Effectiveness of Diaphragmatic Breathing with Quadriceps Exercises on Maximum Phonation Time, Respiratory function and Muscle Strengthening in Community- Dwelling Elderly

Effectiveness of Diaphragmatic Breathing with Quadriceps Exercises on Maximum Phonation Time, Respiratory function and Muscle Strengthening in Community- Dwelling Elderly | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of Diaphragmatic Breathing with Quadriceps Exercises on Maximum Phonation Time, Respiratory function and Muscle Strengthening in Community- Dwelling Elderly Benjamas Prathanee, Netra Buakanok, Tawitree Pumnum, Nantiya Ooppanasak, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4257094/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Most of population in the world recently move to super-aged society. Program of health promotion for community-dwelling elderly requires critical concern. Objectives : The objectives of this study were to compare maximum phonation time (MPT), Maximum counting duration (MCD), Peak expiratory flow rate (PEFR), Maximum inspiratory pressure (MIP), Maximum expiratory pressure (MEP), and quadriceps muscle strengthening before and after breathing with quadriceps exercises. Methods : Twenty- three community-dwelling healthy elderly aged 60–70 years old (mean = 65.52 and standard deviation = 2.41) were enrolled to complete study. Participants did program of breathing with quadriceps exercises twice a day in sitting, standing position and walking for 7 weeks. Results : Median of MPT of /a; u; i:/ before exercises = 8.61–10.14 seconds. Wilcoxon Sign Rank Test was found significant better medians of MPT, MCD, PEFR, MIP, MEP, and quadriceps muscle strength after program. function. Conclusion : Program of breathing with quadriceps exercises could significantly increase MPT, MCD, PEFR, MIP, MEP, and quadriceps muscle strength in community-dwelling healthy elderly within 7 weeks. Breathing exercise Quadriceps exercise Community-dwelling elderly Respiratory function Figures Figure 1 Introduction: People aged ≥ 65 are generally elderly. More than 7% of the population is 65 years or older is defined as an “aged society”; > 14% of the population is 65 years or older as an “aged society”; and > 21% of the population is 65 years or older as a “super-aged society” [ 1 ]. There will be more than one billion of the world’s population was above the age of 60 in 2019 and increase to 1.4 billion by 2030 and 2.1 billion by 2050 .[ 1 , 2 ]. Japan has been > 25% of the population is ≥ 65 years and defined as a super-aged society since 2013 and expected to continue growing in the future. Following in the footsteps of Japan, Hong Kong, South Korea, Taiwan, and Singapore are forecasted to be super-aged societies in 2012, 2017, 2018, 2021, respectively. Thailand (the 6th economy in Asia), has already reached an aged society status in 2022.[ 3 ] Thailand is a country that has the fastest ageing growing in the world. Of its 67 million population, 12 million Thais, are elderly according to the latest national statistics report. The country has been classified as an ‘aged society’ due to people aged ≥ 60 years accounted for 10% of the population. It is expected that the country’s elderly population will increase to 28% and that There will be increase elderly population to be 28% and become a ‘super-aged society’ by the next decade [ 2 ]. The well-being of older persons is the major emerging challenges for families, communities and government in Thailand similar to many countries in Asia. Thai government has been giving the serious attention to ageing conditions because older people have functional limitations and difficulties with self-care and other activities of daily living with age [ 4 ]. At least one of 37% in population aging has such difficulty [ 5 ]. Poor self-assessed health, illness during the past five years, poor vision and hearing, as well as incontinence all increase substantially with age [ 5 ] . Thai government clearly aware of the challenge about long-term care of elderly’s independent living without of assistance. To provide home-based assistance for older persons, the Bureau of Empowerment for Older Persons (now Department of Older Persons) launched program of Home Care Service Volunteers for the Elderly Program to establish a system of community-based care and protection for older persons with chronic illnesses in 2003 [ 4 ] . Diaphragmatic breathing” or “deep breathing”, an efficient integrative body–mind training for dealing with stress and psychosomatic conditions and improve sustained attention, affect, and cortisol levels. Effect of diaphragmatic breathing has important roles for health promotion in healthy individuals[ 6 ]. Deep and slow breathing reduced state anxiety in older adults, attenuate pain [ 8 ], increase lung capacity [ 9 , 10 ], improves digestion or gastroesophageal reflux [ 11 ], sleep [ 12 ], mood [ 13 ], and enhance better oxygenation [ 14 ]. Lung volume is resource of air flow for speaking and breathing is critical to speech. Voice disorders were common among the elderly and prevalence was 47% with 29.1% of participants reporting a current voice disorder[ 15 ]. Sarcopenia is condition that has loss of skeletal muscle mass and function, is one of common age-related disease. Overall estimates of prevalence of sarcopenia in community-dwelling older adults was 10% (95% CI: 8–12%) [ 16 ]. Almost all participants with sarcopenia showed respiratory muscle weakness with 50% had respiratory muscle weakness [ 17 ]. Sarcopenia is a progressive and generalized loss of skeletal muscle mass and function and associated with increased adverse outcomes such as physical disability, poor quality of life, and death [ 18 ]. Prevention of sarcopenia is a critical concern for all hospital staff involved older adults. Osteoarthritis (OA) is also the most common form of arthritis and a leading cause of disability among older people. One of 3 elderly had OA [ 19 ]. Therefore, voice disorders, OA and sarcopenia should be critical task for hospital or community staff who care elderly. One of prevention of voice disorders, OA and sarcopenia was diaphragmatic breathing and quadriceps exercises. Diaphragmatic breathing is benefit for increasing lung volume for speaking, maximum inspiratory pressure (MIP) related to skeletal muscle mass and strength [ 19 ] Quadriceps exercises offer many benefits including improve muscular strength, setter posture & flexibility, strengthens bone density that facilitate overall health and well-being. Strength training of the quadriceps muscles also relieved pain and improved physical function [ 20 , 21 ]. Recent study found that respiratory muscles, particularly inspiration and expiratory pressure were significantly related to limb muscle strength and skeletal muscle mass[ 22 ]. Therefore, combination of breathing exercise and quadriceps exercise were benefit for enhance respiratory system and muscle strengthening that are the important factors for healthy and independent daily live activities in community-dwelling older. Objective of this study to compare maximum phonation time (MPT), Maximum counting duration (MCD), Peak expiratory flow rate (PEFR), Maximum inspiratory pressure (MIP), Maximum expiratory pressure (MEP), and quadriceps muscle strengthening before and after breathing with quadriceps exercises. Materials and Methods This research was approved by the Ethics Committee of Human Research of Khon Kaen University (The project number: HE661240, approved on April 28, 2023). Study design : Quasi-experimental study (one sample prospective pre and post study ) Population : Community-dwelling elderly aged 60-70 years old Sample size was calculated based on mean difference of MPT, MCD, PEER from previous study[9, 10] at a Type I error of 95% confidence interval (0.05) and a Type II error of 0.2, with dropout rate 35% because this study was follow up study for 7 weeks and most community-dwelling elderly in Thailand still work as farmers and need to taking care granddaughters and grandsons due to their parent lived in big city for working. There was high rate of dropout. Calculations a sample size at least 30 was required for this study. Inclusion Criteria : Elderly, aged 60-70 years old who registered to health services at Ban Rue Subdistrict Health Promoting Hospital, Phu Wiang District, Khon Kaen, Thailand was included study. Exclusion Criteria : Elderly who had underlying diseases that might have effect to breathing and quadriceps exercise including knee pain, asthma, Chronic Obstructive Pulmonary Disease: COPD, Lung diseases, stroke, gout, heart diseases, Pulmonary Tuberculosis, knee diseases that effect to body movement. Withdrawal of participant criteria Elderly who could not attend breathing with quadriceps exercises for 4 sessions or could not practice exercises < 80 % of assignment. Thirty-five community-dwelling elderly were included study, 5 were excluded, 7 dropped out from study. Twenty-three participants enrolled completely for 7 weeks (Figure 1). Tools Computer Speech Lab (CSL: Kaypentax 4500): standard tool for voice signal capture and analysis. CSL was used to capture MPT and MCD Peak flow meter or Mini wright peak flow meter for investigation peak expiratory flow rate (PEFR) Micro Respiratory Pressure Meter for assessment MIP and MEP Leg Strength Dynamometer and Five times sit to stand for measurement quadriceps muscle strength Video: Diaphragmatic breathing with quadriceps exercises 1) sitting; 2) standing; 3) walking Videos were animation presentation of diaphragmatic breathing with quadriceps exercises in sitting, standing positions, and walking. Each video provided objective and description of diaphragmatic breathing with quadriceps exercises: slowly deep intake 5 seconds with straight leg raising, hold breath and knee stretching with ankle flexion for 5 seconds then, slowly continuous blow the index finger as long as he/she could for 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20 seconds, respectively (21 video presentations in each position). Assessment : All participants were assessed pre- and post-treatment as follows: Assessment for MPT and MCD by CSL: a multidimensional voice program (MDVP) was used for recording acoustic analysis for prolongation vowels /a: ,u:, and i:/ as well as MCD. After participant’s rest with sitting 10-15 minutes, researcher asked participant to comfortable upright stand, heel and great toe apart approximately 4 and 8 inches. The microphone was placed at an angle of 30 degrees to the plane and 6 inches from participant’s mouth. Before recording, a researcher trained participant to prolong each /a/, /u/, /i/ and counting as long as possible after taking deep breath with optimal loudness and pitch via Thai career phases as followings: "Pai Nai Ma:….. " for vowel /a:/, "Pai jab pu….." for /u:/, and "Sa wat dee…" for /i:/[10]. Then, ask participant to prolong each vowel and counting (MCD) after deep breath with 1-minute interval break each activity. Prolongation of /a:/, /u:/, /i:/ and MCD were recorded after training. Assessment for peak expiratory flow rate (PEFR) by Peak flow meter or Mini Wright peak flow meter (CE 0120) was used for measuring how fast you can push air out of your lungs when you blow out as hard and as fast as you can. After participant’s rest with sitting 5-10 minutes, researcher asked participant to comfortable upright sitting and straight face. Both feet touch the floor. Pinch your nose with nose clip Then breathe in fully, suck the mouthpiece and closed the mouth tightly around the mouthpiece. Then exhale quickly and forcefully until you exhale. Repeat to get at least 3 correct values. Use the highest value for recording. Assessment for maximum inspiratory/expiratory pressure (MIP & MEP) by Micro Respiratory Pressure Meter was used for measuring respiratory muscle strength of inspiratory & expiratory muscle. After participant’s rest with sitting 5-10 minutes, researcher asked participant to comfortable upright sitting and straight face. Both feet touch the floor. Pinch your nose with nose clip Then sucking the mouth piece, breathe in fully and closed the mouth tightly around the mouthpiece and measure the inspiratory and expiratory muscle strength by repeat to get at least 3 correct values. Use the highest value for recording. Measuring of inspiratory muscle strength by participant to comfortable upright sitting and straight face. Both feet touch the floor. Pinch your nose with nose clip Then sucking the mouth piece, breathe in fully and closed the mouth tightly around the mouthpiece. After that the participant to exhale fully and breathe in fully through your mouth and hold for at least 1 second. Repeat to get at least 3 correct values Each break was 5 minutes apart. Use the highest value for recording. Measuring of expiratory muscle strength by participant to comfortable upright sitting and straight face. Both feet touch the floor. Pinch your nose with nose clip Then sucking the mouth piece, After that the participant to inhale fully and exhale fully through your mouth and hold for 1 second. Repeat to get at least 3 correct values Each break was 5 minutes apart. Use the highest value for recording. Assessment for quadriceps muscle strength (FTSTS and back-leg strength) 5 times sit to stand test (FTSTS) war used for assessing functional loner limbs strength, transitional movement, balance and fall risk in older adults. In the testing, the participants were received explanations, demonstration and practice before collect data 1 time. After that the participants sit on a chair with no armrests. The height of chair about 43 cm. Then the participants place both hands crossed over your chest, keep the center of your thighs on the chair by your buttock does not have to be close to be close to the backrest to make it easier to stand up. Place the both feet equal to the width of each person’s shoulder. The participants can stand up from your chair when they heard ‘’start on’’ by as quickly as possible within 5 times. By they stand up straight and sit down for the first time and continue stand up until 5 times. The researcher said “stop” was the end of testing. Repeated collect data 2 rounds by with a 1minute rest between rounds. Collect data by taken the time in 2 rounds to calculated the mean of data and to analysis data. Back-leg strength dynamometer test was used to measure the maximum isometric strength of the back and leg muscles. In this study, we use it for measuring the maximum isometric strength of the leg muscles. By the participants stand up straight on the machine. After that they bring your knees down to no more than your toes. They use the outlet to push the machine as hard as possible. Repeated test 2 times and use the highest value for recording. In data analysis divide your body weight by the kilograms you can weigh. Intervention The 1 st week, the 1 st day After pre-assessment, all participants received description of vocal hygiene and video presentation. Diaphragmatic breathing with quadriceps exercises in sitting positing were described followed by video presentation and practicing by researchers. Participants were assigned to practice home program 20 cycles of diaphragmatic breathing with quadriceps exercises twice a day. Home work: The 1 st day participant practiced to slowly deep intake 5 seconds, hold breath 5 seconds and blowing 10 seconds (5-5-10), the 2 nd day practiced to slowly deep intake 5 seconds, hold breath 5 seconds and blowing 11 seconds (5-5-11), the 3 rd day, participant practiced to slowly deep intake 5 seconds, hold breath 5 seconds and blowing 12 seconds (5-5-12), …….step by step until the 11 th -14 th day participant practiced to slowly deep intake 5 seconds, hold breath 5 seconds and blowing 20 seconds (5-5-20), The 1 st week, the 1 st day The 3 rd week (the 2 nd day of follow-up program) and the 5 rd week (the 3 rd day of follow-up program), all participants received diaphragmatic breathing with quadriceps exercises in standing position and walking. Home practicing was the same patterns and frequencies as the 1 st and the 1 st day The 7 th week (the 4 th day of follow-up program) , post-assessments were provided for all participants. During study, 5 village health volunteers (VHVs) were project’s helpers to followed up and encouraged each participant to practice home program once a week. VHVs had QR code to access video presentation and could contact researcher any time if they need. A research assistant contacted each VHV once a week for helping and followed up participants’ practicing. (Figure 1) Statistical analysis Data were analyzed using IBM SPSS Statistic program by showing descriptive statistics and comparing the number of articulation errors before and after therapy with Paired t–Test if data were normal distribution and Wilcoxon Sign Rank Test if data were non-normal distribution. Results Twenty-three community-dwelling elderly were enrolled into this study. General characteristics were displayed in Table 1. Table 1 Twenty- three community-dwelling healthy elderly aged 60-70 years old (mean = 65.52 and standard deviation= 2.41) were enrolled to complete study. Nineteen of total 23 older adults (82.61 %) had exercises, 14/23 (60.87 %) had exercise 31-45 minutes/day Major they were no underlying disease. (91.30%) At all had no breathing exercise before study and BMI average 23.92 kg/m 2 (23.94+-1.87) Table 2 Means of MPT /a:, u:, i:/ were 8.79, 9.73, 9.53 seconds. MCD, PEER, MIP, MEP, and quadriceps muscle strength and 5 time sit to stand before training program of breathing with quadriceps exercises were 7.40 seconds, 222.39 lit//min, 83.57, 75.65 cm. H 2 O, and 0-91 and 16.35 seconds, respectively. Means of MPT /a:, u:, i:/ were increase after training. MCD, PEFR, MIP, MEP, and quadriceps muscle strength and 5 time sit to stand were increase after training. Box and Whisker Plot analysis revealed that all data were non normal distribution. Descriptive data of pre- and post-treatment parameters by median with minimum and maximum presented as Table 3. Table 3 Median of MPT and MCD after exercises tentatively presented longer than before exercises. Median of MIP, MEP, PEER, and quadriceps muscle strength and FTSTS after exercises were also tentatively presented better than before exercises. as Table 3 At all parameters were increased after training. But quadriceps muscle strength was minimal increased and FTSTS was increased after training. FTSTS was decrease to interpreted improve after training. Wilcoxon Sign Rank Test was used to determine the differences between parameters before and after program of breathing and quadriceps exercises (Table 4). Because this study was small sample size. Table 4 Wilcoxon Sign Rank Test revealed significant increasing of MPT, MCD, MIP, MEP, PEFR, but quadriceps muscle strength and FTSTS were not significant after training. Discussion Thirtycommunity-dwelling healthy elderly were enrolled of this study. Four of them had individual business that needed to do. An older adult had to take care a child who had handicapped, 1 had to do took care a pig who gave birth, and 1 brought a grandchild to hospital with emergency condition. They withdraw from study even though researchers and research assistant tried to give option to follow for breathing with quadriceps exercises on the any day that they could join. These were normal situation in Thailand that most of community-dwelling healthy elderly had responsibility for their families. Twenty- three community-dwelling healthy elderly aged 60-70 years old (mean = 65.52 and standard deviation= 2.41) were enrolled to complete study. Nineteen of total 23 older adults (82.61 %) had exercises, 14/23 (60.87 %) had exercise 31-45 minutes/day. They had mean of MPT of /a:, u; i:/ before breathing with quadriceps exercises = 8.79-9.93 seconds (Table 2) that had tentatively shorter than older people’s MPT of /a/ (mean = 21.77) in United State [23] in the same age. This might be possible that people in western country had physical appearance based on races higher and bigger than Asian people, particularly Thailand, that resulted in larger lung volume and longer MPT. However, comparison to Asian country Thai elderly had still MPT shorter than Japanese’s prolongation /a/ (Mean = 16.8 seconds). This might indicate that Japanese elderly had more physical fitness than Thai because nature of nature Japanese people, particularly older adults were the world's longest-living peopl [24]. Most elderly in Japan still active and commonly walk in daily life activities. A recent study found that epigenetic profile of Japanese supercentenarians that might be factor for life long Japanese elderly [25]. For main outcomes of this study, finding found that breathing with quadriceps exercises significantly increased all parameters after training except quadriceps muscle strength and FTSTS were not significant after training (Table 4). These might be too short training of breathing with quadriceps exercise and quadriceps muscle strength in training did not load during quadriceps muscle strengthening. Therefore, increasing of quadriceps muscle strength was minimal effect and FTSTS was used increased times in this activity. These indicated that intervention of program: breathing with quadriceps exercises in sitting, standing position, and walking for 7 weeks were effectiveness for significant increasing lung functions (MPT, MCD, PEFR, MIP, and MEP) and results in healthy vocal quality. For outcomes of increase quadriceps muscle strength and better FTSTS, results had tentative to increase quadriceps muscle strength and better FTSTS (Table 4). Loaded weight while doing quadriceps exercise as well as need more sample size might quantify better magnitude of effect in increasing quadriceps muscle strength and better FTSTS. They could be implied that this program could improve both respiratory function and skeletal function because MIP and MEP were significantly related to limb muscle strength and skeletal muscle mass [22]. This suggested that Thai government health care should critically concern and implement program of breathing with quadriceps exercises for community-dwelling elderly to enhance better voice and physical strength. Mostly the elderly had deconditioning and knee osteoarthritis. Quadriceps muscle weakness attending to increase risk of knee osteoarthritis. Quadriceps muscle strength can reduce knee pain and improve functions (27-30). Even though the aim of this study calculated sample size based on the effectiveness of breathing with quadriceps exercises to quantify increasing of MPT, MCD and PEFR, results revealed also that positive effectiveness of program on MIP, MEP, and quadriceps muscle strength. Another suggestion also focuses on techniques for increasing endurance and vocal quality, particularly roughness and resonance changes that are common problem in older people, such as voiced oral high-frequency oscillation (VOHFO) technique and the phonation into a silicone resonance tube [26] as well as program for better physical function. Conclusion Program of breathing with quadriceps exercises could significantly increase MPT, MCD, PEFR, MIP, MEP in community-dwelling healthy elderly within 7 weeks. Limitation of study This study focused on main outcomes (MPT, MCD, PEFR, MIP, MEP) before and after breathing with quadriceps exercises, sample size might be too small as well as too short duration of practice (7 weeks). to quantify the effectiveness of breathing with quadriceps exercises on quadriceps strength that need exploration in the further research. Declarations ACKNOWLEDGMENT The authors thank community-dwelling elderly for their cooperation and providing valuable data. Authors thank staff of Ban Ruea Subdistrict Health Promoting Hospital, Phu Wiang District, Khon Kaen for facilitating collecting data and Dr.Kaewjai Thepsuthammarat, Department of Epidemiology Khon Kaen University, Khon Kaen for helping or statistical analysis. The authors also thank the Faculty of Medicine, Khon Kaen University for supporting the research assistant (Grant number AS66006). Authors contribution Benjamas Prathanee involved in conceptualization, project administration, design of the study, supervision, intervention, collecting data, analysis and drafting and final approved of the manuscript; Netra Buakanok, Tawitree Pumnum, and Nantiya Ooppanasak involved in assessment, intervention, and collecting data; Nichanun Panyaek involved the proposal design, assessment, intervention, collecting data, and approval of the manuscript. All authors participated in a meaningful way in the preparation of the manuscript. Funding : This project was supported funding by Khon Kaen University. There was no any involvement in the study. Data Availability The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate This research was approved by the Ethics Committee of Human Research of Khon Kaen University (The project number: HE661240, approved on April 28, 2023). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study Consent for publication Not applicable Competing interests : The authors declare that they have no competing interests. References Arai H, Ouchi Y, Toba K, Endo T, Shimokado K, Tsubota K, et al. Japan as the front-runner of super-aged societies: Perspectives from medicine and medical care in Japan. Geriatr Gerontol Int. 2015;15(6):673–87. 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Komaki S, Nagata M, Arai E, Otomo R, Ono K, Abe Y, et al. Epigenetic profile of Japanese supercentenarians: a cross-sectional study. Lancet Healthy Longev. 2023;4(2):e83–90. Piragibe PC, Silverio KCA, Dassie-Leite AP, Hencke D, Falbot L, Santos K, et al. Comparison of the immediate effect of voiced oral high-frequency oscillation and flow phonation with resonance tube in vocally-healthy elderly women. CoDAS. 2020;32(4):e20190074. Radin EL, Yang Klt RC, Kish VL, Conner O. Relationship between lower limb dynamics and knee joint pain. J Orthop Res. 1991;9(3):398–405. Hurley MV. The role of muscle weakness in the pathogenesis of osteoarthritis. Rheum Dis Clin North Am. 1999;25(2):283–98. Peterson SC, Barrance P, Buchanan T, Binder-Macleod S, Snyder-Mackler L. Mechanisms underlying quadriceps weakness in knee osteoarthritis. Med Sci Sports Exerc. 2008;40:422–7. Bader M. Quadriceps protects the anterior cruciate ligament. J Ortho Res. 2001;19:629–33. Tables Table 1 Elderly ‘s general characteristics Variable Number Percentage Standard Deviation Gender Male 4 17.39 Female 19 82.61 Age Min 59 Max 69 Mean 64 65.52 2.41 Smoking Yes 0 0 No 23 100 Exercise Yes 19 < 30 min/day 5 26.32 31-45 min/day 14 73.68 Frequency Every day 14 73.68 1-2 day/week 1 5.26 3-4 day/week 4 21.05 No 4 17.39 Underlying disease Yes 2 8.70 - Hypertension 2 No 21 91.30 Breathing exercise before study Yes 0 No 23 BMI (kilogram/meter 2 ) Min 21.36 Max 29.43 Average 23.92 23.94 1.87 BMI: Body Mass Index Table 2 Pre- and post-assessment data by mean and standard deviation Parameters Pre-assessment Post-assessment Maximum phonation time (seconds) Mean Standard deviation Mean Standard deviation /a:/ 8.79 4.59 13.31 4.06 /u:/ 9.73 4.82 14.41 4.02 /i:/ 9.53 4.64 14.25 4.23 Maximum counting duration (seconds) 7.40 3.43 9.98 2.42 Maximum inspiratory pressure (cm H 2 O) 83.57 24.85 94.87 27.19 Maximum expiratory pressure (cm H 2 O) 75.65 29.17 98.30 42.60 Peak expiratory flow rate (LPM) 222.39 109.30 376.52 103.42 Quadriceps muscle strength 0.91 0.35 0.95 0.33 FTSTS (seconds) 16.35 3.29 16.55 3.03 FTSTS= Five time sit to stand, LPM = Liter per minute Table 3. Pre- and post- parameter assessment by median, minimum and maximum Parameter Pre-assessment Post-assessment Maximum phonation time (seconds) Median Min: Max Median Min: Max /a:/ 9.02 1.13: 20.36 13.41 4.75: 20.43 /u:/ 10.14 1.77: 19.04 14.44 5.86: 23.33 /i:/ 8.61 1.73: 19.61 14.03 7.15: 22.80 Maximum counting duration (seconds) 6.49 1.82: 14.80 9.97 4.86: 15.86 Maximum inspiratory pressure (cm H 2 O) 85 41: 142 95 44: 154 Maximum expiratory pressure (cm H 2 O) 74 28: 161 89 37: 189 Peak expiratory flow rate (LPM) 190 100: 470 350 220: 650 Quadriceps muscle strength 0.87 0.38: 1.94 0.89 0.35: 1.88 FTSTS (second) 15.53 12.78: 27.31 15.60 12.84: 25.66 FTSTS= Five time sit to stand, LPM = Liter per minute Table 4 Comparison of pre- and post-assessment Parameter Pre-and post-assessment comparison Maximum phonation time (seconds) Median difference (Pre-Post) 95 % Confidence interval p-value /a:/ -4.23 -6.86, -1.92 0.001 /u:/ -4.52 -7.15, -1.49 <0.001 /i:/ -4.31 -7.09, -2.05 <0.001 Maximum counting duration (seconds) -2.66 -4.11, -.85 0.002 Maximum inspiratory pressure (cm H 2 O) -12 -16.5, -6 <0.001 Maximum expiratory pressure (cm H 2 O) -17.5 -33.5, -10 <0.001 Peak expiratory flow rate (lit/minute) -160 -200, -115 <0.001 Quadriceps muscle strength -0.04 -0.11, 0.04 0.217 FTSTS (sec) -0.16 -1.49, 1.14 0.760 FTSTS= Five time sit to stand, LPM = Liter per minute Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4257094","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":297381929,"identity":"935453b8-d3dc-47dd-9413-d80e1f426c40","order_by":0,"name":"Benjamas Prathanee","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"Benjamas","middleName":"","lastName":"Prathanee","suffix":""},{"id":297381930,"identity":"f3fa5590-09fd-450b-90b9-993b3cc0c525","order_by":1,"name":"Netra Buakanok","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"Netra","middleName":"","lastName":"Buakanok","suffix":""},{"id":297381931,"identity":"0f8be310-6f97-4228-ae54-fbc4f6e89329","order_by":2,"name":"Tawitree Pumnum","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"Tawitree","middleName":"","lastName":"Pumnum","suffix":""},{"id":297381932,"identity":"a5b9e1f2-5920-4f48-810d-c0079cd6c7af","order_by":3,"name":"Nantiya Ooppanasak","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"Nantiya","middleName":"","lastName":"Ooppanasak","suffix":""},{"id":297381934,"identity":"1d8738d6-3277-4a67-ab20-b0521a3729b4","order_by":4,"name":"Nichanun Panyaek","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYDACZgY2MM3P3gAkDSxI0CLZcwCkRYIoeyBaDG4kgCgitJizMz978HPH4TyGm8+vbvhRIMHA396dgFeLZTObuWHvmcPFjLNzym72AB0mcebsBrxaDA7zsEnwth1ObJbOSbvBA9RiIJFLWIvkX6CWNskzaTf/EKtFGmRLjwT7sdtE2sJmJi3blp44gyeH7baMgQQPYb+cP/xM8m2bdeL+48ef3Xzzx0aOv70XvxYkwGMAJolVDgLsD0hRPQpGwSgYBSMIAAAUv0UYHjhmkQAAAABJRU5ErkJggg==","orcid":"","institution":"Khon Kaen University","correspondingAuthor":true,"prefix":"","firstName":"Nichanun","middleName":"","lastName":"Panyaek","suffix":""}],"badges":[],"createdAt":"2024-04-12 10:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4257094/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4257094/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55763573,"identity":"3c49dd21-357f-4197-91b7-ee1f7747ae74","added_by":"auto","created_at":"2024-05-02 19:42:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48576,"visible":true,"origin":"","legend":"\u003cp\u003eDesign Outline\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMPT: Maximum phonation time; MCD: Maximum counting duration; PEFR: Peak expiratory flow rate; MIP: Maximum inspiratory pressure; MEP: Maximum expiratory pressure\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4257094/v1/c72e56f0d9b3b84285874963.png"},{"id":61570826,"identity":"274455af-f5ce-473b-ae23-8a3955ffc0e2","added_by":"auto","created_at":"2024-08-01 10:51:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":594830,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4257094/v1/93e7d65b-bb32-40c9-bf84-e7934445022c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of Diaphragmatic Breathing with Quadriceps Exercises on Maximum Phonation Time, Respiratory function and Muscle Strengthening in Community- Dwelling Elderly","fulltext":[{"header":"Introduction:","content":"\u003cp\u003ePeople aged\u0026thinsp;\u0026ge;\u0026thinsp;65 are generally elderly. More than 7% of the population is 65 years or older is defined as an \u0026ldquo;aged society\u0026rdquo;; \u0026gt; 14% of the population is 65 years or older as an \u0026ldquo;aged society\u0026rdquo;; and \u0026gt;\u0026thinsp;21% of the population is 65 years or older as a \u0026ldquo;super-aged society\u0026rdquo; [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. There will be more than one billion of the world\u0026rsquo;s population was above the age of 60 in 2019 and increase to 1.4\u0026nbsp;billion by 2030 and 2.1\u0026nbsp;billion by 2050 .[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Japan has been \u0026gt;\u0026thinsp;25% of the population is \u0026ge;\u0026thinsp;65 years and defined as a super-aged society since 2013 and expected to continue growing in the future. Following in the footsteps of Japan, Hong Kong, South Korea, Taiwan, and Singapore are forecasted to be super-aged societies in 2012, 2017, 2018, 2021, respectively. Thailand (the 6th economy in Asia), has already reached an aged society status in 2022.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThailand is a country that has the fastest ageing growing in the world. Of its 67\u0026nbsp;million population, 12\u0026nbsp;million Thais, are elderly according to the latest national statistics report. The country has been classified as an \u0026lsquo;aged society\u0026rsquo; due to people aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years accounted for 10% of the population. It is expected that the country\u0026rsquo;s elderly population will increase to 28% and that There will be increase elderly population to be 28% and become a \u0026lsquo;super-aged society\u0026rsquo; by the next decade [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe well-being of older persons is the major emerging challenges for families, communities and government in Thailand similar to many countries in Asia. Thai government has been giving the serious attention to ageing conditions because older people have functional limitations and difficulties with self-care and other activities of daily living with age [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. At least one of 37% in population aging has such difficulty [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Poor self-assessed health, illness during the past five years, poor vision and hearing, as well as incontinence all increase substantially with age [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eThai government clearly aware of the challenge about long-term care of elderly\u0026rsquo;s independent living without of assistance. To provide home-based assistance for older persons, the Bureau of Empowerment for Older Persons (now Department of Older Persons) launched program of Home Care Service Volunteers for the Elderly Program to establish a system of community-based care and protection for older persons with chronic illnesses in 2003 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eDiaphragmatic breathing\u0026rdquo; or \u0026ldquo;deep breathing\u0026rdquo;, an efficient integrative body\u0026ndash;mind training for dealing with stress and psychosomatic conditions and improve sustained attention, affect, and cortisol levels. Effect of diaphragmatic breathing has important roles for health promotion in healthy individuals[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Deep and slow breathing reduced state anxiety in older adults, attenuate pain [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], increase lung capacity [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], improves digestion or gastroesophageal reflux [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], sleep [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], mood [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and enhance better oxygenation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Lung volume is resource of air flow for speaking and breathing is critical to speech. Voice disorders were common among the elderly and prevalence was 47% with 29.1% of participants reporting a current voice disorder[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSarcopenia is condition that has loss of skeletal muscle mass and function, is one of common age-related disease. Overall estimates of prevalence of sarcopenia in community-dwelling older adults was 10% (95% CI: 8\u0026ndash;12%) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Almost all participants with sarcopenia showed respiratory muscle weakness with 50% had respiratory muscle weakness [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Sarcopenia is a progressive and generalized loss of skeletal muscle mass and function and associated with increased adverse outcomes such as physical disability, poor quality of life, and death [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Prevention of sarcopenia is a critical concern for all hospital staff involved older adults. Osteoarthritis (OA) is also the most common form of arthritis and a leading cause of disability among older people. One of 3 elderly had OA [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, voice disorders, OA and sarcopenia should be critical task for hospital or community staff who care elderly. One of prevention of voice disorders, OA and sarcopenia was diaphragmatic breathing and quadriceps exercises. Diaphragmatic breathing is benefit for increasing lung volume for speaking, maximum inspiratory pressure (MIP) related to skeletal muscle mass and strength [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Quadriceps exercises offer many benefits including improve muscular strength, setter posture \u0026amp; flexibility, strengthens bone density that facilitate overall health and well-being. Strength training of the quadriceps muscles also relieved pain and improved physical function [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Recent study found that respiratory muscles, particularly inspiration and expiratory pressure were significantly related to limb muscle strength and skeletal muscle mass[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Therefore, combination of breathing exercise and quadriceps exercise were benefit for enhance respiratory system and muscle strengthening that are the important factors for healthy and independent daily live activities in community-dwelling older.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eObjective of this study to compare maximum phonation time (MPT), Maximum counting duration (MCD), Peak expiratory flow rate (PEFR), Maximum inspiratory pressure (MIP), Maximum expiratory pressure (MEP), and quadriceps muscle strengthening before and after breathing with quadriceps exercises.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis research was approved by the Ethics Committee of Human Research of \u003c/p\u003e\n\u003cp\u003eKhon Kaen University (The project number: HE661240, approved on April 28, 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eQuasi-experimental study (one sample prospective pre and post study\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eCommunity-dwelling elderly aged 60-70 years old\u003c/p\u003e\n\u003cp\u003eSample size was calculated based on mean difference of MPT, MCD, PEER from previous study[9, 10] at a Type I error of 95% confidence interval (0.05) and a Type II error of 0.2, with dropout rate 35% because this study was follow up study for 7 weeks and most community-dwelling elderly in Thailand still work as farmers and need to taking care granddaughters and grandsons due to their parent lived in big city for working. There was high rate of dropout. Calculations a sample size at least 30 was required for this study.\u003c/p\u003e\n\u003cp skip=\"true\"\u003e\u003cstrong\u003e Inclusion Criteria\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eElderly, aged 60-70 years old who registered to health services at Ban Rue Subdistrict Health Promoting Hospital, Phu Wiang District, Khon Kaen, Thailand was included study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Elderly who had underlying diseases that might have effect to breathing and quadriceps exercise including knee pain, asthma, Chronic Obstructive Pulmonary Disease: COPD, Lung diseases, stroke, gout, heart diseases, Pulmonary Tuberculosis, knee diseases that effect to body movement. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWithdrawal of participant criteria\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003eElderly who could not attend breathing with quadriceps exercises for 4 sessions or could not practice exercises \u0026lt; 80 % of assignment. \u003c/p\u003e\n\u003cp\u003eThirty-five community-dwelling elderly were included study, 5 were excluded, 7 dropped out from study. Twenty-three participants enrolled completely for 7 weeks (Figure 1). \u003c/p\u003e\n\n\n\u003cp\u003e\u003cstrong\u003eTools\u003c/strong\u003e\u003c/p\u003e\n\n\u003col\u003e\n\u003cli\u003eComputer Speech Lab (CSL: Kaypentax 4500): standard tool for voice signal capture and analysis. CSL was used to capture MPT and MCD\u003c/li\u003e\n\u003cli\u003ePeak flow meter or Mini wright peak flow meter for investigation peak expiratory flow rate (PEFR) \u003c/li\u003e\n\u003cli\u003eMicro Respiratory Pressure Meter for assessment MIP and MEP \u003c/li\u003e\n\u003cli\u003eLeg Strength Dynamometer and Five times sit to stand for measurement quadriceps muscle strength \u003c/li\u003e\n\u003cli\u003eVideo: Diaphragmatic breathing with quadriceps exercises 1) sitting; 2) standing; 3) walking\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eVideos were animation presentation of diaphragmatic breathing with quadriceps exercises in sitting, standing positions, and walking. Each video provided objective and description of diaphragmatic breathing with quadriceps exercises: slowly deep intake 5 seconds with straight leg raising, hold breath and knee stretching with ankle flexion for 5 seconds then, slowly continuous blow the index finger as long as he/she could for 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20 seconds, respectively (21 video presentations in each position).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment\u003c/strong\u003e: \u003c/p\u003e\n\u003cp\u003eAll participants were assessed pre- and post-treatment as follows:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eAssessment for MPT and MCD by CSL: a multidimensional voice program (MDVP) was used for recording acoustic analysis for prolongation vowels /a: ,u:, and i:/ as well as MCD. After participant\u0026rsquo;s rest with sitting 10-15 minutes, researcher asked participant to comfortable upright stand, heel and great toe apart approximately 4 and 8 inches. The microphone was placed at an angle of 30 degrees to the plane and 6 inches from participant\u0026rsquo;s mouth. Before recording, a researcher trained participant to prolong each /a/, /u/, /i/ and counting as long as possible after taking deep breath with optimal loudness and pitch via Thai career phases as followings: \u0026quot;Pai Nai Ma:\u0026hellip;.. \u0026quot; for vowel /a:/, \u0026quot;Pai jab pu\u0026hellip;..\u0026quot; for /u:/, and \u0026quot;Sa wat dee\u0026hellip;\u0026quot; for /i:/[10]. Then, ask participant to prolong each vowel and counting (MCD) after deep breath with 1-minute interval break each activity. Prolongation of /a:/, /u:/, /i:/ and MCD were recorded after training.\u003c/li\u003e\n\u003cli\u003eAssessment for peak expiratory flow rate (PEFR) by Peak flow meter or Mini\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWright peak flow meter (CE 0120) was used for measuring how fast you can push air out of your lungs when you blow out as hard and as fast as you can. After participant\u0026rsquo;s rest with sitting 5-10 minutes, researcher asked participant to comfortable upright sitting and straight face. Both feet touch the floor. Pinch your nose with nose clip Then breathe in fully, suck the mouthpiece and closed the mouth tightly around the mouthpiece. Then exhale quickly and forcefully until you exhale. Repeat to get at least 3 correct values. Use the highest value for recording. \u003c/p\u003e\n\u003col start=\"3\"\u003e\n\u003cli\u003eAssessment for maximum inspiratory/expiratory pressure (MIP \u0026amp; MEP) by Micro\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eRespiratory Pressure Meter was used for measuring respiratory muscle strength of inspiratory \u0026amp; expiratory muscle. After participant\u0026rsquo;s rest with sitting 5-10 minutes, researcher asked participant to comfortable upright sitting and straight face. Both feet touch the floor. Pinch your nose with nose clip Then sucking the mouth piece, breathe in fully and closed the mouth tightly around the mouthpiece and measure the inspiratory and expiratory muscle strength by repeat to get at least 3 correct values. Use the highest value for recording. Measuring of inspiratory muscle strength by participant to comfortable upright sitting and straight face. Both feet touch the floor. Pinch your nose with nose clip Then sucking the mouth piece, breathe in fully and closed the mouth tightly around the mouthpiece. After that the participant to exhale fully and breathe in fully through your mouth and hold for at least 1 second. Repeat to get at least 3 correct values Each break was 5 minutes apart. Use the highest value for recording. Measuring of expiratory muscle strength by participant to comfortable upright sitting and straight face. Both feet touch the floor. Pinch your nose with nose clip Then sucking the mouth piece, After that the participant to inhale fully and exhale fully through your mouth and hold for 1 second. Repeat to get at least 3 correct values Each break was 5 minutes apart. Use the highest value for recording. \u003c/p\u003e\n\u003col start=\"4\"\u003e\n\u003cli\u003eAssessment for quadriceps muscle strength (FTSTS and back-leg strength) \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e5 times sit to stand test (FTSTS) war used for assessing functional loner limbs strength, transitional movement, balance and fall risk in older adults. In the testing, the participants were received explanations, demonstration and practice before collect data 1 time. After that the participants sit on a chair with no armrests. The height of chair about 43 cm. Then the participants place both hands crossed over your chest, keep the center of your thighs on the chair by your buttock does not have to be close to be close to the backrest to make it easier to stand up. Place the both feet equal to the width of each person\u0026rsquo;s shoulder. The participants can stand up from your chair when they heard \u0026lsquo;\u0026rsquo;start on\u0026rsquo;\u0026rsquo; by as quickly as possible within 5 times. By they stand up straight and sit down for the first time and continue stand up until 5 times. The researcher said \u0026ldquo;stop\u0026rdquo; was the end of testing. Repeated collect data 2 rounds by with a 1minute rest between rounds. Collect data by taken the time in 2 rounds to calculated the mean of data and to analysis data.\u003c/p\u003e\n\u003cp\u003eBack-leg strength dynamometer test was used to measure the maximum isometric strength of the back and leg muscles. In this study, we use it for measuring the maximum isometric strength of the leg muscles. By the participants stand up straight on the machine. After that they bring your knees down to no more than your toes. They use the outlet to push the machine as hard as possible. Repeated test 2 times and use the highest value for recording. In data analysis divide your body weight by the kilograms you can weigh. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 1\u003csup\u003est\u003c/sup\u003e week, the 1\u003csup\u003est\u003c/sup\u003e day\u003c/p\u003e\n\u003cp\u003eAfter pre-assessment, all participants received description of vocal hygiene and video presentation. Diaphragmatic breathing with quadriceps exercises in sitting positing were described followed by video presentation and practicing by researchers. Participants were assigned to practice home program 20 cycles of diaphragmatic breathing with quadriceps exercises twice a day.\u003c/p\u003e\n\u003cp\u003eHome work: The 1\u003csup\u003est\u003c/sup\u003e day participant practiced to slowly deep intake 5 seconds, hold breath 5 seconds and blowing 10 seconds (5-5-10), the 2\u003csup\u003end\u003c/sup\u003e day practiced to slowly deep intake 5 seconds, hold breath 5 seconds and blowing 11 seconds (5-5-11), the 3\u003csup\u003erd\u003c/sup\u003e day, participant practiced to slowly deep intake 5 seconds, hold breath 5 seconds and blowing 12 seconds (5-5-12), \u0026hellip;\u0026hellip;.step by step until the 11\u003csup\u003eth\u003c/sup\u003e-14\u003csup\u003eth\u003c/sup\u003e day participant practiced to slowly deep intake 5 seconds, hold breath 5 seconds and blowing 20 seconds (5-5-20), \u003c/p\u003e\n\u003cp\u003eThe 1\u003csup\u003est\u003c/sup\u003e week, the 1\u003csup\u003est\u003c/sup\u003e day\u003c/p\u003e\n\u003cp\u003eThe 3\u003csup\u003erd\u003c/sup\u003e week (the 2\u003csup\u003end\u003c/sup\u003e day of follow-up program) and the 5\u003csup\u003erd\u003c/sup\u003e week (the 3\u003csup\u003erd\u003c/sup\u003e day of follow-up program), all participants received diaphragmatic breathing with quadriceps exercises in standing position and walking. Home practicing was the same patterns and frequencies as the 1\u003csup\u003est\u003c/sup\u003e and the 1\u003csup\u003est\u003c/sup\u003e day \u003c/p\u003e\n\u003cp\u003eThe 7\u003csup\u003eth\u003c/sup\u003e week (the 4\u003csup\u003eth\u003c/sup\u003e day of follow-up program)\u003cstrong\u003e, \u003c/strong\u003epost-assessments were provided for all participants.\u003c/p\u003e\n\u003cp\u003eDuring study, 5 village health volunteers (VHVs) were project\u0026rsquo;s helpers to followed up and encouraged each participant to practice home program once a week. VHVs had QR code to access video presentation and could contact researcher any time if they need. A research assistant contacted each VHV once a week for helping and followed up participants\u0026rsquo; practicing. (Figure 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using IBM SPSS Statistic program by showing descriptive statistics and comparing the number of articulation errors before and after therapy with Paired t\u0026ndash;Test if data were normal distribution and Wilcoxon Sign Rank Test if data were non-normal distribution.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty-three community-dwelling elderly were enrolled into this study. General characteristics were displayed in Table 1. \u003c/p\u003e\n\n\n\u003ctable cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTable 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\n\n\n\n\u003cp\u003eTwenty- three community-dwelling healthy elderly aged 60-70 years old (mean = 65.52 and standard deviation= 2.41) were enrolled to complete study. Nineteen of total 23 older adults (82.61 %) had exercises, 14/23 (60.87 %) had exercise 31-45 minutes/day Major they were no underlying disease. (91.30%) At all had no breathing exercise before study and BMI average 23.92 kg/m\u003csup\u003e2\u003c/sup\u003e (23.94+-1.87)\u003c/p\u003e\n\n\u003ctable cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTable 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\n\n\n\n\u003cp\u003eMeans of MPT /a:, u:, i:/ were 8.79, 9.73, 9.53 seconds. MCD, PEER, MIP, MEP, and quadriceps muscle strength and 5 time sit to stand before training program of breathing with quadriceps exercises were 7.40 seconds, 222.39 lit//min, 83.57, 75.65 cm. H\u003csub\u003e2\u003c/sub\u003eO, and 0-91 and 16.35 seconds, respectively. Means of MPT /a:, u:, i:/ were increase after training. MCD, PEFR, MIP, MEP, and quadriceps muscle strength and 5 time sit to stand were increase after training. Box and Whisker Plot analysis revealed that all data were non normal distribution. Descriptive data of pre- and post-treatment parameters by median with minimum and maximum presented as Table 3. \u003c/p\u003e\n\n\u003ctable cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTable 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\n\n\n\n\u003cp\u003eMedian of MPT and MCD after exercises tentatively presented longer than before exercises. Median of MIP, MEP, PEER, and quadriceps muscle strength and FTSTS after exercises were also tentatively presented better than before exercises. as Table 3\u003c/p\u003e\n\n\u003cp\u003eAt all parameters were increased after training. But quadriceps muscle strength was minimal increased and FTSTS was increased after training. FTSTS was decrease to interpreted improve after training. \u003c/p\u003e\n\u003cp\u003eWilcoxon Sign Rank Test was used to determine the differences between parameters before and after program of breathing and quadriceps exercises (Table 4). Because this study was small sample size.\u003c/p\u003e\n\n\n\u003ctable cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTable 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\n\n\n\n\n\n\u003cp\u003eWilcoxon Sign Rank Test revealed significant increasing of MPT, MCD, MIP, MEP, PEFR, but quadriceps muscle strength and FTSTS were not significant after training.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThirtycommunity-dwelling healthy elderly were enrolled of this study. Four of them had individual business that needed to do. An older adult had to take care a child who had handicapped, 1 had to do took care a pig who gave birth, and 1 brought a grandchild to hospital with emergency condition. They withdraw from study even though researchers and research assistant tried to give option to follow for breathing with quadriceps exercises on the any day that they could join. These were normal situation in Thailand that most of community-dwelling healthy elderly had responsibility for their families. \u003c/p\u003e\n\u003cp\u003eTwenty- three community-dwelling healthy elderly aged 60-70 years old (mean = 65.52 and standard deviation= 2.41) were enrolled to complete study. Nineteen of total 23 older adults (82.61 %) had exercises, 14/23 (60.87 %) had exercise 31-45 minutes/day. They had mean of MPT of /a:, u; i:/ before breathing with quadriceps exercises = 8.79-9.93 seconds (Table 2) that had tentatively shorter than older people\u0026rsquo;s MPT of /a/ (mean = 21.77) in United State [23] in the same age. This might be possible that people in western country had physical appearance based on races higher and bigger than Asian people, particularly Thailand, that resulted in larger lung volume and longer MPT. However, comparison to Asian country Thai elderly had still MPT shorter than Japanese\u0026rsquo;s prolongation /a/ (Mean = 16.8 seconds). This might indicate that Japanese elderly had more physical fitness than Thai because nature of nature Japanese people, particularly older adults were the world\u0026apos;s longest-living peopl [24]. Most elderly in Japan still active and commonly walk in daily life activities. A recent study found that epigenetic profile of Japanese supercentenarians that might be factor for life long Japanese elderly [25]. \u003c/p\u003e\n\u003cp\u003eFor main outcomes of this study, finding found that breathing with quadriceps exercises significantly increased all parameters after training except quadriceps muscle strength and FTSTS were not significant after training (Table 4). These might be too short training of breathing with quadriceps exercise and quadriceps muscle strength in training did not load during quadriceps muscle strengthening. Therefore, increasing of quadriceps muscle strength was minimal effect and FTSTS was used increased times in this activity. These indicated that intervention of program: breathing with quadriceps exercises in sitting, standing position, and walking for 7 weeks were effectiveness for significant increasing lung functions (MPT, MCD, PEFR, MIP, and MEP) and results in healthy vocal quality. For outcomes of increase quadriceps muscle strength and better FTSTS, results had tentative to increase quadriceps muscle strength and better FTSTS (Table 4). Loaded weight while doing quadriceps exercise as well as need more sample size might quantify better magnitude of effect in increasing quadriceps muscle strength and better FTSTS. They could be implied that this program could improve both respiratory function and skeletal function because MIP and MEP were significantly related to limb muscle strength and skeletal muscle mass [22]. \u003c/p\u003e\n\u003cp\u003eThis suggested that Thai government health care should critically concern and implement program of breathing with quadriceps exercises for community-dwelling elderly to enhance better voice and physical strength. Mostly the elderly had deconditioning and knee osteoarthritis. Quadriceps muscle weakness attending to increase risk of knee osteoarthritis. Quadriceps muscle strength can reduce knee pain and improve functions (27-30).\u003c/p\u003e\n\u003cp\u003eEven though the aim of this study calculated sample size based on the effectiveness of breathing with quadriceps exercises to quantify increasing of MPT, MCD and PEFR, results revealed also that positive effectiveness of program on MIP, MEP, and quadriceps muscle strength. Another suggestion also focuses on techniques for increasing endurance and vocal quality, particularly roughness and resonance changes that are common problem in older people, such as voiced oral high-frequency oscillation (VOHFO) technique and the phonation into a silicone resonance tube [26] as well as program for better physical function.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eProgram of breathing with quadriceps exercises could significantly increase MPT, MCD, PEFR, MIP, MEP in community-dwelling healthy elderly within 7 weeks.\u003c/p\u003e"},{"header":"Limitation of study","content":"\u003cp\u003eThis study focused on main outcomes (MPT, MCD, PEFR, MIP, MEP) before and after breathing with quadriceps exercises, sample size might be too small as well as too short duration of practice (7 weeks). to quantify the effectiveness of breathing with quadriceps exercises on quadriceps strength that need exploration in the further research.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank community-dwelling elderly for their cooperation and providing valuable data. Authors thank staff of Ban Ruea Subdistrict Health Promoting Hospital, Phu Wiang District, Khon Kaen for facilitating collecting data and Dr.Kaewjai Thepsuthammarat, Department of Epidemiology Khon Kaen University, Khon Kaen for helping or statistical analysis. The authors also thank the Faculty of Medicine, Khon Kaen University for supporting the research assistant (Grant number AS66006). \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003cbr\u003e Benjamas Prathanee involved in conceptualization, project administration, design of the study, supervision, intervention, collecting data, analysis and drafting and final approved of the manuscript; Netra Buakanok, Tawitree Pumnum, and Nantiya Ooppanasak involved in assessment, intervention, and collecting data; Nichanun Panyaek involved the proposal design, assessment, intervention, collecting data, and approval of the manuscript. All authors participated in a meaningful way in the preparation of the manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was supported funding by Khon Kaen University. There was no any involvement in the study.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eData Availability \u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003eThe datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was approved by the Ethics Committee of Human Research of \u003c/p\u003e\n\u003cp\u003eKhon Kaen University (The project number: HE661240, approved on April 28, 2023).\u003c/p\u003e\n\u003cp\u003eThe procedures used in this study adhere to the tenets of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: \u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArai H, Ouchi Y, Toba K, Endo T, Shimokado K, Tsubota K, et al. Japan as the front-runner of super-aged societies: Perspectives from medicine and medical care in Japan. Geriatr Gerontol Int. 2015;15(6):673\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Oganization. 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List of Japanese supercentenarians 2024 [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://en.wikipedia.org/wiki/List_of_Japanese_supercentenarians\u003c/span\u003e\u003cspan address=\"https://en.wikipedia.org/wiki/List_of_Japanese_supercentenarians\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKomaki S, Nagata M, Arai E, Otomo R, Ono K, Abe Y, et al. Epigenetic profile of Japanese supercentenarians: a cross-sectional study. Lancet Healthy Longev. 2023;4(2):e83\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiragibe PC, Silverio KCA, Dassie-Leite AP, Hencke D, Falbot L, Santos K, et al. Comparison of the immediate effect of voiced oral high-frequency oscillation and flow phonation with resonance tube in vocally-healthy elderly women. CoDAS. 2020;32(4):e20190074.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRadin EL, Yang Klt RC, Kish VL, Conner O. Relationship between lower limb dynamics and knee joint pain. J Orthop Res. 1991;9(3):398\u0026ndash;405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHurley MV. The role of muscle weakness in the pathogenesis of osteoarthritis. Rheum Dis Clin North Am. 1999;25(2):283\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeterson SC, Barrance P, Buchanan T, Binder-Macleod S, Snyder-Mackler L. Mechanisms underlying quadriceps weakness in knee osteoarthritis. Med Sci Sports Exerc. 2008;40:422\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBader M. Quadriceps protects the anterior cruciate ligament. J Ortho Res. 2001;19:629\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1\u0026nbsp;Elderly\u0026nbsp;\u0026lsquo;s general characteristics\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"579\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eMale\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e17.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eFemale\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e82.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eMin\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eMax\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eMean\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e65.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eYes\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eNo\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003eExercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eYes\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026lt; 30 min/day\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e26.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e31-45 min/day\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e73.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eEvery day\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e73.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e1-2 day/week\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e5.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e3-4 day/week\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e21.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eNo\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e17.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003eUnderlying disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eYes\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e8.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;- Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eNo\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e91.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Breathing exercise before study \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eYes\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eNo\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;BMI (kilogram/meter\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eMin\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e21.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eMax\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e29.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.41379310344828%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eAverage\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.137931034482758%\" valign=\"top\"\u003e\n \u003cp\u003e23.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.655172413793103%\" valign=\"top\"\u003e\n \u003cp\u003e23.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.79310344827586%\" valign=\"top\"\u003e\n \u003cp\u003e1.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI: Body Mass Index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 Pre- and post-assessment data by mean and standard deviation\u0026nbsp;\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.52823920265781%\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.229235880398672%\" colspan=\"2\"\u003e\n \u003cp\u003ePre-assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.242524916943523%\" colspan=\"2\"\u003e\n \u003cp\u003ePost-assessment\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003eMaximum phonation time (seconds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003e/a:/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003e8.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e4.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003e13.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003e4.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003e/u:/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003e9.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e4.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003e14.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003e4.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003e/i:/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003e9.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e4.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003e14.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003e4.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003eMaximum counting duration\u0026nbsp;(seconds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003e7.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e3.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003e9.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003e2.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003eMaximum inspiratory pressure\u0026nbsp;(cm H\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003e83.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e24.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003e94.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003e27.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003eMaximum expiratory pressure\u0026nbsp;(cm H\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003e75.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e29.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003e98.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003e42.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003ePeak expiratory flow rate (LPM)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003e222.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e109.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003e376.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003e103.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003eQuadriceps muscle strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.459369817578775%\"\u003e\n \u003cp\u003eFTSTS (seconds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.588723051409618%\"\u003e\n \u003cp\u003e16.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.754560530679933%\"\u003e\n \u003cp\u003e3.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\"\u003e\n \u003cp\u003e16.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.593698175787727%\"\u003e\n \u003cp\u003e3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFTSTS= Five time sit to stand, LPM = Liter per minute\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;3.\u0026nbsp;Pre-\u0026nbsp;and post-\u0026nbsp;parameter assessment by median,\u0026nbsp;minimum and maximum\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"629\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.35668789808917%\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.821656050955415%\" colspan=\"2\"\u003e\n \u003cp\u003ePre-assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.821656050955415%\" colspan=\"2\"\u003e\n \u003cp\u003ePost-assessment\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003eMaximum phonation time\u0026nbsp;(seconds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003eMin:\u0026nbsp;Max\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003eMin:\u0026nbsp;Max\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003e/a:/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003e9.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003e1.13:\u0026nbsp;20.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003e13.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003e4.75:\u0026nbsp;20.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003e/u:/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003e10.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003e1.77:\u0026nbsp;19.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003e14.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003e5.86:\u0026nbsp;23.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003e/i:/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003e8.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003e1.73:\u0026nbsp;19.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003e14.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003e7.15:\u0026nbsp;22.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003eMaximum counting duration\u0026nbsp;(seconds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003e6.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003e1.82:\u0026nbsp;14.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003e9.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003e4.86:\u0026nbsp;15.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003eMaximum inspiratory pressure\u0026nbsp;(cm H\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003e41:\u0026nbsp;142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003e44:\u0026nbsp;154\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003eMaximum expiratory pressure\u0026nbsp;(cm H\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003e28:\u0026nbsp;161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003e37:\u0026nbsp;189\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003ePeak expiratory flow rate\u0026nbsp;(LPM)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003e100:\u0026nbsp;470\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003e350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003e220:\u0026nbsp;650\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003eQuadriceps muscle strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003e0.38:\u0026nbsp;1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003e0.35:\u0026nbsp;1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.289348171701114%\"\u003e\n \u003cp\u003eFTSTS (second)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.92368839427663%\"\u003e\n \u003cp\u003e15.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.01112877583466%\"\u003e\n \u003cp\u003e12.78:\u0026nbsp;27.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.513513513513514%\"\u003e\n \u003cp\u003e15.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.262321144674086%\"\u003e\n \u003cp\u003e12.84:\u0026nbsp;25.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFTSTS= Five time sit to stand, LPM = Liter per minute\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;4\u0026nbsp;Comparison of pre-\u0026nbsp;and post-assessment\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Parameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.596330275229356%\" colspan=\"3\"\u003e\n \u003cp\u003ePre-and post-assessment comparison\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003eMaximum phonation time\u0026nbsp;(seconds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003eMedian difference\u003c/p\u003e\n \u003cp\u003e(Pre-Post)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e95\u0026nbsp;%\u0026nbsp;Confidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003e/a:/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003e-4.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e-6.86,\u0026nbsp;-1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003e/u:/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003e-4.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e-7.15,\u0026nbsp;-1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003e/i:/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003e-4.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e-7.09,\u0026nbsp;-2.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003eMaximum counting duration\u0026nbsp;(seconds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003e-2.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e-4.11,\u0026nbsp;-.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003eMaximum inspiratory pressure\u0026nbsp;(cm H\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003e-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e-16.5,\u0026nbsp;-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003eMaximum expiratory pressure\u0026nbsp;(cm H\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003e-17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e-33.5,\u0026nbsp;-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003ePeak expiratory flow rate\u0026nbsp;(lit/minute)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003e-160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e-200,\u0026nbsp;-115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003eQuadriceps muscle strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e-0.11, 0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003e0.217\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.403669724770644%\"\u003e\n \u003cp\u003eFTSTS\u0026nbsp;(sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.165137614678898%\"\u003e\n \u003cp\u003e-0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.119266055045873%\"\u003e\n \u003cp\u003e-1.49, 1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.311926605504587%\" valign=\"top\"\u003e\n \u003cp\u003e0.760\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFTSTS= Five time sit to stand, LPM =\u0026nbsp;Liter per minute\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breathing exercise, Quadriceps exercise, Community-dwelling elderly, Respiratory function","lastPublishedDoi":"10.21203/rs.3.rs-4257094/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4257094/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMost of population in the world recently move to super-aged society. Program of health promotion for community-dwelling elderly requires critical concern.\u003c/p\u003e \u003cp\u003e \u003cb\u003eObjectives\u003c/b\u003e: The objectives of this study were to compare maximum phonation time (MPT), Maximum counting duration (MCD), Peak expiratory flow rate (PEFR), Maximum inspiratory pressure (MIP), Maximum expiratory pressure (MEP), and quadriceps muscle strengthening before and after breathing with quadriceps exercises.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e: Twenty- three community-dwelling healthy elderly aged 60\u0026ndash;70 years old (mean\u0026thinsp;=\u0026thinsp;65.52 and standard deviation\u0026thinsp;=\u0026thinsp;2.41) were enrolled to complete study. Participants did program of breathing with quadriceps exercises twice a day in sitting, standing position and walking for 7 weeks.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e: Median of MPT of /a; u; i:/ before exercises\u0026thinsp;=\u0026thinsp;8.61\u0026ndash;10.14 seconds. Wilcoxon Sign Rank Test was found significant better medians of MPT, MCD, PEFR, MIP, MEP, and quadriceps muscle strength after program. function.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: Program of breathing with quadriceps exercises could significantly increase MPT, MCD, PEFR, MIP, MEP, and quadriceps muscle strength in community-dwelling healthy elderly within 7 weeks.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Diaphragmatic Breathing with Quadriceps Exercises on Maximum Phonation Time, Respiratory function and Muscle Strengthening in Community- Dwelling Elderly","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-02 19:42:10","doi":"10.21203/rs.3.rs-4257094/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"36e5d6b3-b1e2-44c8-a5e2-d771c0fb2183","owner":[],"postedDate":"May 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-01T10:43:49+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-02 19:42:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4257094","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4257094","identity":"rs-4257094","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}