How To Breathe When Working Out And Running! Via

Image from

Image from

There’s a great article on entitled How To Breathe When Working Out And Running! I wanted to share it with you all it gives some great, concise information. I love how to emphasize the importance of breathing during every type of exercise. However, I wanted to give a little more information or my thoughts on some of the topics in the article.

First, most of our patients are not performing dead lifts, therefore, I DO NOT RECOMMEND using the valsalva maneuver at all. This is a tool that can be helpful as they described, but only during certain activities and only with proper training. I want to be sure that anyone who reads the article does not think it’s appropriate to performing the maneuver when lifting lighter loads like an overhead press, leg press, or something similar. As the author writes in the article, it is appropriate to exhale slowly through pursed lips during the lifting portion of those activities. 

Breathing out through pursed lips is a great technique as it creates more resistance to an exhale and effectively makes you work harder to breathe out. This sets you up to more effectively use your abs (specifically your internal obliques and transverse abdominis) when exhaling. When we exhale with these muscles, our diaphragm is in prime position to be utilized during the next inhalation. This leads to more effective inhalation, better oxygenation, and less overflow into our lower back and/or neck muscles to help us get air in quickly. 

Second, the author describes that as we exhale our ribcages shrink. This should be, but isn’t always, the case. Depending on what exercise we are doing and what position we are in, we may not allow our lower ribs in the front to fully collapse or drop down during an inhalation. When this is the case, our diaphragm is not in a good position for our next inhale and we will compensate to get air in. This can lead to shortness of breath, poor endurance, fatigue/pain at the neck or lower back, and other problems. 

When you position yourself in a supine position (lying on your back), try to keep your lower back as close to the floor as you can get it. Use your abs to pull your lower ribs toward the floor and flatten your back. Try to keep your lower back as close to the floor as possible during your activities WHILE BREATHING. If you are on a bench doing chest work, you may need to keep your feet up on the bench with you. If you need or choose to put them on the floor, be aware that it will be much more challenging to keep your abs engaged and your lower back in a safe position during your activity. Be sure to exhale through pursed lips and drop those ribs toward the floor/bench as you lift. 

Lastly, I love the idea of paced breathing with cardiovascular work. I simply want to mention that just because the author suggested breathing in for 3-4 stairs as well as out for 3-4 stairs does not mean that it is a good pace for your individual body. Because you are doing cardiovascular work, expect to be slightly short of breath during that activity, but please alter your pace if it feels like you are starved for air or that you’re panting. Also, recognize that your pace will change from day to day. If you go into your work out feeling well energized and motivated, you may notice that you are able to ascend/descend 4-5 stairs during a breath without much effort. However, you may feel sluggish at your next work out and notice that you are starving for air at 5 stairs. No problem! Slightly increase your pace of breathing so that you are comfortable again. Listen to your body and react accordingly. 

Just be sure that, no matter what you’re doing with only a few exceptions, never stop breathing and breathe at a rate that feels comfortable to you!

Written by Lesley Callaham, MPT, PRC on January 22, 2019

What's a Rib Flare and What Does it Mean?

rib flare.jpg

Next time you're lying on your back, place your hands on your lower ribs. As you move your hands down those ribs toward your belly button, did you notice a drop off as your ribcage ended and your hands moved onto your abdomin? Was one side worse than the other? You, my friend, have a rib flare. These are very common, but are not normal. They are a clear warning sign that your core strength is lacking and you are on your way to pain and/or dysfunction.

rib flare person.jpg

Our abdominal muscles all attach to the bottom part of our ribcage.  The rectis abdominis (or six pack muscle) attaches to the ribcage in the front where it then travels down an attaches to the pelvis in the front. This muscle curls the trunk forward and is NOT a postural, or true core, muscle. It is also the most superficial muscle.

The next two groups are deeper toward are spine and do function as postural muscles. These are the obliques, specifically the internal obliques, and the transverse abdominis. These groups of abdominals are much wider and also attach to our lower ribs and top of the pelvis, but touch more bony surface area. When these muscles are strong and have good resting tone, they keep the ribcage held in an upright position. When these muscles become weak, they allow the front part of the bottom of the ribcage to flare upward and outward. The entire ribcage becomes extended which flattens out midback, overly arches our lower backs, cause our heads to more forward, and disallow good ribcage motion with walking and breathing. This can cause any number of issues- headaches, neck pain, shoulder problems, lower back pain, etc. 


This also causes our diaphragm to move from a functional, domed position (similar to that with a held exhalation), to a flattened, ineffective one (similar to that with a held inhalation). When the diaphragm loses it's "zone of apposition" that would normally be maintained with good abdominal strength, we cannot effective breathe with it. When we cannot breathe with the diaphragm, the primary muscle of respiration, we must find other ways to get air into our lungs. We can do this many ways: extending our lower backs to open up our abdomin, using our neck muscles to try to lift the ribcage upward, or a combination of the two. This is how pain develops. 

To fix this, the internal obliques and transverse abdominis muscles need to be targeted. Not only does the rehabilitation effort need to be very targeted, it needs to be functional, i.e., it needs to be done with proper breathing mechanics. We must return the position of the diaphragm to one of a functional, domed, exhaled position. The only way to properly do this is with your internal obliques and transverse abdominis. 

It is not possible to fully rehabilitate and restore core strength and control without proper respiration and abdominal strengthening at the same time. 

This is the foundation of any PRI treatment plan. Proper respiration cannot occur without a functional core, and a functional core cannot happen without proper respiration. Let the therapists at the only PRI certified clinic in St. Louis help you to restore your function and reduce or eliminate your pain. Call us at 314-733-5000 or email or 



Our Response to NPR Article About Fixing "Mum Tum"


NPR recently published an article entitled "Flattening the 'Mummy Tummy' with 1 Exercise, 10 Minutes a Day" (read it here) that has been getting a lot of attention. We wanted to give our patients and readers our take on this abdominal strengthening program.

First of all, the "mum tum" or "mommy pooch" as the article calls it, is a real thing. They do a great job describing diastasis recti (read our article on this topic here)  and it's known to cause lower back pain as well as a lot of other pain or dysfunction. Strengthening the abdominal muscles is the best way to correct this problem. In severe cases, a mesh can be surgically applied to essentially replace the ruptured tissue, but this is generally only done if the patient has developed a hernia.

In the article, Leah Keller, fitness coach and creator of this particular exercise program, states that the abdominal muscles need to be realigned in order to resolve this issue. For her exercise, she has her clients sitting cross-legged on the floor. She then has them take a deep inhale and expand their bellies. Then, as they exhale they pull in their abdominals by pulling their belly toward their spine. Next, they take short inhales followed by an exhale in which they try to pull their belly button closer to their spine. Every 2 minutes they change position, sitting on their heels, hands and knees, squatting, etc. until they've exercised for 10 minutes.

In our opinion, the basic component of this exercise is good. By having these women pull their belly button toward their spine as they exhale, they are engaging their transverse abdominis (TA) and internal obliques (IOs). This is essential in correcting a diastasis recti. Although the problem itself lies in the overstretched or ruptured linea alba that lies between the two sides of the rectus abdominis muscle (or six pack muscle), exercising the rectus itself will not improve things at all. The TA and IOs have to be targeted as those are the muscles that create a natural corset around our core, cinching in our waists and giving support to our spine and abdomen.

One problem that we have is initiating this exercise while sitting cross-legged on the floor. This places the thigh bone in too much external rotation in the hip and will draw the pelvis forward, arching the back, and placing the abdominals in an elongated position called "positional stretch". Trying to contract a muscle this way is very difficult and not very efficient.

The main problem we have this exercise is the breathing technique. By taking in small breaths, ribcage motion is restricted, utilizing accessory respiratory muscles from the neck and shoulders is encouraged, and poor respiratory mechanics are being taught during abdominal activation. Sure, this may cause some TA an IO strengthening as the muscles are being contracted for some time, but it's completely nonfunctional. It is essential to learn proper respiration while activating the core. This not only allows the client to strengthen the abdominals, but to teach them to keep them engaged, subconsciously, while they walk, talk, and breathe throughout the day. That is fully correcting the problem and stabilizing the core. The former is simply contracting the abs for 10 minutes a day with poor mechanics.

Want more information or to learn to correctly recruit your core while breathing normally? This is a pillar in all of our treatment programs at Integrate 360 Physical Therapy. Call us at 314-733-5000 or email or today!

Simple Solution for Heel Pain

This is an activity we like to use for heel pain. I have been seeing more children with heel pain in my practice lately. Is it that they wear cushion or minimalist shoes with no support? Perhaps. Or is it the way they sit in front of a computer, ipad or phone to study, text or play games? Maybe. Could it be overuse of specific muscles while playing their sport or running in gym class? The answer can be any or all of the above.

Believe it or not, a child’s overall posture with sitting, standing, running and even breathing can affect their heel or foot pain. From a PRI perspective, attention to breathing is very important. The way you use your muscles changes depending on the position of the powerful respiratory muscle, called your diaphragm.

The diaphragm is a mushroom-shaped muscle that lives in the middle of your body. Its primary role should be to help you breathe efficiently. If it is in the wrong position (i.e. not domed) your brain recruits it for postural demands, which is when things start to change with your posture and pain patterns can begin. Examples of pain caused by a faulty diaphragm position include: back pain, shoulder pain, hip pain, knee pain, and foot pain, including plantar fasciitis.