107 J ournal of N eurological P hysical T herapy
2 • 2005
Application of Ventilatory Strategies to Enhance Functional Activities
for an Individual with Spinal Cord Injury
Cathy E. Henderson, MS, PT, ATP
ABSTRACT
Background and Purpose: This case report describes
the benefits of teaching an individual with C6 tetraplegia
how to use ventilatory movement strategies during func-
tional activities and to thereby improve her level of inde-
pendence. Case Description: The client was a 25-year-old
woman with C6 tetraplegia. Her goal was to become inde-
pendent in 3 functional tasks: leaning forward in her wheel-
chair, repositioning her feet on her footplates of the wheel-
chair, and performing a lateral lean pressure relief. She was
evaluated performing each task with her own ventilatory
strategy, which was a valsalva maneuver. Then, she was
taught specific ventilatory strategies for each activity and
was re-evaluated to determine if the new strategy increased
her ability to perform the task. Outcomes: This client was
unable to perform each activity while using a valsalva
maneuver as her self-selected ventilatory strategy. After
learning the appropriate ventilatory strategy to use while
performing each task, she became independent with each
activity. Discussion and Summary: Clinicians are encour-
aged to incorporate teaching appropriate ventilatory strate-
gies to a client while the client is performing functional
tasks to improve outcomes. Less than 30 seconds is needed
to instruct a client in the appropriate ventilatory strategy.
Many clients are able to learn ventilatory strategies in a short
period of time and therefore improve their ability to per-
form tasks. This training can be a valuable asset to the cur-
rent functional training that is needed for a client with
tetraplegia.
Key Words: breathing, SCI, ventilation, function, tetraplegia
INTRODUCTION
Individuals with spinal cord injury (SCI) have many sec-
ondary problems associated with their injuries. These
include motor and sensory deficits, bowel and bladder dys-
function, cardiopulmonary complications, high risk of skin
breakdown, pain, and inability to perform mobility tasks
and activities of daily living (ADLs) independently.1 The
high incidence of morbidity and mortality from pulmonary
complications, specifically in patients with cervical and
high thoracic SCI, is well documented.2-6 However, regard-
less of the level of injury, respiratory function can be opti-
mized thereby decreasing the risk of pulmonary complica-
tions that could lead to death. It is also possible to use the
respiratory system as an asset to increase a person’s ability
to perform functional tasks. An individual with C1-2
tetraplegia was reported to learn the ventilatory strategy of
Spinal Injury Physical Therapist/Clinical Research Therapist, Methodist Rehabilitation Center, Jackson, MS (Chenderson@hot
mail.com)
Vol. 29 • No.
glossopharyngeal breathing after 5 weeks of training and he
increased his forced vital capacity 35-fold, time off the ven-
tilator went from 0 to 30 minutes, and a nonfunctional
cough went to a weak functional cough.7 With lower levels
of injury, an individual has increasing ability to use spared
respiratory muscles to his or her advantage during postural
activities, dressing, wheelchair mobility, bed mobility, and
other ADLs. The purpose of this paper is to discuss the clin-
ical application of teaching ventilatory strategies to an indi-
vidual with C6 tetraplegia and illustrate the differences in
functional outcomes when the proper ventilatory strategy
is utilized during functional activities.
Muscles of inhalation and exhalation all receive innerva-
tion from nerves arising from the spinal cord. Therefore,
individuals with any level of spinal cord injury experience
some degree of deficit in breathing abilities and in their
ability to stabilize for a functional task. Key respiratory
muscles along with their function and innervation are pro-
vided in Table 1 and 2.
Ventilatory Strategies
A ventilatory strategy as described by Massery et al9,10 is
the use of intentional pairing of inhalation and exhalation
patterns with movement in order to enhance the overall
motor task. To determine the appropriate pairing, a thera-
pist must decide the primary trunk pattern used and the
primary muscle contraction to be used. With this informa-
Table 1. Muscle Support Necessary for Optimal Inspiratory
Function: A “Triad” of Support8
Diaphragm Provides approximately 75% of the effort during nor-
mal inspiratory lung volume
Shape allows for 3-dimensional movement, which
optimizes the potential inspiratory lung volume
Innervated by C3-C5
Intercostals Necessary to stabilize the mobile rib cage to prevent
the chest wall from collapsing inward toward the
negative pressure created during inhalation, thus
maximizing the diaphragm’s effectiveness
Innervated by T1-T12
Abdominals Provides abdominal wall support to maintain visceral
position up and under the dome of the diaphragm
Also serves to stabilize the central tendon to stimu-
late the diaphragm’s peripheral fiber contractions
and intercostals contractions
Innervated T5-T12
Reprinted with permission from Cardiovascular and Pulmonary Physical
Therapy: An Evidence-Based Approach.8 Copyright 2004, The McGraw
Hill Companies.
Vol. 29 • No. 2 • 2005 J ournal of N eurological P hysical T herapy
Table 2. Significant Accessory Muscles of Ventilation8
Erector Spinae Stabilizes thorax posteriorly to allow normal
anterior chest wall movement to occur
Innervated T1-S3
Pectoralis muscles Provides upper chest anterior and lateral expan-
sion
Innervated C5-T1
Can be taught to stabilize rib cage following
paralysis of the intercostals muscles
Can be recruited as an expiratory muscle.
Serratus Anterior Provides posterior expansion of the rib cage
when upper extremities are fixated
Innervated C5-C7
Only inspiratory muscle that is paired with
trunk flexion movements rather than trunk
extension movements
Scalenes Provide superior and anterior expansion of the
upper chest.
Innervated C3-C8
Sternocleidomastoid Same as scalenes
Innervated C2-C3 and accessory cranial nerve
Trapezius Provides superior expansion of the upper chest
Innervated C2-C4 and accessory cranial nerve
Reprinted with permission from Cardiovascular and Pulmonary Physical
Therapy: An Evidence-Based Approach.8 Copyright 2004, The McGraw
Hill Companies.
tion, therapists are able to add the optimal ventilatory strat-
egy and the best sensory strategy to help an individual
improve his ability in a motor task with efficient and effec-
tive breath support.9,10
Individuals with normal motor planning and intact res-
piratory function pair trunk extension (ie, reaching up, or
sitting up) with inhalation and trunk flexion (ie, reaching
down or leaning forward in a wheelchair) with exhalation.
When the primary muscle contraction used during stability
activities is isometric, techniques of breath holding (not val-
salva) can be used. When the primary muscle contraction
used during movement activities is isotonic, then tech-
niques pairing inhalation and exhalation should be used. If
the primary muscle contraction is concentric (moving
against gravity), then it is paired with a concentric breath-
ing pattern (ie, any inspiratory pattern or forceful exhala-
tion). Finally, if the primary muscle contraction is eccentric,
then it is paired with an eccentric breathing pattern (ie,
speech or any controlled expiratory pattern).9,10
Box 1. Significant Ventilatory-Movement Strategies9
1. Pair trunk extension activities with inspiration.
2. Pair trunk flexion activities with exhalation.
3. Pair shoulder flexion, abduction and/or external rotation activities
with inspiration.
4. Pair shoulder extension, adduction and/or internal rotation activities
with exhalation.
5. Pair upward eye gaze with inspiration.
6. Pair downward eye gaze with exhalation.
108
Inhalation always involves a concentric contraction. It
can be used to increase thoracic extension by utilization of
upper accessory muscles or it can be used to maintain a
neutral spine or slight flexion via activation of a more
diaphragmatic pattern.9,10 Clinically the author has noted
that if an individual feels like he is falling forward during a
sitting balance activity, he may inhale quickly and recruit
accessory muscles and back extensor muscles to try to
maintain upright sitting.
Exhalation can be used with many types of muscle con-
tractions. Exhalation is passive during quiet breathing. This
happens because the diaphragm and lungs elastically recoil
letting air out when they are released after inhalation.
Exhalation can be used eccentrically during quiet, con-
trolled activities such as speech or fine motor related activ-
ities. Massery and Cahalin10 explain,“During eccentric exha-
lation, the expiratory phase is prolonged by slowly releasing
(eccentric contractions) the inspiratory muscles until the
chest wall and lungs are near functional residual capacity
(FRC), at which time the expiratory muscles become
active.”10(p600) If an individual has difficulty with eccentric
control of exhalation during talking, their speech will sound
‘breathy’ and he will complain of fatigue during talking.9
Exhalation also can be used during concentric activities to
forcefully expel air during coughing, yelling, or blowing up
balloons. The abdominals and intercostals are recruited by
concentric contractions to help force air out and provide
more breath support for the demand of the activity.
For people with impaired neuromuscular systems, the
pairing of inhalation and exhalation may be mismatched
with the trunk pattern used or the type of muscle contrac-
tion used. This can be due to a decrease in vital capacity
and/or an increase in oxygen consumption leading to more
use of accessory muscles or the extra effort needed to
breathe or cough.9 A decrease or increase in muscle tone
can impair a person’s posture and lead to ineffective venti-
lation. For example, it can be seen clinically that severe
kyphosis and posterior pelvic tilt can cause the chest to col-
lapse and the diaphragm to be limited in movement during
inspiration and exhalation.
Use of Sensory Input to Cue Movement
It is important to pair the optimal sensory input with the
motor task and ventilatory strategy. The direction of a per-
son’s gaze can help assist in guiding the movement. To facil-
itate inhalation, a person should be directed to look up,
while to facilitate exhalation a person should look down.10
The intonation, volume, and emphasis of the therapist’s
voice can have an impact on the resulting movement and
should be adapted to the strategy being applied. A loud
demanding voice usually facilitates more upper accessory
muscle breathing, more thoracic extension, and a quicker
inspiratory effort. A soft, quiet voice usually facilitates lower
chest, diaphragmatic breathing, a neutral or slightly flexed
trunk, and a slower inspiratory effort.
109 J ournal of N eurological P hysical T herapy
How does a therapist now take these concepts and
apply them to clinical practice? Incorporation of ventila-
tory strategies with the functional activities of rolling, com-
ing from supine to sitting, coming from sitting to standing,
and standing back to sitting, dressing, and reaching has been
well described.11-14 The following case study illustrates the
application of the same principles of applying quick and
easy ventilatory strategies to 3 other functional tasks impor-
tant to a person with tetraplegia.
CASE DESCRIPTION
Patient
The client was a 25-year-old woman who was 5’5” in
height and weighed 190 pounds at the time of her injury.
She had C5 tetraplegia complete, ASIA A due to a gunshot
wound to C5 and T2 on 09/25/2003. Her complications ini-
tially included hemothorax (the rehab medical record did
not state if she received a chest tube), urinary tract infec-
tion, and pneumonia and stage II decubitus ulcer in her left
thoracic region. She did not have a history of smoking. She
was admitted to an inpatient rehabilitation hospital on
10/14/2003 and discharged on 10/24/2003 with home
assistance. Functionally, she required total assistance, as
defined by the Functional Independent Measure (FIM)
tool15 with most activities of daily living and mobility. She
was readmitted to inpatient rehabilitation to improve her
functional ability on 10/28/2004 and was discharged on
11/18/2004. She weighed 158 pounds, was without any
medical complications and her decubitus was healed.
Examination
On her second admission, range of motion was within
functional limits throughout her extremities. Her neurolog-
ical level of injury, according to ASIA standards,16 was C6
ASIA A. She had an Ashworth17 score of 3/5 tone in her bilat-
eral knee flexors and hip adductors and experienced
clonus in both ankles. Her forced vital capacity (FVC) was
1.65 L (44%), her forced expiratory volume in one second
(FEV1) was 1.54 L (45%), and her vital capacity (VC) mea-
sured 1.68 L (45%). On this second admission she required
moderate assistance with her bed transfers, dependent with
her toilet and tub transfers. By discharge, she required max-
imum assistance15 with bed mobility and sliding board trans-
fers, supervision with power assist manual wheelchair
mobility skills on level surfaces, and supervision with
propped static sitting balance.
Functional Activities and Outcomes
The client was working on a variety of functional activi-
ties, they were chosen for this case report: (1) leaning for-
ward in her wheelchair, (2) repositioning her feet on the
footplates of her wheelchair, and (3) performing a lateral
lean pressure relief maneuver. This client was unable to per-
form these tasks independently but was motivated to
improve her ability to perform them. These activities were
also chosen for illustration because they have not been pre-
viously described in the literature.
Vol. 29 • No. 2 • 2005
Leaning forward in her wheelchair was an important
movement as it would allow her to do several important
activities. These included access the wheel locks of her
wheelchair, reposition her hips toward the back of her
wheelchair, access her feet as well as objects that are oth-
erwise out of reach in front of her, prepare to transfer to
another surface, and do a forward lean pressure relief if
doing a lateral lean pressure relief is inconvenient. For this
client, the task of leaning forward in her wheelchair
required a flexion and extension momentum of her head,
neck, upper extremities, and trunk. The movement started
with extension of her head and neck, shoulder extension
with scapular retraction, trunk extension against the stable
surface of her wheelchair back followed quickly by a force-
ful head and neck flexion, shoulder flexion with scapular
protraction and trunk flexion. She rocked back and forth
until she was able to flex enough forward to keep her back
away from the back of the wheelchair without falling back
against it.
This patient was asked initially to lean forward in her
wheelchair any way she preferred without assistance. She
initially tried to do so by throwing her arms forward and
using a valsalva ventilatory strategy for stability. She was
only able to flex forward a minimal amount before quickly
sitting back against the back of her wheelchair. She then
attempted to flex forward by pulling on the armrests with
wrist flexion and once again used a valsalva ventilatory
strategy. This strategy gave the same results. After some
frustration, she was instructed to use the following
sequence:“Before attempting to lean forward, extend your
neck, look up, extend shoulders and inhale a really deep
breath. Then, flex your neck, look down, throw your arms
forward into flexion and exhale strongly.” She was using
concentric muscle contractions to perform trunk extension
followed by trunk flexion for this task. Therefore, it was
determined that to help her achieve the maximum breath
support for the initial trunk extension, she needed to
inhale, look up, and the therapist would need to give loud
audible cues. To help her be effective with the trunk flex-
ion component, she would need to exhale, look down, and
the loud audible cues would assist with the quick and fast
exhale needed to finish the task. After using this strategy 1
to 2 times to build momentum, she was able to indepen-
dently lean herself forward in her wheelchair. She kept her-
self from falling too far forward by catching herself with her
hands on her knees. Instruction in this ventilatory strategy
took less than 30 seconds. The amount of time for her to
practice and master this took less than 2 minutes (See
Figure 1 and 2).
The second task this client wanted to be able to do inde-
pendently was that of repositioning her feet on the foot-
plates of the wheelchair. Managing her lower extremities
was important to her because she experienced muscle
spasms on occasion that would cause her feet to come off
of the footplates and potentially drag the ground and cause
injury. She also had a long-range goal of being able to take
Vol. 29 • No. 2 • 2005 J ournal of N eurological P hysical T herapy
Figure 1. Leaning forward in wheelchair step 1: inhalation cou-
pled with trunk extension and eyes up.
Figure 2. Leaning forward in wheelchair step 2: exhalation cou-
pled with trunk flexion and eyes down.
her feet on and off of the footplates as part of indepen-
dently transferring herself in and out of bed with a transfer
board. Being able to remove her feet from the footplates
was a component of that transfer. Initially, she was asked to
try to remove her feet from the footplates any way she
could. She used the new strategy she had previously
learned to lean herself forward in the wheelchair. Then put
her left forearm under her right knee and attempted to lift
it up. While doing so, she once again used a valsalva breath-
ing strategy and was unsuccessful. After a few unsuccessful
attempts, she was instructed to use the following ventila-
tory strategy: “Lean forward in the wheelchair and place
your left arm under your right knee. Before lifting at your
knee, look up with your eyes, extend your neck and trunk,
and inhale deeply (See Figure 3). Then, as you try to pull
your knee up to move your foot, look down, flex your neck
and trunk and exhale forcibly.” Once in the position of for-
ward flexion with her left arm under her right knee, it was
determined that to perform this task, she needed a concen-
tric contraction of her trunk extensors followed by con-
centric trunk flexion. Loud audible cues from the therapist
110
Figure 3. Repositioning feet on footplate: inhalation coupled with
trunk extension and eyes up.
were given to inhale and look up with trunk extension fol-
lowed by loud audible cues to flex her trunk, look down,
and exhale while flexing her bicep to lift her leg to move
her foot off of the footplate. After 4 to 5 practice sessions,
she was able to reposition her foot on the footplate inde-
pendently. The client was unable to consistently reposition
her feet due to her lower extremity spasms and required
occasional assistance when the spasms interfered.
Instruction in this ventilatory strategy took less than 30 sec-
onds and the amount of time it took for her to learn this
ventilatory strategy took less than 3 minutes.
The final task she performed was a lateral lean pressure
relief maneuver. Pressure relief prevents skin breakdown for
individuals with complete spinal cord injury at any level.1
She would likely be alone at times and would need to be
able to do this task on her own. She was able to lean herself
to one side without assistance but she was unable to return
to upright. She used the push handles on her wheelchair to
hold onto as she allowed gravity to assist lateral trunk flex-
ion. Then she tried to pull herself up using her biceps
strength and a valsalva ventilatory strategy. She was unsuc-
cessful and became very fatigued. She was instructed in a
ventilatory strategy using the following sequence: “From the
left lateral lean position and your right arm hooked in the
wheelchair push handle, prepare to return to upright by
looking upward, laterally flexing your neck to the left, later-
ally flexing your trunk to the left with some extension and
inhaling deeply. Then, look to the right, laterally flex your
neck and trunk to the right as you pull your trunk upright
while exhaling forcibly.” As she did this she used her left arm
to help push off of the mat or wheel to assist in coming to
upright. This ventilatory pattern was chosen because the
trunk movement required was concentric flexion/lateral
flexion. To get the most breath support, she needed a big
inhalation then a forcible exhalation to pair with the trunk
flexion. The eye gaze up to start with helped her get a max-
111 J ournal of N eurological P hysical T herapy
imum inhalation and the eye gaze down with the loud audi-
ble cues were paired with the trunk flexion/lateral flexion
toward upright. Instruction in this ventilatory strategy took
less than 30 seconds and with 3 to 5 attempts she was able
perform a lateral lean pressure relief (See Figure 4).
Figure 4. Lateral lean pressure relief returning to upright: inhala-
tion coupled with trunk extension and lateral flexion and eyes up.
DISCUSSION AND SUMMARY
This client was using inefficient neuromuscular tech-
niques to perform her activities. She had the ability to learn
the strategies and incorporate them into her activities to
meet her desired goals of being more independent. These
strategies and the principles behind them are easy to teach
and to apply to any functional task a person may want to
become more efficient and independent in performing.
These strategies can be used to improve endurance in run-
ning marathons or to decrease fatigue while propelling a
wheelchair. The purpose of this paper was to describe and
illustrate the practical application of the principles of venti-
latory strategies to functional activities performed by an
individual with tetraplegia. Clinicians are encouraged to
examine the breathing strategies used by their clients, deter-
mine the efficiency of the strategy, and decide if a new strat-
egy should be chosen and taught to improve efficiency and
independence of functional activities. These principles are
quick and easy to apply and can be taught simultaneously
with the necessary functional training already being done
for clients with tetraplegia. Further research and application
should be done to continue to affirm these principles.
ACKNOWLEDGEMENTS
I would like to acknowledge Mary Massery, PT, DPT for
her assistance in writing this paper and valuable contribu-
tions to the education of health care professionals in the
application of ventilatory strategies to clients with neuro-
muscular deficits.
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