From our first gasp of air when we are born to our last sigh when we pass, one breath follows another in a mostly unbroken progression. One of our most primal movement patterns is breathing, but most of us are unaware it happens automatically unless exertion, a stressful event, an injury including physical and emotional pain, or an unforeseen interruption of respiration occurs.1,4
Breathing has a significant role in its effects on movement quality and stability of the core and spine. If breathing is normal or "functional," posture and stabilization of the spine will be maintained in a healthy manner. The converse is true in that dysfunctional breathing plays a key role in not only posture and stabilization of the spine, but also a myriad of other health issues.
The rhythm and quality of our breathing affects blood pH levels, making it more alkaline or acidic; and altered pH can correlate with asthma, anxiety and chronic pain syndromes. Stress, high altitude, infection, allergies, kidney disease and even "mouth breathing" can affect pH levels. Short-term pH levels are regulated through the lungs, but long-term regulation is through the kidneys. It is the long-term patterns of respiration and pH level that are of concern.1
Breathing patterns can also be consciouslyrestored to functional or normal patterns and replace dysfunctional patterns caused by many of these issues, especially when the pattern has been altered by musculoskeletal pain.
The Role of the Core in Proper (and Improper) Breathing Patterns
Much is mentioned about the "core" regarding not only stabilization of the spine and prevention of injury, but also athletic performance. As an example, some health and fitness professionals still recommend abdominal crunches or lumbar hyperextensions as core or back exercises. This antiquated, "one-size-fits-all" approach has little effect on identifying a therapeutic exercise strategy that addresses a specific dysfunction of the core and spine, let alone correcting a breathing dysfunction.
We can start by defining the core as having inner and outer components. The role of the inner core includes respiration, continence and lumbopelvic anticipatory control, especially with sudden movement or "perturbation" from an external source. Our inner core receives autonomic input, which regulates those functions.2
The muscle we most associate with breathing is the diaphragm, and it is part of the inner core along with the erector spinea, transverse abdominis and pelvic floor muscles. The diaphragm has three parts or sections including the sternal, costal and lumbar, named after those origins.
The other primary muscles responsible for breathing that are not considered as part of the inner core include the intercostals and scalenes. The scalenes are activated with even a light breath, but all too often are "overutilized" with the primary muscles during simple, relaxed breathing. In addition to the scalenes, the other accessory muscles include the sternocleidomastoid (SCM) and upper trapezius, which are often recruited inappropriately for normal, relaxed breathing.1
You will notice that individuals who repetitively recruit accessory muscles inappropriately during normal breathing often appear to have "body-builder"-sized SCMs bulging out of their necks, even when they don't lift heavy weights. This is an example of asking accessory muscles to breathe when primary muscles like the diaphragm have partial amnesia!
The relationship between the diaphragm, breathing and stabilization of the spine is closely linked. When the diaphragm is compromised and breathing patterns are altered, the spine will be involved. And when the spine is involved with dysfunction or pain, the reverse is also true. Patients with a history of neck or back pain, even when the pain is gone, will most likely have an abnormal breathing pattern, causing inner core dysfunction affecting the diaphragm.
Of note, epidemiological studies have shown that disorders of breathing and continence are more closely linked to the development of lower back pain than excessive BMI and physical activity. In addition, incontinence in elite female distance runners has been reported to be present in as high as 35 percent of runners.2-3, 6-7
The outer core includes the rectus abdominis, quadratus lumborum and oblique musculature. The role of the outer core is to connect the thorax to the pelvis and is responsible for postural control and movement / power generation, especially when the body is subjected to an external load. For optimal function, the outer core must have good CNS input and adequate joint mobility, especially of the thoracic spine.2,8
(Remember the Boyle / Cook "joint by joint" approach; that is, the predominate movement pattern for the ankles, hips and thoracic spine needs to favor mobility over "fixation." Moreover, the knee, lower back and shoulders require stability more than mobility.3 Chiropractic adjustments to the thoracic spine are a must in breathing dysfunctions!)
Poor conditioning, posture or repetitive mechanics affect spinal function, which then culminates in another source of altered movement patterns. Combine inner core breathing dysfunction with outer core movement dysfunction and a perfect storm is created for not only spinal dysfunction and pain, but also incontinence, fatigue and anxiety.
The entire core system is a marvel considering it has a unique ability to modulate muscle function and whole-body movement through the central nervous system, while maintaining primary physiological roles such as respiration.
Faulty Movement Patterns, Core Dysfunction and Improper Breathing
Numerous studies have shown that pain alters movement patterns and that once pain is gone, the faulty movement pattern can stubbornly persist well beyond symptom relief. One consequence is that a faulty movement pattern of any sort can lead to an increased risk of a non-contact-sports injury. The durability of athletes can be linked to faulty movement patterns that leave the individual vulnerable to an initial injury and subsequent re-injury as well.2,5,8-9
When there is a history of lower back pain, increased outer-core function will be altered. This is due to increased CNS input, leading to the muscles of the outer core "staying on" longer over greater periods of time. This is known as a "high threshold strategy" (HTS) and is appropriate for lifting a heavy load or increasing and decreasing activation in a sequential and reciprocal manner, such as running or sprinting.
However, this increased CNS drive that remains after an injury has resolved or when a demand no longer exists has consequences, including increased compressive loads of the spine, fatigue, impaired functional movement patterns such as rolling, toe touching, squatting, and most especially decreased activation of the inner-core muscles and breathing pattern alteration. That is, excessive tone or CNS drive to the outer core can suppress inner-core function, which affects breathing.6,9
So, an episode of spinal pain has a lingering effect on both inner and outer components of the core, altering function and breathing. Breathing patterns are affected by physical/emotional pain and that pattern can linger unconsciously long after the initial injury has passed.
Core assessment along with your chiropractic evaluation is critical for prevention of musculoskeletal injuries or pain. It is also critical for the discovery and correction of movement dysfunction after an injury has occurred, especially when the pain is gone, but altered movement patterns persist.
Craig Liebenson, DC, identifies faulty movement patterns with his "Magnificent 7" assessment for inner- and outer- core function, including breathing assessment. Combined with the Functional Movement Screen (FMS) and the Selective Functional Movement Assessment (SFMA), it provides powerful tools to identify and correct neuromuscular dysfunctions of the core, spine and breathing.
Part 2 of this article will describe how to identify and correct breathing dysfunction, and restore normal or functional breathing to patients, friends and even the occasional stressed-out doc you may know.
- Perri M. Rehabilitation of Breathing Patterns (Chapter 17). In: Liebenson C (editor). Rehabilitation of the Spine: A Practitioner's Manual, 2nd Edition. Lippencott Williams & Wilkins, 2006:370-375.
- Kiesel K, Plisky P, Cook G. The Selective Functional Movement Assessment: An Integrated Model to Address Regional Interdependence. Course brochure, 2010.
- Boyle M. The Joint-By-Joint Concept (Appendix 1). In: Cook G, et al. Movement: Functional Movement Systems:319-321.
- Hatherley P. The Internal Development Necessary to Become Loving and Wise. BalboaPress, 2011.
- Smith MC, Russell A, Hodges PW. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust J Physiother, 2006;52(1):11-16.
- Bo K, Borgen JS. Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med Sci Sports Exerc, 2001;33(11):1798-1802.
- Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl, 1989;120(suppl):1-54.
- Cholewicki J, Greene HS, Polzhofer GD, Galloway MT, Shah RA, Gadebold A. Neuromuscular function in athletes following recovery from a recent acute low back injury. J Orthop Sports Phys Ther, 2002;32(11):568-575.
- Cholewicki J, Silfies SP, Shah RA, Greene HS, Reeves NP, Alvi K, et al. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine, 2005;30(23):2614-2620.
Dr. Robert "Skip" George practices in La Jolla, Calif., where he integrates chiropractic, rehabilitation and sports performance training. He is a certified Functional Movement Screen instructor and has lectured nationally on subjects related to the chiropractic profession. He can be contacted with questions and comments at