We are all born with innate primal movement patterns that are built into our central nervous system and come as “standard equipment” with the gift and mystery of being human.
When we think of breathing we think of the respiratory system but what drives the mechanics and coordination of breathing patterns is motor activity or the neuromusculoskeletal system. Dr. Karel Lewit states that respiration is our most important movement pattern(2). It is also our most common faulty movement pattern!
As mentioned in part one of this article, the most important muscle in breathing is the diaphragm or Big “D”. This structure is intimately connected to the lumbar spine, gait and every neuromuscular function in the body. It’s activation especially during exhalation as well as inhalation determines the outcome of not only long term benefits of our chiropractic care but sport performance and overall wellbeing of our patients.
Assessing and correcting dysfunctions of breathing requires a precise application of exercises and manual therapies. This article will discuss some basic respiration dysfunctions and offer basic breathing awareness and exercises for your patients.
A good starting place is to have your patient in a standing or supine position. To start, have your patient stand in front of a mirror and watch their breathing. Do they mouth breathe? Do their stomachs and thorax move horizontally during inhalation or do their collarbones and shoulders moving vertically during inspiration with little expiration at al? Do their SCM’s bulge out like a body-builder as they take a simple breath? Ask them what they see and feel.
When you examine your patient ask them to “take a slow, relaxed, full breath in” vs. “take a deep breath in”(1). This subtle but important cue will provide a more accurate assessment to determine the patient’s most common automatic pattern. Of most importance is having them exhale completely for full diaphragmatic activation.
According to Maria Perri, the first thing to notice is if they breathe with their mouth open. Mouth breathing reduces the pharyngeal air space and patients will compensate by using accessory muscles of respiration. Mouth breathers tend to lean forward with head and shoulders which can cause neck and upper thoracic structural dysfunction. Mouth breathing can also disrupt pH balance of the blood often making it too alkaline. Alkalosis in some individuals can lead to apprehension, anxiety and even panic attacks(1). This pattern of alkalosis can also be associated with chronic pain conditions.
One of the most important dysfunctions described by Travell is erroneous paradoxical breathing and can be observed with the patient in a supine position. During inspiration with only mouth breathing, the abdomen is drawn in while the chest is pushed out. A normal or functional pattern is drawing air in through the nose and mouth equally with abdomen and chest moving out together (horizontally in relationship to patient’s body) and then exhaling through the nose and mouth with abdomen and chest moving in the opposite direction.(6) This chronic problem can have a number of causes including stress, injury, repetitive postural habits or chronic obstructive pulmonary disease. One cause is cultural stemming from an attempt to have a flat stomach! Paradoxical breathing, in addition to vertical breathing, is a common cause of not only lumbar pain and spinal dysfunction but anxiety and incontinence as well(1,5).
Several muscles used for postural control and respiration are the same. Maintaining optimal posture and stability while breathing, especially under load or during athletic participation is not only important but can be a real challenge for many individuals. (7)The inability to brace the abdomen to stabilize the spine and breathe normally is a primary respiratory fault. Given the chance, the CNS will prioritize breathing over spinal stabilization leaving the musculoskeletal system vulnerable to injury(1,4).
Another important breathing fault to observe is if the patient is “vertical” breathing or lifting the collarbones, shoulders and upper thorax with inspiration instead of “horizontally” moving the abdomen and chest during inhalation then drawing the abdomen back in during exhalation. This chronic and repetitive pattern gets ingrained or “grooved” in the CNS and can be linked to cervical pain, headaches, shoulder pain and lumbar spine instability. Keep in mind that if the lower ribs especially on the left side flare out then this is an indication of weak abdominal wall control and diaphragm dysfunction.
If any of these signs are present, have them lie supine with knees bent on your table and put one of their hands just above their umbilicus and the other on their chest. Their throat and shoulder muscles are completely relaxed as they push their lower hand with their stomach straight up towards the ceiling letting the air fill their lungs. Of most importance is that they exhale completely and hold for three seconds before they inhale again. Exhaling fully is something few people do and as a result do not activate the diaphragm completely.
One way to help them exhale completely and more fully activate their diaphragm is to have them lay supine on the ground or on a table with their knees bent. Then have your patient flatten their back as they depress their xiphoid down with their abdomen muscles as they breathe out fully. As they inhale, ask them to maintain that position of the xiphoid with their abdomen muscles as they inhale thereby resisting the ribcage to flair up, especially on the left side. You can assist with gentle pressure upon exhalation on the lower sternum to aid in maintaining this rib cage and chest position then maintain gentle pressure as they inhale using the muscles in the abdomen. Ultimately, one of the goals is to restore the “dome” shape or “Zone of Apposition” of the diaphragm, especially on the left side while keeping the anterior ribs down with the ability to open the ribs in back with inhalation.(8)
Another way to help with vertical and/or paradoxical breathing dysfunction is called “crocodile breathing”. A good visual is to imagine a “croc” on the river bank sunning themselves with just movement of their abdomen and in and out.
Have the patient lie prone on the ground with forehead on top of their crossed hands. The doctor places one hand on patient’s upper back and the other on the lower back. Instruct the patient to breathe in while they press their navel into the ground. You should feel a gentle rising of their lower back and thoracic spine. Pressing the navel into the ground gives the patient a kinesthetic sense of what their abdomen needs to do as they draw in a breath while pushing their abdomen then chest into the ground.
When a patient can breathe functionally in a supine, prone, kneeling, half-kneeling, seated and standing position, then they can progress to functional activities while practicing breathing. With every step of difficulty in a position or activity many patients will revert to a tense and dysfunctional pattern. Simply reduce the challenge, re-cue and remind them how to breathe.
Every patient with breathing dysfunction needs to be given simple homework. At home or during their warm-up at the gym, have them “crocodile” breathe on the floor between sets of exercise. During the day, have them check in with themselves and their breathing. If they are tense, do they notice they are shallow chest breathers or can they remember to create relaxation with deep abdominal respiration through their nose and then full exhalation? At night as they go to sleep, have them lie on their back with one hand on chest and abdomen and breathe feeling their stomach rise as they gently inhale.
Breathing is something most of us take for granted and because it is so seemingly basic and automatic it is easy to pass over to more exotic correctional strategies. Breathing is the most critical movement pattern in the treatment of not only spinal stability and musculoskeletal pain, but chronic fatigue, anxiety and even asthma(9).
In the next article I will be talking about the diaphragm and what makes it perhaps the most important muscle of the body.
- Craig Liebenson, D.C. Rehabilitation of the Spine, Second Edition, Lippincott Williams and Wilkins, Chapter 17, Perri, M., Rehabilitation of Breathing Pattern Disorders, Page 376-386
- Faulty Movement Patterns Seminar and Workbook, Craig Liebenson, D.C., March 2012 Seminar Notes
- Functional Movement Screen II Course Notebook, Brett Jones and Gray Cook, Pg. 7
- McGill SM, Sharratt MT, Sequin JP. Loads on the spinal tissues during simultaneous lifting and ventilator challenge. Ergonomics 1995;38:1772-1792
- Smith, M.D., Russell, A., & Hodges, P.W. (2006). Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust. J Physiother, 52(1), 11-16
- Travell JG, Simons LS: Myofascial pain and dysfunction, the trigger point manual, upper half of body, Baltimore, Williams & Wilkins, 1999
- Boyle, Olinick, Lewis, The Value of Blowing Up a Balloon, NAJSPT. Volume 5, Number 3, Sep. 2010, Page 179
- Hruska,R. Postural Respiration Institute, Zone of Apposition Paper: ZOA Position and Mechanical Function
- Coughlin, K, Hruska,R, Madek,J Cough-Variant Asthma: Responsive to Integrative Management and Postural Restoration, Explore Sep. 2005, Vol. 1, No. 5
Robert “Skip” George, D.C. owns La Jolla Sport and Spine/Optimum Fitness and Health in La Jolla, California where he integrates chiropractic, rehabilitation and sports performance training. He is a fully certified FMS and SFMA provider as well as a Functional Movement Screen instructor. He can be reached at Dr.George@SBCGlobal.net and Facebook: La Jolla Sport and Spine.