A panic attack is no laughing matter. But there I was witnessing one for the first time. Just me and my patient and she was TERRIFIED by a flare up of her symptoms.
If you’ve never observed a panic attack, it’s both fascinating and nerve-wracking. Talking a mile a minute, without apparent pause for breath, her whole body was tense. But the fear in her eyes was most striking. That and the vice grip she had on me.
My hand squeezed like a tourniquet, I tried to console her in a soothing voice and guide her to regulate her breathing. When that didn’t work I figured we were going to have to ride it out.
Then I saw her eyes start to well up. “It’s ok to cry.” I said and she did. After releasing a few tears she was still a bit agitated.
“Don’t leave me” she said with a tone of desperation. I responded with a quip about how with the crazy grip she had on me- I wasn’t going anywhere! She laughed out loud. My mirror neurons kicked in and I started to laugh too.
BAM! It was as if we’d hit a magic light switch. The calming effect of her laughter was exceptional. All of a sudden she could pace her breathing, speak slower, orient her eyes to other things in the room, and transform from a state of tension to increased ease.
Eventually she loosened her grip.
If the effect of that laughter hadn’t been so quick, so drastic, I probably wouldn’t have given it much thought. But the speed of the change struck me and has interested me since.
We say laughter is the best medicine. I wondered; is this a feel good myth or does laughter actually improve health and wellness?
Most of us associate laughter with its psychological benefit, a change in mood. This particular incident made me ponder some bigger questions.
What physiological effects occur from laughter that may provide positive health benefits?
Did something else cause the quick change in my patient?
So, I went on a trip down laughter lane to find out....
Laughter is defined as “a psychophysiological response to humor that involves both characteristic physiological reactions and positive psychological shifts.”(1)
Gelotology, the study of laughter and its effects on the body, has been around for decades. My review of the literature focused on the past 19 years.
So how does laughter affect some of the systems involved in human physiology?
Laughter is a physical act. It recruits the musculoskeletal system to produce changes in facial expressions, vocalizations and posture. Depending on its intensity, we feel the ache in our core when we “laugh so hard its hurts.”
Wagner et al investigated the demand of laughter on trunk muscles by studying the intervention of laughter yoga and relative surface EMG activity of trunk muscles in comparison to “traditional stabilization exercises” aka, crunches and back lifting.(2) Results showed that when laughter reached its peak it was comparable to the mean activity of trunk and core muscles in the “traditional” exercises. Laughter is "exercise."
Speaking of exercise: How much energy does one expend when laughing?
Buchowski et al found that laughter produced a 10–20% increase in energy expenditure (EE) and heart rate above resting values.(3) Laughing for 10–15 min per day could increase total EE by 10–40 kcal. Consider laughter a component of non-exercise activity thermogenesis (NEAT) and yeah, you should get more of it.
Take a walk and laugh about how NEAT life in ripped jeans is
It’s obvious that breathing changes when we laugh. This occurs through the coordination of several muscle groups, including facial, laryngeal, and respiratory muscles.(4)
Respiration during laughter is described as “fits of expiratory saccades of variable length. With short but often rapid and efficient inspirations that occur between the expiratory saccades.”(5)
In one of the more invasive but interesting studies on laughter, Filipelli et al looked at the respiratory mechanics of laughter. They found that bouts of laughter caused substantial decreases in functional residual capacities secondary to quick and sustained increases in intra-thoracic pressures and was associated with considerable dynamic airway compression.(6)
Boyle's Law of HA HA HA: a compressed version
For individuals with hyperinflation, laughing may be a good "treatment." With repetitive forced expirations laughter lead to lower total lung capacity and reserve volume measurements in COPD patients.(5)
Inevitably when we discuss gas exchange we have to acknowledge the relationship between the cardiovascular system and the respiratory system.
Over the years several studies have examined different biomarkers of cardiovascular health including heart rate, blood pressure and more recently vascular/endothelial function.(7)
Research shows laughter produces a beneficial but temporary effect on vascular function by reducing arterial stiffness and increasing vasodilation.(8,9) With these two effects one would assume potential positive effects on cardiac output and peripheral blood flow.
Improved blood flow and tissue perfusion is a good thing and critical to how we deal with stress.
STRESS SYSTEMS (NEURO-ENDOCRINE-IMMUNE)
To maintain homeostasis the nervous, endocrine and immune systems are three of the primary subsystems regulating the stress response.
Laughter, a form of eustress, has been shown to work as a neuro-immune-endocrine enhancer by influencing multiple stress mediators including hormones, growth factors, neurotransmitters and components of the endocrine and immune systems such as cytokines and immunoglobulins.(10)
In patients with type 2 Diabetes, laughter intervention was shown to reduce the postprandial increase in glucose (the amount of glucose, in the plasma after a meal) thereby potentially improving glycemic control.(11)
Individuals with rheumatoid arthritis respond to laughter with a significant decrease in growth hormone potentially assisting in stress coping with this autoimmune disorder.(12)
Multiple studies have shown laughter to positively influence immune mediators including natural killer (NK cells), activated T and B cells, cortisol and salivary IgA levels.(10,13)
You may not have a chronic illness but everyone deals with some type of stress. In physical therapy and in life, pain is a common stress output. Luckily, laughter has been shown to increase pain tolerance.(14)
As you can see, laughter positively influences many aspects of human physiology. But now we come to my second question: Did something else cause the quick change in my patient? And the answer I think is yes.
Recent studies propose that social laughter (laughter with another individual) has more than a physiological effect on us.(15)
Manninen et al used PET scans and changes in MOR (an opioid receptor system involved in stress response) to demonstrate that social laughter was the key to endogenous opioid release in multiple areas of the brain.(16) Co-laughter may be central to preserving and strengthening social bonds.
“Laughter is the shortest distance between two people” Victor Borge
Stepping aside from the physiological focus we can appreciate laughter’s value in terms of evolutionary drive. Our inherent human need for connection has been and continues to be key to our survival.
It is so essential that laughter precedes speech in babies’ development of communication skills. By 2 to 4 months of age infants start to giggle in social interactions seeking a response from caregivers, connecting.
What is remarkable though is the perception of laughter that develops at an early age. Studies show that laughter between adult friends versus laughter between strangers can be distinguished by 5-month-old infants.(17)
The baby knows.
If we expand the concept of stress mediators from physiology to sociology, laughter helps us mediate stress through social bonding. Think about it, genuine laughter is rarely something that you do in isolation.
Laughter is a behavior that brings you to the present. Understanding this is important for anyone working with people.
While there are many variables involved in the positive changes associated with laughter, I wonder if the most significant is laughter’s role as a safety signal.
We want our patients and clients to feel connected with us, as well as with their social network. This attunement is one way we decrease threat and promote the most therapeutic environment. I believe this is what helped my patient during her panic attack.
To better help patients we need to start thinking and treating in a manner that might feel unconventional at times.
The intention of a home program, historically exercise-based, is to address needs identified in an evaluation; to teach your patient how to heal themselves.
Let's consider expanding beyond the exercise prescription. Supplemental methods to enhance health and wellness may even augment the effect of other interventions.
Raise your hand if you believe in #holistichealth
Such holistic strategies can be “prescribed." Some that I have suggested to patients in the past include: connecting with loved ones, sleep, touch, singing, breathing, time in nature or at least outside, meditation, chanting, dancing, crying and definitely laughing.
And now not only is LOL good Rx, its EBP*!
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2. Wagner H, Rehmes U, Kohle D, Puta C. Laughing: a demanding exercise for trunk muscles. J Mot Behav. 2014;46(1):33–37. doi:10.1080/00222895.2013.844091
3. Buchowski MS, Majchrzak KM, Blomquist K, Chen KY, Byrne DW, Bachorowski JA. Energy expenditure of genuine laughter [published correction appears in Int J Obes (Lond). 2014 Dec;38(12):1582]. Int J Obes (Lond). 2007;31(1):131–137.
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11. Hayashi K, Hayashi T, Iwanaga S, et al. Laughter lowered the increase in postprandial blood glucose. Diabetes Care. 2003;26(5):1651–1652. doi:10.2337/diacare.26.5.1651
12. Ishigami S, Nakajima A, Tanno M, Matsuzaki T, Suzuki H, Yoshino S. Effects of mirthful laughter on growth hormone, IGF-1 and substance P in patients with rheumatoid arthritis. Clin Exp Rheumatol. 2005;23(5):651–657.
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14. Lapierre SS, Baker BD, Tanaka H. Effects of mirthful laughter on pain tolerance: A randomized controlled investigation. J Bodyw Mov Ther. 2019;23(4):733–738. doi:10.1016/j.jbmt.2019.04.005
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17. Vouloumanos, A., Bryant, G.A. Five-month-old infants detect affiliation in colaughter. Sci Rep 9, 4158 (2019) doi:10.1038/s41598-019-38954-4