Clinical methodsBreathing evaluation and retraining in manual therapy
Introduction
Practitioners seeing patients with musculoskeletal complaints are often faced with the fact that while many do well with a combination of manual therapy, education and exercise, there are others that are not fully helped with that approach alone. For example, a sizable portion of many body workers’ clientele comprises people with neck or back pain. Systematic reviews on neck pain (Gross et al., 2007) and back pain (van Tulder et al., 1997) found that the strongest evidence supports manual therapy, education and exercise as beneficial interventions, but both suggest there is much room for improvement. It is important to look at alternatives to supplement current approaches given that back and neck pain are estimated to cost $90 billion per year in the US alone, comprising a huge economic burden to society (Luo et al., 2004).
When considering additional treatment approaches current research can offer direction. For example from the epidemiological literature comes a study pointing out that problems with breathing and continence have a higher association with back pain than do obesity and physical activity (Smith et al., 2006).
According to Hodges et al. (2007), trunk muscle functions of spinal stabilization, continence and respiration are all interrelated. They conclude that when dysfunction occurs in one system, it can negatively impact the other two. Further, it is known that people with back pain brace with their superficial abdominal muscles and diaphragm and have poor core muscle activation (Hodges and Richardson, 1999; Radebold et al., 2001; O’Sullivan and Beales, 2007). In normal breathing the diaphragm descends and causes the ribs to move up and out to expand the lower chest (Detroyer, 1989). When the abdominal obliques become overactive they can limit normal chest expansion due to their role as expiratory muscles. The external obliques, for example, reach as high as the 5th rib. Whether the limited diaphragm descent is due to bracing of the diaphragm itself, or whether its motion is limited due to the over-activity of the oblique abdominals limiting chest expansion, is not known. Either way there is a good argument for an alteration in breathing mechanics where lower chest movement is limited, in association with back pain. In neck pain, it is known that there is frequent evidence of over-activation of some of the inspiratory muscles, such as the scalenes, sterno-cleidomastoid and upper fibres of trapezius (Falla, 2004; Nederhand et al., 2000). While a formal link between neck pain and poor breathing has not yet been established, it has been observed that patients with neck pain do commonly have faulty breathing mechanics (Perri and Halford, 2004).
Section snippets
Breathing physiology
Breathing has both reflex and higher centre control. Higher centre control can be either conscious or unconscious, including learned responses or habits (Thomson et al., 1997; Levitsky, 2003). Reflex control of breathing relies principally on arterial and cerebral spinal fluid CO2 levels (Levitsky, 2003). The ideal partial pressure of CO2 in the alveoli and arterial blood is 40 mmHg. This state is referred to as eucapnia with 35–45 mmHg being considered the normal range (Levitsky, 2003).
Hyperventilation syndrome
Symptoms associated with faulty breathing have been discussed in the literature since the 1930s (Gardner, 1996), and have often been put under the label of hyperventilation syndrome. There has been ongoing debate about the definition, and even the existence of hyperventilation syndrome. It has typically, although inappropriately, been viewed as a psychiatric phenomenon related to anxiety and panic (Gardner, 1996). Part of the difficulty stems from a lack of agreement around diagnosis. Most
Capnography
The gold standard for measurement of hypocapnia is through arterial blood gases (Gardner, 1996). The test is invasive requiring a blood sample through an arterial puncture and a laboratory to perform the tests. It gives information about the CO2 level only at that moment in time. Since CO2 levels can change on a breath-by-breath basis (Levitsky, 2003), knowing about one moment in time can limit detection of transient or situational hypocapnia (Gardner, 1996). However, continuous values can be
Clinical application
Poor respiratory chemistry may provide an explanation as to why so many treatment-resistant patients have a constellation of symptoms involving other body systems, in addition to their musculoskeletal complaints. Not only are there changes to breathing, in association with breathing muscle mechanics, but also there can be increases in ventilatory drive secondary to pain and emotion (Levitsky, 2003). Many patients feel stress associated with their pain and diminished function, in addition to the
Conflict of interest
The author is a shareholder, a member of the board of directors and a distributor for Better Physiology, a capnograph manufacturer.
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2022, HeliyonCitation Excerpt :Respiratory rehabilitation may also improve functional capacities and quality of life for patients [7]. There are various methods used to diagnose HVS such as an arterial blood gas (ABG) test, hyperventilation provocation test (HVPT), and capnography [9, 10]. However, these measurements are not appropriate for screening HVS due to its costly or invasive procedure.
Respiratory dysfunction in patients with chronic neck pain: What is the current evidence?
2016, Journal of Bodywork and Movement TherapiesCitation Excerpt :Furthermore, although hypocapnia is usually considered clinically synonymous with hyperventilation (Gardner and Bass, 1989), it is in reality an index expressing a relatively different dimension of respiratory function as there are conditions where PaCO2 and ventilation changes do not present this association. Although there is no known study about ventilation parameters in neck pain patients, with the exception of indirect hypocapnia measures (McLaughlin, 2009; McLaughlin et al., 2011; Dimitriadis et al., 2013a), assumptions could be tested from findings about Respiratory Rate (RR) and Tidal Volume (VT). However, the evidence regarding these indices is also limited and not well-documented.
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2013, Recognizing and Treating Breathing Disorders: A Multidisciplinary Approach'The core': Understanding it, and retraining its dysfunction
2013, Journal of Bodywork and Movement TherapiesCitation Excerpt :Correct breathing patterns are ‘the’ basic building block of ‘core control’. Retraining faulty breathing is multifaceted (Chaitow et al., 2002; McLaughlin, 2009) and may require quite some work in order to reestablish healthy patterns. Once mastered, it is important that they then become incorporated through the ‘stabilizing synergy’ into sustained antigravity postures (Fig. 19) and functional patterns of posturo-movement control.
Relationships between measures of dysfunctional breathing in a population with concerns about their breathing
2011, Journal of Bodywork and Movement TherapiesCitation Excerpt :In fact he found that mean levels of CO2 in healthy individuals were around 36.2 mmHg with 2 standard deviations below this level being 32.2 (Gardner, 1995). Regardless of arguments over CO2 cut-offs it can be concluded that persistently low CO2 and low CO2 in response to challenge testing is an aspect of dysfunctional breathing worthy of measurement, particularly as end-tidal CO2 which fairly accurately represents arterial CO2 can be easily measured with modern capnometry equipment (McLaughlin, 2009). Breath holding ability is an aspect of breathing functionality that is commonly disturbed in individuals with tendencies to hyperventilation and to dysfunctional breathing (Jack, Darke et al., 1998; Warburton and Jack, 2006).