Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 90: Evaluating Diaphragm excursion via Dynamic MRI, an article review
Review of the literature brings us an article from Japan, evaluating diaphragm and chest wall excursion in four different positions in healthy adults. Dynamic MRI was utilized for excursion measurements throughout all four positions in quiet breathing. The initial hypothesis was disproved, allowing for deeper discussion of the effect of position on diaphragm movement.
Join me today as we discuss the impact of patient positioning on the diaphragm and add another tool to the toolbox.
Want to sign up for a mentoring call with Dr. Burriesci? Sign up here: https://www.allthingscardiopulm.com/mentoring
Interested in Jane?
Jane, is an all-in-one practice management software with helpful features to power your practice. Head to jane.app/burriesci to book a personalized demo. Don't forget, you can use the code CARDIOPULM1MO at the time of sign-up for a 1-month grace period applied to your new account
Find me on:
IG: @all_things_cardiopulm
Threads: @all_things_cardiopulm
Website: www.allthingscardiopulm.com
Twitter: @allcardiopulm
Linked-In: Rachele Burriesci
Text at 913-308-4494
Welcome to Talking All Things Cardiopulm. I am your host, Dr Rachele Burriesci, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopulm to the forefront of conversation. Thanks for joining me today, and let's get after it. Before we jump into today's episode, let me take a moment to introduce Jane, the clinic management software and EMR that I use in my practice.
Rachele Burriesci:Change is a normal part of clinic life. Maybe you're expanding your team, introducing new offerings or growing your patient list. As your clinic evolves, it's important to have an EMR that not only supports you, also changes with you. Jane's new balance, practice and thrive pricing plans offer flexibility, allowing you to easily switch from one plan to another, depending on your current and future needs. There's no long-term commitment either, just simple month-to-month payments that let you focus on running your clinic, and with every plan you get features like one-on-one telehealth, email, appointment reminders and unlimited support. Visit janeapp backslash pricing to find a plan that fits your needs, starting at just $39 a month. And when you're ready to get started, use my code Cardiopalm1MO at the time of signup for a one month grace period applied to your new account. Thanks again, jane. All right, welcome. Happy belated Christmas. Merry Christmas If you are of Jewish faith, happy Hanukkah. You're on night two, I believe. This is just end of the season type stuff, and I hope you had a fun holiday week.
Rachele Burriesci:I feel like every year is a little bit different. Every year has a little bit different vibe. As I've kind of moved along in my career and have had changes in types of employment this time of year it's really nice to be able to slow down and actually have some time to enjoy family, do the pre-Christmas stuff and have a little less of that. You know, holiday angst. I do think that the one many things, but one of the things about being in healthcare is that it's not a typical job where you have multiple days off around the holidays. It's always funny to kind of see different dynamics in family. Pending different types of employment. There's different expectations of like availability. In healthcare. It's sometimes luck that you're even off on Christmas, let alone the days around it. So, being in faculty for a period of time, it was nice to have this break right around Christmas time. There's pros and cons to all of that and probably should be a conversation one day.
Rachele Burriesci:But the one thing I really did love about that time was being able to, you know, make cookies without the rush and the panic, or actually take time to enjoy the prep and kind of get that holiday feel. Everyone does different things. Tradition is really important for me and it's not that I have to do it, it's that I want to do it and it makes me feel part of the season and so being able to have some of that time is great. So I was just home with family. It always goes too quick. I was there quite a bit of time, actually this round eight days and always feels like I you know, when I'm leaving I it feels like I just got there. So it's it's always hard to leave in both directions. It's actually quite comical. It's hard to leave and get everything wrapped up to go and it's hard to leave, you know, the, the regular, the regular family stuff on the way out as well. But it was a great trip. It was a good holiday, wonderful food it's one of one of the reasons why I love Thanksgiving and Christmas is just the specific meals that we make around this time and just to be able to hang out with family and enjoy. So I hope you had a nice holiday week holiday, if you celebrate with family or friends, or even if you had one of those low key holidays. Celebrate with family or friends, or even if you had one of those low-key holidays whatever is right for you is right.
Rachele Burriesci:So before I think it was probably last week I came across this article that was in one of the more recent CardioPalm journal articles. It's actually a research report, so it's still a small n", but I thought it was an interesting take because it is something that I use in practice at both the hospital and in mobile practice, as well as with teaching. And the article kind of took a different turn than I expected, based on some of the literature in textbooks. So what I wanted to talk about today was actually diaphragm and chest wall movement pending patient position, and so the article is out of Japan and I believe it was from a DPT program in Tokyo, and it's called Differences in Diaphragmatic and Chest Wall Excursion During Quiet Breathing According to Body Position, using Dynamic Analysis by MRI. So one of the really cool things about this article was just how they actually observed excursion, and so they were using dynamic MRI, which can be superior to ultrasound for a number of reasons. One, the visualization is a little bit more specific, but it can also be seen in real time. So there were no instructions given to the clients, to the subjects. They were just instructed, I guess, to quiet breathe for 30 seconds. Every time they were in a different position. So they actually looked at supine, prone and then right and left side lying position and then they looked at diaphragm excursion as well as lateral costal movement at the upper and lower rib cage in those positions, cage in those positions.
Rachele Burriesci:If I could add to the study, I would have loved to see a sitting position as well, to kind of get the full spectrum of that movement. The outcome was actually a little bit different than I expected. My hypothesis would have been different. So just, you know good conversation. So we know that pending the position that we're in is going to put the diaphragm at an advantage or a disadvantage and each position has pros and cons to them. You know just in general.
Rachele Burriesci:So supine position tends to be the position where patients are able to activate their diaphragm a little bit more efficiently In the world of diaphragm position. When you're in the supine position your diaphragm actually sits higher in your thorax because of the organs kind of being pushed up into them in your thorax. Because of the organs kind of being pushed up into them Because the diaphragm sits higher, it actually typically allows for increased excursion of the diaphragm but not as much increase in lung volume because you're basically pressing against those organs. That's kind of the theory behind it. And then in sidelining, because we have right and left hemidiaphragm, they actually sit differently. The side that is down we'll call the loaded side typically sits higher in the thorax and the upper side that's not loaded sits so it's lower in the thorax. So I would have expected to have a little bit more difference between right and left hemidiaphragms in each side-lying position and it was actually not significant in either. There was a little bit of a difference but did statistically significant change and prone typically isn't spoken about in the world of diaphragm excursion in some texts in this context. Typically when we're talking about diaphragm position they'll talk about supine, right, left side lying and sitting. And now in sitting, when you're upright, diaphragm is now at advantage with gravity and it's going to sit lower, allowing for greater lung expansion but typically not as much diaphragm excursion because it's already lengthened from gravity but has less to push against.
Rachele Burriesci:So just kind of a little background as to typical body positioning and movement. What they pretty much found across the board in this article was prone positioning had the greatest excursion across the board frame excursion, greatest lateral costal movement, greatest upper chest movement. In all categories, compared to all position, prone had the greatest excursion. I was actually a little bit surprised by this. So prone positioning has lots of benefits in the world of ventilation. Perfusion based on gravity Ventilation. Air and blood typically go to the gravity dependent position. We saw prone positioning really taking a forefront during COVID, using the science behind basically ARDS to help ventilate better in this position.
Rachele Burriesci:But the diaphragm excursion piece, I wasn't sure if it was actually going to be more. I thought it might be less due to resistance in the position. So across the board, as per this article, as per dynamic MRI movement, prone positioning had the greatest excursion of diaphragm movement, lower lateral costal movement and upper chest movement. And pretty much across the board there wasn't significant difference between men and women. The only area that was different was upper chest in women had greater excursion across the subjects. So just really interesting to kind of see what positions can be utilized and in your practice that you can actually try different positions to get the most out of your patient. So, for the most part, because they looked at diaphragm excursion, then they looked at lateral costal movement and they looked at upper chest movement in supine, prone, right, left side lying. For each area that they were measuring, prone had the greatest excursion by actually quite a bit two to three times larger than the other positions. Then it was supine and then right and left sideline, they kind of paired together and they called them equal, equal. So something to consider if you're having a hard time ventilating, if you're having a hard time increasing movement at the diaphragm or lateral costals, it's something to consider. It's another thing to add to your toolbox.
Rachele Burriesci:Most of the time, depending what setting you're in, you might have your patient in the supine position or in the sitting position, right, like there's many times, um, that you might have a patient come to you and they're either sitting up in the chair, they're in a wheelchair, they're upright already Right, and I have a specific patient in my mind. Um, it was a patient I had at the VA. He had Guillain-Barre and he had significant weakness and it did affect his diaphragm as well. So he was, uh, a total assist transfer. He was a Hoyer lift. At one point he progressed to, you know, max of two doing squat, pivot transfers eventually, but transferring was a bit of a feat if it transfers eventually, but transferring was a bit of a feat.
Rachele Burriesci:Right, and in this specific setting the patient would come to us in the sitting position in the wheelchair. So there are many times you might be able to, or maybe your plan for the day was to not transfer or to maximize your time while sitting upright. But he had paradoxical movement of his diaphragm and tried all sorts of things, tried sniff technique, tried scooping technique, and he just could not synchronize appropriate movement of the diaphragm. So one way to really try to make a difference is to change the position, um and he. As soon as we put him in supine, he was able to get that diaphragm to fire with the sniff technique. He still couldn't do it with just a one breath Um, but we were able to train in supine position to allow him to get the strength and coordination to then move into different positions. And once we were able to go from three sniffs to two sniffs, to one sniff in the supine position, I started having him roll onto his left side, perform sniffing in left side lying, reverse, go into right side lying and him specifically, we did prone positioning a lot for posture and extensor activation. But we could only hang out in that position for a certain period of time because it would actually make him more short of breath because of the resistance of the diaphragm and his weakness already.
Rachele Burriesci:So he's the person I have in my mind when I'm kind of reading through the study, so a little bit surprised that prone had most excursion. But you start kind of teasing some of it out and you know, maybe not we're talking about healthy subjects, right? Someone who doesn't have Guillain-Barre, who has active, normal diaphragmatic movement. One of the ways that you actually can assess diaphragm excursion without MRI is to have your patient in prone position and use tapping technique to basically determine where the diaphragm is at quiet breathing and then where it moves to with deep breathing and then measure the difference between those two points and so you actually can see quite a bit of movement in that way. I did that quite a bit with my students and so it was always interesting to see that level of movement in the prone position.
Rachele Burriesci:So one of the theoretical reasons why you do actually get increased excursion of the diaphragm and even lateral costal movement AP specifically is because of gravity again, right. So organs are now moving in a gravity dependent position, allowing for increased movement of the posterior diaphragm. So there was some verbiage of you know specific location of what part of the diaphragm that we're talking about. So just another interesting technique I have a current patient who we've actually been really concentrating on increasing lateral costal movement, getting a more normalized excursion at the diaphragm and just more synchronized breath pattern, and so we just started incorporating different positioning with sniffing again to get that. And it's just so interesting to see the different, the ability of the diaphragm to adapt and how much more movement you might get in a different position.
Rachele Burriesci:So just you know, another thing to try with your patients who are either having difficulty activating diaphragm in a normal motion, using the sniff technique in different positions and seeing that movement, and also, if you're having an issue with lateral costal excursion, using side-lying loading and unloading each side to see if you can actually encourage more movement based on that loaded position. So just some really cool things. There's actually a fun article to read. It was wonderful to see it coming out of a DPT program really using some good technology, another thing that we might be seeing more of in the future. And just another thing to try in your intervention toolbox.
Rachele Burriesci:So big picture here prone, greater than supine, greater than side-lying, for diaphragm excursion as well as lateral costal movement based on dynamic MRI. Change positions, utilize breathing exercises in different positions because it's going to carry over differently. And if your person's having difficulty in sitting, standing position, drop it back down to supine and now prone, give prone a try on actually activating. Activating the other thing besides, say, like resistance with the prone positioning is actually the feedback of the table, whatever surface you're on. So similar to placing your hand on a specific segment or diaphragm for cueing, the table can do the same thing. So I can definitely argue that that same point, that it could increase excursion in that position. So change positions. One other piece if you are in the supine position I think I've mentioned this before in order to activate diaphragm and shut everything else down, you want a posterior pelvic tilt, flex the neck, rotate shoulders internally or more towards neutral and then have that feedback at the hand so that there's that tactile cue as well.
Rachele Burriesci:So really great study. It's in the Cardiopalm Journal. I believe it was this last. I think I have it right here. Pretty sure it was the last. I don't have the date the last issue, which I think was in November. So give that a look. Hopefully I'll bring a couple of new articles out. I think I'm going to try to add a few articles in to the podcast world just to keep us all moving in the right direction and giving different point of views, and we'll see where we go from there. So hopefully that was helpful for you. Let me know, if you read this article, what you think and what experience you have with your own clientele and that's always the biggest thing is utilizing the research that exists, incorporating it into your own treatment sessions and then also looking at your patients and what they tolerate, because at the end of the day, what works for your patient is the most important thing. All right, I hope you all have a wonderful day, a beautiful week, happy holidays and, whatever you have to do, get after it.
