Breathing Control – musculoskeletal applications

July 6, 2011 by   Print
Filed under Movement Impairments, Physiotherapy Blog

Breathing control is a topic close to the hearts of most physiotherapists.  My recollection is that respiratory care in general was never a particularly popular speciality in my time as a rotational physiotherapist and I am not sure much has changed.

However, there was a temporary resurgence of interest in musculoskeletal applications of respiratory assessment over a decade ago with the evolution of core stability research.  Don’t worry – we’re not going to get into another laborious discussion on the merits of core control here!

For those whose memories are short, part of the theoretical modelling of  mechanisms of core control as proposed by Hodges and Jull was the synergic interaction of four muscle groups which formed an internal cylinder within the trunk. (see thoracolumbar fascia for  review) These muscle groups consisted of:

The anterolateral abdominal wall.

The deep spinal musculature and associated thoracolumbar fascia.

The pelvic floor

The diaphragm

The conceptual model was that the diaphragm generated a base line level of resting tone to provide mechanical resistance to stiffen the internal muscle cylinder  comprised of the synergic muscles listed above and thereby facilitate spinal support.  Superimposed upon this diaphragmatic postural function was the intermittent phasic contraction associated with the respiratory cycle.  This fitted in nicely with the much described muscle activation model (Bergmark) of sustained tonic low level activation with superimposed bursts of phasic activity related to functional demand.

This became relevant to physiotherapists because of the common observation of breath holding when executing exercises aimed at core muscle activation.  In fact many exercises, both rigorous, high load and fine dexterous tasks, are often associated with temporary breath holding simply associated with concentration on the task.  However, from an instructional perspective, it was deemed important that physiotherapists recognise breath holding as a potential compensatory strategy to artificially achieve core stability, with the obvious disadvantage of not being sustainable for any longer than the period of breath holding.

Around this time also, in the field of occupational medicine, it became evident from EMG studies that prolonged sitting and typically in poor posture, compromised diaphragmatic excursion (simply as a consequence of the mechanical restraints of the thorax and ribcage) and thereby potentiated a compensatory strategy of inhibiting / relaxing the anterolateral abdominal wall as the path of least resistance relative to superior diagrammatic excursion into the restricted chest cavity.

Superimposed upon this sustained static loading scenario, was the frequent clinical observation of elevated / rounded shoulder girdles whether habitual, stress induced, ergonomic or breathing compensation induced, which all fed into a cycle of musculoskeletal compensation.

For some years, well known American physiotherapist Peter Edgelow, has been highlighting the merits of specific breathing control in treating thoracic outlet disorder’s (That well known clinical hot potato at which so many different therapies get thrown).  Edgelow’s contention, also substantiated by the opinions of Travell & Simons’ in the myofascial world, contended that scalene hyperactivity associated with respiratory dysfunction had the potential to either change thoracic outlet dynamics by virtue of their rib attachments, or simply by increasing muscle tone and reducing the diameter of the thoracic outlet and hence the potential for neural irritation.  Coupled with the adaptive changes in this area were potential tightness of the Pectoralis minor and a protracted shoulder girdle all increasing the likelihood of anterior compression.

I have always found teaching breathing control challenging in the clinical situation, partly because of the difficulty in achieving patient compliance and also because of the difficulty in proving direct association with the clinical features.  With this in mind I was interested to see some recent developments in this area, which I intend to explore further.

The first is the work of a Canadian physiotherapist Laurie McLaughlin who presented at the 3rd international conference on movement dysfunction in Edinburgh a couple of years ago.  She is using some interesting techniques to evaluate breathing function and her work is outlined in more detail if you follow the link.

The second factor, (which partly initiated this post) was a recent notification from Human Kinetics on a book publication entitled ‘Breath Strong, Perform better’.  This looks an interesting one and is certainly on my ‘to read’ list.

For those who are interested in this subject the work of Simon Gandevia (who incidentally was a collaborator with Paul Hodges’ original work) has been a significant contribution in this field.  There is a concept in the sports science literature known as ‘respiratory entrainment’, which studies the pattern of respiratory activity in association with limb and body position.  This has been studied in cyclists and rowers in particular, with the view to attempting to understand mechanisms and also determine whether limb / body position and repetitive movement dictate the respiratory pattern or visa versa.

In the context of  the recent Wimbledon Tennis tournament, the much talked about grunting and groaning of female tennis players has achieved it’s usual amount of attention but also appears to be associated with these breathing control / mechanical force output requirements.

So perhaps as musculoskeletal physiotherapists it is time to reconsider our attitude to breathing control and to evaluate the multitude of variables which impinge upon this function from a musculoskeletal perspective,

Let us know if you have any useful clinical strategies or experience in dealing with this type of caseload.

Enjoy the clinical challenge.

 

David

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