|Year : 2014 | Volume
| Issue : 1 | Page : 44-51
Postural correction for kyphosis improves the dyspnea index and pulmonary functions in patients with chronic obstructive pulmonary disease: A randomized trial over 12 weeks
Gajanan S Gaude, Ravi Savadatti, Jyothi Hattiholi
Department of Pulmonary Medicine, J. N. Medical College, Belgaum, Karnataka, India
|Date of Web Publication||15-Apr-2014|
Gajanan S Gaude
Department of Pulmonary Medicine, J. N. Medical College, Belgaum 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Patients with chronic obstructive pulmonary disease (COPD) tend to attain forward shoulder posture and kyphosis and this affects their respiratory functions. Correcting this posture leads to straightening of the spine leading to improvement in the lung functions. The present study was carried out to evaluate the additional effect of correction of kyphosis in COPD patients. Objectives: The objective of the following study is to evaluate the effect of postural correction with respiratory muscle training in patients with COPD. Settings and Study Design: A randomized controlled prospective study in a tertiary care hospital in out-patients for 12 weeks. Materials and Methods: Confirmed cases of COPD were randomly divided into two groups by computer generated randomization: Study and control group. Study group patients received combination of respiratory muscle training and postural correction by a brace, whereas the control group received only respiratory muscle training exercises. The outcome measures evaluated were maximal inspiratory pressure, spirometry values, dyspnea scores and 6-min walk distance (MWD). Statistical Analysis: Statistical analysis was performed using Statistical Package for the Social Sciences version 16. Descriptive statistics are reported as means and standard deviation. Results: A total of 120 patients were included in the study with 60 in each group. Both groups showed a significant improvement in the inspiratory muscle strength, lung functions, dyspnea index and functional capacity at 8 weeks and 12 weeks of intervention. However, the interscapular distance, percentage of kyphotic index (KI) and grades of a plumb line (PL) measurement reduced significantly in the study group when compared to the control group (P < 0.01). There was also significant improvement in the 6-MWD and reduction of Borg scale of dyspnea when compared to the control group (P < 0.01). The pulmonary functions improvement was better in the study group after 12 weeks of therapy. Similarly, there was a significant reduction in KI % and PL grades in the study group as compared to the control group. Conclusions: The postural correction is a meaningful addition to pulmonary rehabilitation programs directed toward COPD patients in improving the overall quality-of-life.
Keywords: Chronic Obstructive Pulmonary Disease, Forward Shoulder Posture, Inspiratory Muscle Training, Kyphosis, Postural Brace
|How to cite this article:|
Gaude GS, Savadatti R, Hattiholi J. Postural correction for kyphosis improves the dyspnea index and pulmonary functions in patients with chronic obstructive pulmonary disease: A randomized trial over 12 weeks. Int J Health Allied Sci 2014;3:44-51
|How to cite this URL:|
Gaude GS, Savadatti R, Hattiholi J. Postural correction for kyphosis improves the dyspnea index and pulmonary functions in patients with chronic obstructive pulmonary disease: A randomized trial over 12 weeks. Int J Health Allied Sci [serial online] 2014 [cited 2021 Jan 23];3:44-51. Available from: https://www.ijhas.in/text.asp?2014/3/1/44/130615
| Introduction|| |
Chronic obstructive pulmonary disease (COPD) is the most common obstructive airway disorder. Global initiative for chronic obstructive lung disease (GOLD) defines COPD as a common preventable and treatable disease and is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and co-morbidities contribute to the overall severity in individual patients.  The diaphragm is the main inspiratory muscle. Patients with COPD have signs of decreased strength and endurance of the diaphragm due to the hyperinflation. This leads to flattening of the diaphragm that alters the length tension relationship of the muscle. Inspiratory muscles dysfunction contributes to dyspnea, decreased exercise capacity and ventilatory failure. For these reasons, inspiratory muscle training could be justified as a strategy with potential clinical benefit in patients with COPD who remain symptomatic, despite optimal therapy.  Since strong inspiratory muscles helps to decrease dyspnea, patients with COPD may benefit from inspiratory muscle training (IMT). Daily IMT sessions of 5-30 min duration and weekly training load increments of -2 to -4 cm H 2 O for 6-weeks with the threshold training device at loads of >30% of baseline maximal inspiratory pressure (PImax) has been shown to improve patients inspiratory muscle strength and decrease the dyspnea. 
Patients with advanced COPD, especially having predominant emphysema, have forward shoulder posture (FSP) (rounded shoulder posture). This posture is assumed due to the shortening of the pectoralis major muscle. Forward shoulder or rounded shoulder is one of the numerous deviations from the normal or standard posture.  Postural kyphosis is a flexible deformity which is not associated with any underlying bony abnormality. Patients with COPD will attain forward shoulders and kyphotic posture affects the respiratory function values.  Imbalance of musculature that results from tightness or weakness in these abnormal postures affects the lung volumes and capacities by reducing the ability to straighten the upper back, which in turn limits the ability to raise and expand the chest and maximize the lung capacity.  Ghanbari  in his study reported a reduction in Forced Vital Capacity (FVC) following an increase in the FSP. Physical and social outcomes of spinal kyphosis include an impairment of respiratory function and fatigability leading to decrease in exercise tolerance.  Posture is one of the components that is often over looked while rehabilitating the patients with COPD, hence there is a need to correct the posture in addition with respiratory muscle training (RMT). There is scarce data on whether an addition of posture correction to respiratory muscle training would provide additional benefits to that achieved by respiratory muscle training alone in COPD patients. Hence, the present study was carried out to evaluate the overall effect of postural correction and respiratory muscle training in patients with COPD.
To evaluate the effect of postural correction with respiratory muscle training on dyspnea, functional capacity and lung functions in patients with COPD.
| Materials and Methods|| |
The study was a prospective randomized trial done in a tertiary care hospital from January 2009 to December 2010. The randomization was done by computer generated method to avoid the selection bias. Patients in the age range of 40-70 years of either sex who are diagnosed cases of moderate to severe stable COPD (GOLD classification) by a physician and who are referred for pulmonary rehabilitation were taken for study. A total of 122 patients were included in the study. The sample size was calculated by using the formula N = 2(Z0α + Zβ) 2 × PQ/(Pa - Pb) 2 = 60 in each group, where Pa - 50%; Pb - 75%; Pa - outcome in the control group, Pb - outcome in the study group (percentage increase); α - 0.05; β - 0.8 (power of 80%); Z0α - 1.96; Zβ - 0.84; P = (Pa + Pb)/2; Q = 100 - P (20% extra included: 10% refusal by patients and 10% loss to follow-up).
The concealed envelopes were used to randomly allocate numbers generated by the computer to the patients to either respiratory muscle training (control group, n = 61), or RMT with postural correction group (study group, n = 61). This avoided any selection bias in randomization.
- Inclusion criteria: Patients with moderate to severe stable COPD (Stage 2, 3 or 4)
- Exclusion criteria: Associated conditions such as IHD, diabetes mellitus, HIV infection, COPD with respiratory failures, COPD patients on long-term oxygen therapy, COPD with complications like pneumothorax.
After briefing about the study an informed written consent from the patient was taken. The demographic data was collected and multiple outcomes were evaluated. Assessment of outcome measures was done on day one before intervention and at 8 weeks and at 12 weeks after intervention. The study was approved by the J. N. Medical College's Ethical Review Board.
This group received only respiratory muscle training which included: 
- Strengthening of inspiratory muscle
- Pursed lip breathing exercise to improve expiration
- Aerobic training to improve general body strength and endurance.
This group was received combination of respiratory muscle training (as mentioned above) and postural correction using a brace, which prevented and corrected the dorsal thoracic kyphosis and FSP.
Spirometry: The spirometry was done as per the ATS guidelines. 
Plumb line (PL) measurement: A PL was hung approximately 3 feet in front of a wall with the plumb bob approximately a quarter inch off the floor. The PL was made to fall just anterior to the lateral malleolus as this point was considered as a reference point for assessing posture in lateral view. The tip of the acromion process was marked with a skin marker. The distance from the tip of the shoulder and the PL was measured with a scale. For the purpose of analysis, forward shoulder was graded as normal or mild that is considered to be within normal limits or grade 1 that is measured from the center of landmark in line with or up to 1 cm anterior to the PL, moderate deviations or grade 2 is measured from posterior border of landmark in line with or displaced up to 1 cm anterior to the PL and severe or grade 3 is measured from posterior border of bony landmark displaced more than 1 cm beyond the PL. 
Interscapular distance (ISD) was measured in inches using an inch tape. The horizontal distance between T3 spinous process and the vertebral border of both the scapulae was measured in inches.
Kyphotic index (KI) measurement was done using a flex curve ruler of 60 cm. This instrument is a malleable ruler which retains the contour or shape of the spine when molded against the spinous process of the vertebral column. Initially, the subjects were asked to expose their spine and adopt their normal posture. The C7 spinous process was identified by asking the participant to bend the head down and palpating the first prominence in the midline at the lower end of the neck. This method of identifying C7 spinous process was given by Ensurd et al.  Skin marking on C7 spinous process and posterior superior iliac spine (PSIS) level was done. The flexi-curve ruler was pressed against their back with the top end placed against the 7 th cervical spine in the midline. The ruler was molded into the shape of the subject's spine in the midline to the level of the PSIS. The flexi-curve ruler was removed and the shape of the spine was then traced on a paper consisting of the horizontal line. The cervical end of the flexi cure was placed on the line and the distal end marked of the ruler was made to coincide with the other end of the horizontal line. The curvatures were then traced on the paper. Thoracic height (H) and thoracic length (L) was measured. The KI was calculated as thoracic height (H) divided by length (L), multiplied by 100 to get the reading in percentage. The larger the KI, the more marked is the kyphosis. 
Inspiratory muscle strength was measured by deriving PImax. PImax was measured with a Magnetic pressure gauge (No. 2000-200 cm) at residual volume according to the method of Black and Hyatt  with the highest pressure generated in five trials taken as PImax. Magnetic pressure gauge is a simple apparatus that consists of a well-fitting disposable cardboard mouth piece connected to a small plastic chamber to which a mechanical pressure gauge is connected through a rubber tube of 2 mm diameter. A small leak was done to the mouth piece that prevented the closure of the glottis during inspiration. The largest negative pressure sustained for 1 s on the pressure gauge was recorded.
The 6-min walk distance (MWD) was calculated as per the guidelines given by the American Thoracic Society.  Subjects were instructed to dress comfortably and avoid vigorous exercise or eating at least 2 h before the test. The subject's usual medical regime was continued; the required equipment for this test was collected prior to the test. The test was performed indoor, along a long flat, straight corridor with a hard surface that was not slippery. The walking course was of 30 m in length and the length of the walking course was marked at every 3 m. The turnaround point was marked with a visible orange cone.
The Borg scale was used to measure the sensation of breathlessness during various activities.  Borg's scale of dyspnea starts at number 0 where the breathing causes no difficulty at all and progresses through to number 10 where breathing difficulty is maximal. Prior to the intervention, the Borg scale, printed on a paper was shown to the patient. Later they were requested to grade their level of shortness of breath using this scale.
IMT was done using a pressure threshold resistive training device. The IMT device is a commercially available lightweight clear plastic cylinder (weight, 36.4 g; diameter, 4.06 cm) that contains a spring-loaded valve at one end and a mouthpiece on the other. Patients inhale through the spring-loaded threshold IMT device that provides resistance to inspiratory muscles. The valve in the device blocks air flow until the patient generates sufficient inspiratory pressure to overcome the resistance provided by the spring-loaded valve. The pressure settings are adjustable in –2 cm H 2 O increments (range, –7 cm H 2 O to – 41 cm H 2 O). The patient was asked to inspire hard enough through the mouth piece to open the valve and permit inspiration against that force. Nose clip were used to occlude nasal air flows.
Endurance program: Training was initiated with incremental exercise program to improve endurance through ambulating on the treadmill or static bicycle (60 revolutions/min). Treadmill exercise was started at a speed ranging from 1.1 to 2.0 miles/hour, 0% elevation for 20 min. When the patients could exercise for a continuous of 20 min, the speed and/or elevation was increased. Intensity of exercise was well within the target heart rate range (THRR) derived from Karvonen's formula, i.e. exercise heart rate (HR) or THRR = HR (rest) + 50-60% (HR max – HR rest). HR maximum was derived from graded exercise testing. A brief warm-up and cool down of 5 min each was done before and at the end of the aerobic training.
Breathing exercises: Patients were made to sit comfortably in a relaxed position and were educated for pursed lip breathing (PLB). The content of educational sessions was similar for all patients. It consisted of a talk delivered by the researcher on the benefits and the technique of PLB. Although sitting in a comfortable position, the patients with mouth closed, were asked to inhale through their nose for at least 2-3 s (with a closed mouth), then exhaled slowly for 4-6 s through pursed lips held in a whistling position. Then the patients were made to practice the technique. This exercise was done for 10 breaths, 4 times daily and also used when the patient was short of breath or performing activities such as stair climbing.
Postural correction procedure: Postural correction was done by bracing (Vissco postural brace). This brace is made from cotton knitted elastic fabric for upper thoracic region. Patient was asked to stand in the upright position, a postural brace that suited the patients size was taken for wearing. Instructions were given to patients about the procedure to wear the brace and to report if any discomfort was felt. Patient was asked to wear the brace throughout the day, except in the night while sleeping or lying down during day time or if any discomfort was felt. Patient was educated about the importance of the brace and to maintain an erect posture throughout the day.
All the patients visited the outpatient department every 15 days until the end of the study. The compliance was measured by taking into account their visit to the OPD. If they did not turn up on the stipulated day, the patients were contacted telephonically and they were reminded about the visit to the hospital. At the end of the rehabilitation program for 12 weeks, patients were re-evaluated for strength of the inspiratory muscles, exercise tolerance, level of dyspnea, spirometry and postural alignment. All the patients were continued on regular medications for COPD which included inhaled corticosteroids and long acting beta2 agonist (ICS and LABA), oral theophyllines and mucolytics.
All analyzes within the groups were carried out using Statistical Package for the Social Sciences version 16. Descriptive statistics are reported as means and standard deviation (SD). A repeated measures analysis of variance for each individual outcome measure time was performed to determine if there was any change in scores at 3 time periods within the groups. The repeated measures of time were baseline, 4 weeks post-intervention and 3 months post-intervention. The data was tested using the Greenhouse-Geisser correction to determine if significant differences existed between conditions. For significant main effects, post-hoc pair-wise comparisons were performed between levels using-t tests with a modified Bonferroni procedure. Significance was set at P < 0.05 (at 95% confidence interval for the mean difference). In between group comparison was carried out using (independent 't' test).
| Results|| |
A total of 122 patients were initially enrolled in the study, but two patients were excluded in the final analysis as they did not follow-up regularly until the end of the study. Hence, the final analysis is done for 120 patients. The baseline characteristics of the 120 patients (60 in each group) are shown in [Table 1]. Patients with mild-to-moderate airflow obstruction with a mean age of 52.83 ± 4.64 in the control group and 54.12 ± 4.44 years in the study group were given intervention. Baseline characteristics were identical in the two groups. The postural assessment, pulmonary function and demographics of the two groups were well-matched with no significant difference for any variable between groups. Within group comparison from baseline to 4 weeks and 12 weeks was done for both groups and are shown in [Table 2] and [Table 3]. The means and standard deviations for ISD in the control group at baseline, 4 weeks and 12 weeks were identical at 5.38 ± 0.78. Similarly the percentage of means and standard deviations for KI (%) in the control group at baseline, 4 weeks and 12 weeks (11.18 ± 0.96, 11.18 ± 0.96 and 11.17 ± 0.95%, respectively) are shown in [Table 2]. The repeated measures analysis of variance (ANOVA) for the KI (%) scores in the control group revealed no significant difference F (1.17, 69.26) = 1.2890, P = 0.2670 among 2 time periods. The percentage means and standard deviations for KI in the study group at baseline, 4 weeks and 12 weeks (11.29 ± 0.86, 10.36 ± 1.01 and 10.82 ± 0.93%, respectively) are shown in [Table 3]. The repeated measures ANOVA for the KI (%) scores in the study group revealed a significant difference F (1.76, 103.86) = 212.93, P < 0.0005 among 2 time periods. A post-hoc pair-wise t test showed means of KI (%) for all 3 time periods (at baseline, 4 weeks and 12 weeks post-intervention) were significantly different from one another (P < 0.0005) [Table 3].
|Table 2: Group comparison of various parameters at baseline and at 12 weeks of study period |
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|Table 3: Comparison of different parameters in two groups after 12 weeks of intervention (independent 't' test) |
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Postural assessment was done by measuring the ISD, KI and PL. There were highly significant changes (t = 5.78, P < 0.01) in all three values of postural assessment between the groups. Study group with postural correction along with RMT showed highly significant reduction in ISD, KI and PL measurement (P < 0.01). The mean values of ISD, KI and PL in control group were 5.38 ± 0.78 in. (confidence interval [CI] 5.2; 5.6), 11.18 ± 0.96% (CI 10.9; 11.4) and 2.28 ± 0.72 (CI 2.1; 2.5) respectively, while in study group it was 4.69 ± 0.50 in. (CI 4.6; 4.2), 10.36 ± 1.01% (10.1; 10.6) and 1.55 ± 0.62 (1.4; 1.7) respectively.
Similarly, there was significant changes (t = 19.83, P < 0.01) for 6-MWD between the groups. Study group showed more improvement in the distance walked when compared with control group. The mean distance walked in control group was 312.9 ± 16.94 m (CI 308.5; 317.3), while in study group it was 373.07 ± 16.57 m (CI 368.8; 377.3). The level of exertional dyspnea significantly improved in the study group (t = 2.27, P < 0.05) indicating an overall improvement in dyspnea. The mean scores of dyspnea in the control group was 2.90 ± 0.80 (CI 2.7; 3.1) and study group was 2.53 ± 0.96 (CI 2.3; 2.8). Both the groups showed gradual improvement in pulmonary function test values (FVC, FEV 1 and FEV 1 /FVC ratio) during the 12 weeks intervention program. The between-group difference was highly significant with P < 0.01 for all three variables (t = –3.13, 4.65 and 4.57 for FVC, FEV 1 and FEV 1 /FVC ratio respectively) [Table 2]. The study group showed better improvement than the control group with a mean difference for FVC as 0.24, FEV 1 as 0.26 and FEV 1 /FVC as 2.66. Maximal voluntary ventilation in study group showed significant improvement (t = –2.32, P < 0.05) when compared to control group.
The strength of inspiratory muscles as measured by PImax was significantly more (t = –2.08, P < 0.05) in the study group as compared to control group. The mean scores of the control group was 91.58 ± 17.21 cm H 2 O (CI 87.1; 96) and the scores for study group was 98 ± 16.52 cm H 2 O (CI 93.7; 102.3).
| Discussion|| |
A total of 120 patients with COPD were prospectively included in the study. The intervention was given for a period of 12 weeks. Patients diagnosed to have COPD were randomly allocated in both groups. This study shows a comparison between a study group receiving postural correction and respiratory muscle training while the control group receiving only respiratory muscle training in patients with chronic obstructive pulmonary disease.
The major findings of this study was that an addition of postural correction along with the regular respiratory muscle training as a part of the pulmonary rehabilitation program led to not only correction of posture, but had additional improvements in inspiratory muscle strength, dyspnea scores, functional capacity and pulmonary function in patients with COPD.
Postural abnormality was assessed by measuring ISD, percentage of kyphotic index (KI%) and PL measurement. Spinal kyphosis causes impairment of respiratory function and fatigue leading to decrease in exercise tolerance, thus affecting activities of daily living. Gosselink et al.  in their study have reported that respiratory muscle dysfunction is attributed to multiple factors related to the presence and severity of COPD. Indeed, intrinsic (muscular and metabolism mass) as well as extrinsic factors (changes in chest wall geometry and diaphragm position and systemic metabolic factors) may alter respiratory muscle function. There was a significant reduction of ISD in between the two groups after 12 weeks of intervention. Similarly, the within group comparison showed no change in the mean KI% of the control group from baseline to 12 weeks of intervention (P > 0.05). The study group showed a significant reduction from 11.3 ± 0.8% to 10.8 ± 0.9% (8.3%) at the end of 12 weeks of intervention (P < 0.001). The use of brace in the study group had played a role in reducing the degree of kyphosis and straightening the spine in patients with COPD. Kendall et al.  has reported that bad posture or weakness of upper back erector spine, middle and lower trapezius muscle interferes with the ability to straighten the upper back, thus limiting the ability to raise and expand the chest and maximize the lung capacity. Hence, we assume that the brace would have played a role in straightening the spine and increasing the lung volume and capacities in patients with COPD. There was a highly significant reduction of the PL measurement in the study group when compared with the control group at 12 weeks of intervention (P < 0.01). With 12 weeks of intervention by the postural brace, the study groups showed significant improvement in posture with reduction of intra scapular distance by 12.1%, KI by 8.3% and PL by 39.5% as compared to the control group that did not receive any postural correction. A pilot study  has shown that there was highly significant correction of posture and inspiratory muscle strength following 8 weeks of intervention and 3 months of follow-up with brace therapy in COPD patients (P < 0.01).
Respiratory muscle weakness may contribute to dyspnea and poor exercise performance. Therefore, it is rational to try respiratory muscle training in these patients, to enhance respiratory muscle function and potentially reduce the severity of breathlessness and improve exercise tolerance.  Reduced inspiratory muscle strength is common in patients with COPD and is associated with dyspnea and decreased exercise capacity. Inspiratory muscle training in patients with COPD has demonstrated increased inspiratory muscle strength.  A study by Larson  reported that in patients with COPD, the intensity of aerobic training is limited by dyspnea. Improving the strength of the inspiratory muscles could enhance aerobic exercise training by reducing exercise-related dyspnea. Reid et al.  has observed that endurance exercise involving lower extremities along with inspiratory muscle training had an added benefit in patients with COPD. Gosselink et al.  reported that in patients with COPD having inspiratory muscle weakness, the addition of inspiratory muscle training to a general exercise training program improved (PImax) and tended to improve exercise performance. In the present study, the FVC, FEV 1 , FEV 1 /FVC and PEF showed significant improvement within the groups after 12 weeks of intervention (P < 0.01). In between group comparison showed significant difference between the groups (P < 0.01) in FVC, FEV 1 , FEV 1 /FVC and PEF (P < 0.05) after 12 weeks of training, however, the study group showed highly significant improvement in FVC, FEVI and PEF (P < 0.01). Emery et al.  showed significant improvement in FVC following aerobic training for 30 days (P < 0.001). The FVC values improved from 2.79 ± 0.85 to 2.93 ± 0.72 L in male patients and in female patients, the FVC values improved from 1.74 ± 0.40 to 1.98 ± 0.43 L. Similarly, Hsieh et al.  reported significant improvement in FVC (2.47 ± 0.70-2.70 ± 0.62 L, P = 0.024) at rest following 6 weeks of high-intensity exercise training in a pulmonary rehabilitation program for patients with COPD. In the present study, the mean value of FVC from baseline to 12 weeks improved from 2.27 ± 0.26 L to 3.08 ± 0.38 L (35.7%) in the control group, while in the study group, FVC improved from 2.24 ± 0.23 L to 3.32 ± 0.46 L (47.8%) (P < 0.01). The mean improvement in FVC in the control group after 12 weeks of intervention was 0.81 L, while in the study group it was 1.08 L. Emery et al.  showed significant improvement in FEV 1 following aerobic training for 30 days (P < 0.001). The FEV 1 values improved from 1.20 ± 0.60 L to 1.24 ± 0.59 L in male patients and in female patients, FEV 1 values improved from 0.78 L ± 0.20 to 0.87 ± 0.25 L.
The mean value of the PImax or MIP from baseline to 12 weeks of intervention was 59.58 ± 11.47-91.58 ± 17.21 (53.7%) cm H 2 O in the control group, while in the study group it was 59.75 ± 11.55-98 ± 16.52 (64.0%) cm H 2 O (P < 0.01). Similarly, when in between group comparison was carried out, there was significant difference observed in-between the groups (P < 0.05), with the study group showing an improvement of 10.3% greater than the control group. Lisoba et al.  reported that, with 5 weeks of inspiratory muscle training with a threshold loading device, there was a 34 ± 11% improvement in the PImax. In the present study, the improvement in the study group was 64% and that of control group was 53.7% following 12 weeks of intervention. Larson et al.  reported an increase in PImax by a mean of 12 ± 9 cm H 2 O following one month of inspiratory muscle training using a threshold device (threshold inspiratory muscle training device) at an intensity of 30% PImax. In agreement with the previous studies, ,, our study confirms that the magnitude of the load used for inspiratory muscle training is a critical determinant of the results in patients with COPD and is key in achieving training effect. A targeted pressure or load of at least 30% of MIP or PImax can give a desirable effect in improving inspiratory muscle strength. Inspiratory muscle training (IMT) of 5-30 min duration and weekly training load increments of -2 to -4 cm H 2 O over a 6-week period with the training device at loads of >30% of baseline PImax improves patient's inspiratory muscle strength and reduces dyspnea. 
The major findings of this study were that an addition of postural correction along with the regular respiratory muscle training as a part of the pulmonary rehabilitation program led to not only correction of posture, but had an additional improvements in inspiratory muscle strength of the study group that received a combination of treatment (i.e. postural correction and respiratory muscle training). From the present study, it can be stated that postural correction along with respiratory muscle training is a meaningful addition to pulmonary rehabilitation programs directed at COPD patients with inspiratory muscle weakness and faulty posture.
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[Table 1], [Table 2], [Table 3]