Just Breathe!

One of the things I get asked about a lot recently is breathing re-training for musculoskeletal rehab and performance. Not having considered this much in my practice I thought I would take a quick look at the claims and the science of breathing re-training and see if it’s something I should be considering.

Respiratory training methods are obviously key interventions for those who work with cardio-respiratory conditions such as Cystic Fibrous, Chronic Obstructive Pulmonary Disease, but are they something that we should be using for musculoskeletal conditions such as back, neck, or shoulder pain?

Honestly, as a MSK physio breathing is something I don’t often consider for most of my patients as usually they don’t mention it or tell me its an issue and they usually have far other more pressing things to tell me.

Breathing is important!

Well duh! Without breathing things tend to go downhill very quickly, so I do highly recommend that almost everyone does it. However, do we need to be focusing on breathing ‘better’ as most breathing re-training tell us we should be doing?

Screen Shot 2017-09-13 at 22.14.46
Personally, I think the best type of breathing I do is the type I do without thinking about it, but I do recognise that when we are pain, or have fear, or under exertion our breathing changes dramatically, often increasing in rate, reducing in tidal volume, and even temporarily stopping.

So, I will admit I do get a patient who I can see is so tense, so guarded, and holding their breath to take a few conscious deep slow breaths before they do something effortful or that they anticipate will hurt to calm and prepare themselves.

So I guess breathing training in some MSK patients is relevant, but this isn’t anything I would class as re-training or fancy, and it isn’t something I usually ask patients to focus on that much. But there are some who do advocate that MSK physios should be focusing more on breathing techniques with their patients to help them function better.

Pain changes things!

There are some studies that have shown that those with back pain 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 just be normal variations and have been pre-existing before they had pain and related to other factors such as low physical activity or high-stress levels.

There are also some studies that show how focusing on breathing can improve pain levels in both acute and chronic low back pain. However, before you all go and get your patients blowing up balloons, or hyperventilating like demented puffer fish, it’s important to consider if it’s worth the time and effort of using these breathing techniques.

Some other research shows that the pain-modulating effects from respiratory training are very small, tiny in fact, and 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, like I said if I were to give a patient some breathing training I just tend to do nothing more than ask them to take a few deep slow breaths. However, there are some who advocate that we should go a lot further into breathing re-training, such as those over at the PRI or the Postural Restoration Institute, see the image below!

Screen Shot 2017-09-13 at 22.03.16
At the PRI, they get patients to focus on their diaphragms and chest expansions by blowing up balloons in some rather crazy positions with their arms and legs waving about in the air, doing some really weird shit.

Then there is Functional Patterns who thinks you should wrap elastic bands around your ribs and push out against them when breathing. Honestly, this profession never ceases to amaze me with some of the  at shot crazy and downright stupid things it thinks is both useful or effective for pain or disability.

Anyway, this kind of breathing re-training is nothing more than a waste of time, energy, and money. I’m sure that many of the advocates of these techniques will tell you about all the patients they have helped, and how their techniques and interventions work, but when there are NO controlled studies comparing them against control groups, then these are just empty anecdotes and marketing and sales pitches for their courses and methods.

Really crazy breathing

Now as daft as the physio profession can be with its breathing re-training interventions, these simply pale into insignificance when it comes to the world of fitness and performance with their even crazier ideas about breathing training improving strength, endurance, and performance.

I think without doubt one of the daftest gimmicks I have seen for this are inspiratory masks and valves that are claimed to replicate high altitude oxygen-deprived environments and create increased physiological responses to training.

Screen Shot 2017-09-13 at 21.43.19
In fact these masks replicate high altitude training about 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 don’t filter oxygen at all.

What they actually do is reduce the airflow into your lungs so increasing the effort to breathe. This is called inspiratory muscle training and 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 have known for decades that this is an effective intervention for those with respiratory conditions or disease, that is inspiratory muscle training, not pillow smothering by the way!

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

However, there are some uses for simple breathing techniques when training, for example, holding your breath to splint the abdomen during a heavy squat or deadlift can help brace and stiffen the trunk, and breathing out forcefully during the effort phase of the lift can help generate power, but thats about it.


So 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 pain, fear, and anxiety, but there is little evidence to say that these breathing issues are causative of these things. There is also very little evidence that breathing training in musculoskeletal conditions are effective. 

As always, thanks for reading.




  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!

Related news