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Monday, September 09, 2013

The Valsalva & Stroke

Time for Everyone to Take a Deep Breath

by Jonathon M Sullivan MD, PhD, SSC, FACEP


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Have you heard? They are telling us that lifting weights under Valsalva isn’t just unsafe, it may soon be illegal. Perhaps not by statute, but in terms of the standard of coaching practice and tort liability. Not long ago, one of the denizens of the Starting Strength forum sent me an article from an online legal journal published specifically for the fitness community [1]. It describes a malpractice case brought against a trainer and facility for failing to warn a client against the “dangers of Valsalva.” The case settled after expert testimony for the defense was undermined by pivotal new data showing that hemorrhagic stroke caused by weightlifting under Valsalva “is not rare at all.”

The message is clear: warning clients against Valsalva – indeed, actively intervening to prevent Valsalva – is the new professional standard for coaches. Allowing your clients to lift under Valsalva is legally indefensible. And actually coaching them to do so? You’re just asking for a trail of corpses leading right to the courthouse steps.

There’s more. The American Heart Association Scientific Statement on Resistance Exercise discourages lifting under Valsalva [2], although they cite no good clinical evidence of an increased risk of stroke. Exercise science papers are often careful to mention that subjects were not permitted to perform Valsalva [3]. A number of physiologic studies in humans and animals claim to show that lifting under Valsalva predisposes to cerebral hemorrhage [4,5]. And there are case reports of individuals blowing an O-ring in their heads while lifting weights – presumably under Valsalva.

Athletes who engage in serious, programmatic, heavy resistance training will do so under Valsalva – whether they want to or not, as we shall see. And a very small number of them do, in fact, suffer hemorrhagic strokes. But is this a cause-effect relationship? Is there either a physiologic or evidentiary basis for claiming that the Valsalva is unsafe under a load? Are you going to die?

The answer to the last question is definitely yes…although probably not today. The answers to the other questions are rather murkier. Let’s try for some clarity, or at least some full-frontal nerdity.

The Valsava Maneuver: Background

Valsalva refers to a Dead Italian Dude named Antonio Maria Valsalva (1666-1723). He was a brilliant physician, surgeon and anatomist. He championed humanitarian reforms in the treatment of the mentally ill, he helped pioneer anatomic pathology, and he wore one badass wig. His work is remembered in a half-dozen eponyms: the Valsalva antrum of the ear, the aortic sinus of Valsalva, Valsalva’s muscle, Valsalva’s ligament, tineae Valsalva, and, of course, the Valsalva maneuver. He is also honored eponymously in the Valsalva device, a unit incorporated into space suits so astronauts working outside the spacecraft can pop their ears without taking off their helmets (which would defeat the purpose). This great physician-scientist reportedly died of a stroke in Bologna at the age of 57. It is not clear whether Valsalva stroked under Valsalva, although it seems a good bet that he was not in a squat rack or a spacesuit at the time.

Valsalva’s principle interest was otology. He was passionate about the ear, and he gave us the first modern description of the Eustachian tube [6]. He was obsessed with the relationship between the ear and the cranial vault. The Valsalva maneuver, which at the time of this writing stands accused of causing cerebral pathology, was first described by Valsalva as a way to treat cerebral pathology. The idea was that exhaling against a closed glottis would cause “salubrious air” to rise against the meninges (the membranes that enclose the brain) and force pathological intracranial material (pus, blood, gunk, goobers, schmutz) through “new foramina” linking the intracranial vault to the ear.

I will explain the expurgation of praeternatural cranial matters: he who has inflated his mouth and nose allows air to reach as far as the dura mater… if with occluded mouth and nostrils air is compressed inwardly, this action will extrude sanies from the middle ear, a remedial exercise, to be repeated, [for] extrusion of praeter-natural cerebral matter either via the wound, via the nostrils, via the mouth, or via the auditory meatus… with great benefit...

De aure humana tractatus –Antonio Maria Valsalva, 1704

Valsalva’s “new foramina” appear to have been figments of his fevered Mediterranean imagination, and in fact the cranial vault is not normally in communication with the ear canal (for which you should be grateful). Jellinek has surveyed Valsalva’s writings [7] and concluded that his sole interest in the maneuver was its supposed demonstration of these non-existent tunnels between the brain pan and the ear. But this great man might rest easier knowing the maneuver that bears his name was subsequently found to have important implications for brain physiology after all.


Figure 1. Obligatory Pictures of Old Stuff for Historical Reference. Left, Antonio Valsalva and his wig. Middle, Valsalva’s anatomy of the ear, demonstrating the Eustachian tube. Right, First edition of the manuscript in which Valsalva and his wig described the Valsalva maneuver for the expurgation of schmutz from the brain. Images reproduced under Creative Commons license or under doctrine of Public Domain.

Physiology of the Valsalva Maneuver

In the three centuries since Valsalva’s death, the physiologic consequences of holding breath against a closed glottis have led to the use of the maneuver in basic research and clinical medicine. In my own practice, I have asked patients to “take a deep breath and bear down” on hundreds if not thousands of occasions – during deliveries (where it has been pro forma for centuries), during vascular procedures (to fill the jugular or subclavian with blood and make it easier and safer to insert or remove a central venous catheter)[8], or in the setting of supraventricular tachycardia, to restore sinus rhythm (where it occasionally works, but not nearly as often as we would like)[9]. To date, no patient has ever stroked in front of me during a medical Valsalva. But I’m getting ahead of myself.

The consequences of the Valsalva with immediate relevance for us are its effects on thoracoabdominal cavitary pressure, its effects on hemodynamics, and its effects on intracranial pressure.

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