Breathing is the first and last thing we do in life and it therefore bookends our existence. Yet most of us probably take breathing for granted and pay little attention perhaps to how we breathe until we encounter difficulties.

The diaphragm, the prime instigator for inspiration, is probably one of the most important muscles in the body. Yet practitioners from many different disciplines, might not spend much time either assessing or even treating it.

Most of us are familiar with the importance of the diaphragm with regards to breathing but its function can affect posture and digestion. The act of breathing, and therefore diaphragmatic function, is very much influenced by our emotional state. How often, while under stress, do we have the tendency unconsciously to hold our breath?

My own practice is an eclectic mix of techniques acquired over the last 45 years since I first became fascinated by complementary medicine in 1975.  My training has included shiatsu, massage, reflexology, many years in 5 Element acupuncture, several Japanese style acupuncture and moxibustion approaches, sotai, ear and scalp acupuncture, nutrition, the Feldenkrais Method etc. Applied Linesiology (AK) has played a major part in my practice since 1980 and is a therapy I have taught for many years. AK greatly informs my approach to assessing and treating the diaphragm. Dr. George Goodheart DC (the founder of AK) theorised that the diaphragm was the piston that energized the meridian system. He noted that patients with a tight diaphragm were often somewhat depleted and that improving their diaphragmatic function helped their energetic state considerably.

The diaphragm is important for a number of reasons. Firstly, a significant number of acupuncture channels pass through the diaphragm. The primary channels of the stomach, spleen, kidney and liver all travel through the diaphragm. The Ren and Chong extra vessels also pass through the diaphragm’s fibres, as do the internal pathways of the lung, large intestine, heart, small intestines, triple heater and gall bladder.

The diaphragm acts as the physical barrier and interface between the upper and middle burners. It is also the bridge between the spiritual and the more mechanical digestive organs. The heart, lungs and pericardium lie above, below are all the six fu and three of the zang organs. Any ‘blockage’ here will affect the function of these organs.

Understanding the anatomy of the diaphragm is always a very good starting point and gives an insight into its nature.

Calais-Germain, in her excellent book The Anatomy of Breathing, states that the diaphragm is like

a blanket draped over the abdominal organs and is the floor for the lungs and heart, the ceiling for the liver, stomach and pancreas.”

It is a double-domed muscle forming the floor of the chest and the ceiling of the abdomen. It is thin but extremely strong and divides the lungs and heart from the abdominal organs below, and is both muscular and tendinous in nature.

The shape of the diaphragm, as seen from the front, curves into the right and left domes. At the back it reaches up to the seventh thoracic vertebrae (T7) and the base to the third lumbar vertebrae (L3). The right dome reaches as high as the upper border of the fifth rib.

The left dome may reach the lower border of the fifth rib. The difference is due to the large size of right lobe of the liver. The right half of the diaphragm is slightly more curved and higher than the left, especially during a strong expiration. The domes support the right and left lungs, whereas the central tendon supports the heart. From the side, the diaphragm appears to look like an ’inverted J.’

The diaphragm has three origins:

  • the Sternal part arising from the posterior surface of the xiphoid process;
  • the Costal part arising from the deep surfaces of the lower six ribs and
  • the Vertebral part from the spine.

The nerve supply comes from the phrenic nerve C3, 4 and 5 though primarily from C3.

The diaphragm moves about 24,000 times per day.  The word  ‘diaphragm’ is related to the Greek word for mind. The muscle is controlled by the phrenic nerve, its Greek root phren designates both mind and muscle. It’s interesting to note that over 2000 years ago the Greeks were aware of the relation between breathing and the mind.

It’s responsible for at least 70% of inspiration. As it contracts downwards it allows the lungs to expand like a concertina. The organs below are pushed down and sideways while the stomach and liver also descend. This provides a massage to the viscera.

Breathing is mostly an unconscious activity and is part of one of the primary rhythms within our bodies. We breathe on average 12-15 X a minute, the cranio-sacral rhythm is said to be 12-14, the resting pulse ideally is 72.

Essentially muscles have three basic states of existence:

  • Normatonic where there is normal tone.
  • Hypertonic where the muscle  is in a state of semi-contraction and has a reduced range of motion.  The hamstrings are a classic example of this.
  • Hypotonic where the muscle tone has slackened and the muscle fibres have lengthened.

The diaphragm can exhibit these three states though its primary tendency is towards hyper-tonicity.

In the case of a hypertonic or tight diaphragm the muscle is in semi- contraction and sits too low thus pulling on its attachments.

Back pain results since the muscle attaches to the last thoracic (T12) and first 3 lumbar vertebrae (L1-3) causing lordosis or excess curving in of the spine. Reflux and hiatus hernia is common. The lowered diaphragm means that the sphincter muscles don’t close properly and allows the stomach content to ascend into the oesophagus.

There may be other conditions such as abdominal hernia, inguinal hernias, disc prolapse (especially in men) and incontinence in women.

There are a number of possible reasons for diaphragmatic constriction: cultural taboo, fight or flight syndrome, tight clothing, trauma to the abdomen, anaesthetic etc.

As with any diagnostic method it’s important not to rely on one approach. Consequently in my own practice I use a number of different observations that hopefully corroborate my findings.

Visual observation is the first thing to do.

  • How does the patient breathe. Is it slow, rapid?
  • Are they chest or abdominal breathers.
  • Palpation can confirm if there is not enough rib swing. Is there more involvement on one side compared to the other?

Some years ago, at the beginning of a Feldenkrais Functional Integration session, while the practitioner was assessing my breathing pattern, she remarked that I didn’t breathe as much into my left rib cage compared to my right. I found this very puzzling especially as I’d been a runner in the past and would regularly do a 10 mile cross-country run on the South Downs. Surely I had good lung capacity and a well functioning rib cage? Then I remembered that in my 30’s I’d cracked a rib on the left side in a knock about football game. Where the injury was located I had restricted movement. The moment my conscious mind recognized that fact my breathing pattern began to change.

There are other ways to assess diaphragm function.

  • How long can the patient hold their breath for after a normal in breath?
  • How much thoracic mobility is there and what’s the measurable difference?

Once a diagnosis of a tight diaphragm is made then the next step is to improve its function through a number of different treatments.

There are a number of acupuncture points that can also be helpful if appropriate. I am very wary of any formulaic approach to treatment and always try to construct a bespoke treatment each session for the patient.  What worked for one patient may not for another one who may exhibit the same symptoms. In this I’m greatly guided by my training in Japanese approaches to acupuncture and moxibustion. Great emphasis is placed on palpation both as a diagnostic indicator but also as a way to assess whether your treatment has made any changes to your original palpatory findings. For instance, my original observation might be that Bladder 17 was only tender on the right.

What about some of the other points such as CV 15 etc?  In my own practice I palpate at least ten different acupuncture points including the trigger points discovered by Janet Travell. Applied Kinesiology has a number of very useful techniques particularly the stimulation of lymphatic reflexes on the breastbone as well as vascular ones on the cranium.

It’s interesting to note that Ren 15 is often regarded as the Mu or Alarm point for the diaphragm, particularly if one thinks of its name Dove Tail. This image perfectly captures the nature of the diaphragm.

It’s also interesting to note that that the first point of the Internal Dragon treatment is the master point below Ren15. Frequently, when I have thought this treatment to be appropriate, I’ve noticed considerable changes in the patient’s breathing pattern.

There are often emotional and psychological reasons for a tight diaphragm.

Consequently merely treating the physical aspect of the condition may mean that it recurs. It’s no surprise that there are many approaches to breathwork from Rebirthing to Holotropic Breathing and Reichian Therapy to name but a few. I have no personal experiences of these approaches but I presume that they can be beneficial when employed by properly trained therapists.

Many schools of meditation place great emphasis on observing the breath without attempting to control breathing.

There are also many different exercises that can improve the function of the diaphragm and can be given to patients as homework.

My own preference is one devised by Dr Tony Andreasen, who was a surgeon and taught anatomy to osteopathic students.

It’s worth bearing in mind that the diaphragm is not the only muscle involved in inspiration.

The psoas is hugely important in diaphragmatic function as well as the quadratus lumborum, lower abdominals, the anterior serratus, the intercostals, the pelvic floor muscles etc.

In conclusion, it’s my opinion that the diaphragm is one of the most important but overlooked muscles in the body. Consequently I include assessing its function with all my patients and frequently find it to be hypertonic.  My approach is continually evolving but has reached a point where there’s a sufficient body of information that other practitioners might find helpful.

Consequently I’ve taught seminars at the College of Integrated Chinese Medicine (CICM) and plan to teach a local CPD group.  I have also included information on the diaphragm in courses for kinesiologists, osteopaths and chiropractors.

This article represents a small portion of the 12,000 words of a thesis  written as part of an MA in Voice Studies at the Royal Central School of Speech and Drama in 2014.

Marek Urbanowicz

Find out more about the one day virtual workshop on the Diaphragm taking place 29th November 2020