Respiratory Treatment of the Adult Patient

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Respiratory Treatment of the Adult Patientwith Spinal Cord InjurySUSAN ENRIQUEZ ALVAREZ, BS,MARGERY PETERSON, MS,and BRENDA RAE LUNSFOR D, MS

The respiratory program of the Spinal In jury Service at Rancho Los AmigosHospi tal has demonstrated effect ive respiratory treatment to be a prerequisi tefor comprehensive rehabi l i tat ion. To faci l i tate program planning, pat ients areclassified according to functional neuro segm ental levels and residual resp iratorym uscles. Breathing m echanics a re the basis of evaluat ion and treatm ent. Eval-uat ive elements are strength of residual respiratory muscles, respiratory rate,vital capa ci ty, breathing patte rn, chest expa nsion, and cou gh. Respiratory func-t ions of pat ients wi th spinal in jury are compared wi th respiratory funct ions ofheal thy subjects. Treatm ent object ives a re prep ared a ccording to the individualpat ient 's funct ional classi f icat ion and evaluat ion. Specif ic methods are d is-cu s s e d , including strengthening, chest wall mobil ization, external support de-vices, and bronchial hygiene.Key Words: Spinal cord injuries, Breathing exercises, Respiratory therapy, Physical

therapy.

Rehab ilitation of patients with paralytic respiratoryinvolvement has had two historical phases. The firstphase was a consequence of the paralytic sequelae ofpoliomyelitis. During the polio epidemic, patientswere cared for in h ospital centers in large metropoli-tan areas of the country. Massive efforts by manyprofessionals engaged in the care of these patientsresulted in enormous clinical expertise. Thus we havea legacy of evaluation and treatment techniques,many of which can be used appropriately for patientswith spinal cord injury. The second historical phasein the development of rehabilitation of patients withparalytic respiratory involvement began in the early1970s with the establishment of regional spinal cordinjury centers: patients with paralytic respiratoryproblems are again receiving treatment in selectedcenters across the country. The current treatmentapproach combines the expertise learned in polio-myelitis rehabilitation with the experience gained intreating large numbers of patients with spinal cordinjuries.1

Before discussing evaluation and treatment tech-niques, we will review the primary respiratory mus-

culature and mechanics of breathing in patients withspinal injury. A functional respiratory classificationhas been developed to represent neurologic levels ofinjury and the associated respiratory muscle pattern(Fig. 1). The major emphasis of physical therapy isfor the patients in Classes II through V. Class Ipatients are totally respirator dependent and Class VIpatients have all respiratory muscles intact. However,patients in Class VI may have abnormal vital capac-ities secondary to pelvic floor muscle involvement.2, 3Great emphasis must be placed on the respiratorycare of patients with injury to cervical or high thoracic

RANCHO LOS AMIGOS HOSPITALFUNCTIONAL RESPIRATORY CLASSIFICATIONCLASS

DIAPHRAGMINSPIRATION

INTERCOSTALS NECKEXPIRATIONABDOMINALS

I C 2II C4III C6IV T4V T 10I T12

0+/-++++

000+/-++

0+++++

0000

+/-+

MUSCLE KEY: 0 = A B S EN T , - = W E A K , + = N O R M A L

Fig. 1. Chart of functional respiratory classificationshowing neurological levels of injury and associated res-piratory muscle pattern.

Mrs. Alvarez is Supervisor I, Spinal Injury Service, Departmentof Physical Therapy, Rancho Los Amigos Hospital, 7601 E ImperialHwy, Downey, CA 90242 (USA).Mrs. Peterson is Physical Therapy Instructor, Spinal Injury Ser-vice, Department of Physical Therapy, Rancho Los Amigos Hospital,Downey, CA.Mrs. Lunsford is Supervisor II, Spinal Injury Service, Depar tmentof Physical Therapy, Rancho Los Amigos Hospital, Downey, CA.

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Fig. 2. Diagram showing diaphragm motion and affectedthoracic volume. Expansion of ch est wall is lost whenthere is paralysis of the intercostal muscles.parts of the spine. B oth inspiration and expiration areaffected inasmuch as the diaphragm remains activeas the main functioning respiratory muscle.4- 6 D epending on the injury level, the diaphragm may alsobe affected because of its innervation by the phrenicnerve (C3-5).7 Full comprehension of the seriousrespiratory im plications of q uadriplegia and h igh paraplegia requires an understanding of the normal mechanics of respiration and the function of the respiratory m uscles.MECHANICS AND ANATOMY OF NORMALVENTILATION

Ventilation has two phases: inspiration and expiration. The major muscles that contribute to inspira-tion are the diaphragm and the external intercostals.8The diaphragm is a dom e-shaped muscular sheet thatseparates the abdom inal and thoracic cavities. It originates from three areas: the sternal portion arises fromthe dorsal aspect of the xiphoid process, the costalpart originates from the last six ribs and the innercartilage, and the lumbar portion arises from thebodies and transverse processes of the upper lumbarvertebrae.7 From this series of origins, the fibers ofthe diaphragm converge to insert into the centraltendon.

Contraction of the diaphragm causes it to descend.Therefore, the vertical diameter of the thoracic cavityincreases and as a result, intrathoracic pressure isreduced. The descent of the diaphragm compresses

the abdominal contents and intra-abdominal pressureincreases.

The external intercostal muscles, innervated by theintercostal nerves,7 elevate the ribs during quiet inspiration by their oblique attachment from the distalborder of one rib to the proximal border of the ribbelow. The contraction of the external intercostalmuscles causes an increase in lateral and anteroposterior diameters of the thorax. A negative intrathoracic pressure gradient, created as a result of theincreased thoracic volume, causes air to flow into thelungs (Fig. 2).

The diaphragm contributes 40 percent of the tidalvolume and the intercostal muscles contribute 60percent, while the diaphragm contributes 60 to 75percent of the vital capacity.6, 9-12 Several accessorymusclesthe sternocleidomastoid and scaleniassistthe elevation and fixation of the ribs during forced ormaximal inspiration.13, 14 The use of these musclesduring quiet breathing is a useful indication of impaired breathing.5, 13, 15

The major muscles that contribute to expiration arethe abdominals and internal intercostals.8 Normally,quiet expiration is a passive process rather than anactive process like the muscle contraction in inspiration. However, postural tone of the abdominal muscles plays an important role in expiration by providing support to the abdom inal contents.16 This supportcauses the viscera to push the relaxed diaphragm backto its resting position. Active con traction of the expiratory muscles usually occurs during forced or maximal expiration as in coughing and sneezing.5 Duringforced expiration, the diaphragm is pushe d further upin the thoracic cavity by contraction of the abdominalmuscles and the ribs are depressed by contraction ofthe internal intercostal muscles.8 Positional changesdo not seem to have any great effect in normalindividuals. The resting level of the diaphragm islower with an individual erect when compared tosupine.6 The effects of gravity on normal personswhen sitting are minimal; often breathing is easierdue to a redistribution of visceral weight and changesin lung volumes.11As previously mentioned, the diaphragm is themajor muscle contributing to ventilation in patientsin Classes II through IV. In a patient with cervical orhigh thoracic sp inal injury, the intercostal muscles areparalyzed. When the intrathoracic pressure is decreased, by action of the diaphragm, the ribs aredepressed and a paradoxical breathing pattern is observed. This breathing pattern results in reduction ofinspiratory volume (Fig. 2).2, 4-6, 16, 17 The intercostaland abdominal muscle paralysis creates a series ofproblems resulting in decreased inspiratory abilitywith a subsequent decrease in expiratory flow.2, 4, 6Intercostal paralysis directly diminishes chest mobility, resulting in decreased compliance, while abdom-

1 7 3 8 PHYSICAL THERAPY


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inal paralysis affects the diaphragm's position forinspiration.18 The clinical significance of intercostaland abdominal muscle paralysis is a decrease in inspiratory volume during quiet breathing, and the lossof expiratory force during cough (Fig. 3). Maintenance of good bronchial hygiene is dependent uponthese expiratory muscles inasmuch as lack of anexpulsive force and loss of chest wall mobilityprevent a functional cough.5, 10, 12, 17, 19 Positionalchanges now can create problems. The main reasonfor ventilation difficulties is that without the assistance of intercostal and abdom inal muscles the descentof the diaphragm is hindered by postural redistribution of viscera and changes in lung volumes.2, 4, 5, 11While the patient is supine, the abdominal contentsforce the diaphragm to a higher resting level than ifthe patient were erect.7, 11, 20 The supine position allows for greater diaphragmatic excursion w hen co mpared to the erect position: when the patient is erect,the demand on the diaphragm increases because it isin a lower resting position due to weight of theabdominal contents being affected by the downwardforce of gravity.20 Because of the lack of abdominaltone, the diaphragm cannot return to its normalresting position, and the inspiratory capacity is decreased. Therefore, the patient will continue to havediminished ventilation unless some mechanism isused to substitute for the abdominal tone and adequate support is provided for the viscera. The patientwill also h ave a diminished vital capacity, that, despitenormal lung conditions, creates a potential for atelectasis.6EVALUATION

Before comprehensive respiratory care of patientswith spinal injury can begin, a thorough evaluationis mandatory. Important general criteria include: 1)strength of the respiratory muscles, 2) compliance ormobility of the chest wall, and 3) any inspiratorysubstitution occurring during quiet breathing.5 Thetherapist should be aware of any prior or currentrespiratory complications related to the spinal injuryand sh ould be fam iliar with the respiratory equipment

Fig. 3. Flow chart showing influence of paralysis of theintercostal an d abdominal muscles on ventilation.the patient m ay be using at the time of the evaluation.The six specific items for the physical therapist toinclude in a clinical respiratory examination are muscle strength, respiratory rate, breathing pattern, chestmobility, cough function, and vital capacity.Respiratory Muscle Strength

Before pursuing the functional aspects of the respiratory evaluation it is important to establish a baseline by measuring the strength of the muscles involved. Neck and trunk musculature are evaluatedusing standard man ual mu scle testing techniques.21, 22A simple technique for assessing diaphragm functionis to observe the supine patient for epigastric riseduring a maximal inspiratory effort. If the patient isin Class III through VI, a normal epigastric rise willbe observed (Fig. 4). A normal epigastric rise indicatesthat the diaphragm is contracting through its fullexcursion. For the patient in Class II, the normalepigastric rise may b e present. If the norma l epigastricrise is not noted, the diaphragm is too weak to complete a full excursion. When the presence of thediaphragm is questionable, the patient should beobserved for Litten's sign. This sign is a ripplingaction observed between the 8th, 9th, and 10th ribsindicating the presence of a weak diaphragm.16 Thesign is created as the intrathoracic pressure decreasesand can be observed best in thin individuals. While

Fig. 4. Contour of epigastric area of a patient with Class III respiratory function shown during a) relaxed expirationand b) maximal inspiration.Volume 61 / N umber 12. Decem ber 1981 1 7 3 9


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the presence of Litten's sign confirms active motionof the diaphragm, the lack of a sign is not a definiteindication the diaphragm is absent. Further examination of a weak diaphragm may be done throughpalpation, double exposure roentgenogram, andfluoroscopy.10, 16 During a fluoroscopy evaluation, thediaphragm can be observed during quiet breathingand deep breathing. During quiet breathing, the normal range of movement of the diaphragm is at least1 to 5 cm w hile during deep inspiration, the range ofmovement is at least 7 to 13 cm.6 A difference mayexist between the diaphragm's descent during quietand deep breathing as well as between both sides ofthe diaphragm. The fact that a patient is able toincrease the diaphragm's descent during deep inspiration indicates inspiratory reserve. While more objective measures of inspiration may be obtained, theequipment to acquire this data is not easily availableto the therapist and the test results do not isolatediaphragm from intercostal function.23, 24 Intercostalsare assessed indirectly by noting chest expansion andvital capacity (see following sections).Respiratory Rate

With a normal diaphragm muscle the respiratoryrate remains regular at approximately 12 to 16 breathsper minute. With a weak diaphragm a commonchange is an increase in respiratory rate. The purposeof evaluating the respiratory rate is primarily to determine the efficacy of the remaining musculature toventilate the patient. The therapist should know thesigns and symptoms of hypoventilation and hyperventilation as either may occur secondary to extremechanges in rate. Hypoventilation may result in drowsiness, irritability, or a decrease in appetite, whilehyperventilation may result in faintness and in tingling and numbness in the extremities.5 The respiratory rate should be observed while the patient is atrest and unaware that the therapist is countingbreaths.Breathing Pattern

The purpose of determining the breathing patternis to evaluate the "quality" of the active muscles aswell as their contribution to inspiration. A normalbreathing pattern consists of rib elevation with thoracic expansion resulting from intercostal muscle contraction and of epigastric rise resulting from diaphragm m otion.16 The most common breathing pattern observed in patients in Classes II through IV isdiaphragmatic, because the diaphragm is the onlyefficient muscle remaining. When the diaphragm isweak, however, the neck accessory muscles, such asthe sternocleidomastoid or scaleni muscles, may assistthe weak diaphragm in ventilation.5, 15,16

Breathing patterns should be observed with thepatient in supine and sitting positions to determinethe effects of gravity. Diaphragm muscle weaknessmay not be obvious when the patient is supine and atrest. When the patient is erect, the effect of weak orparalyzed abdominal muscles is most pronouncedand a change in the breathing pattern may occurbecause of the decreased efficiency of the diaphragm.The breathing pattern also may change when thepatient engages in activities such as talking or exercisebecause these activities increase the need for ventilation. Usually, the major change in the breathingpattern is the added use of the neck accessory muscles.A patient's breathing pattern can be evaluated invarious ways, such as 1) placing one of your handson his chest and the other over his abdominal area tofeel changes in motion; 2) direct observation; and 3)placing both your hands on his chest, thumbs touching, to check for chest expansion. A patient may bemomentarily disconnected from a mechanical ventilator to evaluate his diaphragm function.Ch est Mobility

A mobile chest wall is extremely important to thepatient with impaired intercostal muscle function.Because the resulting paradoxical motion of the ribsdecreases chest expansion, there is a natural predisposition to chest tightness in these patients.2, 5, 10, 25Chest measurements are taken at the axilla and xiphoid process levels with a cloth tape measure to evaluate excursion of both the upper and lower rib cage.Chest expansion measurements are the differencebetween chest measurements at maximal exhalationand at maximal inhalation. These measurements mayproduce a negative value, such as 0.5 in (1.3 cm)because of the paradoxical chest motion; whereas,normal chest expansion is 2.5 to 3 in (6.5-7.6 cm).26These measurements provide an objective indicationof intercostal strength when compared with normalchest expansion. Chest expansion should also be measured with an airshift. An airshift is a maneuverduring which a person inhales maximally, closes theglottis, relaxes his diaphragm, and allows the air toshift from the lower to upper thorax. Airshifts mayincrease chest expansion 0.5 to 2 in (1.3-5.1 cm).Initially, the airshift maneuver allows most patientsto achieve a 0.5-in chest expansion.Cough Function

The purpose of assessing the cough is to evaluatethe patient's ability to clear secretions. The abdominalmuscles are the major muscles creating the expulsiveforce necessary for a cough. When abdominal musclefunction decreases, coughing is impaired.5 Coughsmay be classified as functional, weak functional, and



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nonfunctional. A functional cough is adequate toclear all secretions and no assistance is required. Aweak functional cough is adequate to clear the throatand small amounts of secretions, but assistance tocough would be required to clear mucous with arespiratory infection. A nonfunctional cough meansthe patient is unable to generate any cough force.Inability to clear secretions because of an impairedcough may result in inadequate bronchial hygieneand potentially serious pulmonary com plications. Theimportance of adequate bronchial hygiene must bestressed, because complications arising from respiratory infection are a major cause of death in the pa tientwith spinal cord injury.1,10,12,19, 27Vital Capacity

Routine vital capacity measurements provide anobjective base-line for defining respiratory muscleweakness.5, 10 This measurement can be used to monitor a patient's progress and can be easily measuredwith a handheld spirometer. Vital capacity is recordedas a percent of predicted value or as a volume (cubiccentimeters).16 While the percent value is useful inmost cases, the volume is an important measurementin the patient with severe impairment. Inasmuch asphasing a patient from use of a respirator is anindividual process, the volume measurement providesvalid indication of progress. Any prior history of lungdisease is important to consider to make correct interpretations. Vital capacity should be determinedwith the patient in both supine and erect positions todetermine the effects of gravity. Initial vital capacitymeasurements vary depending on the functional classification and range from less than 25 percent ofnorm al in Class II to 80 percent of normal for patientsin Class VI (Table).TREATMENT

The overall treatment goals for patients with respiratory dysfunction from spinal injury are 1) im-

TABLEVital Capacity (%of Normal)ValuesaBefore an d AfterTreatment

Class

IIIIIIVVVI

BeforeVital Capacity

Treatment (%)25

35507080

AfterTreatment (%)4060809095

a Values are approximate and intended to provide aguideline of expected values to observe at initial evalua tion and for reasonable expected outcome.

provement of ventilation, 2) prevention of chest tightness, 3) improvement of cough force, and 4) prevention of substitute breathing patterns that interferewith function.The treatment program used to accomplish thestated goals includes: diaphragm reeducation andstrengthening, use of appropriate abdom inal support,chest mobilization, and bronchial hygiene includingcough and bronchial drainage. T his program is simpleand straightforward but requires careful monitoringand frequent reevaluation of the patient. Specifictechniques and considerations for each aspect of theprogram are discussed separately.Strengthening

After evaluating the patient, the therapist shouldknow the functional strength of the diaphragm. Totrain the patient to rely only on the diaphragm forbreathing, we have him do diaphragm strengtheningexercises separately from neck strengthening.5, 16 Also,any assistance from the neck accessory muscles isinitially discouraged while the diaphragm is beingstrengthened.15 This precaution is common for ClassII patients who use their neck muscles to assist a weakdiaphragm. The primary method of mobility for this

Fig. 5. Subject positioned with weights for diaphragm strengthening a) during relaxed expiration and b) attaining fullepigastric rise during inspiration.Volume 61 / Num ber 12, December 1981 1741


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Fig. 6. Patient with properly fitted and applied corset.class of p atients is driving a w heelchair, by chincontrol, and certain functional tasks are possible onlyby using a mou thstick. Therefore, breathing with theirneck muscles may interfere with attaining some functions and mobility. For the patient with paralyzedintercostal and abdominal muscles, use of the diaphragm alone for ventilation is more efficient thanuse of the neck accessory muscles and the diaphragmtogether.15 The patient must be allowed to developfully an efficient breathing pattern before resorting touse of another less efficient one.5 If the diaphragm isunable to tolerate progressive resistive exercises, thendeep breathing or manual resistive exercises are begun. "Unable to tolerate" means that the signs andsymptoms of fatigue (such as use of neck accessorymuscles) develop during the strengthening program.15Too much resistance can overload a weak diaphragmand prevent further strengthening. Therefore, carefulmonitoring is important to avoid any fatigue.

With the patient supine, resistance should be applied directly over the epigastric area. This area canbe identified by palpating the lower ribs and notinga triangular-shaped area just below the xiphoid proc-cess. The weights are applied directly or by a weightpan that holds the w eights on the epigastric area (Fig.5) . The da ily treatment is 15 minutes. Endurance with

Fig. 7. Diagram showing im proved resting position ofdiaphragm with corset supporting abdominal mass.

a gradually increasing resistance should be stressed.1The patient should be able to lift the weight withdiaphragmatic contraction for the full treatment timewithout obvious fatigue before more weight is added.

Abdominal Support

Use of a properly fitting corset is important intreating patients with decreased abdominal strength(Fig. 6).5, 16, 20 With paralyzed or weak abdominalmuscles, a corset will support the abdominal contentsagainst the effects of gravity, allowing the diaphragmto assume a normal resting position while the patientis erect (Fig. 7).17 Therefore, proper application andfit of the corset are essential. The corset should lieover the lower floating ribs and extend over the iliaccrests bilaterally. If the corset is placed too high, itimpedes inspiration by restricting the epigastric rise.If the corset is applied too low, it impedes diaphragmfunction by allowing abdominal protrusion. Thelower buckles of the corset should be tighter than theupper one s to provide appropriate support. The corsetshould fit snugly, yet one should be able to slip ahand between the corset and abdomen. Corsets canbe custom fitted or can be a stock size if they giveadequate support. Some patients develop sufficientabdominal muscle tone to substitute for the corset.Use of the corset may be discontinued when there isno difference in the ease of breathing during functional activities with or without the corset.A pneumobelt can be used to assist ventilation forpatients unable to eliminate the neck accessory muscles from the breathing pattern because of inadequa tediaphragm strength.5, 10, 16 The p neumob elt is a corsetwith an inflatable bladder placed over the abdomen(Fig. 8). The bladder is connected to a respirator bya hose. The respirator must deliver an intermittentpositive pressure and have rate settings. The bladderinflates during expiration and pushes the abdominalcontents inward, thus displacing the diaphragm upward to an optimal resting position from which tofunction. Expiration becomes active by using thepneumobelt, and inspiration occurs by using the weakdiaphragm as the bladder deflates. In this way thepneumobelt protects the diaphragm against the adverse effects of gravity. With assistance during expiration, the diaphragm is more efficient during inspiration and is not overchallenged, thereby decreasingor eliminating the patient's use of neck accessorymuscles in the breathing pattern. Two important concepts are 1) the pneumobelt assists during expirationand 2) patients can be benefited only if in the erectposition. In our clinical experience, the pneumobelthas been used successfully on m any patients with aninitial vital capacity of 500 cc. Most of these patientsachieved a vital capacity of about 2000 cc after two



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to cough. The manually assisted cough is very similarin technique to the Heimlich's maneuver taught incardiopulmonary resuscitation classes. The action ofthe person assisting mimics contraction of the paralyzed abdominal muscles. Patients with adequate upper extremity strength can assist their own cough byquickly compressing the abdominal area. For example, this compression can be done with the patient'sarms, with him leaning forward over a pillow placedagainst the abdomen. The use of GPB can also produce a functional cough by increasing the volume ofinspired air and letting it out all at once.

Before discharge, bronchial drainage is routinelytaught to the patient, family, or attendant. The familyis instructed in percussion and proper positioning andtaught that the patient must cough at least once ineach position. The patient is taught to demand treatment at the first sign of congestion.FUTURE RESEARCH

With a comprehensive respiratory evaluation andintensive treatment program, the patient with respiratory dysfunction has the opportunity to develop hisrespiratory capacity and, therefore, maximize hisfunctional potential. Evaluation of respiratory mechanics and physiology has been well-founded. H owever, efficacy of treatment is based on the clinicalexperience gained over the years. To continue toprovide patients with the best possible respiratorycare, all types of current treatment shou ld be criticallyanalyzed both for short-term as well as long-termeffectiveness. For example, a mobile or flexible chestwall is believed to be a major influence on an individual's vital capacity. The two techniques used tomaintain or gain chest wall flexibility are manualchest stretching and intermittent positive pressure,but the relative values of these two techniques havenot been documented for either short- or long-termeffects. Each technique should be evaluated for itsindividual as well as comparative merits.

Another clinical concern requiring research isabout patients who have partial innervation to thediaphragm. While these patients receive much daytime attention, not much is known about their respiratory function during sleep. Not infrequently, a patient with a neurological diagnosis o f C4 quad riplegia,although able to be up in a wheelchair during theday, does not start his daytime activities until latemorning. Such patients are often difficult to awakenand once aroused are slow to respond or "grouchy."

The natural decrease of rate and volume of respiration during sleep may not be well tolerated in thequadriplegic subject with marginal diaphragm function. The normal decrease in minute volume andincrease in Pco 2 may become relatively excessive inthese patients, resulting in the clinical signs notedabove.31

One proposal in pursuing sleep studies with thequadriplegic patient is to first document selected respiratory variables during waking hours and then collect comparable data while the subject sleeps. If significant respiratory change s are noted in certain subjects, perhaps some routine measurement could beused to predict which patients will have intolerablerespiratory decreases du ring sleep. The effect of assistive therapy, including supplemental oxygen and special positioning, could also be docum ented in a similarmanner. The benefit to patients of this effort is to beable to identify those who have excessive respiratorydecreases when sleeping and provide them with theproper therapy, thereby enhancing their ability toparticipate in daytime activities.

A final topic for study is the total effect of normalrespiratory function on all classes of spinal injuredpersons. For example, we have just completed a studyusing an on-line metabolic measurement system todetermine the maximum exercise abilities of a groupof paraplegic patients. While these patients, whencompared with noninjured subjects, had upper extremity strength that was as great or greater and hadheart rates typical of normal maximum effort, theyconsumed less oxygen. Our data show the variablemost likely affecting this was minute ven tilation. Withgrowing interest in endurance training and athleticcompetition among this group of patients, more research is needed to define the most effective trainingmod es for patients who have loss of muscle as well asrespiratory reserve.

While considerable effort has been placed on evaluation and treatment of respiratory deficits, muchneeds to be done to validate the treatment approach.W ith greater understanding o f cause and effect, treatment can be more individualized and staff and patients spared unproductive effort. To ensure optimalrespiratory care efforts of therapists and patients wemust be able to identify those patients for whomspecific therapeutic intervention is necessary andthose in whom functional training adequately challenges the respiratory system. Through research efforts, effective evaluation and treatment methods willbe preserved and new ones will be developed.



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REFERENCES1. Stauffer ES , Bell GD: Traum atic respiratory quadripleg ia andpentaplegia . Or thop Cl in Nor th Am 9(4 ) :1 081 -10 89 , 197 82 . Fugl-Meyer AR: Effects of respiratory muscle paralysis inte t raplegic and paraplegic pa t ients . Scand J Rehabi l Med 3:1 4 1 - 1 5 0 , 1 9 7 13 . Hemingway A, Bors E, Hobby RP: An investigation of thepulmonary function of paraplegics. J Clin Invest 37:773,1 9 5 84 . Mortola JP, Sant 'Ambrogio G: Mechanics of breathing int e t r ap leg i c s . Am Rev Res p ir D is 1 1 9 : 1 31 - 1 34 , 1 9795 . Dail C: Respira tory as pe ct s of rehabili tation in neurom uscula rcondi t ions . Arch Phys Med Rehabi l 46:655-675, 19656. Bergofsky E: Mecha nism s for respiratory insufficiency aftercervical cord injury: A sou rce of alveolar hypoventilation.Ann I n t e r n Med 61 : 435 - 437 , 1 9647. Gray H: Anatomy of the Human B ody, ed 29. P hiladelphia,PA, Lea & F e b ig e r, 1 9 7 3 , p p 4 1 2 - 4 1 48. Wes t JB: Respiratory Physiology. Baltimore, MD, Williams &Wi lk in s Co , 1 974 , pp 8 6 - 1 1 39. Ch op ra SK, Tap lan GV: Ventilation-pe rfusion lung imaging ind i aph r agma t ic pa r a l y s is . Sou t h Med J 72 ( 3 ) : 351 - 352 , 1 9791 0 . Carter RE: Medical managem ent of pulmonary com pl ica t ionsof SCI . Adv Neurol 22:261-269, 1979

1 1 . Wad e OL: Movem ents of the thoracic cage and diaphragm inrespi ra t ion . J Phys io l (Lond) 124:193-212, 19541 2 . Mon tero J, Feldman D, Mon tero D: Effects of glo sso pha ryngeal breathing on respiratory function after cervical cordt r ans ec t ion . Arch Phys Med Rehab i l 48 : 65 0 - 6 53 , 1 9671 3 . Raper AJ , Thompson W, Shapi ro W, e t a l : Scalene andsterno cleido mas toid m uscle function. J Appl Physiol 2 1 :4 9 7 - 5 0 2 , 1 9 6 61 4 . Campbel l EJM: The ro le of sca le ne and s ternocle idomastoidin brea th ing in normal subjec ts . J Anat 89:378-386, 19551 5 . Adkins HV: Improvement of breathing ability in children withr e s p ir a t or y mus c l e pa r al y s i s. Phys The r 48 : 5 77 - 5 81 , 1 96 81 6 . Dail CW: Muscle breathing patterns. Medical Arts and Sciences , Second qua r t e r , 1 956 , pp 64 - 70

17 . Kirby NA, Barn erias M J, Sieb ens AA: An evaluation of as sisted cou gh in quadrip legic patien ts. Arch Phys Med Rehabil4 7 : 7 0 5 - 7 1 0 , 1 9 6 618 . Gibson GJ, Pr ide NB: Lung mech anics in d iaphragm at icpara lys is . Am Rev Respi r Dis 119:119-120, 19791 9 . Siebens AA, Kirby NA, Puolos D: Cough following transections of spinal cord at C6. Arch Phys Med Rehabil 45:1,1 9 6 42 0 . Goldm an M: Me chan ics of specific patt ern s of respiratorymus c l e dys func ti on . Am Rev Resp i r D is 1 1 9 : 1 3 5 - 1 3 6 , 1 97 92 1 . Daniels L, Worthingham C: Muscle Testing. Philadelph ia, PA,W. B . Saund e r s Co , 1 972 , pp 1 6 - 2 0 , 2 2 - 332 2 . Kendall HO, Kendall FS, Wadsworth GE: Muscles, ed 2.Bal timore , MD, Will iams & Wilkins Co, 1 97 1, pp 19 9- 2 35 ,2 6 4 - 2 6 72 3 . Newson-Davis J : The d iaphragm and neurom uscular d isea se .Am Rev Res p ir D is 1 1 9 : 1 1 5 - 1 1 7 , 1 9792 4 . Braun N, Roch es ter DF: Muscular weak nes s and respi ra toryfa i lure . Am Rev Respi r Dis 119:123-125, 19792 5 . Gibson GJ, Pride NB, Davis JN, et al: Pulmonary mechanicsin pat ients with respira tory mus cle wea kne ss . Am Rev Respi rD is 1 1 5 : 3 8 9 - 3 9 5 , 1 9 7 72 6 . Carlson B: Normal ches t excurs ion . Phys Ther 53:10-14,1 9 7 32 7 . Fugl-Meyer AR: A model for treatm ent of impaired ventilatoryfunct ion in te t raplegic pa t ients . Sca nd J R ehabil Med 3 :1 68 -1 7 7 , 1 9712 8 . Dai l CW, Rodgers M, Guess V, e t a l : GlossopharyngealBreathin g. Downey, CA, Professional Staff Association of theRancho Los Amigos Hospi ta l , Inc . 1979, pp 48-492 9 . Warren A: Mobilization of the chest wall . Phys Ther 48:582-5 8 5 , 1 9 6 83 0 . Metcalf V: Vital capa city and g losso pha ryng eal breathin g int r auma t i c quad r ip l eg ia . Phys The r 46 : 83 5 - 8 38 , 1 9663 1 . Fenn WO, Rahn H: Handbook of Physiology, Section 3, vol2 . Washington, DC, American Physio logy Socie ty , 1965, pp1 2 1 9 - 1 2 5 7

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Respiratory Treatment of the Adult Patient