Dysfunctional Breathing Patterns Have Been Associated With Several Musculoskeletal Conditions

Have you ever thought twice about the way you breath?

Properly diaphragmatic breathing results from using our primary respiratory muscles (the diaphragm and external intercostals), causing expansion of the abdomen. However, many rely on accessory respiratory muscles in the upper chest and shoulders rather than the diaphragm – which result in dysfunctional breathing patterns. Dysfunctional breathing patterns have been associated with musculoskeletal conditions such as low back pain, chronic neck pain, and chronic ankle instability. And on the contrary, diaphragmatic breathing patterns correlate with improved postural and core stability, reduction musculoskeletal injuries and in physiological stress.

The prevalence of dysfunctional breathing has been reported as between 29 and 74% in asthmatics, and 62-73% in physically active, healthy adults. In athletes, the prevalence of dysfunctional breathing patterns is not known, nor is it known whether dysfunctional breathing in athletes confers a greater injury risk.

A study was performed in a Japanese population on a wide variety of athletes in competitive sports ranging from elementary school athletes to professional athletes (maximum age 25). It demonstrates that the prevalence of dysfunctional breathing was extremely high (90.6%) in athletes.  The authors hypothesized that the higher proportion of dysfunctional breathing in athletes may be due to greater physiological and psychological stress due to the demands of competitive sport, but this remains to be further studied. There are a few drawbacks of this study. Of note, these athletes were only assessed in the standing position, which may increase the proportion of dysfunctional breathers due to the increased respiratory demand (as compared to supine and sitting). Prior studies have suggested assessing breathing in multiple positions. Also of note, this study does NOT determine the clinical significance of dysfunctional breathing patterns – i.e. we do not know if these breathing patterns actually confer a greater risk of injury.

However, this is an interesting study that draws attention to an area where further research is needed – and is one which reminds us to think again about the way we breath:

  1. Place one hand on your chest and one on your abdomen
  2. Inhale slowly through your nose and focus on expanding your abdomen rather than your chest
  3. Exhale slowly

By: Sarah DeParis, MD and Helena Zhang, BS


Journal Reference:

  1. Shimozawa, Yuka1; Kurihara, Toshiyuki2; Kusagawa, Yuki3; Hori, Miyuki3; Numasawa, Shun4; Sugiyama, Takashi1; Tanaka, Takahiro3; Suga, Tadashi2; Terada, Ryoko S.5; Isaka, Tadao1; Terada, Masafumi1. Point Prevalence of the Biomechanical Dimension of Dysfunctional Breathing Patterns Among Competitive Athletes. Journal of Strength and Conditioning Research: May 24, 2022 10.1519/JSC.0000000000004253 doi: 10.1519/JSC.0000000000004253


Any Amount of Physical Activity Yields Health Benefits and Is Better Than None

 Most of us spend a large portion of our day sitting in office or at home. There is a price we have to pay for prolonged sitting – a detrimental cardio-metabolic health. This includes increasing risk for a group of preventable chronic conditions such as cardiovascular diseases, type 2 diabetes and obesity.  

 A large cohort study of Australian adults aged 45 years and older published by Van der Ploeg et al in 2014 showed a dose-response association between standing time and all-cause mortality. Increasing standing time from 2 to 5 and to more than 8 hours a day decreased all-cause mortality by 10% to 15% and to 24%.  Buffey et all in his meta-analysis and systematic review published recently in 2022 have shown that frequent short interruptions of standing (2 to 20 minutes of standing after every 20 to 60 minutes of sitting) and light-intensity walking (1.5– 4.4 km/hour or a comfortable pace down hallways) can significantly improve postprandial glucose metabolism (improve postprandial insulin, reduce post prandial glucose levels) when compared to sedentary time of prolonged sitting of 5 hours or more. Light-intensity walking was superior when compared to standing. So no matter how slow you go, you’re still lapping everyone on the couch. Any amount of physical activity yields health benefits and is better than none. 

By: Rusly Harsono, MD & Helena Zhang, BS

Journal Reference:

  1. van der Ploeg HP, Chey T, Ding D, Chau JY, Stamatakis E, Bauman AE. Standing time and all-cause mortality in a large cohort of Australian adults. Prev Med. 2014 Dec;69:187-91. doi: 10.1016/j.ypmed.2014.10.004. Epub 2014 Oct 16. PMID: 25456805.
  2. Buffey AJ, Herring MP, Langley CK, Donnelly AE, Carson BP. The Acute Effects of Interrupting Prolonged Sitting Time in Adults with Standing and Light-Intensity Walking on Biomarkers of Cardiometabolic Health in Adults: A Systematic Review and Meta-analysis. Sports Med. 2022 Aug;52(8):1765-1787. doi: 10.1007/s40279-022-01649-4. Epub 2022 Feb 11. PMID: 35147898; PMCID: PMC9325803.

Increasing Weight or Increasing Reps: Can Both Make You Stronger?

This study examined whether progressive overload via increasing weight or increasing repetitions elicited similar muscular adaptations. Progressive overload is the continual increase of workload over time throughout a training regimen, which is necessary to stimulate ongoing muscular adaptation and is traditionally accomplished through increases in load (weight). This study investigated using continual increases in repetitions as compared to weight to progressively increase workload and the resulting outcomes for muscular strength, hypertrophy, and endurance.

Overall, there were improvements in all three variables in both groups that were similar between the groups. Strength (measured by 1RM back squat) increased in both groups and slightly favored the load group with an effect size of 2kg but a wide confidence interval. Muscle endurance increased in both groups and slightly favored the reps group by 2%. Hypertrophy improved similarly in both groups with the exception of one muscle (of 4 tested), the rectus femoris, which slightly favored the reps group.

 A few caveats to note: this study started with quite a high rep range for both groups (8-12 reps as a starting point), and the reps group increased from there. This is quite a high rep range even at the starting point, and the practicality of implementing an increasing rep scheme from that baseline and maintaining good adherence to training might be difficult. Along these lines, the authors noted that the reps group seemed to have a harder time training to actual failure likely due to “greater metabolic acidosis and discomfort” (translation: it was difficult and painful). In addition, this study population was young people with prior weight training experience, and the results may not be generalizable to other groups. The authors attempted to control for dietary factors with self-reported food diaries, but the accuracy of this is questionable and there could be dietary related differences between the groups. Finally, this protocol included training to failure, which when implemented in the real world may increase risks (greater fatigue, injury) and may not be necessary to achieve substantial improvements in the desired outcomes.

Overall, this study suggests that progressive overload in strength training can likely be achieved with either increases in load or reps assuming sufficient training stimulus (effort). Further research is needed to determine if there are benefits for one protocol or the other for relative improvements in strength, hypertrophy, or endurance. Future study should also evaluate practicality/adherence and generalizability to other groups.

By: Sarah DeParis, MD

Journal Reference:

  1. Plotkin D, Coleman M, Van Every D, Maldonado J, Oberlin D, Israetel M, Feather J, Alto A, Vigotsky AD, Schoenfeld BJ. Progressive overload without progressing load? The effects of load or repetition progression on muscular adaptations. PeerJ. 2022 Sep 30;10:e14142. doi: 10.7717/peerj.14142. PMID: 36199287; PMCID: PMC9528903.

Exercise During Difficult Times May Have Prolonged Positive Effects on Mood and Stress

During periods of stress, many of us forgo exercising and indulge in unhealthy eating. This study provides insight into how physical acitivty can lead to stress reduction and enhance positive feelings if we are able to include exercise into our daily schedule during difficult times. The effect of physical activity lasts for hours after the session and has prolonged positive effect.

By: Sarita Khemani, MD, Head, Lifestyle Medicine Stress Pillar

Journal Reference:

  1. Schultchen D, Reichenberger J, Mittl T, Weh TRM, Smyth JM, Blechert J, Pollatos O. Bidirectional relationship of stress and affect with physical activity and healthy eating. Br J Health Psychol. 2019 May;24(2):315-333. doi: 10.1111/bjhp.12355. Epub 2019 Jan 22. PMID: 30672069; PMCID: PMC6767465.

Healthy Lifestyle Habits Have Positive Effects on Mental Health

This review article clearly highlights the importance of healthy lifestyle choices on mental health. Whole plant based diet and daily exercise have remarkable effects on our mood. In many studies, the effect has been described as equivalent to taking antidepressant medications. In addition, good sleep, daily gratitude, positive thoughts about the future, and being of service to others has also been shown to have lasting positive effects on our mental health.

By: Sarita Khemani, MD, Head, Lifestyle Medicine Stress Pillar

Journal Reference:

  1. Morton DP. Combining Lifestyle Medicine and Positive Psychology to Improve Mental Health and Emotional Well-being. Am J Lifestyle Med. 2018 Apr 18;12(5):370-374. doi: 10.1177/1559827618766482. PMID: 30283261; PMCID: PMC6146362.

A One-Hour Walk in Nature Decreases Activity in the Stress-Related Regions of the Brain

A recently published study compared the effects walking in different environments has on the brain. Study participants were randomly assigned to go on a 60-minute walk in a natural or urban environment, and questionnaires and fMRI scans were administered before and after the walk. fMRI scans were used to measure the activation of different brain regions, while questionnaires were used to gauge participant’s perceived mood and stress levels. The study found that a one-hour walk in nature decreased activity in the amygdala, while no change was seen after a one-hour walk in an urban-environment. The amygdala is the part of our brain primarily associated with regulating emotions and processing stressful events. An overactive amygdala is associated with anxiety, while, decreased activity has an anxiolytic effect. Therefore, the findings of thisstudy suggest a walk in nature may be more beneficial for managing stress than a walk in the city. Additionally, our environment plays an important role in the cognitive benefits of walking. This study is a great example of how multiple components of lifestyle medicine can come together. Exercise and being in nature are both powerful tools for managing stress and improving mental health; however, their effect is even more potent when combined.

By: Maya Shetty, BS, Lifestyle Medicine Fellow


Journal Reference:

  1. Sudimac S, Sale V, Kühn S. How nature nurtures: Amygdala activity decreases as the result of a one-hour walk in nature. Mol Psychiatry. 2022 Sep 5. doi: 10.1038/s41380-022-01720-6. Epub ahead of print. PMID: 36059042.

Resistance Training Is an Effective Method for Improving Muscle Mass and Function in Patient’s With Rheumatoid Arthritis

This study found that high-intensity progressive resistance training improves lean mass and function in rheumatoid arthritis patients.

By: Sarah DeParis, MD


Journal Reference:

  1. Lemmey AB, Marcora SM, Chester K, Wilson S, Casanova F, Maddison PJ. Effects of high-intensity resistance training in patients with rheumatoid arthritis: a randomized controlled trial. Arthritis Rheum. 2009 Dec 15;61(12):1726-34. doi: 10.1002/art.24891. PMID: 19950325.

High Intensity and Low Intensity Strength Training are Good for Knee Osteoarthritis

A systematic review found that high intensity strength training is not better than low intensity strength training for pain and physical disfunction caused by knee osteoarthritis (KOA). Overall, strength training has been shown to improve pain and quality of life in patients with KOA.

By: Maya Shetty, BS, Lifestyle Medicine Fellow


Journal Reference:

  1. Turner MN, Hernandez DO, Cade W, Emerson CP, Reynolds JM, Best TM. The Role of Resistance Training Dosing on Pain and Physical Function in Individuals With Knee Osteoarthritis: A Systematic Review. Sports Health. 2020 Mar/Apr;12(2):200-206. doi: 10.1177/1941738119887183. Epub 2019 Dec 18. PMID: 31850826; PMCID: PMC7040944.



High Levels of Physical Activity Do Not Counteract the Detrimental Effects of a Poor Diet on Mortality

A large-scale prospective study found  that high levels of physical activity do not counteract the detrimental effects of a poor diet on mortality risk. You need both pillars for optimal health.

By: Michael Fredericson, MD,  Lifestyle Medicine Program Director


Journal Reference:

  1. Ding D, Van Buskirk J, Nguyen B, Stamatakis E, Elbarbary M, Veronese N, Clare PJ, Lee IM, Ekelund U, Fontana L. Physical activity, diet quality and all-cause cardiovascular disease and cancer mortality: a prospective study of 346 627 UK Biobank participants. Br J Sports Med. 2022 Jul 10:bjsports-2021-105195. doi: 10.1136/bjsports-2021-105195. PMID: 35811091.

Regular Participation in Resistance Training May Prevent Several Musculoskeletal Disorders Later in Life

A review article found that resistance training may have several mechanisms in prophylaxis of joint problems through improved bone mineral density, preserved bone mass, and prevention of knee osteoarthritis.

By: Sarah DeParis, MD


Journal Reference:

  1. Ciolac EG, Rodrigues-da-Silva JM. Resistance Training as a Tool for Preventing and Treating Musculoskeletal Disorders. Sports Med. 2016 Sep;46(9):1239-48. doi: 10.1007/s40279-016-0507-z. PMID: 26914266.