Journal of Bodywork & Movement Therapies 24 (2020) 244e247

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Original Research

Correlation between peak expiratory flow and abdominal muscle

activity in elderly women while holding maximum expiration and
performing the side bridge exercise
Hiroshi Ishida a, *, Hikari Moriyoshi b, Tadanobu Suehiro a, Chiharu Kurozumi a,
Susumu Watanabe a
a
Department of Rehabilitation, Faculty of Health Science and Technology, Kawasaki University of Medical Welfare, 288, Matsushima, Kurashiki City, 701-
0193, Japan
b
Department of Rehabilitation, Shukumo Clinic, 741-5, Shukumo, Okayama, 704-8133, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Expiratory flow is important to minimize the risk of infection by expelling foreign sub-
Received 19 May 2019 stances from the lungs. Abdominal muscle activities primarily produce expiratory flow. However, data on
Accepted 21 May 2019 the association of abdominal muscle activity during expiratory effort and abdominal exercise posture
with expiratory flow rate is limited. This study aimed to assess the correlation between expiratory flow
Keywords: and abdominal muscle activity while holding maximum expiration and performing the side bridge ex-
Electromyography
ercise in elderly women.
Abdominal muscles
Methods: Rectus abdominis (RA), external oblique (EO), and internal oblique (IO) muscle activity was
Peak expiratory flow
measured using electromyography in 14 elderly women (82.8 ± 6.7 years), who could walk indepen-
dently while performing 2 tasks: holding their breath after maximum expiration in the crook-lying
position (maximum expiration), and performing the side bridge exercise on their knees without
breathing instruction (side bridge). Peak expiratory flow (PEF) was obtained using a peak flow meter.
Correlations between PEF and the abdominal muscle activity were determined using the Spearman rank
correlation coefficient.
Results: The correlation coefficients between PEF and RA, EO, and IO activity while holding maximum
expiration were 0.407 (p ¼ 0.149), 0.345 (p ¼ 0.227), and 0.732 (p ¼ 0.003), respectively. The correlation
coefficients between PEF and RA, EO, and IO activity while performing the side bridge exercise
were 0.297 (p ¼ 0.303), 0.552 (p ¼ 0.041), and 0.147 (p ¼ 0.615), respectively.
Conclusions: Higher IO activity while holding maximum expiration or lower EO activity while per-
forming the side bridge exercise was related to higher PEF. Thus, maximum expiration and abdominal
exercise might be effective in the improvement or prevention of the decrease of expiratory flow.
© 2019 Elsevier Ltd. All rights reserved.

1. Introduction flow (Neumann, 2010). Using electromyography (EMG), we recently

The third leading cause of death in Japan is pneumonia (Ministry
of Health, Labor and Welfare in Japan, 2014). Expiratory flow is
important to minimize the risk of infection by expelling foreign
substances from the lungs (McCool, 2006). Activities of the rectus
abdominis (RA), external oblique (EO), internal oblique (IO), and
transverse abdominis (TrA) muscles primarily produce expiratory
* Corresponding author.
E-mail address: ishida@mw.kawasaki-m.ac.jp (H. Ishida).
found that the muscles that are the most active while exerting
isometric forced expiration were the IO, followed by the EO, and
then the RA (Ishida et al., 2017a). However, data regarding the as-
sociation of abdominal muscle activity during expiratory effort
with expiratory flow rate during forced expiration is limited. Dur-
ing forced expiration, increases in abdominal muscle activity were
greater at residual volume, which involved greater expiratory effort
(Shirley et al., 2003). Therefore, we hypothesized that expiratory
flow rate may be positively related to abdominal muscle activity
while holding maximum expiration. If a positive correlation is
found between expiratory flow and abdominal muscle activity

https://doi.org/10.1016/j.jbmt.2019.05.026
1360-8592/© 2019 Elsevier Ltd. All rights reserved.
 H. Ishida et al. / Journal of Bodywork & Movement Therapies 24 (2020) 244e247 245

while holding maximum expiration, maximum expiration as an

exercise might be effective in the improvement of expiratory flow.
In contrast, literature has shown that sit-ups could strengthen
the expiratory muscles in healthy individuals (DePalo et al., 2004).
However, data regarding the association of abdominal muscle ac-
tivity during abdominal exercise with expiratory flow rate during
forced expiration is limited. We have reported, using ultrasonog-
raphy as an imaging method, that thicker EO and IO muscles may
increase the expiratory flow rate in elderly women compared to
that in elderly women with thinner EO and IO muscles (Ishida et al.,
2017b). This might mean that increased EO and IO muscle strength
may be responsible for the increase in expiratory flow rate in the
first category of elderly women. It is impossible to measure the
strength of the individual abdominal muscles, but the normalized
activity levels of the abdominal muscles holding an abdominal
exercise posture would be useful in comparing individual abdom-
inal muscle strength. Compared with elderly women with lower EO
and IO muscle strength, elderly women with higher EO and IO
muscle strength should demonstrate lower EO and IO muscle ac- Fig. 1. Measurements of peak expiratory flow. Peak expiratory flow (PEF) is measured
tivity while holding an abdominal exercise posture. Therefore, we using a peak flow meter. The subjects are seated and wore a nose clip, while being
tested for PEF.
further hypothesized that expiratory flow rate may be negatively
related to normalized EO and IO muscle activity while holding an
abdominal exercise posture. If a negative correlation is observed normalized PEF (absolute PEF/predicted PEF  100) was used for
between expiratory flow and EO and IO muscle activity while statistical analysis (%).
holding an abdominal exercise posture, abdominal exercises that EMG signals were detected using disposable surface electrodes
strengthen the EO and IO muscles might be effective in the (Blue Sensor Pe00S, Mets Co. Ltd., Tokyo, Japan). The EMG signals
improvement of expiratory flow. Abdominal exercise postures were recorded using a wireless surface EMG system (EMG Master,
should be conducted in a way that is safe for the spine. In this study, Mediarea Support, Okayama, Japan) from the right RA, EO, and IO
we selected the side bridge exercise as a safe abdominal exercise muscles. Electrodes were placed in the following positions: RA,
that enhances the activity of the EO and IO muscles (Kavcic et al., 2.5 cm lateral to the umbilicus; EO, the anterior end of the eighth
2004; McGill, 1998). This study aimed to assess the correlation rib; and IO, midpoint between the anterior-superior iliac spine and
between expiratory flow rate during forced expiration and pubic symphysis (McGill et al., 1990; Richardson et al., 1999). Bi-
abdominal muscle activity while holding maximum expiration and polar electrodes were placed longitudinally over the muscle at 2.5-
performing the side bridge exercise in elderly women. cm intervals. A grounded electrode was placed over the anterior
superior iliac spine. The EMG signals were amplified, band-pass
2. Methods filtered (15e500 Hz), and stored with a sample frequency of
1000 Hz.
2.1. Subjects The following 2 tasks were performed: (1) holding breath after
maximum expiration in the crook-lying position, with their knees
Fourteen elderly women able to walk independently partici- at 90 flexion (maximum expiration) (Fig. 2), and (2) performing
pated in this study. Their age, height, and weight (mean ± standard the side bridge exercise on their knees without breathing in-
deviation) were 82.8 ± 6.7 years, 146.8 ± 7.3 cm, and 49.1 ± 7.4 kg, structions (side bridge) (Fig. 3). During the side bridge, subjects
respectively. The participants were recruited from the Rehabilita-
tion Center of the Shukumo Clinic in Okayama, Japan. Exclusion
criteria were as follows: inability to follow instructions due to
cognitive dysfunction; history of orthopedic surgery in the lower
extremities; history of cardiac, pulmonary, or neuromuscular dis-
ease; or history of smoking. This study was approved by the Ethics
Committee of the Kawasaki University of Medical Welfare. In
addition, the director of the Shukumo Clinic approved this study.
Written informed consent was obtained from each subject prior to
participation.

2.2. Procedure

Peak expiratory flow (PEF) (L/min) was measured using a peak

flow meter (Assess, Philips Respironics G.K. Tokyo, Japan). For PEF
measurements, the subjects were seated and wore nose clips
(Fig. 1). They were instructed to inspire fully to total lung capacity,
and then to exhale as fast as possible. The subjects practiced until
they could consistently perform the task, and the measurements
were repeated 3 times. The maximum value of the 3 repetitions was
used for analysis. PEF predicted values were calculated as Fig. 2. Measurements of maximum expiration. Electromyographic (EMG) signals were
(191.3 þ 6.15  age e 0.08472  age {years}2 þ 0.0000981  age recorded using a wireless surface EMG system while holding breath after maximum
{years}3 þ 3.32  height {cm}) (L/min) (Tsukioka et al., 1996). The expiration in a crook lying position, and the subject's knees are at 90 flexion.
246 H. Ishida et al. / Journal of Bodywork & Movement Therapies 24 (2020) 244e247
Fig. 3. Measurements of the side bridge exercise.
Electromyographic (EMG) signals were recorded using a wireless surface EMG system
while performing the side bridge exercise with subjects on their knees without indi-
cation of breathing. During the side bridge, the subjects were in the right side-lying
position with a pad under their upper trunk above the inferior angle of the scapula
level, and their hips and knees are at 30 and 90 flexion, respectively. They are
instructed to lift their right greater trochanter off the treatment table to a height of one
fingerbreadth.
were in the right side-lying position with a pad (Balance-pad Elite;
50 cm  41 cm  6 cm, AIREX Co. Ltd., Nagoya, Japan) under their
upper trunk, above the inferior angle of the scapula level, and their
hips and knees were at 30 and 90 flexion, respectively. They were
instructed to lift their right greater trochanter off the treatment
table to a height of 1 fingerbreadth. The 2 tasks were performed in
random order. Verbal instructions for the maximum expiration
were as follows: “breathe out maximally, hold your breath.” The
subjects were allowed to practice until they could consistently
perform the tasks. Data was collected 3 times for each position with
a 30s rest period between each trial. The subjects were instructed
to hold each task for 5s. While the subjects performed each task,
EMG signals were measured for 3s in the middle of the task. The
integrated EMG signal of the 3s sample for each task was normal-
ized to isometric sub-maximum voluntary contraction tasks (%),
using a standard manual muscle test (MMT) as described by Hisrop
and Montgomery (1995), which depends on the subject's head,
arms, and upper trunk weight without the tester's manual resis-
tance. While the subjects performed each MMT for 5s, EMG signals
were measured for 3s in the middle of the MMT.
2.3. Data analysis
Statistical analysis was performed using IBM SPSS Statistics 23.0
(IBM Inc., Chicago, USA). After using the ShapiroeWilk test, corre-
lations between normalized PEF and normalized abdominal muscle
activity were determined using the Spearman rank correlation
coefficient. The significance level was selected as P < 0.05. To clas-
sify the effect size, a previous study categorized absolute correla-
tion coefficient values of 0.10e0.29, 0.30e0.49, and 0.50 as small,
medium, and large, respectively (Mizumoto and Takeuchi, 2008).
We also used the G-Power software (Franz Faul, Univesitat Kiel,
Germany) to calculate the power of the sample.
3. Results
The absolute and normalized PEF were 293.6 ± 42.9 L/min and
109.2 ± 26.9%, respectively. The abdominal muscle activity and
correlation coefficients are listed in Tables 1 and 2, respectively.
Significant correlations were observed while holding the maximum
expiration in the IO (r ¼ 0.732, P ¼ 0.003, Power ¼ 0.896) and while
performing the side bridge in the EO (r ¼ 0.552, P ¼ 0.041,
Power ¼ 0.569).
4. Discussion
This is the first study to identify the relationships between PEF
and abdominal muscle activity while holding maximum expiration
and performing the side bridge exercise in elderly women. Our first
hypothesis in the present study was that expiratory flow rate may
be positively related to abdominal muscle activity while holding
maximum expiration. In this study, only IO muscle activity while
holding maximum expiration had a significant positive correlation
coefficient with PEF. During maximum expiration, the abdominal
muscle activity would depend on the subjects’ expiratory effort to
increase intrapleural pressure. Although all abdominal muscle ac-
tivity could act on increased intrapleural pressure (Neumann,
2010), different degrees of association of individual abdominal
muscles might be present with forced expiration. We have recently
reported that PEF values were significantly higher during fast
expiration exercise than during forced vital capacity, and among
the abdominal muscles, only the IO muscle showed a significantly
higher peak amplitude during fast expiration exercise than during
forced vital capacity (Ishida et al., 2017a). Results of our earlier
study showed that, among the abdominal muscles, IO activity
might have the highest contribution to develop PEF during fast
expiration. Though abdominal muscle activity was not measured
during PEF in this study, the subjects who had higher activity of the
IO muscle while holding maximum expiration might induce higher
activity of the IO while measuring PEF. Hence, only the IO muscle
activity while holding maximum expiration had a significant pos-
itive correlation with PEF. Measurements of abdominal muscle
activity while measuring PEF were needed to detect associations
with the abdominal muscle activity while holding maximum
expiration.
Our second hypothesis in the present study was that expiratory
flow rate may be negatively related to normalized EO and IO muscle
activities while performing abdominal exercise. In this study, only
EO muscle activity while performing the side bridge exercise had a
significant negative correlation coefficient with PEF. This result
showed that lower EO activity while performing the side bridge
exercise was related to higher PEF in elderly women. While per-
forming the side bridge exercise, the abdominal muscle activity
would depend on the absolute strength of the abdominal muscles
to lift the subjects’ weight. Therefore, elderly women with higher
EO muscle strength might result in lower EO muscle activity while
performing the side bridge exercise compared to elderly women
with lower EO muscle strength. This might mean that higher EO
muscle strength may increase expiratory flow rate in elderly
women compared to their counterparts with lower EO muscle
strength. Our study results indicated that abdominal exercises to
Table 1
Abdominal muscle activity (%).
Maximum expiration Side bridge
Median (interquartile range) Median (interquartile range)
RA 5.9 (2.3e11.8) 17.5 (10.3e35.9)
EO 30.6 (16.8e42.9) 81.8 (43.8e122.9)
IO 48.5 (27.9e69.2) 68.9 (37.9e165.1)
RA: Rectus abdominis.
EO: External oblique.
IO: Internal oblique.
 H. Ishida et al. / Journal of Bodywork & Movement Therapies 24 (2020) 244e247
Table 2
Correlations between normalized PEF and abdominal muscle activity.
Maximum expiration Side bridge
r P Power r P
RA 0.407 0.149 0.313 0.297 0.303
EO 0.345 0.227 0.230 0.552 0.041
IO 0.732 0.003 0.896 0.147 0.615
PEF: Peak expiratory flow.
RA: Rectus abdominis.
EO: External oblique.
IO: Internal oblique.
improve hypertrophy or to prevent atrophy of the EO might be
effective in the improvement or prevention of the decrease of
expiratory flow. Recently, literature showed that sarcopenia was
associated with PEF (Ohara et al., 2018). Other study reported that
influence of age-related atrophy was higher in the RA and EO
compared to the IO and TrA muscle thickness (Ikezoe et al., 2012).
Though muscle mass and abdominal muscle thickness were not
measured in this study, the subjects with sarcopenia might showed
lower PEF compared to those without it. In this study, RA muscle
activity while performing the side bridge exercise did not have a
significant correlation coefficient with PEF. Side bridge exercise
could induce higher activity of the EO and IO muscles compared to
the RA muscle (Kavcic et al., 2004; McGill, 1998). Hence, only the EO
muscle activity while performing the side bridge exercise had a
significant negative correlation with PEF. Other abdominal exercise
posture such as curl-up exercises should be used to show whether
the RA muscle activity while holding curl-up had a significant
negative correlation with PEF. Measurements of muscle mass and
abdominal muscle thickness were needed to detect associations
with the abdominal muscle activity while performing the side
bridge exercise.
4.1. Limitations
There are some limitations of the present study. Firstly, only
female subjects were recruited; therefore any potential gender
difference was not observed. Secondly, a large variation in muscle
activity was found when performing maximum expiration and the
side bridge. This may be due to variations in expiratory effort and
muscle strength among the subjects. Finally, the subjects only
performed the side bridge as abdominal exercise in this study.
Future studies should investigate exercises other than the side
bridge to examine abdominal activity to generalize the findings.
4.2. Conclusion
Our results showed that higher IO muscle activity while holding
maximum expiration or lower EO muscle activity while performing
the side bridge exercise was related to higher PEF.
4.3. Clinical relevance
Maximum expiration and abdominal exercise might be effective
in the improvement or prevention of the decrease of expiratory
flow in consideration of specific and overloading principles,
respectively.
247
Source of funding
This work was supported by JSPS KAKENHI Grant Number
Power
15K16383.
0.178
0.569
0.078 Conflict of interest
There is no conflict of interest. This article is the full-length
version of a conference presentation given at 12th World
Congress of the International Society of Physical and Rehabilitation
Medicine (Paris. 8e12 July 2018) whose abstract was published in
https://www.sciencedirect.com/science/article/pii/
S1877065718308741?via%3Dihub Ishida et al., 2018.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jbmt.2019.05.026.
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