Effect of Water-based Inspiratory Muscle Training on Lung Functions and Respiratory Muscle Strength in Parkinson’s Disease: A Longitudinal Study
Correspondence Address :
Priya Chauhan,
H-168, Block B, Gulmohar Complex, Sector-125, Mohali, Punjab, India.
E-mail: isicpriyachauhan1@gmail.com
Introduction: Water-based exercises are widely accepted exercises due to its acceptance and additional benefits from them. Exclusively, aquatic exercises are more advantageous than Land Exercises (LE), particularly in the early phase after rehabilitation for respiratory benefits.
Aim: To evaluate the efficacy of water-based inspiratory muscle training in respiratory muscle strength, lung functions and functional capacity in patients with Parkinson’s Disease (PD).
Materials and Methods: A longitudinal study was conducted on 30 participants with idiopathic PD, at Chandigarh University, Mohali, Punjab, India, between 50-65 years and in stages I-III (Modified Hoehn and Yahr Scale). Respiratory muscle strength was evaluated through inspiratory muscle training and functional capacity was evaluated with a 6-minute walk test. After the assessment, the participants were randomly assigned into two groups. Group A: Along with conventional exercise, water-based inspiratory muscle training was given to the population of this group. Group B: Along with conventional exercise, land-based respiratory muscle training was given to the population of this group.
Results: Mean age of group A was 69±6 years and group B was 69±4 years (p-value=0.90). As per statistical analysis using paired t-test, both the groups showed improvement from baseline in all the parameters {Forced Vital Capacity (FVC)%, Forced Expiratory Volume in one second (FEV1)%, Maximal Expiratory Pressure (MEP) (cmH2O)} after the intervention. When compared within the groups using independent sample t-test, there was statistically significant change seen in mean value of the parameters and group A was found to be better as compared to Group B.
Conclusion: The study revealed that water-based respiratory muscle training is safe and more effective intervention as compared to land-based exercise. Further, water-based intervention safely helps in improvement of inspiratory and expiratory muscle strength, pulmonary functions as well as for general body activity in patients with mild-to-moderate PD.
Forced vital capacity, Hydrotherapy, Maximum inspiratory pressure
Parkinson’s Disease (PD) is a progressive disorder of neurodegenerative changes having multifactorial aetiology, resulting from the degeneration of various dopaminergic neurons in the substantia nigra (1),(2). The various characteristics include the presence of multiple dysfunctions including Noradrenergic serotonergic and cholinergic system deficits. Medications used for the treatment of PD, found to alter the functions of cardiovascular, musculoskeletal, and respiratory systems due to decline in functional activity (3).
Reduced lung function, muscle strength, joint mobility, bone quality, and respiratory volumes are few secondary symptoms notes in PD. Respiratory system deteriorations are associated with osteoarticular degeneration postural remodelling and alteration in intercostal muscle tone which results in decreased chest mobility and range of motion (4). Changes due to restriction in respiratory function, lead to deterioration in the pulmonary ventilation. This further increases the risk of respiratory complications. The correlation of PD and respiratory dysfunctions is poorly understood; however, it has been proven that medulla oblongata, which is known to control respiratory depth and rate, may be affected during the initial neurodegeneration (5). All this results in a reduction in the levels of lung volume and ventilator function along with variability in inspiratory and expiratory muscle strength (5),(6). There may be obstructive, restrictive, or mixed alteration in pulmonary functions in PD. Respiratory muscle dysfunction is crucial in the depletion of lung functions, making individuals symptomatic with decline in tolerance for functional mobility or exercise (7).
In PD due to decline in physical activity/sedentary lifestyle, there occurs deterioration in physical function and functional capacity of lungs. Many studies have proved the effectiveness of water-based exercises in improving the balance, functional abilities, and gait pattern in various neurological disorders like cerebral palsy, PD and stroke however no study was conducted on patients suffering from PD (8),(9),(11),(12). So, this study aimed to find out whether water-based respiratory muscle training is better as compared to ground training in improving the respiratory function lung function for thoracic mobility and functional capacity in patients with mild to moderate PD.
Stage II indicates bilateral involvement without impairment of balance and
Stage III indicates mild to moderate bilateral disease some postural instability, physical independence.
The UPDRS (Unified Parkinson’s Disease Rating Scale) assesses parkinsonism disease related disability and impairment. The UPDRS composed of 42 items grouped under 4 subscales (16).
Respiratory muscle strength was evaluated through inspiratory muscle training and functional capacity was evaluated with a 6-minute walk test. Along with conventional exercise as prescribed by patient’s neurologist and the water-based inspiratory muscle training in group A and land-based respiratory muscle training in group B was done. In experimental group (group A), patients were encouraged to walk in the hydrotherapy pool, with water level till 4th intercostal space or above (17). The exercise intensity was adjusted to maintain the walking speed at 60% of the heart rate and the walking was continued for 40 minutes a day four times a week for four weeks. Heart rate was measured continuously using wrist-type pulsometer. The subjects were provided with proper outfit to carry out the hydrotherapy protocol.
In control group (group B), similar protocols were adopted and subjects were asked to perform this over a levelled ground for 40 minutes a day four times a week for six weeks.
Statistical Analysis
Data was analysed by using the Statistical Package for the Social Sciences (SPSS) version 20.0 for statistical analysis. Shapiro-Wilk test was used to assess the normality of the data distribution. As variables where shown to be parametric, student t-test was used to compare variables within each group and for comparisons between the groups paired t-test was used to analyse within group differences. A level of significance was set at p-value ≤0.05.
Mean age of group A was 69±6 years and group B was 69±4 years (p-value=0.90) (Table/Fig 1). There was significant change in FVC pretest and post-test (p-value=0.03) in group A and group B (p-value=0.01) (Table/Fig 2),(Table/Fig 3).
Group A showed significant improvement of FVC (%) (p-value=0.013), FEV1 (%) (p-value=0.04), MEP (cmH2O) (p-value=0.05) when compared with Group B (Table/Fig 4).
The present study noted the changes in the functional capacity of lungs with remarkable improvement in forced vital capacity in both groups. However, improvement was more with water-based training protocol as compared to the land-based Inspiratory Muscle Training (IMT) training patients. The present study results are in accordance to the result published by McNamara RJ et al., who concluded that water-based exercise training was significantly more effective than land-based exercise training in increasing peak and endurance exercise capacity in people with Chronic Obstructive Pulmonary Disease (COPD) (18),(19). In a systematic review conducted by De Brandt J et al., also concluded the importance of water-based exercises in comparison to land based to improve various parameters (20). Further, a systematic review with a meta-analysis of Randomised Control Trial (RCT) proved that respiratory muscle training to enhance ventilator function, FEV1, MIP, MEP, and respiratory muscle strength in subjects with Amyotrophic Lateral Sclerosis (ALS) and Multiple Sclerosis (MS), however there was no remarkable benefits in clinical condition, forced vital capacity and six minutes walk test noted with this intervention (19). A study by McNamara RJ et al., documented the remarkably high benefits of water based exercises in comparison to the land based exercise in enhancing the peak and endurance exercise capacity among subjects with COPD (19).
The physiological basis for the improvement in respiratory parameters in aquatic medium is explained by the mechanism by of hydrostatic pressure on the abdominal cavity, leads to elevate the diaphragm and to squeeze the lungs. Moreover, hydraulic pressure led to reduction in the thoracic compliance (21),(22). It is found that the chest wall circumference declines approximately by 0.8 cm with the aquatic pressure, due to water at clavicle level as compared to land (23). Further, expiratory muscle fatigue is instigated more by aquatic movement in comparison to land mobility. Moreover, it is found that the respiratory muscle strength and vital capacity decline with the water level rising above the umbilical level (14). Consequently, it is viewed that the strength of inspiratory muscles improves in the water since augmented pressure of water expands the thorax during inspiration. This can be the possible mechanism for the improvement of the parameters in water-based group (24),(25).
Limitation(s)
The present study was a preliminary investigation which involved small sample size. Further studies which involve higher sample size are needed to confirm these results. Furthermore, the duration of treatment was six weeks, might have been insufficient to promote an optimal response for various parameters for the participants. It remains unknown whether additional benefits can be obtained when this study is carried out with a longer treatment period. Future studies can be done to investigate the possible carry over effects of the therapy.
The result of the study concluded that water-based respiratory muscle training is safe and more effective intervention as compared to land-based exercise in improving inspiratory and expiratory muscle strength and pulmonary functions in patients with parkinsons disease.
DOI: 10.7860/JCDR/2022/49954.15880
Date of Submission: Apr 16, 2021
Date of Peer Review: Jun 09, 2021
Date of Acceptance: Sep 22, 2021
Date of Publishing: Jan 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No
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