Features Practice Technique
Self-Care: Diaphragmatic Breathing

Breathing is often taken for granted, rather like your heart beating or your blood circulating. Yet, unlike most
of the body’s automatic functions, breathing can also be consciously controlled. This is a mixed blessing, because you can develop poor breathing patterns, but then again, can relearn optimal breathing patterns as part of self-care.

The average person breathes 12 to 15 times per minute while resting, or 20,000 times per day (1).

It’s easy to see that inefficient or inappropriate breathing patterns can lead to dysfunction, both structurally and physiologically.

Diaphragmatic breathing is an optimal breathing pattern that encourages relaxation and helps break pain cycles, among other things.

It facilitates good heath and should be part of everyone’s breathing pattern. Babies and young children breathe this way naturally, but life’s pressures can change this. (It can be very helpful if the massage therapist can direct the client to breathe diaphragmatically as a part of every massage treatment.)

How It Works

Muscles involved in relaxed, diaphragmatic breathing are the diaphragm (a thin muscle separating the lungs and the abdominal contents), external intercostals (muscles between the ribs), scalenes and sternocleidomastoids or SCMs (muscles in the side and front of the neck). Other muscles may be used during forced breathing, but not usually with relaxed breathing.

Relaxed Inhalation
The diaphragm, a dome-shaped muscle when relaxed, flattens as it contracts during inhalation.

This pushes the abdominal contents down and outward. As the intercostal muscles contract, the ribs move up and laterally, like the motion of a bucket handle. The scalenes and SCM contract, slightly lifting the upper ribs and
sternum up and forward.

• The combination of these actions creates greater space in the chest, allowing air to move into the lungs.

Relaxed Exhalation
This is a passive process. Once the diaphragm relaxes, the abdominal contents are no longer under pressure, and the abdomen appears to flatten. The intercostals relax, and the ribs move down and in. Then the scalenes and SCMs relax, and the upper ribs and sternum move down.

• In forced exhalation, the abdominal muscles contract to push the air out more forcefully.

Benefits of Diaphragmatic Breathing

• Increasing relaxation
• Reducing blood pressure*
• Breaking the pain cycle
• Movement of the diaphragm “massages” the abdominal organs, helping digestive and bowel function and aiding movement of blood and lymphatic fluid up from the legs
• Optimizing O2 and CO2 exchange in the lungs. This can improve athletic performance if occasional diaphragmatic breaths are taken during activities.
• Reducing muscle tension and even tension headaches, since poor breathing patterns can overuse these muscles.

*(2) In one study, 10 to 20 minutes of meditation
(basically, diaphragmatic breathing with a quiet mind) evoked a relaxation response. One group reduced their
systolic blood pressure an average of 10 points to 137 mm Hg, and their diastolic pressure an average of five points to 88.9 mm Hg. Interestingly, these results were maintained if the breathing sessions continued daily.

Assess Your Personal Breathing Pattern
You can do this yourself while you’re reading this, or if you’re a therapist, while working with your client.

• Breathe in your usual way.
• Lightly place one hand on your abdomen, the other hand over your upper chest. Therapists, be sure not to startle your client – show on yourself first where you’re placing your hands, and explain that you’re assessing the breathing patterns.
• Then move your hands to either side of your ribs. Therapists, move your hands to the lateral ribs.
• What moves? What doesn’t? Do areas move (or not move) on inhalation or exhalation? Compare how you breathe to the optimal breathing patterns mentioned previously in “How it Works.”

Apical breathing, also called stress or upper chest breathing, means the movement is mostly in the upper chest.
On inhalation, the ribs may move slightly, but usually the diaphragm is barely engaged. The muscles of the neck
and accessory muscles of the shoulders are doing all the work, rather than the diaphragm – this is inefficient. Since the breath is shallow, often more breaths are taken. Apical breathing is often seen with respiratory conditions such as asthma, with some postural dysfunctions and when a person is in pain or under stress.

Retraining Yourself to Breathe Diaphragmatically
Inhale through your nose. This warms and filters the air.

• Place one hand over your chest and one hand over your abdomen.
• Take a slow breath in, try to bring it deep down into your abdomen, and feel the abdomen moving outward. (Some people benefit with a visualization such as imagining a balloon filling up in their stomach).
• Your breath then moves your ribs laterally, and chest slightly up and forward. Your shoulders should be relaxed.

Exhalation begins by relaxing your diaphragm and letting your stomach muscles relax, then your ribs drop down
and your upper chest relaxes.

At first, this exercise may be difficult to do and sometimes causes feelings of stress and frustration; some people may experience light-headedness. If any of these occur, it is best to stop and try again at another time.

It’s better to attempt only a few diaphragmatic breaths during each practice. Eventually, inhalation is performed over a count of four, then holding for a count of four,
then exhaling for a count of four.

Who Should Not Do Diaphragmatic Breathing?
Care must be taken when doing slow, deep diaphragmatic breathing if you have IDDM (insulin dependent diabetes mellitus) and with anyone with diabetes who is susceptible to ketoacidosis. To compensate for a tendency towards
acidosis, the person may need to breathe more rapidly.

Diaphragmatic breathing may actually change insulin levels (1). Therapists, if this applies to your client, consult your client’s physician (of course, with your client’s consent) before changes in breathing patterns are attempted.

1. Fried, Robert. 1990. The Breath Connection. New York: Plenum Press.
2. Benson, Herbert, and Miriam Z. Klipper. 1975. The Relaxation Response. New York: William Morrow.

Fiona Rattray, RMT, and Linda Ludwig, RMT, are educators and co-authors of “Clinical Massage Therapy: Understanding, Assessing and Treating Over 70 Conditions,” 2000. They have been motivating clients to do self-care for a combined total of 35 years of clinical practice. Contact them at www.clinicalmassagetherapy.com