The Incredible Rightness of Breathing

When I visited London in April, preparations were well underway for the Queen’s amazing Jubilee celebrations. The British slogan ‘Keep Calm and Carry On’ was plastered everywhere from the sides of buildings to coffee cups. Keeping calm is a wonderful attribute that allows the stoic British to respond efficiently in times of crisis.

During the take off from Heathrow the passenger beside me (not British) became increasingly agitated, gripping the armrest and breathing rapidly as her chest and shoulders heaved up and down. This lady was obviously terrified of flying and struggling to control her panic. I asked her permission to help and she managed a terrified nod. The short version of this story is that I helped her change the rapid, panicked breathing to slow, rib opening breaths, which allowed her to relax.

This incident prompted the theme of today’s newsletter, which is aimed at drawing attention to the central role of breathing and its association with pelvic floor health. Smooth diaphragmatic breathing is difficult and confusing for those with an altered, entrenched breathing pattern. In the clinic, I’m often amazed by the changes clients report with slow mindful breath practice that brings them back in touch with their body’s natural rhythms.


The incredible rightness of breathing

Breathing’s an automatic bodily activity that we recognize as being essential for our existence. Our brain and organs would cease to function without the regular exchange of oxygen and carbon dioxide. But it’s usually only physical exertion, emotions or pain that draws our attention to how we’re breathing. Relaxed (diaphragmatic) breathing is a technique widely taught to improve health and reduce blood pressure, anxiety, stress, panic attacks and menopausal hot flashes.

Chest disease, emotions, pain or injury can reset the ‘automatic’ childhood breathing style to one that’s not optimal for pelvic floor muscles and pelvic organs. The respiratory diaphragm normally has coordinated internal movement with the pelvic floor and core muscles. Maybe until now you’ve never considered that healthy pelvic floor muscle function is directly related to the way you breathe!

Lets start with breathing styles: During diaphragmatic breathing, the in-breath opens the lower ribs and abdomen. This action draws the central diaphragm down to suck air into the lungs. At the same time, the pelvic floor lowers slightly but stays contracted (the same way the quadriceps contracts in a lengthened position when walking down hill). During the out-breath, the diaphragm domes up under the lungs to push air out. The pelvic floor tightens and lifts in coordination with the diaphragm. The diaphragm does most of the work when breathing with some help from the rib intercostals and neck scalene muscles.

In the clinic I regularly see a high number of sub optimal breathing patterns in clients with pelvic floor and spinal issues. Typically (not always) the pattern used involves the shoulders lifting with neck muscles prominent and overactive. This chest-lifting pattern usually combines with tightening (narrowing) of the muscles at the waist and base of the ribs.

This style of breathing prevents the diaphragm from travelling down, then up under the lungs and in turn, the pelvic floor muscles (PFMs) aren’t free to descend and lift. Some clients hold their PFMs tight on both the in and out breath, which leads to chronic stiffness (tight muscles are weak and ineffective and associated with altered bladder and bowel control, prolapse, chronic pelvic and sexual pain).

Try this practical activity: Sit tall in front of a mirror and observe what happens when you breathe in and out. Look at your shoulders and neck, then abdomen and waist.

To change an obvious ‘shoulder lifting’ style of breathing, lie on your back (bent knees) and place one hand on your upper chest and the other on your upper abdomen. Become aware of slowly opening the stomach first on the in breath with much less upper chest movement. Practice this quiet, slow breathing for 5-10 minutes a day to start mapping this pattern into your brain. When sitting, grow tall, become aware of releasing tightness around the base of the ribs (yes, let go of the stomach!) and open the stomach /base of ribs on the in breath.

Practicing (and adopting) abdominal/base of rib opening breathing promotes PFM lengthening before contracting and lifting, which means the muscles are exercised more effectively. PFMs are strongest in their inner (lifted) range but need relaxation before another lift is performed. When the in-breath is consciously connected with PFM relaxation, the tightening, lifting action is most effective on the out-breath. Women with stiff, inflexible PFMs benefit by committing to diaphragmatic breathing and daily specific pelvic muscle stretches and soft tissue mobilisation to gradually release PFM stiffness.




Breathing and babies

Pregnancy prevents mums from taking a deep breath as their growing baby blocks diaphragmatic descent, bringing about a change to upper chest breathing during the later months of pregnancy. Most mums automatically reset their breathing style after baby is born to regain the inner travel of the diaphragm (Grays anatomy describes a 6-10 centimeter travel).

But if they’re in pain due to birth trauma or a C-section, this reset may not automatically happen and the upper chest pattern of breathing may continue. Adopting upper chest breathing (chest and shoulders lift with a narrowed waist) will derail pelvic floor/core/abdominal strengthening post birth, leaving a new mum struggling with pelvic heaviness and continence or spinal issues.

I introduce basal breathing early to new mums to promote an effective pelvic floor contraction. On the out-breath they learn to tighten and lift the PFMs and practice this pattern slowly and gently in the early days following an uncomplicated vaginal birth. A complicated vaginal birth (also C-section) has more potential to disrupt breathing due to pain when they change position or move. PFM damage and stitches cause swelling, pain and difficulty in contracting the pelvic floor.  Relaxed diaphragmatic breathing (combined with pain relief) helps to release pain induced muscle tension and re-establish an effective PFM contraction.

Breathing out with a PFM contraction in turn contracts the inner corset of core muscles (transversus, spinal multifidus and diaphragm). This pattern must become the focus of post-natal exercises to start re building strength from the inside out. As PFMs regain early activation, strength and endurance, bladder and bowel control, organ and spinal support and sexual sensation improves. Another benefit is obvious in the abdomen as muscles and fascia tighten and shorten to flatten the stomach and restore stability to the pelvis and trunk.

Breathing and the bowel

Clients with obstructed bowel emptying, urgency, pain and faecal incontinence find their quality of life is undermined by concerns and stresses, even depression associated with problematic bowel function. Toileting becomes a stressful time with increased general muscle tension, which is counter- productive to smooth bowel emptying.

In the clinic, I ask clients with emptying problems to demonstrate the position they use to empty and the accompanying muscle action. Typically they bend forwards, sometimes lean backwards, breath hold and strongly brace their abdominal muscles.