There is a wealth of evidence that points to a significant connection between chronic conditions—fibromyalgia, chronic fatigue syndrome, chronic pelvic pain—and breathing pattern disorders (BPD). BPD is also commonly described as overbreathing, upper-chest breathing, and, in extreme examples, hyperventilation.
It’s important to clarify that the connections between BPD and fibromyalgia (and the other chronic pain and fatigue-related conditions), are not causal. That is to say that BPD does not necessarily cause the symptoms of fibromyalgia, but frequently aggravates and maintains them. Because the vast majority of people with a diagnosis of fibromyalgia can be shown to display profound BPD, many of their major symptoms may be improved, and sometimes eliminated, by better breathing habits.1

How BPD Can Influence Chronic Pain
It is reasonable to ask how severe symptoms, such as persistent pain and fatigue, can be affected by a disturbed breathing pattern. A large part of the answer lies in important biochemical changes that frequently result from BPD, that I will summarize below. However, before outlining these metabolic changes, the effects of biomechanical overuse patterns deserve to be discussed. Any chronic habitual dysfunction, such as an upper-chest breathing pattern, has adaptation consequences that are likely to aggravate existing symptoms.2
Overuse of accessory and obligatory respiratory muscles
The normal diaphragmatic breathing rate varies with age and current metabolic requirements. Under normal circumstances, an adult averages between 12 and 14 cycles of inhalation/exhalation per minute, which is considered normal. Of course, the breathing rate increases in response to physical or emotional demands, but usually returns to normal after the stimulus ceases.
However, when an upper-chest breathing pattern is habitual, the rate may rise to more than 30,000 cycles of inhalation/exhalation daily, with a likelihood of overuse and repetitive strain. This is because a range of muscles are activated on inhalation, including the diaphragm, sternocleidomastoid, scalenes, pectoralis major and minor, inferior fibers of the serratus anterior and latissimus dorsi, serratus posterior superior, iliocostalis cervicis (along with key abdominal muscles), and the intercostals; the quadratus lumborum is activated on exhalation.
Leaving aside the painful effects of biomechanical overuse, biochemical changes associated with BPD can profoundly affect health, particularly in relation to pain and fatigue.3

Respiratory alkalosis and chronic pain and fatigue
Breathing more rapidly than normal can, at times, be physiologically appropriate; for example, when someone is exercising aerobically, or if the bloodstream becomes excessively acidic as in liver or kidney disease, or in the advanced stages of pregnancy.
In those circumstances, increased carbon dioxide (CO2) elimination helps to reduce the acidity of the blood toward its normal, slightly alkaline state, because CO2 is recruited from carbonic acid in the bloodstream.4 However, excessive exhalation of CO2, such as that which occurs with rapid, upper-chest breathing, leads to a state of CO2 deficiency (hypocapnia), excessively reducing acid levels in the bloodstream, and producing what is known as respiratory alkalosis. This occurs when the normal pH of the blood (between 7.35 and 7.45) shifts slightly more into the alkaline range. The immediate effects are dramatic, and may include any or all of the following:
• Smooth muscles constrict, causing narrowing of blood vessels and all other “tubes” in the body, including those in the digestive and genitourinary system.
• Fatigue increases with this narrowing of vessels. Not only does less blood get to the tissues (alkalosis) due to narrowing of blood vessels, but oxygen is released less efficiently by hemoglobin (known as the “Bohr effect”), adding to symptoms of fatigue. To explain: oxygen is able to attach to hemoglobin due to the alkaline environment in the lungs, whereas the slightly less alkaline bloodstream promotes release of oxygen when delivery to the tissues is required. However, respiratory alkalosis due to BPD causes the hemoglobin molecule to retain more oxygen than usual with less oxygen reaching the tissues and the brain, resulting in fatigue. To summarize: increased alkalinity encourages reduced blood vessel diameter due to smooth muscle constriction, as well as a reluctance of hemoglobin to release its oxygen.
• A relative oxygen deficit in tissues and the brain leads to symptoms such as fatigue, aching, cramping, and cognitive problems (“brain fog”).5
• Heightened sympathetic arousal is also caused by rapid breathing, creating symptoms such as tremors, sweating, clammy hands, palpitations, and autonomic instability affecting blood pressure.6
• The kidneys start to excrete bicarbonate in order to reduce alkalosis and rebalance the pH of the blood, resulting in calcium and magnesium imbalances.7
• Neurological changes occur as a result, including decreased pain threshold, increased likelihood of cramps/spasms, reduced motor control, and a general increase in fascial, and therefore muscular, tone.
• Cardiovascular and gastrointestinal function is affected by the altered behavior of smooth muscles and increased tendency for spasms, with symptoms such as pseudo-angina and irritable bowel becoming more likely.
• An increased sense of apprehension, anxiety, and even panic attacks commonly accompany these changes, encouraging even more rapid breathing.8

Common Features of BPD and Fibromyalgia
Mainly affects females
BPD is at least twice as common in females compared with adult males, possibly because of hormonal influences. For example, progesterone stimulates respiratory rate, so that in the luteal (post-ovulation/premenstrual) phase of the menstrual cycle, CO2 levels drop, on average, 25 percent. Additional stress can then “increase ventilation at a time when CO2 levels are already low,” resulting in a range of symptoms commonly labeled as premenstrual tension.9
A team of researchers identified several participants in a fibromyalgia study who “changed” their diagnosis during the course of a menstrual cycle.10 They fulfilled the diagnostic criteria for fibromyalgia after ovulation, when progesterone levels were high, hyperventilation patterns were more obvious, and pain thresholds at their lowest; but never during the follicular phase when pain thresholds were highest, and breathing more normal.11

Anxiety
Feelings of anxiety have been shown to trigger more rapid breathing.12 However, the converse is also true—rapid breathing creates feelings of apprehension/anxiety and sometimes panic (a sympathetic arousal, fight-or-flight response).
People with fibromyalgia justifiably resent any suggestion that their multiple symptoms are “all in the mind” (i.e., psychosomatic), and therefore often find it difficult to accept that anxiety (about their condition, as well as due to BPD) might be aggravating their pain and fatigue. An understanding of the automatic link between habitual rapid breathing and anxiety can lead to acceptance of the possibility that by improving the breathing pattern, their anxiety levels (and associated symptoms) are likely to be reduced.
Once habitual BPD (possibly including hyperventilation) exists, a variety of triggers start a vicious cycle, leading to a range of pain, fatigue, and other symptoms, as well as even greater anxiety—all of which generates more rapid breathing, and yet more anxiety.

Pain correlations
The general under-oxygenation of the tissues during alkalosis also creates an environment in which myofascial trigger points are more likely to develop, and so begets the evolution of more pain.
Because diaphragm function is closely linked to pelvic floor function, genitourinary symptoms (including stress incontinence) and pelvic pain—all too common in fibromyalgia—are increased in individuals with BPD.
Interestingly, Scandinavian researchers have observed that women with chronic pelvic pain “typically display upper-chest breathing patterns, with almost no movement of the thorax or the abdominal area.”13 They also confirm that such women demonstrate “… a lack of coordination and irregular high costal respiration,” and that “the highest density, and the highest degree of elastic stiffness [is] found in the iliopsoas muscles.”
In addition, anatomical studies show that the fascial envelope around the superior aspects of the psoas connects directly to the medial arcuate ligament of the diaphragm, explaining the structural link between the psoas and breathing function.14
So, breathing too fast—for whatever reason—can result in an avalanche of symptoms, including anxiety, fatigue, increased pain levels, brain fog, as well as gut, pelvic, and bladder symptoms (among others), many of which are commonly associated with fibromyalgia.

Is There a Connection?
When looking at the possible connection between BPD and fibromyalgia, there is much to consider. Researchers have observed that “dysfunctional breathing is implicated in many conditions commonly seen by manual therapists, including fibromyalgia and other chronic pain conditions.”15 Researchers also measured levels of CO2 in the blood of individuals with a fibromyalgia diagnosis, and were able to estimate the proportion who hyperventilated. They found this to be an “obvious” feature in up to 27 percent of fibromyalgia patients, compared with around 2 percent of people without fibromyalgia.16
In 2001, female patients with fibromyalgia were tested for the presence of dyspnoea (labored respiration) and compared with healthy individuals.17 Dyspnoea was present in nearly 60 percent of the fibromyalgia patients, and was far more common in those with the greatest levels of pain. One way of interpreting these findings would be to suggest that the pain itself generated increased anxiety, which further accelerated the breathing rate, and that normalizing the breathing pattern might well reduce many of the symptoms of fibromyalgia, including pain. These researchers concluded that “because unrecognized hypocapnia is common in chronic fatigue syndrome and fibromyalgia, testing levels of CO2 should be a part of the evaluation of patients with such conditions.”  
An unbalanced breathing pattern can be seen to be an associated factor in most individuals with chronic musculoskeletal pain and fatigue who commonly also display symptoms of irritable bowel, together with “foggy brain” and a sense of oppression/heaviness in the chest (dyspnoea). “I can’t take a proper breath,” “I keep sighing,” and “I feel as though there is a rock on my chest” are all key expressions that are often reported. Dyspnoea (“air hunger”) is a feeling of being unable to take a deep breath. It is a common symptom of BPD, and is frequently mentioned by people with fibromyalgia.18
Many such individuals fall into a category of having “medically unexplained symptoms,” or have been offered a diagnosis of fibromyalgia or chronic fatigue syndrome. Such conditions have also been termed “bodily distress” syndromes, presenting with physical symptoms that are not easily medically explained.19
Hyperventilation is the absolute extreme example of BPD, and since studies have identified at least a quarter of fibromyalgia patients as hyperventilating, it is safe to say that a far higher proportion display obvious breathing pattern disorders.
Finally, based on 50 years of experience treating fibromyalgia, it is my clinical experience that more than 90 percent of people suffering from fibromyalgia or chronic fatigue syndrome breathe poorly.

Why Do BPDs Occur?
Claude Lum, MD, one of the pioneers of breathing rehabilitation in cases of chronic hyperventilation, discussed the reasons for people breathing this way: “Neurological considerations can leave little doubt that habitually unstable breathing is the prime cause of symptoms. Why individuals breathe in this way must be a matter for speculation, but manifestly the salient characteristics are pure habit.”20
Apart from habit, the breathing rate is largely determined by the measurement of CO2 levels in the blood by the respiratory centers in the brainstem. These constantly adjust the breathing rate to maintain arterial blood oxygen and CO2 levels in a relatively constant state. Levels of CO2 in the blood act on the central chemo-sensitive areas of the respiratory centers that “instruct” the respiratory muscles.
Just as a thermostat automatically switches on central heating when the room temperature drops, so do the respiratory centers switch to a more rapid breathing rate when the CO2 level rises, as it does during slow diaphragmatic breathing.
In other words, the respiratory center becomes “trained” (habituated) to maintain these higher CO2 levels the individual has become used to as a result of upper-chest breathing.
Whatever the original triggers that started it, Lum says, breathing “badly” can therefore be considered to have become a habit, just as poor posture is usually habitual. And as with most habits, because they are repetitive or constant, they feel normal. The internal guidance system as to what is correct posture or correct breathing adjusts to what we do constantly or repetitively as we become habituated to it. So, just as someone with a habit of standing slouched finds it awkward or impossible to stand up straight, so too does anyone who habitually breathes rapidly finds regular diaphragmatic breathing difficult.
And, as manual therapists know all too well, over time, functional habits such as postural and/or breathing patterns of use evolve adaptive structural changes that prevent normal function.21
The answer to breathing rehabilitation is therefore clear: to normalize the structures that do the breathing (largely by reducing hypertonicity and mobilizing restrictions in the thoracic cage) and rehabilitate the respiratory centers (through regular breathing exercises—see page 69) to tolerate increased levels of CO2 so that a rate of diaphragmatic breathing is allowed that matches current metabolic requirements.

Assessment and Hyperventilation
Assessment of BPD involves skilled palpation and observation. The therapist needs to observe patterns of use, posture, and excessive muscular activity during upper-chest breathing.
The extreme of BPD—hyperventilation—is best diagnosed by a combination of observation, capnography, and the use of instruments such as the Nijmegen questionnaire.22 The accuracy of the Nijmegen questionnaire to identify hyperventilation has been evaluated and shown to be more than 90 percent accurate.23
The questionnaire asks about the following common BPD symptoms to help identify the strong likelihood of breathing being a key feature in the individual’s condition, which indicates probable breathing pattern dysfunction:
• Feelings of tightness in the chest
• Shortness of breath
• Rapid or deepened breathing
• Inability to breathe deeply
• Feeling tense
• Tightness around the mouth
• Stiffness in the fingers or arms
• Cold hands or feet
• Tingling fingers
• Bloated abdominal sensation
• Dizzy spells
• Blurred vision
• Feeling of confusion or losing touch with environment.
A chronic hyperventilation pattern also often involves frequent sighing and obvious shallow breathing involving the upper chest.
A useful test of CO2 tolerance involves assessment of comfortable breath-holding time. The time someone with chronic BPD can comfortably and without strain hold their breath after a full exhalation is usually greatly reduced, often not beyond 10 seconds, with around 30 seconds being considered the approximate dividing line between BPD and normal.24

Better Breathing Reduces Pain and Fatigue
If a chronic pain condition exists for any reason, as is all too apparent with fibromyalgia, the additional layers of pain and fatigue resulting from BPD seem to be helped with improved breathing habits. Is this possible, and if so, how?  
Reforming and retraining breathing involves a number of key elements:
• Initial (and periodic) assessment of breathing function based on functional evidence and palpation determines what needs to be done to improve breathing function.
• Education and information are vital for creating motivation and awareness as to why homework is essential in normalizing BPD. Understanding why exercises are necessary increases the client’s chances of compliance and regular application.
• The client needs to understand that the therapist can do no more than create an environment—a possibility—for restoration of more normal function, but the onus of the breathing work itself falls to the client.
• Mobilization of respiratory muscles and joints alone, no matter how appropriate, can never restore normal breathing patterns unless there is a cooperative rehabilitation effort.
• Conversely, breathing retraining without the mobilization of restricted structures is far more difficult to achieve.
• Manual attention to reduce hypertonicity in accessory breathing muscles (including the upper trapezii, levator scapulae, scalenes, sternocleidomastoid, pectorals, and latissimus dorsi) is usually required.
• The diaphragm area also requires attention as a rule (the lower anterior intercostals, sternum, costal margin, beneath the costal margin, abdominal attachments, quadratus lumborum, and the psoas).
• Active trigger points in these muscles may need to be deactivated manually.
• The thoracic spine and ribs usually
require mobilization.  
• For the retraining of breathing, various exercises individualized to the specific needs of the client should be introduced, commonly involving pursed-lip breathing and/or pranayama yoga methods (see “Breathing Rehabilitation Exercises” on page 69).
• Relaxation methods can usefully
be introduced.
• Sleep pattern disturbances might require attention and advice.25
• Active exercise (walking or very light weight training) should be considered and carefully introduced, within pain tolerance.
• Because of the known link between low blood-sugar levels and breathing pattern imbalances, appropriate dietary advice should be offered by qualified professionals.

Summary
BPDs are a common feature in individuals with fibromyalgia. However, these are rarely recognized or appropriately treated. Breathing retraining is effective clinically and economically, as long as enough patience is exercised to actively engage the fibromyalgia client in a program requiring weeks or months of daily breathing exercise to achieve behavioral change.
Chronic BPDs are commonly successfully treated; however, a time frame of 12–26 weeks may be required, with active client participation throughout, to break well-established habits.26
The implication is that a combination of biomechanical facilitation of breathing (joint and soft-tissue mobilization), as well as education combined with rehabilitation via specific application of breathing exercises, can achieve marked benefit in BPDs—accompanied by reduced levels of pain and fatigue.

Breathing Rehabilitation Exercises
A foundational focus on full exhalation characterizes successful breathing retraining.1 It is not possible or desirable to focus on “how to inhale,” unless and until the ability to exhale fully is achieved. (Note: be mindful of scope of practice in your state as it relates to initiating these exercises.)

Antiarousal Pursed-Lip Breathing
Pursed-lip breathing, combined with diaphragmatic breathing, helps to achieve a “full exhale,” and also enhances pulmonary efficiency.2
• The client is asked to sit or recline and to exhale slowly, and as fully as is comfortably possible, through pursed lips.
• While exhaling, a candle flame about 6 inches from the mouth may be visualized with the exhalation sufficient to flicker the flame but not blow it out.
• Exhalation should continue until the first sign of a need to inhale.
• During exhalation, a slow, silent count is suggested to establish the length of the out breath.
• At the end of the pursed-lip exhalation, without strain, a 1-second pause is suggested, followed by inhalation through the nose.
• Without pausing to hold the breath, the next slow and full exhalation follows, through pursed lips, blowing the air in a thin stream, followed by a pause for a count of one, and then nasal inhalation.
• The inhalation and exhalation sequence should be repeated approximately 30 times, morning and evening.
• After some weeks of daily practice, the inhalation phase should be found to comfortably last 2–3 seconds, and the exhalation phase 4–5 seconds, without strain.
• Exhalation should always be slow and continuous; there is little value in breathing the air out rapidly and then simply waiting before inhaling again!
• Over a period of weeks, feelings of anxiety should diminish and other fibromyalgia symptoms will lessen.

NOTE: When beginning to practice slow, pursed-lip breathing, carbon dioxide (CO2) tolerance might be very low, and can result in:
a. Feelings of increased anxiety/panic after just a few cycles of inhalation-pause-slow-pursed-lip-exhalation. If this happens, the exercise should stop and be briefly tried again later that day. Over time (perhaps after weeks of repetition), as CO2 tolerance increases, this sensation will disappear.
b. After the breathing exercise, a feeling of light-headedness may be experienced due to increased oxygen reaching the brain. If this happens, the advice is to sit quietly for a few minutes until it passes.

Breath-Holding Test
At least once a week, test the breath-holding time.3 As the weeks pass, and CO2 tolerance increases, the comfortable breath-holding period should gradually increase.
Notes
1. G. Fregonezi, V. R. Resqueti, and R. Güell Rous, “Pursed Lip Breathing,” Archivos de Bronconeumología (English Edition) 40, no. 6 (2004): 279–82.
2. V. Busch et al., “The Effect of Deep and Slow Breathing on Pain Perception, Autonomic Activity, and Mood Processing—An Experimental Study,” Pain Medicine 13, no. 2 (February 2012): 215–28; L. McLaughlin, C. H. Goldsmith, and K. Coleman, “Breathing Evaluation and Retraining as an Adjunct to Manual Therapy,” Manual Therapy 16, no. 1 (February 2011): 51–2.
3. R. Courteney, “The Buteyko Method—An Osteopathic Approach to Asthma?” Osteopathy Today (August 2002): 16–19.

Notes
1. D. Bradley, Hyperventilation Syndrome: Breathing Pattern Disorders (London: Kyle Books, 2006): 2; L. Chaitow, C. Gilbert, and D. Morrison, Recognizing and Treating Breathing Disorders: A Multidisciplinary Approach (Edinburgh: Churchill Livingstone, 2014).
2. M. Thomas et al., “The Prevalence of Dysfunctional Breathing in Adults in the Community with and without Asthma,” Primary Care Respiratory Journal 14, no. 2 (2005): 78–82.
3. L. Chaitow, “Breathing Pattern Disorders, Motor Control, and Low Back Pain,” Journal of Osteopathic Medicine 7, no. 1 (2004): 33–40.
4. J. West, Respiratory Physiology (Philadelphia: Lippincott Williams & Wilkins, 2000); B. H. Timmons and R. Ley, eds., Behavioral and Psychological Approaches to Breathing Disorders (New York: Plenum Press, 1994): 115.
5. F. B. Jensen, “Red Blood Cell pH, the Bohr Effect, and Other Oxygenation-Linked Phenomena in Blood O2 and CO2 Transport,” Acta Physiologica Scandinavica 182, no. 3 (November 2004): 215–27.
6. P. D. Drummond et al., “Pain Increases During Sympathetic Arousal in Patients with Complex Regional Pain Syndrome,” Neurology 57, no. 7 (October 2001): 1296–1303.
7. L. L. Vollmer, J. R. Strawn, and R. Sah, “Acid–Base Dysregulation and Chemosensory Mechanisms in Panic Disorder: A Translational Update,” Translational Psychiatry 5, no. 5 (May 2015): e572.
8. S. A. Kendall et al., “A Pilot Study of Body Awareness Programs in the Treatment of Fibromyalgia Syndrome,” Arthritis Care and Research 13, no. 5 (October 2000): 304–11.
9. A. Ghildiyal et al., “Changes in Sympathovagal Balance During Menstrual Cycle,” Current Neurobiology 2, no. 1 (2011): 49–52.
10. A. J. Dunnett, “The Diagnosis of Fibromyalgia in Women May Be Influenced by Menstrual Cycle Phase,” Journal of Bodywork and Movement Therapies 11, no. 2 (April 2007): 99–105.
11. R. L. Toonkel and S. Shafazand, “Respiratory Alkalosis,” in Clinical Decisions in Nephrology, Hypertension and Kidney Transplantation, eds. E. V. Lerma and M. Rosner (New York: Springer, 2013): 151–56.
12. M. E. Kunik et al., “Surprisingly High Prevalence of Anxiety and Depression in Chronic Breathing Disorders,” Chest 127, no. 4 (April 2005): 1205–11.
13. G. K. Haugstad et al., “Continuing Improvement of Chronic Pelvic Pain in Women After Short-Term Mensendieck Somatocognitive Therapy: Results of a 1-Year Follow-Up Study,” American Journal of Obstetrics and Gynecology 199, no. 6 (November 2008): 615.e1–8.
14. J. C. Nduka and A. K. G. Venyo, “Chronic Pelvic Pain in Women—A Review of the Literature,” Hamdan Medical Journal 7, no. 2 (2014).
15. R. Courtney and M. Cohen, “Assessment of the Measurement Tools of Dysfunctional Breathing,” International Journal of Osteopathic Medicine 9, no. 1 (March 2006): 34.
16. J. E. Naschitz et al., “Patterns of Hypocapnia on Tilt in Patients with Fibromyalgia, Chronic Fatigue Syndrome, Nonspecific Dizziness, and Neurally Mediated Syncope,” The American Journal of the Medical Sciences 331, no. 6 (June 2006): 295–303.
17. A. Çetin and A. Sivri, “Respiratory Function and Dyspnea in Fibromyalgia Syndrome,” Journal of Musculoskeletal Pain 9, no. 1 (2001): 7–15.
18. D. C. Knockaert et al., “Chest Pain in the Emergency Department: The Broad Spectrum of Causes,” European Journal of Emergency Medicine 9, no. 1 (March 2002): 25–30.
19. P. Fink and A. Schroder, “One Single Diagnosis, Bodily Distress Syndrome, Succeeded to Capture 10 Diagnostic Categories of Functional Somatic Syndromes and Somatoform Disorders,” Journal of Psychosomatic Research 68, no. 5 (May 2010): 415–26.
20. L. C. Lum, “Hyperventilation Syndromes in Medicine and Psychiatry: A Review,” Journal of the Royal Society of Medicine 80, no. 4 (April 1987): 229–31.
21. W. Garland, “Somatic Changes in Hyperventilating Subject.” Presentation at the International Society for the Advancement of Respiratory Psychophysiology Congress (Paris, 1994).
22. J. Vansteenkiste, F. Rochette, and M. Demedts, “Diagnostic Tests of Hyperventilation Syndrome,” European Respiratory Journal 4, no. 4 (April 1991): 393–9.
23. J. Van Dixhoorn and H. J. Duivenvoorden, “Efficacy of Nijmegen Questionnaire in Recognition of the Hyperventilation Syndrome,” Journal of Psychosomatic Research 29, no. 2 (1985): 199–206.
24. R. Courteney, “The Buteyko Method—An Osteopathic Approach to Asthma?” Osteopathy Today (August 2002): 16–9; B. H. Timmons and R. Ley, eds., Behavioral and Psychological Approaches to Breathing Disorders: 115.
25. M. Shah, S. Feinberg, and E. Krishnan, “Sleep-Disordered Breathing Among Women with Fibromyalgia Syndrome,” JCR: Journal of Clinical Rheumatology 12, no. 6 (December 2006): 277–81.
26. L. C. Lum, “Hyperventilation Syndromes in Medicine and Psychiatry: A Review”; J. N. Han et al., “Influence of Breathing Therapy on Complaints, Anxiety and Breathing Pattern in Patients with Hyperventilation Syndrome and Anxiety Disorders,” Journal of Psychosomatic Research 41, no. 5 (November 1996): 481–93; L. McLaughlin, C. H. Goldsmith, and K. Coleman, “Breathing Evaluation and Retraining as an Adjunct to Manual Therapy.”

Leon Chaitow, ND, DO, is the author of more than 60 books, including Understanding & Treating Breathing Disorders (Elsevier 2014) and Fascial Dysfunction (Handspring 2014). He is founder and editor-in-chief of The Journal of Bodywork & Movement Therapies. He teaches—mainly on manual therapy-related topics—worldwide and online. For details of online courses and books, as well to access many downloadable articles and video clips, see his website at www.leonchaitow.com.