Diaphragmatic Breathing: Techniques and Benefits

• Diaphragmatic breathing is an exercise to consciously engage the diaphragm during breathing.

Uses

• Promotes relaxation and can break the pain cycle.
• Empowers the patient to manage uncomfortable techniques.
• Heightens patient's awareness of their breath.

Indications

• Anxiety
• Pain
• Hypertonic accessory breathing muscles

Effects

• Increases relaxation
• Boosts lymphatic flow and gas exchange efficiency
• Aids in stretching techniques
• Reduces pain and stress

Optimal Breathing

With relaxed inhalation

• Respiratory diaphragm contracts and descends, compressing abdominal viscera.
• Quadratus lumborum muscles stabilize lower ribs and diaphragm.
• External intercostal muscles contract and lift the ribs laterally, like a bucket handle.
• Scalene and sternocleidomastoid muscles contract to elevate the sternum, especially the first two ribs.
• These actions increase space in the thoracic cavity and decrease air pressure within the lungs, which allows air to flow into the lungs.

Relaxed exhalation

• Involves passive relaxation of all inspiration muscles.
• If the diaphragm relaxes first, the largest volume of air can be expired more easily.
• Followed by relaxation of the intercostals, scalenes, and sternocleidomastoids.
• The diaphragm massages the viscera because of its location.
• As the diaphragm contracts, it descends and compresses abdominal organs.
• Rhythmic diaphragmatic action creates a vacuum in the thorax, aiding venous blood and lymphatic fluid return from legs/lower torso to the heart.
• Allows for efficient oxygen intake and carbon dioxide output.

Other Breathing Patterns

Apical Breathing

• Inefficient breathing pattern where the patient mainly uses the upper chest or lung apex to breathe.
• Lateral ribs move slightly, with little abdominal movement.
• Observed in patients with respiratory dysfunctions, postural issues, pain, or under stress.

Paradoxical Breathing

• Patient's abdomen doesn't rise upon inhalation.
• Abdominal muscles don't relax, holding the viscera immobile.
• Lateral rib motion and scalene muscles compensate for lack of visceral motion.
• Common in patients with specific posture training like dancers and gymnasts.
• Could indicate pathology such as pneumothorax or diaphragm paralysis. Taber's Cyclopedic Medical Dictionary, 198 V.

Assessment

• Breathing can assessed before and during any treatment.
• Patient Position: Supine
• Place hands on the patient's abdomen, for palpating and observing motion as the patient inhales and exhales.
• Place hands on the lateral aspect of the ribs and repeat.
• Finally, place hands on your patient's upper chest and repeat.

Technique

• Client inhales through the nose, exhales through the mouth.
• Therapist gives verbal instructions, avoiding finality of "take a breath then another and then a last breath".

Steps for diaphragmatic breathing:

• Patient supine, therapist places hands on the patient's abdomen and asks the patient to lift your hands with their breath.
• Patient may respond to the balloon visualization.
• Done with as little upper chest movement as possible.
• If the patient seems anxious or can't focus, move to the next step.
• Therapist places hands on lateral parts of rib cage. Patient is instructed to move therapists hands out with their breathing.
• Therapist can apply some resistance against inhalation to increase patient's awareness of this correct breathing.
• Therapist places fingertips of one hand on the manubrium. The patient is asked to breathe into the area.
• For proper exhalation, therapist directs patient to relax the diaphragm, then intercostal muscles, and then the neck muscles.

Technique Continued

• Gently touch each area to assist. Exhalation should relax trapezius and scalene muscles using the "shoulders down" cue.
• Diaphragmatic breathing should be slow, full, and not forced, to avoid hyperventilation.

Precautions and Contraindications

• Long-term diabetes and kidney disease
• Breathing should be slow, full, not forced.
• Ensure client does not hyperventilate

Abdominal Massage Indications

• Constipation
• Breathing/Pulmonary conditions
• Anxiety
• Promote relaxation through breathing techniques
• Muscle hypertonicity (rectus abdominis, ext/int obliques, psoas, intercostals, pec major etc.)

Principles of Treatment

• Review the precautions and contraindications.
• Therapist must be grounded/focused.
• Always inform the patient about what you are doing, why and what results to expect (informed consent ahead of treatment).
• Ensure patient has used washroom prior to massage.
• Follow the direction of peristalsis when massaging the colon.
• When treating constipation, follow the descending, transverse, and then ascending colon.
• It is a counterclockwise direction, but techniques are performed in a clockwise direction.
• Ensure you’re at level 2 on the pressure/pain scale because a “1” can feel ticklish/uncomfortable.

Patient Care

• Position patient in supine.
• Use 1-2 pillows under the knees.
• Breast/chest drape should be secure and firmly tucked.
• Begin with diaphragmatic breathing.
• Patient places hands on the exposed abdominal area, followed by the therapist's hands over theirs. Encourage deep breaths.
• When ready, the client removes their hands with the therapist hands over the abdominal area.

Draping

• Breast drape in place (towel folded in 1½ or thirds).
• Ask patient to hold towel while carefully sliding top sheet down.
• Draping boundaries are between xiphoid process and ASIS.
• Ensure the breast drape is secured.
• Ask patient to roll away to tuck the towel under the scapula or lift the arm up. Ensure top sheet secured under their hips.

Precautions and Contraindications

• Severe hypertension (160/115 mmHg)
• Acute attack of colitis, IBS, Crohn's.
• Acute abdominal hernia.
• Nausea, vomiting, diarrhea.
• First trimester of pregnancy.
• Acute inflammation of one of the organs.
• Undiagnosed lump or tumor. High blood pressure (160/90 mmHg) under medication, history of abdominal hernia, chronic hernia, tumor, pregnancy, dysmenorrhea or menstruation, and pregnancy.

Massage Techniques

• Diaphragmatic Breathing
• Palpation & tissue assessment
• Effleurage
• Full Sun Half Moon (Palmar Stroke)
• Wringing
• Palmar, fingertip, and thumb deep stroking
• Palmar, fingertip or thumb kneading
• Light shaking of the abdominal area and vibrations
• Reassessment of tissue