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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
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.
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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