Altered Breathing Pattern/Hyperventilation Syndrome

[gwynnwallace]

When assessing do any of you look at the impact of altered breathing pattern with respect to musculoskeletal assessment. Should we be? e.g. link with alteration of breathing when lifting, link between diaphragm and pelvic floor function, dysfunctional diaphragm and resultant use of secondary accessory respiratory muscles - just a thought.

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[alophysio]

Good thought Thorax dysfunction and lumbopelvic hip dysfunction are closely related IMHO

[Canuck Physio]

This is the most important thing overlooked ever..ever.

A recent study in the UK has shown that there is a close relationship between respiratory rate and onset of MI in patients under vital monitoring suffering from Ischaemic Attacks or other temporal events.

I also have a belief (as I can not back it up by evidence yet), that breathing, stress, and altered patterns of movement and behaviour are all linked to rapid and shallow unconscious breathing. If we were breathing consciously all the time, just imagine how awake we would be to the world around us. Rather than zipping through it.

Try it, take a revitalizing breathe right now.

[alophysio]

i agree - very overlooked...

...but to me, it is the Thorax which is the overlooked issue...breathing is just one aspect of the thorax assessment...

but that is just my opinion.

The morla of the story is the same - don't forget to assess breathing!!!

[gwynnwallace]

well three like minded people is a start

check out "Hyperventilation and the body" c gilbert in A & E nursing 1999 vol 7 130 to 140
and "understanding breathing" by leon chaitow in massage and bodywork june/july 2007 28 - 40.

these for me were the "lightbulb moments" when i began to think we were missing something.
happy reading

[estherderu]

Have treated more than a hundred patients diagnosed with HVS.

How did I get to see so many in a periode of 5-6 yrs?

At the time (70-80's) a study into hyperventilation occurance was being conducted at the University of one of Holland's big cities and as a result, lots of people were diagnosed with a hyperventialtion syndrome. When compaired to other big cities however, the number of HVS patients was much higher in "our" city!

These people were all sent to us physiotherapists of course. When you have a syndrome, you need treatment! At the time patients ( being better informed) were also becoming more and more aware of the treatment possibilities and they expected to be "treated" for it.

We know that hyperventilation is a functional adaptation of our bodies to increased loading. We know it can be stress involved. We know that lots of people are in a permanent state of "inspiration" (I mean postural state of thorax- not mind).
What this taught us, is that it (HVS)can also become epidemic.

Sometimes hyperventilation can be a functional adaptation as a result of thorax immobility.
A good history and assessment is vital;
breathing patterns during rest and specifically when people are talking can be very helpfull
AND I always checked the thoraxic spine and thorax mobility,
in some cases, patients have a weak diaphragma.

Sometimes all a patient needs is reassurance and some relaxation exercises; sometimes mobilisation of the spine and thorax are necessary; sometimes muscle strength training and breathing exercises...

It all depend on:
what you find
how well your patient comprehends the situation
what his/her goals are

Esther

[Canuck Physio]

permanent state of "inspiration" (I mean postural state of thorax- not mind).

great pun

[neuromuscular]

Breathing involves an overlooked muscle - the serratus posterior inferior.

I could not run without hyperventilating.

In my research, I linked a pelvic imbalance which was charaterized by a adductor longus(L), psoas (R) which caused a torsion to the spine or an attempt at a rotoscoliosis. This triggered reposnses from the serratus pos inf (R) and QL (L). The result was breathing problems. This has been missed in much of the research, which focuses on other breathing related disorders.

The serratus pos inf creates the desire in the patient to be a belly breather. Treat the cause - pelvic angle problems, APAS, and the belly breathing will be considerably reduced and the person will start to rib breath again. Breathing problems will be reduced as the force against the serratus is deminished..

Hope this is helpful.

Best regards,

Neuromuscular

[alophysio]

HI - how were you sure it was serratus posterior inferior?

THanks

[neuromuscular]

HI - how were you sure it was serratus posterior inferior?

THanks

The serratus pos inf allows the bottem ribs to flare.

When I was treated for APAS, and the Left QL and the right serratus posterior inf, the breathing returned to normal. This has remained true in all patients that I have treated.

The APAS sets up scoliosis as the anchor for the right psoas often proves to be the left QL and the right serratus pos inf. Most patients with pelvic angle differences show a lateral deviation of the spine to the left in the lumbar region as a result. This shows how the pelvic angle difference works it way through the body.

Palpation reveals that these are very tender. Treatment releaves the patient of his problems. The patient returns to rib breathing after the treatment. The patient stops belly breathing also.


Best regards,

Neuromuscular

[alophysio]

hi neuromuscular - my point is that serr post inf is not that big a muscle compared to serr ant. It most likely plays a synergistic role.

Also, to palpate to the layer of serr post is very difficult because of the many layers of muscles going over it.

I guess what i was asking was did you use RTUS to image it and therefore determine that the muscle in question was actually serr post inf or are you guessing/deducing it to be be ...

Having said that, Serr post inf has a definite line of pull so i am guessing that only lats would have a similar line of pull and so you might be able to feel the difference...

Just a thought...

[neuromuscular]

hi neuromuscular - my point is that serr post inf is not that big a muscle compared to serr ant. It most likely plays a synergistic role.

Also, to palpate to the layer of serr post is very difficult because of the many layers of muscles going over it.

I guess what i was asking was did you use RTUS to image it and therefore determine that the muscle in question was actually serr post inf or are you guessing/deducing it to be be ...

Having said that, Serr post inf has a definite line of pull so i am guessing that only lats would have a similar line of pull and so you might be able to feel the difference...

Just a thought...

The correction of the rib to spine distance and the return to postural anatomical neutral or normal was the criteria. The lats produce a more right lower shoulder than affect the breathing. Often the lats are a synergyst to the serr pos inf that is in distress.

I guess that I am more result driven in clinic than the more use of the radiographic or technical driven results. A, patient of mine had been given every radiographic examination and was slated for a Harrington Rod Implant operation. However, in the rush, no one had considered the effect of or even the possibility of leg length difference. I suggested it and the specialist did not even know where to have it done. This patient has had no symptoms after treeatment and has not had it reoccur after shoe hieght adjustment. Further, through the work I have been doing on him, the scoliosis is reducing. Return to anatomical neutral to me is the prime factor.

The patients treated did not have a reoccurance unless the APAS reoccured or the rib position or misalignment reoccured.

I think that radiographic examination or electronic assesment has its place, but it does have a 15 to 20% failure rate as the trial at the Winnipeg Hospital has shown.

In clinic results impress me more as this is my field of practice and endeavor.

I use postural assessment as my guage of success. if the patient returns to postural neutral throughout the range with hip abduction, I know that the results are evident. Further, pain levels are reduced and do not reoccur.

Thanks for your continued interest.

Best regards,

Neuromuscular.

[bikelet]

Dear Neuromuscular,

This probably is a silly question- just wondering what is wrong with 'belly breathing'. Many non physio ppl such as myself are under the impression that this is the right thing to do and = diaphramatic breathing?

[alophysio]

Hmmm,

Bikelet, read at the end of this post please...

Neuromuscular, i am sorry for not responding to this and other correspondence but i have been away lecturing.

My impression, and this is obviously and opinion, is that you have developed theories and models based on your clinical experience.

As you say, you are a clinician (and so am i BTW ).

For myself, whenever i try to explain what i think is happening clinically, i try to understand what the 'experts' say happens and what other explanations are out there. I also try to ensure i don't fall into the trap of scoffing at other theories but rather, i try to understand them (like i have been with your APAS theory).

From your language, it would seem you have very definite ideas of what is going on and i often want to challenge those ideas - not because it doesn't work but because it may not be theoretically correct - am i making sense?

In this particular instance, i have attached a PDF from Netter's Anatomy and this link from Wikipedia which is taken from Gray's Anatomy... Serratus posterior inferior muscle - Wikipedia, the free encyclopedia.

1. To my way of thinking, internal oblique is in a much better position to flare the ribs. It is larger than Serr Post Inf

2. Lats and the LDF intimately blend into it, making the mm a likely synergist. Also, to generate torque, you would think that it would have a stronger attachment than a thin aponeurosis to the SP and supraspinous ligamanet.

3. I have personally felt dissections of this area - the muscle is TINY compared to the obliques and lats.

Therefore, your strong, confident comments do not seem to me to be well researched... which led me to ask how you were so certain that it was serr post inf.

Looking at the anatomy pictures, there are so many muscles in the same area, you could have treated lats, IO, EO, TrAb, even erector spinae.

To call lats a synergyst may be a misnomer - perhaps dysfunction or overactive but lats are a forced expiratory muscle - which is why people hold on tight when puffing - for the forced inspiration (scalenes etc) and forced expiration (abdo mm and lats etc)

Can you reference the trial at winnipeg hospital please? Just so i can check the facts of the trial.

Also, your assessment methods are subjective (unfortunately) - i too am more concerned by the results than the theory but if we are to propose why something works, i would be a little more careful...it would have been very easy for someone to just dismiss your theories as being unfounded.

However, people do it to me without thinking about what i am trying to say which is why i try to ask you lots of questions to glean what is going on (compared to what you think is going on).

I hope i am making sense...

Your thoughts on the matter are more than welcome of course!

Bikelet,

belly breathing is usually a sign that the person has locked their ribs down and so you seen the belly moving in and out because the rib cage is not moving - the pressure has to go somewhere.

Normal breathing is seen as the chest and the abdo moving equally

cheers

[sharileedahl]

I've been away from this site for a while so I'm joining in on this topic a month after its start but... a few thoughts.

I was first introduced to the thought that changes in breathing pattern can affect chonic pain (and other msk pain...not just in the thorax) a couple years ago. The researcher / clinician that was presenting the material referred to their use of capnometry to measure changes in breathing patterns but also to assist in retraining clients' breathing patterns. They found positive effects on their pain / dysfunction. My thought at that time was that this was a relatively new concept in the world of physiotherapy (other than the Tsp and ribs move with inspiration and expiration) and looked forward to hearing more.

So it is interesting to read Esther's comments regarding her previous work experience in the 70-80s. I guess sometimes our new concepts aren't all that new after all??

Regarding the link between the diaphragm, pelvic floor, TrA, Multifidus etc there is definitely a link that continues to proven in research over the last many years. I heard Paul Hodges speak a couple years ago and based on that I jumped at the chance to take one of his courses when he was recently in Canada. My little brain is now jammed with little factoids and graphs. (Anyone who has met him probably knows what I'm talking about!) Very cool research but as the years go by I start to wonder something....

As physios (researchers and clinicians) we are breaking things down in to minute pieces (i.e. we train folks to contract TrA, multifidus......we train people to change their breathing pattern.....we train folks to do pelvic floor exercises etc etc). I guess the theory is that if our clients can get these little pieces working properly again that they will work properly as we introduce more functional exercise and they return to normal ADL / sport / work...
The reason I find this very interesting is that I have been dabbling in yoga of the past number of years. As I learn more about physiotherapy research, I realize how much of what we teach has been stressed in something like yoga that has been around for a very long time. It would be interesting to see research on yoga postures and practice compared to motor control training as researched by Hodges and the likes.

So back to Esther's comments....it would be interesting to note where that rehab process came from in the 70s and 80s when the present physiotherapy research is presenting the link with msk pain and breathing as a new concept.

Any thoughts??

[alophysio]

Hi sharileedahl,

i am not sure that msk pain and breathing is a new concept. I suppose researchers might emphasise the *findings* as new but as you say, the concept is older. As for Esther's research, perhaps the findings were in Dutch??

I too would be interested in the findings/reference for the research.

Cheers

[neuromuscular]

Dear Alophysio:

Sorry for not replying sooner, but I had an emergency appendectomy.

I guess the facts will be best put forth when the OGI does the assessment this in Lincoln, Nebraska, USA.

I am a clinician and the research comes out of the past 20 years.

You have done your homework and that is commendable.

My research was triggered by my own problem and those of my patients.

As you no doubt will agree that anatomy is absolute, but physiology has some measure of change.

The lats are obviously larger and more global an impact on the posture, but as for breathing they make a minimal of impact. They can be recruited to aid any lateral muscle that is in distress.

The internal oblique has roles related to abdominal position and tonus. However, it can be overrideen by the nervous system to allow belly breathing. Since breath is crutial to existance, the way the body gets breath may change from ideal to a compromised breathing to obtain it. All of the abdominals can be inhibited to keep this process going.


The role of proprioceptive sense is to keep the body in alignment such that the eyes are in plane with the direction of the feet and the rest of normal posture is maintianed. In this aspect, when there is a groin pull, the adductor longus and/or the pectineus create a distortion to the pelvic bones where the torso would be turned to the direction of the tightened add long or pectineus. The contralateral psoas is recruited to stop the distortion or the eyes would be off postiion to the feet. This requires a bracing of the spine or rotoscoliosis would occur. The QL on the contralateral side to the psoas is engaged and this requires the ipsilateral serratus pos inf ( to the psoas) to complete the bracing of the spine. I hope that this explains why the serr pos inf is a factor which cannot be inhibited to obtain the necessary breath, because position in regqards to proprioceptive sense is involved.

I am not sure of any references to this in any research, but the OGI is finding that their research concurrs with mine.

New ideas are not easy to accept and I do not feel offended by your questioning. In times past some ideas were accepted too quickly. However, do not miss the import of this idea. I am positive that the research person at OGI that I mentioned in PM to you will find this to be true.

The reference to the study is to the one done by Dr. T. F. McElligot. There have been several other studies in the USA and Canada. The results of the various trials were 13 to 24% failure rate for electronic diagnisis equipment. The recommendation was that clinical examination should not be overlooked as lives may have been saved. For the physical therapy enviroment, I find that we need to get the most objective information. Postural is the most objective. However, getting enough information out of postural has been a problem.

I hope that this answers your questions. Sorry is I have missed any.

My best to you,

Neuromuscular ED

[neuromuscular]

Dear Alophysio,
.


You state that the four sided assesment using the landmarks of the ASIS and the PSIS is "subjective" but do not give reasons. That is so unlike your usual responses.

You can do the assessment without landmarking and you will see that the patinet twists and distorts. The landmarks only tell you what is happening in the pelvic bone movements. However, the gross overview of say 4 m away from the patient using visual creates the distoritons to the entire body that are repeatable and show the specific problems of the patient. The landmarks give the specific muscular problems.

One person likened the asessment and therapy as giving me a "blue ocean" in therapy. This means that the therapy is so much more successful than current methods that I have little in the way of competition. The researcher at the OGI and I had an exteneded conversation and he would concurr after his inital trials of the method.

The largest problem as I see it for the research paper is that this is so new a direction that many will dismiss it without trying it. The researcher at the OGI is having difficulty finding any papers on the relevance of the pelvic angle measurements. I could find little either and none using hip abduction.

In dialogue with Diane Lee this became obvious as she would not even consider the possibility. The head of the physiotherapy dept for McGill University in Montreal had a similar closed minded view. Andry Vleeming also had difficulty with the idea. I had the impression that he felt it too simplistic and that his more "comprehensive" approach was better.

So as I have said before, try the test and see if it does not give you more new and accurate information on the patient's true condition.

Best regards,

Neuromuscular

[software]

Hi Neuro, I am not a physiotherapist but a hyperventilating guy without much luck from retraining the breathing. I am not sure how to talk to my physiotherapist (I live in Asia) regarding your findings. Any help would be much appreciated.

Sorry for posting so late ..