 on Think Tech Hawaii. I'm Christine Linders, your host and physical therapy orthopedic clinical specialist. I've been back treating patients since Friday at East Oahu Physical Therapy in Aina Jaina here in Oahu. And it's been great to see familiar faces and that so many people have been doing their home exercise programs while we were away on quarantine. That's so important. Today, I'm thrilled to have a returning guest, Dr. Mary Massery, for part two of our talk on the diaphragm, which is such a critical point of interest doing this COVID-19 pandemic. Dr. Massery has been a physical therapist for over 43 years, achieved her doctor in physical therapy as well as her doctor of science and has been invited to give over 900 presentations in the United States as well as 18 countries abroad. Her research pioneered the concept of managing trunk pressures as a new way to visualize core stabilization. And she earned the highest of honors at the American Physical Therapy Association Awards, the Florence Kendall Practice Award for Outstanding and Enduring Contribution to the Practice of Physical Therapy. Let me welcome Dr. Mary Massery to talk about the diaphragm and how to use it, not only to breathe, but to enhance posture, decrease reflux, low back pain and so much more. Welcome, Mary, and thank you so much for joining us on Movement Matters to share your knowledge with us. You're so welcome, Christine. It's fun to be back. It was a lot of fun last time and we barely got a chance to scratch the surface. So I think it's a nice time to come back and see where we can take it from here. That's great though. I think it's so important to see where you came from and to learn what inspired you to get into this. I was fascinated with this. So today we'll go on about how the diaphragm has way more functions than you think. Yeah, yeah. I'm shutting off some more. Can we jump right in? Let's jump right in. So I learned in your class about the diaphragm and I know I was so impressed about its impacts on reflux because I just didn't realize there are functions in a diaphragm. Why don't you share some with us? Yeah. So I think probably the easiest thing to do would be to put up that picture of the gastric junction. All right, so for those of you looking at this picture, if you're not used to looking at anatomy, we're actually looking from the bottom, like the pelvic floor, up and under the diaphragm, right in the front. I don't know if they can see my cursor. Can, nope, they can't see my cursor. But right in the very front where the two blue pieces come together. Well, it's the little blue circle almost, right? No, it's the, we're looking at where the blue is around the rim. And then you have right in the center, which I just can't point to with this. Let's see, can I do animations, Eric? Can you give me that, that skill? Okay, all right, well, you're looking up and under. Look at the very, very top. You see a little bit of yellow. That is the bottom of your sternum. That's called the xyfoid process. Then on either side in that big circle, you're gonna see a blue rim, and that's part of the cartilage that makes up the base of the rib cage, just giving you an orientation. And then you follow those ribs all the way around, they come back to the spine. So now look up and underneath, you see a huge parachute and that is the diaphragm. The red part is actually the diaphragm muscle fibers and the white part is the diaphragm's tendon. Now, what's really important to understand with the diaphragm is that there's only three vessels that come through that diaphragm. On the left side, inside the white part, that's called the central tendon of the diaphragm, you're gonna see a blue circle and that's your inferior vena cava. That's what brings all your blood up from your lower body up to your heart. If you look slightly to the right of that, you're gonna see a circle that looks like it was squashed, kind of like a banana that was sat on. And that is your esophagus. So that's gonna go down into your stomach. And then all the way back against the spine, you can see what looks like a blood vessel because it's a really important blood vessel. That's called your aorta and that's coming from your heart. It comes through the diaphragm, goes to the lower body and delivers all your arterial blood, all your arterial blood for your lower body. So these are three really important aspects that we're gonna look at with the diaphragm. So we're looking from the bottom and going up towards the top. And when you come up towards the top, anything above that diaphragm is part of the lungs and the heart and anything down below would be part of all your intestines and your nominal vera. So we know the diaphragm's a respiratory muscle, that's one thing that's easy. Everybody knows that. I don't care what line of work you're in, you know the diaphragm's important for breathing. But the diaphragm's also really important as a barrier for reflux. So if you've gotten heartburn and that is the layman's term for it, if you've gotten heartburn right at that squished banana in the red portion of the diaphragm, right in the center of the diaphragm, that's your esophagus and that's called your gastric junction. At that level, the diaphragm and the esophagus actually work together like a force couple and maybe if we can go back to my picture, if you would, thank you. Okay, so we're gonna look at this here. I'm gonna turn my hands, make it a little bit easier to see and just make sure I'm back in here. So this is the diaphragm. And excuse me, this is the esophagus and the food is gonna go through here and it's gonna come out the bottom and come into your stomach. This, my right hand, is going to represent the diaphragm. The diaphragm squeezes the esophagus right where the food comes through the diaphragm and into your stomach. So the diaphragm and the little sphincter in the esophagus work together like a force couplet to prevent the food from coming back up and causing reflux. So if you have a weak diaphragm, you may actually have reflux that is caused not by eating spicy food or some kind of gastric disease, but actually poor biomechanics to help to keep your diaphragm as an active component as a reflux barrier. It actually provides 50% of the reason you don't reflux, which is huge. That's unbelievable. I wonder, I know people can have diaphragm weakness from different reasons, but can being very slouched over or hunched over as you would be when you get older or after you've been in a hospital stay and your posture almost is a week and you find that you've been in bed for weeks, like maybe these people coming out of the COVID crisis are weak in their posture. Can that, no, I know that would be weakness in the diaphragm, absolutely. But can sitting slouched for 30 years make your diaphragm weak and make you more prone for that inability to use it as a 50% anti-reflex mechanism? Yeah, it can be. When you bend in half, so you're up nice and tall and you're sitting here and here is your trunk, okay? So if you slouch down like this, you're actually compromising the diaphragm in the middle. So your posture as you're sitting, if my upper body is just collapsing upon itself, I can take away the mechanical advantage of the diaphragm. So it's not technically weak, it's just not in a good position to actually operate effectively. So if I can sit up straighter, I actually help that diaphragm function at a better level. And if I can't do that, one of the, or maybe I'm having difficulty maintaining that, part of your postural retraining should include diaphragm strengthening, like with an inspiratory muscle training. I believe we talked about that last week, didn't we? Or two weeks ago? We talked a little bit about the cystic process and how you can get incontinence from the chronic coughing from the pelvic floor not being a stable base. But I would love to talk about the inspiratory muscle training or training with the posture. Because I know I've used it on family, friends, patients with the trying to sit up better when they're eating and being mindful of that or standing up after and doing this breathing to give the diaphragm the proper excursion to desend and squeeze, like you were showing our viewers around that to prevent the reflex from kind of making inefficient from being in your normal slumped over posture that you may not be aware that you're in. I think the thing that's exciting about an inspiratory muscle trainer is those of your viewers who have zero medical background, they know nothing. All they know is they don't breathe that well. I don't have lung disease, but maybe I have poor posture. Maybe I'm just out of shape. Okay. And one of the things they're noticing, maybe they're 50 years old and they say, oh, I used to exercise a lot. I don't anymore. I've gained a little bit of weight and they just feel uncomfortable and they're winding up getting more reflux and the doctor is saying you need to take medications. Well, considering that your reflux can be both physiologic, there's a problem with how the food goes down and interacts with your chemistry. There's also that biomechanical barrier with the diaphragm. So if you use an inspiratory muscle trainer, which if you want to think of it in its simplest form, it would be a tiny straw from Starbucks. So if I had a tiny straw and I had to suck in against a lot of resistance of the tiny, tiny opening with that straw, that essentially becomes like a barbell for doing your weight training with your arm. You're now doing it for your respiratory muscles. So an inspiratory muscle trainer just simply gives you resistance to inspiratory effort. And because the diaphragm is a huge part of the biomechanical support to prevent reflux for you, as you strengthen the diaphragm, it may, with fingers crossed, decrease your reflux symptoms. There's actually some beautiful research that supports this and in some cases, that's all the patients do is some breathing retraining, some breathing exercises, like with the inspiratory muscle trainer and maybe some postural retraining. But none of that, that is that hard. If you can get away with doing that and not taking medication and you wind up not having symptoms of reflux, why wouldn't you do it? Now, if that doesn't work, you might need medications, you might need surgery. So there's certainly many different levels of medical support. You wanna talk to your whole team, your physical therapist as well as your doctor, but inspiratory muscle training, the worst thing that would happen is that you've got stronger. What's the down size side of that? It's like, oh, it's really a bummer, I got stronger. I would tell my patients, yeah, no, that's the worst thing that you could do is get stronger. I would tell my patients that you have, if you can't do a straw or you don't feel comfortable with a straw, then just use your own inspiratory muscle trainer and form your lips into a small hole and suck into the resistance. And one of my friends said, well, wait, you're gonna get all those wrinkles around your lips. So they suggested I do, then do it that way to increase the resistance through like the Joker grimace. Oh my gosh, that's so funny. That's hysterical. I would rather people just get a straw. That is so funny. The best thing would be, there's a lot of different inspiratory muscle trainers and I don't have any financial arrangements with any company, but my favorite is the one that is currently available without a prescription, it's very simple. Athletes can get it every day, people as well as any kind of medical patient. And that is called the breather. It says basic a name as possible and you can get it through Amazon. It's really breathing somewhere. Yes, the breather. And it has different levels of resistance on it. And the typical program is that you wanna build up to 15 minutes of resistance at the lowest level. So you have a very little resistance and then once you can do it for 15 minutes, then you're gonna add some resistance in the middle. So kind of a warm-up, a peak performance and then a cool down at the end until you can do that level at 15 minutes and then you add another level of resistance in the middle. So most of the resistive trainers have at least three, maybe six different levels of resistance and you don't have to get to the hardest level. Get to the one that challenges you, makes you a little shorter breath, but not uncomfortable. All right, that's great, Mary. So what about the cystic fibrosis case and people such as myself, who since I moved to Hawaii have become a chronic coffer with the allergies and helping to stabilize that soda pop canister from the bottom side using pelvic floor muscles when you have to cough say all night long because you have the post nasal drip or you do have disease such as cystic fibrosis or other diseases that require you to cough or even now people that are just coughing from different chronic coughs that they would have bronchitis and things like that. Okay, and I'm just gonna tell you I've been looking away a lot because my two-year-old grandson is trying to get in my office simply because I'm not letting him in, right? So in case you're hearing some cuteness in the background of a door being moved, that's the two-year-old, my daughter and her family are living with this during quarantine. Yeah, it's fun, it's fun. And everybody understands it because everyone's under quarantine. So if a two-year-old runs in, it's like, oh, well, that's just the way it goes. All right, so when you're looking at chronic cough, chronic cough can be caused by many different problems. It can certainly be caused because you actually have a lung disease like cystic fibrosis or bronchiectasis or many other things, even COPD, emphysema, chronic obstructive pulmonary disease. So there's many different ways you can wind up with a chronic cough. For the patients with COVID, it would not surprise me at all if chronic cough becomes one of the developments that they have long-term. Because they have pretty extensive lung damage for the severe cases and it's very diffuse damage, so it's throughout the entire lungs, that's gonna cause a trigger that means a stimulus to your airway and to your lungs that when the airflow comes through a little bit faster, that is very often a trigger for cough. So you feel it come in faster in the Midwest, it'd be called cold weather. For you guys in Hawaii, it would be maybe tropical or humid weather for you. For us, it would be very typically cold weather. So it stimulates that cough and then one cough stimulates the next. So we can have a physiologic basis but then become a biomechanical problem. Okay. Okay, so what do we do with that? I know the Kegel exercises or pelvic floor muscle strengthening exercises is something that has been around since I think 1948 when Arnold, I think Henry Kegel came up with this idea to strengthen pelvic floor muscles. But what is a great tip that you use or that you like? I know cystic fibrosis you're working with younger girls, but chronic coughers can be from young to elderly. Is there a favorite one that you like to use that's simple? So there's several different things we're going back to that idea of chronic cough. They don't have to have lung disease, but it can happen and the pelvic floor can be a consequence. You'd have to go back to C part one and see the soda pop can that we talked about at that time. But the pelvic floor is definitely linked all the way up from the bottom, providing pressure on the bottom. You've got your diaphragm in the center and then you've got your vocal folds which are right here at the top. So that whole thing creates a pressurized can. So with chronic cough, you had COVID, let's say and you had pneumonia and you developed a cough secondary to that pneumonia. And that cough, cough, cough winds up creating too much pressure on the bottom of the can and you wind up with stress incontinence. So that's how you can see that sequelae of starting with lung disease and winding up with what the heck I have stress incontinence. So learning how to do a kegel to be able to lift your pelvic floor and prepare for the cough can be incredibly helpful beyond just a kegel. There's so many exercises and Christine, that's where I'd be telling them go back and see you or your other physical therapists as we're out of our COVID crises or through telehealth in order to learn how to initiate the pelvic floor muscles. But on top of that, that simple inspiratory muscle trainer again, may be part of your entire incontinence training program because remember again, you're gonna have pelvic floor, diaphragm and then your vocal folds at the top. So if you strengthen the middle at the diaphragm while you're also learning how to control the muscles at the bottom, you may be able to stop that incontinence simply through biomechanical training and strengthening of the diaphragm. Might not, in which case again, if the simple things don't work, then do something more complex. Let's start with, as they say, start with the kiss principle. Keep it simple, stupid. Do the easy things first. I think that's great. I mean, you said it right there, that's why I wanted to, that's what inspired me to host the show is to provide the simple things to people that they could do right away. The simple things that you said, they do no harm, but the best thing that could happen is it helps you, you get stronger, you feel better and you can accomplish playing with your grandsons or picking up your kid without leakage or playing volleyball when you're a 20-year-old and jumping and not worrying about leakage. There's all different ways that if pelvic floor training, diaphragmatic training, all of that abdominal canister muscular training can do that, can be very simple and you can walk away with great results and the kiss principle is wonderful because it's something, oh, hello. There we go, we had a two-year-old and now we have a kitty cat. I've been hanging out with in the quarantine during the three tomorrow. That's to help people not get too bored with just seeing people's faces. That's spooky, I have a Garfield as well. That's great, that's great. But so one of my favorite things to talk about because I did write that book about it, it will be out soon, I've been saying that for two years, but the diaphragm, when I came to your course, I came because I wanted to get some validation for the concepts that I wrote in my book and since then I have added so much more after I took your class in 2017 about diaphragm and I wanna help people with low back pain. I wanna help people because the epidemic is wild and it's way too much and I wanna give them everything that they can have because it hasn't been in articles even as of late. I saw one, they said there's pretty much no go-to treatment for low back pain and the diaphragm basket, right? Tell me what you think about that. So there's a, we talked about just two of the functions of the diaphragm, that it's a respiratory muscle, it's also a reflux, anti-reflux muscle and a third function would be looking at it from a postural control perspective. So if we can go back, let's see, the basket weave if we would, Eric. So looking at this picture and to orient our viewers out in Hawaii, we're looking at from the back of the body through the body to the rib cage, but we're on the inside. So if you look on the inside, you see where you have half of a dome, that's half of the diaphragm that would be on the left side of your screen. And then there would be another half of the dome on the right side, but it's taken out for this picture. What I want you to see is that those vertical fibers are the muscle fibers of the diaphragm going up to that dome. Then look at the ones that are going horizontally. Those are the muscle fibers of the transverse abdominist which is the deepest layer of your abdominal muscles. And what I want you to really notice is that junction between the two. So the diaphragm and the transversus abdominus actually intersect at the xyfoid process, which is the base of your sternum and your lowest ribs, which are ribs eight, nine and 10. And they form kind of a basket weave, as you can see there, meaning that when one muscle contracts, it stretches or stimulates the other muscle to move. So in other words, you can't use your diaphragm for breathing without having it automatically activate the deepest layer of your abdominal muscles. So the diaphragm works with the abdominal muscles for breathing, as well as to support the pressure in your abdominal cavity, which stabilizes your spine and your pelvic floor. What a concept. So I mean, the diaphragm is a pretty cool muscle. That's all I've gotta say is that it's pretty cool and most people just don't know enough about it. And so I want it to be more popular. That's what I'm looking at. It's making that diaphragm more popular. So we have a couple of other things. I'm looking at which ones we covered with that. Another one that's really important for the role of the diaphragm. And this would be very important in this day and age where as we're talking about COVID, is we know that those patients who get sick get very, very sick and some of them are on ventilators. And what happens with that is that the diaphragm also works to enhance venous return. In other words, to bring that blood up from the feet all the way back up to the heart. So let's say that you survived COVID. Let's say that you survived just a pneumonia that had nothing to do with COVID, but some kind of really bad sickness that means your diaphragm weaker. And afterwards you notice your legs are swollen. Like why? Why? Well, because if your diaphragm's not working with that inferior vena cava, that's the venous flow that's coming up from the abdomen, bringing that blood up above the diaphragm and bringing it to the heart. If that diaphragm isn't working with the inferior vena cava to change the appropriate pressures within the trunk, then you may wind up with too much blood staying down low in your body. And that's where the doctors might be prescribing something like Ted Hose or some other kind of compression socks or even full leggings to help you get that venous return. So if you wanna be able to get rid of some of those stockinettes to help your blood flow back to your heart, what you might be doing is actually strengthening your diaphragm, which can be done several ways. We've talked about a simple way, which would be the inspiratory muscle trainer. Simply actually getting a cardio workout will help to strengthen your diaphragm and also doing some weight training. It doesn't have to be heavy weight training, but you want it out far on your arm. So if you've got your arm out far, I'm gonna turn, let's see if I can get, I can't quite get in this picture. Here we go. So if my arm is out far and I'm gonna grab my cup of tea and maybe that's enough weight for me because I've been very sick and just raising my cup is enough exercise. As I have that weight out far on my arm, it means I actually have to have more control from my muscles here to be able to support that weight way out there. So in the beginning, maybe I have to lean back against my chair and then eventually I can do my lifts while I have that glass or cup in front of me and I'm not using the back of the chair. Then maybe kneeling, maybe standing, eventually I'm gonna do it while I stair climb, but I'd recommend not having half coffee in the cup while you're doing stair climbing or you might wind up spilling it. But something like that would be a simple way to have the diaphragm take on its role as a postural stabilizer to have to simultaneously work on your breathing for the cardio while also stabilizing your back, helping to stabilize your shoulder and your pelvic floor. So that's the third functions, postural control. I mean, it doesn't have to be in that order. Fourth function would be looking at it as aiding venous return. And then I would like to mention the one last one and that is that the diaphragm actually helps to squish down your abdomen and release, squish all that viscera and release, which means that it actually works like a lower gastrointestinal system motility stimulus. In other words, if you were sick and you were in the hospital, the first time the PTs would get you up and the first thing you'd wanna do is rush to the bathroom. And then if the patient stays in there for 20 minutes, you as a therapist should be thinking, oh my gosh, I just helped him with lower GI motility. Basically, you could just reward yourself for getting those intestines to get re-engaged because that's part of the role of the diaphragm as well. So we have it as a respiratory muscle, we have it. The second thing would be that postural control. We've got it as a reflux barrier, a lower GI motility stimulant, and very importantly as a venous return muscle. That's a lot of major functions for one muscle that we can't even see because it's on the inside. That's right, that's invisible. Yeah, and at this point, I would like all of your viewers to apologize to their diaphragms because they have no idea how important it was. And they're like, oh, I had no idea you did so much. That is great, and oh, we're out of time, but you just spoke so brilliantly. I need to close. That just means that we need to have you on again. So this is it, we're out of time. Mary, thank you so much again. You're so welcome. An action packed full of information session. And thank you everyone for joining us. Thank you, thank Tech Hawaii for allowing us to be here today. And please stay safe everyone during this quarantine and use your diaphragm. You'll apologize to it, now use it. I look forward to seeing you in two weeks. Life is better when you listen to your physical therapist. Aloha and mahalo.