The Continuity of the Body:
Hypothesis of Treatment of the Five Diaphragms
Bruno Bordoni, DO, PhD,
and Emiliano Zanier, DO, PhD
The diaphragm muscle should not be seen as a segment but as part of a body system. This muscle is an
important crossroads of information for the entire body, from the trigeminal system to the pelvic ﬂoor, passing
from thoracic diaphragm to the ﬂoor of the mouth: the network of breath. Viola Frymann ﬁrst spoke of the
treatment of three diaphragms, and more recently four diaphragms have been discussed. Current scientiﬁc
knowledge has led to discussion of the manual treatment of ﬁve diaphragms. This article highlights the
anatomic connections and fascial and neurologic aspects of the diaphragm muscle, with four other structures
considered as diaphragms: that is, the ﬁve diaphragms. The logic of the manual treatment proposed here is
based on a concept and diagnostic work that should be the basis for any area of the body: The patient never just
has a localized symptom but rather a system that adapts to a question.
Introduction: Anatomy and Fascial and Neurologic
Connections of The Five Diaphragms
Viola Frymann ﬁrst spoke of the treatment of three
and only recently started talking about four
Current scientiﬁc knowledge allows discussion
of manual treatment of ﬁve diaphragms: the diaphragm
muscle, pelvic ﬂoor, ﬂoor of the mouth, thoracic outlet, and
tentorium of the cerebellum. Previous work has shown the
connections between all these structures, with links to fascial
and neurologic continuity.
This article addresses the anatomic continuity of the
respiratory diaphragm to validate the proposed manual
During correct respiration, coughing, or any other dia-
phragmatic physiologic alteration, a symmetric change in
the pelvic ﬂoor can be observed.
For instance, if during
inhalation the main inspiratory muscle descends, there will
be a corresponding lowering of the pelvic ﬂoor.
has been veriﬁed with real-time magnetic resonance imaging
of living persons, and one of its aims is controlling—and
responding to—any change in intra-abdominal pressure, for
However, it also ensures the steadiness of the
human trunk and, obviously, preserves continence during
respiration and coughing.
Various studies prove that, before
an act of inhalation, electrical activity of the muscles of the
pelvic ﬂoor can be observed;
the same electrical activity is
traceable for the musculus transversus and the musculus
The pelvic diaphragm not only plays an
important role in supporting the pelvic organs and in re-
sisting increasing pressure but also affects the correct
functionality of respiration.
The retroambiguus nucleus—
which is an important monitoring center for phrenic med-
ullary areas and is housed in the medulla oblongata or so-
called bulb—controls the abdominal muscles as well.
means that respiration must be supported by the pelvic ﬂoor
in order to properly control the pressure of intra-abdominal
liquid. These same areas, which are connected to the mo-
toneurons of the mouth ﬂoor, probably send the premotor
order to the pelvic zone.
The phrenic nerve innervates the diaphragm and runs
from the roots of C3–C5;
the phrenic neurons are housed in
lamina IX of the ventral horn in the cervical spinal cord and
receive information via presynaptic contacts in the medul-
According to some authors, the path of the phrenic nerve
involves the entire brachial plexus and the entire cervical
Along its pathway, the phrenic nerve
anastomoses with the nervus subclavius, which innervates
the musculus subclavius, speciﬁcally the ﬁrst rib and the
Therefore, if there is a phrenic disorder,
it is possible to contract the subclavius, raising the ﬁrst rib
and reproducing a thoracic outlet syndrome, with the rele-
For example, pressure on C8–T1 can
cause problems in the little ﬁnger.
The scalene muscles,
which are innervated by the cervical and brachial plexuses,
are equally important.
It is worth emphasizing that a
Don Carlo Gnocchi IRCCS, Department of Cardiology, IRCCS S. Maria Nascente, Don Carlo Gnocchi Foundation, Milano, Italy.
School CRESO, Osteopathic Centre for Research and Studies, Falconara Marittima (Ancona) and Castellanza (Varese), Italy.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 00, Number 0, 2015, pp. 1–6
ªMary Ann Liebert, Inc.
brachial disorder can provoke phrenic and diaphragmatic
The same occurs for any other anatomic con-
nection. Moreover, the phrenic nerve meets the stellate
ganglion (and indirectly the cardiac ganglion), which is lo-
cated above the ﬁrst rib and generated from the uniﬁcation
of the median ganglion and the inferior cervical gangli-
this means that a disorder of the former or of the
latter could produce symptoms in the complete cervical
tract. There is a close link between the diaphragm and the
With reference to neurology, the phrenic nerve along its
pathway anastomoses with the vagus, while the vagus runs
through the crural region of the diaphragm, innervating
The vagus is joined to the medial longitudinal
fasciculus by afferent and efferent connections; moreover, it
is in contact with the spinal trigeminal nucleus by afferent
This means that diaphragmatic dys-
function produces symptoms that are observable in the re-
gion of the cervical base, in the mouth ﬂoor, and in the dura,
as well as in the eyes. It is important to proceed in order.
The medial longitudinal fasciculus is composed of ﬁbers
that connect the mesencephalon and most cranial nerves,
such as the trigeminal nerve (V) and the cranial nerves that
innervate the eye (II, III, IV, the ﬁrst division of cranial
nerve V, and VI), the tongue (the hypoglossal nerve, XII),
and the cervical base (C1–C3).
Therefore, the medial
longitudinal fasciculus is an important path of connection
whose margins go from the mesencephalon-diencephalon to
the lumbar spinal cord (L4) and farther, at least according to
With reference to the neurologic con-
nections, the nerve of Arnold or C2 enters the cranium
(probably via the vagus or the hypoglossal nerve), where it
innervates the inferior region of the tentorium cerebelli or
In contrast, the superior area of the
tentorium cerebelli is innervated by the nervus recurrens (of
Arnold), which is a stem of the ﬁrst branch of the trigeminal
FIG. 1. The cervico-cranial
area. 1, occipital nerve or c2;
19, XII cranial nerve; 4,
cranial nerve; 5, cranial
nerve XI; 17, geniohyoid
muscle; 10, phrenic nerve.
Reproduced with permission
from Anatomia Dell’uomo,
4th ed. 2010, Milan, Italy:
2 BORDONI AND ZANIER
nerve connected to the eye.
The reciprocal tension mem-
branes are innervated by the trigeminal system and, ac-
cording to recent reports, also by vagus nerve and by
In regular respiration, the genioglossus and other muscles
of the mouth ﬂoor, such as the hyoglossus, are electrically
involved in coordination with the diaphragm, in a period of
time that brieﬂy precedes the contraction of the diaphragm
The genioglossus moves during the respiratory
cycle; during expiration, the muscle moves posteriorly, and
during inspiration, it moves anteriorly.
Their action assists
in ventilation. The greater the inhalation phase in terms of
rhythm, the greater the electrical response of these mouth
This means that the signals of the pe-
ripheral neurons combine with orders from the central ner-
As has recently been proven, in case of
respiratory problems of any nature this carefully coordinated
relationship can be interrupted, with consequential problems
in mastication, deglutition, and respiration (Fig. 1).
should be noted close relationship between the diaphragm,
the buccal diaphragm, and the dura mater.
The fascial system is also involved: that is, the series of
layers of connective tissue that connects the diaphragm to
the whole body. The fascia transversalis is the continuation
of the endothoracic fascia and is related to the diaphragm.
It originates in the deep and median cervical fascia (i.e., the
neck, including the scalene muscles and the phrenic nerve),
and goes to the occipital pharyngeal tubercle, where the dura
and the membranes that stand in mutual tension commu-
Therefore, the deep cervical fascia reaches the
pubis via the fascia transversalis.
This fascia covers the
epimysium of the transversus abdominis muscle, then ar-
rives at the linea alba of the rectus abdominis, and reaches
the inguinal and pubic regions.
It is important to remember
that the transversus abdominis muscle, along with the re-
spiratory diaphragm and the pelvic ﬂoor, plays a signiﬁcant
role in sacroiliac steadiness.
Another important fascial system is the thoracolumbar
fascia, which develops posteriorly, from the sacral region,
through the thoracic region, and ﬁnally to the cervical re-
It involves muscles such as the latissimus dorsi, the
trapezius, the gluteus maximus, and the external oblique, as
well as the ligaments that connect the ileum to the sacrum
(the sacral bone belongs to the system of the pelvic
The medial and lateral arcuate ligaments of the
diaphragm muscle act as a bridge between the thor-
acolumbar fascia posteriorly and the transversalis fascia
Manual Treatment of the Five Diaphragms
It is important to remember that, as happens for many
methods of treatment, whether manual or otherwise, scien-
tiﬁc proof is not available for every existing treatment. This
does not mean that, in absence of scientiﬁc evidence,
something is not valid; if that were the case there would no
treatments or any improvement in rehabilitative practice.
The operator is more important than the technique, but the
good operator knows good techniques.
Manual treatment is useful in most cases of disease,
systemic and local, where there is always an alteration of the
function and position of the diaphragm. The treatment mo-
dality focuses on the operator’s manual skills. Many tech-
niques are available, both for treating the diaphragm directly
and for treating the body districts previously discussed here
(i.e., the thoracic outlet, the buccal diaphragm, the tentorial
diaphragm, and the muscles of the pelvic ﬂoor). After ac-
curate examination of these areas, it is important to choose
the most appropriate rehabilitative manual approach. This
paper suggests some corrective procedures that aim to co-
ordinate all the previously mentioned body structures as
much as possible. The objective is to relieve symptoms and
to obtain a higher percentage of satisfactory functional re-
covery, always depending on the patient’s particular con-
dition. In fact, even if the techniques here proposed should
not completely resolve the problem (e.g., an evident and
pathologic alteration of the diaphragm) thanks to the pre-
viously mentioned connections, these stimuli can improve
the general symptomatologic picture, releasing any anoma-
lous tension due to an incorrect current physiology. To make
some examples, in case of chronic congestive heart failure
and stroke, the diaphragm is positioned in elevation.
This means that a reduction of the tensions, by manually
inhibiting or balancing them, results in the prominence of
the preserved functionality and reduced symptoms.
Generally, the diaphragm has a greater excursion in a
supine position because it is not engaged in postural control;
this results in a higher recorded lung volume.
contrary, with sitting or standing, the diaphragmatic ex-
pansion is reduced because it is involved in controlling
The right portion usually has a greater power of
The excursion range of the diaphragm in a
physiologic or relaxing state is about 1.5 cm, whereas during
forced inhalation it reaches up to 6–10 cm.
The strategy suggested here (just one among many) con-
sists of initial treatment of the pelvic ﬂoor, moving up to the
diaphragm, the thoracic outlet, the mouth ﬂoor, and, ﬁnally,
the tentorium cerebelli. Figures 2–6 show several manual
techniques recommended for different body districts. They
FIG. 2. Treatment of the pelvic ﬂoor. With the patient
supine, place one hand under the sacral bone and the other
on the pubis, with ﬁngers turned upward, toward the face.
When the patient inhales, carefully help the sacral bone rise,
while at the same time helping the pubic bone to descend.
During exhalation, perform the process in reverse order,
until the previous tensions disappear. This therapeutic ap-
proach was ﬁrst proposed by Dr. J.E. Upledger.
TREATMENT OF THE FIVE DIAPHRAGMS 3
should be used after examination of the aforementioned
districts with a general, nonspeciﬁc, but nevertheless accu-
rate, attention. Emphasis is given to the techniques of Dr.
Upledger, which are simple and easily executable.
nally, note that the anatomic features described in books do
not always correspond to the subjective anatomic appear-
ance, and the palpation of the operator plays an important
role in treatment.
The diaphragm muscle should not be seen as a segment
but as part of a body system. To ﬁnd the correct treatment
solutions, one must see the whole and all the links as
highlighted in this article. With all these connections, the
symptoms can also occur in areas far from the source of the
problem, and work with this manual approach can help
achieve a higher success rate. It is hoped that this article
contributes to the overall view of the patient and spurred
FIG. 5. Treatment of the ﬂoor of the mouth. Place your ﬁn-
gertips in a medial position to the jawline and apply uniform
pressure on both sides to balance the existing muscular tensions.
Stop when your ﬁngers perceive that the tissue has softened.
FIG. 6. Treatment of the tentorium cerebelli. Place your
ﬁngers in a semicircle. Your little ﬁngers go from the ex-
ternal occipital protuberance to the area above the ears so as
to indirectly relax the tentorium cerebelli. This therapeutic
approach stops when your ﬁngers perceive that the tissue
has softened and when the patient experiences less irritation
while leaning his or her head.
FIG. 4. Treatment of the thoracic outlet. Place one hand,
with a delicate touch, on the contact point between the two
clavicles, and place the other hand under the back, in par-
allel position. Apply a slight pressure until your hand per-
ceives a release of the tissues, as if there were no resistance
in trying to make your hands meet. This therapeutic ap-
proach was ﬁrst proposed by Dr. J.E. Upledger.
FIG. 3. Treatment of the diaphragm. Place your thumbs
and the whole tenar side under the diaphragm, in antero-
lateral position. The purpose is to search for a tensional
balance between the right and left hemicupula, hindering or
supporting the different tensions previously observed. Re-
move hands once an equal, slight tension on both sides can
4 BORDONI AND ZANIER
The authors would like to thank their families for their
constant and unfailing support.
Author Disclosure Statement
No competing ﬁnancial interests exist.
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Address correspondence to:
Bruno Bordoni, DO, PhD
Osteopathic Centre for Research and Studies
Via Santorre di Santarosa
60015 Falconara Marittima, Ancona
6 BORDONI AND ZANIER