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ORIGINAL ARTICLE
Sahlgrenska Academy, Gothenburg University, Sweden, 3Centre for Health Care Sciences, rebro County Council and School of
Health and Medical Sciences, rebro University, Sweden, 4Department of Medical Sciences, Clinical Physiology, Uppsala
University Hospital, Sweden
Abstract
The aim of this study was to examine and compare the effect of two alternative instructions when measuring chest expan-
sion. In 100 healthy subjects, chest expansion was measured using a circumference tape. In 30 healthy subjects, chest expan-
sion was measured by a Respiratory Movement Measuring Instrument (RMMI). Both measurements were made at the level
For personal use only.
of the fourth rib and the xiphoid process. The two instructions evaluated were the traditional one: breathe in maximally
and breathe out maximally, which were compared with a new one breathe in maximally and make yourself as big as
possible and breathe out maximally and make yourself as small as possible. The addition of make yourself as big/small
as possible in the new instruction resulted in a significantly increased thoracic excusion, 1.4 cm in upper and 0.9 cm in
lower level of thorax, measured by tape, compared with the traditional instruction ( p 0.001). Measurements obtained using
the RMMI also showed a significant difference, 2.3 mm in upper and 4.1 mm in lower level of thorax, between the two
instructions in favour of the new instruction (p 0.05). The verbal instruction during measurement of chest expansion is of
importance when measured by tape and RMMI. To assess the maximal range of motion in the chest, the patient should be
instructed not only to breathe in/out maximally, but also instructed to make yourself as big/small as possible.
Introduction
rheumatic diseases (1,4), and has further been used
To measure and follow changes in pulmonary func- for evaluation of treatment for scoliosis (5). During
tion, volumes and airflow measurements by spirom- this manoeuvre, the circumference around the thorax
etry are most frequently used. Measurement of is measured at specific measuring points during max-
thoracic mobility and chest expansion could also be imal inspiration and maximal expiration (1,2,6). The
important when exploring reasons for impaired pul- most commonly used levels, during thoracic excursion
monary function, dyspnoea and decreased exercise measurement, are the xiphoid process and the third
tolerance in patients with different kinds of pulmo- to the fourth intercostal space/auxiliary level (13,7).
nary or rheumatic diseases, after thoracic surgery or This method of measuring has been shown to be reli-
after trauma to the rib cage (13). To measure chest able in healthy volunteers (7,8) and in patients with
expansion, different techniques are used. chronic obstructive pulmonary disease (3).
In clinical practice, a simple and inexpensive tech- Sophisticated measurement instruments such as
nique for measurement is to use a tape measure. It is inductive or opto-electronic plethysmography (9),
often used by physiotherapists to diagnose and evalu- computed tomography or video systems for move-
ate treatment, in different patient groups (13). ment measuring (10) are other techniques available
The technique was first used as diagnostic criteria for to measure chest expansion. Breathing movements
Correspondence: Monika Fagevik Olsn, Department of Physical Therapy, Sahlgrenska University Hospital, SE 413 45 Gothenburg, Sweden. E-mail: monika.
fagevik-olsen@vgregion.se
the muscles of the rib cage during measurement of that the aim of the investigation was to evaluate two
thoracic excursion. An additional instruction actively different instructions on chest expansion and that
to increase or decrease the volume of the thorax, over they should listen carefully and follow the instruc-
and above the ordinary instruction to breathe in and tions given. No further verbal instructions were given
out maximally, could possibly optimize measurement during the test.
of chest expansion. The purpose of this study was The traditional instruction for measuring tho-
therefore to examine and compare changes in chest racic excursion was breathe in maximally and
expansion when adopting two different instructions. breathe out maximally (1). This instruction dem-
onstrates thoracic excursion measurement and is
defined as thoracic excursion equals thoracic cir-
For personal use only.
Table I. Results of the thoracic excursion measurement by tape for the two instructions at the level of costae 4 and processus xiphopideus.
Values given as mean SD. Total n 100, women n 53, men n 47. p-value 0.05; p-value 0.01 differences between women
and men.
Measuring chest expansion 131
Table II. Results of the Respiratory Movement Measuring Instrument for the two instructions at the level of costae 4 and processus
xiphoideus.
Values given as mean SD. Total n 30, women n 15, men n 15.
inspiration and maximal expiration, the instruction described in this study. It is therefore important to
by Moll & Wright (1), breathe in/out maximally, is investigate the effects of encouragement in a future
Adv Physiother Downloaded from informahealthcare.com by Deakin University on 09/29/13
matic diseases, but also other groups of patients and used in some clinical trials (1719). It has been
who suffer from impaired range of motion in the shown to have a high reliability (12). It measures
rib cage as after a thoracotomy are measured (15). the anteriorposterior changes, which are closely
The differences in circumference between the connected to circumferential changes (1,11). The
instructions were 0.91.4 cm in healthy subjects. results from the test cannot be compared directly
This is important and of clinical relevance when with the thoracic excursion test; lower values are to
evaluating lung and rib cage functions in several be expected, since there is only registration of the
diseases and conditions. It is still unclear, though, anteriorposterior movement of the rib cage and
whether different categories of patients show the not the circumference. The results also indicate that
same differences as in this sample of healthy sub- the anteriorposterior movement is smaller at the
jects and the topic needs therefore to be further lower thoracic level of the xiphoid process than at
explored. The relation between chest expansion the upper level by the fourth costae (Table II). This
and pulmonary function also needs to be further may be a reflexion that the upper thorax moves
explored while Malaguti et al. (3) has shown that more anteriorlyposteriorly than the lower part that
these do not correlate in patients with chronic moves more laterally.
obstructive pulmonary disease (3). The difference between maximal inspiration and
In a previous trial, normal values of thorax excur- expiration during the thoracic excursion test is cre-
sion measured by tape have been presented (2). Nor- ated by the breathing muscles and restricted by the
mal values in younger (2049 years) men were 6.6 lungs ability to expand and subside. During a maxi-
cm and in women 6.1 cm. This is in accordance with mal inspiration, the diaphragm presses the abdomen
the findings in this study, showing significant differ- downwards and the rib cage expands by lengthening
ences between men and women. Corresponding fig- the thorax and lifting the lower ribs (2022). The
ures for older (5075 years) men and women were external intercostal muscles also move the ribs ante-
6.1 and 4.7 cm, respectively (1). riorly and laterally, a motion that can be increased in
Information about the tests in this trial was given the upper thoracic region if the accessory muscles
prior to measuring, with no further verbal instruction are used. During a maximal expiration, the abdomi-
given during the tests. There are previous trials, nal muscles press the abdominal content upwards to
which have presented different results when encour- decrease the lungs. The internal intercostals lower
agement has been given during the tests (16). How- and decrease the rib cage. Voluntary activation of the
ever, it is not known whether encouragement can whole rib cage during the instruction to make your-
further improve the results of the new instruction self as big/small as possible seems to reflect better
132 M. F. Olsn et al.
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