Effectiveness of Liuzijue and Box Breathing Techniques on Inspiratory Capacity and Blood Pressure Following Femoral Neck Fracture Immobilization: A Retrospective Comparative Study
Phase: NA
Conditions: Femoral Neck Fractures, Breathing Exercises, Inspiratory Capacity, Blood Pressure
Sponsor: Saveetha University

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FULL STUDY PROTOCOL AND 
STATISTICAL ANALYSIS PLAN (SAP)  
 
 
Effectiveness of Liuzijue and Box Breathing Techniques on 
Inspiratory Capacity and Blood Pressure Following Femoral Neck 
Fracture Immobilization: A Retrospective Comparative Study 
 
Ethical Approval: 065/05/2025/ISRB/PGSR/SCPT 
 
 
 
 
 
 
 
 
20th October 2025 

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Table of Contents 
1. Personnel .................................................................................................................................................. 3 
2. Introduction .............................................................................................................................................. 4 
2.1 Background & Aims ......................................................................................................................... 4 
2.2 Background Literature Review ......................................................................................................... 5 
3. Study Protocol ......................................................................................................................................... 7 
3.1 Research Design Outline .................................................................................................................. 7 
3.2 Participants ........................................................................................................................................ 7 
3.3 Recruitment ....................................................................................................................................... 7 
3.4 Administration ................................................................................................................................... 8 
3.5 Assessment & Outcomes Measures .................................................................................................. 9 
4. Statistical Analysis Plan (SAP) ............................................................................................................... 9 
4.1 Primary Outcomes ............................................................................................................................. 9 
4.2. Secondary Outcomes ...................................................................................................................... 10 
4.3 Missing Data .................................................................................................................................... 10 
5. References .............................................................................................................................................. 12     

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1. Personnel 
 
 
 
Principal Investigator 
 
 
Investigators 
 
 
 
Dr. Srivatsan Munusamy 
 
 
Prof. Dr. Shenbaga Sundaram Subramanian 

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2. Introduction 
 
2.1 Background & Aims 
 
Femoral neck fractures are a significant source of morbidity and mortality among the aged population. 
Due in large part to prolonged immobilization and related systemic consequences. Hip fractures among 
the elderly have increased dramatically worldwide, from 1.7 million in 1990 to an anticipated 6.3 million 
in 2050. Immobilization following a fracture frequently leads to decreased inspiratory capacity, 
compromised pulmonary mechanics and altered cardiovascular regulation, which raises the risk of 
pneumonia, hypertension and delayed functional recovery. Early cardiopulmonary rehabilitation during 
the immobilization phase is crucial since respiratory infections and cardiovascular problems have been 
found to be major causes of early mortality after hip fractures. 
 
Due to medical comorbidities and logistical limitations, prolonged bed rest and delays in surgical 
intervention are still typical in older patients despite advancements in surgical management. These 
elements worsen hemodynamic instability and pulmonary deconditioning. While respiratory and 
cardiovascular components receive less attention during early immobility, musculoskeletal recovery is 
frequently given priority in conventional therapy. 
 
Breathing-based therapies provide a practical and affordable way to deal with these issues. In patients 
with chronic respiratory diseases, Liuzijue Qigong, a traditional Chinese breathing practice that combines 
controlled expiration with sound vibration, has been shown to improve lung function, respiratory muscle 
efficiency and overall quality of life. In a similar vein, Box Breathing is an organized breathing method 
that has been demonstrated to improve blood pressure control, autonomic balance and lung volumes. 
 
In cardiopulmonary rehabilitation, breathing-based therapies have become more popular because of their 
ease of use, affordability and viability for older people who are fragile and immobile. Respiratory 

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efficiency and hemodynamic stability can be enhanced by methods like Box Breathing and Liuzijue 
Qigong, which are known to affect autonomic regulation, respiratory muscle function and cardiovascular 
responses. These treatments are especially important for older patients who have suffered femur neck 
fractures since prolonged immobility frequently results in decreased lung volumes, decreased inspiratory 
capacity and altered blood pressure control. 
 
Comparative research assessing the efficacy of these breathing methods in elderly individuals 
immobilized after femur neck fractures is, however, lacking. Furthermore, only a few studies have used 
objective measurement instruments like volume-oriented incentive spirometry to look at their combined 
effects on blood pressure and inspiratory capacity. By methodically contrasting Box Breathing with 
Liuzijue Qigong, this randomized controlled experiment seeks to close this evidence gap and advance 
evidence-based cardiopulmonary rehabilitation techniques for this susceptible group. 
 
2.2 Background Literature Review 
 
Femoral neck fractures are a major contributor to morbidity and mortality among older adults, 
particularly due to prolonged immobilization and associated systemic complications. In a three-year 
follow-up study, Berggren et al. (2016) reported a high prevalence of cardiovascular, respiratory, and 
metabolic comorbidities in individuals with femoral neck fractures, with complications during 
immobilization significantly contributing to mortality. The authors emphasized the necessity of early 
supportive interventions to reduce secondary physiological decline and improve survival outcomes (1). 
 
Expanding on fracture-related risks, Gouzoulis et al. (2025) analyzed the incidence and contributing 
factors of femoral neck fractures and subsequent surgical outcomes. Their findings indicated that 
advanced age, prolonged inactivity, and compromised cardiopulmonary reserve adversely affect recovery 
and increase postoperative complications. The study highlights the importance of adjunctive non-

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pharmacological strategies to optimize cardiopulmonary function during the immobilization period (2). 
 
Mind–body interventions have shown promise in addressing respiratory dysfunction in older populations. 
Feng et al. (2020) evaluated the role of Qigong practices in elderly individuals and demonstrated 
improvements in respiratory efficiency, autonomic regulation, and psychological well-being. Although 
conducted in the context of COVID-19 rehabilitation, the study supports the applicability of Qigong-
based exercises, such as Liuzijue, in enhancing inspiratory capacity in populations with restricted 
mobility (3). 
 
Further evidence is provided by Xu et al. (2022) through a systematic review and meta-analysis 
examining the efficacy of Liuzijue Qigong in patients with chronic obstructive pulmonary disease. The 
analysis revealed significant improvements in inspiratory capacity, pulmonary function, and exercise 
tolerance, confirming Liuzijue as a safe and effective respiratory rehabilitation modality suitable for 
elderly individuals with limited physical capacity (4). 
 
Breathing-focused interventions have also demonstrated cardiovascular benefits. In a randomized 
controlled trial, Zaliene et al. (2025) reported that structured breathing techniques significantly improved 
autonomic balance, respiratory efficiency, and stress regulation. Notably, reductions in blood pressure 
and enhanced parasympathetic activity were observed, supporting the clinical relevance of Box 
Breathing in managing cardiovascular strain associated with immobilization (5). 
 
Collectively, existing literature supports the use of Liuzijue Qigong and Box Breathing techniques in 
improving respiratory and cardiovascular parameters in elderly populations. However, comparative 
evidence assessing their effectiveness specifically in patients following femoral neck fracture 
immobilization remains limited, warranting further investigation. 
 

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3. Study Protocol 
 
3.1 Research Design Outline 
The study aims to perform a Comparative study on older people who have been immobilized due 
to femur neck fractures.in Saveetha Medical College and Hospital. 
 
 
Formerly titled “Effectiveness of Liuzijue and Box Breathing Techniques on Inspiratory Capacity 
and Blood Pressure Following Femoral Neck Fracture Immobilization: A Retrospective 
Comparative Study” involves elderly with femoral neck fracture immobilization by Inspiratory 
capacity and blood pressure were assessed using a volumetric incentive spirometer and a digital 
sphygmomanometer, respectively. Improvement in inspiratory capacity was defined as an increase 
in measured values, with ranges progressing from approximately 1300 mL to 3000 mL. 
Improvement in cardiovascular status was considered when blood pressure remained within a 
stable range, with systolic values between 120-150 mmHg and diastolic values between 70-90 
mmHg. 
3.2 Participants 
 
This retrospective study included elderly individuals diagnosed with femoral neck fracture who 
had undergone a period of immobilization and subsequently received either Liuzijue Qi Gong 
exercise or Box Breathing technique as part of their rehabilitation program. Participants were 
identified through a review of medical and physiotherapy records from Saveetha Medical College 
and Hospital. Eligibility was determined based on inclusion and exclusion criteria documented in 
the clinical records. 
3.3 Recruitment 
 
For this retrospective analysis, medical and physiotherapy records of patients with femoral neck 
fracture immobilization treated at the Saveetha Medical College and Hospital were reviewed. 

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Records of participants who had completed a four-week intervention program and had documented 
outcome measures were included in the study. No direct recruitment or prospective enrollment was 
undertaken. 
Data related to inspiratory capacity measured using a volumetric spirometer and blood pressure 
assessed using a digital sphygmomanometer were extracted from patient records. Outcome 
measures recorded at baseline (pre-intervention), at the second week and at the fourth week were 
included for analysis. Confidentiality of patient information was maintained and the study 
procedures were conducted under the approval and supervision of the institutional ethics 
committee and the principal investigator. 
 
3.4 Administration 
 
Parameter 
Liuzijue Qi Gong Exercise Group 
Box Breathing Technique 
Group 
Position 
Semi-fowlers position or Supine lying or 
half lying 
Semi-fowlers position or 
Supine lying or half lying  
Session 
duration 
20 minutes per session 
20 minutes per session 
Frequency 
Twice daily 
Twice daily 
Weekly 
schedule 
6 days per week 
6 days per week 
Total duration 
4 weeks 
4 weeks 
Intervention 
description 
Coordinated slow breathing while 
expiration producing six distinct sounds are 
produced: (“XU,” “HE,” “HU,” “SI,” 
“CHUI,” and “XI”) 
Structured breathing cycle 
consisting of inhaling for a 
count of four, holding for 
four, exhaling for four and 
holding again for four 
Rest intervals 
Provided as required and documented 
Provided between breathing 
cycles and documented 
Supervision 
Administered under physiotherapist 
supervision 
Administered under 
physiotherapist supervision 
Outcome 
assessment 
points 
Baseline (pre-intervention), 2nd week, 4th 
week 
Baseline (pre-intervention), 
2nd week, 4th week 
 
 
 
 
 

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3.5 Assessment & Outcomes Measures 
 
3.5.1 
Primary outcomes 
 
• Inspiratory Capacity -Volume-Oriented Incentive Spirometer 
o To measure inspiratory capacity in elderly participants, post femoral neck 
fracture immobilization. To objectively monitor changes in pulmonary function.  
o Instructed to inhale slowly and deeply through the mouthpiece after normal 
expiration. 
o Maximum volume achieved recorded as inspiratory capacity. 
 
3.5.2 Secondary outcomes 
 
• 
Blood Pressure - Digital Blood Pressure Monitor (Digital Sphygmomanometer) 
o To measure systolic and diastolic blood pressure. To evaluate cardiovascular 
response to breathing interventions. To monitor physiological changes over the 
intervention period 
o Automated, non-invasive device using Oscillo metric methods. 
o Consists of inflatable cuff and digital display. 
o Blood pressure recorded after adequate rest 
 
4. Statistical Analysis Plan (SAP) 
 
Descriptive and inferential statistics will be used. Normally distributed data will be presented 
by mean and standard deviation (SD) and non-normally distributed data will be presented by 
median and interquartile range. Categorical data will be presented using percentages. SPSS 
(version 27.0) will be used for all statistical analyses. 
4.1 Primary Outcomes 
Statistical analysis will be performed using appropriate statistical software. Descriptive statistics, 
including mean and standard deviation, will be calculated for the primary outcome variables: 
Inspiratory capacity (mL) for both intervention groups. 

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To evaluate changes over time and differences between groups, a mixed-design repeated measures 
analysis of variance (ANOVA) will be used, with time (baseline, 2nd week, and 4th week) as the 
within-subject factor and group (Liuzijue Qi Gong exercise and Box Breathing technique) as the 
between-subject factor. This analysis will determine the effectiveness of the interventions across 
the different time intervals. 
Post-hoc pairwise comparisons with Bonferroni correction will be conducted when significant main 
effects or interactions are observed. Mauchly’s test of sphericity will be applied, and if the 
assumption of sphericity is violated (p < 0.05), the Greenhouse–Geisser correction will be used. A 
p-value < 0.05 will be considered statistically significant. 
4.2 Secondary Outcomes 
Secondary outcome analysis will include systolic and diastolic blood pressure parameters to assess 
cardiovascular responses to the interventions. Descriptive statistics (mean ± standard deviation) 
will be computed for each time point within and between groups. 
A repeated measures ANOVA will be performed to examine within-group changes across time and 
between-group differences in blood pressure values. Where significant effects are identified, post-
hoc analysis with Bonferroni adjustment will be carried out to explore pairwise differences between 
baseline, 2nd week, and 4th week measurements. In cases of sphericity violation, the Greenhouse-
Geisser correction will be applied. Statistical significance will be set at p < 0.05. 
4.3 Missing Data 
 
In the event of missing data due to incomplete clinical records, appropriate statistical handling will 
be undertaken. Where feasible, missing values will be addressed using mean imputation within the 
respective intervention group, provided the proportion of missing data is minimal and missing at 
random. Cases with substantial missing data will be excluded from the final analysis. 

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4.4 Informed Consent Forms (ICF) 
 
Written informed consent had been obtained from participants at the time of clinical treatment as 
part of routine hospital protocol. For the present analysis, waiver of fresh informed consent will be 
sought from the Institutional Ethics Committee, as the study involves reviewing existing medical 
and physiotherapy records without direct participant contact. 
 
4.4.1 Rights and Risks to participants  
 
Rights 
 
Participants’ rights to autonomy, dignity and confidentiality will be fully respected. Participation 
in the retrospective analysis will not affect the standard of care received by the patients. 
Individuals retain the right to withdraw their clinical data from analysis if required by 
institutional policy. No remuneration or reimbursement is associated with participation in this 
study. 
Risks 
No foreseeable physical, psychological or social risks are anticipated, as the study involves 
secondary analysis of previously collected clinical data and does not include any additional 
interventions or assessments. 
 
4.4.2 Privacy and Confidentiality 
 
All patient data will be de-identified prior to analysis. Each participant will be assigned a unique 
study identification code to ensure anonymity. Identifiable information will not be accessed, 
disclosed or published. Data extraction and analysis will be conducted solely by the principal 
investigator and authorized research personnel in accordance with institutional ethical guidelines. 

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5 
References 
 
1. Berggren M, Stenvall M, Englund U, Olofsson B, Gustafson Y . Co-morbidities, complications 
and causes of death among people with femoral neck fracture - a three-year follow-up 
study. BMC Geriatr. 2016 Jun;16120. doi: 10.1186/s12877-016-0291-5. Epub 2016 Jun 03. 
2. Gouzoulis MJ, Vasudevan RS, Kaszuba SV, Seddio AE, Rubin LE, Grauer JN, Li M . Femoral 
Neck Fractures: Incidence, Reasons, and Risk Factors of Conversion From Hemiarthroplasty to 
Total Hip Arthroplasty. J Am Acad Orthop Surg Glob Res Rev. 2025 May;9(5): doi: 
10.5435/JAAOSGlobal-D-24-00312. Epub 2025 May 13. 
3. Feng F, Tuchman S, Denninger JW, Fricchione GL, Yeung A . Qigong for the Prevention, 
Treatment, and Rehabilitation of COVID-19 Infection in Older Adults. Am J Geriatr 
Psychiatry. 2020 Aug;28(8):812-819. doi: 10.1016/j.jagp.2020.05.012. Epub 2020 May 15. 
4. Xu S, Zhang D, He Q, Ma C, Ye S, Ge L, Zhang L, Liu W, Chen Z, Zhou L. Efficacy of Liuzijue 
Qigong in patients with chronic obstructive pulmonary disease: A systematic review and meta-
analysis. Complement Ther Med. 2022 May;65:102809. doi: 10.1016/j.ctim.2022.102809. Epub 
2022 Jan 29. PMID: 35093513. 
5. Zaliene L, Mockute A, Levickiene L . Breathing Interventions Improve Autonomic Function, 
Respiratory Efficiency and Stress in Dysfunctional Breathing: A Randomised Controlled 
Trial. Adv 
Respir 
Med. 2025 Dec;93(6):doi: 10.3390/arm93060056. Epub 2025 
Dec 
10.

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