This article introduces a unique strategy as to how we can utilize a balloon blowing exercise to help improve our breathing mechanics and posture. Faulty breathing mechanics and posture is an important consideration and thought when dealing with patients/clients that are presented with low back and/or sacroiliac joint (SIJ) pain. This particular exercise looks to tackle two problems at once. The first is to optimize posture using lumbar spine and diaphragm/rib positioning exercises. The second is to improve neuromuscular control of the diaphragm, deep abdominal, and pelvic floor muscles.

Firstly, it is important to understand the basic anatomy involved with breathing:

During inspiration:

  • Diaphragm contracts and the rib cage elevates and expands

Muscles of Inspiration:

  • Diaphragm (primary)
  • Upper trapezius (accessory)
  • Internal & external intercostal (accessory)
  • Pec minor (accessory)
  • Sternocleidomastoid (accessory)
  • Scalenes (accessory)

During expiration:

  • Passive recoil of the lungs and rib cage
  • Diaphragm relaxes, rib cage lowers

Muscles of active expiration:

  • Rectus abdominis
  • Internal/External obliques
  • Transverse abdominis
  • Internal intercostal
  • Quadratus lumborum

Normal breathing patterns are more commonly known as diaphragmatic breathing that involves adequate use of the diaphragm muscle and synchronized movement of the abdomen, upper and lower rib cage. There are several different classifications of abnormal breathing that will be more present in patients with more systemic/respiratory conditions. However, for the sake of this article, we will focus on a more common and/or typical abnormal breathing pattern found in the general population. Abnormal breathing patterns, also referred to as thoracic breathing, involves breathing from the upper chest which appears as more of an upper rib cage movement vs lower rib cage movement. Although not directly defined in this article, abnormal breathing instead looked at suboptimal Zone of Apposition (ZOA).

The Zone of Apposition – introduced by the Postural Restoration Institute – is the area from the attachment of the diaphragm (inside the bottom ribs) to the top of the diaphragm. This encompasses the cylinder portion of the diaphragm that presents itself in the shape of a dome. When you inhale, the diaphragm contacts and the fibers shorten (this flattens out the diaphragm while your ribs are up and out). When you exhale, the diaphragm lengthens which ascends and creates the dome inside the rib cage (the ribs move down and in when exhaling). As you exhale, your rib cage should have the appropriate down and in movement to allow the diaphragm to dome inside. If you rotate your torso to the right, the right ribs move up while the left ribs move down and vice versa. If your ribs are not moving down and in a “ribs up” position, this means there is a loss of optimal ZOA (figure 1, see below). If you have suboptimal ZOA, it usually results in decreased expansion of the rib cage, change in postural alignment and compensatory overuse of accessory muscles. Some of the postural changes may include increased lumbar lordosis (low back curve), decreased thoracic spine curvature, forward head posture, protracted and/or winged scapula (abnormal positioning of your shoulder blade).

How can we improve our respiration and postural alignment?
The 90/90 bridge balloon breathing exercise (BBE) provides a comprehensive method to improving both respirational and postural dysfunctions at once. As described by the authors here is how it works:

“The BBE technique is performed in supine with the feet on a wall, hips and knees at 90 degrees and a ball between the knees. This passive 90° hip and knee flexion position places the body in relative lumbar spine flexion, posterior pelvic tilt and rib internal rotation/depression which serves to optimize the ZOA and discourage lumbar extension/anterior pelvic tilt, paraspinal activity, and rib elevation/external rotation. When performed with active hamstring contraction the paraspinals are further inhibited due to the caudal pull of the hamstrings on the pelvis (specifically the ischial tuberosities) which further encourages lumbar flexion. Having a ball between the knees encourages adductor muscle activation (via hip adduction and internal rotation position) and co-contraction of the pelvic floor muscles (levator ani and coccygeus)” This inhalation effort with the balloon in the mouth and the ribs in a depressed/internally rotated state will direct the air into the lungs to expand the apical area of the lungs, especially when an arm is raised above the head to help direct it there. When the ribs are held down and a second inhalation occurs, the surrounding soft tissue i.e. pectoralis muscle lengthens/stretches with chest expansion from air that fills the lungs as the distance between the pectoralis attachment on the ribs and sternum and on the humerus is increased. This apical chest wall expansion may be particularly beneficial for individuals with scoliosis, depressed shoulder girdles, or rounded shoulders.”

ZOne of Apposition
Figure 1.

Below is a short video of how to perform the exercise:

How does this relate to your practice?
Although this article only focused on breathing and LBP and/or SIJ, poor breathing patterns are not exclusive to the two. It has been exhibited in people with poor movement patterns, poor posture, TMJ (jaw) pain, neck pain, scapular dyskinesia (abnormal movement of your scapula), and other musculoskeletal pain. Most patients can benefit from BBE techniques to help improve their posture and breathing mechanics. Improving our posture and breathing mechanics allows for more efficient and synchronised use of our respiratory muscles. Maintaining good balance between posture and breathing mechanics becomes increasingly challenging with exercise as there is greater demand on both systems. Another great reason why we should implement this system is to improve the strength and efficiency of posture and respiration. This goes especially in an athlete’s rehabilitation and/or training program.

Strengthening these muscles allows the ability to increase stiffness of the lumbar spine to lay the solid foundation to building a more resilient spine in an safe and progressive manner. This will not only help with the athlete/patient’s ability to brace themselves when they need to but it also brings more general awareness of their breathing habits. The more patients/athletes understand the importance of breathing mechanics, the more they can incorporate it into their daily lives (i.e. using it as a form of relaxation, improving their recovery during exercise, lifting in a more optimal and safe manner, improving power output and force transmission etc.).

Important to note
Although theoretically and anecdotally, this exercise may be effective but there is no robust evidence to our knowledge that proves the effectiveness of this particular exercise. There have not been any clinical trials done to test this exercise. Therefore, there is no evidence proving ones breathing exercise is superior to another. In addition, there are no clinical trials comparing different forms of breathing exercises. This concludes that future studies comparing different approaches would help establish the effectiveness between them. There is not a recognized or established protocol stating parameters or limitations such as the frequency, duration, and intensity of the BBE. However, using a general guideline stated in a recent study looking at the effectiveness of chronic LBP and breathing exercises found most rehab programs ranged from 2-3 times per week for 4-8 weeks. This exercise and other breathing exercises can be applied in all different populations and is encouraged to be implemented into any rehab/training regimen and/or daily practice of breathing. In conclusion, do not forget to breathe deep!

Writer: Arman Golizadeh BA Kine, MSc PT


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Boulding, Richard., Stacey, Rebecca., Niven, Rob., and Fowler, Stephen. “DYSFUNCTIONAL BREATHING: A REVIEW OF THE LITERATURE AND PROPOSAL FOR CLASSIFICATION.”European Respiratory Review: (2015) 25: 287-294

Boyle, Kyndall L., Josh Olinick, and Cynthia Lewis. “THE VALUE OF BLOWING UP A BALLOON.” North American Journal of Sports Physical Therapy : NAJSPT 5.3 (2010): 179–188.

Bradley, Helen, and Joseph Dr. Esformes. “BREATHING PATTERN DISORDERS AND FUNCTIONAL MOVEMENT.” International Journal of Sports Physical Therapy 9.1 (2014): 28–39.

Hestbaek, Lise, Charlotte Leboeuf-Yde, and Claus Manniche. “Low Back Pain: What Is the Long-Term Course? A Review of Studies of General Patient Populations.” European Spine Journal 12.2 (2003): 149–165. PMC. Web. 15 Oct. 2017.

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