REVIEW ARTICLE (META-ANALYSIS)| Volume 102, ISSUE 12, P2402-2415, December 2021

Download started.


Effects of Manual Therapy on the Diaphragm in the Musculoskeletal System: A Systematic Review

Published:April 28, 2021DOI:


      • Diaphragm manual therapy is effective in improving thoracoabdominal expansion.
      • Diaphragm manual therapy is effective in improving diaphragmatic mobility.
      • Diaphragm manual therapy obtains a better posterior muscle chain flexibility.
      • Limited studies show improvements at lumbar and cervical level.



      To analyze the effects at the musculoskeletal level of manual treatment of the diaphragm muscle in adults.

      Data Sources

      Systematic review using 4 databases: PubMed, Science Direct, Web of Science, and Scopus.

      Study Selection and Data Extraction

      Two independent reviewers applied the selection criteria and assessed the quality of the studies using the Physiotherapy Evidence Database scale for experimental studies. A third reviewer intervened in cases where a consensus had not been reached. A total of 9 studies were included in the review.

      Data Synthesis

      Manual therapy directed to the diaphragm has been shown to be effective in terms of the immediate increase in diaphragmatic mobility and thoracoabdominal expansion. The immediate improvement in the posterior muscle chain flexibility test is another of the most frequently found findings in the evaluated studies. Limited studies show improvements at the lumbar and cervical level in the range of motion and in pain.


      Manual diaphragm therapy has shown an immediate significant effect on parameters related to costal, spinal, and posterior muscle chain mobility. Further studies are needed, not only to demonstrate the effectiveness of manual diaphragm therapy in the long-term and in symptomatic populations, but also to investigate the specific neurophysiological mechanisms involved in this type of therapy.


      List of abbreviations:

      COPD (chronic obstructive pulmonary disease), PEDro (Physiotherapy Evidence Database), PPT (pressure pain threshold), ROM (range of motion)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Downey R
        Anatomy of the normal diaphragm.
        Thorac Surg Clin. 2011; 21: 273-279
        • Anraku M
        • Shargall Y
        Surgical conditions of the diaphragm: anatomy and physiology.
        Thorac Surg Clin. 2009; 19: 419-429
        • Goenka AH
        • Shah SN
        • Remer EM
        Imaging of the retroperitoneum.
        Radiol Clin North Am. 2012; 50: 333-355
        • Wang NS
        Anatomy of the pleura.
        Clin Chest Med. 1998; 19: 229-240
        • Bordoni B
        • Zanier E
        Anatomic connections of the diaphragm: influence of respiration on the body system.
        J Multidiscip Healthc. 2013; 6: 281-291
        • Young RL
        • Page AJ
        • Cooper NJ
        • Frisby CL
        • Blackshaw LA
        Sensory and motor innervation of the crural diaphragm by the vagus nerves.
        Gastroenterology. 2010; 138: 1091-1095
        • Loukas M
        • Du Plessis M
        • Louis RG
        • Tubbs RS
        • Wartmann CT
        • Apaydin N
        The subdiaphragmatic part of the phrenic nerve - morphometry and connections to autonomic ganglia.
        Clin Anat. 2016; 29: 120-128
        • Verlinden TJM
        • van Dijk P
        • Herrler A
        • de Gier-de Vries C
        • Lamers WH
        • Köhler SE
        The human phrenic nerve serves as a morphological conduit for autonomic nerves and innervates the caval body of the diaphragm.
        Sci Rep. 2018; 8: 11697
        • Hidayet MA
        • Wahid HA
        • Wilson AS
        Investigations on the innervation of the human diaphragm.
        Anat Rec. 1974; 179: 507-516
        • Uzun A
        • Sahin B
        • Ulcay T
        • Bilgic S
        The phrenic ganglion in man.
        Folia Neuropathol. 2003; 41: 119-121
        • Ratnovsky A
        • Elad D
        Anatomical model of the human trunk for analysis of respiratory muscles mechanics.
        Respir Physiol Neurobiol. 2005; 148: 245-262
        • Reid WD
        • Dechman G
        Considerations when testing and training the respiratory muscles.
        Phys Ther. 1995; 75: 971-982
        • Barral JP
        • Mercier P
        Visceral Manipulation 1.
        2nd ed. Elsevier, Barcelona2009
        • Fernández-López I
        • Atín-Arratibel MA
        • Peña-Otero D
        El diafragma torácico y su influencia en los distintos sistemas corporales.
        Enfermería Activa. 2020; 6: 25-30
        • Talasz H
        • Kremser C
        • Kofler M
        • Kalchschmid E
        • Lechleitner M
        • Rudisch A
        Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females.
        Int Urogynecol J. 2011; 22: 61-68
        • Degenhardt BF
        • Kuchera ML
        Update on osteopathic medical concepts and the lymphatic system.
        J Am Osteopath Assoc. 1996; 96: 97-100
        • Kolar P
        • Sulc J
        • Kyncl M
        • et al.
        Postural function of the diaphragm in persons with and without chronic low back pain.
        J Orthop Sports Phys Ther. 2012; 42: 352-362
        • Hodges PW
        • Gandevia SC
        Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm.
        J Appl Physiol. 2000; 89: 967-976
        • González-Álvarez FJ
        • Valenza MC
        • Torres-Sánchez I
        • Cabrera-Martos I
        • Rodríguez-Torres J
        • Castellote-Caballero Y
        Effects of diaphragm stretching on posterior chain muscle kinematics and rib cage and abdominal excursion: a randomized controlled trial.
        Braz J Phys Ther. 2016; 20: 405-411
        • Marizeiro DF
        • Florêncio ACL
        • Nunes ACL
        • Campos NG
        • Lima Pedro
        • Olavo de Paula
        Immediate effects of diaphragmatic myofascial release on the physical and functional outcomes in sedentary women: a randomized placebo-controlled trial.
        J Bodyw Mov Ther. 2018; 22: 924-929
        • Ashraf AM
        • Mohamed MI
        • Ibrahim M
        Effect of diaphragmatic and costal manipulation on pulmonary function and functional capacity in chronic obstructive pulmonary diseasepatients: randomized controlled study.
        Int J Med Res Health Sci. 2015; 4: 841
        • González-Álvarez FJ
        • Valenza MC
        • Cabrera-Martos I
        • Torres-Sánchez I
        • Valenza-Demet G
        Effects of a diaphragm stretching technique on pulmonary function in healthy participants: a randomized-controlled trial.
        Int J Osteopath Med. 2015; 18: 5-12
        • Fernández-López I
        • Peña-Otero D
        • Atín-Arratibel de los Ángeles M
        • Eguillor-Mutiloa M
        Influence of the phrenic nerve in shoulder pain: a systematic review.
        Int J Osteopath Med. 2020; 36: 36-48
        • Mac TB
        • Girard F
        • Chouinard P
        • et al.
        Acetaminophen decreases early post-thoracotomy ipsilateral shoulder pain in patients with thoracic epidural analgesia: a double-blind placebo-controlled study.
        J Cardiothorac Vasc Anesth. 2005; 19: 475-478
        • El-Labban GM
        • Hokkam EN
        • El-Labban MA
        • Morsy K
        • Saadl S
        • Heissam KS
        Intraincisional vs intraperitoneal infiltration of local anaesthetic for controlling early post-laparoscopic cholecystectomy pain.
        J Minim Access Surg. 2011; 7: 173-177
        • Zirak N
        • Soltani G
        • Hafizi L
        • Mashayekhi Z
        • Kashani I
        Shoulder pain after caesarean section: comparison between general and spinal anaesthesia.
        J Obstet Gynaecol. 2012; 32: 347-349
        • 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: 1720-1729
        • Frymann VM
        The osteopathic approach to cardiac and pulmonary problems.
        J Am Osteopath Assoc. 1978; 77: 668-673
        • McCoss CA
        • Johnston R
        • Edwards DJ
        • Millward C
        Preliminary evidence of regional interdependent inhibition, using a 'diaphragm release' to specifically induce an immediate hypoalgesic effect in the cervical spine.
        J Bodyw Mov Ther. 2017; 21: 362-374
        • Weerapong P
        • Hume PA
        • Kolt GS
        The mechanisms of massage and effects on performance, muscle recovery and injury prevention.
        Sports Med. 2005; 35: 235-256
        • Gasibat Q
        • Suwehli W
        Determining the benefits of massage mechanisms: a review of literature.
        Rehabil Sci. 2017; 2: 58-67
        • Page P
        Current concepts in muscle stretching for exercise and rehabilitation.
        Int J Sports Phys Ther. 2012; 7: 109-119
        • Valenza MC
        • Cabrera-Martos I
        • Torres-Sánchez I
        • Garcés-García A
        • Mateos-Toset S
        • Valenza-Demet G
        The effects of doming of the diaphragm in subjects with short-hamstring syndrome: a randomized controlled trial.
        J Sport Rehabil. 2015; 24: 342-348
        • Schleip R
        Fascial plasticity: a new neurobiological explanation part 2.
        J Bodyw Mov Ther. 2003; 7: 104-116
        • Rocha T
        • Souza H
        • Brandão DC
        • et al.
        The manual diaphragm release technique improves diaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease: a randomised trial.
        J Physiother. 2015; 61: 182-189
        • Nair A
        • Alaparthi GK
        • Krishnan S
        • et al.
        Comparison of diaphragmatic stretch technique and manual diaphragm release technique on diaphragmatic excursion in chronic obstructive pulmonary disease: a randomized crossover trial.
        Pulm Med. 2019; 2019: 1-7
        • Simonelli C
        • Vitacca M
        • Vignoni M
        • Ambrosino N
        • Paneroni M
        Effectiveness of manual therapy in COPD: a systematic review of randomised controlled trials.
        Pulmonology. 2019; 25: 236-247
        • Noll DR
        • Degenhardt BF
        • Johnson JC
        • Burt SA
        Immediate effects of osteopathic manipulative treatment in elderly patients with chronic obstructive pulmonary disease.
        J Am Osteopath Assoc. 2008; 108: 251-259
        • Woolf AD
        • Pfleger B
        Burden of major musculoskeletal conditions.
        Bull World Health Organ. 2003; 81: 646-656
        • Woolf AD
        • Akesson K
        Primer: history and examination in the assessment of musculoskeletal problems.
        Nat Clin Pract Rheumatol. 2008; 4: 26-33
        • Liberati A
        • Altman DG
        • Tetzlaff J
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339: b2700
        • Maher CG
        • Sherrington C
        • Herbert RD
        • Moseley AM
        • Elkins M
        Reliability of the PEDro scale for rating quality of randomized controlled trials.
        Phys Ther. 2003; 83: 713-721
        • Verhagen AP
        • de Vet HC
        • de Bie RA
        • et al.
        The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus.
        J Clin Epidemiol. 1998; 51: 1235-1241
        • Sherrington C
        • Herbert RD
        • Maher CG
        • Moseley AM
        PEDro. A database of randomized trials and systematic reviews in physiotherapy.
        Man Ther. 2000; 5: 223-226
        • Taylor CF
        • Field D
        • Sansone S
        • et al.
        Promoting coherent minimum reporting guidelines for biological and biomedical investigations: the MIBBI project.
        Nat Biotechnol. 2008; 26: 889-896
      1. PEDro. Physiotherapy Evidence Database (PEDro). Available at: Accessed October 18, 2020.

        • Harbour R
        • Miller J
        A new system for grading recommendations in evidence based guidelines.
        BMJ. 2001; 323: 334-336
        • Mancini D
        • Cesari M
        • Lunghi C
        • Benigni AM
        • Antonelli Incalzi R
        • Scarlata S
        Ultrasound evaluation of diaphragmatic mobility and contractility after osteopathic manipulative techniques in healthy volunteers: a prospective, randomized, double-blinded clinical trial.
        J Manipulative Physiol Ther. 2019; 42: 47-54
        • Leonés-Macías E
        • Torres-Sánchez I
        • Iea Cabrera-Martos
        Effects of manual therapy on the diaphragm in asthmatic patients: a randomized pilot study.
        Int J Osteopath Med. 2018; : 26-31
        • Cahalin LP
        • Braga M
        • Matsuo Y
        • Hernandez ED
        Efficacy of diaphragmatic breathing in persons with chronic obstructive pulmonary disease: a review of the literature.
        J Cardiopulm Rehabil. 2002; 22: 7-21
        • Derom E
        • Marchand E
        • Troosters T
        Pulmonary rehabilitation in chronic obstructive pulmonary disease.
        Ann Readapt Med Phys. 2007; 50 (602-14): 615-626
        • Chen S
        • Liu M
        • Cook J
        • Bass S
        • Lo SK
        Sedentary lifestyle as a risk factor for low back pain: a systematic review.
        Int Arch Occup Environ Health. 2009; 82: 797-806
        • Overgaard K
        • Gjerndrup Aagaard P
        • Grøntved A
        • Nielsen K
        • Dahl-Petersen IK
        • Aadahl M
        [Sedentary behaviour in Denmark is growing and is a possible independent risk factor] [Danish].
        Ugeskr Laeg. 2013; 175: 2631-2635
        • Sollanek KJ
        • Smuder AJ
        • Wiggs MP
        • et al.
        Role of intrinsic aerobic capacity and ventilator-induced diaphragm dysfunction.
        J Appl Physiol. 2015; 118: 849-857
        • Lieber RL
        • Ward SR
        Skeletal muscle design to meet functional demands.
        Philos Trans R Soc Lond B Biol Sci. 2011; 366: 1466-1476
        • Hochhegger B
        • Meirelles GS
        • Irion K
        • et al.
        The chest and aging: radiological findings.
        J Bras Pneumol. 2012; 38: 656-665
        • Wilke J
        • Krause F
        • Vogt L
        • Banzer W
        What is evidence-based about myofascial chains: a systematic review.
        Arch Phys Med Rehabil. 2016; 97: 454-461
        • Myers TW
        Anatomy Trains.
        2nd ed. Elsevier Masson, Barcelona2010
        • Raftry SM
        • Marshall PWM
        Does a 'tight' hamstring predict low back pain reporting during prolonged standing?.
        J Electromyogr Kinesiol. 2012; 22: 407-411
        • Biering-Sørensen F
        Physical measurements as risk indicators for low-back trouble over a one-year period.
        Spine. 1984; 9: 106-119
        • Forman J
        • Geertsen L
        • Rogers ME
        Effect of deep stripping massage alone or with eccentric resistance on hamstring length and strength.
        J Bodyw Mov Ther. 2014; 18: 139-144
        • Chaitow L
        • Bradley D
        • Gilbert C
        Multidisciplinary approaches to breathing pattern disorders.
        Churchill Livingstone, London2002
        • Melo LMO
        • Martins-Costa HC
        • Araújo SRS
        • Menzel HJ
        • Chagas MH
        Validade de testes utilizados para medir a flexibilidade dos músculos posteriores da coxa em estudantes universitários.
        Rev Bras Cien Mov. 2012; 19: 52-60
        • Heneghan NR
        • Baker G
        • Thomas K
        • Falla D
        • Rushton A
        What is the effect of prolonged sitting and physical activity on thoracic spine mobility? An observational study of young adults in a UK university setting.
        BMJ Open. 2018; 8e019371
        • Mohr B
        • Krohn-Grimberghe B
        • Gräf T
        • Schulze J
        • Petermann F
        • Hampel P
        Patients with chronic low back pain: the impact of psychosocial features.
        Rehabilitation (Stuttg). 2009; 48: 288-297
        • Hung C
        • Liu C
        • Fu T
        Depression: an important factor associated with disability among patients with chronic low back pain.
        Int J Psychiatry Med. 2015; 49: 187-198
        • Ebenbichler GR
        • Oddsson LI
        • Kollmitzer J
        • Erim Z
        Sensory-motor control of the lower back: implications for rehabilitation.
        Med Sci Sports Exerc. 2001; 33: 1889-1898
        • Janssens L
        • Brumagne S
        • Polspoel K
        • Troosters T
        • McConnell A
        The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain.
        Spine. 2010; 35: 1088-1094
        • Yeampattanaporn O
        • Mekhora K
        • Jalayondeja W
        • Wongsathikun J
        Immediate effects of breathing re-education on respiratory function and range of motion in chronic neck pain.
        J Med Assoc Thai. 2014; 97: 55
        • Dubrosky V
        Changes in muscle and venous blood flow after massage.
        Soviet Sports Rev. 1982; : 56-57
        • Morelli M
        • Seaborne DE
        • Sullivan SJ
        Changes in h-reflex amplitude during massage of triceps surae in healthy subjects.
        J Orthop Sports Phys Ther. 1990; 12: 55-59
        • Weinberg R
        • Jackson A
        • Kolodny K
        The relationship of massage and exercise to mood enhancement.
        Sport Psychol. 1988; : 202-211
        • Longworth J
        Psychophysiological effects of slow stroke back massage in normotensive females.
        ANS Adv Nurs Sci. 1982; : 44-61
        • Braga D
        • Marizeiro D
        • Florencio A
        • et al.
        Manual therapy in diaphragm muscle: effect on respiratory muscle strength and chest mobility.
        Man Ther Posturol Rehabil J. 2016; 14: 1-5
        • Sueki DG
        • Cleland JA
        • Wainner RS
        A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications.
        J Man Manip Ther. 2013; 21: 90-102
        • McSweeney TP
        • Thomson OP
        • Johnston R
        The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine.
        J Bodyw Mov Ther. 2012; 16: 416-423
        • Vicenzino B
        • Paungmali A
        • Buratowski S
        • Wright A
        Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia.
        Man Ther. 2001; 6: 205-212
        • Arráez-Aybar LA
        • González-Gómez CC
        • Torres-García AJ
        Morgagni-Larrey parasternal diaphragmatic hernia in the adult.
        Rev Esp Enferm Dig. 2009; 101: 357-366
        • Barraclough A
        • Triplett J
        • Tuch P
        Brachial neuritis with phrenic nerve involvement.
        J Clin Neurosci. 2012; 19: 1301-1302
        • Prakash Prabhu LV
        • Madhyastha S
        • Singh G
        A variation of the phrenic nerve: case report and review.
        Singapore Med J. 2007; 48: 1156-1157
        • Mancini F
        • Nash T
        • Iannetti GD
        • Haggard P
        Pain relief by touch: a quantitative approach.
        Pain. 2014; 155: 635-642
        • Inui K
        • Tsuji T
        • Kakigi R
        Temporal analysis of cortical mechanisms for pain relief by tactile stimuli in humans.
        Cereb Cortex. 2006; 16: 355-365
        • Kakigi R
        • Watanabe S
        Pain relief by various kinds of interference stimulation applied to the peripheral skin in humans: pain-related brain potentials following CO2 laser stimulation.
        J Peripher Nerv Syst. 1996; 1: 189-198
        • Nahra H
        • Plaghki L
        The effects of A-fiber pressure block on perception and neurophysiological correlates of brief non-painful and painful CO2 laser stimuli in humans.
        Eur J Pain. 2003; 7: 189-199
        • Rolls ET
        • Kringelbach ML
        • de Araujo IE
        Different representations of pleasant and unpleasant odours in the human brain.
        Eur J Neurosci. 2003; 18: 695-703
        • Rolls ET
        • Grabenhorst F
        • Parris BA
        Warm pleasant feelings in the brain.
        Neuroimage. 2008; 41: 1504-1513
        • Randich A
        • Gebhart GF
        Vagal afferent modulation of nociception.
        Brain Res Brain Res Rev. 1992; 17: 77-99
        • Niedringhaus M
        • Jackson PG
        • Evans SRT
        • Verbalis JG
        • Gillis RA
        • Sahibzada N
        Dorsal motor nucleus of the vagus: a site for evoking simultaneous changes in crural diaphragm activity, lower esophageal sphincter pressure, and fundus tone.
        Am J Physiol Regul Integr Comp Physiol. 2008; 294: 121