a stroke is often accompanied by secondary complications such as nutritional and metabolic 
 disorders , endocrine dysfunction , mental problems , and cardiopulmonary disorders owing to 
 neurological system and musculoskeletal system deficits associated with brain damage1 . among these complications ,
pulmonary 
 disorders are more closely related to life and cause problems with the ability to adjust 
 respiration , swallowing , as well as , language2 .
non - use of the paretic side muscles , and difficulty with movement , 
 accompanied by direct restrictive pulmonary impairments , trigger a secondary reduction in 
 cardiopulmonary function , and the asymmetric trunk induces inefficient energy use related to 
 gait , resulting in a decrease in exercise endurance3 .
patients with hemiplegia caused by stroke undergo abnormal movement 
 of the trunk and , in particular , abnormal movement in posture and motor control . in 
 addition ,
damage to the abdominal area and chest wall , directly and indirectly decrease 
 mobility of the respiratory muscles , and weakens their strength and endurance , affecting the 
 respiratory cycle4 , 5 . during aerobic exercise , which demands endurance ,
when 
 such patients return to their local community , they may have difficulty with activities of 
 daily living , as well as , gait7 .
general 
 rehabilitation programs for stroke patients , that only aim towards functional recovery of 
 the body , are not sufficient to enhance cardiopulmonary system function8 . as such , rehabilitation programs that integrate 
 interventions related to respiration could be more effective in stroke patients for 
 improving functional activities such as gait9 .
chest resistance exercises promote the alignment of respiratory muscles with respiratory 
 rhythms by providing resistance to the sternal and costal areas to resolve the respiratory 
 problem itself10 .
conversely , a chest 
 expansion exercise is a full - body exercise technique that combines deep breathing with 
 active movements of the trunk and limbs .
this exercise is an intervention method more 
 specific to the musculoskeletal system as it moderates inspiration and expiration rates , 
 improves mobility of the intercostal space , relaxes the stiff connective tissue , and relaxes 
 soft tissues such as the pectoralis major , intercostal , and quadratus lumborum muscles11 .
a previous study in stroke patients12 
 noted that chest resistance exercises and diaphragmatic resistance exercises , by way of the 
 proprioceptive neuromuscular facilitation ( pnf ) method , improved the subjects pulmonary 
 function , leading to expansion of the pulmonary tissue , improvements in thorax movement , 
 strengthening of the respiratory muscles , and an enhancement in endurance .
britto et 
 al.4 applied inspiratory muscle training 
 to chronic stroke patients and reported strengthening of the inspiratory muscles , as well 
 as , an improvement in endurance within a short time period . in another study by 
 leelarungrayub et al.13 ,
in which chronic 
 obstructive pulmonary disease patients conducted chest expansion exercises , there was 
 significant improvement in pulmonary function , dyspnea , and the degree of chest expansion . 
 moreover , when stroke patients performed chest resistance exercises based on the pnf method , 
 there was significant improvement in their gait ability , degree of chest expansion , and 
 forced expiratory volume in 1 second ( fev1)14 . indeed , various previous studies in healthy individuals , as well as patients with 
 obstructive pulmonary disease , spinal cord injuries , cerebral palsy , and neuromuscular 
 disease have been performed ; however , studies evaluating respiratory function in stroke 
 patients following chest resistance and chest expansion exercises , and examining the 
 relation of trunk control ability with respiratory function , are lacking . accordingly , this 
 study aims to examine the efficiency of chest resistance and chest expansion exercises for 
 improving respiratory function and trunk control ability in patients with hemiplegia caused 
 by a stroke , and to compare the effects of these interventions .
study subjects was stroke patients who had suffered a stroke and were hospitalized and 
 treated at the n hospital located in daegu city , korea .
all subject was randomly allocated 
 to a chest resistance exercise group ( creg , n = 20 ) or chest expansion exercise group ( ceeg , 
 n = 20 ) .
the criteria for study subject selection included those who were chronic stroke 
 patients whereby the onset of stroke occurred at least six months prior ; those whose korea 
 mini mental state examination score was 24 points or higher ; those who had no special 
 pulmonary disease before the onset of stroke ; those who had no innate deformation of the 
 thorax or rib fracture ; and those who were able to sit independently .
this study was 
 approved by the daegu university institutional review board and all study - related procedures 
 were conducted in accordance with the ethical standards of the declaration of helsinki .
all 
 subjects understood the purpose of the study and written informed consent was received from 
 all subjects prior to their participation .
the patients assumed a supine and side - lying position while undergoing chest resistance 
 exercise patterns and the diaphragmatic palpation technique of the pnf on the costal area . 

briefly , the therapist places both hands on the costa of the patient , with the fingers 
 placed diagonally along the costal line .
pressure is then applied from the costal area , in a 
 caudal and medial direction , in line with the patient s respiratory rhythm so that the 
 patient can sufficiently breathe out during expiration , while in supine position .
the therapist diagonally applies 
 pressure in a caudal and medial direction along the costal line , drawing an arc in line with 
 the patient s respiratory rhythm on side - lying position . the diaphragm is then palpated by pushing it superiorly and laterally with the thumb or 
 other finger from below the thorax .
the therapist gives resistance to the inferior movement 
 of the contracting diaphragm . in order to provide indirect palpation , the therapist places 
 both hands on the abdominal area and
has the patient inhale while pushing diaphragm 
 superiorly with smooth pressure on supine position . in this interventional method
, the therapist pushes the patient s shoulder area in an 
 anterior - inferior direction and pulls the pelvic area in a posterior - superior direction , 
 in line with the patient s respiratory cycle . during inspiration ,
the therapist pulls the 
 shoulder area in a posterior - superior direction and pushes the pelvic area in an 
 anterior - inferior direction so that the thorax can be sufficiently expanded during 
 inspiration while in the side - lying position .
, the patient s trunk is rotated and flexed in the direction 
 of the non - paretic side and the paretic side elbow is pushed in an anterior - inferior 
 direction toward the non - paretic side knee . during inspiration ,
the trunk is maximally 
 rotated in the paretic side direction such that the elbow is in a posterior - superior 
 direction to sufficiently expand the paretic side thorax while the patients is in a seated 
 position .
the chest stretching exercise was also conducted with the patient in a seated 
 position . during expiration
, the therapist pushes together the bilateral elbows anteriorly 
 and flexes the upper part of the patient s trunk . during inspiration ,
the patient spreads 
 the bilateral elbows externally and extends the trunk to expand the thorax .
all subjects 
 who participated in the study conducted an ex - ante evaluation before initiating the 
 exercise program , and were re - evaluated eight weeks later .
the subjects respiratory 
 function was assessed based on forced volume vital capacity ( fvc ) , and fev1 , and their 
 trunk control ability was measured using the trunk impairment scale ( tis ) .
a paired t - test was 
 carried out to examine group differences , before and after the experiment , and an 
 independent t - test was conducted to evaluate differences between the two groups . 

in this interventional method , the therapist pushes the patient s shoulder area in an 
 anterior - inferior direction and pulls the pelvic area in a posterior - superior direction , 
 in line with the patient s respiratory cycle . during inspiration ,
the therapist pulls the 
 shoulder area in a posterior - superior direction and pushes the pelvic area in an 
 anterior - inferior direction so that the thorax can be sufficiently expanded during 
 inspiration while in the side - lying position .
the patient s also underwent trunk rotation 
 exercises . during expiration , the patient s trunk is rotated and flexed in the direction 
 of the non - paretic side and the paretic side elbow is pushed in an anterior - inferior 
 direction toward the non - paretic side knee . during inspiration ,
the trunk is maximally 
 rotated in the paretic side direction such that the elbow is in a posterior - superior 
 direction to sufficiently expand the paretic side thorax while the patients is in a seated 
 position .
the chest stretching exercise was also conducted with the patient in a seated 
 position . during expiration
, the therapist pushes together the bilateral elbows anteriorly 
 and flexes the upper part of the patient s trunk . during inspiration ,
the patient spreads 
 the bilateral elbows externally and extends the trunk to expand the thorax .
all subjects 
 who participated in the study conducted an ex - ante evaluation before initiating the 
 exercise program , and were re - evaluated eight weeks later .
the subjects respiratory 
 function was assessed based on forced volume vital capacity ( fvc ) , and fev1 , and their 
 trunk control ability was measured using the trunk impairment scale ( tis ) .
statistical processing of the data was conducted using spss ver . 12.0 , and descriptive 
 statistics was used to analyze the subjects general characteristics .
a paired t - test was 
 carried out to examine group differences , before and after the experiment , and an 
 independent t - test was conducted to evaluate differences between the two groups . 

table 1table 1.general characteristics ( mean  sd)cregceeggender ( male / female)12 / 811 / 9paretic side ( right / left)9 / 119 / 11diagnosis ( infarction / hemorrhage)11 / 99 / 11age55.50  11.4358.30  11.10time since stroke4.70  1.693.95  1.63mmse - k28.25 
1.8327.35  1.81*creg : chest resistance exercise group , ceeg : chest expansion exercise group , mmse - k : 
 mini mental status examination - korea version , p > 0.05 . shows the general characteristics of the study subjects .
there were no 
 significant differences in any of the characteristics between the creg and ceeg groups ( p 
 > 0.05 ) .
* creg : chest resistance exercise group , ceeg : chest expansion exercise group , mmse - k : 
 mini mental status examination - korea version , p > 0.05 .
table 2table 2.comparison of creg and ceeg respiratory function and trunk control ability ( mean 
  sd)cregceegpretestposttestpretestposttestfvc ( l)2.13  0.902.68  1.21 * 1.89  1.002.62  10.93*fev1 ( l)1.65
 0.702.03  0.83 * 1.52  0.732.18  0.69*fev1/fvc ( % ) 82.52  22.1381.42  18.7282.19  16.4386.88  10.68tis11.56  0.8814.13  0.92 * 11.49  1.1412.17  1.17**significant difference from the pretest at < 0.05 .  
fev1 : forced expiratory volume at one second , tis : trunk impairment 
 scale shows group comparisons of respiratory function and trunk control ability . 

both the creg and ceeg groups showed significant changes in fvc , fev1 , and tis after the 
 intervention ( p < 0.05 ) , but there was no significant difference in either group in 
 fev1/fvc before and after the intervention ( p > 0.05 , table 2 ) .
fev1 : forced expiratory volume at one second , tis : trunk impairment 
 scale between - group comparisons , before and after the intervention , showed no significant 
 differences between the two groups in fvc , fev1 , and fev1/fvc ( p > 0.05 ) .
however , tis 
 was more significantly improved in the creg compared to the ceeg after the intervention ( p 
 < 0.05 , table 2 ) .
this study compared chest resistance exercises and chest expansion exercises applied to 
 patients with stroke - related hemiplegia by closely examining the efficiency of the 
 interventions in improving respiratory function and trunk control ability . to examine 
 respiratory function of the subjects , this study measured fvc , fev1 , and fev1/fvc . according 
 to the results of this study ,
both the creg and the ceeg groups showed significant 
 improvements in respiratory function and trunk control ability . in a previous study , sutbeyaz et al.15 
 classified stroke patients in a sub - acute state into an inspiratory muscle training group , a 
 respiratory retraining group , and a control group , and applied interventions six times per 
 week for six weeks to compare pulmonary function between groups .
the results showed that fvc 
 and fev1 of the inspiratory muscle training group significantly increased .
similarly , kim 
 jae - hyeon12 applied chest mobility 
 exercises , chest resistance exercises using the pnf method , and respiration exercises using 
 diaphragmatic respiration exercise in stroke patients for four weeks , and their vital 
 capacity , fvc , fev1 , and maximal voluntary ventilation significantly changed . in another 
 study by mueller et al.16 ,
respiration 
 exercises in spinal cord injury patients resulted in a significant increase in fev1/fvc and 
 fev1 .
jeong ju - hyeon and kim nan - su17 
 reported that following breathing exercises for six weeks using resistive inspiratory muscle 
 training , the subjects fev1 and maximal expiratory pressure significantly improved but fvc 
 and fev1/fvc did not significantly increase .
britto et al.4 applied respiration exercises , using a respiratory resistance 
 instrument in stroke patients , and reported that there were significant changes in the 
 maximal inspiratory pressure and inspiratory muscle endurance . in line with the results of the previous studies mentioned above , the subjects fvc and 
 fev1 , in the present study , significantly improved after undergoing chest resistance 
 exercises for eight weeks .
this finding is not surprising given that the provision of 
 resistance would be expected to ameliorate the strength and endurance of the respiratory 
 muscles , with effective improvements in the subjects respiratory functions .
kim 
 sang - hoe18 reported that a combination 
 of lumbar stabilization exercises and trunk stretching significantly improved fvc .
lima et 
 al.19 applied a neck and trunk muscle 
 mobilization technique in healthy subjects and found that the fev1 and peak expiratory flow 
 rate were significantly improved .
seo gyo - cheol et al.14 applied chest expansion exercises and resistance exercises to 
 subjects for four weeks and reported that there were significant changes in fvc , fev1 , and 
 maximal expiratory flow , but not in fev1/fvc .
similarly , in the present study , the subjects 
 fvc and fev1 significantly improved after the chest expansion exercises .
this result 
 supports burianova s opinion20 that chest 
 expansion exercises achieve appropriate contraction of the respiratory muscles and enhance 
 ventilation by promoting muscle activity .
jandt 
 et al.21 compared the association between 
 trunk control , respiratory muscle strength , and pulmonary function in stroke patients and 
 noted that a consistent and statistically significant correlation was found between tis and 
 peak expiratory flow and between tis and maximum expiratory pressure . in a study by kim min - hwan22 where 
 stroke patients received expiratory muscle training five times per week for six weeks
, the 
 experimental group showed significant improvements in trunk control ability compared to the 
 control group .
gu tae - wu23 observed that 
 a combination of thoracic mobilization and respiration exercises resulted in significant 
 enhancements in the subjects trunk control ability . in the present study , which examined the subjects trunk control ability after the 
 application of chest resistance and chest expansion exercises ,
the tis significantly 
 improved in both groups with more significant improvements in the creg than in the ceeg . 

this is likely due to improvements in respiratory muscle function following the application 
 of each exercise program which could affect trunk control ability .
more significant 
 improvements observed in the creg group could be attributed to enhancements in respiratory 
 muscle strength and endurance with chest resistance exercises , which more greatly affect 
 trunk stability in comparison to chest expansion exercises .
a limitation of the present study is that it is difficult to generalize the current 
 observations , as the number of subjects is small . as such , further long - term studies on a 
 larger subset of stroke patients , and with regular follow - up intervals to ascertain
nevertheless , the results of the present 
 study show that both chest resistance exercises and chest expansion exercises were effective 
 in improving respiratory function and trunk control ability in hemiplegic stroke patients , 
 however chest resistance exercises were more effective than chest expansion exercises .
thus , 
 chest resistance exercises and chest expansion exercises may be suitable and effective 
 therapeutic intervention methods to improve respiratory function and trunk control ability 
 in stroke patients .
 [ purpose ] the purpose of this study was to examine the efficiency of chest resistance and 
 chest expansion exercises for improving respiratory function and trunk control ability in 
 patients with stroke . 
 [ subjects ] forty patients with stroke were randomly allocated into a 
 chest resistance exercise group ( creg , n = 20 ) and a chest expansion exercise group ( ceeg , 
 n = 20 ) . 
 [ methods ] creg patients underwent chest resistance exercises , and diaphragmatic 
 resistance exercises by way of the proprioceptive neuromuscular facilitation . 
 ceeg 
 patients underwent respiratory exercises with chest expansion in various positions . 
 both 
 groups received 30 minutes of training per day , five times per week , for eight weeks . 
 
 [ results ] both the cerg and ceeg groups showed significant changes in fvc , fev1 , and tis 
 after the intervention . 
 tis was significantly increased in the creg compared to the ceeg 
 after the intervention . 
 [ conclusion ] both chest resistance and chest expansion exercises 
 were effective for improving respiratory function and trunk control ability in stroke 
 patients ; however , chest resistance exercise is more efficient for increasing trunk 
 control ability . 
INTRODUCTION
SUBJECTS AND METHODS
Chest expiration exercise group
Statistical analysis
RESULTS
DISCUSSION