Just breathe…

One of the things I keep getting asked about and that appears to be getting more popular within physiotherapy is breathing re-training for musculoskeletal conditions and rehab. Not having considered this much in my practice I thought I would take a look at the role of breathing re-training and see if it is something I should be using more for things such as back, neck, and shoulder pain.

Now respiratory training methods are key interventions for our colleagues who work with cardio-respiratory conditions such as Cystic Fibrous, Chronic Obstructive Pulmonary Disease etc, but are they also something that should be used for musculoskeletal conditions such as back pain? As an MSK physio breathing is something I don’t often consider for most patients as usually, they don’t tell me its an issue for them and they usually have other more important things to focus on.

Breathing is kinda important!

Now that’s not to say breathing is not important, in fact, its a pretty VITAL activity for general health and well being. Without breathing things tend to go downhill very quickly, therefore I do highly recommend that everyone I see does it. However, I think the best type of breathing is the type you do without thinking about it, usually inhaling followed by exhaling and repeating as often as needed.

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But, I do recognise that pain, anxiety, fear, and physical exertion can and do affect breathing, often increasing its rate, reducing its tidal volume, and even causing it to stop, and I do see these things in some of my patients from time to time. Therefore, occasionally I will get a patient who I can see is tense, guarded, and holding their breath to take a few conscious deep slow breaths before they do something they anticipate will hurt.

So occasionally breathing in MSK patients is relevant, but this isn’t anything fancy, and it isn’t something I usually ask patients to focus on as part of their treatment. But there are some therapists who do advocate that MSK therapists should be focusing more on breathing techniques with their MSK patients to help them function better, and I can kind of understand this.

Pain changes it

There is evidence that those with back pain tend to have different positions and fatigability of their diaphragms than those without pain. However, it needs to be remembered that these changes could be caused by their pain rather than contributing to it. Also, these issues could be normal variations and have been pre-existing before their pain started and related to other factors such as low physical activity or high-stress levels.

There is also some evidence that focusing on breathing can improve pain levels in both acute and chronic low back pain, so it is argued that it may be a good idea to get patients to do this. However, before you all go and get your patients to behave like hyperventilating puffer fish, or start watching their abdominal rise and fall it’s important to consider if it’s worth the time and effort of using breathing techniques.

Some research shows that the pain-modulating effects from respiratory training are very small and actually probably unlikely due to the respiratory training and may not be worth the time and effort doing them. Personally, I think the breathing issues I see in my patients are due to anticipation, fear, anxiety, or pain. Therefore, I prefer to prioritise my treatments that address these things, such as education, exposure and exercise, not to focus on the consequences of them.

Crazy breathing

However, if I do give some breathing tasks for a patient then I just tend to do nothing more complex than asking patients to take a few deep slow breaths, but there are some others who advocate that we should go a lot further into breathing re-training, such as the crazy people over at the Postural Restoration Insititute.

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They get patients to focus on their diaphragms, chest expansions, and inspiratory muscles by blowing up balloons with their arms and legs waving about in the air, doing some really weird and wacky shit. There is also crazy dude from Functional Patterns who thinks you need to wrap elastic bands around your ribs and push out against them when breathing. This profession never ceases to amaze me with some of the daft and stupid things it thinks is both useful or effective for pain or disability.

Anyway, this kind of stupidity is nothing more than a waste of time, energy, and money. I’m sure many of the advocates of these techniques will tell you about all the patients they have helped, but why their techniques and interventions work are not known despite their claims and explanations as there are NO controlled studies comparing them against sham or placebos.

Really crazy breathing

As daft as the physio profession can be with its breathing re-training interventions, these pale into insignificance when it comes to the world of fitness, and strength and conditioning. Here we enter into a whole new world of stupid ideas about breathing training improving strength, endurance, and performance.

I think the daftest gimmicks I have seen around this are these inspiratory masks and valves that are thought to replicate high altitude oxygen-deprived environments to create increased physiological responses to training.

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Actually, these masks replicate high altitude training just as much as sticking your feet out of a car window replicates running fast, or flushing your head down the toilet replicates swimming. To simulate a low oxygen environment, you need… wait for it… a low oxygen environment, these masks simply don’t filter oxygen from the atmosphere.

What these masks actually do is reduce the airflow into your lungs so increasing the effort to breathe. This is called inspiratory muscle training. This is a bit like trying to breathe through a straw or a pillow that is being smothered over your face. Now our cardio-respiratory colleagues will tell us that this is an effective intervention for those with respiratory conditions or disease, that is inspiratory muscle training by the way, not pillow smothering!

However, there is little evidence that inspiratory muscle training and these masks help improve athletic performance or do anything significant except make you look like a twat. There are some studies that show the effects of inspiratory muscle training improve respiratory function in athletes, but surprisingly no evidence that this translates into improvements in their athletic performance.

Now using some simple breathing techniques when training can be useful, for example, holding the breath to splint the abdomen during a heavy squat or deadlift can help brace the trunk via the Valsalva manoeuvre, and then breathing out forcefully during the effort phase of the lift can help generate power, but thats about it.


There is no doubt that breathing is an essential task and most of you should keep doing it. There is no doubt that breathing can be abnormal in the presence of some disease, pain, fear, and anxiety, but there is little evidence to say that these breathing issues are causative of these things.

Many therapists are focusing on breathing training in musculoskeletal conditions when there is little evidence that these are significantly effective and/or important. For me breathing issues do occur in some patients I see, but to help this it is usually nothing more than asking a patient to take a few slow deep breaths with no balloons or masks in sight.

As always, thanks for reading.


6 thoughts on “Just breathe…

  1. Hey Adam, as a second year physio student I really enjoy reading your articles and I hope to employ your challenge everything philosophy in my own practice when the time comes. I suffer from asthma, and have since I was a child. After watching several power/endurance tests at Uni, I theorized about how much WOB really contributes to fatigue in an athlete, let alone a respiratory challenged individual. I decided to employ a “training mask” in my daily cardio etc. I realize that the hypoxic simulation is B/s, but I believed if I could in attempt to train my respiratory system in a progressive overload fashion, maybe that improvement in efficiency when unloaded would translate to improved efficient respiration. I wont lie, it was very hard going initially, but after 12 months of employing it 2-3 days a week on the lowest (3000ft) setting, I had my second respiratory test in a lab at Uni. Sure enough the customary asthmatic dips between FEF25-50 had noticeably improved, but remained lower in the FEF75. I rarely use it now but I run over 30km a week, and have no out of breath moments at all.

    • Hi Ben, thanks for the comment and kind words. Inspiratory muscle training is an effective method for respiratory issues like asthma and glad it worked well for you… however for pain… its kind of meh!!! Cheers and keep running… Adam

  2. As always Adam, you have entertained me with your turn of phrase, and your honesty, I have used breathing with some people who are anxious and in pain, more to help calm them as you said you do, it’s not the focus just an adjunct to get them through and feel safe, cheers Sharon.

  3. I’ve been highly sceptical of the Postural Restoration Institute since I first saw some of their stuff. They make everything sound extremely complicated, and they claim to have figured out important things that nobody else even bothers to talk about. This makes my spider sense tingle.

    Yet I’m aware of more than a few people whom I consider to be otherwise fairly clever, who seem to be very succesful using PRI concepts.

    So I don’t know what to think. I’m sceptical, but on the other hand it’s too easy to dismiss something just because I don’t fully understand it, wouldn’t you say?

  4. I swear that when I read about this nonsense years ago, I wondered how we ever survived the Dark Ages, long before physio., when people might not have known how to breathe properly….. and it didn’t fricking matter!!! As if we could will a difference in how we breathe……. It’s called EVOLUTIONARY BIOLOGY, something that few physios seem to grasp if they buy this crap!!!

    Another beauty post Adam. Thanks for sharing!

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