International Journal of Osteopathic Medicine 51 (2024) 100708

Contents lists available at ScienceDirect

International Journal of Osteopathic Medicine

journal homepage: www.elsevier.com/locate/ijosm

Inter-rater and intra-rater reliability of manual assessment of respiratory

motion in patients with unilateral cervical radiculopathy: A
cross-sectional study
Amin Kordi Yoosefinejad a, b, 1, Raziyeh Yousefiyan c, 1, Raziyeh Nazari c, Iman Rezaei a, b, *
a
Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, 1 Abivardi Avenue, Chamran Blvd., Shiraz, 71345-1733, Iran
b
Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
c
Student Research Committee, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Altered breathing pattern is a consequence of dysfunctional breathing. The respiratory pattern might
Breathing pattern be impaired in patients with cervical radiculopathy due to the involvement of common nerve roots with the
Cervical radiculopathy phrenic nerve (C3– C5).
Manual assessment of respiratory motion
Objective: The aim of this study was to investigate the inter-rater and intra-rater reliability of a technique for
Reliability
evaluating the breathing pattern known as manual assessment of respiratory motion (MARM) in patients with
unilateral cervical radiculopathy.
Design: Cross-sectional study.
Setting: Rehabilitation Sciences Research Center
Participants: Twenty-five patients with unilateral cervical radiculopathy aged 30–55 years participated in this
study.
Methods: Two experienced physical therapists investigated the respiratory pattern of the patients during normal
and deep breathing using MARM, separately. Assessments were repeated again a week apart by each examiner.
The inter- and intra-rater reliability of the MARM were calculated.
Results: “Very good” inter-rater and intra-rater reliability were found with the MARM values during both normal
and deep breathing patterns. (Inter-rater: ICC range = 0.71 to 0.82; intra-rater: ICC range = 0.72 to 0.80).
Conclusions: MARM is a reliable clinical and research tool for assessing breathing patterns with very good inter-
and intra-rater reliability in patients with unilateral cervical radiculopathy.

1. Implications for practice 2. Introduction

• Highlighting the importance of respiratory assessment in patients
with unilateral cervical radiculopathy.
• Introducing the manual assessment of respiratory motion as a clin­
ical, time-efficient, and inexpensive method with an acceptable level
of inter-rater reliability to assess and quantify the breathing pattern
in these patients.
• Manual assessment of respiratory motion has an acceptable level of
intra-rater reliability for investigating breathing pattern in patients
with unilateral cervical radiculopathy.
Cervical radiculopathy is a clinical condition resulting from
compression of cervical nerve roots due to spondylosis or disc hernia­
tion, known as a common cause of neck and arm pain [1]. The average
annual incidence rate of cervical radiculopathy was 83.2 per 100 000
population in Rochester [2]. The clinical manifestations of cervical
radiculopathy are diverse and may include pain, sensory and motor
deficits, diminished reflexes, or any combination of these signs and
symptoms. The pain may radiate into the ipsilateral arm in a derma­
tomal pattern [3,4]. Previous studies have shown that dysfunctional
breathing patterns have been associated with musculoskeletal pain in

* Corresponding author. Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, School of Rehabilitation Sciences,
1 Abivardi Avenue, Chamran Blvd., Shiraz, 71345, Iran.
E-mail address: irezaei@sums.ac.ir (I. Rezaei).
1
Amin Kordi Yoosefinejad and Raziyeh Yousefiyan contributed equally to this work.

https://doi.org/10.1016/j.ijosm.2024.100708
Received 31 May 2023; Received in revised form 20 December 2023; Accepted 2 January 2024
Available online 7 January 2024
1746-0689/© 2024 Elsevier Ltd. All rights reserved.
A. Kordi Yoosefinejad et al.
various parts of body such as chest wall [5], neck, shoulder [6,7] and
lower back [8]. Furthermore, the association between chronic neck pain
and respiratory dysfunction has been previously demonstrated [9].
Respiratory pattern can refer to the relative contribution of thoracic
and abdominal regions during breathing, regardless of respiratory fre­
quency and volume, and other parameters [10]. Optimal breathing oc­
curs when the respiratory effort is evenly distributed between the two
main functional parts of breathing including the upper chest and lower
ribs cage/abdomen. Therefore all diaphragmatic abdominal and rib cage
muscles contribute equally to their relevant length-tension relationships
and co-ordination patterns [11,12].
Respiratory pattern might be impaired in patients with unilateral
cervical radiculopathy. It may occur secondary to the involvement of the
primary respiratory muscles (i.e. diaphragm, scalenes, trapezius, etc.)
receiving innervation from cervical nerve roots. The diaphragm is the
main inspiratory muscle innervated by the phrenic nerve. Impaired
diaphragmatic function in patients with cervical radiculopathy occurs
following the phrenic nerve involvement. Previous studies highlighted
the association between diaphragmatic paralysis and cervical radicul­
opathy [13–18]. Moreover, the diaphragm is firmly connected to neck
muscles via fascia transversalis originating from the endothoracic fascia;
hence, diaphragm and neck muscles have mutual effects on each other
[19]. Fahad et al. found that respiratory parameters including vital ca­
pacity in expiration, forced expiratory volume, forced vital capacity,
peak expiratory flow and mean voluntary ventilation were less in pa­
tients with cervical spinal stenosis in comparison to healthy control
group. The observed changes were attributed to the partial damage of
the phrenic nerve and subsequent decreased strength of the respiratory
muscles [20].
There are several methods for evaluating respiratory pattern. Manual
assessment of respiratory motion (MARM) is a clinical, time-efficient
and inexpensive evaluation method used to assess and quantify the
breathing pattern. Respiratory pattern usually is measured with respi­
ratory induction plethysmography (RIP) and magnetometry [21],
whilst, a cheaper, quick, yet valid and reliable method seems helpful in
clinical environments. MARM was first developed by Dixhoorn in the
1980s [22] to determine the contribution of the upper and lower parts of
the rib cage and abdomen into breathing pattern and also, to illustrate
the asymmetry between the sides of rib cage [10]. It is based on the
estimation of motion perceived by the examiners’ hands at the posterior
and lateral lower rib cage. The examiner constructs a mental picture of
global breathing motion, drawing an upper line and a lower line from
the center of a pie chart [10].
Courtney and Dixhoorn compared the MARM with RIP, an estab­
lished standard for measuring breathing pattern, in twelve experienced
breathers [10]. It was concluded that the MARM was a valid and reliable
clinical tool with acceptable levels of agreement between the examiners
(r = 0.85, p < .001) [10]. It does require practice, but once the skill of
using this technique and recording the findings are acquired, it is a
practical and valuable technique [10]. MARM could be regarded as a
diagnostic method in patients with respiratory disorders [23].
MARM can be used as a clinical diagnostic tool instead of laboratory
equipment to evaluate and quantify the respiratory pattern. To the best
of our knowledge, the reliability of the MARM was investigated in
healthy people, or it was suggested for patients with pulmonary dis­
eases. This is the first study assessing the reliability of the MARM in
patients with cervical radiculopathy. The aim of this study was to
determine the inter-rater and intra-rater reliability of the MARM in
patients with unilateral cervical radiculopathy.
3. Materials and methods
3.1. Study design
This cross-sectional study was conducted to determine the intra- and
inter-rater reliability of the MARM method in patients with unilateral
2
International Journal of Osteopathic Medicine 51 (2024) 100708
cervical radiculopathy. The study was approved by the local Ethics
committee of the vice chancellery of research, Shiraz University of
Medical Sciences, in accordance with the standards of the Helsinki
declaration (Ethics Number: IR. SUMS.REHAB.REC.1401.017). The
study was performed between December 2022 and February 2023 at the
Rehabilitation Sciences Research Center. The evaluation was performed
by two experienced physical therapists that were trained to use MARM.
Breathing pattern assessment was performed twice, a week apart, by
each examiner. The examiners performed the MARM separately and
were blind to the results of each other.
3.2. Participants
The minimum sample size was calculated as 21, based on a pilot
study on 10 participants, regarding the expected calculated ICC as 0.83,
an alpha level of 0.05, and power of 0.80. The sampling method was
convenient and the participants were recruited through the purposive
sampling method via flyers from the physiotherapy and neurology
clinics. Twenty-five volunteers with unilateral C3–C7 cervical radicul­
opathy, involvement of C3–C4 or C4–C5 nerve roots, aged between 30
and 55 years, and a body mass index of less than 30 Kg/m2 participated
in the study. Onset of cervical radiculopathy was at least 3 months with
pain score of 3–10 based on a numerical rating scale and moderate to
severe disability (15–50) based on the neck disability index. All patients
were clinically assessed and diagnosed by a specialist supported by MRI
findings.
Exclusion criteria were chest or lung disorders, acute respiratory
infections, long-term use of steroids or steroid injection during the last
two weeks, nonsteroidal anti-inflammatory drugs consumption during
the previous day, previous neck or thoracic surgeries, musculoskeletal
malalignments like scoliosis and kyphoscoliosis, pregnancy, recent
physiotherapy for the neck, currently smoking, respiratory complica­
tions of COVID-19, positive test for COVID-19 in the last three months,
and professional athletes.
3.3. Description of MARM
The examiner sat behind the patient who was sitting on a backless
chair with hands on the lower lateral rib cage. The examiner’s hands
rested with full contact while neither assisting nor restricting the pa­
tient’s breathing. The hands were open such that the little and ring
fingers were below the lower ribs in a horizontal orientation to feel
abdominal expansion and thumbs were vertical and parallel to the spine.
The patient was asked to breathe normally in an upright and
comfortable sitting position. The examiner got a global sense based on
palpatory impression of the magnitude and freedom of rib cage motion.
Based on palpation, the examiner determined if the relative motion of
the chest was predominantly vertical (upper rib cage motion) or hori­
zontal (lower rib cage motion) or evenly distributed.
The examiner drew an upper line (A) in the pie chart diagram of the
MARM which represents the upper thoracic motion and a lower line (B)
to represent the lower ribs motion (Fig. 1). The two lines of the MARM
are a simplified way for describing the area of expansion and predom­
inant direction of breathing motion in either the upper rib cage/sternum
or the lower rib cage/abdomen. The upper line of diagram can represent
the upward motion of the sternum/upper thorax (pump-handle motion)
as a vertical direction of breathing and the lower line can represent the
lateral expansion and sideways elevation of the lower ribs (bucket-
handle movement) as a horizontal direction. The upper line will be
further from the horizontal and closer to the top if there is more upper
rib cage motion and the lower line will be further from the horizontal
and closer to the bottom if there is lower rib cage motion [10]. Three
variables are calculated from the MARM graphic notation (Table 1). The
MARM variables are derived from one sitting posture and two breathing
instructions. The participants are asked to breathe in an upright or easy
sitting posture, once normally and then more deeply [10].
A. Kordi Yoosefinejad et al. International Journal of Osteopathic Medicine 51 (2024) 100708

using SPSS (SPSS Inc. SPSS Statistics for Windows, Version 25.0. Chi­
cago: SPSS Inc.).

4. Results

This study was conducted on 25 patients with unilateral cervical

radiculopathy. Table 2 shows the mean ± SD of demographic informa­
tion of the participants. The values of the components of the MARM for
both raters are depicted in Table 3. The results of inter-rater reliability of
the MARM during normal and deep breathing patterns between the two
raters are summarized in Table 4.
All the ICCs of inter-rater reliability presented “very good” values
during both normal and deep breathing patterns. The SEM ranges from
3.16 to 5.13. Regarding CVs, volume components of both normal and
deep breathing patterns and percent rib cage of deep pattern were good
(10–20 %), percent rib cage of normal breathing pattern had acceptable
value (20–30 %), while the CV for the balance components could not be
calculated due to negative numbers.
The results of intra-rater reliability of the components of MARM
during normal and deep breathing patterns are summarized in Table 5.
All the ICCs of intra-rater reliability presented “very good” values during
both normal and deep breathing patterns. The SEM ranges from 3.23 to
5.69. The CV for the volume components of both normal and deep
breathing patterns and percent rib cage of deep pattern were good
(10–20 %), percent rib cage of normal breathing pattern had acceptable
value (24.59), while the CV for the balance components could not be
calculated due to negative numbers.

Fig. 1. Graphic notation of the manual assessment of respiratory motion. Note: 5. Discussion
A: the vertical motion of the upper rib cage; B: the horizontal motion of the
lower rib cage; C: horizontal line, AC angle: the upper chest motion and CB
The objective of this study was to determine the intra- and inter-rater
angle: the lower chest motion.
reliability of the MARM in patients with unilateral cervical radiculop­
athy. The results suggested that the MARM is a reliable tool for the
Table 1 assessment of breathing pattern in patients with unilateral cervical
Calculation of the MARM variables. radiculopathy with "very good" inter-rater and intra-rater reliability.
Variable Description Calculation
In the study by Courtney et al., MARM and RIP were performed on
healthy people who were instructed to voluntarily alter their breathing
Volume/area of angle between AandB Angle AB
pattern and posture [10]. Two examiners assessed breathing patterns
breathing
Balance difference of AC angle and CB angle based AC – CB using the MARM and RIP. "Good" levels of agreement between the ex­
on the MARM diagram aminers and between MARM and RIP were reported. It was concluded
Percent rib cage angle aboveC/total angle (AB) × 100 AC/AB × that MARM is a reliable method for assessing breathing pattern in
motion 100
healthy individuals. Hence, the results of their study could not be
Note: Note: A: the vertical motion of the upper rib cage; B: the horizontal motion generalized to any group of patients. However, the altered breathing
of the lower rib cage; C: horizontal line based on the MARM diagram (Fig. 1), pattern observed in our participants was due to the involvement of the
Abbreviations: MARM: manual assessment of respiratory motion. cervical nerve roots innervating the diaphragm.
Ludwig et al. investigated the inter- and intra-rater reliability of the
3.4. Statistical analysis MARM in 16 participants with normal or minimal breathing dysfunc­
tion. The findings demonstrated poor inter-rater reliability of the MARM
To evaluate the inter-rater and intra-rater reliability of MARM, Intra- and high intra-rater reliability [26]. Our results were similar to those by
class correlation coefficient using the two-way random model (ICC [1, Ludwig et al. regarding intra-rater reliability; however, we reported a
2]) was calculated. The ICC [1,2] values are interpreted as follows: "very good" inter-rater reliability in contrast to their findings. In Lud­
excellent: 1.0–0.81, very good: 0.80–0.61, good: 0.60–0.41, fair: wig’s study, individuals with mild respiratory dysfunctions or healthy
0.40–0.21, and poor: 0.20–0.00 [24]. people without respiratory problems were recruited; while, our partic­
Within-subjects variability and systematic changes were calculated ipants had moderate to severe respiratory dysfunctions. Thus, the
by standard errors of measurement (SEM) and change in mean respec­ observed difference could be attributed to different populations.
tively. The SEM was calculated using the following formula:
√̅̅̅ Table 2
SEM = SD × 1– ICC
Demographic information of radiculopathy group.

Where “SD” stands for standard deviation and “ICC” stands for intra- Variables Values
class correlation coefficient [25]. Moreover, the coefficient of varia­ Age (years) 44 (7.42)
tion (CV) was calculated to express the variation of measurement as a Sex (male %) 43.8
Body mass index (kilogram/meter2) 25.1 (3.25)
percentage rather than a raw value. CV values less than 10 % are
Onset of pain (months) 8.40 (9.23)
considered very good; CV values between 10 and 20% are interpreted as Visual analog scale (cm)) 6.68 (1.49)
good; values between 20 and 30% regarded as acceptable and values Neck disability index (0-50) 20.40 (6.64)
more than 30% are unacceptable. Statistical analyses were performed
Note: Values are mean (SD) or %.

3
A. Kordi Yoosefinejad et al. International Journal of Osteopathic Medicine 51 (2024) 100708

Table 3 assessment with acceptable quality and accuracy could be practical in

Values of the components of manual assessment of respiratoty motion during clinical environments. Besides, palpatory methods are the mainstay of
normal and deep breathing patterns for each rater evaluations in physical therapy clinics. So, the MARM would be a helpful
Components Rater 1 Rater 2 manual method for evaluating the respiratory function of patients with
Volume / area of normal 37.20 ± 7.88 (23, 40.04 ± 5.99 (29,
unilateral cervical radiculopathy. Given the high levels of intra and
breathing (degree) 51) 53) inter-rater reliability identified in this study, the MARM can be reliably
Balance of normal breathing − 4.96 ± 7.79 (− 17, − 4.60 ± 9.92 (− 17, used by physical therapists to assess breathing
(degree) 12) 17) One of the limitations of the MARM is that the evaluation must be
Percent rib cage motion of 43.30 ± 10.62 44.97 ± 11.62
done in a sitting position; hence, it cannot be used for people who are
normal breathing (%) (30.23, 66.67) (30.95, 70.73)
Volume/ area of deep breathing 44.72 ± 8.05 (33, 44.68 ± 6.93 (30, unable to sit for any reason. Based on our clinical experience and pre­
(degree) 59) 55) vious studies, it should be noted that postural alteration can have an
Balance of deep breathing 14.56 ± 10.80 11.32 ± 11.12 immediate effect on patient’s respiratory function [27]. The patients
(degree) (− 13, 31) (− 22, 25) should be instructed to keep their usual position, and not to change it
Percent rib cage motion of deep 66.33 ± 12.31 72.79 ± 112.78 (28,
breathing (%) (32.43, 86.11) 81.25)
during the evaluation. Therefore, this method will not be appropriate for
patients unable to maintain their posture during the evaluation.
Note: Values are mean ± SD (Min., Max.). The papers have shown that postural changes can play an important
role in respiratory functions [27,28]. It is suggested that the reliability of
the MARM in postural disorders such as kyphosis, scoliosis, and forward
Table 4
Inter-rater reliability of the components of manual assessment of respiratory
head posture be investigated in future studies. Another suggestion for
motion during normal and deep breathing patterns. further studies is to compare the MARM in patients with unilateral
cervical radiculopathy with the results from research instrumentations
Components ICC CI 95 % (Lower SEM CV
[1,2] limit, Upper limit) (%)
of breathing pattern assessment such as RIP,magnetometry, or
spirometer.
Volume/area of normal 0.73 (0.48, 0.87) 3.16 14.93
breathing (degree)
Balance of normal breathing 0.77 (0.54, 0.89) 3.44 NA 6. Conclusions
(degree)
Percent rib cage motion of 0.80 (0.59, 0.90) 5.13 23.20
The MARM is a reliable clinical and research tool for assessing the
normal breathing (%)
Volume/area of deep 0.72 (0.46, 0.87) 3.22 13.23
breathing patterns with "very good" inter- and intra-rater reliability in
breathing (degree) patients with unilateral cervical radiculopathy.
Balance of deep breathing 0.79 (0.58, 0.90) 3.71 NA
(degree)
Percent rib cage motion of 0.79 (0.58, 0.90) 4.36 16.42
Funding sources
deep breathing (%)
This article was supported financially by the Vice Chancellor for
Abbreviations: ICC [1,2]: Intra-class Correlation Coefficient [two-way random
Research, Shiraz University of Medical Sciences [Grant number: 25551].
model], SEM: Standard Errors of Measurement, CV: Coefficient of Variation, NA:
Not applicable.
Ethical approval details

Table 5 The protocol of this study was approved by the local ethics com­
Intra-rater reliability of the components of manual assessment of respiratory mittee of Shiraz University of Medical Sciences [Ethics code: IR. SUMS.
motion during normal and deep breathing patterns. REHAB.REC.1401.017].
Components ICC CI 95 % (Lower SEM CV
[1,2] limit, Upper limit) (%)
CRediT authorship contribution statement
Volume/area of normal 0.71 0.44, 0.86 3.23 16.72
breathing (degree)
Amin Kordi Yoosefinejad: Conceptualization, Data curation,
Balance of normal breathing 0.81 0.62, 0.91 3.45 NA
(degree) Formal analysis, Methodology, Project administration, Supervision,
Percent rib cage motion of 0.76 0.51, 0.88 5.69 24.59 Validation, Writing – original draft, Writing – review & editing. Raziyeh
normal breathing (%) Yousefiyan: Conceptualization, Formal analysis, Investigation, Meth­
Volume/area ofdeep 0.71 0.45, 0.86 3.74 14.36 odology, Visualization, Writing – original draft, Writing – review &
breathing (degree)
Balance of deep breathing 0.81 0.62, 0.91 4.85 NA
editing. Raziyeh Nazari: Formal analysis, Investigation, Methodology,
(degree) Writing – original draft, Writing – review & editing. Iman Rezaei:
Percent rib cage motion of 0.82 0.63, 0.91 5.36 18.37 Conceptualization, Data curation, Formal analysis, Funding acquisition,
deep breathing (%) Methodology, Project administration, Supervision, Validation, Visuali­
Abbreviations: ICC [1,2]: Intra-class Correlation Coefficient [two-way random zation, Writing – original draft, Writing – review & editing.
model], SEM: Standard Errors of Measurement, CV: Coefficient of Variation, NA:
Not applicable.
Declaration of competing interest
MARM is a time-efficient and inexpensive manual method to eval­
uate the breathing patterns, not only in patients with asthma [23], but None.
also, based on our results, a method with "very good" intra-rater and
inter-rater reliability in patients with cervical radiculopathy. Acknowledgments
Instrumentation used to evaluate the breathing patterns in research
settings is invasive, expensive and time-consuming. Despite the impor­ This article is extracted as a part of a thesis for the master’s degree of
tance of breathing assessment, it is usually ignored or only examined in physical therapy by Raziyeh Yousefiyan. The authors would like to
patients with severe respiratory dysfunctions. The existence of a stan­ thank the Rehabilitation Sciences Research Center for facilitating the
dard, non-invasive, applicable and time-efficient method of breathing assessment process.

4
A. Kordi Yoosefinejad et al.
Abbreviations
ICC Intra-class correlation coefficient
MARM Manual Assessment of Respiratory Motion
RIP Respiratory Induction Plethysmograph
SEM Standard Errors of Measurement
CV Coefficient of Variation
References
[1] Kuijper B, et al. Degenerative cervical radiculopathy: diagnosis and conservative
treatment. A review. Eur J Neurol 2009;16(1):15–20. https://doi.org/10.1111/
j.1468-1331.2008.02365.x.
[2] Radhakrishnan K, et al. Epidemiology of cervical radiculopathy: a population-
based study from Rochester, Minnesota, 1976 through 1990. Brain 1994;117(2):
325–35. https://doi.org/10.1093/brain/117.2.325.
[3] Iyer S, et al. Cervical radiculopathy. Curr Rev Musculoskeletal Med 2016;9(3):
272–80. https://doi.org/10.1007/s12178-016-9349-4.
[4] Rhee JM, et al. Cervical radiculopathy. JAAOS-J Am Acad Orthopaedic Surg 2007;
15(8):486–94. https://doi.org/10.5435/00124635-200708000-00005.
[5] Wheatley CE. Hyperventilation syndrome: a frequent cause of chest pain. Chest
1975;68(2):195–9. https://doi.org/10.1378/chest.68.2.195.
[6] Kapreli E, et al. Respiratory dysfunction in chronic neck pain patients. A pilot
study. Cephalalgia 2009;29(7):701–10. https://doi.org/10.1111/j.1468-
2982.2008.01787.x.
[7] Perri MA, et al. Pain and faulty breathing: a pilot study. J Bodyw Mov Ther 2004;8
(4):297–306. https://doi.org/10.1016/S1360-8592(03)00085-8.
[8] Chaitow L. Breathing pattern disorders, motor control, and low back pain.
J Osteopath Med 2004;7(1):33–40. https://doi.org/10.1016/S1443-8461(04)
80007-8.
[9] Dimitriadis Z, et al. Respiratory dysfunction in patients with chronic neck pain:
what is the current evidence? J Bodyw Mov Ther 2016;20(4):704–14. https://doi.
org/10.1016/j.jbmt.2016.02.001.
[10] Courtney R, et al. Evaluation of breathing pattern: comparison of a Manual
Assessment of Respiratory Motion (MARM) and respiratory induction
plethysmography. Appl Psychophysiol Biofeedback 2008;33(2):91–100. https://
doi.org/10.1007/s10484-008-9052-3.
[11] Simon PM, et al. Distinguishable types of dyspnea in patients with shortness of
Breath 1-3. Am Rev Respir Dis 1990;142(5):1009–14. https://doi.org/10.1164/
ajrccm/142.5.1009.
[12] De Troyer A, et al. Functional anatomy of the respiratory muscles. Clin Chest Med
1988;9(2):175–93. PMID: 3292122, https://pubmed.ncbi.nlm.nih.gov/3292122.
[13] Buszek M, et al. Hemidiaphragmatic paralysis: an unusual complication of cervical
spondylosis. Arch Phys Med Rehabil 1983;64(12):601–3. https://pubmed.ncbi.
nlm.nih.gov/6661023.
International Journal of Osteopathic Medicine 51 (2024) 100708
[14] Hayashi H, et al. Diaphragmatic paralysis caused by cervical spondylosis: case
report. J Neurosurg Spine 2005;2(5):604–7. https://doi.org/10.3171/
spi.2005.2.5.0604.
[15] Keelan E, et al. An unusual case of orthopnea. Clin Med 2017;17(3):245. https://
doi.org/10.7861/clinmedicine.17-3-245.
[16] Reddy YN, Josephson RA. Osteoarthrosis causing altered mental status: a case
report. J Med Case Rep 2014;8:1–4. https://doi.org/10.1186/1752-1947-8-401.
[17] Daniil ZD, et al. An unusual cause of dyspnea in a 77-year-old man. Chest 2004;125
(2):770–4. https://doi.org/10.1378/chest.125.2.770.
[18] O’Beirne SL, et al. Association between diaphragmatic paralysis and ipsilateral
cervical spondylosis on MRI. Lung 2019;197:727–33. https://doi.org/10.1007/
s00408-019-00271-y.
[19] Bordoni B, et al. Anatomic connections of the diaphragm: influence of respiration
on the body system. J Multidiscip Healthc 2013;6:281–91. https://doi.org/
10.2147/JMDH.S45443.
[20] Fahad EM, et al. Cervical spinal stenosis and risk of pulmonary dysfunction. Int J
Critical Illness Injury Sci 2020;10(1):16. https://doi.org/10.4103/2FIJCIIS.IJCIIS_
83_19.
[21] Society ER, et al. ATS/ERS Statement on respiratory muscle testing. Am J Respir
Crit Care Med 2002;166(4):518–624. https://doi.org/10.1183/13993003.01214-
2018.
[22] Dixhoorn Jv. Two year follow up of breathing pattern in cardiac patients. In:
Proceedings 25th annual meeting. USA: Association for Applied Psychophysiology
and Biofeedback: Wheat Ridge, CO; 1994.
[23] Courtney R, et al. Medically unexplained dyspnea: partly moderated by
dysfunctional (thoracic dominant) breathing pattern. J Asthma 2011;48(3):
259–65. https://doi.org/10.3109/02770903.2011.554942.
[24] Sinaei E, et al. Responsiveness and interrater reliability of the short form of
fullerton advance balance scale in women with breast cancer following
chemotherapy. Rehab Oncol 2022;40(4):E54–60. https://doi.org/10.1097/01.
REO.0000000000000303.
[25] Yoosefinejad AK, et al. Reliability and validity of the Persian version of 5-D itching
scale among patients with chronic kidney disease. BMC Nephrol 2021;22(1):16.
https://doi.org/10.1186/s12882-020-02220-x.
[26] Ludwig M. Inter and intra-rater reliability of the manual assessment of respiratory
motion (MARM technique) in adults. Auckland, New Zealand: Unitec Institute of
Technology; 2013 (Unpublished document submitted in partial fulfillment of the
requirements for the Master of Osteopathy), https://hdl.handle.net/10652/2367.
[27] Zafar H, et al. Effect of different head-neck postures on the respiratory function in
healthy males. BioMed Res Int 2018;2018:4518269. https://doi.org/10.1155/
2018/4518269.
[28] Courtney R, et al. Comparison of the manual assessment of respiratory motion
(MARM) and the hi lo breathing assessment in determining a simulated breathing
pattern. Int J Osteopath Med 2009;12(3):86–91. https://doi.org/10.1016/j.
ijosm.2008.10.002.