B – Breathe


We should all take a moment to concentrate on our breathing.

Inspire for a count of 4 and expire to a count of 4………doesn’t that feel better?  After reading A - Assess  you probably need to take a moment!

It’s amazing how little time we spend just calming our minds and bodies with a few controlled breaths.  It is not only you who isn’t breathing optimally but often your clients through anxiety or stress are also holding their breath more often than is healthy for them!

Focused breathing within massage and soft tissue therapies is frequently used when applying a technique and using commands to the individual you are working with to breath in or out while applying a particular hand-skill or intervention.  

This is often for two purposes - 

one to focus the person on what you are doing and away from their pain or discomfort  two to enhance the skill for depth or accuracy of application.

Both purposes have sound reasoning for clinical practice, but what about the act of breathing itself?

Breathing in its own right?

What if the actual muscles involved in breathing are less than optimal in their function?

Many people do not breath correctly! 

You may think that is an absurd statement but it is true that the physical act of inspiration and expiration is often poorly performed because the sequence of muscle/diaphragm contraction is neither optimal or correct.

The mechanism of breathing?

This requires the diaphragm to flatten and move downwards as the ribcage moves upwards and out.  Frequently instead of the diaphragm descending on inspiration it ascends. While the ribcage either only moves minimally in an upward/out movement or in some cases not at all!!

There may be many reasons as to why you or your client/patient isn’t breathing correctly including underlying pathologies, however, everyone can benefit from understanding ‘how’ to breath correctly and therapists can assist in many ways the function of the muscles associated with breathing.

Take your time!

Simple ‘time-out’ to perform 3 or 4 breaths correctly can make an enormous difference to the way you and / or your clients feel.  Try the following exercises:


Find somewhere to sit with the head supported, place your hand on your abdomen just below the sternum in the ‘’V’’ made by the ribs and take a breath in - Can you feel your ‘tummy’ expand or move forward into your hand? Yes - then thats great your diaphragm is descending properly. No - does your hand get sucked into your tummy or up under your rib cage? If this is happening then you need to be taught ‘’how’’ to descend the diaphragm and should consult with an appropriate therapist!  The loss of diaphragmatic breathing means that you are not getting the optimal Pulmonary Ventilation - Inhalation and exhalation that is ‘’Breathing’’. 


Continue in the same head supported sitting position place your hands on the bottom of your ribs and take a breath in - Can you feel your ribs move upwards and outwards? Yes - then thats great your ribcage is moving properly. No - do your ribs move at all? If they move but only either up or out minimally then you need to be given appropriate exercises to improve the mobility of your ribcage (If not limited or immobile  due to underlying pathology) and should consult with an appropriate therapist!


If your breathing pattern is correct then do two inhalations to a count of 4 exhaling for a count of 4 with your hand on your abdomen, followed by placing your hands on your ribs and inhaling to a count of 4 and exhaling for a count of 4, twice.  Try to calm your mind as you breath focusing only on the inspiration and expiration of the air.   

Take Care!

Be careful not to do more than 4 breaths in any one relaxing ‘time - out’ session, as you may suffer dizziness if too much Carbon Dioxide is displaced!

It’s not only the correct pattern of breathing that helps to supply oxygen to our bodies and remove carbon dioxide but the role played by the muscles responsible for the action of the ribcage and diaphragm that are also important.  

Muscles involved in Breathing

The main muscles and those called accessory muscles play an enormous part in ensuring adequate oxygenation occurs.  As therapists we need to know the role of these muscles and how through our massage and soft tissue work we can improve the function of these muscles.

Inspiration - Breathe in

The main muscles of inspiration include the diaphragm, external intercostal and scalene muscles.

The accessory muscles being the sternocleidomastoid, pectoralis major and minor, serratus anterior, latissimus dorsi, and serratus posterior superior. 

Expiration - Breathe out

The main muscles as above stop contracting and return to resting length

The accessory expiratory muscles are the abdominal muscles: rectus, abdominis, external oblique, internal oblique and transversus abdominis. 

In addition the thoracolumbar region the lowest fibres of iliocostalis and longissimus, the serratus posterior inferior and quadratus lumborum. 

Which muscles to focus on?

The amount of use to which each muscle is required depends on the degree of respiratory effort with the addition of the accessory muscles generally only being used under conditions of high demand such as exercise or respiratory conditions/distress - Asthma Attack, Chronic Obstructive Pulmonary Disease (COPD).

It is clear when working with many of our clients some occupational postures, along with long periods of inactivity and underlying pathologies decrease thoracic function and lead to many of the muscles involved in respiration being neglected or over looked when delivering massage to the muscles of the upper back, neck and chest.  Similarly those involved in sport and leisure activities which place a high demand on the delivery of oxygen to the body during exercise also develop thoracic dysfunction and overuse of accessory muscles leading to upper back and neck pain or discomfort.

Not all of these muscles can be easily accessed directly in terms of massage and soft tissue therapy, yet by appropriate positioning and consideration to muscles not normally focused on during massage sessions we can greatly improve the action of the ribcage and thereby improve pulmonary ventilation.

Massage & soft tissue methods, hand-skills / positioning to consider.


Placing a client in side-lie and where necessary placing a bolster in the gap between the plinth and the clients waist we can more easily access the intercostals. Use of appropriate effleurage techniques provide a more focused approach to relevant muscles.  If you are unfamiliar with these hand-skills then access them via our online video series or arrange a one-to-one?

Indirect fascial release techniques provide a gentle approach to relevant muscles. If you have not yet added any Myofascial skills to your manual therapy ‘’tool box’’ then why not attend one of our CPD courses?

Long Sitting

Having a client “sitting up” with their legs out straight can provide a position to teach breathing exercises and help individuals identify the areas of the thorax used in breathing.  Helping people understand which area should move and/or relax during breathing also helps the therapist identify areas which might require assistance through our massage & soft tissue skills.

This position helps us to apply pressure and compression techniques along with STR, MET and MFR relevant to each persons presenting problems. Do you need assistance in this area of application? Then why not consider a One TO One session?

Prone / Supine

These are the traditional positions of ‘face down’ / ‘face up’ for the delivery of massage & soft tissue skills.  Access to the relevant musculature and the intention of the intervention will determine the position adopted.  Your assessment of the client/patients needs and their suitability to receive massage & soft tissue skills will direct your therapy to the desired outcome. 

Complex Positioning

It is important to remember that to have the desired effect/outcome on specific muscles/soft tissue, that less than traditional positioning may need to take place.  This usually involves carefully supporting areas with towels, bolsters etc and in turn can require detailed explanation to a client as to your reasoning in order to gain consent prior to proceeding.

If you have questions or or uncertain about placing clients/individuals in optimal positions then consider a One To One session?

Viv Lancey