Effects of Respiratory Muscle Training on Pulmonary Function in Individuals with Spinal Cord Injury: An Updated Meta-analysis

Rehabilitation to Improve Outcomes after Cervical Spine Surgery: Narrative Review

PURPOSE

The increasing elderly patient population is contributing to the rising worldwide load of cervical spinal disorders, which is expected to result in a global increase in the number of surgical procedures in the foreseeable future. Cervical rehabilitation plays a crucial role in optimal recovery after cervical spine surgeries. Nevertheless, there is no agreement in the existing research regarding the most suitable postsurgical rehabilitation program. Consequently, this review assesses the ideal rehabilitation approach for adult patients following cervical spine operations.

MATERIALS AND METHODS

This review covers activities of daily living and encompasses diverse treatment methods, including physiotherapy, specialized tools, and guidance for everyday activities. The review is organized under three headings: (1) historical perspectives, (2) patient-reported functional outcomes, and (3) general and disease-specific rehabilitation.

RESULTS

Rehabilitation programs are determined on the basis of patient-reported outcomes, performance tests, and disease prognosis. CSM requires strengthening of the neck and shoulder muscles that have been surgically invaded. In contrast, the CCI requires mobility according to the severity of the spinal cord injury and functional prognosis. The goal of rehabilitation for CCTs, as for CCIs, is to achieve ambulation, but the prognosis and impact of cancer treatment must be considered.

CONCLUSIONS

Rehabilitation of the cervical spine after surgery is essential for improving physical function and the ability to perform daily activities and enhancing overall quality of life. The rehabilitation process should encompass general as well as disease-specific exercises. While current rehabilitation protocols heavily focus on strengthening muscles, they often neglect the crucial aspect of spinal balance. Therefore, giving equal attention to muscle reinforcement and the enhancement of spinal balance following surgery on the cervical spine is vital.

Diaphragmatic strengthening exercises for patients with post COVID-19 condition after mild-to-moderate acute COVID-19 infection: a randomized controlled study

OBJECTIVE

To assess the clinical effects of incentive spirometry (IS) and diaphragmatic breathing (DB) in patients with post COVID-19 condition and diaphragmatic dysfunction as compared with the standard care alone.

METHODS

The present longitudinal randomized study included 60 patients with post COVID-19 condition and diaphragmatic dysfunction. Patients were equally randomized to receive standard care plus IS (G1), standard care plus DB (G2) or standard care alone (G3) for 8 weeks. The primary outcome is clinical improvement as evaluated by the modified Medical Research Council (mMRC) dyspnoea scale.

RESULTS

Comparison between the studied groups revealed significant improvement in G1 and G2 in all parameters at the end of follow-up. However, no significant improvement was found in G3. At the end of follow-up, 15 patients (75.0%) in G1, 11 patients (55.0%) in G2, and 3 patients (15.0%) in G3 showed improvement on the mMRC dyspnoea scale. Multivariate logistic regression analysis identified mild acute COVID-19 infection (p = 0.009), use of IS (p < 0.001), and use of DB (p = 0.023) as significant predictors of improvement on the mMRC dyspnoea scale.

CONCLUSIONS

IS or DB training in addition to the standard care in post COVID-19 condition was associated with better clinical improvement as compared with the standard care alone.

Comparison of two inspiratory muscle training protocols in people with spinal cord injury: a secondary analysis

STUDY DESIGN/SETTING

Secondary analysis.

OBJECTIVES

To compare the change in maximal inspiratory pressure (PImax) over the first 4 weeks of two different inspiratory muscle training (IMT) protocols and explore if either method is more effective for people with spinal cord injury.

METHODS

Data originated from two published studies. Participants completed flow-resistive IMT (F-IMT) at 80% daily PImax, 7 days/week (supervised weekly), or threshold IMT (T-IMT) at 30-80% weekly PImax, twice-daily, 5 days/week (supervised every session). Seven participants from each trial were matched by training adherence, level of spinal cord injury, impairment grade (A-C), and height. Differences between F-IMT and T-IMT groups in training intensity, breaths taken, inspiratory work, and the change in the PImax from baseline at the end of week four were analysed.

RESULTS

Over 4 weeks, there was no difference in the change in PImax between groups (Absolute change in PImax (cmH2O): p = 0.456, Percent change in PImax relative to baseline: p = 0.128). F-IMT participants trained at a higher intensity (median: 77 vs 22 cmH2O, p = 0.001 and 80% baseline vs 61% baseline, p = 0.038) but took fewer breaths (840 vs 1404 breaths, p = 0.017) than T-IMT participants. Inspiratory work was similar between groups (64,789 vs 65,910 (% PImax × number of breaths), p = 0.535).

CONCLUSIONS

Our findings support both methods of IMT as the change in PImax and inspiratory work were similar between groups. However, daily high-intensity F-IMT with intermittent supervision, required fewer breaths and less participant and therapist time. Future studies should examine optimal dosage and supervision required to achieve increased PImax.

A Secondary Analysis of Short- and Long-Term Variability of Inspiratory Muscle Performance in People Living With SCI

Objectives

To explore the expected variability in repeated short-term (ST) and long-term (LT) inspiratory muscle performance (IMP) in individuals with chronic spinal cord injury (SCI).

Methods

Maximal inspiratory pressure (MIP), sustained MIP (SMIP), and inspiratory duration (ID) were collected from 22 individuals with chronic SCI (C1-T9, American Spinal Injury Association Impairment Scale [AIS] A-C) over 18 months. ST data were collected four times within 2 weeks (n = 19). LT data were collected at two time points at least 7 months apart (n = 20).

Results

SMIP was the most reliable IMP assessment with an intraclass correlation coefficient (ICC) of 0.959, followed by MIP (ICC 0.874) and ID (ICC 0.689). The ID was the only ST measure to have a significant difference [MIP: F(3, 54) = 2.5, p = .07; SMIP: F(3, 54) = 1.3, p = .29; ID: F(1.4, 25.6) = 4.8, p = .03]. Post hoc analysis showed the mean day 1 ST ID measure was significantly different from both days 3 and 4. The percent change of ID from day 3 to day 6 was 11.6%. No LT measures differed significantly [mean change (SD) [95% CI] for MIP: 5.2 cm H2O (18.8) [-3.6, 13.9], p = .235; SMIP: 60.9 pressure time unit (166.1) [-16.9, 138.6], p = .118; ID: 0.1 s (2.5) [-1.1, 1.3], p = .855].

Conclusion

These data provide a foundation for understanding normal variance in ST and LT IMP in the SCI population. Change in MIP function outside 10% is likely a true and meaningful change and may help clinicians recognize individuals with SCI at risk for respiratory compromise. Future studies should explore changes in MIP and SMIP that are associated with meaningful functional changes.

A preliminary study on the feasibility of community game-based respiratory muscle training for individuals with high cervical spinal cord injury levels: a novel approach

Background

Respiratory disorders result in rehospitalization and premature death of patients with cervical spinal cord injuries (CSCI). Community game-based respiratory muscle training (RMT) programs could reduce secondary complications.

Methods

We examined the feasibility and preliminary efficacy of RMT as a community-based exercise program. Among the 10 included participants (eight male and two female), four, one, one, and four reported C3, C4, C5, and C6 complete injuries, respectively (eight graded by American Spinal Injury Association impairment scale [ASIA] A and two by ASIA B). Their mean age was 43 ± 12.3 y. The time since injury was 10 ± 6.7 y. The participants completed an RMT program for 60 min/day, twice weekly, for 8 weeks. The participants were trained in the use of a newly developed game-based RMT device. The device provides consistent pressure for respiratory muscle strength and endurance training. Seven RMT devices were modified to allow 10 game-based RMT programs. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), peak expiratory flow (PEF), vital capacity (VC), inspiratory capacity (IC), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), and peak cough flow (PCF) were measured.

Results

There were improvements after RMT compared to pre-RMT in FVC (p = 0.027, 10.62%, 0.22 effect size [ES]), PEF (p = 0.006, 23.21%, 0.45 ES), VC (p = 0.002, 35.52%, 0.60 ES), IC (p = 0.001, 46.94%, 0.81 ES), IRV (p = 0.001, 90.53%, 1.22 ES), MIP (p = 0.002, 97.25%, 1.32 ES), MEP (p = 0.005, 141.12%, 1.07 ES), and PCF (p = 0.001, 35.60%, 0.74 ES). The participants reported a positive impact of the program.

Conclusions

Community game-based RMT for individuals with CSCI appears to be safe and feasible. Community exercise with RMT use may have a positive impact on the respiratory measures for patients with CSCI who are vulnerable to respiratory compromise.

Trial registration

KCT0005980.

Adherence to and impact of home-based high-intensity IMT in people with spinal cord injury: a pilot study

Study design

The pilot study was completed in 5 phases (Control and 4 phases of IMT) incorporating assessments at Baseline 1 (BL1), BL2, Follow-up 1 (F1), F2, F3, and F4.

Objective

To assess the adherence and impact of a daily high-intensity (80% of max) inspiratory muscle training (IMT) home program with once weekly supervision for people with spinal cord injury (SCI).

Setting

Assessments: research institution or zoom. IMT: participant’s home.

Methods

Participants completed daily IMT in IMT Phase 1 and 2, once weekly in IMT Phase 3, self-selected frequency in IMT Phase 4. All phases had one weekly supervised session except IMT Phase 4. Primary outcomes included adherence and a difficulty score [DS (0- not difficult to 10- the most difficult)]. Secondary outcomes included respiratory function and seated balance.

Results

Data from 10 people with chronic SCI (>1 year) (Cervical level of injury: 6, AIS: A-B, injury duration: 10.9 years 95% CI [3.9, 18.1]) were used in the analysis. Participants completed 69% of their training days in IMT Phase 1 and 65% overall reporting an average DS of 7.4 ± 1.4. Only one participant completed training during IMT Phase 4. One participant’s training load was reduced due to suspected overtraining. Maximal inspiratory pressure (MIP), sustained MIP (SMIP), and total power (TP), improved significantly (p < 0.05) from BL2 to F1.

Conclusion

Our data suggest that people with SCI can perform high-intensity IMT at home to improve inspiratory performance. It is strongly recommended that participants be intermittently monitored for adherence and safety.

ClinicalTrials.gov Registration number: NCT04210063.

Appropriate Timing and Type of Physical Training in Patients with COVID-19 for Muscle Health and Quality of Life: A Systematic Review

Physical activity is beneficial to modulate immune system function and has inverse relationship to ARDS linked with SARS-CoV-2. Physical activity consists of daily activity and physical training. Studies regarding effect of physical training on patients with COVID-19 are controversial. This systematic review aims to investigate physical training on muscle health and QOL in patients with COVID-19. The literature review was carried out using keywords: (Exercise) AND (COVID) AND (Muscle) AND (Observational Study) in several databases of PubMed and Cochrane Central Register of Controlled Trials (CENTRAL). All references were reviewed using critical appraisal Newcastle Ottawa Scale (NOS) and Centre for Evidence-Based Medicine (CEBM) checklist. The studies were subsequently screened for reporting exercise, muscle, and COVID-19. The descriptions of the extracted data are guided by Preferred Reporting Items for Systematic Reviews (PRISMA) statement with GRADE approach. This study is registered in PROSPERO: ID CRD42021295188. Six studies pooled and entered review synthesis. Studies were reviewed using critical appraisal by NOS and CEBM. Two clinical trial studies and four observational designs were selected. Our result showed physical training improved patients' outcomes in the acute phase, critical phase, and post-COVID-19 phase. Multiple types of physical trainings were suggested by those studies, and most of them showed beneficial effects to patients with COVID-19 in different phases. The level of evidence by GRADE was downgraded, and further investigations are needed to establish guidelines and strong recommendation for a specific stage of COVID-19.

Electrical epidural stimulation of the cervical spinal cord: implications for spinal respiratory neuroplasticity after spinal cord injury

Traumatic cervical spinal cord injury (cSCI) can lead to damage of bulbospinal pathways to the respiratory motor nuclei and consequent life-threatening respiratory insufficiency due to respiratory muscle paralysis/paresis. Reports of electrical epidural stimulation (EES) of the lumbosacral spinal cord to enable locomotor function after SCI are encouraging, with some evidence of facilitating neural plasticity. Here, we detail the development and success of EES in recovering locomotor function, with consideration of stimulation parameters and safety measures to develop effective EES protocols. EES is just beginning to be applied in other motor, sensory, and autonomic systems; however, there has only been moderate success in preclinical studies aimed at improving breathing function after cSCI. Thus, we explore the rationale for applying EES to the cervical spinal cord, targeting the phrenic motor nucleus for the restoration of breathing. We also suggest cellular/molecular mechanisms by which EES may induce respiratory plasticity, including a brief examination of sex-related differences in these mechanisms. Finally, we suggest that more attention be paid to the effects of specific electrical parameters that have been used in the development of EES protocols and how that can impact the safety and efficacy for those receiving this therapy. Ultimately, we aim to inform readers about the potential benefits of EES in the phrenic motor system and encourage future studies in this area.

Development and pilot testing of novel game-based respiratory rehabilitation exercise devices for patients with tetraplegia

BACKGROUND:

Individuals with spinal cord injuries (SCI) show restricted breathing patterns with reduced lung volumes and capacities.

OBJECTIVE:

To improve breathing in such individuals, we aimed to develop breathing exercise devices using a user-centered design (UCD) and then assess the effects of these devices on breathing.

METHODS:

Patients with SCI were involved in the device development. Preliminary online survey participants were recruited from the community, and interview and pilot test participants were recruited from a patient self-help group. The four UCD phases were repeatedly performed. Users required fun, easy, multi-player, and safe exercise devices.

RESULTS:

Seven breathing exercise devices were developed, and 10 different game-based exercises were performed. Two individuals participated in a pilot test involving a respiratory rehabilitation exercise program conducted twice weekly for 60 min/session over 8 weeks. Lung function was assessed using a spirometer. Forced vital capacity, forced expiratory volume in 1 s, and vital capacity showed minimal changes, whereas maximum inspiratory and expiratory pressures improved. Participants reported that the exercises were entertaining and that the competitive nature of the game-like exercises encouraged further participation.

CONCLUSION:

Breathing exercise programs using our developed devices can improve breathing and positively affect the psychological states and sociability of users.