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Breathing Pattern
Dysfunction and Pelvic Pain
Leon Chaitow, ND, DOUniversity of Westminster, London
WORLD MASSAGE CONFERENCENOVEMBER 2008
Learning ObjectivesLearning Objectives
� Recognize and assess breathing pattern disorders (BPD) such as hyperventilation.
� Describe the potential body-wide influence of respiratory alkalosis.
� Understand the connections between BPD and pelvic (and other) pain
� Evaluate various rehabilitation options in breathing pattern disorders.
Definition of HyperventilationDefinition of HyperventilationOverbreathing is
the state of
breathing faster
and/or deeper than
necessary,
therefore reducing
the carbon dioxide
(CO2) concentration
of the blood to
below normal.
Baillie K, Simpson A. http://www.altitudephysiology.org/oxygenphysiology/everestfacts/oxygencalculatorhighaltitude.htm.Accessed December 24, 2007.
When Does Hyperventilation Occur?When Does Hyperventilation Occur?
Hyperventilation (HVS) occurs when
minute ventilation exceeds metabolic
demands, resulting in symptom-
producing, hemodynamic and chemical
changes.
Lum L. Hyperventilation syndromes in medicine and psychiatry: a review. J. R Soc Med. 1987;80:229-231.
DefinitionsDefinitions� Hypocapnia: Deficiency of CO2 in the
blood, resulting from HVS, leading to respiratory alkalosis
� Hypoxia: Reduction of oxygen (O2) supply to tissue, below physiological levels, despite adequate perfusion of the tissue by blood. (cf. Anoxia)
The CancerWEB Project. Department of Medical Oncology, University of Newcastle upon Tyne. Available at: http://cancerweb.ncl.ac.uk/omd/index.html. Accessed December 22, 2007.
HVS Effects on pH & CO2HVS Effects on pH & CO2HVS, the extreme of breathing pattern
disorders (BPD), produces far-ranging
physiological effects via its alteration of
pH and depletion of CO2, resulting in
respiratory alkalosis, acute or chronic.
Gilbert C. Hyperventilation and the body. Accident and Emergency Nursing. 1999;7:130-140.
Naschitz JE, et al. Patterns of hypocapnia on tilt in patients with fibromyalgia, chronic fatigue syndrome, nonspecific dizziness, and neurally mediated syncope. Am J Med Sci. 2006;331:295-303.
Buffering by BicarbonateBuffering by Bicarbonate� In response to alkalosis (loss of CO2
through overbreathing), the kidneys excrete bicarbonate to restore pH.
� This loss of “buffering” influences makes the body more vulnerable to any increase in acidity (e.g., as occurs in anaerobic energy production in deconditioned individuals).
� At that time, the symptoms associated with alkalosis will appear—fatigue, brain fog, increased pain sensitivity, anxiety, and more. Nixon P, Andrews J. A study of anaerobic threshold in
chronic fatigue syndrome (CFS). Biol Psychol. 1996;43:264.
Respiratory Alkalosis Respiratory Alkalosis & the Bohr Effect& the Bohr Effect
� Respiratory alkalosis results when CO2 exhalation exceeds the rate of accumulation and pH rises (normal ±±±± 7.4).
� Alkalosis induces vascular constriction, decreased blood flow, and inhibition of O2 transfer from haemoglobin to tissue cells (Bohr effect).
Fried R. Hyperventilation Syndrome. Johns Hopkins University Press; 1987.
� Incompletely oxidised metabolic products (e.g., lactic and pyruvic acid)accumulate, due to activation of anaerobic energy pathways, particularly in deconditioned individuals.
Pryor JA, Prasad SA. Physiotherapy for Respiratory
& Cardiac Problems. 3rd ed. Edinburgh: Churchill Livingstone; 2002: 81.
Progressive Adaptive ChangesProgressive Adaptive ChangesProgression from acute to chronic pain and dysfunction appears to involve both physiologically and psychologically unsustainable adaptive demands, variably dependent on the individual’s inherited and acquired characteristics, interacting with the type, intensity, and duration of the stressors involved.
Gardner WN. The pathophysiology of hyperventilation disorders. Chest. 1996;109:516-534.
Pain and Other Symptoms Pain and Other Symptoms Resulting from BPD (Particularly Resulting from BPD (Particularly
in Deconditioned Individuals)in Deconditioned Individuals)“Muscular aching at low levels of effort; restlessness and heightened sympathetic activity; increased neuronal sensitivity as well as constriction of smooth-muscle tubes (e.g., vascular, respiratory and gastric-intestinal) can accompany the basic symptom of inability to make and sustain normal levels of effort.”
Nixon P, Andrews J. A study of
anaerobic threshold in chronic fatigue syndrome (CFS). Biol Psychol. 1996;43:264.
BPD/HVS: A Mind-Body Vicious Circle
AnxietyAnxiety
Frightening Frightening SymptomsSymptoms
Aching shouldersAching shouldersHead, neck & Head, neck & chest painchest pain
Ca++ lost Ca++ lost in urinein urine
Tiredness, Tiredness, Sensory Sensory disturbance, disturbance, Dizziness,Dizziness,
Paresthesia, Paresthesia, Cramp, Cramp, Weakness, Weakness, Pain thresholdPain threshold
Low calcium Low calcium Disturbed nerve & Disturbed nerve & muscle functionmuscle function
Sympathetic Sympathetic arousalarousal
Pulse ++, Sweating, Pulse ++, Sweating, Gut symptoms,Gut symptoms,
Increased upperIncreased upper--body tension & body tension & breathing ratebreathing rate
Excessive Excessive CO2 lossCO2 loss
Reduced Reduced carbonic carbonic acid in bloodacid in blood
AlkalosisAlkalosis
Bohr effectBohr effect
Smooth muscles constrict, Smooth muscles constrict, blood vessels & gut narrow, blood vessels & gut narrow, O2 delivery decreases, etc.O2 delivery decreases, etc.
Overbreathing AnxietyOverbreathing AnxietyProblems of lifeProblems of lifeTraumatic eventsTraumatic eventsUnconscious fearsUnconscious fears
Peters D, et al. Integrating Complementary Therapies into Primary Care. Edinburgh: Elsevier; 2002.
Determinants contributing to IDPs : Chronic pain, complex multifactorial diseases, complex traits, fibromyalgia syndrome (FMS)
Genetic variability and environmental events both interact with psychological characteristics and pain amplification status
Note: Pain threshold and emotional status are both affected by BPD
Diatchencko L, et al. Pain. 2006;123:226-230.
Nitric Oxide & PainNitric Oxide & Pain� Nitric oxide (NO) is produced in the nasal cavities
and/or the paranasal sinuses and is stimulated by nasal inhalation and by humming.
Corbelli R, Hammer J. Paediatr Respir Rev. 2007;8:269-272
Imada M, Nonaka S, Ota R. Otolaryngol Head Neck Surg. 2006;135(2 suppl 1):134.
� Decreased NO production induces microcirculation changes leading to exercise intolerance.
Kasikcioglu E, Dinler M, Berker E. Med Hypotheses. 2006;66:950-952.
� Passive and active exercise both increase shear stress to the endothelium, causing release of NO. Exercise and nasal breathing diminish symptoms of chronic pain and fatigue, in as yet unknown ways.
Sackner M Gummels E Adams J. Med Hypotheses. 2004;63:118–123.
Hypermobility, Back Pain, Hypermobility, Back Pain, FMS & RespirationFMS & Respiration
� Hypermobility has been shown to be a major risk factor in the evolution of back pain.
Muller K, et al. Manuelle Medizin. 2003;41:105-109.
� BPDs and anxiety states are much more common in hypermobile individuals, often associated with chronic pain syndromes.
Bulbena A, et al. Psychiatry Res. 1993;46:59-68.
Martin-Santos R, et al. Am J Psychiatry. 1998;155:1578-1583.
� A subgroup of patients with FMS are hypermobile.
Acasuso-Diaz M, et al. Arthritis Care Res. 1998; 11:39-42.
…… Habit, Conditioning?Habit, Conditioning?� Lum discussed the reasons for people
hyperventilating: “Neurological considerations leave little doubt that habitually unstable breathing is the prime cause of symptoms.”
� Van den Bergh et al suggested that HVS may be a learned or conditioned behaviour.Lum L. Editorial: Hyperventilation and anxiety states. J R Soc Med. January 1984: 1-4.
Van den Bergh O, et al. Learning to have psychosomatic complaints: Conditioning of respiratory and somatic complaints in psychosomatic patients. Psychosom Med. 1997;59:13-23.
Who is affected? Patients in whom there is no obvious organic cause?
� Patients with the most common physical symptoms (e.g., abdominal pain, chest pain, headache, back pain)are responsible for half of primary carevisits. Only 10%–15% are caused byorganic illness.
Katon W, Walker E. J Clin Psychiatry. 1998;59(Suppl 20):15-21.
� BPD can result in complex symptoms ranging from cardiovascular to digestive and emotional, to musculoskeletal fatigue, and to brain fog, as well as disturbed levels of systemic calcium and other nutrients.
Schleifer L, et al. Am. J Ind Med. 2002;41:420-432.
Immediate Presenting Symptoms Immediate Presenting Symptoms of Respiratory Alkalosisof Respiratory Alkalosis
Most commonly, the history is
of sudden onset of atypical
chest pain (relieved by
exercise, unrelieved by
nitroglycerin [C3H5[NO3]3)],
dyspnoea, and neurologic
symptoms (e.g., dizziness,
weakness, paresthesias, near
syncope), often following a
stressful event
Foster G, et al. Respiratory
alkalosis. Respir Care . 2001;46:384-391.
Why Are Females Most Affected?Why Are Females Most Affected?Respiratory alkalosis affects:
� Females more than males, in a ratio ranging from 2:1 to 7:1 (peak ages 15–55)
Damas-Mora J, et al. B J Psychiatry. 1980;136:492-497.
� Almost all pregnant women, as acidosis increases
Wise R, et al. Immunol Allergy Clin North Am. 2006;26:1-12.
� Many healthy women, via progesterone, during the post-luteal phase of the menstrual cycle
Slatkovska L, et al. Respir Physiol Neurobiol. 2006;154:379-388.
� Approximately 10% of adult non-asthmatics
Thomas M, et al. Prim Care Respir J. 2005;14:78-82.
Progesterone & HVSProgesterone & HVSPhasic menstrual
cycle changes
observed in resting
minute ventilation
and arterial PCO(2)
may be due, at
least in part, to the
stimulatory effects
of progesterone.Slatkovska L, et al. Respir Physiol Neurobiol. 2006;154:379-388.
Relationship of arterial PCO(2) with plasma progesterone concentration:
CO2 levels drop as progesterone levels rise
OverbreathingOverbreathing & PMS& PMS� PMS symptoms may be caused directly by HVS.
� “It has been known for more than 100 years that women hyperventilate during the second half of the menstrual cycle. Symptoms of chronic HVS are remarkably similar to the symptoms observed in some women with PMS.…[where] the sensitivity of the respiratory centre to CO2 is increased more than normal by progesterone, …….resulting in pronounced hyperventilation.”
Ott H, et al. Fertil Steril. 2006;86:1001.e17-19.
� PMS symptoms include cyclical
discomfort and pain from tender, swollen
breasts, painful cramps, headache, and
stiff neck.
Dell D. Clin O bstet Gynecol. 2004;47:568–575.
Pain Threshold &Pain Threshold &the Menstrual Cyclethe Menstrual Cycle
� Research shows that as progesterone levels rise during the luteal phase of the cycle, the breathing rate accelerates—and the pain threshold drops.
� The suggestions is that respiratory changes are at least partially influential in increased pain perception.
Cimino R, et al. Does the ovarian cycle influence the pressure-pain
threshold of the masticatory muscles in symptom-free women? J Orofac Pain. 2000;14:105-111.
FMS, the Menstrual Cycle, & FMS, the Menstrual Cycle, & Breathing PatternsBreathing Patterns
� In a recent study, several participants “changed” FMS diagnosis during the course of a menstrual cycle, fulfilling the diagnostic criteria during the menstrual or luteal phase, but never during the follicular phase.
Dunnett A, et al. The diagnosis of fibromyalgia in women may be influenced by menstrual cycle phase. Journal of Bodywork and Movement Therapies. 2007;11: 99-105.
� A common feature of FMS is reduced serum CO2.
Naschitz J, et al. Patterns of hypocapnia on tilt in patients with
fibromyalgia, chronic fatigue syndrome, nonspecific dizziness, and neurally mediated syncope. Am J Med Sci. 2006;331:295-303.
� Clinical experience suggests that most FMS and CFS patients overbreathe.
How Widespread Is HVS or BPD?How Widespread Is HVS or BPD?� In the United States, as many as 10% of
patients in general internal medicine practices are reported to have HVS as their primary diagnosis.Lum L. Hyperventilation syndromes in medicine and psychiatry: a review. J. R Soc Med. 1987;80:229-231.
Newton EJ. Hyperventilation Syndrome. September 26, 2005. Available online at: http://www.emedicine.com/emerg/topic270.htm. Accessed: December 22, 2007.
� BPD is far more prevalent.Thomas M, et al. The prevalence of dysfunctional breathing in adults in the community with and without asthma. Prim Care Respir J. 2005;14:78-82.
The HVSThe HVS--Hypoglycaemia ConnectionHypoglycaemia Connection� Feelings of faintness, cold sweats, weakness, and
disturbed consciousness are common to both HVS and low blood sugar.
Brostoff J. Complete Guide to Food Allergy.
London: Bloomsbury; 1992.
� During overbreathing, both EEG and cortical function deteriorate when glucose values are below 100 mg/dL.
� 3 minutes of HVS produce mild effects when blood sugar is in the of range 85 to 90 mg%, but with blood sugar at 70 to 75% (still within normal range), gross EEG disturbances are noted.
Lum L. HVS: Physiological considerations. In: Timmons B, Ley R, eds. Behavioural and Psychological Approaches to Breathing
Disorders. New York, NY: Plenum Press; 1994.
UnderUnder--oxygenation of the Brainoxygenation of the BrainIn this image, O2
availability in the
brain is reduced by
40% as a result of
about a minute of
overbreathing (HVS).
In addition, glucose
critical to brain
functioning is
markedly reduced as
a result of cerebral
vasoconstriction. Litchfield P. A Brief overview of the
chemistry of respiration and the breathing
heart wave. California Biofeedback.
2003;19:1.
Correlation Between Faulty Breathing Correlation Between Faulty Breathing Mechanics & Musculoskeletal Pain ?Mechanics & Musculoskeletal Pain ?� A convenience sample of 111 patients
attending a chiropractic clinic were evaluated for links between their health and pain histories and faulty breathing (criteria included obvious paradoxical breathing, or a tendency to raise the upper chest toinitiate inhalation).
� 56.4% demonstrated faulty breathing on relaxed inhalation, rising to 75% when taking a deep breath.
� 87% reported a history of various musculoskeletal pain problems.
� Only neck pain had a significant relationship with dysfunctional breathing patterns (p = 0.039).
� “Chances are 3 in 4 that new patients seen today will have faulty breathing patterns.”
Perri M, Halford E. Journal of
Bodywork and Movement Therapies. 2004;8:237-312.
Back Pain & Failed Core StabilityBack Pain & Failed Core Stability� Diaphragm and transversus
abdominis tone are key providers of spinal stability.
Panjabi M. J Spinal Disord. 1992;5:383-389
� Reduced spinal support was noted during combined load challenge to the low back and during breathing challenge (e.g., digging).
McGill S, et al. Ergonomics. 1995;38:1772-1792.
� After approximately 60 seconds of overbreathing, both postural (tonic) and phasic functions of the diaphragm and transversus abdominis were reduced or absent.
Hodges P, Gandevia S. J Physiol. 2000;522(Pt 1):165-175.
Breathing RehabilitationBreathing Rehabilitation& Back Pain& Back Pain
� A randomized controlled study showed that patients with moderate chronic low back pain, average 1-year duration, improved significantly (pain and function) after either breathing rehabilitation or physical therapy for 8 weeks (12 x 45-minute sessions)
� 16 patients (mean age 49.7, 31.3% male): breathing rehabilitation
� 12 patients (mean age 48.7, 41.7% male): “gold standard” physical therapy
Mehling W, et al. Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Altern
Ther Health Med. 2005;11:44-52.(continues next slide)
Breathing RehabilitationBreathing Rehabilitation& Back Pain & Back Pain (continued)(continued)
� From baseline to the end of the intervention, patients in both groups experienced a statistical and clinically significant improvement in pain intensity as measured by the 10 cm VAS (breath therapy -2.71; physical therapy -2.43) and the 100-point SF-36 (breath therapy +14.9; physical therapy +21.0).
� At 6 to 8 weeks, there was a trend favoring breath therapy.
� At 6 months, there was a trend favoring physical therapy.
Mehling W, et al. Randomized, controlled trial of breath
therapy for patients with chronic low-back pain. Altern Ther Health Med. 2005;11:44-52.
Painful Gut Symptoms: Painful Gut Symptoms: IBS & BPD/AlkalosisIBS & BPD/Alkalosis
� Symptoms (including pain) attributable to HVS are common among patients with IBS, particularly if anxiety is a feature.
� A study showed that HVS (low CO2 levels) increased colonic tone and phasic contractility in the transverse and sigmoid regions. It was suggested that these physiological gut responses are caused by altered brain or autonomic control mechanisms.
Ford M, et al. Gut. 1995;37:499-504.(continues next slide)
Painful Gut Symptoms: Painful Gut Symptoms: IBS & BPD/Alkalosis IBS & BPD/Alkalosis (continued)
� Hypocapnic hyperventilation significantly increases colonic tone and sensitivity.
Bharucha A, et al. Gastroenterology. 1996;111:368-377.
� Respiratory alkalosis leads to changes in perfusion, motility, and electrolyte handling in the gastrointestinal system.
Foster G, et al. Respir Care. 2001;46:384-391.
BPD, HVS & Chest PainBPD, HVS & Chest Pain� “Mental stress induces myocardial ischemia in
some subjects with known CAD.… Mental stress also leads to significant hemodynamic responses in these subjects.”
Ramachandrun S, Fillingim R, McGorray S, et al. Mental stress provokes ischemia in coronary artery disease subjects without exercise- or adenosine-induced ischemia. J Am Coll Cardio. 2006;47:987-991.
� “Stress and fear often cause rapid breathing or hyperventilation. This usually occurs in young adults and although the hyperventilating patient often complains of chest pain, this is rarely a manifestation of cardiac disease.”
Garfunkel A, et al. Chest pains in the dental environment. Refuat Hapeh Vehashinayim.2002;19:51-59.
Breathing Rehabilitation: Anxiety, Breathing Rehabilitation: Anxiety, Fear & Associated SymptomsFear & Associated Symptoms
� HVS can usually be corrected by breathing retraining.
� Lum reported on a study in which more than 1000 anxious and phobic patients were treated using breathing retraining, physical therapy, and relaxation.
� Symptoms were usually abolished in 1 to 6 months, with some younger patients requiring only a few weeks.
� At 12 months, 75% were still free of all symptoms, and 20% had only mild symptoms; however, about 1 patient in 20 had “intractable symptoms.”
Lum L. Editorial: Hyperventilation and anxiety states. J R Soc Med. January 1984: 1-4.
Breathing Rehabilitation StudiesBreathing Rehabilitation Studies� Intervention studies of breathing retraining have
clearly demonstrated that nonpharmacological treatment can be used successfully to treat dysfunctional breathing in most people, both with asthma and without asthma.
DeGuire S, et al. Breathing retraining: a three-year follow-up study of treatment for hyperventilation syndrome and associated functional cardiac symptoms. Biofeedback Self Regul. 1996;21:191-198.
� The vast majority of BPDs appear to be amenable to correction via a combination of breathing rehabilitation and manual/physical medicine modalities.
Grossman P, et al. A Controlled study of a breathing therapy for
treatment of hyperventilation syndrome. J Psychosom Res. 1985;29:49-58.
Breathing Retraining EfficacyBreathing Retraining Efficacy� 92 HVS patients (60 female) with anxiety disorder
were treated by retraining.
� Diagnosis was based on reproduction of symptoms (including chest pain) by voluntary HVS. Patients with organic diseases were excluded.
� Therapy involved:
� Brief, voluntary HVS to reproduce symptoms
� Reattribution to HVS as the cause of symptoms
� Explanation of the rationale of therapy
� Breathing retraining for 2 to 3 months involving acquisition of abdominal breathing pattern and slowing of expiration.
Han J, et al. Influence of breathing therapy on complaints,
anxiety and breathing pattern in patients with hyperventilation syndrome and anxiety disorders. J Psychosom Res. 1996;41:481-493.
Breathing Retraining Breathing Retraining Efficacy Efficacy (continued)(continued)
� The sum scores of the Nijmegen Questionnaire were markedly reduced. A canonical correlation analysis showed that the improvement of the complaints was correlated mainly with the slowing down of breathing frequency.
Han J, et al. Influence of breathing therapy on complaints,
anxiety and breathing pattern in patients with hyperventilation syndrome and anxiety disorders.
J Psychosom Res. 1996;41:481-493.
Pelvic Floor, Diaphragm & Motor Pelvic Floor, Diaphragm & Motor Control in Patients Control in Patients
with Sacroiliac Joint Painwith Sacroiliac Joint Pain� Abnormal respiratory patterns and pelvic
floor and diaphragmatic function were observed during the active straight legraising test (ASLR), together with an inability to consciously elevate the pelvic floor, in 9 subjects with a clinical diagnosisof sacroiliac joint pain (SIJP).
� This study provided evidence that in subjects with SIJP, aberrant motor control strategies during the ASLR can be enhanced with a motor learning intervention.
O’Sullivan P, Beales D. Changes in pelvic floor and diaphragm kinematics & respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: A case series. Man Ther. 2007;10:242–255.
Spinal/SIJ Instability & Spinal/SIJ Instability & RespirationRespiration
� A clear connection between respiration and pelvic floor function, as well as SIJ stability, has been observed, particularly in women.
Hodges PW, et al. Postural and respiratory functions of the pelvic
floor muscles. Neurourol Urodyn. 2007;26 :362-371.
� If pelvic floor muscles are dysfunctional, spinal support may be compromised, increasing obliquus externus activity, overcoming pelvic floor muscle activity, and resulting in incontinence.
Smith M, et al. Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourol Urodyn. 2007;26: 377-385.
� Lack of spinal or SIJ stability is a prescription for low back pain.
Link Between Incontinence,Link Between Incontinence,Back Pain & Breathing?Back Pain & Breathing?
� Data was analysed from 38,050 women from three age cohorts.
� Back pain incidence was higher for women
reporting incontinence compared to women without incontinence.
� Middle-aged and older women had higher
odds of having back pain when they also experienced breathing difficulties.
� Disorders of continence and respiration were strongly related to frequent back pain, possibly explained by physiological limitations of coordination of postural, respiratory, and continence functions of trunk muscles.
Smith MD, Russell A, Hodges P. Aust J Physiother. 2006;52:11-16.
Breathing as Part of TreatmentBreathing as Part of Treatmentof Interstitial Cystitisof Interstitial Cystitis
� Diaphragmatic breathing, progressive muscle relaxation, exercise, self-visualization, and self-hypnosis are effective in reducing stress and pain perception.
Whitmore K. Complementary and alternative therapies as treatment
approaches for interstitial cystitis. Rev Urol. 2002;4(Suppl 1):S28 -S35.
� In a study of 19 interstitial cystitis patients with pelvic floor dysfunction, who underwent relaxation therapy utilizing diaphragmatic breathing and progressive relaxation techniques, there was a significant decrease in pain and urgency scores after 3 months of therapy.
Mendelowitz F, Moldwin R. Complementary therapies in the
management of interstitial cystitis. In: Sant G, ed. Interstitial Cystitis. Philadelphia, Pa: Lippincott-Raven; 1997: 235–239.
Chronic Pelvic Pain & ProstatitisChronic Pelvic Pain & ProstatitisChronic pelvic pain (involving the
perineum, testicles and penis)
associated with chronic prostatitis
involving nonbacterial urinary
difficulties has been shown, in a
2005 study at Stanford University
School of Medicine, to be capable
of being effectively treated using
trigger point deactivation, together
with relaxation and breathing techniques.Anderson RU, et al. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174:155-160.
Chronic Pelvic Pain SummaryChronic Pelvic Pain Summary� Chronic pelvic pain is commonly associated
with interstitial cystitis and stress urinaryincontinence.
� There are many possible causes of chronicpelvic pain, and accurate diagnosis can bedifficult; misdiagnosis is common.
� At the very least, serious pathology needs to be ruled out before use of CAM or manual treatment methods.
� Psychological issues may be aetiological or may be maintaining features of pelvic pain problems.
� Neurological (e.g., pudendal pain syndrome) and pelvic floor muscle pain syndrome, are two forms that may respond well to appropriate physical medicine approaches.
Lee D, Vleeming A. An integrated therapeutic approach to the treatment
of pelvic girdle pain. In: Vleeming A, Mooney V, Stoekart R, eds. Movement Stability & lumbopelvic Pain. Edinburgh: Churchill Livingstone/Elsevier; 2007: 593.
What to Look for with BPDWhat to Look for with BPD� Restlessness (type A,
“neurotic”)
� ‘Air hunger,” sighing
� Rapid swallowing rate
� Poor breath-holding times
� Rise of shoulders on inhalation
� Obvious paradoxical breathing (“hi-lo” test)
� Visible “cord-like” sternomastoid muscles
� Rapid breathing rate (this may not be obvious)
(continues next slide)
What to Look for with BPD What to Look for with BPD (continued)
� Symptoms including:
� Muscular stiffness and aching (particularly neck and shoulders)
� Fatigue
� Brain fog
� IBS
� “Chronic everything”/chronic pain
� Anxiety/panic/phobias
� Cold extremities
� Paraesthesia
� Photophobia/hyperacusis
� “Can’t take a deep breath”
� Positive Nijmegen test, capnometry evidence
BPD Assessment of InfluencesBPD Assessment of Influences� Observe breathing pattern (e.g., paradoxical
pattern/upper chest).
� Observe posture, particularly crossed patterns.
� Assess spinal, rib mobility/restriction + form/force closure (SLR).
� Look for shortness or weakness of key muscles + firing sequences, as well as active trigger points.
� Test breath holding, breathing wave, and Nijmegen as markers of current status (or record capnography evidence if available).
Chaitow L, Bradley D, Gilbert C.
Multidisciplinary Approaches to
Breathing Pattern Disorders. Edinburgh:
Churchill Livingstone; 2002.
(continues next slide)
BPD Assessment BPD Assessment of Influences of Influences (continued)(continued)Then…..
� Mobilise/tone soft tissues/joints + deactivate trigger points, as appropriate to findings.
� Commence education, rehabilitation strategies (breathing, stress management, posture) + homework.
� Consider referral for psychological/emotional support.
� As appropriate, offer nutritional, relaxation, etc., advice.
� Review and reassess regularly.
Chaitow L, Bradley D, Gilbert C. Multidisciplinary
Approaches to Breathing Pattern Disorders. Edinburgh:
Churchill Livingstone; 2002.
Identifying BPD:Identifying BPD:The Nijmegen QuestionnaireThe Nijmegen Questionnaire
� This a non-invasive test is of high sensitivity (up to 91%) and specificity (up to 95%). It is an easily administered, internationally validated questionnaire and is a simple and accurate indicator of acute and chronic HVS.
� Questions ask about: feelings of constriction in the chest, shortness of breath, accelerated or deepened breathing, inability to breathe deeply, feeling tense, tightness around the mouth, stiffness in the fingers or arms, cold hands or feet, tingling fingers, bloated abdominal sensation, dizzy spells, blurred vision, feeling of confusion or losing touch with environment.
� Van Dixhoorn J, Duivenvoorden H. Psychosom Res. 1985;29:199-206.
� Vansteenkiste J, Rochette F, Demedts M. Eur Respir J. 1991;4:393-399.
� Courtney R, Cohen M. International Journal of Osteopathic Medicine.
2006;9:34.
Nijmegen QuestionnaireNijmegen QuestionnaireRare = less than monthlySometimes = more than monthly, less than weeklyOften = at least weekly, but not dailyVery often = at least daily
Identifying BPD: Identifying BPD: Capnography/CapnometryCapnography/Capnometry
A small breath-training/monitoring device
has the ability to assist in slower and
better breathing, improved blood
chemistry, measuring end tidal CO2
levels, and monitoring heart wave
and rate.
Mindful Physiology Institute, www.bp.edu
capnotrainer
Signs of chronic overbreathing, Nijmegen score 27/64 + CO2
levels below 35mmHg , “chest
painful a lot of the time”;
retraining focused on lengthening exhalation; CO2
rose slightly after a few minutes.
Note: These lines are condensed 20-second averages.
~Normal pattern, CO2 levels around 40 mmHg, slow exhalation
Chaotic rhythm,
diaphragmatic spasm?,
underlying emotional and/or
physical factors?, many peaks under 35 mmHg
Is Biomechanical Is Biomechanical Assessment Essential?Assessment Essential?
“Signs and symptoms of dysfunctional breathing appear
to exist even when PCO2 levels appear normal. Breathing
may reflect the function of many systems of the body and
a purely biochemical view of breathing dysfunction may
be limited. For a complete picture of patients’ breathing it
is necessary to evaluate the biomechanical aspects of
breathing pattern, and symptom patterns, in addition to
the assessment of carbon dioxide.”
Courtney R, Cohen M. Assessment of the measurement tools of dysfunctional breathing. International Journal of Osteopathic Medicine. 2006:9:34.
Painful Trigger Points & RespirationPainful Trigger Points & Respiration� Trigger points in cervical,
shoulder-girdle, thoracic, or lumbar muscles strongly influence and can be strongly influenced by:
� Disturbances of ventilation mechanics
� Disturbances of posture
� Disturbances of the functional dynamics of the neck, shoulder girdle, and lumbar spine
� Paradoxical respiration is a critical link in many such pathogenetic chain reactions
Simons D, Travell J, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. 2nd ed. Baltimore, Md: Williams & Wilkins; 1999
Anterior & Posterior Crossed PatternsAnterior & Posterior Crossed PatternsRespiratory & Pelvic Floor Dysfunction ConnectionsRespiratory & Pelvic Floor Dysfunction Connections
Trunk extension reducedThoracolumbarregion stiff Poor pelvic controlDecreased hip extensionAbnormal axial rotationPelvic floor dysfunctionDysfunctional breathing
Flexors tend to dominateLoss of extension through spineThoracolumbar junctionhyperstabilised in flexionPoor pelvic control Dysfunctional breathing
Key J, et al. 2008A model of movement dysfunction. Journal of Bodywork and Movement Therapies 12(2):105-120
BreathBreath--Holding TestsHolding Tests� No agreed ‘normal’
breath-holding time, but it can bea useful point of reference.
� HVS patients seldom holdbeyond 10 to 12 seconds.
Gardner WN. Chest 1996;109:516-534.
� Control pause: Normal exhalationheld until “need to breathe again”is experienced
� “Normal” is between 25 and 30seconds. Under 15 secondsrepresents low tolerance to CO2.
� In Buteyko system, control pause is practised regularly to encourage increased CO2 tolerance.
Buteyko K. Buteyko Method : Experience of Application
in Medical Practice. Moscow: Patriot; 1990.
Lateral Expansion AssessmentLateral Expansion Assessment� In some individuals,
a normal abdominal excursion is seen on inhalation, with minimal lateral expansion.
� Reliability of measuring thoracic excursion has been established, ideally using a standard cloth tape measure (taken at 5th and 10th thoracic level).
Brockenhauer S, et al. Reliability of a measure of thoracic excursion. Journal of Osteopathic Medicine. 2004; 7:104.
Thoracic Restrictions & Thoracic Restrictions & Breathing WaveBreathing Wave
� Seated patient slumps, and spinal “flat” areas are observed.
� On prone inhalation, segments that fail to flex normally usually rise en bloc, rather than individually.
� Associated ribs may also be restricted.
� Thoracic spine, ribs, and associated muscles may require mobilization.
Lewit K. Manipulative Therapy in
Rehabilitation of the LocomotorSystem. London: Butterworths; 1999: 126.
Assessment of Elevated & Assessment of Elevated & Depressed RibsDepressed Ribs
A rib that fails to move antero-cephalad on inhalation is depressed (locked in its exhalation phase).
A rib that fails to return to neutral on exhalation is elevated (locked in its inhalation phase).
Assessment of 1st Assessment of 1st rib and rib and clavicularclavicularmovement on movement on inhalationinhalation
Ribs 10-12
Ribs 2-10
Functional Assessments for Postural Functional Assessments for Postural Muscle Overactivity/Shortness Muscle Overactivity/Shortness
Assessing :
Upper trapezius/Lev Scapula overactivity
A = Normal psoas
B = Psoas shortness
Quadratus lumborum overactivity
A
B
Chaitow L. Palpation & Assessment Skills. Edinburgh: Churchill Livingstone; 2003.
Psoas/QuadratusPsoas/Quadratus——& the Diaphragm& the Diaphragm
“[T]he remainder of the lumbar part of the diaphragm
arises from the medial and lateral arcuate ligaments,
which are immediately lateral to the crura. The medial
arcuate ligament is a thickening of the fascia covering
psoas major and runs from the side of the body of L2 to
the transverse process of L1. The lateral arcuate
ligament is a thickening of the anterior layer
of the thoracolumbar fascia covering
quadratus lumborum and runs from the
transverse process of L1 to the tip of the
12th rib.”
Palastanga N, Field D, Soames R. Anatomy and Human Movement. 4th ed. Oxford; Butterworth Heinemann; 2002: 478-479.
Diaphragm release:
1. Lower ribs of supine patient are rotated L and R to evaluate restrictions. Tissues are held in that direction as side flexion is evaluated (“shunt”/ translation). Combined directions of restriction are held as patient introduces Valsalva maneuver, after which rotation and translation are re-evaluated. Diaphragm excursion should be fuller subsequently.
Doming diaphragm Diaphragm release Intersegmental
mobilization
Knott M, et al. Lymphatic pump treatments increase thoracic duct flow [abstract]. Journal of Osteopathic Medicine. 2004:7:100.Gosling C, Williams K. Comparison of effects of thoracic manipulation and rib raising on lung function [abstract]. Journal of OsteopathicMedicine. 2004:7:103. “Lymphatic pump”
Rib raising
Osteopathic mobilization approaches
Elderly Hospitalized Elderly Hospitalized Pneumonia PatientsPneumonia Patients
� Osteopathic manual methods were applied to elderly hospitalized patientswith pneumonia, with the result that the length of the hospital stay was reducedfrom a mean of 8.6 days without OMT to 6.6 days with OMT.
� Additional benefits in this study, for those receiving osteopathic manual treatment, included reduced length of use of intravenous antibiotics
Noll D, et al. Adjunctive osteopathic manipulative treatment in the elderly hospitalized with pneumonia: A pilot study .J Am Osteopath Assoc. 1999;99:143-152.
Noll D, et al. Benefits of osteopathic manipulative treatments for hospitalized elderly patients with pneumonia. J Am Osteopath Assoc. 2000;100:776-782.
BPD Retraining EssentialsBPD Retraining EssentialsBreathing retraining requires a combination of elements:
�Understanding the processes – a cognitive, intellectual awareness of the mechanisms and issues involved in BPDs
�Retraining exercises including aspects that operate subcortically, allowing replacement of currently habituated patterns with more appropriate ones
�Biomechanical structural modifications that remove obstacles to desirable and necessary functional changes
�Time for these elements to merge and become incorporated into moment-to-moment use patterns
Q uickTime™ and aPhot o - JPEG decompr essor
ar e needed t o see t his pict ur e.
Pursed Lip BreathingPursed Lip Breathing� Pursed lip breathing (PLB)
enhances pulmonaryefficiency.
� Exhalation through the pursed lips hasbeen shown to relieve dyspnoea, slowthe respiratory rate, increase tidal volume, and help restore diaphragmatic function.
Faling L. Controlled breathing techniques & chest physical therapy in
COPD. In: Casabur R, ed Principles & Practices of Pulmonary Therapy. Saunders; 1995.
Tisp B, et al. Chest. 1986;90:218-221.
Pursed Lip Breathing Pursed Lip Breathing (continued)
� PLB: Using a 3-D optoelectronic plethysmograph (OEP), marked decreases have been shown in end-expiratory lung volume, localized at the abdominal level.
Nerini M, et al. Eur Respir J. 2001;18(Suppl 33):489s.
� Patient sits or lies, with the dominant hand on the abdomen and the other hand on the chest, and inhales through the nose, ensuring diaphragmatic involvement by means of movement of the abdomen against the hand, and exhales slowly through the mouth, using pursed lips.
Inhibiting Shoulder RiseInhibiting Shoulder Rise� During breathing retraining, the patient should adopt
tactics that restrict overactivity of accessory breathing muscles in order to reduce “shoulder rising” on inhalation.
� Methods might include, on inhalation:
� Lightly pushing forearms onto arms of chair
� Arms behind back, grasping wrist with other hand and lightly pulling down (on inhalation only)
� Reclining, with hands behind head (“beach pose”) to open chest and reduce shoulder movement
� Interlocking hands on lap and applying finger-pad pressure to dorsum of hands (on inhalation only) to inhibit shoulder movement
� Adopting Brugger’s relief position
Liebenson C. Journal of Bodywork & Movement
Therapies. 2006;10:65-70.
Breathing RehabilitationBreathing Rehabilitation
Hi-lo test
Shoulder stabilization
Brugger’s Relief Position:**
�Perch on chair edge, arms hanging down, feet below knees, slightly apart and turned outward
�Roll pelvis forward to produce slight lumbar lordosis
�Ease sternum slightly forward and up and tuck chin in
�With palms facing forward, on inhalation, rotate arms outward until thumbs face slightly back; release on exhalation
�Practice slow, pursed lip, anti-arousal breathing
Beach-pose
Chaitow L, Bradley D, Gilbert C. Multi-disciplinary Approaches to Breathing Pattern Disorders. Edinburgh: Churchill Livingstone; 2002.
**
SummarySummaryBPDs influence health by:
� Altering blood pH, creating respiratory alkalosis
� Increasing sympathetic arousal, altering neuronal function
� Encouraging a sense of apprehension, anxiety, and panic
� Depleting Ca and Mg ions, enhancing central and peripheral sensitization, encouraging spasm,and reducing pain thresholds
Chaitow L, Bradley D, Gilbert C. Multidisciplinary
Approaches to Breathing Pattern Disorders. Edinburgh: Churchill Livingstone; 2002.
Summary Summary (continued)
� Triggering smooth muscle cell constriction, leading to vasoconstriction (and possibly altering fascial tone)
� Encouraging painful colon spasm and pseudo-angina
� Reducing O2 release to cells, tissues, and brain (Bohr effect), encouraging ischemia, fatigue, and pain
� Encouraging evolution of myofascial trigger points
� Creating biomechanical overuse stresses and pain
BPDs are:
� Commonly habitual
� Easily recognized
� Usually capable of being improved or eliminated
Chaitow L, Bradley D, Gilbert C. Multidisciplinary
Approaches to Breathing Pattern Disorders. Edinburgh: Churchill Livingstone; 2002.
