Do you struggle with neck or shoulder pain, headaches, poor sleep, snoring, rib pain, shortness of breath during exercise, pelvic floor dysfunctions, or persistent dental issues and bad breath? The issue may be simpler than you think.  Each of these conditions can be caused or worsened by poor breathing patterns, i.e. taking short, shallow breaths through your mouth instead of breathing through your nose. One of the quickest and easiest ways to improve overall health is to adopt more efficient breathing patterns!

Basic anatomy.

Developmentally, the mouth is connected to the digestive system, while the nose is connected to the respiratory system.  Food enters the mouth and passes through the back of the throat, down the esophagus, and into the stomach. Air enters the nose, passes through the pharynx, down the trachea, and into the lungs via a series of tubes called bronchi.  These passageways are distinct in the ways they prepare food and air for use in the body. An anatomical structure called the epiglottis, which acts like a folding door, ensures that food does not pass down the trachea, and that air does not pass down the esophagus.  For normal health, it is important we keep these two pathways separate. You would never consider eating through your nose, so why do so many people breathe through their mouths? Unless we are performing intense exercise, our mouths should be shut and we should be breathing through the nose.  There are numerous health benefits associated with nasal breathing, as well as numerous health issues caused by mouth breathing.

The benefits of nasal breathing.

Breathing through the nose prepares the air for use in the body in three ways.  First, the bony passageways and mucus lining of the inside of the nose act like a natural air filter, cleaning the air before it reaches your lungs.  This function is extremely important if you live in a city or are exposed to inhalants in your line of work. Secondly, the air is humidified as it passes through the inside of the nose, moistening the air, allowing better absorption of oxygen at the lungs.  Third, the air is warmed as it passes through the nose, further allowing a smooth diffusion of oxygen into the lungs. None of these vital preparatory functions occur when breathing through the mouth.

Nasal breathing forces you to use your diaphragm, the body’s main muscle of respiration.  The diaphragm is also an important postural and core stabilization muscle. When you breathe through your nose using your diaphragm, the belly should expand on the inhale and come back to a neutral position on the exhale. I never let my patients suck in their stomachs!  Sucking in your stomach drastically decreases the stability of your core and causes a shortening and tightening of the muscles in the abdomen. We want the muscles in the abdomen to be relaxed when we are at rest, gradually expanding on the inhale and returning to neutral on the exhale.  If you want a perfect example, watch a baby breathe while they are sleeping!

Diaphragmatic breathing is beneficial for patients with conditions related to pelvic floor dysfunction (reproductive organ prolapse, incontinence, sexual dysfunction, etc.).  All of these conditions are characterized by weakness in the muscles lining the pelvic floor which are important for stabilizing the organs in the area. When we inhale and the diaphragm contracts downwards, pressure is directed against the pelvic floor muscles, which lay in parallel alignment with the diaphragm.  The pelvic floor muscles are activated in response to the increased pressure exerted against them during breathing. The pelvic floor muscles are difficult for many to isolate, and learning to breathe into these areas is the first step in recovering muscular function.

Another interesting benefit to nasal breathing is the increased nitric oxide (NO) production associated with nasal breathing.  Nitric oxide is important for the health of your blood vessels and heart. Nitric oxide ‘vasodilates’ or expands your blood vessels, ensuring blood can flow easily to all parts of the body.  A reservoir of nitric oxide producing cells is located at the back of the nose, so make sure to breathe all the way into the back of the nose. Actively flaring the nostrils when practicing breathing will help the air reach the furthest reaches at the back of the nose.

Issues with mouth breathing.

Hypertonicity and tightness seen in the upper trapezius and sternocleidomastoid muscles. Both are classified as ‘accessory muscles of respiration’ and should not be recruited at rest.

The main issue with mouth breathing is the muscle recruitment patterns that develop.  When people breathe through their mouths, it’s very hard for the body to use the diaphragm for breathing.  Instead, the body recruits other muscles to help with breathing which we call ‘accessory muscles of respiration.’  These muscles are located in the neck and top of the shoulder, and normally kick on only when the body is performing intense bouts of exercise.  However, with chronic mouth breathing, these muscles kick on even while we are at rest. When the muscles in the neck and top of the shoulder are used for respiration all throughout the day, they become short, tight, and overused.  Strained muscles in the neck place increased stress on the joints in the neck, causing issues such as headaches and neck pain. Receiving treatment for pain in these areas can be very effective, however if the root cause of the issue is improper mouth breathing habits, the main goal of therapy must be to correct breathing patterns.

Chronic dental issues and bad breath are also related to poor breathing habits.  If we constantly breathe through the mouth, pathogenic bacteria in the mouth are given a ready supply of oxygen to grow and duplicate.  Additionally, these bacteria thrive off of a dry environment, and the mouth becomes very dry with chronic mouth breathing. When the mouth stays closed, saliva is able to flush out the oral disease causing bacteria from the mouth and into the digestive tract where they can be expelled.  Amazingly, many indigenous tribes, who breathe primarily through their noses and speak less frequently, have very low levels of dental issues.

Rib pain is another common condition caused by a mouth and chest dominant breathing pattern.  If we breathe through our chest during the day even when at rest, the ribs are placed under constant stress.  You’ll notice minimal rib movement when you breathe strictly in the belly using your diaphragm. Patients that constantly need to see the chiropractor to have their ribs adjusted can benefit greatly from switching to a diaphragm driven belly breath.

Decrease stress with nasal breathing.

Yoga, meditation, tai chi, and qi gong are excellent practices that promote proper nasal breathing.

Breathing slowly and deeply through the nose activates a state of relaxation in the body.  The hormonal state related to relaxation is governed by the parasympathetic, ‘rest and digest’ system.  Unless we are hunting, competing in athletics, or performing manual labor, the body should be in a state of parasympathetic relaxation.  Focusing on slow, deep, nasal breaths is an excellent way to make sure we are in a state of relaxation when we should be. To ensure full recovery between exercise sessions or competitions, it’s vitally important the body is in the ‘rest and digest’ hormonal state.  Since nasal breathing is our best way to induce the ‘rest and digest’ system, nasal breathing is an excellent tool for athletic recovery!

Where do I start?

Lay on your back with your legs elevated and supported with the hips, knees, and ankles all at 90 degrees.  Place one hand on your chest and one hand on your belly. Take a large inhale breath, then exhale forcefully like you are trying to blow a candle out on the ceiling.  As you exhale, think about sending your ribs downwards and into the table. Taking the ribs out of a flared position and downwards toward the table will put the diaphragm in the optimal position to be recruited for breathing.  With the ribs in a down position, breathe through your belly. Do your best to only let the hand resting on your belly move, while the hand on your chest stays stationery. Take long, slow breaths through the nose, allowing the belly to rise on the inhale and to return to neutral on the exhale.  Stay relaxed through your abdominal muscles. Focus on breathing into the front and sides of your belly and even into your low back as well.

As stated previously, correcting your breathing patterns is one of the fastest ways to improve overall health.  Follow the steps in this post and you will notice the immense benefits right away. If you’d like to learn more: check out the excellent novel The Oxygen Advantage by Patrick Mckeown.

Post written by Dr. Riley Kulm, DC.  Check out his bio here.

Brief History of Yoga

Yoga originated in ancient India circa 3,000 BC and offers an excellent blend of meditation, respiratory training, and movement. Practitioners of yoga enjoy the relaxing benefits of a class, most commonly performed in a heated room. Anyone who has taken a yoga class understands the mental focus and physical resiliency required to successfully complete a practice. In fact, the breathing practice utilized in yoga called ‘pranayama’ is very similar to the diaphragmatic breathing exercises we teach our patients in the clinic.

Should I be doing yoga?

Yoga has gained immense popularity in this country over the last decade. As a result, many patients ask for advice on whether or not they should be practicing yoga. My overwhelming answer is yes! Any physical practice that promotes movement, whether it is yoga, pilates, weightlifting, or running – is beneficial to the human body and should always be encouraged.  However, the main caveat I give my patients when it comes to yoga is they need to understand which movements are healthy for their body’s and which movements are potentially damaging. Certain injuries or movement deficiencies can put the body at risk if you don’t know when to modify the yoga pose or to avoid it all together.

Low back pain and yoga

Let’s look at some examples.  Chiropractors treat many patients with low back pain.  Many patients experience increased back pain with sitting, picking items up off the floor, and bending forward to tie their shoes.  The common theme is rounding postures of the low back, termed ‘flexion’ is provocative for these patient’s low backs. We term this type of back pain ‘flexion intolerant low back pain’. A patient with flexion intolerant low back pain should avoid flexion based activities while their low back is in the healing stages. Very often, these patients respond well to exercises or static positions that place the low back in extension – adhering to the natural lordotic curve of the lumbar spine.

If after assessment in the clinic the Chiropractor decides the patient will benefit from extension based exercises or static positions,  the patient will be counseled to avoid all flexion based activities or postures for the low back (bending forward, prolonged sitting, etc.) during the initial stages of rehabilitation.  If you have taken a yoga class, you are familiar with the numerous forward folds and sustained toe touches that are done during the class to stretch out the calves and hamstrings. If a patient is experiencing flexion intolerant low back pain, performing 20-30 forward folds in an hour practice is harmful to the body.  In a patient prone to back pain, persistent forward bending places stress on the discs, nerves, ligaments, and muscles of the low back. Even Child’s pose position places the low back in end ranges of flexion and should be avoided for most acute back pain patients. Instead of forward folding, perform the downward dog position which will give similar benefits of stretching the calves and hamstrings while keeping a neutral spine.

Shoulder/ neck pain and yoga

Inversion pose requiring extreme amounts of neck, shoulder, and scapular stability.

Another example is a patient with shoulder and/or neck pain.  Handstands, headstands, and other inversion based poses are very popular in yoga. Teachers cite the benefit of reversing the gravitational flow of blood in the body for improvements in circulation.  While I agree with this notion, patients with shoulder and neck pain should not be putting this amount of stress on their muscles and joints. Performing a proper head or hand stand requires extreme levels of shoulder and scapular stability – something many beginning yogis do not possess.  If you have shoulder or neck pain and are new to yoga, do not try and impress the rest of the class by forcing yourself into an inversion pose. Instead, ask your teacher to show you a regressed version that does not place as much stress on your neck and shoulders.

Knee pain and yoga

Standing tree pose. Notice how the knee is in end ranges of flexion and is also placed under rotational stress.

Last, the athlete with knee pain needs to be careful with certain yoga postures. Patient’s with current knee pain or a history of knee pain and surgery need to be cautious with certain yoga poses.  Popular poses that impose large amounts of stress on the knee joint include the full squat (frog pose), hero pose (sitting on heels and laying backwards), pigeon pose (lying body weight on top of figure 4 pose), and standing tree pose.  The common theme with these positions is they add load to the knee joint in extreme ranges of flexion and rotation. When the knee is forced into end ranges of flexion and rotation, the muscles and ligaments of the knee are placed under stress, which is amplified if previous or current injury exists. Instead of fighting through the pain to complete the class, work on poses like the lunge, warrior 1 and 2, bridge pose, and chair pose.  These poses will strengthen the muscles and ligaments of the knee in less extreme ranges of motion.

Pigeon pose places high amounts of rotational stress on the knee.
Warrior 2 pose. Notice how the knee is not in extreme end ranges of motion. This position builds strength and stability in the front knee.

Your Yoga Practice

Practicing yoga should be challenging but pain free and relaxing at the same time.  If you are constantly fighting through pain in yoga, you are missing out on the many benefits of a successful practice. Do not feel bad about modifying your practice to work around injuries.  Always remember it is YOUR practice, and not everyone else in the room. Make sure to communicate all injuries to teachers before the class starts so they can help you with modifications to make sure you get the same benefits as everyone else.  As always, if you have a lingering injury that does not seem to be getting better, make sure to consult a health care professional who can diagnose and correct your specific issue.

Post written by Dr. Riley Kulm, DC.  Check out his bio here.

We’re going to take a quick break from our ‘Treat Yourself like a Professional Athlete’ blog series to address commonly asked questions in our clinic – how much should I be stretching, how should I be stretching, and why do improvements in flexibility from stretching seem to happen so slowly?

Do you feel like you are constantly stretching and foam rolling yet are not improving flexibility? Patients regularly ask me how to become more flexible and mobile. They stretch their hips, hamstrings, and lower backs constantly, yet see little improvement in function, range of motion, or pain. For many patients, the issue is not the extensibility of their tissues, it is poor or inadequate stabilization patterns.  

Create a Stable Base of Support

For the brain to allow movement and lengthening of a muscle, there must be a stable base of support. If a stable base of support is not present, the brain will perceive the movement as threatening and unsafe, and will put the brakes on. The brain does this by preventing muscles from expressing their full ranges of motion. This phenomena may show up as tight hamstrings, hip flexors, and lower back muscles.

Muscles most commonly attach to joints or on bony landmarks next to joints.  With this in mind, the stable base of support required for movement is most often a joint, which includes the vertebrae in the spine. Poor stability at a joint is perceived as a ‘red light’ to movement. We call this ‘neurologic tension’ which refers to muscular tightness caused by the brain putting brakes on a movement. If all we do is stretch the tight muscle, we are not addressing the root cause of the problem – an inadequate base of support. The feet, hips, shoulders, and vertebrae in the lower back and neck are common areas where patients need to improve stability because many muscles attach to these areas.

Breathing to Release Your Hip Flexors

Many of our patients stretch their hip flexors constantly but do not see any improvement.  The main muscle for hip flexion is the psoas major muscle. The psoas muscle attaches to the vertebrae in the spine, crosses the hip joint, and eventually attaches to the top of the leg near the head of the femur.  If the psoas muscle does not have a stable base of support at the spine, the brain will not allow this muscle to fully lengthen, leading to tighter hips. Proper breathing patterns utilizing a diaphragm-driven belly breath and 360-degree cylindrical core stability are essential to create a stable base of support at the spine. At our clinic we teach patients how to breathe deeply into their abdomen. This is important because you must be able to breathe into an area if you want to activate the muscles in the area. Once they can breathe into the front, sides, and back of their abdomen, we teach them how to stabilize the muscles of the core using progressively more difficult exercises.  Many patients notice improved hip flexor mobility simply by achieving better breathing and core stabilization patterns.

Stabilize Instead of Stretch

You should now understand how poor stabilization at joints can lead to an inflexibility of the muscles that attach at or near the joint. The focus of exercise therapies at our clinic teach patients to have better stabilization at their joints. Patients are amazed when they see active and passive ranges of motion dramatically improve once a stable base of support is created.  We rarely give clients traditional stretching exercises because for the vast majority of patients, the root cause of stiffness is neurologic tension due to poor stabilization patterns.

As today’s blog post is more technical than previous posts, please feel free to reach out if you have any questions!

Post written by Dr. Riley Kulm, DC.  Check out his bio here.

1. Use Magnesium, Not Melatonin

     For a supplement option, utilize magnesium to promote healthier sleep.  Magnesium can act as an inducer of GABA, the major inhibitory neurotransmitter of the body.  GABA helps the body slow down internal processes, especially in the nervous system. By decreasing facilitation of nerves, we help the nerves and the muscles they supply recover, which is extremely important for successful repeat athletic performances.  Magnesium comes in many different forms or ‘chelates’, and research suggests that magnesium threonate is the best inducer of GABA in the body, and will ultimately be the best choice for athletic recovery during sleep. Other supplements supported by the research include chamomile, kava kava, and Valerian root.

However, be careful about the popular sleep supplement, melatonin.  While very effective for some people, it’s important to remember that melatonin is a hormone that is naturally produced by the body.  This means that if you are taking the hormone externally, you run the risk of turning off your body’s natural production of the hormone, so reserve this supplement as a last ditch effort.

2. Avoid Late Night Workouts and Meals

Your late night workout or large meal close to bedtime may be disrupting your sleep.  Working out late at night can increase levels of our ‘awake’ hormone, cortisol, and decrease the body’s natural release of our ‘sleep’ hormone, melatonin.  Additionally, we induce a “fight or flight” sympathetic state when working out, which will make falling asleep more difficult. Shoot to finish your workout before 7pm to ensure that you give your body adequate time to calm down and relax before you go to sleep.  If your schedule absolutely requires that you workout late at night, make sure to utilize effective down regulation strategies after your workout to turn off your sympathetic system and activate your “rest and digest” parasympathetic system. Excellent down regulation strategies include post workout foam rolling, static stretching, and deep breathing exercises.

Choosing to eat dinner late at night may also disrupt your sleep.  Embedded in the lining of the digestive tract is the enteric nervous system, a complex web of neurons that has been called the ‘second brain.’  The enteric nervous system is important for the muscular contractions that move food through the digestive tract, the secretion of digestive enzymes, and communication with the brain via the vagus nerve.  The importance of the connection between the gut and the brain via the vagus nerve cannot be understated, especially when one considers that 90% of the nerve communication moves from the gut to the brain. In regards to healthy sleep, it makes sense that an active digestive system will send stimulatory signals from the digestive tract to the brain, keeping us awake at night.  Keeping this in mind, I like to finish eating at least 90 minutes before bedtime.

3. Foam Rolling for the Nervous System

     Many professional athletes utilize massage therapy as a post-performance or before bed treatment.  Massage has been shown to decrease cortisol levels (which are naturally high after exercise), while increasing serotonin and oxytocin, two hormones associated with relaxation and our parasympathetic ‘rest and digest’ state.  While most of us do not have access to a nightly massage, a 10-minute foam rolling session before bed can have a similar down-regulating effect on the nervous system and promote healthy sleep. Focus on the calves, quadriceps, hamstrings, and glutes, as these areas may be prone to tightness after a full day of exercise or after a long day of sitting at work.

4. Consistency is Key

As with any health and fitness related goal you are looking to achieve in life, consistency and adherence to a predetermined plan is essential.  Make it a point to wake up, as well as go to sleep, within the same 60 to 90 minute time frame every morning and evening, even on the weekends. Do your best to schedule social activities during the day and evening so that you don’t feel like you missed out on anything by not staying up late on the weekends. Sporting events, outdoor activities like skiing and hiking, or a trip to the botanical gardens are excellent ways to have fun on the weekends without sacrificing your sleep schedule.

Want to learn more?  Check out Sleep Smarter by Shawn Stevenson.  Many of the ideas mentioned above are draw on methods from this book.     

Post Written by Dr. Riley Kulm, DC. Check out his bio here.