Diaphragmatic Breathing’s Influence on Core Stability and Neck Pain
Ex Rx: Improving poor breathing patterns can go a long way toward helping clients excel in their physical pursuits.
Everyone from elite athletes to average clients can benefit from learning more about breathing or reprogramming the way they breathe. More specifically, by teaching them techniques that emphasize diaphragmatic breathing, you will help them meet their exercise goals.
Diaphragmatic breathingis a pattern of expiration and inspiration in which the diaphragm does most of the ventilatory work. If you observe how babies breathe, you will notice the ease with which their bellies rise and fall. On the flip side, most adults’ breathing patterns are quick and shallow, with very little belly movement and quite a bit of chest elevation. How could this dramatic change develop in such an autonomic function of the body?
Through years of poor postural habits, myofascial restrictions, stress, trying to “suck in” the abdomen and a host of other factors, we’ve steadily removed our diaphragms from the breathing equation and begun to rely on upper-chest accessory muscles to accomplish this all-important task. Shallow and/or quick breathing (extreme cases are referred to as hyperventilation) is associated with many negative health consequences, including respiratory alkalosis, anxiety, irritable bowel syndrome, decreased pain threshold and allergies. In this discussion, we will focus on the impact such breathing has on core stability and chronic neck and shoulder pain (Chaitow 2004). We will also address assessment methods for identifying poor breathing habits in your clients and review some corrective strategies to help them reprogram their dysfunctional habits.
Most people consider breathing a relatively rudimentary task, and they may balk at the prospect of spending time retraining it. If the massive amount of evidence linking poor breathing habits to muscle fatigue and decreased performance is not compelling for your clients, perhaps knowing that other movement patterns cannot be normalized until breathing is addressed will get their attention (Lewit 1980).
Breathing’s effect on movement patterns is chiefly due to the dual role the diaphragm plays in core stabilization and respiration. Traditionally, we have placed the transversus abdominis on a stabilizing pedestal; however, current literature suggests that the diaphragm, transversus abdominis, multifidus and pelvic floor work in unison to create the ideal intra-abdominal pressure for spinal stabilization (Hodges & Gandevia 2000b). These “inner core” muscles fire in an anticipatory manner milliseconds before the prime movers in an effort to stabilize the spine at the segmental level (Hodges & Gandevia 2000b).
Specifically, the diaphragm contributes to spinal stability via a hydraulic effect on the abdominal cavity, thereby increasing intra-abdominal pressure (McGill, Sharratt & Seguin 1995). The problem is that a deconditioned and poorly aligned diaphragm won’t be of much help in providing the pressure and rigidity necessary for the trunk to lift things and move without insult to the spine.
As personal trainers, we see postural breakdown coinciding with poor breathing habits all too frequently. Imagine a chest-breathing runner on the treadmill: without adequate participation of the diaphragm, the rib cage tilts posteriorly, the shoulder girdle elevates and the cervical spine hyperextends. This disorganized body, coupled with the perpetual jarring of the foot strike, places the cervical and lumbar spine in an unstable, vulnerable position.
Shallow-breathing runners often experience tension in their neck and commonly suffer from low-back pain. Consider a chest-breathing client performing his or her last set of deadlifts; the body has to choose between stabilizing the low back and maintaining normal respiration (McGill, Sharratt & Seguin 1995). Since respiration trumps every other function in the body, the low back is now at risk. If this were not the case, we’d see people turning blue and passing out in the gym on a regular basis. The simple truth is that we can manage with less-than-ideal breathing habits, but it will be at the expense of spinal stability.
When the diaphragm’s involvement in breathing decreases, the anterior cervicals (most notably the scalenes) compensate. The scalenes adaptively shorten when they must perform a task they were not designed to do. This becomes problematic because of the potential for the scalenes to entrap the nearby brachial plexus and subclavian artery. Entrapment of these structures is associated with thoracic outlet syndrome, paresthesia, coldness, claudication and lymphedema (Simons, Travell & Simons 1999).
Bilateral tension of the scalenes can also lend itself to forward-head posture, which often results in rounding of the thoracic spine, elevated and protracted shoulders, and scapular winging. Over time, these postural imbalances can result in joint dysfunction at the atlanto-occipital joint, the C4-C5 segment, the cervicothoracic joint, the glenohumeral joint and the T4-T5 segment (Hertiling & Kessler 2006). Forward-head carriage may also promote accelerated aging of intervertebral joints, resulting in degenerative joint disease (White & Sahrmann 1994).
When clients come into the gym with neck and shoulder pain, consider the notion that their problem may actually be stemming from a breathing problem. Although it can be hard to ascertain which came first—dysfunctional breathing or postural distortion—it’s evident that the training protocol needs to address both.
Here are some specific ways to recognize and assess upper-chest breathing:
Posture. Generally speaking, look for a forward head, elevated shoulder girdle, shoulders in a protracted position, an immobile and kyphotic thoracic spine, an anterior tilt of the pelvis and/or a unilateral or bilateral rib flare.
Breathing. The following two breathing assessments are a good place to start an evaluation. Whichever test you choose to administer, observe the length of time for the client to complete a deep breath—a healthy, full inhalation and exhalation should take not less than 10 seconds.
- Fingers and thumbs separation test. Have the client sit in a chair, with you standing behind it. Position your hands so the fingers are facing forward, resting on the superior aspects of the client’s lower ribs, and your thumbs are on the client’s midline posteriorly. Squeeze slightly. Instruct the client to take a deep breath, and note how your fingers and thumbs move. Both the fingers and thumbs should be moving apart from each other, ideally 1.5–2 inches apart (Chaitow et al. 2002).
- The high-low test. Have the client be either supine or in a seated position. Instruct the client to place one hand on the chest, and the other on the belly, and then cue the client to take a few relaxed breaths. During the breaths, take note of positional changes to the client’s hands. Ideally, the hand on the belly should rise before the hand on the chest. The hand on the chest should move slightly forward (not toward the chin). If it moves significantly more than the hand on the abdomen, there is a suggestion of dysfunctional breathing (Simons, Travell & Simons 1999).
A few other telltale signs of dysfunctional breathing are frequent sighs or yawns, repeated throat clearing or air gulping and/or continual mouth breathing.
Even though it may seem less exciting than other protocols, diaphragmatic breathing serves as a basis for functional movement and core stability. Help your clients optimize their diaphragmatic breathing function and you will see them achieve their fitness goals while also reducing some of their nagging aches and pains.
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When introducing heavy loading and powerful movements, coach diaphragmatic breathing in concert with bracing. Bracing is a general tightening of the entire core. Cue the client to pretend he or she is about to be pushed or hit.
The intensity of bracing should be tailored to the perceived difficulty of the action. During simple movements, brace at a level 1 (on a 1-10 scale) across the entire kinetic chain. The greatest coaching challenge is helping clients accomplish the act of simultaneous breathing and bracing. This will require your programming to begin at an appropriate level and to progress as the client masters the task. Progression example: supine; supine with arm movement; supine with arm and leg movement; bird dog; plank; push-ups.
Suzie is an avid runner, competing in at least one marathon per year, and has suffered from chronic neck pain for years. She presents with forward-head posture, limited thoracic-spine mobility and an excessive anterior pelvic tilt. In the high-low breathing test, she shows excessive chest elevation with no abdominal movement. She completes one breath (inhalation and exhalation) in less than 5 seconds, on average.
Suzie’s strength and conditioning program includes exercises to activate the glutes, middle trapezius, rhomboids and serratus anterior muscles. Sessions also include thoracic-spine mobilization and stretching of the pectoral muscles, hip flexors and lumbar erectors. Given her dysfunctional breathing pattern, Suzie’s “retraining” should proceed as follows:
1. Supine (knees flexed, feet flat on floor, arms by her sides). Cue Suzie to breathe in, noting how her chest rises first. With her permission, place your hand on her chest, manually guide the chest down during exhalation and hold it there while she breathes in and out. Tactile feedback is always helpful in the initial stages of retraining breathing habits. Finally, ask her to actively hold her chest in this depressed exhalation position while continuing to breathe in and out. Once she masters this step, it’s time for step two.
2. Supine with arm movement (knees and hips flexed to 90 degrees, shoulders flexed to 90). This stage involves abdominal bracing while breathing (it’s challenging for clients to adopt a braced core while continuing to breathe, so expect this stage to take some time). Instruct Suzie to breathe slowly as she brings her arm back to the floor (shoulder flexion) one arm at a time. Initially, her bracing intensity may be at a level of 8 (on a 10 scale, with 0 being no exertion at all and 10 being extremely difficult), which means she has to work very hard to brace. Once she can breathe over the brace, with a bracing intensity closer to a 1, and she can perform this effectively for 30–45 seconds, add in some randomly placed gentle tapping to her hands, arms and knees. These perturbations will assist in improv-ing Suzie’s reflexive firing of the “inner core” musculature (Cresswell, Oddsson & Thorstensson 1994).
3. Supine with arm and opposite leg movement (knees and hips flexed to 90 degrees, shoulders flexed to 90). Similar to step 2, but cue Suzie to simultaneously drop her heel to the floor.
Also consider adding in bird dogs and planks toward the final stages of this process, with more functional movements such as push-ups and lunges as the ultimate goal. Using this progres-sive sequence is certainly not the only approach you can take, but it illustrates how you can systematically advance your clients into more challenging movements.
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