1

EFFECTS OF RESPIRATORY MUSCLE TRAINING IN THE LUNG

FUNCTION AND QUALITY OF LIFE OF CHILDREN WITH

SPASTIC CEREBRAL PALSY IN CEBU CITY

A Proposal Paper Presented

To the

Department of Respiratory Therapy

College of Rehabilitative Sciences

Cebu Doctors University

In Partial Fulfillment of the

Requirements for the Degree of

Bachelor of Science in Respiratory Therapy

By

Arquillano, Aleck L.
Enopia, Kathlene Mae N.
Lee, Aecarah S.
Remilla, Christelle Faye T.
Villamor, Bryan Jomer G.

March 27, 2017

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TABLE OF CONTENTS

Page

TITLE PAGE i

TABLE OF CONTENTS ii

CHAPTER

1 THE PROBLEM AND ITS SCOPE

INTRODUCTION

Rationale 1

Theoretical Background 2

Review of Related Literature 5

Conceptual Framework 11

THE PROBLEM

Statement of the Problem 12

Significance of the Study

12

Scope and Limitation 13

RESEARCH METHODOLOGY

Research Design 15
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Research Environment 15

Research Respondents 15

Research Instruments 16

Research Procedures

Gathering of Data 18

Treatment of Data 19

DEFINITION OF TERMS 20

REFERENCES 22

APPENDICES

A-1 LETTER OF APPROVAL FOR THE 24

USE OF THE CEREBRAL PASLY QUALITY

OF LIFE QUESTIONNAIRE FOR CHILDREN

(CP QOL CHILD)

A-2 TRANSMITTAL LETTER TO STAC 25

B INFORMED CONSENT FORM 26

C ETHICAL REVIEW FORM 29

D RESEARCH INSTRUMENT 30

E TIMETABLE OFRESEARCH ACTITIES 40

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F RESEARCH BUDGET 41

G RESEARCH DOCUMENTATION 42

H RESEARCH LOCALE 43

CURRICULUM VITAE
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Chapter 1

THE PROBLEM AND ITS SCOPE

INTRODUCTION

Rationale

A neurological disorder caused by a non-progressive brain injury or

malformation that occurs while the childs brain is under developed is called

Cerebral Palsy (CP). This condition primarily affects the body movement and

muscle coordination of a child (Stern, 2017). The most common type of Cerebral

Palsy is the Spastic Cerebral Palsy, which has been reported to be over 70% of

all CP diagnosis. This is caused by the damage to the motor cortex and the

pyramidal tracts, which connects the motor cortex to the spinal cord (Bocheck,

2016). An estimate of 86% of children with cerebral palsy have an oral-motor

dysfunction, which is an ability to control the facial and neck muscles which can

lead to difficulty in swallowing, breathing or communicating (Stern, 2017).

Although CP does not directly affect the respiratory system, this may cause

respiratory muscle impairment (Bocheck, 2016).

In the Philippines, an approximate of 1-2% of the population has been

diagnosed with Cerebral Palsy. This is more than the number of patients

identified to have been diagnosed with polio, spinal lesions, and other movement

disorders combined (PCPI, 2017). Similarly, according to a survey conducted by

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the Philippine Institute for Development Studies (PIDS), 14.63% of the population

in Batangas alone has CP (Reyes et al., 2010). Despite this condition, only the

Philippine Cerebral Palsy Incorporated (PCPI) has been addressing this

condition both in treatment and in prevention. Furthermore, studies show that

children with cerebral palsy have decreased respiratory muscle strength and

respiratory functions. This also affects their quality of life.

The aim of this research is to conduct a study of the effects of respiratory

muscle training in the lung function and the quality of life in children with Cerebral

Palsy. Moreover, it is directed at recognizing the role of respiratory therapists in

the conduct of the Cerebral Palsy rehabilitation program.

Theoretical Background

Cerebral Palsy is a group of disorders of movement and posture resulting

from injury or malformation to the developing central nervous system (Cerebral

Palsy Critical Elements of Care, 2011). Two main groupings of this disorder

include spasticity and non-spasticity. Cerebral Palsy could be a mixture of two

types (2017). Spasticity is characterized by an increase in the muscle tone. With

an increased muscled contraction, limbs become harder to move, rigid, and

resistant to flexing. Usually, the legs and the arms are the ones that are affected.

However, the mouth, the pharynx, and the tongue can also be affected; thus,

impairing the patients ability to swallow, eat, breathe, and talk. On the other

hand, in non spasticity the muscle tone is reduced. The main characteristic of
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this type of Cerebral Palsy is the involuntary movement; it can be fast or slow

and often repetitive, and sometimes rhythmic (2017).

Spastic cerebral palsy is usually described by what parts of the body are

affected. Spastic Diplegia is described as the type of Cerebral Palsy with muscle

stiffness in the legs, arms less affected or not affected at all. Usually they have a

difficulty in walking because their tight hips and leg muscles causes their legs to

pull together. The second type, Spastic Hemiplegia, affects only one side of a

persons body in which the arm is more affected than the leg. The third type,

Spastic Quadriplegia, is the most severe form of Spastic Cerebral Palsy. It affects

all four limbs, the trunk, and the face. People with this type of Spastic Cerebral

Palsy often cannot walk and usually have other developmental disabilities such

as intellectual disability. Specifically, this can lead to seizures or problems with

vision, hearing, or speech (Center for Disease Control and Prevention, 2015).

Normally in the pharyngeal phase, food passes through and the airways

close for a moment then opens again to allow breathing. In the esophageal

phase, the food is swallowed, and the esophageal passage is recoiled and

relaxed while lower esophageal sphincter helps hold the food down. A child may

not be able to cough due to the obstructed airways. Retained secretions can

cause infection and bacterial colonization. These conditions can either lead to

lung infections or pneumonia and can further cause a lethal cycle of recurrent

infections and progressive pulmonary deterioration (2017).

If the child has a more serious case of Cerebral Palsy, the formation of the

airway may be changed due to an exaggerated tone, a chest deformity, or a

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curved spine. Deformities can make breathing and proper lung expansion

difficult, and it can affect the oxygen and nutrient consumption that can lead to

frequent respiratory disorders. Furthermore, this can become a serious

complication in a persons life (2017). In a study conducted by Kwon & Lee

(2013), the changes associated with respiratory functions were assessed through

the respiratory muscle strength, specifically in terms of maximal inspiratory

pressure (MIP). Mirco Direct Inc., Lewiston, ME, USA adopted the maximal

inspiratory pressure (MIP) and maximal expiratory pressure (MEP) as a tool for

measurement of respiratory pressure for muscle strength related to respiration.

These tests assess the highest pressure that respiratory muscles are able to

generate against an occlusion at the mouth. Children were instructed to breathe

in or out against the occluded mouthpiece with maximal voluntary effort and as

much force as possible while keeping the lips sealed tightly around the

mouthpiece and remaining in a sitting position.

Different treatment guidelines depend on the diagnosis, but may include, a

breathing exercise for lung expansion therapy (2017). Many different lung

expansion therapies can help in preventing or fixing lung collapse in selected

patients. However, the precise method to provide in a given situation is often not

clear because no advantage of any one method has been established. The

effective use of resources is a primary concern with any plan to apply lung

expansion therapy. The most common modality in lung expansion therapy

includes an Incentive Spirometer; this device is designed to mimic natural sighing

by encouraging patients to take slow, deep breaths. Moreover, the use of these
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devices to provide visual cues to patients when the desired inspirations flow or

volume had been achieved is called Incentive Spirometry (Egans 10th edition).

Review of Related Studies

Children with spastic cerebral palsy are at risk of developing atelectasis,

bronchiectasis, sleep apnea, pneumonia, and chronic lung diseases due to the

fact that they have weak respiratory muscle strength and lower pulmonary

functions than normal healthy children and weak respiratory muscle strength.

Several studies were conducted to determine whether or not respiratory muscle

training would improve the pulmonary functions and respiratory muscle strength

of children with spastic cerebral palsy.

Young, Jun & Kyoung at Daegu University in Korea conducted a research

study titled The Effect of Feedback Respiratory Training on Pulmonary Function

of Children with Cerebral Palsy. The study had twenty-two (22) participants with

cerebral palsy, which were assigned into two (2) randomized groups (an

experimental group and a control group). The experimental group was instructed

to perform respiratory training while the control group was put through

rehabilitation therapy for a duration of four (4) weeks, three (3) times a week.

Their forced vital capacity (FVC), peak expiratory flow rate (PEFR), forced

expiratory volume at one second (FEV1), vital capacity (VC), inspiratory reserve

volume (IRV) and expiratory reserve volume (ERV) were measured before and

after the 4-week program. The results showed improvements of the vital capacity

by 50% and 40% on the forced expiratory volume in one second of the
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participant in the experimental group, whereas the control group had little to no

changes in their pulmonary functions. This study concluded that respiratory

training can improve the pulmonary function of children with cerebral palsy

(2014).

Maximal Inspiratory Pressure (MIP) has proved to be a vital measurement

in assessing the effectiveness of ones respiratory muscle strength. Children with

Cerebral Palsy have lesser respiratory pressures as to children with normal

development, as studied by Kwon and Lee (2015). In line with this, a study was

conducted by Kim and Lee wherein MIP was used in measuring the differences

between groups, respectively divided into an independent walking group and non

- independent walking group. The study yielded results in which notable

differences in MIP and MEP were found in children in the independent walking

group compared to the children in the non - independent walking group (2014). In

addition, a study was conducted by Lee and Nam, which aimed to investigate the

possible factors that can affect the forced vital capacity of children with Cerebral

Palsy. A total of thirty six (36) children with Cerebral Palsy were gathered for the

study. They had evaluated the MIP, MEP, maximal phonation time and other

variables of these children. The multiple regressions with stepwise method were

used to predict respiratory function with forced vital capacity (FVC) as the

dependent variables. MIP, MEP, together with maximal phonation time were the

independent variables. The results concluded that MIP and MEP have a close

correlation to the improvement in the respiratory muscle strength of the children

with Cerebral Palsy (2013).

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Furthermore, Kwon and Lee conducted a follow up research to determine

the need for children with Cerebral Palsy to undergo respiratory muscle training,

titled Differences in Respiratory Pressure and Pulmonary Function among

Children with Spastic Diplegic and Hemiplegic Cerebral Palsy in Comparison with

Normal Controls. The inclusion criteria were children with Spastic Diplegic or

Hemiplegic Cerebral Palsy based on magnetic resonance imaging (MRI),

language abilities enough to perform respiratory pressure and pulmonary

function test (PFT), gross motor functional status classified as I, II, III of the

GMFCS and no other neurologic disorder other than cerebral palsy. Fourteen

(14) children with Spastic Diplegic Cerebral Palsy, eleven (11) children with

Hemiplegic Cerebral Palsy and fourteen (14) children with normal developments

were gathered for this research. All children were measured for their pulmonary

function tests as well as their respiratory pressure with proper rest periods within

maneuvers. MIP, MEP, FVC, FEV1, FEV1/FVC, and PEF were measured.

Results showed that children with Hemiplegic or Diplegic Cerebral Palsy had

significantly lesser MIP and MEP compared with normal children. There were no

statistical differences between patients with Diplegic and Hemiplegic Cerebral

Palsy. In their PFT, there was a significant gap between their FVC and FEV1,

being lesser in patients with Diplegic and Hemiplegic Cerebral Palsy. These

results indicate the need for children with Spastic Diplegic or Hemiplegic

Cerebral Palsy to be carefully evaluated and undergo respiratory muscle training

(2015).
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A study titled Effects of Respiratory Exercises on the Vital Capacity and

Forced Expiratory Volume in Children with Cerebral Palsy which aimed to

determine benefits of respiratory exercises on the VC and FEV in children was

done by Rothman (1978). The researchers tested ten (10) children with Cerebral

Palsy and divided them into two groups. Five (5) children were designated as the

experimental group and the other five (5) children in the control group. The

children in the experimental group would undergo respiratory exercises for seven

minutes a day, every day for eight (8) weeks while the children in the control

group would not undergo exercise training. The childrens vital capacity (VC) and

forced expiratory volume (FEV) were measured before and after the children had

done the breathing exercises. The breathing exercises were focused on

conditioning the muscle used for inspiration and expiration. In addition, the

children were also taught the proper ways of breathing control. The VC and FEV

of the children of in the control group had no change before and after, whereas

the children in the experimental group had an increase of their vital capacity by

46% after the program. This indicates the benefits of respiratory muscle training

in children with spastic cerebral palsy (1978).

Similarly, Choi, Rha & Park (2016), conducted a study titled Change in

Pulmonary Function after Incentive Spirometer Exercise in Children with Spastic

Cerebral Palsy. A randomized controlled study. This study aimed to explore the

benefits of the pulmonary function and maximal phonation time (MPT) after using

the incentive spirometer exercise in children with Spastic Cerebral Palsy. The

research team had recruited fifty (50) children with Cerebral Palsy who met the
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inclusion and exclusion criteria, the subjects were randomly divided into two

groups. The researchers had all the children undergo rehabilitation therapy;

however, incentive spirometry was performed in the experimental group in

addition to the therapy. The control group only had rehabilitation as an

intervention. The children were to use the incentive spirometer for ten to fifteen

(10 15) breaths per session with ten (10) sessions a day for four (4) weeks.

The pulmonary function testing of the children was performed before the training

and at the end of the four (4) week using a portable spirometer. The spirometer

measurements included forced vital capacity (FVC), forced expiratory volume at

one second (FEV1), FEV1/FVC ratio, peak expiratory flow (PEF) and were to be

used to assess the outcome measures alongside the childrens maximal

phonation time. The study concluded that there were significant improvements in

the childrens pulmonary function and maximal phonation time with the use of

incentive spirometer.

To sum it all up, the article "Effects of Exercise in People with Cerebral

Palsy. A review conducted an extensive literature search using MEDLINE

(PubMed), CINAHL, Sport Discus, Science Direct, PEDro, and Google Scholar.

They had come up with fifty six (56) research articles and eight (8) review

papers. They discovered that children with Cerebral Palsy have lower levels of

oxygen consumption (VO2max) and higher energy demands in walking

compared to children without Cerebral Palsy, which will eventually lead to a

reduction of their health and well-being. Furthermore, these children have greater

energy consumption during running than those without Cerebral Palsy. A

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research performed by Berg (1970) showed that a series of sessions and a 20

minute per week aerobic exercise yielded improvements in their oxygen uptake.

These findings concluded that there are improvements in these patients' Quality

of life through improvement of their cardiorespiratory fitness and reducing muscle

deficits (2014).

Conceptual Framework

Identification of Respondents
(Children with Spastic
Cerebral Palsy in S.T.A.C.)
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Pre-assessment:
Quality of Life using the Cerebral Palsy Quality
of Life Questionnaire and maximum inspiratory
pressure for respiratory muscle strength

4-week Respiratory Muscle

Training using Incentive
Spirometry

Post-assessment:
Quality of Life using the Cerebral Palsy Quality
of Life Questionnaire and maximum inspiratory
pressure for respiratory muscle strength

Figure 1.0 Schematic Diagram of the Study

Fig. 1.0 shows the identification of respondents, the preliminary assessment, the

quality of life using the Cerebral Palsy Quality of Life Questionnaire and their

respiratory muscle strength through maximum inspiratory pressure. A 4-week

respiratory muscle training using Incentive Spirometry will be conducted. Post

assessment will be done after the 4-week therapy to assess their quality of life

and to determine their respiratory muscle strength.

Statement of the Problem

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This study aims to determine the effects of respiratory muscle training on

respiratory functions and quality of life in selected children with spastic cerebral

palsy.

Specifically, it is directed towards accomplishing the following objectives:

1. To determine the effects on the lung function in terms of Maximum

Inspiratory Pressure (MIP) before and after the therapy.

2. To assess the quality of life before and after the therapy.

3. To determine the significant change on the lung function and quality of

life among children with cerebral palsy after the 4-week respiratory

muscle training.

Significance of the Study

The results of the study will be of great benefit to the following:

Children with Cerebral Palsy and their parents, that the result of this study

will provide them with the necessary information related to this condition as to

enhance their knowledge about the benefits of respiratory muscle training and its

effects on their respiratory muscles and on their quality of life.

To the community, that this study may gain awareness, not only to those

families having relatives diagnosed with Cerebral Palsy but also to the other

members of the community, on the importance and implications of respiratory

rehabilitation programs.
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To the Department of Health, that this study will show the implementation

of chest expansion exercise of the respiratory muscles through respiratory

muscle training and the corresponding benefits that it may bring. In addition,

DOH may be able to acknowledge this intervention as an additional instrument to

the rehabilitation therapy for Cerebral Palsy patient.

To the Rehabilitation Centers, that this study may improve the current

rehabilitation programs on children with Cerebral Palsy through the integration of

the studys suggested intervention so as to decrease the complications that the

disorder may bring.

To the Respiratory Therapists, Physical Therapists, Occupational

Therapists, Speech Pathologists, and other medical practitioners, that this study

may inform them that respiratory muscle training is also beneficial to patients with

Cerebral Palsy.

To the future researchers, that this study may be of use as a guide or a

reference to future studies.

Scope and Limitations

This research study will focus on determining the effects of respiratory

muscle training on the respiratory function and the quality of life in children with

spastic cerebral palsy, which are within the age of six (6) to twelve (12) years old.

This study will be conducted at the Stimulation and Therapeutic Activity Center in

Lapu-Lapu City, Cebu.

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Limitations will be encountered as the researchers will proceed with the

conduct of the study. These limitations will include the possible withdrawal of

prospect respondents, the sudden conflict of schedules, the attention span of the

children, the current rehabilitation programs and the condition of the rehabilitation

center. When a respondent suddenly withdraws their participation in the study,

the researchers will render the data of the said respondent invalid. In an event of

respondent withdrawal, back-up respondents are allotted to fill in the attrition of

respondents. If conflict of schedules arises, the researchers will ensure that the

intervention will take place at the time of convenience of the respondents. The

researchers are aware that children have short attention span. As such, the

researchers shall perform activities which are both entertaining and reproducible

of relevant data. In addition, the researchers recognize that there are current

rehabilitation programs being conducted by the physical therapists, occupational

therapists, and speech pathologists. The study will be structured in a way that

does not intervene with such program. The distance from the respondent's house

to the rehabilitation center, and other factors might affect the respondent's

compliance to the study.

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RESEARCH METHODOLOGY

Research Design

The researchers will use a single group pre-test post-test true

experimental design.

Research Environment

The study will be conducted at the Stimulation and Therapeutic Activity

Center (S.T.A.C) Opon, Lapu-Lapu City, Philippines. S.T.A.C. has been taking

care of children with Cerebral Palsy and is fully capable of catering to their

needs. In addition, S.T.A.C. has the highest amount of children with cerebral

palsy in the area.

Research Respondents

The respondents will be children from the Stimulation and Therapeutic

Activity Center in Lapu-Lapu City, who are diagnosed with Spastic Cerebral Palsy

with ages ranging from 6 to 12 years old, and can be either male or female. The

following criteria will determine whether they qualify as a respondent or not:

Inclusion Criteria:

The subjects that will be included in this study are children with the age of

6-12 years that are enrolled at the Stimulation and Therapeutic Activity Center.

Also, these children are those diagnosed with Spastic Cerebral Palsy that are

willing to participate in the study and can follow instructions.

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Exclusion Criteria:

Children that are not within the specific age range, have undergone

pulmonary rehabilitation or other respiratory muscle training, have other

significant coexistent cardiac or pulmonary disease, have chest wall deformities

such as scoliosis or kyphoscoliosis, and have other type of cerebral palsy will not

be included in the study. Other factors for exclusion are language barriers,

cognitive impairment, asocial children, and those with disability.

Research Instruments

The researchers, with the approval of the author, will use the Cerebral

Palsy Quality of Life Questionnaire for Children (CP QOL-Child) by Davis, et. al.

to assess the subjects quality of life. CP QOL Child is a measure of quality of

life for children with Cerebral Palsy. It has been developed specifically for

children with Cerebral Palsy. The CP QOL Child was developed in consultation

with parents, children and health professionals.

The CP QOL Child is composed of seven (7) areas or domains namely:

Social Wellbeing and Acceptance, Participation and Physical Health, Feelings

about Functioning, Emotional Wellbeing and Self-esteem, Pain and Impact of

Disability, Access to Services and Family Health using a nine (9) - point scale

questionnaire before and after the pulmonary rehabilitation program. The

algebraic mean will determine the overall CP QOL- Child score: nine (9) as the

best score (very happy), one (1) is at the other end of the range; five (5), the

score right in the middle of the range. This test can be administered using two
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methods, either a face to face interview or a mail out questionnaire. The scores

interpretation will be based on the questionnaire that the children will use. The

interpretation of these results involves two steps. First, the items are transformed

to a scale with a possible range of 0-100. As shown below:

Table 1.0 The table shows the score with the corresponding scale in the

following domains: Family and Friends, Participation, Communication, Health,

Special Equipment, and Pain and Bother.

Score Scale
1 0
2 12.5
3 25
4 37.5
5 50
6 62.5
7 75
8 87.5
9 100

Table 1.1 The table shows a 5-point score with a corresponding scale

which is under the domain of Pain and Bother.

Score Scale
1 0
2 25
3 50
4 75
5 100

Second, the values of each domain are calculated.

Research Procedure
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Gathering of Data

The researchers sent a transmittal letter to the Lapu-Lapu City Vice

Mayor, Marcial Ycong, to ask permission for the conduct of a study in the S.T.A.C

rehabilitation center. This transmittal letter will be forwarded to S.T.A.C

rehabilitation center to enlist children with spastic cerebral palsy, ages 6-12 years

old as research subjects of this study.

Researchers will explain to the social workers the intervention and how this

study can be of help not only for patients with cerebral palsy but also for parents

who have less knowledge on their childs condition. The parents of these

research subjects will be contacted to inform and explain to them the

interventions that researchers will be giving and the length of time needed for the

conduct of such. After obtaining the informed consent, the subjects will be asked

to answer the questionnaire, Cerebral Palsy Quality of Life Questionnaire.

The intervention will make use of incentive spirometry, which can help

improve respiratory muscle strength. The instrument that the researchers will use

for measuring the improvement of the subjects respiratory muscle strength is

called maximum inspiratory pressure gauge.

The researchers will measure the baseline using maximum inspiratory

pressure procedure. The researchers will only instruct the subjects to inhale deep

and rapid but not forceful while occluding the hole in the mouthpiece. Thereafter,

an instruction and demonstration, with the use of incentive spirometry, will be

given. The researchers will have to instruct the subjects to inhale deep and

sustain that inhalation as long as they can and repeat this procedure 10 times
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with 5-10 mins interval or rest. Maximum Inspiratory Pressure (MIP) procedure

will be performed again to obtain post exercise result after each week. This

intervention will only be done 3 times a week for 4 weeks.

After 4 weeks of intervention, the researchers will gather all pre and post

assessment results. The results will be analyzed.

Treatment of Data

DEFINITION OF TERMS

Quality of Life. A notion that includes domains related to the physical,

mental, emotional, and social functioning of a child. It will be observed by the

subjects before and after they will be given the interventions. It will be measured

through the Cerebral Palsy Quality of Life Questionnaire for Children (CP QOL -

Child) by Davis, et.al, which consisted of 7 domains: Social Wellbeing and

Acceptance, Participation and Physical Health, Feelings about Functioning,

Emotional Wellbeing and Self-esteem, Pain and Impact of Disability, Access to

Service, and Family Health.

Activity Limitation. The difficulty to perform an action such by an individual

with disability.

Symptoms. An experience which can be felt by the subject related to their

health, but does not necessarily indicate an illness.

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Respiratory Muscle Training. A technique that will be used by the

researchers to increase respiratory function of the subjects by improving the

performance of the muscles involved in ventilation. This will help evaluate the

efficacy of respiratory muscles for improvement of muscle function in children

with spastic cerebral palsy.

Maximum inspiratory pressure (MIP). The measurement of the maximum

inspiratory pressure or maximum negative pressure that can be generated by the

respondent will reflect their respiratory muscle strength. The pre- and post-

therapy measurements of MIP will be analyzed to see if there will be a significant

change in the lung function of the respondent.

Incentive spirometry (IS). The type of respiratory muscle training that will

be used in the study among children with cerebral palsy in S.T.A.C. to help

improve their lung function and quality of life. The slow, deep breaths in incentive

spirometry will exercise and improve the respiratory muscle strength. Also, the

Sustained Maximal Inspiration or breath-holding after a maximal inspiration which

is an important maneuver in incentive spirometry will open some collapsed

alveoli and will also facilitate airway clearance which is a great benefit to the

respondents because patients with cerebral palsy are prone to pneumonia

because of their inability to clear their airways properly.

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REFERENCES

Bochek, K. (2016, December 13). Spastic Cerebral Palsy - Causes, Symptoms

and Treatment. Retrieved January 15, 2017, from
https://www.cerebralpalsyguide.com/cerebralpalsy/types/spastic/

Facts about Cerebral Palsy. (2015, July 13). Retrieved February 22,2017, from
https://www.cdc.gov/ncbddd/cp/facts.html

Kacmarek, R. M., Stoller, J. K., &Heuer, A. J. (Eds.). (2013). Fundamentals of

Respiratory Care (10th ed.). Elsevier Inc..

Kyoung, K., Young, L., & Jun, C. (2014). The effect of feedback respiratory
training on pulmonary function of children with cerebral palsy: a
randomized controlled preliminary report [Abstract].Retrieved February 9,
2017, from https://www.ncbi.nlm.nih.gov/pubmed/23897949.

Lee, H., & Kim, K. (2014).Can Walking Ability Enhance the Effectiveness of
Breathing Exercise in
Children with Spastic Cerebral Palsy? Journal Of Physical Therapy
Science,39-542. Retrieved February 21, 2017, from
http://pubmedcentralcanada.ca/pmcc/articles/PMC3996417/

McLaughlin, J., MD & Walker, W., MD. (2011,June). Cerebral Palsy (Critical
Elements of Care). Retrieved February 22,2017, from http://cshcn.org/wp-
content/uploads/files/CriticalElementsofCare-CerebralPalsy.pdf
 22

Nam, K., & Lee, H. (2013).Predictive Factors Affected to Forced Vital Capacity in

Children with Cerebral Palsy [Abstract]. Journal Korean Physical Therapy,

204-209. Retrieved February 20, 2017, from

http://www.kptjournal.org/journal/view.html?
uid=1062&page&pn=mostread&sort=publish_Date
%20DESC&spage&vmd=Full

Philippine Cerebral Palsy Incorporated. (n.d.). Retrieved February 17, 2017, from
http://philippinecerebralpalsy.org/about_cerebral

Priego, C., Lucas, C., Llana, B., & Perez, S. (2014). Effects of exercise in people
with cerebral palsy.A review. . Journal of Physical Education and Sport,
36-41. Retrieved February 9, 2017, from
http://roderic.uv.es/bitstream/handle/10550/36114/094249.pdf?sequence=1

Stern, K. A., Att. (2017). Types of Cerebral Palsy. Retrieved February 22, 2017,
from http://www.cerebralpalsy.org/about-cerebral-palsy/types-and-forms

Stern, K. A., Att (2017). Types of Cerebral Palsy. Retrieved February 22, 2017,
from http://www.cerebralpalsy.org/about-cerebral-
palsy/treatment/therapy/respiratory-therapy

Stern, K. A., Att. (2017). Definition of Cerebral Palsy. Retrieved February 10,
2017, from http://www.cerebralpalsy.org/about-cerebral-palsy/definition

Tilton, A., MD. (2009). Management of Spasticity in children with Cerebral Palsy.
Retrieved February 22,2017, from
http://www.americanchildneurologyuae.com/ar/files/neurological-
disease/cp/SPASTICITYCHILDREN.pdf
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Appendix A-1

LETTER OF APPROVAL FOR THE USE OF THE CEREBRAL PALSY

QUALITY OF LIFE QUESTIONNAIRE FOR CHILDREN (CP QOL CHILD)

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A-2

TRANSMITTAL LETTER TO S.T.A.C REHABILITATION CENTER

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APPENDIX B

INFORMED CONSENT FORM

Consent to Participate in a Research Study

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Title of Research Study. Effects of Respiratory Muscle Training in the Lung

Function and Quality of Life of Children with Spastic Cerebral Palsy in Cebu City.

Investigators. Arquillano, Aleck L., Enopia, Kathlene Mae N., Lee, Aecarah S.,

Remilla, Christelle Faye T., Villamor, Bryan Jomer G., Bachelor of Science in

Respiratory Therapy, Cebu Doctors' University, Mandaue City, Cebu, Philippines,

phone 09089874182.

Purpose and Background. The purpose of this study is to improve the lung

function and quality of life of children with cerebral palsy, and educate not only

the people with a direct relationship with children diagnosed with cerebral palsy

but also the rehabilitation centers that respiratory muscle training will improve the

lung function of the children affected. This is a study that assesses the maximum

inspiratory pressure among children with cerebral palsy before and after the 4-

week respiratory muscle training.

Procedures. If I agree to participate, the following things will happen:

1. I will be asked a series of questions regarding my child's respiratory

condition.

2. My child will perform the Maximum Inspiratory Pressure maneuver for the

baseline measurement. This maneuver is neither painful nor dangerous.

3. My child will perform the incentive spirometry and will be guided by the

researchers throughout the whole procedure. My child will be checked and

assessed frequently for any symptoms or discomfort that my child may

feel during the procedure.

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4. My child will be given time to rest before he perform another Maximum

Inspiratory Pressure maneuver as a post-therapy assessment.

Benefits. My child's participation in this study will assess his/her lung function

and quality of life and then will be given an intervention which will then improve

my child's lung function and quality of life.

Risks. While performing the procedure, my child may experience discomfort and

hyperventilation but this does not affect his/her present health status.

Reimbursement. A financial assistance will be given to my child that will be

shouldered by the researchers for any injuries acquired during the intervention,

given that my child has followed the safety procedures and pre-intervention

instructions.

Confidentiality. The data and results that will be obtained in this study will be

explained to me and will be sent to my child's physician and other therapists.

Except for this disclosure, all data gathered in this study will be considered

confidential and will used for research purposes only. My childs identity and I will

be kept confidential in so far as the law allows.

Questions. Christelle Faye T. Remilla, the researcher, has discussed everything

to me -- including the procedure, risks, benefits, and results from data gathered,

and offered to answer my questions. if I have any further questions, I can contact

her at 09089874182.

Right to Refuse or Withdrawal. The participation of my child in this study is

entirely voluntary, and he/she can refuse or freely withdraw at any time without

affecting my child's future medical care.

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Consent. I have been given a copy of this form and had a chance to read it and I

agree that my child will participate in this study.

Name of Child:

Signature of Parent or Guardian:

Date:

Signature of Investigator:

Appendix C

ETHICAL REVIEW FORM

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Appendix D-1

RESEARCH INSTRUMENT

CEREBRAL PASLY QUALITY OF LIFE QUESTIONNAIRE FOR CHILDREN

(CP QOL CHILD)

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31
32
33
34
35
36
37
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Appendix D-2

RESEARCH INSTRUMENT

PERSONAL DATA SHEET

Date:

PERSONAL DATA SHEET

Name: Age: ________

Date of Birth: Address:

(put an 'x' on the corresponding type of cerebral palsy)

Spastic:_______ Nonspastic:______

If Spastic,

Hemiplegia:_______ Diplegia:_______

Name of Guardian:

Signature:

Contact Number:
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Appendix E

TIMETABLE OF RESEARCH ACTIVITIES

RESEARCH FEB MAR APRIL MAY JUNE JULY AUG SEPT OCT
ACTIVITIES
Assignment of
Research Mentor
Screening and
Approval of Title
Approval of
Proposal Paper

Sample Size and

Advice on
Statistical
Treatment

Ethical Review
Submission of
Thesis Proposal
Paper
Presentation and
Approval of the
Proposal Paper
Implementation
of the Study
Data Processing
and Analysis
Submission of
the Thesis Paper
Final Report
Oral Defense of
the Thesis Paper
Final Report
Approval of the
Revised Thesis
Paper
Approval for
Final Printing of
the Paper
Submission of
Research
Requirements

Appendix F
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RESEARCH BUDGET

Expense/s Cost

Reproduction materials Php 3,000.00

Internet Usage 100.00

Transportation 500.00

Thesis Proposal Hearing Fee 5,000.00

TOTAL Php 8,600.00

Appendix G

RESEARCH DOCUMENTATION
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Appendix H
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RESEARCH LOCALE

CURRICULUM VITAE
 43

Personal Background

Name : Aleck L. Arquillano

Address : Block 11, Lot 19 & 20, Rosal St. V&G Subdivision,

Consolacion, Cebu

Contact No. : 09959721063

Email address: aleck_1995@yahoo.com

Educational Background

2002-2008
Elementary level
Sotero B. Cabahug Forum for Literacy
Cebu City

2008-2012
Secondary Level
Sacred Heart School - Ateneo de Cebu
H. Abellana St., Canduman, Mandaue City

2012-Present
Tertiary Level
Bachelor of Science in Respiratory Therapy
Cebu Doctors University
Mandaue City

CURRICULUM VITAE
 44

Personal Background

Name : Kathlene Mae Nueve Enopia

Address : Dalakit, Poblacion, Zamboanguita, Negros Oriental

Contact No. : 09267498244

Email address: kenopia@gmail.com

Educational Background

2003-2009
Elementary level

Zamboanguita Central Elementary School

Zamboanguita, Negros Oriental

2009-2013
Secondary Level

Zamboanguita Science High School

Zamboanguita, Negros Oriental

2013-Present
Tertiary Level
Bachelor of Science in Respiratory Therapy
Cebu Doctors University
Mandaue City
 45

CURRICULUM VITAE

Personal Background

Name : Aecarah S. Lee

Address : 665 Tisa, Labangon, Cebu City

Contact No. : 09776896234

Email address: aecarahlee@yahoo.com

Educational Background

2001-2003
Elementary Level
Marie Ernestine School

Sepulveda St., Cebu City

2003-2007

Elementary Level

Maria Montessori International School

San Jose Talamban, Cebu City

 46

2007-2010
Secondary Level
Maria Montessori International School

San Jose Talamban, Cebu City

2013-Present
Tertiary Level
Bachelor of Science in Respiratory Therapy
Cebu Doctors University
Mandaue City

CURRICULUM VITAE

Personal Background

Name : Christelle Faye T. Remilla

Address : Yati, Liloan, Cebu

Contact No. : 09089874182

Email address: christelleremilla@gmail.com

Educational Background

2002-2008
Elementary Level
St. Benedict Childhood Education Centre
Redemptorist Plaza, Cebu City

2008-2012
Secondary Level
Sacred Heart School - Ateneo de Cebu
H. Abellana St., Canduman, Mandaue City
 47

2012-2013
Tertiary Level
Bachelor of Science in Pharmacy
University of San Carlos Talamban Campus
Cebu City

2013-Present
Tertiary Level
Bachelor of Science in Respiratory Therapy
Cebu Doctors University
Mandaue City

CURRICULUM VITAE

Personal Background

Name : Bryan Jomer G. Villamor

Address : Lot 4 Block 5 Lacitadella, Cada-uhan, Talamban, Cebu City

Contact No. : 09152609683

Email address: bryaaaaanvillamor@gmail.com

Educational Background

2002-2008
Elementary Level
Maria Montessori International School
San Jose Talamban, Cebu City

2008-2012
Secondary Level
Sacred Heart School - Ateneo de Cebu
H. Abellana St., Canduman, Mandaue City
 48

2013-Present
Tertiary Level
Bachelor of Science in Respiratory Therapy
Cebu Doctors University
Mandaue City