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Optimizing Respiratory Function

There are many different forms of breathing impairments that one can experience, such as COPD, asthma, emphysema, bronchitis, sinusitis, allergies, among others. The impairment we will be discussing in this post is Dysfunctional Breathing.  

Dysfunctional breathing (DB) is characterized by irregular breathing patterns that occur either in the absence of concurrent diseases or secondary to cardiopulmonary diseases. The primary symptom of DB is often dyspnea or “air hunger” but can also be associated with non-respiratory symptoms such as dizziness and palpitations. Other potential signs and symptoms of DB include headache, excessive sighing/yawning, tight chest, panic attacks, cramps/tremors, dizziness/fainting, cough, dry throat, chest pain, anxiety, weakness, and pins/needles in fingers and toes.  

There are several different classifications of DB, with each classification having it’s own set of associated symptoms and presentation. The classifications of DB are hyperventilation syndrome, periodic deep breathing, thoracic dominant breathing, forced abdominal breathing, and frequent sighing with irregular breathing pattern.  

Although there is no gold-standard assessment for determing if someone is exhibiting/experiencing dysfunctional breathing, there is a self-assessment questionnaire you can utilize to determine if you may be experiencing difficulties with your breathing, and therefore reach out to a healthcare professional for further evaluation. The self-assessment questionnaire is called “The Self Evaluation of Breathing Questionnaire (SEBQ).” You can find a link to this questionnaire HERE.  

So how can physical therapy help with breathing? To answer this question, we must first understand the mechanics of how breathing works in the body. There are many joints and muscles that are involved when we are breathing, both during inspiration and expiration. Think about how your ribs must move in order to make room for your lungs when you breathe in, and then return to the original position when you exhale; each one of your ribs has 3 joints (or places of movement) at the spine, plus the joint to the sternum in the front; we also move our spines to a degree when breathing, and each spinal segment has the three rib joints, as well the 4 additional joints with each spinal segment. In other words, there are A LOT of joints involved with breathing. Now, with all those joints to move around, there are also a lot of muscles to control those joints. Muscles involved with inspiration are the diaphragm, levator costarum, external intercostals, and internal intercostals; muscles involved with (forced) expiration are internal obliques, transverse abdominis, external obliques, internal intercostals, rectus abdominis, and transverse thoracis.  

With all these joints and muscles involved it can be very easy for us to not breathe efficiently, as all joints and muscles must work together for breathing to be efficient. Now there are many ways to impact the efficiency of breathing, whether by direct impact to the joints and muscles listed above, or indirectly by other joints and muscles of the body “getting in the way.” For example, our large neck muscles directly attach to some of the ribs and can cause the ribs to be elevated. When this happens it makes it very difficult for the ribcage to move correctly and will thus make our breathing less efficient. Another example is simply our posture, or joint positioning created by movement patterns and posture throughout our day – if we are sitting hunched over at our computers all day, it makes it much more difficult for the ribcage to expand appropriately, thus making our breathing less efficient.  

So where do physical therapists come into play? Well, we will take a look at your entire body and movement patterns to address anything that may be affecting your breathing such as posture, tight muscles, stiff or stuck joints, as well as teaching/re-training you how to use the right muscles for breathing.  

A few examples of breathing techniques you can use to help yourself start breathing more efficiently are diaphragmatic breathing patterns, “box” breathing, 448 breathing, and alternate nostril breathing. Keep in mind this is a short list of breathing patterns/techniques and should not be considered an exhaustive list.  

Diaphragmatic Breathing 

While laying on your back or sitting in a chair with your back supported, place one hand on your chest and one hand on your stomach. The goal is to breathe in and out through your stomach rather than through your chest, your hands are there as a guide to begin utilizing your diaphragm to breathe rather than your accessory muscles. Focus on moving your hand on your stomach while breathing in and out, and trying to keep the hand on your chest as still as possible (it will move a little bit due to lung inflation/deflation) 


“Box” Breathing 

Inhale for a count of 4, hold your breath in for a count of 4, exhale for a count of 4, hold your breath for a count of 4. Continue with this pattern for as long as you feel is necessary/feels good. The count time can be adjusted to your tolerance.  


448/478 Breathing 

Inhale through your nose for a count of 4 seconds, then hold your breath for a count of 4 or 7 seconds, then exhale through your mouth for a count of 8 seconds. Continue with this pattern for as long as you feel is necessary/feels good. 


Alternate Nostril Breathing 

Begin by plugging one nostril with your thumb or index finger. Then breathe in through the other nostril. Switch the nostril that is plugged to the other side, then exhale. Inhale through the same nostril you just exhaled with, then switch the nostril that is plugged back to the original side. Now exhale. Continue with this pattern for as long as you feel is necessary/feels good. 

*Certain techniques will discuss different ways to hold your hand and plug your nose – do what feels best/easiest for you. 


Info pulled from continuing education at the APTA Combined Sections Meeting 2024 in Boston, MA. Presenters were: Colleen Chancler, PT, MHS, PhD; Susan Gerhard, PT, DPT; Amy Humphrey, PT, DPT - Board Certified Orthopedic Clinical Specialist; Rebecca Smith MS, PT - Board Certified Cardiovascular and Pulmonary Clinical Specialist, Board Certified Geriatric Clinical Specialist 


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