Vol.1, No.2, 88-92 (2009)
doi:10.4236/health.2009.12015
SciRes Copyright © 2009 http://www.scirp.org/journal/HEALTH/
Health
Openly accessible at
A comparison study of two breathing exercise
techniques in tetraplegics
Stanley John Winser1, Jacob George2, Priya Stanley1, George Tharion2
1Masterskill University of Health Science (MUCH), Cheras, Malaysia; [e-mail],
2Christian Medical College, Vellore, India.
Received 15 July 2009; revised 23 July 2009; accepted 25 July 2009.
ABSTRACT
Objective: To compare the effectiveness of ab-
dominal weights and incentive spirometry for
improving the strength of diaphragm in tetra-
plegics.
Setting: Department of Physical Medicine and
Rehabilitation, Christian Medical College, Vel-
lore, Tamil Nadu, India.
Study Design: Two group comparison study
Methods: Seventeen patients who fulfilled the
inclusion criteria were assigned into an ABW or
INS treatment groups using judgment sampling
after obtaining an informed consent. Evaluation
of the chest, respiratory status, vital signs and
strength of diaphragm were done during initial
assessment. ABW group underwent diaphrag-
matic strengthening using Abdominal weights
(ABW) and INT group with Incentive Spirometer
(INS) for 15 minutes daily, 6 days a week, for a
period of 6 weeks. The pre and post training
values of peak amplitude in electro myogram
(EMG) of the diaphragm, intercostals and ster-
nocleidomastoid muscles were measured.
Statistical analysis: The analysis was done
using SPSS 11. The pre and post-training values
of peak EMG amplitudes of the diaphragm, inter-
costals and sternocleidomastoid were com-
pared within the groups using Wilicoxon’s sign
test and between the two groups using Mann-
Whitney’s test.
Results: The peak EMG of diaphragm of ABW
group raised from 1.1289 to 1.3036 milli-volts
with a significance of p<0.001, whereas it fell
from 1.7001 to 1.0441 milli-volts among INS
group subjects with a significance of p<0.001.
Comparison between the 2 groups showed sta-
tistically significant improvement in diaphrag-
matic strength among the ABW group.
Conclusion: The results of this study sug-
gests that, in the pulmonary rehabilitation of
motor complete tetraplegic subjects abdominal
weighted training of the diaphragm has better
results in improving the strength of the muscle.
Sponsorship: Fluid research grant of Christian
Medical College, Vellore.
Keywords: Spinal Cord Injury; Tetraplegia;
Diaphragmatic Exercise; Surface EMG; Abdominal
Weights; Incentive Spirometer
1. INTRODUCTION
Spinal cord injury (SCI) at cervical level results in tetra-
plegia with or without paralysis of diaphragm. Among
complete tetraplegics with intercostals and diaphrag-
matic paralysis there is severe respiratory insufficiency
especially in the acute stage of illness [1]. Respiratory
insufficiency leads to high mortality rate in these pa-
tients [2]. Following cervical cord injury there is paraly-
sis of respiratory muscles [3] which leads to accumula-
tion of secretions. Failure of cough mechanism causes
recurrent infections which further compromises lung
functions and add to morbidity and mortality.
Studies on pulmonary function tests of individuals
with complete tetraplegia have shown that there is a ma-
jor loss of expiratory reserve volume due to paralysis of
expiratory muscles causing reduction of maximal expi-
ratory pressure. The work of breathing is increased and
the diaphragm is prone to fatigue particularly in patients
with high cervical cord lesion [4]. Physiotherapy man-
agement strategies aspire at improving efficiency of dia-
phragm and training the available accessory muscles to
compensate for paralyzed respiratory muscles. Progres-
sive resisted exercises have been used in strengthening
respiratory muscles for high tetraplegic patients [5].
There are various methods describe in literature to im-
prove the efficiency of diaphragm [6], which includes
Resisted Inspiratory Muscle Training (RIMT) [7,8,9],
Weighted diaphragmatic exercise [10], Abdominal bind-
ers [11], Trendlenbergs position and Incentive spirometry.

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There is paucity of literature which compares the effec-
tiveness of abdominal weighted training and incentive
spirometry in improving the strength of diaphragm. This
study designed at evaluating the effectiveness of two
pulmonary rehabilitation programmes (weighted dia-
phragmatic exercise against incentive spirometry) which
are commonly practiced for training the diaphragm
among patients with spinal cord injury.
2. MATERIALS AND METHODS
This study was approved by the Institutional review
board and ethics Committee of Christian Medical Col-
lege. The background of the study was explained to the
subjects in his\her language and the patients who were
willing to participate were inducted into the study fol-
lowing an informed written consent. The sample size
was calculated to be 6 in each group with ABW group as
subjects trained with abdominal weights and INS group
as subjects trained with incentive spirometry. The sub-
jects with neurological level between C5 and C8 ASIA
[12] grade A & B, 1 month post injury, muscle strength
of diaphragm more than fair plus, medically stable pa-
tients and without any current lung infections or comor-
bidity were included in the study. Subjects with associ-
ated Traumatic Brain Injury (TBI), past history of
Chronic Obstructive Pulmonary Disease, Tuberculosis
and chronic smokers were excluded.
2.1. Sample Size & Method
The sample size was calculated with 5% alpha level and
80% power, with having a SD of 0.73 and 0.32; the
sample size was found to be 6 in each group. We had
adopted judgment sampling method. The subjects who
underwent weighted diaphragmatic training had to lie
supine. Since some subjects had pressure ulcer over the
sacral region, supine lying was contraindicated, which
made us to assign them into the INS group.
2.2. Evaluation of Strength [13]
The strength of diaphragm was graded using the grades
as follows. “Poor power”: is being graded if the subject
is not able to expand his\her epigastric region fully on
deep inspiration. “Fair power”: if the subject is able to
expand his\her epigastric region fully on deep inspiration.
“Good power”: the therapist’s hands are placed over the
epigastric region with fingers spread, and the subject is
asked to inhale, while maximum manual resistance is
applied. If the subject is able to complete a full epigas-
tric raise against resistance then he\she can be graded as
Good. The subjects who are able to take resistance but
not able to hold can be graded as “Fair plus”. Subjects
with diaphragmatic power of fair plus and above were
considered for progressive resisted exercises. Prior to the
commencement of training, the EMG activity of the
diaphragm, intercostals and sternocleidomastoid muscles
were evaluated.
2.3. Outcome Measure (EMG Analysis)
The EMG activity was measured using 3 pairs of Silver
chloride bipolar surface electrode. The active electrodes
were placed over T7 & T8 intercostal space, T4 & T5
intercostal space and mid portion of sternocleidomastoid
to get the electrical activity of diaphragm, intercostals
and sternocleidomastoid muscles respectively [14],
readings of all three groups of muscles were taken si-
multaneously (see Figure 1). Electrodes were secured to
the skin using adhesive plaster after skin preparation.
While taking the readings the subjects were instructed to
take 3 consecutive deep inspirations followed by expira-
tion, reading were recorded for 10 seconds and the peak
amplititudes in the EMG recordings noted. The investi-
gator who performed this test was blinded to either
group. Three trials were done and the best response of
peak amplitude was noted.
2.4. Intervention
The subjects were allotted into both groups using the
above mentioned sampling method. Subjects of both the
groups concurrently underwent other rehabilitative pro-
grams such as passive range of motion exercise, activi-
ties of daily living, standing using tilt or standing table,
strengthening or re-education for the available muscles.
In the ABW group, diaphragm was strengthened using
abdominal weights for 15 minutes per day for six days
weekly for a period of 6 weeks. The subjects of INS
group underwent training using incentive spirometer for
the same period as ABW group.
2.5. Evaluation of Weight [15]
To train the ABW group, the appropriate weights to
Figure 1. Showing placement of surface electrodes for the
assessment of EMG activity of Intercostals, Diaphragm and
Sternocliedomastoid muscles.
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strengthen the diaphragm were evaluated using the fol-
lowing method. The subject was positioned in supine
lying, then a minimal weight was placed over the epi-
gastric region (weights starts with half a kilogram) and
then the subject was allowed to breath (the weight
should come up fully with each inspiration). If the sub-
ject showed any signs of fatigue or started using his\her
accessory muscles, the weights were taken off immediately.
Adequate rest was given, then the procedure was re-
peated using a lesser weight, and if the patient is able to
take up the weight comfortably for 15 minutes, a short
break was given and the procedure was repeated by in-
creasing the weight by half a kilogram, thus the appro-
priate weight for training the diaphragm was determined
by trial and error method. Using the evaluated weight the
diaphragm was strengthened during the study period.
2.6. Placement of Weight
The evaluated weight was placed over the epigastric
region with an isosceles triangular board. The board is
placed in such a way that one of the corners touches the
xiphisternum and the other two corners touching the
anterior borders of the ribcage (see Figure 2). During
the training period of the ABW group, subjects were
instructed to perform normal breathing with the weights
on for 15 minutes and progression in weights was done
for every 1 week.
2.7. Incentive Spirometry Training
The INS group subjects were trained using an Incentive
spirometer, it is a flow oriented breathing exerciser. The
devise is provided with 3 balls and they provide the pa-
tients an indirect indicator of the inspired volume. Three
color-coded balls (3 shades of green) in each chamber
provide a visual incentive for the patient. Air flows into
single channel, when it passes through the chamber, it
raises each of the three balls depending on the flow in-
haled per second. Flow rates of the spirometer includes
600mL/sec, 900mL/sec and 1200mL/sec. By using dif-
ferent colors of ball it becomes easy to identify the flow
rate. Subjects of this group were instructed to keep the
balls of the spirometer suspended for maximum time
possible, this was repeated for 15 minutes daily for a
period of 6 weeks. Progression was made by increasing
the suspending time of the spirometer ball.
At the end of 6 weeks training, the EMG activities of
diaphragm, intercostals and the sternocleidomastoid
muscles were re-examined and compared for results.
3. STATISTICAL ANALYSIS
The analysis was done using SPSS 11. Baseline values
were tabulated as shown in Table 1.The pre and
post-training values of peak EMG amplitudes of the dia-
Figure 2. Diaphragmatic strengthening using abdominal
weights.
Table 1. Baseline characteristics of analysed data.
Characteristics Group (A) Group (B)
Mean age 36+/-12.32 27.16+/-8.91
Male 7 6
Sex Female - -
Traumatic 6 5
Cause of
lesion Non traumatic 1 1
Time since injury (days) 68+/-32.72 74.32+/-38.71
A 5 3
ASIA clas-
sification B 2 3
Presence of sacral ulcers - 5
phragm, intercostals and sternocleidomastoid were com-
pared within the groups using Wilicoxon’s sign test and
between the two groups using Mann-Whitney’s test.
4. RESULTS
Seventeen subjects were recruited into the study with 9
patients in group A and 8 in group B. Thirteen subjects
had completed the study and were available for the post
training assessment and analysis. Two subjects from
each group dropped out from the study. Among 4 sub-
jects dropped out, two were not willing to undergo post
training assessment, one subject got discharged against
medical advice and another subject was shifted to critical
care unit. The mean age of subjects was 35 years (range
19 to 53 years).
Among 17 subjects, 13 had traumatic SCI and re-
maining 4 patients had infective pathology of the cord.
Mean duration since injury was 71.61 days (range 32 to
142). There was a significant increase in the diaphrag-
matic activity of subjects in the ABW group, shown in
Table 2, whereas there was a significant reduction in the
EMG activity among the INS group, shown in Table 3.
Comparison between the 2 groups using Mann-Whit
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91
Table 2. Change in EMG ( milli volts) within ABW group.
Pre- test Post – test
Group
A Mean SD Mean SD P Z
T4 0.8478 0.8463 1.2915 1.5638 <0.001 -23.490
T5 0.7253 0.7974 1.2366 1.4240 <0.001 -31.986
T7 1.1289 0.7862 1.3036 1.2129 <0.001 -6.273
T8 0.8188 0.6440 0.8977 0.9190 <0.001 -0.475
SCM 1.5027 1.8742 1.2527 1.5241 <0.001 -8.424
Table 3. Change in EMG ( milli volts) within INS group.
Pre- test Post – test
Group
B Mean SD Mean SD
P Z
T4 0.95540.89230.7368 0.7668 <0.001-17.659
T5 1.17561.00810.9361 0.8993 <0.001-14.078
T7 1.70011.41440.9631 0.8993 <0.001-31.584
T8 1.81941.83670.9823 0.9823 <0.001-25.335
SCM 2.39852.43652.0446 1.8431 <0.001-9.838
Table 4. Comparing change in EMG (milli volts) between the 2 groups.
Group (A) Group (B) P Z
Muscle
Pre Post
P
Pre Post Pre post
T4 0.8472 1.2915 0.00 0.9554 0.7368 <0.001 -14.019 -19.676
T5 0.7253 1.2366 0.00 1.1756 0.9631 <0.001 -40.670 -0.105
T7 1.1289 1.3036 0.00 1.7001 1.0441 <0.001 -23.396 -8.030
T8 0.8188 0.8977 0.00 1.8194 0.9823 <0.001 -32.875 -13.278
SCM 1.5027 1.2524 0.00 2.3985 2.0446 <0.001 -20.671 -27.735
ney’s test showed a statistical significance (p<0.001) in
the improvement of diaphragmatic activity in ABW
group, shown in Table 4. The mean EMG of diaphragm
of ABW group raised from 1.1289 to 1.3036 milli-volts
with a significance of p<0.001, whereas it fell from
1.7001 to 1.0441 milli-volts among INS group subjects
with a significance of p<0.001. When comparing the
EMG activities of both the groups a statistically signifi-
cant improvement in diaphragmatic strength was ob-
served among the ABW group.
5. DISCUSSION
The objective of the study was to determine which of the
two techniques, (abdominal weights or incentive spi-
rometry) improves the strength of diaphragm among
complete tetraplegic patients. Results of this study have
shown that patients trained with weighted diaphragmatic
exercise had better improvement in the post training as-
sessment of EMG values. Pulmonary rehabilitation ex-
ercise protocols prescribed for the spinal cord injured
patients with reduced pulmonary function is very effec-
tive to provide a positive outcome. Pulmonary exercises
are simple and effective without any need to procure
sophisticated instruments. Studies done on the progres-
sive resistive exercises for the respiratory muscles have
proved that this method of diaphragm training may be
useful in weaning high level quadriplegic patients from
the ventilator.
Studies on pulmonary function tests of individuals
with complete tetraplegia showed that there is a major
loss of expiratory reserve volume because of paralysis of
expiratory muscles, as a result of which their maximal
expiratory pressure was reduced. The vital capacity ap-
proximates their inspiratory capacity. The work of
breathing is increased and the diaphragm is prone to
fatigue particularly in patients with high cervical cord
lesion [16].
Carolyn Kisner and Lynn Allen Colby in their discus-
sion on various techniques used to strengthen diaphragm
suggested; incentive spirometry is a form of low level
resistance training that emphasizes sustained maximal
inspiration. The training sessions of the above mentioned
studies were typically limited to 15 to 30 minutes each,
with two to three sessions a day, 5 to 7 days a week for a
total period of 6 to 8 weeks.
Previous studies have compared the effectiveness of
resistive inspiratory muscle training (RIMT) and ab-
dominal weights in improving the strength of diaphragm
among tetraplegic patients and have proved that both the
techniques are equally effective [17]. Hwa Lin and Chy
Ching Chuang observed that Abdominal weighted
maximal ventilatory (AWMV) breathing evoked greater
EMG activity, inspiratory flow and inspiratory volume
than did (Inspiratory resistance maximal ventilatory
(IRMV) breathing. The increase of diaphragmatic EMG
was not statistically significant in AWMV breathing.
Weighted diaphragmatic strengthening is a less com-
monly employed strengthening program. Studies had
shown that the use of weighted diaphragmatic exercise
was of great therapeutic use, and have compared the
effects of abdominal weights against resistive inspiration
as mentioned before. On the other hand in recent days
incentive spirometry is the most commonly administered

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92
Openly accessible at
treatment regimen in improving the strength and effi-
ciency of diaphragm among tetraplegics. In our study we
have observed, the most efficient and cost effective mo-
dality in the pulmonary management of tetraplegic pa-
tients is abdominal weighted exercise.
We hypothesized a reduction in the EMG activity of
the sternocleidomastoid muscle following training due to
an improvement in the efficiency of diaphragm which is
the primary respiratory muscle. We found an increase in
the activity of sternocleidomastoid muscle among ABW
group subjects along with the increase in activity of the
other groups of muscles (intercostals and diaphragm).
There was a reduction in activity of sternocleidomastoid
muscle among the INS group subjects. However we
could not explain the reason for this phenomenon. The
results of this study are not concurrent with the previous
literature; instead has proved that resistive diaphragmatic
breathing exercise has better therapeutic effects in im-
proving the strength of diaphragm among complete
tetraplegic patients.
There were few limitations in our study which in-
cludes the sampling technique and spasticity of the sub-
jects. There are possibilities that disturbances from the
abnormally activated trunk muscles could have reduced
the accuracy of EMG activity of the diaphragm and
other respiratory muscles. The sampling method had to
be judgement sampling rather than single blinded simple
random sampling which could have been ideal for this
study.
6. CONCLUSIONS
The peak EMG amplitude showed a significant rise
amongst subjects who were trained using abdominal
weights. This is an apparent indication of improved per-
formance of the target muscle with regards to strength.
Cost effectiveness and ease of administration of this
technique ensures its frequent usage by clinical practi-
tioners. Thus we conclude stating Abdominal weights
can be used as an effective adjunct to pulmonary reha-
bilitation in improving the strength of diaphragm,
thereby reducing the risks associated with pulmonary
complications.
7. ACKNOWLEDGEMENT
We gratefully acknowledge Mr. Ganesh, Movement Analyst who as-
sisted us in collecting EMG recordings for all our patients and Mr.
Vijayakumar for his guidance. We also acknowledge the Fluid research
committee for funding our project.
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