Your chest must first be mobilized because, as you have learned, it is out of correct positioning and stiffened. Next it must have corrected and coordinated movement, because it is not moving properly. And finally the chest muscles must be strengthened, because the immobilized chest has permitted weakness to develop in your breathing muscles .

This is a complex task, and ideally would require a skilled professional Physical Therapist (Chest Physiotherapist) to use "hands on" techniques to augment chest movements and teach corrective and coordinated movements, and enhance joint flexibility with local massage and supplemental heat or diathermy. However, as previously indicated, these services are difficult to find in North America, as indeed there are presently only about 130 credentialed Cardio-Pulmonary Physical Therapists in the United States. We will provide you with self-help instructions that will cover the major points of this technology, but regardless of these instructions, you are encouraged to use them in conjunction with your physician and appropriate other health care providers.

However, there is another option you might consider, and that is Yoga. Dr. Vijai Sharma, a practicing clinical psychologist and credentialed Yoga instructor with a particular interest in COPD, has developed training DVD videos designed specifically for home use by people with COPD. Dr. Sharma is currently offering two DVDs and instruction manuals:
"Stretching Breathing Exercises adapted for people with severe COPD" and
"Stretching Breathing for COPD For all levels of fitness".

The various Yoga spine and neck exercises, coupled with Yoga breathing exercises and breathing coordination with general body movements, seem well suited to substituting for traditional Chest Physical Therapy. Dr. Sharma has a web site with many helpful COPD instructions, and his instruction videos may be purchased at Dr. Sharma's web site

Physical Therapy is much involved with so-called "Adaptive Substitution Movements or so-called "Trick Movements," which basically is the use of different muscular groups to assist the function of impaired neuromuscular groups. There are "Good Trick Movements" (i.e. Adaptive Substitution Movements) which are productive, and "Bad Trick Movements" (i.e. Mal-Adaptive Substitution Movements) which are not efficient or productive.

Bad Trick Movements may develop during the course of a disease, and they may also appear any time one is doing therapeutic neuromuscular training. It is therefore important to watch out for bad trick movements developing, and to correct them. In diaphragmatic breathing training there is one common bad trick movement called the "Belly Puffing Artifact" that must not be allowed to happen.

Normally when one inhales the diaphragm descends toward the abdomen, and as a result the abdomen rises. However, it is important the abdomen rise naturally because of proper rib and diaphragm movement. Belly Puffing, which is not due to diaphragm movement, can mimic normal abdominal protrusion due to correct diaphragm movement. And unfortunately, Belly Puffing can be easily learned. Try this exercise in Belly Puffing on yourself, to see how easy it is to do, and so you can recognize it during your diaphragmatic breathing training.

While standing, breathe IN deeply, and at the same time suck your abdomen IN. Then exhale fully, and while doing so, puff your abdomen OUT. Note this is 180 degrees out of phase with the normal abdominal movement due to diaphragm action. Now, lying flat on your back, do the same Belly Puffing maneuver, and note how easy it is to do. Belly Puffing is not simply a shifting of thoracic-abdominal contents by gravity.

Abdominal Belly Puffing that is 180 degrees out of phase with true diaphragm action is called "Paradoxical Chest Movement," and it is usually easy to detect. However, much more common, and much harder to detect, are partial forms of Belly Puffing, producing various degrees of "Asynchronous Breathing" that may be easily confused for true diaphragm movement. With more severe degrees of Asynchronous Breathing you may think you are getting good diaphragmatic breathing, but in fact your diaphragm movement may be substantially sub-optimal.

The only true abdominal indication of diaphragmatic breathing is the rise of the abdomen that flows naturally from the action of the rib Bucket Handle movement, and this doesn't happen until about 1/4 to 1/3 or more into inspiration. Abdominal puffing prior to this inspiration timeing is Belly Puffing. Even more subtle and difficult to detect, is partial Belly Puffing later during inspiration.

There are two commonly practiced diaphragmatic breathing techniques that should not be done, because they have a substantial chance they are in fact teaching Belly Puffing, not true diaphragmatic breathing training.

Note one hand placed on the upper chest, and the other on the abdomen, just below the ribs. Typically this exercise is done from the sitting or lying position.

The patient is instructed to not move the upper chest while breathing in (i.e. to correct the abnormal "Pump Handle" movement), and at the same time to have the abdomen come out with inhalation, to teach diaphragm movement.

Note however, these instructions are in fact likely to teach Belly Puffing, not true diaphragm breathing.

The proper instruction is to have the patient direct their inspiration breathing to the lowest rib margin, directly beneath the anterior margin of the arm pit. This will make the chest move outwards and upwards because of the "Bucket Handle" movement. There should be no abdominal movement for about 1/4 to 1/3 of inspiration, and at that point the abdomen will then begin to protrude outwards. But this time abdominal protrusion is the result of true diaphragm movement.

All abdominal movement on inspiration should flow naturally from correct "Bucket Handle" chest movement.

Another problematic technique is, while lying down, to have a weight just below the ribs, and to concentrate on making the weight rise on inspiration.

By focusing on making the weight rise, again, this has obvious potential to teach Belly Puffing.

However, this technique can be a useful one, provided the therapist uses two flat sand-bag type weights, each positioned along the lower-lateral rib margin, with no more than half the weight lying on the abdomen. If the patient watches the weights move in this position, they will now have a visual biofeedback prompt to encourage performance of the Bucket Handle chest movement. In addition, with graded weights this exercise may enhance chest wall strength.

The correct hand position for diaphragm breathing training is as noted.

Note the hands on the lower rib margins, directly below the anterior portion of the arm pits. The fingers, preferably only the distal half of the fingers, are over the lowest ribs and on the abdomen. The inspiration breath should be gently directed towards the palms of the hands, which should rise gently. And try to feel the air moving into this region. Learn to recognize this feeling of correct breathing.

There is an alternate hand placement trick, to guide you to the correct Bucket Handle movement, which some patients find easier to do. Raise the elbows up to shoulder height, and let the hands dangle. Then, curl the fingers until they are facing the floor. Then place the backs of the fingers on the very lowest rib margin, directly under the arm pits.

As the ribs swing outward and upwards, with a little practice about 1/3 of the way through inspiration you should be able to feel the diaphragm gently rising against your finger tips. And about this time the abdomen should gently rise, but this time because of true diaphragm movement. The hand positioning is providing the signal to train you in correct diaphragm breathing. With only a month or so of diligent practice you should be able to do this type of breathing naturally, and without using the hand prompting signal.

Note that I have made no mention of inhibiting the abnormal upper-anterior "Pump Handle" chest movement, which causes the upward "Unit Movement" of the chest. This is seldom needed. If indeed you correctly focus on the correct "Bucket Handle" movement this upper chest movement will gradually disappear. Occasionally however, some directed voluntary suppression of this upper chest movement is needed.

Generally you should teach yourself to recognize this abnormal upper chest movement, and during quiet breathing, to voluntarily suppress this upper chest movement.

However, If your breathing reserves are low, and at times of breathing distress, you may need to use your accessory muscles of respiration to employ the Pump Handle movement as an emergency breathing mechanism. This is an advanced breathing technique. The important point to remember, is to let any upper chest movement flow naturally from the dominant lower chest Bucket Handle movement. The Bucket Handle movement is always primary, and the key to success. Just as abdominal diaphragmatic movement flows later from the Bucket Handle movement, so to does the upper chest Pump Handle movement flow later from the Bucket Handle rib action.

You will need this upper chest suppression skill to help correct the Rescue Breathing Pattern. More on this subject in a later module.

The Breathing Belt is a simple device used by Chest Physotherapists to apply directed pressure to the ribs for chest mobilization and breathing enhancement. And as you will see, it has other usefull purposes. But first you must know how to construct a Breathing Belt.

The Breathing Belt may also be used as a Safety Belt. This is an old technique used by Physical Therapists to help ambulate frail patients safely.

Tie the belt snugly around the lower waist of the patient, just above the brim of the pelvic bones, and secure it with a knot (no safety pins or insecure clasps). Then, the person assisting the patient should firmly grasp the belt with one hand in the mid portion of the back. The other hand may be used to otherwise assist the patient.

The Safety Belt may then be used to assist the patient in getting out of bed, getting up from a chair, or walking. Always maintain the belt hand, as this is the controlling hand should the patient lose their balance, or look in danger of falling due to weakness.

Most of the falling accidents happen because a frail patient loses their balance. However, with the controlling hand on the Safety Belt even a small helper can easily control most patient acts of incoordination and stumbling.

And should the patient actually fall, the controlling hand on the Breathing Belt can ease the patient to the floor without serious injury.

The Breathing Belt is best used in the sitting position, though it could be used both standing and lying down.




Place the belt behind you, at the level of the lowest ribs. The lowest portion of the belt should be positioned about an inch below the anterior lowest rib, directly below the collar-bone (or Clavicle). It is important the belt not be lower than this, or you will only be compressing the abdomen, and therefore deriving no rib mobility benefit.













Now, take your right hand and grasp the left belt, just below the anterior portion of the arm pit. And cross your left hand over to the right belt at this same position below the arm pit. Many patients find it convenient to grasp the belt as though one is holding the reins of a horse.

You are now ready to do chest mobilization. Relax. As with all breathing techniques it is important that you do them in a relaxed manner.

Take in a slow, deep and gentle breath, and then totally relax your chest and let the air gently fall out of your chest.


Then, about half way through breathing out, apply chest pressure by pulling your hands towards each other, directly across your chest. As you are pulling, increase the pressure gradually and firmly. Do not pull suddenly or forcefully, as this type of pressure could crack or even fracture a frail rib. Try to get the sensation as though you are wringing water out of a wet bath towel. Make your exhalation time prolonged, at least two to three times your normal time of breathing out.

Then, simultaneously, release the belt pressure and breathe in gently and fully. Direct this inspiration breath down to the bottom of your lungs, and laterally, directly below the anterior portion of your arm pits. This is critically important, as this action is training your rib muscles to do the Bucket Handle movement. Try to feel the air moving into these lower regions of your lungs.

If you have done this correctly, release of the belt pressure should cause your compressed ribs to spring out, and you should feel a satisfying rush of air into your lungs. Repeat this compression cycle, and try to get a rhythm to your chest compressions.

Patients frequently get confused as to when to apply the belt pressure, as indeed the combination of breathing phase and belt pressure is somewhat counterintuitive. If you get these movements mixed-up, the application of the breathing belt pressure will work against your breathing, and your breathing then will immediately get worse.

Done with skill, and without excessive compression force, this can be a useful trick to relieve an acute attack of dyspnea which has resulted in Dynamic Hyperinflation.

For rib mobilization exercises, three to five minutes, done twice or at most three times a day, should be sufficient. Done more than this the exercises can become unpleasant and boring, and you may lose interest. But during these brief practice times you should concentrate on technique perfection, and particularly where to place your inspired breath of air down in the lower-lateral lungs.

A warning: Stiffened ribs that are being mobilized often complain by producing a general aching type of pain, and this discomfort usually takes about five to six weeks to slowly resolve. Local low-level gentle heat and simple pain relievers such as Aspirin may help. However, a sharp localized pain may indicate a cracked or broken rib, and you should stop further belt exercises until you have been checked by your doctor. Be patient. You will find that this discomfort is well worth the trouble if you regain the capacity to take in deeper breaths, and being able to take in deeper breaths easily is what this is all about.

Muscular 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.

And 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.

The "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.

And 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.

The 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 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.

Your chest should now be mechanically ready to learn how to breathe. We will now move on to bad breathing patterns, and why and how to correct them.

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