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Effects of Diaphragmatic Breathing Patterns on Balance: A Preliminary Clinical Trial

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Objective: The purpose of this study was to determine the feasibility of performing a larger study to determine if training in diaphragmatic breathing influences static and dynamic balance. Methods: A group of 13 healthy persons (8 men, 5 women), who were staff, faculty, or students at the University of Western States participated in an 8-week breathing and balance study using an uncontrolled clinical trial design. Participants were given a series of breathing exercises to perform weekly in the clinic and at home. Balance and breathing were assessed at the weekly clinic sessions. Breathing was evaluated with Liebenson's breathing assessment, static balance with the Modified Balance Error Scoring System, and dynamic balance with OptoGait's March in Place protocol. Results: Improvement was noted in mean diaphragmatic breathing scores (1.3 to 2.6, P < .001), number of single-leg stance balance errors (7.1 to 3.8, P = .001), and tandem stance balance errors (3.2 to 0.9, P = .039). A decreasing error rate in single-leg stance was associated with improvement in breathing score within participants over the 8 weeks of the study (-1.4 errors/unit breathing score change, P < .001). Tandem stance performance did not reach statistical significance (-0.5 error/unit change, P = .118). Dynamic balance was insensitive to balance change, being error free for all participants throughout the study. Conclusion: This proof-of-concept study indicated that promotion of a costal-diaphragmatic breathing pattern may be associated with improvement in balance and suggests that a study of this phenomenon using an experimental design is feasible.
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Effects of Diaphragmatic Breathing Patterns
on Balance: A Preliminary Clinical Trial
Rylee J. Stephens, DC,
a
Mitchell Haas, DC,
b
William L. Moore III, DC,
a
Jordan R. Emmil, DC,
a
Jayson A. Sipress, DC,
a
and Alex Williams, DC
a
ABSTRACT
Objective: The purpose of this study was to determine the feasibility of performing a larger study to determine if
training in diaphragmatic breathing influences static and dynamic balance.
Methods: A group of 13 healthy persons (8 men, 5 women), who were staff, faculty, or students at the University of
Western States participated in an 8-week breathing and balance study using an uncontrolled clinical trial design.
Participants were given a series of breathing exercises to perform weekly in the clinic and at home. Balance and breathing
were assessed at the weekly clinic sessions. Breathing was evaluated with Liebensons breathing assessment, static balance
with the Modified Balance Error Scoring System, and dynamic balance with OptoGaits March in Place protocol.
Results: Improvement was noted in mean diaphragmatic breathing scores (1.3 to 2.6, Pb.001), number of single-leg
stance balance errors (7.1 to 3.8, P=.001), and tandem stance balance errors (3.2 to 0.9, P=.039). A decreasing
error rate in single-leg stance was associated with improvement in breathing score within participants over the 8 weeks
of the study (1.4 errors/unit breathing score change, Pb.001). Tandem stance performance did not reach statistical
significance (0.5 error/unit change, P= .118). Dynamic balance was insensitive to balance change, being error free
for all participants throughout the study.
Conclusion: This proof-of-concept study indicated that promotion of a costal-diaphragmatic breathing pattern may
be associated with improvement in balance and suggests that a study of this phenomenon using an experimental design
is feasible. (J Manipulative Physiol Ther 2017;40:169-175)
Key Indexing Terms: Diaphragm; Respiration; Postural Balance; Exercise; Breathing Exercises
INTRODUCTION
Core strength and stability have become central topics in
both injury prevention and physical performance. Core
stability is dependent on the strength, coordination, and
adaptability of the core musculature
1,2
and is necessary for
efficient biomechanical function throughout the kinetic
chain.
3
Increasing core stability has been reported to improve
static and dynamic balance.
4-8
Poor scores on balance tests
have been directly linked to increased injury rates in a healthy
athletic population.
9,10
The diaphragm has been hypothesized to be a respiratory
muscle with postural function.
11
Its attachments to the lumbar
spine help maintain intra-abdominal pressure.
12
The diaphragm
has been found to contract prior to initiation of upper extremity
movement,
12,13
independently of the phase of respiration.
14
Kolar et al used magnetic resonance imaging to demonstrate
that the diaphragm may not function as one cohesive unit.
Increased muscle firing was seen through the middle and
posterior aspects of the diaphragm with isometric extremity
loading.
12
Hodges et al reported that as respiratory demands
increased, the postural function of the diaphragm decreased.
15
Breathing biomechanics have been described with respect
to expansion of the abdominothoracic region during inspiration
at rest. Apical or upper costal breathing occurs when superior
thoracic expansion exceeds the abdominal and lateral costal
expansion. Costodiaphragmatic breathing is observed when
the abdominal and lateral costal expansion is predominant over
the superior thoracic expansion. Electromyography studies
indicate that diaphragm firing patterns differ in apical (chest)
breathers versus diaphragmatic breathers.
16
Although data are
still limited, trends are emerging throughout clinical rehabili-
tation suggesting that a pattern of diaphragmatic breathing may
be beneficial for core stability, posture, upper thoracic
hypertonicity,
16
and decreasing incidence of low back
pain.
17,18
However, a thorough literature review revealed no
empirical link between diaphragmatic breathing and balance.
a
Exercise and Sports Science Department, University of
Western States, Portland, OR.
b
Center for Outcomes Studies, University of Western States,
Portland, OR.
Corresponding author: Rylee J. Stephens, DC, MSc, PO Box
683, Garibaldi Highlands, BC V0N1T0, Canada.
(e-mail: ryleejstephens@gmail.com).
Paper submitted July 20, 2016; in revised form November 30,
2016; accepted January 13, 2017.
0161-4754
Copyright © 2017 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2017.01.005
The purpose of this preliminary study is to explore the
feasibility of performing a study to measure a potential link
between breathing patterns and balance. We had 2 hypotheses:
(1) breathing exercises that promote increased costodiaphrag-
matic movement and decrease upper thoracic movement alter
breathing patterns to be more diaphragmatic in nature; and
(2) as breathing biomechanics become more diaphragmatic in
nature, balance will increase correspondingly.
METHODS
Design
This study was a prospective clinical trial using 1 cohort
without control. The study was conducted in Portland,
Oregon, between April and June 2015.
Participants
Participants were recruited from the students, staff, and
faculty at the University of Western States. The assessors in
this study were four doctor of chiropractic students who
were also enrolled in the Master of Sports Science program.
Assessors were in their final year of both programs.
Participants were included if they were at least 21 years
old, literate in English, ambulatory, and willing to attend 8
visits and complete the prescribed breathing exercises.
Participants were excluded if they had a current or previous
diagnosis of attention deficit disorder or attention deficit
hyperactivity disorder, vascular disease, central nervous
system disorder, benign paroxysmal positional vertigo,
cancer, posttraumatic stress disorder, anxiety, depression,
chronic pain, hypertension, congestive heart failure, or spinal
stenosis. Participants who had had a concussion or brain
injury in the previous year or a lower body injury or ear
infection that required treatment in the past month or who
were currently or trying to become pregnant were excluded.
All participants had to confirm that they could perform the
breathing assessment pain free and were not participating in
any other balance-specific training. Participantsblood
pressure and pulse were taken prior to initiating exercise to
screen for any underlying cardiovascular risk factors.
This study was reviewed and approved by University of
Western States institutional review board. Informed consent
was given by all participants prior to participation in the study.
Outcome Measurements
Breathing and balance assessments were conducted
before each breathing-exercise training session for 8
weeks. To improve the reliability of scoring, all assessments
were scripted and performed by the same evaluator every
week for each of the participants. The dynamic balance was
measured by a computer, but the instructions to participants
were read from a script by the same assessor every week.
The following assessments were made:
Static Balance Assessment. The Modified Balance Error
Scoring System (SCAT3: Sport Concussion Assessment
Tool, 3rd ed) is a standardized, objective test used to assess
balance and postural stability following head trauma.
19,20
The Balance Error Scoring System has been reported to
have good to excellent interrater and test-retest reliability
for the evaluation of healthy young adults
21
and some
evidence of criterion validity in young healthy athletes.
22
Subjects performed the test wearing shorts or pants
rolled up and with shoes removed. Assessors provided
scripted instructions as each subject performed a single trial
of a double-leg stance (DLS), single-leg stance (SLS), and
tandem stance (TS). For the SLS, participants stood on their
nondominant foot. For the TS, the nondominant foot was in
the front. Each trial was performed, with subjectseyes
closed, for 20 seconds while the examiner counted the
number of errors. Types of errors included hands lifting off
iliac crests; eyes opening; a step, stumble, or fall; moving
the hip into more than 30° abduction; lifting forefoot or
heel; and remaining out of the test position longer than 5
seconds. Scores for each test were calculated as the number
of errors. If a participant committed multiple errors
simultaneously, only 1 error was recorded.
23
Participants
were told to reset and start again if they lost their balance.
Scores were generated by the same assessor for all
participants each week in an attempt to improve reliability.
Dynamic Balance Assessment. This was assessed using
OptoGaits March in Place protocol (MicroGait Corp,
Mahopac, NY).
24
By marching in place, the body is
performing a dynamic movement in which balance is needed
to provide a base of support. OptoGaitssoftwaremeasures
flight and contact time on the left and right sides. OptoGait
states that as balance improves, contact time and the
percentage difference between right and left contact times
will decrease.
Participants were asked to stand between the OptoGaits
sensors with shoes off facing the assessor. They were read a
script asking them to march in place with a purpose, quickly,
but comfortably, for 40 seconds.They were instructed to try
and get their knees to 90° and that they would be doing this
2 times, the first time with their eyes openand the second time
with their eyes closed. In the event that the participant
marched out of the testing area, the test was redone
immediately.
25
This protocol has not yet been reported to
be a valid measurement of dynamic balance.
Breathing Assessment. This test was taken from a full-body
assessment of functional movement by Leibenson.
17
It was
used in this study as a marker to monitor response to training
for conversion from apical to diaphragmatic breathing.
Breathing assessment (BA) has not been assessed for
reliability but has face validity in that the mechanics that
distinguish breathing styles can be observed.
Participants were asked to lay on their backs in the 90/90/
90 position (hips and knees 90° flexed with feet dorsiflexed).
Their legs were supported by the assessor while their anterior
170 Journal of Manipulative and Physiological TherapeuticsStephens et al
March/April 2017Effect of Breathing Type on Balance
inferior rib cage was brought into a caudal position, supporting
their thoracolumbar junction. They were asked to maintain that
position while breathing predominantly with their diaphragm.
They were cued to filltheir inferior abdomen and posterior
chest wall. Palpatory cues were used by the assessor.
Participants were then asked to support their legs in the 90/
90/90 position while the assessor released support. Breathing
scorewerebasedonthepatients ability to maintain breathing
biomechanics and posture after their legs had been released.
Scores ranged from 0 to 3, where 0 indicates the
participant is having pain performing the test (and will no
longer be eligible to participate in this study); 1 indicates the
participant is not able to complete the exercise with proper
form; 2 indicates the participant is able to complete the
exercise but with compensation; and 3 indicates the
participant is able to complete the exercise with proper form.
Participants scored a 1 if they had paradoxical respiration
(chest moving inward with inspiration), were unable to
stabilize their ribs when cued, or were unable to stabilize their
ribs when released. Participants scored a 2 if they had chest
breathing predominately on inhalationor a lower rib cage that
did not widen laterally, or if release of their legs caused
anterior inferior rib cage flair. This scale has not been tested
for reliability, validity, or sensitivity to change.
Participant Monitoring. Participants were asked to report
on their activity levels in the 6 months prior to initiating
the study, as well as their physical activity outside of the
study while completing the breathing exercises. Participants
completed daily homework logs and returned them at the end
of the 8 weeks to confirm they had completed the required
exercises. In the final interview, participants were also asked
to give their subjective impressions of the benefits of the
program on their physical activities.
Intervention
Participants were assigned 2 exercises a week. They were
asked to complete each breathing exercise for 5 minutes, twice
daily, for a total of 20 minutes a day at least 5 days per week.
Instruction and feedback were given to participants on
assessment days. A YouTube video of their prescribed
exercises was emailed to them weekly. All exercises were
prescribed in a sequential order and were dependent on the
patient's ability to maintain proper form. All participants
started at progression 1. They were asked to record their
homework in a provided log. Participants were instructed to
do exercises for only as long as they could maintain proper
posture. If they were not able to hold the posture for the full
5 minutes, they were instructed to take breaks and work up to
the 5 minutes.
Five exercise progressions were designed for the purposes
of this study: progression 1: supine breathing and crocodile
breathing; progression 2: supine breathing with Theraband
(The Hygenic Corp, Akron, OH) and crocodile breathing
with Theraband; progression 3: supine breathing with belt
and crocodile breathing; progression 4: seated breathing and
90/90/90 breathing; progression 5: Seated breathing with
Theraband and 90/90/90 breathing with belt.
Supine Breathing. Patients were instructed to lay supine,
knees bent with arms wherever it felt comfortable. They were
cued to focus on breathing with their diaphragm, the breath
filling into their lower abdomen and posterior chest wall. They
were cued to keep their ribs depressed and thoracolumbar
junction supported and to keep their shoulders and neck relaxed.
Crocodile Breathing. Patients were instructed to lay prone
with their hands in a diamond shape supporting their
forehead. They were cued to try and focus on pushing their
ribs out laterally and trying to breathe all the way down to the
sacrum. Duringmeetings, pressure was added to their sacrum
by the examiner, with permission, to help cue this.
Seated Breathing. Participants were seated on a hard
surface with their knees, hip, and ankles all at 90°. They were
told to sit tall, as if a string was pulling them up from the top
of their head,while maintaining all previously discussed
breathing cues: preventing lower rib flair, breathing deeply,
and relaxing their shoulders, neck and arms.
90/90/90 Breathing. Participants were returned to the 90/90/
90 assessment position, but were asked to hold their legs
while maintaining all previously discussed breathing cues:
controlling their ribs and thoracolumbar junction, breathing
deeply and relaxing their shoulders, neck, and arms.
Breathing With Theraband. A Theraband was added around
the lowerribs to help promote lateral excursion. It was applied
to progress supine, crocodile, or seated breathing exercises.
Breathing With Belt. A Theraband was laid flat on the
ground to look like a belt. It was added in the final exercise
progression to help cue caudal rib position. With all the cues
from previous exercises, a Theraband or belt was placed
under the patients thoracolumbar junction. The patient was
instructed to not let the examiner pull the belt away. At home,
patients were instructed to tie the Theraband around a table or
chair and leave tension in it to simulate the effect of pulling.
Statistical Analysis
The primary analysis consisted of Friedmansanalysisof
variance for nonparametric repeated-measures data to test
whether there were any differences between scores over the
8 weeks of the study. The analysis was conducted separately
for breathing assessment, SLS, and TS scores only. This was
because no errorswere recorded for any baseline or follow-up
data for the DLS, and equipment failure was suspected for the
dynamic balance measurements. A nonparametric analysis
was chosen to avoid distribution concerns in smaller samples.
In a secondary analysis, the linear relationship between the
3 variables and time was determined by regression of each of
the variables on time, using generalized estimating equations
(with an exchangeable correlation structure) to account
for correlation of variables within subjects. The 2 balance
variables were then regressed on the breathing score using
171
Stephens et alJournal of Manipulative and Physiological Therapeutics
Effect of Breathing Type on BalanceVolume 40, Number 3
generalized estimating equations to assess the overall linear
association between balance and breathing over the 8 weeks
of the study. The correlation between balance and breathing
scores at each time point was computed using Spearmans
rank-order correlation coefficient.
This study could detect a large effect size (f=.40)inthe
primary analysis with 80% power at the .05 level of
significance.
26
In the secondary analysis, the study had the
same power to detect a linear effect of 0.01 breath-scale points
per week, 0.20 error in balance per week, and 0.85 error in
balance per breath-scale point. Because this was a preliminary
study, all tests were conducted using the .05 level of
significance without correction for multiple tests. All analysis
was performed using SPSS Version 23 (IBM, Armonk, NY).
RESULTS
A total of 15 persons were screened for this study. One
was ineligible because of a history of cancer; 1 dropped out
after the first visit because of scheduling difficulties related to
a job change. The remaining 13 participants completed the
full 8-week intervention and assessment. There were no
missing data. No notable change was observed in physical
activity in terms of frequency, duration, intensity, or type of
sport outside of the study for any of the participants.
Participants did not participate in any balance-specific
training outside the study during the 8-week intervention.
Participants had a mean age of 33 years and were close to
evenly balanced across sex (Table 1). They had a mean body
mass index of 25.2, but the high number was attributable to
athletic physique. No participants blood pressure was above
130 mm Hg systolic and 80 mm Hg diastolic.
Table 2 lists the means and standard deviations as well as
the medians and interquartile ranges for breath and balance
scores evaluated each week for 8 weeks. All 3 scores exhibited
change over the course of the study as evidenced by statistically
significant differences among time points: breathing type
(Pb.001), SLS (P= .001), and TS (P= .039). Trends toward
improvement over time are also illustrated in Figures 1 and 2.
The regression coefficients (B) quantifying the linear
association between the variables and time were B=0.06
point per week for the breathing test (Pb.001), B=0.48
error per week for the SLS (Pb.001), and B=0.18 error per
week for the TS (P=.089).
There was generally poor correlation between balance and
breathing scores with Spearmansρb0.2atmosttimepoints
as seen in Table 3. None of the correlations was statistically
significant. On the other hand, the regression analysis
revealed a statistically significant relationship between
decreasing error rate in SLS and improvement in breathing
score, B=1.4 errors per unit improvement (Pb.001). This
coupled with the poor correlation across persons at individual
time points suggests that an improvement in SLS perfor-
mance is associated with improvement in the breathing test
within participants over time (and more treatment). The trend
for the TS was smaller in magnitude and did not reach
statistical significance (B=0.5 P=.118).
DISCUSSION
This preliminary study was the first to investigate the
relationship between breathing training and balance. We
observed a shift from apical to diaphragmatic breathing as
treatment progressed (Table 2). This suggests the possibility
that a change in breathing pattern can be engendered by the
conscious muscle recruitment in the prescribed exercises.
Concomitant time trends of shifts in breathing patterns and
improvement in balance also suggest the possibility of a
relationship between breathing training and balance (Table 2,
Fig 1).
Training of respiratory muscles has been reported to
increase diaphragm and low back musculature proprioception,
muscle firing,
23,27
and respiratory muscle strength.
28,29
A
Table 1. Demographics (N = 14)
Variable Mean (SD)
a
Females, n (%) 6 (42.8%)
Age 33 (7.5)
Height, cm, mean (SD) 172 (10)
Weight (lb) 167 (39)
Body mass index (kg/m
2
) 25.2 (4.7)
Systolic blood pressure (mm Hg) 123 (12)
Diastolic blood pressure (mm Hg) 73 (8)
Resting heart rate (beats/min) 64 (10)
a
Values are expressed as the mean (SD) unless otherwise noted.
Table 2. Breathing and Balance Scores
a
Week Breathing Test Single-Leg Stance Tandem Stance
1 1.3 (0.5)
1.0 [1]
7.1 (2.9)
7.0 (4)
3.2 (2.7)
3.0 [5]
2 1.2 (0.4)
1.0 [1]
6.3 (2.4)
7.0 [4]
2.3 (2.4)
2.0 [4]
3 1.6 (0.5)
2.0 [1]
6.2 (2.9)
6.0 [5]
1.8 (2.5)
1.0 [3]
4 1.9 (0.4)
2.0 [0]
5.4 (3.6)
5.0 [4]
1.6 (2.3)
1.0 [3]
5 2.1 (0.5)
2.0 [0]
5.1 (3.5)
5.0 [5]
2.5 (2.4)
3.0 [5]
6 2.2 (0.4)
2.0 [0]
4.2 (2.6)
4.0 [5]
2.0 (2.6)
1.0 [4]
7 2.1 (0.3)
2.0 [0]
4.2 (2.9)
4.0 [6]
2.2 (2.6)
1.0 [5]
8 2.5 (0.5)
2.0 [1]
3.8 (2.1)
4.0 [4]
0.9 (1.1)
0.0 [2]
Pb.001 P= .001 P= .039
a
All scores are for pre-intervention evaluation at baseline (week 1)
and follow-up (weeks 2-8). The mean (SD) and median [interquartile range]
are presented for each time point. Friedmans analysis of variance was used
to determine if there were any statistically significant differences between
time points.
172 Journal of Manipulative and Physiological TherapeuticsStephens et al
March/April 2017Effect of Breathing Type on Balance
diaphragmatic breathing style suggests increased movement
through the lateral inferior ribs and abdomen.
16
As there is
likely increased movement in the deep abdominal muscula-
ture, it is reasonable to assume that there is also increased
muscle firing and proprioception of the deep core musculature
and diaphragm. Furthermore, it is not unlikely that increased
strength would have resulted from increased muscle firing
over an 8-week period.
The improvement in balance was indicated by a decrease in
balance errors in the SLS; such improvement was not observed
for the TS (Table 2). Our findings suggest that the SLS is a
promising outcome measure for future studies. However, we
believe there was a floor effect in TS measurements that
precluded demonstrable improvement of performance in the
study population.
Possible explanations for the increase in balance include,
but are not limited to, the following reasons. There may
have been an increase in muscle firing, proprioception, and
strength through the diaphragm and deep core musculature.
These changes may have been associated with a diaphrag-
matic breathing pattern or breathing exercised independent
of breathing style. Alternatively, there may have been a
learning effect from the weekly balance testing over the
course of the study.
We believe thatthe breathing exercises and corresponding
increase in diaphragmatic breathing style may have increased
the strength ofthe diaphragm and deep core musculature, and
that this increase in strength and proprioception may have
contributed to the increase in balance measured. However,
without control groups, we were unable to discern the effects
1
1.2
1.4
1.6
1.8
2
2.2
2.4
2.6
3.5
4
4.5
5
5.5
6
6.5
7
7.5
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8
Mean Breathing Scores
Mean Single Leg Stance Errors
Mean Single Leg Stance Balance Errors Mean Breathing Score (0-3)
Fig 1. Mean single-leg stance errors versus mean breathing scores over 8-week breathing intervention.
1
1.2
1.4
1.6
1.8
2
2.2
2.4
2.6
0.5
1
1.5
2
2.5
3
3.5
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8
Mean Breathing Scores
Mean Tandem Stance Balance Errors
Mean Tandem Stance Balance Errors Mean Breathing Score (0-3)
Fig 2. Mean tandem stance errors versus mean breathing scores over 8-week breathing intervention.
173Stephens et alJournal of Manipulative and Physiological Therapeutics
Effect of Breathing Type on BalanceVolume 40, Number 3
of balance training on diaphragmatic breathing from other
causes such as learning effect and increase in breathing
musculature independent of breathing style.
During the final assessment participants stated that they
had enjoyed doing the breathing exercises and had noticed
improvements throughout other aspects of their lives that they
associated with the changes in their breathing patterns.
Benefits included feeling more balanced rock climbing,
having less low back pain with long road bike rides, and
feeling stronger while Olympic lifting. The effects of
participation in a research study could not be distinguished
from the effects of the exercise program on perceived benefits.
Limitations
Ours was a small, uncontrolled clinical trial, and all the
usual limitations of such studies apply. The most important
concern is that the relationship observed between balance
and breathing was confounded by the possibility of learning
effects from the weekly balance testing over the course of
the study. Also, breathing data were collected only once per
week, so the extent of change in breathing pattern could not
be clearly ascertained.
Another limitation is that the BA used to monitor breathing
style has not been fully validated. However, the linear
association of BA with the number of training sessions
(time) gives preliminary evidence for test responsiveness. The
association between BA and balance over time supports the
construct validity for monitoring a breathing training program,
because it is consistent with the underlying hypothesis
(construct) that change in breathing style can improve balance.
We did not specifically screen for stroke and transient
ischemic attack, nor did we ask about medication in general
and those that could affect balance in particular. However,
participants were screened for a history of vascular disease
and central nervous system disorders. The participants were
also young, active, healthy individuals, so that it was unlikely
they were on medications that could affect balance.
Our findings in a healthy population should also not be
generalized to clinical populations. In particular, the DLS,
uselesshere because it was completely error free, may provide
valuable information for clinical patients. Findings for the SLS
and TS may also be more impressive for various clinical
conditions. Finally, this study could cast no light on the
usefulness of dynamic balance testing because of suspected
equipment failure, and we could not find any empirical data to
support the OptoGait protocols.
Despite these limitations, the relationship between breathing
and static balance is intriguing and worthy of pursuit with
more sophisticated study designs. As these exercises require
very limited supplies and can be done almost everywhere,
we believe that they could benefit a large portion of the
population. It would be also be interesting to compare the
effects of breathing exercise with traditional core exercises on
sports performance. In addition to benefiting a healthy athletic
population, this information may be helpful for populations
that are at high risk for falls.
CONCLUSION
This preliminary study gives proof-of-concept evidence
that there may be a relationship between breathing and
balance. Further research using experimental design needs
to be conducted to investigate the link between breathing
patterns and balance. If verified, there might be applications
to sports performance in the future.
FUNDING SOURCES AND CONFLICTS OF INTEREST
Theraband donated the Theraband resistance bands for
this study. No funding sources or conflicts of interest were
reported for this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
R.J.S., J.A.S.
Design (planned the methods to generate the results):
R.J.S., J.R.E., J.A.S., A.W.
Supervision (provided oversight, responsible for organiza-
tion and implementation, writing of the manuscript): W.L.M.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data): R.J.S.,
W.L.M., J.R.E., J.A.S., A.W.
Analysis/interpretation (responsible for statistical analysis,
evaluation, and presentation of the results): R.J.S., M.H.
Literature search (performed the literature search): R.J.S.,
J.R.E., J.A.S.
Writing (responsible for writing a substantive part of the
manuscript): R.J.S., W.L.M., M.H.
Critical review (revised manuscript for intellectual content,
this does not relate to spelling and grammar checking):
R.J.S., M.H.
Table 3. Correlation of Balance Scores With Breathing Score
a
Week Single-Leg Stance Tandem Stance
1 0.07 0.11
20.28 0.12
3 0.02 0.00
40.03 0.06
50.05 0.17
60.20 0.09
70.23 0.36
80.42 0.02
a
Spearmans rank-sum correlation coefficient. PN.05.
174 Journal of Manipulative and Physiological TherapeuticsStephens et al
March/April 2017Effect of Breathing Type on Balance
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Practical Applications
A link between breathing patterns and
balance was established.
To our knowledge, this topic has not been
researched.
This evidence suggests further investigation is
warranted.
Potential clinical applications include decreasing
risk of lower extremity injury, increasing
performance, and decreasing risk for falls in
patients at high risk.
175
Stephens et alJournal of Manipulative and Physiological Therapeutics
Effect of Breathing Type on BalanceVolume 40, Number 3
... The findings confirm that CP combined with breathing-based interventions for a short period of time produces better pain relief. A previous report findings from a clinical trial among healthy participants who trained for 8 weeks in various breathing techniques were able to improve the participants' balance scores, giving confidence that the breathing exercise is capable of improving the balance [59]. However, the study reported the improvement in static single leg balance scores of healthy participants [59], whereas our study reported the improvement in balance mean score among CAI participants. ...
... A previous report findings from a clinical trial among healthy participants who trained for 8 weeks in various breathing techniques were able to improve the participants' balance scores, giving confidence that the breathing exercise is capable of improving the balance [59]. However, the study reported the improvement in static single leg balance scores of healthy participants [59], whereas our study reported the improvement in balance mean score among CAI participants. An increase in balance mean score was found to have a larger effect on SDDB from baseline to follow-up, indicating the beneficial effects of ankle rehabilitation in improving the dynamic balance of CAI participants in EG. ...
... An increase in balance mean score was found to have a larger effect on SDDB from baseline to follow-up, indicating the beneficial effects of ankle rehabilitation in improving the dynamic balance of CAI participants in EG. It is evidenced from the literatures that the breathing has the ability to improve the diaphragmatic core muscle strength and thus can improve the participants balance by altering the cortical activation of the brain, which is commonly altered in participants with CAI [9,59]. In accordance with the improvement in pain and balance, the results also reported a significant (p < 0.05) increase in attention score due to SDDB. ...
Article
Full-text available
Background Chronic ankle instability (CAI) is the most common injury in youth sports, which leads to psychological stress from doubting their performance. Cost effective and easy to access tool to reduce the stress among this target group are desired. Therefore, the purpose of this study was to investigate the effect of adding on intervention with short-duration deep breathing (SDDB) alongside with conventional physiotherapy (CP) among young adults with chronic ankle instability (CAI). Methods Total of 30 CAI participants attended physiotherapy, who were randomly assigned into control and experimental groups. The participants in the experimental group received combined intervention (SDDB + CP), and the control group received CP for 6 weeks. The effectiveness of interventions was assessed at 3 intervals with a battery of questionnaires (Visual Analog Score, Cumberland Ankle Instability Tool, Mindful Attention Awareness Scale, and Oxford Happiness Questionnaire) at the end of week 3, week 6, and week 12 as follow-up. A two-way repeated measures of ANOVA was applied to report the statistical significance at p < 0.05. Results The results showed a better improvement in pain, balance, happiness, and mindfulness attention among participants in the experimental group, with a significant improvement in mindful attention over the time point as compared to the control group. Conclusion The findings provide insight into incorporating SDDB additions to the existing CP for better CAI management. Breathing techniques that improve attention and happiness play a vital role in CAI, which recommends the biopsychosocial approach in chronic injury rehabilitation. Trial registration Current Controlled Trials using Clinical Trials Registry under ID number NCT04812158 retrospectively registered on 23/03/2021.
... This is supported by a 2017 study, subjects were able to maintain an upright position with the heel of one foot touching the toe of the other and arms crossed on the shoulder for at least 30 seconds (Laura, 2017). This study is in line with Stephen, it is known that there is an increase in static balance with the Tandem examination after the diaphragmatic breathing exercise intervention for 8 weeks with a p value = 0.039 (Stephens et al., 2017). ...
... The Effect of Diaphragm Muscle Strengthening Exercise Using Incentive Spirometry on Body Balance by Rahman, namely the assessment on the Stork Stand Test is divided based on several levels, namely, very good (> 50), good (40-50), medium (25-39), moderate (10-24), poor ( <10) (Rahman, K, A. 2017). The increase in Single Leg Stance static balance after diaphragmatic breathing exercises was also found by Stephens, it was known that the p value = 0.01 (Stephens, R, J. et al. 2017). Interventions in the form of exercises that target the trunk muscles, especially the inspiratory muscles (diaphragm and intercostals), have been shown to contribute to balance. ...
... This study was also strengthened by Stephens in 2017, that diaphragmatic breathing exercise for 8 weeks could be associated with an increase in balance parameters, the significance value in this study showed a significant increase, namely p = 0.001 (Stephens et al., 2017). The results of this study are also in line with research in 2017, which stated that there was an effect of abdominal breathing exercises on postural stability, with a significance value of <0.05 in the initial and final measurements of the two groups in all variables (Miketa et al., 2017). ...
Article
Full-text available
Based on data that has been reported by WHO, every year it is estimated that 684,000 people die cause of falls, which means that there is a failure in postural control. Postural control is known to have a relationship with diaphragmatic muscle contraction, with the intra-abdominal pressure produced by each contraction causing eccentric muscle contractions that affect postural stability. This study was conducted to determine the effect of diaphragmatic muscle strengthening exercises on body balance. This study used a pre-experimental design with one group pre and post test types. This study included 21 students. The diaphragmatic muscle strengthening exercises was held 4 weeks online. The pre-test and post-test of balance were held in the Faculty of Medicine and Health Sciences, Bengkulu University. Sampling techique that has been used is non-probability purposive sampling. The impact of two variables was analyzed using Paired T-Test. The results showed that diaphragmatic muscle strengthening exercises had a significant effect on body balance with a significance value of 0.000. The static and dynamic balance of the students of the Faculty of Medicine and Health Sciences, Bengkulu University was normal and increased after being given diaphragmatic muscle strengthening exercises. Diaphragm muscle strengthening exercises have a significant effect on student body balance.
... The CORE plays a fundamental role in postural control and constitutes an anatomical and functional system that serves as the center for the kinetic chains involved in all bodily movements. It is influenced by changes in intraabdominal pressure orchestrated by diaphragmatic contraction, which gives the diaphragm an important role in trunk stability (17)(18)(19). During inhalation, it increases intra-abdominal pressure, thereby enhancing stability (20). ...
... Conversely, abnormal breathing patterns and reduced respiratory capacities could influence postural control. Even in healthy subjects, a relationship between respiratory patterns and balance has been identified (18). ...
Article
Full-text available
Introduction Fatigue, postural control impairments, and reduced respiratory capacities are common symptoms in persons diagnosed with Multiple Sclerosis (MS). However, there is a paucity of evidence establishing correlations among these factors. The aim of this study is to analyze respiratory function in persons with MS compared to the control group as well as to analyze the relationship between fatigue, respiratory function and postural control in persons with MS. Materials and methods A total of 17 persons with MS and 17 healthy individuals were enrolled for this cross-sectional study. The evaluated parameters included fatigue assessed using the Visual Analog Scale-fatigue (VAS-F) and the Borg Dyspnea Scale, postural control assessed through the Mini Balance Evaluation System Test (Mini-BESTest), Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Trunk Impairment Scale (TIS); and respiratory capacities measured by Maximum Inspiratory Pressure (MIP), Maximum Expiratory Pressure (MEP), Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), FEV1/FVC ratio, Diaphragmatic excursion and diaphragmatic thickness. Results A very high correlation was observed between the Borg Dyspnoea Scale and the BBS (r = −0.768), TUG (0.867), and Mini-BESTest (r = −0.775). The VAS-F exhibited an almost perfect correlation solely with the TUG (0.927). However, none of the variables related to fatigue exhibited any correlation with the respiratory variables under study. Balance-related variables such as BBS and Mini-BESTest demonstrated a very high and high correlation. Respectively, with respiratory function variables MEP (r = 0.783; r = 0.686), FVC (r = 0.709; r = 0.596), FEV1 (r = 0.615; r = 0.518). BBS exhibited a high correlation with diaphragmatic excursion (r = 0.591). Statistically significant differences were noted between the persons with MS group and the control group in all respiratory and ultrasound parameters except for diaphragmatic thickness. Conclusion The findings suggest that decreased postural control and balance are associated with both respiratory capacity impairments and the presence of fatigue in persons with MS. However, it is important to note that the alterations in respiratory capacities and fatigue are not mutually related, as indicated by the data obtained in this study. Discrepancies were identified in abdominal wall thickness, diaphragmatic excursion, and respiratory capacities between persons with MS and their healthy counterparts.
... It is possible to give subjective feedback on the movement of the boat by pushing the floor by itself, and it can also be applied to breathing resistance exercises by using the body weight as resistance (17). Crocodile breathing was effective in reducing pain, muscle tone, and stiffness in patients with low back pain, and was reported to be effective in activating core muscles (18). ...
... As a result of his study, the reported that there was an improvement in respiratory function in both the core stabilization group and the diaphragm, breathing group, but there was no significant difference between the groups. Stephens et al. (18) reported that when archers were trained to strengthen respiratory muscles and core stabilization exercises were combined, they were effective in improving breathing and balance abilities. Park and Lee (22) reported that respiratory resistance exercise combined with lumbar stabilization exercise was more effective in reducing pain, improving psychological stability, and improving motor and breathing functions, compared to the group applying only lumbar stabilization exercise. ...
... The authors did state that the dynamic balance testing done could have been flawed due to equipment malfunction with addition to no empirical data to support OptoGait protocol use in research studies (Stephens et al., 2017). ...
... Second, the impact of DB may vary based on how severe the ailment is. For example, DB may be detrimental to patients experiencing dyspnea due to severe COPD (Stephens 2017). ...
Chapter
Full-text available
Breathe Well is a program that uses an active and engaging approach to give people the tools they need to take control of their lung health. The program places a strong emphasis on the benefits of regular exercise, deep breathing techniques, respiratory muscle training etc the integration of yoga and mind-body activities into the Breathe Well program offers a comprehensive approach that enhances lung capacity, flexibility, and stress management. Respiratory health, which includes respiratory system health, is essential to our general well-being and day-today activities.
... Second, the impact of DB may vary based on how severe the ailment is. For example, DB may be detrimental to patients experiencing dyspnea due to severe COPD (Stephens 2017). ...
Chapter
Breathe Well is a program that uses an active and engaging approach to give people the tools they need to take control of their lung health. The program places a strong emphasis on the benefits of regular exercise, deep breathing techniques, respiratory muscle training etc the integration of yoga and mind-body activities into the Breathe Well program offers a comprehensive approach that enhances lung capacity, flexibility, and stress management. Respiratory health, which includes respiratory system health, is essential to our general well-being and day-today activities.
... It has been demonstrated that stress and anxiety have a modulatory effect on ANS activity and on breathing rate (70)(71)(72). Furthermore, irregular breathing involving shallow and/ or deep rapid breathing patterns and periods of apnea, has been shown to modulate the ANS leading to excitation of the nervous system (70,73,74). With regards to motor control, research has shown that breathing pattern can alter the effectiveness of core musculature used for functional tasks (75)(76)(77). ...
Article
Full-text available
Advances in our understanding of postural control have highlighted the need to examine the influence of higher brain centers in the modulation of this complex function. There is strong evidence of a link between emotional state, autonomic nervous system (ANS) activity and somatic nervous system (somatic NS) activity in postural control. For example, relationships have been demonstrated between postural threat, anxiety, fear of falling, balance confidence, and physiological arousal. Behaviorally, increased arousal has been associated with changes in velocity and amplitude of postural sway during quiet standing. The potential links between ANS and somatic NS, observed in control of posture, are associated with shared neuroanatomical connections within the central nervous system (CNS). The influence of emotional state on postural control likely reflects the important influence the limbic system has on these ANS/somatic NS control networks. This narrative review will highlight several examples of behaviors which routinely require coordination between the ANS and somatic NS, highlighting the importance of the neurofunctional link between these systems. Furthermore, we will extend beyond the more historical focus on threat models and examine how disordered/altered emotional state and ANS processing may influence postural control and assessment. Finally, this paper will discuss studies that have been important in uncovering the modulatory effect of emotional state on postural control including links that may inform our understanding of disordered control, such as that observed in individuals living with Parkinson’s disease and discuss methodological tools that have the potential to advance understanding of this complex relationship.
Article
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Introduction: The diaphragm is one of the most significant skeletal muscles in the human body, performing vital respiratory functions. It is not only the primary inspiratory muscle but is also involved in non respiratory activities and plays a dynamic role in Postural stabilisation. Low Back Pain (LBP) is the leading cause of disability worldwide, presenting a significant health issue that imposes substantial social and economic costs on both the community and healthcare systems. Although the precise cause of non specific LBP is still unknown, its progression has been greatly affected by mechanical factors that are generally agreed upon. Aim: To determine the effect of diaphragmatic breathing exercises on hamstring length and functional disability in subjects with chronic LBP. Materials and Methods: A single-group pre- to post-test quasi-experimental study was conducted with 66 subjects at the Padmashree Rehabilitation Centre, Bengaluru, Karnataka, India from June 2023 to August 2023. Ethical clearance was obtained from the Padmashree Institutional Ethical Committee, and the subjects were recruited based on specific selection criteria. Baseline variables, including age, gender, and Body Mass Index (BMI), were recorded. The main outcomes measured were the Active Knee Extension (AKE) test and the Oswestry Disability Index (ODI) Questionnaire. Values before and after the intervention were recorded and a paired sample t-test was used to compare the scores before and after the intervention. Results: The pretest mean score was 27.85±2.40, while the post-test mean score was 24.77±2.26 (AKE RT). The paired t-test indicated a significant improvement in AKE postintervention for both the right and left lower limb (p-value<0.001). The ODI scores significantly decreased from a pretest mean of 40.41±12.86 to a post-test mean of 36.30±10.08 (p-value<0.001). Conclusion: The diaphragmatic breathing exercise demonstrated a significant improvement in AKE scores and the disability index. The improvements were statistically significant, indicating the effectiveness of the intervention in enhancing flexibility and reducing disability in participants with chronic LBP.
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Although sophisticated forceplate systems are available for postural stability analyses, their use is limited in many sports medicine settings because of budgetary constraints. The purpose of this investigation was to compare a clinical method of evaluating postural stability with a force-platform sway measure. Participants completed a battery of three stance variations (double, single, and tandem) on two different surfaces (firm and foam) while standing on a force platform. This arrangement allowed for simultaneous comparisons between forceplate sway measures and clinical assessments using the Balance Error Scoring System (BESS). Significant correlations were revealed for the single-leg and tandem stances on the firm surface and for double, single, and tandem stances on the foam surface. These results suggest that the BESS is a reliable method of assessing postural stability in the absence of computerized balance systems.
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To compare electromyographic (EMG) activity in young-adult subjects with different breathing types. This study included 50 healthy male subjects with complete natural dentition, and no history of orofacial pain or craniomandibular-cervical-spinal disorders. Subjects were classified into two groups: upper costal breathing type, and costo-diaphragmatic breathing. Bipolar surface electrodes were located on sternocleidomastoid, diaphragm, external intercostal, and latissimus dorsi muscles. Electromyographic activity was recorded during the following tasks: (1) normal quiet breathing; (2) speaking the word 'Mississippi'; (3) swallowing saliva; and (4) forced deep breathing. Sternocleidomastoid and latissimus dorsi EMG activity was not significantly different between breathing types, whereas diaphragm and external intercostal EMG activity was significantly higher in the upper costal than costo-diaphragmatic breathing type in all tasks (P<0·05; Wilcoxon signed rank-sum test). Diaphragm and external intercostal EMG activity suggests that there could be differences in motor unit recruitment strategies depending on the breathing type.
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Objectives Two distinct types of specific respiratory muscle training (RMT), i.e. respiratory muscle strength (resistive/threshold) and endurance (hyperpnoea) training, have been established to improve the endurance performance of healthy individuals. We performed a systematic review and meta-analysis in order to determine the factors that affect the change in endurance performance after RMT in healthy subjects. Data sources A computerized search was performed without language restriction in MEDLINE, EMBASE and CINAHL and references of original studies and reviews were searched for further relevant studies. Review methods RMT studies with healthy individuals assessing changes in endurance exercise performance by maximal tests (constant load, time trial, intermittent incremental, conventional [non-intermittent] incremental) were screened and abstracted by two independent investigators. A multiple linear regression model was used to identify effects of subjects’ fitness, type of RMT (inspiratory or combined inspiratory/expiratory muscle strength training, respiratory muscle endurance training), type of exercise test, test duration and type of sport (rowing, running, swimming, cycling) on changes in performance after RMT. In addition, a meta-analysis was performed to determine the effect of RMT on endurance performance in those studies providing the necessary data. Results The multiple linear regression analysis including 46 original studies revealed that less fit subjects benefit more from RMT than highly trained athletes (6.0% per 10mL · kg−1 · min−1 decrease in maximal oxygen uptake, 95% confidence interval [CI] 1.8, 10.2%; p = 0.005) and that improvements do not differ significantly between inspiratory muscle strength and respiratory muscle endurance training (p = 0.208), while combined inspiratory and expiratory muscle strength training seems to be superior in improving performance, although based on only 6 studies (+12.8% compared with inspiratory muscle strength training, 95% CI 3.6, 22.0%; p = 0.006). Furthermore, constant load tests (+16%, 95% CI 10.2, 22.9%) and intermittent incremental tests (+18.5%, 95% CI 10.8, 26.3%) detect changes in endurance performance better than conventional incremental tests (both p<0.001) with no difference between time trials and conventional incremental tests (p=0.286). With increasing test duration, improvements in performance are greater (+0.4% per minute test duration, 95% CI 0.1, 0.6%; p = 0.011) and the type of sport does not influence the magnitude of improvements (all p>0.05). The meta-analysis, performed on eight controlled trials revealed a significant improvement in performance after RMT, which was detected by constant load tests, time trials and intermittent incremental tests, but not by conventional incremental tests. Conclusion RMT improves endurance exercise performance in healthy individuals with greater improvements in less fit individuals and in sports of longer durations. The two most common types of RMT (inspiratory muscle strength and respiratory muscle endurance training) do not differ significantly in their effect, while combined inspiratory/expiratory strength training might be superior. Improvements are similar between different types of sports. Changes in performance can be detected by constant load tests, time trials and intermittent incremental tests only. Thus, all types of RMT can be used to improve exercise performance in healthy subjects but care must be taken regarding the test used to investigate the improvements.
Article
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Purpose: We have shown that individuals with recurrent nonspecific low back pain (LBP) and healthy individuals breathing against an inspiratory load decrease their reliance on back proprioceptive signals in upright standing. Because individuals with LBP show greater susceptibility to diaphragm fatigue, it is reasonable to hypothesize that LBP, diaphragm dysfunction, and proprioceptive use may be interrelated. The purpose of this study was to investigate whether inspiratory muscle training (IMT) affects proprioceptive use during postural control in individuals with LBP. Methods: Twenty-eight individuals with LBP were assigned randomly into a high-intensity IMT group (high IMT) and low-intensity IMT group (low IMT). The use of proprioception in upright standing was evaluated by measuring center of pressure displacement during local muscle vibration (ankle, back, and ankle-back). Secondary outcomes were inspiratory muscle strength, severity of LBP, and disability. Results: After high IMT, individuals showed smaller responses to ankle muscle vibration, larger responses to back muscle vibration, higher inspiratory muscle strength, and reduced LBP severity (P < 0.05). These changes were not seen after low IMT (P > 0.05). No changes in disability were observed in either group (P > 0.05). Conclusions: After 8 wk of high IMT, individuals with LBP showed an increased reliance on back proprioceptive signals during postural control and improved inspiratory muscle strength and severity of LBP, not seen after low IMT. Hence, IMT may facilitate the proprioceptive involvement of the trunk in postural control in individuals with LBP and thus might be a useful rehabilitation tool for these patients.
Article
Full-text available
Two distinct types of specific respiratory muscle training (RMT), i.e. respiratory muscle strength (resistive/threshold) and endurance (hyperpnoea) training, have been established to improve the endurance performance of healthy individuals. We performed a systematic review and meta-analysis in order to determine the factors that affect the change in endurance performance after RMT in healthy subjects. A computerized search was performed without language restriction in MEDLINE, EMBASE and CINAHL and references of original studies and reviews were searched for further relevant studies. RMT studies with healthy individuals assessing changes in endurance exercise performance by maximal tests (constant load, time trial, intermittent incremental, conventional [non-intermittent] incremental) were screened and abstracted by two independent investigators. A multiple linear regression model was used to identify effects of subjects' fitness, type of RMT (inspiratory or combined inspiratory/expiratory muscle strength training, respiratory muscle endurance training), type of exercise test, test duration and type of sport (rowing, running, swimming, cycling) on changes in performance after RMT. In addition, a meta-analysis was performed to determine the effect of RMT on endurance performance in those studies providing the necessary data. The multiple linear regression analysis including 46 original studies revealed that less fit subjects benefit more from RMT than highly trained athletes (6.0% per 10 mL · kg⁻¹ · min⁻¹ decrease in maximal oxygen uptake, 95% confidence interval [CI] 1.8, 10.2%; p = 0.005) and that improvements do not differ significantly between inspiratory muscle strength and respiratory muscle endurance training (p = 0.208), while combined inspiratory and expiratory muscle strength training seems to be superior in improving performance, although based on only 6 studies (+12.8% compared with inspiratory muscle strength training, 95% CI 3.6, 22.0%; p = 0.006). Furthermore, constant load tests (+16%, 95% CI 10.2, 22.9%) and intermittent incremental tests (+18.5%, 95% CI 10.8, 26.3%) detect changes in endurance performance better than conventional incremental tests (both p < 0.001) with no difference between time trials and conventional incremental tests (p = 0.286). With increasing test duration, improvements in performance are greater (+0.4% per minute test duration, 95% CI 0.1, 0.6%; p = 0.011) and the type of sport does not influence the magnitude of improvements (all p > 0.05). The meta-analysis, performed on eight controlled trials revealed a significant improvement in performance after RMT, which was detected by constant load tests, time trials and intermittent incremental tests, but not by conventional incremental tests. RMT improves endurance exercise performance in healthy individuals with greater improvements in less fit individuals and in sports of longer durations. The two most common types of RMT (inspiratory muscle strength and respiratory muscle endurance training) do not differ significantly in their effect, while combined inspiratory/expiratory strength training might be superior. Improvements are similar between different types of sports. Changes in performance can be detected by constant load tests, time trials and intermittent incremental tests only. Thus, all types of RMT can be used to improve exercise performance in healthy subjects but care must be taken regarding the test used to investigate the improvements.
Data
54 ▸ Additional material is published online only. To view these files please visit the journal online (http://dx.doi. org/10.1136/bjsports-2013-092313). To cite: McCrory P, Meeuwisse WH, Aubry M, et al. Br J Sports Med 2013;47:250–258. PREAMBLE This paper is a revision and update of the recommen-dations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012. 1–3 The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further concep-tual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. This document is developed primarily for use by physi-cians and healthcare professionals who are involved in the care of injured athletes, whether at the recre-ational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document, the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and/or the Child SCAT3 card and none are subject to any restrictions, provided they are not altered in any way or con-verted to a digital format. The authors request that the document and/or the accompanying tools be dis-tributed in their full and complete format. This consensus paper is broken into a number of sections 1. A summary of concussion and its management, with updates from the previous meetings; 2. Background information about the consensus meeting process; 3. A summary of the specific consensus ques-tions discussed at this meeting; 4. The Consensus paper should be read in conjunc-tion with the SCAT3 assessment tool, the Child SCAT3 and the CRT (designed for lay use).
Article
Context: Core training specifically for track and field athletes is vague, and it is not clear how it affects dynamic balance and core-endurance measures. Objective: To determine the effects of a 6-week core-stabilization-training program for high school track and field athletes on dynamic balance and core endurance. Design: Test-retest. Setting: High school in north central West Virginia. Participants: Thirteen healthy high school student athletes from 1 track and field team volunteered for the study. Interventions: Subjects completed pretesting 1 wk before data collection. They completed a 6-wk core-stabilization program designed specifically for track and field athletes. The program consisted of 3 levels with 6 exercises per level and lasted for 30 min each session 3 times per week. Subjects progressed to the next level at 2-wk intervals. After 6 wk, posttesting was conducted Main outcome measures: The subjects were evaluated using the Star Excursion Balance Test (SEBT) for posteromedial (PM), medial (M), and anteromedial (AM) directions; abdominal-fatigue test (AFT); back-extensor test (BET); and side-bridge test (SBT) for the right and left sides. Results: Posttest results significantly improved for all 3 directions of the SEBT (PM, M, and AM), AFT, BET, right SBT, and left SBT. Effect size was large for all variables except for PM and AM, where a moderate effect was noted. Minimal-detectable-change scores exceeded the error of the measurements for all dependent variables. Conclusion: After the 6-wk core-stabilization-training program, measures of the SEBT, AFT, BET, and SBT improved, thus advocating the use of this core-stabilization-training program for track and field athletes.
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The diaphragm plays an important role in spinal control. Increased respiratory demand compromises spinal control, especially in individuals with low back pain (LBP). The objective was to determine whether individuals with LBP exhibit greater diaphragm fatigability compared to healthy controls. Transdiaphragmatic twitch pressures (TwPdi) were recorded in 10 LBP patients and 10 controls, before and 20 and 45minutes after inspiratory muscle loading (IML). Individuals with LBP showed a significantly decreased potentiated TwPdi, 20minutes (-20%) (p=0.002) and 45minutes (-17%) (p=0.006) after IML. No significant decline was observed in healthy individuals, 20minutes (-9%) (p=0.662) and 45minutes (-5%) (p=0.972) after IML. Diaphragm fatigue (TwPdi fall ≥10%) was present in 80% (20minutes after IML) and 70% (45minutes after IML) of the LBP patients compared to 40% (p=0.010) and 30% (p=0.005) of the controls, respectively. Individuals with LBP exhibit propensity for diaphragm fatigue, which was not observed in controls. An association with reduced spinal control warrants further study.
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The purpose of this study was to perform a systematic review to determine if respiratory muscle training (RMT) improves sport performance, and respiratory muscle strength and endurance. Methodology followed the Cochrane Collaboration protocol. MEDLINE, CINAHL, SPORTDiscus, PEDro, EMBASE, EBM reviews, and COCHRANE electronic databases were searched until July 2011. Articles were included if: (1) participants were athletes; (2) RMT was compared to sham or control in a randomized controlled design and included outcomes of respiratory muscle and sport performance; (3) published in English. Quality assessment using PEDro and data abstraction was performed by two authors. Outcomes evaluated were measures of sport performance, exercise capacity, spirometry, and respiratory muscle strength and endurance. Metaanalyses were performed on outcomes reported in two or more papers. Results of this systematic review revealed that of the 6,918 citations retrieved from the search strategy, twenty-one met the inclusion criteria. Meta-analyses demonstrated a significant positive effect of RMT on sport performance outcomes of time trials, exercise endurance time and repetitions on Yo Yo tests. Inspiratory muscle strength and endurance improved in most studies, which in part, was dependent on the type of RMT employed. Determination of the type of athlete that may benefit most from RMT was limited by small sample sizes, differing RMT protocols, and differences in outcome measures across studies. In conclusion, RMT can improve sport performance. Closer attention to matching the ventilatory demands of RMT to those required during athletic competition and more aggressive progression of training intensity may show greater improvements in future studies.