The Effect of Posture on the Diaphragm: Difference between revisions

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== Effect of posture on Diaphragm ==
== Effect of posture on Diaphragm ==
When optimising diaphragm function, vertical length of the body is needed. We need both the thoracic, and the abdominal cavities to be long enough for diaphragm to create negative and positive pressures during inspiration and expiration. A patient needs to be able to take a deep breath down to the base of the lungs so the ribs can flare out, the diaphragm can drop down.
When optimising diaphragm function, vertical length of the body is needed. We need both the thoracic and the abdominal cavities to be long enough for the diaphragm to create negative and positive pressures during inspiration and expiration. A patient needs to be able to take a deep breath down to the base of the lungs so the ribs can flare out, the diaphragm can drop down.


[[Forward Head Posture|Forward head posture]] (FHP) and [[Thoracic Hyperkyphosis|Kyphosis]] have been shown to alter the breathing mechanism including diaphragm mobility.
[[Forward Head Posture|Forward head posture]] (FHP) and [[Thoracic Hyperkyphosis|Kyphosis]] have been shown to alter the breathing mechanism including diaphragm mobility.


== Forward head posture ==
== Forward head posture ==
The increased degree of FHP has a bearing effect on chest expansion and respiratory muscles activities which can lead to reduced alveolar ventilation. <ref>Okuro RT, Morcillo AM, Ribeiro MÂ, Sakano E, Conti PB, Ribeiro JD. [https://www.scielo.br/j/jbpneu/a/tCkpp5ZTsgjpwqvSFmTZfxs/?lang=en Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children]. Jornal Brasileiro de Pneumologia. 2011;37:471-9.</ref> This could be a result of temporary entrapment of the phrenic nerve, which supplies the diaphragm, reduces it neural activity, and consequently weakens the diaphragm activity. <ref>Lane MA. [https://www.sciencedirect.com/science/article/abs/pii/S1569904811002473 Spinal respiratory motoneurons and interneurons]. Respiratory physiology & neurobiology. 2011 Oct 15;179(1):3-13.</ref>
The increased degree of FHP has a bearing effect on chest expansion and respiratory muscles activities which can lead to reduced alveolar ventilation. <ref>Okuro RT, Morcillo AM, Ribeiro MÂ, Sakano E, Conti PB, Ribeiro JD. [https://www.scielo.br/j/jbpneu/a/tCkpp5ZTsgjpwqvSFmTZfxs/?lang=en Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children]. Jornal Brasileiro de Pneumologia. 2011;37:471-9.</ref> This could be a result of temporary entrapment of the phrenic nerve, which supplies the diaphragm, reduces the  neural activity, and consequently weakens the diaphragm activity. <ref>Lane MA. [https://www.sciencedirect.com/science/article/abs/pii/S1569904811002473 Spinal respiratory motoneurons and interneurons]. Respiratory physiology & neurobiology. 2011 Oct 15;179(1):3-13.</ref>


Hodges et al deduced that altered diaphragm function leads to core muscles instability, which will further lead to other systemic and musculoskeletal disorders including spinal instability. <ref>Hodges PW, Gurfinkel VS, Brumagne S, Smith TC, Cordo PC. [https://link.springer.com/article/10.1007/s00221-002-1040-x Coexistence of stability and mobility in postural control: evidence from postural compensation for respiration.] Experimental brain research. 2002 Jun;144(3):293-302.</ref>
Hodges et al deduced that altered diaphragm function leads to core muscles instability, which will further lead to other systemic and musculoskeletal disorders including spinal instability. <ref>Hodges PW, Gurfinkel VS, Brumagne S, Smith TC, Cordo PC. [https://link.springer.com/article/10.1007/s00221-002-1040-x Coexistence of stability and mobility in postural control: evidence from postural compensation for respiration.] Experimental brain research. 2002 Jun;144(3):293-302.</ref>


A FHP, disturbs the normal respiratory biomechanics<ref>Triangto K, Widjanantie SC, Nusdwinuringtyas N. [http://indojournalpmr.org/IJPMR/article/view/249 Biomechanical Impacts of Forward Head Posture on the Respiratory Function.] Indonesian Journal of Physical Medicine & Rehabilitation. 2019;8(02):50-64.</ref>, the therefore results in expansion of the upper thorax and contraction of the lower thorax. The consequence of these chances is decreased respiratory function.<ref>Koseki T, Kakizaki F, Hayashi S, Nishida N, Itoh M. [https://www.jstage.jst.go.jp/article/jpts/31/1/31_jpts-2018-328/_pdf/-char/ja Effect of forward head posture on thoracic shape and respiratory function.] Journal of physical therapy science. 2019;31(1):63-8.</ref>
A FHP disturbs the normal respiratory biomechanics<ref>Triangto K, Widjanantie SC, Nusdwinuringtyas N. [http://indojournalpmr.org/IJPMR/article/view/249 Biomechanical Impacts of Forward Head Posture on the Respiratory Function.] Indonesian Journal of Physical Medicine & Rehabilitation. 2019;8(02):50-64.</ref> and therefore, results in expansion of the upper thorax and contraction of the lower thorax. The consequence of these changes is decreased respiratory function. <ref>Koseki T, Kakizaki F, Hayashi S, Nishida N, Itoh M. [https://www.jstage.jst.go.jp/article/jpts/31/1/31_jpts-2018-328/_pdf/-char/ja Effect of forward head posture on thoracic shape and respiratory function.] Journal of physical therapy science. 2019;31(1):63-8.</ref>


For the diaphragm to be most effective during breathing we need to:
For the diaphragm to be most effective during breathing we need to:
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== Kyphotic posture: ==
== Kyphotic posture: ==
Kyphosis can be a result of torticollis and FHP leading to development of secondary thoracic curve to compensate for flattening of the cervical spine curve.  Alteration of cervicothoracic mobility impairs normal breathing mechanics by reducing diaphragm mobility and strength. <ref>Chaitow L. [https://www.bodyworkmovementtherapies.com/article/S1360-8592(14)00139-9/fulltext Functional movement and breathing dysfunction.] Journal of bodywork and movement therapies. 2016 Jul 1;20(3):455-6.</ref>
Kyphosis can be a result of torticollis and FHP leading to the development of a secondary thoracic curve to compensate for the flattening of the cervical spine curve.  Alteration of cervicothoracic mobility impairs normal breathing mechanics by reducing diaphragm mobility and strength. <ref>Chaitow L. [https://www.bodyworkmovementtherapies.com/article/S1360-8592(14)00139-9/fulltext Functional movement and breathing dysfunction.] Journal of bodywork and movement therapies. 2016 Jul 1;20(3):455-6.</ref>


When an individual is slumped with a kyphotic posture, this approximation of ribs and pelvis has been shown to increase intra-abdominal pressure making movement of diaphragm difficult. This can lead to:  
When an individual is slumped with a kyphotic posture, this approximation of ribs and pelvis has been shown to increase intra-abdominal pressure making movement of the diaphragm difficult. This can lead to:  


# Reduced lung capacity
# Reduced lung capacity
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# Decreased Forced Vital Capacity<ref>Haque MF, Akhter S, Tasnim N, Haque M, Paul S, Begum M. [https://www.banglajol.info/index.php/BMRCB/article/view/42541 Effects of different sitting postures on forced vital capacity in healthy school children.] Bangladesh Medical Research Council Bulletin. 2019 Aug 7;45(2):117-21.</ref>
# Decreased Forced Vital Capacity<ref>Haque MF, Akhter S, Tasnim N, Haque M, Paul S, Begum M. [https://www.banglajol.info/index.php/BMRCB/article/view/42541 Effects of different sitting postures on forced vital capacity in healthy school children.] Bangladesh Medical Research Council Bulletin. 2019 Aug 7;45(2):117-21.</ref>


When assessing a patient with FHP and torticollis , respiratory function should be included. When assessing, the SNIP <ref>Prigent H, Lejaille M, Falaize L, Louis A, Ruquet M, Fauroux B, Raphael JC, Lofaso F. [https://link.springer.com/article/10.1385/NCC:1:4:475 Assessing inspiratory muscle strength by sniff nasal inspiratory pressure.] Neurocritical care. 2004 Dec;1(4):475-8.</ref>tool could be used. It is simple, easy to use and can be integrated into practice for screening individuals with mal-posture.<ref>Zafar H, Albarrati A, Alghadir AH, Iqbal ZA. [https://www.hindawi.com/journals/bmri/2018/4518269/ Effect of different head-neck postures on the respiratory function in healthy males.] BioMed research international. 2018 Jul 12;2018.</ref>
When assessing a patient with FHP and torticollis, the respiratory function should be included. When assessing, the SNIP <ref>Prigent H, Lejaille M, Falaize L, Louis A, Ruquet M, Fauroux B, Raphael JC, Lofaso F. [https://link.springer.com/article/10.1385/NCC:1:4:475 Assessing inspiratory muscle strength by sniff nasal inspiratory pressure.] Neurocritical care. 2004 Dec;1(4):475-8.</ref>tool could be used. It is simple, easy to use and can be integrated into practice for screening individuals with mal-posture. <ref>Zafar H, Albarrati A, Alghadir AH, Iqbal ZA. [https://www.hindawi.com/journals/bmri/2018/4518269/ Effect of different head-neck postures on the respiratory function in healthy males.] BioMed research international. 2018 Jul 12;2018.</ref>


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== Posture in an ICU Bed ==
== Posture in an ICU Bed ==
So let's go ahead and talk about this patient of ours, who is in the ICU bed.
Often to make a patient comfortable, pillows are placed  under the head and under the knees. The patient is now lying in a hammock position in the bed. These steps are in fact reducing the ability of the diaphragm to function.


To make him comfortable, there are a couple of pillows under his bed. He's got an ET tube in there. A pillow under his knees and the rest of him in the middle is like so. We've all seen patients like so, we've all seen them in that little hammock position laying in the bed. Those two pillows that are meant for patient comfort, how much does it increase the forward head angle by? Where's all his breathing happening? Do you see any belly movement at all? Do you feel there's any diaphragm excursion going on at that point? Or it's a shallow breath. The ventilator pushes the breath in, it stays around, comes back out. It's a shallow breathing, all apical breathing. The anterior neck muscles getting tighter and tighter. The cervical extensors getting weaker and looser. Diaphragm is not doing a whole lot of work. In fact, it's at a position of disadvantage, even if it can, it cannot at this given time. And we all know that patient that we've seen in their ICU bed.
Poor ICU positioning results in:


Apply this to patients in ICU beds and prolonged bedrest
* Increased forward head angle
* Increased apical breathing
* Decreased diaphragmatic breathing


So remember how we had spoken earlier how the apertures in the diaphragm, they influence the oesophageal function, the digestive function, the vascular function with the blood pressure. So what do you think is happening at this given time when diaphragm where it's supposed to be nice, toned, active muscle is floppy. Its grip around those valves and apertures, the massaging of the abdominal contents, the peristaltic movements that we talk about, the rhythmic breathing that causes the movement in the intestines. What happens when we said, in terms of, hey, it improves our immune system. See, all those factors come into play now. That's why we needed to know why diaphragm was so important. It helps with immunity because it's creating fresh flow. It's helping with absorption of the nutrients and the vitamins. And all of that is compromised at this point in that patient laying in the bed with his head forward. Pillow under the knees and back in the hammock. So the positioning of your patient right there and then makes a lot of difference to what his outcome is going to be, what his systemic functions are going to be. What his immunity is going to be? Is he compromised with his immunity such that it leaves him open to other iatrogenic infections, which we discussed two slides prior, then hey, that can cause diaphragm damage in turn. So we have the forward head posture with two pillows, let's make the patient comfortable.
=== Consequences: ===
 
# Anterior neck muscle tightness
# Cervical extensor muscle weakness
# Diaphragmatic weakness.
 
== Other factors to consider ==
Diaphragm influences:
 
# Oesophageal function
# Digestive function
#* The peristaltic movements, massaging of the abdominal contents
# Vascular function with the blood pressure
# Immune system
#* The diaphragm helps with immunity because it's creating fresh flow and assists with the absorption of the nutrients and vitamins.


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Revision as of 11:34, 7 October 2021

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

Effect of posture on Diaphragm[edit | edit source]

When optimising diaphragm function, vertical length of the body is needed. We need both the thoracic and the abdominal cavities to be long enough for the diaphragm to create negative and positive pressures during inspiration and expiration. A patient needs to be able to take a deep breath down to the base of the lungs so the ribs can flare out, the diaphragm can drop down.

Forward head posture (FHP) and Kyphosis have been shown to alter the breathing mechanism including diaphragm mobility.

Forward head posture[edit | edit source]

The increased degree of FHP has a bearing effect on chest expansion and respiratory muscles activities which can lead to reduced alveolar ventilation. [1] This could be a result of temporary entrapment of the phrenic nerve, which supplies the diaphragm, reduces the neural activity, and consequently weakens the diaphragm activity. [2]

Hodges et al deduced that altered diaphragm function leads to core muscles instability, which will further lead to other systemic and musculoskeletal disorders including spinal instability. [3]

A FHP disturbs the normal respiratory biomechanics[4] and therefore, results in expansion of the upper thorax and contraction of the lower thorax. The consequence of these changes is decreased respiratory function. [5]

For the diaphragm to be most effective during breathing we need to:

  1. Restore normal length-tension relationship
  2. Improve mobility and expansion in the chest wall
  3. Relieve the load on accessory respiratory muscles in the neck[6]

Kyphotic posture:[edit | edit source]

Kyphosis can be a result of torticollis and FHP leading to the development of a secondary thoracic curve to compensate for the flattening of the cervical spine curve.  Alteration of cervicothoracic mobility impairs normal breathing mechanics by reducing diaphragm mobility and strength. [7]

When an individual is slumped with a kyphotic posture, this approximation of ribs and pelvis has been shown to increase intra-abdominal pressure making movement of the diaphragm difficult. This can lead to:

  1. Reduced lung capacity
  2. Reduced inspiratory flow [8]
  3. Decreased Forced Vital Capacity[9]

When assessing a patient with FHP and torticollis, the respiratory function should be included. When assessing, the SNIP [10]tool could be used. It is simple, easy to use and can be integrated into practice for screening individuals with mal-posture. [11]

Posture in an ICU Bed[edit | edit source]

Often to make a patient comfortable, pillows are placed under the head and under the knees. The patient is now lying in a hammock position in the bed. These steps are in fact reducing the ability of the diaphragm to function.

Poor ICU positioning results in:

  • Increased forward head angle
  • Increased apical breathing
  • Decreased diaphragmatic breathing

Consequences:[edit | edit source]

  1. Anterior neck muscle tightness
  2. Cervical extensor muscle weakness
  3. Diaphragmatic weakness.

Other factors to consider[edit | edit source]

Diaphragm influences:

  1. Oesophageal function
  2. Digestive function
    • The peristaltic movements, massaging of the abdominal contents
  3. Vascular function with the blood pressure
  4. Immune system
    • The diaphragm helps with immunity because it's creating fresh flow and assists with the absorption of the nutrients and vitamins.

References[edit | edit source]

  1. ↑ Okuro RT, Morcillo AM, Ribeiro MÂ, Sakano E, Conti PB, Ribeiro JD. Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children. Jornal Brasileiro de Pneumologia. 2011;37:471-9.
  2. ↑ Lane MA. Spinal respiratory motoneurons and interneurons. Respiratory physiology & neurobiology. 2011 Oct 15;179(1):3-13.
  3. ↑ Hodges PW, Gurfinkel VS, Brumagne S, Smith TC, Cordo PC. Coexistence of stability and mobility in postural control: evidence from postural compensation for respiration. Experimental brain research. 2002 Jun;144(3):293-302.
  4. ↑ Triangto K, Widjanantie SC, Nusdwinuringtyas N. Biomechanical Impacts of Forward Head Posture on the Respiratory Function. Indonesian Journal of Physical Medicine & Rehabilitation. 2019;8(02):50-64.
  5. ↑ Koseki T, Kakizaki F, Hayashi S, Nishida N, Itoh M. Effect of forward head posture on thoracic shape and respiratory function. Journal of physical therapy science. 2019;31(1):63-8.
  6. ↑ Haghighat F, Moradi R, Rezaie M, Yarahmadi N, Ghaffarnejad F. Added Value of Diaphragm Myofascial Release on Forward Head Posture and Chest Expansion in Patients With Neck Pain: A Randomized Controlled Trial.
  7. ↑ Chaitow L. Functional movement and breathing dysfunction. Journal of bodywork and movement therapies. 2016 Jul 1;20(3):455-6.
  8. ↑ Lin F, Parthasarathy S, Taylor SJ, Pucci D, Hendrix RW, Makhsous M. Effect of different sitting postures on lung capacity, expiratory flow, and lumbar lordosis. Archives of physical medicine and rehabilitation. 2006 Apr 1;87(4):504-9.
  9. ↑ Haque MF, Akhter S, Tasnim N, Haque M, Paul S, Begum M. Effects of different sitting postures on forced vital capacity in healthy school children. Bangladesh Medical Research Council Bulletin. 2019 Aug 7;45(2):117-21.
  10. ↑ Prigent H, Lejaille M, Falaize L, Louis A, Ruquet M, Fauroux B, Raphael JC, Lofaso F. Assessing inspiratory muscle strength by sniff nasal inspiratory pressure. Neurocritical care. 2004 Dec;1(4):475-8.
  11. ↑ Zafar H, Albarrati A, Alghadir AH, Iqbal ZA. Effect of different head-neck postures on the respiratory function in healthy males. BioMed research international. 2018 Jul 12;2018.
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