Just as certain exercises will help keep your spine flexible when you have ankylosing spondylitis (AS), deep-breathing exercises keep your chest wall elastic and preserve your ability to take deep breaths.
This is important, because without taking preventive steps, AS can make deep breathing difficult or even impossible.
In normal breathing, the ribs move up and down every time you inhale and exhale. In people with AS, the rib joints that attach to the spine can stiffen or, eventually, even fuse because of inflammation.
As a result, the ribs can lose their ability to rise and fall. This chest wall tightening — which some people describe as a feeling of being “strapped in” — can leave you feeling short of breath, even after moderate activity.
Restricted Chest Expansion Is Common in AS
Up to a third of people with ankylosing spondylitis have reduced chest wall expansion, says John Reveille, MD, the vice chair of the division of rheumatology and clinical immunogenetics at the University of Texas Health Science Center at Houston’s McGovern Medical School.
In addition, while estimates vary, an article published in April 2018 in the journal Seminars in Musculoskeletal Radiology found that 26 percent of people with AS or a related condition experience chest wall inflammation.
"Since we routinely measure chest expansion in our AS patients, it's surprising to see how many of them have no chest expansion whatsoever," says Dr. Reveille, adding that this usually happens later in the course of the disease. "As a rule, by the time you are seeing zero chest expansion, you tend to see a fused spine."
In addition to chest wall inflammation, a condition called costochondritis can cause chest pain in people with AS. This is inflammation of the cartilage that connects the ribs to the breastbone, and it can make deep breathing very painful, according to Reveille.
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How to Keep Your Ribs and Spine Flexible
Deep-breathing exercises “can help maintain your ability to move your ribs at the breastbone and at the thoracic (middle) spine,” says Olivia Ghaw, MD, an associate professor of medicine in the division of rheumatology at the Icahn School of Medicine at Mount Sinai in New York City. “You are basically trying to prevent fusion and stiffening of the ribs.”
Both Reveille and Dr. Ghaw urge people who are newly diagnosed with ankylosing spondylitis to start doing deep-breathing exercises and spinal extension exercises right away.
“Usually, AS progresses from the lumbar (lower) spine upward,” Ghaw notes. “But at this point, we can't predict the rate of progression — everybody's different.”
In addition to doing exercises to protect your ability to breathe deeply, it's crucial that you don't smoke, Reveille warns.
Nicotine promotes inflammation and is one of the strongest factors leading to spinal fusion. It can also make breathing more difficult by causing damage to your lungs and airways. If you need help to quit smoking, talk to your doctor.
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5 Deep-Breathing Exercises to Try
There are a number of different ways to do deep-breathing exercises, some of which may also carry mood or mental health benefits for people with ankylosing spondylitis, according to Nancy O’Brien, a certified yoga therapist who specializes in pain and difficult medical conditions, including arthritis, and works with the Hospital for Special Surgery in New York City.
“These are practices that can add to flexibility and mobility, and also meditation types of breathing that can help with stress,” says O’Brien. “And the less stressed you’re able to be, that contributes to being able to support yourself with these challenges” of living with a chronic medical condition.
Here are five deep-breathing exercises that O’Brien recommends for people with AS. How often you should do them will depend on your needs, but a few times each week or even a couple of times a day may be a good starting point.
As with all physical exercises, check with your doctor before doing them if you have any relevant physical limitations.
1. Centering Breathing Exercise
Sit in a chair or lie on your back and breathe in deeply — expand first your belly, then your lower ribs, then your upper chest (this is how you should inhale for each of the deep-breathing exercises).
As you exhale, turn your head — as far as is comfortable for you — toward one shoulder, and breathe out in three “ha” puffs. As you do this, think about separating yourself from the past and any difficult experiences or regrets.
Then, turn back toward the center and breathe in deeply. For your next exhalation, turn toward the other shoulder and form a small circle with your lips, blowing out in a single stream of air. As you do this, think about separating yourself from the future and any fear or anxiety you carry.
Repeat this process for as long as you’d like to do the exercise.
2. Energizing Breathing Exercise
In a seated or standing position, reach up and out with one arm as far as is comfortable, bending your elbow as much as needed, as you breathe in deeply. Then, exhale quickly as you pull your arm down toward your chest, imagining that you’re pulling down on a rope. If possible, exhale quickly enough that you feel almost like you’re getting punched in the chest.
Relax your arm, then switch to the other side and repeat for as long as you’d like to do the exercise.
3. De-stressing Breathing Exercise
Start in a seated position with your hands on your knees. Slide your hands along your thighs back toward your hips, bringing your elbows back and as close to each other as is comfortable. Keep your chin slightly tucked in a relaxed manner, but lift your upper chest somewhat and lengthen your lower back and hips behind you to create a slight backward bend in your spine.
In this position, breathe in deeply while thinking of an intention like “peace” or “strength.” Then, as you slowly exhale — thinking about exhaling any negativity — slide your hands forward toward your knees and lower your chest and shoulders so that you bend forward as little or as much as is comfortable.
As you repeat this process, you can focus on the same intention each time, or alternate between a couple of different intentions.
4. Meditative Breathing Exercise
In a seated, standing, or lying position, trace with your hand or visualize the outline of a box or square in front of you as you go through the breathing cycle. As you inhale, trace or visualize going up the outside of the box to a count of 3. Then trace across the top of the box as you hold in your breath to a count of 4. Exhale to a count of 5, tracing down the other side of the box. Then trace along the bottom of the box, back to the starting point, and repeat the process.
This breathing exercise, O’Brien notes, can be helpful as a way to relax your mind if you’re in bed and having trouble falling asleep.
5. Relaxing Breathing Exercise and Twist
Lie on your back, using pillows or a folded blanket to support your head and shoulders, and your knees if needed for comfort (this exercise can be done on your bed).
Take a few moments to squeeze and wiggle your arms and legs, and consciously relax your jaw.
Then lift your knees closer to your chest, and lower both knees to one side while turning your head in the other direction. This twist can be as wide or as narrow as you’d like, with a slight twist achieved by supporting your head and knees as desired. Only twist as much as is safe and comfortable for you.
Breathe in deeply and exhale slowly for a couple of minutes, feeling yourself sink into your twisted position. Then bring your head and knees back to the center, and switch to the other side.
“The wonderful thing about breathing in ankylosing spondylitis is you don’t have to go to a class. You’re always breathing,” says O’Brien. “It’s just a matter of awareness, to know you can use that breath to help in different ways. That tool is available to you morning, noon, and night.”
Additional reporting by Regina Boyle Wheeler.