Diaphragm Rehabilitation

Original Editor - Carin Hunter based on the course by Rina Pandya
Top Contributors - Carin Hunter, Jess Bell, Kim Jackson and Ewa Jaraczewska

Introduction

Diaphragm rehabilitation is often overlooked in physiotherapy. This muscle works constantly throughout the day and performs many different breaths and breath holds. Retraining the varying capabilities of the diaphragm muscle is important for optimal function. The aim of this course is to understand and prescribe rehabilitative exercises for the diaphragm muscle

Surgical Diagnoses

• Congenital Diaphragmatic Hernia: This type of hernia is when one or more of a person's abdominal organs (stomach, spleen, liver, intestines) move upward into the chest through a defect in the diaphragm. Congenital hernias are considered a medical emergency and require prompt surgery.
• Acquired Diaphragmatic Hernia (ADH): An Acquired Hernia is usually due to a penetrating injury (e.g. gun shot wound, stabbing etc) or a blunt injury (e.g. fall, motor vehicle accident etc). Penetrating injuries are a far more common cause of diaphragmatic rupture and subsequent hernias, than blunt injuries.

Diaphragm Atrophy Secondary to Mechanical Ventilation

• After an individual has been on mechanical ventilation for an extended period of time, they may experience Disuse Atrophy. This is caused by decreased protein synthesis, increased proteolysis or combination of both factors after Mechanical Ventilation.
• Oxidative stress is "defined as a disturbance in the balance between the production of reactive oxygen species (free radicals) and antioxidant defenses, is discussed in relation to its possible role in the production of tissue damage in diabetes mellitus. Important free radicals are described and biological sources of origin discussed, together with the major antioxidant defense mechanisms." Oxidative stress starts setting in within six hours of Continuous Mechanical Ventilation and this is linked to diaphragmatic dysfunction and weakness. This phenomenon could also be noticed in skeletal muscles, but it takes longer to set in.
• A study conducted by Grosu and Lee in 2017 concluded there was no relationship between changes in diaphragm thickness and extubation outcome. However, another study conducted by Ewan et al reached a conclusion that, the atrophy of the diaphragm developed while the patient was on mechanical ventilation had a strong influence over the clinical outcome. "Targeting an inspiratory effort level similar to that of healthy subjects at rest might accelerate an individual's liberation from ventilation."
• Rehabilitation can be started with patients in ICU, there have been a number of studies released with rgards to the benefits of starting early rehabilitation. Early rehabilitation can lessen the amount of dysfunction due to the mechanical ventilaton and can assist with the extubation of patients.
• The Manual Evaluation Diaphragm (MED) scale, is the only evaluation scale in the world to generate a value for the mobility of the diaphragm (i.e. the main respiratory muscle).

Techniques to strengthen the diaphragm

1. Sandbag breathing
2. Deep Chest Breathing
3. Bellow’s Breath
4. Intercostal Stretching Breath
5. Focused Diaphragmatic Breath
6. Diaphragm stretches
7. Transverse Abdominus Activation
8. Straw breathing
9. Cat-Cow pose

1. Sandbag breathing:

The patient lies in a supine position. The spine is not bent to either side.

Establish a flow of relaxed breathing, in the three following steps:

1.       Feel the breath flowing out and in, repeatedly.
2.       Soften the abdomen and feel it rise as you inhale and fall as you exhale.
3.       Let the breath flow without pause between the breaths.

2. Deep Chest Breathing

The patient should sit on the floor and place two yoga blocks on the floor behind them. One should be lying flat and the other should be at medium height. The patient then needs to lay their shoulder blades on the flat block and your head on the medium height block, as shown in the figure. Relax arms out to each side with palms faced upwards with legs stretched out in front of you. Inhale deeply and allow your chest to completely rise.

On the exhale, allow your stomach to fall first, then your diaphragm, then your lungs and finally your chest.

Repeat this exercise nine times with a regular breath in-between each repetition.

Deep chest breathing will help to tone both the diaphragm and the intercostal muscles.

3. Bellow’s Breath

Bellow’s breath is a detoxifying breathing exercise. To carry out this exercise you need to be in a seated position. Once comfortable, you need to inhale naturally through your nose. On the exhale you need to snap your stomach muscles in, forcing the exhalation. Repeat this breathing pattern for 30 seconds, gradually increasing the pace.

4. Intercostal Stretching Breath

To perform an intercostal stretching breath, begin in a standing position and stretch both of your arms over your head. Inhale deeply and on the exhale, stretch both your arms to the right, stretching your intercostal muscles on the left side of your body.

Inhale and come back to the center;

On the next exhale, stretch your arms to the left, feeling your right intercostal muscles being stretched.

Repeat two more times on each side.

5. Focused Diaphragmatic Breath

When performing a Focused Diaphragmatic Breath, the patient first should understand exactly where their diaphragm is. Take their fingers and place them on the bottom of their sternum. Instruct them to take a few breaths and feel their diaphragm move under their fingers.

To perform this breathing exercise, tense the stomach muscles and keep your fingers on the diaphragm. Inhale and exhale several times, focusing on the diaphragm’s movement.

This exercise can help increase awareness of and tone the diaphragm.

6. Diaphragm Stretches 

To perform a Diaphragm Stretch, the patient should begin in supine, in 90/90 hip-knee flexion. Place the heels of the patient's hands on their thighs, close to the hip creases. They should breathe calmly through their nose a few times. After a deep inhale and full exhale, they should push their hands into their thighs and think of inhaling without actually letting air in. Then suck belly in and expand the ribs to create a vacuum. Try making small movements to bring the spine and pelvis into flexion, extension, and lateral shifts to produce more stretch to different parts of the diaphragm. Breathe normally for a cycle or two repeating 5 times.

7. Transversus Abdominis Activation:

When performing Transversus Abdominis activation the patient should lie on their back with their knees bent (crook lying). Place their feet hip-width apart and a block lengthwise between their thighs. Make sure their pelvis and low back are in neutral, place their fingertips on their lower abdomen, just between their front hip bones (ASIS).

On exhalation, instruct the patient to drop their belly button, engage the pelvic floor, and squeeze the block. They should be feeling for the transversus abdominis tensing under their fingertips. It is key that the patient maintains the neutral curve of the spine as their belly drops. On inhalation, relax and soften the belly. Complete a few times to find the deep activation of your core.

As a progression, repeat the exercise above and at the end of exhalation lift both feet an inch off the floor. Hold during inhalation before lightly placing your feet back down.

8. Straw breathing

For this exercise, hold a straw between your lips, inhale through your nose and exhale through the straw.

Breathing out through a long straw will automatically make your exhalation longer than the inhalation.

9. Cat-Cow Pose

Start this exercise in 4 point kneeling. Breathe in through your nose and out through your mouth.

When the patient breathes in, instruct them to drop their stomach down towards the floor and hollow their back.

When they breathe out, instruct them to round their back and tuck their chin toward their chest. Keep rounding as you blow all the air out of the lungs. Pause at the end of your exhale for five seconds, holding the rounded position. Then, breathe in through your nose again.

8. Diaphragm Stretches in Standing

The fibres being targeted by this stretch are mostly located between the 12th rib and the central tendon along the inside of the rib cage, which is called the Zone of Apposition.

Stand in a comfortable position and begin by stretching the left side of the diaphragm. Lift your left arm over your head, and place your right hand on your lower ribs on the left side.

On exhalation, laterally flex the spine to the right. There are two factors causing the diaphragm to lengthen as this movement is performed, firstly, the exhalation, and secondly the increase in distance between the 12th rib and the top of the diaphragm.

Inhale as you return to the upright position.

Repeat the movement for five breath cycles.

Exhale as you move to the right and inhale as you return to the upright position.

• Step 1: To increase the stretch, gently push down on the left lower ribs (7-12) with your right hand. Repeat the movement on the opposite side for five cycles of breath. As you move to the left, exhale and as you return to the upright position, inhale.
• Step 2: Finally, reach up with both arms and clasp your hands. Laterally flex your spine to the right and left. During lateral flexion, exhale and when you return to the centre, inhale. Move to the right and left four times.
• Step 3: To finish the exercise, reach up with both arms and clasp your hands. Laterally flex your spine to the right and left. During lateral flexion, exhale and when you return to center, inhale. Move to the right and left four times.

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  Standing Breathing Step 1

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  Standing Breathing Step 2

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  Standing Breathing Step 3