When You Can't Catch Your Breath

COPD and Massage Therapy

By Ruth Werner
[Pathology Perspectives]

“If I’m having trouble breathing and there’s any pressure on my chest, it’s too much. But, if a massage therapist can gently help to loosen my upper ribs, I can breathe so much better afterward.”
Chronic obstructive pulmonary disease (COPD) is a group name for a spectrum of progressive conditions that cause permanent damage to the lungs.
The two main conditions under the COPD umbrella are chronic bronchitis and emphysema. Asthma is sometimes listed here too, although that is not consistent because asthma does not always cause irreversible damage. A rare condition called bronchiectasis also appears in this group—this is a complication of chronic conditions including cystic fibrosis and autoimmune disorders that cause systemic inflammation.
COPD is extremely common. Of the roughly 255 million adults in the United States, it is estimated that 12–15 million have been diagnosed with this condition, and another 12 million have it but have not yet been diagnosed. This means that about 10 percent of the adults in this country are affected by COPD. Most of these are over 65 years old with a history of smoking, but this is not always the case.
We invest about $50 billion a year in direct and indirect medical costs associated with COPD. It is the third leading cause of death in this country, causing between 120,000 and 155,000 deaths each year.

COPD—What Goes Wrong?

To talk about the pathophysiology of COPD, it’s useful to do a brief review of healthy lung function. For this, I refer readers to the accompanying video, in which I share my wonder and appreciation for the mechanics of breathing. It’s a miraculous thing that happens every time we take a “free and easy” breath. But when lung structures undergo pathological changes, the act of breathing—which should be almost effortless—becomes labored, and a long list of complicated problems can develop. What follows is a simplified description of the progress from chronic bronchitis through end-stage emphysema.
COPD typically begins with ongoing, long-term irritation to the bronchi and bronchioles. In about 90 percent of all cases, the irritation comes from tobacco or marijuana smoke. Exposure can occur as firsthand smoke (this is what the smoker inhales), secondhand smoke (this is what the smoker exhales and other people may inhale), and side-stream smoke (this is what comes off the cigarette itself). Industrial chemicals and pollutants can also cause bronchial irritation. And a genetic anomaly called alpha-1 antitrypsin deficiency limits capacity to deal with even mild environmental pollutants, so people with this condition are at increased risk for COPD.
With chronic irritation comes inflammation. Over time, the bronchial linings become permanently swollen. Mucus-producing cells replicate, increasing the amount of sticky slime in the respiratory tract. The cilia that line the bronchial tubes may also be damaged, which means contaminant-laden mucus lingers in the lungs—prolonging inflammation and promoting possible infection. These structural changes eventually become irreversible; this is chronic bronchitis. (By contrast, acute bronchitis refers to a short-term infection in the bronchi—although people with chronic bronchitis are very susceptible to bouts of acute bronchitis.)
If the damage that causes chronic bronchitis doesn’t stop, COPD may progress to affect the alveoli. The alveoli, readers may remember, are the tiny cup-shaped epithelial structures that make up the working tissue of the lungs. Each of our 300 million alveoli is surrounded by its own cardiovascular capillary. This is the site where oxygen from the air we inhale enters the bloodstream, and carbon dioxide exits the bloodstream to enter the alveoli, so it can be expelled when we exhale.
If the alveoli are inflamed, several problems develop. First, the elastin fibers that invest the alveolar walls degenerate. This means the lungs lose their ability to recoil to their original shape during exhalation. They become like old, stretched out balloons with remnants of stale air inside—which means fresh, oxygen-rich air can’t get in. The walls between the alveoli degenerate, and multiple discrete cups join together to form large hollow areas called bullae. With less surface area and fewer supplying capillaries, the capacity for oxygen-carbon dioxide exchange is impaired. Oxygen levels in the blood fall (called hypoxia), leading to a host of other complicated and serious problems. Among the complications of COPD we see are polycythemia (too many red blood cells and thickened blood), right-sided heart failure, pulmonary embolism, vulnerability to pneumonia, and ultimately respiratory and cardiovascular collapse.

Symptoms of COPD

It can take years for the damage of COPD to cause symptoms, and because we usually see this in people over age 65, it is easy to assume those changes are age-related. Chronic bronchitis is marked by fatigue, shortness of breath, and a cough that lingers for weeks and months after even a mild respiratory tract infection. The cough is productive, meaning the person brings up clear, sticky sputum.
The fatigue seen with COPD is an important issue. A person with healthy lungs expends about 5 percent of resting energy in the effort of breathing. A person with advanced COPD puts closer to 50 percent of resting energy into this job and must do this every minute, 24 hours a day. For this reason, both eating and sleeping become extremely challenging.
As the condition progresses to emphysema, shortness of breath, wheezing, and rales (a characteristic bubbling, rasping sound of air moving through a narrowed passage) may occur. The patient may develop a habit of pushing air out through pursed lips; this is an attempt to push against increasing back pressure in the lungs. The diaphragm becomes permanently flattened, which forces the abdominal organs downward. Some people with COPD develop “barrel chest” (that is, the intercostals hold the rib cage out as wide as possible).

Treatment for COPD

COPD is irreversible. If it is diagnosed and treated early, further progression can be slowed or stopped, but damaged lung tissue does not regenerate. The first course of action in treating COPD is to remove any irritating stimulus, which is usually cigarette smoke.
Medication can dilate the bronchi and take pressure off the alveoli, remove mucus and edema from the lungs, and ward off potential lung infections. Long-term steroidal anti-inflammatories carry a number of possible side effects, however.
 Patients are strongly urged to be vaccinated against pneumococcus pneumonia and to get a yearly flu vaccine, because they are at higher risk for serious lung infections than the general population.
Oxygen supplementation may be recommended during sleep or following exercise. In addition, doctors may prescribe continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) devices.
Lung volume reduction surgery removes damaged portions of the lung. This increases thoracic capacity and improves cardiovascular function. Lung transplants are a last-ditch option that has been successful for some patients; emphysema is the leading reason for lung transplants.

Can Massage Therapy Help?

Logic suggests that massage therapy may help people with COPD by reducing unnecessary tension in thoracic muscles to allow for easier breathing. Stimulating local circulation in the extremities might also be helpful for people who live with this condition. Maybe tapotement over the chest could help loosen sticky mucus so it can be coughed away. In addition, massage may be a useful adjunct to whatever exercises patients might be given to help preserve and prolong lung function.
The science supports this logic, up to a point. A recent review of seven research articles came to the conclusion that “manual massage therapy” can be a useful option for people with stable COPD when offered alongside physical therapy and exercise (Polastri et al., 2019). Specifically, they found predictable benefits in forced expiratory volume, the perception of dyspnea (shortness of breath), and improvement in 6-minute walking tests. They also found that it was impossible to draw any stronger conclusions because of the scarcity of consistent findings in good-quality research about this question.
A different project found more benefit: this study looked at 12 patients who received a single session of a “soft tissue massage therapy protocol” (Cruz-Montecinos et al., 2017). This report includes a detailed description of the massage therapy protocol. Compared to measures taken before the session, researchers found that one 30-minute massage treatment appeared to improve inspiratory capacity and led to a significant increase in oxygen levels in the blood. A weakness of this project, however, is that they did not take similar measures in a control or comparison group.
Clearly, we need more data, but even this minimal amount of research suggests that massage therapy could be helpful for this population—if appropriate accommodations can be made.


For clients with COPD, it is extremely important to offer a massage therapy environment that is as free as possible from airborne irritants. This can include scents from candles, essential oils, the fabric softener in your sheets, and your previous client’s perfume. The scent of cigarette smoke can be especially irritating.
It is also important to keep in mind that people with impaired lung function have a much higher risk of contracting respiratory infections compared to the rest of the population. What might be the end of a mild cold for one person may quickly become life-threatening pneumonia for the next. To manage this risk, we must be diligent about hygienic practices, including cleaning all the surfaces clients may touch—remembering doorknobs, light switches, and bathroom fixtures—before we work with a person who has COPD.
Another accommodation clients with COPD may need is in positioning. It is often uncomfortable for people with this condition to lie flat, and pressure on the sternum from a massage chair can feel oppressive. Breast recesses may help some clients. Having the option to offer a reclining surface so that their torso is at a roughly 45-degree angle (sometimes called Fowler’s position) is appreciated by many.    
And finally, if the client’s priority is to lessen some of the symptoms related to COPD, we would do well to focus on primary and secondary respiratory muscles, as well as other muscles that may become hypertonic with a lot of tension around the chest, shoulders, and neck. Some practitioners may also offer percussion and/or vibration over the chest in an effort to help support the cough reflex and the movement of sputum out of the lungs, but it is critical to be aware that steroidal anti-inflammatories can compromise bone density, so this must be done with the greatest care.
Do you have any clients who have COPD? What do they look for in a massage session, and how do you know you are providing it? Because COPD is so common, and because massage therapy may have substantial benefits to offer, this is a topic that would benefit greatly from case reports written by massage therapists in the field—that’s you. Will you add to our knowledge about massage therapy for COPD?

Author’s note: I had conversations with several people to help me prepare this article. Their input is incorporated throughout, and I thank them for their generosity. Contributors include:
• VSM—massage therapist whose husband died of emphysema in 2013; she now specializes in working with patients with advanced COPD
• MM—person with bullous emphysema
• AA—massage therapy educator who has COPD along with a complex autoimmune condition
• TB—massage therapist with COPD


Centers for Disease Control and Prevention (CDC). 2018. “COPD Costs.” www.cdc.gov/copd/infographics/copd-costs.html.
Centers for Disease Control and Prevention (CDC). 2019a. “Basics About COPD: Chronic Obstructive Pulmonary Disease (COPD).” www.cdc.gov/copd/basics-about.html.
Centers for Disease Control and Prevention (CDC). 2019b. “Data and Statistics: Chronic Obstructive Pulmonary Disease (COPD).” www.cdc.gov/copd/data.html.
Cruz-Montecinos, Carlos et al. 2017. “The Immediate Effect of Soft Tissue Manual Therapy Intervention on Lung Function in Severe Chronic Obstructive Pulmonary Disease.” International Journal of Chronic Obstructive Pulmonary Disease 12 (February 21, 2017): 691–96. https://doi.org/10.2147/COPD.S127742.
Editorial Team. 2016. “Were You Tested for Alpha-1 Deficiency?” COPD.net, https://copd.net/living/alpha-1-deficiency.
Mosenifar, Zab et al. 2019. “Chronic Obstructive Pulmonary Disease (COPD): Practice Essentials, Background, Pathophysiology.” https://emedicine.medscape.com/article/297664-overview.
National Institutes of Health (NIH). 2019. “NIH Fact Sheets: Chronic Obstructive Pulmonary Disease (COPD).” https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=77.
Polastri, Massimiliano et al. “Manual Massage Therapy for Patients with COPD: A Scoping Review.” Medicina 55, no. 5 (May 2019): 151, https://doi.org/10.3390/medicina55050151.

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at BooksofDiscovery.com), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.