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The Continuity of the Body: Hypothesis of Treatment of the Five Diaphragms


Abstract and Figures

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.
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Original Article
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.
This process
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
obliquus internus.
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
plexus (C1–T1).
Along its pathway, the phrenic nerve
anastomoses with the nervus subclavius, which innervates
the musculus subclavius, specifically the first rib and the
clavicle (C5–C6).
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-
vant symptoms.
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.
Volume 00, Number 0, 2015, pp. 1–6
ªMary Ann Liebert, Inc.
DOI: 10.1089/acm.2013.0211
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
thoracic outlet.
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
some sources.
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
tentorial diaphragm.
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:
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
hypoglossal nerve.
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
contractile areas.
This means that the signals of the pe-
ripheral neurons combine with orders from the central ner-
vous system.
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.
On the
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.
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
new thinking.
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
be perceived.
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
School CRESO
Osteopathic Centre for Research and Studies
Via Santorre di Santarosa
60015 Falconara Marittima, Ancona
... The approach to the five diaphragms in osteopathic manipulative medicine (OMM) is part of the respiratory-circulatory model, whose principle is the free movement of body fluids to maintain or improve patient health [1][2]. The OMM philosophy is based on patient-centred care, applying scientific knowledge and clinical experience [3][4]. ...
... In fact, a chronic physical disorder also leads to dysfunctions in the psychological sphere [41]. There are many chronic pathologies where a disturbance of one of the diaphragms leads to multiple comorbidities, and hence the clinical motivation in manually treating the diaphragm(s) with an osteopathic approach [1][2][7][8][41][42][43]. We also remember the nervous system, which not only communicates with the whole body but passes through the myofascial system. ...
... The vagus nerve is wrapped in the deep cervical fascia, the same fascia that involves the suboccipital muscles [23]. The vagus nerve innervates the subtentorial portion and the crural area of the diaphragm (esophageal hiatus) and with the presence of parasympathetic nerve endings to the pelvic tissues [1][2]. Considering that nervous tissue is a highway of electrical and biochemical information, capable of moving this information both towards the periphery and towards the medulla or the central nervous system, a dysfunction of the myofascial system can be one of the causes of chronic pain that involves more diaphragms: headache, alteration of the relationship between esophagus and diaphragm, impaired swallowing, brachialgia, pelvic pain [44][45][46][47][48]. ...
Full-text available
The article continues the anatomical review of the anterolateral myofascial connections of the five diaphragms in osteopathic manipulative medicine (OMM), with the most up-to-date scientific information. The postero-lateral myofascial relationships have been illustrated previously in the first part. The article emphasizes some key OMM concepts; the attention of the clinician must not stop at the symptom or local pain but, rather, verify where the cause that leads to the symptom arises, thanks to the myofascial systems. Furthermore, it is important to remember that the human body is a unity and we should observe the patient not as a series of disconnected segments but as multiple and different elements that work in unison; a dysfunction of tissue will adversely affect neighboring and distant tissues. The goal of the work is to lay solid foundations for the OMM and the five-diaphragm approach showing the myofascial continuity of the human body.
... The rationale of the respiratory-circulatory model is based on the fact that body fluids must have the ability to circulate freely and the OMM approach will be oriented towards those anatomical structures that can facilitate the objective, including the respiratory diaphragm muscle [1]. The first osteopath who spoke of the treatment of the three diaphragms was Viola Frymann (diaphragm, tentorium cerebelli, and pelvic floor) in 1968 [2]. From the anatomical point of view, a diaphragm is considered as such on the basis of its "horizontal" body position [3]. ...
... In 2013, the first scientific article came out which highlighted the relationship of the diaphragm muscle with an additional diaphragm (the fifth), that is, the tongue, through fascial and neurological connections [7]. In 2015 a second article was published on the five diaphragms, with the hypothesis of manual treatment; in 2019 the first clinical article appeared with the five diaphragms and OMM [2,8]. The article briefly reviews the anatomy of the body diaphragms and the myofascial systemic anterolateral relationships of the same diaphragms. ...
... The occipitofrontalis is innervated by the extracranial portion of the facial nerve (auricular nerve); it merges with the temporoparietalis muscle, the levator muscle of the eyelid and the Müller's muscle [30][31]. The levator muscle and Müller's muscle merge with the extrinsic muscles of the eye via the fascia of Tenon [2]. From an embryological point of view, the musculature of the tongue derives from the occipital area and in adults we find these occipital-cervical relationships in the suprahyoid area, including the perivertebral spaces [19]. ...
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Working on the diaphragm muscle and the connected diaphragms is part of the respiratory-circulatory osteopathic model. The breath allows the free movement of body fluids and according to the concept of this model, the patient's health is preserved thanks to the cleaning of the tissues by means of the movement of the fluids (blood, lymph). The respiratory muscle has several systemic connections and multiple functions. The founder of osteopathic medicine emphasized the importance of the thoracic diaphragm and body health. The five diaphragms (tentorium cerebelli, tongue, thoracic outlet, thoracic diaphragm and pelvic floor) represent an important tool for the osteopath to evaluate and find a treatment strategy with the ultimate goal of patient well-being. The two articles highlight the most up-to-date scientific information on the myofascial continuum for the first time. Knowledge of myofascial connections is the basis for understanding the importance of the five diaphragms in osteopathic medicine. In this first part, the article reviews the systemic myofascial posterolateral relationships of the respiratory diaphragm; in the second I will deal with the myofascial anterolateral myofascial connections.
... In addition, the body diaphragms' manual treatment, especially the thoracic one, is traditionally considered and used in common osteopathic education and practice (Frymann, 1968;Speece and Crow, 2001;Bordoni and Zanier, 2015), even if it is not widely researched nor based on empirical evidence. The thoracic diaphragm manual treatment is considered to be fundamental in the holistic osteopathic approach because it is the main breathing muscle, and breathing is a systemic act, involving the whole body, the viscera, the nervous system and emotions (Bordoni et al., 2016). ...
... The thoracic diaphragm manual treatment is considered to be fundamental in the holistic osteopathic approach because it is the main breathing muscle, and breathing is a systemic act, involving the whole body, the viscera, the nervous system and emotions (Bordoni et al., 2016). Moreover, with reference to neurology connections and the aforementioned associations, it is possible to suppose that a diaphragm dysfunction produces symptoms observable in the cervical region (Bordoni and Zanier, 2015). ...
BACKGROUND Literature concerning the effect of diaphragm treatment to reduce neck pain symptoms is scarce. Aim of this trial was to investigate the effects of diaphragm manual therapy associated with standard physiotherapy treatment on pain in patients with Chronic Neck Pain (CNP). METHODS In a private practice clinic, subjects with CNP were randomly assigned to receive three 30-minute treatment sessions of standard cervical physiotherapy and Diaphragm Manual Therapy (DMT) or Sham Diaphragm Technique (SDT). Participants and assessors were blinded to the assignment. Primary outcome was pain, secondary outcomes were cervical active range of motion, pain pressure threshold, disability and quality of life measured at baseline, before and after each session, at 3 and 6-months. Adverse events were monitored. A non-parametric multivariate approach (combined permutation test) was applied to assess the effect of the treatment on all the outcomes. An intention to treat analysis was performed. RESULTS Forty patients were randomly allocated to DMT and SDT groups. Combined permutation test showed a significant higher improvement in DMT group compared to SDT group (p-value=0.0002). The between-group comparisons on single outcomes showed a statistically significant improvement only for pain pressure threshold on upper trapezius (adjusted p-value=0.029). No adverse events related to the intervention were registered. CONCLUSIONS In patients with CNP, addition of diaphragm manual techniques to standard cervical treatment seems to give a better global outcome, but this improvement is of unclear clinical relevance; the primary outcome seems not to have a role. Further studies are needed to confirm and clarify these results.
... Therefore, the urethral support is provided by a balanced fascial and muscular system as an integrated unit. This musculofascial structure provides a hammock onto which the urethra compresses during increased intraabdominal pressure (14). The above-mentioned structures and hypotheses establish evident anatomical relations between the pelvic girdle (ilia, pubic symphysis, sacrum, and coccyx) and the urinary bladder and urethra and thus are shown to have a significant effect on the lower urinary tract symptoms of females. ...
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Introduction and Aim: International continence society mentions that more than 50 % of females suffer from lower urinary tract symptoms (LUTS) and more than 90% of them were not on any medication. LUTS is a term that covers symptoms resulting from conditions affecting the urinary bladder and urethra, prostate, other pelvic organs or any other part of the body which is related to the bladder and urethra anatomically. LUTS can be classified into 3 subcategories, i.e., storage symptoms (symptoms during storage of urine), voiding symptoms (symptoms during micturition), and post micturition symptoms (symptoms after completing micturition). Patients with LUTS may present with a combination of storage, voiding, and post micturition symptoms. The aim of this study is to assess the effectiveness of osteopathy treatment in patients with lower urinary tract symptoms. Materials and Methods: This is a pre-test post-test single group experimental study conducted at Sri Sri University. In this study, 20 females having the mean age of 21.9± 2.61 years with moderate and severe symptoms voluntarily participated. The pre-test scores were measured in 3 different questionnaires (AUA symptom score index, ICIQ – FLUTS and HPMDQ). The subjects were diagnosed and given 4 osteopathy sessions. The post-test scoring was noted and data was analysed using MS Excel. Results: Compared to the baseline scoring, the post intervention scores on all the questionnaires reduced significantly. Subjects having moderate and severe symptoms were selected for the study. After intervention either the symptoms were absent or mild residual symptoms were seen. Conclusion: The results shows that osteopathy treatment is effective in patients having lower urinary tract symptoms.
... This ability to maintain the internal environment steadiness is a result of coordinated interactions between breathing and other systems (postural, cardiac, lymphatic, gastrointestinal) in human body where the diaphragm plays also an important role [1,2]. When this mechanism fails due to breathing pattern disorders or diaphragm dysfunction, the human body begins to function suboptimally what may lead to a whole set of symptoms that can be observed in a different areas of the body [3][4][5][6][7][8]. However, breathing rhythms can be brought a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 under conscious control and thus can improve coupling between body systems providing an avenue for physiological self-regulation and restoring physiological efficiency [9]. ...
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Many diseases and conditions can alter an ability to maintain body balance. The aim of the present study was to investigate whether thoracic surgery may elicit diaphragm dysfunction thereby impairing postural stability. 40 patients qualified to video-assisted thoracoscopy (VATS) lobectomy or lobectomy via thoracotomy due to pulmonary carcinoma were examined two times: a day before lung resection and 3–5 days after surgical procedure. Diaphragm assessment was performed using ultrasonography, while postural sways were evaluated by Zebris FDM-S stabilometric platform. Thoracic surgery was associated with decrease of diaphragm thickness and movement, as well as, with deterioration of static body balance maintenance. Upper lobe resection was linked with greater diaphragm excursion restriction and worse body sway parameters than middle and lower lobe resection. VATS lobectomy was associated with better postoperative diaphragm function and better postural sway parameters than lobectomy via thoracotomy. Patients after lobectomy via thoracotomy had significantly more load on lower limb on the operated side than patients after VATS lobectomy. Impairment of diaphragm function is closely associated with equilibrium impairment after pulmonary resection. VATS lobectomy was less invasive than lobectomy via thoracotomy in terms of primary respiratory muscle function and body balance maintenance parameters.
... 276 Another method of manual therapy involves using light pressure to release tension in the costal attachments of the diaphragm. 277 This technique may help increase diaphragmatic excursion in those with a poor ability to contract the diaphragm. Manual therapy directed along all of the attachment points of the diaphragm anteriorly and posteriorly including the thoracolumbar fascia may also help with mobility of the diaphragm. ...
• The treatment of sciatica differs according to its cause • Most cases warrant a trial of conservative treatment • Integrated programs including manual therapies and exercise may be superior to any single therapy • Surgery is indicated in the presence of red flags and/or a lack of response to conservative treatment
... This means that a diaphragmatic dysfunction may produce symptoms that are observable in the cervical base region, mouth floor, dura, and eyes. Likewise, the reciprocal tension membranes are innervated by the trigeminal system, VN, and hypoglossal nerve (Bordoni & Zanier, 2015). ...
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Attention-deficit/hyperactivity disorder (ADHD) is a neurobiological disorder. Common symptoms are inattention, hyperactivity, impulsivity, and executive functions deficit, often with comorbidities. Main treatment involves pharmacological and non-pharmacological therapies (cognitive-behavioral therapy, psycho-pedagogical programs). Emerging non-pharmacological treatments include manual therapies (MTs) in mental health. Several MT techniques have shown effectiveness in ADHD. The objectives of this study are as follows: (a) to assess short-term effects and persistence of an MT program on neuropsychological (hyperactivity index through the Conners' Global Index [CGI]) and neurophysiological (time-frequency domain parameters of heart rate variability [HRV]) variables in ADHD children, and (b) to test the feasibility of the design. This study was approved by the Parc Tauli Corporation Clinical Research Ethics Board (#2017311). Pilot, controlled, multidisciplinary study of eight children with ADHD randomly assigned to control group (CG; n = 4) and intervention group (IG; n = 4). Both followed multimodal treatment, and IG also received an MT program per week for 4 weeks. A physiotherapist and a psychologist analyzed short-term effects (1-week post-program) and persistence (36 weeks). Eight children (boys, 62.5%; girls, 37.5%) with an average age of 10.375 ± 0.74 years were included. Baseline HRV parameters showed basal sympathetic predominance. The MT program increased the parasympathetic activity, which was significantly maintained at 1 to 36 weeks; there were no changes in CG. One-week post-program IG showed significant CGI reduction (-7 points, p = .016*), CG without changes (p = .41), with significant differences CG-IG (p = .0097*), and very large effect size (d = 2.235); 36 weeks post-program showed no effects (IG, p = .293; CG, p = .247), without differences CG-IG (p = .369). The MT program reduced the hyperactivity index with a 1-week persistence and increased the parasympathetic activity with a 36-week persistence. More investigations are needed to generalize the outcomes. Additional research is planned to further explore the possibilities of MT in psychiatric disorders with autonomic imbalances.
... The diaphragm also controls the postural stability, defecation, micturition, and parturition by modulating intra-abdominal pressure. Furthermore, its function is associated with metabolic balance [6] and cardiovascular and intraperitoneal lymphatic systems [3]. ...
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Background: Breathing is an essential part of life. Diaphragmatic breathing (DB) is slow and deep breathing that affects the brain and the cardiovascular, respiratory, and gastrointestinal systems through the modulation of autonomic nervous functions. However, the effects of DB on human health need to be further investigated. Methods: The author conducted a PubMed search regarding the current evidence of the effect of DB on health. Results: This review consists of a total of 10 systematic reviews and 15 randomized controlled trials (RCTs). DB appears to be effective for improving the exercise capacity and respiratory function in patients with chronic obstructive pulmonary disease (COPD). Although the effect of DB on the quality of life (QoL) of patients with asthma needs to be investigated, it may also help in reducing stress; treating eating disorders, chronic functional constipation, hypertension, migraine, and anxiety; and improving the QoL of patients with cancer and gastroesophageal reflux disease (GERD) and the cardiorespiratory fitness of patients with heart failure. Conclusions: Based on this narrative review, the exact usefulness of DB in clinical practice is unclear due to the poor quality of studies. However, it may be a feasible and practical treatment method for various disorders.
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Background Myofascial release (MFR) technique is frequently used in musculoskeletal problems. There are many studies of the MFR technique on the diaphragm or iliopsoas muscle. However, no studies in the literature performed both diaphragmatic and iliopsoas MFR techniques in patients with chronic low back pain. Objective To investigate the effects of diaphragmatic and iliopsoas MFR techniques on pain, lumbar spine range of motion (ROM), chest wall mobility, and flexibility in patients with chronic low back pain. Design Randomized controlled clinical study. Participants Forty-two participants with chronic low back pain, aged between 20 and 50 years. Intervention The sample was randomly allocated into one of two groups; the myofascial group (n = 21) and control group (n = 21) received the MFR technique or the placebo MFR technique as a complementary therapy to traditional physiotherapy treatment. Outcome measures: Primary outcomes were pain, chest wall mobility, lumbar spine range of motion (ROM), and flexibility. Secondary outcomes were depression, kinesiophobia, and functional disability. Results The MFR techniques significantly reduced the pain, with a between-group difference of −2.05 (95% CI, −2.93 to −1.15) for rest, −2.62 (95% CI, −3.34 to −1.89) for trunk flexion, and −2.00 (95% CI, −2.84 to −1.16) for trunk extension in favor of the EG. MFR techniques significantly increased the lumbar spine ROM after interventions, with a between-group difference of 16.67° (95% CI, 8.87 to 24.47) for flexion, 7.63° (95% CI, 5.44 to 9.80) for extension and, 9.53° (95% CI, 6.57 to 12.48) for right lateral flexion. There was also a significant difference between the groups in flexibility in favor of the MG of 1.95 cm (95% CI, 1.41 to 2.49) for MST, −13.52 cm (95% CI, −20.18 to −6.86) for trunk flexion and, −4.37 cm (−6.50 to −2.28) for right lateral flexion The MFR techniques also significantly increased the chest wall mobility after interventions, with a between-group difference of 2.52 cm (95% CI, 1.82 to 3.23) for the xiphoid region and 3.48 cm (95% CI, 2.60 to 4.36) for the subcostal region. Conclusion Diaphragmatic and iliopsoas MFR techniques may be effective in pain, lumbar spine ROM, flexibility, and chest wall mobility in patients with chronic low back pain. Clinical trials identifier NCT04415021.
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The article explains the scientific reasons for the diaphragm muscle being an important crossroads for information involving the entire body. The diaphragm muscle extends from the trigeminal system to the pelvic floor, passing from the thoracic diaphragm to the floor of the mouth. Like many structures in the human body, the diaphragm muscle has more than one function, and has links throughout the body, and provides the network necessary for breathing. To assess and treat this muscle effectively, it is necessary to be aware of its anatomic, fascial, and neurologic complexity in the control of breathing. The patient is never a symptom localized, but a system that adapts to a corporeal dysfunction.
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It has been known for over a century that these cranial nerves exist, and that they are not typographical errors nor a sensational event reported in the medical literature. A number of scientific articles on anatomy highlight how textbooks on descriptive anatomy do not always consider variables such as differences related to the geographical areas where people live, and these differences do exist. This is an important concept not only for surgeons, but also for all medical professionals who use manual techniques when treating their patients, ie, osteopaths, chiropractors, physiotherapists, and other manual therapists. This paper highlights the latest developments regarding these cranial nerves, offering at the same time some ideas for further reflection when looking at clinical scenarios that appear to bear little relationship to each other. Inclusion of these concepts in everyday anamnesis is encouraged.
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Rationale: Inhibition of pharyngeal motoneurons accompanies REM sleep and is a cause of hypoventilation and obstructive sleep apnea in humans. One explanation posits that the neurotransmitters glycine and γ-aminobutyric acid are responsible for REM sleep motor inhibition. However, blockade of that mechanism at cranial motor nuclei increases motor activity in all sleep-wake states, and least of all in REM sleep, arguing against it as a major mechanism of REM sleep pharyngeal motor inhibition. Objectives: To identify the mechanism of REM sleep inhibition at the hypoglossal motor pool. Methods: Genioglossus and diaphragm activities were recorded in 34 rats across sleep-wake states. Microdialysis probes were implanted into the hypoglossal motor pool. Measurements and main results: Here we show that muscarinic receptor antagonism at the hypoglossal motor pool prevents the inhibition of genioglossus activity throughout REM sleep; likewise, with G-protein-coupled inwardly rectifying potassium (GIRK) channel blockade. Importantly, the genioglossus activating effects of these interventions were largest in REM sleep and minimal or often absent in other sleep-wake states. Finally, we showed that muscarinic inhibition of the genioglossus is functionally linked to GIRK channel activation. Conclusions: We identify a powerful cholinergic-GIRK channel mechanism operating at the hypoglossal motor pool that has its largest inhibitory influence in REM sleep and minimal or no effects in other sleep-wake states. This mechanism is the major cause of REM sleep inhibition at a pharyngeal motor pool critical for effective breathing.
Horizontal eye movements are conducted by the medial rectus and the lateral rectus muscles, which are innervated by the oculomotor nerve (cranial nerve III) and the abducens nerve (cranial nerve VI), respectively. The oculomotor and the abducens nuclei are interconnected by a tract in the brainstem named the medial longitudinal fasciculus (MLF). Through the MLF, the actions of the oculomotor and the abducens nuclei are coordinated, generating conjugate horizontal eye movements. The disorders of horizontal eye movement that are caused by brainstem lesions are classified into three groups: (a) lateral gaze palsy, (b) internuclear ophthalmoplegia, and (c) one-and-a-half syndrome. Lateral gaze palsy is caused by a lesion involving the paramedian pontine reticular formation (PPRF) or the abducens nucleus. Internuclear ophthalmoplegia occurs as a result of a lesion involving the MLF. One-and-a-half syndrome is a combination of lateral gaze palsy and internuclear ophthalmoplegia and is caused by a lesion involving both (a) the ipsilateral PPRF or the ipsilateral abducens nucleus and (b) the ipsilateral MLF. The pathologic lesions depicted on magnetic resonance images were topographically well correlated with the brainstem pathways and each type of horizontal eye movement disorder. Most of the lesions were tiny acute infarctions and were found in the most posterior region of the pons, which corresponded to the location of the brainstem pathways. Therefore, awareness of the brainstem pathways controlling horizontal eye movement is important to avoid missing a small pontine lesion. © RSNA, 2013.
Cardiac Ganglia, Phrenic Nerve, Coronary Venous System. There is an increasing need for invasive electrophysiologists to appreciate the exact anatomy of the epicardial space and the coronary veins. The location of the epicardial fat, the complementary relationship with the main cardiac veins, and the location of sensitive structures (arteries, phrenic nerve, esophagus) have become required knowledge for electrophysiologists, and accessing the epicardial space with this thorough knowledge of the pericardial sinuses and recesses is essential to allow radiographic correlation during catheter manipulation. In this review, we briefly describe the anatomy of the pericardial space and then discuss the specific correlation for the invasive electrophysiologist, highlighting epicardial access, catheter navigation, and avoidance of collateral injury, with specific attention to the important recesses of the pericardial space, their regional anatomy, and radiographic correlation when navigating catheters to these locations. We also discuss the anatomy of the main cardiac veins in the context of catheter mapping and ablation of the epicardial substrate through the venous system and without subxiphoid pericardial access. In part II of this series we discuss the detailed regional anatomy of the cardiac ganglia, phrenic nerve, and coronary venous system. (J Cardiovasc Electrophysiol, Vol. 22, pp. 104-110, January 2011)
We evaluated the role of the fossa ischioanalis (FI) in functional relations between the levator ani (LA) and gluteus maximus muscles (GM) in healthy female volunteers. Twenty-three nulliparae were examined. Electromyogramms of LA and GM were simultaneously recorded during voluntary contraction of the pelvic floor muscles (PFM) and at rest in six body positions. The surface areas of LA (LAA), FI (FIA) and GM (GMA) were evaluated using MRI. Simultaneous LA and GM contractions were electromyographically observed irrespectively of body position in 97.2 %. MRI revealed synchronous movement of all structures: while LAA (-7.4 %) reduced, GMA increased (+6.8 %), FIA changed significantly (+3.4 %). The LA, FI and GM are morphologically and functionally connected. We recommend considering these structures as the 'LFG-Complex', emphasising the importance of this unit for functional integration of the pelvic floor. The findings of this study may contribute to understanding of urinary continence mechanism and disorders after pelvic floor surgery and obstetrical trauma.
In this overview, new and existent material on the organization and composition of the thoracolumbar fascia (TLF) will be evaluated in respect to its anatomy, innervation biomechanics and clinical relevance. The integration of the passive connective tissues of the TLF and active muscular structures surrounding this structure are discussed, and the relevance of their mutual interactions in relation to low back and pelvic pain reviewed. The TLF is a girdling structure consisting of several aponeurotic and fascial layers that separates the paraspinal muscles from the muscles of the posterior abdominal wall. The superficial lamina of the posterior layer of the TLF (PLF) is dominated by the aponeuroses of the latissimus dorsi and the serratus posterior inferior. The deeper lamina of the PLF forms an encapsulating retinacular sheath around the paraspinal muscles. The middle layer of the TLF (MLF) appears to derive from an intermuscular septum that developmentally separates the epaxial from the hypaxial musculature. This septum forms during the fifth and sixth weeks of gestation. The paraspinal retinacular sheath (PRS) is in a key position to act as a 'hydraulic amplifier', assisting the paraspinal muscles in supporting the lumbosacral spine. This sheath forms a lumbar interfascial triangle (LIFT) with the MLF and PLF. Along the lateral border of the PRS, a raphe forms where the sheath meets the aponeurosis of the transversus abdominis. This lateral raphe is a thickened complex of dense connective tissue marked by the presence of the LIFT, and represents the junction of the hypaxial myofascial compartment (the abdominal muscles) with the paraspinal sheath of the epaxial muscles. The lateral raphe is in a position to distribute tension from the surrounding hypaxial and extremity muscles into the layers of the TLF. At the base of the lumbar spine all of the layers of the TLF fuse together into a thick composite that attaches firmly to the posterior superior iliac spine and the sacrotuberous ligament. This thoracolumbar composite (TLC) is in a position to assist in maintaining the integrity of the lower lumbar spine and the sacroiliac joint. The three-dimensional structure of the TLF and its caudally positioned composite will be analyzed in light of recent studies concerning the cellular organization of fascia, as well as its innervation. Finally, the concept of a TLC will be used to reassess biomechanical models of lumbopelvic stability, static posture and movement.
The term thoracic outlet syndrome (TOS) refers to a heterogeneous group of disorders, all of which have in common compression of one or more neurovascular elements at some point within the thoracic outlet. Of the five disorders comprising this group, four have all of the features expected of a syndrome-a recognized constellation of clinical features; an anatomic derangement accounting for these features; and a method of testing that identifies the anatomic derangement. Consequently, their recognition and management are relatively straightforward. Conversely, one of these five disorders (nonspecific TOS) lacks these correlations, which has generated considerable debate in the literature and caused some experts to doubt its existence altogether. The primary focus in this study is on the neurologic forms of TOS. However, for completeness and a better understanding of these neurologic manifestations, the vascular forms are also reviewed.