Posted by on Nov 7, 2018 in Uncategorized

Breathing re-education

The term breathing re-education has been used in the physiotherapy and scientific literature. For example, the term appears in a chapter on dysfunctional breathing in the latest (fourth) edition of the textbook titled ‘Physiotherapy for Respiratory and Cardiac Problems: Adults and Paediatrics.’ It should be noted that the terms breathing re-education, breathing re-training, breathing exercises, and breathing pattern training are used interchangeably in the literature.

Many people who encounter the term ‘breathing re-education’ for the first time find it very strange and say things like: “The vast majority of people never receive any education about breathing in the first place, so how can they be re-educated?”

However, from a psychological point of view, learning can take place without a ‘teacher’ and such learning can be inferred from observable behaviour. In relation to breathing, the term re-education is used in a positive way, in the sense that its aim is to benefit the recipient of the re-education.

Certain behaviours can be unconsciously learned. Unconscious learning is the process of learning without necessarily being able to describe what it is that you have learnt. This can be the case with breathing. According to the American Psychological Association:

“Learning is a process based on experience that results in a relatively permanent change in behavior or behavioral potential.”

Behavioural potential is the likelihood of engaging in a particular behaviour in a specific situation. Essentially, learning is the modification of behavior through practice, training, or experience in that breathing is behaviour that can be changed; an individual’s experience can result in unconsciously learning to breathe in a dysfunctional way. The unconscious learning of bad breathing habits can adversely affect health. This being the case, the identification and changing of bad breathing habits is a fundamental behavioural aspect of breathing re-education.

Etiological and maintaining factors that may play a role in the unconscious learning of dysfunctional breathing habits might include the following:

  • Poor posture
  • Habitual mouth breathing due to, for example, blockage of the sinuses
  • Chest and nose conditions affecting the airways
  • Chronic negative emotions such as anxiety, fear, panic disorder, depression, anger, and sustained boredom
  • Sleep deprivation
  • Alcohol, nicotine, caffeine, or recreational drug use
  • Taking big breaths to “relax”
  • Mental tasks involving sustained concentration
  • Personality traits e.g. perfectionist or high achiever

In the vast majority of cases, faulty breathing habits are not identified or seriously addressed. Typically, rather than address the causes, only the symptoms are addressed and drugs are prescribed even though the breathing disorder may not have any associated pathology. According to Timmons (1994), patients who hyperventilate may be maintained indefinitely on addictive tranquillizers or inappropriate antidepressants.

Professor Anne Bruton has provided the following description of Breathing Re-training (Re-education):

“Breathing retraining (re-education) is a complex intervention (a ‘package’) with many components (both respiratory and non-respiratory). Respiratory components involve some form of breathing pattern manipulation, while non-respiratory components include, for example: relaxation advice, nutritional advice, medication usage advice, exercise prescription and psychological support. The core of all these different packages (physiotherapy, Buteyko, yoga) is breathing pattern manipulation, which can take many forms. The main elements of breathing pattern that may be manipulated are:

  • route of breathing (encouraging breathing through the nose rather than the mouth)
  • depth of breathing (aiming to reduce the volume of air breathed in and out),
  • rate of breathing (aiming to reduce the number of breaths taken per minute),
  • airflow velocity (aiming to reduce the speed of airflow in and out),
  • timing of breathing (aiming to breathe out for longer than you breathe in),
  • rhythm of breathing (aiming for a regular breathing pattern without too many deep sighs),
  • primary region of movement (aiming to reduce use of the upper chest and increase use of the lower chest and abdomen).
  • breath holds and pauses (various aims, but used to aid in controlling breathing pattern).”

In discussing ‘breathing pattern re-education’, Innocenti and Troup (2014) state the following:

“The initial education and breathing awareness training is followed by re-education of any components (of breathing pattern) that have been identified as being disordered. Any change, especially in volume or rate, must be balanced to attain a decrease in minute volume. The components are:

  • Tidal volume
  • Flow rate
  • Regularity
  • Place of movement.”

Methods of Breathing Re-education

The textbook ‘Middleton’s ALLERGY: Principles & Practice’ (2014) has noted that:

“Breathing re-training (re-education) techniques have been popular with the public and have elicited new therapeutic interest. (p. 1650)

In a 2001 study by Thomas et al; published in the British Medical Journal, it states:

“Although the mechanism by which retraining (re-educating) breathing improves symptoms in patients with the hyperventilation syndrome has been questioned, important and persistent clinical improvements result from this type of intervention.”

Professor Anne Bruton has noted that the breathing re-training (re-education) “techniques that have been formally investigated” have been:

(a) the Buteyko Breathing Method, (b) what she describes as “physiotherapist administered exercises (sometimes called Papworth techniques)”, and yogic breathing.

In the current (2016) ‘British Guideline on the management of asthma’ the Buteyko Method and the Papworth Method are given an ‘A’ grading of recommendation. The grade of recommendation relates to the strength of the evidence on which the recommendation is based. Both methods are given a 1++ rating.

1++ means: High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias. The British guideline also states:

“There is currently insufficient evidence relating to other breathing exercise methods, such as yoga breathing techniques …………………………….”

In relation to Yogic breathing, it is important to note the following:

(a) There are a very large number of modern types of Yoga that do not teach yogic breathing in accordance with the principles of Yogic breathing (pranayama) that were taught in original yoga manuscripts, for example, Hatha Yoga Pradipika, Gheranda Samhita and Shiva Samhita, which advocate restraining, keeping in, calming, and holding the breath.

(b) According to the Indian Yogi, Swami Rama (1925–1996), founder of the Himalayan Institute of Yoga Science and Philosophy, simple breathing exercises such as diaphragmatic breathing can be healthy and helpful. However, in order to really practice pranayama, the knowledge and application of the bandhas is important. Bandhas are “practices for unfolding, controlling, and re-channelling the finer force that is awakened through some of the vigorous pranayama exercises done by yogis.” Swami Rama also noted that without the application of the bandhas, pranayama practices can be injurious to health. Importantly, Swami Rama also noted that the majority of breath practices and pranayama techniques are intended for relatively healthy individuals.

(c) Dr. Shirley Telles and Dr. Nilkamal Singh of the Patanjali Research Foundation in India have noted that some pranayamas are associated with a number of precautions and contraindications.

For the above reasons, Yogic breathing techniques will not be described here. The descriptions of breathing re-education methods will be confined to the Buteyko Method and the Papworth Method.

 

The Buteyko Method

The breathing re-education method that has elicited the most therapeutic interest in recent years, and has the strongest evidence base for effectiveness, is the Buteyko Breathing Method. The Buteyko Method was developed in the 1950′s by a Ukrainian medical doctor and scientist called Professor Konstantin Pavlovich Buteyko.

Professor Buteyko’s extensive research led him to the conclusion that many chronic diseases, including asthma, could be scientifically explained, in large part, as being a consequence of hyperventilation. He postulated that if he could retrain patients who hyperventilate (over-breathe), so that their breathing pattern reverted towards the norm, then he could reverse diseases such as asthma.

Professor Buteyko believed that carbon dioxide deficiency was a major cause of many chronic diseases. After years of experimentation, he developed a method to ‘normalize’ the breathing pattern. This approach has become known as the Buteyko Method. According to Professor Buteyko, his programme of breathing re-training (re-education) could be of benefit in many diseases.

During his research, Professor Buteyko became aware of and was encouraged by work previously done by a few eminent scientists, which supported his theory. These scientists included Joseph Priestly and Christian Bohr. Priestley is usually credited with the discovery of oxygen. Bohr first described the Bohr Effect by stating that haemoglobin’s oxygen binding affinity is inversely related both to acidity and to the concentration of carbon dioxide.

The fundamental principle of the Buteyko theory is that chronic hyperventilation (over-breathing) causes a loss of carbon dioxide (CO2) in the lungs and in the blood. A deficit of CO2 disturbs the body’s acid alkaline balance, causing constriction of blood vessels and smooth muscle, and poor tissue oxygenation. The goal of Buteyko breathing re-education is to reverse chronic hyperventilation and restore a healthy breathing pattern.

The Buteyko breathing method encourages breathing control as part of daily life, particularly at the onset of asthma or other breathing related symptoms. In the early stage of training, patients are taught a structured daily routine of breathing exercises and breath holding techniques.

The main breath control technique of the Buteyko Method is reduced-volume breathing. It is particularly important that patients relax during reduced volume breathing to counteract their body’s natural tendency to increase respiration as a response to decreased tidal volume (i.e. the volume of air that is inspired or expired in a single breath during regular breathing). In recent years there has been a tendency for some Western Buteyko method practitioners to teach breath slowing as an alternative means for reducing minute volume.

The Buteyko method also uses post-expiratory breath holding as a means of assessing and training an individual’s breathing. The method also places a lot of emphasis on the importance of establishing and maintaining nasal breathing at all times including during exercise, during sleep and even when the nose becomes blocked as a result of having a cold or allergic reaction. The Buteyko Method also includes advice on posture, and health and lifestyle guidelines to support a functional breathing pattern.

A leading breathing therapy researcher (Dr. Rosalba Courtney) has expressed the view that it is unlikely that increased levels of carbon dioxide is the sole reason for the health improvements seen in patients who learn and practise the Buteyko method. According to Dr. Courtney, the mechanisms of the Buteyko method are likely to be complex and to include psychophysiological, neurological and biomechanical mechanisms in addition to biochemical mechanisms centred on carbon dioxide.

The Buteyko Method is a programme and method to re-educate and normalize an abnormal ‘automatic’ breathing pattern. Its implementation results in improvements in such conditions as asthma, sleep apnoea, snoring, insomnia, COAD (chronic obstructive airways disease), COPD (chronic obstructive pulmonary disease), sinusitis, hay fever (allergic rhinitis), non-allergic rhinitis, rhinosinusitus, blocked nose, allergies, bronchitis, bronchiectasis, and anxiety conditions.

 

The Papworth Method

Information on the Papworth Method is very sparse. Unlike the Buteyko Method, a literature review, uncovered only one scientific study that specifically mentioned the Papworth Method by name. This was a 2007 study by Holloway and West, titled ‘Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial’ was reported in the journal Thorax.

Also, in sharp contrast to the Buteyko Method, there are no associations/organisations of professionals who practise the Papworth Method. Indeed, in the UK where the Papworth Method was developed (at Papworth Hospital, Cambridge), the vast majority of the members of the main Buteyko professional organisation (Buteyko Breathing Association) are physiotherapists. A list of some of the main Buteyko organisations in different parts of the world is provided following the ‘References’ section below.

In the ‘Conclusions’ section of the published paper of the 2007 study on the Papworth Method, it states:

“The Papworth method appears to ameliorate respiratory symptoms, dysfunctional breathing and adverse mood compared with usual care. Further controlled trials are warranted to confirm this finding ……………….”

According to this 2007 paper, the Papworth method (developed by Dr. Claude Lum) has been implemented by physiotherapists since the 1960s for patients with asthma and dysfunctional breathing. As mentioned earlier, very little appears to have been published about this particular method. However, the 2007 paper describes it as a “sequence of integrated breathing and relaxation exercises” that integrates the following 5 components, the principal one being specific breathing training:


(1) “Breathing training, including teaching of appropriate minute and tidal volume and the development of a pattern of breathing suitable to current metabolic activity. Elimination of dysfunctional breathing, including hyperinflation and hyperventilation patterns is discussed. A specific Papworth method diaphragmatic breathing technique is taught to replace the use of inappropriate accessory muscles of respiration. Emphasis, when relaxed, is placed on calm slow nasal expiration. Patients are encouraged to ‘nose breathe’ rather than ‘mouth breathe’ and eradication or reduction of habits such as yawning, sighing, etc is taught and practised.”


(2) “Education, with the emphasis on the recognition and physical management of stress responses and specifically the interaction with breathing patterns.”


(3) “Relaxation training, specific and general.”


(4) “Integration of ‘appropriate’ breathing and relaxation techniques into daily living activities. Initially the techniques are taught in a semi-recumbent position progressing to sitting, then standing and during daily living activities. Finally, the integration of breathing and relaxation techniques into speech is taught and practised.”


(5) Home exercises with an audiotape or CD containing reminders of the breathing and relaxation techniques are supplied at the third treatment. Encouragement is given to practise at least once a day with the tape.

 


References

Courtney, R. (2014) Buteyko Breathing Method, Chapter 8.2 of the book titled ‘Recognizing and Treating Breathing Disorders’, Churchill Livingstone Elsevier.

Comparative Effectiveness Review Number 71, Breathing Exercises and/or Re-training Techniques in the Treatment of Asthma: Comparative Effectiveness, September 2012

Holloway. E.A. and West, R.J. (2007) Integrated Breathing and Relaxation Training (the Papworth Method) for adults with asthma in primary care: a randomised controlled trial, Thorax, Dec; 62 (12): 1039-1042

Pryor J.A. (2014) Physiotherapy for Respiratory and Cardiac Problems: Adults and Paediatrics (fourth edition), Churchill Livingstone Elsevier

Ruth, A. G. (2013) The Buteyko Method, Irish Medical News, Volume 30, Number 42.

Telles S, Singh N. A review of the use of yoga in breathing disorders (chapter 8.6 of Recognizing and Treating Breathing Disorders: A Multidisciplinary Approach) edited by Chaitow L, Bradley D, Gilbert C. Churchill Livingstone Elsevier (2014)

Timmons B.H. (1994) Breathing-related issues in therapy In: Timmons B.H. and Ley R. (eds) Behavioural and Psychological Approaches to Breathing Disorders, Plenum Press, New York

Professor Anne Bruton’s blog: https://anniebruton.wordpress.com/breathing-retraining