Breathing Pattern Disorders and the Athlete

Tania CliftonSmith MNZSP, DipPhys, NZMTA,
Breathing Works and BradCliff® Method www.bradcliff.com www.breathingworks.com

‘If breathing is not normalised no other movement pattern can be’1

Breathing is one of our most vital functions and a disordered breathing pattern can be the first sign that all is not well, whether it be biomechanically, physiologically or psychologically.

Little attention has been paid to the breathing pattern of the athlete that is until recently. Historically this area of research has been dominated by sports physiologists who have focused on ventilation and the delivery of oxygen. Research is now beyond the capacity of ventilation and starting to look at the muscles of respiration and even breathing patterns. 2, 3, 4

Breathing Pattern disorders.

Breathing pattern disorders appear to be simple yet they are complex not only by historical definition but also in aetiology and treatment regimen. The orthodox medical literature has attempted to define breathing pattern disorders and hyperventilation. In the view of the author both exist as separate but also as co-existing disorders.A current working definition has been postulated within the physiotherapy literature. ; ‘Inappropriate breathing which is persistent enough to cause symptoms, with no apparent organic cause’. 5 This is the favoured definition of the author from the view point that it encompasses hyperventilation and breathing pattern disorders and can encompass acute and chronic episodes. For example - if an athelete has an inefficient breathing pattern when partaking in their activity/ sport  this may cause premature breathlessness or lower limb fatigue that is non reflective of cardiovascular fitness Or any organic pathology. Alternatively if they have a breathing pattern disorder at rest this to may well impair their performance.

What triggers a disorder?

The cause is believed to be compensation for biomechanical, physiological and psychological triggers. There is an extensive list of factors thought to trigger disordered breathing. However once the pattern is established the breathing pattern disorder becomes an entity of its own. 6

Biomechanically

The diaphragm has the ability to perform the duel role of respiration plus postural stability during movement. 7, 8 When all systems are challenged breathing will remain as the final driving force.9 In other words,
“Breathing always wins”. 10

For example, picture the local jogging group out on a sunny morning talking, jogging and breathing. They reach a set of 200 steps - as the ventilatory demand increases so does the work of breathing. It will become harder to converse, and as the demand further increases breathlessness (dyspnoea) may occur.  Dyspnoea alerts the system that it is under pressure, and as a result we respond by  either decreasing the load, i.e ease up our pace, or by stopping and regulating our breathing pattern. The goal of the system is to preserve and re-regulate respiration. This alarm system or warning system applies to the individual with COPD, through to our most elite athletes. It is a complex system, however research in breathing pattern disorders has shown the benefits that good efficient breathing patterns can play in the desensitising of this ‘alarm’.4,11 In the case of the athlete  improve performance.

Pressure Control: muscle length tension relationship

The muscles which control core stability, that is,  the diaphragm, transversus abdominus, multifidis and the pelvic floor muscles, work together to in unison protecting predominantly the lumbar spine plus also creating ideal intra abdominal pressures.12 These muscle groups plus respiration  assist with optimum pressure control within the body, not only playing a major role in  spinal support but also contributing to motility of fluid based systems within the body, i.e gastrointestinal, lymphatic drainage, arterial and venous circulation.10 These functions must all be considered in our assessment protocols.

Structurally at the top of this system regulating pressure control are the vocal folds and the surrounding musculature. The diaphragm sitting in the middle plays a key role in pressure generation. Pressure determines length-tension relationship. If an apical breathing pattern disorder is present  respiratory accessory muscles shorten, the diaphragm is unable return to its optimal resting position, pressure generation of diaphragm is altered dynamic hyperinflation can occur, gas exchange is altered, often towards arterial hypocapnia.13 Shortened muscles create less force: muscle length tension relationship is altered, work of breathing increases. Many athletes including elite athletes present with breathing pattern disorders at rest. So even prior to engaging in sport they are starting from a disadvantaged position. Authors observations.

Muscle recruitment/ motor patterns

Muscle recruitment and motor patterns are important to preserve this internal pressure. Should there be a deviation away from this recruitment pattern i.e the oblique muscles firing first then pressure, ventilation volumes and ultimately work of breathing is affected.

On ultrasound imaging athletes who have been identified with a breathing pattern disorder often display increased resting tone of the oblique muscles (clinical observations). If these muscles are over active at rest they can act as an abdominal corset, preventing diaphragm descent creating an upper chest dominant pattern. In upper chest breathing, the sterno-cleidomastoid muscles the scalene muscles and the upper trapezii muscles are activated. 14, 15 Patients with neck pain commonly have faulty breathing patterns. 16 Breathing problems also predict the development of low back .17 People with back pain brace with their superficial abdominal muscles and diaphragm, and have poor core muscle activation. 18 An awareness of faulty breathing patterns coupled with breathing re-education can provide health professionals valuable, additional tools to help patients with their musculoskeletal disorders. 19

Dynamic Hyperinflation

An end result of an upper chest breathing pattern can be dynamic hyperinflation.  Body mechanics and motor patterns alter and physiologically changes may occur.  The body can acclimatise to this “new” pattern in a short a time as 24 hours. 6 We frequently see clients present with dynamic hyperinflation, increased resting tone of the oblique and abdominal muscles, and contraction of the abdomen so tightly it creates a self-induced corset, so that literally one cannot breathe. Unbeknown to the fashion conscious or fab ab seeker there are a host of serious physiological and mechanical not to mention psychological changes taking place. Hence the mere mention of the return of the corset is enough to trigger fear and create a sense of breathlessness.  Dynamic hyperinflation during exercise certainly means an individual starts from a disadvantaged position and this may lead to a concept called breath stacking. This is when inhalation exceeds the exhalation phase of the breath cycle and airflow can become limited, oxygen reaching the alveoli is decreased as dead space volume increases. 20

Physiologically

Physiologically every cell in the body requires oxygen to survive yet the body needs to rid itself of carbon dioxide (CO2). Carbon dioxide is the most important stimulus for breathing in a healthy person, and the most potent chemical affecting respiration. Altered respiratory patterns can acutely and chronically lead to a state known as hyperventilation.21

Hyperventilation

Hyperventilation is defined as breathing in excess of metabolic demands, resulting in hypocapnia.  Arterial pCO2 is lowered, body pH increases and a state of respiratory alkalosis results. 6, A lowering of CO2 levels in the blood creates many physiological changes but of particular relevance to the musculoskeletal system is a) threshold alteration to sensory and motor axons which causes depolarisation or excitation of the nerve motor unit b) smooth muscle constriction and c) altered Oxygen (O2) uptake via the Bohr Effect. 22 The depolarisation or excitation of the nerve motor unit contributes to an increased central nervous system arousal.  The increase in pH improves muscle function as seen in short duration cycle sprints.23. If prolonged, however, over stimulation, fatigue and ultimately increased sensitisation can become a problem. When ph increases smooth muscles in vessels in the gut and bronchi constrict. 24  Tissue oxygenation is reduced due to vasoconstriction and due to inhibition of oxygen transfer from haemoglobin, i.e respiratory alkalosis increases the affinity of haemoglobin (Bohr Effect), so that haemoglobin binds tightly to oxygen reducing oxygen to tissue cells. This can explain the concept of muscle aching at low levels of effort. 24

Upon the discovery of smooth muscle cells in collagen this potentially can explain the presentation of increased muscular and fascial tension amongst individuals with breathing pattern disorders. This implies breathing disorders will play a part in fascial/connective tissue sites- ligaments, menisci, and spinal discs. 25,26.It has even been suggested that perhaps in the hypermobile individual the altered breathing pattern exists as a means to increase tone and stability via the effect of respiratory alkalosis on contractile smooth muscle cells?27

Did you know that the muscles of respiration steal oxygen rich blood from the lower limbs during intensive exercise?

 It has been  identified that the work of breathing during maximal exercise results in marked changes in locomotor muscle blood flow, cardiac output and both whole-body and active limb oxygen uptake.28 It is believed the compromised locomotor blood flow is associated with noradrenaline (norepinephrine) suggesting enhanced sympathetic vasoconstriction.29 Evidence exists of a metaboreflex, with its origin in the respiratory muscles.30 It is believed this reflex can modulate limb perfusion via stimulation of sympathetic nervous system vasoconstrictor neurones.31 The fundamental goal is the protection of oxygen delivery to the respiratory muscles, thus ensuring the ability to maintain pulmonary ventilation, proper regulation of arterial blood gases and pH and overall homeostasis.

This concept has been refered to as blood stealing. 32 A novel idea that literally the muscles of respiration steal oxygen rich blood from the lower limbs to maintain efficient respiration.

Psychologically

Any athlete, particularly the elite athlete, is exposed to many internal and external pressures. Performance anxiety has been shown to have close associations with breathing pattern disorders.33,34  Similar changes are seen with anticipatory anxiety.35  For example, the fear of the dyspnoea that plays a major factor in panic attacks and anxiety.36   It is often the sensation of dyspnoea or muscle discomfort that will limit performance.

 In the case of the athlete, it is not only the anxiety that surrounds potential symptoms such as breathlessness, but also the anxiety surrounding the performance itself can affect or be affect by a breathing pattern disorder. It is important to note, however, that the factors surrounding anxiety are too complex and interrelated to suggest there can be a simple causal effect. Conditioned respiratory responses have also been shown to occur prior to starting a computer task – a seemingly unrelated aspect of the athlete’s lifestyle.37, 38   The connection between psychological state and respiration is bi-directional, suggesting breathing should be examined as an independent variable affecting the psychological process.

In summary

What happens when an athlete presents to their sports physiotherapist for a recurring shoulder injury? The athlete who is coughing and spluttering with a highly productive cough, and sinuses that are so clogged that mouth breathing is the only reprieve. Does the sports therapist pass a box of tissues or use their clinical skills of observation and clear the excessive secretions, educate on nasal hygiene and breathing pattern disorders. Mouth breathing leads to increased respiratory accessory muscle activation, increased work of breathing all of which can add to musculo-skeletal issues, such as a shoulder problem. Physiological disturbances can also occur, for example sleep disturbance due to mouth breathing can result in fatigue addling recovery.

Athletes and in particular the elite athlete needs to be assessed and treated with all three categories in mind: biomechanics, physiology and psychologically. 

Physiotherapy and the treatment of breathing pattern disorders are historically firmly placed in treatment of the cardiopulmonary system - both in the acute and chronic setting. It is evident from emerging research that it must now be considered in all areas.

This area of research opens new doors to physiotherapists working in the field of breathing pattern disorders. A network of physiotherapists who have trained and are highly skilled in the area of breathing pattern disorders and the athelete exists. I urge you to work in with them and to use them as they are an invaluable resource or to take the plunge and upskill in this area of emerging physiotherapy.

References

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