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

Rehabilitation is a vital part of recovery, and for physiotherapists, it is integral to the treatment plan. However, when patients sustain an injury which causes damage to the diaphragm, or have been on a ventilator, this muscle is often overlooked in the rehabilitation plan. The diaphragm, which is the main respiratory muscle, works constantly throughout the day and performs many different breaths and breath holds. Retraining the diaphragm is, therefore, crucial for optimal function.

Causes of Diaphragm Dysfunction

Some causes of diaphragm dysfunction are discussed below:

Surgical Diagnoses

• Congenital Diaphragmatic Hernia: One or more of a person's abdominal organs (i.e. stomach, spleen, liver, intestines) move upwards into the chest through a defect in the diaphragm. Congenital hernias are considered a medical emergency and require prompt surgery.
• Acquired Diaphragmatic Hernia (ADH): Usually caused by a penetrating injury (e.g. gun shot wound, stabbing) or a blunt injury (e.g. fall, motor vehicle accident). 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: "defined as a disturbance in the balance between the production of reactive oxygen species (free radicals) and antioxidant defenses". Oxidative stress starts to occur within six hours of continuous mechanical ventilation and it is linked to diaphragmatic dysfunction and weakness. This phenomenon also occurs 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, Goligher et al. reached the conclusion that diaphragmatic atrophy that developed while a 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."
• There are a number of studies to highlight the benefits of early rehabilitation in ICU. Early rehabilitation can lessen the amount of dysfunction caused by mechanical ventilation and can assist a patient's extubation.
• The Manual Evaluation Diaphragm (MED) Scale is the only evaluation scale in the world to generate a value for the mobility of the diaphragm.
  • The MED Scale has been designed to make use of a therapist's palpations skills during evaluation. This means it is the first non-instrumental evaluation tool designed for assessing the diaphragm function.
  • Please read the following article for more information on The Diaphragm Muscle Manual Evaluation Scale.

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. Transversus abdominis activation
8. Straw breathing
9. Cat-cow pose

1. Sandbag Breathing

The patient lies in a supine position (Figure 1). The spine is not bent to either side.

Establish a flow of relaxed breathing with the following three 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 (Figure 2). One block 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 their head on the medium height block, as shown in Figure 2. Relax arms out to each side with palms faced upwards with legs stretched out in front. Inhale deeply and allow chest to completely rise.

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

Repeat this exercise nine times with a regular breath 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, the client needs to be in a seated position. Once comfortable, the client inhales naturally through their nose. On the exhale, they need to snap their 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 arms over the head. Inhale deeply and on the exhale, stretch both arms to the right, stretching the intercostal muscles on the left side of your body.

Inhale and come back to the center;

On the next exhale, stretch arms to the left, feeling the a stretch in the right intercostal muscles.

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, the patient must tense their stomach muscles and keep their 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 inhalation and full exhalation, the client should push their hands into their thighs. At this point, they should think about inhaling without actually breathing any air in. They then should suck their belly in and expand their ribs, which creates a vacuum. The client should then make small movements to bring their spine and pelvis into flexion, extension. Introducing lateral shifts will also increase the stretch in different parts of the diaphragm. Breathe normally during one to two cycles and repeat five 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 - 3, showing the Diaphragm Stretch in Standing

• 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