Available via license: CC BY-NC 3.0
Content may be subject to copyright.
J Korean Soc Phys Med, 2018; 13(3): 81-89
http://dx.doi.org/10.13066/kspm.2018.13.3.81
O
nline ISSN:
Print ISSN:
2287-7215
1975-311X
Research Article Open Access
Effectiveness of Breathing Exercises on Spinal Posture, Mobility and Stabilization
in Patients with Lumbar Instability
Jim-Yi Kang, PT, MS⋅Dong-Kwon Seo, PT, PhD⋅Ju-Chul Cho, PT, MS
1
⋅Byoung-Kwon Lee, PT, PhD
†
Department of Physical Therapy, Konyang University
1
Department of Rehabilitation Medicine, Wellciti Hospital
Received: March 1, 2018 / Revised: April 25, 2018 / Accepted: May 24, 2018
ⓒ
2018 J Korean Soc Phys Med
| Abstract |1)
PURPOSE:
This study was conducted to monitor the
performance of breathing exercises by patients with lumbar
instability who had altered breathing patterns.
METHOD S:
To investigate the effects of breathing
exercises on spinal posture, mobility, and stabilization in
patients with lumbar instability with altered breathing
patterns, 30 adult participants were enrolled on the basis of the
selection criteria and randomly assigned to the breathing
exercise group (BEG) or trunk stabilization exercise group
(SEG). A pre-test was performed prior to the intervention
exercise program. The intervention exercise program
consisted of 15 sessions (three sessions per week for 5 weeks)
between August and September of 2016. The post-test was
performed on the 6th week of intervention.
RESULTS:
Pre- and post-test comparisons of BEG and
SEG revealed significant improvements in all tested items in
†Corresponding Author : Byoung-Kwon Lee
lbk6326@konyang.ac.kr, http://orcid.org/0000-0002-1230-6088
This is an Open Access article distributed under the terms of
the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/3.0) which permits
unrestricted non-commercial use, distribution, and reproduction
in any medium, provided the original work is properly cited.
the SEG, except for spinal mobility, while significant
improvements in spinal postures 1 and 2, spinal mobility, and
stabilization were found in the BEG. Between-group
comparisons revealed that there were no significant
differences in spinal posture 1, spinal posture 2, spinal
mobility, or stabilization, whereas significant differences
were found in spinal posture 2 and spinal mobility, with the
BEG showing greater improvements than the SEG.
CONCL USION :
Based on the findings in the present study,
it is believed that breathing exercises have important effects
on spinal posture, mobility, and stabilization in patients with
lumbar instability who have altered breathing patterns.
Key Words:
Breathing exercise, Lumbar instability, Trunk
stabilization
Ⅰ. Introduction
Spinal segment instability refers to displacement of the
mechanical axis of motion from the inside to the outside
of the disc becoming more severe, thereby making it
difficult for muscle activity control to maintain a stable
angle or position within the support plane against
displacement of the body center. Moreover, changes in the
compensatory spine angle from an unbalanced muscle
82 | J Korean Soc Phys Med Vol. 13, No. 3
recruitment that may occur during such a time can
exacerbate pain and dysfunction (Hodges and Richardson,
1999; Selles et al., 2001). Such an increase in instability
causes cord level motor system imbalance while also
causing pain in the lower extremities involved with
activities of daily living (ADLs), such as walking and sitting
(Comerford and Mottram, 2001; McConnell, 2002). Many
previous studies have reported transversus abdominis
dysfunction, along with a trunk muscle activation pattern
that is different in patients with chronic low back pain
(CLBP) or lumbar instability, which include delayed
contraction of the transversus abdominis, reduced motor
control ability, abnormal recruitment patterns, reduced
contraction ability, and excessive activities of the rectus
abdominis muscle and external oblique abdominal muscles
(Ferreira et al., 2004; Urquhart et al., 2005; Hides et al.,
2010).
The diaphragm cooperates with other muscles near the
abdominal cavity to regulate intra-abdominal pressure
(IAP). Such postural control functions of the chest cavity
and abdomen through breathing by the diaphragm cooperate
with other active movement systems to maintain and
increase spinal and truncal mobility and stability, which
have important effects on low back pain (Kalpakcioglu
et al., 2009; Kolar et al., 2010; Bradley and Esformes,
2014). Moreover, cooperation between the abdominal
muscles and diaphragm can reduce spinal stability and
cause changes to movement patterns (Liebenson, 2004).
Contraction of the transversus abdominis and pelvic floor
through abdominal drawing and neutral position control
by the pelvis are the most basic strategies in stabilization
programs (Oliveira et al., 2017). Recently, studies have
begun to investigate the improvement of cardiopulmonary
function by actively using various breathing exercises based
on the breathing function of the active structure of the
trunk, along with changes in trunk structure and function
(McConnell and Romer, 2004; Koppers et al., 2006).
During maximal forced expiration, the transversus
abdominis showed the highest activation changes among
other abdominal muscles, while the activation change
appeared greater than that of the abdominal drawing
strategy (Jhu et al., 2010; Ishida et al., 2012). These effects
increased the possibility of training the transversus
abdominis and pelvic floor through an expiration strategy
in patients with CLBP or lumbar instability.
Trunk breathing pattern changes disturb coordination of
the co-contraction of active movement structures, and a
single dysfunction affects other elements and subsequently
causes problems in mobility and stability, including spinal
posture (Wallden, 2009). The association between CLBP
and instability is very high, with 23
–
69% of patients with
CLBP having lumbar local instability (Sihvonen et al.,
1997). Recently, the number of study cases investigating
breathing exercises in musculoskeletal system patients has
increased; however, clinical studies that apply breathing
exercises in patients with lumbar instability are still lacking
in Korea. Accordingly, the present study investigated
application of breathing exercises for reeducation of
patients with lumbar Instability who have altered breathing
patterns and the effects of such exercises on the spine.
Ⅱ. Methods
1. Subjects
The subjects consisted of adults residing in Gwangju,
South Korea, who received explanations regarding the
objectives and procedures in the study and voluntarily
provided their consent to participate. 1) Adults aged 20
–
40
years with lumbar instability (characterized by excessive
movement in specific segments during active movement
and posterior-anterior spring test causing large movements
and pain), 2) no history of back surgery, inflammatory
spinal disorder, deformed vertebrae, fracture, or
neurological radiating pain, 3) no spinal muscle
strengthening and cardiopulmonary exercises for the past
1 month, 4) and no diagnosis of pathological problems
|83
Effectiveness of Breathing Exercises on Spinal Posture, Mobility and Stabilization
in Patients with Lumbar Instability
Fig. 1. Breathing correction and exercise used in this study
Fig. 2. Breath strengthening exercise used in this study
in the respiratory system were included in this study.
2. Process of Research
A total of 27 adults with lumbar instability and altered
breathing patterns who were selected on the basis of the
selection criteria of the study were randomly assigned into
an experimental group (BEG; n=13) or a control group
(SEG; n=14). After conducting a pre-test, the intervention
was applied for 5 weeks between August and September
of 2016. The intervention consisted of three sessions per
week for a total of 15 sessions. The post-test was performed
on week 6 of the intervention. The overall exercise program
for both groups consisted of 5 min of light treadmill walking
as a warm-up exercise, followed by 30 min of breathing
exercise for the experimental group and trunk stabilization
exercise for the control group as the main exercise and
then 5 min of light trunk stretching for the cool down
exercise.
3. Intervention
A basic breathing exercise program was applied in sitting
and standing postures as shown in Fig. 1 (Lehnert-Schroth,
2000; Perri, 2007). After receiving education regarding
abdominal movement during inspiration and expiration, rib
movement, stabilization and proper direction of the
movement of the sternum, the subjects corrected
problematic breathing on their own. Next, diaphragmatic
breathing was facilitated by diaphragmatic compression
during inspiration and relaxation during expiration.
Afterwards, coordinated exercise with abdominal drawing
and normal mechanism of breathing exercise were applied.
The strengthening exercise method was as follows (Fig.
2). Neutral positions of the spine in the sitting and standing
postures were determined, and inhalation and exhalation
84 | J Korean Soc Phys Med Vol. 13, No. 3
Fig. 3. Stabilization exercise used in this study
were conducted with the mouthpiece of the breathing
equipment in the mouth so that the exercise could
strengthen the pattern of proper breathing by strengthening
the actions of the respiratory muscles. If the subjects felt
dizzy or fatigued during the exercise, they were allowed
to rest, after which the exercise was restarted. The
ventilation bag used in the exercise was adjusted in
accordance with the capabilities of the respiratory muscles
of each patient, while the breathing frequency was set
within the range of resting respiration per minute. Prior
to the experiment, the respiratory capacity for each
individual was determined, and the subjects learned the
exercise methods. The experimental group exercised for
30 min for each session, which was divided into three
sets with each set lasting for 10 min. A rest period of
2 min was provided between each set and the exercise
was performed for 5 weeks.
The trunk stabilization exercise changed from
non-resistance to external resistance (Fig. 3), the direction
of resistance was changed from proximal to distal and from
up and down to lateral, and the support surface was changed
from non-weight bearing to weight-bearing posture. The
exercise was based on the approach of relearning for
reduced deep muscle control ability in patients with low
back pain, and all exercises were accompanied by
contraction of the pelvic floor muscles (O'Sullivan, 2000).
Basic training was performed in the dorsal recumbent,
quadruped, sitting, and standing postures. The subjects
trained for co-contraction of the pelvic floor and transversus
abdominis, as well as determined their neutral spinal
position through pelvic control without corresponding to
global muscles. Contraction was maintained for 10
–
60 s,
and the number of sets ranged between 5 and 10. Each
session lasted for 30 min, and the exercise program was
applied for 2 weeks. For strengthening training, an elastic
band was utilized to apply resistance in the dorsal
recumbent position, while hip joint flexion and standing
were applied in the sitting posture and squatting in the
standing posture. The posture was maintained for 10
–
60
s, while the number of sets ranged between 5 and 10. Each
session lasted for 30 min, and the exercise program was
applied for 3 weeks (Ki et al., 2016).
4. Clinical Measurement
The SPIRO TIGER
®
(ldiag, Switzerland) breathing
exercise equipment was used. This equipment, which
allows forced breathing training, has a mouth piece and
a respirator bag connected by a tube. A ventilation hole
in the tube allows inflow and outflow of air to appear
during breathing. The equipment is designed to allow
proper outflow and inflow of CO
2
and O
2
to prevent
dizziness from breathing (Markov et al., 2001). A Spinal
Mouse (IDLAG AG, Swiss) was used for the spinal
measurements. This is a device that measures spinal
mobility and shape on the sagittal and frontal planes, and
its reliability has been confirmed via correlation analysis
based on time differences and measurers.
5. Statistical Analysis
Descriptive statistics were used to investigate the general
characteristics of the subjects, while paired t-tests were
used for the within-group comparisons of spinal posture,
mobility, and stabilization between pre- and
post-interventions. Independent t-tests were employed to
identify differences between groups. Data analysis was
conducted using the SPSS (Version 18.0; SPSS Inc.,
|85
Effectiveness of Breathing Exercises on Spinal Posture, Mobility and Stabilization
in Patients with Lumbar Instability
Baseline Variable BEG (n=13)* SEG (n=14)* t
Age (years) 26.93±6.01 29.43±5.06 -1.19
Height (cm) 158.50±5.78 162.21±4.00 -1.98
Weight (kg) 56.50±7.91 61.07±7.30 -1.59
BEG=breathing exercise group, SEG=stabilization exercise group.
*Values are expressed as the mean±SD.
Table 1. General Characteristics of the Subjects
Chicago, IL, USA) statistical software. A p <.05 was
considered to indicate statistical significance.
Ⅲ. Result
A total of 27 subjects who participated in the present
study were randomly allocated into the BEG and SEG.
In the homogeneity test, there were no significant
differences between groups (Table 1). With respect to
standing posture 1, there were significant differences in
both thoracic flexion angle (
p
<.01), and lumbar extension
angle (
p
<.05) within the BEG and SEG. Comparison of
the changes between groups revealed no significant
differences in the thoracic or lumbar areas. With respect
to standing posture 2 (with external load), there were
significant differences in the thoracic flexion angle decrease
(extension) and lumbar extension angle decrease (flexion)
(
p
<.01) within the BEG and SEG. Additionally, comparison
of the changes between groups revealed significant
differences in the lumbar area, but not in the thoracic area
(
p
<.01). With respect to spinal mobility, there were
significant differences in the thoracic flexion mobility
increase and lumbar flexion mobility decrease within the
BEG (
p
<.01). Moreover, the thoracic and lumbar flexion
mobility increased and decreased within the SEG,
respectively; however, the differences were not significant.
Comparison of the changes between groups revealed
significant differences in the thoracic flexion mobility
increase (
p
<.01); however, the lumbar flexion mobility
decrease was not significant. With respect to spinal
stabilization, there were significant differences in the
compensatory sagittal plane angle decrease for thoracic
flexion and lumbar extension (
p
<.01) within the BEG and
SEG. Comparison of the changes between groups revealed
no significant differences in the thoracic or lumbar areas
(Table 2).
Ⅳ. Discussion
The present study applied breathing exercises to patients
with lumbar instability who had altered breathing patterns
and measured their spinal posture, segment mobility, and
spinal stabilization ability with loads. The study also aimed
to verify the importance of breathing exercises for patients
with lumbar instability and CLBP by comparing the results
to those of trunk stabilization exercises, which have been
confirmed to be effective for treating spine curvature
changes, as well as inducing spinal mobility and
stabilization in patients with CLBP.
An operating force line in forward and downward
directions in the lumbo-pelvic area from pelvic high,
forward, and upward directions in the thoraco-abdominal
area and upward direction of the head helps create a
balanced spine posture (Chaitow, 2002; Otman et al., 2005).
In general, the operating force line in the extension direction
acts on the thoracic area, and forced breathing exercises
with controlled respiratory rate and speed create extension
of the ribs and facet joints in a coordinated manner
(Neumann, 2013), which further induces changes in the
trunk muscles. Therefore, the results observed in the th
86 | J Korean Soc Phys Med Vol. 13, No. 3
Group/Outcome Baseline
†
5-week
†
tt
Thoracic
Spinal Posture 1
BEG 40.77±3.72 36.54±3.86 9.59** -1.37
SEG 43.00±6.05 39.07±5.49 4.68**
Spinal Posture 2
BEG 43.46±4.29 39.38±4.68 11.13** 1.52
SEG 41.14±5.78 35.93±6.82 7.84**
Spinal Mobility
BEG 9.23±2.48 15.62±3.52 -9.08** 5.44**
SEG 13.00±2.28 14.07±3.17 -1.88
Stabilization
BEG 4.23±2.00 1.38±.96 4.85** -1.62
SEG 4.00±1.92 2.07±1.20 4.40**
Lumbar
Spinal Posture 1
BEG -29.62±4.29 -25.54±4.57 -11.13** -.61
SEG -27.07±7.45 -24.00±7.87 -2.24*
Spinal Posture 2
BEG -32.00±3.80 -27.54±3.77 -14.27** -3.05**
SEG -27.21±5.25 -22.79±4.26 -6.11**
Spinal Mobility
BEG 51.00±9.78 45.08±9.71 5.32** -1.85
SEG 51.50±7.52 49.29±5.60 1.57
Stabilization
BEG -2.85±1.51 .08±1.80 -6.56** 1.30
SEG -3.07±2.33 -.86±1.91 -3.91**
†
Values are expressed as the mean±SD.*and** indicate significant differences at
p
<.05 and
p
<.01, respectively. Spinal Posture 1=standin
g
p
osition; Spinal Posture 2=standing position with an external load, Spinal Mobility=trunk flexion, Stabilization=standing positio
n
with an external load, BEG=breathin
g
exercise
g
rou
p
, SEG=stabilization exercise
g
rou
p
.
Table 2. Comparison of the outcome measures within and between groups
oracolumbar area for spinal postures 1 and 2 in the present
study indicate that pelvic control education and correction
of breathing mechanism, together with coordination and
strengthening of the diaphragm and abdominal muscles,
had a favorable effect on balancing the trunk posture. In
particular, the between-group comparison for spinal posture
2 showed significant differences in the lumbar area. It is
believed that this was the result of correction of the
breathing pattern as a result of the costo-diaphragmatic
breathing mechanism helping to improve mobility in the
sternum and ribs, which facilitated thoracic extension so
that the extension motion in the lumbar area could be
reduced through relative compensation. Moreover, it also
increased the IAP from diaphragmatic depression and
stimulated various abdominal muscles, which supported the
lumbar area to reduce compensatory extension motions
according to the load being applied. Since it has been
reported that breath holding and trunk muscle activation
|87
Effectiveness of Breathing Exercises on Spinal Posture, Mobility and Stabilization
in Patients with Lumbar Instability
pattern changes become more severe in patients with CLBP
when an external load is applied (Perri, 2007), it was
important to train the subjects to not hold their breath
through breathing correction and control training when an
external load was being applied. In the present study, there
were significant differences in spinal mobility within the
BEG, with an increased thoracic flexion mobility and
decreased lumbar flexion mobility. There was also
increased thoracic flexion mobility and decreased lumbar
flexion mobility within the SEG; however, these differences
were not statistically significant. An increased thoracic
mobility through breathing exercises reported in a previous
study supported the findings of the present study (Ekstrum
et al., 2009). It is believed that maintaining proper muscle
length and elasticity from adequate use of the respiratory
muscles through recovery of proper breathing mechanisms
induced thoracic relaxation, which ultimately increased the
thoracic motion. Furthermore, chest relaxation and
increased mobility decreased the lumbar motion during
flexion. In the present study, the spinal stabilization test
revealed significant decreases in the compensatory sagittal
angles of thoracic flexion and lumbar extension within both
groups. Comparison of the amount of changes between
groups revealed no significant differences in the thoracic
and lumbar angles. The present study attempted to identify
changes in the trunk muscle activation patterns indirectly
in patients with lumbar instability by measuring the amount
of compensated angles created by the thoracic and lumbar
areas. Moreover, breathing exercises were used to induce
decreases in the compensated angle change to determine
improvements in the stabilization ability of the spine. A
significant decrease in the compensated angle was found
after the breathing exercises, similar to the significant effect
on compensated angles observed after trunk stabilization
exercises. Perri (2007) stated that abnormal breathing
patterns must be corrected to achieve postural stability and
spinal stabilization. Accordingly, it is believed that
correction of breathing patterns and strengthening exercises
improved spinal stabilization while an external load was
being applied.
The most important limitation of this study is the small
sample size. In addition, it is not clear how long the training
effect lasted as no follow-up was performed. Consequently,
it is difficult to generalize the results of this study to all
lumbar instability patients. Therefore, future studies should
be conducted to overcome these limitations. We suggest
that breathing exercises be considered an important
intervention in clinical practice when lumbar instability
treatments are planned.
Ⅴ. Conclusion
Based on the findings of the present study, it is believed
that breathing exercises have an important effect on the
spinal posture, mobility, and stabilization of patients with
lumbar instability who have altered breathing patterns.
Considering the effects of breathing on physical and mental
health, continued clinical studies of breathing in patients
with various chronic musculoskeletal diseases are
warranted.
References
Bradley H, Esformes J. Breathing pattern disorders and
functional movement. Int J Sports Phys Ther. 2014;
9(1):28-39.
Chaitow L, Bradley D, Gilbert C. Multidisciplinary approaches
to breathing pattern disorders. New York. Churchill
Livingstone. 2002.
Comerford MJ, Mottram SL. Movement and stability
dysfunction--contemporary developments. Man Ther.
2001;6(1):15-26.
Ekstrum JA, Black LL, Paschal KA. Effects of a thoracic
mobility and respiratory exercise program on
pulmonary function and functional capacity in older
adults. Physical & Occupational Therapy in Geriatrics.
88 | J Korean Soc Phys Med Vol. 13, No. 3
2009;27(4):310-27.
Ferreira PH, Ferreira ML, Hodges PW. Changes in recruitment
of the abdominal muscles in people with low back
pain: ultrasound measurement of muscle activity.
Spine (Phila Pa 1976). 2004;29(22):2560-6.
Hides JA, Boughen CL, Stanton WR, et al. A magnetic resonance
imaging investigation of the transversus abdominis
muscle during drawing-in of the abdominal wall in
elite Australian Football League players with and
without low back pain. J Orthop Sports Phys Ther.
2010;40(1):4-10.
Hodges PW, Richardson CA. Transversus abdominis and the
superficial abdominal muscles are controlled
independently in a postural task. Neurosci Lett.
1999;265(2):91-4.
Ishida H, Hirose R, Watanabe S. Comparison of changes in
the contraction of the lateral abdominal muscles
between the abdominal drawing-in maneuver and
breathe held at the maximum expiratory level. Man
Ther. 2012;17(5):427-31.
Jhu JL, Chai HM, Jan MH, et al. Reliability and relationship
between 2 measurements of transversus abdominis
dimension taken during an abdominal drawing-in
maneuver using a novel approach of ultrasound
imaging. J Orthop Sports Phys Ther. 2010;40(12):
826-32.
Kalpakcioglu B, Altinbilek T, Senel K. Determination of
spondylolisthesis in low back pain by clinical
evaluation. J Back Musculoskelet Rehabil. 2009;
22(1):27-32.
Ki C, Heo M, Kim HY, et al. The effects of forced breathing
exercise on the lumbar stabilization in chronic low
back pain patients. J Phys Ther Sci. 2016;28(12):
3380-3.
Kolar P, Sulc J, Kyncl M, et al. Stabilizing function of the
diaphragm: dynamic MRI and synchronized spirometric
assessment. J Appl Physiol (1985). 2010;109(4):
1064-71.
Koppers RJ, Vos PJ, Boot CR, et al. Exercise performance
improves in patients with COPD due to respiratory
muscle endurance training. Chest. 2006;129(4):
886-92.
Lehnert-Schroth C. Three-dimensional treatment for scoliosis:
a physiotherapeutic method for deformities of the
spine. Martindale Pr. 2000.
Liebenson C. Spinal stabilization-an update. Part 1-
biomechanics. Journal of bodywork and movement
therapies. 2004;8(2):80-4.
Markov G, Spengler CM, Knopfli-Lenzin C, et al. Respiratory
muscle training increases cycling endurance without
affecting cardiovascular responses to exercise. Eur
J Appl Physiol. 2001;85(3-4):233-9.
McConnell AK, Romer LM. Respiratory muscle training in
healthy humans: resolving the controversy. Int J Sports
Med. 2004;25(4):284-93.
McConnell J. Recalcitrant chronic low back and leg pain--a
new theory and different approach to management.
Man Ther. 2002;7(4):183-92.
Neumann DA. Kinesiology of the Musculoskeletal System-
E-Book: Foundations for Rehabilitation. Elsevier
Health Sciences. 2013.
Oliveira CB, Negrao Filho RF, Franco MR, et al. Psychometric
Properties of the Deep Muscle Contraction Scale for
Assessment of the Drawing-in Maneuver in Patients
With Chronic Nonspecific Low Back Pain. J Orthop
Sports Phys Ther. 2017;47(6):432-41.
O'Sullivan PB. Lumbar segmental 'instability': clinical
presentation and specific stabilizing exercise
management. Man Ther. 2000;5(1):2-12.
Otman S, Kose N, Yakut Y. The efficacy of Schrot h s
3-dimensional exercise therapy in the treatment of
adolescent idiopathic scoliosis in Turkey. Saudi Med
J. 2005;26(9):1429-35.
Perri M. Rehabilitation of breathing pattern disorders.
Rehabilitation of the Spine: a Practitioners Manual.
USA. Lippincott Williams & Wilkins. 2007.
|89
Effectiveness of Breathing Exercises on Spinal Posture, Mobility and Stabilization
in Patients with Lumbar Instability
Selles RW, Wagenaar RC, Smit TH, et al. Disorders in trunk
rotation during walking in patients with low back
pain: a dynamical systems approach. Clin Biomech
(Bristol, Avon). 2001;16(3):175-81.
Sihvonen T, Lindgren KA, Airaksinen O, et al. Movement
disturbances of the lumbar spine and abnormal back
muscle electromyographic findings in recurrent low
back pain. Spine (Phila Pa 1976). 1997;22(3):289-95.
Urquhart DM, Barker PJ, Hodges PW, et al. Regional
morphology of the transversus abdominis and obliquus
internus and externus abdominis muscles. Clin
Biomech (Bristol, Avon). 2005;20(3):233-41.
Wallden M. The neutral spine principle. J Bodyw Mov Ther.
2009;13(4):350-61.
