COMPARISON BETWEEN INTERCOSTAL STRETCH AND BREATHING CONTROL ON PULMONARY FUNCTION PARAMETER IN SMOKING ADULTHOOD: A PILOT STUDY Shereen Inkaew 1 Kamonchat Nalam 1 Panyaporn Panya 1 Pramook Pongsuwan 1 Yadanuch Boonyaratana 1 Anongnad Mee-inta 1* Department of Physical Therapy, School of Health Science, Mae Fah Luang University, Chiang Rai, Thailand *e-mail anongnad.mee@mfu.ac.th Abstract Intercostal stretching is one of physical therapy technique which is usually applied to the impaired gas exchange patients. Smoking is the most important factor of respiratory disease. It leads to pulmonary dysfunction. Previous studies showed many treatments could improve pulmonary function in smokers. The study of intercostal stretching lacks of evidence-based support. This study was to compare the effect of intercostal stretching and breathing control on pulmonary function parameters in smoking adulthood. Eight smokers voluntarily participated in this study. They were randomly sampling into two groups: control group (breathing control) and treatment group (intercostal stretching). The demographic data, history of smoking and pulmonary function parameters (forced expiratory volume in one second; FEV 1, forced vital capacity; FVC, and ratio of FEV 1 and FVC were measured and analyzed parameters by using Pair-t test. After intervention, FEV 1, FVC, and FEV 1 /FVC have no significant difference in both groups (P>0.05). In conclusion, FEV 1, FVC, and FEV 1 /FVC were increasingly. Intercostal stretching with breathing control may improve pulmonary function in smoker. Keywords : intercostal stretching, smoker, pulmonary function Introduction : Nowadays, the epidemic and prevalence of smoking tend to be increasing. The World Health Organization (WHO) reported more than 5 million of those deaths are the result of direct tobacco use (WHO, 2016). Moreover, the prevalence of tobacco smoking gradually expands to the South East Asia. In 2011, over 11 million people smoked tobacco in Thailand especially in those male (ASH, 2015). Smoker among adolescent aged under 15 years may gradually increasing (NSO, 2012). Cigarette smoke contains more than 7,000 chemicals, including at least 69 carcinogens and many toxicants. Smoking leads to many diseases including Chronic Obstructive Pulmonary Disease (COPD). The systemic inflammation in COPD can cause other comorbidities. Smokers may receive the direct and indirect effects from smoking (Barnes et al., 2009). The pathophysiology changes mostly occur in the lung of smoker such as chronic hypoxia, hypercapnia, hyperinflation, and eventually reduced pulmonary function. From the GOLD guideline reported that many toxicants in tobacco caused pulmonary dysfunction (Vestbo et al., 2013). Previous studies found the relationship between tobacco consumption and pulmonary function (Yang, 1993; Kaur et al., 2011). Cigarette smoking is also associated with slowed growth of lung function in adolescents. Gold and others (1996) found that adolescent girls may be more vulnerable than boys to the effects of smoking on the growth of 8
lung function. The forced expiratory volume in 1 st second (FEV 1 ), forced vital capacity (FVC), and ratio of FEV 1 and FVC (FEV 1 /FVC) were significantly decreased while residual volume (RV) was increased. Moreover, peak expiratory flow rate (PEFR), peak expiratory flow between 25 and 75%, and maximum voluntary ventilation (MVV) were also decreased in smoker s lung (Medabala et al., 2013; Hansen, et al, 2001). Currently, pulmonary rehabilitation is classically treatment for the smoker. The goals are to reduce dyspnea, improve quality of life, improve physical activities, and emotion. This program included exercise training, motivation, education, and nutritional support. The exercise training frequently applied in this population. A pulmonary function of smoker found abnormal value as above, so therapeutic techniques to restore the function are necessary. The intercostal (IC) stretching was applied in the patients since 1975 as the neurophysiological facilitation of breathing in the unconscious adult patients. Bethune (1975) found the IC stretching improved expired tidal volume, decrease dyspnea level, and significantly increase chest expansion. Other studies support the effect of IC stretch. The possible mechanism might be the results of the high firing frequency and activity of the IC muscle spindle afferents in the lower thoracic segments during breathing (Hirai et al, 1996). Moreover, a manual IC stretching changed the connective tissue properties that effected to joint mobility improvement (Threlkeld, 1992). Various studies found that the IC stretch increased lung volume, improved lung function, and oxygenation in healthy subjects (Mohan et al., 2010; Mohan et al., 2012). However, the evidence to support the effect of intercostal stretch and breathing control on pulmonary function parameter in smoking adulthood is lacked. Methodology : The purpose of this experimental study was to compare the effect of intercostal stretching and breathing control on pulmonary function parameter in smoking adulthood. Eight smokers were voluntarily participated. Inclusion criteria are male smokers, had smoking duration more than one year, and aged between 21-40 years. The participants with underlying disease (heart disease and hypertension), aphthous ulcer or any injury which disturb a spirometry test, contraindication to test and abnormal test value were excluded from this study. All participants were voluntarily consent to the study. The study was conducted at Pre-clinic building, School of Health Science, Mae Fah Luang University, Chiang Rai province. All participants were equally divided into two groups: intervention group and control group. Each group had four smokers. The intervention group received the intercostal stretching with breathing control. During the intervention, the participants were in sitting position while the therapist put his hand on the third and eight rib spaces on the one side. The therapist stretched and relaxed the intercostal muscles while the participants breathed in and out, respectively. The control group received breathing control (). The participants were in half lying position (45 o ). The pulmonary function was analyzed by spirometry. Oxygen saturation was immediately recorded after treatment. The procedure was measured 1 time/week for six weeks. All data were analyzed by SPSS version 16. The Shapiro-Wilk test was used to test of normality. The paired t-test was utilized to compare values between pre- and post-test. The unpaired t-test was used to compare values between groups. The significant difference was set at p-value<0.05. Results : There were no statistical significant differences of baseline characteristics between two groups (p>0.05). The age, weight, height, body mass index (BMI), pre-fev 1, pre-fvc, pre FEV 1 /FVC, pre-oxygen saturation (SaO 2 ) were measured before testing as shown in table 1. 9
Table 1 Baseline characteristics of participants (n =8) Baseline characteristics IC stretch + Age (years) 25.75 ± 6.60 23.00 ± 2.00 0.456 Weight (kg) 85.00 ± 1.87 73.00 ± 2.25 0.444 Height (m) 1.67 ± 0.05 1.76 ± 0.08 0.129 BMI (kg/m 2 ) 30.19 ± 6.34 23.04 ± 5.23 0.133 pre-fev 1 (L) 3.26 ± 0.24 4.13 ± 0.79 0.082 pre-fvc (L) 3.61 ± 0.39 4.35 ± 0.94 0.195 pre FEV 1 /FVC (%) 91.00 ± 3.56 96.00 ± 4.83 0.147 pre-sao 2 (%) 97.50 ± 1.29 97.50 ± 0.57 1.000 Abbreviation: kg = kilogram, m = meter, L = liter, % = percentage, SD = standard deviation, FEV 1 = forced expiratory volume in 1 st second, FVC = forced vital capacity, FEV 1 /FVC = ratio of FEV 1 and FVC, SaO 2 = oxygen saturation, = breathing control, IC = intercostal stretch The pulmonary function parameters after receiving breathing control were increased but had no statistical significant difference in FEV 1, FVC, FEV 1 /FVC and O 2 saturation (p>0.05). Thus, the pulmonary function parameters had no observable change (table 2). Table 2 Comparison of pulmonary function parameter before and after breathing control among participants in breathing control group FEV 1 (L) 3.27 ± 0.24 3.34 ± 0.18 0.583 FVC (L) 3.61 ± 0.40 3.62 ± 0.38 0.929 FEV 1 /FVC (%) 91.00 ± 3.55 93.00 ± 6.88 0.583 SaO 2 (%) 97.50 ± 1.29 95.75 ± 4.50 0.480 The pulmonary function parameters after receiving intercostal stretching with breathing control were increased but had no statistical significant difference in FEV 1, FEV 1 /FVC and O 2 saturation (p>0.05). While FVC value decreased but had no statistical significance. The results showed that pulmonary function parameters had no observable changed when compared before and after stretching with breathing exercise (table 3). Table 3 Comparison of pulmonary function parameter before and after intercostal stretch and breathing control among participants in intercostal stretch and breathing control group FEV 1 (L) 4.13 ± 0.79 4.16 ± 0.80 0.402 FVC (L) 4.35 ± 0.94 4.25 ± 0.87 0.139 FEV 1 /FVC (%) 96.00 ± 4.83 98.00 ± 1.70 0.299 SaO 2 (%) 97.50 ± 0.58 98.00 ± 0.82 0.495 When compared between groups, there were no statistical significance differences between groups (p>0.05) as shown in table 4. 10
Table 4 Comparison between group and IC + group (n =4) IC + (n =4) IC + FEV 1 (L) 3.27 ± 0.24 4.13 ± 0.79 0.082 3.34 ± 0.18 4.16 ± 0.80 0.092 FVC (L) 3.61 ± 0.40 4.35 ± 0.94 0.195 3.62 ± 0.38 4.25 ± 0.87 0.239 FEV 1 /FVC (%) 91.00 ± 3.55 96.00 ± 4.83 0.147 93.00 ± 6.88 98.00 ± 1.70 0.189 SaO 2 (%) 97.50 ± 1.29 97.50 ± 0.58 1.000 95.75 ± 4.50 98.00 ± 0.82 0.363 Discussion and Conclusion From this study, we found no statistical significant difference in FEV 1, FVC, FEV 1 /FVC, and oxygen saturation in smoker adulthood. It might be that intercostal stretching and breathing control were not improved pulmonary function. The result was controversial with the study of Mohan and others (2012) that reported the significance difference in pulmonary function in healthy male. However, this study was limited by several factors such as treatment duration, lack of reliability and validity of intercostal stretching protocol. Thus, the result could be not found the pathological changes in smoker lung. For further study, reliability and validity of measurement should be collected before testing. A spirometry should be performed by expert technician for the accurate values. References 1. World Health Organization. Tobacco. 2016 [cited 2016 May 5]. Available from: http://www.who.int/mediacentre/factsheets/fs339/en/ 2. Acting on smoking and health. ASH. Smoking statistics. January 2015 [cited 2015 Oct 3]. Available from: http://www.ashthailand.or.th/en/ 3. National Statistical Office. Smoking prevalences. [internet]. 2012; 8. Available from: http://service.nso.go.th/nso/nsopublish/service/indi_smoke.html 4. Barnes, P. J., & Celli, B. R. (2009). Systemic manifestations and comorbidities of COPD. European Respiratory Journal, 33(5), 1165-1185. 5. Vestbo, J., Hurd, S. S., Agustí, A. G., Jones, P. W., Vogelmeier, C., Anzueto, A.,... & Stockley, R. A. (2013). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American journal of respiratory and critical care medicine, 187(4), 347-365. 6. Yang, SC (1993). Relationship between smoking habits and lung function changes with conventional spirometry. J Formos Med Assoc. 92:S225-31. 7. Kaur, H., Thaman, R. G., Dhillon, S. K., & Kaur, S. (2011). Relationship between smoking and pulmonary functions. NJIRM. 2(4):1-6. 8. Gold, D. R., Wang, X., Wypij, D., Speizer, F. E., Ware, J. H., & Dockery, D. W. (1996). Effects of cigarette smoking on lung function in adolescent boys and girls. N Engl J Med. 335(13):931-7. 9. Medabala, T., Rao, B. N., Glad Mohesh, M. I., & Kumar, P. (2013). Effect of cigarette and cigar smoking on peak expiratory flow rate. J Clin Diagn Res. 7(9):1886. 10. Hansen, E. F., Vestbo, J., Phanareth, K., Kok-Jensen, A., & DIRKSEN, A. (2001). Peak flow as predictor of overall mortality in asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 163(3):690-3. 11. Bethune, DD (1975). Neurophysiological facilitation of breathing in the unconscious adult patient. Physiotherapy Canada. 5:241-5. 11
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