Breathing for activity
Health Disclaimer:
These articles are for educative and entertainment purposes only. They are not intended to be a substitute for professional medical advice, diagnosis or treatment. If you have a current injury or are in pain, please seek the advice of your regular health care provider. You are responsible for your own safety and health at all times. Especially, given physical activity is not without risk and can cause harm. By engaging with any content on this website you acknowledge and agree that The Musculoskeletal Clinic is not liable for any direct, indirect, special, consequential, exemplary, or other damages arising therefrom.
Never disregard professional medical advice or delay seeking medical treatment because of something you have read on or accessed through this web site.
Introduction
This week's topic is about the skill of breathing. Specifically, how we can utilise three different aspects of the skill and mechanisms of breathing in an active and dynamic environment. These include breathing gears and anaerobic threshold, perfusion and breathing flexibility. I will not discuss specifics of breathing in a static environment. However, some of the topics can apply to all of the above.
Perfusion
In its simplest form breathing at its core purpose is a central pump that sucks oxygen into our bodies and propels carbon dioxide out (1). Oxygen is necessary for many processes. Carbon dioxide is the end product of some of our waste production. There is both a passive and active element to this exchange of chemicals, most of which occurs in the lower lobes of the lung (1). Why? This region of the lungs has the greatest interweaving of alveoli, or air sacs, (think grapevines a visual) and arterioles; creating an extremely large surface area for oxygen to diffuse into the bloodstream and Carbon dioxide to diffuse out and exit for exhalation. Importantly, inadequate perfusion leads to increased work of breathing effort and breathlessness and reduced arterial oxygen levels (2)
Below is a useful exercise from Andrew Huberman called a physiological sigh. It helps to increase perfusion and hasten the off-loading of carbon dioxide.
Breathing flexibility
Lower ribcage and abdomen
So how do we utilise this area the most? The answer is slightly different if you are relaxed/static vs being active. Consistent between the two though, is sideways or bucket handle breathing (3,4)! This is where you use your lower ribcage to help expand your lungs and create a negative pressure to pull oxygen in from the outside air (5). Lower ribcage breathing is the primary mode of inspiration via the diaphragm attachments onto the lower ribs and upper lumbar spine (5).
To perform this skill, one needs adequate breathing flexibility in the muscles and joints involved in the movement. This includes: the rib joints, the spinal joints, the abdominal muscles, the between rib muscles and the diaphragm. There are other secondary roles but these are the primary. Interestingly, if you physically restrict the thoracic ribcage we see increased difficulty of breathing (2). Go figure! Why is that important though? If you have reduced breathing flexibility, then you have reduced range of motion and thus reduced perfusion; the negative effects of are described previously.
Upper ribcage
Upper ribcage breathing is an important region to have capability in. Unfortunately, movement here gets a reputation as a ‘dysfunctional’ breathing pattern, or ‘the wrong way to breath’ across a broad spectrum of populations (6). While breathing patterns may be more relevant in respiratory pathologies, in terms of those with musculoskeletal pain, breathing patterns may only be clinically relevant in those with neck pain (5,7). In a sample of 111 people with varying ages and ethnicities, dysfunctional breathing was not found to strongly correlate with other previous or concurrent musculoskeletal pain (5).
In terms of patterning, electromyographic (EMG) studies, albeit small sample sizes, do show that the upper ribcage and scalene muscles are active throughout quiet breathing (5,8). Additionally, that equal pressures throughout the ribcage (combined upper and lower) are expected at rest and during activity (9). Interestingly, if you bias lower ribcage movement during breathing in, the scalenes do quieten down in activity, while the ribcage muscles do not (8). More importantly, biasing lower ribcage movement led to paradoxical upper ribcage movement and reduced total ribcage expansion. What does this mean? It is normal, expected, and ok to breath into your upper ribcage at rest.
Adding to this, a pattern of isolated lower ribcage movement is even paradoxical in people with chronic obstructive pulmonary disease (COPD), where those with COPD will expand their chest wall sooner, and for longer periods than healthy controls (10). As a tangent, this is likely a strategy to help ‘scaffold’ the airways open, as those with COPD typically lose elasticity of their airways. Think rubber band, stretch and recoil.
During activity, there is a coordinated action of the upper and lower regions which maintains ribcage symmetry. This allows for ideal internal pressure during steady-state exercise (9). It is theorised that lack of homeostasis within regions will lead to stiffening of the ribcage and reduced efficiency of breathing mechanics (9). This has been shown in a small study with an obvious external thoracic restriction of a corset (2). During workloads of 60-70% max heart rate, there were significant increases in respiratory rate, subjective breathing discomfort and the volume of air breathed per minute.
So, as always, what is the solution? We must train the skill that a region is capable of, then integrate into the activities that require coordination with other regions. In this context we need to restore upper ribcage breathing and not attempt to isolate it from lower ribcage movement. Ultimately, efficiency of movement is the key here.
How to learn the skills
Where to start then? The tricky thing here is how do we learn, or relearn, new ROM, or skills. Generally one must feel optimistic about the outcome and benefit, be able to change variables autonomously, and have an external focus (11). Two out of the three here are fairly straightforward. The third, external focus, is more challenging as the movement of breathing doesn’t directly act on the environment. This is a unique situation when comparing other body regions. What is the solution? We need the ribcage to act on something. Ideally, something not of your body. Specific interventions in supine and prone can help create awareness of the ribcage acting on the ground, or surface you are on. I cover these in other videos on the channel.
However, a simple cue one can use is to put their hands on their lower ribcage and look to move your hands by breathing in and out. This is a straightforward loop between when you touch an area of your body you can localise it better i.e. you’re more aware of that region. In theory this cue improves your attention to use that area.
Specific exercises for starting to develop this flexibility
1. Prone and extension based flexibility of the spine integrated with lateral or bucket handle breathing of the ribcage
2. Supine and flexion based flexibility of the spine integrated with lateral or bucket handle breathing of the ribcage
3. Full exhalation. This is a flexion biased movement but should also be encouraged as a skill during extension.
Breathing gears
Lastly, what can we learn from breathlessness in real time during an activity and how can we use that information to decide if we want to increase, decrease, or sustain current physical intensity levels. To start, here is an article I wrote on moderating your activity levels based on effort - https://themusculoskeletalclinic.co.nz/articles/autoregulated-exercise.
It is a very similar process for breathlessness. How breathless you are can indicate what energy systems you are using. Different energy systems help us sustain different physical activities. This is in itself a huge discussion, so we won't get into the details. Instead, we can frame it nicely with the analogy of using gears.
Gear 1 – Aerobic - at rest
Gear 2 – Aerobic
Gear 3 – Aerobic > Anaerobic – breathless but comfortable to talk
Gear 4 – Anaerobic > Aerobic – uncomfortable to talk due to breathlessness
Gear 5 – Aerobic – unable to talk
The gears themselves are not so black and white as above, but they give us a good indication of where your current work intensity is at! What does this mean, and how is this useful information? First off, what is the anaerobic threshold (AT)? If is a physiological tipping point where we begin to supplement our aerobic energy system with anaerobic options (12). Essentially, our ability to utilise oxygen and get carbon dioxide out of our system cannot keep up with the activity we are doing. This means we need to supplement it with other forms of energy, such as muscle glycogen. On a slight tangent, it is also useful to know when your power output begins to fail (13). This is a different (but related) topic for another time. In essence, the difference in training to failure or not. There is benefit aerobically in not training to failure (14)!!
Back to the gears. The AT tipping point is around gear 4. This correlates nicely with that level of breathlessness on the table above (15–17). Practically, aim for gear 3 if you are doing a prolonged physical activity such as moderate running, or HIIT style training for 2-3 minutes+. If you are aiming for something more intense like interval sprints or high intensity weightlifting, then Gear 4 and 5 are where you will be. The catch is that with gear 4 and 5 is that you need equitable rest periods. Usually at a ratio of 1:3-5 (14). So if you were doing 30 seconds of work, you might rest 90 seconds.
If your goal is to get aerobically fit and complete a sustained job, focus more on moderating your breathlessness at Gear 3ish. This will match nicely with heart max values as well. If that is your primary measure of physical activity intensity.
ref: https://www.pexels.com/photo/photo-of-golden-cogwheel-on-black-background-3785927/
Chronic low back pain
This has various applications. For example, in chronic low back pain populations we see increased levels of muscle co-activation, or trunk stiffness occurring sooner than in healthy controls, during the same repetitive lifting activities (18). What’s the link here? The degree of co-activation was related to how fatigued the individual was. Of note, the fatigue was measured via self-rating, using a scale that correlates with breathlessness! The primary point is that the fatigue happens sooner in the CLBP group, leading to altered lifting strategies that are less energy efficient and further compound fatigue! So, if you have CLBP, you may benefit from limiting fatigue by trying to stay in gear 3!
Keeping in mind with this article that I am discussing breathing for activity within the context of pain primarily. A secondary focus is performance. That being said, one can improve their VO2max with high intensity training (14). However, one must have adequate rest periods. In the cited study, athletes were compared before and after a five week training period. Their VO2max and Yo-Yo tests scores were assessed. The interventions was a sprint training group (STG) vs an endurance group (EG). The STG performed 5 maximal sprint efforts over 30 seconds with 4.5 minutes of active recovery between sets. The EG performed 40 minute runs at 80% of VO2max. Both groups performed these interventions 2x/week. The results indicated that both groups significantly improved their VO2max. Between group differences were non-significant.
So! What does this mean? Choose your poison. You can become more able at utilising oxygen through various means i.e. improve your aerobic capacity. However, if you are doing something intensely, you must have higher rest periods to benefit.
Conclusion
So, to summarise, you need adequate breathing flexibility and skill to maximise perfusion of oxygen from your lungs to your bloodstream and carbon dioxide vice versa. This has applications both during activity and at rest. Lastly, consider what breathing gears you might aim for based on the goal of your activity. If it is a moderate intensity exercise, stay around Gear 3. If it is more vigorous, aim for gear 4 and 5. Just remember that you can’t last as long and it is not just important, but necessary to have adequate rest periods!!
If you’re interested in reading more about specific breathing dysfunction and symptoms, along with building breath tolerance, have a read of my article here: https://www.eccentricphysio.com/articles/are-you-breathing-to-your-potential
References:
1. Marieb EN, Hoehn K. Human Anatomy & Physiology. 9 edition. Boston: Pearson; 2012. 1264 p.
2. Harty HR, Corfield DR, Schwartzstein RM, Adams L. External thoracic restriction, respiratory sensation, and ventilation during exercise in men. Journal of Applied Physiology. 1999 Apr 1;86(4):1142–50.
3. Bordoni B, Marelli F, Morabito B, Sacconi B. Manual evaluation of the diaphragm muscle. Int J Chron Obstruct Pulmon Dis. 2016 Aug 18;11:1949–56.
4. Bordoni B, Zanier E. Anatomic connections of the diaphragm: influence of respiration on the body system. J Multidiscip Healthc. 2013 Jul 25;6:281–91.
5. Perri MA, Halford E. Pain and faulty breathing: a pilot study. Journal of Bodywork and Movement Therapies. 2004 Oct 1;8(4):297–306.
6. Courtney R, van Dixhoorn J, Cohen M. Evaluation of Breathing Pattern: Comparison of a Manual Assessment of Respiratory Motion (MARM) and Respiratory Induction Plethysmography. Appl Psychophysiol Biofeedback. 2008 Jun 1;33(2):91–100.
7. Yach B, Linens SW. The Relationship Between Breathing Pattern Disorders and Scapular Dyskinesis. Athletic Training & Sports Health Care. 2019 Mar 18;11(2):63–70.
8. Troyer AD, Estenne M. Coordination between rib cage muscles and diaphragm during quiet breathing in humans. Journal of Applied Physiology [Internet]. 1984 Sep 1 [cited 2022 Nov 27]; Available from: https://journals.physiology.org/doi/10.1152/jappl.1984.57.3.899
9. Kenyon CM, Cala SJ, Yan S, Aliverti A, Scano G, Duranti R, et al. Rib cage mechanics during quiet breathing and exercise in humans. Journal of Applied Physiology. 1997 Oct;83(4):1242–55.
10. Aliverti A, Quaranta M, Chakrabarti B, Albuquerque ALP, Calverley PM. Paradoxical movement of the lower ribcage at rest and during exercise in COPD patients. European Respiratory Journal. 2009 Jan 1;33(1):49–60.
11. Wulf G, Lewthwaite R. Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychon Bull Rev. 2016 Oct 1;23(5):1382–414.
12. Lai CW, Minto G, Challand CP, Hosie KB, Sneyd JR, Creanor S, et al. Patients’ inability to perform a preoperative cardiopulmonary exercise test or demonstrate an anaerobic threshold is associated with inferior outcomes after major colorectal surgery. BJA: British Journal of Anaesthesia. 2013 Oct 1;111(4):607–11.
13. Poole DC, Rossiter HB, Brooks GA, Gladden LB. The anaerobic threshold: 50+ years of controversy. The Journal of Physiology. 2021;599(3):737–67.
14. Rowan A, Kueffner T, Stavrianeas S. Short Duration High-Intensity Interval Training Improves Aerobic Conditioning of Female College Soccer Players. International Journal of Exercise Science [Internet]. 2012 Jul 10;5(3). Available from: https://digitalcommons.wku.edu/ijes/vol5/iss3/6
15. Kurihara N, Matsushita H, Wakayama K, Fujimoto S, Nakano N, Hirata K, et al. [Relationship between anaerobic threshold and breathlessness during exercise]. Nihon Kyobu Shikkan Gakkai Zasshi. 1992 Apr;30(4):554–60.
16. Scherr J, Wolfarth B, Christle JW, Pressler A, Wagenpfeil S, Halle M. Associations between Borg’s rating of perceived exertion and physiological measures of exercise intensity. Eur J Appl Physiol. 2013 Jan;113(1):147–55.
17. Zamunér AR, Moreno MA, Camargo TM, Graetz JP, Rebelo ACS, Tamburús NY, et al. Assessment of Subjective Perceived Exertion at the Anaerobic Threshold with the Borg CR-10 Scale. J Sports Sci Med. 2011 Mar 1;10(1):130–6.
18. Varrecchia T, Conforto S, De Nunzio AM, Draicchio F, Falla D, Ranavolo A. Trunk Muscle Coactivation in People with and without Low Back Pain during Fatiguing Frequency-Dependent Lifting Activities. Sensors (Basel). 2022 Feb 12;22(4):1417.
Copyright Disclaimer - This article is protected by the Copyright Act 1994. The author controls the copyright of this article. Recognition of the author’s right to be identified as the author will be acknowledged and when relevant the author will be acknowledged as the author. You will obtain the author’s permission before publishing any material from this article. For further information you can reference the Act here: https://www.legislation.govt.nz/act/public/1994/0143/latest/whole.html