Clinical methods
Breathing evaluation and retraining in manual therapy

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Summary

Patients with back and neck pain commonly seek body work yet there are some who do not experience full recovery with the typical tool kit of manual therapy, education and exercise, suggesting the need for additional clinical approaches. Epidemiological literature linking back pain with breathing difficulties suggests one possibility. Altered motor control associated with back and neck pain appears to negatively impact breathing mechanics, which may have negative consequences on respiratory chemistry. Changes in respiratory chemistry can have profound effects on body system function.

Altered breathing has been recognized for many years as a potential source of a wide variety of unexplained symptoms. There has been controversy around accurate diagnosis with symptoms and questionnaires often being the only methods used. Capnography, which is routinely used in critical care settings, offers an objective measure of respiratory chemistry providing physiological data on which to base a diagnosis of poor breathing. Capnography can also be used as biofeedback to guide breathing retraining.

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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