Breath Control During Lifting and Its Effects On Intra-Abdominal Pressure PDF

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Breath Control during Lifting and its Effects on Intra-abdominal Pressure
and Maximal Isometric Trunk Extensor Force
by
Marshall Hagins
A dissertation submitted in partial fulfillment of the requirements for the degree
of
Doctor o f Philosophy
Department o f Environmental Health Sciences
Program o f Ergonomics and Biomechanics
New York University
May, 2001
\ Ali Sheikhzadeh, Ph.D.
UMI Number: 3009316
Copyright 2001 by
Hagins, Marshall Aiken
All rights reserved.
___ ®
UMI
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© M arshall H agins
All Rights R eserved, 2001
Dedication
For my father,
who always made me think,
and always made me explain what I thought.
iii
Acknowledgements
I have been surrounded during the process of this research with mentors
who are both competent and generous, and I am very grateful. I thank Ali
Sheikhzadeh for his steady and intelligent guidance; Markus Pietrek for his clear
focus and energy; and Margareta Nordin for her discerning questions and
consistently gracious encouragement.
I thank my wife, Kay, for all the extra hours of childcare, meal
preparation, and countless other responsibilities that she performed to support me
during this work. Further, I thank her for doing it with grace and generosity, even
when doing so was a challenge.
I thank my courageous friend, Chuck Susswein, for being willing to be
our first subject, and for keeping his good humor through multiple unpleasant
procedures that were required for refinement of the methodology.
I thank Rudi Hiebert for his statistical assistance on this project, and for
the projects that preceded it, as they all served as steps along my path to this
goal.
I thank Ken Axen, Rebecca States, and Phil Alcabes, for giving of their
time and expertise so freely to improve the quality of this work.
I thank my nephew Matthew Johnson, for giving generously of his time
to create many of the graphics.
I thank Tom Rawe and Jenny Way for their kind friendship through the
entire process and for their practical support with the construction of the weight
lifting device.
Finally, I thank the students o f Long Island University that served as
volunteers during a busy period o f their education.
iv
A bstract
Introduction: Evidence suggests that elevated intra-abdominal pressure (LAP)
may decrease the risk of spinal injury. Although multiple studies have examined
the factors related to IAP generation, few studies have examined the relationship
of breath control to LAP. The purposes o f the present study were: (1) to
determine the effects o f voluntary breath control on IAP magnitude and tim in g;
(2) to determine the effects of voluntary breath control on m ax im u m isometric
trunk extensor force; and (3) to describe naturally occurring breath control during
a symmetrical unrestrained lifting task.
Methods: A total o f 33 healthy subjects were tested with all subjects providing
airflow and force data and a subset o f 11 subjects providing LAP data. Phase I
trials measured airflow and inhaled volume during squat and stoop lift postures
and two levels of load (70% and 35% o f maximal isometric trunk extensor
force). The presence o f inhalation, exhalation, or breath holding, and magnitude
of inhaled volume was determined at five points in time centered on lift-off o f
the weights. Phase II trials measured maximum isometric trunk extension force
in the upright standing and squat lifting postures using three different levels of
breath control: inhalation-hold (I-H), exhalation-hold (E-H), and inhalation-
exhalation (I-E). Phase EH trials measured LAP during lifting using the postures
and loads o f Phase I and the breath control levels of Phase H. A repeated
measures MANOVA was used to determine the effects o f breath on LAP
magnitude and timing. A repeated measures ANOVA was used to determine the
effects of breath on force.
Results: Volume varied significantly over the course of the lift (p < 0.001).
Force production was significandy related to breath control in the upright posture
(p = 0.015) but not in the squat posture (p = 0.089). There was a s i g n ificant
effect of breath control (p < 0.018) and load (p < 0.002), but not of posture (p <
0.434), on IAP magnitude.
Discussion/Conclusion: Breath control is a significant factor in the generation of
IAP magnitude during lifting tasks. Naturally occurring breath control patterns
may assist with regulation of IAP during lifting tasks.
vi
Table of Contents
Dedication................................................................................................................... iii
Acknowledgements....................................................................................................iv
Abstract........................................................................................................................v
List of Figures............................................................................................................. x
List of Tables............................................................................................................. xi
List of Appendices.................................................................................................. xiii
1 Introduction............................................................................................................ 1
1.1 Injuries related to lifting tasks..........................................................................1
1.2 Biomechanical modeling o f lifting tasks using intra-abdominal pressure
(IAP)..........................................................................................................................2
1.2.1 Evidence for the “extensor moment” theory of IAP during lifting tasks
...............................................................................................................................4
1.2.2 Evidence for the “stability theory” of IAP during lifting tasks............ 10
1.3 Factors in IAP generation during lifting.......................................................15
1.3.1 Natural breath control during lifting tasks............................................. 17
1.3.2 Relationship between breath control and IAP magnitude.....................18
1.3.3 Relationship between breath control and LAP timing............................21
1.4 Relationship between breath control and maximal isometric trunk
extension force........................................................................................................ 23
1.5 Needfor the Study.......................................................................................... 24
2 Aim of the Study...................................................................................................25

2. 1 Hypothesis I ....................................................................................................25
2.2 Hypothesis 2 ....................................................................................................26
2.3 Research questions..........................................................................................26
3 Experimental Design and Methods................................................................... 28

3.1 Venue............................................................................................................... 28
3.2 Experimental design....................................................................................... 28
3.2.1 Design o f Phases..................................................................................... 29
3.2.2 Postures................................................................................... 30
3.2.3 B reath............................................................................................. 32
3.2.4 Load............................................................................................................ 32
3.2.5 Randomization........................................................................................... 33
3.3 Subject selection.............................................................................................. 34
3.4 Sample size .......................................................................................................35
3.5 Instrumentation................................................................................................ 35
3.6 Procedure......................................................................................................... 40
3.6.1 Phase I ........................................................................................................40
3.6.2 Phase II trials............................................................................................. 44
3.6.3 Phase III trials............................................................................................ 45
3.6.4 Quality control relative to procedure...................................................... 45
3.7 Data analysis.....................................................................................................47
3.7.1 Processing.................................................................................................. 47
3.7.2 Statistical A nalysis....................................................................................52
4 Results......................................................................................................................55
4.1 Description o f Subjects....................................................................................55
4.2 IAP and Force D ata ........................................................................................57
4.3 Flow and Volume Data....................................................................................60
4.4 Hypothesis I ..................................................................................................... 61
4.5 Hypothesis 2 .....................................................................................................64
4.6 Research Question........................................................................................... 67
5 . Discussion................................................................................................................75
5.1 Subject Characteristics..................................................................................... 75
5.2 Hypothesis 1: Effect o f Breath, Posture, and Load on Magnitude and
Timing o f IAP........................................................................................................... 76
5.2.1 Magnitude...................................................................................................76
5.2.1.1 IAP magnitude across all conditions.................................................. 77
5.2.1.2 IAP magnitude relative to posture.......................................................77
5.2.1.3 IAP magnitude relative to load............................................................ 79
5.2.1.4 IAP magnitude relative to breath.........................................................80
5.2.2 Tim ing.......................................................................................................86
viii
5.3 Hypothesis 2: Effect o f breath on maximal isometric trunk extension force
94
5.4 Research Question:Natural breathing patterns during lifting.................. 100
5.5 Implications....................................................................................................106
5.5.1 Magnitude o f IA P ................................................................................. 106
5.5.2 Timing o f IAP........................................................................................ 110
5.5.3 Effects o f breath on force..................................................................... I l l
5.5.4 Description o f natural breath................................................................ 113
6 Conclusions and Future Studies....................................................................... 114
Appendices............................................................................................................... 117
Reference L ist.......................................................................................................... 139
ix
List of Figures
Figure 1. Mechanism o f IAP to produce extensor moment during lifting tasks.... 5

Figure 2. Transversus Abdominis............................................................................... 7
Figure 3. Diagram of transverse section of abdominal cavity demonstrating
theoretical effects o f LAP on the shape o f the abdominal wall and the
orientation o f tension applied to the lumbar spine via fascial connections. ..11
Figure 4. Diagram of transverse section of lumbar vertebra demonstrating the
stabilizing effect o f tension in fascial layers attached to transverse processes.
..............................................................................................................................13
Figure 5. Three conditions o f posture used in present study..................................31
Figure 6. Schema o f experimental setup demonstrating acquisition of force, flow,
and IAP data........................................................................................................ 38
Figure 7. Representative data from one subject showing identification of peak
force, peak IAP, lift-off, put-down, and determination o f timing of peak IAP.
............................................................................................................................. 48
Figure 8. Representative data from one subject demonstrating methods of
integration o f air flow.........................................................................................53
Figure 9. Frequency distribution of naturally occurring categories of inhalation,
exhalation, and breath holding during dynamic lifting................................... 69
Figure 10. Naturally occurring inhaled volumes during lifting, normalized to peak
inspiratory capacity and relative to load and posture...................................... 74
Figure 11. Force and LAP relative to breath control in knees bent and upright
postures................................................................................................................ 98
Figure 12. Lnhaled volumes during lifting comparing trials with and without the
presence of an LAP catheter (n = 11)............................................................... 103
Figure 13. Mean LAP and volumes 4 and 5 relative to posture and load.............105
List of Tables
Table 1. Demographic and Baecke Questionnaire data o f participants.................55

Table 2. Means and standard deviations of IAP magnitude and timing data
relative to posture, load, and breath control (n = 11).......................................62
Table 3. Results o f repeated multivariate analysis o f variance (MANOVA) for the
main effects and interaction effects of posture, load, and breath on IAP
magnitude and timing (n = 11).......................................................................... 62
Table 4. Results of repeated measures univariate analysis o f variance (ANOVA)
for effects o f load and breath and the interaction of load and breath on IAP
magnitude (n = 11)............................................................................................. 63
Table 5. Results o f repeated measures univariate analysis o f variance (ANOVA)
for the main effect of load and breath, and the interaction of load and breath,
on IAP timing (n = 11)....................................................................................... 63
Table 6. Results of Paired t-Tests on effect of levels of breath condition on IAP
magnitude (n = 11)............................................................................................. 65
Table 7. Means and standard deviations of maximum isometric force data relative
to posture and breath condition (n = 33)...........................................................65
Table 8. Results of separate repeated ANOVAs for effects o f breath control on
maximal isometric force production in the upright and knees bent postures (n
= 33).................................................................................................................... 66
Table 9. Results of paired sample t-Tests for effect of levels o f breath condition
on maximal isometric force production in the upright posture (n = 33)........ 68
Table 10. Means and standard deviations of naturally occurring inhaled volume at
five points in time during lifting (n = 34)......................................................... 71
Table 11. Results of repeated ANOVA for effects of time on volume during
lifting (n = 34).....................................................................................................72
Table 12. Results of paired t-Tests on levels of volume during lifting (n = 34).. 72
Table 13. Comparison o f means and standard deviations o f LAP magnitude from
studies using symmetrical dynamic lifts with low to moderate loads 78
Table 14. Means and standard deviations of IAP magnitude at time o f peak force
and timing of peak IAP relative to peak force..................................................89
Table 15. Means of peak LAP timing relative to breath control and grouped by
peaks occurring prior to peak force and peaks occurring post peak force.... 92
xi
Table 16. Means and standard deviations o f maximal isometric force relative to
posture from studies using similar methodology to the present study 95
Table 17. Mean values o f force and IAP during static maximal exertions in two
postures (n = 11)..................................................................................................97
xii
List o f Appendices
Appendix 1. Consent Forms.................................................................................. 117
Appendix 2. Power calculations on pilot data......................................................120
Appendix 3. Calibration of instruments/Test for timing o f data acquisition 122
Appendix 4. Baecke Questionnaire o f Habitual Physical Activity and
computational methods used for scoring........................................................ 123
Appendix 5. Medical History Form.......................................................................127
Appendix 6. IAP magnitude d ata.......................................................................... 128
Appendix 7. IAP timing data................................................................................. 130
Appendix 8. Force data...........................................................................................132
Appendix 9. Post hoc analysis............................................................................... 133
1 Introduction
1.1 Injuries related to lifting tasks
Two percent of the US workforce has a compensable low back pain
(LBP) injury each year with an estimated total annual cost exceeding $20
billion.118 Approximately 40% of those who report an occurrence o f LBP on the
job associate that injury with overexertion while lifting objects.113 There is a
significant need for increased understanding o f the mechanisms of lifting tasks
in order to improve programs for injury reduction. One potential mechanism
that may contribute to the safe performance o f lifting tasks is intra-abdominal

rr A 1 1 8,24,3 6,39,46,97,104,105, L07.109,126,131 T a D • ., - -t
pressure (IAP). IAP is the pressure mside the
abdominal cavity that is created primarily by coordinated contraction o f the
diaphragm, abdominal, and pelvic floor muscles. Many factors associated with
the generation of IAP have been studied
extensively,3,9'30'33,34'55'64'66'91'95'109'126'130'133 however, the potential role o f breath
control relative to LAP has received little attention.
1.2 Biom echanical m od elin g o f lifting tasks using intra-abdom inal
pressure (IAP)
Injuries to the low back occur when mechanical stress exceeds the
tolerance limits o f the involved tissues (e.g., muscles, bones, tendons, and
ligaments, etc.). Biomechanical models contribute to injury prevention by
quantifying mechanical stress on tissues. One o f the primary considerations
when determining “safe” types o f lifting is the amount of compression and
shear stresses on the spinal structures.46
Many static and dynamic biomechanical models exist that attempt to
estimate the compression and shear forces during lifting
tasks.2’6'11’14’41’45’47’48'57’59’89’98'103’126’132 Two-dimensional models simplify the
complex three-dimensional vectors of multiple trunk extensor muscles into a
single muscle equivalent.46 This strategy appears adequate when e x am in in g
two-handed symmetrical sagittal plane exertions.15,47 Three-dimensional models
more accurately describe multiple muscle forces, as well as compression and
shear forces.
The most common two-dimensional lifting model represents the trunk
extensor muscles as a single vector connecting adjacent spinous processes that
generate force perpendicular to the plane of the lumbar discs.17’113 Although this
model has been used for over 40 years, it produces the paradoxical output o f
predicting compressive loads that exceed the known tolerance o f the vertebral
endplate.3,109 In essence, this model suggests that lifts commonly performed
without injury should, in fact, be creating spinal fractures. There are two
suggested solutions to this paradox: (1) recognize that the paradox is only
“apparent” as the values used for end plate tolerance are too low and the
predicted compression is too high, as suggested by McGill and Norman;103 (2)
add an additional factor into the model that counteracts the compression stress,
namely, IAP.
LAP has been shown to occur consistently during static and dynamic
lifting tasks.3’9’32’33,96,106 Many authors suggest its inclusion in biomechanical
models o f lifting.16,18,24’36’39’46’97’104’105’107’109’126’130’131 The rationale for including
IAP is that it may directly assist with the lift by pressing upwards on the
diaphragm and downwards on the pelvic floor, thereby attempting to separate
these two segments and create an extension moment. Any extension moment
created by IAP would decrease the need for trunk extensor muscle activity and
thereby decrease compression stresses.
In addition, several authors have suggested that IAP increases lumbar
stability by assisting with the formation of a “rigid cylinder” through the
abdominal muscles,43'32 and/or through stabilizing forces delivered via fascial
connections to the vertebral segments.122 Lumbar stability is often a goal in
programs designed to prevent or reduce low back pain.44,102’114,123’123 IAP may
reduce excessive shear forces during lifting tasks through its contribution to
lumbar stability.
1.2.1 Evidence for the “extensor moment” theory of IAP during lifting tasks
Bartelink, in 1957,9 proposed that the addition o f IAP to the simple
mechanical model could effectively relieve the predicted compression forces
that occur at the lumbar discs. Bartelink suggested that IAP serves as a
pressurized “balloon” attempting to separate the diaphragm and pelvic floor
(see Figure I).9 IAP thereby assists the erector spinae in creating an extensor
moment during lifting that would reduce the need for erector spinae activity and
decrease a significant portion o f the resulting compression force on the lumbar
disc. This theory relates IAP function to a specific direction (e.g., extension)
and to movement originating in a specific posture (e.g., flexion).46 The theory
stating that LAP generates a significant extensor moment during lifting has been
investigated from numerous vantage points, which have provided varying levels
o f support to this theory.
Researchers often estimate the amount of extensor moment the LAP is
capable of creating based on calculations using mechanical models. Because
various researchers differ in the equations used, as well as in the input values
used within their equations (regarding area of the diaphragm, length of the
moment arms, and magnitude o f IAP), it is not surprising that the resulting
estimates o f extensor moment vary widely.16,36’39’109’126,131 Suggestions for
reduction in extension moment range from 4-40% o f the extensor
load 16-36-39-109-126’131
Figure 1. Mechanism of IAP to produce extensor moment during lifting

tasks.
LAP may assist extension moment during flexed lifting tasks by

providing force to the diaphragm and pelvic floor. This force may
relieve efforts o f the trunk extensors and therefore decrease
compressive load on lumbar tissue (Adapted from Bartelink9).
A recent study has provided the first direct measurements o f increases in
extensor moment related to increases in IAP.68 The authors used electrical
stim ulation o f the diaphragm to increase IAP. Measures of torque production
were performed during static and dynamic exertions in side lying on a hinged
table. Extensor torque production was related to increases in LAP; however, the
relative magnitude o f the extensor torque production was quite low.
Biomechanical models suggesting large values of extensor moment
generation from IAP have been criticized for failing to include the compressive
effects o f the abdominal musculature in their calculations.80’104 These authors
suggest that the external oblique (EO), internal oblique (IO), and rectus
abdominis (RA) always contribute to IAP, and therefore simultaneously create
added compressive force to the lumbar spine. In their calculations, the added
compressive force o f the EO, IO, and RA negates the potential relieving effect of
IAP on lumbar compression. Recent evidence, however, suggests that it is the
transversus abdominis (TA) that is the primary abdominal muscle responsible for
IAP generation, and that the EO, IO, and RA do not consistently contribute to
IAP generation.9’22’23’25’38’72
The TA is unique in that it does not operate on bony levers, and it is
ideally oriented to create compression of the abdominal contents (see Figure 2).38
A recent modeling study lends further theoretical support to the view that the TA
is an ideal muscle to provide increased IAP for the purpose of spinal unloading,
and that even low amounts o f pressure provided in this manner can produce an
unloading effect.29 The TA is the deepest layer o f the abdominal muscles and
Figure 2. Transversus Abdominis.
The transverse orientation of the muscle fibers is ideally suited for

compressing the abdominal contents during contraction and has little
ability to produce flexor torque (Adapted from Kendall79).
requires fine wire electromyography for study, which may explain its neglect in
studies determining muscular contributions to IAP.
Additional support for clarification of the role o f various abdominal
muscles in IAP generation comes from the findings o f two studies that
examined IAP in normal subjects before and after strength training of the EO,
IO, and RA. Training o f these muscles failed to show any effect on the
development o f IAP during lifting tasks, suggesting that these muscles are less
f\f% 87
important in the generation o f IAP. ’
The theory relating IAP generation to the creation o f an extensor moment
implies that the timing and magnitude o f IAP should relate to the demands for
the extensor moment created during the lifting task. Previous studies examining
the effect o f load on IAP found that IAP increases with increasing load during
static9-30’55’110 and dynamic64-66 ^ , 67 ,83,92.109 lifting tasks.
Many studies examining the time course o f the generation o f IAP have
focused on the body’s response to load perturbations to the trunk.24’26’69’70'75
These studies describe the timing of IAP relative to the onset of the trunk-
perturbation and/or to the onset of muscle EMG. The focus in these studies is
on the motor control programs used to generate IAP to produce stability in the
trunk during “sudden response” situations. There have been no studies
examining the relationship between breath control and the timing of IAP during
lifting tasks. Lifting tasks differ from the sudden loading conditions examined
in previous studies because the rate of application o f stress is slower and levels
of trunk torque are higher.
Some researchers have attempted to control the magnitude of IAP
production during lifting tasks via voluntary valsalva maneuvers, in order to
determine the effects on EMG output and intradiscal pressure as indicators of
spinal compression.80,112 Valsalva maneuvers require a deep inhalation followed
by closing o f the glottis, and a voluntary effort to maximally engage the ribcage
and abdominal muscles to compress the abdominal and thoracic contents.
Nachemson et al.112 found that increases in IAP during valsalva maneuvers
created increases in intradiscal pressure, a finding contrary to that predicted by
the extensor moment theory. Additionally, an EMG study by Krag80 found that
erector spinae output increased with valsalva-induced IAP, which also counters
the extensor moment theory of IAP. In both cases, the relevance o f the findings
rests on the assumption that the muscle recruitment patterns that occur during
the valsalva maneuver are valid representations of the muscle patterns that
occur during normal control of the IAP during lifting tasks. It has been
suggested that this assumption may not be true.58 In fact, regarding his study,
Nachemson states, “Our study does not show that intra-abdominal
pressurization fails to unload the spine: it shows merely that deliberate
voluntary pressurization usually leads to spine load increases rather than
decreases.”
In summary, the evidence for reduction of spinal compression during
lifting tasks, through IAP contributions to an extension moment, remains
controversial. Calculations based on biomechanical models vary widely.
Suggestions that simultaneous abdominal muscle compression forces always
counteract potential IAP unloading should be viewed with caution. These
authors fail to include the TA in their mechanical models, or fail to recognize
potential differences in muscle recruitment patterns between those that occur
during lifting tasks versus those that occur during valsalva maneuvers.
1.2.2 Evidence for the “stability theory” o f IAP during lifting tasks
The theory relating IAP to increased lumbar stability is generally less
controversial than the previously discussed theory. Summary discussions in
textbooks and articles,18'46’105 as well as multiple investigations,23’97’104’107130
support the concept that LAP contributes to lumbar stability. Lumbar stability
provided by IAP is generally viewed as an increase in segmental motion
'‘stiffness”, which potentially provides a protective function in lifting tasks by
creating increased lumbar stability. Unlike the previously discussed theory, the
contribution provided by LAP to lumbar stability is not restricted to sagittal
plane movements or to motions originating in a flexed posture.
The mechanisms linking IAP to lumbar stability fall into two prim ary
categories. First, IAP creates a “rigid cylinder” o f the abdominal cavity. The
abdomen is frequently modeled as a cylinder with the abdominal muscles
serving as the wall, the diaphragm as the top, and the pelvic floor muscles as the
bottom of the cylinder. Typically, the shape o f the abdominal cavity is easily
changed via external pressure or active muscle forces. However, the abdominal
contents are essentially incompressible,109 and therefore, applied forces may
only redistribute the contents or rapidly meet resistance as internal pressures
10
increase. As the musculature contracts around the abdominal contents, IAP
increases and converts the abdomen into a “rigid cylinder” that has a greatly
increased stability compared to the multi-segmented ligamentous spine.109
Figure 3. Diagram of transverse section of abdominal cavity demonstrating

theoretical effects of IAP on the shape of the abdominal wall and the
orientation of tension applied to the lumbar spine via fascial
connections.
Image A demonstrates the theory that high levels of IAP increase the
magnitude of tension in the lumbar fascia and re-orient its direction of
pull more laterally. Image B demonstrates the theory that low levels of
IAP provide little tension and do not provide the necessary opposite
directions o f tension to increase stability o f the lumbar segments
(Adapted from Gracovetsky31).
Second, LAP maintains the necessary hoop-like geometry of the TA and
IO muscles such that the force generated on the spinal segments serves as “guy
11
wires” to the spine.104 TA and 10 connect to the thoracodorsal fascia that then
connects104 to the transverse processes o f the lumbar vertebra122 (see Figure 3).
Modeling the abdomen as a cylinder, it is possible to use LaPlaces’ Law to relate
the IAP to the tension in the fascia l22:
T = PR/4
(where T is the tension in the fascia, P is the IAP, and R is the radius o f the
geometry o f the abdominal wall). Although there are limitations to the use of
this law for contractile hoops and non-uniformly cylindrical models, it has been
suggested to be sufficiently accurate to demonstrate that IAP opposes a change
in the radius of curvature and allows the abdominal muscles to contract without
collapsing into the viscera.122 By maintaining the hooplike geometry o f the TA
and IO, the increase in muscle tension during their contraction is transmitted to
the lumbar spinal segments. This force pulls laterally on the lumbar spinal
segments, providing stability by serving as a “guy wire” similar to that of a tent
pole (see Figure 4).
There are multiple sources of evidence supporting the role o f IAP in the
production o f increased lumbar stability. IAP increases during both flexion and
extension loading of the trunk, in both static and dynamic conditions.2^27
12
Similar results regarding IAP increases were also found in studies examining
lifting and lowering and isoinertial loading.22,26 Further, there is s im ilar
Figure 4. Diagram of transverse section of lumbar vertebra demonstrating

the stabilizing effect of tension in fascial layers attached to transverse
processes.
In the superior image (A) the fascial attachments to the transverse

processes have sufficient tension to resist segmental motion thro u gh
the application o f opposing forces. In B however, the fascial
attachments fail to provide sufficient tension to restrain segmental
motion allowing motion in multiple planes as indicated by the arrows.
(Adapted from Richardson et al.122, p. 56).
13
evidence of IAP response to challenges to lumbar stability during functional
tasks such as running and jumping.38,60
Perturbation studies using sudden expected and unexpected ventral or
dorsal spinal loads found that IAP increased in response to the challenge to
trunk stability, regardless of the direction challenged.26 This suggests a
contribution to a general stiffening of the torso.26 Other perturbation studies
investigated preprogrammed muscle recruitment patterns in which the central
nervous system has knowledge of the exact timing and magnitude of the
perturbation.72,76’77 In these studies, subjects were asked to complete rapid
voluntary motions o f the upper and/or lower extremities in several directions
while muscle recruitment patterns and IAP were measured. In all these studies,
regardless of movement direction, there was a significant rise in IAP that
preceded the activity o f the respective muscle responsible for the limb motion.
The most direct evidence of the relationship between IAP and lumbar
stability comes from a recent study examining the stiffness o f the trunk in three
planes during various levels of voluntarily created LAP.19 Stiffness was
determined by motion analysis o f oscillations after a quick release protocol. In
flexion and lateral bending, increases in trunk stiffness were related to increases
in IAP. Results in extension lacked statistical significance. The authors do not,
however, make any recommendations regarding the voluntary control of LAP
14
through breath control as a possible mechanism for increasing stability o f the
spine.
In summary, there are two mechanisms relating IAP to increases in
lumbar stability. Although there is little evidence contradicting these
mechanisms, they remain so far, mostly theoretical, being primarily based on
known anatomy and mechanical modeling. The most conclusive research
evidence linking IAP to lumbar stability is the maintenance o f significant
levels of IAP in both flexion and extension tasks; the early rise o f IAP in
perturbations that challenge the lumbar spine from multiple directions; and IAP
related increases in trunk stiffness, as measured by motion analysis.
1.3 Factors in IAP generation during lifting
As IAP may decrease compression and/or shear forces during liftin g
tasks, and as it is a significant variable to be included in biomechanical models,
an accurate description o f the factors that determine the generation o f LAP is
needed. LAP generation has been studied relative to lifting technique3,56,64'
66,i09,i33and level Gf load.9,26,28,30,31,35,40-55’58,64-67’81,83-91-92-109'110’" 5 However, few
studies exist that have examined the potential role of breath control in IAP
generation. This is surprising given that EMG onset studies72,74 and
biomechanical models29,109 have shown that the diaphragm contributes
15
significantly to the production of IAP. Therefore, the aim o f tthis study is to
determine the role o f breath control in IAP generation.
The two most clearly defined postures used in IAP studies are the “stoop”
lift and the “squat” lift. The stoop lift is performed with straight knees and a
flexed back, while the squat lift is performed with bent knees and a straight
back. These variations of posture are commonly used in norm al lifting tasks.
The literature regarding the effects of these two posture comditions (knees
straight/knees bent) on IAP during dynamic lifting is unclear. Three studies
show that the knees bent posture produces higher values56’66*’109 while two
studies suggest that the knees straight posture produces higftier values.3’133
During static lifts, the literature finds more consensus, withi three studies
showing that the knees bent posture produces higher IAP valuess.3’110,115 Most
studies of the effect o f load on IAP in static and dynamic lifts suggest that
increases in load increase laj^ 33-3^40-39.66-83-92*109
Few studies have examined the relationship o f breath control to IAP, with
the exception o f studies using the valsalva maneuver. Howevecr, EMG onset
studies72,74 and biomechanical models29’109 have shown that tshe diaphragm
contributes significantly to the production o f IAP. Breath control determines
diaphragm position, and the diaphragm is capable of creatfing increased
compression o f abdominal contents as it descends on inhalaition.67 Breath
control is therefore a potential factor in the production o f IAP during lifting
16
tasks, and may be a confounding variable in many o f the existing studies that
failed to consider its effects. Further, the potential practical benefits that could
be derived from conscious control o f the breath during lifting tasks remains
virtually unexamined.
1.3.1 Natural breath control during lifting tasks
Although many authors make anecdotal reference to the tendency for
people to hold their breath during lifting tasks,9,57'101’105’109 only one study has
provided information on the naturally occurring breathing patterns of subjects
during lifting.67 Hemborg et al.67 examined this issue within a study using normal
subjects, LBP patients, and weight-lifters; however, the authors did not report
their findings relative to normal subjects. Hemborg et al.67 reported the
percentage o f subjects that exhaled, inhaled, or held their breath during the entire
lift period. The method of reporting prevents considerations o f flow changes over
time and excludes the potentially significant portion o f preparatory breath control
prior to the lift. If consistent patterns o f breath control exist during lifting, they
may be related to the previously discussed theories concerning IAP. Breath
control may be regulated by a central neural drive that is attempting to achieve,
through IAP, control of lumbar compression or stability. If that is hue, then
breathing patterns consistent with these ideas should emerge. For example, both
theories might suggest that descent of the diaphragm immediately prior to the
17
lift, as occurs during inhalation, would help insure adequate timing or magnitude
of IAP during the lift.
1.3.2 Relationship between breath control and IAP magnitude
The relationship between breath control and IAP magnitude is relatively
unexamined, although many authors suggest that IAP plays a significant
mechanical role during lifting tasks16,19,26,27'36,39,72’76,77,109,126,131 and that the
diaphragm is very important in the generation o f IAP.72,74 The one method of
breath control that has been extensively studied relative to IAP production is the
valsalva maneuver. Wedin135 describes it as follows: “The principal aim o f the
valsalva maneuver is ... to increase the intrathoracic pressure by a forceful
exhalation against a closed glottis with activation of abdominal wall and
internal intercostal muscles and relaxation o f the diaphragm.” Studies have
clearly shown a relationship between the valsalva maneuver and increases in
LAP.8,23’26’20,6o In fact, the valsalva maneuver typically produces the highest
voluntary IAP values possible.107 The valsalva maneuver is rarely used during
daily activities, with the exceptions o f its conscious control during defecation or
its reflexive control during sneezing. The large increases in intrathoracic
pressure (ITP) which typically result from a valsalva maneuver compromise
venous return,94 and reports of loss of consciousness in weightlifters who use
the valsalva maneuver are often ascribed to this mechanism.90 Researchers use
18
the valsalva maneuver as a method o f controlling the IAP during
experimentation as an independent variable, but do not recommend the use of
the valsalva maneuver during lifting because o f its inherent dangers to
decreased venous return.
What is not clear from the scientific literature, or from the weightlifting
literature,120’121,124 are the potential differences between the types of breath
control known as “holding the breath” and the valsalva maneuver. Although
these consciously controlled breathing maneuvers appear similar, they may
involve very different muscular strategies with different levels of potential risk.
Lifting tasks can create IAP that is not related to intra-thoracic pressure.67'109
This requires the diaphragm to be active and create tension that separates
pressures within the abdomen from pressures within the thorax. Pressure
differences between the two cavities have been shown to be related to
diaphragm activity.37,53,127 Both the valsalva maneuver and breath holding
appear to involve closing o f the glottis. However, breath holding may not have
pressurization o f the thorax as a goal. Further, diaphragm activity can clearly
prevent transmission o f IAP forces into the thorax. Therefore, although the
valsalva maneuver appears to carry significant risks during lifting tasks, it is not
clear to what degree breath holding carries equivalent risks.
There have been only two studies examining the relationship between
breath control and IAP magnitude during lifting tasks that use breath control
19
methods other than a valsalva maneuver.67,106 These two studies suggest
opposite results, with Hemborg et al.67 concluding that IAP is not affected by
breath control, and McGill et al.106 concluding that IAP is affected by breath
control.
Hemborg et al.67 are the only researchers to attempt to determine the
relationship between multiple types o f breath control and LAP production during
lifting tasks. One methodological issue that may have contributed to their
finding that breath control does not relate to IAP magnitude during lifting tasks
is the lack o f normalization of the level o f load lifted by subjects. This is
particularly important in their study, as the subjects were LBP patients, normal
subjects, and weightlifters. Subject groups such as this presumably have a high
variation in ability to generate force via their muscular system. The mechanical
challenge o f a 25 kg load may be easily met with the muscular system o f a
weightlifting subject, requiring little alteration o f the breathing patterns or IAP
magnitude. However, a 25 kg load for the LBP patient, who may have less
muscular support, may require a different strategy with more dependence on
breath control and LAP magnitude.
The description o f the analysis performed by Hemborg et al.67 is unclear
regarding what breath conditions were compared. The authors may have
compared each controlled breath condition with the subject’s natural breath
condition. A direct comparison of the LAP that occurs during maximal
20
inhalation to that which occurs during maximal exhalation may have provided a
different result. Further, Hemborg et al. included two types o f lifting technique
and two levels of load in the methodology. However, their analysis did not
include direct comparisons o f these variables relative to LAP.
McGill et al.106 examined the effects of an abdominal belt on IAP during
lifting tasks both with and without breath holding and exhalation. They found a
significant correlation between breath control and IAP magnitude. This study
differed from Hemborg et al.67 with regard to the level o f loads and with regard
to the level of analysis. In this study, subjects self-selected a load that “ ...they
felt was heavy but could be lifted safely” and the analysis directly compared
breath holding to exhalation.
In summary, only two studies have examined the relationship between
breath control and changes in IAP magnitude.67'106 These studies differ greatly
in their methodologies and suggest opposite conclusions.
1.3.3 Relationship between breath control and IAP timing
The vast majority of studies of LAP have focused on
magnitude.3’9'16'18’24'30’33’34’36'46'55'64'66'91'95’97'104’105'107’109’126’130’131’133 However, the
timing o f IAP is also an important potential factor underlying the extensor
moment and stability theories o f IAP. Increases in IAP magnitude must occur at
critical moments of mechanical challenge.
21
The majority o f studies examining the time course o f the generation o f IAP
have focused on determining the relationship between the onset, and/or peak, o f
IAP and the onset, and/or peak, o f EMG o f trunk muscles.24'26,58,69’70’72’73,96’107
Many of these studies use rapidly applied trunk perturbations as the mechanical
challenge necessitating a rise in LAPJ24-26'69'70'72’73 The focus in these studies is on
the motor control programs used to generate IAP in order to produce stability in
the trunk during “sudden response” situations.
However, lifting is an example o f a slower, planned task that may not be
adequately modeled by the sudden-response studies cited above. Four studies have
examined the timing of IAP during a lifting task.60,61,64’66 Two of these studies
focus on the relationship of the onset of IAP relative to the onset of trunk EMG
and do not consider the timing o f IAP relative to the mechanical challenge to the
body.64,66 The other two studies determined the timing o f peak IAP relative to
either the lifted object leaving the ground60 or to the application of force to the
object being lifted.61 They also used much higher loads (90% of one repetition
maximum), and did not study normal subjects, but weightlifters. No studies have
examined the relationship of breath control to timing o f IAP.
22
1.4 Relationship between b rea th control and m axim al isometric
trunk extension force
In weightlifting manuals, rthe training of breath control has been
advocated as a method to increase the ability to generate force in
weightlifting.120’121,124 There is an absence of recommendations for the training
of breath control during lifting tastks in occupational medicine guidelines,l8,l0:>
with the exception that a valsalva maaneuver should be avoided. If breath control
can be shown to be related to increases in trunk extensor force production, then
methods o f breath control training may be a viable technique to increase the
margin o f safety when a large loacfl must be lifted. In such cases, increases in
IAP may provide further reductilon o f injury risk by decreasing lumbar
compression stresses or increasing lwumbar stability.
Theoretically, both the extensor moment and stability theories of IAP
support a potential relationship baetween IAP and maximal isometric trunk
extension force. The extensor m om ent theory suggests that IAP provides
additional extension moment to She spine during flexed lifting tasks and
therefore, if breath control is related. to IAP, it may also be related to the amount
of maximal force that can be generated. The stability theory suggests that IAP
serves to increase stabilization o f th e spine. The central nervous system may
receive increased afferent input regsarding LAP, indicating improved control of
excessive forces. The central nervoms system may then alter muscle recruitment
23
patterns to reflect less need for stabilization, and therefore have more capability
for additional extensor moment generation.
1.5 Need for the Study
LAP may provide an extensor moment and/or increased stability during
lifting tasks, so therefore an accurate description of the factors that determine
the generation o f IAP is needed. Information regarding these factors may
provide practical methods to reduce injury risk for LBP during manual material
handling. Many factors relative to IAP generation during lifting tasks have been
well studied; however, only two studies have examined the influence of breath
control.67’106 These two studies differed greatly in methodology and suggested
opposite results. If conscious control of the breath influences LAP production,
this relationship may form the basis for practical training regarding breathing
techniques during lifting tasks. Additionally, awareness o f this relationship
could help minimize the potential for breath control to be a confounding
variable in future LAP studies.
There have been no studies examining the potential for increases in force
output with different types o f breath control. This information could provide
further support o f the theories o f LAP as well as provide evidence for sports
training methodologies that advocate specific forms o f breath control to
increase lifting capacity.
24
There are no studies clearly describing naturally occurring breath control
during lifting tasks. It has been suggested that naturally occurring breath control
may help regulate IAP during lifting tasks. If this mechanism exists, then
patterns of breath control that are capable of facilitating IAP magnitude and/or
timing should be present.
2 Aim of the Study
The primary aim o f this study is to determine the role of breath control
(three breathing conditions), load, and posture on the timing and magnitude of
IAP. The effect o f breath control on isometric trunk extensor force production
in two postures will also be examined. Additionally, this study will provide a
description of the naturally occurring breathing patterns of normal subjects
during lifting tasks using two levels of load and two levels of posture.
2.1 Hypothesis 1
There will be a significant effect o f breath control, posture, and load on
magnitude and timing of IAP.
Only two studies have examined the role of breath control relative
to IAP generation during lifting tasks.67,106 These studies used
different methodologies and found contradicting results. One of
25
these studies67 did not report results relative to normal subjects or
effects of load and performed inadequate statistical analyses,
while the other study106 did not standardize lift tasks adequately
and did not examine multiple types o f breathing pattern. There
have been no studies that have examined the tim ing of IAP
relative to breath control during lifting tasks.
2.2 Hypothesis 2
There will be a significant effect on maximal static trunk extensor force
production by breath control.
Although weight-lifting specialists suggest that breath holding
increases the capacity for trunk extensor force production, no
studies have examined the relationship between breath control and
maximal isometric trunk extensor force.
2.3 Research questions
1. What are the patterns of naturally occurring breath control during
lifting tasks?
2. What is the naturally occurring volume o f inspired air at the moment o f
lift-off?
26
Reports from researchers and weightlifting specialists consistently
suggest that breath holding is a common pattern of breath control
during the lifting o f heavy weights. There are no studies that have
reported the breath control patterns or volumes of inspired air of
non-weight-lifting healthy subjects during lifting tasks. The
naturally occurring patterns o f breath control and inspired
volumes o f air during lifting tasks may be related to the
mechanical role o f IAP. Consistent patterns of breath control
and/or volume of inspired air during lifting tasks may support the
concept of a central neural drive that is attempting to optimize the
timing and/or magnitude o f LAP generation.
27
3 Experim ental Design and Methods
3.1 V enue
The study was conducted at the Muscle Recruitment Laboratory, 15th
Floor, The Occupational and Industrial Orthopaedic Center, Hospital for Joint
Diseases, Mount Sinai NYU Health, 301 East 17th St., New York, NY 10003.
The study was approved the Institutional Review Board (IRB) of Research
Associates o f the New York University Medical Center (see Appendix 1).
3.2 Experim ental design
This was an experimental study using repeated measures, with a total o f
75 trials o f 20 seconds each. This study included three phases (I-HI). Testing for
all Phases was performed in a single session. Phases I and H required
approximately 2 hours to complete. A subset of the subjects completing Phases I
and II were recruited to complete Phase m , which required an additional 3/4
hours to complete.
28
3.2.1 Design of Phases
Phase I addressed research questions one and two concerning the
naturally occurring breathing patterns and volume of inspired air during lifting
tasks. Phase I included two independent variables with two levels each: (1) load
(70% and 35% o f maximum isometric exertion in upright posture), and (2)
posture (bent knees, straight knees). Phase I included two dependent variables:
(1) occurrence o f inhalation, exhalation, or breath holding, and (2) volume of
inspired air.
Phase II addressed the third hypothesis concerning the relationship
between breath control and maximum isometric trunk extensor force. Phase II
included two independent variables: (1) posture (upright, bent knees), and (2)
breath condition (inhalation-hold, exhalation-hold, inhalation-exhalation). Peak
lumbar extensor force was the dependent variable for Phase H.
Phase HI addressed the first hypothesis concerning the relationship
between breath control and IAP. Phase IH included three independent variables
with varying levels: (1) posture (bent knees, straight knees), (2) load (70% and
35% o f maximum isometric exertion in upright posture), and (3) breath condition
(inhalation-hold, exhalation-hold, inhalation-exhalation). Phase m had two
dependent variables: (1) peak magnitude o f IAP, and (2) timing o f peak IAP
relative to timing o f lift-off.
29
3.2.2 Postures
Three postures were used within this study as starting positions for the
lifting/extension tasks.
Knees bent (see Figure 5a): The subjects maintained the back relatively
straight and bent the knees.
Knees straight (see Figure 5b): The subjects maintained the knees straight
and flexed the spine and hips.
Upright (see Figure 5c): An adjustable strap between the harness and the
immovable support was used to alter the length of the cable such that
each subject’s trunk angle (e.g., thigh segment versus hip to shoulder
segment angle) could be visually estimated to be in five degrees of
flexion. The subject attempted to extend the spine m ax im a lly by pressing
posteriorly against the harness.
For dynamic loads (70% and 35% o f maximum isometric exertion in the
upright posture), the subject initiated the lift by grabbing the handle and moving
it upwards until they were standing fully erect. Subject maintained full elbow
extension throughout the lift. For static exertions in the knees bent posture, the
subjects exerted trunk extensor force against the handle while attempting to
extend the trunk. For static exertions in the upright posture, the subjects exerted
force against a 5 cm wide nylon harness placed around their back.
30
Figure 5. Three conditions of posture used in present study.
In 5a, 5b, and 5c : 1 = force transducer. In 5c: 2 = trunk harness and 3
= pelvic stabilization pad. Knees bent posture was used in both static
and dynamic trials. Knees straight posture was used only in dynamic
trials and upright posture was used only in static trials.
It has been shown that increases in trunk flexion increase compression
force on the lumbar discs.109 In view of the high degree of trunk flexion that
occurs during the knees straight posture, this posture was not used for the static
maximal exertions. The upright posture was only used for maximal isometric
exertions. The knees bent posture was used for both dynamic and isometric
exertions, as this posture has a lower risk o f injury.
31
3.2.3 Breath
The inhalation-hold and exhalation-hold lifting conditions were selected
based on their potential to vary the position of the diaphragm from the most
inferior position (maximum contraction as found during maximal inhalation) to
the most superior position (relaxation as found during maximal exhalation).
Inhalation-exhalation represented a potential midpoint between the previous
breath conditions. Further, use o f the inhalation-exhalation breath pattern during
a lifting task is commonly recommended for breathing by weight-lifting
specialists.120,121’124 The descriptions of the breath conditions are as follows:
1. Maximally inhale prior to the lift and hold the breath during the lift.
2. Maximally exhale prior to the lift and hold the breath during the lift.
3. Maximally inhale prior to the lift and exhale steadily during the lift.
3.2.4 Load
There were three levels o f load in the study: (1) isometric; maximum; (2)
dynamic; 70% of isometric maximum determined in upright posture; and (3)
dynamic; 35% of isometric maximum determined in upright posture. The
isometric maximum load level represents the most force the subject can exert
under optimal conditions. Two trials of the maximum exertion level in upright
posture were performed prior to Phase I testing in order to determine the
32
appropriate dynamic loads (70% and 35%) for Phase I and Phase HI testing. In
Phase H testing, the isometric maximum exertion in upright and bent knees
postures serves as the dependent variable.
It has been suggested that breath control is related to levels of load.109
However, the magnitudes of load that may produce different patterns of breath
control remain unknown. The decision to include 70% and 35% of isometric
maximum in the upright posture as levels of load was guided by the following
considerations: (1) load levels should be as significantly different in magnitude
as possible, given other considerations, in order to maximize the probability of
being able to determine significant differences in effect on IAP and different
effects on naturally occurring breath patterns; and (2) fatigue demands on the
subject prohibit the use of very high loads, as the larger load will have to be
lifted approximately 35 times within a single session.
3.2.5 Randomization
Randomization occurred within each trial based on the following
variables: (1) breath control, (2) posture, and (3) exertion level, within each
phase. Phases of the study were not randomized due to the requirement that
Phase I subjects not become aware o f the study’s purpose to measure naturally
occurring breathing patterns. Additionally, as Phase II requires maximal force
33
exertions, it was measured early within the testing period to avoid possible
fatigue effects on the dependent variable o f maximal force production.
3.3 S ub ject selection
Phase I included healthy, male and female volunteer subjects recruited
from student populations at N ew York University and Long Island University
via posters and/or announcements during classes. Only subjects between the age
of 20 and 40 years were included. Exclusion criteria demanded that subjects
were not obese (body mass index greater than 30 kg/m2), and did not have a
history o f LBP within the last six months, a history o f back or abdominal
surgery, a history of congenital or acquired muscle diseases, a history of severe
cardiovascular diseases (e.g., cardiac insufficiency, arrhythmia, severe
hypertension, vascular insufficiency, stroke), a history o f severe respiratory
diseases (e.g., asthma, acute infections, chronic bronchitis), current fractures or
a history o f musculoskeletal surgery within the last year, acute or chronic
infections, metabolic diseases (e.g., diabetes, hyperthyroidism), glaucoma,
structural diseases or congenital deformities of the spine of a high degree, or
inguinal, femoral, or umbilical hernia. In addition, elite athletes were excluded.
All subjects in Phases II and EH were recruited from Phase I. Subjects that
participated in the IAP measurement, which required placement o f a naso
gastric tube, received $75.00 in compensation after completion o f all trials, in
34
order to increase recruitment. Level o f physical activity in each subject was
determined by the Baecke habitual physical activity questionnaire7 (see
Appendix 1).
3.4 Sam ple size
Based on a power analysis21 (see Appendix 2), performed on preliminary
data of five subjects, using an alpha level o f 0.5 and a power level o f 0.8, Phase
II required 32 subjects and Phase III required 12 subjects. Phase I was a
descriptive study, and all subjects required for Phase II were used for Phase I.
3.5 Instrum entation
3.5.1 Multi-channel data acquisition system (see Figure 6):
This system can record data from 16 channels through an analog/digital
(A/D) board (Model AT-MIO-64F-F, National Instruments Corporation, Austin,
TX). This system was used to simultaneously collect data from three channels
(force transducer, pneumotach, and esophageal pressure transducer) at 1000 FIz.
Lab VIEW® for Windows software (Version 5.1, National Instruments
Corporation, Austin, TX) was used to collect data via an A/D board. Data was
stored on a PC (HP Vectra) and on 100Mb Iomega Zip discs (Iomega
Corporation, Roy, Utah).
35
3.5.2 Pneumotach / pressure transducer / facemask (see Figure 6):
The facemask (Hans Rudolph, Wyandotte, MO) was connected to a 122
cm long, 35 mm diameter breathing tube, which was connected to the
pneumotach. The subject breathed in and out through the breathing tube,
creating positive and negative airflow velocities within the pneumotach. The
pneumotach (Hans Rudolph, series 4813, 0-800 ml/min, Wyandotte, MO) is a
hollow tube with a series of mesh screens that impede airflow without creating
significant turbulence. Two ports, on either side o f the mesh screens, are
connected via plastic tubes to a pressure transducer that detects differences in
pressure between the two ports.
Changes in breath airflow velocity create changes in pressure differences
between the two ports. The pressure transducer converts mechanical pressure
differences into a continuous voltage output that was acquired by the multi
channel data acquisition system. Calibration o f the pneumotach to zero velocity
airflow, achieved by completely occluding the breathing tube, was performed at
the start and end of each phase of trials. See Appendix 3 for description of
calibration procedures.
3.5.3 Force transducer (see Figure 6):
The transducer was a small mechanical unit approximately 8 x 10 x 3
cm in size, with two attachment sites. During dynamic lifts, the transducer was
36
attached between the handle and the cable connected to the weights. During
isometric lifts, the transducer was connected to either the handle or the trunk
harness and to the immovable wooden supports of the in-house weight-lifting
device. The transducer converts linear mechanical force into continuous voltage
output that is acquired by the multi-channel data acquisition system. Offset was
performed prior to the start o f each subject’s trials by laying the unit on its side
with no tension applied to its attachment sites. See Appendix 3 for description
of calibration procedures.
3.5.4 Esophageal micro-tip pressure transducer (see Figure 6):
A 200 cm silicon rubber catheter (Millar Instruments, Inc., Houston,
TX) with a small diameter (0.162 cm), was connected via an interface cable to a
pressure transducer (TCB-600: Millar Instruments, Inc., Houston, TX). The
catheter transmits changes in pressure, occurring within the stomach, to the
pressure transducer, which converts the mechanical signal into a continuous
voltage output that is acquired by the multi-channel data acquisition system.
37
Force
Multi-Channel
Airflow Data Aquisition
System
IAP
Force
IAP
•Flow
lift-off put-down
Figure 6. Schema of experimental setup demonstrating acquisition of force,

flow, and IAP data.
Force, flow, and LAP data were acquired as pictured above. Force data
were provided by the force transducer attached between the handles
and the cable attached to the weights. IAP data were provided by the
pressure transducer in the gastric ventricle via the nasal cavity. Flow
data were provided by the pneumotach attached to the hose connected
to a facemask covering the nose and mouth.
38
Offset was performed prior to the start of each subject’s trials by placing the
sensor .25 cm below the surface of water at 37 degrees Celsius. See Appendix 3
for a description o f procedures used to insure that data collection o f the IAP
catheter and force transducer were simultaneous.
3.5.4 In-house weight-lifting device:
A weight-lifting device was constructed for application of various loads
to subjects during dynamic lifts, and adequate resistance and stabilization during
isometric exertions. The lifting device consisted o f a wooden standing platform
in which a pulley was embedded (see Figure 5). A second pulley was attached to
a cross bar between two upright wooden beams at one end of the standing
platform. A cable traveled through both pulleys and was connected to a handle
on one end. The non-handle end of the cable was attached to the appropriate
combinations of weights for the dynamic lifts, and to an immovable wooden
support for the isometric exertions. The weights were standard, commercially
available lead weights. Various combinations o f weights were secured to the
cable by being placed on a vertical metal rod with a 15 cm diameter wooden base
attached. A height-adjustable pole, designed to hold the handle, was attached to
the wooden platform. This allowed normalization o f the height of the handles at
the start of the lifts. A removable, and height adjustable, pelvic stabilization pad
39
allowed for stabilization, o f the anterior pelvis during isometric vertical posture
exertions.
3.6 Procedure
3.6.1 Phase I
3.6.1.1 Completion of consent forms and screening
Subjects were informed o f the study protocol and total time needed for
testing. All risks and possible harms as described in the consent form (see
Appendix 2) were verbally explained. All subjects completed a Baecke
Questionnaire of Habitual Physical Activity (see Appendix 4)7 and a medical
history questionnaire (see Appendix 3), signed a consent form (see Appendix
1), and were measured for height and weight. Subjects received a brief clinical
evaluation by a physician who reviewed the questionnaires and confirmed the
appropriateness o f the subjects based on their responses and the exclusion
criteria. Further, the physician observed for scars indicating prior surgery, and
performed a screen for structural deformities o f the spine. Subjects were
allowed to wear gym shoes, t-shirts, and shorts.
For all trials in the study, the subjects were informed immediately prior to
the trial o f the appropriate posture, load, or breathing condition used in that
trial. Throughout all testing, subjects were instructed to stop performance of the
40
lifting tasks immediately shoulcfl they perceive any pain or breathing difficulties,
and to report the presence of p a in or breathing difficulties to the examiners.
3.6.1.2 Warm up / adjustment • of handle and stabilization-pad height
Subjects warmed up the ttrunk muscles by performing 10 repetitions each
o f trunk flexion, lateral flexion right and left, and rotation right and left. While
standing on the lifting platform , the height of the handle was adjusted for all
lifts to originate at a level 2.5 c m superior to the most superior aspect of their
patella. The pad designed to prrovide resistance for the anterior pelvis during
vertical posture trunk extensionas was adjusted such that both anterior superior
iliac spinae of the subjects pusbned directly into its surface. Prior to testing, two
goniometric measurements o f each individual’s trunk-to-thigh angle were
performed in the knees bent anod knees straight postures while the subject held
the handle at the normalized height. Subjects were instructed in the three
postures that were used during testing. For all postures, subjects self-selected
the width of their foot placememt, and aligned the tips o f their toes along a line
drawn on the platform such that the pulley within the platform is approximately
aligned with the midfoot.
41
3.6.1.3 Placement o f face mask
Subjects were fitted for one o f three facemask sizes. The facemask was
placed on the face and checked for air leaks with both inspiratory and
expiratory pressures by occluding the breathing hole. If leaks existed, the straps
connecting the facemask to the head were tightened, and/or a disposable
silicone seal was provided. The subjects were instructed to begin the trial after
the breathing tube was handed to them. The subjects were instructed to
immediately remove the breathing tube at the end of each trial.
3.6.1.4 Phase I trials
Subjects first performed randomized trials designed to acquire force and
airflow data used for normalization o f exertion levels and breath volume. For all
maximal exertions, examiners read the following standardized script to the
subjects:
“In these four trials we are measuring how much force you can generate.
It is very important that you pull on the handle, or against the trunk
harness, with as much force as you can. You should apply the force
smoothly to the cable so that you have reached your m axim um force
output after 2 seconds. Then you must keep pulling at your maximal level
for three additional seconds. Keep pulling until you hear me say stop. If
you feel any pain or breathing difficulties during the exertion, please stop
the trial and tell us.”
42
For maximal inspiratory capacity, subject breathed normally for 2-3
cycles, and on the examiner's cue, maximally inhaled. Care was taken
throughout the recruitment and testing period to avoid direct or explicit
explanations to the subject regarding the purposes of Phase I testing, as
awareness o f the variable o f interest could bias the findings via conscious
control o f the breath. The use o f the purposefully vague, but essentially accurate
term “air exchange” was used within the consent form for Phase I testing (see
Appendix 1).
Subjects then performed randomized trials to address the research
questions regarding naturally occurring breathing patterns. It was considered
that providing the subject with specific cues regarding when to begin the lift
may alter the normal relationship between breath and lifting that would have
occurred if the subject performed the lift without external cues. Therefore, a
standardized script was read to each subject that emphasized that the tim ing of
the lift is totally within their own control:
‘'We are attempting to determine information about how people perform

lifts. Use the bent knee or straight knee posture as I have demonstrated,
and perform the lift as naturally as possible. Perform the lifts without
“jerking" the weight. I will hand you the breathing tube, and after you
attach it, I will say “Anytime you are ready". Begin the lift whenever you
want after I say “Anytime you are ready". The timing is up to you. There
is no rush. Lift the weight at your own pace in a way that feels best to
43
you. I f you fe e l any pain or breathing difficulties during the lifts, please
stop the lift and tell us. ”
3.6.2 Phase H trials
3.6.2.1 Insertion of IAP measurement device (naso-gastric catheter)
The naso-gastric catheter was introduced nasally into the gastric
ventricle after application of one o f two topical anesthetics to reduce discomfort
and the gag reflex (“Hurricane” Benzocaine 20% spray or Lidocaine HCL jelly
USP 2% sterile aqueous solution). The correct location was confirmed by a
series of respiratory and abdominal maneuvers. The subject was instructed in,
and allowed to practice, a maximal valsalva maneuver.
Subjects performed randomized trials designed to address the relationship
between breath control and maximal isometric trunk extensor force. The
examiner described and demonstrated how to perform the three types of
voluntary breath control. The subjects practiced the breathing conditions in
conjunction with both postures and a submaximal isometric exertion. Subjects
then performed maximum isometric exertion trials using two postures and the
three breath control conditions. A standardized script was read to each subject
prior to the trials:
“Do you clearly understand andfeel you can accurately perform the three
breathing conditions, two postures, and maximal exertion, I have
demonstrated and described to you? Immediately prior to each trial, I will
44
repeat the required breath condition and posture two times. I f you are
unsure about what to do during the trial, please stop and tell us. I f you feel
any pain or breathing difficulties during the trials, please stop and tell
us. "
3.6.3 Phase III trials
Subjects performed dynamic exertion trials using two postures, three
breath conditions, and two levels o f exertion. A standardized script was read to
each subject prior to the trials:
“Do you clearly understand and fe e l you can accurately perform the three
breath conditions, two postures, and two levels o f exertion I have
demonstrated and described to you? Immediately prior to each trial, I will
repeat the required breath condition, posture, and level o f exertion two
times. I f you are unsure about what to do during the trial, please stop and
tell us. I f you feel any pain or breathing difficulties during the trials,
please stop and tell us. ”
3.6.4 Quality control relative to procedure
If a trial was stopped by the subject or examiner for any reason, it was
repeated. If the subject did not complete the exertion prior to completion of the
20-second trial, the trial was repeated.
45
3.6.4.1 Posture
Control o f postures was accomplished via two mechanisms: (1)
standardization o f the posture at the point in time that force is applied to the
transducer, and (2) visual monitoring by the examiner. The first method of
control was accomplished in knees bent and knees straight postures by
normalization o f handle height based on anthropometry, as described
previously. In the upright posture, the first method o f control was accomplished
by altering the length o f an adjustable strap between the trunk harness and the
immovable support such that each subject’s trunk angle (e.g., thigh segment
versus hip to shoulder segment angle) was in five degrees of flexion, as
determined by a goniometer. The second method o f control was accomplished
by the examiner observing all trials and stopping a trial when a subject
performed postures inappropriately, such as by: (1) bending the knees when
they should be straight or vice versa; (2) flexing their elbows; (3) moving their
feet; and (4) leaning backward sufficiently to alter the angle of the cable to the
platform to be less than 90 degrees.
3.6.4.2 Load
Standardization o f maximum isometric exertions was achieved through
the reading o f a standardized script as previously described in Section 3.6, and
through consistent clarification and encouragement from the examiners.
46
Dynamic exertion levels (70% and 35%) were determined by the maximal
isometric exertion trials in the upright posture and were standardized through
the application o f the appropriate weights to the cable.
3.6.4.3 Breath
The examiner monitored the subject for appropriate breath conditions by
listening for airflow sounds and observing mouth and lip motions. If a subject
was suspected of not achieving the appropriate breath condition, the airflow
data horn the trial were examined. If the subject failed to achieve the breath
condition, they were re-instructed, and the trial was repeated. The airflow data
from this second trial were then examined to insure compliance with the breath
condition.
3.7 Data analysis
3.7.1 Processing
An analysis program using Matlab® for Windows software (Version
5.3.0; student version, The Mathworks Inc., Natick, MA) was created to perform
signal processing. The Matlab® program determined: (1) timing of “lift-off” and
“put-down" o f the weights during the dynamic exertions; (2) peak force; (3) peak
IAP (4) flow direction (inhalation/exhalation/holding); and (5) volume of
inspired air. Additionally, the analysis program identified the timing o f all
47
variables relative to the instant of lift-off. Detailed descriptions of the criteria
used for signal processing o f these variables are described below.
F o rce a n d LAP
100 Force
IAP
80-
at
x
■Eo 60-
i 1 40~
20-
0 .2 0.4 0.6 0.8 1.4

time irm ms.
Liftoff Putdown
Figure 7. Representative data from one subject showing identification of peak

force, peak IAP, lift-off, put-down, and determination of timing of peak IAP.
The y-axis represents both magnitude o f force (kg) and magnitude o f

IAP (mmHg). They x-axis represents time in milliseconds. Lift-off is
that point at w h ich force exceeds a baseline value by 2.27 kg (5 lbs).
Put-down is tinat point at which force returns to a value below 2.27 kg
above baseline. Peak IAP and peak force are identified as the highest
mean values im each curve during a 0.1 second time period. Peak IAP
and peak for-ce values are only determined in the time period
beginning witHi lift-off and ending at one-half o f the period between
lift-off and purtdown. Timing of IAP is determined by subtracting the
time o f lift-off- from the time of occurrence o f the peak IAP (middle of
the 0.1 second peak IAP period).
48
3.7.1.1 “Lift-off’ and “Put-down”:
Tuning o f the application of force to the handles or trunk harness varied
among subjects. The “lift-off’ in this study was defined as the point in time
during the trial at which the force transducer data exceeded 2.27 kg (5 lbs.)
above baseline (see Figure 7). “Put-down” was defined as the point in time at
which the force transducer data fell below 2.27 kg above initial baseline.
3.7.1.2 IAP magnitude
As the biomechanical events related to lifting (not lowering) the weight
were the primary events o f interest in this study, the analysis program was
designed to restrict its search for IAP values to a specific time period. IAP values
used for analysis were obtained from the time period beginning at lift-off and
ending at a point halfway between lift-off and putdown. This restriction o f the
time period prevented the analysis of IAP values associated with the efforts of
put-down.
In order to explore the effect of the processing method on the values of
peak IAP, values were initially obtained using different time periods: (1) 1
second; (2) 0.5 seconds; (3) 0.1 second; and (4) 0.001 second (i.e., sampling
frequency—single value). The analysis program found the highest mean IAP
value in each o f these windows.
49
3.7.1.3 IAP timing
The time from the mid-point of the peak IAP reference window to the
time o f lift-off was determined by the analysis program (see Figure 7).
3.7.1.4 Peak force
The highest mean o f force values within a one-second window were
determined by the analysis program during maximal static exertions used for
Hypothesis 2. Additionally, peak force values were obtained during dynamic lifts
within windows of .1 second and .3 second in order to explore the effect of data
collection windows of different time periods on peak values.
3.7.1.5 Airflow categorization
Airflow was categorized into inhalation, exhalation, or breath holding.
Nominal and mutually exclusive categories could have been easily formed by
having positive flow represent inhalation, negative flow represent exhalation, and
zero flow represent breath holding. However, a pure zero flow-rate is rarely
found within actual data. Even with the airway fully occluded, the pneumotach is
sensitive to small pressure fluctuations around the zero baseline due to pressures
that arise solely through movement o f the breathing tube or facemask. Further,
50
even valid measures of zero flow can occur in very brief time periods (e.g., .001
second), yet probably do not represent genuine changes in respiratory intent.
Consequently, after viewing multiple airflow curves from the pilot study,
criteria were created in an attempt to obtain a reasonable and valid criterion for
the categorization o f breath holding. Flow rate was categorized as breath holding
if its magnitude deviated from zero by less than ± 5% o f the individual’s
maximum flow rate for that trial and remained within these magnitude
parameters for a minimum of 0.2 seconds. Positive flow not categorized as
breath holding was categorized as inhalation and negative flow not categorized
as breath holding was categorized as exhalation.
3.7.1.6 Categorization of airflow at five points in time
Airflow was categorized using the above methods at five points in time
relative to lift-off: (1) 1 second prior to lift-off; (2) 0.5 seconds prior to lift-off;
(3) lift-off; (4) 0.5 seconds post lift-off; and (5) 1 second post lift-off.
3.7.1.7 Volume of inspired air
In order to determine the volume of inspired air, an assumption was
required that the subject was breathing with regular tidal volume at the initiation
of the trial period. Given this assumption, a relatively stable endpoint o f volume,
assumed to represent functional residual capacity (FRC), occurs at the end of
51
exhalation immediately prior to the start of inspiration. Volumes in excess of
FRC represent active inspiratory effort and volumes below FRC represent active
expiratory effort.
The analysis program began integration of flow velocity at the first
crossing o f the flow from exhalation to inhalation. In this way, the FRC was
established as a zero volume x-axis. The analysis program performed a second
integration by starting at the second crossing o f the flow from exhalation to
inhalation (see Figure 8 for example). The analysis program then identified the
five volumes present at the five time periods as described earlier, based on the
two separate integrations. These values were then normalized to the maximal
inspiratory capacity values obtained in separate trials.
3.7.1.8 Baecke Questionnaire
A total combined work, sports and leisure activity score was computed
using the calculations shown in Appendix 4.
3.7.2 Statistical Analysis
All statistical analysis was performed using a statistical computer software
program (Version 8.0, 1997, SPSS Inc., Chicago, IL). Descriptive statistics (mean,
standard deviation (SD), standard error o f the mean (SEM), 95% confidence
interval (Cl) o f the mean) were computed for demographic, airflow, force, and
52
3000
2000
1000
-1000
-2000
L ift-off P u t-d o w n
-3000
2000 4000 6000 8000 10000 12000
Milliseconds
Figure 8. Representative data from one subject demonstrating methods of

integration o f air flow.
The y-axis represents milliliters o f flow. The x-axis represents time in

milliseconds. This figure shows an example of a flow curve and the
two integrations derived from flow. Note the start of integration # 1 at
the first crossing of flow from negative to positive and the start of
integration # 2 at the second crossing o f flow from negative to
positive. Also, note that the zero flow magnitude level at the end o f a
normal relaxed expiration, immediately prior to inspiration, represents
functional residual capacity (FRC) and serves as a baseline quantity o f
volume within the lungs.
53
IAP data. For Hypothesis one, the statistical procedure multivariate analysis o f
variance (MANOVA) of repeated measure design was used to determine the
effect of breath control, posture, and load on IAP magnitude and timing. If the
overall MANOVA was significant a separate univariate analysis (ANOVA) was
performed on each independent variable. For Hypothesis 2 an ANOVA was used
to determine the effects of breath control on maximal isometric trunk extension
force. For the Research Question, an ANOVA was used to determine the effects
of time (regularly spaced data collection points relative to lift-off) on volume
during lifting. All statistical tests used a p value of .05.
The paired t-test, with a Bonferroni correction, has been suggested as a
reasonable approach for looking at differences between pairs of means within a
repeated measures design.49,54’100 Standard post hoc tests for multiple comparisons
within repeated measures designs are inappropriate as they are based on overall
group differences119 and may provide inflated alphas.49 In all cases in the present
study in which the ANOVA was significant, multiple paired t-Tests using a
Bonferroni correction (based on p < .05) were performed to determine which pairs
of the levels of the independent variable were significant.
54
4 Results
4.1 Description o f S u b jects
Fourteen males and 20 fermales completed the study, although IAP data from two
subjects was not used in the analysis as explained in Section 4.2 below. Ail
subjects completed all trials, with the exception o f five trials in one subject not
being completed due to failure of the force transducer as described immediately
below. Table 1 shows the nneans and standard deviations of the age, height, and
weight of the participants.
Table 1. Demographic an»d Baecke Questionnaire data of participants.
Characteristic Force/Flow/Volume IAP

(n = 34) (n = 11)
M fSDl MfSDl
Age (years) 25.6 (5.5) 24.5 (4.7)
Sex 14M, 20F 4M, 7F
Height (cm) 167.2(11.1) 164.9 (13.3)
Weight (kg) 65.8 (15.5) 64.6(15.0)
Baecke Questionnaire
Leisure 2.37 (.61) 2.45 (.82)

Work 3.34 (.75) 3.18 (.63)
Sports 2.96 (.96) 2.95 (.95)
Total 8.67(1.61) 8.59 (2.00)
Note: Force/Flow/Volume- data (n = 34) used for analysis of research question and
Hypothesis 2. IAP data (n = 11) used for analysis o f Hypothesis 1.
55
The only significant subject complaint was a feeling of “burning” in the
nose secondary to the topical anesthetic (“Hurricane” Benzocaine 20% spray)
applied prior to insertion o f the nasogastric tube. After the first four subjects, the
topical anesthetic sprayed in the nose was replaced by a similar anesthetic in gel
form (Lidocaine HCL jelly USP 2% sterile aqueous solution) that was applied
directly to the leading edge o f the tube. This successfully eliminated further
complaints.
The original design planned to divide subject data into two groups based
on the presence or absence o f IAP measures. Equipment failure of the force
transducer during the last five trials of one subject necessitated the division o f the
data into three subsets: volume and flow data used for the research question (n =
34), force data used for Hypothesis 2 (n = 33) and IAP data used for Hypothesis 1
(n = 11).
Table 1 shows the means and standard deviations for the results of the
Baecke Questionnaire7 for the categories o f leisure, work, sports, and total
activity. Appendix 1 demonstrates the method used to calculate these indices. The
average scores for the indices of leisure, work, sports and total activity for all
subjects were 2.37 (± .61), 3.34 (± .75), 2.96 (± .96), and 8.67 (± 1.61),
respectively.
56
4.2 IA P and Force D ata
Inspection for missing data revealed no missing values unrelated to the
previously described equipment failure. Inspection of the IAP data (n = 13) for
plausibility revealed two subjects in which IAP values were occasionally negative.
Visual inspection o f the relationship between flow and IAP curves for these
subjects revealed a high degree o f probability that the IAP catheter had not been
properly placed within the abdominal cavity. Data from these subjects were not
used in the analysis for Hypothesis 1 regarding IAP. Consequently, analysis for
Hypothesis 1 was performed on data from 11 subjects.
Raw IAP magnitude values ranged from 2-178 mmHg and were within the
ranges o f previously reported values.3’9’26’30’31’35-40*55’56’58’64-66’66'81-83’91-109’110-115-133
Raw IAP timing values ranged from 0.00-3.16 seconds. These values imply that
peak IAP occurred at times ranging from the instant o f lift-off to 3.16 seconds
post lift-off. The rate of lifting was not controlled and observations during testing
suggested that most lifts appeared to require 2-3 seconds to complete. However, as
some subjects occasionally took considerably longer to complete the lifting phase
of the lift, timing values as great as 3.16 seconds were plausible.
IAP magnitude and timing, as well as force data, from the first and second
trial of each combination of conditions were compared using paired t-Tests (p <
.463; p < .429; p < .084, respectively). As these variables were found not to be
57
sig n ifican tly different from trial one compared to trial two, average values of the
two trials were used for all analyses.
Summary descriptions o f magnitude and timing values of peak IAP,
determined within various data collection windows as described in Sections
3.7.1.2 and 3.7.1.3, were inspected for plausibility (see Appendices 6 and 7).
Mean LAP magnitude values (mmHg) increased as expected from longer time
periods (1 second: 45.3 (± 29.6)) to shorter time periods consisting of a single
value at the sampling frequency (.001 o f a second: 54.1(± 31.5)).
Mean IAP timing values of the longest three data collection windows were
similar, ranging from 1.1 (± .6) — 1.3 (± .6) seconds. The single value for the
sampling frequency (.001 second) appeared substantially different than the other
mean values, at 2.1 (± 2.9) seconds. Additionally, this single value had much
higher variability compared to the three longer data collection windows. After
comparison of the data from all collection periods, a data collection window of .1
second was chosen for all IAP analysis. This time period had the advantages of
being brief enough to represent genuine peaks of the IAP curves while having
variability and timing similar to the longer windows.
Summary descriptions of force obtained during dynamic lifting trials were
examined for plausibility (see Appendix 8). As expected, longer data collection
windows produced smaller force values. The mean values for the .1-second and
.3-second data collection windows were 43.4 (± 21.3) and 41.3 (± 20.7) kg,
58
respectively. Force data were also examined relative to static and dynamic
exertions and levels of posture (see Appendix 8). As expected, mean static
exertion values (80.8 (± 34.3) kg) were larger than mean dynamic values (43.5 (±
21.3) kg) and knees bent posture values (97.8 (± 36.5) kg) were larger than
upright posture values (68.6 (± 27.1) kg).
Values in each group of conditions (12 groups o f IAP magnitude data; 12
groups of IAP timing data; 6 groups o f force data) were transformed into z values
and inspected for potential outliers. For IAP groups (n = 11), z values in excess of
2.58129 were identified as outliers. For force groups (n = 33), z values in excess of
3.3129 were identified as outliers. There were seven groups o f IAP data with a
single outlier present. Force data contained no outliers. All statistical results were
shown to be robust in the presence o f the IAP outliers. This was determined by
comparing results o f the statistical analysis performed on the original data to
results obtained on data with the seven outlier values changed by moving them
toward their group means by one standard deviation.
Assumptions of normality for each grouping of conditions were evaluated
using the Kolmogorov-Smirmov test. Three of 24 groupings o f IAP data [3 levels
o f breath x 2 levels of posture x 2 levels o f load x 2 dependent variables (timing
and magnitude)] had p values less than .5, suggesting that these particular groups
had a non-normal distribution. Using random samples o f equal size, the
multivariate analysis of variance (MANOVA) is robust to violations of
59
normality.12 Assumptions of homogeneity o f variance for each grouping of
conditions were evaluated by Mauchly’s Test o f Sphericity54’119 and found to be
adequate.
4.3 Flow and V olum e Data
Flow and volume data were examined for missing values. There were no
missing flow values, however, there were a substantial number of missing volume
values. In approximately 40% of the trials, the second set o f volume data was
missing because subjects began to perform the lift prior to a second crossing o f the
flow data from exhalation to inhalation. Therefore, in these trials a second
measure of the subjects’ naturally occurring functional residual capacity (FRC)
was unavailable. In order to determine the relative impact of the loss of this
second set o f baseline data, a paired samples t-Test was performed using all cases
in which both integrations were available. The two integrations were significantly
different (p = 0.015) using this test. However, the difference of the means of
volume one (872 ml) and volume two (917 ml) was only 45 milliliters. This
represents an approximately 5% difference between the means of the two
integrations. Although this represents a statistically significant difference, it was
judged to be unlikely to have functional significance, and therefore the values for
volume one were used for all analyses.
60
4.4 H ypothesis 1
A repeated MANOVA was performed on two dependent variables: LAP
magnitude and IAP timing. Independent variables were posture, load, and breath
condition. Table 2 shows the means and standard deviations of IAP variables
relative to the independent variables, while Table 3 shows summary results o f the
repeated MANOVA.
Separate repeated univariate ANOVAs were performed on the LAP
magnitude and timing data to investigate the effect of the two independent
variables (load and breath condition) identified in the MANOVA as sign ificant
See Table 4 for summary results regarding LAP magnitude and Table 5 for
summary results regarding LAP timing.
The results o f the repeated measures MANOVA for the main effects o f
posture, load, and breath condition, and their interaction effect on IAP magnitude
and timing are shown in Table 3. Based on Wilks’ Lambda, the combined
dependent variables were significantly affected by both the level of load (p <.01),
and the level o f breath condition (p c.Ol). Posture did not have a significant effect
on the combined dependent variables (p <.744).
61
Table 2. Means and standard deviations of IAP magnitude and timing data
relative to posture, load, and breath control (n = 11).
IAP IAP
Independent Level magnitude timing (sec.)
Variable (mmHg)
M CSD) Mtsm
Posture Knees Bent 40.9 (21.9) 1.10 (.67)
Knees Straight 44.5 (22.6) 1.10 (.66)
Load Large 50.2 (23.2) 1.21 (.68)

Small 34.3 (8.1) 0.93 (.62)
Inhale-Hold 51.6(23.9) 0.89 (.60)

Breath Control Exhale-Hoid 38.7 (15.3) 1.20 (.77)
Inhale-Exhale 39.3 (22.9) 1.13 (.66)
Table 3. Results of repeated multivariate analysis of variance (MANOVA)

for the main effects and interaction effects of posture, load, and breath on
IAP magnitude and timing (n = 11).
F P value
Posture .306 .744

Load 7.955 .010*
Breath 3.887 .010*
Posture x Load 2.397 .146
Posture x Breath 1.417 .247
Load x Breath 3.397 .018*
Posture x Load x Breath 1.644 .183
p < .05
62
Table 4. Results of repeated measures univariate analysis of variance
(ANOVA) for effects of load and breath and the interaction of load and
breath on IAP magnitude (n = 11).
F P value
Load 16.691 .002*

Breath 5.393 .018*
Load x Breath 6.494 .008*
*p < .05
Based on Greenhouse-Geisser,34 IAP magnitude was significantly affected
by both the level o f load (p = .002), and by the level of breath condition (p =
.018), as well as by the interaction o f load and breath (p = .008). IAP timing was
not significantly affected by level o f breath condition (p = .113) or by the
interaction o f load and breath (p = .629). There was evidence that IAP timing was
affected by level o f load (p < .055), although it failed to achieve pre-set levels of
statistical significance.
Table 5. Results of repeated measures univariate analysis of variance

(ANOVA) for the main effect of load and breath, and the interaction of load
and breath, on IAP timing (n = 11).
F P value
Load 4.722 .055

Breath 2.457 .113
Load x Breath .393 .629
63
Because there are only two levels o f the independent variable load (large
and small), the effect o f levels of load on IAP magnitude can be determined
directly from the summary data in Table 2. Large loads produce greater IAP
magnitude values (50.2 ± 23.2 mmHg) than small loads (34.3 ± 8.1 mmHg).
Since there are three levels of the independent variable breath condition, it was
necessary to perform post-hoc tests to determine the effects of breath condition
level on IAP magnitude. The effect of levels of breath control on LAP magnitude
was evaluated using multiple paired t-Tests. A Bonferroni correction for multiple
comparisons was applied whereby the overall alpha was divided by the number of
comparisons (alpha = 0.05/3 = 0.017).
Table 6 shows the results of these comparisons. Inhalation-hold (51.6 ±
23.9 mmHg) was significantly different from exhalation-hold (37.7 ± 16.8 mmHg,
p = 0.001) and from inhalation-exhalation (39.3 ± 22.9 mmHg, p = 0.001).
However, exhalation-hold was not significantly different from inhalation-
exhalation (p = .813).
4.5 H ypothesis 2
The means and standard deviations of maximum isometric force in two postures
are shown in Table 7 relative to the three conditions o f breath. As the effect of
posture on force production was not a question in this study all analyses relative
64
Table 6. Results o f Paired t-Tests on effect of levels of breath condition on
IAP magnitude (n = 11).
Paired t df P value
Differences
95% Confidence
Interval of the
Difference
M SD SEM Lower UDper
Inhalation-Hold to 12.93 21.04 3.17 6.53 19.33 4.07 43 .000**
Exhalation-Hold
Inhalation-Exhalation
Exhalation-Hold to -.610 17.01 2.56 -5.78 4.56 -.238 43 .813
Note: SEM = Standard Error o f the Mean
* *£<0.017; Significance based on Bonferroni correction for multiple comparisons
Table 7. Means and standard deviations of maximum isometric force data

relative to posture and breath condition (n = 33).
Independent Level Force (kg)

Variable
Knees Bent Upright
MfSDl MfSDl
Inhalation-hold 90.7 (36.9) 68.2 (27.6)

Breath Exhalation-hold 93.4 (36.9) 66.7 (25.8)
Condition Inhalation-Exhalation 94.4 (35.8) 70.7 (27.9)
65
to breath control were examined within each posture. As expected, the upright
posture produced less mean force (68.6 ± 27.1 kg) than the knees bent posture
(92.8 ± 36.5 kg).
Separate repeated ANOVAs were performed on the dependent variable
maximum isometric force in the upright and knees bent postures. The independent
variable was breath control. For results of the ANOVA performed on data from
both the upright and knees bent posture, see Table 8. In the knees bent posture,
there was evidence that breath control had an effect on maximal force production
(p = .089), although it failed to achieve pre-set levels o f statistical significance. In
the upright posture there was a significant effect of breath control on maximal
force production (p = .015).
Table 8. Results of separate repeated ANOVAs for effects of breath control

on maximal isometric force production in the upright and knees bent
postures (n = 33).
F P value
Knees Bent Posture 2.596 .089
Upright 4.859 .015*
'p < .05
66
As there were no significant effects of breath condition on maximal isometric
force production in the knees bent posture, further analysis was not performed. In
the knees straight posture, however, it was necessary to perform post-hoc tests to
determine the effect o f level o f breath condition on maximal isometric force. The
effect o f levels o f breath control on maximal isometric force was evaluated using
multiple paired t-Tests. Table 9 shows the results of these comparisons. A
Bonferroni correction for multiple comparisons was applied where the overall
alpha was divided by the number o f comparisons (alpha = 0.05/3 = 0.017).
Inhalation-exhalation (70.7 ± 27.9 kg) was significantly greater than exhalation-
hold (66.7 ± 25.8 kg, p = .014). The two other comparisons were not significantly
different (inhalation-exhalation to inhalation-hold, p = .034; inhalation-hold to
exhalation-hold, p = .206).
4.6 Research Question
Flow and volume data from conditions o f naturally occurring
breath control during dynamic lifting tasks were used to examine the research
question. Frequency distributions o f the occurrence of inhalation, exhalation, and
breath holding during dynamic lifting tasks are presented in Figure 9.
67
Table 9. Results of paired sample t-Tests for effect of levels of breath
condition on maximal isometric force production in the upright posture (n =
33).
Paired t df P value**
Differ
ences
95% Confidence
Interval o f the
Difference
M SD SEM Lower UDDer
Inhalation-Hold to 1.580 7.024 12227 -.911 4.071 1.292 32 .206

Exhalation-Hold
Inhalation-Hold to -2.483 6.456 1.1238 -4.772 -.1940 -2.209 32 .034**

Exhalation-Hold to -4.063 8.941 1.5565 -7.234 -.893 -2.610 32 .014**

**P < 0.017; Significance based on Bonferroni correction for multiple comparisons
Figure 9 displays how the relative frequencies o f inhalation, exhalation, and
breath holding vary from one second prior to lift-off to one-second-post lift-off.
In general, prior to lift-off there is a clear trend toward inhalation ( I s prior =
56.6%; 0.5 s prior = 59.9%) or exhalation (1 s prior = 36.6%; 0.5 s prior = 28.9%)
with little breath, holding. During lift-off and 0.5 seconds post lift-off, the relative
frequencies o f the three types of flow are quite similar and there is no clear
pattern. This implies that as the subjects approached the lift-off time period, they
increased the relative amount of breath holding. By one second post lift-off, the
68
Flow 1 sec. Flow 0.5 secs. Flow 0.5 secs. Flow 1 s e c
Flow at liftoff
prior to liftoff priorto liftoff post liftoff post liftoff
100 -> 100 -> 100 -| 100 -1 100 -1
80 - 80 - 80 - 80 - 80 -
80 ■ — 80 - — so - 80 •
40
HH-U - r— i 40
!§ ]
-
«J I “3aJII HIV-
® Exhalation ■ Holding □ Inhalation
Figure 9. Frequency distribution of naturally occurring categories of

inhalation, exhalation, and breath holding during dynamic lifting.
Figure displays percent of each category of exhalation, breath holding,
and inhalation in all trials at five points in time relative to liftoff. Note
the general trend to decrease inhalation as the lift proceeds while
increasing the amount of breath holding and exhalation.
majority o f subjects are exhaling (53%) with almost equal amounts o f inhalation
(20.6%) and breath holding (25.7%).
Comparisons o f flow type between the knees bent and knees straight
postures and large and small loads were also performed (see Appendix 9; Figure
A). Posture appears to have no effect on the relative frequency of flow types. Load
appears to not affect flow types for the time periods prior to lift-off and lift-off
itself. However, in the two time periods post lift-off it appears that large loads
increase the relative frequency of breath holding compared to low loads.
69
Although Figure 9 displays the relative frequency o f flow types at different
time periods, this figure does not reveal the patterns o f flow for individual
subjects. It is unknown from these figures, for example, how many o f those
individuals who were exhaling at one second prior to lift were also inhaling during
lift-off Using only three time periods (one second prior to lift-off; lift-off; one
second post lift-off), 27 possible breathing patterns are possible. For example, a
subject that exhaled at one second prior to lift-off, then inhaled at lift-off, then
exhaled one second post lift-off would have a pattern o f “Exhale-Inhale-Exhale”
(E —I —E.). See Appendix 9, Figure B, for a display o f the eight most commonly
occurring breath patterns relative to posture and load.
Although 27 potential patterns existed, the eight most frequent breathing
patterns across all trials accounted for 70.3% o f breath patterns used. Seven o f the
eight most frequent patterns used in the small load group were the same patterns
used in the large load group (see Appendix 9; Figure B). Additionally, six of the
eight most frequent patterns used in the knees bent group were the same patterns
used in the knees straight group (see Appendix 9; Figure B). Consequently, there
appears to be no clear difference in breathing patterns between levels of posture or
levels of load. The two most frequent patterns, appearing either in the first or
second position in every grouping, were “I —E —E” and “E —I —E”.
Table 10 shows the means and standard deviations o f volumes 1-5
representing variations in volume relative to time of lift. The values, normalized to
70
peak inspiratory capacity, show a range from 24.8% to 36.3%. In order to
determine if these changes represent significant differences, a repeated ANOVA
for effects o f time on volume was performed (see Table 11). These results show
that the mean volume changed significantly during the time o f the lift (p < 0.001).
Table 10. Means and standard deviations of naturally occurring inhaled

volume at five points in time during lifting (n = 34).
Mean (SD)
Volumes % of Inspiratory Capacity
I 24.8 (16.1)
2 30.9(18.0)
3 36.3 (17.9)
4 35.6(17.0)
5 30.5 (19.0)
Note: Volume 1 = I s prior to lift-off; Volume 2 = 0.5 s prior to liftoff; Volume 3 = lift-off;
Volume 4 = 0.5 s post lift-off; Volume 5 = I s post lift-off. Mean values o f volume normalized to
peak inspiratory capacity for each subject.
The effect of levels of time on volume was evaluated using multiple paired
t-tests. Table 12 shows the results o f these comparisons. A Bonferroni correction
for multiple comparisons was applied where the overall alpha was divided by the
number o f comparisons (alpha = 0.05/10 = 0.005). All volume pairings except two
were significantly different from each other. Volume 3 was not significantly
71
Table 11. Results of repeated ANOVA for effects of time on volume during
lifting (n = 34).
F P value
Time 28.237 .000*
‘p < .05
different from volume four (p = 0.367), and volume two was not significantly
different from volume five (p = 0.864). As shown in Figure 10, comparisons of
volumes three and four reveal a genuine plateau of the volume curve whereas
comparisons o f volumes two and five reveal that these volumes represent the
upward and downward slope of the volume curve centered on lift-off.
Table 12. Results of paired t-Tests on levels of volume during lifting (n = 34).
t df P value
Volume 1 - Volume 2 -6.170 135 .000***

Volume 1 - Volume 3 -8.157 135 .000***
Volume 1 - Volume 4 -7.028 135 .000***
Volume 1 - Volume 5 -3.417 135 .001***
Volume 2 - Volume 3 -7.430 135 .000***
Volume 2 - Volume 4 -4.277 135 .000***
Volume 2 - Volume 5 -.171 135 .864
Volume 3 - Volume 4 .905 135 .367
Volume 3 - Volume 5 4.387 135 .000***
Volume 4 - Volume 5 6.712 135 .000***
***p < 0.005; Significance based on Bonferroni correction for multiple comparisons
72
Volume data relative to levels of posture and levels of load are displayed
in Figure 10. In general, at the two times prior to lift-off there were no differences
in volume relative to posture or load. However, at lift-off, a slight difference
begins to appear, and at the two time periods post lift-off these differences in
volume relative to posture and load grow larger. Figure 10 suggests that, starting
at lift-off, greater volumes are used with large loads relative to small loads, and
with knees straight posture relative to knees bent posture.
Post hoc tests were performed to determine the significance o f the findings
suggested by Figure 10. Five separate repeated ANOVAs were performed on the
volume data to determine the effects o f posture and load at each of the five time
periods (see Appendix 9, Table A). Based on Greenhouse-Geisser, there were no
significant differences due to posture or load during the two time periods prior to
lift-off or during lift-off itself (p values ranged from .153-.982). However, the
two post lift-off volumes, at .5 seconds post lift-off and 1 second post lift-off,
were significantly affected by level of load (p = .032 and p =.004, respectively)
and by level o f posture (p = .014 and p = .004, respectively). The knees straight
posture and large load both create significantly greater volumes of air within the
lung at the two tim e periods post lift-off.
73
60
50
3 40
Q.
co
o 30
g 0
CD 1 2 3 4 5
O
0) 1 = 1 s prior to liftoff; 2 = 0.5 s prior to lift-off; 3 = lift-off; 4 =
0.5 s p o st lift-off; 5 = 1 s p o st lift-off
Small L o a d — • — Large LoadKnees B e n t —* — Knees Straight
Figure 10. Naturally occurring inhaled volumes during lifting, normalized to

peak inspiratory capacity and relative to load and posture.
The y-axis represents percent of inspiratory capacity. The x-axis

represents volumes occurring at five time periods. Mean volumes
across time periods (mean curve not shown in this figure) significantly
increases or decreases relative to the preceding volume in all cases
except volume three compared to volume four and volume two
compared to volume five (see Table 12). Significant differences
related to posture and load as can be observed in this figure, occur at
volumes four and five.
74
5. Discussion
5.1 Subject C haracteristics
The sample population consisted of 14 male and 20 female volunteers,
m ost o f whom were physical therapy students. Subjects were healthy, 20 to 40
years o f age, and without a history o f low back pain within the six months prior to
data collection. Demographic information revealed a mean age o f 25.6 (± 5.5)
years, mean height of 167.2 (± 11.1) cm, and a mean weight of 65.8 (± 15.5) kg.
All subjects participated in measurements of maximal force exertion and natural
breathing. Thirteen subjects participated in measurements o f IAP.
Baecke Questionnaire data revealed a mean leisure score o f 2.37 (± .61), a
mean work score of 3.34 (± .75), and a mean sports score o f 2.96 (± .96) for a
combined total Baecke score o f 8.67 (± 1.61). There is little literature available to
assist with the interpretation of the Baecke Questionnaire values provided by this
study relative to healthy subjects. Studies using the Baecke Questionnaire often
are attempting to determine relationship of activity levels to health outcomes in
specific populations such as those with atherosclerosis,42’116 cardiac
impairments,13 or those of a specific gender.1’117,128 Further, many studies using
the Baecke have altered the survey for specific populations1’99 or provide analyses
that do not include the original values.116 The original article by Baecke and
75
Frijters7 used subjects most closely resembling this study (healthy, 139 men and
167 women, age range of 20-32), used an identical form o f the survey, and
reported the results in the original values. The values reported by Baecke7 for
leisure, work, and sports were 2.6, 2.8, and 2.8 respectively. This suggests that the
subjects used in this study were approximately similar in physical activity levels
to those found in the original Baecke study. The potential utility o f the Baecke
data from the present study lies primarily in future studies that may use the values
as a method o f control for equivalency or contrast between groups.
5.2 H ypothesis 1: Effect o f Breath, Posture, and Load on
M agnitude and Timing o f IA P.
5.2.1 Magnitude
Many studies have addressed the influence of posture and load on IAP
during lifting tasks,3’28’30'35’56’59-64’65’67’83’92’109’1I0’U5>133 while only two67'106 have
addressed the influence of breath control, other than valsalva maneuver, on IAP.
The primary purpose of this segment of the investigation was to determine the
effects o f breath control on IAP. The primary reason for the inclusion of the
conditions o f posture and load within the experimental design was to insure that a
variety o f common functional lifting tasks, with different physiological and
biomechanical demands, were observed. As so little information is known
regarding breath control during lifting tasks, this approach increased the
76
opportunities to observe potential breath effects that may vary across load and
posture. The following discussion will therefore briefly examine the findings
generally across all conditions, then discuss the findings relative to posture and
load, and finally, discuss the findings in a substantive way regarding the
relationship between breath control and IAP.
5.2.1.1 IAP magnitude across all conditions
The mean IAP values averaged across all conditions found in this study for
symmetric dynamic lifting tasks of low-to-moderate loads are comparable to other
studies using similar methodology (see Table 13). Studies o f symmetrical
dynamic lifting using higher loads,28’61,136 weightlifter subjects,61,84'86 or lifting
tasks requiring the toad to be lifted from the floor using a squat,61,86,136 resulted in
much higher IAP values (range: 99-156 mmHg).
5.2.1.2 IAP magnitude relative to posture
The present study found that during all dynamic symmetrical lifts, the
knees bent posture produced an average IAP o f 40.9 (± 21.9) mmHg while the
knees straight posture showed an average IAP o f 44.5 (± 22.6) mmHg. This
difference was not significant as analyzed by repeated measures MANOVA (p =
.744). Studies using similar methodology to the present study (i.e., dynamic lifting
in the knees bent and knees straight postures) are almost evenly divided in their
77
Table 13. Comparison of means and standard deviations of IAP magnitude
from studies using symmetrical dynamic lifts with low to moderate loads.
Author Type of lift Load(SD) Mean LAP (SD)

(kg) (mmHg)
Present study Knees straight mean values: 42 (22)

and Knees bent large: 46 (17)
small: 23 (8)
Mairiaux et at (1988)93 Knees straight, 5, 10, 15 11 (6)-29 (12)

trunk angle 30°
Knees straight
Troup et at. (1983)133 and Knees bent 15 45-60 (NA)
Termed “back
lift” and “leg
lift” within study
Hemborg et at. (1983)66 Knees straight 10, 25,40 45-78 (NA)

and Knees bent
Kumar and Davis (1983)8j Knees straight 25 51(8)
results. Some suggest knees bent posture provides higher values,56'65’109 while
others suggest knees straight postures provide higher values.3,133 The present study
tends to confirm the absence of a clear effect o f posture across multiple studies.
One explanation for the lack of a clear difference in IAP between these
two postures in the present study is that they did not represent very different
positions of the trunk due to the relatively high handle height. Mean trunk-to-thigh
angles between the two postures were 73.5 degrees and 58.1 degrees for knees
bent and knees straight postures, respectively. The mean difference between these
two postural positions was therefore 15.4 degrees. Considering that the functional
78
range o f the spine in many lifting tasks approximates 90 degrees, the difference in
this study between knees straight and knees bent postures represents only a 17%
change in the available functional range during lifting tasks.
The knees straight and knees bent postures were chosen as representative
of lifting styles commonly performed in normal functioning and as postures
commonly observed in previous studies. These postures were not chosen for the
purpose o f a systematic exploration o f the effects of various postures on IAP, as
that purpose would have required multiple postures in more varied ranges. Given
the conflicting information in the literature and the lack of significance in the
current study, it is likely that differences of posture represented by knees bent and
the knees straight positions are not a significant factor for the magnitude o f IAP.
5.2.1.3 IAP magnitude relative to load
The present study found that during dynamic symmetrical lifts the large
load produced an average IAP of 50.2 (± 23.2) mmHg, while the small load
produced an average IAP o f 34.3 (± 8.1) mmHg. This difference was significant
as analyzed by a univariate repeated measures ANOVA (p = .002). Most previous
studies examining the effect of load on IAP during dynamic lifting tasks also
suggest that IAP increases with increasing load_28’35-64-67’83-92’109 The present study
confirms the results o f these studies regarding the relationship between load and
IAP.
79
5.2.1.4 IAP magnitude relative to breath
The present study found that during dynamic symmetrical lifts the average
IAPs produced by the inhale-hold, exhale-hold, and inhale-exhale conditions were
51.6 (± 23.9), 37.7 (± 16.8), and 39.3 (± 22.9) mmHg, respectively. The effects of
breath condition on IAP magnitude were significant as analyzed by a univariate
repeated measure ANOVA (p = 0.18). Paired t-Tests with a Bonferroni correction
factor for multiple tests showed that inhalation-hold was significantly different
from the other two breath conditions (p < 0.001 for both comparisons). However,
the two other breath conditions were not significantly different from each other.
In a broad sense, these results confirm multiple sources of information
suggesting that the diaphragm is a factor in IAP generation.9’40'68,71,109 The
diaphragm is the superior wall of the abdominal cavity, and therefore increases in
IAP logically require its active and/or passive contributions. Further, direct
evidence exists showing that contractions o f the diaphragm are related to increases
in LAP,68,71 and that normal respiration causes fluctuations in LAP.9’40’109
What is not clear from the literature is whether the potential exists for
voluntary control of the diaphragm to influence the magnitude o f IAP
significantly during lifting tasks. Lifting tasks create substantial mechanical
challenges to the body and are a known risk factor for LBP.113 Therefore, the
80
potential to voluntarily influence IAP during lifting has relevance to the
prevention and/or rehabilitation o f LBP.
IAP studies that have included any form o f voluntary breath control can be
categorized according to two distinct purposes. The majority used a single form of
breath control (e.g., valsalva maneuver) to increase IAP and thereby manipulate it
as an independent variable. These studies have examined the effects of IAP on
EMG4,80 or trunk stiffness.20,101 The second group, which consists of only two
studies,105'67 attempted to determine the relationship between multiple forms of
voluntary breath control on the dependent variable IAP, similar to the present
study.
The results obtained in the present study support those o f McGill et al.,106
who found that breath control has a significant effect on IAP magnitude during
lifting, but differ from those o f Hemborg et al.67 who found no effect of breath
control. The methodologies and analyses used in these studies differ substantially
from each other, as well as from the present study. This makes comparisons
difficult.
McGill et al.106 were primarily investigating the effects of lumbar support
belts on IAP. This may explain why the authors included only two types of breath
control and failed to define them thoroughly stating only that: “...trials were
performed while breath holding and ...continuously expiring” (page 148).
Similarly, the authors chose a single load defined only by: “...subjects selected
81
the load magnitude which they felt was heavy but could be lifted safely” (page
148). The authors used a single squat posture with handle heights not reported but
appearing (from figures) to be approximately mid-tibia. The mean values reported
in this study for the “breath held” and “exhale” conditions were 118 and 101
mmHg, respectively. The authors reported that the breath conditions produced
statistically different levels o f IAP, although the statistics used were not identified.
The difference in mean values between “breath held” and “exhale” in the McGill
et al. study was 17 mmHg and compares favorably with the significant differences
found in the present study between inhalation-hold and exhalation-hold (13.9
mmHg) and between inhalation-hold and inhalation-exhalation (12.3 mmHg).
Similar conditions o f breath and posture were used in the present study and
that of Hemborg et al..67 Direct comparison of results between the present study
and Hemborg et al. is difficult because they did not report IAP values. The authors
normalized the LAP data relative to the IAP found in “natural” breath conditions,
and displayed these data in charts only. The largest difference between Hemborg
et al. and the present study lies in the method of analysis. Paired Student t-Tests
were used for all comparisons without any apparent correction for multiple
comparisons or reporting o f p values. Further, it is unclear from the report if
comparisons were made only between experimental breath conditions and natural
breath conditions, or if comparisons were made solely between multiple forms of
experimental breath conditions. Given the lack of IAP values and the lack of
82
sufficient description of the analysis, it is difficult to make comparisons to the
present study.
The strengths o f the present study compared to the two studies discussed
above lie in its systematic and primary focus on the effects o f voluntary breath
control. The present study normalized load with regard to lifting capacity, clearly
defined conditions of breath relative to time and inhaled volume, normalized
posture relative to anthropometries, varied load and posture, and clearly reported
the statistical methods and outcomes o f analysis.
Initial analysis of the IAP magnitude data in the present study was
performed by comparing the three types of breath control to each other. A review
of the Hemborg et al.67 study suggested an alternative method o f analyzing the
data, namely, to compare the multiple types of voluntary breath control to the
naturally occurring breath control within each subject. Differences in the method
of analysis may have different logical applications. The initial analysis in the
present study suggests that different types of breath control influence IAP. One
application o f this information is that efforts to reduce variability in future IAP
studies should include control for breath conditions. However, the initial analysis
does not clearly show that voluntarily controlling breath will produce changes in
IAP that are significantly different from natural breathing patterns.
It is this latter question that may ultimately have greater practical
application in prevention or rehabilitation. Therefore, a post-hoc analysis was
83
performed using a fourth breath condition for comparison—natural breath control.
This data had been collected during the original testing period but had not been
used in the previous analysis (see Appendix 9; Table B, for means and SD o f the
four types o f breath control).
Comparison o f the effect of level of controlled breath condition relative to
the natural breath condition was evaluated using multiple paired t-Tests. A
Bonferroni correction for multiple comparisons was applied where the overall
alpha was divided by the number of comparisons (alpha = 0.05/3 = 0.017). See
Appendix 9, Table C, for the results of these comparisons. Inhalation-hold (51.6 ±
23.9 mmHg) was significantly different from natural breath (39.9 ± 2 1 .5 mmHg, p
= 0.001) but inhalation-exhalation (39.3 ± 22.9 mmHg, p = 0.649) and exhalation-
hold (38.7 ± 15.3 mmHg, p = 0.792) were not significantly different from natural
breath.
The most consistent and important finding of the present study is the
significant effect o f an inhalation-hold breathing pattern on IAP when compared
to either controlled breathing patterns or to natural breathing patterns. The reason
for this may lie in two characteristics o f the inhalation-hold pattern not
simultaneously present in the other patterns: (1) increasing the volume of the
thoracic cavity, and (2) closing the glottis.61 The diaphragm descends on
inhalation as the volume of air within the thoracic cavity increases. As the
abdominal muscles contract to increase LAP, an upward force is exerted on the
84
diaphragm. If the diaphragm fails to resist that force and moves upward, IAP
cannot appreciably increase. The diaphragm can either actively contract to resist
the upwards motion or can provide passive resistance through ITP pushing
downward from above. The closing of the glottis (breath holding) so commonly
described anecdotally as occurring during weightlifting,40’60,67’92’101’108 is assumed
to assist with the build up o f ITP. Closing the glottis may be an energy efficient
method o f passively assisting the diaphragm in the generation o f IAP.
It is informative to remember that pressure is inversely related to volume
in sealed cavities, and that fluids, such as those in the abdominal cavity, are
relatively incompressible, while gases, as in the thoracic cavity, are highly
compressible.61 The fluid-filled abdomen therefore requires little change in muscle
length to increase pressure. However, the contents o f the intrathoracic cavity (i.e.,
air) must decrease in volume considerably in order to increase ITP. The rigid
structure o f the ribcage limits the decrease in thoracic cavity volume and therefore
limits the development o f ITP.
It is reasonable to suggest that a significant passive resistance o f the
diaphragm due to increased ITP requires that the volume within the thoracic
cavity is maximized prior to attempts to increase ITP.61 The inhalation-hold breath
pattern satisfies this requirement both in terms of volume of inhaled air prior to
the lift and in terms o f the closing of the glottis to allow the build up of ITP. The
exhalation-hold pattern uses a closed glottis but fails to increase volume prior to
85
the lift, while the inhalation-exhalation pattern increases volume prior to the lift
but fails to close the glottis.
5.2.2 Timing
The findings o f the present study suggest that there are no statistically significant
effects o f posture or breath control on the time from lift-off to peak IAP during
lifting tasks. Although the effects o f load on IAP timing failed to achieve pre-set
levels o f statistical significance there is some evidence that load has an effect on
IAP timing(p = .055). Large loads created peak IAP at a later time (1.21 ± .68 s)
compared to small loads (0.93 ± .62 s). The mean time values for knees bent
posture (1.10 ± .67 s) and knees straight posture (1.10 ± .66 s) were identical. The
mean time values relative to each level of breath control had a trend similar to that
of the magnitude values with respect to levels of breath. Inhalation-hold created
values that appear to be different (0.89 ± .60 s) from the other two breath
conditions, which appeared to be grouped more closely together (exhale-hold:
1.20 ± .77 s; inhale-exhalation: 1.13 ± .66 s).
The majority of studies examining the time course of the generation of IAP
have focused on determining the relationship between the onset, and/or peak, of
IAP and the onset and/or peak o f EMG o f trunk muscles.24'26,58’69’69,70'72’73’96’107
Many of these studies use rapidly applied trunk perturbations as the mechanical
challenge necessitating a rise in l\ P 24,26’69’69’70’72’73 The focus in these studies is on
86
the motor control programs used to generate IAP in order to produce stability in
the trunk during “sudden response” situations.
The present study usses an alternative model that attempts to identify the
timing of peak IAP during sa normal functional task. If IAP contributes to trunk
stability or trunk extensor moment, it must rise to an appropriate magnitude
during normal functional ta sk s and must occur at a period o f time when the
mechanical challenge to thee body requires it. Only four studies have used this
approach in the study o f IAEP,50'61'64’66 and all have focused on the task o f lifting.
Two o f these studies, both b^y the same authors, focused on the relationship of the
onset o f IAP relative to the o*nset of trunk EMG and did not consider the timing of
IAP relative to the m echanical challenge to the body.64,66
The other two studies, both with Hannan as the primary author,60’61 used
an approach similar to the present study. In the first study,60 Harman et al. had
subjects lift a box and a bar-bell (termed a “dead lift”) from floor height, with a
simple switch recording whaen the object had left the ground. The authors then
determined the timing of p e a k LAP relative to the mechanical event o f the object
leaving the ground. Mean tirme-to-peak LAP values were reported as .28 ± 0.30
seconds for the box lift and. 0.19 ± .16 seconds for the dead lift. These values
cannot be compared to the current study as they represent time periods with
different mechanical events a*s starting points. In the present study, the application
o f force to the handles represented lift-off, whereas in the Harman et al.60 study,
87
lift-off was represented by the movement o f the load. The time delay between
application o f force to a load and its movement can reasonably explain the
difference in the values o f the two studies. The application o f force must occur
prior to object motion, and therefore the timing values in the present study are
larger than those o f Harman et al..60
The methodology in the second study by Harman et al.61 was improved
through the addition o f a force plate, on which the subject stood, and that
measured the ground reaction force (GRF). A dead lift was performed using 90%
o f a one-repetition maximum load. The m ean time from the movement of the
weight to the peak IAP was 0.45 ± .37 seconds. As in the first study, this timing
value was relative to motion of object lifted rather than to application o f force,
which makes comparisons to the present study difficult. However, the study also
provided data regarding timing of peak of IAP relative to timing of the peak of the
GRF. Although this measure of force was not identical to the measures o f force
used in the present study it is plausible that a reasonable association exists
between the timing of the force exerted by the body on a force plate and the
timing of the force exerted by the body on the handles o f a weight.
In the second study by Harman et al.61 the peak IAP occurred, on average,
.61 seconds prior to the peak GRF. As the present study focused on the effects o f
breath on IAP, it did not explicitly address the relationship of the tim ing o f peak
IAP relative to the timing o f peak force. However, existing data from the original
88
testing period included magnitude and timing information o f peak force, and were
therefore summarized for comparison (see Table 14). These data allow an
approximate comparison to the Hannan et al.61 study, and provide a more
complete description o f how breath control may affect the magnitude and timing
of IAP at a critical moment o f mechanical challenge.
Using the same condition of natural breath for comparisons in Table 14, it
is shown that peak IAP occurred .61 seconds prior to peak force in the Harman et
al. study,61 and .31 seconds post peak force in the present study. The differences in
Table 14. Means and standard deviations of IAP magnitude at time of peak
force and timing of peak IAP relative to peak force.
Magnitude (mmHg) Time (seconds)
Study Breath level % Peak IAP at time

of Peak LAP —Peak
Peak Force Force
M fSD) MfSDl
Inhale-Hold 92 (3) .21 (.50)
Exhale-Hold 82(4) .52 (.76)
Present Study Inhale-Exhale 84(7) .47 (.65)
Natural Breath 90(16) .31 (.51)
Harman et al. 61 Natural Breath NA -0.61 (NA)
Note: Force measures differ between studies.

Positive values occurred post peak force and negative values occurred prior to peak force
89
these values may be a result of the differences in methodology. The Harman et al.
study61 study used non-competitive weightlifters lifting a nearly maximal load
from the floor, and used a force plate underneath the subjects to determine peak
force. The present study used untrained healthy subjects lifting moderate loads
from knee height, and used a force transducer in line with the cables supporting
the weight.
It is also informative to note the high variability in the timing data. Both
studies by Harman et al. reported mean times o f peak IAP that differ by 42% (.19
seconds versus .45 seconds) for a similar lift performed by similar subjects.
Further, the coefficient of variation was high for both, being 85% for the first
study and 82% for the second study. The coefficient o f variation in the present
study for time to peak IAP was also high at 65%.
It is difficult to estimate the validity of making comparison of these results
given the differences in methodologies. Nonetheless, it remains surprising that the
difference between the mean values o f the two studies is so large (.92 seconds),
particularly as the total time of the lift periods was approximately 2-3 seconds.
One possible reason for the high variability and the different results in the two
studies is suggested by the magnitude data in Table 14. The percent of peak IAP
magnitude occurring at the time of peak force was quite high for all breath
conditions (82-92%). The measure o f timing o f IAP based on a single peak value
may not be an ideal measure of IAP tuning regulation. If a sufficient “threshold”
90
value o f IAP exists over a critical period o f time, as suggested by the present
study, then a valid search for IAP timing differences may require alternative
methodologies. The timing o f a minimally sufficient “threshold” value, rather than
peak value, may provide more relevant information regarding the regulation of
LAP timing.
Additional data analysis was performed to attempt to better understand the
timing data relative to peak force. Although the present study suggested that the
timing o f peak IAP followed peak force by .25 (± .59) seconds (averaged across
all breath conditions), this mean value obscures the underlying distribution in
which 33% o f the peak LAP values occurred prior to peak force, rather than post
peak force. In order to conceptualize the distribution of timing data in a more
complete way, all values for peak timing that occurred prior to peak force were
averaged separately from all values for peak timing that occurred post-peak force
(see Table 15).
With the exception o f the Harman et al. studies,60,61 all analysis o f LAP
data in the literature that examines lifting has been performed on peak values
without reference to the timing o f mechanical events. The present study initially
took a similar approach in analyzing the effect of breath conditions on LAP.
However, as the validity of the biomechanical rationale o f LAP during lifting
91
Table 15. Means of peak IAP timing relative to breath control and grouped
by peaks occurring prior to peak force and peaks occurring post peak force.
Time (seconds) relative to time of peak force.

Breath Condition
Negative* Positive5
Inhalation-Hold -.12 (.13) .41 054)

Exhalation-Hold -.30 (.35) .99 (.48)
Inhalation-Exhalation -.16 020) .70 (.61)
Natural Breath -.13 021) .46 (.53)
TOTAL MEAN -0.18 0.64
Note: 33% o f peak IAP values occurred prior to peak force values.
1 Negative column values represent means o f peak IAP timing values occurring prior to peak force.
b Positive column values represent means o f peak IAP timing values occurring post-peak force.
depends on both the timing and magnitude relative to the timing of a mechanical
event (i.e., the stress on the spinal tissues), post-hoc analysis was done to
determine if breath control also had significant effects on IAP magnitude at the
moment of peak force. A repeated univariate ANOVA was performed on the IAP
magnitude data at the moment o f peak force, to investigate the effect o f the three
independent variables (load, posture and breath condition). See Appendix 9, Table
D, for summary results regarding IAP magnitude at the moment o f peak force.
Based on Greenhouse-Geisser, LAP magnitude at the moment o f peak
force was significantly affected by both the level of load (p < .001) and by the
level of breath condition (p < .006), but not by the level o f posture (p < .264).
These results are similar to the effects o f breath on peak IAP when the temporal
92
location of that peak is not specified. These results are not surprising given that
the mean percentages o f peak IAP at the moment of peak force follow the pattern
o f their peak values relative to breath control. Nonetheless, these results are
important in that they reinforce the validity o f breath control on IAP at the
moment when significant mechanical stress is occurring during the lifting task.
In a similar vein, it was considered that although breath had no significant
effects on the timing o f peak IAP relative to lift-off (as demonstrated in the
original analysis), the possibility existed that breath may have an effect on the
timing of peak IAP relative to the timing of peak force. A post-hoc repeated
univariate ANOVA was performed on the timing data (time of peak IAP - time of
peak force) to investigate the effect o f the three independent variables (load,
posture, and breath condition). See Appendix 9, Table E, for summary results
regarding IAP timing data relative to the time o f peak force.
Based on Greenhouse-Geisser, the timing o f peak IAP relative to the
timing of peak force was not significantly affected by level of load (p = .235), by
level of breath condition (p = .186), or by level of posture (p = .783). These
results are similar to the effects of breath on timing o f peak IAP relative to lift-off.
Although breath control affects magnitude of IAP, it appears to not influence the
timing of the peak IAP, either relative to the start o f the lift or relative to the peak
force used during the lift.
93
5.3 H ypothesis 2: E ffect o f breath on m a x im a l isometric trunk
extension force
The present study found that in the upright poosture, inhalation-hold,
exhalation-hold, and inhalation-exhalation produced m eant force values of 68.2 ±
27.6, 66.7 ± 25.8, and 70.7 ± 27.9 kg, respectively. The efffect o f breath control on
maximal isometric force production was found to be significant in the upright
posture (p = 0.015). An analysis o f the effect o f levells o f controlled breath
conditions showed that inhalation-exhalation was signirficantly different from
exhalation-hold. However, the other breath level c*omparisons were not
significantly different.
The present study also examined the maximal isormetric force production
in the knees bent posture and found that inhalation-hold, exhalation-hold, and
inhalation-exhalation produced mean values of 90.7 ± 36.90, 93.4 ± 36.9, and 94.4
± 35.8 kg, respectively. Although the effect o f breatln control on maximal
isometric force production in the knees bent posture fa ile d to achieve pre-set
levels of statistical significance (p = .089) there is sonu e evidence that breath
control has an effect on force.
The means and standard deviations for isometric Iforce production found
in this study are comparable to other studies using a similair methodology, but not
controlling for breath conditions (see Table 16).
94
Table 16. Means and standard deviations of maximal isometric force relative
to posture from studies using similar methodology to the present study.
Study Upright Posture (kg) Knees Bent Posture (kg)

M (SD) M (S D )
Present Study 68.5 (27.4) 92.8 (34.3)

Battie et al. (1989)10 77.0 (38.5)
Hazard et al. (1992)63 87.5 (34.1)
Hazard et al. (1993)62 98.8 (41.5)
Kamon et al. (1978)78 49.2 (7.9)
Nachemson et al. (1969)111 51.0(5.6)
Note: All values are means o f men’s and women’s values
There are no studies reported in the literature that have examined the
effects o f breath control on force production. This question has remained
completely unexamined, although sports training experts advocate specific forms
of breath control during weight-lifting.120’121,124 It is unclear whether advocates of
breath control during lifting tasks believe that breath control reduces risk o f injury
or increases lifting capacity, or some combination of both.
If breath control increases IAP during lifting tasks, then injury risk may
theoretically be reduced by increasing lumbar stability and/or by decreasing the
need for trunk extensor force, thereby decreasing maximal force on spinal tissues.
Theoretically, force production may be increased in the presence o f increased IAP
via two distinct mechanisms. IAP that contributes to trunk extensor moment may
contribute directly to maximal extension force. IAP that contributes to segmental
95
spinal stability may contribute indirectly to trunk extension force by reducing
neural inhibition o f trunk extensor muscles. In effect, this theory suggests that
individuals may have more force capabilities in their trunk extensor muscles than
they utilize. Sensory feedback from vertebral segments that are approaching
instability may inhibit trunk extensor muscles to avoid tissue damage due to
excessive motion o f segments. Increased IAP would reduce that inhibition and
thereby increase trunk extensor force. There is some evidence that a sensory
feedback system relative to IAP exists74 although efforts to identify the precise
anatomical structures have not been successful.82
The present study was designed to examine the effects of breath control on
force production without consideration of the effects of breath control on IAP
during the same time period. However, as the theoretical rationale for possible
differences in force due to breath control depends on potential LAP changes, a
post-hoc analysis was performed on the available IAP data. This analysis differs
from the original analysis of force relative to breath in that simultaneous
acquisition o f force and IAP data was only performed on 11 subjects. Further, the
measure of IAP used in this analysis was not determined via a one-tenth second
data collection window, as in the previous dynamic analyses, but rather a measure
o f the mean IAP during a one second data collection window. See Table 17 for
summary values o f IAP and peak force for the two postures.
96
The data in Table 17 show that IAP behaves similarly in static trials as in
dynamic trials relative to breath control. Specifically, in both knees bent and
upright postures, inhalation-hold produces the highest values, followed by
inhalation-exhalation and exhalation-hold.
Table 17. Mean values of force and IAP during static maximal exertions in
two postures (n = 11).
Breath level Force (kg) LAP (mmHg)

M (SD) M (SD)
Inhalation-Hold 64.6 (26.0) 100.9 (44.5)

Upright Posture Exhalation-Hold 62.8 (23.3) 61.7(23.7)
Inhalation-Exhalation 69.9 (26.4) 76.4 (39.4)
Inhalation-Hold 80.1 (34.0) 77.0 (23.0)

Knees Bent Posture Exhalation-Hold 84.6 (35.5) 48.9 (27.9)
Inhalation-Exhalation 86.8 (39.4) 57.1 (28.8)
Note: IAP values represent mean of one-second data collection window
A different pattern emerges for the force data in both postures where
inhalation-exhalation shows the largest values. There appears to be no consistent
relationship between IAP and force production. The data in Table 17 are displayed
graphically in Figure 11 to better appreciate the relationship between IAP and
force variables. This finding is discussed further below.
97
„ 120
CB
X too
° 80
Upright Knees Bent |

1^3right Knees Bent
Figure 11. Force and IAP relative to breath control in knees bent and
upright postures.
The y-axis represents either force magnitude (left figure) or IAP

magnitude (right figure). The x-axis represents nominal categories o f
voluntary breath control. Note the apparent lack o f s im ilarity in
patterns between LAP and force.
A post-hoc analysis using separate repeated univariate ANOVAs was
performed on the LAP magnitude data in the upright and knees bent posture to
investigate the effects o f breath (See Appendix 9; Table F). Breath had a
significant effect on IAP during the maximal exertions in both the upright and
knees bent postures (p = .002 and p = .003 respectively).
The effect o f levels o f controlled breath conditions on IAP magnitude
during maximal static exertions in upright and knees bent posture was evaluated
using multiple paired t-Tests. A Bonferroni correction for multiple comparisons
was applied where the overall alpha was divided by the number o f comparisons
98
(alpha = 0.05/3 = 0.017). Appendix 9, Tables G and H, show the results of these
comparisons for the upright posture and knees bent posture, respectively.
In the upright posture, inhalation-hold was significantly different from
exhalation-hold (p = .001), but was not statistically different compared to
inhalation-exhalation (p = 0.037). The other two levels o f breath were not
significantly different from each other (p = 0.151). In the knees bent posture,
inhalation-hold was significantly different from both exhalation-hold (p = .005)
and inhalation-exhalation (p = .002). As in the upright posture, inhalation-
exhalation was not significantly different from exhalation-hold (p = 0.273). The
results of the initial and the post hoc analyses show that the inhalation-hold form
of breath control significantly increases IAP for both static and dynamic lifts.
In summary, in both upright and knees bent postures, there is evidence of
differences in force due to breath control. In the upright posture these differences
achieved statistical significance (p = .015) but did not do so in the knees bent
posture (p = .089). Variability in both postures was similar and the m axim um
difference between any two conditions of breath control was similar (upright: 4
kg; knees bent: 3.7 kg). What does appear to be clear from Figure 11, is that the
significant force differences due to breath control were not a result of effects of
IAP.
99
5.4 R esearch Question: N atural breathing patterns during
lifting.
Increasing IAP during lifting tasks is one of the explicit rationales for the
use of Lumbar supports in industry and sports,60’61 however there seems to be no
evidence for this theory.134 Further, specific forms of breath control are advocated
during Lifting tasks in sports to increase IAP,120’121’124 although evidence that such
control either reduces injury or facilitates lifting capability has not been
investigated. Current occupational medicine guidelines18'105 do not mention breath
control as a potential factor in lifting tasks or recommend breath strategies as a
method o f reducing injury.
Many authors have pointed out that there is a common and specific
relationship between respiratory function and the mechanical act of
lifting.40,60,67’92’101,108 The reports are surprisingly uniform and suggest that
individuals inhale prior to lifting, then close the glottis and hold the breath during
the strenuous portion o f the lift. These observations suggest that the body may
attempt to regulate IAP through the control of breathing patterns. If this is true,
then the natural breath control of subjects during lifting tasks should display a
pattern that could potentially facilitate the production of IAP during critical
mechanical events o f the Lifting task. The present study attempted to examine this
issue by describing the naturally occurring breathing patterns of normal, healthy
subjects while lifting. The approach used in the present study in defining patterns
100
o f breath control focused on two methods. T lie first used measures o f flow
categorized as inhalation, exhalation, or breath htolding at five evenly spaced time
periods centered on lift-off. The second meth-od used the derivative o f flow,
volume, to determine the amount of air that w*as in the lungs at the same five
periods of time. These methods differ in theLr ability to provide information
relative to IAP generation. Flow is highly variable, and multiple combinations of
flow over the period o f lifting can produce equoal amounts of volume at critical
points of time. Flow may primarily be useful a s an indicator of when the breath
was held, suggesting that a closed glottis provides passive resistance to upward
motion of the diaphragm. The position of the diaphragm is related to net volume,
not flow. If diaphragm position is the mechamism used by breath control to
regulate IAP, then the volume of inhaled air shornld reveal distinct patterns during
lifting tasks. In fact, this was the case in th e present study. Volume was
significantly different during different time pe:riods of the lift (p <0.001). In
general, averaging across all conditions, volume significantly increased from one
second prior to the lift to lift-off. From lift-off to •one-half second later, the volume
did not significantly change. Finally, from one-boalf second post lift-off until one
second post lift-off, the volume significantly decreased (see Tables 10 and 11).
This provides evidence that there is a specific association between
respiratory and motor system function during lifting tasks. Larger volumes occur
101
during the events associated with lift-off. This supports the theory that breath
control is used to facilitate IAP generation through diaphragm position.
The data in the present study also suggest that significantly higher volumes
occur during large loads and the knees straight posture versus small loads and the
knees bent posture, respectively. If lung volume plays a significant role in IAP
generation, then IAP and volumes across these conditions should vary in a similar
pattern. Post hoc attempts to describe this relationship were performed on a subset
of the data.
The original analysis of volume was performed on data from 34 subjects
during natural breathing conditions. These trials did not monitor IAP. However,
during the original data collection period identical trials were performed on 11
subjects while measuring both volume and LAP simultaneously. First, the data
from the two sets o f trials o f the 11 subjects were compared visually to determine
if there were any clear differences in volume due to the presence of the LAP
catheter within the nasal cavity (see Figure 12). The mean o f volumes 1-5 for the
trials with the IAP catheter was 25.20 ± 3.4 %, and for the trials without the LAP
catheter was 31.48 ± 4 . 1 %. The lower means for the trials with the IAP catheter
may represent maturation effects, as the IAP trials always followed the non-IAP
catheter trials. These differences may also be a general response to having a
foreign object within the airway, causing changes in normal quantities of flow.
Nonetheless, as can be seen in Figure 12, the volume data for both collections of
102
trials appear to vary in s im ilar ways. Consequently, data from the trials with
simultaneous IAP and volume measures were considered to reflect natural
breathing.
o 50
co
Q.
co 40
o
Volume 1 Volume 2 Volume 3 Volume 4 Volume 5

1 = 1 s prior to lift-off; 2 = 0.5 s prior to lift-off; 3 = lift-off; 4 = 0.5 s
post lift-off; 5 = 1 s post lift-off
m With IAP catheter ■ Without IAP catheter
Figure 12. Inhaled volumes during lifting comparing trials with and without
the presence of an IAP catheter (n = 11).
The y-axis represents percent of inspiratory capacity. The x-axis

represents volumes at five time periods during the lifting tasks. All
values are from the same subjects using identical conditions with the
exception of the presence or absence o f the IAP catheter within the
nasal cavity. IAP values are the single .1 s data collection window
peak that occurs post lift-off.
103
Figure 13 shows simultaneously recorded IAP and volume data. IAP in
this figure represents a peak value ( . I s data collection window) for each lift that
was determined by an analysis program examining data from lift-off to one second
post lift-off. This is the period o f time associated with volumes four and five.
Further, in the original analysis only volumes four and five varied significantly
due to posture and load. Consequently, only these two volumes were plotted
together with IAP for comparison (see Figure 13). It is difficult to interpret the
relationship o f volume and IAP data in Figure 13. The knees bent and knees
straight data appear to suggest that IAP and volume data follow similar patterns,
however, the large and small load data are less clear.
Only one study exists for comparison with the present study that has
attempted to examine the natural breath patterns performed by subjects during
lifting tasks.67 This study examined net volume o f breath inhaled or exhaled from
lift-off to put-down, dividing the data into two subsets of time based on lifting and
lowering. The findings for the lifting phase showed that 36% o f the subjects use
breath holding, 11% used inhalation, and 53% used exhalation during the lifting
phase o f the lift. These data represented the directions of flow for the net volume
of air for the time period from lift-off to the beginning of lowering. Consequently,
these values may represent combined breath flow of inhalation and exhalation
with a net result o f volume in a single direction. Therefore, these volume values
104
60
o>
X
E
E 50
"O
c:O
C
t 40
CO
Q.
C
OO
30
o
C
I_O
CL
CO
a 20
Small Large Bent Straight
Load Load Knees Knees
CD
Mean IAP Volume 4 - Volume 5
Figure 13. Mean IAP and volumes 4 and 5 relative to posture and load.
The y-axis represents both percent of inspiratory capacity and

magnitude of IAP. The x-axis represents conditions o f load and
posture. IAP values are peak values ( . I s data collection window)
occurring post lift-off. Volume 4 is the volume occurring at .5 seconds
post lift-off and Volume 5 is the volume occurring at 1 second post
lift-off. The mean timing o f peak IAP across all conditions was 1.07
seconds post lift-off.
only provide information relative to net flow but do not provide information
regarding the relative amount o f volume within the lungs during the lift, as
provided in the present study.
105
The data from the Hemborg et al. study were derived from two groups,
weightlifters and LBP patients. Although healthy subjects were included in the
methodology, data relative to these subjects were not reported. The Hemborg et al.
study did not address breath control prior to lift-off and did not provide a
statistical analysis o f the results. The present study addressed these issues by
providing a statistical analysis of naturally occurring breath control patterns in
healthy subjects over the entire time o f the lifting period.
5.5 Im plications
5.5.1 Magnitude of IAP
The implications of the present study are relevant to the reduction o f injury
risk associated with manual material handling. The findings can be viewed as
important in two primary areas: (1) providing new information to assist basic
research on IAP, and (2) providing foundational information that may serve as a
basis for creating practical training methods o f breath control during lifting tasks.
The findings of the present study suggest that future studies seeking to
decrease variability o f IAP magnitude data should control for the effects o f breath.
For example, methodologies could require task performance during the same
portion o f the respiratory cycle for each trial. Findings also demonstrate the
feasibility o f controlling IAP as an independent variable during dynamic lifting
106
tasks. Previous studies have been limited to the use of valsalva maneuvers to
control IAP during static exertions.
The practical application of the findings depends on the theory that the
ability to voluntarily increase IAP magnitude during lifting tasks is beneficial in
reducing risk o f injury. Comparing the IAP theory to a more accepted
recommendation regarding injury reduction during lifting tasks is instructive.
Reducing the horizontal distance from the load to the body is a well-accepted
recommendation during lifting tasks. In principle, the theory of increasing IAP is
similar in that both IAP and horizontal distance, changes result in lowering the
mechanical stress on the spinal tissues. In reducing horizontal distance, the
moment for the load is reduced and therefore the tissue receives less stress. In
increasing IAP magnitude, one or both o f two theories applies: (1) IAP may
increase trunk extensor moment directly, thereby reducing compressive stress on
the spine due to decreased trunk extensor contractions; or (2) IAP may provide
increased trunk stability that reduces the stress on spinal tissue that occurs during
excessive motion o f intervertebral segments.
The increase of IAP is fundamentally different, however, from reducing
horizontal distance. In all cases, reducing the external moment by reducing
horizontal distance reduces internal forces. In the case o f IAP, however, the
relationship between increases in IAP and reduction of internal forces may vary
based on the individual and the circumstances under which the lift is performed. It
107
is unknown, for example, if voluntary increases in IAP performed by a healthy,
normally functioning individual would decrease stress on spinal tissues. The two
theories o f IAP may vary on this point. Direct mechanical assistance with
extension due to the extensor moment theory would suggest that any and all IAP
increases during flexed lifting postures would provide some measure o f decreased
stress to tissues provided that all other factors remain equal. The stability theory is
less clear. If a healthy individual’s normal motor program and reflexive responses
have achieved a threshold value of IAP magnitude that is sufficient to control
intersegmental motion for that specific load, then further increases in IAP may not
contribute in any way to decreasing tissue stress.
This suggests two scenarios in which voluntarily increased IAP through
breath control may have relevance in terms of assisting with stability: (1) For
individuals with an intact IAP-generating system who are attempting lifting tasks
for which their normally occurring IAP magnitude is insufficient—this may occur
while attempting to lift loads at the margins o f capacity or the lifting of normally
acceptable loads in the presence of fatigue; (2) For individuals without an intact
IAP-generating system who are attempting to perform normal lifting tasks. The
reasons for the inability to generate sufficient IAP may be due to factors such as
tissue damage to lumbar proprioceptors that fail to provide necessary feedback
regarding segmental vertebral motion (e.g., LBP patients), poor strength or
coordination of trunk muscles (e.g., deconditioned individuals), or a decreased
108
ability to control diaphragm position (e.g., individuals with respiratory
impairments). Therefore, the potential to alter IAP through breath control may be
of practical value in well-defined situations.
There remain multiple significant areas o f inquiry, however, that may
influence advocacy o f breath control during lifting tasks. Some o f these questions
are: (1) What magnitudes o f IAP increases can reasonably be suggested as
providing decreases in tissue stress? (2) In what groups, or in what situations, does
IAP magnitude become insufficient? (3) Can training o f breath control ultimately
produce a reflexive m otor response to increase IAP during lifting tasks? and (4)
Are there potential harms in some forms of breath control training, such as breath
holding?
The latter question is particularly important prior to advocating the
inhalation-hold form o f breath control found in this study to raise IAP. High levels
o f IAP may decrease venous retum94and increase blood pressure88 thereby placing
added stress on the cardiac system. IAP may be regulated relative to two
competing demands. To avoid harm, IAP must be brief, but to be beneficial, IAP
must occur during critical periods of mechanical stress. During dynamic lifts, it is
possible that these competing demands can be met.
The values o f IAP found in the current study during dynamic lifts o f low-
to-moderate loads do not approach the magnitude necessary to influence vascular
compromise, and therefore advocacy for brief breath holding during these kinds o f
109
lifts does not represent a significant concern. However, the values found during
maximal sustained isometric lifts approach values that may compromise the
vascular system, and therefore it is potentially problematic to advocate the breath
holding method for static lifts.
Interestingly, sports training experts often recommend the inhalation-
exhalation method o f breath control when lifting large loads. This form o f breath
control may balance the competing demands o f LAP to decrease injury risks and to
avoid compromising blood flow. Inhalation is thought to provide sufficient
volume for increases in LAP, while exhalation is thought to prevent high levels of
IAP over prolonged time periods. However, the present study did not find
significant increases in LAP with this method o f breath control compared to
natural breathing.
5.5.2 Timing of IAP
Magnitude changes due to inhalation-hold are presumably being brought
about by two direct and simple mechanisms: (1) inhalation moves the diaphragm
inferiorly, which decreases volume within the abdominal cavity; and (2) breath
holding provides passive resistance to the diaphragm as abdominal muscles begin
to contract. The result is a significantly higher peak IAP during lifting tasks.
However, given these two mechanisms, it is unclear why significant changes in
timing do not also occur. Given that other factors remain equal and that sensory
110
feedback does not modulate efforts, changing the size o f the abdominal cavity and
the resistance o f the superior wall should alter both the timing and magnitude of
IAP.
The lack o f statistical significance in timing changes must be viewed
relative to the manner in which timing is identified within the IAP curve. Timing
is identified by the occurrence o f peak IAP magnitude. However, we have seen in
the present study that across all conditions, 87% o f the peak magnitude o f IAP
occurs at the moment of peak force. The degree of precision the body must use in
IAP generation, both in terms of magnitude and timing, is unclear, but it is
possible that the body regulates IAP by a general strategy of meeting or exceeding
magnitude requirements over a critical period of time. If this is the case, then only
a threshold value is required and the search for meaningful differences in timing
data based on the timing of peak IAP magnitude values may be misleading. The
data from the present study suggest that future studies examining the tim in g o f
IAP should use methodologies that examine the concept of threshold magnitudes
occurring during the time of critical mechanical requirements.
5.5.3 Effects of breath on force
The findings relative to force serve primarily to address theoretical issues.
The initial hypothesis was directed to the relationship o f breath control and force
without consideration of IAP, although IAP served as the theoretical link between
111
these two factors. The findings in the post hoc analysis suggest that the significant
changes in force in the upright posture and the evidence of changes in the knees
bent posture are not related to changes in IAP. Therefore, the findings o f the
present study do not support either the extensor moment or stability theories of
IAP in terms of alteration o f force output.
The increase in force found in the upright posture between inhalation-
exhalation and exhalation-hold could conceivably serve some practical purpose.
However, several points suggest caution in generalizing the practical application
o f these findings: (1) The mean increase in force was 4.1 kg between breath levels
in the upright posture and 4 kg in the knees bent posture. These values represent
an approximately 4-6% increase o f force with the inhalation hold form of breath
control. This increase should be viewed relative to the variation occurring within
subjects between trials 1 and 2 (mean differences: 1.45 ± 9.75 kg). Although the
differences due to breath control appear larger than the normal variation between
trials they are nonetheless small increases in terms o f practical application. (2)
The findings can only be generalized to static exertions, which are rare in normal
functional tasks. (3) The analysis did not compare types of breath control to
normally occurring breath control. Consequently, it is unknown if the voluntary
control o f breath produces a force that exceeds the one produced under normally
occurring breath conditions.
112
5.5.4 Description o f natural breath
The most clear and simple finding from the present study is that, during
single lifting tasks in which oxygen demand is not appreciably changed, subjects
naturally alter their breath control. Flow and volume measures demonstrate that a
link occurs between the motor task o f lifting and respiration.
The interpretation o f these specific patterns relative to the potential to
influence IAP is less clear. The percentage of subjects holding their breath
increases, and the percentage o f subjects inhaling decreases, as the lift proceeds.
Volume significantly increases prior to the actual application o f force to the
handle, and significantly decreases after the maximal exertion in the early portion
o f the lifting period. These patterns are precisely what would be expected if
control o f inhaled air volume were a factor in the regulation of IAP magnitude and
timing. Further support comes from the significant differences found in volume
relative to levels of load and posture. This suggests that volume may not only be
used in a general manner to support IAP during lifting, but that volume may
specifically address particular aspects o f the anticipated task.
113
6 Conclusions and F uture Studies
The following conclusions are made from the present study:
1. Voluntary methods of breath control are significantly related to the
magnitude of peak IAP during dynamic lifting tasks with inhalation-hold
creating values significantly greater than exhalation-hold, inhalation-
exhalation, and natural breath.
2. Voluntary methods of breath control are significantly related to the
magnitude of peak IAP during static maximal exertions. In the upright
posture, inhalation-hold creates values significantly greater than
exhalation-hold and natural breath. In the knees bent posture, inhalation-
hold creates values significantly greater than exhalation-hold, inhalation-
3. Voluntary methods of breath control are not significantly related to timing
o f peak IAP during dynamic lifting tasks.
4. Voluntary methods of breath control are significantly related to maximal
isometric trunk extensor force in the upright posture with inhalation-
exhalation creating values significantly greater than exhalation-hold.
5. Voluntary methods of breath control are not significantly related to
maximal isometric trunk extensor force in the knees bent posture.
114
6. The volume o f inhaled air during dynamic lifting changes significantly
over time with increases in volume prior to lift-off and decreases in
volume post lift-off.
7. The volume of inhaled air during dynamic lifting tasks is significantly
related to posture and load.
The findings of the present study suggest that breath control is a viable area of
inquiry relative to IAP generation. Variati«ons and improvements in the
methodology could yield additional useful information. Below is a list o f possible
suggestions:
1. The present study used a single marker o f the mechanical event o f lift-off
(force > 2.27 kg). Methodologies th a t could identify the relationship
between postures achieved during the pre=cise timing o f peak IAP would be
beneficial. Timing differences related to speed o f lift could also be
controlled and examined.
2. Findings in the present study can only be generalized to the extent to
which subjects represented healthy m ^n and women in the general
population, 20-40 years of age. Differences between various populations
could be examined relative to naturallly occurring breath control and
methods o f voluntary control. For examp-le, do LBP patients use flow and
115
volume during lifting tasks in a similar manner to healthy subjects? Does
glottal closure happen in a similar manner between groups?
3. IAP findings in the present study can only be generalized to dynamic lifts
using 70% and 35% of maximum isometric exertion in the upright posture
during the knee bent and knee straight postures. Studies that systematically
vary posture and load through more extreme ranges, while controlling
breath, may provide further information regarding the theories of IAP.
4. Using breath control to alter IAP, the addition o f EMG to the static lifting
trials could determine if similar levels o f force are being produced with
varying levels o f muscle activity. This information would clarify the
theories o f IAP.
5. The addition o f an ITP measure would provide information on the active
diaphragm contribution to IAP versus the passive contribution from glottal
closure.
116
Appendices
Appendix 1. Consent Forms
^ VE W YORK UNIVERSITY MEDICAL CENTER

2 1"Date Approved I cn BELLEVUE HOSPITAL CENTER
By 1BRA &
HOSPITAL FOR JOINT DISEASES
INFORM ED CONSENT TO PARTICIPATE IN RESEARCH
You are being asked to volunteer to be a subject in a research study. This fotm is designed to provide you with
information about this study, which you should know and understand as well as to answer any questions.
Project Director Margaret* Wnrdin. Dr.Sci. Dept. CHOC Tel. # 212 255-6690
212 2S5-6754
TITLE OF RESEARCH STUDY:
Characteristics o f air exchange related to lifting and EMG activity o f lumbar muscles.
SUBJECT PARTICIPATION: Inpatient/ □ Outpatient/153 Other 13
We expect to enlist the following number of subjects for this study: 60 individuals
Your participation will involve this many visits: 1 visit
Each o f these visits will take the following amount of time: 1 1/2 hours
THE PURPOSE OF THIS RESEARCH IS:

The purpose o f this study is to better understand how characteristics o f air exhange are related to lifting
and how back muscle activity relates to those characteristics.
THE FOLLOWING PROCEDURES WILL BE INVOLVED (IF LIMITED TO DONATION OF BLOOD,

LEAVE BLANK - SEE PAGE 2)
To participate in this study, you will be asked to:

1. Complete questionnaires asking about your medical history and level o f activity.
2. Permit a doctor, physiotherapist o r other clinic personnel to place a face mask with adequate ventilation
for normal breathing over your mouth and nose.
3. Permit a doctor, physiotherapist o r other clinic personnel to gently cleanse and abrade your skin in 4
areas on your low back and 2 locations on your abdomen, and place 6 small self-sticking electrodes
in those places.
4. Perform several maximal exertion, non-moving (static) lifting tasks
5.. Perform approximately 26 moving(dynamic) lifting tasks, o f !ight-to-moderate and moderate - to
lleavy loads using two different postures. The amount o f weight you lift will be based on a
pcrcentage(30% and 60%) o f your own maximum lifting capabilities. Examples: If you can lift a
maximum o f 100 pounds, you would be asked to lift 30 potmds and 60 pounds respectively. If you
can lift a maximum o f 150 pounds, you would be asked to lift 45 pounds and 90 pounds respectively.
117
NEW YORK UNIVERSITY MEDICAL CENTER
g p a a E rn o . BELLEVUE HOSPITAL CENTER
c: 1 Date Apor-jycd &
’•25 \ By IEZRA i
' ' \ nyumc y HOSPITAL FOR JOINT DISEASES
INFORMED CONSENT TO PARTICIPATE IN RESEARCH
You are being aalced to volunteer to be a subject in a research study. This form is designed to provide you with
information about this study, which you should know and understand as well as to answer any questions.
Project Director Maraareta Nordin. DrSci. Dept. OtOC Tel. # 212 2255-6690
Fax.# 212 255-6754
TITLE OF RESEARCH STUDY:
Breath Control during Lifting and its Effects on Intra-abdominal Pressure and Isometric Lifting Capacity.
Phase II and Phase III
SUBJECT PARTICIPATION: Inpatient/ Q Outpatient/O Other ^
We expect to enlist the following number of subjects for this study: 10-20 individuals
Your participation will involve this many visits: 1 visit
Each of these visits will take the following amount of time: 1 1/2 hours
THE PURPOSE OF THIS RESEARCH IS:

The purpose o f this study is to better understand how voluntary breath control affects: (1) pressure In the
abdomen during lifting., and (2) the the amount of maximal static lifting force.
THE FOLLOWING PROCEDURES WILL BE INVOLVED (IF LIMITED TO DONATION OF BLOOD,

LEAVE BLANK - SEE PAGE 2)
To participate in this study, you will be asked to:

1. Complete questionnaires asking about your medical history and level o f activity.
2. Permit a doctor, physiotherapist o r other clinic personnel to place a face mask with adequate ventilation
for normal breathing over your mouth and nose.
3. Permit a doctor, physiotherapist o r other clinic personnel to gently cleanse and abrade your skin in 4
areas on your low back and 2 areas on your abdomen, and place 6 small self-sticking electrodes in
those places.
4. Permit a doctor or physiotherapist to place a topical anesthetic in your nose ("Hurricane'' (Benzocaine
20%)] and then place a narrow catheter through your nose and down into your stomach.
5.. Perform approximately 24'moving (dynamic) lifting tasks, o f light-to-moderate and moderate -to-
heavy loads using two different postures while voluntarily controlling your breath in three different
ways: (l)inhale maximally and hold your breath while you lift, (2) exhale maximally and hold your
breath while you lift, and (3) inhale maximally prior to the lift and exhale during the lift.The amount
of weight you lift will be based on a pereentage(30% and 60%)of your own maximum lifting
capabilities. Examples: If you can lift a maximum o f 100 pounds, you would be asked to lift 30
pounds and 60 pounds respectively. If you can lift a maximum of ISO pounds, you would be asked to
lift 45 pounds and 90 pounds, respectively.
6. Perform several maximal exertion, non-moving (static) lifting tasks while controlling your breath as
described above in number 5. 1
118
Explanation of Load: The ERB protocol describes loads as “60 and 30% o f
maximal lifting capacity”. This description may appear to be different from the
levels of load used in the present study (70% and 35% of isometric maximum as
determined in the upright posture). The language o f the IRB does not specify the
operational definition o f “maximal lifting capacity.” The original intent was to
use maximal isometric trunk extension in the knees bent posture as a
representation o f “maximal lifting capacity.” However, due to the trunk flexion
found in this posture, the level o f risk for subjects with pre-existing LBP was
unacceptable. Although the present study did not include subjects with LBP,
additional studies requiring the use o f an identical methodology are planned, and
therefore an alternative measure o f “maximal lifting capacity” was used. Pilot
testing showed that, on average, 70% of upright trunk extensor force
approximates 60% of knee bent trunk extensor force. In the present study, all
subjects performed both maximal trunk extension in both knees bent and upright
postures. Comparisons were made for each subject to insure that 70% of the
upright trunk extension force did not exceed 60% of the knees bent extensor
force. In this way, the level o f risk described within the language o f the ERB was
maintained appropriately while the ability to compare the results o f this study to
future studies using LBP subjects was obtained. Therefore, for all subjects the
loads were normalized to 70% and 35% of the maximal upright extensor force in
the upright posture as described in the preceding paragraph.
119
Appendix 2. Power calculations on pilot data
Hypothesis 1 concerning IAP magnitude. Power to detect differences in IAP

magnitude among main effects as a function o f sample size and effect size.
Breath Condition Posture Load

N per cell
f = .28 F = .23 F = .58
Levels = 3 Levels = 2 Levels = 2
6 .471 .414 .984
8 .619 .541 1.000
10 .736 .648 1.000
12 .823 .734 1.000
14 .884 .803 1.000
16 .926 .855 1.000
Note: Power = 80%; alpha = 0.05.
Hypothesis 1 concerning LAP timing. Power to detect differences in IAP timing

among main effects as a function of sample size and effect size.
Breath Condition Posture Load

N per cell
f = .35
U<
o
F = .05 CO
II
Levels = 3 Levels = 2 Levels = 2

5 .568 .061 .055
6 .671 .064 .056
7 .755 .067 .058
8 .821 .070 .059
9 .871 .073 .060
10 .909 .076 .062
Note: Power = 80%; alpha = 0.05.
120
Hypothesis 2. Power to detect differences in maximal force among main effects
as a function o f sample size and effect size.
Breath Condition
N per cell
ii
Levels = 3
26 .725
28 .760
30 .791
32 .819
34 .843
36 .865
Note: Power = 80%; alpha = 0.05
121
Appendix 3. Calibration of instruments/Test for timing of data acquisition
1.Force transducer
Weights o f known mass were supported from a cable attached to the force
transducer. Calibration was performed based on comparisons o f the known mass
of the weight and the output o f the force transducer.
2. Pneumotach
A large volume syringe (2 liters) was connected to the breathing tube, which was
connected to the pneumotach. Complete emptying and filling of the syringe was
performed over multiple trials at various rates. Calibration was performed by
setting the mean integration o f trial volumes equal to 2 liters.
3. IAP transducer
The catheter was placed at varying depths of water and the output was checked
for appropriate direction and relative magnitude o f change.
4. Relative timing of acquisition of force data relative to LAP data

In order to insure that a mechanical delay between the acquisition of force and
IAP data was not present the IAP catheter was placed on top of the force
transducer and tapped repeatedly. Visual inspection o f the signals showed that the
occurrence o f the regular peaks of IAP and force data appeared to occur
simultaneously (±. 001 seconds).
122
Appendix 4. Baecke Questionnaire o f Habitual Physical Activity and
computational methods used for scoring.
Name:________________________________________________________
Age:____ Gender:________________
Date:___________
Main Occupation:______________________________________________
W l. THE PHYSICAL ACTIVITY LEVEL OF MY MAIN OCCUPATION IS:

1) Low (i.e., clerical work, shop keeping, driving, teaching, studying, housework,
medical practice, and all other occupations with a university education)
2) Medium (i.e., factory work, carpentry, plumbing, and farming)
3) High (i.e., dock work, construction work, and sport)
W2. AT WORK I SIT:
l)always 2)often 3)sometimes 4)seIdom 5)never
W3. AT WORK I STAND:
l)never 2)seIdom 3)sometimes 4)often 5)always
W4. AT WORK I WALK:
l)never 2)seldom 3)sometimes 4)often 5)always
W5. AT WORK I LIFT HEAVY LOADS:
I)never 2)seIdom 3)sometimes 4)often 5)always
W6. AFTER WORKING I AM TIRED:
l)always 2)often 3)sometimes 4)seIdom 5)never
W7. AT WORK I SWEAT:
l)never 2)seldom 3)sometimes 4)often 5)always
W8. IN COMPARISON WITH OTHERS OF MY OWN AGE, I THINK MY WORK IS
PHYSICALLY:
I)much lighter 2)lighter 3)as heavy 4)heavier 5)much heavier
SI. DO YOU PLAY A SPORT?
I)Yes 2)No
IF YOU PLAY A SPORT:

WHAT IS YOUR PRIMARY OR MOST FREQUENTLY PLAYED SPORT?
THE PHYSICAL INTENSITY LEVEL OF MY PRIMARY SPORT IS:

1) Low (e.g., billiards, sailing, bowling, and golf)
2) Medium (e.g., badminton, cycling, dancing, swimming, tennis, and middle distance
running)
3) High (e.g., boxing, basketball, football, rugby, rowing, and long distance running)
IN A WEEK, I PLAY MY PRIMARY SPORT:
I)Less than 1 hour 2)1-2 hours 3)2-3 hours 4)3-4hours 5)More than 4 hours
IN A YEAR, I PLAY MY PRIMARY SPORT:
l)Less them I month 2)1-3 months 3)4-6 months 4)7-9months 5)More than 9 months
IF YOU PLAY A SECOND SPORT:

WHAT IS YOUR SECOND SPORT? _____ _____
123
THE PHYSICAL INTENSITY LEVEL OF MY SECOND SPORT IS:
1) Low (e.g., billiards, sailing, bowling, and golf)
2) Medium (e.g., badminton, cycling, dancing, swimming, tennis, and middle distance
running)
3) High (e.g., boxing, basketball, football, rugby, rowing, and long distance running)
IN A WEEK, I PLAY MY SECOND SPORT:
l)Less than 1 hour 2)1-2 hours 3)2-3 hours 4)3-4hours 5)More than 4 hours
IN A YEAR, I PLAY MY SECOND SPORT:
l)Less than I month 2)1-3 months 3)4-6 months 4)7-9months 5)More than 9 months
IN COMPARISON WITH OTHERS OF MY OWN AGE:

S2.1 THINK MY PHYSICAL ACTIVITY DURING MY LEISURE TIME IS:
l)Much less 2)Iess 3)the same 4)more 5)much more
S3. DURING MY LEISURE TIME I SWEAT:
l)Much less 2)less 3)thesame 4)more 5)much more
S4. DURING MY LEISURE TIME I PLAY A SPORT:
l)Much less 2)less 3)the same 4)more 5)much more
LI. DURING MY LEISURE TIME I WATCH TELEVISION:
l)Much more 2)more 3)the same 4)Iess 5)much less
L2. DURING MY LEISURE TIME I WALK:
L3. DURING MY LEISURE TIME I CYCLE ( INCLUDING STATIONARY CYCLING);
L4. HOW MANY MINUTES DO YOU WALK/OR CYCLE PER DAY TO AND FROM
WORK, SCHOOL AND SHOPPING?
I)Less than 5 minutes 2)5-15 minutes 3)16-30 minutes 4)31-45 minutes 5)more than
45 minutes
124
HABITUAL PHYSICAL ACTIVITY QUESTIONNAIRE
SCORE CALCULATION
The following calculations are based on Baecke et al.7
1. Calculation of scores of the work index of physical activity:
j Wl + (6 -W 2 ) + W3 + W4 + W5 + W6 + W7 + W8
Work Index = ------------ ------------------------------------------
8
where :
W1 =1if answer to question Wl is I
=3 if answer to question WI is 2
=5 if answer to question WI is 3
W2, W3, W4, W5 = I if answer is 1

= 2 if answer is 2
= 3 if answer is 3
= 4 if answer is 4
= 5 if answer is 5
W6, W7, W8 = 5 if answer is I

= 4 if answer is 2
= 3 if answer is 3
= 2 if answer is 4
= 1 if answer is 5
2. Calculation o f sport index of physical activity:
e r , Sis + S2 +S3 +S4

Sport Index = ---------------------------
4
Where:
2
S ls = £ ( IntensityxTim exProportion)
/=!
125
To determine the intensity equivalent score (SIa or Sib), the following numbers
were substituted for the corresponding test scores:
0.76 Ifor intensity score of 1 (i.e., low intensity sports);

1.26 Ifor intensity score of 2 (i.e., medium intensity sports);
1.76 tfor intensity score of 3 (i.e., high intensity sports).
To determine the weekly frequency equivalent score (Wa or Wb), the following
numbers were substituted for the corresponding test scores:
0.5 flfor weekly frequency score o f 1 (i.e., less than 1

thour);
1.5 fifor weekly frequency score of 2 (i.e., 1-2 hours);
2.5 fifor weekly frequency score o f 3 (i.e., 2-3 hours);
3.5 fifor weekly frequency score o f 4 (i.e., 3-4 hours);
4.5 fifor weekly frequency score o f 5 (i.e., >4 hours);
To determine the yearly frequency equivalent score, the following numbers were
substituted for the corresponding test scores:
0.04 fifor yearly frequency score o f 1 (i.e., less than 1

imonth);
0.17 fifor yearly frequency score of 2 (i.e., 1-3 months);
0.42 fifor yearly frequency score of 3 (i.e., 4-6 months);
0.67 fifor yearly frequency score of 4 (i.e., 7-9 months); or
0.92 fi^or yearly frequency score o f 5 (i.e., >9 months);
If the subject did not play a sport (i.e., those who answered (2) to item S I) the S ic
score is zero.
Values of S2 and S3 will be calculated! similar to W3, and S4 will be calculated

similar to W6.
3. Calculation of Leisure index indaces of physical activity:
C 6 - LI) + L2 + L3 + L4
Leisure Index = ---------------------------------
4
Where LI to L4 scores will calculated similar to W3 and W4.
126
Appendix 5. Medical History Form
Today’s Date_
Subject ID # _
Name: Date o f Birth:______ / _______/ _______
month/ day / year
Sex:___________Male/Female
Height_____________
Weight_____________
Medical History: Please place a check on the line if you have ever had:
_ Stroke Neurological problems JHeart problems
Low Back Pain _Diabetes/High blood sugar _Multiple sclerosis
Muscular dystrophy Parkinson’s Disease _Seizures/Epilepsy
Circulation/vascular problems Lung problems _Osteoporosis
_Hemia _Eye problems _Thyroid problems
Muscle function problems Broken bones/fractures _Blood pressure

problems
Deformities o f the spine (such as scoliosis)
Infectious disease (such as tuberculosis, hepatitis)
Cancer
3. Have you ever had surgery? Yes No

If yes, please describe and include dates:
/ /
month/ day / year
/ /
• When is the last time you ate?
I ate________ hours ago.
At that time, I ate/drank______
• FOR WOMEN ONLY:

Are you currently pregnant? _ Yes No
127
A ppendix 6. IAP m agnitude data
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Appendix 7. IA P tim ing data
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131
Appendix 8. Force data
Static Maximum Exertions. 1 second window (n = 33)
Trial 1 (kg) Trial 2 (kg)
Mean 80.74 80.87

SD 34.10 34.45
Max 189.23 196.80
Min 19.98 17.54
Dynamic Exertions. Comparison of two windows of data collection (n = 11)
0.1 force (kg) 0.3 force (kg)
43.40 41.34
SD 21.25 20.69
Max 120.01 119.53
Min 11.32 10.77
Static Exertions relative to breath, posture. One second window (n = 33)
Inhalation/Hold Exhalation/Hold Inhalation/Exhalation

(kg) (kg) (kg)
Upright Kbent Upright Kbent Upright Kbent

Mean 68.26 90.72 66.68 93.39 70.74 94.37
SD 27.62 36.93 25.79 36.85 27.93 35.76
Max 143.36 184.99 145.07 196.80 150.00 182.62
Min 17.54 28.04 18.97 28.36 19.98 28.20
132
Appendix 9. Post hoc analysis
Flow 1 sec. Flow 0.5sec& Flow 0.5 se c s. Flow 1 s e c

Flow at liftoff
priorto liftoff priorto liftoff post liftoff post liftoff
100 100 100 -i 100 100
80 80 - 80 - 80 80 -I
00 - 80 - 80 - 00 00
40 - 40 40 - 40 4)
(/)
20
a
- 20
0
20
0J
-
M 20
0 t o
20 H
■n
09 too 100 100 -I 100 100
O
-J 80 80 H 80 - 80 80
80 - 00 80 - 00 00
& 40 - 40 40 - 40 41
20 - 20 20 20 20
0 -* s J ]
- -
0 0 0 0J
100 -j 100 100 100 -i 100

80 - 80 - 80 -
00 - 80 - 00 - 80 -
40 - 40 - 40 -
20 - 20 • 20 - 20 ■
100 100 100 - | 100 1 0 0 -i

BJ £ 80 - 80 ■ 80 - 80 - 80 -
00 - 00 - 00 - 80 - 00 -
40 - 40 - 40 - 40 - 40 -
20 - 20 - 20 - 20 - 20 -
0 Exhalation ■ H olding □ Inhalation
Figure A. Frequency distributions of naturally occurrring categories of

inhalation, exhalation, and breath holding relative to load and posture.
Figure displays percent of each category of exhalation., breath holding,
and inhalation relative to levels of posture and load at 5 points in time
relative to liftoff. Top two rows compare small load with large load
conditions. Bottom two rows compare knees bent posture with knees
straight posture. Comparisons reveal no clear differemces in patterns
relative to load and posture.
133
□ I - E - E HE - 1 - E
ill - E - I HI - H - E
iE-I-I ^E-I-H
HI-H-H iE -E -I
Figure B. Eight most common flow patterns during lifting relative to posture
and load.
Patterns represent the categorization of flow into inhalation, exhalation or breath
holding at three time points: 1 second prior to lift-off, at liftoff, and 1 second post
lift-off. The y- axis represents frequency of occurrence of breath pattern. The x-
axis represents the eight most frequent breath patterns. On average, these eight
patterns account for greater than 70% of the total breath patterns used in all trials.
Legend: I = Inhalation; E = Exhalation; H = Breath Holding.
134
Table A. Results o f five separate repeated ANOVAs for effects of posture
and load on volumes occurring during lifting.
Volume 1-5 Independent Variable F P value
.274
Posture 1.236
1 Load .001 .982
.623
2 Posture .246
Load .010 .922
.153
3 Posture 2.141
Load .097 .758
.014*
4 Posture 6.725
Load 4.988 .032*
.004*
5 Posture 9.300
Load 9.342 .004*
*p < .05
Table B. Means and standard deviations of IAP magnitude data relative to

three controlled breath conditions and naturally occurring breath.
IAP
Independent Variable Level magnitude (mmHg)
M fSDl
Inhale-Hold 51.6 (23.9)

Breath Control Exhale-Hold 38.7(15.3)
Inhale-Exhale 39.3 (22.9)
Natural Breath 39.9 (21.5)
135
Table C. Results of paired t-Tests comparing effects on IAP o f controlled
breath conditions to the natural breath condition.
Paired t df P value
Differenc
es
95% Confidence
Interval o f the
Difference
M SD SEM Lower UpDer
Natural Breath
Exhalation-Hold to -1.27 18.394 2.773 -6.865 4.320 -0.459 43 0.649
Natural Breath
Inhalation-Exhalation to -0.66 16.521 2.491 -5.685 4.361 -0.266 43 0.792
Natural Breath
Note: SEM = Standard Error of the Mean

* *j> < 0.017; Significance based on Bonferroni correction for multiple comparisons
Table D. Results of repeated measures univariate analysis of variance

(ANOVA) for the main effects of load, breath, and posture on the magnitude
of IAP at the moment of peak force
F P value
Load 24.15 .001*

Breath 5.71 .006*
Posture 1.40 .264
Note: Four levels o f breath used for analysis: inhalation-hold, exhalation-hold, inhalation-
*p < .05
136
Table E. Results of repeated measures univariate analysis of variance
(ANOVA) for the main effects of load, breath, and posture on peak IAP
timing relative to timing of peak force
F P value
Load 1.597 .235

Breath 1.732 .186
Posture .080 .783
Note: Four levels o f breath used for analysis: inhalation-hold, exhalation-hold, inhalation-
Table F. Results of separate repeated ANOVAs on effects of breath control

on IAP magnitude during maximal static exertions in the knees bent and
upright postures.
Variable Posture F P value
Breath Upright 8.663 .002*
Breath Knees Bent 9.366 .003*
*p < .05
137
Table G. Results o f paired t-Tests on effects o f level of breath on IAP
magnitude during upright posture (n = 11).
Paired t df P value
Differences
95% Confidence
Interval o f the
Difference
Exhalation-Hold
Inhalation-Hold to 24.59 33.942 10.234 1.793 47.398 2.403 10 0.037


* *P < 0.017; Significance based on Bonferroni correction for multiple comparisons
Table H. Results of paired t-Tests on effects of level of breath on IAP

magnitude during knees bent posture.
Paired t df P value
Differences
95% Confidence
Interval o f the
Difference
Exhalation-Hold


* *£ < 0.017; Significance based on Bonferroni correction for multiple comparisons
138
Reference List
1. Ainsworth BE, et al. Evaluation of the Kaiser physical activity survey in
women. Medicine and Science in Sports and Exercise 2000; 32:1327-38.
2. Anderson CK, et al. A biomechanical model of the lumbosacral joint during
lifting activites. Journal of Biomechanics 1985; 18:571-84.
3. Andersson GBJ, Ortengren R, Nachemson A. Quantitative studies o f back
loads in lifting. Spine 1976; 1:178-85.
4. Andersson GBJ, Ortengren R, Nachemson A. Intradiskal pressure, intra
abdominal pressure and myoelectric back muscle activity related to posture
and loading. Clinical Orthopaedics and Related Research 1977; 129:156-64.
5. Armstrong JR. Lumbar Disc Lesions. Baltimore: Williams and Wilkins,
1965.
6. Ayoub MN. Dynamic biomechanical model for sagittal plane lifting
activities. In Drury G.G., ed. Safety in Manual Material Handling
Cincinnati: NIOSH, 2000;78-185.
139
7. Baecke JA, Frijters JER. A short questionnaire for the measurement o f
habitual physical activity in epidemiological studies. The American Journal
of Clinical Nutrition 1982; 36:936-42.
8. Balldin UI, et al. Isometric abdominal muscle training and G-tolerance.
Aviation, Space, and Environmental Medicine 1985; 56:120-4.
9. Bartelink DL. The role of abdominal pressure in relieving the pressure on
the lumbar intervertebral discs. Journal o f Bone and Joint Surgery 1957; 39-
B:718-25.
10. Battie MC, et al. Isometric lifting strength as a predictor of industrial back
pain reports. Spine 1989; 14:851-6.
11. Bejjani FJ, Gross CM, Pugh JW. Model for static lifting: Relationships of
loads on the spine and the knee. Journal o f Biomechanics 1984; 17:281-6.
12. Bray JH, Maxwell SE. Multivariate Analysis o f Variance. Newbury Park,
CA: Sage Publications, 1985;33-4.
13. Bums KJ, Froman RD. Refinement of the habitual physical activity index
for use with american adults. Journal of Nursing Measurement 1997; 5:17-
32.
140
14. Chaffin. D. A computerized biomechanical model-development of and use in
studying gross body actions. Journal o f Biomechanics 1969; 2:429-41.
15. Chaffin D, Freidvalds A, Evans SM. On the validity o f an isometric
biomechanical model o f worker strength. Trans AHE 1987; 19:280-8.
16. Chaffin DB. Functional Assessment for Heavy Physical Labor. In
Alderman,MH, Hanley,MJ, eds. Clinical Medicine for the Occupational
Physician London: Taylor and Francis, 1965.
17. Chaffin DB. A Computerized Biomechanical Model: Development and Use
in Studying Gross Body Actions. Journal o f Biomechanics 1969; 2:429-41.
18. Chaffin DB, Andersson GB, Martin BJ. Occupational Biomechanics ed 3.
New York: John Wiley and Sons, 1999;224-51.
19. Cholewicki J, Juluru K, McGill SM. Intra-abdominal pressure mechanism
for stabilizing the lumbar spine. Journal o f Biomechanics 1999; 32:13-7.
20. Cholewicki J, et al. Lumbar spine stability can be augmented with an
abdominal belt and/or increased abdominal pressure. European Spine
Journal 1999; 8:388-95.
141
21. Cohen J. Statistical Power Analysis for the Behavioral Sciences. New York:
Academic Press, 1969.
22. Cresswell A. Responses of intra-abdominal pressure and abdominal muscle
activity during dynamic trunk loading in man. European Journal o f Applied
Physiology 1993; 66:315-20.
23. Cresswell A, Blake P, Thorstensson A. The effect o f an abdominal muscle
training program on intra-abdominal pressure. Scandinavian Journal of
Rehabilitation Medicine 1994; 26:79-86.
24. Cresswell AG, Blake PL, Thorstensson A. The effect o f an abdominal
muscle training program on intra-abdominal pressure. Scandinavian Journal
o f Rehabilitation Medicine 1994; 26:79-86.
25. Cresswell AG, Grundstrom H, Thorstensson A. Observations on intra
abdominal pressure and patterns of abdominal intra-muscualar activity on
man. Acta Physiologica Scandinavica 1992; 144:409-18.
26. Cresswell AG, Oddsson L, Thorstensson A. The influence of sudden
perturbations on trunk muscle activity and intra-abdominal pressure while
standing. Experimental Brain Research 1994; 98:336-41.
142
27. Cresswell AG, Thorstensson A. The role of the abdominal musculature in
the elevation of the intra-abdominal pressure during specified tasks.
Ergonomics 1989; 32:1237-46.
28. Cresswell AG, Thorstensson A. Changes in intra-abdominal pressure, trunk
muscle activation and force during isokinetic lifting and lowering. European
Journal o f Applied Physiology 1994; 68:315-21.
29. Daggfeldt K, Thorstensson A. The role of intra-abdominal pressure in spinal
unloading. Journal of Biomechanics 1997; 30:1149-55.
30. David GC. Intra-abdominal pressure measurements and load capacities for
females. Ergonomics 1985; 28:345-58.
31. Davis PR. Variations of intra-abdominal pressure during weight lifting in
various postures. Journal o f Anatomy 1956; 90:601.
32. Davis PR. Variations of the human intra-abdominal pressure during weight
lifting in different postures. Journal o f Anatomy 1956; 90:601.
33. Davis PR. Posture of the trunk during the lifting of weights. British Medical
Journal 1959; 1:87-9.
143
34. Davis PR. The use of intra-abdominal pressure in evaluating stresses on the
lumbar spine. Spine 1981; 6:90-2.
35. Davis PR, Troup JDG. Pressures in the trunk cavities when pulling, pushing
and lifting. Ergonomics 1964; 7:465-74.
36. Davis PR, Troup JDG. Effects on the trunk of handling loads in different
postures. Proceedings of 2nd International Congress on Ergonomics 1965.
37. Derenne J-P, Macklem PT, Roussos CH. The respiratory muscles:
mechanics, control, and pathophysiology, Part I. American Review o f
Respiratory Disease 1978; 118-9.
38. Detroyer A, et al. Transversus abdominis muscle function in humans.
39. Eie N . Load capacity of the low back. Journal of Oslo City Hospital 1966;
16:73-98.
40. Eie N, Wehn P. Measurements o f the intra-abdominal pressure in relation to
weight bearing of the lumbosacral spine. Journal of Oslo City Hospital
1962; 12:205-17.
144
41. Ekholm J, et al. Activation o f abdominal muscles during some
physiotherapeutic exercises. Scandinavian Journal of Rehabilitation 1979;
411:75-84.
42. Evenson KR, et al. Physical activity and ischemic stroke risk. Stroke 1999;
30:1333-9.
43. Farfan H. Mechanical Disorders o f the Low Back. Philadelphia: Lea and
Febiger, 1973.
44. Farrell J, Drye C, Koury M. Therapeutic exercise for back pain. Physical
Therapy o f the Low Back 1999.
45. Freivalds A, Chaffin D, Garg A. A dynamic biomechanical evaluation of
lifting maximum acceptable loads. Journal o f Biomechanics 1984; 17:251-
62.
46. Garg A. Occupational biomechanics and low back pain. Occupational
Medicine 1992; 7:609-28.
47. Garg A, Chaffin D. A biomechanical computerized simulation o f human
strength. Trans AIIE 1975; 7:1-15.
145
48. Garg A, Chaffin D, Freidvalds A. Biomechanical Stresses from manual load
lifting: A static versus dynamic evaluation. Trans ABE 1982; 14:272-81.
49. Girden ER. ANOVA Repeated Measures. Newbury Park: Sage Publications
Inc., 1992.
50. Goldish GD, et al. Postural effects on intra-abdominal pressure during
Valsalva Maneuver. Archives Physical Medicine and Rehabilitation 1994;
75:324-7.
51. Gracovetsky S. The Spinal Engine. New York: Springer-Verlag, 1988.
52. Gracovetsky S, Farfan H, Helleur C. The abdominal mechanism. Spine
1985; 10:317-24.
53. Grassino A, et al. Mechanics of the human diaphragm during voluntary
contraction statistics. Journal of Applied Physiology 1978; 44:829.
54. Green SB, Salkind NJ, Akey TM. Using SPSS for Windows; Analyzing and
Understanding Data. Upper Saddle River, N.J.: Prentice-Hall, 1997.
55. Grew ND. Intra-abdominal pressure response to loads applied to the torso in
normal subjects. Spine 1980; 5,149-54.
146
56. Grew ND, Deane G. The physical effect of lumbar spinal supports.
Prosthetics and Orthotics International 1982; 6:79-87.
57. Grieve GP. Dynamic characteristics of man during crouch- and stoop-lifting.
In Nelson,CR, Moorehouse,CA, eds. Biomechanics, 4th ed; Baltimore:
University Park Press, 1974.
58. Grillner S, Nilsson J, Thorstensson A. Intra-abdominal pressure changes
during natural movements in man. Acta Physiologica Scandinavica 1978;
103:275-83.
59. Hall SJ. Effect of attempted lifting speed on forces and torque exerted on the
lumbar spine. Medicine and Science in Sports and Exercise 1985; 17:440-4.
60. Harman EA, et al. Intra-abdominal and intra-thoracic pressures during
lifting and jumping. Medicine and Science in Sports and Exercise 1988;
20:195-201.
61. Harman EA, et al. Effects of a belt on intra-abdominal pressure during
weight lifting. Medicine and Science in Sports and Exercise 1989; 21:186-
90.
147
62. Hazard RG, et al. Test-retest variation in lifting capacity and indices of
subject effort. Clinical Bio mechanics 1993; 8:20-4.
63. Hazard RG, Reeves V, Ferguson SA. Lifting capacity. Spine 1992; 17:1065-
70.
64. Hemborg B, Moritz U. Intra-abdominal pressure and trunk muscle activity
during lifting. H. Chronic low-back patients. Scandinavian Journal of
65. Hemborg B, et al. Intra-abdominal pressure and trunk activity during lifting.
III. Effect o f abdominal muscle training in chronic low-back patients.
Scandinavian Journal of Rehabilitation Medicine 1985; 17:15-24.
66. Hemborg B, et al. Intraabdominal Pressure and trunk muscle activity during
lifting—effect o f abdominal muscle training in healthy subjects.
Scandinavian Journal o f Rehabilitation Medicine 1983; 15:183-96.
67. Hemborg B, Moritz U, Lowing H. Intra-abdominal Pressure and trunk
muscle activity during lifting. IV. The causal factors o f the intra-abdominal
pressure rise. Scandinavian Journal o f Rehabilitation Medicine 1985; 17:25-
38.
148
68. Hodges P, et al. In vivo measurement o f the effect o f intra-abdominal
pressure on the human spine. Journal o f Biomechanics 2001; 34: 347-353
69. Hodges P, Cresswall A, Thorstensson A. Preparatory trunk motion
accompanies rapid upper limb movement. Exp Brain Res 1999; 124:69-79.
70. Hodges P, et al. Three dimensional preparatory trunk motion precedes
asymmetrical upper limb movement. Gait and Posture 2000; 11, 92-101..
71. Hodges P, Gandevia SC. Changes in intra-abdominal pressure during
postural and respiratory activation of the human diaphragm. Journal o f
Applied Physiology 2000; 89:967-76.
72. Hodges PW, et al. Contraction o f the human diaphragm during rapid
postural adjustments. Journal of Physiology 1997; 505:539-48.
73. Hodges PW, Gandevia SC. Changes in intra-abdominal pressure during
postural and respiratory activation of the human diaphragm. Journal o f
Applied Physiology 2000; 89:967-76.
74. Hodges PW, Gandevia SC, Richardson CA. Contractions of specific
abdominal muscles in postural tasks are affected by respiratory maneuvers.
149
75. Hodges PW, Richardson CA. Contraction of the abdominal muscles
associated with movement o f the lower limb. Physical Therapy 1997;
77:132-42.
76. Hodges PW, Richardson CA. Feedforward contraction of transversus
abdominis is not influenced by the direction of arm movement.
Experimental Brain Research 1997; 114:362-70.
77. Hodges PW, Richardson CA. Relationship between limb movement speed
and associated contraction o f the trunk muscles. Ergonomics 1997; 40:1220-
30.
78. Kamon E, Goldfuss AJ. In-plant evaluation of the muscle strength of
workers. American Industrial Hygiene Association Journal 1978; 39:801-7.
79. Kendall F, McCreary E. Muscles: Testing and Function 3rd ed;. Baltimore:
Williams and Wilkins, 1983; 221.
80. Krag MH, et al. Failure of the intra-abdominal pressurization to reduce
erector spinae loads during lifting tasks. Proceedings o f the North American
Congress on Biomechanics 1986;87-8.
150
81. Kumar S. The effect of sustained spinal load on intra-abdominal pressure
and EMG characteristics of trunk muscles. Ergonomics 1997; 40:1312-34.
82. Kumar S, Davis PR. Lumbar vertebral innervation and intra-abdominal
pressure. Journal of Anatomy 1973; 114:47-53.
83. Kumar S, Davis PR. Spinal loading in static and dynamic postures: EMG
and intra- abdominal pressure study. Ergonomics 1983; 26:913-22.
84. Lander JE, Bates BT, Devita P. Biomechanics of the squat exercise using a
modified center of mass bar. Medicine and Science in Sports and Exercise
1986; 18:469-78.
85. Lander JE, Hundley JR, Simonton RL. The effectiveness o f weight-belts
during multiple repetitions of the squat exercise. Medicine and Science in
Sports and Exercise 1992; 24:603-9.
86. Lander JE, Simonton RL, Giacobbe JKF. The effectiveness of weight-belts
during the squat exercise. Medicine and Science in Sports and Exercise
1990; 22:117-26.
87. Legg SJ. The effect of abdominal muscle fatigue and training on the intra
abdominal pressure developed during lifting. Ergonomics 1981; 24:191-5.
151
88. Legg SJ. Metabolic, cardiovascular and spinal strain o f a representative fuel
replenishment task. Ergonomics 1985; 28:773-80.
89. Leskinen TP J, Stalhammar HR, Kuorinka IAA. The effect of inertial factors
on spinal stress when lifting. Eng Med 1983; 12:87-9.
90. MacDougall JD, et al. Arterial blood pressure response to heavy resistance
exercise. Journal o f Applied Physiology 1985; 58(3):785-90.
91. Mairiaux P, et al. Relation between intra-abdominal pressure and lumbar
moments when lifting weights in the erect posture. Ergonomics 1984;
27:883-94.
92. Mairiaux P, Malchaire J. Relation between intra-abdominal pressure and
lumbar stress: effect o f trunk posture. Ergonomics 1988; 31:1331-42.
93. Mairiaux P, et al. Reproducibility of intra-abdominal pressure when lifting.
Scandinavian Journal o f Rehabilitation Medicine 1988; 20:83-8.
94. Mantysarri M, Antila K, Peltonen T. Relationship between the changes in
heart rate and cardiac output during the valsalva manoeuvre. Acta
Physiologica Scandinavica 1984; 537:45-9.
152
95. Marras WS, loynt RL, King Al. The force-velocity relation and intra
abdominal pressure during lifting activities. Ergonomics 1985; 28:603-13.
96. Marras WS, King Al, Joynt RL. Measurements of loads on the lumbar spine
under isometric and isokinetic conditions. Spine 1984; 9:176-88.
97. Marras WS, Mirka GA. Intra-abdominal pressure during trunk extension
motions. Clinical Biomechanics 1996; 11:267-74.
98. Martin BJ, Chaffin D. Biomechanical computerized simulation of human
strength and sagittal plane activities. Trans ATTF. 1972; 4:19-28.
99. Matthews CE, et al. Comparing physical activity assessment methods in the
seasonal variation o f blood cholesterol study. Medicine and Science in
Sports and Exercise 2000; 32:976-84.
100. Maxwell SE. Pairwise multiple comparisons in repeated measures designs.
Journal o f Education Statistics 1980; 5:269-87.
101. McGill S, Seguin J, Bennett G. Passive stiffness of the lumbar torso in
flexion, extension and lateral bending and axial rotation: effect of belt
wearing and breath holding. Spine 1994; 19:696-704.
153
102. McGill SM. Low Back Exercises: Evidence for Improving Exercise
Regimens. Physical Therapy 1998; 78:754-65.
103. McGill SM, Norman RW. Partitioning of the L4-L5 dynamic moment into
disc, ligamentous, and muscular components during lifting. Spine 1986;
11:666-78.
104. McGill SM, Norman RW. Reassessment of the role o f intra-abdominal
pressure in spinal compression. Ergonomics 1987; 30:1565-88.
105. McGill SM, Norman RW. Chapter 4. In Grabiner,MD, ed. Current Issues in
Biomechanics Champaign, EL: Human Kinetics, 1993.
106. McGill SM, Norman RW, Sharratt MT. The effect o f an abdominal belt on
trunk muscle activity and intra-abdominal pressure during squat lifts.
Ergonomics 1990; 33:147-60.
107. McGill SM, Sharratt MT. Relationship between intra-abdominal pressure
and trunk EMG. Clinical Biomechanics 1990; 5:59-67.
108. Miyamoto K, et al. Effects of abdominal belts on intra-abdominal pressure,
intramuscular pressure in erector spinae muscles and myoelectrical activities
of trunk muscles. Clinical Biomechanics 1999; 14:79-87.
154
109. Morris JM, Lucas DB, Bresler B. Role of the trunk in stability o f the spine.
Journal o f Bone and Joint Surgery 1961; 43-A, :327-51.
110. Mueller G, et al. Intramuscular pressure in the erector spinae and intra
abdominal pressure related to posture and load. Spine 1998; 23:2580-90.
111. Nachemson A, Lindstrom I. Measurement of abdominal and back muscle
strength with and without low back pain. Scandinavian Journal of
112. Nachemson AL, Andersson GBJ, Schultz AB. Valsalva maneuver
biomechanics. Effects on lumbar trunk loads of elevated intra-abdominal
pressures. Spine 1986; 11:476-9.
113. NIOSH. A Work Practices Guide for Manual Lifting. Technical Report
No.81-122, U.S.Department o f Health and Human Services 1981; NIOSH.
114. O'Sullivan PB, Twomey L, Allison G. Evaluation o f specific stabilising
exercise in the treatment o f chronic low back pain with radiological
diagnosis o f spondylolysis or spondylolisthesis. Spine 1997; 22:2959-67.
155
115. Ortengren R, Andersson GBJ, Nachemson AL. Studies o f relationships
between lumbar disc pressure, myoelectric back muscle activity, and intra
abdominal (intragastric) pressure. Spine 1981; 6:98-103.
116. Pereira MA, et al. Physical activity and incident hypertension in black and
white adults: the atherosclerosis risk in communities study. Preventive
Medicine 1999; 28:304-12.
117. Philippaerts RM, Westerterp KR, Lefevre J. Doubly labelled water
validation o f three physical activity questionnaires. International Journal of
Sports Medicine 1999; 20:284-9.
118. Pope MH, et al. Occupational Low Back Pain, Assessment, Treatment and
Prevention. St. Louis: Mosby-Year Book, Inc, 1991.
119. Portney LG, Watkins MP. Foundations o f Clinical Research: Applications to
Practice. Norwalk, Connecticut: Appleton and Lange, 1993;514.
120. Reynolds B. Body Building for Beginners. Chicago: Contemporary Books,
1983.
121. Reynolds B. Joe Weiders Ultimate BodyBuilding. Chicago, IL:
Contemporary Books, 1983.
156
122. Richardson C, et al. Therapeutic Exercise for Spinal Segmental Stabilization
in Low Back Pain. London: Churchill Livingstone, 1999;1-191.
123. Richardson CA, Jull GA. Muscle control - pain control. What exercises
would you prescribe? Manual Therapy 1995; 1:2-10.
124. Schloshers SNL. Fitness for Dummies. Foster City: EDG Books Worldwide,
2000 .
125. Schneider G. The reliability of an exercise regime to limit episodes of
lumbar instability. Manipulative Physiotherapists Association o f Australia
Ninth Biennial Conference Proceedings, 1995; 1:140-4.
126. Schultz A, et al. Loads on the lumbar spine. Validation of a biomechanical
analysis by measurements of intradiscal pressures and myoelectric signals.
Journal o f Bone and Joint Surgery 1982; 64-A:713-20.
127. Sears T, et al. The role of the diaphragm in stabilizing ventilation.
Proceedings o f the Intemation Union of Physiological Scientists 1968;
7:394.
128. Stemfeid B, Ainsworth BE, Quesenberry CP. Physical activity patterns in a
diverse population o f women. Preventive Medicine 1999; 28:313-23.
157
129. Tabachnick BG, Fidell LS. Computer Assisted Research Design and
Analysis. Needham Heights, MA: Allyn and Bacon, 2001;86.
130. Tesh KM, Dunn S, Evans JH. The abdominal muscles and vertebral
stability. Spine 1987; 12:501-8.
131. Thomson BCD. On the bending moment capability o f the pressurized
abdominal cavity during human lifting activity. Ergonomics 1988; 31:817-
28.
132. Troup JDG. The etiology of spondylolysis. Orthopedic Clinics of North
America 1977; 8:57-64.
133. Troup JDG, et al. A comparison of intraabdominal pressure increases, hip
torque, and lumbar vertebral compression in different techniques. Human
Factors 1983; 25:517-25.
134. Van Poppel MNM, de Looze MP, Koes BW, Bouter LM. Mechanisms of
action o f lumbar supports. Spine 2000; 25:2103-13.
135. Wedin S, Leanderson R, BCnutsson E. The effect o f voluntary diaphragmatic
activation on back lifting. Scand J Rehab Med 1988; 20:129-32.
158
136. Woodhouse ML. Effects o f back support on intra-abdominal pressure and
lumbar kinetics during heavy lifting. Human Factors 1995; 37:582-90.
159

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INFORMATION TO USERS

The quality o f this reproduction is dependent upon the quality of ttae

Oversize materials (e.g., maps, drawings, charts) are reproduced toy

Photographs included in the original manuscript have been reproduced

ProQuest Information and Learning

and Maximal Isometric Trunk Extensor Force

A dissertation submitted in partial fulfillment of the requirements for the degree

Department o f Environmental Health Sciences

Program o f Ergonomics and Biomechanics

New York University

\ Ali Sheikhzadeh, Ph.D.

All rights reserved.

Bell & Howell Information and Learning Company

who always made me think,

and always made me explain what I thought.

(2) to determine the effects of voluntary breath control on m ax im u m isometric

a symmetrical unrestrained lifting task.

force). The presence o f inhalation, exhalation, or breath holding, and magnitude

of inhaled volume was determined at five points in time centered on lift-off o f

breath control: inhalation-hold (I-H), exhalation-hold (E-H), and inhalation-

measures MANOVA was used to determine the effects o f breath on LAP

effects of breath on force.

0.434), on IAP magnitude.

Discussion/Conclusion: Breath control is a significant factor in the generation of

may assist with regulation of IAP during lifting tasks.

List of Appendices.................................................................................................. xiii

2 Aim of the Study...................................................................................................25

3 Experimental Design and Methods................................................................... 28

6 Conclusions and Future Studies....................................................................... 114

Reference L ist.......................................................................................................... 139

Figure 1. Mechanism o f IAP to produce extensor moment during lifting tasks.... 5

Table 1. Demographic and Baecke Questionnaire data o f participants.................55

1.1 Injuries related to lifting tasks

Two percent of the US workforce has a compensable low back pain

billion.118 Approximately 40% of those who report an occurrence o f LBP on the

significant need for increased understanding o f the mechanisms of lifting tasks

in order to improve programs for injury reduction. One potential mechanism

that may contribute to the safe performance o f lifting tasks is intra-abdominal

abdominal cavity that is created primarily by coordinated contraction o f the

the generation of IAP have been studied

extensively,3,9'30'33,34'55'64'66'91'95'109'126'130'133 however, the potential role o f breath

control relative to LAP has received little attention.

ligaments, etc.). Biomechanical models contribute to injury prevention by

quantifying mechanical stress on tissues. One o f the primary considerations

when determining “safe” types o f lifting is the amount of compression and

shear stresses on the spinal structures.46

Many static and dynamic biomechanical models exist that attempt to

estimate the compression and shear forces during lifting

tasks.2’6'11’14’41’45’47’48'57’59’89’98'103’126’132 Two-dimensional models simplify the

complex three-dimensional vectors of multiple trunk extensor muscles into a

single muscle equivalent.46 This strategy appears adequate when e x am in in g

two-handed symmetrical sagittal plane exertions.15,47 Three-dimensional models

more accurately describe multiple muscle forces, as well as compression and

The most common two-dimensional lifting model represents the trunk

extensor muscles as a single vector connecting adjacent spinous processes that

predicted compression is too high, as suggested by McGill and Norman;103 (2)

lifting tasks.3’9’32’33,96,106 Many authors suggest its inclusion in biomechanical

models o f lifting.16,18,24’36’39’46’97’104’105’107’109’126’130’131 The rationale for including

diaphragm and downwards on the pelvic floor, thereby attempting to separate

thereby decrease compression stresses.

In addition, several authors have suggested that IAP increases lumbar

stability by assisting with the formation of a “rigid cylinder” through the

abdominal muscles,43'32 and/or through stabilizing forces delivered via fascial