Respiration should be considered as part of the compre- hensive view of the neuromuscular network. After all, it is the muscles that bring the air into our bodies. When breathing is done efficiently, the diaphragm is predomi- nantly involved. When respiration becomes inefficient and disordered, it begins to overuse the ancillary muscles of respiration such as the sternocleidomastoid, scalene, or upper trapezius. This type of response may be seen in Figure 9–3. In the case of upper back or neck pain, it is essential to consider inappropriate breathing patterns as part of the assessment. If these are noted, training in
appropriate respiratory patterns is indicated. In addi- tion, training of the respiratory system can be one of the avenues for teaching the patient general relaxation.
Such training reduces the metabolic demands on the breath and increases the mechanical efficiency of the upper back in general.
Teaching a relaxed respiratory pattern involves teaching the patient to breathe abdominally. This goal can be achieved in several ways. The easiest, non- instrumented method involves placing a small (5- pound) sandbag or small phone book on the patient’s abdomen as he or she lies in a well-supported supine posture. Next, the practitioner asks the patient to invite his or her breath down into the abdomen while press- ing up against the weight of the sandbag or book. As the patient exhales, he or she then lets the weight fall.
The patient is asked to let his or her body tell him or her how quickly or slowly he or she should breathe. As the patient increases the tidal volume of each breath (the amount of air breathed), it is not uncommon for the respiration rate to fall and for the patient to report feelings of relaxation. If the patient notes sensations of arousal or anxiety associated with this procedure, the practitioner might suspect a hyperventilation syn- drome and the breathing disorder will need to be treated somewhat differently.16 If all goes well with supine abdominal breathing, the practitioner should make sure that the behavior is generalized to other postures. The practitioner should observe the patient’s ability to breathe abdominally in the sitting and stand- ing postures. Further training may be needed for spe- cific postures. Patients should be encouraged to practice the abdominal breathing in the various postures.
The practitioner may want to use SEMG to monitor the ancillary muscles of respiration during training in abdominal breathing. Electrodes attached to the sca- lene, sternocleidomastoid, or trapezius muscle groups would provide information concerning excessive use of these muscles. Thresholds can be set that encourage the patient to practice breathing while keeping these muscles relaxed.
Treating patients with respiratory anomalies may be quite complex. If simple training in abdominal breath- ing does not correct the problem or makes matters worse, the practitioner may want to consult a respira- tory therapist. For further information on teaching patients how to breathe correctly, see Rama and col- leagues’ The Science of Breath17 or Fried’s The Breath Connection.16
Exhibit 9–2 Guided Imagery Script for General Relaxation
“Now relax and let all stressful memories fade away . . . for the next 20 minutes you can just relax as you listen to suggestions on how to allow yourself to be calm . . . as you begin this period of relaxation let your body get as comfortable as you can . . . if you need to adjust anything, do it now . . . be sure that you can breathe easily . . . keep your eyes gently closed . . . this is your time to forget all cares and worries . . . give yourself permission to use this time to simply be . . . to let go of tension . . . to relax . . .
“Now allow your mind to drift far, far away . . . away from your everyday life . . . away from all your anxieties, worries, and responsibilities . . . let your mind drift to a place where you can feel safe, comfortable, and tranquil . . . as this happens just passively listen to suggestions for relaxation . . . don’t try to make anything happen . . . just let it happen . . . just let your muscles relax all by themselves . . . suggest to your muscles that they may take a vacation now . . . the chair will hold you . . .
“Now focus on your breathing . . . become aware of your breathing . . . let it be deep, and abdominal . . . let it be slow, and regular . . . let the air come in through your nose and go di- rectly to your abdomen . . . feel your stomach muscles expand as you breathe in . . . let your stomach muscles relax as you breathe out . . . just let your breathing be calm . . . and take no effort at all . . . inhale and exhale . . . inhale and ex- hale . . . calm, and placid, and tranquil . . . with no cares or worries . . . just think about relaxing every muscle in your body . . . from the top of your head to the tips of your toes . . . just let the air breathe for you . . . as you focus your at- tention elsewhere . . .
“Let your attention focus on your face and head . . . let the muscles in your forehead relax . . . imagine all those tiny mus- cles becoming smooth and relaxed . . . let the muscles around your nose relax . . . let the muscles around your eyes relax . . . let the muscles in your jaw relax . . . let your teeth part slightly . . . let the muscles in your eyelids relax . . . allow your eyelids to find a place that is just right for them to rest comfortably . . . now let this relaxation spread into the temple area . . . allow your temples to relax . . . as your temples relax you may even be able to feel your ears letting go . . . and drop- ping with gravity ever so slightly . . . notice how good that feels . . . remember to keep your breathing slow, deep, and reg- ular . . . maybe you can even feel the slight tug of gravity on your face and head . . . more and more calm . . . more and more serene with each breath you take . . . feeling your body becoming heavier and heavier . . . now let the muscles in your throat just let go entirely . . . let them relax . . . let all the mus- cles in your throat just let go completely and relax . . . maybe you can imagine that all the muscles from the neck up have be- come loose . . . and soft . . .
“Now just think about relaxing all the muscles in your shoul- ders . . . imagine the back of your neck and your shoulders
. . . feel all the muscles in the back of your neck and shoul- ders becoming very loose and very slack . . . just let all the muscles in your neck and shoulders sink deeper and deeper into the chair . . . each time you exhale you may notice the contact of your body with the surface it is on . . . feeling the surface beneath you, becoming more and more comfort- able . . . let this relaxation flow down your spinal column . . . let all the muscles from the base of your head all the way down to your tailbone relax . . . let them be smooth, and soft . . . loose, and slack . . . feel the comfort of the chair as it holds you . . . let go of the tension as that wonderful feeling spreads into your chest and abdomen . . . feel all your abdominal mus- cles become smooth, and soft . . . loose, and slack . . . keep your breathing slow, and deep . . . let all your internal organs be soft, and comfortable . . . and now your arms . . . feel your arms let go . . . and become heavy, and soft . . . loose, and slack . . . just let your arms and hands be heavy, and warm . . .
“Let all the tension in the muscles of your entire body relax . . . and now focus on your hips and buttocks . . . let those large muscles be at ease . . . smooth, and soft . . . loose, and slack . . . let the large muscles in your thighs relax . . . and the joints of your knees . . . let the calves of your legs relax . . . going very loose and slack . . . and now your feet . . . let them relax . . . perhaps you can imagine that the joints in each and every toe relax . . . as you feel more and more calm . . .
“Now we are going to spend 10 more minutes visualizing a pleasant experience . . . just passively follow the suggestions and enjoy yourself . . . as you begin this next period of relax- ation allow your body to feel comfortable . . . now let yourself focus again on your breathing . . . once again becoming aware of your breathing . . . let it be deep . . . and abdominal . . . let it be slow . . . and regular . . . feel your abdomen expand as you breathe in . . . feel your abdomen relax as you breathe out . . . just let your breathing be still . . . and make no effort at all . . . inhale and exhale . . . inhale and exhale . . . calm . . . relaxed . . . tranquil . . . no cares . . . no worries . . . just think about relaxing every muscle in your body . . . just let the air breathe for you . . . as you focus your attention elsewhere . . .
“Now I am going to ‘paint’ a picture with words . . . listen to the words and see the picture in your mind’s eye . . . allow this
‘voice picture’ to be vivid and real . . . see the colors . . . taste the tastes . . . feel the feelings . . . smell the smells . . . and hear the sounds . . . as I describe the scene, let it be real for you . . . as if you were really there . . . allow your mind to roam freely . . . maybe you can discover new places I may not even de- scribe . . . that would be okay . . . this can become your pic- ture . . . let it develop all on its own . . .
“Now imagine you are on a wonderful vacation . . . with no cares . . . with no worries . . . with no one to be responsi- ble to . . . completely free from your daily pressures and expectations . . .
“You are walking along the beach; it is mid-summer . . . it is warm and comfortable . . . it is late afternoon . . . this perfect summer day . . . the sun is a blazing golden yellow in the brilliant blue sky . . . the sun shines down and warms you . . . as you casually walk along you can feel the hard-packed sand beneath your bare feet . . . feel the warmth of the sand . . . feel the dampness of the sand . . . wiggle your toes in the sand . . . isn’t it wonderful? . . . as you continue to walk you can hear the sound of the surf on the beach . . . the gentle rhythm of the waves lapping in and out . . . in and out . . . hear the distant cry of a gull as it soars through the sky . . . you look toward the sound . . . the sky is a beautiful deep blue . . . it is filled with fluffy white clouds . . . see the clouds slowly moving and changing their shapes . . . you feel overcome with a feeling of peace and tranquility . . . it is a lazy day that reminds you of many wonderful experiences from your past . . .
“You come to a small mound of pure white sand . . . you find a comfortable place to sit . . . you feel alone and still . . . now you lie back and watch the wispy clouds as they float by . . . you drift, and dream that warm summer day . . . you
feel the warmth of the sand beneath you . . . you feel the warmth of the sun as it shines down on you . . . you continue to enjoy this wonderful place for what seems like hours . . . allowing your mind the freedom to wander as it wishes . . . you enjoy this stillness . . . this warmth . . . this quiet . . .
“Now you slowly sit up again . . . as you look toward the sea . . . the sun is beginning to set in the west . . . it reflects in beautiful patterns off the sea . . . colors dance and skip in all di- rections . . . along the horizon there is a sparkling glimmer where the sky touches the water . . . you can see a sailboat, its sails billowing in the wind . . . you can almost feel yourself on that sailboat piercing through the sea . . . there is a gentle ocean spray . . . it is cooling and refreshing . . . you are aware of the fresh smell of the salt in the spray . . . there is a light residue on your lips . . . you can taste it if you lick your lips . . . with each movement of the sun as it slowly sets you find yourself becoming more and more relaxed . . . all your senses are merging with the calm environment around you . . . you allow yourself to enjoy this wonderful time . . . with no cares . . . no worries . . . no uneasiness . . . .”
Exhibit 9–2 (Continued)
Source:Copyright
©
1995, A. Thomas, The Psychophysical Evaluation, Clinical Resources, Inc.Figure 9–3 Surface EMG recordings from scalene (SCA) and lower trapezius (LT) are presented during quiet sitting. The pattern of rhythmic activation is associated with respiration and the inappropriate use of the ancillary muscles.
Source:Courtesy of Will Taylor, Portland, Oregon.
Alexander Technique, and Aston-Patterning, among other techniques.