Could Dysfunctional Breathing Be Suffocating Your Outcomes?
The diaphragm is necessary not only for respiration but for core stability as well. (1-3) The diaphragm is a key trunk stabilizer during postural activity and must properly activate upon demand. Dysfunctional breathing patterns may perpetuate many common musculoskeletal problems involving the head, neck, shoulder, and lower back. (4) Rehabilitation of dysfunctional breathing patterns is essential, yet often overlooked.
Intra-abdominal pressure (IAP) is a key determinant of core stability. (7-13) IAP is largely determined by the strength and tone of the muscles forming the “abdominal canister.” The front and sides of the abdominal canister are formed by the transverse abdominous and intercostal muscles. The back of the canister includes the paraspinal muscles, from the superficial spinal erectors to the deeper multifidi. The bottom of the canister is formed by the pelvic floor, while the diaphragm serves as the roof. Together, these muscles regulate intra-abdominal pressure and core stability. (14-24)
The stabilizing effect of IAP requires a complex synergy between all “canister” components. (25) The process begins when the diaphragm contracts to compress the abdominal cavity while the pelvic floor harmoniously co-activates to provide additional pressure. This is immediately followed by an eccentric contraction of the abdominal wall and lumbar extensor muscles, thereby maximizing intra-abdominal pressure and enhancing core stability. (25,26)
Trunk bracing protects the spine in a neutral position throughout movement. (26) A well-braced core also provides a stable foundation for extremity or head movement in much the same way that, when firing a cannon, a large ship serves as a better platform than a rowboat. In addition to healthy & functioning muscles, “stability” requires adequate central nervous system control. (5) The CNS must be able to reflexively brace the trunk in anticipation of movement. (28-32)
The diaphragm is the key modulator of intra-abdominal pressure. (33-37) The diaphragm must initiate pressurization by contracting before the abdominal wall. However, demands for increased stability (i.e. limb movement) do not always coincide with the initiation of a respiratory cycle. Fortunately, the diaphragm can adapt to perform its dual role of respiration and stabilization simultaneously. (36) The diaphragm’s postural contributions occur independently of breathing and may be controlled voluntarily, irrespective of the phase of respiration. (39,40) EMG studies demonstrate that the diaphragm contracts in anticipation of activity, irrespective of its respiratory phase. (40)
The body is generally able to co-manage its task of respiration during isolated brief limb movements. However, sustained or repetitive movements pose a challenge for the CNS. (40) The diaphragm’s role as a stabilizer varies greatly between individuals. (41) Patients who are unable to efficiently contract their diaphragm for postural stability have an increased risk of lower back pain and spinal disorders, including strain, disc lesion, and spondylolisthesis. (42-46)
“Normal” breathing occurs when the diaphragm contracts and flattens, pressurizing the abdomen and causing it to expand. The upper chest should remain relatively still. Patients with dysfunctional patterns often present with a “paradoxical” pattern where the abdomen remains still or retracts while the upper chest elevates and expands.
The assessment of dysfunctional breathing begins with unannounced observation. Clinicians should look for classic signs of dysfunction including elevation of the upper rib cage, inadequate or asymmetrical lateral rib cage expansion, nasal flaring, labored breathing, frequent yawning, hyperventilation, mouth breathing, excessive paraspinal muscle contraction, and/or initiation of breathing from the chest rather than the abdomen. (49) The latter may be assessed with the patient lying supine, knees bent having the patient place one hand over their umbilicus, the other hand on their sternum. Initiation of a deep breath should start in the abdomen with minimal chest elevation. Normal breathing should cause a wave-like pattern of spinal flexion beginning at the diaphragm, then moving cephalad (best observed in a prone patient).
Detection of rib cage movement may be enhanced when the clinician stands behind the patient and places the (clinician’s) thumbs on the thoracolumbar paraspinal muscles with the second and third fingers lightly positioned over the patient’s lower ribs, while the fourth and fifth fingers are placed on the abdominal wall. As the patient breathes in and out, the clinician may monitor thoracolumbar paraspinal muscle contraction, rib movement, and abdominal wall resistance.
Clinicians may further assess the postural function of the diaphragm by placing their hands at the ends of the supine patient’s abdominal wall and instructing the patient to pressurize the abdomen while holding his or her breath. The clinician should feel pressure against both hands as the patient bears down. (41) Next, the clinician assesses for the preservation of abdominal pressure throughout the normal respiratory cycle by instructing the patient to maintain pressure while breathing. Finally, breathing & IAP should be assessed while the patient performs a functional movement like an overhead squat. (4)
Patients with dysfunctional breathing may rely on the accessory muscles of breathing. Myofascial irritation may be found in the: upper trapezius, scalenes, levator scapulae, SCM and/ or pectoral muscles. (4) Management should include assessment and correction of thoracic and costovertebral joint restrictions.
Rehabilitation of dysfunctional breathing is an essential yet overlooked element of many treatment plans. In patients with “core problems,” diaphragmatic function should be restored prior to initiating balance or stability exercises. Patients with inadequate diaphragmatic function and poor stabilization may not benefit significantly from performing other core exercises. (50-54) Some authors believe that rehabbing abdominal and lumbar musculature prior to restoring diaphragmatic function may even “promote pathological patterns of movement and exacerbate the patient’s pain.” (50,52)
An article by Distano (4) provides an excellent progression for retraining proper breathing mechanics. Begin by educating the patient about the detrimental effect of abnormal breathing and how poor mechanics contribute to their symptoms. Briefly describe the patient’s abnormal breathing pattern and allow the patient to recognize his or her fault by manually palpating the areas of dysfunction breathing while observing themselves breath in a mirror. The clinician should demonstrate normal breathing mechanics, so that the patient may visualize proper abdominal and lower rib cage expansion while the chest remains still.
Clinicians should monitor the patient’s breathing rhythm to ensure that it is an ideal 1:2 ratio for inhalation and exhalation respectively. The ideal breathing cycle is three seconds of inhalation followed by six seconds of exhalation. Patients may be instructed to breathe in normally and then exhale through pursed lips in order to gradually increase the length of exhalation.
Training Proper Breathing Techniques
Training proper breathing techniques may begin with the patient in a supine hook-lying position, placing one hand on the abdomen and the other over the sternum. The patient should breathe in slowly and deeply through their nose. If the patient is breathing properly from the diaphragm, only the hand over the abdomen should rise, and the hand over the chest should remain still. Clinicians must stress the emphasis on abdominal expansion. Instruct the patient to lightly compress the abdomen while breathing in, followed by relaxation of the pressure while breathing out. The patient may apply light pressure to the lower lateral rib borders while inhaling and exhaling. The patient should practice two to three breaths hourly and 10-20 breaths upon awakening and retiring. Patients should “groove” proper breathing mechanics by practicing in a progressive fashion: first in a supine position, then seated, then standing, and finally, while performing dynamic movements (i.e. overhead squat).
Once the diaphragm is properly activating, rehab may progress to include other stability exercises. The ultimate goal of any spinal stability program is to re-train the CNS through repetitive exercise, to subconsciously maintain optimal centration and mechanics throughout activities of daily living, thereby reducing the risk of injury and improving performance. (56) Restoring spinal stability requires re-establishing a balanced co-activation of the diaphragm, pelvic floor, abdominals, and spinal extensors. Well-developed stability programs may decrease pain and improve trunk muscle function. (57-61) Specific exercises could include abdominal bracing exercises, planks, bird dog, and dead bugs. (41)
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