Breathing and the Ribcage
I’ve been spending a lot of time lately teaching people how to breathe. This has been a fascinating experience for me because my understanding of breathing has changed multiple times since starting this career. We will get into all of those, but let’s start with the easier question which is - what is the wrong way to breathe?
We can understand breathing better when we can understand the structures and biomechanics involved. The ribcage produces two types of movement - bucket handle and pump handle motions. Bucket handle is the moving out and up of the sides of the ribs- I often refer to this as lateral excursion breathing. Pump handle is the up and forward movement of the chest. This is sometimes stigmatized as “chest breathing” and we want to differentiate that from “neck breathing” which leads us to the muscle action involved in this process. The primary breathing muscle is the diaphragm which is the dome shaped muscle at the bottom of the ribcage, assisted by the intercostals between the ribs. Neck breathing lifts the ribcage by using the sternocleidomastoid (SCM), scalenes, and trapezius among others. We are oversimplifying here slightly because there are times when we need to force exhale voluntarily- we use our abs to blow out candles or our serratus when we’re running, but in general I think we can all agree that we want to promote the use of our diaphragm over our traps for an action as repetitive as breathing.
Optimizing our Breath through Manual Therapy
With palpation, a therapist can feel what parts of the ribcage aren’t expanding on the inhale, or aren’t recoiling on the exhale. We assess each part in segments, from the side, front, and back. Areas of the thoracic spine can be impacted due to postural habits or dysfunctions, prior injuries, stress holding patterns, or adhesions (perhaps from stomach or chest surgeries). We also assess the diaphragm to understand its tone, length and strength. Treatment explores using the breathing to assist the individual ribs in lifting or lowering appropriately. We are including some examples of treatment here as these can be hard to put into words.
Breathing and Rib Pain (Costochondritis, Rib Subluxations)
As mentioned, there are small muscles in between each or our ribs called the intercostals and the ribs are all attached to the thoracic spine at a joint that is overlaid by many of our back muscles. In the front, the ribs are attached to our sternum via cartilage. Just like most joints get stiff if we are not moving them for long durations, areas of the ribcage can get stiff if we are not moving it- and I mean moving from the inside out. Expanding the ribs demands blowing air into our lungs regularly and completely. Breathing will maintain the appropriate tone (resting tension) in our intercostals to prevent dysfunction in our ribcage. This is very often the remedy for patients who have chronic inflammation in the cartilage or subluxations of the ribs. It becomes trickier in the setting of scoliosis which may mean that the ribcage is rotated or compressed structurally, but I still believe there is a lot of untapped potential here as well.
Breathing and the Pelvic Floor
The motion of the diaphragm works in tandem with the pelvic floor. As the ceiling and floor of the core, they descend and lift simultaneously. Therefore you can imagine if the diaphragm isn’t moving, there’s a strong likelihood that the pelvic floor isn’t either. Consider two scenarios:
One is the simple picture of the person caught in fight or flight who is neck breathing and the diaphragm stays elevated and develops an increase in tension because it never has an opportunity to stretch. In this situation of anxiety, the pelvic floor also stays elevated and contracted creating an upregulated, high tone pelvic floor. Down the line this can lead to stress incontinence where it becomes fatigued and weak due to this chronic tension. Learning to breathe with the diaphragm can help to normalize the motion and therefore length of the pelvic floor to help to restore the pelvic floor.
Second, we have the opposite influence of sucking in the stomach or wearing really tight high waisted leggings that compress the abdomen. This produces the opposite effect of a diaphragm stuck in the ribcage unable to descend against the pressure, and the pelvic floor pushed down from pressure exerted from above. The consistent pressure going down on the pelvic floor creates pressure and heaviness that can create other types of dysfunction like organ descent or urinary frequency. Normalizing breathing helps to change the pressure but breaking bad habits like sucking in our stomach are essential to resolving this tension.
Diaphragmatic breathing and Autonomic Nervous System
Breathing continues to be an emphasis in our wellness industry because of its impact on our nervous systems. Using our diaphragm to breathe gives us the ability to trigger our parasympathetic nervous system which helps us move from the chronic state of “fight or flight” back into “rest and digest” mode. To be more thorough, the nervous system has a sympathetic and parasympathetic branch to help us regulate our body functions based on our needs. When we need to be on alert (and nowadays when we’re stressed), the sympathetic nervous system coordinates a response that switches blood flow to the extremities so that we can react quickly and forcefully. There are branches to all of our organs, too; we also increase heart rate, enlarge our pupils, activate the liver to enhance access to energy stores, and relax airways to increase oxygen uptake. This is not a state we want to get stuck in for long periods, but it seems the majority of us are these days. We don’t have much control over our organs, but we can voluntarily control our lungs. Therefore, if we can slow and deepen our breath, we can trick our nervous system back into a parasympathetic state which also causes decreased heart rate, decreased blood pressure, and brings blood flow back to the organs for digestion and bowel and bladder function. This is one of the reasons that practices that utilize breathing like meditation and yoga are so impactful. In physical therapy, we aim to make the diaphragm and ribcage pliable and unrestricted so that you can have access to this power.
Ultimately, the diaphragm is an integral part of our core stability and the management of our intra-abdominal pressure. Therefore, we feel it is essential to assess and treat the ribcage like we would any other structure in the body.
