CHAPTER 2

Stand Up and Breathe

Eighty percent of young people have back pain. The other 20 percent have no computer.

—UNKNOWN

MYTH: Strength is the foundation of performance.

FACT: It all begins with posture.

I live in West Virginia, but when I run in Central Park, I pause at the “Imagine” mosaic that memorializes John Lennon, and I imagine peace in the world. I also imagine a world in which we are more at peace with our own bodies. It’s a world where there is no back pain, and no metabolic or degenerative illnesses.

That world exists today—for societies in which people avoid prolonged sitting. If you are in your early fifties or older, you may even remember that time—a pre-video-game childhood of summers when the only occasion you sat was at the table for dinner (and maybe on the floor for a board game or an episode of your favorite TV show).

Now we suffer through chronic back pain, poor posture, and incomplete breathing, much of it caused by too much sitting. The good news is that there are simple remedies for these, and they add time to your day, not take it away. All it requires is correcting your posture, spending more time on your feet, finding a bit of comfortable space on the floor, and working on “spine hygiene.”

As John Lennon sings, It’s easy if you try.

HOW SITTING IS KILLING US

Parking ourselves in chairs for extended periods results in a chronic shortening of the hip flexors, the muscles in front that connect the pelvis and lower spine to our legs. Sitting also overstretches and weakens the muscles in back, the glutes—the substantial butt muscles that support much of our movement. When we stand up after hours of being chair-bound, our pelvis and spine don’t immediately return to their balanced, “neutral” position. Our posture remains stooped (sometimes imperceptibly) and our full range of motion is impaired.

This new “default” posture sets off a series of other postural compensations. Without fully realizing it, we end up walking around just slightly “wonky,” with shoulders rolled forward, upper back rounded, and head carried in front of our center of gravity—as shown in the figure on this page. For every inch that your head is positioned forward, five to seven pounds of stress are added to the lower cervical spine. As we will learn in the chapter on feet, modern shoes (and elevated heels in particular) exacerbate this dysfunctional posture.

At left, head and shoulders are slumped forward in “texting position.” The spine is displaced from its natural, tall, straight architecture. Texting or desktop posture is hard on the joints and requires static muscle strength to maintain. On the right: straight, strong, and stable posture.

We simply spend too much time out of balance. When our posture is not tall, balanced, and relaxed, our efficiency of movement is reduced to the point that even standing becomes uncomfortable. This mild discomfort reinforces the desire to sit. As sitting becomes the easy, less painful option, it becomes habitual, and creates a sedentary feedback loop. As athlete and massage therapist Laura Bergman says, “How you stand is how you land.” Cycling—though unquestionably a healthful activity—doesn’t help with this, due to the cyclist’s bent-over, sitting position.

Kids who are confined to school desks for hours (typically followed by more hours on couches at home) quietly begin to suffer a shortening of the deep hip flexors—the psoas and iliacus muscles. Distressingly, the resulting bent-over posture and inefficient movement patterns are imprinted and passed on to adulthood.

The iliacus and psoas are dominant hip flexors.

These major muscles shorten with prolonged sitting.

Physical therapist Kelly Starrett noticed that pre-kindergarten children run naturally, with minimal exertion—sprinting, powering hard, running on the balls of their feet, “like miniature Kenyan marathon runners.” He also saw, as I have seen in my clinic, that by first grade half the kids start heel striking. And by second grade, most children’s running and movement patterns have become dysfunctional. In this case, practice doesn’t make perfect. It makes dysfunctionality permanent.

SITTING SENDS A SIGNAL: STORE UP THE CALORIES

In addition to the structural changes caused by sitting, the mere act of sitting down sends metabolic signals to store energy. As we’ll explore later, sitting and inactivity trigger a dramatic reduction of the enzyme that is essential for the metabolism of triglycerides in muscle mitochondria. Those triglycerides are then converted into fatty acids that accumulate in the liver and in adipose tissues (belly fat), elevating the risk of metabolic diseases. Studies show that prolonged sitting decreases the diameter of arteries, as well, and increases blood pressure and the risk of heart disease, type 2 diabetes, cancer, and early death.

The bigger picture is even scarier. A recent meta-analysis, extracted from multiple studies and pooled data, showed that even rigorous daily exercise doesn’t mitigate the negative health effects of sitting, even for those who exercise regularly and are physically active (including marathon runners). This “active couch potato syndrome” came as a surprise to me because, like many of us, I assumed that a daily thirty-minute run or other activity (as recommended in the Physical Activity Guidelines for Americans) would surely undo the harmful effects of a day of prolonged sitting.

As part of my Air Force flight doctor training, I spent one of the most physically challenging (and body-damaging) days of my life when I was subjected to repeated spins in a human centrifuge. I was taken up to six Gs (six times the force of gravity), then to nine Gs. I survived the test protocol, but the soreness I felt, which lasted several days, made a marathon seem like a Sunday stroll. Our bodies are simply not adapted to this kind of stress.

Joan Vernikos, former director of NASA’s Life Sciences Division and author of Sitting Kills, Moving Heals, has studied the effects of G forces and gravity—and also weightlessness—on the body. She learned that prolonged zero gravity (no G forces) is harder on the body than those excessive G forces. Even relatively short periods in a weightless environment accelerate aging and reduce bone mass and bone mineral density, and this elevates the risk of fracture.

One G and hops of two and three Gs are fine! Gravity is magic, and fun. The most exciting, thrilling activities of earthbound folks involve gravity—managing it, leveraging it, playing with it, trying to defy it. Children understand this innately. Adults sometimes overlook this magic, and they lumpishly resign themselves to gravity’s downward pull. Without even trying, simply by relaxing for hours in chairs, most of us are contributing to a medical study topic that I call “zero-G sedentary physiology.” The science behind this is clear: prolonged sitting is harmful. We simply weren’t designed to sit all day. Prolonged bed rest, too—our closest everyday proxy for zero G—should be banned from health care in almost every instance in which the patient can sit, stand, or walk.

“Gravity plays a big role in our physiological function, and in the aging process,” Dr. Vernikos says. “We are not designed to exist in quasi-microgravity. We were designed to squat. We were designed to kneel. Sitting is okay, but it is uninterrupted sitting that’s bad for us. And it’s not how many hours of sitting that’s bad for you; it’s how often you interrupt that sitting that is good for you!”

DON’T TAKE THIS GOOD NEWS SITTING DOWN

Fortunately, the negative effects of sitting are reversible, and the solution is surprisingly easy: mix it up. If you have a cubicle job, merely standing up from a seated position (at least once every twenty minutes) actively helps your body to burn fat. Create a “dynamic” workstation that allows (and perhaps demands) you to change positions throughout the day. Or, if you’re constantly on your feet—working in retail, for instance—take brief sitting breaks.

In a brilliant move, Kelly Starrett, who compared preschool and primary school kids, convinced his children’s school to use stand-up desks—and they love them! A school in our town is using these now, too.

Standing all day in a static position isn’t good, either. If you try a standing or treadmill desk—I highly recommend them—then be sure to take some time to sit and relax. And you can break up a standing position by alternately elevating a leg on a stool, chair, or windowsill, and slowly stretching the hip flexors. Take advantage of any brief gaps (while cogitating, for instance, or talking on the phone) to squat or to kneel. Mix it up, too. Walk around. If appropriate, lie prone to type or to read, or to play a game.

AVOID SITTING BACK

Not surprisingly, we suffer from a near epidemic of lower back pain. Lumbar pain is one of the leading causes of disability in the military and the civilian population, and it accounts for uncountable days of lost productivity. Treatment for back pain is an $80-billion-a-year industry, despite a growing medical consensus that most modern interventions, from injections to surgeries, have little or no value, and often cause harm.

We need to treat the position, not the condition. Standing up, paying attention to posture, stretching, squatting, and walking are the best ways to maintain good “spine hygiene.” For those who have suffered a back injury or undergone back surgery, the best way to rehabilitate, generally, is to rebuild strength: to bend and twist and subject the spine to natural stresses and loads. Modern medicine doesn’t offer spine transplants.

RELEARNING TO BREATHE

Good posture can’t occur without proper abdominal (belly) breathing, because an engaged diaphragm is the key to stabilizing the core. When you allow the lower belly to fill as you inhale, your powerful diaphragm contracts and you fill the lower areas of the lungs, where maximum oxygen exchange occurs. As your abdomen fills, your upright core stiffens like a pressurized soda can. Notice those around you. Most are breathing from the upper chest, not from the diaphragm and abdomen.

Try breathing through your nose. This forces the diaphragm to work, and allows your carbon dioxide level to rise naturally, which assists in offloading oxygen to the tissues. Sufficient levels of carbon dioxide allow the body to utilize oxygen, so we need to make sure that we have enough CO₂ in our blood. Blowing off excessive CO₂ causes oxygen to bind to the hemoglobin rather than be released to the muscles and other tissues, where it should go. This is why you feel lightheaded when you overbreathe: not enough oxygen is offloading and reaching the brain, because you’re expelling too much CO₂.

As you inhale and fill your lower abdomen with air, your torso stiffens like a pressurized soda can, stabilizing your core and allowing better oxygenation.

Slow, mindful breathing also triggers a soothing parasympathetic response, bringing sustained calm—and performance, too. In most athletic endeavors (outside of those involving only a second or two of explosive power), we perform better when we relax the body. Even in a sprint, Olympian Usain Bolt is relaxed as he accelerates. Michael Jordan’s routine, prior to nailing almost every free throw (regardless of what the opposing fans were yelling at him), relied upon taking deep, slow breaths.

In my medical practice, I commonly see patients with respiratory problems that originate in poor breathing habits. Doctors often treat these patients symptomatically with inhalers, which often stimulate overbreathing. We should be teaching the skill of mindful, diaphragmatic breathing, in combination with an erect, relaxed, balanced posture.

DRILLS

1. Try these antidotes to the epidemic of sitting

There are several habits that you can introduce to your workday that will enhance your productivity, health, and enjoyment. Most important, stand or walk for at least half the day, and avoid sitting for more than twenty minutes at a stretch. If you have to work at a job that involves sitting for long periods, here are a few ways to keep from succumbing to the “sedentary feedback loop”:

• Work at a standing desk. Several years ago, I stacked shoeboxes on my desk at work as a way to elevate my laptop. Now, West Virginia University has installed several stand-up stations, and the U.S. Air Force is embracing them. Be sure to move around, elevate a leg, and stretch whenever you can as you work.

• Test run a treadmill desk. You might have a friend or colleague who has one. Give it a try, for at least a half hour, at a variety of moderate speeds between 1 and 2.4 miles per hour. Remember to maintain proper, erect posture and breathe slowly and deeply. There’s a good chance you’ll feel more productive.

• Walk or ride an elliptical bicycle to work. An elliptical bike is essentially an indoor elliptical trainer mounted on an extended traditional bicycle frame. Some elite runners use them to cross-train, and for nonimpact cardio workouts. This isn’t always realistic, but with a bit of creativity it can fit into at least part of a daily routine—for instance by driving part of the way to work, and walking or cycling or elliptical biking the rest.

My ten-year-old daughter, Lily, takes a spin on an elliptical bike. Look, Ma—no seat!

• Take standing or walking breaks. Stand up for at least two out of every thirty minutes. If possible (while talking on the phone, for instance), walk outside, squat a few times, do some light stretching, dictate email replies on your phone, or have a walking meeting. Movement boosts cognitive processes. As a reminder, try setting a half-hour alarm on your phone each time you sit down, or use an app like Time Out (Mac) or Workrave (Windows).

• Stand up at meetings. If you’re worried about what your colleagues think, tell them you have a bad back! Better yet, hold walking meetings.

The back does not need “support” when sitting correctly.

Sitting erect will alleviate back pain and promote overall health.

• Sit more actively. Slumping passively in a chair isn’t the only way to sit. Sit tall, with head erect, balanced directly over your “sitz” bones. Better yet, try sitting on a yoga ball or stool instead of a chair, which activates several sets of muscles—the ones needed to make small postural adjustments. (Venn Design makes one upholstered brand of this.) For car and airplane seats, I use a product called Backjoy, which better positions the pelvis and lower spine.)

• Sit on the floor whenever you can, and mix up the positions. This mobilizes your joints, muscles, and fascia, from toes to torso, and recruits important stabilizing muscles. The simple acts of sitting and arising are great for your body as well.

Here are some of the numerous positions—”sitting yoga,” if you will—for sitting on the floor. (Kids naturally use many of these.)

2. Reset your standing posture

This entails more relaxation and alignment than it does effort. Throughout, inhale and exhale slowly and deeply with the diaphragm.

• Stand against a wall. Visualize good posture as a straight line that runs through your shoulder, hip, and ankle.

• Position your feet under your hips, thigh-width apart. Ideally, they should point forward, but don’t force this—your natural position may be slightly splayed. Imprint this position in your memory. Through practice and repetition, you will create a new “normal.” This may appear or feel stiff at first, because it’s not how most people tend to stand. (When your feet point forward, as we’ll see later, the arch of your foot is stable, which helps engage the powerful hip and glute muscles.)

• Balance on each foot’s “tripod”: the inner and outer edges of the feet (at the ball), and the heel. Place your feet hip-width apart, facing forward. Lock your knees. Now unlock them. Do you feel the difference? Flexible, unlocked knees give you stability. Let them relax into the most stable position.

Begin by “standing tall” against a wall. Head, shoulders, buttocks, and heels should touch the wall, with space to slide your hand behind the small of your back. Then replicate that position without the wall.

• Now lengthen the back of your neck and make yourself tall, as if pulling yourself upward from the crown of your head. Your chin will naturally drop down.

• Reach up, as if for a cookie jar on a high shelf, and feel your spine lengthen (especially in the rib cage area). Maintain that elongated spine, and lower your arms.

• With your arms at your sides, roll your shoulders forward, then up, then back, and let your shoulder blades slide down your rib cage. Imagine that you are setting your shoulder blades the way an Old West outlaw returns his guns to his holsters. Boom! Stable shoulders.

Your posture should now be connected and straight: Hips over ankles. Shoulders over hips. Ears over shoulders. You should feel most of your weight on your heels. Picture yourself as squarely balanced beneath your head. If in doubt, have someone take a photo of you from the side, and see if the dots connect in a straight line—ears, shoulders, hips, ankles.

Your spine is now elongated and your diaphragm engaged. There’s a simple test to confirm this: have someone stand behind you and push straight downward on your shoulders. If you collapse backward, tilt your torso slightly forward from the hips, and recheck. Find your stable column.

3. Reset your breathing

The short, diaphragmatic breathing drill on the videos page of the book’s website (runforyourlifebook.com) will align and lengthen your spine, activate your diaphragm, enhance oxygenation of your tissues, and release buckets of parasympathetic hormones (the good stuff that relaxes you). It’s a great way to bracket the start and end of your day.

• Slowly, lie down flat on your back. As in the photo on this page, slide your feet toward your butt until your legs are bent at 90 degrees. Now try to lengthen your spine by imagining gentle traction pulling from the top of your head, stretching you into a fully lengthened position.

Lengthen your spine, tuck your shoulder blades, and breathe through the belly. Or, you can lie on a long foam roller and move your arms as if making a snow angel while deep breathing.

• Place your palms out and arms straight, as if making a snow angel, and tuck your shoulder blades under you.

• As a visual reference, place your phone or other small object on your belly button. It will rise and fall as you breathe in and out.

• Breathe all the way out, as if blowing up a balloon. Gently purse your lips to add a bit of controlled resistance, while centering your focus. To a slow count (one thousand, two thousand, three thousand . . .), now inhale into the abdomen through your nose.

• Pause at the top of the breath—then inhale just a bit more. This will engage the diaphragm and push the object on your stomach slightly higher.

• Slowly breathe out, again to a slow count. Pause at the bottom of the breath, then pull your stomach in a little bit more, toward your spine.

As you become more relaxed, increase the count to 4/8 (four counts on inhalation, eight counts on exhalation), then to 5/10, and up to 7/14 or 8/16. Stop if you feel dizzy or short of breath. Your breath should be strong, smooth, and uniform. If you sense restrictions in the flow of your breath, just continue to breathe through them and past them. Try not to gasp or sigh. Do this for two minutes each day.

You can also practice this on hands and knees. Keep your spine “in neutral,” and belly breathe. This improves your ability to exhale with your abdomen, and makes you aware of how your diaphragm and breathing interact with your back muscles.

I’m confident that if you can start making these adjustments to your routine, you’ll be more productive, feel more energetic, and waste less time at doctors’ and therapists’ offices. Cultivate and continue them as daily habits—for the rest of your life!