Effects of breathing exercise and thoracic techniques on pain and disability in low back pain: A systematic review and meta-analysis

Tahere Seyedhoseinpoor; Ramin Jafari; Zohreh Shafizadegan; Maryam Abbaszadeh-Amirdehi

doi:10.1371/journal.pone.0339263

. 2026 Jan 14;21(1):e0339263. doi: 10.1371/journal.pone.0339263

Effects of breathing exercise and thoracic techniques on pain and disability in low back pain: A systematic review and meta-analysis

Tahere Seyedhoseinpoor ^1,^*, Ramin Jafari ², Zohreh Shafizadegan ², Maryam Abbaszadeh-Amirdehi ¹

Editor: Seyed Hamed Mousavi³

PMCID: PMC12803473 PMID: 41533685

Abstract

Purpose

The objective of this study was to systematically review the effectiveness of thoracic-focused interventions, including breathing exercises and thoracic manual techniques (mobilization, high-velocity low-amplitude manipulation, and release techniques), on pain and disability in patients with low back pain (LBP).

Methods

PubMed, Scopus, Web of Sciences, ProQuest, Ovid, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Clinical Trials (CENTRAL), and Google Scholar were searched without language restrictions. Clinical trials with control groups on pain and disability in low back pain patients focusing on the efficacy of breathing exercises or thoracic technique were included. In total, 31 studies contributed to the meta-analysis for pain and 24 for disability.

Results

Pooled analyses using Morris’ dppc demonstrated a statistically significant, small effect for pain reduction (dppc = −0.35, 95% CI = −0.46 to −0.23) and a large effect for disability improvement (dppc = −0.71, 95% CI = −0.86 to −0.57) when compared with control groups. Thoracic manual techniques showed larger effects on both pain and disability compare to breathing exercises. However, substantial statistical heterogeneity (I² > 85%) persisted in most analyses.

Conclusion

Breathing and thoracic manual techniques may be effective in reducing disability and, to a lesser extent, pain in patients with LBP, but the overall certainty of evidence is low. However, the quality of the evidence is low. Variability in treatment protocols, study quality, blinding, and outcome measures likely contributed to inconsistencies. Further high-quality trials with standardized protocols are needed to confirm these findings and inform clinical practice.

Introduction

Chronic low back pain (CLBP) is one of the most common musculoskeletal conditions affecting most of the population [1]. The incidence of CLBP is associated with substantial medical costs and a significant burden on families and society [2,3], and it is the leading cause of years lived with disability [1]. Multiple factors, including biopsychosocial elements, contribute to the development of CLBP, although it may occur in the absence of any discrete pathology. In addition, joints, intervertebral discs, tendons, ligaments, and muscles may be separately involved in its development [4]. Research shows a significant association between persistent or recurrent low back pain (LBP) and deep trunk muscle weakness, especially core muscles, as well as poor coordination and trunk proprioception [5–7].

Although CLBP can usually be treated with traditional physical therapy or manual therapy, most patients do not fully recover from their symptoms. Recently, specialists have emphasized the correlation between LBP and respiratory disorders [8,9]. The respiratory function and spinal stability are supported by the core muscles and the diaphragm. Respiratory dysfunction impairs diaphragm function and, consequently, the diaphragm’s role in spinal stability [10]. Beeckmans et al found that immune, biomechanical, psychosocial and socioeconomic factors may explain the association between CLBP and respiratory disease [8]. Ostwal et al. found that over 71% of individuals suffering from chronic back pain have deviant breathing patterns during movement control tests and irregular movement patterns at rest [11].

Breathing exercises and thoracic manual techniques effectiveness in CLBP management lies in their shared neuromuscular and biomechanical mechanisms. The diaphragm, as a dual-function muscle for respiration and postural control, modulates intra-abdominal pressure (IAP) and lumbar stability through its synergistic action with deep core muscles (transversus abdominis, multifidus) and the thoracolumbar fascia [12]. In CLBP, aberrant breathing patterns (e.g., upper chest dominance) disrupt this synergy, leading to diaphragm dysfunction, reduced IAP, and compensatory lumbar overload [11]. Concurrently, thoracic spine stiffness or ribcage hypomobility -common in CLBP- further impairs diaphragmatic excursion and perpetuates faulty movement patterns [13]. Thoracic mobilization techniques address these restrictions by restoring joint mobility and fascial continuity, while targeted breathing exercises re-establish diaphragmatic-postural coordination. Together, these interventions break the cycle of respiratory dysfunction and spinal instability: thoracic techniques create a mechanically optimal environment for diaphragmatic engagement, and respiratory training reinforces this adaptation through motor relearning [14].

Despite the potential benefits of breathing exercises and trunk manual techniques, evidence for their effectiveness in patients with LBP is still emerging. So far, there have been previous systematic reviews that have analyzed the efficacy of breathing exercises in individuals with LBP [15–18], and additionally, two other systematic reviews have investigated the impact of manual treatment on musculoskeletal and respiratory factors in LBP [19,20]. However, no systematic review or meta-analysis has yet evaluated the combined effectiveness of breathing exercises and thoracic techniques in CLBP. Supporting evidence from other musculoskeletal conditions further strengthens the rationale for this work. Several studies have demonstrated that breathing exercises improve pain, function, and quality of life in chronic neck pain [21], shoulder dysfunction [22], and postural syndromes such as thoracic kyphosis and forward head posture [23,24]. These findings suggest that breathing interventions exert musculoskeletal benefits beyond LBP, likely through their influence on neuromuscular coordination, posture, and pain modulation.

Accordingly, the objective of this systematic review was to synthesize current evidence on the effectiveness of thoracic-focused interventions – including breathing exercises and thoracic mobilization/release techniques – on pain and disability in patients with CLBP. By consolidating the available literature, this review aims to provide clearer insight into the clinical utility of these interventions and to identify priorities for future research.

Methods

The systematic review and meta-analysis was based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement (S1 Appendix) [25]. The initial protocol of this systematic review has been registered prospectively to the International Prospective Register of Systematic Reviews database (PROSPERO; CRD42023439503).

Search methods for the identification of studies and selection of criteria

Initially, an extensive online database searches were performed in PubMed, Scopus, Web of Sciences, ProQuest, Ovid, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Clinical Trials (CENTRAL) and Google Scholar from January 1, 1990, to May 1, 2025, without any language restrictions. The search syntax was developed by combining keywords with Medical Subject Headings (MeSH) terms, where available, in PubMed, and the underlying search strategy was modified to optimize for each of the other databases (Full search syntax provided in S2 Appendix).

To identify additional primary trials and eligible articles, reference lists of included articles and related reviews were scanned, and manual keyword searches of ClinicalTrials.gov and the WHO International Clinical Trial Registry Platform were performed. Authors of published posters or conference proceedings were contacted by e-mail to request further information (if available).

Search results were imported into EndNote software (version X8; Thomson Reuters, NY, USA), and identified duplicates were removed in the software. All titles and abstracts of the remaining studies were preliminarily screened by one reviewer to identify potentially eligible studies. The full text of potentially eligible articles was then assessed by three independent reviewers, and studies were included if they met the following criteria: 1) controlled trials, 2) sample populations consisted primarily of individuals with low back pain, 3) the intervention methods used in these trials focus on the effectiveness of breathing exercises alone or as an adjunct treatment, diaphragmatic exercises, diaphragm activation techniques, or thoracic mobility techniques (thoracic mobilization, high-velocity low-amplitude manipulation, and release techniques), and 4) patient pain or disability scores were reported as the primary or secondary outcome. Studies without a control group, studies in participants with prior lumbar spine surgery or LBP related to fracture, malignancy, infection, or inflammation, and studies measuring the effect of exercise such as wuinxi, tai chi, qigong, yoga, Pilates, running, walking, and relation technique were not included. Consensus was the method used to resolve disagreements that arose during the study selection phase.

Types of outcomes

Low back pain intensity and disability were the predefined primary outcomes and included studies had to report at least one of the described primary outcomes.

Data extraction and management

Two independent reviewers extracted the study data using a data extraction form developed for the study. One of the reviewers checked all data entries for missing information or inaccuracies. Disagreements were also resolved by consensus. The extracted data are shown in detail in Table 1 and S1 File.

Table 1. Studies are in chronological order from oldest to most recent by year of publication.

	Author -year	Study design	Treatment group characteristics	Treatment duration & Type	Control group characteristics	Control duration & Type	Blinding		Outcome measure
	Author -year	Study design	Treatment group characteristics	Treatment duration & Type	Control group characteristics	Control duration & Type	Patient	Assessor
1	Mehling 2005 [26]	Multi-center RCT	N = 14 CLBP Age: 49.7 ± 12.1 Male: 5 Female: 11	• 6 weeks • 12 treatment sessions • Breath therapy	N = 12 CLBP Age: 48.7 ± 12.5 Male: 5 Female: 7	• 6 weeks • 12 treatment sessions • Physical therapy	no	no	Pain: VAS Disability: RMQ
2	de Oliveria 2013 [27]	Sing-center Single-blind RCT	N = 74 NCLBP Age: 45.95 ± 12.30 Male: 24 Female: 50	• Single session • High velocity manipulation T1-T5	N = 74 NCLBP Age: 46.32 ± 10.22 Male: 15 Female: 59	• Single session • High velocity manipulation specific to the painful lumbar vertebrae (L2 to L5)	no	yes	Pain: NRS Disability: -
3	Heo 2015 [28]	RCT	N = 12 CLBP Age: 43 ± 5.4 Male: 8 Female: 4	• 12 weeks • 36 treatment sessions • Physical therapy & Thoracic mobilization &Exs	N = 12 CLBP Age: 45.4 ± 6.4 Male: 11 Female: 1	• 12 weeks • 36 treatment sessions Physical therapy & Exs	no	no	Pain: VAS Disability: -
4	Ho-Hee 2015 [29]	RCT	N = 9 CLBP Age: 23.31 ± 4.55 Male: N/A Female: N/A	• 8 weeks • 40 treatment sessions • Abdominal breathing exs & Stabilization exs	N = 9 CLBP Age: 22 ± 0.86 Male: N/A Female: N/A	• 8 weeks • 40 treatment sessions • Stabilization exs	no	no	Pain: - Disability: ODI
5	Babina 2016 [13]	Single-blind RCT	N = 31 NCLBP Age: 40.75 Male: N/A Female: N/A	• 2 weeks • 10 sessions • Physical therapy & breath therapy & thoracic mobilization	N = 31 NCLBP Age: 40.75 Male: N/A Female: N/A	• 2 weeks • 10 sessions • Physical therapy & breath therapy	no	yes	Pain: - Disability: ODI
6	Kang 2016 [30]	Sing-center RCT	N = 10 CLBP Age: 42.5 ± 5.3 Male: N/A Female: N/A	• 6 weeks • 24 sessions • Exhalation exs	N = 10 CLBP Age: 40.1 ± 5.3 Male: N/A Female: N/A	• 6 weeks • 24 sessions • Trunk stabilization	no	no	Pain: - Disability: ODI
7	Mohanty 2016 [31]	RCT	N = 100 CLBP + spondylolisthesis Age: 42.42 ± 6.96 Male: 34 Female: 66	• 4 weeks • 20 sessions • Physical therapy & • Upper thoracic mobilization	N = 100 CLBP + spondylolisthesis Age: 41.76 ± 5.12 Male: 31 Female: 69	• 4 weeks • Physical therapy	no	no	Pain: - Disability: ODI
8	Finta 2018 [32]	RCT	N = 26 NCLBP Age: 22.31 ± 5.15 Male: N/A Female: N/A	• 8 weeks • 16 sessions • Complex therapy & Diaphragm training	N = 21 NCLBP Age: 21.33 ± 4.73 Male: N/A Female: N/A	• 8 weeks • 16 sessions • Complex therapy	no	no	Pain: VAS Disability: -
9	Marti-Salvador 2018 [33]	Multi-center Double-blind RCT	N = 33 NCLBP Age: 43.4 ± 10.8 Male: 16 Female: 17	• 4 weeks • 5 sessions • Diaphragm training	N = 33 NCLBP Age: 41.7 ± 10.3 Male: 13 Female: 20	• 4 weeks • 5 sessions • Sham diaphragm training	yes	yes	Pain: VAS Disability: ODI
10	Park Ju-jung 2018 [34]	Single-blind RCT	N = 15 CLBP Age: 31.0 ± 16.6 Male: N/A Female: N/A	• Thoracic mobilization (T1-T8)	N = 15 CLBP Age: 32.0 ± 13.7 Male: N/A Female: N/A	• Placebo thoracic mobilization (T1-T8)	yes	no	Pain: VAS Disability: -
11	Fan 2018 [35]	Sing-center RCT	N = 30 NLBP Age: 40.87 ± 9.56 Male: 17 Female: 13	• 4 weeks • 20 treatment sessions • Stabilization exs & Breathing exs	N = 30 NLBP Age: 38.53 ± 11.19 Male: 15 Female: 15	• Stabilization exs	no	no	Pain: VAS Disability: ODI
12	Fisher 2019 [36]	Sing-center Double-blind RCT	N = 52 LBP Age: 38.46 ± 12.07 Male: 20 Female: 32	• 1.5 weeks • 3 treatment sessions • Stabilization exs & Education & thoracic manipulation (T6-T12)	N = 49 lbp Age: 37.78 ± 10.91 Male: 10 Female: 39	• 1.5 weeks • 3 treatment sessions • Stabilization exs & Education & Sham thoracic manipulation (T6-T12)	yes	yes	Pain: NRS Disability: RMQ
13	Cho 2019 [37]	Sing-center RCT	N = 15 CLBP Age: 40.93 ± 6.45 Male: 6 Female: 9	• 12 weeks • 36 treatment sessions • Breathing exs	N = 15 CLBP Age: 42.40 ± 6.93 Male: 6 Female: 9	• 12 weeks • 36 treatment sessions • Stabilization exs	no	no	Pain: VAS Disability: -
14	Park Sam-Ho 2019 [38]	RCT	N = 20 LBP Age: 30.9 ± 4.53 Male: 12 Female: 8	• 4 weeks • 12 sessions • Stabilization exs & respiratory resistance training	N = 23 LBP Age: 30.7 ± 4.32 Male: 12 Female: 11	• 4 weeks • 12 sessions • Stabilization exs	no	no	Pain: NRS Disability: ODI
15	Ahmadnezhad 2020 [4]	Multi-center Single-blind RCT	N = 24 NCLBP Age: 21.43 ± 2.15 Male: 12 Female: 12	• 8 weeks • inspiratory muscle training & regular sport exs	N = 24 NCLBP Age: 22.33 ± 1.41 Male: 12 Female: 12	• 8 weeks • Supervised exs • regular sport exs	no	yes	Pain: VAS Disability: -
16	de Oliveria 2020 [39]	Sing-center Single-blind RCT	N = 74 NCLBP Age: 45 ± 14 Male: 17 Female: 57	• 4 weeks • 10 treatment sessions • Thoracic manipulation (T5-T6)	N = 74 NCLBP Age: 45 ± 13 Male: 16 Female: 58	• 4 weeks • 10 treatment sessions • Mobilization specific to the painful lumbar vertebrae	no	yes	Pain: NRS Disability: RMQ
17	Lim 2020 [40]	Sing-center Single-blind RCT	N = 12 NCLBP Age: 43.33 ± 10.26 Male: 4 Female: 8	• Breathing exs	N = 12 NCLBP Age: 45.33 ± 10.27 Male: 4 Female: 8	• Mobilization specific to the painful lumbar vertebrae	yes	yes	Pain: VAS Disability: -
18	Divya 2020 [41]	RCT	N = 15 CLBP Age: 38.53 ± 7.84 Male: N/A Female: N/A	• 4 weeks • 12 treatment sessions • Electrotherapy& Stabilization exs & Thoracic mobilization & strength	N = 15 CLBP Age: 40.33 ± 8.56 Male: N/A Female: N/A	• 4 weeks • 12 treatment sessions • Electrotherapy& Stabilization exs	no	no	Pain: NRS Disability: ODI
19	Kostodinovic 2020 [42]	Single-blind RCT	N = 40 CLBP + radiculopathy Age: 44.12 ± 10.25 Male: 18 Female: 22	• 8 weeks • Electrotherapy& Stabilization exs & Thoracic mobilization	N = 40 CLBP + radiculopathy Age: 44.3 ± 9.13 Male: 17 Female: 23	• 8 weeks • Electrotherapy& Stabilization exs	no	yes	Pain: VAS Disability: ODI
20	Oh 2020 [43]	Sing-center Single- blind RCT	N = 22 LBP+instability Age: 46.14 ± 2.59 Male: - Female: 22	• 4 weeks • 12 treatment sessions • Stabilization exs & respiratory resistance exs	N = 22 LBP+ instability Age: 44.45 ± 2.54 Male: - Female: 22	• 4 weeks • 12 sessions • Stabilization exs	no	yes	Pain: VAS Disability: ODI
21	Atilgan 2021 [44]	Sing-center RCT	N = 23 NCLBP Age: 32.08 ± 7.15 Male: - Female: 23	• 8 weeks • 24 treatment sessions • Stabilization ex & breath therapy	N = 20 NCLBP Age: 37.7 ± 5.80 Male: - Female: 20	• 8 weeks • 24 sessions • Stabilization exs	no	no	Pain: VAS Disability: -
22	Otadi 2021 [45]	Multi-center RCT	N = 12 NCLBP Age: 36.2 ± 8.9 Male: 7 Female: 5	• 4 weeks • 12 treatment sessions • Supervised exs & home exs • Diaphragm training & TENS	N = 12 NCLBP Age: 34.2 ± 10.8 Male: 5 Female: 7	• 4 weeks • 12 sessions • Supervised exs & home exs • TENS	no	no	Pain: NRS Disability: -
23	Park Sam-Ho 2021 [46]	Sing-center RCT	N = 20 LBP+ instability Age: 47.09 ± 1.15 Male: - Female: 20	• 4 weeks • 12 treatment sessions • Stabilization exs & respiratory resistance exs	N = 20 LBP+ instability Age: 46.68 ± 1.73 Male: - Female: 20	• 4 weeks • 12 sessions • Stabilization exs	no	no	Pain: NRS Disability: ODI
24	Park Sun-Ju 2021 [47]	Sing-center RCT	N = 22 CLBP Age: 41.09 ± 8.94 Male: 12 Female: 10	• 8 weeks • 24 treatment sessions • Stabilization exs & Thoracic manipulation	N = 22 CLBP Age: 39.68 ± 9.38 Male: 12 Female: 10	• 8 weeks • 24 treatment sessions • Stabilization exs	no	no	Pain: VAS Disability: -
25	Park Sam-Ho 2022 [48]	RCT	N = 14 NCLBP+ instability Age: 31.07 ± 6.82 Male: 9 Female: 5	• 5 weeks • 15 treatment sessions • Stabilization exs & respiratory resistance exs	N = 15 NCLBP+ instability Age: 30.29 ± 5.34 Male: 6 Female: 9	• 5 weeks • 15 sessions • Stabilization exs	no	no	Pain: VAS Disability: RMQ
26	Masroor 2023 [49]	Sing-center Single-blind RCT	N = 11 CLBP Age: 25.3 ± 3.4 Male: N/A Female: N/A	• 4 weeks • 12 treatment sessions • Stabilization exs & Diaphragm breathing	N = 11 CLBP Age: 25.6 ± 4.2 Male: N/A Female: N/A	• 4 weeks • 12 treatment sessions • Stabilization exs	yes	no	Pain: NRS Disability: ODI
27	Siglan 2023 [50]	Single-center Double blind RCT	N = 21 CLBP Age: 38.76 ± 8.96 Male: 8 Female: 13	• 4 weeks • 12 sessions • Physical therapy & release	N = 21 CLBP Age: 38 ± 7.78 Male: 12 Female: 9	• 4 weeks • 12 sessions • Physical therapy & sham release	yes	yes	Pain: NRS Disability: RMQ
28	Salah Eldeen 2024 [51]	Sing-center RCT	N = 17 LBP Age: 37.81 ± 8.49 Male: 5 Female: 12	• 6 weeks • 18 sessions • Physical therapy & Thoracic mobilization (T5-T12)	N = 17 LBP Age: 34.94 ± 4.71 Male: 9 Female: 8	• 6 weeks • 18 sessions • Physical therapy	no	no	Pain: VAS Disability: -
29	Dogan 2024 [52]	Single-center Double blind RCT	N = 27 CLBP Age: 36.76 ± 4.32 Male: 12 Female: 15	• 6 weeks • 18 sessions • Stabilization exs & Thoracic mobility exs	N = 27 CLBP Age: 35.56 ± 7.55 Male: 14 Female: 13	• 6 weeks • 18 sessions • Stabilization exs	no	yes	Pain: VAS Disability: QBPDS
30	Elfayoumi 2024 [53]	Single-center Single blind RCT	N = 21 CLBP Age: 25.19 ± 2.87 Male: 9 Female: 12	• 4 weeks • 12 sessions • Stretching and strengthening exs & thoracic lymphatic pump technique	N = 21 CLBP Age: 25.43 ± 2.84 Male: 12 Female: 9	• 4 weeks • 12 sessions • Stretching and strengthening exs	no	no	Pain: NRS Disability: ODI
31	Hwang 2024 [54]	Sing-center RCT	N = 16 NCLBP Age: 56.88 ± 6.93 Male: N/A Female: N/A	• 4 weeks • 12 sessions • Thoracic mobility exs	N = 16 NCLBP Age: 55.88 ± 6.61) Male: N/A Female: N/A	• 4 weeks • 12 sessions • Physical therapy	no	no	Pain: NRS Disability: ODI
32	Mikkonen 2024 [55]	Single blind RCT	N = 9 NCLBP Age: 50.1 ± 11.9 Male: 3 Female: 6	• 8 weeks • Every day • MVT control exs & synchronized breathing	N = 13 NCLBP Age: 53.5 ± 9.7 Male: 5 Female: 8	• 8 weeks • Every day • MVT control exs	yes	yes	Pain: NRS Disability: RMQ
33	Park Donghwan 2024 [56]	Single-center Single blind RCT	N = 15 NCLBP Age: 44.2 ± 5.09 Male: 8 Female: 7	• 6 weeks • 18 sessions • Physical therapy & Thoracic mobility exs	N = 15 NCLBP Age: 42.6 ± 7.41 Male: 7 Female: 8	• 6 weeks • 18 sessions • Physical therapy & Stabilization exs	no	yes	Pain: VAS Disability: -
34	Abdel-Aziz 2025 [57]	Single-center Single blind RCT	N = 27 CLBP Age: 28.21 ± 4.12 Male: - Female: 27	• 6 weeks • 18 sessions • Physical therapy & Diaphragm release and 5 deep breaths	N = 27 CLBP Age: 29.93 ± 3.16 Male: - Female: 27	• 6 weeks • 18 sessions • Physical therapy	yes	no	Pain: - Disability: ODI
35	Abdelhamid 2025 [58]	Single-center Single blind RCT	N = 30 NCLBP Age: 21.43 ± 2.16 Male: 16 Female: 14	• 4 weeks • 12 sessions • Stabilization exs & Ball and balloon exs	N = 30 NCLBP Age: 21.30 ± 2.45 Male: 15 Female:15	• 4 weeks • 12 sessions • Stabilization exs	no	yes	Pain: VAS Disability: ODI
36	Li 2025 [59]	RCT	N = 6 NCLBP Age: 23.83 ± 2.48 Male: 2 Female: 4	• 12 weeks • Home exs • Stabilization exs & Breathing exs	N = 6 NCLBP Age: 25.14 ± 1.35 Male: 2 Female: 4	• 12 weeks • Home exs • Stabilization exs	no	no	Pain: VAS Disability: ODI

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RCT: Randomized Control Trial, NCLBP: Non-Specific Low Back Pain, VAS: Visual Analogue Scale, NPRS: Numerical Pain Rate Scale, ODI: Oswestry Disability Index, RMQ: Roland Morris Questionnaire, QBPDS: Quebec Back Pain Disability Scale, MVT: Movement.

Assessment of risk of bias in included studies

The risk of bias among the included studies was assessed by two reviewers independently of each other according to the Cochrane Collaboration’s Rob-2, which includes the following domains: risk of bias due to confounding, risk due to the randomization process, risk due to deviation from the intended interventions, risk due to missing outcome data, risk in the measurement of the outcome, risk in the selection of the reported outcome, and risk of overall bias. The terms “low risk of bias”, “some concerns”, and “high risk of bias” were used to assign a specific rating to each domain. The Risk-of-Bias VIsualization tool (robvis) was used to generate the risk of bias graph (Cochrane and robvis) [60]. Interrater agreement was assessed through Gwet’s first-order coefficient of agreement (Gwet’s AC1) with its corresponding 95% CI and interpreted using Landis & Koch’s rule of thumb (0 to 0.20 for low, 0.21 to 0.40 for fair, 0.41 to 0.60 for moderate, 0.61 to 0.80 for substantial, and 0.81 to 1 for near perfect agreement) [61]. In contrast to Cohen’s kappa, Gwet’s AC1 is robust against a “kappa paradox” in which low kappa values are reported despite observed agreement values [62]. Disagreements were also the subject of consensus.

Measures of treatment effect

Low back pain intensity and disability were expressed as Morris’s delta (Morris’s dppc) with a 95% confidence interval (CI) to estimate the magnitude of the treatment effect while considering the pre-post value in both treatment and control groups [63,64]. Effect sizes were computed Using the effect size calculator from the Campbell Collaboration (http://ww.campbellcollaboration.org/escalc/html/EffectSizeCalculator-SMD-main.php). Three different categories were used to quantify the magnitude of effect sizes: small (dppc<0.40), medium (0.40 ≤ dppc ≤ 0.70), and large (dppc>0.70). The assessment of a meaningful clinical effect relied on the existence of an effect size that was at least moderately significant [65].

Assessment and investigation of heterogeneity

The heterogeneity among primary studies was assessed using the I² statistic and the Q test (χ²), in accordance with the guidelines provided by the Cochrane Handbook for Systematic Reviews of Interventions [66]. The I² statistic was interpreted in accordance with the following guidelines: a range of 0–40% indicates no significant heterogeneity, while a range of 30–60% suggests moderate heterogeneity. A range of 50–90% indicates substantial heterogeneity, while a range of 75–100% suggests considerable heterogeneity [67]. Prior to conducting the pooled analysis, the existence of heterogeneity was taken into account. When the I² values above 50% and the confidence intervals (CIs) overlapped upon visual examination of the forest plot, the findings were pooled in a meta-analysis utilizing a random effects model [68]. Statistical significance was determined by a p-value less than 0.05.

In the subgroup analysis, the meta-analysis was performed independently for the subgroups of age, patient blinding, rater blinding, quality (risk of bias), sample size, treatment characteristics, treatment duration, treatment sessions, and therapist supervision in two separate meta-analyses including 24 and 31 studies, respectively. Meta-regression was not conducted because the number of studies per covariate was insufficient to produce reliable estimates, and several moderators were categorical. This approach is consistent with PRISMA guidelines for meta-analyses with a modest number of studies [69].

Assessment of publication bias

The assessment of reporting bias was performed using the Egger’s weighted regression test [68] and Egger’s publication bias graph. In addition, the Duval and Tweedie “trim and fill” approach was used to examine the potential influence of publication bias [70].

Sensitivity analysis

The Jackknife (leave-one-out) approach was used to evaluate the impact of each individual research on the combined results [71]. In addition, a sensitivity analysis was conducted through performing a subgroup analysis on high-quality and higher-designed studies inside the meta-analysis. This was done to evaluate any possible alterations in the results.

Data synthesis

All trials included in the analysis were considered appropriate for the meta-analysis because of their clinical homogeneity, precisely because they were randomized trials with a control group. The meta-analysis of study outcomes was performed using Stata software (version 14; Stata Corp., College Station, TX, USA).

The quality of evidence for study outcomes was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation [72] and classified as high, moderate, low, and very low [73].

Results

Studies characteristics

A total of 18307 references were retrieved from the study selection process, as shown in Fig 1. Due to duplication, 9081 references were excluded. A total of 9226 articles were assessed for potential eligibility based on of their title and abstracts. After a thorough title and abstract review, 300 papers had full-text retrieval to evaluate their eligibility criteria. Subsequently, 42 research papers (five in Korean [29,37,47,54,56], one in Chinese [35] and one in Spanish [74]) were selected to be included in the implementation of this systematic review. In addition, six studies were excluded due to incomplete data on their outcome measures [74–79], leaving a total of 36 studies to be included in the analysis. The characteristics of the included studies are summarized in detail in Table 1. The studies were published between 2005 and 2025 with a total sample size of 1833 patients. All non-English studies (Korean, Chinese, Spanish) were accurately translated, ensuring the integrity and reliability of the extracted data.

Among the 36 studies included in the review, 31 [4,26–28,32–56,58,59] reported pain outcomes and 24 [13,26,29–31,33,35,36,38,39,41–43,46,48–50,52–55,57–59] reported disability outcomes, with some studies reporting only pain or only disability. Eleven studies [26,29,35,37,40,44,49,55,58,59,30] used breathing therapy as a treatment for CLBP. Four studies [27,36,39,47] evaluated the efficacy of thoracic manipulation, while six studies [28,31,34,41,42,51] implemented a treatment based on thoracic mobilization. Respiratory muscle training [32,33,38,4,43,45,46,48] was used as an intervention in eight studies. One study [13] used breathing exercises and thoracic mobilization simultaneously in its research, while another two [50,57] employed release methods in conjunction with standard physiotherapy. Three studies used thoracic mobility exercises as their intervention [52,54,56], while one study [53] benefited from thoracic lymphatic pump techniques, which involved a combination of manual and breathing techniques on the rib cage.

Risk of bias assessment

The Cochrane Risk of Bias Questionnaire 2 (RoB 2) was used to assess the quality of 36 selected studies. Two studies [28,32] (5.6%) had high risk of bias, 22 studies [4,13,29–31,34,35,37,38,41–48,51,55,56,58,59] (61.1%) had some level of concern, and 12 studies [26,27,33,36,39,40,49,50,52–54,57] (33.3%) had low risk of bias. The level of inter-rater agreement for quality assessment was substantial or good according to the overall Gwet’s score (KG: 0.66 ± 0.07). Details of the risk of bias assessment for clinical trials are shown in Fig 2. Unclear randomization and deviations from the intended interventions were the main issues of high risk of bias or some concerns.

Study design and outcome measurement

Table 1 details characteristics of studies included in this review regarding study design, treatment group characteristics, treatment duration and type, control group characteristics, control duration and type, assessor or patient blinding, and outcome measures.

Effects of interventions on pain intensity

Among the included studies, 31 studies [4,26–28,32–56,58,59] reported the effect of interventions on patients’ pain levels as one of their outcome measures. According to the data derived from the analysis, the pooled Morris’ dppc for pain showed the statistically significant with small effect in reducing pain in the group of patients with breathing exercises and/or thoracic techniques compared to the control group (dppc = −0.35, 95% CI = −0.46 to −0.23) with a considerable heterogeneity among these studies (χ² = 200.29, I² = 85.0%, p = 0.00) (Fig 3). To identify the source(s) of heterogeneity, subgroup analysis was performed on eight potential factors (details in Table 2).

Table 2. Subgroup analysis for the effect of potential factors on pain intensity.

Potential		Morris’ dppc (95%CI)	NO of studies	Heterogeneity χ²	I²
Main treatment	Just Breath therapy	−0.21 (−0.41 to −0.01)	16	103.61	85.5%
Main treatment	Thoracic techniques with/without breath therapy	−0.42 (−0.57 to −0.27)	15	93.83	85.1%
Treatment weeks	>4 weeks	−0.60 (−0.81 to −0.39)	15	91.28	84.7%
Treatment weeks	=<4weeks	−0.23 (−0.37 to −0.09)	16	100.77	85.1%
Treatment sessions	>12se	−0.63 (−0.83 to −0.43)	15	89.68	84.4%
Treatment sessions	=<12se	−0.20 (−0.35 to −0.06)	16	99.36	84.9%
Patient blinding	yes	−0.72 (−0.94 to −0.49)	8	38.01	81.6%
Patient blinding	no	−0.20 (−0.34 to −0.06)	23	147.54	85.1%
Assessor blinding	yes	−0.64 (−0.82 to −0.46)	12	95.13	88.4%
Assessor blinding	no	−0.12 (−0.28 to 0.03)	19	87.04	79.3%
Sample size	>20	−0.21 (−0.35 to −0.07)	15	137.80	89.8%
Sample size	=<20	−0.69 (−0.91 to −0.46)	16	49.71	69.8%
Age	>40 yrs.	−0.31 (−0.46 to −0.16)	15	76.93	81.8%
Age	<40 yrs.	−0.40 (−0.58 to −0.21)	16	122.81	87.8%
Risk of bias	High	−0.02 (−0.59 to 0.54)	2	58.54	92.9%
	Some concern	−0.58 (−0.77 to −0.39)	18	85.77	87.7%
	low	−0.20 (−0.36 to −0.04)	11	19.05	73.2%
All studies		−0.35 (−0.46 to −0.23)	31	200.29	85.0%

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Subgroup analysis on the effects of interventions on pain intensity

The included studies used different treatment methods. Thirteen studies used only breathing therapy (BT) as the primary treatment, while ten studies used thoracic techniques alone or in combination with breathing therapy (TT). The results of the subgroup analysis indicated a substantial moderate effect of TT in reducing pain (dppc = −0.42, 95% CI = −0.57 to −0.27) compared to BT (dppc = −0.21, 95% CI = −0.41 to −0.01). However, the overall heterogeneity remains constant within each subgroup (Table 2). Treatment more prolonged than four weeks and treatments more than twelve sessions showed a moderate effect in reducing pain intensity (dppc = −0.60, 95% CI = −0.81 to −0.39) (dppc = −0.63, 95% CI = −0.83to −0.43); however, they did not affect the amount of heterogeneity (Table 2).

A large effect size was found in a subgroup of patients who were unaware of the type of therapy they received (dppc = −0.72, 95% CI = −0.94 to −0.49). Additionally, trials with assessor blinding had moderate to large effects on pain intensity (dppc = −0.64, 95% CI = −0.82 to −0.46). The amount of heterogeneity did not change meaningfully in these two post hoc analyses. Regarding sample size, studies with fewer than 20 participants were associated with a larger effect size (dppc = −0.69, 95% CI = −0.91 to −0.46), and the level of heterogeneity decreased by 15.2% in the subgroup of studies with smaller sample sizes (χ² = 49.71, I² = 69.8%, p = 0.00). Subgroup analysis by patients’ age (younger or older than 40 years old) did not change the effect size or heterogeneity.

According to the risk of bias assessment, most of the included studies had some concerns, and this subgroup showed a greater effect size (dppc = −0.58, 95% CI = −0.77 to −0.39) compared to studies with a high or low risk of bias. Additionally, the subgroup of studies with a low risk of bias showed somewhat less heterogeneity (χ² = 19.05, I² = 73.2%, p = 0.00).

Effects of interventions on disability score

Out of the studies included in this meta-analysis, twenty-four studies [13,26,29–31,33,35,36,38,39,41–43,46,48–50,52–55,57–59] evaluated the level of disability as their outcome measure. The pooled Morris’ dppc calculated for disability indicated a statistically significant improvement with large effect compared to the control group (dppc = −0.71, 95% CI = −0.86 to −0.57). Nevertheless, there is a significant degree of heterogeneity among the studies (χ² = 266.16, I² = 91.4%, p = 0.00) (Fig 4). Table 3 presents the results of the subgroup analysis of potential covariates.

Table 3. Subgroup analysis for the effect of potential factors on disability score.

Potential		Morris’ dppc (95%CI)	NO of studies	Heterogenity χ2	Pvalue	I²
Main treatment	Just Breath therapy	−0.39 (−0.67 to −0.12)	12	60.35	0.00	81.8%
Main treatment	Thoracic techniques with/without breath therapy	−0.84 (−1.02 to −0.67)	12	198.43	0.00	94.5%
Treatment weeks	>4 weeks	−0.85 (−1.11 to −0.59)	9	11.50	0.00	30.5%
Treatment weeks	=<4weeks	−0.65 (−0.83 to −0.47)	15	253.06	0.00	94.5%
Treatment sessions	>12se	−1.05 (−1.31 to −0.78)	10	84.00	0.00	93.9%
Treatment sessions	=<12se	−0.56 (−0.74 to −0.39)	14	144.48	0.00	88.2%
Patient blinding	yes	−0.85 (−1.07 to −0.64)	16	11.53	0.00	39.3%
Patient blinding	no	−0.59 (−0.79 to −0.39)	8	251.60	0.00	94.0%
Assessor blinding	yes	−0.47 (−0.66 to −0.28)	9	22.91	0.00	91.7%
Assessor blinding	no	−1.07 (−1.30 to −0.84)	15	237.33	0.00	90.9%
Sample size	>20	−0.66 (−0.83 to −0.50)	11	248.96	0.00	95.2%
Sample size	=<20	−0.87 (−1.18 to −0.57)	13	15.81	0.00	36.7%
Age	>40 yrs.	−0.70 (−0.90 to −0.51)	12	189.97	0.00	94.2%
Age	<40 yrs.	−0.73 (−0.95 to −0.50)	12	76.17	0.00	85.6%
Risk of bias	High	–	0	–	–	–
	Some concern	−0.96 (−1.21 to −0.71)	14	219.73	0.00	94.3%
	low	−0.58 (−0.76 to −0.40)	10	38.78	0.00	71.0%
All studies		−0.71 (−0.86 to −0.57)	24	266.16	0.00	91.4%

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Subgroup analysis on the effects of interventions on disability score

Twelve trials used BT as the primary treatment, while twelve other trials used TT. A subgroup analysis revealed that combining data from trials employing the TT approach yielded approximately twice the improvement in disability scores (dppc = −0.84, 95% CI = −1.02 to −0.67) compared to trials using only BT (dppc = −0.39, 95% CI = −0.67 to −0.12). Subgroup analysis by treatment weeks showed a larger effect for treatments lasting more than four weeks (dppc = −0.85, 95% CI = −1.11 to −0.59), with a significant reduction in heterogeneity to an ignorable amount (χ² = 11.50, I² = 30.5%, p = 0.00). However, studies with more than 12 treatment sessions had a larger effect size (dppc = −1.05, 95% CI = −1.31 to −0.78), but this had no impact on heterogeneity (χ² = 84, I² = 93.9%, p = 0.00) (Table 3).

Trials with blinded patients showed a greater effect on the disability score (DPC = −0.85, 95% CI = −1.07 to −0.64), with a meaningful decrease in heterogeneity to a non-significant level (χ² = 11.53, I² = 39.3%, p = 0.00). However, when considering subgroups of studies with assessor blinding, the effect size diminished and the heterogeneity remained constant (dppc = −0.47, 95% CI = −0.66 to −0.28). Studies with more than 20 samples, however, showed a smaller effect size (dppc = −0.66, 95% CI = −0.83 to −0.50) than studies with fewer than 20 samples. Post hoc analysis of patient age did not alter the overall findings regarding effect size or heterogeneity (Table 3).

None of the studies included in the meta-analysis of treatment effects on disability scores were considered to be at high risk for bias. Studies with some concern of bias had a larger effect size (dppc = −0.96, 95% CI = −1.21 to −0.71, p = 0.00) than studies with a low risk of bias (dppc = −0.58, 95% CI = −0.76 to −0.41, p = 0.00). The level of heterogeneity was smaller in the subgroup of studies with a low risk of bias (χ² = 38.78, I² = 71.0%, p = 0.00; see Table 3).

Sensitivity analysis

Pain Intensity: The presence of bias in the research affects the assessment of the treatment effects on patients’ pain severity. The analysis of studies with a low risk of bias regarding pain revealed a slight decrease in effect size. The same was found for the pooled Morris’ dppc for the trials with not small sample size (Table 4).

Table 4. Sensitivity Analysis using any kinds of blinding and studies with low risk of bias.

Pain Intensity
Combination	Number	Morris’ dppc	Lower limit	Upper limit
Low risk of bias	11	−0.20	−0.36	−0.04
Sample size (>20)	15	−0.21	−0.35	−0.07
All study	31	−0.34	−0.46	−0.23
Disability Score
Low risk of bias	10	−0.58	−0.76	−0.40
Sample size (>20)	11	−0.66	−0.83	−0.50
All study	24	−0.71	−0.86	−0.57

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RCT: Randomized Control Trial.

Disability Score: A sensitivity analysis of low-risk-of-bias and blinded trials revealed a reduction in the magnitude of the treatment effect on patient disability scores, from large to moderate. (Table 4).

Jackknife Method: The effect of 1 study on the estimate of the combined meta-analysis was examined using the leave-one-out method of sensitivity analysis. None of the studies affected the overall combination of the pain intensity or disability score outcomes, except for one study. After removing the Ho-Hee [29] study, the estimated pooled Morris’ dppcs of disability scores changed to −0.58 (95% CI: −0.68, −0.49) (Fig 5).

Assessment of publication bias

Egger’s linear regression did not confirm the presence of substantial publication bias for either pain intensity or disability scores (Fig 6). The application of the trim-and-fill technique also failed to detect any missing studies. However, funnel plots indicated a significant presence of publication bias in the pain intensity studies and disability scores (Fig 7).

Quality of evidence

We evaluated the quality of the evidence for the outcome measures using the GRADE methodology (Table 5). Regarding the effect of breathing exercises and/or thoracic techniques on pain in patients with low back pain, the quality of the evidence was very low (downgraded due to limitations, inconsistencies, and publication bias, and upgraded due to the large effect size). For the outcome disability, the quality of the evidence was also low (downgraded due to limitations and inconsistency, and upgraded due to the large effect size).

Table 5. Grades of Recommendation, Assessment, Development and Evaluation quality of evidence for the primary outcomes.

Outcome	Limitations	Inconsistency	Indirectness	Imprecision	Publication Bias	Effect size	GRADE Quality
Pain	−1^*	−2^†	0	0	−1^ǂ	0	low
Disability	−1^*	−1^†	0	0	−2^ǂ	+2^£	Very low

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* Downgraded by one level as the majority of the studies have a high risk of bias and some concerns.

† Two levels were downgraded. The I² value was > 50% for pain. One level was downgraded. The I² value was > 50% but I2 was < 50% in some subgroups.

ǂ Downgraded by due to suspected publication bias.

£ Upgraded two level due to large effect size.

Discussion

This systematic review and meta-analysis examined the effects of breathing exercises and thoracic techniques on pain and disability in patients with low back pain. Our study is the first to evaluate the impact of thoracic-focused interventions on LBP outcomes, highlighting the clinical importance of considering the thoracic region in rehabilitation strategies. Overall, these interventions modestly reduced pain but demonstrated a larger effect on disability. However, the interpretation of these findings must remain cautious given the overall low certainty of evidence ant the observed heterogeneity across included studies. Although subgroup analyses for treatment duration and methodological quality reduced heterogeneity for disability outcomes, significant variability remain for pain outcomes. This suggests that unmeasured moderators may influence the observed effects.

Our findings align with and extend the growing body of recent evidence supporting the role of respiratory-focused interventions in low back pain management. Shi et al. (2023) [16] and Jiang et al. (2024) [15] both demonstrated that breathing exercises lead to statistically significant but modest improvements in pain and disability, consistent with the small-to-moderate pooled effects observed in our study. Similarly, Zhai et al. (2024) [17] highlighted those respiratory interventions are more effective when delivered beyond four weeks, a result that resonates with our subgroup analysis showing that longer treatment duration reduces heterogeneity and yields more consistent improvements in disability. Importantly, Fabero-Garrido et al. (2024) [18] reported that respiratory muscle training not only improves pain and disability but also enhances respiratory function and functional ability, underscoring the broader physiological and biomechanical relevance of respiratory-targeted rehabilitation strategies. Additionally, systematic reviews of general manual therapy also reported positive effects [20,80]. Collectively, these recent reviews reinforce our conclusion that breathing exercises and thoracic manual techniques may provide meaningful adjunctive benefits in the management of low back pain, though the certainty of these effects remains limited and should be interpreted with caution.

The diaphragm plays a crucial role in spinal stability and interacts synergistically with the transverse abdominis. Altered activation patterns in these muscles have been reported in individuals with CLBP [81]. Dysfunction of the diaphragm as the primary respiratory muscle can result in disordered breathing patterns, hyperventilation, and hypocapnia, negatively affecting muscular function [82]. Approximately 50–60% of individuals with CLBP exhibit altered breathing during trunk stability testing, linked to impaired motor control rather than pain intensity [83].The clinical implications of our findings suggest that integrating thoracic mobilization with breathing exercises may provide superior outcomes.

Several subgroups were used to identify and account for influential elements of the research results, including treatment type, treatment duration, patient blinding, rater blinding, sample size, average age of participants, and risk of bias in the studies. Within a subgroup categorized by treatment technique, studies using breath therapy showed a small effect on reducing pain and disability. In contrast, studies that used a thoracic technique approach showed much larger effect sizes, with moderate and large sizes observed for pain and disability scores, respectively. These results indicate that the thoracic techniques produced superior improvements in both pain and disability in people with LBP, emphasizing their clinical usefulness compared with breathing therapy alone. However, the assessment of the degree of heterogeneity did not change within the subgroups. Therefore, these findings should be viewed as exploratory and hypothesis-generating rather than confirmatory, given the residual variability and low certainty of evidence.The more significant treatment effects of the thoracic technique may be related to increased thoracic spine mobility, which is more accessible with this technique. Restricted motion of nearby joints may cause lumbar motion dysfunction and resultant pain. Restricted hip rotation has previously been reported in LBP [84]. Similarly, excessive lumbar rotation and back pain may result from limited thoracic spine motion [85]. These findings support the concept that restoring thoracic mobility can reduce compensatory lumbar overload and improve overall spinal function. Babina et al. [13] observed that participants who underwent thoracic mobilization together with specific therapy for LBP demonstrated considerably greater improvement in chest wall expansion. This improvement can be attributed to the mechanical effects of posterior-anterior mobilization applied to the thoracic region. Furthermore, breathing is a biological activity involving the muscles and skeleton that is essential to the functioning of our internal organs. Breathing plays a vital role in connecting the body’s physical and internal systems [86]. In addition, manual therapy of the upper back regions may influence autonomic control of the lungs, which receive parasympathetic innervation from the vagus nerve and sympathetic innervation from the T1–T5 spinal segments. This mechanism could partly explain the observed improvement in respiratory function and breathing efficiency [87]. Manual techniques can effectively induce significant plastic deformation in connective tissue, thereby improving joint mobility [88]. Such movement-induced changes stimulate glycosaminoglycans, restore natural lubrication between collagen fibers and promote healthier tissue remodeling, which may contribute to increase contractile protein and oxidative capacity within muscle fibers [89]. While these mechanisms are plausible and supported by existing literature, we have tempered our interpretation to avoid overstating causal relationships. Future mechanistic studies are needed to confirm whether improvements in respiratory and thoracic function directly translate to clinical benefits in LBP.

Subgroup analysis in the current study suggests that increasing treatment duration leads to better outcomes. The timing and duration of treatment have been debated in previous studies. Zhai et al. [17] found that treatment beyond four weeks, delivered three to five times per week, had a greater impact on pain and disabilities reduction. However, Shi et al. [16] did not identify treatment length as a significant factor. In our analysis, restricting the studies to interventions longer than four weeks for disability outcomes reduced heterogeneity to approximately 30%, suggesting that treatment duration may partially explain variability between studies. This reduction indicates that longer treatment programs may yield more consistent and clinically meaningful improvements in disability. For pain outcomes, however, heterogeneity remained high (I² > 85%), which may be due to additional unmeasured factors such as differences in chronicity of LBP, co-interventions, intensity of exercises, or timing of outcome assessments. These observations highlight the importance of standardizing treatment protocols and reporting practices in future studies. Collectively, these findings emphasize the need for future research to establish the most effective and efficient dosage for breathing therapy and thoracic techniques.

Blinding is another critical issue in clinical trials. Our results showed that patient blinding reduced the reported effect size for pain and decreased heterogeneity. While rater blinding, reduced treatment effects overall. Sample size also influenced findings: smaller studies tended to magnify effects on both pain and disability, and also reduced heterogeneity to below 50% for disability. In line with our findings, Divya et al. [41] noted that although the therapy group showed beneficial, the limited sample size may affect the validity of the final results. In contrast, patient age did not influence treatment effects. Our results confirmed the suggestion of previous studies [16] that study quality is an essential factor to mention; trials with lower methodological quality showed larger treatment effects, particularly for disability. This suggests that bias may overestimate the favorable treatment outcomes and the magnitude of the pooled effect size.

Our evaluation of publication bias yielded mixed findings. Egger’s linear regression and the trim-and-fill method did not indicate substantial publication bias for either pain intensity or disability outcomes. However, funnel plot inspection suggested a possible presence of publication bias for both outcomes, reflecting potential small-study effects or heterogeneity in study protocols. Sensitivity analysis using the leave-one-out method showed that most individual studies did not significantly alter the overall pooled effect. The exception was the Ho-Hee [29] study, removal of which changed the pooled Morris’ dppcs for disability to −0.58 (95% CI: −0.68 to −0.49). This indicates that this study had a notable influence on the combined estimate, likely due to its sample characteristics or methodology. These findings suggest that while the overall results are robust, caution is warranted in interpreting effect sizes, particularly for disability outcomes. Clinically, breathing exercises and thoracic techniques appear beneficial, but the magnitude of effect may be sensitive to individual studies. This underscores the need for future high-quality, adequately powered trials to confirm the effectiveness of these interventions.

Strengths and limitations

This study included studies that targeted the thoracic region – through manipulation, mobilization, release, or breathing exercises. The study also performed subgroup analyses and included a broad time frame, more recent studies, and avoided language restrictions, all of which strengthen the comprehensiveness of this review.

However, heterogeneity across protocols—particularly in treatment duration, frequency, and exercise type—limited the meta-analysis. In addition, a meta-analysis based on total treatment time and also on the nature of the outcome measure (whether the outcomes were evaluated primarily or secondarily) might be more informative, but this was not possible due to incomplete reporting in the included study. Even after several subgroup analyses, heterogeneity for pain outcomes remained high, indicating unmeasured factors may have influenced the results. Specifically, differences in LBP chronicity may have contributed to variability, as acute, subacute, and chronic presentations can differ in underlying pathophysiology and recovery potential, affecting responsiveness to interventions. Co-interventions, such as concurrent physical therapy, exercise programs, or pharmacological treatments, may have confounded outcomes by producing additive or synergistic effects that varied across studies. Additionally, variability in the intensity, frequency, and progression of breathing exercises or thoracic techniques likely influenced treatment effects. These variables were not consistently reported in the included studies, and thus could not be analyzed in our review. Furthermore, comparison against minimal clinically important differences (MCID) were not feasible because studies used different scales. Instead, we calculated effect sizes using Morris’s delta based on pre–post differences. Taken together, these limitations highlight the need for standardized intervention protocols, consistent outcome measures, and comprehensive reporting in future trials to reduce heterogeneity and improve interpretability.

Conclusion

Based on the available evidence, breathing exercises and thoracic techniques appear more effective for reducing disability than pain in patients with LBP, with thoracic techniques demonstrating greater benefits overall. Interventions lasting more than four weeks may provide more consistent and clinically meaningful improvements in disability, highlighting the importance of adequate treatment duration. Nevertheless, these results should be interpreted cautiously due to the low certainty of evidence, residual heterogeneity, and limited exploration of moderating factors. Future research should focus on identifying key moderators (e.g., chronicity, co-interventions, exercise intensity) that may explain variability in outcomes, and on conducting high-quality, adequately powered randomized controlled trials using standardized protocols and consistent outcome measures. By addressing these methodological gaps, future studies can provide stronger evidence to guide the integration of thoracic and breathing interventions into physiotherapy practice for low back pain.

Supporting information

S1 Appendix. PRISMA checklist.

(DOCX)

pone.0339263.s001.docx^{(31.3KB, docx)}

S2 Appendix. Full search syntax.

(DOCX)

pone.0339263.s002.docx^{(15.9KB, docx)}

S1 File. Data excel file.

(XLS)

pone.0339263.s003.xls^{(45KB, xls)}

Acknowledgments

The authors would like to thank the Babol University of Medical Sciences for all the support they have provided.

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

The author(s) received no specific funding for this work.

References

1.Chen S, Chen M, Wu X, Lin S, Tao C, Cao H, et al. Global, regional and national burden of low back pain 1990-2019: a systematic analysis of the Global Burden of Disease study 2019. J Orthop Translat. 2021;32:49–58. doi: 10.1016/j.jot.2021.07.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356–67. doi: 10.1016/S0140-6736(18)30480-X [DOI] [PubMed] [Google Scholar]
3.Deyo RA, Cherkin D, Conrad D, Volinn E. Cost, controversy, crisis: low back pain and the health of the public. Annu Rev Public Health. 1991;12:141–56. doi: 10.1146/annurev.pu.12.050191.001041 [DOI] [PubMed] [Google Scholar]
4.Ahmadnezhad L, Yalfani A, Gholami Borujeni B. Inspiratory muscle training in rehabilitation of low back pain: a randomized controlled trial. J Sport Rehabil. 2020;29(8):1151–8. doi: 10.1123/jsr.2019-0231 [DOI] [PubMed] [Google Scholar]
5.Hammill RR, Beazell JR, Hart JM. Neuromuscular consequences of low back pain and core dysfunction. Clin Sports Med. 2008;27(3):449–62, ix. doi: 10.1016/j.csm.2008.02.005 [DOI] [PubMed] [Google Scholar]
6.Hanada EY, Johnson M, Hubley-Kozey C. A comparison of trunk muscle activation amplitudes during gait in older adults with and without chronic low back pain. PM R. 2011;3(10):920–8. doi: 10.1016/j.pmrj.2011.06.002 [DOI] [PubMed] [Google Scholar]
7.Tong MH, Mousavi SJ, Kiers H, Ferreira P, Refshauge K, van Dieën J. Is there a relationship between lumbar proprioception and low back pain? A systematic review with meta-analysis. Arch Phys Med Rehabil. 2017;98(1):120-136.e2. doi: 10.1016/j.apmr.2016.05.016 [DOI] [PubMed] [Google Scholar]
8.Beeckmans N, Vermeersch A, Lysens R, Van Wambeke P, Goossens N, Thys T, et al. The presence of respiratory disorders in individuals with low back pain: a systematic review. Man Ther. 2016;26:77–86. doi: 10.1016/j.math.2016.07.011 [DOI] [PubMed] [Google Scholar]
9.Abdollahzadeh Z, Abbasi H. Altered respiratory function in patients with low back pain: a review article. JMR. 2021. doi: 10.18502/jmr.v15i2.7726 [DOI] [Google Scholar]
10.Rasmussen-Barr E, Magnusson C, Nordin M, Skillgate E. Are respiratory disorders risk factors for troublesome low-back pain? A study of a general population cohort in Sweden. Eur Spine J. 2019;28(11):2502–9. doi: 10.1007/s00586-019-06071-5 [DOI] [PubMed] [Google Scholar]
11.Ostwal PP, Wani SJI. Breathing patterns in patients with low back pain. IJPR. 2014;2(1):347–53. [Google Scholar]
12.Kocjan J, Adamek M, Gzik-Zroska B, Czyżewski D, Rydel M. Network of breathing. Multifunctional role of the diaphragm: a review. Adv Respir Med. 2017;85(4):224–32. doi: 10.5603/ARM.2017.0037 [DOI] [PubMed] [Google Scholar]
13.Babina R, Mohanty PP, Pattnaik M. Effect of thoracic mobilization on respiratory parameters in chronic non-specific low back pain: a randomized controlled trial. J Back Musculoskelet Rehabil. 2016;29(3):587–95. doi: 10.3233/BMR-160679 [DOI] [PubMed] [Google Scholar]
14.Jung S-H, Hwang U-J, Ahn S-H, Kim J-H, Kwon O-Y. Does mobilisation of the thoracic spine using mechanical massage affect diaphragmatic excursion in individuals with thoracic hyperkyphosis? J Back Musculoskelet Rehabil. 2022;35(3):517–23. doi: 10.3233/BMR-210143 [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Jiang X, Sun W, Chen Q, Xu Q, Chen G, Bi H. Effects of breathing exercises on chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Back Musculoskelet Rehabil. 2024;37(1):13–23. doi: 10.3233/BMR-230054 [DOI] [PubMed] [Google Scholar]
16.Shi J, Liu Z, Zhou X, Jin F, Chen X, Wang X, et al. Effects of breathing exercises on low back pain in clinical: a systematic review and meta-analysis. Complement Ther Med. 2023;79:102993. doi: 10.1016/j.ctim.2023.102993 [DOI] [PubMed] [Google Scholar]
17.Zhai H, Zhang L, Xia J, Li C. The efficiency of respiratory exercises in rehabilitation of low back pain: a systematic review and meta-analysis. J Sport Rehabil. 2024;33(3):189–200. doi: 10.1123/jsr.2023-0207 [DOI] [PubMed] [Google Scholar]
18.Fabero-Garrido R, Rodríguez-Marcos I, Del Corral T, Plaza-Manzano G, López-de-Uralde-Villanueva I. Effects of respiratory muscle training on functional ability, pain-related outcomes, and respiratory function in individuals with low back pain: systematic review and meta-analysis. J Clin Med. 2024;13(11):3053. doi: 10.3390/jcm13113053 [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Tatsios P, Koumantakis GA, Karakasidou P, Philippou A. The effectiveness of manual therapy on musculoskeletal and respiratory parameters in patients with chronic low back pain: a systematic review. Crit Rev Phys Rehabil Med. 2021;33(2):71–101. doi: 10.1615/critrevphysrehabilmed.2021038977 [DOI] [Google Scholar]
20.Narenthiran P, Granville Smith I, Williams FMK. Does the addition of manual therapy to exercise therapy improve pain and disability outcomes in chronic low back pain: a systematic review. J Bodyw Mov Ther. 2025;42:146–52. doi: 10.1016/j.jbmt.2024.12.004 [DOI] [PubMed] [Google Scholar]
21.Cefalì A, Santini D, Lopez G, Maselli F, Rossettini G, Crestani M, et al. Effects of breathing exercises on neck pain management: a systematic review with meta-analysis. J Clin Med. 2025;14(3):709. doi: 10.3390/jcm14030709 [DOI] [PMC free article] [PubMed] [Google Scholar]
22.Şahin O, Kocamaz D. Effects of diaphragmatic mobilization and diaphragmatic breathing exercises on pain and quality of life in individuals with shoulder pain: a randomized controlled trial. IJDSHS. 2021;4(2):113–23. doi: 10.33438/ijdshs.976285 [DOI] [Google Scholar]
23.Jeong G-H, Lee B-H. Effects of telerehabilitation combining diaphragmatic breathing re-education and shoulder stabilization exercises on neck pain, posture, and function in young adult men with upper crossed syndrome: a randomized controlled trial. J Clin Med. 2024;13(6):1612. doi: 10.3390/jcm13061612 [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Zhang J, Zhao Y, Wang Q. Effects of Pilates combined with breathing exercise on lung function, body posture and postural stability among female college students: a randomized controlled trial. PLoS One. 2025;20(8):e0330874. doi: 10.1371/journal.pone.0330874 [DOI] [PMC free article] [PubMed] [Google Scholar]
25.Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi: 10.1371/journal.pmed.1000097 [DOI] [PMC free article] [PubMed] [Google Scholar]
26.Mehling WE, Hamel KA, Acree M, Byl N, Hecht FM. Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Altern Ther Health Med. 2005;11(4):44–52. [PubMed] [Google Scholar]
27.de Oliveira RF, Liebano RE, Costa L da CM, Rissato LL, Costa LOP. Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Phys Ther. 2013;93(6):748–56. doi: 10.2522/ptj.20120256 [DOI] [PubMed] [Google Scholar]
28.Heo M-Y, Kim K, Hur B-Y, Nam C-W. The effect of lumbar stabilization exercises and thoracic mobilization and exercises on chronic low back pain patients. J Phys Ther Sci. 2015;27(12):3843–6. doi: 10.1589/jpts.27.3843 [DOI] [PMC free article] [PubMed] [Google Scholar]
29.Son H-H. The effects of stabilization exercise with abdominal breath on balance and oswestry disability index for low back pain patients. J Korean Soc Phys Med. 2015;10(1):107–13. doi: 10.13066/kspm.2015.10.1.107 [DOI] [Google Scholar]
30.Kang J-I, Jeong D-K, Choi H. Effect of exhalation exercise on trunk muscle activity and oswestry disability index of patients with chronic low back pain. J Phys Ther Sci. 2016;28(6):1738–42. doi: 10.1589/jpts.28.1738 [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Mohanty PP, Pattnaik M. Mobilisation of the thoracic spine in the management of spondylolisthesis. J Bodyw Mov Ther. 2016;20(3):598–603. doi: 10.1016/j.jbmt.2016.02.006 [DOI] [PubMed] [Google Scholar]
32.Finta R, Nagy E, Bender T. The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain. J Pain Res. 2018;11:3031–45. doi: 10.2147/JPR.S181610 [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Martí-Salvador M, Hidalgo-Moreno L, Doménech-Fernández J, Lisón JF, Arguisuelas MD. Osteopathic manipulative treatment including specific diaphragm techniques improves pain and disability in chronic nonspecific low back pain: a randomized trial. Arch Phys Med Rehabil. 2018;99(9):1720–9. doi: 10.1016/j.apmr.2018.04.022 [DOI] [PubMed] [Google Scholar]
34.Park J, Chon S. Effect of posterior-anterior mobilization of the thoracic spine on pain, respiratory function, and thoracic circumference in patients with chronic low back pain. Phys Ther Korea. 2018;25(4):37–45. doi: 10.12674/ptk.2018.25.4.037 [DOI] [Google Scholar]
35.Fan X-Y, Yan B-X, Ding J-Y, Gao Q, Xu R-N, Liu B, et al. Effects of breathing exercise on nonspecific low back pain. 2018:93–6. 10.3969/j.issn.1006-9771.2018.01.018 [DOI]
36.Fisher LR, Alvar BA, Maher SF, Cleland JA. Short-term effects of thoracic spine thrust manipulation, exercise, and education in individuals with low back pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2020;50(1):24–32. doi: 10.2519/jospt.2020.8928 [DOI] [PubMed] [Google Scholar]
37.Cho B, Yoon J. Effects of breathing exercise on flexion relaxation phenomenon and thoracic excursion in patients with chronic low back pain. J Korean Soc Integr Med. 2019;7(1):125–34. doi: 10.15268/ksim.2019.7.1.125 [DOI] [Google Scholar]
38.Park S-H, Lee M-M. Effects of a progressive stabilization exercise program using respiratory resistance for patients with lumbar instability: a randomized controlled trial. Med Sci Monit. 2019;25:1740–8. doi: 10.12659/MSM.913036 [DOI] [PMC free article] [PubMed] [Google Scholar]
39.de Oliveira RF, Costa LOP, Nascimento LP, Rissato LL. Directed vertebral manipulation is not better than generic vertebral manipulation in patients with chronic low back pain: a randomised trial. J Physiother. 2020;66(3):174–9. doi: 10.1016/j.jphys.2020.06.007 [DOI] [PubMed] [Google Scholar]
40.Lim CJJoIAoPTR. Comparison of the effects of joint mobilization, gym ball exercises, and breathing exercises on flexion relaxation phenomenon and pain in patients with chronic low back pain. 2020;11(1):1981–91. 10.14474/ptrs.2020.9.1.25 [DOI]
41.Divya, Parveen A, Nuhmani S, Ejaz Hussain M, Hussain Khan M. Effect of lumbar stabilization exercises and thoracic mobilization with strengthening exercises on pain level, thoracic kyphosis, and functional disability in chronic low back pain. J Complement Integr Med. 2020;18(2):419–24. doi: 10.1515/jcim-2019-0327 [DOI] [PubMed] [Google Scholar]
42.Kostadinović S, Milovanović N, Jovanović J, Tomašević-Todorović S. Efficacy of the lumbar stabilization and thoracic mobilization exercise program on pain intensity and functional disability reduction in chronic low back pain patients with lumbar radiculopathy: a randomized controlled trial. J Back Musculoskelet Rehabil. 2020;33(6):897–907. doi: 10.3233/BMR-201843 [DOI] [PubMed] [Google Scholar]
43.Oh Y-J, Park S-H, Lee M-M. Comparison of effects of abdominal draw-in lumbar stabilization exercises with and without respiratory resistance on women with low back pain: a randomized controlled trial. Med Sci Monit. 2020;26:e921295. doi: 10.12659/MSM.921295 [DOI] [PMC free article] [PubMed] [Google Scholar]
44.Atilgan ED, Tuncer A. The effects of breathing exercises in mothers of children with special health care needs: a randomized controlled trial. J Back Musculoskelet Rehabil. 2021;34(5):795–804. doi: 10.3233/BMR-200327 [DOI] [PubMed] [Google Scholar]
45.Otadi K, Nakhostin Ansari N, Sharify S, Fakhari Z, Sarafraz H, Aria A, et al. Effects of combining diaphragm training with electrical stimulation on pain, function, and balance in athletes with chronic low back pain: a randomized clinical trial. BMC Sports Sci Med Rehabil. 2021;13(1):20. doi: 10.1186/s13102-021-00250-y [DOI] [PMC free article] [PubMed] [Google Scholar]
46.Park S-H, Oh Y-J, Jung S-H, Lee M-M. The effects of lumbar stabilization exercise program using respiratory resistance on pain, dysfunction, psychosocial factor, respiratory pressure in female patients in ’40s with low back pain: randomized controlled trial. Ann Appl Sport Sci. 2021;9(3):1–10. doi: 10.52547/aassjournal.937 [DOI] [Google Scholar]
47.Park S-J, Kim E-K, Kim Y-M, Kang D-Y. Effects of trunk stability exercises and thoracic manipulation on spine flexibility in chronic low back pain patients. Korean Soc Phys Med. 2021;16(2):115–23. doi: 10.14474/ptrs.2024.13.1.1 [DOI] [Google Scholar]
48.Park S-H, Oh Y-J, Seo J-H, Lee M-M. Effect of stabilization exercise combined with respiratory resistance and whole body vibration on patients with lumbar instability: a randomized controlled trial. Medicine (Baltimore). 2022;101(46):e31843. doi: 10.1097/MD.0000000000031843 [DOI] [PMC free article] [PubMed] [Google Scholar]
49.Masroor S, Tanwar T, Aldabbas M, Iram I, Veqar Z. Effect of adding diaphragmatic breathing exercises to core stabilization exercises on pain, muscle activity, disability, and sleep quality in patients with chronic low back pain: a randomized control trial. J Chiropr Med. 2023;22(4):275–83. doi: 10.1016/j.jcm.2023.07.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
50.Sığlan Ü, Çolak S. Effects of diaphragmatic and iliopsoas myofascial release in patients with chronic low back pain: a randomized controlled study. J Bodyw Mov Ther. 2023;33:120–7. doi: 10.1016/j.jbmt.2022.09.029 [DOI] [PubMed] [Google Scholar]
51.E SEAA, Rehab NI, Shendy WS, Alsaid HM. Effect of thoracic spine mobilization on pain and lumbar mobility in patients with lumbosacral radiculopathy: a randomized controlled trial. Benha Int J Phys Ther. 2024;2(2):35–41. 10.21608/bijpt.2024.303076.1034 [DOI] [Google Scholar]
52.Doğan OA, Atıcı E, Sürenkök Ö. The impact of lumbar stabilization and thoracic mobilization exercises on pain, disability and quality of life in individuals with chronic low back pain. J Innov Healthc Pract. 2024;5(3):123–31. doi: 10.58770/joinihp.1571454 [DOI] [Google Scholar]
53.ElFayoumi BHH, Mohamed NAA, Balbaa AAE, Soliman ES. Effects of combining thoracic lymphatic pump technique and exercises on patients with chronic mechanical low back pain. Fiz Pol. 2024;24(3):72–81. doi: 10.56984/8zg020am9t [DOI] [Google Scholar]
54.Hwang D-K, Jang H-Y, Lee S-M, Lee B-H. Effects of thoracic mobility exercise on the range of motion, pain, disability index and quality of life in middle-aged women with chronic back pain. JKPTS. 2024;31(2):15–29. doi: 10.26862/jkpts.2024.06.31.2.15 [DOI] [Google Scholar]
55.Mikkonen J, Luomajoki H, Airaksinen O, Goubert L, Pratscher S, Leinonen V. Identical movement control exercises with and without synchronized breathing for chronic non-specific low back pain: a randomized pilot trial. J Back Musculoskelet Rehabil. 2024;37(6):1561–71. doi: 10.3233/BMR-230413 [DOI] [PMC free article] [PubMed] [Google Scholar]
56.Park D, Lee K-S. Effects of thoracic mobility exercise program on pain, proprioception, and static balance ability in patients with non-specific chronic low back pain. Phys Ther Rehabil Sci. 2024;13(1):1–7. doi: 10.14474/ptrs.2024.13.1.1 [DOI] [Google Scholar]
57.Abdel-Aziz SS, Badr NMH, El-Azizi HM, El Sawy RES, El-Moatasem AM. Core stability exercises versus diaphragmatic release on respiratory functions on physical therapists with low back pain. Adv Rehabil. 2025;39(1):1–16. doi: 10.5114/areh.2024.146098 [DOI] [Google Scholar]
58.Abdelhamid AS, Ali F, Asal MS, Salem S. Effect of lumbar stabilization exercises combined with ball and balloon exercise in treatment of chronic non-specific low back pain: randomized clinical trial. Bull Phys Ther Res Stud. 2025;3(1):1–19. doi: 10.21608/bptrs.2025.306953.1038 [DOI] [Google Scholar]
59.Li Y, Zhao Q, Zhang X, E Y, Su Y. The impact of core training combined with breathing exercises on individuals with chronic non-specific low back pain. Front Public Health. 2025;13:1518612. doi: 10.3389/fpubh.2025.1518612 [DOI] [PMC free article] [PubMed] [Google Scholar]
60.McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12(1):55–61. doi: 10.1002/jrsm.1411 [DOI] [PubMed] [Google Scholar]
61.Walsh DP, Chen MJ, Buhl LK, Neves SE, Mitchell JD. Assessing interrater reliability of a faculty-provided feedback rating instrument. J Med Educ Curric Dev. 2022;9:23821205221093205. doi: 10.1177/23821205221093205 [DOI] [PMC free article] [PubMed] [Google Scholar]
62.Loef M, Walach H, Schmidt S. Interrater reliability of ROB2 - an alternative measure and way of categorization. J Clin Epidemiol. 2022;142:326–7. doi: 10.1016/j.jclinepi.2021.09.003 [DOI] [PubMed] [Google Scholar]
63.Morris SB. Estimating effect sizes from pretest-posttest-control group designs. Organ Res Methods. 2007;11(2):364–86. doi: 10.1177/1094428106291059 [DOI] [Google Scholar]
64.Gholipour MA, Hamedi H, Seyedhoseinpoor T. Effects of exercise therapy with blood flow restriction on shoulder strength: protocol for a systematic review and meta-analysis. BMJ Open. 2025;15(4):e097640. doi: 10.1136/bmjopen-2024-097640 [DOI] [PMC free article] [PubMed] [Google Scholar]
65.Pourahmadi M, Mohseni-Bandpei MA, Keshtkar A, Koes BW, Fernández-de-Las-Peñas C, Dommerholt J, et al. Effectiveness of dry needling for improving pain and disability in adults with tension-type, cervicogenic, or migraine headaches: protocol for a systematic review. Chiropr Man Therap. 2019;27:43. doi: 10.1186/s12998-019-0266-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
66.Higgins J. Cochrane handbook for systematic reviews of interventions. Version 5.1. 0. The Cochrane Collaboration; 2011. [updated 2011 Mar]. Available from: www.cochrane-handbook.org [Google Scholar]
67.Jpt H. Cochrane handbook for systematic reviews of interventions; 2008. Available from: http://www.cochrane-handbook.org [Google Scholar]
68.Pourahmadi MR, Taghipour M, Ebrahimi Takamjani I, Sanjari MA, Mohseni-Bandpei MA, Keshtkar AA. Motor control exercise for symptomatic lumbar disc herniation: protocol for a systematic review and meta-analysis. BMJ Open. 2016;6(9):e012426. doi: 10.1136/bmjopen-2016-012426 [DOI] [PMC free article] [PubMed] [Google Scholar]
69.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71 [DOI] [PMC free article] [PubMed] [Google Scholar]
70.Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 2000;56(2):455–63. doi: 10.1111/j.0006-341x.2000.00455.x [DOI] [PubMed] [Google Scholar]
71.Patsopoulos NA, Evangelou E, Ioannidis JPA. Sensitivity of between-study heterogeneity in meta-analysis: proposed metrics and empirical evaluation. Int J Epidemiol. 2008;37(5):1148–57. doi: 10.1093/ije/dyn065 [DOI] [PMC free article] [PubMed] [Google Scholar]
72.Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–6. doi: 10.1016/j.jclinepi.2010.07.015 [DOI] [PubMed] [Google Scholar]
73.Pourahmadi M, Mohseni-Bandpei MA, Keshtkar A, Koes BW, Fernández-de-Las-Peñas C, Dommerholt J, et al. Effectiveness of dry needling for improving pain and disability in adults with tension-type, cervicogenic, or migraine headaches: protocol for a systematic review. Chiropr Man Therap. 2019;27:43. doi: 10.1186/s12998-019-0266-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
74.Astudillo Ganora I, Escolar Reina MP. Efectividad de la manipulación vertebral combinada con otras intervenciones de fisioterapia en pacientes con dolor lumbar inespecífico: un ensayo clínico aleatorizado. Retos. 2024;61:1191–8. doi: 10.47197/retos.v61.110304 [DOI] [Google Scholar]
75.Kiran R, Mohanty P, Pattnaik M. Thoracic mobilisation and periscapular soft tissue manipulations in the management of chronic Prolapsed Intervertebral Disc (PIVD) - An innovative manual therapy approach. AMJ. 2017;10(10):838–47. doi: 10.21767/amj.2017.2851 [DOI] [Google Scholar]
76.KU DK. Effect of expiratory training and inspiratory training with lumbar stabilization in low back pain:a randomized controlled trial. IJPHRD. 2020;11(2):236. doi: 10.37506/v11/i2/2020/ijphrd/194790 [DOI] [Google Scholar]
77.Shah S, Shirodkar S, Deo M. Effectiveness of core stability and diaphragmatic breathing vs. core stability alone on pain and function in mechanical non-specific low back pain patients: a randomised control trial. Int J Health Sci Res. 2020;10(2):232–41. [Google Scholar]
78.O’Neill J. The effects of a breathing exercise-based intervention on low back pain and anxiety symptoms. SWCSJ. 2024;4(2):4. [Google Scholar]
79.Sawant KU, Rai RH, Kalra S, Sharma A, Chahal A, Sharma N. Combined effects of breathing exercise and core strength training on fatigue, abdominal strength, and cardiovascular fitness among subjects with mechanical nonspecific lumbago using tele-physiotherapy: a randomized clinical trial. J Datta Meghe Inst Med Sci Univ. 2024;19(2):247–56. doi: 10.4103/jdmimsu.jdmimsu_675_23 [DOI] [Google Scholar]
80.Tatsios P, Koumantakis GA, Karakasidou P, Philippou A. The effectiveness of manual therapy on musculoskeletal and respiratory parameters in patients with chronic low back pain: a systematic review. Crit Rev Phys Rehabil Med. 2021;33(2):71–101. doi: 10.1615/critrevphysrehabilmed.2021038977 [DOI] [Google Scholar]
81.Hastreiter D, Ozuna RM, Spector M. Regional variations in certain cellular characteristics in human lumbar intervertebral discs, including the presence of alpha-smooth muscle actin. J Orthop Res. 2001;19(4):597–604. doi: 10.1016/S0736-0266(00)00069-3 [DOI] [PubMed] [Google Scholar]
82.Hodges PW, Heijnen I, Gandevia SC. Postural activity of the diaphragm is reduced in humans when respiratory demand increases. J Physiol. 2001;537(Pt 3):999–1008. doi: 10.1111/j.1469-7793.2001.00999.x [DOI] [PMC free article] [PubMed] [Google Scholar]
83.Roussel N, Nijs J, Truijen S, Vervecken L, Mottram S, Stassijns G. Altered breathing patterns during lumbopelvic motor control tests in chronic low back pain: a case-control study. Eur Spine J. 2009;18(7):1066–73. doi: 10.1007/s00586-009-1020-y [DOI] [PMC free article] [PubMed] [Google Scholar]
84.Avman MA, Osmotherly PG, Snodgrass S, Rivett DA. Is there an association between hip range of motion and nonspecific low back pain? A systematic review. Musculoskelet Sci Pract. 2019;42:38–51. doi: 10.1016/j.msksp.2019.03.002 [DOI] [PubMed] [Google Scholar]
85.Yasuda T, Jaotawipart S, Kuruma H. Effects of thoracic spine self-mobilization on patients with low back pain and lumbar hypermobility: a randomized controlled trial. Prog Rehabil Med. 2023;8:20230022. doi: 10.2490/prm.20230022 [DOI] [PMC free article] [PubMed] [Google Scholar]
86.Masarsky CSaMT-M. Somatovisceral aspects of chiropractic: an evidence-based approach; 2001. [Google Scholar]
87.Engel RM, Vemulpad S. The effect of combining manual therapy with exercise on the respiratory function of normal individuals: a randomized control trial. J Manipulative Physiol Ther. 2007;30(7):509–13. doi: 10.1016/j.jmpt.2007.07.006 [DOI] [PubMed] [Google Scholar]
88.Threlkeld AJ. The effects of manual therapy on connective tissue. Phys Ther. 1992;72(12):893–902. doi: 10.1093/ptj/72.12.893 [DOI] [PubMed] [Google Scholar]
89.Babina R, Mohanty PP, Pattnaik M. Effect of thoracic mobilization on respiratory parameters in chronic non-specific low back pain: a randomized controlled trial. J Back Musculoskelet Rehabil. 2016;29(3):587–95. doi: 10.3233/BMR-160679 [DOI] [PubMed] [Google Scholar]

PLoS One. 2026 Jan 14;21(1):e0339263. doi: 10.1371/journal.pone.0339263.r001

Author response to Decision Letter 0

17 May 2025

Attachment

Submitted filename: Responds to the comments made on the original manuscript.docx

pone.0339263.s004.docx^{(14.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0339263.r002

Decision Letter 0

Seyed Hamed Mousavi

26 Sep 2025

Dear Dr. Seyedhoseinpoor,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Dear Authors

I would like to thank you for giving me an opportunity to consider this work for publication. You well done the a point by point answer to the comments of the reviewers about previous revision. Paper needs few minor edits actually now:

- I recommend adding a few sentences in the introduction, about the effectiveness and usefulness of the Effects of Breathing Exercise in various musculoskeletal disorders, neck pain, shoulder pain, low back pain.

- Discussions should be reviewed in light of the overall improvement of the paper. Redundant sentences and prewritten information should be avoided. Focus on take-home messages and how that information impacts the clinical practice of management these patients.

- I suggest to add this reference:

Cefalì A, Santini D, Lopez G, Maselli F, Rossettini G, Crestani M, Lullo G, Young I, Dunning J, de Abreu RM, Mourad F. Effects of Breathing Exercises on Neck Pain Management: A Systematic Review with Meta-Analysis. J Clin Med. 2025 Jan 22;14(3). doi: 10.3390/jcm14030709. Review. PubMed PMID: 39941380; PubMed Central PMCID: PMC11818914.

Reviewer #2: This is a well-structured systematic review and meta-analysis examining the effects of breathing exercises and thoracic techniques on pain and disability in patients with low back pain (LBP). The study addresses an important clinical topic, given the high prevalence of LBP and the need for non-invasive interventions. The methods are rigorous, adhering to PRISMA guidelines, with a registered protocol on PROSPERO, comprehensive search strategy, appropriate risk of bias assessment using RoB 2, and quality evaluation via GRADE. The inclusion of subgroup and sensitivity analyses to address heterogeneity is commendable. However, the high heterogeneity in results, low quality of evidence, and potential publication bias limit the strength of conclusions. The revised version incorporates an updated search (to May 1, 2025) and additional studies, strengthening the analysis compared to prior iterations.

Major Comments:

1. Heterogeneity: High heterogeneity (I² > 85% for pain, >90% for disability) persists despite subgroup analyses. While some reductions occur (e.g., I² = 30.5% for >4 weeks treatment in disability), sources remain unclear. Discuss potential unmeasured factors (e.g., LBP chronicity, co-interventions, outcome measurement timing) more deeply. Consider meta-regression if data allow, or explicitly state why it was not performed. In the revised version, the shift to SMD in some sections (e.g., page 67) is inconsistent with Morris' dppc—clarify and standardize.

2. Quality of Evidence and Interpretation: GRADE rates evidence as low/very low, yet conclusions emphasize effectiveness (e.g., "thoracic techniques are more effective"). Temper claims to reflect this (e.g., "may be effective based on low-quality evidence"). Highlight implications for practice: given low evidence, these interventions should be adjunctive, not first-line. Address why thoracic techniques show larger effects— is it due to higher bias in those studies?

3. Publication Bias: Funnel plots suggest bias for disability (and pain in some versions), but Egger's/trim-and-fill do not. This discrepancy warrants discussion. The jackknife method identifies one influential study (Ho-Hee 2015) for disability—exclude it in sensitivity analysis and report if results change substantially.

4. Search Update: The search ends May 1, 2025, but the current date is September 24, 2025. While the revision addresses prior PLOS ONE concerns, perform a quick update to ensure no new studies (e.g., via PubMed alert). If none, state this. The inclusion of non-English studies (Korean, Chinese, Spanish) is a strength, but confirm translations were accurate.

5. Outcome Measures: Pain and disability are primary, but tools vary (VAS/NRS for pain, ODI/RMQ for disability). Discuss if this contributes to heterogeneity. Consider pooled results by specific tool in subgroups. Also, the abstract reports 36 studies in meta-analysis, but text specifies 31 for pain/24 for disability—clarify.

Minor Comments:

- Abstract: Update to reflect revised effect sizes (e.g., large for disability). Specify "thoracic manual techniques" for clarity.

- Methods: Search syntax in S1 Appendix is noted—ensure it's included. Define "thoracic techniques" more precisely (e.g., HVLA vs. mobilization).

- Results: Tables 2-4 are clear, but label effect sizes consistently (Morris' dppc vs. SMD in revisions). Figures 3-7 need legends for clarity.

- Discussion: Integrate recent studies (added in revision) more explicitly. Compare to Fabero-Garrido et al. (2024) on respiratory muscle training.

- References: Up-to-date, but check formatting (e.g., DOI consistency).

- Writing and Clarity: Minor typos (e.g., "Based on of the included studies" in conclusion; "dppc" vs. "SMD" inconsistencies). Ensure consistent terminology (e.g., "CLBP" vs. "LBP").

- Supplementary Materials: PRISMA checklist is referenced—verify completion. Include flow diagram (Fig 1) details.

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Reviewer #1: No

Reviewer #2: Yes: Sarvenaz Karimi

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PLoS One. 2026 Jan 14;21(1):e0339263. doi: 10.1371/journal.pone.0339263.r003

Author response to Decision Letter 1

1 Oct 2025

Dear Editor and Reviewers,

We sincerely thank you for your thoughtful and constructive comments, which have greatly helped us improve the quality of our manuscript. We provide detailed, point-by-point responses to each reviewer’s comments and upload to the submission system.

With best regards

Attachment

Submitted filename: Response to Reviewers.docx

pone.0339263.s005.docx^{(33.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0339263.r004

Decision Letter 1

Seyed Hamed Mousavi

20 Oct 2025

Dear Dr. Seyedhoseinpoor,

Please submit your revised manuscript by Dec 04 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Seyed Hamed Mousavi

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: Dear Authors

I would like to thank you for giving me an opportunity to consider this work for publication. You well done the a point by point answer to the comments of the reviewers Thanks

Reviewer #2: This revised manuscript shows substantial and meaningful improvement compared with the original version. The authors have carefully addressed most major reviewer comments raised in the first round, particularly those concerning methodological clarity, conceptual depth, and consistency in reporting. The study is now more coherent, transparent, and aligned with PRISMA and GRADE standards.

The topic remains highly relevant, as it investigates the effects of breathing exercises and thoracic manual techniques—an innovative, non-invasive approach to low back pain (LBP) rehabilitation. The revision strengthens the overall scientific and clinical credibility of the work. However, a few issues related to residual heterogeneity, limited exploration of moderators, and overinterpretation of low-certainty evidence still need refinement before acceptance.

Minor Comments

Include abbreviations in table footnotes for clarity (e.g., RMQ = Roland–Morris Questionnaire, ODI = Oswestry Disability Index).

Ensure figure legends clearly describe the direction of effect and metric (Morris’ dppc).

Confirm that all supplementary materials (search syntax, PRISMA checklist, flow diagram) are included and updated.

Check reference formatting (consistent DOI presentation)

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: Yes: Sarvenaz Karimi-ghasemabad

**********

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PLoS One. 2026 Jan 14;21(1):e0339263. doi: 10.1371/journal.pone.0339263.r005

Author response to Decision Letter 2

21 Oct 2025

Dear respected Editor and reviewers,

We are grateful for the reviewers’ valuable feedback, which has helped us significantly strengthen the scientific rigor and clarity of our manuscript. We believe these revisions further enhance the transparency, methodological robustness, and clinical relevance of the study.

Regards

Reviewer #1

Comment:

Dear Authors,

I would like to thank you for giving me an opportunity to consider this work for publication. You well done the point-by-point answer to the comments of the reviewers. Thanks.

Response:

We sincerely thank the reviewer for their kind words and for taking the time to evaluate our revised manuscript. We greatly appreciate your recognition of our efforts to address all prior comments thoroughly and improve the clarity and quality of the paper.

Reviewer #2

General Comment:

This revised manuscript shows substantial and meaningful improvement compared with the original version. The authors have carefully addressed most major reviewer comments raised in the first round, particularly those concerning methodological clarity, conceptual depth, and consistency in reporting. The study is now more coherent, transparent, and aligned with PRISMA and GRADE standards.

Response:

We thank the reviewer for the positive and constructive feedback. We are pleased that you found the revised version substantially improved in terms of methodological clarity, conceptual depth, and consistency with PRISMA and GRADE standards. We have carefully addressed the remaining concerns as detailed below.

General Comment:

Response:

We appreciate the reviewer’s insightful comment. The Discussion and Conclusion sections have been revised to more clearly address residual heterogeneity, acknowledge potential moderators, and moderate the interpretation of low-certainty evidence. These changes ensure a more balanced and transparent presentation of our findings.

Specific Comments and Responses

1. Comment: Include abbreviations in table footnotes for clarity (e.g., RMQ = Roland–Morris Questionnaire, ODI = Oswestry Disability Index).

Response: We thank the reviewer for the observation. The abbreviations (e.g., RMQ, ODI, etc.) were already included in the table footnotes in the previous version; we have rechecked and ensured that all abbreviations are clearly defined for consistency and clarity.

2. Comment: Ensure figure legends clearly describe the direction of effect and metric (Morris’ dppc).

Response: Figure legends have been revised to explicitly indicate the direction of effect and the metric used (Morris’ dppc).

3. Comment: Confirm that all supplementary materials (search syntax, PRISMA checklist, flow diagram) are included and updated.

Response: We confirm that all supplementary materials have been included and updated, including the full search syntax, PRISMA checklist, and revised flow diagram reflecting the final number of included studies.

4. Comment: Check reference formatting (consistent DOI presentation).

Response: We have reviewed and corrected all references to ensure consistent DOI formatting according to the journal’s style guidelines.

Attachment

Submitted filename: Response_to_Reviewers_auresp_2.docx

pone.0339263.s006.docx^{(16.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0339263.r006

Decision Letter 2

Seyed Hamed Mousavi

2 Dec 2025

Effects of Breathing Exercise and Thoracic Techniques on Pain and Disability in Low Back Pain: A Systematic Review and Meta-analysis

PONE-D-25-26341R2

Dear Dr. Seyedhoseinpoor,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Reviewer2 raised a few minor comments that can be addressed during the proofing stage.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Seyed Hamed Mousavi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: (No Response)

**********

Reviewer #2: PLOS ONE Peer-Review Report

Manuscript Number: PONE-D-25-26341R2

Title: Effects of Breathing Exercise and Thoracic Techniques on Pain and Disability in Low Back Pain: A Systematic Review and Meta-analysis

Overall Recommendation: ACCEPT with very minor revisions

(The manuscript is now of publishable quality for PLOS ONE, and the authors have satisfactorily addressed almost all previous concerns.)

Summary

This R2 version represents a clear and substantial improvement over the original submission and R1. The authors have carefully responded to both reviewers, updated supplementary files, clarified statistical methods, improved figure legends, ensured consistent abbreviation definitions, and moderated the language in the Conclusion to better reflect the low/very low certainty of evidence according to GRADE.

The topic remains highly clinically relevant: combining breathing/retraining of the diaphragm with thoracic manual therapy is an emerging, low-risk approach in non-specific low back pain, and this is the most comprehensive meta-analysis on this specific combination to date .

Strengths

• Comprehensive, pre-registered (PROSPERO), PRISMA-compliant search with no language restrictions and translation of non-English trials

• Appropriate use of Morris’ dppc2 (pre-post-control effect size) for the predominant study designs

• Transparent risk-of-bias assessment (RoB 2 + robvis figures) and correct application of GRADE (downgraded for inconsistency, imprecision, and risk of bias)

• Subgroup and sensitivity analyses that partially explain the high heterogeneity

• Clinically useful distinction between “breathing exercises only” vs. “thoracic manual techniques” (the latter showing clearly superior effects)

• Balanced discussion of mechanisms (diaphragm–core synergy, thoracic stiffness, regional interdependence)

Remaining very minor issues (can be corrected in proof stage)

1. Abstract (line about heterogeneity): the sentence “However, statistical heterogeneity remained across studies” is correct but slightly understates the issue. Consider changing to: "However, substantial statistical heterogeneity (I² > 85%) persisted in most analyses.”

2. Table 1 (Characteristics of included studies): Please add one column indicating “LBP duration” (acute/subacute/chronic/mixed) for each study – this is a major source of clinical heterogeneity and would take only a few minutes to insert.

3. Figure legends (Forest plots): Already much improved, but add one short sentence to each: Negative values favour the thoracic/breathing intervention.”

4. Discussion – page ~29: Add one small typo: “catious” → “cautious”

Final decision

The manuscript is now suitable for publication in PLOS ONE.

Decision: ACCEPT with very minor revisions

(The above four points can be addressed by the editorial office during copy-editing or by the authors in proof. No further peer-review round is required.)

Congratulations to the authors on a well-conducted and clinically meaningful systematic review.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2: Yes: Sarvenaaz Karimi-ghasemabad

**********

PLoS One. doi: 10.1371/journal.pone.0339263.r007

Acceptance letter

Seyed Hamed Mousavi

PONE-D-25-26341R2

PLOS One

Dear Dr. Seyedhoseinpoor,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

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If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Seyed Hamed Mousavi

Academic Editor

PLOS One

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Appendix. PRISMA checklist.

(DOCX)

pone.0339263.s001.docx^{(31.3KB, docx)}

S2 Appendix. Full search syntax.

(DOCX)

pone.0339263.s002.docx^{(15.9KB, docx)}

S1 File. Data excel file.

(XLS)

pone.0339263.s003.xls^{(45KB, xls)}

Attachment

Submitted filename: Responds to the comments made on the original manuscript.docx

pone.0339263.s004.docx^{(14.5KB, docx)}

Attachment

Submitted filename: Response to Reviewers.docx

pone.0339263.s005.docx^{(33.4KB, docx)}

Attachment

Submitted filename: Response_to_Reviewers_auresp_2.docx

pone.0339263.s006.docx^{(16.4KB, docx)}

Data Availability Statement

All relevant data are within the paper and its Supporting information files.

[pone.0339263.ref001] 1.Chen S, Chen M, Wu X, Lin S, Tao C, Cao H, et al. Global, regional and national burden of low back pain 1990-2019: a systematic analysis of the Global Burden of Disease study 2019. J Orthop Translat. 2021;32:49–58. doi: 10.1016/j.jot.2021.07.005 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref002] 2.Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356–67. doi: 10.1016/S0140-6736(18)30480-X [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref003] 3.Deyo RA, Cherkin D, Conrad D, Volinn E. Cost, controversy, crisis: low back pain and the health of the public. Annu Rev Public Health. 1991;12:141–56. doi: 10.1146/annurev.pu.12.050191.001041 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref004] 4.Ahmadnezhad L, Yalfani A, Gholami Borujeni B. Inspiratory muscle training in rehabilitation of low back pain: a randomized controlled trial. J Sport Rehabil. 2020;29(8):1151–8. doi: 10.1123/jsr.2019-0231 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref005] 5.Hammill RR, Beazell JR, Hart JM. Neuromuscular consequences of low back pain and core dysfunction. Clin Sports Med. 2008;27(3):449–62, ix. doi: 10.1016/j.csm.2008.02.005 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref006] 6.Hanada EY, Johnson M, Hubley-Kozey C. A comparison of trunk muscle activation amplitudes during gait in older adults with and without chronic low back pain. PM R. 2011;3(10):920–8. doi: 10.1016/j.pmrj.2011.06.002 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref007] 7.Tong MH, Mousavi SJ, Kiers H, Ferreira P, Refshauge K, van Dieën J. Is there a relationship between lumbar proprioception and low back pain? A systematic review with meta-analysis. Arch Phys Med Rehabil. 2017;98(1):120-136.e2. doi: 10.1016/j.apmr.2016.05.016 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref008] 8.Beeckmans N, Vermeersch A, Lysens R, Van Wambeke P, Goossens N, Thys T, et al. The presence of respiratory disorders in individuals with low back pain: a systematic review. Man Ther. 2016;26:77–86. doi: 10.1016/j.math.2016.07.011 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref009] 9.Abdollahzadeh Z, Abbasi H. Altered respiratory function in patients with low back pain: a review article. JMR. 2021. doi: 10.18502/jmr.v15i2.7726 [DOI] [Google Scholar]

[pone.0339263.ref010] 10.Rasmussen-Barr E, Magnusson C, Nordin M, Skillgate E. Are respiratory disorders risk factors for troublesome low-back pain? A study of a general population cohort in Sweden. Eur Spine J. 2019;28(11):2502–9. doi: 10.1007/s00586-019-06071-5 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref011] 11.Ostwal PP, Wani SJI. Breathing patterns in patients with low back pain. IJPR. 2014;2(1):347–53. [Google Scholar]

[pone.0339263.ref012] 12.Kocjan J, Adamek M, Gzik-Zroska B, Czyżewski D, Rydel M. Network of breathing. Multifunctional role of the diaphragm: a review. Adv Respir Med. 2017;85(4):224–32. doi: 10.5603/ARM.2017.0037 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref013] 13.Babina R, Mohanty PP, Pattnaik M. Effect of thoracic mobilization on respiratory parameters in chronic non-specific low back pain: a randomized controlled trial. J Back Musculoskelet Rehabil. 2016;29(3):587–95. doi: 10.3233/BMR-160679 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref014] 14.Jung S-H, Hwang U-J, Ahn S-H, Kim J-H, Kwon O-Y. Does mobilisation of the thoracic spine using mechanical massage affect diaphragmatic excursion in individuals with thoracic hyperkyphosis? J Back Musculoskelet Rehabil. 2022;35(3):517–23. doi: 10.3233/BMR-210143 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref015] 15.Jiang X, Sun W, Chen Q, Xu Q, Chen G, Bi H. Effects of breathing exercises on chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Back Musculoskelet Rehabil. 2024;37(1):13–23. doi: 10.3233/BMR-230054 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref016] 16.Shi J, Liu Z, Zhou X, Jin F, Chen X, Wang X, et al. Effects of breathing exercises on low back pain in clinical: a systematic review and meta-analysis. Complement Ther Med. 2023;79:102993. doi: 10.1016/j.ctim.2023.102993 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref017] 17.Zhai H, Zhang L, Xia J, Li C. The efficiency of respiratory exercises in rehabilitation of low back pain: a systematic review and meta-analysis. J Sport Rehabil. 2024;33(3):189–200. doi: 10.1123/jsr.2023-0207 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref018] 18.Fabero-Garrido R, Rodríguez-Marcos I, Del Corral T, Plaza-Manzano G, López-de-Uralde-Villanueva I. Effects of respiratory muscle training on functional ability, pain-related outcomes, and respiratory function in individuals with low back pain: systematic review and meta-analysis. J Clin Med. 2024;13(11):3053. doi: 10.3390/jcm13113053 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref019] 19.Tatsios P, Koumantakis GA, Karakasidou P, Philippou A. The effectiveness of manual therapy on musculoskeletal and respiratory parameters in patients with chronic low back pain: a systematic review. Crit Rev Phys Rehabil Med. 2021;33(2):71–101. doi: 10.1615/critrevphysrehabilmed.2021038977 [DOI] [Google Scholar]

[pone.0339263.ref020] 20.Narenthiran P, Granville Smith I, Williams FMK. Does the addition of manual therapy to exercise therapy improve pain and disability outcomes in chronic low back pain: a systematic review. J Bodyw Mov Ther. 2025;42:146–52. doi: 10.1016/j.jbmt.2024.12.004 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref021] 21.Cefalì A, Santini D, Lopez G, Maselli F, Rossettini G, Crestani M, et al. Effects of breathing exercises on neck pain management: a systematic review with meta-analysis. J Clin Med. 2025;14(3):709. doi: 10.3390/jcm14030709 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref022] 22.Şahin O, Kocamaz D. Effects of diaphragmatic mobilization and diaphragmatic breathing exercises on pain and quality of life in individuals with shoulder pain: a randomized controlled trial. IJDSHS. 2021;4(2):113–23. doi: 10.33438/ijdshs.976285 [DOI] [Google Scholar]

[pone.0339263.ref023] 23.Jeong G-H, Lee B-H. Effects of telerehabilitation combining diaphragmatic breathing re-education and shoulder stabilization exercises on neck pain, posture, and function in young adult men with upper crossed syndrome: a randomized controlled trial. J Clin Med. 2024;13(6):1612. doi: 10.3390/jcm13061612 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref024] 24.Zhang J, Zhao Y, Wang Q. Effects of Pilates combined with breathing exercise on lung function, body posture and postural stability among female college students: a randomized controlled trial. PLoS One. 2025;20(8):e0330874. doi: 10.1371/journal.pone.0330874 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref025] 25.Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi: 10.1371/journal.pmed.1000097 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref026] 26.Mehling WE, Hamel KA, Acree M, Byl N, Hecht FM. Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Altern Ther Health Med. 2005;11(4):44–52. [PubMed] [Google Scholar]

[pone.0339263.ref027] 27.de Oliveira RF, Liebano RE, Costa L da CM, Rissato LL, Costa LOP. Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Phys Ther. 2013;93(6):748–56. doi: 10.2522/ptj.20120256 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref028] 28.Heo M-Y, Kim K, Hur B-Y, Nam C-W. The effect of lumbar stabilization exercises and thoracic mobilization and exercises on chronic low back pain patients. J Phys Ther Sci. 2015;27(12):3843–6. doi: 10.1589/jpts.27.3843 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref029] 29.Son H-H. The effects of stabilization exercise with abdominal breath on balance and oswestry disability index for low back pain patients. J Korean Soc Phys Med. 2015;10(1):107–13. doi: 10.13066/kspm.2015.10.1.107 [DOI] [Google Scholar]

[pone.0339263.ref030] 30.Kang J-I, Jeong D-K, Choi H. Effect of exhalation exercise on trunk muscle activity and oswestry disability index of patients with chronic low back pain. J Phys Ther Sci. 2016;28(6):1738–42. doi: 10.1589/jpts.28.1738 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref031] 31.Mohanty PP, Pattnaik M. Mobilisation of the thoracic spine in the management of spondylolisthesis. J Bodyw Mov Ther. 2016;20(3):598–603. doi: 10.1016/j.jbmt.2016.02.006 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref032] 32.Finta R, Nagy E, Bender T. The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain. J Pain Res. 2018;11:3031–45. doi: 10.2147/JPR.S181610 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref033] 33.Martí-Salvador M, Hidalgo-Moreno L, Doménech-Fernández J, Lisón JF, Arguisuelas MD. Osteopathic manipulative treatment including specific diaphragm techniques improves pain and disability in chronic nonspecific low back pain: a randomized trial. Arch Phys Med Rehabil. 2018;99(9):1720–9. doi: 10.1016/j.apmr.2018.04.022 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref034] 34.Park J, Chon S. Effect of posterior-anterior mobilization of the thoracic spine on pain, respiratory function, and thoracic circumference in patients with chronic low back pain. Phys Ther Korea. 2018;25(4):37–45. doi: 10.12674/ptk.2018.25.4.037 [DOI] [Google Scholar]

[pone.0339263.ref035] 35.Fan X-Y, Yan B-X, Ding J-Y, Gao Q, Xu R-N, Liu B, et al. Effects of breathing exercise on nonspecific low back pain. 2018:93–6. 10.3969/j.issn.1006-9771.2018.01.018 [DOI]

[pone.0339263.ref036] 36.Fisher LR, Alvar BA, Maher SF, Cleland JA. Short-term effects of thoracic spine thrust manipulation, exercise, and education in individuals with low back pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2020;50(1):24–32. doi: 10.2519/jospt.2020.8928 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref037] 37.Cho B, Yoon J. Effects of breathing exercise on flexion relaxation phenomenon and thoracic excursion in patients with chronic low back pain. J Korean Soc Integr Med. 2019;7(1):125–34. doi: 10.15268/ksim.2019.7.1.125 [DOI] [Google Scholar]

[pone.0339263.ref038] 38.Park S-H, Lee M-M. Effects of a progressive stabilization exercise program using respiratory resistance for patients with lumbar instability: a randomized controlled trial. Med Sci Monit. 2019;25:1740–8. doi: 10.12659/MSM.913036 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref039] 39.de Oliveira RF, Costa LOP, Nascimento LP, Rissato LL. Directed vertebral manipulation is not better than generic vertebral manipulation in patients with chronic low back pain: a randomised trial. J Physiother. 2020;66(3):174–9. doi: 10.1016/j.jphys.2020.06.007 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref040] 40.Lim CJJoIAoPTR. Comparison of the effects of joint mobilization, gym ball exercises, and breathing exercises on flexion relaxation phenomenon and pain in patients with chronic low back pain. 2020;11(1):1981–91. 10.14474/ptrs.2020.9.1.25 [DOI]

[pone.0339263.ref041] 41.Divya, Parveen A, Nuhmani S, Ejaz Hussain M, Hussain Khan M. Effect of lumbar stabilization exercises and thoracic mobilization with strengthening exercises on pain level, thoracic kyphosis, and functional disability in chronic low back pain. J Complement Integr Med. 2020;18(2):419–24. doi: 10.1515/jcim-2019-0327 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref042] 42.Kostadinović S, Milovanović N, Jovanović J, Tomašević-Todorović S. Efficacy of the lumbar stabilization and thoracic mobilization exercise program on pain intensity and functional disability reduction in chronic low back pain patients with lumbar radiculopathy: a randomized controlled trial. J Back Musculoskelet Rehabil. 2020;33(6):897–907. doi: 10.3233/BMR-201843 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref043] 43.Oh Y-J, Park S-H, Lee M-M. Comparison of effects of abdominal draw-in lumbar stabilization exercises with and without respiratory resistance on women with low back pain: a randomized controlled trial. Med Sci Monit. 2020;26:e921295. doi: 10.12659/MSM.921295 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref044] 44.Atilgan ED, Tuncer A. The effects of breathing exercises in mothers of children with special health care needs: a randomized controlled trial. J Back Musculoskelet Rehabil. 2021;34(5):795–804. doi: 10.3233/BMR-200327 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref045] 45.Otadi K, Nakhostin Ansari N, Sharify S, Fakhari Z, Sarafraz H, Aria A, et al. Effects of combining diaphragm training with electrical stimulation on pain, function, and balance in athletes with chronic low back pain: a randomized clinical trial. BMC Sports Sci Med Rehabil. 2021;13(1):20. doi: 10.1186/s13102-021-00250-y [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref046] 46.Park S-H, Oh Y-J, Jung S-H, Lee M-M. The effects of lumbar stabilization exercise program using respiratory resistance on pain, dysfunction, psychosocial factor, respiratory pressure in female patients in ’40s with low back pain: randomized controlled trial. Ann Appl Sport Sci. 2021;9(3):1–10. doi: 10.52547/aassjournal.937 [DOI] [Google Scholar]

[pone.0339263.ref047] 47.Park S-J, Kim E-K, Kim Y-M, Kang D-Y. Effects of trunk stability exercises and thoracic manipulation on spine flexibility in chronic low back pain patients. Korean Soc Phys Med. 2021;16(2):115–23. doi: 10.14474/ptrs.2024.13.1.1 [DOI] [Google Scholar]

[pone.0339263.ref048] 48.Park S-H, Oh Y-J, Seo J-H, Lee M-M. Effect of stabilization exercise combined with respiratory resistance and whole body vibration on patients with lumbar instability: a randomized controlled trial. Medicine (Baltimore). 2022;101(46):e31843. doi: 10.1097/MD.0000000000031843 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref049] 49.Masroor S, Tanwar T, Aldabbas M, Iram I, Veqar Z. Effect of adding diaphragmatic breathing exercises to core stabilization exercises on pain, muscle activity, disability, and sleep quality in patients with chronic low back pain: a randomized control trial. J Chiropr Med. 2023;22(4):275–83. doi: 10.1016/j.jcm.2023.07.001 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref050] 50.Sığlan Ü, Çolak S. Effects of diaphragmatic and iliopsoas myofascial release in patients with chronic low back pain: a randomized controlled study. J Bodyw Mov Ther. 2023;33:120–7. doi: 10.1016/j.jbmt.2022.09.029 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref051] 51.E SEAA, Rehab NI, Shendy WS, Alsaid HM. Effect of thoracic spine mobilization on pain and lumbar mobility in patients with lumbosacral radiculopathy: a randomized controlled trial. Benha Int J Phys Ther. 2024;2(2):35–41. 10.21608/bijpt.2024.303076.1034 [DOI] [Google Scholar]

[pone.0339263.ref052] 52.Doğan OA, Atıcı E, Sürenkök Ö. The impact of lumbar stabilization and thoracic mobilization exercises on pain, disability and quality of life in individuals with chronic low back pain. J Innov Healthc Pract. 2024;5(3):123–31. doi: 10.58770/joinihp.1571454 [DOI] [Google Scholar]

[pone.0339263.ref053] 53.ElFayoumi BHH, Mohamed NAA, Balbaa AAE, Soliman ES. Effects of combining thoracic lymphatic pump technique and exercises on patients with chronic mechanical low back pain. Fiz Pol. 2024;24(3):72–81. doi: 10.56984/8zg020am9t [DOI] [Google Scholar]

[pone.0339263.ref054] 54.Hwang D-K, Jang H-Y, Lee S-M, Lee B-H. Effects of thoracic mobility exercise on the range of motion, pain, disability index and quality of life in middle-aged women with chronic back pain. JKPTS. 2024;31(2):15–29. doi: 10.26862/jkpts.2024.06.31.2.15 [DOI] [Google Scholar]

[pone.0339263.ref055] 55.Mikkonen J, Luomajoki H, Airaksinen O, Goubert L, Pratscher S, Leinonen V. Identical movement control exercises with and without synchronized breathing for chronic non-specific low back pain: a randomized pilot trial. J Back Musculoskelet Rehabil. 2024;37(6):1561–71. doi: 10.3233/BMR-230413 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref056] 56.Park D, Lee K-S. Effects of thoracic mobility exercise program on pain, proprioception, and static balance ability in patients with non-specific chronic low back pain. Phys Ther Rehabil Sci. 2024;13(1):1–7. doi: 10.14474/ptrs.2024.13.1.1 [DOI] [Google Scholar]

[pone.0339263.ref057] 57.Abdel-Aziz SS, Badr NMH, El-Azizi HM, El Sawy RES, El-Moatasem AM. Core stability exercises versus diaphragmatic release on respiratory functions on physical therapists with low back pain. Adv Rehabil. 2025;39(1):1–16. doi: 10.5114/areh.2024.146098 [DOI] [Google Scholar]

[pone.0339263.ref058] 58.Abdelhamid AS, Ali F, Asal MS, Salem S. Effect of lumbar stabilization exercises combined with ball and balloon exercise in treatment of chronic non-specific low back pain: randomized clinical trial. Bull Phys Ther Res Stud. 2025;3(1):1–19. doi: 10.21608/bptrs.2025.306953.1038 [DOI] [Google Scholar]

[pone.0339263.ref059] 59.Li Y, Zhao Q, Zhang X, E Y, Su Y. The impact of core training combined with breathing exercises on individuals with chronic non-specific low back pain. Front Public Health. 2025;13:1518612. doi: 10.3389/fpubh.2025.1518612 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref060] 60.McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12(1):55–61. doi: 10.1002/jrsm.1411 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref061] 61.Walsh DP, Chen MJ, Buhl LK, Neves SE, Mitchell JD. Assessing interrater reliability of a faculty-provided feedback rating instrument. J Med Educ Curric Dev. 2022;9:23821205221093205. doi: 10.1177/23821205221093205 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref062] 62.Loef M, Walach H, Schmidt S. Interrater reliability of ROB2 - an alternative measure and way of categorization. J Clin Epidemiol. 2022;142:326–7. doi: 10.1016/j.jclinepi.2021.09.003 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref063] 63.Morris SB. Estimating effect sizes from pretest-posttest-control group designs. Organ Res Methods. 2007;11(2):364–86. doi: 10.1177/1094428106291059 [DOI] [Google Scholar]

[pone.0339263.ref064] 64.Gholipour MA, Hamedi H, Seyedhoseinpoor T. Effects of exercise therapy with blood flow restriction on shoulder strength: protocol for a systematic review and meta-analysis. BMJ Open. 2025;15(4):e097640. doi: 10.1136/bmjopen-2024-097640 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref065] 65.Pourahmadi M, Mohseni-Bandpei MA, Keshtkar A, Koes BW, Fernández-de-Las-Peñas C, Dommerholt J, et al. Effectiveness of dry needling for improving pain and disability in adults with tension-type, cervicogenic, or migraine headaches: protocol for a systematic review. Chiropr Man Therap. 2019;27:43. doi: 10.1186/s12998-019-0266-7 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref066] 66.Higgins J. Cochrane handbook for systematic reviews of interventions. Version 5.1. 0. The Cochrane Collaboration; 2011. [updated 2011 Mar]. Available from: www.cochrane-handbook.org [Google Scholar]

[pone.0339263.ref067] 67.Jpt H. Cochrane handbook for systematic reviews of interventions; 2008. Available from: http://www.cochrane-handbook.org [Google Scholar]

[pone.0339263.ref068] 68.Pourahmadi MR, Taghipour M, Ebrahimi Takamjani I, Sanjari MA, Mohseni-Bandpei MA, Keshtkar AA. Motor control exercise for symptomatic lumbar disc herniation: protocol for a systematic review and meta-analysis. BMJ Open. 2016;6(9):e012426. doi: 10.1136/bmjopen-2016-012426 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref069] 69.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref070] 70.Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 2000;56(2):455–63. doi: 10.1111/j.0006-341x.2000.00455.x [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref071] 71.Patsopoulos NA, Evangelou E, Ioannidis JPA. Sensitivity of between-study heterogeneity in meta-analysis: proposed metrics and empirical evaluation. Int J Epidemiol. 2008;37(5):1148–57. doi: 10.1093/ije/dyn065 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref072] 72.Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–6. doi: 10.1016/j.jclinepi.2010.07.015 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref073] 73.Pourahmadi M, Mohseni-Bandpei MA, Keshtkar A, Koes BW, Fernández-de-Las-Peñas C, Dommerholt J, et al. Effectiveness of dry needling for improving pain and disability in adults with tension-type, cervicogenic, or migraine headaches: protocol for a systematic review. Chiropr Man Therap. 2019;27:43. doi: 10.1186/s12998-019-0266-7 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref074] 74.Astudillo Ganora I, Escolar Reina MP. Efectividad de la manipulación vertebral combinada con otras intervenciones de fisioterapia en pacientes con dolor lumbar inespecífico: un ensayo clínico aleatorizado. Retos. 2024;61:1191–8. doi: 10.47197/retos.v61.110304 [DOI] [Google Scholar]

[pone.0339263.ref075] 75.Kiran R, Mohanty P, Pattnaik M. Thoracic mobilisation and periscapular soft tissue manipulations in the management of chronic Prolapsed Intervertebral Disc (PIVD) - An innovative manual therapy approach. AMJ. 2017;10(10):838–47. doi: 10.21767/amj.2017.2851 [DOI] [Google Scholar]

[pone.0339263.ref076] 76.KU DK. Effect of expiratory training and inspiratory training with lumbar stabilization in low back pain:a randomized controlled trial. IJPHRD. 2020;11(2):236. doi: 10.37506/v11/i2/2020/ijphrd/194790 [DOI] [Google Scholar]

[pone.0339263.ref077] 77.Shah S, Shirodkar S, Deo M. Effectiveness of core stability and diaphragmatic breathing vs. core stability alone on pain and function in mechanical non-specific low back pain patients: a randomised control trial. Int J Health Sci Res. 2020;10(2):232–41. [Google Scholar]

[pone.0339263.ref078] 78.O’Neill J. The effects of a breathing exercise-based intervention on low back pain and anxiety symptoms. SWCSJ. 2024;4(2):4. [Google Scholar]

[pone.0339263.ref079] 79.Sawant KU, Rai RH, Kalra S, Sharma A, Chahal A, Sharma N. Combined effects of breathing exercise and core strength training on fatigue, abdominal strength, and cardiovascular fitness among subjects with mechanical nonspecific lumbago using tele-physiotherapy: a randomized clinical trial. J Datta Meghe Inst Med Sci Univ. 2024;19(2):247–56. doi: 10.4103/jdmimsu.jdmimsu_675_23 [DOI] [Google Scholar]

[pone.0339263.ref080] 80.Tatsios P, Koumantakis GA, Karakasidou P, Philippou A. The effectiveness of manual therapy on musculoskeletal and respiratory parameters in patients with chronic low back pain: a systematic review. Crit Rev Phys Rehabil Med. 2021;33(2):71–101. doi: 10.1615/critrevphysrehabilmed.2021038977 [DOI] [Google Scholar]

[pone.0339263.ref081] 81.Hastreiter D, Ozuna RM, Spector M. Regional variations in certain cellular characteristics in human lumbar intervertebral discs, including the presence of alpha-smooth muscle actin. J Orthop Res. 2001;19(4):597–604. doi: 10.1016/S0736-0266(00)00069-3 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref082] 82.Hodges PW, Heijnen I, Gandevia SC. Postural activity of the diaphragm is reduced in humans when respiratory demand increases. J Physiol. 2001;537(Pt 3):999–1008. doi: 10.1111/j.1469-7793.2001.00999.x [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref083] 83.Roussel N, Nijs J, Truijen S, Vervecken L, Mottram S, Stassijns G. Altered breathing patterns during lumbopelvic motor control tests in chronic low back pain: a case-control study. Eur Spine J. 2009;18(7):1066–73. doi: 10.1007/s00586-009-1020-y [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref084] 84.Avman MA, Osmotherly PG, Snodgrass S, Rivett DA. Is there an association between hip range of motion and nonspecific low back pain? A systematic review. Musculoskelet Sci Pract. 2019;42:38–51. doi: 10.1016/j.msksp.2019.03.002 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref085] 85.Yasuda T, Jaotawipart S, Kuruma H. Effects of thoracic spine self-mobilization on patients with low back pain and lumbar hypermobility: a randomized controlled trial. Prog Rehabil Med. 2023;8:20230022. doi: 10.2490/prm.20230022 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0339263.ref086] 86.Masarsky CSaMT-M. Somatovisceral aspects of chiropractic: an evidence-based approach; 2001. [Google Scholar]

[pone.0339263.ref087] 87.Engel RM, Vemulpad S. The effect of combining manual therapy with exercise on the respiratory function of normal individuals: a randomized control trial. J Manipulative Physiol Ther. 2007;30(7):509–13. doi: 10.1016/j.jmpt.2007.07.006 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref088] 88.Threlkeld AJ. The effects of manual therapy on connective tissue. Phys Ther. 1992;72(12):893–902. doi: 10.1093/ptj/72.12.893 [DOI] [PubMed] [Google Scholar]

[pone.0339263.ref089] 89.Babina R, Mohanty PP, Pattnaik M. Effect of thoracic mobilization on respiratory parameters in chronic non-specific low back pain: a randomized controlled trial. J Back Musculoskelet Rehabil. 2016;29(3):587–95. doi: 10.3233/BMR-160679 [DOI] [PubMed] [Google Scholar]

PERMALINK

Effects of breathing exercise and thoracic techniques on pain and disability in low back pain: A systematic review and meta-analysis

Tahere Seyedhoseinpoor

Ramin Jafari

Zohreh Shafizadegan

Maryam Abbaszadeh-Amirdehi

Roles

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Methods

Search methods for the identification of studies and selection of criteria

Types of outcomes

Data extraction and management

Table 1. Studies are in chronological order from oldest to most recent by year of publication.

Assessment of risk of bias in included studies

Measures of treatment effect

Assessment and investigation of heterogeneity

Assessment of publication bias

Sensitivity analysis

Data synthesis

Results

Studies characteristics

Fig 1. Flow diagram for the study selection process.

Risk of bias assessment

Fig 2. Summary of the risk of bias assessment: the review authors’ judgments about each item of risk of bias for each included study.

Study design and outcome measurement

Effects of interventions on pain intensity

Fig 3. Forest plot of the effect of the breathing exercises and/or thoracic techniques group compared to the control group on the intensity of pain (Morris’ dppc; negative values favor the intervention).

Table 2. Subgroup analysis for the effect of potential factors on pain intensity.

Subgroup analysis on the effects of interventions on pain intensity

Effects of interventions on disability score

Fig 4. Forest plot of the effect of the breathing exercises and/or thoracic techniques group compared to the control group on the disability score (Morris’ dppc; negative values favor the intervention).

Table 3. Subgroup analysis for the effect of potential factors on disability score.

Subgroup analysis on the effects of interventions on disability score

Sensitivity analysis

Table 4. Sensitivity Analysis using any kinds of blinding and studies with low risk of bias.

Fig 5. Influence analyses of each separate study on the overall estimates of a) Pain intensity b) Disability score.

Assessment of publication bias

Fig 6. Egger’s graphs for determining publication bias in the meta-analysis for: a) Pain intensity b) disability score.

Fig 7. Funnel plot for determining publication bias in the meta-analysis for: a) Pain intensity b) disability score.

Quality of evidence

Table 5. Grades of Recommendation, Assessment, Development and Evaluation quality of evidence for the primary outcomes.

Discussion

Strengths and limitations

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Author response to Decision Letter 0

Decision Letter 0

Seyed Hamed Mousavi

Roles

Author response to Decision Letter 1

Decision Letter 1

Seyed Hamed Mousavi

Roles

Author response to Decision Letter 2

Decision Letter 2

Seyed Hamed Mousavi

Roles

Acceptance letter

Seyed Hamed Mousavi

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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