NECK PAIN AND BREATHING PATTERN DISORDERS
- 1 Introduction
- 1.1 Definition/Description
- 1.2 Clinically relevant anatomy
- 1.3 Epidemiology/Etiology
- 1.4 Incidences of Breathing Pattern Disorders
- 1.5 Symptoms of breathing pattern disorder
- 1.6 Differential Diagnosis - Differentiating between Breathing Pattern Disorder and Neck Pain
- 1.7 Cranio-Cervical Flexion Test
- 1.8 Breathing Pattern Disorder (BPD) Assessment
- 1.9 Questionnaires/Inventories
- 1.10 Physiotherapy Interventions
- 1.11 Physiotherapy for Breathing Pattern Disorders
- 1.12 Physiotherapy for Neck Pain
- 1.13 References
IntroductionThis document aims to provide information of how Dysfunctional Breathing Pattern (DBP) disorders are associated with neck pain (NP). Including information on; epidemiology, aetiology, presentation of symptoms and provide recent evidence of the recommended management of the symptoms.
Breathing with normal respiratory mechanics has a potent role in the musculoskeletal system. Respiratory mechanics play a key role in both posture and spinal stabilization. Respiratory mechanics must be intact for both normal posture and spinal stabilization. There is a dynamic interaction between the key muscles of respiration. (Perri & Halford, 2003). Dysfunction in one can lead to a dysfunction in the other (co-dependency).During respiration, there is a need of stabilized cervical and thoracic spine in order other muscles to act, moving the ribs up or down. In case of instability, rib cage could present mechanical alterations leading to insufficient respiratory dysfunction, influencing all muscles involved such as diaphragm, intercostals or abdominals due to adapted contraction pattern based on muscles’ force-length curve. Thus, it could be suggested that inspiration and expiration strength could be lessen in patients with neck pain.
Evidence shows there is an association between neck pain and pulmonary function: A systematic review, included 68 studies, 9 were observational studies. The studies found a significant difference in maximum inspiratory and expiratory pressures with chronic neck pain compared to asymptomatic patients. Respiratory volumes were lower in patients with chronic neck pain. Muscle strength and endurance, cervical range of motion, lower Pco2 were also found to be significantly correlated with reduced chest expansion and neck pain. Respiratory retraining was found to effective in improving some cervical musculoskeletal and respiratory impairment. (Kahlaee et al, 2017)
Clinically relevant anatomy
The thoracic spine and the interconnected muscles are responsible for normal inspiration and expiration. When breathing becomes harder work or altered the body compensates by recruiting the Cervical Accessory Muscles.Trapezius
Scalene are invariably active during the inspiratory phase of breathing, even when the increase in lung volume is very small. The sternocleidomastoids are not active during resting breathing but they participate during strong inspiratory efforts.
‘A disordered breathing pattern can be the first sign that all is not well, whether it be a mechanical, physiological or psychological dysfunction’ (CliftonSmith & Rowley, 2011)
Incidences of Breathing Pattern Disorders
• 5-11% in general population
• 30% in asthmatics
• 83% in anxiety sufferers
• 6-10 % of patients that present to their GP may have an underlying breathing disorder
Symptoms of breathing pattern disorder
Symptoms of a breathing pattern disorder can be complex, variable and involve multi-systemic reactions from the body. Breathlessness is ne of the main symptoms of a BPD, especially once any other underlying pathology has been ruled out. If a patient is unable to take a satisfying deep breath, tight chested, 'air hungry', sighing, yawning or coughing & throat clearing. Signs and symptoms of a BPD may also include Cardiac palpitations, chest pain, tachycardia, pseudo angina and changes on an ECG. Physiological signs such as atrophy and weakness in the muscles of respiration, hypertrophy of accessory muscles, 'barrel chest' or mouth-breathing can also be indicative of a BPD.
Symptoms can also include:
• Neurological - Dizziness, faintness, numbness & tingling (facial and extremities), blurred vision, headaches, detachment from reality, muddled, lack of concentration, poor memory
• Gastrointestinal - Dysphagia, heartburn, epigastric pain, reflux, burping, bloatedness, air swallowing, IBS
• Muscular - Muscular Cramps, aches & pains, tremor, involuntary contractions, jaw clamping
• Psychological - Anxiety, panic attacks, phobias, depression, tension
• Systemic - General Weakness, exhaustion, fatigue, lethargy, Sleep disturbance, dry mouth.
Differential Diagnosis - Differentiating between Breathing Pattern Disorder and Neck Pain
(Dimitriadis et al, 2013)
• Patients with CNP were found to have significant deficits in strength and endurance performance of their global and local Cervico-scapulothoracic muscles when compared to healthy patients
• Dysfunction of these muscles is believed to lead to reduced respiratory performance partly due to the common functioning of sternocleidomastoid, trapezius, and scaleni on cervical movement and inspiration.
• Psychological states (e.g anxiety, depression, catastrophizing) also show significant contributions to the patients' experience of pain, respiratory and cervical dysfunction
• Clinicians are advised to consider the respiratory functioning of patients with CNP along with their psychosocial state, during their assessment to appropriately choose and administer effective treatments
Patients with CNP were found to have reduced performance of their global and local cervico-thoracic muscles. Dysfunction of these muscles is believed to lead to reduced respiratory performance partly because of the common function of sternocleidomastoid, trapezius and scalenes on cervical movement and inspiration.
(Beeckmans et al, 2016) 
• Systematic review (16 articles) assessing the literature pertaining to the relationship between LBP and Respiratory Disorders (RD)
• A significant correlation was observed between the presence of LBP + RD (eg. asthma, dyspnoea)
• Literature indicated individuals with these particular RD reported higher rates of LBP and vice versa
• However, evidence in support of the physical mechanisms to explain this association is inconclusive
The chance of reporting LBP is greater for patients suffering from asthma or asthma-like symptoms when compared to patients without asthma. Vice versa, the occurrence of asthma is greater in patients who reported LBP ever or in the past year.
When treating LBP in patients with RD or asthma-like symptoms, adequate management of RD may also be important, together with an optimal focus LBP treatment (see page on LBP)
Dysfunctional breathing may be an important focus in the rehabilitation of patients with asthma-like symptoms, in particular, stressful conditions (e.g. exercise) may lead to RD during athletic performance.
Existing evidence supports the relationship between BPD and lower back pain (Lumbar vertebra L1-L5), dysfunction of local and global muscles further up the spine that assist in respiration may contribute to NP (Cervical vertebra C1-C7).
Assessment/ Outcome Measures
(Blanpiedet al, 2017)
An evidence-based literature review and evaluation of literature and existing medical guidelines relating to the assessment, intervention and overall management of musculoskeletal (MSK) disorders.
In addition to standard movement and strength subjective and objective examination of the neck (e.g. posture, breathing, active/passive range of motion, manual muscles tests)
While not a measure of function, pain has an effect on function and can be used as an evaluative tool
A recent piece of literature (Fillingim et al, 2015) involved in this review recommended assessing 4 components of symptomatic pain:
(1) pain intensity (eg, numeric pain-rating scale)
(2) other perceptual qualities of pain (eg, asking the patient to describe the character of the pain)
(3) bodily distribution of the pain (eg, by using a body chart)
(4) temporal features of pain (eg, asking the patient how the pain fluctuates with activity and rest, and over a day, week, or month)
• Clinicians consider the use of a mechanism-based approach, such as screening tools for neuropathic pain.• Quantitative sensory testing, including tuning forks, monofilaments, and tools for cold hyperalgesia could also play a key role in the assessment of a patient’s pain.
• Pain assessment should be combined with not only physical but psychosocial functioning examinations. 
Cranio-Cervical Flexion Test
The Cranio-cervical flexion test (CCFT) is a clinical test of the anatomical action of the deep cervical flexor muscles, the longus capitis, and colli. It has evolved over 15 years as both a clinical and research tool and was devised in response to research indicating the importance of the deep cervical flexors in support of the cervical lordosis and clinical observations of their impairment with NP.
While the test in the clinical setting provides only an indirect measure of performance, the construct validity of the CCFT has been verified in a laboratory setting by direct (EMG) measurement of deep and superficial flexor muscle activity.
This particular test can be adapted and utilized as an endurance focused exercise aimed at improving the functioning of the deep cervical flexors.
Breathing Pattern Disorder (BPD) Assessment
• Breath Holding – People can normally hold their breath between 25 and 30 seconds. If less than 15 seconds may mean low tolerance to carbon dioxide.
• Breathing Hi-Low Test (seated or supine) – Hands on chest and stomach, breathe normal – what moves first? What moves most? Looking for lateral expansion and upward hand pivot.
• Breathing Wave – Lay prone, breathe normal, spine should flex in a wave-like pattern towards the head. Segments that rise as a group may represent thoracic restrictions.
• Seated Lateral Expansion – Place hands on lower thorax and monitor motion while breathing. Looking for symmetrical lateral expansion.
• Manual Assessment of Respiratory Motion (MARM) - Assess and quantify breathing pattern, in particular the distribution of breathing motion between the upper and lower parts of the rib cage and abdomen under various conditions. It is a manual technique that once acquired is practical, quick and inexpensive.
• Respiratory Induction Plethysmography (chest diameter/pulmonary ventilation) and Magnetometry (abdomen/chest expansion measure)
Additional questionnaires in assessment of BPD associated physical and psychological related symptoms and dysfunctions (see BPD Physiopedia page)
(Turk et al, 2016)
Overview of outcome measures and procedures to assess a set of key psychosocial and behavioural factors that could be important in the assessment of pain.
Turk et al, 2016 advise that the presence of pain and chronic pain has a number of psychosocial and functional consequences in multiple areas of functioning (e.g. cognition, emotion, and behaviour). Because chronic pain persists over time (+3 months), each of these areas will, in turn, affect the experience and reporting of pain and related symptomatic dysfunction.
- Brief Pain Inventory Short Form - (pain, physical, emotional functioning) assess the extent of the effect of pain on emotional/physical functioning
- Nijmegen Questionnaire- Assess the symptoms associated with breathing pattern disorders
- Neck Disability Index - assess functional activities and effect of pain on dysfunction
- Quality of Wellbeing Scale - relating physical and mental symptom measures to functional aspects of life to assess the overall quality
When assessing patients with neck pain and a breathing pattern disorder, it is important to establish whether the pain is influencing the pattern of breathing, or if the breathing pattern is contributing to mechanical pain. However, to develop and implement a comprehensive treatment program, both issues must be addressed in equal measure. When a patient presents with a combination of neck pain and a BPD, it is essential as a physiotherapist to include rehabilitation goals for both problems.
As previously discussed, there are many assessments which may be used to assess BPD (Nijmegen, Breath-holding test, Breathing Hi-Low Test), mechanical neck pain (strength, ROM, ‘special tests’) and questionnaires covering the biopsychosocial effects of pain on physical function (Brief Pain Inventory Short Form, Neck Disability Index). Once a comprehensive subjective and objective assessment is complete, and specific outcome measures taken at baseline, the current evidence-based for physiotherapy interventions include:
Physiotherapy for Breathing Pattern Disorders
- Breathing Retraining:
1. Making patient aware of disordered pattern of breathing.
2. Teach/encourage relaxation of the jaw, upper chest, shoulders and neck (Accessory Muscles).
3. Re-educate breathing pattern to utilise nose-abdominal/diaphragmatic breathing technique.
- Sniff Test:
Can be used to diagnose bilateral lack of diaphragmatic excursion, in patients who commonly use their upper-chest or accessory muscles to breath. This test can be taught to a patient and repeated as part of a treatment program, but also used a to monitor muscular re-training progress. 
- Bradcliff Angle Check:
For patients with hypertonic abdominal muscles, a decrease in the xyphocostal angle (normal angle 75-90 degrees) can reduce the normal range of movement of the diaphragm, and therefore disturb the normal breathing pattern. Measuring this angle prior to commencing a treatment program, and taking subsequent measures over time can also be used as an outcome measure. 
- Psychosocial Interventions:
BPD's are commonly associated with psychological distress - panic attacks, anxiety and depression can all be contributing factors to disordered breathing. Signposting patients to local services which address the care of psychological well-being, alongside retraining of the respiratory musculature, may prove a useful multifaceted treatment approach. 
- Total Body Relaxation and Sleep Hygiene:
To encourage patients to learn a variety of mental and physical relaxation techniques which can help to combat stress and anxiety. Educating patients on the ANS stress response systems and the mental and physical increase in tension that sustained stress or anxiety can create in the body can be a useful conversation starter. This can then be built upon over treatment sessions to equip a patient with a self-management program for day-to-day stresses. This could include mindfulness, a practise centred around focusing on you pattern of breathing and consciously 'letting go' of physical and mental strain. The education program should also include education on sleep hygiene and maintaining a good night time routine.
- Exercise and Nutrition:
Exercise depends upon the bodies cardiovascular and respiratory systems working together to increase oxygen to the muscles, and remove carbon dioxide. Using exercise in patients with breathing pattern disorders can aid in encouraging diaphragmatic breathing. Apical breathing and hyperventilation can use up to 30% of the total oxygen consumption, whereas breathing at rest uses as little as 2%. Therefore it is important to be aware of the symptoms of fatigue associated with BPD's when considering a treatment program.
Any increase in Physical Activity for most people will be beneficial for their health in the long term - even as little as 2 minutes, 3 times a day can have a positive impact on the cardiovascular system of a person with very limited exercise tolerance. Taking patients through a step-by-step process of introducing them to their own body's cardiovascular adaptations (increased heart rate, increased tidal volumes, feeling of breathlessness) during exercise can also be a useful starting point, especially for patients suffering with anxiety or panic related BPD's. Nutritional advice also plays an important role in education for patients, to maintain energy and improve digestive function.
In 2014 Bradley et al. found there to be a significant association between breathing pattern disorders and reduces scores on functional movement assessments. The individuals who had signs and symptoms of BPD's were likely to demonstrate increased movement dysfunction on the Functional Movement Screen. By using exercise based interventions, Physiotherapists are perfectly positioned to encourage both a regulation and return to normal breathing patterns, and increasing overall cardiovascular fitness in our patients.
By practising a holistic approach when managing breathing pattern disorders in combination with cervical spine pain, we can encourage patients to optimise their breathing pattern and efficient respiratory muscle recruitment in all activities of daily living. The evidence base suggests that, although there may not yet be a direct causal link between neck pain and BPD, being aware of a potential link and assessing patients accordingly is key to biopsychosocial practise. As physiotherapy continues move forward continuing to encourage increased physical activity and a personal awareness of breathing patterns, both at rest and during exertion, could provide benefit to many patients struggling with BPD's.
Physiotherapy for Neck Pain
(Blanpiedet al, 2017) proposed a model outlining important aspects of the examination, diagnosis, and treatment of patients experiencing NP or chronic NP.
Cochrane systematic review (21 trials) assessing the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with NP.
• For chronic NP a moderate quality of evidence supports cervico‐scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment and at short‐term follow‐up.
• Scapulothoracic and upper extremity endurance training contributes to a slight beneficial effect on pain at immediate post treatment and short‐term follow‐up.
• Combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment and up to long‐term follow‐up, a medium magnitude of effect improving function was also observed at both immediate post treatment and at short‐term follow‐up.
• Cervico‐scapulothoracic strengthening/stabilization exercises contributed to improvements in perceived pain and function at intermediate-term assessment.
There appears to be minimal effect on neck pain and function when only stretching or endurance type exercises are used to improve NP and functioning.
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