Expert Insights: Breath Work in Pain Management with Jill Miller

[00:18] Dr. Linda Bluestein: Welcome back, every bendy body. This is the Bendy Bodies Podcast, and I'm your host and founder, Dr. Linda Bluestein, the Hypermobility MD. This is going to be a great episode, so be sure to stick around until the very end so you won't miss any of our special hypermobility hacks. This information is for educational purposes only and is not a substitute for personalized medical advice. Today I am so excited to have Jill Miller with me. Jill Miller has 30 years of corrective movement expertise that forges the links between the worlds of yoga, massage, athletics, and pain management. Her signature self-care fitness programs, Yoga Tune-Up and The Roll Model, are found at gyms, yoga studios, hospitals, athletic training facilities, and corporations worldwide. Jill is the former anatomy columnist for Yoga Journal and has been featured in New York Times, Wall Street Journal, Shape, Women's Health, O, The Today Show, and is a contributing expert on the Oprah Winfrey Network. She is the author of The Roll Model: A Step-by-Step Guide to Erase Pain, Improve Mobility, and Live Better in Your Body, and a contributing author on self-myofascial release in the textbook Fascia, Function, and Medical Applications. She is the creator of dozens of instructional DVDs, including Rolling Along the Anatomy Trains with Tom Myers and Walking Well with Katy Bowman, and Treat While You Train with Kelly Starrett, DPT. Her new bestselling book is Body by Breath: The Science and Practice of Physical and Emotional Resilience. A couple of seasons ago, co-host Jennifer Milner and I interviewed Jill in an extremely popular episode, number 30, focusing on fascia. So be sure to listen to that episode as well. Jill, hello and welcome back to Bendy Bodies.

[02:08] Jill Miller: I'm so happy to be here, Linda. Thank you for having me back.

[02:11] Dr. Linda Bluestein: Of course. I'm so excited to chat about your latest book, which I have to say — this is an amazing book. It's also available in Kindle, right? So people can get it that way too. This is an incredible — yeah, this is an incredible book. So this book, Body by Breath: The Science and Practice of Physical and Emotional Resilience. This is a beast. This book has — I think you could spend such an amount of time going through the exercises, reading through all the different things. There's QR codes to do further exercises. It's just an incredible resource. What inspired you to write this book?

[02:51] Jill Miller: Yeah, the book is a very large book. It ended up becoming 480 pages. Believe it or not, Linda, when we were finishing up the first draft, we ended up cutting about 380 pages more from the book. So there were dozens and dozens of client testimonials and first-case stories that we ended up deleting from the book because we didn't want it to become larger than it already ended up being. So how did it come about? There are many different tributaries to the formation of the book. This is really my life's work. Much of this work is my own healing journey of going through my body to deal with my own mental health challenges that ended up being corrective work for soft tissue imbalances, that ended up being emotional self-regulation strategies. So there are many, many different areas of health and wellness and complementary medicine that this book fits into, which I'm really happy about. I'm sure we'll discuss on the podcast.
[04:06] But technically, how it came about: about a dozen years ago, I was doing a webinar with my friend Dr. Kelly Starrett. He's a physical therapist. He's the founder of something called MobilityWOD. He's basically a god in the CrossFit space at the time. He had a webinar on a platform called CreativeLive, and he was a good friend of mine. He and I had been collaborating on some YouTube videos — he had a very popular YouTube channel. I introduced him to my approach to self-myofascial release and breath-based self-corrective work using my tools, the Roll Model balls, things that we may have talked about on the last podcast. But I introduced him specifically to a mobilization for the gut and the diaphragm using a soft, squishy, pliable, gorgeous ball, which is one of my tools. And I didn't know at the time when I introduced this to him that he is an asthmatic. He was so blown away by what happened to him — this was during the videotaping of a 3-minute YouTube video. And by the way, when you're filming, you're under performance pressure, there's this whole other stress going on. But he was so impacted and affected by what happened to him with this very simple self-treatment.
[05:27] That is his mission and our shared mission: giving people permission to treat themselves. Anyway, long story short, that was part of the genesis of our friendship. He ended up bringing me onto this webinar to present on breath and fascia, and I did two 1-hour lectures that were seen around the world. The next day, I got an email from his publisher. His publisher, Victory Belt Publishing, published his New York Times bestselling book, Becoming a Supple Leopard. They reached out to me and said, "Hey, we'd like to publish your book." And I wrote back, "I don't have a book." And they wrote back, "Write one and we will publish it." Which is a gift, as you know, because you are also an author — it is not easy to secure a publishing deal.
So I had this incredible opportunity. It was so open-ended: "Write one." I really thought about what I wanted to write. I wanted to write this gut-based approach to self-healing, to talk about breathing. But this was 12, 13 years ago, and in the greater wellness and fitness space, breath was not trending. Breath wasn't interesting to anybody except for the yogis, the martial artists, and performing arts professionals — singers, dancers, instrumentalists who know they need to use their breath strategically. But it was not the thing. So I ended up deciding I would share my self-myofascial release approach with the world because I knew that rolling was a rising trend and I knew I had something very significant to share about that. So I wrote The Roll Model, which you shared in the intro.
[07:20] I was hoping it would go well, because if it went well, maybe I would get the opportunity to write the book I had really been wanting to write, which is Body by Breath. This is almost 20-something years of writings I've been doing on the topic of self-myofascial release, emotional regulation, and breath-based strategies for health. They offered me a contract about 8 years ago for this second book, and it took me that long to write it. There were a lot of things in the way, including having my second child, having a total hip replacement, and oh, by the way, there was a pandemic. All of these things gave me significant writer's block. I would start and stop and start and stop, but I finally finished it. In February the book was published, and it's been an absolutely incredible book release experience ever since.

[08:18] Dr. Linda Bluestein: Wow. So this is really 20 years of work in this book, but 8 years of actually working on it.

[08:26] Jill Miller: More easily than 20, because I started discovering the work that's embedded in the book when I was a co-ed at Northwestern University — 18 or 19 years old is when I started to discover this approach, this experimentation that is now pervasive throughout the book and throughout my pedagogy.

[08:54] Dr. Linda Bluestein: Amazing. And can you explain to us a little bit about how the book is organized?

[08:59] Jill Miller: Yes. Oh, thank you for asking. Let me grab the book. So the book is heavy — 480 pages — but it's beautiful, a beautiful hardback. The first 200 pages are the how, why, and why bother. It breaks down many different aspects of respiration, the mechanics of respiration, fascia science, aspects of the vagus nerve and its influences on performance, and the role of breath in performance. All of the physiology and the science and the research is upfront.
However, within that first section, I understand how people can only take in so much, so there are off-ramps throughout that take you to QR codes so you can head to YouTube and I'll re-explain things more magazine-style. I'll take you into body excursions. You can actually embed the experiences I'm trying to describe in your body.
[10:02] The second part of the book contains four different chapters of techniques. The categories that help one create a Body by Breath are: breathe, of course; roll; move; and non-sleep deep rest, also known as yoga nidra. Those techniques are in the second part of the book. And then at the very back there are two appendixes that I was constantly asked about. One is on scars and the other is on diastasis recti. They didn't really belong in the interior of the book, but I wanted to share strategies and some how, why, and why bothers for those topics.

[10:52] Dr. Linda Bluestein: Okay. So this is really actually a combination of a book and a course, it seems like.

[10:59] Jill Miller: Yes. Self-practice. I mean, we actually do have a course. So if people want to be led more concretely and be able to easily create a programming paradigm around this, there is a course. But people who are book learners will find, if they go through this and use the strategies I give them for approaching their own work, they can do self-guided work. We're also creating an app, because I understand so many people are not book learners — they're more kinesthetic learners or auditory learners. That app, which will live on our website first before we create the standalone app, is coming soon. We've been editing it for the last couple of months.

[11:47] Dr. Linda Bluestein: That's really exciting because I feel like a lot of people like to learn in snippets, and maybe they might have the book in one part of their house, but we always have our phone on us. So I feel like that's going to be a really cool addition to all of your incredible offerings.

[12:09] Jill Miller: Oh, for sure. And it's over 100 different exercises. You can really create your own compound pharmacy to induce the relaxation response. This is really geared towards you being able to tolerate a parasympathetic state as a help towards your own embodied resilience.

[12:38] Dr. Linda Bluestein: Yeah, and I want to make sure we can dig into all of what you just said. So hold that thought while we talk a little bit about why bendy bodies should care about fascia. I feel like we need to back up and start there as we get into some of the details about this topic.

[12:57] Jill Miller: Great. Well, I hope that your listeners do go back into the archive and listen to our first episode together — I re-listened to it in preparation for connecting with you. The reason we should care about fascia is because collagen is our most pervasive molecule in the body in terms of the formation of all structures. And if your collagen is the afflicted bit of your being because of your diagnosis, then we need to pay attention to all parts of the body. Your fascial tissues are the organizing tissue of the entire body. It is the structural scaffolding that gives every organ its ability to have form and shape. That includes your muscles, that includes your liver. It doesn't include your brain — the brain is very special — but all the other parts are collagen-based tissues.
[14:04] So understanding the reliance of our mobility and stability on collagen that has good integrity, it's imperative that we look at how our fascia is impacting us, and how we are trying to impact our fascia in the way that we move, train, and move our bodies through space — or stillness.

[14:24] Dr. Linda Bluestein: And obviously we did talk in the other episode about self-mobilization and some of the techniques that you teach. If someone has a limited budget and they want to get the book and get some props, where do you recommend they start?

[14:47] Jill Miller: Well, obviously the book is a great resource, but if resources are limited, go to your library. Don't worry about buying the book. Go to your local library and request it — request it multiple times, they'll get it. It should be offered for free to the public. I obviously need to pay for my own life here too, but we can take advantage of public resources in that way.
[15:15] Obviously I'm also an entrepreneur and I will always encourage people to get the tools that I provide. But you can use tools that you might have around your house as long as they are pliable — we can talk about why that's important — and have a bit of grip and aren't injurious to your tissue. I think there's one tool that almost everybody at this point has or has been gifted, and that is just a simple yoga mat. If you roll up a yoga mat or an exercise mat, the front or back has a ton of grip, and you can roll it up to a cylinder shape that has just enough density to use it for a point-based massage into different parts of your body that may be ailing.
[16:03] While I am a self-myofascial release researcher in addition to being an entrepreneur, you don't need only these tools and you don't need only this book. There are free resources. YouTube is a free resource where I've put many, many videos. Our website has many articles that detail the how, why, and wherefore of self-myofascial release. So I encourage people not to be discouraged by a financial wall that might feel like it blockades you from these self-treatments. They are available for free if you can be clever about it.
[16:47] But if you have the finances to invest, go to Amazon, get The Roll Model, go to Amazon, get Body by Breath, and head to our website to get something called the Roll Model Starter Kit. The Roll Model Starter Kit gives you all of the balls that we sell. I always encourage people to get a second Coregeous Ball because there are a number of spinal decompression exercises throughout Body by Breath — not anywhere else except for my online library — that are not just for decompressing the spine. What they do is profoundly adjust autonomic tone. That is very important for a bendy body: to have a reliable input that can take you out of a highly anxious state and help you ground into your body, help you feel at home in your structure, give you a place to land.
[17:57] There are specific exercises in the book that I typically highlight when I'm being interviewed because I think they're helpful for all bodies — whether you're bendy or stiff as a board — that will immediately change autonomic tone. These are so important for our ability to think clearly, to be able to make decisions, and frankly, to just relax, to be able to chill.

[18:19] Dr. Linda Bluestein: And I'm so glad you just said that about whether you're bendy or stiff as a board, because I think sometimes it is confusing that you can be bendy and stiff within the same body. I used to be very hypermobile when I was younger, but because I went through a period where I didn't stretch at all and just got tighter and tighter, now I have mostly things that are tight.

[18:23] Jill Miller: Right.

[18:50] Dr. Linda Bluestein: So I think that's an important point for the listeners — we call this the Bendy Bodies Podcast, recognizing that some people have more historical bendiness and they're not bendy anymore. Could you talk a little bit about if someone has a mixed picture like that, and what might be beneficial for them?

[19:14] Jill Miller: Yeah, it seems like a paradox, but it really makes a lot of sense. I get this question every time I post something about hypermobility. I get a lot of people who are afraid because they've heard, "I'm too bendy, I shouldn't stretch, and I probably shouldn't roll because rolling equals stretching." Let me just dispel that myth right away. And I think if you listen to my friend Libby Hensley — you guys interviewed her as well, Yoga for Bendy Bodies — she explains this so beautifully in her book.
[19:53] There will be parts of your body that I call bully muscles. There are going to be tissues that do the work for the rest of the guys because it's like, "I'll handle it — my upper trap and levator, I'll handle this neck instability," for all the other lax ligaments that are not coming online. Something has to take control so that your body doesn't feel like it's going to fall apart all the time. This is not your conscious doing — this is your brain deciding which tissues are going to be hypertonic in order for you not to fall into a puddle on the floor. I'm obviously exaggerating. But in order to maintain your posture against gravity, something's got to support you. And if it's not going to be the deep intrinsic muscles, which should be doing their job, it's going to be these more superficial ones that are full of knots and kinks and tension.
[20:49] If you listen to the work of Tina Wang also, she'll talk about this too. I love Tina's work and have encountered her via the Fascia Research Congress. So you can look up that podcast too — I am like a Rolodex for your podcast. I share your podcast all the time.

[21:05] Dr. Linda Bluestein: Oh, thank you so much.

[21:05] Jill Miller: So what I need to do is help my body and brain to no longer feel like they have to be on guard, in order to treat those tissues that are hypertonic. If I'm not treating those hypertonic tissues, my exercise practice is more than likely going to bypass them because a muscle locked continuously in contraction isn't really going to contract well anymore. So I need to figure out different strategies to reduce the bracing response throughout the body.
[21:47] That muscle bracing response — also known as resting tone — is not restful. It is extremely metabolically expensive day in and day out. That is one of the reasons why Body by Breath type of work is so helpful for a bendy body, because it addresses holistically your entire autonomic tone. It switches off that gatekeeper that's telling your upper trap, your left psoas, your right soleus to stay on guard and tight all the time.
[22:25] Then, once I reduce that miserable resting tone — by the way, you're going to feel even looser than before — that's when I can use an implement to roll those areas that tend to be hotspots, and then do exercise protocols based on whatever you like to do, whether it's Pilates or Gyrotonics or isometrics or Yoga Tune-Up or weightlifting, whatever strategy helps you to feel put back together again. You're going to have more available tissues to both lengthen and contract through their entire movement cycle, so that over time I can continuously remodel this body and this brain's overriding resting tone challenges that typically bendy bodies face.
[23:16] That really is the protocol. It's not just, "Oh, just relax." Yes, relax so that we can turn off this guard dog that is always on guard. Then massage those tissues and the fascial tissues that accompany them — and the unfortunate abundant logjam of inflammatory cytokines that might be in that area from the tonicity — and flush that stuff out through rolling, and then start to retrain those tissues to learn a new behavior pattern. That's going to be a lifelong process.
[23:58] What I tell my hypermobile people in terms of the rolling is: don't go after your joint junctions the way your Viking neighbor would. Stick to the center, stick to the muscle bellies more so. That would be the big differentiator of rolling strategies when working with hypermobile populations — let's not focus on joint junctions, but on the muscle bellies rather than on Golgi tendon and myotendinous junction regions, because of the risk of dislocating. Also, use softer tools. The softer the tool, the safer it is in and around a joint junction. If I'm using a hard foam roller or lacrosse balls, I really do risk overstretching delicate tissues, creating bruising, irritation, further overstretching, or dislocations. But the Yoga Tune-Up balls are so gummy and chewy and have this amazing grip that they're able to receive the bony prominence without further punching at it or irritating that region.

[25:13] Dr. Linda Bluestein: I love how you're describing this, because this is exactly why I am not a fan of muscle relaxants. The biggest benefit that people generally get from them is it makes them sleepy — it kind of relaxes them that way and generally relaxes muscle tone. But then, of course, that may increase someone's risk of subluxation, dislocation, et cetera. It's not doing anything for the actual local hypertonicity that you said is trying to compensate for other things. I love that bully muscle concept. A lot of my colleagues — that's one of the first things they do is prescribe muscle relaxants, because tight muscles are painful muscles. But really what you need to do is address the root of the problem and not just put a Band-Aid on it.

[26:59] Jill Miller: Yeah, and the muscle relaxant doesn't address the irritants local in the tissue because of the tissue congestion, because of the stagnation from lack of movement. That needs to be moved out. You can call that movement of lymphatics — I'm talking about movement of the extracellular matrix and the inability for the vesicles to decongest. What's in that area when I have a muscle that's in chronic contraction — or a number of fascicles within a muscle that are in chronic contraction — is a backup of cell death, frankly, which is what I call the poo and pee of the cells. We need to flush it out of the toilet. The therapy ball movement, the rolling, the gentle pressure of it, as well as then doing correct contractions after — that's what's really going to move that stuff out.

[26:59] Dr. Linda Bluestein: Yeah, that makes a lot of sense. And besides working towards the middle of the muscle, working with softer tools, et cetera, as you just described, are there other exercises that you think are most helpful for bendy bodies?

[27:28] Jill Miller: I'd like to cycle back to something I mentioned earlier, which are these spinal decompression exercises using two Coregeous Balls. But before I describe that, I want to reemphasize that the bendy body may have pervasive challenges with tension in so many different parts of the body. We talked about resting tone not being restful. And that unrestful resting tone recycles the anxiety that hypermobile bodies are known to already have at higher rates than other bodies. Tension begets tension.
[28:18] So the first thing is: we want to do movements effectively that address our emotional tone, that address our state. In the book I outline something called the 5 Ps of the parasympathetic nervous system. If I can do exercises that take advantage of these 5 Ps, then I'm almost guaranteed that whatever thing I choose in the book — or whatever exercise I found on YouTube from our output — is going to be beneficial to me. Should I describe the 5 Ps and then get into the double — sure. Okay.
[29:07] So the 5 Ps — remember, these are 5 Ps of the parasympathetic nervous system. We're trying to do things that allow us to first let go of tensions, both known and unknown. The first P is perspective. Perspective has to do with mindset, and the mindset is about allowing your embodied experience to occur. When we start to go into deep relaxation states, often what happens is we get uncomfortable — we can start to experience the disappointment we might have about our pain, or other emotional disturbances that tend to rock a highly sensitive, hypermobile person maybe a little more than the next person. So we want to make sure that all of this is allowed, that our body is a safe place for the experience of our body to take place.
[30:07] The one I'm currently working with in terms of perspective is: "All of me is welcome here." That really helps, especially if I'm nervous before doing a podcast — I know I'm going to say some goofy things, I might misspeak. All of me is welcome here. That really helps me to allow whatever's going to transpire to transpire. Another good generic one is: "I embody my body." Most people can get on board with that.
[30:58] The second P is place. The place must be safe. For a body to truly relax, you have to feel like you can let go. Maybe it's the bathroom floor for you, maybe it's a closet, maybe it's your bed. Find yourself in a place that's safe.
[31:24] The third P is position. When we bring position into the relaxation stew, it allows us to take advantage of the baroreceptor reflex. Now, I know for the bendy people, you're thinking, "But I have orthostatic intolerance. I get super dizzy, or I might have a heart condition — laying down is challenging for me." In a body where that is not an issue, typically if the heart is slightly higher than the head, the baroreceptor reflex kicks in. Essentially your brain can only handle so much blood. If you're just a little bit upside down — say you put your pelvis on a couple of blocks, a yoga block, a Coregeous Ball, or a stack of books — then you have a gentle slope in your body. Your blood starts to rush towards your brain. The stretch sensors in the side of the neck, mediated by the vagus nerve, start to sense too much fill happening in those vessels. There's a very quick reflex arc that happens in the brainstem, which basically slows down the heart rate and narrows all the blood vessels. That slowing down of the heart rate and breath pace is an inherent, implicit relaxation response built into your body.
[32:54] My bendy body people, please know your own tolerance for a slope like that, and proceed accordingly. For some of you, it might just be laying down in your bed — you don't necessarily need to prop your pelvis up. And of course, when you come back upright later, just take your sweet, sweet time and apply precautions. So: position means get grounded, let gravity help you.
[33:30] We have perspective, place, position. Number 4 is pace of breath. This is where the breath part comes in. We haven't even talked about breathing yet! In terms of the relaxation response, extended exhales are typically what helps you to downregulate. But here's the other thing: breathe slowly and not like you usually do. Change your breath pattern so that you are breathing more slowly and consistently for 3 to 5 minutes. Fast breathing is going to pep you up; slow, extended exhales are going to enhance your relaxation response. That's the fourth P.
The fifth P is palpation. How do we do palpation in Body by Breath? We can do it with balls, we can do it with hands, we can do it with objects strategically placed to mitigate that unconscious muscle bracing and/or to go into certain portals of tissue within the body that are known to enhance the relaxation response. Any questions about that before I get into this decompression exercise I keep teasing?

[36:14] Dr. Linda Bluestein: The only question I have is if you have any of the balls to be able to show us. We will put this up on YouTube at the same time the audio goes out, and I think it would be helpful for people to see if you have any of those props nearby.

[36:25] Jill Miller: I sure do — I always do. So this is the Coregeous Ball. It's about the size of my — well, I have a very long head, but if I had a round head, that's the size of a Coregeous Ball. It's made from a grippy, pliable, air-filled rubber, and you can always modulate the fill. So it can have less air in it if you don't like to have that much displacement in your structure. And then we have a variety of solid rubber balls made from grippy, pliable rubber in three different sizes. The lime green ball is called the Yoga Tune-Up Ball — it's smaller than a tennis ball. The Therapy Ball Plus is the medium size, slightly larger than a tennis ball. And then the Alpha Ball is slightly smaller than a softball. But all of them are made from a squishy, pliable rubber with a ton of grip.
[37:21] So when it takes a hold of tissue — I'm putting this on my chest right now for people listening and I'm turning it. As I'm turning it, it's twisting my tissue into a vortex, grabbing the skin, grabbing the fatty layer, grabbing superficial fascia, transmitting stretch all the way to deep fascia, all the way down to the periosteum. That grip is really important for exciting the many different sensory neurons that are pervasive throughout your fascial tissues.
[37:54] And that's another really important aspect of the rolling: while it's affecting all these autonomic aspects — which is really the emphasis of Body by Breath — it's also affecting the proprioceptors, the mechanosensors in those tissues, so that when you do roll, it helps your brain know how to locate those tissues in your body. They're then better able to contract, and you're better able to sense those contractions. Research has shown that rolling enhances force production and also enhances proprioception. Those are two big wins for a bendy body that trips and is inelegant unless they're doing their sport or their dance.

[38:41] Dr. Linda Bluestein: Yeah. And it's so common for people to not be able to feel their knees going to hyperextension or their elbows going to hyperextension. It's hard to avoid something if you can't feel it. And I love what you just described about the stickiness of it. Dr. Helene Langevin talks a lot about the stretch of tissues — that's how acupuncture works, right? They put the needle in and then they twist. When we think of stretch, sometimes we think of big stretches. We don't think about just this small amount of stretch that we need. But when we move less and less, we don't get that kind of little bit of stretching, and so we get more inflamed, more tension, and a lot of other problems — like you said, inflammatory cytokines and all kinds of bad things happening in the body.

[39:37] Jill Miller: Yeah. The local arousal of areas of tissue to enhance proprioception is really profound for a bendy body, because it gives you a sense of place in your structure, and it gives you an end feel. That is something that is so missing. I really like to have those tactile elements to give the biofeedback. And the benefit of that versus a muscle relaxant is it propagates better force production and better force control of those areas that are rolled. No weary side effect — you're not going to be groggy. Your body is going to be more alert in the best possible way.
[40:33] So, we keep teasing this exercise. I call it — oh my gosh, it's the worst title. It's so long. It's: Low Back Decompression via the Lateral Raphe.

[40:42] Dr. Linda Bluestein: Oh my.

[40:46] Jill Miller: It's a tragedy that I named it that. But it's so important, I have it in the book twice — in the early pages and again in further detail in the back — and I have it as a QR code. I just want people to do this exercise. Not to make you more mobile, bendy body people, but to enhance your ability to sense your low back, your rib cage, your pelvis, and to sense the profound interrelationship of your respiratory diaphragm to everything from pelvic floor to face.
[41:31] This one exercise — I'm going to sell it all to you — will also give you the relaxation response. It takes advantage of all 5 Ps as I described before. But where do you put the balls? We need to put a link in the podcast notes to a YouTube video — yes, we will. I have one on Instagram and I have it on YouTube. It's that important.
[41:51] And if you don't have two Coregeous Balls like I'm showing you right now, you can use two rolled-up yoga mats, or one yoga mat and a rolled-up towel, or a folded pillow. It's not going to be as effective — you want to have that grip — but it will do. Okay, so where the balls go — it looks like I'm taking off my pants, but I'm just revealing my low back. I'm also tethered by this cord, so let me turn this way. Okay, so the two balls are placed on the sides of your low back, to put it simply. What they're looking for is a connective tissue aponeurosis called the thoracolumbar aponeurosis. The balls are not together on your low back, they're not on the sides of your waist, but just inland from the waist towards the low back. Then you lay on the ground and it feels like your low back is resting in a hammock that stretches your low back from side to side.
[43:16] When you lay down, your sacrum will be firmly on the ground. Your low back will be tractioned across — it feels like there are two massage therapists doing a four-handed massage, pulling your tissue laterally instead of vertically. So when people see balls, they always want to roll up and down their spine, but this doesn't even touch the spine. You just lay there and breathe for many minutes. You don't want to feel like you're in hyperextension of the low back, you don't want to feel like you're in a backbend. The rib cage is on the ground and the head is on the ground.
[43:58] The first few minutes is just breathing into the right and left balls and moving your awareness into the perception of movement in your back body. The time under — I call this "time under intention," not time under tension — with your perspective in place, is to get a sense of the excursion of these lower ribs into the balls. This is an experience of the movement of your respiratory diaphragm. First of all, you can't really sense your diaphragm because it doesn't have mechanosensors that tell you where it is in space, so it's really profound to be able to feel its impact here in your low back. In the meantime, this is also tractioning the sacrum and the thoracolumbar junction as well. These are places where bendy bodies — and all bodies — tend to have hypermobility, but usually the treatments on the back are not these horizontal strokes.
[45:14] So you'll have an incredible sense of length and decompression, this traction experience. Within that, I start to have people do tiny pelvic tucks and untucks, creating an undulation-like movement. You'll start to create little tiny spinal undulations that will have a ripple effect from sacrum to skull in tandem with the breathing. So we add up all of the 5 Ps together — the palpation, the perspective, the position, the pace of breath, and a little bit of movement to increase the palpation experience.
[45:55] Then you take the therapy balls out after 2 to 5 minutes, and you will have flipped what I call your off switch. This will change resting tone. And then from there — this is something I do when I'm really spun out, but it's also something I like to do before core training, because now I know I no longer have muscles gripping unconsciously throughout my spine. Maybe it's your left QL, maybe it's your right psoas, maybe it's your multifidi in your mid-thoracics. There's such a profound pervasive relaxation response that happens throughout here. Now you can try to turn on the muscles you want to turn on and slowly rebuild your core strength, which is a great place for bendy people to start from. So I think that might be a good recipe.

[46:48] Dr. Linda Bluestein: That sounds like a fabulous one. And people who are in chronic pain tend to breathe very shal—

[46:58] Jill Miller: Oh my goodness, where do I start?

[47:02] Dr. Linda Bluestein: Excuse me. Oh my gosh.

[47:04] Jill Miller: It's dry where you are.

[47:08] Dr. Linda Bluestein: It is incredibly dry. And I struggle more in the morning than I do later in the day — probably my coffee doesn't help. I love that exercise so much. And especially as I'm thinking about people in chronic pain and how so often once we get into chronic pain — I know I've done this a lot myself — we start to breathe more and more shallowly. And I think some of the things that I've struggled with: as an anesthesiologist who puts people to sleep and controls their breathing, I've been breathing my whole life. So then I hear things about breath and I'm like, "Well, but we just do that, right?" But we could be doing it in a way that is not serving us — that's the point.

[47:51] Jill Miller: Oh my gosh, can we talk about breath now? The book is called Body by Breath! This exercise and all the things you just said is so helpful because it pours our attention into what I call zone 1 of respiration — the stuff below the rib cage — to try to improve the excursion of the diaphragm into and upon the tissues it rests atop of, which are all your different abdominal layers, all of these organs, and obviously the pelvic floor as the basement membrane of diaphragmatic impact. So it attunes us to improving this zone 1 range of motion for breathing. And when we get into zone 1 breathing — this area below the diaphragm — its happy place is a parasympathetic dominant state. So it's going to turn on a relaxation response.
[48:55] A body in a high pain response is typically going to be in either zone 2, which I'll describe, or worse, zone 3. By the way, this is my model — I have it laid out in the book. It's not medical; it's just a helpful model for how we might treat different myofascial tissues throughout the trunk, head, neck, and face based on pain, movement, and breathing patterns.
[49:26] Zone 2 occurs within the rib cage itself, and that is an important area to breathe. That is our area of breathing for sport — when the intercostals and diaphragm collaborate to allow the ribs to upwardly rotate on inhale and downwardly rotate on exhale. This is the area we breathe in when we're excited, when we're hyped up, when we're lifting heavy loads. We should not be breathing in our gut area when we're lifting heavy loads — we should be bracing there and having the mobility of breathing happen in zone 2. But we don't get as much oxygen saturation if we're exclusively a zone 2 breather. And often if we tend to breathe in zone 2 day in and day out, we don't have good exhale capacity. We don't really get all the air out. And that can deflect us into zone 3.
[50:16] Zone 3 is when we use muscles of the face, neck, and shoulders to get air in. You can see that in a body in fear or shock, or even quick bursts of delight — orgasm typically involves some zone 3 breathing. So it's not always diabolical to be a zone 3 breather, but it is harmful if that's your consistent way of breathing. It's so metabolically costly to use your scalenes and your sternocleidomastoid and your trapezius and your levator scapulae to get breath into your life. We want to use them in case of emergency only.
[51:03] This model of zone 1, zone 2, and zone 3 really helps. It relates to the pain model, to movement models, and it helps people map their emotional state, because it's going to map with state: high stress if you're in zone 3, sympathetic dominant if you're in zone 2, and parasympathetic dominant if you're in zone 1. What's ideal? A blend of zone 1 and zone 2, with zone 3 sparingly in case of emergency.

[51:31] Dr. Linda Bluestein: And so if someone is listening to this and says, "Wow, I think I must spend a lot of time in zone 2 and 3, and I want to learn how to get more into zone 1," what can they do?

[51:48] Jill Miller: Listen to the podcast again and do all the things, do all the things in Body by Breath, and jump over to my feed and find so many different free posts that describe how one can turn on their off switch. Commingle these 5 Ps and these principles that can allow you to stay present in a parasympathetic state longer and longer.
[52:15] Because it can be pretty scary. When I say scary, it's because when people start to let down their guard, they start to have their feelings — the feelings we've been running from, or avoiding, or would rather not experience. That is part of enduring the relaxation response. That's why having the first P, perspective, is so important. And then, of course, you want to make sure that you're communicating your feelings with paper — as in journaling — or with providers. That's another P.

[52:53] Dr. Linda Bluestein: Or two more Ps!

[52:56] Jill Miller: Peoples — peoples that you love, right? So find your people to share this experience, this developmental reach for you.

[53:08] Dr. Linda Bluestein: You just added three more Ps to your 5 Ps. I love it. It's like me with the Bs — always adding more. That's fantastic.

[53:19] Jill Miller: We can have a new podcast called The Alliteration Sisters, right?

[53:22] Dr. Linda Bluestein: Right, exactly. I love alliteration. So we may have already covered this, and if so that's totally fine. But are there other self-myofascial treatments that can help hypermobile bodies breathe better?

[53:38] Jill Miller: To breathe better. Yeah. So we did this deep gut thing. You can also do something similar in the ribs — attune the tools to your stretch and pressure tolerance. For many people, if you're afraid you might dislocate, go to the wall, lean against it. Use the smaller, firmer balls, lean against the wall.
[54:00] There are neck things that are really helpful for the hypermobile person, and I don't have time to describe all of that, but a really short, easy thing that I think can be very helpful for zone 3 hypertonicity is just a finger massage on the cheeks, the forehead, and plucking on your own sternocleidomastoid. It's not illegal to do that. Right now you can see I've got a very prominent one — everyone says, "Your sternocleidomastoid is so tight." I'm like, "No, no, no. You can see every piece of my anatomy because of my hypermobility. You can see through me like a translucent muscle shirt." This is a very nicely compliant SCM. But anyway, you can pluck on that.
[54:46] You can also take your fingers right onto — this is really helpful for my TMJ people too — the front of your chompers, your masseter, like you had a horse bit. You can just do some pressure against your masseter. How do I know I'm on the masseter? Just try to clench your teeth and you'll feel the front border of that muscle pop in. I don't need to go on my jaw joint, but I can just latch there. I can also use the chubby cheek technique — pinch that muscle and pluck it out. And if you're like, "I don't want to touch the muscle," you can pinch the skin of the face and traction it away. Allow yourself to breathe. That's really great for decongesting the maxillary sinus. I'm doing all this on camera, that's why I sound funny, folks.
[55:38] So I can do skin rolling along the face — pinch and walk your fingers all around the mask of your face, because many of these muscles are floating superficially, very close to the surface. Many of them are innervated by the facial nerve, some by the trigeminal. The facial nerve and the trigeminal nerve share source nuclei with the vagus nerve. So just by doing face-based massage, you can slow down your stress response, alter a high heart rate, slow down your breath pace. And this is all just right here at your face. Wash your hands first, especially if you're going anywhere around the eye — soap and water. But the face is a great, easy target.
[56:41] You can do this while — I don't want to say you should multitask, but if computer work is stressing you out, give yourself another input. Roll your face while you're doing the computer stuff so that at least you have this other option of making a shift.

[57:00] Dr. Linda Bluestein: And that's a great little break you can take from your computer work too. I agree with you about the multitasking, but you can also do this pretty easily and quickly in a little mini break. I love that. And I think you get asked this question a lot, but how do you manage your own hypermobility symptoms?

[57:26] Jill Miller: Rolling, and strength training. I love doing strength-based work — resistance training. It's been well over 20 years working with weights. But also my program Yoga Tune-Up, which I created many years ago — that work has in general been very helpful for keeping me stable and mobile and being able to continuously stay awake to my end ranges and not blow past them.
[58:14] So it's a combination of mobility work, disassembling yoga poses, prioritizing healthy movement, rolling, strength training — and embedded within all of that is breath-based work. I don't like to call it breathwork, that's really the buzzword. I just breathe strategically in anything that I do. How's that?

[58:37] Dr. Linda Bluestein: I was going to ask you what we should call this episode. I think "Breathing Strategically" might be a good title. Do you have any other ideas?

[58:55] Jill Miller: Oh gosh, yeah. I don't think that's really a zinger. It doesn't sound very zingy.

[59:03] Dr. Linda Bluestein: Yeah, we need to think of a zingy title.

[59:06] Jill Miller: Maybe this is about — Body by Breath is about using breathing as a body-wide experience. It is not a nose-to-lungs trip. That's one of the many things the book is trying to help emphasize: what this blast radius of breathing on every cell and system of your body is something that we can account for, improve, and harness its virtues for our health and well-being. So maybe this is like "improving your breath smartness." I don't have a title for you. I'm usually pretty good, but you also have a specific audience that you know you're speaking with.
[1:00:01] The other ways that I deal with my hypermobility: I know that I am not injury-proof, and I'd love to be injury-proof, as all of us would. I know that injuries are going to come, so I think of a lot of the work that I do as preventative, on a constant preventative basis. I'm not just waiting for the next accident to happen. I know it's going to happen. And so one of the tools I've really come to rely on when I start to experience acute pain that's not going away — that I can't seem to roll away or exercise away — is extracorporeal shockwave therapy. I am such a zealot and proponent of this tech. Have you used it, Linda?
[1:00:44] I just finally did a reel about it yesterday. I've been wanting to do it for five years, but I didn't have a cameraman in the room until my son — my 7-year-old son took a wonderful video while I was at my chiropractor on Saturday. So I could finally show people this amazing treatment that I get when I have acute spells that are not showing up in any type of testing. Like, the muscle tests were all fine, but I have pain near my bicipital groove and I'm not sure what it's from.
[1:01:35] Anyway, the extracorporeal shockwave therapy sends acoustic waves into your body and finds areas of calcification within connective tissues, within ligaments, within tendons, within nerve sheaths — the epineurium. It's an adaptation of lithotripsy —

[1:02:01] Dr. Linda Bluestein: Lithotripsy! Yes, my husband is a urologist and did lithotripsy his entire career.

[1:02:12] Jill Miller: Right. So that's the protocol where they're sending shockwaves to bust up stones in your body so they don't have to cut you open and do invasive work. This is a non-invasive technique that they then readapted, because they noticed that people getting this treatment had their back pain go away even when it wasn't necessarily related to the kidney stones. And they said, "Well, this must be doing something to other tissues." So they've adapted this tech for connective tissue, musculoskeletal tissues, and myofascial tissues.
[1:02:45] The most pervasive research has been on plantar fasciitis, with a very high success rate, but it works on any area of the body that has muscles and fascia and ligaments and tendons. It also reduces inflammation. So maybe you aren't calcified, but when there's suddenly this acute flare-up — "I don't know what I did, did I overtrain?" — it can even help with that. And it's a very low-cost intervention relative to pills or surgery or MRIs or what have you. So I'm a huge fan.

[1:03:25] Dr. Linda Bluestein: I do have a neighbor who has had that done several times and said it was very, very helpful. I've just never done it personally myself.

[1:03:37] Jill Miller: And if people are wondering where to find this — usually it's physical therapists or chiropractors who have the unit. In Germany, I think every orthopedist's office has one. It's a very common technology there. In the US, it's not FDA approved yet — it's still on the outskirts. I just think every person should have this in their house, because it is so effective. It's like an electric toothbrush for your connective tissues.

[1:04:07] Dr. Linda Bluestein: Oh, oh my gosh. That's brilliant. An electric toothbrush for your connective tissues. I love that.

[1:04:14] Jill Miller: But also, Carla Stecco, who's one of my fascia research heroes — if she hasn't been mentioned on your podcast before, let me be the first. She and her team, including Caterina Fede over in Padua, recently did some research on mechanism and found that the electroshock therapy upon fibroblasts caused dormant fibroblasts to start spurting out hyaluronan within an hour of the stimulation, and kept doing it for up to 24 hours. So it's altering the extracellular matrix — that decalcification and de-agglomeration of connective tissues that have become stuck and immobile within the body. It really brings tissues back to life in a way that basic friction with massage or rolling cannot.
[1:05:07] That's why I'm so thrilled to find a treatment for — who knows why you got this thing or that thing or the other thing, but you got it. And if exercise and massage and physical therapy and this treatment and that treatment are not working, try this, see if it works. It's working for my mom and her adhesive capsulitis. If you go to my Instagram page today, you can see the number of people saying, "Oh my gosh, this totally solved this problem I was having here, there, the other."

[1:05:39] Dr. Linda Bluestein: That's especially interesting to me because I am currently dealing with bilateral adhesive capsulitis. I just had MRIs of both of my shoulders, and I have arthritis and some subacromial cysts and various different things — rotator cuff tendinopathy, et cetera, et cetera.

[1:05:58] Jill Miller: Oh my gosh, Linda, I'm so sorry to hear that.

[1:06:00] Dr. Linda Bluestein: The impression was very long, but no frank tear — nothing that's probably surgical. And even if there were a surgery for that, like a fusion, how are they going to get rid of the fluid? So I am going to try that and I will report back.

[1:06:20] Jill Miller: Please do. And do you know who has a unit near you?

[1:06:24] Dr. Linda Bluestein: I do. I'm going to go to the person my neighbor recommended.

[1:06:24] Jill Miller: I'm so excited for you, Linda. I just sent one of my longtime clients — he had a knee replacement and had persistent chronic pain in his rectus femoris that just would not go away no matter what he did. The massage, the PT, nothing. I said, "Just go see Dr. Tosh, get a treatment." And within one treatment, the pain he had had for a year and a half was gone.

[1:06:26] Dr. Linda Bluestein: Really?

Jill Miller: Yes. It turned out he had calcification at his articularis genu — the superior aspect of the joint capsule of the knee. That's where the catch was.

[1:07:10] Dr. Linda Bluestein: Wow. Fascinating.

[1:07:14] Jill Miller: You can't get it with massage. You can't de-agglomerate that amount of thickening, but this tech can.

[1:07:23] Dr. Linda Bluestein: And what I love about that is so often, people with hypermobility who have surgery end up with all kinds of complications, and it didn't address the root problem anyway. So I think if we can have as many tools as possible to try to avoid surgery and improve function — and like you said, there are a lot of other things to try: physical therapy, massage therapy, nutrition—

[1:07:52] Jill Miller: Of course. Yeah. Psychedelics, whatever — all the things. There was one thing where I was like, "I am ready to try psychedelics, I am in so much pain around this one thing." And then it was like, "Oh, all I had to do was the shockwave." Yeah.

[1:07:53] Dr. Linda Bluestein: Yeah.

[1:08:09] Jill Miller: Because then you start blaming yourself. You get into that game with your pain — you know what I'm talking about.

[1:08:13] Dr. Linda Bluestein: Oh, yes, I do.

[1:08:18] Jill Miller: I'm here for the long haul, and I know I have the hypermobility, and I think I do pretty well staying pretty pain-free for the most part. But when stuff comes up, I'm really happy to have this tech, and for researchers to keep doing more work to figure out what the mechanism is and why it's working this way.

[1:08:43] Dr. Linda Bluestein: Definitely. Well, I will give it a try and, like I said, report back. So do you have a favorite hypermobility hack? This is how I like to end every episode — by getting a good collection of hypermobility hacks.

[1:08:56] Jill Miller: My favorite hypermobility hack. Well, this is going to sound crazy, but I do like talking to people about my hypermobility — amongst friends. I do like community, and that is a really big thing. I'm in my DMs with other professional movement professionals who are part of my community. I really do get a lot of strength in community. That's also one of the reasons why I love your podcast. In terms of health, the community part is a huge part of my health.
But in terms of a specific health hack, the first thing that really comes to mind is deadlifts.

[1:09:43] Dr. Linda Bluestein: Interesting.

[1:09:44] Jill Miller: I love the type of strength that I get from doing deadlifts on a regular basis. About once a week I'll try to do pretty heavy weight with deadlifts.

[1:10:00] Dr. Linda Bluestein: Wow, that's really incredible. And when you said community, I think an important thing to point out is — if you wouldn't mind sharing your thoughts on support groups, pros and cons. I think they can be wonderful things, but have you experienced or heard of people having different experiences that might be helpful at times, but also sometimes get you too much into your own head and increase anxiety?

[1:10:33] Jill Miller: Linda, I don't have experience with support groups around this per se, and I don't have any clients that have reported anything to me, so I really have nothing to give you there.
[1:10:41] I realize I left out one category of movement that I do on a regular basis. May I add that?

[1:10:52] Dr. Linda Bluestein: Yes, please do.

[1:10:54] Jill Miller: So there's one other category of movement that after my total hip replacement I started to introduce with a great amount of fear and reluctance: high-intensity interval training. Prior to having my hip replaced, doing HIIT-type work would leave me in pain or injured — something new would get injured. So I had real hesitancy to do it. About 6 months into PT, my physical therapist said, "You need to push yourself. You need to go run up hills. You need to do high-intensity interval training." She was listing off all these things: "You're not going to adapt or change anymore unless you push this hip."
[1:11:39] So I ended up finding a woman on Instagram named Doc Jenn Fit — her name is Jenn Fabroni, and she's a physical therapist. I did one of her challenges on Instagram, a 12-minute HIIT challenge, and the way she cued was very approachable and very safe. I could only do about 8 minutes of the HIIT, but I understood completely what my assignment was from that point on.
Long story short, I've included healthy HIIT in my movement practice ever since. Jenn and I even created a program called Roll into HIIT: Adapting Intensity for Every Body. One of the things we address within the context of the HIIT is adaptations for people with joint replacements or hypermobile bodies, and why it's important to include this type of variability for your health, adaptation, and well-being. So I just wanted to give a shout out to those of you who may have joint replacements or are approaching HIIT with great hesitancy. There is a safe place for you, and our program was specifically designed with that type of cohort in mind.

[1:13:07] Dr. Linda Bluestein: That's really fantastic because HIIT — high-intensity interval training — is the best way to increase aerobic capacity, which is critical for the functioning of your autonomic nervous system. And I think what often happens is, we kind of fall down the EDS hole or hit the EDS wall, however you want to say it, and inactivity leads to other problems. We get kinesiophobia. I definitely had that more than a decade ago — I was so afraid to move because it seemed like every time I moved I hurt myself.

[1:13:40] Jill Miller: Like going into the ocean — "Oh God, forget it. Danger, danger." But to be able to build strength, to be able to tolerate high heart rate intervals — for me, it's like a miracle, and what it's done for my spirit and for my soul and for the hedonic tone in my body, the ability to tolerate pleasure — it's been amazing. So I've been very grateful to her and to my physical therapist for telling me, "You need to move. You need to push yourself."

[1:14:20] Dr. Linda Bluestein: That's honestly shocking to hear, though.

[1:14:24] Jill Miller: Well, she's a very progressive, amazing local in LA — Dr. LeFille-McCurdy — and she happens to have a robust client list full of hypermobile dancers. It tends to be her subspecialty. And I was blessed to end up getting assigned to her through my insurance, back when she took insurance. It was really a blessing.

[1:14:47] Dr. Linda Bluestein: Wow, that's incredible. And we'll have links in the show notes to as many of these things as we possibly can.

[1:14:47] Jill Miller: I'd love that. And she's been sent your podcast by me before, so — fabulous.

[1:15:01] Dr. Linda Bluestein: I love it. Where can people find you online?

[1:15:05] Jill Miller: My website is Tune Up Fitness — tuneupfitness.com — where you can find long articles on fascia, on rolling, and we have one right now on muscle recovery. You can find me on Instagram at @thejillmiller, and also on Instagram at @tuneupfitness, which is our brand page. And we're on Facebook at Tune Up Fitness and Jill Miller. I'm not on Facebook as much anymore — I'm mostly always on Instagram, posting. Yes.

[1:15:39] Dr. Linda Bluestein: I love it. And we will definitely have a link to your YouTube channel as well. Would people be able to find that by searching Tune Up Fitness, or how would they best find it?

[1:15:58] Jill Miller: If you go to the website, all those links are there.

[1:16:00] Dr. Linda Bluestein: Okay, excellent. Well, Jill, I can't thank you enough for coming on the Bendy Bodies Podcast today and sharing your incredible knowledge and wisdom with us. This has been such a great conversation. I mark little clips that I think are particularly quote-worthy, and I think I marked more clips during this conversation than in any other I've done in quite a while. There were so many different things that I think are just going to be so helpful for people. So I can't thank you enough for taking the time to chat with me and share your wisdom with the audience.

[1:16:39] Jill Miller: Thank you, Linda. I appreciate you and appreciate what you do. Let's get the information out there. Most definitely.

[1:16:46] Dr. Linda Bluestein: Well, you've been listening to the Bendy Bodies Podcast today, and our guest has been Jill Miller. Thank you so much for listening, and we will catch you next time. Thank you for listening to this week's episode of the Bendy Bodies with the Hypermobility MD Podcast. Visit our new website at bendybodiespodcast.com where you can now view guest profiles and show notes with links to products and journal articles. Leave me a comment, sign up for updates, leave a review or a voicemail, and access the podcast on your favorite player, all directly from our website. You may hear your voicemail in a future episode where we answer your question or dive into your gracious feedback. Follow us on Instagram at @bendy_buddies. We love seeing your posts and stories, so be a buddy and engage our community by using the hashtag #bendy_buddy. That's hashtag B-E-N-D-Y B-U-D-D-Y. You can also find me, Dr. Linda Bluestein, on Instagram, Facebook, Twitter, or LinkedIn at @hypermobilitymd. Visit hypermobilitymd.com for information about medical services and one-on-one coaching. This podcast is for general informational purposes only and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. Do not disregard or delay obtaining medical advice for any medical condition you have. Opinions shared are that of the guest and do not necessarily represent the views of the host or any particular organization. Sponsorship of the podcast does not necessarily mean an endorsement. Thank you for being a part of our community, and we'll catch you next time on the Bendy Bodies Podcast.