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Purpose: We have shown that individuals with recurrent nonspecific low back pain (LBP) and healthy individuals breathing against an inspiratory load decrease their reliance on back proprioceptive signals in upright standing. Because individuals with LBP show greater susceptibility to diaphragm fatigue, it is reasonable to hypothesize that LBP, diaphragm dysfunction, and proprioceptive use may be interrelated. The purpose of this study was to investigate whether inspiratory muscle training (IMT) affects proprioceptive use during postural control in individuals with LBP. Methods: Twenty-eight individuals with LBP were assigned randomly into a high-intensity IMT group (high IMT) and low-intensity IMT group (low IMT). The use of proprioception in upright standing was evaluated by measuring center of pressure displacement during local muscle vibration (ankle, back, and ankle-back). Secondary outcomes were inspiratory muscle strength, severity of LBP, and disability. Results: After high IMT, individuals showed smaller responses to ankle muscle vibration, larger responses to back muscle vibration, higher inspiratory muscle strength, and reduced LBP severity (P < 0.05). These changes were not seen after low IMT (P > 0.05). No changes in disability were observed in either group (P > 0.05). Conclusions: After 8 wk of high IMT, individuals with LBP showed an increased reliance on back proprioceptive signals during postural control and improved inspiratory muscle strength and severity of LBP, not seen after low IMT. Hence, IMT may facilitate the proprioceptive involvement of the trunk in postural control in individuals with LBP and thus might be a useful rehabilitation tool for these patients.
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Inspiratory Muscle Training Affects
Proprioceptive Use and Low Back Pain
LOTTE JANSSENS
1
, ALISON K. MCCONNELL
2
, MADELON PIJNENBURG
1
, KURT CLAEYS
1,3
, NINA GOOSSENS
1
,
ROELAND LYSENS
4
, THIERRY TROOSTERS
1,5
, and SIMON BRUMAGNE
1
1
KU Leuven Department of Rehabilitation Sciences, University of Leuven, Leuven, BELGIUM;
2
Centre for Sports Medicine
and Human Performance, Brunel University, Uxbridge, UNITED KINGDOM;
3
KU Leuven Department of Rehabilitation
Sciences, University of Leuven, Kulab, Bruges, BELGIUM;
4
Department of Physical Medicine and Rehabilitation,
University Hospitals Leuven, Leuven, BELGIUM;
5
Respiratory Rehabilitation and Respiratory Division, University Hospitals
Leuven, Leuven, BELGIUM
ABSTRACT
JANSSENS, L., A. K. MCCONNELL, M. PIJNENBURG, K. CLAEYS, N. GOOSSENS, R. LYSENS, T. TROOSTERS, and S.
BRUMAGNE. Inspiratory Muscle Training Affects Proprioceptive Use and Low Back Pain. Med. Sci. Sports Exerc., Vol. 47, No. 1,
pp. 12–19, 2015. Purpose: We have shown that individuals with recurrent nonspecific low back pain (LBP) and healthy individuals
breathing against an inspiratory load decrease their reliance on back proprioceptive signals in upright standing. Because individuals with
LBP show greater susceptibility to diaphragm fatigue, it is reasonable to hypothesize that LBP, diaphragm dysfunction, and proprio-
ceptive use may be interrelated. The purpose of this study was to investigate whether inspiratory muscle training (IMT) affects propri-
oceptive use during postural control in individuals with LBP. Methods: Twenty-eight individuals with LBP were assigned randomly into
a high-intensity IMT group (high IMT) and low-intensity IMT group (low IMT). The use of proprioception in upright standing was
evaluated by measuring center of pressure displacement during local muscle vibration (ankle, back, and ankle–back). Secondary out-
comes were inspiratory muscle strength, severity of LBP, and disability. Results: After high IMT, individuals showed smaller responses
to ankle muscle vibration, larger responses to back muscle vibration, higher inspiratory muscle strength, and reduced LBP severity
(PG0.05). These changes were not seen after low IMT (P90.05). No changes in disability were observed in either group (P90.05).
Conclusions: After 8 wk of high IMT, individuals with LBP showed an increased reliance on back proprioceptive signals during postural
control and improved inspiratory muscle strength and severity of LBP, not seen after low IMT. Hence, IMT may facilitate the propri-
oceptive involvement of the trunk in postural control in individuals with LBP and thus might be a useful rehabilitation tool for these
patients. Key Words: POSTURAL BALANCE, SENSORY REWEIGHTING, METABOREFLEX, DIAPHRAGM
Low back pain (LBP) is a well-known health problem
in the Western society and now seems to be extending
worldwide (3). Various studies have identified im-
paired postural control in individuals with LBP, although it
depends on the postural demands (33). The human upright
standing requires proprioceptive input at the level of the
ankles, knees, hips, and spine (1). When ankle propriocep-
tive input becomes less reliable, for example by standing on
an unstable support surface, people rely more on proximal
proprioceptive input, a process known as proprioceptive re-
weighting (8,10,21). Previous studies showed reduced back
proprioceptive acuity in individuals with LBP (42), although
others have questioned this (30). When back proprioceptive
signals lose reliability because of LBP, individuals rely on
ankle proprioception, irrespective of the postural demands
(8). In other words, the ability of individuals with LBP to
adapt their proprioceptive use to the changing postural de-
mands is impaired because they show a dominant ankle
proprioceptive use rather than a flexible reliance on more
proximal proprioceptive input (10).
Similar to people with LBP, this dominant ankle propri-
oceptive use is also observed in individuals with chronic
obstructive pulmonary disease (COPD), particularly those
with compromised inspiratory muscle function, and in healthy
individuals breathing against inspiratory loads (22,25). Al-
though the mechanisms may differ between these popula-
tions, the proprioceptive dominance possibly contributes to
deficits at proximal level whether in terms of reduced spinal
muscle control (8,10) or joint mobility (22). These findings
suggest an important role for inspiratory muscle function in
LBP and proprioceptive control, but the underlying mecha-
nisms remain poorly understood.
The human diaphragm is the principal inspiratory muscle,
and it plays an essential role in controlling the spine during
postural control (19). It seems reasonable that an increased
Address for correspondence: Lotte Janssens, Ph.D., KU Leuven Department
of Rehabilitation Sciences, University of Leuven, Tervuursevest 101 Box
1501, 3001 Leuven, Belgium; E-mail: Lotte.Janssens@faber.kuleuven.be.
Submitted for publication January 2014.
Accepted for publication May 2014.
0195-9131/15/4701-0012/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
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Copyright Ó2014 by the American College of Sports Medicine
DOI: 10.1249/MSS.0000000000000385
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demand for inspiratory function of the diaphragm might in-
hibit its contribution to trunk stabilization during challenges
to postural balance. Healthy individuals seem to be capable
of compensating efficiently for modest increases in inspira-
tory demand by active multisegmental control (20). Never-
theless, this compensation seems less effective in individuals
with LBP, resulting in impaired balance control (16). Fur-
thermore, and as mentioned previously, specific loading of
the inspiratory muscles impairs postural control by de-
creasing lumbar proprioceptive sensitivity, forcing dominant
ankle proprioceptive use (24). This might be explained by
fatigue signaling of the inspiratory muscles, inducing a de-
crease in peripheral muscle oxygenation and blood flow,
which also affects the back muscles (25). Furthermore, in-
dividuals with LBP show a greater magnitude and a greater
prevalence of diaphragm fatigue compared with healthy con-
trols (23). Although it is tempting to speculate on a causal
relation between inspiratory muscle function and proprio-
ceptive use during postural control, support for this mecha-
nism awaits the results of studies that enhance inspiratory
muscle function and assess the influence of this change upon
postural control. Inspiratory muscle training (IMT) provides
such an intervention and has already been shown to affect
spinal curvature in swimmers (40), functional balance in
those with heart failure (6), and inspiratory muscle strength
and endurance in those with COPD (14). Furthermore, IMT
improves blood flow to resting and exercising limb muscles
in patients with COPD (5). However, to the authors’ knowl-
edge, no studies exist on the effect of IMT on individuals
with LBP.
Therefore, the primary objective of this study was to in-
vestigate the effect of IMT on proprioceptive use during pos-
tural control in individuals with recurrent nonspecific LBP. A
secondary aim was to study the effect of IMT on inspiratory
muscle strength, severity of LBP, and disability. We hypoth-
esize that IMT would enable individuals with LBP to increase
reliance on back proprioceptive input rather than dominantly
use ankle proprioception during postural control. Secondary,
we speculate that this may improve LBP symptoms.
METHODS
Participants
Twenty-eight individuals (18 women and 10 men) with a
history of nonspecific recurrent LBP participated voluntarily
in this study. Participants were included in the study if they
had at least three episodes of nonspecific LBP in the last
6 months and reported a score of at least 10% on the Oswestry
Disability Index, version 2 (adapted Dutch version) (ODI-2)
(13). The participants did not have a more specific medical
diagnosis than nonspecific mechanical LBP. Participants
were excluded from the study in case of previous spinal
surgery, specific balance problems (e.g., vestibular or neuro-
logical disorder), respiratory disorders, lower limb problems,
neck pain, or use of pain-relieving medication or physical
treatment. A physical examination was performed by a
physician to confirm eligibility. Participants meeting the in-
clusion criteria were further selected on the basis of their
habitual relative proprioceptive use during postural control
(relative proprioceptive weighting (RPW) ratio, 90.5) in an
upright stance (see ‘‘Data Reduction and Analysis’’). None
of the participants showed evidence of airflow obstruction
upon examination of forced expiratory volume in 1 s (FEV
1
),
forced vital capacity (FVC), and FEV
1
/FVC (17). A physical
activity questionnaire was completed (2). Isometric hand grip
force was measured using a hydraulic hand grip dynamome-
ter (Jamar Preston, Jackson, MI).
The characteristics of the study participants are summa-
rized in Table 1. All participants gave their written informed
consent. The study conformed to the principles of the Dec-
laration of Helsinki (1964) and was approved by the local
Ethics Committee of Biomedical Sciences, KU Leuven, and
registered at www.clinicaltrials.gov (NCT01505582).
Study Design
The study participants were assigned randomly to an in-
tervention group (high-intensity IMT, ‘‘high-IMT group’’)
and control group (low-intensity IMT, ‘‘low-IMT group’’).
The primary objective of this study was to investigate the
effect of IMT on proprioceptive use during postural control.
Secondary outcomes were inspiratory muscle strength, se-
verity of LBP, and LBP-related disability, fear, and beliefs.
Outcome measures were evaluated at baseline and after 8 wk
of intervention. Figure 1 displays the flowchart of the study.
On the basis of previous studies (8,10,22,24,25), a sample
size of 14 per group provides adequate power (0.80, two-
tailed, >= 0.05) to detect a clinically relevant difference in
center of pressure (CoP) displacement on unstable support
surface (primary outcome measure with smallest effect size).
Materials
Proprioceptive use during postural control. Pos-
tural sway characteristics were assessed by anterior–posterior
CoP displacement using a six-channel force plate (Bertec,
Columbus, OH), which recorded the moment of force around
TABLE 1. Participants characteristics.
High-IMT Group
(n= 14)
Low-IMT Group
(n= 14) PValue
Age (yr) 32 T933T7 0.770
Height (cm) 172 T8 171 T8 0.824
Weight (kg) 73 T11 68 T10 0.189
BMI (kgIm
j2
)25 T423T3 0.261
ODI-2 19 T920T8 0.665
NRS back pain 5T25T2 0.785
Duration of back pain (yr) 7T77T5 0.988
FEV
1
(% pred) 113 T11 110 T11 0.473
FVC (% pred) 116 T6 116 T8 0.945
FEV
1
/FVC (% pred) 84 T680T5 0.102
PAI 8.16 T1.17 8.06 T1.76 0.866
HGF (kg) 44 T14 38 T13 0.253
Data are presented as mean TSD.
% pred, percentage predicted; BMI, body mass index; HGF, hand grip force; PAI, Physical
Activity Index (maximum score, 15).
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the frontal axis and the vertical ground reaction force. Force
plate signals were sampled at 500 Hz using a Micro1401
data acquisition system using Spike2 software (Cambridge
Electronic Design, United Kingdom), and a fourth-order low-
pass Butterworth filter was applied with a cutoff frequency
of 5 Hz.
Local muscle vibration was used to investigate the role
of proprioception in postural control. Muscle vibration is a
powerful stimulus of muscle spindle Ia afferents (11,45),
which can induce both motor (i.e., tonic vibration reflex
and/or antagonistic vibration reflex) and perceptual effects
(i.e., an illusion of muscle lengthening) (11). When the CNS
uses proprioceptive signals of the vibrated muscles for pos-
tural control, it will cause a directional corrective CoP dis-
placement. When the triceps surae (TS) muscles are vibrated,
a postural sway in a backward direction is expected. During
lumbar paraspinal (LP) muscle vibration, a forward postural
body sway is expected because in this condition, the brain
considers the pelvis as a ‘‘mobile’’ body part compared with
the ‘‘stationary’’ trunk (10). These directional body sways
have been shown by previous studies (8,10,22,24,25). The
amount of CoP displacement during local vibration may
represent the extent to which an individual makes use of the
proprioceptive signals of the vibrated muscles to maintain
the upright posture. Simultaneous vibration on TS and LP
muscles may identify the individual’s ability to gate con-
flicting proprioceptive signals (TS vs LP) during postural
control (22,25). During simultaneous TS–LP muscle vibra-
tion, a dominant backward body sway suggests a dominant
use of ankle proprioception whereas a forward body sway
indicates a dominant use of back proprioception. Straps
were used to hold the muscle vibrators (Maxon Motor,
Switzerland). The straps were applied bilaterally over the
muscle bellies of the TS and LP muscles by the same in-
vestigator for all trials, and vibration was offered at high
frequency and low amplitude (60 Hz and 0.5 mm) (45).
To evaluate the use of proprioception during postural
control, the participants were instructed to stand barefoot on
the force plate, with their arms relaxed along the body. Two
conditions were used: 1) upright standing on a stable support
surface (force plate) and 2) upright standing on an unstable
support surface (Airex balance pad; 49.5 cm long 40.5 cm
wide 6.5 cm high). On the unstable support surface, ankle
proprioceptive signals are less reliable (21). When visual
input is restricted, this enforces reliance upon proximal pro-
prioceptive signals (i.e., proprioceptive weighting), thereby
highlighting proprioceptive deficits. A standardized foot po-
sition was used, with the heels placed 10 cm apart and a free
forefoot position. The vision of the participants was occluded
by nontransparent goggles. Participants were instructed to
maintain their balance at all times, and an investigator was
standing next to the participant to prevent actual falls. Within
each of the two conditions, three experimental trials were
implemented: muscle vibration was added bilaterally to the
TS muscles (trial 1), LP muscles (trial 2), and to the TS and
LP muscles simultaneously (trial 3). Each trial lasted for 60 s,
with muscle vibration starting at 15 s and lasting 15 s.
Severity of LBP, LBP-related disability, and LBP-
related fear and beliefs. Severity of LBP was scored
by the numerical rating scale (NRS) from 0 (‘‘no pain’’) to
10 (‘‘worst pain’’), and LBP-related disability was evaluated
using the ODI-2 (13). The Fear Avoidance Beliefs Ques-
tionnaire was completed to identify how work and physical
activity affect LBP (49). The Tampa Scale for Kinesiophobia
was completed to identify the participants’ fear of (re)injury
after movements or activities (29).
FIGURE 1—Flowchart of the study.
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Inspiratory muscle strength. Inspiratory muscle strength
was evaluated by measuring maximal inspiratory pressure
(PImax) using an electronic pressure transducer (MicroRPM;
Micromedical Ltd., Kent, United Kingdom). The PImax was
measured at residual volume according to the method of
Black and Hyatt (4). A minimum of five repetitions was
performed, and tests were repeated until there was less than
5% difference between the best and second best test. The
highest pressure sustained over 1 s was defined as PImax
and was compared with reference values (44).
IMT. The participants completed an IMT training pro-
gram over a period of 8 wk, known as an effective training
duration (46). They were instructed to breathe through a
mouthpiece (POWERbreathe Medic; HaB International Ltd.,
Warwickshire, United Kingdom) with their nose occluded
while standing upright (35). With every inspiration, resis-
tance was added to the inspiratory valve, forcing the in-
dividuals to generate a negative pressure of 60% of their
PImax (‘‘high-IMT group’’) or 10% of PImax (‘‘low-IMT
group’’), respectively, a protocol also studied in patients
with COPD (9). The specific intensity of 60% PImax was
justified as ‘‘effective’’ IMT training on the basis of its op-
timal responses in terms of blood flow and pressure gener-
ation (34,47). The participants were instructed to perform
30 breaths, twice daily, 7 days per week, with a breathing
frequency of 15 breaths per minute and a duty cycle of 0.5.
The participants in both groups were coached to use dia-
phragmatic (bucket handle) breathing rather than thoracic
(pump handle) breathing by providing verbal and tactile cues.
With each training session, the participants were instructed to
write down the applied resistance, perceived effort (Borg
scale, 0–10), and additional remarks (e.g., dizziness, dyspnea)
on a standardized form. Once a week, the training was eval-
uated under supervision of an investigator, and the resistance
was adapted to the newly produced PImax (if relevant) in
both groups.
Data Reduction and Analysis
Force plate data were calculated using Spike2 software
and Microsoft Excel. To evaluate proprioceptive use during
postural control, the directional effect of muscle vibration
on mean values of anterior–posterior CoP displacement was
calculated. Positive values indicate a forward body sway,
and negative values indicate a backward body sway. To
provide additional information about the proprioceptive
dominance, an RPW ratio was calculated using the equa-
tion RPW = (abs TS)/(abs TS + abs LP). ‘‘Abs TS’’ is the
absolute value of the mean CoP displacement during TS
muscle vibration, and ‘‘abs LP’’, during LP muscle vibra-
tion. An RPW score equal to one corresponds to 100% re-
liance on TS muscle input in upright standing, whereas a
score equal to zero corresponds to 100% reliance on LP
muscle input (8,10,22,24,25). Participants were included in
the study if they showed an RPW score 90.5 (dominant
ankle proprioceptive use) when standing on an unstable
support surface. According to Kiers et al. (26), the calcula-
tions of CoP displacements during muscle vibration and the
calculation of RPW are the most reliable indicators of the
response to muscle vibration.
A one-way ANOVA was used to examine differences in
baseline characteristics between the two groups (Table 1). A
two-way ANOVA was used to examine differences between
subjects and within subjects with factors of intervention
(high IMT vs low IMT) and time (before vs after); results are
reported with Fand Pvalues. A post hoc test (Tukey) was
performed to further analyze these results in detail; results
are reported with Pvalues. Correlations were calculated by
the Pearson test. The statistical analysis was performed with
Statistica 9.0 (Statsoft). The level of significance was set
at PG0.05.
RESULTS
At baseline, no differences in the participants’ character-
istics (Table 1) and primary and secondary outcome mea-
sures were found between both groups (P90.05).
Inspiratory Muscle Strength
After the intervention, inspiratory muscle strength (PImax)
was significantly different between both groups (F
1,26
=
19.33, P= 0.001). Post hoc results showed that PImax
increased significantly in the high-IMT group after the in-
tervention (94 T30 vs 136 T34 cm H
2
O) ($42 cm H
2
O,
P= 0.001). In contrast, low IMT did not influence PImax
(92 T27 vs 94 T26 cm H
2
O) ($2cmH
2
O, P= 0.989).
Proprioceptive Use during Postural Control
RPW during standing on a stable and unstable
support surface. On a stable support surface, when
comparing the relative use of ankle versus back muscle
proprioceptive input (RPW, 0–1), there was no difference
between groups after the intervention, although a trend was
present (F
1,26
= 3.29, P= 0.081). However, according to the
post hoc test, the high-IMT group exhibited a decrease in
RPW, suggesting a more dominant back over ankle propri-
oceptive use compared with that before IMT ($0.19, P=
0.002). No such difference was apparent in the low-IMT
group ($0.09, P= 0.465).
When standing on an unstable support surface, a signifi-
cant difference in RPW between groups was observed after
the intervention (F
1,26
= 4.54, P= 0.047). The post hoc test
revealed that the IMT group switched to a more dominant
back over ankle proprioceptive use, as shown by the de-
creased RPW values after high IMT compared with baseline
($0.23, P= 0.001). No such difference was apparent in the
low-IMT group ($0.10, P= 0.579). Figures 2 and 3 display
the individual RPW ratios before and after intervention on a
stable and unstable support surface, respectively.
No significant correlation was found between the change
in RPW on a stable support surface and the change in PImax
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after intervention (r=j0.22, P= 0.305). In contrast, on an
unstable support surface, a significant negative correlation
was observed (r=j0.41, P= 0.049), suggesting that an
increment of PImax was associated with a more facilitated
back proprioceptive use during postural control.
Standing on a stable support surface. After the
intervention and on a stable support surface, no differences
in postural responses on muscle vibration were observed
between the groups (F
1,26
= 0.039, P= 0.846 (TS vibration);
F
1,26
= 2.10, P= 0.146 (LP vibration); F
1,26
= 1.24, P=
0.278 (TS–LP vibration)). However, the post hoc test re-
vealed that the high-IMT group decreased their reliance on
ankle proprioceptive signals after the intervention, as
evidenced by a significant reduction in posterior body sway
during TS muscle vibration ($2.6 cm, P= 0.049). This is
corroborated by the finding that the high-IMT group showed
a significantly smaller posterior body sway during simulta-
neous TS and LP muscle vibration compared with that be-
fore IMT ($3.8 cm, P= 0.048). The high-IMT group did
not show a change in reliance on back proprioceptive signals
after IMT ($1.7 cm, P= 0.128). In contrast, in the low-IMT
group, there were no changes in responses to TS vibration
($2.4 cm, P= 0.105), LP vibration ($0.1 cm, P= 0.995),
and simultaneous TS–LP vibration ($2.4 cm, P= 0.644)
after the intervention. Figure 4 displays the absolute CoP
displacements during muscle vibration while standing on a
stable support surface.
No significant correlation was found between the change
in PImax and the change in CoP displacement during TS
vibration (r=j0.16, P= 0.457), TS–LP vibration (r= 0.14,
P= 0.506), or LP vibration (r= 0.31, P= 0.145).
Standing on an unstable support surface. After
the intervention and on an unstable support surface, no dif-
ferences in postural responses were observed between the
groups during TS vibration (F
1,26
= 0.78, P= 0.384) and LP
vibration (F
1,26
= 2.49, P= 0.126); however, during TS–LP
vibration, a significant difference in postural sway was found
(F
1,26
= 5.10, P= 0.034). The post hoc test revealed that in
the high-IMT group, LP vibration elicited a significantly
larger anterior body sway after the intervention ($2 cm,
P= 0.027), indicative of an increased use of back proprio-
ceptive signals during postural control. Furthermore, the
high-IMT group also decreased their reliance on ankle pro-
prioceptive signals, as evidenced by a significantly smaller
posterior body sway during simultaneous TS–LP vibration
after the intervention ($2.0 cm, P= 0.040). This difference
was not present during TS vibration after IMT ($0.9 cm,
P= 0.665). In contrast, in the low-IMT group, there were
no changes in responses to TS ($0.5 cm, P= 0.999), LP
FIGURE 2—Individual and mean TSD RPW ratios while standing on a
stable support surface, measured before and after high-intensity IMT
(high-IMT group) and low-intensity IMT (low-IMT group), respec-
tively. Higher values correspond to higher reliance on ankle muscle
proprioception; lower values correspond to higher reliance on back
muscle proprioception. Pvalues refer to post hoc test results.
FIGURE 3—Individual and mean TSD RPW ratios while standing on
an unstable support surface, measured before and after high-intensity
IMT (high-IMT group) and low-intensity IMT (low-IMT group), re-
spectively. Higher values correspond to higher reliance on ankle muscle
proprioception; lower values correspond to higher reliance on back
muscle proprioception. Pvalues refer to post hoc test results.
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($0.7 cm, P= 0.856), and TS–LP ($0.4 cm, P= 0.986)
vibration after the intervention. Figure 5 displays the ab-
solute CoP displacements during muscle vibration while
standing on an unstable support surface.
No significant correlation was found between the change
in PImax and the change in CoP displacement during TS
vibration (r=j0.10, P= 0.639) or TS–LP vibration (r=
0.18, P= 0.395), although a significant positive correlation
was observed in the change in CoP displacement during LP
vibration (r= 0.44, P= 0.034), suggesting that an increment
of PImax values was associated with a more facilitated back
proprioceptive use during postural control.
Severity of LBP, LBP-Related Disability, and
LBP-Related Fear and Beliefs
After the intervention, LBP severity (NRS score, 1–10)
was significantly lower in the high-IMT group compared
with that in the low-IMT group (F
1,26
= 7.14, P= 0.013).
Severity of LBP decreased significantly in the high-IMT
group (5 T2vs2T2) ($3, P= 0.001), whereas no change
was observed in the low-IMT group (5 T2vs5T2) ($0, P=
0.864). Disability associated with LBP did not differ be-
tween groups after the intervention (F
1,26
= 0.73, P= 0.402)
and was not significantly different before and after high-
IMT (19% T9% vs 13% T10%) ($6%, P= 0.099) and
before and after low IMT (20% T8% vs 17% T7%) ($3%,
P= 0.628). Scores on the Fear Avoidance Beliefs Ques-
tionnaire did not differ between groups after the intervention
(F
1,26
= 0.95, P= 0.343) and were not significantly different
before and after high IMT (28 T5vs24T5) ($4, P= 0.073)
and before and after low IMT (27 T9vs26T13) ($1, P=
0.662). Scores on the Tampa Scale for Kinesiophobia were
not different between groups after the intervention (F
1,26
=
0.01, P= 1.000) and were not significantly different before
and after high IMT (39 T5vs36T6) ($3, P= 0.735) and
before and after low IMT (35 T6vs36T6) ($1, P= 0.735).
DISCUSSION
The results of this study suggest that high IMT (i.e., 60%
PImax) affects proprioceptive use to a greater extent than
low IMT (i.e., 10% PImax) when standing on an unstable
support surface (significant interaction effect). As a consis-
tent within-group effect was observed only in the high-IMT
group, the study suggests that individuals with recurrent non-
specific LBP decrease their reliance on ankle proprioceptive
input and increase their reliance on back proprioceptive input
during postural control after 8 wk of high IMT. Moreover,
high IMT improved inspiratory muscle strength and decreased
the severity of LBP; the decrease in NRS is clinically impor-
tant, according to international consensus (41). These changes
were not present in individuals with LBP who underwent
low IMT. These findings indicate that improving inspiratory
muscle function enhances proprioceptive weighting, sup-
porting the premise that inspiratory muscle dysfunction may
exacerbate poor proprioceptive use in individuals with LBP.
IMT may contribute to an enhancement of propriocep-
tive use in individuals with LBP via several potential
mechanisms. First, previous research has demonstrated that
an increase in intra-abdominal pressure provides ‘‘stiffness’
and, thus, control of the lumbar spine, which is needed to
unload the spine during balance and loading tasks (18). The
diaphragm has been shown to contribute to postural control
by increasing intra-abdominal pressure and possibly via its
anatomical connection to the spine (19). Our findings showed
that the enhanced inspiratory muscle strength after IMT is
accompanied by an improved proprioceptive use (i.e., more
reliance on back proprioception) during postural control. A
study examining the effect of glottal control (breath hold-
ing or not) on postural balance concluded that optimal pos-
tural control needs a dynamic midrange respiratory muscle
control that is neither too flexible nor too stiff (32). This
may be facilitated by IMT because it is known to induce
changes in pressure generation (improve stiffness), on the
one hand (46); and on the other hand, IMT may also reduce
FIGURE 4—CoP displacement (mean TSD) while standing on a stable
support surface during vibration on 1) TS muscles, 2) LP muscles, and
3) TS and LP muscles simultaneously, measured before (black) and
after (white) high-intensity IMT (high-IMT group) and low-intensity
IMT (low-IMT group), respectively. Positive values indicate an anterior
body sway; negative values indicate a posterior body sway. Pvalues
refer to post hoc test results.
FIGURE 5—CoP displacement (mean TSD) while standing on an un-
stable support surface during vibration on 1) TS muscles, 2) LP mus-
cles, and 3) TS and LP muscles simultaneously, measured before (black)
and after (white) high-intensity IMT (high-IMT group) and low-
intensity IMT (low-IMT group), respectively. Positive values indicate
an anterior body sway; negative values indicate a posterior body sway.
Pvalues refer to post hoc test results.
INSPIRATORY MUSCLE TRAINING AND LOW BACK PAIN Medicine & Science in Sports & Exercise
d
17
CLINICAL SCIENCES
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
excessive expiratory/trunk muscle activity (improve flexi-
bility), known to compromise postural control (39). As
muscle spindles show a dense network of blood vessels (27)
and IMT is known to improve blood flow in resting and
exercising peripheral muscles (5), IMT may have favored
the lumbar muscle spindle function in these individuals.
Thus, IMT might enhance the trunk-stabilizing function of
the diaphragm, enabling individuals to up-weight lumbar
proprioceptive signals and thus induce access to a larger
variety in proprioceptive use during postural control. Recent
studies have identified a smaller diaphragm excursion and a
higher diaphragm position in individuals with LBP (28).
Furthermore, people with LBP attempt to compensate for
their suboptimal diaphragm position by increasing their tidal
volume during lifting and lowering tasks to provide ade-
quate pressure support (15,31). Our data suggest that it may
be possible to reverse the suboptimal proprioceptive use in
patients with LBP through IMT and support a role for in-
spiratory muscle dysfunction in some individuals with LBP.
Prospective studies must further reveal whether this associ-
ation can be related to the development and recurrence of
nonspecific LBP.
An additional mechanism contributing to the positive ef-
fect of IMT in individuals with LBP may be found in the
modification of ‘‘pain gate control’’ (38). Next to stimulating
inspiratory muscles, IMT also stimulates extrapulmonary
muscles, joints, and skin receptors possibly involved in pos-
tural control. IMT might stimulate sensory afferents, which
enhance sensing, localizing, and discriminating muscle activ-
ity and joint position, which might have previously been
overwhelmed by a nociceptive input (37). This might explain
why low IMT and high IMT decreased the ankle proprio-
ceptive use, even though no effect of low IMT was observed
upon PImax. Moreover, it has been shown that altered
breathing itself, free from resistive loading, can change
the respiratory physiology and improve tissue oxygenation
consequently (36). Taken together, this might suggest that
IMT favors the use of back proprioception in individuals
with LBP possibly by an improved trunk-stabilizing func-
tion of the diaphragm and/or additional pain gate control
mechanisms.
A top priority identified in 2013 for LBP research relates
to the identification of underlying mechanisms rather than
to the effect of interventional studies (12). Our study reveals
a potential association between inspiratory muscle function
and LBP. More specifically, the findings suggest relative
overloading of the inspiratory musculature, for example,
during high-intensity sports (43) or physically demanding
occupations (7), as a potential but reversible contributor
in proprioceptive use and LBP. These findings might help
unravel why individuals with breathing problems have an
increased risk of developing LBP and why individuals with
LBP are also more likely to develop breathing problems
(48). We believe that our data provide justification for
further exploration of this phenomenon in a randomized
controlled trial with a larger sample size and long-term
follow-up. This will reveal whether IMT is a valuable tool
in the rehabilitation of individuals with LBP and which
specific individuals will benefit from it. In addition, our re-
sults justify additional three-dimensional motion and EMG
analysis to unravel the accompanied posturo-kinetic strategy
of a specific proprioceptive use (i.e., to study the motor
output vs sensory input, to maintain posture).
CONCLUSIONS
After 8 wk of IMT at an intensity of 60% PImax, in-
dividuals with recurrent nonspecific LBP show increased
reliance on back proprioceptive signals during postural
control, show an increase in inspiratory muscle strength, and
report a decrease in LBP severity. Back proprioceptive use
might be improved after IMT by enhancing the trunk-
stabilizing function of the diaphragm and/or by modifying
pain gate control. These changes may enable individuals to
reweight proprioceptive signals and to shift to a more opti-
mal proprioceptive use adapted to the postural demands. The
results of this study provide evidence that the proprioceptive
deficits observed in individuals with LBP, potentially due to
relative overloading of the inspiratory musculature, can be
reversed by IMT.
This work was supported by the Research Foundation—Flanders
(FWO) grants 1.5.104.03, G.0674.09, and G.0871.13. M. P. is a Ph.D.
fellow of the Agency for Innovation by Science and Technology—
Flanders (IWT).
A. K. M. acknowledges a beneficial interest in an inspiratory
muscle training product in the form of a share of license income to
the University of Birmingham and Brunel University. She also acts
as a consultant to POWERbreathe International Ltd. For the remain-
ing authors, no conflicts of interest were declared.
The results of the present study do not constitute endorsement
by the American College of Sports Medicine.
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... The singled-blinded, parallel-group, randomized clinical trial (blinded evaluator) was performed through a simple randomization sampling recruitment of 80 athletes with non-specific LPP who met the inclusion criteria, who were evaluated for descriptive data and outcome measurements and allocated to the two intervention groups (RUSI+IMT or IMT) according to a simple randomization process using the EPIDAT 4.1 program (Xunta de Galicia, Conselleria de Sanidade; Galicia, Spain). One group received isolated highintensity inspiratory muscle self-training (IMT; n = 40) for 8 weeks [28]. The other group received the same IMT for 8 weeks plus ultrasound visual biofeedback (RUSI+IMT; n = 40) with the proposed thoracic orthotic device for diaphragmatic reeducation during normal breathing activity for 6 weeks [22,28,33,37]. ...
... One group received isolated highintensity inspiratory muscle self-training (IMT; n = 40) for 8 weeks [28]. The other group received the same IMT for 8 weeks plus ultrasound visual biofeedback (RUSI+IMT; n = 40) with the proposed thoracic orthotic device for diaphragmatic reeducation during normal breathing activity for 6 weeks [22,28,33,37]. An experienced physiotherapist applied both treatments in IMT and RUSI techniques. ...
... Patients were instructed to perform 30 breaths twice daily, 7 days per week, at a rate of 15 breaths per minute and a duty cycle of 0.5. In addition, all participants were trained to use primarily diaphragmatic breathing ("bucket-handle" motion) rather than thoracic breathing ("pump arm" motion) by providing verbal and tactile signals [28]. 40) for 8 weeks, instructing athletes to breathe through a mouthpiece (POWER Medic; HaB International Ltd., Warwickshire, United Kingdom) with their nose o while standing, generating approximately a negative pressure corresponding to their maximum inspiratory pressure (MIP) via an inspiratory valve that resisted spiration ( Figure 1). ...
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... Therefore, inspiratory muscles play a key role in both breathing and posture control, and trunk stability. [64][65][66][67][68] Decreased postural control is associated with the presence of LBP. It has been shown that the diaphragm is in suboptimal function and in a higher position, exhibiting less excursion during inspiration in patients with LBP. ...
... Furthermore, it has been found that patients with LBP have decreased chest wall expansion and a predisposition to diaphragmatic fatigue compared to healthy people. [64][65][66][67][68] Altered breathing patterns have been observed during lumbopelvic control tests in patients with chronic LBP. The breathing pattern changes when the trunk stabilizer muscles need to work in these patients. ...
... It is thought that the diaphragm's participation in respiration decreases when it helps postural control in patients with chronic LBP. [64][65][66][67][68] The transversus abdominis (TA) and multifidus muscle together stabilize the spine during inspiration and the TA muscle alone during expiration. Biomechanically, these two muscles pull the ribs along their margins and increase the internal abdominal pressure, thereby helping the respiratory muscles to generate effective respiratory force. ...
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... On average, the methodological quality score of the included studies rated with the PEDro scale (Table 2) was 5.28/10. Specifically, only one study was rated 9/10 24 ; two 7/10 27,34 ; 6/10 16,17,28,31 ; seven 5/10 [21][22][23]25,26,35,36 ; five 4/10 19,20,29,30,32 ; and one 3/10. 18 Analysis of each of the 10 items of the PEDro scale showed that risk of bias mainly arose from the following five categories: concealed allocation, blinding of subjects, therapists, assessors, and as planned/intention-to-treat analysis. ...
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The Effectiveness of Manual Therapy on Musculoskeletal and Respiratory Parameters in Patients with Chronic Low Back Pain: A Systematic Review pages 71-101 DOI: 10.1615/CritRevPhysRehabilMed.2021038977 Petros Tatsios School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; Laboratory of Advanced Physiotherapy (LAdPhys), Physiotherapy Department, University of West Attica (UNIWA), Athens, Greece George A. Koumantakis Laboratory of Advanced Physiotherapy (LAdPhys), Physiotherapy Department, University of West Attica (UNIWA), Athens, Greece Palina Karakasidou Physiotherapy Department, University of West Attica (UNIWA), Athens, Greece Anastasios Philippou Physiology Laboratory, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece ABSTRACT Patients with chronic low back pain (CLBP) exhibit respiratory dysfunction. Dysfunction in motor control of trunk muscles (diaphragm included) negatively affects the mechanics and biochemistry of breathing. The aim of this systematic review was to analyze evidence from randomized controlled trials (RCTs) investigating the effect of manual therapy on musculoskeletal and respiratory parameters in patients with CLBP. Systematic search and selection of RCTs was performed using specific keywords in three scientific databases (Medline, Scopus, and the Physiotherapy Evidence Database, or PEDro) from inception to March 2021. Relevant studies published in English were extracted, evaluated, and independently rated for methodological quality by two assessors using the PEDro scale. Data extraction and methodological ratings were inspected by a third assessor. Out of 943 initially collected studies, 922 were excluded (did not meet inclusion criteria or were duplicates). Twenty-one clinical trials were finally included, though they were characterized by moderate methodological quality (PEDro scale). Meta-analysis was not performed due to differences in techniques utilized (targeting spinal joints or trunk or respiratory muscles) and the outcomes were assessed across studies. Overall, there was evidence, of moderate methodological quality, that manual therapy on the low back joints or trunk stabilization exercises, diaphragmatic release techniques, and respiratory exercises significantly improve musculoskeletal as well as respiratory parameters in patients with CLBP. More and higher-quality RCTs are required, especially those that will utilize respiratory reeducation and exercise of the respiratory muscles as therapeutic interventions contributing to the holistic management of patients with CLBP. KEY WORDS: chronic low back pain, manual therapy, breathing exercises, respiratory dysfunction, breathing education, randomized controlled trials
... 16 In addition to a biomechanical role, there is evidence that the proprioceptors in the diaphragm may affect the somatosensory system. [15][16][17][18] A discrepancy in sensory input has been observed in individuals with COPD and concurrent inspiratory muscle training through a greater reliance on ankle proprioception than on low back sensory information during balance activities. 17 Individuals with low back pain also had a dependence on ankle proprioception rather than sensory input from the low back, which was reversed with inspiratory muscle training. ...
... 17 Individuals with low back pain also had a dependence on ankle proprioception rather than sensory input from the low back, which was reversed with inspiratory muscle training. 18 Many individuals with SCI have a fully or partially neurologically intact diaphragm even if other postural muscles are paralyzed, but the diaphragm may be weak. Biomechanical and neurologic changes post SCI are responsible for muscle weakness, and inspiratory muscle training is recognized clinically to partially account for the high rate of respiratoryrelated complications and deaths post SCI. ...
Article
Objective To examine the relationship between inspiratory muscle performance (IMP) and functional sitting balance (FSB) in persons with chronic SCI. We hypothesized that a moderate correlation would be found between IMP and FSB, and that individuals with better balance would have better IMP. Design The SCI-specific modification of the Function in Sitting Test (FIST-SCI) measured FSB. The IMP measures included: 1) maximal inspiratory pressure (MIP), 2) sustained MIP (SMIP), and 3) inspiratory duration (ID). Upper extremity motor score (UEMS) and level of injury (LOI) were taken from ISNCSCI exams. Spearman correlational analyses assessed relationships among these factors in the sample (n=37). Mann-Whitney U tests explored differences between two comparison group pairs (Tetraplegia Group (TG) vs. Paraplegia Group (PG); Independent Transfer Group (ITG) vs. Assisted Transfer Group (ATG)). Regression analysis examined variables predictive of FSB in the TG. Setting Research Facility Participants Volunteers with tetraplegia (n=21, ASIA Impairment Scale (AIS) A = 8, B= 7, C = 6) and paraplegia (n=16, AIS A= 9, B=4, C=3) Main Outcome Measures IMP, LOI, UEMS, FIST-SCI Results UEMS, MIP, SMIP, and LOI had moderate/high correlations with FIST-SCI scores (rs = 0.69, 0.53, 0.53, 0.49, respectively, p< .05). UEMS, MIP, and FIST-SCI scores were higher in the PG and ITG compared to the TG and ATG, respectively (p< .05). Further, SMIP and UEMS predicted FIST-SCI balance scores in the TG, accounting for 55% of total variance (p= 0.00) (FIST-SCI = 11.88 + 0.03(SMIP) + 0.425(UEMS)). Conclusions The relationship between IMP and balance appears preserved after SCI. FSB was predicted, in part, via UEMS and SMIP in the TG. Future research should focus on the impact of SCI-based breathing interventions on FSB.
... In accordance with these statements, prior MRI studies showed a thinner diaphragm with a reduced excursion during breathing, suggesting an altered muscle motor control in patients with lumbopelvic pain [24]. Patients who suffered from this condition presented greater fatigue [25], decreased excursion, and a higher position of the diaphragmatic dome [26]. However, the RUSI technique was shown to be more portable and cheaper than MRI, justifying its increased use in the physical therapy and rehabilitation fields [11,12]. ...
... In addition, the proposed holding device used to fix the US probe in a thoracic orthotic device may reduce measurement errors of the diaphragm thickness as assessed by transcostal RUSI in conjunction with the facilitation of visual diaphragm re-education during normal breathing thus avoiding the problems related to the use of a probe manual fixation. Previous studies have suggested an altered diaphragm muscle motor control in patients with lumbopelvic pain [24], greater fatigue [25], and decreased excursion and a higher position of the diaphragmatic dome [26], which could be improved by visual diaphragm re-education during normal breathing. Re-education of the breathing patterns may modify these respiratory patterns by improving the range of motion, improving diaphragm muscle contraction, and decreasing accessory muscle activity in patients who suffer from musculoskeletal disorders [46]. ...
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The use of rehabilitative ultrasound imaging (RUSI) to evaluate diaphragm thickness during breathing in athletes who suffer from non-specific lumbopelvic pain presents some measurement errors. The purpose of this study was to evaluate intra- and inter-sessions, intra- and inter-rater reliabilities, and concurrent validity of diaphragm thickness measurements during breathing using transcostal RUSI with a novel thoracic orthotic device that was used to fix the US probe versus those measurements obtained using manual fixation. A total of 37 athletes with non-specific lumbopelvic pain were recruited. Intra- (same examiner) and inter-rater (two examiners) and intra- (same day) and inter-session (alternate days) reliabilities were analyzed. All measurements were obtained after manual probe fixation and after positioning the thoracic orthotic device to fix the US probe in order to correctly correlate both measurement methods. Both left and right hemi-diaphragm thickness measurements were performed by transcostal RUSI at maximum inspiration, expiration, and the difference between the two parameters during relaxed breathing. Intra-class correlation coefficients (ICC), standard errors of measurement (SEM), minimum detectable changes (MCD), systematic errors, and correlations (r) were assessed. Orthotic device probe fixation showed excellent reliability (ICC = 0.852–0.996, SEM = 0.0002–0.054, and MDC = 0.002–0.072), and most measurements did not show significant systematic errors (p > 0.05). Despite manual probe fixation with a reliability ranging from good to excellent (ICC = 0.714–0.997, SEM = 0.003–0.023, and MDC = 0.008–0.064 cm), several significant systematic measurement errors (p < 0.05) were found. Most significant correlations between both orthotic device and manual probe fixation methods were moderate (r = 0.486–0.718; p < 0.05). Bland–Altman plots indicated adequate agreement between both measurement methods according to the agreement limits. The proposed novel thoracic orthotic device may allow ultrasound probe fixation to provide valid and reliable transcostal RUSI measurements of diaphragmatic thickness during relaxed breathing thus reducing some measurement errors and avoiding systematic measurement errors. It may be advisable to measure diaphragm thickness and facilitate visual biofeedback with respect to diaphragm re-education during normal breathing in athletes with non-specific lumbopelvic pain.
... Muchos estudios científicos han demostrado el papel fundamental del diafragma en la estabilización del tronco y en el control postural (318)(319)(320)(321)(322). La conexión entre el diafragma y la columna lumbar ha sido muy estudiada en distintas investigaciones, demostrándose beneficios a nivel de movilidad lumbar aplicando técnicas manuales de relajación del diafragma (151,158,160,166,171). ...
Thesis
Effects of diaphragm muscle treatment in shoulder pain and mobility in subjects with rotator cuff injuries. Introduction: The rotator cuff inflammatory or degenerative pathology is the main cause of shoulder pain. The shoulder and diaphragm muscle have a clear relation through innervation and the connection through myofascial tissue. In the case of nervous system, according to several studies the phrenic nerve has communicating branches to the brachial plexus with connections to shoulder key nerves including the suprascapular, lateral pectoral, musculocutaneous, and axillary nerves, besides, the vagal innervation that receives the diaphragm and their connections with the sympathetic system could make this muscle treatment a remarkable way of pain modulation in patients with rotator cuff pathology. To these should be added a possible common embryological origin in some type of vertebrates. Considering the connection through myofascial system, the improving of chest wall mobility via diaphragm manual therapy could achieve a better function of shoulder girdle muscles with insertion or origin at ribs and those that are influenced by the fascia such as the pectoralis major muscle, latissimus dorsi and subscapularis. Objectives: • Main objective: To compare the immediate effect of diaphragm physical therapy in the symptoms of patients with rotator cuff pathology regarding a manual treatment over shoulder muscles. • Specific objectives: 1. To evaluate the immediate effectiveness of each of the three groups in shoulder pain using a numerical pain rating scale (NPRS) and compare between them. 27 2. To evaluate the immediate effectiveness of each of the three groups in shoulder range of motion (ROM) using an inclinometer and compare between them. 3. To evaluate the immediate effectiveness of each of the three groups in pressure pain threshold (PPT) using an algometer and compare between them. Material and method: A prospective, randomized, controlled, single-blind (assessor) trial with a previous pilot study in which a final sample size of 45 subjects was determined to people diagnosed with rotator cuff injuries and with clinical diagnosis of myofascial pain syndrome at shoulder. The sample were divided into 3 groups of treatment (15 subjects per group): 1. A direct treatment over the shoulder by ischemic compression of myofascial trigger points (MTP) (control / rotator cuff group). 2. Diaphragm manual therapy techniques (diaphragm group). 3. Active diaphragm mobilization by hipopressive gymnastic (hipopressive group). The pain and range of shoulder motion were assessed before and after treatment in all the participants by inclinometry, NPRS of pain in shoulder movements and algometry. The data obtained were analyzed by an independent (blinded) statistician, who compared the effects of each one of the treatments using the Student’s t-test for paired samples or the Wilcoxon signed rank test, and calculated the post -intervention percentage of change in every variable. An analysis of variance (ANOVA) followed by the post-hoc test or a non-parametric Kruskal-Wallis test for non-parametric multiple-groups comparisons were performed to compare pre- to post-intervention outcomes between groups. Effect-size estimates of each intervention and between groups were calculated to allow interpretation of results in a more functional and meaningful way. Results: Both the control group and diaphragm group showed a statistically (p< 0.005) and clinically significant improvement, as well as a significant effect size (moderate to strong), on the NPRS in shoulder flexion and abduction movements. Regarding NPRS in shoulder external rotation, only the control group obtained a significant effect size. There was a significant increase in shoulder abduction and external rotation ROM (p< Efectos del tratamiento del músculo diafragma en el dolor y la movilidad del hombro en sujetos con patología del manguito rotador. 28 0.001) with a significant effect size in the control group. The PPT at the xiphoid process of the sternum showed a statistically (p< 0.001) and clinically significant improvement in the diaphragm group. The hipopressive gymnastic treatment was found to be no clinically effective in the shoulder pain and mobility, and showed a less efficacy than the other two groups. Conclusion: Both the shoulder non-direct treatment by a protocol of diaphragm manual therapy techniques and the rotator cuff MTP intervention showed been clinically effective in reducing pain (NPRS) immediately in shoulder flexion and abduction movements. The ROM assessment improvements obtained post- intervention by the diaphragm group have not been enough to consider them as clinically significant. The control group has obtained a significant effect size in shoulder abduction and external rotation ROM improvement. Both the control group and the diaphragm group treatments have been more effective in improving shoulder pain and mobility than the hipopressive group. The control group intervention has been the most effective in improving shoulder external rotation pain and mobility. The diaphragm group intervention was more effective in improving PPT at the xiphoid process than the other groups. Neither the effect size nor clinical significance proves the short-term benefit of the hipopressive gymnastic treatment in shoulder pain and mobility. Future studies are necessary to show the effectiveness of the diaphragm manual therapy applied in several sessions to determine its long-term effects in shoulder pain and mobility.
... The mind-body components of yoga make it an attractive option to add to postsurgical pain management. As a safe t reatment adjunct, the mindfulness meditation and diaphragmatic breathing components of yoga have a strong potential to induce relaxation and reduce anxiety, 16 leading to reduced pain [17][18][19][20][21][22] and potentially diminished use of pharmacological therapies that impede patient recovery. 19,[22][23][24] Core muscle isometric contractions are also beneficial to improve trunk stabilization following LSS. ...
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