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Original Article
Eect of diaphragm breathing exercise applied
on the basis of overload principle
Hae-Yong Lee, PhD1), Song-Hee CH eon, PhD1), Min-Sik Yong, PhD1)*
1) Department of Physical Therapy, Youngsan University: 288 Joonam-ro, Yangsan,
Gyeongsangnam-do, Republic of Korea
Abstract. [Pur pose] The purpose of this study was to examine effects of diaphragm breathing exercise applied
on the basis overload principle on respiratory function. [Subjects and Methods] The subjects of this study were 35
normal adults. They were randomly assigned to t wo group; the maneuver-diaphragm exercise group and self-dia-
phragm exercise group. The respiratory function was evaluated using the CardioTouch 3000S (BIONET, Korea) as
a pulmometry device. [Results] The maneuver-diaphragm exercise was more effective on functional vital capacity
and forced expiratory volume at one second when compared to the self-diaphragm exercise. [Conclusion] According
to the results of this study, although the self-diaphragm exercise did not show effects as much as the maneuver one,
but the self-diaphragm exercise had a similar effects as the maneuver-diaphragm exercise. The self-diaphragmatic
respiration applied on the basis of overload principle may be used as an effective respiratory exercise as a part of
home respiration program.
Key words: Diaphragm, Breathing exercise, Respirator y function
(This article was submitted Feb. 10, 2017, and was accepted Mar. 20, 2017)
INTRODUCTION
When the diaphragm is contracted and descended to be at, several organs within the abdominal cavity are pressed
anteriorly and inferiorly and the abdomen is swelled anteriorly1). During breathing out, the diaphragm is recovered and the
abdominal swelling is reduced2, 3). The diaphragm as an important factor of diaphragmatic respiration plays a key role in
the respiratory pump, respiratory function of controlling breathing, and human posture. Also, the diaphragm is known to
contribute to stability of the trunk by enhancing intra-abdominal pressure to reinforce the lumbar vertebra4, 5).
In particular, there have been many studies related to diaphragmatic respiration; the diaphragmatic respiration has been
used partially in yoga, pilates, and exercises focusing on core stability and emphasized in the eld of alternative medicine6).
The basic principle of reinforcing skeletal muscles is based on the overload principle. The inspiratory muscles including
the diaphragm are known to show morphologic, functional reactions consistent with those of the skeletal muscles of other
regions when proper physiological loads are applied7, 8). The skeletal muscles only show enhancement when at least 60%
of resistance is applied on the basis of overload principle, which should be applied for enhancement of the diaphragm. But,
previous the diaphragm breathing exercises are difcult to dene the exact amount of resistance. Also it can cause errors in
the accuracy when performing each time. For this reason, the effect of self-breathing exercise can be reduced. If the patient
learns the correct breathing exercise from therapists, the self-breathing exercise will also be able to effect similar to the effect
of diaphragm breathing by the therapist. The present study investigated effects of diaphragm breathing exercise applied
overload principle on respiratory function.
J. Phys. Ther. Sci. 2 9: 1054 –1056, 2017
*Corresponding author. Min-Sik Yong (E-mail: Peast4ever@naver.com)
©2017 The Societ y of Physical Therapy Science. Published by IPEC Inc.
This is an open-access article distributed under the terms of the Creative Com mons Att ribut ion Non-Commercial No Derivatives (by-nc-nd)
License <https://creativecommons.org/licenses/by-nc-nd/4.0/>.
The Journal of Physical Therapy Science The Journal of Physical Therapy Science
1055
SUBJECTS AND METHODS
Thirty-ve subjects without any of neuromuscular disorder, orthopedic disorders and cardiopulmonary disorder were re-
cruited, for this study. They were randomly assigned to two group; the maneuver-diaphragm exercise (MDE) group (thirteen
females, four males; age, 21.18 ± 0.23 years; height, 161.88 ± 1.94 cm; weight, 56.19 ± 1.92 kg) and self-diaphragm exercise
(SDE) group (seven females, eleven males; age, 22.17 ± 0.43 years; height, 169.89 ± 1.71 cm; weight, 65.56 ± 2.08 kg). All
the patients understood the purpose of this study and provided their written informed consent prior to their participation, in
accordance with the ethical principles of the Declaration of Helsinki.
The maneuver-diaphragmatic respiration was an up and down motion of the diaphragm, performed by a therapist, who
demonstrated an accurate method of the respiration. A subject in a hooklying position was asked to put his/her hands on the
rectus abdominis muscle immediately below the anterior costal cartilage, and to inhale slowly and deeply only by swelling
his/her abdomen without moving his/her upper chest while relaxing his/her shoulders. Then, the subject exhaled all the air
slowly. During inhalation, the air was breathed in through his/her nose, and his/her abdomen was swollen. After the breathe
was suspended at the last moment, the subject exhaled the air according to the pursed lip breathing, with which the subject
breathed out the air through his/her mouth with his/her lips half-opened and his/her abdomen made hollow. One breathing
consisted of three seconds of inhalation, three seconds of suspension, and six seconds of exhalation. A subject was asked to
put one hand on the chest and the other one on the abdomen, not to show movement of the upper chest.
The maneuver-diaphragmatic respiration was applied in a way that a subject could perform respiration with 11 to 13 of the
Borg rating of perceived exertion scale (RPE) and that the investigator set the tolerable resistance as 11 to 13 of the RPE on
the upper abdomen while the subject inhaled and suspended during the exercise.
The investigator observed the facial expression and breathing of the subject during the exercise, and encouraged him/
her to maintain 11 to 13 of the RPE by showing him/her the RPE. A subject was asked to swell his/her abdomen sufciently
while inhaling. The 30-minute exercise was performed four time per week for four weeks. The self-diaphragm exercise
method was consistent with the method of maneuver-diaphragmatic respiration. The investigator observed the initial week of
performance in order to provide accurate method of respiration and resistance of 11 to 13 of the RPE. In order to conrm that
the subjects underwent the respiratory exercise as a home program, the exercise was lmed and identied.
Subjects were assessed using pre-value and post-value measurement pulmonary function (forced vital capacity; FVC,
forced expiratory volume at one second; FEV1, forced expiratory volume at one second / functional vital capacity; FEV1/
FVC, peak expiratory ow; PEF, slow vital capacity; SVC, tidal volume; TV, expiratory reserve volume; ERV, inspiratory
reserve volume; IRV). The respiratory function was evaluated using the CardioTouch 3000S (BIONET, Korea) as a pul-
mometry device when a subject sat on a chair comfortably. We gave sufcient explanation and demonstration for enhancing
accuracy before measuring. Wilcoxon signed ranks test was used to examine the effects of diaphragm breathing exercises on
the respiratory function and in each group. Statistical analyses were performed using SPSS 21.0 for Windows (SPSS Inc.,
Chicago, IL, USA) with a signicance level of α=0.05
RESU LT S
There was a signicant difference in the FVC, FEV1, PEF, SVC and IRV those of before and after the all breathing
exercise. In addition, there was also a signicant difference in FVC and FEV1 according to the breathing exercise methods
(Table 1).
Tab le 1. Effects of breathing exercise on the respirator y function
SDB MDB
Pre Post Pre Post
FVC (l) 3.15 ± 0.93 3.49 ± 0.84* 2.21 ± 0.99 2.85 ± 0.90*, †
FEV1 (l) 2.91 ± 0.90 3.21 ± 0.73* 1.97 ± 0.95 2.70 ± 0.83*, †
FEV1/FVC (%) 96.56 ± 4.91 93.94 ± 5.95 98.47 ± 2.00 97.19 ± 3.19
PEF (l/s) 6.08 ± 2.09 7.18 ± 2 .16* 4.33 ± 2.00 5.64 ± 1.88*
SVC ( l) 5.43 ± 1.51 6.13 ± 1.35* 4.51 ± 1.63 5.17 ± 1.31*
TV (l) 0.67 ± 0.31 0.61 ± 0.22 0.54 ± 0.31 0.62 ± 0.30
ERV (l ) 1.55 ± 0.71 1.67 ± 0.79 1.46 ± 0.69 1.61 ± 0.48
IRV (l) 3.21 ± 1.17 3.85 ± 0.80* 2.38 ± 0.95 2.95 ± 0.78*
Values are reported as the Mean ± SD.
*p<0.05, within group, †p<0.05, between groups
J. Phys. Ther. Sci. Vol. 29, No. 6, 2017
1056
DISCUSSION
The diaphragm breathing exercise is being performed in a variety of ways. However the exact methods is not xed and the
amount of resistance. In any case, the purpose of diaphragm breathing exercises was strengthening of diaphragm function.
So, the purpose of this study was to examine the effects of diaphragm breathing exercise applied overload principle. The
maneuver-diaphragmatic respiration by the therapists was more effective on FVC and FEV1 when compared to the SDE
group. However, the SDE had a similar effects as the MDE. Indicating that difculty in diaphragmatic respiration due to the
characteristics of diaphragm breathing exercise made the maneuver one more effective. The MDE could receive feedback
during the diaphragm breathing exercise, but not the SDE. Also, the SDE may be performed unwittingly by lowering the
intensity of the breathing exercise. In this way, if the SDE is set to the minimum intensity, it can be as effective as MDE. Also,
the disadvantage of SDE is that it can be supplemented if the patient takes a video and received feedback from the therapist,
or visits a therapist.
The respiratory muscles can be expected to improve respiratory functions by increasing muscular strength and endurance
through various types of exercise. By enhancing ventilation through reinforcing strength and endurance of the respiratory
muscles, respiratory imbalance is improved and tissue oxygenation is promoted to enhance daily life activities and quality
of life9). When compared to outpatient respiratory rehabilitation, home respiratory rehabilitation maintained longer positive
effects of rehabilitation. Efciency and availability of home respiratory rehabilitation can be seen in that the home exercise
is easily mixed within daily life and its effects can be maintained for a long term10). However, to go into or visit a hospital
for respiratory recovery is practically difcult, requires much time, and give the subjects burden of expense and difculty in
adjusting to daily life, and it is needed to develop a program that is easier and cost-efcient for them to perform by themselves
under familiar environment11). The self-diaphragm exercise applied on the basis of overload principle may be used as an
effective respiratory exercise as a part of home respiration program, and can be provided as a new method of respiration
exercise when the overload principle is applied.
ACKNOWLEDGEMENT
This research was supported by Youngsan University Research Grants in 2016.
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