Postural function of the diaphragm in persons with and without chronic low back pain.

Denen Studien beskriver på en svært god måte hvordan diafragmas posisjon og bevegelse kan relateres til ryggplager. Når diafragm får lite bevegelse, spesielt i de fremre og mitre delene, blir vinkelen diafragma står i kroppen brattere. Dette kobles til ryggsmerter. Jo brattere vinkelen er, jo større sjangse for ryggsmerter. Bildene viser hvordan diafragma beveger seg mindre og står høyere opp i kroppen hos det med kroniske ryggsmerter. Den viser også hvordan største delen av bevegelsen i diafragma skjer på bakre del, ikke fremre eller midtre, men ved korsryggplager blir det minst bevegelse i fremre og midtre del, mens bakre del har lige god bevegelse. Spesielt interessant å legge merke til er at den viser ingen forskjell mellom Control og Patients diafragma bevegelse under Tidal Breathing (abdominal pust). Dette viser at for å øke styrke og bevegelse i diafragma må man ta i mer. Abdominal pust er ikke diafragma trening.

http://www.ncbi.nlm.nih.gov/pubmed/22236541/

Hele her: http://www.rehabps.cz/data/JOSPT.pdf

Abstract

STUDY DESIGN:

A case-control study.

OBJECTIVES:

To examine the function of the diaphragm during postural limb activities in patients with chronic low back pain and healthy controls.

BACKGROUND:

Abnormal stabilizing function of the diaphragm may be an etiological factor in spinal disorders. However, a study designed specifically to test the dynamics of the diaphragm in chronic spinal disorders is lacking.

METHODS:

Eighteen patients with chronic low back pain due to chronic overloading, as ascertained via clinical assessment and magnetic resonance imaging, and 29 healthy subjects were examined. Both groups presented with normal pulmonary function test results. A dynamic magnetic resonance imaging system and specialized spirometric readings were used with subjects in the supine position. Measurements during tidal breathing (TB) and isometric flexion of the upper and lower extremities against external resistance with TB were performed. Standard pulmonary function tests, including respiratory muscle drive (PI(max) and PE(max)), were also assessed.

RESULTS:

Using multivariate analysis of covariance, smaller diaphragm excursions and higher diaphragm position were found in the patient group (P<.05) during the upper extremity TB and lower extremity TB conditions. Maximum changes were found in costal and middle points of the diaphragm. A 1-way analysis of covariance showed a steeper slope in the middle-posterior diaphragm in the patient group both in the upper extremity TB and lower extremity TB conditions (P<.05).

CONCLUSION:

Patients with chronic low back pain appear to have both abnormal position and a steeper slope of the diaphragm, which may contribute to the etiology of the disorder.

 

Perhaps the most clinically important finding of this study concerns the ab- normal coordination of the diaphragm in the patient group during inspiration with postural tasks. This impairment was demonstrated by reduced move- ment of the diaphragm in the anterior and middle portion, while the posterior (crural) part moved in the same manner as in the control group. This pattern of diaphragmatic recruitment resulted in a steeper angle in the middle-posterior part of the diaphragm (FIGURE 4), which may exacerbate the symptomology of chronic low back pain by increasing the anterior shear forces on the ventral region of the spinal column.

Poor coordination of particular di- aphragmatic parts in the patients (points B and C) resulted in an asymmetric dia- phragmatic activation during inspiration, as demonstrated by a steeper slope of the crural part of the diaphragm. Evidently, limited motion of the costal part may result in a more domed inspiratory diaphragmatic position.

In healthy subjects, the diaphragm is able to perform the dual task (trunk stability and respiration) when trunk stability is challenged.19 Generally, dur- ing any body movement, with activation of the extremities during weight-bearing or weight-lifting activities and transi- tional movements, there is simultaneous spinal bracing and transdiaphragmatic pressure elevation.11,22 Intra-abdominal pressure increases, with a simultaneous decrease of intrapleural pressure, during a contraction of both the posterior (cru- ral) and anterior (costal) portions of the diaphragm.7 This coordination may be compromised in patients with chronic low back pain.

CONCLUSION

We found reduced diaphragm movement when isometric flexion against resistance of the up- per or lower extremities was applied. The combined, more cranial position in the anterior and middle portions of the diaphragm and, particularly, the steeper slope between the middle and crural por- tions of the diaphragm in patients with chronic low back pain may contribute to low back pain symptoms. However, given that the results are based on cross- sectional analysis, we cannot exclude the possibility of reverse causation. Still, the results support the theory that patients with low back pain complaints present with compromised diaphragm function, which may play an important role in pos- tural stability.

KEY POINTS

FINDINGS: We found reduced diaphragm movement in patients with chronic low back pain compared to healthy controls when isometric flexion against resis- tance of the upper or lower extremity was applied, mainly in the anterior

and middle portions. This pattern of diaphragmatic recruitment resulted in
a steeper angle in the middle-posterior part of the diaphragm and likely a great- er strain during activity on the ventral region of the spinal column. IMPLICATIONS: Abnormal postural activa- tion of the diaphragm during the pos- tural task of isometric resistance to the extremities may serve as 1 underlying mechanism of chronic low back pain. CAUTION: Only an isolated analysis of the diaphragm excursion was performed, due to the limited field of view. In ad- dition, the diaphragm excursion alone may not be sufficient to understand all mechanical actions of the rib cage and related musculature. We used a con- venience sample in which the patient and control groups differed in size and certain demographic characteristics. Because our study was cross-sectional in nature, we cannot exclude the possibil- ity that low back pain symptoms may be indicative of an initial pathogenic insult resulting in secondary quantitative as well as qualitative adaptive changes in diaphragmatic function.

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