Original article| Volume 91, ISSUE 6, P857-861, June 2010

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Expiratory Muscle Training in Spinal Cord Injury: A Randomized Controlled Trial


      Roth EJ, Stenson KW, Powley S, Oken J, Primack S, Nussbaum SB, Berkowitz M. Expiratory muscle training in spinal cord injury: a randomized controlled trial.


      To assess the effectiveness of expiratory muscle training on the pulmonary function of spinal cord injured patients.


      Randomized controlled trial.


      Acute inpatient rehabilitation hospital.


      Patients (N=29, 22 men and 7 women) with recent traumatic, motor complete, spinal cord injury (SCI) at or above level T1 consecutively admitted to an SCI rehabilitation service. Subjects were randomized to either resistance training (n=16) or sham training (n=13).


      The subjects completed either sham training or expiratory muscle resistive training with maximal expiratory force using a small handheld device, which is a tube with an aperture at the distal end, for 10 repetitions twice a day 5 days a week for a total of 6 weeks.

      Main Outcome Measures

      Pulmonary function tests were measured before and after the training program and included forced vital capacity (FVC); forced expiratory volume in 1 second (FEV1); maximum expiratory pressure (MEP), which is often referred to as forced expiratory pressure; maximum inspiratory pressure (MIP), which is often referred to as negative inspiratory force; inspiratory capacity (IC); expiratory reserve volume (ERV); total lung capacity (TLC); functional residual capacity (FRC); and residual volume (RV).


      FVC, FEV1, and ERV improved in both groups. Although exit values of MEP were improved in both groups compared with entry values, this increase was statistically significant only in the resistance training group. No significant improvements occurred in IC, TLC, FRC, or RV from entry to exit. MIP improved in both groups, but this increase was statistically significant only in the resistance training group. There was also a significant between-group difference in MEP exit values (98cmH2O for the resistance training group and 59cmH2O for the sham training group, t=3.45, P=.002). Multivariate analyses failed to reveal significant effects of treatment for any of the pulmonary function tests.


      The resistance training group had significantly greater exit MEP values than the sham training group in univariate analysis only. However, improvements in pulmonary function were noted in both the resistance training and sham training groups. Although multivariate analysis failed to reveal a significant difference between groups, these findings offer some indication that expiratory training may benefit people with SCI.

      Key Words

      List of Abbreviations:

      ERV (expiratory reserve volume), FEV1 (forced expiratory volume in 1 second), FVC (forced vital capacity), MEP (maximum expiratory pressure), PEFR (peak expiratory flow rate), SCI (spinal cord injury)
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        • Linn W.S.
        • Adkins R.H.
        • Gong H.
        • Waters R.L.
        Pulmonary function in chronic spinal cord injury: a cross-sectional survey of 222 Southern California adult outpatients.
        Arch Phys Med Rehabil. 2000; 81: 757-763
        • Brown R.
        • DiMarco A.F.
        • Hoit J.D.
        • Garshick E.
        Respiratory dysfunction and management in spinal cord injury.
        Respir Care. 2006; 51: 853-868
        • Baydur A.
        • Adkins R.H.
        • Milic-Emili J.
        Lung mechanics in individuals with spinal cord injury: effects of injury level and posture.
        J Appl Physiol. 2001; 90: 405-411
        • Roth E.J.
        • Lu A.
        • Primack S.
        • et al.
        Ventilatory function in cervical and high thoracic spinal cord injury: relationship to level of injury and tone.
        Am J Phys Med Rehabil. 1997; 76: 262-267
        • Spungen A.M.
        • Grimm D.R.
        • Lesser M.
        • Bauman W.A.
        • Almenoff P.L.
        Self-reported prevalence of pulmonary symptoms in subjects with spinal cord injury.
        Spinal Cord. 1997; 35: 652-657
        • Roth E.J.
        • Nussbaum S.B.
        • Berkowitz M.
        • et al.
        Pulmonary function testing in spinal cord injury: correlation with vital capacity.
        Paraplegia. 1995; 33: 454-457
        • Kim J.
        • Davenport P.
        • Sapienza C.
        Effect of expiratory muscle strength training on elderly cough function.
        Arch Gerontol Geriatr. 2009; 48: 361-366
        • Linn W.S.
        • Spungen A.M.
        • Gong Jr, H.
        • Adkins R.H.
        • Baumann A.
        • Waters R.L.
        Functional vital capacity in two large outpatient populations with chronic spinal cord injury.
        Spinal Cord. 2001; 39: 263-268
        • Uijl S.G.
        • Houtman S.
        • Folgering H.
        • Hopman M.T.
        Training of the respiratory muscles in individuals with tetraplegia.
        Spinal Cord. 1999; 37: 575-579
        • Wang A.Y.
        • Jaeger R.J.
        • Yarkony G.M.
        • Turba R.M.
        Cough in spinal cord injured patients: the relationship between motor level and peak expiratory flow.
        Spinal Cord. 1997; 35: 299-302
        • Jain N.B.
        • Brown R.
        • Tun C.G.
        • Gagnon D.
        • Garsick E.
        Determinants of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC in chronic spinal cord injury.
        Arch Phys Med Rehabil. 2006; 87: 1327-1333
        • Hopman M.T.
        • van der Woude L.H.
        • Dallmeijer A.J.
        • Snoek G.
        • Folgering H.T.
        Respiratory muscle strength and endurance in individuals with tetraplegia.
        Spinal Cord. 1997; 35: 104-108
        • Mueller O.
        • Perret C.
        • Spengler C.M.
        Optimal intensity for respiratory muscle endurance training in patients with spinal cord injury.
        J Rehabil Med. 2006; 38: 381-386
        • Van Houtte S.
        • Vanlandewijck Y.
        • Gosselink R.
        Respiratory muscle training in persons with spinal cord injury: a systematic review.
        Respir Med. 2006; 100: 1886-1895
        • Gounden P.
        Static respiratory pressures in patients with post-traumatic tetraplegia.
        Spinal Cord. 1997; 35: 43-47
        • Estenne M.
        • Knoop C.
        • Vanvaerenbergh J.
        • Heilporn A.
        • DeTroyer A.
        The effect of pectoralis muscle training in tetraplegic patients.
        Am Rev Respir Dis. 1989; 139: 1218-1222