Effect of All Fours Belly Breathing Exercise on Aerobic Capacity Among Athletes
Avanianban Chakkarapani1*, Abdul Rahman2*, Wen Yi Yap2, How Kuan Ling2
1Department of Physiotherapy, Faculty of Medicine and Health Sciences, Malaysia
2Department of Physiotherapy, Universiti Tunku, Malaysia
Submission: July 7, 2019; Published: August 06, 2019
*Corresponding author: Avanianban Chakkarapani and Abdul Rahman, Department of Physiotherapy, Faculty of Medicine and Health Sciences, Universiti Tunku, Malaysia
How to cite this article: Avanianban Chakkarapani, Abdul Rahman, Wen Yi Yap, How Kuan Ling. Effect of All Fours Belly Breathing Exercise on
Aerobic Capacity Among Athletes. J Yoga & Physio. 2019; 7(5): 555721. DOI: 10.19080/JYP.2019.07.555721
Study Design: Controlled laboratory study, experimental (1 group X 2-time frame) study.
Background: The role of breathing exercise and their effect on a wide range of aspects relevant to orthopedics and sports rehabilitation has become the focus of a growing body of research, yet their effect in sport physical therapy is not well established.
Objectives: To assess the effect of all fours belly breathing exercise on shuttle run performance among athletes.
Methods: A total of 20 participants participated in this study. Group 1(n = 20) athletic group. Informed consent and study procedure was explained to all the participants and a pre- shuttle run test (SRT) was assessed. After assessment the participants were engaged in all fours belly breathing exercise for 4 weeks and post SRT was assessed.
Results: The mean SRT score before 4 weeks of all fours belly breathing exercise was 3.305. (Standard deviation = 1.46) The minimum score was 1.143 while the maximum score was 8.182. Whereas the mean SRT score after 4 weeks of all fours belly breathing exercise was 3.95 (Standard deviation = 1.36) The minimum score was 2.5 while the maximum score was 8.364. Whereas using student t test the mean difference between SRT score before 3.31 (1.47) and SRT score after 3.95 (1.37) is statistically significant (p<0.001). As well as the mean difference between predicted VO2max before 23.78 (4.90) and predicted VO2max after 25.87 (4.74) is statistically significant (p<0.001)
Conclusion: Thus, this study concludes that all fours belly breathing is effective in improving the shuttle run performance among the normal subjects
Keywords: Belly breathing; Shuttle run; Breathing exercise; Quadruped position
Abbreviations: SRT: Shuttle Run Rest; DOMS: Delayed Onset of Muscle Soreness; EMG: Electromyography; ZOA: Zone of Apposition; RA: Rectus Abdominus; IO: Internal Oblique; EO: External Obloque; TA: Transvers Abdominus; CRF: Cardiorespiratory Fitness; METs: Metabolic Equivalents
During exercise the ventilation demand keeps on raising the peak, this process defines an increased neural drive to the muscles of respiration. In turn there will be increased mechanical power developed by the muscles. Muscle power always depends on the velocity of shortening and the pressure generated the muscle under contraction. During exercise the diaphragm is primarily a “flow generator”. Hence the diaphragm muscle generates mechanical power is mainly expressed as velocity of shortening rather than pressure. Conversely, rib cage and abdominal muscles are primarily “pressure generators”, i.e. develop
the pressures required to move the rib cage and abdomen,
respectively . During exercise the expiratory muscles play an active role in breathing. Within each single breath their action is highly coordinated with the inspiratory muscles. During inspiration, while the rib cage muscles contract, the abdominal muscles gradually relax, and vice versa during expiration. This mechanism has several effects:
i. It prevents rib cage distortion;
ii. The diaphragm is unloaded and can act as a flow generator
iii. The volume of the abdomen is decreased below resting levels [1,2].
As a result, end-expiratory lung volume is decreased
during exercise and the mechanics of breathing is optimized
for several reasons. Tidal volume occurs in the most compliant
part of the respiratory system; the diaphragm is lengthened
and thus works near its optimal length; at each breath part of
the required inspiratory work is previously stored in the form
of elastic energy during the previous expiration . Based on
the role and physiology of abdominal and diaphragm muscles
it is well known that exercise therapist should give significant
priority to these muscles. Similarly, the diaphragm, a component
of core stability, plays a role in respiration as discussed earlier
and trunk stability by controlling intra-abdominal pressure and
reducing the stress on the spine through coordinated action with
the abdominal and pelvic floor muscles [4,5].
There are still many “experts” who give advice regarding
core stabilization but completely fail to mention the diaphragm.
There has however, been more frequent mentioning of diaphragm
breathing lately. Unfortunately, it often only gets added to trunk
stability exercise prescriptions as final comment of “make sure
to maintain diaphragm breathing while exercising”. It is clearly
understood that neuro-muscular activation of diaphragm
during trunk stability exercise is missing. Thus, neuromuscular
activation of the diaphragm which in turn promotes optimal
activation of the transversus abdominis may further help to
address suboptimal respiration and posture which is associated
with low back pain. This research work experiment an exercise
called, all fours belly breathing exercise with an assumption
as it will help in the activation of the diaphragm which in turn
promotes optimal activation of the transversus abdominis may
further help to address suboptimal respiration and posture.
For this study, 20 participants (8male, 12female and mean
age of 20.10) were participated in this study; participants were
screened to meet the inclusion criteria of normal subjects.
Initially on the first day of first week all the participants were
assessed with shuttle run and later participants were training
with all fours belly breathing and at the end of fourth week all
the participants were reassessed with shuttle run.
The 20m Shuttle Run Test (SRT) is used to measure the
maximal running aerobic fitness, which are also known as beep
or bleep test. It has a total number of twenty-one levels and
different number of shuttles for each level according to the speed.
Throughout the study, this test was requiring conducting twice.
The first SRT was conducted as a pretest after the participants
had been chosen. After four weeks of all fours belly breathing
exercise, a final Shuttle Run Test (posttest) was held.
a. Before the test started, a 10m distance running track
was pre-measured and checked to make sure the flooring
and environment was suitable to run.
b. Marking cones were arranged as landmark of the
starting and ending points, so that participants were clear
about where and when to start and turn during running.
c. Every subject was asked to perform a brief warm up for
about 5 minutes to prevent injury.
d. Subject was asked to run to and fro between two lines
within timing by listening to recorded beeps.
e. At first, the subject stood behind the beginning line and
began to run to the second line and returned when instructed
by the recorded audio.
f. The initial speed was quite slow, and subject had to
continue running and turning between the two lines when
signaled by the recording. Among the several versions of
the shuttle run test, the commonly used version was chosen
in this study. It had an initial running velocity of 8.5 km/hr,
which increased by 0.5 km/hr each minute.
g. About one minute later, there was a sound which
indicated increase in speed, and this continued every minute
h. When the subject reached the line before the beep
sounds, he/she will wait and continue until the beep sounds
are heard, where as if the beep sounds came before the
subject reached the line, a warning was given and must
continue to run to the line, and tried to catch up with the
pace within two more ‘beeps’.
i. The test was terminated when the subject failed to
reach the line (within two meters) for two consecutive ends
after a warning or subject intended to stop
j. After termination of test, subjects were required to have
a cool down session for around five minutes. Slow walking
and some stretching exercises were taught by researcher to
prevent delayed onset muscle soreness (DOMS).
The level and number of shuttles (20m) reached was recorded
before the subject was unable to keep up with the recording.
The last level completed was marked down in a prepared beep
recording sheet. After 4-week of breathing exercise training,
the aerobic fitness of subjects were also measured by Shuttle
Run Test. In order to increase validity of the results of study, a
Beep Test VO2max Calculator developed by to pend Sports from
the tables in a published article to calculate predicted VO2max.
By entering the age, gender, the level and number of shuttles
completed, the calculator will generate the results (predicted
All the subjects had participated in 4-weeks of all fours
belly breathing training. The training started immediately the
day after pre SRT session. During the first week of training, researcher taught and monitored the breathing technique one to
one. The following three weeks of training, the twenty subjects
were divided into four groups for group therapy. To obtain a
training response muscles must be overloaded, this overloading
can be applied by altering duration, intensity or frequency. For
respiratory muscles of a healthy individual, the training should
be takes place daily or at least three times per week, and once
or twice per day. The suggested intensity is 50–70% (typically
yields failure within 30 breaths), or 2-3 minutes and durations
are 30 breaths or 2 to 3 minutes per session . Therefore, in
this study, the parameters were standardized to minimize error:
a. intensity = 50-70%
b. duration = 30 breaths
c. frequency = 3 times/week; twice/day
A mat was set up in front of mirror for all fours belly
breathing. By doing in front of mirror, the subjects can get a
feedback on their way of performing the breathing technique
and able to correct it back immediately. In order to minimize
error, along with the explanation of procedures to the subjects,
researcher also demonstrated the correct way of the breathing
Instructions for All Fours Belly Breathing:
i. Start in quadruped position with slight posterior tilt
of pelvis, and place both hands shoulder width apart while
both knees pelvis width apart. It should be in 90 degree
or perpendicular to the body. Subject’s spine should be in
neutral position (Figure 1).
ii. Take a deep breath through nose and try to imagine
the air is pushing into the stomach, fell the stomach blow up
with the air.
iii. While breathing out through mouth, drive the sternum
up towards the ceiling to create a hump in the upper back
iv. Focus the breath and imagine the air get into the dome
created and slowly and fully breathed out through mouth.
v. Maintain the position for 6 breaths and return to the
vi. Subject was asked to have 1 min resting interval and
then repeat the above procedures for 5 cycles.
I. Subjects are not allowed to hold breath throughout the
II. One min resting interval is given to prevent
Statistical Analysis: Student t test was used for analysis
of data collected from pre exercise and post exercise training
shuttle run rest.
Results: SRT increased from 3.31 to 3.95 of predicted oxygen
uptake from 23.78 to 25.87. Although the SRT score doesn’t
shows much difference whereas the predicted Vo2 max shows
reasonable difference (Tables 1 & 2).
The objective of this study was to identify the effect of
4 weeks of all fours belly breathing exercise on shuttle run
performance among normal subjects. All fours belly breathing
exercise is defined as a respiratory technique and corrective
exercise that performed in a quadruped position, aimed to
restore thoracic flexion of and to promote better control of pelvis
and ribcage. This new respiratory technique implemented is to
fulfill the dearth of breathing technique with activation of all
abdominal muscles (RA, IO, EO and TA), as well as diaphragm at
the same time. According to length-tension relationship, muscle
activated maximally at its optimum length and relatively less
force generated at either shorter or longer lengths . “Optimal
length-tension relationships, recruitment patterns, and joint
motions in core muscles establish neuromuscular efficiency
throughout entire human movement system which allows
efficient acceleration, deceleration, and stabilization during dynamic movements, as well as prevention of possible injuries
.” An all fours is a position which the muscles are in relaxed
state, it is ideally for the respective muscles to get recruited
and trained. It is an ideal position for the anterior part of body
(abdominals) to work while the posterior part (excessive tone of
extensor muscles) is inhibited.
It is believed that all fours belly breathing exercise has many
benefits. Firstly, all fours require subjects to hold their spine in
neutral position which helps in correcting the excessive (hyper
lordosis) or loss of normal lumbar curvature (flat back) of the
spine. While in the quadruped position itself, posterior pelvic tilt
is achieved. As a breathing technique, all fours belly breathing
primarily works on the activation of respiratory muscles like
abdominal muscles and diaphragm. While inhaling and making
sure that the air goes to the stomach, diaphragm is activated. Then
follow by exhaling through mouth and slowly driving the sternum
up towards the ceiling to create a dome shape in the upper back.
Make sure the belly is drawn in towards the spine to activate
the local abdominal muscle. In order to against the gravitational
pull, abdominal muscles are activated and strengthened at the
same time during this process. Besides, subjects are required to
exhale fully which also facilitate the abdominals. Subjects need to
maintain this position and breathe in and out for another 5 to 6
breaths. In this position, the posterior mediastinum is expanded
and creating a better zone of apposition (ZOA) for diaphragm
function. It also helps in restoring the thoracic flexion for people
with flat T-spine. On the other hand, pump handle movement of
ribcage is relatively increased throughout the proper breathing
patterns. By expanding the ribcage posteriorly, there is an
increase in the antero-posterior diameter of thoracic cavity. This
movement is essential in the mechanism of breathing for the
expansion and reduction of the intra-thoracic volume.
The results of our study showed improvement on the
SRT score after 4 weeks of training. SRT is one of the field
tests developed and widely used to monitor changes in
cardiorespiratory fitness. Cardiorespiratory fitness (CRF)
essential for both health and fitness and is usually expressed
in metabolic equivalents (METs) or maximal oxygen uptake
(VO2max). CRF has a close relationship with physical activity.
Studies shown regular physical activity can improve CRF of
individuals [9-11]. Similarly, the level of CRF depends on several
modifiable and non-modifiable causal factors  (Table 3).
Among the modifiable factors, physical activity is the primary
determinant to the level of CRF. In order to sustain endurance
and eliminate waste products during prolonged exercise, both
respiratory and circulatory systems play important roles by
Lee et al. (2010), Journal of Psychopharmacology, 24(11), p. 32.
Copyright 2010 by Lee, et al.)
The mean difference between pre and post test score
showed the result is statistically significant (p<0.001). There
is an association between all fours belly breathing exercise and
shuttle run performance. We can conclude that after 4 weeks of
all fours belly breathing exercise, participants had improved in
their CRF, as shown in the improvement in VO2max predicted
from the SRT before and after training (p<0.001). By the results
scored in SRT, VO2max of the individual can be estimated. SRT
is one of the field tests developed and widely used to monitor
changes in CRF. The results may be affected by several factors:
a. familiarity to the test and instructions given
b. running and turning technique
c. environmental factor like weather and running surface
d. attire and condition
e. motivation and purpose of testing.
In our study, first, instructions were clearly explained to
each of the participants and a trial was given for them before
running the test. Running and turning techniques were not equally familiarized among all the individuals. Besides, the SRT
was conducted indoor and a non-slip running surface. However,
some of the participants felt that the surrounding air was a
limiting factor to the run. They felt breathless easily if keep
inhaling the dry air (air-con). All subjects were presented with
their sport attires and their health conditions of the day were
considered. The purpose of study had been clearly explained
to all participants and they were willing to take part. No one
was forced or done the test unpleasantly. Some of them were
participated with their friends, thus there was a motivation
and courage from the peers, which may further increase the
In addition to that, the research question was ‘Does all
fours belly breathing exercise have the effects on shuttle
run performance?’ After analyzing the result, we found that
male participants have scored higher and had a higher mean
difference in the SRT score before and after intervention than
females, which shows that all fours belly breathing has more
effect on CRF among male participants. As it may due to the
gender difference in VO2max, with the body mass difference;
the anthropometric variables can affect their CRF level. It was
proved that the “gender differences in aerobic power were not
fully explained by differences in body size [12,13].” The CRF of
females is lower than males.
There were several limitations in our study. We only recruited
small sample size in the study due to the difficulty in recruiting
the participants in the short period of time. It is quite difficult to
identify the significant relationships between the variables with
small sample size. A larger sample size should be recruited in
future studies to get a more representative result. In this study,
we did not measure the electromyography (EMG) activities
of the target muscles due to budget and resources constraint,
causing no evidence of the muscle activity. For example, during
the study period, we did not know whether the participants
had participated in any other physical activity or training that
may be one of the confounding variables to our findings. By
doing other physical activity, it is believed that there will be
some improvement in CRF, which may also secondarily cause
subjects to perform better in the post SRT. We did not include a
control group that did not receive any respiratory training in this
study because this is a pilot study to determine the association
between the two variables. After our study proved the effects of
all fours belly breathing, other researcher can work in comparing
between the effects of two different respiratory trainings.