in hemiplegia patients , weakened respiratory muscles in relation to chest expansion cause 
 fatigue or dyspnea when performing tasks that demand intensive efforts1,2,3 , and such patients may have problems with activities of daily 
 living4 . a combined program of 
 rehabilitation and respiration - related intervention would be effective in enhancing stroke 
 patients functional activities , such as gait5 , 6 . accordingly , this study aimed to examine exercise tolerance of chronic stroke patients with 
 hemiplegia when chest expansion resistance exercises ( cere ) facilitating respiratory 
 function was applied to them prior to a functional rehabilitation intervention by looking at 
 its effects on their respiratory function , chest expansion , and gait function which requires 
 muscle endurance . the subjects of this study were 40 chronic stroke patients who had been diagnosed and 
 hospitalized with a stroke at a rehabilitation hospital and were receiving a stroke 
 rehabilitation treatment . patients who had normal cognitive functions ( scores > 24 on the 
 mini - mental state examination ) and therefore could understand the content of this research 
 and the reasoning behind it , who could walk more than 10 meters and for more than six 
 minutes , and who had not received respiration - related rehabilitation previously were 
 considered to be eligible for this research . all of the protocols used in this study were 
 approved by the university of daejeon . before participation , the procedures , risks , and 
 benefits the 
 participants rights were protected according to the guidelines of the university of 
 daejeon . the 40 chronic stroke patients ( table 
 1table 1.general characteristics of subjects ( n=40)cere group(n=20)control group(n=20)gender ( male / female)10/1011/9age ( yrs)57.35.156.94.3height ( cm)167.75.8168.67.8weight ( kg)6710.77012.4tobacco abuse45%40%paretic side ( right / left)13/714/6time since stroke ( months)215.1225.4lesion type ( ischemic / hemorrhagic)14/613/7meansd ; cere : chest expansion resistance exercise ) were randomly and equally divided into a cere group and a control group . the 
 10mtwt ( 10-meter timed walking test ) and 6mwt ( 6-minute walk test ) were performed on all the 
 subjects one day after the experiment started . at the same time , after one day lapsed , their 
 vc ( vital capacity ) , fvc ( forced vital capacity ) , fev1 ( forced expiratory volume in one 
 second ) , and chest expansion were measured . after the application of cere , then 10mtwt and 6mwt were 
 applied to the subjects , and the values before and after the intervention were compared . the 
 control group conducted passive range of motion exercise within a range that would not 
 affect respiratory function using lower extremity automatic instruments , while the 
 intervention was applied to the cere group . to facilitate respiration , cere was applied to 
 the cere group based on the concept of proprioceptive neuromuscular facilitation ( pnf ) . for 
 cere , patients lay on their side with the affected side upward , and the therapist placed 
 both hands obliquely along the ribs from the apex of the lower ribs . for 5 minutes , the 
 therapist trained each patient on inspiration using a quick stretch while breathing out 
 completely . after the patient fully understood this process , the therapist applied 
 resistance in caudal and medial directions in such a way as to cause responses in all ranges 
 of motion but not to such a degree that movements were suppressed7 . this technique was applied to the cere group for 20 
 minutes , and when a patient complained of dizziness or fatigue , the patient was allowed to 
 rest until the symptoms disappeared . using a tape measure , the xiphoid process were marked with a pen , 
 and the measurement was made during inspiration by linking the two marked points in parallel 
 with the ground8 . as a tool for 
 measurement in the pulmonary function test , a spirometer ( easyone spirometer , ndd medical 
 technologies , zrich , switzerland ) was used ; the 
 10mtwt was applied to measure the time taken to move 10 meters9 . to reduce errors from the acceleration and deceleration sections at 
 the beginning and end of gait , the subjects were made to walk 14 meters , and the velocity 
 for 10  m excluding the first 2  m and the last 2  m was measured10 . a track was drawn indoors , 
 and a mark was made every 1 meter with tape . the length of the tape was measured to 
 calculate the distance travelled in 6 minutes after the subject walked for 6 minutes . with 
 this method , a stroke patient s muscle endurance and functional gait ability may be 
 evaluated2 . meansd ; cere : chest expansion resistance exercise windows spss version 18.0 was used to analyze the data for this research . the values of the 
 cere group and control group were expressed as means and standard deviations . a paired 
 t - test was applied to compare changes between the cere group and the control group after the 
 exercise . a p - value less than 0.05 was considered to be statistically significant . the clinical and demographic features of the patients are shown in table 1 . prior to the experiment , there was no difference between 
 the two groups in gender , age , height , weight , affected side , time after the onset of a 
 stroke , lesion type , smoking rates , pulmonary functions ( vc , fvc , and fev1 ) , 10mtwt result , 
 6mwt result , and chest expansion . table 2table 2.a comparison of chest expansion , vc , fvc , and fev1 ( n=40)nbeforetrainingaftertrainingchest expansion ( cm)cere group203.61.13.91.1*control group203.61.23.60.8vc ( l)cere group202.70.42.70.3control group202.80.32.80.4fvc ( l)cere group201.90.42.00.4control group201.90.41.90.4fev1 ( l)cere group201.50.41.60.4control group201.60.31.70.410mtwt ( m / s)cere group2066.337.964.035.9control group2066.639.265.339.56mwt ( m)cere group2068.230.070.329.1*control group2069.331.270.132.3meansd . cere : chest expansion resistance exercise ; vc : vital 
 capacity ; fvc : forced vital capacity ; fev1 : force expiratory volume at one 
 second ; 10mtwt : 10-meter timed walking test ; 6mwt : 6-minute walking test shows the chest expansion values and vc , fvc , fev1 , 10mtwt , and 6mwt values 
 measured before and after the intervention . the cere group s chest expansion increased 
 ( p<0.05 ) , whereas the control group s chest expansion did not differ before and after the 
 exercise . both the control group and the cere group saw no change in vc , fvc , and fev1 after 
 the exercise . in the 10mwt , however , in the 6mwt , the cere 
 group saw functional improvement , whereas the control group did not experience any 
 significant improvement ( p<0.05 ) . cere : chest expansion resistance exercise ; vc : vital 
 capacity ; fvc : forced vital capacity ; fev1 : force expiratory volume at one 
 second ; 10mtwt : 10-meter timed walking test ; 6mwt : 6-minute walking test to examine the effect of cere , an exercise to facilitate respiration , vc , fvc , fev1 , and 
 chest expansion were measured before and after cere . to look at changes in functional gait 
 ability , the 10mtwt and 6mwt were performed , and movement distances were measured and 
 compared one day before and after cere . the result of cere application was that the control group did not experience any 
 significant change in chest expansion , whereas the cere group experienced a significant 
 change ( p<0.05 ) . this was similar to the result of research12 that compared changes in chest expansion prior to and 
 after the application of a pnf deep - breathing exercise to myotonic dystrophy patients , 
 although there were numerical differences between the two studies . this result provides 
 clinical grounds for the effects of a cere intervention in facilitation of respiration , and 
 other research results13,14,15 that found that 
 improved chest expansion capability translates into increased inflow of air into the lungs 
 support the significance of the changes in this research . regarding vc , defined as the maximum amount of air a person can expel from the lungs after 
 a maximum inspiration , the control group s change amount was 0.01 ( l ) and the cere group s 
 change amount was 0.4 ( l ) , which were not statistically significant . regarding fvc , defined 
 as the volume change of the lung between a slow full inspiration to total lung capacity and 
 a rapid maximal expiration to residual volume , the control group s change amount was 0.02 
 ( l ) and the cere group s change amount was 0.11 ( l ) , which were also not statistically 
 significant . regarding fev1 , defined as the maximum volume of air expired in one second , the 
 control group s change amount was 0.02 ( l ) and the cere group s change amount was 0.05 ( l ) . nonetheless , the cere group s vc , fvc , and 
 fev1 numerically increased by more than those of the control group . this may be interpreted 
 as meaning that cere is not expected to have an immediate effect that improves pulmonary 
 function but may have a positive influence on pulmonary function . reduced respiratory function is a crucial issue in stroke patients ; decreased 
 cardiopulmonary function among different types of damage makes up a large part of the 
 disorders in chronic stroke patients and acts as an important factor , along with declined 
 gait and movement ability , in their return to the community after rehabilitation 
 treatment16 , 17 . among the functional gait tests , the changes measured by the 
 10mtwt to evaluate gait velocity were not statistically significant in either group the control group s changes were 
 not statistically significant , whereas the cere group s changes were . therefore , the 
 importance of respiratory exercise in an approach to rehabilitation treatment intervention 
 for stroke patients was verified , and addition of respiratory exercise to a rehabilitation 
 treatment intervention program should be considered a priority . future research needs to 
 examine the minimum time period required for cere to cause significant changes pulmonary 
 function and chest expansion in stroke patients and to include a larger number of stroke 
 patients with different ages as subjects .
[ purpose ] the aim of this study was to examine the initial effects of chest expansion 
 resistance exercise ( cere ) applied to chronic stroke patients on their pulmonary 
 functions , chest expansion , and functional gait ability . [ subjects ] forty chronic stroke 
 patients without any respiration - related rehabilitation program experience ( 21 men and 19 
 women ; times elapsed since occurrence of stroke : 21.8  5.3 months ) were randomly and 
 equally allocated to a cere group ( experimental group ) and a control group . 
 [ methods ] an 
 ordinary stroke rehabilitation program was performed on the subjects . 
 while the 
 experimental group received a cere intervention , the control group performed passive range 
 of motion exercise with automatic instruments . 
 [ results ] the cere group s chest expansion 
 significantly increased after the intervention , whereas the control group did not see any 
 significant difference . as regards vc ( vital capacity ) , fvc ( forced vital capacity ) , and 
 fev1 ( forced expiratory volume in one second ) , there were no significant 
 changes in either the cere or control group . 
 in the 10mtwt ( 10-meter timed walking test ) , 
 there were no significant changes in either group , but in the 6mwt ( 6-minute walk test ) , 
 while there were no significant differences in the control group , the cere group saw 
 significant changes . 
 [ conclusion ] the results of application of cere to chronic stroke 
 patients demonstrated the importance of respiratory exercise in an approach to stroke 
 rehabilitation treatment intervention and the need to add respiratory exercise to a 
 rehabilitation intervention program .