full article 4000 words
Difficulty breathing (dyspnea) is a common complaint, affecting about 1 in 10 adults1 .… and a tough diagnostic challenge. Like abdominal pain, dizziness, or fatigue, minor breathing difficulties can have many possible causes.2
Obviously you should discuss stubborn breathing troubles with a doctor — especially if you have other worrisome symptoms, like pain or trouble staying upright. In older patients who mostly feel short of breath during exercise, it’s much more likely to be a symptom of disease of the heart and/or lungs. For everyone else, there are at least three causes of shortness of breath that are possible, minor, and fairly treatable:
If you’re short of breath for any (or all) of those reasons, easy relief is possible. It’s safe, cheap, and almost fun to experiment with self-massage for trigger points. Results are hardly guaranteed, but it’s a sensible thing to experiment with.
Changing bad habits is always tricky,but it’s a more likely path to relief, and increasing your respiratory strength is possible with a little oomph345 — and it’s a worthwhile fitness goal in any case.
Anxiety is the toughest problem to beat, but everyone can benefit from trying.
These three issues can all get tangled up together, each one complicating the others. The bright side of that mess is that any progress with one is likely to help the others. Some simple and interesting ideas for self-treatment are provided in this short article, with plenty of links to other information and resources for those who want to delve.
It’s nice that some people may be able to find an easy solution to their shortness of breath, or at least be reassured that it’s mostly harmless. Unfortunately, more ominous causes of dyspnea are also common, so please always alert your doctor about any difficult breathing. If your doctor cannot find any explanation, and you have none of these “red flags,” then you can pursue the possibility of muscle knots and weak breathing muscles. Safety first! And second.
Any of these factors could be associated with a slow, sneaky onset of a serious condition.
Many things contribute to a sensation of shortness of breath,6 and the symptom breaks down into three messily overlapping qualities, which are interesting but don’t tell us much about what’s going on, just a couple very rough clues:
Trigger points — better known as muscle knots — can cause shortness of breath. They are small patches of sensitive muscle tissue, maybe caused by a localized spasm, or “just” neurological hypersensitivity. Trigger points are a big topic.
Trigger points may form in the muscles we use to breathe, making it difficult or even painful to move the ribs and expand the chest. Even the diaphragm itself might develop trigger points that make it feel weak and tired, and limit its range of contraction.7
Trigger points in the muscles of the throat, neck, chest, and back may also interfere with the nervous system’s control of respiration.8
Trigger points may afflict the respiratory musculature for reasons unrelated to breathing, such as postural strain. Or they can arise in response to bad breathing habits: a chicken and egg problem. Do you get breathing trouble because you have trigger points? Or do you get trigger points as a symptom of breathing trouble? The answer is surely both. If there is an obvious problem in the area, such as an old shoulder injury, then it’s a good bet that the shoulder was the “chicken” that started it all, and it may remain the primary source of discomfort and muscular dysfunction in the area.9 In such a straightforward case, treating the trigger points caused by the old shoulder injury might just solve the problem.
On the other hand, if there is no obvious cause of discomfort in the area, but you are out of shape and sit slumped in a chair all day long, a better guess is that respiratory dysfunction was the “egg” that started it all, and the real challenge is to learn to breathe and sit better.
Muscle trigger points are unpredictable and mysterious: exactly what they are and how to treat them is controversial. Sometimes they seem to melt as easily as ice cream in the sun, and so the first thing to try is just a little simple self-massage, or a warm bath, or both. The problem could be solved by a self-treatment as simple as digging with your thumbs into some aching muscles between your ribs. Voila — no more shortness of breath! I’ve seen it go like that many times, and even experienced it myself…
My story: I am generally prone to muscle pain, and one of the most persistent specific challenges I’ve had is with breathing pain — not “shortness of breath” in my case, but “breathing limited by pain.” For about twenty years, I had routine episodes of strong pain that choked off my breath. The pain would ease when I relaxed for long enough … but it’s hard to relax when you can’t breathe.Once every few days, I would be nearly paralyzed by it for several minutes, and sometimes nightmarish episodes of an hour or more. The pain would ease when I relaxed for long enough … but it’s hard to relax when you can’t breathe.
I recovered! During my first year of massage college in 1997, I experimented with self-massage of my intercostals, discovered that I could easily stop any “attack” of this pain within a minute just by rubbing between the ribs near the pain.10 It was a revelation. I’ve probably never been so happy to learn anything! Over a year or two, I massaged my intercostals regularly until I stopped having these episodes at all.
Unfortunately, it’s not always that easy. Trigger points can be so stubborn they become a major source of grief. Self-massage is definitely no miracle cure, and trying to treat tougher trigger points can become an epic journey of rehabilitation. You might have a complex array of trigger points, both causing and caused by many factors, including really tricky ones like seriously dysfunctional breathing behaviour and intractable emotional factors.
Again, if you want to learn a lot more about trigger points and how to manage them, please see my advanced tutorial.
The main muscles of respiration are:
And one more minor respiratory muscle in the low back may be clinically significant:
It is also well worthwhile to massage other muscles throughout the neck, shoulders, and chest. Even the upper back! Soothing them may indirectly help the actual respiration muscles. And even if they don’t control breathing themselves, they often produce sensations that feel related to breathing in a way that is hard to describe. After professional massage in the upper back, patients often say something like, “I feel like I can breathe again!” Even if they didn’t feel short of breath to begin with!Feeling “stiff” in the upper back often has a lot of sensory overlap with shortness of breath — they are similar and probably related sensations.
For instance, it’s startling how much trigger points between the shoulder blades can feel related to breathing (and indeed there are some actual minor muscles of respiration back there). After professional massage of this area, patients often say something like, “I feel like I can breathe again!” Even if they didn’t feel short of breath to begin with!
I once developed a sharp pain in the side of my neck when I coughed or sneezed. It was clearly a muscular pain,11 specifically of the scalenes muscle group that kick in when you breathe hard. If I took a really deep breath, I could feel it a little too — but it was mostly only clear when I coughed or sneezed.
Until I went for a run.
After a few minutes of huffing and puffing, that pain started up. I also felt distinctly short of breath, despite being generally quite fit. The pain was like a stitch in my side, but in my neck, and I was not getting full breaths. I realized I was barely using my diaphragm to breathe, and so my scalenes were working overtime to make up the difference — and hurting and failing. (More about this below.) I started using my diaphragm again … and the pain steadily eased even though I kept running.
Not only was the pain clearly caused by over-using my scalenes while breathing, but I was able to fix a fairly significant pain problem without stopping my workout — just by breathing differently. That’s a good, clear example of the easiest kind of breathing trouble to fix. What was going on?
The most common form of respiratory dysfunction is usually just chronic shallow breathing, eventually leading to an inability to breathe deeply due to weakness and stiffness — you don’t use deep breathing, so you lose deep breathing. A lifelong habit of breathing shallowly is only a short hop away from feeling short of breath. Shallow, weak breathing is mostly a result of trying to breathe with the upper chest muscles instead of the belly and diaphragm. Such habits can easily become reinforced by the trigger points they cause — you get “locked in.” For instance, if you chronically try to breathe with the neck muscles, which are too weak to do the job on their own, they get exhausted and then cranky and full of trigger points … and then they really can’t handle it.
But why would we breathe shallowly and “badly” in the first place? It’s not like anyone is conscious of trying to breathe with their scalenes instead of their diaphragm! Respiratory dysfunction is usually driven by postural, psychological, and emotional factors, especially anxiety, which is the next major topic.
Maybe you feel so stressed that it’s obvious that the stress is “squeezing” the breath out of you … or maybe it’s not. If you’re not sure, it’s time to ask yourself some hard questions: could that be me? Could I be “choking” myself? Almost literally? Don’t underestimate this possibility.
Anxiety — excessive worry, either too much, or too long, or both12 — is a surprisingly potent and amazingly common cause of many odd symptoms. Shortness of breath and chest pain are among the most frequently reported.
Although it’s common, anxiety is badly neglected as an explanation for many problems. Even though it’s almost the same thing as “stress,” many people don’t recognize that they are anxious, or they deny it or minimize it. And many people just don’t know that shortness of breath can be caused by anxiety! It really can.
There’s no clear explanation for how anxiety causes shortness of breath, chest pain, or any other strange symptom: it’s just one of those things. And while anxiety can cause shortness of breath as a direct and immediate symptom, it can also probably cause trouble indirectly by chronically eating away at us in other ways, like creating the dysfunctional breathing pattern discussed above.
The way we breathe is a powerful aspect of self-expression. Anxiety, “emotional constipation,” and other habits of mind and dysfunctional and self-limiting behavioural patterns are may be associated with strong breathing patterns, especially shallow breathing.
Shallow breath is what we do when we literally hide (from a predator, say). It is also what we do when we feel like we want to hide! Deep breathing is one of the main practical suggestions for fighting anxiety. It’s a feedback loop.
Habitually breathing shallowly can be so subtle for so long that we don’t even realize there’s a problem until all the contributing factors and bad habits and vicious cycles are too deeply entrenched to break free — a classic “boiling frog” kind of problem.
There’s also a basic Catch-22 in life — a basic problem with being human — that keeps us from perceiving and correcting our own worst habits and their consequences: the kinds of trouble we get into are always, to some degree, a consequence of the lack of the very same awareness and skills we needed to avoid the trouble in the first place, or to deal with it. So these kinds of problems tend to be identified later in life, if ever, and often go hand-in-glove with a lack of self awareness and denial — it just goes with the territory, and there’s certainly no shame in it. Who isn’t “emotionally constipated” about something? Most of us are. Sometimes we get the “wake up call” in the form of being short of breath enough to get nervous about it, at which point we may or may not realize that there’s a connection with lifelong attitudes and behaviours.
All of this is a rather complicated mess to try to sort out, but I’m not going to leave you hanging. Here are several relevant, practical self-help articles. They all focus on what you can do about these issues:
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
— Thorough editing of the introduction, upgraded sources, various minor corrections, and a new section about the qualities of dyspnea.
— Major revision. Rewrote and revised to put a much stronger spotlight on anxiety and “head games” as a factor in shortness of breath. Reorganized the article in three clearer parts. Added a new summary.
Mild to moderate dyspnea occurs in about 10% of adults under the age of 40, climbing to nearly double that in middle age and beyond, in adults who are still up and about. Source (for this and many other factoids in this article):
Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012 Feb;185(4):435–52. PubMed #22336677. PainSci #53725.BACK TO TEXT
This review of the evidence indicates that exercising your breathing musculature probably works pretty darned well, and benefits take about “20 to 30 minutes per day for 10 to 12 weeks” to achieve. Better yet, the evidence also shows that it’s reasonable to expect some benefits “regardless of method”! In other words, there’s no great concern about which technique to use. Common protocols for respiratory training “are generally safe, feasible, and effective.”BACK TO TEXT
Since we know that inspiratory muscle training can improve inspiratory muscle function, lung volume, lung capacity, and work capacity, what level of intensity will “do the trick”? This was a randomized and controlled trial — good science stuff — with three groups, each group training at a different level. The results suggest that high intensity is better than low intensity: “High-intensity IMT set at 80% of maximal effort resulted in increased MIP and SMIP, lung volumes, work capacity, and power output in individuals who were healthy, whereas IMT at 60% of maximal effort increased work capacity and power output only. Inspiratory muscle training intensities lower than 40% of maximal effort do not translate into quantitative functional outcomes.”BACK TO TEXT
After a gunshot wound, a “high-intensity, interval-based threshold inspiratory muscle training (IMT) was undertaken” for the 38-year-old man. The treatment was found to be “safe and well tolerated. It was associated with improvements in maximum forced inspiratory flow and changed the locus of symptom limitation during high-intensity exercise from dyspnea to leg fatigue.”BACK TO TEXT
Association, American Psychiatric (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association. p. 222.
Anxiety is a feeling of worry, nervousness, or unease, usually specific. Generalized anxiety disorder (GAD) is when that feeling gets chronic, excessive, uncontrollable, irrational, and associated with surprisingly diverse symptoms. At least 3 symptoms must persist for at least 6 months for a formal GAD diagnosis.BACK TO TEXT