The Respiration Connection - How dysfunctional breathing might be a root cause of a variety of common upper body pain problems and injuries
Many common aches and pains, particularly around the head, neck and shoulders, may be caused in part by inefficient breathing. This can be a difficult problem to understand, let alone repair, and it is theoretical — no better than an educated guess. There is little or no direct scientific evidence to support the hypothesis. Most clients need some convincing before they believe that their chronic headaches, numb hands, or debilitating back pain might actually caused by a respiratory problem, and all the more so because the breathing exercises required to address the problem can be tedious. On the bright side, there are likely to be some benefits to such exercises regardless of whether or not they solve any pain problems. This article will trace a plausible series of steps connecting respiratory dysfunction to a constellation of painful upper body conditions: from garden variety stiffness to seemingly unlikely and severe consequences such as rotator cuff injuries, whiplash and thoracic outlet syndrome.
The connection
If it exists, the connection between dysfunctional breathing and pain is straightforward in principle: if the diaphragm doesn’t do its job well, muscles in the upper chest (pectoralis minor) and throat (sternocleidomastoid and scalenes) try to take over. Unfortunately, these muscles aren’t built for routine respiration, and they exhaust and eventually injure themselves. A cascade of potential consequences results. This scenario is common. About 75% of my clients consistently try to inhale by lifting their rib cages with muscles in the upper chest and throat. Most are able to stop doing so when they put their mind to it, but easily slip back into the habit. A few are unable to make the change at all without diligent practice. I recently saw a client who seemed incapable of breathing with her diaphragm at all, and instead clenched her scalene muscle group so tightly with every breath that cords of muscle stood out in her neck with every inhalation. That just can’t be good! That’s the connection. But what is dysfunctional breathing, and why do we ask such unsuitable muscles to work so hard in the first place?
Hydraulics
If you understand the principle of hydraulics, you can quickly grasp how breathing should work. When your diaphragm moves, your belly has to move — if it doesn’t move, you simply aren’t using your diaphragm. The diaphragm is your primary breathing muscle. It is a thin, wide sheet of muscle that separates the rib cage from the abdomen. It has a high domed shape which flattens out significantly when it contracts. The dome-shape is much more pronounced that most people realize, and that shape is important to understand. When the diaphragm contracts, that dome flattens significantly, and as it flattens it pushes downwards on the viscera like a hydraulic plunger. Since the watery viscera cannot be compressed, they have to get out of the way. So where do they go? They go outwards! The abdominal contents are forced down and out. When you inhale with your diaphragm, your belly expands. Hence, good breathing is usually described as “abdominal breathing” or “diaphragmatic breathing.”
The buddha belly
The way in which the belly sticks out during healthy inhalation can often be see in statuary of the Buddha. Good breathing and a flexible pot belly are associated with enlightenment, apparently! Enlightenment aside, good breathing is generally associated with vitality (as well as some other unusual phenomena). Only the liveliest people are breathing well: athletes and martial artists, dancers and actors and people who belly laugh a lot. The rest of us — me included — struggle to maintain both our breath and our vitality.
Eight reasons people don’t breathe diaphragmatically
If breathing diaphragmatically was good enough for Buddha and is a key to vitality, why doesn’t everyone do it?
1)Monkey see, monkey do — no else does, so we don’t. Shallow breathing is a pattern that we start imitating when we are infants.
2)Breathing is emotionally stimulating and expressive, and most people avoid emotions and expressiveness as carefully as they steer clear of pot bellies.
3)Men and women alike are afraid to have little pot bellies like Buddha, even for a moment. Belly sucking-in may be the most popular postural habit.
4)Life in chairs — with the hips flexed and the belly compressed from below — makes diaphragmatic breathing mechanically difficult.
5)Rat racey stress tends to accumulate high in the body: face, jaw, neck and shoulders. Many of my clients are too busy grinding their teeth to breathe from the gut.
6)A churning, tight belly is another common consequence of stress, and obstructs abdominal breathing even more effectively than facial tension distracts you from it.
7)Once lost, diaphragmatic strength is difficult to regain. It is one thing to be out of the habit of breathing abdominally (at age ten, say) and quite another to have lost the diaphragmatic strength and coordination for it (by age twenty-two, for instance).
8)It's not like you can't breathe without strong diaphragmatic contraction — it’s just more difficult. So perhaps the most insidious reason that people don't breathe with their diaphragms is because they can. Most people would rather stick with an understated respiratory style rather than work harder. They can get away with it, so they do. But what exactly happens when you don't use your most important respiratory muscle? How do you get away with it?
The alternative: reverse breathing
When people don’t breathe well, they tend to breathe in reverse: that is, the movement of their abdomen during respiration is the opposite of what is normal and healthy! Instead of letting the belly move outward during inhalation, they try to suck it in. And on exhalation, they relax the belly slightly. Of the next ten people you pass on the street, nine of them are probably reverse breathing.
Healthy versus “Reverse” Respiration
Healthy Breathing:
Inhalation - belly goes out
Exhalation - belly sucks in
Reverse Breathing:
Inhalation - belly sucks in
Exhalation - belly goes out
Even people who can breathe diaphragmatically when they go slowly will start to reverse breathe when they pick up the pace. Only after years of practice have I learned to breathe diaphragmatically at speed. It's purely a matter of coordination, a pat-your-head/rub-your-tummy challenge! Reverse breathing is not inherently bad, but it’s not a good idea to go it all the time. It's hard to ventilate thoroughly if you are sucking in your belly while your diaphragm is trying to descend. In fact, it's so challenging to inhale while your belly is sucked in that it surprising that all those reverse breathers don't black out more often. Shouldn't the side walks be littered with dazed, gasping reverse breathers? How are they managing to get air at all, if not through contraction of the diaphragm?
“Emergency” breathing
The body is equipped with several emergency backup respiratory muscles. The diaphragm does not work alone. Any breath that uses extra muscle is considered to be forced respiration. Normal, healthy, relaxed breathing doesn’t take much effort. Inhalation can be managed by the diaphragm alone, and exhalation takes no muscle contraction at all: the lungs collapse elastically, pushing air out effortlessly. A sneeze or a cough, on the other hand, takes everything you’ve got: every fibre of muscle attached to your rib cage contracts violently. Yawning is not as heavy a recruiter, but is still much more intense than normal breathing. And, of course, you also use more breathing muscles when you exercise — depending on the intensity, this can range anywhere from just a little bit to quite a lot of extra breathing power. Here are the muscles involved in respiration, and their roles in healthy breathing:
-Diaphragm: This is your most important breathing muscle — it always has to work, even in relaxed breathing.
-Intercostals: Tiny muscles between the ribs, recruited for slightly forced respiration.
-Abdominals:The abdominals pull the rib cage down and push the diaphragm up, so they are vital for strong exhalation.
-Quadratus Lumborum: “Quad” meaning “four-sided” and “lumb” as in “lumbar” — throw in some suffixes, and you’ve got some Latin.This is a low back muscles that pulls down hard on your bottom ribs. People sometimes tear it when they sneeze! It is recruited only for the strongest exhalations.
-Pectoralis Minor: The pectoralis minor muscles are tiny chest muscles that pull up on the rib cage. The rib cage is heavy: this is definitely an emergency breathing muscle only.
-Sternocleidomastoids: These prominent throat muscles form a distinctive V-shape. Like the pectoralis minors, they are rib cage lifters that should only be used when you absolutely, positively have to get something out of your trachea. I can breathe hard without ever feeling these muscles twitch!
-Scalenes: Weirdest (and most important) of all the respiratory helper muscles are the scalenes. I have written entire articles about them. They descend from the sides of the neck and attach to the uppermost ribs — and sometimes even attach to the top of the lungs. Their primary job is to move necks, but they also get involved in rib cage lifting when the need is great.
Unfortunately, most people don’t use their diaphragms to breathe, so they have to use their emergency breathing muscles. It’s inefficient, so they have to work hard to take normal breaths, as if every moment was like a respiratory emergency! Does stress cause people to breathe poorly? Or does breathing poorly cause stress? It’s both, obviously: each pattern aggravates the other. What a pickle. So, other than always breathing like you’re trying to run from lions, and giving your sternocleidowhatsis muscles a lot of exercise, what’s the big deal? What’s so bad about breathing with your chest and neck muscles?
The consequences
Chronic upper chest and neck breathing presumably exhausts and then eventually damages the emergency breathing musculature, causing a list of bad news: exercise gets more difficult, and the risk of both acute and chronic injuries and painful conditions in the neck and shoulders increases dramatically — especially whiplash injuries. The importance of exercise should not be underestimated. Canadians suffer from a general plague of poor fitness — when “the burn” is much worse, because we can’t breathe properly, how much more difficult is it to start and maintain an exercise program? The consequences of a sedentary lifestyle are far-reaching. The increased risk of neck and shoulder injuries is easier to define, however, and I treat the symptoms of this disease in my practice every day. Exhausted muscles develop what I call “sick muscle syndrome” — they develop hard knots, technically known as myofascial trigger points, that radiate pain in characteristic patterns. The intensity of this phenomenon can range from mild to crippling, and it doesn’t just hurt: anything that lies in the path of that radiating pain is vulnerable, interfering with normal function in a variety of ways.
Sick muscles don’t do their own job very well, either: the more you’ve worn out your neck and chest muscles trying to breathe without your diaphragm, the more likely you are to have a problematic upper body posture and lousy mechanics of the shoulder and spinal joints, which leads to yet more injuries. The combination of sick muscle syndrome and bad joint mechanics and posture cause and/or aggravate many problems:
-A significant portion (probably more than half) of all upper back pain is caused by problems in the neck.10
-Shoulder tendinitises.
-Whiplash. The more exhausted your neck muscles, the more a whiplash injury is going to hurt, and the longer it’s going to take to heal — in many cases, people never really heal at all.
-Frozen shoulder, a condition in which the shoulder joint mysteriously seizes up. While it is a strange condition whose ultimate causes are not known, it seems likely to me that it is at least aggravated by respiratory and upper body postural dysfunction.
-“Cricks” in the neck, most of which are probably caused by small mechanical problems in the spine (known as minor intervertebral derangements, or MIDs1112) that can cause days or weeks of painful protective spasm and months of stiffness.
-Ringing in the ears and other hearing and balance problems — believe it or not. Bizarrely, referred pain from sick sternocleidomastoid muscles is well known to massage therapists to interfere with hearing, balance, and to cause tinnitus (ringing) either directly or indirectly via effects on the muscles of the jaw.
-Numbness and pain in the entire arm can be caused by a condition called thoracic outlet syndrome (TOS), in which nerves and blood vessels that supply the arm are impinged by two specific muscles — two muscles that also happen to be the most abused respiratory muscles — pectoralis minor and scalenes!
That’s the tip of the iceberg, but it gives you a good sense of the complex interconnections and the potential for totally exhausted chest and neck muscles to wreak havoc on your upper body. Most people are suffering from these and many other consequences of inefficient respiration by — no kidding — about age twenty. In other words, most of the people who walk into my office are suffering from problems which can be traced, at least in part, to respiratory dysfunction.
I’ve seen people’s lives changed forever by some of these conditions — especially whiplash injuries that are effectively permanent, or people with TOS who are unable to lift their arms without excruciating pain or total numbness. In all such cases, the connection to respiratory dysfunction is surprisingly straightforward. Breathing matters!
Some clarifications
To really understand this phenomenon, it’s necessary to go just a bit deeper into respiratory mechanics. This section is for the devoted reader who wants to understand exactly what’s going on when breathing goes wrong. It’s easy enough to understand that breathing without the benefit of diaphragmatic contraction is probably not such a good thing. But why, exactly, is it such a problem? Exhalation without the aid of the diaphragm is no big deal — even strong exhalation. The diaphragm simply isn’t used for that in the first place. The muscles that pull the rib cage down are aided by gravity: those ribs are heavy, and it doesn’t take much to pull them down a little more. And the muscles we use for the job are quite large and strong: the abdominals and the quadratus lumborum are large, each of them bigger than any of the muscles used to assist inhalation. And, furthermore, we don’t really have any psychological inhibitions against contracting our abdominal muscles — it’s the relaxed belly we shy away from.
It’s inhaling without the diaphragm that is so difficult. Without the diaphragm, inhalation is extremely hard work: somehow or other, you’re going to have to get that rib cage lifted up against the pull of gravity, and against the pull of abdominal and back muscles that don’t like to relax. The only muscles that are really designed for serious rib-lifting are the intercostals, and they can only do so much. So people end up recruiting the pectoralis minors, sternocleidomastoids, and (worst of all) the scalenes. And even that is not, in itself, necessarily a bad thing: the trouble is when you do it all the time, for ordinary breathing. Imagine a handful of muscles the size of pencils trying to lift your rib cage several times per minute.
All day long, every day. For years. That is the ultimate and specific problem with not using your diaphragm. So now what?
Scalenes From Hell
Every vocal student struggling with excessive effort or vocal dysphonia probably has scalene muscles from hell. Wherever Spencer Welch sees an elevated larynx, my hands would probably feel scalene muscles with the texture of dump truck tires. Your scalene muscle group fills a triangular area on the side of the throat that I call the “Anatomical Bermuda Triangle,” because I can get lost while I am working in there. Seriously, this is a strange area. The scalenes fan out from the neck bones to attach to the top of the rib cage, behind the collarbones. Sometimes, they even reach between the ribs and attach directly to the top of the lungs! The scalenes move the neck, but they are also breathing muscles. And, like organized criminals, they always have something to do with anything that goes wrong in the whole region, and many other areas besides. The scalenes are notorious for generating widespread and exotic “referral pain”: radiating sensations throughout the head, neck, shoulders, back, arms, chest, and even into the hands and fingers. Scalene referred pain patterns are not vague. They are consistent enough from one individual to the next that they can be charted, and they are vivid! Usually, the first time I press on someone’s scalenes, they say something extremely predictable, such as “Hey, I can feel that in my pinkie finger.” So the scalenes are as weird as snake sneakers.
Scalenes are closely associated with breathing, both mechanically and emotionally. Mechanically, scalenes are used as pinch-hitters when the diaphragm isn’t doing its job. Normally they are only recruited for emergency breathing procedures, such as a sneeze. They should otherwise stay out of the breathing business. However, when the diaphragm is dysfunctionally underactive — common with emotional and expressive stagnancy, by the way, and this means most of the people you see on the street and probably the person you see in the mirror every morning as well — the scalenes are recruited to do workaday breathing. And they hate it. These muscles are powerful for their size, but they are not designed for lifting an entire rib cage several thousand times per day. They get utterly worn out, sensitive and rigid, and it gets difficult to do anything efficiently or comfortably with the neck and throat. Such as sing. Or breathe.
The scalenes are also what I call an “emotional” muscle group, with unusual sensitivity to emotional states and an unusual ability to generate and control emotional states. Together with other throat musculature, the scalenes determine the pliability of the head-body connection and the vitality of your voice. Want to say or sing something? Better ask your scalenes for permission. Want to get an idea from your skull to your torso? It’s got to go through scalenes. If you do not wish to say much of what you think, or express much of what you feel, the easiest way to achieve it is to quite literally choke it off at the neck. Not only are there literal nerve and blood vessel impingements possible here, but it’s just hard to be groovy when you’ve got a stiff neck.
Given their privileged position and peculiar significance, the scalenes are powerful agents of both change and the status quo. We use them to establish and maintain our comfort zone. When we try to leave it, they try to bring us back. But they are also a great place to try to break limiting habits. Change the scalenes, and you change not-so-subtle limitations on your voice, breath and life.
A Continuing Experiment
Spencer and I have already started trading clients. What happens when people who are trying too hard get their scalenes worked over by a massage therapist? What happens when someone who is rigid all over learns to sing in a comfortable, talking way? This is an experiment that will take years to unfold. Considering how much trouble people have with them, both singing and breathing are surprisingly simple physical activities, requiring no exceptional skill. It is revealing and fascinating that children do both of them comfortably and well. “Children may not organize their notes very well,” says Spencer, “but their vocal technique is perfect!” If grown up people get tired or struggle to do something simple but expressive, it’s usually a dead giveaway that they are resisting the experience. This is much easier to understand about singing, which is why Spencer’s observations fascinate me. They capture perfectly, in a much more understandable way, the problems that people have with breathing, and with life in general.
Perfect Spot No. 4
Perfect Spot No. 4 is in what I call the Anatomical Bermuda Triangle, filled with the mysterious scalene muscle group. Massage therapists have vanished while working in the anatomical Bermuda Triangle, never to be seen again. Seriously, this is a strange area. The scalenes harbour trigger points with some of the strangest effects in the body. The mechanism for this strangeness is the phenomenon of referred pain, in which the nervous system has trouble locating a trouble spot and you end up feeling pain in a spreading pattern, instead of feeling it only where the trouble is. Referred pain effects are par for the course with most muscle pain and other internal pains, but the scalene muscles produce unusually complex and large patterns of referred pain, patterns that vary more between people than the patterns produced by other muscles, and patterns that can even vary dramatically from day to day in the same person.
But scalene trigger points can also have effects on your voice, on swallowing, on emotions, on sensations that sweep through the entire head, the sinuses, hearing, and teeth. I have found scalene trigger points to be obviously clinically relevant to conditions as seemingly different as:
-A professional singer with a mysterious degradation of quality in his voice (helped by releasing scalene and other throat trigger points)
-At least two patients with severe chronic sinus infections that they’d actually had surgery to try to correct (one of them virtually cured by scalene trigger point release alone, the other significantly helped)
-Several people with severe cases of what I call “brick back,” where the space between the shoulder blades feels so stiff and stuck that it’s like there’s a cinderblock there instead of bone and muscle
Scalene trigger point effects are so elaborate and seemingly out of proportion that they are almost always making at least some contribution to do with anything else that goes wrong in the whole region — like organized criminals, scalene trigger points can be counted on to mess up the area. Anterior scalene in particular is a trouble-maker, I find, causing and complicating many other problems in the area. A strange muscle group indeed! The scalenes fan out from the neck bones to attach to the top of the rib cage, behind the collarbones. The group consists of three muscles, the anterior, middle and posterior scalenes. They generally attach to the sides of the neck vertebrae at one end, and to the uppermost ribs at the other end. Thus, they pull the head from side to side. And although they certainly move the neck, they are also breathing muscles, because of the way they pull up on the ribs. And here’s some more weirdness that makes this group rather interesting: in some people — quite a few, actually —at the lower end, the scalene muscles even reach between the ribs and attach directly to the top of the lungs!
The scalenes as a group are not hard to find, although they are intricate in their details. The scalenes simply fill the space between three obvious structures: your collarbone, your trapezius muscle on top of your shoulder, and the long v-shaped throat muscles (sternocleidomastoid). Perfect Spot 4 is as much a method as it is an actual location. By massaging the scalenes in a certain way, you are likely to produce sensation and stimulation which is both interesting and useful, without risking some of the nastier (sharp, burning) sensations that scalenes can also produce. Place your partner lying face up on a bed, with his or her head in the corner of the bed. Sitting above, hold your fingers flat and place your fingertips in the hollow of the triangle. Your fingertips are fairly far inward. Your hands are angled, pointing downwards and inwards at the sternum. Now press down and perhaps a little bit inwawrds with a fairly broad pressure on the ropy muscles that fill the triangle. By using a broad pressure, you can fairly easily stimulate some trigger points without having to worry about being too accurate.
Is there any danger, massaging in this seemingly vulnerable area?
Many people are concerned about the possibility of impinging blood vessels or nerves. Don’t worry about: if you touch the carotid artery or the jugular vein, there’s no missing the intensity of the pulse, and you simply back off. Smaller vessels are simply not a concern, and nerves — even nerve roots — are remarkably robust, and generally tolerate far more pressure than most people realize. Are there “other things” in the throat? Well, the trachea and voice box are certainly more brittle and delicate structures — but they are also quite obviously too central to be pushing on them when doing scalene massage. No one will tolerate careless pressure on these parts! And there really just isn’t anything else you need to worry about. You can also feel free to explore in the anatomical triangle with your fingertips: it is a rich minefield of trigger points, many of which may be worthwhile and interesting. Just be aware that if you get into detail in this area, you may well encounter trigger points that feel hot and burning and nasty — not really at all the kind of trigger point you want to mess around with for fun. As I’ve already suggested, sensation produced by massage in this area can be unpredictable, strange. The broad pressure is likely to produce the most straightforward possibility: a peculiar but more or less pleasant deep ache spreading into the head, chest, back, and or arm. But be prepared for anything!
One possibility with scalenes to be aware of is that it doesn’t always feel good at first. Posterior scalene in particular is grouchy, and even the gentle approach to Perfect Spot No. 4 may feel kind of hot, nasty and vulnerable at first. But if you persist respectfully, there is a good chance that the sensation will go from hot to warm, and begin to spread. Spreading is a good sign that it’s going well, and it will start to feel like scratching an itch you didn’t even know you had.
A surprising relationship between the scalenes and tennis elbow
The scalene muscle group has surprising importance to a condition called “tennis elbow” or lateral epicondylitis, which commonly afflicts typists as well as racquet sports players. It is generally characterized (by its name!) as an inflammatory condition, but it is probably not that simple.1 It is likely that myofascial trigger points, particularly Perfect Spot No. 5 in the muscles of the forearm, play a significant role in tennis elbow. And Perfect Spot No. 4 seems, in turn, to significantly affect Perfect Spot No. 5. Travell and Simons write, “Scalene muscle trigger points are frequently the key to [treatment of] forearm extensor digitorum trigger points.”2 This is a great example of an odd benefit to treating Perfect Spot No. 4. For more information, see Massage Therapy for Tennis Elbow and Wrist Pain.
Notes
1.An excellent diagram of this can be found in the Atlas of Human Anatomy, 2nd Edition (Netter, 1997), plate 182.
2.Simons, David and Janet Travell. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Philadelphia: Lippincott, Williams & Wilkins, 1998. This text describes at length how exhaustion and injury of overused muscles occurs via the mechanism of myofascial pain syndrome.
3.Calais-Germaine, Blandine. Anatomy of Movement. Seattle: Eastland Press, 1993. pp88-9. The details of diaphragmatic movement are described and diagrammed with great skill in this widely respected and wonderfully readable text, which also reveals that my statement is not strictly true, although including the details in the body of the article might have obscured the point. It actually is possible to use the diaphragm without the abdomen expanding — sort of. If the centre of the diaphragm cannot descend due to abdominal muscle contraction, then it pulls on the lower ribs instead. In this case, diaphragmatic contraction causes slight flaring and lifting of the ribcage. However, it’s not a particularly efficient way to breathe, and it tends to involve recruitment of the upper chest muscles to assist in lifting the ribcage, which is what most people need to avoid.
4.For those who may not be familiar with heavy mechanics, the operating principle of hydraulics is that fluids cannot be compressed (actually, they can be compressed — just not very much, a lot less than gases). No matter how much force you apply to it, it fills pretty much the same volume. Its constituent molecules simple cannot be crammed significantly closer together than they already are. The contents of the abdomen, the guts, are extremely watery. If you press down on them with the descending diaphragm, they don’t get smaller — they have to have somewhere to move.
5.For instance, the bulging eyes of Tibetan statuary are caused by something quite different, though still associated with something that evolved out of a spiritual breathing practice. The low-frequency sounds of Tibetan throat singing (which requires exceptional respiratory control) have some bizarre effects on bodily fluids, a standing wave phenomenon that causes eyeballs to swell and brains to hallucinate. Plate tectonics and space shuttle launches produce the same low frequencies, resulting in — get a load of this — disproportionately common reports of hauntings and demonic possession near fault lines and Cape Canaveral! Wow. (I wish I had a citation for this. All I can tell you is that I read an article about it about five years ago in a science magazine, and have remembered it ever since.)
6.I’ve learned these lessons mainly from personal communication and training with Joanne Peterson, Jock McKeen, and Bennet Wong of The Haven Institute for Professional Training, as well as from their books, particularly The New Manual for Life (Wong, McKeen, 1998). It’s always interesting to review the assertions I make in my articles and asking how do I know this? In this case, I know it because Jock, Ben and Joanne taught me, and they are good sources: combined, about a sixty years of exceptional clinical experience with tens of thousands of people. If they say that breathing is emotionally stimulating and expressive, and that people start shutting that down when they are very small, I’m going to run with it. Much of this article depends upon it, in fact, hence the detailed footnote.
7.Whiplash injuries routinely damage the tissues of the scalene muscle groups and sternocleidomastoid muscles, as outlined in detail in Management of Common Musculoskeletal Disorders, 3rd Edition (Hertling, Kessler, 1996: pp548-551). Both of these muscles are also exhausted by chronic over-use in respiratory dysfunction. It’s a bad combination.
8.See 7 Reasons Older Adults Don’t Stay in Exercise Classes, which reports on a lot of recent scientific evidence about the importance of exercise.
9.Simons, op. Cit., from the introduction to Vol. 1.
10.Hertling, Randolph, & Kessler. Management of Common Musculoskeletal Disorders, 3rd Edition. p575. New York: Lippincott, 1996.
11.Maigne R. Manipulation of the spine. In Basmajian JV (ed): Manipulation, Traction and Massage. Baltimore: Williams & Wilkins, 1986.
12.Hertling, op. Cit., p574. Darlene Hertling clearly elucidates Maigne’s ideas about MIDs, with reference to the thoracic spine. Likely the idea can be sensibly applied to other sections of the spine as well.
13.Simons, op. Cit., Vol. 1, p314.
14.Magee, David J. Orthopedic Physical Assessment. 219-221. Toronto: WB Saunders Company, 1997. This text describes special orthopedic tests for determining which of the scalenes or pectoralis minor muscles may be impinging circulatory supply to the arm.
15.Padula et al. Research and Theory For Nursing Practice. 2006. This review of the evidence indicates that exercising your breathing musculature probably works pretty darned well, and benefits take about “20 to 30 minutes per day for 10 to 12 weeks” to achieve. Better yet, the evidence also shows that it’s reasonable to expect some benefits “regardless of method”! In other words, there’s no great concern about which technique to use. Common protocols for respiratory training “are generally safe, feasible, and effective.”
The solutions
People never (ever) come to me and say, “Please, Mr. Massage Therapist, sir — please fix my breathing! It’s so dysfunctional!” No, people come to me with whiplash, they come to me with back pain, they come to me with a terrible posture and ringing in their ears. So the first step is understanding that respiratory dysfunction is one of just a few major factors that are usually at the root of upper body pain, and stand in the way of healing from upper body injury.
Once you’re a believer, the solution is (drum roll please) … diaphragm exercise!
To stop breathing with your chest and throat muscles, you must learn how to breathe with your diaphragm. Absolutely, positively the only way to do this is to practice using your diaphragm. Research has shown that exercising your respiratory musculature is quite effective.15 But it’s a challenge! The diaphragm is a muscle you can’t see and can’t feel directly. It’s like trying learn how to wiggle your ears. A lifetime of bad habits may stand in your way. Above all, you will doubt that it is really necessary — it’s an awful lot of trouble for a muscle you barely knew you had. But it’s the only way. Take heart, though: it’s no different than what any singer or martial artist has to learn. It’s difficult, but hardly impossible. The following sections offer several useful perspectives and strategies that can serve you well.
Solution Idea No. 1: Strength is coordination
When people start a weight training program, it takes weeks for the first obvious increases in strength to manifest. These initial gains are not due to an increase in muscle mass — that comes later. The increase comes from coordination alone. Specifically, a beginner learns to “recruit” more muscle fibres. Every muscle consists of millions or billions of microscopic fibres. Individual nerves stimulate clusters of fibres — together, nerve and fibres are called a “motor unit.” The more motor units you can stimulate at once, the stronger a contraction you can generate. Recruiting a lot of motor units at once takes coordination, a physical skill that can only be learned with practice, practice, practice. It’s true for your biceps, and it’s true for your diaphragm. Learning to breathe with your diaphragm is mainly about learning how to recruit more of its motor units every time you inhale. It’s important to understand this, so that you realize that your goal is not exactly a big, beefy diaphragm, but simply a well-coordinated one — you just want to learn how to use what you’ve got. But how do you do that when you can’t even feel it?
Solution Idea No. 2: Book lifting
Learning to breathe diaphragmatically really is like learning to raise one eyebrow or wiggle your ears — only worse, because it’s difficult to even tell when you’ve succeeded. To learn to use your diaphragm, you have to make the results visible. Here’s how:
Find yourself a good, heavy book. This book should pass the “thunk test” — it should make a good, satisfying thunk when you drop it on the ground. Lie down on your back with your knees up. Place the book square on your belly. Take a deep breath. If the whole book lifts up, you used your diaphragm. If it didn’t lift up, or lifts unevenly, you didn’t use your diaphragm. Laws of hydraulics. It is absolutely impossible to contract your diaphragm without your belly sticking out. So there you go: visual feedback is how you’re going to learn when you are actually contracting your diaphragm. Now, do that at least twenty times in a row, and your diaphragm isn’t strong unless you can lift it at least two inches every time. Four inches would be better.
Solution Idea No. 3: Water breathing
Standing up to your chin in a swimming pool is an even more ingenious way of providing resistance to diaphragmatic contraction. Can you see why? Strength training is usually called “resistance” training by professionals, because “weight” training is too narrow a term. Weights such as barbells and stacks of iron plates in a machine are only one way of providing resistance to muscle contraction. It is also possible to use big elastic bands, springs, body weight, other muscles, and even just stationary objects. And water … Water pressure resists expansion of the abdomen uniformly on all sides — and therefore it resists diaphragm contraction. Water pressure is strong: even just a couple of feet under water, the pressure on one square foot of abdominal surface is an amazing 150 pounds! Every square inch of your torso has about a pound of pressure on it — less closer to your chest, and more closer to your waist. That’s a lot of resistance to abdominal expansion! And it’s perfectly uniform. Anything that resists abdominal expansion is resisting diaphragmatic contraction, of course. Lifting the book, as described above, obviously resists abdominal expansion: but not much, and only in one direction, and somewhat awkwardly. That exercise is really intended for the visual feedback, not the resistance.
Breathing while standing in water, however, requires the diaphragm to overcome a strong, unrelenting water pressure evenly distributed over the abdomen. It’s like wearing a broad, elastic garter belt. It’s a phenomenal strength (resistance) training exercise for the diaphragm. In fact, it’s so difficult that most beginners will hardly be able to budge their diaphragm, and will — uh oh! — end up trying to lift their rib cage instead. It’s actually a great way to demonstrate how the chest and neck muscles tend to get recruited when the diaphragm isn’t being used, or can’t be used — you can really feel all those secondary muscles kicking in and trying to take over! So do experiment with this in the early stages, just so you can see what it feels like, but don’t try to use it as a strength-building exercise until you’ve mastered book lifting. Happy water breathing!
Solution Idea No. 4: Bioenergetic or round breathing
Everyone’s emotionally constipated, unless you’re a sociopath or still in diapers — the price of maturity is that you repress much of your Genuine Self, and end up with a comfort zone that is often suffocating, respiratory dysfunction, and upper body pain. Ain’t life grand? Believe it or not, this is the can of worms people are opening when they come to my office with a stubborn case of whiplash! So, shallow breath and emotional constipation usually go together, and they can only be fixed together. Oddly enough, the best cure for shallow breathing is … deeper breathing. Gee, this is rocket science, isn’t it? Specifically, I recommend a breathing technique originally pioneered in a psychotherapeutic context in North America by Carl Jung, and the popularized by his student, Alexander Lowen, who called it “bioenergetic breathing.” It is also similar to what the Chinese call “round breathing,” which is my preferred label.
In a nutshell, round breathing is fast, deep, continuous breathing that is hyperventilatory and gets you all dizzy and emotionally vulnerable. What fun! You don’t have to be able to breath diaphragmatically to do it: the point is that it breaks down the emotional rigidity that makes it so hard to breathe diaphragmatically in the first place. That’s important. Read it three times!
Bioenergetic breathing breaks down the emotional rigidity that makes it so hard to breathe diaphragmatically in the first place.
If this sounds dreadful, don’t knock it until you’ve tried it. Round breathing is the closest thing I know of to a fountain of youth. Human beings are amazingly uptight critters. We get hung up on a whole lot of stuff, and this is the single best way to loosen up that I know of. There are at three other major articles on this website on this subject, and they are listed at the end of this one.
Solution Idea No. 5: The abdominal lift
This exercise is straightforward and is vital for mastering many breathing techniques. It has several benefits: in addition to strongly stimulating diaphragmatic breathing, this ancient yoga exercise will also …
-Exercise your "other" abdominal muscles (the obliques and transversus abdominis, which are often neglected even by professional trainers, even though they are very much relevant to core stability and belly shape).
-Wake you up in the morning by mobilizing the significant amount of blood that is "stored" in your viscera over night.
-Make "round breathing" much easier (see above).
-Strengthen your pelvic floor muscles, touted as an essential component of sexual prowess for women and men! Also helpful in the prevention of bowl and urinary dysfunction.
And a host of other minor benefits. In all my years of experimenting with qigong, taiqi, martial arts, yoga and other physical disciplines, this exercise still offers more bang-for-buck than any other single exercise. It’s what I call a “lifer,” best done once a day for the rest of your life.
Here are the instructions:
1)Stand with your upper body supported on your knees.
2)Take at least three deep breaths to prepare yourself.
3)When you feel you have oxygenated sufficiently, blow all of your air out, hold your breath, and then suck your belly in hard against your spine. Particularly focus on your low belly, below the navel.
4)Hold the position and your breath for several seconds (go as long as you can).
5)Relax the belly before breathing again (if you try to breath first and then relax, it can hurt a bit).
6)Repeat at least three times, or until you are exhausted.
Solution Idea No. 6: Stay out of chairs
My father always told me to stay out of bars, advice which has served me well, I think. I wish he had also told me to stay out of chairs — they are just as corrupting and dangerous! This is not easy advice to follow, of course, but it is good advice nevertheless. Chronic sitting is an obvious mechanical barrier to diaphragmatic breathing: the belly is compressed, and cannot expand as easily or as far. And, of course, if you’re in a chair … you’re not getting any exercise, are you? Says the massage therapist who has spent thousands of hours in a chair creating this website. Do as I say, not as I do! Seriously, if you can’t avoid working in chairs, do everything you can to mitigate the harmful effects. Above all, take micro-breaks!
Solution Idea No. 7: Stress reduction
“Reduce your stress level” is the most vague and unhelpful advice I can imagine! It’s a huge topic, and I can’t properly address it here. For the purposes of this article, I just want to instill in you some respect for the consequences of stress: if you are so stressed out that you can’t breathe properly, what else is stress doing to you? It’s time to take a serious look solving some problems in your life, and/or changing the way you react to challenges — for the sake of your health. We are a society of shallow breathers.
Quick conclusion
We are a society of shallow breathers: afraid of moving our bellies, afraid of expressing ourselves, living our lives in chairs, and stressed out by our busy minds. Instead of breathing with the diaphragm, people tend to breathe with upper body musculature that is inadequate to the task, with a cascade of musculoskeletal consequences and vulnerabilities. These are the solutions to dysfunctional breathing:
-The book lifting exercise, to learn how to recruit the diaphragm
-Water breathing, to increase your diaphragmatic strength and coordination
-Bioenergetic or round breathing, to break down the emotional rigidity that makes it so hard to breathe diaphragmatically in the first place
-The abdominal lift exercise, to strengthen and stimulate the abdominal musculature and increase your body awareness of abdominal movement during breathing
-Stay out of chairs as much as possible, so that your diaphragm actually has room to do its job
-Embark on a program of stress reduction, whatever that means to you
The Art of Bioenergetic Breathing
Breathing is a potent tool for the stimulation of personal growth and transformation. This article discusses the what and the how of a specific breathing therapy called bioenergetic breathing or round breathing. For the why of breathing, you can read this more poetic essay, The Anatomy of Vitality.
Someone tells you to “take a deep breath.” There’s more to it than you think. It’s the tip of an iceberg most people have never seen or heard of. For more than a decade now, I have been practicing, teaching and exploring an unusual form of therapeutic breathing. It is known as “bioenergetic breathing,” and has its origins in the bodywork philosophies that emerged originally from Alexander Lowen’s interpretations of Reich and Jung. Interestingly, the same breathing style is called “round” breathing by the Chinese in the context of qigong, and has deep roots in that culture, although in a much different way. So when I teach this kind of breathing, I stand on the shoulders of giants. I learned about bioenergetic breathing from Joanne Peterson and Drs. Jock McKeen and Bennet Wong at Gabriola Island's reknowned Haven Institute for Professional Training. What I teach today is an adapation of what I am still learning whenever I visit Gabriola.
What I enjoy most about this form of “therapy” is that it is no therapy at all, but simply a kind of education. I do not have the conceit of the healer when I do this work. I am more of a coach. And it’s easy. Although I offer many suggestions while “coaching” a breathing session, this is not because anyone ever breathes incorrectly. Every kind of breathing is intrinsically expressive of the individual, and potentially useful. My job is to encourage new and unfamiliar breathing – to stimulate altered states, and to use deep breath to reveal personal habits, limitations and resistance to full experience of life. Bioenergetic breathing is basically just fast, deep breathing. It emphasizes inhalation, which is assertive and full. It does not pause at the top or the bottom of the breath, forming a smooth sine wave. The mouth and throat are open wide, removed from the path of the breath, never shaping or controlling the movement of air. Most people attempt to breathe predominantly with their mouth, nose and throat. In fact, it is the body that breathes, and the upper respiratory tract is simply an obstacle course. In a typical bioenergetic breathing session, you might work up to a vigorous pace of breathing in the space of a minute or two, continue for five to ten minutes, and then wind down again.
And what’s the point of all this?
Breathing is stimulating. It induces heightened and altered states of awareness and sensation. For more information about the deeper philosophy of breathing, read The Anatomy of Vitality. But I suggest that you just try it first … I think that you’ll like it.
For something so simple, bioenergetic breathing proves to be a surprising challenge for nearly everyone. Most struggle, experiencing fear, frustration or apathy. Obviously, the challenge isn’t technical — it’s just heavy breathing. So what is it that gives people such trouble? The challenge is emotional. Shallow breathing is the norm in our society. In fact, it is typical of most aging biological organisms. Shallow breath constitutes a comfort zone that we are reluctant to leave. Breathing hard stirs up interesting and alarming sensations, and we humans have an enormous repertoire of tactics for controlling and limiting the experience so that it is a little less boat-rocking.
Some common avoidance behaviours that I've observed over the years include chain yawning, squirming, blowing and hissing, wheezing, dry throat, aches and pains that magically pop out of nowhere, an attack of silliness, giggles or ticklishness, and so on. As they attempt to proceed, most people will experience anxiety, frustration or (most problematic) a suspiciously intense apathy. As a coach, "the fade" is the most difficult of all avoidance tactics to navigate, and it happens to be my own favourite reaction to breathing: when the going gets tough, I get sleepy and tune out. Shallow breath constitutes a comfort zone that we are reluctant to leave. Getting past these defenses is so surprisingly difficult that most people need coaching. As a breathing coach, I can spot all your tricks, keep you breathing clearly, and encourage you to actually experience all of the new sensations – instead of developing a sudden, intense interest in something else.
Parasthesia, tetanus and tremors, oh my!
The challenge is complicated by the fact that bioenergetic breathing tends to cause three harmless but potentially alarming side-effects: parasthesia, tetanus, and tremors. Sounds dramatic, doesn’t it? Well, it is kind of exciting. This is powerful stuff. But these experiences really are harmless, and they tend to go away with practice. I myself went through them and came out the other side many years ago. Parasthesia simply means “altered sensation,” usually in the form of tingling that starts around the mouth, at the fingertips and in the toes. As it advances and spreads, it is usually accompanied by tetanus — sustained but mild contraction of muscles. The hands and feet tend to “claw up,” and your lips will feel like you’ve just been to the dentist! This is different than spasm, and it is more stiff than painful. It wears off quickly. Finally, tremors may sweep through the body erratically, perhaps favouring a specific limb or side, but this too passes rapidly — and should actually be indulged when it occurs. Let yourself shake. Be free! Martial arts and yoga practitioners may study their entire lives without knowing the sensation of qi.
These symptoms are produced by an altered mind-body state, both physiological and psychological. The tetanus is a consequence of some changes in blood chemistry. The tingling is the sensation of qi — when your hands are tingling fiercely with qi, it feels like you are holding balls of fire. It’s a very distinctive sensation, and a privilege to experience. I often explain to people that martial arts and yoga practitioners may study for their entire lives without knowing the sensation of qi, simply because they don’t breathe enough. The tendency to tremor is a “letting go.” We are all hanging on tightly to so very much, including out own bodies. The breathing shakes us loose. I advise you not to try to stop it. I must emphasize again that all of these side-effects are temporary. Bioenergetic breathing is not hyperventilation. It is not dangerous in any way. Any sensation you experience during breathing will go away as you slow down and stop.
Soul diving
You might become emotional during bioenergetic breathing. Most people feel like crying. Feeling sad and frustrated are the most common reactions to breathing. But many also feel like they want to hit something (hint: try a pillow!), and virtually any other kind of emotional experience is possible for different people, or for the same person in different sessions. Sadness and anger are the two great unexpressed emotions in our society. Most of us have deep wells of them. Bioenergetic breathing can be a handy way to deliberately induce cathartic crying jags. Indeed, some people notice that they cry every time they breathe like this, prompting the question, “What else is there? When will I be done crying?” The answer is, “When you’re done.” If you’ve been holding back sadness for thirty years, expect it to take a while. But trust me: there is something beyond all the crying. And that is what this work is all about. It’s soul diving.
Possibilities
Go to it. Slow down and stop if you get alarmed. There are no rules, but many possibilities. I’ll leave you with a few of those …
-Try breathing like mad for a five minutes and then holding your breath for a while. You’ll be amazed at how long you can do it.
-Try breathing in different positions. Some classic positions are: draped over an exercise ball (face up or face down), touching your toes, leaning backwards, flat on your back with the knees up, squatting, child’s pose, while doing virtually any stretch …
-Try breathing in different patterns: three sharp breaths in, one out.
-Try breathing by “filling” different parts of your body: the deep belly, the solar plexus, the upper chest. For a real challenge, “fill” the less flexible parts of yourself.
-Try adding movement to the breathing, either rhythmically and repetitively, or randomly.
-Try visualizations. The possibilities in this category alone are virtually limitless. Two examples: pull energy in through your head with the intake and flush it out your toes on the exhalation; or visualize yourself like a coal that swells with heat and light when you blow on it! I like that one …
-Try breathing with music that you love.
-Try adding sound to breathing. Start with noisy exhalations, like you are groaning with satisfaction and weariness at the end of the week. That’s a good place to start. But you can work up to all kinds of noisy nonsense. If you have the privacy, do not hesitate to be emotionally noisy.
And on and on …
