COPD Manual Diaphragm Manipulation

Research

The Manual Diaphragm Release Technique improves diaphragmatic mobility,inspiratory capacity and exercise capacity in people with chronic obstructive

pulmonary disease: a randomised trial

Taciano Rocha a, Helga Souza a, Daniela Cunha Brandão a, Catarina Rattes a, Luana Ribeiro a,Shirley Lima Campos a, Andrea Aliverti b, Armèle Dornelas de Andrade a

a Department of Physical Therapy, Universidade Federal de Pernambuco - UFPE, Recife, Brazil; b Dipartimento di Elettronica, Informazione e Bioingegneria Politecnico di Milano,Milan, Italy

Introduction

Chronic obstructive pulmonary disease (COPD) causes chronicinflammation of the airways and destruction of the lungparenchyma, which lead to structural changes and dynamiccollapse in the small airways.1 Its most striking feature isexpiratory airflow limitation (ie, the ability to perform a completeexhalation is impaired, causing air trapping and lung hyperinfla-tion).1 The hyperinflation causes the diaphragm muscle fibres,which usually lie vertically in the zone of apposition, to becomemore transversely oriented. This makes the diaphragm’s contrac-tion less effective at raising and expanding the lower rib cage, andmay even lead to a decrease in the transverse diameter of the

lower rib cage during inspiration.2,3 The diaphragm then under-goes a reduction in the number of sarcomeres to restore itspressure-generating capacity; however, as a consequence, dia-phragmatic mobility is reduced. The reduction of diaphragmaticmotion is a major risk factor for increased mortality in peoplewith COPD.4

The deterioration in airflow limitation with COPD progressesslowly, so most people who present with symptoms of COPD areelderly.5 Thus, in addition to the parenchymal abnormalities,musculoskeletal changes inherent to the ageing process contributeto worsening symptoms in these people.5 These musculoskeletalchanges include increased chest wall stiffness due to thecalcification of the costal cartilages and costovertebral joints.

Journal of Physiotherapy 61 (2015) 182–189

K E Y W O R D S

Respiratory therapyManual therapyCOPDUltrasonographyOptoelectronic plethysmography

A B S T R A C T

Questions: In people with chronic obstructive pulmonary disease, does the Manual Diaphragm ReleaseTechnique improve diaphragmatic mobility after a single treatment, or cumulatively? Does thetechnique also improve exercise capacity, maximal respiratory pressures, and kinematics of the chestwall and abdomen? Design: Randomised, controlled trial with concealed allocation, intention-to-treatanalysis, and blinding of participants and assessors. Participants: Twenty adults aged over 60 years withclinically stable chronic obstructive pulmonary disease. Intervention: The experimental group receivedsix treatments with the Manual Diaphragm Release Technique on non-consecutive days within a 2-weekperiod. The control group received sham treatments following the same regimen. Outcome measures:The primary outcome was diaphragmatic mobility, which was analysed using ultrasonography. Thesecondary outcomes were: the 6-minute walk test; maximal respiratory pressures; and abdominal andchest wall kinematics measured by optoelectronic plethysmography. Outcomes were measured beforeand after the first and sixth treatments. Results: The Manual Diaphragm Release Technique significantlyimproved diaphragmatic mobility over the course of treatments, with a between-group difference incumulative improvement of 18 mm (95% CI 8 to 28). The technique also significantly improved the 6-minute walk distance over the treatment course, with a between-group difference in improvement of22 m (95% CI 11 to 32). Maximal expiratory pressure and sniff nasal inspiratory pressure both showedsignificant acute benefits from the technique during the first and sixth treatments, but no cumulativebenefit. Inspiratory capacity estimated by optoelectronic plethysmography showed significantcumulative benefit of 330 ml (95% CI 100 to 560). The effects on other outcomes were non-significantor small. Conclusion: The Manual Diaphragm Release Technique improves diaphragmatic mobility,exercise capacity and inspiratory capacity in people with chronic obstructive pulmonary disease. Thistechnique could be considered in the management of people with chronic obstructive pulmonarydisease. Trial registration: NCT02212184. [Rocha T, Souza H, Brandão DC, Rattes C, Ribeiro L, CamposSL, Aliverti A, de Andrade AD (2015) The Manual Diaphragm Release Technique improvesdiaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronicobstructive pulmonary disease: a randomised trial. Journal of Physiotherapy 61: 182–189]! 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article

under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

J o u rn a l o fPHYSIOTHERAPY

journa l homepage: www.e lsev ier .com/ locate / jphys

http://dx.doi.org/10.1016/j.jphys.2015.08.0091836-9553/! 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Those changes hinder rib cage expansion, increase the work ofbreathing and reduce functional capacity.6,7

Given the interdependent relationship between the respiratoryand musculoskeletal systems, various manual techniques havebeen proposed for the treatment of COPD symptoms. A commongoal is increasing the mobility of the thoracic structures involved inrespiratory mechanics.8,9 The Manual Diaphragm Release Tech-nique is an intervention intended to directly stretch thediaphragmatic muscle fibres, which is described in detail intextbooks.10,11 Although this technique is widely used in clinicalpractice in some regions, it is believed that, to date, there are noquantitative studies or clinical trials evaluating the effects of thistechnique. The present study aimed to evaluate the effects of theManual Diaphragm Release Technique on respiratory function ofpeople with COPD.

Therefore, the research questions for this study were:

1. In people with COPD, does the Manual Diaphragm ReleaseTechnique improve diaphragmatic mobility after a singletreatment, or cumulatively?

2. Does the technique also improve exercise capacity, maximalrespiratory pressures, and kinematics of the abdomen and chestwall?

Method

Design

A single-centre, randomised, controlled trial was conducted inthe Physiotherapy Department of the Universidade Federal dePernambuco, Brazil, to determine the effects of the ManualDiaphragm Release Technique in adults with clinically stableCOPD. Eligible participants were randomly allocated to one of twogroups according to a random number table, which was held by aresearch associate who was not otherwise involved in the study. Toensure that allocations remained concealed until eligibility andenrolment were confirmed, the associate did not indicate to thetherapist which group the participant would be allocated to untilimmediately before the intervention. Participants who wererandomised to the experimental group received six treatmentswith the Manual Diaphragm Release Technique, while the controlgroup received six sham treatments. Outcomes were measuredbefore and after the first and sixth treatments. The researchersresponsible for outcome measurement and data analysis were notpermitted to know which group each participant belonged to. Theprotocol complied with the Declaration of Helsinki.

Participants, therapists and centre

The study’s inclusion criteria were: ex-smokers; clinicallystable (ie, no exacerbation in the previous 6 weeks); aged >60 years; and post-bronchodilator measurements of forcedexpiratory volume in one second (FEV1) < 80% predicted andFEV1 ! 0.7 of forced vital capacity (FVC).1 The exclusion criteriawere: other cardiopulmonary diseases, body mass index > 30 kg/m2, previous thoracic surgery, lack of consent, and inability tounderstand the verbal commands necessary for the outcomeassessments.

A portable spirometera was used to assess FEV1 and FVCaccording to American Thoracic Society/European RespiratorySociety criteria,12 which were interpreted against predicted valuesfor the Brazilian population.13 Age and gender were also recordedat baseline.

The interventions were applied by a single investigator, whohad 8 years of experience as a physiotherapist and 3 years ofexperience specifically treating respiratory patients. Participantswere recruited from the local university hospital. The study wasconducted in a dedicated laboratory for cardiopulmonary physio-therapy research within the Physiotherapy Department.

Intervention

Participants in both groups received six treatments, separatedby 1 to 2 days, during a 2-week period. The same therapistperformed the intervention in both groups, in order to ensuresimilar application of the experimental and sham interventions.

Participants assigned to the experimental group received theManual Diaphragm Release Technique, as shown in Figure 1. Theparticipant lay supine with relaxed limbs. Positioned at the head ofthe participant, the therapist made manual contact with thepisiform, hypothenar region and the last three fingers bilaterally tothe underside of the seventh to tenth rib costal cartilages, with thetherapist’s forearms aligned toward the participant’s shoulders. Inthe inspiratory phase, the therapist gently pulled the points ofcontact with both hands in the direction of the head and slightlylaterally, accompanying the elevation of the ribs. During exhala-tion, the therapist deepened contact toward the inner costalmargin, maintaining resistance. In the subsequent respiratorycycles, the therapist progressively increased the depth of contactinside the costal margin. The manoeuvre was performed in twosets of 10 deep breaths, with a 1-minute interval between them.

In the control group, a sham protocol was applied. Manualcontacts, duration, and positioning of the therapist and participantwere the same as in the experimental group, but the therapistmaintained only light touch with the same anatomical landmarks,without exerting pressure or traction.14 This was intended to blindall participants about their group assignment during the study.

Outcome measures

The primary outcome was diaphragmatic mobility and thesecondary outcomes were exercise capacity, maximal respiratorypressures, and abdominal and chest wall kinematics. Outcomeswere measured in both groups on four occasions: before andimmediately after the first treatment session (Pre 1 and Post 1) andimmediately before and after the sixth treatment session (Pre6 and Post 6). The only exception was exercise capacity, which wasmeasured at Pre 1 and Pre 6.

Diaphragmatic mobilityTo evaluate diaphragmatic mobility, a high-resolution ultra-

soundb with a 3.5 MHz convex transducer was used according tothe protocol suggested by Testa and colleagues.15 Each participantwas verbally instructed to perform an inspiratory capacitymanoeuvre, and each curve corresponding to the diaphragmatic[(Figure_1)TD$FIG]

Figure 1. Manual Diaphragm Release Technique. Source: Authors’ own photo.With the participant lying supine, the therapist made manual contact (pisiform,hypothenar region and the last three fingers) with the underside of the costalcartilages of the seventh to tenth ribs. During the participant’s inspiration, thetherapist pulled gently in a cephalad direction accompanying the elevationmovement of the ribs. During exhalation, the therapist deepened contact towardthe inner costal margin. On subsequent breaths, the therapist sought to gaintraction and smoothly deepen the contact. The manoeuvre was performed in twosets of 10 deep breaths, with a 1-minute interval between them.

Research 183

displacement was measured (in mm) immediately after obtainingthe images. The manoeuvres were repeated until five satisfactoryimages were obtained. The final value used in the analysis was theaverage of the three highest values that did not differ from eachother by more than 10%. All ultrasound assessments wereperformed by the same assessor, aiming to reduce evaluationbias, as recommended by Testa and colleagues.15 Figure 2 showsthe measurement of the diaphragmatic displacement during aninspiratory capacity manoeuvre performed by one of theparticipants.

Exercise capacityExercise capacity was measured with the 6-minute walk test,

which was performed in accordance with the American ThoracicSociety criteria,16 at Pre 1 and Pre 6.

Maximal respiratory pressuresMaximum inspiratory and expiratory pressures were obtained

from the residual volume and total lung capacity, respectively,according to American Thoracic Society/European RespiratorySociety criteria.12 A portable digital manometerc was used toperform the evaluation. This manometer was also used to assesseach participant’s sniff nasal inspiratory pressure by placing thenasal plug into one nostril, without contralateral occlusion. Tensniff manoeuvres were performed with maximal inspiratory effort(with 1 minute of rest between manoeuvres) and the greatest valueachieved was used in the analysis.17

Optoelectronic plethysmographyVolumes of the chest wall and abdomen, and regional variations

in those volumes with respiratory manoeuvres, were measured byoptoelectronic plethysmographyd. Eighty-nine reflective markerswere placed on the participant’s skin using a hypoallergenicadhesive over specific anatomical points of the chest wall andabdomen.18 Changes in chest wall volumes were calculated,allowing acquisition of total chest wall volume (Vcw) and thedivision into three compartments: pulmonary rib cage (Vrcp),abdominal rib cage (Vrca) and abdomen (Vab).19 These measure-ments were recorded during quiet breathing, a slow vital capacitymanoeuvre and an inspiratory capacity manoeuvre. The optoelec-tronic plethysmography was performed with the participantsitting upright. After the pre-treatment assessment was complete,the markers on the participant’s back were removed and theirpositions marked by a non-toxic pen, allowing their replacement inexactly the same location for the post-treatment assessment.

Data analysis

The immediate effect of the first application of the interventionfor each participant was calculated by subtracting the Pre 1 valuefrom the Post 1 value, with the average effect then determined asthe mean between-group difference in change, with a 95% CI. Theimmediate effect of the sixth application was analysed the sameway (ie, subtract Pre 6 from Post 6 for each participant andcalculate the mean between-group difference and 95% CI). Thecumulative effect of the repeated applications of the interventionswas calculated by subtracting the Pre 1 value from the Pre 6 valuefor each participant, and again calculating the mean between-group difference in change with a 95% CI. Analysis was by intentionto treat. Correlations between some variables were also assessedusing linear regression analysis.

The sample size was calculated using commercial softwaree

that accepts the anticipated data from each group to determinesample size. In the absence of published data to guide theanticipated values, it was decided a priori to calculate the samplesize required for the primary outcome variable (ie, diaphragmaticmobility) with power (1–b) of 80%, an a of 5%, and data from thefirst seven experimental-group participants and seven control-group participants: 88 mm (SD 5) and 62 mm (SD 19), respectively.The sample size was estimated at 12 (six per group). To account forpossible loss to follow-up, 20 participants were enrolled.

Results

Flow of participants through the study

Figure 3 shows the flow of participants through the study. Thebaseline characteristics of the participants are presented in Table 1and in the first two columns of data in Tables 2 and 4. The groupswere well balanced at baseline.

Compliance with the study protocol

One participant, who was allocated to the experimental group,completely withdrew from the study after the first assessment (Pre1). All other participants received all scheduled treatments asallocated by the randomisation process and were analysed in thosegroups (ie, intention-to-treat analysis).

Effect of the Manual Diaphragm Release Technique

Diaphragmatic mobilityThe diaphragmatic mobility data of both groups are presented

in Figure 4 and Table 2. The average acute effect during the firsttreatment session was a between-group difference of 2 mm infavour of the experimental technique, but this was not statisticallysignificant (95% CI –2 to 6). The average acute effect during thesixth treatment session was larger, with a between-groupdifference of 6 mm, which was statistically significant (95% CI2 to 9). When the cumulative effect of the treatments wasestimated by the change from before the first session to before thesixth session, the between-group difference was 18 mm in favourof the experimental technique, which was also statisticallysignificant (95% CI 8 to 28). Individual participant data arepresented in Table 3 on the eAddenda.

Exercise capacityThe experimental group showed a mean cumulative improve-

ment on the 6-minute walk test of 15 m (SD 14) from before thefirst session to before the sixth session, whereas the control groupdeteriorated by a mean of 6 m (SD 6). This equated to a statisticallysignificant between-group difference in change for the 6-minutewalk distance in favour of the experimental group by 22 m (95% CI11 to 32). Individual participant data are presented in Table 3 onthe eAddenda.

[(Figure_2)TD$FIG]

Figure 2. M-mode diaphragm ultrasonography. Source: Authors’ own photo.A = gallbladder, B = reference beam for M-mode evaluation, C = diaphragm, D =positioning of markers for diaphragm displacement measurements, TO =inspiratory time (s), DO = diaphragmatic displacement (mm), VO = velocity ofdisplacement (mm/s).

Rocha et al: Manual Diaphragm Release Technique for COPD184

Maximal respiratory pressuresThe mean between-group difference in change in maximal

inspiratory pressure favoured the experimental group whenanalysed as change during the first session, change during the sixthsession, and cumulative change over the course of treatments.

However, none of these were statistically significant. Maximalexpiratory pressure and sniff nasal inspiratory pressure bothshowed significant acute benefits of the Manual Diaphragm ReleaseTechnique during the first and sixth treatments. Neither measureshowed a significant benefit when cumulative change was analysed.See Table 2, and Table 3 on the eAddenda for individual patient data.

Optoelectronic plethysmographyOptoelectronic plethysmographic estimates of vital capacity

showed a significant benefit from the experimental interventionduring the first treatment (mean between-group difference inchange 295 ml, 95% CI 151 to 439) and again during the sixthtreatment (249 ml, 95% CI 114 to 383). However, no significantcumulative benefit was observed, as shown in Figure 5. Theestimates of inspiratory capacity showed a significant benefit fromthe experimental intervention during the first treatment (meanbetween-group difference in change 237 ml, 95% CI 95 to 380) but

[(Figure_3)TD$FIG]

Excluded (n = 36)• did not meet inclusion criteria (n = 27)• declined to participate (n = 9)

Control group• sham technique as above

• 4 sessions• 1 to 2 days between

sessions

Experimental group• MDR technique as above• 4 sessions• 1 to 2 days between

sessions

Pre 6Measured diaphragmatic mobility, exercise capacity, maximal respiratory pressures and OEP

(n = 10) (n = 9)

Control group• sham technique

• 2 sets x 10 breaths

Experimental group• MDR technique• 2 sets x 10 breaths

Post 6 Measured diaphragmatic mobility, maximal respiratory pressures and OEP(n = 10) (n = 9)

Control group• sham technique

• 2 sets x 10 breaths

Patients with chronic obstructive pulmonary disease contacted (n = 66)

Assessed for eligibility (n = 30)

Measured diaphragmatic mobility, exercise capacity, maximal respiratory pressures and OEP

Randomised (n = 20)(n = 11) (n = 9)

Pre 1

Experimental group• MDR technique• 2 sets x 10 breaths

Post 1 Measured diaphragmatic mobility, maximal respiratory pressures and OEP(n = 10) (n = 9)

Lost to follow-up• discontinued (n = 1)

Excluded (n = 10)• FEV1 > 80% and/or FEV1/FVC > 0.7 (n = 5)• declined to participate (n = 2)• misunderstood verbal commands (n = 1)• recent thoracic surgery (n = 1)• body mass index > 30 kg/m2 (n = 1)

Figure 3. Design and flow of participants through the trial. MDR = Manual Diaphragmatic Release, OEP = optoelectronic plethysmography.

Table 1Baseline characteristics of participants.

Characteristic Exp(n = 9)

Con(n = 10)

Age (yr), mean (SD) 71 (6) 71 (5)Gender, male:female 6:3 8:2BMI (kg/m2), mean (SD) 26 (3) 24 (4)FEV1 (%pred), mean (SD) 36 (13) 33 (12)FVC (%pred), mean (SD) 52 (17) 48 (9)FEV1/FVC (%), mean (SD) 53 (5) 49 (9)

Exp = experimental group, Con = control group.

Research 185

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Rocha et al: Manual Diaphragm Release Technique for COPD186

not during the sixth treatment. Despite this, a significantcumulative benefit of 330 ml (95% CI 100 to 560) was observed,as shown in Figure 6. When compartmental volumes wereanalysed during the inspiratory capacity manoeuvre, there wereno significant between-group differences in Vcw or Vab. AlthoughVrcp and Vrca each showed an acute benefit from the experimentalintervention during the sixth session, they each also showeddeterioration due to the experimental intervention when thecumulative effect was analysed, see the last two columns ofTable 4. Although statistically significant, these could be clinicallytrivial effects because the 95% CI around the mean estimates do notexclude effects of 18 ml or smaller. When data from the first andsixth sessions were pooled, the acute improvements in diaphrag-matic mobility and abdominal compartment volume during asession moderately correlated (r = 0.45), as shown in Figure 7. Theindividual participant data for all the optoelectronic plethysmo-graphic outcomes are presented in Table 3 on the eAddenda.

Discussion

In the present study, the Manual Diaphragm Release Techniqueproduced statistically significant improvements in diaphragmaticmobility, 6-minute walking distance and inspiratory capacity in

people with COPD. Immediate but non-cumulative benefits werealso noted in vital capacity, maximum expiratory pressure andsniff nasal inspiratory pressure. The improvement in diaphrag-matic mobility showed moderate correlation with abdominalvolume during inspiratory capacity manoeuvres.

It is not possible to compare many of the present results withother published results because the evaluation methods used inthe present study have not previously been applied to theexperimental intervention. Indeed, the Manual DiaphragmRelease Technique has undergone little research at all. The lackof studies on manual therapy in people with COPD washighlighted by Heneghan and colleagues in their systematicreview,20 which also revealed widespread non-concealment ofallocation and lack of blinding in the studies that have beenpublished. The use of these procedures in the present study istherefore one of its strengths.

The acute effects of the experimental intervention might seemto be an important outcome. However, the analysis of thecumulative effect may be more relevant because it reflects asustained effect developing over the course of treatment. The lackof reference values for diaphragmatic mobility in a largepopulation of healthy individuals weakens the comparisonbetween the present study treatment outcomes against normative

[(Figure_4)TD$FIG]

-24

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Session 1 Session 6 Cumulative

Cha

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a

b

Figure 4. Change in diaphragmatic mobility in both groups during the treatment.Exp = experimental group, Con = control group.Session 1 = acute effect of first treatment session (Post 1 minus Pre 1). Session 6 =acute effect of sixth treatment session (Post 6 minus Pre 6). Cumulative =cumulative effect of first five sessions (Pre 6 minus Pre 1). Numerical data arepresented in Table 2.a mean difference in change 6 mm (95% CI 2 to 9).b mean difference in change 18 mm (95% CI 8 to 28).

[(Figure_5)TD$FIG]

-600

-400

-200

0

200

400

600

Session 1 Session 6 Cumulative

Cha

nge

in v

ital c

apac

ity (ml)

ExpCon

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Figure 5. Change in vital capacity in both groups during the treatment.Exp = experimental group, Con = control group.Session 1 = acute effect of first treatment session (Post 1 minus Pre 1). Session 6 =acute effect of sixth treatment session (Post 6 minus Pre 6). Cumulative =cumulative effect of first five sessions (Pre 6 minus Pre 1). Individual patient dataare presented in Table 3.a mean difference in change 295 ml (95% CI 151 to 439).b mean difference in change 249 ml (95% CI 114 to 383).

[(Figure_6)TD$FIG]

-400

-200

0

200

400

600

Session 1 Session 6 Cumulative

Cha

nge

in in

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tory

cap

acity

(ml)

ExpCon

a

b

Figure 6. Change in inspiratory capacity in both groups during the treatment.Exp = experimental group, Con = control group.Session 1 = acute effect of first treatment session (Post 1 minus Pre 1). Session 6 =acute effect of sixth treatment session (Post 6 minus Pre 6). Cumulative =cumulative effect of first five sessions (Pre 6 minus Pre 1). Individual patient dataare presented in Table 3.a mean difference in change 237 ml (95% CI 95 to 380).b mean difference in change 330 ml (95% CI 100 to 560).

[(Figure_7)TD$FIG]

-10

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0

5

10

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with

one

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t (mm)

Change in inspiratory capacity with one treatment (l)

Session 1, ExpSession 1, ConSession 6, ExpSession 6, Con

Figure 7. Relationship between changes in diaphragmatic mobility and inspiratorycapacity within a single treatment (session 1 or session 6) in the trial.Exp = experimental group, Con = control group.

Research 187

data. However, if it is considered that the mean diaphragmaticmobility in 38 healthy individuals presented by Testa andcolleagues was 79 mm (SD 14),15 the cumulative effect of therepeated administration of the Manual Diaphragm ReleaseTechnique (ie, approximately 18 mm) seemed surprisingly to beenough to bring people with COPD close to the normal range ofdiaphragmatic mobility.

Given this beneficial effect on diaphragmatic mobility, it can behypothesised that the manual action on the underside of the lastfour costal cartilages allows the traction of the lower rib cage in acranial direction and that the manual compression of the tissues inthe area of insertion of the anterior costal diaphragm fibreslengthens the diaphragm in its insertional zone. At the moment,this is only a speculative hypothesis, not supported by directmeasurements. This hypothesis, however, could be tested in futurestudies, again by ultrasound, placing a larger probe at themidaxillary line in order to perform a quantitative evaluation ofthe diaphragm’s zone of apposition, as previously suggested.21

According to Aliverti and colleagues,21 in healthy people,accurate continuous measurements of abdominal volume varia-tions allow estimation of instantaneous diaphragm displacementduring quiet breathing, accounting for 89% of the variability ofdiaphragm displacement in the zone of apposition, whereas ribcage displacement accounts for less than 1%. More recently, Prioriand colleagues22 showed similar results in people with COPD,where change in Vab accounted on average for 76% of diaphrag-matic displacement in the zone of apposition during quietbreathing in the seated position. The results of the present study,as shown in Figure 7, regarding the relationship betweenabdominal displacement (assessed by optoelectronic plethysmog-raphy) and diaphragmatic motion (assessed by ultrasound) duringthe inspiratory capacity manoeuvre confirm that these twomeasures of diaphragmatic displacement were correlated, al-though with a smaller regression coefficient. This might be becausein the previous studies it was possible to record both measure-ments simultaneously, with diaphragmatic motion being assessedby placing the ultrasound probe on the lateral rib cage, thusallowing visibility of the markers. In the present study, diaphrag-matic motion was assessed by placing the ultrasound probe on theanterior subcostal abdominal surface. It was therefore not possibleto achieve simultaneous measurements and this probably led tothe lower regression coefficient. Nevertheless, the significanteffects of the intervention on diaphragmatic motion werecorroborated by two independent methods of evaluation.

To date, no studies have evaluated changes in tidal volume bystudying thoraco-abdominal kinematics in people with COPD aftermanual therapy techniques. Wilkens and colleagues observed thatdespite the structural remodelling of the diaphragm in thispathology, its ability to generate tidal volume remains preserved.23

Despite this preserved capacity to generate not only tidal volume,but also tension,24 of the diaphragm muscle in people with COPD,the compensatory adjustments that have been reported in theliterature in terms of muscle remodelling25 may not ensure normaldiaphragmatic function in the presence of the persistent altera-tions in its geometry and coupling with the chest wall.26 Thepresent hypothesis was that direct intervention on the diaphragmand the chest wall, irrespective of residual diaphragm muscleability to generate force, can partially reverse muscle remodelling,namely attenuating the shortening of the length of sarcomeres.

In people with obstructive lung disease, inspiratory capacityrepresents the operating limits for tidal volume expansion duringthe increased ventilation of exercise. Moreover, this variable canpredict the peak symptom-limited oxygen uptake and is adeterminant of exercise performance in these people.27 Thecomparison of inspiratory capacity values between the presentparticipants and healthy individuals would be biased by thephysiopathology of this disease. Thus, the cumulative improve-ment of inspiratory capacity after the treatment (ie, approximately330 ml) should be considered together with the functional gain inexercise capacity. The between-group difference in 6-minute walk

distance in favour of the experimental group was slightly higherthan the value presented as the smallest worthwhile effect ofpulmonary rehabilitation in people with COPD.28 According toMacNamara and colleagues, from the patient’s perspective, anincrease of 20 m on the 6-minute walk test can make the costs,risks and inconvenience of 8 weeks of pulmonary rehabilitationworthwhile.28 Given that the Manual Diaphragm Release Tech-nique is a more passive treatment administered in shorter sessionsover 2 weeks, people with COPD would presumably consider the22 m improvement worthwhile.

The cumulative analysis in this study demonstrated somesubstantial effects, but this may only represents effects maintainedsince the preceding treatment (ie, 1 or 2 days earlier). If the effectsobserved in this study were shown to be sustained for a longerperiod, a combination of manual therapy with pulmonary rehabili-tation programs may be appropriate, as previously performed byZanotti and colleagues.29 In their study, the group that receivedrehabilitation with manual therapy showed significantly greaterbenefits in residual volume and 6-minute walk distance. Unfortu-nately, the authors did not describe the manual techniques used.29

The acute changes in maximal respiratory pressures may berelated to a learning effect because no significant cumulative effectof the treatment on those variables (as determined by the changefrom Pre 1 to Pre 6) was found. Therefore, despite the increase indiaphragmatic mobility, the intervention did not appear to lead toany sustained improvement in the pressure generation of themuscle. This suggests that the proposed intervention has lowinfluence over the diaphragm’s contractile properties.

A limitation of the present study was that the study cohort wasnot sufficient to allow the effect of the experimental intervention tobe analysed in different subgroups such as age or disease severity.However, the study cohort was representative of many people withCOPD and subgroup analyses could be examined in a larger study.

Given that chest wall stiffness results from calcification of thecostovertebral joints, intervertebral discs and costal cartilages inthe elderly, causing the decline in vital capacity,6 it might behypothesised that the increased overall chest wall expansionobserved in the experimental group, as seen in the increased vitalcapacity, is partly due to the effects imposed by this technique (ie,traction of the lower rib cage in a cranial direction). Duringrepeated respiratory cycles, the technique may have promoted themobilisation of rib cage joints and increased the range of motion ofthe entire rib cage. Nevertheless, it is difficult to comment aboutthe effects of the proposed manual release technique on the chestwall as no studies are reported in the literature. Therefore, anotherhypothesis, to be confirmed in future studies, is that the techniqueacts both on diaphragm length and lower rib cage compliance.

In conclusion, the present study has demonstrated that theManual Diaphragm Release Technique improves diaphragmaticmobility, inspiratory capacity and exercise capacity, suggesting thatit should be considered in the management of people with COPD.

What is already known on this topic: People with chronicobstructive pulmonary disease (COPD) have impairment ofexpiratory airflow, lung hyperinflation, flattening of the dia-phragm and reduced exercise capacity. Many people withCOPD are older adults, so the natural reduction in chest wallmobility with age may exacerbate their respiratory limitation.What this study adds: The Manual Diaphragm ReleaseTechnique applies manual pressure under the costal margin,with the intention of stretching the lower thoracic cage and theinsertional fibres of the anterior diaphragm. Six sessions of thistechnique lead to cumulative improvements in diaphragmaticmobility, inspiratory capacity and exercise capacity.

Footnotes: a Micro Loop 8, Micromedical, England. b SonoaceR3,Samsung Medison, South Korea. c MVD 3001, MDI Ltd, Brazil. d

Optoelectronic plethysmograph, BTS Bioengineering, Italy. e GPower 3.1.3, Heinrich-Heine-Universität Düsseldorf, Germany.

Rocha et al: Manual Diaphragm Release Technique for COPD188

“This course was developed and edited from the open access article: The Manual Diaphragm Release Technique improves diaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease: a randomised trial - Rocha T, Souza H, Brandao DC, Rattes C,

Ribeiro L, Campos SL, Aliverti A, de Andrade AD (2015), Journal of Physiotherapy 61: 182–189 (http://dx.doi.org/10.1016/j.jphys.2015.08.009), used under the Creative Commons Attribution License.”