BREATHING PATTEREN BREATHING PATTEREN DISORDERSDISORDERS

A Multidisciplinary ApproachA Multidisciplinary Approach

It is relatively easy to observe and discern whether your patient’s breathingis functional or dysfunctional.

How Does It Begin?How Does It Begin?

An emotionally stressful period often An emotionally stressful period often produces an altered breathing produces an altered breathing pattern, in which diaphragmatic pattern, in which diaphragmatic function is reduced and an anxiety function is reduced and an anxiety linked upper-chest pattern evolveslinked upper-chest pattern evolves

At first, this response is a physiologically normal adaptation to an acute/alarm situation—the sympathetically driven fight-or-flight response.

If, however, the stress is prolonged and/or repetitive, the subsequent changes (not just the breathing ones) are likely to become chronic, as the adaptation phase of what has been called the GeneralAdaptation Syndrome (GAS) develops.

ALL ACTION NEEDS ALL ACTION NEEDS BREATHINGBREATHING

Dysfunctional Dysfunctional breathing results in breathing results in an inefficient degree an inefficient degree of spinal support of spinal support from the respiratory from the respiratory diaphragm and diaphragm and leads to increased leads to increased pressure on the pressure on the stomach leading to stomach leading to hiatel hernia and hiatel hernia and GERDGERD

Upright Paradoxical Breathing Upright Paradoxical Breathing AssessmentAssessment

Palpate the abdomen, with the person Palpate the abdomen, with the person seated, inhale deeply.seated, inhale deeply.

Does the abdomen (slightly) bulge on Does the abdomen (slightly) bulge on inhalation? inhalation?

If yes, this is normal.If yes, this is normal. In some instances, breathing is so In some instances, breathing is so

faulty that the abdomen is drawn in on faulty that the abdomen is drawn in on inhalation and pushed outward on inhalation and pushed outward on exhalation—further evidence of a exhalation—further evidence of a paradoxical pattern.paradoxical pattern.

Scalene Overactivity Scalene Overactivity EvaluationEvaluation

Rest your hands over the upper-shoulder area, finger pads Rest your hands over the upper-shoulder area, finger pads lightly resting on the superior aspect of the clavicles.lightly resting on the superior aspect of the clavicles.

On inhalation, do the SHOULDERS rise?On inhalation, do the SHOULDERS rise? Does either clavicle rise on inhalation?Does either clavicle rise on inhalation? Neither the clavicles nor your hands should rise, except Neither the clavicles nor your hands should rise, except

on maximal inhalation, if the individual is breathing on maximal inhalation, if the individual is breathing diaphragmatically.diaphragmatically.

If any of these palpated structures do move, scalene If any of these palpated structures do move, scalene overactivity is implicated, and these muscles require overactivity is implicated, and these muscles require further assessment for shortness and for the presence of further assessment for shortness and for the presence of trigger points.trigger points.

With the hands still in this position, assess whether one With the hands still in this position, assess whether one side moves more than the other. If so, local restrictions side moves more than the other. If so, local restrictions (clavicles, upper ribs) or muscle tensions may be (clavicles, upper ribs) or muscle tensions may be implicated.implicated.

BreatheBreathe

DiaphragmDiaphragm

Low rateLow rate

Bell jarBell jar

Stand/supineStand/supine

Signs of TroubleSigns of Trouble

1.What is the resting respiratory rate per minute? Normal adult range is 1.What is the resting respiratory rate per minute? Normal adult range is ten to fourteen per minute.ten to fourteen per minute.

2. Is the client a nose or mouth breather? Inhalation via the mouth is 2. Is the client a nose or mouth breather? Inhalation via the mouth is seldom appropriate.seldom appropriate.

3.With the resting breathing pattern, is there: Upper-chest breathing, 3.With the resting breathing pattern, is there: Upper-chest breathing, even with quiet breathing?even with quiet breathing?

Accessory muscle overactivity (i.e., shoulders rise on inhalation)?Accessory muscle overactivity (i.e., shoulders rise on inhalation)?

Frequent sighs/yawns?Frequent sighs/yawns?

Breath holding (“statue breathing”)?Breath holding (“statue breathing”)?

Abdominal splinting?Abdominal splinting?

Air hunger (where an attempt to inhale seems almost strangled, as there Air hunger (where an attempt to inhale seems almost strangled, as there has not been a full exhalation, limiting capacity for inhalation)?has not been a full exhalation, limiting capacity for inhalation)?

Repeated throat clearing/air gulpingRepeated throat clearing/air gulping

Why forward drawn Why forward drawn shoulders?shoulders?

Confirming Your SuspicionsConfirming Your Suspicions

The Nijmegen questionnaire provides a noninvasive The Nijmegen questionnaire provides a noninvasive test of high sensitivity (up to 91 percent) and test of high sensitivity (up to 91 percent) and

specificityspecificity (up to 95 percent). (up to 95 percent).

This easily administered, internationally validated This easily administered, internationally validated questionnaire is the simplest, kindest, and to date, questionnaire is the simplest, kindest, and to date, most accurate indicator of acute and chronic most accurate indicator of acute and chronic hyperventilation.hyperventilation.

This questionnaire is not diagnostic ,but offers a This questionnaire is not diagnostic ,but offers a strong indication that breathing is disturbed and that strong indication that breathing is disturbed and that retraining (combined with appropriate Chiropractic retraining (combined with appropriate Chiropractic care) will assist in improving this.care) will assist in improving this.

A combination of breathing exercises/homework and bodywork should be part of beginning rehabilitation.Strategies that can help to normalize such a cascade of health problems have been shown in many studies to require (for optimum results) a combinationof breathing retraining and physical medicine interventions that focus attention on mobilization of the thoracic cage, diaphragm, and normalization of lengthand strength of the accessory respiratory muscles (including trigger point deactivation).

The Manual Therapy Side of The Manual Therapy Side of RehabilitationRehabilitation

The treatment sequence outlined is one I have The treatment sequence outlined is one I have found effective in treating many patients with found effective in treating many patients with breathing pattern disorders; however, each breathing pattern disorders; however, each individual requires a slightly different approach.individual requires a slightly different approach.

Some of the elements of this protocol have been Some of the elements of this protocol have been discussed in this class, and details of others can discussed in this class, and details of others can be found in books such as be found in books such as Multidisciplinary Multidisciplinary Approaches to Breathing Pattern Disorders Approaches to Breathing Pattern Disorders (Churchill Livingstone, 2002) and (Churchill Livingstone, 2002) and Maintaining Maintaining Body Balance, Flexibility &Stability Body Balance, Flexibility &Stability (Churchill (Churchill Livingstone, 2004).Livingstone, 2004).

Treatment SequenceTreatment Sequence

Research and clinical experience suggests Research and clinical experience suggests that treatment and retraining for chronic that treatment and retraining for chronic breathing pattern disorders commonly breathing pattern disorders commonly involve up to twelve weekly sessions, involve up to twelve weekly sessions, followed by treatment every two to three followed by treatment every two to three weeks, up to approximately six months.weeks, up to approximately six months.

Note: an educational component should Note: an educational component should be included at each session to help the be included at each session to help the patient’s understanding of the condition patient’s understanding of the condition and why the homework that is being and why the homework that is being suggested is necessarysuggested is necessary

First two treatments First two treatments (not less than weekly). (not less than weekly).

Focus on the upper fixators/accessory Focus on the upper fixators/accessory breathing muscle (upper trapezius, levator breathing muscle (upper trapezius, levator scapulae, scalenes, strenocleidomastoid, scapulae, scalenes, strenocleidomastoid, pectorals, latissimus).pectorals, latissimus).

Release/stretch if hypertonic and Release/stretch if hypertonic and identify/deactivate active trigger points.identify/deactivate active trigger points.

Diaphragm area (anterior intercostals, Diaphragm area (anterior intercostals, sternum, abdominal attachments costal sternum, abdominal attachments costal margin, quadratus lumborum/psoas)—margin, quadratus lumborum/psoas)—release and stretch if hypertonic and release and stretch if hypertonic and deactivate active trigger points.deactivate active trigger points.

Retraining—pursed lip breathing/control and Retraining—pursed lip breathing/control and possibly additional breathing exercisespossibly additional breathing exercises

Pursed Lip Breathing—The Pursed Lip Breathing—The Start of RetrainingStart of Retraining

One of the best ways to tone the diaphragm and One of the best ways to tone the diaphragm and retrain breathing is to use a slow exhalation retrain breathing is to use a slow exhalation pattern, breathing out through your mouth with pattern, breathing out through your mouth with the lips pursed into as narrow an aperture as can the lips pursed into as narrow an aperture as can be managed (as though blowing out through a be managed (as though blowing out through a drinking straw).drinking straw).

Note: the action of slow, controlled exhalation against resistance (which is what is happening with pursed lipbreathing) is an example of an isotonic eccentric contraction.The diaphragm is being asked to work harder (by creating a counter force agienst the abdominal muscles with which you are blowing), at the same that it is relaxing from its contracted position (which it achieves during inhalation).

Breath out using the Breath out using the Abdominal Muscle’sAbdominal Muscle’s

Sessions (weeks) three and Sessions (weeks) three and fourfour

Perform as before, as well as Perform as before, as well as mobilization of thoracic spine and mobilization of thoracic spine and ribs ribs

Pay attention to fascial and osseous Pay attention to fascial and osseous links (cranial, pelvic, limbs).links (cranial, pelvic, limbs).

Retraining—antiarousal breathing, Retraining—antiarousal breathing, plus specific relaxation methods, plus specific relaxation methods, stress management, autogenics, stress management, autogenics, visualization, meditation, counseling.visualization, meditation, counseling.

Sessions (weeks) five to Sessions (weeks) five to twelvetwelve

Follow the protocol, plus other body Follow the protocol, plus other body influences (ergonomics, posture).influences (ergonomics, posture).

Retraining—additional exercises as Retraining—additional exercises as needed.needed.

Supine ExerciseSupine Exercise

While lying on the back, the abdominal contents rest While lying on the back, the abdominal contents rest against the diaphragmagainst the diaphragm

Practice with knees raised and hands placed to Practice with knees raised and hands placed to improve sensory feedbackimprove sensory feedback

Knee’s down to increased resistanceKnee’s down to increased resistance Use 10 to 20 lbs on belly (sand bag or plates) Use 10 to 20 lbs on belly (sand bag or plates)

ADLADL

All actions require breathing so start with All actions require breathing so start with simple actions; ie. getting out of chair, simple actions; ie. getting out of chair, getting up from squatting and all lifting.getting up from squatting and all lifting.

The Karate guy does it and you should tooThe Karate guy does it and you should too Breathing out deeper by hollowingBreathing out deeper by hollowing Practice 30 reps only 1X/day 7days/weekPractice 30 reps only 1X/day 7days/week Use a mirror for visual feedback Use a mirror for visual feedback

Sessions (weeks) thirteen to Sessions (weeks) thirteen to twenty-sixtwenty-six

Review and treat residual Review and treat residual dysfunctional patterns/tissues as dysfunctional patterns/tissues as indicated: nutrition, psychotherapy, indicated: nutrition, psychotherapy, plus adjunctive methods such as plus adjunctive methods such as hydrotherapy, tai chi, yoga, Pilates, hydrotherapy, tai chi, yoga, Pilates, massage, acupuncture (in many massage, acupuncture (in many instances, these elements are instances, these elements are introduced earlier in the course of introduced earlier in the course of treatment—particularly tai chi).treatment—particularly tai chi).

TrainingTraining

Tai ChiTai Chi’s slow, focused ’s slow, focused movements of practice movements of practice provide provide an environment, whereby an environment, whereby the proprioceptive the proprioceptive information being fed back information being fed back to the brain stimulates an to the brain stimulates an intense, dynamic "listening intense, dynamic "listening environment" to further environment" to further enhance mind/body enhance mind/body integration. integration.