By: Anthony C. Distano, M.S., D.C., C.S.C.S.
Breathing is the process that moves air in and out of the lungs for the purpose of delivering oxygen to tissues in exchange for carbon dioxide. The centers for the motor engram of breathing are located in parts of the brain stem, the medulla oblongata and the pons and are under the control of the autonomic nervous system. More specifically, these centers are referred to as the pneumotaxic center, the apneaustic center, and the dorsal and ventral respiratory groups. Breathing, although essential for living, can be detrimental to the spine if the motor engram for breathing is dysfunctional. Alterations in the motor engram for breathing may occur as a result of pain, poor posture, poor nutrition, stress, or anxiety. In the presence of breathing pattern dysfunction in patients with spine pain, rehabilitation of the spine, upper or lower quadrants alone may be unsuccessful or short lived unless the breathing pattern is also normalized.
A MISSING LINK IN SPINAL REHABILITATION
Clinicians involved in spine rehabilitation are well aware of the presence of overactive and/or shortened muscles, weak or inhibited muscles, altered motor control, and decreased muscular endurance in spine pain patients. Clinicians who are thinking outside the box realize that the site of pain may not be the cause of pain and will perform a functional examination of the entire upper and lower quadrants, in addition to the spine, to uncover a weak link to be targeted in the rehabilitation program. An overlooked component of the functional examination may be the assessment of breathing patterns.
A normal breathing pattern is essential for the maintenance of spine stability. Inherently, the rehabilitation of dysfunctional breathing patterns is paramount in spine rehabilitation. Assessment of breathing patterns is quick and easy and can be achieved in a relatively short period of time, starting from the initial subjective examination of the patient. The information gained from assessing breathing patterns is invaluable and could play a major role in the rehabilitation of spine pain patients.
THE RELATIONSHIP BETWEEN BREATHING AND SPINAL STABILIZATION
The diaphragm, scalenes, transverse abdominis, pelvic floor and deep intrinsic spinal muscles are among the primary muscles of breathing. The sternocleidomastoid and upper trapezius are accessory muscles that get recruited when respiration demands are increased. The latissimus dorsi, pectoralis major and pectoralis minor are not typically thought of as accessory muscles of breathing, but may be recruited in the faulty movement pattern of paradoxical breathing (the abdomen moves in on inspiration and out on expiration).
A complex interplay exists between the diaphragm, transverse abdominis and pelvic floor during normal quiet breathing. During normal quiet inhalation the diaphragm contracts and descends towards the abdomen. This causes a decrease in intra-pleural pressure and increase in intra-abdominal pressure. The increased intra-abdominal pressure causes an outward expansion of the abdomen. The transverse abdominis and pelvic floor work synergistically with diaphragm to increase intra-abdominal pressure. As the diaphragm continues to contract and descend, its attachment to the lower ribs causes the lower ribs to begin to expand horizontally. The horizontal expansion of the ribs proceeds rostrally, providing a gentle mobilization to the spine and ribs at every level. A dysfunctional breathing pattern existed when there is decreased, asymmetrical or absent lateral rib excursion. This is indicative of an inhibited diaphragm. As a result, normal rib and spine motion is lost and spine stabilization is compromised. Recurrent or chronic thoracolumbar pain may be the end result of an inhibited diagram in this example of dysfunction.
The scalenes play a crucial role in stabilizing the rib cage during inhalation. The scalenes were once thought to be an accessory muscle of breathing. It is now understood that they are active at a low level with every breath. As intra-pleural pressure decreases, the scalenes along with the parasternal muscles contract to prevent inward movement of the upper ribs during inhalation. This creates a horizontal expansion of the upper ribs and sternum. The dysfunctional breathing pattern of chest breathing (vertical elevation of the upper ribs, sternum, or clavicles) is indicative of over activity of the upper trapezius, scalenes, and/or levator scapulae. If chronic, deep supraclavicular grooves may be observed. This dysfunctional breathing pattern may be a cause of repetitive stress and overload to pain sensitive structure of the cervical spine. Also, vertical elevation the rib cage may cause thoracolumbar pain due to repetitive hyperextension of the thoracolumbar junction that occurs as the rib cage is vertically elevated with each breath. Normal quiet exhalation is the exact opposite and involves passive elastic recoil of the ribs, lungs and abdomen. A dysfunctional breathing pattern during exhalation exists if breath holding occurs and air is not fully exhaled or paradoxical breathing occurs.
EVALUATION OF BREATHING PATTERN DYSFUNCTION
As previously stated, evaluation of breathing pattern dysfunction begins during the subjective examination of the patient. It is essential to avoid informing the patient that his or her breathing pattern is being assessed. This may alter the patient’s stereotypical motor engram for breathing and give the clinician a false positive. Simple observations such as frequent yawning, rapid or labored breathing, nasal flaring, mouth breathing, tension in the face lips or jaw, shoulder elevation on inspiration, and altered respiratory rate are indications that a dysfunctional breathing pattern may be present. In addition, the presence of deep supraclavicular grooves, gothic shoulders, upper or lower cross syndrome, thoracolumbar hypertonicity are all compensations that may occur in the presence of a dysfunctional breathing pattern. Formal assessment of the breathing pattern should be performed in the standing, seated and supine position.
The following is a list of key findings indicative of a dysfunctional breathing pattern:
- Breathing is initiated in the chest during inhalation
- Chest breathing predominates over abdominal breathing during inhalation. This finding is best assessed in the supine position, as the postural role of the abdominal muscles is eliminated. Chest breathing can be assessed visually or manually by the clinician placing one hand on the chest of the patient and one hand on the abdomen of the patient during normal quiet breathing. Alternatively, the clinician can ask the patient to place his or her hands on the chest and abdomen as previously described while the clinician observes the breathing pattern
- Decreased, absence or asymmetrical lateral excursion of the lower ribs. This finding is best assessed in the seated position. The clinician stands behind the patient and places his or her hands on the lateral borders of the lower ribs of the patient during normal quite breathing.
- Vertical elevation of the upper rib cage, sternum, and/or clavicles during inhalation
- Paradoxical breathing
One or more of these findings may be present. In addition to assessment in the standing, seated and supine positions, it is also important to observe the patient’s breathing pattern during manual muscle testing or during a functional movement (such as the overhead squat). A patient may display a normal pattern of breathing when assessed standing, seated and supine, however, when a patient is presented with a challenge the aberrant breathing pattern may be revealed.
REHABILITATION OF BREATHING PATTERN DYSFUNCTION
Besides poor posture, stress, anxiety, or poor nutrition, breathing pattern dysfunction can result from sinister pathology. If breathing pattern dysfunction is found, the clinician must first rule out underlying pathology contributing to the etiology of the dysfunction. If an underlying pathology is suspected, a referral to the appropriate specialist must be made before beginning breathing pattern rehabilitation.
Once underlying pathology is ruled out, breathing pattern rehabilitation may begin. The following is a suggested protocol for breathing pattern rehabilitation:
- Educate the patient on the relationship between an altered breathing pattern and repetitive stress and strain to the spine.
- Suggest spine sparing strategies such as the Brugger relief position and McGill’s overhead reach to improve posture and facilitate normal breathing mechanics.
- Allow the patient to experience his or her breathing dysfunction. This can be done by having the patient observe his or her breathing in a mirror and by having the patient manually palpate the dysfunctional pattern of chest breathing, aberrant lateral rib excursion, and/or vertical deviation of the upper ribs, sternum or clavicles.
- Provide a visual demonstration of normal breathing mechanics. This can be demonstrated fairly easily and effectively with a balloon. Emphasize to the patient that as air enters the balloon, expansion of the balloon begins from the bottom and proceeds upward as the balloon expands from both front to back and side to side. Also, if possible, demonstrate the anatomy of the spine and ribs on a skeleton to re-enforce the anatomy involved in the process of breathing that was described during the balloon demonstration. This allows the patient to visualize what the lungs and rib cage should be doing during normal breathing and provides the patient with an improved and accurate cortical representation of normal breathing mechanics. Visualization is an invaluable tool in rehabilitation.
- Retrain the dysfunctional breathing pattern. One or more of the key findings associated with a dysfunctional breathing pattern may have been identified in the assessment. Each of findings may initially require separate rehabilitation and then must be integrated together into a normal breathing pattern. Techniques can be used to help to facilitate the diaphragm and lateral rib excursion.
- If chest breathing initiates or predominates during inhalation: place the patient in the supine position with feet flat on the table, with 45 degrees of hip flexion and 90 degrees of knee flexion. Instruct the patient to place both hands on the abdomen. As the patient inhales, instruct the patient to exert a slight pressure on the abdomen with both hands. As the patient exhales, instruct the patient to relax the pressure on the abdomen.
- If there is a decrease, asymmetrical or absence of lateral rib excursion during inspiration: place the patient in the supine position with feet flat on the table, with 45 degrees of hip flexion and 90 degrees of knee flexion. Instruct the patient to place both hands on the lateral border of the lower ribs. As the patient inhales, instruct the patient to exert a slight pressure on the lateral border of the lower ribs with both hands. As the patient exhales, instruct the patient to relax the pressure on the lateral border of the lower ribs. This can also be accomplished by tying elastic tubing around the lateral border of the lower ribs.
- If vertical elevation of the upper ribs, sternum, and/or clavicles is present during inhalation: place the patient in the supine position with feet flat on the table, with 45 degrees of hip flexion and 90 degrees of knee flexion. The patient is then instructed to place both hands behind the head interlocking the fingers with 90 degrees of shoulder abduction and external rotation. If in addition to vertical elevation of the upper ribs, sternum, and clavicle, chest breathing and/or altered lateral rib excursion is also present, the clinician may then manually facilitate the diaphragm and/or lateral rib excursion using the same instructions described above.
- Once a normal pattern of breathing is established, the next step is to focus on the breathing rhythm. Initially, instruct the patient to gradually increase the length of exhalation relative to inhalation. The patient can be instructed to exhale with pursed lips (visualize blowing out of straw) to decrease exhalation time. An ideal goal is to achieve 3 seconds of inhalation followed by 6 seconds exhalation (1:2 ratio) during breathing pattern rehabilitation.
- Practice the normal breathing pattern and rhythm in a seated, then standing position. Eventually, integrate the new breathing pattern while performing spinal stabilization exercises.
- Prescribe home breathing exercises for the patient. Have the patient perform 2-3 breaths every hour the patient is awake and 10-20 breaths upon awakening in the morning and before bed. Instruct the patient to perform the breaths with the newly learned pattern of breathing along with the 1:2 ration of inhalation to exhalation as previously described. Instruct the patient to stop the exercises if they feel weakness, dizziness or light headedness.
The importance of rehabilitating breathing pattern dysfunction to aid in the rehabilitation and restoration of spine stability cannot be overstated. The same muscles that are weakened, inhibited or facilitated in spine pain patients can become dysfunctional if a patient’s breathing pattern is dysfunctional. Spine pain can lead to changes in the breathing pattern of the patient, conversely altered breathing patterns can cause a repetitive stress and overload to pain sensitive structure in the spine. In the presence of breathing pattern dysfunction in spine pain patients, rehabilitation of the spine, upper or lower quadrants alone may be unsuccessful or short lived unless the breathing pattern is also rehabilitated and normalized.
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