Neck Pain and Breathing Problems

Normal respiratory mechanics play an important role in the musculoskeletal system. Breathing mechanics are key to both posture and spinal stabilisation, and these mechanisms must remain intact to maintain normal posture and spinal stability. There is a dynamic interaction between the principal muscles of respiration [1]. Dysfunction in one muscle can lead to dysfunction in another (mutual interdependence).

Under respirasjon er det behov for en stabilisert cervical- og thoracalcolumna slik at andre During respiration, the cervical and thoracic spine require adequate stabilisation so that other muscles can elevate or depress the ribs. If instability is present, the rib cage may undergo mechanical changes that lead to insufficient respiration and altered contraction patterns—affecting the diaphragm, intercostals and abdominal muscles via length–tension relationships. Consequently, inspiratory and expiratory strength may be reduced in patients with neck pain [2].

Evidence

A systematic review synthesising 68 studies (nine observational) found significant differences in maximal inspiratory and expiratory pressures in individuals with chronic neck pain compared with asymptomatic controls. Lung volumes were lower in those with chronic neck pain. Muscle strength and endurance, cervical range of motion and lower PCO₂ were significantly correlated with reduced chest expansion and neck pain. Breathing training improved selected cervical muscle and respiratory impairments [5].

Clinically Relevant Anatomy

The thoracic spine and associated muscles drive normal inspiration and expiration. When breathing becomes laboured or altered, the body compensates by recruiting cervical accessory muscles:

• Scalenes

• Sternocleidomastoid

• Trapezius

The scalenes are active in inspiration even with small increases in lung volume, while sternocleidomastoid is inactive at rest but contributes during forceful inspiration [2].

Epidemiology / Aetiology

“A dysfunctional breathing pattern can be the first sign that all is not well, whether the underlying dysfunction is mechanical, physiological or psychological.” (CliftonSmith & Rowley, 2011) [6]

• 5–11% in the general population

• 30% in people with asthma

• 83% in people with anxiety

• 6–10% of primary-care patients may have an underlying breathing disorder [7]

Symptoms of Breathing Pattern Disorders

Symptoms are often complex, variable and multisystemic. Dyspnoea is common, especially where other pathology has been excluded. Typical features include:

• Inability to take a satisfying deep breath, chest pressure, “air hunger”, sighing, yawning, cough or throat clearing

• Palpitations, chest pain, tachycardia, pseudo-angina and ECG changes

• Atrophy and weakness of respiratory muscles, hypertrophy of accessory muscles, “barrel chest”, mouth breathing

• Neurological: dizziness, numbness/tingling, blurred vision, headache, poor concentration

• Gastrointestinal: dysphagia, reflux, bloating

• Muscular: cramps, pain, tremor, jaw tension

• Psychological: anxiety, panic attacks, depression

• Systemic: fatigue, sleep disturbance, dry mouth

Differential Diagnosis

Distinguish breathing pattern disorder (BPD) from neck pain–dominant presentations [8]:

• Patients with cervical neck pain show significantly reduced strength and endurance in cervico-scapulothoracic musculature versus healthy controls

• Dysfunction of these muscles is thought to reduce respiratory capacity, partly due to their dual roles in cervical movement and breathing

• Psychological factors (anxiety, depression, catastrophising) also contribute to pain experience, respiration and cervical dysfunction

Clinical implication: include respiratory assessment and psychological screening alongside cervical evaluation.

Association Between Low Back Pain and Breathing Disorders

• There is a significant association between low back pain and breathing disorders (e.g., asthma, dyspnoea)

• Individuals with these disorders report a higher prevalence of low back pain, and vice versa

• Mechanisms are not fully understood; stressful situations (e.g., exercise) may trigger breathing disturbances

Clinical implication: when low back pain co-exists with BPD, treat both conditions.

Assessment

Use an evidence-based approach aligned with medical guidelines for MSK assessment [10], in addition to standard cervical subjective/objective examination (posture, breathing, active/passive ROM, manual muscle testing). Pain is not a function measure per se but affects function and can be used as an evaluative parameter.

Fillingim et al. (2016) recommend assessing four pain domains [11]:

• Pain intensity (e.g., numerical rating scale)

• Other perceptual qualities (ask the patient to characterise the pain)

• Pain location (e.g., body chart)

• Temporal features (variation with activity/rest; across day/week/month)

Consider a mechanism-based approach (e.g., neuropathic pain screen). Quantitative sensory testing—tuning fork, monofilaments, cold hyperalgesia—can inform pain profiling. Combine pain assessment with physical and psychosocial function measures [11].

Craniocervical Flexion Test

A clinical test targeting the deep cervical flexors (longus capitis and longus colli) [12]. Developed over 15 years as a clinical/research tool, it addresses the importance of deep flexors for supporting cervical lordosis and their impairment in neck pain. In clinic it provides an indirect functional measure; laboratory EMG has validated selective activation patterns. The test can also be used as an endurance-oriented training drill for these muscles.

Assessment of Breathing Pattern Disorders

• Breath-hold test: Typical hold 25–30 s; <15 s may indicate low CO₂ tolerance• Hi–Low Test (sitting or supine): Hands on chest and abdomen; observe which moves first and most; look for lateral expansion and upward hand motion• Breathing wave (prone): Normal breathing should create a cranially moving wave along the spine; block segments may indicate thoracic restriction• Seated lateral expansion: Hands on lower thorax; assess symmetry of expansion• Manual Assessment of Respiratory Motion (MARM): Practical appraisal of pattern and distribution (upper vs lower rib cage vs abdomen) in different positions• Respiratory inductance plethysmography (chest wall motion/ventilation) and magnetometry (abdominal/thoracic excursion)

For additional tools, see the BPD page on Physiopedia.

Psychosocial Assessments

Overview of outcome measures and procedures for psychosocial and behavioural contributors to pain [13]. Turk et al. (2016) highlight that persistent pain (>3 months) has widespread cognitive, emotional and behavioural impacts, shaping symptom reporting and lived function.

Outcome Measures

• Brief Pain Inventory – Short Form (pain, physical/emotional function)• Nijmegen Questionnaire (symptoms associated with breathing pattern disorders)• Neck Disability Index (activity limitation and pain impact)• Quality of Well-Being Scale (links symptom states to functional aspects of life)

Physiotherapy Management

When neck pain and BPD co-exist, determine whether pain alters breathing or breathing contributes to mechanical pain. A comprehensive programme should address both. After thorough baseline subjective/objective assessment and outcome measures (e.g., Nijmegen, breath-hold; cervical ROM/strength; biopsychosocial questionnaires), current evidence supports the following:

Physiotherapy for Breathing Pattern Disorders

Breathing retraining

• Raise awareness of irregular patterns

• Promote relaxation of jaw, upper chest, shoulders and neck (accessory muscles)

• Teach nasal and diaphragmatic breathing

• Educate on normal frequency and rhythm at rest and during speech/activity [6][14]

Sniff test

• Identifies diaphragmatic under-recruitment in patients defaulting to upper-chest/accessory patterns

• Can be taught for home practice and used to monitor progress in motor retraining [14]

BradCliff angle control (xyphocostal angle)

• Hypertonic abdominals may reduce the xyphocostal angle (normal ~75–90°), restricting diaphragmatic excursion• Measure pre-/intra-treatment as an outcome metric [14]

Psychosocial interventions

• BPD commonly co-exists with stress; support referral to mental-health services where appropriate

• Combine with respiratory muscle retraining for a multifaceted strategy [14]

• Whole-body relaxation and sleep hygiene

• Teach mental and physical relaxation techniques to reduce stress/anxiety

• Educate on stress physiology and how persistent stress drives somatic tension

• Incorporate mindfulness, breath awareness and daily self-management; include sleep hygiene guidance [6]

Exercise and nutrition

• Exercise relies on cardio-respiratory coupling to deliver O₂ and remove CO₂

• Use graded activity to promote diaphragmatic breathing

• Apical breathing/hyperventilation may consume up to 30% of O₂ use (resting breathing ≈2%)—monitor for fatigue

• Even brief activity bouts (2 min, 3×/day) can help low-activity patients

• Coach expected adaptations (↑HR, ↑tidal volume, breathlessness) to reduce fear in anxiety/panic-related BPD

• Provide basic nutrition advice to support energy and digestion [6]

Physiotherapy for Neck Pain

Blanpied et al., 2017 outline key examination, diagnosis and treatment components for neck pain [10]. Evidence suggests:

• Moderate evidence supports cervico-scapulothoracic and upper-limb strength training to reduce pain (moderate to large effects) immediately and short-term

• Shoulder/scapulothoracic endurance training yields small pain reductions

• Combined exercises (neck, shoulder, scapulothoracic) show variable but positive effects on pain and function short- and long-term

• Strength and stabilisation improve pain and function mid-term

• Stretching or endurance alone has limited effect on pain and function

Conclusion

A holistic approach to co-existing breathing pattern disorders and neck pain can optimise breathing mechanics and efficient respiratory muscle recruitment in daily activities. While direct causality between neck pain and BPD is not firmly established, clinicians should recognise their potential interrelationship and assess and treat within a biopsychosocial framework [6][14].

Sources:

1. Perri MA, Halford E. Pain and faulty breathing: a pilot study. Journal of Bodywork and Movement Therapies. 2004 Oct 1;8(4):297-306.

2. A. Legrand, E. Schneider, P.A. Gevenois, A. De TroyerRespiratory effects of the scalene and sternomastoid muscles in humans J Appl Physiol, 94 (2003), pp. 1467-1472

3. Kapreli, E., Vourazanis, E., & Strimpakos, N. (2008). Neck pain causes respiratory dysfunction. Medical Hypotheses, 70(5), 1009–1013. https://doi.org/https://doi.org/10.1016/j.mehy.2007.07.050

4. Kapreli, E., Vourazanis, E., & Strimpakos, N. (2008). Neck pain causes respiratory dysfunction. Medical Hypotheses, 70(5), 1009–1013. https://doi.org/https://doi.org/10.1016/j.mehy.2007.07.050

5. Kahlaee AH, Ghamkhar L, Arab AM. The association between neck pain and pulmonary function: a systematic review. American journal of physical medicine & rehabilitation. 2017 Mar 1;96(3):203-10. 

6. Clifton Smith, T., & Rowley, J. (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession. Physical Therapy Reviews, 16(1), 75–86. https://doi.org/10.1179/1743288X10Y.0000000025

7. Courtney, A. C., & Courtney, M. W. (2009). A thoracic mechanism of mild traumatic brain injury due to blast pressure waves. Medical Hypotheses, 72(1), 76–83. https://doi.org/https://doi.org/10.1016/j.mehy.2008.08.015

8. Dimitriadis, Z., Kapreli, E., Strimpakos, N. and Oldham, J. (2013). Respiratory weakness in patients with chronic neck pain. Manual Therapy, 18(3), pp.248-253.

9. Beeckmans, N., Vermeersch, A., Lysens, R., Van Wambeke, P., Goossens, N., Thys, T., Brumagne, S. and Janssens, L. (2016). The presence of respiratory disorders in individuals with low back pain: A systematic review. Manual Therapy, 26, pp.77-86.

10. Blanpied, P., Gross, A., Elliott, J. and Devaney, L. (2017). Neck Pain Guidelines: Revision 2017: Using the Evidence to Guide Physical Therapist Practice. Journal of Orthopaedic & Sports Physical Therapy, 47(7), pp.511-512.

11. Fillingim, R., Loeser, J., Baron, R. and Edwards, R. (2016). Assessment of Chronic Pain: Domains, Methods, and Mechanisms. The Journal of Pain, 17(9), pp.T10-T20.

12. Jull, G., O'Leary, S. and Falla, D. (2008). Clinical Assessment of the Deep Cervical Flexor Muscles: The Craniocervical Flexion Test. Journal of Manipulative and Physiological Therapeutics, 31(7), pp.525-533.

13. Turk, D., Fillingim, R., Ohrbach, R. and Patel, K. (2016). Assessment of Psychosocial and Functional Impact of Chronic Pain. The Journal of Pain, 17(9), pp.T21-T49.

14. Chaitow, L; Bradley, Dinah; Gilbert, Christopher. Recognising and Treating Breathing Disorders - A Multidisciplinary Approach; Elsevier Ltd; 2nd Edition; 2014. Chap. 7.3 pgs 185-196.

15. Bradley, Helen; Esformes, Joseph; 2014.Breathing Pattern Disorders and Functional Movement; International Journal of Sports Physical Therapy; 9(1): 28-39

16. Gross, A., Kay, T.,Paquin, J., Blanchette, S., Lanlonde,P., Christie,T., Dupont, G., Graham, N., Burnie, S., Gelley, G., Goldsmith, C., Forget, M., Hoving, J., Bronfort, G., Santaguida, P. (2015). Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews.