Have you been investigated and told there is no medical explanation for your symptoms?
‘Medically unexplained symptoms (MUS)’: could one reason contributing to these symptoms be related to the individual's underlying breathing efficiency? Watch the video to hear how I worked with one of my patients who had been given a diagnosis of ‘MUS’ to relieve her symptoms*
The term ‘Medically Unexplained Symptoms” (MUS) is controversial and has been applied to patients for whose symptoms the clinician is unable to find a satisfactory explanation on usual assessment and testing. Typically, the patient has a variety of seemingly unrelated symptoms. However, this does not mean that there is no significant underlying physical disease. Conditions often mislabelled as MUS include Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS), Long COVID, Postural Orthostatic Tachycardia Syndrome (PoTS), Ehlers-Danlos Syndrome (EDS), Hypermobility Spectrum Disorder (HSD), Mast Cell Activation Syndrome (MCAS), irritable bowel syndrome, non-ulcer dyspepsia, premenstrual syndrome, chronic pelvic pain, fibromyalgia, atypical or non-cardiac chest pain, hyperventilation syndrome, tension headache, atypical facial pain, globus syndrome, chronic back pain, multiple chemical sensitivity, and others. These diagnoses should be considered before deciding that there is no physical illness and applying a label of ‘MUS’. For many of these, specialised testing is required and for others, no reliable test exists yet and diagnosis is dependent on a careful clinical assessment. Sadly, many clinicians have limited knowledge about these conditions and often patients end up doing their own research and seeing multiple providers to obtain a diagnosis. Also, there remains an incorrect belief amongst some clinicians that these conditions are wholly or partly psychological in origin, which creates an added barrier to accessing appropriate investigations and treatment.
The biopsychosocial model (BPS) has been used in the management of ‘MUS’; however more emphasis has been placed on the psychosocial aspects, and research into the biological causes of these conditions has been limited (1). I am not an expert in this area; however, I have walked alongside patients and clients seeing how these conditions can significantly impact their daily life. One biological contributing factor that I believe is being overlooked is the breathing efficiency of the individual whilst resting, moving and sleeping. This will not be relevant to everyone labelled as MUS; however, I recommend assessing if it is relevant to that individual. Click for a video on how to assess your breathing efficiency.
In 1975 Dr Lum a Respiratory Consultant at Papworth & Addenbrookes Hospital in Cambridge published a paper that described 700 patients who had been assessed but 82% had no detectable disease pathology and their symptoms were largely or entirely related to over-breathing (breathing inefficiently). (2) Dr Lum noted frequently patients had been through cardiological (heart) and respiratory (lungs) investigations. Dr Lum stated ‘a collection of bizarre and apparently unrelated symptoms which may affect any part of the body, and any organ or any system...... Such patients.... end up with the label of anxiety state' (2)
Table 1 in his paper lists the main symptoms observed by a general physician in 270 cases. Hyperventilation means over-breathing and it can be very subtle (2)
In the paper Dr Lum describes that he is not the first person to have noticed this phenomenon. Dr Lum observed these patients frequently sighed and used their upper chest to breathe rather than the diaphragm. I thought it was interesting he notes 'Nor are these the weaklings. The most prone are the meticulous, hard-working perfectionists, prone to make excessive demands on themselves'
Dr Lum concluded 'two thirds of all patients so treated are completely relieved of symptoms. It is very uncommon to find a patient who does not experience marked improvement. To recapitulate:
1. We each probably see at least one of these patients a week.
2. The type of breathing is utterly characteristic, virtually diagnostic, and seldom recorded in the notes.
3. The size of the case folder is a frequent pointer to the diagnosis.'
When I first read this paper I was tearful. I could not understand how nearly 50 years later this is not widely known. I could visualise patients I had seen in the past whom fitted this category however due to my lack of knowledge I had missed the opportunity to explore if their breathing was impacting their symptoms. I want to change this. From working as a breathing practitioner I have seen how the body changes when breathing efficiency is improved. I do not believe improving breathing efficiency is a cure all however I firmly believe providing a basic efficient foundation of life (breathing) provides the opportunity for every cell, tissue, organ and system in the body to work efficiently. If you are curious to learn what conditions, signs, symptoms and medication increase the likelihood of inefficient breathing click here.
I find it fascinating the symptoms in table 1 can appear in pre-menstrual syndrome (PMS), perimenopause and menopause. Progesterone is a respiratory stimulant which means it increases how fast the individual is breathing. (3) In those who are breathing efficiently this may not be noticed however in those who are breathing inefficiently it may tip them into symptoms of over-breathing (hyperventilation). I believe it is important for women experiencing symptoms of pre-menstrual syndrome (PMS), perimenopause and menopause to assess their breathing efficiency.
I understand Dr Lum's paper received criticism as not every individual who is over-breathing had reduced carbon dioxide levels in the blood; also, this was one group of 270 patients; the response to treatment may not be generalisable to all patients with these symptoms. As a GP & breathing practitioner I am unable to measure the blood carbon dioxide level however I work with carbon dioxide tolerance which is more practical. Click here to understand carbon dioxide tolerance. In my clinical experience I have seen consistently when an individual improves their carbon dioxide tolerance the individual's natural unconscious breathing slows down and their sleep, exercise tolerance and stress resilience improves. See the feedback from those who have taken part in my programmes on the testimonial page and at the bottom of the menopause and webinar page.
However carbon dioxide tolerance is only one aspect of functional (efficient) breathing. Breathing efficiently involves breathing in and out of the nose whilst resting, moving and sleeping in addition to the three dimensions of breathing:
Biochemical - BREATHE LIGHT – carbon dioxide tolerance
Biomechanical – BREATHE LOW- using breathing muscles correctly
Psychophysiological – BREATHE SLOW- slowing speed of breathing in order to influence the autonomic functioning of the body and bring calmness to the mind
Breathing in and out of the nose whilst resting, moving and sleeping
At the beginning of my deep dive into breathing during Intra Uterine Device (IUD) procedures I suggested different ways of breathing in the hope of providing relaxation and pain relief to my patients. I initially started suggesting breathing using their diaphragm at 6 breaths per minute (4 second inhale and 6 second inhale) and this is what I observed:
One patient * who had a severe fight, flight response during a IUD fitting (due to a recent traumatic birth) was able to change her autonomic nervous system state to a profound parasympathetic (relaxation) response by breathing silently in and out of her nose, using her diaphragm at 6 breaths per minute. She remained conscious during the procedure however she was unaware I had fitted a coil as she had entered a profound relaxed state. It was at this moment I decided I wanted to embark on my breathing practitioner training. This moment truly opened my eyes to the immense power of breathing.
Whereas other patients had very different responses. Some experienced a significant feeling of air hunger (feeling of suffocation or needing to take a bigger breath or not getting enough air) and/or anxiety when I asked them to breath silently in and out of their nose, using their diaphragm at 6 breaths per minute. Some could only tolerate breathing using their diaphragm at 6 breaths per minute by breathing loudly with their mouth. Frequently these individuals felt lightheaded and developed pins and needles around their mouth and in their hands and feet after breathing in this manner.
These experiences combined with my breathing practitioner training opened my eyes to the importance of 24-hour nasal breathing and carbon dioxide tolerance. When I teach individuals to breathe efficiently I generally start with nasal breathing and carbon dioxide tolerance. Carbon dioxide is what drives the next breath (primary driver to breathe) therefore as carbon dioxide tolerance improves the individual breathes slower (psychophysiological dimension) and has time to naturally breath lower using the diaphragm (biomechanical dimension) before the drive for the next breath arrives. In some individuals with severe carbon dioxide intolerance their drive to take the next breath arrives before they have had a chance to fully exhale. A very distressing symptom and can lead to air trapping in the chest.
Unfortunately, carbon dioxide tolerance is the most difficult aspect to research and teach. Carbon dioxide can make the individual experience air hunger and can generate a fight, flight, freeze (sympathetic) response therefore this needs to be taught carefully and gently so the individual can slowly improve carbon dioxide tolerance without feeling distress.
If you would like me to be your guide in improving your breathing efficiency please click here.
* these patients have given me permission to discuss this information anonymously
(With thanks to Dr Asad Khan for his input into this blog)
Dr Asad Khan FRCP(Edin) FRACP(NZ) PGCertClinEd (Auckland)
Consultant (retired) in Respiratory & General Medicine
Specialist interest in Sleep disorders & Chronic Complex Illness
@doctorasadkhan Doctors with ME- Associate Long Covid Kids- Champion https://linktr.ee/doctorasadkhan
David F Marks. (2022). The Rise and Fall of the Psychosomatic Approach to Medically Unexplained Symptoms, Myalgic Encephalomyelitis and Chronic Fatigue Syndrome. Arch Epidemiol Pub Health Res, 1(2), 97-143.
Lum LC. Hyperventilation: the tip and the iceberg. J Psychosom Res. 1975;19(5-6):375-83. doi: 10.1016/0022-3999(75)90017-3. PMID: 1214233.
Saaresranta T, Polo O. Hormones and breathing. Chest. 2002 Dec;122(6):2165-82. doi: 10.1378/chest.122.6.2165. PMID: 12475861.
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