Neck and Back Pain and Breathing Pattern Disorders
Introduction:[edit | edit source]
A dysfunctional breathing pattern is defined as “inappropriate breathing that is persistent enough to cause symptoms with no organic cause” (Bradley and Esformes, 2014). Normal breathing involves synchronised upper rib cage and lower rib cage movement as well as activation of the diaphragm and abdominal muscles. Abnormal breathing, also known as thoracic breathing” instead involves breathing from the upper chest with greater upper rib cage motion compared to lower rib cage. Thoracic breathing is produced by recruiting the accessory muscles of respiration (including upper trapezius, sternocleidomastoid and scalene muscles) rather than abdominal motion. A cross-sectional study by Deshmunk et al (2022) found that 74% of participants complaining of back pain and 68% of those complaining of neck pain presented with a dysfunctional breathing pattern. Individuals with poor posture, scapular dyskinesis, low back pain and neck pain have also been shown to exhibit faulty breathing mechanics, suggesting a link between spinal mechanics and dysfunctional breathing.
There is evidence suggesting a relationship between lower back pain and respiration. The diaphragm is a key driver of the respiratory pump and attaches onto the lower six ribs, xiphoid process and the lumbar vertebral column. Hodges et al (2007) stated that as the diaphragm has an important role in both postural and breathing functions, disruption in one could negatively affect the other. A systematic review (Beeckmans et al, 2016) found a significant correlation between lower back pain and dysfunctional breathing including both pulmonary pathology and non-specific breathing pattern disorders. Furthermore, a case-control study (Roussel et al, 2009) observing patients with chronic lower back pain found significantly more altered breathing patterns during performance of motor testing.
Spinal stability and respiration use similar muscles to function and there is a need for a stabilised cervical and thoracic spine to assist movement of the ribs during inspiration and expiration. Spinal stability is derived from co-contraction of the abdominal muscles which increases the intra-abdominal pressure (Park, Kueon and Hong, 2015). Spinal instability could cause mechanical alterations leading to insufficient respiratory function and the activation of accessory muscles, producing a dysfunctional breathing pattern. A systematic review (Kahlaee, Ghamkhar and Arab, 2017) including 68 studies found a significantly lower maximum inspiration and expiration pressures in patients with chronic neck pain compared to asymptomatic patients. Muscle strength and endurance, cervical range of motion and lower Pco2 were found to be significantly correlated to reduced chest expansion and neck pain. The study concluded breathing re-education to be effective in improving come cervical musculoskeletal impairment and breathing pattern disorders.
Clinically Relevant Anatomy[edit | edit source]
The thoracic cage is inclusive of the spine, ribs, and the adjacent muscles. The anatomy at this area is important to ensure effective inspiration and expiration in the functional breathing process. Primary inspiratory muscles are the diaphragm and external intercostals, to help elevate the ribs and sternum, with a ‘bucket handle’ rib motion. Expiration is usually a passive process, with additional muscles such as the internal intercostals, and abdominal muscles, making this forceful if required.
The muscles of the diaphragm are directly connected to the spine, via the lower six ribs and their costal cartilage, upper three lumbar vertebrae as right crus, and upper two lumbar vertebrae as left crus, separating the thoracic cavity from the abdominal cavity. The intercostal muscles are located between ribs to aid expansion of the thoracic cage on inspiration.
Accessory muscles aid these original breathing mechanics when additional power is needed to generate larger, deeper breaths. These often include the sternocleidomastoid, scalenes, and trapezius, however any muscle attached to the upper limb and thoracic cage can act as an accessory muscle for inspiration.
Differential diagnoses[edit | edit source]
Neck pain (cervical spine)
| Neck Pain without radiculopathy | Neck pain with radiculopathy | ||
|---|---|---|---|
| Non-specific neck pain | Abscess | ||
| Acute disc prolapse | Anterior interosseous nerve entrapment | ||
| Acute torticollis | Arteriovenous malformation | ||
| Acute trauma (e.g. Whiplash) | Carpal tunnel syndrome | ||
| Adverse drug reactions | Cubital tunnel syndrome | ||
| Osteoarthritis of the cervical spine | Herpes zoster | ||
| Inflammatory arthritis | Parsonage-Turner syndrome (brachial plexopathy) | ||
| Cervical strain | Posterior interosseus nerve entrapment | ||
| Cervical fracture or dislocation | Radial tunnel syndrome | ||
| Cervical radiculopathy | Reflex sympathetic dystrophy | ||
| Fibromyalgia | Rotator cuff tendinosis | ||
| Infection | Thoracic outlet syndrome | ||
| Malignancy | |||
| Carotid or vertebral artery dissection | |||
| Neurological disorders leading to dystonia | |||
| Psychogenic dystonia |
Thoracic spine pain
| Thoracic pain | |||
|---|---|---|---|
| Costochondritis | |||
| Lower rib pain syndrome | |||
| Sternalis syndrome | |||
| Thoracic costovertebral joint dysfunction | |||
| Fibromyalgia | |||
| Rheumatoid arthritis | |||
| Axial spondyloarthropathy | |||
| Psoriatic arthritis | |||
| Osteoporotic fracture | |||
| Neoplasm with pathological fracture or bone pain |
Lower back pain (lumbar spine)
| Lower back pain without radiculopathy | Lower back pain with radiculopathy | ||
|---|---|---|---|
| Neurological: | metastatic neoplasm | ||
| Sciatica | Acute cholecystitis | ||
| Myelopathy or a higher cord lesion | Cardiac or pulmonary disease | ||
| Peroneal palsy or other neuropathies | Pancreatitis | ||
| Deep gluteal syndrome/Piriformis syndrome | Pelvic inflammatory disease | ||
| Spinal stenosis | Pelvic mass | ||
| Systemic: | Prostatitis | ||
| Sacroiliitis in spondyloarthropathies | Pyelonephritis | ||
| Vascular claudication | |||
| Other: | |||
| Abdominal aortic aneurysm | |||
| Aseptic necrosis of femoral head | |||
| Facet joint arthropathy | |||
| Greater trochanteric pain | |||
| Intra-abdominal pathology | |||
| Osteoarthritis of the spine or hip | |||
| Osteoporosis | |||
| Polymyalgia rheumatica | |||
| Rheumatoid arthritis | |||
| Shingles (Herpes zoster) |
Red flag conditions[edit | edit source]
Neck pain assessment[edit | edit source]
Subjective assessment
Take a detailed history around the neck pain. Some areas to explore include:
- Onset of the pain- acute/chronic/recurring/sudden/related to trauma or a particular activity.
- Nature and location of the pain- any radiation.
- Pain severity
- Occupational and social history.
- Medical and drug history.
- Symptoms of anxiety or depression.
- Previous injury or infection.
- Presence of fever.
- History of cancer.
- Presence of symptoms of spinal cord compression- lower limb weakness or altered sensation, disturbance of bowel or bladder function.
Objective
Conduct a physical examination to explore the potential causes of the neck pain further:
- Clear the shoulder and thoracic spine.
- Assess the appearance of the neck, including posture.
- Inspect the skin (e.g. for rashes or bruising)
- Assess range of motion- flexion, extension, side flexion, rotation.
- Palpate the neck for tenderness (Significant specific bony tenderness or midline tenderness is suggestive of other pathology).
- Check for cervical lymphadenopathy (could suggest infection, malignancy or an inflammatory cause)
- Assess deep neck flexor muscle strength
Perform a neurological examination:
- Myotomes (power).
- Tone.
- Reflexes.
- Dermatomes (sensation).
Special tests for cervical radiculopathy
A combination of special tests can be used to help identify cervical radiculopathy:
Imaging
Cervical X-rays and other imaging/investigations are not routinely required. However, MRI is indicated in people with complex cervical radiculopathy, for example if there is reason to suspect myelopathy/abscess, progressively worsening objective neurological findings or failure to improve after 4-6 weeks of conservative treatment.
Management for patients with linked neck pain and dysfunctional breathing[edit | edit source]
It is worth including elements of usual care for neck pain in the management of patients with a combination of neck pain and dysfunctional breathing in order to ensure the problem is tackled from all angles.
This management includes:
- Reassurance - neck pain is a common problem that usually resolves within a few weeks.
- Advice and education- around pillows for sleeping, return to activity and normal lifestyle, driving, speaking to GP/pharmacist around pain medication and discourage use of cervical collars.
- Physiotherapy exercises- strengthening, stretching, range of motion, manual therapy and advice on participation in regular exercise (e.g. Pilates or yoga).
- Consider referral for psychological therapy if there are psychological symptoms or risk factors.
- Consider referral to occupational health if pain is related to work.
- Consider referral to pain clinic if the person has had neck pain for more than 12 weeks and is not improving with treatment.
Additional management techniques for people with a combination of neck pain and dysfunctional breathing should be used.
Breathing re-education, cervical stabilisation exercises, stretching exercises incorporating slow deep breaths, breathing retraining alongside manual therapy.
