132 - Rosalba Courtney & Hadas Golan - Dysfunctional Breathing in Long Covid

Episode 132 of the Long Covid Podcast is a chat with the wonderful Hadas Golan & Rosalba Courtney. Hadas and Rosalba have been collaborating on working with people with Long Covid and have recently published a series of case studies detailing their successes.

We take a deep dive into my favourite subject - breathing - discussing some of the underlying pathology and how this relates to using breathing as an intervention to help Long Covid, if done correctly.

This is the link to the published article in the journal of Voice: https://pubmed.ncbi.nlm.nih.gov/37316403/

Contact info: info@breatheon.com

Hadas Golan website: https://www.breatheon.com/ & link to Long COVID page https://www.breatheon.com/long-covid/

Long COVID page on the BMC website: https://www.bmc.org/long-covid-breathing-groupI

Rosalba Courtney website: www.rosalbacourtney.com 

And information about IBT: www.integrativebreatingtherapy.com

For more information about Long Covid Breathing courses & workshops, please check out LongCovidBreathing.com

(music credit - Brock Hewitt, Rule of Life)

Transcript

Jackie Baxter  
Hello, and welcome to this episode of the long COVID Podcast. I am super excited today to be joined by Hadas Golan and Rosalba Courtney. And we are here to talk about my favorite subject, which is breathing. 

So these guys have just released a paper, I think is that the correct word, on basically how amazing breathing is. So we're gonna talk a lot about that and dive into all sorts of rabbit holes, I'm sure. So a very warm welcome, both of you, to the podcast.

Rosalba Courtney  
Thanks, Jackie.

Jackie Baxter  
So to start with, would you mind saying a little bit about yourselves. And I guess what it is that you kind of do?

Hadas Golan  
All right. Just to add to what you said about the paper, there was a third author. Jeremy Wolfberg, who was a graduate intern working with me at the time that I was doing the beginning of my work with long COVID. And so he helped with the measurements and the writing of the article. And now he's doing other really important research as a PhD student at Mass General Hospital, but not related to breathing anymore. 

And introduce myself, I'm a speech language pathologist or SLP. And I specialize in upper airway, or any kind of breathing and voice disorders. So medical SLPs, like myself, we treat disorders of the upper airway, meaning vocal cords related, so you know hoarseness, cough and vocal cord dysfunction, which is a condition with many different names, where kind of the people cannot breathe and the problem is in the valve kind of thing, the vocal cords, they can't breathe in. 

And I work in Boston University Medical Center in the Department of Otolaryngology or ENT. And but my real interest in breathing started after my lifelong asthma was healed with the Buteyko method, and that was complete, life changing. And after that I wanted to help others and spread the mission really, spread the word. I was so excited about that. 

So I became a practitioner, and then trainer and I developed courses for speech pathologist, promoting the idea that they need to be trained in dysfunctional breathing, the whole system, not only the upper airway, because it's common in our patients population. 

But you know, over the years, as  a Buteyko practitioner and clinician and a health professional, I had some unanswered questions with Buteyko. And I felt like it's only one piece of the story. And many patients might benefit from other approaches. And when COVID, when a pandemic started, I finally had the opportunity to get trained with Rosalba.

Rosalba Courtney  
I guess that's my turn to talk now. Okay, so I'm Rosalba Courtney. And my background is that I'm an osteopath. Also, you know, I've trained in other allied health areas as well. But when I was, a long time ago, probably more than 30 years ago, I know it was 30 years ago, because it was when my second child was born. And I took some time out of my practice, and I decided to really focus on learning more about breathing. 

And at that time, the Buteyko method had just come to Australia. So I got very involved with that. And, you know, became chairperson of the association and traveled to Russia and met Buteyko, and started training practitioners doing training courses with practitioners and working with patients. But it was like similar to Hadas, the more I learned, the more questions I had. And I ended up with more questions than answers. 

So then some of the big questions were like, how does breathing really heal? Do you know, and what is dysfunctional breathing? In the 90s there was a lot of controversy around what is hyperventilation? Is dysfunctional breathing hyperventilation, or is it something else? And so I actually did a PhD, which, you know, lasted for a good eight or nine years, and that PhD was called "dysfunctional breathing, its parameters, measurements, and clinical relevance". 

And out of that, I developed some models for assessing and treating and thinking about breathing disorders, and breathing therapy, and that became integrative breathing therapy. And, uh, so, yeah, when the pandemic came, I'd been teaching people just where I was in Australia, or traveling and doing some courses. But when the pandemic came, and I had a bit of time out of work, I actually developed a practitioner training course, that ran over about six months. 

And Hadas was, you know, in that first cohort, and you know, she's an amazing breathing practitioner in her own right, didn't really need me at all. But anyway, it was really great. And you know, that's where our collaboration started. 

And Hadas has done amazing work with long COVID. We both got very interested in long COVID. I got very interested in the research and looking at what is disordered breathing in long COVID? How does it affect people? What's likely to be, you know, the most useful approach? Because the whole IBT model is that, you know, the treatment's never about the technique. It's never about the technique, which I'm sure you would agree, Jackie, it's really about, you know, what's going to work for this person, how do we solve this problem? 

And how you solve the problem has to do with understanding, you know, the pathophysiology of the condition, what are the different ways that breathing is impacted? How potentially could you best work with breathing to, you know, impact that particular problem that you've got? And how do you adapt to what you're doing for for the patient? 

So, Hadas really took that into her, she was seeing a lot of long COVID patients. And she really took that integrative breathing therapy model, which is a very structured assessment, which Hadas I'm sure will talk about a bit more, it's a very structured assessment. And then there's a protocol that moves through the unified breathing system is one of the ideas. You know that the nose, upper airway, the lungs are all connected. 

And she, she developed a protocol, or delivered the protocol, which moved through all the different systems that worked with all the dimensions of breathing, as well as the other idea and integrative breathing therapy, that breathing is multi dimensional. That it's got a biomechanical leaning, like the muscles and the movement, and the patterns of breathing. And a biochemical which is about oxygen, carbon dioxide, pH. And then a psycho physiological component, which is that mind body aspect of breathing. Anyway. So that's a very long introduction, introducing integrative breathing therapy and myself.

Jackie Baxter  
Amazing, and I love what you're saying about, it's not a one size fits all. And I think, you know, no two people are the same. You know, nothing is ever a one size fits all, but certainly from what I've experienced with long COVID. And what I'm now seeing with the people that I'm working with, is that, you know, people with long COVID, and I think this probably includes other chronic conditions such as ME and and stuff that I have less personal experience with, is that these these people, they don't fit into the sort of traditional breathing models, or if they do, it's in a very special sort of careful, gentle way. 

And I think this is where, you know, this sort of adaption of existing stuff, exercises, protocols is important. And it's not to try and sort of stuf them into the asthma category or the whatever other, you know, conditions that you sort of traditionally see. And this is really interesting to me as well, because this is kind of what I've been doing. 

Maybe before we dive too deep into that bit, we should do a kind of what is dysfunctional breathing? And I know, you've just kind of alluded to the fact that this isn't really just one thing. But maybe a kind of overview of that would be really helpful.

Rosalba Courtney  
So it's interesting, because in recent years, people have been starting to interchangeably use the terms dysfunctional breathing and breathing pattern disorder, you might hear that term more in the UK, they're using that term breathing pattern disorder a lot. But in the literature, you'll find the term dysfunctional breathing. 

And so from the Buteyko perspective, you know, dysfunctional breathing is always hyperventilation, it's always, you know, breathing out more carbon dioxide than your body makes. You know, there are two dimensions. So breathing disorder would be one dimension of dysfunctional breathing, and hyperventilation would be another. 

But then there's this other dimension of dysfunctional breathing, which is just when the person is not accurately perceiving their breathing. So they're over perceiving or under perceiving their breathing, and breathing has become a symptom, it's become alert, if you like symptom, like pain becomes a symptom. 

So there's something disordered in the perception. So people are hyper vigilant to breathing or they're just disconnected from breathing. And their breathing is carrying messages of distress and unpleasantness, and they can't access you know, relaxed, pleasant breathing. So that's kind of the three key dimensions. 

So dysfunctional breathing is breathing, here's my definition, breathing that doesn't fulfill its primary or secondary functions, right? The idea being that breathing has lots of functions in the body. And those functions change depending on what you need the body to do. Right. So you breathe differently, if you're exercising, the breathing pattern, the Co2, the, everything needs to change when you're exercising. 

So the different functions of breathing are really much more than just moving air in and out of the lungs, you know, breathing functions as a rhythm, as an oscillating pattern that interacts with lots of different systems in the body. Breathing is talking to the heart, it's helping to move venous blood back to the heart, it's, you know, it's very important for speech and vocalization, it's important for a core stability, and it's part of the movement system, it's integrated with the movement system. 

So, you know, it's like, whenever breathing isn't fulfilling its functions well, it's dysfunctional. And it can show up in different ways. So if you're coming at it, from a clinician, you know, who has a clinical problem to solve, you try to understand how the breathing arose from that condition and how it might be reinforcing that condition. 

So dysfunctional breathing is breathing that doesn't have EAARS, so it means it's not efficient, adaptive, appropriate, responsive, or supportive of body systems. And I mean, I hope that's not too complicated a definition. But it's kind of to say, it simply, it's just breathing that isn't doing what breathing should do, and it doesn't feel good. It's leading to symptoms, and it's reinforcing the patient's condition.

Jackie Baxter  
Yeah, and like, I think this is amazing, because me of four and a half years ago, would have said, breathing is just something you do, you know, there's no right or wrong way of breathing. You either are or you aren't. And it's amazing how your perception of that can change as you discover it in whatever way that is for you. For me, it was through having experience of long COVID and discovering that my breathing was dysfunctional. 

And, you know, now, kind of understanding that it's not just some like woowoo thing, either, it is literally everything in the body, you know, it affects every single part of your body. It's not just anything. And it's, you know, it really is that kind of incredible power of it. Anyway. Yeah, I get so excited talking about breathing, my partner always tells me to stop talking about breathing, because it's all I ever talk about. So I think while I'm talking to you guys, I can talk breathing, right? 

Rosalba Courtney  
Yeah. And we can talkabout it for weeks. *laughs*

Jackie Baxter  
So yeah, you know, dysfunctional breathing, and long COVID? Or, you know, more widely, chronic illness. Why is this such a problem in chronic illness? Or is it more just that it is more apparent in someone with chronic illness?

Rosalba Courtney  
Yeah, that's really interesting. Something we're trying to understand it's like, yeah, it's like people with... long COVID is primarily a respiratory illness, although it hits the blood vessels as well. And it can affect, you know, especially with lung COVID affect all organs of the body. But you could say it starts off in the respiratory system, quite quickly moves into the vascular system. And we know that the respiratory and the vascular system are quite linked. 

So people who develop ongoing symptoms within the respiratory system, they often show up with dysfunctional breathing, so the breathing pattern changes and that can be hyperventilation and also, you know, breathing distress around breathing. 

And the reason that that is, is I think, my current feeling, and I'd like to hear what Hadas has to say, but my current feeling is that, you know, it's it's often driven by the bit of damage that's been done, you know, to the lungs into the vascular system, but also to the mitochondria. Because when Hadas and I both measure carbon dioxide in our patients, and we do find that, you know, there's a lot of hyperventilation. And the more severe the patient, the more likely they are to have a hyperventilation. 

But they're not breathing quickly. They're not like your classic hyper ventilator. So my thought is, so what's going on? So there's more co2 being breathed off than is produced, but the breathing doesn't appear to be excessively rapid, or even deep. So, is it really a problem with internal respiration? Is it really a problem with the mitochondria? Do you know, not making Co2. 

So in some ways, you know, the hyperventilation that you see in long COVID might be functional, meaning that it's responding to something that's going on in the body, the body's still needs to get oxygen, right. So person's still breathing to get oxygen. And if you just give them classic reduced volume breathing, like one would in Buteyko, it makes them feel terrible, you know, they can't do it makes them feel terrible, because they're not low in co2, because they're over breathing. They might be low in co2, because they're under producing. 

So the point being, then what they're not picking up, you know, oxygen well, and they're not matching, you know, ventilation to blood flow very well in their body. So that's kind of, there's a background of pathology that's driving all of this. And they try to get by the best way they can. So in working with breathing, you've got to work quite, you know, gently, but still, okay, so you get the person who then has been hyperventilating for a while. 

What we know is then that develops a whole lot of compensations in the body. And those compensations can become problematic in themselves. So that means that you work very gently to correct the hyperventilation, taking into account that that way that person's breathing, is in a way functioning for them. So you can't just come in with all guns blazing, do you know, to try and fix that. 

And then looking at some of the other research studies that have looked at the dysfunctional breathing in long COVID, they go, ah, we found diaphragm dysfunction. This weak, small, thin little diaphragms, these people have not been really using the diaphragm to breathe. And so you know, a lot of the treatments are around inspiratory resistance training and, you know, training the diaphragm to strengthen the diaphragm. 

And it's really interesting, why is that diaphragm gone weak? So it's because maybe the breathing pattern has changed, and so they haven't used the diaphragm. So it becomes important to train the diaphragm, because that diaphragm and the strong good action of the diaphragm is part of what's helping venous return, it's helping the blood get back to the heart, which then becomes your stimulus for improving the function of the circulatory system, and venous return in the blood going back to the heart. It's really important for beginning the respiratory afferent activation, and the baro reflex activation of the vagus. So it helps with the dysautonomia. 

Anyway, I hope that wasn't too technical. But so there's sort of all these levels, you know, the breathing goes wrong, for a reason. And it's sort of serving a purpose in a way, but then it becomes its own problem. So you want to try and fix it with kind of a respect and with patience, and with realistic expectations about how much you're going to be able to achieve. So knowing that, you know, that person may need help on lots of levels as well. 

And then on top of that people who are unwell, just become psychologically distressed. And they don't often don't sleep well. And then autonomic nervous system goes into disarray, and the sympathetic nervous system, you know, the sympathetic nervous system is activated in infection. So often the high sympathetic arousal, it's because the body's still trying to deal with infection, or the sympathetic nervous system has been activated by the infection. 

So in a way, even that, you got to have a bit of respect for it's not just that a person to neurotic because they're in sympathetic dominance. It's really that their body has responded to this illness, they're doing this stuff. So then you work very gently, carefully to work on all that. And then of course, there's the nasal obstruction, nitric oxide, the effects on the upper airway and so on, that occur. 

And that's all within that protocol, you know, that Hadas and I've been using with our patients, where we work on all those parts of the breathing system, but in a kind of a gentle and a respectful way. Respectful of the body, you know, and its intelligence if you like.

Hadas Golan  
The first thing that really surprised me. I was there very early before the literature came out on long COVID. So it was really I was using my own kind of, I was very excited. I just finished Rosalba's course and I was equipped with even better understanding of dysfunctional breathing. And how breathing interacts with and influences other physiological systems, and how dysfunctional breathing can really disrupt homeostasis kind of in these systems. And how you can also Use breathing to restore balance in these systems. 

So I, and then long COVID really caught my attention because I said, Well, I don't know anything about it. But it kind of sounded familiar like, to other conditions I was treating, including, of course, asthma and anxiety and the MECFS. And so kind of like the complex nature and multiple physical symptoms, cognitive symptoms, and like it was all, it sounded familiar. 

So I kind of reached out through the long COVID clinic in the hospital, and I said, I think I can help. And they were really more than happy to send their patients to me, because all they did was sending, I'm not dismissing that, sending referring people to other professions, to specialists, only to find very little, and referring to mental health professionals. So really like very limited treatment options, or really none. 

So I started to get a lot of patients and I was really doing everything by the protocol. I was kind of... So it started with a good comprehensive evaluation. So the first thing that really caught my attention was the extremely low co2 In many of them, not everyone but like in the 20s. And like before I saw it in asthma like 30, 32. So it was kind of not severely low. So, so really, really low. And then kind of, so I asked myself, Why is that? 

I didn't think, I wouldn't say oh, all these symptoms are because you're hyperventilating. No, it was very obvious that these people are really sick. And then yeah, so it didn't feel right right away to kind of correct their co2 with Buteyko. So So yeah, I really appreciated that I had all this knowledge from the course and I can start super gently. And even then I had to really, I learned from the patients a lot. Very quickly I realized, no, no, I need to really slow it down and even tone my own energy down. So I've not overstimulating. 

And really, because I had, really my schedule was overwhelmed. So I just Okay, let's do group, patient groups. And, and that also because my short session is not long enough, so that allowed me kind of to give, like, explain the theory behind everything and, and introduce information. But then really crucial was it was combined with individual therapy sessions. Because, yeah, that, you know, that's all the information I gather from the evaluation. Super important. Yeah, and I can talk later more about what exactly we were measuring in the findings.

Jackie Baxter  
Yeah. And I think the community element, you know, that the groups actually are incredibly powerful. You know, we are starting to understand now more about the nervous system, and how important that social connection is for our nervous system. But when you have something like long COVID, you know, you are out of energy, you are feeling terrible all the time, you may be not working, you're maybe not able to do the things that you used to do. So you're not seeing the people that you used to see, and your world gets slowly smaller and smaller and smaller. 

And then bringing people together to breathe together, you know, you're doing something that is practically useful. So you are teaching them a skill that is going to help them, that they will see that improvement, even if it's just 1% at a time. But you're also I think, just as importantly, they're joining together with other people, they're getting that validation, they're seeing faces, they're interacting with people. And I think that, in some ways, is maybe as powerful as the breathing itself, in some ways, for sure.

Hadas Golan  
Absolutely. I think that was such a great success. Again, it was very early on, people didn't even know that there are other people dealing with similar things. And since the beginning and until now help people feel a lot less alone or isolated, and validated. And it became really the beginning, the first classes were really became like support groups, until when they took it out of my classes because I didn't have time to teach anything. 

But it's so important and, and then also the dynamics you know, because some people obviously improved better than others. But when someone tell us about you know, how they're, you know, how it went for them and what they did, they really learn from each other, and support each other and it was just awesome. Yes, it still is.

Rosalba Courtney  
Oh, absolutely. I find the same too. And it's a big factor is the motivation factor, keeping people going. Because one of the things when people are unwell, they lose motivation to do things for themselves. And so it's the having the structure in place to keep them going with seeing and hearing that other people are improving or that other people had a dip and then got better. Do you know that just because you had a backslide doesn't mean that you're going to keep backsliding, that you can keep going forward. 

It's that kind of encouragement and motivation, element as well is hugely important. So yeah, thank you zoom, thank you online. Means that people who can't leave the house can actually participate, you know, and get the benefits of group the group support. Yeah. 

Hadas Golan  
Yeah, at the same time, I really, while I really learned to work and love zoom, and telehealth, I think the in person and the measurements were so important. I miss things when I see people on the screen, you know, and somehow I'm still able to help them better when I actually see them with the hands on and

Rosalba Courtney  
you can see more and feel more admit do proper measures. Yeah, this is true. Absolutely. So you need at least that initial measure if possible, right? That's what I find too. You want that initial measurement. So you can see how low is the co2? What is that breathing pattern doing? How does that upper airway look?

Hadas Golan  
Yeah. And then we did we use the, it's called the MARM, the manual assessment of respiratory motion. It's where the clinician is sitting behind the patient with the hands on their posterior diaphragm. And you're just assessing for how balanced is the upper ribcage movement to lower ribcage and abdominal motion. So that was also interesting. I think the most common pattern was very fast and very shallow, to the point that I really have to stay there for a while to see, like, what do I even feel? So that was one pattern. 

And others were kind of irregular, intentional, kind of effortful. Yeah, I, I don't think I could see it if I didn't put my hands on them. Yeah, and then this symptoms questionnaires, so we use the Nijmegen questionnaire, which is a list of symptoms that initially originally was for hyperventilation. But now it's dysfunctional breathing. And then we use the self evaluation breathing questionnaire, which also kind of asked about quality of breathing, quantitative and perception, patient perception of breathing. 

And then there is one tool for upper airway called dyspnea Index, which is also kind of just to quantify these symptoms. So initially, they all scored pretty high on all these measurements, and there was improvement after the treatment in all the symptoms questionnaires. As well as the biomechanics improved and the co2 has increased as well, after treatment, which was super cool. And the most exciting is that with that, also symptoms improved, and people really became more and more functional, which is really what we care about the most.

Jackie Baxter  
Yeah, I think you're right, you know, I think, you know, obviously, for the purposes of research, you know, you need to be measuring things, because you need that objective data in order to actually be able to have your results and to publish them. 

But actually, if you were to ask someone with long COVID, do you want your co2 to increase? They would really not care, what they would care about was, I want to feel better, I want to have less symptoms, I want to be able to do some of the things that I couldn't do before. So yeah, you know, I think that is the mark of how people feel. But yeah, you know, for sure, for the research, you know, you do need those numbers.

Rosalba Courtney  
And for the clinician to be precise with the treatment, you know, then you know which techniques to focus on. That's what those measures give you. So you pick up in that assessment, you know, how you need to tweak it for the person. And then you can also, because you reassess, and then when you reassess, and you go, Oh, that really improved, but that didn't. So let me change the techniques so that they'll get this to move or let me look deeper into trying to understand why that particular metric, you know, didn't improve. 

So that's where the kind of precision if you like, the precision of the of this stuff comes from from the assessment. Because yeah, patients just want to feel better, but it's sort of like that's very blunt, sort of measure, do you know, just feeling better? You want to know that you're going to Feel Better, that that feeling better is robust, it's stable, it's going to last, it's not going to tip over. You know, and when you've really made the body function better, when you've really improved the physiology, then that improvement becomes, you know, stable. That's what I would say. 

Jackie Baxter  
Yeah, absolutely. Yeah. Because, you know, I feel better. It's very subjective. You know, and that's great. But it's not a lot of use in your research paper. And, yeah, I suppose like you say, you know, you don't actually understand what's going on internally, if someone says I feel better, although that is obviously a great result.

Rosalba Courtney  
Bottom line, it's the only thing that matters in the end, isn't it? 

Jackie Baxter  
It is just yeah, 

Rosalba Courtney  
Having that strong and stable. And last is the thing. Yeah. 

Jackie Baxter  
Yeah. So how did you recruit people for this? Was there any sort of inclusion criteria? Did they need to have breathing difficulties? Or was it sort of anybody? How did you do that?

Hadas Golan  
The people who were referred to me were people with Long COVID in dysfunctional breathing. So that's kind of the people I included, if I diagnose dysfunctional breathing, which was really everyone I assessed. Only later on, I saw a couple people who didn't have it. I didn't think their breathing is. But at that time, yeah, it was all dysfunction breathing. 

And because I'm working with, you know, third party payer, then they also needed to have some upper airway related or speech related diagnosis. So people were having either hoarseness or cough or stuttering, or this vocal cord dysfunction, that I could also. And obvious they had the long COVID symptoms, like the chronic one, like the chronic fatigue and insomnia, and the brain fog, and anxiety, etc, right? exercise intolerance. 

The exclusion was real pathologies, like cardiovascular or pulmonary pathologies. And then we really take the five consecutive patients that I could complete the measurements on time, it was a very hectic time, we're kind of limited in person availability of me and the patients, you know. So it was really that was the challenges at that time, to see people for the measurements before and after. So it's the first five that I got the measurements.

Rosalba Courtney  
Which is really significant in itself, because it means that she didn't just pick her best patients, you know, she did five consecutively, which is important for research, because it shows no, this is the thing that's consistently, you know, working in this type of patient.

Hadas Golan  
I definitely didn't pick the ones who improved the most. I wish I could but yeah, it wasn't? Yeah, like all of them really improved. Some of them got really near normal function, and some of them not. But still, the progress was very impressive and significant for them.

Rosalba Courtney  
Lots of ups and downs too 

Hadas Golan  
Absolutely, yes. 

Rosalba Courtney  
Just to encourage the people with the long COVID, who might be listening, lots of ups and downs, keep going. 

Hadas Golan  
Yeah, and the group it was great, because and I think I also kind of I have this, whenever people see me, they come out and they feel more motivated. I'm a good cheerleader, or giving hope and kind of just encouragement. And but yeah, lots of... 

And people also got COVID again, and again, some of them. But the cool thing was that they were saying how much, especially the longer they were in the program with me, they were using the techniques, like lots of humming and breath hold and slow breathing, and they were using it and they believe that that's what kept the long COVID symptoms from getting worse. 

Jackie Baxter  
Yeah, because when I talk about this all the time, you know, my breathing was what - it was, it was the first thing that I found that helped me with long COVID. And that really then put me on the trajectory to find the next thing. And then the next thing that helped me to eventually recover. But I still use these breathing exercises in my daily life now, all the time. You know, it's a skill that's going to help you with recovery, but it's also a skill for life. 

You know, because life isn't perfect when you recover, stress still happens, you still get sick, you know, these things do still happen. And you know, having that foundation of functional breathing and, you know, being able to impact your nervous system and all these things like, you still need them. That's still super, super important. So I yeah, I talk about this all the time. You know how important that is. 

So, yeah, I'd love to talk a little bit more about the protocol. I think that is that the right word? You know we sort of talked about the what it was based on? So yeah, it'd be cool to dive into a bit of, you know, how long did you do this for? And was there any sort of modifications that you made when you were working with the long COVID people?

Hadas Golan  
So there was Evaluation Session, sometimes two, just because again, my session is not long enough. And I, you know, hearing the full story first and getting kind of this talk, sometimes takes the whole session, and then the measurement takes another session. But evaluation. Then, at that time, I was having six weeks, kind of once a week, one hour zoom class, group class. And then individual sessions, it all really varied. 

So this is why it's not a great research, because again, it was a difficult time. So the individual sessions were between two and four kind of individual sessions. And then many people again, especially the beginning, because I was still modifying and learning, people really benefited more when they took the class again, like six more weeks, starting from the beginning. 

And I we found that really this is when they started to notice, like the techniques help them. Before that it was just exhausting. And like they were seeing it through the fog of everything or falling asleep in the. So I did record every class and they got handouts. And they appreciated that. 

So and because I really kept encourage them them. If you don't feel well, you just lie down, you can rest, you can fall asleep. I really gave them permission to do that, after I saw how bad they are. 

So the first two sessions, and it was all following Rosalba's protocol, just slowing it down, was improving nasal functions, talking a little bit of breath awareness, posture, but nasal functions, which really covered all the three dimensions already. It is very cool stuff. 

And after that there was mindfulness and Mind Body connections, training diaphragmatic breathing, and each is kind of each one is kind of two sessions, and then addressing hyperinflation and hyperventilation. And then we did the resonant frequency breathing slower, which is slow breathing, I think you call it cadence, right? It's kind of four in six out, but building towards that. 

And then later on, I felt I felt that people really couldn't tolerate reduced breathing. So we switched the order. So we did slow breathing first. But in this study, it was still, Buteyko first of reduced volume breathing first, before slow breathing. And then we also covered how to pace yourself talking and breathing. 

And the physical pacing. I really learned that people don't understand what is it like, they sometimes weren't aware that they are pushing themselves beyond their capacity. So even walking from the waiting room to my office, I could see that they're walking way faster, and then they reach my office, and they're so breathless. And then or some people just wouldn't stop talking, which is also really you know, so if they're hooked to the capnometer. And they see that after talking their co2 goes to 15. That's the lesson. And so I really worked with people how to pace themselves. 

Yeah, and then individual sessions, we just reinforced whatever was individual for their challenges. So after at least one course of six sessions, some people who are remeasured then, some people are remeasured and then kept going to get a second time. So but but yeah, at least six, after six weeks, there was the second measurements.

Jackie Baxter  
Yeah, and it's, I think this is so awesome. And you're talking about sort of six week blocks. And you know, breathing is incredible, and it has such an amazing impact on everything in the body. But it takes time. You know, you don't start doing something that is new to you, and suddenly become really good at it. You know, you have to practice. 

As a musician, as a music teacher, this is something that I'm very used to kind of instilling into people and that I'm used to doing myself, you know, you don't pick up a piece of music and are instantly able to play it. And you don't go from having a dysfunctional breathing pattern to instantly your breathing being perfect. 

And when you're talking about working with people with long COVID, for example, these people are severely fatigued. They've got cognitive challenges. They've got dysautonomia, you can't make these changes fast, because actually that's going to make things worse. So like you say, you know that six week block is important and then actually, as you say, doing it again. Maybe that's what they need. And did you see more improvements in the people that did the second six week block? Or is that not something that you're able to measure?

Hadas Golan  
Yeah, absolutely. Yes. And now, I still, I think I saw around 80 people, I counted before talking to you today. So yeah, people stay again, like they just first of all, it really helps them to stay with the program. I think if you leave after six weeks, it's very hard to continue on your own. So people choose to continue. And I have the advantage, their insurance pays for that. So people can afford it, too. So it's easy. 

Yes, absolutely, I find it the people who stay longer. And there is so much more that I don't cover in the course. And I can only, now I offer what I call advanced breathing course, which doesn't mean that the people are you know, with less severe long COVID, it just means that they've heard me enough that they, you know, they move to the next. So there's so much more that we can do. And definitely the people who stay longer have much better results.

Rosalba Courtney  
Yeah, for sure. I just wanted to say something about the, you know, like getting your breathing perfect and breathing in the right way and learning to breathe correctly. One of the ideas in integrative breathing therapy is that having rigid ideas about perfect breathing is counterproductive. And that it's actually really important to understand that how the way that your breathing is a reaction or a response to the things that have happened to you. And you know, your history, which might be trauma, or COVID, or whatever. 

And that it's a lot of it is about you know, listening to, and observing the breath. And it's actually about developing a new relationship with your breath. So that there's a lot of time spent in, you know, listening and observing and noticing natural changes. Part of the protocol to is about noticing, and observing natural changes in breath, that occur with different things. 

And then being able by observing the breath to know yourself, so therefore, to be able to, you know, be better at pacing or better at knowing that you need withdrawal time or whatever. So rather than always like doing something to the breath, it's also about noticing, and feeling and developing a new way of kind of relating to the breath. 

Because the big difference I think, because Hadas and I've talked about, you know, other breathing techniques, and I haven't looked at your program, Jackie, but you know, other things that was pretty much everyone's taught to do the same box breathing, or they're taught to do resonance frequency breathing, you know, in for four, out of six, or whatever. And that's all they do. 

And that's really missing a big part of the story. Because it's not just about doing, imposing something. It's like, if you go to a cocktail party, and someone just talks to you, and they don't listen, they are so boring. It's such an inefficient communication segment right there, because there's not sufficient, you know, listening, and kind listening. 

And it's like that kind listening is what needs to happen with breath, with very sick people, with long COVID, with MECFS, with people that the system has lost homeostasis, and it's become hugely dysregulated. You have to be really able to be with what is, and listen and be kind listening, you know?

Jackie Baxter  
Yeah, absolutely. And I loved what you said about perfection. I mean, I'm a recovering perfectionist. I think, you know, it's not everybody, but I think this is quite a common trait and people with long COVID. And, you know, I love it when people who, you know, are working as breathing instructors, are working, you know, in that sort of world. And they talk about how they still practice breathing. 

And I'm like, This is great, because even the people who are the best at it, they still practice, you know, your concert soloists, they still practice, they probably practice more than anybody else. Nobody is perfect, we can all be better. And we can all as you say, listen into our breath, because it changes all the time. You know, the way that your breath is in the morning, it's not the same that your breath is in the evening. And it's not the way that your breath is the next day. So you know, it's a Yeah, it's such a powerful tool and it just so many ways, isn't it? It's, it's just Yeah, it's awesome. I think this is brilliant. 

So what is next? You know, we've cracked long COVID with breathing. I mean, you know, we haven't, but you know, you've proved that, you know, you can see a huge amount of improvement by doing better breathing for want of a better word, right? 

So, where are you going from here? And what are you maybe hoping that other people might do with what you've produced? I suppose that's a really big question, isn't it? 

Hadas Golan  
Yeah, I know Rosalba will have a lot of ideas about what research should happen. And personally, I'm a clinician, and I'm very busy. Like I really literally spend all day seeing kind of many many, like patient after patient. So I don't have a research capacity, but I continue to see the patients and continue to get referral, new referrals every week. 

And I just collect the data in as best as I can, hoping that one day, either I will, again, make the time, or someone else will get interested, to look more deeply into that. But definitely, there is much more interesting research that, like understanding the mechanisms that Rosalba will talk about.

Rosalba Courtney  
Yeah, I mean, I'm a clinician, too, as well as a researcher. And I just think, you know, Hadas and I both, you know, as, as clinicians, what's happening, what we want, maybe, implicitly, you know, which I might state explicitly, for both of us is that we just want to keep learning to do what we're doing better and better. 

And we do that by doing what we do in a structured way, do you know, and using kind of assessment tools and then reassessing and then you know. So kind of what we want to keep doing is talking to each other, and learning how to improve what we do. 

In terms of getting the word out there, Hadas can't see any more patients. Packed to the rafters. And do you know, I mean, we both do want to see patients, but it's like, what we want to do is to train more people really, to be able to do this. So more training, so that it can go out to more people. 

And research would be fantastic. And the research that's happened, you know, in breathing therapy has often been quite siloed, and narrow, you know. It's just been on a particular technique, you know, diaphragm release, with some inspiratory muscle training, and inspiratory muscle training, or just do you know, on a particular technique, or combined with exercise rehabilitation. 

I did a literature review, actually, I think I ended up with 13 studies that have used breathing as an intervention. But a lot of them weren't terribly well structured, you know, then it's like they hadn't fully committed to really understanding breathing. And I think that this particular protocol is unique. And the refinements of this protocol, you know, really should be studied in a bigger cohort, you know, maybe with a control group. 

Usually, you know, with research, you often start off with a case study or a case series, like this one here, you know, that we published. And then the next is to do a pilot study that's bigger or then to do a controlled trial. But we'd need kind of resources and help and other people jumping on board, you know, to help with that, because we're not in a position to really do that. 

So sort of reaching out for anyone who wants to test this protocol, in some format that goes beyond the case series. And then also, you know, I mean, I do more of this integrative breathing, therapy practitioner training, you know, the general training, you know, perhaps Hadas, and I could do some mini trainings on long COVID and breathing techniques. We haven't spoken about that. That's a possibility, that kind of thing.

Hadas Golan  
And also look into mechanisms of how breathing retraining will affect, like, what will it look like in the brain and MRI? 

Rosalba Courtney  
Yes, exactly. Yeah. What's really changing, like, we know that the measures of dysfunctional breathing are changing, the co2, the breathing pattern, the symptoms. That's improving. But what else is improving, you know, in the pathophysiology?

Jackie Baxter  
Yeah. Oh, fantastic. Well, there's a wish list. I'm in. Let's see if we can get anyone else. And let's make this happen. 

Guys, thank you so much for giving up your precious time and energy to chat to me. This has been an absolute pleasure. I feel like we could continue all night. So yeah, thank you so much. And yeah, all of the links that you've mentioned will go into the show notes, if anyone wants to check out any of that. And yeah, I'm excited to see what happens next.

Rosalba Courtney  
Thank you, Jackie. Thank you so much. That was wonderful. It was wonderful talking to you.

Hadas Golan  
Thanks for your great work.

Transcribed by https://otter.ai