Effects of aerobic training combined with respiratory muscle stretching on the functional exercise capacity and thoracoabdominal kinematics in patients with COPD: a randomized and controlled trial

Figures & data

Table 1 Respiratory muscle stretching (treatment group)

Muscles	Positioning	Start position	Final position
aMajor pectoralis^Citation11	Supine decubitus	90° shoulder abduction with external rotation, 90° elbow flexion, and sternal stabilization	Maximum horizontal extension of the shoulder
Minor pectoralis^Citation9	Supine decubitus	Shoulder elevation with upper ribs stabilization	Maximum depression of third to fifth ribs
aUpper trapezius^Citation2	Supine decubitus	Neck contralateral rotation and lateral inclination with shoulder stabilization	Maximum neck flexion
aScalene^Citation11	Supine decubitus	Neck lateral inclination with shoulder stabilization	Maximum neck lateral inclination
aSternocleidomastoid^Citation11	Supine decubitus	Neck ipsilateral rotation and extension with manubrium stabilization	Maximum manubriumdepression
Intercostals and anterior serratus^Citation11	Lateral decubitus	Maximum shoulder abduction with lower ribs stabilization	Maximum lower ribs depression
Abdominal^Citation49	Prone decubitus	Both hands on the stretcher with elbow extension, extension of the trunk	Maximum extension of the trunk

Note:

a Exercises using the hold–relax technique.

Table 2 Upper and lower limb muscle stretching (control group)

Muscles	Positioning	Start position	Final position
Wrist flexors^Citation50	Standing	90° shoulder flexion and elbow supination. The contralateral hand supporting the palmar surface of the limb to be stretched	Maximum wrist extension
Wrist extensors^Citation50	Standing	90° shoulder flexion, elbow pronation. The contralateral hand supporting the dorsal surface of the limb to be stretched	Maximum wrist flexion
Ankle flexors^Citation50	Sitting	The limb to be treated crossed over the contralateral limb. One hand stabilizes the ankle and the other positioned on the dorsal surface of the foot	Maximum ankle extension
Ankle extensors^Citation50	Standing	Both hands against the wall and the lower limb to be treated in knee and hip extension with flexion of the ankle	Maximum ankle flexion

Table 3 Baseline characteristics of the study patients

Variables	CG	TG
Anthropometric data
Gender (M/F)	7/7	8/6
Age (years)	64±5.6	61±5.4
Height (m)	1.65±0.07	1.65±0.08
BMI (kg/m^2)	25.9±2.9	25.7±3.8
Pulmonary function
FEV1 (% pred)	42.6±9.5	45.9±15.5
FEV1/FVC ratio	0.49±0.09	0.56±0.13
Functional exercise capacity
6MWT (m)	439±103	473±68
BODE (I/II/III/IV; n)	3/5/3/1	6/6/2/0
Compartmental volumes (mL)
At rest
URC	94±54	100±44
LRC	49±37	63±42
ABD	295±114	268±117
During exercise with workload
URC	202±93	161±83
LRC	97±93	114±112
ABD	604±253	556±222
Inspiratory muscle activity (RMS, 10^−3 mV)
At rest
Sternocleidomastoid	0.010±0.01	0.011±0.01
Upper intercostal	0.008±0.01	0.009±0.005
Diaphragm	0.006±0.002	0.007±0.003
Rectus abdominis	0.007±0.001	0.007±0.002
During exercise with workload
Sternocleidomastoid	0.010±0.01	0.020±0.02
Upper intercostal	0.009±0.002	0.020±0.04
Diaphragm	0.013±0.01	0.010±0.01
Rectus abdominis	0.009±0.005	0.010±0.01

Note: Data are presented as mean ± standard deviation, except BODE which is expressed by the number of patients.

Abbreviations: ABD, abdominal; BMI, body mass index; BODE, Body-mass index, airflow Obstruction, Dyspnea, and Exercise; CG, control group; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; LRC, lower ribcage; M/F, male/female; 6MWT, 6-minute walk test; pred, predicted; RMS, root mean square; TG, treatment group; URC, upper ribcage.

Figure 1 Study flow diagram.

Abbreviations: CG, control group; TG, treatment group.

Figure 2 Effect of accessory respiratory muscle stretching on the thoracoabdominal kinematics during exercise.

Notes: Data are presented as mean ± standard deviation. The exercise was performed with 25% of the maximal predicted load according to Jones et al.²⁴ *P<0.05, CG vs TG (ANCOVA test).

Abbreviations: ABD, abdominal; ANCOVA, analysis of covariance; CG, control group; LRC, lower ribcage; TG, treatment group; URC, upper ribcage.

Figure 3 Effect of accessory respiratory muscle stretching on minute volume (A) and EF (B) during exercise.

Notes: Data are presented as mean ± standard deviation. The exercise was performed with 25% of the maximal predicted load according to Jones et al.²⁴ *P<0.05, CG vs TG (ANCOVA test).

Abbreviations: ANCOVA, analysis of covariance; CG, control group; EF, expiratory flow; TG, treatment group.

Figure 4 Effect of accessory respiratory muscle stretching on the rate of RC (URC and LRC) and ABD contribution during exercise.

Notes: Lower RC/ABD ratio values reflect an increase in ABD mobility.^30,31 Data are presented as mean ± standard deviation. The exercise was performed with 25% of the maximal predicted load according to Jones et al.²⁴ *P<0.05, CG vs TG (ANCOVA test).
Abbreviations: ABD, abdominal; ANCOVA, analysis of covariance; CG, control group; LRC, lower ribcage; RC, ribcage; TG, treatment group; URC, upper ribcage.

Figure 5 Effect of accessory respiratory muscle stretching on the total respiratory muscle activity divided by the CW volume (EMG/CW) during exercise.

Notes: Lower EMG/L reflects less respirator muscle activity per liter of breathed air.³² Data are presented as mean ± standard deviation. The exercise was performed with 25% of the maximal predicted load according to Jones et al.²⁴ *P<0.05 CG vs TG (ANCOVA test).
Abbreviations: ANCOVA, analysis of covariance; CG, control group; CW, chest wall; EMG, respiratory muscles electromyography; TG, treatment group.

Figure 6 Effect of accessory respiratory muscle stretching on the 6MWT performance.

Notes: Data are presented as mean ± standard deviation. According to Holland et al,²² the clinically significant difference is 33 m.

Abbreviations: CG, control group; TG, treatment group; 6MWT, 6-minute walk test.

Figure 7 Effect of accessory respiratory muscle stretching on the modified dyspnea scale (Borg) post-6MWT.

Notes: The data are presented as mean ± standard deviation. Borg, dyspnea scale. *P<0.05, CG vs TG (ANCOVA test).
Abbreviations: ANCOVA, analysis of covariance; CG, control group; 6MWT, 6-minute walk test; TG, treatment group.

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