Breathing influences low back pain
We have all used or been told to use stabilization exercises to treat low back pain. While many people will improve with physical therapy, we too frequently experience recurrences of back pain, requiring more physical therapy or pain medications.
Several studies have demonstrated the role of respiration on postural stability. In one such study, individuals with low back pain were compared to pain-free subjects during an active straight leg raise, an exercise that requires core control. Real-time ultrasound was used to examine the activity of the diaphragm and the pelvic floor. The subjects with low back pain demonstrated an increase in respiratory rate, a greater descent of the pelvic floor, and decreased diaphragmatic excursion compared to their pain-free counterparts.
These results indicate that subjects with low back pain had to work harder to breathe during a core control activity, but they used their diaphragm less. As a result, they likely overused their accessory breathing muscles and they did not use their diaphragm for core stability. Additionally, the increase in respiratory rate indicates that sympathetic activity and stress increased as well.
This is a perfect storm for pain and decreased postural stability.
The result? Low back pain.
Similar results were found in a study that examined diaphragmatic activity during upper and lower extremity isometric activities with external resistance. Individuals with low back pain presented with smaller diaphragmatic excursion than pain-free control subjects during the resistance exercises.
Essentially, the subjects with low back pain were not using the diaphragm to its fullest potential. They were therefore more vulnerable to decreased core control and resultant low back pain. Collectively, these results highlight the role of breathing in physical therapy and call for stabilization interventions that involve the diaphragm.
In order to achieve optimal core stabilization, the diaphragm must be simultaneously involved in respiration and postural stability. Individuals who are limited in their ability to contract the diaphragm for stabilization have a higher risk of developing back pain.
Breathing dysfunction restricts mobility
Inefficient breathing patterns are often closely linked to mobility restrictions. If you present with a mobility limitation anywhere from the neck to the pelvis, we should consider the possibility of a breathing dysfunction.
Many clients who present with head, neck, and shoulder pain are likely suffering from accessory respiratory muscle overuse. We need to retrain breathing in physical therapy in order to decrease accessory muscle overload and increase activation of the diaphragm.
Inefficient breathing patterns may also restrict the rib cage or thoracic spine or decrease general flexibility. In order to improve joint mobility, range of motion and/or flexibility, we may need to calm the nervous system down with breathing in physical therapy. The parasympathetic nervous system will allow our muscles to relax, whereas the sympathetic nervous system causes them to contract. By learning how to slow down breathing, prolong exhalation, and breathe through their diaphragm, we can increase flexibility.
Breathing determines movement patterns
In order to achieve optimal movement patterns, we need a stable core from which our muscles can generate movement. Lumbar and pelvic stability depend on coordination between the diaphragm, pelvic floor, and transverse abdominis. These muscles activate prior to purposeful movements in order to establish a stable base. This allows for optimal load transference along the entire kinetic chain and minimizes stress on passive structures, such as ligaments, joint capsules, and joint surfaces.
Failure to coordinate the core stabilizers with the regulation of intra-abdominal pressure makes it difficult to efficiently transfer force from the trunk to the extremities. If we can't properly activate the diaphragm during a simple activity, like an active straight leg raise, then we are certainly not recruiting it properly when kicking a soccer ball or performing a squat. This impairs both our core stability and the resultant movement patterns. If we send our patients back to sports or complex activities without having assessed and treated their breathing in physical therapy, then we have left them vulnerable to re-injury.
Breathing changes pain perception
People with chronic pain benefit from exercises that induce relaxation. Since deep breathing calms the nervous system, it will help decrease the stress response associated with pain.
Patients with chronic pain may have an up-regulated nervous system in which there is an increase in sympathetic activity. This increases their sensitivity to touch and heightens their perception of pain. Deep breathing will mediate sympathetic arousal and increase pain thresholds. By teaching patients how to diaphragmatically breathe, we can increase parasympathetic activity, thereby inducing relaxation and decreasing the pain response.
Additionally, dysfunctional breathing may predispose individuals to faulty muscular adaptations, resulting in chronic musculoskeletal pain. For example, people who overuse their neck to breathe will be more susceptible to neck pain. Similarly, weakness in the diaphragm and pelvic floor can lead to overuse of compensatory muscles and result in chronic low back pain. By addressing breathing in physical therapy, we can restore muscle balance and decrease pain.
Assessment of breathing patterns
A breathing assessment is an often overlooked component of an orthopedic physical therapy examination. However, breathing is the foundation of stability and normal movement patterns. Therefore, a breathing assessment should be a basic starting point for all orthopedic evaluations.
When assessing breathing, we must the first rule out structural problems, such as airway obstructions or a deviated septum. For example, before posture can be addressed, we should make sure that they are not standing that way due to an anatomical obstruction. Treatment of these respiratory health problems are beyond our scope of practice and will require referral to another specialist.
After we clear anatomical obstructions, we can examine breathing pattern itself. The easiest way to do this is by lying supine and placing one hand on the stomach and the other on the chest. If you are diaphragmatically breathing, you will see more movement through the stomach and less movement in the chest. If you are an apical breather, you will see minimal movement through the abdominal wall and excess movement through the upper chest. Also take note of the rate of breathing. Is the breathing slow or rapid? Are the inhalations longer than the exhalations?
There are of course more in-depth methods of examining breathing in physical therapy, but this is all that will fit in this blog post.
Re-training breathing in physical therapy
Breathing can be an essential tool in the treatment of musculoskeletal dysfunction. However, like any intervention, breathing re-training should not be done in isolation. Breathing dysfunction may be the cause, or result of, your primary complaint. Therefore we should coordinate mobility and strength interventions with breathing in physical therapy.
When first instructing diaphragmatic breathing, it is easiest to lay supine on a mat or plinth. Place one hand on the stomach and the other on the chest in order to compare the excursion of both areas. During diaphragmatic breathing, you should feel the stomach rise and fall and the lower rib cage should expand laterally. There should be minimal movement through the chest.
While practicing diaphragmatic breathing, watch for compensation of spinal extensors (excess lumbar lordosis) as well as overuse of the rectus abdominis. Also, make sure that you do not revert to the old patterns by using accessory respiratory muscles of the chest and neck. This can happen with fatigue.
After mastering simple corrective breathing exercises, proper breathing should be incorporated into functional activities. When participating in complex activities, like running, there are increased demands for stability and respiration.
Start breathing in physical therapy today
Breathing is the root of all movement. We must therefore respect the role of breathing in physical therapy. By incorporating breathing into our assessment and treatment of musculoskeletal impairments, we can improve outcomes and increase the likelihood of lifelong recovery.
