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Respiratory muscle weakness and respiratory muscle training in severely disabled multiple sclerosis patients☆1,☆2,☆3,☆4,☆5,☆6,☆7,☆8,☆9

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Abstract

Gosselink R, Kovacs L, Ketelaer P, Carton H, Decramer M. Respiratory muscle weakness and respiratory muscle training in severely disabled multiple sclerosis patients. Arch Phys Med Rehabil 2000;81:747-51. Objective: To evaluate the contribution of respiratory muscle weakness (part 1) and respiratory muscle training (part 2) to pulmonary function, cough efficacy, and functional status in patients with advanced multiple sclerosis (MS). Design: Survey (part 1) and randomized controlled trial (part 2). Setting: Rehabilitation center for MS. Patients: Twenty-eight bedridden or wheelchair-bound MS patients (part 1); 18 patients were randomly assigned to a training group (n = 9) or a control group (n = 9) (part 2). Intervention: The training group (part 2) performed three series of 15 contractions against an expiratory resistance (60% maximum expiratory pressure [PEmax]) two times a day, whereas the control group performed breathing exercises to enhance maximal inspirations. Main Outcome Measures: Forced vital capacity (FVC), inspiratory and expiratory muscle strength (PImax and PEmax), neck flexion force (NFF), cough efficacy by means of the Pulmonary Index (PI), and functional status by means of the Extended Disability Status Scale (EDSS). Results: Part 1 revealed a significantly reduced FVC (43% ± 26% predicted), PEmax (18% ± 8% predicted), and PImax (27% ± 11% predicted), whereas NFF was only mildly reduced (93% ± 26% predicted). The PI (median score, 10) and EDSS (median score, 8.5) were severely reduced. PEmax was significantly correlated to FVC, EDSS, and PI (r =.77, −.79, and −.47, respectively). In stepwise multiple regression analysis, PEmax was the only factor contributing to the explained variance in FVC (R2 =.60), whereas body weight (R2 =.41) was the only factor for the PI. In part 2, changes in PImax and PEmax tended to be higher in the training group (p =.06 and p =.07, respectively). The PI was significantly improved after 3 months of training compared with the control group (p <.05). After 6 months, the PI remained significantly better in the training group. Conclusions: Expiratory muscle strength was significantly reduced and related to FVC, cough efficacy, and functional status. Expiratory muscle training tended to enhance inspiratory and expiratory muscle strength. In addition, subjectively and objectively rated cough efficacy improved significantly and lasted for 3 months after training cessation. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Section snippets

Part 1

Twenty-eight bedridden or wheelchair-bound MS patients (mean age, 58 ± 14yrs; mean duration of the disease, 27 ± 13yrs) were studied to examine the contribution of respiratory muscle weakness to their impaired health status. FVC, inspiratory and expiratory muscle strength (PImax and PEmax), Pulmonary Index (PI), and Extended Disability Status Scale (EDSS) were measured. All patients were in a clinically stable condition for at least 4 weeks (no recent infection or exacerbation). All tests were

Pulmonary function, cough efficacy, and functional status

A significantly reduced FVC (1.4 ± 0.9L, 43 ± 26% predicted) was observed. The median PI score was 10 (ranging from 6 to 11) indicating severely impaired cough efficacy. The high median score on the EDSS (8.5, ranging from 6.5 to 9.5) (table 1) confirmed the markedly reduced mobility of the patients, nearly all being wheelchair bound or bedridden.

Respiratory muscle strength

The PEmax (29 ± 15cmH2O, 18 ± 8% predicted) was significantly more reduced than the PImax (25 ± 14cmH2O, 27 ± 11% predicted) (p <.01). Mean isometric

Discussion

It was concluded from the first part of the study that in wheelchair-bound and bedridden MS patients, expiratory muscle strength was more affected than inspiratory muscle strength. Expiratory muscle strength was significantly related to FVC, cough efficacy, and functional status.

From the second part of the study, it was concluded that expiratory muscle training tended to enhance both inspiratory and expiratory muscle strength and significantly improved the objectively and subjectively rated

Acknowledgements

The authors gratefully thank Mrs. R. Schepers for her expert help with statistical analysis, and Mrs. V. Debusschere, G. DeDekker, and N. Demolon for their assistance in data collection and supervision of the training.

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    ☆1

    Supported by the Fonds voor Wetenschappelijk Onderzoek–Vlaanderen, grant P. 0188.97.

    ☆2

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

    ☆3

    Reprint requests to Rik Gosselink, PhD, Professor of Respiratory Rehabilitation, Division of Respiratory Rehabilitation, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven Belgium.

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