Hold Relax Pectoral Stretch vs Inspiratory Muscle Training
Hold Relax Pectoral Stretch vs Inspiratory Muscle Training
Frailty is a clinical syndrome that alters the structure and function of respiratory system
 which causes stiffness of thoracic cage and reduces the chest wall compliance in addition of
 respiratory muscle weakness that can lead to the reduction of pulmonary function. The aim of
 this study was to compare the effect of inspiratory muscle training (IMT) and hold-relax
 pectoral stretch on pulmonary function (FVC, FEV1 and FEV1/FVC) among frail elderly
Aging leads to the biological and physiological changes in the human body but it is more
 pronounced in frail elderly. One of the body systems which will undergo changes due to aging
 is the respiratory system. Respiratory system changes can be in terms of mechanics, muscular
 and immunological aspects. These changes often lead to respiratory impairment or more often
 defined as spirometrically airflow limitation or restrictive- pattern. Aging will change the
 structure of thoracic cage, causing a reduction in chest wall compliance. Moreover, aging
 disease such as osteoporosis also causes stiffening of the thoracic cage and kyphosis. As a
 result, the ribcage is unable to expand and contract, causing difficulty in breathing. In
 addition, atrophy of skeletal muscles leads to increased loss of lean tissue. With the loss
 of lean tissue in the respiratory muscles, the pulmonary function of an elderly will
 subsequently be compromised. All these changes decrease the volume of the thoracic cavity and
 reduce lung volumes which leads to limitation of air flow, decrease of FEV1, FVC and FEV1/FVC
 as well as increase in residual volume and functional residual capacity. As a result, elderly
 will tend to have increased work of breathing compared to younger individuals.

 Other than that, immunological changes that occur in the elderly increases their risk of
 getting respiratory tract infection, leading to development of pulmonary disease such as
 pneumonia. In addition, elderly have higher exposure to second-hand smoke, toxin exposure
 from the environment which can predispose them to chronic obstructive pulmonary disease
 leading to dyspnea and alter the pulmonary function. All these changes can have a strong
 impact on morbidity, mortality and quality of life in elderly.

 As a person ages, observable changes can be seen in body composition and body phenotype.
 These changes will alter the structure and function of the respiratory system. Prevention and
 intervention programs are necessary to minimize the loss of respiratory function in order to
 reverse the progression of frailty condition. Exercises such as inspiratory muscle training
 (IMT) and hold relax pectoral stretch has been found to be helpful in strengthening the
 breathing muscles and improving pulmonary function respectively. Studies have shown that
 these two exercises will help in increasing the pulmonary function but till date there is no
 study which has been carried out to find the effectiveness of these 2 exercises on pulmonary
 function in frail elderly.

 A total of 34 residents from Seavoy Nursing Home were recruited after screening (excluded;
 bed ridden participants, not able to communicate and give their consent, suffering from a
 ruptured eardrum or any other condition of the ear, abnormally low perception of dyspnea,
 presence of cardiac pacemaker, unable to do overhead movement and hyper-mobility of
 shoulder). Based on the inclusion criteria, the participants needed to be above 60 years of
 age, currently residing in a care facility, a citizen of Malaysia, ability to understand
 Malay, English, Mandarin and Cantonese and able to score more than 16 out of 30 in Montreal
 Cognitive assessment (MoCA). Score of 16 and above on MoCA was to make sure participants were
 able to follow and understand the instructions given during testing and intervention. This
 was followed by assessment for frail criteria. At least 3 of the frail criteria; shrinking,
 weakness, poor endurance, slowness of gait, and low physical activity level needed to be met
 by participants. Questions such as body weight, height, losing weight, their daily physical
 activity, their endurance and power status by self reported exhaustion were asked. For
 shrinking, body weight and height were measured and compared to nursing homes past 1 year
 record. Participants with unintentional weight loss of 4.5Kgs or more from past 1 year were
 considered for this study. Weakness criterion was evaluated by checking the grip strength of
 the dominant hand with cut-off point for different BMI. Besides that, the poor endurance
 criterion was assessed using two statements of the CES-D scale: "I felt that everything I did
 was an effort" and "I could not get going" for much or most of the time, when asked. A low
 physical activity criterion was met if male scored less than 64 and female less than 52 on
 Physical Activity Scale for the Elderly (PASE). Besides the slow gait speed criterion was met
 if the participant took more than 10 seconds to walk back and forth over a ten-foot.

 After meeting all the inclusion criteria, participants were randomly divided into either into
 experimental group who did inspiratory muscle training or control group who did hold-relax
 pectoral stretch. Pulmonary function (FVC, FEV1, FEV1/FVC) were measured by spirometer in
 sitting upright position. A nose clip was used and participants were instructed to tightly
 securing the lips around the mouth piece of spirometer. A single trail was run to make sure
 participants know how to use the spiromter before actual test was conducted.

 For screening purpose, Montreal Cognitive assessment (MoCA) was used to evaluate the
 cognitive status. Physical Activity Scale for the Elderly (PASE) was used to evaluate the
 physical activity level of the elderly. Center for Epidemiologic Studies Depression Scale
 (CES- D) was used to evaluate the poor endurance and energy of the elderly. Dynamometer
 (Jamar hydraulic hand dynamometer) was used to measure the grip strength of the elderly to
 evaluate the weakness. Furthermore, Portable spirometer (MIR Spirobank II ®) was used to
 measure the outcome measures (FVC, FEV1, FEV1/FVC). Last but not least, IMT device
 (Respironics Threshold IMT) was used for inspiratory muscle training.

 34 participants were assigned into two groups; control group and experimental group. Each
 participant was supposed to complete a total of 12 sessions of exercises, 3 sessions per week
 for 4 weeks. In control group, the participants received 3 sets of passive hold- relax
 pectoral stretch for each session. Each stretch was maintained for 10 seconds with a rest
 period of 30 seconds given between the sets. Participants were in sitting position, shoulders
 held in abducted position with elbows flexed and both hand joined behind the neck. The
 subjects were asked to contract the agonist muscles and hold for 10 seconds while resistance
 was applied to the contraction.

 On the other hand, participants in the experimental group were given Inspiratory Muscle
 Training by using an IMT device (Respironics Threshold IMT). Participants were in Fowler's
 position. Based on the protocol of Inspiratory Muscle Training, a nose clip was used during
 the training. Participants were advised to inform the researchers and stop the exercise
 immediately if they felt dizziness or breathlessness. Before the training, participants were
 taught how to use the device and were instructed to use the correct breathing technique while
 using the device. For this training, the inspiratory load for each participant was set at 30
 cmH2O. During the protocol, researchers observed the participants for their facial expression
 to ensure that they do not breath forcefully to exhaust themselves. Verbal cue such as don't
 lift up the chest when doing the breathing exercise, use diaphragm to perform the exercise
 were given. Participants performed three sets of ten breaths with resting period of one
 minute between the sets.

 The primary outcome measure in this study was pulmonary function. The measures of pulmonary
 function were: Forced vital capacity (FVC), forced expiratory volume in one second (FEV1),
 FEV1/FVC. These were assessed by spirometry and expressed in litres. The measures were
 assessed with the participants in sitting position with the use of nose clip. A clear
 instruction was given to the participants to expire forcefully out into the disposable
 mouthpiece and after the machine provide a sound, the participants were asked to inspire
 forcefully from the disposable mouthpiece. A trail run was performed before running the
 actual test. The measurement of FVC, FEV1 and FEV1/FVC was evaluated before and after the
 intervention. Data was recorded in the data collection sheet. However, during this study
 there were 2 dropouts from experimental group who refused to continue the exercise after
 first week of intervention. There were also 2 dropouts from the control group as 1
 participant was discharged from the nursing home in the second week of the study and another
 one felt sick in the last week of intervention. Hence, data analysis was performed only for
 15 participants in each group.
Inclusion Criteria:

 -  Above 60 years of age

 -  residing in a care facility

 -  Able to score more than 16 out of 30 in Montreal Cognitive assessment (MoCA). Score of
 16 and above on MoCA was to make sure participants are able to follow and understand
 the instructions given during testing and intervention.

 -  At least 3 of the frail criteria (shrinking, weakness, poor endurance, slowness of
 gait, and low physical activity level)

 Exclusion Criteria:

 -  Low cognitive status (MoCA score less than 16)

 -  Suffering from a ruptured eardrum or any other condition of the ear

 -  Severe exacerbations , abnormally low perception of dyspnoea

 -  Presence of cardiac pacemaker

 -  Refusal to participate