ORIGINAL RESEARCH| Volume 103, ISSUE 7, P1303-1310, July 2022

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Inspiratory Muscle Performance Is Related to Seated Balance Function in People With Spinal Cord Injury: An Observational Study

Published:December 16, 2021DOI:



      To examine the relationship between inspiratory muscle performance (IMP) and functional sitting balance (FSB) in persons with chronic spinal cord injury (SCI). We hypothesized that a moderate correlation would be found between IMP and FSB and that individuals with better balance would have better IMP.


      The SCI-specific modification of the Function in Sitting Test (FIST-SCI) measured FSB. The IMP measures included (1) maximal inspiratory pressure (MIP), (2) sustained MIP (SMIP), and (3) inspiratory duration. Upper extremity motor score (UEMS) and level of injury (LOI) were taken from International Standards for Neurological Classification of Spinal Cord Injury examinations. Spearman correlational analyses assessed relationships among these factors in the sample (N=37). Mann-Whitney U tests explored differences between 2 comparison group pairs (tetraplegia group [TG] vs paraplegia group [PG]; independent transfer group [ITG] vs assisted transfer group [ATG]). Regression analysis examined variables predictive of FSB in the TG.


      Research facility.


      Volunteers with tetraplegia (n=21, American Spinal Injury Association Impairment Scale (AIS) A=8, B=7, C=6) and paraplegia (n=16, AIS A=9, B=4, C=3) (N=37).


      Not applicable.

      Main Outcome Measures



      UEMS, MIP, SMIP, and LOI had moderate to high correlations with FIST-SCI scores (ρ=0.720 (P<.001), 0.480 (P=.003), 0.467 (P=.004), 0.527 (P=.001), respectively). UEMS, MIP, and FIST-SCI scores were higher in the PG and ITG than the TG and ATG, respectively (PG vs. TG P values=<.001, .008, .002, respectively, and ITG vs. ATG P values=<.001, .032, <.001, respectively). Further, SMIP and UEMS predicted FIST-SCI balance scores in the TG, accounting for 55% of total variance (P<.001) (FIST-SCI=11.88+0.03 [SMIP]+0.425 [UEMS]).


      The relationship between IMP and balance appears preserved after SCI. FSB was predicted, in part, via UEMS and SMIP in the TG. Future research should focus on the effect of SCI-based breathing interventions on FSB.

      List of abbreviations:

      AIS (American Spinal Injury Association Impairment Scale), ATG (assisted transfer group), COPD (chronic obstructive pulmonary disease), FIST-SCI (Function in Sitting Test for individuals with spinal cord injury), FSB (functional sitting balance), IMP (inspiratory muscle performance), ITP (independent transfer group), LOI (level of injury), MIP (maximal inspiratory pressure), PG (paraplegia group), SCI (spinal cord injury), SMIP (sustained maximal inspiratory pressure), TG (tetraplegia group), UEMS (upper extremity motor score)


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        • Anderson KD.
        Targeting recovery: priorities of the spinal cord-injured population.
        J Neurotrauma. 2004; 21: 1371-1383
        • Arora T
        • Oates A
        • Lynd K
        • Musselman KE.
        Current state of balance assessment during transferring, sitting, standing and walking activities for the spinal cord injured population: a systematic review.
        J Spinal Cord Med. 2020; 43: 10-23
        • Bolin I
        • Bodin P
        • Kreuter M.
        Sitting position–posture and performance in C5-C6 tetraplegia.
        Spinal Cord. 2000; 38: 425-434
        • Bernard PL
        • Peruchon E
        • Micallef JP
        • Hertog C
        • Rabischong P.
        Balance and stabilization capability of paraplegic wheelchair athletes.
        J Rehabil Res Dev. 1994; 31: 287-296
        • Tsang WW
        • Gao KL
        • Chan KM
        • Purves S
        • Macfarlane DJ
        • Fong SS.
        Sitting tai chi improves the balance control and muscle strength of community-dwelling persons with spinal cord injuries: a pilot study.
        Evid Based Complement Alternat Med. 2015; 2015523852
        • Forslund EB
        • Jorgensen V
        • Franzen E
        • et al.
        High incidence of falls and fall-related injuries in wheelchair users with spinal cord injury: a prospective study of risk indicators.
        J Rehabil Med. 2017; 49: 144-151
        • Seelen HA
        • Potten YJ
        • Drukker J
        • Reulen JP
        • Pons C.
        Development of new muscle synergies in postural control in spinal cord injured subjects.
        J Electromyogr Kinesiol. 1998; 8: 23-34
        • Seelen HA
        • Potten YJ
        • Huson A
        • Spaans F
        • Reulen JP.
        Impaired balance control in paraplegic subjects.
        J Electromyogr Kinesiol. 1997; 7: 149-160
        • Hodges PW
        • Butler JE
        • McKenzie DK
        • Gandevia SC.
        Contraction of the human diaphragm during rapid postural adjustments.
        J Physiol. 1997; 505: 539-548
        • Hodges PW
        • Gandevia SC.
        Activation of the human diaphragm during a repetitive postural task.
        J Physiol. 2000; 522: 165-175
        • Hodges PW
        • Eriksson AE
        • Shirley D
        • Gandevia SC.
        Intra-abdominal pressure increases stiffness of the lumbar spine.
        J Biomech. 2005; 38: 1873-1880
        • Hodges PW
        • Gurfinkel VS
        • Brumagne S
        • Smith TC
        • Cordo PC.
        Coexistence of stability and mobility in postural control: evidence from postural compensation for respiration.
        Exp Brain Res. 2002; 144: 293-302
        • Hodges PW
        • Heijnen I
        • Gandevia SC.
        Postural activity of the diaphragm is reduced in humans when respiratory demand increases.
        J Physiol. 2001; 537: 999-1008
        • Kocjan J
        • Adamek M
        • Gzik-Zroska B
        • Czyzewski D
        • Rydel M.
        Network of breathing. Multifunctional role of the diaphragm: a review. Response to the letter to Editor of Prof. Bordoni.
        Adv Respir Med. 2017; 85: 292-293
        • Janssens L
        • Brumagne S
        • Polspoel K
        • Troosters T
        • McConnell A.
        The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain.
        Spine. 2010; 35: 1088-1094
        • Kocjan J
        • Gzik-Zroska B
        • Nowakowska K
        • et al.
        Impact of diaphragm function parameters on balance maintenance.
        Plos One. 2018; 13e0208697
        • Janssens L
        • Brumagne S
        • McConnell AK
        • et al.
        Proprioceptive changes impair balance control in individuals with chronic obstructive pulmonary disease.
        Plos One. 2013; 8: e57949
        • Janssens L
        • McConnell AK
        • Pijnenburg M
        • et al.
        Inspiratory muscle training affects proprioceptive use and low back pain.
        Med Sci Sports Exerc. 2015; 47: 12-19
        • Claxton AR
        • Wong DT
        • Chung F
        • Fehlings MG.
        Predictors of hospital mortality and mechanical ventilation in patients with cervical spinal cord injury.
        Can J Anaesth. 1998; 45: 144
        • McDonald T
        • Stiller K.
        Inspiratory muscle training is feasible and safe for patients with acute spinal cord injury.
        J Spinal Cord Med. 2019; 42: 220-227
        • Levine S
        • Nguyen T
        • Taylor N
        • et al.
        Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans.
        N Engl J Med. 2008; 358: 1327-1335
        • Smuder AJ
        • Gonzalez-Rothi EJ
        • Kwon OS
        • et al.
        Cervical spinal cord injury exacerbates ventilator-induced diaphragm dysfunction.
        J Appl Physiol. 2016; 120 (1985): 166-177
        • Como JJ
        • Sutton ER
        • McCunn M
        • et al.
        Characterizing the need for mechanical ventilation following cervical spinal cord injury with neurologic deficit.
        J Trauma. 2005; 59 ([discussion: 916]): 912-916
      1. Palermo AE, Janyszek E, Young A, Villane A, Kirk-Sanchez NJ, Cahalin LP, Nash MS. Inspiratory muscle performance and anthropometric measures—novel assessments related to pulmonary function in people with spinal cord injury: a pilot study. Arch Phys Med Rehabil; in press.

        • Rana S
        • Zhan WZ
        • Mantilla CB
        • Sieck GC.
        Disproportionate loss of excitatory inputs to smaller phrenic motor neurons following cervical spinal hemisection.
        J Physiol. 2020; 598: 4693-4711
        • Mueller G
        • de Groot S
        • van der Woude LH
        • Perret C
        • Michel F
        • Hopman MT.
        Prediction models and development of an easy to use open-access tool for measuring lung function of individuals with motor complete spinal cord injury.
        J Rehabil Med. 2012; 44: 642-647
        • Hopman MT
        • Dueck C
        • Monroe M
        • Philips WT
        • Skinner JS.
        Limits to maximal performance in individuals with spinal cord injury.
        Int J Sports Med. 1998; 19: 98-103
        • Ovechkin A
        • Vitaz T
        • de Paleville DT
        • Aslan S
        • McKay W.
        Evaluation of respiratory muscle activation in individuals with chronic spinal cord injury.
        Respir Physiol Neurobiol. 2010; 173: 171-178
        • Terson de Paleville DGL
        • McKay WB
        • Folz RJ
        • Ovechkin AV.
        Respiratory motor control disrupted by spinal cord injury: mechanisms, evaluation, and restoration.
        Transl Stroke Res. 2011; 2: 463-473
        • Abou L
        • Sung J
        • Sosnoff JJ
        • Rice LA.
        Reliability and validity of the function in sitting test among non-ambulatory individuals with spinal cord injury.
        J Spinal Cord Med. 2020; 43: 846-853
        • Boswell-Ruys CL
        • Sturnieks DL
        • Harvey LA
        • Sherrington C
        • Middleton JW
        • Lord SR.
        Validity and reliability of assessment tools for measuring unsupported sitting in people with a spinal cord injury.
        Arch Phys Med Rehabil. 2009; 90: 1571-1577
        • Jorgensen V
        • Elfving B
        • Opheim A.
        Assessment of unsupported sitting in patients with spinal cord injury.
        Spinal Cord. 2011; 49: 838-843
        • Lynch SM
        • Leahy P
        • Barker SP.
        Reliability of measurements obtained with a modified functional reach test in subjects with spinal cord injury.
        Phys Ther. 1998; 78: 128-133
        • Palermo AE
        • Cahalin LP
        • Garcia KL
        • Nash MS.
        Psychometric testing and clinical utility of a modified version of the Function in Sitting Test for individuals with chronic spinal cord injury.
        Arch Phys Med Rehabil. 2020; 101: 1967-1972
        • Raab AM
        • de Groot S
        • Berlowitz DJ
        • et al.
        Development and validation of models to predict respiratory function in persons with long-term spinal cord injury.
        Spinal Cord. 2019; 57: 1064-1075
        • Raab AM
        • Krebs J
        • Perret C
        • Michel F
        • Hopman MT
        • Mueller G.
        Maximum inspiratory pressure is a discriminator of pneumonia in individuals with spinal-cord injury.
        Respir Care. 2016; 61: 1636-1643
        • Boswell-Ruys CL
        • Lewis CRH
        • Wijeysuriya NS
        • et al.
        Impact of respiratory muscle training on respiratory muscle strength, respiratory function and quality of life in individuals with tetraplegia: a randomised clinical trial.
        Thorax. 2020; 75: 279-288
        • Ivanenko Y
        • Gurfinkel VS.
        Human postural control.
        Front Neurosci. 2018; 12: 171
        • Palermo AE
        • Cahalin LP
        • Nash MS.
        A case for inspiratory muscle training in SCI: potential role as a preventative tool in infectious respiratory diseases like COVID-19.
        Spinal Cord Ser Cases. 2020; 6: 87
        • Cahalin LP
        • Arena R.
        Novel methods of inspiratory muscle training via the Test of Incremental Respiratory Endurance (TIRE).
        Exerc Sport Sci Rev. 2015; 43: 84-92
        • Formiga MF
        • Vital I
        • Urdaneta G
        • Campos MA
        • Cahalin LP.
        Beyond inspiratory muscle strength: clinical utility of single-breath work capacity assessment in veterans with COPD.
        Respir Med. 2019; 147: 13-18
        • Bruton A.
        A pilot study to investigate any relationship between sustained maximal inspiratory pressure and extubation outcome.
        Heart Lung. 2002; 31: 141-149
        • Gorman SL
        • Harro CC
        • Platko C
        • Greenwald C.
        Examining the function in sitting test for validity, responsiveness, and minimal clinically important difference in inpatient rehabilitation.
        Arch Phys Med Rehabil. 2014; 95: 2304-2311
        • Gorman SL
        • Radtka S
        • Melnick ME
        • Abrams GM
        • Byl NN.
        Development and validation of the function in sitting test in adults with acute stroke.
        J Neurol Phys Ther. 2010; 34: 150-160
        • Gorman SL
        • Rivera M
        • McCarthy L.
        Reliability of the Function in Sitting Test (FIST).
        Rehabil Res Pract. 2014; 2014593280
        • Black LF
        • Hyatt RE.
        Maximal respiratory pressures: normal values and relationship to age and sex.
        Am Rev Respir Dis. 1969; 99: 696-702
        • Neder JA
        • Andreoni S
        • Lerario MC
        • Nery LE.
        Reference values for lung function tests. II. Maximal respiratory pressures and voluntary ventilation.
        Braz J Med Biol Res. 1999; 32: 719-727
        • Cahalin LP
        • Garcia C
        • Denis TS
        • et al.
        Normative values for the Test of Incremental Respiratory Endurance (TIRE).
        Am J Respir Crit Care Med. 2016; 193: A6363
        • Austin PC
        • Steyerberg EW.
        The number of subjects per variable required in linear regression analyses.
        J Clin Epidemiol. 2015; 68: 627-636
        • Chen CL
        • Yeung KT
        • Bih LI
        • Wang CH
        • Chen MI
        • Chien JC.
        The relationship between sitting stability and functional performance in patients with paraplegia.
        Arch Phys Med Rehabil. 2003; 84: 1276-1281
        • Sprigle S
        • Maurer C
        • Holowka M.
        Development of valid and reliable measures of postural stability.
        J Spinal Cord Med. 2007; 30: 40-49
        • Quinzanos J
        • Villa AR
        • Flores AA
        • Perez R.
        Proposal and validation of a clinical trunk control test in individuals with spinal cord injury.
        Spinal Cord. 2014; 52: 449-454
        • Dallmeijer AJ
        • van der Woude LHV.
        Health related functional status in men with spinal cord injury: relationship with lesion level and endurance capacity.
        Spinal Cord. 2001; 39: 577-583
        • Mateus SR
        • Beraldo PS
        • Horan TA.
        Maximal static mouth respiratory pressure in spinal cord injured patients: correlation with motor level.
        Spinal Cord. 2007; 45: 569-575
        • Gee CM
        • Williams AM
        • Sheel AW
        • Eves ND
        • West CR.
        Respiratory muscle training in athletes with cervical spinal cord injury: effects on cardiopulmonary function and exercise capacity.
        J Physiol. 2019; 597: 3673-3685
        • Wadsworth BM
        • Haines TP
        • Cornwell PL
        • Paratz JD.
        Abdominal binder use in people with spinal cord injuries: a systematic review and meta-analysis.
        Spinal Cord. 2009; 47: 274-285
        • Urmey W
        • Loring S
        • Mead J
        • et al.
        Upper and lower rib cage deformation during breathing in quadriplegics.
        J Appl Physiol. 1986; 60 (1985): 618-622
        • Nguyen DAT
        • Boswell-Ruys CL
        • McCaughey EJ
        • Gandevia SC
        • Hudson AL
        • Butler JE.
        Absence of inspiratory premotor potentials during quiet breathing in cervical spinal cord injury.
        J Appl Physiol. 2020; 128 (1985): 660-666