Diaphragmatic Breathing as an Intervention for Low Back Pain

Jenna Silver, SPT

 

Background:

During my first rotation, a majority of the patients I saw were suffering from insidious chronic low back pain. While some patients’ function and pain improved with the McKenzie Method, manual therapy, postural retraining, and/or therapeutic exercise, others did not. Despite my best efforts, these patients did not improve. I began hounding my professors as well as delving into the research, desperate for answers but found very little. When I heard physical therapist Jean Massé’s presentation on Chronic Pain Rehabilitation, I became inspired. She discussed what the three sources of pain, peripheral, central, and biobehavioral, were and how retraining patients in diaphragmatic breathing eliminated their chronic pain. I was astounded that something so simple could make such an impact. I decided to put this method to the test during my ICE experience in the fall of 2018 semester.

A particular patient came in with insidious back pain who was responding functionally with therapeutic exercise and manual therapy, but he was still experiencing high levels of pain. I noted that he primarily used his chest to breath and did not utilize his abdomen. After a session of retraining him in diaphragmatic breathing and providing a breathing exercise, his pain decreased from a 7/10 on the VAS pain scale to a 4/10. By the next session, the patient’s pain continued to decrease. Seeing this dramatic improvement turned my spark into a passion for this method and spurred me into making this my Capstone topic.

 

Overview/Purpose:

Chronic low back pain is one of the most common ailments in the United States. Approximately 80% of adults in the United States will experience low back pain in their lifetime.¹To break this down further, a quarter of adults will experience low back pain yearly with an incidence rate of 1.39 per 1,000 person-years.^2,3To seek relief from their pain, many will go to the emergency department. These people accounted for 3.16% of all emergency department visits between the years 2004-2008 and how were they typically treated?³With opioids. Opioid prescriptions have increased from 164 million to over 234 million between 2000-2010.⁴Consequently, opioid-related ED visits increased from 150% to 200%.⁴In 2014, over 18,000 people died due to prescription drug overdose, leading to President Trump declaring the opioid crisis a Public Health Emergency.^4,5Despite this declaration, physicians are still quick to order unnecessary imaging and prescribe opioids to treat patients’ pain. Low back pain is so common that it alone makes up approximately $87.6 million of the healthcare expenditures.⁶That’s huge. To combat this rising epidemic, healthcare has been pushing for physicians to limit imaging as well as the use of prescription drugs in favor of physical therapy instead based on the compelling evidence supporting positive treatment outcomes. As healthcare progresses, physical therapists will begin to take a larger role in treating chronic low back pain and diaphragmatic breathing can be used as an intervention.

 

Statement of Need:

Physical therapists will begin to take a larger role in treating chronic low back pain as healthcare addresses the opioid epidemic. In order to appropriately treat these patients, physical therapists will need to be knowledgeable of several different assessment and treatment techniques to treat their patients effectively. While we have been instructed on disorders that contribute to chronic low back pain as well as a few treatments during our time at Carolina, I still felt unsure on what to look for and how to treat. We have been told throughout our time in this program, you can never have too many tools in your toolbox, a saying I have truly taken to heart. It is my hope to contribute to that toolbox by giving the first years a presentation on how to integrate diaphragmatic breathing into their treatment of chronic low back pain. This presentation will be adjunct to the breathing component of the course PHYT 722: Modalities. Additionally, I will provide them and the clinic Mobility Human Performance a reference guide on how to assess breathing patterns, identify abnormal breathing patterns, and how to treat them.

 

Products:

I created two products for my Capstone Project. The first product is a presentation on Diaphragmatic Breathing as an Intervention for Chronic Low Pain which discusses the prevalence of low back pain, how anxiety and depression affect chronic pain, the prevalence of anxiety as well as depression in patients with low back pain, and how diaphragmatic breathing can be used to treat anxiety, depression, and low back pain. This presentation was given to the University of North Carolina at Chapel Hill, Doctor of Physical Therapy program’s Class of 2021 during their Modalities (PHYT 722) course.

The presentation also contained a lab component where the second product, a Resource Guide, was distributed. The class was instructed on what normal versus abnormal breathing patterns are, how to assess breathing patterns, and exercises to treat these abnormalities and encourage diaphragmatic breathing. The students were then provided time to practice these skills on each other and ask questions on technique. The resource guide contains the information from the lab and will be given to the clinicians from Mobility Human Performance.

The objectives of the presentation, lab, and resource guide were to:

1. Provide the demographics of chronic low back pain
2. Give a basic understanding of the sources of pain perception
3. Demonstrate the efficacy of diaphragmatic breathing as an intervention for anxiety and depression
4. Demonstrate the efficacy of diaphragmatic breathing as an intervention for low back pain
5. Instruct on the correct sequence and recruitment muscles for diaphragmatic breathing
6. Provide basic knowledge as well as the ability to assess and treat breathing patterns

 

Evaluation:

For my Capstone, I utilized the presentation guidelines while creating my presentation to ensure that it was user-friendly and appropriate for the students’ knowledge level at that point in their curriculum. To make sure that my presentation addressed all of the topics I wanted to cover, I worked very closely with the wonderful Dr. Jon Hacke, PT, DPT, OCS, MA, who provided feedback consistently as my project progressed. I also received excellent guidance and advice from Dr. Mike Gross, PT, Ph.D., FAPTA, on my products. Both provided phenomenal advice on how to structure my products and additional research to add that was invaluable through several meeting, phone calls, and emails. I also received feedback from physical therapist Justin Wilhelm, PT, DPT, OCS, who is the owner of the physical therapy clinic Mobility Human Performance. Justin also allowed me to visit his clinic to shadow him as well as his coworkers to gain greater knowledge of how diaphragmatic breathing is incorporated into their practice and treatments.

The students were also provided with two evaluation materials. The first evaluation tool given was a pre- and post- test to evaluate the amount of learning that took place during the presentation. The students averaged 45.59% on the pre-test and 99.62% on the post-test, indicating that the students did learn from my presentation. The second evaluation tool given was an evaluation form to the students and Dr. Hacke to assess my skills as a presenter and the presentation itself. Overall, I received excellent feedback on my skills as a presenter and the presentation itself. The most common suggestion I received was to speak slower. The students could tell I was nervous at the beginning of my presentation, which caused me to speak quickly and stumble over a few words. The materials themselves (the Pre/Post Test and Evaluation Form) and the results of the materials (the Evaluation Results) can be accessed below.

Pre.Post Test

Evaluation Form

Evaluation Results

 

Self-Reflection:

One of my professional goals in my career is to become a clinical instructor, which will require me to be an efficient teacher. An efficient teacher must communicate effectively in an appropriate time frame, explain difficult concepts in a way that the student can understand them, manage time appropriately, and be patient while the students practice mastering the new skills. It was my objective to use this project to develop these skills further to help prepare me in becoming a clinical instructor. This experience taught me a lot about how to appropriate manage my time and how much time to allow for each task. A lot of time and research goes into preparing a presentation for a group of people with a high level of knowledge, more time than I originally anticipated. It also provided me with a whole new perspective on how much effort goes into preparing a presentation. I now have a new, healthy amount of respect and thanks for the amount of time our professors put into the presentations they give us daily.

While I feel that I accomplished my goals for my Capstone project, I do feel like I have opportunities for growth in my communication. It is difficult to correspond with three professionals and ensure that all three have enough time to provide feedback. Moving forward, I will implement the lessons I learned from this experience and incorporate more time to receive feedback from any colleagues. I will also reach out more often to make sure that everyone on the team is on the same page. It is better to over communicate than under communicate.

Finally, I received some excellent feedback from my committee member, Justin, to build on my work. He recommended that I create a brochure on how to diaphragmatically breathe appropriately and exercises they can do to encourage diaphragmatic breathing to give directly to the patients. He also mentioned creating a video that depicts what normal diaphragmatic breathing looks like and what abnormal breathing patterns look like to compliment the resource guide I provided. These suggestions would be nice to incorporate at a later time.

 

Acknowledgments:

First and foremost, I would like to thank my committee members Dr. Mike Gross, Dr. Jon Hacke, and Justin Wilhelm for their time and patience. Their feedback was instrumental in making my project what it is. I would especially like to thank Dr. Gross and Dr. Hacke for their guidance and belief in me during this whole experience. I cannot adequately express the gratitude and thanks I have for seeing me through every bump in the road, every setback, and every meltdown with kind words and encouragement.

I would also like to take this opportunity to thank my family and friends for their unwavering support and love throughout my physical therapy journey. You were always there to remind me that yes, I can actually do this and yes, ice cream does actually solve all problems (looking at you Jasmine, Anna, and Justin). It has been a long, draining, rewarding experience that I could not have gotten through without you guys (or the copious amounts of ice cream, shout out to Ben & Jerry’s).

Finally, I want to thank my classmates for making these last 3 years as special as it was. Each of you has challenged me, supported me, and built me up, making me the clinician I am today. There are no other humans I would want to go through this program with!

 

 

Resources

1. Early physical therapy benefits low-back pain patients | Newsroom. Available at: https://newsroom.uw.edu/news/early-physical-therapy-benefits-low-back-pain-patients. Accessed March 26, 2019.
2. Low-Back Pain | NCCIH. Available at: https://nccih.nih.gov/health/pain/lowback.htm. Accessed March 26, 2019.
3. Waterman BR, Belmont PJ, Schoenfeld AJ. Low back pain in the United States: incidence and risk factors for presentation in the emergency setting. Spine J.2012;12(1):63-70. doi:10.1016/j.spinee.2011.09.002.
4. Soelberg CD, Brown RE, Du Vivier D, Meyer JE, Ramachandran BK. The US opioid crisis: current federal and state legal issues. Anesth. Analg.2017;125(5):1675-1681. doi:10.1213/ANE.0000000000002403.
5. The Opioid Crisis | The White House. Available at: https://www.whitehouse.gov/opioids/. Accessed December 3, 2018.
6. Dieleman JL, Baral R, Birger M, et al. US Spending on Personal Health Care and Public Health, 1996-2013. JAMA2016;316(24):2627-2646. doi:10.1001/jama.2016.16885.
7. Image: 7995d34da8a59e781896efaa5226678d.jpg