Low Back Pain and Breathing Pattern Disorders

Original Editors - Jeroen Verwichte

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Definition/Description

Low back pain (LBP) is a leading cause of disability around the world and is the most common reason for seeking medical care. Most cases of low back pain are non-specific. This means that the low back pain does not have a specified physical cause, such as nerve root compression, trauma, infection, or the presence of a tumor. This is the case in about 85-90% of all low back pain patients.

Breathing pattern disorders (BPD), also known as dysfunctional breathing, are respiratory patterns that are abnormal. Breathing can become dysfunctional when the person is unable to breathe efficiently, and when the breathing is inappropriate, unhelpful or inefficient in responding to environmental conditions and the changing needs of the individual. BPD are in relation with over-breathing which can go from simple upper chest breathing to hyperventilation, which is very extreme. Hyperventilation is the most recognized form of dysfunctional breathing. BPD can be chronic or can be defined as changes in the breathing pattern that cannot be ascribed to a specific diagnosis. This disorder can cause respiratory and non-respiratory complaints. BPD is a distinct syndrome, they are not an inevitable result of pathologic changes due to illness/disease. BPD can be caused by some factors but those can different from the factors that perpetuate it. Once a pattern is established and the disorder becomes habituated it can be a disorder of its own. BPD can, in long term conditions, destabilise mind, mood, metabolism, inspiratory muscle hypertonification and in some cases can also cause motor control impairment in for example postural muscles because of abnormal levels of O2 and CO2 in the brain. It can also play a part in chronic fatigue, depression/anxiety, premenstrual syndrome, fibromyalgia, neck-, back- and pelvic pain.

There is some evidence suggesting a relationship between respiration and low back pain. A review study found moderate evidence supporting the use of breathing exercises when treating patients with chronic, non-specific low back pain. One study found the presence of a respiratory disease such as an BPD, is a predictor for low back pain. A systematic review found a significant correlation between low back pain and breathing pattern disorders, including both pulmonary pathology and non-specified breathing pattern disorders. Non-optimal coordination of postural and respiratory functions of trunk muscles is proposed as an explanation for this relationship. A case-control study has shown that significantly more altered breathing patterns were observed in patients with chronic LBP during performance of the motor control testing.

Clinically Relevant Anatomy

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. The muscles of the diaphragm are also directly connected to the spine.

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) 

Epidemiology /Etiology

Breathing pattern disorders are multifaceted. Dysfunctional breathing (DB) is defined as chronic or recurrent changes in breathing pattern that cannot be attributed to a specific medical diagnosis, causing respiratory and non-respiratory complaints.

People with respiratory problems are less able to exercise due to breathing difficulties and are therefore more sedentary than healthy individuals. It is therefore possible that these patients will evolve back pain. Several studies also point the specific role of a sedentary lifestyle that includes mechanical factors such as prolonged wrong postures leading to wasting and weakness of postural muscles and chronic muscle spasm resulting from psychologic stress in the etiology of chronic low back pain.

Charactersitics/Clinical presentation 

For more information: Breathing Pattern Disorders.

Diaphragmatic and transversus abdominis tone are key features in providing the body of core stability, however it has been noted that reduction in the support offered to the spine, by the muscles of the torso, may occur if there is both a load challenge to the low back, combined with a breathing challenge. It has been demonstrated that, after approximately 60 seconds of hypercapneoa, the postural (tonic) and phasic functions of both the diaphragm and transversus abdominis are reduced or absent. Breathing rehabilitation offers the potential for reducing the negative influences resulting from breathing pattern disorder. Another study suggest that breath therapy may enhance proprioception and, therefore, may be an appropriate complementary intervention particularly for patients with back pain.

Symptoms of Breathing Pattern Disorders (BPD) can be:

• Dizziness
• Chest pain
• Altered vision
• Feelings of depersonalization and panic attacks
• Nausea
• Reflux
• General fatigue
• Concentration difficulties
• neurological/psychological/gastro-intestinal and musculoskeletal changes can occur
• dyspnoea with normal lung function
• deep sighing
• exercise induced breathlessness
• frequent yawning
• hyperventilation

Differential Diagnosis

Breathing pattern disorders and low back pain may be present with more serious conditions including cardiac, respiratory, abdominal organ pain referral patterns which must be ruled out by medical personnel.

Other differential diagnosis for abnormal breathing include:

• brain stem injury
• stroke
• asthma
• gastrointestinal disorders
• cardiac disorders
• other respiratory disorders

There are characteristics for recognizing and diagnosing breathing pattern disorders:

• Restlessness (type A, “neurotic”)
• ‘Air hunger’
• Frequent sighing
• Rapid swallowing rate
• Poor breath-holding times
• Poor lateral expansion of lower thorax on inhalation
• Rise of shoulders on inhalation
• Visible “cord-like” sternomastoid muscles
• Rapid breathing rate
• Obvious paradoxical breathing
• Positive Nijmegen Test score (23 or higher)
• Low end-tidal CO2 levels on capnography assessment (below 35mmHg)
• Reports of a cluster of symptoms such as fatigue, pain (particularly chest, back and neck), anxiety, ‘brain-fog’, irritable bowel or bladder, paresthesia, cold extremities.

Outcome Measures

There are no standard low back pain AND breathing dysfunction outcome measures.

A 10 cm VAS can be used to assess pain intensity.

The Roland Morris Scale (24-item) to assess low back pain-specific functional disability.

The Short Form-36 (SF-36) measures functional overall health status.

The measurement of postural stability at baseline and immediately after therapy can provide a surrogate measure for whole-body proprioception and body awareness. This can be done with computerized dynamic posturography or with a traditional static force plate on which patients stand on a force platform and attempt to maintain balance while standing in a neutral position. Patients can then be assessed on their ability to integrate visual, vestibular and proprioceptive components of balance (eyes closed, static vs compliant platform, static or moving surround visuals).

Examination

Perform examination of the low back. See Low Back Pain.

Breathing Pattern Disorders are diagnosed using physical assessment, a validated questionnaire (the Nijmegen) and a capnometer, which measures respiratory carbon dioxide levels.

Capnography has been shown to have a good concurrent validity when compared to arterial carbon dioxide measures. Previous studies of breathing therapy have not included capnography in their research. Therefore, it’s difficult to say anything about the validity of the device in function of therapy

The Nijmegen questionnaire provides a non-invasive test of high sensitivity (up to 91%) and specificity (up to 95%).This easily administered, internationally validated diagnostic questionnaire is the simplest, kindest and to date most accurate indicator of acute and chronic hyperventilation. The questions enquire as to the following symptoms, and their intensity:

• Constriction in the chest (the feeling of tightness in the chest)
• shortness of breath, accelerated or deepened breathing, inability to breathe deeply, feeling tense, tightness around the mouth, stiffness in the fingers or arms, cold hands or feet,
• tingling fingers,
• bloated abdominal sensation
• dizzy spells,
• blurred vision
• feeling of confusion or losing touch with environment.

Medical Management

Low back pain

The most commonly prescribed medications for low back pain are nonsteroidal anti-inflammatory drugs (NSAIDs), skeletal muscle relaxants, and opioid analgesics.

A review by the American Pain Society and the American College of Physicians shows that several medications evaluated in this report are effective for short-term relief of acute or chronic low back pain, although each is associated with a unique set of risks and benefits. There is evidence that NSAIDs, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain) are effective for short-term relief. For mild or moderate pain, a trial of acetaminophen might be a reasonable option because it may offer a more favorable safety profile than NSAIDs, that is used for more severe pain. For very severe, disabling pain, a trial of opioids may be an option to achieve adequate pain relief and improve function, despite some potential risks. For all medications included in this review, evidence of beneficial effects on functional outcomes is limited and further research is required.

Surgery may be recommended for low back pain due to a disc herniation, spondylolisthesis or spinal stenosis. In a large follow-up study with patients with spondylolisthesis and associated spinal stenosis, one group received a surgical treatment and the other group a non-surgical treatment. Results of this study report that the group that was treated surgically maintains substantially greater pain relief and improvement in function for four years. In another study where they focused on patients with disc herniation, the study concluded that after 4 years, patients who underwent surgery for a lumbar disc herniation achieved greater improvement than those treated non-operatively.

Breathing pattern disorders
The most frequently used drug for treatment of asthma in children and adults are the beta-agonists. These agonists are the most potent bronchodilators available. Using these bronchodilators helps increase the airway caliber and suppress the inflammation and causes quick relief of symptoms of asthma. The beta-agonists are taken by inhalation, because inhalation is preferable to other routes because of the better dose effect ratio and the quicker effect.

Another study has determined if deterioration could be slowed in patients with asthma or COPD during bronchodilator therapy by a treatment with an inhaled corticosteroid. The study was a 4 year prospective study where during the first 2 year of treatment, the patients were given only bronchodilator therapy and during the last two years additional treatment with corticosteroid. This study showed that adding corticosteroid to the treatment, slowed the unfavorable course of asthma or COPD. In asthmatic patients, this effect was most evident.

Physical Therapy Management

Breathing rehabilitation offers the potential for reducing the negative influences resulting from breathing pattern disorders.

The particular quality of breath therapy in low back pain patients is that the patients learn to focus on the subtle sensations of breath as it moves the inner physical space of those body areas where patients would rather not want to focus on. Patients generally want to get away from pain and invest considerable effort into avoiding the perception of painful areas. Moreover, low back pain seems to develop particularly in those neglected areas of the body, where patients have the greatest difficulty and the least practice in focusing on the perception of autonomous non-manipulated breath movements. Through verbal guidance and skilled touch, breath therapists help in the development of the patients’ skill to allow and fully experience such autonomous breath movements within the area of pain. The results of this descriptive study suggest that breath therapy may enhance proprioception and, therefore, may be an appropriate complementary intervention particularly for patients with back pain.




BREATHING DISORDERS

Patients who suffer from respiratory problems may be treated by physiotherapists. This treatment tries to manage the breathlessness, to control the symptoms, to improve or maintain the mobility and function, to clear the airway and cough enhancement or support. Physiotherapy can also be helpful for musculoskeletal or/and postural dysfunction and pain and improving continence during coughing and forced expiratory maneuvers. Physiotherapist can offer pulmonary rehabilitation and can be non-invasive.

Techniques could be:

• Exercise testing
• Exercise prescription
• Airway clearance
• Position techniques
• Breathing techniques

The basic principles are common in the most physiotherapy treatment protocols

• Education on the pathophysiology of the disorder
• Self-observation of one’s own breathing pattern
• Restoration to a, personally adapted, basic physiological breathing pattern: relaxed, rhythmical nose–abdominal breathing.
• Appropriate tidal volume
• Education of stress and tension in the body
• Posture
• Breathing with movement and activity
• Clothing Awareness
• Breathing and speech
• Breathing and nutrition
• Breathing and sleep
• Breathing through an acute episode

The effectiveness of physiotherapy on patients with asthma has been studied in a randomised clinical trial. Asthma is a functional breathing disorder and this study shows a clinical relevant improvement in quality of life following a short physiotherapy intervention.

The British Thoracic Society has guidelines for physical therapy management of patients with medical respiratory dysfunction.

Studies have shown that eight weeks inspiratory muscle training in individuals with LRP to a training resistance of 60% of the 1RM leads to a significant improvement in inspiratory muscle strength, a more multi-segmental postural control strategy, increased inspiratory muscle strength and decrease of LBP severity.

According to following Wolf E. Mehling et al, examined the effect of breathing therapy on low back pain. However changes in pain and disability were comparable to those resulting from extended physical therapy. They compared the effects of breathing therapy with the effect of physical therapy. Each group received one introductory evaluation sessions of 60 minutes and 12 individual therapy sessions of equal duration, 45 minutes over 6 to eight weeks. The breath therapy was given by 5 certified breath therapists. Physical therapy was given by experienced physical therapy faculty members in the Department of Physical Therapy and Rehabilitation Science.

The 90/90 bridge with ball and balloon technique was designed to help restore the ZOA (Zone of Apposition) and spine to a proper position in order to allow the diaphragm optimal ability to perform both its respiratory and postural roles. It's a therapeutic exercise that promotes optimal posture and neuromuscular control of the deep abdominals, diaphragm, and pelvic floor would be desirable for patients with breathing disorders en patients with LBP. The balloon blowing exercise (BBE) technique is performed in supine with the feet on a wall, hips and knees at 90 degrees and a ball between the knees. This passive 90˚ hip and knee flexion position places the body in relative lumbar spine flexion, posterior pelvic tilt and rib internal rotation/depression which serves to optimize the ZOA
and discourage lumbar extension/anterior pelvic.
Studies of the effects of a single BBE and/or training effects of multiple BBE’s could include EMG for abdominal muscle, spirometry for changes in breathing parameters, real time ultrasound for diaphragm length and/or changes in abdominal muscle thickness. Additionally, future studies designed to describe changes in pain and function attributable to the BBE are needed to investigate the clinical efficacy of this promising therapeutic exercise technique.


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.
Exercises
According to the article by Laurie McLaughlin et al, breathing retraining should improve end-tidal CO2 (ETCO2), pain and function in most patients complaining of neck or back pain.
Abdominal Breathing Technique:
How it’s done: With one hand on the chest and the other on the belly, take a deep breath in through the nose, ensuring the diaphragm (not the chest) inflates with enough air to create a stretch in the lungs. The goal: Six to 10 deep, slow breaths per minute for 10 minutes each day to experience immediate reductions to heart rate and blood pressure
The three-part breath:
The patiënt lies down on the back with the eyes closed, relaxing the face and the body. Then begin to inhale deeply through the nose. On each inhale, fill the belly up with your breath. Expand the belly with air like a balloon. On each exhale, expel all the air out from the belly through your nose. Draw the navel back towards your spine to make sure that the belly is empty of air.
On the next inhale, fill the belly up with air as described before. Then when the belly is full, draw in a little more breath and let that air expand into the rib cage causing the ribs to widen apart. with the exhale, let the air go first from the rib cage, letting the ribs slide closer together, and them from the belly, drawing the navel back towards the spine. On the next inhale, fill the belly and rib cage up with air as described above. Then draw in just a little more air and let it fill the upper chest. On the exhale, let the breath go first from the upper chest, then from the rib cage, letting the ribs slide closer together. Finally, let the air go from the belly, drawing the navel back towards the spine.

Breathing excercises in combination with strenght training:

The following excercises39 are performed with a powerbreathe KH1 device. This handheld device applies a variable resistance provided by an electronically controlled valve (variable flow resistive load). Loading is maintained at the same relative intensity throughout the breath, by reducing the absolute load to accommodate the pressure–volume rela- tionship of the inspiratory muscles. The application of a tapered load allows patients to get close to maximal inspiration, even at high-training intensities.
Performing excercises for training the backmuscles in combination with this device can increase the muscle strength of the inspiratory muscles and also the muscles of the back.
Excercise 1
Stand on one leg with the device in the mouth and with one arm extended above you holding the resistance ( cable machine or resistance band).
Make sure that you have a straight body line between your ankle and shoulders, that you have a neutral spine and that your abdominal corset muscles are braced. Flex forward, rotating at the hip and inhale forcefully through the device. Exhale as you retrn to the upright start position. You can swap breathing phases between sets
You can make tis excercise more dificult by using more weight at the cable machine. You can also increase the resistance of the device.
2 sets with 15 repetitions.

Excercise 2
Begin with your feet shoulder width apart and with the device in the mouth. Hold the resistance (cable cord or resistance band) in one hand, with your hand near your shoulder.<o:p></o:p>
Make sure you have a neutral spine and brace your abdominal corset muscles.<o:p></o:p>
Press the handle of the cable away from you., lunging forward. As you move forward, inhale forcefullu through the device and exhale when you return back to the upright start position. You can swap breathing phases between sets. <o:p></o:p>
You can make tis excercise more dificult by using more weight at the cable machine. You can also increase the resistance of the device.
2 sets with 15 repititions.

Excercise 3
Begin with a lean position on your toes and on your arms. Hold your hands together. Hold the divice in your mouth.
Make sure you have a neutral spine and brace your abdominal corset muscles.
Hold this position for 30 seconds while you breath through the device.
You can make this excercise more dificult by bringing one leg to your body and return it afterwards. You repeat this with the other leg during the excercise.
You can also increase the resistance of the device.
3 sets

Excercise 4
Lie down on your back and keep your arms at your sides. Hold the device in your mouth. Lift your hips towards the ceiling while you make sure that you brace the abdominal corset muscles. Also make sure you keep your knees and thighs parallel. Hold this for 30 seconds while you breath through the device.
You can make this excercise more dificult by raising one leg during the excercise and bring it back to the ground. you can do this alternating with the other leg.
You can also increase the resitance of the device.

                                                                    

Key Research

One level 1B RCT  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. The review states that there is evidence of a weak but statistically significant positive correlation between low back pain and respiratory problems. All the studies in this review were cross sectional 2A level cohort studies.
In one case serie  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

Janssens L, Brumagne S, Polspoel K, Troosters T, McConnell A.  The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain. Spine (Phila Pa 1976). 2010 May 1;35(10):1088-94. doi: 10.1097/BRS.0b013e3181bee5c3.

Janssens L, Brumagne S, McConnell AK, Hermans G, Troosters T, Gayan-Ramirez G.  Greater diaphragm fatigability in individuals with recurrent low back pain. Respir Physiol Neurobiol. 2013 Aug 15;188(2):119-23. doi: 10.1016/j.resp.2013.05.028. Epub 2013 May 31.

Clinical Bottom Line

Breath therapy would provide a short-term improvement in pain and related functional limitations, but in the longer term one has to deal with a major downturn which it is not significantly better than conservative physiotherapy. Other research has shown that yoga is more effective than a self-care book, but there is only weak evidence that it is more effective than physical exercises.

Recent Related Research (from Pubmed)

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