Recognizing and Treating Breathing Disorders: A Multidisciplinary Approach by Leon Chaitow

Book Notes

Recognizing and Treating Breathing Disorders: A Multidisciplinary Approach by Leon Chaitow does an amazing job of describing the many negative effects that breathing disorders can cause. This book is very well researched and has many practical insights that any personal trainer or physical therapist can benefit from.

Selected Notes

  1. In the latter stages of the menstrual cycle (post-ovulation) progesterone levels increase naturally. Since progesterone stimulates respiration, women with an existing tendency towards upper-chest overbreathing are more likely to hyperventilate
  2. Nasal congestion or obstruction can lead to alteration of the breathing pattern
  3. Conditions that involve chronic pelvic pain and abdominal splinting are commonly associated with breathing pattern disorders. The anatomical and structural connection between the pelvic floor and the diaphragm help to explain this association
  4. General levels of deconditioning (the opposite of aerobic fitness) lead to altered forms of energy production (anaerobic glycolysis) that encourages acidosis – hence a greater tendency to hyperventilation
  5. From clinical experience, it is known that a marked individual difference exists in the extent of respiratory and non-respiratory movements of the diaphragm. Individuals who do not demonstrate sufficient ability to contract the diaphragm during trunk stabilization pose a greater risk of low back pain
  6. Diaphragm dysfunction is viewed as one of the essential causes of GERD… In short, it can be stated that patients with GERD are also ‘respiropathics’ as far as the force of the respiratory musculature is concerned,
  7. If a pattern of breathing has been disturbed for any length of time, clinical experience suggests that normalization of the muscles and joints associated with the breathing process frequently require primary attention, before normal patterns of use can be restored. In some instances however, even where structural changes are well established, a reformed breathing pattern alone may reverse changes – for example involving the accessory breathing muscles – allowing enhanced thoracic biomechanics to manifest (
  8. Neiva et al (2009) confirm that children who are mouthbreathers, are prone to altered respiratory function, and commonly exhibit: ‘forward head posture, a reduced physiological cervical lordosis, protrusion of the shoulders, elevation and abduction of the scapulas.’ These adaptive changes usually involve forward head posture, a low and forward tongue position and increased activity of the accessory muscles of respiration (sternocleidomastoid, scalenes and pectorals) that tend to hypertrophy over time (Correa & Berzin 2008, Hall & Brody 2005). This pattern is perpetuated by the decreased activity of the diaphragm and hypotonicity of the abdominal musculature that weaken due to inactivity (
  9. respiratory dysfunctions are commonly seen in patients with low back pain, pelvic floor dysfunction and poor posture.
  10. Additional evidence exists connecting diaphragmatic and breathing pattern disorders, with various forms of pelvic girdle dysfunction – including sacroiliac pain
  11. Individuals with LBP have been shown to perform lifting tasks with more inhaled lung volume than individuals without LBP. These findings are consistent with the theoretical link between breath control, intra-abdominal pressure, and lumbar segmental control
  12. Nasal breathing (as opposed to mouth breathing) increases circulating blood oxygen and carbon dioxide levels, slows the breathing rate and improves overall lung volumes… The nose provides a resistance to breathing that is twice that of the open mouth (Swift et al 1988). This increased resistance to inspiration and expiration appears to have a number of physiological benefits. Nasal breathing increases total lung volume (Swift et al 1988). The corresponding increase in functional residual capacity (volume of air present in the lungs present after passive expiration) is thought to improve arterial oxygen concentrations. In a study of arterial Pa02 (partial pressure of oxygen: the measurement of oxygen in arterial blood) levels before and after jaw wiring (this forced patients to breathe through their noses), Pa02 level increased by nearly 10% (Swift et al 1988). End tidal pCO2 levels, which are considered to be a reliable indirect measure of the CO2 partial pressure in the arterial blood, also increase with nasal breathing. This may be due to an increase in dead space (Tanaka et al 1988).
  13. Many lower respiratory tract diseases, such as asthma and chronic obstructive pulmonary disease, are associated with both breathing pattern disorders as well as significant upper respiratory disease
  14. Increased airflow though the right nostril is correlated to increased left brain activity and enhanced verbal performance, whereas increased airflow through the left nostril is associated with increased right brain activity and enhanced spatial performance (Shannahoff-Khalsa 1993). Brain wave cycles during sleep are also synchronized to this nasal cycle
  15. Nasal resistance is also inversely related to end tidal pCO2 levels. People who are anxious typically have lower arterial pCO2 levels and are thus more likely to present complaining of nasal congestion
  16. During exercise, nasal breathing causes a reduction in FEO2, indicating that on expiration the percentage of oxygen extracted from the air by the lungs is increased, and an increase in FECO2, indicating an increase in the percentage of expired air that is carbon dioxide
  17. Nasal breathing also increases the timing of the expiratory phase of the respiratory cycle (Ayoub et al 1997). Increasing the expiratory phase of the respiratory cycle is known to increase the body’s relaxation response
  18. Theoretically, improvement of upper airways inflammation should improve asthma symptoms and control. A limited number of studies indicate that this may occur (
  19. Migraine, tension headache and temporomandibular pain can be associated with breathing pattern disorders
  20. Faulty breathing patterns also have the potential to cause nasal congestion. Nasal congestion is related to arterial pCO2 levels. If arterial CO2 levels are low due to hyperventilation, then the nose becomes congested
  21. 74% of 50 patients with asthma experienced significant improvement without medication following an elimination diet. 62% were shown to have attacks provoked by food alone and 32% by a combination of food and skin contact?
  22. When 113 individuals with irritable bowel syndrome were treated by an elimination diet, marked symptomatic improvement was noted. 79% of the patients who also displayed atopic symptoms, including hay fever, sinusitis, asthma, eczema and urticaria, showed significant improvements in these symptoms as well
  23. vegan diet which eliminated all dairy products, eggs, meat and fish as well as coffee, tea, sugar and grains (apart from buckwheat, millet and lentils) was applied to 35 asthmatics, of whom 24 completed the 1-year study. There was a 71% improvement in symptoms within 4 months and 92% after 1 year
  24. Crosscultural research has yet to be done, but in a population of French subjects, anger, erotic love and tenderness varied consistently in duration of post-expiratory pause, breathing amplitude and breathing rate. For sadness, joy and fear, the time ratio of inhalation to exhalation differentiated the emotions most clearly
  25. There is clear evidence that respiratory responses can be conditioned. Ley (Ley et al 1996, Ley 1999) confirmed this by monitoring end-tidal CO2 in college students while they coped with brief mental stressors such as doing calculations in their heads or counting backwards by sevens from 200. This was sufficient to increase their skin conductance, heart rate and breathing rate, and also to shift CO2 in the direction of hyperventilation. In this situation there was no clear threat which would justify activating the bodily stress response, so either a psychosocial threat (a blow to the ego) was present from the risk of failing the test, or else the effort involved in the mental tasks activated the body changes. Ley presented a specific sound to the subjects along with the ‘start’ instructions, linking the tone with the demand to perform. Eventually, sounding the tone became sufficient to set off the same stress responses even when no task performance was required. Hyperventilation was now conditioned to the neutral tone.
  26. Subjects were exposed to low concentrations of particular smells along with either normal room air or a 7% concentration of CO2. (This procedure is often used in panic studies to test for sensitivity to excess CO2, since the gas quickly stimulates increased breathing.) After a few pairings of a particular odour with the high- CO2 air, the odour by itself, in ordinary room air, would stimulate both an increase in breathing and complaints of breathlessness, chest tightness and other respiratoryrelated sensations.
  27. Increased variability from breath to breath is known to correlate with anxiety states (Han et al 1997, Beck et al 2000). Low PaCO2 and increased frequency of sighing are typical of those with panic disorder, even when not panicking
  28. One marker for panic disorder consists of delayed return of end-tidal CO2 to a normal range following voluntary hyperventilation (Wilhelm et al 2001b). A delayed return to baseline after another 3 minutes is also a positive diagnostic sign for hyperventilation syndrome, as based on symptom reports. Conway and colleagues (1988) found that those who showed slow return to baseline tended to be habitual overbreathers, and were usually most bothered by the physiological distress accompanying hyperventilation. This group would probably score higher on the Anxiety Sensitivity Index (see Ch. 6.4), meaning they were hypersensitive to the sensations of anxiety
  29. This study showed at least that individuals who reported several symptoms indicating hyperventilation (including chest pain and palpitations, dizziness, etc. – not exclusively respiratory symptoms) displayed rather strong hyperventilation in response to recalling emotionally disturbing events, whereas the control subjects did not. Bereavement, loss of control, grief and anger were common topics associated with the symptoms.
  30. With these controls applied, there was a clear deficit in performance, both in slower reaction times and in more errors, in a subset of subjects during the ‘true hyperventilation’ trials in which PaCO2 was actually lowered. Subjects whose performance suffered generally had brief apnoeas during the 3-minute recovery stage. The resulting performance deficits were tentatively explained as due to ‘prolonged central hypoxia’. The authors describe other data showing that while PaCO2 recovered faster in subjects with apnoeas, oxygen saturation stayed lower
  31. lower PaCO2 in naturally occurring stressful situations. Young adolescent students were differentiated into high and low test-anxious by a standard questionnaire; during a task performance, end-tidal CO2 was lower in the first group than the second… End-tidal CO2 level was also measured in the 2012 study, and was found to correlate with performance anxiety. In general, reports of hyperventilation-related symptoms increased as the reported anxiety increased
  32. More specifically UT has been found to be overactive (and therefore by implication shortened) in mouth-breathing children
  33. Scalene dysfunction and the presence of trigger points in them (‘functional pathology’) were identified in more than 50% of individuals, in a series of 46 hospitalized patients who demonstrated paradoxical patterns of respiration
  34. Lucas et al (2004) found that the presence of trigger points in myofascial structures alters activation (firing) sequences in entire kinetic chains. In addition MTrPs in the cervical, shoulder-girdle, thoracic or lumbar muscles strongly influence, and can be strongly influenced by, disturbances of ventilation mechanics, such as paradoxical respiration, or by abnormal postural patterns
  35. Sciotti et al (2001) demonstrated that four blinded experienced examiners who ‘trained extensively together prior to the study’ were able to reliably (80% agreement) identify the location of latent MTrPs in the upper trapezius muscle
  36. when thoracic paraspinal muscles palpated as ‘abnormal’ (tense, dense, indurated) the same tissues also had lowered pain threshold (using an algometer).
  37. myofascial trigger points can be visualized using diagnostic ultrasound and sonoelastography. Myofascial trigger points are hypoechoic on two-dimensional ultrasound and appear stiffer than the surrounding muscle on vibration sonoelastography.
  38. Specific oropharyngeal exercises have also been shown to reduce snoring, and OSA
  39. Those who had high scores on the ASI judged their heart rate changes as larger, and their anxiety as more intense, than those with low scores on the ASI. However, the actual changes in heart rate and skin conductance did not differ between the two groups; the difference was due to biased perception alone. ‘Anxiety sensitivity’ somehow amplified the bodily changes in the minds of the subjects
  40. Anxiety sensitivity is also associated with deficient coping resources for emotional distress (Kashdan et al 2008), and this is associated with magnification and persistence of anxiety symptoms, including disordered breathing and its effects
  41. Breathing 6–8 times a minute has a profound restorative effect on the autonomic nervous system (Bernardi et al 2001), as well as a mobilizing effect on the musculoskeletal system involved in breathing. It may also affect the mental state
  42. brain regions implicated in the regulation of emotion are both responsive to breathing-related bodily changes, and important in influencing the appearance and persistence of breathing-related symptoms
  43. We conducted a clinical trial comparing an experimental group (following physical exercise plus relaxation and breathing) and a control group (physical exercise only). The outcome showed a clear additional benefit
  44. Inspiratory muscle training (IMT) has been shown to be of benefit in abdominal/ diaphragmatic pattern strengthening and in reducing exertional dyspnoea in mild to moderate asthma
  45. IMT has been shown to benefit those with limited exercise capacity because of obesity
  46. Patients with neck, shoulder and general upper torso pain commonly have faulty breathing patterns
  47. Performance anxiety has been shown to have close associations with breathing pattern disorders
  48. There have been at least six published clinical trials on the Buteyko Method for asthma
  49. Research has shown that slow breathing decreases chemoreceptor sensitivity and enables the patient to tolerate higher levels of CO2 (Bernardi et al 2001). Slow breathing has also been shown to be very beneficial for treating asthma (
  50. Research with athletes has shown that including breath holding to maximum capacity in their training routines resulted in increased production of endogenous antioxidants and higher anaerobic threshold
  51. Maximal breath-holds also cause splenic contractions with subsequent increased haematocrit and haemoglobin levels and possible immune stimulation effects
  52. It appears that this is an important part of asthma treatment as it has been shown that replacing mouth breathing with nasal breathing, even without other breathing exercises, improves lung function and reduces asthma exacerbations
  53. Asthmatics have been found to suffer from much higher levels of anxiety, depression and panic disorder than the average population
  54. In asthma there is increased activity of the brain’s emotional neural circuitry involving structures in the limbic system such as the insula and anterior cingulate gyrus that are part of the brain’s fear network. The extent of activation of this neural circuitry predicts the magnitude of lung function decline (
  55. Posture in older adults is shown to improve (Kaesler et al 2007) with Pilates practice, as is the dynamic posture of dancers (McMillan et al 1998), and the dynamic balance of healthy adults (Johnson et al 2007).

 

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