One of the things I keep getting asked about recently and that appears to be getting more popular within physiotherapy is the use of breathing techniques for musculoskeletal conditions. Not having considered this much in my practice I thought I would take a look at the role of breathing training and see if it is something I should be focusing on in things such as back, neck, and shoulder pains.
Now breathing techniques and respiratory training are key interventions for our colleagues who work with patients with cardio-respiratory conditions such as COPD, Cystic Fibrous etc etc, but should we be using these techniques for musculoskeletal conditions? Personally, as an MSK physio breathing is something I don’t often consider for patients I see as usually there are far more important things to focus on.
Now that’s not to say breathing is not important, in fact, breathing is an essential activity and I highly recommend everyone does it regularly, but usually I think the best type of breathing is the type you do without thinking about it, usually inhaling followed by exhaling and repeating as often as needed I find works just fine.
However, I do recognise that pain, anxiety, fear, and physical exertion can affect breathing, often increasing its rate, reducing its tidal volume, and even causing it to stop at times, and I do see some of these things occur in some of my patients in response to some of the tasks I ask them to do. So I do occasionally get a patient who I can see is tense, guarded, and holding their breath to take a few deep slow breaths before they do something they anticipate will hurt. I also get some patients who I can see are breathing too fast or too shallow due to fear or anxiety to also take a few deep slow breaths to help calm and slow their breathing rate down.
So I do focus on breathing in MSK patients from time to time, but this certainly isn’t intentional and certainly doesn’t use any fancy techniques, and it isn’t something I usually ask patients to focus on as part of their treatment. But there are some therapists who do advocate that MSK therapists should focus more on breathing techniques with their back, hip, knee or any other MSK patients to help them function better, and I can kind of understand this thinking.
There is evidence that those with back pain have different positions and fatigability of their diaphragms than those without pain. However, it needs to be remembered that these changes could be because of pain rather than contributing to it. Also these things could have been pre-existing before pain even started and related to other factors such as low physical activity or high stress levels. There is also some evidence that focusing on breathing can improve reported pain levels in both acute and chronic low back pain, so it is argued by some that it may be a good idea to get patients to do this.
However, before you all go and get your patients to behave like hyperventilating puffer fish, or start watching their abdominal rise and fall it’s important to consider if it’s worth the time and effort of using breathing techniques. Some research shows that the pain modulating effects from respiratory training are quite small and actually probably unlikely due to the respiratory training and so my question remains why bother?
Personally, I think the breathing issues I see in my patients are due to the anticipation of, or as a consequence of fear, anxiety, or pain. Therefore, I prefer to prioritise my treatments that address these things, such as education, exposure and exercise, not to focus on the consequences of them. If I do give some breathing training then I just tend to do nothing more complex than asking patients to take a few deep slow breaths.
However, there are some others such as the bonkers Postural Restoration Institute who advocate that we should go a lot further into breathing re-training and get our patients to focus on their diaphragms, chest expansions, and inspiratory muscle strength, even blowing up balloons with their arms and legs waving about in the air and doing some other weird and wacky shit. Or there is the bat shit crazy Naudi Aguilar from Functional Patterns who thinks you need to wrap elastic bands aound your ribs and push out against them when breathing. This profession never ceases to amaze me with some of the daft and stupid things it thinks is both useful or effective for pain or disability.
Simply put this kind of stupidity is nothing more than a waste of time, energy, and money. I’m sure many of the advocates of these techniques will tell you about all the patients they have helped, but im afraid to say the reasons why their stupid interventions work are not by the explanations given, instead it will be due a host of other non-specific effects that I have discussed before here.
As daft as the physio profession can be with its breathing re-training interventions, these pale into insignificance when it comes to the crazy world of strength and conditioning and breathing training. Here we enter into a whole new world of stupid ideas about how breathing training can improve strength, endurance, and performance. The daftest gimmicks are these inspiratory masks and valves that are thought to replicate high altitude oxygen deprived environments and so create increased physiological responses to training.
Well I’m afraid to say that these masks replicate high altitude training just as much as sticking your feet out of a car window replicates running fast, or flushing your head down the toilet replicates swimming. To simulate a low oxygen environment, you need… wait for it… a low oxygen environment, these masks simply don’t filter oxygen from the atmosphere.
What these masks actually do is reduce the airflow into your lungs so increasing the effort to breathe, this is whats called inspiratory muscle training. This is a bit like trying to breathe through a straw or a pillow that is being smothered over your face. Now our cardio-respiratory colleagues will tell us that this is an effective intervention for those with respiratory conditions or disease, that is inspiratory muscle training by the way, not pillow smothering!
However, there is little evidence that inspiratory muscle training and these masks help improve athletic performance or do anything significant except make you look like a twat. There are some studies that show the effects of inspiratory muscle training improve respiratory function in athletes, but surprisingly no evidence that this translates into improvements in their athletic performance.
Don’t get me wrong using some simple breathing techniques when training can be useful. For example, breathing in deeply and holding the breath at the bottom of a heavy squat or deadlift can help brace and splint the abdomen and trunk via the Valsalva manoeuvre, thrn breathing out forcefully during the effort phase of the lift can help generate power, but thats about it. Again when it comes to training and breathing, my advice is simple… do it as much and as often required.
So in summary, there is no doubt that breathing is essential and most of you should definitely keep doing it. There is no doubt that breathing can be abnormal in the presence of disease, pain, fear, and anxiety, but there is little evidence to say that these breathing issues are causative of these things. Many therapists are focusing on breathing training in musculoskeletal conditions such as back pain when there is also little evidence that these interventions are signficantly effective, and for me breathing interventions are low on the list of things to focus on with the people I see. However, if I do then it usually is nothing more than asking a patient to take a few slow deep breaths with no balloons or stupid masks in sight.
As always, thanks for reading.