The Effect of Incentive Spirometry on Level of Fatigue and Creatine

Kinase in Chronic Spinal Cord Injury Patients

Rendra Sanjaya Yofa

, Farida Arisanti

,Vitriana Biben

, Indriati M.S Tobing

, Rosiana Pradanasari

Department of Physical Medicine and Rehabilitation, Hasan Sadikin General Hospital,

University of Padjadjaran, Bandung, Indonesia

Department of Physical Medicine and Rehabilitation,

Fatmawati General Hospital, Jakarta, Indonesia

Keywords: Creatine- Kinase, Fatigue Severity Scale, Inspiratory Muscle Training, Incentive Spirometry, Respiratory

Training, Spinal Cord Injury

Abstract: The reduced ability of the respiratory muscles in Spinal Cord Injury (SCI) patients is associated with the

physical fatigue. Incentive Spirometry (IS) breathing exercise can be used as a strategy to minimize the

fatigue through its effect improving bloodstream and oxygenation on the diaphragm and periphery muscles.

Creatine Kinase (CK) can be used to monitor muscle damage due to exercise or overtraining status. The

study was aimed to investigate the effect of IS on the level of fatigue and CK in blood. A quasi

interventional design with a pre- and posttest approach was done to eleven patients with chronic SCI

patients. It was measured the fatigue level using the Fatigue Severity Scale (FSS) before and after the

treatment. It was also measured the value of CK before treatment and after treatment in 2 and 4 weeks. There

was a significant decline in the FSS value, 35.45±9.699 to 25.36±11.918(p=0.007) after 4 weeks intervention. On

the other hand, there was a significant increase in CK value, from 111. 63±77.628 U/l to 146.36±81.185 U/l

(p=0.033), after 2 weeks intervention. However, it was not significant CK value was to be 127.45±82.117

U/l (p=0.168) after 2 weeks intervention. These findings showed IS breathing exercise after 4 weeks can

improve fatigue level and no muscle damage due to IS exercise in chronic SCI patients.

1 INTRODUCTION

Fatigue becomes one of the concerns in chronic SCI

patients (Lidal, 2013). There are two types of fatigue

following SCI, namely physical fatigue and chronic

fatigue. Physical fatigue is defined as intrinsic

muscular fatigue that occurs in muscles partially or

total paralyzed at the level of or below the spinal

cord lesion. Chronic fatigue is defined as a

debilitating condition involving multiple factors

including physical, psychological and aging

components (Craig, 2012). The incidence of fatigue

in SCI patients varied between 18–57% (Nooijen,

2015; Hammel, 2009).

After SCI, paralyzed skeletal muscle generally

becomes atrophic including respiratory muscle,

possesses lower tension generating capacity and is

less fatigue resistant. Muscle histochemical and

metabolic profile shifts toward type II (fast

glycolytic) fibers have been well documented

following SCI and may explain the problem of rapid

muscle fatigability in SCI survivor (Pola, 2014; Kim,

2017). This may lead to more rapid fatigue of the

respiratory pump in patients with SCI during

physical activity.

The cause of fatigue is probably multifactorial,

but a central role for changes in high-energy

phosphates (i.e., ATP and ADP) or accumulation of

by-products of rapid energy metabolism has been

postulated. A key enzyme for maintaining a constant

ATP/ADP ratio during rapid energy turnover is CK,

which catalyzes phosphate exchange between the

high free energy phosphates ATP and

phosphocreatine (PCr) via the reaction:

PCr + ADP+ H creatine (Cr)+ ATP (1)!

Yofa, R., Arisanti, F., Biben, V., Tobing, I. and Pradanasari, R.

The Effect of Incentive Spirometry on Level of Fatigue and Creatine Kinase in Chronic Spinal Cord Injury Patients.

DOI: 10.5220/0009087901910196

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 191-196

ISBN: 978-989-758-409-1

191

CK is employed to mark muscle injury that

occurs after an exercise. CK value is primarily used

to know whether there is an overload limit achieved

or instead, muscle adaptation has occurred. Muscle

damage regarding an exercise can occur due to

unaccustomed exercise or heavy exercise intensity.

The increase of CK value is related to the number of

type II muscle fiber in the muscle. As we know that

following SCI, become predominantly composed of

type II muscle fiber. The increase of CK value in

serum significantly occurs in the initial exercise

indicates that the exercise intensity exceeds muscle

capability. Exercise will affect the decrease

elevation of CK when it is done regularly in a

certain period. Such an effect is called a repeated

bout effect, indicating that there is muscle adaptation

towards the exercise. (Soon-Gi, 2015; Margaritelis,

2015).

The effects of respiratory training in SCI patients

are related to increased strength and endurance of

respiratory muscle fitness, as well as reduced

ventilation efforts required during training by the

process of adaptation. Respiratory training also

increases neural adaptation which is required to

coordinate muscle contractions synergistically,

thereby maximizing the respiratory muscle

activation. Increased respiratory muscle strength

directly correlates with reduced muscle fatigue due

to increased training capacity and tolerance, so

inspiratory muscle training (IMT) can be used as a

strategy to minimize respiratory fatigue (Sisto, 2014;

Hartz, 2018).

Incentive Spirometry is one of the assistive

devices of respiratory training which can be used to

maintain maximum inspiration by providing

feedback of predetermined air volume. A study

found that the use of IS in respiratory training with

additional abdominal drawing-in maneuver resulted

in improvement in pulmonary function of a patient

with SCI (Kim, 2017).

Several studies had investigated the effects of

IMT on fatigue. Bosnak-Guclu et al. conducted a

study of IMT using Inspiratory Muscle Trainer in

NYHA II-III congestive heart failure patients and

Turner et al conducted a study on asthma patients.

Both of these studies show positive effect in

reducing the fatigue (Bosnak-Guclu, 2011; Turner,

2011).

In this study, we provide IS breathing exercise to

investigate its effects on the level of fatigue and CK

value on chronic SCI patients in Sasana Bina Daksa

Budi Bhakti, Pondok Bambu, East Jakarta. The

severity of fatigue is assessed by the Fatigue

Severity Scale (FSS) questionnaire. It assesses a

person's perception of fatigue and its use has been

validated in patients with neuromuscular disease.

We hypothesized that IS breathing exercise can

improve fatique level and no more muscle damage

caused by IS breathing exercise after 4 weeks

intervention.

2 METHODS

This study used a quasi-interventional research

design with a pre- and posttest approach. The

samples were recruited from subjects who met the

inclusion criteria in population of chronic SCI

patients who occupied in the Social Care Center of

Sasana Bina Daksa Pondok Bambu, East Jakarta,

Indonesia.

The inclusion criteria are chronic SCI, aged 18 –

59 years old, paraplegic, no acute infection, stable

spinal structure, able to perform breathing muscle

training inspiration procedure for 30 minutes,

Hamilton Depression Score (HDS) less than 20,

Mini Mental State Examination (MMSE) score

between 22–30. Exclusion criteria unable to take a

deep breath due to pain, taking statin drug

and patients with vital capacity <10 mL/kg. The

subjects signed an informed consent to be included

in the study. After each set, a one-minute rest was

allowed.

The subjects signed informed consent in order to

be included in the study. All the subjects were given

respiratory muscle training with IS intensity from

residual capacity to total lung capacity. The IS

breathing exercise prescriptions are 5 days a week,

once a day, with total of five sets, with 10 repetitions

making up one set. After each set, a one-minute rest

was allowed.

The IS training program was conducted after

the subjects were given explanations of the exercise

device, watched a video about the use of the exercise

and familiarizing the device for 2 consecutive days.

To do the exercise, the subjects sat in reclining

chairs with their torso upright. The pulse oxymeter

was pinned to the subject's fingers as a tool to

monitor the general condition during training. The

IS was held with one hand in an upright sitting

position, mouthpiece was placed into the mouth

between the teeth with the lips clamped tightly

around the mouthpiece The subjects maintained a

maximal inspiration position for 3 to 5 seconds, and

then performed maximal expiration. This exercise

was performed for a total of five sets, with 10

repetitions making up one set. After each set, a one-

minute rest was allowed.

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

192

The primary endpoint measurements included

fatigue evaluated with the FSS and CK level in

blood. FSS were assessed before and after

intervention, while the CK levels were examined

before intervention, after 2 weeks and 4 weeks

intervention (in 24 hours after exercising).

Numerical data including age were presented

with mean and standard deviations, maximum

values, and minimum values. The subjects’

characteristic data were presented in frequency

distribution tables. Categorical variables were

presented in percentage (%) and continuous

variables were presented in mean ± standard

deviation (SD). Statistical analysis was carried out

by performing normality test to determine that the

data were normally distributed or not normally

distributed.

Data distribution were discovered using the

Shapiro Wilks test since the samples were less than

50. Paired t test was used to compare FSS variables

between before and after the intervention since the

data were normally distributed. Wilcoxon test was

used to compare CK before and after 2 weeks and to

compare before and after 4 weeks intervention since

the data were not distributed normally. Significance

of the statistical test results was determined based on

p value (<0.05). All procedures were performed

using the SPSS for Windows version.

The study was approved by the Ethics

Committee of Padjadjaran University, Bandung,

Indonesia with ethical numbers of 0318050767. All

data and information of the subjects will be kept

confidentially.

3 RESULTS

The study enrolled 11 chronic SCI patients. Mean

age of the subjects was 44 years old. Number of

male subjects (90.9 %) were higher than female

subjects. The subjects had SCI approximately 260

months due to trauma (90. 9%) (Table 1). Most of

the subjects had complete SCI (81.8 %). Based on

body mass index (BMI), the subjects was mostly

underweight (63.6 %) with an average of 18.72

kg/m2 without any other complications of chronic

SCI. Occupation of the subjects was mostly

craftspeople. Eighty one percents of the subjects had

smoking history. In addition, there was no subject

has pressures sore and did not consume medicines

which could influence CK levels. The mean of pre-

and post-training FSS scores were respectively 35.45

± 9.699 and 25.36 ± 11.918. There was a significant

improvement in the FSS after the intervention (table

2, p = 0.007). For The CK value, there was a

significant increase after 2 weeks intervention (table

3, p=0.033), but there was no significant increase

after the 4 weeks intervention (table 4, p =0.168).

4 DISCUSSIONS

From baseline data in table 1, the mean age of the

patient is 44 y.o. with 10 male patients and 1 female

patient. Based on international data, male accounts

for eighty-one percent of new SCI cases and the

average age at injury is 42 years old. In developing

countries, SCI is more frequent in male than female,

with a male: female ratio of 10: 1 to 6.69: 1. The

high incidence of SCI in male is associated with the

higher activity of men in the community, moreover,

men do dangerous activities more frequently than

women (WHO, 2013).

The lower FSS score in our study after four

weeks intervention with IS (Table 2) demonstrated

that the level of fatigue was reduced significantly.

Several studies had investigated the effects of

IMT on fatigue but never been done in individuals

with SCI. Bosnak-Guclu et al. conducted a study of

IMT using Inspiratory Muscle Trainer in NYHA II-

III congestive heart failure patients, dividing the

study subjects into two groups: the treatment group

(receiving 40% dose of MIP) and the control group

(receiving 15% dose of MIP). A statistically

significant (p≤0.0001) reduction in FSS score was

demonstrated in both treatment and control group

(p=0.008). However, the difference in FSS reduction

between these groups was not statistically

significant, indicating that low-dose Inspiratory

Muscle Trainer gives the same effect in reducing

fatigue perceptions. Bosnak-Guclu et al. concluded

that the IMT using Inspiratory Muscle Trainer may

increase peripheral blood flow, peripheral muscle

strength and exercise capacity, thereby reducing the

severity of fatigue in daily activities and training

(Bosnak-Guclu, 2011).

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193

Table 1: Characteristics of subjects.

Variables

n=11

Age (year-old)

44.27±7.695

Gender (male/female)

10 (90.9%) / 1(9.1%)

Bodyweight (kilogram)

51.09±6.64

BMI

Underweight

Normal

Overweight

18.72±2.17

7(63.6%)

3(27.3%)

1(9.1%)

Vocational

Craftsman

Mechanics

10(90.9%)

1(9.1%)

Smoking status

9(81.8%)

Medication

Mecobalamin

1(9.1%)

10(90.9%)

Pressure sores history

Yes

11(100%)

0(0%)

AIS classification (complete/incomplete)

10 (90.9%) / 1(9.1%)

MMSE>24

11(100%)

HDS<20

11(100%)

Categoric data are expressed as number/frequency and percentage, numeral data as mean±standar deviation. BMI, body

mass index; AIS, American Spinal Injury Association Impairment Scale.

Table 2: Fatigue Severity Scale (FSS) before and after the intervention.

Before Intervention

After Intervention

P value

Mean±SD

35.45±9.699

25.36±11.918

0.007**

**p value<0,05: statistically significant different. SD = Standard Deviation.

Table 3: CK value before and after 2 weeks intervention.

Variable

Before Intervention

2 Weeks after Intervention

P value

CK Value (U/l)

0.033**

Mean±SD

111.63±77,628

146.36±81.185

Median

84.00

145.00

Range

(Min- Max)

53.00-335.00

64.00-321.00

**p value<0,05: statistically significant different. SD = Standard Deviation.

Table 4: CK value before and after 4 weeks intervention.

Variable

Before Intervention

2 Weeks after Intervention

P value

CK Value (U/l)

0.168

Mean±SD

111.63±77.628

127.45±82.117

Median

84.00

119.00

Range

(Min- Max)

53.00-335.00

56.00-338.00

SD = Standard Deviation.

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

194

Duruturk et al. conducted a study on asthma

patients. The study subjects were divided into two

groups: the treatment group (receiving a 50% dose

of IMT) for 6 weeks and the control group

(receiving respiratory training only). A significant

reduction in the FSS score was only demonstrated in

the treatment group (p = 0.028). Positive impacts

were also seen in respiratory muscle strength,

exercise capacity and quality of life in asthma

patients. Increased respiratory muscle strength is

believed to have a dyspnea-reducing-effect during

training due to the reduced need for required

oxygen. The reduction of required respiratory effort

leads to the reduction of required energy thereby

reducing the severity of fatigue in a person (Durutur,

2018). The results of our study demonstrated that

respiratory training using IS significantly reduced

the severity of fatigue in individuals with SCI after

four weeks of intervention. Respiratory muscles are

vital and play an important role in performing

training. Having strong, long-lasting respiratory

muscles may increase exercise capacity because they

improve lung function, delay fatigue in respiratory

muscles, and increase blood flow to respiratory

muscle tissues as well as other peripheral muscles.

The association between respiratory muscle function

and fatigue had been investigated by Ray et al. They

investigated the association between respiratory

muscle function and fatigue in 37 multiple sclerosis

patients with mild to moderate disability (still able to

ambulate). There was a negative correlation between

respiratory muscle strength (MIP and MEP) and

fatigue perception using Modified Fatigue Impact

Scale (MFIS) questionnaire (Ray, 2015).

Following the CK value in this study, a

significant statistical increase occurred in this study

after 2 weeks intervention (table 3) and became not

significant statistical increase of CK value after 4

weeks intervention (table 4). This is following the

literature stating that increased CK value usually

happens in the initial weeks of exercise indicating

that the initial exercise intensity is given exceeds

muscle capability. This is based on the exercise

principle that in order to give a strengthening effect,

overload exercise intensity should be given. After 4

weeks intervention, CK value increase occurred

insignificantly. This indicates that there has been

muscle adaptation towards the exercise. Several

works of literature mentioned that muscle adaptation

can occur in the third week of the exercise, depends

on the exercise intensity and muscle condition (Ray,

2015; Magal, 2010).

Research on the effect of exercise on CK value

in blood of SCI patient has been done by Robergs et

al., in 1993. They conducted research on CK and

endothelin level of SCI patient (level C7-L1)

through bicycle exercise added by Functional

Electrical Stimulation (FES). The exercise was done

three a week by comparing the CK enzyme and

endothelin level before the exercise, the first week,

the third week, the sixth week and the twelfth week

of the exercise. There was a significant increase of

CK level each week, however, since the third week

on, the increase of CK was not as much as the first

week. This indicated that muscle adaptation started

in the third week of exercise.

Barroso et al performed research on the effect of

regular elbow flexor eccentric exercise. One of the

markers used was the CK examination. The result of

the research indicated that there was a significant

increase in CK value in the first week, while in the

fourth and sixth week, the increase was less. This is

called a repeated-bout effect mechanism which is the

effect of muscle adaptation towards the exercise.

The repeated-bout effect has a protective effect on

the muscle, thus during such condition, muscle

damage will not happen, or even it happened, the

effect will be minimal. Repeated-bout effect

involved a combination of neural, mechanical and

adaptation of cellular. Barroso et al concluded that

there was protection effect towards the effect of

myofibril structure so that it will prevent the

occurrence of muscle damage in the fourth week

(Barroso, 2010). Research conducted by Chen et al

indicated that there was significant muscle damage

for the first two weeks of elbow eccentric exercise,

and it started to decrease in the third week. After the

fourth week of the exercise, the effect of muscle

damage became insignificant. This can be explained

by the occurrence of neural adaptation in the form of

motor unit recruitment efficiency, firing

synchronization increase from the motor unit and the

increase of low type muscle fiber ratio (Chen, 2009).

The limitation of this study did not assess several

factors that may influence the level of fatigue such

as pain, sleep problem, nutrition, the effort of

coping, activity level and spasticity severity.

5 CONCLUSIONS

Four-week respiratory training with IS was effective

at reducing the severity of fatigue in individuals with

SCI. This study also obtained results that there was

no significant increase in the value of CK after 4

week intervention which indicates that the muscles

have adapted to exercise so that there is no longer

any effect of muscle damage due to exercise. Thus,

The Effect of Incentive Spirometry on Level of Fatigue and Creatine Kinase in Chronic Spinal Cord Injury Patients

195

respiratory training with IS was one of the safety and

effective strategies to reduce fatigue in individuals

with SCI.

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KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

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