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Effects of Diaphragmatic Breathing Patterns on Balance: A Preliminary

Clinical Trial

Article  in  Journal of manipulative and physiological therapeutics · March 2017

DOI: 10.1016/j.jmpt.2017.01.005

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Effects of Diaphragmatic Breathing Patterns
on Balance: A Preliminary Clinical Trial
Rylee J. Stephens, DC, a Mitchell Haas, DC, b William L. Moore III, DC, a Jordan R. Emmil, DC, a
Jayson A. Sipress, DC, a and Alex Williams, DC a

ABSTRACT

Objective: The purpose of this study was to determine the feasibility of performing a larger study to determine if
training in diaphragmatic breathing influences static and dynamic balance.
Methods: A group of 13 healthy persons (8 men, 5 women), who were staff, faculty, or students at the University of
Western States participated in an 8-week breathing and balance study using an uncontrolled clinical trial design.
Participants were given a series of breathing exercises to perform weekly in the clinic and at home. Balance and breathing
were assessed at the weekly clinic sessions. Breathing was evaluated with Liebenson’s breathing assessment, static balance
with the Modified Balance Error Scoring System, and dynamic balance with OptoGait’s March in Place protocol.
Results: Improvement was noted in mean diaphragmatic breathing scores (1.3 to 2.6, P b .001), number of single-leg
stance balance errors (7.1 to 3.8, P = .001), and tandem stance balance errors (3.2 to 0.9, P = .039). A decreasing
error rate in single-leg stance was associated with improvement in breathing score within participants over the 8 weeks
of the study (–1.4 errors/unit breathing score change, P b .001). Tandem stance performance did not reach statistical
significance (–0.5 error/unit change, P = .118). Dynamic balance was insensitive to balance change, being error free
for all participants throughout the study.
Conclusion: This proof-of-concept study indicated that promotion of a costal-diaphragmatic breathing pattern may
be associated with improvement in balance and suggests that a study of this phenomenon using an experimental design
is feasible. (J Manipulative Physiol Ther 2017;40:169-175)
Key Indexing Terms: Diaphragm; Respiration; Postural Balance; Exercise; Breathing Exercises

INTRODUCTION spine help maintain intra-abdominal pressure. 12 The diaphragm

Core strength and stability have become central topics in
both injury prevention and physical performance. Core
stability is dependent on the strength, coordination, and
adaptability of the core musculature 1,2 and is necessary for
efficient biomechanical function throughout the kinetic
chain. 3 Increasing core stability has been reported to improve
static and dynamic balance. 4-8 Poor scores on balance tests
have been directly linked to increased injury rates in a healthy
athletic population. 9,10
The diaphragm has been hypothesized to be a respiratory
muscle with postural function. 11 Its attachments to the lumbar
a
Exercise and Sports Science Department, University of
Western States, Portland, OR.
b
Center for Outcomes Studies, University of Western States,
Portland, OR.
Corresponding author: Rylee J. Stephens, DC, MSc, PO Box
683, Garibaldi Highlands, BC V0N1T0, Canada.
(e-mail: ryleejstephens@gmail.com).
Paper submitted July 20, 2016; in revised form November 30,
2016; accepted January 13, 2017.
0161-4754
Copyright © 2017 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2017.01.005
has been found to contract prior to initiation of upper extremity
movement, 12,13 independently of the phase of respiration. 14
Kolar et al used magnetic resonance imaging to demonstrate
that the diaphragm may not function as one cohesive unit.
Increased muscle firing was seen through the middle and
posterior aspects of the diaphragm with isometric extremity
loading. 12 Hodges et al reported that as respiratory demands
increased, the postural function of the diaphragm decreased. 15
Breathing biomechanics have been described with respect
to expansion of the abdominothoracic region during inspiration
at rest. Apical or upper costal breathing occurs when superior
thoracic expansion exceeds the abdominal and lateral costal
expansion. Costodiaphragmatic breathing is observed when
the abdominal and lateral costal expansion is predominant over
the superior thoracic expansion. Electromyography studies
indicate that diaphragm firing patterns differ in apical (chest)
breathers versus diaphragmatic breathers. 16 Although data are
still limited, trends are emerging throughout clinical rehabili-
tation suggesting that a pattern of diaphragmatic breathing may
be beneficial for core stability, posture, upper thoracic
hypertonicity, 16 and decreasing incidence of low back
pain. 17,18 However, a thorough literature review revealed no
empirical link between diaphragmatic breathing and balance.
170 Stephens et al
Effect of Breathing Type on Balance
The purpose of this preliminary study is to explore the
feasibility of performing a study to measure a potential link
between breathing patterns and balance. We had 2 hypotheses:
(1) breathing exercises that promote increased costodiaphrag-
matic movement and decrease upper thoracic movement alter
breathing patterns to be more diaphragmatic in nature; and
(2) as breathing biomechanics become more diaphragmatic in
nature, balance will increase correspondingly.
METHODS
Design
This study was a prospective clinical trial using 1 cohort
without control. The study was conducted in Portland,
Oregon, between April and June 2015.
Participants
Participants were recruited from the students, staff, and
faculty at the University of Western States. The assessors in
this study were four doctor of chiropractic students who
were also enrolled in the Master of Sports Science program.
Assessors were in their final year of both programs.
Participants were included if they were at least 21 years
old, literate in English, ambulatory, and willing to attend 8
visits and complete the prescribed breathing exercises.
Participants were excluded if they had a current or previous
diagnosis of attention deficit disorder or attention deficit
hyperactivity disorder, vascular disease, central nervous
system disorder, benign paroxysmal positional vertigo,
cancer, posttraumatic stress disorder, anxiety, depression,
chronic pain, hypertension, congestive heart failure, or spinal
stenosis. Participants who had had a concussion or brain
injury in the previous year or a lower body injury or ear
infection that required treatment in the past month or who
were currently or trying to become pregnant were excluded.
All participants had to confirm that they could perform the
breathing assessment pain free and were not participating in
any other balance-specific training. Participants’ blood
pressure and pulse were taken prior to initiating exercise to
screen for any underlying cardiovascular risk factors.
This study was reviewed and approved by University of
Western States institutional review board. Informed consent
was given by all participants prior to participation in the study.
Outcome Measurements
Breathing and balance assessments were conducted
before each breathing-exercise training session for 8
weeks. To improve the reliability of scoring, all assessments
were scripted and performed by the same evaluator every
week for each of the participants. The dynamic balance was
measured by a computer, but the instructions to participants
were read from a script by the same assessor every week.
The following assessments were made:
Journal of Manipulative and Physiological Therapeutics
March/April 2017
Static Balance Assessment. The Modified Balance Error
Scoring System (SCAT3: Sport Concussion Assessment
Tool, 3rd ed) is a standardized, objective test used to assess
balance and postural stability following head trauma. 19,20
The Balance Error Scoring System has been reported to
have good to excellent interrater and test-retest reliability
for the evaluation of healthy young adults 21 and some
evidence of criterion validity in young healthy athletes. 22
Subjects performed the test wearing shorts or pants
rolled up and with shoes removed. Assessors provided
scripted instructions as each subject performed a single trial
of a double-leg stance (DLS), single-leg stance (SLS), and
tandem stance (TS). For the SLS, participants stood on their
nondominant foot. For the TS, the nondominant foot was in
the front. Each trial was performed, with subjects’ eyes
closed, for 20 seconds while the examiner counted the
number of errors. Types of errors included hands lifting off
iliac crests; eyes opening; a step, stumble, or fall; moving
the hip into more than 30° abduction; lifting forefoot or
heel; and remaining out of the test position longer than 5
seconds. Scores for each test were calculated as the number
of errors. If a participant committed multiple errors
simultaneously, only 1 error was recorded. 23 Participants
were told to reset and start again if they lost their balance.
Scores were generated by the same assessor for all
participants each week in an attempt to improve reliability.
Dynamic Balance Assessment. This was assessed using
OptoGait’s March in Place protocol (MicroGait Corp,
Mahopac, NY). 24 By marching in place, the body is
performing a dynamic movement in which balance is needed
to provide a base of support. OptoGait’s software measures
flight and contact time on the left and right sides. OptoGait
states that as balance improves, contact time and the
percentage difference between right and left contact times
will decrease.
Participants were asked to stand between the OptoGait’s
sensors with shoes off facing the assessor. They were read a
script asking them to “march in place with a purpose, quickly,
but comfortably, for 40 seconds.” They were instructed to try
and get their knees to 90° and that they would be doing this
2 times, the first time with their eyes open and the second time
with their eyes closed. In the event that the participant
marched out of the testing area, the test was redone
immediately. 25 This protocol has not yet been reported to
be a valid measurement of dynamic balance.
Breathing Assessment. This test was taken from a full-body
assessment of functional movement by Leibenson. 17 It was
used in this study as a marker to monitor response to training
for conversion from apical to diaphragmatic breathing.
Breathing assessment (BA) has not been assessed for
reliability but has face validity in that the mechanics that
distinguish breathing styles can be observed.
Participants were asked to lay on their backs in the 90/90/
90 position (hips and knees 90° flexed with feet dorsiflexed).
Their legs were supported by the assessor while their anterior
Journal of Manipulative and Physiological Therapeutics
Volume 40, Number 3
inferior rib cage was brought into a caudal position, supporting
their thoracolumbar junction. They were asked to maintain that
position while breathing predominantly with their diaphragm.
They were cued to “fill” their inferior abdomen and posterior
chest wall. Palpatory cues were used by the assessor.
Participants were then asked to support their legs in the 90/
90/90 position while the assessor released support. Breathing
score were based on the patient’s ability to maintain breathing
biomechanics and posture after their legs had been released.
Scores ranged from 0 to 3, where 0 indicates the
participant is having pain performing the test (and will no
longer be eligible to participate in this study); 1 indicates the
participant is not able to complete the exercise with proper
form; 2 indicates the participant is able to complete the
exercise but with compensation; and 3 indicates the
participant is able to complete the exercise with proper form.
Participants scored a 1 if they had paradoxical respiration
(chest moving inward with inspiration), were unable to
stabilize their ribs when cued, or were unable to stabilize their
ribs when released. Participants scored a 2 if they had chest
breathing predominately on inhalation or a lower rib cage that
did not widen laterally, or if release of their legs caused
anterior inferior rib cage flair. This scale has not been tested
for reliability, validity, or sensitivity to change.
Participant Monitoring. Participants were asked to report
on their activity levels in the 6 months prior to initiating
the study, as well as their physical activity outside of the
study while completing the breathing exercises. Participants
completed daily homework logs and returned them at the end
of the 8 weeks to confirm they had completed the required
exercises. In the final interview, participants were also asked
to give their subjective impressions of the benefits of the
program on their physical activities.
Intervention
Participants were assigned 2 exercises a week. They were
asked to complete each breathing exercise for 5 minutes, twice
daily, for a total of 20 minutes a day at least 5 days per week.
Instruction and feedback were given to participants on
assessment days. A YouTube video of their prescribed
exercises was emailed to them weekly. All exercises were
prescribed in a sequential order and were dependent on the
patient's ability to maintain proper form. All participants
started at progression 1. They were asked to record their
homework in a provided log. Participants were instructed to
do exercises for only as long as they could maintain proper
posture. If they were not able to hold the posture for the full
5 minutes, they were instructed to take breaks and work up to
the 5 minutes.
Five exercise progressions were designed for the purposes
of this study: progression 1: supine breathing and crocodile
breathing; progression 2: supine breathing with Theraband
(The Hygenic Corp, Akron, OH) and crocodile breathing
with Theraband; progression 3: supine breathing with belt
Stephens et al 171
Effect of Breathing Type on Balance
and crocodile breathing; progression 4: seated breathing and
90/90/90 breathing; progression 5: Seated breathing with
Theraband and 90/90/90 breathing with belt.
Supine Breathing. Patients were instructed to lay supine,
knees bent with arms wherever it felt comfortable. They were
cued to focus on breathing with their diaphragm, the breath
filling into their lower abdomen and posterior chest wall. They
were cued to keep their ribs depressed and thoracolumbar
junction supported and to keep their shoulders and neck relaxed.
Crocodile Breathing. Patients were instructed to lay prone
with their hands in a diamond shape supporting their
forehead. They were cued to try and focus on pushing their
ribs out laterally and trying to breathe all the way down to the
sacrum. During meetings, pressure was added to their sacrum
by the examiner, with permission, to help cue this.
Seated Breathing. Participants were seated on a hard
surface with their knees, hip, and ankles all at 90°. They were
told to sit tall, as if a “string was pulling them up from the top
of their head,” while maintaining all previously discussed
breathing cues: preventing lower rib flair, breathing deeply,
and relaxing their shoulders, neck and arms.
90/90/90 Breathing. Participants were returned to the 90/90/
90 assessment position, but were asked to hold their legs
while maintaining all previously discussed breathing cues:
controlling their ribs and thoracolumbar junction, breathing
deeply and relaxing their shoulders, neck, and arms.
Breathing With Theraband. A Theraband was added around
the lower ribs to help promote lateral excursion. It was applied
to progress supine, crocodile, or seated breathing exercises.
Breathing With Belt. A Theraband was laid flat on the
ground to look like a belt. It was added in the final exercise
progression to help cue caudal rib position. With all the cues
from previous exercises, a Theraband or belt was placed
under the patient’s thoracolumbar junction. The patient was
instructed to not let the examiner pull the belt away. At home,
patients were instructed to tie the Theraband around a table or
chair and leave tension in it to simulate the effect of pulling.
Statistical Analysis
The primary analysis consisted of Friedman’s analysis of
variance for nonparametric repeated-measures data to test
whether there were any differences between scores over the
8 weeks of the study. The analysis was conducted separately
for breathing assessment, SLS, and TS scores only. This was
because no errors were recorded for any baseline or follow-up
data for the DLS, and equipment failure was suspected for the
dynamic balance measurements. A nonparametric analysis
was chosen to avoid distribution concerns in smaller samples.
In a secondary analysis, the linear relationship between the
3 variables and time was determined by regression of each of
the variables on time, using generalized estimating equations
(with an exchangeable correlation structure) to account
for correlation of variables within subjects. The 2 balance
variables were then regressed on the breathing score using
172 Stephens et al Journal of Manipulative and Physiological Therapeutics
Effect of Breathing Type on Balance March/April 2017

Table 1. Demographics (N = 14) Table 2. Breathing and Balance Scores a

a
Variable Mean (SD) Week Breathing Test Single-Leg Stance Tandem Stance
Females, n (%) 6 (42.8%) 1 1.3 (0.5) 7.1 (2.9) 3.2 (2.7)
Age 33 (7.5) 1.0 [1] 7.0 (4) 3.0 [5]
Height, cm, mean (SD) 172 (10) 2 1.2 (0.4) 6.3 (2.4) 2.3 (2.4)
Weight (lb) 167 (39) 1.0 [1] 7.0 [4] 2.0 [4]
Body mass index (kg/m2) 25.2 (4.7) 3 1.6 (0.5) 6.2 (2.9) 1.8 (2.5)
Systolic blood pressure (mm Hg) 123 (12) 2.0 [1] 6.0 [5] 1.0 [3]
Diastolic blood pressure (mm Hg) 73 (8) 4 1.9 (0.4) 5.4 (3.6) 1.6 (2.3)
Resting heart rate (beats/min) 64 (10) 2.0 [0] 5.0 [4] 1.0 [3]
a 5 2.1 (0.5) 5.1 (3.5) 2.5 (2.4)
Values are expressed as the mean (SD) unless otherwise noted.
2.0 [0] 5.0 [5] 3.0 [5]
6 2.2 (0.4) 4.2 (2.6) 2.0 (2.6)
2.0 [0] 4.0 [5] 1.0 [4]
generalized estimating equations to assess the overall linear 7 2.1 (0.3) 4.2 (2.9) 2.2 (2.6)
association between balance and breathing over the 8 weeks 2.0 [0] 4.0 [6] 1.0 [5]
of the study. The correlation between balance and breathing 8 2.5 (0.5) 3.8 (2.1) 0.9 (1.1)
scores at each time point was computed using Spearman’s 2.0 [1] 4.0 [4] 0.0 [2]
P b .001 P = .001 P = .039
rank-order correlation coefficient.
a
This study could detect a large effect size (f = .40) in the All scores are for pre-intervention evaluation at baseline (week 1)
primary analysis with 80% power at the .05 level of and follow-up (weeks 2-8). The mean (SD) and median [interquartile range]
are presented for each time point. Friedman’s analysis of variance was used
significance. 26 In the secondary analysis, the study had the to determine if there were any statistically significant differences between
same power to detect a linear effect of 0.01 breath-scale points time points.
per week, 0.20 error in balance per week, and 0.85 error in
balance per breath-scale point. Because this was a preliminary
study, all tests were conducted using the .05 level of error per week for the SLS (P b .001), and B = –0.18 error per
significance without correction for multiple tests. All analysis week for the TS (P = .089).
was performed using SPSS Version 23 (IBM, Armonk, NY). There was generally poor correlation between balance and
breathing scores with Spearman’s ρ b 0.2 at most time points
as seen in Table 3. None of the correlations was statistically
significant. On the other hand, the regression analysis
RESULTS revealed a statistically significant relationship between
A total of 15 persons were screened for this study. One decreasing error rate in SLS and improvement in breathing
was ineligible because of a history of cancer; 1 dropped out score, B = –1.4 errors per unit improvement (P b .001). This
after the first visit because of scheduling difficulties related to coupled with the poor correlation across persons at individual
a job change. The remaining 13 participants completed the time points suggests that an improvement in SLS perfor-
full 8-week intervention and assessment. There were no mance is associated with improvement in the breathing test
missing data. No notable change was observed in physical within participants over time (and more treatment). The trend
activity in terms of frequency, duration, intensity, or type of for the TS was smaller in magnitude and did not reach
sport outside of the study for any of the participants. statistical significance (B = –0.5 P = .118).
Participants did not participate in any balance-specific
training outside the study during the 8-week intervention.
Participants had a mean age of 33 years and were close to
evenly balanced across sex (Table 1). They had a mean body DISCUSSION
mass index of 25.2, but the high number was attributable to This preliminary study was the first to investigate the
athletic physique. No participant’s blood pressure was above relationship between breathing training and balance. We
130 mm Hg systolic and 80 mm Hg diastolic. observed a shift from apical to diaphragmatic breathing as
Table 2 lists the means and standard deviations as well as treatment progressed (Table 2). This suggests the possibility
the medians and interquartile ranges for breath and balance that a change in breathing pattern can be engendered by the
scores evaluated each week for 8 weeks. All 3 scores exhibited conscious muscle recruitment in the prescribed exercises.
change over the course of the study as evidenced by statistically Concomitant time trends of shifts in breathing patterns and
significant differences among time points: breathing type improvement in balance also suggest the possibility of a
(P b .001), SLS (P = .001), and TS (P = .039). Trends toward relationship between breathing training and balance (Table 2,
improvement over time are also illustrated in Figures 1 and 2. Fig 1).
The regression coefficients (B) quantifying the linear Training of respiratory muscles has been reported to
association between the variables and time were B = 0.06 increase diaphragm and low back musculature proprioception,
point per week for the breathing test (P b .001), B = –0.48 muscle firing, 23,27 and respiratory muscle strength. 28,29 A
Journal of Manipulative and Physiological Therapeutics Stephens et al 173
Volume 40, Number 3 Effect of Breathing Type on Balance

7.5 2.6

Mean Single Leg Stance Errors

7 2.4

Mean Breathing Scores

6.5 2.2

6 2

5.5 1.8

5 1.6

4.5 1.4

4 1.2

3.5 1
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8

Mean Single Leg Stance Balance Errors Mean Breathing Score (0-3)

Fig 1. Mean single-leg stance errors versus mean breathing scores over 8-week breathing intervention.

3.5 2.6
Mean Tandem Stance Balance Errors

2.4
3

Mean Breathing Scores

2.2
2.5
2

2 1.8

1.6
1.5
1.4
1
1.2

0.5 1
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8

Mean Tandem Stance Balance Errors Mean Breathing Score (0-3)

Fig 2. Mean tandem stance errors versus mean breathing scores over 8-week breathing intervention.

diaphragmatic breathing style suggests increased movement
through the lateral inferior ribs and abdomen. 16 As there is
likely increased movement in the deep abdominal muscula-
ture, it is reasonable to assume that there is also increased
muscle firing and proprioception of the deep core musculature
and diaphragm. Furthermore, it is not unlikely that increased
strength would have resulted from increased muscle firing
over an 8-week period.
The improvement in balance was indicated by a decrease in
balance errors in the SLS; such improvement was not observed
for the TS (Table 2). Our findings suggest that the SLS is a
promising outcome measure for future studies. However, we
believe there was a floor effect in TS measurements that
precluded demonstrable improvement of performance in the
study population.
Possible explanations for the increase in balance include,
but are not limited to, the following reasons. There may
have been an increase in muscle firing, proprioception, and
strength through the diaphragm and deep core musculature.
These changes may have been associated with a diaphrag-
matic breathing pattern or breathing exercised independent
of breathing style. Alternatively, there may have been a
learning effect from the weekly balance testing over the
course of the study.
We believe that the breathing exercises and corresponding
increase in diaphragmatic breathing style may have increased
the strength of the diaphragm and deep core musculature, and
that this increase in strength and proprioception may have
contributed to the increase in balance measured. However,
without control groups, we were unable to discern the effects
174 Stephens et al
Effect of Breathing Type on Balance
Table 3. Correlation of Balance Scores With Breathing Score a
Week Single-Leg Stance Tandem Stance
1 0.07 0.11
2 –0.28 –0.12
3 0.02 0.00
4 –0.03 0.06
5 –0.05 –0.17
6 –0.20 0.09
7 –0.23 –0.36
8 –0.42 0.02
a
Spearman’s rank-sum correlation coefficient. P N .05.
of balance training on diaphragmatic breathing from other
causes such as learning effect and increase in breathing
musculature independent of breathing style.
During the final assessment participants stated that they
had enjoyed doing the breathing exercises and had noticed
improvements throughout other aspects of their lives that they
associated with the changes in their breathing patterns.
Benefits included feeling more balanced rock climbing,
having less low back pain with long road bike rides, and
feeling stronger while Olympic lifting. The effects of
participation in a research study could not be distinguished
from the effects of the exercise program on perceived benefits.
Limitations
Ours was a small, uncontrolled clinical trial, and all the
usual limitations of such studies apply. The most important
concern is that the relationship observed between balance
and breathing was confounded by the possibility of learning
effects from the weekly balance testing over the course of
the study. Also, breathing data were collected only once per
week, so the extent of change in breathing pattern could not
be clearly ascertained.
Another limitation is that the BA used to monitor breathing
style has not been fully validated. However, the linear
association of BA with the number of training sessions
(time) gives preliminary evidence for test responsiveness. The
association between BA and balance over time supports the
construct validity for monitoring a breathing training program,
because it is consistent with the underlying hypothesis
(construct) that change in breathing style can improve balance.
We did not specifically screen for stroke and transient
ischemic attack, nor did we ask about medication in general
and those that could affect balance in particular. However,
participants were screened for a history of vascular disease
and central nervous system disorders. The participants were
also young, active, healthy individuals, so that it was unlikely
they were on medications that could affect balance.
Our findings in a healthy population should also not be
generalized to clinical populations. In particular, the DLS,
useless here because it was completely error free, may provide
valuable information for clinical patients. Findings for the SLS
Journal of Manipulative and Physiological Therapeutics
March/April 2017
and TS may also be more impressive for various clinical
conditions. Finally, this study could cast no light on the
usefulness of dynamic balance testing because of suspected
equipment failure, and we could not find any empirical data to
support the OptoGait protocols.
Despite these limitations, the relationship between breathing
and static balance is intriguing and worthy of pursuit with
more sophisticated study designs. As these exercises require
very limited supplies and can be done almost everywhere,
we believe that they could benefit a large portion of the
population. It would be also be interesting to compare the
effects of breathing exercise with traditional core exercises on
sports performance. In addition to benefiting a healthy athletic
population, this information may be helpful for populations
that are at high risk for falls.
CONCLUSION
This preliminary study gives proof-of-concept evidence
that there may be a relationship between breathing and
balance. Further research using experimental design needs
to be conducted to investigate the link between breathing
patterns and balance. If verified, there might be applications
to sports performance in the future.
FUNDING SOURCES AND CONFLICTS OF INTEREST
Theraband donated the Theraband resistance bands for
this study. No funding sources or conflicts of interest were
reported for this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
R.J.S., J.A.S.
Design (planned the methods to generate the results):
R.J.S., J.R.E., J.A.S., A.W.
Supervision (provided oversight, responsible for organiza-
tion and implementation, writing of the manuscript): W.L.M.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data): R.J.S.,
W.L.M., J.R.E., J.A.S., A.W.
Analysis/interpretation (responsible for statistical analysis,
evaluation, and presentation of the results): R.J.S., M.H.
Literature search (performed the literature search): R.J.S.,
J.R.E., J.A.S.
Writing (responsible for writing a substantive part of the
manuscript): R.J.S., W.L.M., M.H.
Critical review (revised manuscript for intellectual content,
this does not relate to spelling and grammar checking):
R.J.S., M.H.
Journal of Manipulative and Physiological Therapeutics
Volume 40, Number 3
Practical Applications
• A link between breathing patterns and
balance was established.
• To our knowledge, this topic has not been
researched.
• This evidence suggests further investigation is
warranted.
• Potential clinical applications include decreasing
risk of lower extremity injury, increasing
performance, and decreasing risk for falls in
patients at high risk.
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