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The respiratory program of the Spinal Injury Service at Rancho Los Amigos
Hospital has demonstrated effective respiratory treatment to be a prerequisite
for comprehensive rehabilitation. To facilitate program planning, patients are
classified according to functional neurosegmental levels and residual respiratory
muscles. Breathing mechanics are the basis of evaluation and treatment. Eval-
uative elements are strength of residual respiratory muscles, respiratory rate,
vital capacity, breathing pattern, chest expansion, and cough. Respiratory func-
tions of patients with spinal injury are compared with respiratory functions of
healthy subjects. Treatment objectives are prepared according to the individual
patient's functional classification and evaluation. Specific methods are dis-
cussed, including strengthening, chest wall mobilization, external support de-
vices, and bronchial hygiene.
Key Words: Spinal cord injuries, Breathing exercises, Respiratory therapy, Physical
therapy.
Rehabilitation of patients with paralytic respiratory culature and mechanics of breathing in patients with
involvement has had two historical phases. The first spinal injury. A functional respiratory classification
phase was a consequence of the paralytic sequelae of has been developed to represent neurologic levels of
poliomyelitis. During the polio epidemic, patients injury and the associated respiratory muscle pattern
were cared for in hospital centers in large metropoli- (Fig. 1). The major emphasis of physical therapy is
tan areas of the country. Massive efforts by many for the patients in Classes II through V. Class I
professionals engaged in the care of these patients patients are totally respirator dependent and Class VI
resulted in enormous clinical expertise. Thus we have patients have all respiratory muscles intact. However,
a legacy of evaluation and treatment techniques, patients in Class VI may have abnormal vital capac-
many of which can be used appropriately for patients ities secondary to pelvic floor muscle involvement.2, 3
with spinal cord injury. The second historical phase Great emphasis must be placed on the respiratory
in the development of rehabilitation of patients with care of patients with injury to cervical or high thoracic
paralytic respiratory involvement began in the early
1970s with the establishment of regional spinal cord
injury centers: patients with paralytic respiratory RANCHO LOS AMIGOS HOSPITAL
FUNCTIONAL RESPIRATORY CLASSIFICATION
problems are again receiving treatment in selected
centers across the country. The current treatment CLASS INSPIRATION EXPIRATION
approach combines the expertise learned in polio- DIAPHRAGM INTERCOSTALS NECK ABDOMINALS
Fig. 4. Contour of epigastric area of a patient with Class III respiratory function shown during a) relaxed expiration
and b) maximal inspiration.
Vital Capacity
provement of ventilation, 2) prevention of chest tight
Routine vital capacity measurements provide an ness, 3) improvement of cough force, and 4) preven
objective base-line for defining respiratory muscle tion of substitute breathing patterns that interfere
weakness.5, 10 This measurement can be used to mon with function.
itor a patient's progress and can be easily measured The treatment program used to accomplish the
with a handheld spirometer. Vital capacity is recorded stated goals includes: diaphragm reeducation and
as a percent of predicted value or as a volume (cubic strengthening, use of appropriate abdominal support,
centimeters).16 While the percent value is useful in chest mobilization, and bronchial hygiene including
most cases, the volume is an important measurement cough and bronchial drainage. This program is simple
in the patient with severe impairment. Inasmuch as and straightforward but requires careful monitoring
phasing a patient from use of a respirator is an and frequent reevaluation of the patient. Specific
individual process, the volume measurement provides techniques and considerations for each aspect of the
valid indication of progress. Any prior history of lung program are discussed separately.
disease is important to consider to make correct in
terpretations. Vital capacity should be determined Strengthening
with the patient in both supine and erect positions to
determine the effects of gravity. Initial vital capacity After evaluating the patient, the therapist should
measurements vary depending on the functional clas know the functional strength of the diaphragm. To
sification and range from less than 25 percent of train the patient to rely only on the diaphragm for
normal in Class II to 80 percent of normal for patients breathing, we have him do diaphragm strengthening
in Class VI (Table). exercises separately from neck strengthening.5, 16 Also,
any assistance from the neck accessory muscles is
TREATMENT initially discouraged while the diaphragm is being
strengthened.15 This precaution is common for Class
The overall treatment goals for patients with res II patients who use their neck muscles to assist a weak
piratory dysfunction from spinal injury are 1) im- diaphragm. The primary method of mobility for this
Fig. 5. Subject positioned with weights for diaphragm strengthening a) during relaxed expiration and b) attaining full
epigastric rise during inspiration.
Abdominal Support
Chest Mobility