Effects of back and respiratory muscle exercises on posture and respiratory function in elderly patients with osteoporosis

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1 Effects of back and respiratory muscle exercises on posture and respiratory function in elderly patients with osteoporosis Salameh Al Dajah, Hariraj Muthusamy Aims: To examine the impact of respiratory and thoracic muscle strengthening exercises on kyphosis, chest expansion, dyspnoea and peak expiratory flow rate in elderly people with osteoporosis. Methods: Twenty elderly patients with mild osteoporosis-related kyphosis and respiratory impairment participated in this study. Participants undertook breathing and thoracic extension exercises three times a week for 6 weeks, in which they performed 40 minutes of resistive diaphragmatic exercise with 50% of their one repetition maximum (1RM). Results: Participants in this study demonstrated improvements in: i) dyspnoea, with a reduction in mean score of 8 to 5 on a 10-point dyspnoea grading scale; ii) chest expansion, with a mean increase of 2.01 inches (95% CI ); iii) peak expiratory flow rate, with a mean increase of litre/ minute (95% CI ); iv) range of motion of the spine, with a mean increase of 1.66 inches (95% CI ). Conclusions: A combination of breathing and thoracic muscle strengthening exercises improves respiratory function and dyspnoea relief. Thus, strengthening exercise programmes should be a part of the rehabilitation protocol for improving the respiratory function of elderly patients with osteoporosis. Key words: Strengthening exercises Osteoporosis Kyphosis n Respiratory function n Elderly Submitted 9 January 2015; sent back for revisions 23 January 2015; accepted for publication following double-blind peer review 9 February 2015 Osteoporosis is a condition associated with ageing, and acute episodes of pain associated with osteoporosis can lead to periods of restricted mobility and significant cardiopulmonary dysfunction in the elderly (Carter and Hinton, 2014). A number of factors can affect bone health, including physical activity, genetics, nutrition, hormones and environmental influences (Kauffman et al, 2007; Frownfelter and Dean, 2012). Therefore, it is necessary for the older population to practice strengthening exercises on a regular basis to reduce systemic deterioration. Bone has the ability to adapt to physical and mechanical loads by altering its mass and constitution (Ksiezopolska-Orlowska, 2010). Bones appear to change in response to direct impact from weight-bearing activity and through the action of muscles attached to them. High levels of physical activity can have a positive effect on the human skeleton at various stages in life (Ksiezopolska-Orlowska, 2010). Isaksson et al (2009) found that bone mass improves after physical exercise and also reported a significant increase in bone matrix mineralisation and in the mechanical properties of the collagen network after exercise. Vertebral deformities in patients with osteoporosis can lead to postural kyphosis, muscle activity impairment, postural deviation and respiratory dysfunction. Respiratory dysfunction occurs due to impairment in the movement of the rib cage and thoracic structures, including the anterior thoracic muscles (Frontera et al, 2008). Culham et al (1994) concluded that lung volumes and rib mobility were significantly impaired in women with thoracic kyphosis. Dimitriadis et al (2013) found that patients with neck pain have inspiratory weakness; when the anterior and posterior neck muscles and the upper back muscles are weak, this affects inspiratory efficiency. Barnett et al (2003) and Cimen et al (2003) found that women with postmenopausal osteoporosis without spinal compression fractures have reduced respiratory muscle endurance. Accentuated thoracic kyphosis alters the shape of the thoracic cage, increases the anteroposterior diameter of the thorax, and reduces the distances between the xiphisternum and pubis, which alters Salameh Al Dajah, Professor and Head of physical therapy and rehabilitation, College of Allied Medical Sciences, The Hashemite University, Jordan; Hariraj Muthusamy, Lecturer, Physical Therapy Department, Majmaah University, Saudi Arabia. Correspondence to: Salameh Aldajah s.aldajah@mu.edu.sa International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5 233

2 Research the position of the thoracic cage (Frownfelter and Dean, 2012). The spinal and thoracic cage deformities cause a decrease in rib mobility and impair the mechanics of the respiratory system. These respiratory impairments occur due to musculoskeletal alterations, placing the respiratory muscles at a mechanical disadvantage and resulting in a decrease in respiratory muscle efficiency that is related to dyspnoea (Croitoru and Bogdan, 2013). In their study of sedentary elderly subjects, Vaz Fragoso et al (2014) concluded that respiratory impairment and dyspnoea are prevalent in sedentary older persons and associated with objectively measured physical inactivity. In addition, Layne and Nelson (1999) in their literature review found that resistance training may have a more profound site-specific effect than aerobic exercise. They found that 24 cross-sectional and longitudinal studies have shown a direct and positive relationship between the effects of resistance training and bone density. Long-term high-level exercise promotes muscle reinnervation in elderly subjects (Mosole et al, 2014). To deal with these postural, muscular and respiratory changes, it is necessary for elderly people, especially those with osteoporosis, to participate in rehabilitation programmes that include respiratory muscle exercises. The aim of this experimental study was to determine the impact of diaphragmatic and upper back strengthening exercises on thoracic kyphosis, chest expansion, dyspnoea and peak expiratory flow rate in elderly patients with osteoporosis. METHODS A sample of 20 patients (10 males and 10 females) with osteoporosis participated in this study. Participants were recruited from the outpatient orthopaedic clinic at the SPM Medical Center, Tiruchengode, Tamilnadu, India. The inclusion criteria were: n Aged years n A diagnosis of osteoporosis with mild thoracic kyphosis (15 25 degrees of flexion) n Non smoker n A sedentary lifestyle. Exclusion criteria included patients with: pulmonary disease; neurological disorders; medical conditions preventing them from exercising; osteoporosis with severe kyphosis. Experimental details were explained fully and all participants signed a consent form provided by the SPM Medical Center. Participants were evaluated by the same physiotherapist who was trained for reliability in using all of the measurement tools. Participants demographic data were recorded and their heart rate and blood pressure measured. Pre-test evaluation was undertaken after patients became acclimatised to the exercises. Thoracic spine range of motion (ROM) was measured using an inclinometer over the mid-thoracic area, and chest expansion was measured using an inelastic tape. Dyspnoea was measured using a 10-point dyspnoea grading scale, where 1 is very severe and 10 is not severe. Peak expiratory flow rate was measured using the Omron PFM20 peak flow meter (Omron Health Care Europe, Netherlands). Participants were asked to adhere to the exercise programme three times per week for 6 weeks, and encouraged not to participate in other exercise regimes during this period. The exercise protocol used in this study consisted of 5 minutes of warm up, including general stretching of the pectoralis muscles, upper back muscles, shoulder region and lower limb muscles. The warm-up routine was followed by 20 minutes of back strengthening exercise, in which the patient would lie in a prone position with sand bag weights placed on the upper thoracic region. The weights used for each patient were 50% of the patient s one repetition maximum (1RM), which was determined by the maximal weight that the patient was able to lift once through a full ROM. Participants were instructed to lift the weight 10 times, with a 5-second hold time and 10 seconds rest. A session of weight-training included three sets, with 3 minutes of rest between sets. After performing the thoracic strengthening exercises, patients were given a 5-minute rest period before starting the second 20-minute exercise session. For the respiratory muscle exercises, participants were asked to lie in a supine position. Sand bag weights were placed on the participant s abdomen, which offers resistance to diaphragmatic movement and serves as a stimulus for training. According to patients 1RM test results, the initial weight given was 2 kg, which was later raised according to the patient s tolerance. The exercise comprised three sets of contractions with 10 repetitions. Participants were asked to lift the weight by making an inspiratory effort (i.e. abdominal expansion). Rest was given between sets, and all patients were given 5 minutes to cool down. The cool down included neck and upper chest stretches and shoulder flexion/extension to their maximum available functional range. The whole training session lasted about 40 minutes. 234 International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5

3 Table 1. Distribution of mean, standard deviation and range of descriptive measures before and after exercise Pre-test Post-test Percentage Variable Mean SD Range Mean SD Range increase (%) Range of motion Chest expansion Peak expiratory flow rate Dyspnoea Chest expansion Peak expiratory flow rate Dyspnoea Inches Litre/minute Score Figure 1. Mean pre- and post-test values of chest expansion Figure 2. Mean pre- and post-test values of peak expiratory flow rate Figure 3. Mean pre- and post-test dyspnoea scores Participants were advised that they should leave at least 1 hour between food intake and undertaking the exercises. Participants were also told to immediately report any severe discomfort, giddiness or nausea to the researchers. Care was taken to avoid the Valsalva manoeuvre. Blood pressure was monitored before and after the exercise programme. Patient 1RM was re evaluated every week to check the patient s progression and adjust the training weight if necessary. A post-test was administered 6 weeks after the intervention. Statistical analysis Statistical analysis was administered using the paired sample t-test to assess thoracic spine ROM, chest expansion and peak expiratory flow rate, and the Wilcoxon signed-rank test to assess the dyspnoea scale. RESULTS Twenty-two patients were invited to participate in this study over a period of 4 months; two participants were excluded from the study due to instability in blood pressure. Statistical outcomes of descriptive measures on ROM, chest expansion, peak expiratory flow rate and dyspnoea before and after participating in the exercise programme are summarised in Table 1. A comparison of measurements before and after the intervention showed improvements in: n ROM, from 9.63 inches (SD=2.95) to inches (SD=3.13) n Chest expansion, from inches (SD=3.00) to inches (SD=2.61) (Figure 1) n Peak expiratory flow rate, from litre/ minute (SD=37.18) to litre/minute (SD=37.25) (Figure 2) n Mean dyspnoea score, from 8 (SD=0.79) to 5 (SD=0.79) (Figure 3). Statistical outcomes of paired t test analysis on ROM, chest expansion and peak expiratory flow rate before and after the intervention are shown in Table 2. The mean pre-test ROM score was 9.63 (standard error (SE)=0.65), with an increased post-test score of (SE=0.70) after the intervention. The 95% confidence interval (CI) increased from in the pre test to in the post-test, with a paired mean difference of The 95% CI difference was , with a t value of There was an increase in mean chest expansion from inches (SE=0.67) before the intervention to inches (SE=0.58) after the intervention. The 95% CI increased from pretest to post-test, with a paired mean difference of The 95% CI difference in chest expansion was , with a t value of The mean peak expiratory flow rate was litre/minute (SE=8.31) before the International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5 235

4 Research Table 2. Paired t test analysis of pre- and post-test scores of chest expansion and peak expiratory flow rate Pre test Post test Paired 95% CI Variables Mean SEM 95% CI Mean SEM 95% CI difference difference t value Range of motion Chest expansion , * Peak expiratory flow rate , * SEM: standard error of mean *Significant at p<0.05 Table 3. Wilcoxon signed-rank test analysis of dyspnoea scores Percentile Variable 25th 50th 75th Pre-test Post-test *Significant at p<0.001 intervention, which increased to litre/ minute after the intervention. The 95% CI increased from in the pre-test to in the post-test. The 95% CI difference in peak expiratory flow rate was , with a t value of Table 3 shows the statistical outcomes of the Wilcoxon signed-rank test for dyspnoea before and after the intervention. The 25th percentile of participants had grade 7 dyspnoea, which was reduced to grade 4 dyspnoea after the intervention; the 50th percentile of participants had grade 8 dyspnoea, which was reduced to grade 5 dyspnoea after the intervention; the 75th percentile of the patients had grade 9 dyspnoea, which was reduced to grade 6 dyspnoea after the intervention. The Wilcoxon signed-rank test analysis showed significant results, with a z value of and p< DISCUSSION Mean rank Sum of ranks z value * It is well established that osteoporosis is related to ageing and a lack of physical activity. The prevalence of osteoporosis is increasing in various parts of the world, especially among females (Carter and Hinton, 2014). Special attention is required to prevent respiratory weakness among these patients to avoid averse respiratory consequences to the wellbeing of this subsection of the older population. It is important to draw public attention to the importance of regular respiratory muscle exercise (Dimitriadis et al, 2013) and the impact of exercise on reducing the effects of kyphotic posture among older people with osteoporosis. This study tested a resistance exercise protocol that aimed to improve respiratory efficiency in sedentary participants with osteoporosis. Previous studies show that kyphotic posture has a negative effect on respiratory efficiency (Frontera et al, 2008). Kyphosis causes tightness of the intercostal muscles and imbalances in the pectoralis major, pectoralis minor, latissimus dorsi and serratus anterior muscles. Kyphosis also affects the muscles attached to the scapulae, e.g. the levator scapulae and upper trapezius muscles. Back extensor strengthening exercises stretch the anterior thoracic muscles and strengthen the accessory inspiratory muscles (Vaz Fragoso et al, 2014). Results from this study confirmed that strengthening exercises for the back extensor muscles help to correct kyphotic posture and muscle action lost due to abnormal kyphosis. The stretching of the muscles causes the contracted muscles of the anterior thorax to lengthen and aids mobility of the ribs, leading to an increase in chest expansion, which positively affects inspiration. These results are in agreement with the study by Cimen et al (2003). Our results also showed that diaphragm muscle resistance causes an increase in inspiratory pressure and helps in deep inspiration, which maximises expiratory capacity. Padula and Yeaw (2006) concluded that a standard protocol of exercise using 30% 1RM for a duration of minutes daily for weeks improves dyspnoea and inspiratory strength. In this study, participants used 50% 1RM training for a shorter period and attained significant improvements in dyspnoea. Exercise of the back muscles and diaphragm should be undertaken regularly to improve posture and respiratory function. Limitations As previously mentioned, bone health is influenced by other factors besides physical activity, such as genetics, nutrition, hormones and environmental influences. The authors would hence recommend repeating this study with a control group in a controlled environment in order to reduce the influence of these variables on the findings. Additionally, expanding the participant sample would further improve the validity and reliability of these findings. 236 International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5

5 CONCLUSIONs In this study, diaphragm strengthening exercises improved inspiratory pressure and volume while strengthening exercises for the back muscles helped in the correction of posture and in the maintenance of the corrected posture by proper muscle action. In conclusion, the strengthening exercise programme in this study produced a significant improvement in the posture and respiratory function of patients with osteoporosis. Based on the findings of this study, we recommend that back strengthening exercise programmes should be a part of the rehabilitation protocol for improving the respiratory function of elderly patients with osteoporosis. IJTR Conflict of interest: none declared. Barnett A, Smith B, Lord SR, Williams M, Baumand A (2003) Community-based group exercise improves balance and reduces falls in at-risk older people: A randomised controlled trial. Age Ageing 32(4): Carter MI, Hinton PS (2014) Physical activity and bone health. Mo Med 111(1): Cimen OB, Ulubas B, Sahin G, Calikoglu M, Bagis S, Erdogan C (2003) Pulmonary function tests, respiratory muscle strength, and endurance of patients with osteoporosis. South Med J 96(5): Croitoru A, Bogdan MA (2013) Respiratory muscle training in pulmonary rehabilitation [Article in Romanian]. Pneumologia 62(3): Culham EG, Jimenez HA, King CE (1994) Thoracic kyphosis, rib mobility, and lung volumes in normal women and women with osteoporosis. Spine (Phila Pa 1976) 19(11): Dimitriadis Z, Kapreli E, Strimpakos N, Oldham J (2013) Respiratory weakness in patients with chronic neck pain. Man Ther 18(3): doi: /j.math Key points n Osteroporosis in the elderly commonly leads to reduced mobility and significant cardiopulmonary dysfunction n Range of motion of the spine, chest expansion, peak expiratory flow rate and dyspnoea were measured before and after 6 weeks of prescribed exercise n The combination of respiratory and thoracic muscle strengthening exercises significantly improved posture and respiratory function in elderly patients with osteoporosis. Frontera WR, Silver JK, Rizzo TD (2008) Essentials of Physical Medicine and Rehabilitation. 2nd edn. Saunders, Elsevier, Philadelphia Frownfelter D, Dean E (2012) Cardiovascular and Pulmonary Physical Therapy: Evidence to Practice. 5th edn. Saunders, Elsevier, Philadelphia Isaksson H, Tolvanen V, Finnilä MA et al (2009) Physical exercise improves properties of bone and its collagen network in growing and maturing mice. Calcif Tissue Int 85(3): Kaufman JJ, Luo G, Siffert RS (2007) A portable real-time ultrasonic bone densitometer. Ultrasound in Medicine and Biology 33: Ksiezopolska-Orłowska K (2010) Changes in bone mechanical strength in response to physical therapy. Pol Arch Med Wewn 120(9): Layne JE, Nelson ME (1999) The effects of progressive resistance training on bone density: A review. Med Sci Sports Exerc 31(1): Mosole S, Carraro U, Kern H et al (2014) Long-term highlevel exercise promotes muscle reinnervation with age. J Neuropathol Exp Neurol 73(4): Obayashi H, Urabe Y, Yamanaka Y, Okuma R (2012) Effects of respiratory-muscle exercise on spinal curvature. J Sport Rehabil 21(1): 63 8 Padula CA, Yeaw E (2006) Inspiratory muscle training: Integrative review. Res Theory Nurs Pract 20(4): Vaz Fragoso CA, Beavers DP, Hankinson JL et al (2014) Respiratory impairment and dyspnea and their associations with physical inactivity and mobility in sedentary community-dwelling older persons. J Am Geriatr Soc 62(4): Tools for Continuing Professional Development 2nd edition Chia Swee Hong, Deborah Harrison Indispensable one-stop shop for learning all you need to know about continuing professional development: what is it, why you need it and how you can achieve it Revised and updated with new chapters on recent methods and tools and the auditing process Tools for Continuing Professional Development 2nd Edition Practical new case studies and examples included ISBN-13: ; 210 x 148 mm; paperback; 244 pages; publication 2011; Order your copies by visiting or call our Hotline +44(0) edited by Chia Swee Hong and Deborah Harrison International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5 237