According to Alison McConnell’ s book, Breathe Str ong,
Perform Better , the lungs do not respond to physical training.35 Research
confirms that lung volume and function, including the ability of the lungs to
transfer oxygen to the blood, is not improved by training.35–38
During intense physical exercise, the breathing rate can increase to
between 40 and 50 breaths per minute. Since the volume of each breath is
around 3 liters of air, this equates to a breathing volume of as much as 120
to 150 liters per minute. For Olympic-level male endurance athletes, the
tidal volume (volume of air per breath) can be as high as 5 liters. Thisresults in a minute ventilation of 200 to 250 liters.35 Bear in mind that
normal resting minute ventilation is between 5 and 8 liters, increasing to 40
to 60 liters during moderate exercise. WHEN THE BREA THING MUSCLES TIRE
Because breathing increases substantially in this way during physical
exercise, the extra work of inhaling and exhaling places much greater
demands on the breathing muscl es. Unsurprisingly , this often causes fatigue
in those  musc les. According to the Lore of Running , by exercise
physiologist Tim Noakes, there is strong evidence that the diaphragm
(which is our main breathing muscle) and other respiratory muscles may
become exhausted during both short-term high-intensity exercise, such as
MMA or boxing, and extended activities like marathon running.39
The ventilatory response to CO2 influen ces the work of the breathing
muscles during physical exercise. If you have a low BOL T score, you will
need to breathe harder . Effortful breathing like this requires significant
increases in respiratory muscle work, both on the inhalation and on the
exhalation.40 As the breathing muscles tire, blood flow is diverted from the
legs to help support respiration. The decrease in blood flow to the working
muscles causes the legs to becom e fatigued, and you will be forced to slow
down or stop. As the breathing muscles overexert, metabolic by-products,
such as lactic acid, accumulate in the blood. Too high a concentration of
these metabolites further reduces blood circulation, hampering blood flow
to the limbs. Research into breathing techniques has shown that, when the
effort of inhalation is reduced, blood flow to the legs increases by up to 7%. Evidence suggests that the diaphragm is the most important breathing
muscle to target during respiratory muscle training. For instance, one 2016
study demonstra tes that over 50% of healthy athletes with varyi ng levels of
fitness will develop diaphragmatic fatigue after bouts of high-intensity
exercise.41
EXERCISING THE BREA THING MUSCLESIt is widely accepted that to stimulate any muscle to adapt, that muscle must
be worked harder than usual . But since aerobic physical exercise is
practiced within the comfort limits of the breathing muscles, it cannot
provide sufficient stimulus to cause the breathing muscles to adapt. In fact,
it is impossible for most people to sustain high-intensity exercise for long
enough to provide a load sufficient to improve the stren gth of the
respiratory muscles. However , the Oxygen Advantage exercises (see
Chapter Two) provide a meaningful strategy to improve respiratory muscle
strength, as that extra load can be added to the breathing muscles in a
nonstressful and controlled environment. In terms  of function, respiratory muscles are divided into the inspiratory
muscles, used during inhalation, and expiratory muscles, used during
exhalation. Exhaling requires less effort than inhaling, as the natural
elasticity of the breathing muscles helps push out the air. Therefore, it is the
inspiratory muscles that are most prone to fatigue. That is why the practice
of breathing against resistance, or inspiratory muscle training, specifically
targets the inspiratory muscles. This resistance can be provided by a SportsMask, a training support that
makes the breathing muscles work harder . The SportsMask has an
adjustable valve  opening, making it possible to vary the level of resistance
during inhalation. This resistan ce conditions the breathing muscles in a
manner similar to the progressive muscle training achieved in weight
lifting. The technique of restricting airflow with a specialist device is called
inspiratory flow resistive loadin g (IFRL). Studies show that it can improve
respiratory muscle strength between 20% and 50%. Breath holding,  done properly , can also provide a workout for the
respiratory muscles. Holding the breath after a passive exhalation creates a
strong air hunger and disturbs  the blood’ s acid-base balance. When the
breath is held, excess CO 2 cannot leave the blood through the lungs, and the
cells continue to extract oxygen. This alters blood gas concentrations,
increasing CO2 (hypercapnia) and decreasing oxygen saturation (hypoxia). Because CO2 levels are the primary stimulus to breathe, the excess CO2
will cause the breathing muscle s to respond. To restore blood gas levels to
normal, the respiratory center begins to send messages to the breathing
muscles to resume breathing. As the breath hold continues, these impulsesincrease in intensity , causing repeated contractions of the diaphragm. This
is somet imes called the “struggle phase.” As the diaphragm continues to
contract through the breath hold, it essentially receives a workout. According to a 2013 study of maximal breath hold in free divers, the
relative intensity of diaphragmatic and inspiratory rib-cage muscle
contractions increases by aroun d 5 and 15 times respectively , from the
beginning to the end of the struggle phase, approaching potentially
fatiguing levels by the time breathing is resumed.42
In 2016,  scienti sts at the Unive rsity of Zagreb, Croatia, ran a study to
determine the effects of hypercapnic-hypoxic training on respiratory muscle
strength among elite swimmers. Those swimmers who were subjected to a
hypercapnic-hypoxic regimen significantly improved the stren gth of their
inspiratory muscles when compared to swimmers who breathed normally . Participants who reduced their breathing improved their inspiratory muscle
strength by 14.9% and expirator y muscle strength by 1.9%. The researchers
noted that voluntary breath holding might have resulted in involuntary
contractions of the breathing muscles, increasing diaphragm thickness.43
The thickness of the diaphragm plays an important role in sporting
performance and endurance. The precise mechanisms by which respiratory muscle training improves
exercise performance have not been fully determined. The positive effects
on endurance may be due to the direct impact on fatigue in the respiratory
muscles. Indirectly , the improved blood flow to working muscles that
comes from more efficient breathing and better oxygenation is also
beneficial. It is also likely that the increased resistance to breat hing during
respiratory muscle training may simply make normal physical exercise feel
easier .44
When the breathing muscles are stronger , they are better able to cope
with more intensive training. This means that more intense exercise is
possible before the metaborefl ex reduces blood flow to the legs. This
ultimately improves performance as well as endurance. The effects of
respiratory muscle training have been shown across a variety of sports,
including rowing,45 sustained heavy-endurance exercise,46 and cycling.47A SIMPLE MEASURE OF DYSFUNCTIONAL
BREA THING
As we’ve seen, breathing pattern disorders are multidimensional, comprised
of a series of biochemical, biomechanical, and psychological components. So, it can be difficult to achieve a definitive diagnosis with any single test. Also, many methods to assess dysfunctional breathing rely too much on
subjective infor mation. As with any dysfunction, the body and mind can
adapt to a certain degree until the problem becomes normali zed, and so
personal experie nce rarely provides clear information. This is perhaps part
of the reason why breathing pattern disorders are so often overlooked in
physical therapy . In 2017 , the lack of effective screening was addressed by a research
team led by Dr. Kyle Kiesel, a professor and chair of physical therapy , who
has done extensive research in areas including motor control of the core and
functional movement.2 The result was a simple screening procedure to
enable fitness and healthcare providers to accurately identify disordered
breathing in their patients.2 Kiesel’ s study examined 51 subjects, 27 females
and 24 males, with an average age of 27 years and a BMI of 23.3. Breathing
was assessed in terms of biochemical, biomechanical, and psychological
function. The biochemical  dimension of breathing was evaluated by monitoring
ETCO 2. ETCO 2 is the average amount of CO2 in exhaled air. This is
measured using capnography , which measures the pressure of blood CO2,
because normally the pressure of CO2 in the lungs determines the pressure
of CO 2 in the blood. The normal range of ETCO 2 is betwe en 35 mmHg and
40 mmHg. Less than 35 mmHg suggests the presence of dysfunctional
breathing.21
The biomechanical  dimension was assessed using a test called the Hi-
Lo. This is a visual evaluation during which abdominal expansion and
perceived displacement and functional movement of the upper and lower
rib cage are recorded. The patient lies face up and breathes normally , with
one hand  on the chest and the other on the abdomen. How much  the tummy
and ribs move during a normal breathing cycle is measured.For the psychophysiological  dimension of the experiment, participants
answered questions from the Self-Evaluation of Breathing Symptoms
Questionnair e (SEBQ) and Nijmegen Questionnair e (NQ). The NQ has
been a popular screening tool for the diagnosis of hyperventilat ion for over
30 years . It gives a broad view of symptoms associated with dysfunctional
breathing and asks 16 question s about breathing discomfort. The patient
responds using a numbered scale ranging from “never” (0 points) to “very
often” (4 points). A score of 23 points or more is considered to indicate the
presence of hyperventilation syndrome.48
I am not a fan of the Nijmegen Questionnair e. Its questions neglect
some of the most common signs of breathing pattern disorders. It does not
include frequent sighing or yawning, nasal congestion, fatigue, or
wheezing. While it could be argued that these are omitted because they are
all caused by organic conditions, people with these symptoms generally do
have breathing pattern disorders. On the other hand, the NQ does include
symptoms such as confusion, tingling and stiffness in the fingers, stiffness
in the arms, and tightness aroun d the mouth. In almost 20 years of teaching
exercises to address chronic hyperventilation, I’ve only seen a handful of
people present with those symptoms. Kiesel’ s team failed to find any strong correlation between the 3
measures of disordered breathing.2 This goes some way to explaining why
these common methods of diagnosis are so continually unreliable. Of the
participants, 5 were deemed to have normal breathing, 14 failed at least 1
measure, 20 failed at least 2 of the measures, and 12 failed all 3. Only 10%
of partic ipants who passed all three dimensions of breathing actually had
normal breathing. While the capnometer , Hi-Lo  test, and self-evaluation questionnaires
were found wanting, Kiesel discovered that a simple screening test could
accurately asses s the presence of dysfunctional breathing. The proposed test
consisted of just four question s from the Functional Movement Screen
(FMS) and a breath-hold time of 25 seconds. FMS identifies physical weakness and imbalance. To assess movement
patterns crucial to normal mobility, it uses a straightforward ranking and
grading system of seven functio nal movements. These are deep squat, in-
line lunge, hurdle step, active straight leg raise, shoulder mobility , trunkstability push up, and rotary stability. It pinpoints any functional limitations
and asymmetries that may inhibit the ability to move correc tly or train
without injury . The four questions Kiesel found effective to diagnose
dysfunctional breathing ask whether the patient feels tense, has cold hands
or feet, yawns frequently , or mouth breathes at night. These symptoms are
all common among people with breathing pattern disorders. To accurately measure breath-hold time, each participant was directed to
hold the breath at the end of a standard exhalation. The breath-hold was
measured until the tester noted the subject’ s first involuntary contraction of
the diaphragm or throat muscles.2 This technique  exactly replicates the
BOL T measurement that we use in the Oxygen Advantage. Kiesel’ s team concluded that, if an individual passed the screening
composed of the four questions plus the breath-hold test, there was an 89%
chance that their breathing was not dysfunctional. The test, therefore,
provides an easy way for clinicians to accurately detect DB in their
patients.2 In the same way, the BOL T provides an accurate measure of
functional breathing. By checking your BOL T score and observing what’ s
going on in your body , you can assess your own breathing witho ut the need
for fancy equipment. This puts you in a strong position to tackle the
problem. WHA T DO FUNCTIONAL MOVEMENT SCORES MEAN FOR
PERFORMANCE? Dr. Paul Sly is an Oxygen Advantage Master Instructor in Canada. He has
more than 25 years’ experience as a practicing chiropractor and is an
acupuncture provider , certified in Functional Movement Systems. He sent
me this explanation of functional movement screening and its implications
for functional breathing and performance:
In Functional Movement Systems, there is the Functional Movement
Screen (FMS) and the Selective Functional Movement Assessment
(SFMA). The FMS is a performance enhancement tool, while the
SFMA is the clinical arm, designed to arrive at a diagnosis. I use
both, but as a clinician I use the SFMA a lot. In particular ,
“breakouts” of the movement patterns determine whether a specificdysfunction is a Tissue Extensibility Dysfunction (TED) or a
Stability or Motor Control Dysfunction (SMCD). Take the classic standing toe touch. If an individual can’t do
that, there are two possibilities. Either something (typically the
hamstrings) along the posterior chain is too tight (TED) or the
patient can’t stabilize their core well enough to allow the hips to
shift back and the spine to flex (SMCD). We are finally  coming around to the idea that functiona l
breathing, recruiting a strong diaphragm with appropriate timing, is
a big part of core stabilization. When breathing is dysfunctional, it
can create a SMCD. What also happens, however , is that TEDs  will
cause an individual to change their breathing patterns. For insta nce,
people often hold their breath  in order to try to overcome the
dysfunction. A TED can therefore cause a breathing pattern
disorder , which in turn can cause or exacerbate a SMCD. So,
breathing can be, and often is, central to both types of dysfunc tion. If you can’t breathe functionally through a particular movement or
posture, then you don’ t “own” that movement or posture. This has significant implications for professional athletes. It also
contributes to the huge rise in incidence and cost of repetitive strain
injury in many occupations and workplaces. The other overlooked and interesting application of functional
breathing is for cognition in sport, especially team sport. I always
tell the hockey players I work with that, while the mistakes you see
players make, especially towa rd the end of a game, are often
attributed to “pressure,” they are also, at least in part, due to the
continual hyperventilation you see on the bench during recovery . During recovery , players breathe through an open mouth, resulting
in a decrease in cerebral blood flow that impacts their ability to
think clearly . Nasal, functional breathing during recovery from an
acute anaerobic bout, makes a difference to cognitive ability which
is vital for perfo rmance. I’m not aware of any study backing this up,
and I’m not sure how such a study could be designed, but I have
seen it in action, and it makes sense. —Paul SlyFUNCTIONAL BREA THING IS FUNCTIONAL STRENGTH
Tim Anderson is cofounder of Original Strength and has been a personal
trainer for more than two decades. He is a well-known author and a sought-
after speaker . He has written and cowritten books on this subject, including
The Becoming Bulletpr oof Project . As I was preparing the final manuscript
for this book, Tim wrote to me with the following practical explanation of
the science we have covered in this chapter:
Strength starts with breath. Proper breathing literally strengthens the
body from the center out. The diaphragm is the chief spinal
stabilizer of the inner core muscles. When it is functioning properly ,
when it is being  used to fill the lungs from the bottom to the top, it
rhythmically dances with the pelvic floor . This dance, which also
involves the transverse abdominus and the multifidi, stabilizes the
spine and pelvis. When the diaphragm is functioning properly , the
pelvic floor and the other spinal stabilizers are getting the
stimulation they need to function properly . This is the foundation  for
a strong, powerful and ef ficient moving body . A body  that has a properly functioning diaphragm, a nasal
breather who keeps their tongue  on the roof of their mouth and fills
their lungs up from the bottom to the top, has a nervous system that
feels safe to express itself without restriction. Not only does this
result in better performance in speed, strength, power and efficiency,
it results in a more resilient and durable body , a body that is less
prone to injury . Trying to expres s strength and power while mouth breathing not
only throws the nervous system into the sympathetic mode, it causes
the body  to recruit prime movers to stabilize the spine because the
inner core unit’s chief stabilizer (the diaphragm) is not functioning
optimally . This compensation can lead to poor performance and
even injury . It may help to think of the body  as an “X”? Functional breathing
creates a body with a solid center , a reflexively strong inner core
unit. When the body has a strong center , the forces it creates  and
encounters can easily and efficiently travel from one side of thebody to the other, through that solid center . The result is a body that
can move with grace, ease, and power . Dysfunctional breathing creates instability of the spine because
the inner core muscles are not able to properly do their job. This
means when the body creates or encounters force, those forces
cannot efficiently travel through  the center of the body . Instead, they
may end up in regions of the body they shouldn’ t causing movem ent
issues, pain, or injury . Typically , the body of a dysfunctional
breather , does not express optimal, fluid posture, or ease of
movement. It lacks a poetry of movement because the body cannot
express its full movement potential. I like to tell people that breathing properly , nasal breathing with
your tongue on the roof of your mouth, filling your lungs up from
the bottom to the top, gives you a center of strength. It makes  the
body and mind strong and resilient. Improper breathing, mouth
breathing, filling  the lungs up from the top, rarely filling the bottom
of the lungs; gives the body a soft or hollow center . It leaves  the
body and mind weak and fragile. In other words, mouth breathing  can create fragility while nasal
breathing can create resiliency . —Tim Anderson
OceanofPDF .comACHAPTER SIX
WHEN BREATHING MAKES YOU HURT
PAIN IS A SIGN OF DYSFUNCTION
s we have been discussing, the diaphragm, the primary respira tory
muscle, is essential for stabilizing the core, spine, and posture. Dysfunctional breathing can compromise the body’ s fundamental
stability . Poor breathing patterns can also cause pain in sometimes
unexpected places. Over time, poor breathing patterns create faulty
movement patte rns that lead to pain and injury in the muscles, tendons, and
joints. For instan ce, if you breat he into the upper chest, alteratio ns occur in
the position of your lower ribs, which need to move up to allow enough air
into the lungs. The result is likely to be pain or dysfunction in part of the
spine. If you continually neglect the primary muscles that hold your body
upright, such as the core and the diaphragm, the body will compensate by
overusing smaller muscles that aren’ t really designed for the job. This is
why muscular adaptations caused by breathing pattern disorders can
contribute to all sorts of pain conditions that you might not intuitively
associate with breathing. For example, paradoxical breathing, a
dysfunctional breathing pattern in which the abdomen contracts on
inhalation and expands on exhalation, often coexists with muscle
imbalances and pain in the cervical spine. Weakness in the pelvic floor
muscles can show up as injuries in areas as varied as the knee,1,2 ankle,
anterior cruciate ligament,2 and lower back .3 Problems in the hands can be
caused by tension in the should ers and neck stemming from dysfunctionalbreathing.4 Poor blood flow to the brain caused by chronic hyperventilatio n
can result in excruciating headaches.5
Imbalances in the autonomic nervous system, which can be influenced
by breat hing, can also lead to pain. For the body to move, the nervous
system and muscles must work together . If problems exist in either system,
the other will adapt to compen sate. This is why autonomic dysfunction
caused by psychological stress can display as physical symptoms. Stress has been clearly identified  as both a contributing and a risk factor
in musculoskeletal injuries and chronic pain. In one 2012 study , researchers
observed patien ts with ongoing shoulder and neck pain and found that
sympathetic activation was dominant and the parasympathetic system was
suppressed, suggesting an imbalance in the autonomic nervous system.6
When the nervous system is in a state of heightened arousal, the body is
likely to adjust breathing patte rns to restore homeostasis. This alters the
recruitment of respiratory muscles, impacts motor control, and leads to
chronic or acute musculoskeletal pain. Another valuable window into how well the body’ s systems are
functioning is provided by myofascial trigger points . These are tender areas
in the muscles that often cause referred pain, a phenomenon where pain
originating in one place shows up elsewhere in the body . Trigger points
manifest as muscle stiffness, weakness, dizziness, nausea, and postural
distortions.7 Left untreated, they can result in ongoing disruption of
movement patterns. Trigger points can be activated by psychological stress. In 1994 , researchers observed what happened to a trigger point under
different conditions, including mental stress induced by an arithmetic task. The results showed that the trigger point was stimulated during stress,
suggesting that physical pain is directly influenced by the emotio ns.8 A new
paper from 2020 suggests that the stronger stimulation of the baroreflex that
occurs during guided slow, deep breathing may offer a “cheap-and-easy
way to ‘behaviorally’ stimulate  the afferent vagus and reduce  pain,” but
still, not much is known about this pathway . The stimulation and function
of the barorecep tors have not been well studied in research examining the
impact of slow, diaphragm breathing on pain, but it is known that the pain-
blocking effects of baroreceptor stimulation are lessened during mental
stress.9A 2016 study explored the assessment and treatment of breathing
pattern disorders in three patients whose musculoskeletal pain complaints
were related to trigger points, motor control adaptations, and muscle
imbalances.10 The participants were treated using breathing exercises and
manual trigger point therapy . Breathing reeducation focused on a physical
exercise called the “clamshell exercise,” which is designed to alter intra-
abdominal pressure and prompt the patient’ s breathing reflex. Pain
decreased in all three participants, although it was unknown whether this
was due to impr ovement in diaphragm function and core stability , lessening
of tender trigger points, or the restoration of functional movement.10
According to researchers, breathing therapy is not typically considered to be
as effective as physical therapy in the treatment of pain conditions, yet there
is clear evidence that it is possib le to achieve similar improvements in pain,
function, and physical and emotional factors with both techniques.11
While we have so far focused on the diaphragm, both in terms of its
importance for functional breathing and its role in spinal stabil ity, it’s also
helpful to acknowledge other respiratory muscles. The diaphragm is
responsible for around 70% to 80% of the work of respiration under quiet
breathing conditions. The other  30% is performed by the scalene, external
intercostals, sternocleidomastoids, and parasternal intercostal muscles.12
The scalene muscles are a group of three pairs of muscles in the sides of
the neck . They are called secon dary breathing muscles but are considered
by some  scientists to be primar y to respiration as they lift and expand the
rib cage during inhalation and are active at a low level even during light
breathing.13 It’s easier to see these muscles at work during exercise, when
ventilatory demand is high.13 Trigger point pain in the scalene muscles is
often associated with pain radiating to the arm, which is commonly
misdiagnosed as disc herniatio n or prolapse, neck pain, or carpal tunnel
syndrome. This type of misdiagnosis leads to mismanagement of the
condition which can perpetuate the existing problem.14
BREA THING AND THE PERCEPTION OF P AIN
How we breathe directly affects how badly something hurts. Beyond factors
such as postural control and muscle tension, breathing pattern disorders canplay a role in the amplification of pain.15 For instance, respiratory alkalosis
caused by overbreathing can induce muscle spasm and heighten the body’ s
response to stress hormones including adrenaline. These factors  combine to
create inadequa te blood flow and poor oxygenation of the tissues and
organs. One 2006 study used functional magnetic resonance imaging (fMRI) to
explore the way that hyperv entilation influences pain mechanisms.16
Researchers found that low blood CO2 may affect the processing of motor
tasks and pain input. They discovered changes in the relative levels of
oxygenated and deoxygenated  blood, which they believed indicated
widespread constriction of blood vessels in the gray matter of the brain. This was thought to represent an acute reaction to reduced blood CO 2. Constriction of the blood vesse ls due to overbreathing stops the blood
from flowing freely to the brain and limits oxygenation of the tissues.17
This has implications for the excitability of nerve cells in the brain and can
potentially impact both motor control and pain perception. Respiratory
alkalosis, caused by low levels of blood CO 2, increas es the sensitivity of the
peripheral nerves. The periphera l nerves send messages from the brain and
spinal cord to the rest of the body , allowing us, for examp le, to sense
whether our feet are cold and to move our muscles to walk.18 This increased
sensitivity is what causes the muscular tension, spinal reflexes, muscle
spasm, and a much greater perception of pain, light, and sound, which are
all typical of alkalosis. Alkalosis can also cause mood swings, panic
attacks, anxiety , and phobic behavior ,19 all of which can result in a negative
feedback loop of poor breathing and deepening psychological distress. The impact of hyperventilation  on the excitability of the neurons was
explored in a 1991 paper in Brain . Resear chers looked at the effects of low
blood CO2 on two condi tions that impact movement, paresthesia  and
tetany .20 Paresthesia is an abnormal tingling or prickly sensation, like pins
and needles, which is caused by pressure on or damage to peripheral nerves. Tetany is a condition characteriz ed by spasms of the hands, feet, and voice
box; cramps; and overactive neurological reflexes. Tetany , which is
generally caused  by very low blood calcium levels, can also be the result of
severe alkalosis.Scientists monitored the excit ability of nerve fibers in six healthy
subjects. Partic ipants were asked to hyperventilate until paresthesia
occurred in the hands, face, and trunk. This occurred when the pressure of
alveolar CO2 had decreased by, on average, 20 mmHg. Spontaneous EMG
activity—muscle activity in response to stimulation by the nerves—
developed when CO2 had dropped by a further 4 mmHg. Neuronal
excitability increased progress ively in all participants as CO2 levels
dropped, producing a “statistica lly significant inverse correlat ion.” When
neurons or nerve cells are “excitable,” it means they are generating
electrical impulses that transmit information throughout the nervous system. The changes in the neurons happened before any sensation of paresthesia or
tetany developed. Two of the subjects also perceived spontaneous bursts of
neuronal activit y to be pins and needles. The study concluded that the
physical symptoms of paresthesia and tetany induced by hyperventilation
were entirely the result of changes in neuronal excitability .20 This is best
described as hyperventilation causing an imbalance in the electrical
equilibrium of the brain due to constriction of blood vessels in the brain,
and this causes the physical symptoms. BACK P AIN
When researchers looked for links between health, pain histories, and faulty
breathing, they found a much higher prevalence of dysfunctional breathing
than expected. Their 2003 paper published in the Journal of Bodywork and
Movement Therapies  examined 111 patients attending a clinic for
chiropractic pain. To their surprise, more than half of the study participants
demonstrated faulty breathing on relaxed inhalation, and three-quarters
breathed in a dysfunctional way when taking a deep breath. Nearly 90% of
the subjects had experienced some kind of musculoskeletal pain in the head,
neck, back, buttocks, leg, or arm. Based on their findings, the report’ s
authors commen t that clinicians can expect three in every four new patients
to have faulty breathing patterns.19
As we already know , in a healthy body , the diaphragm dyna mically
stabilizes the lumbar spine, lowering on inhalation. Together with the
expansion of the lower ribs, this creates sufficient intra-abdominal pressurefor postural stability . In people with chronic lumbar problems, the
diaphragm remains higher and flatter , moving less. During inhalation, the
ribs do not move, and the diaphr agm does not lower to its usual fixed point. Consequently , the body becomes less able to regulate IAP, and the lumbar
and sacroiliac regions become unstable. According to a 2016 study from  the Osteopathic Centre for Research
and Studies in Ancona, Italy, people who suffer from pain in their lower
back and sacroiliac joint often have early fatigue of the diaphragm,
otherwise descri bed as poor diaphragmatic endurance, which can be caused
by overe xertion of the respiratory muscles.21 Breathi ng too hard, a feature
of chronic, effortful, inefficient overbreathing, can exhaust the breathing
muscles. A 2004 research paper by Dr. Leon Chaitow , a well-regarded osteopath
and naturopath, explains that the core stability of the diaphragm and abs can
be compromised  if both poor breathing and a “load challenge” to the lower
back are present.3 A load challeng e is anything that adds a “load” or weight
to the task at hand, which, in this case, is movement. Chaito w uses the
example of shoveling snow , but digging the garden, pushing a pram, using a
vacuum cleaner , and many other day-to-day tasks have the same effect. Results showed that, after only 60 seconds with elevated blood CO 2, muscle
function was reduced or lackin g in postural muscles and in the muscles
used for movement. This underlines the extent to which chronic
dysfunctional breathing can interfere with the body’ s ability to move freely . Although more research is need ed, Chaitow’ s results were clear: increased
respiratory demand compromises postural control so that the likelihood of
spinal injury is significantly higher . This is especially true during strenuous
exercise when the load on the spine is greater . In 2018, scientists at South Korea’s Konyang University carrie d out a
study to monitor the effectiven ess of breathing exercises in patients with
lumbar instability and dysfunctional breathing.22 Instability in the lower
spine causes pain even during simple activities like walking and sitting, and
it creates imbalances in the motor system. Many studies have reported that
the activ ation of muscles in the trunk is different in people with chronic
lower back pain. For instance, pain and dysfunction in the lower spine
affects the transversus abdominis muscles, leading to abnormal musclerecruitment patterns and excessive use of other supporting muscles to
compensate.22
Twenty-seven adults aged between 20 and 40 years took part in the
study . Each person was assigned to a breathing exercise group or to a trunk
stabilization exercise group where they focused either on diaphragmatic
breathing or on physical exercises for 15 sessions over five weeks. One
focus of their breathing education was avoiding involuntary breath holding
when an extra load is applied. At the end of the study , significant
differences were observed in the lumbar area in the breathing exercise
group. Diaphrag matic breathing exercises had improved the mobility of the
sternum and ribs, allowing for thoracic extension, increasing intra-
abdominal pressure (IAP), and stimulating the abdominal muscles.22
Back pain is incredibly common in the general population. It is also a
significant factor in sports. Lower back pain is the primary reason for
missed playing time among professional athletes.23 Again, this is often due
to comp ensatory muscle activation. For example, dysfunctional breathing
correlates with an increased resting tone in the superficial abdominal
muscles.24 Studies show evidence of delayed activation of the transversu s
abdominis muscle and heightened activity of the superficial lumbo-pelvic
muscles. If these muscles are overactive at rest, they can behave almost like
a corset. That bracing of the trunk, often associated with overinflation of the
lungs, may be the body’ s attempt to boost spinal stability with IAP. However , becau se the abdominal muscles are not working with the
diaphragm, it ultimately reduces stability . In treating back pain, it is important that clinicians and physical
therapists consid er the role of breathing and the respiratory muscles as well
as the stability of the trunk. While there are many exercises for the muscles
of the lumbar and pelvic regions, most fail to integrate breathin g. Adopting
a holistic, whole-body approach, in which respiratory patterns are
incorporated into various postures, makes it possible to better address back
pain. Just as important, correcting breathing pattern disorders can be
preventive, providing optimal stability for the spine and functional
movement, and better oxygenation of working muscles, meaning less risk
of injury in the first place.Dysfunctional breathing create s levels of anxiety that can be high
enough to alter physical balance and motor control.3 Changes in respiratory
chemistry cause d by dysfunctional breathing can have profound effects on
the body ’s systems. A 2010 study of patients with back or neck pain found
that all participants had low ETCO 2.25 Remem ber, low ETCO 2 is
considered a measure of breathing pattern disorders because it indicates a
low level of blood CO2, which is associ ated with hyperventilation. None of
the patients had had any success using manual therapy and exercise to help
with pain and mobility . However , when they practiced breathing pattern
retraining, all experienced improvements in ETCO 2, pain and function, with
93% achieving clinically significant changes.25
When CO 2 levels are chronically low, the result is respiratory alkalosis. This causes symptoms such as decreased oxygenation of tissues and organs
(including the brain), higher pain perception, constriction of blood vessels,
and the onset of myofascial trigger points. Each of these, on their own, can
change the normal motor control of skeletal muscles. NECK P AIN
It is easy to understand why poor diaphragm control might cause back
trouble, but it may be less obvious why faulty breathing might frequently
lead to neck pain.19 Between 10% and 20% of the population suffer with
neck pain every  year.26 But how could  this be connected to the way they
breathe? The answer may lie in the biomechanics of dysfunctional breathing. One of the most common respiratory movement pattern faults involves
lifting the thorax with small muscles, such as the scalene muscles (the pairs
of accessory muscles at the sides of the neck), instead of allowing it to
widen naturally by IAP. This interference or “overdoing” puts a strain on
the uppe r spine and the muscles around the neck and can cause recurring
pain.27
Like so many of the issues we’ve covered in this book, neck pain is both
caused by and the cause of dysfunctional breathing. A 2014 study observed
patients with chronic neck pain before and after a 30-minute breathingreeducation exercise. Researchers evaluated movement in muscles
including the anterior scalene muscles during normal and deep breathing. They found that pain intensit y and muscle activity were significantly
reduced after breathing reeducation. The study concluded that breathing
exercises can change breathing patterns and increase expansion of the chest,
leading to an improvement in the range of motion in the neck.28 This
improvement could be attributed to better diaphragm function or to reduced
compensatory activity in other breathing muscles. A reduced ability of the abdominal muscles to maintain postural control
is also believed to lead to increased tone in the diaphragm and cervical
accessory muscles. In other words, when the core is not functioning well
enough to support the body , the diaphragm muscles and the breathing
muscles in the neck work harder to compensate. More muscle  tone is not
always a good thing. Instead of implying good health, it can indicate that a
particular muscle is overactive or tense. Increased tone of the diaphragm
and neck  muscle s has been observed in people with forward head posture,
chronic sinus problems, and temporomandibular joint dysfu nction,12 a
condition charac terized by pain and dysfunction in the muscles that move
the jaw and connect it to the skull. A 2002 empirical study showed a link between work-related
musculoskeletal disorders in the upper extremities and job stress. Previously , it had been unclear how psychosocial stress contrib uted to the
development of muscle and joint pain.15 Researchers explain that the
respiratory alkalosis caused by excessive loss of CO2 during
hyperventilation triggers an unhealthy domino effect in the body, causing
physiological reactions, including muscle tension and spasm.15
The shift from diaphragmatic to chest breathing typical in chronic
overbreathing causes biomechanical stress on the neck and shoulders. When
we breathe “big” into the upper chest, muscles in the neck and shoulders
compensate for the lack of diaphragm function. A theory centering on
hyperventilation provides a new way to understand how job stress factors
into the physi cal processes leading to work-related musculoskeletal
disorders. It also offers important insights into how employers might focus
interventions and manage individual stress in their employees. Understanding work-related injury in terms of hyperventilation provides aunique opportunity to address job stress and associated musculoskeletal
pain through breath reeducation, light exercise, and rest breaks.15
Forward head posture can be caused by many different things, not least
being the habitu al tension that comes from spending many hours in front of
a computer screen.29 When the head is pushed forward, the deep flexor
muscles in the neck become inhibited, while the muscles at the base of the
skull become overactive. Habitu al forward head posture can be caused by
hours in front of a screen, compounded by eyestrain and the effort of
maintaining a healthy seated posture in a sedentary job. It can also develop as the result of long-term ongoing breathlessness and
nasal congestion . Some people develop a forward head posture in childhood
due to untreated swollen adenoi ds and mouth breathing.30,31 This can lead
to poor airway development, af fecting breathing and posture into adulthood,
and resulting in pain. (We’ll learn more about this in Chapter Eight .) Others
begin mouth breathing as the result of chronic respiratory conditions. When
mouth breathing  is caused by nasal obstruction, the head pushes  forward as
a way to increa se airflow through the oral airway and ease feelings of air
hunger . It is likely that neck pain is directly related to chronic stress. Tension in
the neck and shoulders can be a direct result of stress, even in the absence
of a physical load.32 The “startle” reflex, the norma l response to a sudden,
intense stimulus  such as a loud noise, may also contribute. During the
startle reflex, the shoulders lift and the head juts forward in a complex
flexion pattern that begins in the head and travels down throug h the entire
body .33,34 These reflexive movements are normal and designed to keep us
safe, but when they become embedded in the nervous system  so that the
body defaults to this reaction under relaxed conditions or when the trigger
is no longer present, they become problematic. In a study where three-quarter s of participants were found to have
dysfunctional breathing, the relationship between chronic neck pain and
chest breathing was found to be statistically significant.19 Researchers noted
that, while only 38% of the study’ s participants experienced neck pain
(compared to 53% who suffered with headaches and 65% with lower back
pain), 83% of those found to have faulty breathing had some experience of
neck pain.19TEMPOROMANDIBULAR JOINT P AIN
Low blood CO2 is common in people with chronic pain disorders.16 It is
known that stress and acute pain, or a combination of the two, can cause a
hyperventilation-induced decrease in blood CO 2. Growing eviden ce suggests that the onset of idiopathic pain disorders
(with “pain of unknown origin”) , such as temporomandibular joint disorder ,
peripheral neuro pathy , and fibromyalgia, is linked to both physical and
psychological triggers. From a physical point of view , joint or muscle
trauma can contribute. Emotionally , stress responses may initiate pain
amplification and mental distress. Idiopathic pain disorders are
characterized by pain and a variety of abnormalities in motor function,
autonomic balance, and sleep. Temporomandibular joint disease (TMD) is the name given to several
conditions of the chewing musc les and the joint connecting the jaw to the
skull. It causes pain and can contribute to migraines and tension
headaches35. Traditionally , it was thought that these symptoms were related
to misal ignment of the jaw, but scientists have failed to identify a link. More recently , the significance of psychosocial factors has been accepted.35
The term psychosocial  refers to both psychological and social or
interpersonal aspects and can involve problems, including anxiety , fatigue,
and sleep disorders. While relaxation techniques and coping strategies are often used in
therapy , the role of breathing reeducation in temporomandibular joint
dysfunction is seldom mention ed. However , breathing patter n disorders
could offer a biomechanical explanation as to how and why the
physiological changes in the joints and muscles occur . A 2011 paper
published in the Journal of Bodywork and Movement Therapies  suggests
that a forward head posture could lead to increased pressure in the
temporomandibular joint. Researchers also suggest that health professionals
can gain valuable insights into temporomandibular joint disorder and its
treatment by paying attention to breathing and postural rehabilitation.35
While gaps in research are acknowledged, the connections between
TMD, breathing, and posture are detailed in a 1997 study . It examines the
influences of dysfunctional breathing and describes the effects of poor corestrength and diaphragm function on temporomandibular disorders. Overuse
and overdevelopment of accessory inspiratory muscles; forward head
posture; altered  proprioception ; increased compression of the cervical,
cranial, and mandibular joints; hypermobility or hyperactivity in the
temporomandibular joint; and craniofacial pain all contribute to the
development of TMD.12
TMD is also linked with bruxism , which is grinding or clenching  of the
teeth. Bruxism can occur during both wakefulness and sleep. It has been
connected with the use of antidepressant medication, a fact that may offer a
window into the connection to the psychological and biochemical
dimensions of breathing. A letter in the Journal of Neur opsychiatry  in 2007
described the case of an 81-year -old man who suffered with depression. He
was treated with paroxetine, a selective serotonin reuptake inhib itor (SSRI). While his depression was controlled, once his dosage increased to 30 mg
per day, he began to experience  night and day jaw clenching and sore teeth
and jaws.36 Similar ly, a paper from The Netherlands Pharmacovigilance
Centre, Lareb, describes 10 reports of bruxism in which an SSRI was the
suspected cause.37 The report explains that bruxism  often exists alongside a
dopamine imbalance and can result from disturbances to neurotransmitters
or neuronal excitability . It shoul d be noted that both of those can be caused
by hyperventilation and low levels of blood CO 2.38
Bruxism during sleep, also called parasomnia, is experienced by around
8% of the adult population.39 It is characterized by rhythmic tooth grinding
and is associated with tooth wear and temporomandibular joint problems. Scientists are still unclear exactly what causes it, but recent studies suggest
that it is the result of transient arousals during sleep. Evidence suggests that
tooth grinding occurs simultane ously with apnea or hypopnea in patients
with obstructive sleep apnea  (OSA).39 An apnea is when breathing stops
completely and a hypopnea is a reduction to the flow of breat hing for 10
seconds or more due to partial collapse of the throat. A 2014 study found correlati ons between the occurrence of sleep
bruxism and microarousal apnea or hypopnea events.40 Researchers
concluded that patients with OSA had a high risk of bruxism, and that the
phasic episodes of teeth grinding were directly related to apnea events. Thissuggests that an improvement in OSA may prevent the worsen ing of sleep
bruxism.40
A 2016 study explored the link between TMD and breathing further in
looking at the relationship between craniofacial pain and daytime
sleepiness.41 Daytime fatigue is an indicator of sleep-disordered breathing. Researchers studied 1,171 patients seeking treatment for chronic pain,
sleep-disordered breathing, or both. Each subject attended one of 11
international treatment centers. The results showed a high instance of
comorbidity , in which patients experienced both sleep-disordered breathing
and craniofacial pain, including headaches. The study also demonstrated,
for the first time, a link between craniofacial dysfunctions,  such as a
locking jaw, and poor sleep scores. (We will look at sleep-disordered
breathing, including OSA, in much more detail in the next chapter .) As with other conditions where chronic pain is a characterizing factor ,
there is considerable evidence that heightened pain sensitivity and
psychological distress can contribute to the onset and persistence of
TMD.42 Further evidence suggests that imbalances in the autonomic
nervous system factor in the development and persistence of the condition. TMD is associated with a stronger sympathetic response and lower
baroreflex sensitivity . In one 2018 study , researchers found that patients
with TMD had significantly lower heart rate variability (HRV), higher pain
intensity , and increased cortisol levels when compared with a control group
of peopl e witho ut TMD.43 The study’ s findings indicate that people with
TMD could benefit from interventions such as breathing retraining to
restore autonomic function and stress balance. Breathing pattern disorders are also common in people with
fibromyalgia.44 This fact is not widely recognized, and the clinical
effectiveness of breathing retraining is often overlooked.44 It is, however ,
necessary to practice breathing exercises daily for several weeks or even
months to achieve results. According to a 2017 article by Leon Chaitow ,
when a chronic  pain condition such as TMD or fibromyalgia exists, the
“layers of pain and fatigue” that build up as a result of dysfunctional
breathing can be helped by improving breathing habits.44 In these pain
conditions, he recommends that manual therapy be used alongside
breathing exercises to help restore functional movement, explaining that“active trigger points . . . may need to be deactivated manuall y.” He also
suggests that relaxation techniques can be helpful and that sleep
disturbances are likely to require “attention and advice.”44
PROPRIOCEPTION: BREA TH AND MOVING IN SP ACE
Research has identified a connection between breathing pattern disorders
and joint position sense error. A 2019 paper in the Journal of the Korean
Society of Integr ative Medicine  found that patie nts with chronic lower back
pain and joint position error had low levels of blood CO2, fast respiratory
rates, and chest breathing—all symptoms of chronic hyperv entilation45. Joint position error can be best described as your ability to accurately return
your head to a predefined position after a neck movement.46 It is used by
doctors to evaluate proprioception  because joint position sense error can
result from faulty proprioception. The term proprioception  is used to describe our perception of
movement. It encompasses things like spatial awareness and how the body
positions itself in space, ensuring that the brain knows where the arms and
legs are so that the body can coordinate movement. It is controlled by cells
called proprioceptors that process sensory information when the body
moves.47 Proprioception makes it possible to bring a cup to your mouth
with appropriate speed and force so that you don’ t pour the contents all over
yourself or throw hot coffee in your own face. People with poor
proprioception often appear to have weak muscles and difficulty
balancing.47
The muscles in the neck are instrumental in proprioception, so they are
particularly important to postur al control. The small muscles in the head
and neck contain a high number of something called muscle spindles . Muscle spindles are stretch receptors (mechanoreceptors) in the muscle
fibers. When you move your head, these spindles send inform ation to the
nervous system about the length of the muscles.48 The high concentration of
muscle spindles in the soft tissue of the neck provides the nervous system
with information  about the positioning of the head in relation to the rest of
the body .People with joint position sense error have an increased incid ence of
neck pain.46 Many studies have shown reduced postural control with neck
pain49 and following fatigue, anesthesia, or vibration of the neck musc les.50
According to one 2019 study , the neck area is the only region with direct
access to the senses of sight and balance.45 While many different
mechanisms and systems contribute to a healthy sense of proprioception,
disturbance to the nerve signals in the neck is believed to be one possible
cause of symptoms including unsteadiness, dizziness, chronic lower back
pain, and dysfunctional postural stability .45
SUBSYSTEMS OF POSTURAL ST ABILITY
Problems in the three dimensions of breathing can lead to a variety of
painful postural adaptations. In 1992, Yale University Professor Emeritus
Manohar Panjabi suggested another way to understand spinal stabilization
and its impact on the body’ s system.51 Panjabi suggested that the stability of
the spine relies on three subsystems:
1. The passive subsystem—the vertebrae, discs, and ligaments
2. The active subsystem—all the muscles and tendons surrounding the spinal column
that can apply forces to the spinal column
3. The neural subsystem—the nerves and central nervous system, which assesses
what is needed for spinal stability by monitoring signals and directs the active
subsystem to provide that stability51
Dysfunction in any of these three subsystems may lead to short-term
compensation by the other subsystems, long-term adaptation, or injury51. When adaptation is only temporary , it is still possible for the system to
maintain normal function, but when the problem persists, alterations
develop in the systems that stabilize the spine. When injury occurs,
dysfunction is introduced into the whole system. This manifests as
symptoms including lower back pain. Conversely , when these subsystems
function correctly , the body can adapt to accommodate extra loads or
complex postur es. In this instance, the neural subsystem works to alter
recruitment of muscles to temporarily “superchar ge” spinal stability . Significant evidence indicates how altered breathing patte rns can
negatively influe nce these neurological and muscular systems, contributingto the onset or persistence of dysfunction in the lumbopelvic region. Let’s
look at this in terms of the three dimensions of treatment for breathing
pattern disorders:
Biochemical:  Hyperventilation decreases levels of blood CO2 and
causes a higher pH in tissues and body fluids. This triggers changes in the
nervous system and the way it moderates input from the eyes and ears, and
negatively impa cts postural control.52 Breathing exercises that normalize
levels of blood CO 2 help bring these systems back into balance. Biomechanical : Fatigue in the inspiratory muscles causes “a rigid
proprioceptive postural control strategy ,” like that observed in patients with
lower back pain. You know how stiffly you hold your muscles  when your
back hurts in an attempt to avoid pain? This actually inhibits postural
stability and may explain why many people with lower back pain
experience recurrence of their injury .53
When the breathing muscles become overworked and exhausted,
proprioceptive input from the lower back also becomes less reliable. This
disrupts the way the brain receives and processes information and can
impact postural control. Remem ber, diaphragm function is a key aspect of
spinal stability through the creation of IAP. The diaphragm is the primary
muscle of the respiratory system and sustains posture and stability . When
chronic over breathing occurs, the diaphragm cannot maintain support of
both systems. Postural control will be compromised as the body always
prioritizes its need for oxygen. By practicing diaphragm breathing through
the nose, you will increase oxygenation and gain better postura l support of
the spine and pelvis. Cadence:  A pape r from 2020 reported that paced diaphragm breathing
at six breaths per minute can reduce pain. This effect was enhanced when
the exhalation was longer than the inhalation.54 This may be because
autonomic imbalance can itself directly contribute to pain. Breathing at six
breaths a minute activates the parasympathetic nervous system, inhibiting
sympathetic stress activation. There is a direct relationship between the level of diaphragm
dysfunction and the intensity of pain experienced by people who suffer with
lower back problems. One explanation is that, when chronic back pain is
present, the sympathetic nervou s system, which is responsible for the fight-or-flight response, becomes overstimulated. An overactive stress response
makes the body more sensitive to touch and increases perception of pain.55
Also, when breathing is predominantly into the upper chest, as it is when
the diaphragm is not functioning properly , it tends to involve a lar ge volume
of air and decrease in blood CO2. This creates a biochemical trigger for
panic symptoms, which feeds back into the stress response, making anxiety
worse. When treating musculoskeletal  pain, it is important to look at the
problem holistic ally. Trigger points can be deactivated with manual therapy . Pain in the spine and joints can be viewed in terms of muscle tension or as
the body compensating for muscle dysfunction by recruiting smaller
muscles. Alongside this, it is important to acknowledge the role of lifestyle,
psychological factors, and habits including sleep, posture, and breathing.56
It turns out that if you want to address chronic pain, the breat h, the most
fundamental and sustaining of all movement patterns, is a very good place
to start. OceanofPDF .comSCHAPTER SEVEN
SLEEP-DISORDERED BREATHING
leep is a behav ioral and neurological state in which homeo static
functions essent ial to health and well-being occur .1 Modern science
doesn’ t yet fully understand the purpose of sleep or its physiological
relationship with the autonomic nervous system. However , significant
research confirms the relationsh ip between quality of sleep and breathing—
and highlights the fact that sleep disorders and sleep-disordere d breathing
(SDB) are increasingly prevalent. When you are asleep, you probably are not aware that your breathing is
causing problem s. Your partner may complain that you snore, but unless
you know how to spot the signs, there’ s little obvious feedback as to
whether you breathe through your mouth or nose, or how fast, slow,
shallow , or deep your breathing  is.2,3,4 Regard less of your awareness, the
body prioritizes respiration. How you breathe when you are asleep is very
important. Just as your waking breathing patterns affect the functions of
your brain and body , nighttime  breathing affects the quality of your sleep
and to a lar ge extent, how each day subsequently unfolds. In the introduction to this book, I recounted how exhausted I felt during
my teens and early twenties due to poor breathing and sleeping habits. This
all changed after I learned to decongest and breathe through my nose and to
slow down my breathing. Two days after switching to nasal breathing
during sleep, I experienced what it was like to wake up feeling refreshed
and alert. I remember being amazed at the difference. Even if you don’t feel
like you are sleeping badly , if you suffer with nasal congestion due to
allergies, asthma, or rhinitis, you are almost twice as likely to experience
moderate to severe sleep-disordered breathing.5The following symptoms occur in people with SBD:
• Insomnia
• Snoring
• Sleep apnea
• Disrupted sleep
• Nightmares
• Nighttime asthma symptoms (usually around 3 a.m. to 5 a.m.)
• Needing to use the bathroom during the night
• Bed-wetting in children
• Fatigue first thing in the morning
• Dry mouth
• Symptoms upon waking, such as wheezing, coughing, breathlessness, or a stuf fy
nose
If you or your child commonly experiences one or more of these, it is likely
that you already know how disruptive insomnia, snoring, and sleep apnea
can be to sleep. A low BOL T score corresponds with strenuous,  upper chest
breathing and will result in many of the symptoms listed above. If you would like to sleep better and wake up feeling energized and
refreshed, this is easily achievable if you commit to adopting good
breathing habits  and increasing your BOL T score. The light, calm, nasal
breathing taught  throughout this book reduces snoring and obstr uctive sleep
apnea and activates the body’ s relaxation mode, leading to deeper and
better -quality sleep. By improving your BOL T score, you will regain
control of your breathing and alleviate many common problems. MOUTH BREA THING DURING SLEEP
To some extent, the knowledge I’m about to share with you has been around
for a long time. Yet for some reason, it has failed to become  part of the
common consci ousness. Way back at the end of the sixteenth century , the
Dutch physician and author Levinus Lemnius noted that breathing through
an open mouth results in poor sleep quality6. Around 200 years later in
1869, the American painter , author , and traveler Geor ge Catlin published a
book called Shut Your Mouth and Save Your Life. Caitlin observed that
Native America ns had a technique to ensure their babies main tained nasal
breathing during  sleep. He saw that each time a baby breathed through its
mouth, the mother would gentl y press the child’ s lips together to restorenasal breathing. In contrast, he described European settlers gasping for
breath through open mouths as they slept. Mouth breathin g in adults has attracted only limited research. This
creates some difficulty when it comes to determining exactly how common
the problem is. However , many of us spend at least part of the night
breathing throug h an open mouth. It has been proven that the habit of
mouth breathing during sleep is to some extent age-related. By the time you
reach 40, you are around six times more likely to spend at least 50% of your
sleep switching between nasal and oral breathing.7
It is generally agreed that mouth breathing develops because the ability
to breathe nasally is impaired in some way.8 If the incidence and impact of
mouth breathing  still attracts debate among experts, it is simply because
total mouth breathing rarely occurs. A paper published in the American Journal of Orthodontics and
Dentofacial Orthopedics  in 1988  assessed the relations hip between nasal
obstruction and nasal-oral breathing in 116 adults. Researchers aimed to
determine the switching range from nasal to nasal-oral breat hing and to
quantify the term “mouth breathing.” They found that breathing habits are
affected by the size of the nose—97% of subjects with small noses were
mouth breathers to some extent, while only about 12% of those with an
adequate airway habitually mouth-breathed8. What is not fully understood
is whether the small size of the nose causes mouth breathing or whether
mouth breathing results in an underdeveloped nasal airway . There is significant evidence that mouth breathing influences the way
the face, jaws, and upper airways develop—which is one reason why
research in this area is so heavily weighted toward child ren. Mouth
breathing in childhood can result in poor development of the airways and
contribute to habitual mouth breathing in later life. INSOMNIA
Insomnia is defined as difficulty  falling or staying asleep, waking early , and
experiencing interrupted or nonrestorative sleep.9 “Tired but wired” is the
phrase often used by my clients. Insomnia is one of the most common sleep
disorders. According to 2007 research, it affects between 25% and 30% ofthe general population, with 10% of people presenting chronic complaints
and seeking medical help.9 It is frequently caused, at least in part, by
psychological factors, such as anxiety , depression, periods of prolonged
stress, an overactive mind, or a reaction to a traumatic event. Anyone who has had trouble sleeping will relate to the frustration
associated with insomnia, the sense of irritation or even desperation,
frequently aggra vated by persistent thoughts that simply won’ t go away . Even if you have never experienced insomnia, I am sure you have, at some
time, found it difficult to fall asleep due to stress or worry . A niggling
internal monolo gue traipses back and forth through your mind, and you
spend the night twisting and turning instead of enjoying restful, deep sleep. If you do suf fer from this common sleep disorder , spend between 15 and
20 minu tes before sleep slowing down your breathing to achieve a tolerable
air hunger . This technique works for two key reasons. First,  by paying
attention to your breath, you take your focus away from the mind, thereby
reducing thought activity . Second, reducing the breathing volume activates
the parasympath etic relaxation response, making you more able to deal with
the physiological aspects of stress. One 2019 article by US scientis ts in Geor gia, explores the relationship
between insomnia and the therapeutic role of slow breathing.1 Deep
breathing is often used for relaxation in insomnia, but much less research
has been done into the therap eutic benefits of slow breathing. This is
despite the fact that autonomic dysfunction often plays a role in insomnia
and slow breathing can increase vagal tone, promoting better quality
sleep.10
The average adult needs at least seven hours sleep every night.
_OceanofPDF.com_The_Breathing_Cure_-_Patrick_McKeown.txt
Summarize the following text section accurately and concisely. Maintain specific details and numerical information, and use anti-repetition mechanisms:

        According to Alison McConnell’ s book, Breathe Str ong,
Perform Better, the lungs do not respond to physical training. 35 Research
confirms that lung volume and function, including the ability of the lungs to
transfer oxygen to the blood, is not improved by training. 35–38
During intense physical exercise, the breathing rate can increase to
between 40 and 50 breaths per minute. Since the volume of each breath is
around 3 liters of air, this equates to a breathing volume of as much as 120
to 150 liters per minute. For Olympic-level male endurance athletes, the
tidal volume (volume of air per breath) can be as high as 5 liters. Thisresults in a minute ventilation of 200 to 250 liters. 35 Bear in mind that
normal resting minute ventilation is between 5 and 8 liters, increasing to 40
to 60 liters during moderate exercise. WHEN THE BREA THING MUSCLES TIRE
Because breathing increases substantially in this way during physical
exercise, the extra work of inhaling and exhaling places much greater
demands on the breathing muscl es. Unsurprisingly, this often causes fatigue
in those  musc les. According to the Lore of Running, by exercise
physiologist Tim Noakes, there is strong evidence that the diaphragm
(which is our main breathing muscle) and other respiratory muscles may
become exhausted during both short-term high-intensity exercise, such as
MMA or boxing, and extended activities like marathon running. 39
The ventilatory response to CO2 influen ces the work of the breathing
muscles during physical exercise. If you have a low BOL T score, you will
need to breathe harder. Effortful breathing like this requires significant
increases in respiratory muscle work, both on the inhalation and on the
exhalation. 40 As the breathing muscles tire, blood flow is diverted from the
legs to help support respiration. The decrease in blood flow to the working
muscles causes the legs to becom e fatigued, and you will be forced to slow
down or stop. As the breathing muscles overexert, metabolic by-products,
such as lactic acid, accumulate in the blood. Too high a concentration of
these metabolites further reduces blood circulation, hampering blood flow
to the limbs. Research into breathing techniques has shown that, when the
effort of inhalation is reduced, blood flow to the legs increases by up to 7%. Evidence suggests that the diaphragm is the most important breathing
muscle to target during respiratory muscle training. For instance, one 2016
study demonstra tes that over 50% of healthy athletes with varyi ng levels of
fitness will develop diaphragmatic fatigue after bouts of high-intensity
exercise. 41
EXERCISING THE BREA THING MUSCLESIt is widely accepted that to stimulate any muscle to adapt, that muscle must
be worked harder than usual. But since aerobic physical exercise is
practiced within the comfort limits of the breathing muscles, it cannot
provide sufficient stimulus to cause the breathing muscles to adapt. In fact,
it is impossible for most people to sustain high-intensity exercise for long
enough to provide a load sufficient to improve the stren gth of the
respiratory muscles. However, the Oxygen Advantage exercises (see
Chapter Two) provide a meaningful strategy to improve respiratory muscle
strength, as that extra load can be added to the breathing muscles in a
nonstressful and controlled environment. In terms  of function, respiratory muscles are divided into the inspiratory
muscles, used during inhalation, and expiratory muscles, used during
exhalation. Exhaling requires less effort than inhaling, as the natural
elasticity of the breathing muscles helps push out the air. Therefore, it is the
inspiratory muscles that are most prone to fatigue. That is why the practice
of breathing against resistance, or inspiratory muscle training, specifically
targets the inspiratory muscles. This resistance can be provided by a SportsMask, a training support that
makes the breathing muscles work harder. The SportsMask has an
adjustable valve  opening, making it possible to vary the level of resistance
during inhalation. This resistan ce conditions the breathing muscles in a
manner similar to the progressive muscle training achieved in weight
lifting. The technique of restricting airflow with a specialist device is called
inspiratory flow resistive loadin g (IFRL). Studies show that it can improve
respiratory muscle strength between 20% and 50%. Breath holding,  done properly, can also provide a workout for the
respiratory muscles. Holding the breath after a passive exhalation creates a
strong air hunger and disturbs  the blood’ s acid-base balance. When the
breath is held, excess CO 2 cannot leave the blood through the lungs, and the
cells continue to extract oxygen. This alters blood gas concentrations,
increasing CO2 (hypercapnia) and decreasing oxygen saturation (hypoxia). Because CO2 levels are the primary stimulus to breathe, the excess CO2
will cause the breathing muscle s to respond. To restore blood gas levels to
normal, the respiratory center begins to send messages to the breathing
muscles to resume breathing. As the breath hold continues, these impulsesincrease in intensity, causing repeated contractions of the diaphragm. This
is somet imes called the “struggle phase. ” As the diaphragm continues to
contract through the breath hold, it essentially receives a workout. According to a 2013 study of maximal breath hold in free divers, the
relative intensity of diaphragmatic and inspiratory rib-cage muscle
contractions increases by aroun d 5 and 15 times respectively, from the
beginning to the end of the struggle phase, approaching potentially
fatiguing levels by the time breathing is resumed. 42
In 2016,  scienti sts at the Unive rsity of Zagreb, Croatia, ran a study to
determine the effects of hypercapnic-hypoxic training on respiratory muscle
strength among elite swimmers. Those swimmers who were subjected to a
hypercapnic-hypoxic regimen significantly improved the stren gth of their
inspiratory muscles when compared to swimmers who breathed normally. Participants who reduced their breathing improved their inspiratory muscle
strength by 14. 9% and expirator y muscle strength by 1. 9%. The researchers
noted that voluntary breath holding might have resulted in involuntary
contractions of the breathing muscles, increasing diaphragm thickness. 43
The thickness of the diaphragm plays an important role in sporting
performance and endurance. The precise mechanisms by which respiratory muscle training improves
exercise performance have not been fully determined. The positive effects
on endurance may be due to the direct impact on fatigue in the respiratory
muscles. Indirectly, the improved blood flow to working muscles that
comes from more efficient breathing and better oxygenation is also
beneficial. It is also likely that the increased resistance to breat hing during
respiratory muscle training may simply make normal physical exercise feel
easier. 44
When the breathing muscles are stronger, they are better able to cope
with more intensive training. This means that more intense exercise is
possible before the metaborefl ex reduces blood flow to the legs. This
ultimately improves performance as well as endurance. The effects of
respiratory muscle training have been shown across a variety of sports,
including rowing,45 sustained heavy-endurance exercise,46 and cycling. 47A SIMPLE MEASURE OF DYSFUNCTIONAL
BREA THING
As we’ve seen, breathing pattern disorders are multidimensional, comprised
of a series of biochemical, biomechanical, and psychological components. So, it can be difficult to achieve a definitive diagnosis with any single test. Also, many methods to assess dysfunctional breathing rely too much on
subjective infor mation. As with any dysfunction, the body and mind can
adapt to a certain degree until the problem becomes normali zed, and so
personal experie nce rarely provides clear information. This is perhaps part
of the reason why breathing pattern disorders are so often overlooked in
physical therapy. In 2017, the lack of effective screening was addressed by a research
team led by Dr. Kyle Kiesel, a professor and chair of physical therapy, who
has done extensive research in areas including motor control of the core and
functional movement. 2 The result was a simple screening procedure to
enable fitness and healthcare providers to accurately identify disordered
breathing in their patients. 2 Kiesel’ s study examined 51 subjects, 27 females
and 24 males, with an average age of 27 years and a BMI of 23. 3. Breathing
was assessed in terms of biochemical, biomechanical, and psychological
function. The biochemical  dimension of breathing was evaluated by monitoring
ETCO 2. ETCO 2 is the average amount of CO2 in exhaled air. This is
measured using capnography, which measures the pressure of blood CO2,
because normally the pressure of CO2 in the lungs determines the pressure
of CO 2 in the blood. The normal range of ETCO 2 is betwe en 35 mmHg and
40 mmHg. Less than 35 mmHg suggests the presence of dysfunctional
breathing. 21
The biomechanical  dimension was assessed using a test called the Hi-
Lo. This is a visual evaluation during which abdominal expansion and
perceived displacement and functional movement of the upper and lower
rib cage are recorded. The patient lies face up and breathes normally, with
one hand  on the chest and the other on the abdomen. How much  the tummy
and ribs move during a normal breathing cycle is measured. For the psychophysiological  dimension of the experiment, participants
answered questions from the Self-Evaluation of Breathing Symptoms
Questionnair e (SEBQ) and Nijmegen Questionnair e (NQ). The NQ has
been a popular screening tool for the diagnosis of hyperventilat ion for over
30 years. It gives a broad view of symptoms associated with dysfunctional
breathing and asks 16 question s about breathing discomfort. The patient
responds using a numbered scale ranging from “never” (0 points) to “very
often” (4 points). A score of 23 points or more is considered to indicate the
presence of hyperventilation syndrome. 48
I am not a fan of the Nijmegen Questionnair e. Its questions neglect
some of the most common signs of breathing pattern disorders. It does not
include frequent sighing or yawning, nasal congestion, fatigue, or
wheezing. While it could be argued that these are omitted because they are
all caused by organic conditions, people with these symptoms generally do
have breathing pattern disorders. On the other hand, the NQ does include
symptoms such as confusion, tingling and stiffness in the fingers, stiffness
in the arms, and tightness aroun d the mouth. In almost 20 years of teaching
exercises to address chronic hyperventilation, I’ve only seen a handful of
people present with those symptoms. Kiesel’ s team failed to find any strong correlation between the 3
measures of disordered breathing. 2 This goes some way to explaining why
these common methods of diagnosis are so continually unreliable. Of the
participants, 5 were deemed to have normal breathing, 14 failed at least 1
measure, 20 failed at least 2 of the measures, and 12 failed all 3. Only 10%
of partic ipants who passed all three dimensions of breathing actually had
normal breathing. While the capnometer, Hi-Lo  test, and self-evaluation questionnaires
were found wanting, Kiesel discovered that a simple screening test could
accurately asses s the presence of dysfunctional breathing. The proposed test
consisted of just four question s from the Functional Movement Screen
(FMS) and a breath-hold time of 25 seconds. FMS identifies physical weakness and imbalance. To assess movement
patterns crucial to normal mobility, it uses a straightforward ranking and
grading system of seven functio nal movements. These are deep squat, in-
line lunge, hurdle step, active straight leg raise, shoulder mobility, trunkstability push up, and rotary stability. It pinpoints any functional limitations
and asymmetries that may inhibit the ability to move correc tly or train
without injury. The four questions Kiesel found effective to diagnose
dysfunctional breathing ask whether the patient feels tense, has cold hands
or feet, yawns frequently, or mouth breathes at night. These symptoms are
all common among people with breathing pattern disorders. To accurately measure breath-hold time, each participant was directed to
hold the breath at the end of a standard exhalation. The breath-hold was
measured until the tester noted the subject’ s first involuntary contraction of
the diaphragm or throat muscles. 2 This technique  exactly replicates the
BOL T measurement that we use in the Oxygen Advantage. Kiesel’ s team concluded that, if an individual passed the screening
composed of the four questions plus the breath-hold test, there was an 89%
chance that their breathing was not dysfunctional. The test, therefore,
provides an easy way for clinicians to accurately detect DB in their
patients. 2 In the same way, the BOL T provides an accurate measure of
functional breathing. By checking your BOL T score and observing what’ s
going on in your body, you can assess your own breathing witho ut the need
for fancy equipment. This puts you in a strong position to tackle the
problem. WHA T DO FUNCTIONAL MOVEMENT SCORES MEAN FOR
PERFORMANCE. Dr. Paul Sly is an Oxygen Advantage Master Instructor in Canada. He has
more than 25 years’ experience as a practicing chiropractor and is an
acupuncture provider, certified in Functional Movement Systems. He sent
me this explanation of functional movement screening and its implications
for functional breathing and performance:
In Functional Movement Systems, there is the Functional Movement
Screen (FMS) and the Selective Functional Movement Assessment
(SFMA). The FMS is a performance enhancement tool, while the
SFMA is the clinical arm, designed to arrive at a diagnosis. I use
both, but as a clinician I use the SFMA a lot. In particular,
“breakouts” of the movement patterns determine whether a specificdysfunction is a Tissue Extensibility Dysfunction (TED) or a
Stability or Motor Control Dysfunction (SMCD). Take the classic standing toe touch. If an individual can’t do
that, there are two possibilities. Either something (typically the
hamstrings) along the posterior chain is too tight (TED) or the
patient can’t stabilize their core well enough to allow the hips to
shift back and the spine to flex (SMCD). We are finally  coming around to the idea that functiona l
breathing, recruiting a strong diaphragm with appropriate timing, is
a big part of core stabilization. When breathing is dysfunctional, it
can create a SMCD. What also happens, however, is that TEDs  will
cause an individual to change their breathing patterns. For insta nce,
people often hold their breath  in order to try to overcome the
dysfunction. A TED can therefore cause a breathing pattern
disorder, which in turn can cause or exacerbate a SMCD. So,
breathing can be, and often is, central to both types of dysfunc tion. If you can’t breathe functionally through a particular movement or
posture, then you don’ t “own” that movement or posture. This has significant implications for professional athletes. It also
contributes to the huge rise in incidence and cost of repetitive strain
injury in many occupations and workplaces. The other overlooked and interesting application of functional
breathing is for cognition in sport, especially team sport. I always
tell the hockey players I work with that, while the mistakes you see
players make, especially towa rd the end of a game, are often
attributed to “pressure,” they are also, at least in part, due to the
continual hyperventilation you see on the bench during recovery. During recovery, players breathe through an open mouth, resulting
in a decrease in cerebral blood flow that impacts their ability to
think clearly. Nasal, functional breathing during recovery from an
acute anaerobic bout, makes a difference to cognitive ability which
is vital for perfo rmance. I’m not aware of any study backing this up,
and I’m not sure how such a study could be designed, but I have
seen it in action, and it makes sense. —Paul SlyFUNCTIONAL BREA THING IS FUNCTIONAL STRENGTH
Tim Anderson is cofounder of Original Strength and has been a personal
trainer for more than two decades. He is a well-known author and a sought-
after speaker. He has written and cowritten books on this subject, including
The Becoming Bulletpr oof Project. As I was preparing the final manuscript
for this book, Tim wrote to me with the following practical explanation of
the science we have covered in this chapter:
Strength starts with breath. Proper breathing literally strengthens the
body from the center out. The diaphragm is the chief spinal
stabilizer of the inner core muscles. When it is functioning properly,
when it is being  used to fill the lungs from the bottom to the top, it
rhythmically dances with the pelvic floor. This dance, which also
involves the transverse abdominus and the multifidi, stabilizes the
spine and pelvis. When the diaphragm is functioning properly, the
pelvic floor and the other spinal stabilizers are getting the
stimulation they need to function properly. This is the foundation  for
a strong, powerful and ef ficient moving body. A body  that has a properly functioning diaphragm, a nasal
breather who keeps their tongue  on the roof of their mouth and fills
their lungs up from the bottom to the top, has a nervous system that
feels safe to express itself without restriction. Not only does this
result in better performance in speed, strength, power and efficiency,
it results in a more resilient and durable body, a body that is less
prone to injury. Trying to expres s strength and power while mouth breathing not
only throws the nervous system into the sympathetic mode, it causes
the body  to recruit prime movers to stabilize the spine because the
inner core unit’s chief stabilizer (the diaphragm) is not functioning
optimally. This compensation can lead to poor performance and
even injury. It may help to think of the body  as an “X”. Functional breathing
creates a body with a solid center, a reflexively strong inner core
unit. When the body has a strong center, the forces it creates  and
encounters can easily and efficiently travel from one side of thebody to the other, through that solid center. The result is a body that
can move with grace, ease, and power. Dysfunctional breathing creates instability of the spine because
the inner core muscles are not able to properly do their job. This
means when the body creates or encounters force, those forces
cannot efficiently travel through  the center of the body. Instead, they
may end up in regions of the body they shouldn’ t causing movem ent
issues, pain, or injury. Typically, the body of a dysfunctional
breather, does not express optimal, fluid posture, or ease of
movement. It lacks a poetry of movement because the body cannot
express its full movement potential. I like to tell people that breathing properly, nasal breathing with
your tongue on the roof of your mouth, filling your lungs up from
the bottom to the top, gives you a center of strength. It makes  the
body and mind strong and resilient. Improper breathing, mouth
breathing, filling  the lungs up from the top, rarely filling the bottom
of the lungs; gives the body a soft or hollow center. It leaves  the
body and mind weak and fragile. In other words, mouth breathing  can create fragility while nasal
breathing can create resiliency. —Tim Anderson
OceanofPDF. comACHAPTER SIX
WHEN BREATHING MAKES YOU HURT
PAIN IS A SIGN OF DYSFUNCTION
s we have been discussing, the diaphragm, the primary respira tory
muscle, is essential for stabilizing the core, spine, and posture. Dysfunctional breathing can compromise the body’ s fundamental
stability. Poor breathing patterns can also cause pain in sometimes
unexpected places. Over time, poor breathing patterns create faulty
movement patte rns that lead to pain and injury in the muscles, tendons, and
joints. For instan ce, if you breat he into the upper chest, alteratio ns occur in
the position of your lower ribs, which need to move up to allow enough air
into the lungs. The result is likely to be pain or dysfunction in part of the
spine. If you continually neglect the primary muscles that hold your body
upright, such as the core and the diaphragm, the body will compensate by
overusing smaller muscles that aren’ t really designed for the job. This is
why muscular adaptations caused by breathing pattern disorders can
contribute to all sorts of pain conditions that you might not intuitively
associate with breathing. For example, paradoxical breathing, a
dysfunctional breathing pattern in which the abdomen contracts on
inhalation and expands on exhalation, often coexists with muscle
imbalances and pain in the cervical spine. Weakness in the pelvic floor
muscles can show up as injuries in areas as varied as the knee,1,2 ankle,
anterior cruciate ligament,2 and lower back. 3 Problems in the hands can be
caused by tension in the should ers and neck stemming from dysfunctionalbreathing. 4 Poor blood flow to the brain caused by chronic hyperventilatio n
can result in excruciating headaches. 5
Imbalances in the autonomic nervous system, which can be influenced
by breat hing, can also lead to pain. For the body to move, the nervous
system and muscles must work together. If problems exist in either system,
the other will adapt to compen sate. This is why autonomic dysfunction
caused by psychological stress can display as physical symptoms. Stress has been clearly identified  as both a contributing and a risk factor
in musculoskeletal injuries and chronic pain. In one 2012 study, researchers
observed patien ts with ongoing shoulder and neck pain and found that
sympathetic activation was dominant and the parasympathetic system was
suppressed, suggesting an imbalance in the autonomic nervous system. 6
When the nervous system is in a state of heightened arousal, the body is
likely to adjust breathing patte rns to restore homeostasis. This alters the
recruitment of respiratory muscles, impacts motor control, and leads to
chronic or acute musculoskeletal pain. Another valuable window into how well the body’ s systems are
functioning is provided by myofascial trigger points. These are tender areas
in the muscles that often cause referred pain, a phenomenon where pain
originating in one place shows up elsewhere in the body. Trigger points
manifest as muscle stiffness, weakness, dizziness, nausea, and postural
distortions. 7 Left untreated, they can result in ongoing disruption of
movement patterns. Trigger points can be activated by psychological stress. In 1994, researchers observed what happened to a trigger point under
different conditions, including mental stress induced by an arithmetic task. The results showed that the trigger point was stimulated during stress,
suggesting that physical pain is directly influenced by the emotio ns. 8 A new
paper from 2020 suggests that the stronger stimulation of the baroreflex that
occurs during guided slow, deep breathing may offer a “cheap-and-easy
way to ‘behaviorally’ stimulate  the afferent vagus and reduce  pain,” but
still, not much is known about this pathway. The stimulation and function
of the barorecep tors have not been well studied in research examining the
impact of slow, diaphragm breathing on pain, but it is known that the pain-
blocking effects of baroreceptor stimulation are lessened during mental
stress. 9A 2016 study explored the assessment and treatment of breathing
pattern disorders in three patients whose musculoskeletal pain complaints
were related to trigger points, motor control adaptations, and muscle
imbalances. 10 The participants were treated using breathing exercises and
manual trigger point therapy. Breathing reeducation focused on a physical
exercise called the “clamshell exercise,” which is designed to alter intra-
abdominal pressure and prompt the patient’ s breathing reflex. Pain
decreased in all three participants, although it was unknown whether this
was due to impr ovement in diaphragm function and core stability, lessening
of tender trigger points, or the restoration of functional movement. 10
According to researchers, breathing therapy is not typically considered to be
as effective as physical therapy in the treatment of pain conditions, yet there
is clear evidence that it is possib le to achieve similar improvements in pain,
function, and physical and emotional factors with both techniques. 11
While we have so far focused on the diaphragm, both in terms of its
importance for functional breathing and its role in spinal stabil ity, it’s also
helpful to acknowledge other respiratory muscles. The diaphragm is
responsible for around 70% to 80% of the work of respiration under quiet
breathing conditions. The other  30% is performed by the scalene, external
intercostals, sternocleidomastoids, and parasternal intercostal muscles. 12
The scalene muscles are a group of three pairs of muscles in the sides of
the neck. They are called secon dary breathing muscles but are considered
by some  scientists to be primar y to respiration as they lift and expand the
rib cage during inhalation and are active at a low level even during light
breathing. 13 It’s easier to see these muscles at work during exercise, when
ventilatory demand is high. 13 Trigger point pain in the scalene muscles is
often associated with pain radiating to the arm, which is commonly
misdiagnosed as disc herniatio n or prolapse, neck pain, or carpal tunnel
syndrome. This type of misdiagnosis leads to mismanagement of the
condition which can perpetuate the existing problem. 14
BREA THING AND THE PERCEPTION OF P AIN
How we breathe directly affects how badly something hurts. Beyond factors
such as postural control and muscle tension, breathing pattern disorders canplay a role in the amplification of pain. 15 For instance, respiratory alkalosis
caused by overbreathing can induce muscle spasm and heighten the body’ s
response to stress hormones including adrenaline. These factors  combine to
create inadequa te blood flow and poor oxygenation of the tissues and
organs. One 2006 study used functional magnetic resonance imaging (fMRI) to
explore the way that hyperv entilation influences pain mechanisms. 16
Researchers found that low blood CO2 may affect the processing of motor
tasks and pain input. They discovered changes in the relative levels of
oxygenated and deoxygenated  blood, which they believed indicated
widespread constriction of blood vessels in the gray matter of the brain. This was thought to represent an acute reaction to reduced blood CO 2. Constriction of the blood vesse ls due to overbreathing stops the blood
from flowing freely to the brain and limits oxygenation of the tissues. 17
This has implications for the excitability of nerve cells in the brain and can
potentially impact both motor control and pain perception. Respiratory
alkalosis, caused by low levels of blood CO 2, increas es the sensitivity of the
peripheral nerves. The periphera l nerves send messages from the brain and
spinal cord to the rest of the body, allowing us, for examp le, to sense
whether our feet are cold and to move our muscles to walk. 18 This increased
sensitivity is what causes the muscular tension, spinal reflexes, muscle
spasm, and a much greater perception of pain, light, and sound, which are
all typical of alkalosis. Alkalosis can also cause mood swings, panic
attacks, anxiety, and phobic behavior,19 all of which can result in a negative
feedback loop of poor breathing and deepening psychological distress. The impact of hyperventilation  on the excitability of the neurons was
explored in a 1991 paper in Brain. Resear chers looked at the effects of low
blood CO2 on two condi tions that impact movement, paresthesia  and
tetany. 20 Paresthesia is an abnormal tingling or prickly sensation, like pins
and needles, which is caused by pressure on or damage to peripheral nerves. Tetany is a condition characteriz ed by spasms of the hands, feet, and voice
box; cramps; and overactive neurological reflexes. Tetany, which is
generally caused  by very low blood calcium levels, can also be the result of
severe alkalosis. Scientists monitored the excit ability of nerve fibers in six healthy
subjects. Partic ipants were asked to hyperventilate until paresthesia
occurred in the hands, face, and trunk. This occurred when the pressure of
alveolar CO2 had decreased by, on average, 20 mmHg. Spontaneous EMG
activity—muscle activity in response to stimulation by the nerves—
developed when CO2 had dropped by a further 4 mmHg. Neuronal
excitability increased progress ively in all participants as CO2 levels
dropped, producing a “statistica lly significant inverse correlat ion. ” When
neurons or nerve cells are “excitable,” it means they are generating
electrical impulses that transmit information throughout the nervous system. The changes in the neurons happened before any sensation of paresthesia or
tetany developed. Two of the subjects also perceived spontaneous bursts of
neuronal activit y to be pins and needles. The study concluded that the
physical symptoms of paresthesia and tetany induced by hyperventilation
were entirely the result of changes in neuronal excitability. 20 This is best
described as hyperventilation causing an imbalance in the electrical
equilibrium of the brain due to constriction of blood vessels in the brain,
and this causes the physical symptoms. BACK P AIN
When researchers looked for links between health, pain histories, and faulty
breathing, they found a much higher prevalence of dysfunctional breathing
than expected. Their 2003 paper published in the Journal of Bodywork and
Movement Therapies  examined 111 patients attending a clinic for
chiropractic pain. To their surprise, more than half of the study participants
demonstrated faulty breathing on relaxed inhalation, and three-quarters
breathed in a dysfunctional way when taking a deep breath. Nearly 90% of
the subjects had experienced some kind of musculoskeletal pain in the head,
neck, back, buttocks, leg, or arm. Based on their findings, the report’ s
authors commen t that clinicians can expect three in every four new patients
to have faulty breathing patterns. 19
As we already know, in a healthy body, the diaphragm dyna mically
stabilizes the lumbar spine, lowering on inhalation. Together with the
expansion of the lower ribs, this creates sufficient intra-abdominal pressurefor postural stability. In people with chronic lumbar problems, the
diaphragm remains higher and flatter, moving less. During inhalation, the
ribs do not move, and the diaphr agm does not lower to its usual fixed point. Consequently, the body becomes less able to regulate IAP, and the lumbar
and sacroiliac regions become unstable. According to a 2016 study from  the Osteopathic Centre for Research
and Studies in Ancona, Italy, people who suffer from pain in their lower
back and sacroiliac joint often have early fatigue of the diaphragm,
otherwise descri bed as poor diaphragmatic endurance, which can be caused
by overe xertion of the respiratory muscles. 21 Breathi ng too hard, a feature
of chronic, effortful, inefficient overbreathing, can exhaust the breathing
muscles. A 2004 research paper by Dr. Leon Chaitow, a well-regarded osteopath
and naturopath, explains that the core stability of the diaphragm and abs can
be compromised  if both poor breathing and a “load challenge” to the lower
back are present. 3 A load challeng e is anything that adds a “load” or weight
to the task at hand, which, in this case, is movement. Chaito w uses the
example of shoveling snow, but digging the garden, pushing a pram, using a
vacuum cleaner, and many other day-to-day tasks have the same effect. Results showed that, after only 60 seconds with elevated blood CO 2, muscle
function was reduced or lackin g in postural muscles and in the muscles
used for movement. This underlines the extent to which chronic
dysfunctional breathing can interfere with the body’ s ability to move freely. Although more research is need ed, Chaitow’ s results were clear: increased
respiratory demand compromises postural control so that the likelihood of
spinal injury is significantly higher. This is especially true during strenuous
exercise when the load on the spine is greater. In 2018, scientists at South Korea’s Konyang University carrie d out a
study to monitor the effectiven ess of breathing exercises in patients with
lumbar instability and dysfunctional breathing. 22 Instability in the lower
spine causes pain even during simple activities like walking and sitting, and
it creates imbalances in the motor system. Many studies have reported that
the activ ation of muscles in the trunk is different in people with chronic
lower back pain. For instance, pain and dysfunction in the lower spine
affects the transversus abdominis muscles, leading to abnormal musclerecruitment patterns and excessive use of other supporting muscles to
compensate. 22
Twenty-seven adults aged between 20 and 40 years took part in the
study. Each person was assigned to a breathing exercise group or to a trunk
stabilization exercise group where they focused either on diaphragmatic
breathing or on physical exercises for 15 sessions over five weeks. One
focus of their breathing education was avoiding involuntary breath holding
when an extra load is applied. At the end of the study, significant
differences were observed in the lumbar area in the breathing exercise
group. Diaphrag matic breathing exercises had improved the mobility of the
sternum and ribs, allowing for thoracic extension, increasing intra-
abdominal pressure (IAP), and stimulating the abdominal muscles. 22
Back pain is incredibly common in the general population. It is also a
significant factor in sports. Lower back pain is the primary reason for
missed playing time among professional athletes. 23 Again, this is often due
to comp ensatory muscle activation. For example, dysfunctional breathing
correlates with an increased resting tone in the superficial abdominal
muscles. 24 Studies show evidence of delayed activation of the transversu s
abdominis muscle and heightened activity of the superficial lumbo-pelvic
muscles. If these muscles are overactive at rest, they can behave almost like
a corset. That bracing of the trunk, often associated with overinflation of the
lungs, may be the body’ s attempt to boost spinal stability with IAP. However, becau se the abdominal muscles are not working with the
diaphragm, it ultimately reduces stability. In treating back pain, it is important that clinicians and physical
therapists consid er the role of breathing and the respiratory muscles as well
as the stability of the trunk. While there are many exercises for the muscles
of the lumbar and pelvic regions, most fail to integrate breathin g. Adopting
a holistic, whole-body approach, in which respiratory patterns are
incorporated into various postures, makes it possible to better address back
pain. Just as important, correcting breathing pattern disorders can be
preventive, providing optimal stability for the spine and functional
movement, and better oxygenation of working muscles, meaning less risk
of injury in the first place. Dysfunctional breathing create s levels of anxiety that can be high
enough to alter physical balance and motor control. 3 Changes in respiratory
chemistry cause d by dysfunctional breathing can have profound effects on
the body ’s systems. A 2010 study of patients with back or neck pain found
that all participants had low ETCO 2. 25 Remem ber, low ETCO 2 is
considered a measure of breathing pattern disorders because it indicates a
low level of blood CO2, which is associ ated with hyperventilation. None of
the patients had had any success using manual therapy and exercise to help
with pain and mobility. However, when they practiced breathing pattern
retraining, all experienced improvements in ETCO 2, pain and function, with
93% achieving clinically significant changes. 25
When CO 2 levels are chronically low, the result is respiratory alkalosis. This causes symptoms such as decreased oxygenation of tissues and organs
(including the brain), higher pain perception, constriction of blood vessels,
and the onset of myofascial trigger points. Each of these, on their own, can
change the normal motor control of skeletal muscles. NECK P AIN
It is easy to understand why poor diaphragm control might cause back
trouble, but it may be less obvious why faulty breathing might frequently
lead to neck pain. 19 Between 10% and 20% of the population suffer with
neck pain every  year. 26 But how could  this be connected to the way they
breathe. The answer may lie in the biomechanics of dysfunctional breathing. One of the most common respiratory movement pattern faults involves
lifting the thorax with small muscles, such as the scalene muscles (the pairs
of accessory muscles at the sides of the neck), instead of allowing it to
widen naturally by IAP. This interference or “overdoing” puts a strain on
the uppe r spine and the muscles around the neck and can cause recurring
pain. 27
Like so many of the issues we’ve covered in this book, neck pain is both
caused by and the cause of dysfunctional breathing. A 2014 study observed
patients with chronic neck pain before and after a 30-minute breathingreeducation exercise. Researchers evaluated movement in muscles
including the anterior scalene muscles during normal and deep breathing. They found that pain intensit y and muscle activity were significantly
reduced after breathing reeducation. The study concluded that breathing
exercises can change breathing patterns and increase expansion of the chest,
leading to an improvement in the range of motion in the neck. 28 This
improvement could be attributed to better diaphragm function or to reduced
compensatory activity in other breathing muscles. A reduced ability of the abdominal muscles to maintain postural control
is also believed to lead to increased tone in the diaphragm and cervical
accessory muscles. In other words, when the core is not functioning well
enough to support the body, the diaphragm muscles and the breathing
muscles in the neck work harder to compensate. More muscle  tone is not
always a good thing. Instead of implying good health, it can indicate that a
particular muscle is overactive or tense. Increased tone of the diaphragm
and neck  muscle s has been observed in people with forward head posture,
chronic sinus problems, and temporomandibular joint dysfu nction,12 a
condition charac terized by pain and dysfunction in the muscles that move
the jaw and connect it to the skull. A 2002 empirical study showed a link between work-related
musculoskeletal disorders in the upper extremities and job stress. Previously, it had been unclear how psychosocial stress contrib uted to the
development of muscle and joint pain. 15 Researchers explain that the
respiratory alkalosis caused by excessive loss of CO2 during
hyperventilation triggers an unhealthy domino effect in the body, causing
physiological reactions, including muscle tension and spasm. 15
The shift from diaphragmatic to chest breathing typical in chronic
overbreathing causes biomechanical stress on the neck and shoulders. When
we breathe “big” into the upper chest, muscles in the neck and shoulders
compensate for the lack of diaphragm function. A theory centering on
hyperventilation provides a new way to understand how job stress factors
into the physi cal processes leading to work-related musculoskeletal
disorders. It also offers important insights into how employers might focus
interventions and manage individual stress in their employees. Understanding work-related injury in terms of hyperventilation provides aunique opportunity to address job stress and associated musculoskeletal
pain through breath reeducation, light exercise, and rest breaks. 15
Forward head posture can be caused by many different things, not least
being the habitu al tension that comes from spending many hours in front of
a computer screen. 29 When the head is pushed forward, the deep flexor
muscles in the neck become inhibited, while the muscles at the base of the
skull become overactive. Habitu al forward head posture can be caused by
hours in front of a screen, compounded by eyestrain and the effort of
maintaining a healthy seated posture in a sedentary job. It can also develop as the result of long-term ongoing breathlessness and
nasal congestion. Some people develop a forward head posture in childhood
due to untreated swollen adenoi ds and mouth breathing. 30,31 This can lead
to poor airway development, af fecting breathing and posture into adulthood,
and resulting in pain. (We’ll learn more about this in Chapter Eight. ) Others
begin mouth breathing as the result of chronic respiratory conditions. When
mouth breathing  is caused by nasal obstruction, the head pushes  forward as
a way to increa se airflow through the oral airway and ease feelings of air
hunger. It is likely that neck pain is directly related to chronic stress. Tension in
the neck and shoulders can be a direct result of stress, even in the absence
of a physical load. 32 The “startle” reflex, the norma l response to a sudden,
intense stimulus  such as a loud noise, may also contribute. During the
startle reflex, the shoulders lift and the head juts forward in a complex
flexion pattern that begins in the head and travels down throug h the entire
body. 33,34 These reflexive movements are normal and designed to keep us
safe, but when they become embedded in the nervous system  so that the
body defaults to this reaction under relaxed conditions or when the trigger
is no longer present, they become problematic. In a study where three-quarter s of participants were found to have
dysfunctional breathing, the relationship between chronic neck pain and
chest breathing was found to be statistically significant. 19 Researchers noted
that, while only 38% of the study’ s participants experienced neck pain
(compared to 53% who suffered with headaches and 65% with lower back
pain), 83% of those found to have faulty breathing had some experience of
neck pain. 19TEMPOROMANDIBULAR JOINT P AIN
Low blood CO2 is common in people with chronic pain disorders. 16 It is
known that stress and acute pain, or a combination of the two, can cause a
hyperventilation-induced decrease in blood CO 2. Growing eviden ce suggests that the onset of idiopathic pain disorders
(with “pain of unknown origin”), such as temporomandibular joint disorder,
peripheral neuro pathy, and fibromyalgia, is linked to both physical and
psychological triggers. From a physical point of view, joint or muscle
trauma can contribute. Emotionally, stress responses may initiate pain
amplification and mental distress. Idiopathic pain disorders are
characterized by pain and a variety of abnormalities in motor function,
autonomic balance, and sleep. Temporomandibular joint disease (TMD) is the name given to several
conditions of the chewing musc les and the joint connecting the jaw to the
skull. It causes pain and can contribute to migraines and tension
headaches35. Traditionally, it was thought that these symptoms were related
to misal ignment of the jaw, but scientists have failed to identify a link. More recently, the significance of psychosocial factors has been accepted. 35
The term psychosocial  refers to both psychological and social or
interpersonal aspects and can involve problems, including anxiety, fatigue,
and sleep disorders. While relaxation techniques and coping strategies are often used in
therapy, the role of breathing reeducation in temporomandibular joint
dysfunction is seldom mention ed. However, breathing patter n disorders
could offer a biomechanical explanation as to how and why the
physiological changes in the joints and muscles occur. A 2011 paper
published in the Journal of Bodywork and Movement Therapies  suggests
that a forward head posture could lead to increased pressure in the
temporomandibular joint. Researchers also suggest that health professionals
can gain valuable insights into temporomandibular joint disorder and its
treatment by paying attention to breathing and postural rehabilitation. 35
While gaps in research are acknowledged, the connections between
TMD, breathing, and posture are detailed in a 1997 study. It examines the
influences of dysfunctional breathing and describes the effects of poor corestrength and diaphragm function on temporomandibular disorders. Overuse
and overdevelopment of accessory inspiratory muscles; forward head
posture; altered  proprioception ; increased compression of the cervical,
cranial, and mandibular joints; hypermobility or hyperactivity in the
temporomandibular joint; and craniofacial pain all contribute to the
development of TMD. 12
TMD is also linked with bruxism, which is grinding or clenching  of the
teeth. Bruxism can occur during both wakefulness and sleep. It has been
connected with the use of antidepressant medication, a fact that may offer a
window into the connection to the psychological and biochemical
dimensions of breathing. A letter in the Journal of Neur opsychiatry  in 2007
described the case of an 81-year -old man who suffered with depression. He
was treated with paroxetine, a selective serotonin reuptake inhib itor (SSRI). While his depression was controlled, once his dosage increased to 30 mg
per day, he began to experience  night and day jaw clenching and sore teeth
and jaws. 36 Similar ly, a paper from The Netherlands Pharmacovigilance
Centre, Lareb, describes 10 reports of bruxism in which an SSRI was the
suspected cause. 37 The report explains that bruxism  often exists alongside a
dopamine imbalance and can result from disturbances to neurotransmitters
or neuronal excitability. It shoul d be noted that both of those can be caused
by hyperventilation and low levels of blood CO 2. 38
Bruxism during sleep, also called parasomnia, is experienced by around
8% of the adult population. 39 It is characterized by rhythmic tooth grinding
and is associated with tooth wear and temporomandibular joint problems. Scientists are still unclear exactly what causes it, but recent studies suggest
that it is the result of transient arousals during sleep. Evidence suggests that
tooth grinding occurs simultane ously with apnea or hypopnea in patients
with obstructive sleep apnea  (OSA). 39 An apnea is when breathing stops
completely and a hypopnea is a reduction to the flow of breat hing for 10
seconds or more due to partial collapse of the throat. A 2014 study found correlati ons between the occurrence of sleep
bruxism and microarousal apnea or hypopnea events. 40 Researchers
concluded that patients with OSA had a high risk of bruxism, and that the
phasic episodes of teeth grinding were directly related to apnea events. Thissuggests that an improvement in OSA may prevent the worsen ing of sleep
bruxism. 40
A 2016 study explored the link between TMD and breathing further in
looking at the relationship between craniofacial pain and daytime
sleepiness. 41 Daytime fatigue is an indicator of sleep-disordered breathing. Researchers studied 1,171 patients seeking treatment for chronic pain,
sleep-disordered breathing, or both. Each subject attended one of 11
international treatment centers. The results showed a high instance of
comorbidity, in which patients experienced both sleep-disordered breathing
and craniofacial pain, including headaches. The study also demonstrated,
for the first time, a link between craniofacial dysfunctions,  such as a
locking jaw, and poor sleep scores. (We will look at sleep-disordered
breathing, including OSA, in much more detail in the next chapter. ) As with other conditions where chronic pain is a characterizing factor,
there is considerable evidence that heightened pain sensitivity and
psychological distress can contribute to the onset and persistence of
TMD. 42 Further evidence suggests that imbalances in the autonomic
nervous system factor in the development and persistence of the condition. TMD is associated with a stronger sympathetic response and lower
baroreflex sensitivity. In one 2018 study, researchers found that patients
with TMD had significantly lower heart rate variability (HRV), higher pain
intensity, and increased cortisol levels when compared with a control group
of peopl e witho ut TMD. 43 The study’ s findings indicate that people with
TMD could benefit from interventions such as breathing retraining to
restore autonomic function and stress balance. Breathing pattern disorders are also common in people with
fibromyalgia. 44 This fact is not widely recognized, and the clinical
effectiveness of breathing retraining is often overlooked. 44 It is, however,
necessary to practice breathing exercises daily for several weeks or even
months to achieve results. According to a 2017 article by Leon Chaitow,
when a chronic  pain condition such as TMD or fibromyalgia exists, the
“layers of pain and fatigue” that build up as a result of dysfunctional
breathing can be helped by improving breathing habits. 44 In these pain
conditions, he recommends that manual therapy be used alongside
breathing exercises to help restore functional movement, explaining that“active trigger points. may need to be deactivated manuall y. ” He also
suggests that relaxation techniques can be helpful and that sleep
disturbances are likely to require “attention and advice. ”44
PROPRIOCEPTION: BREA TH AND MOVING IN SP ACE
Research has identified a connection between breathing pattern disorders
and joint position sense error. A 2019 paper in the Journal of the Korean
Society of Integr ative Medicine  found that patie nts with chronic lower back
pain and joint position error had low levels of blood CO2, fast respiratory
rates, and chest breathing—all symptoms of chronic hyperv entilation45. Joint position error can be best described as your ability to accurately return
your head to a predefined position after a neck movement. 46 It is used by
doctors to evaluate proprioception  because joint position sense error can
result from faulty proprioception. The term proprioception  is used to describe our perception of
movement. It encompasses things like spatial awareness and how the body
positions itself in space, ensuring that the brain knows where the arms and
legs are so that the body can coordinate movement. It is controlled by cells
called proprioceptors that process sensory information when the body
moves. 47 Proprioception makes it possible to bring a cup to your mouth
with appropriate speed and force so that you don’ t pour the contents all over
yourself or throw hot coffee in your own face. People with poor
proprioception often appear to have weak muscles and difficulty
balancing. 47
The muscles in the neck are instrumental in proprioception, so they are
particularly important to postur al control. The small muscles in the head
and neck contain a high number of something called muscle spindles. Muscle spindles are stretch receptors (mechanoreceptors) in the muscle
fibers. When you move your head, these spindles send inform ation to the
nervous system about the length of the muscles. 48 The high concentration of
muscle spindles in the soft tissue of the neck provides the nervous system
with information  about the positioning of the head in relation to the rest of
the body. People with joint position sense error have an increased incid ence of
neck pain. 46 Many studies have shown reduced postural control with neck
pain49 and following fatigue, anesthesia, or vibration of the neck musc les. 50
According to one 2019 study, the neck area is the only region with direct
access to the senses of sight and balance. 45 While many different
mechanisms and systems contribute to a healthy sense of proprioception,
disturbance to the nerve signals in the neck is believed to be one possible
cause of symptoms including unsteadiness, dizziness, chronic lower back
pain, and dysfunctional postural stability. 45
SUBSYSTEMS OF POSTURAL ST ABILITY
Problems in the three dimensions of breathing can lead to a variety of
painful postural adaptations. In 1992, Yale University Professor Emeritus
Manohar Panjabi suggested another way to understand spinal stabilization
and its impact on the body’ s system. 51 Panjabi suggested that the stability of
the spine relies on three subsystems:
1. The passive subsystem—the vertebrae, discs, and ligaments
2. The active subsystem—all the muscles and tendons surrounding the spinal column
that can apply forces to the spinal column
3. The neural subsystem—the nerves and central nervous system, which assesses
what is needed for spinal stability by monitoring signals and directs the active
subsystem to provide that stability51
Dysfunction in any of these three subsystems may lead to short-term
compensation by the other subsystems, long-term adaptation, or injury51. When adaptation is only temporary, it is still possible for the system to
maintain normal function, but when the problem persists, alterations
develop in the systems that stabilize the spine. When injury occurs,
dysfunction is introduced into the whole system. This manifests as
symptoms including lower back pain. Conversely, when these subsystems
function correctly, the body can adapt to accommodate extra loads or
complex postur es. In this instance, the neural subsystem works to alter
recruitment of muscles to temporarily “superchar ge” spinal stability. Significant evidence indicates how altered breathing patte rns can
negatively influe nce these neurological and muscular systems, contributingto the onset or persistence of dysfunction in the lumbopelvic region. Let’s
look at this in terms of the three dimensions of treatment for breathing
pattern disorders:
Biochemical:  Hyperventilation decreases levels of blood CO2 and
causes a higher pH in tissues and body fluids. This triggers changes in the
nervous system and the way it moderates input from the eyes and ears, and
negatively impa cts postural control. 52 Breathing exercises that normalize
levels of blood CO 2 help bring these systems back into balance. Biomechanical : Fatigue in the inspiratory muscles causes “a rigid
proprioceptive postural control strategy,” like that observed in patients with
lower back pain. You know how stiffly you hold your muscles  when your
back hurts in an attempt to avoid pain. This actually inhibits postural
stability and may explain why many people with lower back pain
experience recurrence of their injury. 53
When the breathing muscles become overworked and exhausted,
proprioceptive input from the lower back also becomes less reliable. This
disrupts the way the brain receives and processes information and can
impact postural control. Remem ber, diaphragm function is a key aspect of
spinal stability through the creation of IAP. The diaphragm is the primary
muscle of the respiratory system and sustains posture and stability. When
chronic over breathing occurs, the diaphragm cannot maintain support of
both systems. Postural control will be compromised as the body always
prioritizes its need for oxygen. By practicing diaphragm breathing through
the nose, you will increase oxygenation and gain better postura l support of
the spine and pelvis. Cadence:  A pape r from 2020 reported that paced diaphragm breathing
at six breaths per minute can reduce pain. This effect was enhanced when
the exhalation was longer than the inhalation. 54 This may be because
autonomic imbalance can itself directly contribute to pain. Breathing at six
breaths a minute activates the parasympathetic nervous system, inhibiting
sympathetic stress activation. There is a direct relationship between the level of diaphragm
dysfunction and the intensity of pain experienced by people who suffer with
lower back problems. One explanation is that, when chronic back pain is
present, the sympathetic nervou s system, which is responsible for the fight-or-flight response, becomes overstimulated. An overactive stress response
makes the body more sensitive to touch and increases perception of pain. 55
Also, when breathing is predominantly into the upper chest, as it is when
the diaphragm is not functioning properly, it tends to involve a lar ge volume
of air and decrease in blood CO2. This creates a biochemical trigger for
panic symptoms, which feeds back into the stress response, making anxiety
worse. When treating musculoskeletal  pain, it is important to look at the
problem holistic ally. Trigger points can be deactivated with manual therapy. Pain in the spine and joints can be viewed in terms of muscle tension or as
the body compensating for muscle dysfunction by recruiting smaller
muscles. Alongside this, it is important to acknowledge the role of lifestyle,
psychological factors, and habits including sleep, posture, and breathing. 56
It turns out that if you want to address chronic pain, the breat h, the most
fundamental and sustaining of all movement patterns, is a very good place
to start. OceanofPDF. comSCHAPTER SEVEN
SLEEP-DISORDERED BREATHING
leep is a behav ioral and neurological state in which homeo static
functions essent ial to health and well-being occur. 1 Modern science
doesn’ t yet fully understand the purpose of sleep or its physiological
relationship with the autonomic nervous system. However, significant
research confirms the relationsh ip between quality of sleep and breathing—
and highlights the fact that sleep disorders and sleep-disordere d breathing
(SDB) are increasingly prevalent. When you are asleep, you probably are not aware that your breathing is
causing problem s. Your partner may complain that you snore, but unless
you know how to spot the signs, there’ s little obvious feedback as to
whether you breathe through your mouth or nose, or how fast, slow,
shallow, or deep your breathing  is. 2,3,4 Regard less of your awareness, the
body prioritizes respiration. How you breathe when you are asleep is very
important. Just as your waking breathing patterns affect the functions of
your brain and body, nighttime  breathing affects the quality of your sleep
and to a lar ge extent, how each day subsequently unfolds. In the introduction to this book, I recounted how exhausted I felt during
my teens and early twenties due to poor breathing and sleeping habits. This
all changed after I learned to decongest and breathe through my nose and to
slow down my breathing. Two days after switching to nasal breathing
during sleep, I experienced what it was like to wake up feeling refreshed
and alert. I remember being amazed at the difference. Even if you don’t feel
like you are sleeping badly, if you suffer with nasal congestion due to
allergies, asthma, or rhinitis, you are almost twice as likely to experience
moderate to severe sleep-disordered breathing. 5The following symptoms occur in people with SBD:
• Insomnia
• Snoring
• Sleep apnea
• Disrupted sleep
• Nightmares
• Nighttime asthma symptoms (usually around 3 a. m. to 5 a.
No, research confirms that lung volume and function, including the ability to transfer oxygen to the blood, is not improved by training.
According to the book "Breathe Strong, Perform Better", does physical training improve lung function?
The normal range for blood CO2 is between 35-40 mmHg.
What is the normal range for a person's blood CO2 levels?
The average adult needs at least 7 hours of sleep every night.
What is the recommended amount of sleep for an average adult?
The study suggests that it is the result of chronic overbreathing.
What is the main reason why people with TMD may experience neck pain?
Yes, research has shown that breathing exercises can lead to improvements in pain and function, as seen in the 2016 study on patients with chronic pain.
Can breathing exercises help with chronic pain?