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70 m a s s a g e & b o d y w o r k j a n u a r y / f e b r u a r y 2 0 1 7 • The thoracic spine and ribs usually require mobilization. • For the retraining of breathing, various exercises individualized to the specific needs of the client should be introduced, commonly involving pursed-lip breathing and/or pranayama yoga methods (see "Breathing Rehabilitation Exercises" on page 69). • Relaxation methods can usefully be introduced. • Sleep pattern disturbances might require attention and advice. 25 • Active exercise (walking or very light weight training) should be considered and carefully introduced, within pain tolerance. • Because of the known link between low blood-sugar levels and breathing pattern imbalances, appropriate dietary advice should be offered by qualified professionals. SUMMARY BPDs are a common feature in individuals with fibromyalgia. However, these are rarely recognized or appropriately treated. Breathing retraining is effective clinically and economically, as long as enough patience is exercised to actively engage the fibromyalgia client in a program requiring weeks or months of daily breathing exercise to achieve behavioral change. Chronic BPDs are commonly successfully treated; however, a time frame of 12–26 weeks may be required, with active client participation throughout, to break well-established habits. 26 The implication is that a combination of biomechanical facilitation of breathing (joint and soft-tissue mobilization), as well as education combined with rehabilitation via specific application of breathing exercises, can achieve marked benefit in BPDs—accompanied by reduced levels of pain and fatigue. • The client needs to understand that the therapist can do no more than create an environment—a possibility—for restoration of more normal function, but the onus of the breathing work itself falls to the client. • Mobilization of respiratory muscles and joints alone, no matter how appropriate, can never restore normal breathing patterns unless there is a cooperative rehabilitation effort. • Conversely, breathing retraining without the mobilization of restricted structures is far more difficult to achieve. • Manual attention to reduce hypertonicity in accessory breathing muscles (including the upper trapezii, levator scapulae, scalenes, sternocleidomastoid, pectorals, and latissimus dorsi) is usually required. • The diaphragm area also requires attention as a rule (the lower anterior intercostals, sternum, costal margin, beneath the costal margin, abdominal attachments, quadratus lumborum, and the psoas). • Active trigger points in these muscles may need to be deactivated manually. Mobilization of respiratory muscles and joints alone, no matter how appropriate, can never restore normal breathing patterns unless there is a cooperative rehabilitation effort.