diaphragm and posture

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Diaphragm and Posture/Core Stability Luc Peeters, MSc.Ost. & Grégoire Lason, MSc.Ost. Joint-Principals of The International Academy of Osteopathy Core stability refers to the abdominal muscles, the diaphragm, the perineum and the paravertebral muscles. It also refers to the intra-abdominal pressure during breathing and exercise. All these structures and functions must work together in correct co-ordination to provide stability of the body during movement. The diaphragm can be actively moved without breathing. By holding the breath the diaphragm moves 32.5 mm, +/-16.2 mm, on average. The range of motion of the costo-diaphragmal angle is 39 mm, +/-17.6 mm, on average, during normal respiration and 45.5 mm, +/-21.2 mm during active motion without breathing. This means that the diaphragm also has an important static function for the spine. A weak diaphragm no longer provides support for the spine leading to kyphosis of the thoracic spine and a secondary increase in cervical and lumbar lordosis. Asthenia and a weakened diaphragm occur together. Good diaphragm function is therefore essential for a good posture or core stability. Good breathing expands the lower ribcage without any cranial movement of the ribcage and is accompanied by a synchronized activity of the entire abdominal wall which expands slightly while contracting eccentrically thus controlling the intra-abdominal pressure. The advantage of proper breathing versus posture or core stability means that there is enough abdominal pressure to support the lumbar spine instead of accessory muscle contractions. It is therefore essential to maintain a proper intra-abdominal pressure. The abdominal muscles (eccentric contraction) must form an opposition to the diaphragm action. The opposing activity of the abdominal muscles increases the diaphragm’s efficiency by ensuring the optimal length and dome shape of the diaphragm. The position of the chest and its effect on the zone of apposition (attachments) is crucial for proper diaphragm activation. Postural assessment can be indicative for the quality of the core stabilization and thus for diaphragm function. The position of chest and pelvic area are important for diaphragm function. The often seen combination of elevated chest and anterior rotated pelvis compromises proper stabilization of the core.

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The ideal postural situation is that the diaphragm and the pelvic floor are more or less parallel.

In core stability the important muscles are:

• Transversus abdominus. • Multifidus. • Pelvic floor muscles. • Internal and external obliques. • Rectus abdominus. • Erector spinae. • Diaphragm.

Figure 1 - Elevated chest and

anterior rotated pelvis

Figure 2 - Diaphragm and

pelvic floor parallel

Diaphragm

Erector spinae

Abdominals

Perineum

Figure 3 - Functional unit

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The following muscles play a minor role: • Latissimus dorsi. • Gluteus maximus. • Quadratus lumborum. • Trapezius.

Good core stability provides:

• Stiffness of the lumbar spine with lateral tension through the attachments to the transverse processes (stabilizes rotational motions).

• Good counter-force against the apex (L3) of the lumbar lordosis. • Prevents spinal extension. • Counteracts the pull of the psoas m. • Stabilizes the spine. • Controls intervertebral compression. • Controls vertebral translations. • Creates a pressurized visceral cavity.

The core can be seen as functional unit that provides: • Spinal stability. • Intra-abdominal pressure. • Continence. • Breathing.

Role of the diaphragm in core stability: • The diaphragm is the key component to core stability and the muscle can

perform its dual function of breathing and stabilization simultaneously. • The diaphragm can perform the breathing task at a lowered position ensuring

that the stabilizing pressure is maintained throughout the breathing cycles. • There is a close relationship between the diaphragm and the transversus

abdominis m., which contributes to as well the respiratory as the postural control.

• In ideal diaphragm contraction (inhalation) the entire diaphragm pushes down into the abdominal cavity and can be observed by an expansion of the lower ribcage and the abdominal wall in all directions.

• When the diaphragm contracts it pushes down into the abdominal cavity, which combined with the resistance created by the pelvic floor and an eccentric contraction of the abdominal wall, increases the pressure in front of the spine. The pressure from the front is counteracted by contraction of the lumbar extensor muscles and the spine is fully stabilized. Without proper diaphragm contraction the increased intra-abdominal pressure will not reach all the way down to the lower lumbar spine, where the loading is most prominent.

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The diaphragm in patients with low back pain: • The lower back is stabilized by intra-abdominal pressure. • With the persons relaxed, there is not much difference between the diaphragm

movement between people with and without low back pain. • As soon as people with back pain apply resistance (upper or lower extremities

movements) the diaphragm moves upwards (comes higher in the thorax) and its mobility is clearly reduced during breathing. In this case the diaphragm only moves in its posterior part, thus pulling on the spine, which can cause even more pain.

• There are characteristics for recognizing and diagnosing breathing pattern disorders:

o Restlessness (neurotic type). o “Air hunger”. o Sighing. o Rapid swallowing rate. o Poor breath-holding times. o Poor lateral expansion of lower thorax on inhalation. o Rise of shoulders on inhalation. o Visible hard sternocleidomastoideus muscles. o Rapid breathing rate. o Paradoxical breathing. o Positive Nijmegen Test score (23 or higher). o Reports of a cluster of symptoms such as fatigue, pain (particularly

chest, back and neck), anxiety, irritable bowel or bladder, paraesthesia, cold extremities.

o If a patient has low back pain in combination with one of these characteristics, treating the diaphragm, thorax and core is indicated.

How to address the core? There are several systems to evaluate and treat:

• Bony integrity: the bones of the spine must be in a rather normal state. Problems such as arthritis, malformation, Scheuermann disease, Bechterew disease and similar conditions compromise the core stability. This cannot be treated osteopathically.

• Articular and capsular mobility: the different spinal and pelvic joint must be mobile around the normal physiological axes. Somatic dysfunctions can be treated by the osteopath through HVLAT or mobilisations. Especially:

o The lumbar spine must be mobile towards flexion. o The pelvis must be mobile towards posterior rotation. o The thoracic spine must be mobile towards flexion and extension. o The 6 lower ribs must be mobile.

• Ligamentary elasticity: the ligaments of the spine, the pelvis and the diaphragm must be of a normal elasticity to be able to adapt to changes.

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Osteopaths can contribute with mobilisations and General Osteopathic Treatment - GOT.

• Muscular strength, length, trophicity and tone (diaphragm, abdominals, erector truncate, perineum, psoas): there must be a good balance between agonists and antagonists. Osteopaths can contribute through Muscle Energy Techniques MET and proper training of muscle chains must be advised in co-operation with breathing training.

• Visceral abdominal congestion must be addressed. • Intra-thoracic congestion must be addressed. • Fascial (pleura, pericard, peritoneum) quality must be optimal.

Note: there are recently several scientific articles on the use of core stability. Strengthening the abdominals and training of back muscles are all techniques that were long time seen as essential for good core stability. Recent studies reveal that there is no benefit from this approach towards prevention of injury. When we analyse these articles we note that the different muscles are addressed separately. This is not the aim of a good core stability treatment and training. The muscular system works in co-ordination and should be treated accordingly. Bibliography

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2. Boussuges A., Gole Y. & Blanc P. (2009) Diaphragmatic Motion Studied by M-Mode Ultrasonography Methods, Reproducibility, and Normal Values. CHEST Journal - journal.publications.chestnet.org.

3. Chaitow L. (2004) Breathing pattern disorders, motor control and low back pain. Journal of Osteopathic Medicine Volume 7, Issue 1, pp. 33-40.

4. DePalo V.A., Parker A.L., Al-Bilbeisi F. & McCool D. (2004) Respiratory muscle strength training with non-respiratory manoeuvres. Journal of Applied Physiology 96, 731-734.

5. Flanagan S., Kohler J. & Whiting WC. (2010) Activation of core musculature during exercise with stable and unstable loads and unstable surfaces. J. Of Strength & Conditioning Research 24.

6. Gandevia S.C., Butler J.E., Hodges P.W. & Taylor J.L. (2002) Balancing acts respiratory sensations, motor control and human posture. Clin. Exp. Pharmacol. Physiol. 29 (1-2), 118-121.

7. Hagins M. & Lamberg E.M. (2010) Natural breath control during lifting tasks: effect of load. Eur. J. Appl. Physiol. 109 (2): 279-286.

8. Hagins M., Pietrek M., Nordin M. & Axen K. (2004) The effect of breath control on intra-abdominal pressure during lifting tasks. Spine 29(4): 464-469.

9. Hammill R., Beazell J. & Hart J. (2008) Neuromuscular consequences of low

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back pain and core dysfunction. Clin. Sports Med. 27. 449-462. 10. Hodges P.W., Cresswell A.G., Daggfeldt K. & Thorstenson A. (2001) In vivo

measurement of the effect of intra-abdominal pressure on the human spine. J. Biomech 34 (3); 347-53.

11. Hodges P.W., Eriksson A.E.M., Shirley D. & Gandevia S.C. (2004) Intra-abdominal pressure increases stiffness of the lumbar spine.

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13. Hodges P.W. & Gandevia S.C. (2000) Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm. Journal of Applied Physiology 89, 967-976.

14. Hodges P.W., Heijnen I. & Gandevia S.C. (2001) Postural activity of the diaphragm is reduced in humans when respiratory demand increases. J. Physiol. 537: 999-1008.

15. Hodges P.W. & Richardson C.A. (1996) Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of Transversus Abdominis. Spine 21(22) 2640-2650.

16. Hodges P.W. & Richardson C.A. (1999) Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch. Phys. Med. Rehabil. 80 (9), 1005-1012.

17. Hodges P.W. & Richardson C.A. (1998) Delayed postural contraction of Transversus Abdominis in low back pain associated with movement of the lower limb. J. Spinal. Disord. 11 (1) 46-56.

18. Kolar P., Neuwirth J., Sanda J., Suchanek V., Svata Z., Pivec M. (2009) Analysis of diaphragm movement during tidal breathing and during its activation while breath holding using MRI synchronized with spirometry. Physiol. Res. 58:383-392.

19. Kolar P., Sulc J., Kyncl M., Sanda J., Neuwirth J., Bokarius A.V, Kriz J. & Kobesova A. (2010) Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J. Applied Physiol.

20. Kolar et al (2012) Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. Journal of Orthopaedic and Sports Physical Therapy. Vol 42, no 4.

21. Lederman E. (2010) The myth of core stability. Journal of Bodywork & Movement therapies. 14, 84-98.

22. Okada T., Huxel K.C. & Nesser T.W. (2010) Relationship between core stability, functional movement and performance. J. Strength & Cond. Research.

23. Stokes I.A.F. et al. (2010) Intra-abdominal pressure and abdominal wall muscular function: spinal unloading mechanism. Clin. Biomech. doi: 10.1016.

24. Vostatek P., Novak D., Rychnovsky T. & Rychnovska S. (2013) Diaphragm Postural Function Analysis Using Magnetic Resonance Imaging. DOI: 10.1371/journal.pone.0056724.

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If you want to know more about the diaphragm and its function, please visit http://osteopedia.iao.be The ebook “The Diaphragm” will soon be published.