Download Respiratory Function in Multiple Sclerosis

Respiratory
Function
Utility of Clinical
Muscle Function
Suzanne
Raymond
Marc
C.
Smeltzer,
H. Lavietes,
The
clinical
assessment
Thtients
and
performed
M.D.,
neurologic
findings,
weakness,
cerebellar
and
clinical
function
and
living,
indices
pulmonary
on a
Reaulis:
Mean
and
percent±
19),
contrast,
MVV
PEmax
single
telectasis,
weak
index
(68
percent±20),
percent±
were
patients,
pulmonary
formed,
respiratory
muscle
weakness
14)
VC
decreased.
(91
By
±27)
muscle
strength,
occult
frequently
is found
in
pulmonary
symptoms
or
is
temporal
muscle
an
insensitive
although
indicator
relationweakness
routinely
of
per-
respiratory
muscle
weakness.
Although
the performance
of the
vc maneuver
requires
both inspiratory
and expiratory
muscles,
severe
muscle
weakness
may be accompanied
5From
the College
ofNursing,
Rutgers,
the State University
of New
Jersey
(Dr. Smeltzer);
the University
of Medicine
and Dentistry
ofNew
Jersey,
Newark,
NJ: Department
of Medicine,
Pulmonary
Division
(Dr. Lavietes
and Mr. Duran);
Department
of Neuroscience
(Drs.
Troiano
and
Cook);
Department
of Preventive
Medicine
and Community
Health (Dr. Skurnick).
Supported
in part
by a Rutgers
Research
Council
Grant
and a
Rutgers College
ofNursing
Grant.
Manuscript
received
March
13; revision
accepted
June 7.
Reprint
requests:
Dr. Smeltzer,
Department
of Nursing,
Thomas
Jefferson
University,
Philadelphia
19107-5233
assessment
and
60
percent
of
is a better
spirometry
supplemented
MVV
can
in patients
by
uncover
with
(Chest
subtle
MS.
1992;
101:479-84)
of variance;
EDSS
expanded
disability
status scale; ERV
expiratory
reserve
volume;
FEV1
forced
expiratory
volume
in 1 5; FRCfunctional
residual
capacity;
Ic= inspiratory
capacity;
MS
multiple
sclerosis;
MVV
maximal
voluntary
ventilation;
PEFRpealc
expiratory
flow
rate; PEmax
maximal
expiratory
pressure;
Pimax
maximal
inspiratory
pressure;
RV residual
volume;
TLC
total
lung
capacity;
VC vital capacity
ANOVAanaIysis
by little
suggested
expiratory
or no volume
loss.4
A recent
study
has
that analysis
of both
the inspiratory
and
limbs
of a flow-volume
curve
provides
a
specific
but
muscle
ease.5
and
not
a sensitive
prediction
weakness
in patients
with
This analysis
is somewhat
would
pulmonary
The
MS
not likely
be
laboratories.
plaques
often
and
upper
cervical
speech
or weakness
both,
testing,
for
Stepwise
dysfunction.
function
clinical
dysarthria
and pneumonia
have long been
terminal
events
for MS patients.’
suggest
that when
MS patients
perform
Pulmonary
a systematic
assessment
as
of onset
of such weakness
and the
ship between
the onset ofrespiratory
that
accounted
that clinical assessment
muscle weakness
than
muscle
Since
specific
tests
of respiratory
muscle
are rarely
performed
in this population
of
clinicians
often are unaware
ofboth
the time
strength
and
ventilation
in PEmax.
We conclude
of respiratory
respiratory
aspiration
studies
voluntary
the variance
in activities
normal.
(74 percent
Punax
22)
maximal
indicated
muscle
of index
combination
predictor
lesions
that the best single predictor
weakness
was the index score;
the
score, upper extremity
weakness,
and
regression
of expiratory
comprised
of TLC (95 percent±
percent±
34) were
specific
tests
of respiratory
respiratory
muscle
weakness
those
patients
free
from
and
voice,
multiple
Conclusion:
detailed
extremity
cerebral
dependence
RV (106
and
recognized
disease.2’3
of
evidence
of
lower
exhalation.
values
(51
history
De-
of four
report
of difficulty
in clearing
his report of a weakened
cough,
ofthe patient’s cough,
and ability
observation
to count
Recent
and
proce-
strength.
and
including
patient’s
secretions
the examiner’s
and
the
a
of breath,
devised
an
shortness
We
signs:
muscle
upper
signs,
standard
using
included
including
dysphagia.
clinical
tests
of respiratory
signs
and
F.C.C.P
of this study was to assess the utility
of
of respiratory
muscle
weakness
in MS.
methods:
We studied
40 MS
patients
who
dures
and
measures
scriptive
clinical
of daily
of Respiratory
aim
pulmonary
other
Assessment
Sclerosis*
Ed.D.,
R.N.; Joan H. Skurnick,
Ph.D.;
M.D.;
Stuart
D. Cook,
M.D.;
Walck
Duran;
Troiano,
Purpose:
in Multiple
which
would
performed
are
lateral
tal and
neurons
close
cord,
lation
found
cord.
or more
result
from
in the
to innervate
hospital
brain
stem
Abnormalities
muscle
groups
such
plaques,
motoneurons
group
traverse
abdominal
muscles.6
to respiratory
and
the
are
originating
the ventral
phrenic,
Therefore,
extremity
of
or
intercos-
since
muscles
motolie in
proximity
in the brain
stem and cervical
spinal
we speculate
that there
should
be some
correbetween
motor
weakness
found
on the general
neurologic
ness.
tory
medulla
in most
spinal
of one
common
in MS. Respiratory
in the ventral
respiratory
and
of respiratory
neuromuscular
discomplex,
however,
examination
and
To determine
the
muscle
weakness,
function,
strength
neurologic
in 40 MS
function
patients.
CHEST
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21639/ on 05/10/2017
respiratory
muscle
best discriminator
we have
studied
and
I 101
respiratory
I 2 I FEBRUARY,
weak-
of respirapulmonary
muscle
1992
479
PATIENTS
Forty-three
the
patients
criteria
invited
of Poser
to
Data
Spirometry,
seated
stand,
published
age.’
signed
MS
informed
to complete
dilution
an
and
predicted
standards
using
we
MVV
automated
MA).
article,
were
VC%
TLC%
IC%
FRC%
the
study
were
Mean
90.7
95.4
96.0
Standard
21.3
14.2
21.3
were
testing
system
Since
some
subjects
values
for
pulmonary
arm
span
define
rather
normal
performed
Static
height
and
volumes
to
ability
sex and
weak
as 80 percent
measured
with
Hyatt.’
an aneroid
A small
spuriously
leak
high
cough
following
inspiration
to TLC.
subject’s
best
analysis.
Predicted
Hyatt.9
of the
appropriate
range
The
Kurtzkel2
second
whose
was
than
indicating
from
MS.
The
normal
An EDSS
swallow
of the
One
author
association
neurologic
of 9.5
reflects
The
subjects’
(S.D.C.)
with
perform
for
those
data
post
of Black
dependence
in
weakness
was
format;’
muscle
scored
A profile
weak
of
that
and
or Index
ofPulmonary
study.
This
Table
1 -index
(Circle
PATIENTS
coded
as a clinical
index
One
extremity
Cough
daily
values.”
living
was
3.
to eat,
Dysfunction
predictor
signs
(patient
Muscle
normal
of patient’s
asked
Sclerosis
analyze
associations
volumes.
Forward
0.05
used
is
function
are
described
to calculate
means
criterion
in
The
error
<0.05
adjusted
muscle
regression
enter
for
levels
was
were
and
drop.
multiple
probability
muscle
Data
are
values
which
weakness
presented
significance
was
comparisons
to
static
to identify
of expiratory
of statistical
used
and
strength
used
degree
volumes,
of disability.
coefficients
respiratory
criterion
All reported
and
lung
to
Scheffe
the
with
and
and
and
whether
associated
scores
results
ANOVA
to determine
was
predictive
to
± SD.
test
t tests,
index
stepwise
means
used
correlation
most
which
include
in
Lung
and
Static
function
Table
3.
percent
normal.
as normal
normal:
weak:
age
by
as
a type
1
Bonferroni’s
are two-tailed.
of the 40 subjects
of the subjects
were
the
Respiratory
was 40± 11 years.
female.
Thirty-four
average
Muscle
smoking
history
Test Results
Function
lung
volumes
appear
in Table
2; airway
and respiratory
muscle
test results
appear
in
The TLC measured
5.3 ± 1.0 L, or 95±14
of predicted.
The VC, FRC and RV also are
Therefore,
static lung volumes
are normal
for
group.
Both
normal:
voluntarily
weak:
as possible
very
1
Table
2
Respiratory
3-
PEFR
(5.2±
1.8
Ifs,
or
71 ±20
reached
aloud
on a single
when
inspiratory
patient
exhalation
30:
counts
after
effort
and
40)
20-29:
2
Mean
10-19:
3
Standard
Score:
%
PEFR
%
MVV %
Pmax
Pemax
%
1
-
-
-
80.8
70.6
68.4
74.2
50.8
9.8
20.2
20.4
27.3
22.3
deviation
4
Summed
Tests ofAirway
Function
Muscle
Strength
(No.
3
weak/inaudible:
FEV,/VC
480
index
function
weakness
between
were
was
or current
smokers.
Their
was 13± 16 pack years.
dysfunction
in strength)
cough
to cough
Value
maximum
pulmonary
of this
on
and
HAliNG:
as forcefully
4.
score
signs
subjects
were white
and six black.
The average
duration of MS from the time ofdiagnosis
was 9 ± 7.5 years
( range: < 1 to 40 years). Thirty
subjects
were previous
(+5)
handling
rates
disturbed
Two-tailed
were
muscle
Mean
Twenty-five
signs,
in Multiple
signs
clinical
Sample
pres-
assessment
of respiratory
ofclinical
tests.
comparisons
method.
( + 1).
as present
The
RESULTS
bulbar
than
more
of a
secretions.
for their
spasticity.
as less
patients
report
without
the
ofPulmonary
Dysfunction
Muftiple
Sclerosis
Responsefor
Each Category)
of difficulty
Strength
when
hoc
with
from
death
signs
neumlogic
graded
subject’s
pseudobulbar
and
more
validity
results.
weakness,
a standard
is comprised
or weak/diminished
EXAMINER’S
hypothesis
moment
included
dyspnea,
the
patient’s
is 4 to 1 1 . A higher
of
pulmonary
symptoms,
ranging
(S.C.S.),
the
pulmonary
index
program
of
product
assigned
neurologic
Signs
statistical
deviations
clinical
indicating
test
and
Pearson
mucus/secretions
2.
34.3
Analysis
of respiratory
RATING:
1. History
106.2
33.0
‘
specific
(inability
was
function
voice),
as weak
in this
78.5
25.1
and
presence
with
predicted),
each
score
disability
score
specific
using
strength
used
to 10,
total
(0) of upper
activities
1) was
findings,
dysftinction.
assessed
(Table
to describe
one
pulmonary
pulmonary
dysphagia,
used
on the
120 percent
in predicted
provides
EDSS
analyzed
( + 1) or absence
(dysarthria,
was
EDSS
or communicate).
knowledge
94.5
examiner
clearing
the
Reliability
SPSS-X
times.’#{176}The
80 percent
made
The
standard
used
were
was
following
RV exceeded
less
were
EDSS
offunction.
zero,
was
three
of scores
elsewhere.
Statistical
of
Plmax
PEmax,
strength
was
for volume
the
results.
by the
exhalation
difficulty
indicates
parameters
standard
level
RV%
and
Assessment
global
ence
and
one
subjects
(or TLC
of Black
as rated
to be associated
detail
were
generation
The
repeated
for muscle
few
value
method
muscles.
RV
for
pressures
prevented
was
effort
corrections
Clinical
to
measure
values
For those
by the
buccal
exhalation
Each
muscle
mouthpiece
by
sustained
predicted
ERV%
value.
on a single
and
index
test
expiratory
manometer
in the
pressures
measured
and
and
predicted
cough
to count
possible
Pressures
inspiratory
ofa
a weakened
from
the
Respiratory
static
40)
PLUS,
unable
function
than
static
(DSII
were
percent
*%
with
expected
Maximal
Lrnsg Volumes
Test Resuks)
(No.
Function
consent.
or greater.
Maximal
2-Statk
(Pulmonary
meeting
Thsts
using
In this
of definite
All
and
deviation
obtained
of predicted
diagnosis
study.
unwilling
Braintree,
we
clinic
analysis.
helium
Collins,
Table
METHODS
to a neurology
for the
subjects
final
Function
Pulmonary
patients
al
in the
three
from
WE
et
participate
from
omitted
AND
presenting
*%
percent
ofa
predicted
Respiratory
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21639/ on 05/10/2017
value.
Function
in Muftiple
Sclerosis
(Sm&tzer
et a!)
Table 4-Pearson
Correlation
Respiratory
Muscle Strength
(No.
Coefficients
and Static
between
Volumes
Relationships
Degree
of
to
Respiratory
Static
Volumes
MuscleStrength
VC
%
TLC
%
IC %
FRC
%
ERV
%
9),
median
implies
the
ability
arbitrarily
-
(% Predicted)
RV %
groups:
Pimax
0.62t
0.34
0.56t
-0.07
0.32
-0.32t
PEma.x
0.56t
0.23
0.61t
-0.27
0.14
-0.42t
*Significance
cent
=
level
ofa
predicted
p0.0002.
tTwo-tailed
p<O.007.
Bonferroni’s
7
to
ambulatory
=(0.05)/12 =0.0042.
a
% = per-
MVV
these
muscle
results
may
more
of Pimax
so than
measurements
expiratory
for
volumes
the
reflect
group
were
of airway
correlated
with
muscle
strength.
on
function,
either
lung
was
and
p
not
The
subjects
and those
or crutches)
who
combined,
in their
=
We
three
there
between
By contrast,
greater
value
TLC
than
10.0;
and
The
who
are
were
pulmonary
predicted)
or the
bedridden
groups
(F valuel4.5;
The RV of the latter
group,
0.0003).
with
require
assisfor ambulation;
since
mean
relationship
distinguish
the groups.
The relationships
between
tion testing
and disability
respiratory
or
both
predicted,
was significantly
of the
other
groups
(F
and
FEV,/FVC,
normal
volumes
percent
predicted)
p<O.000l).
normal,
Plmax
were
differences
results.
chai,
into
pulmonary
VC in
was
(82
(62 percent
df2,
37;
174 percent
that of either
df
2, 37;
FEV1/FVC
respiratory
appear
in
no
func-
and EDSS
is shown
in Figure
1. The
the least disabled
group,
102 percent
predicted,
greater
than that for either
the wheelchair-bound
Direct
average
test
of 2
but
and
propel
the
the
40 subjects
includes
groups
(range
(EDSS
<7);
wheelchair-hound
bedridden
(EDSS
8.5).
and
8);
7.0
a wheelchair
function
weakness,
static lung
of both
4). The
.
160
w
show
While
the
L:
-J
Cl)
and
did
not
muscle
funcFigure
2. The
.
I 80
Cl)
I-
weakness.
and PEmax
inspiratory.
there
was significant
correlation
PEmax
with VC, IC and RV (Table
a measure
(83.9 ± 28.9
L or
minimally
dimineffort-dependent,
were
are
to
group
two
tion
of predicted)
and
68 ± 20 percent
of predicted)
ished.
Since
PEFR
and MVV
for all subjects,
completely
ambulatory
tance
(canes,
walkers
these
percent
EDSS
to transfer
categorized
significant
test
Dysfunction
confinement
ambulatory
(EDSS
value.
tTwo-tailed
Pulmonary
Disability
40)*
The
Measures
between
ofClinical
RV%
FEV1/FVC
I 40
CflO
LLJW
za
2w
0
120
ioo:=
--1
00.
zLL.
Li.0
>-
80
60
z
0
40
-J
20
0
Ambulatory
without
or
with
assist
Wheelchair
Bound
(n=19)
1 . Pulmonary
(n
=
3)
(n=18)
CATEGORY
FI;uisE
predicted.
Bedridden
function
test
results
OF
by category
NEUROLOGIC
of netirologic
DISABILITY
disability
expressed
CHEST
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21639/ on 05/10/2017
as
I 101
percent
I 2 I FEBRUARY,
1992
481
100
I
z
w
Cl)
80
w
-I
0
Cl)
60
0
I-
40
0
Cl)
w
LI.
0
20
Cl)
w
Cl)
w
0
Ambulatory
without
with
assist
or
Wheelchair
Bound
(n=19)
(n=18)
CATEGORY
2. Nleasures
pre(licted.
FI;uIF:
percent
ANOVA
demonstrated
MVV
I
the
0.02).
=
cant
(F
Post
hoc
2, 37;
groups;
PEmax
for
(c<O.Ol)
than
that
Mean
values
given
clinical
Table
5. The
those
Patients
upper
the
ambulatory
finding
is
PEmax
two
for
or
greater
absent
whom
Findings
Clinical
Sign
=
extremity
=
Present
(n
Absent
(n=
(Unpaired
dysarthria
Weak
44.3
10)
68.0±25.9
and
MVV,
Expiratory
Muscle
Clinical
Data
weakness
expiratory
into
the
multiple
482
to
muscle
three
that
ability
(EDSS),
Weakness
strength
for
entry
the
F-to-enter
of VC,
and
PEmax,
groups
3. 12
0.004*
1.53
0.14
1.50
0.14
3.08
0.004*
2.31
0.03
0.95
0.35
3.05
0.01
2.71
0.01
53.5±21.8
voice
32.0±27.7
Absent
52.3±21.5
(n =35)
35.5±15.7
57.6±
(n26)
score,
upper
.
Disability
analysis
of each
value
was
variable
was
PEFR
the
measure
was
(n = 3)
carried
to the
significant
Pseudobulbar
23.0
53.0±
(n36)
in activities
of
*Statistically
33.1±11.0
=27)
57.7
± 23.8
motor
lesions
Present(n32)
Absent
the
(n
of tipper
neuron
equation
22.7
living
Absent
Signs
the
at
37.0±31.1
Absent
Present(n=9)
Stepwise
out;
Signs
Dependence
of
± 12.2
53.1±21.4
Present(n=2)
daily
categorized
described.
previously
the
in
extremity
a sensitive
22.3
Dysphagia
Present
index
ofdysarthria
predict
regression
criterion
was
score
or absence
presence
the
compared
Kurtzke
p Value
Dysarthria
In order
to determine
which
parameters
were
best predictors
of pulmonary
muscle
dysfunction
we
± 18.3
35.8±23.0
Ahsent(n=35)
sample,
Two-Tailed
Value
weakness
28)
Present(n12)
this
and
Values by
t Tests)
PEmOX
Present(n=3)
Absent
Tue Ability
to predict
Lsiboratory
and
as
Two-Tailed
PEmax
(ii=33)
Absent
in
for
0.004)
weakness.
f rout
expressed
ofMean
5-Comparison
Clinical
Present(n=4)
a
appear
(p
without,
disability
Dyspnea
in
significantly
vs those
Upper
three
groups.
subjects
present
differs
with,
extremity
other
PEmax
was
of neurologic
tTest
signifiall
DISABILITY
Table
not Pimax
df
2, 37;
that
group
by category
and
between
existed
for the
for
but
ROLOGICAL
both
in
4.3;
=
NEU
function
p<O.000l)
indicated
comparisons
in
MVV
differences
muscle
differences
df
12.71;
=
OF
respiratory
(F = 14.8, df= 2, 37; p<O.000l),
three
functional
groups
(F
PEIIIaX
for
of
significant
values
test
Bedridden
(n = 3)
(n
46.7±19.6
=5)
74.4 ± 32.8
significant
at Bonferroni’s
Respiratory
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21639/ on 05/10/2017
Function
a
=0.05/8 =0.00625.
in Multiple
Sclerosis
(Smeltzer
et a!)
Table
6-Stepwise
Variables
Variable
in
Univariate
Equation
Index
Upper
extremity
weakness
MVV
of Clinical
Multiple
Regression
on PEmax
(No.
Multiple
trials
38)
Adjusted
Two-Thiled
R
R
R’
R5
p Value
0.70
0.70
0.48
0.49
0.46
0.74
0.51
0.54
0.047
0.77
0.77
0.56
0.60
0.042
<0.0001
may
be
diction
Table 6 identifies
and contribute
of the outcome
(index
score,
accounted
for
variables
MW)
those
variables
that
significantly
to the
met
pre-
variable
(PEmax);
these
three
upper
extremity
weakness
and
60 percent
of the variance
of
PEmax.
COMMENT
This
weakness,
study
demonstrates
that
respiratory
muscle
especially
expiratory
muscle
weakness,
is
common
in patients
with multiple
in patients
who are ambulatory
are confined
to a wheelchair
invariably
present
in patients
or
coughing
with
upper
amination.
standard
rate.
with
removing
arm
sclerosis
and occurs
as well as those
who
or bed. Such weakness
is
who describe
difficulty
airway
weakness
secretions
observed
or
on
ex-
Such
patients
may perform
normally
on
tests ofeither
lung volume
or maximal
airflow
To our knowledge,
this
a greater
range ofgeneral
survey
motor
includes
patients
dysfunction
than
published
surveys
of pulmonary
function
in MS, in
which
patients
were either
ambulatory
or had severe
motor
impairment.2’3
ofLaboratory
Methods
There
are two potential
sources
measurement
of Pimax
and PEmax.
standards
used here may overestimate
ofairway
pressures
that the inspiratory
of error
in the
One,
the normal
the magnitude
and expiratory
.
one
and
served
muscle
inverse
relationship
an
R% This
individuals
with
weakness.
Second,
we
have
oh-
relationship
has been
between
observed
PEmaX
previously
and
in
muscle
weakness
data.
Normal
muscle
two decades
ago
tories
gested
Pimax
slightly
pretation
chosen.
estimates
assure
While
subjects
pressures
and have
used here were published
been used by many labora-
since.
By contrast,
recent
authors
have sugthat these
norms
may overestimate
maximal
by as much
as 15 percent
and PEmax
by a
greater
percentage.’’9
Thus,
our data interIn
may be biased
by the standards
we have
addition,
previous
authors
have
varied
of the number
of repetitions
required
to
that subjects
have learned
as few as three
trials are
to achieve
maximal
to perform
the test.
necessary
for normal
pressures,
as many
as nine
who
free from cardiopulmonary
testing
was repeated
at least
disease.,2L
three
times
it
to
is unlikely
that
failure
learn
are
otherwise
Finally,
since
in all subjects,
has
led
to
the
underestimation
of mouth
pressures
in this study.
Failure
to observe
significant
differences
in Pimax
may be due to low power,
given
the relatively
small
sample
and
size
subjects
in this
high
Do Clinical
Why
Weakness
These
talking,
variability
in values
obtained
by
sample.
indices
“Predict”
in Multiple
Respiratory
Muscle
Sclerosis?
data show that clinical
indices
coughing
and upper
extremity
which
involve
strength
may
be used to predict
expiratory
muscle
should
not be surprising
because
the
weakness.
generation
This
of an
effective
cough
requires
expiratory
muscle
contraction
against
a closed
glottis.
Talking
also requires
coordination
of respiratory
muscle
contractions
along
with
complicated
muscles.
Brain
motions
stem
bulbar
expected
that
ities requiring
of the
pathology
signs
are
when
both
patients
laryngeal
tongue
occurs
common.
and
laryngeal
frequently
in
Thus,
have difficulty
and abdominal
it
can
with
activmuscles
be
that
ities
deficiencies
in the ability
to perform
these
activshould
serve
as a marker
for expiratory
muscle
weakness.
Similarly,
the use of upper
extremity
mus-
tract (thought
responsible
of accessory
inspiratory
expiratory
axons, located
perform
weak-
ness were an artifact
of spuriously
high standards,
would
expect
to observe
excess
ofboth
inspiratory
requires
subject
to
of spurious
true
that
conweak-
des
well
failure
to teach
the
will lead to collection
with
19
First,
it is apparent
can occur
without
weakness.
If muscle
muscles
ofnormal
subjects
can develop.
Two, patients
with weakness
may fail to repeat
the strength
testing
sufficiently.
Since
successful
performance
of this test
learning,
optimally
in patients
muscles.
weakness
muscle
MS;
Critique
learning
ness of expiratory
expiratory
muscle
comitant
inspiratory
in those
physical
for
disease
‘
these
data demonstrate
expiratory
0.05 level.
the criterion
required
respiratory
system
We believe
that
governed
by
as high thoracic
15
of the
regions
spinal
spinal
nerve
cord
cord and low cervical
as
roots.
Pathology
in those
may
abut
the outer
margin
of the ventral
surface
ofthe
spinal
cord.6’
Clinical
Implications
Identification
bles the clinician
cough
tract
ened
be
used
disease.
rate
who are
infection.
respiratory
the
corticospinal
for the voluntary
activation
muscles)
or the descending
in a discrete
bundle
between
of This
of expiratory
to identify
horn
and
the
ventral
Study
muscle
patients
weakness
enawith inadequate
at risk for upper
and lower
respiratory
However,
the identification
of weakmuscles
in any given patient
cannot
to predict
the course
of this unpredictable
Serial
studies
would
be helpful
to chart
of change
in expiratory
CHEST
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21639/ on 05/10/2017
muscle
weakness
I 101 I 2 I FEBRUARY,
when
1992
the
a
483
single
study
for respiratory
that
demonstrates
infection.
weakness
nervous
observation3
from
in MS
system
that
disuse
supported
not often
that
Finally,
results
the
patient
from
irreversible
changes.
However,
some
of the weakness
atrophy
rather
than
central
the
previous
may result
pathology
by the fact that the expiratory
called
into use in patients
with
limited
is at risk
presumed
it is usually
may
muscles
MS who
10 Larson
J, Kim MJ. Reliability of maximal
inspiratory
pressure.
Nun Res 1987; 36:317-19
11 Black LF, Hyatt
RE.
Maximal
static
respiratory
pressures
in
generalized
neuromuscular
disease.
Am Rev Bespir Dis 1971;
103:641-50
12
are
have
13
14
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Function
in Muftiple Sclerosis
(Sm&tzeetal)