Vengata Subramani Manoharan¹, Ramani Subramaniyam², Siti Nurziehan Mohd Nawi¹ and Sandheep Sugathan³

¹Physiotherapy Department, Faculty of Pharmacy and health Sciences, Universiti Kuala Lumpur Royal College of medicine Perak

²Radiology Department, Faculty of Medicine, Universiti Kuala Lumpur Royal College of medicine Perak

³Department of Community Medicine, Faculty of Medicine, Quest International University Perak. Malaysia

DOI : https://dx.doi.org/10.13005/bpj/1804

Abstract

A progressive, generalized loss of skeletal muscle mass and associated deterioration in muscle strength and performance increases with age. Aging affect the respiratory muscle performance on respiratory system due to anatomical and physiological changes in muscle strength as well as thickness of the respiratory muscles. During resting breathing the limitation of movement is more evident in expiration than inspiration were the FEV₁/FVC% falls in older people. There are lot of study on peripheral muscle thickness and muscle torque among elderly population, but not much study on respiratory muscle training. This made us to conduct a study on pulmonary function and muscle thickness in elderly population by training the expiratory muscles. To determine the effects of external oblique muscle training on pulmonary function and muscle thickness in elderly population. 60 geriatric voluntary subjects were assigned to experimental and control group as (n=30) each. Experimental group subjected to 16 weeks of external oblique strengthening along with incentive spirometer training. Control group subjected to incentive spirometer alone. Pre and post training muscle thickness and pulmonary parameters were assessed. The paired t test found there is significant difference (P<0.05) between pre and post training muscle thickness and pulmonary parameters in experimental group. We recommend that resistance training, not only maintain the muscle thickness also improve the muscle thickness and pulmonary parameters among elderly population.

Keywords

External Oblique Strengthening, Muscle Thickness, Pulmonary Parameters

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Copy the following to cite this article: Manoharan V. S, Subramaniyam R, Nawi S. N. M, Sugathan S. Biomed Pharmacol J 2019;12(4)

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Introduction

Aging is a progressive process leading to constriction of homeostatic reserve of organs. The most significant impact of aging on respiratory system are decline in elastic recoil of the lungs and performance of respiratory muscle due decreased anatomical and physiological parameters especially respiratory muscle strength i.e. sarcopenia.

The world’s population over 60 years of age increased from 9.2% to 11.7% in about 23 years and by 2050, it is expected to be about 21.1%.¹ Aging is associated with reduced chest wall compliance and increased air trapping. The decline in forced expiratory volume in first second (FEV1) with age, has a nonlinear phase with acceleration in rate of decline after age of 70 years. With aging, due to loss of supportive elastic tissues, there is an increase in airspace size.   As age advances, respiratory muscle strength declines much more so in men than in women.²

The external oblique muscle is the largest and the outermost of the three flat muscles of the lateral anterior abdomen. The external oblique muscle pulls the chest downwards and compresses the abdominal cavity which increases the intra-abdominal pressure as in a valsalva maneuver.

Even in healthy population, lung functions decline throughout adult life. Aging leads to changes in pulmonary mechanics, respiratory muscle strength, gas exchange and ventilatory control. Increased rigidity of chest wall and decline in respiratory muscle strength with aging result in increased closing capacity and a decreased forced expiratory volume in first second (FEV1) and Forced vital capacity (FVC). During resting breathing the limitation of movement is more evident in expiration than inspiration, perhaps because there are no efficient accessory muscles of expiration. Due to these changes the cough efficiency, FEV1 and FVC will be reduced in elderly people.

Geriatric population are susceptible to risk factors such as chronic diseases, impaired physical condition, as well as cardiopulmonary dysfunction and muscle weakness. Thus, it is essential for the elderly to perform aerobic and strengthening exercises, and to manage the risk of falls to ensure their good health.³

Both cross section and longitudinal studies have demonstrated that there is decline in maximum oxygen uptake, VO2 with advanced aging. Another factor which implicated in reduction of maximum uptake with age is customary level of physical activity, the rate of decline in (ml/kg.min) may be reduced as much as half by a high level of customary physical activity.⁴ Electrical stimulation applied to the rectus abdominis and muscles around the abdomen, was shown to improve tidal volume and pulmonary ventilation in spinal cord injury patients.⁵ The IMT group showed significant improvement in balance, TA and IO thickness, FVC, FEV1, and PEF.⁶

Background and purpose

A progressive, generalized loss of skeletal muscle mass and associated deterioration in muscle strength and performance occurs with increase in age. Negative outcomes of the elderly population include disabilities, comorbidities, hospital admissions and death. Aging affect the respiratory muscle performance on respiratory system due to anatomical and physiological changes in muscle strength as well as thickness of the respiratory muscles. Progressive loss of protective reflexes in the airway with the advancement of age is one of the commonest changes in the respiratory system.⁷ During resting breathing the limitation of movement is more evident in expiration than inspiration, perhaps because there are no efficient accessory muscles of expiration. Due to these changes the cough efficiency will be reduced and the FVC falls in older people. There are lot of study on peripheral muscle thickness and abdominal muscle thickness among elderly population, but not much study on external oblique muscle training. Hence we conducted a study on pulmonary function and muscle thickness in elderly population by training the external oblique muscles.

Methodology

Study design

Experimental design

Study setting

Universiti Kuala Lumpur- Royal College of Medicine Perak.

Participants

60 geriatric voluntary persons were randomly selected

Inclusion criteria

Age between 55-65

Males only.

Independent ADL.

Exclusion criteria

Haemodynamically unstable

Asthmatics

Dementia

Depression

Tools required

spyrolyser SPL-10, Diagnostic ultrasound machine

The procedure and benefits were discussed with the voluntary subjects and informed consent were obtained before the procedure. Sixty voluntary subjects were randomly assigned to experimental group (n=30) and subjected to strengthening of external oblique muscle along with expiratory training using incentive spirometer, control group (n=30) with incentive training alone were subjected to pulmonary function test (FEV1, FVC, PEF values) and muscle thickness measurement prior to the study. Then the experimental group were subjected to expiratory muscle strengthening especially external oblique using various exercise and incentive spirometer as a visual feedback for a period of 16 weeks. Post-training measurements were taken and they were correlated with pre-training values. The referred point of external oblique muscle was about 15 cm lateral to the umbilicus (right side) in standing position.

Muscle thickness

Muscle thickness was measured by TOSHIBA XARIO ultrasound equipment. Participants were tested before and after 16 weeks period for muscle thickness of external oblique. All tested were conducted at the same day and participants were instructed to hydrate normally a day before the test. Measurement were taken 5 days after the last training session. During these time participants were instructed not to involve in any other resistance training in abdominal area. Muscle thickness were measured by a trained radiologist at 13 cm lateral to umbilicus using M-mode ultrasound by a water based gel with 7.5 MHz ultrasound probe was placed perpendicular to the tissue while not depressing the skin.

Scheme 1   Click here to View figure

Lung parameters

Lung parameters such as FVC, FEV1 and PEF were assessed using Spyrolyser SPL-10. The pre and post intervention lung parameters were recorded in upright sitting posture.

Exercise protocol

Participants were randomly assigned in to two groups. The experimental group performed resistance exercise and incentive spirometer training, were as the control group were trained using incentive spirometer only. The exercise protocol was designed in according to the guideline of American college of sports and Medicine, with three sets of 8 to 12 maximum repetition. Subjects were instructed to perform concentric and eccentric phase without pause between them. Training were conducted 2 days per week with a minimum of 48 hours rest and 2 to 3 sets, per exercise session is suitable with about 2.5 minutes rest between each set.  Cool down phase for 10 – 15 minutes. The warm up phase include mild stretching and allow individuals to walk in the treadmill for 10 to 15 minutes. Cool down phase that includes mild stretching and 3-4 repetition of deep breathing exercise of inspiration through nose, hold the breath for 3 seconds and expire through mouth slowly. Exercise regimen that initiated with incentive spirometer for 2 days and followed by strengthening of external oblique muscle.

In a study they had suggested that 8 to 12 repetitions should be done per set. When the individual is capable of performing 12 repetitions, the resistance is to be increased to a point where only 8 repetitions are possible.⁹ A minimum of one set, preferably 2 to 3 sets, per exercise session is suitable with about 2.5 minutes rest between each set. The author of that study also recommends exercising 1 to 3 days a week, for not more than one hour per session and with at least 2 days between the sessions. We followed the same principle of strengthening external oblique in elderly adults.

Statistical analysis

All the values were reported as mean (standard deviation) and significance were analyzed using SPSS 23 version. Paired t test was used to analyse the significance of the intervention.

Result

Repeated-measures paired t test revealed that, in the experimental group, FEV1, FVC, PEF and muscle thickness in external oblique muscle had significantly increased after sixteen weeks (p<0.05),

In the control group, FEV1 and PEF had improved significantly after sixteen weeks (p<0.05), but were significantly reduced in FVC and muscle thickness of external oblique following sixteen weeks (p<0.05).

Table 1: Mean and standard deviation of control group

Paired Samples Statisticsa
		Mean	N	Std. Deviation	Std. Error Mean
Pair 1	PRSN	6.933b	30	2.2959	.4192
	POSN	6.933b	30	2.2959	.4192
Pair 2	PRSDE	8.727	30	3.0977	.5656
	POSDE	8.730	30	3.0917	.5645
Pair 3	PRFVC	72.357	30	15.8593	2.8955
	POFVC	72.807	30	16.4604	3.0052
Pair 4	PRFEV1	81.010	30	17.5475	3.2037
	POFEV1	82.337	30	17.4143	3.1794
Pair 5	PRPEF	83.797	30	24.9727	4.5594
	POPEF	85.103	30	24.5222	4.4771
a. group = cont
b. The correlation and t cannot be computed because the standard error of the difference is 0.

Table 2: Comparison of Pre and Post-test values in control group using paired t tesT

Paired Samples Testa
		Paired Differences					T	df	Sig. (2-tailed)
		Mean	Std. Deviation	Std. Error Mean	95% Confidence Interval of the Difference
					Lower	Upper
Pair 2	PRSDE – POSDE	-.0033	.0556	.0102	-.0241	.0174	-.328	29	.745
Pair 3	PRFVC – POFVC	-.4500	1.7033	.3110	-1.0860	.1860	-1.447	29	.159
Pair 4	PRFEV1 – POFEV1	-1.3267	1.8351	.3350	-2.0119	-.6414	-3.960	29	.000
Pair 5	PRPEF – POPEF	-1.3067	2.7787	.5073	-2.3443	-.2691	-2.576	29	.015
a. group = cont

Table 3: Mean and standard deviation of experimental group

Paired Samples Statisticsa
		Mean	N	Std. Deviation	Std. Error Mean
Pair 1	PRSN	6.927	30	2.3960	.4374
	POSN	7.063	30	2.4212	.4421
Pair 2	PRSDE	8.763	30	3.1545	.5759
	POSDE	9.293	30	2.9686	.5420
Pair 3	PRFVC	73.903	30	16.9274	3.0905
	POFVC	82.160	30	12.6083	2.3019
Pair 4	PRFEV1	84.407	30	19.1309	3.4928
	POFEV1	90.540	30	18.4747	3.3730
Pair 5	PRPEF	85.663	30	26.3785	4.8160
	POPEF	93.557	30	22.3215	4.0753
a. group = exp

Table 4: Comparison of Pre and Post-test values in experimental group using paired t test

Paired Samples Testa
		Paired Differences					T	Df
		Mean	Std. Deviation	Std. Error Mean	95% Confidence Interval of the Difference
					Lower	Upper
Pair 1	PRSN – POSN	-.1367	.2723	.0497	-.2383	-.0350	-2.749	29	.010
Pair 2	PRSDE – POSDE	-.5300	.3725	.0680	-.6691	-.3909	-7.794	29	.000
Pair 3	PRFVC – POFVC	-8.2567	6.5148	1.1894	-10.6893	-5.8240	-6.942	29	.000
Pair 4	PRFEV1 – POFEV1	-6.1333	4.7340	.8643	-7.9010	-4.3656	-7.096	29	.000
Pair 5	PRPEF – POPEF	-7.8933	7.8666	1.4362	-10.8308	-4.9559	-5.496	29	.000
a. group = exp

Discussion

The major finding of the present study was there is significant difference on pre and post training outcome in experimental group. Exercise selection is crucial step in designing resistance training. However, there are many controversies in prescribing resistance training for older individuals. In a previous study they reported that both single joint and multi joint training both improves the muscle thickness in elbow group of muscles.⁸ But in our present study it will be difficult to strengthen the external oblique muscle alone, so multiple joint resistance exercise was given. However, the post FEV1 and PEF of control group showed significant improvement in control group, the possible reason could be incentive spirometer expiratory training may move FEV1 and PEF but there is no significant difference in FVC and muscle thickness among control group.

In another study the author recommended that an ideal progressive resistance training program for sarcopenia should be dynamic and should aim at the major muscle groups using concentric and eccentric movements.⁹ In our present study also we followed the same technique of both eccentric and concentric contraction of external oblique muscle.

In a study, 10 weeks of progressive resistance training with 3 session of training per week increased muscle cross sectional area by about 3 to 9% and enhanced muscle strength and performance.¹⁰ In our present study there is significantly increase in external oblique muscle thickness among experimental group, but we gave 16 week of resistance training with 2 sessions of training per week. In another study the author stated that there is increase in FVC, FEV1 and rectus abdominal muscle thickness improved due to Feedback Breathing Exercise (FBE) for about 15 minutes, and 3 sets of Balloon-Blowing Exercises (BBE) for four weeks.¹¹ This is contrary to our study, for control group due to expiratory training using incentive spirometer improved the FEV1 and PEF in 16 weeks of training but there is no significant improvement in FVC and external oblique muscle thickness.

In another study, while assessing the electromyography for the maximal contraction force, the placement of active electrode for external oblique was about 13 cm lateral to the umbilicus and about 3 cm medial and inferior to the right Anterior Superior Iliac Spine (ASIS) for internal oblique.¹³ We also used the same point as a reference for taking external oblique muscle thickness.

A limitation of the present study was that the study population included only male subjects due to social characteristics and there was no criterion set for all elderly individuals. Further bigger and future research studies should address these limitations.

Conclusion

Aging is a key cause of disability and augmented health care costs. Though being very common, muscle wasting remains underdiagnosed and undertreated among elderly population. Muscle wasting should be evaluated in patients from 50 years of age and above to prevent decline in physical strength and function. We recommend that resistance training, not only maintain the muscle thickness also improve the muscle thickness and pulmonary parameters among elderly population.

Acknowledgement

The authors would like to acknowledge the participants of the study without whom the study would not have been possible.

Conflict of Interest

The authors state that there are no conflicts of interest.

Funding source

Nil

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