Sutbeyaz, S. T., Koseoglu, B. F., & Gokkaya, N. K. O. (2005). The combined effects of controlled breathing techniques and ventilatory and upper extremity muscle exercise on cardiopulmonary responses in patients with spinal cord injury. Inter J of Rehab Res, 28, 273-276.

Abstract
Rebecca Conklin

Purpose:
According to the National Spinal Cord Injury Association (NSCIA), 7,800 new injuries occur each year in the U.S. It is currently estimated that 250,000 to 400,000 individuals are living with spinal cord injury (SCI) or spinal dysfunction in the U.S. In the past, renal failure was the most common cause of death. More recently, an increasing number of people with SCI are dying of unrelated causes such as cancer or cardiovascular disease, similar to that of the general population. Within the past two decades, cardiopulmonary disease has emerged as the major cause of death and an important source of morbidity for aging persons with SCI. Several studies have associated this risk with sedentary lifestyle and low levels of fitness observed in personas with tetraplegia and paraplegia.

The purpose of this study was to evaluate the effects of controlled breathing techniques and ventilatory and upper-extremity training on cardiopulmonary and metabolic function and exercise tolerance in individuals with SCI.

Participants:
The participants consisted of 20 individuals with paraplegia (12 men and 8 women) from the inpatient rehabilitation department. All the participants had thoracic lesions (T6 - T12), and all were considered minimally active and not trained aerobically in their upper extremities. Inclusion criteria included: sufficient upper torso and extremity nerve function, strength to accomplish arm crank ergometry, no previous history of cardiovascular or respiratory problems, and no medication that would influence metabolic or cardiorespiratory response to exercise. Exclusion criteria included chronic pulmonary or cardiac disease or clinical evidence of cardiac or respiratory disease.

Method:
The exercise program was designed for individuals with SCI and required the participants to train 60 minutes a day, three times per week, for 6 weeks. The exercise program consisted of 15 minutes of diaphragmatic breathing exercises combined with pursed-lips breathing, 5 minutes of air-shifting techniques, 10 minutes of voluntary isocapneic hyperpnea, and arm crank exercise, which was started at 75% of the maximum VO2 achieved during baseline maximum cardiopulmonary exercise testing. The exercise intensity was gradually increased to maximal exercise as tolerated over the 6 weeks. Measurements were taken at baseline and at the end of the training program, which included forced vital capacity (FVC), forced expiratory volume in 1s (FEV1), forced expiratory flow rate 25-75% (FEF%25-75), peak expiratory flow rate (PEF), vital capacity (VC), the ratio of FEV1 to FVC, and maximum voluntary ventilation.

Results:
The participants were tested for cardiopulmonary and metabolic values. Baseline values showed a restrictive ventilatory pattern in five individuals, generalized airway obstruction in four individuals, and a mixed respiratory dysfunction in three individuals. After 6 weeks of training, there were significant increases in FVC, FEV1, VC, peak HR, RER, peak VE, peak PO and time to fatigue. It was also observed that peak ratio of physiological space to tidal volume (VD/VT) decreased with training. All these values were found to be statistically significant. The authors did not document any injuries or mortality in the study.

Discussion:
The study showed that a combined exercise training program can improve resting spirometric values, peak VO2, peak PO, time to fatigue, RER, peak minute ventilation and peak VD/VT, which correlates with previous findings documented in the literature. The exercise program used in this study may be a practical and beneficial way for improving controlled breathing and ventilatory muscle fitness in SCI individuals. The authors suggest that the program should be considered during routine rehabilitation to avoid cardiopulmonary problems and deconditioning in individuals with paraplegia. Also, this is the first study to assess the effects of controlled breathing techniques and voluntary isocapneic hyperpnea in a large group of individuals with paraplegia. It was noted that limitations were present in this study, the main concern being the open-label protocol used, in which both the researchers and participants were aware of the treatment being administered.