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Background:  While asthma and exercise-induced bronchoconstriction (EIB) can explain some cases of exertional dyspnea, the differential diagnosis of dyspnea is extensive. Dysfunctional breathing (DB) is a condition that is often overlooked and underdiagnosed. Pharmacologic treatments are available and widely utilized by clinicians for exertional dyspnea, but a better understanding of the non-pharmacologic treatments as well as psychological factors that play a role in DB can provide professional, elite amateurs, and recreational athletes with more therapeutic options. Measurement tools for mental toughness:  Given the psychological components involved with these conditions, a tool to measure domains of sports mental toughness in athletes could help medical providers create a more comprehensive athlete profile which can be used in conjunction with standard pharmacologic therapy to provide a more effective treatment plan. Diagnosing DB:  While normal breathing mechanics help shape appropriate posture and spinal stabilization, DB has been shown to contribute to pain and motor control deficits resulting in dysfunctional movement patterns, which further contribute to DB. Most respiratory specialists are unaware of how to assess the role of faulty sports technique, especially running gait, in dysfunctional breathing patterns making it difficult to recommend appropriate treatment and offer referrals for relevant therapies. Assessing postural changes:  Three key components of proper running gait are reviewed and described in detail including trunk counter-rotation, extension of atlanto-occipital joint in conjunction with a forward tilted trunk, and ankle and hip joint range of motion. Conclusions:  When underlying gait abnormalities and mental skills are addressed properly, they can disrupt poor breathing mechanics, facilitating a transition away from DB and toward healthier breathing patterns.KEY POINTS In summary, the following points should be considered when evaluating athletes who are having difficulty breathing even when compliant with their medications or if there is not an indication of asthma or EIB:Assess dysfunctional breathing (DB) with Nijmegen questionnaire (NQ).If DB is present, measure mental skills using the Sisu Quiz to determine an athlete’s mental skills profile.Evaluate postural changes that may impact an athlete’s ability to breathe.Using the three tools of the NQ, Sisu Quiz, and Postural assessments creates an athlete profile that is clinically useful to improve breathing technique.DB is often mistaken for other conditions for which medications are prescribed. By identifying DB early and making appropriate changes may negate or reduce the need for pharmacotherapy.Improving DB will improve athletic performance. In summary, the following points should be considered when evaluating athletes who are having difficulty breathing even when compliant with their medications or if there is not an indication of asthma or EIB: Assess dysfunctional breathing (DB) with Nijmegen questionnaire (NQ). If DB is present, measure mental skills using the Sisu Quiz to determine an athlete’s mental skills profile. Evaluate postural changes that may impact an athlete’s ability to breathe. Using the three tools of the NQ, Sisu Quiz, and Postural assessments creates an athlete profile that is clinically useful to improve breathing technique. DB is often mistaken for other conditions for which medications are prescribed. By identifying DB early and making appropriate changes may negate or reduce the need for pharmacotherapy. Improving DB will improve athletic performance.

The impact of mental toughness and postural abnormalities on dysfunctional breathing in athletes