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ISBN: 978-0-7020-4980-4; PII: B978-0-7020-4980-4.00008-3; Author: Chaitow & Gilbert & Bradley; 00008
f0010 A B C D
Figure 6.1.1 ABCD Chest-spine-pelvis alignment: A Forward drawn chest position. Chest is positioned in front of the pelvis.
B Optimal alignment, chest positioned above the pelvis, normal spinal curvatures, optimal balance between the anterior and
posterior musculature. C Thorax positioned behind the lumbosacral junction. D ‘Open Scissors’ Syndrome: ‘Inspiratory’ (cranial)
chest position and an anterior pelvic tilt. Abnormal chest–pelvis relationship results in A,C,D situations in patients with
abnormal spinal curvatures in the sagittal plane and hyperactivity of the paraspinal muscles.
4 3 Ch. 2a), the thorax should be positioned so that the deficit (Fig. 6.1.1A), as well as a thorax positioned behind
anterior-posterior axis between the insertion of the dia- the lumbosacral junction, which is the result of an incor-
phragm’s pars sternalis and the posterior costophrenic rect spinal curvature in the sagittal plane (Fig. 6.1.1C).
angle is almost horizontal. The axis of the lower thoracic This malalignment is often observed in individuals with
aperture and the pelvic axis are parallel to the chest, which spinal stenosis or ankylosing spondylitis and it is typically
is ‘positioned’ above the pelvis (Fig. 6.1.1B). Only such accompanied by a kyphotic or semi-flexed posture.
an alignment allows for ideal respiratory-postural coordi- The increased activity of the upper portion of the p0050
nation between the diaphragm, pelvic floor and the abdominal musculature together with a drawing-in of the
abdominal muscles. In healthy individuals, the parallel abdominal wall are considered typical deficits. This is
cranio-caudal movement of the diaphragm and the pelvic referred to as an ‘hour-glass syndrome’ (Fig. 6.1.3). Con-
floor and the synchronous changes in the diameter of the stant isometric activation of the upper sections of the
abdominal wall occur during breathing. Therefore, posture abdominal wall and the inability to relax the abdominals
may affect the recruitment of these muscles (Talasz et al prevents the diaphragm from sufficient caudal descent
2011). Based on an ideal (physiological) standing posture during inspiration and during postural strain. Abdominal
derived from developmental kinesiology, the above movement closely correlates with diaphragmatic move-
described alignment between the thorax and pelvis and ment, in other words, abdominal movement increases
the coordinated muscle activity can be observed in a 14- to diaphragmatic excursions (Wang et al 2009). Shoulder
16-month-old healthy infant (Fig. 6.1.2). alignment should also be noted. Their protraction often
p0045 An inspiratory position of the thorax known as the suggests dominance and shortening of the pectoral
‘inspiratory alignment of the thorax’ is usually accompa- muscles. The rib cage elevates when shoulder retraction is
nied by an anterior pelvic tilt. Clinically, this abnormal attempted and there is a muscle imbalance between
posture is known as ‘open scissors’ syndrome (Fig. 6.1.1D). the upper and lower trunk stabilizers (the pectoral and
A forward shift of the thorax presents another common abdominal muscles).
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ISBN: 978-0-7020-4980-4; PII: B978-0-7020-4980-4.00008-3; Author: Chaitow & Gilbert & Bradley; 00008
95
ISBN: 978-0-7020-4980-4; PII: B978-0-7020-4980-4.00008-3; Author: Chaitow & Gilbert & Bradley; 00008
f0020 A B C
Figure 6.1.3 ‘Hour-glass syndrome’ (A,B): A Constant concentric activation of the abdominal wall, especially in its upper
section, with the umbilicus in a cranial and a ‘drawn-in’ position. Such muscle coordination results in a cranial position of the
diaphragm, limits diaphragmatic descent during postural tasks, thus altering postural stabilization. During postural activity,
the diaphragmatic excursion is small and the direction of activation is toward the centrum tendineum (blue arrows) because
the diaphragmatic attachments on the lower ribs are not stabilized via an eccentric abdominal contraction. B Clinical picture
of an ‘hour-glass syndrome’. The activity of the upper abdominal wall predominates; the patient cannot eccentrically activate
the lower section of the abdominal wall (pushing clinician’s thumbs outwards and caudally). C A diagram depicting the proper
model of stabilization. Balanced function of all the abdominal wall sections, the diaphragm descends during postural tasks and
its costal attachments are stabilized. Note opposite direction of the blue arrows and greater diaphragmatic excursion when
compared to picture A. The umbilicus moves caudally as a result of increased intra-abdominal pressure and diaphragmatic
descent. The abdominal wall expands proportionally in all the directions.
s0020 Assessment of the breathing (scalenes, pectorales, upper trapezius, etc.) are physiologi-
pattern and the diaphragm’s cally relaxed during resting breathing.
In a pathological scenario, the sternum moves cranio- p0070
respiratory function
caudally and the thorax expands only minimally while the
p0065 Movement of the ribs (thorax) and the abdominal cavity intercostal spaces do not expand. The accessory muscles
are observed. During diaphragmatic breathing, the dia- are activated during inspiration. A patient’s inability to
phragm descends caudally, flattens and compresses the perform diaphragmatic breathing suggests an insufficient
internal organs caudally. With inspiration, for example, or impaired synchronization between the diaphragm and
the kidney shifts several centimetres caudally while during the abdominal muscles. This is often caused by an inabil-
expiration it migrates cranially (Xi et al 2009). The tho- ity to relax the abdominal wall (especially the upper
racic and abdominal cavities symmetrically expand. It is portion). The nature of the breathing pattern and its
important that during physiological diaphragmatic breath- control usually correlate with the results of clinical tests
ing, the lower aperture of the thorax also expands in addi- focused on the stabilizing function of the spine.
tion to the abdominal cavity. The sternum moves ventrally. If the upper chest stabilizers (pectoralis, upper trapezius, p0075
During rib palpation, it is observed that the intercostal scalenes, SCM) dominate and pull the thorax into an
spaces expand and the lower thorax expands proportion- ‘inspiratory position’, the thoracic position is commonly
ately in the lateral, ventral and dorsal directions (Fig. accompanied by impaired costovertebral joint mobility.
6.1.4B). Simultaneously, both thumbs then palpate the This dysfunction is compensated for by movement in
dorsolateral aspect of the abdominal wall below the 12th the thoracolumbar junction even during breathing (see
rib and observe whether the palpated area expands Fig. 6.1.1D). The spine moves into extension during
during inspiration. The inhalation wave reaches as far inspiration while during expiration it moves into flexion.
as the lower abdominal wall, i.e. the patient can also With thoracic spine straightening, the entire thorax moves
breathe into the abdominal wall just above the groin cranially; however, physiologically, it should remain in
(Fig. 6.1.4A). The sternum does not change its position in a neutral position during inspiration and expiration (see
the transverse plane. The accessory breathing muscles Fig. 6.1.2).
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ISBN: 978-0-7020-4980-4; PII: B978-0-7020-4980-4.00008-3; Author: Chaitow & Gilbert & Bradley; 00008
f0025 A B
Figure 6.1.4 A,B: Assessment of the respiratory–postural function of the diaphragm. With inspiration, the individual should
be able to expand all sections of the abdominal wall while maintaining an upright sitting position and relaxed shoulders. The
clinician palpates the area above the groin from the front (A); and between and below the lower ribs from behind (B). To
assess solely the postural diaphragmatic function, the client is asked to exhale and push actively against the clinician’s fingers.
The expansion should be relatively strong, symmetrical and without any pathological synkineses (i.e. the chest, pelvis and spine
position remain neutral). The same position can be used for training. The clinician guides the patient manually and verbally.
p0080 When assessing the breathing pattern as described Assessment of the diaphragm’s s0025
above, the patient’s natural pattern is examined, i.e.
postural function
without any specific instruction or corrections. The area
between and below the lower ribs is observed and pal- During the assessment, the patient sits at the edge of a p0085
pated. Most of the patients, including individuals with treatment table, feet unsupported, arms relaxed along the
dysfunction as well as healthy individuals, do not demon- trunk. The same rule as described above is utilized. First,
strate an ideal pattern as their default movement stereo- the patient’s natural pattern is observed and then, if neces-
type. However, it is the ability to modify the stereotype sary, the patient is instructed in how to correct it. The upper
that matters. The second step of the assessment consists of extremities are freely positioned without the patient leaning
patient instruction. The patient is instructed to relax the on them. Laterodorsal portions of the abdominal wall are
upper chest stabilizers, sit upright and breathe into the palpated below the lower ribs from behind (see Fig. 6.1.4B)
lower chest cavity and into the latero-dorsal aspects of and the groin area is palpated from the front medially to
the abdominal wall as well as into the lower abdominal the anterior superior iliac spines above the femoral heads
wall above the groin. The examiner guides the patient (see Fig. 6.1.4A). The patient, while holding their breath,
verbally and manually. Most of the patients are ‘locked’ in is asked to expand the laterodorsal sections of the abdomi-
their insufficient stereotype. They cannot follow the nal wall posteriorly and laterally or to push their abdomi-
instruction and cannot modify their respiratory-postural nal wall caudally and ventrolaterally against the pressure
stereotype. The overactivity of certain muscles or muscle of the examiner’s thumbs. In this test, the abdominal wall
sections (constantly substituting for the insufficient ones), is assessed during increased abdominal pressure.
overloading of certain spinal or joint segments and finally, A symmetrical pressure of the abdominal wall against p0090
pain syndromes are all results of the constant uniformity. the examiner’s thumbs is considered to be the correct
From our experience, the ability to better modify the pattern. Through activation of the diaphragm, an eccentric
breathing and/or movement patterns and the ability to bowing out of the abdominal wall in all its sections occurs
better follow the clinician’s instructions indicate better first. This is followed by an isometric contraction of the
prognosis. The treatment will be shorter and simpler and abdominal muscles. This principle is clearly apparent in a N
the results will last longer. weightlifter when lifting a heavy load (Fig. 6, Ch. 2a). 65
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ISBN: 978-0-7020-4980-4; PII: B978-0-7020-4980-4.00008-3; Author: Chaitow & Gilbert & Bradley; 00008
p0095 The test is positive if the patient is not able to freely in the palpated area without symmetrical bowing out of
activate the palpated abdominal wall or if the pressure the lower abdomen is also considered incorrect.
against the resistance from the examiner’s thumbs is asym- Additional assessment approaches are described in p0100
metrical or bilaterally weak and the upper portion of the Chapters 6.2 Osteopathic approaches; 6.3 Physiotherapy
rectus abdominis and the external obliques dominate. Approaches; 6.4 Psychological approaches; 6.5 Question-
The abdominal wall is drawn in at its upper half and naires and manual methods and 6.6 Capnography in
the umbilicus migrates cranially (see Fig. 6.1.3A,B). The assessment of BPD.
patient also substitutes the activation of the lower abdomi- Treatment and rehabilitation methods, based on DNS p0105
nal wall with a posterior pelvic tilt. Activation of muscles methodology, are summarized in Chapter 7.1.
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ISBN: 978-0-7020-4980-4; PII: B978-0-7020-4980-4.00008-3; Author: Chaitow & Gilbert & Bradley; 00008