CPT CHEST WALL COORDINATIONMuscular movement is seldom as a result of a single muscle moving in one direction. Muscles act together in groups, that support the activity of one another in a coordinated and synergistic manner. Much of that coordination and synergism of breathing has been lost in the development of the "Barrel Chest" deformity of COPD.As noted previously, much of the abnormal COPD chest movement is the stiff upward "Unit Movement" involving the "Pump Handle" action. And because of the overinflated positioning and chest stiffening of the lower chest, the crucial "Bucket Handle" movement is now minimal, which results in a failure to provide synergistic support for the all important movement of the diaphragm. Remember, the diaphragm is the major muscle of breathing, and restoring its function as much as possible is the major objective of chest physiotherapy. This is why this type of therapy is generaly known as "Diaphragm Breathing Exercises" or "Diaphragmatic Breathing Training" or just Diaphragmatic Breathing."To provide the crucial synergistic support from the lower rib cage structures for optimal diaphragm movement the "Bucket Handle" movement must be restored. To achieve this, the focus of your inspiratory breath must be on the lowest-lateral ribs, at a point directly below the anterior portion of your arm pits. Placing your hands, or having an assistant place their hands in the correct position (as shown in the diagrams in the last section) is helpful in getting started. You should try to feel these lower ribs moving outward, and also try to feel air moving into this region. After some initial practice you should be able to perform this chest movement naturally, and without needing to have hand placement to remind you. And as your ribs become more mobile with Belt Exercises you will find this easier to do, and with improved rib excursions.And what about teaching specific diaphragm movement? Well, this is what you are doing by learning correct Bucket Handle rib movement. Remember, the diaphragm and the rib cage muscles performing the Bucket Handle movement act as a synergistic muscle group. By activating the Bucket Handle movement, the diaphragm movement will naturally follow.Note the synergistic progressive flow of muscular group movement here. First is the rib cage Bucket Handle movement, and then soon after the upper abdomen begins to rise due to diaphragm movement into the abdomen. At this juncture, do not attempt to puff your upper belly out to aid inspiration. Continue to focus on the Bucket Handle movement, and the abdomen will rise on it's own with further diaphragm movement.UPPER CHEST MOVEMENTAnd what about reducing the abnormal upper chest movement? Almost always that movement will gradually go away if you simply maintain focus on the lower rib, Bucket Handle movement. I do not advocate, and in fact discourage the popular "Two Hand Technique," with one hand on the upper chest (to encourage minimal movement) and the other hand on the central upper abdomen (to encourage maximal diaphragm movement). As we have seen earlier, this technique unfortunately tends to teach the abnormal trick movement of Belly Puffing.However, with very large breaths you will note the upper chest now moving upward. This is normal, as you are now activating the so-called "Accessory Breathing Muscles" driving the "Pump Handle" movement. This is a normal emergency breathing movement to provide maximal breathing. It can be easily seen as the "heaving" upper chest of an athlete who has just finished an exhausting race. Think of this movement as an emergency breathing reserve, to be encouraged. However, it is important to maintain focus on the lower Bucket Handle movement as is the dominant movement. Let the upper chest movement flow from the lower Bucket Handle movement.Note the synergist flow of muscle group activity. First the lower chest Bucket Handle movement, then the abdomen rises with diaphragm activity. Then, with larger breaths there is more Bucket Handle movement and more diaphragm activity and a further rise of the abdomen, and the upper chest now starts to rise with Pump Handle movement.UPPER CHEST MOVEMENT MOVEMENT WITH ANXIETYThe "Pump Handle" upper chest movement is basically a defensive, emergency type of breathing. This is probably how it became ingrained as part of the abnormal "Unit Movement" of the "Barrel Chest" deformity.However, it is very interesting to note, that anxiety will frequently trigger this type of upper chest movement, and it does so both in people with with COPD as well as those with perfectly normal lungs. Presumably this is because tension and anxiety is part of the overall defensive, emergency reaction.In distressed patients with COPD having an acute dyspnea attack it may be impossible to tell if upper chest movement is at least partially due to this anxiety based type of breathing. Most likely most such upper chest movement in this situation is a part of a desirable muscular recruitment to assist breathing (i.e. due to deranged pulmonary mechanics resulting from Dynamic Hyperinflation). To resolve this problem it is best to focus on the lower chest "Bucket Handle" movement, and if in doubt about residual upper chest movement, try to voluntarily limit the upper chest movement.Some people will immediately display upper chest breathing when starting the Rescue Breathing Pattern. These people should immediately try to limit upper chest breathing, while at the same time calming themselves.In people with normal lungs suffering an anxiety attack or "Panic Attack" and an overbreathing condition known as the "Hyperventilation Syndrome" will frequently exhibit a heaving upper chest manner of breathing. The link between acute anxiety and this type of breathing seems so compelling, that many therapists make elimination of upper chest movement a priority in reducing anxiety and establishing breathing control.EXPIRATION CONTROLAnd what about expiration? Expiration is mainly about timing of the length of breathing out. Generally speaking, expiration should be entirely relaxed and passive, to allow sufficient time for the air to get out, and also permit rest of the respiratory muscles. However, if you do need to provide some muscular force to exhale, it is best done by gently tightening the upper abdominal muscles, and from there there will flow some exhalation activity to the lower ribs. Remember, if you need to forcefully exhale, do it as gently as possible, in order to minimize any "Dynamic Bronchial Compression," which will make the airways smaller, and therefore impair air flow. More on this subject later.RESPIRATORY MUSCLE STRENGTHENINGThe rib muscles of breathing, having been encased in the stiffened Barrel Chest deformity, have undergone at least some measure of atrophy and weakness. And unfortunately, when liberated from the stiff Barrel Chest they initially may be so weak they tire very easily. Most patients will gradually improve this muscle strength with increased activity made possible by breathing control, and progress well with their rehabilitation process. However, occasionally some initial post chest mobilization muscular strengthening is needed to speed the rehabilitation process. If so, a modification of the Breathing Belt technique can be used for this purpose.To strengthen the rib muscles, perform the Belt Exercise as noted above. However, instead of suddenly releasing the belt and allowing the chest wall to spring out, gradually release the belt tension as you inhale, and force the expanding chest to work a bit. This requires a little practice to do properly, as maintaining a steady pressure as the chest moves out on inspiration is a subtle skill. Initially the pressure applied should be gentle. And as your strength improves, increase the inspiration belt tension until you are using a firm tension and working fairly hard to breathe in. These strengthening exercises should be done only two or three times a day, and never more than five minutes at a time. The amount of fatigue you feel at the end of this exercise will be your indicator as to whether or not you should increase of decrease the amount of belt tension.Another useful option are the commercial "Inspiratory Muscle Training (IMT)" devices. These simple devices are quite economical. Your doctor will need to prescribe one for you, and if so, be sure to get a so-called "threshold" training device. The inspiration pressure needs to be set, and start with about 10 to 15 cm water pressure, and gradually work up to between 30 and preferably 40 cm water pressure. Some advocate using these devices for 15, 20 or even 30 minutes 3 or 4 times a day. I believe these are excessively prolonged, unpleasant, and unnecessary exercise sessions. Again, as with belt exercises I would suggest that your exercise sessions with these IMT devices be limited to five minutes, and only two or at most three times a day.The RESPIRATORY SQUEEZEThe Respiratory Squeeze is basically an exaggerated Breathing Belt exercise. The object is to squeeze as much air out of your lungs as possible, in preparation for a better inspiration breath. The method can be used for rapid lung decompression of an overinflated lung causing an acute attack of dyspnea. And it may also be used to advantage in clearing retained bronchial mucus (phlegm) as part of the "Huff Cough" technique. More on this aspect in another module.The Respiratory Squeeze is performed in the sitting position, with the knees touching. The Breathing Belt technique is then done as described above, but with a longer time spent on expiration, at least four or five or more times longer than your usual exhalation time.However, instead of maintaining an upright posture, lean your body forward on expiration as you are applying belt pressure. As you near the end of expiration your hands should now be together in the center of your upper abdomen, and by leaning against your legs, your hands will assist in pushing your diaphragm upward for enhanced lung emptying. Then, on inspiration release the belt pressure and simultaneously return your body to the upright position, and feel the air rush in.For correction of even severe lung overinflation, properly done, only one or two Respiratory Squeezes should be needed. For clearing stubborn sticky retained phlegm, repeating a Respiratory Squeeze before each Huff Cough maneuver can be very helpful.