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Does the way you're breathing affect your back and neck pain?

It goes without saying that breathing is an essential process for human beings. We take in oxygen and expel carbon dioxide 12-20 times per minute even when resting. Most of us hardly put any thought into how we breathe as it is an automatic, subconscious process. But how we breathe is important for reasons that go beyond the obvious.

Because it is an unconscious process this means that altered breathing patterns also go unnoticed. Those with abnormal breathing patterns may report headaches, dizziness, cramps, chest pains or have more subtle symptoms such as frequent sighing or yawning, fatigue, chronic neck/shoulder pain and even low back pain.

Why is proper breathing important?

Breathing plays an important role in the autonomic nervous system which controls much of the subconscious processes. Respiration increases with physical, emotional or chemical stress and returns to normal naturally. However, this high rate of breathing can become the more prevalent breathing pattern even at rest leading to increased stress. This is why many relaxation techniques incorporate breathing as they are closely linked.

This makes training new breathing patterns difficult as they have been subconsciously ingrained. However, like exercise and rehabilitation deliberate training in breathing will be rewarded with improved pain and function.

Respiration also plays an important role in spinal stability. The reason for this is due to an important muscle called the diaphragm. The diaphragm primarily works to contract and relax as we breathe to allow the lungs to fill with air. This muscle also works along with other core muscles to stabilize the spine by increasing abdominal pressure.

Fig 1. Notice the diaphragm, along with the core and pelvic floor, encloses the abdomen. When these muscles contract in unison they increase intraabdominal pressure which braces the core, providing stability.

What happens when breathing mechanics are altered?

Faulty breathing patterns can cause neck pain or stiffness. Chest breathing can perpetuate forward head posture. In these cases, the upper chest will move forward instead of widening in all directions. This often occurs because of the over-activity of scalenes, traps, and levator scapulae muscles.

Altered breathing mechanics can lead to low back pain or risk of injury due to the lack of core stability.

Shallow, short breathing will often increase the breathing rate. This can increase stress or cause other physiological responses such as altered blood pH. Respiration can also alter heart rate affecting circulation and blood pressure among other involuntary systems.

In some cases, paradoxical breathing can occur in which the abdomen is drawn in during inhalation and out during exhalation. In most cases, it is not this obvious however chest movement is greater than the abdominal movement and there is no expansion of the lower ribs.

Why can breathing patterns become altered?

· Mechanical factors: includes posture, past injury and/or pain.

· Psychosocial factors: Such as anxiety, stress, anger, and depression.

· Physiological factors: including blood pH, allergens, kidney function, poor diet, etc.

What does “normal” breathing look like?

With relaxed breathing, both inspiration and expiration should occur through the nose. The ribs should expand in all directions and the breath should be initiated from the abdomen (belly breath).

Recruitment of accessories muscles and movement in the upper chest is normal with increased demands. However, this pattern is not considered normal with resting breathing.

Primary muscles involved in breathing:

· Diaphragm

· Intercostal muscles

· Scalenes

· Transverse abdominus

· Muscles of the pelvic floor

· Intrinsic muscles of the spine

When demand increases secondary muscled may become involved including:


· Upper trapezius

· Serratus anterior

· Latimssimus dorsi

· Abdominals

Fig 2. As you can see there are many muscles involved in this process. In order to inhale and exhale there must be coordinated effort for these muscles to contract and relax. If one muscle is not functioning properly, others will compensate, causing altered patterns.

How to train proper breathing

It is first important to become aware of any altered breathing mechanics. This can be done by lying on your back with the knees bent. Place one hand on the chest and the other on the abdomen. Simply pay attention to what moves first. You should notice the belly initiate the breath by expanding during inhalation.

Next place your hands on either side of the lower ribs. You should notice the lower ribs move outward laterally during inhalation.

You may notice you have difficulty with one or both movements. You may also notice that you are able to complete these motions when you are consciously breathing but throughout the day are not breathing in this manner. If this is the case it is important to start training.

Key points when training

· Practice in a relaxing environment. It is important not to feel rushed or stressed.

· Focus on steady normal breathing as opposed to deep exaggerated breaths.

· Low and slow. Think of the breath originating from deep in the abdomen.

· Focus on exhalation and gradually increasing the length of each exhale.

How to improve breathing mechanics

1. Become aware of how your normal breathing pattern. Notice if your chest elevates with each breath. Complete the tests mentioned above to identify where you have faulty mechanics.

2. Focus first on the exhalation process. When you breathe out, notice your abdomen move inward. During diaphragmatic breathing, the abdominals should remain relaxed. DO NOT think about pushing the air out and pulling it in using the with the abs. Allowing for the full exhalation allows for a deeper inhalation to follow.

3. Facilitate the diaphragm. Place one hand behind the back and one just below the sternum. As you exhale relax the pressure. When you inhale apply slight pressure, so you are breathing in against some resistance.

4. Facilitate outward motion of the ribs. Place the hands on the outside of the lower ribs. As you exhale relax the pressure. When you inhale apply slight pressure, so you are breathing in against some resistance.

5. Lengthen the exhalation. With these techniques, the goal is to lengthen the exhale 7-8 seconds with an inhale of 2-3 seconds.

6. Introduce bracing and movements. Once you can complete these steps it is important to practice these patterns with more challenging activities. This requires you to be able to breathe appropriately with an abdominal brace or when challenged aerobically.

If you are still struggling with these patterns here are some further tips:

· Place our hands over your head. This may make it easier to relax the upper chest.

· Try these exercises in the prone position (lying on the stomach). This will help limit chest movement.

· Purse the lips when exhaling to create slight resistance. This will help slow the respiratory rate. This will require you to breath out of the mouth.

· If needed push into the floor or squeeze a ball.

When abnormal breathing patterns are identified it is important to train the new patterns daily. When fatigued or stressed it is common to resort back to the inefficient patterns. Complete this low and slow breathing technique twice a day for 10-20 breaths.

Check-in a few times a day (shoot for every hour) and if you notice you have resorted back to old patterns complete 2 low and slow breaths.

It will take time to learn these new habits. However, by becoming aware of faulty patterns and practicing new ones you may start to see less tension, or stress, decreased pain, and improved energy throughout the day.

Below is a video summarizing the assessment process and corrective exercises.


Chapman EB, Hansen-Honeycutt J, Nasypany A, Baker RT, May J. A clinical guide to the assessment and treatment of breathing pattern disorders in the physically active: Part 1. International journal of sports physical therapy. 2016 Oct;11(5):803.

Hansen-Honeycutt J, Chapman EB, Nasypany A, Baker RT, May J. A clinical guide to the assessment and treatment of breathing pattern disorders in the physically active: part 2, a case series. International journal of sports physical therapy. 2016 Dec;11(6):971.

Liebenson C, editor. Rehabilitation of the spine: a practitioner's manual. Lippincott Williams & Wilkins; 2007.

Bertelsman T. The Role of the Diaphragm [Internet]. 2016 Nov 13 [cited 2020 Apr 21]. In: Available from:

Physiopedia. Muscles of respiration [Image on internet]. [cited 2020 Apr 21]. Available from:


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