Dawn is debuting a new course, Pediatric Postural Development, with Herman & Wallace on September 29, 2024.

Most physical and occupational therapists learn about one diaphragm in school: the respiratory diaphragm. But did you know that Osteopathic Manipulative Medicine recognizes 5 different diaphragms within the body? They include tentorium cerebelli, tongue, thoracic outlet, respiratory diaphragm, and pelvic floor. (1)

The intricate myofascial connections between all these diaphragms are fascinating! But as a pediatric pelvic floor therapist, what’s the significance of these connections when you look at kids’ functional mobility and strength?

The pelvic floor and respiratory diaphragm are the two main structures that we’ll be discussing today. You’ll learn how they develop during infancy and childhood and how their functional relationship affects your assessment and treatment for kids with bowel and bladder dysfunction.

Development Of The Pelvis, Spine, And Diaphragm During Infancy

Pelvic Structure At Birth

Pelvic structure and spinal curvatures develop based on the activities of infants and young children. The educational role that you have as a pediatric therapist is significant during a child’s first years of life, especially for children with congenital or developmental delays. Doing your best to help them achieve these developmental goals will greatly affect their life in later years.

At birth, the pelvis of the baby is funnel shaped and the respiratory diaphragm is oblique. You can observe a neonate with a wide rib cage, which only allows for a short descent of the ribs. You can hear evidence of this as a newborn’s cry is very short. At this time, their pelvic floor has no posture.

Cervical Lordosis

The first curve to develop in an infant is cervical lordosis. Neck control improves as the head is challenged against gravity. In an upright position, the neck is challenged to maintain a neutral position. In prone, the neck is challenged to extend and re-enforces a lordotic curve.

Tummy time is important to begin at a young age. Not only do kids develop neck and core strength, but extending the neck in a prone establishes proper cervical lordosis for later in life.

Thoracic Kyphosis And Ribcage

Thoracic kyphosis develops when a child begins sitting. Again, thinking about sitting from a trunk control perspective is important, but establishing proper kyphotic alignment should not be overlooked. A mild degree of kyphosis is normal, but congenital deformities can exaggerate children’s kyphosis and increase the difficulty of achieving good sitting posture.

Independent sitting is an important milestone itself and further affects: (2)

• object perception
• language development
• spatial memory
• visual processing
• overall cognition

When treating infants, let’s remember to teach how important the skill of independent sitting is. We will discuss this further in the last section and how it relates to pelvic floor function.

As an infant increases their activity in the quadruped position, the diaphragm angle gets steeper inside the ribcage. This angle also increases through weight-bearing positions and with the development of the scapular stabilizers around the ribcage.

Lumbar Lordosis And Sacrum

Standing influences lumbar lordosis. Once again, standing challenges core stability and develops strength. But also recognize how standing helps the child establish proper lordotic lumbar posture.

Furthermore, in standing, the diaphragm orientation changes. The diaphragm becomes more parallel to the pelvic floor. As the diaphragm establishes a more horizontal orientation with standing and walking, the muscular tone increases as it responds to the vertical pressure and pull of the viscera.

This upright position also develops the pelvic floor to counteract the pressure of the viscera being pulled down by gravity. Counternutation of the sacrum protects the pelvic floor from full visceral pressures.

Let’s take a look at the functional relationship as the diaphragm and pelvic floor develop.

Functional Relationship Of Diaphragm And Pelvic Floor During Childhood

When the diaphragm and pelvic floor are developed in their horizontal orientations, they begin moving together during breathing. When inhaling, the diaphragm and pelvic floor descend as the ribcage and abdominal cavity expand. When exhaling, the diaphragm and pelvic floor ascend. The continued alternating movement mobilizes the viscera and creates a lymphatic pump.

This relationship between the diaphragm and pelvic floor is why it’s so important to look at breathing mechanics in kids. Ribcage mechanics and good diaphragm strength and tone affect the mobilization of the viscera, including the stomach and intestines. This is especially relevant when treating kids with constipation.

If you watch constipated children breathe, you will notice that they often breathe more anteriorly through their bellies instead of up and down. You will also notice minimal or no expansion of the ribcages.

Additionally, when the viscera descend, this cues the pelvic floor to activate and continue developing. Around ages 2-3, the pelvic floor develops enough stretch to react to bowel and bladder function. This is the age when children typically develop urinary continence.

Although therapists usually use the term pelvic “floor”, it’s important for you to consider this as a “diaphragm”. The pelvic “diaphragm” is a dynamic partition that serves to adjust pressures and pump fluids within the body.

Lymphatics throughout the trunk, head, and limbs are all regulated by the pumping of the body’s five diaphragms. The diaphragms work together to regulate pressures, pulling fluids and toxins into the lymph system to detoxify the body. The colon has a great lymphatic network, so this is especially important in kids with bowel issues.

Now you understand how the respiratory diaphragm and pelvic floor influence function in typically developing children. What about kids with impaired functional mobility or impaired gross motor delays? Let’s dive into these considerations.

Pediatric Postural Impairments And Gross Motor Developmental Delays

Children with physical developmental delays will have delayed pelvic floor control as well. As you learned earlier in this blog, establishing control in positions including prone, sitting, quadruped, and standing, develops a baby’s spinal curvatures.

If children have conditions such as spina bifida or cerebral palsy, those developmental positions may be delayed or sometimes never reached.

Improper spinal curvature early in life will affect a child’s ability to attain or maintain postural positions required for voiding and defecation. This will also delay the development of the relationship between the diaphragm and pelvic floor control.

Start looking at these milestones not only from your perspective of postural control and gross motor function but also to help improve their bowel and bladder function:

• holding head up in prone
• sitting independently
• quadruped reaching and crawling
• standing independently
• walking

If a child never stands or walks, they will struggle to develop diaphragm and pelvic floor control because gravity will not challenge this system. Spending time in upright positions by using assistive devices such as standers or walkers will help develop respiratory capacity and pelvic floor control.

When you have this treatment outlook, you can help parents shift their perspectives too. Parents of children with disabilities are often overwhelmed and tired. Help them to understand the benefits of continued work in practicing and attaining developmental postural and motor skills.

The new course, Pediatric Postural Development debuts on September 29, 2024 and focuses on the role of the pelvic floor, diaphragm, and core. This one-day course is designed to help therapists understand the development of the diaphragm and pelvic floor muscles (PFM) as they relate to core function and continence in children. Learn how to connect the ribcage, the diaphragm, and the pelvic floor for proper core activation, as well as receive instruction in anatomy and development of the diaphragm and its relationship to the pelvic floor/core. The information presented in the course applies to children who have been diagnosed with Cerebral Palsy, Down syndrome, ASD, Hypotonia, and more.

References:

1. Bordoni B. The Five Diaphragms in Osteopathic Manipulative Medicine: Myofascial Relationships, Part 1. Cureus. 2020 Apr 23;12(4):e7794. doi: 10.7759/cureus.7794. PMID: 32461863; PMCID: PMC7243635.
2. Kretch, K. S., Marcinowski, E. C., Hsu, Y., Koziol, N. A., Harbourne, R. T., Lobo, M. A., & Dusing, S. C. (2023). Opportunities for learning and social interaction in infant sitting: Effects of sitting support, sitting skill, and gross motor delay. Developmental Science, 26(3), e13318. https://doi.org/10.1111/desc.13318

Special thanks to Dawn for allowing The Pelvic Rehab Report to reprint her article, originally published on her website at kidsbowelbladder.com.

AUTHOR BIO:

Dawn Sandalcidi PT, RCMT, BCB-PMD

Dawn Sandalcidi is a trailblazer and leading expert in the field of pediatric pelvic floor disorders. She graduated from SUNY Upstate Medical Center in 1982 and is actively seeing patients in her clinic Physical Therapy Specialists, Centennial CO.

Dawn is a national and international speaker in the field, and she has gained so much from sharing experiences with her colleagues around the globe. In addition to lecturing internationally on pediatric bowel and bladder disorders, Dawn is also a faculty instructor at the Herman & Wallace Pelvic Rehab Institute. Additionally, she runs an online teaching and mentoring platform for parents and professionals.

In 2017, Dawn was invited to speak at the World Physical Therapy Conference in South Africa about pediatric pelvic floor dysfunction and incontinence. Dawn is also Board-Certified Biofeedback in Pelvic Muscle Dysfunction (BCB-PMD). She has also been published in the Journals of Urologic Nursing and Section of Women’s Health.

In 2018, Dawn was awarded the Elizabeth Noble Award by the American Physical Therapy Association Section on Women's Health for providing Extraordinary and Exemplary Service to the Field of Physical Therapy for Children.

Faculty member Ginger Garner PT, DPT, ATC/L is offering a new short course, The Voice and The Pelvic Floor. This course introduces foundational concepts needed to be able to use vocal techniques to treat the pelvic floor and core. Dr. Garner is a clinician, educator, and longtime advocate committed to making physical therapy services accessible, affordable, and equitable, especially for pelvic health.

When you think of pelvic health, what comes to mind? Obvious variables like the pelvic floor & girdle, abdominals and related synergists, mental health, and gut and respiratory health are probably at the top of your list. 

But how often do we consider the voice as a biomarker of pelvic health? It can impact all of the variables above and more. 

Historically, speech-language pathologists’ study of vocal health has stopped at the respiratory diaphragm, while physical and occupational therapists’ study of pelvic health has stopped, well, in the same place. Neither has traveled beyond that until recently. 

However, there is a third diaphragm beyond the respiratory and pelvic, the laryngeal diaphragm. It’s also known as the cervical, cervico-thoracic, vocal, and/or thoracic diaphragm. The three diaphragms include: 

• The Laryngeal Diaphragm - is responsible for neurological optimization of stress response and physiological control of swallowing and communication; but, it also influences vagal tone for cardiorespiratory functioning and respiratory and pelvic diaphragm functioning. It contains the muscles that are responsible for phonation, which includes intrinsic variables such as the arytenoids, but also extrinsic components which have a direct impact on the vocal fold health, such as the suprahyoid muscles.
  
  
• The Respiratory Diaphragm - is the connecting point between cephalad and caudad diaphragms and is the main muscle influencing pulmonary function. However, the respiratory diaphragm exacts a major influence on mind-body health, which goes far beyond pressure regulation of the vocal and pelvic diaphragms.
  
  
• The Pelvic Diaphragm - is the terminal end of the tri-diaphragmatic (3D) system, and can bear the brunt of trauma and impairment if dysfunction is present in the two upstream diaphragms. The pelvic diaphragm contains the levator ani, coccygeus, and related synergists, pelvic fascia, and neurovascular structures, which in turn can work with or against breathing and voicing tasks. 

The diaphragms are in constant movement and none work in isolation. Together, their intersectional action provides us with the key to both internal and external biopsychosocial stability and structure of the mind-body. 

The laryngeal diaphragm has a supradiaphragmatic vagal impact, while the pelvic diaphragm exacts subdiaphragmatic vagal health, chiefly through afferent and efferent input, respectively. The 10th cranial nerve lives up to its namesake, “the wandering,” as it touches each of the three diaphragms on its journey, harnessing the capacity to lessen pelvic and visceral pain, while also improving vocal quality and lung function, and changing pain, mood, and digestive function. 

The mind-body interface of the 3D system has been further defined in recent years, broken down into a voluntary motor system (the one we spend all our time studying and treating), and the “emotional motor system,”  and the implications are profound. Anatomists and researchers tell us that in order to generate speech, we need both motor systems to function. But specifically, our emotional motor system must first perceive safety before speech can be produced or produced well.  

To get a feel for your own emotional motor system health, try this brief exercise: 

1. Think about a recent incident that made you feel nervous, or anxious. 
2. How well could you breathe? 
3. Talk? 
4. Sing or hum? 
5. Engage in intimacy with someone? 

Not very well, right? This feeling is the fallout from your emotional motor system perceiving danger or threat. It’s what Dr. Stephen Porges means by the phrase, “neuroception.” Neuroception is the ability to detect risk - but it’s not just the ability to detect it - neuroception is the ability to accurately detect risk. 

Here lies the problem: 

If we cannot detect external risk or internal threat accurately, aka if our neuroception wiring is faulty, then we may move to 1 of 4 default modes for behavior: fight, flight, freeze, or fawn. If we are left in this state of reactivity, courtesy of the sympathetic nervous system, then polyvagal theory predicts we will enter into a dissociative state, termed a dorsal vagal response (DVR). The DVR drives self-preservation in severe trauma states, which can preserve life; but it is also to blame for bradycardia and left unchecked, death. Especially now post-COVID, it’s imperative that all therapists understand how to recognize, screen for, and help nurture healthy self-regulatory strategies via trauma-informed care.  

We must also learn how to create a therapeutic landscape conducive to healthy neuroception, one that appeals to the “safety switch” of the emotional motor system. Establishing this healthy therapeutic alliance with our patients and clients is critical in pelvic health because the same motor system that controls the creation of sound, dictates everything associated with pelvic health, including micturition, defecation, partuition, stress response, and sexual function.

Understanding the basis of “3D” neurophysiology makes targeting the voice a perfect alternate but necessary pathway for successful comprehensive pelvic health care. The ability to create sound literally determines how we interact with the world around us, and whether or not we can do so with empathy and safety. Additionally, the success of our intervention as pelvic health therapists is also determined by the degree to which we are using a biopsychosocial model, which has long been supported as the most effective and cost-effective way to manage pain and tackle chronic disease and impairment. 

What does including the voice look like in pelvic health? 

For starters, the first step is evaluating the orofacial and vocal health of the patient or client. Second, and perhaps surprising to some, is the evaluation of the therapist’s own voice as a therapeutic agent. These assessments work to identify red flags that place undue stress through the downstream diaphragms and stress response system. More complex assessment can include lumbopelvic ultrasound imaging as well, which provides a more comprehensive way to individualize therapy prescription. 

Assessment is essentially a 4-pronged process - The first two prongs consist of building on existing evaluation skills in respiratory, core, and pelvic floor and girdle assessment. The final two include an assessment of the physiological functioning of the orofacial area and voice and an evaluation of psychosocial determinants which would influence cranial nerve and vocal functioning. The voice is an incredible tool for improving pelvic health outcomes, if we learn how to harness its frequency and power. 

Join Dr. Ginger Garner for a virtual short course, The Voice and the Pelvic Floor scheduled for October 1, 2022, to learn more.

Sources 

1. HOLSTEGE, G., 2016. How the Emotional Motor System Controls the Pelvic Organs. Sexual Medicine Reviews, 4(4), pp. 303-328.
2. HOLSTEGE, G. and SUBRAMANIAN, H.H., 2016. Two different motor systems are needed to generate human speech. The Journal of comparative neurology, 524(8), pp. 1558-1577.
3. Speer LM, Mushkbar S, Erbele T. Chronic Pelvic Pain in Women. afp. 2016;93(5):380-387. 
4. Miciak M, Gross DP, Joyce A. A review of the psychotherapeutic “common factors” model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scand J Caring Sci. 2012;26(2):394-403. doi:10.1111/j.1471-6712.2011.00923.x
5. Padoa A, McLean L, Morin M, Vandyken C. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med Rev. 2021;9(1):76-92. doi:10.1016/j.sxmr.2020.04.002
6. Wijma AJ, van Wilgen CP, Meeus M, Nijs J. Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education. Physiother Theory Pract. 2016;32(5):368-384. doi:10.1080/09593985.2016.1194651
7. Porges SW. The polyvagal perspective. BiolPsychol. 2007;74(2):116-143.