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My breath: “Direct patient/client in diaphragmatic breathing”

 The evidence we summarize here may require a drastic revision of our current conceptions of the physiology of respiration, which are based on gas exchange and olfactory sensation. We suggest a radically new view of respiration by proposing that respiration directly modulates cognitive brain function by synchronizing neuronal activity across large areas of neocortex. Since cognitive processes in turn affect respiratory behavior, respiratory modulation of cognitive function indicates the presence of an intimate, life-long interaction between mind and body.”  (Heck, 2016)

The pandemic has highlighted the importance of maintaining a healthy immune system, and in particular a healthy respiratory system. It took a pandemic for the world to stop and recognize the importance of cultivating healthy breathing and respiration habits. In addition to the impact of COVID-19 on the respiratory system, clinicians report an increase in mental health complaints. The World Health Organization states: “In public mental health terms, the main psychological impact to date is elevated rates of stress or anxiety. But as new measures and impacts are introduced – especially quarantine and its effects on many people’s usual activities, routines or livelihoods – levels of loneliness, depression, harmful alcohol and drug use, and self-harm or suicidal behaviour are also expected to rise.”

In their review article, Torales et.al states: “Despite all resources employed to counteract the spreading of the virus, additional global strategies are needed to handle the related mental health issues.”

What role can massage therapists have in meeting the health care needs of the population? Perhaps the unravelling of this question lies within the RMT’s scope of practice.

Massage therapists provide treatment and care management strategies for various medical complaints including respiratory health and mental wellbeing. In fact, the guidelines from the Inter-Jurisdictional Competency Profile Appendix (FOMTRAC, 2016) is very explicit. An excerpt found on page 25 states: “Entry-level Massage Therapists should possess knowledge of the etiology, pathophysiology and clinical manifestations of commonly-occurring conditions and impairments, and apply this knowledge in order to safely and effectively assess and treat patients/clients who present with these conditions and impairments. Relevant Performance Indicators are associated with Practice Competencies 2.c and 3.1.c.”

Common clinical conditions that present as variables of: 

• a.    Stress 
• b.    Pain 
• c.    Mood 
• d.    Anxiety 
• e.    Sleep
• f.    Cognition

Also, within the scope of practice is another competency that I call our “superpower occupational competency.” Competency 3.2p, under the section “massage techniques,” (this needs to be reviewed, but that’s for another discussion) states: “Direct patient/client in diaphragmatic breathing.” This is followed by two performance indicators (PIs). The first is to demonstrate knowledge of indications, safety considerations, effects and outcomes of diaphragmatic breathing, and the second is to incorporate diaphragmatic breathing into treatment. 

Other PI considerations may include:

1. Explain the anatomical and physiological concepts of the diaphragmatic breath, and discuss the outcomes of emerging clinical research that supports the myriad benefits of diaphragmatic breathing. 
2. Explain the clinical rational for nose breathing verses mouth breathing
3. Incorporate diaphragmatic breathing into a comprehensive treatment plan, and adopt modifications based on client/patient /person history, presentation and response.
4. Cultivate diaphragmatic breathing practices as an important self-care modality

In staking claim to these important competencies, at this point it might be useful to introduce some clinical research that suggest a link between breathing and health outcomes such as anxiety, depression and pain disorders.

 Increasingly, clinical investigations into the subtleties of breathing practices highlights several findings including a reversible relationship between cortical activity and respiratory rhythms (Heck, 2016), slow breathing can induce a state of calmness (Stanford Medicine News Center, 2017), and research suggest specific breathing patterns and practices for reducing symptoms of stress, anxiety, insomnia, posttraumatic stress disorder, obsessive-compulsive disorder, depression, attention deficit disorder, and schizophrenia (Brown, Gerbarg, & Muench, 2013). In addition, other areas of research suggest a very close relationship between respiratory dysregulation and anxiety, cardiac and pain disorders (Wlhelm, Gevirtz, & Roth, 2001). 

While the RMT can get very focused on managing and treating the musculoskeletal complaints such as headaches, sprains, strains, lower back pain, motor vehicle accident injuries and sport injuries, there is likely a subgroup of RMTs with an area of interest in mental well-being. Massage therapists in general should be able to recognize when a client/patient/person is exhibiting breathing pattern disorders, and treat accordingly to restore full diaphragmatic and functional breathing patterns. However, and more specifically, RMTs who are interested in mental well-being are encouraged to further inquire into the many subtleties between breathing practices and its relationship to mental well-being. 

Here’s what Dr. Jonathan P. Parsons, M.D., Professor of Internal Medicine and Director of the Division of Pulmonary, Allergy, Critical Care and Sleep Medicine at the Ohio State University Asthma Center, has to say about our lungs: “The lungs are over-engineered to accomplish the job that we ask them to do. In healthy people without chronic lung disease, even at maximum exercise intensity, we only use 70 percent of the possible lung capacity.” (Lung Health Institute, 2017). 

The Lung Health Institute also references the study “Pulmonary function is a long-term predictor of mortality in the general population: 29-year follow-up of the Buffalo Health Study,” in making the case for pulmonary health. In their conclusion, the authors of this study suggest that “pulmonary function is a long-term predictor for overall survival rates in both genders and could be used as a tool in general health assessment.” (Schunemann; et. al; 2000)

Based on the earlier references to the Occupational Competencies (FOMTRAC, 2016), I argue that the RMT scope of practice allows for the notion of “improving pulmonary function and health.” Now, while exercise, posture, breath awareness, diaphragmatically breathing, diet etc., are all ways to improve lung and pulmonary capacity and function, questions will arise as to where the RMT scope of practice begins and ends. Some initial follow-up questions might include: How does one describe pulmonary function and health? What can inhibit/restrict pulmonary function? What are the limitations to assessment and treatment for the RMT? 

Everything we’ve discussed brings some rational for the question posed at the start of this article: “What role can massage therapists have in meeting the health care needs of the population?”  I’ve made the attempt to link the role of the RMT via our scope of practice to mental well-being AND to pulmonary health as the long term predictor of mortality. From personal experience, when practicing full diaphragmatic breathing awareness the lobes and aveoli spaces of the lungs are more fully engaged and will naturally increasing overall lung capacity. 

Before getting ahead of ourselves, let’s take a step back and consider the responsibility of  direct patient/client in diaphragmatic breathing. Is the RMT educational programs devoting enough time to this important competency?

While the general anatomy is taught, and the notion of “belly breathing” is introduced as a means to engage the diaphragm (which it does, and is at the most basic and superficial level), is it enough? Many of you might be thinking, “what’s the big deal, I’m breathing, of course I can use the diaphragm to breathe.” 

Well, that’s what I thought until I purposefully and somatically experienced the anatomy, physiology and healing life-altering effects of this gift we call breath. 

Breath awareness–self practice

1. Sit with your torso/spine held in the upright, lifted, straight position.
2. Balance your weigh evenly on your sit bones.
3. Head and neck is upright, not tilted or rotated.
4. Chin is slightly lowered /tucked in towards the neck.
5. Keep the mouth closed; lips and teeth slightly touching, gentle smile on lips, and all facial muscles, nose and nostrils relaxed. 
6. Eyes lowered and gently closed.
7. Breath flows only through the nose.
8. Place your left hand just over the belly button/ naval area, right hand on your right thigh with the elbow slightly bent/flexed.
9. Keep the breath silent, smooth without jerks, with even length and force of inhalation and exhalation.
10. Let there be no pauses between inhalation and exhalation. A continuous breath.
11. The breath begins with the belly moving into expansion. Gently push the belly into you left hand and observe the flow of air/breath gently rushing into your nostrils. Do this to your normal breath capacity- no excessive pushing out of the belly.
12. Relax the belly and feel the flow of air/breath gently rushing out of the nostrils – no excessive pulling in.
13. Repeat steps 11 and 12, nine times. Each time experience your full inhalation and exhalation.

This was originally published in the Summer 2020 edition of Massage Therapy Canada.

REFERENCES

Allen, R. (2015, January). The health benefits of nose breathing. Nursing in General Practice, 40-42.

Brown, R., Gerbarg, P. L., & Muench, F. (2013, March). Breathing Practices for Treatment of Psychiatric and Stress-Related Medical Conditions. The Psychiatric clinics of North America , 121-140.

Burgdorfa, J., & Panksepp, J. (2006). The neurobiology of positive emotions www.elsevier.com/locate/neubiorev. Neuroscience and Biobehavioral Reviews , 173-187.

FOMTRAC. (2016). Inter‐Jurisdictional Practice Competencies and Performance Indicators for Massage Therapists at Entry‐to‐Practice. Toronto.

Heck, D. e. (2016, April 16). Cortical rhythms are modulated by respiration. Retrieved from bioRxiv: http://biorxiv.org/content/early/2016/04/16/049007

Leslaw, K. (2012). Relaxation Techniques and States – Applications to Physical Therapy. Retrieved June 3, 2017, from https://www.intechopen.com/books/physical-therapy-perspectives-in-the-21st-century-challenges-and-possibilities/relaxation-techniques-and-states-applications-to-physical-therapy

Lung Health Institute. (2017, May 3 ). Lung Capacity: What does it Mean? Retrieved from Lung Health Institute: https://lunginstitute.com/blog/lung-capacity-what-does-it-mean/

Petruson, B., & Bjuro, T. (1990). The Importance of Nose-breathing for the Systolic Blood Pressure Rise during Exercise. Acta Oto-Laryngologica(109), 461-466.

PRICE, A., & ECCLES, R. (2016). Nasal airflow and brain activity: is there a link? The Journal of Laryngology & Otology,.

Schunemann, H. J. (2000). Pulmonary Function Is a Long-term Predictor of Mortality in the General Population. CHEST Journal, 656-664.

Shinde, N. e. (2013). Immediate Effect of Jacobson’s Progressive Muscular Relaxation in Hypertension. Scholars Journal of Applied Medical Sciences, 80-85.

Smith, J. C. (2007). The New Psychology of Relaxation and Renewal. Biofeeedback, 35(3), 85-89.

Stanford Medicine news Center. (2017, March 17). Study shows how slow breathing induces tranquility. Retrieved from Stanford Medicine news Center: https://med.stanford.edu/news/all-news/2017/03/study-discovers-how-slow-breathing-induces-tranquility.html

Torales, J., & et., a. (2020). The outbreak of COVID-19 coronavirus and its impact on global mental health. Retrieved May 2020, from Saje Journals: https://journals.sagepub.com/doi/pdf/10.1177/0020764020915212

WHO. (2020, May 10). Mental health and COVID-19. Retrieved from World Health Organization- Regional office for Europe: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance-OLD/coronavirus-disease-covid-19-outbreak-technical-guidance-europe-OLD/mental-health-and-covid-19

Wlhelm, F., Gevirtz, R., & Roth, W. (2001, September). Respiratory Dysregulation in Anxiety, Functional Cardiac, and Pain Disorders. Behavior Modification, 25(4), 513-545.