Editor's note: Part 1 of this article appeared in the June 17, 2012 issue.
We are all born with innate primal movement patterns that are built into our central nervous system and come as "standard equipment" with the gift and mystery of being human. When we think of breathing, we think of the respiratory system, but what drives the mechanics and coordination of breathing patterns is motor activity of the neuromusculoskeletal system. Dr. Karel Lewit states that respiration is our most important movement pattern.2 It is also our most common faulty movement pattern.
It's important to observe and detect respiration dysfunction, and help teach our patients to breathe in a more functional or authentic way. The quality of our breathing affects posture, alignment and function of our entire musculoskeletal system. Checking for breathing dysfunction takes just a few moments and can be assessed seated, standing, supine, prone or during a functional activity. Your patients will benefit greatly from a few minutes of daily breathing exercises.
Evaluating Breathing Patterns
A good starting place is to have your patient in a standing or supine position. When you examine your patient, ask them to "take a slow, relaxed, full breath in." Don't just ask them to "take a deep breath in."1 This subtle but important cue will provide a more accurate assessment to determine the patient's most common automatic pattern without conscious alteration for the sake of performance.
According to Maria Perri, the first thing to notice is if they breathe with their mouth open. Mouth breathing reduces the pharyngeal air space and patients will compensate by using accessory muscles of respiration. Mouth breathers tend to lean forward with the head and shoulders, which can cause neck and upper thoracic structural dysfunction. Mouth breathing can also disrupt pH balance of the blood, often making it too alkaline. Alkalosis in some individuals can lead to apprehension, anxiety and even panic attacks.1 This pattern of alkalosis can also be associated with chronic pain conditions.
The most important breathing fault is "vertical" breathing or lifting the collarbones, shoulders and upper thorax with inspiration instead of "horizontally" pushing the lower abdomen and lower rib cage out during inhalation, and then drawing the abdomen back in during exhalation. This chronic and repetitive pattern gets ingrained or "grooved" in the CNS and can be linked to cervical pain, headaches, shoulder pain and lumbar spine instability.
Normal movement of the upper thorax is appropriate during respiration depending on the demand imposed during physical exertion. Upper chest lifting is not appropriate for relaxed breathing.
A serious movement fault or dysfunction Perri describes is paradoxical breathing. The abdomen is drawn in during inspiration and pushed out during exhalation or reversed from a normal pattern. This chronic problem can have a number of causes including stress or chronic obstructive pulmonary disease, but one cause is cultural, stemming from an attempt to have a flat stomach. Paradoxical breathing, in addition to vertical breathing, is a common cause of not only lumbar pain and spinal dysfunction, but also anxiety and incontinence.1,5
The inability to brace the abdomen to stabilize the spine and breathe normally is a primary respiratory fault. Given the chance, the CNS will prioritize breathing over spinal stabilization, leaving the musculoskeletal system vulnerable to injury.1,4
With functional breathing, the abdomen at the umbilicus moves in and out horizontally with very little or no movement of the collarbones or shoulders. The lower rib cage should expand laterally with inspiration and expiration through the nose in a relaxed and rhythmic fashion.1
There are several ways to help patients become aware of their breathing dysfunction after their initial breathing check. For starters, put them in front of a mirror and have them watch their breathing. Do they mouth breathe? Does their stomach and lower rib cage move horizontally during inhalation or are their collarbones and shoulders moving vertically? Do their SCMs bulge out like a body-builder as they take a simple breath? Ask them what they see and feel.
If any of these signs is present, have them lie supine on your table and put one hand on their umbilicus and the other on their chest, just below the episternal notch. Have them visualize a skinny tube going into a big bowl. When they breathe in through their nose, they can imagine taking air in through a skinny tube to fill a bowl in their abdomen. Their throat and chest muscles should be completely relaxed as they push their lower hand with their stomach straight up toward the ceiling, letting the air fill their lungs. To exhale, ask them permission to gently push on their lower hand with your hand while they pull in their navel in a smooth and relaxed fashion.1
This is easier than in looks. You may find many patients breathe in a "paradoxical" fashion. This dysfunction can be overcome with training, and this new functional pattern can become subcortical or automatic with short periods of practice every day.1 This can also be considered "regrooving" a new CNS pattern.
A way to help with vertical and/or paradoxical breathing dysfunction is called "crocodile breathing." A good visual is to imagine a "croc" on the river bank sunning themselves with just movement of their abdomen, in and out.
Have the patient lie prone on the ground with their forehead on top of their crossed hands. Place one hand on the patient's upper back and the other on their lower back. Instruct the patient to breathe in as they press their navel into the ground. You should feel a gentle rising of their lower back with essentially no movement of the upper back. Pressing the navel into the ground gives the patient a kinesthetic sense of what their abdomen needs to do as they draw in a breath while pushing their abdomen into the ground.
As the patient is breathing, place your middle three fingers gently underneath each side of the patient's lateral rib cage. You should feel lateral pressure pushing out with each breath as the abdomen is expanding during inspiration. You can also instruct the patient to push out laterally as they breathe into your fingertips.3
One asymmetry you may discover is that the patient may have pressure on one side as they breathe in, but absent or diminished pressure on the other. Simply push gently into the side that is diminished and see if the patient, upon instruction, can push into your fingertips with conscious effort on that side. The verbal instruction and the tactile cues from your fingertips will give the patient a feeling / sense and memory of how to breathe more symmetrically.
Another way to help patients discover how to breathe horizontally, instead of vertically, is to have them sit in a chair and push their fingertips into both sides underneath their rib cage at the bottom of their thorax, and then take a slow, relaxed, full breath in. If their fingertips push out laterally and symmetrically while their lower abdomen extends and their shoulders and upper thorax remain still, then they are developing a functional breathing pattern.
When a patient can breathe functionally in a supine, prone, seated and standing position, they can progress to functional activities while practicing breathing. With every step of difficulty in a position or activity, many patients will revert to a tense and dysfunctional pattern. Simply reduce the challenge, re-cue and remind how to breathe. (There is also respiratory training for asthma called the "Buteyko control pause," which can be read about online.)1
Every patient with breathing dysfunction needs to be given simple homework. The most basic is to lie supine when they go to bed at night and put one hand on the lower abdomen and the other on the upper chest below the throat. Instruct them to push the abdomen toward the ceiling as they take a "slow, relaxed, full breath in" through their nose, breathing out through their mouth. Remind them of the "skinny tube and big bowl."
During their warm-up at the gym (or in your office, if you do exercise / rehab protocols in-house), have them "crocodile" breathe on the floor between sets of exercise. During the day, they can check in with themselves and their breathing. If they are tense, do they notice they are shallow chest breathers, or can they remember to create relaxation with deep, abdominal respiration?
If progress is slow and there is trouble maintaining normal breathing, make sure to check for tight scalene, upper trapezius and levator scapulae musculature. Check for fixations / subluxations in ribs 1-4 and the thoracic spine, as well as trigger points in the diaphragm.1
Breathing is something most of us take for granted, and because it is so seemingly basic and automatic, it is easy to pass over in favor of more exotic correctional strategies. Breathing is the most critical movement pattern in the treatment of not only spinal stability and musculoskeletal pain, but chronic fatigue and anxiety as well.
There are numerous techniques and applications to teach breathing, from yoga to rehab to high-performance athletics. Teaching your patients the basics of how to breathe well is an essential adjunct to an effective treatment and lifestyle plan.
- Perry M. Rehabilitation of Breathing Pattern Disorders. In: Liebenson C. Rehabilitation of the Spine, Second Edition. Lippincott Williams and Wilkins: pages 376-386.
- Liebenson C. Faulty Movement Patterns (seminar and workbook). March 2012 seminar notes.
- Jones B, Cook G. Functional Movement Screen II (course notebook): page 7.
- McGill SM, Sharratt MT, Sequin JP. Loads on the spinal tissues during simultaneous lifting and ventilator challenge. Ergonomics, 1995;38:1772-1792.
- Smith MD, Russell A, Hodges PW. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust J Physio, 2006;52(1):11-16.
Dr. Robert "Skip" George practices in La Jolla, Calif., where he integrates chiropractic, rehabilitation and sports performance training. He is a certified Functional Movement Screen instructor and has lectured nationally on subjects related to the chiropractic profession. He can be contacted with questions and comments at