The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain

Regina Finta, Edit Nagy, Tamás Bender, Regina Finta, Edit Nagy, Tamás Bender

Abstract

Purpose: The aim of this study was to assess the effects of diaphragm training on low back pain and thickness of stabilizer muscles of the lumbar spine.

Patients and methods: Fifty-two individuals were recruited with a history of chronic low back pain in our randomized controlled trial. The participants were divided randomly into two groups. One of the groups took part in a complex training program and completed with diaphragm training (DT group, n=26). The control (C) group took part only in the complex training (n=21). The thickness of transversus abdominis, diaphragm, and lumbar multifidus muscle was measured with ultrasonography in two positions: lying and sitting. All muscles were assessed in relaxed and in contracted state in the lying position and in a relatively relaxed (calm sitting) and relatively contracted state (during weightlifting) in the sitting position.

Results: After the training, severity of the pain was significantly reduced in both the groups. Regarding the thickness of the muscles, there were no changes in group C. The thickness of transversus abdominis increased significantly in relaxed and in relatively relaxed state, but there were no changes in contracted and relatively contracted state in group DT. As for the diaphragm muscle, there were significant increase in the state of supine position and in relatively contracted state, but there was no notable change in relatively relaxed state. With regard to the thickness of lumbar multifidus, a significant increase was only found in the left-sided muscle in relaxed, relatively relaxed, and relatively contracted state and in case of the right-sided one in relatively contracted state in group DT.

Conclusion: Our results suggest that diaphragm training has an effect also on the thickness of other active stabilizers of the lumbar spine, such as transversus abdominis and lumbar multifidus muscles.

Keywords: chronic low back pain; lumbar stabilization; postural function; ultrasound assessment.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Flowchart of the study design. Abbreviations: C, control group; DT, diaphragm training group; VAS, visual analog scale.
Figure 2
Figure 2
The applied postures during the ultrasonography: (A) supine position; (B) prone position; (C) quiet sitting; (D) weightlifting.
Figure 3
Figure 3
The positions of the transducers: (A) transversus abdominis muscle; (B) diaphragm muscle; (C) lumbar multifidus muscle (right-sided).
Figure 4
Figure 4
Changes in the thickness of transversus abdominis muscle in supine position, in the relaxed and in the contracted states (mean ± SE). Note: *P<0.05. Abbreviations: C, control group; DT, diaphragm training group; SE, standard error.
Figure 5
Figure 5
Changes in the thickness of transversus abdominis muscle in a functional, sitting position in the relatively relaxed and in the relatively contracted state (mean ± SE). Note: **P<0.01. Abbreviations: C, control group; DT, diaphragm training group; SE, standard error.
Figure 6
Figure 6
Changes in the thickness of diaphragm muscle in supine position in the relaxed and in the contracted state (mean ± SE). Notes: *P<0.05; **P<0.01. Abbreviations: C, control group; DT, diaphragm training group; SE, standard error.
Figure 7
Figure 7
Changes in the thickness of diaphragm muscle in the functional, sitting position in the relatively relaxed and in the relatively contracted state (mean ± SE). Note: **P<0.01. Abbreviations: C, control group; DT, diaphragm training group; SE, standard error.
Figure 8
Figure 8
Lumbar multifidus muscle thickness in the prone position (mean ± SE). Note: **P<0.01. Abbreviations: C, control group; DT, diaphragm training group; SE, standard error.
Figure 9
Figure 9
Lumbar multifidus muscle thickness during sitting (mean ± SE). Note: *P<0.05. Abbreviations: C, control group; DT, diaphragm training group; SE, standard error.

References

    1. Duthey B. Lower back pain. 2013. [Accessed November 9, 2017]. Available from: .
    1. Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(6):968–974.
    1. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344(5):363–370.
    1. Panjabi MM. Clinical spinal instability and low back pain. J Electromyogr Kinesiol. 2003;13(4):371–379.
    1. Fritz JM, Erhard RE, Hagen BF. Segmental Instability of the Lumbar Spine. Phys Ther. 1998;78(8):889–896.
    1. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord. 1992;5397(4):390–397. Discussion.
    1. Hodges PW, Moseley GL. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J Electromyogr Kinesiol. 2003;13(4):361–370.
    1. Bruno P. The use of “stabilization exercises” to affect neuromuscular control in the lumbopelvic region: a narrative review. J Can Chiropr Assoc. 2014;58(2):119–130.
    1. Macintosh JE, Bogduk N, Gracovetsky S. The biomechanics of the thoracolumbar fascia. Clin Biomech. 1987;2(2):78–83.
    1. Hodges PW, Butler JE, Mckenzie DK, Gandevia SC. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997;505(Pt 2):539–548.
    1. Hodges PW, Gandevia SC. Activation of the human diaphragm during a repetitive postural task. J Physiol. 2000;522(Pt 1):165–175.
    1. Kolar P, Sulc J, Kyncl M, et al. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol. 2010;109(4):1064–1071.
    1. Ning X, Zhou J, Dai B, Jaridi M. The assessment of material handling strategies in dealing with sudden loading: the effects of load handling position on trunk biomechanics. Appl Ergon. 2014;45(6):1399–1405.
    1. Zhou J, Dai B, Ning X. The assessment of material handling strategies in dealing with sudden loading: influences of foot placement on trunk biomechanics. Ergonomics. 2013;56(10):1569–1576.
    1. Sweeney N, O’Sullivan C, Kelly G. Multifidus muscle size and percentage thickness changes among patients with unilateral chronic low back pain (CLBP) and healthy controls in prone and standing. Man Ther. 2014;19(5):433–439.
    1. Yates JW, Karwowski W. An electromyographic analysis of seated and standing lifting tasks. Ergonomics. 1992;35(7–8):889–898.
    1. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368–2383.
    1. Ki C, Heo M, Kim HY, Kim EJ. The effects of forced breathing exercise on the lumbar stabilization in chronic low back pain patients. J Phys Ther Sci. 2016;28(12):3380–3383.
    1. Janssens L, Mcconnell AK, Pijnenburg M, et al. Inspiratory muscle training affects proprioceptive use and low back pain. Med Sci Sports Exerc. 2015;47(1):12–19.
    1. Huskisson EC. Measurement of pain. Lancet. 1974;304(7889):1127–1131.
    1. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP. Arthritis Care Res. 2011;63(Suppl 11):S240–S252.
    1. Vasconcelos T, Hall A, Viana R. The influence of inspiratory muscle training on lung function in female basketball players - a randomized controlled trial. Porto Biomed J. 2017;2(3):86–89.
    1. Williamson A. Issues in clinical nursing Pain: A Review of Three Commonly Used Pain Rating Scales. [AccessedSeptember 15, 2018]. Available from:
    1. Feuerstein M, Beattie P. Biobehavioral factors affecting pain and disability in low back pain: mechanisms and assessment. Phys Ther. 1995;75:267–280.
    1. Dellve L, Ahlstrom L, Jonsson A, et al. Myofeedback training and intensive muscular strength training to decrease pain and improve work ability among female workers on long-term sick leave with neck pain: a randomized controlled trial. Int Arch Occup Environ Health. 2011;84(3):335–346.
    1. Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Med Hypotheses. 2007;68(1):74–80.
    1. Bonica JJ. Management of myofascial pain syndromes in general practice. J Am Med Assoc. 1957;164(7):732.
    1. Akbari A, Khorashadizadeh S, Abdi G. The Effect of Motor Control Exercise versus General Exercise on Lumbar Local Stabilizing Muscles Thickness: Randomized Controlled Trial of Patients with Chronic Low Back Pain. Journal of Back and Musculoskeletal Rehabilitation. 2008;21(2):105–112.
    1. Lima PO de P, de Oliveira RR, de Moura Filho AG, Raposo MCF, Costa LOP, Laurentino GEC. Reproducibility of the pressure biofeedback unit in measuring transversus abdominis muscle activity in patients with chronic nonspecific low back pain. J Bodyw Mov Ther. 2012;16(2):251–257.
    1. Storheim K, Bø K, Pederstad O, Jahnsen R. Intra-tester reproducibility of pressure biofeedback in measurement of transversus abdominis function. Physiother Res Int. 2002;7(4):239–249.
    1. Rasouli O, Arab AM, Amiri M, Jaberzadeh S. Ultrasound measurement of deep abdominal muscle activity in sitting positions with different stability levels in subjects with and without chronic low back pain. Man Ther. 2011;16(4):388–393.
    1. Hodges PW. Is there a role for transversus abdominis in lumbo-pelvic stability? Man Ther. 1999;4(2):74–86.
    1. Moseley GL, Hodges PW, Gandevia SC. Deep and Superficial Fibers of the Lumbar Multifidus Muscle Are Differentially Active During Voluntary Arm Movements 27. [Accessed September 17, 2018]. Available from: .
    1. Kolar P, Neuwirth J, Sanda J, et al. Analysis of diaphragm movement during tidal breathing and during its activation while breath holding using MRI synchronized with spirometry. Physiol Res. 2009;58(3):383–392.
    1. Kolář P, Sulc J, Kyncl M, et al. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther. 2012;42(4):352–362.
    1. Dülger E, Bilgin S, Bulut E, et al. The effect of stabilization exercises on diaphragm muscle thickness and movement in women with low back pain. J Back Musculoskelet Rehabil. 2018;31(2):323–329.
    1. Macintosh JE, Bogduk N. The biomechanics of the lumbar multifidus. Clin Biomech. 1986;1(4):205–213.
    1. Li KW, Wang CW, Yu R. Modeling of predictive muscular strength for sustained one-handed carrying task. Work. 2015;52(4):911–919.
    1. Kim E, Lee H. The effects of deep abdominal muscle strengthening exercises on respiratory function and lumbar stability. J Phys Ther Sci. 2013;25(6):663–665.
    1. Hodges P, Kaigle Holm A, Holm S. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm. Spine VivoPorcineStudies Phila Pa 1976. 2003;28(23):2594–2601.
    1. Cholewicki J, Ivancic PC, Radebold A. Can increased intra-abdominal pressure in humans be decoupled from trunk muscle co-contraction during steady state isometric exertions? Eur J Appl Physiol. 2002;87(2):127–133.
    1. Janssens L, Brumagne S, Mcconnell AK, Hermans G, Troosters T, Gayan-Ramirez G. Greater diaphragm fatigability in individuals with recurrent low back pain. Respir Physiol Neurobiol. 2013;188(2):119–123.
    1. Rezkallah SF, Abd El-Hady AA, Hamid A, Botros FF. [Accessed September 16, 2018];Sonographic Response of Diaphragmatic Excursion to Threshold Inspiratory Muscle Trainer in Elderly. 2017 85 Available from: .
    1. Haytham HM, Azza AE, ES M. NEG Response of Diaphragmatic Excursion to Inspiratory Muscle Trainer Post Thoracotomy. Int J Med Heal Sci. 2016;10(1):15–18.
    1. Caron O, Fontanari P, Cremieux J, Joulia F. Effects of ventilation on body sway during human standing. Neurosci Lett. 2004;366(1):6–9.
    1. Kuczyński M, Wieloch M. Effects of accelerated breathing on postural stability. Hum Mov. 2009;9(2):107–110.
    1. Lewit K. Relation of faulty respiration to posture, with clinical implications. J Am Osteopath Assoc. 1980;79(8):525–529.
    1. Hodges PW, Gurfinkel VS, Brumagne S, Smith TC, Cordo PC. Coexistence of stability and mobility in postural control: evidence from postural compensation for respiration. Exp Brain Res. 2002;144(3):293–302.
    1. Rankin G, Stokes M, Newham DJ. Abdominal muscle size and symmetry in normal subjects. Muscle Nerve. 2006;34(3):320–326.
    1. Harper CJ, Shahgholi L, Cieslak K, Hellyer NJ, Strommen JA, Boon AJ. Variability in diaphragm motion during normal breathing, assessed with B-mode ultrasound. J Orthop Sports Phys Ther. 2013;43(12):927–931.
    1. Kiesel KB, Uhl TL, Underwood FB, Rodd DW, Nitz AJ. Measurement of lumbar multifidus muscle contraction with rehabilitative ultrasound imaging. Man Ther. 2007;12(2):161–166.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe