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!
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:
To the point...
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:
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:
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:
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:
I am very excited to have just booked a course with Mary Massery, a physical therapists out of the United States, who would arguably be the leading expert in breathing and movement. Her main focus is the influence of breathing on posture mechanics and how if you can't breathe, you can't move. And she is quite right. I am often referred people whose main complaint is that they seem to get out of breath quite quickly with activity. They aren't able to coordinate both movement and breathing. Sometimes when I am working with patients with low back pain, I see them hold their breath to move. They haven't got the right stabilization pattern, so use their breath to create pressure within the abdomen to create that stability.
Mary points out some interesting things with regards to breathing and movement. And the funny thing is, is if you are paying attention, it's quite obvious how we regulate breathing and movement. Try this first example. Stand up from your chair. We are going to sit back down in the chair, so make sure you can do that safely. So, again, stand up. Breathe out (like a sigh) as you sit down. Now, if I had yelled out "oh, don't sit there, there's gum on the chair!" would you have been able to reverse direction easily? Likely not. With that sigh out, you were sitting down without much control. This time, stand up. Take a breath in, hold it and start to sit down, just before you sit down, let your air out. Once again, you probably plopped down in your chair, and there was no way you were going to stop part way down. Now this time, stand up. We are going to use breathing and vocal management to provide a bit more stability to your movement. Take a breath in, and as you lower yourself down, count quite loudly to seven. What did you notice this time? A bit more stable and controlled, right? If I shouted not to sit down, you would have been able to reverse your direction, right? And the only thing we changed was breath control.
Here's another interesting trick. Stand up again. Raise your arms up over your head. Bring them down. Repeat this a few times (your elbows should remain straight through this). What do you notice happens with your breathing? That's right, as you raise your arms up, you breathe in. Now this time, breathe out as you raise your arms up. Repeat it a couple of times. What happens now? Not nearly the same range of motion is there? And it probably feels a bit stiff to do so. Again, all we changed was the way we were breathing.
So for those of you who think breathing issues are only for those who feel short of breath, maybe breathing issues are also for those of you who are having trouble with moving. Yep, that means you with the sore back. And you with the chronic shoulder pain. And you with the stiff neck. And you...
I have been working with a couple of pelvic floor physiotherapists lately, because we physiotherapists know about the connection between breathing and pelvic floor muscle function. But I realized, that likely most people don't realize there is a connection there. Think about it. What do you do when you really, really, really have to go to the bathroom, but you are stuck in traffic. Maybe hold your breath? Suck in your stomach? Perhaps a quick lesson on how the two systems work together can help you manage those extra minutes a bit better.
Our main breathing muscle is the diaphragm, a dome shaped muscle under the rib cage. When we breathe in, the diaphragm flattens out and pushes on our abdominal contents (stomach, intestines, bladder, etc), sending them down toward our pelvis. At the same time, the abdominal muscles tighten a little bit and the muscles of the pelvic floor, located between your pubic bone and tailbone, lengthen a little bit. This allows us to manage the increase in pressure in our abdomen that occurs when the diaphragm flattens out. When we breathe out, essentially the opposite happens: the diaphragm relaxes and goes back up toward the heart, the organs move up as well and the pelvic floor muscles contract.
Now if you have to cough or shout - something that requires us to breathe out forcefully, the abdominal muscles are going to contract more forcefully. This increases the pressure in our abdomen a lot. The pelvic floor muscles now have to contract a lot as well, to help prevent things from being pushed down.
For people that have issues with continence, it is often this coordinated movement that is disrupted. Muscles may be too tight (not relaxing enough) or too weak (not contracting enough).
One place to start to help engage the right muscle pattern is to focus on breathing. Try this exercise: lie on your back with a pillow under your head and one under your knees. Breathe in through your nose gently and feel the rise of your belly. Now exhale gently through your nose. Imagine the up and down motion of the diaphragm and the effects on the organs. Do this a few times. Now bring your awareness to your pelvic floor muscles. As you breathe out, see if you can engage them by squeezing them gently. This would be the same as stopping the flow of urine when going to the bathroom (do NOT do that as an exercise). The key is to not only contract when you exhale, but also relax when you inhale. As this gets easier to do, practice in a variety of positions.
And the next time you really, really need to go, but are still a few minutes away from the bathroom, focus on breathing out and contracting your pelvic floor muscles. Trust me, it will help a lot more than holding your breath or breathing in!
Just last week I was asked to speak to the Respirology Division at the Alberta Children's Hospital here in Calgary about some of the work I have been doing with treating vocal cord dysfunction. And it became quite clear that they are seeing many patients that have some sort of excerise induced vocal cord dysfunction (EIVCD). EIVCD is described as an inappropriate closure of the vocal cords on inhalation during strenuous activity. Usually, when we breathe in, the vocal cords widen, to allow for air to enter the airways and lungs. When we exhale they may close slightly, and when we talk they narrow more, and then they completely close when we cough and swallow. But sometimes, the reflexive opening and closing becomes dysfunctional and we see the vocal cords coming together on the in breath. As you can imagine, this makes breathing very difficult: symptoms of EIVCD are shortness of breath, inspiratory stridor (a hoarse wheezing on inhale), and tightness of the throat. Sometimes this can be quite alarming and may lead to hyperventilation and panic.
Often EIVCD is misdiagnosed as asthma, although it does tend to occur in conjunction with asthma. A few clues that the vocal cords may be involved is the report of throat tightness - usually in asthma it is chest tightness; inspiratory sounds - with asthma it is generally a wheeze on breathing out; and if symptoms do not resolve with taking a bronchodilator (like Ventolin) EIVCD should be suspected. Of note, it is three times more likely to occur in females than males.
So all that being said, where does breathing fit into this? Well, there is some evidence to indicate that the muscles that help open the vocal folds are linked to the movement of the diaphragm. That is, the downward motion of the diaphragm that occurs during inhale assists in the activation of these "throat opening" muscles. In all of the patients I have seen with complaints of EIVCD, they have demonstrated a breathing pattern that relies heavily on the accessory muscles of breathing located in the neck and chest, with very little activation of the diaphragm. We also know there is a link between tight muscles in the neck and tight muscles around the larynx (where the vocal cords are located).
Management of EIVCD generally includes education and breathing retraining. Patients who have an understanding about what is going are less likely to panic when experiencing symptoms. Learning new breathing patterns that help to relax tense neck muscles and activate the diaphragm assist in decreasing the frequency and severity of events. "Rescue breathing" exercises are also taught to help gain control in an acute episode. I also include postural retraining and manual therapy to address neck muscle tension. There is also some evidence showing that low load inspiratory muscle training assists in restoring reflexive opening of the vocal folds. I have certainly noticed clinically an improvement in breathing patterns when adding this modality to my treatment programs.
If you or someone you know has asthma, and struggles during strenuous exercise, take note of your symptoms and compare them to the ones mentioned here. If you are finding it has been hard to manage your symptoms to this point, perhaps you may want to consider if exercise induced vocal cord dysfunction is involved.
I'll be stressed for Christmas,
You can count on me.
Too much snow and shovelling,
Leaves no time for the tree!
Christmas Eve will find me,
Chugging nog and 'Beam'
I'll be stressed for Christmas
Can't find that toy of their dreams
Are you feeling a bit stressed out this Christmas season? It's not surprising really, with the the pressure to produce the "perfect" Christmas that seems to flow out of every commercial, billboard and Facebook share. Perfectly decorated gingerbread, perfectly quaint stockings hung under a perfectly accessorized mantle. And of course, "just found the perfect gift for my second cousin's niece!" Really? I'm lucky remember gifts for my in-laws!
From parties to shopping, decorating to baking...there just seems to be a never-ending list of things to do to prepare for the holidays. Add on top of that, regular life goes on - so there is still work, school and taxiing the kids here and there and everywhere. Little chance to just stop and take a breath.
The trouble is, if we don't stop to take a breath, we end up paying for it later. Who hasn't experienced the immune system break down on the first day of Christmas vacation? Finally, the hustle and bustle slows and you wake up that first morning to a scratchy throat and achey bones.
We know that too much stress isn't good for us. It weakens our immune system, disturbs our sleep and takes our bodies away from precious rest-and-repair phases. So this holiday season, instead of letting stress carry you from one task to the next, try these tips for a happier, healthier Noel!
1. Stop and smell the gingerbread. That's right, use your nose. Nose breathing stimulates our diaphragm, our main breathing muscle, to work. Simply using your diaphragm can help activate our rest-and-digest side of the nervous system and put the brakes on the fight-or-flight response. Bonus: belly breathing is good for the digestive system and will help "massage" some of that holiday baking through the system!
2. Enjoy your cup of tea. Or coffee, or hot chocolate. Pour yourself a cup, sit down and enjoy it. Wrap your fingers around the warm mug and take that time to hit the reset button. Focus your attention on the sensations of breathing, the warmth and smell of your drink, feel supported in your chair. Put your "to do" list away and simply enjoy the moment.
3. Breathe. Seriously. When we get busy and flustered, sometimes we forget to breathe. Or sometimes we just breathe poorly. So every time you sit back down in your office chair, or get behind the wheel of the car, or find yourself sitting in some other new space, take a moment to reset. Place your feet on the floor to ground yourself. Close your mouth and breathe softly in and out of your nose. Feel your belly expand gently as you breathe in, and then let go of any tension on the exhale (hint: the tensions probably in your shoulders so let them drop). Do 5 breaths, then move on to the task at hand. These mini-breaks throughout the day will do wonders for your mood and energy.
4. Go for a walk. Park at the other end of the parking lot at the mall. Park an extra block away from work. Take a brisk walk at lunch. Studies have shown, time and again, that walking is beneficial to both our physiology and our psychology. I know for me personally, I come up with my best ideas when I'm exercising!
5. Get some zzz's. I know, I know, always easier said than done. But stick with your sleep schedule and try not to stay up late fitting in that last minute batch of cookies. To settle an excited mind at night, focus on your breathing. Again, softly in and out through the nose, allowing your belly to expand on inhale and letting go of tension on exhale. See my previous posts about sleep tips to help you find a restful sleep.
Make this holiday season one to cherish, not one to "just get through."
Wishing you the best this holiday season! Breathe well and be well!
Last week I talked about how dysfunctional breathing and sleep disturbances are linked and gave you a few exercises that may help with easing tension to facilitate a better night's sleep. Using the breathing exercises as a way to access and then ease muscle tension helps to turn off the ever-active "flight or fight" response we have to our everyday stresses and allows our bodies to spend time in "rest and digest" mode for more restful sleep. But for some, simple breathing exercises aren't enough. This is when we start to introduce behaviour changes to encourage better sleep hygiene. Described by Dr. Peter Hauri, sleep hygiene refers to "the habits, environmental factors, and practices that may influence the length and quality of one's sleep." The concept of sleep hygiene is to allow for a smooth transition between the hectic demands of your day and sleep. If you are dealing with stressors (work, family, etc) right up until the light's go off, it's unlikely you will have smooth transition to sleep. You simply cannot flip a switch and drop into blissful sleep. By establishing a pre-sleep ritual to break the connection between stress and sleep, we may limit the amount of time spent tossing and turning, waiting for sleep to come. We all did this with our kids when they were younger, right? Bath time, story time...everything meant to be done calmly and quietly to get them ready for bed. Why not offer ourselves the same courtesy? Here are a few tips to improve your sleep hygiene for a better night's sleep:
And don't forget to breathe! A nice, relaxed belly breathing pattern with an effortless exhale helps to settle that busy brain as you rattle through your "to-do" list. And if you struggle with finding that pattern, do try to find a physiotherapist with skills in treating dysfunctional breathing to help you find a pattern that works for you!
I'm a physiotherapist who is passionate about educating anyone and everyone about the impact breathing has on our health.