Note: The following is based heavily off of my training from the Prague School of Rehabilitation and the Postural Restoration Institute. For more information, I recommend the DNS Level 1 course and the PRI Postural Respiration course.
People from all types of lifestyles and demographics can suffer from pain and injury. Whether they are physically active or sedentary, old or young, healthy or unfit, injury can plague anybody. Although most people who are experiencing chronic pain have many differences, the one thing that they all have in common is that they breathe. Unfortunately, most of them are likely breathing in a suboptimal manner, and this may be having an effect on their health and well-being.
During inhalation, the diaphragm is supposed to concentrically contract while the internal obliques and hamstrings isometrically contract to prevent rib external rotation. During exhalation, the rectus abdominus and transverse abdominus are supposed to concentrically contract in order to internally rotate the rib cage. This process creates a Zone of Apposition (ZOA) that allows proper core stability and joint arthrokinematics to occur.
Unfortunately, over the course of time, many people develop compensatory breathing patterns that deviate from the optimal model, and this can lead to a wide array of negative effects on joint function, pain, and overall well-being. In fact, one study found that subjects with poor breathing patterns scored significantly lower on a measure of movement quality called the Functional Movement Screen (1). Luckily, research shows that with a small amount of concentrated practice, breathing patterns can be retrained and optimal habits can be naturally adopted (2-11).
When breathing is dysfunctional, this can often lead individuals to become stuck in an “extended” posture. The anterior core will reduce activity and the lumbar erectors will become overactive to maintain lumbar extension. Over time, this can become a major contributor to low back pain.
According to research, dysfunctional breathing is extremely common in patients with low back pain (12-20). When patients work on improving their breathing, posture changes and the angles of the lumbar decrease (21). Over time, this can lead to a dramatic improvement in back pain symptoms (22).
When the diaphragm is underactive, nearby muscles such as the pectorals, upper trapezius, and SCM can become overactive in an attempt to assist with inhalation. This can be a common cause of neck tension or shoulder dysfunction.
Not surprisingly, research has shown that dysfunctional breathing is extremely common in patients who suffer from neck or shoulder problems (23-26).
Some research has even found a connection between dysfunctional breathing and Temporomandibular Joint Dysfunction (TMJ) and other orofacial pains (27-28).
Hip Flexibility and Pelvic Floor Dysfunction
When poor diaphragmatic breathing causes patients to become stuck in an “extended” state, this increase in lumbar extension will lead to anterior pelvic tilt. When the pelvis is in an anteriorly tilted position, this minimizes space in the hip socket and can decrease hip range of motion (29).
One study found that subjects who practiced proper breathing mechanics experienced improvements in hip range of motion (28). Another study found that manual techniques directed towards the diaphragm can lead to apparent improvements in hamstring flexibility (31).
When it comes to the hips, the pelvic floor is particularly affected by the function of the diaphragm. Much research has found a strong connection between dysfunctional breathing, incontinence, and various pelvic floor disorders (32-35).
For patients who are stuck in an “extended” posture, excessive flaring of the rib cage will lead to an anterior displacement of one’s center of gravity. As a result, this can cause a shift towards the forefoot and may cause alterations in the function of the ankle joint. Research has found that individuals with chronic ankle instability are more likely to exhibit dysfunctional breathing (36).
It is well known that anxiety and panic attack disorders are associated with altered breathing patterns (37-44). Slow diaphragmatic breathing promotes activation of the parasympathetic (“Rest and Digest”) branch of the nervous system. When patients have weak diaphragms and adopt altered breathing patterns, however, this can increase drive to the sympathetic (“Fight or Flight”) nervous system and increase the body’s sensitivity to stressful events. Interestingly, studies have found that people who suffer from asthma are twice as likely to suffer from anxiety or other mood disorders (45-46).
Luckily, much research has found that practicing proper breathing can lead to short-term and long-term changes in the body’s susceptibility to stress, anxiety, and depression (47-54). Breathing practice has even been shown to reduce feelings of pain (55). Some experts have successfully utilized breathing training as a treatment for PTSD and panic disorders (56-57).
Interestingly, dysfunctional breathing has been associated with reduced ability to focus and perform during cognitive tasks (58). Studies have found that working on proper breathing can decrease test anxiety in students and improve overall ability to concentrate (59-61).
There appears to be a very strong prevalence of breathing dysfunction among heart attack patients (62-63). Luckily, breathing programs can be utilized to improve the health of the cardiovascular system. Research has shown that practicing proper breathing can lead to dramatic reductions in blood pressure (64-65). Other research conducted on subjects who had already suffered from one heart attack found that when subjects underwent a breathing program, they were less likely to suffer from future complications (66-67).
Proper breathing is extremely important for digestion to optimally occur. Dysfunctional breathing is a major factor in GERD and other digestive related impairments (68-71).
Amazingly, research has found that diabetecs who practiced diaphragmatic breathing experienced decrease oxidative stress and improved blood sugar levels after eating (72-73).
During long-duration physical activities, oxygen is extremely important in order to sustain stamina levels. By strengthening the diaphragm, more oxygen can be inhaled during each breath. Consequently, it is not surprising that athletes who strengthen their inspiratory muscles experience significant improvements in cardiorespiratory endurance (74-80).
Overall, the benefits of training proper breathing patterns are extensive. Whether the goal is to improve movement quality, decrease anxiety, improve digestive and cardiovascular health, or enhance endurance, there is a good chance that practicing proper breathing patterns can offer value.
- Bradley, H., & Esformes, J. D. (2014). Breathing pattern disorders and functional movement. International journal of sports physical therapy, 9(1), 28.
- Boyle, K. L., Olinick, J., & Lewis, C. (2010). The value of blowing up a balloon. North American journal of sports physical therapy: NAJSPT, 5(3), 179.
- Courtney, R. (2009). The functions of breathing and its dysfunctions and their relationship to breathing therapy. International Journal of Osteopathic Medicine, 12(3), 78-85.
- de Medeiros, A. I. C., Fuzari, H. K. B., Rattesa, C., Brandão, D. C., & de Melo Marinho, P. É. (2017). Inspiratory muscle training improves respiratory muscle strength, functional capacity and quality of life in patients with chronic kidney disease: a systematic review. Journal of Physiotherapy, 63(2), 76-83.
- Hill, K., & Eastwood, P. (2011). Effects of loading on upper airway and respiratory pump muscle motoneurons. Respiratory physiology & neurobiology, 179(1), 64-70.
- Padula CA, Yeaw E. Inspiratory muscle training: integrative review. Research & Theory For Nursing Practice. 2006 Winter;20(4):291–304.
- Philippot, P., Chapelle, G., & Blairy, S. (2002). Respiratory feedback in the generation of emotion. Cognition & Emotion, 16(5), 605-627.
- Ramsook, A. H., Koo, R., Molgat-Seon, Y., Dominelli, P. B., Syed, N., Ryerson, C. J., … & Guenette, J. A. (2016). Diaphragm Recruitment Increases during a Bout of Targeted Inspiratory Muscle Training. Medicine and science in sports and exercise, 48(6), 1179-1186.
- Sheel, A. W. (2002). Respiratory muscle training in healthy individuals. Sports Medicine, 32(9), 567-581.
- Yamaguti, W. P., Claudino, R. C., Neto, A. P., Chammas, M. C., Gomes, A. C., Salge, J. M., … & Carvalho, C. R. (2012). Diaphragmatic breathing training program improves abdominal motion during natural breathing in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Archives of physical medicine and rehabilitation, 93(4), 571-577.
- Yeampattanaporn, O., Mekhora, K., Jalayondeja, W., & Wongsathikun, J. (2014). Immediate effects of breathing re-education on respiratory function and range of motion in chronic neck pain. Journal of the Medical Association of Thailand= Chotmaihet thangphaet, 97, S55-9.
- Beeckmans, N., Vermeersch, A., Lysens, R., Van Wambeke, P., Goossens, N., Thys, T., … & Janssens, L. (2016). The presence of respiratory disorders in individuals with low back pain: A systematic review. Manual therapy, 26, 77-86
- Chaitow, L. (2004). Breathing pattern disorders, motor control, and low back pain. Journal of Osteopathic Medicine, 7(1), 33-40
- Hagins, M., & Lamberg, E. M. (2011). Individuals with low back pain breathe differently than healthy individuals during a lifting task. journal of orthopaedic & sports physical therapy, 41(3), 141-148.
- Hodges PW, Gurfinkel VS, Brumagne S et al 2002 Coexistence of stability and mobility in postural control: evidence from postural compensation for respiration. Exp Brain Res 144:293–302.
- Janssens L, et al “The effect of inspiratory muscle fatigue on postural control in people with and without recurrent low back pain” Spine 2010 May; 35(10): 1088-94
- Kolář, P., Šulc, J., Kynčl, M., Šanda, J., Čakrt, O., Andel, R., … & Kobesová, A. (2012). Postural function of the diaphragm in persons with and without chronic low back pain. journal of orthopaedic & sports physical therapy, 42(4), 352-362.
- O’sullivan, P. B., Beales, D. J., Beetham, J. A., Cripps, J., Graf, F., Lin, I. B., … & Avery, A. (2002). Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine, 27(1), E1-E8.
- Smith, M. D., Russell, A., & Hodges, P. W. (2006). Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Australian Journal of Physiotherapy, 52(1), 11-16.
- Wang, S., & McGill, S. M. (2008). Links between the mechanics of ventilation and spine stability. Journal of applied biomechanics, 24(2), 166-174
- Obayashi, H., Urabe, Y., Yamanaka, Y., & Okuma, R. (2012). Effects of respiratory-muscle exercise on spinal curvature. Journal of sport rehabilitation, 21(1), 63-68
- Mehling, W. E., Hamel, K. A., Acree, M., Byl, N., & Hecht, F. M. (2005). Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Alternative therapies in health and medicine, 11(4), 44.
- Dimitriadis, Z., Kapreli, E., Strimpakos, N., & Oldham, J. (2013). Respiratory weakness in patients with chronic neck pain. Manual therapy, 18(3), 248-253
- Kahlaee, A. H., Ghamkhar, L., & Arab, A. M. (2017). The association between neck pain and pulmonary function: a systematic review. American journal of physical medicine & rehabilitation, 96(3), 203-210.
- Lo´ pez-de-Uralde-Villanueva, I., Sollano-Vallez, E., & Del Corral, T. (2017). Reduction of cervical and respiratory muscle strength in patients with chronic nonspecific neck pain and having moderate to severe disability. Disability and Rehabilitation, 1-10
- .Perri, M. A., & Halford, E. (2004). Pain and faulty breathing: a pilot study. Journal of Bodywork and Movement Therapies, 8(4), 297-306.
- Ross, J. R., Nepple, J. J., Philippon, M. J., Kelly, B. T., Larson, C. M., & Bedi, A. (2014). Effect of changes in pelvic tilt on range of motion to impingement and radiographic parameters of acetabular morphologic characteristics. The American journal of sports medicine, 42(10), 2402-2409.
- Bartley, J. (2011). Breathing and temporomandibular joint disease. Journal of Bodywork and movement therapies, 15(3), 291-297.
- Hruska Jr, R. J. (1997). DYSFUNCTIONAL, RESPIRATORY MECHANICS ON OROFACIAL PAIN. Dental Clinics of North America, 41(2), 211.
- Hamilton, A. R., Beck, K. L., Kaulbach, J., Kenny, M., Basset, F. A., DiSanto, M. C., & Behm, D. G. (2015). Breathing Techniques Affect Female but Not Male Hip Flexion Range of Motion. The Journal of Strength & Conditioning Research, 29(11), 3197-3205.
- Valenza, M. C., Cabrera-Martos, I., Torres-Sánchez, I., Garcés-García, A., Mateos-Toset, S., & Valenza-Demet, G. (2015). The effects of doming of the diaphragm in subjects with short-hamstring syndrome: a randomized controlled trial. Journal of sport rehabilitation, 24(4), 342-348
- Haugstad, G. K., Haugstad, T. S., Kirste, U. M., Leganger, S., Wojniusz, S., Klemmetsen, I., & Malt, U. F. (2006). Posture, movement patterns, and body awareness in women with chronic pelvic pain. Journal of psychosomatic research, 61(5), 637-644.
- Hung, H. C., Hsiao, S. M., Chih, S. Y., Lin, H. H., & Tsauo, J. Y. (2010). An alternative intervention for urinary incontinence: retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. Manual therapy, 15(3), 273-279
- O’Sullivan, P. B., & Beales, D. J. (2007). Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: a case series. Manual therapy, 12(3), 209-218
- Smith, M. D., Russell, A., & Hodges, P. W. (2006). Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Australian Journal of Physiotherapy, 52(1), 11-16.
- Terada, M., Kosik, K. B., Mccann, R. S., & Gribble, P. A. (2016). Diaphragm Contractility in Individuals with Chronic Ankle Instability. Medicine and science in sports and exercise, 48(10), 2040-2045.
- Beck, J. G., Shipherd, J. C., & Ohtake, P. (2000). Do panic symptom profiles influence response to a hypoxic challenge in patients with panic disorder? A preliminary report. Psychosomatic medicine, 62(5), 678-683.
- Freeman, L. J., Conway, A., & Nixon, P. G. F. (1986). Physiological responses to psychological challenge under hypnosis in patients considered to have the hyperventilation syndrome: implications for diagnosis and therapy. Journal of the Royal Society of Medicine, 79(2), 76-83.
- Han, J. N., Stegen, K., Simkens, K., Cauberghs, M., Schepers, R., Van den Bergh, O., … & Van de Woestijne, K. P. (1997). Unsteadiness of breathing in patients with hyperventilation syndrome and anxiety disorders. European Respiratory Journal, 10(1), 167-176
- Ley, R., & Yelich, G. (1998). Fractional end-tidal CO 2 as an index of the effects of stress on math performance and verbal memory of test-anxious adolescents. Biological Psychology, 49(1), 83-94.
- Masaoka, Y., & Homma, I. (1997). Anxiety and respiratory patterns: their relationship during mental stress and physical load. International Journal of Psychophysiology, 27(2), 153-159.
- Studer, R., Danuser, B., Hildebrandt, H., Arial, M., & Gomez, P. (2011). Hyperventilation complaints in music performance anxiety among classical music students. Journal of psychosomatic research, 70(6), 557-56
- Studer, R. K., Danuser, B., Hildebrandt, H., Arial, M., Wild, P., & Gomez, P. (2012). Hyperventilation in anticipatory music performance anxiety. Psychosomatic medicine, 74(7), 773-782.
- Wilhelm, F. H., Gerlach, A. L., & Roth, W. T. (2001). Slow recovery from voluntary hyperventilation in panic disorder. Psychosomatic Medicine, 63(4), 638-649.
- Lehrer, P., Feldman, J., Giardino, N., Song, H. S., & Schmaling, K. (2002). Psychological aspects of asthma. Journal of consulting and clinical psychology, 70(3), 691.
- Rosenkranz, M. A., & Davidson, R. J. (2009). Affective neural circuitry and mind–body influences in asthma. Neuroimage, 47(3), 972-980.
- Anup Sharma, Marna S. Barrett, Andrew J. Cucchiara, Nalaka S. Gooneratne, Michael E. Thase. A Breathing-Based Meditation Intervention for Patients With Major Depressive Disorder Following Inadequate Response to Antidepressants.The Journal of Clinical Psychiatry, 2016;
- Bernardi, L., Sleight, P., Bandinelli, G., Cencetti, S., Fattorini, L., Wdowczyc-Szulc, J., & Lagi, A. (2001). Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms: comparative study. BMJ: British medical journal, 323(7327), 1446.
- Ma, X., Yue, Z. Q., Gong, Z. Q., Zhang, H., Duan, N. Y., Shi, Y. T., … & Li, Y. F. (2017). The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Frontiers in Psychology, 8.
- MCCLAIN, S. L., BROOKS, A. M., & JARVIS, S. S. (2017). An Acute Bout of a Controlled Breathing Frequency Lowers Sympathetic Neural Outflow but not Blood Pressure in Healthy Normotensive Subjects. International Journal of Exercise Science, 10(2), 188.
- Song, H. S., & Lehrer, P. M. (2003). The effects of specific respiratory rates on heart rate and heart rate variability. Applied psychophysiology and biofeedback, 28(1), 13-23.
- Vlemincx, E., Van Diest, I., & Van den Bergh, O. (2016). A sigh of relief or a sigh to relieve: The psychological and physiological relief effect of deep breaths. Physiology & behavior, 165, 127-135.
- Yackle, K., Schwarz, L. A., Kam, K., Sorokin, J. M., Huguenard, J. R., Feldman, J. L., … & Krasnow, M. A. (2017). Breathing control center neurons that promote arousal in mice. Science, 355(6332), 1411-1415.
- Zucker, T. L., Samuelson, K. W., Muench, F., Greenberg, M. A., & Gevirtz, R. N. (2009). The effects of respiratory sinus arrhythmia biofeedback on heart rate variability and posttraumatic stress disorder symptoms: A pilot study. Applied psychophysiology and biofeedback, 34(2), 135.
- Seppälä, E. M., Nitschke, J. B., Tudorascu, D. L., Hayes, A., Goldstein, M. R., Nguyen, D. T., … & Davidson, R. J. (2014). Breathing‐based meditation decreases posttraumatic stress disorder symptoms in US Military veterans: A randomized controlled longitudinal study. Journal of traumatic stress, 27(4), 397-405.
- Meuret, A. E., Wilhelm, F. H., Ritz, T., & Roth, W. T. (2008). Feedback of end-tidal pCO 2 as a therapeutic approach for panic disorder. Journal of Psychiatric Research, 42(7), 560-568
- Meuret, A. E., Rosenfield, D., Seidel, A., Bhaskara, L., & Hofmann, S. G. (2010). Respiratory and cognitive mediators of treatment change in panic disorder: Evidence for intervention specificity. Journal of consulting and clinical psychology, 78(5), 691.
- Jafari, H., Courtois, I., Van den Bergh, O., Vlaeyen, J. W., & Van Diest, I. (2017). Pain and respiration: a systematic review. Pain, 158(6), 995-1006.
- Van Diest, I., Stegen, K., Van de Woestijne, K. P., Schippers, N., & Van den Bergh, O. (2000). Hyperventilation and attention: effects of hypocapnia on performance in a Stroop task. Biological psychology, 53(2), 233-252
- Cho, H., Ryu, S., Noh, J., & Lee, J. (2016). The Effectiveness of Daily Mindful Breathing Practices on Test Anxiety of Students. PloS one, 11(10), e0164822.
- Gorman, T. E., & Green, C. S. (2016). Short-term mindfulness intervention reduces the negative attentional effects associated with heavy media multitasking. Scientific reports, 6
- Hymes, A., & Nuernberger, P. (1991). Breathing patterns found in heart attack patients. International Journal of Yoga Therapy, 2(1), 25-27.
- Pettersson, H., Faager, G., & Westerdahl, E. (2015). Improved oxygenation during standing performance of deep breathing exercises with positive expiratory pressure after cardiac surgery: A randomized controlled trial. Journal of rehabilitation medicine, 47(8), 748-752.
- Mori, H., Yamamoto, H., Kuwashima, M., Saito, S., Ukai, H., Hirao, K., … & Umemura, S. (2005). How does deep breathing affect office blood pressure and pulse rate?. Hypertension research, 28(6), 499-504
- Sangthong, B., Ubolsakka-Jones, C., Pachirat, O., & Jones, D. A. (2016). Breathing training for older patients with controlled isolated systolic hypertension. Medicine & Science in Sports & Exercise, 48(9), 1641-1647.
- van Dixhoorn, J. J., & Duivenvoorden, H. J. (1999). Effect of relaxation therapy on cardiac events after myocardial infarction: a 5-year follow-up study. Journal of Cardiopulmonary Rehabilitation and Prevention, 19(3), 178-185
- van Dixhoorn, J., Duivenvoorden, H. J., Staal, H. A., & Pool, J. (1989). Physical training and relaxation therapy in cardiac rehabilitation assessed through a composite criterion for training outcome. American heart journal, 118(3), 545-552.
- Ford, M. J., Camilleri, M. J., Hanson, R. B., Wiste, J. A., & Joyner, M. J. (1995). Hyperventilation, central autonomic control, and colonic tone in humans. Gut, 37(4), 499-504.
- Pandolfino, J. E., Kim, H., Ghosh, S. K., Clarke, J. O., Zhang, Q., & Kahrilas, P. J. (2007). High-resolution manometry of the EGJ: an analysis of crural diaphragm function in GERD. The American journal of gastroenterology, 102(5), 1056-1063.
- Smejkal, M., Bitnar, P., Dolina, J., Sulc, J., Tvrdon, J., Pazdro, A., … & Kolar, P. (2010). The importance of the diaphragm in the etiology and the possibility of its use in the treatment of Gerd. Diseases of the Esophagus, 23, 31A.
- Villoria, A., Azpiroz, F., Burri, E., Cisternas, D., Soldevilla, A., & Malagelada, J. R. (2011). Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension. The American journal of gastroenterology, 106(5), 815-819
- Hegde, S. V., Adhikari, P., Subbalakshmi, N. K., Nandini, M., Rao, G. M., & D’Souza, V. (2012). Diaphragmatic breathing exercise as a therapeutic intervention for control of oxidative stress in type 2 diabetes mellitus. Complementary therapies in clinical practice, 18(3), 151-153.
- Martarelli, D., Cocchioni, M., Scuri, S., & Pompei, P. (2011). Diaphragmatic breathing reduces postprandial oxidative stress. The Journal of Alternative and Complementary Medicine, 17(7), 623-628
- Archiza, B., Andaku, D. K., Caruso, F. C. R., Bonjorno Jr, J. C., Oliveira, C. R. D., Ricci, P. A., … & Arena, R. (2017). Effects of inspiratory muscle training in professional women football players: a randomized sham-controlled trial. Journal of Sports Sciences, 1-10.
- Edwards, A. M., Maguire, G. P., Graham, D., Boland, V., & Richardson, G. (2012). Four weeks of inspiratory muscle training improves self-paced walking performance in overweight and obese adults: a randomised controlled trial. Journal of obesity, 2012.
- Enright SJ, Unnithan VB. Effect of Inspiratory Muscle Training Intensities on Pulmonary Function and Work Capacity in People Who Are Healthy: A Randomized Controlled Trial. Phys Ther. 2011 Jun;91(6):894–905. PubMed #21493747.
- Harms, C. A., Wetter, T. J., St. Croix, C. M., Pegelow, D. F., & Dempsey, J. A. (2000). Effects of respiratory muscle work on exercise performance. Journal of applied physiology, 89(1), 131-138.
- Romer, L. M., McConnell, A. K., & Jones, D. A. (2002). Inspiratory muscle fatigue in trained cyclists: effects of inspiratory muscle training. Medicine & Science in Sports & Exercise, 34(5), 785-792
- Tong, T. K., McConnell, A. K., Lin, H., Nie, J., Zhang, H., & Wang, J. (2016). “Functional” Inspiratory and Core Muscle Training Enhances Running Performance and Economy. The Journal of Strength & Conditioning Research, 30(10), 2942-2951.
- Volianitis, S., McConnell, A. K., Koutedakis, Y., McNaughton, L. R., Backx, K., & Jones, D. A. (2001). Inspiratory muscle training improves rowing performance. Medicine & Science in Sports & Exercise, 33(5): 803-809