May 10, 2019

Breathing and Low Back Pain

Author: Dr. Alyssa George

It has long been thought that obesity and physical activity are strong predictors of low back pain. While this may be somewhat true, a study by Paul Hodges et al in 2006 revealed an even stronger correlation that may help us understand the physiological mechanisms behind low back pain. Hodges found that women are actually more likely to have low back pain if they have urinary incontinence or breathing difficulties while obesity and physical activity were not consistently associated with low back pain.1 These findings have revealed the importance of restoring coordination between breathing, pelvic floor, and postural muscles in individuals with low back pain.

One of the main muscles responsible for breathing is the diaphragm. It is a large dome-shaped muscle that sits under the rib cage. When we inhale, it descends, moving towards the pelvis and when we exhale, it moves back up towards the head.

Your pelvic floor muscles form a bowl-like structure at the base of the pelvis and help to support your pelvic organs. A 2011 study using MRI found that the pelvic floor muscles and the diaphragm actually move in sync with one another so as we inhale, the pelvic floor muscles also descend; as we exhale they move back up towards the head, just like the diaphragm.2

Understanding this relationship and being able to coordinate these muscles groups while grading the activation appropriately depending on the difficulty of the task is the most effective and efficient use of your “core.” For example: you likely do not need the same amount of muscle activation when you are bending over to tie your shoes as you do when you are lifting a couch. Being able to exhale during both of these activities ensures that the pelvic floor and abdominal muscles are activating to follow the movement of the diaphragm.

How to coordinate your breathing diaphragm with your pelvic floor and abdominal muscles:

  • Step 1: Find a comfortable position that allows you to focus on your body. This may be lying on your back, sitting comfortably with your back supported, or getting on your hands and knees.
  • Step 2: Let go of tension in your abdomen.
  • Step 3: Inhale deeply, allowing your rib cage to expand outward in all directions like an umbrella opening. As you inhale, allow your abdomen and pelvic floor to expand out and down, respectively (do not push them out, but allow them to “open up” in response to your inhalation).
  • Step 4: Exhale and allow your abdominal and pelvic floor muscles to recoil back to their resting position. This will feel like tensioning or lifting the pelvic floor muscles and drawing in the abdomen.

Often, this sequence of muscle activation and breathing feels like the opposite of what is natural. Most people feel like they should be “sucking in” their abdomen when they inhale so it can be difficult to break this habit. Practicing this sequence in different positions may allow you more success with achieving the correct coordination.

  1. Smith MD, 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;52:11-16.
  2. Talasz H, Kremser C, Kofler M, et al. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females. Int Urogynecol J Pelvic Floor Dysfunct, 2011, 22: 61–68.