Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment

A Secondary Analysis of Gender Respiratory Features for Ultrasonography Bilateral Diaphragm Thickness, Respiratory Pressures, and Pulmonary Function in Low Back Pain

The aim of the present study was to determine the gender respiratory differences of bilateral diaphragm thickness, respiratory pressures, and pulmonary function in patients with low back pain (LBP). A sample of 90 participants with nonspecific LBP was recruited and matched paired by sex (45 women and 45 men). Respiratory outcomes included bilateral diaphragm thickness by ultrasonography, respiratory muscle strength by maximum inspiratory (MIP) and expiratory (MEP) pressures, and pulmonary function by forced expiratory volume during 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC spirometry parameters. The comparison of respiratory outcomes presented significant differences (p < 0.001), with a large effect size (d = 1.26-1.58) showing means differences (95% CI) for MIP of -32.26 (-42.99, -21.53) cm H2O, MEP of -50.66 (-64.08, -37.25) cm H2O, FEV1 of -0.92 (-1.18, -0.65) L, and FVC of -1.00 (-1.32, -0.69) L, with lower values for females versus males. Gender-based respiratory differences were presented for maximum respiratory pressures and pulmonary function in patients with nonspecific LBP. Women presented greater inspiratory and expiratory muscle weakness as well as worse lung function, although these differences were not linked to diaphragm thickness during normal breathing.

Auto-segmentation of thoraco-abdominal organs in pediatric dynamic MRI

Purpose

Analysis of the abnormal motion of thoraco-abdominal organs in respiratory disorders such as the Thoracic Insufficiency Syndrome (TIS) and scoliosis such as adolescent idiopathic scoliosis (AIS) or early onset scoliosis (EOS) can lead to better surgical plans. We can use healthy subjects to find out the normal architecture and motion of a rib cage and associated organs and attempt to modify the patient's deformed anatomy to match to it. Dynamic magnetic resonance imaging (dMRI) is a practical and preferred imaging modality for capturing dynamic images of healthy pediatric subjects. In this paper, we propose an auto-segmentation set-up for the lungs, kidneys, liver, spleen, and thoraco-abdominal skin in these dMRI images which have their own challenges such as poor contrast, image non-standardness, and similarity in texture amongst gas, bone, and connective tissue at several inter-object interfaces.

Methods

The segmentation set-up has been implemented in two steps: recognition and delineation using two deep neural network (DL) architectures (say DL-R and DL-D) for the recognition step and delineation step, respectively. The encoder-decoder framework in DL-D utilizes features at four different resolution levels to counter the challenges involved in the segmentation. We have evaluated on dMRI sagittal acquisitions of 189 (near-)normal subjects. The spatial resolution in all dMRI acquisitions is 1.46 mm in a sagittal slice and 6.00 mm between sagittal slices. We utilized images of 89 (10) subjects at end inspiration for training (validation). For testing we experimented with three scenarios: utilizing (1) the images of 90 (=189-89-10) different (remaining) subjects at end inspiration for testing, (2) the images of the aforementioned 90 subjects at end expiration for testing, and (3) the images of the aforesaid 99 (=89+10) subjects but at end expiration for testing. In some situations, we can take advantage of already available ground truth (GT) of a subject at a particular respiratory phase to automatically segment the object in the image of the same subject at a different respiratory phase and then refining the segmentation to create the final GT. We anticipate that this process of creating GT would require minimal post hoc correction. In this spirit, we conducted separate experiments where we assume to have the ground truth of the test subjects at end expiration for scenario (1), end inspiration for (2), and end inspiration for (3).

Results

Amongst these three scenarios of testing, for the DL-R, we achieve a best average location error (LE) of about 1 voxel for the lungs, kidneys, and spleen and 1.5 voxels for the liver and the thoraco- abdominal skin. The standard deviation (SD) of LE is about 1 or 2 voxels. For the delineation approach, we achieve an average Dice coefficient (DC) of about 0.92 to 0.94 for the lungs, 0.82 for the kidneys, 0.90 for the liver, 0.81 for the spleen, and 0.93 for the thoraco-abdominal skin. The SD of DC is lower for the lungs, liver, and the thoraco-abdominal skin, and slightly higher for the spleen and kidneys.

Conclusions

Motivated by applications in surgical planning for disorders such as TIS, AIS, and EOS, we have shown an auto-segmentation system for thoraco-abdominal organs in dMRI acquisitions. This proposed setup copes with the challenges posed by low resolution, motion blur, inadequate contrast, and image intensity non-standardness quite well. We are in the process of testing its effectiveness on TIS patient dMRI data.

Bi-parametric MRI of the Diaphragm Using Dynamic and Static Images: The Initial Experience

BACKGROUND

With recent technological advances, magnetic resonance imaging (MRI) has offered new sequences that can evaluate the real-time motion of anatomic structures. This study aims to evaluate the interobserver agreement in the diagnosis of diaphragmatic dysfunctions using bi-parametric MRI, in which dynamic sequences for diaphragm movement and static sequences for soft tissue resolution are used together to provide a visualization of the diaphragm.

METHODOLOGY

Twenty-nine cases that underwent a bi-parametric magnetic resonance examination which includes coronal T2 single-shot turbo spin echo and the coronal SENSE single-shot balanced turbo field echo real-time sequences were retrospectively evaluated. The images of the patients were assessed by two independent observers. Cohen's kappa coefficient was calculated to evaluate the interobserver agreement.

RESULTS

The mean age of the patients was 44.86 ± 17.57, ranging from 18 to 80 years. The kappa value was calculated as 0.889, indicating a strong agreement between the interobservers.

CONCLUSIONS

Our experience suggests that bi-parametric MRI is a promising tool in the evaluation of diaphragmatic abnormalities.

Associations between respiratory function, balance, postural control, and fatigue in persons with multiple sclerosis: an observational study

Introduction

Fatigue, postural control impairments, and reduced respiratory capacities are common symptoms in persons diagnosed with Multiple Sclerosis (MS). However, there is a paucity of evidence establishing correlations among these factors. The aim of this study is to analyze respiratory function in persons with MS compared to the control group as well as to analyze the relationship between fatigue, respiratory function and postural control in persons with MS.

Materials and methods

A total of 17 persons with MS and 17 healthy individuals were enrolled for this cross-sectional study. The evaluated parameters included fatigue assessed using the Visual Analog Scale-fatigue (VAS-F) and the Borg Dyspnea Scale, postural control assessed through the Mini Balance Evaluation System Test (Mini-BESTest), Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Trunk Impairment Scale (TIS); and respiratory capacities measured by Maximum Inspiratory Pressure (MIP), Maximum Expiratory Pressure (MEP), Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), FEV1/FVC ratio, Diaphragmatic excursion and diaphragmatic thickness.

Results

A very high correlation was observed between the Borg Dyspnoea Scale and the BBS (r = -0.768), TUG (0.867), and Mini-BESTest (r = -0.775). The VAS-F exhibited an almost perfect correlation solely with the TUG (0.927). However, none of the variables related to fatigue exhibited any correlation with the respiratory variables under study. Balance-related variables such as BBS and Mini-BESTest demonstrated a very high and high correlation. Respectively, with respiratory function variables MEP (r = 0.783; r = 0.686), FVC (r = 0.709; r = 0.596), FEV1 (r = 0.615; r = 0.518). BBS exhibited a high correlation with diaphragmatic excursion (r = 0.591). Statistically significant differences were noted between the persons with MS group and the control group in all respiratory and ultrasound parameters except for diaphragmatic thickness.

Conclusion

The findings suggest that decreased postural control and balance are associated with both respiratory capacity impairments and the presence of fatigue in persons with MS. However, it is important to note that the alterations in respiratory capacities and fatigue are not mutually related, as indicated by the data obtained in this study. Discrepancies were identified in abdominal wall thickness, diaphragmatic excursion, and respiratory capacities between persons with MS and their healthy counterparts.

Motor Dysfunctions in Fibromyalgia Patients: The Importance of Breathing

The classification of fibromyalgia (FM) is not always immediate and simple, with the time from the first diagnosis, compared to the onset of symptoms, of a few years. Currently, we do not have instrumental or biochemical tests considered as gold standards; the clinician will make a diagnosis of FM based on the patient's medical history and subjective assessment. The symptoms can involve physical, cognitive and psychological disorders, with the presence of pain of different origins and classifications: nociplastic, nociceptive and neuropathic pain. Among the symptoms highlighted, postural disorders and neuromotor uncoordination emerge, whose functional dysfunctions can increase the mortality and morbidity rate. An alteration of the diaphragm muscle could generate such functional motor problems. Considering that the current literature underestimates the importance of breathing in FM, the article aims to highlight the relationship between motor and diaphragmatic difficulties in the patient, soliciting new points of view for the clinical and therapeutic framework.

Nose vs. mouth breathing- acute effect of different breathing regimens on muscular endurance

BACKGROUND

It has been reported that the way we breathe (whether through the nose or mouth) can influence many aspects of our health and to some extent, sport performance. The purpose of this study was to evaluate the acute effects of different breathing regimens on muscular endurance and physiological variables.

METHODS

A randomized experiment to verify the acute effect of different breathing regimens (NN- inhaling and exhaling through the nose; NM- inhaling through the nose, exhaling through the mouth; MM- inhaling and exhaling through the mouth) on the muscular endurance performance was conducted. 107 physically active college students (68 males, 39 females) performed repeated bench press testing protocol (repetitions to failure (RTF) with 60% of body weight for males (BP60), respectively 40% of body weight for females (BP40)) with various breathing regimens (NN, NM, MM) in random order. Heart rate (HR), blood oxygen saturation (SpO2) and perceived exertion by Borg scale (RPE) were measured as well. A short questionnaire, given after the testing protocol and observation during familiarization, was used to detect each subject's normal breathing approach during resistance training.

RESULTS

In both genders, no significant differences in RTF, RPE and SpO2 were found. No individual case of deviation of arterial oxygen saturation outside the physiological norm was recorded. ​​In the male group, significantly lower HR values were found during the NN trials, compared to during the NM (p = 0.033) and MM (p = 0.047) trials with no significant differences in females. The HR differences in the males demonstrated a small effect size (NN < NM, d = 0.32; NN < MM, d = 0.30). Questionnaire results suggest that 80% of our participants use NM breathing, 15% use MM breathing and 5% use NN breathing during resistance training.

CONCLUSION

It seems, that various breathing regimens have none or only minor effect on muscular endurance performance and selected physiological parameters. NN seems to be as efficient as other two regimens, which are mostly used in practice (NM, MM).

Clarifying the relationships between trunk muscle endurance, respiratory muscle strength and static/dynamic postural control in Latin dancers

Sufficient study has not been performed to clarify the role of trunk/respiratory muscles strength/endurance in providing postural control in dancers. The purpose of this study was to identify predictors affecting static/dynamic postural control in Latin dancers and to compare these measurements with non-dancers. The study included 38 (26F; 12 M) Latin dancers and 33 (21F; 11 M) non-dancers. Static/dynamic postural control, trunk muscle endurance, respiratory muscle strength/pulmonary functions, flexibility, and reaction tests were assessed with a force platform system, the McGill battery, spirometer, sit-and-reach test and Nelson-reaction-tests, respectively. Trunk muscle endurance times, respiratory muscle strength, FEV1/FVC, gender, hours of training per week and dancing experience were significant predictors of static/dynamic postural control in dancers (p < 0.05). All the trunk muscle endurance times, reaction tests results, and maximal inspiratory pressure were higher in the dancers compared to the non-dancers (p < 0.05). The limits of stability for forward and backward directions were higher, and anteroposterior sway in normal stability with eyes open was lower in the dancers compared to the non-dancers (p < 0.05). Trunk muscles endurance, respiratory muscle strength, dancing experience, and hours of training per week were positively associated with static/dynamic postural control. These predictors should be taken into consideration to improve postural control in dancers.

Volitional inspiration is mediated by two independent output channels in the primary motor cortex

The diaphragm is a multifunctional muscle that mediates both autonomic and volitional inspiration. It is critically involved in vocalization, postural stability, and expulsive core-trunk functions, such as coughing, hiccups, and vomiting. In macaque monkeys, we used retrograde transneuronal transport of rabies virus injected into the left hemidiaphragm to identify cortical neurons that have multisynaptic connections with phrenic motoneurons. Our research demonstrates that representation of the diaphragm in the primary motor cortex (M1) is split into two spatially separate and independent sites. No cortico-cortical connections are known to exist between these two sites. One site is located dorsal to the arm representation within the central sulcus and the second site is lateral to the arm. The dual representation of the diaphragm warrants a revision to the somatotopic map of M1. The dorsal diaphragm representation overlaps with trunk and axial musculature. It is ideally situated to coordinate with these muscles during volitional inspiration and in producing intra-abdominal pressure gradients. The lateral site overlaps the origin of M1 projections to a laryngeal muscle, the cricothyroid. This observation suggests that the coordinated control of laryngeal muscles and the diaphragm during vocalization may be achieved, in part, by co-localization of their representations in M1. The neural organization of the two diaphragm sites underlies a new perspective for interpreting functional imaging studies of respiration and/or vocalization. Furthermore, our results provide novel evidence supporting the concept that overlapping output channels within M1 are a prerequisite for the formation of muscle synergies underlying fine motor control.

Diaphragm and core stabilization exercises in low back pain: A narrative review

INTRODUCTION

Core stabilization is a vital concept in clinical rehabilitation (including low back pain rehabilitation) and competitive athletic training. The core comprises of a complex network of hip, trunk and neck muscles including the diaphragm.

AIMS

The paper aims to discuss the role of the diaphragm in core stability, summarize current evidence and put forth ideal core training strategies involving the diaphragm.

METHOD

Narrative review RESULTS: The diaphragm has a dual role of respiration and postural control. Evidence suggests that current core stability exercises for low back pain are superior than minimal or no treatment, however, no more beneficial than general exercises and/or manual therapy. There appears to be a higher focus on the transversus abdominis and multifidi muscles and minimal attention to the diaphragm. We propose that any form of core stabilization exercises for low back pain rehabilitation should consider the diaphragm. Core stabilization program could commence with facilitation of normal breathing patterns and progressive systematic restoration of the postural control role of the diaphragm muscle.

CONCLUSION

The role of the diaphragm is often overlooked in both research and practice. Attention to the diaphragm may improve the effectiveness of core stability exercise in low back pain rehabilitation.

The effect of abdominal bracing on respiration during a lifting task: a cross-sectional study

BACKGROUND

Abdominal bracing is a maneuver widely used by rehabilitation specialists and sports trainers to improve spinal stability. This study aimed to investigate how lifting tasks with and without abdominal bracing affect the respiratory function of the diaphragm.

METHODS

M-mode ultrasonographic assessment of diaphragmatic motion combined with spirometry was performed on 31 healthy adults. Participants were asked to breathe continuously whilst lifting a load with spontaneous abdominal muscle contraction (natural loaded breathing) and abdominal bracing (AB loaded breathing).

RESULTS

Pearson's correlations revealed strong correlations between ultrasonography and spirometry measures (p < 0.001) for all types of breathing: tidal breathing (r = 0.709, r2 = 0.503), natural loaded breathing (r = 0.731, r2 = 0.534) and AB loaded breathing (r = 0.795, r2 = 0.632). Using paired-samples t-tests, the natural loaded breathing ultrasonography revealed more caudal diaphragm positions during inspiration (p < 0.001) but not during expiration (p = .101). Spirometry demonstrated lower lung volumes (L) at the end of inspiration and expiration (p < 0.001), with no changes in total lung volume (p = 0.06). The AB loaded breathing ultrasonography revealed more caudal diaphragm positions during inspiration (p = 0.002) but not during expiration (p = 0.05). Spirometry demonstrated lower lung volumes at the end of inspiration (p < 0.001), expiration (p = 0.002), and total lung volumes (p = 0.019).

CONCLUSION

This study demonstrated that abdominal bracing performed during a lifting task reduces lung volume despite an increase in diaphragmatic motion. Diaphragm excursions strongly correlate with lung volumes even under postural loading.

TRIAL REGISTRATION

The study was prospectively registered on 8 April 2021 at ClinicalTrials.gov with identification number NCT04841109.

Effect of Dynamic Neuromuscular Stabilization and Vojta Therapy on Respiratory Complications in Neuromuscular Diseases: A Literature Review

Objective

The purpose of this study was to review the literature on the effect of dynamic neuromuscular stabilization (DNS)/Vojta on respiratory complications of neuromuscular diseases.

Methods

The search strategy was conducted, based on the population, intervention, comparison, and outcome method, in the PubMed, Embase, ISI Web of Knowledge, ProQuest, and Scopus databases from inception to August 2021. The quality assessment of included papers was performed through the Physiotherapy Evidence Database scale. A narrative analysis was performed since a meta-analysis could not be conducted.

Results

A total of 7 papers were chosen for the final assessment. All studies, except 1, evaluated individuals with neurological disease. Three studies evaluated Vojta therapy effects, and 4 studies evaluated DNS effects on respiratory parameters. Although the studies had limitations in their methodology according to the Physiotherapy Evidence Database scale, 4 were identified as level 1 evidence. None of the studies reported any adverse effects of Vojta therapy or DNS on respiratory parameters. However, not enough clinical trials were found to examine the effect of DNS on respiratory disease.

Conclusion

Although the studies were weak in internal and external validity, this review suggests that Vojta therapy and DNS may influence respiratory parameters, such as blood gases, diaphragm movements, and functional respiratory parameters, in patients with neuromuscular diseases.

The effects of dynamic neuromuscular stabilization approach on clinical outcomes in older patients with chronic nonspecific low back pain: a randomized, controlled clinical trial

OBJECTIVE

We aimed to examine the effects of Dynamic Neuromuscular Stabilization (DNS) approach in older patients with chronic non-specific low back pain (CNSLBP).

METHODS

A total of 72 participants with CNSLBP were assigned to either the experimental group (n = 36) or control group (n = 36) in this randomized study. A conventional physiotherapy program was administered to the participants in the control group for 3 days per week for a total of 6 weeks. In addition to the conventional program, DNS exercise protocol was performed for 3 days per week for 6 weeks for the participants in the experimental group. While quality of movements and exercise capacity were our primary outcomes, functional balance and quality of life constituted our secondary outcomes. The participants were assessed both at baseline and post-treatment.

RESULTS

The improvement in a deep squat, in-line lunge, hurdle step, shoulder flexibility, rotary trunk stability, total Functional Movement Screening score, and Timed-up and Go Test score was greater in the experimental group (p<.05). The improvement was similar in both groups in terms of the rest of outcome measures.

DISCUSSION

This study demonstrated the effectiveness of the DNS approach on some functional movement patterns and functional balance performance in older patients with CNSLBP.

Effects of Inspiratory Muscle Warm-Up on Physical Exercise: A Systematic Review

This study aimed to systematically review the literature to examine the effects of inspiratory-muscle warm-up (IMW) on the inspiratory, metabolic, respiratory and performance parameters of a main exercise performed by athletes and healthy and active individuals. Methods: This systematic review included randomized studies in English based on the criteria of the PICOS model. The exclusion criteria adopted were studies that applied inspiratory exercise to: i. promote long-term adaptations through inspiratory training (chronic responses); ii. obtain acute responses to inspiratory load (overload) during and in breaks from physical effort and in an inspiratory-exercise session (acute training effect); iii. evaluate the effects of IMW on participants with cardiorespiratory and/or metabolic disease. Data Sources: PubMed, Embase, MedLine, Scopus, SPORTDiscus and Google Scholar (until 17 January 2023). Results: Thirty-one studies were selected. The performance and respiratory parameters were the most investigated (77% and 74%, respectively). Positive effects of IMW were reported by 88% of the studies that investigated inspiratory parameters and 45% of those that evaluated performance parameters. Conclusions: The analyzed protocols mainly had positive effects on the inspiratory and performance parameters of the physical exercises. These positive effects of IMW are possibly associated with the contractile and biochemical properties of inspiratory muscles.

Relationship between inspiratory muscle strength and balance in women: A cross-sectional study

BACKGROUND

There is scarce evidence on changes at the functional level associated with the respiratory area in women. This study aims to analyse the relationship between inspiratory muscle strength and balance in women.

MATERIAL AND METHODS

In this cross-sectional observational study, the sample consisted of groups according to the results obtained in the balance test. Inspiratory muscle weakness was defined as maximum inspiratory pressure (MIP) ≤ 80% of the predictive value. MIP was carried out using through a mouthpiece, with an electronic manometer. Logistic regression model was used to examine if MIP predicts balance.

RESULTS

159 women participated in the study. Approximately 20% of them achieved balance ≤ 2 seconds and 18% presented MIP≤80%. MIP was associated with the time achieved in the one-leg support test. Subjects with MIP ≤ 80% of the predictive value show 3 times more risk of having a lower performance in the balance test (OR = 3.26).

CONCLUSIONS

Inspiratory muscle weakness is associated with deficient balance in this sample. It shows the need for multidimensional assessment and rehabilitation strategies for patients identified as having MIP weakness and/or balance disorders.

Is There a Correlation between Dental Occlusion, Postural Stability and Selected Gait Parameters in Adults?

Background: There is still an ongoing debate about the role of the craniomandibular system, including occlusal conditions, on postural stability. This study aims to assess the role of antero-posterior malocclusion on postural control and plantar pressure distribution during standing and walking. Methods: 90 healthy volunteers (aged 19 to 35) were qualified for the study. The subjects were assigned to three groups, depending on the occlusion type. Each group (Angle Class I, II and III) consisted of 30 people. The research procedure included a clinical occlusal assessment performed by a dentist. Postural control measurements were carried out using a force platform by measuring plantar pressure distribution during standing (six trials with and without visual control) and walking test conditions. Results: The tendency to shift the CoP forward is demonstrated by Angle Class II subjects and backwards by Class I and III subjects (p < 0.001). Individuals with a malocclusion demonstrated significantly higher selected stabilographic parameters while standing on both feet (with eyes open and closed) and during the single-leg test with eyes open (p < 0.05). The analysis of the dynamic test results showed no significant correlations between Angle Classes and the selected gait parameters. Conclusions: Analyses conducted among individuals with malocclusions showed the impact of occlusion on static postural stability. In order to diagnose and effectively treat malocclusion, a multidisciplinary approach with the participation of dentists and physiotherapy specialists is necessary, with the use of stabilometric and kinematic posture assessments.

Olympic fencer with femoroacetabular impingement syndrome uses active rehabilitation to avoid surgery: A case report

INTRODUCTION

Femoroacetabular impingement (FAI) syndrome is a musculoskeletal condition characterized by hip symptoms. Conservative therapy is indicated prior to surgical intervention. However, no literature has described conservative management of FAI in detail. This report provides a detailed active rehabilitation plan for an elite athlete with FAI to guide future research and clinicians.

CASE PRESENTATION

A 30-year-old male Olympic fencing athlete presented with unilateral hip pain less than 1 year prior to the Olympic Games. Radiographic imaging demonstrated bilateral cam morphology. Hip mobilizations and stretching did not provide a meaningful pain reduction. Cortisone injection was then suggested prior to the Games where surgery was suggested following the Games.

MANAGEMENT AND OUTCOME

Active rehabilitative exercises targeted motor control of the lumbo-pelvic-hip complex, which led to significant pain reduction and full return to sport. Surgical intervention and cortisone injections were deemed unnecessary due to resolution of symptoms.

CONCLUSION

Athletes with FAI syndrome may benefit from specific active rehabilitation exercises. Future clinical trials should explore rehabilitative exercises that address improved motor control to manage individuals with FAI syndrome.

The Importance of the Diaphragm in Neuromotor Function in the Patient with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a constant and chronic narrowing of the respiratory airways, with numerous associated symptoms, not always related to the pathological adaptation of the lungs. Statistical projections show that COPD could become the third leading cause of death globally by 2030, with a significant increase in deaths by 2060. Skeletal muscle dysfunction, including the diaphragm, is one of the causes linked to the increase in mortality and hospitalization. Little emphasis is given by the scientific literature to the importance of the diaphragm towards functional neuromotor pathological expressions. The article reviews the adaptation of the skeletal muscles, with greater attention to the adaptations of the diaphragm, thereby highlighting the non-physiological variations that the main respiratory muscle undergoes and the neuromotor impairment found in COPD. The text could be an important reflection from a clinical and rehabilitation point of view, to direct greater attention to the function and adaptation of the diaphragm muscle.

Abdominal wall tension increases using Dynamic Neuromuscular Stabilization principles in different postural positions

BACKGROUND

Intra-abdominal pressure (IAP) is an important mechanism stabilizing the spine and trunk. IAP regulation depends on the coordination of abdominal muscles, diaphragm and pelvic floor muscles.

OBJECTIVE

To determine the differences in abdominal wall tension (AWT) of various postural positions, first without any correction, then after verbal and manual instructions according to Dynamic Neuromuscular Stabilization (DNS) principles.

METHODS

In a cross-sectional observational study, thirty healthy individuals (mean age = 22.73 ± 1.91 years) were fitted with two Ohmbelt sensors contralaterally above the inguinal ligament and in the upper lumbar triangle. AWT was measured during five postural positions: sitting, supine with legs raised, squat, bear and hang position. First, spontaneous AWT was measured, then again after manual and verbal instructions following DNS principles.

RESULTS

AWT increased significantly with DNS instructions compared to spontaneous activation. Both sensors recorded significant increases (p < .01; Cohen's d = -1.13 to -2.06) in all observed postural situations. The increase in activity occurred simultaneously on both sensors, with no significant differences noted in pressure increases between the sensors. The greatest activation for both sensors occurred in the bear position. Significant increases in activity were identified for both sensors in the supine leg raise position and in the bear position compared to spontaneous activation in sitting (p < .001). There were no statistically significant differences (for both sensors) between women and men in any position.

CONCLUSION

The amount of AWT significantly increases after verbal and manual instructions according to DNS. The greatest abdominal wall activation was achieved in the bear position.

Stabilising function of the human diaphragm in response to involuntary augmented breaths induced with or without lower-limb movements

NEW FINDINGS

What is the central question of this study? Is the stabilising function of the diaphragm altered differentially in response to involuntary augmented breaths induced with or without lower-limb movements? What is the main finding and its importance? At equivalent levels of ventilation, the diaphragm generated higher passive pressure but moved significantly less during incremental cycle ergometry compared with progressive hypercapnia. Diaphragm excursion velocity and power output did not differ between the two tasks. These findings imply that the power output of the diaphragm during stabilising tasks involving the lower limbs may be preserved via coordinated changes in contractile shortening.

ABSTRACT

Activity of key respiratory muscles, such as the diaphragm, must balance the demands of ventilation with the maintenance of stable posture. Our aim was to test whether the stabilising function of the diaphragm would be altered differentially in response to involuntary augmented breaths induced with or without lower-limb movements. Ten healthy volunteers (age 21 (2) years; mean (SD)) performed progressive CO₂ -rebreathe (5% CO₂ , 95% O₂ ) followed 20 min later by incremental cycle exercise (15-30 W/min), both in a semi-recumbent position. Ventilatory indices, intrathoracic pressures and ultrasonographic measures of diaphragm shortening were assessed before, during and after each task. From rest to iso-time, inspiratory tidal volume and minute ventilation increased two- to threefold. At equivalent levels of tidal volume and minute ventilation, mean inspiratory transdiaphragmatic pressure ( P ¯ di ${\bar P_{{\rm{di}}}}$ ) was consistently higher during exercise compared with CO₂ -rebreathe due to larger increases in gastric pressure and the passive component of P ¯ di ${\bar P_{{\rm{di}}}}$ (i.e., mechanical output due to static contractions), and yet diaphragm excursion was consistently lower. This lower excursion during exercise was accompanied by a reduction in excursion time with no difference in the active component of P ¯ di ${\bar P_{{\rm{di}}}}$ . Consequently, the rates of increase in excursion velocity (excursion/time) and power output (active P ¯ di ${\bar P_{{\rm{di}}}}$ × velocity) did not differ between the two tasks. In conclusion, the power output of the human diaphragm during dynamic lower-limb exercise appears to be preserved via coordinated changes in contractile shortening. The findings may have significance in settings where the ventilatory and stabilising functions of the diaphragm must be balanced (e.g., rehabilitation).

Inspiratory Muscle Training and Physical Fitness in Children With Down Syndrome: A Randomized Controlled Trial

OBJECTIVE

To investigate the effect of inspiratory muscle training (IMT) on physical fitness in children with Down syndrome (DS).

DESIGN

Randomized control trial.

SETTING

The study was conducted in a private physical therapy center.

PARTICIPANTS

Forty boys and girls with DS aged between 7 and 10 years were enrolled in this study (N=40). They were randomly and equally divided into 2 groups (A and B).

INTERVENTIONS

All participants received 30 minutes of aerobic exercise training 3 times per week for 12 weeks, whereas group B received an additional 30 minutes of IMT before each aerobic exercise session.

MAIN OUTCOMES MEASURES

Maximal inspiratory pressure (MIP); maximal expiratory pressure (MEP); submaximal aerobic endurance; muscular strength; endurance.

RESULTS

Among the group undergoing IMT, there were significant improvements in MIP, MEP, and submaximal aerobic endurance using the six-minute walk test (6MWT); strength and endurance using the curl-up, dumbbell press, trunk lift, standing long jump, seated push-up, pull-up, and flexed-arm hang; and back saver sit and reach tests (P > 0.05).

CONCLUSIONS

Inspiratory muscle training and aerobic exercise training demonstrated more significant improvements in physical fitness than in those children who received only aerobic exercise training.

Effects of Diaphragmatic Breathing Exercise on Respiratory Functions and Vocal Sustenance in Apparently Healthy Vocalists

BACKGROUND

Effective vocalization is dependent on breathing efficiency. Previous studies have reported the efficacy of Diaphragmatic Breathing Exercise (DBE) on the respiratory muscles and breath control of vocalists. There is a paucity of data on the effects of DBE on their vocal sustenance (VS), which is determined as Maximum Phonation Time (MPT). No known published study has considered physiotherapy as influencing voice dynamics amongst vocalists; evaluated the relationship between respiratory functions (Forced Vital Capacity - FVC, Forced Expiratory Volume in one second - FEV1, FEV1/FVC, and Peak Expiratory Flow - PEF) and VS in apparently healthy vocalists. Moreover, literature on the benefits of DBE to vocalists has not considered explicitly this aspect of vocalization skill, VS.

METHODS

This is a pre-test - post-test experimental study involving a total of 37 participants (17 males and 20 females) selected by purposive and convenience sampling techniques. The subjects were grouped into DBE and control groups. Spirobank MIR spirometer was used to assess the respiratory function of the singers, while a stopwatch and keyboard were used in assessing the MPT. Statistical analysis was done with SPSS version 21.0. Alpha level set at 0.05.

RESULTS

Significant improvement was found in respiratory functions (FVC, FEV1, FEV1/FVC, PEF) of the DBE group when pre- and post-test results were compared. The DBE and control groups differed significantly. Respiratory values correlated significantly with the MPT values (FVC - r[p] - 0.416[0.011]; FEV1 - r[p] - 0.416[0.010]; PEF - r[p] - 0.566[0.000]), except for FEV1/FVC - r(p) - 0.248(0.138). Voice category did not correlate with respiratory parameters or MPT. While male singers showed more changes in respiratory function the female singers showed more improvement in MPT.

CONCLUSION AND RECOMMENDATION

DBE can improve respiration and VS (increased MPT). Therefore, it can be recommended for vocalists, and Physiotherapy can be relevant in trainings to improve vocal dynamics.

Adherence to and impact of home-based high-intensity IMT in people with spinal cord injury: a pilot study

Study design

The pilot study was completed in 5 phases (Control and 4 phases of IMT) incorporating assessments at Baseline 1 (BL1), BL2, Follow-up 1 (F1), F2, F3, and F4.

Objective

To assess the adherence and impact of a daily high-intensity (80% of max) inspiratory muscle training (IMT) home program with once weekly supervision for people with spinal cord injury (SCI).

Setting

Assessments: research institution or zoom. IMT: participant’s home.

Methods

Participants completed daily IMT in IMT Phase 1 and 2, once weekly in IMT Phase 3, self-selected frequency in IMT Phase 4. All phases had one weekly supervised session except IMT Phase 4. Primary outcomes included adherence and a difficulty score [DS (0- not difficult to 10- the most difficult)]. Secondary outcomes included respiratory function and seated balance.

Results

Data from 10 people with chronic SCI (>1 year) (Cervical level of injury: 6, AIS: A-B, injury duration: 10.9 years 95% CI [3.9, 18.1]) were used in the analysis. Participants completed 69% of their training days in IMT Phase 1 and 65% overall reporting an average DS of 7.4 ± 1.4. Only one participant completed training during IMT Phase 4. One participant’s training load was reduced due to suspected overtraining. Maximal inspiratory pressure (MIP), sustained MIP (SMIP), and total power (TP), improved significantly (p < 0.05) from BL2 to F1.

Conclusion

Our data suggest that people with SCI can perform high-intensity IMT at home to improve inspiratory performance. It is strongly recommended that participants be intermittently monitored for adherence and safety.

ClinicalTrials.gov Registration number: NCT04210063.

Postural-respiratory function of the diaphragm assessed by M-mode ultrasonography

OBJECTIVES

The diaphragm changes position and respiratory excursions during postural loading. However, it is unclear how it reacts to lifting a load while breath-holding or breathing with simultaneous voluntary contraction of the abdominal muscles (VCAM). This study analyzed diaphragm motion in healthy individuals during various postural-respiratory situations.

METHODS

31 healthy participants underwent examination of the diaphragm using M-mode ultrasonography, spirometry, and abdominal wall tension (AWT) measurements. All recordings were performed simultaneously during three consecutive scenarios, i.e., 1. Lifting a load without breathing; 2. Lifting a load and breathing naturally; 3. Lifting a load and breathing with simultaneous VCAM.

RESULTS

Using paired-samples t-tests, lifting a load without breathing displaced the diaphragm's expiratory position more caudally (P < .001), with no change noted in the inspiratory position (P = .373). During lifting a load breathing naturally, caudal displacement of the diaphragm's inspiratory position was presented (P < .001), with no change noted in the expiratory position (P = 0.20) compared to tidal breathing. Total diaphragm excursion was greater when loaded (P = .002). Lifting a load and breathing with VCAM demonstrated no significant changes in diaphragm position for inspiration, expiration, or total excursion compared to natural loaded breathing. For all scenarios, AWT measures were greater when lifting a load (P < .001).

CONCLUSION

In healthy individuals, caudal displacement and greater excursions of the diaphragm occurred when lifting a load. The postural function of the diaphragm is independent of its respiratory activity and is not reduced by the increase in AWT.

Pistol Shooting Performance Correlates with Respiratory Muscle Strength and Pulmonary Function in Police Cadets

Breathing patterns play a crucial role in shooting performance; however, little is known about the respiratory muscle strength and pulmonary capacities that control these patterns. The present study aimed to examine the relationship between shooting performance, respiratory muscle strength, and pulmonary function and to determine differences in respiratory capacities according to the shooting performance categories in police cadets. One hundred sixty-seven police cadets were recruited to assess respiratory muscle strength, pulmonary function, and shooting performance in a well-controlled environment. Measurements included maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), slow vital capacity (SVC), maximal voluntary ventilation (MVV), and pistol shooting scores. The shooting score had a moderate positive correlation with MIP (ρ = 0.33) and MEP (ρ = 0.45). FVC (ρ = 0.25), FEV1 (ρ = 0.26), SVC (ρ = 0.26) (p < 0.001) and MVV (ρ = 0.21) (p < 0.05) were slightly correlated with shooting score. There were differences between shooting performance categories in MIP, MEP, FVC, FEV1, SVC, and MVV (p < 0.001, p < 0.05). The results imply that both strong respiratory muscles and optimal pulmonary function may be one of the necessary prerequisites for superior shooting performance in police.

Intra-Rater Reliability of Ultrasound Measurements of Diaphragm Thickness and Contractility in Individuals with Nonspecific Chronic Neck Pain

Objective

This study aimed to determine within-day intra-rater reliability of ultrasound measurements of the right and left hemidiaphragm thickness and contractility (quantified by percentage thickness change) in supine position during deep breathing in individuals with nonspecific chronic neck pain.

Methods

Seventeen volunteers (20-55 years of age) participated in this observational study. Bilateral diaphragm muscle thickness and contractility (percentage thickness change) were compared between 2 measurement sessions administered by a radiologist using B-mode real-time ultrasound (30 minutes apart). Intraclass correlation coefficient (ICC [3, 3]) as well as the standard error of measurement (SEM), minimal detectable change (MDC), and the coefficient of variation (CV) were used to determine the intra-rater reliability.

Results

The right and left hemidiaphragm thickness showed good to excellent reliability at the end of deep inspiration (ICC, 0.90; 95% confidence interval [CI], 0.72-0.96; and ICC, 0. 93; 95% CI, 0.81-0.97, respectively) as well as at the end of deep expiration (ICC, 0.91; 95% CI, 0.75-0.96; ICC, 0.91; 95% CI, 0.77-0.97; SEM, 0.19; MDC, 0.54; and CV, 7.84%, respectively) and the percentage thickness change (ICC, 0.83; 95% CI, 0.54-0.94; and ICC, 0.93; 95% CI, 0.82-0.97, respectively).

Conclusion

This study found that diagnostic ultrasound measurements of the right and left hemidiaphragm thickness and contractility in supine position during deep breathing in individuals with nonspecific chronic neck pain was reliable. The SEM, MDC, and CV reported may allow for accurate interpretation of diaphragm assessment in a clinical research setting.

The immediate effect of thoracolumbar manipulation and diaphragmatic release on inspiratory muscle strength in healthy smokers: A randomized clinical trial

BACKGROUND

Diaphragmatic release technique and thoracolumbar manipulation have been found effective in restoring normal diaphragmatic movement in healthy and diseased populations. Smoking has deleterious effects on human systems, including the musculoskeletal system.

OBJECTIVE

The current study aimed to investigate the immediate effects of diaphragmatic release technique and thoracolumbar manipulation on diaphragm muscle strength in healthy smokers.

METHODS

A double-blinded randomized clinical trial was conducted on 30 asymptomatic healthy smokers randomly assigned into two groups [intervention group (IG) and sham group (SG)] with 15 participants each. The IG received thoracolumbar manipulation and diaphragmatic release techniques, while the SG received no active treatment. The outcome measure was sniff nasal inspiratory pressure (SNIP).

RESULTS

The IG showed a significant increase in the SNIP with a mean difference of 20.13 cmH2O (95% CI: 13.62-26.64; P< 0.001), while the SG had a reduction in the SNIP value -3.27 cmH2O (95% CI: -0.65 to -5.89; P= 0.02). Diaphragmatic release technique and thoracolumbar manipulation significantly improved SNIP values immediately after the intervention, with a between-group difference of 31.07 cmH2O (95% CI: 15.26-46.87; P< 0.001).

CONCLUSIONS

Diaphragmatic release technique and thoracolumbar manipulation increased the diaphragm strength in healthy adult smokers, suggesting its potential utility in the management of participants with reduced respiratory muscle strength.

The Main Role of Diaphragm Muscle as a Mechanism of Hypopressive Abdominal Gymnastics to Improve Non-Specific Chronic Low Back Pain: A Randomized Controlled Trial

Background: Chronic low back pain (LBP) has been stated as one of the main health concerns in the XXI century due to its high incidence. Objective: The objective of this study was to determine the effects of an 8-week program of hypopressive abdominal gymnastics (HAG) on inspiratory muscle strength, diaphragm thickness, disability and pain in patients suffering from non-specific chronic LBP. Methods: A total of 40 patients with chronic LBP were randomly divided into two groups. The experimental group carried out an 8-week supervised program of HAG (two sessions/week), whereas the control group did not receive any treatment. Outcomes were measured before and after the intervention, comprising diaphragm thickness during relaxed respiratory activity, maximal inspiratory pressure (PI_max), pain intensity (NRS), pressure pain threshold and responses to four questionnaires: Physical Activity Questionnaire (PAQ), Roland–Morris Disability Questionnaire (RMQ), Central Sensitization Inventory (CSI) and Tampa Scale of Kinesiophobia-11 Items (TSK-11). Results: Statistically significant differences (p < 0.05) were observed for greater thickness of the left and right hemi-diaphragms at inspiration, as well as higher PI_max and decreased NRS, CSI and RMQ scores in the intervention group. After treatment, the increases in the thickness of the left and right hemi-diaphragms at inspiration and PI_max, as well as the decrease in the NRS and RMQ scores, were only predicted by the proposed intervention (R² = 0.118–0.552). Conclusions: An 8-week HAG intervention seemed to show beneficial effects and predicted an increase in diaphragm thickness and strength during inspiration, as well as a reduction in pain intensity, central sensitization and disability, in patients suffering from chronic non-specific LBP with respect to non-intervention.

Evaluation of a nurse-supervised rehabilitation programme on clinical features and systemic inflammation in Chinese children with asthma: A propensity score-matched analysis

AIMS

To evaluate whether a nurse-supervised rehabilitation programmes could improve respiratory functions and systematic inflammation in children with asthma.

BACKGROUND

Children with asthma always suffer from poor life quality, and physical training and pulmonary rehabilitation could be beneficial to asthma.

DESIGN

A retrospective, observational, single-centre cohort analysis.

METHOD

Baseline characteristics between the nurse-supervised rehabilitation programme and usual-care groups were matched by propensity-score matching (PSM) in a 1:1 ratio. We compared the lung function and inflammatory markers between groups.

RESULTS

Among 52 pairs of children, differences in lung function were improved in the nurse-supervised rehabilitation group compared with those in usual-care group, including the oxygen saturation, forced expiratory volume in 1 second, forced expiratory flow of 25%-75% and peak expiratory flow (all P < 0.05). Two asthma-related inflammatory markers (hypersensitive C-reactive protein and immunoglobulin E) also significantly decreased in the nurse-supervised rehabilitation group (both P < 0.001).

CONCLUSIONS

The results indicate that the nurse-supervised rehabilitation programme might be effective in improving symptom control, respiratory functions and systemic inflammation in children with asthma. The study suggests that the NSR for asthma merits further research.

Diaphragm thickness, thickness change, and excursion in subjects with and without nonspecific low back pain using B-mode and M-mode ultrasonography

Background: Previous studies have demonstrated that respiratory dysfunction has a potential association with low back pain (LBP). Despite the role of the diaphragm for respiration and spinal stability, knowledge of the function of both sides of the diaphragm in subjects with LBP is still limited.Objective: This study aimed to compare the structural integrity and function of the right and left hemidiaphragm by ultrasonography (USG) in subjects with and without nonspecific chronic low back pain (NS-CLBP).Methods: A total of 37 subjects with NS-CLBP and 34 healthy subjects participated in this case-control study. The thickness, thickness change, and excursion of the right and left hemidiaphragm were compared within and between the groups during quiet breathing (QB) and deep breathing (DB) through B-mode and M-mode ultrasound imaging.Results: The LBP group had a significantly smaller degree of right hemidiaphragm thickness change (P = .001) compared with the healthy control group, with a strong effect size. Nevertheless, there was no significant change for diaphragm thickness and excursion between the two groups. The result showed that, in the healthy group, the right hemidiaphragm had a significantly smaller thickness at expiration and larger thickness change compared with the left hemidiaphragm, with a moderate effect size. Based on the multivariate prediction analysis, the right hemidiaphragm thickness change might significantly predict LBP.Conclusion: We found that participants with LBP had a smaller degree of right hemidiaphragm thickness change. Also, the right hemidiaphragm thickness change might significantly predict LBP.

The influence of the trunk muscle activation on occlusion pressure and respiratory muscle strength in healthy participants: Randomized controlled trial

OBJECTIVES

The purpose of the study was to check if the trunk muscle activation done in accordance with rules of the Bobath concept affects the occlusion pressure and respiratory muscle efficacy in forced breathing manoeuvres in healthy participants.

DESIGN

Randomized controlled trial. Between-subjects design.

PARTICIPANTS

Seventy-four healthy volunteers, aged 20-26 years, were recruited from medical students, randomly assigned to the experimental or control groups.

INTERVENTION

The intervention in the experimental group was individual physiotherapy based on the Bobath concept. It was provided by qualified physiotherapist and lasted about 60 min. The Bobath concept is an inclusive, individualized therapeutic approach to optimize movement recovery, informed by contemporary movement and neuro-sciences. The control group participated in a 45-minute lecture on the importance of the stability of trunk muscle and the diaphragm position that is adequate for its respiratory work. The described interventions, in both groups, were performed once, between the initial and final measurement of the respiratory drive.

OUTCOME MEASURES

The subjects underwent two assessments of the following variables: occlusion pressure (P0.1) and the respiratory muscle strength: maximal inspiratory pressure (PImax), maximal expiratory pressure (PEmax), maximal occlusion pressure (P0.1max) with the use of MasterScope Spirometer. In experimental group, the physiotherapy assessment was carried out before intervention.

RESULTS

As a result of the applied intervention, P0.1 in the experimental group increased (p = 0.001; 82.45 vs 103.73), which was not observed in the control group (p = 0.629; 88.95 vs 85.83). The intervention did not change the results of all other outcomes including P0.1 max; PImax and PEmax.

CONCLUSION

The activation of trunk muscles such as transversus abdominis, multifidius and muscles of the pelvic floor was found to improve the effectiveness of diaphragmatic work during tidal breathing as measured with P0.1 values. Established abdominal pressure, which stabilizes the trunk and prevents chest mobility, might be the reason why forced measurements (PImax, PEmax, P.01 max) remain unchanged.

ACR Appropriateness Criteria® Imaging of Mediastinal Masses

Mediastinal masses can present with symptoms, signs, and syndromes or incidentally. Selecting the appropriate diagnostic imaging study for mediastinal mass evaluation requires awareness of the strengths and weaknesses of the various imaging modalities with regard to tissue characterization, soft tissue contrast, and surveillance. This publication expounds on the differences between chest radiography, CT, PET/CT, ultrasound, and MRI in terms of their ability to decipher and surveil mediastinal masses. Making the optimal imaging choice can yield diagnostic specificity, avert unnecessary biopsy and surgery, guide the interventionist when necessary, and serve as a means of surveillance for probably benign, but indeterminate mediastinal masses. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Postural and respiratory function of the abdominal muscles: A pilot study to measure abdominal wall activity using belt sensors

BACKGROUND: The abdominal muscles play an important respiratory and stabilization role, and in coordination with other muscles regulate intra-abdominal pressure (IAP) to stabilize the spine. OBJECTIVE: To examine a new, non-invasive method to measure activation of the abdominal wall and compare changes in muscle activation during respiration while breathing under a load, and during instructed breathing. METHODS: Thirty-five healthy individuals completed this observational crossover study. Two capacitive force sensors registered the abdominal wall force during resting breathing stereotype, instructed breathing stereotype and under a load. RESULTS: Mean abdominal wall force increased significantly on both sensors when holding the load compared to resting breathing (Upper Sensor: P< 0.0005, d=-0.46, Lower Sensor: P< 0.0005, d=-0.56). The pressure on both sensors also significantly increased during instructed breathing compared to resting breathing (US: P< 0.0005, d=-0.76, LS: P< 0.0005, d=-0.78). CONCLUSIONS: The use of capacitive force-sensors represent a new, non-invasive method to measure abdominal wall activity. Clinically, belts with capacitive force sensors can be used as a feedback tool to train abdominal wall activation.

Effects of core-postural stabilisation on fluoroscopy diaphragmatic measurement and dyspnea in chronic obstructive pulmonary disease: A randomized single-blinded clinical trial

BACKGROUND:

While respiratory and core-postural stabilisation has recently gained a widespread acceptance to improve pulmonary function and dyspena, the therapeutic effects of and rationale underlying the use of respiratory and core-postural stabilisation in the management of patients with chronic obstructive pulmonary disease have not been investigated.

OBJECTIVE:

This study aimed to compare the effects of abdominal breathing and respiratory and core-postural stabilisation on diaphragmatic movement and pulmonary function.

METHODS:

Fourteen patients with moderate chronic obstructive pulmonary disease were randomly assigned to either the respiratory and core-postural stabilisation or abdominal breathing group. All patients underwent fluoroscopy-guided chest X-ray imaging and pulmonary function tests before and after the interventions; the modified Medical Research Council questionnaire was also administered before and after the interventions. Six sessions of either intervention were consistently provided. The obtained data were assessed using independent t-tests and Wilcoxon signed-rank test with a significance threshold of P< 0.05.

RESULTS:

Respiratory and core-postural stabilisation was more effective in increasing diaphragmatic movements than abdominal breathing (P< 0.05). Pulmonary function tests revealed more significant differences in the forced vital capacity (FVC(%)predicted) only after respiratory and core-postural stabilisation (P= 0.004). The Medical Research Council questionnaire score was significantly different within the Respiratory and core-postural stabilisation group (P= 0.014).

CONCLUSIONS:

Our novel results suggest that the effects of respiratory and core-postural stabilisation breathing on diaphragmatic movement and pulmonary function were superior to those of abdominal breathing in patients with chronic obstructive pulmonary disease.

Ultrasound and non-ultrasound imaging techniques in the assessment of diaphragmatic dysfunction

Diaphragm muscle dysfunction is increasingly recognized as an important element of several diseases including neuromuscular disease, chronic obstructive pulmonary disease and diaphragm dysfunction in critically ill patients. Functional evaluation of the diaphragm is challenging. Use of volitional maneuvers to test the diaphragm can be limited by patient effort. Non-volitional tests such as those using neuromuscular stimulation are technically complex, since the muscle itself is relatively inaccessible. As such, there is a growing interest in using imaging techniques to characterize diaphragm muscle dysfunction. Selecting the appropriate imaging technique for a given clinical scenario is a critical step in the evaluation of patients suspected of having diaphragm dysfunction. In this review, we aim to present a detailed analysis of evidence for the use of ultrasound and non-ultrasound imaging techniques in the assessment of diaphragm dysfunction. We highlight the utility of the qualitative information gathered by ultrasound imaging as a means to assess integrity, excursion, thickness, and thickening of the diaphragm. In contrast, quantitative ultrasound analysis of the diaphragm is marred by inherent limitations of this technique, and we provide a detailed examination of these limitations. We evaluate non-ultrasound imaging modalities that apply static techniques (chest radiograph, computerized tomography and magnetic resonance imaging), used to assess muscle position, shape and dimension. We also evaluate non-ultrasound imaging modalities that apply dynamic imaging (fluoroscopy and dynamic magnetic resonance imaging) to assess diaphragm motion. Finally, we critically review the application of each of these techniques in the clinical setting when diaphragm dysfunction is suspected.

Respiratory kinematics and the regulation of subglottic pressure for phonation of pitch jumps - a dynamic MRI study

The respiratory system is a central part of voice production as it contributes to the generation of subglottic pressure, which has an impact on voice parameters including fundamental frequency and sound pressure level. Both parameters need to be adjusted precisely during complex phonation tasks such as singing. In particular, the underlying functions of the diaphragm and rib cage in relation to the phonation of pitch jumps are not yet understood in detail. This study aims to analyse respiratory movements during phonation of pitch jumps using dynamic MRI of the lungs. Dynamic images of the breathing apparatus of 7 professional singers were acquired in the supine position during phonation of upwards and downwards pitch jumps in a high, medium, and low range of the singer's tessitura. Distances between characteristic anatomical landmarks in the lung were measured from the series of images obtained. During sustained phonation, the diaphragm elevates, and the rib cage is lowered in a monotonic manner. During downward pitch jumps the diaphragm suddenly changed its movement direction and presented with a short inspiratory activation which was predominant in the posterior part and was associated with a shift of the cupola in an anterior direction. The magnitude of this inspiratory movement was greater for jumps that started at higher compared to lower fundamental frequency. In contrast, expiratory movement of the rib cage and anterior diaphragm were simultaneous and continued constantly during the jump. The data underline the theory of a regulation of subglottic pressure via a sudden diaphragm contraction during phonation of pitch jumps downwards, while the rib cage is not involved in short term adaptations. This strengthens the idea of a differentiated control of rib cage and diaphragm as different functional units during singing phonation.

The Five Diaphragms in Osteopathic Manipulative Medicine: Myofascial Relationships, Part 1

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.

Comparison of balance changes after inspiratory muscle or Otago exercise training

The inspiratory muscles contribute to balance via diaphragmatic contraction and by increasing intra-abdominal pressure. We have shown inspiratory muscle training (IMT) improves dynamic balance significantly with healthy community-dwellers. However, it is not known how the magnitude of balance improvements following IMT compares to that of an established balance program. This study compared the effects of 8-week of IMT for community-dwellers, to 8-week of the Otago exercise program (OEP) for care-residents, on balance and physical performance outcomes. Nineteen healthy community-dwellers (74 ± 4 years) were assigned to self-administered IMT. Eighteen, healthy care-residents (82 ± 4 years) were assigned to instructor-led OEP. The IMT involved 30 breaths twice-daily at ~50% of maximal inspiratory pressure (MIP). The OEP group undertook resistance and mobility exercises for ~60 minutes, twice-weekly. Balance and physical performance were assessed using the mini Balance Evaluation System Test (mini-BEST) and time up and go (TUG). After 8-week, both groups improved balance ability significantly (mini-BEST: IMT by 24 ± 34%; OEP by 34 ± 28%), with no between-group difference. Dynamic balance sub-tasks improved significantly more for the IMT group (P < 0.01), than the OEP group and vice versa for static balance sub-tasks (P = 0.01). The IMT group also improved MIP (by 66 ± 97%), peak inspiratory power (by 31 ± 12%) and TUG (by -11 ± 27%); whereas the OEP did not. IMT and OEP improved balance ability similarly, with IMT eliciting greater improvement in dynamic balance, whilst OEP improved static balance more than IMT. Unlike IMT, the OEP did not provide additional benefits in inspiratory muscle function and TUG performance. Our findings suggest that IMT offers a novel method of improving dynamic balance in older adults, which may be more relevant to function than static balance and potentially a useful adjunct to the OEP in frailty prevention.

The Kinematic Chain of Arm Elevation Is Impaired in Patients with Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) often complain about difficulties in performing activities with their arms above shoulders height. These difficulties have been associated with increased cardiorespiratory demand and altered lung mechanics; however, musculoskeletal-related mechanisms may also contribute to constrain the mechanics of the upper body quadrant, increasing the effort to perform the activities. This exploratory research aimed to assess potential changes in the kinematic chain of arm elevation in patients with COPD. A secondary analysis from a cross-sectional exploratory case-control and prediction study was conducted in 15 patients with COPD (2 females) and 15 controls (8 females) matched for age and body mass index. The sagittal alignment and active range of motion (ROM) of the head, thoracic spine and shoulder complex were measured, using a computer software, in digital lateral photographs obtained in three different testing positions: arms at rest, arms at 90° of shoulder flexion and full arm elevation. From rest to full arm elevation, both groups moved from a more flexed to a less flexed or more upright thoracic spine position (∼7°, p < 0.001, 0.419 < ηp2 <0.767). However, the COPD group showed significantly less shoulder flexion (∼12°, p = 0.007, d = 1.05) and thoracic spine extension (∼6°, p = 0.015, ηp2 = 0.139) ROM than the control group in the full arm elevation position. These findings suggest that this population may show changes in the kinematic chain of arm elevation that possibly contribute to arm movement-related complains and limited performance in their daily living.

Assessment of Resisted Trunk Rotation Exercise With and Without Kiai Double-Pulse Breathing Technique on Hockey Shot Velocity: A Pilot Study

Objective

The purpose of this study was to assess the feasibility of a study to measure the effect of resisted band antirotation exercises with the use of a double-pulse (DP) breathing kiai exercise on slapshot and snap shot velocity and subjective assessment of performance.

Methods

Ten participants between 20 and 30 years of age who play ice hockey were recruited. The study was conducted over 3 weeks, and participants were randomized into 2 groups; group 1: resisted band antirotations with DP kiai (a shout used in martial arts) exercises, and group 2: resisted band antirotations alone. After week 1, there was a 1-week washout period, after which group 1 performed resisted band antirotations alone, and group 2 performed resisted band antirotations with DP kiai exercises.

Results

Data were successfully collected on all 10 participants. There appeared to be no difference between groups regarding slapshot and snap shot velocity.

Conclusion

The design for this study appears to be feasible. Preliminary data show that the average shot velocity before and after the intervention did not show a positive relationship between DP kiai breathing and hockey shot (slapshot and snap shot) velocity.

The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain

PURPOSE

The aim of this study was to assess the effects of diaphragm training on low back pain and thickness of stabilizer muscles of the lumbar spine.

PATIENTS AND METHODS

Fifty-two individuals were recruited with a history of chronic low back pain in our randomized controlled trial. The participants were divided randomly into two groups. One of the groups took part in a complex training program and completed with diaphragm training (DT group, n=26). The control (C) group took part only in the complex training (n=21). The thickness of transversus abdominis, diaphragm, and lumbar multifidus muscle was measured with ultrasonography in two positions: lying and sitting. All muscles were assessed in relaxed and in contracted state in the lying position and in a relatively relaxed (calm sitting) and relatively contracted state (during weightlifting) in the sitting position.

RESULTS

After the training, severity of the pain was significantly reduced in both the groups. Regarding the thickness of the muscles, there were no changes in group C. The thickness of transversus abdominis increased significantly in relaxed and in relatively relaxed state, but there were no changes in contracted and relatively contracted state in group DT. As for the diaphragm muscle, there were significant increase in the state of supine position and in relatively contracted state, but there was no notable change in relatively relaxed state. With regard to the thickness of lumbar multifidus, a significant increase was only found in the left-sided muscle in relaxed, relatively relaxed, and relatively contracted state and in case of the right-sided one in relatively contracted state in group DT.

CONCLUSION

Our results suggest that diaphragm training has an effect also on the thickness of other active stabilizers of the lumbar spine, such as transversus abdominis and lumbar multifidus muscles.

Effects of breathing exercises on resting metabolic rate and maximal oxygen uptake

[Purpose] The aim of the present study is to examine effects of diaphragm breathing exercise and feedback breathing exercise on maximal oxygen uptake and resting metabolic rate. [Participants and Methods] Thirty-eight healthy participants were randomly assigned to two groups; the diaphragm breathing exercise group and the feedback breathing exercise group. The diaphragm breathing exercise group was asked to perform diaphragm respiration, and the feedback breathing exercise group was asked to breathe with feedback breathing device. Maximal oxygen uptake and resting metabolic rate were measured before and after two breathing exercises. [Results] Significant difference was found in maximal oxygen uptake before and after two breathing exercises. There was also significant difference in resting metabolic rate before and after diaphragm breathing exercise. However, significant difference was not found in resting metabolic rate before and after feedback breathing exercise. There were not significant between-group differences in both maximal oxygen uptake and resting metabolic rate. [Conclusion] Diaphragm breathing exercise and feedback breathing exercise could influence maximal oxygen uptake. Diaphragm breathing exercise could influence resting metabolic rate, but feedback breathing exercise could not.

Effects of inspiratory muscle training in children with cerebral palsy: a randomized controlled trial

BACKGROUND

Respiratory muscle weakness and its relation to other impairments in children with cerebral palsy (CP) have been shown in the latest studies. The effects of inspiratory muscle training (IMT) in this population have not been comprehensively investigated so far.

OBJECTIVES

To investigate the effects of IMT on trunk control, pulmonary functions, respiratory muscle strength, daily living activities, exercise capacity and quality of life in children with CP.

METHODS

This was a prospective-randomized controlled trial. Twenty-five children with CP were randomly assigned to the treatment (n=13) or the control group (n=12). The treatment group received IMT at 30% of maximal inspiratory pressure (MIP) and the control group received sham therapy (5% of MIP) for 6 weeks. Also, both groups received routine conventional physical therapy (stretching, strengthening, and functional exercises, etc.) for 6 weeks. The primary outcome measure was trunk control. Secondary outcome measures were pulmonary function, respiratory muscle strength, daily living activities, functional exercise capacity and quality of life.

RESULTS

The treatment group had better outcome for trunk control (3.87, 95% CI 3.72-4.02). Also, respiratory muscle strength, daily living activities, functional exercise capacity and quality of life were significantly improved in the treatment group compared with controls. No improvements were observed in the pulmonary function test scores between the groups.

CONCLUSION

Inspiratory muscle training improves trunk control, respiratory muscle strength, daily living activities, functional exercise capacity and quality of life in children with CP and it can be included in the physiotherapy and rehabilitation programs.

Individualized dry-land intervention program for an elite Paralympic swimmer

The aim of this retrospective case study is the longitudinal description of the physical and functional parameters of a top-level Paralympic swimmer class S9-SB8-SM9 during four swimming seasons of training, from the Paralympic games in London 2012 to the Paralympic games in Rio 2016. A 22-year-old male swimmer underwent a specific preventive dry-land training based on diaphragmatic breathing, postural alignment, and slow-velocity resistance training aimed to improve his muscle strength. He was tested by using the Functional Movement Screen™, photographic postural assessment and vertical jump. The swimmer improved his functional, postural and strength parameters indicating a better functional movement and muscular power. These results show that a four-year specific dry-land intervention could be capable of enhancing the functional and physical requirements of a top-level Paralympic swimmer. This approach might be a suitable novel alternative for coaches and athletic trainers to integrate their training protocols for athletes with similar impairments.

Effects of 4 weeks of dynamic neuromuscular stabilization training on balance and gait performance in an adolescent with spastic hemiparetic cerebral palsy

[Purpose] The purpose of this study investigated the effects of 4 weeks of dynamic neuromuscular stabilization training on balance ability. [Subject and Methods] An adolescent with spastic hemiparetic cerebral palsy was recruited. The subject performed 4 weeks of dynamic neuromuscular stabilization training. We assessed the balance subtest of the Bruininks-Oseretsky Test of Motor Proficiency-Second Edition, the 10-meter walk test, and the 6-min walk test. [Results] The balance subtest scores were improved significantly after training. [Conclusion] This study suggests that 4 weeks of dynamic neuromuscular stabilization training is effective for improving balance and gait performance in spastic hemiparetic cerebral palsy.

Diaphragm Contractility in Individuals with Chronic Ankle Instability

INTRODUCTION/PURPOSE

Previous investigations have identified impaired trunk and postural stability in individuals with chronic ankle instability (CAI). The diaphragm muscle contributes to trunk and postural stability by modulating the intra-abdominal pressure. A potential mechanism that could help to explain trunk and postural stability deficits may be related to altered diaphragm function due to supraspinal sensorimotor changes with CAI. The purpose of this study was to examine the diaphragm contractility in individuals with CAI and healthy controls.

METHODS

Twenty-seven participants with self-reported CAI and 28 healthy control participants volunteered. A portable ultrasound unit was used to visualize and measure the right and left hemidiaphragm thickness at the end of resting inspiration and expiration in supine while breathing quietly. The diaphragm movement was imaged and recorded on B-mode ultrasonography. The degree of diaphragm contractility was calculated from the mean of three images from the end of resting inspiration and expiration. Independent t-tests were used to compare the degree of diaphragm thickness of right and left sides between the CAI and the control groups.

RESULTS

The CAI group had a smaller degree of left hemidiaphragm contractility compared with the control group (P = 0.03). There was no between-group difference in other diaphragm variables.

CONCLUSION

Individuals with CAI appear to have altered diaphragm contractility, which may be an illustration of diaphragm dysfunction and central nervous system changes in CAI population. The association between CAI and altered diaphragm contractility provides clinicians a more comprehensive awareness of proximal impairments associated with CAI. Future investigation is needed to determine whether altered contractility of the diaphragm contributes to functional impairments, activity limitations, and participant restrictions commonly observed in patients with CAI.

The effect of balance training intervention on postural stability in children with asthma

OBJECTIVE

Pulmonary rehabilitation is mainly focused on exercise training and breathing retraining in children with asthma. Conversely, balance training is not usually recommended for the treatment, although postural deficits were found in these patients. Therefore, this study assessed the effect of balance training intervention on postural stability in children with asthma.

METHODS

Nineteen children with mild intermittent asthma (age 11.1 ± 2.1 years, height 147.6 ± 13.9 cm, weight 41.8 ± 13.3 kg) were randomly assigned to an experimental group or a control group and completed a four-week physiotherapy program including breathing exercises and aerobic physical training (six times/week, 45 minutes). Both groups performed the same training, but only the experimental group underwent exercises on balance devices. The center of pressure (CoP) velocity in the anteroposterior (V_y) and mediolateral (V_x) directions, and total CoP velocity (V_tot) were recorded before and after training in the preferred and the adjusted stances under eyes open (EO) and eyes closed (EC) conditions.

RESULTS

The addition of balance intervention led to significant improvements of V_tot (p = 0.02, p = 0.04) in both types of stance, V_x in the preferred stance (p = 0.03) and V_y in the adjusted stance (p = 0.01) under EO conditions. Significant improvements were also found in V_y in the adjusted stance (p = 0.01) under EC conditions.

CONCLUSIONS

Results of this study support the effectiveness of balance training as a part of physiotherapy treatment for improving balance performance, predominantly under EO conditions, in children with mild asthma.