By Noelle Ekonomou, PT, DPT

The diaphragm is often one of the most underestimated muscles in the body. It has a systemic impact on our health, including our pain perception, autonomic nervous system, lymphatic drainage, digestion, mood, and sleep. I often argue that it is the most important muscle in the body- it is the core of the core. Breathing is a coordinated movement of muscle and visceral contractions. It is a synchronous activity between the upper chest and rib cage, lower rib cage, and abdominal musculature. Our diaphragm not only attaches to the thorax, but it is strongly anchored to our spine and has connections to our deep hip flexor muscles (psoas), obliques, and transversus abdominus. Countless number of research studies have confirmed the relationship between faulty breathing mechanics and poor posture, abnormal scapular movements, low back pain, neck pain, temporomandibular joint pain, and pelvic floor disorders.

Faulty breathing patterns are correlated with hyperventilation. When our normal respiratory rate goes above 12-16 breaths per minute, we are actually “over-breathing” (or rather “over-inhaling”).  This mechanism of over-inhalation can eventually alter our posture, leading to a hyperinflated postural pattern. This means we are holding too much air in our lungs, called “air trapping”.  A cascade of hemodynamic and neurologic changes can then occur. The CO2 levels in our blood lower, which in turn increases the sympathetic or “fight and flight” response system. Your body is then constantly on high alert and in a stressful state. This is a very common breathing pattern for adults with sleep apnea, asthma, COPD, and anxiety- but we also often find this posture in many of our patients. This is because stress is often a large culprit of this breathing pattern.

This hyperinflated breathing pattern is also associated with over dominance of the “accessory” or secondary muscles of respiration in our neck and chest.  These muscles include the sternocleidomastoid, upper trapezius, scalenes, and pectoralis. When these muscles are over-worked to help us breathe, it alters abdominal pressure gradients, and can lead to painful trigger points which cause neck discomfort and headaches. Additionally, several studies including one published in the Journal of Biomechanics have discovered a relationship between the diaphragm and low back pain. Professor Paul Hodges of the University of Queensland (a chief researcher of the diaphragm), found that poor coordination of the diaphragm can result in compromised stability of the lumbar spine, altered motor control, and dysfunctional movement patterns (Hodges et al. 2005).

At One to One Physical Therapy, we use manual techniques and therapeutic exercises to restore breathing patterns, functional movement, and eliminate pain. Because our breathing dysfunction often involves holding our breath and hyperventilating, we place more focus on exhaling in our breathing exercises.  Exhalation promotes relaxation- imagine taking a sigh of relief. We couple exhalation with core activation and postural exercises, which aim to restore rib cage positioning, reduce accessory muscle use, and improve diaphragm coordination.  One way we do this is a specific breathing training technique utilizing a balloon.

We also believe in pairing breathing with mindfulness practices and “visualization” exercises for many of our patients. One major breathing technique we use is called Buteyko breathing. Buteyko breathing teaches you to slow down your breathing which promotes relaxation.

For more information about breathing we suggest you refer to our other blog videos and articles here.

Bordoni B, Zanier E. Anatomic connections of the diaphragm: influence of respiration on the body system. J Multidisciplinary Healthcare. 2013; 6: 281-291. Doi:  10.2147/JMDH.S45443

Hodges PW, Eriksson AE, Shirley D, et al. Intra‐abdominal pressure increases stiffness of the lumbar spine. J Biomech. 2005; 38(9): 1873–1880[PubMed]