Functional assessment of the respiratory system in swimming para-athletesAbstract
Introduction: In postgraduate osteopathy programs, the adoption of active learning methodologies faces challenges such as insufficient faculty training, student resistance, and a lack of structured materials to guide their implementation.
Objective: To develop and validate a practical guide on active learning methodologies for postgraduate osteopathy faculty.
Methods: This was a methodological study conducted in three stages. The first stage consisted of an integrative literature review to inform the guide's development. The second involved content validation by experts using the content validity index (CVI ≥ 0.80). Participants included faculty members holding at least a specialist qualification, experience with active learning methodologies in higher education, and scoring ≥ 8 on an adapted Fehring model scale. Experts evaluated clarity, pertinence, organization, logical sequence, suitability, applicability, and relevance. The third stage was semantic validation involving physio-therapist faculty members from the postgraduate osteopathy program at the Brazilian School of Osteopathy and Manipulative Physiotherapy, who assessed the guide's clarity, pertinence, and applicability. Both validation instruments utilized a 1-to-5 Likert scale. Data were analyzed using descriptive statistics.
Results: All items in the content validation phase showed a CVI ≥ 0.90, with five items achieving a CVI of 1.00. In the semantic validation phase, all items exceeded the minimum criteria, confirming the guide's clear language and practical applicability.
Conclusion: The guide demonstrated robustness and pedagogical relevance, serving as a structured tool to support faculty in implementing active learning methodologies.
Keywords:
Postgraduate education; Study guide; Active learning; Osteopathy
Resumo
Introdução: O número de pessoas com deficiência que praticam esportes tem aumentado significativamente, sendo a natação adaptada uma modalidade que favorece a melhora da capacidade funcional e cardiorrespiratória. Contudo, ainda há es-cassez de estudos que avaliem o desempenho respiratório de paratletas com comprometimentos motores.
Objetivo: Avaliar o pico de fluxo expiratório (PFE) e a força muscular respiratória de paratletas de natação adaptada com comprometimentos motores.
Métodos: Foram recrutados paratletas participantes do programa de natação adaptada do Complexo Aquático Antônio Macca, em Presidente Prudente, São Paulo. Foram mensurados o PFE, as pressões inspiratória e expiratória máximas (PIMÁX e PEMÁX), além de dados antropométricos e clínicos. A normalidade dos dados foi testada por Shapiro-Wilk e os resultados expressos em média ± desvio-padrão, mediana e intervalo interquartílico, ou frequência e porcentagem.
Resultados: Foram avaliados oito paratletas (5 homens e 3 mulheres), com idade mediana de 23 anos (20-32) e índice massa corporal de 25 ± 5 kg/m2. A amostra apresentou 84 ± 23% do predito para o PFE, 116 ± 35% para a PIMAX e 77 ± 19% para a PEMÁX. Três indivíduos apresentaram PFE abaixo da normalidade, um apresentou PIMÁX reduzida, e 50% apresentaram PEMAX abaixo do predito. Participantes com maiores valores de PFE demonstraram também melhores desempenhos em PIMÁX e PEMÁX.
Conclusão: Paratletas com comprometimentos motores apresentaram função inspiratória preservada e redução parcial da força muscular expiratória, sugerindo maior comprometimento desse componente da musculatura respiratória. Esses achados contribuem para a caracterização do perfil respiratório dessa população e podem subsidiar futuras investigações sobre a função respiratória em paratletas.
Palavras-chave:
Paratletas; Natação; Testes de função respiratória; Exercício físico; Sistema respiratório
Introduction
In recent decades, increasing numbers of people with disabilities have engaged in sports, which has been associated with relevant physical and functional benefits, such as increased muscle strength, improved pulmonary ventilation, and better quality of life. Adapted sports play an essential role for individuals with motor limitations by contributing to cardiorespiratory fitness, preservation of function, and promotion of personal autonomy.1
Among Paralympic sports, adapted swimming stands out because it requires precise ventilatory control and refined breathing coordination. The aquatic environment resists chest expansion because of hydrostatic pressure, increasing the effort required for inspiration and stimulating greater recruitment of the respiratory muscles.2,3 These characteristics make swimming capable of promoting specific adaptations in the respiratory system and in the muscles involved in ventilation.
These physiological demands make assessment of respiratory function essential in athletes and para-athletes and commonly include parameters such as peak expiratory flow (PEF), maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP). These indicators are fundamental for understanding respiratory muscle strength and ventilatory efficiency in these athletes.4
Recent research has shown that inspiratory muscle training can significantly increase inspiratory strength and optimize ventilatory performance, although its effects on athletic performance vary among studies.5–7 Some studies have reported improved ventilation and reduced inspiratory fatigue, whereas others found no significant effect on swimming performance. However, whether these findings apply equally to para-athletes remains unclear, because their motor conditions and specific muscle recruitment patterns may influence respiratory mechanics and the response to training. Understanding the respiratory capacity of para-athletes is therefore essential to advance knowledge and support strategies that combine athletic performance and health.
Accordingly, this study aimed to assess PEF and respiratory muscle strength in adapted swimming para-athletes with motor impairments.
Methods
This cross-sectional observational study involved swimming para-athletes enrolled in the adapted swimming program at the Antônio Macca Aquatic Complex in Presidente Prudente, São Paulo, Brazil. Individuals who practiced adapted swimming, had motor impairments, regularly participated in the training program, and agreed to take part in the study were eligible. Individuals with acute respiratory infections during the data collection period, decompensated clinical conditions, an inability to perform the respiratory maneuvers, or who did not complete all stages of the protocol were excluded. Assessments were conducted at the training site in a quiet, previously prepared environment. All participants were informed about the study procedures and signed an informed consent form. The study was approved by the Research Ethics Committee of Universidade do Oeste Paulista (opinion No. 7,548,392; CAAE No. 85060624.8.0000.5515).
Initially, participants completed a structured questionnaire designed to collect information on health conditions, respiratory diseases, medication use, smoking, sports history, and aspects of daily life. Respiratory assessments were then performed.
Respiratory muscle strength was assessed using an MRN-150 analog manovacuometer (±300 cmH2O; commercially calibrated). The procedure followed the American Thoracic Society/European Respiratory Society (ATS/ERS) recommendations for respiratory muscle testing.8 For comparison and interpretation of the results, predicted values for the Brazilian adult population were used according to the equations described by Costa et al.9
PEF was measured using a Medicate® device, with the participant seated and using a disposable mouthpiece. After maximal inspiration, the volunteers performed a rapid, forceful expiration. Three technically acceptable maneuvers were recorded, and the highest value was used for analysis. Results were interpreted using reference values for healthy adults, as described by Nunn and Gregg.10
The collected data were analyzed using Statistical Package for the Social Sciences, version 29.0 (IBM Corp., Armonk, NY, USA). Variable normality was assessed using the Shapiro–Wilk test. Quantitative variables were presented as mean and standard deviation or median and interquartile range (25–75%), according to their distribution. Qualitative variables were described as absolute frequencies and percentages. Results were presented individually, for the overall sample, and stratified by gender.
Results
Eight swimming para-athletes were evaluated; their median age was 23 years (20–32), and five were male and three were female. The anthropometric, hemodynamic, and clinical characteristics of the sample are described in Table 1. One participant reported a history of bronchitis, and another reported exposure to an industrial environment. Two participants reported a history of orotracheal intubation, and none had respiratory symptoms at the time of assessment.
Mean PEF for the overall sample was 84 ± 23% of the predicted value (Table 2). Three of the eight participants had values below 80% of predicted, whereas the others performed within or above the expected range for the healthy population.
For MIP, the sample achieved a mean of 116 ± 35% of the predicted value (Table 3). Only one participant had a MIP value below 80% of predicted, indicating adequate inspiratory strength in most of the sample. Mean MEP was 77 ± 19% of the predicted value (Table 3). Four of the eight participants had MEP values below 80%, showing that reduced expiratory strength was more frequent than reductions in the other parameters investigated.
Assessment of maximal inspiratory pressure and maximal expiratory pressure in the sample (n = 8)
Discussion
This study assessed respiratory function in swimming para-athletes and found that, although mean PEF and MIP remained within predicted values, some participants performed below 80% of the reference values. Three para-athletes had reduced PEF, only one had reduced MIP, and four had MEP values below expected levels, indicating greater impairment of expiratory than inspiratory function. These findings agree with studies reporting a more pronounced reduction in expiratory strength among individuals with some degree of motor impairment or reduced trunk control, which may occur in some para-athletes depending on the nature of the disability.1,2,11 Silva et al. 11 evaluated wheelchair basketball athletes and found proportionally lower MEP than MIP values, a pattern also observed in the present study. In an integrative review, Pereira et al.1 further noted that respiratory training protocols for para-athletes often need to emphasize the expiratory muscles because they may receive less functional stimulus during sports practice. Moreover, although adapted swimming promotes ventilatory conditioning and inspiratory control, it does not necessarily strengthen the expiratory muscles to the same extent.12
The predominance of reduced MEP may be explained by the physiological role of the expiratory muscles, which depends on active recruitment of the abdominal and intercostal muscles-regions that may be limited depending on the type of disability.2,11,13 By contrast, the diaphragm tends to remain functionally preserved in several motor conditions and is repeatedly recruited during swimming, which may explain the preserved MIP in most of the para-athletes evaluated.7,12
Other studies support this interpretation. Paralympic swimmers exhibit seasonal variations in breathing patterns and trunk stabilization that influence respiratory mechanics in Cavaggioni et al.'s study.2 Carvajal-Tello et al.5 and Araujo et al.14 demonstrated that structured inspiratory muscle training can improve inspiratory strength and ventilatory parameters in swimmers. In addition, Antonelli et al.15 found that progressive respiratory training programs increased MIP and MEP in wheel-chair basketball athletes, reinforcing the importance of including stimuli directed at the expiratory muscles in respiratory preparation protocols for adapted sports.
This study's limitations include the small number of participants (n = 8), which was attributable to the specific inclusion criteria and the difficulty of recruiting para-athletes with motor impairments. Participants were heterogeneous in the type and degree of disability, which may have increased result variability. In addition, spiro-metry could not be performed because of technical and logistical limitations, restricting the analysis to respiratory pressure measurements and PEF.
Despite these limitations, the results reinforce the relevance of including simple, accessible assessments, such as manovacuometry and PEF, in the respiratory monitoring of swimming para-athletes. These tools enable early identification of expiratory muscle deficits and can guide specific physiotherapy interventions, such as trunk strengthening, respiratory muscle training, and breathing retraining techniques. Future studies with larger samples, comparisons among functional classes, and spirometry may provide deeper insight into this topic and help refine training and rehabilitation strategies for this population.
Conclusion
This study showed that most swimming para-athletes had preserved inspiratory muscle strength, whereas reduced expiratory muscle strength was more frequent, suggesting greater impairment of this component of the respiratory musculature. These findings contribute to characterizing the respiratory profile of this population and may support future investigations of respiratory function in para-athletes.
Data availability statement
Data are available from the corresponding author upon reasonable request.
References
-
1 Pereira BCN, Staroy TMV, Santos EL, Vara MF, Ribeiro JAC, Eduardo FMC. Análise dos protocolos de treinamento muscular respiratório em paratletas: revisão integrativa. Braz J Health Rev. 2022;5(3):10922-33. https://doi.org/10.34119/bjhrv5n3-245
» https://doi.org/10.34119/bjhrv5n3-245 -
2 Cavaggioni L, Trecroci A, Formenti D, Hogarth L, Tosin M, Alberti G. Seasonal changes in breathing pattern, trunk stabilization, and muscular power in paralympic swimmers. Adapt Phys Activ Q. 2021;38(2):215-31. https://doi.org/10.1123/apaq.2020-0088
» https://doi.org/10.1123/apaq.2020-0088 -
3 Szczepan S, Danek N, Michalik K, Wróblewska Z, Zatoń K. Influence of a six-week swimming training with added respiratory dead space on respiratory muscle strength and pulmonary function in recreational swimmers. Int J Environ Res Public Health. 2020;17(16):5743. https://doi.org/10.3390/ijerph17165743
» https://doi.org/10.3390/ijerph17165743 -
4 Tamiya H, Mitani A, Isago H, Ishimori T, Saito M, Jo T, et al. Measurement of chest wall motion using a motion capture system with the one-pitch phase analysis method. Sci Rep. 2021;11(1):21497. https://doi.org/10.1038/s41598-021-01033-8
» https://doi.org/10.1038/s41598-021-01033-8 -
5 Carvajal-Tello N, Ortega JG, Caballero-Lozada AF, Devia-Quiñonez MJ, González-Calzada I, Rojas-Hernández D, et al. Effects of inspiratory muscle training on lung function parameter in swimmers: a systematic review and meta-analysis. Front Sports Act Living. 2024;16;6:1429902. https://doi.org/10.3389/fspor.2024.1429902
» https://doi.org/10.3389/fspor.2024.1429902 -
6 Ohya T, Kusanagi K, Koizumi J, Ando R, Katayama K, Suzuki Y. Effect of moderate- or high-intensity inspiratory muscle strength training on maximal inspiratory mouth pressure and swimming performance in highly trained competitive swimmers. Int J Sports Physiol Perform. 2022;17(3):343-9. https://doi.org/10.1123/ijspp.2021-0119
» https://doi.org/10.1123/ijspp.2021-0119 -
7 Cunha M, Mendes F, Paciência I, Rodolfo A, Carneiro-Leão L, Rama T, et al. The effect of inspiratory muscle training on swimming performance, inspiratory muscle strength, lung function, and perceived breathlessness in elite swimmers: a randomized controlled trial. Porto Biomed J. 2019;4(6):e49. https://doi.org/10.1097/j.pbj.0000000000000049
» https://doi.org/10.1097/j.pbj.0000000000000049 -
8 American Thoracic Society/European Respiratory Society. ATS/ERS Statement on respiratory muscle testing. Am J Respir Crit Care Med. 2002;166(4):518-624. https://doi.org/10.1164/rccm.166.4.518
» https://doi.org/10.1164/rccm.166.4.518 -
9 Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MIL. New reference values for maximal respiratory pressures in the Brazilian population. J Bras Pneumol. 2010;36(3):306-12. https://doi.org/10.1590/s1806-37132010000300007
» https://doi.org/10.1590/s1806-37132010000300007 -
10 Nunn AJ, Gregg I. New regression equations for predicting peak expiratory flow in adults. BMJ. 1989;298(6680):1068-70. https://doi.org/10.1136/bmj.298.6680.1068
» https://doi.org/10.1136/bmj.298.6680.1068 -
11 Silva NCB, Lira AO, Santos AGPS, Pena JCV, Pereira RN, Normando VMF. Força muscular respiratória de jogadores de basquetebol em cadeira de rodas: comparação entre os valores obtidos e preditos. Rev Eletr Acervo Saude. 2021;13(5):e6974. https://doi.org/10.25248/REAS.e6974.2021
» https://doi.org/10.25248/REAS.e6974.2021 -
12 Bougault V, Turmel J, Levesque B, Boulet LP. The respiratory health of swimmers. Sports Med. 2009;39(4):295-312. https://doi.org/10.2165/00007256-200939040-00003
» https://doi.org/10.2165/00007256-200939040-00003 - 13 Levitsky MG. Fisiologia pulmonar. 8th ed. Barueri: Manole; 2016.
-
14 Araujo LS, Marostegan AB, Scariot PPM, Orsi JB, Cirino C, Papoti M, et al. Inspiratory muscles pre-activation in young swimmers submitted to a tethered swimming test: effects on mechanical, physiological, and skin temperature parameters. Sci Rep. 2024;14(1):5975. https://doi.org/10.1038/s41598-024-52312-z
» https://doi.org/10.1038/s41598-024-52312-z -
15 Antonelli CBB, Hartz CS, Santos SS, Moreno MA. Effects of inspiratory muscle training with progressive loading on respiratory muscle function and sports performance in high-performance wheelchair basketball athletes: A randomized clinical trial. Int J Sports Physiol Perform. 2020;15(2):238-42. https://doi.org/10.1123/ijspp.2018-0979
» https://doi.org/10.1123/ijspp.2018-0979
