Sonographic Response of Diaphragmatic Excursion to Threshold Inspiratory Muscle Trainer in Elderly

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1 Med. J. Cairo Univ., Vol. 85, No. 2, March: , Sonographic Response of Diaphragmatic Excursion to Threshold Inspiratory Muscle Trainer in Elderly SAMUEL F. REZKALLAH, M.Sc.*; AZZA A. ABD EL-HADY, Ph.D.**; FATMA A. HAMID, Ph.D.** and FAYEZ F. BOTROS, M.D.*** The Departments of Physical Therapist* and Physical Therapy for Cardiovascular/Respiratory Disorder & Geriatrics**, Faculty of Physical Therapy, Cairo University and National Heart Institute***, Cairo Abstract Background: The proportion of the older population reached 8.5 percent of the total population around the world. Training of inspiratory muscles is very important to delay the morbidity and to ameliorate the quality of life. Aim of the Study: To investigate the response of diaphragmatic excursion to inspiratory muscles training in elderly. Methods: Forty elderly subjects were recruited from retirement home in Cairo. They were assigned into two groups equal in number; study group (9 men-1 1 women) who received threshold IMT and diaphragmatic exercises, and the control group (9 men-11 women) who received diaphragmatic exercises only. The training program in both groups was three times per week for 10 weeks, diaphragmatic excursion during normal and deep was measured by ultrasonography for all subjects pre and post the study. The mean age and BMI of the study group were ±2.74 years and ± 1.28kg/m 2 respectively and that for the control group were 63.7 ±4.12 years and 28.56± 1.15kg/m 2 respectively. Results: Analysis of the results showed that diaphragmatic excursion in elderly significantly improved post-treatment in the study group by 25.6% in quiet and by 15.6% in deep (p-value 0.000), while improved to a lesser extent in the control group by 4.97% ( p-value ) in quiet and 5.04% (p-value 0.004) in deep. The improvement in diaphragmatic excursion may be due to improvement of diaphragm mechanics, power and inspiratory muscle strength. Conclusion: Inspiratory muscle training had a large positive effect on diaphragmatic excursion in elderly. Key Words: Inspiratory muscle training Diaphragmatic excursion Elderly. Introduction THERE are many changes that appear with aging leading to a decline in lung function as in other Correspondence to: Dr. Samuel Farid Henry Rezkallah, Samuel_f2006@yahoo.com systems. The main changes in the respiratory system of the elderly are loss of chest wall compliance, decrease in strength of elastic recoil of lung parenchyma, decrease in respiratory muscle strength, and decreased responsiveness to hypoxemia and hypercapnia [1]. The diaphragm is the primary inspiratory muscle and accounts nearly 70% of the tidal volume exchanged under normal conditions. The diaphragm is typical to limb skeletal muscle in that its ability to produce force efficiently is related to the length of the muscle fibers and the stimulation frequency applied to the muscle. Efficient respiratory muscle function is dependent upon accurate afferent information on its position and load, and although the intercostals compensate for loads with a rich supply of muscle spindles, the diaphragm contains few proprioceptive muscle spindles. It has been suggested that any load changes on the diaphragm may be sensed via a phrenic to phrenic reflex or, in response to alterations in rib cage shape [2]. It is suggested that the increase in respiratory muscle strength may contribute to improve exercise capacity and decrease the risk of respiratory infections and hospitalizations due to expiratory force gain that generates greater effectiveness of coughing [3]. Training of the inspiratory muscles is one component of a pulmonary rehabilitation program that can be applied in either combination with physical exercise, or as an independent intervention. IMT (inspiratory muscle training) has a growing evidence base to support its efficacy as a method of improving breathlessness, exercise tolerance and quality of life, it offers a lifeline to many patients 541

2 542 Sonographic Response of Diaphragmatic Excursion to Threshold Inspiratory Muscle Trainer for whom pharmacological treatment options have been exhausted [4]. The most common technique used for respiratory muscles strengthening is the respiratory threshold loading. Inspiratory threshold loading devices (eg, Threshold IMT) have emerged as a simple, relatively and an effective method to increase inspiratory muscle strength and endurance, independent of pattern [5]. When training through a pressure-threshold device, the individual must generate a minimum inspiratory muscle power to overcome a threshold load by generating an inspiratory pressure sufficient to open the spring-loaded valve, and must hold this pressure level throughout the inspiration (an isotonic load). The inspiratory pressure load provided by a pressure-threshold device does not change airflow mechanics. Therefore, pressurethreshold training provides a quantified pressure challenge to the inspiratory muscles that is independent of airflow [6]. Therefore the aim of the study was to investigate the response of diaphragmatic excursion to inspiratory muscles training in elderly. Material and Methods Forty elderly subjects (18 men-22 women) were recruited from retirement home in Cairo for this study. The training program was conducted from March 2016 to May The subjects were assigned into two groups equal in number; study group (9 men-11 women) who received threshold IMT and diaphragmatic exercises, and the control group (9 men-11 women) who received diaphragmatic exercises only. The training program for subjects in both groups was three times per week for 10 weeks. Ethical consideration: The purpose, nature and potential risks of the study were explained to all patients, and a consent form was taken from all participants as an agreement to be included in the present research study. The study was reviewed and approved by Ethical Committee for Scientific Researches of Faculty of Physical Therapy, Cairo University. Inclusion criteria: Healthy elderly subjects included in this study were aging from years, both genders were allowed to participate, nonsmokers or quit smoking at least 10 years ago, body mass index <30kg/m 2 and waist circumference <90cm for man and <100 for woman. Exclusion criteria: Post-operative patients, patients who have pulmonary diseases, cancer, psychiatric disorders, neurological disorders, with senile emphysema, have no recent thoracic surgeries or fractures, gastric tumors and liver cirrhosis were excluded from the study. A- Evaluation tools: BMI was calculated using formula "weight (kg)/hight (m 2 )" as weight and height measured by (electronic patient weighing scale MDW-250L). Diaphragmatic excursion was measured by ultrasonography (Aloka prosound 4000 with a 3.8MHz convex probe) during quiet and deep for all elderly subjects before and after the 10 weeks of the training program. B- Treatment tools: Threshold inspiratory muscle trainer that was used for application of inspiratory muscle training for elderly subjects in the study group. Procedures: All the procedures have been explained for all the subjects met the inclusion criteria of the study. All subjects signed a consent form of approval. The weight and height were measured for every subject in both groups using weight and height scale (electronic patient weighing scale MDW- 250L) in order to calculate BMI according to the formula BMI=body weight (kg)/height (m 2 ) Freedman et al., [7] Diaphragmatic excursion was measured by using ultrasonography: (Aloka prosound 4000 with a 3.8MHz convex probe) during normal while patient is in semi-recumbent position on a comfortable bed, by an expert radiologist at the beginning and end of training program. Measurement of diaphragmatic excursion was done by 2 methods: The first method is two measurement, in which a point was put on the thoracic surface of the right diaphragmatic cupola (dome) and the distance between the same points during end expiration and end inspiration is measured on 2-D images in Cm, and the second method is M- mode measurement, in which the distance between the same leading edge of the diaphragm at end expiration and end inspiration is calculated by M- mode tracing. The training program for Group A (study group), which included 20 subjects was in the form

3 Samuel F. Rezkallah, et al. 543 of Inspiratory Muscle Training (IMT) using threshold IMT (Respironics, Cedar Grove, NJ) and diaphragmatic exercises 3 times/week for 10 weeks. Training by threshold IMT was done in the following sequence: The control knob on the top of the inspiratory muscle training device was turned to align the edge of the pressure indicator to the resistance needed, then the mouthpiece was attached to the device, the subject was sit in a comfortable position and put the nose clip on the subject nose while making sure the lips are sealed around the mouthpiece and that the tongue does not occlude it and the maximum training effort was set by trial and error method. The users identifies the effort at the point that they can successfully execute 10 breaths against maximum resistance by the inspiratory muscle trainer depending on the subject's rate of perceived exertion which determined by the modified Borg scale Borg [8]. The resistance load of the device was set at approximately 60% of subject's maximal inspiratory resistance which remained for the first 2 weeks then was increased to approximately 70% of their original maximal inspiratory resistance value during weeks 3 and 4 of the training period, and then was increased again to approximately 80% during the remaining period. Treatment was repeated 3 times per week for 10 weeks Sonetti et al., [9]. Diaphragmatic exercises which performed for subject's by the following technique COPD Foundation, [10]. The subject's lied on the back on a flat surface or in bed, with the knees bent then he breathed in slowly through the nose, so that the stomach moves out against the hand. The hand on the chest remained as still as possible, and then he exhaled through pursed lips. This exercise consisted of 10 sets, 4-5 repetitions in each set with rest in between sets, 3 times per week for 10 weeks. Training program for control group was in the form of diaphragmatic exercises by the same technique in the study group. The exercise consisted of 10 sets, 4-5 repetitions in each set with rest in between sets, 3 times per week for 10 weeks. The training program was conducted from March 2016 to May Results The demographic data of the subjects in both groups as shown in (Table 1) showing non-significant differences between both groups in means of age, height, weight, BMI (p>0.05). Comparison of diaphragmatic excursion between both groups before and after the study as shown in (Table 2): Revealed non statistical significant differences between both groups before the study either in quiet or deep (p>0.05) which changed into statistical significant differences after the study in quiet (p>0.05) in favor of the study group but remained non statistical significant differences in deep (p>0.05). Comparison between pre and post-treatment mean values of DE within each group showed statistical significant differences both in quiet and deep with the favour for the study group. Table (1): General characteristics of subjects in both groups. Item Group A Group B p- value Sig Age (years) 63.35± ± NS Height (cm) ± ± NS Weight (Kg) 78.81± ± NS BMI (Kg/m 2) 28.33± ± NS M/F (NO) 9/11 9/11 Cm Kg BMI Kg/m2 SD : Centimeter. : Kilogram. : Body Mass Index. : Kilogram/metre2. : Standard Deviation. p : Probability. Sig : Significance. NS : Non Significant. M/F (NO) : Male to female number. Table (2): Comparison between mean values of diaphragmatic excursion between both groups before and after the study. Items DE before the study Quiet Deep DE after the study Quiet Deep p-value quiet p-value deep Group A 2.18± ± ± ± Group B 2.21 ± ± ± ± p-value DE : Diaphragmatic Excursion. SD : Standard Deviation.

4 544 Sonographic Response of Diaphragmatic Excursion to Threshold Inspiratory Muscle Trainer Discussion Several physiological changes occur with aging in all organ systems, among which the most important are sarcopenia and loss of muscle strength. The functional capacity in elderly individuals is intimately related to lung function and to changes induced by aging, such as a reduction in the static elastic recoil of the lung parenchyma, a decrease in respiratory muscle strength and a decrease in chest wall compliance Frontera et al., [11]. The aim of this study was to investigate the response of Diaphragmatic Excursion (DE) to Inspiratory Muscle Trainer (IMT) in elderly. The analysis of the results of the current study showed that diaphragmatic excursion in elderly significantly improved in the study Group (A) post treatment in comparison with the control Group (B). This improvement in diaphragmatic excursion may be due to improvement of diaphragm mechanics, power and inspiratory muscle strength. The respiratory muscles are morphologically and functionally skeletal muscles and therefore respond to training, just as any muscle of the locomotor system and improvements vary according to the frequency, intensity, and type of IMT paradigm used. Inspiratory Muscle Training (IMT) is a technique used to increase strength or endurance of the diaphragm and accessory muscles of inspiration (Illi et al., [12] and Mc Connell and Romer, [13] ). The results of this study supported by Enright et al., [14] and Stephanie et al., [15] who showed that regimen of high-intensity IMT produces an increase in inspiratory muscle function and induces morphological changes in the diaphragm in people who are healthy. The results of this study met the results of a study done by Hill et al., [5] who found that six months of inspiratory threshold loading training, added to general exercise reconditioning, markedly improved inspiratory muscle strength and endurance, as well as exercise tolerance, in patient with COPD, and the improvement in this group of patients was significantly greater than that achieved with general exercise reconditioning alone. A moderate intensity inspiratory muscle training protocol induced increase in maximal inspiratory pressure, maximal expiratory pressure, diaphragm thickness, and mobility in elderly women Souza et al., [16]. In agreement with the results of the current study, Donina et al., [17] revealed that IMT has a significant effect on resistance to fatigue of the diaphragm in healthy humans during high intensity exercise and as a result a significant improvement in maximal work performance occur. In contrast, results achieved by Ried, [18] showed that the benefit of IMT in adolescents and adults with cystic fibrosis for outcomes of inspiratory muscle function is supported by weak evidence. Its impact on exercise capacity, dyspnea and quality of life is not clear, but the differences may be due to the small sample size which was 10 participants in each group, the mean ages which ranged from 17 to 24, 8 years and because of the relatively short period of the study which lasted for 6 weeks. In conclusion, inspiratory muscle training by threshold IMT device 3 times/week for 10 weeks in elderly, significantly improved the diaphragmatic excursion during both quiet and deep in addition to improvement of mechanics. Conclusion: From the results obtained in this study, it can be concluded that inspiratory muscle trainer by threshold IMT should be used with elderly as it helps to restore inspiratory muscles strength which eventually increases the exercise tolerance and help the elderly to maintain their level of activity independently. References 1- LALLEY P.M.: The aging respiratory system-pulmonary structure, function and neural control. Respir. Physiol. Neurobiol., 187: , CARUANA L., PETRIE M.C., McMURRAY J.J. and MacFARLANE N.G.: Altered diaphragm position and function in patients with chronic heart failure. Chest, 3 (2): 183-7, WITT J.D., GUENETTE J.A., RUPERT J.L., McKENZIE D.C. and SHEEL A.W.: Inspiratory muscle training attenuates the human respiratory muscle metaboreflex. J. Physiol., 584 (Pt 3): , McCONNELL A.K.: The role of inspiratory muscle function and training in the genesis of dyspnea in asthma and COPD. Prim. Car. Respir. J., 14 (4): , HILL K., CECINS N.M., EASTWOOD P.R. and JENKINS S.C.: Inspiratory muscle training for patients with chronic obstructive pulmonary disease: A practical guide for clinicians. Archives of Physical Medicine and Rehabilitation, 91 (9): , VAN'T HUL, GOSSELINK R., HOLLANDER P., POST- MUS P. and KWAKKEL G.: Training with inspiratory pressure support in patients with severe COPD. Eur. Respire J., 27: 65-72, FREEDMAN D.S., HORLICK M. and BERENSON G.S.: A comparison of the Slaughter skinfold-thickness equations

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