Luckily, breathing is an automatic action performed by the body that we don’t really have to think about too much. Breathing plays a key role in both posture and spinal stabilization. But just because it is automated, doesn’t mean that we will never have issues with breathing. In fact, a recent study demonstrated that 75% of the subjects being evaluated were considered to have a breathing dysfunction.
The primary muscles responsible for breathing are the diaphragm, intercostal (rib) muscles, scalenes, transverse abdominus, muscles of the pelvic floor and the deep intrinsic muscles of the spine. With normal inspiration, the diaphragm contracts and flattens, allowing air to enter the lung cavity. This causes the abdomen to expand, and leads to the lower ribs opening up in a bucket-handle motion. In normal breathing at rest you take 10-14 breaths per minute.
Breathing has 3 major functions:
- Add oxygen to hemoglobin in your blood
- Removes carbon dioxide from your lungs
- Maintain normal pH level in the blood
Why do things go wrong with breathing?
- postural stress
- chest and nose conditions affecting airways
- work environment
- fear, anxiety and depression
- liver or kidney disease
- lung or cardiac disease
- adrenal tumors
- hormonal issues
- sleep deprivation
- caffeine, nicotine, alcohol or drug use
- certain sports (gymnastics and dance)
Recruiting the accessory breathing muscles (upper trapezius, levator scapulae and SCM’s) is normal as physical demand increases and you require more oxygen for exercise. The accessory breathing muscles lift the chest wall in an upward direction to allow more air into the upper lobes of the lungs. The problem arises when the accessory muscles are active during normal, relaxed breathing. The faulty pattern of lifting up of the sternum vertically, instead of widening in the horizontal plane is called chest breathing. Chest breathing can lead to chronic neck strain and shoulder issues. At BTF, we see this pattern in many of our clients as they look as though they have been doing body building exercises focused mostly on their anterior neck musculature due to this faulty breathing pattern.
Expiration is the reverse as the passive, elastic recoil from the abdominal wall, rib cartilages and lungs pushes air out. Expiration is faulty when the breath is held and not fully exhaled, rib motion is reduced or paradoxical breathing occurs. Paradoxical breathing is when the abdomen is drawn in during inhalation and out during exhalation. This can result from chronic stress, severe lung disease like COPD, or simply result from the habit of holding the abdomen rigid in an attempt to have the appearance of a flat stomach!
What does normal breathing look like?
- Initiate in the abdomen, which would expand outward during inhalation and inward during exhalation.
- Have some degree of horizontal lower rib motion (even if slight).
- Have no lifting up motion in the upper ribs.
- Have no clavicular grooves.
Evaluation and treatment of breathing pattern disorders must be addressed, especially in the rehabilitation of chronic neck and back pain and many shoulder disorders. If breathing is not normalized, no other movement pattern can be. Breathing mechanics play a key role in both posture and spinal stability. If a breathing pattern disorder is present, the accessory respiratory muscles shorten and the diaphragm is unable to return to its optimal resting position. Patients with neck pain commonly have faulty breathing patterns. In order to address the patients neck pain, the altered length-tension relationship of the accessory muscles needs to be fixed by alleviating the breathing pattern disorder.
Observations of a Breathing Pattern Dysfunction:
- mouth/chest vs. nose/abdominal breathing pattern
- increased # of breaths per minute >14
- throat clearing, dry cough, yawns, sighs
- speech (rapid sentences/sentence endings tailing off)
Symptoms of a Breathing Pattern Dysfunction:
- neck, shoulder and low back pain
- fatigue, exhaustion
- inappropriate breathlessness or dizziness
- knees wobbly, heavy legs
- chest pains
- sweaty, clammy hands
Once you have a breathing pattern dysfunction, you need to spend time on retraining your breathing habits. There are 2 components to breathing pattern retraining. The first involves learning a new motor pattern to train the inspiratory muscles to be recruited in the optimal way. With practice, the new muscle firing pattern will become efficient and eventually automatic. This usually happens in the first 4-6 weeks of retraining if the breathing pattern is consistently applied. The two main techniques used in breathing pattern retraining are diaphragmatic breathing and pursed lip breathing.
Diaphragmatic breathing retraining requires a conscious effort of inspiring air to the lung bases with a slight forward abdominal displacement and is used to delay recruitment of the accessory breathing muscles and to encourage breathing at optimal lung volumes. Pursed lip breathing is taught to help elongate the expiratory phase of breathing to maintain an optimal inspiration to expiration ratio.
The second part of breathing retraining is more difficult as it involves re-programming the brain stem respiratory centers to respond to a higher level of carbon dioxide (CO2). The normal reaction of the body to a rising CO2 level is to increase the respiratory rate to bring the CO2 level back to normal. When a breathing pattern disorder is established, the CO2 level in the blood may be lower than normal due to hyperventilation. One aim of breathing pattern retraining is to decrease the respiratory rate to 10-14 breaths per minute. As a result, the level of CO2 will start to rise relative to the brain stem’s incorrect perception or “normal” and the appropriate but undesired response of trying to increase respiration is initiated. As a result, this second part of breathing retraining is more difficult to master.
A session of breathing retraining is broken into small groups of “correct” breathing, interspersed with comfortable breathing to build tolerance to the new CO2 levels. Be prepared to feel significant discomfort when trying to correct a dysfunctional breathing pattern. The good news is that once automatic breathing has been reprogrammed and causative factors like anxiety or postural factors have been addressed, no ongoing breathing intervention is necessary.
Breathing Retraining (10 minutes daily):
- lie on your back with both hands firmly on your chest
- 1st breath – breathe in through your nose, out through your mouth, pressing down on your upper chest as you breathe out, feeling the top of your chest deflate
- all the rest of breaths – keep firm pressure on your chest so that when you breathe you cannot move your chest, your abdomen will move up as you breathe in and fall as you breathe out, all breaths must be in and out of your nose
- use the 1-2-3-4 rhythm – breathe in for the count of 1, breathe out for the count of 2 and 3, pause for 4.
- initially start with 5 breaths in this rhythm then revert back to your comfortable breathing
- spend 10 minutes alternating between the correct 1-2-3-4 pattern and your comfortable breathing
- as you get more comfortable with the correct breathing pattern try to breathe for more breaths in a row until you can do 10 minutes with the correct rhythm
Breathing When Exercising:
- try to breathe into you abdomen for as long as possible
- at some point you might revert to breathing into your upper chest but try to delay this as long as possible
- when you breathe in think of sipping the air over your bottom lip
- when you breathe out blow the air over your bottom lip as if blowing out a straw
- try to keep your mouth opening as small as possible for as long as possible
Vickery, R. The Effect of Breathing Pattern Retraining on Performance in Competitive Cyclists. October 2007.
Bradley, H et al. Breathing Pattern Disorders and Functional Movement, IJSPT. 2014.
CliftonSmith, T et al. Breathing Pattern Disorders and Physiotherapy. PT Reviews. 2011.
Perri, M et al. Pain and Faulty Breathing. J of Bodywork and Movement Therapies. 2003.