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Peak Performance: An Integrative Breath Therapy Program


Peak Performance

The average healthy person breathes over 20,000 times per day. Most people take their breath for granted and give little thought to the mechanisms involved unless respiration is severely impaired. Yet, many breathe inefficiently, especially those experiencing pain and disability. This article will describe a breathing program titled “Peak Performance” and the strategies used to help clients identify their current “habit” of breathing and experience other possibilities to better support their occupations and lifestyle.

Breathing is a dynamic process that changes according to the needs of the activity. There is no single right way to breathe. Our breathing adjusts to support the diverse challenges of our life – pushing a vacuum requires a different kind of breathing than wiping a counter top, as donning socks and shoes does from talking with a friend. Inefficient, obligatory breathing patterns limit the ability of our body to make these adjustments.

Inefficient breathing can be driven by a variety of factors. How we posture ourselves at work, past injuries, mental stress, emotional responses to life events, disease and culture all have an impact on our “habit” of breath. These patterns are unconscious and even though our current way feels familiar and “right”, it may not necessarily be the most efficient way to breathe at any particular moment. Just as we address postural habits in our work with clients to improve their day-to-day function, it is vital that we address their habit of breath or they will continue to use these inefficient, breathing patterns while engaged in functional activities..

As our breath becomes more adaptive, we tend to feel calmer and expend less effort. This is due to physiological changes in the body. Almost immediately, the balance of oxygen and carbon dioxide levels in the blood is modified, promoting healthier cellular metabolism and neurological changes. Other studies indicate that breath work can be used effectively to address coronary heart disease , hypertension , chronic pain , , migraine headaches , asthma , epilepsy , menopausal hot flashes and panic attacks .

Common Inefficient Breathing Patterns

On any given day in the clinic it’s not uncommon to see a variety of breath holding patterns that impede functional progress.

Most common is chest breathing, where the abdomen is inappropriately contracted, constricting the movement of breath to the upper chest. With this breathing pattern the shoulders rise and fall as the secondary muscles of inspiration (scalenes, sternocleidomastoid, trapezius and pectoralis minor) work to make up for the relatively immobile diaphragm. When these secondary muscles work full time, the person will eventually experience chronic tension and discomfort in the neck, upper shoulders and back. This pattern can also impede the healthy functioning of the digestive organs and elicit a chronic state of hyperarousal experienced as anxiety which stimulates the sympathetic nervous system.

In Paradoxical or Reverse breathing the diaphragm lifts up during inhalation and drops down during exhalation. This pattern is the reverse of normal “textbook” breathing and when obligatory, is very inefficient. Like chest breathers, reverse breathers eventually experience neck, shoulder and upper back tension, digestive problems, anxiety and “often encounter great difficulty learning movement, feeling clumsy and uncoordinated because their most basic pattern of movement (breathing) is completely upside down” (Farhi, 1996, p.76).

Hyperventilation is characterized by quick rapid breathing and often goes undetected unless it is in its extreme, acute form. The causes can be organic (i.e., to compensate for kidney dysfunction), physiologic (i.e., when running a race), emotional (i.e., fear or anger) or habitual. When habitual, people breathe quickly regardless of the activity. This over-breathing causes a reduction of the carbon dioxide levels in the blood (respiratory alkalosis).This metabolic shift from acid to alkaline alters a panoply of cellular chemical reactions. Hyperventilation can manifest in a myriad of symptoms such as headache, dyspnea, numbness, light-headedness, chest pain, palpitations, fatigue, rapid pulse, visual disturbances, stomach pain, muscle pain, cramps, anxiety, insomnia, impairment of concentration and memory. ,

Peak Performance

The Peak Performance curriculum outlined in this article is designed to facilitate the rehabilitation of people recovering from diverse diagnosis such as neurological, orthopedic, cardiopulmonary, chronic pain and injury. The format was intended to be experiential and explorative, rather than prescriptive and includes seven lessons. Each session starts with an explanation of pertinent anatomy and a logical, psychophysiology-based, rationale for the lesson. This didactic portion prepares the group for the experiential component. The lessons can be taught as part of an individual treatment session or in a group format and arranged in any sequence, as each lesson stands by itself.

Helping participants develop an awareness of their current habit for breathing lays the foundation for change. In each session, participants are encouraged to notice how they breathe during various activities. To facilitate this awareness, a handout is given that asks “how do you breathe when you are dressing…showering…walking…cooking… cleaning…eating… exercising…talking…watching television.” This internal focus is encouraged throughout the program so participants will begin integrating what they’ve learned within the context of day-to-day activities.

The goals of the program are to maximize engagement in occupation by:

  • 1) improving the efficiency of respiration to
  • a. conserve energy and therefore be able to more fully engage in meaningful activities
  • b. improve coordination and ease of movement
  • 2) decrease anxiety for
  • a. pain management
  • b. facilitate motor learning and learning of new information

Peak Performance Lessons

A complete account of three lessons will be presented with a brief overview of the remaining sessions.

(1) Why Zebra’s Don’t Get Ulcers

In this lesson, participants learn a breath and word focused meditation as a means to improve the quality of their breath. This strategy helps quiet the mind, decreases habitual muscle tension and stress, thereby promoting the patient’s ability to attend to critical features of the environment, learn new information (i.e., cues to facilitate motor learning, hip precautions), and provides a non-pharmaceutical intervention to manage pain.


The discussion begins with the question “why don’t Zebras get ulcers and what does this have to do with breathing?” After a wide variety of answers, the following scenario is presented. Zebras grazing in the field are in a relaxed state. When the Lion appears there is shift physiologically, from the rest and digest mode to the flight or flight mechanism of the autonomic nervous system, enabling the Zebras to go quickly from a blissful state to running at full speed. If the Zebras outrun the Lion and survive, they go back to grazing peacefully and the rest and digest mechanism is re-engaged. For many people, the ability to disengage the fight or flight mechanism is not so easy.

The discussion focuses on how excessive mental tension can perpetuate breathing pattern disorders, pain and the stress response, just as inefficient respiration can cause an increased stress response, pain and mental tension. In this way, breath is the bridge between the mind and the body. Breath awareness can help anchor the mind into the present moment and have a global positive impact on health. Most of our mental stress (which in turn amplifies muscle tension, pain and illness) stems from our dissatisfaction with some aspect of the past (if only I had not had this stroke!) and from worrying about the future (I know I’ll never get back to where I was…). Breath and word focused meditations are an effective means to break that cycle by quieting the mind and bringing us into the present. The ability to temporarily “turn off” the mental chatter is not only important to health but, as noted above, can foster our ability to learn new information and be more present in our communication with other people.


The breath focused meditation is explored first. Participants are asked to sit upright and, if possible, slightly forward with their back away from the chair. If someone is unable to assume or maintain this posture, they can rest against the chair. The group/individual is directed to focus on their breath by sensing and feeling the movement of the air as it goes in and out, and to keep their focus on this movement. Participants are then told “when the mind wanders (not if but when), gently bring the focus back to the breath and we will continue to breathe in this way for 4 minutes.” A short discussion follows where participants describe their experience and what if any changes they feel. Most often people report feeling relaxed, having a clearer focus and less physical discomfort.

The word focused meditation is explored next. This alternative is offered as some people find it easier to stay focused on a word, rather than their breath - instead of keeping one’s awareness on the breath, the focus shifts to saying the word “one” internally with every exhalation

(2) Respiratory Sinus Arrhythmia

Respiratory Sinus Arrhythmia refers to the physiological changes in blood pressure and heart rate that occur throughout the respiratory cycle - when we inhale our blood pressure and heart rate increase and when we exhale they decrease. Respiration occurs automatically, but it can also be controlled. In this lesson participants learn they can modify their respiratory rate to better support activity demands and provides strategies for extending the exhalation.


The session begins with participants counting the number of times they exhale in a minute. These numbers are compared to average respiratory rates for women (13-14) and men (12-13). Many participants report respiratory rates above 20 which leads to a discussion regarding the potential consequences of rapid breathing, as noted in the Common Holding Patterns section, and the health benefits of improved respiratory control (i.e., lowered blood pressure and heart rate, more efficient breathing and improved adaptive potential).


An effective strategy for regulating breathing is to synchronize a gentle, easy movement with the breath. Participants start by resting their hands on their thighs. On the inhalation, they are instructed to slowly begin opening and horizontally abducting their arms, letting the chest open, spine extend and head roll upward. The movements should be made within an easy comfortable range. On the exhale, the movement is reversed with the arms moving back toward the thigh, the chest closing as the spine and head gently round down. The breath and arm movements should be continuous and participants should breathe at their “normal” rate. Once the arm movements comfortably match their current respiratory rate, the next step is to match the breath to a slower movement and finally to a faster movement. If a participant has physical limitations any number of variations can be offered. For example, matching the breath to the opening and closing of a hand or a gentle rocking of the head up and down can be effective alternatives.

After experiencing the ability to control their respiratory rate, the next phase of the lesson is extending the exhalation. Two methods are practiced. First exhaling through a straw and then through pursed lips. After practicing each method, participants count the number of times they exhale, using either approach, for one minute. The results are usually dramatic with most people falling within or close to “normal” respiratory rates and reporting they feel more relaxed and present.

(3) The Pelvic Clock

The pelvis is anchored by the spine and femurs. When we breathe, there is a kinetic chain of movement that occurs throughout the body. This movement is often restricted by chronic tensions held in any number of muscles. This lesson will focus on initiating movement from the pelvis as a means to help participants identify and release habitual holding patterns and promote more efficient breathing and functional movement.


The discussion begins with participants observing a life sized skeleton that is seated in a chair. After identifying the pelvis, spine, ribs, and femurs, the pelvis is rolled forward and back, and then left and right, while participants describe the observed movements. This demonstration highlights how movement in one part of the body, influences movement throughout the body and habitual muscle tension in any one place (i.e., abdomen, intercostals, throat, neck, back) impedes movement and the quality of our breath. The connection to functional movement is made by demonstrating how the pelvis rolls forward for activities such as reaching forward, sit to stand and transfers. That when we don/doff shoes and socks the pelvis rolls back, and when we reach to the left or right outside our base of support, for example to retrieve items from a cabinet, the pelvis shifts and the ribs expand in the direction one is reaching.


Participants are asked to imagine they are sitting in the middle of a clock. When the pelvis rolls forward (anterior pelvic tilt) that’s 12 o’clock and when the pelvis rolls back, (posterior tilt) that’s 6 o’clock. Tilting the pelvis left (lateral tilt) is 9 o’clock and to the right is 3 o’clock.

Participants start by rolling their pelvis toward 12 o’clock while inhaling and exhaling as they move back toward the center of their clock. The cue to move within a comfortable, easy range is given. Participants are directed to notice as the pelvis shifts forward how the spine lengthens, the space between the ribs expands in front, shortens in back and the head tilts gently upward. Anyone having difficulty feeling the movement is instructed to make the movement even smaller and easier.

The next movement is toward 6 o’clock and participants are instructed to exhale as they roll back and inhale as they return to the clocks center. This time participants are cued to notice that as the pelvis shifts backward how the spine rounds, the ribs close in front, open in back and the head rolls down.

Then both movements are put together with the cue to inhale while rolling toward 12 o’clock and exhale as you move toward 6 o’clock, continually sensing and feeling the movements of the pelvis, spine, ribs, neck and head.

The next step is to move the pelvis toward 3 o’clock. Participants are directed to notice the asymmetrical pattern of movement when their pelvis shifts right. How the ribs expand on the right side, shorten on the left and the head laterally tilts to the left. When moving toward 9 o’clock, the reverse pattern of movement occurs. Participants are instructed to inhale and exhale in a manner that feels comfortable and easy.

This lesson usually takes place over two sessions as many people require time to “let go” of habitual tensions and begin to feel the kinetic chain of movement. Once the pelvis to head connection is made, participants report a positive change in the quality of their breath and an ease and freedom of movement.

An abridged description of the remaining lessons follows.

(4) Breath -A Moving Experience

Breath is about movement. This lesson focuses on the mechanism of breathing (movements of the diaphragm, its attachments, the exchange of gases, and the role of the secondary muscles) and factors inhibiting efficient breathing (posture, culture, pain, emotion and habit). It also addresses how muscles, tendons, joints and organs are influenced by our breath, as these also affect our breathing. The experiential component helps participants experience the natural oscillation of the breath reflected in movement throughout the body.

(5) The Inner Tube

When the primary muscles for respiration are efficiently engaged, most of the movement is in the lower abdomen. When the secondary muscles are most active, the upper chest moves more. Participants are asked to imagine a triangle super imposed on their trunk, with the base of the triangle closest to the ground. This represents abdominal breathing which provides postural stability and a sense of being grounded. Chest breathing is represented by having the triangle turned with the apex pointing down - with this pattern there is less postural stability. This lesson helps participants experience and allow more movement throughout the “base of the triangle” - in the belly, the sides and lower back by imaging an inner tube placed in their lower abdomen. Verbal cues are given to initially direct the breath to different compartments of the inner tube and eventually to inflate and deflate the whole tube.

(6) Core Connection: Awareness builds stability

Back pain impedes function and is often caused by inefficient coordination between muscles of the trunk and pelvis. Improved breathing patterns can facilitate lumbopelvic stability by coordinating movements of the diaphragm, pelvic floor and transverses abdominus. In this lesson, participants learn to isolate and then coordinate these muscles thereby improving trunk stability, respiration and function.

(7) Biofeedback

When clients find the appropriate rate and quality of breath, a measurable relaxation response is elicited. A simple and cheap way to measure this psychophyliological response is thermal biofeedback with hand thermometers. With relaxed breathing, blood flow to the skin is increased, which in turn elevates hand temperature. Participants see that by manipulating the breath, they are also changing blood flow patterns. This can be an especially useful approach to facilitate wound healing.

The lessons presented are meant to serve as a foundation from which a breathing program can be developed. There are many other approaches especially from Yoga and Chi-Gong that can be incorporated into a breath therapy program.


The Occupational Therapy Practice Framework: Domain and Process states that occupational therapists devise intervention strategies to “facilitate engagement in occupation to support participation in life” (2002, p.609). Inefficient breathing patterns limit our clients’ ability to fully engage in day-to-day activities. Therefore, helping our clients substitute inefficient breathing habits with efficient habits is an important component of any intervention strategy and clearly within the domain of occupational therapy. As noted in the Occupational Practice Framework, performance patterns are “patterns of behavior related to daily life activities that are habitual or routine” (2002, p.623). Some habits are “useful” promoting performance and life satisfaction, some are “impoverished” or “dominating habits” that interfere with function. The Peak Performance curriculum outlined in this article provides the occupational therapists with strategies that can help their clients discover “useful habits” for breathing; thereby, providing them the means to manage pain and anxiety, conserve energy, improve coordination and engage more fully in meaningful occupations and activities.