“The Use of Breathing Exercises in the Treatment of Chronic, Non-Specific Low Back Pain” by Anderson BE, Huxel Bliven KC

Journal of Sport Rehabilitation

© 2016 Human Kinetics, Inc.

Note: This article will be published in a forthcoming issue of

the Journal of Sport Rehabilitation. The article appears here in
its accepted, peer-reviewed form, as it was provided by the
submitting author. It has not been copyedited, proofed, or
formatted by the publisher.

Section: Critically Appraised Topic

Article Title: The Use of Breathing Exercises in the Treatment of Chronic, Non-Specific Low
Back Pain

Authors: Barton E. Anderson1 and Kellie C. Huxel Bliven2

Affiliations: 1Athletic Training Programs, Arizona School of Health Sciences, A.T. Still
University, Mesa, AZ. 2Interdisciplinary Health Sciences, Arizona School of Health Sciences,
A.T. Still University, Mesa, AZ.

Journal: Journal of Sport Rehabilitation

Acceptance Date: April 2, 2016

©2016 Human Kinetics, Inc.

DOI: http://dx.doi.org/10.1123/jsr.2015-0199
 The use of breathing exercises in the treatment of chronic, non-specific low back

pain

Barton E. Anderson, DHSc, ATC1

Kellie C. Huxel Bliven, PhD, ATC2

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Athletic Training Programs, Arizona School of Health Sciences, A.T. Still University1

Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University2

Corresponding Author: Barton E. Anderson

Athletic Training Programs

A.T. Still University

5850 E. Still Circle,

Mesa, AZ 85206

Telephone: 480-219-6000;

Fax: 480-219-6100

Email: banderson@atsu.edu

Disclosures: No funding was received for this research.

 CLINICAL SCENARIO

Research has demonstrated a relationship between poor core stability and back pain, with

noted decreases in core muscle activity and spinal stabilization in those suffering from both acute

and chronic conditions.1-4 This relationship has also led to studies examining differences in

breathing patterns between persons with and without low back pain. Several authors have

reported altered breathing patterns in persons with chronic, non-specific low back pain, including

differences in lung capacity2,5 and diaphragm mechanics.2,6 These findings indicate a possible
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link between (a) respiratory function, (b) breathing patterns, (c) core stability, and (d) low back

pain.

Athletic trainers and physical therapists commonly work with persons suffering from

acute and chronic back pain. Traditional approaches for non-surgical treatment of chronic, non-

specific low back pain have focused on exercise and manual therapy interventions, with limited

evidence that this approach is slightly effective at reducing pain and increasing function.4

Complimentary or alternative therapies such as breathing exercises may offer an additional

approach to the treatment of chronic, non-specific low back pain.

FOCUSED CLINICAL QUESTION: In adults with chronic, non-specific low back pain, are

breathing exercises effective in reducing pain, improving respiratory function and/or health

related quality of life?

 SUMMARY OF SEARCH, “BEST EVIDENCE” APPRAISED, AND KEY FINDINGS

 The initial search using identified search terms returned 167 results across all searched

databases. Once duplicate results were removed, 97 articles remained. Following a

review of article titles and abstracts, 20 of the 97 articles were determined to be relevant

to the focused clinical question. From these 20 results, three studies met the inclusion

criteria for the focused clinical question.

 This review found moderate evidence for the use of breathing exercises for the treatment
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of chronic, non-specific low back pain. Two level 2 studies showed significant

improvements in low back pain following breathing program intervention.7,8 Two level 2

studies showed significant improvements in quality of life following a breathing program

intervention.8,9 One level 2 study showed significant improvements in respiratory

function following a breathing program intervention.7

 Breathing interventions that were effective in reducing pain and increasing respiratory

function included (a) deep breathing with a 10-second hold following inspiration; (b)

focused breathing to increase awareness of patterns, rate, and volume; (c) yoga breathing;

and (d) resisted inspiration. Durations of programs included a one week intensive

program,9 six to eight weeks,8 and eight weeks7, with frequency of performance ranging

from daily to 2-3 times per week.

CLINICAL BOTTOM LINE

From these results, moderate evidence exists for the use of breathing exercises in the

treatment of chronic, non-specific low back pain. These results should be considered along with

the clinician’s own clinical expertise and the values and preferences of each
 individual patient to determine how to be integrated into a plan of care. Continued research is

necessary to strengthen the quality of evidence supporting breathing interventions for chronic,

non-specific low back pain, including randomized controlled trials examining differences

between (a) type, (b) frequency, and (c) duration of breathing exercises.

Strength of Recommendation: Collectively, the results of the included studies

indicate there is grade B evidence that breathing exercises improve pain, respiratory function,

and/or quality of life in patients with chronic, non-specific low back pain.
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SEARCH STRATEGY

Terms Used to Guide Search Strategy

Multiple search terms were used to identify the best available evidence to answer the

focused clinical question and utilized the following Boolean strings:

Patient/Client group: low back pain OR sacroiliac joint pain OR back pain

Intervention (or assessment): breathing OR respiration OR inhalation OR

expiration OR diaphragm AND exercise OR rehabilitation

Comparison: none/not applicable

Outcome(s): pain OR quality of life OR respiratory function

Sources of Evidence Searched

 Citations and Abstracts for Literature of Nursing and Allied Health (CINHAL)

 The Cochrane Library

 Medline

 PubMed

 SPORTDiscus
 Inclusion and Exclusion Criteria

Inclusion Criteria

 Limited to studies utilizing any form of breathing exercise to treat back pain.

 Limited to studies that included outcomes of pain, quality of life, and/or

respiratory function.

 Limited to studies of Level 3 evidence or better.10

 Limited to studies conducted in humans.

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 Limited to studies published in English.

 Limited to studies conducted and published within the last 10 years (2005-2015).

Exclusion Criteria

 Studies that examined interventions other than breathing exercises for the

treatment of low back pain

 Studies that examined conditions other than low back pain

 Studies that utilized outcome measures other than pain, quality of life, or

function.

 Studies of level 4 or 5 evidence.

RESULTS OF SEARCH
8,9,11
Three studies were retrieved from the sources of evidence searched and determined

met the inclusion criteria, shown in Table 1. Level of evidence was determined using criteria

outlined by the Oxford Centre for Evidence Based Medicine (OCEBM) in 2011.10
 BEST EVIDENCE

The three studies identified as best evidence for inclusion to answer the focused clinical

question in this critically appraised topic (CAT) are described in Table 2. These studies were

selected because they were considered level 2 evidence and assessed pain, respiratory function

and/or quality of life in chronic, non-specific low back pain patients who underwent a breathing

exercise intervention.

IMPLICATIONS FOR PRACTICE, EDUCATION, AND FUTURE RESEARCH

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The three studies included in this review examined the effects of breathing exercises on

pain and respiratory function in persons with chronic, non-specific low back pain. In a

randomized controlled trial, Mehling et al.8 compared a breathing exercise program with

traditional physical therapy in persons suffering from chronic low back pain. The breathing

program included exercises focused on increasing awareness of breathing

(a) patterns, (b) rate, and (c) volume, as well as a breathing home exercise program.

Results showed significant improvements in pain and function in both breathing and physical

therapy groups, with no significant differences between the two types of interventions.8 These

findings suggest that breathing exercises focusing on awareness of breathing (a) patterns, (b)

rate, and (c) volume performed regularly over a four-week period are comparable in

effectiveness to traditional physical therapy exercises for the treatment of chronic, non-specific

low back pain.

Janssens et al.11 examined the effects of a high-intensity inspiratory muscle training

program on function and chronic, non-specific low back pain. The breathing program included

resisted inspiration performed with a specialized mouthpiece; two sessions of 30 breaths per

day were performed seven days a week for eight weeks.

 Results showed significant increases in respiratory function and decreases in low back pain

following the eight-week intervention.11 These results indicate that a high intensity inspiratory

muscle training program performed daily over eight weeks can be effective in decreasing pain

and increasing respiratory function in patients suffering from chronic, non-specific low back

pain.

Although both of these studies showed significant improvements in chronic, non- specific

low back pain and postural control, they utilized different breathing intervention protocols.
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Mehling et al.8 utilized breathing interventions that focused on increasing the subject’s awareness

of the physical sensations of breath movements; these breathing sessions included verbal and

tactile feedback from the breathing therapist. In the study by Janssens et al.,11 high-intensity

inspiratory muscle training was performed daily over an 8 week period with weekly supervised

sessions. Based on these protocols, it appears that both a hands-on, clinician supervised

intervention and a patient-driven intervention can be effective in reducing chronic, non-specific

low back pain in the short term. This information provides options for clinicians to choose from,

based on their availability, clinical experience, and patient load. However, because different

outcome measures were utilized, it is difficult to identify if one approach is more effective than

the other.

In contrast, Tekur et al.9 studied the effects of a 1-week intensive yoga training

camp compared to a 1-week intensive physical therapy program on stress and quality of life. The

yoga group demonstrated significantly better measures of quality of life and lower stress values

when compared to the physical therapy group, suggesting that yoga that includes breathing

exercises may be an effective way to treat back pain. However, the intensive nature of this

intervention, coupled with the other physical and psychological

 aspects of yoga exercise make it difficult to generalize the results of this study to traditional

athletic training or physical therapy practice where patients are seen for short sessions several

times per week. This 1-week intensive training program is yet another option for the treatment of

chronic, non-specific low back pain.

Other studies with an emphasis on breathing exercises that did not meet the inclusion

criteria for this CAT may be helpful in determining exercise options. Kim & Lee12 demonstrated

increased respiratory function and core stability in healthy participants with decreased tidal
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volume and limited rib cage excursion who underwent deep breathing exercises once daily for

four weeks as compared to a control group. Exercises included five sets of 10 repetitions of deep

breathing with a 10-second holding of the breath at the end of inspiration. Results showed

significant changes in respiratory function and core muscle activation during breathing. Although

this study was conducted using healthy participants who were not suffering from low back pain,

the findings suggest that simple deep breathing exercises performed daily over four weeks can

improve respiratory function and core stability, two factors related to chronic, non-specific low

back pain.

Collectively, the reviewed studies showed that a variety of different breathing exercise

programs were effective at (a) reducing chronic, non-specific low back pain; (b) improving

respiratory function; or (c) improving quality of life. All studies were critically appraised as level

2 evidence according to the OCEBM 2011 guidelines based on (a) study design, (b) methods,

and (c) reported outcomes.10 However, only one of the three studies included in this CAT

reported a follow up of six months, so it is difficult to determine the long term effects of a

breathing program intervention on improving chronic, non-specific low back pain.

 Future research should focus on comparing different types of breathing programs and

their effects on chronic, non-specific low back pain and function. Specifically, studies that

compare (a) types of breathing exercises, (b) frequency of breathing exercise performance, (c)

duration of breathing exercise programs and (d) long term effects of breathing program

interventions should be considered. Once more high quality randomized controlled trials are

conducted, a systematic review and meta-analysis of these trials should be undertaken to produce

high quality clinical recommendations for the inclusion of breathing exercises for the treatment
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of low back pain. This CAT should be reviewed in 2 years or when additional best evidence

becomes available that may change the clinical bottom line.

 REFERENCES

1. D'Hooge R, Hodges P, Tsao H, Hall L, Macdonald D, Danneels L. Altered trunk muscle

coordination during rapid trunk flexion in people in remission of recurrent low back pain. J
Electromyogr Kinesiol. 2013;23(1):173-181.

2. O'Sullivan PB, Beales DJ. Changes in pelvic floor and diaphragm kinematics and
respiratory patterns in subjects with sacroiliac joint pain following a motor learning
intervention: A case series. Man Ther. 2007;12(3):209-218.

3. Cholewicki J, Silfies SP, Shah RA, et al. Delayed trunk muscle reflex responses
increase the risk of low back injuries. J Spine. 2005;30(23):2614-2620.
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4. Hayden J, van Tulder Maurits W, Malmivaara A, Koes Bart W. Exercise therapy for
treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005(3).

5. Hagins M, Lamberg EM. Individuals with low back pain breathe differently than healthy
individuals during a lifting task. J Orthop Sports Phys Ther. 2011;41(3):141- 148.

6. Kolar P, Sulc J, Kyncl M, et al. Postural function of the diaphragm in persons with and
without chronic low back pain. J Orthop Sports Phys Ther. 2012;42(4):352-362.

7. Janssens L, Brumagne S, Polspoel K, Troosters T, McConnell A. The effect of inspiratory

muscles fatigue on postural control in people with and without recurrent low back pain. J
Spine. 2010;35(10):1088-1094.

8. Mehling WE, Hamel KA, Acree M, Byl N, Hecht FM. Randomized, controlled trial of
breath therapy for patients with chronic low-back pain. Altern Ther Health Med.
2005;11(4):44-52.

9. Tekur P, Chametcha S, Hongasandra RN, Raghuram N. Effect of yoga on quality of life of

clbp patients: A randomized control study. Int J Yoga. 2010;3(1):10-17.

10. OCEBM Levels of Evidence Working Group. The oxford 2011 levels of evidence. 2011;
http://www.cebm.net/ocebm-levels-of-evidence/. Accessed October 20, 2015.

11. Janssens L, McConnell AK, Pijnenburg M, et al. Inspiratory muscle training affects
proprioceptive use and low back pain. Med Sci Sports Exerc. 2015;47(1):12-19.

12. Kim E, Lee H. The effects of deep abdominal muscle strengthening exercises on
respiratory function and lumbar stability. J Phys Ther Sci. 2013;25(6):663-665.
 Table 1 Summary of Study Designs of Articles Retrieved

Level of Evidence Study Design Number Retrieved Reference

2 Randomized 3 Janssens et al.11
controlled trial Mehling et al.8
Tekur et al.9
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 “The Use of Breathing Exercises in the Treatment of Chronic, Non-Specific Low Back Pain” by Anderson BE, Huxel Bliven KC
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

Table 2 Characteristics of Included Studies

Janssens et al.11 Mehling et al. 8 Tekur et al.9

Study Design Randomized control trial Randomized control trial Randomized control trial
Participants 28 individuals (10 male,18 28 individuals (10 male, 18 80 individuals (44 male, 36
female) with non-specific female) with continuous LBP female) with chronic LBP
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LBP volunteered to participated. participated.

participate
Participants experienced chronic
Participants experienced > 3 LBP > 3 months, pain in the lumbar
episodes of nonspecific LBP spine with or without radiation into
in last 6 months and a score lower extremity.
of > 10% on the ODI

Intervention Participants were randomly Participants were randomly Participants were randomly
investigated assigned to a high-intensity assigned to breath therapy assigned into a yoga (n=40, age:
(n=14, 60% negative pressure (n=16, age: 49.7±512.1 49±3.6 years) or control (n=40,
during maximal pulmonary years, pain duration=11.6±5.9 48±4 years) intervention.
inspiration) or low-intensity months) or physical therapy
(n=15, 10% negative pressure (n=16; age=48.7± 12.5 years, Examiners were blinded to group
during maximal pulmonary pain duration 13.7±5.9 assignment.
inspiration ) IMT group months).
The yoga program included exercises
Each group completed 8 All participants underwent focused on improving posture,
weeks of IMT program, an introductory evaluation breathing, relaxation, and meditation.
which included 30 breaths, followed by 12 individual The breathing exercises promoted
twice a day, 7 days per week therapy sessions (45 min. slow, rhythmic breathing focusing on
IMT included coaching on each) over six to eight slowing breath rate, longer exhalation
use of diaphragmatic weeks. than inhalation, and internal
awareness.
Credentialed therapists
administered breath and
 breathing using verbal and physical therapy session The control group included non-
tactile cues and followed a study yoga breathing, stretching, and core
protocol. stabilization physical therapy
exercises.
Breath therapy focused on
supine exercises using verbal Participants were enrolled in the study
and tactile feedback to for one week, with outcomes
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increase participants’ measured on day 1 and 7. Both groups

awareness and attention of completed the same daily routine,
breathing movements. including approximately four sessions
of yoga or physical exercises
Physical therapy was (control), lasting 90 min, 45 min, 3
individualized and included hours, and 2 ½ hours, respectively.
soft-tissue mobilization, joint
mobilization, postural
correction exercises, pain
relief, stabilization and
strengthening exercises, and
patient education.

All participants were

instructed in home
exercises.
Outcome measure(s) Proprioceptive use during Measurements were Quality of life was measured using
postural control was obtained at baseline, six the WHOQOL-BREF, which
assessed using postural weeks, and six months. contains 26 items across four
sway on stable and unstable domains: physical health,
surfaces Pain intensity was assessed psychological health, social
using a VAS. relationships, and environmental
Patient-reported outcome health.
measures assessed LBP The modified Roland Morris
severity (numeric rating Scale was used to assess
scale), disability (ODI), and
 fear-avoidance beliefs (Fear LBP specific functional The perceived stress scale assessed
Avoidance Belief disability. global perceptions of stress
Questionnaire, Tampa Scale response using 10 items.
for Kinesiolphobia) The Short Form-36 was
used to assess overall The straight leg raising test was used
Inspiratory muscle strength health status. to measure the amount of hip flexion
was assessed using maximal during a passive straight leg test. The
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inspiratory pressure A perceived recovery scale end point was when the patient
was administered at six weeks reported pain.
and six months, with “much
worse” and “completely
recovered” anchors.

Postural stability, using the

SOT on a NeuroCom Smart
Balance Master (NeuroCom,
Clackamas, OR) was
measured at baseline and six
weeks to assess whole-body
proprioception and body
awareness.

Center of pressure velocities,

measured with a force plate,
progressing from eyes open,
stable surface, eyes closed,
unstable surface.

Participants maintained a
diary during the intervention
 to record feelings about their
treatment experience and
how their body perceptions
changed.

Main findings One participant in the low- Participants in both groups Both intervention groups QOL
intensity IMT group was lost displayed significant overall and in each domain, as
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to follow-up. Fourteen improvements in pain measured with the WHOQOL-

participants were analyzed in intensity (BT:-2.71 ± 2.23 BREF, improved significantly
each group. VAS, PT: -2.43 ± 2.05 VAS) between pre- and post-tests. The
and on the SF-36 yoga group improved significantly
Use of ankle versus back (BT:+14.9±1.5, PT: more than the control group.
proprioceptive input during +21.0±2.5). The BT group
postural sway on a stable displayed significantly The perceived stress scale
surface was unchanged greater improvements in LBP responses at baseline were
between groups following related functional disability negatively correlated with QOL
IMT. The high-IMT group and physical and emotional total and domain scores.
displayed a significant change role components of the SF-
in using more back 36. The PT groups displayed There was a significant increase in the
proprioceptive input during significantly greater range of motion for the straight leg
postural sway on an unstable improvements in the vitality raise in both groups between pre- and
surface compared to the low- component of the SF-36. post-tests. The yoga group displayed
IMT group. significantly more passive motion
Both BT and PT groups than the control group for the right
The high-IMT group improved in balance (SOT and side, but there were no differences
displayed significantly progression sequence), but between group for the left side.
decreased severity of LBP gains were not significantly
compared to the low-IMT different between baseline or
group. Disability and fear- group.
avoidance behaviors were
unchanged. At six months follow-up
testing, the BT group
 Inspiratory muscle strength reported more
increased significantly relapse/exacerbation of LBP
following IMT compared to (BT: 5/15, PT: 1/11)
pre-test and the low-IMT
group

Level of evidence 2 2 2
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Validity score PEDro score: 6/10 PEDro score: 6/10 PEDro score: 5/10
Conclusion Following 8 weeks of IMT, Following six to eight weeks Following one week of intensive yoga
the high-IMT program of therapy, both BT and PT intervention, participants with chronic
promoted proprioceptive use participants displayed LBP increased their QOL and spinal
of back input over an ankle improvements in pain and flexibility more than the control
input compared to a low- function. group, who performed physical
IMT program when therapy exercises for chronic LBP.
balancing on an unstable This study provided evidence
surface. to support the use of BT in the
management of LBP patients.
IMT programs, regardless of
high or low intensity, do not
appear to affect perceptions of
LBP severity, disability, or
fear-avoidance behaviors, or
inspiratory muscle strength.

Abbreviations: Low back pain, LBP; Oswestry Disability Index, ODI; inspiratory muscle training, IMT; visual analog scale, VAS;
sensory organization test, SOT; quality of life, QOL; World Health Organization Quality of Life, WHOQOL-BREF