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Use of real-time ultrasound imaging for biofeedback of diaphragm motion during normal breathing in healthy subjects
Physical Therapy Rehabilitation Science 2018;7:95-101
Published online September 30, 2018
© 2018 Korean Academy of Physical Therapy Rehabilitation Science.

Ji-Eun Choa, Dal-Yeon Hwangb, Joohee Hahna, Wan-Hee Leec

aDepartment of Physical Therapy, Graduate School, Sahmyook University, Seoul, Republic of Korea
bDepartment of Rehabilitation Medicine, Myongji Choonhye Rehabilitation Hospital, Seoul, Republic of Korea
cDepartment of Physical Therapy, College of Health Science, Sahmyook University, Seoul, Republic of Korea
Correspondence to: Wan-Hee Lee (ORCID
Department of Physical Therapy, College of Health Science, Sahmyook University, 815 Hwarang-ro, Nowon-gu, Seoul 01795, Republic of Korea
Tel: 82-2-3399-1633 Fax: 82-2-3399-1639 E-mail:
Received March 21, 2018; Revised April 18, 2018; Accepted April 20, 2018.
cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective: To determine if the provision of visual biofeedback using real-time rehabilitative ultrasound imaging (RUSI) enhances
the acquisition and retention of diaphragm muscle recruitment during exercise.
Design: Two group pretest posttest design.
Methods: Thirty healthy subjects were randomly assigned to the verbal feedback group (VG, n=15) or the visual and verbal feedback group (VVG, n=15). The VG performed breathing exercises 10 times with verbal feedback, and the VVG also performed breathing exercises 10 times with verbal feedback and visual feedback with the use of RUSI to measure changes in diaphragm thickness (DT). For DT, the mid-axillary lines between ribs 8 and 9 on both sides were measured in standing, and then the chest wall was perpendicularly illuminated using a linear transducer with the patients in supine to observe the region between rib 8 and 9 and to obtain 2-dimensional images. DT was measured as the distance between the two parallel lines that appeared bright in the middle of the pleura and the peritoneum. After one week, three repetitions (follow-up session) were performed to confirm retention effects. Intra- and between- group percent changes in diaphragm muscle thickness were assessed.
Results: In the VVG, the intervention value had a medium effect size compared to the baseline value, but the follow-up value decreased to a small effect size. In the between-group comparisons, during the intervention session, the VVG showed no significant effect on percent change of DT but had a medium effect size compared to the VG (p=0.050, Cohen’s d=0.764). During the follow-up session, retention effect did not persist (p=0.311, Cohen’s d=0.381).
Conclusions: RUSI can be used to provide visual biofeedback and improve performance and retention in the ability to activate the diaphragm muscle in healthy subjects. Future research needs to establish a protocol for respiratory intervention to maintain the effect of diaphragmatic breathing training using RUSI with visual feedback.
Keywords : Biofeedback, Diaphragm, Respiratory muscles, Ultrasonography


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