The P.I.E. Approach

Logo of the PIE Approach
Proactive. Practical. Personal.

Exercise-induced laryngeal obstruction (EILO) is more commonly called Vocal Cord Dysfunction (VCD). It is a complex upper airway disorder that occurs in some athletes and is characterized by a closing of the vocal folds during breathing, resulting in a narrowing of the airway. Due to its complexity, Sharon Frank created a holistic* approach for treating EILO where Sharon connects with the patient on multiple levels: physically, intellectually, and emotionally. And that is why she named it the P.I.E. Approach.

The PHYSICAL (“P”) Component:

There are 2 fundamental components of the “P” (Physical) piece of the P.I.E. Approach:

Buteyko Breathing Techniques: Buteyko breathing aims at restoring the body’s natural way to breathe. In therapy we use the principles and some of the methods of Buteyko breathing, which aim at normalizing the breathing pattern and optimizing oxygenation – from rest to exertion. Key benefits of using Buteyko breathing in treating EILO: proactive, practical, natural, calming, and can be used for managing stress beyond sports.


Manual Therapy: A gentle, light-touch, hands-on technique (using a combination of myofascial release and some craniosacral techniques) to facilitate overall relaxation, balance of the nervous system, and release of muscle tension. It is based on osteopathic principles: that all systems in the body are interrelated and depend on each other for good health, that structure governs function, and that the body has the ability to heal itself.


The INTELLECTUAL (“I”) Component:

A core principle of the P.I.E. Approach is to have patients understand and recognize how each piece of the P.I.E. is related to the root cause of their breathing problem, and to the therapeutic processes used in treating EILO. We explain the rationale for using this holistic approach, how it differs from traditional therapy methods, and the expected outcome and applications of using this approach.

We have patients gain an understanding of EILO and the therapy process by thinking about and experiencing the physical sensations of normalized breathing which, in turn, develops a sense of control and relaxation, and connects the mind and body through increased breathing awareness.

The evaluation includes obtaining a thorough medical history, assessing breathing at rest and at various levels of exercise, and trying out some therapeutic respiratory retraining techniques.

At the end of the evaluation, the results and recommendations are reviewed with the goal of helping the patient and their family members understand the following:

  • -why inhalers may not have helped.
  • -why breathing devices may not have helped.
  • -why previous attempted methods (i.e., rescue techniques) did not help or only partially helped.
  • -why breathing less is better than breathing more.
  • -why we use a holistic approach.
  • -what is the manual component and why it is so important.
  • -why a hierarchical, practical approach is important.
  • -how portions of the P.I.E. Approach can be applied to life situations (driver’s test, taking SATs, meeting someone new, etc.), not just sports.
  • -the relationship between emotion/stress and breathing, and its effect on the body’s performance during sports and in general.
  • -how the Physical, Intellectual (cognitive), and Emotional components are inter-connected.


The EMOTIONAL (“E”) Component:

Most of the patients we see have experienced EILO for quite some time. Prior to coming here, the vast majority were seen by numerous medical providers such as: primary care, asthma/allergy, pulmonology, otolaryngology (Ear, Nose, and Throat), cardiology, gastroenterology, neurology, psychology/psychiatry, sports medicine, other speech-language pathologists, and others. Many were prescribed inhalers and/or various medications. Some tried recommended breathing devices, or other therapy techniques/self-help methods, to little or no avail.

So, by the time a patient comes here for an evaluation, they (and their families) can frequently be a bit skeptical. They also have experienced fear, frustration, embarrassment, sadness, and other emotions. The P.I.E. Approach allows us to connect with patients and families, by gathering information on the patient’s overall demeanor, their sources of stress and coping mechanisms, their level of self-expectations, level of competitiveness in various areas, their relationship with teammates and coaches, family dynamics, history of anxiety, and past/present psychological counseling.

We listen closely to patient’s stories and the emotional roller-coaster that often accompanies them when searching for a diagnosis and treatment. By forming a closer bond with the patient, we can discover the various nuances specific to each individual, help foster a positive outcome, and encourage mindfulness, self-monitoring and self-correction of breathing techniques.

*”Holistic medicine tries to treat the ‘whole person’ rather than focusing too narrowly on single symptoms…It emphasizes the connections between the mind and the body…” Cite: “Holistic.” Dictionary, Merriam-Webster, Accessed 28 Dec. 2021

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