November 10, 2014
Where is your pain coming from?
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Last week in R2P club (Rehab to performance) we went over breathing mechanics, how to assess breathing, and how to fix it. So I thought I would share it with everybody, since breathing evaluation should be incorporated into every clinician’s evaluation.
This is what sets you to the next level as a clinician. In people with chronic neck and low back pain, who hasn’t responded to traditional treatments, other Chiropractic care or surgery, I bet their breathing was not assessed.
Basics of breathing
Neurodevelopmentally breathing is the first thing we do. Before we cry or turn our heads or move, we started breathing first. This is why when we are correcting any dysfunction in the musculoskeletal system, we should check breathing first. Why? This can be summed up by a quote from the great Karel Lewit.
“IF BREATHING IS NOT NORMALIZED- NO OTHER MOVEMENT PATTERN CAN BE”
The main muscle involved in breathing is the diaphragm. The diaphragm is the dome shaped muscle which attaches to the ribs, sternum and lumbar vertebra. Thus, it is part of the core musculature and should be evaluated for proper function before any type of core conditioning program is started. Also, breathing should also be assessed with any low back pain patient who could benefit from core stabilization exercises.
Breathing is controlled by the brain stem globally and locally by the phrenic nerve, which exits from the spinal column at C3-C5. Normal breathing is controlled by the CO2 (carbon dioxide) in our blood, and not the oxygen level (O2). When we breathe in, the diaphragm contracts, and descends down. The diaphragm is responsible for 75% of normal breathing. The other muscle involved in quiet respiration is the external intercostals, which only contributes to 25% of breathing. Very commonly the SCM (sternocleidomastoid), pectoralis minor and scalenes are involved with quiet breathing, however these should only be called upon when the demand for O2 is increased (during stressful situations or exercise). Craig Liebenson calls the most common fault for chest breathers is substitution of the scalenes and upper trapezius for inhibited diaphragm. We will get to assessment and treatment in a minute.
We have 2 cavities in our body with breathing, the thoracic cavity and the abdomen. The thoracic cavity contains our lungs and heart, while our abdomen houses the rest of our organs (liver, intestines, stomach, etc). When the diaphragm descends it causes a decrease in pressure in the lungs and an increase in volume, so according to Boyle’s law, air will move into the lungs. This is because the pressure inside the lunges is less than the atmosphere. During expiration, the diaphragm contracts passively, without energy and we breathe out because the pressure in the lungs is increasing.
On the other hand, when the diaphragm descends this creased an increased pressure in the abdomen because it is being compressed. This is what creates spinal stability is the increase in abdominal pressure or intra-abbdominal pressure (IAP). We will get to the IAP test in a minute under assessment. During quiet expiration only the diaphragm should be used. However during times of metabolic demand, we have other muscles which help get air out of the lungs such as the rectus abdominis, transversus abdominis, both obliques and the internal intercostals.
Normal breathing mechanics include the movement of the ribs. We have 2 movements of the ribs, the bucket handle and the pump handle. Normally the lower rib cage should expand laterally, this is what is referred to as the bucket handle movement. Also the upper rib cage should expand out, not up. This is what is referred to as the pump handle movement.
The diaphragm has 3 functions:
Normal respiration is considered to be within the range of 12-20 breaths/minute. However, around 20 breaths/minute equals around 28,800 breaths/day. Optimally you should be in the lower end of the range around 12-13, even down to 8 breaths/minute, according to Liebenson. 8-12 breaths per minute puts you in the range of 11,500-17,000 breaths/minute. Look at how much energy your body is wasting! If you feel like you constantly do not have enough energy, and cannot find the cause, poor breathing might be that cause!
Here are two other consequence of poor breathing mechanics. When people feel like their brain is not functioning the way it should and/or headaches, you should check their breathing. Over-breathing causes you to be in a state of alkalosis, which means you do not have enough CO2. This is what is known as respiratory alkalosis. A lack of CO2 in the blood, also known as hypocapnia, causes constriction of blood vessels, including in the brain, and to your tissues, creating a constant state of hypoxia and ischemia. This may prevent proper healing, of tissues are chronically deprived of oxygen. Also foggy brain function and headaches might be from chronic over-breathing!
Additionally, this lack of CO2 therefore causes an alkalosis blood pH. Low levels of CO2 in the blood causes a decrease in calcium (hypocalcemia) ions which can increase nerve and muscle excitability. This can explain other common symptoms of chronic over-breathing including tingling, unusual sensations such as paresthesia, cramps and muscle tetany. Hypocalcemia lowers the threshold for pain nerve impulses, causing hypersensitivity or the increase in sensation of pain.
Now we know that chronic over-breathing deprives your brain and tissues of O2, which can lead to chronic headaches and fatigue. Have you ever heard that sighing often means your brain needs more oxygen? It’s true, sighing often might be a indication that you have breathing mechanic dysfunction, it’s a signal from your brain letting you know it needs more oxygen!
Now onto Assessment
Ideally you should get an idea of how your patient breathes before you assess breathing. That way you can tell if they are altering it when assessing. You can do this during the history or at any other time you are with the patient without them knowing.
Before assessing breathing, a posture analysis should also be performed. Upper crossed syndrome, people that sit at a desk all day and who are constantly in a state of flexion, can affect breathing negatively. You may have to address posture dysfunction as well when assessing and correcting breathing mechanics.
Breathing should be assessed in the following positions:
What to look for:
Treatment in Office
Craig Liebenson, Rehabilitation of the Spine.
Martini. Anatomy and Physiology