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TO DETERMINE EFFECT OF DIAPHRAGM RELEASE ON TL PAIN IN FEMALES / K.Koul / 151
TO DETERMINE THE EFFECT OF DIAPHRAGM RELEASE ON THORACOLUMBAR PAIN IN FEMALES
Khushboo Koul , Prof Maneesh Arora
TO DETERMINE THE EFFECT OF DIAPHRAGM RELEASE ON THORACOLUMBAR PAIN IN FEMALES .
BACKGROUND: The diaphragm muscle is the main breathing muscle as well as it provides good mechanical function of the spine and sacroiliac joint, as well as affect the working of the pelvic floor muscles. It is hypothesized that structures of diaphragm may become less motile because of various unknown factors which may hinder the function of diaphragm and eventually give rise to many secondary problems. The fascial system might be involved in diaphragm dysfunction as it maintains a balance of tension and elasticity which allows for smooth, unrestricted movement of each muscle group while holding everything in place. It can be found immediately beneath the skin, around muscles, groups of muscles, bones, nerves, blood vessels, organs and cells. Fascia is everywhere. As a result of this any tension in fascia causes imbalance of tension and elasticity and hampers normal functioning of other systems . Diaphragm release is a structure specific facial release to relax the tense, horizontally oriented diaphragm fibres as a facilitator in order to access other structural systems that are inhibited in performing their intended functionality which could adversely affect the health. It evaluates and treats the dynamics of motion and suspension in relation to organs, membranes, fascia, and ligaments and increases proprioceptive communication within the body, thereby revitalizing it, and relieving symptoms of pain, dysfunction, and poor posture.
OBJECTIVE: To evaluate thoraco-abdominal tranverse fascia mobility. After application of diaphragm release, find the effect on diaphragm mobility.
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METHODS: An experimental (pre-post design) study involving 30 subjects. Using simple random sampling 30 subjects were used to treat thoracolumbar pain by the diaphragm release. Intensity of pain was evaluated by a 0-10 visual analog scale (VAS) .VAS was taken previous to the treatment followed by diaphragm release for three alternate days and then VAS taken again after the 3 alternate treatment sessions. RESULT: The mean average of VAS before the treatment was 6.37±1.47 and after intervention the mean average of VAS was 2.60±1.14. There was reduction in VAS by 3.77, which was found to be statistically significant.(p<0.001)
CONCLUSION: It is concluded that diaphragm release significantly decreases thoracolumbar pain in females.
Keywords: fascial imbalance, diaphragm release, thoracolumbar pain, diaphragm dysfunction
Fascia forms a continuous tensional network throughout the human body, covering and connecting every single organ, every muscle, and even every nerve or tiny muscle fiber.Fascia is virtually inseparable from all structures in the body and acts to create continuity amongst tissues to enhance function and support.1 The diaphragm muscle is the main breathing muscle, influencing with its contractions the respiratory activity.2It provides good mechanical function of the spine and sacroiliac joint, as well as affect the working of the pelvic and buccal floor muscles.3 With regard to anatomic attachments, a costal, a lumbar, and a sternal portion can be identified.2 The sternal part arises with two small fiber bundles from the posterior aspect of the xiphoid process, near to the apex. The costal (or lateral) portion arises from the inner and superior aspect of the last six ribs, with interdigitation with the transverse muscle of the abdomen.The lumbar portions arises from the medial, intermediate, and lateral ligaments of the diaphragm.2 and it is important to emphasize the fact that the main pillars, i.e., the medial and lateral pillars, make contact with the retropericardial and the perinephric tract.4 It is in the form of two strong tendons or crura which are continuous with the anterior longitudinal ligament of the vertebral column. The large right crus arise from the anterior surfaces of the borders and intervertebral discs of the first three lumbar vertebrae, the left crus arises from the corresponding parts of the upper two lumbar vertebrae only.5
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It is important to remember that the transversusabdominis muscle, along with the respiratory diaphragm and the pelvic floor, plays a significant role in the stability of the sacroiliac joint. Another important fascial system is the thoracolumbar fascia, which develops posteriorly from the sacral region through the thoracic region, and finally to the cervical region. The thoracolumbar fascia is essential for muscles that involve the column and diaphragmatic dysfunction will negatively affect this tissue, leading to central and peripheral symptoms4. . This is a bidirectional process, and this fascial bridge may explain pain related to the sacroiliac joint in the event of dysfunction between the diaphragm and the pelvic floor.1 There is also a close relationship between emotion, respiration, and the intervention of baroreceptors.6The intervention of the baroreceptors affects the muscle tone, as it decreases the activity of the sympathetic nervous system, reducing the contractile tone.7 Emotional experience influences the response to pain, because the pain response is not simply a neural process started by nociceptive afferents.7 Emotional states, such as anxiety or depression, and psychiatric disorders are able to negatively alter the baroreceptor response.8 Diaphragm movement changes the body pressure, as it facilitates the venous return and lymphatic flow upward.9This modulation of pressure influences the redistribution of blood.10Studies have shown that vagal afferents respond to nociceptive mechanical and chemical stimulation from the visceral area and this leads to brain stem representation of nociceptive signals.11We know that the NTS stimulates the vagus nerve. We can assume that a physiological function of the diaphragm muscle can somehow reduce the afferent nociceptive stimulation from the vagus nerve, or through adequate visceral pressure and/or proper functions of the viscera at the lowering of the diaphragm.12 As such, diaphragm dysfunction is probably under diagnosed, but should not be neglected, as it can negatively impact quality of life, can be a marker of disease severity and, in some instances, such as inthe intensive care unit, be a prognostic marker. The aim of this review is in part to provide clinicians with an overview of the possible causes of diaphragm dysfunction, but also to explore the diagnostic methods available to investigate diaphragm function and to review current and future therapeutic strategies available to patients with diaphragm weakness.13
METHODS The present study was experimental study. A sample of 30 subjects was included using simple random sampling. The subjects included in the analysis were those with age between 18 to 25 years.
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Females with thoracolumbar pain were selected. Excluded from analysis were subjects with prediagnosed PIVD, any trauma or surgery, pathology in the abdomen, Any inflammatory, infectious, malignant or metabolic disease of the spine, pregnancy.
The VAS evaluations and manual evaluations were performed before and just after treatment as the primary outcome. Subject was asked to lie in supine lying position. Therapist placed non dominant hand transversely under T12- L1 junction and dominant hand over the diaphragm area i.e. Contacting ribs borders/xiphoid processfor releasing the muscular tension and increasing the depth of the field which was palpated. It was begun by palpating on which side the tightness was present.While using one hand under the patient as a rather firm and immovable foundation ,pressure was applied from anterior to posterior with the anteriorly placed hand. Initially the pressure applied was light ,then was increased slowly until the motion was felt within the patient.When the motion was perceived, then the fascia was stretched towards the free side for 1 minute and relaxed for 1 minute. This was done in all the directions – medial lateral, superior inferior, clockwise anticlockwise. Maintain the anterior-posterior compression with just enough force to cause this inherent motion to occur and continue.15The procedure was repeated 3 times in each direction per session for 3 days alternatively. Data was recorded and analysed.
FIG 1: DIAGRAM SHOWING DIAPHRAGM RELEASE
DATA ANALYSIS AND RESULT The data was analysed using Graph Pad. Descriptive statistics were used to summarize the variables. Paired t-test was used to check the effect of diaphragm release in thoracolumbar
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pain in females. The mean average of VAS before the treatment was 6.37±1.47 and after the
intervention the mean average of VAS was 2.60±1.14. There was reduction in VAS by 3.77, which was found to be statistically significant.
Mean ± SD
<0.001 (Significant) Post -intervention 2.60±1.14
Table showing Comparison of Mean and SD between pre and post values.
Graph showing comparison of Mean and SD between pre and post values
Comparison of Mean and SD between pre and post values
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The primary findings of this study showed a significant improvement from pretest to posttest variability of VAS scores after intervention with diaphragm release (p<0.001) i.e. is statistically highly significant.
Research shows that fascia plays important roles in posture, circulation, force transfer, balance, coordination, and is one of the most common causes of musculoskeletal pain. Fascia has elastic properties much like a plastic band; it provides load transfer from our bodyweight as we move. These elastic properties are able to stretch and recoil when in an optimal state; far too often this is not the case. Restrictions such as adhesions, inflammation or scar tissue in fascia cause a pull in the fascial system, which restricts the recoil properties. These pulls , restrictions or imbalances are responsible for movement dysfunction in muscles and joints, which can lead to postural faults, pain and muscle imbalances. Most of the fascial tissues are oriented longitudinally in our body ,only four fascias are oriented horizontally ,that are : 1. Falx and tentorium 2. Thoracic inlet 3. Respiratory diaphragm 4. Pelvic diaphragm
Any dysfunction in these transverse fascias will disturb the longitudinally placed fascias giving adverse repercussions.
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FIG 4 :DIAGRAM SHOWING FOUR HORIZONTAL FASCIA
In the beginning of the intervention first the diaphragm of subjects were manually assessed which is stated by Bruno Bordoni at el (2016) in ‘Manual evaluation of the diaphragm muscle’ that A complete evaluation of the diaphragm is mandatory for several professional subjects. . It aims to describe a strategy of manual evaluation of the diaphragm, with particular attention to anatomical fundamentals, in order to stimulate further research on this less explored field.2 In the treatment diaphragm release was given which aimed to release the naturally occurring cross restrictions as diaphragm dysfunction could be a cause for several underlying problems. It is also stated by John Upledger (1983) in ‘Craniosacral therapy’ that The significant point is that abnormal hypertonus of the diaphragm is a common secondary finding in a vast number of conditions. Frequently after the primary condition is cleared, the diaphragm autonomously maintains and continues the asymmetrical tension patterns and abnormal hypertonus created within it .The dysfunctioning diaphragm then interferes not only with proper breathing activity but also with craniosacral system function and freedom of fascial mobility
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accounting for recurrent illnesses ,vague complaints of fatigue, migratory pains, the accumulation of toxic wastes due to reduced fluid mobility and gaseous exchanges , depression and general malaise.14 In one study which was done by Taciano Roca et al (2015) he stated that the hyperinflation causes the diaphragm muscle fibres, which usually lie vertically in the zone of apposition, to become more transversely oriented. This makes the diaphragm’s contraction less effective at raising and expanding the lower rib cage, and may even lead to a decrease in the transverse diameter of the lower rib cage during inspiration. The diaphragm then undergoes a reduction in the number of sarcomeres to restore its pressure-generating capacity, however reducing the diaphragm mobility. Hence these restrictions need to break to get the diaphragm muscle fibres oriented back to normal and restore the functioning of diaphragm which was hampering other related parts of the body.15 Diaphragm being such an important muscle is being neglected which is stated by Carina Hagman (2011) in ‘Breathing retraining’ that diaphragm dysfunction is probably under diagnosed, but should not be neglected, as it can negatively impact quality of life ,hence treating diaphragm dysfunction can correct several underlying problems about which we are not aware of.13 CONCLUSION It is concluded that diaphragm release significantly decreases thoracolumbar pain in females. REFERENCES 1. Kumka M, Bonar J. Fascia: a morphological description andclassification system based on a literature review. J Canadian Chiropractor Association. 2012; 56(3):179-191. 2. Bordoni B, Marelli F, Morabito B, Sacconi B. Manual evaluation of the diaphragm muscle. International Journal Of Chronic Obstructive Pulmonary Disease.2016; 11: 1949-1956. 3. Bordoni B, Marelli F, Bordoni G. A review of analgesic and emotive breathing: a multidisciplinary approach. Journal Of Multidisciplinary Healthcare. 2016; 9: 97-102. 4. Zanier E, Bordoni B. Anatomic connections of the diaphragm: influence of respiration on the body system. Journal Of Multidisciplinary Healthcare.2013; 6: 281-291. 5. Stecco C, Stecco L. FascialManulation- Practical part. FascialManuplation Association.2009: 1-3. 6. Reyes Del Paso GA, Muñoz Ladrón de Guevara C, Montoro CI. Breath-holding during exhalation as a simple manipulation to reduce pain perception. Pain Med. Epub. 2015; 16(9): 1835-1841.
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