Thursday, January 21, 2010

Cervical spine problems leading to Diaphragm weakness can be a self sustaining mechanism for cervical pain

Why a musculoskeletal physiotherapist should become familiar with assessment of the respiratory muscles? (Adpoted from the original source: Thorax 1995;50:1131-1135)

1. Firstly, because dyspnoea in patients in whom no pulmonary cause can be detected may be due to respiratory muscle weakness. Even moderately severe muscle weakness may be difficult to detect clinically and, indeed, it is possible to have total paralysis of the diaphragm without life threatening consequences.
2. Secondly, because patients with clearly documented generalised neuromuscular disease usually also have respiratory muscle weakness and, for selected cases, treatment in the form of non-invasive ventilation is indicated.
3. Finally, there has recently been increased awareness that respiratory muscle weakness can be a compounding factor in other disease processes such as malnutrition and steroid therapy.

For most patients the suspicion of clinically important respiratory muscle weakness may be confirmed or excluded by simple tests that can be performed without the purchase of expensive equipment, but in some patients complex tests in a specialised laboratory are necessary.

A case study of diaphragm weakness due to cervical disc disorder

Ralph B. Cloward; Diaphragm Paralysis from Cervical Disc Lesions British Journal of Neurosurgery (1988, Vol. 2, No. 3, Pages 395-399)

An opera singer, who “made her living with her diaphragm”, developed a post-traumatic unilateral radiculopathy due to cervical disc lesions, C3 to C6. During one year of severe neck and left arm pain she gradually lost the ability to sing difficult operatic passages which brought an end to her music career. Following a three level anterior cervical decompression and fusion, the neck and arm pain was immediately relieved. One week later her voice and singing ability returned to its full strength and power permitting her to resume her activities as a vocalist. The diagnosis of paresis of the left hemi-diaphragm as part of the cervical disc syndrome was implied by postoperative retrospective inference.

Diaphragm weakness: a cause of neck pain (A proposed mechanism by the author of this blog article)

1. Weakness of diaphragm due to cervical spine dysfunction
2. Accessory muscles recruitment to compensate diaphragm function
3. Accessory muscle recruitment alter the biomechanics of the cervical area
4. Cervical pain becomes self perpetuating due to diaphragm’s impaired respiratory mechanism
5. Local treatment of cervical spine + diaphragm strengthening should be the forte of the treatment.

The common clinical methods are: There are several clinical & laboratory tests one can go through them from the following journals:

1. Physical Therapy / Volume 75. Nuinber 11 / November 1995
2. Thorax 1995;50:1131-1135

How to know that Accessory muscles of respiration are compensating for Diaphragm? & How do you do a respiratory muscle strength assessment from observation?

See the figures above.

In a typical pattern called “apical” breathing, a tense pattern of breathing, in which the diaphragm muscle is, used less, while the neck and shoulder muscles are primarily relied on for respiration. Apical breathing recruits the upper trapezius, levator scapula, scalenes and sternocleidomastoid muscles for every breath taken. Repercussions of this type of breathing can be decreased oxygen intake and tightened, and thus shortened, neck and shoulder muscles. As Physiotherapists are aware, these tightened muscles can lead to temple headaches, upper back, neck and shoulder pain, and the emotional state of carrying the world’s stresses upon one’s shoulders.

“Diaphragmatic breathing is inherently relaxing. Without this diaphragmatic practice apical breathers will go to bed with tense neck muscles, and then spend all night using their neck muscles to breathe, rather than relax and recover from the stresses and strains of the day.”

Hoover's Sign and Recruitment of Accessory Muscles of the Neck
Patients with severe chronic obstructive pulmonary disease who have high degrees of hyperinflation can have diaphragms that become flattened such that the muscle fibers that normally run parallel to the rib cage in the zone of apposition run transversely inward across the costal margins. Contraction of these muscles can result in a net reduction in the transverse diameter of the rib cage, which is called Hoover's sign.

These patients generally must resort to accessory muscles of inspiration and depend on lifting the anterior chest wall with the neck muscles ("pump handle motion") for rib cage expansion. The neck muscles, particularly the Sternocleidomastoid and scalenus muscles, become grossly hypertrophied, and the patients learn to lean forward to support their upper girdle while standing. This compensatory maneuver enables them to more effectively use these muscles.

Therapeutic Solution- Teaching the diaphragmatic breathing:

Strengthening muscles that normally receive little attention can make a monumental impact on your client’s health. One of our forgotten, yet essential, muscles is the diaphragm. The diaphragm is the large muscle just posterior to the rib cage that is used for respiration, and it is often disregarded as an involuntary muscle.
Learning to use the diaphragm for respiration can add a great deal of benefit to the health of your apical breathing clients. Strengthening the actual diaphragm muscle can effectively break the apical breathing habit.

Restoration of normal abdominal (diaphragmatic) breathing can be accomplished by coaching your clients to engage their diaphragm. Have your client in a supine position while he/she places one hand on his/her belly (below the umbilicus), and one hand on his/her chest. Upon inhalation, have your client focus on belly expansion by being aware of the belly hand rising. Inhalation continues until he/she feels movement of the other hand on his/her chest. During the exhale, have your client focus on belly deflation, with that hand sinking towards the spine. This exercise can help strengthen diaphragmatic breathing. However, it may not be enough to break the cycle of apical breathing. Many apical breathers have difficulty learning to use their diaphragm (and thus strengthen it), or they forget about breathing into their belly when under stress.

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