Journal of Back and Musculoskeletal Rehabilitation 37 (2024) 13–23 13

DOI 10.3233/BMR-230054
IOS Press

Review Article

Effects of breathing exercises on chronic low

back pain: A systematic review and
meta-analysis of randomized controlled trials
Xiaoyu Jianga , Wenyu Sunb , Qiang Chena , Qiling Xua , Guoming Chenb and Hongyan Bib,∗
a
College of Rehabilitation Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
b
Department of Rehabilitation Medicine, Affiliated Hospital of Shandong University of Chinese Medicine, Jinan,
Shandong, China

Received 26 February 2023

Accepted 20 June 2023

Abstract.
BACKGROUND: A range of studies concerning the effects of breathing exercises on chronic low back pain (CLBP) have been
proven inconclusive.
OBJECTIVE: The study aimed to evaluate the effectiveness of breathing exercises for the treatment of CLBP.
METHODS: We considered randomized controlled trials in English or Chinese that used breathing exercises for the treatment of
CLBP. An electronic search was performed in the MEDLINE, EMBASE, Web of Science, Cochrane Library, CNKI, Wan Fang,
and CBM databases for articles published up to November 2022. Two reviewers independently screened the articles, assessed
the risk of bias using the Cochrane risk of bias tool, and extracted the data. The outcomes included pain, lumbar function and
pulmonary function post-intervention.
RESULTS: A total of thirteen studies (n = 677) satisfied the inclusion criteria. The meta-analysis results demonstrated a
significant effect of breathing exercises on the Visual Analog Scale (VAS) score (SMD = −0.84, 95% CI: −1.24 to −0.45, P <
0.0001), the Oswestry Disability Index (ODI) score (SMD = −0.74, 95% CI: −0.95 to −0.54, P < 0.00001), Forced Vital
Capacity (FVC) score (MD = 0.24, 95% CI: 0.10 to 0.37, P = 0.0006), Forced Expiratory Volume in 1 second /Forced Vital
Capacity (FEV1/FVC) (MD = 1.90, 95% CI: 0.73 to 3.07, P = 0.001), although there was no significant difference between the
breathing exercises and control interventions for Forced Expiratory Volume in the first second (FEV1) score (MD = 0.22, 95% CI
= [0.00, 0.43], P = 0.05), and Maximal Voluntary Ventilation (MVV) score (MD = 8.22, 95% CI = [−4.02, 20.45], P = 0.19).
CONCLUSION: Breathing exercises can reduce pain, assist people with lumbar disabilities, and improve pulmonary function,
and could be considered as a potential alternative treatment for CLBP.

Keywords: Low back pain, respiratory exercise, exercise therapy, pulmonary function, meta-analysis

1. Introduction margin and above the inferior gluteal folds, with or

without leg pain [1]. Chronic low back pain (CLBP)
Low back pain (LBP) is clinically defined as pain, is characterized as experiencing LBP for more than 12
muscle tension, or stiffness localized below the costal weeks [2]. It causes pain and functional impairment
and has in recent years, been the leading cause of dis-
∗ Corresponding author: Hongyan Bi, Department of Rehabilitation
ability across the globe [3,4]. The lifetime prevalence
Medicine, Affiliated Hospital of Shandong University of Chinese of LBP is approximately 80% while the prevalence of
Medicine, Jinan, Shandong 250011, China. E-mail: hy_bi@163.com. CLBP is in the region of 23% [5] with more than half

ISSN 1053-8127/$35.00 c 2024 – IOS Press. All rights reserved.

14 X. Jiang et al. / Effects of breathing exercises on ClBP: A systematic review and meta-analysis of RCT

a billion people suffering from CLBP globally [6]. As 2. Methods

global incidents of CLBP have escalated, it has im-
pacted its sufferers physically and psychologically; ad- This systematic review was performed in accordance
ditionally, it has placed overwhelming financial strain with the preferred reporting items for systematic re-
on economies around the world, due to the expense of views and meta-analyses (PRISMA) and was registered
medical treatment and widespread absenteeism from in the PROSPERO database under identification num-
work in all socio-economic areas [7,8]. ber CRD42022380578.
Currently, there is no well-defined, established
paradigm for the treatment and management of CLBP. 2.1. Search strategy
Although patients with CLBP are frequently managed
with pharmacological therapy, a lack of efficacy com- We searched for articles in PubMed, EMBASE,
bined with adverse events can result in unresolved com- Web of Science, Cochrane, CNKI, Wan Fang, and
plications [9]. Nonpharmacologic therapies, including the CBM databases from their inception to November
exercise and psychosocial management, are the pre- 2022. The following Medical Subject Headings (MeSH)
ferred approach for the majority of patients and may be terms and keywords were used as the primary search
supplemented with adjunctive drug therapies [10–12]. terms: breathing exercise, respiratory exercise, expira-
According to clinical practice guidelines, the imple- tory training, respiratory muscle training, LBP, back
mentation of exercise therapy is advocated as a primary pain, and CLBP. Reference lists of the relevant stud-
treatment as it performs a fundamental role in pain re- ies and reviews were manually screened to ascertain
duction and developing improved levels of mobility the existence of additional studies that were suitable
and function [13,14]. Clinical observations have noted for inclusion. The Appendix provides an example of
PubMed’s search strategy.
that breathing exercises are crucial to the treatment
and prevention of CLBP [15–17]. Breathing exercises
2.2. Inclusion and exclusion criteria
support muscle activation which strengthens core mus-
cles; greatly improves spinal stabilization via the co-
Studies were eligible if they met the following cri-
contracting of deep muscles such as the internal oblique
teria: (1) used the randomized controlled trial (RCT)
abdominals, multifidus, and pelvic floor muscles; and
design; (2) included participants diagnosed with CLBP
significantly increases muscle thickness (in contrac-
(18 years of age or older), regardless of gender, social
tion); and improves contraction rates [18,19]. Addition-
factors, or the clinical setting; (3) compared breathing
ally, breathing exercises modify the patient’s pulmonary
exercises with the placebo (sham tape) or routine reha-
function by improving their forced vital capacity along- bilitation intervention (e.g., physical therapy, exercise
side other oxygenation and blood volume indicators, therapy, spinal stabilization); (4) the study included at
allowing for the development of enhanced breathing least one of the following outcome assessments: pain,
patterns and improving lumbar pain and function [20]. pulmonary function, or lumbar function; and (5) where
A combination of these physical factors creates a sce- chronic pain was defined as lasting more than 12 weeks.
nario whereby a patient will experience reduced lev- Studies were excluded if any of the following criteria
els of anxiety concerning their motor performance and were met: (1) studies were crossover trials, quasi-RCTs,
improvements in their mental well-being [21]. case reports, animal experiments, conference abstracts,
While some studies have demonstrated the poten- and review articles; (2) studies with unavailable data
tial benefits of breathing exercises for the treatment or low-quality; (3) included patients with LBP caused
of CLBP, it remains whether breathing exercises are by pathological changes such as tumours, spinal infec-
more effective than the current rehabilitation therapy tions, ankylosing spondylitis, spondylolisthesis, or any
paradigm [22]. Therefore, this systematic review and extensive neurological disorder.
meta-analysis intend to quantitatively analyze clini-
cal studies concerning the implementation of breath- 2.3. Literature screening and data extraction
ing exercises for the treatment of CLBP as it relates to
the symptoms (pain, lumbar function, and pulmonary After the titles and abstracts from the search results
function) and to conduct a direct comparison between on the electronic databases were browsed, the full texts
breathing exercises and the current routine rehabilita- of all potentially eligible studies were downloaded and
tion exercises. analyzed. Relevant data, including the title, first author,
 X. Jiang et al. / Effects of breathing exercises on ClBP: A systematic review and meta-analysis of RCT 15

Fig. 1. Flowchart of search strategy and study selection.

publication year, details of participants (size in each concealment, blinding of participants, blinding of out-
group, baseline characteristics), details of the study come assessment, incomplete outcome data, selective
(study design; Randomization methods), interventions reporting and other sources of bias. Each study was
for each group (details of breathing exercises used), independently assessed by the research team, and any
measurements of primary and secondary outcomes, sta- discrepancies were resolved through discussion.
tistical methods, exit conditions and reasons, informa-
tion was independently extracted and confirmed by the 2.5. Statistical analysis
independent researchers using standardized data extrac-
tion tables according to inclusion criteria. A research Statistical analyses were performed using Cochrane
team obtained information from the included studies, Review Manager 5.3 and Comprehensive Meta-
and disagreements among the reviewers were resolved Analysis. Continuous data will use the weighted
through discussion. mean difference (MD) or standardized mean difference
(SMD), while the corresponding 95% confidence in-
2.4. Quality assessment terval (CI) will be reported. Heterogeneity among the
studies was evaluated using the I2 statistic and the χ2
The quality of all included studies in this review was test. The fixed effects model was employed when the
independently evaluated by the research team by using heterogeneity test did not reveal any statistical signif-
the Cochrane collaboration tool of risk of bias. Studies icance (I2 6 50%, P > 0.05). If a significant degree
included low, unclear or high risk of bias in the follow- of statistical heterogeneity was seen (I2 > 50%, P <
ing domains: random sequence generation, allocation 0.05), then the random effect model was employed for
16 X. Jiang et al. / Effects of breathing exercises on ClBP: A systematic review and meta-analysis of RCT

Table 1
Summary of included studies
Author (year) Country Group (n): Male/ Description of intervention Duration Outcome
age (mean ± SD) Female Intervention group Control group measurements
Ahmadnezhad, Iran E(23)21.43 ± 2.16 11/12 Breathing exercise + Strength 8 ws, 2t/d, FVC, FEV1,
2020 [19] C(24)22.33 ± 1.41 12/12 Strength Training Training 7x/wk VAS,
Park, 2020 [20] Korea E(20)39.5 ± 9.43 20 Breathing exercise + Lumbar 6 ws, 10-min FVC, FEV1
C1(20)43.42 ± 9.92 20 Lumbar stabilization stabilization sessions, 5x/wk
C2(19)40.20 ± 9.17 19 exercise exercise
Borujeni, Iran E(24) 20.14 ± 1.34 11/13 Breathing exercise + Strength 8 ws, 2t/d, VAS
2020 [18] /22.34 ± 1.67 12/12 Strength Training Training 7x/wk
C(24)21.65 ± 1.25
/22.20 ± 1.64
Park, 2019 [21] South Korea E(20)30.9 ± 4.53 12/8 Breathing exercise + lumbar 4 ws, 40-min FVC, FEV1,
C(23)30.70 ± 6.32 12/11 lumbar stabilization stabilization sessions, 3x/wk FEV1/FVC,
exercises exercises MVV, ODI
Mehling, USA E(16)49.7 ± 12.1 5/11 Breathing exercise + physical 6 ws 45-min VAS
2005 [23] C(12)48.7 ± 12.5 5/7 physical therapy therapy sessions,
12t/6ws
Oh, 2020 [16] South Korea E(22)46.14 ± 2.59 0/22 Breathing exercise + lumbar 4 ws, 50-min FVC, FEV1,
C(22)44.45 ± 2.54 0/22 lumbar stabilization stabilization Sessions, 3x/wk FEV1/FVC,
exercises exercises MVV, VAS,
ODI
Kang, Korea E(10)42.5 ± 5.3 10/0 Breathing exercise + spinal 6 ws. 20-min ODI
2016 [24] C(10)40.1 ± 5.3 10/0 spinal stabilization stabilization sessions, 5x/wk
exercise exercise
Zhang, China E(33)39.43 ± 3.65 18/15 Breathing exercise + core strength 4 ws, 10 to VAS
2019 [25] C(33)40.18 ± 4.01 20/13 core strength training training 30-min
sessions, 5x/wk
Fan, 2018 [26] China E(30)40.87 ± 9.56 17/13 Breathing exercise + core strength 4 ws, 10 to VAS, ODI
C(30)38.53 ± 11.19 15/15 core strength training training 30-min
sessions, 5x/wk
Fei, 2018 [27] China E(13)25.78 ± 5.39 5/8 Breathing exercise + sling exercise 8 ws, 30 to VAS, ODI
C(14)25.69 ± 4.44 5/9 sling exercise training 55-min
training sessions, 3x/wk
Yang, 2020 [28] China E(42)28.26 ± 6.60 27/15 Breathing exercise + Postural con- 6 ms, 3x/wk VAS, ODI
C(42)27.18 ± 7.79 24/18 Postural control trol
training training
Zhang, China E(40)67.22 ± 6.67 25/15 Breathing exercise + Core strength 3 ms, 15-min VAS, ODI
2021 [29] C(40)67.87 ± 6.03 23/17 core strength training training sessions, 4x/wk
Liu, 2022 [30] China E(24)40.1 ± 9.3 10/14 Breathing exercise + Core strength 6 ws, 2t/d, VAS, ODI
C1(23)42.5 ± 11.6 12/11 core strength training training 5x/wk
C2(23)39.8 ± 10.6 11/12
Note: EG: experimental group; CG: control group; FVC: Forced Vital Capacity; FEV1: Forced Expiratory Volume in the first second; FEV1/FVC:
Forced Expiratory Volume in the first second /Forced Vital Capacity; MVV: Maximal Voluntary Ventilation VAS: Visual Analog Scale; ODI:
Oswestry Disability Index; ws: weeks; ms: months.

merging the results. P < 0.05 indicates that the differ- through database searching and 2 additional records
ence between the two groups is significant. The source were identified through reading the published reviews.
of heterogeneity was explored by performing the sensi- After the whole selection process, 13 studies with 807
tivity analysis method. A potential publication bias was patients were included in the meta-analysis for statisti-
qualitatively evaluated using Egger’s test. cal comparison.

3.2. Characteristics of included literature

3. Results
The main features of the included studies are
3.1. Literature selection recorded in Table 1. Sixteen studies (from China, the
USA, Iran, and Korea) were included in this summary.
The flow diagram of the article screening process is All of the results were published between 2005 and
exhibited in Fig. 1. 643 related articles were identified 2022 and contained the details of a total of 807 partici-
 X. Jiang et al. / Effects of breathing exercises on ClBP: A systematic review and meta-analysis of RCT 17

pants. The baseline data of the included studies demon- 3.4.3. FEV1
strated no significant difference. Ten studies [20,21,28] Four studies [16,19–21] reported that FEV1 was used
chose VAS assessment as the primary method of pain to evaluate pulmonary function. The meta-analysis in-
assessment for CLBP patients. Eight studies [20,21,28] dicated that breathing exercises could not significantly
elected to use the ODI for lumbar function assess- improve pulmonary function when compared with the
ment. Four studies [23–25,27,29,30,33,35] assessed control group (MD = 0.22, 95% CI = [0.00, 0.43], P =
pulmonary function by FEV1; four studies [22–25,32, 0.05). The result indicated no significant heterogeneity
33,35] assessed pulmonary function using FVC; three (χ2 = 3.72, P = 0.29, I2 = 19%) and a fixed-effect
studies assessed pulmonary function by FEV/FVC, and model was applied (Fig. 5).
two studies reported pulmonary function with MVV.
3.4.4. FVC
3.3. Quality assessment Four studies [16,19–21] reported that FVC was used
to evaluate pulmonary function. The meta-analysis in-
The quality assessment results for the included arti- dicated that breathing exercises could significantly im-
cles are shown in Fig. 2. Randomization was performed prove pulmonary function when compared with the con-
in all the studies, and eight of them detailed the random- trol group (MD = 0.24, 95% CI = [0.10, 0.37], P =
ization methods [16,19,21,23,26–28,30]. The blinding 0.0006). The result revealed no significant heterogene-
of participants and personnel was mentioned in two arti- ity (χ2 = 5.16, P = 0.16, I2 = 42%) and a fixed-effect
cles [16,19]; two studies reported the blinding of partic- model was applied (Fig. 6).
ipants and personnel [16,21], and four studies recorded
the blinding of outcome assessment [18,19,27,30]. Only 3.4.5. FEV/FVC
one study [26] contained incomplete data as it should Three studies [16,19,21] reported that FVC/FEV1
have reported dropout reasons and was, therefore, con- was used to evaluate pulmonary function. The meta-
sidered to demonstrate high-risk detection bias. The analysis indicated that breathing exercises could signif-
overall risk of bias was assessed as low when consider- icantly improve pulmonary function compared with the
ing incomplete outcome data, selective reporting, and control group (MD = 1.90, 95% CI = [0.73, 3.07], P =
other forms of bias. 0.001). The result revealed no significant heterogeneity
(χ2 = 0.55, P = 0.76, I2 = 0%) and a fixed-effect
model was applied (Fig. 7).
3.4. Results of meta-analysis
3.4.6. MVV
3.4.1. VAS Two studies [16,21] reported that the MVV was used
Ten studies [16,18,19,23,25–30] reported that VAS to evaluate pulmonary function. The meta-analysis in-
was employed to evaluate lumbar pain. The meta- dicated that breathing exercises could not significantly
analysis indicated that breathing exercises could sig- improve pulmonary function when compared with the
nificantly improve lumbar pain when compared with control group (MD = 8.22, 95% CI = [−4.02, 20.45],
the control group (SMD = −0.84, 95% CI = [−1.24, P = 0.19). The result indicated no significant hetero-
−0.45], P < 0.0001). The result indicated a lack of geneity (χ2 = 0.50, P = 0.48, I2 = 0%) and a fixed
significant heterogeneity (χ2 = 0.30, P < 0.00001, effects model was applied (Fig. 8).
I2 = 77%) and the random effects model was applied
(Fig. 3).
4. Discussion
3.4.2. ODI
Eight studies [16,21,24,26–30] reported that ODI was CLBP is a complex musculoskeletal disorder char-
used to evaluate lumbar function. The meta-analysis acterized by pain, reduced muscle strength, imbalance
indicated that breathing exercise could significantly im- and motor dysfunction [29]. The primary cause of LBP
prove lumbar function when compared with the con- is lumbar instability and muscle imbalances [3,30]. Ad-
trol group (SMD = −0.74, 95% CI = [−0.95, −0.54], ditionally, many studies have demonstrated that CLBP
P < 0.00001). The result indicated no significant het- patients are susceptible to respiratory diseases and res-
erogeneity (χ2 = 8.59, P = 0.28, I2 = 18%) and a piratory muscle atrophy, and there may be an associa-
fixed-effect model was applied (Fig. 4). tion between respiratory function, breathing patterns,
18 X. Jiang et al. / Effects of breathing exercises on ClBP: A systematic review and meta-analysis of RCT

Fig. 2. Plot of the risk of bias of the included studies.

Fig. 3. Forest plot of pain. Abbreviation. VAS, Visual Analog Scale.

 X. Jiang et al. / Effects of breathing exercises on ClBP: A systematic review and meta-analysis of RCT 19

Fig. 4. Forest plot of lumbar function. Abbreviation. ODI, Oswestry Disability Index.

Fig. 5. Forest plot of lung function. Abbreviation. FEV1, Forced Expiratory Volume in the first second.

Fig. 6. Forest plot of lung function. Abbreviation. FVC, Forced Vital Capacity.

Fig. 7. Forest plot of lung function. Abbreviation. FEV1/FVC, Forced Expiratory Volume in 1 second /Forced Vital Capacity.

core stability, and CLBP [12,31]. Clinical studies have demic databases, thirteen studies with 677 participants
revealed that breathing exercises can enhance respira- were involved in this meta-analysis. The results of the
tory function, reduce pain, and improve low back func- meta-analysis conclude that breathing exercises were
tion in patients experiencing CLBP [27,28]. This study effective for the treatment of CLBP: in cases involving
was the first meta-analysis to evaluate the effectiveness the use of VAS and ODI, breathing exercises provided
and safety of breathing exercises for treating CLBP. improved pain relief and enhanced lumbar function in
Following a comprehensive search of the major aca- comparison with the control group. In addition, when
20 X. Jiang et al. / Effects of breathing exercises on ClBP: A systematic review and meta-analysis of RCT

Fig. 8. Forest plot of lung function. Abbreviation. MVV, Maximal Voluntary Ventilation.

examining the indicators of pulmonary function out- Many studies have demonstrated that respiratory
comes such as FVC and FEV/FVC, the implementation muscle function and back proprioception control are
of breathing exercises improved pulmonary function mechanically and physiologically dependent on each
more effectively than the control group. However, no other [38]. The intense contraction of the abdominal
statistical significance was demonstrated in FEV1 and muscles caused by breathing exercises increases intra-
MVV: these results should be interpreted with care due abdominal pressure, which may lower the lumbar curve
to the low number of studies available for FEV1 and and significantly reduce the pressure exerted vertically,
MVV pulmonary function outcomes (6 4), and this helping to improve balance and proprioception [16,39].
area requires further research to confirm these findings. Breathing patterns have been demonstrated through im-
The meta-analysis revealed that breathing exercises provement following the introduction of various forms
significantly improved VAS and ODI scores compared of breathing exercises which activate the deep stabi-
to the control group, indicating that breathing exercises lizing muscles of the trunk to maintain spinal stabil-
are effective for relieving and enhancing low back func- ity and control [35]. When focusing on diaphragmatic
tion in CLBP patients. The underlying mechanisms of breathing, it is essential to re-establish correct breath-
breathing exercises for the treatment of CLBP were ing patterns and ensure lumbar spine stabilization by
unclear; however, chronic pain can occur when the increasing intraabdominal pressure and activating core
muscles of the low back experience instability caused structures to transfer force from the centre of the body
by dysfunction and motor control damage [31]. Stud- to the lower extremities [40]. Following the action of
ies have revealed that postural control and respiratory the diaphragm, intra-abdominal pressure increases and
function are mechanically and neuromuscularly co- activates the pelvic floor muscle causing it to contract,
dependent [32]. Respiration and spinal stabilization in- which enables the transversus abdominis to be easily
volve the diaphragm, the transverse abdominal muscle, activated during breathing due to strong abdominal con-
the pelvic floor muscle, and the intercostal and inter- tractions [24]. Furthermore, the nerves of the associ-
nal oblique muscles [33,34]. The pain experienced by ated muscles are stimulated by the movement, such
CLBP patients can be effectively managed and reduced as the thoracoabdominal nerve, are stimulated by the
via increased local muscle activity. Co-contraction of movement, which results in increased local muscle ac-
the muscles, instigated by breathing exercises, com- tivity [19,41]. Respiratory interventions can enhance
bined with sustained muscle activity, proper muscle the diaphragm’s trunk stabilizing function, enabling
length and muscle strength, promotes the development individuals to use lumbar proprioception and reduce
of the deep abdominal muscles [32,35]. As a result, the postural sway during balance control [35].
distribution of stimuli on pain receptor tissues surround- The findings of this review have partially clarified
ing the spine, articular capsules, and ligaments will de- that breathing exercises can improve the respiratory
crease [33]. As well as being vital to respiration, the res- function of CLBP patients, as demonstrated by FVV
piratory muscles play a fundamental role in controlling and FEV/FVC. CLBP is closely correlated with respira-
posture, acting as core stabilizing muscles. Therefore, tory disorders [42]. Patients with CLBP are reported to
breathing exercises are likely to impact postural control be susceptible to diaphragmatic and muscular fatigue,
by affecting the core stabilisers and altering posture, lung capacity deviations, and diaphragm biomechan-
increasing co-contraction of the core muscles that de- ics [35,43]. Respiratory function is often overlooked
termine trunk stabilisation, improving the intervertebral when examining patients with CLBP, although it can
joints and increasing motor control, which may lead to contribute to the instability of the lumbar spine and in-
an increase in a patient’s spinal stability and balance juries in this region [30]. Meanwhile, a bi-directional
ability [36,37]. interconnection exists between pain and respiration:
 X. Jiang et al. / Effects of breathing exercises on ClBP: A systematic review and meta-analysis of RCT 21

respiratory fluctuations can occur in response to pain. 4.1. Strengths and limitations
As established by previous theories, long-term respira-
tory exercise has the potential to influence core mus- Breathing exercises are beneficial and are proven
cle activity and improve respiratory and lumbar func- clinically effective. They do not require any rehabilita-
tion [19,44]. The respiratory muscles may promote lung tion equipment and, once mastered, can be performed
ventilation, improve lung function parameters, deliver at home, at work or in a hospital as part of a preven-
oxygen to the blood, and relieve pain [45]. Local muscle tion or recuperation programme. In addition, no ad-
activity may also alter lung function parameters [46,47]. verse events were reported in the literature analysed
Enhancing the stability of the trunk muscle through ap- by this study, and the employment of breathing exer-
propriate breathing pattern training, has been demon- cises should be promoted. However, the meta-analysis
strated to be a vital factor in reducing CLBP and pre- conducted by this study does contain limitations which
venting recurrence [38]. When considering reports de- require consideration. Meta-analysis can increase diag-
tailing the adverse effects of respiratory training in- nostic power by amalgamating small-scale, low-quality
cluded in the literature, it was found that only one pa- studies; however, its findings can be affected by certain
tient, in a study conducted by Mehling et al. [19], chose factors, including the variety of exercises (abdominal
to withdraw due to the resurfacing of old memories, breathing, inspiratory muscle training, and respiratory
which resulted in the participant experiencing uncom- resistance training), the varied quality and heterogene-
fortable emotions. Subsequent other studies found no ity of the studies selected for inclusion, and possible
other adverse events. biases. There were significant variances between the ten
clinical trials included in the meta-analysis; these dis-
Breathing exercises appear to be a promising and
parities concerned factors such as sample size, study de-
practical approach to treating CLBP and may enhance
sign, and outcome definition. Additionally, these stud-
performance, prevent injury, encourage rehabilitation,
ies lacked indicators such as balance function and long-
and improve breathing capacity, trunk stability and bal-
term prognosis, and there is a requirement for addi-
ance [34]. Currently, control intervention (passive phys-
tional, well-organised trials to further evaluate the effi-
iotherapy) is not recommended by the National In-
cacy of breathing exercises.
stitute for Health and Care Excellence (NICE) [48].
The current consensus is that any active component
of the intervention is more likely to demonstrate im- 5. Conclusion
proved long-term outcomes for pain than passive phys- In this study, the evidence indicated that breathing
iotherapy [48,49]. Breathing exercises are aerobic exer- exercises may be an effective treatment for CLBP. How-
cises that focus on motor control and reinforcing proper ever, further studies with rigorous methodological qual-
breathing patterns, which can increase the strength of ity are needed to support the conclusions of this re-
respiratory muscles, improve spinal stability, and can search. Future studies should investigate different va-
be easily incorporated into daily activities to prevent rieties, frequencies and intensities of breathing exer-
CLBP and its related conditions [19,35]. A recent study cises to discover the most clinically effective breathing
also reported reduced diaphragm thickness and lower exercises.
respiratory function in athletes who suffered from LBP
compared to healthy athletes [50]. For sports people Ethical approval
undergoing CLBP rehabilitation or sports training, it
is essential to incorporate breathing exercises to effec- Not applicable.
tively activate the deeper trunk muscles and nerves as-
sociated with the low back, improve muscle blood flow Funding
and muscle oxygenation to the low back, and enhance
athletic physical performance [51]. For medical work- The authors report no funding.
ers with CLBP, such as nurses, breathing exercises ef-
fectively lower the parasympathetic nerves, inhibit pain Informed consent
gate control, improve stress management, and relieve
CLBP symptoms, preventing occurrences of LBP or Not applicable.
accelerating recovery [49,52,53]. Therefore, it is rec-
ommended that athletes and workers employ breathing Acknowledgments
exercises in training or daily activities to strengthen the
health management of CLBP. The authors have no acknowledgments.
22 X. Jiang et al. / Effects of breathing exercises on ClBP: A systematic review and meta-analysis of RCT

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