Have you ever been told by someone that you need to have a strong “core” to avoid back pain or to help it go away? While this is certainly correct for both questions, there is often a big misconception of what having a strong, stable core really means. It does not simply mean that doing 100 crunches a day or having a “six pack” implies that you have a strong core. In fact, those that already have lumbar or core instability might actually be worsening their condition with crunches or sit-ups, as these two exercises can put extra stress on the lumbar spine if not performed correctly. While there are many contributing factors to what builds a strong, stable core, today we are going to talk about how the diaphragm and proper breathing mechanics can set the foundation for optimal trunk stability.
What is the diaphragm?
The diaphragm is actually composed of two muscles, the right and left hemidiaphragm, which together create a dome separating our lungs and thorax from our viscera (organs and abdomen). The diaphragm as a whole functions primarily in respiration or breathing, but also provides postural stability throughout the spine. This muscle, as well as the transverse adbominus muscle and the pelvic floor muscles together act as a cylinder to form the true muscles of the “core”. When we take a breath in, the diaphragm contracts and flattens out and pushes our organs and the pelvic floor downward creating an increase in intra-abdominal pressure. This flattening/contraction of the diaphragm also creates a negative pressure in the chest that forces air into our lungs allowing us to breathe normally. The exhalation process occurs in just the opposite way. Once our diaphragm relaxes, the “dome” is recreated, causing an increase in pressure in the chest cavity forcing air out of the lungs. This process gives us the ability to consume and exchange oxygen for carbon dioxide to feed our red blood cells and tissues.
How can this “breathing” muscle help to form a stable core?
As previously mentioned above, the diaphragm works with the transverse abdominus and pelvic floor muscles during inhalation to create intra-abdominal pressure. This pressure that is created during inhalation acts in a way to provide stability and moderate decompression to the spine. Since we do not have a stabilizing muscle on the front of the spine, intra-abdominal pressure helps to offset the extension/compression stabilizing mechanism created by the erector spinae and multifidi muscle groups on the posterior aspect of the spine. Karel Lewit once said that if breathing is not normalized, no other movement in the body can be. Lewit believed that if one did not have proper diaphragmatic breathing patterns, “the diaphragm likely lacked the coordination, endurance, and strength to function in its role of a postural stabilizer.” This thought process leads us to believe that proper breathing mechanics need to be addressed before further developmental movements can be conquered. In a study done by Kolar et al., they found that during limb/extremity movement, the diaphragm had significant activation. Another study performed by Kolar showed a distinct connection between back pain, core function, and activation of the diaphragm. Participants of this study with chronic low back pain were shown to have decreased function of the diaphragm as well as a higher resting position of the muscle. This may be due to an increase in breathing rate and chest breathing during bouts of pain. This study found that the breathing and stabilizing functions of the diaphragm are synchronized and individuals lacking the stabilizing function put an increased stress on spinal segments. Bringing us back to my previous point about the erector spinae group stabilizing through extension/compression mechanisms, if our diaphragm is not functioning properly, this will ultimately lead to compression and degeneration of our intervertebral discs down the road. Through research, we have also found that the human body will prioritize breathing over stability in times of increased stress to the system. For example, for those having to shovel in the wintertime, there is an decrease in support to the spine from the diaphragm when there is an increased load as well as an increased breathing challenge during the activity. It is easy to assume then that those with dysfunctional breathing patterns will be at an increased risk for injury during strenuous activity like shoveling versus those with proper and less fatigable breathing patterns.
What do improper breathing patterns look like?
As most of you know or can tell, breathing is a subconscious activity that is controlled by our autonomic nervous system and different chemical, emotional or physical stressors can cause an increase or decrease in breathing rate and volume. During increased times of stress to the brain or body, you may notice that your breathing may become faster or more shallow. On the other hand, when we are at rest, our breathing should be slowed and felt more in the belly than in the chest. While both of these responses are perfectly normal in a healthy individual, dysfunction occurs when you are unable to return to slowed, calm breathing when returning to a restful state after increased stress to the body. If you are someone that is a chest breather at rest, this can create a further dysfunctional breathing pattern when your respiratory system is challenged leading to instability of the spine. Over time, this dysfunctional breathing pattern can become ingrained in our brains and turned into a habit unless forced to change at a conscious level. Other than spinal instability, poor breathing habits can have many other adverse effects including anxiety, alkalosis decreasing the amount of blood getting to the brain and muscles, increased muscle tension, decrease in motor control, as well as an increase in trigger points, muscle spasms and pain sensitization.
How do we fix improper breathing habits?
While seeming like a rather simple task, retraining breathing habits can take up to a couple weeks and needs to be practiced multiple times a day to ensure a subconscious motor pattern is being established. At first, while practicing diaphragmatic breathing and establishing proper intra-abdominal pressure, you will have to actively think about breathing not only into your belly, but into your sides and low back as well. As mentioned earlier, our true core acts as a 360 degree cylinder that we should be able to control and expand with our breath. Outside of our office, one easy way to begin this process is to lay on your back, with your knees bent in a relatively relaxed position. The next step is to place one hand on your chest with the other hand on your belly. As you inhale through the nose (should take 2-4 seconds), try to increase the pressure in the abdomen or feel your belly hand move towards the ceiling while keeping the hand on the chest in its starting position. When exhaling, do so with pursed lips as if you were blowing air out through a straw or into a balloon. This will help the ribs stay lowered and stacked over the pelvis to refrain from flaring or bringing the breath back into the chest. The exhaling process should take about 4-8 seconds to complete. It is typically recommended to practice these exercises for 5-10 minutes 1-2 times per day for the first couple weeks until diaphragmatic breathing becomes more automatic and subconscious. Once this proper breathing is established there are endless exercises and movements that we can perform in office to combine with proper breathing to ensure great core stability.
If you have any questions regarding diaphragmatic breathing and/or core stability, feel free to reach out to Dr. Steffan at email@example.com or set up an appointment at Spring Grove Physical Medicine to begin your recovery process.
Nelson, N. 2012. Diaphragmatic breathing the foundation of core stability, Strength and Conditioning Journal, 34(5): 34-40