What's Breathing Got to Do With It? Low Back Pain

Welcome to the second instalment of "What's breathing got to do with it?"  As I mentioned in the first post on this topic, breathing is much more complicated than we might think, and disruptions in breathing have impacts that are far reaching (read:  it doesn't just create shortness of breath).  Today we will discuss how breathing and low back pain are connected.

When it all began...
Ok, so we might not be able to pinpoint exactly when we starting linking breathing and low back pain, but the Smith/Russell/Hodges study that came out of Australia in 2006 sure gave us some ammunition to investigate further.  Their longitudinal study of over 38,000 women found that "middle aged and older women had higher odds of having low back pain when they experienced breathing difficulties."  Hodges (2000) had previously found that the diaphragm - thought to be only a breathing muscle - demonstrated recruitment behaviours that suggested it had a role in postural stability, so this perhaps led him down the path to search for more connections.

Breathing affects movement
Due to that ground-breaking study showing the diaphragm played a role in postural stability, there have been numerous studies since that suggest altered breathing patterns affect how we move.  Belgian physiotherapist Lotte Janssens discovered that when the respiratory muscles (diaphragm and rib muscles) fatigue, they cause an otherwise healthy individual to have a balance strategy similar to someone with low back pain.  It should be noted that persons with low back pain have a less than optimal balance strategy - relying on muscles in their feet and ankles to keep them upright when jostled, as opposed to healthy individuals who will use their back and abdominal muscles. Janssens further discovered that the respiratory muscles fatigued faster in those people with low back pain.  Noted Czech physiotherapist Pavel Kolar discovered that individuals with low back pain had an altered position of their diaphragm, which may affect the muscles' ability to behave in a coordinted fashion.

Which came first...the chicken or the egg?
These kind of discoveries always lead us down the path of trying to discover, which came first - low back pain or breathing dysfunction?  Sometimes, there may be clues in the history - maybe someone had battled severe asthma all their life, maybe there was an incidence of of increased stress and anxiety, or maybe it was a prolonged illness that disrupted breathing patterns and therefore core strategies,  leaving the individual vulnerable to back pain.  Sometimes we may find it was the other way around - that quick twist or bend that resulted in acute, sharp back pain.  Usually that kind of pain causes us to breathe in quickly and hold it, often bracing our abdominal muscles for protection.  When this bracing pattern is adopted for a prolonged period, it can become habitual, leading to shallow breathing, which as you will learn below, disrupts normal muscle function.

How should our muscles work together?
The best way to understand how our muscles work, is to consider what muscles actually make up our "core."  We previously considered this to be just our transversus abdominus (TA - deep abdominal) muscle, but we've since discovered, that just like breathing, our core is much more complicated.  Having good spine and trunk support means we need to have a balanced effort between many muscles - the major players being the diaphragm, the pelvic floor muscles, the TA and a deep back muscle called multifidus.  When these muscles work as a team - we are unstoppable!  Okay, maybe not unstoppable, but we should at least be in a better position to reduce injuries.  The team works together like an internal elevator:  when we breathe in, the diaphragm will contract and flatten out into the abdominal cavity, pushing our organs towards the pelvis.  In a balanced situation, the abdominal muscles and pelvic floor muscles will lengthen to decrease the pressure the movement of the diaphragm would cause.  When we exhale, the diaphragm relaxes and moves upward and the pelvic floor and TA will experience a recoiling effect (a really small contraction) and the organs are moved back up (we will talk more about how this affects digestion in a later post!).  This up/down motion of the diaphragm and pelvic floor usually created an efficient, balanced movement strategy.  The amount of movment and recruitment of these muscles will depend on our activity level - but it is important to note that this strategy should be employed with most movement (heavy lifts will require a slightly altered strategy but the underlying teamwork must still be balanced).

How does it go wrong?
So what might happen to break up the team?  An obvious answer would be injury - because despite how much we work on having optimal muscle recruitment, things happen.  And when we experience pain, our breathing patterns often change.  Think about the time you banged your shin on a hard surface - ouch!  There is that quick indrawing of breath, the breath hold, then the slightly laboured breathing as your whole body tenses from the pain.  Luckily, the acute pain in our shin usually dies down after a few minutes, but in other situations, we may experience pain for a prolonged period.  That shallow breathing pattern may become habit. 

I often see that same type of breathing pattern in my patients with asthma.  Having a real struggle for breath can often lead to a situation where the body is constantly in "red alert" breathing mode.  Fast, upper chest breathing means the diaphragm may not be going through it's full range of motion.  And because the pelvic floor and TA muscles need that downward motion of the organs to go through their range of motion, their strength and recruitment may be affected by upper chest breathing.  This means your core strategies are less than optimal and can put you at risk for injury.  In this scenario, I often feel that breathing disorder came before the back pain.
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One last influence on both breathing and back pain, is stress.  This becomes a topic in itself (which we will cover in a later post), but suffice it to say, that stress will often disrupt breathing patterns, leaving you in "red alert mode" which not only affects your breathing pattern, but also increases your sensitivity to painful stimuli - this part we will address in the next post.

What can you do?
When breathing patterns and core muscle recruitment strategies are disrupted, the key is to go back to the basics and start from there.  Breathing is the foundation for good health, so restoring normal, relaxed breathing patterns are key to optimizing core and movement strategies.  Without addressing breathing, it would be like trying to build a house on a foundation of sand - eventually the waves of movement would erode that foundation leaving you with a host of problems.

For a few tips on how to re-establish better breathing patterns, you can check my previous blog post here.  Keep in mind that if you have developed a history of upper chest, faster breathing, restoring diaphragm breathing does not happen overnight.  Think about how hard it is to break a habit or start a new one (think New Year's Resolutions!).  Sometimes, you may need a little outside assistance with re-learning diaphragm breathing - just as someone with suboptimal running or walking form would have to re-learn.  This is where physiotherapists with training in assessing and treating breathing patterns come in!  Check out www.bradcliff.com for practitioners near you.  For those who don't have someone near them, Breathe Well Physio offers on-line consults as well - drop me a line and we can see what we can do for you!

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