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. 

What's Next?
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.

 One of my most frequent referrals from respiratory professionals is for helping people get better control of their asthma.  These people are often well controlled medically - meaning the medication they are on significantly improves their lung function - but they still struggle with symptoms of shortness of breath.  Often this occurs when they are exerting themselves - either during exercise or during normal activities of daily living (stairs!).  At first, it doesn't seem to make sense to them - if the asthma medication is working, why do I feel so bad?  The answer is that we have to "think outside the lung," and consider what else might be going on to contribute to symptoms.  Both scientific research and clinical evidence indicate that the WAY you breathe when you have asthma, impacts HOW you feel.

What the research says:

• Thomas et al (2001) found that nearly one third of women and one fifth of men with asthma have symptoms suggestive of dysfunctional breathing
• Agache et al (2012) found that of those with asthma and symptoms of dysfunctional breathing, 17% exhibited dysfunctional breathing during exercise testing
• Grammatopoulou et al (2011) found that physiotherapy-based breathing retraining improved asthma control 

Clinical Evidence:

• In my practice, many kids and adolescents are being referred for symptoms that are not in line with their lung function.  These individuals frequently exhibit mouth breathing, accessory (neck and chest) muscle use and increased breathing rates
• Many people that come in are simply breathing inappropriately for their body's needs, resulting in troubling symptoms that includes shortness of breath
• Typically a few weeks of working on breathing awareness, breathing pattern retraining and integration of core stability and breathing strategies will produce a significant change in symptoms

To the point...

• It is important for asthma to be medically managed so talk to your doctor or respiratory educator to make sure you have an accurate diagnosis and are on the right medication for you
• While medications are critically important in managing airway inflammation and constriction, they aren't able to change the impact of poor breathing patterns
• If you have asthma, and continue to struggle with shortness of breath, despite good medical management, consider getting a breathing assessment to determine if your breathing pattern is limiting your quality of life

Check back in a few weeks for Part 2, where I will discuss some tips for breathing better with asthma.

​Do you find yourself sighing frequently?  Feel like you can’t take a deep enough breath?  Or maybe you feel breathless with exercise before or more than you should.  These are signs that you may have a breathing pattern disorder.

I don’t have lung disease, how can breathing go wrong?
​
Although it may seem simple, breathing is actually very complex.  The breathing centre in the brain receives input from various places in the body – from stretch receptors in the lungs (giving feedback on the amount of inflation), to chemical (oxygen and carbon dioxide) receptors in the brain and arteries, to muscle receptors in the chest wall and body.

 We also have voluntary input (like blowing up a balloon) and emotional inputs (laughing, crying) that will determine what kind of breathing pattern we have.

Just like many things in the new high tech world (like say, washing machines), the more complex something is, the more opportunities there are for things to go wrong.

What is a breathing pattern disorder?

Like breathing itself, breathing pattern disorders are complex.  They can rarely be narrowed down to one thing, and often involve multiple factors.  They may have musculoskeletal implications – like poor posture or a chronic injury that changes how you use muscles involved in breathing.  They may have a psychological basis, where fear of breathing (or not breathing) impacts how you breathe.  Or there may be some respiratory factors involved, like asthma, that affect your breathing pattern - which in turn affects your symptoms.

Probably the most basic and inclusive definition to use for breathing pattern disorders is breathing inappropriately for your body’s requirements, which lead to persistent, troubling symptoms.

How would I know if I have a breathing pattern disorder?

Breathing pattern disorders aren’t easily identifiable – it’s not like, say, breaking a wrist or spraining an ankle, where the diagnosis is easy to come by.   Often, clients come to me after going through exhaustive testing with still no answer to their problems.   The following is a list of symptoms that often accompany breathing pattern disorders:

• headaches
• breathlessness
• palpitations
• light headedness
• tingling or numb lips or extremities
• upset stomach or irritable bowel syndrome
• achy muscles or joints
• tiredness, weakness, broken sleep and nightmares
• dry throat, frequent swallowing
• anxiety
• unexplained pain

 
Are you checking “yes” on  a few of those?  Why not see how your breathing is yourself: place one hand on your chest and one on your belly.  Observe your breathing for one minute.  You should notice that a) you are breathing through your nose, b) your hand on your belly moves first and the most, c) your breathing rate is between 8-12 breaths per minute and d) your breathing is quiet and easy. 

Ok, so my breathing isn’t great….now what?

A comprehensive breathing assessment that looks at how you are breathing – including muscle use and strength, posture, core stability and respiratory chemistry – will provide you with information on whether your breathing pattern is contributing to your symptoms.

From there, a treatment plan is developed to help you reach your goal.  Learning to breathe well is like learning a new skill.  It requires awareness, practice and small, simple steps to reach the long term goal.  Contrary to what many people think, it’s not about “deep breathing” or even just “belly breathing.”  Breathing well is a complex interaction between varying levels of breathing requirements (lying down is different from standing, which is different from walking) and varying levels of movement tasks (walking, versus running, versus reaching for your groceries out of the car). 

The BradCliff Method of breathing retraining is an evidence-based physiotherapy intervention that incorporates all dimensions of breathing inputs and resulting outputs.   Its primary goals are to improve awareness of abnormal breathing habits and restore efficient breathing patterns.  Practitioners provide you with resources and techniques to help guide you through the process of changing your breathing from “uh-oh” to “oh wow!”

As a physiotherapy intervention, most insurance companies will cover assessments and treatments.  And while it may take a few months to correct a dysfunctional breathing pattern, sessions are spread out. 

If you have concerns about your breathing, or maybe have some of the symptoms listed above, but have not found a reasonable solution, book in for a breathing assessment.   As a certified BradCliff Method practitioner, my goal is getting you to breathe well, move well and ultimately, be well.

Just this past weekend, I had a few keen individuals attend a Breathing Matters workshop, where they learned about how to breathe better at rest and during activity.  It seems that breathing has become the topic of interest these days (which is great) and there is a lot of advice out there about how to breathe better (which isn't always so great).  My background as a physiotherapist means that I have to be up to date with the most recent research and evidence to support the techniques and education I give individuals about breathing.  

And so, just a few days after the workshop, I came across this article at Women's Running discussing tips for breathing better during running.  While it's great that people are realizing the importance of breathing well during activity, I've got a few tweaks to the tips.

1. Rib Mobility
During normal quiet breathing, the diaphragm does 95% of the work on inhalation.  Exhalation is passive due to the elastic recoil of the lungs and intercostal (rib) muscles.  This means that at rest, we should really only see the lower parts of the ribs expand depicted in the second image below:

​If, when you breathe, you notice your chest lifting - or worse yet, your shoulders lifting, then you are likely using more of your accessory (neck) muscle to breathe. Which then bring about a bit of a chicken-or-the-egg conodrum - are you breathing using your neck muscles because your lower ribs are tight, or are your lower ribs tight and therefore you are breathing upwards?  Regardless, if you want to be a better diaphragm breather, you need to make sure you have good lower rib mobility.  Here are two exercises to help encourage better rib mobility during breathing: 

2.  Diaphragm Breathing

Now that you have loosened up those ribs, it's time to start breathing into them, using the star of the show, the diaphragm.  There are a couple of ways that you can learn how to breathe using your diaphragm:

•  Beach Pose:  Lie on your back with a pillow under your knees.  Bring your arms behind your head, just like you were relaxing on the beach.  Place a small weight, like a wheat bag on your tummy.  Breathe in through your nose and feel your belly rise under the weight.  Exhale through your nose without effort; that is, let the air fall out rather than push the air out.
• Poolside Pose:  Lie on your stomach, head supported on your hands.  Feel your stomach in contact with the ground.  Breathe in gently through your nose and feel your body expand as your breath pushes your stomach into the ground.  The exhale should feel as if you are simply deflating, the weight of your body squeezing the air out.
• Theraband Breathing:  tie a piece of light elastic around your lower ribs.  Sit upright on your sit bones (not slouched back on your tailbone).  Breathe in through your nose and feel the elastic expand in all directions.  Allow the exhale to simply be the recoil of your ribs and lungs.  

​3.  Establish Breathing Rhythms
There is a lot of advice regarding synchronizing breathing to steps during activity.  Most of it involves inhaling for two steps and exhaling for two steps.  My experience, and that of my colleagues, has been that this type of breathing leads to "breath stacking."  Breath stacking occurs when an exhale is incomplete before the next inhale starts.  This leads to air gets trapping in the lungs.  Try this for yourself:  breathe in a normal breath, but then exhale only 75%, then breathe in a normal breath and breathe out only 75%.  The next breath is going to feel very restricted, shallow or even panicked.  Is this something you notice during activity?  If so, you may be breath stacking too.  To help eliminate this problem, try "asynchronous" breathing:  

• breathe in through your nose for two steps
• breathe out through your nose for three steps
• If you can't breathe out through your nose, try breathing through "pursed-lips" - like a silent whistle
• If a 2/3 ratio feels too fast, you can play around with a rhythm that works for you, maybe 3/4 or even 4/5
• You may need to slow your pace down at first until this feels comfortable
• Try placing your hands on your belly while walking and using the breathing rhythms to encourage a diaphragm breathing pattern

Work on these three tips for a few weeks and see what happens to your breathing.  Remember that changing a breathing pattern can sometimes take months - the body likes to keep doing what it's been doing, whether it's a good thing or not!  Breathing well is also not an easy task if you have had dysfunctional breathing patterns, so if you are having difficulty establishing relaxed breathing, let alone comfortable breathing patterns during activity, be sure to see a health professional with experience in treating breathing pattern disorders.

  Does this happen to you?  You are out for drinks with friends and a joke is told and suddenly it's not so funny because, well, because you leaked a little?  Or maybe you are like a friend of mine who said, no I don't really leak - except if I drink anything when I am running.  Or like most moms, who will NEVER get on a trampoline again.  Well, you are not alone.  Estimates are that one in six women over 30, and one in four women over 40 experience incontinence in one form or another.  But what you should realize, is that while leaking is common, it is NOT normal.
  Now there are a lot of factors that go into why women experience leaking, but perhaps the most common is that the muscles of the pelvic floor and core are not working well together.  Consider this study in 2007 by Smith et al, that found between three groups - continent, mildly incontinent and severely incontinent - the incontinent groups actually had stronger pelvic floor and abdominal muscles than the continent group.  However, the issue was the balance between these muscles:  the incontinent group's abdominal muscles where overpowering their pelvic floor muscles, whereas the continent group demonstrated a "balanced, effiecient and task appropriate system" (J. Wiebe, PT).
  We should also consider how alignment fits into the picture as well.  Alignment can change the availablility of a muscle; in a study by Sapsford et al in 2006, it was demonstrated that there was greater activation of the pelvic floor muscles as alignment improved.  In a later study those same researchers also found that continent women had a better lumbar curve, wherease those with incontinence were more likely to have a kyphosis.
  All interesting stuff, but how does that all fit together for someone who can't cough without peeing a little?  Well, when we take all of that into consideration, what happens when we improve alignment, re-establish muscle balance and connect both of those to functional tasks?  We see that we have set the core up for success.  We see less breath holding, less unwanted low back and pelvic movement and best of all less leaking during activity.
  My interest in retraining breathing patterns has naturally progressed into how the diaphragm works with the pelvic floor and core muscles to create efficient, funcional movement strategies.  I see often people with breathing difficulties who struggle with coordinating tasks of movement with breathing (that is, they hold their breath).  By restoring not only breathing patterns, but also the interaction of the diaphragm with the pelvic floor and core, we see an improvement in functional movement as well as symptoms of breathlessness.  
  And this is now taking me onto a new and exciting area of women's health.  By restoring the interactions of the breath, the core and pelvic floor, I can make a real change to women's quality of life and enable them to continue on with the activities they love.  For more information on how the pelvic floor and diaphragm work together, see my blog post here or visit www.juliewiebept.com which is a great resource for women.

In May, I'll be hosting a number of classes throughout the city titled Breathe, Stretch and Move (borrowed from a title of a book by my mentors, Tania Clifton-Smith and Dinah Bradley, founders of the BradCliff Method).  The class was born out of observations I was making clinically, which was that patients were having difficulty coordinating those three tasks.  They could breathe, although it wasn't a fantastic pattern (it was all upper chest and quite rapid).  They could move...but then they held their breath when they did.  And stretch?  Well, that was a problem too.  Maybe it's too much time in front of a computer, or hunched over in a car, or maybe because here in Calgary, we spend too much time huddled up against the cold (although admittedly this year was pretty tame, right?).  

Whatever the case, I noticed I was correcting breathing patterns but was having to spend a lot of time integrating those patterns into core stability strategies.  And in order to breathe easier and better, there was lots of attention to getting the upper back and ribs moving better, as restrictions in those areas makes it harder for the diaphragm to work.  And while treatment is very focused to each individual, there tended to be a pattern to what exercises I was giving.  And so Breathe, Stretch and Move incorporates the basic principles of better breathing - low, slow, diaphragmatic (belly ) breathing, with various movement patterns.  The stretching component will help with traditionally tight areas - like the chest muscles (the pecs), the low back area, the neck and upper back.  We will use breathing to help mobilize some of those areas so that we get the ribs moving easier.  The move component will incorporate progressive core stability strategies in a way that participants are still able to maintain efficient breathing strategies.  

What tends to happen with traditional core strengthening programs at the gym, is that in an effort to be exciting, they leave out the basic steps of engaging the deep core muscles.  The result is that people often "brace" or hold their breath and push down with their diaphragm and hold their tummy muscles tight.  This can be disastrous for pelvic floor muscles (beware of this new moms!).  This class will focus on the basics, using the diaphragm (breathing) to coordinate the muscles of the core - see this post that discusses the interaction of these muscles.  

So I will leave you with this test to see if you can Breathe, Stretch and Move:

• Lie on your back with your knees bent and your arms at 90 degrees (so fingers pointed to the ceiling)
• Breathe in and allow your arms to move over your head trying to get your hands to the floor.  Notice your ribs and low back - do your ribs flare out a lot, or your low back arch a lot?  You should notice that all of your ribs expand with the movement and your lower back will extend a little bit, but not too much.  You should also notice that you can easily breathe into your belly in this position.
• Now, breathe out as you bring your arms back down by your sides.  You should be able to maintain a soft breath as you bring your arms down, and you should notice the muscle of your pelvic floor and lower abdomen tense.  It should not feel like you are breathing out forcefully and that your ribs are being forced down by tight abdominal muscles.
• This time, lie on your back with your legs straight.  Put your fingers on the front of your hips (just above your pockets).  Lift one leg straight off the ground a few inches.  If you have good core stability and breathing strategies, you will notice that you don't have to hold your breath, your hip bones stay relatively level (not dipping down on one side) and that it isn't hard to lift that leg.  If this is a hard exercise, then likely you are not able to coordinate tasks of breathing and stability!