Balloon Blowing, as a Respiratory Muscle Training Technique, for Spinal Cord Injury Patients to Improve Outcomes - An Evidence Based Analysis

Transcription

1 Balloon Blowing, as a Respiratory Muscle Training Technique, for Spinal Cord Injury Patients to Improve Outcomes - An Evidence Based Analysis By: Stefan Hardy Doctoral Candidate University of New Mexico School of Medicine Division of Physical Therapy Class of 2016 Advisor: Kathy Dieruf, PT, PhD Approved by the Division of Physical Therapy, School of Medicine, University of New Mexico in partial fulfillment of the requirements for the degree of Doctoral of Physical Therapy.

2 Table of Contents Abstract 3 Section 1: Background and PICO Question. 6 Section 2: Case Description 11 Examination.. 16 Evaluation. 22 Interventions. 24 Section 3: Evidence Based Analysis.. 26 Article Selection Flow Chart. 29 Reference Table.. 30 Discussion 34 References Appendix A: Reference Summaries. 40 Appendix B: Evidence Appraisal Worksheets 57 Appendix C: Reference Inclusion/ Exclusion Criteria

3 Abstract Purpose: This project presents a case of an individual who was limited in his participation and mobility on an SCI unit due to the nature of his spinal cord injury. He, like many people with acute spinal cord injuries, are restricted to bed or sitting for long periods of time with minimal activity causing cardiopulmonary endurance issues and musculoskeletal weakness. These two problems for patients with spinal cord injury often lead to pulmonary complications causing respiratory secretions and infection of the pulmonary system. This individual case answers the following PICO question via evidence-based analysis: Does balloon therapy as a respiratory muscle training technique, added to standard of care physical therapy for patients with a spinal cord injury, improve outcomes? Background: Physical therapy for patients with spinal cord injury often focuses on transfer training, upper extremity strengthening and endurance, stretching for range of motion, and sometimes work on ambulation. It is not often physical therapists who work with patients with spinal cord injury focus on respiratory training improvements. Respiratory issues for this population as explained by Schilero, et al., (2009), remain a major cause of morbidity and mortality (p.130). Physical therapists have the time with these patients and the knowledge to intervene and help decrease the risk of these patients acquiring a pulmonary/respiratory complication. Adding a respiratory muscle training intervention, like balloon blowing, can be a highly beneficial exercise for patients with spinal cord injury. Case Description: Patient W is a 64-year-old hispanic male with history of low back pain and L1 discectomy in In 2015, patient W complained of low back pain near the site of his discectomy. An MRI was performed and found a ventral epidural abscess, L1-L2 discitis, and multiloculated left psoas abscess. The MRI also found osteomyelitis had completely degenerated his L3 vertebrae. This led to his recent spinal cord injury of incomplete paraplegia, and an ASIA C. Patient W was given precautions of only allowed to sit upright for 2 hours with the need of TLSO for support and no axial loading. He was sent to ABQ VA SCI unit and referred to PT for strengthening and endurance issues. Outcomes: A review of the literature shows respiratory muscle training in spinal cord injury patients does have a positive effect on pulmonary outcomes, but more research does need to be done. It also shows there are multiple ways to do this training. It can be done with different devices and expiratory and inspiratory training can be provided. Performing both with a patient who has a spinal cord injured is more appropriate as both muscle groups are necessary to have a good pulmonary/respiratory system. Improving pulmonary outcomes like Forced Expiratory Volume in 1 second (FEV1), Total Lung Capacity (TLC), Vital Capacity (VC), Maximum Inspiratory Pressure (MIP), and Maximum Expiratory Pressure (MEP) can help these patients have more efficient pulmonary/respiratory systems. These improvements can lead to a more productive cough thus decreasing the risks of acquiring pulmonary complications, like pneumonia. Research also shows that physical therapists spend a large amount of time with these patients working on strength, mobility, and wheelchair mobility but do not often incorporate respiratory training into their interventions. Discussion: This case presentation describes a patient with a L1-L2 spinal cord injury but due to necessary precautions was limited in his mobility and ability to exercise his pulmonary system. The focus of this search was to understand if respiratory muscle training through balloon blowing exercises could help improve his overall outcomes. The research for balloon blowing therapy is very limited and only has case reports and anecdotal evidence to support it. The topic of respiratory muscle training has more evidence, but still needs a greater 3

4 amount of higher quality studies to solidify its use with spinal cord injury patients to improve pulmonary outcomes. Some studies report that expiratory muscle training is best for improving cough production in these patients and some report inspiratory training is better to improve efficiency of breathing. One study reports that performing both types of training is necessary in spinal cord injury population to attain an efficient and healthy pulmonary/respiratory system in SCI patients. Physical therapists dedicate most treatment time with these patients to strength and mobility improvement to increase the patient s participation in every day life. Adding respiratory muscle training could help improve patient participation further as well as keep them from acquiring respiratory illnesses better than present standard of care physical therapy alone. 4

5 Section 1: Background and Purpose of PICO Question Background: Patient W is a 64 year old hispanic male with incomplete paraplegia, ASIA C, with type 2 diabetes, status-post L1 discectomy in 2014 to deal with low back pain and mobility issues affecting his functional activities and activities of daily living. In June of 2015, patient W reported low back pain again along with lower extremity numbness, which at the time was diagnosed as peripheral neuropathy. The patient was evaluated and had a spinal X-ray done that showed benign findings. In August of 2015, patient W went to his primary care provider complaining of a change in his low back pain as well as new onset of urinary incontinence. The primary care provider then ordered an MRI of the patient s spine. MRI findings included osteomyelitis of L3, more subtle discitis at L1-L2 with a ventral epidural abscess and a multiloculated L1 abscess, and left psoas abscess. Patient W was admitted to the hospital for draining of the multiple abscesses and a hemilamenctomy of L1 to remove the abscess. Patient W was then transferred to the ABQ VA SCI unit, where in July of 2015 he became septic and had to be admitted to UNMH for sepsis and a right upper extremity deep vein thrombosis. Patient W was stabilized and returned to VA with neurological deficits of left greater than right in his lower extremities. Another MRI was done and found degeneration of his L3 vertebrae due to osteomyelitis. He was put on axial loading precautions, sitting precautions of only 2 hours per day, and had to wear a TLSO (thoracolumbosacral orthotic) whenever he was sitting. The patient was allowed to participate in therapy after he was given a power chair to get to the therapy sessions with all precautions in place. Patient W s sitting restrictions, need of the TLSO, and multiple months in a hospital bed had severely de-conditioned him in multiple areas. He was globally weak and had poor endurance. The author began seeing patient after he had been on the VA SCI 5

6 unit for about a month and a half and had just received his power chair for mobility. The author did not get to see patient at discharge as patient was scheduled to have a surgery and would be spending an undetermined amount of time in the VA SCI unit. Purpose: Almost all patients with spinal cord injury will receive physical therapy to address the body s new functional limitations and individual lifestyle modifications. According to van Langeveld, et al., (2011), Most therapy time was spent on interventions in the categories of Muscle power, Walking, and Hand rim wheelchair propulsion (p.416). Depending on the level of injury, physical therapists focus in these areas with interventions like upper extremity strengthening, mobility, transfers, and joint mobility. Improvement in these areas are important to allow patients with a spinal cord injury to return to some of their prior level of function or allow them to perform a portion of their daily activities. Gomara-Toldra, et al., (2014) found a, relationship between PT interventions and improvement in participation and the exercise programs impacted the individuals perceived participation and QOL positively with statistically significant results (p.373). Physical therapy for these patients can have a large impact on their daily lives and how they participate in the community and in their own lives. Though physical therapists address many of the physical issues that are necessary to help these patients we do not often enough address one area that is crucial for this patient population. The respiratory system for a majority of patients with spinal cord injury is an area of great importance and is an area physical therapists can help address. Mueller, et al., (2008) explains, pulmonary complications occur in 50-67% of persons with a spinal cord injury, (1) with pneumonia being the most common cause of death (p.269). Spinal cord injury patients often succumb to an inability to clear secretions due to loss of respiratory muscle strength or lack of ability to use respiratory muscles because of the 6

7 level of injury. Improving this physical complication is something physical therapists can address. Physical therapists usually spend more time with spinal cord injury patients than other therapies. In a study by van Langeveld, et al., (2011) looking at physical therapy, occupational therapy, and sports therapy, forty-six percent of all treatment sessions were provided by the PT staff members (p.415). The amount of time physical therapists spend with spinal cord injury patients, in addition to their knowledge of exercise, puts them in a prime position to enhance the respiratory systems of this population. By improving the respiratory system in these patients, physical therapists can help prevent pulmonary complications that often lead to increased mortality in the spinal cord injury population. An excellent way to do this is through respiratory muscle training. There are two types of respiratory muscle training: inspiratory muscle training and expiratory muscle training. Both can help improve pulmonary function, but Schilero, et al., (2009) found that, expiratory muscle function is more compromised than inspiratory muscle function (p. 129) in patients with spinal cord injury. Pulmonary function is an outcome that is looked at throughout the literature when it comes to respiratory muscle training. Measurements including FEV1, TLC, VC, MIP, and MEP are used to see if training improves pulmonary function. Since a productive cough is often a concern for spinal cord patients FEV1 is often looked at to see how well a patient can get air out quickly, like a cough. A cough requires muscles of expiration to be strong in order to produce a productive cough and resistive expiratory muscle training can accomplish this. A study by Roth et al., (2010) with a resistive expiratory muscle training group and sham group found, in the resistance training group, significant improvements in FVC, FEV1, ERV, MIP, and MEP (p.859) were found. It makes sense that improving the strength of the muscles of expiration 7

8 would improve a cough, especially in a patient with a spinal cord injury who has weakness in these muscles or is limited by the level of their injury. Exercises to improve muscle strength include use of incentive spirometers, acapellas, manual resistance, and exercise. Incentive spirometers are used to work on inspiratory muscle and ability to bring air into the lungs. Acapellas work on expiratory muscles to help clear the lungs of secretions and PTs can use manual resistance on patient s chests to improve the strength of external and internal intercostal and diaphragm, if C3-5 levels are intact. The exercise that is often used to improve cardiopulmonary function for patients with SCI is the arm bike. Respiratory function is not a high priority for PTs who work with patients with SCIs. More often upper extremity muscle strength, walking, and wheelchair propulsion are the focus of rehabilitation. Teaching a patient how to use an incentive spirometer, acapella, and resistive exercises to increase respiratory muscle strength and its importance is not difficult. The hard part about the exercises is getting the patient to continually keep performing the exercises after physical therapy is completed. A fun and effective way to get patients to practice pulmonary strengthening exercises is through balloon-blowing therapy. Balloon-blowing makes the patient exercise inspiratory and expiratory muscles in an effective way. Boyle, et al., (2010) explain that, BBE (balloon blowing exercise) is a conservative exercise intended to assist patient/athlete in obtaining optimal posture and respiration i.e. diaphragm and neuromotor control (p.186). Balloon-blowing therapy as a respiratory muscle training technique can help to improve pulmonary outcomes and decrease likelihood of pulmonary complications in the spinal cord injury population. Adding this to standard of care physical therapy would be easy and effective in improving the patients participation in physical therapy sessions, participation in activities outside of PT, and the 8

9 patients overall outcomes including quality of life and pulmonary outcomes. Patient W was assigned to practice balloon-blowing therapy in addition to standard physical therapy interventions. Though patient W had an L1-L2 spinal cord injury, his precautions limited him in ways similar to a higher-level injury. Patient W s TLSO restricted chest expansion and the 2 hour per day sitting limitation prevented him from being able to exercise his cardiopulmonary system. Balloon-blowing therapy allowed him to work on his pulmonary system even though he could not physically work on it as much as other patients with SCI who could exercise on an arm bike more often. It is an intervention that was added to his standard of care physical therapy that physical therapists do not often focus on with this patient population. The research provides good evidence on the benefits of respiratory muscle training for pulmonary function in SCI patients. Balloon-blowing therapy is an easy to teach intervention that addresses the pulmonary system for both inspiration and expiration. It is an intervention that can be repetitively reassessed and re-taught to maintain any improvements by physical therapists since patients spend most of their therapy time with physical therapists. 9

10 Section 2: Case Description Introduction: Patient W. is a 64 year old hispanic male with incomplete paraplegia, ASIA C, with type 2 diabetes. He is status-post L1 discectomy in In June of 2015, patient W complained of low back pain again along with lower extremity numbness, which at the time was considered peripheral neuropathy. Patient W was worked up and had an X-ray done on his spine but the X-ray was negative. In August of 2015, patient W went to his primary care provider complaining of different low back pain than his original pain. Patient W also complained of urinary incontinence, which the patient had not previously had. The primary care provider then ordered an MRI of the patient s spine. The MRI findings were osteomyelitis of L3, more subtle discitis at L1-L2 with a ventral epidural abscess and a multiloculated L1 abscess, and left psoas abscess. The patient also had a high fever, high white blood cell count, and tachycardia. Patient was admitted to the hospital and the multiple abscesses were drained. A hemilamenectomy of L1 was performed to remove this abscess. Patient W was then moved to the VA SCI unit where in early July of 2015 he became septic and had to be admitted to UNMH for sepsis and a right upper extremity deep vein thrombosis. Patient W was stabilized and returned to VA with neurological deficits of left greater than right in his lower extremities. Another MRI was done and found a loss of his L3 vertebrae due to osteomyelitis. He was put on axial loading precautions, sitting precautions of only 2 hours per day, and had to wear a TLSO whenever he was sitting. The patient was allowed to participate in therapy after he was given a power chair to get to the therapy sessions with all precautions in place. 10

11 Reason for Referral: Patient is a 64-year-old male recently retired from construction work with a spinal cord injury at L3 considered an incomplete paraplegia, ASIA C referred to PT for evaluation and treatment of strength, endurance and ROM of BUE and BLE. Patient/Client History: Recorded by physician and physical therapists. General Demographics o Patient W is a 64-year-old Hispanic male with prior history of back surgery in August 2014, but no other medical issues until present problems. History of Current Condition o Patient W had a L1 discectomy in 2014 due to complaints of back pain. Patient complained of back pain again in June of 2015 and of numbness in his LE, which was found to be peripheral neuropathy. Patient was worked up and had X-Ray performed but nothing was found. In August, patient went to his PCP complaining of chronic back pain and that his back pain had, "changed." At this time, patient also complained of urinary incontinence, which he had not had before. Patient's PCP ordered an MRI to be performed. The MRI found osteomyelitis and more subtle discitis at L1-L2 with a ventral epidural abscess and multioculated L1 left psoas abscess. The patient also had a high fever, high WBCs, and had tachycardia. Patient had abscesses drained and a hemilamenectomy L1 for abscess at UNMH and then was placed at ABQ VA SCI Unit. Early July patient became septic and was transferred back to UNMH for sepsis and a RUE DVT. Patient eventually returned to ABQ VA SCI Unit in late August with a PEG tube, tracheostomy, and neurological deficits L>R. Patient had an MRI done which 11

12 showed a complete loss of L3 vertebrae and an unstable lumbar spine. He is allowed to sit up for 2 hours a day with a TLSO brace for support. MOI (mechanism of injury) o Multiple abscesses in patient's lumbar spine and psoas muscle led to osteomyelitis and degeneration of patient's L3 vertebrae. Chief complaint, location, onset, nature/behavior of symptoms, change since onset, better/worse o Patient's chief complaint is of low back pain and inability to move left ankle. He also complains of some leg pain and swelling in LE. His LBP is not always consistently there and is better since initial injury. His inability to move his left ankle has not improved since the initial injury nor has the swelling. Past Medical History (PMH) o Patient has a history of Type 2 diabetes and is s/p L1 discectomy in He recently had L1-L2 discitis, ventral epidural abscess, and psoas abscess that led to osteomyelitis and degeneration of his L3 vertebrae leaving him with neurological deficits L>R. Past Surgical History (PSH) o Patient had L1 discectomy in 2014 o IND at UNMH for abscesses in 2015 o Hemilamenectomy at L1 in 2015 o Tracheostomy tube placement in 2015 Medications o Metformin for Type 2 diabetes 12

13 o Lovenox for DVT prevention o Gabapentin o Oxycodone o Colace Diagnostic Testing o X-Ray looking at lumbar spine. o MRI looking at lumbar spine. o Urodynamics checked due to new onset urinary incontinence. Precautions/Contraindications o No axial loading o Transfers by mechanical lift only o DVT precautions o Allowed to sit up right for 2 hours a day total with TLSO. Past History of this Condition o Previous episodes and treatment: Patient had surgery for prior LBP issues in Prior Level of Function o Patient was independent for all functional mobility. o Bed mobility: minimal assist for supine to sit with pull to sitting. o Transfers: Sit to stand from EOB and to chair with supervision. o Ambulation: 100 feet with shopping cart supervised. Current Level of Function o Bed mobility: Max assist for all movements. 13

14 o Transfers: Max assist needing mechanical lift due to axial loading precautions. o Ambulation: Unable due to precautions. Occupation/Employment o Retired construction worker and prior military service. Living Environment o Patient W lives in a one-story home in Santa Fe, NM. Social/Recreational History o Patient enjoyed attending UNM lobo basketball games and spending time with friends and family. General Health Status o Patient W has history of Type 2 diabetes but overall was generally healthy. Developmental and Family History o Patient has a wife and 3 sons that have their own homes and often see their father. Patient s Goals o Patient wants to walk again. o Patient wants to go home. o Patient wants to perform all duties as a husband he was performing prior to injury. 14

15 Examination Systems Review Musculoskeletal: o 10 Key Muscles on ASIA Exam o R L o C5 5 5 o C6 5 5 o C7 5 5 o C8 4 4 o T1 3 3 o L2 3 1 o L3 1 1 o L4 2 0 o L5 3 0 o S1 2 0 Neuromuscular o DTR (Deep Tendon Reflexes) R L Biceps 1 1 Triceps 1 1 Supinator 0 0 Patellar 0 0 Achilles

16 Anal NT Babinski 0 0 o Sensory Light Touch Pin Prick R L R L C C C C C C C T T T T T T T T T T T

17 T L L L L L S S S S = =106 VAC: Yes Cardiopulmonary o Thorax symmetric with good excursion, CTAB. o RRR s m/r/g, N1 S1, S2. Integumentary o Neck supple, trachea midline. Tracheostomy 6.0 DCT cuffed, Shiley in place. o Abdomen S,NT, NABS. No masses or organomegaly. Communication/Cognition o Patient alert and oriented x 3 o Mental status: WNL o CN II-XXII: Intact 17

18 Tests and Measurements Aerobic Capacity/Endurance o Temperature: (37.9 C) o BP: 143/70 o Pulse: 95 o RR: 20 o Weight: lbs. (95.2 kg) o O2 Saturday: 94 o Pain: 1/10 Assistive Technology: Patient issued a mid-wheel power chair by OT to allow the patient to get around while sitting up on the SCI Unit. Balance: Not tested due to patient unable to stand or sit without TLSO brace. Circulation o LE: No edema Cranial and Peripheral Nerve Integrity o CN II-XXII: Intact Environmental Factors o Patient has excellent family support to help with any changes from existing injury. Gait: Patient is non-ambulatory. Integumentary Integrity: No skin break down noted. Joint Integrity and Mobility: All WFL. Mental Functions 18

19 o Alert and Oriented x 3 o Mental stats: WNL Mobility (Locomotion, Functional Mobility, Transfers) o Patient is not ambulatory. o Patient is max A to roll and sit up in bed. o Patient is max A to transfer via mechanical lift due to axial loading restrictions. Motor Function (Motor Control and Motor Learning) o Patient has good UE and LE motor control. Muscle Performance (Including Strength, Power, Endurance, and Length) o MMT of 10 Key Muscles from ASIA Exam o L R o C5 biceps 5 5 o C6 wrist extension 5 5 o C7 triceps 5 5 o C8 finger flexion 4 4 o T1 Finger ABD 3 3 o L2 hip flexion 1 3 o L3 knee extension 1 1 o L4 DF 0 2 o L5 Big toe ext. 0 3 o S1 PF 0 2 Pain o Pain: 1/10 in low back 19

20 Posture: Patient has a good sitting posture in his power chair while wearing his TLSO. Range of Motion o BUE AROM WFL o BLE PROM WFL Self-Care and Domestic Life: Patient is mod A for self-care and has excellent family support. Ventilation and Respiration o Pulse: 95 o RR: 20 o O2 Sat: 94 Work Life: Patient is a retired construction worker with military service. Physical Exam o Gen: WD, WN make in NAD o HEENT: AT/NC, DOBHOF in place, PERRLA, EOMI, OP clear, MMM. Tongue midline. No pharyngeal exudate. o Neck: Supple trachea midline. Tracheostomy 6.0 DCT cuffed shiley in place. o Pulm: Thorax symmetric with good excursion, CTAB. o Cor: RRR s m/r/g. N1 S1,S2. o ABD: S, NT, NABS. No masses or organomegaly o LE: No edema 20

21 Evaluation PT Diagnosis o G82.20 paraplegia, unspecified o G82.22 paraplegia, incomplete o M62.81 muscle weakness (generalized) PT Problem List o UE endurance o LE muscular weakness o Limited ROM globally o Lack of movement in left ankle due to SCI o Unable to attend Lobo basketball games with family o Unable to transfer independently o Unable to perform duties as a husband Narrative Assessment: Patient is a 64 y/o Hispanic male s/p L1 discectomy in 2014 with subsequent ventral epidural abscess, psoas abscess and osteomyelitis of L3 vertebrae in 2015 causing incomplete paraplegia, ASIA C referred to PT to address LE weakness, endurance and ROM. Patient presents in ABQ VA SCI unit with LE muscular weakness, limited general ROM, and endurance issues which are limiting his ability to participate in transfers, perform ADLs, bed mobility, community participation, and perform his duties as a husband. Skilled Physical Therapy is necessary to address LE muscular weakness, limited ROM and endurance to improve patient's ability to perform future transfers, bed mobility, participate in family activities, and participate in the community. Patient's prognosis at this time is fair due to axial 21

22 load limitations and sitting time limitations with TLSO. Added to the fair prognosis is his lack of an L3 vertebra, which patient is presently being looked at for caging surgery to stabilize his spine. Patient's barriers are his unstable spine, axial load limitations, and sitting limitations. These barriers will be addressed by keeping patient in his TLSO brace in his power chair while performing exercise with PT and by not performing any axial loading exercises during PT. Goals Impairment Patient will increase LE strength by one muscle grade in 3 months to allow him to perform a stand-pivot transfer to his power chair. Activity-Functional Limitation Level Patient will attend a family function with his power chair performing all mobility and transfers (I) in 6 months. Patient will attend a Lobo basketball game using a 4WW independently in 6 months. Participation-Disability Level Patient will perform all his duties as a husband in 1 year. Education Goals Patient will be educated about weight reliefs in his power chair to prevent skin breakdown. Patient will be educated about wearing TLSO during all times of sitting. 22

23 Interventions and Plan of Care Patient related instructions: Patient will be instructed on performing proper weight reliefs and how often they need to be performed while sitting and in bed. Patient will be educated on need of his TLSO brace. Patient will be instructed in bed exercises that he can perform outside of his physical therapy sessions. Coordination and communication with other health professionals: PT will work with patient s nurses, speech therapy, and patient's doctor to address patient's impairments. We will also coordinate so to not fatigue the patient before each other s appointments. Direct Interventions: o Active assisted ROM to lower extremities to prevent joint contractors and improve lower extremity strength. o Passive ROM to lower extremities to prevent joint contractures. o Active ROM to upper extremities to improve ROM and prevent contractures. o Electrical stimulation to address lost movement of left ankle. o Strength training to increase upper extremity and lower extremity strength to improve bed mobility. o Endurance training to decrease time to fatigue and allow patient to perform more daily activities. o Neuromuscular re-education to improve movement and control of lower extremities. o Motor control training to upper and lower extremities to improve mobility and 23

24 help with future ambulation exercises. o Cardiopulmonary training to increase efficiency of breathing and allow patient to clear lung secretions independently. Frequency/duration of treatment o 5 days per week, 1 hour per session Outcomes: Patient W made modest gains in lower extremity strength. He was close to 3/5 on all lower extremity strength tests. Patient W never re-gained movement of his left ankle while author was working with him. He did improve his endurance, ability to help with transfers, and bed mobility. Patient W was being seen at UNMH for a stabilization surgery during the authors last few days of the clinical rotation. Patient W was still waiting to find out when his surgery would be scheduled. He was going to be staying at the ABQ VA SCI unit until then and would continue working with physical therapy until time of his surgery. 24

25 Section 3: Evidence Based Analysis Search Methodology: The research methodology performed sought to answer the PICO question: Does balloon therapy as a respiratory muscle training technique added to standard of care physical therapy for patients with spinal cord injury improve outcomes? The databases used were PubMed, CINAHL, and PEDro. Search terms were the same for every database, using a Boolean search format. Search terms included balloon blowing, balloons, respiratory muscle training, spinal cord injury, respiratory muscle training and spinal cord injury, respiratory issues, respiratory issues and spinal cord injury, pulmonary function, pulmonary function and spinal cord injury, physical therapy treatment, physical therapy and spinal cord injury, physical therapy treatment and spinal cord injury, and physical therapy treatment postspinal cord injury. Table 1. Representing search methodology. Search Terms Number of Articles Excluded/Included PubMed balloon blowing 4 articles 4 excluded due to title and abstract irrelevance spinal cord injury and pulmonary function 259 articles 13 articles selected due to title and abstract relevance. Of those 1 used as a reference. (Schilero et al. 2009) spinal cord injury and respiratory issues 24 articles 8 articles selected based on title and abstract relevance. Of those 1 included as a PICO relevant study. (Mueller et al. 2008) respiratory muscle training 1774 articles Too many articles 25

26 respiratory muscle training and spinal cord injury pulmonary function and spinal cord injury 41 articles 2 articles inlcuded. 1 used as a reference only. (Sapienza and Wheeler, 2006) 1 included as a PICO relevant study based on title and abstract. (Van Houtte et al. 2006) 260 articles 5 articles selected based on title and abstract relevance. 1 articles used as a reference only. (Schilero et al. 2009) physical therapy and spinal cord 1676 articles Too many articles injury physical therapy post spinal cord injury CINAHL 193 articles 2 articles selected based on title. 1 excluded due to abstract irrelevance. (Tansey 2012) 1 included as PICO relevant study. (Gomara-Toldra, Sliwinski, and Dijkers, 2014) balloon therapy 75 articles All excluded based on title and abstract. balloon blowing 2 articles 1 included as a PICO relevant study. (Boyle, Olinick, and Lewis 2010) 1 excluded due to title and abstract. (Kim and Lee 2012) pulmonary function and spinal cord injury physical therapy and spinal cord injury and treatment PEDro 42 articles All excluded due to title, abstract, and overlap with other databases. 160 articles 3 articles selected. 2 excluded due to abstract. (Zanca et al. 2011, Taylor-Schroeder et al. 2011) 1 included as a PICO relevant study. (van Langeveld et al. 2011) respiratory muscle training 494 articles Too many articles 26

27 respiratory muscle training and spinal cord injury 16 articles 1 included as a PICO relevant study. (Roth et al. 2010) Others excluded due to title, abstract, or overlap with other databases. balloon blowing 1 article Not included due to title and overlap with other databases. pulmonary complications and spinal cord injury respiratory issues in spinal cord injury physical therapy post spinal cord injury 4 articles None included due to title and overlap with other databases. 8 articles None included due to overlap with other databases. 10 articles None included due to title and overlap with other databases. physical therapy and spinal cord 47 articles 1 included as a reference only. injury (Harvey, Lin, Glinsky, and Wolf 2009) Articles included for Analysis: Boyle (2010) Gomara-Toldra (2014) Houtte (2006) Mueller (2008) Postma (2014) Roth (2010) Stubeyaz (2005) van Langeveld (2011) 27

28 Article Selection Flow Chart 4231 MeSH Database Different keyword combinations & 3 limits Keyword Search Different keyword combinations & 3 limits Keyword Search Different keyword combinations 19 Some keywords: balloon blowing; SCI & respiratory issues; SCI & RMT; Selected based on appropriateness/ relevance of title in relation to PICO question 2 Balloon Blowing 234 Total Articles (Relevant to Topic) 18 SCI and pulmonary function 8 SCI and respiratory issues 3 RMT and SCI 6 Physical therapy post SCI and treatment 197 Excluded: Topic not closely related, Nonsimilar population to subject, >10 years old, overlap with other databases 29 Excluded: Abstract relevance, study s purpose not closely related to P.I.C.O. question, overlap with other databases Balloon Blowing 1 SCI and Respiratory Issues 1 RMT and SCI 4 Physical Therapy post- SCI and treatment 2 8 Total Studies -Reviewed -Analyzed -Compared to PICO 28

29 # Author(s) Oxford Pedro Level Score 1 Boyle, Olinick, & Lewis (2010) 2 Gomara- Toldra, Sliwinski, & Dijkers (2014) 3 Houtte, Vanlandewijck, Gosselink (2006) Reference Table Purpose 5 N/A To discuss the clinical value of patients performing an exercise called the 90/90 bridge with ball and balloon as it relates to suboptimal respiration and posture. 3a 2b N/A To assess the extent, content, and outcomes of physical therapy interventions focused on improving participation of individuals with spinal cord injury. N/A To review the effectiveness respiratory muscle training has on respiratory strength, endurance, pulmonary function, QOF, respiratory complications, and exercise performance in patients with spinal cord injury. Outcome Measures None, this is a clinical suggestion paper, so there are not outcome measures. Single-item participation outcome measures, indices combining multiple items into a single score, healthrelated quality of life with respect to participation. Respiratory muscle strength, like pectorals strength. Pulmonary measures, like expiratory reserve volume, vital capacity, forced expiratory volume, total lung capacity, residual volume, etc. Results None, this is a clinical suggestion paper, so there are not results. PT interventions Yes with SCI patients can help improve participation in ability to work, leisure activities, family life, and social functioning. Respiratory muscle training does help improve respiratory function in patients with spinal cord injury. Relevant to PICO Yes Yes 29

30 4 Mueller, de Groot, der Woude, & Hopman (2008) 5 Postma, Haisma, Hopman, Bergen, Stam, & Bussman (2014) 1b 1b N/A To investigate the time-courses of lung function and respiratory muscle pressure generating capacity after spinal cord injury. 7/10 To assess the immediate and long term effects of resistive inspiratory muscle training in addition to usual rehabilitation care, as compared to usual care alone, on respiratory function in people with spinal cord injury who have impaired pulmonary function. Lung function including; forced vital capacity, forced expiratory volume in 1 second, forced inspiratory volume in 1 second, peak expiratory flow, peak inspiratory flow, maximal inspiratory and expiratory muscle pressure generating capacity. Objective and subjective measurements of respiratory function. Maximum inspiratory pressure, maximum expiratory pressure, forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, health-related quality of life, perceived limitations in daily life, and respiratory complications. Increasing level of injury was related to increase in worsening of outcome measures. No matter what level of injury an SCI patient is their lung function will be affected in some way. Improvements can be made in the inpatient setting but outside of it these improvements fall away. Resistive inspiratory muscle training can help improve respiratory function in patients with SCI. The patient must stay compliant with the exercise to maintain it s benefits. This exercise can be added to a standard PT regiment for this population to improve respiratory and QOF outcomes. Yes Yes 30

31 6 Roth, Stenson, Powley, Oken, Primack, Nussbaum, & Berkowitz (2010) 7 Sutbeyaz, Koseoglu, & Gokkaya (2005) 1b 3b 5/10 To assess the effectiveness of expiratory muscle training on pulmonary function of spinal cord injured patients. 5/10 To evaluate the effects of controlled breathing techniques and ventilatory and upper extremity muscle training on cardiopulmonary and metabolic functions and exercise tolerance in patients with SCI. Pulmonary function including; forced vital capacity, forced expiratory volume in 1 second, maximum expiratory pressure, maximum inspiratory pressure, inspiratory capacity, expiratory reserve volume, total lung capacity, functional residual capacity, and residual volume. Pulmonary functions were measured. They included; forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow rate, peak expiratory flow, vital capacity, FEV1/FVC, and maximum voluntary ventilation. Exercise tolerance was measured with an arm bike. Expiratory Yes muscle training can help improve some pulmonary functions. It can also help improve the ability of an SCI patient to have a productive cough to clear secretions and decrease likelihood of a pulmonary complication. An upper Yes extremity exercise regiment along with a respiratory training regiment can improve cardiopulmonary outcomes, exercise endurance, and exercise tolerance in patients with a SCI. These improvements can help SCI patients, who often have some 31

32 Heart rate, oxygen consumption, carbon dioxide inhaled, oxygen pulse, minute ventilation, respiratory exchange ratio, oxygen saturation, and power output. sort of pulmonary restriction, improve their pulmonary system. This means better breathing, coughing, and the ability to clear secretions. 8 van Langeveld, Post, van Asbeck, ter Horst, Leenders, Postma, Lindeman (2011) 4 N/A To describe the contents of the interventions to improve self-care and mobility for patients with spinal cord injury in early post-acute rehabilitation, using the Spinal Cord Injury-Intervention Classification System, and to compare these interventions between rehabilitation centers. The amount of treatment time between PT, OT, and sports therapy and the treatments and interventions performed by each therapy. PT spends more Yes time with SCI patients than other therapies. Interventions and treatment are highly focused on walking, muscle power, and wheelchair mobility. This shows that physical therapists could focus on other treatments to improve outcomes for these patients. 32

33 Discussion The literature supports educating, training, and implementing a pulmonary/respiratory muscle exercise program to decrease the likelihood of patients with spinal cord injury acquiring cardiopulmonary complications. The research shows that both expiratory and inspiratory training techniques can be utilized to improve pulmonary functions. The specific type is dependent on the level of injury. Sapienza, et al., explain, patients with spinal cord injury occurring at the cervical level would have difficulty with both inspiratory and expiratory muscle strength and could be a candidate for both training types, whereas individuals with spinal cord injury at the thoracic level may have more difficulty with expiratory muscle weakness and be a candidate for expiratory muscle training (p. 237). Either system can be implemented for this patient population, and best would be an exercise that works both inspiratory and expiratory muscles to improve pulmonary function and a productive cough. In a systematic review by Houtte, et al., increased expiratory pressure will increase driving pressure for forced expiration, while improved inspiratory muscle strength will enhance inspiratory volume and thus will also contribute to driving pressure for expiration (p.1895). Encouraging patients with spinal cord injury to exercise these muscles of respiration can have a significant impact on their function and participation in society. It is also important patients with spinal cord injury continue this training long after their initial training. Postma, et al., (2014) found with resistive inspiratory muscle training, the positive short-term effect on MIP found in our study was partly sustained at follow-up but was no longer statistically significant (p.1716). It is imperative that these patients are educated on why this training is so important and why it needs to be continued. Physical therapists spend more time with patients than other healthcare professions, allowing them the opportunity to reinforce respiratory strengthening exercises. 33

34 Research by van Langeveld, et al., (2011) showed that physical therapists are the healthcare professional who work with spinal cord injury patients most often. This extra time to interact with patients puts physical therapists in an excellent position to teach and re-teach, if necessary, pulmonary muscle training exercises. Physical therapists can add respiratory muscle training to standard treatment that usually includes upper extremity strengthening, wheelchair mobility, and transfers. Improving pulmonary functioning for these patients can help improve their participation in physical therapy, decrease their likelihood of pulmonary complications, and decrease their time to fatigue so they can perform more activities of daily living. Sutbeyaz, et al., found with an exercise training program and ventilator training program, values of FVC, FEV1, VC, peak VO2, peak HR, RER, peak VE, peak PO and time to fatigue were significantly higher than baseline values (p.275). The research shows multiple ways that a respiratory training program can be performed. Resistive devices are among the most common that are used to train these muscles. Another way to train these muscles is through balloon blowing. There is limited research on balloon-blowing therapy. Any literature found on this exercise is only as a clinical suggestion at this time. This intervention needs more research performed to prove its efficacy. Most of the evidence is anecdotal or by case. The research by Boyle, Olinick, & Lewis (2010) did report on a male athlete who had asthma, his spirometry scores improved from 1800 cc to 2700 cc on one visit and from 1500 cc to 3200 cc on a subsequent visit (p.185). The balloon is a simple resistive device that forces a patient to work on bringing in air, blowing it out, and maintaining a certain level of pressure to not allow the balloon to deflate. It works both inspiratory and expiratory muscles, which is important for patients with spinal cord injury to create a productive cough. Patient W showed improvements in his spirometry as well once this balloon-blowing was implemented. 34

35 Patient W improved from an average of 1800 cc of expired air, which was well below the average for an able-bodied person his age to 3200 cc of expired air. This was closer to his age expected score. His improvements were not only seen on spirometry but on the arm bike as well. Patient W would work on an arm bike that assisted when the patient would have trouble moving the crank with his or her own strength. This machine also had pedals for biking that assisted just as it did with the arms. When the author first saw the patient at the beginning of October 2015, he could barely complete 10 minutes with his arms and legs. By the end of the author s rotation in early December 2015, the patient was able to complete 20 minutes on the arm portion and 20 minutes on the leg portion. Then the patient was able to work on more exercises with minimal fatigue. Patient W also reported he was clearing his secretion without a problem and could more easily help with bed mobility. Implementing a respiratory muscle training program into patient W s standard PT care in the SCI unit helped the patient improve in other aspects that are important to physical therapists. Though patient W was limited by his sitting precautions, axial loading precautions, and TLSO, he made improvements with his standard of care PT and respiratory muscle training program. The findings from the studies included in this capstone show that a respiratory muscle training system whether performed through a resistive device or a balloon can be effective in improving pulmonary function in spinal cord injury patients. Improvements by respiratory muscle training decrease the chance that these patients will acquire a pulmonary complication and improve their overall participation. Applying these findings to patient W means the respiratory muscle training program was a good decision. Respiratory training should be initiated by physical therapists earlier and more often with this patient population. Initiation of this training is important to improve outcomes of the SCI population, even though there is still 35

36 limited research in both balloon blowing and respiratory muscle training. To improve research in respiratory muscle training and balloon blowing higher quality studies with larger sample sizes are needed. Higher quality studies will help show the effectiveness of respiratory training and balloon blowing at improving pulmonary function in spinal cord injury patients. Conclusion/Bottom Line: The literature review and working with patient W it is concluded that respiratory muscle training through balloon blowing therapy can be highly beneficial when added to standard of care PT for spinal cord injury patients. Pulmonary complications are a main cause of mortality and morbidity in the spinal cord injury population. Adding a relatively simple intervention to their plan of care can help decrease the chance of SCI patients dying from a respiratory issue. Physical therapists have time with patients with SCI and the knowledge to add a respiratory muscle training program by way of balloon therapy to decrease their pulmonary risks. Patient W benefitted from having this intervention added to his physical therapy routine by increasing his endurance and allowing him to clear his secretions. These improvements occurred for patient W even with his multiple precautions that kept him in bed and in his power chair. Adding a respiratory muscle training program to standard of care PT for patients with spinal cord injury should become routine. The benefits of the intervention far out-weigh any small issues the intervention may cause. Physical therapists can easily add this into the patient s plan of care and should educate spinal cord injury patients on the importance of the exercise and its necessity after physical therapy. Physical therapists are always looking to improve a person s physical function so they can achieve a better quality of life and perform activities of daily living. Including respiratory muscle training by way of balloon blowing is a simple and effective way to help achieve the goals physical therapists want for patients with spinal cord injury. All patients with spinal cord injuries have some issue with their respiratory system and 36

37 improving that function is important. Improved breathing allows for more efficient breathing, decreased time to fatigue, the ability to perform more daily activities, and decreased likelihood of getting pulmonary complication, like pneumonia. The addition of balloon blowing therapy as a respiratory muscle training program to standard PT for spinal cord patients is an excellent way to improve outcomes for this patient population. Patient W greatly benefitted from this intervention but he would have gained even more had it been started at an earlier time. Patient W likely would have improved faster in his physical therapy sessions as well. The respiratory training through balloon therapy would have also helped patient W with speech therapy, if balloon therapy was started earlier. If another patient like patient W would have come onto the SCI unit this respiratory training with balloon therapy would have been instituted almost immediately. This holds true even though the research for both respiratory training and balloon therapy are relatively low quality studies. What research is available does show this intervention can be effective in improving spinal cord injury patient s pulmonary outcomes and improve quality of life outcomes. 37

38 References 1. Boyle, K., Olinick, J., & Lewis, C. (2010). The value of blowing up a balloon. North American Journal Of Sports Physical Therapy, 5(3), p. 2. Gómara-Toldrà, N., Sliwinski, M., & Dijkers, M. P. (2014). Physical therapy after spinal cord injury: a systematic review of treatments focused on participation. Journal Of Spinal Cord Medicine, 37(4), p. doi: / y Houtte, S., Vanlandewijck, Y., & Gosselink, R. (2006). Respiratory muscle training in persons with spinal cord injury: A systematic review. Respiratory Medicine, 100, doi: /j.rmed Mueller, G., de Groot, S., van der Woude, L., & Hopman, M. (2008). Time-courses of lung function and respiratory muscle pressure generating capacity after spinal cord injury: a prospective cohort study. Journal Of Rehabilitation Medicine (Stiftelsen Rehabiliteringsinformation), 40(4), p. 5. Postma, K., Haisma, J. A., Hopman, M. E., Bergen, M. P., Stam, H. J., & Bussmann, J. B. (2014). Resistive Inspiratory Muscle Training in People With Spinal Cord Injury During Inpatient Rehabilitation: A Randomized Controlled Trial. Physical Therapy, 94(12), p. doi: /ptj Roth, E., Stenson, K., Powley, S., Oken, J., Primack, S., Nussbaum, S., & Berkowitz, M. (2010). Expiratory muscle training in spinal cord injury: a randomized controlled trial. Archives Of Physical Medicine & Rehabilitation, 91(6), p. doi: /j.apmr Sapienza, C., & Wheeler, K. (2006). Respiratory Muscle Strength Training: Functional Outcomes versus Plasticity. Semin Speech Lang Seminars in Speech and Language, 27(4), doi: /s Schilero, G. J., Spungen, A. M., Bauman, W. A., Radulovic, M., & Lesser, M. (2009). Pulmonary function and spinal cord injury. Respiratory Physiology & Neurobiology, 166(3), doi: /j.resp Sutbeyaz, S., Koseoglu, B., & Gokkaya, N. (2005). The combined effects of controlled breathing techniques and ventilatory and upper extremity muscle exercise on cardiopulmonary responses in patients with spinal cord injury. International Journal Of Rehabilitation Research, 28(3), p. 10. van Langeveld, S. A., Post, M. W., van Asbeck, F. W., ter Horst, P., Leenders, J., Postma, K., & Lindeman, E. (2011). Contents of physical therapy, occupational therapy, and sports therapy sessions for patients with a spinal cord injury in three Dutch rehabilitation centres. Disability & Rehabilitation, 33(5), p. doi: /