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The diaphragm is obviously the primary muscle of respiration, however, it serves a secondary role as a core stabilizer. Intraabdominal pressure (IAP) is a key determinant of spinal stability- as increased intraabdominal pressure equates to improved spinal stability. IAP is largely determined by the strength and tone of the muscles forming the “abdominal canister.”  The front and sides of the abdominal canister are formed by the transverse abdominous and intercostal muscles.  The back of the canister includes the paraspinal muscles- from the superficial spinal erectors to the deeper multifidi.  The bottom of the canister is formed by the pelvic floor, while the diaphragm serves as the roof.  Together, these muscles regulate intraabdominal pressure and core stability.

Patients who suffer from lumbosacral pain often exhibit early fatigue of the diaphragm.
A recent article published in the Journal of Pain Research (1) attempts to link failed back surgery syndrome with diaphragmatic dysfunction.

 “Failed back surgery syndrome (FBSS) is a term used to define an unsatisfactory outcome of a patient who underwent spinal surgery, irrespective of type or intervention area, with persistent pain in the lumbosacral region with or without it radiating to the leg. The possible reasons and risk factors that would lead to FBSS can be found in distinct phases: in problems already present in the patient before a surgical approach, such as spinal instability, during surgery (for example, from a mistake by the surgeon), or in the post-intervention phase in relation to infections or biomechanical alterations. The dysfunction of the diaphragm muscle is a component that is not taken into account when trying to understand the reasons for this syndrome, as there is no existing literature on the subject. The diaphragm is involved in chronic lower back and sacroiliac pain and plays an important role in the management of pain perception.”

This study is an example of the emerging literature shift from pathoanatomical diagnoses (structural) to more logical pathophysiological (functional) considerations. The authors highlight possible mechanisms by which diaphragmatic dysfunction may contribute to FBSS, specifically implicating: decreased proprioceptive abilities, decreased mobility of the lumbar vertebrae, reduction in core stabilization, and altered pain perception. The authors focus on the relationship between diaphragmatic dysfunction and FBSS, but breathing dysfunction certainly contributes to low back pain long before surgery.

Learn how to quickly assess diaphragmatic function here.

Effective care requires recognizing the clinical problem, treating it effectively, and changing the habits, environment, and posture leading to that person’s condition. Chiropractors are uniquely suited to help failed back surgery patients, but more importantly, we can identify and correct dysfunction before it necessitates surgery in the first place.

Review how to retrain proper diaphragmatic function here.

To learn more, check out this 15-minute webinar for a quick synopsis of the etiology, evaluation and management of dysfunctional breathing.

1.  Bordoni B, Marelli F. Failed back surgery syndrome: review and new hypotheses. Journal of Pain Research. 2016;9:17-22.

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman


Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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