Valsalva Maneuver for Lifting

Originally published on December 13, 2008

What is the Valsalva Maneuver?

The valsalva maneuver was named for Antonio Valsalva, an 18th-century physician. Used as a way to evaluate the cardiovascular system, it is often done, both consciously and unconsciously, by those engaged in vigorous movement; especially where those movements encounter resistance, as with strength training. Described simply, the valsalva maneuver is a forced expiration against a closed glottis.

The “KIA” in karate can be compared to the modified vasalva maneuver, which is the technique most lifters use. Any unconscious grunt under exertion likewise can be compared to this technique. It is NOT holding ones breath and completely holding one’s breath during heavy weight lifting, in this writer’s opinion, should never be recommended. Instead, we use this “modified” technique in which the glottis is partially closed in order to maintain more pressure during the most difficult portion of the lift. Some air is allowed to escape in a controlled way. Your breath should be allowed to release quickly just upon passing the ‘sticking point’ of the lift.

The vasalva maneuver helps to increase intra-thoracic and intra-abdominal pressure. With resistance training and lifting, it is this intra-abdominal pressure we are concerned with. This increase in pressure results in decreased venous return and reduced cardiac output. The heart rate speeds up and vasoconstriction increases so that blood pressure is maintained. If intense and prolonged enough you may become lightheaded or even faint due to lack of oxygen in the brain. Also, when the pressure is released, blood pressure can sky rocket due to the vasoconstriction and high cardiac output.

Valsalva Maneuver Purpose

Increased intra-abdominal pressure during lifting or other exertion has been referred to as a “fluid ball”, which is a rigid compartment of fluid in the lower torso. This increases the rigidity of the torso and helps to support the vertebral column. This is basically similar to the effect of a weight belt but naturally produced in the body, much to our benefit. The purpose of the valsalva maneuver during lifting is to increase this intra-abdominal pressure.

Many authoritative sources claim that using the valsalva is necessary to bring this about, including such books as Essentials of Strength Training and Conditioning. According to Stuart McGill, this “fluid ball” is a natural and automatic response of the body under heavy load. The valsalva maneuver (VM) just helps to increase this pressure. And indeed this claim is borne out by a great deal of clinical data. ¹McGill, Stuart. Low Back Disorders Evidence-Based Prevention and Rehabilitation. Human Kinetics, 2016.

Understanding more about what happens abdominally when you lift a heavy load may help. During heavy lifting activities or vigorous exercise, such as deadlifts, squats, or even demanding barbell curls or situps, the both the abdominal muscles and the diaphragm help to stabilize teh spine. When they contract, intrabdominal pressure is increased and this increase decreases the compressive force on the spine while helping to stabilize the torso. The diaphraghm is pushed up into the thoracic cavity (chest cavity) so that intrathoraic pressure is also increased. If you are not blocking air from escaping your lungs by closing your glottis, this increase in intrathoraic pressure will force air out of the lungs. If your glottis is closed, thus blocking air from escapting and thus decreasing the pressure, a valsalva is being performed. This also increases your blood pressure and this causes the left ventricle of your heart to have to work much harder to push blood into circulation. ²Kraemer, William J., et al. Exercise Physiology: Integrating Theory and Application. Wolters Kluwer, 2016.

Clinically, the VM is considered to have four phases.

1) A temporary rise in mean arterial blood pressure as a result of the increased intra-thoracic pressure

2a) A fall in atrial filling pressure leading to a decrease in mean arterial blood pressure. b) An increase in sympathetic activation which increases peripheral vascular resistance so mean arterial blood pressure rises a small amount once again and heart rate increases a bit.

3) The strain is released and mean arterial blood pressure falls suddenly as the intra-thoracic pressure falls.

4) The increased sympathetic tone and systemic vascular resistance is persistent so there is an overshoot in mean arterial blood pressure. This results in a reflexive slowing of the heart rate (bradycardia) and both blood pressure and heart rate return to normal. ³Critical closing pressure explains cerebral hemodynamics during the Valsalva maneuver — Dawson et al. 86 (2): 675 —.” Journal of Applied Physiology. Web. 15 Sept. 2009. <http://jap.physiology.org/cgi/content/full/86/2/675>.

If you’ve ever experienced an exertional headache, for instance, during barbell squats, this may be one cause of it. But it is important to note that resistance exercise causes acute increases in blood pressure regardless if someone holds his/her breath during a lift. This is temporary and, according to research, has no long term effect on resting blood pressure. Also, this transitory increase in blood pressure becomes blunted in trained individuals compared to untrained ones. ⁴Marcardle, William D.; Katch, Frank I.; Katch, Victor L. Exercise Physiology: Energy, Nutrition, and Human Performance.4th ed. Baltimore: Williams & Wilkins, 1996. 220-222, 276-277. The valsalva maneuver does not change this and some of the dire warnings against the maneuver are a bit unfounded.

Contrary to popular belief, higher peak blood pressures are associated with submaximal high volume lifting more than with maximal lifting. During the last few reps of high volume sets the pressure reaches its peak, regardless of valsalva maneuver use although the valsalva is associated with even higher peaks. However, the valsalva is really not necessary for such submaximal training and would be difficult since oxygen deprivation and the need to breathe in a regular way is contrary to its performance. It is exactly for this reason that most trainers teach trainees to breathe in during the eccentric and out during the concentric as a simple way to maintain breathing during the kind of resistance training most people engage in, which entails lighter weights and moderate to high volume.

I should point out that although huge increases in blood pressure have been recorded during resistance training and even more during the valsalva maneuver there is nothing to indicate a negative effect on resting blood pressure. Things quickly normalize and return to baseline. And indeed, resistance training seems to lead to lower blood pressure than that of sedentary individuals, especially in men.

So, obviously, the untrained maneuver should be used with caution. I say untrained because this negative effect can be minimized by trained diaphragmatic breathing while using the valsalva (more below). Without care, high lifting volume and lack of normalization of blood pressure…which can take minutes, can lead to some very serious consequences. The good thing is that the valsalva is not necessary for higher volume lifting at lesser intensities. Indeed, it is not necessary at all since increased intra-abdominal pressure is an automatic response in heavy lifting. The valsalva is very useful for increasing that pressure, but it is not true that you need it to create pressure in the first place. However, the conclusion of one study by Haykowsky, et al. suggested that cerebral arterial stress was actually lower when the valsalva maneuver was used during resistance training than when resistance training was performed without the maneuver. According to the study, this was due to a “canceling out” effect of the rise in systolic blood pressure being accompanied by increased intrathoracic pressure. These authors revealed similar results for left ventricle wall stress in that brief Valsalva maneuver was not associated with an alteration in LV wall stress or LV systolic function in healthy young men. The resistance exercises used, however, were the biceps curl and the leg press, respectively. ⁵HAYKOWSKY, MARK J.; EVES, NEIL D.; R. WARBURTON, DARREN E.; FINDLAY, MAX J. Resistance Exercise, the Valsalva Maneuver, and Cerebrovascular Transmural Pressure. Medicine & Science in Sports & Exercise: January 2003 – Volume 35 – Issue 1 – pp 65-68,⁶Haykowsky, Mark J.; Taylor, Dylan; Teo, Koon; Quinney, Arthur; Humen, Dennis. Left Ventricular Wall Stress During Leg-Press Exercise Performed With a Brief Valsalva Maneuver. CHEST January 2001 vol. 119 no. 1 150-154

By using a proper bracing technique and breathing diaphragmatically while employing the valsalva, the rise in intrathoracic pressure is reduced. By breathing in your “belly” the diaphragm moves down into the intraabdominal cavity, thus increasing pressure there while relieving pressure in the thoracic cavity and helping to stabilize the spine and reduce forces on it.

To make the maneuver safer, as stated above, you do not hold your breath during an entire lift. You can release your breath in a controlled way. Hold the tongue against the glottis and exhale slowly. Or, you can hold your breath until you are past your sticking point and then do a controlled release. The valsalva maneuver is about abdominal bracing and it is not just the act of holding your breath. During lighter lifting, it is not necessary at all.

More on the adbominal breathing and bracing technique below.

Valsalva Induced Retinopathy (Vitreous Hemorrhage)

Although trainees are often warned of the risk of eye hemorrhage (vitreous hemorrhage), this is not a common finding associated with the valsalva maneuver and is much less likely when the modified valsalva is employed. Holding one’s breath completely during lifting, as discussed above, especially during high volume lifting, would be an excessive use of the valsalva and their may certainly be a risk of valsalva induced retinopathy such as vitreous bleeding. There are no controlled studies to indicate this risk because, of course, intentionally causing such eye injury would not be ethical. However, several case studies can be found describing eye injuries of this sort due to the valsalva maneuver. It should be noted, that not all of these are associated with heavy weight lifting. Prolonged vomiting, blowing up balloons, etc. are more likely to cause such a problem than the controlled use of modified valsalva during weight training. The risk is up to you, however.

How to Perform the Valsalva Maneuver

Boris of Squat Rx does a great job of explaining and demonstrating breathing maneuvers and also show just exactly what a “sticking point” is. But to define it clearly: it is the point in a lift that is most strenuous due to having the least mechanical advantage (really a region rather than one point).

Boris’s breathing technique here is second to none. I use much the same technique myself with very heavy loads. Although I tend to verbalize more, which can be a good way to go since a deep grunt is a handy way to control breath release.

Bracing Technique with Valsalva

So to summarize: Immediately before you push or pull take a deep breath into the abdomen then tense your midsection, pushing down and out. This is not poking out your belly. The entire midsection should expand. To test whether you are doing it right, practice with your hands on your sides. You should feel an expansion both in front and in back as you breathe.

As you start the lift perform the valsalva by closing your glottis so that air cannot be forced out. This helps increase pressure. However, during the lift, it is fine to let air escape a little bit. It escapes under pressure. Once you’ve passed the sticking point, you can exhale fully if you want. I will usually inhale as I lower again. But some individuals may need to experiment, according to the lift, with when they should inhale and perform the maneuver. During deadlifts, especially, many people find it easier to do it at the bottom while setting up for the next lift.

Myth: The Valsalva is Necessary to Maintain Core Stability

I want to say more on whether the valsalva maneuver is strictly necessary during heavy lifting. The needs of a heavy lift have nothing to do with the needs of most athletic activities. Most athletes have a need for continued stability under dynamic conditions while also maintaining a steady supply of oxygen.  On the other hand, you can actually hold your breath during a heavy deadlift or squat. And, for better or worse, the valsalva has become synonymous with core stability in the minds of many trainees. Since this entails restricted breathing this presents a conundrum.

Likewise, one cannot compare playing in a Soccer match to doing higher volume resistance training, where breathing can be regulated and controlled. Resistance training usually consists of discrete skills performed repetitively. These skills are also closed skills. A Soccer match, on the other hand, is much more unpredictable, highly dynamic, and completely non-conducive to a controlled breathing pattern. Some find during lifting that they are unable to both breathe deeply and maintain a stable core. Since they cannot engage in a pattern of regular breathing while still feeling like they are able to keep their core muscular engaged, the valsalva becomes an attractive and easily justified action. The question then because how can you breathe deeply during lifting?

Athletes are often instructed to “breathe naturally”. The word naturally is meaningless in and of itself but this instruction can be narrowed down to mean “to breathe without affectation or specific intent”. While for some athletes this could be correct, for others it could be inefficient and even injurious depending on their habitual breathing patterns. So how does one breathe deeply while maintaining a strong and stable core?

The answer lies in proper diaphragmatic breathing and developing what McGill calls an “athletic diaphragm” which allows continuous breathing without sacrificing control of the torso, which tends to happen when breathing becomes labored and shifts to a high chest pattern. There is a good way to begin practicing this:

• After a period of vigorous exercise when your breathing is somewhat heavy but not strained perform a timed front plank while maintaining your breathing solely in the diaphragm. The plank position makes it necessary to both use diaphragmatic breathing and to contract the core musculature. Doing the exercise while fatigued creates the proper environment.

The supine bridge position with hips extended can also be used to practice belly breathing as it forces the breath into the “belly”.

Valsalva’s Test and Spinal Pain

The valsalva maneuver is a common test used to evaluate the presence of spinal injuries or lesions. As it increases intraabdominal pressure it also increases intrathecal pressure. Intrathecal refers to anything happening inside the spinal canal. The result of this increase in intrathecal pressure during the valsalva can cause pain secondary to a herniated disc or other lesion that is occupying space in the spinal canal. If you have back pain and experience an increase in this pain upon performing the valsalva maneuver or if you are asymptomatic but experience back pain as a result of the maneuver stop and seek professional medical advice.

Remember that whether you use the maneuver or not is up to you. It is not strictly necessary in order to perform a proper abdominal brace so don’t feel obligated to do it just because other lifters do. The purpose of this article is to provide some information to help you decide for yourself how and when to use it in your training, not to tell you what to do.

Remember that how you breathe during resistance training has very little relation to how you breathe in an open environment.