Biofeedback speech therapy for stuttering

Biofeedback speech therapy for stuttering

Stuttering is an action-induced speech disorder with involuntary, audible, or silent repetitions or prolongations in the utterance of short speech elements (sounds, syllables) and words. Stuttering typically begins in childhood and may persist into adulthood. It can vary in severity, with some individuals experiencing only mild stuttering while others may have more pronounced difficulties speaking fluently. Treatment for stuttering often involves a combination of therapeutic approaches tailored to the individual’s needs and goals. Biofeedback speech therapy for stuttering is a therapeutic technique that can help individuals gain better control over physiological processes, such as muscle tension and stress, that may effectively contribute to stuttering. Several modalities of biofeedback speech therapy for stuttering can be used for treatment to help individuals gain better control over physiological processes that may contribute to disfluency.

What stuttering is?

Stuttering, or stammering, is a speech disorder characterized by disruptions in the normal flow of speech. People who stutter may experience difficulty producing sounds, syllables, words, or phrases, manifesting as repetitions of sounds or words, prolongations of sounds, or blocking, where the person cannot produce any sound for a brief period. These disruptions in speech can be accompanied by physical tension, such as facial grimaces or rapid eye blinking, as well as feelings of frustration and anxiety.

Stuttering typically begins in childhood and may persist into adulthood. It can vary in severity, with some individuals experiencing only mild stuttering while others may have more pronounced difficulties speaking fluently. The exact cause of stuttering is not fully understood, but it is believed to result from genetic, neurological, and environmental factors.

Treatment for stuttering often involves speech therapy. In this approach, a trained speech-language pathologist works with individuals to enhance their fluency and reduce both the frequency and severity of stuttering episodes. Specifically, therapists may use techniques such as speech modification, fluency shaping, and stuttering modification. These methods aim to help individuals manage their speech more effectively. Furthermore, early intervention is crucial for children who stutter. By addressing the issue early, it is possible to prevent the disorder from becoming more ingrained and severe.

It’s important to note that stuttering does not reflect a person’s intelligence or competence, and many individuals who stutter lead successful lives and careers with appropriate support and therapy. Supportive environments and understanding from family, friends, and peers can also play a significant role in helping individuals with stuttering feel more confident and comfortable in their communication.

Pathophysiology of stuttering

The pathophysiology of stuttering, or the underlying biological and neurological processes contributing to the disorder, is not fully understood. Stuttering is believed to be a complex condition influenced by a combination of genetic, neurological, and environmental factors. While researchers continue to study the condition, no single, universally accepted theory explains all aspects of stuttering. However, several hypotheses have been proposed to shed light on the potential mechanisms involved:

Overview

1. Genetic Contributions: Evidence suggests that stuttering may have a genetic component. Studies have shown that stuttering tends to run in families, and certain genetic variations may increase susceptibility to the disorder. However, no specific “stuttering gene” has been identified, and genetics alone cannot account for all cases of stuttering.

2. Neurological Differences: Stuttering involves abnormalities in the brain’s speech-processing areas and neural pathways. Some studies have identified differences in brain structure and function in individuals who stutter. For example, there may be variations in the size or activity of regions like the left inferior frontal gyrus, which is involved in speech production and language processing.

Neural and Developmental Influences on Stuttering

3. Neural Processing Challenges: Stuttering may be associated with differences in how the brain processes speech and language. It is hypothesized that individuals who stutter may have difficulties with the timing and coordination of the neural circuits responsible for speech production, leading to disruptions in fluency.

4. Developmental Factors: Stuttering often begins in childhood during rapid language and speech development. Some researchers suggest that developmental factors, such as the rate at which a child’s speech and language skills develop, may contribute to stuttering. Children who experience a rapid increase in speech demands without a corresponding increase in their abilities for motor control of speech may be more susceptible to stuttering.

Environmental and Psychological Factors

5. Environmental and Emotional Influences: While genetic and neurological factors play a role, environmental and psychological factors can also influence the severity and persistence of stuttering. Stress, anxiety, and social pressure can exacerbate stuttering, while supportive and communicative environments can help individuals manage their stuttering more effectively.

It’s important to note that stuttering is a highly variable condition, and the pathophysiology may differ from one individual to another. Additionally, ongoing research continues to refine our understanding of the disorder, and new insights are regularly emerging. Speech-language pathologists and researchers work together to develop and refine therapies that address the specific needs of individuals who stutter, considering the complex interplay of genetic, neurological, and environmental factors.

Stuttering signs and symptoms

Stuttering signs and symptoms may include:

  • Difficulty starting a word, phrase, or sentence,
  • Prolonging a word or sounds within a word,
  • Repetition of a sound, syllable, or word,
  • Brief silence for certain syllables or words or pauses within a word (broken word),
  • Addition of extra words such as “um” if difficulty moving to the next word is anticipated,
  • Excess tension, tightness, or movement of the face or upper body to produce a word,
  • Anxiety about talking,
  • Limited ability to effectively communicate.

Classification of stuttering

Stuttering can be classified into several categories or types based on various factors, including its characteristics and presentation. The classification of stuttering helps clinicians and researchers understand the nature of the disorder and tailor treatment approaches accordingly. Here are some standard classifications of stuttering:

Types of Stuttering

1. Developmental Stuttering:

  • Developmental stuttering is the most common type and typically begins in childhood as a child learns to speak.
  • It often starts between 2 and 4 when language and speech skills develop.
  • Developmental stuttering can vary in severity, and many children naturally outgrow it with age or through speech therapy.

2. Neurogenic Stuttering:

  • Neurogenic stuttering is associated with neurological conditions or injuries that affect the brain’s speech centers or motor control.
  • It can result from conditions such as strokes, traumatic brain injuries, or other neurological disorders.
    • Neurogenic stuttering may have a sudden onset and typically occurs in adulthood.

3. Psychogenic Stuttering:

  • Psychogenic stuttering is thought to be related to psychological factors and is often a response to stress, anxiety, or psychological trauma.
  • It can occur suddenly and may resolve with appropriate psychological therapy or intervention.

4. Cluttering:

  • Cluttering is a speech disorder characterized by rapid and disorganized speech, which may include frequent interruptions, irregular pacing, and unclear articulation.
  • Unlike stuttering, which involves disruptions in speech flow, cluttering often involves overly rapid and hasty speech.
  • Treatment for cluttering focuses on slowing down speech and improving articulation.

Additional Classifications

5. Acquired Stuttering:

  • Acquired stuttering refers to stuttering that develops later in life due to specific events, such as head injuries, illnesses, or psychological trauma.
  • It can be associated with sudden and noticeable changes in speech fluency.

6. Persistency:

  • This classification considers whether stuttering persists into adulthood or if it is outgrown during childhood.
  • Some individuals continue to stutter into adulthood, while others naturally recover or see significant improvements.

7. Secondary Behaviors:

  • Stuttering may also be classified based on the presence of secondary behaviors. These are physical or verbal reactions to stuttering, such as facial grimaces, eye blinking, or word substitutions, used to avoid stuttering.
  • Stuttering with secondary behaviors can be more complex and challenging to treat.

8. Severity Levels:

  • Stuttering can be classified by severity, ranging from mild to severe. Severity is often determined by the frequency and duration of disfluencies and their impact on communication.

It’s important to note that these classifications are not always mutually exclusive, and some individuals may exhibit characteristics of more than one type of stuttering. Additionally, the presentation and classification of stuttering can vary from person to person. Stuttering is a complex communication disorder, and assessment by a qualified speech-language pathologist is essential to determine the most appropriate treatment and management strategies for each individual.

Stuttering therapy

  • Treatment for stuttering often involves a combination of therapeutic approaches tailored to the individual’s needs and goals. Here is a list of some of the standard therapeutic approaches used for the treatment of stuttering:

Speech Modification Techniques

  • Fluency Shaping: This approach teaches individuals who stutter to speak more fluently by modifying their speech patterns. Techniques may include slowing speech rate, prolonging vowel sounds, and using gentle onsets (soft starts to words).
  • Easy Onset: Encourages individuals to start words or sentences with gentle, easy starts instead of sudden or forceful starts, reducing tension and improving fluency.

Stuttering Modification Strategies:

  • Cancellation: After a stuttering event, individuals pause, acknowledge the stutter, and repeat the word or phrase with reduced tension. Addressing and correcting the stutter improves fluency.
  • Pull-Out: When stuttering occurs, individuals pause and smoothly transition out of the stutter. Corrects the stutter mid-speech for improved fluency.
  • Preparation: Involves anticipating challenging words or situations and using techniques like stretching sounds or lightly tapping. Reduce stuttering by preparing for difficult speech moments.

Cognitive-Behavioral Therapy (CBT):

CBT aims to address the emotional and psychological aspects of stuttering, such as anxiety, fear, and negative self-perceptions. It helps individuals develop coping strategies and improve their self-esteem.

Desensitization and Confidence-Building:

Therapy may involve desensitization techniques, such as voluntarily stuttering or speaking in challenging situations to reduce anxiety and build confidence.

Group Therapy:

Group therapy provides a supportive environment for individuals who stutter to practice fluency techniques, share experiences, and gain social confidence.

Parent/Caregiver Training:

Parents and caregivers can learn strategies to create a supportive communication environment for their child who stutters, helping them communicate more comfortably.

Stress and Anxiety Management:

Stress and anxiety can exacerbate stuttering. Techniques such as relaxation exercises, mindfulness, and stress reduction strategies can be integrated into therapy to manage emotional triggers.

Neurofeedback and Biofeedback:

Neurofeedback or biofeedback is used to gain better control over physiological responses associated with stuttering, such as muscle tension or stress.

Electronic Devices and Apps:

Speech therapy apps and devices may provide visual or auditory feedback to assist individuals in monitoring and improving their speech patterns.

Supportive Counseling:

Some individuals find it helpful to engage in counseling to discuss the emotional and psychological aspects of living with stuttering, such as self-acceptance and managing societal pressures.

It’s important to note that stuttering therapy should be personalized to meet the unique needs of each individual. A qualified and experienced speech-language pathologist (SLP) or therapist specializing in stuttering can assess the specific challenges faced by the person who stutters and develop a tailored treatment plan. Early intervention is crucial in helping children who stutter, but therapy can also benefit teenagers and adults. Therapy aims to improve speech fluency, communication confidence, and overall quality of life.

Biofeedback speech therapy for stuttering

Biofeedback speech therapy for stuttering is a therapeutic technique to help individuals gain better control over physiological processes, such as muscle tension and stress, that may contribute to stuttering. While biofeedback is not a standalone treatment for stuttering, it can be a valuable component of a comprehensive therapy program. Here’s how biofeedback can be used in the treatment of stuttering:

1. Muscle Tension Monitoring:

Electromyographic (EMG) biofeedback speech therapy for stuttering can monitor muscle tension, especially in the muscles associated with speech production (e.g., facial muscles and neck muscles).

Individuals who stutter can learn to recognize patterns of excessive muscle tension during speech, which can contribute to disfluencies. Biofeedback provides real-time information about muscle activity, helping them become more aware of tension and relaxation in these muscles.

2. Relaxation Training:

Biofeedback can assist in teaching individuals relaxation techniques to reduce muscle tension and stress.

By seeing or hearing their physiological responses on a biofeedback monitor (e.g., muscle activity or skin conductance), individuals can practice relaxation exercises and learn to control their bodily responses.

3. Stress Reduction:

Stress and anxiety can exacerbate stuttering. Biofeedback can help individuals learn to manage stress and anxiety levels by providing feedback on physiological stress indicators, such as heart rate variability or skin temperature.

Individuals can develop strategies to reduce stress and anxiety during speaking situations with biofeedback.

4. Control of Breathing:

Breathing patterns play a significant role in speech production and fluency. Respiratory biofeedback speech therapy for stuttering can monitor and adjust breathing patterns during speech.

Individuals can learn to control their breath and reduce breath-related disfluencies by providing feedback on respiratory rate and depth.

5. Generalization and Self-Regulation:

The skills learned through biofeedback training can be applied in real-life speaking situations. Individuals can use the self-regulation techniques acquired during biofeedback therapy to improve their speech fluency.

6. Progress Monitoring:

Biofeedback sessions can track and record progress over time, allowing individuals and therapists to assess the effectiveness of relaxation and self-regulation strategies.
It’s important to note that biofeedback is typically used with other evidence-based stuttering therapy approaches, such as speech modification techniques, stuttering modification strategies, and cognitive-behavioral therapy. A qualified speech-language pathologist or therapist specializing in stuttering therapy can integrate biofeedback into an individualized treatment plan based on the specific needs and goals of the person who stutters.

The effectiveness of biofeedback in stuttering treatment can vary from person to person, and the choice to use biofeedback should be made in consultation with a qualified therapist. When integrated appropriately, biofeedback can help individuals become more aware of and better control the physiological factors contributing to stuttering, ultimately improving speech fluency and communication confidence.

What modalities of biofeedback speech therapy for stuttering can be used for effective treatment?

Several modalities of biofeedback can be utilized for stuttering treatment to assist individuals in gaining better control over physiological processes that may contribute to disfluency. Specifically, these modalities provide real-time feedback on specific physiological indicators, which allows individuals to monitor and adjust their responses. For example, here are some of the biofeedback modalities that can be employed in stuttering treatment:

1. Electromyographic (EMG) Biofeedback speech therapy for stuttering:

  • EMG biofeedback measures muscle activity and tension by using electrodes placed on the skin’s surface or inside the mouth to monitor the activity of speech-related muscles.
  • For stuttering treatment, EMG biofeedback can help individuals become aware of excessive tension in muscles involved in speech production (e.g., facial and neck muscles).
  • By visualizing muscle activity in real-time, individuals can learn to relax these muscles during speech to reduce tension-related disfluencies.

2. Respiratory Biofeedback:

  • Respiratory biofeedback focuses on monitoring and controlling breathing patterns closely related to speech fluency.
  • To reduce breath-related disfluencies, individuals can use respiratory biofeedback to adjust their breathing rate, depth, and coordination during speech.

3. Heart Rate Variability (HRV) Biofeedback:

  • HRV biofeedback measures the variation in time between successive heartbeats, which reflects the body’s physiological response to stress and relaxation.
  • It can help individuals learn to manage stress and anxiety levels, which can impact stuttering.
  • By increasing heart rate variability, individuals can promote relaxation and reduce the physiological stress response during speaking situations.

4. Skin Conductance Biofeedback:

  • Skin conductance biofeedback monitors the electrical conductance of the skin, which can indicate changes in emotional arousal and stress levels.
  • Individuals can use skin conductance biofeedback to become aware of stress reactions and learn relaxation techniques to reduce stress-related disfluencies.

5. Temperature Biofeedback:

  • Temperature biofeedback measures changes in skin temperature, which emotional and stress responses can influence.
  • It can help individuals learn to regulate their body’s temperature and reduce the physiological effects of stress on speech.

6. Neurofeedback or Brainwave (EEG) Biofeedback speech therapy for stuttering:

EEG biofeedback, or neurofeedback, monitors brainwave activity and provides feedback on brainwave patterns to help individuals regulate brain activity associated with speech production and anxiety.

7. Biofeedback Apps and Software:

  • Various biofeedback apps and software programs are available for smartphones and computers.
  • These apps may provide visual or auditory feedback on physiological indicators and can be used for self-regulation and practice outside therapy sessions.

The choice of biofeedback modality depends on the specific needs and goals of the individual who stutters. Therefore, it should be determined in collaboration with a qualified speech-language pathologist or therapist who specializes in stuttering therapy. In addition, biofeedback is often integrated into a comprehensive stuttering therapy program. Furthermore, it is combined with other evidence-based therapeutic approaches to help individuals improve speech fluency and enhance communication confidence.

Role of EMG biofeedback in the treatment of stuttering

EMG (Electromyography) biofeedback is a therapeutic technique that can be used as a component of the treatment of stuttering. Its primary role is to assist individuals who stutter in gaining greater awareness and control over the muscle tension and coordination involved in speech production. Here’s how EMG biofeedback can be beneficial in the treatment of stuttering:

Benefits of EMG Biofeedback in Stuttering Treatment

1. Muscle Tension Awareness: EMG biofeedback provides real-time feedback on the activity of specific muscles involved in speech production, such as the muscles around the mouth, lips, jaw, and throat. By monitoring muscle activity, individuals who stutter can become more aware of patterns of excessive tension and learn to recognize when they are tensing these muscles unnecessarily.

2. Tension Reduction: The visual or auditory feedback provided by EMG biofeedback can help individuals reduce excessive muscle tension during speech. When they see or hear that they are tensing their speech muscles, they can work to relax and release that tension, which can lead to smoother and more fluent speech.

3. Muscle Coordination: Stuttering often involves disruptions in the coordination of speech muscles. EMG biofeedback can help improve muscle coordination by assisting individuals to learn to activate and deactivate the relevant muscles correctly during speech.

4. Biofeedback-Based Practice: EMG biofeedback allows individuals to practice speech with immediate feedback in a controlled environment. This practice can help them develop new, more fluent speech patterns while reducing tension-related behaviors.

Additional Considerations for EMG Biofeedback

5. Self-Regulation: Individuals can learn to self-regulate their muscle tension and speech patterns over time without needing continuous biofeedback. They can carry the skills and awareness gained from biofeedback sessions into everyday communication.

6. Individualized Therapy: EMG biofeedback can be tailored to the specific needs of each stutterer. Therapists can target specific muscle groups and patterns of tension unique to the individual’s speech difficulties.

It’s important to note that EMG biofeedback is often used as part of a comprehensive stuttering therapy program, which may include other therapeutic approaches such as speech modification techniques, stuttering modification strategies, and cognitive-behavioral therapy. The choice of therapy approaches, including EMG biofeedback, will depend on the individual’s specific needs and goals for improving their fluency and reducing stuttering.

As with any therapeutic intervention, the effectiveness of EMG biofeedback in stuttering treatment can vary from person to person. Therefore, it should be administered and supervised by a qualified speech-language pathologist or therapist specializing in stuttering therapy and can tailor the treatment plan to the individual’s unique needs.

EMG electrode placement sites for biofeedback for stuttering

Electromyography (EMG) biofeedback involves placing electrodes on specific muscle groups associated with speech production and providing visual or auditory feedback to the individual about the activity of these muscles. This feedback can assist in reducing tension and improving muscle coordination during speech. Here are some common electrode placement sites for EMG biofeedback in stuttering therapy:

Head Muscles:

1. Orbicularis Oris Muscle: The orbicularis oris muscle is a circular muscle that surrounds the mouth and plays a significant role in speech production. This muscle controls lip movements during speech, and excessive tension in this muscle can lead to difficulties in articulation and fluency. EMG electrodes can be placed on the corners of the mouth or along the upper and lower lips to monitor muscle activity. This can help individuals become aware of excessive muscle tension and facilitate relaxation.

2. Mentalis Muscle: The mentalis muscle is located in the chin area and can be involved in the lower lip and chin movements during speech. Excessive tension in this muscle can lead to difficulties in articulation and fluency. Electrodes can be placed on the chin to monitor this muscle’s activity and help individuals reduce unnecessary tension.

3. Frontalis Muscle: The frontalis muscle is located in the forehead and involves facial expressions. Although not directly related to speech, it can be monitored to assess overall muscle tension and relaxation.

4. Facial Muscles: Various facial muscles, including the frontalis (forehead) and corrugator supercilii (between the eyebrows), can become tense during stuttering moments, contributing to facial tension that may impact speech.

5. Buccinator Muscle: This muscle is located in the cheeks and controls the oral cavity during speech. Tension in the buccinator muscle can influence articulation.

6. Temporalis Muscle: This muscle is located on the side of the head. It can influence jaw movement and tension.

7. Masseter Muscle: The masseter muscle is part of the jaw muscles and can contribute to jaw tension during speech.

8. Palatal Muscles: These are muscles of the soft palate (velum), such as the palatoglossus and palatopharyngeus, which affect resonance and articulation.

Neck muscles

Upper Neck Muscles

1. Suprahyoid Muscles: The suprahyoid muscles include the digastric and mylohyoid, which play a role in laryngeal control and swallowing. The suprahyoid muscles are located under the chin and beneath the jaw and are involved in jaw and tongue movement during speech, laryngeal control, and swallowing. Tension in these muscles can affect vocal control and fluency.
Electrodes may be placed along the neck or jawline to monitor the activity of these muscles.

2. Infrahyoid Muscles: The infrahyoid muscles (sternohyoid and omohyoid) are under the chin, below the suprahyoid muscles. They can influence laryngeal control and voice production and are also involved in speech-related movements. Monitoring and training these muscles can help reduce tension-related disfluencies.
Electrodes can be placed in the neck area to monitor these muscles.

3. Platysma Muscle: The platysma muscle is a thin sheet covering the front of the neck. It can contribute to neck tension during speech. Electrodes may be placed along the neck to monitor platysma muscle activity.

Lower Neck and Upper Back Muscles

4. Trapezius Muscle: The trapezius muscle is a large muscle that extends down the neck and upper back. Specifically, the upper portion of the trapezius muscle in the neck and upper back can become tense during stuttering. It may contribute to neck and shoulder tension, affecting overall speech tension.

5. Sternocleidomastoid (SCM) Muscle: The sternocleidomastoid muscle runs from the base of the skull to the collarbone and sternum. Tension in the SCM can affect head and neck posture and potentially contribute to speech tension.

6. Scalene Muscles: The scalene muscles are located on the sides of the neck and play a role in neck movement and respiration. Tension in the scalenes can affect overall neck tension and posture during speech.

7. Longus Colli Muscle: This muscle is situated in the anterior (front) of the neck and contributes to neck flexion and head movement. Monitoring and training this muscle can help reduce tension in the front of the neck.

These muscles collectively contribute to the coordination, tension, and control involved in speech production. Monitoring and training them with EMG biofeedback can assist individuals who stutter in becoming more aware of and regulating muscle activity to improve speech fluency and reduce disfluencies.

The electrode placements may vary based on the individual’s unique speech patterns and muscle tension. EMG biofeedback aims to help individuals become more aware of muscle tension patterns and learn to control and reduce tension during speech, ultimately improving fluency.

Role of Breathing Biofeedback in Stuttering Treatment

Breathing biofeedback can be a helpful component of stuttering therapy by assisting individuals in developing better control over their breathing patterns during speech. Proper breathing techniques can contribute to improved speech fluency and reduced stuttering. Here’s the role of breathing biofeedback in the treatment of stuttering and how it can be performed:

1. Increased Awareness: Breathing biofeedback helps individuals become more aware of their breathing patterns, such as shallow or irregular breathing, which can contribute to stuttering.

2. Controlled Breathing: It teaches individuals how to control their breath, allowing for more relaxed and controlled speech production.

3. Reduction of Tension: Proper breathing techniques can help reduce overall muscle tension, including tension in the speech muscles, enhancing speech fluency.

4. Anxiety Management: Breath control techniques can also be beneficial for managing anxiety, which can exacerbate stuttering. Deep, slow breaths can promote relaxation and reduce anxiety-related tension.

Performing Breathing Biofeedback for Stuttering

Here are the general steps for Breathing biofeedback:

1. Assessment: The therapist will first assess the individual’s current breathing patterns and their impact on speech fluency. This may involve monitoring chest, diaphragmatic, or abdominal breathing and the rate and depth of breaths.

2. Sensor Placement: Small sensors or electrodes may be attached to the individual’s chest, abdomen, or other relevant areas to monitor breathing patterns. These sensors are connected to a biofeedback device.

3. Feedback Display: The biofeedback device provides real-time visual or auditory feedback based on the individual’s breathing patterns. This feedback can be displayed on a computer screen or through audio cues.

4. Training: The therapist will guide the individual through exercises and techniques to improve their breathing patterns. This may include exercises to promote diaphragmatic breathing (deep belly breathing) and control breath rate and rhythm.

5. Practice: The individual practices these techniques while receiving feedback from the biofeedback device. They learn to adjust their breathing to achieve smoother and more controlled speech.

6. Generalization: Over time, the goal is for the individual to apply these breathing techniques in everyday communication, not just during therapy sessions. The therapist helps the individual transfer these skills to real-life situations.

7. Progress Monitoring: Progress is monitored throughout therapy to track improvements in breathing patterns and speech fluency. Adjustments to the treatment plan can be made as needed.

The effectiveness of Breathing biofeedback speech therapy for stuttering can vary from person to person, and it is essential to work with a qualified speech-language pathologist or therapist who can tailor the treatment to the individual’s specific needs and goals.

Role of Heart Rate Variability biofeedback speech therapy for stuttering

Heart Rate Variability (HRV) biofeedback is a therapeutic technique for treating stuttering, particularly for managing stress and anxiety, which are known to exacerbate stuttering. HRV biofeedback focuses on regulating the variation in time between successive heartbeats, which reflects the body’s physiological response to stress and relaxation.

Here’s the role of HRV biofeedback in stuttering treatment and how it works:

1. Stress Reduction: Stuttering often occurs or worsens in stressful situations. HRV biofeedback helps individuals learn to manage stress by providing real-time feedback on their physiological responses, such as heart rate variability. By increasing HRV, individuals can promote relaxation and reduce the physiological stress response during speaking situations.

2. Anxiety Management: Anxiety is a common trigger for stuttering. HRV biofeedback can teach individuals to regulate their anxiety levels by monitoring changes in heart rate variability. As they become more skilled in HRV control, they can apply these techniques to reduce anxiety associated with speaking.

3. Emotional Regulation: Stuttering can lead to negative emotions, which can exacerbate speech difficulties. HRV biofeedback can help individuals better control their emotional responses by promoting emotional regulation and resilience.

4. Improved Self-Regulation: HRV biofeedback enhances an individual’s self-regulating physiological responses. This can be especially valuable during stuttering moments, as individuals can learn to stay calm and composed, reducing the likelihood of disfluencies caused by increased tension.

How HRV Biofeedback Works

1. Sensor Placement: HRV biofeedback typically involves placing sensors on the individual’s skin, often on the chest or wrists, to monitor heart rate variability.

2. Data Collection: The sensors continuously collect data on the time intervals between heartbeats (R-R intervals) representing HRV.

3. Real-Time Feedback: The collected data are processed and displayed in real-time on a computer screen or through a mobile app. Individuals can see graphical representations of their HRV.

4. Breathing Techniques: HRV biofeedback often incorporates specific breathing techniques, such as slow, deep diaphragmatic breathing. The individual is guided to synchronize their breathing with the displayed HRV pattern.

5. Feedback and Practice: As individuals practice controlled breathing and see changes in their HRV patterns, they learn to associate specific breathing techniques with increased HRV and reduced stress. This reinforces relaxation and stress reduction skills.

6. Progress Monitoring: Individuals can monitor their progress in increasing HRV and reducing stress and anxiety levels over time. They may see improvements in their ability to remain calm during speaking situations and experience fewer stuttering incidents.

7. Generalization: The self-regulation skills learned through HRV biofeedback can be applied in real-life speaking situations, helping individuals manage stress and anxiety while communicating.

HRV biofeedback, when integrated into a comprehensive stuttering therapy program, can be a valuable tool for individuals seeking to reduce the impact of stress and anxiety on their speech fluency. It empowers them with the skills to regulate their physiological responses better, ultimately contributing to improved speech confidence and fluency.

Role of acoustic biofeedback in stuttering treatment

Acoustic biofeedback is a therapeutic tool used in stuttering treatment to help individuals manage their speech patterns and improve fluency. Specifically, it provides real-time auditory feedback on different aspects of speech. As a result, individuals can monitor and adjust their speech production more effectively. Here’s how acoustic biofeedback plays a role in stuttering treatment:

Introduction to Acoustic Biofeedback in Stuttering Treatment

1. Awareness of Stuttering Patterns: Acoustic biofeedback helps individuals who stutter to become more aware of their patterns, including the frequency and severity of disfluencies (stuttering moments). By hearing their speech in real time, individuals can identify specific problem areas and patterns.

2. Monitoring Speech Rate: Acoustic biofeedback can provide feedback on speech rate or speak too quickly, contributing to stuttering. Individuals can learn to adjust their speaking rate to a more comfortable and controlled pace.

3. Smoothness and Fluency: Acoustic biofeedback can highlight moments of speech tension or disruptions in the flow of speech. By listening to their speech in real time, individuals can work on producing smoother, more fluent speech patterns.

4. Pitch and Volume Control: Some acoustic biofeedback systems can provide feedback on pitch and volume variations in speech. This can help individuals achieve consistent pitch and volume levels, contributing to fluency.

Advanced Applications and Benefits of Acoustic Biofeedback

5. Delay or Altered Auditory Feedback: In some cases, acoustic biofeedback systems introduce a slight delay or alter the pitch of the individual’s voice. These alterations can create a “choral” effect, which may reduce stuttering and improve fluency for some individuals.

6. Practice and Self-Regulation: Acoustic biofeedback allows individuals to practice speech techniques and strategies while receiving immediate feedback. With guidance from a speech-language pathologist, they can develop self-regulation skills to adjust their speech in real time.

7. Transfer to Everyday Communication: Acoustic biofeedback therapy aims to help individuals generalize the skills learned in therapy sessions to their everyday communication. They can apply the techniques and strategies to reduce stuttering and improve fluency in real-world situations.

8. Progress Tracking: Acoustic biofeedback sessions can track and record progress. This data can be used to evaluate the effectiveness of therapy and adjust the treatment plan as needed.

The choice of therapy approaches and the inclusion of acoustic biofeedback will depend on the individual’s specific needs and goals for improving their fluency and reducing stuttering.

As with any therapeutic intervention, the effectiveness of acoustic biofeedback in stuttering treatment can vary from person to person. Therefore, it should be administered and supervised by a qualified speech-language pathologist or therapist specializing in stuttering therapy who can tailor the treatment plan to the individual’s needs.

How to perform acoustic biofeedback for stuttering

Performing acoustic biofeedback for stuttering typically involves using specialized equipment and software under the supervision of a qualified speech-language pathologist or therapist specializing in stuttering therapy. 

Here’s a general overview of how acoustic biofeedback for stuttering can be performed:

Initial Steps and Setup for Acoustic Biofeedback Therapy

1. Assessment and Evaluation:

  • Before starting acoustic biofeedback therapy, the speech-language pathologist (SLP) will conduct a comprehensive assessment to evaluate the individual’s stuttering patterns, speech characteristics, and specific needs.
  • The SLP will determine which aspects of speech (e.g., speech rate, fluency, pitch, volume) would benefit from acoustic biofeedback.

2. Selecting and Setting Up Equipment:

  • The SLP will choose appropriate acoustic biofeedback equipment and software based on the individual’s therapy goals and needs. This may include software designed for speech therapy that provides real-time auditory feedback.
  • The equipment typically includes a microphone to capture the individual’s speech and speakers or headphones to deliver the auditory feedback.

3. Baseline Recording:

  • The initial session may involve recording the individual’s baseline speech patterns without biofeedback. This helps establish a starting point for therapy and provides a reference for progress.
Conducting Biofeedback Sessions and Progress Monitoring

4. Biofeedback Sessions:

  • During biofeedback sessions, the individual will speak into the microphone while the system provides real-time auditory feedback.
  • The feedback may focus on problematic aspects of speech, such as speaking rate, pitch, or fluency. For example, the system might provide auditory cues when the individual speaks too quickly or stutters.
  • Based on the feedback provided, the individual will work with the SLP to develop strategies for adjusting their speech. This may involve practicing speaking at a more controlled rate, producing smoother speech, or adjusting pitch and volume.
  • The individual and SLP will review and discuss the feedback during the session, identifying areas for improvement and setting goals for future sessions.

5. Practice and Generalization:

  • The individual will practice the techniques learned in biofeedback sessions and attempt to generalize them to real-world communication situations.
  • The SLP will work with the individual to apply the strategies learned in therapy to everyday speaking scenarios, such as conversations with family and friends and in various social contexts.

6. Progress Tracking and Adjustments:

  • Progress will be monitored and tracked throughout therapy using data collected during biofeedback sessions.
  • The SLP will make adjustments to the treatment plan based on the individual’s progress, changing therapy goals as needed.

7. Termination and Maintenance:

  • Therapy may continue until the individual achieves their therapy goals or experiences significant improvement in fluency and stuttering management.
  • After therapy is completed, individuals may benefit from periodic follow-up sessions to maintain their progress and address any challenges.

The SLP will tailor the treatment plan to the individual’s unique needs and provide guidance and support throughout therapy. Acoustic biofeedback is just one component of a comprehensive stuttering therapy program that may include other therapeutic approaches and techniques.

Use of the Forbrain audio-vocal biofeedback device in the treatment of stuttering

The Forbrain audio-vocal biofeedback device was marketed as a tool that combines bone conduction and auditory feedback to help individuals improve their speech and communication skills. It was primarily designed to assist with various speech and language challenges, including stuttering. Here’s how the Forbrain device is typically used and its potential role in the treatment of stuttering:

1. Auditory Feedback: The Forbrain device includes a microphone and bone conduction technology that delivers auditory feedback directly to the wearer’s ears. It enhances the perception of their voice as they speak.

2. Voice Enhancement: Forbrain is designed to provide more precise and resonant auditory feedback, which can help individuals become more aware of their speech patterns, including any stuttering or disfluencies.

3. Speech Practice: Users can practice speaking while wearing the device, which provides real-time auditory feedback, allowing individuals to monitor their speech.

4. Attention and Focus: Forbrain also aims to help users improve their attention and concentration. Wearing the device during speech practice may help individuals become more focused on their speech, which can indirectly help reduce stuttering.

5. Neurological Training: Forbrain may promote neuroplasticity, potentially leading to improved speech fluency and reduced stuttering.

Forbrain improves self-awareness, which makes speech easier to correct. It also helps correct the processing of sensory and auditory information and improves listening skills.

Role of neurofeedback in the treatment of stuttering. How to perform?

Brain Regions and Electrodes for Speech Neurofeedback

Stuttering has been linked to weakness in the fibers that carry nerve impulses among three regions: the thalamus, which relays sensory signals; the basal ganglia, which coordinates movements; and the cerebral cortex, which is involved in cognition and integration of sensory and motor signals.

There are many connections within and among these brain areas. A key fiber link in the cortex is the arcuate fasciculus, which shows deficiencies in people who stutter. Other potentially poor connections are within the basal ganglia and the network linking all areas, such as the cortico-basal ganglia-thalamocortical loop.

1. Brain Regions Linked to Stuttering
Stuttering has been linked to weaknesses in the neural connections among three key brain regions:

  • Thalamus: Relays sensory signals.
  • Basal Ganglia: Coordinates movements.
  • Cerebral Cortex: Involved in cognition and integration of sensory and motor signals.

2. Key Fiber Links and Deficiencies
Important connections include:

Arcuate Fasciculus: A key fiber link in the cortex that shows deficiencies in individuals who stutter.
Cortico-Basal Ganglia-Thalamocortical Loop: A network linking all areas may exhibit poor connections in stuttering.

Electrode Placement Using the International 10-20 System

The International 10-20 System is a standardized method for electrode placement used in electroencephalography (EEG) to locate specific areas of the scalp relative to underlying brain regions. While the primary focus of the 10-20 system is on general brain activity monitoring, it can be adapted for speech neurofeedback by targeting areas of the brain associated with language and speech processing. Here are some electrode placement sites based on the 10-20 System that can be relevant for speech neurofeedback:

 

1. Frontal Electrodes:
F7 and F8: These electrodes are located over the left and right frontal lobes. They may be relevant for speech neurofeedback as the frontal lobes involve various aspects of language production and executive functions.

2. Temporal Electrodes:
T3 and T4: These electrodes are positioned over the left and right temporal lobes, which are crucial for language comprehension, auditory processing, and speech.

3. Central Electrodes:
C3 and C4: These electrodes are situated over the central region of the scalp and may be relevant for speech neurofeedback as they are associated with motor functions, including motor control of speech.

4. Parietal Electrodes:
P3 and P4: These electrodes are located over the left and right parietal lobes, which are involved in various aspects of language processing and sensory integration.

5. Frontocentral Electrodes:
FC5 and FC6: Positioned between the frontal and central regions, these electrodes may capture neural activity related to speech planning and execution.

Specific Electrode Areas for Speech Fluency

6. Supplementary Motor Area (SMA):
FCz: Located at the midline of the scalp, FCz is associated with motor planning and may be relevant for speech motor control.

7. Broca’s Area (Left Hemisphere):
F5 and F3: These electrodes are located over the left frontal region and may particularly interest speech neurofeedback, as Broca’s area is essential for language production and speech fluency.

8. Wernicke’s Area (Left Hemisphere):
T5: Positioned over the left temporal lobe, T5 may be associated with language comprehension and processing.

9. Angular Gyrus (Left Hemisphere):
P5: Over the left parietal lobe, P5 may play a role in language processing and comprehension.

Neurofeedback for Stuttering Management

Neurofeedback can be effective in rewiring the brain in the specific brain area responsible for speech fluency and by regulating the conditions concomitant to stuttering.

1. Stress and Anxiety Management: Stress and anxiety can often exacerbate stuttering. Neurofeedback may help individuals learn to regulate their stress response and reduce anxiety levels, indirectly contributing to improved fluency by reducing tension associated with stuttering.

2. Attention and Concentration: Neurofeedback can be used to train individuals to enhance their attention and concentration abilities. Improved attention control may help individuals who stutter maintain focus on their speech and reduce the likelihood of stuttering interruptions.

3. Relaxation and Self-Regulation: Neurofeedback can teach individuals self-regulation skills, which may be beneficial for managing emotional responses and muscle tension during speech production.

It’s important to note that the choice of electrode placement should be guided by the specific objectives of the speech neurofeedback therapy and the individual’s unique needs. Electrode positions can be adjusted to target brain regions associated with speech production, language comprehension, and fluency. Additionally, a qualified clinician or therapist with expertise in neurofeedback for speech and language disorders should be consulted to determine the most appropriate electrode montage for achieving therapeutic goals.

The electronic devices that can be used for treatment of stuttering

Several electronic devices and technologies can be used to assist in the treatment and management of stuttering. These devices often use traditional speech therapy techniques to provide real-time feedback and enhance therapy outcomes. Here is a list of some electronic devices and their descriptions:

Wearable and Tactile Devices

1. SpeechEasy Device:

  • SpeechEasy is a wearable electronic device that resembles a hearing aid. It uses delayed auditory feedback (DAF) or altered auditory feedback (AAF) to provide real-time auditory feedback to stuttering individuals.
  • How It Works: When the person speaks, their voice is slightly delayed or altered in pitch, which can reduce the frequency and severity of stuttering.

2. VibroTactile Feedback Devices:

  • These devices provide tactile (vibratory) feedback to help individuals monitor and control their speech rate and fluency.
  • How They Work: VibroTactile feedback devices can be worn as wristbands or placed on the skin. They vibrate in response to specific speech patterns, providing a tactile cue to slow down or ease tension.

3. FluencyMaster Device:

  • FluencyMaster is a handheld electronic device designed to assist individuals in practicing fluency-enhancing techniques.
  • How It Works: The device generates a metronome-like beat with which individuals can synchronize their speech to achieve a more controlled and fluent speech pattern.

Digital and Biofeedback Tools

4. Apps and Software:

  • Various smartphone and computer apps are available to support individuals in practicing speech techniques and monitoring their progress.
  • Some apps provide visual or auditory feedback, such as fluency charts or metronome-like cues, to assist with speech modification and fluency shaping.

5. Voice Analysis Software:

  • Specialized voice analysis software can analyze speech patterns and provide visual feedback on pitch, intensity, and speech rate.
  • This software can help individuals and therapists track progress and identify areas for improvement.

6. Biofeedback Devices:

  • Biofeedback devices can monitor physiological indicators of stress and tension, which can be associated with stuttering.
  • They may include sensors for measuring muscle tension, heart rate variability, or skin conductance. The data can help individuals learn to manage stress during speech.

7. Mobile Communication Devices:

  • Mobile devices such as smartphones and tablets offer various apps and tools to aid individuals in communication, including text-to-speech apps, speech synthesis software, and augmentative and alternative communication (AAC) apps.

It’s important to note that the effectiveness of electronic devices in stuttering treatment can vary from person to person. These devices are often used as adjuncts to traditional speech therapy techniques, and selecting a specific device should be based on an individual’s needs, goals, and preferences. A qualified speech-language pathologist or therapist specializing in stuttering therapy can help assess whether and how these devices may be beneficial and guide their use.

Conclusion

Biofeedback Speech Therapy for Stuttering represents a promising and innovative approach to stuttering treatment. This therapeutic method harnesses the power of real-time physiological feedback to empower individuals who stutter with tools for enhanced fluency and communication confidence. Through the precise monitoring and training of muscles, breathing patterns, and even neural activity, biofeedback speech therapy offers a holistic approach to address the multifaceted challenges associated with stuttering.

By delving into biofeedback speech therapy’s principles, techniques, and potential benefits for stuttering, we have uncovered a dynamic strategy that goes beyond traditional interventions. It equips individuals to gain better control over muscle tension, reduce stress and anxiety, and even modulate neural patterns related to speech production.

Biofeedback speech therapy for stuttering is a testament to the evolution of speech therapy practices, driven by a commitment to improving the lives of those affected by stuttering. This innovative approach reflects the interdisciplinary nature of stuttering therapy, drawing on insights from psychology, physiology, and neurology to provide a comprehensive toolkit for clinicians and individuals alike.

As we look ahead, the continued research and application of biofeedback techniques in stuttering therapy promise even more personalized and effective treatments. Tailoring therapy plans to each individual’s unique needs, addressing their specific muscle tension patterns, emotional triggers, and neural responses, is a significant advancement in the field.

Biofeedback Speech Therapy for Stuttering reminds us that innovation, coupled with a deep understanding of the challenges faced by individuals who stutter, can lead to transformative results. As clinicians and researchers continue to explore the potential of biofeedback in stuttering therapy, we can anticipate brighter prospects for those seeking to unlock the fluent and confident communicators within themselves.

Biofeedback Speech Therapy for Stuttering Home Use Device

EMG Biofeedback Speech Therapy for Stuttering Home Use Device

Breathing Biofeedback Speech Therapy for Stuttering Home Use Device

HRV Biofeedback Speech Therapy for Stuttering Home Use Device

Temperature Biofeedback Speech Therapy for Stuttering Home Use Device

Skin Conductance Biofeedback Speech Therapy for Stuttering Home Use Device

Acoustic Biofeedback Speech Therapy for Stuttering Home Use Device

Pelvic floor biofeedback and stim device for urinary incontinence

Pelvic Floor Biofeedback for Urinary incontinence

Urinary incontinence (UI), a prevalent condition affecting individuals across various age groups, can profoundly impact one’s quality of life. The involuntary loss of bladder control can lead to not only physical discomfort but also emotional and social challenges. In pursuing innovative and effective solutions, medical research and treatment has turned its attention to the promising biofeedback technique. Biofeedback therapy pelvic floor for urinary incontinence offers a transformative path to regain control and confidence. Urinary incontinence, affecting countless lives, stems from multifaceted factors like muscle weakness and bladder overactivity. Pelvic floor biofeedback bridges this gap by facilitating real-time communication with the body. Individuals learn to interpret and influence physiological responses through sensors and personalized cues, targeting the root causes.

What urinary incontinence is?

Urinary incontinence (UI) refers to the involuntary loss of bladder control, leading to the unintentional leakage of urine. It’s a common condition that can range in severity from occasional minor leaks to complete loss of bladder control. This loss of power can occur during activities such as coughing, sneezing, laughing, lifting, or even during sudden urgency to urinate.
According to the World Health Organization, the prevalence of urinary incontinence reported in population-based studies ranges from 9.9% to 36.1%. It is twice as high in older women as in older men. UI can occur at any age, but it is more common among women over 50. Urinary incontinence may be a temporary condition that results from an underlying medical condition. It can range from the discomfort of slight urine losses to severe, frequent wetting.
Urinary incontinence can result from various factors. These factors include weakened pelvic floor muscles, overactive bladder muscles, nerve damage, hormonal changes, and certain medical conditions. Additionally, urinary incontinence can affect people of all ages and genders. However, it is more prevalent among older adults and women, particularly after childbirth or during menopause.

What are the four types of urinary incontinence?

There are four types of urinary incontinence: urgency, stress, overflow, and neurogenic incontinence.

Stress Urinary Incontinence

The most common type of stress urinary incontinence concerns urine leakage associated with physical exertion, coughing, and sneezing. Weakness or damage to the pelvic floor muscles and tissues that support the bladder and urethra can result in stress incontinence. 

During activities that increase intra-abdominal pressure, such as sneezing, coughing, laughing, or lifting, the bladder’s pressure exceeds the weakened muscles’ ability to keep the urethra closed. Women commonly experience stress incontinence, especially after childbirth, often due to weakened pelvic floor muscles or damaged urethral sphincters, which leads to urine leakage. Stress incontinence usually results from weakened or stretched pelvic floor muscles and tissues supporting the bladder and urethra. Factors such as pregnancy, childbirth, obesity, hormonal changes, or aging can contribute to this weakening.

Urgency urinary incontinence

Overactive bladder (OAB) causes a sudden and intense urge to urinate, often leading to involuntary urine leakage before reaching a restroom. Individuals with urgency incontinence frequently experience an uncontrollable need to urinate throughout the day and night. This condition primarily arises from involuntary contractions of the bladder’s detrusor muscle, which triggers a strong sense of urgency. Various factors contribute to this type of incontinence. For example, neurological conditions, bladder irritation, certain medications, and infections can all play a role. Additionally, sometimes the cause remains unknown.

Overflow and Neurogenic Urinary Incontinence

Overflow urinary incontinence is characterized by frequent or constant dribbling of urine from the bladder, often with the sensation of incomplete bladder emptying. Individuals may also experience difficulty initiating urination and a weak urinary stream. This type of incontinence is typically caused by an obstruction or blockage in the urinary tract, which prevents the bladder from emptying fully. Common causes include an enlarged prostate in men, urinary stones, constipation, or nerve damage that affects bladder contraction.

Neurogenic urinary incontinence occurs when there is a disruption in the regular communication between the nervous system and the bladder. Depending on which nerves are affected, It can manifest as overactive or underactive bladder function. Neurogenic incontinence can result from various neurological conditions or injuries, such as multiple sclerosis, Parkinson’s disease, spinal cord injuries, or stroke. These conditions can disrupt the coordination between the brain, spinal cord, and bladder, leading to frequent and urgent voiding (overactive bladder) or an inability to empty the bladder (underactive bladder).

What are the causes of urinary incontinence?

Urinary incontinence can be caused by various factors that affect the normal function of the urinary system. Some common causes include:

Common Causes of Urinary Incontinence

1. Weak Pelvic Floor Muscles

Weakened pelvic floor muscles, often due to childbirth, aging, or obesity, can lead to stress incontinence, where pressure on the bladder from activities like sneezing, laughing, or lifting causes urine leakage.

2. Overactive Bladder Muscles

When the muscles of the bladder contract involuntarily, creating a strong urge to urinate, it can result in urge incontinence or “overactive bladder.” Various factors, including neurological conditions, infections, and certain medications, can cause this.

3. Neurological Disorders

Conditions that affect the nervous system, such as multiple sclerosis, Parkinson’s disease, and stroke, can disrupt the signals between the brain and the bladder, leading to various types of incontinence.

4. Hormonal Changes

Hormonal fluctuations, especially in women during menopause, can lead to changes in the lining of the urethra and the bladder’s ability to store urine, contributing to incontinence.

5. Prostate Issues

In men, an enlarged prostate gland (benign prostatic hyperplasia) or prostate surgery can impact bladder control and lead to incontinence.

6. Urinary Tract Infections

Infections in the urinary tract can cause irritation and overactivity of the bladder, resulting in temporary incontinence.

Additional Causes of Urinary Incontinence

7. Obstruction

An obstruction in the urinary tract, such as kidney stones or tumors, can disrupt urine flow and cause overflow incontinence.

8. Medications

Certain medications, like diuretics, sedatives, and alpha-blockers, can affect bladder function and contribute to incontinence.

9. Chronic Coughing

Conditions such as chronic bronchitis or smoking-related lung diseases can lead to chronic coughing, which can put stress on the pelvic muscles and lead to stress incontinence.

10. Physical Impairments

Mobility issues or physical disabilities that hinder a person’s ability to reach a restroom in time can contribute to functional incontinence.

11. Genetics

Some individuals may be genetically predisposed to developing weak pelvic floor muscles or other anatomical factors that increase the risk of incontinence.

12. Lifestyle Factors

Obesity, excessive caffeine or alcohol consumption, and inadequate fluid intake can exacerbate urinary incontinence symptoms.

Understanding the underlying cause of urinary incontinence is crucial for proper diagnosis and effective treatment.

The mechanism of urinary incontinence

The mechanism of urinary incontinence is closely tied to the role of pelvic floor muscles. Pelvic floor muscles are a group of skeletal muscles that form a sling-like structure at the base of the pelvis. These muscles are crucial for maintaining urinary continence. Here’s how they function:

1. Support: Pelvic floor muscles provide essential support to the bladder and other pelvic organs, keeping them in their proper position.

2. Sphincteric Function: The pelvic floor muscles encircle the urethra and the anal canal. They play a significant role in maintaining the closure of the urethra and preventing involuntary urine leakage. When these muscles contract, they compress the urethra, keeping it closed.

3. Voluntary Control: The external urethral sphincter, a part of the pelvic floor muscles, allows voluntary control over urination. When you choose to urinate, this muscle relaxes, releasing urine. When you want to delay or stop urination, the external urethral sphincter contracts to close off the urethra.

Pelvic Floor Muscles and Contributing Factors

The pelvic floor consists of layers of muscles and connective tissues connecting those muscles (ligaments) and wraps around the entirety of the pelvis. Two main muscles intertwine to form pelvic floor muscles:
Levator ani composes the bulk of the pelvic floor muscles and consists of three separate muscle components:
– pubococcygeus,
– puborectalis and
– iliococcygeus.
The coccygeus is the more minor muscle component in the pelvic floor muscles. It’s located toward the back of the pelvis.

Factors Affecting Pelvic Floor Muscles

Pelvic floor muscles can weaken due to injury or trauma, including childbirth and surgery. They can become stressed during pregnancy or from overuse (repeated heavy lifting, chronic coughing, constipation). They may grow weaker due to hormone changes during menopause and lose strength as a natural part of aging. Conditions like diabetes may also play a role in weakening pelvic floor muscles.

Understanding the role of pelvic floor muscles in maintaining continence and recognizing the factors that disrupt this balance is essential for diagnosing and effectively treating urinary incontinence. Strengthening these muscles through Kegel exercises can be a valuable part of managing certain types of incontinence, particularly stress incontinence. However, treatment approaches vary depending on the specific type and underlying causes of incontinence.

Common signs and symptoms of urinary incontinence include:

  • Leaking urine when coughing, sneezing, laughing, or exercising.
  • Feeling sudden, uncontrollable urges to urinate.
  • Frequent urination.
    Waking up many times at night to urinate.
  • Urinating during sleep.

Although pelvic floor muscles are hidden, they can be consciously controlled and trained, such as the arm, leg, or abdominal (tummy) muscles. Strengthening pelvic floor muscles will help actively support and maintain the bladder, reducing the likelihood of accidentally leaking from the bladder. Like other muscles in the body, pelvic floor muscles will become more robust with a regular exercise program. This is important for both men and women.

Treatment of urinary incontinence

The treatment of urinary incontinence varies based on the type and underlying causes of the condition. Here are some  treatment approaches for different types of urinary incontinence:

1. Behavioral Interventions:

Behavioral interventions involve modifying habits and patterns that contribute to urinary incontinence. These include bladder training, scheduled voiding, and fluid and diet management to reduce irritants and excessive urine production.

  • Bladder Training: This technique involves gradually increasing the time between trips to the restroom to improve bladder capacity and reduce the frequency of urge incontinence.
  • Scheduled Voiding: Establishing a regular bladder emptying schedule can help manage urge and overflow incontinence by preventing overfilling or constant dribbling.
  • Fluid and Diet Management: Adjusting fluid intake, particularly reducing caffeine and alcohol consumption, can help decrease bladder irritability and excessive urine production.

2. Pelvic Floor Muscle Exercises (Kegel Exercises):

Kegel exercises strengthen the pelvic floor muscles that support the bladder and urethra. Improving muscle tone and control is effective in reducing stress and urge incontinence.

  • Stress Incontinence: Strengthening the pelvic floor muscles through Kegel exercises can provide better bladder support and reduce stress incontinence episodes.
  • Urge Incontinence: Kegel exercises can also help individuals gain better control over their bladder and reduce urgency.

3. Medications:

Medications can help manage urinary incontinence by reducing overactive bladder contractions or relaxing bladder muscles. Anticholinergics and beta-3 adrenergic agonists are commonly prescribed for urge incontinence.

  • Anticholinergics: These medications relax the bladder muscles and reduce spasms, making them helpful in treating urge incontinence. Examples include oxybutynin, tolterodine, and solifenacin.
  • Beta-3 Adrenergic Agonists: Some medications like mirabegron can increase bladder capacity and decrease the frequency of contractions, helping with both urgency and frequency.

4. Medical Devices:

Medical devices, such as pessaries, support the bladder and urethra, temporarily relieving stress incontinence. Additionally, urethral inserts can prevent leakage during specific activities. These devices help manage symptoms effectively for individuals dealing with stress incontinence.

  • Pessaries: A pessary is a device inserted into the vagina to provide support to the urethra and bladder, helping manage stress incontinence.
  • Urethral Inserts: These are tampon-like disposable devices that can be inserted into the urethra to prevent leakage during specific activities.

5. Incontinence Pads and Products:

  • Absorbent pads and adult diapers can provide temporary relief and increased confidence, especially for individuals with more severe incontinence.

6. Surgery:

Surgical options are considered for more severe cases of urinary incontinence. Procedures like sling placement or bladder neck suspension can support the urethra for stress incontinence.

  • Sling Procedures: Surgical sling placement under the urethra or bladder neck can provide additional support to prevent stress incontinence.
  • Bladder Neck Suspension: A surgical procedure that supports the bladder, neck, and urethra to treat stress incontinence.
  • Artificial Urinary Sphincter: For severe cases of stress incontinence, an artificial urinary sphincter can be implanted to provide manual control over the urethral opening.

Advanced and Complementary Treatments

7. Pelvic floor biofeedback:
Pelvic floor biofeedback is a non-invasive technique that uses sensors to provide real-time feedback about muscle activity and bladder function. For urinary incontinence, biofeedback therapy pelvic floor assists in training individuals to strengthen pelvic floor muscles for stress incontinence and gain control over bladder contractions for urge incontinence.

  • Pelvic floor biofeedback for urinary incontinence and pelvic floor muscle retraining are treatments that help patients learn to strengthen or relax their pelvic floor muscles to improve bowel or bladder function and decrease some types of pelvic floor pain.
  • Auxiliary muscles biofeedback: In addition to pelvic floor muscles, several other muscle groups, such as abdominal, gluteal, quadriceps, etc., can play a role in managing urinary incontinence, depending on the type and underlying causes of the condition. EMG pelvic floor biofeedback is a valuable therapeutic technique used to target and train various muscle groups beyond the pelvic floor muscles in managing urinary incontinence, depending on the specific type and causes of the condition.

8. Neuromodulation:

  • Sacral Nerve Stimulation: Electrical stimulation of the sacral nerves can help regulate bladder function and treat urge incontinence.

9. Botox Injections:

  • Botox injections into the bladder muscle can help control overactive bladder symptoms by temporarily relaxing the muscle and reducing spasms.

10. Lifestyle Modifications:

  • Maintaining a healthy weight, avoiding constipation, practicing good hygiene, and managing chronic cough can help alleviate urinary incontinence symptoms.

It’s important to note that appropriate treatment depends on a thorough evaluation by a healthcare professional. The professional will consider factors such as the type and severity of incontinence, underlying causes, the individual’s overall health, and preferences. A comprehensive treatment plan may involve a combination of approaches, with pelvic floor biofeedback playing a pivotal role in empowering individuals to gain control over their bodily functions and improve their quality of life.

Pelvic Floor Muscle Exercises (Kegel Exercises)

In urinary incontinence, particularly stress and some urge incontinence, targeting and strengthening the pelvic floor muscles is essential. These muscles support the bladder, urethra, and other pelvic organs and are directly involved in urinary control. Strengthening these muscles can improve their ability to contract and relax appropriately, helping to prevent leakage and improve bladder control.

1. Support: Pelvic floor muscles support the bladder, helping keep it in its proper position.
2. Sphincteric Function: These muscles help maintain closure of the urethra, preventing urine leakage when there is increased abdominal pressure (as in stress incontinence).
3. Urge Control: Strong pelvic floor muscles can also help suppress sudden urination urges (as in some forms of urge incontinence) by providing better voluntary control.

Pelvic floor muscle exercises, often called Kegel exercises, are designed to target and strengthen these muscles. Kegel exercises can effectively reduce urinary incontinence episodes and improve overall bladder control when done correctly and regularly.

To perform Kegel exercises:

1. Locate the Muscles: Identify the pelvic floor muscles by trying to stop urine flow during urination. The muscles you engage to do this are the ones you’ll be working on during Kegel exercises.

2. Isolate the Muscles: Once you’ve identified the muscles, practice contracting and relaxing them without using other muscles, such as the abdomen or buttocks.

3. Start Slowly with short contractions, hold for a few seconds, and then relax. Gradually increase the duration and intensity of the contractions as you become more comfortable.

4. Be Consistent: Perform these exercises regularly. Aiming for several sets of 10 repetitions is often recommended throughout the day.

Remember that it’s crucial to perform Kegel exercises correctly to avoid straining other muscles and effectively target the pelvic floor muscles. If you’re uncertain how to do Kegel exercises correctly, consider consulting a healthcare professional or a pelvic floor physical therapist who can provide guidance and personalized instructions. Additionally, pelvic floor biofeedback techniques can assist in ensuring that you’re engaging the right muscles during pelvic floor exercises, enhancing their effectiveness in managing urinary incontinence.

Auxiliary muscles exercise in urinary incontinence

In addition to pelvic floor muscles, several other muscle groups can play a role in managing urinary incontinence, depending on the type and underlying causes of the condition. Here are some of the muscles and muscle groups that may be involved in the treatment of urinary incontinence:

Muscle Groups Contributing to Urinary Incontinence Management

1. Abdominal Muscles (Transverse Abdominis): Strengthening the transverse abdominis, the deepest layer of abdominal muscles, can help support the pelvic organs and reduce pressure on the bladder. This is particularly relevant for stress incontinence.

2. Oblique Abdominal Muscles: The internal and external oblique muscles can help stabilize the trunk and support the pelvic area. Exercises that engage these muscles can assist in managing stress incontinence.

3. Gluteal Muscles: The gluteal muscles (buttocks) play a role in pelvic stability and posture. Strengthening these muscles can help maintain proper pelvic alignment and contribute to better overall pelvic health.

4. Thigh Muscles (Quadriceps and Hamstrings): Strong thigh muscles can assist in activities like rising from a seated position and maintaining balance, which can reduce the risk of falls and related stress incontinence.

5. Lower Back Muscles (Erector Spinae): Strengthening the lower back muscles can help support the spine and maintain proper posture, indirectly contributing to pelvic health.

Additional Muscle Groups Impacting Urinary Health

6. Diaphragm: The primary breathing muscle is connected to the pelvic floor through the core muscles. Learning to engage and coordinate the diaphragm with the pelvic floor can assist in overall core stability and urinary control.

7. Hip Adductors and Abductors: The muscles responsible for moving the thighs toward or away from the body’s midline can impact pelvic stability and balance.

It’s important to note that while these muscle groups can indirectly influence urinary continence, the primary focus for addressing urinary incontinence remains the pelvic floor muscles. Strengthening the pelvic floor muscles through exercises like Kegel exercises is usually the first-line approach for treating stress incontinence and some forms of urge incontinence.

However, a comprehensive approach to managing urinary incontinence may include exercises that engage these other muscle groups as part of a broader physical therapy or rehabilitation program. Additionally, maintaining overall physical fitness, which involves working on various muscle groups, can contribute to improved pelvic health and better urinary control. Consultation with a healthcare professional or a pelvic floor physical therapist can help design a personalized exercise regimen tailored to your specific needs and condition.

EMG Pelvic floor biofeedback for urinary incontinence

What pelvic floor biofeedback muscle retraining is?

Pelvic floor biofeedback muscle retraining is a treatment to help patients learn to strengthen or relax their pelvic floor muscles to improve bowel or bladder function. It is a painless process that uses special sensors and a computer or mobile phone monitor to display information about muscle activity. This information or “feedback” is used to gain sensitivity and, with practice, control over pelvic floor muscle function. An essential part of biofeedback therapy pelvic floor is the consistent practice of pelvic floor muscle exercises at home. With pelvic floor biofeedback, an individual can learn to stop using the incorrect muscles and start using the correct ones.

Biofeedback for pelvic floor has shown promising effectiveness in managing urinary incontinence, particularly for conditions like stress and urge incontinence. This non-invasive technique utilizes real-time physiological data to help individuals gain awareness and control over their pelvic floor muscles and bladder function. Here’s how pelvic floor biofeedback proves effective:

Stress Incontinence: Pelvic floor biofeedback helps individuals strengthen their pelvic floor muscles, which are crucial for supporting the bladder and preventing leakage during activities that increase intra-abdominal pressure. Individuals can learn proper muscle engagement techniques by providing visual or auditory cues that indicate when the correct muscles are being contracted. Over time, consistent practice guided by pelvic floor biofeedback can improve muscle strength and endurance, reducing or eliminating stress incontinence episodes.

Urge Incontinence (Overactive Bladder): Pelvic floor biofeedback assists in training individuals to recognize the early signs of an impending urge to urinate. By monitoring bladder contractions and providing feedback when the bladder muscles start to contract involuntarily, individuals can learn to control these and suppress the urge. This technique empowers individuals to retrain their bladder and enhance their ability to delay urination until an appropriate time and place.

Efficacy and Benefits of pelvic floor biofeedback

Numerous clinical studies have demonstrated the effectiveness of pelvic floor biofeedback in reducing urinary incontinence episodes and improving overall bladder control. It offers several benefits, including:

1. Personalized Training: Pelvic floor biofeedback tailors training to an individual’s specific needs, adapting to their progress and challenges.
2. Non-Invasive: Unlike surgical interventions, pelvic floor biofeedback is non-invasive and carries minimal risks or side effects.
3. Empowerment: By providing real-time feedback, individuals feel empowered and engaged in their treatment process.
4. Holistic Approach: Pelvic floor biofeedback complements other treatment options, such as pelvic floor exercises and lifestyle modifications.
5. Psychological Well-being: Gaining control over bladder function often improves self-esteem, confidence, and emotional well-being.
6. Long-Term Benefits: Consistent pelvic floor biofeedback training can lead to sustainable improvements, reducing the need for medication or more invasive procedures.

While pelvic floor biofeedback offers promising outcomes, its effectiveness can vary based on individual commitment, incontinence severity, and skilled healthcare professionals’ guidance. Combining pelvic floor biofeedback with other strategies, such as exercises and behavioral modifications, can enhance its overall impact. As technology advances and research continues, biofeedback holds the potential to play an increasingly significant

Electromyographic (EMG) biofeedback for auxiliary muscles in UI

Electromyographic (EMG) biofeedback is a valuable therapeutic technique used to target and train various muscle groups beyond the pelvic floor muscles in managing urinary incontinence, depending on the specific type and causes of the condition.

Here’s how EMG auxiliary muscle biofeedback can be employed for these purposes:
1. Abdominal Muscles (Transverse Abdominis and Obliques):
• Purpose: Strengthening the transverse abdominis and oblique abdominal muscles can provide additional support to the pelvic area, reducing pressure on the bladder and assisting in managing stress incontinence.
EMG sensors can be placed on the abdominal muscles to monitor their activity during specific exercises. Patients can visualize this activity on a screen or receive auditory cues, helping them learn to engage and strengthen these muscles effectively.

2. Lower Back Muscles (Erector Spinae):
Purpose: Strengthening the erector spinae muscles can contribute to better spinal stability and posture, indirectly influencing pelvic health and urinary control.
EMG sensors can be positioned on the lower back muscles, allowing patients to monitor muscle engagement and ensure they target the correct muscles during exercises.

3. Hip Muscles (Adductors and Abductors):
Purpose: The hip adductors and abductors play a role in pelvic stability and balance, which can affect urinary control.
EMG biofeedback can be used to assess the activity of these hip muscles during specific movements or exercises, helping individuals focus on improving their strength and coordination in this area.

4. Diaphragm:
Purpose: Coordinating the diaphragm with pelvic floor muscles and other core muscles can enhance overall core stability and control, indirectly impacting urinary continence.
EMG sensors placed on the diaphragm can assist individuals in learning to coordinate their activity with the pelvic floor and other muscle groups during exercises to improve core strength and stability.

How EMG biofeedback for auxiliary muscles works

• EMG biofeedback involves the placement of sensors or electrodes on the targeted muscle groups. These sensors detect and record the electrical activity generated by muscle contractions.
• The EMG signals are then transmitted to a monitoring device, a computer screen, or an auditory feedback system.
• Patients receive real-time visual or auditory cues based on their muscle activity. This feedback allows them to observe and adjust muscle engagement, ensuring they target the right muscles and use proper exercise techniques.
• Over time, patients can learn to control and strengthen these muscle groups effectively, which can contribute to improved bladder control and the management of urinary incontinence.

EMG biofeedback can be particularly beneficial when working on specific muscle groups to complement other treatment approaches, such as pelvic floor exercises. It helps individuals gain awareness of muscle activity and ensures that exercises are performed correctly, ultimately enhancing the effectiveness of the overall incontinence management plan.

Sacral Area Biofeedback

This area biofeedback and stimulation are therapeutic approaches used in the treatment of urinary incontinence, particularly for certain types of incontinence, such as overactive bladder (urge incontinence) and some cases of mixed incontinence.

Sacral area biofeedback involves using sensors or electrodes placed on or near the sacral area, which is the region at the base of the spine near the tailbone. These sensors detect electrical or muscular activity in the pelvic floor and bladder muscles. Here’s an overview of these techniques:

• Mechanism: During biofeedback sessions, the sensors provide real-time information on the pelvic floor muscles and bladder activity. Patients can see this feedback on a monitor, making them aware of muscle contractions and bladder function.
• Benefits: Sacral area biofeedback helps individuals learn to control pelvic floor muscles more effectively, improve coordination, and increase the ability to suppress unwanted contractions. It can also enhance the relaxation of the bladder muscles when needed.
• Training: Biofeedback sessions are often conducted by trained healthcare professionals, such as pelvic floor physical therapists. These sessions guide patients in practicing muscle control techniques while monitoring their progress on the biofeedback display.
• Effectiveness: Sacral area biofeedback is particularly useful for people with urge incontinence or overactive bladder. It assists in training individuals to gain better control over bladder contractions, reduce urgency, and improve bladder capacity.

Sacral Nerve Stimulation (SNS)

Sacral nerve stimulation, or neuromodulation, involves implanting a device that sends electrical impulses to the sacral nerves involved in bladder control.

• Mechanism: The implanted device delivers controlled electrical stimulation to the sacral nerves, modulating their activity. This neuromodulation affects the communication between the brain, spinal cord, and bladder, helping to regulate bladder function.
• Benefits: SNS is typically recommended for individuals with overactive bladder symptoms who have not responded to conservative treatments. It can reduce urgency, frequency, and incontinence episodes.
• Procedure: The SNS device is surgically implanted, and a healthcare professional can adjust its settings externally. It is a reversible procedure, and if the individual does not experience relief or encounters side effects, the device can be turned off or removed.
• Effectiveness: SNS has shown promising results in treating overactive bladder, improving urinary symptoms, and the quality of life for many patients.

Both sacral area biofeedback and sacral nerve stimulation are typically considered after conservative treatments like pelvic floor exercises and medications have been tried without success. They offer alternative options for individuals who are seeking additional interventions to manage urinary incontinence, mainly when it is related to overactive bladder or neurological factors. These treatments are usually recommended and managed by urologists or healthcare providers with expertise in incontinence management.

It’s important to note that the effectiveness of biofeedback for urinary incontinence can vary based on factors such as the individual’s dedication to the therapy, the severity of their condition, the guidance of a skilled healthcare professional, and the consistency of practice.

Clinical studies have generally reported success rates ranging from around 60% to 90% regarding symptom improvement and quality of life. However, these success rates can vary widely depending on the study population, methodology, and duration of treatment.

Auxiliary Muscles and Pelvic Floor Biofeedback Device for Personal Use

NeuroTrack MyoPlus 2 Pro
NeuroTrac Simplex EMG Biofeedback box
NeuroTrac MyoPlus Pro EMS & EMG Biofeedback device
CT Scan of lung in COVID - pulmonary rehab exercises

Biofeedback for Pulmonary Rehab-COVID 19

As the world continues to grapple with the effects of COVID-19, the importance of pulmonary rehabilitation has come to the forefront. Pulmonary rehab is essential for patients recovering from the virus, as it helps restore lung function and improve overall health. Incorporating targeted breathing exercises for the lungs can significantly enhance this rehabilitation process, promoting better oxygenation and respiratory efficiency. Additionally, utilizing a breathing exercise device for lungs can further aid recovery by providing structured support for lung function improvement. Many individuals can benefit from pulmonary rehab exercises at home, allowing them to engage in effective recovery routines in a comfortable environment. This article explores the role of breathing and HRV biofeedback in optimizing pulmonary rehabilitation after COVID-19, highlighting how these techniques can support patients on their journey to recovery.

COVID-19 ASSOCIATED PNEUMONIA

SARS-CoV-2, the virus that causes COVID-19, is part of the coronavirus family.

When the virus gets in your body, it comes into contact with the mucous membranes that line your nose, mouth, and eyes. The virus enters a healthy cell and uses the cell to make new virus parts. It multiplies, and the new viruses infect nearby cells.

Think of your respiratory tract as an upside-down tree. The trunk is your trachea or windpipe. It splits into smaller and smaller branches in your lungs. At the end of each branch are tiny air sacs called alveoli. This is where oxygen goes into your blood, and carbon dioxide comes out.

As the infection travels the respiratory tract, the immune system fights back. The lungs and airways swell and become inflamed. This can start in the alveoli of one part of the lung and spread to the nearby alveoli of other parts.

In pneumonia, air sacs in the lungs fill with fluid, limiting their ability to take in oxygen and causing shortness of breath, cough, and other symptoms.

Doctors can see signs of respiratory inflammation on a chest X-ray or CT scan.

On a chest CT, they may see “ground-glass opacity” because it looks like the frosted glass on a shower door.

 (a) Axial thin-section non-contrast CT scan shows diffuse bilateral confluent and patchy ground-glass (solid arrows) and consolidative (dashed arrows) pulmonary opacities. (b) The disease in the right middle and lower lobes has a striking peripheral distribution (arrow). [Radiological Society of North America].

THE EFFECT OF COVID-19 IN SHORT-TERM AND LONG-TERM FOLLOW-UP

The effect of COVID-19 will vary significantly throughout the disease, with most people experiencing some of the following symptoms:

  • fever,
  • cough, sputum production, shortness of breath,
  • fatigue,
  • anorexia,
  • myalgia,
  • central nervous system manifestations (such as headaches, migraines, dizziness, and ataxia),
  • and peripheral nervous system manifestations (such as nerve pain, speech, vision, and taste problems).

While some of these symptoms may resolve naturally, some people may have impairments that persist, particularly following a prolonged hospital and ICU stay.

Doctors in Hong Kong (March 13, 2020) reported the findings of the first follow-up clinics of recovered Covid-19 patients. They suppose some recovered patients have lost between 20% and 30% of their previous lung function (South China Morning Post). The doctors report that lung scans of recovered patients also reveal substantial lung damage.

Researchers revealed that six weeks after hospital dischargemore than half of the patients had at least one persistent symptom, predominantly breathlessness and coughingCT scans still showed lung damage in 88% of patients. However, by the time 12 weeks after discharge, the symptoms had improved, and lung damage was reduced to 56% (COVID-19 Patients Suffer Long-Term Lung and Heart Damage – But They Can Recover With Time – By European Lung Foundation, September 7, 2020). There’s the initial injury to the lungs, followed by scarring. Over time, the tissue heals, but it can take three months to a year or more for a person’s lung function to return to pre-COVID-19 levels.

In the recovery period, people with COVID-19 may be expected to present with significant muscle wasting in both the locomotor and respiratory muscles. This may contribute to ongoing breathlessness and fatigue, reduced exercise capacity, poor balance, and loss of functional independence (Rehabilitation following COVID-19 in the pulmonary rehabilitation setting. JUNE 2020. Respiratory Network).

PULMONARY REHABILITATION PROGRAMS AFTER COVID-19

Changes in the anatomical and physiological properties of the chest’s tissues and organs caused by disease lead to decreased elasticity in the lungs and surrounding tissues. As a result, the energy cost of ventilation increases. The respiratory muscles must work harder to overcome both elastic and bronchial resistance, significantly raising their workload. This increased energy cost, combined with the depletion of respiratory muscles, contributes to shortness of breath and a sensation of air hunger. Together, these sensations form the complex experience commonly referred to as “shortness of breath.”

Many pulmonary diseases reduce the respiratory surface of the lungs and lead to ventilation disorders, such as restrictive syndrome. This decrease in lung volume occurs for two main reasons. First, hardening of the lung tissue contributes significantly. Second, restricted lung mobility also plays a crucial role. Together, these factors lead to a notable reduction in lung volume. Adhesions can form and prevent the lungs from expanding fully. When pleural inflammation also occurs, chest movement becomes intentionally limited, as severe pain restricts chest excursion.

Exercise therapy in pulmonology has several key tasks. First, it aims to achieve regression of reversible changes in the lungs. Second, it focuses on stabilizing irreversible changes. Additionally, exercise therapy promotes compensation and normalization of lung function.

  • General tonic effect: stimulation of metabolic processes, increase in neuropsychic tone, recovery, and increase of tolerance to physical activity, stimulation of immune processes;
  • Preventive effect: mastery of breathing control technique, an increase of the protective function of the respiratory tract, reduction of intoxication;
  • The pathogenic (therapeutic) effects include several essential improvements. First, exercise therapy enhances external respiration functions. Second, it corrects the mechanics of breathing. Additionally, it accelerates resorption during inflammatory processes and improves bronchial patency. Furthermore, it removes or reduces bronchospasm. Finally, it regulates external respiration functions and increases their reserves.

General Tonic and Special Breathing Exercises

In exercise therapy for respiratory issues, various techniques are applied to improve overall health and target specific respiratory functions.

First, general tonic exercises help enhance the function of all organs and systems, while moderate and high-intensity exercises specifically stimulate external respiration.

Low-intensity exercises, however, lack a training effect on the cardiovascular and respiratory systems.

Additionally, special breathing exercises strengthen the respiratory muscles, increase chest and diaphragm mobility, and reduce congestion. These exercises promote pleural stretching, ease sputum excretion, and enhance breathing coordination and movement.

Furthermore, breathing gymnastics techniques focus on correcting pathological breathing patterns, relaxing tense muscle groups, and improving respiratory muscle function.

Muscle Relaxation Techniques

Techniques such as autogenous training, post-isometric muscle relaxation, and physical exercises for associative and segmental muscles are helpful to support relaxation. Therapeutic massages, including myofascial release and segmental reflex massage, also address myofascial muscle changes. Exercises involving segmental and associative muscles are most effective for these issues. Moreover, incorporating weights like sandbags in breathing exercises strengthens the abdominal and intercostal muscles and increases diaphragm mobility.

Fundamental Lows of Breathing

Performing breathing exercises requires compliance with the fundamental laws of breathing:

  • before any physical activity, it is necessary to remove residual air from the lungs, for which it is necessary to exhale through the lips folded into a tube;
  • inhalation is mainly (80%) carried out by the diaphragm, while the muscles of the shoulder girdle should be relaxed;
  • the duration of the exhalation should be approximately 1.5-2 times longer than the inhalation;
  • Inhalation occurs when the chest is extended, and exhalation occurs when it is compressed (for example, when bending over).

Techniques for Exhalation and Breathing Rate Control

Exhalation is usually carried out by relaxing the muscles involved in inhalation under the influence of the chest’s gravity; delayed exhalation occurs with the dynamic inferior work of these muscles. The elastic forces of the lung tissue remove air from the lungs.

Forced exhalation happens when the muscles responsible for exhalation contract. You can strengthen exhalation by tilting the head forward, bringing the shoulders together, lowering the arms, flexing the trunk, and raising the legs forward. Additionally, breathing exercises allow you to adjust the breathing rate freely.

More frequently, exercises focus on voluntarily slowing down the respiratory rate. In this case, it is helpful to count silently to yourself. This practice reduces the speed of air movement and decreases resistance as air passes through the airways. Increased breathing frequency increases breathing speed. Consciously learning to regulate breathing starts with static exercises. Incorporate rhythmic static breathing exercises, as these help decrease respiratory movements by deepening them. At the same time, this practice strengthens the respiratory muscles and tones the intercostal muscles.

Enhanced Breathing Techniques and Muscle Strengthening

Breathing with additional resistance (inhalation through lips folded into a tube, through a tube, inflation of rubber toys) reduces the frequency. It increases the depth of breathing and activates the work of the respiratory muscles. Breathing through the nose is recommended because it moistens and purifies the inhaled air. Moreover, irritation of the receptors in the upper respiratory tract reflexively expands the bronchioles. As a result, this deepens breathing and increases blood oxygen saturation.

If necessary, to spare the affected lung, apply the initial positions that limit the chest’s mobility from the affected side (lying on the affected side).

Using weights such as sandbags when performing breathing exercises helps strengthen the abdominal and intercostal muscles and increases the mobility of the diaphragm.

To dose physical activity effectively, you can adjust several factors. First, change the initial position. Second, modify the pace and amplitude of the movements. Additionally, vary the degree of muscle tension, the number of exercises performed, and their duration. Finally, rest pauses and relaxation exercises should be incorporated to enhance the overall effect.

  • THE ONLY RMT DEVICE FEATURING INDEPENDENT INSPIRATORY/EXPIRATORY DIAL CONTROL.
    The Breather functions as both an inspiratory and expiratory muscle trainer, with adjustable dials for independent resistance settings for inhalation and exhalation. It is the ultimate device for respiratory care. Think of it as a lung trainer, supporting respiratory health and efficiency by promoting diaphragmatic (belly) breathing.
  • DESIGNED TO HELP IMPROVE OXYGEN FLOW.
    This inspiratory exerciser benefits those undergoing respiratory treatment. The Breather is a respiratory trainer or exerciser that improves lung strength and capacity by increasing oxygen uptake to vital organs.
  • DRUG-FREE THERAPY FOR COPD, CHF, AND DYSPHAGIA
    The Breather is used by those affected by COPD, CHF, dysphagia, and neuromuscular disease. Continued use has improved dyspnea, peak cough flow, laryngeal function, QOL, vent weaning, and speech and swallowing performance.
  • ONLINE VIDEOS AND A DEDICATED MOBILE APP.
    PN Medical, creators of The Breather, offers self-paced, online video protocol training for therapists, patients, and consumers. Additionally, the Breather Coach mobile app lets you track and monitor your progress from your phone.
  • There are five expiratory and six inspiratory adjustable independent pressure settings. You can adjust the resistance on each inhalation and exhalation. The higher the setting, the higher the resistance.

CLINICAL BENEFITS

The Breather exercise optimizes the blood flow to your working muscles, increasing your performance capacity and extending your exercise limits. It improves the strength of your diaphragm and other respiratory muscles while maximizing lung function. The exercise strengthens your cardiac system and circulation, reducing blood pressure and improving sleep.

Special techniques of breathing exercises

Sound gymnastics

It is a unique breathing exercise consisting of pronouncing consonant sounds in a certain way – buzzing (zh, z), sibilant and hissing (s, f, ts, ch, sh), growling (r), and their combinations. In this case, the vibration of the vocal cords is transmitted to the smooth muscles of the bronchi, lungs, and chest, relaxing the spasmodic bronchi and bronchioles. Sound gymnastics aims to develop the correct ratio of inhalation and exhalation – 1: 2 (1.5). All sounds should be pronounced in a strictly defined way, depending on the purpose of gymnastics. For example, in bronchial asthma, buzzing, growling, and hissing sounds are pronounced loudly, energetically, exciting, and in chronic obstructive bronchitis with severe respiratory failure – softly, quietly, acceptable in a whisper (soothing).

Method of volitional elimination of deep breathing (VEDB) K.P. Buteyko

This technique originated in 1960 when Novosibirsk doctor K.P. Buteyko developed it. Its goal is to voluntarily correct incorrect (deep) breathing and gradually eliminate it. This is important because deep breathing can lead to a lack of carbon dioxide in the blood. Consequently, this deficiency causes a shift in the acid-base balance towards alkalosis and results in tissue hypoxia. When low carbon dioxide levels, oxygen binds firmly to hemoglobin and fails to enter cells and tissues.

The main tasks of the VEDB method are:

  • to normalize the ratio of inhalation and exhalation,
  • to reduce the speed and depth of inhalation,
  • to develop a compensatory pause after a long and calm exhalation,
  • to normalize the carbon dioxide content in the blood,
  • to reduce the number of asthma attacks and prevent their occurrence.

Paradoxical breathing exercises

These exercises help relieve an attack of suffocation. Gymnastics is called “paradoxical” because inhalation and exhalation are performed simultaneously with the movements of the arms, trunk, and legs, complicating this breathing phase. When the chest is compressed, inhalation is made, and when the chest expands, exhalation is made. The inhalation should be short, sharp, noisy, active, and forced by the diaphragm; exhalation occurs passively and spontaneously. Inhalation is carried out only through the nose, exhalation independently, passively (so that it is not audible), preferably through the mouth. You should not delay exhalation. 

The action mechanism of paradoxical respiratory gymnastics on the body consists of restoring disturbed nasal breathing, improving the drainage function of the bronchi, and activating the work of the diaphragm and chest muscles. Gymnastics promotes the resorption of inflammatory formations, the restoration of normal lymph and blood supply, and the elimination of local congestion. Eliminating morphological changes in the bronchopulmonary system enhances alveoli and tissue respiration gas exchange. It leads to an increase in oxygen absorption by tissues, which has a positive effect on metabolic processes. The coordination of breathing and movement helps to restore the regulation of breathing by the central nervous system, improves the psycho-emotional state, and has a general tonic effect.

The Role of Modern Oriental Respiratory Techniques and Pulmonary Rehabilitation in Health Recovery

Modern oriental respiratory systems, such as qigong, tai chi, and hatha yoga, focus on voluntarily controlling breath depth and frequency while balancing inhalation and exhalation. In these practices, the diaphragm plays an active role in breathing, and concentration and relaxation are equally important. Learning specific types of breathing—such as upper chest, costal, diaphragmatic, and full breathing—also becomes essential. Eastern breathing techniques are often promoted by enthusiasts and used in alternative medicine. Beyond their physical benefits, these techniques carry philosophical meanings to achieve harmony, harness inner strength, and enhance overall health.

To determine if a technique is suitable, one should consider one’s health status after exercise. Physical activity, in general, directly improves muscle function, motivation, mood, and symptoms. It also positively impacts the cardiovascular system, contributing to overall well-being.

Video – How to perform pulmonary rehab exercises at home

Special Considerations for COVID-19 Pulmonary Rehab

For individuals recovering from COVID-19 and undergoing pulmonary rehab, it is essential to consider the risk of pulmonary rehab exercise at home desaturation due to impaired gas transfer. Monitoring oxygen saturation levels may be necessary, and some individuals may require supplemental oxygen during rehabilitation exercises. Pulmonary rehabilitation programs should integrate both physical and psychological components and begin as early as possible after hospital discharge. Ideally, rehabilitation should continue for weeks or months to promote full recovery. By extending this support, patients are less likely to experience long-term disability after pneumonia and more likely to regain health.

THE ROLE OF RESPIRATORY (BREATHING) AND HRV BIOFEEDBACK IN PULMONARY REHAB AFTER COVID-19

Respiratory (breathing) and Heart Rate Variability (HRV) Biofeedback is a relatively new method of teaching people to change the parameters of respiration and cardiac activity. Recent research indicates the effectiveness of these biofeedback modalities in the treatment of many medical and psychological conditions, including:

  • anxiety disorders,     
  • depression,
  • asthma,
  • chronic obstructive pulmonary disease,
  •  cardiovascular diseases,
  • cardiac rehabilitation,
  • hypertension of various origins,
  • chronic fatigue,
  • chronic muscle pain,
  • post-traumatic stress disorder (PTSD),
  • insomnia
  • and other conditions, as well as to improve performance and professional efficiency.

Since the onset of the coronavirus pandemic, breathing and HRV biofeedback have been widely used in pulmonary rehabilitation after COVID-19.

Breathing and HRV biofeedback are not separate forms of therapy/training but are part of a larger multimodal team approach to pulmonary rehab exercises after COVID-19.

What is the mechanism of action and effectiveness of breathing and HRV biofeedback in pulmonary rehabilitation after COVID-19?

The HRV biofeedback technique includes training in breathing at the resonant frequency of the cardiovascular system. Breathing at this rate causes the heart rate to increase and decrease in the same phase as breathing. The heart rate increases with inhalation and decreases with exhalation. Then, the efficiency of gas exchange in the respiratory tract is maximal. The higher the HRV indicator (that is, the greater the difference in heart rate during inhalation and exhalation), the higher the degree of organism adaptation to the different external and internal stressors.

HRV biofeedback stimulates a specific reflex in the cardiovascular system with a particular rhythm. It is called “baroreflex” and helps control blood pressure. It also helps control emotional reactivity and improves breathing efficiency. Baroreflex is controlled by the nucleus of the solitary tract located in the brainstem. This center communicates directly with the amygdala, the center of emotional control, through a pathway through the islet. It is perhaps for this reason that various studies have shown the beneficial effects of respiratory biofeedback and HRV in the treatment of anxiety, phobias, and depression.

When blood pressure goes up, the baroreflex causes the heart rate to go down, and when blood pressure goes down, the heart rate goes up. This causes a rhythm in heart rate fluctuations. The baroreflex system resonates when a person breathes at this exact rhythm (which varies among people, generally between 4.5 and 6.5 times a minute).

How do we find the frequency at which the baroreflex system resonates for each person?

This frequency will produce the most significant swings in heart rate between inhaling and exhaling. To find this frequency, a person should try to breathe at various rates per minute to find the exact frequency at which the cardiovascular system resonates. This will be his/her resonance breathing frequency. This frequency varies from individual to individual, but it is approximately 0.1 Hz or six breaths per minute. The baroreflex system is stimulated and strengthened when people breathe at this frequency. Through projections to other systems in the body (e.g., inflammatory and limbic systems), different events occur that produce the many beneficial effects of HRV biofeedback. These changes are achieved with the help of HRV biofeedback training.

The Benefits of Controlled Breathing and HRV for COVID-19 Recovery

At around six breaths per minute, controlled breathing enhances internal regulation by establishing a balanced respiratory cycle. With each cycle, this method creates pronounced shifts in the autonomic nervous system, smoothly transitioning from parasympathetic to sympathetic states and back again. Heart rate variability (HRV) reflects this dynamic balance between sympathetic and parasympathetic influences on the heart rate, which signals autonomic flexibility. This flexibility represents the body’s ability to respond in a well-regulated way to various stimuli.

The resonance of the baroreflex circuit amplifies respiratory sinus arrhythmia, resulting in significant fluctuations in vascular tone, heart rate, and blood pressure. This ideal balance of relaxation and alertness supports homeostatic functions, optimizes neurovisceral integration, enhances efficient gas exchange in the lungs, reduces pain perception, stimulates anti-inflammatory responses, and builds resistance to both physical and emotional stress. Because of these benefits, patients with COVID-19 are encouraged to practice controlled breathing at a rate of six breaths per minute in the early stages of the disease. This practice promotes neuromodulation and may help prevent vascular and immuno-inflammatory complications.

Pulmonary Rehabilitation with Breathing and HRV Biofeedback

Incorporating breathing exercises and HRV biofeedback into COVID-19 pulmonary rehabilitation accelerates lung function recovery, restores tone in respiratory and skeletal muscles, and improves gastrointestinal and psychoemotional health. This comprehensive approach may also prevent pulmonary complications following COVID-19, offering holistic support for full and sustained recovery.

HOME-USE PERSONAL BIOFEEDBACK DEVICES FOR PULMONARY REHABILITATION AFTER COVID-19

Today, thanks to the development of technology, there are many HRV and breathing biofeedback devices for personal use at home.

Various companies have developed and presented commercial products ranging from $80 to $200.
The main requirements for HRV and breathing biofeedback devices for personal use are that the equipment must have a sensor for measuring heart rate (heart rate variability) using an electrocardiogram (ECG) and a respiration sensor using a breathing belt (recording the respiratory rate).

The eSense Respiration and eSense Pulse HRV Biofeedback devices are the most effective home-use devices for breathing and HRV biofeedback, allowing individual home comfort training.

HRV in sport performance

Heart Rate Variability in Athletes

Heart rate variability in athletes has gained significant attention as a crucial indicator of physical fitness and recovery. This metric reflects the body’s ability to adapt to stress and is particularly valuable for monitoring the training and performance of athletes. Analyzing the HRV of athletes, coaches, and trainers can gain insights into an athlete’s autonomic nervous system activity, recovery status, and overall well-being. Understanding heart rate variability (HRV) helps optimize training loads and plays a vital role in preventing overtraining and injuries. In this article, we will explore the importance of HRV in athletes, its impact on performance, and how it can be effectively utilized to enhance athletic outcomes.

Athletes' Pursuit of Improvement and the Role of HRV

As an athlete, you always look for that 1% improvement in every aspect of your game. However, as elite athletes improve and the margin for improvement narrows, achieving a 1% improvement becomes harder. With that in mind, athletes are conditioned to revert to the “train harder” mentality to grab that 1%. This mentality doesn’t always work because, much too often, overtraining and injuries occur. If you want to ensure your body is peaking at the right moments, having insight into HRV becomes that coveted 1% of all athletes are looking for.

Heart rate variability (HRV) represents variations between consecutive heartbeats (beat-to-beat or R-R interval) over time. This beat-to-beat variation in heart rhythm is considered normal and even desirable. When variations between consecutive heartbeats disappear, autonomic dysfunction is often the cause. This dysfunction can link to neurological, cardiovascular, and psychiatric diseases. Many studies show that higher heart rhythm variability relates to reduced mortality, improved quality of life, and enhanced physical fitness. (Learn more about Heart Rate Variability here).

Physiological Background and HRV’s Impact on Athletes’ Performance

The physiological background of HRV is complex and affected by circulating hormones, baroreceptors, chemoreceptors, and muscle afferents. An important factor influencing HRV is respiratory sinus arrhythmia – the natural variation in heart rate (HR) during breathingDuring inspiration, HR increases, whereas during expiration, HR decreases. The autonomic nervous system (ANS), through sympathetic (SNS) and parasympathetic (PNS) pathways, regulates the function of internal organs and the cardiovascular system. During training or competition, sympathetic activity (“fight or flight”) increases an athlete’s cardiac contractility, heart rate, breathing, and muscle tension.

In contrast, parasympathetic (vagal) stimulation (“rest and digest”) reduces an athlete’s heart rate, relaxes muscles, and allows for digestion. Any source of stress (psychological, physical, or illness) will provoke disturbance in the ANS and, consequently, in HRV. The long-term presence of an imbalance between sympathetic and parasympathetic tones can impair athletes’ performance.

HRV data offers a unique view into nervous system activity. This insight helps athletes find the right balance between training and recovery.

Heart rate variability in athletes

HEART RATE VARIABILITY IN ATHLETES DURING AND AFTER EXERCISE (INDICATORS OF STRESS/TRAINING LOAD)

During exercise, HRV is reduced (shorter R-R intervals), and heart rate is increased due to augmented SNS and attenuated PNS activity. Not only are the intervals between R-R peaks shorter, but they also become more uniform (reduced R-R variability).

The relationship between sympathetic and parasympathetic activity during exercise depends directly on training intensity. During physical activity, sympathetic nerves can increase cardiac output to 2 to 3 times the resting value.

Caution should be taken when interpreting HRV analysis during exercise. When exercise intensity exceeds 90% of VO2 max, breathing frequency rises. This increase boosts vagal contribution, or PNS activity, due purely to the heart’s mechanical properties rather than any neural input from the ANS. As a result, PNS activity, driven by faster respiration, can mask actual SNS activity at these higher intensities. To ensure accurate results, the athlete should maintain a stable respiration rate as much as possible during an incremental test to exhaustion.

TRAINING LOAD

The distribution of training loads is a fundamental component of periodization. The elements that comprise the training load are training volume and intensity. The interplay between these two elements will define the total training load. Higher training loads will cause greater ANS disturbance and sympathovagal imbalance. Post-exercise HRV analysis appears to be a valuable indicator for evaluating variations in performance level and can indirectly reflect training loads. There is evidence that HRV parameters are highly correlated with the intensity and volume of exercise and are inversely related to the training load level.

RECOVERY AND HEART RATE VARIABILITY IN ATHLETES PERFORMANCE

Understanding Stress, Adaptation, and Recovery in Training

On the assumption that physical activity causes stress (a stimulus), the body will respond with a stress reaction on different physiological levels. In addition to a stress reaction, adaptation processes occur during recovery. Suppose the magnitude of the stress stimulus (training load) is high enough (overload principle) to evoke a reaction in the body. In that case, the response will be proportional to the stress level, and, as a result, greater training effects will be accomplished (adaptation).

To reach higher performance levels in sports, it is essential to understand that well-designed and integrated rest periods are crucial. Recovery after training is considered an integral part of the training methodology. Performance will not improve if there is a lack of optimal recovery. Problems occur when the demands are so frequent that the body cannot adapt. This means the body will continuously be under sympathetic domination during rest and activity.

Most athletes and sports science personnel understand the importance of recovery after exercise, defined as the return of body homeostasis after training to pre-training or near pre-training levels.

The Role of Recovery and Its Impact on Performance

Recovery involves getting adequate rest between training sessions/competitions to allow the body to repair and strengthen itself in preparation for the subsequent bout. Optimal athletic performance is supported when recovery to pre-training or near pre-training levels is permitted. If recovery is insufficient, hindrance of physiological adaptation and reduced athletic performance should be expected. Recovery plays a major role in minimizing the harmful effects of training (fatigue) while retaining the positive impact (improved fitness/strength/performance).

Without monitoring recovery after exercise, fatigue can build up and become excessive before competition. This buildup reduces athletic performance and may even lead to overtraining syndrome. The overtraining syndrome occurs when training stress is too high, and recovery is insufficient, causing fatigue and decreased performance.

Heart rate variability in athletes performance: Train-Recover-Perform

Every training session stresses the body and disturbs homeostasis and ANS modulation. These changes in ANS activity manifest as increased sympathetic activity or decreased parasympathetic activity, which reflects in HRV parameters. One crucial aspect of recovery is sleep, during which parasympathetic activity should dominate. However, an optimal recovery state typically features parasympathetic (vagal) predominance of the ANS, regardless of the time of day.

HRV as a Noninvasive Tool for Monitoring Recovery

Various parameters can be used to measure post-exercise recovery (VO2 max, creatine kinase, C-reactive protein, plasma cortisol, blood leukocyte, myeloperoxidase protein level, and glutathione status). However, these methods are mostly invasive, time-consuming, and expensive for everyday use. Accordingly, the importance of a noninvasive, easy, and affordable method to evaluate recovery is obvious. Thus, HRV technology is increasingly used to evaluate the status and level of recovery.

Long-term high-intensity training sessions gradually decrease the parasympathetic component of HRV, which increases during the rest of the period. The sympathetic component demonstrates the opposite tendency.

Reactivating HRV’s parasympathetic activity to pre-exercise levels as quickly as possible significantly improves athletes’ recovery. When HRV parameters cannot return to pre-exercise or optimal levels within a reasonable time, this indicates a chronic disturbance in ANS activity. Such a disturbance can lead to overtraining.

Today, HRV-based devices and software assist in athletes’ recovery analysis, providing easily interpretable data to trainers and athletes. The most common procedure to evaluate recovery level involves overnight measurement (nocturnal) of HRV, although systems that can assess a quick recovery index (5-minute measurement) are also available.

THE USE OF HEART RATE VARIABILITY IN ATHLETES: OVERTRAINING AND HOW AVOID IT?

Sometimes, the line between optimal performance level and overtraining is skinny.

Overtraining syndrome (OTS) results from a long-term imbalance between stress (internal and external) and recovery periods. A large body of evidence implies that overtraining syndrome causes significant cardiac autonomic imbalance between the two ANS pathways (sympathetic and parasympathetic).

The literature contains conflicting results about ANS modulation in overtrained athletes. Some studies report a predominance of sympathetic and parasympathetic autonomic tone during an overtrained period. The description of different types of overtraining might explain these disputed results.

Two types of OTS have been reported: sympathetic and parasympathetic overtraining, each with specific physiological characteristics.

Sympathetic tone

Insomnia

Irritability

Tachycardia

Agitation

Hypertension

Restlessness

Parasympathetic tone

 

Fatigue

Bradycardia

Depression

Loss of motivation

 

The early stages of performance impairment feature sympathetic domination of the ANS at rest. This condition is often called an “overreaching state” or “short-term overtraining.” This means that the disturbance of homeostasis was not high and long enough to provoke a chronic overtraining state. Therefore, the time needed to fully recover all physiological systems typically encompasses several days to weeks.

Sports that require higher exercise intensity generally show increased sympathetic tone. If the overreaching state (sympathetic autonomic tone domination) continues for longer, OTS and domination of parasympathetic autonomic tone will develop. Parasympathetic OTS dominates in sports characterized by high training volume.

LIMITATIONS, IMPROVEMENTS AND FUTURE PERSPECTIVES OF ANALYSIS OF HEART RATE VARIABILITY IN ATHLETES PERFORMANCE

Analysis of heart rate variability in athletes’ performance has become a widely accepted method for noninvasive evaluation of ANS modulation during and after exercise. To overcome the aforementioned disadvantages, the recording signal must contain a minimum of 5 minutes of HRV fluctuation to get reliable results.

In the last 5 years, the number of devices and software programs/apps using HRV technology has increased exponentially. The current trend in software engineering is to make all wireless sensors for capturing and transmitting HRV data compatible with smartphones. Hardware and software engineers are continuously improving the accuracy of sensors that record and receive HRV signals (heart rate belts, wireless technologies, and protocols) and HRV analysis techniques (software, mathematical models). This provides the trainer and athlete with quick and easy analysis of HRV data during and after a training workout (training load, recovery, and overtraining).

THE GOAL OF MONITORING OF HRV IN ATHLETES PERFORMANCE

HRV provides an excellent objective status of the autonomic nervous system. The primary goal is reducing injuries, decreasing overreaching, improving player health, increasing adaptation, and learning more about training. However, winning requires that talent is available and optimized in performance, not just uninjured. The essence of monitoring heart rate variability in athletes is to drive a routine and accountability process for winning. The data collected from HRV can guide athletes like a compass to a training program blueprint, but only if the commitment exists with everyone. Winning requires talent and preparation, and while only a few can be on top of the mountain, HRV can increase those odds if appropriately used.

MEASUREMENT PROTOCOL

Metrics

  • RMSSD is the most commonly used and trusted metric. It is a clear marker of parasympathetic activity (recovery). RMSSD is linked to performance changes, fatigue states, overreaching, and overtraining. The return of RMSSD to baseline after exercise has been related to the clearance of plasma catecholamine, lactate, and other metabolic byproducts, in addition to restoring fluid balance and body temperature.
    Therefore, RMSSD serves as a global marker of homeostasis, reflecting various aspects of recovery. This marker may explain why planning intense training when HRV is at or above baseline can help improve endurance performance.
  • Duration: 60 seconds to 2 minutes in the morning is the ideal measurement protocol for reliability and practical applicability in team settings. Night measurements are also a valid method.
  • Frequency: To establish a valid baseline, at least three days per week are required. More measurements can be beneficial, up to five ideally. If compliance is an issue, prioritize the three days in the middle of the week, far from matches, to avoid residual fatigue.

Data analysis: The most important parameters to examine are baseline HRV and the coefficient of variation (CV).

  • HRV baseline: computed as the average HRV over a week (or 3-5 days if daily measurements are challenging to obtain). An athlete’s average values should be analyzed. Typical values are a statistical way to represent historical data collected in the previous 30 to 60 days. This should give us insights into where we expect the HRV baseline to be, provided no significant stressors are present. In case of such significant stressors or issues in responding to training or lifestyle stressors, the baseline will deviate from the expected typical values.
  • CV: Coefficient of Variation, or the amount of day-to-day variability in HRV.

Insights

Pre-session: load can be adjusted based on individual responses as shown in baseline HRV and CV. In particular:

  • Athletes showing a reduced HRV and increased CV most likely struggle with the load and might benefit from reduced load or other recovery strategies (sleep, diet, yoga, or different ways to minimize non-training-related stress, for example).
  • Athletes showing a stable or increasing HRV are likely coping well with the increased load.
  • Athletes showing a reduced CV likely cope well with the increased load unless their baseline HRV reduces or goes below average. In this case, the reduced CV might highlight an inability to respond to training.

The same patterns throughout the session can help you understand individual responses to changes in training load. Use HRV as a continuous feedback loop rather than a target to optimize toward a specific value. Staff working with athletes and physiological measures should prioritize baseline and CV changes to determine individual responses and adaptations.

HRV ADDITIONAL INFORMATION AND PRACTICAL RECOMMENDATION

  • HRV is an indication of your resilience – the ability of the nervous system to respond and recover from physical or psychological stressors;
  • HRV values depend on the length of the measurement
    – 5 minutes = short term HRV
    – 24 hours = long term HRV;
  • HRV is age and gender-dependent;
  • HRV has a circadian rhythm;
  • HRV may change day to day with your biorhythm or due to emotional or physical stress;
  • HRV is dependent on body position;
  • Chronic low HRV is an indication of systemic health (psychological or physical) issues;
Circadian Rhythm of HRV
HRV and body position
  • HRV measurement should be provided for the same length of time each day (3 minutes typical);
  • HRV should be taken at the same time each day
    – First thing in the morning is recommended
  • HRV should be taken in the same position
    – Lying down
    – Sitting
    – Standing

ESENSE PULSE WEARABLE ECG MONITOR

Heart Rate Variability (HRV) refers to the variable time between individual heartbeats. An ECG can accurately measure HRV. A basic heart rate monitor can also provide this data, but the HRV will not be as accurate.
Only elite athletes and their coaches had access to HRV data in the past because devices that measure ECG were costly and difficult to wear.

In the last five years, innovations in wireless technology have significantly increased the number of devices on the market that use HRV indices to control and manage athletes’ training processes. Now, with accessible, wearable, and user-friendly technology like the eSense Pulse wearable ECG monitor, everyone from professional athletes to weekend warriors can use HRV data to enhance their training.

TARGET HEART RATE

While using eSense Pulse, the eSense App displays the current heart rate and the target heart rate during recording in the overview area. The target heart rate can be adjusted at any time in the settings of your eSense App. You can either set it directly or as a percentage of the predicted maximum heart rate. By default, the target heart rate value is 85% of the expected maximum HR.

The predicted maximum heart rate is calculated using the following formula: Predicted Maximum Heart Rate = (220—your age in years). Normally, you should maintain your heart rate below your target level (85% of a predicted maximum heart rate, based on your age and medical conditions).

HRV focuses on the distance between peaks. In the eSense App, the SDNN (Standard deviation of all NN intervals) and RMSDD (Root Mean Square of the Successive Differences) is one of a few time-domain tools used to assess heart rate variability, the successive differences being neighboring RR intervals) values relate to the time interval between peaks, but RMSDD best shows parasympathetic or “rest and digest” activity. Accurate RMSDD measurements can also be taken in 60 seconds or less, which makes RMSDD quick and easy.

HOW CAN RMSDD BE USED TO CALCULATE HRV AND PLAN OPTIMAL ATHLETIC TRAINING?

The power of HRV as a training tool comes from establishing an RMSDD baseline. To establish a baseline, an athlete needs to wake up, strap on the eSense Pulse for a minute, and take a reading each day for one week. At the end of the week, if they average all of their RMSDD measurements, they will have a baseline RMSDD number.

In the future, if their RMSDD numbers fall below their baseline in the morning, they will know to ease off on training for optimal performance. If their RMSDD number goes above their baseline, they are more than recovered and can take on a challenging workout. In other words, higher RMSDD numbers correspond with more parasympathetic activity or a more recovered state.

RMSDD AND HRV LET YOU KNOW WHEN AND HOW TO TRAIN

In a perfect world, an athlete’s mind and body would be in total sync, and athletes would intuitively know how hard to push themselves. In reality, athletes may gradually stop making progress without knowing exactly why. They are either over or undertraining. They may attribute their fatigue to not working hard enough when, in fact, they are working too hard. HRV measurements like RMSDD give athletes an objective way to justify a rest day or, on the other end of the spectrum, prompt them to increase the intensity and volume of the training. Heart rate variability in athletes used to be available only to world-class athletes. However, with technologies like eSense Pulse, HRV analysis can be used by cyclists, runners, endurance athletes, and even gym enthusiasts.

References

Bojan Makivic, Pascal Bauer – Heart Rate Variability Analysis in Sport, Utility, Practical Implementation, and Future Perspectives. Aspetar Sports Medicine Journal, p.326-331 – www.aspetar.com/journal

Simon Wegerif. – Using Heart Rate Variability to Schedule the Intensity of Your Training. – https://www.trainingpeaks.com/

Cian Carroll. – Monitoring An Athlete’s Internal Response: A Comprehensive Guide To Analysing Heart Rate Variability & Heart Rate Recovery. – https://statsports.com/