Effect of breathing exercises combined with dynamic upper extremity exercises on the pulmonary function of young adults

Abstract

BACKGROUND:

The abdominal muscles, upper extremities, and diaphragm work in synergy to maintain trunk stability during breathing.

OBJECTIVE:

This study aimed to investigate the effects of a breathing technique combined with dynamic upper extremity exercise on the pulmonary function of healthy adults.

METHOD:

Forty male participants in their 20s were recruited and randomly divided into two groups of 20 participants each: the experimental group performed a dynamic upper extremity exercise with breathing, and the control group only performed the breathing exercise. The experimental duration was 4 weeks, and both groups performed each training three times per a week. We performed pulmonary function test.

RESULTS:

Forced vital capacity increased significantly in both groups after the training period, but it was not significantly different between the two groups. Similarly, the forced expiratory volume at one second was not significantly different after training, but was significantly different between the two groups. In contrast, the peak expiratory flow did not show any significant within-group or between-group difference.

CONCLUSION:

Consequently, we came up with result that breathing exercise with dynamic upper extremity exercise improves pulmonary function. Our findings indicate that the breathing and dynamic upper extremity exercise described here should be considered in patients who require breathing therapy, since it seems to have beneficial effects on pulmonary function.

Keywords

Dynamic upper extremity exercise breathing exercise pulmonary function

1. Introduction

Unsupported arm exercise is considered as a respiratory muscle function-dependent activity that has greater dependence on the activation of inspiratory muscles (i.e., the diaphragm and accessory muscles) than other types of exercise [1]. The most recent guidelines on pulmonary rehabilitation recommend the inclusion of exercise training targeted at the muscles of the upper extremities in physical therapy programs specific to patients with chronic obstructive pulmonary disease (COPD); these guidelines are based on the results of previous randomized [2] and observational trials [3].

The muscles of the upper extremities along with the fascia surround most dorsal muscles of the trunk. Among these upper extremity muscles, the trapezius originates from the thoracic spine and the spinous processes of the occipital bone, cervical vertebrae and thoracic vertebrae, and surrounds the upper part of the dorsal trunk muscles. The latissimus dorsi surrounds the lower part of the back. The deep abdominal muscles, upper extremities including the shoulder girdle, and the diaphragm, are closely involved in breathing and the maintenance of stability.

Once movement of the upper extremity starts, the diaphragm increases abdominal pressure to achieve stability and thereby activates the abdominal muscles to affect the activity of the pelvic floor muscles [4]. The oblique, rectus abdominis, and transverse abdominis follow a specific pattern during movement of the upper extremity. That is, for movement of the distal upper extremity, the above muscles are activated first regardless of speed and direction [5]. Thus, it is not possible to perform a dynamic task with only single independent trunk muscle activity [6], and breathing and posture control are closely related and work in synergy during movement [7, 8].

Breathing exercises can improve the efficiency of respiratory muscles in patients with weak respiratory muscles [9] and improve motor ability. It can also help correct any difficulties in breathing and thereby improve the quality of life of the patients [10]. In recent years, studies on the abdominal drawing-in maneuver [11] and maximum expiration method of diaphragmatic respiration [12] have shown that these are effective methods for the activation of respiratory function and abdominal muscles. Breathing techniques with shoulder joint exercises have been reported to be more effective for improving abdominal muscle function than breathing techniques only [13]. Moreover, dynamic and resistant exercises of the upper extremities have been found to be effective for activating deep abdominal muscles, and abdominal muscle activity can be increased by fixing the pelvis [14]. In addition, the activity of deep abdominal muscles can be increased further by combining the activity of these muscles with movements of the upper or lower extremities in the distal part [4, 15]. However, very few studies have been conducted on the effect of breathing exercises with dynamic upper extremity exercises, including of shoulder girdle exercises on pulmonary function. Thus, the present study aims to determine the effect of breathing techniques with dynamic upper extremity exercise on pulmonary function.

2. Methods

2.1 Participants

This study included 40 male adults. The study group was randomly divided into two sub-groups of 20 participants each: one group was asked to perform breathing with dynamic upper extremity exercises (experimental group), while the other group was asked to practice only the breathing technique (control group). The exercise protocol in the experimental group was as follows: 10 min of warm-up exercise, 5 min of diaphragm breathing exercise and 25 min of breathing with dynamic upper extremity exercise, and 10 min of cool-down exercise. The protocol in the control group was as follows: 10 min of warm-up exercise, 5 min of diaphragm breathing exercise and 25 min of regular breathing exercise, and 10 min of cool-down exercise. The experimental duration was 4 weeks, and both groups performed each trainrng three times per week. The purpose of the study was explained to all the participants, who provided their written informed consent prior to participation, in accordance with the ethical principles of the Declaration of Helsinki.

2.2 Warm-up exercise

The warm-up exercise included light stretching (neck stretching, spinal twist, upper limb stretching, and wrist stretching) in the standing position for 8 min. This was followed by relaxation by placing the arms in a relaxed posture for 2 min while seated on a chair.

2.3 Breathing with dynamic upper extremity exercise

An elastic band was used in this exercise. An elastic band that provided 40% resistance for 1-repetition maximum during the breathing technique was selected [16]. Participants wear a band at the back, start upper extremity exercises, holding each end of band with both hands. The exercise protocol was as follows: while seated on a chair, the participant kept his feet shoulder width apart with the knee and hip joints bent at 90 ${}^{\circ}$ , with the face facing forward. The upper extremity exercise was a modification of the one proposed by Tarnanen et al. [14], and was in accordance with the objective of the present study. The protocol used in the present study involved dynamic upper extremity exercises along with breathing exercises. While seated on a chair, the subjects were asked to breathe in deeply through their nose for 3 s while expanding their diaphragm and abdomen (diaphragmatic breathing). This was followed by expiration with pulling in of the diaphragm and abdomen for 6 s; this movement was accompanied by a “sheee” sound [17]. During the 3-s inspiration phase, the participants prepared themselves for the upper extremity exercise, and they performed the upper extremity exercise during the 6-s expiration phase. This breathing with upper extremity exercise was performed for 25 min.

Table 1
Upper limb exercise (ULE)

Type	Upper limb exercise method
A	Bilateral horizontal adduction & elbow extension
B	Bilateral shoulder extention & elbow extension
C	Bilateral shoulder flexion & elbow extension
D	Bilateral shoulder adduction & elbow extension

Table 2

Mean and standard deviation (SD) of the balance each group (unit: L)

Parameters		Experimental group		Control group
		Pre	Post	Pre	Post
Pulmonary function	FVC	4.85 $\pm$ 0.60	5.26 $\pm$ 0.23 ${}^{*}$	4.59 $\pm$ 0.78	5.11 $\pm$ 0.33 ${}^{*}$
	FEV1 ${}^{\dagger}$	4.68 $\pm$ 0.50	4.73 $\pm$ 0.38	4.59 $\pm$ 0.75	4.36 $\pm$ 0.27
	PEF	9.60 $\pm$ 1.53	10.06 $\pm$ 0.24	9.30 $\pm$ 1.10	9.95 $\pm$ 0.37

Experimental group: upper limb exercise $+$ diaphragmatic breathing maneuver group. Control group: diaphragmatic breathing maneuver group. FVC: forced vital capacity, FEV1: forced expiratory volume at one second, PEF: peak expiratory flow. ${}^{*}$ significant difference between pre- and post-test ( $p<$ 0.05). ${}^{\dagger}$ significant difference compared with the control group ( $p<$ 0.05).

2.4 Diaphragm breathing exercise

The exercise protocol for this was as follows: while seated on a chair, the participant kept his feet shoulder width apart, with the knee and hip joint bent at 90 ${}^{\circ}$ , and the arms and hands placed comfortably on both legs.

In the same sitting position, the participants then performed the diaphragmatic breathing exercise described in the previous subsection (3 s of deep inspiration with expansion of the diaphragm followed by 6 s of expiration with shrinking of the diaphragm and abdomen) [17].

2.5 Cool-down exercise

For cooling down, the subjects walked on the treadmill at a 5% slope at a speed of 4.8 km/h for 10 min.

2.6 Pulmonary function test

Cardiotouch 3000 (Bionet, Korea) was used to measure the pulmonary function of the experimental and control groups. The measurement was obtained with the subjects in the seated position with the knee and hip joints bent at 90 ${}^{\circ}$ . Before the measurements were taken, the subjects were asked to breathe in and out three times normally. The participants were then asked to breathe in and out as quickly as possible by expanding their lungs completely each time with maximum effort. Once the above process was complete, the subjects were asked to push the “STOP” button to indicate that the measurement was complete. Forced expiratory volume at one second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF) were calculated using the measured data.

2.7 Statistical analysis

Demographic data, such as sex and age, were analyzed using an independent $t$ -test. The pre- and post-intervention data were examined using the paired $t$ -test for within-group differences and analysis of covariance for between-group differences. Analysis of covariance was used to control for any variance in the pre-test score. The pre-test score was considered as the covariate, the group was considered as the independent variable, and the post-test score was considered as the dependent variable. All statistical analyses were performed using PAWS 20.0 (SPSS Inc., Chicago, IL, USA), and $p<$ 0.05 was considered to indicate statistical significance.

3. Results

The patients in the experimental and control group did not differ significantly with regard to age, gender ratio, height, weight, and left and right grip strength. [male: 20, age: 23.62 years, height (cm): 176.46, weight (kg): 75.23, right grip strength (kg): 43.85, left grip strength (kg): 42.36] did not differ significantly from the control group [male: 20, age: 27.73 years, height (cm): 173.64, weight (kg): 71.12, right grip strength (kg): 44.63, left grip strength (kg): 42.82].

The post-test FVC was significantly higher than the pre-test FVC in both groups ( $p<$ 0.05), but it was not significantly different between the two groups at both time points. The post-test FEV1 was not significantly different from the pre-test value in the two groups, but was significantly different between the two groups at both time points ( $p<$ 0.05). Further, the PEF did not significantly increase after the protocols and was not significantly different between the two groups.

4. Discussion

The present study aimed to determine the effect of a breathing technique combined with dynamic upper extremity exercise on pulmonary function. The study results showed that FVC was significantly different in the experimental group before and after the experiment, but it was not significantly different between the two groups. Bach et al. reported that expansion of the thoracic cage and expiration through abdominal strengthening training resulted in an increase in FVC and PEF [18]. The significant increase in the experimental group was probably the result of an increase in muscle activity and abdominal muscle strengthening attributable to the dynamic upper extremity exercise, and the increase in forced expiratory flow was probably attributable to the diaphragm breathing exercise. Further, the study results showed that FEV1 was not significantly different within the groups before and after the experiment, but the change in FEV1 was significantly different between the two groups: the FEV1 had increased by 0.05 $\pm$ 0.28 L in the experimental group, while it had decreased by 0.02 $\pm$ 0.58 L in the control group. It is possible that the training period in the present study was not sufficient, as other studies [19, 20] have reported effective results after breathing training at a frequency of two to five times per week for 4–12 weeks.

A previous study demonstrated that the FVC value significantly increased after 8 weeks of upper body gravity resistance exercises and proprioceptive neuromuscular facilitation training [21]. This study that was in agreement with the above one reported statistically significant improvement in FVC but no change in FEV1. Further, in another study on the effect of breathing-enhanced upper extremity exercises on the respiratory function of patients with multiple sclerosis, a clear improvement in FEV1 and FVC was observed [22]. Singh et al. reported that the combination of upper body resistance training and conventional breathing exercises is safe and well tolerated, even in chronic smokers, and it is associated with a statistically significant improvement in FEV1 but no significant change in FVC [23]. These previous study results support the results of the present one.

The present study results showed that PEF was not significantly different within the groups before and after the experiment, and it was not significantly different between the two groups as well. PEF is determined physiologically based on the elasticity and compliance of the lungs, airway caliber, and expiratory muscles. It is possible that no significant increase in PEF was observed in the present study because all the participants were normal healthy adults. Moreover, although the PEF had increased in both groups, the difference was not significant. The reason for this was that the present study did not target pathological factors such as neurological diseases even though the exercise invloved expiratory muscle strength. However, a study by Bach et al. reported that expansion of the thoracic cage and expiration through abdominal strengthening training resulted in an increase in FVC and PEF [18].

Costa et al. reported that inversion of inspiration/ expiration could probably be an interesting strategy for respiratory exercises of the upper limbs that aim to minimize thoracoabdominal asynchrony in COPD patients [24]. Myers reported that muscle contraction in the distal extremities could affect muscle contraction of the distanced trunk, as contracted muscle force can be transmitted to other connected muscles and tendons through the originand-insertion: for example, the deltoid, which is involved with the movement of the shoulder joints in the deep back arm line, is connected to the trapezius muscle and thereby increases contraction of the transverse abdominis and the internal oblique by increasing contraction of the thoracolumbar fascia along the myofascial meridian [25]. This provides a basis for how this breathing technique when combined with dynamic upper extremity exercise affects pulmonary function. Therefore, this breathing technique with dynamic upper extremity exercise can be used for breathing training in the clinical field based on its positive effects on pulmonary functions.

The limitations of the present study are as follows: First, only a few motions were selected from the dynamic upper extremity exercise. Second, the training was conducted only over a short period, which may have affected its effectiveness. Third, the subjects were healthy adults in their 20s, so the results cannot be generalized to all patients. In the future, more studies with various other upper extremity motions are required, in order to determine the effect of these different motions on pulmonary function and respiratory muscle strength.

Footnotes

Conflict of interest

None to report.

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Effect of breathing exercises combined with dynamic upper extremity exercises on the pulmonary function of young adults

Abstract

BACKGROUND:

OBJECTIVE:

METHOD:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Methods

2.1 Participants

2.2 Warm-up exercise

2.3 Breathing with dynamic upper extremity exercise

Table 1 Upper limb exercise (ULE)

2.5 Cool-down exercise

2.6 Pulmonary function test

2.7 Statistical analysis

3. Results

4. Discussion

Footnotes

Conflict of interest

References

Table 1
Upper limb exercise (ULE)