The often overlooked relationship between the diaphram and low back pain...

The Value of Core Stabilization Exercises for Chronic LBP

Core stabilization exercises (CSEs) are a key component in the management of CLBP. During CSEs, the local muscles are activated through isometric contraction of the transverse abdominis (TrA), which causes a co-contraction of the lumbar multifidus. The lumbar multifidi, small segmental muscles of the spine which cannot be contracted consciously, provide segmental control over primary stabilizers; facilitate movement control over the entire spine in bending, extending and twisting; and maintain posture through precise control of each individual vertebra.

The Role of the Diaphragm

The diaphragm is the primary inspiratory muscle that affects the stability of the lumbar spine during postural activity. Proper activation of the diaphragm during normal breathing expands the lower ribs from inside to outside. This expansion provides space for increased intra-abdominal pressure.

The TrA acts like a corset by providing stretching forces on the fascia, which builds up the intra-abdominal pressure that stabilizes and unloads the lumbar spine. Studies show that diaphragm fatigability is common among individuals who have recurrent LBP, thus reducing the pulling forces of TrA on the fascia, which compromises the stability of the lumbar spine.

What Research Suggests

In today’s spotlight study, “Effect of Adding Diaphragmatic Breathing Exercises to Core Stabilization Exercises on Pain, Muscle Activity, Disability, and Sleep Quality in Patients With Chronic Low Back Pain: A Randomized Control Trial,¹ the authors added specific diaphragmatic breathing exercises to current CSEs to see if this addition improved measured parameters.

Twenty-two patients with CLBP were randomly allocated to the experimental (DBE + CSE) or control group (CSE only). Each group had 12 treatment sessions three times a week for four weeks. Patients were evaluated before and after the 12 sessions.

Surface electromyography of the transverse abdominis, Oswestry Disability Index, Fear Avoidance Belief Questionnaire, Pittsburgh Sleep Quality Index, Numeric Pain Rating Scale, and chest expansion were used as outcome measures for pain, muscle activity, disability, and sleep quality. These parameters typically are negatively correlated with CLBP, in addition to numeric pain rating. For example, 55% of CLBP patients report restless sleep, chest expansion is significantly reduced in CLBP, and patients with LBP report elevated levels of fear of activities that could elicit pain.

Results showed the combination of DBE and CSE compared to CSE alone showed significant improvement in all outcome measures and improved core muscle activation and chest expansion.

The Diaphragmatic Breathing Technique

How to Perform:

• Lie on your back on a flat surface or in bed, with your knees bent and your head supported. You can use a pillow under your knees to support your legs. Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe.
• Breathe in slowly through your nose so that your stomach moves out against your hand. The hand on your chest should remain as still as possible.
• Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips. The hand on your upper chest must remain as still as possible.
• Practice these 2-5 minutes each day until it feels natural and then try it in the seated position.

Diaphragmatic Breathing Exercises and LBP Treatment: The Connection

Diaphragmatic breathing exercises are important for treating low back pain for several reasons:

Reduces Stress and Tension: Diaphragmatic breathing engages the parasympathetic nervous system, promoting relaxation and reducing stress, which is a key factor in exacerbating low back pain.

Improves Breathing Mechanics: Many people with low back pain use accessory muscles instead of the diaphragm for breathing, leading to increased tension in the neck and back. Diaphragmatic breathing helps shift the workload back to the diaphragm, reducing strain on these areas.

Enhances Core Stability: The diaphragm acts as a trunk stabilizer, supporting posture and spinal stability. Strengthening it through diaphragmatic breathing can improve core stability and reduce low back pain.

Clinical Evidence: Studies show that breathing exercises, including diaphragmatic breathing, can improve lung function, reduce back pain, and enhance quality of life in individuals with chronic low back pain.

Muscle Strengthening: Diaphragm training can increase the thickness of stabilizer muscles like the transversus abdominis and lumbar multifidus, further supporting lumbar stability.

Clinical Pearls

Diaphragmatic breathing exercises are easy to perform and safe for most patients with low back pain. Incorporating them into a chiropractic recovery program can provide significant benefits for managing low back pain and increase the effectiveness of the chiropractic treatment.

Reference

1. Masroor S, et al. Effect of adding diaphragmatic breathing exercises to core stabilization exercises on pain, muscle activity, disability, and sleep quality in patients with chronic low back pain: a randomized control trial. J Chiropr Med, 2023 Dec;22(4):275-283.