Functional training of the respiratory muscles
THE RATIONALE FOR FUNCTIONAL TRAINING
As was discussed in Chapter 3 (section ‘Non-respiratory functions of the respiratory muscles’), the role of the respiratory muscles extends far beyond that of driving the respiratory pump. This fact explains why most, if not all patients, find walking makes them more breathless than riding a stationary cycle ergometer. However, the contribution of the respiratory muscles to postural control (balance) and core stabilization is not addressed directly in a rehabilitation context. This is surprising because these non-respiratory roles have profound implications for how we should train these muscles to optimize their function and minimize the unpleasant symptoms that they generate. A detailed description of the trunk musculature and its non-respiratory roles can be found in Chapter 3. The current section will focus upon the specific rationale for functional training of the respiratory muscles.
The non-respiratory roles of the respiratory muscles are often brought into conflict with their role in breathing; the external manifestation of this conflict is dyspnoea that is disproportionate to the ventilatory demand of the activity. Similarly, in patients with abnormal respiratory mechanics, muscles that do not normally make a substantive contribution to breathing can become vital contributors to thoracic expansion. This helps to explain why patients become breathless during activities of daily living that engender only modest increases in ventilatory demand, such as dressing and hair washing.
Because of the multiple roles of the trunk muscles, respiratory muscle training cannot be optimized if it is delivered using an exclusively ‘isolationist’ model of training, i.e., if optimal function is to be achieved, the core stabilizing role of the diaphragm must be trained in the context of an activity that challenges core stability. Notwithstanding this, there remains a role for the isolated training of the ‘Foundation’ phase (see Ch. 6), which provides the foundation onto which functional training is built – in other words, an ‘isolate, then integrate’ approach to training.
The rationale for functional respiratory training is identical to the rationale for any kind of functional training. When functional conflicts occur within the muscular system, the risk of system failure can be mitigated by providing the muscles in question with reserve capacity (Foundation inspiratory muscle training: IMT), as well as by establishing specific neural activation patterns as routine through training (Functional IMT).
As was explained in Chapter 5, muscles respond to training in highly specific ways that limit the transferability of training benefits when the training stimulus is non-functional (e.g., an isolated leg extension is unlikely to improve walking performance). In functional training, muscles are subjected to forces during functional movements in order to develop the neuromuscular system in ways that are transferable to real-world activities. To date, a missing element from the functional training repertoire has been any consideration of the role of respiratory muscles (major trunk stabilizers and controllers) in functional movements, and vice versa.
As well as satisfying the demands of breathing, the trunk muscles are responsible for a wide range of movements during activities of daily living, e.g., flexion, extension, rotation, stabilization and so on. Ambulation involves continuous perturbation to postural control whilst simultaneously increasing the demand for breathing. These challenges are exacerbated still further if ambulation is combined with carrying, as the trunk must also be stabilized exerting a compressive influence on the thorax. The respiratory muscles must accommodate all of these functions simultaneously, a requirement that demands specific training.
Although it is commonplace to use functional training techniques in a clinical rehabilitation context, functional training movements are typically undertaken as brief, isolated exercises in which the ventilatory demand remains modest. Thus, these exercises rarely simulate the simultaneous challenge of elevated breathing and functional movement accurately; indeed, it is typical for therapists to seek actively to minimize conflicts between breathing and movement by coaching patients to synchronize breathing movements so that the actions of the inspiratory and expiratory muscles coincide with extension and flexion movements of the trunk. Unfortunately, whilst helpful, this synchronization is rarely achievable in everyday life, with the result that the patients may remain unable to deal with the conflicting requirements of breathing and movement.
In his book on low back disorders, Professor Stuart McGill rightly highlights the specific challenge that elevated ventilation represents to spine stability, as well as the increased risk that it poses for back injury (McGill, 2007). The therapeutic approach suggested by McGill is to undertake a range of stabilizing exercises (e.g., side bridge) immediately after an activity that raises ventilation, the idea being that the resultant hyperpnoea is superimposed on exercises that challenge the stabilizing musculature. The aim is to produce what McGill calls a ‘grooved’ pattern of muscle activation, similar to a rope running in a well-worn slot, so that breathing and stabilization take place simultaneously but without any compromise to either. Often, people cope with their inability to meet the conflicting demands on their respiratory muscles by holding their breath during exercises such as a side bridge. This is clearly a bad ‘groove’ to get stuck in.
The breathing challenge that is recommended in this chapter is not limited to raising ventilatory flow rate (as recommended by McGill); rather, the functional exercises that are recommended will also increase the requirement for inspiratory pressure (force) generation by the inspiratory muscles. These exercises involve breathing against an inspiratory load during functional movements. This is actually no different from using any external resistance during functional training (e.g., elastic resistance or dumbbell); its purpose is to challenge the neuromuscular system's ability to bring about controlled movements.
In addition to providing a stable platform, the respiratory muscles play an important role in postural control during brief perturbations to balance. A good example of this is the automatic, anticipatory activation of specific trunk muscles immediately before large arm movements (see Ch. 3). The role of the diaphragm in this type of postural control is pre-programmed (‘grooved’); this is known because diaphragm activation precedes movements that destabilize the body (Hodges et al, 1997a; Hodges et al, 1997b). However, this automatic activation does not mean that the programme is not dynamic or adaptable; rather, the programme varies according to the movement parameters of the task and according to factors such as the prevailing postural conditions (stable or unstable), muscle fatigue, injury, pain and so on. For muscles that are involved in automatic anticipatory postural adjustments, such as the transversus abdominis, isolated specific training can normalize previously abnormal patterns of motor activation, i.e., restore a programme to normality (‘flip the rope back into the groove’) (Tsao & Hodges, 2008). In other words, isolated voluntary training of muscles involved in automatic anticipatory postural adjustments leads to improvement in complex automatic control strategies. The similarity of the diaphragm's role to that of the transversus abdominis makes it extremely likely that this effect is also present for the diaphragm. Therefore, isolated voluntary training of the diaphragm (the kind of training undertaken during Foundation IMT) most likely enhances its automatic functioning during complex movements. The implications of this pre-programmed role of the diaphragm also need to be considered, and they are incorporated within the guidance on functional training provided below.
Finally, on a practical note, any close-fitting clothing (e.g., bras, waistbands, corsets) will restrict breathing by impeding inspiratory (outward) thoracic and abdominal movements. This needs to be considered in the context of functional training. Patients undertaking their training in loose-fitting exercise clothing will find the benefits diminished when wearing their normal clothing if this is tight fitting, and may be disheartened as a result. It is possible to simulate restrictions imposed by clothing, and this is also addressed in the guidance on functional training provided below.
ASSESSING PATIENT NEEDS
This section will suggest some methods for assessing patients in order to select the most appropriate types of exercise to meet their specific needs. However, by way of an introduction, patient assessment is placed in the context of what has typically been done to assess patients prior to implementing Foundation IMT.
Historically, patients being considered for Foundation IMT have typically been assessed on the basis of their inspiratory muscle function, and specifically their maximal inspiratory pressure (MIP) (see Ch. 6, sections ‘Patient selection’ and ‘Assessment of respiratory muscle function’). However, as was explained in Chapter 6, there are a number of reasons why MIP is not a good predictor of the likely benefits of Foundation IMT, and especially of Functional IMT. First, although reference values for MIP exist, the measurement is not straightforward to undertake, the equations have very poor predictive power (Enright et al, 1994; McConnell & Copestake, 1999) and the definition of ‘weakness’ is primarily statistical and not functional (Enright et al, 1994). Secondly, although patients with a MIP < 60 cmH2O appear to show larger improvements than those with stronger inspiratory muscles (Lotters et al, 2002; Gosselink et al, 2011), those with stronger inspiratory muscles still show an improvement in breathlessness and exercise tolerance after IMT (Lotters et al, 2002). Thirdly, MIP takes no account of the demand side of the demand / capacity relationship of the inspiratory muscles; the closest functional correlates of dyspnoea are not indices of airway obstruction or gas exchange impairment, but rather inspiratory muscle function (O'Donnell et al, 1987; Killian & Jones, 1988) and the degree of lung hyperinflation (O'Donnell et al, 1998; Marin et al, 2001) – in other words, the relative load upon the inspiratory muscles. Finally, in the context of Functional IMT, MIP provides no insight into the conflicts that might exist between the respiratory and non-respiratory functions of the trunk muscles.
Accordingly, the use of functional, patient-centred indices would seem to be the most appropriate way to approach assessing the degree of functional overload of the inspiratory muscles, and thence the most appropriate approach to IMT. For severely incapacitated patients, Foundation IMT may be the most that can be achieved, but for those who are ambulatory, or have the potential to become so, functional training regimens can be developed. Since a functional approach has not been applied to date, there is no empirical evidence to guide the prescription of IMT based upon the demand / capacity imbalance principle. However, in order to ‘get the ball rolling’ in terms of generating functional, patient-centred indices of inspiratory muscle overload, one potential method is suggested below (see section ‘Assessment of load / capacity imbalance’). Prior to this, the assessment of dyspnoea is described briefly; as dyspnoea is not only the primary correlate of load / capacity imbalance, it is also relatively easy to assess.
Assessment of dyspnoea
Dyspnoea can be assessed in three main contexts: (1) by reflection upon the type of everyday tasks that elicit dyspnoea, (2) by quantifying the severity of dyspnoea during exercise using a rating scale, and (3) by quantifying the severity of dyspnoea during loaded breathing using a rating scale. Each has their own pros and cons, and the best ‘picture’ of a given patient's limitations is probably obtained by using a combination of methods.
Reflexive assessment of dyspnoea
Of the many reflexive methods available, two of the most widely used and best supported by evidence are the Medical Research Council (MRC) Scale and the Baseline Dyspnoea Index (BDI) and Transition Dyspnoea Index (TDI) (BDI-TDI). Copies of these instruments can be found in Boxes 7.1 and 7.2A,B, respectively. These scales provide a useful insight into the limitations imposed upon everyday life by dyspnoea. In addition, the BDI-TDI allows changes to be monitored in response to interventions or disease progression.
In addition, patients can be quizzed regarding the specific movements and tasks that elicit dyspnoea, since this information will provide a guide to the type of functional exercises that address these deficits. For example, if patients identify hair brushing / washing as a task that specifically elicits dyspnoea, exercises that simulate this challenge can be selected. If, on the other hand, the patient reports feeling unsteady or off balance when they get out of breath, this may suggest that they have lumbopelvic dysfunction that can be addressed with specific exercises. The following is a list of suggested questions, which is by no means exhaustive:
• What activities cause you to get out of breath, e.g., gardening, drying after bathing?
• How long can you do the activity for before you stop or slow down?
• What position are you in when you get breathless, e.g., standing?
• How breathless are you when you sit / stand / walk / etc. (a rating scale can be used to quantify this)?
• What activities have you changed or stopped doing because of breathlessness, e.g., gardening?
• How have you modified your activities because of breathlessness, e.g., sit instead of stand, use a walking aid?
• Do you ever lose your balance when you are out of breath, or feel that you need to steady yourself?
• Do you get low back pain, or feel your back is weak, or unstable?
Assessment of dyspnoea during exercise
The most commonly used and well-validated scale for the assessment of dyspnoea during exercise is the Category Ratio scale created by Borg (1982, 1998). This is a general intensity scale with ratio properties that can be used to quantify either breathing or limb effort independently, as well as concurrently within the same exercise test (Borg et al, 2010). A copy of the instrument and instructions for its use can be found in Boxes 7.3 and 7.4 respectively. Typically, the scale is presented to the participant periodically during exercise, and they report their perception verbally or by pointing at the scale. This enables symptom profiles to be generated, as well as isolated ratings at specified intensities of exercise. Furthermore, participants can be asked to exercise to a specified level of perceived effort for the purposes of exercise training, or to compare physical capacity between individuals.
Assessment of dyspnoea during loaded breathing
The Borg CR-10 can also be used during a loaded breathing task to assess breathing effort perception and its response to training (Weiner et al, 2000; Magadle et al, 2002; Weiner et al, 2003; Beckerman et al, 2005). Typically, participants breathe against a series of fixed-pressure threshold loads corresponding to unloaded breathing, and 5, 10, 20 and 30 cmH2O. After breathing against each load for 1 minute, participants provide an intensity rating using the Borg CR-10. Ideally, the test should be discontinuous such that each rating is discrete, independent of other ratings and unaffected by accumulated inspiratory muscle fatigue; randomization of load presentation is also recommended. The test is susceptible to differences in breathing pattern, so use of a breathing pacer is advisable (a breathing pacer App can be obtained at www.physiobreathe.com/apps).
No published data are currently available to define normal ranges for this test, but ratings of effort are inversely proportional to inspiratory muscle strength (MIP), and the test also exhibits excellent sensitivity to changes in MIP following IMT (Weiner et al, 2000; Magadle et al, 2002; Weiner et al, 2003; Beckerman et al, 2005). Since no normative data exist currently, it is recommended that practitioners / clinics develop their own methods and normative data for identifying patients with abnormally high ratings of dyspnoea. Notwithstanding the lack of published normative data, a look-up chart can be found in Figure 7.1 (see also section ‘Assessment of load / capacity imbalance’, below). It should also be noted that some patients with asthma may have abnormally low ratings (Kikuchi et al, 1994), which is a contraindication for IMT (see Ch. 6, section ‘Contraindications’).
Figure 7.1 Load / capacity imbalance chart. Chart for assessing the extent of functional imbalance between the combined intrinsic and extrinsic loading of the inspiratory muscles, and the capacity of the inspiratory muscles to deliver inspiratory pressure. After breathing against a given load for 60 seconds, the participant rates their effort using the Borg CR-10 scale. Good = no imbalance and above average inspiratory muscle function.
Normal = no imbalance with normal inspiratory muscle function.
Poor = imbalance such that intrinsic and extrinsic inspiratory loading exceeds inspiratory muscle capacity.
Very poor = large imbalance such that intrinsic and extrinsic inspiratory loading exceeds inspiratory muscle capacity considerably. (The chart is based on unpublished data from McConnell and colleagues.)
Assessment of load / capacity imbalance
The look-up chart in Figure 7.1 can be used to assess the extent to which there is a functional imbalance between the combined, intrinsic and extrinsic loading of the inspiratory muscles and the capacity of the inspiratory muscles to deliver inspiratory pressure. The chart is based upon unpublished data collected from normal individuals and those with respiratory disease by McConnell and colleagues over the course of two decades. To undertake the test, the participant breathes against one to three inspiratory loads using the methods described in the section ‘Assessment of dyspnoea during loaded breathing’, above. The resulting Borg CR-10 rating can then be compared with the rating classifications on the chart.
FUNCTIONAL TRAINING EXERCISES
The remainder of this chapter is devoted to a description of a range of functional inspiratory muscle training (IMT) exercises. Two approaches can be taken to the selection of exercises for a particular patient: (1) use a generic set of around 10 exercises that provides a holistic set of benefits (some suggested workout protocols are provided at the end of this chapter), and (2) create a bespoke set of exercises based upon specific patient weaknesses, e.g., situations and tasks that are particularly challenging for the patient. A combination of these two approaches probably represents an optimal solution.
Underlying principles
Functional IMT should be preceded by a 6-week period of Foundation IMT, and the development of good diaphragm breathing technique (see Ch. 6). When embarking upon the Functional phase of training, it is important to ensure that patients have good technique and exercise form, before adding any resistances. Start patients off by performing each exercise with nothing more than a focus on maintaining slow, deep diaphragmatic breathing throughout. Using an external breathing pacer that provides an auditory cue (obtainable via www.physiobreathe.com/apps) can be very helpful for supporting this process, as well as during the functional exercises themselves. Next add an external resistance to inhalation using an inspiratory muscle-training device (IMTD) set on its minimum load. Gradually increase the load on the IMTD over a period of a few weeks until it reaches the prescribed level for the exercise. See Box 7.5 for guidance regarding abdominal bracing and achieving a neutral spine position, as well as the sections on breath control and load setting in Chapter 6. In addition, consider incorporating IMT into interval training, drills or circuits; the IMT can be introduced into the recovery phase of interval training, or it can be a separate station during a drill or circuit.
Before using these exercises, be sure to note the following principles:
• The limb resistances imposed using cords or bands should be low to begin with, but they can be increased as the training progresses. Don't be too ambitious with the resistance, which is intended primarily to create a postural challenge to the trunk, not to create a resistance-training stimulus to the limbs.
• Ensure elastic resistances are under tension at the start of the exercise (see the previous point for guidance on resistance level).
• For exercises involving hand weights, if these are not available they can be substituted with other items such as cans of food or bags loaded with heavy items.
• For exercises that incorporate abdominal bracing (see section ‘Tips for Bracing and Posture’), add the IMTD only once patients able to force their diaphragm into the braced abdominal compartment.
• The compressive effects of tight clothing can be simulated by wrapping elastic resistance bands around the appropriate areas of the trunk (Fig. 7.3).
Figure 7.2 Neutral spine position; the pelvis is level. (From McConnell AK, 2011. Breathe strong, perform better. Human Kinetics, Champaign, IL, with permission.)
The exercises have been designed specifically to minimize the requirement for special equipment. Below is a list of the equipment used, as well as potential alternatives:
| Ideal equipment | Alternative equipment |
| Inspiratory muscle training device | Pursed lips with braced trunk |
| Swiss ball | Chair with balance cushion |
| Balance cushion | Close foot stance |
| Dumbbells (1–10 kg) | Canned food, small sand bags |
| Small medicine ball (2–10 kg) | Canned food, medium sand bags |
| Step | Stairs |
| Elastic resistance band or cord | |
| Exercise mat | Carpeted area |
| Bounceable ball | |
| Small shopping bag | |
| Chair with and without arms |
Where an IMTD is used during an exercise, the loads to be used will be graded as ‘light’ or ‘moderate’. These correspond to the following ‘repetition maximum’ and maximal inspiratory pressure (MIP) percentage settings:
• Light: equivalent to the 50- to 100-repetition maximum (20–40% of MIP, or an effort rating of 2 to 3 on the Borg CR–10 scale)
• Moderate: equivalent to the 20- to 40-repetition maximum (50–60% of MIP, or an effort rating of 4 to 6 on the Borg CR-10 scale).
The exercises are grouped into four sections: (1) trunk strength and lumbopelvic stabilization exercises, (2) dynamic trunk activation exercises, (3) postural control exercises, and (4) pushing and pulling exercises. Each section is subdivided into exercises with ‘Easy’, ‘Moderate’ and ‘Difficult’ classifications. Within each of these classifications, the challenge can be increased progressively, and this is described as appropriate. It is essential that clinical judgement is applied at all times in relation to the suitability of any given exercise for any given patient. For example, the ‘Difficult’ stretches shown below would be entirely unsuitable for a patient with osteoporotic kyphosis.
During most exercises that involve rhythmic movements, there is a requirement to swap breathing phases halfway through a set, i.e., to switch from inhaling whilst overcoming a resistance (concentric phase) to exhaling. This can be achieved easily by pausing between repetitions and adding half a breath cycle. For example, for a bicep curl, at the end of a series of repetitions where inhalation occurs during the concentric phase, pause with the hands raised, exhale and then inhale as the resistance is lowered (eccentric phase). In this way, the inhalation is switched from the concentric to the eccentric phase of the movement.
Individual workouts should be preceded by stretching and mobilizing exercises (see below). An individual workout should consist of around 10 exercises, with an even mix from each of the four sections. Patients should undertake these functional workouts at least three times per week. On other days, Foundation IMT should be undertaken once daily (at least 3 days per week). The difficulty of the exercises should be increased progressively; firstly by adding resistances, and then by progressing through moderate and difficult classifications. It is also good to vary the exercises from time to time to introduce new challenges.
Some suggested workout protocols are provided at the end of this chapter, and video clips of all exercises are available at www.physiobreathe.com.
Stretching and mobilizing
Developing range of movement is as important for the thorax as it is for any other part of the body. However, the trunk and rib cage are often overlooked when it comes to these activities, despite the fact that these areas include numerous muscles, their attachments, and associated connective tissue (e.g., the rib cage). The rib cage is potentially a huge source of resistance to inhalation, especially in restrictive diseases such as kyphoscoliosis. Any resistance to thoracic expansion increases the work of breathing and the associated perception of breathing effort. The exercises below are grouped into sets of ‘Easy’, ‘Moderate’ and ‘Difficult’ exercises that stretch the trunk in the anterior, posterior and lateral planes, as well as during rotation. Easy and moderate stretches are based on those of Minoguchi et al (2002). These sets can be used to stretch and mobilize the rib cage in order to free-up rib expansion and reduce breathing effort. Each movement should be sustained at maximum range of movement for around 30 seconds.
Diaphragm breathing can be practised during the stretches. In particular, the tension in the trunk muscles that is created during the anterior stretch over a Swiss ball provides a useful resistance for the diaphragm to work against.
Easy
Easy stretching and mobilizing exercises are performed seated on a chair, in the sequence:
(A) anterior trunk stretch
(B) posterior trunk stretch
(C) lateral stretch (perform on both sides)
(D) seated rotation (perform in both directions).
Moderate
Moderate stretches and mobilizing exercises are performed standing on both feet, in the sequence:
(A) upper trunk anterior stretch
(B) standing posterior stretch
(C) standing lateral stretch (perform on both sides)
(D) standing rotation (perform in both directions).
Difficult
Difficult stretches and mobilizing exercises are performed over a Swiss ball, on hands and knees, then lying down, in the sequence:
(A) anterior stretch over Swiss ball
(B) lateral stretch over Swiss ball (perform on both sides)
(C) posterior ‘cat’ stretch
(D) supine rotation (perform in both directions).
Breath control
As was described in Chapter 6, developing breath control is a skill that can and should be practised, because it maximizes breathing efficiency and minimizes the distracting influence of dyspnoea. This can be practised in situations where breathing demand / distress is high; under these conditions, patients should be encouraged to practise deep, slow breath control, and to slow their breathing frequency as much as they can tolerate (a breathing pacer App can be obtained at www.physiobreathe.com/apps). Keeping breathing calm and relaxed under stressful conditions can help to minimize stress and anxiety, and build a sense of mastery.
In addition, below are three further exercises that can help overcome the urge to synchronize breathing with the cadence of movement, which is almost always too high. The exercises involve high-cadence body movements, during which the patient should practise deep, slow, controlled breathing that is deliberately not synchronized with movement (a breathing pacer App can be obtained at www.physiobreathe.com/apps).
Marching on the spot
Procedure:: The patient should march on the spot at a challenging but manageable pace. This exercise will also increase breathing demand, and is therefore more difficult than the Swiss ball bounce. The natural urge will be to synchronize breathing to the cadence of the movement, but this should be replaced by a deep, slow breathing pattern that is deliberately slower than the movement, and asynchronous.
Ball bounce on the spot
Procedure:: The patient should bounce the ball on the spot. This exercise will increase breathing demand slightly, but will also challenge postural control and stabilization. The natural urge will be to synchronize breathing to the cadence of the bouncing, but this should be replaced by a deep, slow breathing pattern that is deliberately slower than the movement, and asynchronous.
Trunk strength and lumbopelvic stability exercises
As was described in Chapter 3, an association has been found between respiratory problems and low back pain. For example, epidemiological data suggest that back pain is more prevalent in women with disorders of continence and respiration than in those without (Smith et al, 2006). Furthermore, physiological data show that the postural function of the diaphragm, abdominal and pelvic floor muscles is reduced by incontinence (Deindl et al, 1994) and respiratory disease (Hodges et al, 2000). Accordingly, it is reasonable to suggest that lumbopelvic stability is impaired in people with respiratory problems, and that correcting this deficit will be beneficial for patients’ back pain as well as their dyspnoea. Typical responses in people who are unable to accommodate the simultaneous demands of both stabilization and breathing are either to suspend breathing or to seek stability from an external support, e.g., wall, furniture or walking aid. Thus, training patients so that they are able to accommodate the demands of stabilization and breathing simultaneously should enhance their functional capacity during a wide range of daily activities.
The exercises below are graded, but in all instances training should commence without any resistance to breathing. During the initial phase of training, the focus should be upon maintaining, deep, slow, controlled breathing throughout. Once this can be achieved, the IMTD can be added to the exercise.
Plank
Benefits:: This is a ‘bread-and-butter’ core exercise for developing trunk strength and lumbopelvic stability. It engages the entire trunk- and pelvic-stabilizing musculature including the diaphragm. This exercise builds ‘inner strength’, facilitating the ability to maintain pelvic stability in the face of large posturally challenging movements of the legs, such as walking and stair climbing. Combining this stabilizing exercise with a breathing challenge ensures that both functions can be performed without compromise to either.
Procedure:: Adopt the starting position shown above for the selected level of difficulty. If using an IMTD, this should be held in the mouth, without using the hands. Once in position, brace the abdominal muscles (maximally) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, inhale forcefully through the IMTD before exhaling slowly and fully for about 4 seconds (breathing rate should be around 12 per minute). Ensure maintenance of a completely straight bodyline and do not allow flexion at the hip or abdomen.
Variations:: To add difficulty, do any of the following: raise one straight leg off the floor and move it toward the ceiling, bring one knee toward the elbow on the same side of the body (as if climbing a rock face), or bring one knee in and underneath the body toward the opposite elbow. As the leg is raised, inhale forcefully through the IMTD before exhaling slowly as it is lowered. Repeat using the opposite leg. Swap breathing phases between sets so that the exhalation occurs as the leg is lifted.
Side bridge
Benefits:: This is another ‘bread-and-butter’ core exercise for developing trunk strength and lumbopelvic stability. It engages the entire trunk- and pelvic-stabilizing musculature including the diaphragm, as well as the back extensors. Superimposing the requirement for increased breathing effort onto this exercise helps ensure that the challenge of keeping the trunk stiff does not lead to a failure to maintain deep, controlled breathing.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (maximally) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, inhale forcefully through the IMTD before exhaling slowly and fully for about 4 seconds (breathing rate should be around 12 per minute). Ensure maintenance of a completely straight bodyline and do not allow flexion at the hip or abdomen.
Bridge
Benefits:: This exercise helps to develop balance between the posterior and anterior muscles of the trunk. When undertaken with a leg lift, the exercise challenges the ability to maintain pelvic alignment (if the unsupported hip drops towards the floor, the deep stabilizers are weak).
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (maximally) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, inhale forcefully through the IMTD before exhaling slowly and fully for about 4 seconds (breathing rate should be around 12 per minute). Ensure maintenance of a completely straight bodyline and do not allow flexion at the hip or abdomen.
Variations:: To add difficulty, raise a straightened leg as high as possible (there is a tendency to sag in the middle or tilt to one side). As the leg is raised, inhale forcefully through the IMTD before exhaling slowly as it is lowered. Repeat using the opposite leg. Swap breathing phases between sets so the exhalation occurs as the leg is lifted.
Plank with lower body instability
Benefits:: This is a slightly more advanced version of the plank in which a postural control dimension is added to the exercise so that trunk stabilization must be maintained under conditions of instability. Because the lower body is the unstable section, the emphasis is on the pelvic stabilizers. This exercise helps to develop control over the linkage between movements of the upper and lower body.
Procedure:: Adopt the starting position shown above for the selected level of difficulty. If using an IMTD, this should be held in the mouth, without using the hands. Once in position, brace the abdominal muscles (maximally) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, inhale forcefully through the IMTD before exhaling slowly and fully for about 4 seconds (breathing rate should be around 12 per minute). Ensure maintenance of a completely straight bodyline and do not allow flexion at the hip or abdomen.
Plank with upper body instability
Benefits:: This is a slightly more advanced version of the plank in which a postural control dimension is added to the exercise so that trunk stabilization must be maintained under conditions of instability. Because the upper body is the unstable section, the emphasis is on the trunk stabilizers. This exercise helps to develop control over the linkage between movements of the upper and lower body.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth, without using the hands. Once in position, brace the abdominal muscles (maximally) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, inhale forcefully through the IMTD before exhaling slowly and fully for about 4 seconds (breathing rate should be around 12 per minute). Ensure maintenance of a completely straight bodyline and do not allow flexion at the hip or abdomen.
Gluteal bridge
Benefits:: This is a good exercise for the gluteals and hamstrings, as well as the trunk and deep pelvic stabilizers. It challenges the ability to breathe effectively during hip extension.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (maximally) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, inhale forcefully through the IMTD before exhaling slowly and fully for about 4 seconds (breathing rate should be around 12 per minute). In the Easy and Difficult versions, ensure maintenance of a completely straight bodyline and do not allow flexion at the hip or abdomen.
Variations:: To add difficulty to the Difficult version, raise one foot off the floor and straighten the leg in line with the rest of the body; hold for 5 seconds. Alternate the raised leg for the duration of the exercise. If the pelvis tilts towards the floor when weight is taken off one foot, this indicates that the deep stabilizers are weak.
Gluteal bridge with upper body instability
Benefits:: This is a slightly more advanced version of the gluteal bridge in which a postural control dimension is added to the exercise. Because the upper body is the unstable section, the emphasis is on the trunk stabilizers. This exercise helps to develop control over the linkage between movements of the upper and lower body.
Procedure:: Adopt the starting position shown above for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (maximally) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, inhale forcefully through the IMTD before exhaling slowly and fully for about 4 seconds (breathing rate should be around 12 per minute). In the Easy and Difficult versions, ensure maintenance of a completely straight bodyline and do not allow flexion at the hip or abdomen.
Variations:: To add difficulty to the Moderate and Difficult versions, raise one foot off the floor and straighten the leg in line with the rest of the body; hold for 5 seconds. Alternate the raised leg for the duration of the exercise. If the pelvis tilts towards the floor when weight is taken off one foot, the deep stabilizers are weak. Be careful to maintain a straight bodyline and to keep the hips level.
Gluteal bridge with lower body instability
Benefits:: This is a slightly more advanced version of the gluteal bridge in which a postural control dimension is added to the exercise. Because the lower body is the unstable section, the emphasis is on the pelvic stabilizers. This exercise helps to develop control over the linkage between movements of the upper and lower body.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (maximally) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, inhale forcefully through the IMTD before exhaling slowly and fully for about 4 seconds (breathing rate should be around 12 per minute). In the Easy and Difficult versions, ensure maintenance of a completely straight bodyline and do not allow flexion at the hip or abdomen.
Variations:: To add difficulty, raise one foot off the support and straighten the leg in line with the rest of the body; hold for 5 seconds. Alternate the raised leg for the duration of the exercise. If the pelvis tilts towards the floor when weight is taken off one foot, the deep stabilizers are weak. Be careful to maintain a straight bodyline and to keep the hips level.
Leg raise
Benefits:: This exercise challenges the pelvic and low back stabilizers during hip flexion. As with other exercises in this sub-section, it challenges the ability to maintain lumbopelvic stability without suspending breathing.
Procedure:: Adopt the starting position shown above for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (maximally) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, please follow the instructions regarding breathing pattern for each level of difficulty. Push the back towards the floor, but concentrate on maintaining a neutral spine (it may help to place the fingers under the small of the back). For Moderate and Difficult versions, raise the feet about 15 to 20 cm (6 to 8 inches) off the floor and brace the abdominal corset muscles (maximally).
Variations:: To add difficulty, extend duration, add ankle weights or move the legs in a continuous scissor action, breathing steadily throughout.
Easy
With the feet lightly in contact with the floor, slide both heels towards the buttocks and return immediately to the start position with a controlled cadence. Inhale forcefully through the IMTD as the heels are moved towards the buttocks and swap breathing phases between sets.
Braced curl-up
Benefits:: During this exercise, the rectus abdominis and other expiratory muscles pull the ribs downwards in an expiratory movement. Developing the ability to inhale under these conditions will enhance the ability to breathe in situations where the body movements and breathing are out of phase in terms of the actions required of the respiratory muscles, i.e., inhaling during non-respiratory activation of expiratory muscles.
Procedure:: Adopt the starting position shown; this is the same for all levels of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (maximally). Curl up and raise the shoulders off the floor 8 to 10 cm (3 to 4 inches), curling into the brace and keeping the neck position neutral (don't allow the chin to rest on the chest). While in the ‘up’ position, take three to six rapid, but deep and forceful inhalations through the IMTD. Maintain the up position for long enough to complete the required number of breath repetitions. Make sure the brace is maintained during the up phase. Then relax, release the brace and rest the shoulders on the floor for no more than 2 or 3 seconds before repeating (15 to 30 seconds up, 2 or 3 seconds down).
Variations:: To add difficulty, take the feet off the floor and pulse them up and down a few centimetres. Here are two other alternatives: keep one leg extended, either resting on the floor or raised 2 to 3 inches (swap legs between sets); extend one leg and the opposite arm, raising them off the floor in time with the inhalations (swap limbs between sets).
Seated hip extension
Benefits:: This exercise requires activation of the trunk-stabilizing muscles to prevent toppling backwards. The muscles involved exert compressive forces on the chest wall and abdomen, which must be overcome during inhalation.
Procedure:: Adopt the starting position shown. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). Ensure that the hips are extended as far as is comfortable so that the shoulders are behind the hips. Rest the hands on the thighs, or fold the arms across the chest. Once in position inhale forcefully through the IMTD, completing the 30 repetitions continuously.
Reverse curl
Benefits:: During this exercise, compressive (expiratory) forces are exerted on the rib cage and abdomen. The exercise therefore develops the ability to inhale under these conditions, which will enhance the ability to breathe in situations where the body movements and breathing are out of phase in terms of the actions required of the breathing muscles, i.e., inhaling during non-respiratory activation of expiratory muscles.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (maximally). For specific guidance see the description for each version.
Variations:: To add difficulty, resist the pelvic tilt using the hands (Moderate) or elastic resistance bands looped across the hips and anchored to the floor using the hands (Easy and Difficult).
Easy
Tilt the pelvis posteriorly (see arrows), inhaling forcefully through the IMTD with each posterior tilt (swap breathing phases between sets, exhaling during the tilt).
Hip extension
Benefits:: This exercise challenges core stabilization in all three planes of movement, as well as engaging the gluteals and hamstrings and encouraging full hip extension. The ability to extend at the hip is essential for efficient ambulation and is impaired in patients who use walking aids.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, adopt a neutral spine alignment and brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: To add difficulty, add resistance to the leg (Easy and Moderate), or hold a dumbbell (Difficult).
Easy
Standing on both feet, lean forward into the starting position so that the leg / trunk angle is around 130 to 150 degrees and one or both hands are resting on the Swiss ball. Extend one leg back (on the same side as the hand resting on the ball) so that the leg and back form a straight line. As the hip is extended, inhale forcefully through the IMTD. Hold the hip extension for 3 to 5 seconds, then return to the leg start position (maintaining the forward flexed trunk) and exhale. Ensure the hip is fully extended at the end of the movement. Swap breathing phases halfway through the set, and swap sides between sets.
Moderate
Standing on both feet, lean forward into the starting position so that the leg / trunk angle is around 130 to 150 degrees. Extend one leg back so that the leg and back form a straight line. As the hip is extended, inhale forcefully through the IMTD. Hold the hip extension for 3 to 5 seconds, then return to the leg start position (maintaining the forward flexed trunk) and exhale. Ensure the hip is fully extended at the end of the movement. Swap breathing phases halfway through the set, and swap sides between sets.
Difficult
Stand on one foot and lower the opposite hand toward the standing foot so that the trunk is parallel to the floor and the free leg is extended to the rear. Whilst bending forward, inhale forcefully through the IMTD. Next, return to the standing position and exhale, ensuring that the hip of the supporting leg is fully extended. Swap breathing phases halfway through the set and swap sides between sets.
Superman
Benefits:: This exercise is a bread-and-butter exercise for promoting healthy, ‘grooved’ muscle activation patterns whilst ensuring that this can be combined (automatically) with breathing. It involves the deep pelvic stabilizers, the extensors of the hip and lumbar spine as well as the transversus abdominis. This exercise places a particular emphasis on developing lumbopelvic stability.
Procedure:: Adopt the starting position shown above for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, adopt a neutral spine alignment and brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: To add difficulty, wrist and ankle weights can be used. Also pause in the extended position to ‘draw’ a square in the air with the hand and foot, inhaling against the IMTD as this is done.
Easy
There are always three points of contact with the floor in this version of the exercise, and the moving limb is changed during a series of 4 sets. Lift one limb until it is horizontal. As the limb moves toward the horizontal position, inhale against the IMTD. Pause for 1 or 2 seconds and commence a slow, controlled exhale as the limb is brought back towards the starting position (swap breathing phases between sets). Do not allow the limb to touch the floor; instead immediately return it to the horizontal position and inhale. Ensure that the back remains flat and the shoulders level. Complete the required number of repetitions as a continuous set before swapping limbs.
Moderate
Supported by a Swiss ball, lift the right hand and left knee off the floor and extend the arm and leg until both are horizontal. As the arm and leg move toward the horizontal position, inhale against the IMTD. Pause for 1 or 2 seconds and commence a slow, controlled exhalation as the hand and knee are brought back towards the starting position (swap breathing phases between sets). Do not allow the hand and knee to touch the floor; instead, immediately return the arm and leg to the horizontal position and inhale. Ensure that the back remains flat and the shoulders level. Complete the required number of repetitions as a continuous set before swapping sides.
Difficult
Lift the right hand and left knee off the floor and extend the arm and leg until both are horizontal. As the arm and leg move toward the horizontal position, inhale against the IMTD. Pause for 1 or 2 seconds and commence a slow, controlled exhalation as the hand and knee are brought back towards the floor (swap breathing phases between sets). Do not allow the hand and knee to touch the floor; instead bring them together under the body, and then immediately return the arm and leg to the horizontal position and inhale. Ensure that the back remains flat and the shoulders level. Complete the required number of repetitions as a continuous set before swapping sides.
Ski squats with leg lift
Benefits:: This exercise challenges the ability to keep the hips level, and it puts emphasis on the development of strength in the lumbopelvic stabilizers. The added breathing challenge helps ensure that forceful breathing does not jeopardize pelvic stability.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, adopt a neutral spine alignment and brace the abdominal muscles (maximally). Extend one knee and inhale forcefully through the IMTD before exhaling slowly and fully for about 3 seconds, whereupon the starting position is resumed (the breathing rate should be around 15 per minute). Be careful not to allow the hip to drop to the unsupported side. Repeat with the opposite leg, alternating for as many repetitions as possible.
Bent leg deadlift
Benefits:: This exercise has been described as ‘the best core exercise of them all’, because it is such a great challenge to the entire lumbopelvic-stabilizing system as well as to the trunk (from ankles to shoulders). This exercise is a staple of weight training, but carries a high risk of injury if not performed with good style. A common fault is losing the flat-back posture, and this can occur if the drive to breathe overwhelms the ability to maintain the braced position. By using a manageable resistance and imposing a breathing challenge simultaneously, the dual demands that these challenges impose can be accommodated.
Procedure:: Adopt a starting position appropriate to the level of difficulty, i.e., bring the hands closer to the ankles for greater difficulty. If using an IMTD, this should be held in the mouth, without using the hands. Once in position, adopt a neutral spine alignment and brace the abdominal muscles (maximally). As the hips are extended, inhale forcefully through the IMTD and exhale when returning to the starting position. Alternate this pattern between sets so that the exhalation occurs during hip extension. Concentrate on not allowing the brace to release during either phase of breathing. Also concentrate on maintaining good lifting form and extending fully at the hip (rolling the shoulders back can help with this).
Dynamic trunk activation exercises
Benefits:: The exercises are all designed to train the ability of the trunk to move and control a resistance imposed via the upper limbs without the need to suspend breathing. These types of challenges engage the diaphragm and transversus abdominis in a feed-forward manner that is intended to stiffen the trunk. Although this mechanism is good for stability, it impedes breathing. These exercises therefore develop the ability to manage the demands of dynamic trunk loading without impairing breathing.
Procedure:: Difficulty is graded primarily according to posture, which can be: (1) seated, (2) standing on two feet, or (3) standing on one foot. Difficulty can also be graded according to the size of the resistance being moved in the hands; the exercise can commence with no resistance. Adopt the starting position appropriate to the level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, adopt a neutral spine alignment and brace the abdominal muscles (moderately). As the hand resistance is overcome, inhale forcefully through the IMTD and exhale when returning to the starting position. Arm movements should ideally be unilateral to maximize the postural challenge created. Alternate the breathing pattern between sets so that the exhalation occurs as the resistance is overcome.
Stance variations
Easy
Perform exercises seated on a chair or Swiss ball. Add difficulty by lifting one leg or both legs.
Moderate
Perform exercises in a standing position with the following posture variations: (A) standing on two feet with close stance, (B) standing on one leg with toe providing support, (C) marching on the spot, (D) tapping the ground with the toe, moving it ‘round the clock’, and (E) with rhythmic knee flexion.
Arm movement variations
These can be performed with any of the stance variations. The arm movements can be undertaken without any resistance, or with the added challenge of an elastic resistance band or hand weight. Unless a single resistance is held in both hands (e.g., halo), arm movements can be bilateral (less challenging) or unilateral (more challenging).
Rise with overhead weight
Benefits:: In this exercise, a weight is held overhead whilst either moving from sitting to standing or stepping up. This is an exercise that combines the need for lumbopelvic and thoracic stabilization with a demand for postural control. It is a good ‘compound’ exercise that will be beneficial to a wide range of everyday activities.
Procedure:: Adopt the starting position shown above for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, adopt a neutral spine alignment and brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: Increase the size of the weight or the height of the step.
Easy
Place the weight overhead and rise from the seated to the standing position, then return to the start position. Stand and sit at a comfortable but challenging pace. Inhale forcefully through the IMTD during the stand phase (swap the breathing phase between sets so that the inhale occurs during the sitting phase).
Moderate
Place the weight overhead and lift the right foot onto the step, tapping the step. Then return it to the start position standing on both feet in front of the step. Alternate the lead ‘stepping’ leg with each repetition, and ‘step’ at a comfortable but challenging pace. Inhale forcefully through the IMTD as the foot is lifted onto the step (swap the breathing phase between sets so that the inhalation occurs on the step-down).
Difficult
Place the weight overhead and begin stepping. Step up with the right leg and stand on this leg briefly on the step. Then step down, leading with the left leg, and return to the start position standing on both feet in front of the step. Alternate the lead stepping leg with each repetition, and step at a comfortable but challenging pace. Inhale forcefully through the IMTD during the step-up (swap the breathing phase between sets so that the inhale occurs on the step-down).
Squat with overhead resistance
Benefits:: This exercise is more challenging than it appears, involving the quadriceps, gluteals, lumbopelvic stabilizers, upper back, shoulders and chest. By combining a body-weight squat with an additional challenge to the trunk (from the overhead resistance) and a breathing resistance, the exercise becomes more challenging than a conventional squat. This exercise enhances the ability to coordinate and control multiple actions involving large muscle groups.
Procedure:: Adopt the starting position shown above for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, adopt a neutral spine alignment and brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: In addition to increasing duration, make the exercise more challenging by increasing cadence, squeezing a weight between the hands or standing on a large balance cushion.
Easy
Perch with the buttocks resting on the edge of a stool, table or the back of a chair with feet shoulder-width apart. Place both hands above the head with one palm resting on the back of the other hand; press the hands together, ensuring that the brace and the hand pressure are maintained throughout the squat exercise. Stand up and then return to perching on the edge of the stool; try not to rest too heavily on the stool. Move at a comfortable but challenging pace, concentrating on maintaining hand pressure and squat style. Inhale forcefully through the IMTD during the sitting phase (exhale when standing up). Alternate this pattern between sets so that the exhalation occurs during the squat. Halfway through each set, swap hands so that the opposite hand is in front.
Moderate
Standing upright with feet shoulder-width apart, place both hands above the head with one palm resting on the back of the other hand; press the hands together, ensuring that the brace and the hand pressure are maintained throughout the squat exercise. Squat to a knee angle of about 150 degrees (roughly a quarter-squat); then follow the instructions for the Easy version.
Difficult
Standing upright with feet shoulder-width apart, place both hands above the head with one palm resting on the back of the other hand; press the hands together, ensuring that the brace and the hand pressure are maintained throughout the squat exercise. Squart to a knee angle of about 130 degrees (roughly a half-squat); then follow the instructions for the Easy version.
Bag pick-up
Benefits:: This exercise simulates the everyday demands of picking up and carrying a bag of shopping, challenging both trunk stabilization and postural control. The former compresses the trunk, whereas the latter necessitates feed-forward activation of the diaphragm and transversus abdominis. Superimposing a controlled breathing demand upon these challenges facilitates the ability to meet them in daily life.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, adopt a neutral spine alignment and brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: In addition to increasing duration, make the exercise more challenging by swinging the arms, marching on the spot, adding periodic lowering and lifting of the weight.
Easy / Moderate
The Easy form of this exercise is without any weight, whereas the Moderate form requires a weight to be held in the reaching hand. Standing upright with feet shoulder-width apart and arms at the sides of the body, squat down as if to pick-up a heavy bag. The hand should reach down to a typical height for a bag handle (30 to 45 cm, or 12 to 18 inches); pause briefly in the squat position before returning to the start position and then reaching down on the opposite side for the next repetition (if using a weight, transfer this between the hands). Inhale forcefully through the IMTD during the reach-down phase (exhale when standing up). Alternate this pattern between sets so that the exhalation occurs during the active phase.
Difficult
This is effectively a static lunge exercise. Begin by standing upright with feet together holding a weight in one or both hands, then step forward and drop down into the lunge as deeply as is comfortable (active phase) and reach forward with one hand (the weighted one); reverse the manoeuvre by pushing back to the start position with feet together (recovery phase). Next, repeat the lunge with the opposite leg, and continue at a comfortable but challenging pace. Inhale forcefully through the IMTD during the active phase (exhale during the recovery phase). Alternate this pattern between sets so that the exhalation occurs during the active phase.
Side crunch
Benefits:: This lateral trunk flexion exercise involves not only the oblique muscles but also those of the rib cage. Developing these muscles is beneficial for activities that involve twisting or flexing the trunk. This exercise essentially compresses the rib cage so combining it with a breathing exercise that requires forceful inhalation will help to build the ability to inhale during movements that compress the chest.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Easy
Lie supine on a mat with calves resting on a box or chair so that the hips and knees are bent at ~ 90 degrees. Flex the upper body to one side, reaching towards the box / chair and inhaling forcefully through the IMTD. Exhale when returning to the start position, then repeat on the same side. Swap breathing phases halfway through each set and swap sides between sets.
Moderate
Lie on one side on a mat, with hips and knees bent at 90 degrees. Flex the upper body upwards, lifting the upper trunk off the mat and inhaling forcefully through the IMTD. Exhale when returning to the start position, then repeat on the same side. Swap breathing phases halfway through each set and swap sides between sets.
Difficult
Position the trunk sideways on the ball with feet against a wall (one slightly in front of the other). Flex the upper body toward the wall, inhaling forcefully through the IMTD. Exhale when returning to the start position. Swap breathing phases halfway through each set and swap sides between sets.
Trunk lateral rotation
Benefits:: This exercise involves the trunk rotators, which are responsible for controlling the counter-rotation of the shoulders during walking. Too much rotation will generate instability, inefficiency, and loss of balance. This exercise will help to develop the ability to control trunk movement, even when breathing demand is high, as well as overcoming the trunk compression that the rotation produces.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Easy
Stand or sit sideways to the resistance source. Fold the arms and hold the resistance in one hand, close to the body. The hips should remain facing forward throughout. Rotate the upper body away from the anchor point, inhaling forcefully through the IMTD. Exhale as the upper body returns to the starting position. Halfway through the set, swap breathing phases so that the exhalation occurs during the rotation away from the anchor point. On the second set, place the resistance on the opposite side of the body and repeat. Add difficulty by increasing the resistance or standing on a large balance cushion.
Trunk anti-rotation press
Benefits:: This exercise requires the ability to resist a rotational force, which is as hard as actually generating rotational movement. The exercise is harder than it looks; watch out for asymmetry between sides and work to correct this.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: Vary the height of the resistance anchor to add upward and downward force to the lateral force.
Easy / Moderate
Adopt a seated position on a chair (Easy) or Swiss ball (Moderate) sideways to the resistance source, which can be an elastic cord/band, or a cable weight machine, providing resistance at shoulder height. With tension on the band, hold the band at mid-sternum level with both hands. Extend the handle directly forward in a straight line whilst resisting the increasing rotational force that is being applied to the outstretched arms. As the arms are extended forward, inhale forcefully through the IMTD, and hold this end position for 3 to 5 seconds. Exhale as the hands are brought back toward the chest. Without pausing, repeat the manoeuvre, swapping breathing phases halfway through the set so that the exhalation occurs as the hands extend forward.
Close arm dip
Benefits:: The emphasis of this exercise is not the triceps (as it would be in a normal dip), but the complex of muscles around the shoulders that are responsible for pulling movements. These actions compress the thorax and therefore oppose inhalation.
Arms should remain close to the body to maximize scapular involvement and thoracic compression.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: Add weight on the lap.
Easy
Sit on a chair or Swiss ball and place the hands next to the buttocks. Raise the buttocks off the chair / ball by pushing down and bringing the shoulder blades closer together. Inhale forcefully through the IMTD during the push, and hold this end position for 3 to 5 seconds. Exhale during the return to the relaxed sitting position. Without pausing, repeat the manoeuvre, swapping breathing phases halfway through the set so that the exhalation occurs during the push. Arms should remain close to the body to maximize scapular involvement and thoracic compression.
Moderate
Sit on a chair with arms and place the hands on the arms so that they are close to the body. Keep the feet flat on the floor, close to the chair, to provide assistance. Push down on the arms of the chair to take the body weight through the hands. Then follow the instructions for the Easy version.
Postural control exercises
Benefits:: Standing on one leg is challenging for most people, but when breathing effort perturbs balance it can be virtually impossible. This exercise will develop the ability to dissociate the destabilizing influence of breathing from balance.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately) and breathe slowly and deeply at around 12 breaths per minute throughout the exercise. If using an IMTD, inhale forcefully through the IMTD before exhaling slowly and fully for about 4 seconds (breathing rate should be around 12 per minute). For specific guidance see the description for each version.
Variations:: Stand on a balance cushion to add difficulty. Use an elastic resistance band tied around the ankle and anchored beneath the standing foot. Abduct the lifted leg.
Easy
Stand next to a wall, mantlepiece, or piece of furniture that can provide support. Lift the foot furthest away from the support off the ground by bending the knee and hip. Then lower the leg, tapping the ground briefly before repeating the movement. Move at a comfortable but challenging pace, inhaling forcefully through the IMTD so that 5 to 6 deep breaths are completed in 30 seconds (10 to 12 in 60 seconds). Try to breathe out of synch with movements.
Dumbbell running
Benefits:: This exercise involves the entire trunk musculature, deltoids and biceps. It challenges the ability of the postural control system to maintain an upright posture. Most people find that they become much more breathless during walking and running activities than they do during cycling. This is because the postural control system is required to make continuous adjustments to posture during walking or running, which brings the breathing function into conflict with the postural function of these muscles. This exercise helps develop the ability to cope with external destabilizing forces that can cause loss of balance and breathlessness during ambulation.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: To add difficulty, stand on a balance cushion.
Easy
Sit on a chair or Swiss ball, with a light weight in each hand. Then pump the arms back and forth as if sprinting. Do this using a cadence that is challenging but comfortable (enough to disturb balance slightly). At the same time, inhale forcefully through the IMTD so that 5 to 6 deep breaths are completed in 30 seconds (10 to 12 in 60 seconds). Try to breathe out of synch with the arm movements.
Resisted front raise
Benefits:: Simply flinging the arms away from the body requires feed-forward activity of the diaphragm and tranversus abdominis to maintain balance. In situations where breathing demand is high, there is a direct conflict between the requirements for breathing and the requirements for postural control – and breathing always wins (see Ch. 1). This exercise helps to develop the ability to meet both of those demands comfortably, without compromising either. The benefits will be translated into a myriad of everyday activities where the demands of postural control and breathing are high (e.g., walking on uneven ground). Resistance can be generated using a weight or elastic resistance band. A weight is preferable, because it acquires momentum during movement.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: In addition to increasing duration, or the size of the resistance, this exercise can be made more challenging by increasing cadence, using a balance cushion, or adopting a split stance (one foot in front of the other, shoulder-width apart).
Easy
Stand upright with feet shoulder-width apart, knees bent slightly and a weight in both hands or holding each end of an elastic resistance (anchored under the feet). Swing the arms forward and upward, finishing with them at shoulder height. Do this with a cadence that is challenging but comfortable (enough to be slightly off balance). At the same time, inhale forcefully through the IMTD so that 5 to 6 deep breaths are completed in 30 seconds (10 to 12 in 60 seconds). Be careful not the rock back on the heels and to maintain complete control of the resistance at all times.
Step-up / down
Benefits:: This exercise involves the lumbopelvic stabilizers, as well as the hip, knee and ankle extensors. Stepping is an activity that causes many people to become breathless. This is not only because stepping is metabolically hard work, but also because it requires the respiratory muscles to be engaged simultaneously in active postural control. This exercise develops the ability to deal with these dual demands.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: In addition to increasing duration or step height, the exercise can be made more challenging by increasing cadence, or using hand weights.
Easy
Stand upright with hands by the sides or crossed on the chest (try not to use the arms to assist with balance). Step up with the right foot, placing it on the step briefly before returning to the start position. Alternate the leg with each repetition, moving at a comfortable but challenging pace. Inhale forcefully through the IMTD as the leg is lifted, and exhale as it is lowered (swap breathing phases between sets so that the exhalation occurs as the leg is lifted).
Moderate
The procedure is as for Easy, but progresses so that the finish position is standing on top of the step. Step down backwards with the same lead leg.
Difficult
The procedure is as for Easy, but progresses so that the finish position is standing on opposite side of the step. Step up with the right leg, stand on the step with both feet, then step down the other side of the step with the right leg. Turn through 180 degrees to face the step and repeat. If using stairs, turn through 180 degrees when standing on the stair, and again for the next repetition.
Sit-stand
Benefits:: Sitting and standing doesn't just require adequate strength in the hip and knee extensors, it also requires good core stability and postural control. Typically, people inhale just before rising, and perform a weak Valsalva to produce stability and stiffness in the trunk and pelvis. This exercise will reduce the reliance upon this pneumatic pressure for stability, replacing it with good neuromuscular strength and coordination.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Easy
Begin in a seated position with the arms folded across the chest. Rise to the standing position as swiftly as possible, then return immediately to the seated position (under control) and repeat. Inhale forcefully through the IMTD when rising; exhale when sitting (swap breathing phases between sets so that the exhalation occurs when rising).
Lunge
Benefits:: This exercise challenges the ability to maintain postural control during a compound exercise that involves large muscle groups. It will develop the capacity to breathe effectively during movements that require forceful activation of large muscle groups.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Easy
This is a static lunge exercise, which can be undertaken with support if necessary. However, it should be undertaken with hands on hips for maximum benefit. Begin by standing upright with feet together, then step forward and drop down into the lunge as deeply as is comfortable (active phase) then reverse the manoeuvre by pushing back to the start position with feet together (recovery phase). Next, repeat the lunge with the opposite leg and continue at a comfortable but challenging pace. Inhale forcefully through the IMTD during the active phase (exhale during the recovery phase). Alternate this pattern between sets so that the exhalation occurs during the active phase.
Moderate
This is a dynamic lunge exercise that should be undertaken with hands on hips for maximum benefit. Step forward and drop down into the lunge as deeply as is comfortable (active phase) then bring the trailing leg through and stand upright again with feet together (recovery phase). Next, step forward with the opposite leg, walking forward with large, deep steps, punctuated by standing. Alternate the leading leg with each repetition, and step at a comfortable but challenging pace. Inhale forcefully through the IMTD during the active phase (exhale during the recovery phase). Alternate this pattern between sets so that the exhalation occurs during the active phase.
Pushing and pulling exercises
Benefits:: The chest press requires the ability to transform the trunk into a stable platform, but doing so places huge demands on the ability of the trunk muscles to carry out their breathing function (because the muscle actions tend to compress the rib cage). This exercise will help develop the coordinated action of the trunk stabilization and control musculature during the press movement. Undertaking this exercise in an unstable standing position and with a breathing challenge will improve the ability to coordinate the stabilizing and breathing actions of the trunk during an exercise that compresses the rib cage. This transforms a simple chest press into a core exercise that is highly functional.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: Add difficulty by using only one arm at a time, which creates additional rotational and postural challenges.
Easy
A resistance band should be anchored at its middle, at chest height. Facing away from the anchor point in a seated position (chair or Swiss ball), hold opposite ends of the band in each hand. Press the hands away from the body, and inhale forcefully through the IMTD throughout the movement (exhale as the hands return to the starting position). Swap breathing phases between sets so that the exhalation occurs during the press. Concentrate on not allowing the brace to release during either phase of breathing.
Shoulder press
Benefits:: This exercise is good for postural control, and it involves the trunk musculature, shoulders and triceps. As with the chest press, the shoulder press requires the ability to transform the thorax into a stable platform. This places huge demands on the ability of the trunk muscles to carry out their breathing function because this action stiffens the trunk (making inhalation more challenging). This exercise will help develop the coordinated action of the trunk stabilization and control musculature during the shoulder-press movement. An unstable standing position and a breathing challenge improve the ability to coordinate the stabilizing and breathing actions of the trunk. This transforms the exercise into a core exercise that is highly functional.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: The exercise can also be undertaken using hand weights. Add difficulty by using only one arm at a time, which creates an additional postural challenge.
Easy
A resistance band should be anchored at floor level. Seated above the anchor point (chair or Swiss ball), hold one end of the band in each hand. Press the hands above the head, and inhale forcefully through the IMTD throughout the movement (exhale the hands return to the starting position). Swap breathing phases between sets so that the exhalation occurs during the press. Concentrate on not allowing the brace to release during either phase of breathing. Also concentrate on maintaining good lifting form and a neutral spine.
Resisted pull
Benefits:: This exercise is good for postural control, and it involves the back, shoulder and biceps muscles. Any action that compresses the rib cage creates a challenge to breathing, which is precisely what pulling movements impose. The use of a low anchor point for the resistance creates a postural challenge that pulls the body downwards as well as forwards. Undertaking the exercise in an unstable, upright position transforms it into a functional core activity. The single-arm version of the exercise also adds a rotational challenge that will train the trunk rotators.
Procedure:: Adopt the starting position shown for the selected level of difficulty. If using an IMTD, this should be held in the mouth without using the hands. Once in position, brace the abdominal muscles (moderately). For specific guidance see the description for each version.
Variations:: Add difficulty by using only one arm at a time, which creates additional rotational and postural challenges.
Easy
A resistance band should be anchored at floor height. Facing the anchor point in a seated position (chair or Swiss ball), hold one end of the band in each hand. Pull the hands towards the abdomen, and inhale forcefully through the IMTD throughout the movement (exhale as the hands return to the starting position). Swap breathing phases between sets so that the exhalation occurs during the pull. Concentrate on not allowing the brace to release during either phase of breathing.
Suggested workout protocols
Protocol one: ambulatory patient with moderate chronic obstructive pulmonary disease (COPD) and breathlessness during activities with arms overhead
1. Easy stretch set 184
2. Swiss ball bounce 186
3. Easy plank 188
4. Easy bridge 190
5. Easy seated hip extension 198
6. Easy bent leg deadlift 203
7. Seated lateral raise 204 and 205
9. Easy rise with overhead weight 206
10. Easy bag pick-up 208
11. Easy sit / stand 217
12. Easy shoulder press 220
Protocol two: ambulatory patient with heart failure and low back pain
1. Easy stretch set 184
2. Marching on the spot 186
3. Easy plank 188
4. Easy bridge 190
5. Braced curl-up 197
6. Easy seated hip extension 198
7. Easy superman 201
8. Seated bicep curl 204 and 205
9. Seated anterior raise 2 204 and 205
10. Easy squat with overhead resistance 207
11. Easy close arm dip 212
12. Easy sit / stand 217
13. Easy upright chest press 219
Protocol three: active patient with neuromuscular disease and a history of falls
1. Moderate stretch set 185
2. Swiss ball bounce 186
3. Moderate plank 188
4. Moderate gluteal bridge 193
5. Moderate seated hip extension 198
6. Moderate bent leg deadlift 203
7. Standing front swing 205
9. Moderate bag pick-up 208
10. Moderate trunk lateral rotation 210
11. Moderate dumbbell running 214
12. Moderate resisted front raise 215
13. Easy shoulder press 220
Protocol four: healthy older person with idiopathic dyspnoea
1. Moderate stretch set 185
2. Ball bounce on the spot 186
3. Moderate plank 188
4. Moderate gluteal bridge with upper body instability 194
5. Moderate gluteal bridge with lower body instability 195
6. Braced curl-up 197
7. Moderate reverse curl 199
8. Moderate bent leg deadlift 203
9. Standing side swing 204 and 205
11. Moderate rise with overhead weight 206
12. Moderate bag pick-up 208
13. Moderate trunk lateral rotation 210
14. Difficult sit / stand 217
15. Moderate chest press 219
16. Moderate resisted pull 221
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