Breathing and pain


Why would breathing have anything to do with musculoskeletal injuries and pain? Most people simply know we need to breathe to stay alive. However, our breathing can have a much greater impact on the quality of our lives besides just survival. Our bodies can automatically regulate our breathing patterns so it is quite easy to not pay attention to it. Breathing can have major implications on our health and wellbeing, so it is worth putting it under the spotlight. In fact, breathing can affect your psychological state, biochemical state, neurological state, and biomechanical state. Essentially, breathing is at the core of our very being. Breathing provides us with oxygen, which fuels the processes in our body that give us energy.
Ideally, the act of breathing itself should not take much energy. However for many individuals, their breathing is extremely energy cost inefficient. The average healthy adult takes 12-20 breaths per minute, which is 17,280-28,800 breaths per day! So if an individual is breathing incorrectly, they are reinforcing a dysfunctional movement pattern over 17,000 a day. With that in mind, let’s learn about the basics and clean up that form!
The main muscle of respiration is the diaphragm. It is a flat muscle that connects to the bottom of our rib cage as seen in the pictures below. When you breathe in, the muscle pulls down, which allows your lungs to fill up with air.  When you exhale, the muscle relaxes by rising toward your neck, pushing the air out of your lungs. Using your diaphragm to breathe is the most efficient form of breathing. This is because it takes no energy for the diaphragm to push the air out of your lungs. Instead, it uses elastic recoil. Think of the muscle as a rubber band. When you breathe in you are stretching the rubber band down, and when you breathe out you are simply letting the rubber snap back to its original size. This allows you to only have to use energy to breath in, and not out. It is a ‘buy one get one free’ deal that is always available to you.

Unfortunately, many people do not take advantage of this deal. Instead, they fall into a poor pattern of breathing that results in using accessory muscles of breathing in the upper chest and neck instead of the diaphragm. Accessory muscles of breathing function to as a “backup” when you need to breathe quicker and deeper, such as when you are exercising. However, the main function of these muscles is not for breathing, so they have poor muscular endurance making their use very cost inefficient. So those that use primarily accessory muscles to breathe instead of diaphragm are essentially paying 2-3x more energy, like paying for a bottle of water at Wrigley Field. If accessory muscles are used to breathe 17,280-28,800 breaths per day, they are going to get dysfunctional and painful. In addition, your body will not be getting as oxygen.

Healthy Breathing (picture above)
Inhalation: Belly expands, chest doesn’t move
Exhalation: Belly pulls in
Abnormal Breathing
Inhalation: Belly pulls in, upper chest expands
Exhalation: Belly expands
Reasons for Starting Poor Breathing

  1. Sucking gut in – cultural postural habit
  2. Anxiety and/or emotional Stress
  3. Expectation of Pain
  4. Poor breathing technique when exercising
  5. Prolonged Sitting with Slumped Posture – diaphragmatic breathing mechanically difficult

Importance of Proper Breathing for Core Stability
The human body has a few major deep core muscles that contribute to stability and postural control of the body. They do this in part by pushing air/abdominal contents inward, which increases the amount of pressure in the abdomen. Increased pressure in the abdomen creates stability in the core. Think of this concept as an unopened can of soda vs. an open/empty can of soda. If you were to step on top of an unopened can of soda filled with air and drink, it would not be crushed. However if you were to stand on top of an empty can of soda, the air in the can would fly out and the can would crush into a pancake. The diaphragm plays a crucial part in this as it acts as the top of the soda can, which pushes air downward as seen in the figures below.

Symptoms of Breathing Pattern Disorders

  • Dizziness
  • Chest pain
  • Altered vision
  • Panic attacks
  • Nausea
  • Reflux
  • General fatigue
  • Hyperventilation


  • Concentration difficulties
  • Neurological/psychological/gastro-intestinal and musculoskeletal changes
  • Dyspnea with normal lung function
  • Deep sighing
  • Exercise induced breathlessness
  • Frequent yawning


Evidence for Breathing Disorders and Back Pain
Back pain tends to be complex and have many contributing factors, and breathing can be a factor for many individuals. There have been many studies that have established correlations between those with breathing dysfunction and back pain. Studies performed by Jansenns et al in 20131 and 20152 found that those with lower back pain had poor diaphragm muscle endurance, and also that training inspiratory muscles such as the diaphragm resulted in reduction in pain and increased postural control. This shows us evidence that if we train our diaphragm and ability to use it more frequently, that the stability in our bodies increases and pain can decrease.
Aside from the mechanical support proper breathing provides the spine, other aspects of breathing disorders have been supported by evidence for causes of low back pain. When one is not breathing properly, the amount of oxygen (what we breathe in) and carbon dioxide (what we breathe out) is not balanced. Research shows that even 60 seconds of increased carbon dioxide in the body can result in decreased endurance of the diaphragm (Hodges et al3). In addition, the research also shows those who hyperventilate (breathe too much too fast) can experience muscle aching, restlessness, and increased sympathetic nerve activity (Nixon et al4).
Poor breathing habits can contribute to low back pain through our psychological state as well. Poor breathing increases anxiety, and anxiety increases poor breathing. Anxious thoughts alone have shown to increase muscle activity in a negative manner (Lotze et al5). A study used MRI imaging and found that even talking about painful experiences increased muscle activity in individuals with low back pain. Too much muscle activity can be a cause for low back pain. Lastly, another study showed that anxious thoughts can trigger the body to recruit only specific muscle fibers, which can become severely overused because the entirety of the muscle is not being worked. This leads to trigger points and pain, which most people have experienced as muscle “knots” at some point in their lifetime (Simon et al6).
So what can we do to work on it?
There are many ways to work on the muscles of respiration, but we will discuss a very basic exercise you can perform anywhere you are. As mentioned earlier in the article, when properly using the diaphragm to breathe, our belly’s expand while our chest does not. We can monitor this with some simple cues. Follow the directions below:

  1. Lay on your back with your knees bent and feet flat on the ground as shown in the picture
  2. Place one hand over your belly button and place one hand on your chest over your sternum
  3. Inhale slowly through your nose and try to have the hand on your belly rise, while the hand on your sternum stay in the same exact place
  4. Exhale slowly through your mouth, with your lips puckered as if you were blowing out a candle. Let the hand on your belly fall, while the hand on your chest to remain motionless

As you improve your ability to perform this breathing exercise, you can progress it by completing it in various positions such as in sitting and standing.

  1. Janssens L, Brumagne S, McConnell AK, Hermans G, Troosters T, Gayan-Ramirez G.

Greater diaphragm fatigability in patients with recurrent low back pain. Respir
Physiol Neurobiol 2013a;188(2):119e23.

  1. Janssens L, McConnell AK, Pijnenburg M, Claeys K, Goossens N, Lysens R, et al.

Inspiratory muscle training affects proprioceptive use and low back pain.
Med Sci Sports Exerc 2015;47(1):12e9.

  1. Hodges P, Heinjnen I, Gandevia S. Postural activity of the diaphragm isreduced in humans when respiratory demand increases. Journal of Physiology. 2001;537(3):999-1008
  2. Nixon P, Andrews J. Astudy of anaerobic threshold in chronic fatigue syndrome (CFS). Biological Psychology. 1996;43(3):264.
  3. Lotze M, Montoya P, Erb M et al. Activation of cortical and cerebellar motor areas during executed and imagined hand movements: an fMRI study. Journal of Cognitive Neuroscience. 1999;11:491-501.
  4. Simons D, Travell J, Simons L. Myofascial pain and dysfunction: the trigger point manual, Vol 1, upper half of body. 2nd ed.Baltimore: Williams and Wilkins; 1999.
  5. “Low Back Pain and Breathing Pattern Disorders.” Physiopedia,
  6. Michelle D. Smith et al., “Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity”, Australian Journal of Physiotherapy, vol 52:1, pag 11 – 16. (level of evidence: 2B)
  7. Chaitow, L. Breathing pattern disorders, motor control, and low back pain. Journal of Osteopathic Medicine, 2004; 7(1): 34-41
  8. Roussel et al., “Altered breathing patterns during lumbopelvic motor control tests in chronic low back pain: a case–control study”, European Spine Journal, 2009, 18.7: 1066-1073. (level of evidence: 3B)
  9. Yuri Elkaim. “How to Do Belly Breathing Like a Pro.” Yuri Elkaim,, 26 Sept. 2018,
  10. Shiels, Beth. “The Diaphragm: It Does More Than We Think – Breathing & Core Stability!” Elite Sport & Spine, 9 Nov. 2018,
  11. Bengoa, Miguel. “Pilates Principles #2: Deep Core Activation.” Birmingham Pilates Studios, 21 Feb. 2019,
  12. “Breathing. Movement of Ribcage during Inspiration and Expiration. Diaphragm Functions. Enlarging the Cavity Creates Suction That Draws Air into the Lungs. Illustration for Medical, and Educational Use.” Breathing Movement Ribcage During Inspiration Expiration Stock Vector (Royalty Free) 1301643043,
  13. Gfycat. “Best Diaphragm Breathing GIFs: Find the Top GIF on Gfycat.” Gfycat, breathing.