Breathing, It’s Not Just Air



Most of us take something as common as breathing for granted. It’s a bodily function which occurs thousands of times per day. On average, an adult breaths between 17,000 and 23,000 times per day. That is a lot of activity that we are unaware of. Rarely do we think about it, unless we are exercising and feel like passing out after running a mile (my current pitiful fitness level). All of the sudden, this minor part of our everyday life becomes a very important thing and we have a hard time NOT focusing on it…I hate running.

The important thing to know about breathing is that it affects our bodies in multiple ways. The obvious way is the intake of oxygen which is, of course, used throughout our bodies. However, something a little more applicable to massage therapy is the effect it has on certain muscles. Breathing is a very active process which uses multiple muscles to help draw air into the lungs. Because of the involvement of certain muscles in the process, it is only natural that these same muscles can become overworked or problematic, just like any other muscle in the body.

Just like any other muscle, when there is overworking or improper usage, those muscles can become injured. In the case of breathing, the injury usually occurs to muscles which are ancillary or agonist to the primary breathing muscles. To understand this, we must know how breathing works.

There are two forms of breathing. The first occurs when you are at rest and the need for oxygen is at a normal rate (known as Quiet Breathing). In other words, when you are sitting or relaxing and breathing is the last thing you are thinking about. This type of breathing uses the diaphragm and external intercostal muscles to expand the chest cavity volume, drawing air into the lungs. When this is functioning correctly, slight elevation and expansion of the ribs occur. However, the majority of expansion happens inferiorly as the diaphragm contracts, creating expansion into the abdominal cavity.

Accessory Muscles of Respiration

The second type of breathing occurs during activity or exercise when more oxygen is needed for bodily processes (known as Forced or Active Breathing). This type of breathing involves many more muscles, not only for inhalation but also for exhalation as well. This process also uses the diaphragm and external intercostals for chest cavity expansion. However, other muscles are used to help elevate and expand the ribs and sternum for faster and stronger breaths. These include but are not limited to: pectoralis minor and major, serratus posterior superior, scalenes, sternocleidomastoid, serratus anterior, levator costorum, quadratus lumborum, and serratus posterior inferior. Depending on the degree of respiration, any or all of these muscles can assist in respiration.

Accessory Muscles of Breathing

Both of these forms of breathing when done correctly are labeled as diaphragmatic breathing. No matter how relaxed or forced your breathing is, it should be done diaphragmatically. In other terms, the diaphragm should always be the primary muscle contributing to breathing.

The list of involved muscles may surprise you. Many of you may have thought breathing was a simple action done by only the diaphragm, end of story. It’s not.  With these many muscles involved in breathing you may now wonder how breathing DOES occur so easily. Well, it does this because of the amazing ability of the muscles specifically designed for this job. The diaphragm is an amazing muscle which does a great job of drawing air into our lungs repeatedly…without issue. This along with the lung’s elasticity and the intercostal muscles combines for a great system for breathing.

So how does dysfunction occur?

Poor Sitting Posture

There are a few ways structural dysfunction can occur, barring any sort of nerve paralysis, injury, or medical condition.  The first is sitting. While we sit, especially if we slouch and have poor posture, the thoracic cavity becomes compressed. This does not allow room for the diaphragm to contract and draw inferiorly. When this occurs, the ribs are forced to expand more to compensate. Naturally, more rib elevation is going to occur with this, creating expansion where possible. Over time, this abnormal rib elevation and expansion can become the new “normal”. This changes the primary process of inhalation from diaphragm usage to a rib movement focus. In other words, the primary breathing tool becomes the muscles of rib elevation (like pectoralis minor, scalenes, and sternocleidomastoid), as opposed to the diaphragm, causing chest breathing. Although this demonstrates an amazing adaption produced by the brain and body, it is not correct and will eventually lead to overuse of the accessory muscles involved.

Although these accessory muscles can do the action of rib elevation and assist in breathing, their primary design is not meant to be used for repeated contraction that goes along with regular, quiet breathing (remember, 17,000 breaths per day at a minimum). They are only meant to help with breathing when necessary for exercise and forced respiration, not as primary facilitators. Over time hypertonicity and shortening will occur.

The second dysfunction is a bit more complex but can have a similar effect on breathing. Stress and anxiety have a huge effect on the way our bodies function. This certainly applies to breathing as well. When we are under stress or have anxiety, the natural tendency is to breath shallower and faster. This does not allow for the diaphragm to contract fully, and recruits accessory muscles to help expand the ribs quickly for faster breaths. This is, of course, a natural response to stress and is okay short term. However, when stress and anxiety become a chronic condition, this form of breathing becomes habit and dysfunction occurs as the muscles being used become overtaxed.

Knowing this result of anxiety and stress, it is important to realize that chronic anxiety conditions can truly affect our musculoskeletal system. I say this because of the potential ability we as therapists have to affect this condition. This might seem like a reach, but stay with me and I’ll explain.

Once improper breathing technique (chest breathing) becomes normal for an individual, many of the accessory muscles involved can become hypertonic and very restrictive due to being overworked. These include muscles that can be very restrictive to rib movement and chest expansion. When these muscles become chronically affected, breathing can actually become restricted, leading to shortness of breath. For an individual with anxiety, this can be very anxiety-inducing, furthering the anxiety and creating a downward cycle of anxiousness.  In other words, the anxiety created by the hypertonic muscles can create more anxiety.

It may seem strange, but treating and releasing muscles like serratus anterior, pectoralis major, pectoralis minor, serratus posterior superior and even the diaphragm itself can have a dramatic effect on anxiety. Simply by releasing muscles that restrict breathing, the feeling of chest tightness and anxiousness can be reduced, possibly helping break the cycle of anxiety.

The last dysfunction I will mention may seem funny but it is a legitimate cause. During proper breathing, the diaphragm contracts and moves inferiorly, compressing the contents of the abdominal cavity. This usually presents as a pushing out or expanding of the stomach. For some, this can be embarrassing (whether they are overweight or not). A common reaction is to constantly contract the abdominal muscles (or suck the stomach in) to maintain the look of a flatter abdomen.  By doing this, the diaphragm is unable to contract fully. Once again, this will lead to a change in breathing technique and chest breathing with rib elevation becoming normal.

One Common Them.

All of these dysfunctions lead to a common theme; the overworking of accessory breathing muscles. These muscles which I listed earlier, are not meant to be primary breathing muscles. They are simply meant to help when forced (or heavy) breathing is needed for increased oxygen in the body. Each one of these accessory muscles has other purposes which are their actual primary function. Unfortunately, these primary functions get affected by improper breathing.

The point I would like to make is many times breathing can be the root cause of a dysfunction in the body which does not seem to be connected. Let us use forward head posture and upper cross syndrome as examples. Most people would agree that the scalenes, sternocleidomastoid, and pectoralis major and minor are contributors to these postural conditions. Although activities, like working on a computer or looking down at a smartphone for hours, can cause these issues, it is also no coincidence that these exact same muscles are also involved with improper chest breathing. Chronic improper breathing leads to shortening of these muscles due to continual and repeated contraction. The longer we breathe improperly, the worse forward head posture and upper cross syndrome can become.

The improper usage of these muscles can lead to injury, especially if this pattern of breathing continues and becomes the primary way of breathing. Trigger points can form in the sternocleidomastoid muscle leading to headaches and migraines and many other symptoms (read more about this in my Sternocleidomastoid and Chronic Headaches article). Chronic shortening of the scalenes and pectoralis minor can lead to brachial plexus nerve entrapment (thoracic outlet syndrome). Chronic cervicothoracic junction tension will occur due to serratus posterior superior hypertonicity which can lead to dorsal scapular nerve entrapment (read more about that in Shoulder Blade Pain…Everyone’s Bane here).

These are just a few conditions which can be a result of improper breathing. I am certainly not trying to come off as someone who is trying to sell proper breathing technique as the cure-all for every condition in the body. However, I think it is important to demonstrate how involved improper breathing is in the body.  It truly is not just bringing in air.

Hopefully, we as therapists can integrate these principals into our assessment and treatment of clients. By being aware of the possible effects that improper breathing can have on the body, we may be able to get to the root cause of some stubborn cases.

Additional resources:

Here are a couple videos on proper diaphragmatic breathing which should be done to help re-educate the ability of the body to breath properly.

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