My thoughts on breathing...
A bit more information as it occurs to me about how breathing impacts your health and well-being. If you have questions or want me to address a particular topic, please don't hesitate to contact me!
Today's blog augments my social media posts this week on chronic cough. I mean, now is definitely not the time to be dealing with chronic cough, am I right? With the coronavirus pandemic having us all just a bit twitchy about every scratchy throat, runny nose and cough, dealing with chronic cough can be even more stressful (which ironically can make your cough worse!). So today we're going to talk about the role of reflux - and more specifically "silent reflux," in the role of chronic cough.
What is Silent Reflux?
The medical term used is laryngopharyngeal reflux (say that 3 times fast!) or LPR. It occurs when the stomach contents flow back up in the the larynx and pharynx (so the back of the throat and mouth). The symptoms are different than traditional GERD (gastroesophageal reflux disease - which is heartburn and regurgitation); LPR symptoms usually involve symptoms in the throat - cough, sore throat, voice issues like hoarseness and difficulty talking loudly and the sensation that something is in the throat (usually lots of throat clearing).
Treating LPR/Silent Reflux
Many patients who come to me for treatment of chronic cough are on, or have been on anti-reflux medications - usually proton-pump inhibitors (PPI's) like Prevacid, Protonix or Dexilant. However, studies show that PPI's are ineffective at treating LPR, and indeed, are ineffective at treating chronic cough. PPI's are meant for treating GERD, not LPR which is why they don't seem to have an effect. And cough is more associated with LPR than GERD. My first choices in dealing with suspected LPR are diet and diaphragm strengthening.
Diet: Often it is acidic and spicy foods that will contribute to worsening symptoms of LPR. I usually give people a list of foods (like this one) that highlight those associated with increased reflux, have them check it and compare it to their usual diet. If they tend to eat a lot of the "reflux causing" foods, I will ask them to reduce those foods for a couple of weeks. If their cough symptoms improve, then we can start suspecting diet/LPR as a factor and figure out a plan from there. If there has been no change in symptoms, then we continue to look for other causes.
Diaphragm: the Lower Esophageal Sphincter (basically the gate keeper between the stomach and the esophagus) is located within the diaphragm muscle. Its job is to keep stomach contents from coming back up the esophagus. Studies have shown that dysfunction of this sphincter can lead to LPR. Studies have also shown that the diaphragm can directly impact this. Strengthening the diaphragm via inspiratory muscle training has shown to reduce LPR. Inspiratory muscle training can also have a positive impact on the muscle function of the upper airway (larynx), which can also be beneficial for chronic cough.
If you want a bit more science on LPR and treatments, I encourage to read this helpful review. This blog is by no means comprehensive for treating LPR, nor chronic cough, but merely addr
I spoke with David Bidler from the Distance Project and Breathe to Perform about all things breathing and the impact of COVID-19 on our appreciation of health. We recorded the session and it's available to view on YouTube. Check it out!
It’s the start of a new year — a new decade. It’s often a time of renewed energy and resolutions. Exercise and lifestyle changes are at the top of many of those lists. Most of us know that “exercise is medicine”. Yet somehow it is so hard to regularly take that medicine. Habits, mindset, time and so many other facts of life can hamper momentum forward. Add to the mix chronic disease, acute illness or injury and the path towards your goals seems even more complex. It can be hard to know where to start and what works for you and your unique health scenario.
Have you ever heard of health coaching?
Health coaching is a style of treatment and therapeutic communication that helps patients gain the knowledge, skills, tools and confidence to become active participants in their care, so that they can reach their self-identified health goals. Self-management supports an active role for patients with chronic conditions by enabling patients to learn to manage their symptoms, maintain independence, and achieve a better quality of life. Health coaching has been shown to improve patients’ physical and mental health.
Health coaching with a physiotherapist will see you have focused discussions on what matters most to you, what motivates you and why you are seeking change. As the patient you bring the expertise in “you". As physiotherapists we bring the expertise in cardiorespiratory, musculoskeletal, and neurological conditions, in therapeutic exercise, in strength and conditioning, and in behaviour and habit change. Here at Breathe Well Physiotherapy, we have particular expertise in all things breathing. We are here to guide you towards the goals that you have identified. And if your goals are still a bit fuzzy, we are here to help you refine that vision. Health coaching is a process in change. Chronic conditions, like COPD, lung disease, arthritis and many others, are not going to be “cured” so the focus shifts to influencing the factors that can be modified. Exercise, lifestyle, mindset, beliefs and understanding about our health can have powerful impacts on improving physical and mental wellness. Sustainable change does not happen overnight and often has many hiccups along the way. When a strong therapeutic relationship is at the core, you are more likely to learn how to overcome those hiccups and continue forward towards what matters most to you.
At Breathe Well Physiotherapy, we believe that empowering our patients to breathe well, move well and live well is the most meaningful work we can do.
Time for another installment of "What's breathing got to do with it?" This time we are talking about sleep, because, as it turns out, breathing and sleep are pretty intricately related. Today we will look at a few ways that poor breathing patterns might be impacting your quality of sleep.
Getting to sleep
Do you climb into bed each night, only to lie there staring at the ceiling, wondering when sleep will come? A lot of patients that I see report having difficulty falling asleep. These patients also tend to have a more stimulating breathing pattern: rapid and dominated by upper chest movement. This type of breathing tends to keep the body in a hyper-aroused state - it's ready for anything, anytime. Indeed, research has shown that patients with insomnia have increased brain activity, abnormal hormone secretion, elevated heart rate and sympathetic nervous system arousal when they do sleep. It's as if their bodies don't know how to turn off.
This is where breathing retraining comes in. Learning how to engage in a slower, more effortless breathing pattern, can help to activate our parasympathetic nervous system. This the "rest and digest" part of our autonomic (automatic) nervous system, and helps to put the brakes on the flight or fight side. Those of us who try to cram as many things into the day as possible, running from one activity to the next, dealing with stressful work situations, spouses, kids, etc may not remember what it feels like to turn off, tune out and relax. Learning how to let go as well as using mindfulness to help deactivate the stress response is key to getting the body better prepared for transitioning to sleep. I've had many clients report that they ended up falling asleep practicing finding calm- and that wasn't even the intended goal!
Breathing During Sleep
During normal sleep stages, several changes occur to our breathing. As we transition into sleep, there is a decrease in signals to the muscles of the chest and upper airways. This results in increased resistance in the upper airways and less activation of the chest muscles. During the next transition into REM sleep, all of the skeletal muscles of the body become atonic - meaning they relax nearly completely. The theory behind this being that we do not then act out our dreams. During this time, breathing is critically dependent on the function of the diaphragm, as it will often have an increase in activity. For most individuals, these changes to breathing patterns at night do not pose a problem. However, for anyone that has altered breathing patterns due to diaphragm weakness, this can lead to sleep disorders. Diaphragm weakness is seen in a number of situations:
Treatment for Sleep Disordered Breathing
The gold standard for addressing sleep apnea is continuous positive airway pressure - or CPAP. Essentially a machine will deliver a constant stream of air through the mouth or nose at night to ensure that the airways do not collapse and cause a stoppage in breathing. In addition, lifestyle changes such as weight loss and sleep hygiene are encouraged.
What is also showing some promise in the treatment of sleep apnea, is inspiratory muscle training (IMT). IMT strengthens the diaphragm, and studies are showing that IMT can decrease snoring, improve sleep quality and decrease blood pressure issues related to sleep apnea. IMT is non-invasive, inexpensive and relatively easy to perform and should be considered to help treat sleep apnea.
In addition to strengthening the diaphragm, there has also been some interesting results using didgeridoo playing as a way to tone the muscles of the upper airways. One ear, nose and throat doctor in the UK advocates the use of these exercises to help tone the throat muscles to help reduce snoring. Another study suggests that singing might just do the same!
If you are concerned about your sleep quality, feel free to drop us a line to discuss what kind of treatment options we have here at Breathe Well Physio. We can help you turn off the fight or flight response to help you transition to sleep if you struggle to fall asleep. We can also get you started with an IMT program to strengthen your diaphragm to get you through all sleep phases. And if the problem is your upper airway function, we even offer voice exercises from a professional voice teacher to help tone those muscles to reduce snoring and sleep disruptions!
Well I suppose that seems like an obvious title. Of course breathing has everything to do with asthma, but today we are going to look at it from a slightly different perspective. We'll think outside the lung so to speak, although first we need to just quickly review what asthma is and why it makes breathing difficult.
What is Asthma?
Asthma is classified as a chronic disease that affects the airways or breathing tubes. With asthma, the airways tend to be more sensitive to things like air pollution, cold, viruses and sometimes exercise. Airways become inflamed and swollen, and the muscles around them also contract, making it harder to breathe - think of trying to drink a thick milkshake through a very tiny straw instead of a fat one.
Symptoms of asthma include shortness of breath, wheezing (noisy breathing), coughing and tightness in the chest.
When triggered, the increased struggle to breathe can lead to feelings of anxiety and panic - which makes sense, since for our brain, breathing is the number one thing it tries to preserve on a daily basis.
Why Think Outside the Lung?
So the good news about asthma, is that it responds quite well to medications and therfore is labelled as "reversible." This does not mean that medications cure asthma, simply that they can help control the inflammation and make breathing easier. However for some people, despite having optimal medication therapy, symptoms of breathlessness persist. And in these instances, we need to think outside the lung to understand why.
When breathing is difficult - whether due to asthma, or maybe heavy exercise or sometimes even from a really bad cold - our body calls upon our helper, or accessory, muscles of breathing. These muscles are located in the chest, neck and shoulder region and help to lift up the ribs and breastbone to allow for more enter the lungs. At this point, we may also switch to mouth breathing as it offers up less resistance to breathing. You can try this on yourself to see: put one hand on your chest and one on your belly and breathe normally through your nose. Now open your mouth and take a slightly bigger breath. You will notice that your breathing has less resistance and your chest moves more than with your mouth closed. When breathing is more laboured, this mouth-chest breathing pattern is a good response to have.
The problem arises when this emergency response breathing pattern becomes the new normal. This can happen in people with asthma. Studies (see references below) have shown that breathing dysfunction is common in persons with asthma, and that sub-optimal breathing patterns are associated with decreased perceived asthma control.
The reasons behind changing breathing patterns are many, but the important point is that most dysfunctional breathing patterns are learned. Here is an example of how the body learns: let's say Mary has asthma. When Mary's asthma is triggered, she feels anxious and short of breath. When she takes her medication, her symptoms are relieved.
However, Mary goes to work, she has a manager that she doesn't get along with. Often, interactions with her manager leave Mary feeling quite anxious and short of breath. When she feels this way, Mary takes her asthma medication because she feels like it could be her asthma. Only the medications don't seem to help. She returns to her doctor for more testing because her asthma symptoms are worsening. The testing shows her lungs are not any worse, despite her increase in breathlessness.
This is a common scenario in my practice. What has happened is that Mary's stress and anxiety from work triggers a similar response to asthma. Poor breathing patterns can often mimic asthma symptoms, yet because the problem is not airway inflammation, medications don't often help. Sometimes, being anxious and changing your breathing pattern (generally, anxiety causes a faster, shallow breathing pattern) may actually trigger asthma too, so it can become a bit confusing.
How Physiotherapy Can Help
So what is someone like Mary to do, if the testing shows her lungs are not any worse, yet her symptoms are?
Accessing treatment by a physiotherapist trained in treating breathing disorders may be a step in the right direction. Here at Breathe Well Physio, we become "breathing detectives" to find out what is causing the symptoms. We look at breathing patterns and breathing chemistry, we factor in things like stress, anxiety and sleep and we also look at how you move (you'd be surprised at how many people come through our doors that hold their breath every time they move!).
There is plenty of evidence to support the use of breathing retraining as a way to improve asthma control (again, see the references listed below). Learning optimal breathing strategies and incorporating them into everyday functional activities is essential in helping to control asthma. For Mary, a big component would be recognizing the difference between asthma and stress-related breathing dysfuntion. We may not be able to do anything about Mary's manager, but we can teach Mary to recognize her physical symptoms and use strategies to help settle them.
I must point out at this point, breathing retraining is not meant as a "cure" for asthma - and I would advise anyone with asthma to be very wary of any product or method that claims to cure asthma. Breathing retraining is an adjunct to medical therapy and is not a replacement. It is also very important, given that statistics show nearly 30% of asthma diagnoses are actually misdiagnosed, that if you have been told you have asthma, be sure this is confirmed with appropriate lung testing. Simply being out of breath when exposed to environmental allergens or exercise is not enough to confirm asthma.
If you are wondering if you can get better control of your asthma or have concerns about your breathing, be sure to check in with us here at Breathe Well Physio and we would be happy to discuss it with you. Until next time...breathe well, move well ...BE WELL!
Mike Thomas, R K McKinley, Elaine Freeman, Chris Foy. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. BMJ VOLUME 322 5 MAY 2001 bmj.com
Jane Upton et al. Correlation between Perceived Asthma Control and Thoraco-Abdominal Asynchrony in Primary Care Patients Diagnosed with Asthma. Journal of Asthma, 2012; 49(8): 822–829
Eirini Grammatopoulou et al. The Effect of Physiotherapy-Based Breathing Retraining on Asthma Control. Journal of Asthma, 48:593–601, 2011
Elizabeth A Holloway, Robert J West. Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial. Thorax 2007;62:1039–1042. doi: 10.1136/thx.2006.076430
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!
Welcome to the second instalment of "What's breathing got to do with it?" As I mentioned in the first post on this topic, breathing is much more complicated than we might think, and disruptions in breathing have impacts that are far reaching (read: it doesn't just create shortness of breath). Today we will discuss how breathing and low back pain are connected.
When it all began...
Ok, so we might not be able to pinpoint exactly when we starting linking breathing and low back pain, but the Smith/Russell/Hodges study that came out of Australia in 2006 sure gave us some ammunition to investigate further. Their longitudinal study of over 38,000 women found that "middle aged and older women had higher odds of having low back pain when they experienced breathing difficulties." Hodges (2000) had previously found that the diaphragm - thought to be only a breathing muscle - demonstrated recruitment behaviours that suggested it had a role in postural stability, so this perhaps led him down the path to search for more connections.
Breathing affects movement
Due to that ground-breaking study showing the diaphragm played a role in postural stability, there have been numerous studies since that suggest altered breathing patterns affect how we move. Belgian physiotherapist Lotte Janssens discovered that when the respiratory muscles (diaphragm and rib muscles) fatigue, they cause an otherwise healthy individual to have a balance strategy similar to someone with low back pain. It should be noted that persons with low back pain have a less than optimal balance strategy - relying on muscles in their feet and ankles to keep them upright when jostled, as opposed to healthy individuals who will use their back and abdominal muscles. Janssens further discovered that the respiratory muscles fatigued faster in those people with low back pain. Noted Czech physiotherapist Pavel Kolar discovered that individuals with low back pain had an altered position of their diaphragm, which may affect the muscles' ability to behave in a coordinted fashion.
Which came first...the chicken or the egg?
These kind of discoveries always lead us down the path of trying to discover, which came first - low back pain or breathing dysfunction? Sometimes, there may be clues in the history - maybe someone had battled severe asthma all their life, maybe there was an incidence of of increased stress and anxiety, or maybe it was a prolonged illness that disrupted breathing patterns and therefore core strategies, leaving the individual vulnerable to back pain. Sometimes we may find it was the other way around - that quick twist or bend that resulted in acute, sharp back pain. Usually that kind of pain causes us to breathe in quickly and hold it, often bracing our abdominal muscles for protection. When this bracing pattern is adopted for a prolonged period, it can become habitual, leading to shallow breathing, which as you will learn below, disrupts normal muscle function.
How should our muscles work together?
The best way to understand how our muscles work, is to consider what muscles actually make up our "core." We previously considered this to be just our transversus abdominus (TA - deep abdominal) muscle, but we've since discovered, that just like breathing, our core is much more complicated. Having good spine and trunk support means we need to have a balanced effort between many muscles - the major players being the diaphragm, the pelvic floor muscles, the TA and a deep back muscle called multifidus. When these muscles work as a team - we are unstoppable! Okay, maybe not unstoppable, but we should at least be in a better position to reduce injuries. The team works together like an internal elevator: when we breathe in, the diaphragm will contract and flatten out into the abdominal cavity, pushing our organs towards the pelvis. In a balanced situation, the abdominal muscles and pelvic floor muscles will lengthen to decrease the pressure the movement of the diaphragm would cause. When we exhale, the diaphragm relaxes and moves upward and the pelvic floor and TA will experience a recoiling effect (a really small contraction) and the organs are moved back up (we will talk more about how this affects digestion in a later post!). This up/down motion of the diaphragm and pelvic floor usually created an efficient, balanced movement strategy. The amount of movment and recruitment of these muscles will depend on our activity level - but it is important to note that this strategy should be employed with most movement (heavy lifts will require a slightly altered strategy but the underlying teamwork must still be balanced).
How does it go wrong?
So what might happen to break up the team? An obvious answer would be injury - because despite how much we work on having optimal muscle recruitment, things happen. And when we experience pain, our breathing patterns often change. Think about the time you banged your shin on a hard surface - ouch! There is that quick indrawing of breath, the breath hold, then the slightly laboured breathing as your whole body tenses from the pain. Luckily, the acute pain in our shin usually dies down after a few minutes, but in other situations, we may experience pain for a prolonged period. That shallow breathing pattern may become habit.
I often see that same type of breathing pattern in my patients with asthma. Having a real struggle for breath can often lead to a situation where the body is constantly in "red alert" breathing mode. Fast, upper chest breathing means the diaphragm may not be going through it's full range of motion. And because the pelvic floor and TA muscles need that downward motion of the organs to go through their range of motion, their strength and recruitment may be affected by upper chest breathing. This means your core strategies are less than optimal and can put you at risk for injury. In this scenario, I often feel that breathing disorder came before the back pain.
One last influence on both breathing and back pain, is stress. This becomes a topic in itself (which we will cover in a later post), but suffice it to say, that stress will often disrupt breathing patterns, leaving you in "red alert mode" which not only affects your breathing pattern, but also increases your sensitivity to painful stimuli - this part we will address in the next post.
What can you do?
When breathing patterns and core muscle recruitment strategies are disrupted, the key is to go back to the basics and start from there. Breathing is the foundation for good health, so restoring normal, relaxed breathing patterns are key to optimizing core and movement strategies. Without addressing breathing, it would be like trying to build a house on a foundation of sand - eventually the waves of movement would erode that foundation leaving you with a host of problems.
For a few tips on how to re-establish better breathing patterns, you can check my previous blog post here. Keep in mind that if you have developed a history of upper chest, faster breathing, restoring diaphragm breathing does not happen overnight. Think about how hard it is to break a habit or start a new one (think New Year's Resolutions!). Sometimes, you may need a little outside assistance with re-learning diaphragm breathing - just as someone with suboptimal running or walking form would have to re-learn. This is where physiotherapists with training in assessing and treating breathing patterns come in! Check out www.bradcliff.com for practitioners near you. For those who don't have someone near them, Breathe Well Physio offers on-line consults as well - drop me a line and we can see what we can do for you!
Welcome to the first installment of a new regular feature called "What's breathing got to do with it?" Over the next few weeks I'll attempt to make some connections to help pave the way to understanding just how important breathing well is. We will link poor breathing patterns to a number of conditions in which you may not have considered breathing to be a factor, such as jaw disorders, low back pain and anxiety. You'll gain better awareness of your own breathing pattern and nagging symptoms and I'll give you a few tips to help improve your breathing.
I shouldn't have to think about breathing...
Despite being an automatic function, breathing is easily disrupted by illness, injury and emotions. Breathing is not merely just about charging the blood with oxygen and clearing the body of carbon dioxide, but it is an intricate series of inputs from many areas of the body, including muscles in the limbs, stretch receptors in the chest wall and lungs as well as our own voluntary requirements (talking, blowing up a balloon, etc).
I like to emphasize that breathing is also a movement pattern - just as walking or lifting are movement patterns. And just like walking or lifting, we can sometimes (often subconsciously) choose a less effective way of moving that leads to problems. The good news is that a disrupted breathing pattern is not a disease. It can cause troubling symptoms, but it's not life threatening. It takes a bit of work to retrain breathing patterns, but it's not impossible to restore normal, functional breathing.
Stay tuned for more installments of "What's breathing got to do with it?" to find out what breathing does indeed have to do with good health (or poor health, as it may be). In the meantime, if you have pressing issues about your own breathing, please feel free to connect with me!
This month I have a guest blogger...Dr. Rachel Goldenberg, who I will be joining forces with to provide a program of combined physical therapy and singing for better lung health (more info here). Dr. Goldenberg is a professional voice teacher, with a special interest in using singing as a platform for improved lung health. Dr, Goldenberg has recently published a literature review on singing lessons for respiratory health in the Journal of voice (click here to view). I'm thrilled to be working with Rachel and hope you enjoy her blog!
Singing for Better Respiratory Health!
by Rachel Goldenberg, D.M.A.
At first, singing seems simple, something that’s fun, makes you happy and distracts you from the daily grind. However, as a random nurse practitioner I met at my very first medical conference exclaimed: “Of course! You’re going to teach us how to breathe!”
I’ve found that although singing is indeed a happy, fun and energizing activity that distracts and heals you, it is also a useful physical therapy. Below, I share some of my most frequently asked questions:
1. Why sing?
Singing is the product of many interactions between the physical (the brain, ear, breath, larynx and articulators,) and the creative (musical notes, rhythm, instrumentation and poetry.) When we sing, the breath passes through the larynx to create sound waves. These sound waves are then filtered in the vocal tract to produce vowels, while the articulators such as the jaw, tongue and lips make consonants. When we breathe in a mindful way to facilitate all these interactions, we develop a useful skill for people with compromised respiratory systems. Understanding the connection between body and breath through the physicality of singing and the rhythm and notes of the music enhances your physical and emotional wellbeing.
2. How is breathing for singing different from everyday breathing?
When the lungs change shape, the resulting internal negative pressure causes air to rush into them, like a vacuum. The lungs are attached to the ribcage and the diaphragm, so movement of either of these structures allows the breath to come in. Breathing when we are resting does not require much movement and generally relies on the natural elastic recoil of the lungs. Breathing for exercise and singing is much more active. When we inhale to sing, we allow the diaphragm to descend and the abdominal wall to relax. When we exhale, the abdominal wall (and pelvic floor) contracts, pushing the internal organs up against the relaxing diaphragm, in turn pushing the air out of the body. By using the large, strong abdominal muscles to move the air, we control the exhalation and are better able to meet the demands of the music.
3. How is breathing for singing different than the breathing exercises I learn in physical therapy?
There are many areas of overlap, which is why an integrated program of physical therapy and singing classes is helpful for respiratory patients. Breathing exercises are part of most singers’ practice regimes. We reinforce these concepts about breathing by applying them to the task of singing a song. Because you are subject to the demands of the music, you may either have a long time to consider your breath between phrases or you may have to inhale quickly. You may also have to exhale for a long time and vary the amount of breath pressure you use (higher and louder notes require more pressure). Either way, you give your breathing apparatus a workout you can’t find elsewhere. I’d also like to think that singing is fun and more interesting than simply doing breathing exercises.
4. What are the other benefits to singing besides learning to breathe?
There has been a marked increase of research about the use of singing for respiratory diseases and ailments. One of the most commonly reported physical benefits is an increase in maximum expiratory pressure, likely the result of strengthened breathing muscles. Study participants also report increases in breath control and reduced breathlessness. They feel more confident and aware of their body, and find singing to be an enjoyable activity with few risks and little cost. They enjoy the socialization with other singers and the singing teacher. The overall quality of the voice, particularly speech, also improves, enhancing the ability to communicate effectively.
5. I’d really like to try singing, but I have the worst voice in the world. In fact, my choir director in elementary school told me to lip synch at the concert.
This isn’t a question but it’s something I hear ALL THE TIME and it’s unfortunate these kinds of experiences hold people back from enjoying singing later in life. Singing is a physical coordination between the brain, ear, breath, larynx and articulators. Usually, people are only legitimately tone deaf if there is a physical disruption in one of these elements (but I’m not going to let breathing be your excuse because I have lots of tools to work around that one!) Even if you don’t have the most beautiful voice in the world, that doesn’t mean it isn’t worthy of being heard. My goal is not to have you sing on the stage of the Metropolitan Opera (unless you want to) but to help you develop an instrument with which you can express yourself. Most voice teachers have stories of students who can’t sing a note in tune at first but with efforts on both sides, they overcome this challenge. It’s usually a matter of ironing out the coordination.
6. What types of music will we sing and will I have to sing publicly?
In our group singing class for respiratory patients, we begin each hour-long session with physical and vocal warm ups, including breathing exercises. Then, we’ll sing all kinds of songs, usually in English to help you develop your instrument. Some songs will be familiar popular tunes, while others will be new. I am always open to suggestions. We’ll conclude each session with a short cool down. As for public performance, this is a group class so you’ll likely sing in front of each other at some point. However, most of the time, we will be singing together. If you’re feeling particularly confident, we can discuss performing opportunities.
If you have further questions about the program, please reach out to either Jessica or myself. I look forward to hearing from you!
On my last blog, we looked at the research that linked breathing patterns and asthma, and how addressing faulty patterns can be beneficial. For part 2, I'm offering up some tips based on the work I do with people with asthma. I generally follow the guidelines of the BradCliff Method of breathing retraining, an evidence-based program to restore normal breathing patterns and decrease symptoms related to dysfunctional breathing.
1. Use your nose:
The nose is essential for good respiratory health. It cleans, warms and- most importantly for Calgary-humidifies the air we breathe. The airways of the lungs do not particularly like cold, dry, dirty air and so breathing through your mouth can lead to increased irritation of the airways. The nose also helps facilitate diaphragm breathing, as the resistance created by the smaller passages (as opposed to the mouth) help to recruit the diaphragm in breathing. Try this yourself: put one hand on your chest and one on your belly. Take a few breaths through your nose; then open your mouth and breathe through your mouth. You probably noticed that when you opened your mouth, your hand on your chest moved much more than when you breathed through your nose. If you have been predominantly a mouth breather, then breathing through your nose will at first feel like you are not getting enough air. But the more you practice, the easier it gets, and the more clear your nose will feel. If you have significant nasal congestion, it is worth having it investigated to make sure there are no underlying issues (allergies, polyps) that are impeding nose breathing. For those with recurrent nasal congestion, daily sinus rinses can help.
2. Use your diaphragm:
I recently completed a study looking at breathing patterns in kids with asthma and found that 83% of participants used their neck and chest muscles to breathe. Previous research has found that this type of breathing is more likely to contribute to shortness of breath. Normally the chest and neck muscles are meant to assist in breathing, such as during exercise. At rest, the diaphragm is the main breathing muscle. However, mouth breathing, or prior difficulty breathing (such as happens in asthma), can alter breathing patterns so that chest/neck muscle breathing becomes the new normal. Restoring diaphragm breathing and decreasing the amount of chest/neck muscle use may help alleviate symptoms of shortness of breath. For tips on how to restore diaphragm breathing, check out breathe-to-movetips-for-breathing-better-during-activity.html I have also had a lot of success using an inspiratory muscle trainer such as the POWERbreathe Plus to restore and strengthen diaphragm breathing. This can be helpful for a wide range of conditions like asthma, vocal cord dysfunction, and even improving sport performance.
3. When in doubt breathe out:
Asthma is classified as an obstructive disease. This means that it is more difficult to get the air out and air can get trapped in the lungs. When this happens it makes it harder to breathe in – think of a balloon that is almost filled up and how hard it is to get the last bit in. Your lungs work the same way; when they get filled up, the muscles have to work very hard to get air in. When breathing is hard, it can leave you feeling panicked. If you find this happening, try to breathe out through pursed lips (like a silent whistle) to help you empty the air out. You will find that it is easier for the next breath to come in. It helps to practice blowing out when you don’t feel distressed by blowing a toy windmill, or holding a tissue in front of your face and gently blowing it for as long as you can. Learning to breathe out in a controlled fashion and to the end of exhale helps to train your body into recognizing not only what a complete exhale feels like, but that it is okay to do that. This becomes especially important for activity, where breath stacking (breathing in before completely breathing out) can lead to premature shortness of breath and stoppage of activity.
Asthma medications have come a long way, and are absolutely vital in good asthma management. But we must not forget to "think outside the lung" and include things like good breathing awareness and optimal breathing patterns to ensure that those with asthma can continue to function at their desired level. If you have concerns about your own breathing, be sure to seek out a health professional trained in recognizing dysfunctional breathing. You can find a BradCliff Method trained therapist by clicking on this link, and selecting find a clinic.
I'm a physiotherapist who is passionate about educating anyone and everyone about the impact breathing has on our health.