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Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note

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Erik Peper at San Francisco State University
Erik Peper
Annette Booiman at University of Applied Sciences Leiden
Annette Booiman
I-Mei Lin at Kaohsiung Medical University
I-Mei Lin
Richard Harvey at San Francisco State University
Richard Harvey
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Abstract and Figures

Diaphragmatic breathing from a developmental perspective is a whole-body process. During exhalation, the abdominal wall contracts, and during inhalation, the abdominal wall relaxes. This pattern is often absent in many clients who tend to lift their chest when they inhale and do not expand their abdomen. Even if their breathing includes some abdominal movement, in many cases only the upper abdomen above the belly button moves while the lower abdomen shows limited or no movement. This article describes factors that contribute to the lack of abdominal movement during breathing, as well as a methodology to record the surface electromyography (SEMG) activity from the lower abdominal muscles (external/internal abdominal oblique and transverse abdominis). Strategies are presented to teach clients how to engage the lower abdominal muscles to facilitate effortless breathing. For example, when the person exhales, the lower abdominal muscles contract to flatten the abdomen and push the diaphragm upward, and these muscle relax during inhalation to allow the diaphragm to descend. Lower abdominal SEMG recording can also be used as a surrogate indicator for SEMG activity from the pelvic floor. To enhance activation of the lower abdominal muscles during a breathing cycle, specific exercises are described. In summary, lower abdominal SEMG feedback is a useful strategy to facilitate complete abdominal involvement during breathing.
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Biofeedback ÓAssociation for Applied Psychophysiology & Biofeedback
Volume 44, Issue 1, pp. 42–49 www.aapb.org
DOI: 10.5298/1081-5937-44.1.03
FEATURESFEATURES
Abdominal SEMG Feedback for Diaphragmatic
Breathing: A Methodological Note
Erik Peper, PhD, BCB,
1
Annette Booiman, MSCT, BCB,
2
I-Mei Lin, PhD, BCB,
3
Richard Harvey,
PhD,
1
and Jasmine Mitose
1
1
Institute for Holistic Health Studies, San Francisco State University, San Francisco, CA;
2
Biofeedback in Beweging, Wormer, the Netherlands;
3
Department of
Psychology, Kaohsiung Medical University, Taiwan
Keywords: surface electromyography, respiration, diaphragmatic breathing, pelvic floor pain
Diaphragmatic breathing from a developmental perspective
is a whole-body process. During exhalation, the abdominal
wall contracts, and during inhalation, the abdominal wall
relaxes. This pattern is often absent in many clients who tend
to lift their chest when they inhale and do not expand their
abdomen. Even if their breathing includes some abdominal
movement, in many cases only the upper abdomen above the
belly button moves while the lower abdomen shows limited
or no movement. This article describes factors that contribute
to the lack of abdominal movement during breathing, as well
as a methodology to record the surface electromyography
(SEMG) activity from the lower abdominal muscles (exter-
nal/internal abdominal oblique and transverse abdominis).
Strategies are presented to teach clients how to engage the
lower abdominal muscles to facilitate effortless breathing.
For example, when the person exhales, the lower abdominal
muscles contract to flatten the abdomen and push the
diaphragm upward, and these muscle relax during inhalation
to allow the diaphragm to descend. Lower abdominal SEMG
recording can also be used as a surrogate indicator for SEMG
activity from the pelvic floor. To enhance activation of the
lower abdominal muscles during a breathing cycle, specific
exercises are described. In summary, lower abdominal SEMG
feedback is a useful strategy to facilitate complete abdominal
involvement during breathing.
Background
When asking clients to demonstrate inhaling diaphragmat-
ically, many lift their chest and do not expand their
abdomen, even though they think their stomach/abdomen
expanded. In other cases, during exhalation, their chest goes
down and their abdomen goes out, a pattern known as
paradoxical breathing. Even if their breathing includes
abdominal movement, in many cases only the upper
abdomen above the belly button moves while the lower
abdomen shows limited or no movement.
Factors that contribute to the lack of abdominal
movement during breathing include:
1. ‘‘Designer jean syndrome’’ (the modern girdle): The
abdomen is constricted by a waist belt, tight pants, or
slimming underwear (Peper & Tibbitts, 1994).
2. Self-image: The person tends to pull his or her abdomen
inward in an attempt to look slim and attractive.
3. Defense reaction: The person unknowingly tenses the
abdominal wall—a flexor response—in response to
perceived threats (e.g., worry, external threat, loud
noises, feeling unsafe). Defense reactions are commonly
seen in clients with anxiety, panic, or phobias.
4. Learned disuse (Peper et al., 2015): The person covertly
learned to inhibit any movement in the abdominal wall
to protect themselves from experiencing pain because of
a. Prior abdominal injury/surgery (e.g., hernia surgery,
appendectomy, cesarean operation)
b. Abdominal pain (e.g., irritable bowel syndrome,
recurrent abdominal pain, ulcers, acid reflux)
c. Pelvic floor pain (e.g., pelvic floor pain, pelvic girdle
pain, vulvodynia, sexual abuse)
d. Low back pain
5. Inability to engage abdominal muscles because of the
lack of muscle tone.
a. The abdominal wall relaxes as a biological signal of
defenselessness. This is sometimes observed in
clients who feel defeated, depressed, or hopeless.
The person will predominantly breathe shallowly in
their chest with episodic sighs.
b. Age or a sedentary life. The person has limited
abdominal muscle strength and has reduced activa-
tion of muscles around the trunk during movement.
Whether the lower abdominal muscles are engaged or not
(either by chronic tightening or lack of muscle activation),
AdaptedfromPeper,E.,Booiman,A.C.,Lin,I-M.,Harvey,R.,Mitose,
J. (2015) Abdominal SEMG feedback for diaphragmatic breathing: A
methodological note. Poster presented at the 46th Annual Meeting of
the Association for Applied Psychophysiology and Biofeedback, Austin,
Texas, March 11–14, 2015.
42
Spring 2016 |Biofeedback
the resultant breathing pattern tends to be shallow, rapid,
irregular, and punctuated with sighs in their chest. Over
time, participants may not able to activate or relax the lower
abdominal muscles during the respiratory cycle.
Breathing from a developmental perspective is a whole-
body process, and whole-body involvement in respiration
can usually be observed in infants and young children. When
a person feels safe, optimum breathing should be effortless
(van Dixhoorn, 1998, 2007). During inhalation, the abdom-
inal wall expands and the lower abdominal muscles—
transverse abdominis and abdominal oblique—relax, which
allows the diaphragm to move caudally to increase lung
volume in the thorax. During exhalation, the transverse
abdominis and abdominal oblique muscles tighten to pull the
abdomen inward, flattening the abdomen so that the
abdominal circumference decreases, which pushes the
diaphragm cranially upward to reduce lung volume in the
thorax (Booiman & Peper, 2013; Peper et al., 2015; Talasz,
Kalchschmid, Kofler, & Lechleitner, 2012; Talasz, Kofler,
Kalchschmid, Pretterklieber, & Lechleitner, 2010).
Diaphragmatic breathing is the intrinsic respiratory
pattern of mammals, as illustrated by a dog standing on
all fours. During exhalation, the abdomen wall contracts
upward against gravity, and during inhalation, the abdom-
inal wall relaxes, allowing the abdomen to drop down.
Moreover, during early embryological development, the
respiratory tract and the urinary system develop from the
same tissue. This connection is still present during
breathing. For example, when a person with normal
functional breathing exhales through pursed lips while
making a hissing sound (psssssss), the muscles of the pelvic
floor and lower abdomen will slightly tighten (Hodges,
Sapsford, & Pengel, 2007; Sapsford et al., 2001; van
Dixhoorn, 2007).
1
When people improve their breathing
patterns, numerous disorders are ameliorated, such as
chronic obstructive pulmonary disease (Cahalin, Braga,
Matsuo, & Hernandez, 2002; Gosselink, Wagenaar, Rijs-
wijk, Sargeant, & Decramer, 1995), asthma (Thomas et al.,
2003), and pelvic floor disorders (Zivkovic et al., 2012).
Conventional recording of respiration with strain gauges
placed around the waist records the expansion of the abdomen
during inhalation or constriction during exhalation; however,
it usually records the upper abdomen, and in many people, it
does not reflect the movement of the lower abdominal wall.
Purpose
The purpose of this methodological note is to describe a
methodology to record the surface electromyography
(SEMG) activity from the lower abdominal muscles (exter-
nal/internal abdominal oblique and transverse abdominis) to
monitor and to teach engagement of these lower abdominal
muscles to facilitate effortless, whole-body breathing. Using
this methodology, the participants can once again learn how
to activate the lower abdominal muscles to flatten the
abdominal wall during exhalation, thereby pushing the
diaphragm upward, and then, during inhalation, relax the
muscles of the abdominal wall to expand the abdomen to
allow the diaphragm to descend. The location of the muscles
and electrode location are illustrated in Figure 1.
Lower Abdominal SEMG Electrode
Placement
Electrode Placement Options
Narrow electrodes placement. The Triode electrode is
placed about 1 cm to the midline from the spina iliaca
anterior superior (SIAS), as shown in Figure 1. The
participant is asked to loosen material around the waist
(e.g., beltline) and fold the clothing down on the side where
the electrode is placed, as shown in Figure 2. This works
well with people who are slim and do not have much
adipose tissue or tissue folds. The band-pass filter is usually
set between 20 and 500 Hz as the electrocardiogram (EKG)
artifact is minimal; however, if the EKG artifact is large, the
band-pass filter is set between 100 and 200 Hz (Peper,
Gibney, Tylova, Harvey, & Combatalade, 2008).
Wide electrodes placement. One single active electrode is
placed 1 cm from the right SIAS, and the other active
electrode is placed on the other side 1 cm inward from the
left SIAS, as shown in Figure 1. The reference electrode is
placed midway between the two active electrodes. The
band-pass filter is set between 100 and 200 Hz to reduce the
EKG artifact. This electrode placement works well with
people having significant adipose tissue or tissue folds
(Peper et al., 2008).
Observations
For healthy participants who breathe diaphragmatically,
there was a close correspondence between breathing activity
measured by respiratory strain gauges and the SEMG
sensor placed on the lower abdominal wall during slow,
effortless breathing.
2
The SEMG activity increases during
1
For additional information about effortless breathing, see the
comprehensive work on whole-body breathing by van Dixhoorn
(1998, 2007).
2
The detailed methodology for monitoring muscle activity with SEMG
and respiration with strain gauges are described in the book Biofeedback
Mastery (Peper et al., 2008). The physiological recordings for this
methodological note were done with a Procomp Plus Infiniti system
with Biograph Infinity 6.1 software (Thought Technology, Ltd) using
MyoScan-Pro
TM
sensors to record the SEMG.
43
Biofeedback |Spring 2016
Peper et al.
exhalation and decreases during inhalation, as shown in
Figure 3.
The abdominal breathing pattern is often affected by the
posture of the trunk. When the person sits collapsed with a
posterior tilt of the pelvis, the lower abdomen muscles are
more difficult to activate during exhalation as shown in
Figure 4.
Challenges in Recording SEMG from the Lower
Abdomen
The participant has excessive adipose tissue under the
abdominal wall, which reduces the SEMG signal recorded
with narrow placement electrode. Solution: Explore the
use of wide placement electrodes.
Slouching posture of the client may increase tissue folds
in that area and push the triode away from the muscle,
thereby decreasing the signal amplitude. Solution: Have
the person sit erect.
Clients with little abdominal fat who have experienced
weight fluctuations (e.g., significant weight loss or
pregnancy) may have loose skin that moves away from
the muscles, especially with a slouching posture, which will
reduce the signal. Solution: Use wide placement electrodes
or let the person lie down on his or her back on a couch/
floor.
Clothing may interfere with sensor placement and shift
during position changes. Solution: Have person wear
clothing that allows electrodes to be discretely placed on
the abdominal wall and discuss how clothing may
restrict abdominal movement during breathing.
The absence of lower abdominal muscle tension has been
associated with a history of abdominal pain and pelvic floor
Figure 1. Approximate transverse and external abdominal oblique placement of surface electromyography (SEMG) sensors for detecting lower SEMG activity. From
http://www.muscledudelife.com/wp-content/uploads/2014/12/abdominal-muscles-anatomy.jpg.
Figure 2. Placement of a triode electrode on the lower abdomen.
44
Spring 2016 |Biofeedback
Abdominal SEMG Feedback for Diaphragmatic Breathing
Figure 3. Correspondence between respiratory strain gauge changes and surface electromyography (SEMG) activity during breathing. When the person exhales,
the lower abdominal SEMG activity increases, and when the person inhales, the SEMG decreases.
Figure 4. Effect of posture on abdominal surface electromyography recording.
45
Biofeedback |Spring 2016
Peper et al.
discomfort in which the muscle activity is inhibited because
of learned disuse (Gilbert & Chaitow, 2012; Haugstad et al.,
2008; Haugstad, Kirste, Leganger, Haakonsen, & Haugstad,
2011). Low chronic abdominal muscle tension has been
associated with the chronic triggering of the defense
reaction (Haugstad et al., 2008). For many clients with this
chronic low-tension pattern, especially those who are
fearful and guarding, learning to relax the lower abdominal
wall during inhalation as well as learning to increase
slightly the tension of the abdominal wall muscles during
exhalation is challenging. After mastering the skill, these
individuals often report feeling more relaxed and safe.
The abdominal SEMG placement measures the low
abdominal muscle function and may also be used as a
surrogate indicator for SEMG activity from the pelvic floor,
as measured by an internal probe shown in Figure 5.
For clients with pelvic floor pain such as vulvodynia or
those with sexual abuse history, using lower abdominal
SEMG recording may be a noninvasive and less threatening
approach to teaching lower abdomen and pelvic floor
relaxation (Peper et al., 2015). It may avoid retraumatizing
that could occur when placing sensors in the vagina or anus.
The benefits of learning slower lower abdominal breathing
include facilitating circulation and lymph fluid and venous
blood return in the abdomen. At the same time, the slower
resonant frequency breathing would enhance the sympa-
thetic-parasympathetic balance and reduce sympathetic
arousal and trigger-point activity (Lehrer, Vaschillo, &
Vaschillo, 2000).
Self-Practices to Increase Lower Abdominal Movement
During Slower Breathing
The following practices can be used by the client to facilitate
lower abdominal breathing (Klemmetsen, 2005; Jonker-
Kaars Sijpensteijn, 1996):
1. Holding the hands against the lower abdomen
Clients place their hands below their belly button with
the outer edge of hands resting on the groin. During
inhalation, they practice bringing their lower abdomen/
belly into their hands so that the person can feel the lower
abdomen expanding. During exhalation, they pull their
lower abdomen inward and away from their palms, as
shown in Figure 6.
Figure 5. Comparison between low and normal abdominal breathing while recording surface electromyography (SEMG) from the transverse/obliques and an
internally placed vaginal EMG probe.
Figure 6. Hands placed below the belly button to sense the movement of the
lower abdomen.
Figure 7. Position of fingers to feel the lower abdominal tension during
exhalation and relaxation (expansion) during inhalation.
46
Spring 2016 |Biofeedback
Abdominal SEMG Feedback for Diaphragmatic Breathing
2. Feeling the muscles contracting
Clients place their fingertips just inside the SIAS on the
abdomen with a light pressure, as shown in Figure 7. While
exhaling, they focus on feeling the muscles of the abdomen
slightly tighten and relax/soften during inhalation. Clients
can also practice this covertly during the day by putting
their fingers/hands in the pockets of their pants and feeling
the muscles of their own abdomen; nobody will know that
they are doing their home practice.
3. Cats and dogs
The client is on all fours on the floor on their hands and
knees. The arms and upper thighs are perpendicular from
the trunk and floor. During exhalation, the client tightens
the abdominal muscles upward from the pubic bone to the
ribcage (like pulling up a zipper) while curling the back and
tucking the head down. During inhalation, the client relaxes
and expands the lower abdomen and stomach while arching
the back and lifting the head up, as shown in Figure 8.
4. Pelvic rocking
The client sits erect on a chair on the ‘‘sit’’ bones of the
pelvis. Then the client moves the pelvis slowly backward with
use of the abdominal muscles, so he or she sits behind the sit
bones, and then moves the pelvis in the forward position
while relaxing the abdominal muscles so that at the end of the
movement, the client will sit in front of his or her sit bones.
The client slowly rocks the pelvis forward and backward
several times with the use of the abdominal muscles, as
shown in Figure 9.
This pelvic rocking exercise was so helpful! I am realizing that
my hyperventilation was intertwined with my inability to rock
the pelvis back and forward. Now I am able to move my
pelvis, my breathing problems are becoming better too.
Conclusion
Lower abdominal SEMG feedback is a useful tool to
facilitate complete abdominal involvement during breath-
ing. It is especially useful when teaching clients to breath
slowly at resonant frequency so that sympathetic and
parasympathetic balance can be enhanced. This methodol-
ogy can be used by psychologists, physical therapists, and
biofeedback practitioners who neither want nor are allowed
Figure 8. Illustration of ‘‘cats and dogs’’ practice. During inhalation, the lower abdomen expands while arching the back and lifting the head up; during exhalation,
the lower abdomen is moved upward from the pubic bone to the ribcage while curling the back and tucking the head down.
Figure 9. Illustration of pelvic rocking while sitting on a tool or at the edge of a chair.
47
Biofeedback |Spring 2016
Peper et al.
to directly interact using internal placements of sensors for
pelvic floor problems.
Lower abdominal SEMG feedback is also useful in
retraining breathing for people with depression, rehabilita-
tion after pregnancy, operations in the abdomen or chest
(e.g., cesarean surgery, hernia, or appendectomy opera-
tions), anxiety, hyperventilation, stress-related disorders,
difficulty becoming pregnant or maintaining pregnancy,
pelvic floor problems, headache, low back pain, and lung
diseases.
Biofeedback might be the single thing that helped me the
most. When I began to focus on breathing, I realized that it
was almost impossible for me since my body was so
tightened. However, I am getting much better at breathing
diaphragmatically because I practice every day. This has
helped my body and it relaxes my muscles, which in turn
help reduce the vulvar pain.
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Spring 2016 |Biofeedback
Abdominal SEMG Feedback for Diaphragmatic Breathing
Eric Peper Annette Booiman I-Mei Lin
Richard Harvey Jasmine Mitose
Correspondence: Erik Peper, PhD, Institute for Holistic Healing Studies/Department of Health Education, San Francisco State University, 1600
Holloway Avenue, San Francisco, CA 94132, email: epeper@sfsu.edu; web: www.biofeedbackhealth.org; blog: www.peperperspective.com.
49
Biofeedback |Spring 2016
Peper et al.
... [5] Furthermore, during diaphragmatic breathing training, there are many cases in which only the upper abdomen moves, and the lower abdomen has limited movement, or the abdominal wall contracts while inhaling and relaxes while exhaling. [7] To compensate for such challenges, previous studies have applied biofeedback through ultrasound, respiratory apparatus, virtual reality based game, and surface electromyography (sEMG). [7][8][9][10][11] Among the several methods applying real-time biofeedback during diaphragmatic breathing training, sEMG has been reported to improve selective control of muscles. ...
... [7] To compensate for such challenges, previous studies have applied biofeedback through ultrasound, respiratory apparatus, virtual reality based game, and surface electromyography (sEMG). [7][8][9][10][11] Among the several methods applying real-time biofeedback during diaphragmatic breathing training, sEMG has been reported to improve selective control of muscles. [12][13][14] In addition, sEMG has been used as a biofeedback method for training patients to self-regulate muscle contraction and tension. ...
... The EMG electrodes (AgCl electrode, 3M Inc., Seoul, Korea) were attached on both sides at a point 1 cm from the superior anterior iliac spine to the umbilicus with a distance of not more than 2 cm between the electrodes. [7] The diaphragm is a deep muscle, from which it is difficult to receive sEMG signals. In addition, this study did not aim to examine the muscle activity of the diaphragm during diaphragmatic respiration. ...
Effect of diaphragmatic breathing training with visual biofeedback on respiratory function in patients with multiple rib fractures: A randomized-controlled study
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  • Jan 2024
Objectives The aim of this study was to investigate the effect of diaphragmatic breathing training with visual biofeedback on respiratory function in patients with multiple rib fractures. Patients and methods Between June 2021 and October 2021, a total of 16 patients (15 males, 1 female; mean age: 49.50±11.85 years; range, 25 to 66 years) who were diagnosed with multiple rib fractures were randomly assigned into two groups as the control group (CG, n=8) and the visual biofeedback group (VBG, n=8). The effect of each diaphragmatic breathing training on respiratory function was evaluated before and after eight interventions. For respiratory function, pulmonary function test was used to measure pulmonary function and respiratory muscle strength, and the Pain, Inspiratory capacity, Cough (PIC) score was used to evaluated pain, inspiratory capacity, and cough ability. Results In both groups, the pulmonary function representing the ratio of measurements to predicted values of both forced vital capacity (CG mean difference=25.37±4.58, p=0.002, VBG mean difference=24.25±3.96, p=0.007) and forced expiratory volume in 1 sec (CG mean difference=32.38±5.7, p=0.002, VBG mean difference=26.15±5.73, p <0.001) increased significantly. The maximal inspiratory (CG mean difference=14.00±0.35, p=0.002, VBG mean difference=20.5±6.26, p=0.009) and expiratory pressure (CG mean difference=43.72±29.44, p=0.034, VBG mean difference=25.76±6.78, p=0.015), the indicators of respiratory muscle strength, increased significantly in both groups. The PIC score, which evaluated pain, inspiratory capacity, and cough ability, also increased significantly in both groups (CG mean difference=1.63±0.26, p≤0.001, VBG mean difference=3.13±0.19, p <0.001). The change of PIC score after intervention did not significantly differ between the groups (F=1.439, p=0.250); however, there was a significant difference over time (F=38.476, p <0.001). The change of PIC scores differed over time between the groups (F=2.806 p=0.011). Conclusion Diaphragmatic breathing training and diaphragmatic breathing training with visual biofeedback can improve pulmonary function, respiratory muscle strength, pain, inspiratory capacity, and cough ability in patients with multiple rib fractures.
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... By focusing on diaphragmatic breathing with relaxing imagery, it is possible to restore abdominal expansion during inhalation and slight constriction during exhalation. This dynamic breathing while lying supine enhances abdominal blood and lymph circulation as well as muscle relaxation (Peper et al., 2016). While doing the practices, people were asked to wear clothing that did not constrict the waist to allow their abdomen to expand during inhalation, as waist constriction by clothing (designer jean syndrome) interferes with abdominal expansion. ...
... Abdominal movement is facilitated during the breathing cycle. This means reducing the factors that prevent the abdomen from expanding during inhalation or constricting during exhalation (Peper et al., 2016). * Eliminate designer jean syndrome (the modern girdle). ...
... When respondents discussed experiences of menstrual cramps, they also anecdotally described how they at times curl up in a protective defense posture. A defense posture would maintain pelvic floor muscle contractions and inhibit blood and lymph flow in the abdomen and increase shallow rapid thoracic breathing, which can decrease pCO 2 and increase vasoconstriction and muscle constriction (Peper et al., 2015;Peper et al., 2016). ...
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Full-text available
  • Sep 2023
Dysmenorrhea is one of the most common conditions experienced by women during menstruation. A recent systematic review and meta-analysis accounting for more than 20,000 women across 37 studies suggested that the prevalence of pain symptoms associated menstrual cramps is as high as 70%, accounting for economic, cultural, national, and educational factors. Although most treatment commonly focuses on pain relief with medication, self-medication strategies for menstrual cramps vary widely, commonly with unintended effects from misuse of self-medications. Whereas traditional herbal preparations, nutritional supplements, and other home remedies are used to address pain and discomfort symptoms, self-regulation strategies are nonmedication, nonsubstance use interventions to prevent and reduce discomfort. This article reports observations of self-regulation strategies used as part of a university class. In self-reported homework practice, 32 college women tried a set of self-regulation techniques that included holistic health techniques of (a) raising awareness of stress, (b) dynamic relaxation, and (c) slow diaphragmatic breathing with warming imagery. Students were asked to report anonymously on a variety of symptoms, which included menstrual cramps. In addition to any treatment as usual (TAU) strategies already being used (e.g., medications or other treatments), 91% (20 of 22 women) who reported menstrual cramps along with any other symptoms also reported a decrease in dysmenorrhea symptoms when they practiced the self-regulation and diaphragmatic breathing techniques. Discussed are possible mechanisms why a self-regulation approach could reduce discomfort in addition to TAU. In conclusion, an education approach that includes holistic health techniques should be taught to students, including women who may be relying on pain-reducing medications to reduce or prevent discomfort from menstrual cramps.
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... Clothing restrictions (designer jeans syndrome). The clothing is too tight around the abdomen; thereby, the abdomen cannot expand (MacHose and Peper, 1991;Peper et al., 2016). An extreme example were the corsets worn in the late 19th century that were correlated with numerous illnesses. ...
... When a person has had abdominal surgery (e.g., Cesarean section, appendectomy, hernia repair, or episiotomy), they unknowingly may have learned to avoid pain by not moving (relaxing or tensing) the abdomen muscles (Peper et al., 2015;Peper et al., 2016). Each time the abdomen expands or constricts, it would have pulled on the injured area or stitches that would have caused pain. ...
Breathing for health: Mastering and generalizing breathing skills. Townsend Letter-Innovative Health Perspectives
Article
Full-text available
  • Nov 2024
Breathing techniques are commonly employed with complimentary treatments, biofeedback, neurofeedback or adjunctive therapeutic strategies to reduce stress and symptoms associated with excessive sympathetic arousal such as anxiety, high blood pressure, insomnia, or gastrointestinal discomfort. Even though it seems so simple, some participants experience difficulty in mastering effortless breathing and/or transferring slow breathing skills into daily life. The purpose of this article is to describe: 1) factors that may interfere with learning slow diaphragmatic breathing (also called cadence or paced breathing, HRV or resonant frequency breathing along with other names), 2) challenges that may occur when learning diaphragmatic breathing, and 3) strategies to generalize the effortless breathing into daily life.
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... Electrodes were placed bilaterally over the lower abdominal muscles 1 cm medial to the anterior superior iliac spines. [9] Electrodes were not attached to the diaphragm since it is difficult to record the signal when noise occurs due to ICU monitoring devices and equipment. Moreover, it was challenging to secure an electrode attachment site due to dressings after exploratory laparotomy for the abdomen. ...
... [14] Our aim was not to record the muscle activity of the diaphragm but to provide visual biofeedback to the patient by confirming the muscle contraction and relaxation of the abdomen in real time instead of the contraction and relaxation of the diaphragm that occurs during the DB. According to Peper et al., [9] DB can be effectively performed using visual sEMG biofeedback. The patient was unaware of shoulder and chest lifting with inhalation during conventional DB training, and control was difficult. ...
Pulmonary rehabilitation in the intensive care unit using surface electromyography in a patient with diaphragmatic injury: A case report
Article
Full-text available
  • Jun 2022
Diaphragmatic injury (DI) following blunt trauma can cause pulmonary complications and increased duration of ventilator-dependent intensive care unit stay. Herein, we present a 62-year-old female patient with severe trauma who was diagnosed with liver laceration and multiple rib fractures and underwent emergency laparotomy. Extubation was attempted; however, the patient had to be reintubated due to dyspnea. After reintubation, decreased right diaphragmatic excursion was confirmed by ultrasonography and the patient was diagnosed with DI. Surface electromyographic biofeedback was performed during diaphragmatic breathing training to increase the effect of pulmonary rehabilitation. Early diagnosis of DI may be possible using ultrasonography, and the use of surface electromyographic biofeedback is suggested for pulmonary rehabilitation in critically ill trauma patients.
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... This breathing pattern increases the risk for anxiety since it tends to decrease pCO2 Meuret, Rosenfield, Millard & Ritz, 2023;Paulus, 2013;Smits et al., 2022;Van den Bergh et al., 2013). Sitting slouched also tends to inhibit abdominal expansion during the inhalation because the waist is constricted by clothing or a belt -sometimes labeled as 'designer jean syndrome' and may increase abdominal symptoms such as acid reflux and irritable bowel symptoms (Engeln & Zola, 2021;Peper et al., 2016;. When students learn diaphragmatic breathing and practice diaphragmatic breathing whenever they shallow breathe or hold their breath, they report a significant decrease in anxiety, abdominal symptoms and even menstrual cramps (Haghighat et al., 2020;Peper et al., 2023). ...
0 Smartphone affects social communication, vision, breathing, and mental and physical health Published
Article
Full-text available
  • Sep 2024
regarding technology can work against us, leading to overuse, which in turn influences physical, mental and emotional development among current ‘Generation Z’ and ‘Millennial’ users (e.g., born 1997-2012, and 1981-1996, respectively). Compared to older technology users, Generation Z report more mental and physical health problems. Categories of mental health include attentional deficits, feelings of depression, anxiety social isolation and even suicidal thoughts, as along with physical health complaints such as sore neck and shoulders, eyestrain and increase in myopia. Long duration of looking downward at a smartphone affects not only eyestrain and posture but it also affects breathing which burden overall health. The article provides evidence and practices to show how cell phones and slouching posture may cause an increase in emotional health symptoms and increases in physical health symptoms such as eye strain, myopia, decreased mood and energy, or body aches and pains especially related to technology overuse. Suggestions and strategies are provided for reversing the deleterious effects of slouched posture and shallow breathing to promote health.
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... 1. Maintain diaphragmatic breathingrhythm or tempo may change but the breath must be generated from the diaphragm with emphasis on full exhalation. Use strain gauge feedback and/or SEMG feedback to monitor and train effortless breathing (Peper et al., 2016). Strain gauge feedback is used to teach a slower and diaphragmatic breathing pattern, while SEMG recorded from the scalene to trapezius is used to teach how to reduce shoulder and ancillary muscle tension during inhalation 2. Perform activities or stretching/strengthening exercises so slowly that they don't trigger or aggravate pain during the exhalation phase of breathing. ...
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... With verbal and tactile coaching, she learned slower diaphragmatic breathing, where she gently and slowly exhaled by making a sound of pssssssst (exhaling through pursed lips), which tends to activate transverse and oblique abdominal muscles as well as tighten the pelvic floor muscles so that her lower abdomen would slightly come in at the end of the exhalation (Peper et al., 2016b). The inhalation occurred by allowing the lower abdomen and pelvic floor to relax so that the abdomen would expand in 360 degrees 1 . ...
How a Chronic Headache Condition Became Resolved with One Session of Breathing and Posture Coaching
Article
Full-text available
  • Dec 2021
This case example reports how a 32-year-old female student with chronic headaches since age 18 became headache-free after one session of breathing and posture coaching. She self-medicated and took between 2 and 10 Excedrin tablets per week. The class coaching session focused on shifting her habitual thoracic breathing to slower lower abdominal diaphragmatic breathing and posture retraining. While working at the computer, she used an app installed on her computer that provided visual and auditory feedback each time she slouched. She used the app 2–6 hours per day for 2 weeks, and each time in response to the slouching feedback she sat up erect and breathed slower and lower. After the first coaching session and for the following 14 weeks, she has been headache-free and not used any medications. After implementing breathing and posture changes, she also reported significant reduction in shoulder pain, back pain, depression, anxiety, and improvement in motivation. We recommend that when college students report headaches, anxiety, and gastrointestinal distress that they are first offered self-mastery interventions.
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... Thus breathing exercises are used to improve low back pain (Anderson et al., 2017). In the mentioned training sEMG sensors have been used (Peper et al., 2016), as well as smart textile (Rozevika et al., 2018), (Paquin et al., 2019), Breath, Inc., Smartex, Inc., photoplethysmography breathing belts (Neurotechnologies, 2011), (Liu et al., 2011), S.L.P., Inc. to provide the visual feedback which increased the chest excursion and diaphragm activation (Odenbach et al., 2016). ...
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... (Vrana et al., 2018) Since diaphragm is one of the main deep core muscle, abnormal breathing pattern in low back pain have been recognized. (Ostwal et al., 2014) Thus breathing exercises are used to improve low back pain (Anderson et al., 2017) In the mentioned training sEMG sensors have been used (Peper et al., 2016), as well as smart textile (Rozevika et al., 2018) (Paquin et al., 2019), Breath, Inc., Smartex, Inc., photoplethysmography breathing belts (Neurotechnologies, 2011) (Liu et al., 2011), S.L.P., Inc. to provide the visual feedback which increased the chest excursion and diaphragm activation (Odenbach et al., 2016). ...
Technological solutions for low back pain physical therapy real-time monitoring with feedback
Preprint
Full-text available
  • Dec 2021
The advancement of technology may result in significant improvements in physical therapy in terms of sustained rehabilitation, interpretation, and long-term monitoring in a population suffering from low back pain with no identified cause or standardized treatment. The research on systems that monitor vital signs and movement data simultaneously during the physical therapy sessions must be expanded. The aim of the article is to perform analysis and discussion concerning the present technology solutions to monitor vital signs in combination with muscle activity and quality of movement in the light of physical therapy requirements and challenges for the population with secondary conditions. The conclusion-the literature review outcomes show contraindicatory results concerning the combination of sensor, technology use and the artificial intelligence algorithm real-time efficiency on providing information that will change the user's habits and provide specific user targeted simple data interpretation. At the same time studies have proved that participants expressed greater engagement in self-management.
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Effect of Neuromuscular Electrical Stimulation Addition in Exercise with Expiratory Muscle Trainer on FEV1 And FVC in Untrained Healthy Subjects
Article
Full-text available
  • May 2021
Coughing is a mechanism for expelling foreign particles or excess mucus in the airway by increasinghigh expiratory pressure. When coughing, the respiratory muscles that control cough production are theinspiratory and expiratory muscles. Weakness of the expiratory muscle can affect to the ability to generatesufficient pressure to cough. In generally, a decrease in respiratory muscle’s strength can occur in patientswho have experience of prolonged immobilization, elderly people who suffer from sarcopenia, to strokepatients. The untrained healthy persons were not realizing the effects of their lifestyle which can reduce therectus abdominis muscle as an additional expiratory muscle. If it occurred in long time, it will reduce thelung function capacity of force expiratory volume (FEV1) and force vital capacity (FVC). The subjects ofthis study were 16 untrained healthy males with aged 18-40 years. Furthermore, they divided into 2 groups,the intervention group with Expiratory Muscle Trainer (EMT) training plus of Neuromuscular ElectricalStimulation (NMES) on the rectus abdominis muscle and the control group with exercise with ExpiratoryMuscle Trainer only. The outcome was measured for FEV1 and FVC by spirometry. The results of this studywere indicating an increase in FEV1 and FVC in each group however. The intervention group was increaseof FEV1 0.22+0.22 (p value=0.18) and the control group was 0.01+0.39 (p value=0.92). The interventiongroup was increase of FVC 0.50+0.48 (p value=0.02) and the control group was 0.32+0.51 (p value=0.12).The FEV1 results between the two groups were not significant difference (p value=0.21) and as well as FVCresults after 4 weeks of training. In summary, this study concluded that EMT training with NMES increasedFVC even though the difference between the two was not significant.
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Did You Ask About Abdominal Surgery or Injury? A Learned Disuse Risk Factor for Breathing Dysfunction
Article
Full-text available
  • Dec 2015
Abdominal surgery or injury may affect breathing and, if the disturbed breathing pattern is maintained, illness may result, as illustrated by two case examples. This report describes the process of learned avoidance of pain through which abdominal surgery may cause dysfunctional breathing. This clinical note is a reminder to clinicians to ask about abdominal surgery or injury during the intake. In cases in which symptoms occurred months after the abdominal surgery or injury, it may be possible to reduce the symptoms through teaching effortless breathing.
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Vulvodynia Treated Successfully with Breathing Biofeedback and Integrated Stress Reduction: A Case Report
Article
Full-text available
  • Jun 2015
Millions of women experience substantial pain and suffering from vulvodynia, which is pain around the entrance to the vagina (vulva). A common treatment is surgical removal of the tissue (vestibulectomy). This case report describes the detailed process of a holistic biofeedback-based intervention that successfully resolved the vulvodynia in a 23-year-old woman. The four-session treatment interventions included teaching diaphragmatic breathing to transform shallow thoracic breathing into slower diaphragmatic breathing. Treatment transformed her feeling of powerlessness, a belief that there was nothing she could do, into empowerment and a hope that she could reduce her symptoms and optimize her health. She also practiced self-healing imagery and learned to change her posture from collapsed to erect/empowered. Each time she felt discomfort or was fearful, her lower abdomen tended to tighten. After treatment, she used this sensation as a reminder to breathe lower and slower and sit or stand erect. After 6 weeks, she once again could initiate and enjoy intercourse and has been symptom free during the 8 month follow-up.
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Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding
Article
Full-text available
  • Jun 2012
  • Eur J Phys Rehabil Med
Dysfunctional voiding (DV) in neurologically normal children is characterized by involuntary intermittent contractions of either the striated muscle in external urethral sphincter, or the pelvic floor during voiding. Urinary incontinence, pelvic holding maneuvers, voiding difficulties, urinary tract infections (UTIs), constipation and vesicoureteral reflux are highly associated with DV. To investigate the role of abdominal and pelvic floor muscle (PFM) retraining in children with DV. Prospective clinical controlled study Outpatient clinical facility Forty-three children, 5-13 years of age, with dysfunctional voiding In addition to standard urotherapy (education, timed voiding, adequate fluid intake, voiding posture and pattern, constipation management and hygiene issues), children were assigned abdominal and PFM retraining. Diaphragmatic breathing exercises were done in lying and sitting positions, for the purpose of achieving abdominal muscle relaxation. PFM retraining consisted of low-level three-second contractions followed by thirty-second relaxation periods. Selected children received pharmacotherapy (anticholinergics or desmopressin). Recurrent symptomatic UTIs were treated with antibiotic prophylaxis. Uroflowmetry with PFM electromyography and ultrasound residual urine volumes were obtained before and at the end of the 12-month treatment period. Clinical manifestations and uroflowmetry parameters were analysed before and after the therapy. After one year of therapy, urinary incontinence was cured in 20 out of 24 patients (83%), nocturnal enuresis in 12 out of 19 children (63%), while 13 out of 19 children (68%) were UTI free. All 15 patients recovered from constipation. Post-treatment uroflowmetry parameters showed significant improvements and a bell-shaped curve was observed in 36 out of 43 children. In combination with standard urotherapy, abdominal and pelvic floor muscle retraining is beneficial for curing urinary incontinence, nocturnal enuresis and UTIs in children with DV, as well as for normalizing urinary function. Further trials are needed to define the most effective treatment program which would result in the best treatment outcome. To improve clinical and objective treatment outcome in dysfunctional voiders. Diaphragmatic breathing and pelvic floor muscle exercises are simple and easy to learn and could be assigned to children aged 5 or older. As they do not require special equipment, they can be performed at all health care levels.
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Breathing with the pelvic floor? Correlation of pelvic floor muscle function and expiratory flows in healthy young nulliparous women
Article
Full-text available
  • Dec 2009
  • INT UROGYNECOL J
The aim of this cross-sectional study was to determine correlations between pelvic floor muscle (PFM) function and expiratory function in healthy young nulliparous women. In 40 volunteers, PFM function was assessed by vaginal palpation. Forced expiration patterns were evaluated visually and by palpation of the suprapubic insertion region of the anterolateral abdominal muscles. Forced vital capacity (FVC) and forced expiratory flows (FEF) were determined by spirometry. Incremental positive correlation was found between voluntary PFM contraction strength and forced expiratory flow at 25%, 50% and 75% (FEF(25%), FEF(50%), FEF(75%)) of the FVC, respectively. Positive correlation was also found between PFM contraction strength and forced expired volume in 1 s (FEV(1)). No correlation was found between PFM contraction strength and FVC or peak expiratory flow (PEF). Despite some limitations of this study, the observed correlation between PFM contraction strength and forced expiratory flows may serve as theoretical background for a potential role of coordinated abdominal and PFM training in diseases with expiratory flow limitations.
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Continuing improvement of chronic pelvic pain in women after short-term Mensendieck somatocognitive therapy: results of a 1-year follow-up study
Article
Full-text available
  • Nov 2008
Chronic pelvic pain is a common source of disability among women in the western world. Here we report that 3 months of Mensendieck somatocognitive intervention in chronic pelvic pain patients was followed by continued improvements of outcomes at 1-year follow-up in a randomized, controlled study design. Forty women with chronic pelvic pain unexplained by pelvic pathology were randomly assigned to 2 groups: (1) standard gynecologic treatment and (2) gynecologic treatment plus somatocognitive therapy aimed at reducing physical pain by changing posture, movement, and respiration patterns. A standardized Mensendieck test (SMT) of motor function (assessing posture, movement, gait, sitting posture, and respiration), a self-rating questionnaire assessing psychologic distress and general well-being (GHQ-30) and a visual analog score of pain (VAS) were obtained before, after 90 days of treatment and 1 year after inclusion. Patients treated by standard gynecologic treatment/supervision did not improve significantly at 1-year follow-up in any of the test modalities. By contrast, those who in addition received somatocognitive therapy had improved scores for all motor functions and pain, as well as GHQ-30 scores for coping, and anxiety-insomnia-distress. Mensendieck somatocognitive therapy combined with standard gynecologic care improves psychologic distress, pain experience, and motor functions of women with chronic pelvic pain better than gynecologic treatment alone. The effect lasted and even further improvement occurred 9 months after treatment.
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Ontspanningsinstructie: Principes en oefeningen
Book
  • Jan 2017
Dit boek gaat in op spierontspanning, ademhaling en ademtherapie, lichaamshouding en -bewustwording en mentale ontspanning. Ruim vijftig oefenvoorbeelden zijn in het werk opgenomen. Ontspanningsinstructie is een volwaardige behandel- en instructievorm die vanuit verschillende disciplines toegepast kan worden. Alle kennis hierover is gebundeld in dit handboek en biedt professionals de kans om hun kennis te verdiepen en de oefeningen in de praktijk toe te passen. De auteur J. van Dixhoorn raakte tijdens de studie geneeskunde aan de Universiteit van Amsterdam gegrepen door de mogelijkheden van lichaamsbewustwording en zelfregulatie voor de gezondheid. Tijdens zijn lange carrière heeft hij veel lezingen en cursussen gegeven over dit onderwerp en zette hij veel publicaties over stressmanagement op zijn naam.
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Somatocognitive therapy in the management of chronic gynaecological pain. A review of the historical background and results of a current approach
Article
  • Jul 2011
Historic background and development of our somatocognitive approach Mensendieck physiotherapy of the Oslo School is a tradition of physiotherapy founded by the American physician Bess Mensendieck, a contemporary and fellow student of Sigmund Freud at the Paris School of Neurology. It builds on the principles of functional anatomy and the theories of motor learning. We have further developed the theory and practice from this physiotherapy tradition, challenged by the enormous load of patients with longstanding, incapacitating pain on western health care systems, by seeking to incorporate inspirational ideas from body oriented dynamic psychotherapy and cognitive psychotherapy. We developed somatocognitive therapy as a hybrid of physiotherapy and cognitive psychotherapy by focusing on the present cognitive content of the mind of the patient, contrary to a focus on analysis of the subconscious and interpretation of dreams, and acknowledging the important role of the body in pain-eliciting defense mechanisms against mental stress and negative emotions. The core of this somatocognitive therapy (1) To promote awareness of own body, (2) graded task assignment related to the motor patterns utilized in daily activities, (3) combined with an empathic attitude built on dialogue and mutual understanding, and emotional containment and support. The goal is for the patient to develop coping strategies and mastery of own life. In addition, (4) manual release of tensed muscles and applied relaxation techniques are important. Methods and results of an illustrative study One area in particular need of development and research is sexual pain disorders. We have applied this somatocognitive therapy in a randomized, controlled intervention study of women with chronic pelvic pain (CPP).Wesummarize methods and results of this study. Methods 40 patients with CPP were included in a randomized, controlled intervention study. The patients were randomized into (1) a control group, receiving treatment as usual (Standard Gynecological Treatment, STGT) and (2) a group receiving STGT + Mensendieck Somatocognitive Therapy (MSCT). The patients were assessed by means of Visual Analogue Scale of Pain (VASP), Standardized Mensendieck Test (SMT) for analysis of motor patterns (posture, movement, gait, sitting posture and respiration), and General Health Questionnaire (GHQ-30) assessing psychological distress, at baseline (inclusion into study), after three months of out-patient therapy and at 1 year follow-up. Results: The women averaged 31 years, pain duration 6.1 years, average number of previous surgical procedures 1.8 per women. In the STGT group, no significant change was found, neither in pain scores, motor patterns or psychological distress during the observation period. In the group receiving STGT + MSCT, significant reduction in pain score and improvement in motor function were found at the end of therapy, and the significant improvement continued through the follow-up (64% reduction of pain scores, and 80% increase in the average score for respiration, as an example of motor pattern improvement). GHQ scores were significantly improved for anxiety and coping (p < 0.01). Conclusions Somatocognitive therapy is anewapproach that appears to be very promising in the management of chronic gynecological pain. Short-term out-patient treatment significantly reduces pain scores and improves motor function. Implications Chronic pelvic pain in women is a major health care problem with no specific therapies and poor prognosis. A novel, somatocognitive approach has documented positive effects. It is now studied by other clinical researchers in order to reinforce its evidence base.
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Somatocognitive therapy in the management of chronic gynaecological pain. A review of current approach and historical background
Article
  • Jul 2010
Introduction We have developed somatocognitive therapy as a hybrid of Mensendieck physiotherapy and cognitive psychotherapy. Womenwith chronic pelvic pain (CPP) and vulvodynia (chronic pain of the vulvae and vestibulum, VD) were recruited into two separate treatment protocols as described. Methods 60 patients with CPP were recruited from the Department of Gynaecology at the Oslo University Hospital into a randomized, controlled intervention study. The patients were randomized into three treatment groups, receiving (1) treatment as usual, (2) somatocognitive therapy, and (3) in addition receiving cognitive therapy. The patients were assessed by means of SMT, Visual Analogue Score of Pain (VAS), and General Health Questionnaire (GHQ-30) at baseline, after three months of out-patient therapy and at 1 year follow-up. 9 women with VD were treated in an outpatient setting by physiotherapy students under senior supervision, each receiving in all 16 therapy sessions over 8 weeks, and scored for motor patterns (SMT) and pain (VAS) before and after therapy. Results In the control group, no significant change was found. In the group receiving somatocognitive therapy, significant reduction in pain score and improvement in motor function were found the end of therapy, and the significant improvement continued through the follow-up period. GHQ scores were significantly improved for the scores representing level of anxiety and coping, and improved for depression. In the group receiving cognitive therapy in addition, the VAS scores were reduced to the same level as the group receiving only somatocognitive therapy, whereas the motor patterns showed slightly less improvement than for those women that did not receive cognitive intervention. In the women with VD somatocognitive therapy resulted in significantly reduction in pain scores (by an average of 66%), and significant improvement of motor patterns, especially for the scores for gait (56%) and respiration (88%). Conclusions Somatocognitive therapy is a new approach that appears to be very promising in the management of chronic gynaecological pain. Short-term out-patient treatment significantly reduces pain scores and improves motor function, especially with respect to respiration, gait and movement (ability to relax). The approach is now being used in a randomized, controlled intervention study including patient with chronic low back, neck and shoulder, and widespread pain.
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Co-activation of the abdominal and pelvic floor muscles during voluntary exercise
Article
  • Jan 2001
  • NEUROUROL URODYNAM
The response of the abdominal muscles to voluntary contraction of the pelvic floor (PF) muscles was investigated in women with no history of symptoms of stress urinary incontinence to determine whether there is co-activation of the muscles surrounding the abdominal cavity during exercises for the PF muscles. Electromyographic (EMG) activity of each of the abdominal muscles was recorded with fine-wire electrodes in seven parous females. Subjects contracted the PF muscles maximally in three lumbar spine positions while lying supine. In all subjects, the EMG activity of the abdominal muscles was increased above the baseline level during contractions of the PF muscles in at least one of the spinal positions. The amplitude of the increase in EMG activity of obliquus externus abdominis was greatest when the spine was positioned in flexion and the increase in activity of transversus abdominis was greater than that of rectus abdominis and obliquus externus abdominis when the spine was positioned in extension. In an additional pilot experiment, EMG recordings were made from the pubococcygeus and the abdominal muscles with fine-wire electrodes in two subjects during the performance of three different sub-maximal isometric abdominal muscle maneuvers. Both subjects showed an increase in EMG activity of the pubococcygeus with each abdominal muscle contraction. The results of these experiments indicate that abdominal muscle activity is a normal response to PF exercise in subjects with no symptoms of PF muscle dysfunction and provide preliminary evidence that specific abdominal exercises activate the PF muscles. Neurourol. Urodynam. 20:31–42, 2001. © 2001 Wiley-Liss, Inc.
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Effects of multidimensional pelvic floor muscle training in healthy young women
Article
  • Aug 2011
  • ARCH GYNECOL OBSTET
Cross-sectional and interventional study to assess pelvic floor muscle (PFM) function in healthy young nulliparous women and to determine the effects of a 3-month PFM training program with emphasis on co-contraction of PFM and anterolateral abdominal muscles and on correctly performed coughing patterns. PFM function was assessed by digital vaginal palpation in 40 volunteers and graded according to the 6-point Oxford grading scale. The PFM training program was comprised theoretical instruction, as well as verbal feedback during hands-on instruction and repeated training sessions focussing on strengthening PFM and anterolateral abdominal muscle co-contraction during forced expiration and coughing. At baseline, 30 women (75%) were able to perform normal PFM contractions at rest (Oxford scale score ≥ 3); only 4 of them (10%) presented additional involuntary PFM contractions before and during coughing. The remaining 10 women (25%) were unable to perform voluntary or involuntary PFM contractions. Mean Oxford scale score in the whole group was 3.3 ± 1.7. After completing the PFM training program, 29 women (72.5%) performed cough-related PFM contractions and group mean Oxford scale score increased significantly to 4.2 ± 1.0. The study shows that PFM dysfunction may be detected even in healthy young women. Multidimensional training, however, may significantly improve PFM function.
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