The Valsalva Maneuver - A Coach's Perspective

** For a more succinct version of this content click here to view my Facebook post on the topic. **

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The Valsalva maneuver (from now on to be referred to as VM) is two things primarily:
1.  It's a natural and nearly unavoidable technique when exerting maximal muscular force (#1, #2, #3, #4), and
2. It's stated as being very high risk and therefore warned against when lifting weights (#5, #6).

So, as someone who both uses and teaches the VM regularly and has yet to have any negative side effects or see anyone else have any negative side effects as a result, I wanted to do some research to establish the validity of the warnings against using this breathing technique when lifting weights. And, as it turns out, the risk of the VM in weight lifting appears to be quite overstated (#1, #2, #3).

I've included ten links at the bottom of this post -- as well as throughout this post -- to the sources used to create this write up. I encourage you to read them and come to your own conclusions, but in this write-up I'll detail my conclusion; the VM is effective and nearly unavoidable when it comes to maximal weight lifting and is the necessary breathing technique if you want to safely move some heavy weight in and out of the gym. However, I do want to point out that while I support the use and teaching of the VM, I do also recognize that the risks have not been disproven but instead are poorly cataloged, poorly studied, and poorly understood. My personal experience would suggest that the purported risks are unfounded, but the literature has yet to entirely agree with me.

So, what exactly IS the Valsalva maneuver?

It is a technique of breathing in which you forcefully attempt to exhale against a closed airway, which includes holding your nose. A modified version of the VM -- which is used in weight lifting -- is the forceful exhalation against a closed glottis with the nose being free (#2, #7). In practice while lifting weights, what this feels like is taking a deep breath in right before your lift and then holding that breath while pressing the abdomen out, sometimes against a weight belt, for the duration of the movement. It's very likely, even if you haven't been coached on this breathing technique, that you've been using it when your weights get heavy enough to require it for maximal muscular force production. 

An extended version of the VM, occurring over about 35 seconds includes four physiological phases detailed in the following images (#2, #7):

 Graphical representation of the four physiological phases of the VM. (#7)

Graphical representation of the four physiological phases of the VM. (#7)

 Table detailing each of the four phases of the VM. (#2)

Table detailing each of the four phases of the VM. (#2)

So, the physiological effects of the VM include changes in blood pressure, heart rate, stroke volume, intracranial pressure, cerebral perfusion pressure, and intrathoracic-intraabdominal pressure.  The concerns regarding the VM in weight lifting are those that include a supposed increased risk of stroke (#2, #5, #6). The train of thought is that the strain, the increased blood pressure, and the increased cranial and cerebral pressures can lead to cerebral hemorrhage. However, as mentioned above, these risks are poorly cataloged, poorly studied, poorly understood, and quite frankly, overstated (#1, #2, #3). Furthermore, source #2 even suggests that the VM is protective against cerebral hemorrhage thanks to the evening of pressure gradients granted by the use of the maneuver. (For a more eloquent explanation please see pages 7-9 of the full #2 article linked below.)

Now, before we go any further, let's go ahead and address the fact that these physiological effects are very real, and for someone who is in a condition of unmanaged high blood pressure, it's certainly contraindicated to use the VM. It's contraindicated to be lifting maximally in that condition at all, because of the spike in blood pressure it induces in a system that is already suffering from unmanaged high blood pressure. However, these people represent a special population, and their limitations should not dictate the perception of the VM across the general, able-bodied population. 

With the physiological effects and the supposed risks having been explained, it's time to explore why you'd want to use the VM in the first place.

When lifting heavy weights, especially with a barbell, the primary safety component is the ability to maintain a neutral and rigid spine throughout the movement. This is one of the main facets of proper form along with the ability to keep the barbell in balance. It's absolutely essential to the process. Along these lines, the VM has been shown to increase intra-abdominal pressure (IAP), and that increased IAP has been shown to aid with spinal rigidity and stability (#2, #3, #8, #9). This is the same reason that weight belts are worn; to increase the stability of the spine in order to protect it. When you wear a weight belt and perform the VM so that you're pressing your abdomen out into the belt, the effects of increased IAP and stability of the lumbar spine are enhanced (#10). 

I'd like to reiterate here that the VM is a natural process that will occur voluntarily unless you think about NOT doing it. One of my favorite arguments in favor of this maneuver is Mark Rippetoe's; imagine the scenario where your car has broken down, and you have to get out and push it. The sequence of events you're going to follow after putting the car in neutral are to take a big breath, hold it, and push. And why? Well, as Rippetoe says, "because your DNA is smarter than the people [arguing against using the VM] (#1)." Many of the linked articles tout this same sentiment (#2, #3, #4), and no one is arguing that the VM doesn't increase IAP (#2, #3), so I'm looking at all this information and thinking to myself, "why WOULDN'T I use this breathing technique?!"

All of this research brought me to the following conclusion: while the risks of the VM are unconfirmed and poorly studied, the benefits and voluntary nature of the maneuver are not. The VM is a naturally occurring mechanism that functions as a protective measure for the spine and potentially as a protective measure against cerebral hemorrhaging when lifting heavy weights and exerting maximal muscular force. There are many who warn against using this maneuver in weight lifting, and while the physiological effects of the VM do deem maximal lifting inappropriate for the subset of the population with unmanaged high blood pressure, the risks in general appear to be quite overstated. I will continue to use the VM with the knowledge that it is the most efficient and protective way to lift maximally, and I will continue to teach this maneuver where it's appropriate.

SOURCES:

1. Mark Rippetoe: Rip On Breath - YouTube/Mark Rippetoe seminar - https://www.youtube.com/watch?v=QkeN_fkXrdE

2. The Valsalva and Stroke: Time For Everyone To Take a Deep Breath - Starting Strength - http://startingstrength.com/contentfiles/valsalva_stroke_sullivan.pdf

3. The Valsalva maneuver: its affect on intra-abdominal pressure and safety issues during resistance exercise - NCBI - http://www.ncbi.nlm.nih.gov/pubmed/23222073

4. Factors affecting blood pressure during heavy weight lifting and static contractions - Journal of Applied Physiology - http://jap.physiology.org/content/73/4/1590.short

5. The Valsalva Maneuver Revisited: The Influence of Voluntary Breathing on Isometric Muscle Strength - NCBI - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2883611/

6. Influence of breathing technique on arterial blood pressure - Science Direct -http://www.sciencedirect.com/science/article/pii/S0003999395805788

7. Valsalva Maneuver - Wikipedia - https://en.wikipedia.org/wiki/Valsalva_maneuver

8. Intra-abdominal pressure mechanism for stabilizing the lumbar spine - Journal of Biomechanics - http://www.jbiomech.com/article/S0021-9290(98)00129-8/abstract

9. Intra-abdominal pressure increases stiffness of the lumbar spine - Journal of Biomechanics - http://www.jbiomech.com/article/S0021-9290(04)00410-5/abstract

10. The Belt Bible - StrengthTheory - http://strengtheory.com/the-belt-bible/