For those that have been in to the clinic, you know that I make a big deal about breathing. We are respiratory animals. Our growth, development, and function are driven by our respiratory demands. The number one thing we need to live is oxygen. Our bodies will sacrifice everything to get proper oxygen to meet the demands of our tissues. To understand what proper breathing means for our body mechanics we need to dive in to the anatomy of the human body.
The most important muscle in our body that contributes to the way we function as bipedal animals is a muscle we cannot see, touch, or feel. That muscle is your respiratory diaphragm. The diaphragm is a dome shaped muscle connected to the bottom of your lungs and attach to the base of your lower ribs and front part of your vertebral bodies in your low back. It is surrounded by viscera, including your liver under the right half and stomach under the left. Above the left side of your diaphragm are two lobes of your lung and your heart. On the right side sit three lobes of your lung. The right side of your diaphragm is about 66% larger than your left. As we inhale, the dome-shaped diaphragm should contract and flatten to pull air into the lungs. As it flattens and pulls the lungs down, the diaphragm pushes out against the ribs, causing the ribs to externally rotate and the lower rib cage to expand. The diaphragm attachments on the lumbar spine pull the spine forward and up as it contracts. As we exhale, the tension of our abdominal muscles pull the ribs back down so the diaphragm can return to its normal dome shape. The abs’ purpose in life are not to make us look good on the beach, rather, the purpose is to oppose the diaphragm and return it to its relaxed position. This is a brief overview of how our respiratory mechanics SHOULD work.
I say ‘should’ because many of the people that we see in the clinic have a thorax that is not operating in this manner. Many of the people that we see in the clinic are in an extended, hyper-inflated state. The diaphragm is “stuck” in a flattened, contracted position and the abdominals are not functioning properly to pull the ribs down so the diaphragm can return to its domed, relaxed state. This can be caused by many different factors. Respiratory issues such as asthma and any other airway obstruction issues (broken noses, deviated septum, etc.) will result in this. People who have back muscles that are too strong and tight will overpower the abdominals and lead to this state. Athletes in sports that require a lot of extension and back muscle use such as running, swimming, gymnastics, volleyball, basketball, dancing, equestrian riding, and weight lifting will often present in a hyper-inflated state with a flat diaphragm and abdominals not doing their job. In addition, not crawling for a sufficient amount of time in the first year of life may contribute to abdominal under-development and high extensor tone, leading to a lack of opposition to the diaphragm. Any and all of these things can contribute to an extended, hyper-inflated state.
A flat, contracted diaphragm may lead to a variety of symptoms. Our bodies crave oxygen and does everything it can to pull in air for survival through accessory muscles of inspiration. If our diaphragm is not regularly returning to its natural, domed state via abdominal opposition, we will utilize our neck and back muscles in an attempt to fill our lungs with oxygen. However, our neck and back muscles are not designed to be a diaphragm. This can lead to chronic neck and back tightness, headaches, as well as jaw and facial pain. Additionally, sub-optimal respiratory mechanics will lead to a state of hyperinflation and a rise in the pH of our blood. This hyperinflated state (also known as respiratory alkalosis) has been shown to increase “fight and flight” responses and anxiousness, restricts circulation in the brain, decreases peripheral blood flow, promotes fatigue and weakness, impairs nerve conduction, negatively affects sleep quality, and increases sympathetic adrenaline activity and hypersensitivity to lights and sounds. Athletes experiencing respiratory alkalosis will have decreased performance and endurance, and they may start feeling “tight” throughout their body. Repercussions from respiratory alkalosis are multi-systemic and extensive.
From a pure musculo-skeletal standpoint, diaphragm position and function will directly affect rib position and mobility. Rib position and mobility will influence shoulder motion and function. The diaphragmatic attachments on the lumbar spine can contribute to excessive forces and torque on the spine if it stays in the flat, tonic state. The diaphragm also directly attaches to and blends into the psoas muscle, thus affecting pelvic, hip, and leg mechanics. Athletes in this hyper-inflated state may experience excessively tight back and neck muscles, as well as overly-tight calf and quad muscles.
Appropriate treatment of symptoms caused by improper diaphragm function will likely include breathing exercises that promote full exhalation and abdominal activation followed by an inhale without activation of neck and back muscles. In the clinic, we often have patients blow up balloons to encourage a full exhale with abdominal activation and diaphragm opposition. Patients may also find themselves on their hand and knees or toes completing abdominal and shoulder exercises to further promote abdominal activation for breathing. They may also be squatting or sitting against the wall as they reach forward and breathe. All of these exercises promote proper diaphragm position as they decrease back muscle tone and activation.
Proper assessment of diaphragm function, rib mechanics, and abdominal opposition is essential for any pain in your back, neck, shoulder, pelvis, head, and extremities. It is easy to get caught up chasing and treating areas of pain without stepping back and properly evaluating your “core” – the thorax and diaphragm. Be sure you take a moment today to pause and breathe. That is, fully exhale, then inhale without using your neck and back muscles. Heck make it a party, blow up a balloon!