spinal cord injuries ( scis ) are most often traumatic and caused by lateral bending , 
 dislocation , rotation , axial loading , and hyperflexion or hyperextension of the cord or 
 cauda equine .
motor vehicle accidents are the most common cause of scis , while other causes 
 include falls , work - related accidents , sports injuries , and penetrations such as stab or 
 gunshot wounds1 .
persons with scis have a 
 high lifetime risk of serious debilitating and costly medical conditions such as pressure 
 ulcers , urinary tract infections , pain , spasticity , and respiratory2 . in normal subjects
, breathing occurs primarily through the use of the intercostal muscles 
 and the diaphragm3 .
however , when this 
 condition is disrupted by an sci , control of respiratory muscles ( intercostal muscles ) 
 innervated below the injury level is compromised , leading to respiratory muscle dysfunction 
 and pulmonary complications4 .
the 
 weakening of the expiratory muscles may also cause a restrictive lung disease , which is 
 accompanied by lung volume reduction , including lung capacity . at the same time , the 
 weakening of inspiratory muscle strength reduces ventilation5 .
these conditions are among the leading causes of death in patients 
 with scis6 . from the perspectives of physics and physiology , aquatic environments are beneficial in the 
 management of a variety of musculoskeletal , neurological , and cardiopulmonary 
 pathologies7 due to the advantages of 
 hydrostatic forces ( buoyancy ) and drag resistances unique to the water medium8 .
aquatic exercises have advantages when full 
 weight bearing ambulation is not possible or contraindicated , such as for those who are 
 severely obese , arthritic , have balance limitations , or are in the early stages of 
 rehabilitation when joint range of motion should be actively progressed9 .
masumoto et al.10 reported that walking 
 in water elicits higher muscles activities , higher cardiorespiratory responses , and 
 increased perceived exertion levels in older adults than walking on dry land at the same 
 speed .
jung et al.11 studied the 
 application of additional weights to the affected leg to reduce the limb circumduction 
 during aquatic treadmill walking in people poststroke .
baena - beato et al.12 ) reported that an aquatic therapy program decreased 
 levels of back pain and disability , increased quality of life , and improved health - related 
 fitness in adults with chronic low back pain .
alberton et al.13 reported that in water , cardiorespiratory responses to stationary 
 running exercise are higher on land in healthy women . although there have been many recent studies in aquatic environments , few studies on 
 pulmonary function in patients with spinal cord injury have been reported .
therefore , the 
 purpose of this study was to examine the effects of aquatic exercise on pulmonary function 
 in patients with spinal cord injury .
the subjects were 
 provided with a full explanation of the experimental procedure , and all provided their 
 written consent signifying voluntary participation .
this study was approved by the sahmyook 
 university human studies committee ( syuirb2013 - 037 ) .
the subjects were inpatients at o 
 hospital in pohang city which is located in the north kyungsangbuk - do in korea , diagnosed 
 with an american spinal injury association ( asia ) grade b , c , or d spinal cord injury at the 
 levels of c8 to l5 .
there were no significant differences in the injury levels and asia 
 grades between the groups in this study .
the subjects were randomly divided into an aqua 
 group ( 10 subjects ) and a land group ( 10 subjects ) ; exercise programs were performed in 
 60-minute sessions three times per week , over a period of 8 weeks .
the general 
 characteristics of the aqua group and land group are shown in table 1table 1 .
characteristics of the participants ( n=20)aqua group ( n=10)land group ( n=10)gender ( % ) male7 ( 70.0)5 ( 50.0)female3 ( 30.0)5 ( 50.0)age ( y)42.1 ( 10.6)51.1 ( 8.7)height ( cm)170.0 ( 10.5)163.1 ( 9.1)weight ( kg)64.2 ( 11.2)59.2 ( 12.1)time since onset ( months)8.5 ( 3.9)8.4 ( 3.4)n ( % ) or mean ( sd ) . the training programs used in this study was applied after modifying and supplementing the 
 obstacle course used by boswell - ruys et al14 .
( 1 ) warming - up included 
 range of motion exercises and breathing exercises ( 10 minutes ) .
( 2 ) the main exercises were 
 upper extremity exercises for function including weight bearing to the left and right with 
 the arms spread out ( 90 degree angle ) while sitting , moving forward and backward with the 
 hands clasped together while sitting , and moving a heavy ball ( sensory - therapy ball ) forward 
 and backward and left or right ( 40 minutes ) .
( 3 ) cooling down included range of motion 
 exercise for flexibility and breathing exercises ( 10 minutes ) .
pulmonary function was measured using a cardiotouch 3000s ( bionet , tustin , ca , usa ) in a 
 sitting position .
the forced vital capacity ( fvc ) , forced expiratory flow rate ( fer ) , force 
 expiratory volume at one second ( fev1 ) and forced expiratory volume at one 
 second / forced vital capacity ( fev1/fvc ) were measured .
the paired t - test was used to determine whether there were 
 changes in pulmonary function between before and after the training . the independent t - test 

comparison of pulmonary function within groups and between groups ( n=20)valueschange valuesparametersaqua group ( n=10)land group ( n=10)aqua group ( n=10)land group ( n=10)beforeafterbeforeafterbefore - afterbefore - afterfvc(l)2.5 ( 0.7)4.3 ( 1.4 ) * * 3.0 ( 0.9)3.4 ( 1.4)1.8 ( 1.3)0.31 ( 1.6 ) * fer ( l / sec)80.5 ( 15.5)90.5 ( 17.0 ) * 85.2 ( 18.0)90.6 ( 18.0 ) * 10.0 ( 9.7)5.4 ( 7.0)fev1 ( l)2.1 ( 0.9)3.2 ( 1.2 ) * 2.7 ( 1.0)2.9 ( 1.0)1.1 ( 1.2)0.21 ( 0.3 ) * fev1/fvc ( % ) 89.3 ( 3.8)93.0 ( 3.6 ) * * 88.3 ( 4.6)90.4 ( 3.2)3.7 ( 2.3)2.1 ( 3.4)values are means ( sd ) .
fvc , forced vital capacity ; fer , forced expiratory flow rate ; 
 fev1 , force expiratory volume at one second;fev1/fvc , forced expiratory volume at one 
 second / forced vital capacity .
* p<0.05 , * * p<0.01 .. the aqua group showed significant differences in fvc ( p=0.001 ) , fer 
 ( p=0.010 ) , fev1 ( p=0.019 ) , and fev1/fvc ( p=0.001 ) .
there were significant differences in fvc ( p=0.031 ) and fev1 
 ( p=0.038 ) between the two groups after the interventions , but there were no differences in 
 fer ( p=0.238 ) and fev1/fvc ( p=0.243 ) .
fvc , forced vital capacity ; fer , forced expiratory flow rate ; 
 fev1 , force expiratory volume at one second;fev1/fvc , forced expiratory volume at one 
 second / forced vital capacity .
this aim of this study was to evaluate the effect of water - based functional exercise on 
 pulmonary function in sci patients .
respiratory complications are the most common cause of 
 morbidity and mortality in sci15 , and 
 lisa16 reported that lung disease can 
 contribute to cardiac dysfunction in several ways .
lung disease invariably threatens oxygen 
 transport by its effects on respiratory mechanics and ventilation - perfusion matching .
hypoxemia secondary to inadequate ventilation - perfusion 
 matching may predispose the patient to cardiac dysrhythmias . possessing an understanding of 
 these topics
is assumed to be of great importance for clinicians involved in the care 
 rehabilitation of patients with a spinal cord injury , as well as for researchers in the 
 field , especially when armed with knowledge that pulmonary complications remain a major 
 cause of morbidity and mortality in this population4 .
the present study shows that fvc , fev1 , 
 fev1/fvc , and fef improved in both groups ( p<0.05 ) .
however , fer improved in 
 the land group ( p<0.05 ) , and there was also a significant between - group difference in fvc 
 and fev1/fvc ( p<0.05 ) .
estenne et al.17 reported that 
 progressive resistance training improves expiration of ventilator function in people with 
 sci .
roth et al.18 reported implications 
 for breathing exercise in treatment of patients with an sci that may reduce respiratory 
 morbidity and improve outcome .
walker et al.19 reported a combination of incentive spirometry and arm ergometry 
 improves vital capacity ( vc ) and increases the maximum volume of expired air during 
 exercise .
mclachaian et al.20 reported an 
 increase in fvc and fev1 throughout the training period and that the absence of a 
 change before or after training suggests that passive abdominal fes training can be used for 
 respiratory rehabilitation in sci .
soyupek et al.21 reported that body weight supported treadmill training 
 significantly improves cardiopulmonary functions in patients with an incomplete sci .
it is 
 also that such advanced research coincides with the results of this study showing that the 
 functional training applied both in water and on land has a significant effect on 
 improvement of fvc , fev1 , fev1/fvc , and fef , which is considered to 
 support the reliability and suitability of the intervention program .
it is also considered 
 that future intervention programs for patients need to include training that can cope with 
 daily danger and complex environments like functional training .
stevens and morgan22 reported that while an underwater 
 treadmill training program meaningfully improved motor function by improving stability 
 during transfers to walking , leal et al .
such an 
 advanced research coincides with the results of this study finding that referred to 
 hydrostatic pressure and is the second property of water .
the degree of hydrostatic pressure 
 that is exerted upon the tissue depends on two factors , the density of the fluid and the 
 depth of immersion . when the fluid density increases , so does the hydrostatic pressure .
when 
 an individual who is standing or sitting is immersed in water to the shoulder level , the 
 hydrostatic pressure exerted will assist the vc while at the same time resisting inspiratory 
 capacity .
training in water can be largely applied to many patients , as it can be easily applied to 
 patients with various illnesses in every age group , and the impact on the joints can be 
 largely reduced by the buoyancy of water in the case of functional training in water . in our 
 study , although measurements of pulmonary function showed that fvc , fev1 , 
 fev1/fvc , and fef were improved in both the groups , the error decreased more in 
 the aquatic exercise group than in the land exercise group .
therefore , we assume that 
 aquatic exercise therapy is more effective than land exercise therapy , even though land 
 exercise therapy is also effective .
   [ purpose ] the purpose of this study was to determine the effects of aquatic exercise on 
 pulmonary function of patients with spinal cord injury . [ subjects ] 
 the subjects were 
 randomly allocated to an aqua group ( n=10 ) and a land group ( n=10 ) . [ methods ] 
 both groups 
 trained for 60 minutes , 3 times a week for 8 weeks . 
 pulmonary function was assessed by 
 measuring the forced vital capacity ( fvc ) , forced expiratory flow rate ( fer ) , force 
 expiratory volume at one second ( fev1 ) and force expiratory volume at one 
 second / forced vital capacity ( fev1/fvc ) . [ results ] following the intervention , 
 the aqua group showed significant changes in fvc , fer , fev1 , and 
 fev1/fvc . 
 the land group showed only significant differences fer . 
 
 [ conclusion ] the results of this study suggest the effects on the aqua group were 
 significantly higher than those on the land group in patients with spinal cord injury . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION