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pnf and movement 2020 18 2 297 303 print issn 2508 6227 https doi org 10 21598 jkpnfa 2020 18 2 297 online issn 2508 6472 original article open access ...

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              PNF  and  Movement,  2020;  18(2):  297-303                                   Print  ISSN:  2508-6227
              https://doi.org/10.21598/JKPNFA.2020.18.2.297                              Online  ISSN:  2508-6472
                Original  Article                                                            Open  Access
                          Effects  of  Inspiration  and  Expiration  Exercise  Combined  with 
                          Upper  Extremity  Proprioceptive  Neuromuscular  Facilitation  on 
                                 Forced  Volume  Vital  and  Peak  Expiratory  Flow
                                                                        †
                                                Sang-Yeol Lee, P.T., Ph.D. 1)
                              Department  of  Physical  Therapy,  Kyungsung  University,  Busan,  South  Korea
               Received: July 20, 2020 / Revised: July 27, 2020 / Accepted: July 27, 2020
               ⓒ 2020 Journal of Korea Proprioceptive Neuromuscular Facilitation Association
               This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License 
               (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction 
               in  any  medium,  provided  the  original  work  is  properly  cited. 
                 | Abstract |
              Purpose: The purpose of this study was to examine the effects of inhalation and exhalation exercise combined with upper extremity 
              proprioceptive neuromuscular facilitation pattern on two spirometry values: forced volume vital (FVC) and peak expiratory flow 
              (PEF).
              Methods: Thirty-two healthy adults were divided into two groups: 1) a combined group, which performed upper extremity D2 
              flexion pattern (shoulder flexed/abducted/external rotated, forearm supinated, wrist radial deviated, and finger extended) during 
              exhalation and D2 extension pattern (shoulder extended/adducted/internal rotated, forearm pronated, wrist ulnar deviated, and 
              finger flexed) during inhalation; and 2) reverse combined group, which performed the D2 flexion pattern during inhalation and 
              the D2 extension pattern during exhalation. The inverse application of upper extremity movements during inhalation and 
              exhalation induced selective resistance or assistance on respiration. FVC and PEF were measured at two time points, before and 
              after four weeks. 
              Results: In both groups, the pre-post intervention comparison showed significant increases in FVC and PEF (p < .05). In the 
              between-groups comparison, the reverse combined group showed a significantly higher PEF than the combined group at four 
              weeks post intervention (p < 0.05).  
              Conclusion: The combined respiration exercise with reverse PNF upper extremity patterns using selective resistance showed 
              an  effective  increase  in  PEF  in  healthy  adults.  Clinicians  and  researchers  might  consider  using  selective  resistance  as 
              a  widely  applicable  and  cost-effective  option  for  respiratory  rehabilitation  planning. 
              Key Words:  PNF upper  extremity  pattern,  Respiratory  exercise,  Spirometry  values
              †Corresponding  Author  :  Sang-Yeol  Lee  (sjslh486@daum.net)
                     298 | PNF and Movement Vol. 18, No. 2
                                           Ⅰ. Introduction                                      The  applicable  and  cost  effective  respiratory 
                                                                                             rehabilitation may not require a high intensity of physical 
                         Chronic  respiratory  diseases  are  common  conditions             activity and/or strength exercise as well as it should be 
                     observed  in  a  billion  of  individuals  worldwide  (Prince           able  to  conduct  by  patients  themselves.  Respiratory 
                     et al., 2015) and include chronic obstructive pulmonary                 rehabilitation  using  the  Proprioceptive  Neuromuscular 
                     disease  (COPD),  asthma  or  interstitial  lung  disease               Facilitation  (PNF)  on  thorax  is  easy  and  concise 
                     (Armstrong & Vogiatzis., 2019; Bousquet et al., 2010).                  intervention  conducting  movement  patterns  using  joint 
                     These diseases can cause difficulty in breathing during                 range of motion with a low intensity of physical activity 
                     physical  activity  such  as  a  shortness  of  breath  and/or          (Kim et al.,  2000).  Thus,  it  is  possible  to  be  used  for 
                     chronic cough producing sputum. When the difficulties                   patients  with  limitation  of  movement.  To  assist  the 
                     become chronic conditions, they may negatively impact                   thoracic movement, upper extremity movement is often 
                     on  disorder  and/or  quality  of  life  in  those  with  the           applied during respiration in rehabilitation training. For 
                     respiratory  diseases  (Carreiro-Martins  et  al.,  2016).  As          example,  Areas  et  al.  (2013)  conducted  a  randomized 
                     a  long-term  effect,  the  difficulties  in  breathing  could          control  study  using  upper  extremity  PNF  pattern  in  healthy 
                     restrict  a  chance  of participation in their physical activity        women  for  four  weeks,  and  showed  a  significantly 
                     (e.g.  daily  living)  and  could  further  result  in  decreased       increased  maximum  pressure  for  inhalation/exhalation 
                     quality  of  life  (American  Thoracic  Society,  1999).                (effect  size  for  maximum inhalation/exhalation pressures: 
                         A number of exercise and educational program have                   1,74/1.56).  This  increased  capacity  of  respiration  from 
                     been developed for respiratory rehabilitation and showed                the  added  upper  extremity  movement  pattern  may  be 
                     positive effect  on  increased  strength  of  respiratory  muscles      associated with increased extension and elevation of trunk 
                     and/or     capacity    of    respiration.    The     respiratory        movement as the kinematic chain effect while the upper 
                     rehabilitation with positive effect includes training using             extremities  are  elevated  and/or  flexed  (Stapley  et  al., 
                     physical  activity  (Summerhill  et  al.,  2007),  selective            1998).  Fayad  et  al.  (2008)  examined  the  amount  of 
                     muscle  strength  exercise  (HajGhanbari  et  al.,  2013),              increased  extension  and  elevation  in  trunk  while  arms 
                     respiratory exercise using an instrument for lung capacity              were fully  elevated  using  3D  motion  analysis,  and  reported 
                     (Clanton et al., 1985) and respiration re-education training            that  7°  of  extension  and  8°  of  elevation  in  trunk. 
                     (Troosters  et  al.,  2005).  Of  these,  the  training  using             Although the application of the PNF upper extremity 
                     physical activity and selective muscle strength exercise                pattern for thoracic movements needs assistance of experts 
                     report a maximized effect on capacity of respiration but                (e.g.  therapists),  it  requires  less  cost  than  other 
                     they may not be suitable for most patients with chronic                 interventions  as  it  can  be  implemented  by  patients 
                     respiratory diseases since these diseases are common in                 themselves  once  trained  appropriately.  The  other 
                     old individuals. In addition, the respiratory exercise using            advantage of using the PNF upper extremity pattern is 
                     an  instrument  for  lung  capacity  and  respiration                   that the direction of resistance (flexion or extension) to 
                     re-education training leaded by experts require a higher                thorax  can  be  chosen  during  either  inhalation  or 
                     cost  than  other  interventions.  Thus,  it  is  essential  to         exhalation.  To  date,  the  PNF  upper  extremity  pattern 
                     develop     a    widely     applicable    and     cost-effective        during  respiration  has  shown  a  significant  effect  on 
                     intervention for patients with chronic respiratory disease.             capacity  of  respiration.  However,  no  studies  examined 
                              Effects of Inspiration and Expiration Exercise Combined with Upper Extremity Proprioceptive... | 299
                     the  effect  of  two  different  directions  of  resistance  on        and fingers  movements in two directions  including  D2 
                     capacity of respiration when it combines with inhalation               flexion and D2 extension patterns. The D2 flexion pattern 
                     and  exhalation,  as  a  widely  applicable  and  cost-effect          starts  in  shoulder  extension,  adduction  and  internal 
                     rehabilitation  intervention.  Thus,  the  aim  of  this  study        rotation, forearm pronation, and wrist and finger flexion, 
                     was to examine the effects of inhalation and exhalation                and  ends  in  shoulder  flexion,  abduction,  and  external 
                     exercise combined with upper extremity PNF patterns on                 rotation, forearm supination, wrist and finger extension. 
                     the spirometry values including the forced volume vital                The D2 extension pattern reverses the D2 flexion pattern. 
                     (FVC)  and  peak  expiratory  flow  (PEF).                             Intervention  for  Combined group consisted of PNF D2 
                                                                                            flexion pattern during inhalation and PNF D2 extension 
                                                                                            pattern  during  exhalation,  which  provided  selective 
                                             Ⅱ. Methods                                     support to trunk movement while respiration. On the other 
                                                                                            hand, intervention for Reverse combine group consisted 
                        1. Participant                                                      of PNF D2 extension pattern during inhalation and PNF 
                                                                                            D2  flexion  pattern  during  exhalation,  which  provided 
                        A four weeks intervention trial  was  performed  in  Busan          selective resistance to trunk movement while respiration. 
                     city,  South  Korea.  Participants  were  recruited  from  a           During the intervention, a physiotherapist assisted speed 
                     university  in  the  city  through  advertisements,  social  media,    of PNF patterns for patient to maximize the amount of 
                     word of mouth, and email contact. Eligible participants                inhalation and exhalation, and applied manual resistance 
                     included 32 healthy adults between 20 and 30 years old.                to  facilitate  correct  upper  extremity movement if needed. 
                     They were provided information of the study and decided                To minimize muscle fatigue, one minute rest was provided 
                     to participate. Participants were included if they did not             after  every  five  minutes  intervention. 
                     have i) a history of malformation or deformation of spine, 
                     ii)  a  medical  issue  on  respiratory  system,  or  iii)  acute         3. Outcome measurements 
                     or chronic pain in any other body. All participants were 
                     noticed that they were able to withdraw their participation               A  pulmonary  dynamometer  (SP-260  Pneumotacho 
                     at  any  point  of  the  study  with  or  without  personal  reason    Sensor, SCHILLER, Swiss) was used to measure FVC 
                     or  discomfort.                                                        and  PEF  before  and  after  four  weeks  intervention. 
                                                                                            Participant was provided information of how to use the 
                        2. Intervention                                                     dynamometer with an additional demonstration from an 
                                                                                            examiner. Two measurements were conducted for each 
                        Participants were divided into two groups: Combined                 test  position  for  sitting  and  standing  and  the  average  value 
                     group and Reverse combine group. Both groups conducted                 from  the  two  measurements  were  used  for  analysis. 
                     a  15 minutes intervention every day for four weeks. For 
                     upper  extremity  PNF  movement,  the  bilateral  PNF                     4. Analysis
                     diagonal 2 pattern (D2) was chosen to drive synergistic 
                     upper body movement during respiration. The D2 pattern                    All analyses were performed using the SPSS version 
                     is  a  technique  that  encompasses  the  shoulder,  elbow,  wrist     25.0 (SPSS Inc., Chicago, USA). Independent t-test was 
                  300 | PNF and Movement Vol. 18, No. 2
                  used for comparison of demographic information and PEF       reported in FVC and PEF measured before intervention 
                  after  four  weeks intervention between two groups. Paired   between  two  groups  (p>0.05)  (Table  1). 
                  t-test  was used to identify effect of intervention in each 
                  group between pre- and post-intervention. The statistical       2. FVC and PEF at four weeks post intervention
                  significant  level  α was  set  at  0.05. 
                                                                                  When  comparing  two  groups  after  four  weeks  of 
                                                                               intervention,  for  FVC,  no  significant  difference  was 
                                       Ⅲ. Results                              reported  between  groups  (p<0.05).  For  PEF,  Reverse 
                                                                               combined  group  reported  a  significantly  higher  PEF 
                     1. Demographic information, FVC and PEF at                compared  to  Combined  group  (p<0.05)  (Table  2).
                        pre-intervention
                                                                                  3. Pre vs post intervention in each group
                     No significant difference was reported in demographic 
                  information including age, height and weight between two        Both groups showed a significant increase in FVC and 
                  groups  (p>0.05).  No  significant  difference  was  also    PEF after  four  weeks  of  intervention  compared  to  pre 
                  Table  1.  General  characteristics  of  subjects  at  pre  intervention
                                          Reverse  combined  group                Combined  group
                                                                                                                  t            p
                                                 (mean±SD)                          (mean±SD)
                                                           †
                      Age  (years)               22.12±1.31                          21.62±1.20                 -1.12        0.27
                      Height  (㎝)               173.68±4.25                         174.81±3.76                 0.79         0.43
                      Weight  (㎏)                71.18±2.37                          70.31±2.08                 -1.10        0.27
                       FVC (ℓ)                   3.83±0.34                           3.98±0.33                  1.25         0.21
                       PEF  (ℓ/s)                5.45±0.49                           5.70±0.57                  -1.34        0.19
                   FVC:  forced  vital  capacity,  PEF:  peak  expiratory  flow
                   †
                    Mean ± SD
                  Table  2.  Comparison  of  FVC  and  PEF  between  two  groups  at  post  intervention 
                                            Reverse  combined  group              Combined  group                T            p
                                                            †
                         FVC (ℓ)                   4.45±0.65                         4.83±0.50                 1.81          0.80
                                                                                                                                *
                        PEF  (ℓ/s)                  6.46±0.41                        5.92±0.43                 -3.62         0.00
                   †            *
                    Mean ± SD,  p<0.05
                  Table  3.  Comparison  of  FVC  and  PEF  between  pre  and  post  measurement
                                                                              Pre                 Post             t           p
                                                                                    †                                            *
                                                        FVC (ℓ)            3.83±0.34           4.45±0.65         -5.55       0.00
                      Reverse  combined  group 
                                                                                                                                 *
                                                        PEF  (ℓ/s)         5.70±0.57           6.46±0.41         -7.68       0.00
                                                                                                                                 *
                                                        FVC (ℓ)            3.98±0.33           4.83±0.50         -7.09       0.00
                          Combined  group 
                                                                                                                                 *
                                                        PEF  (ℓ/s)         5.45±0.49           5.92±0.43         -5.30       0.00
                   †            *
                    Mean ± SD,  p<0.05
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...Pnf and movement print issn https doi org jkpnfa online original article open access effects of inspiration expiration exercise combined with upper extremity proprioceptive neuromuscular facilitation on forced volume vital peak expiratory flow sang yeol lee p t ph d department physical therapy kyungsung university busan south korea received july revised accepted journal association this is an distributed under the terms creative commons attribution non commercial license http creativecommons licenses by nc which permits unrestricted use distribution reproduction in any medium provided work properly cited abstract purpose study was to examine inhalation exhalation pattern two spirometry values fvc pef methods thirty healthy adults were divided into groups a group performed flexion shoulder flexed abducted external rotated forearm supinated wrist radial deviated finger extended during extension adducted internal pronated ulnar reverse inverse application movements induced selective resis...

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