to compare the results of a spirometry test (FVC, FEV1, FEV1/ FVC%, PEF) before and after single-session intervention and between groups.

RESULTS

Based on the inclusion and exclusion criteria for the study, 60 patients took part in the measurement. The values of FEV1/FVC% were higher in PNF-treated group than in PNF-untreated group, if the post-intervention measures (P = .04) are considered. The difference between the pre- and post-intervention results of the FEV1/FVC% values in PNF-untreated group was substantially lower than in PNF-treated group (P = .001).

CONCLUSION

A single application of respiratory stimulation through PNF positively affect air flow in the respiratory tract. Application of PNF stimulation contributed to an increase in the FEV1/FVC% parameter. However, no positive changes were noted in the other parameters, which would provide proof of the beneficial effect of facilitation on the respiratory system function.

Relationship between pulmonary function, functional independence, and trunk control in patients with stroke

OBJECTIVE

Stroke often leads to abnormalities in muscle tone, posture, and motor control that may compromise voluntary motor function, thus affecting the motor control required for maintaining the synergy of both peripheral and respiratory muscles. To evaluate respiratory muscle strength, pulmonary function, trunk control, and functional independence in patients with stroke and to correlate trunk control with the other variables.

METHODS

This was a cross-sectional study of patients diagnosed with stroke. We assessed respiratory muscle strength, trunk control as assessed by the Trunk Impairment Scale, spirometric variables, and the Functional Independence Measure.

RESULTS

Forty-four patients were included. Pulmonary function and respiratory muscle strength were significantly lower than predicted for the study population, and the mean Trunk Impairment Scale score was 14.3 points. The following significant correlations were found between the variables: trunk control vs. maximal inspiratory pressure (r = 0.26, p < 0.05); trunk control vs. forced vital capacity (r = 0.28, p < 0.05); trunk control vs. forced expiratory volume in one second (r = 0.29, p < 0.05), and trunk control vs. the Functional Independence Measure (r = 0.77, p < 0.05).

CONCLUSION

The present study showed that respiratory muscle strength, pulmonary function, functional independence, and trunk control are reduced in patients diagnosed with stroke.

Progressive Respiratory Muscle Training for Improving Trunk Stability in Chronic Stroke Survivors: A Pilot Randomized Controlled Trial

BACKGROUND

Stroke weakens the respiratory muscles, which in turn may influence the trunk stability; it is unclear whether the progressive respiratory muscle training (RMT) is effective in improving the trunk stability. The aim of this study was to investigate the effects of progressive RMT with trunk stabilization exercise (TSE) on respiratory muscles thickness, respiratory muscle functions, and trunk stability in chronic stroke survivors.

METHODS

This is a pilot randomized controlled trial. Chronic stroke survivors (n = 33) who were able to sit independently participated in the tstudy. The participants were allocated into the RMP with TSE group or the TSE group. The respiratory muscle thickness during resting and contraction were measured. Maximal expiratory pressure (MEP), peak expiratory flow (PEF), and forceful expiratory volume at 1 sec (FEV1) for forced expiratory muscle function and maximal inspiratory pressure (MIP), peak inspiratory flow (PIF), and vital capacity (VC) for inspiratory muscle function were examined. Trunk stability was estimated by maximal velocity and path length of the center of pressure (COP) by using a balance board with sitting posture.

RESULTS

The respiratory muscle thickness was significantly increased on the affected side in the RMT group than in the TSE group. The MEP, PEF, MIP, and PIF were significantly increased in the RMT group than in the TSE group; however, FEV1 and VC showed no significant differences between the 2 groups. Trunk stability for the maximal velocity of COP of extension and affected side bending was significantly increased in the RMT group than in the TSE group. In addition, the maximal path length of COP of flexion, extension, affected/less affected side bending was significantly increased in the RMT group than in the TSE group.

CONCLUSIONS

RMT combined with TSE can be suggested as an effective method to improve the respiratory muscle thickness, respiratory muscle functions, and trunk stability in chronic stroke survivors as opposed to TSE only.

Effectiveness of mid-thoracic spine mobilization versus therapeutic exercise in patients with subacute stroke: A randomized clinical trial

BACKGROUND

Although commonly used in clinical settings, evidence regarding the beneficial effectiveness of joint mobilization and therapeutic exercise in patients with stroke is still lacking.

OBJECTIVE

This study aimed to investigate the effects of mid-thoracic spine mobilization and therapeutic exercise on dynamic balance and inspiratory function in patients with subacute stroke.

METHODS

The participants included 33 patients with subacute stroke. Participants were randomly allocated to 1 of 2 groups: (1) a group that received segmental mobilization (T4-8), and (2) a group that received foam roller exercises (T4-8). Outcome measure included the limits of stability (LOS), inspiratory function, and global rating of change (GRC).

RESULTS

The improvement in inspiratory function was statistically significant at 4 and 6 weeks after the initiation of the intervention and changes in the LOS were statistically significant at 6 weeks in the mobilization group (p< 0.05). In addition, 15 of 17 (88.2%) participants in the mobilization group, compared to 9 of 16 participants (56.2%) in the exercise group, indicated a GRC score of +4 or higher at the 4-week follow-up.

CONCLUSIONS

This study demonstrates that patients with subacute stroke who receive mid-thoracic spine mobilization demonstrate effective short-term improvements in LOS and GRC.

Correlation between grip strength and pulmonary function and respiratory muscle strength in stroke patients over 50 years of age

Age-related skeletal muscle changes may impact respiratory muscle function, and low muscle mass is associated with low pulmonary function in older adults. Stroke not only causes weakness in the muscles of the upper and lower limbs, but it can also affect the respiratory system. This study aimed to investigate the relationships between grip strength and pulmonary function and respiratory muscle strength in stroke patients over 50 years of age. Fifty-one patients (68.69±10.40 years) who had been clinically diagnosed with ischemic or hemorrhagic stroke were included in this study. We measured these patients' forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV₁), peak expiratory flow (PEF), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and hand grip strength. The data were analyzed using descriptive statistics and Pearson correlation analysis. Grip strength showed significant correlations with FVC (r=0.686, P=0.000), FEV₁ (r=0.607, P=0.000), PEF (r=0.494, P=0.000), MIP (r=0.239, P=0.091), and MEP (r=0.348, P=0.012). This study demonstrated that grip strength is associated with pulmonary function and MEP in stroke patients over 50 years of age.

Decreased Respiratory Muscle Function Is Associated with Impaired Trunk Balance among Chronic Stroke Patients: A Cross-sectional Study

The abdominal muscles play a role in trunk balance. Abdominal muscle thickness is asymmetrical in stroke survivors, who also have decreased respiratory muscle function. We compared the thickness of the abdominal muscles between the affected and less affected sides in stroke survivors. In addition, the relationship between respiratory muscle function and trunk balance was evaluated. Chronic stroke patients (18 men, 15 women; mean age, 58.94 ± 12.30 years; Mini-Mental Status Examination score ≥ 24) who could sit without assist were enrolled. Abdominal muscle thickness during rest and contraction was measured with ultrasonography, and the thickening ratio was calculated. Respiratory muscle function assessment included maximum respiratory pressure, peak flow, and air volume. Trunk function was evaluated using the Trunk Impairment Scale, and trunk balance was estimated based on the center of pressure velocity and path length within the limit of stability in sitting posture. Abdominal muscles were significantly thinner on the affected side, and the thickening ratio was lower in the affected side (P < 0.05). In addition, the higher thickening ratio of the affected side showed significant relationship with higher trunk function. Moreover, higher respiratory muscle function was significantly correlated with higher level of trunk function and balance in stroke patients (P < 0.05). Thus, chronic stroke survivors have decreased abdominal muscle thickness on the affected side, and respiratory muscle function has positive correlation with trunk function and balance. We propose that respiratory muscle training should be included as part of trunk balance training in chronic stroke patients.

Prevalence of dyspnea after stroke: a telephone-based survey

OBJECTIVE

Dyspnea is a relevant outcome to be taken into consideration during stroke rehabilitation. Prevalence, severity, and effects of this condition on individuals with stroke remain uncertain. This study investigated the prevalence and severity of dyspnea after a stroke, as well the associations between dyspnea, activity limitations, and participation restrictions.

METHODS

A telephone-based survey was conducted with 285 individuals with stroke. The survey included information regarding the onset and severity of the dyspnea, activity limitations, and participation restrictions. Prevalence of dyspnea was reported as percentage of individuals who had the symptom. Chi-square tests were used to investigate the associations between dyspnea, activity limitations, and participation restrictions. Relative risks and respective 95% confidence intervals were calculated.

RESULTS

Out of the 285 participants, 124 (44%) reported having dyspnea after stroke. Severe symptoms were reported by 51% of the participants with dyspnea. In addition, dyspnea limited activity and restricted social participation in 85% and 49% of the participants, respectively. Dyspnea was significantly correlated with activity limitations (r=0.87; 95% CI 0.82-0.92; p<0.01) and participation restrictions (r=0.53; 95% CI 0.46-0.62; p<0.01). The analyses indicated that individuals with dyspnea were more likely to report that it limited their activities (RR: 6.5; 95% CI 4.3-9.9) and restricted social participation (RR: 1.7; 95% CI 1.5-2.0).

CONCLUSIONS

Dyspnea is an important symptom after stroke and showed to be associated with activity limitations and restrictions in community participation. Earlier detection of dyspnea in people with stroke, followed by appropriate management, is strongly recommended and has the potential to improve activity and social participation.

Immediate Effects of Thoracic Spinal Manipulation on Pulmonary Function in Stroke Patients: A Preliminary Study

OBJECTIVES

The purpose of this study was to investigate the immediate effects of thoracic spinal manipulation (TSM) on pulmonary function in stroke patients.

METHODS

Thirty-six volunteers with stroke (20 men, 16 women) were recruited and randomized to a TSM group (n = 18) and a sham group (n = 18). All participants underwent initial pulmonary function test and then rested supine for 10 minutes before the intervention. Pulmonary function test was repeated immediately after the intervention. Forced vital capacity, forced expiratory volume at 1 second, maximum voluntary ventilation, and residual volume were measured by a spirometer in preintervention and post-intervention.

RESULTS

Significant between-group differences were observed in forced vital capacity and forced expiratory volume at 1 second in the TSM group (P < .05). No significant changes in dependent variables were seen in the sham group.

CONCLUSION

The pulmonary function values for patients in the TSM group were significantly enhanced with no significant improvement in maximum voluntary ventilation and residual volume. Mechanical factors may be responsible for the improved pulmonary function in the TSM group.

The effect of respiratory exercise on trunk control, pulmonary function, and trunk muscle activity in chronic stroke patients

[Purpose] This study aims to identify the effect of respiratory exercise on trunk control, pulmonary function, and trunk muscle activity in chronic stroke patients. [Subjects and Methods] The study included 24 chronic stroke patients who were randomly assigned, 12 each, to the experimental and control groups, and received neurodevelopmental treatment. Moreover, the experimental group underwent respiratory exercise. In each patient, the trunk control was measured using the Trunk Impairment Scale (TIS); muscle activity of the trunk, through the surface electromyogram; and pulmonary function, using the pneumatometer. [Results] The intragroup comparison showed significant differences in TIS, Forced vital capacity (FVC), Forced expiratory volume at one second (FEV1), Rectus Abdominis (RA), Internal Oblique (IO) and External Oblique (EO) in the experimental group. The intergroup comparison showed that the differences in TIS, FVC, FEV1, RA, IO and EO within the experimental group appeared significant relative to the control group. [Conclusion] Based on these results, this study proved that respiratory exercise was effective in improving trunk control, pulmonary function, and trunk muscle activity in patients with chronic stroke.

The effect of chest expansion exercise with TENS on gait ability and trunk control in chronic stroke patients

[Purpose] The purpose of this study was to investigate the effect of chest expansion exercise with transcutaneous electrical nerve stimulation (TENS) on gait ability and trunk control of patient with stroke. [Subjects and Methods] The subjects were divided into 7 in the chest expansion exercise with TENS group (experimental group) and 7 in the chest expansion exercise with placebo TENS (control group). The gait ability and trunk contol were measured using Six-Minute Walk Test, Tinetti gait index and Trunk impairment scale (TIS). [Results] Both the experimental group and the control group showed significant improvement in the Six-Minute Walk Test, Tinetti gait index, and TIS total score. The dynamic sitting balance and coordination of TIS showed significant improvement only in the experimental group. In comparison between the two groups, the experimental group showed a more significant improvement in Tinetti gait index and TIS total score than the control group. [Conclusion] This study showed that chest expansion exercise with TENS was an effective method for improving gait ability and trunk control in chronic stroke patients.

Respiratory muscles stretching acutely increases expansion in hemiparetic chest wall

Individuals post-stroke may present restrictive ventilatory pattern generated from changes in the functionality of respiratory system due to muscle spasticity and contractures. Objective was to assess the acute effects after respiratory muscle stretching on the ventilatory pattern and volume distribution of the chest wall in stroke subjects. Ten volunteers with right hemiparesis after stroke and a mean age of 60 ± 5.7 years were randomised into the following interventions: respiratory muscle stretching and at rest (control). The ventilatory pattern and chest wall volume distribution were evaluated through optoelectronic plethysmography before and immediately after each intervention. Respiratory muscle stretching promoted a significant acute increase of 120 mL in tidal volume, with an increase in minute ventilation, mean inspiratory flow and mean expiratory flow compared with the control group. Pulmonary ribcage increased 50 mL after stretching, with 30 mL of contribution to the right pulmonary rib cage (hemiparetic side) in comparison to the control group. Respiratory muscle stretching in patients with right hemiparesis post-stroke demonstrated that acute effects improve the expansion of the respiratory system during tidal breathing.

CLINICAL TRIAL REGISTRATION

NCT02416349 (URL: https://clinicaltrials.gov/ct2/show/ NCT02416349).

The effect of the inspiratory muscle training on functional ability in stroke patients

[Purpose] This study was to find out an inspiratory muscle training (IMT) program therapeutic effects on stroke patients' functional ability. [Subjects and Methods] Twenty stroke patients were assigned to one of two groups: inspiratory muscle training (n=10), and control (n=10), randomization. The inspiratory muscle training participants undertook an exercise program for 30 minute per times, 5 times a week for 6 weeks. The investigator measured the patients' trunk impairment scale (TIS) and 6 minute walking test (6MW) for functional ability before and after IMT. [Results] The TIS appeared some significant differences in both groups before and after the training. The 6MW test showed some significant differences in the inspiratory muscle training group, but didn't show any significant difference in the control group. And the differences in both groups after depending the inspiratory muscle training were significantly found in the tests of TIS and 6MW test [Conclusion] The results showed that the inspiratory muscle training in stroke patients are correlated with the trunk stability and locomotion ability, suggesting that physical therapist must take into consideration the inspiratory muscle training, as well as functional training to improve physical function in stroke patients.

Combined respiratory muscle training facilitates expiratory muscle activity in stroke patients

[Purpose] The aim of this study was to investigate the effect of combined respiratory muscle training on expiratory muscle activity in stroke patients. [Subjects and Methods] Twenty-five stroke patients were assigned to either the intervention group (n=12) or the control group (n=13). Both groups participated in a conventional stroke rehabilitation program, while the intervention group also received respiratory muscle training for 20 to 30 minutes a day, 3 times a week, for 8 weeks. Surface electromyographic data were collected from the rectus abdominis, internal oblique, and external oblique on the paretic side. Pulmonary function (forced vital capacity) and cough capacity (peak expiratory flow) also were measured. [Results] Both groups showed a significant increase in muscle activity after the intervention. However, the intervention group also showed significant increases in forced vital capacity and peak expiratory flow. Comparison of the 2 groups revealed that the intervention group had greater improvements in pulmonary function, cough capacity, and muscle activity. [Conclusion] The results of this study suggest that combined respiratory muscle training has positive effects on both respiratory function and expiratory muscle activity in stroke patients.