The Effect of Posture on the Diaphragm: Difference between revisions

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== The Effect of Posture on the Diaphragm ==
== The Effect of Posture on the Diaphragm ==
When optimising diaphragm function, a 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.
Posture has a significant impact on the function of the diaphragm. In order to optimise diaphragm function, vertical length is needed - i.e. the thoracic and abdominal cavities need to be long enough for the diaphragm to create negative and positive pressure during inspiration and expiration.<ref name=":0">Pandya R. The Effect of Posture on the Diaphragm Course. Physioplus, 2021.</ref> A patient must be able to take a deep breath down to the base of the lungs, so that the ribs can flare out and the diaphragm can descend.<ref name=":0" /> A detailed discussion of breathing is available [[How We Breathe|here]] and [[The Science of Breathing Well|here]]. However, specific postures such as [[Forward Head Posture|forward head posture]] (FHP) and [[Thoracic Hyperkyphosis|kyphosis]] have been found to affect breathing mechanics, including diaphragm mobility.<ref name=":1">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>


[[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 ==
FHP is "a poor habitual neck posture that is defined by hyperextension of the upper cervical vertebrae and forward translation of the cervical vertebrae".<ref name=":2" />


== Forward Head Posture ==
FHP affects chest expansion and the activity of the respiratory muscles, which can lead to reduced alveolar ventilation.<ref name=":1" /><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> Zafar et al.<ref name=":1" /> has found that induced FHP in healthy subjects has an immediate impact on respiratory function.  They suggested that this could be caused by a temporary phrenic nerve entrapment (the nerve which supplies the diaphragm), which decreases neural activity, and ultimately weakens the diaphragm.<ref name=":1" />
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 neural activity, and consequently weakens 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 <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> deduced that altered diaphragm function leads to core muscle instability, which will further lead to other systemic and musculoskeletal disorders including spinal instability.  
Hodges et al<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><ref>Hodges PW, Butler JE, McKenzie DK, Gandevia SC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1160083/ Contraction of the human diaphragm during rapid postural adjustments]. J Physiol. 1997;505 ( Pt 2)(Pt 2):539-48.</ref> deduced that altered diaphragm function leads to core muscle instability, which can result in other systemic and musculoskeletal disorders, including spinal instability.  


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>
A FHP has an impact on respiratory biomechanics.<ref>Triangto K, Widjanantie SC, Nusdwinuringtyas N. [https://www.researchgate.net/publication/344879018_Biomechanical_Impacts_of_Forward_Head_Posture_on_the_Respiratory_Function Biomechanical Impacts of Forward Head Posture on the Respiratory Function.] Indonesian Journal of Physical Medicine & Rehabilitation. 2019;8(02):50-64.</ref> It results in an expansion of the upper thorax and contraction of the lower thorax. These changes decrease respiratory function.<ref name=":2">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 of patients with a FHP to be more effective during breathing, we need to:<ref name=":3" />


# Restore normal length-tension relationship
# Restore normal length-tension relationship
# Improve mobility and expansion in the chest wall
# Improve mobility and expansion in the chest wall
# Relieve the load on accessory respiratory muscles in the neck<ref>Haghighat F, Moradi R, Rezaie M, Yarahmadi N, Ghaffarnejad F. [https://assets.researchsquare.com/files/rs-53279/v1/4bd8d8b9-3540-4500-a169-66aab3be8027.pdf?c=1631854601 Added Value of Diaphragm Myofascial Release on Forward Head Posture and Chest Expansion in Patients With Neck Pain: A Randomized Controlled Trial.]</ref>
# Relieve the load on accessory respiratory muscles in the neck<ref name=":3">Haghighat F, Moradi R, Rezaie M, Yarahmadi N, Ghaffarnejad F. [https://assets.researchsquare.com/files/rs-53279/v1/4bd8d8b9-3540-4500-a169-66aab3be8027.pdf?c=1631854601 Added Value of Diaphragm Myofascial Release on Forward Head Posture and Chest Expansion in Patients With Neck Pain: A Randomized Controlled Trial.]</ref>
{{#ev:youtube|9OdAid7vO5w}}
{{#ev:youtube|9OdAid7vO5w}}


== Kyphotic Posture ==
== Kyphotic Posture ==
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.  Altered 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 is defined as: "an increase in the forward curvature of the spine that is seen along the sagittal plane".<ref>Lam JC, Mukhdomi T. Kyphosis. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558945/</ref>
 
It can be caused by torticollis (i.e. when the neck twists to one side<ref name=":1" />) and FHP leading to the development of a secondary thoracic curve to compensate for the flattening of the cervical spine curve. Altered cervicothoracic mobility impairs normal breathing mechanics by reducing diaphragm mobility and strength.<ref name=":1" /><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 the diaphragm difficult. This can lead to:  
There is approximation of the ribs and pelvis in individuals who are slumped in a kyphotic posture. This approximation can lead to an increase in intra-abdominal pressure, which affects diaphragmatic movement.<ref name=":1" /> This can lead to:<ref name=":1" />


# Reduced lung capacity
# Reduced lung capacity
# Reduced inspiratory flow <ref>Lin F, Parthasarathy S, Taylor SJ, Pucci D, Hendrix RW, Makhsous M. [https://www.sciencedirect.com/science/article/abs/pii/S0003999305014723 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.</ref>
# Reduced inspiratory flow <ref>Lin F, Parthasarathy S, Taylor SJ, Pucci D, Hendrix RW, Makhsous M. [https://www.sciencedirect.com/science/article/abs/pii/S0003999305014723 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.</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>
# 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>
Respiratory function should also be assessed in patients presenting with FHP and torticollis. The SNIP tool (Sniff Nasal Inspiratory Pressure)<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> is useful for assessing respiratory function. It is simple, easy to use and can be integrated into practice for screening individuals with maladaptive 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>
{{#ev:youtube|9D4qWWc9MKc}}Respiratory function should, therefore, be assessed in patients presenting with postures such as FHP and torticollis.<ref name=":1" /> The SNIP tool (Sniff Nasal Inspiratory Pressure)<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> is useful for assessing respiratory function. It is simple, easy to use and can be adopted in clinical practice to screen patients who have postural dysfunction.<ref name=":1" />
 
{{#ev:youtube|9D4qWWc9MKc}}


== Posture in an ICU Bed ==
== Posture in an ICU Bed ==
Pillows placed under the head and knees are often used to make patients comfortable in bed. This results in the patient lying in a 'hammock' position in the bed which reduces the ability of the diaphragm to function optimally.
Pillows are often placed under patients' heads and knees in ICU settings to make them comfortable in bed. However, this positioning causes them to lie in a 'hammock' position, which reduces the ability of the diaphragm to function optimally.<ref name=":0" />


'''Poor ICU positioning results in:'''
'''Poor ICU positioning results in:'''<ref name=":0" />


* Increased forward head angle  
* Increased forward head angle  
Line 42: Line 42:




'''Consequences''':
'''Consequences''':<ref name=":0" />
* Anterior neck muscle tightness
* Anterior neck muscle tightness
* Cervical extensor muscle weakness
* Cervical extensor muscle weakness
Line 48: Line 48:


== Other Factors to Consider ==
== Other Factors to Consider ==
'''The diaphragm influences:'''  
'''The diaphragm influences:'''<ref name=":0" />


# Oesophageal function
# Oesophageal function
# Digestive function
# Digestive function
#* The peristaltic movements, massaging of the abdominal contents
#* Peristaltic movements, massaging of the abdominal contents
# Vascular function with the blood pressure
# Vascular function (i.e. blood pressure)
# Immune system
# Immune system
#* The diaphragm helps with immunity because it's creating fresh flow and assists with the absorption of nutrients and vitamins.
#* The diaphragm helps with immunity because it creates "fresh flow"<ref name=":0" /> and assists with the absorption of nutrients and vitamins
{{#ev:youtube|a-XUTeQQFjU}}
More information on the role of the diaphragm is available [[How We Breathe#Basics of Breathing|here]].{{#ev:youtube|a-XUTeQQFjU}}


== References ==
== References ==

Revision as of 11:25, 3 December 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

The Effect of Posture on the Diaphragm[edit | edit source]

Posture has a significant impact on the function of the diaphragm. In order to optimise diaphragm function, vertical length is needed - i.e. the thoracic and abdominal cavities need to be long enough for the diaphragm to create negative and positive pressure during inspiration and expiration.[1] A patient must be able to take a deep breath down to the base of the lungs, so that the ribs can flare out and the diaphragm can descend.[1] A detailed discussion of breathing is available here and here. However, specific postures such as forward head posture (FHP) and kyphosis have been found to affect breathing mechanics, including diaphragm mobility.[2]

Forward Head Posture[edit | edit source]

FHP is "a poor habitual neck posture that is defined by hyperextension of the upper cervical vertebrae and forward translation of the cervical vertebrae".[3]

FHP affects chest expansion and the activity of the respiratory muscles, which can lead to reduced alveolar ventilation.[2][4] Zafar et al.[2] has found that induced FHP in healthy subjects has an immediate impact on respiratory function. They suggested that this could be caused by a temporary phrenic nerve entrapment (the nerve which supplies the diaphragm), which decreases neural activity, and ultimately weakens the diaphragm.[2]

Hodges et al[5][6] deduced that altered diaphragm function leads to core muscle instability, which can result in other systemic and musculoskeletal disorders, including spinal instability.

A FHP has an impact on respiratory biomechanics.[7] It results in an expansion of the upper thorax and contraction of the lower thorax. These changes decrease respiratory function.[3]

For the diaphragm of patients with a FHP to be more effective during breathing, we need to:[8]

  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[8]

Kyphotic Posture[edit | edit source]

Kyphosis is defined as: "an increase in the forward curvature of the spine that is seen along the sagittal plane".[9]

It can be caused by torticollis (i.e. when the neck twists to one side[2]) and FHP leading to the development of a secondary thoracic curve to compensate for the flattening of the cervical spine curve. Altered cervicothoracic mobility impairs normal breathing mechanics by reducing diaphragm mobility and strength.[2][10]

There is approximation of the ribs and pelvis in individuals who are slumped in a kyphotic posture. This approximation can lead to an increase in intra-abdominal pressure, which affects diaphragmatic movement.[2] This can lead to:[2]

  1. Reduced lung capacity
  2. Reduced inspiratory flow [11]
  3. Decreased forced vital capacity[12]

Respiratory function should, therefore, be assessed in patients presenting with postures such as FHP and torticollis.[2] The SNIP tool (Sniff Nasal Inspiratory Pressure)[13] is useful for assessing respiratory function. It is simple, easy to use and can be adopted in clinical practice to screen patients who have postural dysfunction.[2]

Posture in an ICU Bed[edit | edit source]

Pillows are often placed under patients' heads and knees in ICU settings to make them comfortable in bed. However, this positioning causes them to lie in a 'hammock' position, which reduces the ability of the diaphragm to function optimally.[1]

Poor ICU positioning results in:[1]

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


Consequences:[1]

  • Anterior neck muscle tightness
  • Cervical extensor muscle weakness
  • Diaphragmatic weakness.

Other Factors to Consider[edit | edit source]

The diaphragm influences:[1]

  1. Oesophageal function
  2. Digestive function
    • Peristaltic movements, massaging of the abdominal contents
  3. Vascular function (i.e. blood pressure)
  4. Immune system
    • The diaphragm helps with immunity because it creates "fresh flow"[1] and assists with the absorption of nutrients and vitamins

More information on the role of the diaphragm is available here.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Pandya R. The Effect of Posture on the Diaphragm Course. Physioplus, 2021.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 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.
  3. ↑ 3.0 3.1 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997;505 ( Pt 2)(Pt 2):539-48.
  7. ↑ 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.
  8. ↑ 8.0 8.1 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.
  9. ↑ Lam JC, Mukhdomi T. Kyphosis. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558945/
  10. ↑ Chaitow L. Functional movement and breathing dysfunction. Journal of bodywork and movement therapies. 2016 Jul 1;20(3):455-6.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
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