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Journal of Voice

Vol. 9, No. 4, pp. 341-347


© 1995 Lippincott-Raven Publishers, Philadelphia

Influence of Body Position on Breathing and Its


Implications for the Evaluation and Treatment of Speech
and Voice Disorders

Jeannette D. Hoit

National Center for Neurogenic Communication Disorders. Department of Speech and Hearing Sciences, University
of Arizona, Tacson. Arizona, U.S.A.

Summary: This paper examines how breathing differs in the upright and supine
body positions. Passive and active forces and associated chest wall motions are
described for resting tidal breathing and speech breathing performed in the two
positions. Clinical implications are offered regarding evaluation and treatment
of breathing behavior in clients with speech and voice disorders. Key Words:
Body position--Breathing--Speech--Voice.

Breathing is critical to normal speech and voice aimed at changing breathing behavior. Presented
production. Therefore, it is not surprising that the first is a simplified description of the structure of
evaluation and treatment of breathing behavior is the breathing apparatus and its function during per-
considered to be an important component of the formance of various activities, including relaxing,
clinical process when dealing with clients with resting tidal breathing, and conversational speech
speech and voice disorders. However, evaluating breathing in the two body positions of interest. This
and treating breathing behavior is a complex task, is followed by a discussion of how this information
in part because breathing is influenced by so many relates to clinical applications.
different variables, one of which is body position.
Although there is a substantial body of scientific
THE BREATHING APPARATUS
literature on how body position affects breathing
(1-9), including speech breathing (10-12), little of The breathing apparatus provides driving pres-
the existing knowledge has made it into the clinical sure to downstream structures for the production of
literature. Without this knowledge, the clinician is normal speech and voice. It can accomplish its task
at a disadvantage when faced with the challenge of in a variety of ways, even when viewed within a
solving speech breathing problems. fixed gravitational context. However, if body posi-
The purpose of this paper is to provide the clini- tion changes, and correspondingly the gravitational
cian with a set of fundamental principles to serve as context changes, so do the inherent recoil forces
a guide for clinical practice, with an emphasis on and mechanical relationships among the various
the influence of body position on breathing. These muscles, cartilages, tendons, and connective tis-
principles are illustrated using the upright and su- sues that make up the breathing apparatus. Thus,
pine body positions because these are the most for each body position assumed, a different muscu-
common body positions used in clinical treatments lar solution is required.
The breathing apparatus is made up of the pul-
Accepted September 27, 1994. monary system, consisting of the lungs and air-
Address correspondence and reprint requests to Dr. J. D. Hoit
at Department of Speech and Hearing Sciences, University of ways, and the chest wall system, consisting of the
Arizona, Tucson, AZ 85721, U.S.A. rib cage, abdomen, and diaphragm. The pulmonary

341
342 J. D. H O I T

system is a "passive" system in that it contains no


skeletal muscle. By contrast, the chest wall system
contains numerous skeletal muscles that can inspire Relaxing
or expire the pulmonary system and can change the
shape of the torso. Specifically, the rib cage con-
tains both inspiratory and expiratory muscles, the
abdomen contains only expiratory muscles, and the
diaphragm is an inspiratory muscle. Between the
abdominal wall and the diaphragm are housed the
abdominal contents.
Relaxing
Figure I depicts a relaxed and motionless breath-
ing apparatus in both the upright and supine body
positions (Fig. la and b, respectively). In the up-
right body position, such as that assumed during
standing or sitting, gravity acts to expire the rib
cage by pulling down on it. By contrast, gravity acts
to inspire the diaphragm and abdomen by pulling
the abdominal contents footward (I), causing the
abdomen to distend outward and the diaphragm to
(a)
flatten. This inspiratory action on the diaphragm-
abdomen enlarges the pulmonary system so that
there is a substantial amount of air in the lungs and
airways at the resting lung volume (i.e., functional
residual capacity, FRC). When the breathing appa-
ratus is relaxed at FRC, its recoil forces are in equi-
librium. At lung volumes larger than FRC, the net
recoil force is expiratory, whereas at lung volumes
smaller than FRC, the net recoil force is inspiratory
(2).1 Within the abdominal contents, there is a hy- (b)
drostatic pressure gradient, just as there is in a col- FIG. 1. The breathing apparatus during relaxation of the chest
wall muscles in the upright (a) and supine (b) body positions. The
umn of water. The gradient is vertical in the upright dashed lines in (b) represent the configuration of the upright
body position so that pressure increases in the foot- apparatus and are included for the purpose of comparison to the
ward direction. supine configuration. [Adapted with permission from Prentice-
Hall ( 13).]
The effects of gravity on the breathing apparatus
are different in the supine body position. In this
position, gravity operates in the expiratory direc- upright, the net recoil force is expiratory at lung
tion on the rib cage and abdomen and drives the volumes larger than FRC and inspiratory at lung
abdominal contents and diaphragm headward (I). volumes smaller than FRC. In this position, the hy-
That is, gravity expires the entire breathing appara- dostatic pressure gradient within the abdominal
tus. This means that, at rest, the supine breathing contents is such that pressure is lowest near the
apparatus is relatively small, and the pulmonary anterior abdominal wall and highest near the back.
system contains a smaller amount of air than it did
when in an upright position (2). As was the case in Resting Tidal Breathing
Given that the mechanical state of the breathing
This can be demonstrated by performing the following simple apparatus changes with body position, it is not sur-
exercise. Inspire a moderate amount of air, close your larynx,
and relax your breathing muscles. The force on your breathing prising that the muscular mechanism used in per-
apparatus should feel like a "squeezing" force (i.e., expiratory). forming various breathing activities also changes
Next, expire a moderate amount of air below your resting lung with body position. Depicted in Fig. 2 are the mus-
volume level, close your larynx, and relax your breathing mus-
cles. Now, the force on your breathing apparatus should feel like cular mechanisms involved in resting tidal breathing
a "sucking" force (i.e., inspiratory). in the upright and supine body positions. In the up-

Journal of Voice, Vol. 9, No. 4, 1995


BOD Y P O SITIO N 343

abdomen is almost always overlooked in textbook


Breathing descriptions of breathing function.
Why is the abdomen active during upright resting
Inspiration Expiration tidal breathing? The answer is related to the way in
which the abdomen and diaphragm are mechani-
cally linked. When the abdomen is distended, such
as when the abdominal muscles are quiescent, the
diaphragm assumes a somewhat flat configuration
and its fibers are relatively short. By contrast, when
the abdomen is displaced inward, the diaphragm is
displaced headward. This improves the function of
the diaphragm by placing it on a more advantageous
portion of its length-tension characteristic (4,5,1 I,
21). Thus, the abdomen, by being displaced inward,
(a) (b) serves to " t u n e " the diaphragm mechanically.
The muscular mechanism used in resting tidal
breathing changes when the breathing apparatus as-
sumes the supine body position (see lower portion
of Fig. 2). Inspiration is driven by the diaphragm (as
indicated by the arrow in Fig. 2c) and expiration is
driven by recoil force alone. The major difference
(c) (d) between upright and supine resting tidal breathing is
FIG. 2. Muscular actions of the rib cage, abdomen, and dia- that the abdomen is not active in the supine posi-
phragm during resting tidal breathing--including inspiration (a) tion. It need not be active in this position because
and expiration (b) in the upright body position and inspiration (c)
and expiration (d) in the supine body position. Arrows indicate gravity performs the function that the abdomen per-
the direction of the muscular pressures applied. [Adapted with forms in an upright position. That is, gravity me-
permission from Prentice-Hall (13).] chanically tunes the diaphragm by expiring the ab-
domen, thus driving the diaphragm headward. Be-
right position, inspiration is accomplished primarily cause the abdomen is passive, it is highly compliant
with the diaphragm, as indicated by the arrow in the and easily moved by contraction of the diaphragm.
figure (Fig. 2a). The rib cage muscles also are ac- This is why the motions of the abdomen are notice-
tive, but probably do not function as prime movers ably large during supine resting tidal breathing (6),
(3). Rather, they probably serve to stiffen the rib particularly when contrasted with those during up-
cage so that it is not pulled inward when pleural right resting tidal breathing.
pressure drops with inspiratory efforts of the dia-
phragm. Expiration is driven by the net recoil force Conversational Speech Breathing
provided by the breathing apparatus (Fig. 2b). The muscular mechanism used during conversa-
However, this does not mean that the breathing ap- tional speech breathing is illustrated in Fig. 3. Be-
paratus is completely relaxed. Rather, as shown by ginning with the upright body position, the inspira-
the arrow, the abdominal muscles are active tory phase of the speech breathing cycle is accom-
(4,8,12,14-20). In fact, they remain active through- plished primarily by the diaphragm (Fig. 4a). The
out the entire breathing cycle and displace the ab- expiratory phase of the cycle, which is the speaking
dominal wall inward from its relaxed position to phase of the cycle, is accomplished by a combina-
counteract the distending force of gravity on the tion of rib cage and abdominal muscular pressures,
abdomen and its contents. The further footward one with the latter predominating (Fig. 3b) (11). The ab-
moves along the wall of the abdomen, the more domen is very active throughout the upright speech
active are the abdominal muscles (12,14,20). This breathing cycle, more so than it is during resting
reflects the need to counteract the higher pressure tidal breathing. The abdomen is maintained in an
in the lower part of the abdomen resulting from the inwardly displaced position and moves little. Lung
hydrostatic pressure gradient within the abdominal volume displacement during both inspiration and
contents. Thus, the abdomen plays a prominent role expiration is reflected primarily in motion of the rib
in upright resting tidal breathing. Nevertheless, the cage (10,I1,17-19,22,23). In fact, it is common for

Journal of Voice, Vol. 9, No. 4, 1995


344 J. D. H O l T

phragm-abdomen unit. Thus, the rib cage does not


Speaking( have to move as far as the abdomen to effect the
same change in lung volume.
Inspiration Expiration Clearly, the abdominal muscles serve important
functions for both phases of the upright speech
breathing cycle. During the inspiratory phase, the
abdomen mechanically tunes the diaphragm by de-
fending its length and providing a relatively firm
base against which it can contract (l l, 12). Tuning of
the diaphragm is critical to meeting the communi-
cative demand that inspirations be rapid and mini-
mally interruptive to ongoing speech. One way to
appreciate how important the abdomen is to inspi-
ratory efforts during upright speech breathing is to
(a) (b) observe someone whose abdomen is paralyzed. The
paralyzed abdomen will be distended, the dia-
phragm flattened, and the inspirations abnormally
slow (24).
The active role of the abdomen also is critical to
the expiratory (speaking) phase of the cycle. To be-
gin, when the abdominal muscles are maintained in
an active state, the abdomen can serve as a stable
(c) Cd) base against which the rib cage can contract to raise
FIG. 3. Muscular actions of the rib cage, abdomen, and dia- pulmonary pressure. If the abdomen were not ac-
phragm during conversational speech breathing--including inspi- tive, contraction of rib cage muscles would force
ration (a) and expiration (b) in the upright body position and
inspiration (c) and expiration (d) in the supine body position. the abdomen outward so that much of the rib cage
Arrows indicate the direction of the muscular pressures applied. muscular effort would be " w a s t e d . " Another con-
[Adapted with permission from Prentice-Hall (13).] sequence of displacing the abdomen inward is that
the rib cage is enlarged through the raising of ab-
the abdomen to remain fixed and for only the rib dominal pressure. Abdominal pressure enlarges the
cage to move when rapid volume expenditures are rib cage via two potential mechanisms (5,11,21,25-
required, such as during the production of/h/. This 27). First, abdominal pressure acts directly on the
appears to be an effective strategy because the rib inner surface of the lower rib cage through the zone
cage covers a larger proportion of the pulmonary of apposition (i.e., the region where the diaphragm
system (up to three-quarters) than does the dia- overlaps with the lower portion of the rib cage) to
expand the rib cage circumferentially. That is, as
Changc in Change in
• Breathing Body abdominal pressure increases, it forces the rib cage
Activity , Posilion
upward and outward in the inspiratory direction.
' SUPINE BREATHINGI S U P [ N E SPEAKING " UPRIGHT SPEAKING Second, as abdominal pressure increases, it forces
I Ch,"mgem Change in
the central tendon to be displaced rostrally, which,
Behavioral
Goal
Mechanical
Charactcnstics
in turn causes the costal fibers of the diaphragm to
pull the rib cage upward and outward in the inspi-
Change ia Chaag¢ in ratory direction. This mechanical linkage between
Ncural Control Neural Control
the abdomen and rib cage is a passive feature of the
breathing apparatus, as can be illustrated by the fact
that manual compression of the abdomen of a ca-
daver will expand the rib cage (28). The advantage
of an expanded rib cage for speaking is that the rib
[ c,.°,.,.
Muscular Mechanism ]i Muscular c,..,.,.
Mechanism )
cage muscles are elongated and their capacity for
FIG. 4. Summary of how change in breathing activity (from rest- generating rapid pressure change is improved. An
ing tidal breathing to conversational speech breathing) and body
position (from supine to upright) influence muscular mechanism. expanded rib cage also is advantageous for classical
See text for further explanation. singing, in which the demands for rapid and precise

Journal of Voice, Vol. 9, No. 4. 1995


BOD Y P O SITIO N 345

pressure control are even greater than for speaking. (c) speech breathing in the upright body position.
In fact, classical singers have been shown to em- As illustrated in Fig. 4, moving from one step to the
ploy very large inward displacements of the abdo- next involves a change in breathing activity in one
men to elevate the rib cage to a high position during case and a change in body position in the other
performance (29,30). case. What are the consequences of these changes
The lower portion of Fig. 3 depicts the muscular on the breathing apparatus and its performance? To
mechanism used during conversational speech begin, the change from the resting tidal breathing to
breathing in the supine body position. The inspira- speech breathing involves a significant change in
tory phase of the cycle is driven by the diaphragm the behavioral goal. While both resting tidal breath-
and the expiratory phase of the cycle is driven by ing and speech breathing have as a goal the ex-
the rib cage (Fig. 3c and d, respectively). The ab- change of oxygen and carbon dioxide for the pur-
dominal muscles are usually quiescent. During su- pose of ventilation, only speech breathing includes
pine speech breathing, the motions of the abdomen the additional goal of communicating a spoken mes-
are a consequence of the actions of the diaphragm sage. Unsurprisingly, these important goal-related
(during inspiration) and rib cage (during speaking). differences are accompanied by differences in the
Nevertheless, there are occasions when the abdo- neural mechanisms used to control these two
men becomes active, such as during loud speaking breathing activities (31).
or when speaking at low lung volumes (11,12). The change in body position from supine speech
breathing to upright speech breathing dramatically
CLINICAL IMPLICATIONS alters the mechanical characteristics of the breath-
As is clear from the foregoing discussion, the be- ing apparatus. This is caused by several interacting
havior of the breathing apparatus differs substan- factors, including those related to gravitational ef-
tially depending on body position (supine or up- fects on the inherent recoil forces of the apparatus
right) and performance activity (resting tidal breath- and the geometrical relationships of its muscles.
ing or speech breathing). Thus, it follows that Some of these factors have been discussed in this
approaches used in clinical evaluation and treat- paper. Along with these mechanical changes come
ment should be sensitive to these differences. How- alterations in the sensory function of the breathing
ever, some clinical practices do not take these dif- apparatus (6). That is, the relative strength of the
ferences into account. Consider, for example, what sensory messages used in the neural control of
is perhaps one of the most commonly used ap- breathing changes with body position. 2 The conse-
proaches for modifying breathing behavior in cli- quences of all these changes in breathing activity
ents with hyperfunctional voice disorders. This ap- and body position are that the muscular mechanism
proach involves first placing the client in the supine used to accomplish the respective behavioral goal
body position. This is done to relax the client and also must change. And, in fact, muscular mecha-
facilitate emergence of what is sometimes referred nism has been shown to change substantially across
to as the most "natural" breathing pattern. This breathing activity and body position.
pattern is said to be characterized by relatively Figure 5 provides a summary of the muscular
large abdominal motion and little or no rib cage mo- mechanisms used during supine resting tidal breath-
tion. The client is asked to attend to the rise and fall ing, supine conversational speech breathing, and
of the abdomen while breathing quietly, and then to upright conversational speech breathing. As illus-
practice vocalizing using the same large abdominal trated in the figure, supine resting tidal breathing
motion. Next, the client is brought to an upright involves only efforts of the diaphragm ( - D I ) for
seated or standing position and instructed to main- inspiration (recoil force drives expiration), whereas
tain the same breathing pattern. The goal is that the supine speech breathing involves efforts of the dia-
client eventually will carry over the so-called natu- phragm ( - D I ) for inspiration and efforts of the rib
ral breathing pattern from the supine body position
to everyday speaking activities performed in the up-
2 One clinical example of how body position can have a major
right body position. influence on sensorimotor function for speech breathing is found
This treatment approach includes three major in subjects with motor neuron disease (32). Although such sub-
steps relevant to the present discussion: (a) resting jects may report relatively normal sensation and demonstrate
relatively normal speech breathing behavior when in the upright
tidal breathing in the supine body position, (b) body position, they often become dyspneic and exhibit abnormal
speech breathing in the supine body position, and speech breathing movements when in the supine position.

Journal of Voice, Vol. 9, No. 4, 1995


346 J. D. H O l T

SUPINE BREATHING St/PiNE SPEAKING UPRIGIIT SPEAKING using nonspeech activities to modify speech-related
behavior has been criticized by others (34,35). A
second reason to question the efficacy of using su-
pine resting tidal breathing as a model for upright
speech breathing relates to the problem of general-
izing across body positions. If this novel breathing
~c L'f'x- °'~
pattern were substituted for the one that is typically
used during upright speech breathing, this could re-
sult in replacing a biomechanically efficient pattern
FIG. 5. Summary of the muscular mechanisms involved in su-
for one that is probably much less efficient in the
pine resting tidal breathing, supine conversational speech breath- upright position. 3
ing, and upright conversational speech breathing, lnspiratory In summary, breathing activity and body position
muscular pressure exerted by the diaphragm (DI) is represented
by a minus sign ( - ) and expiratory muscular pressure exerted by
have a profound influence on breathing behavior. 4
the abdomen (AB) and rib cage (RC) is represented by a plus sign Thus, both breathing activity and body position
(+). Inspiratory and expiratory phases of breathing cycles are should be taken into account in any quest to under-
illustrated in tracings of lung volume change (expressed in per-
centage vital capacity, %VC). Functional residual capacity stand the mechanism underlying breathing behav-
(FRC) is indicated with a dashed line. ior, in any effort to evaluate the nature of speech
breathing function and its functional potential, and
cage ( + R C ) for expiration. In contrast to supine in any attempts to modify behavior for the purpose
speech breathing, upright speech breathing involves of alleviating breathing-based speech and voice dis-
efforts of the diaphragm and abdomen ( - D I , orders. A rational approach to understanding, eval-
+ AB) for inspiration and efforts of the rib cage and uating, and treating breathing behavior should be
abdomen, with the latter predominating ( + R C < conducted within the context of the breathing ac-
+ A B ) , for expiration. Clearly, these muscular tivity of interest--usually breathing for speaking (or
mechanisms are substantially different from one an- for singing)--and within the body position of inter-
other. The result is that certain output variables est--usually upright. Any approach that is based on
also differ in critical features. Some of these vari- these simple principles will have a greater potential
ables are illustrated in the time-volume graphs in for success than those that are not.
Fig. 5. For example, there are position-related dif-
ferences in FRC, activity- and position-related dif- Acknowledgment: This work was supported in part by
ferences in lung volume range, and activity-related National Multipurpose Research and Training Center
Grant DC-01409 from the National Institute on Deafness
differences in inspiratory and expiratory volume, and Other Communication Disorders. Thanks go to
duration, and flow (33). Monica C. Pepitone for her contributions to this manu-
It is apparent that the goal of the treatment under script and to Todd C. Hixon for his graphic illustrations.
discussion--to model upright speech breathing after
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Journal of Voice, Vol. 9, No. 4, 1995