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A Study on Efficacy of Respiratory Exercises Coupled with Neuro Developmental Treatment on Pulmonary Function of Children with Spastic Quadriplegic Cerebral Palsy.

Cerebral palsy is a group of condition characterized by motor dysfunction due to non-progressive brain damage early in life. Along with motor dysfunction, children with cerebral palsy can have abnormality of respiratory function such as poor airway clearance, decreased chest wall mobility, respiratory muscle weakness and lung distensibility.

Prevalence of cerebral palsy is in the range of 1.5 to 2.5 per 1000 live births. The rate is higher in males than in females. It is 1.3 times more common in males, 8 to 10 % of the cases are due to perinatal damage, while genetic factors contribute to 2% of the cases, birth asphyxia, especially a prolonged one, increases the risk of cerebral palsy, accounting for about 10% of the cases, preterm birth and underlying pathological lesions, such as periventricular hemorrhage; venous infarcts are also contributory.

Children with cerebral palsy breath in a poorly coordinated fashion, relying on the abdominal muscle instead of the chest muscles, eventually movement of the chest is restricted and the chest muscles weaken resulting in reduced expansibility of the lungs, as a result the ability to take a larger breath is impaired.

Normal breathing is slow, regular, nasal only, diaphragmatic, invisible and inaudible consisting of a small inhalation and relax for the exhalation and the exhalation is followed by an automatic pause of about 2 seconds. Normal breathing at rest is about 18-30 breaths per minute. Children with Cerebral Palsy breath more slowly when compared to normal children, and at rest the phase of their respiratory muscle activity appears to be different. In healthy children, the maximal activity of the abdominal muscles occurred later after maximal chest expansion, whereas in children with Cerebral Palsy, abdominal muscle activity occurred earlier, due to decreased firing of muscles of the chest. Normal breathing is not just a matter of inhaling the good air and exhaling the bad used air, the entire respiratory parameters such as rate, depth, timing; pattern and consistency of breath are all important to the delicate balance of respiratory and metabolism.

Children with Cerebral Palsy who have respiratory problems show a poorly coordinated pattern of respiratory muscles, shallow and low breathing volume, and decreased cardiopulmonary capacity. All the factors increase the risk for respiratory complications such as recurrent pneumonia, atelectasis; bronchiectasis, chronic obstructive and restrictive lung disease in these children. Respiratory dysfunction is known to be a leading cause of death among children with Cerebral Palsy. However respiratory dysfunction in children with Cerebral Palsy has not been well studied, possibly due to difficulty in testing the respiratory parameters as the child will not cooperate for it.

Young Hyun et al in their study concluded that understanding respiratory functional level of children with Cerebral Palsy will be important for clinical assessment and therapeutic intervention. Respiratory training may improve the respiratory functional level of the children with Cerebral Palsy.


Study design: Experimental study

Sample Size: 30

Group A Control Group--15 Nos

Group B Experimental Group--15 Nos

Sampling method: Convenient sampling (Random Sampling)

Study setting: NIEPMD Special school

Study Duration: 6 weeks

Inclusion criteria

Children with spastic quadriplegic Cerebral Palsy

1. Age of children ranging between 6-14 years of both gender.

2. Children who could understand and follow commands given by the therapist

3. Children who were able to sit independently or with support using assistive devices

4. Children who blow air independently

Exclusion criteria

1. Children with spastic diplegia; athetoid; ataxic; flaccid Cerebral Palsy

2. Children with impaired cognitive function

3. Children who received any recent surgical procedures or botulinum toxin injections

4. Convulsion


* Computerised spirometer

* Computer

* Weighing machine

* Incentive spirometry


Dependent variable: Pulmonary function test

Independent Variable: Respiratory exercises; Neuro Developmental


Outcome measure

1. FVC

2. FEV1

3. FEV1/FVC Ratio

4. PEF


From the special school of NIEPMD, 30 children with spastic quadriplegic Cerebral Palsy who met the inclusion and exclusion criteria was selected. They were randomly allocated into 2 groups. Group A (Control group) consists of 15 participants who were given Neuro-developmental Treatment and general movements for 45 minutes (30 min and 15 min), 5 days in a week for 6 weeks. The exercise program follows the basics principles of Neuro-developmental therapy such as key points of control, handling methods; facilitatory and inhibitory techniques. And general movements include moving of shoulders, rotation exercises and elbow movements. Group B (Experimental Group) consists of 15 participants who were given Neurodevelopmental treatment along with Respiratory Exercises for 45 minutes (30 min and 15 min), 5 days in a week for 6 weeks. Respiratory Exercises includes breathing exercises, Active shoulder/ shoulder girdle ROM exercises; Diaphragmatic breathing exercise; thoracic expansion exercise and incentive spirometry. Informed consent is obtained from the parents of the participants. Pre and post values of FVC, FEV1, FEV1/FVC % and PEF were obtained using pulmonary function tests and were taken statistical analysis.

Data analysis

The outcome values obtained were tabulated in Microsoft Excel 10 spread sheet, and were exported to SPSS statistics 20.0 version for windows 7 for statistical analysis.

The effects of the intervention on the changes from pre to posttest values in both groups were analyzed using Paired 'T' test for within group analysis and independent sample 'T' test for between group analyses.

The P value was chosen as per the description given by SPSS statistics for windows 7 ultimate version.


The study was done on 30 subjects who consists of 15 subjects in each group with the duration of 6 weeks intervention.

Mean value of independent variable before the pretest an post test of FEV1, FVC, PEF & FEV1 /FVC % values of Respiratory Exercises with Neurodevelopmental treatment (NDT) shows significant difference in improvement.

Paired-t test value of pretest and post test of FEV1 & FVC shows very significant in experimental group.

Paired-t test value of pretest and post test of FEV1/FVC %& PEF shows significant in experimental group.

The results on analysis between groups on improvement of FVC, FEV1, FEV1/FVC% & PEF shows significant improvement by independent sample t test value (p<0.05).


The results of our study have shown that Respiratory Exercises along with NDT helps in improving the expansibility of lungs in experimental group when compared to NDT program alone. The improvement in lung function is documented by significant difference in respiratory parameters noted in pulmonary function test. Although NDT program has been widely used as conventional method of treating clients with cerebral palsy, Respiratory exercises when added with NDT program showed significant changes in respiratory function. Respiratory function is vital to the maintenance of cellular metabolism for maintenance of life. Recent studies suggest that children with cerebral palsy show respiratory dysfunction due to multiple neuromuscular symptoms such as paralysis of respiratory muscles, limited chest expansion, increased tone of the muscles, inefficient biomechanics of breathing structures, faulty posture, increased thoracic kyphosis and abnormal neuromotor development.

Gonzalez coast et al in their study stated that chest wall restriction is one of the indication for recovery for these respiratory symptoms, respiratory training programs have increasingly been viewed as clinical necessity. Based on the increasing need Respiratory Exercises is implemented in this study to support its efficiency in improving pulmonary function. Respiratory Exercises given in this study includes Deep Breathing exercises, Diaphragmatic strengthening exercises, thoracic expansion exercise and active exercises to shoulder girdle. Abdominal muscle prepare the diaphragm at the end of expiration for next inspiration. The diaphragmatic strengthening exercises given to the clients in this study improved FVC values in experimental group may be because of the above mentioned reason. Improvement in the lung volume is by improving ventilation and by reducing airway resistance which further results in improving lung compliance.

The overall result of this study shows that respiratory parameters FVC, PEF & FEV1 are improved significantly in the experimental group. Probable reason for improvement in breathing exercises reduces the shoulder tension, facilitates the use of muscles of the chest resulting in thoracic expansion, thereby it automatically improves the lung expansion. Respiratory comprise results in complication such as shortness of breath, poor airway clearance and so forth. These problems deteriorate the quality of life and are life threatening, hence respiratory training should be considered in clients with cerebral palsy.


From the result of this study, it was concluded that the Respiratory Exercises along with NDT is more effective on improving the lung function in children with spastic quadriplegic cerebral palsy than that of conventional NDT program alone.


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B.S. Santhosh Kanna (1) * and K. Balabaskar (2)

(1) Lecturer, Physiotherapy, NIEPMD (Govt. of India) & Ph.D--Scholar, SRM Institute of Science and Technology, Chennai--603203, India,

(2) Head of the Department, Department of Adult Independent Living, National Institute for Empowerment of Persons with Multiple Disabilities (NIEPMD), Chennai 603112, India,

* Corresponding author E-mail:

(Received: 22 April 2019; accepted: 17 September 2019)
Table 1. Description of P value:

P value              Description        Summary

< 0.001         Extremely significant     ***
0.001 to 0.01     Very significant        **
0.01 to 0.5          Significant           *
> 0.05             Not Significant        NS

Table 2. Within group analysis of 'T' test in FVC of Experimental
and Control group

S.No   Group                Analysis         Mean[+ or -] SD

1      Experimental Group   Pre-test    1.03687 [+ or -] 0.780385
                            Post-test   1.65553 [+ or -] 0.976147
2      Control Group        Pre-test    0.471301 [+ or -] 0.121689
                            Post-test   0.396140 [+ or -] 0.102283

S.No   T- Value   Significance

1       -3.232      0.006 **

2       -2.842      0.013 *

From the above table it indicates that, there is a Statistically
significant improvement in both the groups

Table 3. Within group analysis of 'T' test in FEV1 of Experimental
and Control group

S.No         Group          Analysis         Mean + SD

1      Experimental Group   Pre-test    0.74007 + 0.594382
                            Post-test   1.28307 + 0.845454
2      Control Group        Pre-test    0.32653 + 0.197419
                            Post-test   0.59787 + 0.435999

S.No         Group          Analysis    T- Value   Significance

1      Experimental Group   Pre-test     -3.629      0.003 **
2      Control Group        Pre-test     -2.280       0.039 *

From the above table it indicates that, there is a Statistically
significant improvement in both the groups

Table 4. Within group analysis of 'T' test in FEV1/FVC % of
Experimental and Control group

S.No   Group                Analysis           Mean + SD

1      Experimental Group   Pre-test    61.27273 + 25.521925
                            Post-test   80.63400 + 16.781738
2      Control Group        Pre-test    52.78000 + 25.758604
                            Post-test   65.30200 + 9.991159

S.No   Group                Analysis    T- Value   Significance

1      Experimental Group   Pre-test     -2.398      0.031 *
2      Control Group        Pre-test     -2.215      0.044 *

From the above table it indicates that, there is a Statistically
significant improvement in both the groups

Table 5. Within group analysis of 'T' test in PEF of Experimental and
Control group

S.No   Group                Analysis           Mean + SD

1      Experimental Group   Pre-test    1.38153 + 0.908011
                            Post-test   2.12933 + 1.274954
2      Control Group        Pre-test    0.97413 + 0.58338
                            Post-test   1.23853 + 0.642078

S.No   Group                Analysis    T- Value   Significance

1      Experimental Group   Pre-test     -2.778      0.015 *
2      Control Group        Pre-test     -2.352      0.034 *

From the above table it indicates that, there is a Statistically
significant improvement in both the groups

Table 6. Between the group analysis of Respiratory exercises with
Neurodevelopmental treatment (Experimental group) Vs Neuro
developmental therapy (Control group)

S.No   Area          Analysis       Group

1      FVC           Post-test      Experimental Group
                                    Control Group
2      FEV1          Post-test      Experimental Group
                                    Control Group
3      FEV1/ FVC %   Post-test      Experimental Group
                                    Control Group
4      PEF           Post-test      Experimental Group
                                    Control Group

S.No        Mean + SD          T- Value   Significance

1       1.65767 + 0.982390      -2.336      0.011 *
        1.01873 + 0.396140
2       1.28307 + 0.845454      -2.790      0.027 *
        0.59787 + 0.435999
3      80.66267 + 16.805197     -3.043      0.039 *
        65.30200 + 9.991159
4       2.32933 + 1.233205      -3.039      0.049 *
        1.23853 + 0.642078
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Article Details
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Author:Kanna, B.S. Santhosh; Balabaskar, K.
Publication:Biomedical and Pharmacology Journal
Article Type:Report
Date:Sep 1, 2019
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