Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses three breathwork strategies: box breathing, physiological sighs, and 4-7-8 breathing and their implications to PT practice.

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

ZAC MORGANThanks for watching! Good morning, PT on ICE Daily Show. I'm Dr. Zac Morgan, Lead Faculty here with Cervical and Lumbar Spine Management, bringing you this morning our top three strategies for breathwork. So breathwork is one of those things that clinically I've used a lot more the last couple of years than I did the first few years of my career. And part of that is, or a lot of that is, I think my ability to describe it to people. But another big part of it is personal experience with breath work. So I think early on I had a healthy amount of skepticism myself about things like doing nothing or sitting around focusing on nothing but your breath. And it wasn't something that I practiced regularly. So it was something that was harder for me to implement clinically when I would, when I would suggest it to clients. didn't have good uptake rates. They often did not do the breath work or did not do mindfulness meditation. And there often were just barriers in the way. And really personally for me, this journey started a little bit around a year ago, a little bit over a year ago. My dad had open heart surgery and it just was a stressful time of life, a lot of busy things going on. And then on top of that, a big surgery like that with a family member, And I remember during that time having some realizations about stress internally that clinically have helped me a ton. I mean, for instance, my shoulders, I grew up as a swimmer, so my shoulders have always been fairly mobile. And that was never really an issue for me. But I can't tell you how many clients stand in my office and kind of complain about in the front side of their shoulders and it was something I always had a hard time relating to when I would hear people describe it and I always thought of it as muscle tightness and a lot of just issues surrounding the shoulder and then during that week that my dad was in the hospital the same thing happened to me. So like I said I've always had plenty of mobility and then all of a sudden that just went away. I had that same exact feeling of tightness there in the front side of my shoulder. It's very familiar from a lot of subjective exams And that's where I started implementing some breath work. And starting to implement that breath work, I noticed an immediate impact on my shoulder mobility, which was not what I was expecting. I was expecting to just be able to sleep better or unwind a little bit better. But from a musculoskeletal perspective, my shoulder range of motion improved, shoulders felt better. I was able to kind of return to all the activities that I was looking to return to. So it really made me buy in, which has helped me a lot clinically from a being able to leverage that personal experience with the client in front of me. So I would encourage you to start using this some, but within using Breathwork, I think some really actionable strategies surrounding it are what make for more success. So rather than just saying, hey, try some breath work with your clients, which is probably maybe a little simplified version of what I was doing prior to starting it myself. Now what I do is I give it more like a prescription. So rather than just encouraging trying some breath work, I give a very specific prescription of different types of breathwork for people, all to stimulate parasympathetic outflow. So let's go through the top three that I've had success with. And again, I feel like the more prescriptive you are with these things, the more your client will believe that it's important to you as a provider. And then also something about receiving a prescription makes people a little more compliant. So there's three big ones that I want to talk about this morning. The first one's box breathing. The second one's physiological sigh. And then the last one is 4-7-8 breathing. I do feel like I get the best uptake with box breathing, so let's start there. And let's just describe what box breathing is and how to prescribe this with clients. I've had a lot more success by having them on the front end, prior to starting the box breathing, testing their CO2 discard time. So the reason this kind of came into my purview was the Huberman article that came out a couple years ago. I'll put that link in the comments of this video. But essentially they just kind of described how they use some of these protocols with the clients in that study. They were looking at breathwork, mindfulness meditation, and kind of seeing what helped. And it turned out all of it helped. But they gave a little protocol to determine someone's CO2 discard time. And essentially what you do is have the person seated comfortably. They take four normal breaths, breathing in and out of their nose. And then they take a very large breath in their nose. then they exhale as slowly as possible. That exhale can come from nose or mouth or both. The point though is to exhale as slowly as possible. Now you as the therapist are going to time your client doing that prolonged exhale. And if their time lands between zero and 20 seconds, their box breathing time, so how long they breathe, hold, breathe, hold. So inhale, hold, exhale, hold. The time that they do that protocol, if it's 0 to 20 seconds, their prolonged exhale is going to be 3 to 4 seconds. If they can do a prolonged exhale between 25 and 45 seconds, I'm going to have them do their box breathing with 5 to 6 seconds of each chunk of the box. And then lastly, if they're able to do a really long exhale beyond 50 seconds, then I would have them do their box breathing with 8 to 10 seconds. So that specificity of having them test prior to doing the box breathing protocol, for whatever reason, has really increased the compliance rate for a lot of my clients. I think knowing that it's designed for you versus just, hey, here's some breath work, just for whatever reason, builds some compliance. So definitely box breathing is the one that I get the most success with. Again, to quickly describe box breathing, you're going to inhale for a period of time, hold for a period of time, exhale for a period of time, hold for a period of time. That period of time is determined by that CO2 discard test. Secondly is physiological sigh. So probably a little bit of an easier setup here because you don't need to test anything. But the point of a physiological sigh is going to be two inhales through the nose and then a really prolonged exhale that kind of sounds like a sigh, kind of a sigh. type sigh, that can come through the mouth. But those two prolonged inhales, they're going to come through the nose. And the first one is going to be about 80% of your lungs capacity, and then the second one is going to be the top 20%. So you take a really big inhale through the nose, kind of cap things off with a second inhale through the nose, and then as long of an exhale as you can do, making that kind of sigh sound as you do so. So it kind of looks like this. The longer you can make that exhale, the better. So that's physiological sigh. So there's just another option outside of box breathing. And then the last one is 4-7-8. So for 4-7-8, you're going to breathe in for four seconds through the nose. Hold for seven seconds and then exhale however you want to for eight seconds. So that prolonged exhale in both the physiological sigh and in 4-7-8 breathing seems to really stimulate parasympathetic outflow. So with all three of these strategies, the person has to be really compliant to see success. And honestly, it's a more the merrier type of situation. Now, obviously, if you were only sitting around doing breathwork all day, that would be an issue. But for most people, they're not going to do that. So what I usually try to start with is a minimum of once a day. So the person needs to set a three to five minute timer and just perform whatever breathwork strategy we just dictated with that person. and perform it for three to five minutes. Now, I would really prefer that person to do this three to five times a day, especially if they kind of run higher stress, if they're a little higher anxiety, if their blood pressure is up. If they're basically anyone that we interact with in the clinic, most of those people would benefit from doing this a little bit more frequently throughout their day. And so I kind of describe it to them as an acute way of dropping your blood pressure, an acute way of dropping your stress. And if you can kind of titrate that throughout your day, you'll be able to stay a little bit more regulated. And so within that, I would really suggest spending a little bit of time mapping that person's day out with them, like helping them strategize. Here's where this could work, like perhaps before the baby wakes up, but perhaps before the kids wake up, perhaps at lunch, just finding a quick spot that they could do the quick three to five minutes of breathing. The beautiful thing is we're really only asking for five to 15 minutes of this person's day. which is a really small ask, but they won't be successful without your help figuring out where to put that in their day. So I think that's the biggest tip is really regardless of which of these strategies you choose, I think they all work well. Make sure you help that client figure out where they're going to put it throughout their day. and how to fit this into their habits. Once they start doing it, usually compliance is pretty decent because they feel so much better. So it's really just breaking down that first wall of compliance and I think being specific with your prescription and then helping them fit it into their day are the main ways that I've had success with that. So I think this is a really important thing that should be in a lot of our plan of cares, because you think about when people are so stressed, whether that's because they're in pain or just the other demands of being a human on planet Earth, most of our clientele tends to run a little bit higher stress. And so due to that, it's really nice to help them find that release valve in ways other than exercise or sleep. not that I don't want them focusing on that as well. Just another kind of focal strategy for managing these things. Again, personal experience and being prescriptive has been really helpful for me with. So just some actionable things to try in the clinic. So my big suggestion is breach this subject with people. Be willing to talk about it. Be willing to practice some of these yourself so that that way you have some personal experience with them and then help them fit it in their day. If you do those things If you're able to do those things, you'll have a lot more success getting compliance with breathwork with your clientele. SUMMARY That's all I've got for you all this morning, so just some really quick actionable strategies. Try some of these today in the clinic, whether that's on yourself or with a client. If you have anybody that seems really wound up, I would really encourage trying these things. If you're looking for some upcoming courses, I want to kind of just point you in the direction of the next few cervical and lumbar that we have coming up with ice. So if you're looking for cervical, August 24th and 25th will be over in Bend, Oregon, so on the west coast. If you're looking more in the middle of the country, September 7th and 8th, we've got Midwest City, Oklahoma, and then more on the east side of the U.S., October 5th and 6th in Candler, North Carolina, so right outside of Asheville. If you're looking for lumbar this weekend, we'll be right outside of Pittsburgh in Aspen Wall, Pennsylvania. August 10th and 11th, Longmont, Colorado. So right outside of Denver. And then August 17th and 18th, Grass Valley, California. So beautiful northern California there, not too far from Sacramento. So if you're looking for any courses, we'll be kind of all over the place these next few weeks. That's all I have for you all this morning, team. I'll drop that article that I mentioned in the comments of this video and let me know if you have any successes or issues with breathwork as you're implementing this this week. Thanks, team. That's all I got for you. Have a good rest of your Tuesday.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.