Vol.2, No.5, 407-411 (2010)
doi:10.4236/health.2010.25061
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/
Health
Openly accessible at
Respiratory rehabilitation with abdominal weights:
a prospective case study
Stanley John Winser1, Priya Stanley1, George Tarion2*
1Department of Physiotherapy Masterskill University college of Health Science (MUCH), Cheras, Malaysia;
2Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, India; *Corresponding Author:
[e-mail], stanjw_pt@ yahoo.com,
Received 6 January 2010; revised 21 January 2010; accepted 24 January 2010.
ABSTRACT
Objective: Abdominal weights was used to
strengthen the diaphragm of a C6 ASIA (A)
tetraplegic subject with the aim of studying the
long term effect of the technique as a part of
respiratory rehabilitation. Setting: Department
of Physical Medicine and Rehabilitation, Chris-
tian Medical College, Vellore, Tamil Nadu, India.
Study Design: Prospective case study. Material
and methods: The peak EMG amplitude of the
diaphragm (DIA), intercostals (INT) and sterno-
clidomastiod (SCM) were assessed using a
surface EMG and inspired lung volume (ILV)
was assessed using an adjustable portable
spirometer. The measurements were repeated
after 3, 6, 9 and 12 months of inspiratory muscle
training for a period of 15 minutes daily, 6 days a
week for 12 months. Results and discussion:
Peak amplitudes recorded by the EMG of DIA
and SCM muscles showed a progressive in-
crease, INT muscle did not show a consistent
change. INV showed a gradual rise from 1772ml
to 2760 ml over the study period. These values
have the following significance: 1) Use of ab-
dominal weights as a part of respiratory reha-
bilitation has beneficial long term effects; 2) In
patients with tetraplegia, respiratory muscles in
particular the diaphragm, are trainable in terms
of muscle efficiency; 3) The improvement in the
muscle efficiency obtained during the early re-
habilitation can be maintained or improved us-
ing simple non sophisticated exercises like
abdominal weights post discharge. Conclusions:
Abdominal weights can be used as an effective
adjunct to pulmonary rehabilitation in improving
the efficiency of diaphragm on a long term basis,
thereby reducing the risks associated with
pulmonary complications.
Keywords: Tetraplegia; Abdominal Weights; EMG
1. INTRODUCTION
Complete lesions of the spinal cord affect the respiratory
inspiratory and expiratory muscles. The degree of im-
pairment in respiratory function is related to the level of
the lesion [1]. If the lesion is below the C3–C4 level, the
diaphragm is intact but the loss of other respiratory mus-
cles decreases the vital capacity (VC) to approximately
50% [2,3] and total lung capacity (TLC) to approxi-
mately 70% [3-5] of predicted normal values. Paralysis
of the expiratory muscles reduces the ability to force
expiration leading to an increased residual volume and
reduced ability to huff (forcefully exhale) and cough.
This may cause secretion to accumulate in the airways.
In complete lesions above the Th6 level, the autonomic
nervous system is injured, and bronchial hypersecretions
occur, which further aggravates problems regarding se-
cretions [6].
Currently a complete retrival of the muscle efficiency
following spinal cord injury (SCI) is not known. Cases
in which patients are unable to maintain adequate venti-
lation, long-term mechanical ventilator support is indi-
cated [7]. Although this treatment is effective, it can also
lead to serious medical complications such as infection,
pneumonia, atelectasis, and even death [8-10]. In fact,
the primary cause of death after SCI, regardless of the level
of injury, is caused by respiratory insufficiency and
complications associated with impaired respiratory func-
tion.
Training of these muscles may improve the daily ac-
tivities. Respiratory muscle training in healthy subjects,
COPD (Chronic Obstructive Pulmonary Disease) and
other pulmonary patients has shown positive effects
[11-17]. In individuals with tetraplegia, training of the
inspiratory muscles has been applied by Gross et al. [18]
Biering-Sorensen et al. [19] and Derrickson et al. [20].
Use of abdominal weights, resistive inspiratory muscle
training, Abdominal binders [21], Trendlenbergs posi-
tion and Incentive spirometry [22] have been reported in
literature to have useful effects in improving the effi-

S. J. Winser et al. / HEALTH 2 (2010) 407-411
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408
ciency of diaphragm among the target population. In the
survey done we found a paucity of literature on the long
term effects of these therapeutic modalites on the respi-
ratory status of tetraplegic patients, thus we intended to
observe the influence of abdominal weights on the effi-
ciency of the available respiratory muscle on a tetraple-
gic patient over a period of 1 year.
2. CASE REPORT
A 30-yr-old male patient presented with complaints of
weakness of arms and legs, with fecal and urinary incon-
tinence, in March 2004. The patient’s history revealed
that a C5 vertebrate fracture caused SCI after a fall from
height (mango tree) in December 2003. He had applied
to a clinic and had been managed conservatively with
bed rest for 3 months.
The patient's history included an internal fixator at his
femur because of a fracture that occurred in another ve-
hicle accident before 6 yrs. The patient's medical status
was stable. He had no pressure ulcers, range of motion
(ROM) of all four limbs were full and free. On clinical
neurologic examination, he had spastic tetraplegia with
loss of motor function below the C6 level and loss of all
sensation below C7 dermatome. Spasticity was found to
have grade 1+ in Modified Asworth scale (MAS) in all 4
limbs. Deep tendon reflexes were hyperactive, and plan-
tar response was extensor bilaterally. The patient was
classified as C6 American Spinal Injury Association
grade A and admitted to a rehabilitation program. The
rehabilitation program involves concurrent sessions of
physiotherapy, occupational therapy, vocational training,
prosthetics and orthostics and recreation classes. In the
department of physiotherapy the patient was undergoing
re-education exercises for the upperlimbs, progressive
orientation to erect stance using tilt table to counteract
postural hypotension, passive movement for the lower-
limbs, passive stretching for hamstrings and tendo achil-
les. In addition to this the patient was given strengthen-
ing to the diaphragm muscle using Abdominal weights
as a part of respiratory rehabilitation.
3. RESPIRATORY ASSESSMENT
Patient had no history of COPD, TB or other chronic
respiratory illnesses. Patient demonstrated a diaphrag-
matic breathing pattern. Chest expansion was 2 cms at
the level of xiphisternum and nil at nipple and axilla.
Cough was weak functional. Auscultatory findings re-
vealed a good air entry in all lobes and no added sounds
were recorded. Muscle strength of the Diaphragm was
good. The strength of the diaphragm involves interpreta-
tion of the total neurological involvement, complete res-
piratory evaluation and observational techniques. It is
best done in supine lying. “Poor power” is being graded
if the subject is not able to expand his/her epigastric re-
gion fully on deep inspiration. “Fair power”, if the sub-
ject 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 man-
ual resistance is applied. If the subject is able to com-
plete a full epigastric 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” [23]. Subjects with diaphragmatic power of
fair plus and above are candidates for progressive re-
sisted exercises.
4. MATERIALS AND METHODS
A prospective case study of a 30 year-old tetraplegic
patient, with complete spinal cord section at C6 level,
was considered. The subject gave written consent to par-
ticipate in the trial, the study was approved by the re-
search board of Christian Medical College, Vellore, In-
dia. Initial assessment was done in march 2004 and sub-
sequent assessments were planned at an interval of three
months for the next one year. The 2 outcome measures
which were considered are peak amplitude of Electro-
myographic (EMG) readings of diaphragm, intercostals
and sternocliedomastoid muscles and Inspired Lung
Volume (ILV). The investigator who performed these
tests was blind to the situation.
4.1. 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 (DIA), inter-
costals (INT) and sternocleidomastoid (SCM) muscles
respectively as shown in Figure 1. Readings of all three
groups of muscles were taken simultaneously [24]. Elec-
trodes were secured to the skin using adhesive plaster
after skin preparation. While taking the readings the
subject was instructed to take 3 consecutive deep inspi-
rations followed by expiration, readings were recorded
for 10 seconds and the mean of peak amplititudes in the
EMG were recorded. Three trials were done and the best
response of peak amplitude was noted.
Figure 1. Placement of surface electrodes.

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4.2. ILV Analysis
The ILV was assessed using a volume adjustable port-
able spirometer (Spectra SpirometerTM) The spirometer
has calibrations for adjusting the flow rate (100 cc, 200
cc,…800 cc) The device has a single chamber with 1 ball
inside. Air flows into this channel on inspiration and
raises the ball depending on the flow inhaled per second.
This upward movement of the ball during inspiration
provides the patient with visual feedback i.e. an indirect
indicator of the inspired volume. The patient was in-
structed to perform a deep inspiration through the mouth
piece and while inspiring he was required to keep the
ball inflated for the maximum seconds possible. As
shown in Figure 2.
ILV was measured using the formula: ILV = Flowrate
× seconds
Flow rate: was kept constant at 400 cc. Seconds: was
a measure of patients ability to keep the spirometer ball
inflated during inspiration and was calculated using a
stop watch.
4.3. Treatment Protocol
Diaphragm was strengthened using abdominal weights
for 15 minutes/day for six days/week for a period of 1
year. An initial evaluation of weight to be placed over
the abdomen was done. The subject was positioned in
supine lying, then a minimal weight was placed over the
epigastric 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 ac-
cessory muscles, the weights were taken off immediately.
Adequate rest was given, then the procedure was re-
peated using a lesser weight. 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 increasing
the weight by half a kilogram, thus the appropriate
weight for training the diaphragm was determined by
trial and error method [23]. The evaluated weight was
placed over the epigastric region with an isosceles tri-
angular board. The board was 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. Cushioning is provided with the under surface
of the triangular board in order to prevent skin irritation,
as shown in Figure 3. Evaluated weights were added to
the triangular board using dish weights. During the
training period the subject was instructed to perform the
exercise in supine lying and do normal breathing with
the weights on for 15 minutes. Progression in weights
was done during each review. Subsequent assessments
were planned during the routine medical screening and
checkups of the client.
Figure 2. Analysis of ILV using spirometer.
Figure 3. Placement of abdominal weights.
5. RESULTS
Weights were progressively increased during each visit.
Initial weight was 5 kgs and the patient progressed to 12
kgs by the end of the trial, as shown in Table 1.
Increment in the mean of peak amplitudes of EMG
values were noted in DIA and SCM muscles, progress in
the INT muscle did not show a consistent change (shown
in Figure 4). Similarly the INV showed a gradual rise
from 1772 ml to 2760 ml over the study period (shown
in Figure 5).
6. DISCUSSION
The efficiency of respiratory muscles were studied over
a period of 1 year, following administration of abdomi-
nal weighted training with the aim to determine the long
term effects of the examined respiratory muscle training.
The subjects respiratory muscle efficiency was assessed
using recordings made over key respiratory muscles with
the help of surface EMG. EMG was chosen because it
captures the electrical activity happening within the mus-
cle which is a direct measure of maximal contraction of
the assessed muscle. Work done by Jennifer Beck et al on
healthy individuals states there is no artifactual effect of
lung volume on the diaphragm EMG signal strength dur-
ing voluntary contractions [25]. Thus the EMG readings

S. J. Winser et al. / HEALTH 2 (2010) 407-411
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410
Table 1. Progress of the study.
DATE Weights used
in Kgs
EMG in milli
volts INV in ml
DIA 1.2453
INT 0.7237 Day 1 3
SCM 1.5234
1772
DIA 1.4356
INT 0.5634 3 months 5
SCM 1.5735
2080
DIA 1.5643
INT 0.8675 6 months 8
SCM 1.6876
2280
DIA 1.7536
INT 0.7457 9 months 10
SCM 1.7453
2440
DIA 1.9675
INT 0.9656 12 months 12
SCM 1.8758
2760
Figure 4. Peak amplitude of the analyzed muscles.
Figure 5. ILV over the study period.
can be considered as an objective measure of respiratory
muscle efficiency. ILV was considered as the secondary
outcome measure because of the ease of administration.
Though the objectivity of the test has not been tested, the
results obtained are directly related to strength of the
respiratory muscles and pulmonary compliance.
Our study shows the following findings:
1) Measures of EMG of the DIA and SCM muscles as
well as the ILV have showed a gradual rise which im-
plies: Use of abdominal weights as a part of respiratory
rehabilitation has beneficial long term effects; 2) In pa-
tients with tetraplegia, respiratory muscles in particular,
the diaphragm is trainable in terms of muscle efficiency,
provided that the muscle performance is not severely
compromised as in cases of ultra high lesions who re-
quire ventilator assistance; 3) The improvement in the
muscle efficiency obtained during the early rehabilita-
tion can be maintained or improved using simple non
sophisticated exercises like abdominal weights. Clini-
cally we did not observe any deterioration in the patients
respiratory as well as functional status which is a good
sign for a tetraplegic.
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 on the
subject along with the increase in activity of the dia-
phragm. However we could not explain the reason for
this phenomenon.
There were few limitations in our study which in-
cludes spasticity and adherence of the subject to the
training program. There are possibilities that distur-
bances from the abnormally activated trunk muscles
could have reduced the accuracy of EMG activity of the
diaphragm and other respiratory muscles. Outcome
demonstrated by the ILV has shown a consistent rise
which can be considered to overcome the limitation of
misleading values from the EMG if any. Though we
used a log book for tracking the adherence to the treat-
ment protocol a direct supervision of the subject on a
regular basis at community level can be considered for
upcoming studies, for more accurate results.
7. CONCLUSIONS
The peak EMG amplitude and ILV showed a consistent
rise on the subject who was trained using abdominal
weights. This is an apparent indication of improved per-
formance of the target muscle with regards to strength
and pulmonary function. The improvement of the muscle
efficiency was maintained throughout the study period
which is a positive sign of long term effects of the tech-
nique. Cost effectiveness, ease of administration of this
technique ensures its frequent usage by clinical practi-

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tioners. With adequate instructions and proper training,
this technique does not require direct supervision by a
therapist and so is useful for community based rehabili-
tation. Thus we conclude stating Abdominal weights can
be used as an effective adjunct to pulmonary rehabilita-
tion in improving the efficiency of diaphragm on a long
term basis, thereby reducing the risks associated with
pulmonary complications.
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