Positioning Concerns

All patients spend some portion of the day in a horizontal position for rest or sleep. Some who are acutely ill or medically compromised spent extended time in bed, and major emphasis must be placed on the mobilization of patients early and often to prevent immobility from exerting its negative effects on all body systems (see Chapter 18). Studies have shown that patients who are medicated and spend extended time on ventilators in the ICU have developed critical illness neuromuscular syndrome or ICU-acquired weakness. Interventions shown to help prevent this problem are physical therapy/activity and daily interruptions of sedative medication.^1,2,3 These studies validate the need for intervention to prevent untoward effects of immobility and sedation.

Despite these problems, the time spent in a horizontal position can be used as an opportunity to assist patients in passive drainage and preventing the retention of lung secretions. It can be a natural beginning in the development of a patient’s long-term respiratory program (e.g., the prevention of respiratory complications in a patient with tetraplegia). Specific postural drainage positions are covered under airway clearance interventions (see Chapter 21). Using a combination of these positions and the patient’s position in bed, in the hospital or at home, can help to achieve multiple goals. First, various horizontal positions can assist patients in passively clearing secretions that they may have difficulty clearing actively. Pneumonia is still the leading cause of death in patients with spinal cord injury (SCI) who are tetraplegic.⁴ Second, these position changes provide for skin relief and better circulation. Finally, they assist in retarding the development of joint contractures or other musculoskeletal abnormalities. A four-position rotation (i.e., supine, prone, and side-to-side) or a modified six-position rotation (supine, three-quarter supine, side-lying, three-quarter prone on each side) is usually an effective and reasonable means of incorporating these goals into a long-term prophylactic program.

Simple adaptations may make ventilation easier in each of these postures. For example, when the patient is in the supine position, placing the patient’s arms up over his or her head facilitates greater anterior upper chest expansion.⁵ Likewise, positioning the pelvis in a slight posterior tilt facilitates more diaphragmatic excursion. (Detailed explanations of positioning are discussed in Chapter 42.) Observation of all precautions and contraindications to passive positioning is still warranted, and positions should be modified based on the individual need of each patient.

Just as passive positioning of the patient in bed helps to maintain airway clearance and improve ventilation potential, optimal passive positioning of the patient’s skeletal frame in an upright posture (sitting, standing) helps to maximize the mechanical advantages that facilitate breathing and improve cardiovascular fluid shifts. For example, patients with SCIs resulting in tetraplegia will be unable to support their intestinal contents properly under the diaphragm to allow for maximal expansion of the chest in all three planes of ventilation (see Chapter 39). The use of an abdominal support from the iliac crest to the base of the xiphoid process provides positive-pressure support to restore intestinal positioning to an upright position (Figure 23-1). Research has documented well the significant improvements in vital capacity (VC), inspiratory capacity, and tidal volume (TV) in sitting with the use of a strong abdominal support.⁶ These binders have also been used in nursing care to provide for better circulation and the prevention of hypotension.

The abdominal binder’s value in cosmesis may be underrated. Many patients with neurological issues were once healthy individuals with high self-esteem who took great pride in their appearance. Many now present with protruding bellies (the anterior and inferior shift of the intestines resulting from flaccid abdominal muscles), which may be psychologically disturbing to them. Thus the use of a binder may greatly aid in the restoration of these patients’ self-esteem, which should be a high-priority goal in any rehabilitation program.

A rigid type of abdominal support can be used when the vertebral column and the abdominal viscera need support. These are called body jackets or total contact thoracic lumbar sacral orthoses (TLSOs) (Figure 23-2). A TLSO is a rigid trunk support molded individually to the shape of the patient’s entire trunk from the axilla down to the pubis. It is composed of two separate pieces, a front and a back, ideally with an anterior cutout in the abdomen to allow for normal diaphragmatic displacement of the viscera. In addition to these jackets, an elastic binder is applied around the abdomen to allow for diaphragmatic motion but minimize excessive displacement of the abdominal contents. This is particularly appropriate for a growing child who needs more spinal stability and for the completely flaccid patient with tetraplegia, who may also require the same support. Because head and neck positioning are so dependent on trunk positioning, a body jacket may make the difference for these patients between being dependent or independent in an upright posture. It may result in significantly better head control and eye contact and improved phonation. However, because the TLSO limits trunk movement, its usefulness for each patient must be assessed carefully.

The next consideration in passive respiratory techniques is proper wheelchair positioning. Optimal performance in ventilatory functioning, as well as many other areas of rehabilitation, depends on good alignment of the body against the force of gravity. Symmetry must be strived for through the use of a body jacket, lateral trunk supports in the wheelchair, abdominal binders, or some other means (Figure 23-3). This is especially important for patients with hemiplegia in whom habitual asymmetrical posturing leads to musculoskeletal problems later. Symmetrical breathing patterns and uniform aeration of all lung segments are augmented by careful upright positioning. Therefore everything from the type of neck and trunk support to the height and width of the arm rests to the length and type of the foot supports must be carefully analyzed for each patient.

Ventilatory and Movement Strategies for Improving Functional Outcomes

Observing patient movement and ventilation is inherent in the physical therapist’s examination and evaluation of the patient. Patients often will hold their breath during activities. This will limit their ability to perform functional activities. When it is observed that breath holding is occurring or that the patient has dyspnea with activity, it is important to incorporate ventilatory strategies.

The patient is first positioned for successful ventilation. Then motor activities should be introduced. Interventions chosen will improve the patient’s ventilatory support, or the therapist should capitalize on the patient’s good ventilatory support to improve the motor activity. Using ventilatory strategies to improve motor performance or movement strategies to improve ventilation performance enables patients to achieve their functional goals sooner and have better health, including fewer respiratory complications. Generally, these simple concepts take no more than 1 to 2 additional minutes of therapy time, with no additional equipment costs other than a few extra pillows or towels. Therefore time and money are not mitigating factors. However, these ideas do require the practitioner to look carefully at the patient before beginning any treatment intervention and to ask, “Have I positioned my patient for ventilatory success?”; “Am I simply treating the patient in whatever position I found her or him in?”; and “Have I carefully chosen my verbal cues to include a ventilatory response and a functional response?” The practitioner must actively include ventilation in every activity to help the patient understand that breathing transcends all activities. Breathing is the bridge to function. A summary of the most important ventilation-movement strategies is listed in Box 23-2.

Considerations in Teaching Breathing Control to Patients with Primary Versus Secondary Pulmonary Dysfunction

Patients with primary lung disease, such as COPD, asthma, bronchitis, or cystic fibrosis, present a picture very different from that of patients with secondary pulmonary deficits, SCI, Parkinson disease, myasthenia gravis, or Guillain-Barré syndrome. In general, patients with primary lung disease tend to overuse their accessory muscles and greatly increase the work of breathing secondary to shortness of breath or coughing. They often complain that they have difficulty “getting the air out,” which demonstrates the decreased expiratory flow rates noted on pulmonary function tests. This can lead to dynamic hyperinflation, in which patients continue to gasp and increase the respiratory rate so more air is coming in, but there is not time for the air to be exhaled. Large volumes of air can get trapped in the lungs, which causes increased feelings of shortness of breath and panic. The goal with these patients is to teach them to relax the neck and chest accessory muscles and use more diaphragmatic breathing (abdominal and lateral costal breathing) to reduce the work of breathing in combination with relaxed pursed-lips breathing and prolonged exhalation. Their treatment programs focus on energy conservation, relaxation, and pacing activity with breath control. In pulmonary rehabilitation programs, exercise is a key component. Patients learn to coordinate their breathing with their activities and find that they have less dyspnea with exertion.16,17

There has been controversy in the literature about the effectiveness of diaphragmatic breathing. No standardized “norms” of how to perform diaphragmatic breathing exist. However, many skilled cardiovascular and pulmonary physical therapists would consider teaching the patient with COPD how to relax the accessory muscles and use the diaphragm as an important part of the patient’s pulmonary rehabilitation. Dechman reported that in a search of the literature, pursed-lips breathing was considered most effective by people with COPD and that the literature does not strongly support the use of diaphragmatic breathing in people with COPD.¹⁸ Cahalin found there are both positive and potentially detrimental effects to diaphragmatic breathing training.¹⁹ Each individual patient needs to be evaluated to consider whether diaphragmatic breathing may be beneficial. For example, patients with severe hyperinflation and flattened diaphragms secondarily will most likely not benefit from diaphragmatic breathing because the muscle length tension relationship is abnormal and will not result in an appropriate movement of the diaphragm. With patients who have mild to moderate COPD and are overusing the accessory muscles, diaphragmatic breathing may be very helpful; it may require less oxygen consumption, decrease the respiratory rate, and increase the tidal volume.

Patients with secondary pulmonary dysfunction, such as SCI, have a more restrictive component to inspiration. In these cases, accessory muscles may be intact, but they are not being used to facilitate deep breathing or coughing. Patients may have strong diaphragmatic breaths, but the upper chest collapses on inspiration (paradoxical breathing; see Chapter 39). The goal is to teach these patients to use the accessory muscles to balance the upper and lower chest. This facilitates an increase in vital capacity that prevents atelectasis and pneumonia by increasing the volume of ventilation and improving the cough mechanism.

The choice of appropriate ventilatory strategies is determined by the individual patient’s problem. The following questions should be considered when evaluating a patient:

Patients with primary pulmonary disease generally benefit from ventilatory strategies that relax the accessory muscles and facilitate relaxed diaphragmatic breathing. On the other hand, patients with secondary pulmonary dysfunction usually benefit from the balanced use of the diaphragm and accessory muscles to increase vital capacity and breath support for activities.

Pursed-Lips Breathing

Pursed-lips breathing is a strategy that is often spontaneously used by people with COPD during episodes of dyspnea. Many patients feel this breathing pattern helps to decrease their breathlessness. The effect of PLB is an increase in the time of exhalation, which results in a decrease in the end-expiratory volume and an increase in the total time of the respiratory cycle. This results in a decreased respiratory rate and increased TV. According to studies, a decrease in the Borg scale of perceived exertion also occurs when PLB is used.²⁰ This technique has been acknowledged by many patients with respiratory impairments as being very easy to learn and yet very effective, quick to use, and readily incorporated into their activities to reduce dyspnea.²¹

When instructing a patient in PLB, emphasis should be placed on a relaxed, slow, prolonged, controlled exhalation. Often when patients initiate PLB spontaneously, they use a forceful exhalation, which tightens the neck musculature and oral area. This builds a significant pressure that can counteract the effectiveness of the technique and the subsequent relief of dyspnea. A relaxed head, neck, and mouth are essential. If patients have difficulty relaxing the mouth, they may be encouraged to try making an sssss, or hissing, sound, which will still prolong exhalation and provide back pressure.

Relationship of the Diaphragm and Posture

The respiratory action of the diaphragm and other respiratory muscles is normally coordinated with the need to provide postural control of the trunk during movement of the extremities.⁸ The diaphragm acts both as a muscle of respiration and as a muscle that works in providing core stability to the trunk. However, when respiratory demand increases, the diaphragm may not be able to continue to provide both of these functions.^22–27 Because the diaphragm is the primary muscle of respiration, postural control may be impaired. A complete discussion of this concept is provided in Chapter 39.

Facilitating Diaphragmatic Breathing

In the initial phases of breathing retraining, patients are taught to use the easiest intervention that facilitates diaphragmatic breathing; if it is not successful, a progression of specific facilitation and inhibition techniques will be tried. A summary of methods of facilitating diaphragmatic ventilation patterns is given in Box 23-6.

Diaphragmatic Controlled Breathing

Diaphragmatic breathing is the normal mode of ventilation. The diaphragm and intercostals are the normal muscles of quiet inspiration. When evaluating a patient’s breathing pattern, the use of accessory muscles during quiet breathing should be noted; the patient with primary pulmonary disease needs to be instructed in relaxation of the accessory muscles to decrease the work of breathing. However, in a patient with a spinal cord injury or other neuromuscular disorder, these accessory muscles may assist in balancing ventilation and may also be useful in increasing vital capacity, improving the ability to cough, improving breath support for speaking, and increasing the potential for functional activities.

In general, controlled diaphragmatic breathing should be emphasized in each posture and in all therapeutic activities because carry-over of the breathing pattern from one posture to another or one activity to another is not necessarily present. If the patient is shown the pattern only when in the supine position, it may not carry over to sitting or to a sliding-board transfer, when the activity becomes more complex. A helpful sequence might be to teach the breathing pattern in side-lying, supine, sitting, and standing positions and in walking, stair climbing, and other functional activities, especially in patients with COPD. Patients with neurological impairment may require modification of the breathing pattern so that it fits well with their activity levels and capabilities.

The first step in facilitating any breathing pattern is to position the patient for ventilatory success. The details are discussed in this chapter and in Chapter 42. Often a patient’s posture and pelvic position have dramatic effects on breathing. In general, a slight, relative posterior tilt of the pelvis facilitates diaphragmatic breathing, and a relative anterior tilt facilitates the opening of the anterior chest and upper chest breathing. It is helpful to see what difference a slight, relative change in pelvic position will do to a patient’s ability to ventilate. This is especially true in secondary pulmonary problems related to neurological and neuromuscular dysfunction. A lumbar roll or a roll under the ischial tuberosities can facilitate an anterior pelvic tilt (see Chapter 42).

Relaxation of Upper Chest and Shoulders

Jacobsen’s progressive relaxation exercises are familiar to physical therapists. Jacobsen proposed that a maximal muscle contraction would yield a maximal muscle relaxation. This technique can be applied to the upper chest and shoulders. The therapist places his or her hands on the patient’s shoulder girdle. The patient is asked to shrug his or her shoulders up into the therapist’s hands and hold it. “Don’t let me push your shoulders down,” is the therapist’s command. Then, “Let your shoulders relax, let them go.” The emphasis is on the relaxation phase. Verbal commands can be very important with this procedure. A strong command to “Raise your shoulders into my hands” is followed by a quiet, calmer, “Now relax and let them go,” repeating quietly, “That’s it, let them go, feel them relax.” The addition of counter-rotation of the shoulder girdle can make this intervention more effective. Patients can learn the techniques independently and can relax their shoulders when they begin to feel tense. In addition, making shoulder circles in both directions, forward and backwards, can loosen the shoulder girdle. Sometimes the relaxation activity is all that it takes to resume a more natural pattern of breathing, and the therapist can move on to other therapeutic activities. If the patient starts to use accessory muscles again, the technique is repeated. The patient learns to feel the difference between tension and relaxation of the shoulders and can self-monitor and perform the relaxation independently.

Repatterning Technique

If a patient needs more support to gain control of breathing and is experiencing shortness of breath, a simple repatterning technique may be beneficial. An example might be a patient with asthma who has a high respiratory rate and is feeling panicky. When the patient is asked why he or she is breathing so fast, the reply will usually be, “I am not getting enough air. I can’t catch my breath.” The patient is asked to start with exhalation: “Try to blow out easily with your lips pursed. Don’t force it; just let it come out.” A helpful technique for producing a prolonged, easy exhalation is to ask the patient to visualize a candle with a flame and then imagine exhaling in a way that makes the flame flicker but not go out. Doing this allows the respiratory rate to decrease automatically. When the patient feels some control of this step, then add, “Hold your breath at the top of inspiration just for a second or two.” Make sure the patient does not bear down as in a Valsalva maneuver or hold the breath longer. Last, ask the patient to take a slow breath in, hold it, and let it go out through pursed lips. Patients learn that when they are short of breath, this technique often helps them to gain control, making them feel less panicky.

Procedure for Teaching Controlled Diaphragmatic Breathing (Scoop Technique)

Minimal patient instruction is necessary to facilitate diaphragmatic breathing using the scoop technique. It allows the patient to feel the breathing pattern; then it is brought to the patient’s cognitive awareness. The patient then learns to self-cue to incorporate the breathing pattern.

The following is a suggested sequence:

1. Position the patient for success, generally side-lying in a semi-Fowler position or supine in a semi-Fowler position, with a bend in the knees to achieve a relative posterior pelvic tilt and relaxation of the abdominal muscles.

2. Place your hand on the patient’s abdomen at the level of the umbilicus. Tell the patient you want to feel his or her breathing. Follow the patient’s breathing pattern for a few cycles until you are in synchrony with his or her respiratory rhythm. Do not invade the patient’s breathing pattern; rather, at first, follow its movement.

3. After the normal end of the patient’s exhalation, give a slow stretch and “scoop” your hand up and under the anterior thorax as shown in Figure 23-4, A. Then ask the patient, “Now, breathe into my hand,” as the slow scoop stretch is done.

4. As the scoop stretch is performed, instruct the patient to “breathe into my hand” during the inspiration. Give a scoop at the end of exhalation with each breath. The verbal command can be effectively replaced after a few respiratory cycles with the therapist’s audible breathing to facilitate the ventilatory pattern.

5. After achieving some success, call the patient’s attention to the awareness of the breathing pattern. For example, ask, “Can you feel how your abdomen rises as you breathe in and your ribs go up to the side?” The patient’s hand can be placed on the abdomen with the therapist’s hand on top. Reinforce the breathing pattern, then remove your hand and allow the patient to feel independently the ventilatory pattern (Figure 23-4, B).

A few things should be taken into consideration. Don’t ask patients to take too many deep breaths; they may begin to feel lightheaded because they may hyperventilate and blow off too much CO₂. The fact that they are breathing more with their diaphragms is the important consideration. Note also the position of the pelvis and trunk.

When the patient has mastered the breathing pattern in the side-lying position, try supine. Then progress to sitting (Figure 23-5, A), then standing (Figure 23-5, B), then walking (Figure 23-5, C) and, finally, stairs (Figure 23-5, D). Each position increases the difficulty in performing diaphragmatic breathing. In the side-lying or supine position, the patient is fully supported. The side-lying position is especially good for initial teaching of diaphragmatic breathing because the diaphragm is in a gravity-eliminated position. In the supine position, the patient must breathe against gravity. As he or she progresses to sitting, the patient must also provide trunk support and maintain stability against gravity, as well as relax the shoulders. In standing, the entire body must be supported, and when walking and stairs are added, the elements of breathing coordination, weight shifting, and balance increase the complexity of the activity.

Coordination of breathing for walking involves being careful not to allow the patient to hold the breath. It is important to keep inspiration and exhalation regular at a ratio of at least 1 to 1, preferably exhaling a little longer—1 to 2 or 1 to 4. In some yoga breathing techniques the exhalation is significantly longer—1 to 6, 1 to 8, or at times even longer.

In general, the preferred pattern for a patient with primary pulmonary dysfunction is as follows:

A patient with neuromusculoskeletal issues who has lower extremity weakness may benefit from inspiration while ascending stairs and exhalation during descent. Going downstairs uses an eccentric muscle pattern, and exhalation is a relatively eccentric contraction of the diaphragm. Refer to the section on ventilatory and movement strategies in this chapter for additional information.

Lateral Costal Breathing

Lateral costal breathing also facilitates diaphragmatic excursion. It may be done bilaterally or unilaterally (Figure 23-6). Lower chest lateral costal expansion facilitates diaphragmatic and intercostal breathing in which the mid-chest recruits primarily intercostal activity.²⁹

Mobilizing the Thorax

For some patients, controlled breathing alone may not alleviate inefficient ventilatory patterns, even with use of good positioning and appropriate ventilatory strategies. The thorax itself may be incapable of moving freely enough to allow for the adequate chest wall excursion necessary for that breathing pattern. For example, a patient with a spinal cord injury who is demonstrating an excessive diaphragmatic pattern that is unbalanced by the normal neuromuscular support of the intercostal and abdominal muscles can breathe using minimal chest wall expansion. This is often referred to as “belly breathing.” It may be necessary to mobilize individual rib segments to gain the potential for chest wall expansion in all three planes of ventilation before facilitating a specific breathing pattern. If the potential for movement is not there, the breathing pattern cannot change. Likewise, a patient having primary pulmonary dysfunction and COPD, undergoing chest surgery, having chest tubes, or suffering from acute chest trauma may also find the rib cage stiff or sore and thus limited in its potential expansion. All these patients may benefit from the inclusion of rib cage mobilization in their therapy programs. The rib cage musculoskeletal limitation may be secondary to muscular atrophy or spasticity or to pain. Thus patients with either primary pulmonary dysfunction or secondary pulmonary dysfunction can benefit from the practice of chest mobilization.

It is beyond the scope of this textbook to detail all the numerous techniques involved in musculoskeletal mobilization of the thorax, but some simple techniques and suggestions for further study are presented. A summary of mobilization techniques is found in Box 23-7.

Once again, the therapist should note that the initial step toward achieving success is positioning. Starting with the patient in the supine position, anterior chest wall mobility can be improved by placing a vertical towel roll down the length of the thoracic spine and allowing gravity to pull the shoulders back to the bed. In this position, the anterior chest is opened up, stretching the intercostal and pectoralis muscles for easier facilitation of upper chest expansion.

In the side-lying position, the lateral aspect of the chest can be passively mobilized with gravity’s assistance by placing one or more towel rolls or pillows under the lower chest (ribs 8 to 10) on the weight-bearing side. To determine an appropriate amount of side-bending, make sure that the patient’s shoulder and pelvis are still in direct contact with the surface, even with the towel rolls in place. This maximizes the stretch of the chest without placing the patient in a position that is too advanced for his or her current chest wall mobility. Patients vary from tolerating only a single thin towel roll to tolerating three pillows under the lower ribs.

In both postures, active or passive stretching can be added after positioning for success. In the supine position, the patient is asked to move arms directly up over his or her head (shoulder flexion) as far as possible while watching his or her hands. Using the appropriate ventilatory strategy, the patient is also instructed to inhale during this movement. Because both full shoulder flexion and inspiration require the opening of the individual rib segments, pairing them in this gravity-assisted position promotes a greater passive chest wall stretch than either technique alone. If straight flexion is not a viable option, use a butterfly position, raising the arms up in shoulder flexion, abduction, and external rotation with elbows bent (like butterfly wings), again pairing this with voluntary maximal inspiration and upward eye gaze. Pairing inspiration and shoulder flexion maximizes the stretch on the chest and encourages better ventilatory strategies.

Ask the patient, who is in a side-lying position, to bring his or her arm up in straight flexion to maximize anterior chest expansion or to move the arm into abduction as a way of maximizing the lateral costal expansion. Pair either movement with inspiration and upward eye gaze. If upper extremity movement is not possible, passively use counter-rotation of the trunk to mobilize the chest while the patient is in the side-lying position over a towel or pillow. Continue to ask the patient to follow the movement with his or her eyes.

The same concepts can be used in upright postures, such as sitting or standing. Use a vertical towel roll along the thoracic spine, either along the back of a chair or wheelchair or along a wall. Move the patient’s arms passively or actively up into the most extreme flexion or butterfly position possible. The patient will experience a more significant stretch in the anterior chest wall using the towel roll than without it. Precautions must be taken in patients with musculoskeletal problems along the spine and in patients with impaired skin tolerance.

If these general mobilization techniques do not produce enough chest wall mobility to allow freer breathing patterns to occur, more specific techniques must be considered, including the following:

Use the positioning and ventilatory strategies previously suggested (e.g., side-lying over a towel roll) during these specific interventions to maximize the potential gains in chest wall mobility. It is beyond the scope of this textbook to detail all the numerous techniques involved in musculoskeletal mobilization and release of the thorax. These three interventions are intended as suggestions for further study in other texts dealing primarily with musculoskeletal issues.

Facilitating Accessory Muscles in Ventilation

If the patient is still not demonstrating an optimal breathing pattern after experiencing appropriate positioning, appropriate ventilatory strategies, chest wall mobilization, and diaphragmatic retraining, specific facilitatory or inhibitory techniques should be initiated to stimulate the accessory muscles of ventilation. Specific techniques are discussed here in detail. A summary of interventions is listed in Box 23-8.

Because the diaphragm normally supplies the bulk of the inspired air during quiet breathing, diaphragmatic breathing is the preferred pattern of breathing. However, after certain neurological insults, strictly diaphragmatic breathing may not be possible or even preferred.³⁰ Unlike pulmonary rehabilitation programs for people with COPD or asthma, in which diaphragmatic breathing is almost always encouraged and use of accessory muscles discouraged, the restoration of independent, efficient breathing patterns for people with neurological impairment may require the regular use of accessory muscles.

Positioning continues to be the single most important aspect of all ventilatory facilitation techniques. If the patient is positioned for success, the probability of a successful response is much higher. By assessing the patient’s head, upper extremity, trunk, pelvic, and lower extremity positions before every activity or technique, the therapist is empowered to use mechanical positioning and gravity to the patient’s advantage rather than disadvantage. For example, a slightly posteriorly tilted pelvis tends to facilitate diaphragmatic breathing, whereas a slightly anteriorly tilted pelvis tends to facilitate upper chest breathing. Thus when the therapist is facilitating breathing with accessory muscles, the patient would be put in an advantageous posture by slightly tilting the pelvis anteriorly. In the supine position, this could be as simple as decreasing the amount of knee flexion that is present or using a small towel roll under the lumbar spine.

Pectoralis Facilitation

The pectoralis muscle group provides powerful anterior and lateral expansion of the upper chest and can substitute quite effectively for paralyzed intercostal muscles in the upper chest when trained to do so. Training usually begins in either a modified side-lying or a supine position. To increase the use of this muscle group during inspiration, the therapist should place his or her hand in the same direction as the contracting muscle fibers. Specific proprioceptive input is very important when facilitating a muscle, so make sure the hand is placed diagonally on the upper thorax (Figure 23-7).

The heel of the therapist’s hand should be near the sternum and the fingers aligned up and out toward the shoulder in a diagonal pattern. The patient is asked to breathe into the therapist’s hands while the therapist applies a quick manual stretch (as in repeated contractions in techniques of PNF to the muscle fibers (down and in toward the sternum). This elicits the quick stretch reflex of the muscle and simultaneously provides added sensory input, which facilitates a stronger and more specific muscle contraction. To emphasize an increase in lateral expansion, facilitation should gradually be transferred from the sternal area out toward the therapist’s fingertips by the patient’s shoulder. The verbal cues are stronger and require more effort than the quieter verbal cues for diaphragmatic breathing.

Inhibition of the Diaphragm

Two techniques are described to inhibit the excessive use of the diaphragm during inspiration. Ideally, the therapist is venturing to balance the use of accessory muscles—especially the intercostal, sternocleidomastoid, scalene, and trapezius muscles—with the diaphragm’s contraction. This is done to prevent paradoxical movements of the chest, or worse, to prevent adverse musculoskeletal changes in the chest wall, such as pectus excavatum, which can result from muscle imbalance.

Inhibiting the diaphragm may be necessary during breathing retraining for some patients with spinal cord injuries, polio, spina bifida, developmental delays, head traumas, and cerebral palsy. The diaphragm may be too weak to produce an adequate TV or VC without the assistance of accessory muscles. In these cases the diaphragm-inhibiting technique is used to encourage the use of the accessory muscles to assist in independent voluntary ventilation. Patients learn to use their weakened diaphragm muscles in concert with intact accessory muscles. Not only does this allow for increased TV and VC, but it also may provide better aeration of all lung segments and better mobilization of the entire thorax.

An unusually strong diaphragm, acting without support from surrounding musculature, specifically the intercostals and abdominal muscles, may also need to be inhibited. For example, patients with paraplegia or lower-level tetraplegia with intact diaphragm but absent abdominal and intercostal muscles may demonstrate a paradoxical breathing pattern (see compensatory breathing patterns, Chapter 39). In this case, the accessory muscles must be encouraged to keep the diaphragm in check, attempting to avoid the development of a pectus excavatum. The goal of this breathing retraining method is to stop the paradoxical movements of the upper chest during inspiration by balancing the use of the upper and lower chest. In some cases, spastic intercostal muscles, found in some spinal cord injuries, may intercede to prevent this paradoxical movement by maintaining the upper chest’s position during inspiration in spite of the negative pressure within the chest and gravity’s influence on the chest. Balancing the movement of the chest should produce an increase in TV and VC potential and mobilize a greater portion of the chest.

To perform the diaphragm-inhibiting technique, the patient is positioned in a supine, semi-sitting, or side-lying position, with the top arm positioned overhead or pulled back at the waist to open up the upper chest. If the patient can tolerate it, pillows are removed from under his or her head, the pelvis tilted anteriorly, and airway safety is assessed by checking to see whether the patient can still swallow comfortably. The heel of the therapist’s hand is placed lightly on the patient’s abdomen at about the level of the umbilicus. No instructions are given to the patient at this point. As the patient begins to exhale a normal breath of air, the therapist gently allows the heel of his or her hand to move up and in toward the central tendon of the patient’s diaphragm (see Figure 23-4). When the expiration of that breath is complete, the therapist strictly maintains the hand position in that shortened expiratory position. During the following inspiratory phase, the diaphragm will experience some gentle resistance to its inferior descent, causing inhibition to its full ROM. On the next expiration, the technique is repeated, with the therapist carefully pushing the heel of his or her hand further up and in, maintaining greater inhibition during each inspiratory phase. After two or three ventilatory cycles, a patient usually begins subconsciously to alter his or her breathing pattern to include more upper chest expansion in order to reconcile the diaphragm’s transient inability to produce enough chest expansion to yield an adequate TV. The therapist should carefully observe which accessory muscles the patient spontaneously chooses. Are they used symmetrically? What is the general quality of the movement? Is the onset harsh or smooth? Does the patient appear fatigued or uncoordinated?

It is not until this point that the therapist should verbally acknowledge any alteration of the patient’s breathing pattern. Without changing the hand position, the therapist tells the patient what he or she observed that is encouraging about the new breathing pattern (e.g., balance between upper and lower chest expansion or less paradoxical motion of the sternum). Then the patient is asked whether he or she notices any difference from before, bringing this breathing pattern to a conscious level. Only after some orientation to this pattern, usually no more than four to six breathing cycles in the full inhibiting pattern, should the therapist begin gradually to release the pressure being applied.

While slowly releasing pressure with each cycle of inspiration, the therapist asks the patient to try reproducing the desired pattern cognitively. It should take the same number of cycles to release the pressure as it did to apply it. This technique easily allows for gradations of inhibition, from full inhibition, when the patient is forced to use upper accessory muscles or risk becoming short of breath, to a barely proprioceptive reminder to change his or her breathing pattern. It also allows for gradation of inhibition while the patient is learning to assume control over the new breathing pattern. If, during the releasing phase of this technique, the patient begins to lose control over the new pattern, the therapist can gently reapply some pressure during the next expiratory phase to help the patient regain that control. At that point, the therapist can release or reapply pressure as necessary until the desired pattern is obtained and full release of pressure is acceptable.

This technique is particularly effective in patients who are having difficulty cognitively altering their own breathing patterns, such as small children, brain-damaged patients, or slow motor learners, because it requires no cognitive effort until success has already been achieved. Extra care must be taken to avoid initiating any applied pressure quickly because of the likelihood of eliciting unwanted abdominal contractions or spasticity³² or eliciting a stronger diaphragmatic contraction resulting from the quick stretch reflex. The technique should never be painful. The therapist must keep his or her hand on the abdomen, not the rib cage, to properly influence the diaphragm. This technique can be progressed by changing postures, which requires greater trunk control. Can the patient still maintain the overall pattern? Can the patient breathe without paradoxical movements against gravity?

The second technique is for the more advanced patient and simply presents a physical block to diaphragmatic excursion. The patient is positioned in a prone-on-elbows position (Figure 23-8, A). In patients who are most severely impaired neurologically, the lower chest will be in direct contact with the surface, so lower anterior and inferior expansion is inhibited and lateral costal expansion is limited. The upper chest is positioned in extension and the upper extremities are fixed, optimizing the length-tension relationship of the anterior and superior accessory muscles for easy facilitation. In addition, anterior excursion of the upper chest is now in a gravity-assisted posture. Through the use of head and neck patterns, such as in PNF diagonals, or the use of static-dynamic activities, such as in weight shifting to one supporting limb while reaching out with the other extremity, the therapist can readily facilitate greater upper chest breathing (Figure 23-8, B). Therapists can use these same patterns to achieve other goals, such as increased head and neck control, increased shoulder stability, or increased upper body balance. Thus by helping patients to coordinate movement goals with ventilatory patterns, it becomes more likely that patients will incorporate these patterns functionally into their daily activities. This is the ultimate goal of any ventilatory retraining procedure.

The manual diaphragm-inhibiting technique is usually less threatening to the patient than is the prone-on-elbows inhibition technique. Prone-on-elbows position can inhibit the diaphragm so completely for neurological patients lacking spinal extensors that they become extremely short of breath. Consequently, do not position the patients in this more demanding posture until success appears likely.

Patients with Asymmetrical Dysfunction

Patients with asymmetrical weakness need a different approach from the controlled or upper chest breathing patterns presented previously.³³ These patients need facilitation of the weaker side to promote symmetrical chest wall expansion in both the upper and lower chest. A summary of techniques is listed in Box 23-9.

Reducing Respiratory Rates

In addition to altering breathing patterns through facilitation and inhibition techniques, reducing RRs may also be necessary before arriving at an efficient breathing pattern for some patients. See Box 23-10 for a summary of techniques. Many patients with neurological impairment who have high neuromuscular tone increase their RRs to compensate for a decrease in their TVs or because of brainstem impairments that affect the respiratory centers. In addition, many patients who are anxious, such as people with asthma and those who have orthopedic or surgical conditions and are experiencing pain, may also demonstrate excessively high RRs. Attempting to restore ventilatory efficiency may require increasing TV while concurrently decreasing RR.

The techniques described in this chapter promote an increase in TV by improving the overall ventilatory patterns and often cause a secondary reduction in RR. Interventions such as PLB and repatterning, mobilization of the thorax, and upper chest breathing facilitation for neurologically impaired patients are often helpful in accomplishing slower, deeper, more controlled breathing.

Butterfly Technique

If a patient has good motor control, an upright version of this technique may be appropriate. In unsupported sitting, stand behind or in front of the patient, depending on his or her balance needs, and ask the patient to bring the arms up into a butterfly posture (or assist the patient to bring the arms into this posture). Starting from a comfortable ROM position for that patient, begin to breathe audibly in time with the patient’s RR. When the patient inhales, raise the arms up into slightly more shoulder flexion. When the patient exhales, lower the arms slightly. Slowly begin to move in greater and greater increments of range, while breathing loudly with your patient. Through your audible breathing cues, begin to “ask” your patient to slow down the RR and take deeper slower breaths. The use of the following concurrent ventilatory strategies promotes deeper inhalations and exhalations: (1) shoulder flexion and trunk extension paired with inspiration; and (2) shoulder extension and trunk flexion paired with exhalation. Thus it becomes possible for the patient to increase TV and decrease RR.

As in the previous technique, the therapist begins by breathing loudly at the patient’s respiratory rate and transitions to breathing audibly at a slower, more desirable pace. The patient picks up on this subtle cue and subconsciously reduces his or her own RR, even if unable to follow verbal commands.

This technique can be modified to encourage more intercostal and oblique abdominal muscle contractions by using a diagonal rather than a straight plane of movement. Have the patient look up and over one shoulder as he or she breathes in and brings arms up and behind the head. Then have the patient look down and away toward the opposite knee while breathing out and bringing arms down to the opposite knee (Figure 23-9).

Relaxed pursed-lips breathing can also be incorporated into the previously described techniques to reduce RR. By prolonging the expiratory phase through pursed lips, the patient secondarily decreases his or her RR automatically.

Glossopharyngeal Breathing

A small number of patients with neurological impairments require more than just promoting the use of accessory muscles or changing RR to meet basic ventilatory needs.³⁴ In the past decade, more people experiencing high-level SCIs (above C4) have survived the initial trauma because of advances in medical technology. The therapist in the rehabilitation setting is then faced with the difficult task of restoring quality of life. For these patients, as well as many older adult polio patients, mastery of the glossopharyngeal breathing (GPB) technique allows for greater voluntary ventilation, which many patients say improves the quality of their lives. This augmented breathing pattern allows patients to regain some control over their lives and to regain control over their ventilation, which was lost as a result of severe neurological insult.

GPB is a technique developed in the 1950s by polio patients looking for a way to reduce their dependence on the iron lung for ventilation. It was found that by using the lips, soft palate, mouth, tongue, pharynx, and larynx, a patient could actually inhale enough air to sustain life without mechanical ventilation. Only intact cranial nerves are required. This method is sometimes referred to as “frog breathing” because it uses the principles of inspiration common to the frog. The patient learns to create a pocket of negative pressure within the buccal cavity (mouth) by maximizing that internal space, thereby causing the outside air to rush in. At that point, the patient closes off the entrance (the lips) and proceeds to force the air back and down the throat with a stroking maneuver of the tongue, pharynx, and larynx.

Research has shown consistently that use of this technique in patients who have severe neurological impairment can increase pulmonary functions significantly, especially TV and VC. If GPB is the only means of ventilation possible when a patient has been disconnected from a ventilator or phrenic nerve stimulator, mastery of this technique is critical to the patient’s survival in case of mechanical or electrical failure. All attempts should be made to teach GPB to this patient population.

A clinical example may help to illustrate the usefulness of GPB. A 14-year-old male sustained a C1 complete SCI while racing in front of a train. After he was medically stable, two phrenic nerve stimulators were implanted in his chest. The patient had no unassisted means of ventilation. Neuromuscularly, the patient had limited use of one trapezius, the sternocleidomastoid, and intrinsic neck muscles. The patient and family worried that long-term nursing home placement would be inevitable because of their fear that his phrenic nerve stimulator would malfunction or a battery would wear out, causing immediate respiratory distress. The family believed it could not bear the psychological burden placed on them if the patient went home to live. GPB instruction was suggested and was begun slowly because the patient stated that he learned motor skills slowly. After a painstaking 2-month period, the patient learned to breathe without the use of his phrenic nerve stimulator for 3 to 5 minutes before becoming fatigued and hypoventilating. Within the next 1 to 2 months, he learned to breathe for up to 2 hours off of his stimulator, using GPB only. To the staff’s surprise, he even learned to talk and operate his sip-and-puff wheelchair while using GPB. The patient was then successfully discharged to his home. This was not the only factor considered in his discharge planning, but it was perhaps the most significant.

Instruction in GPB takes time and concentration. It is best to start off in small time blocks of 10 to 15 minutes because it can be very fatiguing. However, for successful learning of the technique, it is also important that the patient get consistent, preferably daily, training. Once the patient has mastered the technique, practice sessions can be lengthened considerably, and the patient can be taught self-monitoring techniques. The specific goals of GPB training must be explained to the patient before the beginning of treatment in order to gain his or her support and cooperation. In addition to providing the ventilator- or stimulator-dependent patient with a TV necessary for gaining independence from mechanical assists, GPB has many other benefits. For the patient with tetraplegia who has a partially intact diaphragm (C3 to C4) or the loss of essential accessory muscles (C5 to C8), GPB can accomplish the following:

The muscles used in this technique do not have the same internal proprioceptive, sensory, or visual feedback mechanisms as the trunk and limb muscles, so necessary adjustments in the technique are sometimes difficult to perceive. The patient cannot see his or her tongue pushing the air back or truly feel the pharynx swallowing the air into the lungs, so the therapist’s external feedback system is very influential. Use of a mirror can greatly enhance the visual component of feedback. Small changes, like adjustments in posture or the suggestion of another sound to imitate, may be all that is needed for the patient to learn the stroking maneuver correctly. Success in GPB can be assessed objectively with a spirometer and a pulse oximeter. For patients incapable of breathing independently, any TV reading will indicate successful intake of air. For patients who are not ventilator dependent, a VC reading that is greater than 5% over the baseline indicates successful use of GPB. Patients with low-level tetraplegia (C5 to C8) have demonstrated increases in VC by as much as 70% to 100%.

Therapists can monitor their own successes with this technique by taking VC readings with and without GPB or by subjective analyses. Maximal inhalation, followed by three or four successful GPB strokes, will cause a feeling that the chest will burst if an attempt is made to inhale more air. Likewise, the sensation of “needing to cough” is another subjective indication of successful GPB. Conversely, a feeling of indigestion is usually indicative that air has been swallowed into the stomach instead of the lungs.

During the initial treatment session, the therapist demonstrates several times what a stroking maneuver looks like, giving the patient an idea of the motion required. The therapist continues to mimic the pattern as the patient attempts to duplicate it. This gives the patient an active model to mimic and decreases feelings of uneasiness surrounding the necessary but somewhat silly facial grimaces. If the patient is able to breathe independently, his or her ability to breath-hold and to close off the nasal passageway should be checked because air leakage is a common cause of failure. The patient is then instructed to take in a maximal inspiration before attempting the stroking maneuvers in order to eliminate the possibility of using other accessory muscles during the technique.

If possible, the patient is positioned in an upright or at least a symmetrical position. Specifically, the patient is instructed to bring the jaws down and then forward as if reaching the bottom lip up for a carrot dangling just in front and above the upper lip (Figure 23-10, A). Slight cervical hyperextension is necessary to allow for maximal temporal mandibular joint (TMJ) excursion. (A contraindication for this technique is a TMJ disorder.) The lips should be shaped as if they were making the sound oop. The patient is then told to close the mouth, reaching the bottom lip up to the top lip (Figure 23-10, B). The tongue and jaw are drawn back toward the throat, with the mouth and tongue formed as though saying up or ell (see Figure 23-10, B). The lower jaw moves in a roughly rectangular pattern. Most patients learn the stroking maneuvers by making the sounds; as they become more proficient, the sounds and excessive head and neck motions diminish. Often, the students (patients) outperform the teachers (therapists) because through consistent use, they learn all of the technique’s finer subtleties.

Although this technique can be broken down into several stages, as it has been here for the purpose of description, most of the literature cautions the therapist against doing so.³⁵ Simple, minimal instructions seem to accomplish more, perhaps because the continuity of movement is so essential to the success of the inhalation. Specific instructions can be given later if necessary.

Common problems encountered with GPB instruction can be found in Box 23-11. Avoiding any instruction for the tongue seems to produce better results. Concentrate on assisting the patient in learning the external physical movements.

Tolerance of GPB can be increased when mastery of a single stroke becomes consistent. For patients using it as an assist to their own voluntary ventilation, three to four strokes on top of a maximal inspiration is usually sufficient. Ventilator- or stimulator-dependent patients may need to use as many as 10 to 14 strokes per breath. These figures should be used only as rough guidelines. Each patient will use a slightly different technique and a different number of strokes; the only important factor is a method that works for the individual. Fatigue after long trials of GPB can be monitored effectively by an oximeter. The oxygen saturation level should stay above 90% to maintain adequate PaO₂ levels. For example, if the patient begins the GPB session with an oxygen saturation level in the upper 90s, fatigue can be monitored and anticipated by watching to see whether the oxygen level decreases. If the level begins to fall to the mid-90s and then the low 90s, you can anticipate when they will reach 90%. At that point, end the GPB training and put the patient back on the previous ventilatory support system. Pulse oximetry not only allows for accurate monitoring but also provides an objective means of monitoring progress over time. In addition, a spirometer objectively measures improvements in using GPB. It gives the patient concrete indications of success or failure in mastering the technique.

Enhancing Vocalization Skills

In contrast to procedures that assist a patient in inhalation, procedures intended to improve a patient’s phonation skill must focus on elongating the expiration phase. Coughing is a gross-motor skill that relies more on force than on fine control of the ventilatory muscles for its effectiveness. Conversely, phonation requires precise, fine-motor control of these muscles and demands that the vocal folds provide a consistent air flow through the larynx. Both are expiration activities and they depend on the preceding inspiration for optimal performance; however, coughing uses concentric contractions of the expiratory muscles to force the air out, whereas quiet talking uses primarily eccentric contractions of the inspiratory muscles to slowly release the air during expiration. Because of these differences, procedures to improve coughing and phonation are different in focus. Considering the relationship between speaking and breathing and the concepts of shared respiratory control, it is notable that speaking can lead to shortness of breath and shortness of breath can alter speaking ability.³⁶ Previous discussions of posture and use of abdominal binders in patients with spinal cord injury should also be considered when speaking is impaired.³⁷ A summary of techniques is listed in Box 23-12. Coughing is covered in detail in Chapter 22.

Because the patient’s TV and total inspiratory capacity are the power source for phonation, they become important concerns in a phonation program. Generally, a normal TV is adequate for conversational speech. However, larger volumes of air, thus greater inspiratory capacities, are required for singing, loud talking, or professional speaking. Therefore the breathing pattern facilitation techniques described earlier in this chapter are ideal for use before instructing the patient in better expiration control. For example, facilitating diaphragmatic and accessory-muscle breathing techniques, along with the use of quick stretches or repeated contractions, can facilitate the desired deeper inhalation.

Summary

The use of appropriate choices in positioning, together with use of an appropriate ventilatory and movement strategy for any given task, will make success in mastering that task all the more likely. If these simple, time-efficient methods of facilitation do not produce adequate ventilatory changes by themselves, it is then appropriate to add the next layer of facilitation—manual facilitation techniques. Specifically, the techniques that are described in this chapter assist in facilitating the following:

Obviously, not all techniques are appropriate for any single patient. It is up to the therapist to determine which techniques will best address a particular patient’s deficits.

Positioning is vital to increasing ventilation potential and functional skills. From the beginning of the patient’s respiratory program, optimizing ventilation and breath control through passive and active positioning techniques should be a priority of all health team members, not just the physical therapist. As patients progress, the clinician can and should assist them in developing better and more efficient movement strategies for higher-level activities by coordinating appropriate breathing patterns, such as trunk extension-inhalation or trunk flexion-exhalation strategies, into all activities. After these quick and easy suggestions are used, a therapist who has been exposed to numerous methods of manual facilitation and techniques to promote more effective and efficient breathing patterns can choose the most appropriate interventions. In some cases, increasing diaphragmatic breathing may be the desired outcome. In other patients, increased upper chest breathing or increased movement on one side of the chest may be more desirable. Some may benefit even more from techniques to reduce the high RR or to mobilize the thorax. For a select patient population, instruction in GPB may be necessary to support breathing without mechanical ventilatory support. Finally, the therapist can choose to use techniques to assist the patient in developing adequate breath support for vocalization and communication.

As therapists come to understand how profound the influence of effective ventilation can be on a patient’s recovery from disease or trauma, they will incorporate breathing and ventilation strategies into all patient treatment. Understanding that facilitating effective ventilation goes far beyond diaphragmatic exercises, therapists can be empowered to incorporate other techniques and strategies to help their patients become healthier more quickly and to assist them in reaching their highest potential and prevent future respiratory complications.

The take-home message is that the cardiovascular and pulmonary system will be either an asset or a detriment to a patient’s function. Examination and evaluation of breathing patterns and breath control will promote improved patient outcomes.