Mindfulness practices have become omnipresent; thanks to a rise in interest in "health and wellness." Take a local yoga class and the instructor will consistently remind you to "come back to the moment." Attend a meditation retreat and your entire experience will be predicated on your ability to alter your nervous system through breath-work. Our kids are being taught about mindfulness in school. Functional medical practitioners may even suggest treating your ailments, in part, with a daily dose of meditation. At the center of all these experiences of mindfulness is controlled, volitional nasal breathing.
Despite its use for thousands of years in Eastern practices and more recent validation in Western scientific literature, breath-work has not been integrated into "mainstream" physical rehabilitation practices. Breath-work and physical rehabilitation influence the same bodily systems (the musculoskeletal, cardiovascular, and nervous systems), yet clinicians largely ignore the utility in using a person's diaphragm as foundation to their physical health. With the benefits of focused breath-work already being established both anecdotally and scientifically, the article below is brief primer on the anatomy of the diaphragm, it's role in respiration, and how breathing is fundamentally inseparable from long-term back pain rehabilitation and injury prevention.
You can live for 3 weeks without food, 3 days without water, but only 3 minutes without air. The importance of breathing itself is self evident, but the relationship breathing has to the musculoskeletal system is not as apparent. Mechanically, a muscle, the diaphragm, controls your breath. The diaphragm sits below the lungs, wraps around the spine and divides your thoracic and abdominal cavities with its attachments to the rib cage. When you contract your diaphragm, either automatically or mindfully, it descends into your abdomen, creating negative pressure in your thoracic cavity, compelling the flow of air into your lungs. When you relax your diaphragm, either automatically or mindfully, it rises back up into your thoracic cavity creating positive pressure in your lungs, compelling the flow of air back into the atmosphere.
When the diaphragm contracts, you can use one of two airways. If we use our nose for the inhalation/exhalation process we drive air deeper into our lungs for a better oxygen (O2)/carbon-dioxide (CO2) exchange, we get a stronger stimulation of our "rest and digest" nervous system state, and we get a more forceful contraction of the diaphragm. If we use our mouth for the inhalation/exhalation process, we engage in shallow breathing, we get a stronger stimulation of our "fight or flight" nervous system state, and we get a less efficient contraction of the diaphragm.
The depth of our breath, our nervous system state and the efficiency diaphragmatic contractions are central to relieving your low back pain and the prevention future exacerbations of back pain. The western scientific literature has shown that a person with acute and/or chronic back pain will likely have a more shallow breathing pattern, manifest signs of stress in their musculoskeletal system, and have less efficient diaphragmatic contractions, than their pain-free cohorts. The rehabilitation literature shows that altering this population’s breathing mechanics can reverse these conditions.
The diaphragm is a crucial element in spinal stability. Because the diaphragm is a muscle, when it contracts it creates rigidity across the joints it attaches to. Given that it attaches to the spine directly and indirectly through it's attachments to the ribs, when you contact your diaphragm for an inhale, you are stabilizing your spine. Additionally, that inhale increases the pressure within your thoracic and abdominal cavity, further stabilizing your spine. That's why we automatically take a deep breath before lifting something heavy! But there is an additional step your body takes to provide spinal stability. Our diaphragm automatically contracts when we are about to move, lift, carry, or push something. This reflex is anticipatory, automatic and diminished in a person with acute and chronic back pain. But most importantly, this reflex is trainable.
All of this has led me to assert, and manifest clinically, that learning to breath properly, in stillness or moving, is central to long-term relief from, and prevention of, back pain. How does one breath properly? Breath slowly an through your nose. More specifically, lay on your back on the floor with your knees bent or sit comfortably, in a chair, or on the floor. Place one hand on your stomach and one hand on your chest. Inhale through your nose; your stomach should expand more than your chest. Feel this with your hands. When your chest expands, it should push out, not up. Practice this style of breathing for a minute or two. The next step is to slow your inhale to 5 seconds and your exhale to 5 seconds. That is a full breath cycle (inhale-then-exhale) of 10 seconds. If this is too difficult or easy, shorten or lengthen your inhale/exhale rhythm accordingly. Do this daily for 5 minutes at first, with a goal of sitting quietly and controlling your breath for 10 - 20 minutes. You will be able to master this in a week or two if you give it the time.
Once you have established daily breath-work practice, it is time to focus on postural stability and movement. In next month's article I will delve deeper into good breathing posture, and progressive exercises for the spine, from the low back to the neck. For those eager to begin these exercises, you can find exercise progressions for the low back and neck on my blog, https://www.returntosportphysio.com/blog/.