Dry Needling to Improve Diaphragm Contractility
The diaphragm, just like any other muscle, can atrophy and lose contractile ability from phrenic nerve compression, tension, hypoxia, demyelination, and a number of other factors. But how do we alleviate this? Dry Needling.
Luckily for us, the diaphragm is innervated by 3 spinal levels: C3-C5. A friend of mine in our class this weekend had a C2-T2 fusion about 6 years ago. He apparently had significant spinal cord impingement and nerve root impingement bilaterally. Obviously, he has lost a significant amount of cervical and upper thoracic ROM.
50% of total cervical rotation comes from C1/C2, so his rotation is halfway decent. With palpation during respiration, you can’t feel the L side of the diaphragm contract. He has been like this since surgery, but he has never had anyone specifically try to improve the atrophied portion of the muscle.
The phrenic nerve follows the internal jugular caudally after it exits the spine. Remember, the external jugular is on the outside of the SCM, and the internal jugular is deep to the SCM. Abnormal muscle shortening and thickening, especially of the SCM, the omohyoid, and the scalenes, can place abnormal tension or compression on the phrenic nerve as it follows the internal jugular down to the diaphragm. The SCM and the omohyoid typically run in between the internal and external jugular, and a branch of the phrenic nerve may exit from the spine through the middle scalene. The middle scalene also attaches to the first rib which, if elevated, can lead to all sorts of neurovascular compromise. Upper thoracic and cervical joint displacement may also lead to phrenic nerve pathology since the nerve roots exit around the TPs of C3-C5.
In the case of my friend this past weekend, his cervical spine, aside from C0-C1, is fused, so there is nothing that can be done about those joints. However, there is something to be done about the muscles close to the phrenic nerve and the joints above and below the fusion. He also had his 5th rib at the sternal attachment in significant anterior displacement, which was visibly noticeable and painful to the touch. It was also painful with full inspiration.
How Dry Needling Can Improve Diaphragm Contractility
During class, I needled superficially:
- over the L diaphragm
- into the L SCM
- L middle scalene at C3-C5
- L upper trap
- L omohyoid
- bilaterally down to the lamina
- through the multifidus at C3-C5
- at about T10-L1.
I connected 10 Hz of stim from the cervical spine needles to the needles over the L & R diaphragm, from the cervical spine to the thoracic spine, and from the thoracic spine to directly over the L diaphragm.
Following the needles, I manipulated his mid to lower thoracic and lumbar spines along with C0-C1 and the L 6th rib at the sternal attachment.
Here is my initial thought with this treatment: Maybe it is possible to reduce muscular hypertrophy and improve vascular dilation of the cervical musculature close to the phrenic nerve, where we can safely needle.
Remember, nerves need blood just like everything else, and nerve hypoxia can significantly affect electrical conductivity and function. Rib hypomobility can also significantly limit diaphragm function. Multiple large, deep cavitations of the spine and ribs were achieved somewhere around C5 or so, which may also help part of the sensory innervation and blood supply to the L aspect of the diaphragm. Following the treatment, the anteriorly deviated rib was reduced back into place and was no longer painful.