The document discusses the relationship between diaphragm function and core stability. It states that a weak diaphragm does not provide proper support for the spine, leading to postural issues. Good diaphragm function requires coordinated activity of the abdominal wall and intra-abdominal pressure during breathing to support the lumbar spine. Evaluating diaphragm and breathing function is important for assessing core stability and treating low back pain. Treatment should address bony, articular, ligamentary, muscular and fascial aspects of the core to improve coordination between structures like the diaphragm and pelvic floor.

1. The International Academy of Osteopathy – IAO – 03/01/2015
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Diaphragm and Posture/Core Stability
Luc Peeters, MSc.Ost. & Grégoire Lason, MSc.Ost.
Joint-Principals of The International Academy of Osteopathy
Core stability refers to the abdominal muscles, the diaphragm, the perineum and the
paravertebral muscles. It also refers to the intra-abdominal pressure during breathing
and exercise. All these structures and functions must work together in correct co-
ordination to provide stability of the body during movement.
The diaphragm can be actively moved without breathing. By holding the breath the
diaphragm moves 32.5 mm, +/-16.2 mm, on average. The range of motion of the
costo-diaphragmal angle is 39 mm, +/-17.6 mm, on average, during normal
respiration and 45.5 mm, +/-21.2 mm during active motion without breathing. This
means that the diaphragm also has an important static function for the spine. A weak
diaphragm no longer provides support for the spine leading to kyphosis of the
thoracic spine and a secondary increase in cervical and lumbar lordosis. Asthenia
and a weakened diaphragm occur together.
Good diaphragm function is therefore essential for a good posture or core stability.
Good breathing expands the lower ribcage without any cranial movement of the
ribcage and is accompanied by a synchronized activity of the entire abdominal wall
which expands slightly while contracting eccentrically thus controlling the intra-
abdominal pressure.
The advantage of proper breathing versus posture or core stability means that there
is enough abdominal pressure to support the lumbar spine instead of accessory
muscle contractions.
It is therefore essential to maintain a proper intra-abdominal pressure. The abdominal
muscles (eccentric contraction) must form an opposition to the diaphragm action.
The opposing activity of the abdominal muscles increases the diaphragm’s efficiency
by ensuring the optimal length and dome shape of the diaphragm. The position of the
chest and its effect on the zone of apposition (attachments) is crucial for proper
diaphragm activation.
Postural assessment can be indicative for the quality of the core stabilization and
thus for diaphragm function. The position of chest and pelvic area are important for
diaphragm function.
The often seen combination of elevated chest and anterior rotated pelvis
compromises proper stabilization of the core.

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The ideal postural situation is that the diaphragm and the pelvic floor are more or less
parallel.
In core stability the important muscles are:
• Transversus abdominus.
• Multifidus.
• Pelvic floor muscles.
• Internal and external obliques.
• Rectus abdominus.
• Erector spinae.
• Diaphragm.
Figure 1 -
Elevated chest and
anterior rotated pelvis
Figure 2 -
Diaphragm and
pelvic floor parallel
Diaphragm
Erector spinae
Abdominals
Perineum
Figure 3 - Functional unit

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The following muscles play a minor role:
• Latissimus dorsi.
• Gluteus maximus.
• Quadratus lumborum.
• Trapezius.
Good core stability provides:
• Stiffness of the lumbar spine with lateral tension through the attachments to
the transverse processes (stabilizes rotational motions).
• Good counter-force against the apex (L3) of the lumbar lordosis.
• Prevents spinal extension.
• Counteracts the pull of the psoas m.
• Stabilizes the spine.
• Controls intervertebral compression.
• Controls vertebral translations.
• Creates a pressurized visceral cavity.
The core can be seen as functional unit that provides:
• Spinal stability.
• Intra-abdominal pressure.
• Continence.
• Breathing.
Role of the diaphragm in core stability:
• The diaphragm is the key component to core stability and the muscle can
perform its dual function of breathing and stabilization simultaneously.
• The diaphragm can perform the breathing task at a lowered position ensuring
that the stabilizing pressure is maintained throughout the breathing cycles.
• There is a close relationship between the diaphragm and the transversus
abdominis m., which contributes to as well the respiratory as the postural
control.
• In ideal diaphragm contraction (inhalation) the entire diaphragm pushes down
into the abdominal cavity and can be observed by an expansion of the lower
ribcage and the abdominal wall in all directions.
• When the diaphragm contracts it pushes down into the abdominal cavity,
which combined with the resistance created by the pelvic floor and an
eccentric contraction of the abdominal wall, increases the pressure in front of
the spine. The pressure from the front is counteracted by contraction of the
lumbar extensor muscles and the spine is fully stabilized. Without proper
diaphragm contraction the increased intra-abdominal pressure will not reach
all the way down to the lower lumbar spine, where the loading is most
prominent.

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The diaphragm in patients with low back pain:
• The lower back is stabilized by intra-abdominal pressure.
• With the persons relaxed, there is not much difference between the diaphragm
movement between people with and without low back pain.
• As soon as people with back pain apply resistance (upper or lower extremities
movements) the diaphragm moves upwards (comes higher in the thorax) and
its mobility is clearly reduced during breathing. In this case the diaphragm only
moves in its posterior part, thus pulling on the spine, which can cause even
more pain.
• There are characteristics for recognizing and diagnosing breathing pattern
disorders:
o Restlessness (neurotic type).
o “Air hunger”.
o Sighing.
o Rapid swallowing rate.
o Poor breath-holding times.
o Poor lateral expansion of lower thorax on inhalation.
o Rise of shoulders on inhalation.
o Visible hard sternocleidomastoideus muscles.
o Rapid breathing rate.
o Paradoxical breathing.
o Positive Nijmegen Test score (23 or higher).
o Reports of a cluster of symptoms such as fatigue, pain (particularly
chest, back and neck), anxiety, irritable bowel or bladder, paraesthesia,
cold extremities.
o If a patient has low back pain in combination with one of these
characteristics, treating the diaphragm, thorax and core is indicated.
How to address the core?
There are several systems to evaluate and treat:
• Bony integrity: the bones of the spine must be in a rather normal state.
Problems such as arthritis, malformation, Scheuermann disease, Bechterew
disease and similar conditions compromise the core stability. This cannot be
treated osteopathically.
• Articular and capsular mobility: the different spinal and pelvic joint must be
mobile around the normal physiological axes. Somatic dysfunctions can be
treated by the osteopath through HVLAT or mobilisations. Especially:
o The lumbar spine must be mobile towards flexion.
o The pelvis must be mobile towards posterior rotation.
o The thoracic spine must be mobile towards flexion and extension.
o The 6 lower ribs must be mobile.
• Ligamentary elasticity: the ligaments of the spine, the pelvis and the
diaphragm must be of a normal elasticity to be able to adapt to changes.

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Osteopaths can contribute with mobilisations and General Osteopathic
Treatment - GOT.
• Muscular strength, length, trophicity and tone (diaphragm, abdominals,
erector truncate, perineum, psoas): there must be a good balance between
agonists and antagonists. Osteopaths can contribute through Muscle Energy
Techniques MET and proper training of muscle chains must be advised in co-
operation with breathing training.
• Visceral abdominal congestion must be addressed.
• Intra-thoracic congestion must be addressed.
• Fascial (pleura, pericard, peritoneum) quality must be optimal.
Note: there are recently several scientific articles on the use of core stability.
Strengthening the abdominals and training of back muscles are all techniques that
were long time seen as essential for good core stability. Recent studies reveal that
there is no benefit from this approach towards prevention of injury.
When we analyse these articles we note that the different muscles are addressed
separately. This is not the aim of a good core stability treatment and training. The
muscular system works in co-ordination and should be treated accordingly.
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