A Physiotherapist's Take on a Common Injury

In part two of  an "Neurological Outlook on Pain and Performance", Physiotherapist Ken Moy dives into the power of a breath. How does it relate to chronic pain? How can we use breathing to improve our day-to-day?

What is breathing?

As discussed in part 1, the brain’s biggest priority is to keep us alive. Breathing is the fundamental task the brain and body needs to ensure basic human function and movement. And this is both volitional (meaning manual) and automatic. Mammals (like humans) in particular display a distinct feature called the diaphragm, otherwise known as ‘the breathing muscle’.

At rest, the diaphragm performs the active component of the inspiration breath, which creates a doming effect and expands the rib cage, allowing air to rush in from the environment. (As physicians, inspiration is the process of taking air into the lungs). The diaphragm works constantly to keep us alive, which is why learning how it works will help us understand the phenomenal process in athletes and in the general population.

How is Breathing Linked to Chronic Pain?

To understand how breathing is linked to chronic pain, we first must understand the concept of compensation.

Compensation happens when there is a pain signal sent up to the brain, which can lead to muscle imbalance and movement inefficiency as the brain attempts to protect our bodies from feeling pain. Believe it or not, like all movements, the act of breathing is also subject to the effects of compensation. If you’re thinking, “does that mean it hurts the body to breathe?” The answer is yes. For example, do you experience chronic neck and shoulder tension despite consistent stretching and warm ups? If yes, keep reading below.

How Inefficient Breathing Leads to Unwanted Tension and Pain

One form of compensation that can occur in a breathing pattern is the use of accessory or other muscles to help the diaphragm. In such a case, the muscles in the neck, pecs, and upper back play a bigger role than they normally would to assist in your breathing. On average a person breathes 22,000 times per day (Notter). Over a long period of time, muscles in the neck, pecs, and upper back will develop inefficient movements and unwanted tension. With this tension, the nervous system is also more likely to “work harder” (operating at an elevated level), and will continue to feed pain signals to the brain.

One form of compensation that can occur in a breathing pattern is the use of accessory or other muscles to help the diaphragm. In such a case, the muscles in the neck, pecs, and upper back play a bigger role than they normally would to assist in your breathing.

So, what can patients and physiotherapist's do with this information?

By accessing more of the diaphragm and thus the parasympathetic nervous system, we can improve treatments, particularly for those suffering from chronic pain. Understanding and bringing awareness to this movement compensation is the first step in breaking compensation patterns and stopping pain signals to the brain.

On a more mechanical level, inefficient breathing can also impede other functions. Active expiration (think of when you are exercising) involves muscles of the abdominals and in between ribs. If there is poor engagement of the intercostal muscles, rib positions can look flared up and out, rather than “hugged” in, therefore destabilizing the trunk (Grey). In this position, the diaphragm is not fully utilized because breathing will more likely look like an elevation of the rib cage rather than an expansion of the diaphragm. This can also negatively affect stability and function of the lower limbs because the ribs are connected to the pelvis (fascial connections).

For those interested in diving deeper, The Prague School of Rehabilitation also discusses something similar called Dynamic Neuromuscular Stability, and it all starts at the diaphragm. Ultimately, we want to teach the body to stabilize centrally in the intended areas (diaphragm), rather than continuously feeding into compensatory loops caused by pain signals.

Exercise: How to Use Breathing to Improve Chronic Pain at Home

See if you can try this exercise, a task taken from my mentor, Dr. Jeff Almon, creator of the Ground Control program for neurological reprogramming of chronic pain.

1. Lie down on your back with knees bent. Place your hands on top of your hip bone. Cough or sniff to feel your trunk engage (Dr. Jeff Almon calls this step pressurizing the cylinder). Hold this contraction and breath through it! Think of expanding the ribs and try to feel the sensation of the breath end at your mid-back
2. Perform for 10 minutes, progress to 20 minutes. Make sure everything else in the body is relaxed (take note of neck, shoulders, and glutes)

Challenging right? It takes time to reprogram what your body has grown accustomed to, like stabilizing via muscular compensation. It takes a great deal of focus, motivation, and mass practice – the primary teachings of this program. Check out this video to try it at home.

Summary

As you can see, breathing is truly the central aspect of the human body. Quality, purposeful breathing is the root of trunk stability and plays a big role in the nervous system. Studies have shown proper breathing to improve learning and memory (particularly with nasal breathing), alertness and reaction time (Huberman).

It’s easy for many of us to compensate for pain from daily life, poor posture, or common injuries with breathing. Even physiotherapists do it! If you have seen me for treatment in the past, you probably heard me say that inefficient breathing is the ultimate compensation. Whether you are a high-level athlete looking to optimize physiology or someone going through rehab from an injury, breathing is a fundamental aspect of human physiology. Curious? Let’s chat ☺

As always, as physios, we always recommend prevention. Make sure to warm up before physical activity, and don't hesitate to reach out if you have any nagging pain.