Abdominal bloating and distension are common symptoms reported in pelvic health practice. While many individuals experience occasional bloating that resolves without intervention, persistent or long-standing distension can significantly impact quality of life. Patients often report discomfort, sleep disruption, dietary restrictions, and frustration when symptoms persist without clear answers.

One condition associated with these symptoms is abdomino-phrenic dyssynergia, a disorder involving a paradoxical relationship between the diaphragm and abdominal wall.

Under normal conditions, when intraluminal gas increases in the gastrointestinal tract, the body responds with a coordinated pattern:

• the diaphragm relaxes, and
• the abdominal wall contracts

This response helps maintain abdominal shape and pressure regulation.

However, in abdomino-phrenic dyssynergia, the opposite pattern occurs. The diaphragm contracts downward while the abdominal musculature relaxes, leading to visible abdominal distension and discomfort. Dysfunction of the pelvic floor is also frequently associated with this condition, reinforcing the importance of a comprehensive evaluation of the entire pressure management system.

Traditional management strategies include biofeedback therapy and breathing retraining, both aimed at restoring appropriate neuromuscular coordination.

A Clinical Case Example

In our clinic, we are seeing an increasing number of referrals for patients diagnosed with abdomino-phrenic dyssynergia. One recent patient illustrates how breathing mechanics and musculoskeletal restrictions can contribute to these symptoms.

The patient was a 72-year-old female with a long-standing history of abdominal bloating and distension.

She reported:

• Bloating and abdominal distension throughout the day, worsening toward evening
• Limiting evening food intake due to abdominal discomfort and “tightness”
• Pain rated 3–5/10 in the morning, increasing to 8/10 by late evening
• Difficulty sleeping due to the abdomen feeling “hard and tight” at bedtime

Examination Findings

Physical examination revealed several contributing factors:

• Significant tightness in the posterior chain and erector spinae in the thoracic and lumbar regions
• Reduced thoracic rotation and mobility
• Connective tissue restrictions in the upper abdominal quadrants, especially the epigastric region and inferior rib cage
• Decreased lower rib cage mobility
• Difficulty producing a prolonged or forceful exhale
• Reduced ability to relax the pelvic floor following contraction

These findings highlighted the interaction between breathing mechanics, rib cage mobility, myofascial restrictions, and pelvic floor coordination.

Treatment Approach

Treatment included a multi-system approach addressing breathing, mobility, and neuromuscular coordination.

Interventions included:

• Biofeedback therapy
• Visceral mobilization techniques
• Thoracic spine and rib joint mobilizations
• Soft tissue techniques, including gentle diaphragm release
• Breathing retraining
• Techniques focused on pelvic floor relaxation

The patient completed nine treatment sessions, combined with a structured home maintenance program that she followed consistently.

Outcomes

By the end of treatment, the patient reported:

• 70% overall improvement in symptoms
• Ability to eat evening meals without discomfort
• Restful sleep through the night without abdominal tightness

This case highlights how restoring efficient breathing mechanics and rib cage mobility can significantly influence abdominal pressure regulation, pelvic floor function, and patient comfort.

Why Breathing Matters for Pelvic and Orthopedic Therapists

Breathing is far more than a respiratory function. The diaphragm plays a central role in:

• pressure regulation
• core stability
• pelvic floor coordination
• movement efficiency

Understanding how breathing integrates with the musculoskeletal system can significantly expand a clinician’s ability to address persistent symptoms that may otherwise be overlooked.

In the course Breathing and the Diaphragm: Pelvic and Orthopedic Therapists, we explore these relationships in depth and provide clinicians with practical tools to assess and treat dysfunctional breathing patterns.

Participants will learn how to:

• Explain normal diaphragmatic breathing and the role of the internal and external oblique musculature
• Assess and treat dysfunctional breathing patterns including chest, abdominal, and paradoxical breathing
• Understand the role of intra-abdominal pressure (IAP) in spinal stability
• Apply the concept of regional interdependence in patients with pelvic or back pain
• Recognize how postural patterns influence diaphragm and pelvic floor function
• Identify myofascial contributors to dysfunctional breathing and apply appropriate treatment techniques
• Perform rib and thoracic spine mobilizations to improve respiratory mechanics
• Develop exercise progressions for breathing retraining in clinic and home programs
• Integrate diaphragmatic breathing strategies into athletic rehabilitation

Understanding the relationship between breathing mechanics, mobility, and pelvic floor function allows clinicians to address dysfunction from a more integrated perspective and can lead to meaningful improvements in patient outcomes.

Aparna Rajagopal, PT, MHS, WCS, PRPC, Capp-OB Certified is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interest in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction.

Leeann Taptich DPT, SCS, MTC, CSCS leads the Sports Physical Therapy team at Henry Ford Macomb Hospital where she mentors a team of therapists. She also works very closely with the pelvic team at the hospital which gives her a very unique perspective of the athlete.

Aparna and Leeann co-authored the course, Breathing and the Diaphragm: Pelvic and Orthopedic Therapists, which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.

Course Dates: March 14, 2026

Price: $450
Experience Level: Beginner
Contact Hours: 13.5

Description: This remote course is an integrated approach where participants will learn how the diaphragm, breathing, and the abdominals can affect core and postural stability through intra-abdominal pressure changes while looking at structures from the glottis and the cervical region to the pelvic floor.

This course includes assessment and treatment of the barriers by addressing thoracic spine articulation and rib cage abnormalities in the fascial system of muscles related to breathing and the diaphragm. Instructed techniques are applicable to patients who present with Diastasis Rectus Abdominis, pelvic pain, incontinence, and prolapse, as well as cervical, thoracic, scapular, and lumbar pain.

Pelvic floor rehabilitation is often associated with urinary continence or pelvic support, but recent research highlights its broader role, including significant impacts on respiratory health. Studies now suggest that combining pelvic floor muscle (PFM) training with pulmonary rehabilitation can enhance lung function, particularly in elderly patients recovering from orthopedic surgery.

Pelvic Floor Muscle Training and Pulmonary Function
A 2025 randomized controlled trial investigated the effects of combining pelvic floor muscle training with pulmonary rehabilitation in elderly patients following surgery for intertrochanteric femur fractures (Ji et al., 2025). Fifty patients were randomly assigned to either pulmonary rehabilitation alone or pulmonary rehabilitation combined with PFM training. After four weeks, both groups showed improvements in forced vital capacity (FVC), peak expiratory flow (PEF), and the FEV1/FVC ratio, with the combined intervention group demonstrating significantly greater gains. Diaphragm excursion and thickening fraction were also improved, suggesting a synergistic relationship between the diaphragm and pelvic floor muscles that enhances respiratory mechanics.

Supporting Evidence
Additional studies support the connection between PFM function and respiratory performance. A recent study using sensor-based diaphragm exercises combined with PFM training in women with stress urinary incontinence demonstrated improvements in both pelvic floor function and respiratory parameters (Yakıt Yeşilyurt et al., 2025). Similarly, pelvic floor electrical stimulation has been shown to enhance diaphragm excursion and rib-cage movement during tidal and forceful breathing and coughing (Hwang et al., 2021). Foundational work also demonstrated that co-activation of abdominal and pelvic floor muscles contributes to improved expiratory function and intra-abdominal pressure regulation (Sapsford et al., 2001). Together, these studies highlight the physiological link between the pelvic floor, diaphragm, and respiratory system.

Why This Matters
For elderly patients recovering from hip fractures, optimizing lung function is critical to reducing postoperative complications such as pneumonia and supporting overall recovery. Integrating PFM training with pulmonary rehabilitation provides a novel and underutilized approach to enhance respiratory efficiency and accelerate functional recovery. Moreover, these findings expand the role of pelvic floor rehabilitation beyond traditional urogenital outcomes, emphasizing its value in multidisciplinary rehabilitation programs.

Takeaway
The pelvic floor contributes significantly to respiratory mechanics. Combining pelvic floor muscle training with pulmonary rehabilitation can improve lung function in elderly post-surgical patients and may support broader recovery goals. As research evolves, pelvic floor specialists have the potential to play a key role in integrated rehabilitation approaches.

Practical Next Step: Elevate your clinical expertise by enrolling in Breathing and the Diaphragm, scheduled for December 6. This course covers diaphragm anatomy, breathing mechanics, and how the diaphragm, abdominals, and pelvic floor interact to regulate intra‑abdominal pressure, support core stability, and influence posture. Lab sessions include assessment and treatment of dysfunctional breathing patterns, ribcage and thoracic-spine restrictions, and practical strategies for clinical integration. While broadly applicable to pelvic pain, incontinence, prolapse, and core/abdominal issues, these techniques can be adapted for elderly post-hip-fracture patients to optimize lung function and recovery.

References

• Yakıt Yeşilyurt S, Şahiner Pıçak G, Başol Göksülük M, Balıkoğlu M, Özengin N. Investigating the Effectiveness of Pelvic Floor Muscle Training, Including Sensor-Based Diaphragm Exercises in Women With Stress Urinary Incontinence: A Randomized Controlled Study. Arch Phys Med Rehabil. 2025 Jul 11:S0003-9993(25)00796-8. doi: 10.1016/j.apmr.2025.06.019. Epub ahead of print. PMID: 40653184. https://pubmed.ncbi.nlm.nih.gov/40653184/
• Ji D, Fu Y, Wu L, Tian C, Jin S. Effect of pelvic floor muscle combined with pulmonary rehabilitation training on lung function in elderly patients after surgery for intertrochanteric fractures of the femur: a randomized controlled trial. Eur J Med Res. 2025 May 14;30(1):381. doi: 10.1186/s40001-025-02610-7. PMID: 40369675; PMCID: PMC12076919. https://pubmed.ncbi.nlm.nih.gov/40369675/
• Hwang UJ, Lee MS, Jung SH, Ahn SH, Kwon OY. Effect of pelvic floor electrical stimulation on diaphragm excursion and rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence: A randomized controlled trial. Medicine (Baltimore). 2021 Jan 8;100(1):e24158. doi: 10.1097/MD.0000000000024158. PMID: 33429797; PMCID: PMC7793445. https://pubmed.ncbi.nlm.nih.gov/33429797/
• Sapsford RR, Hodges PW, Richardson CA, Cooper DH, Markwell SJ, Jull GA. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn. 2001;20(1):31-42. doi: 10.1002/1520-6777(2001)20:1<31::aid-nau5>3.0.co;2-p. PMID: 11135380. https://pubmed.ncbi.nlm.nih.gov/11135380/

Aparna Rajagopal, PT, MHS, WCS, PRPC, Capp-OB Certified is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interest in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction.

Leeann Taptich DPT, SCS, MTC, CSCS leads the Sports Physical Therapy team at Henry Ford Macomb Hospital where she mentors a team of therapists. She also works very closely with the pelvic team at the hospital which gives her a very unique perspective of the athlete.

Aparna and Leeann co-authored the course, Breathing and the Diaphragm: Pelvic and Orthopedic Therapists, which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.

Abdominal bloating and distension are two very commonly reported GI symptoms in the pelvic practice setting. However, these symptoms are not commonly recognized in other physical therapy settings. While many people experience occasional bloating/discomfort it does not necessitate medical intervention, but repeated and long-standing bloating/distention can impact the quality of life.

One diagnosis which is associated with these symptoms is Abdomino-Phrenic dyssynergia where patients develop a paradoxical abdomino-phrenic response. Normally, as a response to an increase in intraluminal gas, the diaphragm relaxes, and the abdominal musculature contracts. When dyssynergia is present, the opposite happens and the diaphragm contracts, and the abdominals relax. Abnormal pelvic floor function is also associated with this diagnosis. Treatments typically used are biofeedback therapy and breathing techniques.

Where Leeann and I work, we are seeing patients increasingly referred with this diagnosis. Recently we treated a 72-year-old female patient with a long-standing history of troublesome bloating and distention, with the diagnosis of Abdomino phrenic dyssynergia.

• The patient had complaints of bloating and abdominal distension all day long, worsening toward evening
• She reported limiting her food intake in the evenings on account of the discomfort and "tightness" in the abdomen
• She rated the discomfort as 3-5/10 in the morning time with an increase to 8/10 by late evening
• She also reported poor sleep because of how "hard and tight" the abdomen felt by bedtime

Upon examination, amongst other findings, the patient demonstrated:

• Significant tightness in her posterior chain and her erector spinae in both thoracic and lumbar regions
• Decreased thoracic rotation/mobility
• Increased connective tissue restrictions in both upper abdominal quadrants, especially in the epigastric area and inferior to the rib cage
• Decreased lower rib cage mobility
• Poor ability to prolong exhale or to exhale strongly
• Decreased ability to relax the pelvic floor musculature after a contraction

In addition to biofeedback and visceral mobilizations, treatment techniques included joint mobility techniques inclusive of simple rib and thoracic spine mobilizations, soft tissue mobility techniques including gentle diaphragm releases, breath training, and breathing techniques to aid in pelvic floor relaxation.

The patient received 9 treatment sessions and a home maintenance program which she followed with good compliance. She reported a 70% overall improvement and was now able to sleep through the night and eat in the evenings without discomfort.

In our course, Breathing and the Diaphragm: Pelvic and Orthopedic Therapists, you will learn:

• Explain normal diaphragmatic breathing and the role of the internal and external oblique musculature.
• Assess and treat dysfunctional breathing patterns including but not limited to chest, abdominal, and paradoxical breathing patterns.
• Understand the concept of Intra-Abdominal Pressure (IAP) and the control and use of IAP with the diaphragm in a lowered position as a stabilizing mechanism for the spine.
• Understand the concept of regional interdependence and its application in the treatment of back or pelvic pain patients.
• Recognize the effects of postural patterns and the linkage to the diaphragm and pelvic floor.
• Understand the muscles and myofascial components involved in dysfunctional breathing and techniques to effectively treat the same.
• Understand and demonstrate mobilizations of the rib and thoracic spine and develop a comprehensive treatment program.
• Develop an exercise progression for dysfunctional breathing for use in the clinic and in-home programs.
• Integrate diaphragmatic breathing and mobility in the athletic clientele

Breathing and the Diaphragm

Description: This remote course is an integrated approach where participants will learn how the diaphragm, breathing, and the abdominals can affect core and postural stability through intra-abdominal pressure changes while looking at structures from the glottis and the cervical region to the pelvic floor.

This course includes assessment and treatment of the barriers by addressing thoracic spine articulation and rib cage abnormalities in the fascial system of muscles related to breathing and the diaphragm. Instructed techniques are applicable to patients who present with Diastasis Rectus Abdominis, pelvic pain, incontinence, and prolapse, as well as cervical, thoracic, scapular, and lumbar pain.

Aparna Rajagopal, PT, Mhs, PRPC, and Leeann Taptich, PT, DPT are the authors and instructors of the Breathing and the Diaphragm remote course. Aparna and Leeann bring a wealth of experience to this course. 

Aparna: About 10-plus years ago I had a patient who had a large para esophageal hernia which had been surgically repaired. She had been referred to therapy because of general debility and weakness and she couldn't do endurance-based things like gardening or walking for long periods of time. She was in her mid-sixties. She had seen 2 or 3 therapists and they couldn’t figure things out. She had the same complaint that she couldn’t breathe and every time she said she couldn’t breathe the therapist would obviously refer her back to the doctor who would run cardiac tests, and all kinds of other tests and say she was cleared from a medical standpoint and then send her back to therapy. So in this process, the patient came to me and one of the first things she said was that she had difficulty taking in a breath of air -that she felt like she couldn’t expand - not that she couldn’t breathe.

Based on that complaint, I started my assessment. I started looking at the thoracic spine and found that she actually couldn’t expand from the rib cage at all because of her surgery to fix her large para esophageal hernia. One of the things we know about para esophageal hernias is also that it can be associated with increased intraabdominal pressure - related to things like chronic severe constipation, chronic cough, etc. She got better. She healed, and I realized that this was something that patients needed. In the process of treating her, my interest in breathing and the diaphragm developed.

Leeann: I started at Henry Ford Health Systems, where Aparna and I currently work together, about 7 years ago. Around that time, Aparna did a one-hour lecture on dysfunctional breathing and breathing to help us understand the mechanics of the pelvic floor and the abdominals, and the diaphragm. I’ve always looked for my missing link in my treatment, specifically in my lumbar/low back pain patients. The lecture was a lightbulb moment for me, and it made sense to me. What I used to focus on at that time was Transverse Abdominis engagement and it didn't always work for all patients.

I call Aparna my missing link. So, it started off with the one-hour lecture that she delivered. Then we collaborated and worked on developing a four-hour course on the same topic that ended up with eight hours worth of content because of how much great research there was available about the topic. Gradually the four-hour class transitioned into what we have now -  a full weekend course. It’s a great mash-up of ortho and pelvic floor approaches for both of us and has really helped both of us treat our patients better from both a pelvic standpoint and an orthopedic standpoint.

Aparna: We work together. We are able to treat patients jointly, bringing in the diaphragm/breathing aspect,  incorporating the sports and manual training that Leeann has and the pelvic knowledge that I have. We are able to tie everything together and treat our patients in a very holistic way.

Leeann: My big thing is that we try to incorporate more of the regional interdependence model. When patients come in with symptoms in an area, we look above, below, and beyond to see how the whole system is functioning together. We like to see how the body moves as a whole instead of focusing on just one part of it. That’s where most of our treatment is derived from and how we work together.

Breathing and the Diaphragm - Remote Course

Course Dates:
November 19-20
January 21-22, 2023

Price: $450
Experience Level: Beginner
Contact Hours: 14

Description: This remote course is designed to expand the participant's knowledge of the diaphragm and breathing mechanics. Through multiple lectures and detailed labs, participants will learn how the diaphragm, breathing, and the abdominals can affect core and postural stability through intra-abdominal pressure changes. As an integrated approach, the course looks at structures from the glottis and the cervical region to the pelvic floor and helps in understanding a multi-component system that works together. Optimal function of the diaphragm and breathing patterns are key to a healthy pelvic floor, a normal functioning core, and postural stability. Evidence-based methods to assess the diaphragm and breathing mechanics are presented along with easy-to-apply practical intervention strategies.

This course includes assessment and treatment of the barriers by addressing thoracic spine articulation and rib cage abnormalities in the fascial system of muscles related to breathing and the diaphragm. The assessment concepts and treatment techniques can easily be integrated into a therapist's current evaluation and intervention strategies.

Proper breathing is discussed and taught in many ways and forms. All of this is a step in the right direction, but what if the person physically can not lengthen tissues to expand certain key structures that are essential to the breathing mechanism? In the remote course, Breathing and the Diaphragm, Aparna Rajagopal and Leeann Taptich teach different methods to identify breathing patterns, dysfunctional breathers, and how to determine motor control issues from mobility or strength issues.

Breath is utilized widely in the exercise world. Pilates uses breath for core stability. Yoga utilizes breath to help connect the body. Strength and conditioning coaches and personal trainers emphasize breath to provide power to lift. Breathing mechanics, aka proper breathing, is also core to any type of abdominal exercise.

Respiratory muscles are directly involved in these core abdominal strengthening, stability, and stretching exercises (1). Research led by DePalo, way back in 1985, concluded that the diaphragm is actively recruited during resistance exercises such as sit-ups (2). Inefficient breathing can lead to muscular imbalances, and motor control changes that can affect motor quality. Therapists are taught at length about tissue and joint mobility versus motor control or strength issues. These same principles can be applied to assess and treat the diaphragm, breathing, and abdominals.

In regards to working with patients, Aparna shares, "Different cues work with different patients. While verbal and tactile cues to correct patterns can work with some of our patients, they do not necessarily work in all of our patients. We need different ways to correct patterns in patients that have a tissue or joint mobility issue. Such issues can cause restriction and force the patient to breathe in a specific way."

Aparna and Leeann deep dive into mobility and learn to assess and treat joint restrictions of the ribs and the thoracic spine during their remote course Breathing and the Diaphragm scheduled for October 23-24, 2021. These mobility techniques combined with specific motor control and strengthening exercises can improve myofascial restrictions that restrict breathing.

Breathing and the Diaphragm will help build a foundation to improve your patients' functional activities. No matter if it is coughing, having a bowel movement, performing wall ball in CrossFit, or hitting a tennis ball!

1. Luca Cavaggioni, Lucio Ongaro, Emanuela Zannin, F. Marcello Iaia, Giampietro Alberti.Effects of different core exercises on respiratory parameters and abdominal strength. J Phys Ther Sci. 2015 Oct; 27(10): 3249–3253. Published online 2015 Oct 30. doi: 10.1589/jpts.27.3249.
2. DePalo VA, Parker AL, Al-Bilbeisi F, et al.: Respiratory muscle strength training with nonrespiratory maneuvers.J Appl Physiol 1985 2004, 96: 731–734.

Leeann Taptich DPT, SCS, MTC, CSCS is Co-Author of the new Herman & Wallace offering, Breathing and Diaphragm: Pelvic and Orthopedic Therapist. Leeann leads the Sports Physical Therapy team at Henry Ford Macomb Hospital in Michigan where she mentors a team of therapists. She also works very closely with the pelvic team at the hospital which gives her a very unique perspective of the athlete.

According to a paper from Manual Therapy, the thoracic spine is the least understood part of the spine, despite the huge role it plays in both movement and in regulation of our Autonomic Nervous System.¹ Researchers found that the thoracic spine is the least studied of the three spinal regions; thoracic, cervical, and lumbar. I am frequently asked by fellow therapists for help in objectively assessing and treating the thoracic region which has led to the realization that even amongst experienced therapists the thoracic spine’s importance is less understood especially in terms of its function.

Anatomically, the thoracic spine along with the ribs and sternum provide a frame that supports and protects the lungs and heart. Despite the rigidity that is required to fulfill that function, the thoracic spine contributes significantly to a person’s ability to rotate.²

One of the biggest roles the thoracic spine plays is in the regulation of the Sympathetic Nervous System, which is a part of the Autonomic Nervous System. The sympathetic nervous system, also known as the “Fight or Flight” system is in overdrive in our patients who present with pain. One of the many complications that arise from an upregulated sympathetic system is increased respiratory rate and/or dysfunctional breathing.³ Carefully applied manual therapy techniques to the thoracic region can help regulate the Autonomic Nervous System by affecting the diaphragm, the intercostals, and other respiratory musculature.⁴ Specific thoracic mobilizations/manipulations can improve respiratory function.⁴

In the Breathing and Diaphragm course, Aparna Rajagopal and I discuss the importance of the thoracic spine from both a regional and global perspective. Thoracic spine assessment is taught along with multiple mobilization techniques and manipulations all of which will help the clinician link the thoracic spine to the treatment of pelvic pain, low back pain, and breathing pattern disorders. Join Aparna and I in either Sterling Heights, MI this March or Princeton, NJ in December for Breathing and the Diaphragm: Pelvic and Orthopedic Therapists: From Assessment to Clinical Applications for Pelvic and Orthopedic Therapists!

1. Heneghan NR, Rushton A. Understanding why the thoracic region is the ‘Cinderella’ region of the spine. Man Ther. 2016; 21: 274-276.
2. Narimani M, Arjamand N. Three-dimensional primary and coupled range of motions and movement coordination of the pelvis, lumbar, and thoracic spine in standing posture using inertial tracking device. Journal of Biomechanics. 2018; 69: 169-174.
3. Bernston GG. Stress effects on the body: Nervous system. American Psychological Association. https://www.apa.org/helpcenter/stress/effects-nervous. January 18, 2020.
4. Shin DC, Lee YW. The immediate effects of spinal thoracic manipulation on respiratory functions. Journal of Physical Therapy Science. 2016; 28: 2547-2549.