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Winston Churchill Fellowship

2015

Investigating How to Improve

Awareness, Diagnosis and Treatment

of Hyperventilation.

Carolyn Bell Grad Dip Phys, MCSP

Carolyn Bell – Winston Churchill Fellowship 2015 1

List of Contents

Page Number

1 Acknowledgements

2

2 Executive Summary

4

2.1 Recognition and Prevention 5

2.2 Treatment

5

3 Fellowship Introduction

6

3.1 Aims of the Winston Churchill Fellowship 6

3.2 Objectives of the Winston Churchill Fellowship

6

4 Approach Method

8

5 Learning

10

5.1 Assessment and Treatment 10

5.2 Asthma 12

5.3 New Developments 13

5.4 Inspiratory Muscle Training 14

5.5 The Nose 15

5.6 Education 16

5.7 Challenges of Service Provision 17

5.8 Sleep 20

5.9 Pelvic Floor and Breathing 21

5.10 Anxiety and Stress 23

5.11 Elite Sport

24

6 Conclusions

26

7 Key Messages and Recommendations

29

8 Reflections

31

Appendix 1

33

References 34


1. Acknowledgements:

This experience would not have been possible without support from the Winston

Churchill Trust in conjunction with the Burdett Trust for Nursing. Thank you for

believing in me.

I would also like thank NHS Lanarkshire for their support, particularly the

Physiotherapy Managers, and the Physiotherapy staff at Monklands Hospital for their

support throughout this whole process.

In New Zealand I would like specifically to thank the staff at The Breathing Works

Clinic:

Tania Clifton Smith who has given freely of her great experience and allowed this trip

to take place.

Scott Pierce and Brooke Pierce who allowed me the privilege of shadowing

Physiotherapists within their practice, and Scott for sharing his great enthusiasm for

patients and research.

Janet Rowley for demonstrating great skill, poise and calm in the treatment of this

patient group.

I would also like to thank all of the other individuals who gave up their time to allow

this Fellowship to take place:

These included:

Physiotherapists:

Sarah Mooney

Jeanette Tolich

Jacqui Davidson

Vickie Li Ogilvie

Tamsin Chittock

Liz Childs

Ietje Van Stolk

Bronagh Quinn

Emily Gray

Justine Turner


Dr Margot Skinner

and

Dr Ben Brockway

Dr Jim Bartley

Dr David White

Professor Richard Beasley

Dr James Fingleton

Finally I would like to thank my family who gave me the courage to follow my

passion.


2. Executive summary

Hyperventilation or Dysfunctional Breathing is a condition that has been recognised

for many centuries. Throughout this report I have used the term Dysfunctional

Breathing as it allows for consideration of a wider spectrum of altered breathing

patterns.

There are many definitions of dysfunctional breathing however I prefer to consider a

practical description of this condition:

An altered breathing pattern which results in physical symptoms with no apparent

organic cause.

Dysfunctional Breathing has been known by many different names throughout

history, including fat folder syndrome, due to the thickness of patient’s medical files,

and has been classed, alongside Asthma, as a psychological illness before being

recognised as a physical complaint.

It is recognised that 10% of the population may suffer from dysfunctional breathing 1

and yet the number of practitioners who recognise and treat this condition does not

reflect this statistic.

I work in Monklands hospital, which serves a population of 260,000 and I received 65

referrals in 2015 = 0.025%. The majority of these referrals originated from respiratory

consultants. Many of the patients are at the severe end of the dysfunctional

breathing presentation pattern and many have had multiple investigations prior to

reaching a diagnosis.

The recognition and treatment of dysfunctional breathing appears to be greater in

New Zealand. Much of this being driven by the passion of a small number of

individuals.

My travels to New Zealand allowed me to meet, and discuss, this under-recognised

condition with world experts and practitioners as passionate as myself.

Early recognition and treatment provides better quality of life for patients and a

potential reduced cost to the Health Service due to the financial cost of unwarranted

investigations and hospital admissions.

Breathing is essential to life and in all activities. Unfortunately, consideration of the health benefits of maintaining a healthy breathing pattern appears to have been lost in the health promotion explosion of the last decade.


The key messages from my trip can divided into two main themes.

Recognition and Prevention

Treatment

Key Messages

2.1 Recognition and Prevention Education of patients, Physiotherapists, other medical professionals and the general public is paramount in order to raise the profile of normal breathing and dysfunctional breathing patterns. Prevention, recognition and self-management of dysfunctional breathing needs to be highlighted through health promotion and the public health agenda. Education of breathing control and maintenance of normal breathing patterns within individuals with asthma should begin at diagnosis and be emphasised throughout the course of the disease. Do “major incidents” precipitate an increase in development of dysfunctional breathing? Is this a matter that could be addressed through Public Health? 2.2 Treatment Greater consideration needs to be given to the diaphragm as a key muscle in maintenance of core stability within the body. The nose needs to be included in all assessments of the respiratory system. We need to maintain awareness of current research into new modalities of treatment to improve patient treatment and outcomes. Within Physiotherapy we need to emphasise the holistic approach to patient care. Sleep re-education should be considered an integral part of assessment and treatment of patients with dysfunctional breathing. Consideration of breathing pattern within athletes is a developing field in which physiotherapists can play a key role.


3. Fellowship Introduction

I am a Specialist Respiratory Physiotherapist working within the NHS in Scotland and I have been treating patients with dysfunctional breathing for 25 years. Research indicates that 10% of the population will suffer from dysfunctional breathing1. Unfortunately, this under-recognised group of patients often have a delayed diagnosis of dysfunctional breathing. Too often they are a diagnosis of exclusion. Patients often undergo years of unwarranted investigations which result in misdiagnosis and treatment. This generates a human cost in terms of years lived with disability and a financial cost to the health service due to unwarranted investigations. In order to scope out and compare the breadth and depth of my personal knowledge, skills and experience in this area of practice, I applied for a Travelling Fellowship. I had been aware of the Winston Churchill Memorial Trust for a number of years, receiving emails advising of its availability on an annual basis. I applied for the Fellowship to allow me to travel to New Zealand to shadow the world’s experts in the treatment of this patient group.

3.1 Aims of the Winston Churchill Fellowship:

To improve my clinical knowledge and skills in the management of

dysfunctional breathing.

Inform optimal level of treatment for patients.

Enable me to provide training for Physiotherapy colleagues.

To benchmark against, model and establish a clinical programme which would

inform the development of a service which educates healthcare professionals

and the wider population in dysfunctional breathing.

Ensure a pro-active approach to prevention, recognition and treatment.

3.2 Objectives of the Winston Churchill Fellowship

Investigate how a service can be developed to ensure that:


General Practitioners have a heightened awareness of these conditions and

feel confident to diagnose and refer patients at an early stage.

Awareness of the condition is raised among employers whose staff would

benefit from breathing education.

Self-referral access to services is made available to individuals with breathing

pattern disorders.

Breathing education becomes integral to asthma management.


4. Approach Method

My Fellowship entailed travelling to New Zealand to shadow the world’s experts in

the treatments of breathing pattern disorders in the Breathing Works clinic in

Auckland. This allowed me to benchmark my current skills and improve and refine

treatment strategies.

I also travelled throughout New Zealand, to Wellington, Christchurch and Dunedin

meeting clinical experts in the recognition and treatment of dysfunctional breathing.

These included physiotherapists, lecturers in physiotherapy, mechanical engineering

and rehabilitation, and an Ear Nose and Throat (ENT) surgeon. All of these

individuals were involved in maintaining respiratory health within their widely varying

day to day practice.

Map of New Zealand

Background

Within New Zealand there is a network of physiotherapists who are trained in the

treatment of breathing pattern disorders. BradCliff® is a recognised training

programme which has helped standardise approaches to treatment within this

patient group.

Dinah Bradley and Tania Clifton-Smith founded the BradCliff® breathing method.

The BradCliff® method is a structured research-based physiotherapy assessment

and treatment programme for functional breathing pattern disorders. The method

http://www.bradcliff.com/


looks at breathing dysfunction as an indicator of physiological and mechanical

imbalances and psychological stress in the human body.

All practitioners are educated in the assessment and treatment strategies utilised to

treat these individuals and they become registered BradCliff® practitioners.

Subsequent training programmes are offered to these individuals allowing them to

extend their skills in this area.

BradCliff® has been responsible for the development of a network of

physiotherapists across New Zealand facilitating professional discussion and

support. A standardised training has been developed which clinicians and patients

now recognise and this has helped set a recognised standard for treatment.

The majority of these Physiotherapy practitioners are not respiratory specialists

however they have recognised the importance of including respiratory assessment

and treatment with many of their patients.


5. Learning Key learning points during my Fellowship to New Zealand will be considered under the following headings.

5.1 Assessment and Treatment 5.2 Asthma 5.3 New developments 5.4 Inspiratory muscle training 5.5 The nose 5.6 Education 5.7 Challenges in service provision 5.8 Sleep 5.9 Pelvic floor and breathing 5.10 Anxiety and stress 5.11 Elite Sport

5.1 Assessment and Treatment

Breathing Works Clinic Auckland

Carolyn Bell (author) at Breathing works clinic My Fellowship began in Auckland and I was based at the Breathing Works clinic. I was privileged to shadow three very experienced Physiotherapists.

Scott Pierce (BHSc (Physiotherapy), PGCert (W. Acupuncture), MPNZ, BradCliff Practitioner),


Tania Clifton Smith (NZ Dip Phys MNZSP NZMTA ITEC (Lon))

Janet Rowley (NZ Dip Phys, MNZSP, MHSc, Bradcliff Practitioner)

The Breathing Works clinic (www.breathingworks.com) is situated in Remuera a suburb of Auckland and the staff are recognised world experts in treating breathing pattern disorders. They also specialise in:

Breathing coaching for sports teams and elite athletes.

Treatment of chronic chest problems and respiratory health maintenance plans.

Self-help techniques for anxiety and depression.

Breath based relaxation. Referrals are accepted from General Practitioners and medical consultants or patients can self-refer. The Physiotherapists within the practice have a wide range of experiences and have come to the clinic from a variety of backgrounds. Whilst they all utilise the same core assessment their approach to this varies depending on the patient’s requirements and on their personal experience. Continuing professional development is a statutory obligation for all Physiotherapists. Within the UK this is regulated by HCPC standards of Continuing Professional Development. Physiotherapists develop their skills throughout their career and draw on these experiences with all patients facilitating a holistic approach to patient treatment. It is evident that there is a strong musculoskeletal approach to treating patients in NZ. This is a differing concept to my experience within the UK where treatments are predominantly provided by Physiotherapists with a background in respiratory medicine.

All treatments are based on thorough assessment and all practitioners are trained in

the BradCliff®method.

Assessment and treatment include:

Identification of triggers/stressors at all ages and stages.

Nasal health.

Body mechanics and breathing dysfunction.

Physical coping skills for stress fatigue, anxiety and pain management.

Life style skills and sleep architecture.

Performance / voice problems.

Asthma, COPD, breathless patient breathing retraining guidelines if appropriate.

Athletes and peak respiratory performance if appropriate.


It is clear that the patient is considered in a holistic manner. This embodies the core principles of Physiotherapy as defined by the Chartered Society of Physiotherapists2:

“Physiotherapy is a science-based profession and takes a ‘whole person’ approach

to health and wellbeing, which includes the patient’s general lifestyle.

At the core is the patient’s involvement in their own care, through education,

awareness, empowerment and participation in their treatment.”

This ethos was very well evidenced in the treatments I observed at the Breathing Works clinic.

5.2 Asthma A recent WHO report states that 235 million people worldwide suffer from asthma 3. The term asthma comes from a Greek word aazein, meaning to pant, to exhale with the open mouth, sharp breath. This definition clearly describes the abnormal breathing pattern that many patients with asthma develop. Asthmatics often develop a breathing pattern characterised by the overuse of accessory muscles resulting in breathing with their upper chest, through an open mouth and breathing too quickly. This can lead to hyperventilation which in itself results in a number of distressing symptoms, including breathlessness, chest pain, tingling in fingers, feelings of anxiety, headaches and dizziness1. Throughout my time at the Breathing Works clinic I observed the treatment of many patients who had asthma as an underlying diagnosis. Within my own caseload approximately 60% of patients have underlying asthma or chronic obstructive pulmonary disease. (This figure may be high due to the majority of referrals originating from Respiratory Consultants rather than GP’s or AHP’s.) A recent article by Thomas and Brunton looked at the benefit of breathing exercises

for asthma4.

They looked at available evidence and concluded that there is now a compelling body of evidence showing that instruction in fairly simple breathing exercises provided by a trained therapist can improve patients’ experience of their disease and reduce their reliance on rescue medication.

In 2001 a small study was carried out, in a semi rural GP practice in England, to estimate the prevalence of dysfunctional breathing in adults with asthma who were treated in the community.


Although further studies are needed to confirm the validity of the screening tool and findings, the study showed that one third of women and one fifth of men had scores suggestive of dysfunctional breathing. This leads us to speculate about the potential magnitude of this problem 5.

5.3 New Developments Diaphragmatic breathing is essential in maintaining a normal breathing pattern. A challenging aspect of treatment in all patients with dysfunctional breathing is education on the use of their diaphragm. Within the treatments that I observed, emphasis was placed on the use of the diaphragm using wheat bags or hands on facilitation to provide feedback to patients. Scott Pierce is pioneering the use of M mode ultrasound to allow the measurement of the diaphragm excursion during respiration. This proved to be an exceptionally powerful tool with a number of patients. Being able to view the diaphragm during respiration provided biofeedback to the patient and also allowed us to collate real measurement of improvement.6 Patients viewed this as a motivational tool and were keen to compare measurements from one treatment session to the next. Athletes and children responded well to the challenge of improving their measurements session upon session. Whilst the use of ultrasound by Physiotherapists in this manner is a relatively new pioneering treatment its impact was marked. I very much look forward to following Scott’s research into this area.

Photographic representation of tracing seen utilising m mode ultrasound. (Photograph courtesy of Breathing Works)


5.4 Inspiratory Muscle Training The diaphragm plays a key role in the maintenance of core stability within the body. It is therefore important to maintain the strength of the diaphragm to ensure balance within the core muscle groups 7. Within the clinic inspiratory muscle training is utilised across a broad spectrum of patients from patients suffering with asthma to elite athletes. When considering the patient as a whole, a training plan may need to be devised with the aim to improve both breathing pattern and strength of the diaphragm. The effectiveness and strength of the diaphragm may be improved by developing an inspiratory muscle training programme.

Scott Pierce carrying out inspiratory muscle training utilising K5 power breathe programme. (Photograph courtesy of Breathing Works) A combination of ultrasound and inspiratory muscle training provides an adjunct to treatment for many individuals from asthmatics to athletes, be they international Olympians or school children taking part in school championships. More than that, it provides individuals with a good breathing pattern which is a core life skill. Throughout my travels in New Zealand it was apparent that there was a greater awareness of the importance of breathing in all physiotherapy practice compared with the practice I have observed in the UK. Physiotherapists working within many specialism’s demonstrated awareness of altered breathing patterns and had developed basic tools to deal with this. This resulted in earlier recognition and treatment of the individual with dysfunctional breathing.

Key Learning Points

Education of breathing control and maintenance of normal breathing patterns within individuals with asthma should begin at diagnosis and be continued throughout the


course of the disease. There is a need to maintain awareness of current research into new modalities of treatment to improve patient treatment and outcomes8. Greater consideration needs to be given to the diaphragm as a key muscle in maintaining core stability within the body.

5.5 Nose Awareness of the importance of nose breathing was a key principle of all treatment within the Breathing Works clinic and throughout all the other areas that I visited. Great emphasis is placed on the importance of nose breathing from the outset of assessment and treatment. Nasal patency is assessed in every patient during assessment and action taken to remedy any issues which are identified at the outset. This will include maintaining nasal hygiene using nasal washouts, education in the importance of nose- tummy breathing and maintenance of hydration. If required, the advice of an ENT surgeon may be requested. This is an area that I have not included in my assessment and treatment of patients with dysfunctional breathing however these techniques are utilised frequently in the treatment of individuals with bronchiectasis. Whilst in Auckland I met ENT surgeon Dr Jim Bartley FRACS who is passionate about the function of the nose and its importance in breathing. He collaborated with Tania Clifton Smith and wrote a book, Breathing Matters: A New Zealand Guide (2006) 9. Within this he dedicates 3 chapters to the nose and there are multiple other mentions throughout the book. Within Breathing Matters: A New Zealand Guide (2006) Jim Bartley considers the numerous reasons why the human body is designed to breathe through the nose. These include: Warming, filtering and humidifying air. Providing a resistance to exhalation improving blood oxygenation and lung function. (Breathing out through the nose provides a constant resistance preventing the alveoli collapsing) Our nose supplies Nitric Oxide which sterilises the incoming air. Many people who mouth breath relate this to having problems with their nasal cavity however Jim Bartley has found that this is often not the case. He reports that patients with defective breathing patterns are more likely to complain of nasal congestion whilst people with good breathing patterns and poor nasal passages often have no problems.


Nasal congestion is often caused by faulty breathing leading to low levels of PCO2 which may be caused by hyperventilation. To maintain good nasal hygiene and nasal patency, nasal rinsing is recommended for all patients. This involves preparing a solution which is isotonic to the body. It is recommended this is carried out daily10. I also met Dr David White TC,NZCE (mech),BE, ME,PhD. David is a mechanical engineer who has carried out research in:

Human upper airway and respiratory mechanics

Breathing therapies and devices

Medical device design Two hours were spent discussing the intricacies of the nose and its important role in respiration. David is currently working in collaboration with Jim Bartley and has recently published a paper looking at the effects of pressure elicited change in nasal airflow geometry and airflow. I look forward to their future work. Suffice to say that I am now much better versed in the role of the nose and will certainly be integrating the nose into future treatment of all patients.

Key Learning Points

The nose needs to be included in all assessments of the respiratory system. Maintenance of nasal patency by carrying out nasal rinsing should be carried out daily.

5.6 Education

Education plays a key role in the treatment of patients, however education of professionals and the public is also extremely important. Many of the staff working in Breathing Works are involved in the educational programmes run by BradCliff®. This facilitates the education of physiotherapy staff throughout New Zealand.

Tania Clifton-Smith lectures within the medical profession. She has also developed a high profile corporate seminar series presenting extensively throughout NZ to business professional and sport groups.

Furthermore Tania is a recognised practitioner for the NZ Academy of Sport.


This educational component appears to have raised the profile of breathing pattern disorders throughout New Zealand within the general public, physiotherapy and medical communities.

Typical patients present to their GP with a diverse range of symptoms over a prolonged period of time. Investigations into each individual symptom does not always reveal a recognised cause. Not until these symptoms are considered collectively and the patient considered holistically is a diagnosis made.

Earlier recognition and suspicion of a diagnosis of dysfunctional breathing will provide a better quality of treatment for patients and a reduced cost to the Health Service.

The individual involved may have many investigations. These may include consideration of cardiac, gastric, and neurological issues. These investigations rule out pathologies but they do not bring the patient any closer to a diagnosis. They also result in a cost to the health service.

Key Learning Points

Education of patients, GPs, Physiotherapists and the general public is paramount in order to raise the profile of breathing pattern disorders, provide patients with a good quality service and reduce the cost of unwarranted investigations, both in human cost and financial cost. We need to address all patients holistically in every discipline of physiotherapy.

5.7 Challenges in Service Provision Middlemore Hospital Whilst in Auckland, I was very keen to explore how patients with dysfunctional breathing presented and were treated in a hospital setting. I chose to go to Middlemore Hospital which is an 800 bedded Hospital in a poor socio-economic area of Auckland. Although a larger hospital than the one in which I work the demographic of patients was similar. There I met Jacqui Davidson and Vickie Li Ogilvie who are physiotherapists responsible for treating patients referred with dysfunctional breathing. Many of these referrals are generated from patients who have had an inpatient admission. The referral rate is approximately 30 patients per month and there are 0.3 wte physiotherapy staff to treat these patients. In an attempt to cope with the huge demand they run classes for patients. The classes have an average attendance of 25 patients, although more are invited as there is a recognised failed to attend rate.


Within the classes a self assessment using the Nijmegen score is carried out. (See appendix 1) An explanation of the condition is given including anatomy, gaseous exchange, symptoms and cause. The effects of their lifestyle are also discussed. Numerous staff attend this session to allow some 1:1 time with patients. Approximately 20% of this group will then go on to attend individual treatment sessions as identified by staff attending the group. Jacqui leads the group sessions and Vicki is responsible for the 1:1 treatments. 1:1 Treatment sessions. Patients are seen individually and the number of treatments varies. On average between 2-4 treatments are required although this will be extended if required. Patients who have attended 1:1 treatment sessions but are found to require a refresher will be referred into the class. The principle of 1:1 treatment sessions follows the same format as those observed in the other areas of physiotherapy which I visited. Discussion Providing treatment in a group setting is a method that has developed due to demand outstripping capacity. The question remains as to how we provide individualised treatment programmes within this setting. At Middlemore Hospital many physiotherapists attend the class at one time in an attempt to provide some element of individualised treatment programme. In very challenging financial times due to NHS budget cuts and the ever increasing demand on services alternative methods of treatment delivery need to be explored. However, we also need to address lack of recognition and under funding of treatment for this very substantial patient group. Objective Measure The Nijmegen questionnaire is a questionnaire which is commonly used by physiotherapists as an outcome measure when treating patients with dysfunctional breathing11. It was developed in the 1980’s in the Netherlands and is widely used by clinicians and researchers. Vickie Li Ogilvie has been involved in compiling a critical review of the psychometric properties of the Nijmegen Questionnaire for hyperventilation syndrome. The paper examines the evidence in relation to the conceptual basis, validity, and reliability of the Nijmegen Questionnaire12.


Vickie would like to extend her research in this area and is looking to carry out further research into the validation / use of the Nijmegen Questionnaire.

Carolyn Bell and Vickie Li Ogilvie at Middlemore Hospital Auckland University of Technology (AUT) Whilst in Auckland I also met staff working at the AUT. These included Sarah Mooney, Janette Tolich and Richard Ellis. Their expertise and knowledge lead to many varied discussions across a wide range of subjects! It appears that the problems we encounter with our client group are mirrored within New Zealand society. Increasing incidence of obesity, heart disease and respiratory disease provide challenges in service provision for us all. It was recognised that alternative evidenced based methods of delivering treatment will need to be considered to ensure high quality treatment can be delivered within current resource.

Key Learning Points

We need to ensure that within all areas of service delivery capacity meets demand and this may require some investigation of alternative methods of service delivery.

Team Meetings Dunedin Hospital and Wellington Hospital When travelling in Dunedin and Wellington I had arranged to meet with some of the multi-disciplinary team (MDT) that treat respiratory patients or those with identified dysfunctional breathing. The groups of individuals included respiratory consultants, ENT surgeons, respiratory nurses, physiotherapists, occupational therapists and physiotherapy students.


I was asked to present my experience of treating patients with dysfunctional breathing and my current reflections on my travels to these MDTs. By sharing my experiences, I was able to generate some stimulating discussions amongst the MDTs furthering both their learning and my own. These meetings also provided me with the opportunity to increase awareness of the Winston Churchill Memorial Trust. Interesting discussions were generated with an ENT consultant who felt that there are a proportion of patients who are investigated for sinus headaches / ear problems who end up going around the medical system with very little benefit. He felt there was a huge area where liaison between ENT and physiotherapy may prevent unwanted investigations and hasten appropriate diagnosis and treatment of dysfunctional breathing. Asthma was also discussed widely and the very beneficial role that education of breathing control can have in the management of these patients. In Wellington however it was felt that there are a few specialist physiotherapists who treat these patients but with limited capacity patients often face a delay in treatment. It is interesting to note that within the private health care sector this is not so much of an issue. Many Musculo-skeletal physiotherapists are now BradCliff® trained and are therefore able to offer a standardised service to patients. Training physiotherapists to recognise and treat this condition could lead to earlier recognition of problems, improve access for patients, and help to address the hidden needs of this group.

Key Learning Points

Enhancing links with ENT may provide quicker diagnosis and treatment for patients displaying symptoms of breathing pattern disorders. Breathing education in asthma is paramount and should be commenced at an early stage in the disease process. We need to address the availability of physiotherapists able to recognise and treat this condition. There is a need to move away from dysfunctional breathing being solely considered as a respiratory problem and the remit of Respiratory Physiotherapists.

5.8 Sleep The importance of sleep was also highlighted within these discussions.


Oxford English Dictionary Definition: a condition of body and mind which typically recurs for several hours every night, in which the nervous system is inactive, the eyes closed, the postural muscles relaxed, and consciousness practically suspended Rest and refreshing sleep are essential to maintaining a healthy lifestyle. Sleep can be divided into two phases. Quiet sleep and REM sleep. During REM sleep we dream and the brain is active. Heart rate increases, metabolic rate increases and breathing can become irregular. Both of these patterns can be affected in the individuals with dysfunctional breathing. During quiet sleep breathing rate will become deep and regular however in patients with dysfunctional breathing their bodies may have become accustomed to lower levels of carbon dioxide and therefore the respiratory centre responds by sending signals to increase breathing rate to restore PCO2 levels. As a result the patient will wake with feelings of air hunger. Additionally, within REM sleep breathing may become irregular. As individuals with dysfunctional breathing are more susceptible to fluctuations in CO2 the irregular breathing may produce vivid dreams or nightmares resulting in a lack of satisfying sleep. Lack of rest leads to exhaustion and increased stress levels resulting in further worry and disturbed sleep. Addressing breathing pattern during waking hours will result in improved breathing pattern during sleep resulting in restoration of restful sleep. Sleep re-education is addressed with all individuals. Relaxation techniques are taught to be carried out at night in bed. These will vary depending on the severity of problems and the individual needs of the patients.

Key Learning Points

Sleep re-education should be considered in all patients.

5.9 Pelvic Floor and Breathing During my time in Wellington I met with Liz Childs, a physiotherapist who specialises in the treatment of the pelvic floor.


Liz Childs Pelvic Health Physiotherapist Whilst Liz specialises in the treatment of pelvic floor dysfunction she is also a trained BradCliff® practitioner. Liz spoke passionately about the treatment of patients with pelvic floor dysfunction and articulated the importance of employing the holistic approach to patient care, which is required to facilitate the efficient and co-ordinated work of the pelvic floor muscles. When assessing individuals Liz considers the balance of the core muscle groups. It is vital to maintain balance between the muscles of the pelvic floor, spine, trunk and the diaphragm (as illustrated in diagram below.) The co-ordinated action of these muscles groups is required to ensure maintenance of correct posture, and stability within the body and allow for efficient and effective movement.

Muscles of Core stability


The importance of recognising the role the diaphragm plays in maintaining core stability cannot be underestimated and this was stressed throughout my time in the Breathing Works Clinic and my travels throughout New Zealand.

Key Learning Points

When identifying or treating individuals with pelvic floor dysfunction it is essential to consider the role the diaphragm plays in maintaining core strength and balance within the body. Consideration of correct posture and muscle balance is key.

5.10 Anxiety and Stress Many of the patients that I treat suffer from increased levels of stress and anxiety. This leads to an increased dominance in the sympathetic activity of the autonomic nervous system resulting in their breathing pattern reflecting that of an individual who is ready to fight or flee. Prolonged breathing in this manner ie breathing in excess of what our body physiologically requires at that moment in time, will result in dysfunctional breathing. Individuals may present with hyperinflation of the chest, increased respiratory rate, accessory muscle use and increased heart rate. It is important to establish what the driving factors are for this often well established pattern. This may be very difficult for an individual, however to allow them to move forward it is important that they recognise the underlying cause of their anxiety. This was demonstrated during my visit to Christchurch. I visited two physiotherapists. Ietje Van Stolk and Tamsin Chittock. Ietje Van Stolk is a physiotherapist who works on the outskirts of Christchurch city. Her clinic is within a private gym. Like many professionals Ietje was required to move her practice following the earthquake of 2011 when there was devastation of the infrastructure of Christchurch. One of Ietje’s specialities is treating patients with anxiety related problems utilising breathing control as a core element of treatment. Ietje had recognised within her own practice and personal life that many Christchurch residents now live in a heightened state of anxiety due to the ongoing earthquakes. Anecdotally Ietje estimates 50 – 60% of individuals who were affected by the earthquake may have developed dysfunctional breathing. The ongoing earthquakes act as triggers raising the anxiety levels of individuals further and reinforces the fight or flight patterns of respiration. As though trying to prove her point Ietje entertained me in her home and laid on a 3.4 earthquake just to reinforce the issues.


On reflection within my own caseload I can draw parallels with the E .coli outbreak in Lanarkshire in 1996. In this outbreak, centred around Wishaw, there were approximately 200 recognised cases of E. coli with 20 deaths. This had a physical and emotional impact on many families within the local area. Some of the effected individuals may have ongoing health needs and I have had a number of patients who were affected by E .coli who subsequently developed dysfunctional breathing. Some presented early after the event whilst others are presenting many years later.

5.11 Elite Sport

Tamsin Chittock Tamsin also works in a physiotherapy clinic on the outskirts of Christchurch city centre. She works in a Multi-disciplinary clinic specialising in the treatment of MSk injuries and working with elite athletes. Tamsin reinforced the role of breathing as part of the core stability of the body and she firmly embeds the role of the diaphragm and breathing pattern in her holistic approach to treatment. It was very enlightening talking to Tamsin and viewing how she incorporates breathing re-education and inspiratory muscle training into her predominantly MSk based caseload. This reflected much of the activity I had observed within the Breathing Works clinic. Development of the consideration of oxygen delivery in athletes is a relatively new concept however this is a developing area which again reinforces the necessity to consider the holistic approach to patient care13.


Tamsin discussed that since the earthquake many individuals who have presented, with MSk issues have demonstrated dysfunctional breathing. The majority of these individuals would not recognise this as a feature of their problem, however having an experienced physiotherapist who recognises dysfunctional breathing has allowed the patient to receive a more comprehensive treatment preventing a potential picture of deteriorating health and unwarranted investigations.

Key Learning Points

Consideration of breathing pattern within athletes is a developing field in which Physiotherapists can play a key role. Increased levels of anxiety and stress can precipitate dysfunctional breathing. Improving knowledge of dysfunctional breathing amongst all physiotherapy practitioners will improve recognition of dysfunctional breathing and allow for a more active approach to treatment of this patient group. Do “major incidents” precipitate an increase in development of dysfunctional breathing? Is this a matter that could be addressed through Public Health?


6 Conclusions Reflecting on my aims and objectives as highlighted at the beginning of this report. Aims To improve my clinical knowledge and skills in the management of dysfunctional

breathing, informing optimal level of treatment for patients and enabling me to

provide training for Physiotherapy colleagues.

I now have additional areas of skill that I will utilise allowing me to treat a

wider range of patient profiles. Use of inspiratory muscle training and M mode

ultrasound imaging are techniques which not only provide us with valuable

objective measures but provide vital feedback for patients. Having reliable

outcome measures which are reproducible and comparable will also facilitate

quantitative research being conducted in this area of treatment in the future.

It was heartening to realise that whilst I have expanded my repertoire of

available treatment strategies for patients, my basic assessment and

treatment skills were sound. This has reinforced that the use of clinical

reasoning and research into your subject will always stand you in good stead.

I have gained confidence through the additional skills learned and the

feedback of peers and the world experts that my clinical skills and knowledge

are at a level that I can now provide education and training courses to others.

The links that I have made with the community in New Zealand will facilitate

international collaboration and will continue to provide peer support and

opportunities for CPD.

Recognition of dysfunctional breathing and its implication for many patient

presentations must be taught from an early stage within physiotherapy

training. Emphasising this within undergraduate physiotherapy training will

reinforce the holistic approach to physiotherapy treatment and improve patient

care.

To benchmark against, model and establish a clinical programme which would

inform the development of a service which educates healthcare professionals and

the wider population in dysfunctional breathing, ensuring a pro-active approach to

prevention, recognition and treatment.

Benchmarking my service provision against a service that provides some of

the most comprehensive and well evidenced treatment in the world has

allowed me to plan service development within my own service. There is a

need to:

Improve the recognition of patients with dysfunctional breathing.


Develop clinical referral pathways for both GP’s and Respiratory Physicians

through consultation with relevant groups and disseminate widely through the

Respiratory MCN and Respiratory forums throughout Scotland.

Address how to disseminate information regarding normal breathing pattern to

the public at large. Investigate utilising Public Health Platforms and charitable

organisations’ e.g. One You campaign in England, British Lung Foundation

(BLF), Asthma UK.

Objectives

Investigate how a service can be developed to ensure that:

General practitioners have a raised awareness of these conditions and feel confident

to diagnose and refer patients at an early stage.

Use of Clinical GP referral pathway and education of GP’s through the

Respiratory MCN.

Ensure the importance of normal breathing patterns are emphasised

throughout medical training.

Awareness of the condition is raised among employers whose staff would benefit

from breathing education.

It is recognised that there are certain professions with an increased

presentation of Dysfunctional Breathing. These include call centre workers,

teachers, and lecturers, to name a few. Targeting these recognised groups

and providing advice and education at times of induction or other stressful

times eg redundancy or retirement would allow us to provide targeted health

promotion in line with 20:20 vision.

Self referral access to services is made available to individuals with breathing pattern

disorders.

Improving awareness of normal breathing patterns within the general public is

key. Utilising video presentations within GP practices and hospital

departments we can educate the general public. Early recognition of an

abnormal breathing pattern can result in quicker more effective treatment if

services are readily available to patients. Self referral to Physiotherapy is an

option for this patient group.

Breathing education becomes integral to asthma management.


We are aware of the high incidence of breathing dysfunction within the

population of individuals who have asthma. Educating this patient group from

day of diagnosis could be integral to their long term management.

Providing all newly diagnosed asthmatics with written information or sign

posting to online material on maintenance of normal breathing patterns may

be key to preventing long term issues. This should be highlighted at every

face to face intervention of patient and GP, Nurse or Physiotherapist.


7 Key Messages and Recommendations

Education of patients, physiotherapists, other medical professionals and the general

public is paramount in order to raise the profile of normal breathing and dysfunctional

breathing.

Establish close links with Health Education Institutes (HEI’s) to ensure normal

breathing patterns are integral within the training of physiotherapists and

medical trainees.

Develop GP referral pathways for patients with dysfunctional breathing.

Develop an e-learning module on normal breathing.

Establish an education package and training program for physiotherapy staff.

Establish a network of individuals with an interest in dysfunctional breathing.

Present Fellowship findings through a number of forums including Respiratory

MCN, Physiotherapy Frontline and conferences.

Link with employers to promote normal breathing to “high risk “workforce.

Prevention, recognition and self management of dysfunctional breathing needs to be

highlighted through health promotion and the public health agenda.

Utilise video presentations within GP practices and Hospital clinics to promote

normal breathing patterns.

Link with BLF

Education of breathing control and maintenance of normal breathing patterns

within individuals with asthma should begin at diagnosis and be emphasised

throughout the course of the disease.

Link with Asthma UK to develop information leaflet and podcast to provide to

all asthmatics on diagnosis.

Ensure all staff members treating patients with asthma utilise a brief

intervention approach to education at every face to face intervention.

Further evidence is required to establish whether “major incidents” precipitate an increase in development of dysfunctional breathing? Is this an area for targeted intervention? This needs further consideration.


Messages for Physiotherapists

Greater consideration needs to be given to the diaphragm as a key muscle in

maintenance of core stability within the body.

Link with Musculo-skeletal physiotherapist to increase their awareness of the

diaphragm as a muscle of core stability

The nose needs to be included in all assessment of the respiratory system.

Education of physiotherapists working within respiratory medicine to ensure

the nose is considered in all assessments of the respiratory system.

Develop an e-learning module on the importance of the nose in normal

respiration.

Need to maintain awareness of current research into new modalities of treatment to

improve patient treatment and outcomes.

Through CPD ensure up to date research is critically appraised and integrated

into practice.

Maintain links with colleagues in New Zealand to ensure peer support

Within physiotherapy we need to emphasize the holistic approach to patient care.

Education through Health Educations Institutes and e.learning platforms

e.g.Learnpro

Sleep re-education should be considered an integral part of assessment and

treatment of patients with dysfunctional breathing.

Ensure the relevance of sleep is discussed within an education package on

dysfunctional breathing and included within assessment paperwork.

Consideration of breathing pattern within athletes is a developing field in which

physiotherapists can play a key role.

Investigate further the use of implementing inspiratory muscle training with

athletes.


8 Reflections The Oxford English dictionary definition of breathing: Take air into the lungs and then expel it, especially as a regular physiological process: George Bernard Shaw is stated as saying that “awareness of breathing already indicates problems.” This remains true today. On diagnosis many individuals remain completely unaware that their breathing pattern is highly abnormal. Before we can recognise abnormal we must be aware of the normal. My journey to New Zealand has provided me with the opportunity to assess the service provision for patients with dysfunctional breathing. There are areas where we can increase our knowledge and improve practice however I was hugely reassured that many of the treatment strategies used in New Zealand are currently employed by myself. On reflection since returning from my Fellowship, one area that has been highlighted is the lack of awareness amongst professionals and the public as to what “normal” breathing actually is. Whilst each individual is different there are core principles of breathing that should be common to all. Margot Skinner PhD, MPhEd, DipPhty Honorary Fellow, Physiotherapy New Zealand (PNZ) Honorary Life Member, PNZ Fellow, New Zealand College of Physiotherapy , has described a Physiotherapist’s unique contribution as the: “non Pharmacological management of non communicable diseases.”

Physiotherapists are involved in all aspects of health care from prevention, diagnosis and treatment, and palliative care. Breathing is central to all aspects of the human journey and therefore should be included in all aspects of the patient journey. For physiotherapists to act within the CSP definition of physiotherapy, which is, Physiotherapy is a science-based profession and takes a ‘whole person’ approach to health and wellbeing, which includes the patient’s general lifestyle14, we must take breathing pattern into consideration at each physiotherapy contact. Breathing is essential to life and in all activities. Unfortunately, consideration of the health benefits of maintaining a healthy breathing pattern appears to have been lost in the health promotion explosion of the last decade.

This whole journey has renewed my passion for ensuring that physiotherapy truly

adopts a holistic approach to patient health and well-being. Addressing and

correcting a dysfunctional breathing pattern has a profound effect on patients’ lives

and its importance in maintaining health should not be underestimated.


Contact

Email address: [email protected]

Further Reading:

Tania Clifton-Smith, Janet Rowley (2011) Discussion Paper. Breathing pattern

disorders and physiotherapy: inspiration for our profession. Physical Therapy

Reviews, 16 (1), pp. 75 – 86.

Dinah Bradley (2007) Hyperventilation Syndrome. 3rd edit. New Zealand: Random

House.

Dinah Bradley, Tania Clifton-Smith (2002) Dynamic Breathing for asthma. rev.ed

(2008). New Zealand: Random House.

Dinah Bradley, Tania Clifton-Smith (2005) Breathe Stretch and Move. New Zealand:

Random House.

Dr Jim Bartley FRACS with Tania Clifton-Smith Dip Phys(2006).Breathing Matters, a New Zealand guide. New Zealand: Random House.

Tania Clifton-Smith (2003) Breathe to succeed: In All Aspects of your life. New Zealand: Penguin Books.


Appendix 1 NIJMEGEN QUESTIONNAIRE

Please mark with a tick how often you suffer

From the complaints listed:

A score of 24 or over out of 64 is said to be highly suggestive of hyperventilation

NEVER

0

RARE

1

SOMETIMES

2

OFTEN

3

VERY OFTEN

4

CHEST PAIN

FEELING TENSE

BLURRED VISION

DIZZY SPELLS

FEELING CONFUSED

FASTER OR DEEPER BREATHING

SHORT OF BREATH

TIGHT FEELINGS IN CHEST

BLOATED FEELING IN STOMACH

TINGLING FINGERS

UNABLE TO BREATHE DEEPLY

STIFF FINGERS OR ARMS

TIGHT FEELINGS ROUND MOUTH

COLD HANDS OR FEET

HEART RACING (Palpitations)

FEELINGS OF ANXIETY

TOTAL : /64


References

1 Dr LC Lum MB FRCP FRACP (1997) Breathing Exercises in the treatment of

Hyperventilation and anxiety states. Chest Heart and stroke journal, 2(1) Spring, pp

7-11.

2 Chartered Society of Physiotherapy ( 2011) Code of Members’ Professional Values and Behaviours [online].Available from:{ CSP.org.uk}. 3 World Health Organisation Fact file. 10 facts on asthma[Online]. WHO. Available from: { www.WHO.Int/features/factfiles/asthma/asthma_facts/en/index9.html}. 4 Thomas, M and Brunton, A (2014) Breathing exercises for asthma. Breathe, 10 (4),

pp313-322.

5 Thomas Mike, McKinley R K, Freeman Elaine, Foy Chris (2001) Prevalence of

dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey.BMJ; 322 :1098.

6 Alain Boussuges,MD,PhD; Yoann Gole ,MSc; and Philppe Blanc, MD (2009) Diaphragmatic Motion studied by M Mode ultrasonography. Chest, 35(2) Feb, pp. 391 – 400. 7 Hodges P, Butler J, McKenzie D, Heijenen I,Gandevia S (1997) Contraction of the human diaphragm during postural adjustments. J Physiol(Lond), 505, pp. 239 -48.

8 HCPC (2016) Standards of Performance and ethics [online]. Available from:{hcpc-uk.org.uk}.

9 Dr Jim Bartley FRACS with Tania Clifton Smith Dip Phys(2006).Breathing Matters,a New Zealand guide.New Zealand: Random House NZ.

10 Swift AC et al (1988) Oronasal obstruction, lung volumes and arterial oxygenation. Lancet; (1)pp. 73-75. 11 J Vabnsteenkiste, F.Rochette, M Demedts (1991) Diagnostic tests of

hyperventilation. Eur J,4 (4) pp. 393 – 399.

12 Vickie Li Ogilvie, Paula Kersten (2015) Literature review A critical review of the psychometric properties of the Nijmegen Questionnaire for hyperventilation syndrome. New Zealand journal of Physiotherapy, 43 (1) pp. 3 – 10. 13 Sheel A, Derchak P, Morgan B, Pegelow D, Jacque A, Dempsey J (2001) Fatiguing inspiratory work causes reflex reduction in resting leg blood flow in humans. J Physiology,537,pp. 277 – 289. 14 Chartered Society of Physiotherapy What is Physiotherapy? [Online].Available from: {.csp.org.uk/your-health/what-physiotherapy}.

http://www.csp.org.uk/your-health/what-physiotherapy

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