The Scenario: intermittent episodes of neck pain that have been ongoing for years. Any/all treatment (ie. physio, chiro, massage) helps, as does a maintenance home exercise program, but it invariably always comes back. Someone points out that you’re a chest breather… could this be contributing?
The link between faulty breathing patterns and neck pain is a relatively new one in the field of physiotherapy. Most authors will credit a textbook published in 2002 (multidisciplinary approaches to breathing pattern disorders) by Leon Chaitow and company as being one of the earliest pieces in really establishing and detailing this relationship.
How can breathing affect the neck?
Let’s first look at the anatomy.
We have 2 groups of muscles that control our breathing: the neck/chest (ie. apical) breathing group and the diaphragm.
Neck/Chest Breathing Musculature: predominantly your scalenes and your sternocleidomastoid (SCM for short). Your scalenes are a group of 3 slender muscles that run down the side of your neck to attach to the top of your first and second ribs. Although they’re individually responsible for specific neck movements, due to their anchor point onto the ribs, when they contract they also aid in elevating these upper ribs in order to create space for the lungs to expand when you’re breathing.
Your SCM is another slender muscle that originates off your mastoid process – a bony ridge located directly behind your ear – and runs down to anchor itself onto the inside edge of your collar bone and the top of your sternum. Similar to the scalenes, they’re also responsible for both specific neck movements but instead of elevating the ribs, they help to elevate the collarbone and sternum when you’re breathing.
Diaphragm: your diaphragm on the other hand is a massive dome-shaped muscle located at the bottom of the lungs. When it contracts it flattens and moves downwards, allowing the middle and lower part of your thorax to expand outwards in all directions like a balloon. Your diaphragm is designed to be the workhorse behind your breathing – during quiet breathing conditions, your diaphragm should be responsible for 70 – 80% of the work.1 During exercise, your body needs more air, which requires more chest/lung expansion, which is when apical breathing is meant to kick in. Otherwise, it should be predominantly your diaphragm the rest of the time.
At least, that’s how it should be.
Many of us are apical breathers more or less all the time – which (A) these apical muscles were never designed to do, and (B) will lead to overuse and increased strain and eventual neck pain. In 2004 Maria Perri and Elizabeth Halford from Highland Mills, New York examined the breathing patterns of 94 people from their community.2 They categorized their breathing patterns into 2 simple categories: normal and abnormal. “Normal” breathing in this study was defined as abdominal expansion (ie. diaphragmatic) with all other types of breathing patterns (including lifting of the chest or collar bones) defined as “abnormal”. They also gave these people a survey asking if they were experiencing any current or previous pain and to state where. The study was simple in its purpose – examine if any relationships existed between breathing pattern and pain location.
During relaxed breathing in standing, they found that 56.4% of their study group demonstrated faulty “abnormal” breathing. Ask them to take in a deep breath – this increased to 75.0%. Correlating this with pain – they found that only one region of pain seemed to have a relationship with faulty breathing – neck pain. The percentage of those with faulty breathing that also were experiencing, or had recently experienced, neck pain was 83.8%. Interestingly enough, several research papers in the early 2000s had previously established that those with neck pain typically show increased overall muscular activity within their scalenes and SCM.3,4
Building on Perri’s findings, in 2009 Eleni Kapreli from Greece wanted to investigate if those with neck pain were more likely to demonstrate faulty breathing mechanics.5 Kapreli took 12 people with chronic neck pain (neck pain persisting longer than 6 months) and matched them to 12 pain-free people of the same age, gender, height, weight, and activity level. Kapreli had everyone complete a spirometry exam – ie. a collection of tests used to measure lung function.
Looking at lung function, Kapreli found that those with neck pain had significantly reduced overall function vs the pain-free group: 14% less maximum voluntary ventilation (L/min), 21.4% less maximum inspiratory pressure, 16.5% less maximum expiratory pressure and significantly reduced overall respiratory muscle strength.
So there seems to be a relationship between faulty apical breathing patterns and neck pain. So the next question: would re-training a faulty breathing pattern in those with neck pain help reduce symptoms?
Surprisingly the answer is – we don’t really know. We think so, and some of the research is trending towards a yes, but we don’t really know with certainty yet.
Most of the research surrounding breathing re-training involves those with respiratory disorders (ie. asthma or COPD) with very little research actually examining the effect of breathing re-training on those with neck pain.
A literature review article published in 2017 referenced only 2 articles that examined breathing re-training in those with neck pain – an article published in the Journal of the Medical Association of Thailand in 2014, and an article in press by McLaughlin and company out of McMaster University in Hamilton Ontario.6 – 8 However neither study strictly examined the effect of breathing re-training on reducing neck pain as compared to a control group.
It seems only 1 study to date has examined breathing re-training in those with neck pain compared to a control group.9 Mohan and colleagues took 10 people with neck pain lasting longer than 3 months, and randomly split them into 2 groups: a control group which received neck stretching and mobility exercises, and a breathing intervention group that received the same exercises in addition to a diaphragmatic breathing exercise that was to be performed 2x/week for 8 weeks. At the end of the study, the authors did find a significant reduction in neck pain intensity scores in the diaphragmatic breathing group – unfortunately very little of this finding was elaborated upon in the discussion section of their article.
Although good strong research hasn’t been performed (yet) in this realm, the logic is there. Majority of us are chest/neck breathers leading to overuse of these apical muscles which can lead to neck pain. Re-train yourself how to diaphragmatically breathe, take that work-load off the apical muscles, and this could transfer to a reduction of neck pain.
In almost everyone with neck issues I often teach diaphragmatic breathing as the very first exercise: legs elevated with one hand on the stomach and the other on the chest. The idea is to use your hands as feedback – diaphragmatic breathing to move the hand on the belly without moving the hand on the chest. I make my guys breathe in over a count of and out over a count of 4 to 6 and prescribe this for 10 – 15 minutes/session.
The effects of this exercise alone on reducing neck pain is sometimes pretty impressive.
Constantly chest breathing can absolutely be contributing to your neck pain. Dealing with nagging neck pain? Have rehab gains seemingly plateaued? Have you and your physio assessed your breathing mechanics yet? Maybe it’s time you should.
References:
Hruska Jr RJ. “Influences of dysfunctional respiratory mechanics in orofacial pain.” Orofacial Pain and Related Disorders 1997;41(2):211-227.
Perri MA, Halford E. “Pain and faulty breathing: a pilot study.” Journal of Bodywork and Movement Therapies 2004;8:297-306.
Falla D, Jull G, Hodges PW. “Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain.” Experimental Brain Research 2004;157:43-48.
Falla D, Rainoldi A, Merletti R, Jull G. “Myoelectric manifestations of sternocleidomastoid and anterior scalene muscle fatigue in chronic neck pain patients.” Clinical Neurophysiology 2003;114:488-495.
Kapreli E, Vourazanis E, Billis E, Oldham JA, Strimpakos N. “Respiratory dysfunction in chronic neck pain patients. A pilot study.” Cephalalgia 2009;29:701-710.
Kahlaee AH, Ghamkhar L, Massoud A. “The association between neck pain and pulmonary function. A systematic review.” American Journal of Physical Medicine and Rehabilitation 2017;96:203-210.
Yeampattanaporn O, Mekhora K, Jalayondeja W, Wongsathikun J. “Immediate effects of breathing re-education on respiratory function and range of motion in chronic neck pain.” Journal of the Medical Association of Thailand 2014;97(7):55-59.
McLaughlin L, Goldsmith CH, Coleman K. “Breathing evaluation and retraining as an adjunct to manual therapy.” Manual Therapy article in press.
Mohan V, Ahmad NB, Tambi NB. “Effect of respiratory exercises on neck pain patients: a pilot study.” Polish Annals of Medicine 2016;23:15-20.