Respiration is a complex psycho-biological function that serves a number of purposes: 1) air passage: ventilation, sound production and smelling, 2) rhythmic volume changes: a central ‘pumping action’, involved in internal movement of air, fluids, organs, spinal column and in external body movement and balance, 3) sensory awareness of the body: internal tension state and external place of the body in space.

Disturbance of any of these functions can be caused by somatic or mental factors. It can also be caused by a disturbance in respiration itself. Often, there is a combination of a somatic or psychological cause and a functional disturbance of respiration itself. The term ‘Dysfunctional Breathing’ (DB) refers to disturbance in any of the above respiratory functions, as far as there is no adequate physical or mental cause for it. Such dysfunctional breathing is involved in for instance lung diseases, postural problems, anxiety and hyperventilation complaints. It can also be involved in the origin and maintenance of voice disorders (stuttering, functional dysphonia).

The degree to which DB is involved in the origin or maintenance of complaints and disorders can be assessed by the attempt to restore functional breathing. Thus, restoration of functional breathing by way of breathing therapy is important in both the differential diagnostic effort to assess the cause of the trouble, and in the actual treatment. The diagnosis of DB can be made with certainty only in retrospect: DB was present to the degree that restoration of functional breathing was possible and that this coincided with amelioration of the problem.

Under optimal physical and mental conditions functional breathing has the following characteristics:

- air passage is soundless

- transitions between in- and exhaling are smooth, non-abrupt

- rhythmic volume changes occur all over the trunk

- these volume changes are perceptible to the subject

- there is a co-ordination of ribcage and abdomen with spinal column motion

- it is responsive to, for instance, movement, touch and mental imagery

The functionality of breathing should be assessed and corrected under optimal, resting conditions, without active voice production. The role of DB can be established within a few (3-4) individual sessions. Assessment consists of procedures that elicit changes in the direction of more functional breathing. They are specifically developed verbal instructions and manual techniques. About 50 of them are described in my book (Van Dixhoorn, 1998). There are four possible outcomes:

1) When respiration responds to them and there is also a response in the complaints, there is an indication for continuation of breathing therapy.

2) When respiration responds, but there is no change in the complaints at all, there is a reason to doubt the causative role of DB in the origin or maintenance of the trouble.

3) When respiration does not respond and there is little or no change in the direction of more functional breathing, there are to all probability specific factors that limit the possibility for change. These may be somatic or mental causes or the dysfunctional pattern may be thoroughly ingrained and resistant to quick change.

4) When respiration does not respond, but the complaints do improve, the reason for the improvement is not related to the specific influence of the treatment, but due to aspecific influences (placebo-effect) or due to simultaneous changes in the somatic or psychic causes.

The procedures of breathing therapy focus mostly at the functions of rhythmic volume change and sensory awareness. The normal respiration pattern can be classified in two forms, dependent upon the co-ordination with the spinal column.

When the spinal column is straight and the body is lying supine or sitting or standing upright, the normal respiration movement form is one of extension of the spinal column during inhalation and flexion during exhalation. The lumbar lordosis increases slightly during inhalation, thus lifting the thorax and increasing the distance between symphysis and chestbone (xyfoid process). The upper spine flattens somewhat during inhalation, but the cervical lordosis increases somewhat during exhalation. Thus, the thorax changes shape and increases in volume, but also rolls a little upwards during inhalation and downward during exhalation.

The presence of this normal pattern can be assessed for instance in the supine position as follows. The clinician presses the spinal column softly with one hand under the lumbar spine and the other under the upper thoracic spine. After some time, the resistance to pressure is lower in the lumbar spine during inhalation than during exhalation and the pressure increases inhalation a little. The resistance to pressure is lower in the upper thoracic spine during exhalation than during inhalation, and the pressure stimulates exhalation. The degree of sensory awareness can be assessed by asking the subject about the perception of the effect of the pressure on respiration. When the body is relaxed and the mental state is relatively quiet, the spinal column allows the effect of pressure to influence respiration and this is perceived passively. There is no urge to modify respiration consciously, the changes are simply perceived.

This normal pattern tends to become easily exaggerated. It is the most common dysfunctional breathing pattern: the lumbar lordosis loses flexibility and becomes stiff in the extended state. This is shown by difficulty in obtaining the second respiration form.

The second respiration form is the opposite of the first pattern. It occurs naturally when the spinal column is flexed, as for instance when sitting in a slump posture or lying curled up on the side. During inhalation the lumbar lordosis flattens and flexes even more. The upper thoracic area flexes as well. This allows for the lower ribs to spread and elevate maximally. The thorax does not roll upwards during inhalation and the body does not extend. The body widens sideways.

The presence of this pattern can be assessed for instance in the sitting position, by way of the hands of the clinician on either side of the spinal lumbar column, with the thumbs medially and the fingers spread out laterally. When the ribs elevate and spread laterally during inhalation, and the head and upper body do not raise, the pattern of sideways expansion is present. It can be strengthened by adding medial pressure on the ribs during exhalation. When this leads to gradually increased lateral spreading with inhalation, the pattern is clearly present. A relaxed mental and physical state favours this respiratory pattern. The body weight is clearly perceived, the back is not straightened with effort, respiration is allowed its natural course in this position. The effect of adding pressure with exhalation on the ribs, or of stimulating respiration by audible exhaling through slightly pursed lips, is simply perceived and can be described by the subject.

Both of these patterns can be elicited by way of changing posture. For instance, in the sitting position, when the body is moved easily forward and backward, while the head remains pointed at more or less the same angle. The forward movement tends to elicit inhalation with extension of the spine, the backward movement tends to elicit inhalation with lateral spreading. A fully flexible respiration can switch easily between both patterns. This is assessed by having the person remain in one position and continue to breathe in and out. Than, by changing the posture and again breathe in and out a number of times, the opposite pattern is tested.

The existence of the two patterns implies that so-called ‘abdominal breathing’ is not the best or most natural or relaxed or efficient breathing pattern. Flexibility of the spine, together with volume changes in both abdomen and chest is more important than movement in one compartment of the body. In the first pattern, extension of the spine facilitates abdominal expansion, while at the same time the chest is elevated. There is adequate costo-abdominal co-ordination and there is no point to try and limit the expansion of the chest and elevation of the chestbone. In so-called ‘upper-thoracic breathing’, the speed of inhalation is increased and the chestbone raises while at the same time abdominal expansion lessens. Thus, the problem is not the chest movement, but the lack of adequate co-ordination. In the second pattern, sideways expansion limits abdominal movement forward somewhat. When the abdomen relaxes however, the whole of the lower body widens with inhalation, including the pelvic area. Respiratory movement in the pelvic area facilitates awareness of this area, which in turns promotes a relaxed sitting posture. The posture shows a relatively round back, but does not become too slumped, because of contracting the lower ribs and abdomen with exhalation.

Voice production, particularly singing, is a form of activity that requires respiratory effort. It goes beyond the area of breathing therapy to coach subjects in this activity. However, the effects of breathing therapy are often noticeable. First, it facilitates the return to the normal, relaxed respiration pattern after the activity. The subjects recovers more quickly and more fully after a period of intense use of the voice. Second, voice production itself becomes easier. Often, after some of the procedures that stimulate both patterns, the voice becomes more clear and strong.

The concept and practice of so-called ‘breath support’ becomes more clear with the understanding of the two patterns of breathing. In the standing position, the body tends to extend with inhalation. However, with ‘breath support’ inhalation retains also strong sideways expansion in the lumbar area. This is stimulated by retaining full awareness of the weight and pressure of the body to the floor and of the area of the back. Thus, the body is filled up maximally with relatively little effort. The head does not come forward or look up, but flattening of the cervico-thoracic junction brings the chin slightly backwards and facilitates raising the chestbone. ‘Breath support’ in the upper area of the body means to maintain this inhalation position during exhalation. The normal pattern of the thorax rolling down with exhalation is stopped and replaced by remaining in the extended state. ‘Breath support’ in the lower area of the body means to retain the sideways and forward expansion of inhalation in the abdomen and pelvis during exhalation. Exclusive focus on the lower area of support diminishes the support in the upper area. Thus, the focus of support can shift up and down the body.

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