BREATHING BETTER
Why and How I Teach Breathing as a Physical Therapist
Pain, elevated muscle tone, constipation, posture abnormalities, headaches, work stress, or emotional stress are a few of the many reasons I address breathing with the majority of my clients in the physical therapy setting.
If you have a fitness tracker, you may have your respiratory rate recorded between the “normal” range of 12-20 breaths per minute. Most of the population breathes with a dysfunctional pattern described as apical, which means an increased movement in the chest and shoulders upwards toward the head with a lack of movement in the abdomen. With this pattern, our diaphragm, the primary muscle of respiration, is minimally utilized, and instead, our accessory breathing muscles overcompensate.
Let’s learn how to breathe optimally. Start with locating the diaphragm, the primary muscle of respiration. This amazing muscle lives under our rib cage and separates the chest chest cavity from the abdominal cavity with a circular shape. It’s a large muscle that moves somewhat like a jellyfish as it relaxes and descends to expand lung space on an inhale and raises and contracts to push air out on an exhale. Let me explain one more time that the diaphragm lowers and expands on an inhale, and rises and contracts as the ribcage narrows on an exhale.
After reading these instructions, position both your hands on your lower outer rib cage. This should be at the end of the boney ribs as the bottom of your fingers may contact the soft spot on your trunk. I like to direct people to breathe in low and wide to get lateral rib expansion and really get the diaphragm moving. This is called diaphragmatic excursion. With your hands in place, inhale as if you’re filling up a balloon low and wide that’s expanding towards the walls of the room. As you exhale, feel the rib cage and waist become narrow as you let the air out. Try this for several breaths to practice the low and wide expansion of the diaphragm on your inhale.
Measuring diaphragm excursion can be done in the clinic (Chandrasekhar) and can measure on average 6cm (over 2 inches) during deep breathing (Boussuges). Interestingly, this number decreases significantly in critically ill patients to around 1cm (Zambon). During quiet breathing, which likely was studied in the 12-20 breaths per minute range, diaphragmatic excursion was only measured to 2cm in most adults (Boussuges). That’s not a lot of diaphragmatic movement!
Another reason we coach slow breathing and improving the use of your diaphragm is the increased use of the lower lung lobes during respiration. In contrast to rapid chest breathing, expansion through the lower lobes is thought to increase activation of the parasympathetic nervous system—the rest and digest, the heal and feel control unit. A higher density of parasympathetic nerves are concentrated in these lower lung lobes. (Nester). Since many dysfunctions are rooted in an overactivation of the sympathetic nervous system, which leads to increased cortisol release, activating the parasympathetic nervous system helps bring balance to the body.
Now that you are practicing breathing slow and low, let’s clarify your goal of breathing slowly versus breathing deeply. Breathing slowly for six breaths per minute to a rhythm of a 5-second inhale and 5-second exhale does not mean you have to fill your lungs to the maximum capacity with each inhalation.
Healthy adults will have plenty of oxygen in their bodies, often measured with basic pulse oximetry to be over 95% oxygen saturation. There is a growing amount of evidence that our bodies actually need more carbon dioxide, the other respiratory gas produced on exhalations (Nester). Therefore, the concept of breathing less may actually have tremendous health benefits.
This brings us back to the optimal breathing rate of 5.5 breaths per minute. Once again, we recommend the six breaths per minute at approximately 5-second inhales and 5-second exhales. If you feel this pace is very strange at first, that is a common reaction. In some cases, the body calibrates the overbreathing, asymmetrical rhythms as its familiar baseline, and when a new stimulus is introduced, even healthy, good breathing rhythms might be perceived as a threat (Thurber). If you need to start at an easier pace of 3-second inhales and 3-second exhales and work your way up to five seconds each, that is perfectly acceptable. Find a rhythm that works for you and your body will adapt with training and practice.
There is one other rhythm worth mentioning. Did you know that your heart rate actually accelerates during inhalations and decelerates during exhalations? This is called respiratory sinus arrhythmia (RSA), and it’s a completely normal function of heart rhythms. One measure of heart rate variability, and health and longevity, is seeing good variation between highest heart rate at an inhalation and the lowest heart rate at the bottom of an exhalation. Because the heart rate acceleration during inhalation activates the sympathetic (stress) nervous system and the heart rate deceleration during exhalation activates the parasympathetic (vagus nerve-controlled rest and digest) nervous system, some providers advocate for a breathing ratio of 1:2 inhalations to exhalations. Those long exhalations are believed to improve vagal nerve stimulation, which slows down heart rate and may also improve the carbon dioxide deficiency problem previously mentioned.
This could look like a variety of patterns such as a 4-second inhalation and 8-second exhalation. Research has compared the 1:1 paced breathing (5-second inhale:5-second exhale) to 1:2 paced breathing (approximately 3.5-second inhale and 6.5-second exhale exhale) with no significant difference in heart rate variability and power frequency noted (Shaffer). Therefore, the 365 Breath Beads bracelet will still work as a 5-minute timer at 6 breaths per minute if you would like to try a pace of 3-second inhalations and 7-second exhalations. Personally, I find this helpful or may recommend it to a patient if the goal is to reduce anxiousness or calm the body.
Finally, how do you know if you’re breathing at the right pace? As mentioned earlier, you can download a free metronome app on your phone and set it to 12 beats per minute for the 5-second inhalation and 5-second exhalation rhythm. Another great free app is the Insight Timer, which has a recorded 5-minute track called “5.5 breaths per minute” with a calming chime to guide pace.
Honestly, the easiest way to find your rhythm is to count in your head and “warm up” for several breaths before you replace the counting with a breath prayer. This can be repeated in your mind slowly with “inhale-2-3-4-5, exhale-2-3-4-5”. If you feel you’re a quick breather, try adding, “inhale-2 one thousand-3 one thousand-4 one thousand- 5 one thousand, etc.” Or, if you want to have some fun: “one-banana, two-banana, three-banana, etc”. Positive Breathing is meant to be a rewarding and relaxing experience, so don’t stress over how precisely your breath is to the goal pace. If you’re breathing slower than normal, you’re doing well!
In summary, breathe slowly. Focus the breath inhalation low and wide to move the diaphragm. It’s more about breathing less versus breathing deeply. Find a slow pace that works for you. Your body will adapt and build slow breathing resiliency with training. Be patient with this process. Slow breathing is great, and Positive Breathing is even better. Enjoy the time of restoring your body and renewing your mind and spirit with breath prayers.
References
Nestor, J. Breath: The New Science of a Lost Art. Riverhead Books; 2020.
Thurber, MR, McCraty R, et al. HeartMath Interventions Program for Health Professionals: Establishing a new baseline for sustained behavior change. HeartMath LLC; 2017.
Van der Kolk, Bessel A. "The body keeps the score : brain, mind, and body in the healing of trauma." New York, New York : Viking, 2014.
Boussuges A, Finance J, Chaumet G, Brégeon F. Diaphragmatic motion recorded by M-mode ultrasonography: limits of normality. ERJ Open Res. 2021;7(1):00714–2020. https://doi.org/10.1183/23120541.00714-2020.
Zambon M, Greco M, Bocchino S, Cabrini L, Beccaria PF, Zangrillo A. Assessment of diaphragmatic dysfunction in the critically ill patient with ultrasound: a systematic review. Intensive Care Med. 2017;43(1):29–38. https://doi.org/10.1007/s00134-016-4524-z.
Shaffer F, Ginsberg JP. An Overview of Heart Rate Variability Metrics and Norms. Front Public Health. 2017;5:258. Published 2017 Sep 28. doi:10.3389/fpubh.2017.00258
Chandrasekhar, A. Method of Exam. Loyola University Chicago Stitch School of Medicine. Accessed December 3, 2023. <https://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/step28a.htm>.
