ARTICLE IN PRESS

Journal of Bodywork and Movement Therapies (2006) 10, 96–98

Journal of
Bodywork and
Movement Therapies
www.intl.elsevierhealth.com/journals/jbmt

SCIENTIFIC REPORT

Breath therapy for chronic low back pain

Wolf E. Mehling, MD

Osher Center for Integrative Medicine, University of California San Francisco, 1701 Divisadero #150,
San Francisco, CA 49115, USA

Received 1 September 2005; accepted 2 September 2005

KEYWORDS Summary Hands-on mind-body techniques claim to help patients with low back
Breath therapy; pain (LBP) by focusing on body-awareness. Their efficacy has been studied only in a
Low back pain; few controlled research studies of limited rigor. A randomized controlled clinical
Body-awareness; pilot trial of Breath Therapy (BT) was conducted to determine whether patients with
Physical therapy; cLBP would benefit from an approach primarily focusing on body-awareness. BT is a
Middendorf Western mind-body therapy developed in Germany that integrates body-awareness,
breathing, meditation, and movement. Thirty-six patients seeking primary medical
care for chronic LBP of at least 3 months duration were randomly assigned either to
receive BT or PT at an academic medical center. Main outcome measures at baseline,
6–8 weeks, and 6 months were pain, function, and overall health. Balance as a
potential surrogate for proprioception and body-awareness was measured at the
beginning and end of treatment. Patients suffering from cLBP improved clinically
with BT. Changes in standard self-reported LBP measures of pain and disability were
comparable to changes measured following high-quality, extended PT. The full
details of the study are published elsewhere [Mehling, W.E., et al., 2005.
Randomized, controlled trial of breath therapy for patients with chronic LBP.
Alternative Therapies in Health and Medicine 11 (4), 44–52].
& 2005 Elsevier Ltd. All rights reserved.

Introduction Clinics of North America 35(1), 57–64; Koes, B.W.,

Physical therapy (PT) is the gold standard treat-
ment for chronic low back pain (cLBP) and known to
be effective [Maher, C.G., 2004. Effective physical
treatment for chronic low back pain. Orthopedic
Tel.: +415 353 9506 (office), +415 499 1951 (home);
fax: +415 353 7358.
E-mail address: mehlingw@ocim.ucsf.edu.
et al., 2001. Clinical guidelines for the manage-
ment of low back pain in primary care: an
international comparison. Spine 26(22), 2504–2513,
discussion 2513–2514; van Tulder, M.W., Koes, B.W.,
Bouter, L.M., 1997. Conservative treatment of acute
and chronic nonspecific low back pain. A systematic
review of randomized controlled trials of the most
common interventions. Spine 22(18), 2128–2156]. It
focuses on biomechanical and neuro-motor control

1360-8592/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2005.09.003
 ARTICLE IN PRESS
Breath therapy for chronic low back pain
issues. Hands-on mind-body techniques, such as
Alexander, Feldenkraı̈s, Rolfing, Trager, Eutony,
Sensory Awareness, Body Awareness Therapy, and
Breath Therapy, claim to help patients with LBP by
focusing on body-awareness [Ives, J.C., 2001.
Comments on ‘‘the Feldenkrais Method: a dynamic
approach to changing motor behavior’’. Research
Quarterly for Exercise and Sport 74(2), 116–123,
discussion 124–126; Mueller-Braunschweig, H.,
1992. Psychohygiene und koerperorientierte Psy-
chotherapie: Allgemeine Grundlagen (Psycho-hy-
gene and body-oriented psychotherapy: general
basics). In: Buehring, M., Kemper, F.H. (Eds.),
Naturheilverfahren (Methods of natural healing).
Springer, Berlin]. Their efficacy has been studied
only in a few controlled research studies of limited
rigor [Mehling, W., Diblasi, Z., Hecht, F., 2005. Bias
control in trials of bodywork. A review of metho-
dological Issues. Journal of Alternative and Com-
plementary Medicine, in press]. A randomized
controlled clinical pilot trial of breath therapy
(BT) was conducted to determine whether patients
with cLBP would benefit from an approach primar-
ily focusing on body-awareness. The full details of
the study are published elsewhere [Mehling, W.E.,
et al., 2005. Randomized, controlled trial of breath
therapy for patients with chronic low-back pain.
Alternative Therapies in Health and Medicine 11(4),
44–52].
Breath therapy (BT) is a Western mind-body
therapy developed in Germany that integrates
body-awareness, breathing, meditation, and move-
ment. It includes exercises and skilled touch with
soft tissue interventions (Mehling, 1999, 2001).
Methods
Thirty-six patients seeking primary medical care for
cLBP of at least 3 months duration were randomly
assigned either to receive BT or physical therapy
(PT). BT was provided by certified breath therapists
from the Middendorf Breath Institute in Berkeley,
California, and PT by physical therapist in the
university Department of Physical Therapy and
Rehabilitation Science. Patients in both groups
equally received one evaluation session (60 min)
and 12 individual 45-min therapy sessions over 6–8
weeks in the same building at the medical center.
They were introduced to 20–30 min of home
exercises.
Main outcome measures at baseline, 6–8 weeks,
and 6 months were pain by visual analog scale
(VAS), function by Roland Scale, and overall health
by SF-36. Balance as a potential surrogate for
97
proprioception and body-awareness was measured
at the beginning and end of treatment. Patients
kept a diary and were asked to report about their
treatment experience, thoughts and feelings about
the therapy, their therapist, body, back, pain, or
life in general. Overall outcomes were compared
within and between groups by Repeated Measures
ANOVA. Pre–post-intervention changes were com-
pared by t-tests or Mann–Whitney tests.
Results
Eight of the 36 randomized patients did not receive
any intervention mostly due to scheduling pro-
blems. Analyses were performed in an intention-to-
treat fashion for 14 subjects in the BT and 12
subjects in the PT group (two participants were lost
to follow-up). Two subjects did not complete all of
the 12 therapy sessions. Participants performed
their home exercises on average 11 (BT) and 17 (PT)
minutes per day.
Patients were similar in their baseline character-
istics for pain (intensity and duration), function and
other baseline variables with the exception of
three out of five postural sway measures. Subjects
were 64% female, on average about 49 years old,
and had suffered from LBP for 1 year (mean).
Fortyfour percent in the BT group and 25% in the PT
group also had sciatica. Most patients had had PT
for back pain in the past (BT: 75%/PT: 92%).
From baseline to the end of the intervention,
patients in both groups experienced a statistical
and clinically significant improvement in pain
intensity as measured by the 10 cm VAS (BT

2.71; PT
2.43) and the 100-point SF-36 (BT
+14.9; PT +21.0). The BT group improved signifi-
cantly in LBP-related functional disability (Roland
Morris Score) and in the physical and emotional role
components of the SF-36. The PT group improved
significantly in the vitality component of the SF-36.
Change scores at 6–8 weeks and 6 months were
similar in both groups. Considering a change of two
points or more on the VAS for pain or three points or
more on the Roland Morris Scale for function as
clinically significant, 10 out of 14 improved in the
BT group and 6 out of 12 improved in the PT group
(between-group difference: P ¼ 0:42). There were
no differences between groups for average number
of LBP-related doctor visits or changes in disability.
No significant adverse effects were reported in
either the BT or PT group. Between-group differ-
ences were seen in the patients’ diary entries
regarding emotional effects and insights about pain
and coping with stress with few or no entries in the
PT and rich entries in the BT group.
 ARTICLE IN PRESS
98
We could not replicate previously reported
beneficial effect of BT on balance measures in
healthy volunteers (Aust and Fischer, 1997). The
low correlation between our various balance
measures and between these measures and other
independent variables casts doubt upon the validity
of these balance measures for research on cLBP and
complementary or traditional therapies.
At 6-months follow-up, patients in both groups
maintained statistically significant improvements in
the main outcome measures. During the 6–8 weeks
of intervention, 71% of participants in the BT group
demonstrated clinically meaningful (as defined
above) improvement (VAS, Roland Morris) com-
pared to 50% in the PT group. After 6 months,
40% (VAS) or 66.7% (Roland Morris) of the BT group
had still a similar improvement compared to 45%
(VAS) or 72.7% (Roland Morris) in the PT group.
BT appeared to be as good as but not better than
PT, the gold standard therapy for patients with
cLBP. The average improvements in pain of 2.7 for
BT and 2.4 for PT on the VAS were comparable to a
prior study of PT and LBP (Deyo, 1990). Both
approaches use hands-on touch and are provided
by highly motivated and empathic practitioners,
but they differ greatly in practitioner training,
treatment goals and philosophy, as well as in their
degree of pathology-oriented treatment individua-
lization. BT is not a therapeutic method developed
to specifically target LBP.
Our qualitative data suggested a different kind of
learning in the BT group that involved a new and
improved relationship to the body. In the BT group
there was greater experiential insight into the
connection between daily stress and back pain.
New and improved coping strategies were reported
mostly from participants in the BT group.
Summary and conclusions
The reported study is the first study providing
evidence that patients suffering from chronic low
back pain can clinically improve with BT, an
approach primarily focused on body-awareness.
Changes in standard self-reported LBP measures
of pain and disability appear to be comparable to
W.E. Mehling
changes measured following high-quality, extended
PT. BT is generally safe in patients with cLBP.
Qualitative data suggest that BT might teach
improved coping skills and new insight into the
effect of stress on the body and the LBP. Other
bodywork techniques using a hands-on mind-body
approach might provide comparable benefits for
patients with chronic low back pain. A future study
should determine whether an approach combining
BT and PT would render more benefits than either
BT or PT alone. Objective force-plate balance
measures may not be a valid measure of clinical
change in patients with cLBP.
References
Aust, G., Fischer, K., 1997. Changes in body equilibrium response
by breathing. A posturographic study with visual feedback.
Laryngorhinootology 76 (10), 577–582.
Deyo, R.E.A., 1990. A controlled trial of transcutaneous
electrical nerve stimulation (TENS) and exercise for chronic
low back pain. New England Journal of Medicine 322 (23),
1627–1634.
Ives, J.C., 2001. Comments on ‘‘the Feldenkrais method: a
dynamic approach to changing motor behavior’’. Research
Quarterly for Exercise and Sport, 74 (2) 116–123, discussion
124–126.
Koes, B.W., et al., 2001. Clinical guidelines for the management
of low back pain in primary care: an international compar-
ison. Spine, 26 (22) 2504–2513, discussion 2513–2514.
Maher, C.G., 2004. Effective physical treatment for chronic low
back pain. Orthopedic Clinics of North America 35 (1), 57–64.
Mehling, W.E., 1999. Breath Therapy. Dissertation Berlin Free
University. Aachen, Shaker.
Mehling, W.E., 2001. The experience of breath as a therapeutic
intervention. Forsch Komplementärmed Klass Naturheilkd 8,
359–367.
Mehling, W., DiBlasi, Z., Hecht, F., 2005. Bias control in trials of
bodywork. A review of methodological Issues. Journal of
Alternative and Complementary Medicine 11 (2), 333–342.
Mehling, W.E., et al., 2005. Randomized, controlled trial of
breath therapy for patients with chronic low-back pain.
Alternative Therapies in Health and Medicine 11 (4), 44–52.
Mueller-Braunschweig, H., 1992. Psychohygiene und koerperor-
ientierte Psychotherapie: Allgemeine Grundlagen (Psycho-
hygene and body-oriented psychotherapy: general basics).
In: Buehring, M., Kemper, F.H. (Eds.), Naturheilverfahren
(Methods of Natural Healing). Springer, Berlin.
van Tulder, M.W., Koes, B.W., Bouter, L.M., 1997. Conservative
treatment of acute and chronic nonspecific low back pain. A
systematic review of randomized controlled trials of the most
common interventions. Spine 22 (18), 2128–2156.