Highlights
- •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.
Abstract
Objectives
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.
Conclusion
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.
Keywords
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 accessOne-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:
Subscribe to Archives of Physical Medicine and RehabilitationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Anatomy of the normal diaphragm.Thorac Surg Clin. 2011; 21: 273-279
- Surgical conditions of the diaphragm: anatomy and physiology.Thorac Surg Clin. 2009; 19: 419-429
- Imaging of the retroperitoneum.Radiol Clin North Am. 2012; 50: 333-355
- Anatomy of the pleura.Clin Chest Med. 1998; 19: 229-240
- Anatomic connections of the diaphragm: influence of respiration on the body system.J Multidiscip Healthc. 2013; 6: 281-291
- Sensory and motor innervation of the crural diaphragm by the vagus nerves.Gastroenterology. 2010; 138: 1091-1095
- The subdiaphragmatic part of the phrenic nerve - morphometry and connections to autonomic ganglia.Clin Anat. 2016; 29: 120-128
- 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
- Investigations on the innervation of the human diaphragm.Anat Rec. 1974; 179: 507-516
- The phrenic ganglion in man.Folia Neuropathol. 2003; 41: 119-121
- Anatomical model of the human trunk for analysis of respiratory muscles mechanics.Respir Physiol Neurobiol. 2005; 148: 245-262
- Considerations when testing and training the respiratory muscles.Phys Ther. 1995; 75: 971-982
- Visceral Manipulation 1.2nd ed. Elsevier, Barcelona2009
- El diafragma torácico y su influencia en los distintos sistemas corporales.Enfermería Activa. 2020; 6: 25-30
- 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
- Update on osteopathic medical concepts and the lymphatic system.J Am Osteopath Assoc. 1996; 96: 97-100
- Postural function of the diaphragm in persons with and without chronic low back pain.J Orthop Sports Phys Ther. 2012; 42: 352-362
- Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm.J Appl Physiol. 2000; 89: 967-976
- 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
- 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
- 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
- Effects of a diaphragm stretching technique on pulmonary function in healthy participants: a randomized-controlled trial.Int J Osteopath Med. 2015; 18: 5-12
- Influence of the phrenic nerve in shoulder pain: a systematic review.Int J Osteopath Med. 2020; 36: 36-48
- 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
- Intraincisional vs intraperitoneal infiltration of local anaesthetic for controlling early post-laparoscopic cholecystectomy pain.J Minim Access Surg. 2011; 7: 173-177
- Shoulder pain after caesarean section: comparison between general and spinal anaesthesia.J Obstet Gynaecol. 2012; 32: 347-349
- 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
- The osteopathic approach to cardiac and pulmonary problems.J Am Osteopath Assoc. 1978; 77: 668-673
- 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
- The mechanisms of massage and effects on performance, muscle recovery and injury prevention.Sports Med. 2005; 35: 235-256
- Determining the benefits of massage mechanisms: a review of literature.Rehabil Sci. 2017; 2: 58-67
- Current concepts in muscle stretching for exercise and rehabilitation.Int J Sports Phys Ther. 2012; 7: 109-119
- The effects of doming of the diaphragm in subjects with short-hamstring syndrome: a randomized controlled trial.J Sport Rehabil. 2015; 24: 342-348
- Fascial plasticity: a new neurobiological explanation part 2.J Bodyw Mov Ther. 2003; 7: 104-116
- 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
- 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
- Effectiveness of manual therapy in COPD: a systematic review of randomised controlled trials.Pulmonology. 2019; 25: 236-247
- Immediate effects of osteopathic manipulative treatment in elderly patients with chronic obstructive pulmonary disease.J Am Osteopath Assoc. 2008; 108: 251-259
- Burden of major musculoskeletal conditions.Bull World Health Organ. 2003; 81: 646-656
- Primer: history and examination in the assessment of musculoskeletal problems.Nat Clin Pract Rheumatol. 2008; 4: 26-33
- The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.BMJ. 2009; 339: b2700
- Reliability of the PEDro scale for rating quality of randomized controlled trials.Phys Ther. 2003; 83: 713-721
- 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
- PEDro. A database of randomized trials and systematic reviews in physiotherapy.Man Ther. 2000; 5: 223-226
- Promoting coherent minimum reporting guidelines for biological and biomedical investigations: the MIBBI project.Nat Biotechnol. 2008; 26: 889-896
PEDro. Physiotherapy Evidence Database (PEDro). Available at: https://search.pedro.org.au/advanced-search. Accessed October 18, 2020.
- A new system for grading recommendations in evidence based guidelines.BMJ. 2001; 323: 334-336
- 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
- Effects of manual therapy on the diaphragm in asthmatic patients: a randomized pilot study.Int J Osteopath Med. 2018; : 26-31
- Efficacy of diaphragmatic breathing in persons with chronic obstructive pulmonary disease: a review of the literature.J Cardiopulm Rehabil. 2002; 22: 7-21
- Pulmonary rehabilitation in chronic obstructive pulmonary disease.Ann Readapt Med Phys. 2007; 50 (602-14): 615-626
- Sedentary lifestyle as a risk factor for low back pain: a systematic review.Int Arch Occup Environ Health. 2009; 82: 797-806
- [Sedentary behaviour in Denmark is growing and is a possible independent risk factor] [Danish].Ugeskr Laeg. 2013; 175: 2631-2635
- Role of intrinsic aerobic capacity and ventilator-induced diaphragm dysfunction.J Appl Physiol. 2015; 118: 849-857
- Skeletal muscle design to meet functional demands.Philos Trans R Soc Lond B Biol Sci. 2011; 366: 1466-1476
- The chest and aging: radiological findings.J Bras Pneumol. 2012; 38: 656-665
- What is evidence-based about myofascial chains: a systematic review.Arch Phys Med Rehabil. 2016; 97: 454-461
- Anatomy Trains.2nd ed. Elsevier Masson, Barcelona2010
- Does a 'tight' hamstring predict low back pain reporting during prolonged standing?.J Electromyogr Kinesiol. 2012; 22: 407-411
- Physical measurements as risk indicators for low-back trouble over a one-year period.Spine. 1984; 9: 106-119
- Effect of deep stripping massage alone or with eccentric resistance on hamstring length and strength.J Bodyw Mov Ther. 2014; 18: 139-144
- Multidisciplinary approaches to breathing pattern disorders.Churchill Livingstone, London2002
- Validade de testes utilizados para medir a flexibilidade dos músculos posteriores da coxa em estudantes universitários.Rev Bras Cien Mov. 2012; 19: 52-60
- 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
- Patients with chronic low back pain: the impact of psychosocial features.Rehabilitation (Stuttg). 2009; 48: 288-297
- Depression: an important factor associated with disability among patients with chronic low back pain.Int J Psychiatry Med. 2015; 49: 187-198
- Sensory-motor control of the lower back: implications for rehabilitation.Med Sci Sports Exerc. 2001; 33: 1889-1898
- The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain.Spine. 2010; 35: 1088-1094
- Immediate effects of breathing re-education on respiratory function and range of motion in chronic neck pain.J Med Assoc Thai. 2014; 97: 55
- Changes in muscle and venous blood flow after massage.Soviet Sports Rev. 1982; : 56-57
- Changes in h-reflex amplitude during massage of triceps surae in healthy subjects.J Orthop Sports Phys Ther. 1990; 12: 55-59
- The relationship of massage and exercise to mood enhancement.Sport Psychol. 1988; : 202-211
- Psychophysiological effects of slow stroke back massage in normotensive females.ANS Adv Nurs Sci. 1982; : 44-61
- Manual therapy in diaphragm muscle: effect on respiratory muscle strength and chest mobility.Man Ther Posturol Rehabil J. 2016; 14: 1-5
- A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications.J Man Manip Ther. 2013; 21: 90-102
- The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine.J Bodyw Mov Ther. 2012; 16: 416-423
- Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia.Man Ther. 2001; 6: 205-212
- Morgagni-Larrey parasternal diaphragmatic hernia in the adult.Rev Esp Enferm Dig. 2009; 101: 357-366
- Brachial neuritis with phrenic nerve involvement.J Clin Neurosci. 2012; 19: 1301-1302
- A variation of the phrenic nerve: case report and review.Singapore Med J. 2007; 48: 1156-1157
- Pain relief by touch: a quantitative approach.Pain. 2014; 155: 635-642
- Temporal analysis of cortical mechanisms for pain relief by tactile stimuli in humans.Cereb Cortex. 2006; 16: 355-365
- 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
- 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
- Different representations of pleasant and unpleasant odours in the human brain.Eur J Neurosci. 2003; 18: 695-703
- Warm pleasant feelings in the brain.Neuroimage. 2008; 41: 1504-1513
- Vagal afferent modulation of nociception.Brain Res Brain Res Rev. 1992; 17: 77-99
- 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
Article info
Publication history
Published online: April 28, 2021
Accepted:
March 23,
2021
Received in revised form:
February 14,
2021
Received:
October 31,
2020
Footnotes
PROSPERO Clinical Trial Registration No.: CRD42020156186.
Disclosures: none
Identification
Copyright
© 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
