Manual Assessment of Respiratory Motion (MARM)

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Objective

The MARM is a palpatory procedure based on the examiners interpretation and estimation of motion perceived by their hands at the posterior and lateral lower rib cage. The examiner using the MARM can gauge various aspects of breathing such as rate, regularity, but its particular utility is for assessing breathing pattern and the relative distribution of breathing motion between upper rib cage and lower rib cage and abdomen.

Intended Population

Subjects with Dysfunctional Breathing or Altered Breathing

Method of Use

The MARM also takes into account the form of the spinal column, whose extended or flexed form constitutes a third degree of freedom of breathing movement (Smith and Mead 1986). Extension of the spinal column increases the distance between the pubic symphysis and xiphoid process, elevates the ribcage, facilitating upward motion of the sternum/upper thorax (pump-handle motion) as well as abdominal expansion. Thus, it facilitates inhalation in a vertical direction (‘length breathing’). By contrast, a slumped posture inhibits the vertical movement of inhalation, increases pressure of abdominal contents to increase diaphragm length and promotes lateral expansion and sideways elevation of the lower ribs or bucket-handle movement. Thus, it facilitates inhalation in a horizontal direction (‘width breathing’). The
MARM is able to differentiate between these breathing patterns and assess asymmetry between the two sides of the body. In case of scoliosis or sideways distortion of the spinal column there is a marked difference in breathing movement between the left and right sides of the body and this can be registered clearly by the examiners two hands. Such asymmetry adds even more degrees of freedom of breathing
movement, but would remain unobserved when one relies on assessment by RIP.

An assumption of the MARM procedure is that breathing is a global movement of expansion (inhalation) and contraction (exhalation) of the body. From the manual assessment of motion at the lower ribs the examiner constructs a mental picture of global breathing motion, represented by an upper line and a lower line, originating from the centre of a circle or ellipse, together creating a slice in a pie chart, which represents the area of expansion. Specific features of the global change in form that can be estimated are: the degree that the sternum and upper thorax are lifted upwards, the degree that the lower ribs lift and expand sideways and the degree that diaphragmatic descent expands the abdomen outwards. The predominance of motion in either the upper rib cage/sternum or the lower rib cage/abdomen determines the direction of the global change with inhalation, as either predominantly in an upward or downward direction and the shape as either elongation or widening. Individuals may differ in their breathing response to postural change. For example when the spine is extended inspiration may result in a general increase in breathing motion with greater involvement of both upper thorax and abdomen or result in upward elevation of the chest with little increase or paradoxical decrease in abdominal motion.

With the MARM, having the subject intentionally breathe in different ways, the examiner can test the functionality of breathing.

Evidence

Reliability& Validity

The MARM appears to be a valid and reliable clinical and research tool for assessing breathing movement with good inter-examiner and a greater ability to distinguish vertical ribcage motion. Further studies to confirm its clinical utility are warranted.

Recent Related Research (from Pubmed)

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References

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