Do You Teach Patients How to Breathe Properly?

Spinal manipulation often produces quick results in terms of pain alleviation and improved range of motion. Unfortunately, once the patient is no longer in pain, they may discontinue therapy, only to be plagued by the same complaint at a future date. Without appropriate spinal stabilization strategies, these patients continue to suffer from low back pain symptoms.

So, how do we begin the process of promoting spinal stabilization? The answer is simple: diaphragmatic breathing. According to Karel Lewit, "If breathing is not normalized – no other movement can be." Both spinal and pelvic stability begin with optimal breathing patterning.

The Physiology of Breathing

During normal inspiration, the diaphragm contracts concentrically, flattens and descends toward the abdominal cavity. The abdominal wall musculature, in particular the transverse abdominus, eccentrically contracts in response to positive intra-abdominal pressure resulting from downward visceral movement. Activation of the pelvic floor muscles occurs to maintain continence, and support both the abdominal and pelvic organs.

During this process, the resultant increase in intra-abdominal pressure functionally stiffens the spine through activation of the deep or local spinal stabilization system. This system consists of the diaphragm, transverse abdominus, psoas, quadratus lumborum, lumbar multifidi, and pelvic floor muscles.

Furthermore, the right and left crura of the diaphragm attach to the upper lumbar vertebral bodies; and the medial and lateral arcuate ligaments, which are essentially thickened fascia bands, attach to both the psoas and quadratus lumborum. Coactivation of the psoas and quadratus lumborum is essential for low back stability.

Additionally, proper diaphragm breathing mobilizes the thorax, improving the health of the discs, improves oxygenation of the body and downregulates the central nervous system, thereby restoring parasympathetic function.

Functional control of the thoracopelvic canister (TPC) is achieved by the deep stabilization system. Most important in this control are the transversus abdominis (TrA), which supports the front and sides; the quadratus lumborum, which controls the posterior aspect; and the psoas major and multifidi, which control the anterior and posterior aspects of the spine, respectively, in addition to the diaphragm and pelvic floor.

These structures are fascially bound superiorly through the thoracolumbar fascia and inferiorly through the pelvic floor fascia. Collectively, they function to provide a stable base of support for the kinetic chain, and act as a relay station between the upper and lower extremities, in addition to their role in visceral support.

Why Proper Breathing Matters

The diaphragm is key to maintaining optimal stability of the thoracopelvic canister, as well as improving intra-abdominal pressure. Fascially attaching to the quadratus lumborum, psoas and TrA, the diaphragm forms the roof of the TPC. Because of its unique attachments, the interlinking fascial attachments of the diaphragm act to stabilize the thoracolumbar junction – the important region where the thoracic spine meets the lumbar spine.

In the absence of optimal TPC stabilization, many of the faulty stabilization and resultant movement pattern dysfunctions will be noted. The characteristic lumbar hyperlordosis more commonly occurs at the thoracolumbar junction than at the lumbosacral junction, as these individuals use a posterior extensor stabilization strategy, rather than a circumferential-type stabilization strategy. Individuals with a flexion-dominant strategy will rely too much on their trunk flexors, and anterior myofascial and ligamentous structures, for stability.

Respiration is necessary for sustaining life. It is understood that without vital oxygen, our organ systems would shut down rapidly. It is also understood that the human body has a mechanism by which oxygen is grasped from the environment and utilized in the most efficient ways it knows how.

Basic anatomy and physiology tells us that during inspiration, our primary respiratory muscle, the diaphragm, descends, producing a pressure gradient which results in air entering our lungs. Respiration is under autonomic control. Therefore, we don't need to think about taking a breath every few seconds to maintain proper blood oxygenation levels. So, it would stand to reason that we would automatically adopt the most efficient breathing strategy for optimal respiration.

Unfortunately, this isn't the case. In fact, breathing is the most common dysfunctional movement pattern humans adopt. As a result, issues with spinal stabilization develop, leading to joint restriction and myofascial pain syndromes.

How to Teach Diaphragmatic Breathing to Your Patients

• The patient should be in a supine position with a neutral cervical spine. Hands should be placed lightly on the stomach; knees and hips flexed to 90 degrees and resting on a surface.
• Patient should concentrate on breathing using the diaphragm, not the chest, and feeling the stomach rise slightly and the lower ribs expand. The breath should be felt all the way to the pelvis.
• Tell patient to visualize breathing three-dimensionally; the abdomen and lower rib cage should expand like a balloon.
• Also instruct patient to let their stomach fall naturally when breathing out by relaxing the diaphragm. The rib cage should be positioned downward in line with the pelvis.

Editor's Note: Dr. Robert George addressed functional breathing in a four-part series back in 2012. Part 4 (Dec. 16, 2012 issue, available in our online archives) includes links to parts 1-3.