Are Your Patients Breathing… or B‑R‑E‑A‑T‑H‑I‑N‑G?

When your patients or athletes complain of persistent pain, do they breathe with their mouths open and look as if they are laboring—even during rest or low-level activity?

For a large part of my 36-year career as a physical therapist and athletic trainer, I mistakenly assumed that if a patient or athlete was not “blue in the face” or in obvious respiratory distress, the breathing system was not contributing to their pain, injury, or dysfunctional movement. I have now learned that dysfunctional breathing can be a root contributor to many of the persistent pain and dysfunctional movement patterns I see in my clinical practice.

What Is Dysfunctional Breathing?

Dysfunctional breathing is defined as “inappropriate breathing which is persistent enough to cause symptoms with no apparent organic cause.”1 Research suggests that dysfunctional breathing is present in 5 to 11 percent of the general population, in 30 percent of people with asthma, and in 83 percent of those with anxiety.2

Dysfunctional breathing can be observed in athletes as well as sedentary individuals. It has been linked to persistent and chronic pain states3 and has been identified as a major cause of frequent primary care visits.4

Symptoms and Signs of Dysfunctional Breathing

While dysfunctional breathing can be obvious, as in the case of a person with clearly labored breathing, sometimes the signs can be more subtle. You should suspect dysfunctional breathing if the person you are treating reports:

  • Dyspnea not due to other organic causes
  • Chest tightness
  • Frequent sighing/yawning/“air hunger”
  • Persistent musculoskeletal pain
  • Tissue hypoxia
  • Hyperarousal/constant sympathetic state
  • Depression/anxiety
  • Sleep disturbance

What Are the Root Causes of Dysfunctional Breathing?

The breathing apparatus can reset to a sympathetic level during a physical or emotional trauma and stay that way, even once the body progresses through the stages of inflammation and repair. Dysfunctional breathing often leads to the peripheral and central sensitization states that perpetuate persistent pain in our patient and athletic populations.

Which Key Evaluative Techniques Help Identify Dysfunctional Breathing?

While there is no consensus regarding the most valid and reliable tests to help identify dysfunctional breathing, a number of investigations have identified assessments that would be valuable additions to your current clinical skills, including:

  • Observation (rib flare, excessive accessory muscle use)
  • Manual palpation (Manual Assessment Respiratory Motion [MARM], Hi-Lo Breathing)5, 6
  • Functional movement assessments

These assessments are discussed in depth and demonstrated in my MedBridge course, “Dysfunctional Breathing: Part 1.”

Watch the following video of the Breath Holding Test, one of the evidence-based assessments investigated in current literature to help identify dysfunctional breathing in your patients.7

What Are the Most Effective Interventions to Help Alleviate the Effects of Dysfunctional Breathing?

The most effective treatment strategies for alleviating the effects of dysfunctional breathing remain a source of controversy in the literature. Many experts advocate manual therapy to facilitate neurophysiological mechanisms that lead to pain modulation and restoration of normal breathing patterning and therapeutic exercise/neuromuscular retraining.8, 9

My MedBridge course, “Dysfunctional Breathing: Part 2,” covers evidence-based interventions suggested to help restore functional breathing.

Watch the following video Graston Technique® therapy applied to the diaphragm to facilitate a normal breathing pattern in an athlete.

Dysfunctional breathing is present in many of our patients and athletes. Are you up for the task of identifying it in the folks you treat?

Assessing, identifying, and treating dysfunctional breathing in your patients and athletes can have a profound impact on pain modulation, quality of life, and even performance enhancement. My MedBridge course series on dysfunctional breathing covers the critical assessment and intervention strategies that will help take your clinical practice to the next level.

  1. Clifton-Smith, T. & Rowley, J. (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession. Physical Therapy Reviews, 16: 75–86.
  2. Courtney, R. (2009). Functions and dysfunctions of breathing and their relationship to breathing therapy. International Journal of Osteopathic Medicine, 12: 78–85.
  3. Chaitow, L. (2004). Breathing pattern disorders, motor control, and low back pain. Journal of Osteopathic Medicine, 7(1): 33–40.
  4. Bartol, T. G. (2019). Top reasons for primary care visits. Medscape. Accessed 5/17/19.
  5. Chapman, E. B., Hansen-Honeycutt, J., Nasypany, A., Baker, R. T., & May, J. (2016). A clinical guide to the assessment and treatment of breathing pattern disorders in the physically active: part 1. International Journal of Sports Physical Therapy, 11(5): 803–809.
  6. Courtney, R., Cohen, M., & Reece, J. (2009). Comparison of the Manual Assessment of Respiratory Motion (MARM) and the Hi Lo Breathing Assessment in determining a simulated breathing pattern. International Journal of Osteopathic Medicine, 12(3): 86–91.
  7. Kiesel, K., Rhodes, T., Mueller, J., Waninger, A., & Butler, R. (2017). Development of a screening protocol to identify individuals with dysfunctional breathing. International Journal of Sports Physical Therapy, 12(5): 774–786.
  8. Yilmaz Yelvar, G. D., Çirakm Y., Demir, Y. P., Dalkilinç, M, & Bozkurt, B. (2016). Immediate effect of manual therapy on respiratory functions and inspiratory muscle strength in patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease, 11: 1353–1357.
  9. Cruz-Montecinos, C., Goday-Olave, D., Contreras-Briceño, F. A., Gutiérrez, P., Torres-Castro, R., Miret-Venegas, L., & Engel, R. M. (2017). The immediate effect of soft tissue manual therapy intervention on lung function in severe chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease, 12: 691–696.