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Inside-Out Paradigm

By Dale G. Alexander, LMT, MA, PhD

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A Bridge to Reducing Chronic Anxiety and Panic Attacks, Part 2

The first article in this series (February 2016 Massage Today), proposed that attending to the physical correlations of paradoxical breathing can serve as a bridge to decreasing the frequency and the severity of chronic anxiety or panic attacks. I described an educational and kinesthetic technique to assist clients to normalize their breathing pattern, which has been effective for my clients in my clinical practice. For many, this behavioral technique makes a significant contribution to resolving the breath disruption all by itself, while for others, more re-calibration efforts are needed. Taking the time to notice any disruption in the breath pattern was enthusiastically encouraged. Here, we will explore the anatomy related to the physical correlations of paradoxical breathing in further detail. This will assist you in helping your clients when paradoxical breathing is more deeply anchored in the nervous system.

Paradoxical breathing was described as a reflex during which an individual consistently initiates breathing, even during quiet respiration, from the SCM and scalene muscles rather than from the respiratory diaphragm. This is a reversal of the normal neuromuscular pattern of breathing in which the diaphragm descends inferiorly as it contracts and the resulting inferior pull by its lower sternal fibers triggers a wave upward along the sternum. During active breathing as when one is exercising, the SCM's and scalenes participate in lifting the sternum which creates a bend at the manubrial/gladiolar junction of the sternum at the level of the second thoracic rib. Their combined contraction expands the anterior to posterior dimension of the upper thorax, increasing the quantity of air inhaled into the lungs. During quiet breathing, the SCM's and scalenes have minimal participation in the breath wave.1

A Bridge to Reducing Chronic Anxiety and Panic Attacks, Part 2 - Copyright – Stock Photo / Register Mark Initiating breathing from the cervical region is normal during heavy physical exertion as just described, and when one is approaching and experiencing sexual climax. Typically, this reversal of function lasts just a few minutes following the exertion, until the heart rate decreases and normal lung expansion resumes, along with diaphragmatic initiation of breathing. Paradoxical breathing is also normal during the latter stages of pregnancy when the uterus occupies so much of the space within the abdominal and pelvic cavities. Obviously, this duration can last for a few weeks to a few months and typically resumes diaphragmatic initiation after the birth event. Nature uses whatever is necessary to perpetuate our species.

The triggering of the paradoxical breathing reflex is often a sequela to whiplash, head injuries, chest or spinal impact injuries, or lung dysfunction or diseases. My clinical experience suggests this reflex has implications for co-perpetuating a plethora of chronic somatic physical complaints such as neck pain, migraines, upper radicular syndromes, TMJ dysfunction and pain, and is especially a significant perpetuating influence in chronic anxiety and panic attacks.

In the late 1980's, I worked extensively with pregnancy and infant massage. This is when I first recognized and described the paradoxical breathing phenomena in a published article.2 It is unlikely that I was the first to have noticed this reversal of the normal breathing pattern associated with the latter stages of pregnancy yet, in response to this publication, in 1993, I was invited to San Antonio to present this thesis to the Sections Conference of the APTA. Over a 35 year career, time and experience allows one to gather impressions and see what effectively works with and for clients. Then as one looks back, the opportunity emerges to theorize about the progression of processes and to postulate a gestalt as to why, as in this case.

In 1995, I had the opportunity to work with an infant who was experiencing chronic non-epileptic seizures. My wife at that time was a gifted physical therapist with a reputation for successfully treating young children and infants. Through many spirited discussions about the infant's symptoms, I had proposed that tensions within the esophagus could provoke a response by the Autonomic Nervous System (ANS) such as a non-epileptic seizures. My reasoning was based on the centrality of its anatomical relationships: its superior mooring from the cranium, the fact that it is cradled by the heart, that its fibers flow into and become the organ of the stomach and that it is innervated by both sympathetic and parasympathetic neurons. My wife was open to the idea but suggested we seek further input from medical sources.3

We decided to call Ohio State University College of Medicine, where she had graduated, and to our surprise and delight we were connected with a Pediatric GI specialist. Fumbling at first, we eventually articulated the thesis that a contracted esophagus might be a primary variable that would provoke the autonomic nervous system to use seizure activity to re-calibrate the length of this primary connecting tube between the brain, specifically, the superior sympathetic ganglia and its vagal confluence there, and between the enfoldment of the esophagus behind the heart, sitting atop the central tendon of the diaphragm muscle.4

The GI specialist was quite candid at first, suggesting that five years earlier he would have considered such a notion poppycock yet, he had actually performed surgeries to lengthen the esophagus in infants who had also presented with unexplained non-epileptic seizure activity, but he did not cite any specific literature references. When I pressed him for his opinion or knowledge as to whether some people could be born with an overly-reactive esophagus, or one only slightly shortened, he back-pedaled quickly, responding that he could only comment on what he had directly observed. When I furthered described my alternate thesis that such a shortness or overly-reactive esophagus could participate in chronic anxiety or panic attacks, he froze, then after a long pause, suggested that he had never considered such a proposal. Respectfully, I invited him to do so.

The ensuing decades of clinical experiences have contributed to my clarity of conviction that the gastrointestinal tract is our first responder to the experience of stress via heightened sympathetic neural activity within us and typically begins with a shortening of the esophagus. Reflect on your own internal reactions to anticipatory anxiety, a lump in your throat, pressure in your chest, your stomach churning or feeling tied into a knot. All of these, to my perception, are esophageal related. It was enlightening to later learn that during our human embryological development, the lungs are an off-shoot of the gastrointestinal tract (GI). Such an intimate early embryological relationship supports the thesis of how and why alterations within the organs and tubes of the GI system can readily alter breathing mechanics.5

It was about a another year later that the fullness of an epiphany coalesced to produce the Sacs and Tubes Theory of Stress that is a cornerstone of the Inside-Out Paradigm. This theory distilled, suggests that the human body is composed of mostly sacs and tubes and that when we feel stressed, these body sacs "cringe" while the tubes that compose our organs and those that connect them "shorten, narrow, and can even twist."6 Traumatic events, whether physical or psychological, simply create more extreme manifestations of these proposed intrinsic responses. These responses are proposed to induce increasing elements of compression, congestion, and dis-coordination within the autonomic nervous system.7

What I think is important for our consideration from this evolution of clinical perceptions is to reconsider and redefine chronic anxiety, panic attacks, and non-epileptic seizures as correlated reactive expressions of physical states, rather than strictly emotional events; analogous to a spring being wound so tightly by accumulated stress and trauma that the central nervous system takes matters into its own hands to release and "reset" itself.

Appreciating how our ANS endeavors to re-calibrate such states of internal discomfort and physiological dysfunction back toward homeostasis by using what it has at its disposal, I propose that the ANS often utilizes chronic anxiety and panic attacks to achieve its reset. This thesis could also shed an entirely new light on those who have suffered with periods of bulimia during their lives as an active expression of their chronic anxiety with a behavioral effort to induce a relaxation of the esophagus by the act of vomiting.

I believe these physical states can be altered by our capacity to touch skillfully and intelligently. This does not disregard the psychological elements that may also be a driving force in their creation; yet, it allows us another way into the matrix of neurophysiology in search of ways to normalize the functioning of the whole person. Let's now walk through the five most common physical correlations to chronic anxiety and panic attacks identified by my clinical experience:

  • Thoracic rigidity - the chest is less compressible.
  • Mild-to-moderate spasm of the diaphragm muscle.
  • Contracted or spasmed esophagus.
  • Contraction and spasms of varying intensity of the SCM's and scalenes.
  • Restricted TMJ and associated soft tissues.

If the breath wave of an individual has become paradoxical with the cervical SCM's and scalenes initiating, then as the condition persists, the chest wall tends to becomes more rigid and less compressible. Lifting from the top as opposed to expanding and descending at the bottom will influence the intercostals and other thoracic soft tissues to adapt to the new arrangement by shortening. I theorize that this is just one variable among many others that may produce this pattern; yet, it is the most common one I have observed and palpated.

What I mean by a mild to moderate spasm of the diaphragm is easily perceived and palpated by motion testing the lateral excursion of each hemi-diaphragm. Standing at the lower thoracic side with the client lying supine, contact the opposite-sided costal arch and pull the arch toward you, then softly push it away. When contracted or in spasm, you will feel the reduced range of motion quite vividly. If either or both sides of the diaphragm is restricted in its excursion, then it is in some degree of spasm. And, if either or both hemi-diaphragms are spasmed, what effect might this have on the capacity of the heart to expand?

Does this state of diaphragmatic spasm or contraction relate to the shortening of the esophagus? Yes, it is my experience that they exist hand-in-hand, especially when a client presents with chronic anxiety and panic attacks. Might this degree of tension also have an impact on the ability of the heart to expand fully? Might this inability to expand fully trigger physiological anxiety?

The heart and pericardial sac clearly enfolds the esophagus anatomically and is firmly attached to the diaphragm.4 To my knowledge, no one has raised the question of this anatomical confluence of tensions or its physiological implications except myself. My most reliable indicators of esophageal contraction or spasm are two-fold: first, the amount of space between the occiput and C-1 and second, the ease of stretching the occiput superiorly from the atlas. The less space and less ease, the more the esophagus is shortened has been my consistent inference.

The degree of spasm of the SCM's is easy to palpate. Its fibers will feel thickened and tight to simple palpation. With your client supine, place your fingers above and below the SCM and request the client extend their neck a bit then flex it slightly and its architecture will reveal itself readily. Often one SCM is more in spasm than the other which allows us to correlate this phenomena as a common result of whiplash and head trauma events. How could it be otherwise? Our reflexes are designed to turn us away from perceived impact.

Contraction and spasm of the scalenes is easily detected, not only by their palpated tension, but also by restriction to side-bending of the head and neck. In my experience, if one of these myofascial structures is contracted or in spasm, then many other structures of the cervical support system for the cranium have also re-calibrated their length and tension. Additionally, because of the anterior, medial, and posterior scalenes attachment to the first two ribs, any spasm within them can decrease nerve and blood supply to the shoulder, arm, and hand. Finally, consider the central importance of the TMJ. Addressing the tensions of these joints is crucial to sustained changes of chronic conditions, including chronic anxiety and panic attacks.

My clinical experience suggests that the buccinator muscles, the sphenomandibular ligaments, and the zygomatic arches are essential actors in this complex pattern, and appropriate attention to normalize their elasticity, length, and tone will help to reduce the tendency to perpetuate the neural signals of anxiety which leads to the ANS's "spring tightening" toward eventual release and reset, which a panic attack accomplishes by restoring and equalizing pressure within the thorax as a whole and within the fibers of the esophagus more specifically.8

Instead, we would prefer to restore thoracic normalcy via gentle, comfortable manual techniques which will also potentially eliminate future iterations of the anxiety/panic attack pattern. I euphemistically consider this therapeutic attention to the TMJ to be the "cherry on top" of the other highly correlated physical presentations of chronic anxiety and panic attacks. In summary, do compassionately ask your clients if they experience frequent anxiety or have ever experienced a panic attack. You will be surprised just how many do and how often. Please consider these physically correlated variables in your massage and bodywork applications. Trust that you already possess kinesthetic skill sets to address these to some degree. Then, commit to developing additional therapeutic understanding, knowledge, comprehension, and touch skills to assist your clients. They will thank you for your commitment and will reward you with ongoing referrals of their family and friends.

Chronic anxiety and panic attacks are rarely the topic of cocktail conversation as are shared stories of cosmetic surgeries and other physical troubles. People "hide" that they suffer with these. Allow your clients the opportunity to find the light of hope and the prospect of an improved quality of life.

References:

  1. https://en.wikipedia.org/wiki/Muscles_of_respiration
  2. Freeing the Breath Wave During Pregnancy, Hands Across Ohio, Spring, 1994, FSMTA Massage Message, Summer, 1994.
  3. Janice M. Alexander PT, contributions can be made to the Janice Alexander Scholarship Fund, at First National Bank in Dover, 824 Boulevard, Dover, Ohio 44622.
  4. Atlas of Human Anatomy, Frank Netter M.D., Plates 61, 124, 203, 221, Ciba-Geigy, 1989 and The Fasciae, Anatomy, Dysfunction, & Treatment, Serge Paoletti, Eastland Press, 2006, pg. 81.
  5. https://web.duke.edu/anatomy/embryology/GI/GI.html also, Human Structure, Cartmill, Hylander, & Shafland, Harvard University Press, 1987, pg. 19.
  6. The Sacs and Tubes Theory of Stress, Massage Today, January 2014, Vol 14, Issue 1.
  7. A Look at Compression, Congestion, And Dis-coordination, Massage Today August, 2014, Vol. 14, Issue 08.
  8. Temporomandibular Disorder and Dysfunctional Breathing, Braz J Oral Sci. 3(10):498-502
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