Many common aches and pains, particularly around the head, neck and shoulders, may be caused in part by inefficient breathing. Problems like chronic headaches, numb and tingling hands, neck pain, or upper back pain might actually caused by a respiratory issue. The breathing exercises that might help are tedious and unappealing, but they are worthwhile regardless of whether or not they actually solve any painful problems.
This article will trace a series of unproven but plausible connections1 between respiratory dysfunction and a constellation of painful upper body conditions: from garden variety stiffness to seemingly unlikely and severe consequences such as rotator cuff injuries, whiplash, and thoracic outlet syndrome.
If it exists, the connection between dysfunctional breathing and pain is straightforward in principle: if the diaphragm doesn’t do its job well, muscles in the upper chest (pectoralis minor) and throat (sternocleidomastoid and scalenes) will try to help out.2 Unfortunately, these muscles aren’t built for routine respiration, and they get exhausted and tender (more on how this works below). If this occurs, it could trigger a cascade of uncomfortable consequences over time.If the diaphragm doesn’t do its job well, muscles in the upper chest (pectoralis minor) and throat (scalenes) will try to help out.
This scenario may be common. About three quarters of my massage therapy clients3 seemed to be trying to lift their rib cages with muscles in the upper chest and throat.4 Most were able to stop doing this on request, but only when they focussed.
Some seemed unable to make the change at all, their scalene muscles obviously contracting with every breath, no matter how much they put their minds to it. I recall one client who seemed particularly incapable of breathing with her diaphragm; with each inhalation, she clenched her scalene muscle group so tightly that cords of muscle stood out in her neck, while her abdomen remained still. That just can’t be good! She was no more able to change it than I can wiggle my ears.
That’s the connection, in theory.
Why would we ask such unsuitable muscles to work too hard in the first place? Why would we ever breathe dysfunctionally?
Lots of reasons. Anything that makes breathing more difficult could provoke over-use of the scalenes and other accessory breathing muscles. Perhaps the best example is smoking: obvious, common, and preventable. (It’s also risk-factor for chronic pain independently,5 so that’s a double whammy.) More examples ahead…
If you understand the principle of hydraulics, you can quickly grasp how breathing should work. The diaphragm is your primary breathing muscle. It is a thin, wide sheet of muscle that separates the rib cage from the abdomen. It has a high domed shape that flattens out significantly when it contracts. That dome-shape is much more pronounced that most people realize, and it’s important to understand.
When the diaphragm contracts, that dome flattens significantly, and as it flattens it pushes downwards on the viscera like a hydraulic plunger, like a piston in a cylinder. Since the watery viscera cannot be compressed,6 they have to get out of the way. So where do they go?
They go outwards! The abdominal contents are forced down and out. When you inhale with your diaphragm, your belly expands. When your diaphragm moves, your belly must move — if it doesn’t move, you simply aren’t using your diaphragm.7 So good breathing is described as “belly breathing,” “abdominal breathing,” or “diaphragmatic breathing.”
The way in which the belly sticks out during healthy inhalation can be seen in most statuary of the Buddha. Good breathing and a flexible pot belly are associated with enlightenment!
Enlightenment aside, good breathing is generally associated with vitality (as well as some other unusual phenomena8 ). Probably only the liveliest people are breathing well: effective athletes, martial artists, dancers and actors, and people who belly laugh a lot.
The rest of us — me included — struggle to maintain our respiration quality (and our vitality).
If breathing diaphragmatically was good enough for Buddha and is a key to vitality, why doesn’t everyone do it?
What happens when you get out of the habit of using your most important respiratory muscle, and you habitually overuse the accessory respiratory muscles for two or three decades?
When people don’t breathe well, they tend to breathe in reverse: that is, the movement of their abdomen during respiration is the opposite of what is normal and healthy! Instead of letting the belly move outward during inhalation, they try to suck it in. And on exhalation, they relax the belly slightly. Of the next ten people you pass on the street, nine of them are probably breathing in reverse.
|Healthy Breathing||belly goes out||belly sucks in|
|Reverse Breathing||belly sucks in||belly goes out|
Even people who can breathe diaphragmatically when they go slowly will start to reverse breathe when they pick up the pace. Only after years of practice have I learned to breathe diaphragmatically at speed. It’s purely a matter of coordination, a pat-your-head/rub-your-tummy challenge!
Reverse breathing is not inherently bad, but it’s not a good idea to do it all the time. It’s hard to ventilate thoroughly if you are sucking in your belly while your diaphragm is trying to descend.It's so challenging to inhale while your belly is sucked in that it surprising that all those reverse breathers don't black out more often!
In fact, it’s so challenging to inhale while your belly is sucked in that it surprising that all those reverse breathers don’t black out more often. Shouldn’t the side walks be littered with dazed, gasping reverse breathers? How are they managing to get air at all, if not through contraction of the diaphragm?
The body is equipped with several emergency backup respiratory muscles. The diaphragm does not work alone. Any breath that uses extra muscle is considered to be forced respiration.
Normal, healthy, relaxed breathing doesn’t take much effort. Inhalation can be managed by the diaphragm alone, and exhalation takes no muscle contraction at all: the lungs collapse elastically, pushing air out effortlessly.
A sneeze or a cough, on the other hand, takes everything you’ve got: every fibre of muscle attached to your rib cage contracts violently. Yawning is not as heavy a recruiter, but is still much more intense than normal breathing. And, of course, you also use more breathing muscles when you exercise — depending on the intensity, this can range anywhere from just a little bit to quite a lot of extra breathing power.
Here are the muscles involved in respiration, and their roles in healthy breathing:
(Note: I have removed some helpful anatomical drawings from this section because I did not own the rights to them. I eagerly look forward to hiring some artists to create some original illustrations. This is in the works for 2009 and 2010. Meanwhile, plain old text will just have to do!)
Unfortunately, most people don’t use their diaphragms to breathe, so they have to use their emergency breathing muscles. It’s inefficient, so they have to work hard to take normal breaths, as if every moment was like a respiratory emergency! Does stress cause people to breathe poorly? Or does breathing poorly cause stress? It’s both, obviously: each pattern aggravates the other. What a pickle.
So, other than always breathing like you’re trying to run from lions, and giving your sternocleidowhatsis muscles a lot of exercise, what’s the big deal? What’s so bad about breathing with your chest and neck muscles?
Chronic upper chest and neck breathing presumably exhausts and then eventually damages the emergency breathing musculature, causing a list of bad news: exercise gets more difficult, and the risk of both acute and chronic injuries and painful conditions in the neck and shoulders increases dramatically — especially whiplash injuries.10
The importance of exercise should not be underestimated. Canadians suffer from a general plague of poor fitness — when “the burn” is much worse, because we can’t breathe properly, how much more difficult is it to start and maintain an exercise program? The consequences of a sedentary lifestyle are far-reaching.11The risk of both acute and chronic injuries and painful conditions in the neck and shoulders increases dramatically
Chronic overuse of the scalenes and other respiratory helpers may lead to their “injury” in the form of metabolically exhausted and painful patches of muscle tissue known as “trigger points.”12 This article leans heavily on this idea, and yet it’s questionable — some experts dispute the existence or nature of trigger points,13 and even if they do exist, no one actually knows if they are caused by chronic muscle overuse. It’s just a theory — a reasonable one, but just a theory. On the other hand, I also don’t have to invoke the idea of trigger points to explain why tired muscles might be a problem for the area.
Assuming that trigger points are a factor, their intensity can range from mild to crippling. “Sick” muscles like this feel rotten and don’t do their job well: the more you’ve worn out your neck and chest muscles trying to breathe without your diaphragm, the more likely you are to have a problematic upper body posture and lousy mechanics of the shoulder and spinal joints, which leads to yet more injuries.
Fatigue and/or trigger points and poor posture might cause and/or aggravate many other problems:
That’s the tip of the iceberg, but it gives you a good sense of the complex interconnections and the potential for totally exhausted chest and neck muscles to wreak havoc on your upper body. Most people are suffering from these and many other consequences of inefficient respiration by — no kidding — about age twenty. In other words, most of the people who walk into my office are suffering from problems which can be traced, at least in part, to respiratory dysfunction.
I’ve seen people’s lives changed forever by some of these conditions — especially whiplash injuries that are effectively permanent, or people with TOS who are unable to lift their arms without excruciating pain or total numbness. In all such cases, the connection to respiratory dysfunction is surprisingly straightforward. Breathing matters!
To really understand this phenomenon, it’s necessary to go just a bit deeper into respiratory mechanics. This section is for the devoted reader who wants to understand exactly what’s going on when breathing goes wrong. It’s easy enough to understand that breathing without the benefit of diaphragmatic contraction is probably not such a good thing. But why, exactly, is it such a problem?
Exhalation without the aid of the diaphragm is no big deal — even strong exhalation. The diaphragm simply isn’t used for that in the first place. The muscles that pull the rib cage down are aided by gravity: those ribs are heavy, and it doesn’t take much to pull them down a little more. And the muscles we use for the job are quite large and strong: the abdominals and the quadratus lumborum are large, each of them bigger than any of the muscles used to assist inhalation. And, furthermore, we don’t really have any psychological inhibitions against contracting our abdominal muscles — it’s the relaxed belly we shy away from.
It’s inhaling without the diaphragm that is so difficult. Without the diaphragm, inhalation is extremely hard work: somehow or other, you’re going to have to get that rib cage lifted up against the pull of gravity, and against the pull of abdominal and back muscles that don’t like to relax.Exhaling without the diaphragm is no big deal — it’s inhaling without the diaphragm that’s a challenge!
The only muscles that are really designed for serious rib-lifting are the intercostals, and they can only do so much. So people end up recruiting the pectoralis minors, sternocleidomastoids, and (worst of all) the scalenes. And even that is not, in itself, necessarily a bad thing: the trouble is when you do it all the time, for ordinary breathing. Imagine a handful of muscles the size of pencils trying to lift your rib cage several times per minute.
All day long, every day.
That is the ultimate and specific problem with not using your diaphragm.
So now what?
People mostly aren’t interested in breathing better — they are interested in fixing pain, of course. But one thing at a time: can you breathe better? Less dysfunctionally?
Probably. To stop breathing with your chest and throat muscles, you must have the strength and coordination to breathe well with your diaphragm. It can be done both directly with diaphragm exercises, or indirectly by practicing activities that demand good diaphragmatic function.
Studies have shown that exercising your respiratory musculature directly is effective,18 but also that it probably can’t be done half-heartedly: some intensity and dedication may be necessary to get anywhere with it.1920
Another approach is a breathing technique used by swimmers: controlled frequency breathing (CFB) is a common involves holding the breath for about 7 to 10 strokes (feels like a long time when you’re working hard). A 2016 test of CFB in in competitive college swimmers showed that they way were more resistant to fatigue of the muscles of inspiration21 — which is potentially exactly what we want. (Note that CFB had no other effect on performance, e.g. aerobic capacity.) Obviously you don’t have to swim to work with this idea: essentially any rhymic breath holding during exercise probably works the same way.
The diaphragm is a muscle you can’t see and can’t feel directly. It’s like trying to learn how to wiggle your ears. A lifetime of bad habits may stand in your way. Above all, you will doubt that it is really necessary — it’s an awful lot of trouble for a muscle you barely knew you had. But it’s the only way.
Take heart, though: it’s no different than what any singer or martial artist or swimmer learns. It’s difficult, but hardly impossible. The following sections offer several useful perspectives and strategies that can serve you well.
It was a “probably” for learning to breathe better, but it’s just a big fat “maybe” when it comes to actually treating pain. Consider thoracic outlet syndrome (TOS), a controversial and ambiguous condition with a variety of possible causes: it’s plausible that respiratory dysfunction is one factor in thoracic outlet syndrome, perhaps even a big one, but it is hardly a sure thing. A stubborn case of TOS (or anything) could be just as resistent to respiratory training as any other therapy. Respiratory dysfunction might simply be another symptom of TOS, not a cause — in that case, learning to breathe better might help you cope with one of the effects of TOS, but never come anywhere close to curing it.
It’s a gamble, but it’s a gamble where you win something either way: learning to breathe better is undoubtedly inherently valuable, even if it doesn’t touch the pain.
When people start a weight training program, it takes weeks for the first obvious increases in strength to manifest. These initial gains are not due to an increase in muscle mass — that comes later. The increase comes from coordination alone.
Specifically, a beginner learns to “recruit” more muscle fibres.22 Recruiting a lot of motor units at once takes coordination, a physical skill that can only be learned with practice, practice, practice. It’s true for your biceps, and it’s true for your diaphragm. Learning to breathe with your diaphragm is mainly about learning how to recruit more of its motor units every time you inhale.
It’s important to understand this, so that you realize that your goal is not exactly a big, beefy diaphragm, but simply one that you have a good neurological relationship with. You mostly just want to learn how to use what you’ve got. But how do you do that when you can’t even feel it?
Learning to breathe diaphragmatically really is like learning to raise one eyebrow or wiggle your ears — only worse, because it’s difficult to even tell when you’ve succeeded. To learn to use your diaphragm, you have to make the results visible. Here’s how:
Find yourself a good, heavy book. This book should pass the “thunk test” — it should make a good, satisfying thunk when you drop it on the ground.
Lie down on your back with your knees up.
Place the book square on your belly.
Take a deep breath.
If the whole book lifts up, you used your diaphragm. If it didn’t lift up, or lifts unevenly, you didn’t use your diaphragm. Laws of hydraulics. It is absolutely impossible to contract your diaphragm without your belly sticking out.
So there you go: visual feedback is how you’re going to learn when you are actually contracting your diaphragm. Now, do that at least twenty times in a row, and your diaphragm isn’t strong unless you can lift it at least three centimetres every time. Six would be better.
Standing up to your chin in a swimming pool is an even more ingenious way of providing resistance to diaphragmatic contraction. Can you see why?
Strength training is usually called “resistance” training by professionals, because “weight” training is too narrow a term. Weights such as barbells and stacks of iron plates in a machine are only one way of providing resistance to muscle contraction. It is also possible to use big elastic bands, springs, body weight, other muscles, and even just stationary objects. And water …
Water pressure is strong: even just a couple of feet under water, the pressure on just 1 square centimetre is an amazing 2.2 kilograms — less closer to your chest, and more closer to your waist. That’s a lot of resistance to abdominal expansion! And it’s perfectly uniform.
Anything that resists abdominal expansion is resisting diaphragmatic contraction, of course. Lifting the book, as described above, obviously resists abdominal expansion: but not much, and only in one direction, and somewhat awkwardly. That exercise is really intended for the visual feedback, not the resistance.
Breathing while standing in water, however, requires the diaphragm to overcome a strong, unrelenting water pressure evenly distributed over the abdomen. It’s like wearing a broad, elastic garter belt. It’s a phenomenal strength (resistance) training exercise for the diaphragm.
In fact, it’s so difficult that most beginners will hardly be able to budge their diaphragm, and will — uh oh! — end up trying to lift their rib cage instead. It’s actually a great way to demonstrate how the chest and neck muscles tend to get recruited when the diaphragm isn’t being used, or can’t be used — you can really feel all those secondary muscles kicking in and trying to take over!
So do experiment with this in the early stages, just so you can see what it feels like, but don’t try to use it as a strength-building exercise until you’ve mastered book lifting. Happy water breathing!
Simply deep breathing while submerged to your chin is a simple way to challenge your respiratory musculature. The exercise challenge can be made much more acute — with surprising physics on display — if you add a breathing tube to the equation and sink just a little further into the water.
It’s super difficult to breathe through a narrow (¼ to ½-inch) tube while submerged, and the hardship spikes impressively with every inch of depth. Unless you stop it, the small diameter of the tube becomes the sole pressure outlet for the weight of all that water. Air whooshes out of your lungs and through the tube, if you don’t stop it. Put your tongue over the tube end, and you will notice a formidable suction. When you try to inhale through that tube, you have to first match the suction and then exceed it to get any air! It becomes well nigh impossible as you descend.
This pressure differential happens with a snorkel too, and snorkelling would be indeed good respiratory exercise in itself, but there are two differences that make all the difference:
So both sides of the pressure equation are smaller, resulting in a much more modest force to overcome.
The breathing tube physics described above were a matter of life and death in early diving suits — the old-timey kind with a big metal helmet and a long breathing tube to the surface. The same physics were at work, but at hyperbolic extremes, due to the depth. The tube had to be pressurized from the surface to match the water pressure. If it wasn’t, something really horrible happened. Not only was the diver crushed, but — if the depth was great enough — he would literally be sucked into the helmet and tube, reduced to a paste of meat and bone chips.
For realsies.23 That’s the power of water pressure multiplied both by area and depth! Pressure math is spooky.
Everyone’s emotionally constipated, unless you’re a sociopath or still in diapers. The price of maturity is that you repress much of your Genuine Self, and end up with a comfort zone that is suffocatingly narrow, respiratory dysfunction, and upper body pain. Ain’t life grand? Who knew neck pain could open such a can of worms?
So, shallow breath and emotional constipation usually go together, and so they should be fixed together. Oddly enough, the best cure for shallow breathing is … deeper breathing. Rocket science.
Specifically, I recommend “round breathing.”24 In a nutshell, round breathing is fast, deep, continuous breathing that is hyperventilatory and gets you all dizzy and emotionally raw. What fun! You don’t have to be able to breathe diaphragmatically to do it: the point is that it breaks down the emotional rigidity that makes it hard to breathe diaphragmatically in the first place.Round breathing breaks down the emotional rigidity that makes it so hard to breathe diaphragmatically in the first place
If this sounds dreadful, don’t knock it until you’ve tried it. Round breathing is the closest thing I know of to a fountain of youth (except maybe “exercise”). Human beings are amazingly uptight critters. We get hung up on a whole lot of stuff, and this is the single best way to loosen up that I know of.
There are at least three other major articles on this website on this subject, and they are listed at the end of this one.
This exercise is straightforward and is vital for mastering many breathing techniques. It has several benefits: in addition to strongly stimulating diaphragmatic breathing, this ancient yoga exercise will also …
And a host of other minor benefits. In all my years of experimenting with qigong, taijiquan, martial arts, yoga and other physical disciplines, this exercise still offers more bang-for-buck than any other single exercise. It’s what I call a “lifer,” best done once a day for the rest of your life.
Here are the instructions:
My father always told me to stay out of bars, advice which has served me well, I think. I wish he had also told me to stay out of chairs — they are just as corrupting and dangerous!
This is not easy advice to follow, of course, but it is good advice nevertheless. Chronic sitting is an obvious mechanical barrier to diaphragmatic breathing: the belly is compressed, and cannot expand as easily or as far.
And, of course, if you’re in a chair … you’re not getting any exercise, are you? Says the massage therapist who has spent thousands of hours in a chair creating this website. Do as I say, not as I do! Seriously, if you can’t avoid working in chairs, do everything you can to mitigate the harmful effects. Above all, take micro-breaks!
“Reduce your stress level” is the most vague and unhelpful advice I can imagine. It’s a huge topic, addressed thoroughly in some other articles:
For the purposes of this article, I just want to instill in you some respect for the consequences of stress: if you are so stressed out that you can’t breathe properly, what else is stress doing to you? It’s time to take a serious look solving some problems in your life, and/or changing the way you react to challenges — for the sake of your health.We are a society of shallow breathers
There is such a thing as a respiratory therapist. They primarily work with people who have respiratory diseases (such as asthma, bronchitis, emphysema, and the respiratory components of things like heart attacks and stroke), and might be difficult to access and a bit puzzled by a patient seeking help for a less obvious respiratory problem. If you’re interested in improving the strength of your breathing, it certainly wouldn’t hurt to inquire, but you might find it to be a bit of a dead end.
Any physical therapist or physiatrist might have some ideas about the respiration connection, but many would not — they would either have no particular knowledge of it, or they would dismiss it as a consideration because they disagree with my hypothesis, or because they know something about your case that eliminates it as a consideration.
In short, there isn’t really any particular sort of professional who can assist, though the idea will be of interest to many.
We are a society of shallow breathers: afraid of moving our bellies, afraid of expressing ourselves, living our lives in chairs, and stressed out by our busy minds. Instead of breathing with the diaphragm, people tend to breathe with upper body musculature that is inadequate to the task, with a cascade of musculoskeletal consequences and vulnerabilities. These are the solutions to dysfunctional breathing:
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
Jeff N. of Atlanta, Georgia, sent me this story about his respiration connection:
I read this article a few years ago as I looked for reasons for severe neck pain that I was suffering with. It made sense, as my scalenes were extremely tight and my first rib was fixed in an elevated position. After reading the article, I tried to alter my breathing, which had been shallow, usually from my mouth. This went on for a few weeks, but didn’t get anywhere and gave up.
Fast forward to last year: My daughter had some breathing issues as a baby and learned poor breathing habits (shallow manner and through her mouth, like me). That’s when the light went on again for me. I started working on my breathing again, concentrating on breathing through my nose and using my diaphragm. A year later, I’m about 85% better. Another year and I think I’ll have total resolution.
The reason I’m emailing you is because you say that the connection between respiration and pain is theory. I’m here to tell you that it is not. I’ve spent thousands of dollars and considered surgery for thoracic outlet syndrome (which I’m sure would have done me no good in the long run). It’s disappointing that not one of the healthcare professionals that I saw over the years even suggested that breathing might be a factor. Now, after 10 years of excruciating pain, I’m almost healed. I hope my story will offer some hope to others.
Six updates have been logged for this article since publication (2005). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.
I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
— More general revision, mostly organizing and clarifying treatment suggestions.
— Added a paragraph and footnote about controlled frequency breathing.
— More editing. Modernization of footnotes and citations. Added a drawing of a man beathing, and an anatomical diagram of the diaphragm.
— More thorough editing of the introduction, and modernization of discussion of trigger points.
— Some basic editing of the first half of the article, through “8 reasons.”
— Upgraded “hydraulics” diagram.
The original version of this article was unmodified for a long, long time!
This review of the evidence indicates that exercising your breathing musculature probably works pretty darned well, and benefits take about “20 to 30 minutes per day for 10 to 12 weeks” to achieve. Better yet, the evidence also shows that it’s reasonable to expect some benefits “regardless of method”! In other words, there’s no great concern about which technique to use. Common protocols for respiratory training “are generally safe, feasible, and effective.”BACK TO TEXT
Since we know that inspiratory muscle training can improve inspiratory muscle function, lung volume, lung capacity, and work capacity, what level of intensity will “do the trick”? This was a randomized and controlled trial — good science stuff — with three groups, each group training at a different level. The results suggest that high intensity is better than low intensity: “High-intensity IMT set at 80% of maximal effort resulted in increased MIP and SMIP, lung volumes, work capacity, and power output in individuals who were healthy, whereas IMT at 60% of maximal effort increased work capacity and power output only. Inspiratory muscle training intensities lower than 40% of maximal effort do not translate into quantitative functional outcomes.”BACK TO TEXT
After a gunshot wound, a “high-intensity, interval-based threshold inspiratory muscle training (IMT) was undertaken” for the 38-year-old man. The treatment was found to be “safe and well tolerated. It was associated with improvements in maximum forced inspiratory flow and changed the locus of symptom limitation during high-intensity exercise from dyspnea to leg fatigue.”BACK TO TEXT