How Breathing May Be Influencing your Strength or Rehabilitation Program

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Breathing is currently a buzz word in the rehab, strength and performance settings.

Recently Physical Therapists, Chiropractors, Personal Trainers and Strength Coaches have been discussing breathing and how it relates to core stabilization and shoulder, neck, back and hip pain. In a rehab setting Hodges et al (2002) observed that the diaphragm contributes to spinal stability by adding to intra-abdominal pressure and enhanced spinal stiffness. In a performance setting breathing and “bracing” properly can help to increase strength and promote improved recovery through promoting a return to a relaxed state after a hard workout.

I am not the first person nor will I be the last to discuss breathing and how it relates to posture, hip, back and shoulder pain, core stability and athletic performance. Though I may be the first person to bring it to your attention and how it may be affecting your pain and recovery.
Contrary to popular belief your lungs are not your primary muscle of inhalation. Instead it is your diaphragm that should drive inhalation as it “acts like a pump at the base of the lungs. (Calais-Germain, 2006).” If you watch the video below you will see the 4 month old breathing diaphragmatically, eliciting a proper overall expansion of its belly to the front, sides, and back. This is what a proper diaphragmatic breathing pattern looks like.
The central nervous system drives this breathing pattern as it drives all other bodily functions. Nowhere during development did someone teach the baby to breath this way, it intuitively knew that in order to survive, this is how it needed to breathe. When the baby breathes this way his diaphragm is contracting and relaxing properly and by doing so he is able to promote the proper exchange of gases in a passive manner, not even thinking about each breath that he takes. This diaphragmatic breathing then serves as the baby’s basis for core stability as they will brace from their diaphragm prior to reaching outside of their base of support, learning to crawl and squat. As you see in the pictures below you will not see an increase in the baby’s lower back curve in any of these movements. Instead you will see a cylindrical expansion of the belly to promote core stability. This is not always the case in an adolescent or adult.
As people age whether it be daily Central Nervous System Stressors or postural habits somewhere along the line most of us lose the ability to properly breathe with our diaphragm. Take a look at your spouse or child and be more aware of how you, yourself is breathing. Do you see their chest rise and neck muscles turn on? Are they using their chest and neck muscles to drive their breathing pattern, or do you see their belly cylindrically expand?
Breathing apically, or with upper chest and neck musculature, can lead to many physiological and structural changes that can negatively influence a person’s spinal column, pelvic positioning and soft tissue attachments. This may lead to neck, shoulder and chest tightness causing headaches, shoulder problems and back pain.
When your neck, low back, or shoulders are out of position or alignment due to increased soft tissue restriction, weakness, increased low back curve, increased anterior pelvic tilt or elevated rib position, injuries occur due to a weak link in the kinetic chain. For instance in a patient with an elevated rib position their shoulder blade will not sit in an optimal, mechanically advantageous position which may lead to problems after repetitive throwing or lifting overhead activities. When a patient has an increased anterior pelvic tilt or increased low back curve this may lead to low back pain or hip problems.
In patients with low back pain, studies by both Radebold et al (2001) and O’Sullivan and Beales (2007) found that these individuals tend to have poor core muscle activation and brace their superficial abdominal muscles and diaphragm. This negatively influences normal diaphragm function, inhibiting abdominal breathing and encouraging an upper chest or apical breathing pattern. This can lead to neck pain, rounded shoulder posture and resulting rotator cuff or thoracic outlet syndrome symptoms.
As you see everything is connected and not all pathologies originate at the point of pain. Often there is an underlying cause somewhere else in the kinetic chain that leads to the presenting symptoms. By no means are proper diaphragmatic breathing patterns the end all be all but it is certainly an often overlooked component to the treatment plan of care and subsequent rehabilitation.
Contributed by Dr. Jon Herting, PT, DPT, CSCS
Calais-Germain, B. (2006) Anatomy of Breathing. Seattle, WA:  Eastland Press.
Gibbons,  S.G.T.,  2001. The model of, psoas major stability function., In: Proceedings of 1st International, Conference on Movement, Dysfunction,  Sept 21–23,  Edinburgh, Scotland
Hodges PW, Gurfinkel VS, Brumagne S et al 2002 Coexistence of stability and mobility in postural control: evidence from postural compensation for respiration. Exp Brain Res 144:293–302.
Jones,  R.,  2001. Pelvic floor muscle, rehabilitation. Urol. News 5 (5),  2–4
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
O’Sullivan P Beale D  2007 Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention Manual Therapy 12:209–218
Radebold  A Cholewicki J  Polzhofer B  et al 2001., Impaired Postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine 26(7):724–730

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