Individuals with spinal pain often show breathing dysfunctions. Although the effects of breathing interventions in general have been studied, no distinctions regarding types of breathing interventions were made. Therefore, we summarized the effects of different types of breathing interventions on spinal pain and disability.
Data sources
PubMed, Web of Science, PEDro, Cochrane, PsycArticles, and Embase were systematically searched till September 2, 2025.
Review methods
Studies that described therapies using active instructions to modulate breathing or increase breathing awareness in adults with spinal pain were eligible. Breathing interventions were categorized into slow deep breathing, respiratory resistive breathing, and breathing awareness. Effects were subdivided into additional (breathing intervention + other intervention vs. other intervention) and comparative effects (breathing intervention vs. other intervention). The Downs and Black checklist was used to assess methodological quality. Meta-analyses were performed with standardized mean differences, and certainty of evidence was evaluated based on the GRADE assessment.
Results
Twenty studies involving 814 participants were included. Seventeen were of fair to good quality, three of poor quality. Meta-analyses revealed that slow deep breathing positively affected spinal pain (n = 223; SMD = -1.03; low certainty of evidence) and disability (n = 132; SMD = -1.34; very low certainty of evidence) when added to other interventions. Moreover, respiratory resistive breathing decreased spinal pain compared to other interventions (n = 75; SMD = -1.31; low certainty of evidence).
Conclusion
Breathing interventions may be valuable for the management of patients with spinal pain. Clinicians should be aware of, and consider, the various types of breathing interventions and their underlying mechanisms to tailor them to the treatment goals of their patients.
HoyDMarchLBrooksP, et al.The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis2014; 73: 968–974.
2.
HoyDMarchLWoolfA, et al.The global burden of neck pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis2014; 73: 1309–1315.
3.
HartvigsenJHancockMJKongstedA, et al.What low back pain is and why we need to pay attention. Lancet2018; 391: 2356–2367.
4.
BeeckmansNVermeerschALysensR, et al.The presence of respiratory disorders in individuals with low back pain: a systematic review. Man Ther2016; 26: 77–86.
5.
Rasmussen-BarrEMagnussonCNordinM, et al.Are respiratory disorders risk factors for troublesome low-back pain? A study of a general population cohort in Sweden. Eur Spine J2019; 28: 2502–2509.
6.
VermeerschAJLThysTGoossensN, et al.Preliminaire studie over het belang van de opsporing van ademhalingsproblemen bij patiënten met lage rugpijn. Tijdschr Geneeskd2017; 73: 529–540.
7.
López-de-Uralde-VillanuevaIDel CorralTSalvador-SánchezR, et al.Respiratory dysfunction in patients with chronic neck pain: systematic review and meta-analysis. Disabil Rehabil2023; 45: 2422–2433.
8.
VostatekPNovákDRychnovskýT, et al.Diaphragm postural function analysis using magnetic resonance imaging. PLoS One2013; 8: e56724.
9.
KolarPSulcJKynclM, et al.Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther2012; 42: 352–362.
10.
JanssensLBrumagneSMcConnellAK, et al.Greater diaphragm fatigability in individuals with recurrent low back pain. Respir Physiol Neurobiol2013; 188: 119–123.
11.
DimitriadisZKapreliEStrimpakosN, et al.Respiratory weakness in patients with chronic neck pain. Man Ther2013; 18: 248–253.
12.
BorisutSTantisuwatAGaogasigamC. The study of respiratory muscles activation during respiratory muscle strength effort in adult females with chronic neck pain. J Phys Ther Sci2021; 33: 689–694.
13.
RousselNNijsJTruijenS, et al.Altered breathing patterns during lumbopelvic motor control tests in chronic low back pain: a case-control study. Eur Spine J2009; 18: 1066–1073.
14.
StephenSBrandtCOlivierB. Neck pain and disability: are they related to dysfunctional breathing and stress?Physiother Can2022; 74: 158–164.
15.
GlynnCJLloydJWFolkhardS. Ventilatory response to intractable pain. Pain1981; 11: 201–211.
16.
DimitriadisZKapreliEStrimpakosN, et al.Hypocapnia in patients with chronic neck pain: association with pain, muscle function, and psychologic states. Am J Phys Med Rehabil2013; 92: 746–754.
17.
FosterNEAnemaJRCherkinD, et al.Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet2018; 391: 2368–2383.
18.
CorpNMansellGStynesS, et al.Evidence-based treatment recommendations for neck and low back pain across Europe: a systematic review of guidelines. Eur J Pain2021; 25: 275–295.
19.
FrenchJBrownRJBellT. Breathing techniques in the treatment of depression: a scoping review and proposal for classification. Counselling Psychotherapy Res2024; 24: 870–883.
20.
McCrackenLM. Personalized pain management: is it time for process-based therapy for particular people with chronic pain?Eur J Pain2023; 27: 1044–1055.
21.
CefalìASantiniDLopezG, et al.Effects of breathing exercises on neck pain management: a systematic review with meta-analysis. J Clin Med2025; 14: 709.
22.
JiangXSunWChenQ, et al.Effects of breathing exercises on chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Back Musculoskelet Rehabil2024; 37: 13–23.
23.
ShiJLiuZZhouX, et al.Effects of breathing exercises on low back pain in clinical: a systematic review and meta-analysis. Complement Ther Med2023; 79: 102993.
24.
ZhaiHZhangLXiaJ, et al.The efficiency of respiratory exercises in rehabilitation of low back pain: a systematic review and meta-analysis. J Sport Rehabil2024; 33: 189–200.
25.
TatsiosPIGrammatopoulouEDimitriadisZ, et al.The effectiveness of spinal, diaphragmatic, and specific stabilization exercise manual therapy and respiratory-related interventions in patients with chronic nonspecific neck pain. Systematic review and meta-analysis. Diagnostics (Basel)2022; 12: 1598.
26.
UsmanATanwarTVeqarZ. Exploring the role of respiratory intervention as an effective adjunct tool in the management of chronic low back pain: a scoping systematic review. J Bodyw Mov Ther2023; 33: 60–68.
27.
FurlanADMalmivaaraAChouR, et al.2015 updated method guideline for systematic reviews in the Cochrane Back and Neck Group. Spine (Phila Pa 1976)2015; 40: 1660–1673.
28.
MoherDLiberatiATetzlaffJ, et al.Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med2009; 6: e1000097.
29.
DownsSHBlackN. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health1998; 52: 377–384.
30.
O’ConnorSRTullyMARyanB, et al.Failure of a numerical quality assessment scale to identify potential risk of bias in a systematic review: a comparison study. BMC Res Notes2015; 8: 224.
31.
CohenJ. Statistical power analysis for the behavioral sciences. 2nd ed. New York, NY: Routledge, 1988.
32.
LöweBToussaintARosmalenJGM, et al.Persistent physical symptoms: definition, genesis, and management. Lancet2024; 403: 2649–2662.
33.
GuyattGOxmanADAklEA, et al.GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol2011; 64: 383–394.
34.
AnwarSArsalanAZafarH, et al.Effects of breathing reeducation on cervical and pulmonary outcomes in patients with non specific chronic neck pain: a double blind randomized controlled trial. PLoS One2022; 17: e0273471.
35.
Dareh-DehHRHadadnezhadMLetafatkarA, et al.Therapeutic routine with respiratory exercises improves posture, muscle activity, and respiratory pattern of patients with neck pain: a randomized controlled trial. Sci Rep2022; 12: 4149.
36.
KapitzaKPPassieTBernateckM, et al.First non-contingent respiratory biofeedback placebo versus contingent biofeedback in patients with chronic low back pain: a randomized, controlled, double-blind trial. Appl Psychophysiol Biofeedback2010; 35y: 207–217.
37.
MasroorSTanwarTAldabbasM, et al.Effect of adding diaphragmatic breathing exercises to core stabilization exercises on pain, muscle activity, disability, and sleep quality in patients with chronic low back pain: a randomized control trial. J Chiropr Med2023; 22: 275–283.
38.
AnwarSArsalanSAAhmadA, et al.Effects of breathing re-education on clinical outcomes in patients with nonspecific chronic neck pain. J Pak Med Assoc2022; 72: 2278–2282.
39.
AtilganEDTuncerA. The effects of breathing exercises in mothers of children with special health care needs: a randomized controlled trial. J Back Musculoskelet Rehabil2021; 34: 795–804.
40.
BorujeniBGYalfaniA. Effect of respiratory muscle training session on ankle muscle activity in athletes with chronic low back pain performing overhead squats: a randomized controlled trial. Int J Evid Based Healthc2020; 18: 256–264.
41.
FintaRNagyEBenderT. The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain. J Pain Res2018; 11: 3031–3045.
42.
JanssensLMcConnellAKPijnenburgM, et al.Inspiratory muscle training affects proprioceptive use and low back pain. Med Sci Sports Exerc2015; 47: 12–19.
43.
LimC-G. Comparison of the effects of joint mobilization, gym ball exercises, and breathing exercises on breathing pattern disorders and joint position sense in persons with chronic low back pain. Phys Ther Rehabil Sci2020; 9: 25–35.
44.
MehlingWEHamelKAAcreeM, et al.Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Altern Ther Health Med2005; 11: 44–52.
45.
OhYJParkSHLeeMM. Comparison of effects of abdominal draw-in lumbar stabilization exercises with and without respiratory resistance on women with low back pain: a randomized controlled trial. Med Sci Monit2020; 26: e921295.
46.
ParkSHLeeMM. Effects of progressive neuromuscular stabilization exercise on the support surface on patients with high obesity with lumbar instability: a double-blinded randomized controlled trial. Medicine (Baltimore)2021; 100: e23285.
47.
ParkSHOhYJSeoJH, et al.Effect of stabilization exercise combined with respiratory resistance and whole body vibration on patients with lumbar instability: a randomized controlled trial. Medicine (Baltimore)2022; 101: e31843.
48.
ThongtipmakSBuranrukOEungpinichpongW, et al.Immediate effects and acceptability of an application-based stretching exercise incorporating deep slow breathing for neck pain self-management. Healthc Inform Res2020; 26: 50–60.
49.
YuDYuYPengQ, et al.Clinical efficacy of breathing training combined with core stability training in chronic nonspecific low back pain. Pak J Med Sci2023; 39: 1008–1012.
50.
LiYZhaoQZhangX, et al.The impact of core training combined with breathing exercises on individuals with chronic non-specific low back pain. Front Public Health2025; 13: 1518612.
51.
MohanVAhmadNBTambiNB. Effect of respiratory exercises on neck pain patients: a pilot study. Pol Ann Med2016; 23: 15–20.
52.
OtadiKNakhostin AnsariNSharifyS, et al.Effects of combining diaphragm training with electrical stimulation on pain, function, and balance in athletes with chronic low back pain: a randomized clinical trial. BMC Sports Sci Med Rehabil2021; 13: 20.
53.
ParkSHLeeMM. Effects of a progressive stabilization exercise program using respiratory resistance for patients with lumbar instability: a randomized controlled trial. Med Sci Monit2019; 25: 1740–1748.
54.
ChalayePGoffauxPLafrenayeS, et al.Respiratory effects on experimental heat pain and cardiac activity. Pain Med2009; 10: 1334–1340.
55.
JerathRBeveridgeCBarnesVA. Self-regulation of breathing as an adjunctive treatment of insomnia. Front Psychiatry2018; 9: 780.
56.
BuschVMagerlWKernU, et al.The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing—an experimental study. Pain Med2012; 13: 215–228.
57.
ChungOYBruehlSDiedrichL, et al.Baroreflex sensitivity associated hypoalgesia in healthy states is altered by chronic pain. Pain2008; 138: 87–97.
58.
RussoMASantarelliDMO’RourkeD. The physiological effects of slow breathing in the healthy human. Breathe (Sheff)2017; 13: 298–309.
59.
GiardinoNDGlennyRWBorsonS, et al.Respiratory sinus arrhythmia is associated with efficiency of pulmonary gas exchange in healthy humans. Am J Physiol Heart Circ Physiol2003; 284: H1585–H1591.
SagheerMAKhanMFSharifS. Association between chronic low back pain, anxiety and depression in patients at a tertiary care centre. J Pak Med Assoc2013; 63: 688–690.
62.
Del NegroCAFunkGDFeldmanJL. Breathing matters. Nat Rev Neurosci2018; 19: 351–367.
63.
FinchamGWStraussCMontero-MarinJ, et al.Effect of breathwork on stress and mental health: a meta-analysis of randomised-controlled trials. Sci Rep2023; 13: 432.
64.
KornelsenJMcIverTAStromanPW. Unique brain regions involved in positive versus negative emotional modulation of pain. Scand J Pain2019; 19: 583–596.
65.
WirthBAmstaldenMPerkM, et al.Respiratory dysfunction in patients with chronic neck pain - influence of thoracic spine and chest mobility. Man Ther2014; 19: 440–444.
66.
GrimstoneSKHodgesPW. Impaired postural compensation for respiration in people with recurrent low back pain. Exp Brain Res2003; 151: 218–224.
67.
BerenshteynYGibsonKHackettGC, et al.Is standing balance altered in individuals with chronic low back pain? A systematic review. Disabil Rehabil2019; 41: 1514–1523.
68.
Gholami BorujeniBYalfaniA. Reduction of postural sway in athletes with chronic low back pain through eight weeks of inspiratory muscle training: a randomized controlled trial. Clin Biomech (Bristol, Avon)2019; 69: 215–220.
69.
KolarPNeuwirthJSandaJ, et al.Analysis of diaphragm movement during tidal breathing and during its activation while breath holding using MRI synchronized with spirometry. Physiol Res2009; 58: 383–392.
70.
WhittakerJL. Ultrasound imaging of the lateral abdominal wall muscles in individuals with lumbopelvic pain and signs of concurrent hypocapnia. Man Ther2008; 13: 404–410.
71.
BouvierGLavioletteLKindlerF, et al.Dyspnea-pain counterirritation induced by inspiratory threshold loading: a laser-evoked potentials study. J Appl Physiol (1985). 2012; 112: 1166–1173.
72.
Morélot-PanziniCDemouleAStrausC, et al.Dyspnea as a noxious sensation: inspiratory threshold loading may trigger diffuse noxious inhibitory controls in humans. J Neurophysiol2007; 97: 1396–1404.
73.
ChoiSNahSJangHD, et al.Association between chronic low back pain and degree of stress: a nationwide cross-sectional study. Sci Rep2021; 11: 14549.
74.
KoleckMMazauxJMRascleN, et al.Psycho-social factors and coping strategies as predictors of chronic evolution and quality of life in patients with low back pain: a prospective study. Eur J Pain2006; 10: 1–11.
75.
VlemincxECortez-VázquezG. Slow breathing for anxiety: a critical perspective towards personalization. Anxiety disorders and related conditions: conceptualization and treatment from psychodynamic and cognitive behavioral perspectives. Cham, Switzerland: Springer Nature Switzerland AG, 2024, p. 67–86.
76.
TortaDMLegrainVMourauxA, et al.Attention to pain! A neurocognitive perspective on attentional modulation of pain in neuroimaging studies. Cortex2017; 89: 120–134.
77.
BushnellMCCekoMLowLA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci2013; 14: 502–511.
78.
BogaertsKWalentynowiczMVan Den HouteM, et al.The interoceptive sensitivity and attention questionnaire: evaluating aspects of self-reported interoception in patients with persistent somatic symptoms, stress-related syndromes, and healthy controls. Psychosom Med2022; 84: 251–260.
79.
GinzburgKTsurNBarak-NahumA, et al.Body awareness: differentiating between sensitivity to and monitoring of bodily signals. J Behav Med2014; 37: 564–575.
80.
PaulusMPSteinMB. An insular view of anxiety. Biol Psychiatry2006; 60: 383–387.
81.
MatheveTBogaertsKTimmermansA. Virtual reality distraction induces hypoalgesia in patients with chronic low back pain: a randomized controlled trial. J Neuroeng Rehabil2020; 17: 55.
82.
WagnerBSteinerMHuberDFX, et al.The effect of biofeedback interventions on pain, overall symptoms, quality of life and physiological parameters in patients with pelvic pain: a systematic review. Wien Klin Wochenschr2022; 134: 11–48.
83.
MittintyMMVanlintSStocksN, et al.Exploring effect of pain education on chronic pain patients’ expectation of recovery and pain intensity. Scand J Pain2018; 18: 211–219.
84.
VambheimSMKylloTMHeglandS, et al.Relaxation techniques as an intervention for chronic pain: a systematic review of randomized controlled trials. Heliyon2021; 7: e07837.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
