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Study design: Transversal. Objectives: The few studies concerning maximal static mouth respiratory pressures in patients with spinal cord lesions suggest a marked reduction. We studied the correlation of these parameters with the motor level of injury. Setting: Rehabilitation Center, Brası´lia/DF, Brazil. Methods: One hundred and thirty-one patients with traumatic spinal cord injury (C4-L3) were recruited. The participants were assessed by standard spirometry and maximal static mouth respiratory pressure. Results: Forced vital capacity was most reduced in tetraplegics (subgroup C4-C5, 49%725 predicted) and increase successively for each descending subgroup (C6-C8, 61%722 predicted; T1-T6, 70%715 predicted), becoming normal in low paraplegia (T7-L3, 84%715 predicted). There is no evidence of an obstructive disturbance throughout all groups. The lowest average percent predicted of maximal static inspiratory pressure (MIP) was in the subgroup C4-C5 (50%723). The average percent predicted of maximal static expiratory pressure (MEP) improved from 19%714 in the C4-C5 subgroup to 51%719 for T7-L3 subgroup. The average percent predicted of all participants for MIP was 74%730 and for MEP was 37%721. In patients with complete motor lesion, the correlation with the level of injury was stronger for MEP (r ¼ 0.81, Po0.0001; r 2 ¼ 0.65) than for MIP (r ¼ 0.62, P ¼ 0.004; r 2 ¼ 0.38). No correlation was found among incomplete motor lesion patients. Conclusions: The linear regression equations for the relationship of percent predicted MIP or MEP to level of injury are applicable only to complete motor lesions and may be useful to establish normative association between them.

Introduction Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease affecting both upper and lower motor neurons, and lead to respiratory failure. Strategies are suggested to respiratory management in ALS patients, as the breath stacking and Expiratory muscle training (EMT), which have been used as aid to assist cough in neuromuscular disorders. However, the randomized controlled trials performed in ALS patients have not investigated the addiction of EMT together breath stacking in this population. This trial aims to determine if breath stacking plus EMT is more effective than breath stacking alone to decrease the decline rate on the inspiratory/expiratory muscle strength, FVC and voluntary PCF in ALS patients. Methods This parallel-group, assessor-blinded randomized controlled trial, powered for superiority, aims to assess pulmonary function, respiratory muscle strength, peak cough flow as primary outcomes. Forty-two participants are being recruited referral neuromuscular disease center at Brasilia, Brazil. Following baseline testing, participants are randomized using concealed allocation, to receive either: a) breath stacking technique alone or b) breath stacking technique plus EMT. Conclusion There is a lack of evidence regarding the benefit of EMT plus breath stacking in ALS patients. This trial will contribute to evidence currently being generated in national and international trials by implementing and evaluating a respiratory therapy program including two components not yet combined in previous research, for people with ALS involving longer-term follow-up of outcomes. This trial is ongoing and currently recruiting. Trial registration This trial was prospectively registered on the Clinical Trials Registry NCT04226144.

Study design: A case report. Objectives: To demonstrate forced oscillation technique's (FOT) utility in a tetraplegic patient with tracheostenosis. Setting: A Rehabilitation Hospital, BrasõÂ lia, Brazil. Methods: Serial evaluations of spirometry, bronchoscopy and forced oscillation assessment. Results: A 16-year-old male with C7 spinal cord injury, initially required mechanical ventilation and subsequent tracheostomy over a period of 4 weeks. Five months after the accident the onset of tracheostenosis was diagnosed. Flow-volume data were compatible with a ®xed tracheal stenosis. FOT showed an obstructed pattern, manifested by high levels of resonance frequency and impedance. The FOT pattern returned to normal after dilatation. The FOT abnormalities recurred with two subsequent broncoscopicaly con®rmed episodes of tracheal restenosis without parallel changes in spirometric parameters. Conclusion: This case suggests a role for FOT in the non invasive detection and follow up of tracheal stenosis. FOT may be particularly useful in tetraplegic patients, in whom the restriction from muscle weakness may make interpretation of forced expiratory¯ow-volume data problematic. Spinal Cord (2000) 38, 445 ± 447

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Objective: To describe and analyze parameters and effects of surface electrical stimulation on the respiratory muscular function among individuals with spinal cord injuries, especially while coughing. Methods: A systematic literature review was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The search was conducted in the PubMed, PEDro, and LILACS databases, using the following descriptors: "functional electrical stimulation," "electrostimulation, electrical stimulation," "coughing," "bronchial hygiene," "quadriplegia," "spinal cord injury", "tetraplegia", and "individual with tetraplegia" -in Spanish, English and Portuguese, with no restrictions on year of publication. Inclusion criteria were: articles describing studies with samples of individuals with spinal cord injuries treated with electrical stimulation and outcomes related to the respiratory system. Articles containing studies with invasive cough stimulation trials were excluded. Results: The 12 selected articles revealed the heterogeneity of electrostimulation protocols for expiratory function, which can include frequencies ranging from 30 to 50 Hz; pulse from 25 to 400 µs; applied in up to eight electrodes distributed across the expiratory and accessory muscles. Time of administration also varied, and the current amplitude was usually estimated by the patient's perception, reaching values higher than 100mA. Conclusion: Even though the review did not find rigorous parameters for physical therapy using electrical stimulation, because of the shortage and low-quality of the studies that systematically compare stimulation parameters among subgroups, positive changes were observed in the assessed respiratory muscle function variables, such as peak expiratory and cough flow in individuals with cervical and thoracic spinal cord injury. ResumoObjetivo: Descrever e analisar parâmetros e efeitos da estimulação elétrica de superfície na função muscular respiratória de pessoas com lesão medular, sobretudo durante a tosse. Métodos: Foi realizada uma revisão sistemática da literatura, com base no Preferred Reporting Items for Systematic Reviews and MetaAnalyses. A busca foi realizada nas bases de dados PubMed, PEDro e LILACS, por meio dos seguintes descritores: "estimulação elétrica funcional", "eletroestimulação, estimulação elétrica", "tosse", "higiene brônquica", "quadriplegia", "lesão medular espinhal", "tetraplegia" e "sujeito com tetraplegia" -em espanhol, inglês e português, sem restrição quanto ao ano de publicação. Foram incluídos artigos com amostra de indivíduos com lesão medular assistidos por estimulação elétrica com desfecho relacionado ao sistema respiratório, e foram excluídos artigos com ensaios invasivos de estímulo a tosse. Resultados: Os 12 artigos incluídos revelam heterogeneidade nos protocolos de eletroestimulação da função expiratória, que podem incluir frequências de 30 a 50 Hz, com pulsos de 25 a 400 µs, aplicada por até oito eletrodos distribuídos pelos músculos expiratórios e acessórios. ...

Study design: Case-control study. Objectives: To evaluate the resting airway caliber in subjects with tetraplegia; to define the participation of cholinergic innervation in this condition; and to determine if baclofen modifies this pattern. Setting: A rehabilitation hospital, Brası´lia, Brazil. Methods: We studied 18 tetraplegic patients, with complete motor loss between C4 and C8, and 18 healthy control subjects by measuring airway conductance, before and after inhaled ipratropium bromide. Results: At baseline, the pulmonary function parameters revealed mild-to-moderate restrictive impairment in tetraplegic patients as defined by decreases in total lung capacity and predicted percent of slow vital capacity. The average baseline specific airway conductance (sGaw) was less in tetraplegic patients (0.2570.11) than in the control group (0.4170.10 l/s/cm H 2 O) (Po0.0001). All patients had improved postbronchodilator sGaw X40% compared with only four of the 18 controls (Po0.001). The average increase for tetraplegic patients was 235% (793) versus 25% (724) for controls (Po0.0001). Analysis of variance for repeated measurements showed significant difference in sGaw between the control and spinal cord injury (SCI) groups (Po0.0001) following bronchodilator challenge, but found no difference for total gas volume. No difference for mean basal sGaw and bronchodilator challenge was encountered comparing tetraplegic patients using baclofen to those not using it. Conclusions:Cervical SCI patients have a reduced baseline conductance compared to controls. Marked improvement occurs after an inhaled anticholinergic drug. This behavior was not affected by the use of baclofen. The study adds support to the hypothesis of an increased cholinergic bronchomotor tone in tetraplegic patients.

Introduction Individuals with spinal cord injury (SCI) frequently have an ineffective cough ability due to dysfunctions in expiratory muscles. In such cases, several articles have reported the occurrence of residual muscular activity in muscles that are accessory to coughing. The knowledge about this activity may be useful for building cough assistance devices. The goal of this review is to investigate and to describe the electromyographic signals generated during voluntary coughing in healthy people and in patients with SCI. Methods Two researchers performed, blindly and independently, a systematic review of the following databases: PubMed, PEDro, LILACS, and Science Direct. We conducted the searches using descriptors in English, Portuguese, and Spanish, with no limitations regarding the publication year. The review included articles describing experiments performed in humans and with the use of electromyographic signals in the analysis of voluntary coughing. Results Among the 156 initially found articles, only nine had results that described the study of electromyographic signals associated with voluntary coughing. The results showed evidence that, during voluntary coughing, electromyographic signals are generated both in expiratory and accessory muscles in healthy subjects. In individuals with SCI below the 5th cervical level (C5), the electromyographic signal appeared only in the clavicular portion of the pectoralis major, especially in the explosive cough phase. Conclusion Our evaluation of the current literature shows that, according to the analysed studies, the electromyographic signals are more pre‐eminent in the expiratory phase of the pectoralis major, during voluntary cough of individuals with SCI (C5–T12).