Ventilatory Effects of Manual Breathing Assist Technique (MBAT) and Shaking in Central Nervous System Disease Sufferers

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1 Original Article Ventilatory Effects of Manual Breathing Assist Technique (MBAT) and Shaking in Central Nervous System Disease Sufferers J. Phys. Ther. Sci. 22: , 2010 HIDEAKI KURITA, MS, RPT 1,2), OSAMU NITTA, PhD, RPT 1), MITSUAKI HARADA, RPT 3), MASAFUMI MIZUKAMI, PhD, RPT 3) 1) Department of Physical Therapy, Tokyo Metropolitan University Graduate School of Human Health Sciences 2) Department of Physical Therapy, Nihon Kogakuin College: Nishikamata, Ota-ku, Tokyo , Japan. TEL: , FAX: , h-kurita@neec.ac.jp 3) Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Abstract. [Purpose] This research was carried out to evaluate the effects of Manual Breathing Assist Technique (MBAT) and shaking on the ventilation of central nervous system (CNS) disease patients. [Subjects and Methods] The subjects were thirteen healthy individuals (normal group) and twenty-one CNS diseases sufferers without upper airway obstruction (subject group). We evaluates of Tidal Volume (TV), Peak Expiratory Flow Rate (PEFR) and Expiratory Time (Te) under rest respiration, MBAT, and shaking conditions. Administration of MBAT and shaking was performed by a single physiotherapist. [Results] Two-way factorial analysis of variance showed a significant interaction effect for TV between the subject group and the normal group, while PEFR showed no significant interaction. TV of the normal group was increased about 65% by MBAT and about 110% by shaking, compared to TV under rest respiration. While TV of the subject group was increased about 10% by MBAT, no increase was observed under the condition of shaking. [Conclusion] Significant differences in TV and Te were observed between the subject group and normal group in terms of the effects of MBAT as well as shaking. Both MBAT and shaking were effective methods for increasing PEFR. Key words: Manual Breathing Assist Technique, Shaking, Central nervous system diseases (This article was submitted Dec. 16, 2009, and was accepted Jan. 21, 2010) INTRODUCTION Lung diseases are among the important causes of death for central nervous system (CNS) disease sufferers including cerebral palsy. Reddihough 1) reported that the cause of death of about half of 155 children, who suffered severe spastic quadriplegia, intellectual disability or epilepsy and had died between 1970 and 1995, was pneumonia. Eyman 2) asserted that the disabled who suffer mental retardation will, if they are immobile and require tube feeding, have an extremely short life expectancy, and most of them will die of respiratory insufficiency. Plioplys 3) also pointed out that of the cause of death for severely disabled children was pneumonia in 77% of cases. Fitzgerald 4) mentioned pulmonary aspiration, impaired mucociliary clearance, recurrent infection leading to bronchiectasis, kyphoscoliosis, upper airway obstruction, and lower airway obstruction as factors promoting lung diseases in cerebral palsy sufferers. Regarding impaired mucociliary clearance, he

2 210 J. Phys. Ther. Sci. Vol. 22, No. 2, 2010 asserted that if a child cannot cough effectively or clear their secretions adequately, or develops an acute lower respiratory tract infection, the child may need more active chest physiotherapy. Chest physiotherapy for airway clearance, postural drainage (PD), percussion and vibration for patients of cystic fibrosis (CF) has often been reported to have promoted the removal of tracheal secretions 5 7). A systematic review of the literature 8) also noted that, the administration of standard chest physiotherapy (PD, percussion and vibration) for treatment of CF patients resulted in more effective ejection of mucus, compared to spontaneous coughing or leaving the condition without any treatment. Reports on the ejection of secretion by children with cerebral palsy recommend modified PD, consisting of supine 30 head up, prone horizontal, left and right horizontal side lying, and upright sitting for apical segment of the upper lobe, instead of conventional PD 9). Moreover, the removal time for secretion is reported to have been reduced by percussion and vibration applied in combination with modified PD 6). However, the administration of chest physiotherapy for children with cerebral palsy has not been fully investigated. According to the International Physiotherapy Group for Cystic Fibrosis (IPG/CF) 10), chest compression is defined as manual or mechanical compression of the chest in the direction of the normal expiratory movement of the ribs, while chest shaking / vibration is shaking or vibration of the chest wall, in the direction of the normal movement of the ribs, during expiration. In Japan, manual chest compression is widely known and applied under the name of the Manual Breathing Assist Technique (MBAT). MBAT was originally proposed by Waldemar Kolaczkowski, who reported its physiotherapeutic effects on respiration improvement for pulmonary emphysema patients in ). The main purpose of MBAT is respiration improvement through manually assisting respiratory movement 12). Ihashi et al. 13) reported that MBAT applied to healthy adult individuals doubled the tidal volumes and decreased the functional residual volumes. Sadamori et al. 14) also examined the effects of MBAT on the esophageal and stomachic pressures and on the partial pressures of transdermal gases after applying MBAT to severe cerebral palsy patients for two to four minutes. Their findings showed that MBAT significantly decreased the esophageal pressure and transdiaphragmatic pressure difference as well as the transdermal partial pressure of carbon dioxide, while significantly increasing the transdermal partial pressure of oxygen in the rest expiration position. MBAT is relatively non-invasive, since this intervention only involves assisting chest movement in respiration movement performed by the subject and does not squeeze the chest wall forcibly. Moreover, removal of secretions as well as improvement of pulmonary atelectasis and chest motion are expected as incidental effects of the ventilation improvement, and these are the main reasons why MBAT is commonly applied to children with cerebral palsy as manual chest physiotherapy, to promote ventilation improvement, as well as ejection of secretion. Regarding chest shaking /vibration, McCarren 15) examined the effect of manual vibration on the respiratory organs, and reported that peak expiratory flow rate (PEFR) was increased by more than 50% by the vibration over that under rest conditions. In general, chest shaking / vibration is considered effective as a manual practice for improving ventilation. In Japan, shaking is applied mostly in combination with MBAT. However, the experimental effects of combined treatment of MBAT and shaking have not yet been studied. In summary, patients with CNS diseases often have trouble with respiration, and the practices of chest physiotherapy, such as postural drainage, percussion and vibration, and MBAT have been shown to be beneficial. The reported effects and benefits are the promotion of secretion removal and increase of the partial pressure of oxygen. However, the evaluation of MBAT by examination of the condition of ventilation of the subjects respiration has not yet been reported, despite the fact that the immediate purpose of MBAT is ventilation improvement. As MBAT is a direct intervention for ventilation condition, evaluation by indirect factors such as oxygen partial pressure may be insufficient. In light of this, our research tried to focus on MBAT and shaking as practices of manual chest physiotherapy for CNS disease patients. The practices of these interventions were selected on the basis of the frequency of their use in Japan, of their causing little stress for patients as well as their high safety. Percussion was excluded because of its potential to induce the stretch reflex in CNS disease patients. This research was thus carried out to evaluate the

3 211 effects of MBAT and shaking on the ventilation of CNS disease patients. SUBJECTS AND METHODS This research was approved by the Ethics Committee of the Tokyo Metropolitan University. Prior to participation, each of the participants (or his/her guardian) gave his or her documented consent after having been orally informed about the nature and purpose of the study. The subject group consisted of twenty-one central nervous system diseases sufferers without upper airway obstruction. All of the subjects were level V according to the Gross Motor Function Classification System(GMFCS) 16), and concurrently had serious movement disorder or mental retardation. The CNS diseases were cerebral palsy (ten patients), encephalitis sequelae (five), epilepsy (five), and nodular sclerosis (one). The normal group consisted of thirteen healthy adults without any respiratory disorder. Tidal volume (TV) data were measured by AE300-S of Minato Medical Science, and were recorded on a computer separately for each breath. Following this, the analogue flow curve data generated from AE300-S were converted into digital format by AD Instruments Power Lab, and input into another computer. The two computers, the one operating AE300-s and the other accepting the analogue flow curve data, were synchronized, so that each TV corresponding to the flow curve was measurable. Facemasks were employed for each measurement. Facemasks of the normal control group were fixed by a belt. For the subject group, the facemasks were fixed manually by the measurer because fixation by a belt was not always possible for these subjects. The reproducibility and reliability of the measurements with the manually fixed facemask was confirmed prior to the research. The measurement of SpO 2 was not executed. Each of the subjects was measured under three conditions: rest respiration, MBAT, and shaking. Each measurement lasted for three minutes, after confirming the rest condition of the participant. Each subject was measured in the supine position on a bed. After the rest respiration was measured, respirations of MBAT and of shaking were measured at random. All of the MBAT and shaking interventions were administered by a single physical therapist, who had been well trained in the administration of MBAT and shaking, and had experience of teaching these skills in training courses. For MBAT, the PT pressed the lower thorax of the subject with both palms in accordance with the respiration movement of the subject. Manual pressures of MBAT and shaking were directed in accordance with the respiratory movement of the subjects. The pressure was stopped at the terminal expiration position, and gradually decompressed in accordance with the subject s respiration, while paying attention to avoid rapid decompression. For shaking, the thorax was pressed as in MBAT, while being shaken manually at 5 to 6 Hz. The frequency of the shaking was kept constant from the beginning to the end of expiration, and was stopped, at the same time as pressure, at the end of expiration. The reproducibility and reliability of the same intervention of the PT involved was confirmed in advance. The flow curve data of the three conditions, rest respiration, MBAT and shaking, were analyzed with waveform analysis software by AD Instruments (Chart 5). The waveform of a respiration was defined to begin at the beginning of expiration and to end at the beginning of next expiration (Fig. 1). Ten relatively stable respiration waveforms were selected from the three minutes of data for each participant. Three parameters, Peak Expiratory Flow Rate (PEFR), Expiratory Time (Te), and the Tidal Volume (TV) corresponding to each waveform, were used for the analysis. The values of these parameters were obtained from the average of eight respirations (excluding the largest and smallest values of ten respirations). Statistical analysis was conducted for the age between the two (normal and subject) groups by the t-test, and by cross tabulation for genders. A two-way analysis of variance (ANOVA) was carried out for three items, TV, PEFR and Te setting the normal and subject groups as the factors between the subjects, and rest respiration, MBAT, and shaking as the factors within the subjects. When main effects were observed, multiple comparisons by the Bonferroni method were carried out in order to test the differences between each level. Multiple comparisons within the normal and subject groups were also performed in order to test the differences between the levels. When the p values were less than 0.05, they were regarded as significant; all the tests were done as two-tailed

4 212 J. Phys. Ther. Sci. Vol. 22, No. 2, 2010 Fig. 1 Flow Curve. Top: Air Flow Curve during rest respiration. Middle: Air Flow Curve during the administration of MABT. Bottom: Air Flow Curve during the administration of shaking years old. There was no significant difference between the subject and normal groups in terms of gender or age (Table 1). The results of a two-way ANOVA for TV, PEFR and Te are shown in Table 2. Main effects were observed between the normal and subject groups as well as the methods of intervention. Furthermore, significant interaction was detected between the normal and subject groups. Within the normal group, significant differences were detected in the order of rest < MBAT < shaking. As for the subject group, a significant difference of rest < MBAT was detected, while the effect of shaking was found to be less than that of MBAT, which indicates that the effect of shaking on the subject group was different from that on the normal group. In the normal group, MBAT caused a significant increase in TV of about 65% from the rest respiration; and shaking increased TV by about 110%. In the subject group, on the other hand, MBAT caused an increase in TV of about 10%. A main effect was observed among the methods of intervention for PEFR. Between the normal and subject groups, however, no main effect or interaction was seen. Within the normal group, significant differences were found in the order of rest < MBAT < shaking, and in the order of rest < shaking, for the subject group. In addition to these differences, both the normal and subject groups showed the pattern of rest < MBAT < shaking. A main effect was observed between the normal and subject groups as well as the methods of intervention for Te, and a significant interaction between the normal and subject groups was detected. Within the normal group, significant increases of Te were found in the order of rest < MBAT < shaking. However, there were no significant differences in Te among the different methods of intervention within the subject group. tests. All the statistical analyses were processed with Dr.SPSS II software (SPSS Inc, Chicago, IL, USA). RESULTS The subject group consisted of twelve males and nine females with an average age of 41.3 ± 9.4 years old. Ten normal group consisted of five males and eight females with an average age of 36.9 ± DISCUSSION Our research examined the effects of MBAT and shaking on the respiratory ventilation of CNS disease sufferers in comparison with those of healthy individuals. For the normal group, MBAT and shaking were shown to increase the values of TV effectively, but an effect of shaking was not observed in the subject group, with the values of TV showing no difference from those of the rest

5 213 Table 1. Baseline characteristics of subjects Normal group Subject group Age (y) 35.9 ± ± 9.4 Sex (W:M) 8:6 9:12 Height (cm) ± ± 9.7 ** Weight (kg) 59.9 ± ± 7.7 ** GMFCS All Level V Cobb angle 42.1 ± 37.3 **: p<0.01 NOTE: Values are mean ± SD unless otherwise stated. Abbreviation: GMFCS, Gross Motor Function Classification System. Table 2. Summary of two-way analysis of variance Subject Test p Value Rest MBAT Shaking Subject Test Interaction nomal ± ± 368.0*** ± 437.0*** Tidal Volume (ml) *** *** *** subject group ± ± 160.7* ± nomal ± ± 126.9* ± 131.5*** Peak Expiratory Flow Rate (ml/s) n.s. *** n.s. subject group ± ± ± 290.4** nomal 2.8 ± ± 1.0*** 6.2 ± 2.1*** Expiratory Time (sec) *** *** *** subject group 2.5 ± ± ± 0.7 n.s.: not significant, *p<0.05, **p<0.01, ***p<0.001 Results presented as mean values for each test with significance for main and interaction effects. condition. When MBAT is performed, the thorax is pressed to its maximum expiration position, and therefore the expiratory reserve volume of the lung capacity is forcibly ejected. At the same time, the vibrating stimuli of the shaking cause the recoiling action of the lungs, encouraging expiratory ejection, and this probably led to the significant increase of TV over that of MBAT in the normal group. In the subject group, on the other hand, the method of shaking was ineffective, with no significant difference from the rest respiration being seen. A possible explanation for this is that subjects were unable to accommodate external stimuli, a condition in which CNS disease sufferers might easily fall into, for they tend to have troubles with abnormal muscle tonus. It is most likely that the subject group failed to gain an improvement in TV because of intensified muscle tonus caused by the vibration stimuli of shaking, which might have brought on the blockage of thorax motion. Increase of TV through MBAT, on the other hand, can be understood as a benefit of not employing vibration stimuli; there was no affect on muscle tonus of the subjects, hence no blockage of thorax motion. In the subject group, the increase of TV through MBAT was limited to about 10%. The problem of the expiration reserve volume of the subject group is currently suspected to be influential. The thoraxes of the patients of the subject group generally have less motion than those of healthy individuals due to abnormal muscle tonus or deformity. Particularly for sufferers of idiopathic scoliosis, it is widely believed that the greater the angle of curvature, the less TV 17,18), and it has been reported that the severer the deformity of scoliosis, the less motion of the thorax 19). Considering all these factors, we think the relatively limited increase of TV by MBAT of about 10% in the subject group was partly due to the decrease of the expiratory reserve volume. Although the subject group s TV increase was very small in comparison with that of the normal group, it was clearly shown that the application of MBAT does increase TV. Equally important, this relatively non-invasive

6 214 J. Phys. Ther. Sci. Vol. 22, No. 2, 2010 manual intervention is highly beneficial. McCarren et al. reported the increase of expiratory flow rate caused by the administration of manual vibration, and stated that this increase was influenced by the recoiling effect of the lungs through vibration stimulus. In line with this, our results showed that PEFR was increased more by shaking than by MBAT, both for the normal and subject groups. In the subject group, we assume that the application of the vibration stimulus stimulated the recoiling effect of the lungs, and inducing a larger PEFR than by MBAT, similar to the normal group. While the increase of TV seems to have been influenced by the accomodation of stimuli, the increase of PEFR seems to have resulted from the recoiling effect of the lungs induced by vibration stimulus, regardless of the accomodation of stimuli. Incidentally, the removal of secretions in the respiratory tract is usually considered to require an increase of expiratory flow rate 20). In addition to the improvement of ventilation, our results suggest that MBAT and shaking can be expected to directly improve the removal of secretion through an increase in PEFR as well. While significant extension of Te was detected through the interventions in the normal group, the subject group showed no significant change in Te. The extension of Te requires a certain extent of TV increase. If sufficient increase of TV is not attained, the ejection of expiratory reserve volume of lung capacity can only be achieved by an increase of expiratory flow rate, with no change in the expiratory time. Therefore, it could be difficult to extend the expiratory time of subjects with spinal curvature or deformity by the administration of MBAT and shaking, since these subjects have decreased expiratory reserve volume. In conclusion, our present research has shown that the effects of MBAT and shaking on TV and Te of healthy individuals differ from those of CNS disease sufferers. It is especially notable that although MBAT for CNS disease sufferers was able to increase TV, shaking had no beneficial effect. On the other hand, MBAT and shaking showed the same effects on PEFR in both the normal and subject groups, which supports the effectiveness of MBAT and shaking for CNS disease sufferers, as well as suggesting an immediate improvement effect on the removal of secretion. Nevertheless, the conditions of CNS disease sufferers differ from person to person; therefore, various interventions for each individual are required. Moreover, on the basis of our current results, more studies are needed to investigate the efficacy of manual chest physiotherapies, as well as their clinical assessments. REFERENCES 1) Reddihough DS, Baikie G, Walstab JE: Cerebral palsy in Victoria, Australia: mortality and causes of death. J Paediatr Child Health, 2001, 37: ) Eyman RK, Grossman HJ, Chaney RH, et al.: The life expectancy of profoundly handicapped people with mental retardation. N Eng J Med, 1990, 323: ) Plioplys AV, Kasnicka I, Lewis S, et al.: Survival rates among children with severe neurologic disabilities. South Med J, 1998, 91: ) Fitzgerald DA, Follett J, Van Asperen PP: Assessing and managing lung disease and sleep disordered breathing in children with cerebral palsy. Paedeatr Respir Rev, 2009, 10: ) Rossman CM, Waldes R, Sampson D, et al.: Effect of chest physiotherapy on the removal of mucus in patients with systic fibrosis. Am Rev Respir Dis, 1982, 126: ) Boeck C, Zinman R: Cough versus chest physiotherapy. A comparison of the acute effects on pulmonary function in patients with cystic fibrosis. Am Rev Respir Dis, 1984, 129: ) Baldwin DR, Hill AL, Peckham DG, et al.: Effect of addition of exercise to chest physiotherapy on sputum expectoration and lung function in adults with cystic fibrosis. Respir Med, 1994, 88: ) Thomas J, Cook DJ, Brooks D: Chest physical therapy management of patients with cystic fibrosis. A metaanalysis. Am J Respir Crit Care Med, 1995, 151: ) Button BM, Heine RG, Catto-Smith AG, et al.: Postural drainage and gastro-oesophageal reflux in infants with cystic fibrosis. Arch Dis Child, 1997, 76: ) Lannefors L, Button B, Chevaillier J, et al.: International Physiotherapy Group for Cystic Fibrosis (IPG/CF) 2007 Physiotherapy for Respiratory Conditions Glossary (1st edn). _edn_july_2007. pdf (Accessed Jul. 19, 2009). 11) Kolaczkowski W, Taylor R, Hoffstein V: Improvement in oxygen saturation after chest physiotherapy in patients with emphysema. Physiother Can, 1989, 41: ) Masuda M, Yoshino T, Ihashi K, et al.: Change in the level of skill for Manual Breathing Assist Technique in the practical workshop. 15th International WCPT congress proceedings. Vancouver, Canada, CD ROM abstracts. 13) Ihashi K, Saitou A, Yahata J, et al.: Effect of manual

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