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Effects of diaphragm stretching on posterior chain muscle kinematics and rib cage and abdominal excursion: A randomized controlled trial

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Background: Few studies have explored the effects of stretching techniques on diaphragm and spine kinematics. Objective: To determine whether the application of diaphragm stretching resulted in changes in posterior chain muscle kinematics and ribcage and abdominal excursion in healthy subjects. Method: Eighty healthy adults were included in this randomized clinical trial. Participants were randomized into two groups: the experimental group, which received a diaphragmatic stretching technique, or the placebo group, which received a sham-ultrasound procedure. The duration of the technique, the position of participants, and the therapist who applied the technique were the same for both treatments. Participant assessment (cervical range of movement, lumbar flexibility, flexibility of the posterior chain, and rib cage and abdominal excursion) was performed at baseline and immediately after the intervention by a blinded assessor. Results: The mean between-group difference [95% CI] for the ribcage excursion after technique at xiphoid level was 2.48 [0.97 to 3.99], which shows significant differences in this outcome. The remaining between-group analysis showed significant differences in cervical extension, right and left flexion, flexibility of the posterior chain, and ribcage excursion at xiphoid level (p<0.05) in favor of the experimental group. Conclusion: Diaphragm stretching generates a significant improvement in cervical extension, right and left cervical flexion, flexibility of the posterior chain, and ribcage excursion at xiphoid level compared to a placebo technique in healthy adults.
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http://dx.doi.org/10.1590/bjpt-rbf.2014.0169 1
Braz J Phys Ther.      
Effects of diaphragm stretching on posterior chain
muscle kinematics and rib cage and abdominal
excursion: a randomized controlled trial
Francisco J. González-Álvarez1, Marie C. Valenza1,
Irene Torres-Sánchez1, Irene Cabrera-Martos1,
Janet Rodríguez-Torres1, Yolanda Castellote-Caballero1
ABSTRACT | Background: Few studies have explored the effects of stretching techniques on diaphragm and spine
kinematics. Objective: To determine whether the application of diaphragm stretching resulted in changes in posterior
chain muscle kinematics and ribcage and abdominal excursion in healthy subjects. Method: Eighty healthy adults were
included in this randomized clinical trial. Participants were randomized into two groups: the experimental group, which
received a diaphragmatic stretching technique, or the placebo group, which received a sham-ultrasound procedure.
The duration of the technique, the position of participants, and the therapist who applied the technique were the same
for both treatments. Participant assessment (cervical range of movement, lumbar exibility, exibility of the posterior
chain, and rib cage and abdominal excursion) was performed at baseline and immediately after the intervention by a
blinded assessor. Results: The mean between-group difference [95% CI] for the ribcage excursion after technique at
xiphoid level was 2.48 [0.97 to 3.99], which shows signicant differences in this outcome. The remaining between-group
analysis showed signicant differences in cervical extension, right and left exion, exibility of the posterior chain,
and ribcage excursion at xiphoid level (p<0.05) in favor of the experimental group. Conclusion: Diaphragm stretching
generates a signicant improvement in cervical extension, right and left cervical exion, exibility of the posterior chain,
and ribcage excursion at xiphoid level compared to a placebo technique in healthy adults.
Keywords: muscle stretching exercises; diaphragm; movement; physical therapy.
Clinical Trials Identier: NCT01753726.
BULLET POINTS
Diaphragmatic stretching improved cervical movement and lumbar exibility.
Diaphragmatic stretching increased exibility of the posterior chain.
After diaphragmatic stretching, ribcage movement increased at xiphoid level.
HOW TO CITE THIS ARTICLE
González-Álvarez FJ, Valenza MC, Torres-Sánchez I, Cabrera-Martos I, Rodríguez-Torres J, Castellote-Caballero Y. Effects
of diaphragm stretching on posterior chain muscle kinematics and rib cage and abdominal excursion: a randomized controlled
trial. Braz J Phys Ther.        http://dx.doi.org/10.1590/bjpt-rbf.2014.0169
1 Department of Physical Therapy, University of Granada, Granada, Spain
Received: May 05, 2015 Revised: Oct. 28, 2015 Accepted: Feb. 23, 2016
Introduction
The dynamic mobility of an articulated chain
is determined by the range of the individual joint
movements and the muscular properties, dening
the range of motion capacity1. Muscular chains
are composed of gravitational muscles that work
synergistically in the maintenance of the standing
position. It has been described that the shortening of
a muscle creates compensation in the adjacent and
also in distant muscles2.
The diaphragm is recognized as the primary muscle
of respiration that plays an important role in breathing
and physiological regulation. It is formed by a central
trefoil-shaped tendon that blends superiorly with the
brous pericardium
3
. The abdominal and thoracic
cavities on which the diaphragm action takes place
are also involved in postural stability and control.
Several studies4,5 have found a relationship between
the activity of the human diaphragm and intercostal
muscles and both respiratory and postural functions.
From a biomechanical point of view, the equilibrium
of the spine is achieved by a local and a global system
of muscle engagement. The stabilizing muscles
with insertion or origin at vertebrae (multidus,
transversus abdominis, diaphragm, internal oblique)
González-Álvarez FJ, Valenza MC, Torres-Sánchez I, Cabrera-Martos I, Rodríguez-Torres J, Castellote-Caballero Y
2Braz J Phys Ther.      
provide intersegmental stability, whereas the longer
trunk muscles (erector spinae, rectus abdominis) are
dedicated to general movement
6
. Hence, the local
system, where the diaphragm plays an important
role, performs an action of stabilization and posture.
Over the last few decades, numerous studies7,8
have been conducted on the effects of stretching
and provided evidence of increased muscle control,
exibility, and range of motion. Although such studies
have traditionally focused on muscles of the lower
extremities and yielded high-quality research, the
biomechanical and structural characteristics of the
diaphragm imply an additional difculty. Techniques
aimed at the diaphragm have been used to increase
movement in the rib cage and the spine9,10.
Some evidence supports11 a relationship between
trunk muscle activity and posterior chain muscle
movement. Different studies
12-14
have used stretching
techniques including diaphragm stretching for spinal
pain relief, improving the posture12, stability13, and
the length of the posterior muscle chain14. However,
few studies have explored the effect of stretching
techniques on diaphragm and spine kinematics. Taking
into account the complex structure of the diaphragm
and its important role in the postural chain
2
, we
were prompted to verify the effects of a diaphragm
technique on posterior chain muscle kinematics and
rib cage and abdominal excursion in healthy subjects.
Method
Participants
This study was completed in the laboratory of the
Faculty of Health Sciences, University of Granada,
Granada, Spain. Asymptomatic volunteers ranging
in age from 18 to 60 years were recruited from the
general population between June 2012 and January
2015. Participants were excluded if they exhibited
history of neck trauma, history of fracture in any
part of the body, herniated disk or lumbar protrusion,
history of back surgery, signicant respiratory or
neurological condition, or regular use of analgesic or
anti-inammatory drugs. Those who were pregnant,
reported experiencing major psychological stress, or had
consumed caffeinated food and/or beverage products
within the previous 24 hours were also excluded.
The randomization sequence was drawn up and
kept off-site by a statistician who was not aware of
the study aims, using a random number generator in
blocks of eight with no stratication. The randomization
schedule was delivered, in a sealed envelope, to a
research assistant who assigned participants to the
groups and organized appointments for the participants
by phone. Each subject signed an informed consent
statement prior to involvement in the study. Approval
for the study was obtained from Ethics Committee of
the University of Granada, Granada, Spain (ID number
DF0037UG) and the procedures conducted in accordance
with the Declaration of Helsinki of 1975. The name
of the public trials registry is www.clinicaltrials.gov
and the registration number NCT01753726.
Outcome measures
The study assessor who collected the outcome
measurements was blinded to the study hypotheses
and group allocation.
Anthropometric measures
All subjects completed the same tests before and
after the intervention. For descriptive purposes,
anthropometric measurements were taken at baseline.
Body mass was measured in kilograms (Kg) to the
nearest 0.1 Kg on a calibrated digital medical scale
(Seca 843, Switzerland). Height was measured in
centimeters (cm) to the nearest 0.5 cm via a standard
wall-mounted stadiometer.
Chain muscle kinematics
Cervical range of motion
A Baseline Bubble Inclinometer (Fabrication
Enterprises Inc., White Plains, NY, USA) was used
to measure the active range of motion of the cervical
spine. The measurements were performed in two
planes of movement, lateral exion (frontal plane)
on the right and left side and exion-extension
(sagittal plane). The subject was seated comfortably
on a chair. The inclinometer was placed on the top
of his/her head, and the subject was asked to move
his/her head as far as possible in each movement.
A comparison of radiographs and inclinometer measures
showed excellent correlations (r<0.9997, P<0.05)15.
The standard values of cervical extension in healthy
subjects of 30-39 years are 36-102 degrees, for left
lateral exion 20-60 degrees and for right lateral
exion 27-62 degrees16.
Schober’s test
Schober’s test is a trunk exion test to evaluate
lumbar exibility. While the subject was in the
standing position, marks were made on the midpoint
Effects of diaphragm stretching on kinematics
3
Braz J Phys Ther.      
between the posterior superior iliac spines and
10 cm above this point. The 10 cm distance was
then compared to the distance between the same two
marks when the subject was in the forward exed
position. Elongation of 5 cm or more between the
two marks during forward exion is considered to
be normal lumbar spine movement17. The validity of
Schober’s test against radiographs was found to be
strong (r=0.90) to moderate (r=0.68). The intraclass
(r=0.96) and interclass (r=0.90) reliability was found
to be excellent18.
Finger-to-floor test
In the nger-to-oor test (FFT), subjects stood on
a stool and exed the trunk forward to reach as far as
possible with both hands, without bending their knees19.
The distance (cm) between the level of the stool and
the middle nger was measured by the therapist. FFT
has high reliability and sensitivity scores19.
Abdominal and rib cage excursion measures
Abdominal and ribcage measurements can be used
as an evaluative method for diaphragmatic breathing
excursion to quantify possible alterations in thoracic
capacity and abdominal and chest wall compliance as
achieved by all expiratory and inspiratory muscles20.
By recording the abdomen and ribcage excursion
with a measuring tape over the second intercostal
space (axillary level), xiphoid process, and midpoint
between the xiphoid process and umbilicus (abdominal
level), competency in diaphragmatic breathing can be
demonstrated by a reduction in ribcage excursion20.
These indirect measurements have an intra-rater
reliability of 0.96-0.98 and an inter-rater reliability
of 0.84-0.87 with correlation coefcients not less
than 0.8420,21.
Experimental procedure
Subjects were randomly allocated by selection of
sealed envelope into one of two groups – an experimental
group or a placebo group. After all the measures were
taken, subjects were led to another room where they
received the diaphragmatic technique or the placebo
intervention. Subjects were then taken back to the
rst room for the post-treatment measures.
The stretching of the diaphragm technique was
executed as described previously by Chaitow et al.
22
.
Each subject was positioned seated erect. The therapist
stood behind the subject and passed his hands around
the thoracic cage, carefully introducing ngers
under the costal margins. The subject rounded the
trunk slightly in order to relax the rectus abdominis
(Figure 1). When the subject exhaled, the therapist
grasped the lower ribs and costal margin and eased
the hands caudally. The stretching was performed
once and the tension was maintained for 5-7 minutes.
In the placebo group, disconnected ultrasound was
applied in the same position for 7 minutes as placebo
treatment. The patients had to be seated erect, and the
ultrasound was applied in the costal margins.
Statistical analysis
Data were initially analyzed with regard to their
statistical distribution using the Shapiro-Wilks W
test. The demographic data and initial assessment
results were compared using the t-test with SPSS
software, version 17.0 (Statistical Package for the
Social Sciences, SPSS Inc., Chicago, IL, USA).
The sample size in the current study was powered
to detect statistical differences between the 2 groups
with 85% power based on a previous pilot study.
The t-test for paired samples was used to compare the
results of the assessment before and after treatment for
parametric data. The Wilcoxon signed rank test was
used to perform the above-mentioned comparisons for
non-parametric data. The independent t-test and the
Mann–Whitney U-test were used to conduct analyses
Figure 1. Diaphragm stretching technique.
González-Álvarez FJ, Valenza MC, Torres-Sánchez I, Cabrera-Martos I, Rodríguez-Torres J, Castellote-Caballero Y
4Braz J Phys Ther.      
between groups for parametric and non-parametric
data, respectively. The alpha level was set at 0.05.
Results
The ow of participants through the trial is shown
in Figure 2.
Baseline characteristics (Table 1) of both groups
were similar although the stretching group had
comparatively fewer men, 19 (44.18%) vs. 15 (40.54%).
They also had very similar body mass index (BMI)
values (23.26±3.3 vs. 23.02±3.36).
Baseline characteristics between groups in the
primary outcomes are provided in Table 2, with no
signicant differences between groups in any of the
primary variables (p>0.05).
In the diaphragm stretching group, signicant
changes were found between pre- and post-intervention
measurement variables in between-group analysis
(Table 3).
For the control group, signicant differences were
found at abdominal level (p=0.02).
The between-group analysis showed signicant
differences in cervical extension, right and left exion,
exibility of the posterior chain, and ribcage excursion
at xiphoid level (p<0.01).
Discussion
The main purpose of the study was to determine
whether the application of a diaphragm stretching
resulted in changes in posterior chain muscle kinematics
Figure 2. Flow diagram of the progress through the phases of the randomized trial.
Table 1. Baseline characteristics of stretching and control group
participants.
Stretching group
(n=43)
Control group
(n=37)
Sex
n (% males)
19 (44.18) 15 (40.54)
Age (years)
Mean±SD
36.33±15.93 37.4±15.82
Height (cm)
Mean±SD
167±0.83 169±0.99
Weight (kg)
Mean±SD
65.22±12.59 66.5±12.10
BMI (kg/cm2)
Mean±SD
23.26±3.31 23.02±3.36
Smokers n (%) 22 (51.16) 19 (51.35)
Effects of diaphragm stretching on kinematics
5
Braz J Phys Ther.      
and ribcage and abdominal excursion in healthy
subjects. The results supported the hypothesis that a
manual technique improves the variables measured by
Schober’s test and the nger-to-oor test, as well as
cervical mobility and xiphoid level ribcage excursion
immediately after the technique. No signicant
differences were observed in rib cage excursion at
axillary and abdominal level between groups. It is
normal that the highest changes were observed at the
xiphoid level, the nearest to the diaphragm, where
the stretching was performed. Due to the anatomical
access to the diaphragm, an anterior approach was
performed. The biomechanical relationship between the
diaphragm and other structures supports the hypothesis
that a diaphragm technique can have a repercussion
on other distant structures, as previously reported2,14.
Therefore, we have included the variables related to
mobility of the posterior chain in this study.
Table 2. Primary outcomes at baseline.
Stretching
group
(n=43)
Control
group
(n=37)
Cervical range of movement
Flexion (degrees) 46.21±9.36 49.07±6.66
Extension (degrees) 53.14±11.02 55.19±8.02
Right lateral exion
(degrees)
40.35±7.59 41.67±7.07
Left lateral exion
(degrees)
40.51±6.19 43.52±7.05
Schober’s test (cm) 14.52±1.06 14.28±1.08
Finger-to-oor test (cm) 4.66±6.76 3.37±5.24
Rib cage excursion
Axillary level (cm) 3.89±2.50 3.83±1.59
Xiphoid level (cm) 4.30±2.41 4.69±2.08
Abdominal level (cm) 0.10±2.87 –0.74±1.68
Data are expressed as mean±SD.
Table 3. Primary outcomes at baseline and post-technique.
Stretching
group
(n=43)
P-value Control group
(n=37) P-value
Mean between-group
difference
(95% CI)
Between-
groups
p value
Cervical range of movement
Flexion
Pre-technique
Post-technique
46.21±9.31
51.51±7.62 p<0.001**
49.07±6.61
50.00±6.72 0.379 1.51 [–2.06 to 5.09] 0.402
Extension
Pre-technique
Post-technique
53.14±11.0
59.3±9.9 p<0.001**
55.19±8.0
55.00±6.35 0.852 4.3 [0.006 to 8.59] 0.050*
Right lateral exion
Pre-technique
Post-technique
40.35±7.5
44.42±6.51 p<0.001**
41.67±7.01
41.30±5.90 0.646 3.12 [0.01 to 6.23] 0.049*
Left lateral exion
Pre-technique
Post-technique
40.51±6.11
46.98±6.2 p<0.001**
43.52±7.01
43.7±5.20 0.832 3.27 [0.37 to 6.17] 0.028*
Schober’s test
Pre-technique
Post-technique
14.52±1.05
15.01±1.03 p<0.001**
14.27±1.07
14.33±1.10 0.376 0.67 [0.15 to 1.19]
0.011*
Finger-to-oor test
Pre-technique
Post-technique
4.66±6.76
3.37±5.80 0.001**
3.37±5.21
3.33±5.32 0.646 0.039 [–2.72 to 2.8] 0.978
Rib cage excursion
Axillary level
Pre-technique
Post-technique
3.89±2.50
4.27±1.87 0.352
3.83±1.59
3.87±1.43 0.895 0.34 [–0.43 to 1.23] 0.347
Xiphoid level
Pre-technique
Post-technique
4.30±2.40
6.93±3.45 p<0.001**
4.69±2.08
4.44±2.36 0.582 2.48 [0.97 to 3.99] 0.002*
Abdominal level
Pre-technique
Post-technique
0.10±2.87
–0.12±2.57 0.885
–0.74±1.68
0.741±1.66 0.020* -0.75 [-1.86 to 0.35] 0.181
Data are expressed as the mean±SD. *Signicant differences p<0.05. **Signicant differences p≤0.001.
González-Álvarez FJ, Valenza MC, Torres-Sánchez I, Cabrera-Martos I, Rodríguez-Torres J, Castellote-Caballero Y
6Braz J Phys Ther.      
The control group showed signicant changes in
abdominal excursion, which can be explained by the
relaxing posture adopted.
The sample of subjects included in the groups
was representative of a generally homogeneous
adult population (similar percentage of smokers, age
range, and BMI values). This homogeneity reduced
the probability of obtaining confounding factors that
might affect the value of our results.
Muscular chain contractions can cause changes in
the range of motion in other distant structures/muscles,
because muscles work synergistically in the same
chain2. It has been suggested that the shortening of a
muscle creates compensation in adjacent and also in
distant muscles2. From an anatomical viewpoint, the
diaphragm is a muscle with a central trefoil-shaped
tendon that blends superiorly with the fibrous
pericardium. The origins of the diaphragm are placed
in the crura from the bodies of the lumbar vertebrae,
the arcuate ligaments, the costal margins, and the
xiphoid23. Therefore, the biomechanical relationship
between the diaphragm and other structures support
the hypothesis that diaphragm stretching can have a
repercussion on other distant structures2, improving
the exibility of the posterior chain muscle and spine
structure mobility.
Our ndings are consistent with those previously
reported by other authors22,24 who have explored the
use of different techniques of manual therapy as an
option to increase the mobility of the spine in healthy
subjects. Saíz-Llamosas et al.24 suggested that using
a cervical myofascial induction technique increases
cervical exion, extension, and left lateral-exion.
Among the various types of manual therapy,
stretching techniques have been used in several studies
on the effects of stretching and evidenced increased
muscle control, exibility, and range of motion8,25.
Additionally, stretching techniques have been suggested
to be efcient in promoting respiratory variables such
as maximal respiratory pressures, thoracic expansion,
and abdominal mobility
26
. An interesting nding of our
study is that diaphragm stretching improves cervical
motion. Similarly, Kasunich
27
found that an abnormal
functioning of supporting distal structures can induce
biomechanical disturbances in proximal areas.
The analysis of pre-to-post stretching values provided
important data on posterior chain muscle kinematic
changes after diaphragm stretching. From a therapeutic
approach, diaphragm stretching can be used as an
effective therapeutic tool with an immediate response.
The results obtained are important in a therapeutic
context because it is evidenced that obtaining and
maintaining range of motion is very important and a
key factor in injury prevention.
Some limitations need to be mentioned, such as the
absence of follow-up in order to determine how long
the changes in kinematics were maintained and the
application in healthy subjects. Due to the anatomical
access to the diaphragm, an anterior approach was
performed and only the costal portion of the diaphragm
was lengthened, but our results have shown that there
is a positive effect in the main outcome measures.
The short length of the therapeutic session (5-7 minutes)
could be one of the limitations of this study. However,
previous studies2,14 have investigated the immediate
effects of manual techniques with benecial results.
Diaphragm stretching is a safe and well-tolerated
technique with an immediate signicant effect. Further
studies are needed to evaluate the applicability of this
technique in symptomatic populations. This research
could be used in other case scenarios and future research,
not only to prevent injury. Diaphragm stretching
could also be added to traditional interventions in
the treatment of whiplash, which can affect cervical,
thoracic, and lumbar regions as well and the rib cage.
Conclusions
Diaphragm stretching generated a signicant
improvement in posterior chain muscle kinematics
measured by Schober’s test, the nger-to-oor test,
cervical range of motion, and ribcage excursion at xiphoid
level immediately after the technique. In contrast, the
placebo technique showed no pre- or post-technique
differences in any of the measures. The between-group
analysis showed signicant differences in cervical
right and left exion, exibility of the posterior chain,
and ribcage excursion at xiphoid level.
References
1. Hodges PW, Gurfinkel VS, Brumagne S, Smith TC, Cordo
PC
. Coexistence of stability and mobility in postural control:
evidence from postural compensation of respiration. Exp
Brain Res. 2002;144(3):293-302. http://dx.doi.org/10.1007/
s00221-002-1040-x. PMid:12021811.
2
.
Hamaoui
A
,
Le Bozec
S
,
Poupard
L
,
Bouisset
S
. Does postural
chain muscular stiffness reduce postural steadiness in a
sitting posture? Gait Posture. 2007;25(2):199-204. http://
dx.doi.org/10.1016/j.gaitpost.2006.03.012. PMid:16697201.
3. Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner
CL, Godwin JD. Imaging of the diaphragm: anatomy and
function. Radiographics. 2012;32(2):E51-70. http://dx.doi.
org/10.1148/rg.322115127. PMid:22411950.
Effects of diaphragm stretching on kinematics
7
Braz J Phys Ther.      
4. Hodges PW, Gandevia SC. Changes in intra-abdominal
pressure during postural and respiratory activation of
the human diaphragm. J Appl Physiol. 2000;89(3):967-76.
PMid:10956340.
5. De Troyer A, Kirkwood PA , Wilson TA. Respiratory action
of th intercostal muscles. Physiol Rev. 2005;85(2):717-56.
http://dx.doi.org/10.1152/physrev.00007.2004. PMid:15788709.
6. Granata KP, Wilson SE. Trunk posture and spinal stability.
Clin Biomech. 2001;16(8):650-9. http://dx.doi.org/10.1016/
S0268-0033(01)00064-X. PMid:11535346.
7. Wicke J, Gainey K, Figueroa M. A comparison of self-
administered proprioceptive neuromuscular facilitation to
static stretching on range of motion and flexibility.
J Strength
Cond Res
.
2014
;
28
(
1
):
168
-
72
.
http://dx.doi.org/10.1519/
JSC.0b013e3182956432. PMid:23588485.
8. Young W, Clothier P, Otago L, Bruce L, Liddell D. Acute
effects of static stretching on hip flexor and quadriceps
flexibility, range of motion and foot speed in kicking a
football.
J Sci Med Sport
.
2004
;
7
(
1
):
23
-
31
.
http://dx.doi.
org/10.1016/S1440-2440(04)80040-9. PMid:15139161.
9. Noll DR, Degenhardt BF, Johnson JC, Buró SA. Immediate
effects of osteopathic manipulative treatment in elderly
patients with chronic obstructive pulmonary disease. J Am
Optom Assoc. 2008;108(5):251-9. PMid:18519835.
10. Noll DR, Degenhardt BF, Johnson JC, Burt SA. The immediate
effect of individual manipulation techniques on pulmonary
function measures in persons with COPD. Osteopath Med
Prim Care. 2009;3(1):9. http://dx.doi.org/10.1186/1750-4732-
3-9. PMid:19814829.
11
.
Souchard
P-E
,
Meli
O
,
Sgamma
D
,
Pillastrini
P
.
Rieducazione
postural globale
.
Paris
:
Elsevier Masson SAS
;
2009
.
Medicina
Riabilitativa, 26-061-A-15.
12
.
Cunha
AC
,
Burke
TN
,
França
FJ
,
Marques
AP
. Effect of global
posture reeducation and of static stretching on pain, range
of motion, and quality of life in women with chronic neck
pain: a randomized clinical trial. Clinics. 2008;63(6):763-
70
.
http://dx.doi.org/10.1590/S1807-59322008000600010
.
PMid:19060998.
13. Fernandez-de-Las-Peñas C, Alonso-Blanco C, Alguacil-Diego
IM
,
Miangolarra-Page
JC
. One-year follow-up of two exercise
interventions for the management of patients with ankylosing
spondylitis: a randomized controlled trial. Am J Phys Med
Rehabil
.
2006
;
85
(
7
):
559
-
67
.
http://dx.doi.org/10.1097/01.
phm.0000223358.25983.df. PMid:16788386.
14
.
Valenza
MC
,
Cabrera-Martos
I
,
Torres-Sánchez
I
,
Garcés-García
A
,
Mateos-Toset
S
,
Valenza-Demet
G
. The Immediate Effects
of Doming of the Diaphragm Technique in Subjects With
Short Hamstring Syndrome: A Randomized Controlled
Trial.
J Sport Rehabil
.
2015
.
In press
.
http://dx.doi.org/10.1123/
JSR.2014-0190.
15. Mayer T, Brady S, Bovasso E, Pope P, Gatchel RJ. Noninvasive
measurement of cervical tri-planar motion in normal subjects.
Spine (Phila Pa 1976).
1993
;
18
(
15
):
2191
-
5
.
http://dx.doi.
org/10.1097/00007632-199311000-00007. PMid:8278830.
16
.
Youdas
JW
,
Garrett
TR
,
Suman
VJ
,
Bogard
CL
,
Hallman
HO
,
Carey JR. Normal range of motion of the cervical spine: an
initial goniometric study. Phys Ther. 1992;72(11):770-80.
PMid:1409874.
17. Macedo CSG, Souza PR, Alves PM, Cardoso JR. Study of
validity and intra and interobserver reliability of the modified
version of Schöber test modified in individuals with low
back pain. Fisioter Pesqui. 2009;16(3):233-8.
18. Rahali-Khachlouf H, Poiraudeau S, Fermanian J, Ben Salah
FZ
,
Dziri
C
,
Revel
M
. Validité et reproductibilité des mesures
cliniques rachidiennes dans la spondylarthrite ankylosante.
Ann Readapt Med Phys
.
2001
;
44
(
4
):
205
-
12
.
http://dx.doi.
org/10.1016/S0168-6054(01)00091-5. PMid:11587665.
19. Perret C, Poiraudeau S, Fermanian J, Colau MM, Benhamou
MA, Revel M. Validity, reliability, and responsiveness
of the fingertip-to-floor test.
Arch Phys Med Rehabil
.
2001
;
82
(
11
):
1566
-
70
.
http://dx.doi.org/10.1053/apmr.2001.26064
.
PMid:11689977.
20. Cahalin LP, Braga M, Matsuo Y, Hernandez ED. Efficacy of
diaphragmatic breathing in persons with chronic obstructive
pulmonary disease: a review of the literature.
J Cardiopulm
Rehabil. 2002;22(1):7-21. http://dx.doi.org/10.1097/00008483-
200201000-00002. PMid:11839992.
21
.
Derom
E
,
Marchand
E
,
Troosters
T
. Pulmonary rehabilitation
in chronic obstructive pulmonary disease.
Ann Readapt Med
Phys. 2007;50(7):615-26, 602-14. http://dx.doi.org/10.1016/j.
annrmp.2007.04.022. PMid:17559963.
22
.
Chaitow
L
,
Bradley
D
,
Gilbert
C
.
Patterns of breathing
dysfunction in hyperventilation syndrome and breathing pattern
disorders
. In:
Chaitow
L
,
Bradley
D
,
Gilbert
C
. Multidisciplinary
approaches to breathing pattern disorders.
London
:
Churchill
Livingstone; 2002. p. 51-86.
23. Downey R. Anatomy of the normal diaphragm. Thorac
Surg Clin. 2011;21(2):273-9, ix. http://dx.doi.org/10.1016/j.
thorsurg.2011.01.001. PMid:21477776.
24. Saíz-Llamosas JR, Fernández-Pérez AM, Fajardo-Rodríguez
MF, Pilat A, Valenza-Demet G, Fernández-de-Las-Peñas C.
Changes in Neck Mobility and Pressure Pain Threshold
Levels Following a Cervical Myofascial Induction Technique
in Pain-Free Healthy Subjects. J Manipulative Physiol Ther.
2009
;
32
(
5
):
352
-
7
.
http://dx.doi.org/10.1016/j.jmpt.2009.04.009
.
PMid:19539117.
25. Batista LH, Vilar AC, Ferreira JJA, Rebelatto JR, Salvini
TF
. Active stretching improves flexibility, joint torque,
and functional mobility in older women. Am J Phys Med
Rehabil
.
2009
;
88
(
10
):
815
-
22
.
http://dx.doi.org/10.1097/
PHM.0b013e3181b72149. PMid:21119314.
26. Moreno MA, Catai AM, Teodori RM, Borges BL, Cesar MC,
Silva E. Effect of a muscle stretching program using the
Global Postural Reeducation method on respiratory muscle
strength and thoracoabdominal mobility of sedentary young
males. J Bras Pneumol. 2007;33(6):679-86. http://dx.doi.
org/10.1590/S1806-37132007000600011. PMid:18200368.
27. Kasunich NJ. Changes in low back pain in a long distance
runner after stretching the iliotibial band. J Chiropr Med.
2003
;
2
(
1
):
37
-
40
.
http://dx.doi.org/10.1016/S0899-3467(07)60071-
8. PMid:19674593.
Correspondence
Marie Carmen Valenza
University of Granada
Department of Physical Therapy
Avda. de la Ilustración, 18016
Granada, Spain
e-mail: cvalenza@ugr.es
... Se tiene la hipótesis que la técnica de liberación manual del diafragma provee de una mayor flexibilidad de los músculos respiratorios y en la cavidad torácica, además de un incremento en la relación longitud tensión, lo cual permite un efecto positivo en el desarrollo de la mecánica respiratoria (159). Las técnicas de liberación diafragmática son ampliamente conocidas y usadas en la práctica clínica, y no han sido evidenciados ningún tipo de contraindicaciones o de efectos secundarios (160,161). ...
... Desde un punto de vista terapéutico, la terapia manual del diafragma puede ser usada como una herramienta clínica efectiva con una respuesta inmediata (160), mejorando la viscoelasticidad muscular y consecuentemente reduciendo la rigidez muscular e incrementando la movilidad torácica (162)(163)(164)(165). Ha obtenido beneficios en ganancia de movilidad espinal (151,160,166) y de la cadena muscular posterior (160,166). Se ha demostrado su beneficio a nivel respiratorio mejorando la función pulmonar de pacientes con EPOC (167), aumentando la movilidad diafragmática en esta misma patología (161), incrementando significativamente la capacidad vital forzada (FVC), el volumen espirado máximo en el primer segundo de la espiración forzada (FEV1) y la capacidad funcional (FC) (168), y consiguiendo una mejora en la presión espiratoria máxima (169). ...
... Desde un punto de vista terapéutico, la terapia manual del diafragma puede ser usada como una herramienta clínica efectiva con una respuesta inmediata (160), mejorando la viscoelasticidad muscular y consecuentemente reduciendo la rigidez muscular e incrementando la movilidad torácica (162)(163)(164)(165). Ha obtenido beneficios en ganancia de movilidad espinal (151,160,166) y de la cadena muscular posterior (160,166). Se ha demostrado su beneficio a nivel respiratorio mejorando la función pulmonar de pacientes con EPOC (167), aumentando la movilidad diafragmática en esta misma patología (161), incrementando significativamente la capacidad vital forzada (FVC), el volumen espirado máximo en el primer segundo de la espiración forzada (FEV1) y la capacidad funcional (FC) (168), y consiguiendo una mejora en la presión espiratoria máxima (169). ...
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.
... 16 Numerous studies have demonstrated the fundamental role of the diaphragm in stabilizing the trunk 17,18 with a coactivation of the transversus abdominis, coordinating breathing and control of the spine during different postural tasks. 18 Benefits have also been demonstrated in many cases by applying manual therapy on the diaphragm, not only in spinal mobility 19,20 but also in pulmonary parameters, such as improving both ventilatory functions and functional capacity in patients with chronic obstructive pulmonary disease (COPD) 21 as well as maximal respiratory pressures, forced vital capacity, and forced expiratory volume in the first second in healthy adults. 22 The relationship between the phrenic nerve and shoulder pain has even been demonstrated, analyzing a high incidence of this after visceral surgery, 23 which is up to 97% of the participants who underwent thoracotomy, 24 71.4% who underwent laparoscopy, 25 and 40% of women who underwent cesarean delivery. ...
... 26 These findings make the diaphragm a muscle that could have relevance on the biomechanics and function of many structures to which it is anatomically related, as some studies have shown. 19,27 Muscle stretching and myofascial release are known as manual therapy techniques 28 and have been used to approach the diaphragm in different studies. 19,29 There is limited information on the possible mechanisms of performance of this type of therapies. ...
... 19,27 Muscle stretching and myofascial release are known as manual therapy techniques 28 and have been used to approach the diaphragm in different studies. 19,29 There is limited information on the possible mechanisms of performance of this type of therapies. 30,31 The stretching techniques focus on increasing the length of a musculotendinous unit, in essence increasing the distance between the origin and insertions of the diaphragmatic muscle to reduce the tension generated by the shortening of their fibers and promote greater effectiveness of muscle contraction, 32 and are some of the most frequently studied in the scientific literature. ...
Article
Objectives To analyze the effects at the musculoskeletal level of manual treatment of the diaphragm muscle in adults. Data Sources Systematic review using four databases: PubMed, Science Direct, Web of Science and Scopus. Study selection and data extraction Two independent reviewers applied the selection criteria and assessed the quality of the studies using the Physiotherapy Evidence Database (PEDro) scale for experimental studies. A third reviewer intervened in cases where a consensus had not been reached. A total of 9 studies were included in the review. Results Manual therapy directed to the diaphragm has been shown to be effective in terms of the immediate increase in diaphragmatic mobility and thoracoabdominal expansion. The immediate improvement in the posterior muscle chain flexibility test is another of the most frequently found findings in the evaluated studies. Limited studies show improvements at the lumbar and cervical level in the range of motion and in pain. Conclusion Manual diaphragm therapy has shown an immediate significant effect on parameters related to costal, spinal and posterior muscle chain mobility. Further studies are needed, not only to demonstrate the effectiveness of manual diaphragm therapy in the long term and in symptomatic populations, but also to investigate the specific neurophysiological mechanisms involved in this type of therapy.
... Direct stretching of the diaphragm using a manual diaphragm release (DR) technique promotes improvement in diaphragmatic contraction (16), pulmonary function, dyspnoea, and exercise capacity (17). ...
... Furthermore, because it increases diaphragm excursion, which improves respiratory function, lowers sympathetic excitability (40), and thus reduces dyspnoea (16), DR is thought to be an indirect method of increasing muscular contraction effectiveness. ...
Article
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Objective: To determine whether the addition of manual diaphragm release to an inspiratory muscle training programme is more effective than inspiratory muscle training alone in reducing blood pressure, dyspnoea, fatigue, and aerobic performance capacity in men with post-COVID-19 syndrome. Design: A prospective, randomized-controlled trial. Setting: Chest Disease Department, Outpatient Clinic, Cairo University, Egypt. Participants: Fifty-two men with post-COVID-19 syndrome were allocated randomly to the study and control groups. Intervention: The study group underwent diaphragm release plus inspiratory muscle training, whereas the control group received inspiratory muscle training only. Outcome measures: All patients were assessed with the following measures at baseline and 6 weeks postintervention: maximum static inspiratory pressure for inspiratory muscle strength, peripheral arterial blood pressure, Modified Medical Research Council scale for dyspnoea, Fatigue Severity Scale, serum lactate level, and 6-min walk test distance for aerobic performance. Results: All outcome measures showed a significant improvement in favour of the study group (p < 0.001) over the control group. However, maximum static inspiratory pressure increased significantly, by 48.17% (p < 0.001) in the study group with no significant change in the control group. Conclusion: Addition of manual diaphragm release to an inspiratory muscle training programme potentiates the role of inspiratory muscle training in the management of men with symptomatic post-COVID-19 syndrome.
... Commonly used diaphragm manual treatments for patients with COPD include diaphragm release technique and diaphragm stretching technique. 72,73 Both techniques achieve the distraction or release of the anterior part of the diaphragm during respiration by expanding the diameter of the anterolateral lower edge of the thorax. The aim is to increase thoracic mobility, enhance oxygen transport and lymphatic return, and improve respiratory efficiency while promoting autonomic regulation, vasodilation, and smooth muscle relaxation, thus improving diaphragmatic mobility. ...
... In addition to the effect on diaphragmatic mobility, diaphragmatic stretching provides immediate improvement in pulmonary function and joint mobility in healthy adults. Gonzalez et al 73,75 found that diaphragm stretching improves pulmonary function in healthy adults in a short period. The maximal respiratory pressure, FVC, and FEV1 significantly improve after 5 and 20 min of stretching treatment. ...
Article
Full-text available
Purpose: This review summarizes the characteristics, assessment methods, and targeted rehabilitation therapies of diaphragm dysfunction in patients with chronic obstructive pulmonary disease (COPD). Methods: Extensive literature was searched in PubMed, the Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure Database, Wanfang, and SinoMed. Results: Under the influence of oxidative stress, inflammation, and other factors, the diaphragm function of patients with COPD changes in mobility, muscle strength, thickness, and thickening. In patients with COPD, diaphragm mobility can be assessed using ultrasound, X-ray fluoroscopy, and magnetic resonance imaging. Diaphragmatic strength can be measured by transdiaphragmatic pressure and maximal inspiratory pressure. Diaphragmatic thickness and thickening can be assessed using ultrasound. Rehabilitation therapies targeting the diaphragm include diaphragmatic breathing, diaphragm-related manual therapy, and phrenic nerve electrical stimulation. Diaphragmatic breathing is safe, simple, and not limited by places. Diaphragmatic manual therapies, which require patient cooperation and one-on-one operation by a professional therapist, are effective. Phrenic nerve electrical stimulation is suitable for patients with severe conditions. These therapies improve the diaphragmatic function, lung function, dyspnea, and exercise capacity of patients with COPD. Conclusion: The diaphragmatic function is commonly assessed in terms of mobility, strength, thickness, and thickening. Diaphragmatic targeted rehabilitation therapies have proven to be efficient, which are recommended to be included in the pulmonary rehabilitation strategy for patients with COPD.
... Improved thoracic biomechanics and deep trunk muscle activation has been suggested to enhance posterior back chain muscle mobility. [30][31][32] Thus, the aim of this study is to examine the effects of an HE program on ventilatory parameters, posterior back chain kinematics, and low back pain in professional female basketball players. ...
... Similarly, Marizeiro et al 31 described improved chest wall mobility and improved posterior chain flexibility after applying a diaphragmatic release technique in sedentary women. Both diaphragm release techniques described in these studies 30,31 were similar to the one used during the warmup of our HE intervention. The diaphragm is known to not only play a respiratory function, but also an important role in spinal stabilization. ...
Article
Context: Hypopressive exercise (HE) has been used as an alternative lumbo-pelvic injury prevention program and claimed to be a means of respiratory and flexibility improvement. However, the possible effects of HE on athletic populations and physical performance remain unclear. Objective: Examine the effects of a HE program on posterior back chain kinematics, thoracic mobility, pulmonary function, and lower lumbar pain in female basketball players over an 8-week training period. Design: Prospective (1) baseline, (2) midpoint (4 wk), and (3) after 8 weeks. Setting: Sports field. Participants: A total of 17 professional female basketball players (mean age 20.7 y, SD: 3.50; body mass index, 21.71, SD: 1.69). Intervention: Participants performed 8 HE weekly sessions of 30 minutes. Main outcome measures: Back chain kinematics was assessed with the sit and reach and finger to floor test, and back pain was assessed through numerical rating scale. Respiratory parameters were assessed by spirometry and through thoracic mobility. Results: The analysis of variance revealed significant differences between the 3 measurement periods for thoracic mobility (P > .01); forced expiratory volume in the first second (P < .05) while no statistical differences were found for the rest of spirometry outcomes. Significant differences were also revealed between baseline and after the intervention for the sit and reach test (P > .01), peak expiratory flow (P = .01), and forced expiratory volume in the first 25 seconds (P = .04). Also, significant differences between weeks were found in levels of lumbar pain (P = .003) and the finger to floor test (P = .002). Conclusions: These preliminary findings suggest that a HE program can improve posterior back chain and chest wall kinematics as well as lower lumbar pain levels. However, no gains seem to be observed for the majority of pulmonary variables except for peak expiratory flow and forced expiratory volume in the first seconds.
... Um objetivo comum é melhorar a mobilidade das estruturas torácicas relacionadas à mecânica da respiração. A manipulação miofascial é uma intervenção destinada a reduzir a tensão muscular através do alongamento indireto das fibras musculares diafragmáticas para, normalizar a relação de comprimento e tensão da fibra e promover uma maior eficiência da contração muscular e consequentemente melhora da biomecânica (González-Álvarez, et al., 2016). Lim (2020) investigou os efeitos da mobilização articular, exercícios com bola de ginástica e exercícios respiratórios sobre as alterações biomecânicas, padrões respiratórios, e senso de posição articular em pessoas com dor lombar crônica. ...
Article
Full-text available
Objetivo: O objetivo da presente pesquisa é identificar as diferentes intervenções, utilizando como base a abordagem manual ou exercícios direcionados sobre o músculo diafragma, bem como sua eficácia, em pacientes com dor lombar inespecífica. Metodologia: O presente estudo trata-se de uma revisão bibliográfica. A revisão foi baseada em artigos indexados nas bases de dados Scielo, PubMed e PEDro, na qual utilizou-se as palavras-chave: Dor lombar; Exercício; Terapia Manual; Diafragma; Dor e seus respectivos em inglês: Low back pain; Exercise; Manual Therapy; Diaphragm; Pain. Como critérios de inclusão foram definidos apenas ensaios clínicos randomizados controlados, em inglês ou português, com amostras constituídas por adultos, com dores crônicas lombares e que apresentavam exercício ou terapia manual como uma das intervenções. Resultados: Após o levantamento bibliográfico inicial, foram encontrados 12 artigos no total. Após análise 05 artigos do tipo randomizados foram incluídos na amostra do estudo. Conclusão: As principais intervenções como terapia manual, exercício físico e treino respiratório aumentaram a capacidade respiratória e ventilatória, reduziram a dor, aumentou a mobilidade lombar, a estabilidade e melhoraram a qualidade de vida dos pacientes.
Article
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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 purpose of this case study was to present the effectiveness of physiotherapeutic treatment based on manual orthopedic techniques in an amateur athlete with costochondritis due to physical strenuous exercise. A 31 years old experienced, well-trained, endurance amateur athlete presented chest pain suggesting costochondritis after physical and kinetic examination. Patient reported to present pain after physical effort in the last two weeks (combination of mountain biking, route cycling, running, swimming and yoga). Manual therapy including techniques as resonant oscillation mobilization of the thoracic region, Lewit ́s post-isometric relaxation and sliding of the right humeral head, cervico-thoracic high speed technique mobilization, active-assisted mobilization of 7th to 10th ribs during expiratory phase, superficial myofascial induction in lower costal area and, muscle power technique, is effective to relieve pain increase mobility of cervical rotation, increase mobility of glenohumeral joint (e.g., internal rotation), in an amateur athlete with costochondritis due to physical strenuous exercise.Keywords: chest pain, manual therapy, physical endurance, acute injury
Article
Background Respiratory failure resulting from diaphragmatic muscle weakness is a major cause of long-term hospitalization in children with cerebral palsy (CP). Manual diaphragmatic stretching technique (MDST) can be directly applied to stretch diaphragmatic muscle and has been reported to improve respiratory function in patients with asthma and COPD. However, there have been no studies among CP. This study aimed to examine the effects of a six-week MDST course on respiratory function among CP. Methods Fifty-three children with spastic CP were randomly assigned to experimental (n=27) and control (n=26) groups. The experimental group received MDST on non-consecutive days, three days per week for six weeks alongside standard physiotherapy (SDPT), while the control group received only SDPT. The outcome variables were diaphragmatic mobility, pulmonary function and chest wall expansion. Results MDST significantly improved diaphragmatic mobility on both sides of the body, with a between-group difference of 0.97cm (95% CI 0.55 to 1.39cm, p<0.001) for the right side and 0.82cm (95% CI 0.35 to 1.29cm, p=0.001) for the left side. MDST significantly improved chest wall expansion at the xiphoid process and umbilical levels, with between-group differences of 0.57cm (95% CI 0.12 to 1.20cm, p=0.013) and 0.87cm (95% CI 0.31 to 1.43cm, p=0.003), respectively. There was no significant difference in pulmonary function testing between the groups. Conclusion MDST could significantly improve diaphragmatic mobility, and lower and abdominal chest wall expansion, among children with CP. Therefore, MDST could be considered as an additional technique for physiotherapy programmes, to improve diaphragmatic function in spastic CP.
Article
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Taken into account the complex structure of the diaphragm and its important role in the postural chain, we were prompted to check the effects of a diaphragm technique on hamstring flexibility. The aim of this study was to evaluate the effects of the doming of the diaphragm technique on hamstrings flexibility and spine mobility. Randomized placebo controlled trial. University laboratory. Sixty young adults with short hamstring syndrome were included in this randomized clinical trial using a between-group design. The sample was randomly allocated to a placebo group (n = 30) or to an intervention group (n = 30). Duration, position, and the therapist were the same for both treatments. Hamstring flexibility was assessed using the forward flexion distance and the popliteal angle tests. The spinal motion was evaluated using the Modified Schober's test and the cervical range of movement. Two-way ANOVA afforded pre-to-post intervention statistically significant differences (p<0.001) in the intervention group compared to the placebo group for hamstrings flexibility measured by the forward flexion distance (mean change 4.59±5.66 intervention group vs 0.71±2.41 placebo group) and the popliteal angle tests (mean change intervention group 6.81± 8.52 vs. placebo group 0.57± 4.41). Significant differences (p<0.05) were also found in the modified Schober test (mean change intervention group -1.34±3.95 vs. placebo group 1.02±3.05) and the cervical range of movement. Significant between-groups differences (p<0.05) were also found in all the variables measured. The doming of the diaphragm technique provides a sustained improvement on hamstrings flexibility and spine mobility. Key words: clinical trial, kinesiology, physical-therapy, posture.
Article
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Osteopathic manipulative treatment (OMT) has long been advocated for patients with respiratory disorders, but little definitive evidence exists to support its use in this population. To investigate the immediate effect of OMT on pulmonary function parameters in elderly subjects with chronic obstructive pulmonary disease. Subjects aged 65 years or older with a forced expiratory volume in 1 second to forced vital capacity ratio of less than 70% were recruited and randomly assigned to receive either OMT or sham therapy. The OMT protocol consisted of seven standardized osteopathic manipulative techniques, while the sham therapy protocol comprised light touch applied to the same anatomic regions and for the same duration (20 min). All subjects received baseline and posttreatment pulmonary function testing. A telephone survey was conducted 1 day after the intervention to collect subjective feedback and assess the success of blinding protocols. Of the 35 study participants, 18 were randomly assigned to the OMT group and 17 to the sham group. Compared with the sham group, the OMT group showed a statistically significant decrease in the forced expiratory flow at 25% and 50% of vital capacity and at the midexpiratory phase; the expiratory reserve volume; and airway resistance. The OMT group also had a statistically significant increase in the residual volume, total lung capacity, and the ratio of those values compared with the sham group. Most subjects (82%, OMT group; 65%, sham group) reported breathing better after receiving their treatment. Only 53% of subjects in the OMT group and 41% in the sham group correctly guessed their group assignment. Results suggest an overall worsening of air trapping during the 30 minutes immediately following one multitechnique OMT session relative to the sham group.
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