A Randomized Controlled Trial of The Diaphragmatic Manual Therapy on Respiratory and Cardiovascular Functions in Severe Pneumonia Patients

Mai M. Saleh ^1*, Mohamed T. Said ², Sawsan B. Elsawy ³,  Zeinab R. Adawy ^3,4, Amr I. Shehata 5, Taher S. Abd-Elkareem ⁶, Marwa M. El. Abdelrahman Ahmed ⁷, Heba A. Shoman ⁸, Eman  R. M. Mostafa ⁸, Amal k. A. Abouelnour ⁹, Eman Wahsh ¹⁰, Ghada M. M. Salah Eldin ¹¹, Sara N. M. Mousa ¹², Passant M. Hewady ¹³

This study demonstrated diaphragmatic manual therapy significantly improves diaphragmatic excursion and respiratory function in severe pneumonia patients, enhancing overall prognosis.

Abstract

Background: Pneumonia is the leading cause of ICU admissions and a common secondary infection in critically ill patients, often leading to septic shock and requiring respiratory support. The role of diaphragmatic and right ventricular (RV) function evaluation in pneumonia prognosis is not well understood. Diaphragmatic manual therapy, including diaphragmatic stretch and manual diaphragm release, aims to improve respiratory function by enhancing diaphragm mobility and flexibility. Methods: This randomized controlled trial included hospitalized adults with severe pneumonia at Tanta Faculty of Medicine, Beni-Suef Faculty of Medicine, and Zhraa Hospital, Faculty of Medicine for Girls. Participants were randomly assigned to a control group receiving standard medical treatment or an interventional group receiving additional diaphragmatic manual therapy. The interventional group was further divided into two subgroups: one receiving the diaphragmatic stretch technique (DST) and the other the manual diaphragm release technique (MDST). Diaphragmatic excursion (Dex), RV and pulmonary functions were evaluated using ultrasonography and echocardiography before and after the interventions. Results: Thirty cases were included, with ten patients in each group. There were significant improvements in pulmonary function tests (FEV1/FVC), arterial blood gases, and diaphragmatic mobility in the interventional groups compared to the control group. Both DST and MDST showed significant improvements in diaphragmatic excursion and RV functions. However, there were no significant differences between the two techniques. Conclusion: Both DST and MDST can be safely recommended for patients with severe pneumonia to improve diaphragmatic excursion, chest expansion, and RV functions. These findings suggest that diaphragmatic manual therapy could be an effective adjunctive treatment in the management of severe pneumonia, warranting further research to explore its long-term benefits and applications.

Keywords: Severe pneumonia, Diaphragmatic manual therapy, Diaphragmatic excursion, Respiratory function, Pulmonary function tests

References

Abdelaal, A. A., Ali, M. M., & Hegazy, I. M. (2015). Effect of diaphragmatic and costal manipulation on pulmonary function and functional capacity in chronic obstructive pulmonary disease patients: Randomized controlled study. International Journal of Medical Research & Health Sciences, 4(4), 841. doi: 10.5958/2319-5886.

Atchison, J. W., Tolchin, R. B., Ross, B. S., & Eubanks, J. E. (2021). Manipulation, traction, and massage. In Braddom's Physical Medicine and Rehabilitation (pp. 316-337). Elsevier.

Bordoni, B., Marelli, F., Morabito, B., & Sacconi, B. (2016). Manual evaluation of the diaphragm muscle. International journal of chronic obstructive pulmonary disease, 1949-1956.

Braga, D. K., Marizeiro, D. F., Florêncio, A. C., et al. (2016). Manual therapy in diaphragm muscle: effect on respiratory muscle strength and chest mobility. Manual Therapy, Posturology & Rehabilitation Journal = Revista Manual Therapy, 1(14).

Chaitow, L. (2002). “Osteopathic assessment and treatment of thoracic and respiratory dysfunction,” in Multidisciplinary approaches to breathing pattern disorders, L. Chaitow, D. Bradley, and C. Gilbert, Eds..

Chukwu, S. C., Egbumike, C. J., Ojukwu, C. P., Uchenwoke, C., Igwe, E. S., Ativie, N. R., ... & Uduonu, E. M. (2022). Effects of Diaphragmatic Breathing Exercise on Respiratory Functions and Vocal Sustenance in Apparently Healthy Vocalists. Journal of Voice.

Demi L, Wolfram F, Klersy C, De Silvestri A, Ferretti VV, Muller M, Miller D, Feletti F, Welnicki M, Buda N, Skoczylas A, Pomiecko A, Damjanovic D, Olszewski R, Kirkpatrick AW, Breitkreutz R, Mathis G, Soldati G, Smargiassi A, Inchingolo R, Perrone T. New International Guidelines and Consensus on the Use of Lung Ultrasound. J Ultrasound Med. 2023 Feb;42(2):309-344. doi: 10.1002/jum.16088. Epub 2022 Aug 22. PMID: 35993596; PMCID: PMC10086956.

Duncan, R. (2021). Myofascial release. Human Kinetics.

ELIMY, D. A., EZZELREGAL, H. G., & ELSAYED, M. M. (2022). Influence of manual diaphragm release technique combined with inspiratory muscle training on selected persistent symptoms in men with post-Covid-19 syndrome: a randomized controlled trial. Journal of Rehabilitation Medicine, 54.

Fernandez-Lopez, I., Pena-Otero, D., De los Angeles Atin-Arratibel, M., & Eguillor-Mutiloa, M. (2021). Effects of manual therapy on the diaphragm in the musculoskeletal system: a systematic review. Archives of Physical Medicine and Rehabilitation, 102(12), 2402-2415.

Gonzalez-Álvarez, F. J., Valenza, M. C., Torres-Sánchez, I., et al. (2016). Effects of diaphragm stretching on posterior chain muscle kinematics and rib cage and abdominal excursion: A randomized controlled trial. Brazilian Journal of Physical Therapy, 20(5), 405–411.

Jones, B. E., D. D. Herman, C. S. Dela Cruz, G. W. Waterer, J. P. Metlay, J. K. Ruminjo, & C. C. Thomson. (2020). Summary for Clinicians: Clinical Practice Guideline for the Diagnosis and Treatment of Community-acquired Pneumonia. Ann Am Thorac Soc, 17(2), 133-138.

Metlay JP, Waterer GW, Long AC, et al. (2019). Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. American Thoracic Society Documents.

Mittal, R., Chourasia, N., Bharti, V. K., Singh, S., Sarkar, P., Agrawal, A., Ghosh, A., Pal, R., Kanwar, J. R., Kotnis, A. (2022). Blood-based biomarkers for diagnosis, prognosis, and severity prediction of COVID-19: Opportunities and challenges. J Family Med Prim Care, 11(8), 4330-4341. doi: 10.4103/jfmpc.jfmpc_2283_21.

Mukherjee, A., Chakravarty, A. (2010). Spasticity mechanisms - for the clinician. Frontiers in Neurology, 1.

Noll, D. R., Degenhardt, B. F., Johnson, J. C., Burt, S. A. (2008). Immediate effects of osteopathic manipulative treatment in elderly patients with chronic obstructive pulmonary disease. The Journal of the American Osteopathic Association, 108.

Roberts, A., Harris, K., Outen, B., Bukvic, A., Smith, B., Schultz, A., ... & Mondal, D. (2022). Osteopathic manipulative medicine: a brief review of the hands-on treatment approaches and their therapeutic uses. Medicines, 9(5), 33.

Rocha, T., Souza, H., Brandão, D. C., et al. (2015). The MDST Technique improves diaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease: A randomised trial. Journal of Physiotherapy, 61(4), 182–189.

Rocha, T., Souza, H., Brandão, D. C., Rattes, C., Ribeiro, L., Campos, S. L., ... & De Andrade, A. D. (2015). The manual diaphragm release technique improves diaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease: a randomized trial. Journal of physiotherapy, 61(4), 182-189.

Rocha, T., Souza, H., Brandão, D. C., Rattes, C., Ribeiro, L., Campos, S. L., ... & De Andrade, A. D. (2015). The manual diaphragm release technique improves diaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease: a randomised trial. Journal of Physiotherapy, 61(4), 182-189.

Roshan, P. S. B., & and Niranjan Meenar, S. S. (2021). Effectiveness of diaphragmatic breathing exercise and Jacobson’s progressive muscle relaxation on cardio pulmonary parameters in pre-hypertensive patients. International Journal of Physical Education, Sports and Health, 8(6), 01-05.

Saad M, Pini S, Danzo F, Mandurino Mirizzi F, Arena C, Tursi F, Radovanovic D, Santus P. (2023). Ultrasonographic Assessment of Diaphragmatic Function and Its Clinical Application in the Management of Patients with Acute Respiratory Failure. Diagnostics (Basel), 13(3), 411.

Shebl E, Gulick PG. Nosocomial Pneumonia. StatPearls [Internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535441/.

Siatras T. A, Mittas V. P, Mameletzi D. N,et al The duration of the inhibitory effects with static stretching on quadriceps peak torque production. The Journal of Strength and Conditioning Research, 22(1), 40–46.

Turton P, ALAidarous S, Welters I. (2019). A narrative review of diaphragm ultrasound to predict weaning from mechanical ventilation: where are we and where are we heading? Ultrasound J, 11(1), 2. doi: 10.1186/s13089-019-0117-8.

Yilmaz Yelvar G. D, Cirak Y, Parlak Demir Y, et al. (2016). Immediate effect of manual therapy on respiratory functions and inspiratory muscle strength in patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease, 11(1), 1353–1357.