Low Back Pain and Breathing Pattern Disorders

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Search Strategy[edit | edit source]

Databases Searched: PubMed

Keywords Searched: breathing pattern disorders, hyperventilation syndrome, low back pain, respiratory alkalosis, diaphragm

Definition/Description[edit | edit source]

A breathing pattern disorder is defined as hyperventilation or over-breathing that does not occur as a result of an underlying pathology. a level 2B study[1] has shown that the presence of respiratory disease such as a breathing pattern disorders is a strong predictor for lower back pain. Stronger than other established risk factors

What is defined as a normal breathing pattern:
• Abdominal, not chest breathing should initiate inhalation, which then expand outwards during inhalation.
• Lifting the chest up while breathing is faulty
• Lack of or a upwards lateral lifting pattern is faulty
• Paradoxical breathing is faulty
• Breathing that has no clavicular grooving formed by chronic chest lifting

Clinically Relevant Anatomy[edit | edit source]

The thoracic cage is formed by the spine, rib cage and associated muscles. While the spine and the ribs form the sides and the tops, the diaphragm forms the floor of the thoracic cage. The muscles connecting the twelve pairs of ribs are called the intercostal muscles, and the muscles running from the head and neck to the sternum and the first two ribs are the sternocleidomastoids and the scalenes.

Muscles used for ventilation:

- Inspiratory muscles: external intercostals, diaphragm, sternocleidomastoids, scalenes

- Expiratory muscles: internal intercostals and the abdominal muscles (expiration during quiet breathing is called passive expiration, because it involves passive elastic recoil)[2] [3]

Epidemiology /Etiology[edit | edit source]

Breathing pattern disorders are because of hormonal influences (progesterone stimulates respiration) female dominated with a female to male ratio ranging from 2:1 to 7:1
Currently, there isn’t a consensus as to the scale of breathing pattern disorders in the general population, but a pilot study [4] examined the relationship between BPD and musceloskeletal pain and showed that 75% of those examined showed faulty breathing patterns. Although interesting, this study has several limitations. It was not designed or intended to be a reliability study. Its methods have no proven reliability. Future research is needed to validate the inter-examiner reliability of the methods of assessing breathing mechanics and the criteria of normal and faulty patterns of respiration. But if this numbers reflect to the general population, there is a 3 in 4 chance that your patient will have faulty breathing patterns.

Biochemical and neurological changes because of BPD.
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the biochemical effects of BPD (such as hyperventilation) will lead to systemic respiratory alkalosis. This is characterized by the decrease in CO2 and an increase in pH. This induces vascular constriction, decreasing blood flow, as well as inhibiting transfer from hemoglobin of oxygen, to tissue cells (due to the Bohr Effect). Also there is found to be an altering of the magnesium, calcium and potassium balance. Muscle cells affected in this way will show an interfering with the motor control, normal muscular function and the pain perception.

A study [5]revealed that with Moderate hyperventilation, there will be loss of CO2 ions from neurons which stimulates neuronal activity. This causes for an increase in sensory and motor discharges, muscular tensions and spasms, speeding of spinal reflexes and other sensory disorders.
Research from Seyal et al [6] demonstrated that hyperventilation increased the excitability of the human corticospinal system


Biomechanical effects of BPD and the effects on the low back
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Spinal instability occurs when either passive or active stiffness is disturbed.
Muscle behavior alters in conditions of respiratory alkalosis and the bohr effect ensures that both hypoxia and ischemia are more likely. chronic hypoxemia reduces muscle force generation by skeletal muscles and their ability to endure fatigue. It also affects not only the metabolic paths but also changes the gain of sensorimotor reflex loops. Another study [7] found that reoxygenation improved the muscles performance but reduced motor unit recruitment. This all suggests that spinal stability is likely to be compromised by the effects of overbreathing.
BPD also affects the diaphragm wich muscle contraction produces (with participation of the back and abdominal muscles) the intra abdominal pressure that augments the stability of the back during tasks of heavy lifting or extraordinary demands. When a challenge occurs that demands the stabilizing function of the diaphragm at the same time of extraordinary respiratory demands, the diaphragm will choose the respiratory factor over the stabilizing factor, wich compromises the spinal stability.

Diagnostic Procedures[edit | edit source]

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Outcome Measures[edit | edit source]

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Examination[edit | edit source]

BPD is diagnosed using physical assessment, a validated questionnaire (the Nijmegen) and a capnometer (measures respiratory Co2 levels)

  • Nijmegen questionnaire provides a non-invasive test of high sensitivity (up to 91%) and specificity (up to 95%). a score of 23 out of 64 on the test suggest a positive diagnose of hyperventilation syndrome.
  • Capnography have been shown to have a good concurrent validity when compared to arterial CO2 measures and can provide acces to this very important physiological information[8]

Because previous studies of breathing therapy have not included capnography in their research, it’s difficult to say anything about the validity of the device in function of therapy [9]



Medical Management
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Physical Therapy Management
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According to following article, Laurie McLaughlin et al, breathing retraining should improve end-tidal CO2 (ETCO2), pain and function in most patients complaining of neck or back pain.
Poor breathing profiles were found in patients with neck or back pain: high respiratory rate, low CO2, erratic non-rhythmic patterns and upper chest breathing. These patients received awareness training and biofeedback with capnograph and manual therapy to achieve better profiles. The number of sessions they received varied from two to fifteen sessions. Once the patient is convinced that he understands, feels in control over his breathing and is able to keep his ETCO2 within the normal range, then the breathing retraining is completed. [10]


Following another article, Wolf E. Mehling et al, breathing therapy should improve patients with chronic low back pain. However changes in pain and disability were comparable to those resulting from extended physical therapy. Breathing therapy had results such as: improved coping skills and new insights into the effects of stress on the body.
During the breathing therapy, the patient lies down on a massage table while the therapist guids him by verbal intervention and skilful touch (gentle pressure, holding, gentle stretching at the back, neck and legs). This to enhance the concentration of the patient and to facilitate a spontaneous pattern of subtle breathing.
The physical therapy sessions had a longer duration to match the intervention of the breath therapy. In this intervention the therapists gave limited attention to diaphragmatic breathing and proprioception.Both groups of therapists instructed their patients to do daily exercises at home, which lasted 20 to 30 minutes. [11]

Key Research[edit | edit source]

One level 1B RCT [12] studied the effects of breathing therapy on chronic low back patients. Patients improved significantly with breathing therapy. The changes in standard low back pain measures of pain and disability were comparable to those resulting from high-quality, extended physical therapy
There is also a review that describes the relationship between low back pain and breathing pattern disorders[13]. The review states that there is evidence of a weak but statistically significant positive correlation between LBP and respiratory problems. All the studies in this review were cross sectional 2A level cohort studies.
In one case serie [14] of 24 patient with low back or pelvic pain, they all showed an altered respiratory chemistry. Breathing dramatically improved with breathing retraining (all but one reached normal ETCO2 values). 75% of the patients reported improvements in pain, 50% reported improvements in functional activity. These results were both clinically important and statistically significant.


Resources
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Clinical Bottom Line[edit | edit source]

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Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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  1. ↑ Smith MD, Russell A, Hodges PW. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust J Physiother 2006;52:11–6.
  2. ↑ B.R. Johnson, W.C. Ober, C.W. Garrison, A.C. Silverthorn. Human Physiology, an integrated approach, Fifth edition. Dee Unglaub Silverthorn, Ph.D.
  3. ↑ Theodore A. Wilson and Andre De Troyer. diaphragm Diagrammatic analysis of the respiratory action of the. J Appl Physiol 108:251-255, 2010. First published 25 November 2009; doi:10.1152/japplphysiol.00960.2009(A1)
  4. ↑ Perri MA, Halford E. Pain and faulty breathing: a pilot study. J Bodyw Mov Ther 2004;8:297–306
  5. ↑ Lum L. Hyperventilation Syndromes. In: Timmons B, Ley R. (eds) Behavioral and Psychological Approaches to Breathing Disorders. New York: Plenum Press; 1994.
  6. ↑ Seyal M, Mull B, Gage B. Increased excitability of the human corticospinal system with hyperventilation. Electroencephalography and Clinical Neurophysiology/Electromyography and Motor Control. 1998;109(3):263-267
  7. ↑ Y. Jammes, M. C. Zattara-Hartmann and M. Badier .Functional Consequences of Acute and Chronic Hypoxia on Respiratory and Skeletal Muscles in Mammals. Comparative Biochemistry and Physiology Part A: Physiology, Volume 118, Issue 1, September 1997, Pages 15-22
  8. ↑ Laurie McLaughlin, Charlie H. Goldsmith, Kimberly Coleman. Breathing evaluation and retraining as an adjunct to manual therapy. Manual therapy, volume 16, Issue 1, pages 51-52
  9. ↑ J. S. Gravenstein,Michael B. Jaffe,David A. Paulus. Capnography: clinical aspects : carbon dioxide over time and volume. Br. J. Anaesth. (May 2005) 94 (5): 695-696. doi: 10.1093/bja/aei539
  10. ↑ Laurie McLaughlin a, *, Charlie H. Goldsmith b, Kimberly Coleman c. Breathing evaluation and retraining as an adjunct to manual therapy. Manual Therapy 16 (2011) 51e52 (B)
  11. ↑ Wolf E. Mehling, MD, Kathryn A. Hamel,PhD, Michael Acree,PhD, Nancy Byl, PhD, PT, Frederick M. Hecht, MD, MPH. RANDOMIZED, CONTROLLED TRIAL OF BREATH THERAPY FOR PATIENTS WITH CHRONIC LOW-BACK PAIN. ALTERNATIVE THERAPIES, July/aug 2005, VOL. 11, NO. 4 (B)
  12. ↑ Mehling WE, Hamel KA, Acree M, Byl N, Hecht FM. Randomized, controlled trial of breath therapy for patients with chronic low-back pain, Alternative Therapies in Health and Medicine 2005 Jul-Aug;11(4):44-52
  13. ↑ Lise Hestbaek, DC,a Charlotte Leboeuf-Yde, DC, MPH, PhD,b and Claus Manniche, DrMedScc . IS LOW BACK PAIN PART OF A GENERAL HEALTH PATTERN OR s IT A SEPARATE AND DISTINCTIVE ENTITY?A CRITICAL LITERATURE REVIEw OF COMORBIDITY WITH LOW BACK PAIN. J Manipulative Physiol Ther. 2003 May;26(4):243-52.
  14. ↑ Laurie McLaughlin, Charlie H. Goldsmith, Kimberly Coleman. Breathing evaluation and retraining as an adjunct to manual therapy. Manual therapy, volume 16, Issue 1, pages 51-52
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