Allow natural breathing with abdominal muscle biofeedback [1, 2]

When I allowed my lower abdomen to expand during inhalation without any striving and slightly constrict during exhalation, breathing was effortless.  At the end of exhalation, I just paused  and then the air flowed in without any effort.  I felt profoundly relaxed and safe. With each effortless breath my hurry-up sickness dissipated.

Effortless breathing from a developmental perspective is a whole body process previously described by the works of Elsa Gindler, Charlotte Selver and Bess M. Mensendieck  (Brooks, 1986; Bucholtz, 1994; Gilbert 2016, Mensendieck, 1954). These concepts underlie the the research and therapeutic approach of  Jan van Dixhoorn (2008, 2014) and is also part of the treatment processes of Mensendieck/Cesar therapists (Profile Mensendeick) .  During inhalation the body expands and during exhalation the body contracts. While sitting or standing, during exhalation the abdominal wall contracts and during inhalation the abdominal wall relaxes.  This whole body breathing pattern is often absent in clients who tend to lift their chest and do not expand or sometimes even constrict their abdomen when they inhale . Even if their breathing includes some abdominal movement, often only the upper abdomen above the belly button moves while the lower abdomen shows limited or no movement. This may be associated with physical and emotional discomfort such as breathing difficulty, digestive problems, abdominal and pelvic floor pains, back pain, hyper vigilance, and anxiety. (The background, methodology to monitor and train with muscle biofeedback, and pragmatic exercises are described in detail in our recent published article, Peper, E., Booiman, A.C, Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49.)

Some of the major factors that contribute to the absence of abdominal movement during breathing are (Peper et, 2015):

1. ‘Designer jean syndrome’ (the modern girdle): The abdomen is constricted by a waist belt, tight pants or slimming underwear such as Spanx and in former days by the corset as shown in Figure 1 (MacHose & Peper, 1991; Peper & Tibbitts, 1994).

1. Self-image: The person tends to pull his or her abdomen inward in an attempt to look slim and attractive.
2. 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.
3. Learned disuse: The person covertly learned to inhibit any movement in the abdominal wall to protect themselves from experiencing pain because of prior abdominal injury or surgery (e.g., hernia or cesarean), abdominal pain (e.g., irritable bowel syndrome, dysmenorrhea, vulvodynia, pelvic floor pain, low back pain).
4. Inability to engage abdominal muscles because of the lack of muscle tone.

Figure 1. How clothing constricts abdominal movement.  Previously it was a corset as shown on the left and now it is Spanx or very tight clothing which restricts the waist.

Whether the lower abdominal muscles are engaged or not (either by chronic tightening or lack of muscle activation), the resultant breathing pattern tends to be more thoracic, shallow, rapid, irregular and punctuated with sighst. Over time participants may not able to activate or relax the lower abdominal muscles during the respiratory cycle. Thus it is no longer involved in whole body movement which can usually be observed in infants and young children.

In our published paper by Peper, E., Booiman, A.C, Lin, I-M, Harvey, R., & Mitose, J. (2016), we describe a methodology to re-establish effortless whole body breathing with the use of surface electromyography (SEMG) recorded from the lower abdominal muscles (external/ internal abdominal oblique and transverse abdominis) and strategies to teach engagement of these lower abdominal muscles. Using this methodology, the participants can once again learn how to activate the lower abdominal muscles to flatten the abdominal wall thereby pushing the diaphragm upward during exhalation.  Then, during inhalation they can relax the muscles of the abdominal wall to expand the abdomen and allow the diaphragm to descend as shown in Figure 2.

Figure 2.  Correspondence between respiratory strain gauge changes and SEMG activity during breathing. When the person exhales, the lower abdominal SEMG activity increases and when the person inhales the SEMG decreases.

The published article discusses the factors that contribute to the breathing dysregulation and includes guidelines for using SEMG abdominal recording. It describes in detail–with illustrations–numerous  practices such as tactile awareness of the lower abdomen, active movements such as pelvic rocking and cats and dogs exercises that people can practice to facilitate lower abdominal breathing. One of these practices, Sensing the lower abdomen during breathing, is developed and described by Annette Booiman, Mensendieck therapist

Sensing the lower abdomen during breathing

The person 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 3.

Figure 3. Hands placed below the belly button to sense the movement of the lower abdomen.

Lower abdominal SEMG feedback is useful in retraining breathing for people with depression, rehabilitation after pregnancy,  abdomen or chest surgery (e.g., Cesarean surgery, hernia, or appendectomy operations), anxiety, hyperventilation, stress-related disorders, difficulty to become pregnant or maintain pregnancy, pelvic floor problems, headache, low back pain, and lung diseases.   As one participant reported:

“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.”

REFERENCES

Brooks, C. V. W. (1986). Sensory Awareness: Rediscovery of Experiencing Through the Workshops of Charlotte Selver. Felix Morrow Pub.

Buchholz, I. (1994). Breathing, voice, and movement therapy: Applications to breathing disorders. Biofeedback and Self-regulation, 19(2), 141-153.

Mensendieck, B.M. (1954). Look better, feel better.  Pymble, NSW, Australia: HarperCollins.

Peper, E., Gilbert, C.D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173-179.

Peper, E., Martinez Aranda, P., & Moss, D. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback.43(2), 103-109.

Peper, E., & Tibbetts, V. (1994). Effortless diaphragmatic breathing. Physical Therapy Products, 6(2), 67-71.

Profile Mensendieck remedial therapy. Dutch Mensendieck Remedial Therapists Association Vereniging van Oefentherapeuten Cesar en Mensendieck (VvOCM)

van Dixhoorn, J. (2008). Whole body breathing. Biofeedback. 3I(2), 54-58

Van Dixhoorn, J. (2014). Indirect approaches to breathing dysregulation.  In: Chaitow, L., Gilbert, C., & Morrison, D. (2014). Recognizing and treating breathing disorders pp. 155-161). Elsevier Health Sciences.

Gilbert, C. (2016). Working with breathing , some early influences. Paper presented at the 47th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Seattle WA, March 9-12, 2016.

1.  Adapted from: Peper, E., Booiman, A., Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49. 

2. .I thank Annette Booiman for her constructive feedback in writing this blog.