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Breath: The Missing Key To Positive Results with Many Complex Manual Therapy Clients

publication date: Jan 5, 2017
author/source: Elizabeth Browning RMT


by Elizabeth Browning


Life is a balance between holding on and letting go ~ Rumi


Section I: Introduction


Do you ever find yourself frustrated after getting good manual therapy results but then finding that clients with complex presentations return with an intense list of symptomology? I know I did.


After learning about breathing pattern disorders (BPD), I had a “lightbulb” moment. This was the key I was waiting for in my clinical practice. This discovery was the common denominator of understanding what I had been searching for, both in my personal life as well as with complex clients. I was amazed how impactful a healthy breathing pattern was on my clients overall good health and wellbeing. This set in motion for me a cascade of great things: physiological understanding of breathing patterns, personal self discovery and most importantly... triumphs in the clinic with improved long term outcomes for clients that had previously returned with symptoms after we had resolved them in the clinic. I want other manual therapists to be introduced to the immense benefits that breathing awareness and exercises can bring.


I met Leon Chaitow in New Mexico in 2006. I took his class on breathing pattern disorders at a neuro-muscular therapy conference. If you aren’t familiar with Leon Chaitow DO, he is a living legend in many manual therapy circles. Chaitow is an Osteopath and prolific author who splits time between London, Corfu, and lecturing internationally. He passionately introduced us to his book, Multidisciplinary Approaches to Breathing Pattern Disorders (1). It is co-authored with Respiratory Physiotherapist Dinah Bradley, and Clinical Psychologist Christopher Gilbert. My immense gratitude to Chaitow and devotion to studying his work started that day. I was hooked. I purchased the book and immediately dove in deep. This new information couldn’t have come at better time.


My story


I had just spent the last two years working in a pelvic pain clinic in Denver, CO. I did CranioSacral therapy and Yoga therapy for clinic clients with very complex presentations. They quite often reported a decrease in symptoms after the Yoga therapy sessions. This was thrilling, until they came back two months later, often with an intense exacerbation of symptoms! At the time, I was puzzled as to why.


In my personal life, I was also having nagging symptoms after a car accident in 2002. I had tried multiple forms of therapy that all helped tremendously, but not permanently. CranioSacral therapy was one of my favorite therapies because it helped me recover so quickly and restore some lost function. However, despite physical therapy, chiropractic, acupuncture,Frank Lowen Biovalent therapy, Pilates, and Yoga I still struggled with full recovery from neck pain, headaches and abdominal/pelvic floor trigger points.


Walk the talk


Four months later I finished the book cover to cover. I had to dig through new challenging terminology, and do the exercises to establish a new breathing pattern. Yes, it took me four to five months of almost daily practice to have this new breathing pattern become my new normal. The payoff was big. Really Big. My new normal was being free of headaches, neck pain and abdominal and pelvic floor trigger points. This first hand experience was not just important for me, but was also critical in being able to understand what many of my clients were going through.


So what exactly is a breathing pattern disorder (BPD)?


It starts with understanding hyperventilation syndrome and its more subtle cousin chronic hyperventilation (CHV), both are breathing patterns that involve being more in a state of inhalation than exhalation. This is commonly seen in shallow or chest breathers, that don’t use their full lung capacity or exhale fully. This pattern leads to hypocapnia (a lack of carbon dioxide in the blood due to hyperventilation). Eventully this can become respiratory alkalosis, a decrease in oxygen to tissues and cells (2).


This scenario creates upregulation of the sympathetic system, and fight or flight symptoms start surfacing. Eventually these changes can lead to anxiety, blood ph shifts, increased muscle and fascial tone, decreased pain thresholds, even pseudo angina like symptoms.


The range of symptoms is incredibly wide and can include stiff and painful neck, sore tight chest, cold hands and feet, dizziness or fainting (too little oxygen reaching brain), headaches, palpitations, allergies more pronounced, bloating and digestive problems, painful legs, increased colonic spasms, menstrual distress, profound fatigue, muscle cramps, brain fog, lowered pain threshold, sympathetic arousal, increased sensitivity to light and sound, and feelings of extreme anxiety (3).


It is commonly believed that hyperventilation is from too much oxygen being breathed out. It is actually caused from too much carbon dioxide being breathed out, causing a deficit. A cascade then starts a chain reaction in the whole body. This is a pattern most chest/ shallow breathers are unaware of. It is particularly common in those that have asthma or even more likely a pattern learned in childhood (we generally inherit our breathing pattern from one of our parents). Once the carbon dioxide has been breathed out, we quickly find that our blood becomes alkaline and the symptoms can appear instantly.


Two steps are important with the muscles involved in hyperventilation and its milder form, Chronic Hyperventilation (CHV). Firstly, the muscles need to be addressed with manual therapy and released. Secondly, to maintain the change a different breathing pattern needs to be introduced to replace the ‘over breathing’ as CHV is called. “Over breathing” happens during acute stress and easily becomes a normal pattern for the body. The over breathing causes upregulation of the sympathetic division of the central nervous system. CHV often comes on at rest and is often misdiagnosed. This diagnosis is often missed. Multiple tests and thousands of dollars later clinicians still are not sure what has caused the patient such intense distress. Clinical diagnosis of primary HVS /BPD is made at the exclusion of other diseases. So far there is no one test that easily determines chronic HVS. Many clinicians use the Nijmegem questionnaire to help provide a non invasive test with high sensitivity/specificity (4). The overall benefits of this kind of breath training and manual therapy are upregulation of the parasympthetic division of the CNS, improvements in lung capacity, improvement in posture, decreases in pain and hypersensitivity, better hormone regulation, better sleep, better digestion, and much more (5).


As many of my peers found out about my extremely passionate interest in treating breathing patterns, they started sending me their most challenging clients and I loved it. The more complicated the better, as that was a tip to me to start with breathwork. For the previous 4 years, I had studied with profound devotion, Structural and Ayurvedic Yoga therapy with Yogi Mukunda Stiles. He taught me all parts of a Yoga practice but we spent alot of time of pranayama. He used to tell me that Pranayama is the subtlest and quickest way to get yourself back in balance (6). I had been using his breath work and alternate nostril breathing with clients but adding in the Chaitow breathing pattern awareness and exercises into my work with clients really started getting the results I wanted to see. This was the key.


Section II: Incorporating breath awareness into your practice


Integrate breath awareness into your personal practice


Try the following guidelines for including breath awareness in your clinical practice. First try them out on yourself for a good month before trying them with clients. My yoga teacher, Mukunda Stiles would always have us practice what we preach. It was his pet peeve for yoga teachers to learn something in a weekend workshop and teach it on Monday. If you feel it in your own being, and notice what changes happen over time you will have the depth of wisdom to be of help to your clients in the clinic. I can’t stress enough: practice and experience first. When you are feeling really clear on what it takes to do it successfully, you can share with your clients.


Begin by taking a look at the handout included at the end of the article and ask yourself what you suspect your natural breathing patterns are (Figure 1). Then schedule yourself some time with a skilled manual therapist to begin addressing some of your soft tissue patterns.


Integrating breath awareness into your clinical practice


With clients, I’ll take them through the following sequence:

  1. Self reflection:
    • I show clients the handout (See Kersti Ferelli and Dee Marie’s Calming Kids workbook reference) as the part of their introductory paperwork on their first visit to visually show them what different breathing patterns look like. I read through it with them briefly. Ask them about their breathing.
  2. Assessment/Evaluation (For the manual therapist):
    • Check diaphragms (pelvic, respiratory, thoracic inlet/outlet)
    • Check rib articulations (one of my favorite techniques is taught in the CST working with Chronic Depletion class.)
    • Check intercostals, scalenes, and other muscles of the neck
  3. Manual therapy:
    • Use your current manual therapy tools to address what you discovered.
  4. Discussion/Demonstration:
    • Discuss breathing regulation in easy brief terms and why it will help. I use a quick easy discussion of the sympathetic and parasympathetic divisions of the nervous system as well as what determines upregulation and down regulation. Explain briefly about flight flight or freeze -as opposed to rest, digest and heal.
      • E.g.: When you go to get on the highway and it is jammed up and you really need to be at an appointment you automatically do a sharp quick deep inhale unconsciously. When you get home after a really long day you finally sit down and let a long exaggerated exhale.
      • At this point they nod in agreement because this is something they already experience, a universal response in the CNS. I continue to explain that deep in their brain and brain stem is a old system that still doesn’t know the difference between being chased by a saber tooth tiger and driving in rush hour traffic on Denver’s I-25! Easy laughing loosens up the heaviness of learning something new.
    • Demonstrate Beach Pose Breath Exercise (see exercises at end of the article) while client is still on table. I also coach them that they should rest after for few minutes after breath exercises, and warn of transient dizziness. I also tell them if they get dizzy, stop and come back to it tomorrow. I do tell them that their blood gasses are shifting in response to the exercise. After a few months of practice the nervous system recognizes this as ‘The New Normal’.
    • I offer easy ways to implement these exercises:
      • A great example that is easy for most patients is to practice while watching TV! On back with knees bent and hands behind head.
      • Another fabulous and easy example is to practice a modified version with just a long exhale, at stop lights and waiting in line at the bank, grocery store, airport, or in long lines for the bathrooms.
      • I offer clients little stickies with “Exhale” written on them to put on the mirror, on the fridge, on their dashboard as little reminders.
  5. Client homework:
    • Hi- lo test, beach breath, next appointment alt nostril and Yogic breath watching. (see suplemental exercises)
  6. Follow up:
    • At next appointment check in to find out if they had success. Support them in continuing the practice. Clarify technique and have them show it to you.


Teach what is within you,

Not as it applies to you, to yourself But as it applies to the other.

It is not that the person must accommodate himself to Yoga

But rather that yoga must be tailored to suit each person.

~T. Krishnamacharya (7)


Client Education

“Non invasive client education sustains progress between sessions”.

~Moya (8)


There are many choices when helping clients with breathing. Popular choices include Buteyko, advanced pranayama, and heart rate variblity styles. According to Chaitow, however, ”The problem with extreme methods and techniques, when trying to modify/ improve poor breathing habits, is the degree of difficulty in their application. Change is difficult for a lot of clients. When it comes to homework compliance, whether this be a change in diet/ exercise pattern/or anything else, the homework needs to be easily understood and not particularly difficult or unpleasant to carry out. And methods such as Buteyko, are neither easy or pleasant. They undoubtedly ‘work‘ if persevered with, but most people with a breathing pattern imbalance/ disorder will not comply. Most individuals can restore a normal pattern over time, most of the time". (9)


There are many more extremely useful excercises in Chaitow's book including Brugger relief position and various seated breath exercises by Dinah Bradley. Get a copy to give yourself the full education on BPD, as this article can only scratch the surface of deep pond of information.


My favorite quotation on client education comes from mentor therapist Eric Moya,”My job as a therapist is not tell you what to do with your life! But I can support you in making the changes that will help you get the results you want!" Brilliant, I love this. It is inline with my own treatment philosophy - allow the client to stay tuned into the wisdom of their own being, and be there to facilitate what the body wants! In this instance, we are doing that by cueing them to observe the breath. This way they are empowered by their own observation. Feeling empowered after so much frustration and suffering allows the client to be the leader on their path to healing, whatever that maybe for them. Overall, this leads to more compliance with home exercises.


It helps to let them know that symptoms are often the way the body speaks to them. A man I met briefly once mentioned to me, “My check engine light is on”. I never forgot that. You wouldn’t blame your car or ignore it if your check engine light was on. You just take notice of it, and take it in to have it checked out. If you miss the gift of what the body signals are offering, you can miss the key to keep you healthy well and balanced. This type of support and education is a multi session process. Clients will greatly benefit in hearing that they will get your support in this process over the next four to five months.


My goal in this article was to enlighten manual therapists to immense benefits that breath awareness and exercises can bring. By illuminating this and the general lack of awareness of how disabling this dysfunction can be, we are now being opened to a whole new field of exploration and hope. The bewildering mix of often seemingly unrelated symptoms that arise, now have a place of understanding as you head back into your clinic. What was confusion, fear, and loss now become a place of self discovery and empowerment, for the clients who most need it most. Your toolbox of techniques to sustain client progress has been expanded. Try the exercises yourself, maybe it is the key you were looking for.



Before treating clients for breathing pattern disorders it is important to get a valid diagnosis in case a more serious pathology exists. This introductory article is educational and exploratory in nature and offers guidelines for awareness and opportunities to explore more education. Check your regional professional medical standard requirements in order to establish the right patient/therapist protocols.The author nor the publisher will be liable for any loss or damage due to relying on the material contained in the article. 



(1) Chaitow, L., Bradley, D., & Gilbert, C. (2002). Multidisciplinary approaches to breathing pattern disorders. Edinburgh: Churchill Livingstone.

(2) Chaitow, L., Bradley, D., & Gilbert, C. (2002). Multidisciplinary approaches to breathing pattern disorders. Edinburgh: Churchill Livingstone. in comments figure 10.2. pg. 246 Blood alkaline.

(3) Chaitow, L., Bradley, D., & Gilbert, C. (2002). Multidisciplinary approaches to breathing pattern disorders. Edinburgh: Churchill Livingstone. symptoms Figure 10.2, pg. 246 Could you be hyperventilating.

(4) Chaitow, L., Bradley, D., & Gilbert, C. (2002). Multidisciplinary approaches to breathing pattern disorders. Edinburgh: Churchill Livingstone. Nijmegen questionnaire. p.176 box 7.3.

(5) Chaitow, L. (2004). Maintaining body balance, flexibility, and stability: a practical guide to the prevention and treatment of musculoskeletal pain and dysfunction. Edinburgh: Churchill Livingstone.


(6) Stiles, M. (2007). Ayurvedic yoga therapy. Twin Lakes, WI: Lotus.

(7) Mala SrivatsanSrivatsa quoting T Krisnamacharya in “Guru Parampara”. Darsanam magazine, Madras:Krisnamacharya Mandiram, Nov. 1995 (Vol 4 No.3) pg.39.

(8) S. Eric Moya, quote taken from CST working with Chronic Depletion class, Vancouver, Canada Dec. 2016

(9) Chaitow, L. (2015, November 7). Breathing Pattern Disorders and lumbosacral pain and dysfunction-an update. Retrieved from Leonchaitow.com

(9) Chaitow, L. (2004). Maintaining body balance, flexibility, and stability: a practical guide to the prevention and treatment of musculoskeletal pain and dysfunction. Edinburgh: Churchill Livingstone.

(10) Frigell, K., & Marie, D. (2005). What kind of breather are you. [Respiratory diaphragm illustration. Energy Source Inc]. Retrieved from www.calmingkids.org



Figure 1:


Exercises mentioned in article:


Hi-lo upper chest breathing pattern exercise

One hand on chest, one hand on abdomen Inhale and exhale several times. Notice which hand is moving more. If the upper hand moves more and toward chin, you may have a chest breathing pattern.


Chaitow/ Bradleys Beach Pose

Position: On Back, Knees bent, hands behind head, shoulders and head on pillow. Exhale deeply.

Inhale: Through nose, chest, ribs widen to side and back, belly lifts slightly.

Exhale: Out though pursed lips, diaphragm relaxes in its natural recoil (pursed lip exhale is like breathing out a straw).

Chaitow and Bradley suggest 30x, twice daily. (In my clinic, depending on the client I have them start with 5-10x, and work up 30x over the next 3-4 months. It is not overwhelming and less likely to cause dizziness, which can often turn clients off of practicing.) This should be accompanied by stretching of SCM, scalenes, levator scapula and trapezius. Pursed lip exhale breathing is slow exhalation against resistance and an example of isotonic eccentric contraction. The diaphragm is toned and relaxes at the same time.


Alternate Nostril

Sit comfortably, spine elongated, with your R hand fold in your index and middle finger.You will use the thumb and ring finger on either nostril alternating. Exhale, Press the ring finger into R nostril holding it closed. Inhale with the L nostril. Pause and hold both finger to the nostrils. Hold the L exhale out the R nostril. Hold the L inhale through the R nostril. Pause and hold both fingers to the nostrils. Hold the R nostril and exhale out the L nostril. This is one round. Try 3 rounds to start. Rest quietly for 3 minutes at the end. Work you way up to 9 rounds after you have practiced for awhile. Best on an empty stomach.


Yogic breath watching

The breath is there to support you in being mindful. Breath watching is an age old Yogic technique for assessing your energy and the start of deep relaxation practices 1.) Invite the breath to come into your awareness. 2.) Focus on the sensation of breath coming in and down, 3.) Then out and up. 4.) As your awareness increases overtime, notice that there is a slight pause or rest as the breath turns around.