Transcript

Dr. Jonathan Chung: 00:01
That there are yogis that have gone so deep into breath work where they could use breath work in such a way that it could change their physiology enough that they could actually give themselves a fever. And they could actually give themselves a fever that could actually cause the sweat on their clothes to evaporate. So this is even beyond the level of what we're using for our patients, but it just opens the possibility that if you control your breath, you can control your physiology. And giving that people a sense that they can control their physiology is really empowering for a subset of patients that feels like their physiology is just running out of control on them.

Dr. Ayla Wolf: 00:40
Welcome to Life After Impact, the Concussion Recovery Podcast. I'm Dr. Ayla Wolf, and I will be hosting today's episode where we help you navigate the often confusing, frustrating, and overwhelming journey of concussion and brain injury recovery. This podcast is your go-to resource for actionable information, whether you're dealing with a recent concussion, struggling with post-concussion syndrome, or just feeling stuck in your healing process. In each episode, we dive deep into the symptoms, testing, treatments, and neurological insights that can help you move forward with clarity and confidence. We bring you leading experts in the world of brain health, functional neurology, and rehabilitation to share their wisdom and strategies. So if you're feeling lost, hopeless, or like no one understands what you're going through, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. Okay, Dr. Jonathan Chung, you are a chiropractic neurologist and you specialize, uh one of the things you specialize in is in post-concussion syndrome. And I'd love for you to give a little bit about your background before we dive into the specific topic today of breath work, which I am so excited to talk to you about.

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Dr. Jonathan Chung: 02:02
Yeah, so uh my background, I originally started out as an upper cervical chiropractor. So I did a lot of work um related to cervical spine injuries, particularly related to whiplash. That took me down into the concussion space because as we know now, a lot of people with concussions are starting to recognize like cervical spine plays a really, really big role. Um, through that, I ended up going and pursuing some training through the Kerrick Institute, as you're pretty well familiar with. Um, I took the traumatic brain injury modules with Dr. Carrick. I've taken several other modules through the Carrick Institute. And once I achieved diplomate status through the Carrick Institute, I actually became a faculty member for the Kerrick Institute as well. Um, a big passion of mine is just working with patients, especially related to concussion and a lot of the concomitants related to concussion. Um, because I feel like if you understand concussion, you understand a lot of other neurological dysfunctions that occur in patients even not related to concussion. Um, and that actually took me down the road towards understanding dysautonomia. So we started seeing, you know, more patients with POTS, just because our relation are just a lot of POTS patients, or a lot of concussion patients have POTS. And obviously a lot of vestibular disorders, a lot of concussion patients have vestibular problems. So I thought that concussion served as this great mental model for thinking about how do we treat other conditions that have a lot of these, I guess, non-specific symptomatology that's associated with hurting your brain. And it gives you this good jumping off point to really be able to design treatment regimens to help some of these patients because you have this holistic understanding of what's happening at the brain.

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Dr. Ayla Wolf: 03:43
Absolutely. That's so true. I mean, you can't really uh successfully or comprehensively treat people with brain injuries unless you understand all aspects of what the brain is capable of doing and supposed to do, which means you have to learn like every aspect of brain function, which then, like you said, also translates to other neurological conditions.

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Dr. Jonathan Chung: 04:04
Yeah, for sure. And that was one of the places where just treating people with upper cervical chiropractic, we're able to get pretty good results because so many patients have cervical spine injuries. But when you see enough patients that have concussions and you're like, yeah, a lot of these patients are getting better with, let's say, headaches or getting better with their equilibrium, but you can still see, like, hey, there's these deficits here. Like, they're still having this movement disorder, they're developing some of these FNDs. And without the knowledge that we're getting from in-depth neurosework that we've taken through our neurology training, you're just like, man, they're not even thinking about things like basoganglionic issues and the autonomic nervous system and all of these things. Now that concussion has become a much larger topic, not only in the neurology space, but everywhere, you they're starting to recognize, like, hey, you know, lots of concussion patients have autonomic nervous system problems. And that research has only been like super prevalent really in the past 10 years. So this is like still kind of a new phenomenon in the concussion space.

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Dr. Ayla Wolf: 05:11
Yeah. And I think there's really a lot more that we still need to learn about how the autonomic nervous system works and then how to effectively treat it when it's uh dysfunctional. And so that brings us to kind of our topic today, which is on breath work and I and I would say maybe just breathing in general, which is something that we don't always consciously think about. And obviously, when we are asleep, our autonomic nervous system is taking over our breathing mechanics. But I think what, you know, it's one of those things where when it's working, people don't think about it. But then all of a sudden, when you have a brain injury, we have to recognize that our brainstem has these uh, you know, nuclei that are responsible for inspiration and expiration. And this is like this finely tuned balance that can actually get disrupted. So why don't you first talk about maybe how concussions and brain injuries can actually cause disrupted breathing patterns? And uh let's start there.

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Dr. Jonathan Chung: 06:08
So there's probably a couple of mechanisms that we're looking at with concussion in particular. So we do know that the automatic parts of the nervous system, so we call them the pontomedullary reticular formation, which is basically you know a big word for brainstem. So that area is loaded with the neurons and the centers that control these automatic um control of our respiratory rate. So when we have a concussion, a lot of people have associated concussion with these cortical injuries. So even today, there's a lot of people that would associate like concussion with a bruise to the brain or something along those lines. But now we know that concussion is really associated with like these exonal shear type of an injury, and that external shear could happen through the superficial layers of the brain or into the deep layers of the brain. And when we talk about the brain stem, we're like looking at these really deep structures where that acceleration, deceleration is probably putting some exonal injury through not just the cortical layers, but also through some of those brainstem motor pathways, too. So that's one mechanism. And the other mechanism is going back to what we understand with the autonomic nervous system is concussions are so heavily associated with disruptions between the balance of the sympathetic nervous system that dictates our fight or flight response and the parasympathetic nervous system, which is going from a simplistic standpoint, is going to be that rest and digest response. And when that system starts to go out of balance, most of the time, people leaning much more into that hypersympathetic type of a physiology, then that's going to affect all the systems that are connected to the autonomic nervous system, which includes your respiratory rate, your cart rate, um, your digestive rhythms, and all of those things that are connected into that. So I think those are some of the big ways that you can affect breathing on a physiological level. But we also have to kind of take into account that when people have some of these mental concomitants, meaning that after concussion, they start to become more anxious, they have anxiety, then that's going to affect the way that they're processing some of these fear-related responses. And then you can have a mental input into how you're breathing as well. So I think those are the three ways we're probably seeing some of the effects in um affecting someone's respiratory rhythms.

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Dr. Ayla Wolf: 08:34
Yeah. And I know you usually for me, there's a bit of a red flag that goes up when I have a patient that comes in and says after a concussion and they say, uh, every morning when I wake up, I feel dizzy or lightheaded, I have brain fog, I have headaches, I'm exhausted. And, you know, they will often say, like, I feel hungover even though I haven't had any alcohol. And so when someone like that walks into your office, are you kind of immediately jumping to, hmm, I wonder what's happening with their breathing patterns when they've been asleep for eight hours at night?

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Dr. Jonathan Chung: 09:06
Yeah, totally. Um, and we know that uh sleep disruption is pretty well established in the literature and concussion, where there's a lot of um sleep-related disorders that occur, which obviously sleep apnea kind of falls into that spectrum, but there's also circadian rhythm disruption, too. Um and there's some really interesting, fascinating research on using circadian types of therapies to help um restore sleep rhythms in patients with concussion using um really early morning light types of therapy. So I'd think both that circadian disruption and the potential for sleep apnea developing, especially if that patient with a concussion has an underlying metabolic dysregulation. So they have obesity or other types of diabetes, some of these other metabolic syndromes, and they're going to be at a higher risk for that sleep disordered breathing, regardless of the concussion picture. But concussion is probably going to make that come to the surface a lot easier.

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Dr. Ayla Wolf: 10:03
Yeah. And so for our listeners, can you maybe define the difference between uh sleep apnea as a diagnosis versus sleep disordered breathing?

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Dr. Jonathan Chung: 10:12
So sleep apnea is basically a condition in which someone is going to have a stoppage in their breathing rate at some point during their sleeping cycle. Um, people don't usually know that they have it unless they share a bed with someone and they wake up in the middle of the night and they recognize that someone stops breathing for all intents and purposes, then they start to breathe quickly in order to try to catch their breath. And a lot of this happens below the level of consciousness. So people that have this have no idea that this is actually going on. They'll wake up, they feel like sleep is very unrefreshed. Um, and there's a lot of negative physiological consequences that come with sleep apnea, including higher risk of metabolic disease, higher risk of cardiovascular disease being two of the main drivers of that. And sleep apnea has a lot of um other concomitants related to it. We talked about how metabolic disease is part of it, but there could also be airway restriction problems, which I know people in dental medicine are looking at that. They're evaluating the airway on technology like CONE BMCT scans and looking at that um piece of the puzzle. Um, and sleep disordered breathing can encompass multiple layers of breathing disruption that occur with that. And you could even put sleep apnea underneath that umbrella with it. But sleep apnea is like the one that kind of sits at the top because we have diagnostics that pick up on this pretty readily that can be done at home. So other types of disorders you might have to go through like a sleep lab in order to get assessed for that type of thing. But sleep apnea, there's so many ENTs and dentists and other physicians that actually can send you and order a home kit to pick up on if you have sleep apnea. Um, so that would say those are the kind of the way that we think about it.

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Dr. Ayla Wolf: 12:05
Yeah. And I think it's so helpful now that we have that technology, because I know sometimes it can be a six to 12 month wait list to get into an actual sleep laboratory where you're going to a clinic to sleep and have have your sleep monitored well the whole time.

Dr. Jonathan Chung: 12:19
Yeah, and it's expensive. And a lot of people like just the act of going to a place where you're going to be monitored, it's probably going to be a very unusual situation for you to even see what a normal night of sleep actually looks like for you. So this allows you to have a non-invasive way of getting probably a good picture of that. Um, while the home study is, you know, more incomplete. But if you're just looking for sleep apnea, then it's probably more than suitable to pick up on that type of thing.

Dr. Ayla Wolf: 12:51
Yeah, definitely. And then, you know, I have some patients that talk about having um air hunger where they feel like they just can't get enough air in. Um, we also kind of mentioned the idea of anxiety can potentially cause shallow breathing. And so when someone comes into your clinic, like what are some of the ways that you're kind of assessing their breathing patterns or their um their, you know, breath work, so to speak.

Dr. Jonathan Chung: 13:16
So when they're in clinic, I'm mainly just looking at things like their resting respiratory rates. So where I'm gonna get a lot of that information is really gonna come from their history. So I'm going to ask questions that kind of steer me towards the idea that they may have something like sleep disorder, breathing, or sleep apnea. So we'll ask them questions about their sleep. We'll ask them, do they feel refreshed in them if you get eight hours of sleep, or do they still feel pretty unrefreshed? Do they have issues like when you wake up? Do you have headaches? Do you have any symptoms when you're first waking up in the morning? Um, we'll also take a look at just the way that they breathe. So we'll look at the mechanics of how they're breathing when I'm in the middle of a consultation. So we do we notice do they take really shallow breaths and is their respiratory rate really high? Do we notice that they breathe a lot through their neck? So do we see a lot of shoulder elevation when they're breathing? So those are some things that I'm kind of taking a look at while someone is in the room with me. And then when we actually start to examine the patient, we'll actually feel some things, like we'll feel the for the tone of their scalene muscles and their SCMs, because people that are breathing through their chest and through their neck is going to tend to have hypertonicity along those scalenes. Um, we'll put our hands along their ribs and we'll kind of feel if there's any asymmetry in the way that their ribs are moving. So if you notice that one side is moving more than the opposite side, then we might think, oh, they might have some problems at the ribs, the intercostal muscles. And then we could also do some palpation at the level of the diaphragm and observe for any signs of tension or anything along those lines. So those are some cues that tell us, hey, maybe there are some mechanical restrictions to the way that their diaphragm can't get a full inspiration. And that's leading them to get these compensatory patterns on that. Um, but then we'll also take a look at things like, hey, how is your history? Do you have a history of anxiety before you had this head injury, or do you even have anxiety after you've had the head injury? Because obviously we know that the mental emotional circuits can have some of these pronounced effects on their muscle tone too. So those are some things that we're looking at. And then we might do one of those things from just like a test and retest type philosophy that we use in functional neurology, is we'll actually challenge the patient to see if they could actually take breaths through their diaphragm versus taking their normal breaths and how much different does that look? Because when we teach people, it's like, I want you to breathe through your diaphragm and try to inhale into your belly and into your abdomen. And when you see people do that, instead of breathing into their abdomen, they're like, they're raising their chest higher instead of going into that abdominal form of breathing. So those are some cues that just tell us, like, hey, this person just like the way that they've gotten used to breathing over a long period of time, it's probably dysfunctional and it might not be any muscular or mechanical problems at all. It's just the way that they've their brain has become plastic to how they've been taught to breathe has been a little bit uh, I don't want to say that it's negative, but like it's not, it doesn't fit an optimal pattern for someone that wants to get the most out of their breath.

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Dr. Ayla Wolf: 16:25
Do you find that there's a lot of correlate or overlap between people that do have disordered breathing patterns and also have uh more severe forms of dysautonomia or even moderate forms of dysautonomia, where um you're you're also doing these autonomic assessments and finding some clinical findings there, or maybe looking at heart rate variability and seeing that those scores are also low.

Dr. Jonathan Chung: 16:50
I don't know if the correlation is quite there, to be honest, because I think dysautonomia is there's so much complexity in there between the metabolic cascade issues where a lot of people with dysautonomia probably have these gut health issues. They have um some of these inflammatory and autoimmune issues that are probably contributing. So you could have someone with autonomic issues where they actually mechanically breathe fine, but we actually have to teach them a new way of pacing their breathing in order to help them address some of their autonomic complaints. So they might not have a dysfunctional breathing from a mechanical standpoint, but because of their symptomatology, their bodies have adopted this way of having a more rapid pace of breathing. And then obviously, when you just don't feel well, um, that's going to impact the way that you breathe on a day-to-day basis because you're breathing in a way that reflects someone that has a physiology that is kind of sick. And that doesn't necessarily mean that it needs to be fixed in such a way, but it allows us to have an entry point into the autonomic nervous system to help the patient gain a little bit of control over their physiology. I think that's one of the more powerful aspects of breath work is the fact that I don't necessarily have to fix something on you. I just need to give your nervous system a window into something that is more calming so you have something that you use for yourself to self-regulate.

Dr. Ayla Wolf: 18:24
Yeah, well, what a great transition into this whole concept of breath work. And I think that there's a lot of information obviously out there on the internet about breath work. And so people often have some preconceived notions about what it is or maybe what it isn't. So why don't you talk about kind of less like umbrella of what breath work is? And then I'm there are lots of different practices that fall underneath that umbrella, some that are maybe beneficial for a person with post-concussion syndrome, and some that maybe are not. Uh so let's let's dive into that.

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Dr. Jonathan Chung: 18:58
Totally. So, in some of the coursework that I've taught, I've um kind of classified breath work into two large types because you could go into the weeds of all these different forms of breath work. You have ones that are pretty popular, like the Wim Hof breathing style, which we would classify as more of a fast-paced hyperventilation style of breath work. And then most of the breath work that is taught through spaces like yoga and um we'll use like the oxygen advantage taught by Patrick McKehan. Um, they use a slow paced style of breath work as a way to train their autonomic nervous system to be a little bit more calm. We're getting into things like vagal activation and things along those lines. So the way that I instruct breath work is gonna be we're gonna go with a fast paced, stimulating type of breath work versus a slow paced, calming type of breath work. And the literature is actually pretty interesting because both styles actually help people in terms of. Their mental health outcomes. So that's the good news is that both styles can actually help people on average. Now, when we're working with patients from a neurology standpoint, we're not necessarily looking for what can help the person on average, we're looking for what can help the person and the individual in front of you. Because one style of breath work for that type of person that is usually beneficial might not be helpful for that specific person. So, what we do know from the concussion literature, they've been using tools like heart rate variability to measure how slow-paced breathing affects some of these patients with concussions. So, one of my favorite methods is using HRV biofeedback breath work, where you could use an app or you could use a device to actually measure your heart rate and your heart rate variability in real time while you're doing breath work. And getting that biofeedback actually helps to entrain the nervous system to get used to that slow pace of breathing, and it gives them a positive feedback loop that actually is quite calming for their nervous system when they are actually accomplishing the goal set by the app. So for a concussion patient, I usually default towards a slow paced breathing style called resonance frequency breathing, which encompasses one breath cycle taking about 10 seconds. So on a very easy way is a five-second inhale and a five-second exhale. But the closer you can get that to a four to six ratio of a four-second inhale and six-second exhale, that's usually kind of the sweet spot for optimizing heart rate variability.

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Dr. Ayla Wolf: 21:30
Awesome. That's great that you can let people have that kind of immediate biofeedback looking at the heart rate variability as they go through the breathwork.

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Dr. Jonathan Chung: 21:40
Yeah, and there's some pretty easy to use tools. I advise many of my patients to use the tool. The one that I have people use, if you have an iPhone, it's called HRV for biofeedback. Um it was developed by some of the same people that use the app. It's called HRV for training. So it's really simple. It costs about nine or 10 bucks. And it gives you that real-time feedback on what your heart rate is doing while you're going through the breathwork practice.

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Dr. Ayla Wolf: 22:09
Awesome. Awesome. Well, I'll definitely put a link uh in the show notes to that so people can check it out. And so you you have some pretty well-established tools and kind of a breathwork model that seems to, for the most part, work well for people who benefit from more slower-paced breathing techniques. And so you're kind of assessing people in your office and seeing where there's a place to incorporate these breathing techniques into their day-to-day lifestyle. How often are you recommending people actually do this type of breath work or for how long?

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Dr. Jonathan Chung: 22:44
For many of my patients, especially from a nervous system regulation, I want them to engage in this with about five minutes per day. So if you could get someone training five minutes per day, it's going to establish a habit that they feel is beneficial for them. And it's like a place where once it becomes a habit, then they can start to use it as a pattern interrupt whenever they feel like their nervous system is getting a little bit too revved up. So I don't need patients to do a long period of time for breath work, even though the longer periods of breath work can probably be more beneficial for them. But if I could give them a short window, it's like, hey, can you give me five minutes per day to work on this? Most patients are going to say yes. And once they say yes and they actually start to do it, like about 80, 90% of patients that I teach this to, it's like, yeah, it's really useful for me. Like I feel like when I'm starting to get a little bit anxious, I'll just
take a slow exhale out and they can feel some of the anxiety start to wash off of them in that moment in time, which is actually quite empowering for a patient that, hey, I have something that I could use that will keep me from possibly flaring some of these autonomic symptoms that make people feel miserable. So there's a lot to the psychology of just giving something that a patient can do actively that gives them some measure of control of their physiology. And one of the things that I talked about in my course is that there are yogis that have gone so deep into breath work where they could use breath work in such a way that it could change their physiology enough that they could actually give themselves a fever. And they could actually give themselves a fever that could actually cause the sweat on their clothes to evaporate. So this is even beyond the level of what we're using for our patients, but it just opens the possibility that if you control your breath, you can control your physiology. And giving that people a sense that they can control their physiology is really empowering for a subset of patients that feels like their physiology is just running out of control on them.

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Dr. Ayla Wolf: 24:49
Yeah, absolutely. And then uh tell me a little bit about nasal breathing. Um, I've practiced some different types of nasal breathing, but um, I know you had mentioned that there's some really interesting research on that as well. So let's uh let's go there.

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Dr. Jonathan Chung: 25:05
Yeah, so nasal breathing has become really popular because there's a couple of different things. Like mouth breathing has become something that people kind of deem as like this socially unacceptable thing where it's actually used to like make fun of people. And in the dental research, there's some interesting stuff that shows that people at mouthbreat actually have a lot of um facial structural changes um that occur when people are mouthbreathers. So we see this when people have like adenoids that are very enlarged and it forces people to become mouth breathers. They actually see that there's this constriction of their jaw and there's a narrowing of their facial structures that reflect that. But from a brain standpoint, um there's actually a really interesting study that showed that people that nasal breathe can actually get greater entrainment of their cerebral cortex for whatever activity that they're doing. And for listeners that don't necessarily know what entrainment is, it means that you're getting wide areas of your brain that are basically firing together. So the more that you can entrain your brain, you have a greater chance of creating plasticity because you have multiple neurons that are actually working together for a specific purpose. And one of the studies, they actually use nasal breathing versus mouth breathing while they are conducting some of these cognitive tests and cognitive assessments on patients. And what they notice is that when you nasal breathe, they were creating this widespread entrainment of all these cortical regions, but they actually perform better on those cognitive assessments compared to the mouth breathing group. So they think that there's this mechanism that when you breathe through the nose, you're activating certain structures within the olfactory bulb that probably aids in stimulating some of those frontal centers and how the neurotransmitters will spread from those frontal centers throughout the rest of the brain that might be aiding in the plastic effects from nasal breathing. And they've done some animal studies too, where they think that we had evolved to become nasal breathers because four-legged animals they use their nose to basically map out their environment. And because that was such an important feature for quadruped animals, it's something that is left over from that. So even though we use our nose for smell identification, and that's really about it, we're not using it for spatial navigation, but the remnants of that neurology probably means that when we breathe through our nose, it's probably having this greater effect on plasticity when we use it that way.

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Dr. Ayla Wolf: 27:43
And then would that also translate to some people talk about you know breathing in through one nostril and then breathing out through the other nostril and kind of alternating nostril breathing as a way to somehow get more like cross-hemisphere connectivity going? Um, is there any research to substantiate that type of practice?

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Dr. Jonathan Chung: 28:02
There is some research. Research is kind of mixed though. So they have done research comparing um unilateral nostril breathing to see if there's any specific effects from breathing through one nostril versus the other side. And they weren't able to find unique effects from breathing through the left nostril versus the right nostril, but they did find that the practice of nasal unilateral nostril breathing is pretty effective in improving cognitive awareness and alertness and things of those on those lines. So, one of the things that um we think that multiple styles of breath work tend to have a trend towards having similar effects across groups, is that just being being conscious of how you're breathing is probably doing some unique features into our cerebral cortex that enhances plasticity. So, while there might not be a unique hemispheric effect of breathing through one nostril for the other, at least based on the current research, it does show that if that's a style of breath work that is interesting to you and has saliency, it's probably going to aid in neuroplasticity because it just makes you more conscious and aware of what you're doing from a respiratory rate. And because breathing is so fundamental, anything that we use to manipulate our breathing and put a lot of um mental real estate towards that effect is probably going to have some favorable changes from a cognitive standpoint and a mental health standpoint.

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Dr. Ayla Wolf: 29:26
Sure. And then a lot of the times when I have somebody with a concussion, they often, well, I won't say often, but there are some cases where people do have an elevated kind of resting heart rate, where maybe their resting heart rate was 70 beats per minute, they get a concussion, and now they're finding they're like hanging out at 90 to 95. Um you find that if people practice these kinds of uh slower breathing practices, that that can actually help to kind of modulate that back to where they were at baseline?

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Dr. Jonathan Chung: 29:59
Definitely. And it's certainly one of the first go-to strategies that I use for patients with POTS and they're having some just resting tachycardia, is we will spend a lot of their first visit just working on slow-paced breathing. So we'll work on the mechanics of how they're breathing. Um, but most importantly, I just want that rhythm to start to slow down. And it's one of the things that we have to like be gentle with how we teach people and how we change their style of breathing when they have something like POTS. Because any time that we're changing things with a patient with dysautonomia, there's a non-zero possibility that it's going to be overstimulating for their nervous system and they might have a short-term negative effect from that. Um, but for those patients, if we could actually get them to buy in and actually practice that breath work and kind of endure some of those short-term negative effects, then it'll help them get to the point where it actually feels quite therapeutic for them. Um, so that is something that we have seen is that sometimes if their nervous system is really overstimulated and it's very easy to overstimulate, you probably want to be very slow in how you transition someone to doing slow-paced breathing. So, taking an example, if I want someone to breathe at a rate of about five second inhales and five second exhales, like
I might not start at five seconds for a patient that I sense is going to be overstimulated. I might start them at three and three. So I just want their exhale to be equal to their inhale because most people they spend a lot of time in the inhalation phase, but I actually want to start to train people to actually make the exhalation phase longer because the longer that we exhale, the more you're actually getting access to some of those vagal parasympathetic fibers through the exhalation.

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Dr. Ayla Wolf: 31:44
Yeah, you know, I've I've experienced that myself with running. I I used to be a trail runner. Now I hate running, but I have to do it in CrossFit. And so I find that I will try to breathe through my nose in a very controlled way while I'm running. And then it's like all of a sudden, it's like the kind of like pressure builds and builds and builds where it just feels hard. And all of a sudden I find myself like hyperventilating. And so I've even found for me that it is very much easy to do nice, very slow inhalations and very hard to control that exhalation.

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Dr. Jonathan Chung: 32:19
Yeah. And like the cool thing is, is like when you get control of that exhalation phase, it is such an easy way where anytime anything is making you anxious, I just tell patients, hey, just focus on the exhalation. Just make that exhalation nice and long. And so many times you'll actually feel the stress kind of drop off your shoulders just from starting to think about your exhalation instead of starting to think about that inhalation. Because inhalation, like we think about taking a nice big deep breath. Like our inhales are actually sympathetic stimulating in a short little bit of a way. So if I could switch gears with them and just get them a little bit more into that parasympathetic mind by doing an exhalation and getting used to the idea that the exhalation phase is where that parasympathetic nervous system kicks in, then it does something pretty cool for patients.

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Dr. Ayla Wolf: 33:09
Yeah, no, that's magic right there. And you're absolutely right. So many people, when they think about deep breathing, they immediately put their emphasis and their focus on the inhalation when it's really the exhalation where a lot of the magic is happening.

Dr. Jonathan Chung: 33:23
Yeah, and that's probably one of the other things that I learned a lot during my research is that when people feel short of breath, it's not because they lack oxygen. Because if you actually measure someone's O2 saturation, like it takes a long period of time without oxygen in order to get that number to actually start to drop down if you have normal physiology. So when people feel that sense of air hunger, like they need to breathe, it's not because we don't have enough oxygen, it's because our bloodstream has a lot of carbon dioxide in it. And we could actually train our ability to have increased carbon dioxide tolerance, meaning that that feeling that we have where we feel like, oh, I gotta take that breath, we could actually hold our breath a little bit longer if we just get used to how much carbon dioxide is inside of our bloodstream. So there's a whole segment of people that do athletic performance breath work, where it's called CO2 tolerance testing, where they do these long breath holes to help the brain and help the nervous system recognize that, hey, if your CO2 is a little bit high in your bloodstream, you're gonna be okay. And by having it be okay, like there's actually some other interesting studies that show that if you treat a patient with anxiety and have them breathe like carbon dioxide rich air, it'll actually cause a little bit of induced a little bit of a panic type of attack. But if you can actually train someone to actually get used to the sense that there's a lot of carbon dioxide in your blood and that they're going to be fine, it actually helps to lessen the anxiety in some of these small studies.

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Dr. Ayla Wolf: 34:54
Yeah, interesting. I mean, it's always incredible to me to hear about like the free divers who can be under the water for like five minutes. Amazing. Amazing. Yeah, yeah. And that just, I mean, that's the same concept, right? It's like they've just trained their body to not panic when they have that sense of like, I need air.

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Dr. Jonathan Chung: 35:11
Yeah, correct. And this is like part of like why I've kind of taken on this, like the anti-fragile chiropractor moniker, is that, and it's my belief system, whether we are healthy or whether we are sick with something like a concussion or other issue, is that our bodies are likely more capable of what we think they are capable of. And we see this every day when we see like someone like we'll take the free diving example. Like, there's a whole subculture of women in Korea that goes free diving for pearls and they could hold their breath for like seven minutes underwater. And it's just these little tiny Asian women that are like in their 50s and 60s that are just doing this remarkable feat of athleticism, and they're not even thinking about it because it's just embedded into their culture. And it shows us that we could actually train ourselves to be tolerant and to be capable of things that are beyond what we think of because what we think we can accomplish is just created by what society says this is what normal is supposed to look like. But we see people that end up doing things like they go and Cert du Soleil and do these amazing feats of balance or these amazing feats of strength, or we go in the CrossFit and someone that had never imagined lifting 225 pounds off the ground is suddenly doing 400 pound deadlifts. So it's all just about like having the little bit of belief and then doing what's necessary from a behavioral standpoint to accomplish the goal that they wish to accomplish.

Dr. Ayla Wolf: 36:44
Yeah, I love that. I think I read a well, I know I read a book about the the women in Korea that were doing the diving for for I think pearls, but also like for you know seafood as well. But yeah, there was a whole phenomenal book I read about that. It was incredible.

Dr. Jonathan Chung: 36:60
Yeah, I think it was uh maybe it was Endure by Alex Hutchinson. You ever read that one?

Dr. Ayla Wolf: 37:05
Well, I think the book I maybe I think the book I read was a fiction novel, but it was kind of historical based.

Dr. Jonathan Chung: 37:11
Cool. Yeah, I know there's a couple of people that wrote about it. So it was it's a pretty cool thing.

Dr. Ayla Wolf: 37:16
Yeah, absolutely. But yeah, like you said, it's it brings up that point. Like if you grow up in a culture where that's normal and it's like you start out uh small in small increments and you just kind of work up and work up to being able to dive deeper and stay under longer, then it's like, yeah, that just becomes the norm.

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Dr. Jonathan Chung: 37:33
Yeah, exactly right. And it's the same thing with like elite level like Kenyan runners. So like they have some advantages, like you know, they have some genetic advantages and they have some environmental advantages by living at you know certain altitudes. But there's people that will make the cases that like a lot of Kenyan runners, they grow up where they live far away from their schools and they have to run to school. So if you are running to school from the ages of like five to like 13, of course you're going to have this unbelievable VO2 max. Of course you're going to be one of the best runners in the world if you keep on developing that skill and that talent. Um, so I think there's there's something to that.

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Dr. Ayla Wolf: 38:15
Yeah, yeah, so true. Well, I it's fascinating that you talk about this idea that you actually bring breath work in sometimes at the very first visit with patients. And I that just kind of speaks volumes to um giving somebody the tools, like right out of the gate. You know, they come in for the first visit and you're immediately handing them a tool that they can use anywhere, anytime to help regulate their physiology. So that's that's incredible.

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Dr. Jonathan Chung: 38:42
Yeah, and it also goes back to, I know some of our training through the Kerrick Institute is like we see this pyramid, right? So in that pyramid, we're looking at what are the priorities for what we should think about when a patient is struggling with neurological issues. And at the base of that pyramid are gonna be your autonomics, right? So we have to have a patient get some level of control over their autonomics. Otherwise, some of the conscious planning and some of the movement issues and some of the reflexes are gonna be less effective if we know that patient can't control their autonomic nervous system um in a meaningful way. So I take that into account as like, hey, we're going to target your autonomic nervous system. One of the things that we need to get good control over is the fact that your sympathetic nervous system is on this overdrive. So let's just start from the beginning and get your sympathetic nervous system to find some methodology to wind down. And we're going to do other things besides breath work with you, but nothing else that we do is going to be as effective if we can't get your autonomics under some meth some semblance of control.

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Dr. Ayla Wolf: 39:47
Yeah, absolutely. Well, and as you mentioned too, with the the ability to have proper and healthy rib cage excursion, you know, so many people with concussions have been in car accidents where they have a seatbelt that, you know, is causing actual bruises. And trauma to their chest and their ribcage. And so a lot of people are coming in with actual kind of mechanical and physiological reasons for why they're struggling to have good, you know, deep breathing mechanics.

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Dr. Jonathan Chung: 40:13
Totally. And that's where, like, you know, I'm grateful for being a chiropractor and having that training. So like we could adjust the thoracic spine, we could do some manual therapy into some of those muscles that are around their respiratory system. So we might have to do a little bit of manual work on their scalines. Maybe we have to do a little bit of work into the rib cage. So being able to have some of these tools, I think, is really useful because not only do we want people to adjust the pace of their breathing, but we want their breathing to be more comfortable, more robust, and feel like they could get more units of oxygen per breath than they could before.

Dr. Ayla Wolf: 40:49
Yeah, absolutely. Um, well, is there anything that we haven't talked about that you wanted to dive into today regarding breath work and this whole topic?

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Dr. Jonathan Chung: 41:01
Um, I think one of the things that kind of inspired me to get into breathwork was I had abdominal surgery back in 2022. And as I was recovering from abdominal surgery, um, I read this really great book. It's called Breath. It's by James Nestor, and he's kind of like probably the most famous person in regards to breath work right now. So it's a really short read, and it's really inspiring what you see that's in that book because you can see how like breathing is just this really fundamental thing, but it's also a way where no matter what type of illness that you have, if you improve your breathing, you're probably gonna have some positive impact on your illness. And they use it to talk about like patients with autoimmune diseases and patients with asthma and all these other things that you know people default to treating with medicine, which there's a time and place for all that. But if you want to give patients control over what's going on inside of their bodies, then this is such an easy way to do that. And it made a big difference for me because as I was recovering from my surgery, like fitness has always been a really important thing to me. And I wasn't allowed to exercise for eight weeks after I had this abdominal surgery. But one of the things that they did say is like, hey, you could, you know, do breathing exercises, and they encouraged me to do breathing exercises while I was in the hospital. Um, so my 30 minutes of exercise I would do per day, I would actually just get a pillow, put it against my belly, and then I would just practice doing breathing exercises and slow-paced breathing while I was in the hospital. And they it got gave me the green light. And one of the things that I noticed is that like when I was in the hospital, my HRV tanked, obviously, because of the stress of having surgery and being on antibiotics and just the negative environment of the hospital itself. So it was pretty low for a couple of weeks. But as I started to do the breath work, we actually see like my HRV was actually rising back up to my baseline levels, even without doing a lot of the physical activity that I'm used to doing. So it that just spoke to me of like how powerful something like this could be for someone's physiology just by adding something so simple. And yeah, I took a longer period of time to do that breath work during that hospital stay. But now, like it's just a five-minute part of my day. Like I wake up in the morning, I did five minutes of breath work in, and then I start off the rest of my day after that.

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Dr. Ayla Wolf: 43:27
Yeah, I think sometimes we want to like seek out some of these super high-tech, cool cutting-edge therapies, and then uh we forget that something as simple as uh focused breath work can have such powerful effects on things like our heart rate variability and our entire physiology, and it's free and it's pretty easy.

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Dr. Jonathan Chung: 43:48
Yeah, and especially like if you talk to like some elite athletes too, like some of these MMA fighters that train, like they're not talking about like this gadget that helps you like accelerate your punch as fast as possible. They're not talking about like, you know, we have some cool tools that help people recover. But one of the things that if you train, like the first thing that a martial artist is going to tell you when you're in the heat of combat is like you have to control your breath. Because if you don't control your breath, you're gonna flame out and it's just
gonna make it that much easier for your opponent to take you down. So they teach as like their fundamental things, like when you're in the heat of battle, like you have to control your breathing because you have to control your physiology, otherwise, you're just gonna burn out. And it's something that I think uh it's a good lesson to take for just the the fight everyday battles that we have in life, too.

Dr. Ayla Wolf: 44:40
Yeah, absolutely. And you know, there are times when I show up to CrossFit and I look at the workout and I'm just like, oh, this is totally gonna suck. And I have and I have to tell myself, like, see it as literally a breathing exercise. Like, forget about all the actual movements that you're gonna have to do for the next 22 minutes here. Just literally, like all and all I'm gonna focus on is doing the movements, but my awareness is gonna be on my breath the whole time. And then before you know it, it's like the workout's over.

Dr. Jonathan Chung: 45:08
The workout's over. Yeah, exactly right. Exactly right. And yeah, like we know it's going to suck, but when you could actually control your breath and your physiology, then it just makes it suck just a little bit less to actually maybe get a little bit more performance out of it.

Dr. Ayla Wolf: 45:24
Yeah, yeah. Well, and if you can, you know, avoid that kind of anxiousness that can build up when you're tired or like if you're in a physical fight. Um, yeah, I mean, I've done jujitsu, I know what it's like to, you know, feel like you're being choked, or someone is just you know on top of you and you can't breathe and you've got all this weight on your stomach. And it's like if you don't control your breathing in that moment, uh you you just lost.

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Dr. Jonathan Chung: 45:47
Yeah, correct. Correct.

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Dr. Ayla Wolf: 45:49
There was a time I was learning how to surf in Australia and a huge wave came and I just got sucked into the washing machine of the wave, and the board hit me on the back of the head really hard. And in that moment, it was like my brain just said, You need to be super relaxed right now because if you panic, you're gonna drown. And I just remember my my whole body just going into this like really quiet space where I was like, Okay, we're just gonna like wait to wait for this washing machine to kind of like ease up so that we can swim back to the surface of the of the ocean here. But it was like in that moment, I think a lot of my athletic training kicked in to say, like, you just got hit on the back of the head of the surfboard, you're stuck in the washing machine of this really powerful wave, and you need to be absolutely calm right now.

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Dr. Jonathan Chung: 46:43
Yeah, no, that's so true. And like, you know, that is a thing for people that drown. And unfortunately, like there's a lot of drowning that happens in Florida. But one of the things that they teach you is like, you know, you have to control your physiology when you're in the water because so many people will have these drowning accidents and they're not in any deep water water that's deeper than three feet, but they're so panicked that like they didn't even recognize that they could just stand up and they're actually gonna be fine. So there's there's things like that that do happen, which is why like being able to make your mind and bring your mind under a sense of control, which is like we talk about the top-down components of breathing, like using your cerebral cortex to actually physically demand that your physiology start to calm down, I think is such a really powerful influence on our nervous system.

Dr. Ayla Wolf: 47:37
Yeah, yeah. And all of that can be trained through breath work.

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Dr. Jonathan Chung: 47:40
Yep, totally.

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Dr. Ayla Wolf: 47:42
Yeah, love it. Awesome. Um, well, why don't you tell people kind of where where they can find you, uh where your clinic is located, and then I'll put links to all of that in the show notes. And um, and just for clinicians who might want to learn more about breath work too, I know your breath work course is a 15-hour course, um, primarily for clinicians, correct?

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Dr. Jonathan Chung: 48:03
Yes. So I'm in uh West Palm Beach, Florida. So I'm in Wellington. My clinic is called Keystone Chiropractic and Neuroplasticity. Um, people that follow me, like they follow me at Dr. Jonathan Chung on Instagram or TikTok. Um I'm also my clinic webpage is at Keystone Neuro. Um and for the Carrick Institute, I teach an eight-hour course on breathwork. And it's at uh if you go to at the Carrick Institute.com, um you could look up the neuroscience of breath work, and then you'll see my class on there, which you know it's a fun class to teach. And then we get into like the nitty-gritty science of a lot of that stuff. So if you're pretty nerdy about that stuff, like the actual recommendations for practice of breath work is pretty simple. But if you just really want to get into the weeds on what's going on from a neuroscience level, then we break into a lot of those pathways and other methods that people can train their ability to breathe and other methods like um we'll talk about hypoxic air breathing, um, we'll talk about breath hold training and all that stuff. So if you have an interest in that stuff, then uh definitely check it out.

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Dr. Ayla Wolf: 49:11
Excellent. Well, I'll put all that in the show notes for people.

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Dr. Jonathan Chung: 49:14
Sounds good.

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Dr. Ayla Wolf: 49:15
Yeah, well, thank you so much for coming on the show. This has been just a wealth of knowledge and a topic I've wanted to talk about for a while here on the show. So I'm so glad to do it with you.

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Dr. Jonathan Chung: 49:24
Thanks, I would.

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Dr. Ayla Wolf: 49:25
Yeah, yeah. Well, have a good night.

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Dr. Jonathan Chung: 49:28
You too.

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Dr. Ayla Wolf: 49:29
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