OT PRACTICE • JANUARY 23, 2006 15

he average healthy personbreathes more than 20,000times per day. Most of us take

our breath for granted and give littlethought to the mechanisms involved,unless respiration is severely impaired.Yet many breathe inefficiently, espe-cially those experiencing pain and dis-ability.

Breathing is a dynamic process thatchanges according to the needs of theactivity. There is no single right way tobreathe. Our breathing adjusts to sup-port the diverse challenges of our life—pushing a vacuum requires a differentkind of breathing than wiping a coun-tertop; donning socks and shoesrequires a different kind of breathingthan talking with a friend. Yet ineffi-cient, habitual breathing patterns limitthe ability of our body to make theseadjustments.

Inefficient breathing can be drivenby a variety of factors. Our posture,past injuries, mental stress, emotionalresponses to life events, disease, andculture all have an impact on our“habit” of breath. These patterns areunconscious, and even though our cur-rent way feels familiar and “right,” itmay not necessarily be the most effi-cient way to breathe at any particularmoment.

As our breath becomes more adap-tive, we tend to feel calmer and expendless effort, due to physiological changesin the body. Almost immediately, thebalance of oxygen and carbon dioxidelevels in the blood are modified, pro-moting healthier cellular metabolismand neurological changes.1 Other stud-ies have indicated that breath work canbe used effectively to address coronaryheart disease,2 hypertension,3,4 chronic

pain,5,6 migraine headaches,7 asthma,8

epilepsy,9 menopausal hot flashes,10 andpanic attacks.11

Occupational therapy interventionsare designed to “foster engagement inoccupations and to support participa-tion in life” (p. 618).12 Within our prac-tice we address performance patterns,which “refer to habits, routines, androles that are adapted by an individualas he or she carries out occupations ordaily life activities” (p. 612)12 and activ-ity demands, which “affect skill andeventual success of performance” (p.613).12 Migliore described an occupa-tional therapy intervention for threeoutpatients with chronic obstructivepulmonary disease in which “the occu-PH

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A Breath Therapy Program To Promote OccupationalPerformance

P oor breathing habits are so

ingrained that clients may

not realize the effect they

have on their ability to participate in

valued occupations.

S U M M A R Y

T

PeakPerformance

RICHARD SABEL

BILL GALLAGHER

pational therapy focused on teachingpatients how to reduce and managetheir dyspnea while performing light tomoderate effort activities such as bedmaking, gardening, sweeping floors, andstair climbing” (p. 644).13 Occupationaltherapy practitioners’ unique under-standing of occupation and daily lifeactivities provides the foundation toweave a breath-focused interventioninto day-to-day function to facilitatelearning and the integration of “habitsthat support performance in daily life”(p. 623).12

COMMON INEFFICIENT BREATHINGPATTERNSOn any given day in the clinic, it is notuncommon to see a variety of breath-holding patterns that impede functionalprogress. Most common is chestbreathing, where the abdomen is inap-propriately contracted, constricting themovement of air to the upper chest.With this breathing pattern the shoul-ders rise and fall as the secondary muscles of inspiration (scalenes, stern-ocleidomastoid, trapezius, and pec-toralis minor) work to make up for therelatively immobile diaphragm. When

these secondary muscles work full-time,the person will eventually experiencechronic tension and discomfort in theneck, upper shoulders, and back. Thispattern can also impede the healthyfunctioning of the digestive organs,elicit a chronic state of hyperarousal,and stimulate the sympathetic nervoussystem. This can be experienced asanxiety, “butterflies in the stomach,”and muscular tension.

In paradoxical or reverse breath-ing the diaphragm lifts up duringinhalation and drops down during exha-lation. This pattern is the reverse ofnormal “textbook” breathing and, whenhabitual, is very inefficient. Like chestbreathers, reverse breathers eventuallyexperience neck, shoulder, and upper-back tension; digestive problems; andanxiety; and they “often encountergreat difficulty learning movement, feel-ing clumsy and uncoordinated becausetheir most basic pattern of movement(breathing) is completely upside down”(p. 76).1

Hyperventilation is characterizedby quick, rapid breathing and oftengoes undetected unless it is in itsextreme, acute form. The causes can be

organic (i.e., to compensate for kidneydysfunction), physiologic (i.e., whenrunning a race), emotional (i.e., due tofear or anger), or habitual.14 When it ishabitual, people breathe quickly regard-less of the activity. Over-breathingreduces carbon dioxide levels in theblood (respiratory alkalosis), and thismetabolic shift from acid to alkalinealters a panoply of cellular chemicalreactions.

Hyperventilation can manifest in amyriad of symptoms such as headache,dyspnea, numbness, light-headedness,chest pain, palpitations, fatigue, rapidpulse, visual disturbances, stomachpain, muscle pain, cramps, anxiety,insomnia, and impairment of concentra-tion and memory.1,14

PEAK PERFORMANCEThe Peak Performance curriculum outlined in this article is designed tofacilitate the rehabilitation of clientsrecovering from diverse conditions,including neurological, orthopedic, orcardiopulmonary issues; chronic pain;and injury. The format is intended to be experiential and explorative, ratherthan prescriptive, and includes sevenlessons. Each Peak Performance ses-sion starts with an explanation of pertinent anatomy and a logical, psy-chophysiology-based rationale for thelesson. This didactic portion preparesthe group for the experiential compo-nent. The lessons can be taught as partof an individual treatment session or ina group format and arranged in anysequence, as each lesson stands byitself.

Helping participants develop anawareness of their current habit forbreathing lays the foundation forchange. To facilitate this awareness, ahandout is given with the followingquestions:

To help identify your currentbreathing patterns and habits, howdo you breathe when you are dress-ing, showering, walking, cooking,cleaning, eating, exercising, talking,and watching television? During theactivity, are you holding yourbreath at any point? Are you strug-gling for breath or is it adequate for the activity you are performing? Is there a noticeable differencebetween the length of the inhala-tion and exhalation? Is your breath

16 JANUARY 23, 2006 • WWW.AOTA.ORG

The goals of the programare to maximize engagement in

occupation by

(a) improving the efficiency

of respiration to conserve

energy and therefore

engage more fully in

meaningful activities;

(b) improving coordination

and ease of movement;

and

(c) decreasing anxiety to

manage pain, facilitate

motor learning, and

learn new information.

fast or slow? Does your breath feelsmooth and even or is it jerky anduneven? Is your posture influencingthe quality of your breath?

This internal focus is encouragedthroughout the program so participantswill begin integrating what they havelearned within the context of day-to-day activities. The goals of the programare to maximize engagement in occupa-tion by (a) improving the efficiency ofrespiration to conserve energy andtherefore engage more fully in meaning-ful activities; (b) improving coordina-tion and ease of movement; and (c) decreasing anxiety to manage pain,facilitate motor learning, and learn newinformation.

PEAK PERFORMANCE LESSONSThe lessons presented in the programare meant to serve as a foundation from which a breathing program can be developed. There are many otherapproaches, especially from yoga andqigong, that can be incorporated into a breath therapy program. A completeaccount of three lessons are presented,with a brief overview of the remainingsessions.

Lesson 1: Why Zebras Don’t Get UlcersThis title comes from a book by RobertSapolsky titled Why Zebras Don’t GetUlcers: An Updated Guide to Stress,Stress-Related Diseases, and Coping.15

In this lesson, participants learn a breath-and word-focused meditation as ameans to improve the quality of theirbreath. This strategy helps quiet themind and decreases habitual muscletension and stress, thereby promotingthe client’s ability to attend to criticalfeatures of the environment and tolearn new information (i.e., cues tofacilitate motor learning, hip precautions),and it provides a nonpharmaceuticalintervention for managing pain.

DiscussionThe discussion begins with the question“why don’t zebras get ulcers, and whatdoes this have to do with breathing?”After a wide variety of answers, the fol-lowing scenario is presented. Zebrasgrazing in the field are in a relaxedstate. When a lion appears there is shiftphysiologically, from the rest and digestmode to the flight or flight mechanism

of the autonomic nervous system,enabling the zebras to go quickly from ablissful state to running at full speed. Ifthe zebras outrun the lion and survive,they go back to grazing peacefully andthe rest and digest mechanism is reen-gaged. For many people, the ability todisengage the fight or flight mechanismquickly is not so easy.

The discussion focuses on howexcessive mental tension can perpetu-ate breathing pattern disorders, pain,and the stress response, just as ineffi-cient respiration can cause an increasedstress response, pain, and mental ten-sion. In this way, breath is the bridgebetween the mind and the body. Breathawareness can help anchor the mindinto the present moment and have aglobal positive impact on health. Mostof our mental stress (which in turnamplifies muscle tension, pain, and ill-ness) stems from our dissatisfactionwith some aspect of the past (if only Ihad not had this stroke!) and from wor-rying about the future (I know I’ll neverget back to where I was...). Meditationis an effective way to practice breakingthat cycle by quieting the mind andbringing us into the present.16 The abil-ity to temporarily “turn off” the mentalchatter is not only important to health,

but it can foster our ability to learn newinformation and be more present in ourcommunication with other people.

ExplorationThe breath-focused meditation isexplored first. Participants are asked tosit upright and, if possible, slightly for-ward in the chair. Those who are unableto assume or maintain this posture canrest against the chair. The group isdirected to focus on their breath bysensing and feeling the movement ofthe air as it goes in and out, and tokeep their focus on this movement.Participants are then told “when themind wanders (not if but when), gentlybring the focus back to the breath andwe will continue to breathe in this wayfor 4 minutes.” During a short discus-sion that follows, participants describetheir experience and what if anychanges they feel. Most often theyreport feeling relaxed, having a clearerfocus, and experiencing less physicaldiscomfort.

We next explore the term focusedmeditation. We offer this alternativebecause some people find it easier tostay focused on a word rather than ontheir breath. Instead of keeping one’sawareness on the breath, the focusshifts to saying the word “one” inter-nally with every exhalation.17

Lesson 2: Respiratory Sinus ArrhythmiaRespiratory sinus arrhythmia refersto the physiological changes in bloodpressure and heart rate that occurthroughout the respiratory cycle—whilewe inhale our blood pressure and heartrate increase, and while we exhale theydecrease. Respiration can occur auto-matically, but it can also be controlled.In this lesson participants learn thatthey can modify their respiratory rateto better support activity demands,along with strategies for extending theexhalation.

DiscussionThis session begins with participantscounting the number of times theyexhale in 1 minute. These numbers arecompared with average respiratory ratesfor women (13–14) and men (12–13).Many participants report respiratoryrates of more than 20, which leads to a discussion of the potential conse-

Case Report: Improving Dyspnea Managementin Three Adults With Chronic ObstructivePulmonary DiseaseBy A. Migliore, 2004. American Journal ofOccupational Therapy, 58, 639–646.

Functional Performance in Older Adults (2nd ed.)By Bette R. Bonder & Marilyn B. Wagner, 2001.Philadelphia: F. A. Davis. ($53.95 for members,$71 for nonmembers. To order, call toll free 877-404-AOTA or shop online at www.aota.org. Order#1219-MI)

Occupational Therapy With Elders: Strategiesfor the COTA (2nd ed.)Edited by S. Byers-Connon, H. L. Lohman, & R. L. Padilla, 2004. St. Louis, MO: Mosby, Inc.($47.95 for members, $68 for nonmembers. Toorder, call toll free 877-404-AOTA or shop onlineat www.aota.org. Order #1394-MI)

Using Environments To Enable OccupationalPerformance By L. Letts, P. Rigby, & D. Stewart, 2003.Thorofare, NJ: Slack. ($35.95 for members, $51 for nonmembers. To order, call toll free 877-404-AOTA or shop online at www.aota.org.Order #1376-MI)

F O R M O R E I N F O R M A T I O N

OT PRACTICE • JANUARY 23, 2006 17

18 JANUARY 23, 2006 • WWW.AOTA.ORG

quences of rapid breathing, and thehealth benefits of improved respiratorycontrol (i.e., lowered blood pressure andheart rate, more efficient breathing,improved adaptive potential).

ExplorationAn effective strategy for regulatingbreathing is to synchronize a gentle,easy movement with the breath.Participants start by resting their handson their thighs. On the inhalation theyare instructed to slowly begin openingand horizontally abducting their arms,letting the chest open, spine extend,and head roll upward. The movementsshould be made within an easy comfort-able range. On the exhale the move-ment is reversed, with the arms movingback toward the thigh, and the chestclosing as the spine and head gentlyround down. The breath and arm move-ments should be continuous, and par-ticipants should breathe at their usualrate. After the arm movements comfort-ably match one’s current respiratoryrate, the next step is to match thebreath to a slower movement, thenlastly to a faster movement. If a partici-pant has physical limitations, any num-ber of variations can be offered; forexample, matching the breath to open-ing and closing a hand or gently rockingthe head up and down.

The next phase of the lesson is toextend the exhalation through twomethods: (a) exhaling through a strawand (b) through pursed lips. After prac-ticing each method, participants countthe number of times they exhale, usingeither approach, for 1 minute. Theresults are usually dramatic, with mostpeople falling within or close to “nor-mal” respiratory rates and reporting thatthey feel more relaxed and “present.”

Lesson 3: The Pelvic ClockThe pelvis is anchored by the spine andfemurs. When we breathe, a kineticchain of movement occurs throughoutthe body. This movement is oftenrestricted by chronic tension held inany number of muscles. This lessonfocuses on initiating movement fromthe pelvis to help participants identifyand release habitual holding patternsand promote more efficient breathingand functional movement.

DiscussionThe discussion begins with participantsobserving a life-size skeleton that isseated in a chair. After identifying thepelvis, spine, ribs, and femurs, thepelvis is rolled forward and back, andthen left and right, while participantsdescribe the observed movements. Thisdemonstration highlights how move-ment in one part of the body influencesmovement throughout the body, andhow habitual muscle tension in any oneplace (i.e., abdomen, intercostals,throat, neck, back) impedes movementand the quality of our breath. The con-nection to functional movement is madeby demonstrating how the pelvis rollsforward for activities such as reachingforward, sit-to-stand, and transfers. Aswe don or doff shoes and socks thepelvis rolls back, and when we reach tothe left or right outside our base of sup-port (e.g., to retrieve items from a cabi-net), the pelvis shifts and the ribsexpand in the direction of the reach.

ExplorationParticipants are asked to imagine thatthey are sitting in the middle of a clock.When the pelvis rolls forward (anteriorpelvic tilt) that is the 12:00 position,and when the pelvis rolls back (poste-rior tilt) that is the 6:00 position. Tiltingthe pelvis to the left (lateral tilt) is 9:00and to the right is 3:00.

Participants start by rolling theirpelvis toward 12:00 while inhaling andexhaling as they move back toward thecenter of their clock. The cue to movewithin a comfortable, easy range isgiven. Participants are directed tonotice that as the pelvis shifts forwardthe spine lengthens, the space betweenthe ribs expands in front and shortensin back, and the head tilts gentlyupward. Anyone having difficulty feeling the movement is instructed tomake the movement even smaller andeasier.

The next movement is toward 6:00,and participants are instructed toexhale as they roll back and inhale asthey return to the clock’s center. Thistime participants are cued to noticethat as the pelvis shifts backward thespine rounds, the ribs close in front andopen in back, and the head rolls down.

Then both movements are puttogether with the cue to inhale while

rolling toward 12:00 and exhale whilemoving toward 6:00, continually sensingand feeling the movements of thepelvis, spine, ribs, neck, and head.

The next step is to move the pelvistoward 3:00. Participants are directedto notice the asymmetrical pattern ofmovement when their pelvis shiftsright: how the ribs expand on the rightside and shorten on the left, and thehead laterally tilts to the left. Whenmoving toward 9:00, the reverse patternof movement occurs. Participants areinstructed to inhale and exhale in amanner that feels comfortable and easy.

This lesson usually takes place overtwo sessions because many peoplerequire time to “let go” of habitual ten-sions and begin to feel the kinetic chainof movement. After the pelvis-to-headconnection is made, participants reporta positive change in the quality of theirbreath and an ease and freedom ofmovement.

Lesson 4: Breath—A Moving ExperienceBreath is about movement. Lesson 4focuses on the mechanism of breathing(movements of the diaphragm, itsattachments, the exchange of gases,and the role of the secondary muscles)and factors inhibiting efficient breathing(posture, culture, pain, emotion, andhabit). It also addresses how muscles,tendons, joints, and organs are influ-enced by our breath because these alsoaffect our breathing.18 The experientialcomponent helps participants under-stand the natural oscillation of theirbreath reflected in movement through-out their body.

Lesson 5: The Inner TubeWhen the primary muscles for respira-tion are efficiently engaged, most of themovement is in the lower abdomen.When the secondary muscles are mostactive, the upper chest moves more.Participants are asked to imagine a tri-angle superimposed on their trunk, withthe base of the triangle closest to theground. This represents abdominalbreathing, which provides postural sta-bility and a sense of being grounded.19

Chest breathing is represented by hav-ing the triangle turned with the apexpointing down—with this pattern thereis less postural stability. This lessonhelps participants experience and allow

OT PRACTICE • JANUARY 23, 2006 19

more movement throughout the “baseof the triangle”—in the belly, sides, andlower back—by imaging an inner tubeplaced in their lower abdomen. Verbalcues are given to initially direct thebreath to different compartments of theinner tube and eventually to inflate anddeflate the whole tube.

Lesson 6: Core Connection—Awareness Builds StabilityBack pain impedes function and is often caused by inefficient coordinationbetween muscles of the trunk and pelvis.Improved breathing patterns can facili-tate lumbopelvic stability by coordinat-ing movements of the diaphragm, pelvicfloor, and transverses abdominus. Inthis lesson, participants learn to isolateand then coordinate these muscles,thereby improving trunk stability, respiration, and function.

Lesson 7: BiofeedbackWhen clients find the appropriate rateand quality of breath, a measurablerelaxation response is elicited. A simpleand inexpensive way to measure thispsychophysiological response is thermalbiofeedback with hand thermometers.With relaxed breathing, blood flow tothe skin increases, which in turn ele-vates hand temperature. Participantssee that by manipulating their breath,they are also changing blood flow patterns.

PUTTING THE PIECES TOGETHERTo truly integrate the Peak Perfor-mance lessons, the occupational thera-pist needs to incorporate the strategiesinto daily intervention sessions. Forexample, if a client is breathing rapidlyand expresses feeling anxious during acooking activity, the therapist can guidehim or her to use pursed lip breathingto slow the respiratory rate anddecrease anxiety. If a client has diffi-culty breathing and fatigues quicklywhen performing lower-body dressing,the therapist can use the pelvic clock topromote an easier posterior pelvic tiltand reduce muscular effort, therebyallowing more efficient breathing. If aclient with a hip replacement is unfo-cused and having difficulty learning hipprecautions using adaptive equipment,a word- or breath-focused meditationcan be used to help improve focus.

After a client has experienced moreefficient movement of the diaphragm in Peak Performance, the occupationaltherapist and occupational therapyassistant can use verbal cues or gentletactile cues to promote diaphragmaticbreathing to promote occupational performance.

CONCLUSIONInefficient breathing patterns limit ourclients’ ability to fully engage in day-to-day activities. Therefore, helping themlearn efficient breathing habits is animportant component of any interven-tion strategy and clearly within thedomain of occupational therapy. Asnoted in the Occupational TherapyPractice Framework: Domain andProcess, performance patterns are “patterns of behavior related to dailylife activities that are habitual or rou-tine” (p. 623).12 Some habits are “use-ful,” promoting performance and lifesatisfaction, whereas some are “impov-erished” or “dominating” and interferewith function.12 The Peak Performancecurriculum outlined in this article provides occupational therapists withstrategies that can help their clients discover “useful habits” for breathing,thereby helping them to manage painand anxiety, conserve energy, improvecoordination, and engage more fully inmeaningful occupations and activities. n

References1. Farhi, D. (1996). The breathing book: Good

health and vitality through essential breathwork. New York: Henry Holt.

2. Shannahoff-Khalsa, D. S., Sramek, B. B., Kennel,M. B., & Jamieson, S. W. (2004). Hemodynamicobservation on a yogic breathing techniqueclaimed to help eliminate and prevent heartattacks: A pilot study. Journal of Alternative and Complementary Medicine, 10(5), 757–766.

3. Elliot, W. J., Izzo, J. L. Jr., White, W. B., Rosing, D. R., Snyder, C. S., Alter, A, et al. (2004). Gradedblood pressure reduction in hypertensive outpa-tients associated with use of a device to assistwith slow breathing. Journal of ClinicalHypertension (Greenwich), 6(10), 553–561.

4. Fahrion, S. (1986). Biobehavioral treatment ofessential hypertension: A group outcome study.Biofeedback and Self-Regulation, 11, 257–278.

5. Carlson, C. R., Bertrand, P. M., Ehrlich, A. D.,Maxwell, A. W., & Burton, R. G. (2001). Physicalself regulation training for management of tem-poromandibular disorders. Journal of OrofacialPain, 15(1), 47–55.

6. Luna-Massey, P., & Peper, E. (1986). Clinicalobservation on breath patterns and pain relief inchronic pain patients. Proceedings of theSeventeenth Annual Meeting of the Associationfor Applied Psychophysiology and Biofeedback(pp. 82–84). Wheat Ridge, CO: BSA.

7. Brown, J. M. (1984). Imagery coping strategies inthe treatment of migraine. Pain, 18(2),157–167.

8. Bingol Karakoc, G., Yilmaz, M., Sur, S., UfukAltintas, D., Sarpel, A., & Guneter Kendirli, S.(2000). The effects of daily pulmonary rehabilita-tion program at home on childhood asthma.Allergologia et Immunopathologia, 28(1), 12–14.

9. Panjwani, U., Selvamurthy, W., Singh, S. H.,Gupta, H. L., Thakur, L., & Rai, U. C. (1996).Effect of sahaja yoga practice on seizure control& EEG changes in patients of epilepsy. IndianJournal of Medical Research, 103, 165–172.

10. Freedman, R. R., & Woodward, S. (1992).Behavioral treatment of menopausal hot flushes:Evaluation by ambulatory monitoring. AmericanJournal of Obstetrics and Gynecology, 167(2),257–278.

11. Bonn, J. A., Readhead, C. P., & Timmons, B. H.(1984). Enhanced adaptive behavioral responsein agoraphobic patients pretreated with breath-ing retraining. Lancet, 9, 665–669.

12. American Occupational Therapy Association.(2002). Occupational therapy practice frame-work: Domain and process. American Journalof Occupational Therapy, 56, 609–639.

13. Migliore, A. (2004). Case report: Improving dysp-nea management in three adults with chronicobstructive pulmonary disease. AmericanJournal of Occupational Therapy, 58, 639–646.

14. Porth, C. (1994). Pathophysiology: Concepts ofaltered health states. Philadelphia: Lippincott.

15. Sapolsky, R. M. (2004). Why zebras don’t getulcers: An updated guide to stress, stress-related diseases, and coping (3rd ed.). NewYork: Henry Holt.

16. Kabat-Zinn, J. (1990). Full catastrophe living:Using the wisdom of your body and mind toface stress, pain, and illness. New York: Dell.

17. Benson, H., & Klipper, M. (1975). The relaxationresponse. New York: Harper Torch.

18. Speads, C. (1995). Ways to better breathing(excerpts). In D. H. Johnson (Ed.), Bone, breathand gesture: Practice of embodiment (pp.36–49). Berkley, CA: North Atlantic Books.

19. Middendorf, I. (1990). The perceptible breath: Abreathing science. Paderborn, West Germany:Junfermann-Verlag.

Richard Sabel, OTR, MA, MPH, is the program man-

ager for Inpatient Rehabilitation Therapies at Beth

Israel Medical Center in New York City, where he

has integrated Western therapeutic approaches with

Eastern philosophy and practice. He has worked to

promote occupational performance and wellness of

clients with diverse diagnoses throughout the reha-

bilitation continuum, including community wellness,

acute rehab, and outpatient settings. He teaches

these ideas at several occupational therapy

programs in New York.

Bill Gallagher, MSPT, CMT, CYT, is the director of the

East West Rehabilitation Institute and an advanced

clinician in integrative rehabilitation at Mount Sinai

Medical Center in New York City. He integrates the

rehabilitation techniques of the East (yoga, tai chi

chaun, tuina) with Western therapies. He teaches

these approaches to practicing clinicians as well as

students at several doctoral degree programs.