Clinical Science (1970) 39,407-422.
CHEST MOVEMENTS I N PATIENTS WITH T R A U M A T I C
I N J U R I E S OF T H E CERVICAL C O R D
Liverpool Regional Paraplegic Centre, Promenade Hospital, Southport
(Received 25 February 1970)
SUMMARY
1. The chest movements of three normal subjects and three patients with traumatic
tetraplegia were studied with a specially designed caliper and correlated with the
volume of air breathed while seated.
2. The chest movements of the tetraplegic patients were reduced; and there was
paradoxical sucking in of the lateral wall of the rib cage.
3. The movements were estimated in a further normal subject and the three tetraplegic patients during tilting procedures (30" head up, horizontally and 30" head
down); postural effects were observed in the apical and sternochondral regions of
the tetraplegics.
4. These paradoxical movements appeared to be due to both the loss of the action
of the paralysed intercostal muscles and the impairment of the action of the diaphragm
secondary to the paralysis of intercostal and abdominal muscles.
Since Duchenne's classical observations in 1867, many studies and reviews of the actions of the
respiratory muscles have been carried out, notably by Keith (1909) and Wade (1954) who, by a
combination of spirometry, X-ray screening and direct measurements of the chest, correlated
the movements of the diaphragm with the movements of the chest wall. In 1958 Campbell
introduced the techniques of electromyography to study directly the actions of all respiratory
muscles, apart from the diaphragm. There have been several recent papers devoted entirely to
the mechanical properties of the chest wall and the movements produced by the respiratory
muscles and how these are modified by posture and respiratory loading (Agostoni, Mognoni,
Torri & Saracino, 1965; Agostoni 8z Mognoni, 1966; Konno & Mead, 1967 and Jordanoglou,
1969). It seemed that since there were many patients with well defined spinal cord lesions, as a
result of trauma, there was an opportunity to determine the individual actions of the diaphragm
and accessory muscles of respiration in tetraplegic patients when the intercostal and abdominal
Correspondence: Dr J. R. Silver, Liverpool Regional Paraplegic Centre, Promenade Hospital, Southport,
Lancashire.
407
A . Moulton and J. R. Silver
muscles were paralysed together with their relationship to the movements of the chest wall and
abdomen. The results found in tetraplegics may be of value in determining the action of these
muscles in normal subjects.
MATERIALS A N D METHODS
Subjects
Four normal subjects and three patients with spinal cord lesions in the cervical region were
studied. Their anthropological details together with their vital capacities and predicted vital
capacities derived from the formula of Kory, Callahan, Boren & Syner (1961) quoted by
Cotes, 1968, are presented in Table 1.
TABLE
1. Anthropological details of four normal subjects
and three patients together with vital capacities (V.C.)and
predicted vital capacities (Pred. V.C.)
Subject
Age
(years)
B.
M.
BR.
L.
18
40
28
53
Height
(cm)
196
173
168
169
BTPS
Weight
(kg) V.C. Pred.V.C.
76
76
56
89
(1)
(1)
5.0
5.5
5.0
3.6
5.8
4.6
4,6
4.2
Patients with spinal cord lesions
Duration
BTPS
of
injury V.C. Pred. V.C.
(years)
(1)
(1)
Patient
Age
(years)
Height
(cm)
Diagnosis
Dr
Du
Cr
25
32
45
178
183
173
Complete spinal cord lesion below C.6.
Complete spinal cord lesion below C.7.
Incomplete spinal cord lesion below C.8,
complete below T.3.
6
11
1
2.7
2.9
4.8
5.1
5.3
4.3
Three of the normal subjects and all the patients were studied seated. A fourth normal
subject, not previously studied seated, and the three tetraplegic patients were studied on a tilting
table.
Respiratory movements of the thoracic cage were measured by specially designed calipers
(Davis & Moore, 1962; Davis & Troup, 1966); displacement of the arms of these calipers
induced a directly proportional electrical signal. The volume of air breathed was measured with
a spirometer; an electrical signal directly proportional to the air breathed was obtained from a
potentiometer replacing the balance wheel of the spirometer. Both electrical signals were
simultaneously recorded by a squirt jet recorder (Elema Schonander Mingograf 34). Calibration
Chest movements in tetraplegia
409
was carried out before and after each run and the sensitivity of the recorder adjusted so that a
breath of 1.01. gave a recording of 1.0 cm and a deflection of the calipers of 1 cm gave a similar
displacement.
For descriptive purposes the terminology of Keith (1909) and Campbell (1958) is used.
Measurements of the movements of the chest were made with the caliper at the following
points :
Anterior posterior movements:
1. The suprasternal notch and the spine of T.2.
2. The sternomanubrial junction and the spine of T.3.
Corresponding with
thoracic apices.
3. The junction of the upper one-third and the lower two-thirds of
18 -W
-*'A l L U
Correspondiathe sternum and the spine of T.5.
the veTf-L-.eoro-sternal
.
4. The junction of the upper two-thirds and lower one-third of the
sternum and the spine of T.6.
J
5. Xiphisternum and the spine of T.8 (corresponding with the vertebro-chondral ribs).
Lateral movements:
6. At the fourth rib in the mid-axillary line (corresponding with the vertebro-sternal ribs).
7. The level of the ninth costal cartilage (corresponding with the vertebro-chondral ribs).
8. In some subjects an intermediate recording between these two points was made in the
tilting positions.
The calipers were held horizontally and adjusted so that they were in firm contact with the
chest wall and recorded continuously.
Subjects seated
Initially observations were made on three normal subjects and the three tetraplegic patients
seated comfortably in their wheelchairs or in a chair facing the spirometer. Each subject was
asked to breathe quietly and take breaths of 0~5,1,1~5,2,2~5,3
1. and then a maximum breath.
Several runs were carried out on successive days to accustom the subject to the procedure and
several observations were made for each position of the caliper. The figures were corrected to
BTPS and are expressed in Table 2.
The vital capacity was determined without recording the chest movements; this figure was
corrected to BTPS and is compared with the predicted vital capacity.
Subjects tilted
In another normal subject and the three tetraplegics further studies were made of the relationship of chest movements in different positions on a tilting table-30" head up, horizontally
and 30" head down. Tilts of 30", head up and head down, were the maximum that the paralysed
patients could tolerate without undue discomfort.
The relationship of the movements of the apices to the position of the arms was also studied
in some of the subjects by recording the movements between the suprasternal notch and the
spine of T.2 with the arms of the subject free, locked behind the chair and then gripping the
wheels of his chair.
410
A . Moulton and J. R. Silver
RESULTS
Studies in the seated position (Table 2)
Normal subjects
In all subjects there was little movement of the A/P diameter of the thoracic apices when
breaths of 0.55 1. were taken, the movements being of the order of 0.2 cm. There was a progressive increase in the apical movements as larger breaths were taken, a breath of 3.3 1. producing a
movement of 1.9 cm in the subject B whilst the smallest movement was 0.95 cm in subject L.
In the vertebro-sternal part of the chest two of the three subjects showed greater movement
with breaths of 0.55 1. than at the thoracic apices with breaths of the same size. In one subject M
the movement was of the same order, 0.2 cm. The expansion was usually greater in the A/P
(junction upper 1/3, lower 2/3 of sternum) than in the lateral (upper lateral chest). In one
subject (B) this was true with breaths of all sizes. Whereas in L and M the expansion was
approximately equal until breaths of over 2.7 1. were taken, when the A/P expansion became
greater than the lateral.
In the vertebro-chondral region both diameters increased, the A/P (xiphisternum) usually
more than the lateral (lower lateral chest). The increase in A/P was consistently greater than
lateral movement in subjects B and L, whilst in subject M movements were approximately
equal in both directions. Movement of the lower lateral chest was consistently greater than the
upper lateral chest in subject M. In subject B the lower lateral movement was greater than the
upper part of the chest at four of the inspired volumes, whilst in subject L there was no consistent difference between the two parts of the chest.
Patients
At the apices in two of the patients, Du and Cr, the anterior-posterior movements were
positive at all the inspired values, although the expansion was not as large as in the normal
subjects. In the third patient (Dr) there was initially, with breaths of up to 1.65 l., aprogressive
sucking in of the chest wall up to -0.2 cm but with larger breaths the chest expanded. In this
subject with the largest breaths a biphasic wave of an initial sucking in followed by a positive
expansion could clearly be detected.
At the vertebro-sternal region the two patients Du and Cr again showed a positive expansion
of the chest in the A/P diameter and this was greater than the expansion of the apices at all
the inspired values. In the third patient (Dr) chest movement in this region was similar to that
at his apices, an initial sucking in of the chest being followed by a positive expansion of a
greater size than the initial negative movement (see Fig. 1).
The lateral movement in the vertebro-sternal region in all subjects at all values was negative
and became more negative with larger breaths. In Du and Cr this was of small magnitude
(-0.05 and -0-1 cm), but in Dr it was larger (-0.4 cm) when breaths of 2.7 1. were taken. This
contrasted strikingly with the progressive expansion seen in the normal subjects in this region.
At the vertebro-chondral region the movements were smaller than at the vertebro-sternal
region. In the A/P diameter, Du showed a small but progressive increase in the movement of
the chest from t o - 2 to +0.35 cm. In one subject (Cr) there was a progressive sucking in of
the chest from -0-1 cm to -0.3 cm when breaths of 2.2 1. were taken. Dr showed a similar
biphasic wave of initial sucking in of the chest followed by a positive expansion in a manner
similar to that seen at his apices and vertebro-sternal region.
0.5
0.35
0.35
0.5
0-3
0.4
0.5
0-5
0.6
0.4
0.3
0.1
B.
M.
L.
B.
M.
L.
0.3
015
0.2
0.3
0.7
0.9
0.7
1.1
1-3
0.8
0.8
0.5
0.6
0.7
0.7
0.6
1.15
0.7
0.7
0.8
0.6
0.6
0.6
0.8
0.7
0.7
0.8
1.0
Xiphisternum
0.6
1.4
1.3
1.0
1.2
1.6
1.0
1.0
0.8
0.4
0.5
0.55
0.55
0.8
0.6
0.65
0.9
0.7
0.25
0.6
0.4
0.35
0.7
0.5
0.5
1.0
0.8
0.7
1.3
0.8
Lower lateral chest
0.2
0.4
0.4
1.9
1.3
1.6
1.5
lower Q sternum
1.2
1.0
1.2
1.6
1.3
0.95
3.3
1.4
0.6
1.0
0.8
0.9
0.8
1.4
1.8
1.1
+ lower + sternum
!
j
1.0
0.75
0.9
Upper lateral chest
0.3
B.
M.
L.
0.5
0.65
0.5
Junction upper
0.3
0.5
0.6
0.3 0.3
0.4
0.4
0.2
0.45
2.7
Suprasternal notch
2.2
Sternomanubrial junction
0.3
0.5
0.5
1.65
Junction upper
0.2
0.2
0.25
0.2
1.1
0.3
B.
M.
L.
B.
M.
L.
B.
M.
L.
B.
M.
L.
Litres at
BTPS 0.55
Subject
Du
Dr
Cr
Du
Dr
Cr
Du
Dr
Cr
Du
Dr
Cr
Du
Dr
Cr
Du
Dr
Cr
Du
Dr
Cr
Litres at
BTPS
+
- 0.2
0.2
+0.35
+ 0.4
-0.05
+0.4
-0.05 to +0.2
+0.2
-0.05 to +0.1
0.5
-0.1
-0.05
+
+
0.8
+0.25
Upper lateral chest
+ 0.6
-0.05
Lower lateral chest
-0.05
-0.05
-0.1
+0.3
+
+
+
-0.3
0.45
0.5
-0.2
-0.1
-0.05 to +0.25
-0.3
Xiphisternum
-0.15 to f0.25 -0.15 to +0.25
0.3
+0.3
Junction upper 8 lower 4 sternum
+ 0.2
sternum
+0.7
+0.2
-0.1 to $0.35
0.5
4 lower
+0.9
+0.6
+0.2
+0.6
+0.15
2.2
+0.35
Sternomanubrial junction
Suprasternal notch
1.65
Junction upper
+0*15
- 0.1
-0.1
+0.25
1.1
+0.15 -0.05 to +0.25 -0.05 to f0.2
-0.1
-0.15
-0.1
+ 0.2
+0.1
+0.2
+0.3
+ 0.1
+0.1
+0.1
0.55
Patient
+0.35
-0.1
-0.4
-0.1
+0.35
-0.1 to +0*5
-0.15 to +045
2.7
TABLE
2. Chest movements (cm) in three normal subjects and three patients with tetraplegia seated. All values for the normal subjects are positive
P
c
2.
k
Q
rrc
2
5
3
3
x
9
2
3
3
5
n
A . Moulton and J.
412
R. Silver
The recordings from the corresponding lateral diameter were most interesting, since the
subject who showed the progressive expansion in the A/P diameter (Du) was consistently
negative at all respiratory values laterally, whereas the subject (Cr) who was negative at all
.
0.-.
.
__ .
. .. .. .
I
,..
. . .. .
.. . _ ,
.
.
.,
.
.
(b)
FIG.l(a). Tracing of a normal subject. Upper tracing ventilation recorded from the spirometer
inspiration upwards. Lower tracing represents expansion of the chest in the A/P diameter at the
upper one-third of the sternum. Time scale: 0.5cmp. There is a progressive increase in the expansion of the chest with larger breaths. A breath of 2 1. produces an A/P expansion of 1.5 cm.
(b) Tracing of a patient with complete cervical cord lesion (Dr). Upper tracing ventilation recorded
from the spirometer inspiration upwards. Lower tracing expansion of the chest in the A/P
diameter at the upper one-third of the sternum in a tetraplegic. Time scale: 0.5 cmjs. With breaths
of up to 0.5 1. the chest is sucked in but with breaths greater than this the chest is expanded. All
movements are small in amplitude compared with normal. The figure illustrates the negative
movement of the upper sternum during quiet breathing caused by the lowering of the pleural
pressure; due to the contraction of the diaphragm which is not balanced by the intercostal muscles
(paralysed) or the inspiratory muscle of the neck (which are not yet active). When the tidal volume
is increased the scalenii and sternomastoids act and the sternum moves out during inspiration.
values in the A/P diameter was positive in all values laterally. Dr who had a biphasic wave
A/P showed a similar wave at breaths of 1.1 I., but expanded his chest with larger breaths.
The movements of all parts of the chest were smaller than the corresponding movements in
normal subjects.
Vital capacities. The normal subjects had vital capacities of between 3-6 and 5.5 1.; these
figures are quite comparable to their predicted values derived from their height and age.
413
Chest movements in tetraplegia
The two most severely paralysed patients (Dr and Du),with complete lesions at the sixth and
seventh cervical segments, had reduced vital capacities (2.7 and 2.9 I., compared with predicted
values of 5.1 and 5.3 1. respectively). The third patient (Cr) who was less severely paralysed,
with sensory sparing to the third thoracic segment, had a vital capacity of 4.8 1. compared to a
predicted value of 4.3 1.
Studies in direring positions relative to gravity on a tilting X-ray table (Table 3).
Full details of these experiments are set out in Clinical Science Table 3918 which has been
deposited with the Librarian of the Royal Society of Medicine, London, from whom copies
may be obtained.
Normal subjects
It was found in the one normal subject (Br) that with comparable breaths the lower lateral
chest expanded more than the upper (see Figs. 2 and 3). In the vertebro-sternal region there
A
4!
m
A
3
A
08
A
A
v)
c
D
?!
c
2
_1
A
Horizontal
Feet down
Feet up
I
I
I
I
2
1
3
Chest movement (cm)
FIG.2. Comparison of the movements of the upper lateral chest with ventilation in a normal
subject, 30"feet down, horizontally and 30" feet up. All movements are positive in all positions and
do not alter significantly with position.
Br
Du
Dr
Cr
Br
Du
Dr
Cr
Br
Du
Dr
Cr
Br
Du
Dr
Cr
Br
Du
Dr
Cr
+0,4
+0.2
+0.2
-0.1
fO.2 -0.3
+0.25 +0.25
+0.2 +0.2
-0.1
-0.3
-0.1
t0.5
+0.2
+0.3
+O.I
-0.5
+0.2
+0.6
-0.2
-0.2
+0.2
tO.2
+0.3
+0.2
i0.2
- 0.2
-0.3
+0.2
10.3
-0.2
-0.3
+0.3
+0.3
-0.3
-0.3
+0.2
+0.1
-0.2
-0.3
C
+0.5
-0.1
-0.1
+0.2
- 0.2
-0.3
-0.25
+0.6
+0.2
-0.25
+0.4
+0.3
+0.2
+0.2
+0.2
+0.3
-0.3
- 0.4
-0.2
Br
Du
Dr
Cr
B
+ 0.2
-0.2
+0.1
-0.4
+0.2
A
+0.3
-0.2
+0.1
-0.2
Br
Du
Dr
Cr
)
0.9
Br
Du
Dr
Cr
+0,2
-0.15
- 0.3
Breaths
BTPS
(
1
+0.2
-0.3
-0.2
-0.2
+0.3
-0.3
-0.4
+0.6
-0.3
-0.3
fO.2
+0.4
+0.1
-0.2
A
1.3
B
-0.1
+0.4
-0.2
-0.2
-0.3
+0.3
+0.3
+0.2
-0.3
+0.3
+0.2
+0.6
-0.3
-0.2
+0.2
+0.3
+0.5
10.2
+0.3
10.3
C
+0.2
+0.3
f0.3
+0.3
+I.O
+0.4
-0.3
+0.3
+0.7
-0.4
-0.5
+0.2
+0.9
-0.3
-0.4
f0.2
+0.5
-0.3
-0.1
-0.2
-0.2
+0.7
+0.3
-0.3
-0.2
-0.2
+0.5
+0.3
+0.2
I .o
-0.3
-0.2
+0.5
-0.4
+1.0
+0.9
10.3
+0.5
+0.3
+0.4
10.6
-0.6
+04
-0.6
+0.3
+0.2
+0.4
+0.4
C
+0.4
+0.5
10.4
-0.4
f0.8
+0.4
+0.4
t0.6
B
-0.5
-0-4
+0.5
+0.4
-0.3
+0.4
A
1.6
-0.2
-0.3
+0,2
-0.2
f0.2
-0.4
+0.5
+0.5
-0.4
+0.5
+0.6
+0.4
+0.5
A
2.0
+@I
i~l.1
+0.5
+0.7
-t 0.9
+0.6
+0.8
+0.7
+0.6
B
C
f0.3
+0.3
-0.4
+1.0
+0.6
-0.5
+0.7
+0.3
+ 1.6
+0.3
-0.3
-0.2
-0.3
+0.6
-0.5
+I.O
+0.7
-0.8
-0.5
-1-03
+0.7
+0.6
+
+ 1.6
+0.7
0.7
+1.1
t0.4
B
-0.6
+0.6
+0.7
+ 1.2
10.6
+0.6
A
2.3
-0.2
-0.3
-0.1
-0.3
-0.3
+0.6
+1.3
3-0.4
+0.4
+1.1
+0.6
+0.7
C
A
+0.3
-0.4
-0.1
+1.0
+0.6
+O5
+04
+1.2
+0.9
+0.4
+0.7
+1.2
+0.3
-0.3
1.6
-0.2
+0.7
-0.4
+I.O
-1-1.4
+1.I
+0.7
+0.9
+1.2
tl.3
B
2.7
Sternomanubrial
junction
Suprasternal notch
+ of sternum
Mid chest
Upper lateral chest
Xiphisternum
Lower
1.6 Lower lateral chest
-0.4
+0.9
+1.9
+0.4
+0.6
+0.6
+1.5
+2.0
+0.7 Upper 3 of sternum
iO.8
+1.0
+ 1.0
+1.0
C
TABLE
3. Chest movements in one normal subject and in three tetraplegic patients, 30" head down (A), horizontal (B) and 30" head up (C)
1
9
-e?
4
?j
Q
9
!5
5
b
Chest movements in tetraplegia
415
was more A/P movement (upper 113 of sternum) than lateral (upper lateral chest) and that at
the five values recorded there was greater movement of the vertebro-sternal region than the
apices. The movements were substantially the same irrespective of position. The movements
were comparable to those found in the three seated normal subjects.
Patients
Movements at the apices. Postural changes could be detected in two of the three patients.
In Du the chest was sucked in in all positions with breaths of less than a litre. With breaths of
A
I
I
I
0
A
3
A
Horizontal
0
Feet down
I
Feet up
I
I
I
I
2
3
Chest movement (cm)
FIG.3. Movements of the lower lateral chest in a normal subject in Werent postural attitudes,
30" feet down, horizontally and 30" head down. All movements are positive in all positions.
1 *3and 1.6 1. the chest was sucked in -0.2 cm. and -0.3 cm. in the head down position whereas
when he was tilted head up the chest expanded +0.3 and + 0.6 cm respectively. With larger
breaths the chest expanded in all positions but the movement was greater in the head UP
position.
There was no indrawing of the chest of Cr in any position but there was a greater expansion
of the chest in the head up than in the horizontal or head down positions. In the third patient
(Dr), the most severely paralysed, the movements, as in the seated position, remained negative
F
416
A . Moulton and J. R. Silver
until breaths of 1.9 1. were taken. There was insufficient data to determine whether there was a
significant change with position in this patient.
Movements at the vertebro-sternal region. All three patients showed postural changes in
movement of the A/P diameter similar to those found at the apices; Dr and Du showed negative movements with small breaths (0-9 1. Dr, 0.9 and 1.3 1. Du) in all positions, but with larger
breaths (1.3-2.3 1.) movements in Dr remained negative in the head down position, but became
positive in the head up position (Fig. 4). In Du where comparable readings were available (at
0.
I
A
I
I
I
A
A &
k
I
I
A
Horizontal
0
Feet down
I
Feet up
II
-0.5
0.5
I
I .o
Chest movement (cm)
FIG.4. Movement (upper one-third chest A/P) in tetraplegic Dr correlated with volume of air
breathed (in 1. BPTS) in the positions of 30" feet down, horizontally and 30" feet up. This graph
shows a marked postural effect. The movements are wholly negative in the feet up position but
become positive in the horizontal and feet down positions with maximum breaths when the
accessory muscles overcome the negative intrathoracic pressure.
1.6 and 1.9 1.) the same held true. In Cr, who was the least severely paralysed, there was a
similar sucking in of his chest which was noted with breaths of 0.9 and 1.3 1. in the head down
position, but his chest expanded with breaths of a similar size when the head was up. When
larger breaths were taken the chest expanded in all positions.
There did not appear to be any corresponding postural changes in the upper lateral chest.
The movements were like those in the seated position being very small or negative in all posi-
Chest movements in tetraplegia
417
tions in all patients (see Fig. 5). One or two positive readings were obtained when maximum
breaths were taken. These could have been due to artefacts from the movement of the shoulder
muscles attached to the chest wall. The chest was progressively sucked in from -0.1 cm with
breaths of 0.5 l., to a maximum of -0.7 cm (Fig. 6).
Movements at the vertebro-chondral region. The changes found were comparable with those
found in the seated position. The movements were much smaller than normal and if one part
3
A
A
2 A
A
Horizontal
0
Feet down
I Feet up
Chest movement (cm)
FIG.5. Movements of the upper lateral chest in a tetraplegic patient (Dr) correlated with the
volume of air breathed (in 1. BF'TS) in the positions of 30" feet down, horizontally and 30"feet up.
This graph shows that nearly all movements are negative. The upper lateral chest thus responds
to the negative intrathoracic pressure and not to the weight of the abdominal contents.
of this region of the chest expanded another adjacent part was sucked in. One patient (Cr.),
in the head up position, progressively expanded his chest in the A/P diameter (xiphisternum)
with increasing breaths, but there was a similar progressive sucking-in of the lower lateral
ribs. In contrast, in the head down position, while there was no consistent change in the A/P
diameter, the lateral ribs were progressively expanded.
Chest movements of Dr in the A/P diameter were predominantly negative in the head down
and horizontal position but positive in the head up position; he behaved like Cr in that the
lower lateral chest expanded in the head down position. (Fig. 7).
A . Moulton and J. R. Silver
418
FIG.6. Tracing of a tetraplegic patient (Cr) taken in the horizontal position. The upper tracing
represents ventilation recorded from the spirometer, inspiration upwards, lower tracing represents
chest movement in the mid-lateral chest. Time scale: 0.5 cm/s. With small breaths, movements
of the chest wall are very small but when larger breaths are taken the negative intrathoracic pressure
pulls the chest wall in.
.
0
mA
0.
2
0 0.
F
8
A
I
A Horizontal
I
0
Feet down
8
Feet up
0
I
I
-0.5
0.5
Chest movement (cm)
Fig. 7. Comparison of the movements of the lower lateral chest with ventilation (in1BPLS)in a tetraplegic patient @r) in the positions of 30"feet down, horizontally and 30"feet up. The graph shows
that the movements are smaller than normal. There is also a postural effect. In the horizontal and
head down position the lower lateral chest wall expands due to the direct weight of the abdominal
contents pushing on the ribs. When the patient is in the feet down position the abdominal contents
no longer expand the ribs by direct contact and the chest is sucked in by the negative intrathoracic
pressure.
Chest movements in tetraplegia
419
DISCUSSION
Our equipment and procedure only permitted us to measure one diameter of the chest at a
time. As a result the procedures proved fatiguing to the patients, who were liable to faint and
develop headaches during the tilting procedures and consequently it was not always possible to
obtain full sets of readings.
Other investigators have experienced technical difficulties in measuring and recording the
movements of the chest which probably explains the lack of interest in this field up to the last 5
years and the multiplicity of techniques which have been employed even by the same investigators.
Two of our normal subjects when seated showed the greatest expansion of the rib cage in the
vertebro-chondral region. In two of the subjects the expansion was greater in the anteroposterior diameter than in the lateral and in the remaining subject the movements were substantially equal. This is similar to the findings of Agostoni et al. (1965). Their studies led them
to the conclusion that the main muscular forces acted upon the lateral aspects of the chest
while the A/P diameter passively followed the forces generated. They showed that the chest
became more circular during quiet inspiration when small transthoracic pressures are developed
and more elliptical during the following expiration. In contrast when breathing with massive
inspiratory effort against closed airways the rib cage became more elliptical and when expiring
with effort against closed airways the chest became more circular. There have been no comparable direct measurements of the chest movements in patients with tetraplegia until the present
studies. However, Duchenne (1867), Bergofsky (1964) and Sandor (1966), have observed that
there was a negative inspiratory movement in these patients.
The tetraplegic patient in addition to the loss of the function of his intercostal and abdominal
muscles has a partial or total paralysis of the upper cuirass of shoulder muscles. These muscles
are of considerable importance in expanding the apices, and this is substantiated by the
observation that all three patients showed less movement here than the normal subjects.
The greatest movement of the chest in two of the three tetraplegic patients was in the A/P
diameter at the vertebro-sternal region. In all three patients the lateral part of the chest in this
region was sucked in contrasting to the normal subjects in whom it expanded. This sucking in
did not vary with posture and has been observed in patients with upper thoracic lesions, but
not in patients with lower thoracic lesions. This would be in accordance with the views of
Agostoni et al. (1965) that the A/P diameter passively follows the intrathoracic pressure, in this
case generated by the diaphragm, and that the lateral part of the chest wall lacking the support
of the intercostal muscles collapses.
In the vertebro-chondral region the movements of the tetraplegic patients were much
reduced compared with the normal and all three patients showed a sucking-in of part of the
chest at some stage during inspiration.
In this region there are two possible explanations for this phenomenon. A view favoured by
Bergofsky (1964) is that the paralysis of the intercostal muscles makes it impossible for them
to exert their normal action of everting the rib margin. An alternative explanation favoured by
Duchenne (1867) is that for the diaphragm to exert its normal action of expanding the lower rib
cage, it must preserve its normal relationship with the abdominal contents; when this does not
pertain due to the paralysis of the abdominal muscles, the diaphragm assumes a lower position
and the ribs are sucked in, instead of expanding during inspiration. This is supported by the
420
A . Moulton and J. R. Silver
observations of Campbell (1958) in patients with emphysema. The tilting experiments showed
that two of the patients progressively expanded the lower lateral chest with increasing breaths in
the head down position, but when they were tilted head up they progressively sucked the chest
in. This too would support the views of Duchenne (1867) and Campbell (1958) since when the
feet were elevated the diaphragm was pushed up by the weight of the abdominal viscera. The
diaphragm thus had a fulcrum to act against. The weight of the abdominal contents themselves
would exert a direct effect upon the ribs which, lacking the support of the paralysed intercostal
muscles, would be moved outwards. Postural changes in the vital capacity in tetraplegic
patients have been observed by Cameron, Scott, Jousse & Botterell(1955), who found that the
diaphragm was much more mobile in tetraplegic patients than in normal subjects.
In contrast to the lower part of the chest which is affected by the position of the abdominal
contents, the apices were affected by two main factors; the actions of the intact accessory
muscles and the position of the arms, which fix the pectoral girdle. The negative intrathoracic
pressure generated by the diaphragm could be detected in one of the three patients seated,
the chest was sucked in with small breaths. However, with larger breaths, when the accessory
muscles were mobilized, the upper part of the chest was expanded. A further patient showed this
effect during tilting. The upper part of the chest is far removed from the attachments of the
diaphragm and the direct effect of the weight of the abdominal contents.
When the patients were tilted head down, the movements at the apices were smaller in all of
three subjects; this could have been due to the head being flexed due to the uncomfortable position, or the clavicle could have assumed a higher position, thus rendering the sternomastoid less
efficient. When the patients were tilted feet down the sternomastoid acted more efficiently and
expanded the chest. Again it was found that when the arms were fixed by locking them behind
the chair there was a greater expansion of the chest than when the arms were allowed to rest
floppily by the side. This is a well known phenomenon, due to the fixation of the insertion of
latissimus dorsi and pectoralis major muscles, their origins in the upper chest thus moving.
This is, of course, a reversal of the normal function of these muscles.
The functional effects of these severe paralyses is reflected in the reduced vital capacity of the
tetraplegic subjects and in their weakness in coughing. This substantiates the findings of Hemingway, Bors & Hobby (1958), Cameron et al. (1955) and Bergofsky (1964). All these investigators were surprised at the size of the vital capacity that these patients could achieve, being as
large as two-thirds normal when respiration was supported entirely by the diaphragm and the
accessory muscles.
The other remarkable feature is that these patients whose chief expiratory muscles are
paralysed can cough at all. Several investigators who have been interested in the respiratory
mechanics of tetraplegic patients have investigated this problem. Draper, Ladefoged & Whitteridge (1960) attributed their ability to raise the intrathoracic pressure to the action of the
rhomboid and latissimus dorsi muscles which clothe the upper part of the chest, Siebens,
Kirby & Poulos (1964) studied this problem in detail in three patients with cervical transection
at C.6 and found that the patients could cough, but the cough differed from that in a normal
subject. The flow rates were lower, being 4.54 l/s compared to a normal of 7.09 l/s. The duration
of the cough was longer, being 2.3 s compared with 1.09 s in a normal and the intrathoracic and
abdominal pressures generated were reduced. They attributed the forces of coughing generated
not to active contraction of the muscles clothing the thorax, but to the result of the elastic
recoil of the lung and thoracic tissues generated by the previous breath.
Chest movements in tetraplegia
421
It is apparent that there are many problems yet to be solved in the mechanics of breathing
in the tetraplegic patients; in particular, the role of the abdominal muscles has yet to be
determined. It is not clear whether the abdominal muscles play any part in respiration. While
it is apparent from electromyographic studies of Guttmann & Silver (1965) that there is no
expiratory force generated by them during coughing and straining, activity has been detected
at the height of inspiration comparable to that seen in normal subjects and this activity may be a
stretch reflex generated by the descent of the diaphragm pushing on the abdominal contents
and thus stretching the abdominal musculature. On the other hand, it may be that the abdominal musculature is under a different control to the other respiratory muscles, a view advanced
by Campbell (1958). Furthermore, the development of spasms in the abdominal muscles as
part of a mass reflex may compress the abdominal contents and thus render breathing difficult
(Bergofsky, 1964). These problems will be further studied by a combination of electromyography and spirometry.
The clinical implications of these findings are that, while it is well recognized that there is a
high mortality in the immediate stages after cervical injury from respiratory failure, there is in
the later stages still a significant mortality from pneumonia. This is partly due to the paralysis
of the abdominal muscles and the intercostal muscles which render expiration less efficient.
ACKNOWLEDGMENTS
One ofus, J.R.S., wishes to thank the Action for the Crippled Child for the grant with which this
work was carried out.
We would like to thank Professor P. R. Davis of the University of Surrey for the loan of the
calipers, Dr K. F. Morle, Consultant Radiologist for screening the patients, Dr E. J. M.
Campbell and Dr N. Pride for advice. We would like to thank Mr L. Henry of Sierex for building the potentiometer circuit for the respiratory recording and for his assistance during the
tilting experiments.
A small part of this work was presented in Israel at the Scientific Meeting of the International
Society of Paraplegia. We would like to thank the Editor and Publishers of their journal for
permission to publish Figs. 2, 5, and 6.
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