Breathing Alignment into the Painful Shoulder

Have you ever had a shoulder pain that seems to have crept up on you for no traumatic reason? Maybe it’s a too-much-sitting-not-enough-moving type of injury or the too-much-moving-in-poor-posture sort of injury. It could be a problem of alignment.

If you have been following this blog, you are already familiar with the link between diaphragm dysfunction and low back pain. Perhaps your shoulder pain could also benefit from the inclusion of respiration activities. The exercises described in this post are meant to provide you with a possible home remedy for non-traumatic shoulder pain; and to alert you to an important, but possibly missing, piece of your prescribed home exercise program following traumatic shoulder injury.

Most gym workouts targeting the upper body focus on the visible outer layer of muscles to develop shoulder strength. Lying deep to those is the rotator cuff, a more delicate group of muscles that stabilize and guide the bones to articulate properly within the primary shoulder joint.  If the shoulder muscles aren’t balanced in strength, or the shoulder is not aligned with good posture, these deeper muscles and their associated tissues cry out with pain.

Dysfunctional breathing patterns and poor position of the diaphragm leads to imbalanced inhalation and twisting in the rib cage. If your shoulder blades are sitting on a misaligned rib cage your shoulder is out of alignment. Exercises for stabilizing the shoulder blades are essential to every home exercise program for shoulder rehabilitation. Unfortunately, these exercise programs often lack respiratory activities to address the ribcage component; this may result in stabilizing yourself in poor position – a situation that leads to abnormal wear and tear on the shoulder complex.

Various postural bodywork disciplines, including the Rolf Method of Structural Integration, address alignment quite effectively. As a living, breathing, moving human being, your muscles also need to be trained to support your alignment.  The exercises described in this post train the muscles that influence the ribcage.

The diaphragm muscle has an elaborate array of connections and influences in the human body as described here. The Postural Restoration Institute and the therapists trained in their method have had excellent results treating chronic pain by incorporating diaphragm training into their home exercise routines; considering the proximity of the shoulder girdle to the rib cage it makes sense to include this training in shoulder rehabilitation.

The first exercise described below was previously included in my blog post  The Diaphragm is a Core Muscle. The second exercise – 90/90 Bridge with Ball and Balloon – was designed by the Postural Restoration Institute; a thorough rationalization for this exercise was published in the North American Journal of Sports Physical Therapy in 2010. Though I recommend it here for shoulder pain, it was originally developed as a remedy for low back pain, another condition often attributed to misalignment.

DIAPHRAGMATIC BREATHING EXERCISE

• Lie on the floor with your legs up on a chair or couch so that your hips and knees are at right angles. This passive position allows you to focus your attention on your breathing mechanics while allowing your body to settle into balance.
• Place your hands on the sides of your ribcage and abdomen.
• Expand your abdominal region and your chest as you breathe in. This expansion naturally occurs when the diaphragm descends and displaces the abdominal organs outward.
• Allow the expansion of your ribs out to the sides to create space for the air filling up your lungs.
• Your shoulders should not move toward your head as this indicates unnecessary contraction of the neck and upper chest muscles – a breathing pattern that can lead to fatigued and tender neck muscles.
• Practice breathing into your abdomen in this position for 10 minutes a day to regulate your nervous system and to bring awareness to how it feels to breathe correctly.

90/90 BRIDGE WITH BALL AND BALLOON

• Lie on your back with your feet flat on a wall and knees and hips bent to a 90-90 degree angle
• Place a 4-6 inch ball between your knees, squeezing with light pressure on the ball
• Hold the balloon in one hand and place the other arm above the head in a relaxed position
• Perform a posterior pelvic tilt (tailbone is slightly raised off floor, the back is flat against the floor). Make sure you are not pushing your feet into the wall, but rather slightly pulling your heels down, contracting your hamstrings. Maintain this position throughout the exercise!
• Inhale through your nose (~75% of max) and slowly blow out into the balloon (3-4 seconds)
• Pause for 3 seconds with your tongue on the roof of your mouth to prevent airflow out of the balloon and without pinching the neck of the balloon
• Inhale through your nose again, and slowly blow back out into the balloon (Do not perform too forcefully, you should not be straining your neck or cheeks)
• Repeat breathing technique a total of 4x
• After the 4th breath in, pinch the neck of the balloon, remove it from your mouth, breath normally and let the air out of the balloon
• Relax and repeat the entire process a total of 5 times!

(Credit for 90/90 Bridge with Ball and Ballon Exercise: “The Value of Blowing up a Balloon” by Kyndall L Boyle, PT, PhD, OCS, PRC; Josh Olinick, DPT, MS; and Cynthia Lewis, PT, PhD

 

 

 

 

Your Diaphragm is a Core Muscle

BREATHE LIKE A BABY

The first thing you did when you were born was breathe air into your lungs — and you did it perfectly. A baby’s breathing pattern, expanding its little belly with every inhalation, is a beautiful demonstration of healthy breathing technique. As life goes on, stress, poor posture, injuries, trauma, vanity, and even well-intentioned exercise programs can result in a dysfunctional diaphragm that compromises your capacity to breathe air into your lungs and to stabilize your core.

Deep and controlled breathing techniques have long been prescribed for stress management and reduction of blood pressure. Some recent studies indicate that diaphragm training potentially has other benefits. A review article in the Journal of Multidisciplinary Healthcare 2013 explains anatomically how the diaphragm is intimately connected to multiple systems within your body and its dysfunction can be implicated as a component of neck and low back pain, headaches, incontinence, gastric reflux, and sluggish lymphatic and blood flow. A 2012 study published in the Journal of Orthopedic and Sports Physical Therapy indicated that there is a close association between chronic low back pain and a sub-optimally performing diaphragm. In a 2013 study, researchers used Magnetic Resonance Imaging to compare diaphragm performance of healthy subjects to those with low back injuries and found stability and respiratory functions were compromised in the subjects with low back injuries.

Faulty posture and altered breathing patterns diminish the capability of the diaphragm to perform core stabilization and inhalation of air. Postural training and focused breathing exercises described in this post are basic techniques you can practice at home. Disciplines such as yoga, sitting meditation, qigong, tai chi, and other forms of martial arts integrate healthy diaphragmatic breathing into their practices.

HOW THE DIAPHRAGM WORKS

When you are sitting up or standing the diaphragm muscle forms the floor of your breathing chamber spanning the circumference of the bottom of our rib cage. It is 5mm thick and shaped as an upward facing dome. Ideally, it is parallel to the pelvic floor so it can descend directly down like a piston drawing air into your lungs.

The diaphragm performs as a deep core muscle that provides stability from the inside out. It forms a lid over the top of your abdominal section connecting to a multitude of structures including the inner surfaces of the bottom five ribs, the top 3 lumbar vertebrae, and the psoas and quadratus lumborum muscles to create a complex unit that stabilizes the core. In my physical therapy practice, patients with low back pain often have tight and tender psoas muscles in the front and quadratus lumborum muscles in the back. Hip flexors tend to be shortened. The strain from these tight muscles along with abdominal weakness puts the diaphragm in a disadvantaged position; the result is shallow breathing, recruitment of neck and upper chest muscles that compensate by lifting the ribcage, and instability of the low back.

START WITH THE BASICS

The diaphragm exercises shown in this post are performed lying on the floor so that your posture is supported while you learn the basics. This is the first hurdle in training yourself in healthy diaphragmatic function. After practicing a while you may learn to adjust your breathing pattern at other times of the day. Good times to check in are when you are sitting at a stoplight, or standing in line at the grocery store. The goal is constant diaphragmatic breathing during all of your activities.

DIAPHRAGMATIC BREATHING EXERCISE

• Lie on the floor with your legs up on a chair or couch so that your hips and knees are at right angles. This passive position allows you to focus your attention on your breathing mechanics while allowing your body to settle into balance.
• Place your hands on the sides of your ribcage and abdomen .
• Expand your abdominal region and your chest as you breathe in. This expansion naturally occurs when the diaphragm descends and displaces the abdominal organs outward.
• Allow the expansion of your ribs out to the sides to create space for the air filling up your lungs.
• Your shoulders should not move toward your head as this indicates unnecessary contraction of the neck and upper chest muscles – a breathing pattern that can lead to fatigued and tender neck muscles.
• Practice breathing into your abdomen in this position for 10 minutes a day to regulate your nervous system and to bring awareness to how it feels to breathe correctly.

The exercise below builds on the first exercise by adding the core stabilization component.

DIAPHRAGMATIC CORE STABILIZATION EXERCISE

• Lie in the same position as the first exercise, knees shoulder width apart
• move your hands down to your lower abdominal area on either side of the rectus abdominis (aka your six-pack muscle).
• Inhale deeply to expand your abdomen down into your lower abdominals so you feel pressure against your hands.
• Maintain the lower abdominal pressure against your hands as you lift your legs off the couch
• Hold that position for 5 breaths, expanding your chest on inhalation
• Keep your neck relaxed.
• Feel the stability coming from the inside out throughout your core*.

*If you find the abdominal pressure drop away from your hands, you have lost your stability from the inside. If this happens, start again but slowly take the weight off your legs to the extent that you can maintain the lower abdominal pressure against your hands. This is a skill that takes practice.

Awareness of how it feels to use the diaphragm for stabilization can go a long way, but when you get up on your feet things get a bit trickier as your upright postural alignment plays a role in how effectively your diaphragm can function.

THE IDEAL POSTURAL ALIGNMENT

The diaphragm is optimally positioned when it is level and parallel to the pelvic floor so it can easily descend during inhalation. If the rib cage is tipped backward, which often occurs with tight back muscles and weak abdominals, or tipped forward, which happens when sitting slouched, the diaphragm is not in an optimal position to contract normally. There are also torsional factors in the trunk from imbalanced posture left to right that can interfere with optimal diaphragm function.

Addressing all possible postural faults is beyond the scope of this post, but the fault most commonly seen in my practice is a forward tipped pelvis that results from too much sitting. Sitting allows adaptive shortening of the hip flexor muscles which in turn create a downward pull on the front of the pelvis when you are standing. A forward tipped pelvis creates stretched weakened abdominals and a relative backward tipped ribcage; this make the pelvic floor and diaphragm out of alignment – a situation that causes the diaphragm to be dysfunctional for both breathing and core stability. In our culture, just about everybody would benefit from lengthening their hip flexors.

My favorite hip flexor stretch involves a modified lunge position as shown in the picture below. This is an active stretch that demands effort when performed properly.

HIP FLEXOR STRETCH

• Place a cushion on the floor under the kneeling knee
• Step forward with the opposite foot so your front knee is directly over your foot
• Keep your body upright and tuck your pelvis so your tailbone points to the floor — this protects your low back and is accomplished by engaging your lower abdominals. Do not arch your back.
• Shift your body forward (without bending over) until you feel a stretch in the front of your hip
• Contract the buttock muscles in the hip of the back leg. Contraction of the buttock reflexively relaxes the hip flexors.
• Reach with the arm on the same side as your kneeling knee up and toward your head
• Side bend your trunk slightly away from your kneeling side
• Hold this position for 3 minutes using diaphragmatic breathing the full duration

The diaphragm is intimately connected to your stability, respiration, nervous system, blood flow, digestion, and more. Hence, regular practice of these exercises has the potential to improve your well-being in a multitude of ways. Why not give it a try?