Effects of Exercise Training on Forced Expiratory Flow in

Individuals with Spinal Cord Injury with Prone Positioning:

A Serial Case Report

Ayu Amalia Utami Putri

, S. C. Widjanantie

, R. E. Pakasi

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo Hospital,

University of Indonesia, Jakarta, Indonesia

Cardiorespiratory Division, Department of Physical Medicine and Rehabilitation, Persahabatan Hospital,

University of Indonesia, Jakarta, Indonesia

Neuromuscular Division, Department of Physical Medicine and Rehabilitation, Fatmawati Hospital,

University of Indonesia, Jakarta, Indonesia

Keywords: Exercise Training, Forced Expiratory Flow, Spinal Cord Injury, Prone Position.

Abstract: Two Spinal Cord Injury (SCI) patients with the diagnosis of thoracic level Asia Impairment Scale (AIS) A

chronic phase were re-hospitalized. A 23-year-old male with accompanying problem of multiple pressure

sores, deep vein thrombosis (DVT), and anemia; and a 13-year-old-female with accompanying problem of

pressure sores and anemia. Debridement and flap surgeries were performed in treating existing pressure

sores. Six weeks of tailored-made rehabilitation program were given including the prone positioning in the

midst of the ongoing program. Each subject completed peak cough flow (PCF), peak flow rate (PFR), and

Spinal Cord independence Measure (SCIM) for respiratory function-interview based. Re-admitted chronic

SCI patients had exercise tolerance which put them at risk of pulmonary complications. A good exercise

tolerance will support the respiratory function by increasing vital capacity (VC), thus enhancing cough

ability as a protection of respiratory system. Prone position also has certain advantages that can still be

conducted by SCI patients in preserving respiratory capacity. Conclusions: Good exercise tolerance along

with good airway cleansing technique is an effective way to prevent complications of the respiratory system

in chronic SCI patients who must be in a prone position for a certain period of time.

1 CASE DIAGNOSIS

Case I, A 13-year-old female patient with chronic

phase of high paraplegia (T3) SCI is being admitted

to hospital due to multiple pressure sores and

anemia. Case II, H, 23-year-old male, suffered from

chronic SCI of lower thoracis (T9) re-admitted to

hospital due to DVT, multiple pressure sores, and

anemia. Both patients needed to be maintained in

prone position due to debridement and flap surgery

performed in treating existing multiple pressure

sores while rehabilitation program remains

continued.

2 CASE DESCRIPTION

Case I, A 13-year-old female patient with chronic

phase of high paraplegia (T3) SCI is being admitted

to hospital due to multiple pressure sores and

anemia, due to limited activity for past 1.5 years.

Patient had no history of pulmonary infection before

admitted to hospital. For the physical examination,

she has inadequate cough ability, and was found to

be low endurance cardiorespiratory due to inability

to maintain active upright position. One week after

admitted to hospital she had worsening anemia

which was thought to be due to worsening pressure

sores. She was then underwent a debridement and

flap surgery procedure. She had been doing active

rehabilitation consist of proper positioning,

breathing exercise with chest splinting, advanced

wheeling to increase cardiorespiratory endurance,

Putri, A., Widjanantie, S. and Pakasi, R.

Effects of Exercise Training on Forced Expiratory Flow in Individuals with Spinal Cord Injury with Prone Positioning: A Serial Case Report.

DOI: 10.5220/0009090503430346

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 343-346

ISBN: 978-989-758-409-1

343

and transfer techniques prior to surgery, but she was

unable to continue training due to worsening anemia

for the next 2 weeks. Blood cultures and wound

swabs were carried out, and she had been treated

with specific antibiotics. She was then scheduled for

debridement and flap surgery. After procedures, she

was ordered to be in prone position for at least 2

weeks. While in the prone position, she can only do

expiratory muscle training using Positive Expiratory

Pressure (PEP) device. PCF and PFR measurements

were taken prior to the exercise (baseline), before

the prone position (P1), and after the prone position

(P2). (table 1).

Case II, H, 23-year-old male, suffered from

chronic SCI of lower thoracis (T9) re-admitted to

hospital due to DVT, multiple pressure sores, and

anemia. Patient had no previous history of

pulmonary infections. After medically stable, he was

given training to improve cardiorespiratory

endurance. He was also scheduled for debridement

and flap surgery, and was ordered to be in prone

position for at least 2 weeks. Before being in a prone

position, the patient had gone through an upper

extremity strengthening exercise program and was

capable of wheeling advanced. PCF and PFR

measurements were taken prior to the exercise

(baseline), before the prone position (P1), and after

the prone position (P2). (table 1).

3 RESULTS

Exercises provided during the 6 weeks of hospital

treatment include proper positioning, breathing

exercise technique, respiratory muscles training,

upper limb strengthening include body weight lifting

exercise, aerobic exercise to increase

cardiorespiratory endurance, and transfer technique.

All exercises were tailored-made to patient’s needs.

Case I, patient had done very well for the first

two weeks, but entering the third week, patient had

fever and anemia, her pressure sore started to build a

tunnel around the first wound and actively bleed,

thus she had to stop exercising for a while. On the

fourth week, she had to do the debridement and flap

surgery that required prone position for at least 2

weeks after the operation was performed. At that

time, she still hadn’t been able to lift the body using

the upper limbs strength, thus she only did exercises

using positive expiratory pressure (PEP) device

started with 30% dose of maximal expiratory

pressure (MEP) with a gradual increase. The results

obtained were increase in PCF and PFR at week 4

(P1) and at week 6 (P2) . No increase in SCIM score

for management sphincter and respiratory (table 2).

In case II, patient had already had a good

exercise capacity before starting the regiments. the

patient was able to do exercise regimen in the first 4

weeks of treatment in the form of strengthening the

muscles of the upper limbs and cardiorespiratory

endurance, so that after debridement and flap

surgery on the fifth week and the patient is required

to be in a prone position, he was able to continue the

strengthening exercise regimen that has been done

before, although he has not been able to continue

aerobic exercise due to limited space. The results

showed, the patient had an increase in PCF and PFR

in the fourth week before the prone position (P1),

and at the end of the sixth week after the prone

position lasted for 2 weeks (table 1). No increase in

SCIM score for management sphincter and

respiratory (table 2).

Table 1: Results of Peak Flow Meter (PFM) at baseline,

before prone positioning (P1), after prone positioning

(P2).

Table 2: Results of Spinal Cord Independence Measure for

sphincter management – bowel at baseline, and post

treatment (S1 (S0)).

Subject

SCIM

Baseline

(S0)

Post

(S1)

Case I 10 10

Case II 8 8

4 DISCUSSION

Pulmonary complications remain a major cause of

morbidity and mortality in SCI population. Injury to

the upper and lower thoracic cord may disrupts

function of the intercostal muscles, accessory

respiratory muscles, and abdominal muscles.

Patients may have ineffective cough and difficulty

clearing secretions which in turn predispose to

mucus retention, atelectasis and pulmonary

infections, and ultimately to significant morbidity

and mortality.

Baseline

(l/m)

PCF PFR PCF PFR PCF PFR

Case

110 130 140 160 150 170

Case

350 360 420 400 480 460

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

Medicine and Rehabilitation Association

344

Ability to generate adequate cough is important

to protect respiratory functions in SCI patients. Peak

Cough Flow is the maximum flow recorded

immediately following opening of the glottis. This

leads to the rapid expulsive phase of a cough,

resulting from the sudden release of high intrapleural

and thoraco-abdominal pressures. To achieve a

functional PCF (to expectorate secretions) requires

at least 50% of vital capacity and sufficient thoraco-

abdominal pressure (in excess of 100 cmH

O) to

produce at least a flow of 270 l/m. In order to move

any mucus within the airways, PCF must exceed at

least 160l/m. Combination with sufficient expiratory

muscle strength is required to generate the required

thoraco-abdominal pressures (Anderson, 2005).

Both patients had been through rehabilitation

program for six weeks. The results corresponding to

the PCF and PFR before and after rehabilitation

program are described in Table 1. In case I, patient

experienced an increase in PCF and PFR during

active rehabilitation following training to improve

cardiorespiratory endurance, this is in line with

research by Houtte et al and Moro et al which

confirmed that respiratory muscle training tended to

improve expiratory muscle strength, vital capacity,

residual volume, and also increasing ventilation

efficiency in subjects with SCI (Moro et al, 2005).

She continues to train her expiratory muscles using

PEP. In case II, after the prone position is applied,

the patient is still able to do strengthening exercises

on the upper limb in the form of push up and weight

training for as long as 30 minutes/day, 5 days a

week. Patient wasn’t given training using PEP

because he have good PCF and PFR baselines (more

than 270 l/m).

Pulmonary function in SCI is mainly limited by

the weakness of respiratory muscles, therefore,

training of the remaining respiratory muscles in SCI

and the use of compensatory respiratory mechanism,

such as m. pectorals function for expiration may

improve pulmonary function (Houtte et al, 2006).

Prone position can also give benefit to respiratory

function by improving lung parenchyma mechanics

and arterial oxygenation, attenuating lung inflation

gradient, eliminating lung compression by the heart,

and make regional alveolar ventilation become more

homogenous resulting in reduction of alveolar

atelectasis and hyperinflation. Decreased atelectasis

and more uniform inflation may result in more

homogenous and increased average alveolar septal

tension (Metzelopoulos et al, 2005). The

gravitational gradient of intrapleural pressure is

suggested to be less in prone posture than supine.

Thus the gravitational distribution of ventilation is

expected to be more uniform prone, potentially

affecting regional ventilation-perfusion ratio

(Henderson et al, 2014).

In the supine position, there is predominance of

ventilation in the ventral area of the lung and

perfusion in the dorsal area of the lung, resulting in a

heterogeneous ventilation-perfusion ratio in various

lung areas. This is due to the influence of gravity on

the solid mass of the lung, pulmonary

vascularization and the transpulmonary gradient

associated with alveolar size. In contrast to the

pronation position, the solid lung mass and blood

flow are distributed to the ventral by the influence of

gravity, resulting in a more homogeneous

ventilation-perfusion ratio in the ventral and dorsal

areas so as to improve gas exchange and increase

oxygenation (Glenny et al, 2011).

Patients with prone positioning experience a

more even distribution of tidal volume because the

vertical gradient of pleural pressure becomes more

negative in the dorsal portion of the lung. In the

pronation position, the pressure from the heart and

the abdominal cavity also decreases so that the lung

volume in the dorso-caudal region increases (Glenny

et al, 2011).

In the supine position, the size of the alveolar

will become more heterogeneous, where the size of

the alveolar from the non-dependent (ventral) to the

dependent (dorsal) area of the lung will become

smaller, thereby increasing the risk of atelectasis in

the lung-dependent area. In contrast to the pronation

position, alveolar size in the lung dependent area

will be greater due to the Slingky effect on lung

tissue, thus, alveolar size will become more

homogeneous while reducing the risk of atelectasis

(figure 1) (Hopkins et al, 2015).

Figure 1: Slinky effect.

5 CONCLUSIONS

Good exercise tolerance is required to maintain

activities level needed by SCI patients along with

good airway cleansing technique to prevent

Effects of Exercise Training on Forced Expiratory Flow in Individuals with Spinal Cord Injury with Prone Positioning: A Serial Case Report

345

complications of the respiratory system in chronic

SCI patients.

Prone position turns out to have benefits for both

SCI patients in Case I and Case II. In Case I, there is

no episodes respiratory tract infections during

treatment in the hospital despite having a minimum

PCF and PFR limits to be able to do good airway

clearance. In Case II, patient was still able to carry

out exercise activities while in the prone position,

and showed increasing PCF and PFR which are the

reflection of improving airway clearance ability.

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Medicine and Rehabilitation Association

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