Part I of this series dealt with breathing anatomy and mechanics. Knowledge and understanding of the anatomy and mechanics of breathing is essential for a proper assessment and intervention. This post will expand on the previous post and go over some indications, assessment, and intervention for breathing.
So what type of patients do breathing mechanics apply to? Pretty much anyone that moves or breathes.
Seriously though, you should strongly consider breathing mechanics in all of your patients. Even if it isn’t the main culprit of their dysfunction, it might help return them back to optimal functioning.
Some more specific examples:
- Spine, Hip, and Shoulder Dysfunction
- Postural Faults
- High-Threshold Patterns
- Impaired Neurodynamics
- Psychological (apprehension, anxiety, central sensitization)
To keep it simple, you want to visually observe their posture and how they mechanically breathe. Compare this to an ideal breath and look for any signs/symptoms of dysfunctional breathing. Assess this in various postures (supine, seated, standing) and movements. The patient doesn’t need to know. In fact, I find it better if the patient isn’t aware. If you do find a patient with a breathing dysfunction you can then go into a more detailed assessment with palpation techniques (discussed under dysfunctional breathing).
Sure, you can make it more complicated by assessing breath holding times, questionnaires, and spirometry. However, this puts the patient through unnecessary discomfort and may affect your rapport. They walked into your clinic because they’re having back pain, not because they want to talk about their breathing patterns and blow into some device.
It’s important to note that there is a great variance in breathing patterns. Therefore it is difficult to create a protocol and thorough checklist for an ideal breath. However, there is alot of evidence for dysfunctional breathing. So it may be more clinically efficient to look for dysfunctional breathing rather than ideal breathing patterns.
The ideal breath is a smooth, segmental, 3-dimensional motion. During inspiration there is abdominal distension (circumferentially) and a postero-lateral lower ribcage expansion. During expiration there is contraction of abdominals and pelvic floor that returns the ZOA to an optimal position as evident by a depressed sternum and IR of ribs (no anterior ribflare).
Overall what you’re looking for is the inspiratory cascade of events that leads to controlled increased intra-abdominal pressure and proper muscle activation. On the exhale you want to see adequate expiration of air with no signs of hyperventilation.
What you never want to see is excessive accessory muscle activation, disproportionate shoulder movement, T-L junction hinging, or vertical ribcage movement. Other signs include: mouth breathing, frequent sighs/throat-clearing, rapid and/or shallow breathes, and asynchronous breaths
Paradoxical breathing is a common breathing dysfunction. This is when the patient inhales and there is a vertical and posterior motion of the ribcage and a hollowing of the abdominal cavity.
One of the biggest signs of dysfunctional breathing is lack of postero-lateral expansion of the lower ribcage. This can be assessed using the MARM (Manual Assessment of Respiratory Motion). Research has shown that the MARM can be be a useful assessment for dysfunctional breathing. This test is simply performed by having the patient seated and facing away from you. You place your fingers on the lower lateral ribcage and align your thumbs with the spine. Then have the patient breath naturally while you assess for the postero-lateral expansion of the lower ribcage. Patrick Ward performs a similar technique in this video around 3:15.
This section is purposefully placed between assessment and intervent because it essentially both. A high-threshold strategy is when an individual performs a task using excessive activity/tone in global musculature in a compensatory or protective manner. Gray Cook has described it as when “the body is splinting instead of stabilizing”. One of the major signs of this strategy is dysfunctional breathing patterns.
An example of this is when you give a patient an exercise that is too difficult for them. They start to hold their breath and squeeze every muscle they have. A patient won’t be able to perform a proper breathing pattern if they are using a high-threshold strategy.
So how do you use this to your advantage? You can use breathing assessment throughout all of your interventions to verify that the patient is not using a high-threshold strategy to perform the task.
There are many ways to treat breathing dysfunctions. Which rabbit hole you go down depends on your patient and what they need.
However, the first place to start for everyone should be from an educational stand-point. It is advantageous to explain to the patient why breathing is important to them specifically (use knowledge from Part I). Then you should teach the patient about dysfunctional breathing and what you expect for a proper breath. To avoid overcomplicating this, I usually simply give the patient a cue that has them focus on the circumferential lower ribcage and abdominal distension.
Some example cues I’ve heard and used: “breath into your lower ribs and abs”, “breath into an imaginary belt around your stomach”, “breath down and out”, “inhale into a balloon inside your stomach”, “push your breath down”, “expand your ribs out with your breath” etc. The possibilities are endless.
You can also use tactile cues. Put your hands or a theraband around their lower ribcage to increase sensory afferent input. Then have them to breath into the resistance of your hands/theraband.
For patients who have great difficulty with this or use paradoxical breathing patterns you may need to start simple. I usually start with a simple progression of hi-lo breathing, lateral expansion breathing, and finally a combination of the two for an “ideal breath”. It’s important to educate them and have them feel the difference in their hands and their body. As the patient gets comfortable you can cue the patient to breath in through the nose and out through the mouth, exhale longer than the inhale, and try to expire all of their air.
Other biomechanical interventions can be separated into mobility and stability categories. Part I focused on the stability aspect of the inspiration, but it can also be used for mobility (yoga has been doing this for thousands of years).
Much like ligament locking for joint mobilization/manipulation, the breath can be directed by altering postures and positions. Leslie Kaminoff describes breathing as the act of “shape changing”. Using this theory you can alter your posture to direct the where the breath (“shape change”) occurs. It’s physics. The shape change from inspiration (expansion) will always go towards the place of least resistance.
For example, if a patient has a restricted R posterior lumber quadrant, then you would put them in a childs pose reaching contralaterally with their R UE. Since you closed off the L side by laterally sidebending/flexing and closed off the anterior R rib cage by flexing, the only place for the shape change to occur would be into the R posterior quadrant. You can further increase the expansion (stretch) into this area using tactile or verbal cues to get them to breath into the postero-lateral R rib cage.
Another mobility aspect of breathing is it’s amplification of the parasympathetic NS. This can be very advantageous when performing manual techniques or corrective exercises to increase tissue extensibility. Muscle guarding and reflexive activation can be minimized by focusing on breathing.
As mentioned before with the high-threshold strategies, simply having your patient breath properly during exercises will help establish proper inner core stabilization. One important consideration is that you must simultaneously monitor their posture. You always want a neutral spine. Performing a task with an anterior pelvic tilt not only causes compensatory mechanisms, but it prevents proper breathing mechanics (decreased ZOA, decreased eccentric abdominal & PF contraction).
Again, the guy with a positive scour sign, hip impingement, and anterior pelvic tilt doesn’t want to hear about breathing. He just wants his hip to stop hurting so he can get back to golfing. So instead of going into too much detail about the mechanics of breathing or working on isolated breathing exercises, simply have your patient breath with a neutral spine during all their exercises. It’s a great place to start and ensures that the patient is performing the exercise with the correct musculature.
Since I have learned about the importance of breathing I no longer time my patients with a stopwatch. I now have everyone counting their breaths (i.e. holding quadruped diagonals for 7 breathes instead of 30 sec).
For advanced patients you can progress to “breathing behind the shield”. This is a term coined by the great Pavel Tsatouline. It’s a great way to incorporate breathing with core stability. It describes the act of maintaining abdominal tension while breathing. “Breathing behind the shield” is the balance of controlling intra-abdominal pressure and abdominal & pelvic floor muscle tone. It displays that the patient is able to use the diaphragm’s dual function: respiration and stabilization.
Hans Lindgren has an amazing video on assessing and interventions for breathing and core stability. At about 2:10 into the video he goes over a great technique to help you teach your patients how to “breath behind the shield”. This is a great place to begin and can be progressed through the developmental sequence.
There are many ways to assess and treat dysfunctional breathing patterns. Hopefully this article will give you a good place to start. Below are some great articles, videos, and descriptions of breathing patterns. As with every intervention, it is important to master this yourself before you try to teach your patient.
Simple Exercise – Crocodile Breathing
Tom Myers & Leslie Kaminoff. The Breath in the Pelvis – Seminar (NYC 2012).
Courtney R,Reece J (2009). Comparison of the Manual Assessment of Respiratory Motion (MARM) and the Hi Lo breathing assessment determining a simulated breathing pattern. International Journal of Osteopathic Medicine.
Courtney R (2009). The functions of breathing and its dysfunctions and their relationship to breathing therapy. International Journal of Osteopathic Medicine
Courtney R (2011). Dysfunctional Breathing – It’s paramaters, measurement and relevance. Thesis RMIT University. (a must read – click here)
Kaminoff L. (2006). “What yoga therapists should know about the anatomy of breathing.” International Journal of Yoga Therapy.
McLaughlin L. (2009). “Breathing evaluation and retraining in manual therapy.” Journal of Bodywork and Movement Therapies.
McGill S , Sharratt M ,Sequin J P. (1995). “Loads on spinal tissues during simultaneous lifting and ventilatory challenge.” Ergononomics.
Janssens L , Brumagne S, Polspoel K, Toosters T, McConnell A. (2010). “The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain.” Spine.
Hodges P , Heijnen I, Gandevia S C. (2001). “Postural activity of the diaphragm is reduced in humans when respiratory demand increases.” Journal of Physiology.
Hodges P , Butler J ,Mackenzie D K, Gandevia S C. (1997). “Contraction of the human diaphragm during rapid postural adjustments.” Journal of Physiology 505(Pt. 2
Wang S., McGill S (2008). Links Between the Mechanics of Ventilation and Spine Stability. Journal of Applied Biomechanics.
McGill S, Sharratt M & Seguin J (1995). Loads on the spinal tissues during simultaneous lifting and ventilatory challenge. Ergonomics.
Robey J, Boyle K (2009). Bilateral Functional Thoracic Outlet Syndrome in a College Football Player. N Am J Sports Phys Ther.
Boyle K, Olinick J, & Lewis C (2010). The value of blowing up a balloon. N Am J Sports Phys Ther.
Kolar P, Sulc J, Kyncl M, et al. (2010) Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol.
Kolar P, Sulc J, Kyncl M, et al. (2012). Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. JOSPT.
Hagins M, Lamberg EM (2011). Individuals with low back pain breathe differently than healthy in- dividuals during a lifting task. JOSPT.
Clifton-Stmith T, Rowley J (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession. Physical Therapy Review.
Hruska R (2005). ZOA Position & Mechanical Function. Postural Restoration Institue.
Cook, Gray. Movement: Functional Movement Systems : Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010.
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