What's breathing got to do with...pain?

In the last post, we discussed how breathing is related to low back pain, albeit in a simplified version.  We focused a bit more on what we would call the mechanics of breathing, or the movement and muscle involvement.  This time, we will dive a bit deeper and look at breathing's complex relationship with pain.


What happens to our body when we breathe badly
As we discussed, one of the main way ways we "breathe badly" is when we shift to an upper chest pattern of breathing, instead of nice, relaxed diaphragm breathing.  This shift is often accompanied by more rapid, shallow breathing.  Contrary to what people might think, the problem is not related to getting enough oxygen.  In fact, with this type of breathing, you rarely see a fall in oxygen levels and will often see a rise in it.  The problem is seen with what most people think of a waste gas - carbon dioxide.  Indeed, carbon dioxide is a by-product of our cell's use of oxygen; however it plays a very important role in maintiaining our body's acid-base balance or, pH.  Not breathing enough, can lead to a build-up of carbon dioxide, which can be deadly.  Breathing too much, can lead to a depletion of carbon dioxide - not deadly, but certainly causes a variety of worrisome symptoms.

​Too much of a good thing
Most of my patients are often surprised when I tell them that you can breathe too much.  Especially given the buzz around the "need to take deep breaths" these days.  I would say that 90% of the people that seek treatment for breathing disorders breathe too much, not too little.

Now as I said, over-breathing causes a drop in carbon dioxide.  I often explain to my patients that they are breathing like they are running, when in fact, they are just sitting in a chair.  This drop in carbon dioxide sets off a whole host of chemical disruptions in the body.  This chemical imbalance will pave the way for heightened sensitivities in nerves and muscles.   This can mean that stimuli that would not normally be painful, are interpreted as pain.  We also get an increased susceptibility to muscle spasms and muscle fatigue.  

What the research says
Physiotherapy is very much an evidence-based profession.  This essentially means we have to have research to back up what we say and do.  And since there is SO much attention being paid to breathing these days (especially on the internet!), it's important we look at what the evidence says with regards to breathing and pain.

In 2013, Dimitriadis et al, published a study in the American Journal of Physical Medicine & Rehabilitation titled "Hypocapnia in patients with chronic neck pain."  Hypocapnia refers to low blood carbon dioxide levels, such as what happens when we over-breathe.  They looked at 45 patients with chronic neck pain and found they had significantly reduced carbon dioxide levels compared to a similar group of healthy normals, and this correlated with pain intensity and neck muscle weakness.  Incidentally, these same researchers also found that participants with chronic neck pain also had reduced respiratory (breathing) muscle strength.

In 2010, Canadian physiotherapist Laurie McLaughlin along with her co-authors published a study in Manual Therapy that looked at 29 patients with neck or back pain that had plateaued with manual therapy and exercise.  They found that all of the 29 patients had below normal carbon dioxide levels on initial testing.  They also found that after an intervention of breathing retraining, their breathing and function improved, and pain was reduced.

A very interesting article in the medical journal Pain by Jafari et al in 2017, reviewed the research studies that investigated the relationship of breathing and pain. They found that acute pain tended to cause hyperventilation, which may provide a bit of an analgesic affect (as the body sets up for fight or flight), but that in chronic pain, hyperventilation was likely more a hinderance.  The authors also found that breathing has an influence on pain, although this remains poorly understood.  Slow deep breathing has shown to be clinically effective in helping to decrease pain, although the reasons behind this are still not clear.  We will have to keep an eye on this area of research, as it seems to be an up and coming area of interest.

The endless loop
So we see that pain can cause faulty breathing, and faulty breathing can contribute to pain.  Often, this becomes an endless loop...we experience acute pain and hyperventilate.  The pain does not subside immediately and the over-breathing strategy continues...until it becomes habit.  At this point, it now starts to reinforce breathing patterns...and round and round we go.

Recognition of poor breathing behaviours and their influence on pain can be crucial to helping break this endless loop.  If you are experiencing pain, notice your own breathing.  Is it up high in your chest?  Are you breathing faster than 10 breaths per minute?  If so, and you haven't addressed breathing patterns before, maybe now is the time to consider it.  

Until next time, breathe well, move well....be well!

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