It is essential that massage therapists develop a good basic understanding of ribcage and thoracic spine (t-spine) biomechanics and their relationship to optimal breathing. So let’s delve into the relationship between breathing and back pain.
When we think of breathing, usually we think of the respiratory system, but, in fact, most believe the neuromyoskeletal system drives the mechanics and coordination of human respiration.
The famed Czech researcher Dr. Karel Lewit states: “Respiration is our primary and most important movement pattern… and also the most dysfunctional.” Most clinicians are aware of how breathing affects posture, alignment and bodily functions, but there is much confusion when it comes to treating underlying joint and myofascial disorders. This article presents an overview of breathing anatomy, assessment and treatment strategies to help clients breathe in a more functional and authentic way.
During inhalation efforts, the ribcage has the unique ability to increase its anterior/posterior and lateral dimensions at the same time. The structure most responsible for the generation of negative intra-thoracic pressure is the diaphragm (Fig, 1). Inhalation causes the diaphragm to contract and move inferiorly. This action flattens the dome-shaped muscle causing a decrease of pressure in the thorax and an increase in air taken into the lungs. As we exhale, the diaphragm relaxes, the dome shape is restored, and air space in the lungs decreases causing us to push air out (Fig. 2). Any increase in abdominal pressure via inhalation flattens spinal curves causing an increase in t-spine and ribcage stiffness and stability. Test on your own body.
This involuntary respiratory action works in close coordination with other structures we loosely call the “core”. Because of the intimate relationship between breathing and bony structures, anything that weakens the diaphragm also adversely affects t-spine and ribcage function. And when the body’s joints stiffen, normal breathing patterns suffer. It matters little if you are engaged in a competitive sporting activity, or simply lifting an infant from a car seat, the core muscles must be properly engaged. Dysfunction in any respiratory-related structure makes us more susceptible to pain and injury.
Restoring function reduces the metabolic cost of movement
When tension, trauma and poor posture alter biomechanics and undermine smooth integrated core movement, it is usually easily detectable during gait and palpation examination. Because clumsy uncoordinated movement is less efficient, it alters the body’s loading and muscle activation patterns. Oddly, many chronic pain clients develop ‘movement amnesia’ and are unable to describe or feel alterations in their movement patterns. But, you’ll find the following conditions often go hand-in-hand with a weakened core and loss of proper diaphragmatic breathing:
- Chronic low back pain
- Frequent tension-type headaches
- Emotional system overload, high stress and persistent anxiety
- Chronic postural strain from desk-occupied postures, etc.
- Repetitive and painful rib fixations
The ribcage and core work as a unit and coordinated movement is essential. Pain manifests if a rib loses the ability to properly coordinate movement with the rest of the ribs and spine as part of a functional unit. This would be similar to a rowing team where one oarsman uses his ore out of sequence with the group. Altered rib function can cause difficulty breathing, restricted shoulder movement, referred pain to other areas, and reactive muscle guarding. Additionally, misaligned ribs can pinch intercostal nerves, sending excruciating pain through the length of the rib and, occasionally, the chest wall (the ole heart attack scare).
It’s virtually impossible to overstate the influence of breathing on t-spine and rib mobility and postural stability. The diaphragm, abdominals, and accessory respiratory muscles produce upward of 21,000 breaths a day. With a strong, freely moving diaphragm serving as the primary muscle for respiration, auxiliary muscles are able to remain soft and relaxed. However, many clients with upper t-spine restrictions (such as a dowager’s hump) breathe primarily with the scalenes and upper scapular fixators (See the attached treatment and training video below)
A weakened diaphragm causes increased resting tone in upper rib cage muscles such as the scalenes, upper trapezius, levator scapula, and pectorals. The latissimus dorsi, pectoralis major and minor are not typically thought of as accessory muscles of breathing, but may be recruited in faulty movement patterns such as paradoxical breathing, where the abdomen moves in on inspiration and out on expiration. This common muscle imbalance pattern creates shoulder girdle protraction, forward head carriage, and decreased lumbar lordosis. Forward head posture may result in significant suboccipital and cervicothoracic pain, as these areas are now asked to bear excessive loads to compensate for the hyperkyphotic t-spine.
An often-overlooked way of relieving nagging neck, shoulder, or low-back pain is to improve ribcage mobility. In Fig. 3, I demonstrate a (bucket-handle) rib lifting technique. This powerful soft-tissue stretch helps create space between the rib cage and pelvic girdle. In Fig. 4, I activate an inhibited diaphragm while mobilizing the ribcage. As the client inhales, he gently presses his elbow against my hand as I resist to a count of 5. Upon deep exhalation, my fingers work up under the costal cage and pump all the stale air from the diaphragm muscle (repeat 5 times).
Every client with breathing problems must be given exercise advice. A basic routine I’ve found effective is to have the client place one hand over the lower abdomen and the other on the upper chest wall just below the throat. Instruct them to push the abdomen out as they take a slow, relaxed, full breath in through their nose, and forcefully pull the belly in as the exhale through their mouth (Fig. 5).
As we age and the thoracic spine stiffens, breathing compensations begin. We tend to take breathing for granted because it is so seemingly basic and automatic. Manual and movement therapists are often guilty of neglecting breathing assessment and treatment in favor of more exotic correctional strategies.
But, breathing is one of the most essential innate movement patterns in the treatment of not only spinal stability and myoskeletal pain, but chronic fatigue and anxiety as well. There are numerous techniques and modalities that teach breathing including yoga, fascial fitness and various forms functional rehab. Treating the dysfunctions and teaching your clients proper ways to breathe are essential for optimal health and athletic performance.