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Functional respiratory muscle training

The book "Respiratory Muscle Training: theory and practice" contains over 150 functional respiratory muscle training exercises (see below for the rationale for using a functional approach). Each set of exercises targets a specific functional outcome, and is presented with three levels of difficulty, thereby maximising applicability to the widest possible range of patients. Thanks to our partnership with Physiotec, all of these exercises are available to view as video clips, and a sample of those on offer from Physiotec's Physiobreathe training module is available by following this link. Purchasers of 'Respiratory muscle training: theory and practice' can obtain FREE access to Physiotec's encyclopaedic rehabilitation resources for 30 days. Click here to learn more about the free trial.

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The rationale for functional training

The role of the respiratory muscles extends far beyond that of driving the respiratory pump. This fact explains why most, if not all patients, find walking makes them more breathless than riding a stationary ergometer. However, the contribution of the respiratory muscles to postural control (balance) and core stabilisation is not addressed directly in a rehabilitation context. This is surprising, because these non-respiratory roles have profound implications for how we should train these muscles to optimise their function and minimise the unpleasant symptoms that they generate.

The non-respiratory roles of the respiratory muscles are often brought into conflict with their role in breathing; the external manifestation of this conflict is dyspnoea that is disproportionate to the ventilatory demand of the activity. Similarly, in patients with abnormal respiratory mechanics, muscles that do not normally make a substantive contribution to breathing can become vital contributors to thoracic expansion. This helps to explain why patients become breathless during activities of daily living that engender only modest increases in ventilatory demand, such as dressing, and hair washing.

Because of the multiple roles of the trunk muscles, respiratory muscle training cannot be optimised if it is delivered using an exclusively "isolationist" model of training, i.e., if optimal function is to be achieved, the core stabilising role of the diaphragm must be trained in the context of an activity that challenges core stability. Notwithstanding this, there remains a role for the isolated training of the "Foundation" phase (Link to Foundation training info on the About page), which provides the foundation onto which functional training is built. In other words, an "isolate, then integrate" approach to training.

The rationale for functional respiratory training is identical to the rationale for any kind of functional training. When functional conflicts occur within the muscular system, the risk of system failure can be mitigated by providing the muscles in question with reserve capacity (Foundation IMT), as well as by establishing as routine, specific neural activation patterns, through training (Functional IMT).

Because muscles respond to training in highly specific ways, this limits the transferability of training benefits when the training stimulus is nonfunctional (e.g., an isolated leg extension is unlikely to improve walking performance). In functional training, muscles are subjected to forces during functional movements in order to develop the neuromuscular system in ways that are transferable to real-world activities. To date, a missing element from the functional training repertoire has been any consideration of the role of respiratory muscles (major trunk stabilisers and controllers) in functional movements, and vice versa.

As well as satisfying the demands of breathing, the trunk muscles are responsible for a wide range of movements during activities of daily living, e.g., flexion, extension, rotation, stabilisation, and so on. Ambulation involves continuous perturbation to postural control, whilst simultaneously increasing the demand for breathing. These challenges are exacerbated still further if ambulation is combined with carrying, since the trunk must also be stabilised, exerting a compressive influence on the thorax. The respiratory muscles must accommodate all of these functions simultaneously, a requirement that demands specific training.

Whilst it is commonplace to use functional training techniques in a clinical rehabilitation context, functional training movements are typically undertaken as brief, isolated exercises in which the ventilatory demand remains modest. Thus, these exercises rarely simulate the simultaneous challenge of elevated breathing and functional movement accurately; indeed, it is typical for therapists to actively seek to minimise conflicts between breathing and movement by coaching patients to synchronise breathing movements so that the actions of the inspiratory and expiratory muscles coincide with extension and flexion movements of the trunk. Unfortunately, whilst helpful, this synchronisation is rarely achievable in everyday life, with the result that the patients may remain unable to deal with the conflicting requirements of breathing and movement. This is the deficiency that functional respiratory muscle training can overcome.

The functional exercises that are recommended in "Respiratory Muscle Training: theory and practice", and featured in the video content, involve breathing against an inspiratory load during functional movements. This is actually no different from using any external resistance during functional training (e.g., elastic resistance or dumbbell); its purpose is to challenge the neuromuscular system's ability to bring about controlled movements, and to "multitask".

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