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Respiration and Postural Stability

Original Editor - Maitreyi Nachuri

Top Contributors - Maitreyi Nachuri  

Introduction

This article explores the interplay of Intraathoracic Pressure (ITP) and Intraabdominal Pressure (IAP) on postural stability as it relates to fall prevention and functional mobility. In addition to the local and global muscle systems, the respiratory muscles, including the respiratory diaphragm and the intercostals, pelvic diaphragm and the glottis also contribute to postural stability by regulating ITP and IAP.[1]

Postural Stability: According to Shumway-Cook, "Postural stability (PS) is described as the ability to maintain the vertical projection of the centre of body mass called also the centre of gravity (COG) inside the base of support"[2][3]

Physiology

See the video below for a review of respiratory mechanics:

[4]

Interplay of Respiration and Postural Stability

Glottis activity and postural stability[1]: Breath-holding after inhalation involves closure of the glottis. Breath-holding is a common strategy to maintain stability when lifting weights or instances during functional tasks such as transfers in the elderly.[1][5] When the neuromuscular system uses glottis closure as a strategy to stabilise the diaphragm in the face of abdominal muscle contraction, it causes the highest increase in IAP compared with any other breathing pattern. The resultant increase in trunk stiffness is helpful in tasks involving heavy demands (lifting/opening a heavy door)

Frontal sections through glottis illustrate various possible positions during the vibratory cycle of vocal cords[6]

However, glottis closure also increases thoracic stiffness and decreases overall postural stability in response to a perturbation.[1] At the other end, the completely open glottis as in a sigh also causes a decrease in postural stability due to the trunk becoming more flexible.[1] Voicing a vowel, or counting, which necessitates the glottis to be actively kept partially open and controlling the expiratory flow of air, appears to help the most in maintaining dynamic balance.[1]

See the video below for the clinical application of voicing in improving functional mobility:

[5]

Diaphragm activity and postural stability: Contraction or tensing of the diaphragm increases IAP and decreases ITP, thereby enhancing stability and unloading spinal segments. It works in synergy with the pelvic floor, glottis, deep extensors, and abdominals.[7] On the other hand, in ambulatory patients with bilateral diaphragmatic paralysis, dyspnoea has been noted with activities involving bending forward or lifting weights due to an unopposed increase in ITP.[8] Also see The Role of the Diaphragm in Trunk Stability for a more detailed review of this function.

Postural function of Intercostals: In addition to respiration, intercostal muscles contribute to trunk rotation. The rotated position of the trunk alters their inspiratory activity.[9]

Clinical Applications

Respiratory movements challenge trunk stability. In quiet standing, respiratory movements are compensated by small movements of lower extremities and trunk so that the centre of pressure (CoP) perturbation is minimised. [1][10]

People with lung disease and low back pain show decreased postural stability.[1] In people with lung disease, the diaphragm cannot contribute effectively to postural stability due to increased respiratory demand.[11] People with low back pain show decreased compensatory movements in response to respiratory disturbances to CoP.[1] People with COPD, demonstrate weakness in inspiratory muscles that also relates to impaired postural stability.[11]Postural control and balance deficits in People with Multiple Sclerosis (MS) are associated with a decrease in respiratory capacities, with a high correlation noted between Borg Dyspnea Scale and the Berg Balance Scale, Timed Up and Go, and Mini-BESTest.[12]In patients with Parkinson's Disease, diaphragm function has a significant correlation with postural stability. Its contraction velocity and excursion were found to be increased in patients with poorer postural control. [7]According to a Brazilian study, balance deficiencies are linked to inspiratory muscle weakening in middle-aged and older, healthy women.[13]

Treatment Implications

Respiratory Muscle Training can thus be considered as a necessary component of falls and balance training in women, the elderly, and any clinical population with compromised respiratory function. It is a new approach to enhancing dynamic balance in the elderly, as it seems to give distinct benefits when compared to static balance training and general strength training.[13][14]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Massery M, Hagins M, Stafford R, Moerchen V, Hodges PW. Effect of airway control by glottal structures on postural stability. Journal of Applied Physiology. 2013 Aug 15;115(4):483-90.
  2. ↑ Shumway-Cook A. Motor control: Translating research into clinical practice. Lippincoot Williams & Wilkins. 2007.
  3. ↑ Jarosz M, Pawlak K, Jarosz W, Wiernicka M, Barinow-Wojewódzki A, Stemplewski R. The effect of surgical repair of the chest on postural stability among patients with pectus excavatum. Scientific Reports. 2024 Jan 2;14(1):45.
  4. ↑ Video: Breathing Mechanics
  5. ↑ 5.0 5.1 Massery PT. Using Voicing Strategies -- Massery PT -- Mary Massery -- If You Can’t Breathe, You Can’t Function [Internet]. YouTube. 2013. Available from: https://www.youtube.com/watch?v=c_VlBI-QgOw
  6. ↑ File:Contractions of Glottis.jpg - Wikimedia Commons [Internet]. 2016. Available from: https://commons.wikimedia.org/wiki/File:Contractions_of_glottis.jpg#filelinks
  7. ↑ 7.0 7.1 Yu X, Jiang HY, Zhang CX, Jin ZH, Gao L, Wang RD, Fang JP, Su Y, Xi JN, Fang BY. The role of the diaphragm in postural stability and visceral function in Parkinson’s disease. Frontiers in Aging Neuroscience. 2021 Dec 23;13:785020.
  8. ↑ Al-Bilbeisi F, Dennis McCool F. Diaphragm recruitment during nonrespiratory activities. American journal of respiratory and critical care medicine. 2000 Aug 1;162(2):456-9.
  9. ↑ Hudson AL, Butler JE, Gandevia SC, De Troyer A. Interplay between the inspiratory and postural functions of the human parasternal intercostal muscles. Journal of neurophysiology. 2010 Mar;103(3):1622-9.
  10. ↑ Gandevia SC, Butler JE, Hodges PW, Taylor JL. Balancing acts: respiratory sensations, motor control and human posture. Clinical & Experimental Pharmacology & Physiology. 2002 Jan 14;29.
  11. ↑ 11.0 11.1 Tounsi B, Acheche A, Lelard T, Tabka Z, Trabelsi Y, Ahmaidi S. Effects of specific inspiratory muscle training combined with a whole-body endurance training programme on balance in COPD patients: randomised controlled trial. PLoS One. 2021 Sep 23;16(9):e0257595.
  12. ↑ Sanchez-Ruiz R, de la Plaza San Frutos M, Sosa-Reina MD, Sanz-Esteban I, García-Arrabé M, Estrada-Barranco C. Associations between respiratory function, balance, postural control, and fatigue in persons with multiple sclerosis: an observational study. Frontiers in Public Health. 2024 Mar 20;12:1332417.
  13. ↑ 13.0 13.1 Azevedo IG, da Câmara SM, Maciel AC, Vieira ER, Espinoza CF, Pichún SM, Viana ED, Sousa SL. Relationship between inspiratory muscle strength and balance in women: a cross-sectional study. Plos one. 2023 Feb 15;18(2):e0280465.
  14. ↑ Ferraro FV, Gavin JP, Wainwright TW, McConnell AK. Comparison of balance changes after inspiratory muscle or Otago exercise training. PloS one. 2020 Jan 24;15(1):e0227379.
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