Breathing and Pain

One of the best tools each and every one of us has for managing pain is the breath. The simple yet powerful act of breathing, which we typically perform more than seventeen hundred times a day without even thinking about it, can be a potent weapon for working past the pain and regaining control of your life. I realize that what I’m telling you here may make you feel like you just bought a popular cookbook, eagerly opened it, and found that the best cooking tip is to use something as ubiquitous as tap water. But take it from someone who has treated thousands of patients and monitored the long-term effects of just about every treatment imaginable: There are no magic potions or super-duper gadgets that will serve you more admirably than your breath.

The subject of breathing may, at first glance, seem simple, but I urge you to resist the temptation to gloss over it. Progressing from a “breathing apprentice” to a “breathing expert” requires practice and skill. Though it may seem tedious and trivial, I can assure you that mastering and implementing breathing techniques will bring you one of the greatest rewards imaginable: the gift of control. Taking charge of this simple action makes you the captain of your ship once again.

Many of us find ourselves stuck in traffic at one point or another, and some of us slog through thick commuter gravy five days a week getting to work and back. This type of driving can trigger tension and stress, which can manifest as a sore neck, tight shoulders, and a rapid heart rate. We also become “emotionally tense” and agitated, sometimes spitting out choice expletives at the car that just cut us off. We typically assume that our physical and emotional responses are inevitable and unavoidable, but the next time you are caught in terrible traffic, try turning off the radio chatter and focusing on your breath. Pay attention to the slow rise and fall of your belly as you breathe in and out, tuning out all thoughts about what’s happening on the road. You may be surprised, but you will certainly be delighted, to discover that not only will your muscles begin to relax and your heart stop pounding, you will also gain control of you, instead of allowing the situation to dictate how your body and mind feel and react.

Remember that you have control over how you breathe, and how you breathe affects you physically and emotionally. This means you always have a pain-managing “medicine” at your disposal, and no one or nothing, including your pain, can take that away from you unless you let it.

The Rhythm of a Beating Diaphragm

Let’s review some fundamentals about breathing. For starters, the second-by-second action of inhaling and exhaling air is managed by a very vigilant portion of the brain known as the brain stem, which deals with involuntary activities. Acting on information received from other parts of the nervous system and brain, the brain stem sets a pace or rhythm for the respiratory system to follow.

The brain uses a specific nerve, the phrenic nerve, like a telephone line to instruct the diaphragm to contract. Every time it receives “the call,” the diaphragm lowers itself, pushing the abdominal muscles out and allowing the lungs to expand and fill with air. Then the diaphragm relaxes, moving back up to its starting position. This allows the abdominal muscles to move back into place, forcing the lungs to push air out. There are also accessory muscles around the ribs and abdomen that help the lungs expand even more and squeeze out extra air upon exhalation. With each inhalation, the lungs bring in oxygen, which moves into the blood so the heart can pump it to all the tissues that need it for energy. With each exhalation the lungs eliminate carbon dioxide, a waste product found in the blood that is produced when our bodies burn fuel.

Think of the diaphragm as a large, flexible dome sitting at the bottom of the rib cage. A large muscle, it helps separate the heart and lungs above, in the thorax (chest cavity), from the intestines, liver, and other organs below, in the abdominal cavity. When the diaphragm contracts, it forces itself down onto the abdomen. This action opens up more space around the lungs. The resulting expansion of the chest creates negative pressure on the lungs, which allows air to flow in from the outside. The diaphragm then moves back up toward the chest as it relaxes. This exerts positive pressure on the lungs, and air is pushed back out.

This back-and-forth motion of air is rhythmic, meaning it repeats itself at regular intervals, like the rhythmic beat of music. With music, sound is carried through matter in the form of waves. The waves transfer energy through particles of air to our ears, brains, and, if we get up and dance, to our fingers and toes. The energy released from a musical instrument can move into us and re-create the same pulsating beat inside our bones, connecting us with the instrument. Likewise, the rhythm of breathing involves the transfer of energy back and forth from within us to our external environment.

Have you ever walked down the street and heard a talented street musician playing an instrument? If you are like me, you feel a sense of joy as the harmony resonates within. We humans enjoy calming harmonic motions, whether in the form of waves lapping on the beach or beautiful music. A calming breathing rhythm has the power to improve our outlook in a manner similar to music. When you learn how to use your breath as a form of calming harmonic motion, you can dispel physical tension and emotional stress in the form of energy released through respiration.

We know that stress, acting through the fight-or-flight response, changes our breathing pattern; it becomes quicker and shallower. If we breathe too fast, or hyperventilate, we get dizzy because we are releasing too much carbon dioxide. Rapid breathing can also generate a sense of gasping for air, which creates even more anxiety, makes us breathe ever faster and shallower, triggers more anxiety, and on and on. We also know that the brain stem is part of the pain matrix inside the brain, so deliberately sending the brain positive feedback about breathing will influence what is being “said” inside this matrix. You can do this via the parasympathetic nervous system (PNS). When the PNS becomes more active, you are better able to relax. Consciously slowing down a respiratory rate accelerated by stress “turns on” the PNS and you start to calm down.

As you can see, breathing can connect the body with the mind, instantaneously linking the involuntary, unconscious mind with active, conscious thoughts. Since our thoughts play an integral role in the emotions we experience, you can use your breath to cut negative thoughts off at the pass before they get a chance to hijack your emotions. Before you know it, your breath can help you short-circuit the chronic pain cycle. (Your breath can also help you kick the road rage habit, getting you to your destination in a much better mental and physical state.)

Time for You to Be With You

At my center, patients spend time in a special room called the Wellness Room, where my staff trains them in meditation, relaxation, and breathing exercises. You might be thinking that I’m a very nice doctor for encouraging my patients to set aside time each day just to chill. It turns out this is often the hardest class for my patients to participate in. Clearing the mind of all other thoughts and focusing on breathing is surprisingly difficult. The brain likes to wander, even toward negative or dysfunctional thoughts. It can be extremely hard to sit still and be calm if your thoughts continue to drift. You run the risk of being afraid to be alone with yourself, which robs you of the opportunity to take advantage of the healing that breathing and meditation or prayer has to offer.

Because we are so accustomed to stimulation from cell phones, computers, televisions, radios, and other sources, we seldom find ourselves alone for quiet time. I think the central nervous system becomes so used to the noise it becomes like an addiction. It starts to crave the noisy stimulation; it needs it to feel “normal.” Our minds seem to constantly seek information from e-mails, text messages, and television shows. This makes it all the more important to be disciplined about shutting off these tempting distractions and giving your brain the time it needs to help heal both mind and body. I tell my patients that there are many ways to do this, including switching off the cell phone and taking a short walk, turning off the TV and reading a good book, or playing board games with their children or grandchildren. Technology is not going to vanish and it is not inherently bad for us, but you need to contain it in order to optimize your physical and emotional well-being.

You may already know about the great importance of contact time, which is the amount of time patients spend in comprehensive treatment programs. The evidence tells us that intensive programs with lots of contact time provide numerous valuable, long-lasting results. I like to connect that contact-time dot to you, the reader, imploring you to carefully decide how you spend your time each day.

Mastering the art of therapeutic breathing requires lots of contact time, which means you have to devote time to mastering it. My patients don’t just walk in the Wellness Room, dash through two minutes of breathing exercises, and then walk out. They spend about an hour per session with one of our wellness instructors doing some of the exercises you will read about here. Take a moment to consider which breathing and meditation practice would best fit into your day and commit yourself to it. It doesn’t matter whether you practice in the morning, in the afternoon, in the evening, or at night, as long as you create a space in your day, every day, to let breathing nourish you to a greater vitality.

Getting Started

One well-founded, time-honored approach to breathing, called diaphragmatic breathing, involves relaxing the belly during inhalation. The first step in diaphragmatic breathing involves thinking about the belly during breathing. Lie flat on your back and observe how it rises during inhalation and falls naturally during exhalation. Notice how much easier it is to breathe when the belly is relaxed. Try tensing it and see how much harder it feels to move air in and out of the lungs. The softer the abdomen gets, the more the lungs can fill with air and breathing shifts from shallow to deep. This change is easier to appreciate if you put your hand on your belly and feel it move back and forth.

Try these easy steps to become acquainted with diaphragmatic breathing:

  1. Sit down or lie flat on your back in a quiet place.
  2. Close your eyes.
  3. Concentrate on the motion of the belly.
  4. If your mind wanders—and it will—reconnect with the motion of the belly and movement of the breath.
  5. See if you can do this for at least five minutes.

Now take this concept into your daily life. When you feel yourself becoming tense or angry, wait a moment. Place your hand on your belly and become aware of the motion. Concentrate on this motion for several breaths, and then ask yourself how you feel. The negative emotions you just had should be mostly gone as you become more relaxed.

You can use breathing exercises to do more than quiet the mind: They can also stimulate the mind and boost mental clarity. You don’t have to rely on a double, extra-hot vanilla latte to get you there! Try the following exercise when you wake up in the morning:

  1. Sit up tall with your eyes closed and your tongue up against the roof of your mouth.
  2. Breathe in and out very quickly through your nose with your mouth closed.
  3. Notice the pumping sensation taking place at your abdomen while you do this breathing. This means some of those accessory muscles are active.
  4. You will hear noise as the air is rapidly pushed in and out.
  5. At first you may not be able to breathe this way for more than about fifteen seconds, but it will get easier with practice.

Practice this exercise for a few minutes each morning.

I personally find this exercise helpful when I wake up anxious about the day ahead and need to calm myself down so that I can focus on what is important and reduce excess nervous tension. Not only do I work full-time in a busy medical practice, but I am also a self-employed small business owner responsible for things like rent and payroll. This special breathing exercise is one tool that helps prevent the typical daily stressors we all face from overloading my coping circuits so that I can still focus my attention on my patients, or even family, when they need me.

Because the diaphragm is a large muscle, it helps to warm it up before exercising it, just as you do other muscles. I remember participating in a workshop that strongly advocated doing just that. They put a group of us in a room and had us all belt out “huh, huh, huh. . .” Try it; you’ll warm up your diaphragm and give your neighbors’ eardrums a good workout at 6:00 a.m.

Exercising Your Breath

Let me share with you some of the other breathing exercises my patients learn in the Wellness Room. Most of these come from Eastern practices, including yoga. We often use relaxing rhythmic music during these sessions. Feel free to pick music that works for you; we all have different tastes.

Sun and Moon Breathing

This exercise involves alternating breaths between the nostrils. Use one hand to gently close the right nostril. Exhale through the left nostril, then inhale. Now, with the same hand, release your right nostril and gently seal your left nostril. Exhale and then inhale through the right. Now back to the other side. You can continue this exercise for five minutes or longer. In yogic tradition, the left side represents the energy of the moon, while the right side is the energy of the sun. Consider using this for help with stress, anxiety, unwanted cravings, and even headaches.

The Body Scan

This breathing technique also engages the mind in some thoughtful meditation. When you feel overwhelmed by pain, use it as a tool to try to put your pain in a “box.” In other words, do not allow your pain to identify with the real you. Here’s how to do it:

  1. Lie on your back with your arms and legs outstretched.
  2. Close your eyes and become aware of your belly’s movement with each inhalation and exhalation.
  3. Draw your attention first to your left foot. Breathe into and out of it for a few moments. Visualize the air moving down to and expanding into the foot as you inhale; then imagine the foot relaxing as the air flows out of it during exhalation.
  4. Slowly make your way all the way up your body, “breathing into” each part of your body in succession.
  5. As you leave each body part or section, let it go from your mind and redirect your attention to the next part.
  6. When your attention is drawn to a painful part of the body, avoid becoming judgmental. Instead of creating opinions about the pain, simply recognize its presence while you breathe.

Thirty-five-year-old Natalie suffered for years with a great deal of neck pain, even after trying many treatments, medicines, and an extensive four-level cervical fusion in her neck. Unfortunately even after all of this, her pain continued and her neck got as stiff as a board. In fact her neck became so immobile that she was unable to shampoo her own hair or otherwise groom herself, and driving was out of the question. Having suffered through many failed treatments, she was amazed to see how much the body scan helped her situation. It took her a few weeks to get comfortable making it a part of her regular routine, but now it has become a great tool to relax tight muscles in her neck and shoulders so she can move her neck more freely and with less pain. The body scan has also made it easier for her to drift off to sleep at bedtime as well as get back to sleep, instead of tossing and turning, in the middle of the night.

Exhaling First

Exhaling before you begin a breathing exercise forces you to engage accessory muscles around your ribs and abdomen as you blow the air out. (Think about squeezing the air out of an inflatable beach ball; imagine these muscles are your fingers pressing in on the beach ball.) Reversing your breathing pattern by exhaling first also makes you much more aware of your breath. This should increase the amount of air you move in and out of the lungs and restore calmness. Try this exercise for a few minutes every day.

Awakening the PNS

I have extolled the virtues of inducing the parasympathetic nervous system (PNS) as a way to reduce stress and anxiety and manage pain. This breathing exercise will help boost parasympathetic tone:

  1. Inhale through your nose with your mouth closed and your tongue raised to the roof of your mouth.
  2. After a full inhalation, hold your breath for five counts, or whatever length of time feels right.
  3. Exhale deeply out the mouth. This typically creates a noise as the air is pushed out . . . hhhhhaaaaahhhhh.

Try doing this for three to five minutes at a time. Don’t feel you have to go the full five minutes. Do it as long as you comfortably can. Some people have trouble getting started with this exercise and even feel a little light-headed in the beginning. So start slowly, and make sure you’re sitting down when you begin.