Introduction
Some of the common “symptoms” of Parkinson’s Disease could be reframed as behavioural patterns contributing to overall symptomology, but which can be ameliorated through appropriate retraining to help with progressive symptom reduction. Examples of such retrainable “habits” include issues with posture, mindset and breathing. These patterns tend to impact each other, for example habitual mouth breathing can result in the forward head position common in PD. People with PD will often see in hindsight that, once identified, these problematic habits were apparent years before diagnosis. In this article, we specifically consider how unhealthy, but fixable, breathing patterns could be an exacerbating factor in PD. We will cover how poor breathing interacts with, and may even be causal of, many other symptoms, and explore what we can do to improve our quality of life by taking action to retrain our breath.
In her book, “Music as Medicine: Particularly in Parkinson’s”, Daphne Bryan reviewed the scientific literature of breathing problems in PD:
“One study… found that 35.8% reported shortness of breath on exertion (dyspnea), 17.9% reported a cough and 13% reported phlegm production… a higher proportion of Parkinson’s patients die of pneumonia than in the general population. There is also a chance of increased respiratory infections… “;
“…the most common manifestation of which is soft speech which affects as many as 70% of people with the disease… people with Parkinson’s produce more variable and less efficient movements of the chest wall when preparing to speak, taking in less breath before speaking and continuing to speak when breath reserves were finished… identified inspiratory muscle weakness, even in early-stage patients. Rigidity, a common symptom of Parkinson’s, can affect the muscles of the chest wall and the diaphragm, which will restrict the movement needed to breathe fully… stooped posture, affecting many, can reduce lung volume… the reduction in dopamine of the condition itself may cause shortness of breath or the perception of shortness of breath… the loss of dopaminergic input to the brainstem and carotid bodies can cause altered regulation of the carbon dioxide and oxygen and consequently an altered perception of breathing. “
Also, people with PD tend to breathe fast and shallow, through the mouth not through the nose, and from the chest or the neck not from the diaphragm. Taking myself as an example, at the time of writing this, I breathe unconsciously once every two to three seconds, or 20 to 30 breaths per minute, and the more symptomatic I am, the faster, but the shallower, I breathe. Although the breath is shallow, the rapidity of it means I am moving much more gas in and out of my lungs than normal. I have observed similar patterns of breathing in other people with PD. We will see that the very same features of dysregulated breathing are associated with generalized breathing disorders, outwith PD, and, moreover, that the symptoms associated with these general disorders overlap strongly with those of Parkinson’s Disease. Consequently, breath retraining methods which have been developed to ameliorate these disorders are likely to significantly benefit people with PD.
Recognizing Breathing Disorders
A good introduction to this field is the book “Recognizing and Treating Breathing Disorders: A Multidisciplinary Approach,“ by Leon Chaitow and co-workers, and his blog post “Remembering the Connection: Respiratory Alkalosis and your Patient’s Symptom Catalogue”. These provide very clear explanations of how unhealthy hyperventilation or overbreathing, corresponding to shallow, but fast breathing with many more inhales and exhales per minute than normal for the resting state. can become habitualized, how this is associated with anxiety or chronic stress, and also the list of symptoms these breathing disorders cause.
The major mechanisms at play here are to do with the role of carbon dioxide (CO2) in the blood. CO2 arises as “waste” products from the normal metabolic activity of cells, and is partially expelled out of the body during the exhalation part of breathing. For example, during sustained active exertion, the faster energy conversion in the cells results in increased levels of CO2 being produced, and hence to maintain safe levels, chemical sensors in the body and brain, which constantly assess CO2 levels, tell the body to involuntarily breathe more rapidly in order to expel the excess CO2 from the system, and to restore balance.
However, if one is persistently overbreathing or hyperventilating even when the body is passive or at rest, as in common in people with PD, then the CO2 in the body is constantly being expelled faster than it can it build up, resulting in chronically low levels in the blood. This has huge implications for health, not only because then the blood becomes too alkaline, but also because CO2 levels in the blood have an absolutely vital role in the delivery of oxygen to the tissues of the body and brain.
In the normal course of events, oxygen taken in from the air via the lungs during inhalation is circulated around the body by becoming bound to the haemoglobin of red blood cells. Some of this bound oxygen can dislodge from the blood cells and pass into the tissues to oxygenate the muscles, organs, brain, etc. However, the degree of stickiness of oxygen to haemoglobin, and hence the ease with which it can dislodge and enter the tissues, depends sensitively on the amount of CO2 present in the blood. The less CO2 there is, the more sticky the oxygen and haemoglobin become, and the less easy it is for the oxygen to detach. Thus, far from just being a “waste” product, the CO2 has a crucial role in regulating oxygen delivery.
We now see why chronically low levels of CO2 in the blood caused by overbreathing has enormous implications for health, because when the blood is low on CO2, the oxygen and haemoglobin become tightly bound together: the oxygen becomes very stuck to the red blood cells and does not readily detach in order to diffuse into the tissues. This means that although the blood may be completely saturated with oxygen, the brain and body are in fact getting very little of the oxygen which the tissues need to survive and thrive.
Moreover, when overbreathing becomes habitual, a vicious circle occurs, because the body gets used to the low CO2 levels, and settles into a new equilibrium. Once this occurs, the body becomes intolerant to more CO2, such that any increase sets off alarm bells in the system, causing even more hyperventilation through panic attack like symptoms in order to quickly bring the CO2 levels back down to the habitualized low level. Overcoming low CO2 tolerance, and hence returning CO2 levels to normal is therefore not easy or straightforward and requires a programme of graduated breathing exercises performed daily over the long term in order to gradually reacclimatize the system to tolerate normal levels of CO2.
Chronic overbreathing, and the resulting low levels of blood CO2 and increased alkalinity of the blood, creates a wide variety of symptoms and health issues. Since these arise in part due to a lack of oxygen to the muscles and brain, it is pertinent to compare the symptoms of these types of breathing disorders with those of PD, and indeed to consider if overbreathing is compounding or may even be causing other symptoms of PD. According to the article by Leon Chaitow cited above:
“The ramifications of altered blood pH, towards the alkaline end of the spectrum, may also relate to more general features such as muscle tone, balance and motor control.”
These are the primary features of PD. Furthermore,
“symptoms associated with alkalosis emerge - fatigue, brain fog, increased pain sensitivity, anxiety”
which are also primary symptoms of PD. Leon also lists tremor, one of the most obvious signs of PD, as a possible symptom of overbreathing. The figure below, taken from the article, summarizes the principle symptoms of breathing disorders, and people with PD will recognize many of these.
Medical Recognition of Breathing Disorders
The existence of these breathing disorders have been known about, but largely ignored, in medical circles, for decades. Indeed, L.C. Lum, a cardiologist at Papworth & Addenbrookes Hospitals, Cambridge, UK, wrote an article on this entitled “Hyperventilation: the Tip of the Iceberg” in 1975. Here are some relevant excerpts:
"...this syndrome... shows up in medical clinics under many other guises. This is merely the tip of the iceberg; the body of the iceberg, the ninety nine per cent who do not present [with extreme/obvious hyperventalition], presents a collection of bizarre and often apparently unrelated symptoms, which may affect any part of the body, and any organ or any system. The many organs involved are often reflected in the number of specialists to whom the patient gets referred, and my colleagues have variously dubbed this the ‘multiple doctor’ or the ‘fat folder syndrome’. Indeed the thickness of the case file is often an important diagnostic clue."
"The main symptoms observed by a general physician in a series of 270 cases are below. Symptoms may show up anywhere, in any organ, in any system; for we are dealing with a profound biochemical disturbance, which is as real as hypoglycemia, and more far-reaching in its effects. Such patients are often pursued relentlessly with every investigative device known to modern science, and end up with the label of ‘anxiety state’ and the implication that they are inadequate or in some way inferior. They may be advised: ;’pull yourself together, it's only your nerves"‘or possibly a more sympathetic surgeon may be persuaded to tinker with or remove the complaining organ--an organ, which, I may say, is merely protesting against an unbalanced diet deficient in carbon dioxide, bicarbonate, oxygen, and calcium ions: to name but a few of the well-known biochemical disturbances which accompany acute hypocapnia [lack of CO2]."
Lum lists many symptoms, many of which are also common in PD: palpitations, disturbance of consciousness/vision, shortness of breath. "asthma" chest pain, dysphagia, muscle pains, tremors, tension, anxiety, fatigability, weakness, exhaustion, sleep disturbance nightmare, constipation, diarrhea, twitching eyelids, headache, giddiness, difficulty in breathing, weak limbs, painful limbs, vague pain, weakness, irritability, insomnia.
"Some forty years ago [in the 1930s], Kerr, Dalton and Gliebe wrote ‘patients presenting the well known pattern of symptoms haunt the offices of physicians and specialists in every field of medical practice, they are often shunted from one physician to another, and the sins of commission inflicted upon them fill many black pages in our book of achievement.’ Unfortunately… this to be still true today, despite the many and excellent reviews which have appeared in the intervening years. Among the sins of commission are fruitless operations on the abdomen, the spine, and other organs-- invasive investigations which are not without risk--and, even worse, damaging diagnoses like epilepsy and cardiac infarction".
Origins of Breathing Disorders
The book by Leon Chaitow and co-authors cited above explains how breathing disorders are intrinsically linked to chronic stress and anxiety. The shallow, fast chest breathing through the mouth is a hallmark of the body preparing itself for the exertion of flight or fight due to a stress response. While this adaptive in acute stress situations, when stress is chronic and the body is spending a lot of time in fight or flight, the associated pattern of breathing becomes habitual, and eventually the system gets stuck in the new equilibrium of the CO2 intolerant state. However, the vicious circle work both ways, because overbreathing itself puts the body into a stress response state and feeds anxiety. A very good tutorial about the two way links between anxiety and breathing patterns is given by Robert Litman in the video below.
It is not surprising therefore that people with PD can present with disordered breathing associated with chronic stress and anxiety, since there are very significant overlaps between the other symptoms of chronic stress and those of Parkinson’s Diseases, and ingrained fight or flight behaviours are common to the pre-diagnosis background histories of people with PD. Conversely, it is important to note that techniques which have been developed to treat breathing disorders should also help to decrease the symptoms of PD, including reduction of anxiety and increasing resilience to stress.
Robin Rothenberg, author of “Restoring Prana: A Therapeutic Guide to Pranayama and Healing Through the Breath, for Yoga Therapists, Yoga Teachers and Healthcare Practitioners”, which contains perhaps the most accessible, yet thorough, exposition on the biochemistry and biomechanics of healthy and unhealthy breathing that I’ve read, lists other factors which may contribute to the onset of disordered patterns of breathing:
prolonged low grade stress;
overeating or eating highly acidic/processed foods;
lack of exercise/movement;
overuse of stimulants;
exposure to pollutants;
chronic pain, illness;
grief;
emotional outbursts;
excessive talking (teachers and sales people especially susceptible);
allergies, hay fever;
chronic cough, COPD, asthma.
Self-Assessment of Breathing Disorders
There are a couple of simple methods for self-assessment of breathing patterns, and in particular for giving some rule-of-thumb measures for CO2 intolerances. The first is from the Buteyko breathing method called the “Control Pause” test, as demonstrated in the video below with Patrick McKeown, author of The Oxygen Advantage, who refers to it as the BOLT (Body Oxygen Level Test) score.
To measure the Control Pause: close mouth and breathe normally through the nose for 30 seconds; take a normal breath in and out through nose; at the end of the exhale gently close nose with thumb and forefinger and start stop-watch; as soon as first feeling the need to breathe, release the nose, stop the clock and take a normal breath through the nose.
Remember, it is not how long the breath can be held, but how long it takes before feeling a need to breathe. Thus, the first breath after the test should be normal, not gasping for air. The rule of thumb indicator is that a Control Pause measurement of less than 10 seconds signifies serious breathing disorder problems, less than 25 and breathing needs attention, 30-40 seconds is satisfactory, while 60+ seconds is excellent. At the time of writing this, when I measure my Control Pause, it is consistently under the 10 second mark, and the more symptomatic I am while doing the test, the lower the score. So this indicates that I for one have a marked breathing disorder. I suspect many people with PD will have similar low scores.
Another self-assessment breath test has been developed by SH//FT, a human performance company, which they refer to as the “CO2 Tolerance Test”, claiming this is a good indicator of personal response to stress.
Here are the directions for this test:
“Get a stopwatch, all breaths are through nose only; take 3 normal nasal breaths; take one more full nasal inhale and fill lungs all the way; start to nasal exhale, start timer; exhale through nose as slowly as possibly, for as long as able; don’t hold breath or swallow, when no air left to exhale, stop timer, record time".
Here is their interpretation of the test:
60-80 seconds - advanced, reflects a healthy pulmonary system, good motor control, and relatively low arousal;
40-60 seconds -intermediate, this range generally improves quickly with a focus on CO2 tolerance training;
20-40 seconds - average, moderate to high arousal state, breathing mechanics need improvement.;
<20 seconds - poor, very high arousal and stress sensitivity.
At the time of writing, whenever I do the test, my score is consistently below 7 seconds, and the more symptomatic I am, the lower the score. This test therefore also indicates I have a severe breathing disorder and high stress sensitivity. Again, I believe that many people with PD will have similar outcomes.
Exercises for Restoring Health Breathing
There are various suggested types of exercise which can help gradually shift the equilibrium point of CO2 intolerance back to healthy states. However, all of these emphasize nose breathing over mouth breathing (at least for the inhale), and diaphragmatic breathing over chest breathing. This represents an immediate roadblock for people with PD, for whom mouth breathing is likely to have become so ingrained that it feels like the nose is permanently stuffed up, and who have diaphragms which are so frozen that it cannot voluntarily be flexed. However, it is possible to open the nose in the majority cases through some simple exercises. Robert Litman in the above video demonstrates this, and below is another video of Patrick McKeown on the topic. See also my article on how I restored nose breathing with the help of a red light anti-allergy device. It is also possible to restore access to diaphragmatic breathing, as I covered in another article, which explains how I used Block Therapy to achieve this.
Once nasal and diaphragmatic breathing is made possible there are a few different types of breathing exercises one try for restoring CO2 tolerance to more normal levels. It is important to note that these exercises are not necessarily targeted at immediate regulation of the Nervous System, unlike breathing methods designed for in-the-moment relaxation or mobilization, but are aimed at long term retraining of breathing patterns in order to restore healthy oxygenation levels to the brain and muscles.
An example of such exercises, that I found particularly easy to access, was developed by Leon Chiatow specifically for treatment of hyperventilation/overbreathing disorders, which he terms “Anti-arousal Breathing Exercise”:
"…in a comfortable (ideally seated/reclining) position, exhale fully through partially open mouth, lips just barely separated. This outbreath should be performed slowly. Imagine a candle flame is about 6 inches from your mouth and exhale (blowing a thin stream of air) in such a way as to not blow the candle out… exhale, count silently to establish the length of the outbreath [or use a stopwatch app on phone]. After exhaling fully, without any sense of strain, allow the next inhalation to be full, free and uncontrolled [through nose]. Count to establish how long inhalation lasts. Without pausing to hold the breath, exhale fully, through the mouth, blowing the air in a thin stream (again, count at the same speed). Many people find a brief (one second) pause at the end of the exhalation helps to establish an unhurried rhythm."
"Continue to repeat the inhalation [through nose] and the exhalation for not less than 30 cycles of in and out (with a one second pause after breathing out). The objective is that in time – after some weeks of practising this daily – this should, without strain, achieve an inhalation phase which lasts for 2–3 seconds while the exhalation phase lasts from 6–7 seconds. Most importantly, the exhalation should be slow and continuous. It is no use breathing the air out in 2 seconds and then simply waiting until the count reaches 6, 7 or 8 before inhaling again. By the time you have completed 15 or so cycles, a sense of calm is frequently apparent. Apart from practising this once or twice daily, it may be useful to repeat the exercise for a few minutes (about five cycles of inhalation/exhalation takes a minute) if feeling anxious or ‘stressed’".
I've personally found this useful to get started with, because I can extend the mouth exhale through pursed lips much longer than I can out through the nose, hence it allows me to more easily reduce the amount of gas moved in and out per minute, and hence give time to build up CO2 levels.
Buteyko type methods are another example of this type of exercise, and focus on breathing as lightly and as little as possible, all via the nose. In his video above, Robert Litman provides some instructions on how to do Buteyko stylre breathing.
SH//FT also provide a series of cadence breathing exercises (timing of inhales and exhales and breath holds in between) for increasing CO2 tolerance. The exercises are bespoke depending on the score on their CO2 tolerance test. They have also developed an app to assist with0 these exercises.
In her book on Music as Medicine cited above, Daphne Bryan suggests a couple of prolonged (slow) diaphragmatic breath exercises for people with PD. She also surveys the research on the benefits of singing and humming exercises for PD. Both may help because they not only help teach better breath control and awareness, but also can significantly slow down the number of breaths taken per minute, which allows time for CO2 levels to build up, and hence allow proper oxygenation of the body and brain. Indeed, according to Daphne, humming practices can reduce breathing rates to 4–6 breaths per minute.
As a person with PD herself, Daphne practices what she preaches, with a daily programme consisting of ten minutes slow diaphragmatic breathing, five minutes humming and five to ten minutes singing each day. Daphne has relatively mild symptoms and slow disease progression. Perhaps unusually for someone with PD, she scores in the higher end of normal on the CO2 tolerance tests mentioned above. It would seem that these breathing exercises, along with other music based therapies, has afforded Daphne much protection from the ravages of the disease.
In her book “Restoring Prana” cited above, Robin Rothenberg provides a complete programme of breath retraining for increasing CO2 tolerance, including a Buteyko style exercise she terms “Subtle Breathing” . Robin has incorporated this breath work into her yoga teaching. Furthermore, Robin has developed yoga based programmes specifically for people with MS, Parkinson’s Disease and other types of dystonia, combining the breath work, and elements from somatics and Feldenkrais. Her students enthusiastically express how yoga and the breath retraining has provided a crucial tool in their treatment protocol.
I would like to give special thanks to Stephen Donald, Tore Kersten and Nicky McLeod for many valuable and educational discussions and pointing me to various resources.