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HOW BPD CAN INFLUENCE CHRONIC PAIN It is reasonable to ask how severe symptoms, such as persistent pain and fatigue, can be affected by a disturbed breathing pattern. A large part of the answer lies in important biochemical changes that frequently result from BPD, that I will summarize below. However, before outlining these metabolic changes, the effects of biomechanical overuse patterns deserve to be discussed. Any chronic habitual dysfunction, such as an upper- chest breathing pattern, has adaptation consequences that are likely to aggravate existing symptoms. 2 Overuse of accessory and obligatory respiratory muscles The normal diaphragmatic breathing rate varies with age and current metabolic requirements. Under normal circumstances, an adult averages between 12 and 14 cycles of inhalation/exhalation per minute, which is considered normal. Of course, the breathing rate increases in response to physical or emotional demands, but usually returns to normal after the stimulus ceases. However, when an upper-chest breathing pattern is habitual, the rate may rise to more than 30,000 cycles of inhalation/exhalation daily, with a likelihood of overuse and repetitive strain. This is because a range of muscles are activated on inhalation, including the diaphragm, sternocleidomastoid, scalenes, pectoralis major and minor, inferior fi bers of the serratus anterior and latissimus dorsi, serratus posterior superior, iliocostalis cervicis (along with key abdominal muscles), and the intercostals; the quadratus lumborum is activated on exhalation. Leaving aside the painful effects of biomechanical overuse, biochemical changes associated with BPD can profoundly affect health, particularly in relation to pain and fatigue. 3 Respiratory alkalosis and chronic pain and fatigue Breathing more rapidly than normal can, at times, be physiologically appropriate; for example, when someone is exercising aerobically, or if the bloodstream becomes excessively acidic as in liver or kidney disease, or in the advanced stages of pregnancy. In those circumstances, increased carbon dioxide (CO2) elimination helps to reduce the acidity of the blood toward its normal, slightly alkaline state, because CO2 is recruited from carbonic acid in the bloodstream. 4 However, excessive exhalation of CO2, such as that which occurs with rapid, upper-chest breathing, leads to a state of CO2 defi ciency (hypocapnia), excessively reducing acid levels in the bloodstream, and producing what is known as respiratory alkalosis. This occurs when the normal pH of the blood (between 7.35 and 7.45) shifts slightly more into the alkaline range. The immediate effects are dramatic, and may include any or all of the following: • Smooth muscles constrict, causing narrowing of blood vessels and all other "tubes" in the body, including those in the digestive and genitourinary system. • Fatigue increases with this narrowing of vessels. Not only does less blood get to the tissues (alkalosis) due to narrowing of blood vessels, but oxygen is released less effi ciently by hemoglobin (known as the "Bohr effect"), adding to symptoms of fatigue. To explain: oxygen is able to attach to hemoglobin due to the alkaline environment in the lungs, whereas the slightly less alkaline bloodstream promotes release of oxygen when delivery to the tissues is required. However, respiratory alkalosis due to BPD causes the hemoglobin molecule to retain more oxygen than usual with less oxygen reaching the tissues and the brain, resulting in fatigue. To summarize: increased alkalinity encourages reduced blood vessel diameter due to smooth muscle constriction, as well as a reluctance of hemoglobin to release its oxygen. • A relative oxygen defi cit in tissues and the brain leads to symptoms such as fatigue, aching, cramping, and cognitive problems ("brain fog"). 5 • Heightened sympathetic arousal is also caused by rapid breathing, creating symptoms such as tremors, sweating, clammy hands, palpitations, and autonomic instability affecting blood pressure. 6 • The kidneys start to excrete bicarbonate in order to reduce alkalosis and rebalance the pH of the blood, resulting in calcium and magnesium imbalances. 7 • Neurological changes occur as a result, including decreased pain threshold, increased likelihood of cramps/spasms, reduced motor control, and a general increase in fascial, and therefore muscular, tone. • Cardiovascular and gastrointestinal function is affected by the altered behavior of smooth muscles and increased tendency for spasms, with symptoms such as pseudo- angina and irritable bowel becoming more likely. • An increased sense of apprehension, anxiety, and even panic attacks commonly accompany these changes, encouraging even more rapid breathing. 8 64 m a s s a g e & b o d y w o r k j a n u a r y / f e b r u a r y 2 0 1 7