Supervised Deep Breathing Exercises Improve Functional Aerobic Capacity in Patients with Severe Spinal Deformity Quality, Safety and Value (QSVI)

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Karina A. Zapata
Kayla M. Clem
Rupha H. Stevens
Charu Sharma
Amy L. McIntosh


Background: Our institution has traditionally treated children with severe spine deformity using halo gravity traction (HGT) to improve curve magnitude and increase flexibility.

Local Problem: Assessing the non-radiographic benefits of HGT such as pulmonary function, is difficult. Pulmonary function is commonly reflected by pulmonary function testing (PFT) which is dependent on MAXIMAL patient effort.  Six-minute walk test (6MWT) reflects functional exercise capacity.

Specific Aims: This quality initiative (QI) was performed to evaluate the addition of supervised deep breathing exercises (DBE) utilizing an incentive spirometer (IS) to supervised physical therapy exercise in patients with severe spinal deformity that require HGT.

Methodology: A QI core team was established with the aim of improving the pulmonary function aspect of our HGT program. The team consisted of 1 orthopaedic surgeon, 1 quality improvement program manager, 2 physical therapists (PTs), and 1 respiratory therapist (RT). The QI core team met every 4 to 6 weeks to discuss patients and processes.

Intervention: RTs supervised HGT patients performing DBE 4 times per day, and asked families to independently perform DBE 4 additional times per day.

PTs performed the six-minute walk tests (6MWT). A pulse oximeter was used to monitor oxygen saturation levels. RTs performed the PFTs. The 6MWT and PFTs were performed prior to halo application, and every 2 weeks while in HGT treatment.

Results: The intervention HGT patients who received supervised DBE (n=14) demonstrated significantly improved 6MWT scores from 1440±546 feet pre-halo to 1663±398 feet pre-surgery (p=0.02).  A historic cohort of HGT patients who did not receive supervised DBE (n=10) demonstrated no significant changes in 6MWT scores at 1493±391 feet pre-halo and 1477±406 feet pre-surgery. Averaged forced vital capacity worsened 4±10% and average forced expire volume in one second worsened 1±8%.

Conclusions: Children in HGT undergoing supervised DBE and physical therapy demonstrate improved functional aerobic capacity according to the 6MWT despite no improvement in pulmonary function tests.


Article Details

How to Cite
Zapata, K. A., Kayla M. Clem, Rupha H. Stevens, Charu Sharma, & McIntosh, A. L. (2022). Supervised Deep Breathing Exercises Improve Functional Aerobic Capacity in Patients with Severe Spinal Deformity: Quality, Safety and Value (QSVI). Journal of the Pediatric Orthopaedic Society of North America, 4(2).
Author Biography

Amy L. McIntosh

Amy McIntosh is a Professor of Orthopedic Surgery and the medical director of patient safety at Texas Scottish Rite Hospital (TSRH) for Children in Dallas, TX. She has been married to her husband, Rich, for 25 years. She has 2 children Quincy (boy: 13 years) and Campbell (girl: 10 years).

She was born and raised in the Upper Peninsula of Michigan. She graduated from Gladstone High School in 1992. She received her Bachelor of Science degree (Summa Cum Laude) in Sports Medicine from Central Michigan University in 1996. She then matriculated to Michigan State University College of Human Medicine and graduated with honors and AOA induction in 2001.

She completed her orthopedic surgery residency at the Mayo Clinic in 2006, followed by her fellowship in pediatric orthopedic surgery and scoliosis at TSRH in 2007.

She then returned to the Mayo Clinic for 7 years as a staff orthopedic surgeon. In 2014, she transitioned her practice back to TSRH, where she currently remains in practice.


Awards include: 

2001 Medical Student of the Year - MSU-KCMS

2005 OREF Zimmer Resident Leadership Forum - American Orthopaedic Association

2013 Mayo Clinic Coventry Award Winning Paper

2013 AAP Section on Orthopedics: Young Investigators Award: Clinical Science

2013 Mayo Clinic Continuing Medical Education Outstanding Course Director of the Year

2014 Minnesota Orthopedic Society: Best Clinical Research Award

2014 Mid-America Orthopaedic Association E.W. Johnson, Jr. Award

2015 POSNA/APPOS Traveling Fellowship

2016 POSNA/ Peter Armstrong Best QVSI Award

2017 POSNA / Medtronic Spine Research Grant

2018 Texas Hospital Association Bill Aston Quality Improvement Award

2019 Women Who STEAM Award

2020 SRS OREF Spine Grant

2021 POSNA QVSI Grant