The effect of stabilization exercises on diaphragm muscle thickness and movement in women with low back pain

Abstract

BACKGROUND:

Diaphragm is an important component of spinal stability. In presence of low back pain, there may be some alterations in this muscle like other muscles that are responsible for lumbal stabilization.

OBJECTIVE:

This study aims to assess the effects of stabilization exercises on diaphragm muscle thickness and motion along with lumbopelvic stability.

METHODS:

Twenty-one women with low back pain participated in the study. Stabilization exercises including motor control training were performed on treatment group ( $n=$ 11). In control group ( $n=$ 10), strentghening exercises were peformed for back muscles, abdominal muscles and hip muscles. The patients underwent a total of 30 sessions of treatment, 3 days in a week for 10 weeks. The diaphragm muscle thickness and motion was evaluated using ultrasound (US), and lumbopelvic stability was evaluated using lumbopelvic stability tests.

RESULTS:

After the treatment, in the treatment group, increase in diaphragm thickness and improvement in lumbopelvic stability were statically significant ( $p<$ 0.05). However, there were no significant changes in diaphragm motion in both groups ( $p>$ 0.05).

CONCLUSIONS:

As a result, stabilization exercises increase diaphragm muscle thickness and improve lumbopelvic stability in women with low back pain. Therefore, stabilization exercises should be considered as a part of the treatment program in low back pain.

Keywords

Low back pain diaphragm ultrasound stabilization exercises general exercises lumbopelvic stability

1. Introduction

Low back pain, is a common health problem with high levels of recurrence and disability [1, 2]. When it comes to treatment, while some guidelines don’t make a statement about the effectiveness of different kind of exercises [3, 4], others indicate that some specific exercises should be used in treatment of low back pain [5]. Spinal stabilization exercises are effective treatment options for low back pain. This approach includes a healthy connection between local muscles which are responsible with lumbal stabilization and central nervous system (CSS). Mechanical stability of lumbar spine is decribed as the safe area or tolerance level that lumbar spine could resist external perturbations [6]. Transversus Abdominis (TrA), Multifidus (MU), Diaphragm ve Pelvic Floor muscles are the muscles which provide lumbar stability [7, 8]. These muscles protect spine from extra and extreme movements by being activated prior to superficial muscles [9, 10]. In presence of low back pain, changes such as delayed activation of TrA between 50–450 ms [11], decreased activity of MU [12] , fatigue [13], and waste of muscle mass [14] were observed.

Diaphragm is the main respiratory muscle that also contributes spinal stability by activating prior to external perturbations [10], increasing intra abdominal pressure (İAP) [15, 16] and its crura’s anatomical connection to lumbar spine [17]. Kolář et al. [8] found reduced diaphragm movement in patients with chronic low back pain compared to healthy controls when isometric flexion against resistance of the upper or lower extremity was applied, mainly in the anterior and middle portions. They reported that this pattern of diaphragmatic recruitment resulted in a steeper angle in the middle-posterior part of the diaphragm and likely a greater strain during activity on the ventral region of the spinal column. Other studies indicated that there are changes in breathing pattern and motor control of lumbopelvic region [18, 19, 20], and it was shown that there is limited downward movement of diaphragm resulting limited ability of generate İAP [10, 21, 22] in people with low back pain.

Stabilization exercises aims to reorganize motor control disorders in local muscles and provide synergy between local and global muscles [23, 24]. It was shown that stabilization exercises is effective for TrA and MU muscles [7]. Diaphragm is an important muscle for stabilization and meets some serious changes in people with low back pain. Since there are no studies showing the effects of stabilization exercises on diaphragm muscle, this study may contribute the clinical implications in physical therapy and rehabilitation.

The purpose of this study is to determine the effects of stabilization exercises on diaphragm muscle thickness, movement and lumbopelvic stability.

2. Materials and methods

2.1 Participants

Twenty-one participants who reported low back pain longer than six months were recruited the study. The participants were diagnosed with lumbar degeneration using magnetic resonance imaging and clinical examination by a neurosurgery specialist. Patients with lumbar stenosis, spondylolysis, ankylosing spondylitis, moderate to severe scoliosis, malignancy, fracture, spinal cord compression, previous back surgeries, and who had any pulmonary dieases or participated in a physiotherapy program in the past 6 months were excluded.

This study met ethics committee approval in Hacett-epe University Non-interventional Ethics Committee and the procedures were conducted according to the Declaration of Helsinki. Participants provided written informed consent.

2.2 Physical features

Age (years), sex, body height (cm), body weight (kg), BMI values, pain duration (months) and jobs of the participants were recorded.

2.3 Ultrasound imaging

Patients were examined in the supine position with Aplio XG ultrasonography (Toshiba, Tokyo, Japan) by a ten year experinced radiologist. Thickness of the diaphragm was assessed using B mode ultrasound with a 7 MHz sector array transducer. Thickness of both hemidiaphram were measured at the end of expiration from transvers and sagittal images obtained at the 9th intercostal space on anterior axillary line [25]. Diaphragmatic motion was examined with the longitudinal semicoronal plane from a subcostal or low intercostal approach. Examinations were made from only right hemidiaphragm because images that were required from left hemidiaphragm were low quality due to anatomic position of the structures [26]. Excursion with quiet breathing, maximum excursion with deep inspiration, and excursion with the sniff test (quick nasal inspiration with a closed mouth) were assessed using M-mode ultrasonography with a 3.5 MHz curved array transducer from right hemidiaphragm. In the analysis, the diaphragm movement difference between inspiration and expiration in three different breathing cycles were used.

2.4 Lumbopelvic stability

Lumbopelvic stability was evaluated using a stabilizer Pressure Biofeedback Unit ${}^{\rm TM}$ (Chatanooga, Australia). With the participant lying supine on a plinth, the cushion was inflated underneath the participant’s lumbar spine to 40 mmHg. Changes in pressure during subsequent testing reflected uncontrolled movement of the lumbar spine. Prior to testing, all participants were instructed in the “abdominal hollowing” manoeuvre that activates TrA muscle, and told to perform and continue the contraction this during subsequent lumbopelvic stability testing while attempting to minimize contraction of rectus abdominis. The procedure was conducted as decribed by Mills et al. [27] at five different levels of movements.

Scores were recorded as the highest level completed (0–5) with a pressure change no greater than 10 mmHg. The highest level attained in three trials was used for statistical analyses.

2.5 Exercise program

Eleven patients were assigned to the treatment group that stabilization exercises were performed. Ten patients were assigned to the control group and strengthening exercises for back muscles, abdominal muscles and hip muscles were performed. The program lasted for 10 weeks and 45-minute sessions occurred thrice a week under supervision of a physiotherapist.

In the treatment group ( $n=$ 11), prior to exercises, abdominal hallowing maneuver instructed to patients along with diaphragmatic breathing to activate TrA. The purpose was increasing the activity of the local muscles while keeping global muscle activity minimum. After that, global muscles activity incorporated with local muscle activity. Exercises progressed gradually. Support surface and contact points were diminished in order to improve position sense.

In control group ( $n=$ 10), strengthening exercises were performed for back muscles, abdominal muscles and hip muscles. It was considered that exercises would not cause any pain. Exercises were progressed from isometric exercises to isotonic exercises gradually.

Before every session, stretching exercises were performed in both groups.

2.6 Statical analysis

In this study, considering 20% of data loss, it was calculated in order to obtain 1% of increase in diaphragm thickness, 10 participants should be assigned each group.

The normality for continuous variables was checked by using Kolmogorov-Smirnov test. The descriptive statistics were presented mean values and standard deviation or median (min-max) according to the assumption of normal distribution. Independent samples t-test was performed to compare the means of two independent groups. Mann Whitney U test was used to compare two groups for non-parametric data. Paired sample t-test was used to determine whether there was a significant difference between the pre and post values. Wilcoxon Test was applied for the dependent group comparisons, when the data were not normally distributed. Two-way repeated measures ANOVA were used to assess the significance of continuous variables between two groups, and change within times. In addition, the interaction between time and groups were examined by using repeated measures ANOVA. Chi Square test (Fisher exact) was used to examine difference between groups for categorical variables. Relation between diaphragm thickness and age and BMI variables was evaluated by using Spearman’s rank correlation coefficient. For all the analyses, a p-value $<$ 0.05 was considered significant. Data analysis was performed by IBM SPSS Statistics 23.0 software package.

3. Results

All of 21 participants included in the study were women. Baseline characteristics are shown in Table 1. The control group had higher values of body weight ( $p<$ 0.05), other demographic characteristics were similar across groups ( $p>$ 0.05).

Table 1
Physical features of patients in treatment and control groups

	Treatment group	Control group
	( $n=$ 11)	( $n=$ 10)
	X $\pm$ SD	X $\pm$ SD	p
Age (years)	27.36 $\pm$ 8.00	32.40 $\pm$ 8.11	0.169
Height (cm)	161.63 $\pm$ 7.51	164.20 $\pm$ 6.10	0.405
Body weight (kg)	59.63 $\pm$ 5.92	68.40 $\pm$ 10.76	0.030 ${}^{*}$
BMI (kg/m ${}^{2}$ )	23.01 $\pm$ 3.56	25.49 $\pm$ 3.95	0.148
Pain duration	10.54 $\pm$ 5.29	11.60 $\pm$ 6.91	0.698
(months)

X: mean, SD: standard deviation, Student t test, ${}^{*}p<$ 0.05.

3.1 Ultrasound imaging

Pre-treatment values of diaphragm thickness and movement are represented in Table 2. Prior to treatment, the control group had higher values of diaphragm thickness ( $p<$ 0.05), but the values of diaphragm movement were similar across groups ( $p\linebreak>$ 0.05).

Table 2
Comparison of the values of diaphragm thickness and movement in both groups

	Treatment		Control
	X $\pm$ SD		X $\pm$ SD		p
Diaphragm thickness	1.75	$\pm$ 0.16	1.92	$\pm$ 0.20	0.046*
Movement (n)	21.791	$\pm$ 9.24	17.32	$\pm$ 3.27	0.157
Movement (d)	64.26	$\pm$ 20.32	71.36	$\pm$ 14.47	0.373
Movement (s)	33.40	$\pm$ 12.66	35.100	$\pm$ 14.56	0.779

Independent samples t-test, n:quiet breathing, d:deep inspiration, s:sniff, ${}^{*}p<$ 0.05.

The relationship between diaphragm thickness and age and BMI is presented in Table 3. It was shown that diaphragm thickness is correlated with both parameters (Table 3, $p<$ 0.05).

Table 3

The relationship between diaphragm thickness and age and BMI

	Age (years)		BMI (kg/m ${}^{2})$
	r	p	r	p
Diaphragm thickness	0.424	0.056*	0.543	0.011*

Spearman rho correlation coefficient, ${}^{*}p<$ 0.05.

Table 4

Comparison of Diaphragm thickness and movement values before and after the treatment

	Treatment group		Control group		time	group*time
	X $\pm$ SS		X $\pm$ SS		p	p
Diaphragm thickness
Before treatment	1.75	$\pm$ 0.16	1.92	$\pm$ 0.20	0.020*	0.020*
After treatment	1.97	$\pm$ 0.33	1.92	$\pm$ 0.20
Diaphragm movement (n)
Before treatment	21.79	$\pm$ 9.24	17.32	$\pm$ 3.27	0.868	0.693
After treatment	21.22	$\pm$ 12.05	18.70	$\pm$ 4.82
Diaphragm movement (d)
Before treatment	64.26	$\pm$ 20.32	71.36	$\pm$ 14.47	0.865	0.691
After treatment	65.36	$\pm$ 13.96	68.61	$\pm$ 15.55
Diaphragm movement (s)
Before treatment	33.40	$\pm$ 12.66	35.10	$\pm$ 14.56	0.353	0.340
After treatment	40.47	$\pm$ 11.89	35.02	$\pm$ 11.56

Repeated measures ANOVA, $p>$ 0.05, ${}^{*}p<$ 0.05, n:quiet breathing, d:deep inspiration, s:sniff.

After the treatment, when diaphragm thickness in the treatment and the control group was compared, changes within times and the interaction between time and groups were statically significant ( $p<$ 0.05). After the treatment, the increase of diaphragm thickness in the treatment group was statically significant ( $p=$ 0.002), while there were no changes in diaphragm thickness in the control group (Table 4, $p=$ 1.00).

After the treatment, when the values of diaphragm movement in the treatment and the control group was compared, changes within times and the interaction between time and groups were not statically significant (Table 4, $p>$ 0.05).

3.2 Lumbopelvic stability

Lumbopelvic stabiliy values of the participants are shown in the Table 5. After the treatment while there was a statically significant increase in lumbopelvic stability values in the treatment group (Table 5, $p<$ 0.05), there were no changes in lumbopelvic stability values in the control group (Table 5, $p=$ 1.00).

Table 5
The lumbopelvic stability values of the groups before and after the treatment

	Pre-treatment	Post-treatment	p
	median (min-max)	median (min-max)
Treatment group	1 (0-5)	5 (5-5)	0.007*
Control group	0 (0-5)	0 (0-5)	1.00

Mann Whitney U test, ${}^{*}p<$ 0.05.

4. Discussion

In this study, we investigated the effects of stabilization exercises on diaphragm muscle thickness and movement along with lumboplevic stability comparing with general exercises. As a result we concluded that stabilization exercises are more effective on increasing diaphragm muscle thickness and lumbopelvic stability than general exercises.

Low back pain is a common health problem. Studies showed that delayed activation of local muscles may be a risk factor for low back pain [28, 29]. Stabilization exercises were developed in order to train this delayed activaton of TrA, MU, diaphragm and pelvic floor muscles. Although, there are various studies that examine the effects of stabilization exercises on TrA, MU, and pelvic floor muscles [28, 30, 31, 32], there were no studies that investigate the effects of stabilization exercises on diaphragm muscle thickness and motion. Thus, we expect that our study will contribute the subject. In this study, we assessed the diaphragm thickness and motion using ultrasound. Ultrasound is a reliable and valid method for assessing the diaphragm muscle [33]. Because of the ineligible anatomic posisiton of splen and the compression of the left lung to the diaphragm especially during deep breathing [34], we used right hemidiaphragm for evaluation.

We did not come across any studies that examines the thickness of diaphragm with US in people with low back pain. There are researches that investigate the diaphragm thickness with B-mode US in healthy people [26] and in people with different groups of diseases [35, 36, 37]. Before the treatment, the mean values of diaphragm thickness were 1.75 mm and 1.92 mm in the treatment and in the control group, respectively. The values of the diaphragm thickness of our participants were similar to healthy subjects with same sex, age and BMI in other studies [33, 38]. Since, there is no evidence of that the diaphragm muscle thickness is affected in people with low back pain and our sample size is small, this result may not reflect all low back pain population. Therefore there is a need for more studies with greater sample size.

BMI and age, may affect the thickness of the diaphragm. Orrey [26] found that BMI and diaphragm thickness had a strong, and age and diaphragm thickness had a moderate relationship. Our findings are compatible with this study. In the control group the diaphragm thickness was bigger than the treatment group. We think that the difference at the begining is related to the bigger values of age and BMI in the control group.

We obtained an increase in the diaphragm thickness in the treatment group. This shows that stabilization training may increase diaphragm thickness. This is the first study that investigates the diaphragm muscle thickness in people with low back pain therefore we think that these results should be supported with other studies. Diaphragm is one of the important muscles that are responsible for providing the stabilization of the lumbal region. Hellyer et al. [39] pointed out that the increase in diaphragm thickness may be related to the increase in TrA activation. In this study, we did not assess TrA muscle, but the significant increase in lumbopelvic stability may indicate the increase of activation of TrA; thus we could say that it is related to diaphragm thickness increase. Therefore stabilization exercises may be considered as a part of the treatment program of low back pain. Based on our results, we think that, including stabilization exercises in other diseases affecting diaphragm muscle may be helpful.

In this study, pre-treatment assessment of diaphragm movement was 21 mm, 64 mm, 33 mm in normal breathing, deep breathing, sniffing in the treatment group respectively. In the control group it was 17 mm, 71 mm and 35 mm in normal breathing, deep breathing, sniffing, respectively. A study that assessed diaphragm motion with m-mode ultrasound with participants who have same BMI values compared to our patients had similar diaphragm movement values with ours [34]. Our study showed that stabilization exercises does not effect the movement of the diaphragm. Kolar et al, showed that during isometric contractions of upper and lower extremities diaphragm movements decreased in people with low back pain but did not change in healthy controls [8]. We think that the reason why diaphragm movement did not change in our study is that we did not use any forced activities during the assessment of diaphragm movement. Also ultrasound assessment may not be as sensitive as MRI for showing changes in diaphragm of people with low back pain. In addition to this, Kolář et al. [8] could investigate all parts of the diaphragm seperately but, one-dimensional images provided by US is not detailed enough to show all parts of the diaphragm that are expected to be affected in people with low back pain.

4.1 Limitations

Our study has a couple of limitations. Firstly, the control group had greater values of body weight. Secondly, we did not use any forced activities during the assessment of diaphragm movement. Lastly, greater sample size is needed.

5. Conclusions

Diaphragm is one of the important muscle that provides stability. In people with low back pain, like other muscles that provide stability, diaphragm undergoes some changes. Stabilization exercises increase diaphragm muscle thickness and improve lumbopelvic stability. Therefore stabilization exercises should be considered as a part of the treatment program of the patients with low back pain.

Footnotes

Acknowledgments

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

None to report.

References

Andersson

. Epidemiological features of chronic low-back pain. The Lancet. 1999; 354(9178): 581-5.

Fujii

Matsudaira

. Prevalence of low back pain and factors associated with chronic disabling back pain in Japan. European Spine Journal. 2013; 22(2): 432-8.

Airaksinen

Brox

Cedraschi

Hildebrandt

Klaber-Moffett

Kovacs

, et al. Chapter 4 European guidelines for the management of chronic nonspecific low back pain. European Spine Journal. 2006; 15: s192-s300.

Koes

van Tulder

Lin

C-WC

Macedo

McAuley

Maher

. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal. 2010; 19(12): 2075-94.

Manniche

. Low back pain: frequency, management and prevention from HTA perspective. 1999; Danish Institute for Health Technology Assessment.

Reeves

Narendra

Cholewicki

. Spine stability: the six blind men and the elephant. Clinical Biomechanics. 2007; 22(3): 266-74.

Hides

Stanton

Mendis

Sexton

. The relationship of transversus abdominis and lumbar multifidus clinical muscle tests in patients with chronic low back pain. Manual Therapy. 2011; 16(6): 573-7.

Kolář

Šulc

Kynčl

Šanda

Čakrt

Andel

, et al. Postural function of the diaphragm in persons with and without chronic low back pain. Journal of Orthopaedic & Sports Physical Therapy. 2012; 42(4): 352-62.

Hodges

Richardson

. Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine. 1996; 21(22): 2640-50.

10.

Hodges

Richardson

. Contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy. 1997; 77(2): 132-42.

11.

Hodges

Richardson

. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. Clinical Spine Surgery. 1998; 11(1): 46-56.

12.

Hides

Richardson

Jull

. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine. 1996; 21(23): 2763-9.

13.

Biedermann

Shanks

Forrest

Inglis

. Power Spectrum Analyses of Electromyographic Activity: Discriminators in the Differential Assessment of Patients with Chronic Low-Back Pain. Spine. 1991; 16(10): 1179-84.

14.

Hides

Stokes

Saide

Jull

Cooper

. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1994; 19(2): 165-72.

15.

Hodges

Eriksson

Shirley

Gandevia

. Intra-abdominal pressure increases stiffness of the lumbar spine. Journal of Biomechanics. 2005; 38(9): 1873-80.

16.

Beales

O’Sullivan

Briffa

. Motor control patterns during an active straight leg raise in pain-free subjects. Spine. 2009; 34(1): E1-E8.

17.

Shirley

Hodges

Eriksson

Gandevia

. Spinal stiffness changes throughout the respiratory cycle. Journal of Applied Physiology. 2003; 95(4): 1467-75.

18.

Roussel

Nijs

Truijen

Vervecken

Mottram

Stassijns

. Altered breathing patterns during lumbopelvic motor control tests in chronic low back pain: a case – control study. European Spine Journal. 2009; 18(7): 1066-73.

19.

O’Sullivan

. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual Therapy. 2005; 10(4): 242-55.

20.

Silfies

Squillante

Maurer

Westcott

Karduna

. Trunk muscle recruitment patterns in specific chronic low back pain populations. Clinical Biomechanics. 2005; 20(5): 465-73.

21.

Hodges

Heijnen

Gandevia

. Postural activity of the diaphragm is reduced in humans when respiratory demand increases. The Journal of Physiology. 2001; 537(3): 999-1008.

22.

Hodges

Gandevia

. Activation of the human diaphragm during a repetitive postural task. The Journal of Physiology. 2000; 522(1): 165-75.

23.

Richardson

Jull

Hodges

Hides

Panjabi

. Therapeutic exercise for spinal segmental stabilization in low back pain: scientific basis and clinical approach: Churchill Livingstone Edinburgh; 1999.

24.

Hodges

. Is there a role for transversus abdominis in lumbo-pelvic stability? Manual Therapy. 1999; 4(2): 74-86.

25.

Boon

Harper

Ghahfarokhi

Strommen

Watson

Sorenson

. Two-dimensional ultrasound imaging of the diaphragm: Quantitative values in normal subjects. Muscle & Nerve. 2013; 47(6): 884-9.

26.

Orrey

. The relationship between diaphragm thickness, diaphragm strength and diaphragm endurance in young, healthy individuals: Stellenbosch: Stellenbosch University; 2014.

27.

Mills

Taunton

Mills

. The effect of a 10-week training regimen on lumbo-pelvic stability and athletic performance in female athletes: a randomized-controlled trial. Physical Therapy in Sport. 2005; 6(2): 60-6.

28.

Hodges

Richardson

. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Archives of Physical Medicine and Rehabilitation. 1999; 80(9): 1005-12.

29.

Hodges

Richardson

. Transversus abdominis and the superficial abdominal muscles are controlled independently in a postural task. Neuroscience Letters. 1999; 265(2): 91-4.

30.

Hosseinifar

Akbari

Behtash

Amiri

Sarrafzadeh

. The effects of stabilization and McKenzie exercises on transverse abdominis and multifidus muscle thickness, pain, and disability: a randomized controlled trial in nonspecific chronic low back pain. Journal of Physical Therapy Science. 2013; 25(12): 1541-5.

31.

Barker

Shamley

Jackson

. Changes in the cross-sectional area of multifidus and psoas in patients with unilateral back pain: the relationship to pain and disability. Spine. 2004; 29(22): E515-E9.

32.

Hodges

Sapsford

Pengel

. Postural and respiratory functions of the pelvic floor muscles. Neurourology and Urodynamics. 2007; 26(3): 362-71.

33.

Baldwin

Paratz

Bersten

. Diaphragm and peripheral muscle thickness on ultrasound: Intra-rater reliability and variability of a methodology using non-standard recumbent positions. Respirology. 2011; 16(7): 1136-43.

34.

Boussuges

Gole

Blanc

. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest Journal. 2009; 135(2): 391-400.

35.

Pinto

Alves

Pimentel

Swash

de Carvalho

. Ultrasound for assessment of diaphragm in ALS. Clinical Neurophysiology. 2016; 127(1): 892-7.

36.

Enright

Chatham

Ionescu

Unnithan

Shale

. The influence of body composition on respiratory muscle, lung function and diaphragm thickness in adults with cystic fibrosis. Journal of Cystic Fibrosis. 2007; 6(6): 384-90.

37.

Baria

Shahgholi

Sorenson

Harper

Lim

Strommen

, et al. B-mode ultrasound assessment of diaphragm structure and function in patients with COPD. CHEST Journal. 2014; 146(3): 680-5.

38.

Orozco-Levi

Gayete

Rodríguez

Ramírez-Sarmiento

Méndez

Tous

, et al. Non-invasive Functional Evaluation of the Reserve in Fatigue and the Diaphragm Structure using Transthoracic Echography in B and M Modes. Archivos de Bronconeumología (English Edition). 2010; 46(11): 571-9.

39.

Hellyer

Andreas

Bernstetter

Cieslak

Donahue

Steiner

, et al. Comparison of Diaphragm Thickness Measurements Among Postures Via Ultrasound Imaging. PM&R. 2016.

The effect of stabilization exercises on diaphragm muscle thickness and movement in women with low back pain

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Materials and methods

2.1 Participants

2.2 Physical features

2.3 Ultrasound imaging

2.4 Lumbopelvic stability

2.5 Exercise program

2.6 Statical analysis

3. Results

Table 1 Physical features of patients in treatment and control groups

Table 2 Comparison of the values of diaphragm thickness and movement in both groups

Table 5 The lumbopelvic stability values of the groups before and after the treatment

4.1 Limitations

5. Conclusions

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Physical features of patients in treatment and control groups

Table 2
Comparison of the values of diaphragm thickness and movement in both groups

Table 5
The lumbopelvic stability values of the groups before and after the treatment