Clapham Manual Therapy and Functional Movement

Unlocking the Mysteries of Long COVID

As all regular readers of our blog know, we talk a lot about the importance and benefits of proper breathing technique. For the last year, we’ve discussed COVID-19 extensively, for obvious reasons. Today we want to share this really interesting article, ‘Unlocking the Mysteries of Long COVID’, with you as it focuses on the intersection of these two topics.  The breathing exercises that we are passionate about at Backs Etc are the foundation of a healthy body and mind, and this article indicates how they may also be the key in the recovery from a group of symptoms that are being described as ‘long-COVID’. But why wait to develop a life-threatening disease when you can use these techniques in your daily life? Good breathing can reduce the likelihood of developing many chronic ailments and enhance your body’s capacity, as we have discussed in previous blog posts. Poor breathing (especially through the mouth) can put your whole system into fight-flight mode, changing your biochemistry, worsening mood issues and insomnia and depressing your immune system.

The article describes the severe symptoms that can persist for months after an acute COVID infection.  It focuses on two groups of patients at Mount Sinai hospital in New York who were still suffering from symptoms months after their initial illness. The first group had obvious damage to their hearts or lungs, so were simply referred to the correct specialist for treatment.  The second, far larger, group had symptoms such as extreme tiredness, brain fog, chest tightness, shortness of breath, tachycardia, or gut dysfunction, often causing long-term disability.  But none of the tests showed any pathology, leaving the doctors without an obvious course of action.  This is something we have been seeing for many years, when a collection of similar symptoms have been labelled as post-viral, fibromyalgia or chronic fatigue syndrome, and where patients have sometimes been made to feel that the problem is not real and ‘all in their head’.

The piece talks at length about the difficulties experienced by these patients and how the rehabilitation team tried to help using a variety of treatments and protocols.  Finally, they came to the conclusion that the most effective form of initial treatment was breathing exercises. Restoring the breathing patterns was an essential precursor before other rehabilitation protocols would help. They realised that even mild COVID cases might be affecting respiration long after the acute phase of the disease. Evidence began to accrue that long-COVID patients were breathing shallowly through their mouths and into their upper chests. By contrast, proper breathing happens in the nose and goes deep into the lower lungs, stimulating the vagus nerve along the way, and helping regulate heart rate and the nervous system. This is exactly the type of breathing we teach at Backs Etc.

Similar symptoms (fatigue, shortness of breath, racing heart) can occur in people who have low carbon-dioxide levels in their blood, a condition known as hypocapnia, which can be triggered by hyperventilation, or shallow, rapid breathing through the mouth. Oxygen is key to our health, but carbon dioxide plays an equally crucial role by balancing the blood’s pH level. We teach patients to decrease their breathing rate (which should be around 5-6 breaths/min not the 10 or more that is increasingly common), and use breath holding exercises to increase the tolerance to carbon dioxide levels.  A very quick and easy way to test your current tolerance is to take a normal nasal inhale and exhale, holding the breath at the end of the exhale. Then, using a timer, see how long before you feel the first need to breathe in again. You only want to hold this to a point where you can then take a gentle nasal inhale, not holding your breath to the point that you need to gulp air to recover.  This is called a ‘control pause’, and is detailed in the book The Breathing Cure. If you have a healthy tolerance for carbon dioxide, your control pause should be at least 30 seconds (and more than 45 seconds for optimal athletic performance). If less than 20 seconds, this is something that should be addressed using breathing drills to optimise your health and performance.

In conclusion, it makes us happy to see more mainstream medics and researchers starting to validate the approach to breathing that we’ve been practising and teaching for years. It’s also encouraging that there are at least some positives coming out of this difficult COVID period. One final takeaway is that breathing drills should be for life, something you should be practising consistently for basic health maintenance, just like brushing and flossing your teeth. If you want more information, drop us a line or schedule an appointment to see how we can help you improve your breathing and quality of life.

The Importance of Vitamin D

As we head into autumn with increasing concerns about a second wave, we believe that everyone should be getting a vitamin D test to ensure that you have sufficient levels for maximal health.  Even if you have spent time getting a tan over the summer, do not assume that your levels are high enough. Everyone’s ability to turn sunlight into active vitamin D is different, and this decreases as we get older. If your levels are low, you should consider supplementation to minimise your risk of severe COVID-19 symptoms this winter.  It is estimated that in excess of 20% of the UK population is deficient in vitamin D, with the elderly and BAME population being at higher risk. Also remember that the recommended levels are actually very conservative, only indicating the level needed to avoid deficiency disease, not what’s required for optimal health, making supplementation even more important for many of us. You can get tested at your GP or check your levels yourself with a home test kit from Monitor My Health, whose profits go to fund the NHS.

Even though the mainstream is focused on vaccination and pharmaceutical solutions to COVID-19, there is increasing evidence showing that vitamin D is vitally important both in the prevention of severe disease and in treatment in the hospital setting as it modulates the immune system.  A new piece of research from Spain followed the treatment of 76 patients who were hospitalised with COVID-19.  They were given the same standard of care, except 50 patients were also given calcifediol, a form of vitamin D3.  In this group, only one patient (2%) was admitted to the ICU and recovered, whereas of the 26 untreated, 13 (50%) needed transfer to the ICU where 2 died and 11 recovered. This result is statistically significant and hopefully will be replicated in future larger trials.

The following graph shows the severity of COVID-19 symptoms by vitamin D status, indicating that it is important for prevention as well as treatment.

Vitamin D chart

Vitamin D is actually misnamed as technically it is a hormone not a vitamin.  It is synthesised in the skin in response to ultraviolet light from the sun, and is then transported to the liver and kidneys where it is converted to an active hormone. There are receptors throughout the tissues of the body, where its functions include:

  • Modulating the function of the immune system, stimulating it to produce antibodies
  • Regulating and suppressing the cytokine inflammatory response. The ability to downregulate the inflammatory response is particularly important for COVID-19, as out of control inflammation (cytokine storm) is a primary cause of death
  • Essential for the proper absorption of calcium into bones therefore reducing fracture risk and improving bone health
  • Important for proper contraction and relaxation of muscles, so making us stronger
  • There are many vitamin D receptors in the lungs and so can reduce inflammation here, which is very important in all respiratory illnesses
  • Reducing the risk of  high blood pressure and cardiovascular disease
  • Helping to regulate kidney function
  • Protective of cognitive function. Research has shown that seniors with low vitamin D levels have an increased risk of dementia
  • Reducing the risk of depression and multiple sclerosis
  • There is even some research that says that it is necessary for leptin, the satiety hormone, to work well.  So low levels could leave you permanently hungry, making it much harder to lose weight.

As you can see, there are many reasons beyond COVID-19 to ensure that your vitamin D levels are optimal.  A final thought is that if you do decide that you need supplementation beyond extra sunlight, which is going to be hard to get in the UK as we head into the winter months, you should seriously consider adding vitamin K2 into the mix. D and K2 work together to ensure that calcium is deposited into bones rather than into the soft tissues and arteries,  thus improving bone density rather than increasing atherosclerosis.  Vitamin K2 can be obtained naturally in natto (a Japanese fermented bean product that many people find disgusting, although we quite like it), some hard cheeses, and liver, but most people are not eating enough of these to get sufficient amounts of this vitamin, making supplementation even more important. So get tested, get some sun and, if your levels aren’t up to snuff, then get some supplements.


Coronavirus and your immune system

coronavirus and masked womanFour weeks into lockdown and we are well into our new routine here in Clapham: daily meditation and exercise followed by video calls with patients, a daily walk, and more time for study, reading etc.  We are also preparing for the possibility that we will contract COVID-19 at some time over the next year. We are approaching this as though we were training for a race or other athletic endeavour. We are not hoping to get it. However, with the reality of a vaccine being at least 18 months away, it seems unlikely and undesirable, considering the effects on the population’s mental, financial health that we can all stay on strict lockdown until then.  We, therefore, want to spend this time preparing our immune systems to be in the best possible shape to mount an effective response to the virus.

Although the knowledge of this pathogen is evolving from day to day, we know that there is a vast difference in the effect it has, with most people getting mild symptoms easily treated at home, but a few suffering very badly and needing intensive medical support. Why is there this difference? The answer is multifactorial and may relate to the amount of the pathogen they were exposed to i.e. viral load, which may explain the number of medical staff treating COVID-19 patients without adequate PPE that have succumbed. But the other factor is the response of the infected person’s immune system, which has a genetic component but is also related to a person’s current state of health and metabolic function.  Almost everyone who is getting seriously ill is suffering from an underlying condition or conditions such as heart disease, diabetes or obesity. It is known that all of these have a lifestyle component and are hitting people at increasingly early ages.  Therefore, there is much we can do whilst in lockdown to improve our health and immune systems.

In short, the things that you can do to improve your immune system response are also things that will improve your metabolic health and resilience. So here are some ideas split into three groups: nutrition, exercise, and psychological. Now, none of us is perfect, and doing all these things all the time may be too much, so we believe in the 80:20 rule, especially in lockdown: try and do as much as you can (80%), but don’t beat yourself up too much when you trip up (20%).

Nutrition – immune health starts in the gut!

  1. If you are overweight or obese, this is the time to try and tackle this problem as it really does increase your risk of a poor outcome with COVID-19. This is often related to insulin resistance.  If you want help with diet or exercise, Jack has a wealth of experience.

  2. Even if you are of normal weight you need to think about your diet and try to eat as healthily as possible.  Much of the immune system is in the gut lining, so if you are constantly bombarding this with too much sugar, alcohol and processed food, this puts the system on alert, starting the chronic inflammation which is the underlying factor in most lifestyle diseases.  So do try to eat real and nutrient-dense food to get sufficient micronutrients for the normal physiological function of your body.  We focus on unprocessed meat (including organ meats) and fish, with plenty of vegetables and a moderate amount of fruit and fermented dairy.

  3. There is also some evidence that industrial vegetable oils drive inflammation, so another reason to avoid processed foods which are full of these. Cook with butter, olive oil, coconut oil or animal fat.

  4. Many of us now have more time under lockdown to get into the habit of cooking meals from scratch. If you do want a comforting sugary treat, make it yourself from real ingredients.

  5. It is also important to support your microbiome, so we make sure to eat fermented foods such as kombucha, kefir, and sauerkraut every day

  6. We have increased our use of supplements as an insurance policy, but supplementation is not a substitute for a nutrient-rich diet. We are currently using:

    1. Vitamin D

    2. Vitamin C

    3. Fermented cod liver oil

    4. Astragalus

    5. Turmeric

    6. Magnesium

    7. Zinc

  7. We also use intermittent fasting as this can boost immunity and enhance longevity via autophagy. We generally skip breakfast, resulting in a 12-16 hour intermittent fast, and since lockdown have added a weekly dinnertime to dinnertime (24 hour) fast.

  8. Don’t drink too much. Alcohol is not great for the immune system. Sometimes the reduction in stress from a glass of wine is more important, but don’t overdo it.

  9. Stop smoking – this shouldn’t need any explanation


Exercise has an effect on the immune system but it is a Goldilocks situation. Rather than HIIT or long runs, both of which can contribute to an inflammatory state that can suppress the immune system, focus on lower-intensity activities such as walking, mobility, breathwork, and bodyweight training.

Check out our new video where Jack puts Sue through a bodyweight training session, offering some ideas on how to improve your fitness without much space or proper gym equipment. Also don’t forget that Jack can help design you your own workout by video, or if pain is stopping you from exercising, both Sue and Joel are offering video calls to help you.


Our mental state literally affects our physiology, and increased stress levels suppress our immune system, so we do need to try and keep fear under control at this difficult time:

  1. Breathing and or mindfulness. Check out the breathing video we featured in the last newsletter.  Diaphragmatic breathing can stimulate the spleen, the home of your immune cells.  It sits under the lower ribs on your left side so encouraging the movement here may improve its function.

  2. Limit consumption of news and social media. We do need to stay abreast of world developments, but ration it to maybe once a day, and try not to focus on the things that you can’t do anything about.  That fear and stress amp up your cortisol levels and suppress your immune system.

  3. Watch some comedy or put on some music and dance instead.

  4. If you are not in a vulnerable group, try not to obsess about contracting COVID-19, but do be concerned about not passing it on.

  5. Try some gratitude, even though the world is in a difficult situation, trying to focus on a few small good things can be really helpful for our state of mind, as without effort we do tend to focus on the negative.

  6. The Greek philosophy of stoicism, which advocates facing challenges with grace, humour and perspective may be of help.

  7. Maintain virtual contact with friends and family. We’ve been arranging a few ‘quarantini’ dates (remember the 80:20 rule for drinks) with friends near and far.

  8. Cold showers can give your immune system a boost, as well as wake you up!

  9. Sufficient sleep is a huge factor in immune function.  Some people find that lockdown is giving them the chance to sleep more as they are no longer ruled by the tyranny of the alarm and the commute, but for others, anxiety levels may be increased and make sleep harder.  It’s important to follow good sleep hygiene rules, and try to avoid caffeine and alcohol close to bedtime, and if you still need a little assistance try herbal remedies such as valerian, reishi mushrooms, magnesium or 5-HTP rather than sleeping pills, which don’t provide true restorative sleep and may leave you feeling knocked out the next day.

mona lisa with a mask

To Your (Gut) Health

Microbiome. Microbiota. Beneficial bacteria. Gut bugs. Call it what you will, you’ve probably read or heard somebody talking about this subject recently. But did you know that gut health is correlated with everything from Parkinson’s disease to cardiovascular health to skin conditions like eczema and psoriasis, to anxiety, depression and cognitive function?. There is more and more evidence that the vast quantity of microscopic critters in our guts can play a huge role in our physical and mental health, both positive and negative.

This is achieved via another term you may have heard of: the gut-brain connection. Gut microbes influence how we digest and metabolise the precursors of important neurotransmitters like serotonin and dopamine. Then there is a direct line of communication to the brain, through the vagus nerve, which has receptors near the gut lining that allow it to keep a check on our digestion. Microbes in the intestine can therefore release chemical messengers that alter the signalling of the vagus nerve – and, as a consequence, the brain’s activity.

These pathways are not one-way streets, however, as brain activity can also influence the gut flora composition. Stress can increase inflammation, for instance, which can then affect the microbes in our gut. The result can be a feedback loop. Gut, brain, gut, brain, gut.

Humans used to eat a huge quantity of fermented foods as fermentation was one of the few ways to preserve fresh foods for later.  This would have included pickled vegetables, dairy (yoghurt and cheeses) and meat. However, the advent of packaged foods and refrigeration has lead to the reduction and even, sometimes, elimination of this category from our diets.

Over the past 10 years or so, the idea of feeding and maintaining our gut microbiome has become increasingly mainstream. It seems clear that today’s Western lifestyle featuring vast amounts of stress, poor sleep, antibiotics and nutritionally-depleted diets are impacting the type and amount of microbes present in our guts, leading to a variety of health problems. This has led to a booming probiotic supplement industry that aims to help increase the number and variety of microbes. We believe that even though probiotics can be helpful to deal with specific conditions – we always take a supplement to increase resilience when travelling –  it is better to include fermented foods as a mainstay of the diet.  So we regularly eat home-made sauerkraut, pickles and kombucha. Of course not everyone has the time and inclination to make all of these from scratch (even though basic fermented veggies are dead easy!) but fortunately some of the commercial products out there get the job done handily and tastily (Okay, not sure if that’s a real word, but if not, it should be.) UK friends, check out the kefir made by our friends at Ki, straight outta Vauxhall!  (Shameless plug alert)

Ki Kefir is a new sustainable & organic company based in South West London, hand delivering traditional and powerful kefir to your door. Frustrated with buying kefir without the powerful kick of life it should have, we decided it was time for Londoners to get their hands on a real kefir, full of probiotic goodness that’s exceptionally powerful and really makes a difference to your gut health. Unlike many shop-bought Kefirs who use a powdered (lab-made) bacteria to make kefir,  at Ki we make it the traditional way with living cultures. This ensures the highest quantity and most diverse range of good bacteria. Our kefir also contains a cocktail of vital vitamins and minerals crucial for good health, including B12, K2, calcium and magnesium. It is made with the finest organic milk from grass-fed cows in Sussex. We are also a minimal waste company, packaging our kefir in glass and offering local deliveries.

To find out more about Ki you can visit
Instagram: @ki.kefir

Is Sunscreen the New Margarine?

tub of sunscreen on beachCurrent guidelines for sun exposure are unhealthy and unscientific, controversial new research suggests—and quite possibly even racist. How did we get it so wrong?

In this article, author Rowan Jacobsen discusses how our obsession with protecting ourselves from the sun is contributing to many health issues. Studies have shown that supplementing with vitamin D is not very effective, whereas moderate amounts of sunlight exposure is. But that’s only the start. Sunlight triggers the release of a number of other important compounds in the body, including nitric oxide, serotonin and endorphins. It reduces the risk of prostate, breast, colorectal, and pancreatic cancers. It improves circadian rhythms. It reduces inflammation and dampens autoimmune responses.


Read the full article, Is Sunscreen the New Margarine?

If You Want To Save The World, Veganism Isn’t The Answer

dry field with one treeVeganism is becoming more and more popular these days. Understandably so, as people are becoming increasingly concerned about the impact of Intensively farmed meat and dairy’s toll on the environment. However, in this article, farmer Isabella Tree discusses the potential negative implications that veganism can have on the sustainability of our farmland, as well as our health. This article is a great read no matter which side of the debate you may stand on.

Read the full article, If You Want To Save The World, Veganism Isn’t The Answer

Will a Low-Carb Diet Shorten Your Life?


Last week, a new study was published in The Lancet that claimed to find that both very low-carb and very high-carb diets shorten our lifespan. Predictably, the mainstream media jumped on this finding without doing a shred of due diligence and we were subjected to splashy headlines like this:

  • Low-carb diets could shorten life, study suggests (BBC News)
  • Low and high carb diets increase risk of early death, study finds (CNN)
  • Low-carb diet may cut years off life, study suggests (Newsweek)
  • Your low-carb diet could be shortening your life (Fast Company)
  • Paleo fail: meat-heavy low-carbohydrate diets can shorten lifespan, researchers say (South China News)

In this article, Chris Kresser breaks down the arguments, and in the process, points out many of the shortcomings of the study.

Read the full article, Will a Low-Carb Diet Shorten Your Life?

The Reliability of Diagnostic Imaging Without Clinical Correlation In Musculoskeletal Medicine: An Evidence-based Review.

X-RayA summary of the evidence on the reliability of scans for musculoskeletal issues, showing that in most cases there are just any many people with structural issues that don’t have pain and dysfunction. It’s not how it looks, but how it works that is important, that’s why at Backs Etc we focus on improving movement patterns.


Read the article, The Reliability of Diagnostic Imaging Without Clinical Correlation In Musculoskeletal Medicine: An Evidence-based Review.

Footwear Habits Influence Child and Adolescent Motor Skill Development

child with bare feetNew research finds that children and adolescents who spend most of their time barefoot develop motor skills differently from those who habitually wear shoes. Published in Frontiers in Pediatrics, this is the first study to assess the relevance of growing up shod vs. barefoot on jumping, balancing and sprinting motor performance during different stages of childhood and adolescence. The study shows that habitually barefoot children are noticeably better at jumping and balancing compared to habitually shod children, particularly from 6-10 years of age. While these beneficial barefoot effects diminished in older adolescents, the research nevertheless highlights the importance of barefoot exercise for motor development as children grow and mature.


Read the full article, Footwear Habits Influence Child and Adolescent Motor Skill Development.