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Respiratory Management (Rehab Phase)

Girdle/Abdominal Binder

Abdominal binders are used to prevent the abdominal contents from falling forward in order to maintain abdominal pressure in upright subjects with SCI. The increase in abdominal pressure is considered to position the diaphragm at a longer dome-shaped length and hence, improve inspiratory function. Abdominal binders are most commonly used in subjects with loss of abdominal wall strength (generally lesions above T6). Some early work (primarily level 4 studies) looking at the effects of abdominal binders on respiratory function in SCI was done prior to 1980 but was not included in this review. Studies on the effects of abdominal binders need to include positioning information as position greatly influences lung volumes in tetraplegia. In addition to being used as a respiratory intervention, abdominal binders are used as an intervention in subjects with postural hypotension (see the Orthostatic Hypotension module).

Author Year; Country
Score
Research Design
Total Sample Size

Methods Outcome

Cornwell et al. 2014; Australia
Prospective Cohort
N=13

Population: N=13 acute traumatic motor-complete SCI patients from ICU (12M 1F) Mean age (SD): 36.9(21.8), lesion levels C3-T1
Treatment:
Abdominal binders (AB), measurements taken while AB-on & AB-off for each patient
Outcome Measures: VC, FVC, FEV1, PEFR, MEP, and various speech measures

  1. Significant increase in VC, FCV, & FEV1 when AB is on, compared to when AB is off.

Wadsworth et al. 2012; Australia
PEDro=5
Randomized crossover study
N=14

Population: N=14 (13M; 1F) people with motor complete, C4-T1 SCI; mean (SD) age: 32(16)yrs.
Treatment: Abdominal binder (AB) on/off with participant seated in upright wheelchair, with 3 repeated measures at 6 weeks, 3 months, and 6 months after commencing daily use of an upright wheelchair.
Outcome measures: FVC, FEV1, PEFR, MIP, MEP, MAP, maximum sustained vowel time, sound pressure level

  1. AB significantly improved FVC (weighted mean difference .34L [95% confidence interval (CI) .10 –.58], P<.005), FEV1 (.25L [.01-.51], P<05), PEFR (.81L/s [.13–1.48], P<.02), MIP (7.40cmH2O [1.64 –13.14], P<.01).
  2. Participants stopped wearing an AB daily; reasons included “I think the AB will stop my abs from working” (n=2) and “the AB keeps riding up my ribs when I’m exercising” (n=1).

West et al. 2012; UK
Pre-post
N=21 (13 SCI)

Population: N=13 individuals with SCI and N=8 matched AB controls. SCI group: 12M 1F; mean(SD) age: 32(8). Control group: 6M 2F; mean(SD) age: 32(8) yrs.
Treatment: Participants underwent three trials for assessment of: 1) diaphragm and ventilator function, 2) pulmonary function, and 3) cardiovascular function. For each trial, participants were exposed to 3 conditions: 1) unbound (UB), 2) loose-bound (LB) and 3) tight- bound (TB).
Outcome measures: VC, expiratory flow, IC, maximal expiratory mouth pressure, residual volume, functional residual capacity, tidal and twitch transdiaphragmatic pressures, cardiac output, systolic mitral annular velocity, late- diastolic mitral annular velocity.

1. In SCI, TB increased VC (14%), expiratory flow throughout VC (15%), IC (21%), and MEP (25%). In contrast, TB reduced residual volume (-34%) and functional residual capacity (-23%).

2. TB increased tidal and twitch transdiaphragmatic pressures (~45%). TB increased cardiac output (28%), systolic mitral annular velocity (22%), and late-diastolic mitral annular velocity (50%).

Julia et al. 2011; Malaysia
Pre-post
N=21

Population: 18M, 3F; 17 tetraplegia, 4 paraplegia; 13 complete, 8 incomplete
Treatment: Single-strap abdominal binder (SSAB) and triple-strap abdominal binder (TSAB)
Outcome Measures: Voluntary cough PEFR

  1. Both binders improved PEFR, but TSAB improved to a greater extent. The difference in binder effects was significant for the tetraplegic group but not for the paraplegic group.
  2. In participants with incomplete injury, PEFR increased from 290.0(105.8) L/min at baseline to 332.5(110.5) and 366.3(101.5) L/min with SSAB and with TSAB, respectively.

Prigent et al. 2010; France
Prospective observational
N=72

Population: Regular corset users: 28 males, 8 females, mean age 37, mean YPI 7
Controls (no longer used corset): matched for sex and injury level; 28M, 8F, mean age 39, mean YPT 16
Treatment: use of corset
Outcome measures: VC, IC, Expiratory residual volume (ERV)

  1. In supine, VC did not differ between users and nonusers, but in sitting, VC was less for the users without the corset than nonusers. Corset use increased VC in sitting.
  2. 19 corset users compared at least 1 day with and without the corset during their usual activities and wearing the corset was associated with a significant drop in the severity of dyspnea.

Hart et al. 2005; France
Pre-post
N=10

Population: 7 tetraplegia, 3 paraplegia, mean age: 35.8 yrs, age range:18-56 yrs, 3-27 months post-injury, post-traumatic SCI levels: C5-T6, ASIA A,
Treatment: Custom girdle, designed to provide truncal stability and abdominal support
Outcome measures: Spirometry

Abdominal binding resulted in:

  1. Decrease in respiratory effort measured by Borg scale (4.3(1.8) to 2.3(1.8)).
  2. Increase in IC and FVC,
  3. Decrease in functional residual capacity;
  4. Increase in diaphragm pressure-time product – a measure of diaphragm work;
  5. Increases in twitch and maximal transdiaphragmatic pressure – measures of diaphragm force.

Estenne et al. 1998; USA
Pre-post
N=8

Population: 8 participants with SCI; Age range: 21-41 years; level of injury C5-C8; length of injury: 6-200 months
Treatment: Abdominal strapping
Outcome measures: Spirometry

Strapping the abdomen in SCI resulted in:

  1. Increase in VC;
  2. Decrease in FRC and residual volume.
  3. Small but inconsistent increases in maximal esophageal pressure and expiratory flow rate that might not improve cough.

McCool et al. 1986; USA
Prospective Controlled Trial
N=13

Population: 13 tetraplegia (C4-C7), 9 able- bodied controls, all male, mean(SD) age: 29.9(11.4) yrs
Treatment: 3 Body Positions: supine, head-up tilted (37o) and seated – with and without abdominal binders
Outcome measures: Spirometry

Abdominal binding in SCI resulted in:

  1. Increase IC in all positions, and total lung capacity in the tilted and sitting positions
  2. Decrease in functional residual capacity in all positions
  3. An increase in rib cage dimensions at TLC.

Discussion

Well-designed studies demonstrate that abdominal binders in people with tetraplegia significantly increase IC or VC, and decrease FRC in all positions (McCool et al. 1986; Estenne et al. 1998; Hart et al. 2005; Prigent 2010; Julia et al. 2011; West et al. 2012; Wadsworth et al. 2012). One randomized cross-over design of long term use (Wadsworth et al. 2012) showed that abdominal binding significantly improved spirometry and inspiratory muscle strength. One study examining a small sample (n=10) showed that a custom girdle reduces the sensation of respiratory effort as measured by the Borg Rating of Perceived Exertion (Hart et al. 2005). Abdominal binding can improve PEFR (Wadsworth et al. 2012; West et al. 2012; Julia et al. 2011) but its relevance to an improved cough has been questioned enhance cough (Estenne et al. 1998). Worthy of further study, the diaphragmatic pressure-time product increases after abdominal binding may represent enhanced diaphragmatic force production but it is not known if this change translates to an improved efficiency of breathing and decreased work of breathing. Interventions to increase abdominal pressure and decrease the laxity of abdominal chest wall, which in turn affects diaphragm length and position, have been used in other patient groups. Abdominal binding for people with SCI should be introduced cautiously and be rigorously assessed because of the potential for alteration of diaphragm length to result in mechanical inefficiency, increased dyspnea, and inspiratory muscle fatigue. The design of the abdominal binder may influence the impact of the abdominal binder (Julia et al. 2011). One study has shown intermediate or long-term effects of abdominal binding on people with SCI (C4-T1). Positioning and using other interventions that increase abdominal pressure in other chronic respiratory conditions improve diaphragm force production but also can induce diaphragm fatigue and have variable influence on dyspnea reduction. The clinical outcomes of abdominal binding should be carefully evaluated for each individual. Abdominal binding could potentially have positive or deleterious effects on inspiratory muscle efficiency and dyspnea in different people after SCI.

Conclusion

There is level 2 evidence (Wadsworth et al. 2012; Cornwell et al. 2014) that abdominal binding in tetraplegic individuals can improve respiratory function, and longer term use can continue to be effective.

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