Question (rather lengthy unfortunately) about Valsalva maneuver

[solidsnake123]

First off, I really have been enjoying your book Coach Rippetoe. Although, after reading the section on breathing in the squat section of Starting Strength I am thoroughly confused on whether or not to use the Valsalva maneuver. It is not that you did not make it clear that it was an essential technique in the weight room, but I have a few questions on the matter. I apologize for the length in advance; I am just trying to present all the necessary information. I know you are a very busy individual, but I would greatly appreciate your insight on the matter.

Here are the points made in the section regarding the safety of the maneuver.

- The likelihood of a cerebrovascular accident is overplayed in regard to the Valsalva maneuver

- The likelihood of an orthopedic injury is greatly downplayed in regard to the Valsalva maneuver

- The pressure applied by the Valsalva maneuver is a natural response to heavy exertion, as the opposing forces being applied to the cerebrospinal fluid and the cardiovascular system in the trunk are in balance.

- The process of inhalation increases pressure in your thoracic cavity, which provides support to the surrounding abdominals, obliques and spinal erectors.

- The Valsalva maneuver is used by fighter pilots to keep blood in the brain in momentary high-G conditions to prevent a blackout.

- The cardiovascular system adapts to resistance training just like all the other tissues and systems in the body.

- It is a good practice to take and hold the biggest breath you can before every heavy rep.


However I wonder if the positive effects of the Valsalva maneuver are good enough reason to use the technique considering the possible negative implications such as syncope, stroke, blown aneursym or death. I assume that these possible implications are the result of heightened blood pressure.

I do not know how common these occurences are, and how closely they are linked to the health of an individual. For example, the NASM Essentials of Personal Fitness Training says for those with hypertension to avoid Valsalva maneuvers. Someone with hypertension is obviously something to take into account when discussing exercise methods.

This book: http://books.google.com/books?id=bte...l=en#PPA275,M1
whether or not a legitimate source (although it appears to be as it is a textbook; however, textbooks have been wrong), says that a prolonged Valsalva maneuver actually produces an acute drop in blood pressure. Also stated is that resistance exercise rises blood pressure (273).

It says that the confusion regarding the matter arises because a Valsalva held for too short a period of time usually accompanies the straining found in resistance training (274). That sounds as if the Valsalva maneuver is realatively safe in that regard, although I would like to find a few more legitimate and educated sources on the matter.

The other thing to consider is blood circulation and oxygen deprivation. According to that source, a prolonged Valsalva maneuver during a static exercise that involves straining lowers the heart rate, and thus reducing venous return and blood pressure. The negative side effects of this lowered heart rate diminish blood supply to the brain, which can produce dizziness, "spots before the eyes" (same thing as stars?), or snycope (otherwise known as passing out) (274). I have heard that many older people die because they are straining on the toilet or otherwise. I guess those are conditions in which they are not in good health in the first place though. I have definitely had a headache after heavy deadlifts before and have most definitely seen stars after a set of squats. Were those occurrences a result of the Valsalva?

It would be nice if the book told the reader how long a prolonged Valsalva maneuver is. It could be a couple seconds, or a minute, but we do not know because the only description is "prolonged". Since the Valsalva maneuver involves holding ones breath, doesn't that restrict oxygen flow to the brain and muscles (which would be counterproductive)? I assume that a Valsalva of sufficient length to cause lightheadedness, syncope or poor oxygen circulation to the brain and muscles is being performed for way too long, longer than one would use the maneuver for a rep.

By the way, you said in your book to hold your breath during each of your heavy reps, but I have heard differing opinions on the matter. I have heard the ever common "inhale as you go down, exhale as you go up", "only use the Valsalva for 2-3 seconds as your go through your sticking point", and "do not consciously think about breathing or the Valsalva during exercise as it will come naturally". When you say deep breath, how deep do you mean? A truly deep breath can take a few seconds which would throw off your timing during reps wouldn't it?

You seem to have an impeccable reputation when it comes to matters regarding strength training, but on a subject with so much controversy and possibility of injury (orthopedic injury without, fainting, lightheadedness, even death with) I would find it very helpful and reassuring to have other sources that back up your very clear stance that consciously applying the Valsalva maneuver during weight lifting is a good, safe idea in which the good effects outweigh the possible negative effects.

Again, sorry for the length, but thank you for your help.

[Mark Rippetoe]

Several things are interesting about your post.

First: "However I wonder if the positive effects of the Valsalva maneuver are good enough reason to use the technique considering the possible negative implications such as syncope, stroke, blown aneursym (sic) or death. I assume that these possible implications are the result of heightened blood pressure."

The incidence of training-associated cerebrovascular accident (CVA) in the weight room is so low as to be statistically unmeasurable. We have done a thorough search of the literature and there is a complete absence of any documented case of stroke during barbell training. There are, however, lots of back injuries. Which eventuality would you rather prepare for? As for a blown aneurysm, first you have to have an aneurysm to blow one out, and THAT is always just plain old bad luck (despite the fact that the incidence of weight training-associated aneurysm dissections is also statistically insignificant).

Second: "I have definitely had a headache after heavy deadlifts before and have most definitely seen stars after a set of squats. Were those occurrences a result of the Valsalva?"

I don't know. But headache and death are certainly two unrelated phenomena. I've had lots of headaches that were associated with Guinness, during the consumption of which no Valsalva or deadlifting occurred.

Third: "By the way, you said in your book to hold your breath during each of your heavy reps, but I have heard differing opinions on the matter. I have heard the ever common "inhale as you go down, exhale as you go up", "only use the Valsalva for 2-3 seconds as your go through your sticking point", and "do not consciously think about breathing or the Valsalva during exercise as it will come naturally".

Which one do you think Andy Bolton used during his world record 1003 lb. deadlift? It makes absolutely no difference what the NASM, the ACSM, the NSCA, AFAA, ACE, the YMCA, or Pat Robertson thinks about how one ought to breathe during exercise. The fact is that every heavy deadlift that has ever been pulled off the floor was done with some form of a Valsalva, and the death toll fails to mount. What does this tell you about the safety of the Valsalva for your workout this afternoon? The last remark about the Valsalva coming naturally is correct, but a 1003 deadlift is not "natural" in the commonly understood sense of the word, and the Valsalva that accompanied it was not "natural" either -- it was deliberate, thorough, and lasted for the whole deadlift. The inexperienced, lawyer-spooked fools at the certification organizations can issue any position papers they like, but the fact remains that as long as heavy weights are being lifted, people will be holding their breath while they do it, and everybody will be just fine if they don't hurt their backs or pull a hamstring.

Furthermore, Mr. Bolton was adapted to both a very goddamn heavy deadlift and a deliberate, thorough, and long Valsalva manuver, because he'd trained for it. He didn't just wander in off the street, and neither have you. Since tissues adapt to stress, the stress of a Valsalva is adapted to by whatever structures are subjected to the stress as the intensity of the load accumulates, just like the spine, the ligaments holding the spine together, and the muscles that keep the spine straight have that make the deadlift possible. This fact -- that adaptation occurs in response to exercise in all affected tissues -- along with the fact that lots of people have lifted heavy weights with no known incidence of stroke, even in the absence of an explanation for why, should provide solace and balm for your furrowed brow.

[big pull]

Blood pressure typically rises significantly during heavy lifts, regardless if you employ the valsalva maneuver, or not. The protective increase in intrathoracic pressure is definitely beneficial, and I've personally noticed a boost in strength when I hold my breath, and bear down. You would be more likely to have a syncopal episode(fainting/near fainting) due to the vagal response, which lowers your heart rate, while you bear down. If you don't currently take prescribed beta blockers, which lower your pulse rate to control high blood pressure, you should have no issues. Like coach Rippletoe advised, the potential risks are practically nonexistent.

[Polynomial]

I was once one of the spotters for a 40-some year old man who did 405lbs box squats for 16 reps. His lips were purple by the end, and he took a whole 5 or so minutes to fully recover, but he's alive, well, and damn strong.

As a fun exercise, try exhaling with a decent amount of weight over your head. When you're done, please don't sue me

[Mark Rippetoe]

And as an added treat, here is the abstract from a paper presented in 2005 at the American Society of Exercise Physiology National Conference


The Valsalva Manuver: Risk or Risk Management?

Becky Kudrna, Lon Kilgore, PhD, and Mark Rippetoe


Within the clinical community, the major risk associated with the Valsalva maneuver is cerebrovascular accident. The term cerebrovascular accident can refer to stroke, aneurysm, or hemorrhage of the blood vessels of the brain. It has been suggested that the extremely high, although transient blood pressures created when an individual utilizes the Valsalva maneuver are simply too high for the vessel walls to handle (Linsenbardt et al., 1992). Thus conventional wisdom states that the Valsalva maneuver causes cerebrovascular accidents by raising blood pressure beyond a safe level.

There have been documented cases of cerebrovascular accident occurring while weightlifting. Haykowsky et al. (1996) reported three case studies of subarachnoid hemorrhage in otherwise healthy individuals during weight training. These authors noted that all of the individuals recovered and returned to normal activities within 3 months. Cayen & Cullen, report an additional case of cerebral hemorrhage during resistance exercise in 2002. A fifth occurrence was reported in an anabolic steroid user who suffered both a myocardial infarction and cerebral hemorrhage during resistance exercise, (Kenedy et al., 1993). This individual died as a result of his injuries. In deceased populations, one case of a cerebral hemorrhage occurred in a preexisting brain tumor during resistance exercise, (Goetting & Swanson, 1987). Finally, one case of an effaced lateral ventricle and one case of a subdural hematoma were reported in two males performing sit-ups with the Valsalva maneuver (Uber-Zac & Venkatesh, 2002). It is important to note here that of all the reported cases of CVA in both healthy and diseased populations only one resulted in mortality.

Whereas Narloch & Brandstater (1995) and Uver-Zac & Venkatesh (2002) interpreted the cause of the cerebrovascular hemorrhage in two male recreational lifters as transient vascular hypertension caused by the Valsalva maneuver, Haykowsky et al. (1996), attributed the three cases of subarachnoid hemorrhage in resistance-exercised individuals to preexisting, but undetected aneurysms. Haykowsky (1996), and McCartney (1999) suggest that the few incidences of CVA that do occur with resistance exercise may be linked to undetected cerebral aneurysms and thus are not entirely attributable to resistance exercise or the Valsalva maneuver. According to McCartney, approximately 1% of the population has cerebral aneurysms and the response of such individuals to the transient stresses of weightlifting should not be viewed as the normal or typical response. With millions of people participating in resistance exercise daily, the small number of reported CVA events actually represents a frequency that is statistically insignificant.

When considering exercise induced CVA it is important to understand that aerobic exercise, an exercise modality that is not associated with the Valsalva maneuver is also associated with a small number of CVA incidences, (Cayen & Cullen, 2002).

Not all researchers hold that the Valsalva maneuver during resistance exercise is dangerous. McCartney (1999) and Hughes et al., (1989) acknowledged that the Valsalva maneuver is an instinctive response and should be used particularly in lifts above 85% of 1 repetition maximum. Further, there is compelling evidence suggesting the Valsalva maneuver actually prevents catastrophic cerebrovascular injuries rather than causes them.

The work of Haykowsky et al. (2003) suggests that elevated vascular pressure is only dangerous to the delicate vascular walls of the brain if intracranial pressures remain low, and thus transmural pressure is high. Essentially, if the pressure surrounding the vessel increases and pushes back against the vessel wall, the blood pressure within the vessel will not be transmitted across to the cranial tissue, meaning that transmural pressure is low. The measure of the difference in pressures between vascular pressure and intracranial pressure should therefore be a better indicator of the stress the vessel walls are under and thus be a better indicator of the danger of cerebrovascular accident. Haykowsky et al, (2003) found that performing the Valsalva maneuver decreased the pressure differences across the cerebrovascular wall, theoretically decreasing the risk of aneurysm or hemorrhage. This finding corroborated the much earlier and ignored work of Hamilton et al. (1944). These studies strongly suggest that performing a heavy lift without the Valsalva maneuver places individuals at greater risk of CVA than performing the same lift with the Valsalva maneuver. This is directly contrary to the conventional wisdom.

The mechanism through which the Valsalva maneuver raises intracranial pressure is theorized as follows: (1)The Valsalva maneuver directly increases thoracic pressure by attempting to force air through the closed glottis. (2)This elevated thoracic pressure is transferred to the cerebrospinal fluid in much the same way that thoracic pressure increases abdominal pressure. Because the cerebrospinal fluid surrounding the spinal cord is continuous with fluid of the subdural space in the skull, intracranial pressure also rises. The rapid nature of fluid pressure transfer within this system means that arterial pressure and intracranial pressure rise at the same rate, yielding a balanced transmural pressure from the beginning to the end of the lift. Thus the lifter is protected throughout the entire lift so long as the Valsalva maneuver is performed.

[solidsnake123]

Interesting. How did the presentation of your article go over? Both you and Doctor Kilgore appear to have very good credentials and that article appeared to have multiple (I assume reputable) credentials. As any (I believe) educated individual would, I always like to see multiple sources agreeing on the same thing. I am not saying that you are wrong, in fact your statements seem very reasonable.

I assume you have other sources to back up you and Doctor Kilgore's stance on the use of the Valsalva maneuver (even though your credentials seem to speak for themselves). A textbook that I found (link: http://books.google.com/books?id=bte...l=en#PPA273,M1) said that the Valsalva was not the cause of high blood pressure, but lifting was and that the Valsalva commonly occured as lifting weights. It did say that a prolonged Valsalva (it said during a static, straining-type exercise, said nothing about dynamic) could cause dizziness and lack of blood supply (and I suppose oxygen supply as well) to the brain. I wouldn't think one would have enough time to perform a "prolonged Valsalva" it they were doing weight they could handle.

If someone was attempting a 1RM and could not get it up and said at their sticking point and strained for like 10 seconds I can see a prolonged Valsalva there. I guess that constitutes as a static, straining-type exercise eh? I assume those that are worried about lawyers include institutions such as the NASM, ACSM, and NSCA. However, couldn't they just put a disclaimer after such a statement that concludes the use of a Valsalva maneuver for lifting heavy weights is a good idea?

Since the Valsalva is less understood, even such a statement probably still wouldn't keep them out of trouble with lawyers. So many people would probably go into the gym, do a lift wrong, with too much weight, or do something else stupid and blame the institution for their injury. Of course there are probably those who have medical conditions where the Valsalva maneuver, let alone heavy or any lifting would be a bad idea.

I guess the deal with lack of oxygen the body adapts to. Also, if someone is breathing correctly (as I perceive it) they would take the deepest breath they can into their chest right? That would give them enough oxygen to complete a rep. I wouldn't say the average time to complete a rep would ever exceed 10 seconds, and I say 10 seconds as a case of someone straining as hard as they can during a 1RM. Well, what do you think?

Thanks for your input so far. I am pretty sure I can start your beginner workout on Tuesday as the doctor is going to give me a lidocaine shot and tell me to go lift to see if my joint feels any better. Since I have had roughly 1.5-1.75 years of experience (although each .75-.85 years separated by about 2 years of inactivity) I think I would consider myself a beginner. That being said can you give an "accurate" estimate of how long before I would need to switch to intermediate training methods? I have heard that it is about 3 to 9 months for your beginner workout but I was not sure if that time period is for brand new beginners, people that have began a few times, or if it doesn't matter and applies for both. Whew, time to get some sleep. Thanks again.

[solidsnake123]

It is just since the idea is so controversial and I have not really seen any other sources that say the same thing about the safety of the Valsalva except for you and Doctor Kilgore that the acceptance of the maneuver is difficult for me. Holding your breath during heavy exertion seems instinctive to me as I have naturally done it before without thinking about it, but I am uncertain of holding the breath the entire rep, that seems too long. I have heard this is for reps that are more than 85% of the 1RM, but I do not know how reliable those sources are.

So let me get this straight, according to your book, you take a deep breath before you begin the rep and as you are doing the "work" portion of the rep, e.g. pushing up for a squat you hold that breath until you get back to the top and then exhale and breathe in again? I watched the video of Andy Bolton doing his world record deadlift and he holds that breath the entire time. However, that is a 1RM. Sorry to throw another source in here that says different.. but.. : (). Here is a source that talks about the Valsalva as well, but it is so wordy I can't understand what it is really saying: (http://eurheartj.oxfordjournals.org/...ract/10/10/896)

Here is a book that covers some stuff from the NSCA: (http://eurheartj.oxfordjournals.org/...ract/10/10/896)
That says that pressure can be created without the Valsalva, although many competitive lifters choose to do that if they accept the risks, and know not to use it so lnog as to produce the risk of passing out. Would it be just as effective as Valsalva to only use it through and maybe a bit after the sticking point and then start to exhale, or just to slowly exhale as you go up? I read a study that said the same 1RM was done by the same people with slow exhalation and Valsalva and the only thing that changed was blood pressure increases. Here is the link: (http://www.staylimy.com/we/weight/we...our_life.shtml)
This article seems to say stuff more similar to what you are saying: (http://faculty.css.edu/tboone2/asep/...March2008.html)

What I gather from the information about the Valsalva putting a lot of strain on the cardiovascular system is that the cardiovascular system is simply getting worked pretty hard. If researchers were to look at what the muscles were experiencing during a heavy lift wouldn't they also say that a whole lot of stress was being put on them as well and tell people that heavy lifting has the potential to hurt muscles? Also, when would you recommend the use of a weight lifting belt (rep wise, like 3 heavy reps or something?)

Dude, really sorry for these really long posts. I am frankly just quite anxious and frightened to use the maneuver since nobody has came to the same consensus about the matter.

[Polynomial]

I read a study that said the same 1RM was done by the same people with slow exhalation and Valsalva and the only thing that changed was blood pressure increases.

A 1RM effort is a lot different than a 5RM, or a 10RM. Do this: put some decent weight on the bar and do a walk out with and without the Valsalva maneuver. See which one feels more stable. Pull some deadlifts both ways as well.

[Mark Rippetoe]

I read a study that said the same 1RM was done by the same people with slow exhalation and Valsalva and the only thing that changed was blood pressure increases.

I don't care about blood pressure increases. I'm adapted to those. I don't care about the statistically unmeasurable risk of CVA. I've never seen or heard of it happening. I don't care about internet articles (this is not a study) that say things like this: The reason for this type of research were some cases of acute stroke in otherwise healthy weight lifters. without substantiation. I really, really, REALLY don't care about 35 year old female personal training clients doing 3 lb. alternate dumbbell presses on a Swiss ball. I care much more about not hurting my back. I care even more about your observation that Andy Bolton had enough sense to hold his breath during his 1003, and that he --quite significantly -- managed to get off the platform without being entirely dead. Is this fact meaningless to you? Is the fact that everybody that deadlifts heavy holds their breath while doing it and that nobody has had a stroke when they did meaningless to you? Is the fact that all record cleans, jerks, snatches, squats, bench presses, and deadlifts heve been done with a Valsalva somehow not relevant? We do it this way because it works better, and because it keeps us from hurting ourselves. And as your strength increases your ability to withstand the stress of a Valsalva does too. It's a part of the adaptation to lifting weights, and heavy weights cannot be lifted safely without it.

[solidsnake123]

I see. The body adapts to the high blood pressure spikes as well as to everything else, i.e. your arterial walls get used to it and get stronger. It makes perfect sense to me that the Valsalva is a natural movement. Now that I recall I have definitely used it before without thinking about it, especially during my PR attempts. As you have said, the case of having a stroke or a blackout using the Valsalva is very low. Even after finding articles and such on the subject they say "in this case, so and so had a stroke", not "the possibility of getting a stroke while doing the Valsalva is 1 in 5.

Every 5th PR attempt you are likely to have a stroke." All I have seen is "do not do it. It raises your blood pressure a lot and restricts blood flow". Along with looking at those articles I came across the information that heavy weight training restricts blood flow and increases blood pressure regardless of the use of the Valsalva. Saturday when I was lifting at my gym the powerlifting group (the owner of the gym and his friends) were doing their training.

I usually talk to them when I am there, but I decided to ask one of them about the Valsalva. He replied almost instantaneously and said "yes, the Valsalva is crucial for lifting heavy. Hold your breath through the entire rep. On the contrary, in athletic events like the 40, a brief Valsalva is used at the beginning to get the crucial explosion needed to get a good time." I told him that I had heard that it was not safe or recommended to use the Valsalva, and he replied "Well, those people must have not been very strong." Strange, exactly what you said.

The maneuver feels uncomfortable if I try it now, I suppose because I am unadapted to it. About 5 weeks ago I am pretty sure I was using it (I wasn't consciously using it) when I was doing sets of 12 squats and by about the tenth rep my arms had gotten tingly and were beginning to get numb and I got really lightheaded. Could that be something else? Not breathing deep enough perhaps? I talked to someone else a few weeks ago about the tingling sensation in the arms and he said that he did the same thing when his shoulder flexibility was not that good? Sound reasonable?

Thanks for your help.