The correlation between diaphragm thickness, diaphragmatic excursion, and pulmonary function in patients with chronic stroke

Effects of usual yoga practice on the diaphragmatic contractility: A cross-sectional controlled study

Objectives

The aim of this study is to observe and compare the effects of regular yoga practice on the main inspiratory muscle, the diaphragm, by analyzing its thickness, excursion, velocity and contraction time, using ultrasound.

Design

A Cross-Sectional Controlled Study.

Participants

80 healthy subjects (40 habitual yoga practitioners and 40 non-practitioners), without previous respiratory pathology participated in this study. During maximum diaphragmatic breathing, the diaphragmatic thickness (at rest and after maximum inspiration), excursion, velocity and contraction time were measured by ultrasound.

Results

in the experimental group, practicing yoga, statistically significant differences (p < 0.001) were observed compared to the control group, not practicing, in the thickness of the diaphragm at rest (0.26 ± 0.02 vs 0.22 ± 0.01 cm); the diaphragmatic thickness in maximum inspiration (0.34 ± 0.03 vs 0.28 ± 0.03 cm); contraction velocity (1.54 ± 0.54 vs 2.23 ± 0.86 cm/s), contraction time (3.28 ± 0.45 vs 2.58 ± 0.49 s) and Borg scale of perceived exertion (1.05 ± 1.6 vs 1.70 ± 1.34), p = 0.05. However, the diaphragmatic excursion was greater in the control group (5.45 ± 1.42 vs 4.87 ± 1.33 cm) with no statistically significant differences (p = 0.06).

Conclusions

the regular practice of yoga improves the parameters of diaphragm thickness, speed and contraction time measured in ultrasound and the sensation of perceived exertion during a maximum inspiration. So it can be considered as another method for training the inspiratory muscles in clinical practice.

Diaphragm thickness by ultrasound in pediatric patients with primary malnutrition

Skeletal muscle atrophy is known to be a marker for nutritional deficiency. The diaphragm is both a skeletal muscle and a respiratory muscle. There is not enough data in the literature about the change in diaphragm thickness (DT) in children with malnutrition. We think that malnutrition may have negative effects on diaphragm thickness. Therefore, in this study, we aimed to compare the diaphragm thicknesses of pediatric patients with primary malnutrition and a healthy control group. The DT of pediatric patients diagnosed with primary malnutrition by a pediatric gastroenterologist was prospectively evaluated by a radiology specialist by ultrasonography (USG). The obtained data were statistically compared with the data of the healthy control group. There was no statistically significant difference between the groups in terms of age and gender (p = 0.244, p = 0.494). We found that right and left diaphragm thicknesses were significantly thinner in the malnourished group than in the healthy control group (p = 0.001, p = 0.009, respectively). We found that right and left diaphragm thicknesses were thinner in those with moderate and severe malnutrition compared to the normal group (p < 0.001, p = 0.003, respectively). We found a significant weak positive correlation between weight and height Z score and right and left diaphragm thickness (respectively, r: 0.297, p < 0.001; r: 0.301, p < 0.001).   Conclusion: Malnutrition is a disease that affects all systems. Our study shows that the DT is thinner in patients with malnutrition. What is Known: •Malnutrition causes skeletal muscle atrophy. What is New: •Diaphragm muscle thickness decreases in malnutrition. •There is a significant positive correlation between diaphragm muscle thickness and height, weight and BMI z scores.

Diaphragmatic ultrasound can help evaluate pulmonary dysfunction in patients with stroke

Objective

Pulmonary dysfunction after stroke is increasingly gaining attention from clinical and rehabilitation specialists. However, owing to cognitive and motor dysfunction in patients with stroke, determining the pulmonary function of these patients remains challenging. The present study aimed to devise a simple method for an early evaluation of pulmonary dysfunction in patients with stroke.

Methods

Overall, 41 patients with stroke in the recovery period (stroke group) and 22 matched healthy controls (control group) were included in the study. We first collected data regarding baseline characteristics for all participants. Furthermore, the participants with stroke were examined using additional scales, such as the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer assessment scale (FMA), and modified Barthel Index (MBI). Subsequently, we examined the participants with simple pulmonary function detection and diaphragm ultrasound (B-mode). Ultrasound indices calculated were as follows: the thickness of the diaphragm under the position of functional residual capacity (TdiFRC), the thickness of the diaphragm under the position of forced vital capacity (TdiFVC), thickness fraction, and diaphragmatic mobility. Finally, we compared and analyzed all data to identify group differences, the correlation between pulmonary function and diaphragmatic ultrasound indices, and the correlation between pulmonary function and assessment scale scores in patients with stroke, respectively.

Results

Compared with the control group, patients in the stroke group exhibited lower values for indices of pulmonary and diaphragmatic function (p < 0.001), except for TdiFRC (p > 0.05). The majority of the patients with stroke had restrictive ventilatory dysfunction, as indicated by a significantly higher incidence ratio (36 in 41 patients) than that in the control group (0 in 22 patients) (p < 0.001). Moreover, significant correlations were found between pulmonary function and diaphragmatic ultrasound indices (p < 0.05), with the strongest correlation between TdiFVC and pulmonary indices. In the stroke group, pulmonary function indices were negatively correlated with the NIHSS scores (p < 0.001) and positively correlated with the FMA scores (p < 0.001). No (p > 0.05) or weak (p < 0.05) correlation was found between pulmonary function indices and the MBI scores.

Conclusion

We found that patients with stroke had pulmonary dysfunction even in the recovery period. Diaphragmatic ultrasound can be used as a simple and effective tool for detecting pulmonary dysfunction in patients with stroke, with TdiFVC being the most effective index.

Immediate Effects of Diaphragmatic Breathing with Cervical Spine Mobilization on the Pulmonary Function and Craniovertebral Angle in Patients with Chronic Stroke

Background and Objectives: Patients with stroke have a forward neck posture due to neurological damage and often have impaired pulmonary function. This study investigated the effect of diaphragmatic breathing with cervical mobilization to improve pulmonary function cervical alignments. Materials and Methods: This study used a one-group pre-test-post-test design including 20 patients with stroke. Two types of cervical joint mobilization techniques, consisting of left and right lateral glide mobilization and posterior-anterior mobilization, were utilized. During joint mobilization, the patients performed diaphragmatic breathing. The measurements were performed immediately after the intervention. Pulmonary function was evaluated using a spirometer to measure the forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF). The craniovertebral angle (CVA) was measured using lateral photographs. Results: After diaphragm breathing with cervical joint mobilization, subjects had significantly increased FEV1, FVC, PEF and CVA. Conclusion: Diaphragm breathing with cervical joint mobilization are possible interventions to increase pulmonary function and improve the craniovertebral angle in patients with stroke. However, a complete conclusion can be reached only after a follow-up study has been conducted with a comparison of more subjects and controls.

Yoga-An Alternative Form of Therapy in Patients with Blunt Chest Trauma: A Randomized Controlled Trial

BACKGROUND

Yoga as alternative form of therapy has shown positive impact on pulmonary functions, exercise capacity, behavioral changes, and inflammation in non-trauma patients. However, the efficacy of Yoga has not been studied in chest trauma patients.

METHODS

This randomized controlled trial was conducted at level-1 Trauma Centre. Isolated chest injury patients were randomized into either standard physiotherapy or Yogatherapy groups. Patients in physiotherapy group received conventional chest physiotherapy and Yogatherapy group received a set of Yogic exercises in addition to conventional chest physiotherapy. Primary outcome measure was changes in pulmonary function tests (PFT) at 4 weeks of discharge. Secondary outcomes were changes in quality of life (QoL), respiratory muscle strength and endurance, chest wall mobility, and levels of cytokines at 4 weeks. Data were analyzed using STATA v14.0.

RESULTS

A total of 89 eligible patients were randomized to physiotherapy (n = 46) and Yoga therapy (n = 43) groups. Demographic characteristics were comparable in both the groups. There were statistically significant improvements in PFT in the Yogatherapy group compared with physiotherapy with an increase in Forced vital capacity (p = 0.02) and Forced expiratory volume (p = 0.01) at 4 weeks. In addition, there were significant improvement in physical component of QoL, respiratory muscle endurance (p = 0.003) and axillary cirtometry (p = 0.009) in the Yogatherapy group. However, no statistically significant difference in the trends of cytokine markers seen between the groups.

CONCLUSION

Yoga was found to be effective in improving pulmonary functions and QoL in patients with chest trauma. (Trial registered at ctri.nic.in/clinicaltrials/login.php, numberREF/2016/05/011,287).

Ultrasonographic measurement of diaphragm thickness in patients with severe thoracic scoliosis

PURPOSE

This study aimed to measure diaphragm thickness using ultrasound in adult patients with severe idiopathic scoliosis.

METHODS

This prospective case-control study included patients with severe idiopathic scoliosis and a healthy control group. The control and patient groups' demographic features, pulmonary function tests, diaphragm thickness, and thickening fraction measured using ultrasonography were compared.

RESULTS

End-expirium values were similar between the two groups (p = 0.902). However, end of inspirium, change level, and diaphragm thickening fraction were significantly lower in the scoliosis group (p < 0.001 for all). Cobb degree values were inversely correlated with forced expiratory volume in 1 s (%) (r =  - 0.909, p < 0.001), forced vital capacity (%) (r =  - 0.887, p < 0.001), and end-inspirium thickness (r =  - 0.673 and p < 0.001) values. Furthermore, diaphragm thickness at the end of inspirium was positively correlated with forced expiratory volume in 1 s (%) (r = 0.636, p = 0.001) and forced vital capacity (%) (r = 0.646, p = 0.001) values. No significant correlation was found between diaphragm thickening fraction and forced expiratory volume in 1 s or forced vital capacity.

CONCLUSION

Ultrasound can provide valuable information about diaphragm morphology and quantify diaphragm contraction.

Randomized, controlled trial comparing respiratory and analgesic effects of interscalene, anterior suprascapular, and posterior suprascapular nerve blocks for arthroscopic shoulder surgery

Background

Interscalene brachial plexus block (ISB) provides excellent analgesia for arthroscopic shoulder surgeries but is associated with adverse effects including hemidiaphragmatic paresis. We aimed to compare the respiratory effects, forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) between suprascapular nerve block (SSB) and ISB.

Methods

Sixty patients were recruited and randomized into ISB, anterior SSB, and posterior SSB groups. FVC, FEV1, and diaphragmatic excursion were evaluated at baseline and 30 minutes after intervention. Blocks were performed under ultrasound guidance with 15 ml of 0.5% ropivacaine. Pain scores were assessed at 1, 6, 12, and 24 hours postoperatively.

Results

The ISB group showed a reduced FVC of 31.2% ± 17.5% (mean ± SD), while the anterior and posterior SSB groups had less reduction of 3.6% ± 18.6% and 6.8% ± 6.5%, respectively (P < 0.001). The ISB group showed more reduction in diaphragmatic excursion than the anterior and posterior SSB groups (median [IQR]): −85.7% (−95.3% to −63.3%) vs. −1.8% (−13.1% to 2.3%) and −1.2% (−8.8% to 16.8%), respectively (P < 0.001). The median pain scores (IQR) in the ISB and anterior SSB groups were lower than those in the posterior SSB group at 6 hours on movement: 0 (0–2), 1.8 (0–4.5) vs. 5 (2.5–8), respectively (P = 0.002). There was no significant difference in oxycodone consumption postoperatively.

Conclusions

Anterior SSB preserves lung function and has a comparable analgesic effect as ISB. Thus, it is recommended for arthroscopic shoulder surgeries, especially in patients who have reduced lung function.

Relationship between the fall in blood pressure in the standing position and diaphragmatic muscle thickness: proof of concept study

BACKGROUND

The diaphragm is an important muscle of respiration, and regulates the intrathoracic pressure. Blood pressure is regulated by the baroreceptor reflex system, and is also affected by intrathoracic pressure. We examined the relationship between the diaphragmatic muscle thickness and the degree of drop in blood pressure in the standing position.

METHODS

We prospectively studied 15 healthy subjects. The diaphragmatic muscle thickness was measured using a B-mode ultrasonic imaging device. The blood pressure before and after standing was measured by a head-up tilt test.

RESULTS

The diastolic blood pressure difference during expiration and inspiration showed a significant correlation with the diaphragmatic muscle thickness (r = 0.578, P = 0.024 and r = 0.518, P = 0.048, respectively).

CONCLUSION

The diaphragmatic muscle thickness was related to the fall in diastolic blood pressure in the standing position. This indicates that adequate diaphragmatic muscle thickness helps to maintain intrathoracic pressure and prevents excessive drop in blood pressure in the standing position.

Comparison Between M-Mode Ultrasonography and Fluoroscopy for Diaphragm Excursion Measurement in Patients With Acquired Brain Injury

OBJECTIVES

Patients with acquired brain injury show decreased pulmonary function and diaphragm excursion (DE), which can affect functional outcomes. This study aimed to compare ultrasonography (US) and fluoroscopy for DE assessment and to determine how the relationship between pulmonary function test results and DE differs according to the paralytic condition.

METHODS

From September 2017 to April 2018, we prospectively enrolled patients with acquired brain injury. The patients underwent a pulmonary function test, including the functional vital capacity, forced expiratory volume at 1 second, forced expiratory volume at 1 second-to-functional vital capacity ratio, peak cough flow, and respiratory muscle strength such as the maximal inspiratory pressure and maximal expiratory pressure. Diaphragm excursion was measured with M-mode US and fluoroscopy on admission. A partial correlation analysis was used to assess the correlation between US and fluoroscopy for DE assessment.

RESULTS

During the study period, 50 patients with acquired brain injury were enrolled. After adjusting for age, sex, height, and weight, the correlation coefficients between US and fluoroscopy were 0.744 for the right side (P < .001) and 0.631 for the left side (P < .001). In a subgroup analysis for patients with hemiplegia, the correlation coefficients were 0.507 for the paretic side (P = .007) and 0.677 for the nonparetic side (P < .001). Diaphragm excursion in the nonparetic side was significantly correlated with the maximal inspiratory pressure, maximal expiratory pressure, and peak cough flow (P < .05).

CONCLUSIONS

M-mode US can be an alternative method for DE measurement in patients with impaired locomotion function after acquired brain injury. Preserved function of the nonparetic side might affect pulmonary function after brain injury, which suggests the importance of prestroke respiratory function.

Ultrasonographic measurement of the diaphragm thickness in patients with obstructive sleep apnea syndrome

PURPOSE

The aim of this study was to evaluate the diaphragm thickness in patients with obstructive sleep apnea syndrome (OSAS).

METHODS

This prospective study included patients who underwent polysomnography evaluation for the first time with a clinical suspicion of OSAS. All patients underwent polysomnographic evaluation with a 55-channel Alice 6 computerized system (Respironics; Philips, IL). Diaphragm thickness was measured as the distance between the peritoneum and the pleura using electronic calipers with a 7-12-MHz linear probe (PHILIPS EPIQ 5G).

RESULTS

A total of 108 patients (67 males, 41 females) were enrolled in the current study. The mean age of the patients was 48.92 ± 11.47 years. The diaphragm thicknesses were significantly higher in OSAS patients both at end-inspirium and end-expirium compared with the normal group (p < 0.05). No significant difference was observed regarding the change level and thickening ratio (%) (p > 0.05). When the patients were allocated into OSAS subtypes; diaphragm thicknesses at the end of inspirium and expirium on both sides were significantly higher in the severe OSAS group and OSAS+OHS group compared with the other groups of normal, mild OSAS, and moderate OSAS subgroups (p < 0.05 for all). There was no significant difference between the groups regarding the thickening ratio (p > 0.05 for all). There was a positive correlation between the severity of OSAS and diaphragm thickness.

CONCLUSION

Diaphragm thickness seems to be increased in OSAS patients and the thickness correlates with the severity of OSAS. However, the thickness ratio of OSAS patients does not differ from that of normal subjects.

Ultrasonographic evaluation of the diaphragm thickness in patients with multiple sclerosis

BACKGROUND

Diaphragm weakness or dysfunction have been previously reported in multiple sclerosis (MS) patients. The aim of this study was to evaluate diaphragm thickness and thickenning ratio (TR) using ultrasound in MS patients.

METHODS

This prospective study comprised MS patients and a control group. Ultrasound examination was performed using a linear transducer (6-15 MHz). The diaphragm was seen as a hypoechoic structre between the peritoneum and pleura. End-expirium and end-inspirium measurements were obtained. Change levels and TR (%) were calculated. All participants were assessed using the Expanded Distability Status Scale (EDSS) and Fatigue Severity Scale (FSS).

RESULTS

Evaluation was made of 45 MS patients (11 males, 34 females) with a mean age of 37.36±9.0 years and 36 healthy subjects (3 males, 33 females) with a mean age of 35.19±9.3 years. The diaphragm thicknesses were similar at end-expirium (1.86±0.3 vs. 1.83±0.3 mm) and end-inspirium (3.14±0.6 vs. 3.46±0.6 mm). The change level with inspirium (0.90±0.6 vs. 1.31±0.7 mm) and TR (49.77±37.7 vs. 72.30±40.1%) were significantly higher in the control group compared to the values of MS patients. A weak and negative correlation was determined between EDSS and TR values (r=-0.293, p = 0.008), and no significant correlation was observed between the FSS values and diaphragm thickness (p>0.05 for all).

CONCLUSION

Although the diaphragm thickness of MS patients seems to be similar to those of healthy subjects, the change level and TR of MS patients seem to be lower. Furthermore, the change level and TR were found to be associated with EDSS.