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 Understanding and Rehabilitating Unbalanced Breathing By Leon Chaitow, ND, DO In the inaugural issue of Naturopathy Digest,1 I outlined some of the symptoms that can be created or aggravated by Breathing Pattern Disorders (BPD) such as hyperventilation. This article contains information focusing on three overlapping areas: the background to BPDs, how to recognize BPD in a new patient and how to begin rehabilitation. More detailed information can be found in my co-authored book published by Elsevier, Multidisciplinary Approaches to Breathing Pattern Disorders (Chaitow, Bradley & Gilbert 2002).Back Pain Research and Breathing Rehabilitation2 A very recent research paper has been published that demonstrates another aspect of the benefit of breathing rehabilitation - improvement in chronic low back pain! In this randomized, controlled study, patients with moderate chronic low back pain (average duration of one year) improved significantly (both pain and function) whether they were treated with breathing rehabilitation or what was described as "gold standard" physical therapy. Both groups received one introductory evaluation session of 60 minutes, and 12 individual therapy sessions of equal duration of 45 minutes, over six to eight weeks. Summary of Some of the Main BPD Effects3 Excessive carbon-dioxide loss causes blood pH to rise, creating respiratory alkalosis. This induces increased sympathetic arousal, altering nerve function (including motor control). It also encourages a sense of apprehension and anxiety, which affects balance. Calcium and magnesium ions are lost as the kidneys attempt to restore pH balance by excreting bicarbonate. This enhances neural sensitization, encouraging spasm and reducing pain threshold. Smooth muscle cells constrict, leading to vasoconstriction (and possibly altering fascial tone). Smooth muscle constriction can lead to colon spasm and pseudo-angina. Due to alkalinity, the so-called Bohr effect reduces oxygen release to the cells, because haemoglobin retains oxygen more effectively in an alkaline environment, thus affecting tissues and the brain, encouraging ischemia, fatigue and pain. Ischemia encourages the evolution of myofascial trigger points. Overbreathing creates biomechanical overuse stresses, particularly on the accessory breathing muscles (scalenes, sternomastoid, upper trapezius, etc.), as well as compromising core stability and posture. Breathing pattern disorders are habitual, easily recognized and usually capable of being improved or eliminated. Background and Definition of Breathing Pattern Disorders The extreme of a BPD is hyperventilation, which is defined as breathing in excess of metabolic requirements. A patient might show an odd arrhythmic breathing pattern and not be hyperventilating, and perhaps more importantly, might look as if they are breathing OK, but actually be hyperventilating even if apparently fit with good lung function. About 10 percent of all patients attending general internal medicine practice in the U.S. are estimated to be suffering from chronic hyperventilation.4 My own clinical experience with this sort of problem suggests that a large patient population exists with BPDs who don't meet the criteria for hyperventilation, but whose breathing patterns contribute greatly to their symptom picture. What Are the Symptoms? The vast majority of patients who chronically overbreathe in this way present with symptoms such as fatigue, widespread pain (e.g., fibromyalgia), irritable bowel symptoms, chronic bladder problems, anxiety, allergies, chemical sensitivities, headaches, premenstrual syndromes, photophobia and hyperacusis. In many such conditions, BPDs rarely are causal (except perhaps if anxiety is a major feature), but they almost always are contributory, and sometimes become a major obstacle to recovery. As will become clear, the effects of BPDs are global, affecting all systems, having profound neurological, psychological, digestive and circulatory influences. BPDs commonly are habitual, and with a cooperative patient, usually are capable of significant improvement and are sometimes curable over a three- to six-month time frame. Chronic HVS can present with respiratory, cardiac, neurological or GI symptoms, without any clinically apparent overbreathing by the patient.5 BPDs More Common in Women HVS/BPD is female dominated, ranging from a ratio of 2:1 to 7:1 (peak ages 15-55 years). Women are more at risk, possibly because progesterone is a respiratory accelerator. This also can have implications for women on hormone replacement therapy. During the postovulation phase, carbon-dioxide levels drop about 25 percent and additional stress then "increases ventilation at a time when CO2 levels are already low."6 Blood Sugar and BPD Feelings of faintness, cold sweats, weakness and disturbed consciousness are common to both hyperventilation and low blood sugar, and symptoms are far worse when both situations are present at the same time.
It also has been found that fluctuating blood glucose levels, even when these stay within normal limits, can trigger hyperventilation/BPD symptoms. People affected in this way are recommended to eat breakfast (including protein) and to avoid going without food for more than three hours or following a little-and-often or grazing pattern of eating. This is particularly important to patients who experience panic attacks or seizures.9 Perspective of a Cardiologist Peter Nixon, a leading U.K.-based cardiologist, reported: "When dysfunctional thoracic breathing predominates, a shift occurs towards excessive arousal, which as a catabolic state predisposes the soma towards pathology."10 Someone suffering from BPD could experience catabolic changes; protein, fat and carbohydrate synthesis halted; energy mobilized from increased breakdown of protein, fat and carbohydrates; blood levels of glucose, LDL and cholesterol increase; decrease in repair and replacement of bone; decrease in repair and replacement of skin and gut cells; decreased production of immune cells (thymus shrinks, less WBCs); decreased sexual function; increased blood pressure; and increased salt and fluid retention. Why do people breathe this way? One of the major medical researchers of BPD, Claude Lum, discussed the reasons for people becoming hyperventilators, "Neurological considerations leave little doubt that habitually unstable breathing is the prime cause of symptoms. Why people breathe in this way must be a matter for speculation, but manifestly the salient characteristics are pure habit."11 Diagnosis Although an absolute diagnosis only can be made with CO2 monitoring using a capnograph that monitors carbon-dioxide levels in exhaled air, a simple questionnaire (Nijmegen Questionnaire) is internationally accepted as being over 90 percent accurate in suggesting that hyperventilation exists as a contributory feature of a person's symptom picture. This noninvasive test is a simple and accurate indicator of acute and chronic hyperventilation.12,13 What Patient Signs Might Alert You to BPD?
Possible Treatment Sequence for HVS/BPD Note: The sequence outlined below is one I have evolved for my own practice and is not a recommendation for others. It does, however, contain the elements I feel are necessary for a successful restoration of breathing. Treatment and retraining commonly involves eight to 12 weekly sessions, followed by treatment every two to three weeks, for approximately six months. An educational component should be included at each session. First two treatments: (Not less than weekly): release and/or stretch of upper fixators of the shoulders/accessory breathing muscle (upper traps, levator, scalenes/SCS, pecs, lats) as well as attention to trigger points in these; soft tissue (NMT, MET, PRT, etc.), attention to the diaphragm area (anterior intercostals, sternum, abdominal attachments costal margin, quadratus lumborum/psoas), as well as attention to trigger points in these. Retraining: pursed lip breathing, as well as guidance as to restricting shoulder rise during inhalation. Give an introduction of the capnograph biofeedback method. Sessions (weeks) three and four: As above, plus mobilization of thoracic spine and ribs (as well as lymphatic pump/drainage methods), plus address fascial and osseous links (cranial, pelvic, limbs). Retraining: anti-arousal breathing, plus specific relaxation methods, stress management, autogenic training, visualisation, meditation, counselling. Sessions of capnograph biofeedback training as required. Sessions (weeks) five to 12: As above, plus focus on other body influences (ergonomics, posture). Retraining: additional exercises as appropriate. Sessions (weeks) 13 to 26: Review and treat residual dysfunctional patterns/tissues. Throughout: As indicated, incorporate nutrition, psychotherapy and adjunctive methods, such as hydrotherapy, tai chi, yoga, Pilates, massage, acupuncture, etc. Successful Breathing Retraining There have been many reports and studies showing the value of breathing rehabilitation.14 Lum15 reported on a study in which more than 1,000 anxious and phobic patients were treated using breathing retraining, physical therapy and relaxation. Symptoms were usually abolished in one to six months, with some younger patients requiring only a few weeks. At 12 months, 75 percent were free of all symptoms and 20 percent had only mild symptoms; however, about one patient in 20 had "intractable symptoms." Instructions for Anti-Arousal/Pursed Lip Breathing16-19 Place yourself in a comfortable (seated/ or reclining) position, and exhale slowly and fully through pursed lips (as though you are blowing through a drinking straw), with your lips just barely separated. Imagine that a candle flame is about 10 inches from your mouth and exhale (blowing a thin stream of air) in such a way as to not blow this out, but to just make it flicker. When you have exhaled fully, without strain, close your lips and pause for a count of one and then inhale through your nose. The complete exhalation will have created a "coiled spring" so you do not have to try to control how you inhale. Then, without pausing to hold the breath, exhale fully and slowly through pursed lips once again, blowing the air in a thin stream until you feel the need to inhale. Close your lips, pause for a count of one, and then inhale freely through the nose again. Repeat the inhalation and exhalation for not less than 30 cycles of in and out. Practice this exercise morning and evening. You might feel light-headed after the 30 cycles, so rest for a few minutes before resuming normal activities. Shoulder Restraint Methods need to be taught to encourage the restraining of shoulder movement (accessory muscle activation) during breathing using one of a variety of methods. For example: The patient is seated at the edge of a chair with arms hanging down, palms facing forward. On inhalation, the patient gently turns the arms so the thumbs point slightly backwards, and on exhalation this is released and relaxed. The rhythmic breathing pattern, along with this gentle restraint of accessory breathing muscles, starts the process of separating the act of inhalation from their overactivity. The information in this article has focused on the background, appearance, assessment and rehabilitation of breathing pattern disorders. These are not pathologies, any more than poor posture is a pathology, but they can profoundly influence emotions, chemistry and structure. I sincerely hope you can use the essential features of this message to benefit your patients - and perhaps yourself. References
Among his many professional responsibilities, Dr. Chaitow is active teaching in America, Australia and Europe. He has written more than 75 books on such topics as manual methods of treatment, breathing rehabilitation and chronic pain conditions. Currently, he is involved in a major project editing and partially writing a new textbook, Naturopathic Physical Medicine, in collaboration with 15 leading naturopathic, chiropractic and osteopathic experts from the U.S., Canada, Australia and the U.K. Dr. Chaitow can be reached at www.leonchaitow.com.
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All Rights Reserved, Naturopathy Digest, 2011.
Date Last Modified - Friday, 17-Oct-2008 12:10:28 PDT
About the Author: Dr. Leon Chaitow was born in South Africa and then moved to London, where he trained in osteopathy and naturopathy. In 1992, he joined the team that developed the courses and modules that became the nucleus of the curriculum of The School for Integrated Health, University of Westminster, where for 10 years (until 2003) he was a senior lecturer in therapeutic bodywork (including neuromuscular techniques) and naturopathy.