“Dysfunctional breathing” usually refers to a group of disorders including paradoxical breathing (upper chest breathing), erratic breathing, breath holding, and hyperventilation syndrome. (1) All of these are problems that will cause oxygenation deprivation problems. (2) Dysfunctional breathing also effects the spine and core musculature and it is this aspect of poor breathing mechanics that will be discussed. 

The diaphragm is a thin skeletal muscle that separates the chest from the belly and it plays a key role in breathing and core stability. (3) The diaphragm acts as a key trunk stabilizer during activity and like other core muscle it must properly activate upon demand. That is why dysfunctional breathing can lead to common musculoskeletal problems involving the head, neck, shoulder, and lower back. (4)  

This is because there is a lack of functional “stability.” This is when a joint remains in a neutral position throughout its range of motion. This reduces mechanical strain on ligaments, capsule, cartilage, and joint surfaces. This reduction in strain allows the muscles to perform at their greatest mechanical advantage. (5) Correlated to functional stability of other joints in the body is intraabdominal pressure (IAP). It is responsible for spinal stability. (6) 


Causes of dysfunctional breathing 

Intraabdominal pressure determines the strength and tone of the muscles forming the “abdominal canister.” Imagine that the area from your pubic bone, hip bones, and tailbone up to the bottom of your shoulder blades and nipples is a canister. The front and sides of this canister are formed by the transverse abdominus and intercostal muscles. The back of the canister includes the paraspinal muscles- from the superficial spinal erectors to the deeper multifidi. The bottom of the canister is formed by the pelvic floor and the diaphragm serves as the roof. All these muscles work in a coordinated fashion to regulate intraabdominal pressure and core stability. (7) 

When they are working as a team there is a stabilizing effect. (8) This process is initiated when the diaphragm contracts to compress the abdominal cavity. This pressure is matched my a co-activation of the pelvic floor. The pressure from the top and bottom are maintained while an eccentric contraction of the abdominal wall and lumbar extensor muscles provide front to back stability. This 3D engagement maximizes intraabdominal pressure and enhances core stability. (9) 

The maintenance of IAP can also be thought of as bracing your trunk. When you move with a braced trunk you are protecting the spine throughout movement. The braced core provides a stable foundation for movement of the head and the limbs. The combination of healthy functioning muscles in conjunction with central nervous system (CNS )control creates “stability.” The nervous system will reflexively brace the trunk in anticipation of movement. (10) 

As mentioned before the diaphragm is the key modulator of intraabdominal pressure. (11) It initiates the pressurization by contracting which then leads to contraction of the abdominal wall. This is easy to achieve when breathing, but sometimes movement of the limbs do not coincide with the initiation of a respiratory cycle. With training the diaphragm can adapt to perform its dual role of respiration and stabilization simultaneously. (12) Learning to engage the diaphragm’s postural contributions independent of breathing is an important component of spine stability. (13)  


Common symptoms of dysfunctional breathing 

Sustained or repetitive movements can cause a challenge for the body and mind. The body doesn’t maintain adequate intraabdominal pressure and the mind doesn’t adequately initiate stabilization. (14) If this is the case then the diaphragm’s role as a stabilizer must be enhanced. (15) That is because individuals who can’t efficiently contract their diaphragm have an increased risk of lower back pain from strains, disc lesions, and spondylolisthesis. (16) Poor diaphragmatic contraction can even de-stabilize the spine and cause over activation of the spinal erectors. This leads to low back and sacroiliac pain that can be remedied by fixing the altered breathing patterns during activity. (17)


How to evaluate dysfunctional breathing 

The most common form of dysfunctional breathing is paradoxical breathing. In a “normal” inhale the diaphragm contracts and flattens, pressurizing the abdomen and causing it to expand. The upper chest will remain relatively still while this is taking place. A “paradoxical” pattern is where the abdomen remains still or retracts while the upper chest elevates and expands during inhalation.   

Assessment involves looking for the elevation of the upper rib cage, asymmetrical lateral rib cage expansion, labored breathing, frequent yawning, hyperventilation, excessive paraspinal muscle contraction, and/or initiation of breathing from the chest rather than the abdomen. (18) Initiation of a deep breath should start in the abdomen with minimal chest elevation.  

Detection of rib cage movement can be enhanced by placing pressure on the thoracolumbar paraspinal muscles, lower ribs, and the abdominal wall. Another way to assess the postural function of the diaphragm is by instructing the patient to pressurize their abdomen while holding their breath. The goal is to be able to preserve abdominal pressure while breathing. Then abdominal pressure and breathing must be maintained during an overhead squat.

If there is dysfunctional breathing you will rely on accessory muscles of breathing which can lead to irritation of the: upper trapezius, scalenes, levator scapulae, SCM and/ or pectoral muscles.


Upper cervical chiropractic for dysfunctional breathing 

Rehabilitation of dysfunctional breathing is an essential to restore diaphragmatic function which must be achieved before doing balance or stability exercises. This is a primary core function and no benefit will be achieved from core exercises if dysfunctional breathing is present. (19)  

The progression for retraining proper breathing mechanics is as follows.  

  1. Educate yourself about the detrimental effect of abnormal breathing and poor mechanics 
  2. Understand your abnormal breathing pattern and recognize it by feeling the areas of dysfunction while observing yourself in a mirror.  
  3. See a demonstration of normal breathing mechanics

After this the training of proper breathing techniques can begin. The ideal breathing cycle is three seconds of inhalation followed by six seconds of exhalation. Lay on your back and place one hand on their abdomen and the other over their sternum. Breathe slowly and deeply through your nose. Only the hand over their abdomen should rise, and the hand over their chest should remain still. Maintain a mild compression of the abdomen while you breathe in, followed by relaxation of the pressure as they breathe out. Practice two to three breaths hourly and 10-20 breaths upon awakening and retiring. Once you have achieved proper breathing mechanics on your back then practice seated, then standing, and while performing dynamic movements (i.e. overhead squat). 

When the diaphragm is properly activating progress to other stability exercises. Maintaining the balanced co-activation of the diaphragm, pelvic floor, abdominals, and spinal extensors. Specific exercises could include abdominal bracing exercises, planks, bird dog, and dead bugs.


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