Have Low Back Pain? How’s Your Breathing?

Stop holding your breath. It’s not good for your health. I mean it; for the obvious and not so obvious reasons. Today, I’m here to tell you about the latter as I’m guessing you probably have a good understanding of the former. Dysfunctional breathing and low back pain are interconnected. Many of my patients think I’m a little crazy, initially, when I start asking them about their breathing habits. I usually preface my question with, “I know this might sound silly, and you may not think this is relevant, but I want to take a look at your breathing pattern.” As I examine the movement around their ribcage, or rather lack there of, while they’re breathing I go on to explain, “If you’re not breathing properly, then your deep core can’t activate. If you’re deep core can’t activate, then your body can’t maintain a stable base to work from. This eventually leads to low back pain and pelvic floor dysfunction.” Hmmm… any of that sound familiar? This is usually the moment where the light bulb begins to flicker above my patient’s head, where they begin to understand how their breathing is connected to their low back and pelvic pain. Interesting connection, right? Now before I go further, lets take a moment to talk about our breathing muscles and their relationship to the deep core.

The primary breathing muscle in our body is the diaphragm. It’s an incredible muscle that resembles an umbrella separating the lungs from the abdominal organs. It attaches onto our spinal column near L1-L3 and branches out to the ribs, and sternum. Keep those attachments in mind as you keep reading. When we inhale the diaphragm contracts, moving downward, expanding the ribcage with the help of the intercostal muscles to facilitate the entry of air into our lungs. When we exhale, the diaphragm relaxes, moving upward, causing our chest cavity to recoil, which in turn facilitates the expulsion of air out of the lungs. Now there’s a secondary team of breathing muscles that include the following: sternocleidomastoid, scalenes, pectoralis major and minor, serratus anterior and latissimus dorsi. This group is collectively called the accessory breathing muscles. They are there to assist (key word) the diaphragm and intercostals, most notably with forced inhalation and exhalation.

When we’re breathing properly we’re breathing from our bellies, also known as diaphragmatic breathing. This calms the nervous system and allows for the most efficient intake of air with each breath. However, when we’re in pain, stressed, and/or have poor posture, diaphragmatic breathing often becomes disrupted. Our sympathetic nervous system (fight-or-flight response) becomes excited and our body compensates by using our accessory muscles, also known as chest breathing, instead of our diaphragm. Think about what happens to you when you’re scared or stressed. We usually begin to enter into a state of hyperventilating…When the accessory muscles become the primary movers, our breathing becomes shallow and our bodies become tense due to our heightened sympathetic nervous system response. Now imagine how your body would feel if it had to function in that environment over time…Chest breathing if left unaddressed will cause postural imbalances (i.e. forward head posture, upper crossed syndrome, neck and shoulder pain, etc). This will disrupt the diaphragm’s ability to ascend/descend fully with each breath resulting in poor ribcage and spinal mobility and the inability to coordinate with the deep core system [1, 2]. It’s a domino effect.

In my previous post, I discussed how the diaphragm is one of the four main players of our deep core system. The diaphragm is supposed to move in a coordinated fashion with our pelvic floor. Think of them like a piston. When we inhale the diaphragm and pelvic floor descend and the transverse abdominus and multifidi relax; the reverse should occur when we exhale. These four muscles act as a team, creating a supportive muscular corset around our abdomen as we exhale. The effectiveness of this muscular corset is dependent upon the intra-abdominal pressure (IAP) that the deep core system creates during contraction [3]. If our diaphragm isn’t moving then the intra-abdominal pressure becomes disrupted, resulting in low back pain, pelvic floor dysfunction and incontinence issues [2,3]. Same is true when we hold our breath. The diaphragm doesn’t move, which means our IAP will be disrupted, which means the deep core can’t engage. See what I mean now about how important it is to not hold your breath?! You could be doing all the right deep core exercises forever and not get relief from your low back or pelvic pain if you’re doing them while holding your breath [4]. It’s critical that the deep core muscles are coordinated together with our breath in order to create a stable foundation and not put extra stress on the low back and/or pelvic floor systems.

Many of my patients with low back and pelvic floor pain are chest breathers and often deploy breath holding as their bracing strategy for lifting. These two mechanisms often go hand in hand and must be addressed before introducing any other strengthening exercises [4]. Breathing is easy. Breathing properly is a whole other ball game. When our bodies are working through pain, stress, and/or working against poor postures, our breathing becomes compromised.

Take a few minutes to check in with your own breathing and alignment (if you haven’t already done so). Follow these steps to assess your breathing and ensure that you are setting your body up to be successful for movement:

  1. Are you a chest breather or belly breather? Watch this video to find out.
  2. If you’re a chest breather, take a few minutes each day to practice belly breathing as demonstrated in the video above. With practice you will be able to retrain your breathing pattern.
  3. Make sure when you exercise that you don’t hold your breath! I encourage my patients to try and pair their exhale with the exertional phase or the more difficult phase of an exercise (ex: inhale as you descend into a squat, then exhale as you return up tall to standing). A helpful phrase to remember…inhale to prepare, exhale to move.

Here are two other videos from Dr. Julie Wiebe, PT, that help review what I’ve discussed in this post. Julie’s website and blog are also great resources to check out!

The diaphragm and our internal pressure system

The impact of alignment of diaphragm and pelvic floor availability


  1. Nelson, Nicole. “Diaphragmatic breathing: The foundation of core stability.”Strength & Conditioning Journal5 (2012): 34-40.
  2. Smith, Michelle D., Anne Russell, and Paul W. Hodges. “Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity.” Australian Journal of Physiotherapy1 (2006): 11-16.
  3. Frank, Clare, Alena Kobesova, and Pavel Kolar. “Dynamic neuromuscular stabilization & sports rehabilitation.” International journal of sports physical therapy1 (2013): 62.
  4. Cavaggioni, Luca, et al. “Effects of different core exercises on respiratory parameters and abdominal strength.” Journal of physical therapy science 10 (2015): 3249.