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.

When physical therapists think about core stability, the focus often turns to individual muscles such as the transversus abdominis, multifidus, or pelvic floor. Yet at the center of this intricate system lies the diaphragm, a key player in the generation and modulation of intra-abdominal pressure (IAP). The ability to coordinate the diaphragm with the abdominals and pelvic floor through effective IAP regulation is critical not only for postural control but also for spine protection and efficient movement strategies.

IAP refers to the pressure within the abdominal cavity, bounded superiorly by the diaphragm, inferiorly by the pelvic floor, and circumferentially by the abdominal wall and spine. As the diaphragm contracts and descends during inhalation, it compresses the abdominal contents, while the pelvic floor and abdominal wall counteract this pressure to maintain balance. This pressurization acts as an internal stabilizer, creating a dynamic support system that reduces shear and bending stress on the lumbar spine. Recent biomechanical modeling by Murray and colleagues (2025) highlighted that IAP’s stabilizing role becomes particularly significant when external mechanical loads shift rapidly, emphasizing its importance for both daily and athletic movements.

Emerging evidence reinforces that IAP is not a passive byproduct of breathing; it is an active mechanism of stabilization. Kawabata and Shima (2023) demonstrated that breathing patterns and postural orientation strongly influence IAP and abdominal muscle recruitment. Their cross-sectional study revealed that forced exhalation in supine produced significant transversus abdominis and internal oblique activation, while exertion inhalation during a plank posture elicited similar effects, confirming that posture and breath type dictate how effectively the core musculature contributes to trunk stiffness.

Sembera et al. (2023) added an intriguing layer by showing that abdominal bracing, although stabilizing, can compromise respiration during lifting tasks. Their findings indicated that bracing reduces lung volumes even when diaphragmatic excursion increases, suggesting a necessary balance between spinal stability and ventilatory function. Clinically, this underscores the need to coach patients on modulating (not maximizing) IAP, to avoid respiratory compromise while preserving spinal support.

When the diaphragm, abdominal wall, and pelvic floor fail to coordinate efficiently, IAP regulation becomes dysfunctional. Patients with chronic low back pain often exhibit altered breathing strategies or underuse IAP mechanisms, relying instead on excessive paraspinal activation. Similarly, postpartum individuals with diastasis recti or individuals with pelvic floor dysfunction may struggle to modulate IAP effectively, resulting in impaired load transfer and increased spinal demand. In patients with respiratory disorders such as asthma or COPD, restricted diaphragmatic excursion can further limit the ability to generate stabilizing intra-abdominal pressure.

Recent clinical studies support the integration of breathing and core training in rehabilitation. Li et al. (2025) found that individuals with chronic non-specific low back pain who engaged in core training combined with breathing exercises demonstrated greater improvements in pain, function, and strength than those performing core training alone.

Likewise, Seo et al. (2024) reported that diaphragmatic strengthening within a core training protocol enhanced diaphragm thickness, respiratory pressure, and postural stability compared to traditional training methods. Together, these findings affirm that targeted interventions to optimize IAP and diaphragmatic coordination can yield meaningful functional benefits.

While the science of IAP is growing, the clinical application remains refreshingly practical. The following cues can help practitioners integrate IAP-based interventions into patient care.

Clinical Cues & Strategies: How to “Use IAP” Without Overdoing It

1. Start with breathing awareness
   • Use diaphragmatic or “belly” breathing cues in supine/recumbent first, encouraging gentle expansion in all directions.
     Use ultrasound or palpation (if available) to see diaphragm descent or amplitude changes.
2. Introduce gentle co-activation
   • Once diaphragm movement seems adequate, cue light abdominal engagement (e.g., light TrA) while breathing to gently harness IAP.
     Avoid immediate high bracing; the goal is dynamic modulation, not always maximal stiffening.
3. Progress posture + load
   • Move from supine → quadruped → half-kneel → standing → loaded tasks (bird-dog, dead bug, split stance).
     In each, cue breathing + abdominal co-activation together in a coordinated rhythm, not sequentially.
4. Load under breathing constraints
   • Challenge patients to maintain coordinated breathing + IAP during functional tasks: lifts, carries, squats.
     Use feedback (tactile cue, visual diaphragm ultrasound, breathing sensors) if possible.
5. Monitor for compensation
   • Watch for breath holds, neck accessory overuse, scapular shrugging, or paradoxical breathing.
     If compensations appear, regress posture or reduce load.
6. Balance ventilation and stability
   • Be cautious in populations with respiratory compromise, too much bracing may reduce lung capacity.
     When in doubt, prioritize breathing first, then layer in stabilization.

In summary, intra-abdominal pressure serves as a powerful yet nuanced mechanism of spinal protection. The coordinated activity of the diaphragm, abdominals, and pelvic floor forms an adaptable cylinder that stabilizes the spine, enhances postural control, and supports efficient movement. Current research emphasizes that effective IAP regulation requires both breath control and muscular timing, skills that can be refined through intentional training. Clinicians who integrate IAP strategies into their treatment approaches are better positioned to optimize function and alleviate pain across a wide spectrum of patients, from postpartum individuals to high-performance athletes.

Register Now: Breathing and the Diaphragm - December 6
For clinicians ready to deepen their understanding of the diaphragm and its vital relationship with IAP, join us on December 6 for Breathing and the Diaphragm, an interactive Zoom-based continuing education course.

Learn evidence-based assessment and treatment techniques that connect the diaphragm, abdominals, and pelvic floor to optimize intra-abdominal pressure, postural control, and functional performance. Perfect for clinicians treating patients with pelvic pain, diastasis, incontinence, spinal dysfunction, or athletes seeking enhanced stability.

Don’t miss this opportunity to translate current research into practical, evidence-based interventions that enhance your patients’ stability and performance.

References

1. Kawabata, M., & Shima, N. (2023). Interaction of breathing pattern and posture on abdominal muscle activation and intra-abdominal pressure in healthy individuals: A comparative cross-sectional study. Scientific Reports, 13(1), 1-9. https://doi.org/10.1038/s41598-023-37629-5
2. Li, Y., Zhao, Q., Zhang, X., E, Y., & Su, Y. (2025). The impact of core training combined with breathing exercises on individuals with chronic non-specific low back pain. Frontiers in Public Health, 13, 1518612. https://doi.org/10.3389/fpubh.2025.1518612
3. Murray SA, Driscoll M. Finite element investigation of the intrinsic stiffness contribution of intra-abdominal pressure in a transient spine and trunk model. Comput Biol Med. 2025 Sep;196(Pt A):110549. doi: 10.1016/j.compbiomed.2025.110549. Epub 2025 Jul 3. PMID: 40614524. https://pubmed.ncbi.nlm.nih.gov/40614524/
4. Sembera, M., Busch, A., Kobesova, A. et al.The effect of abdominal bracing on respiration during a lifting task: a cross-sectional study. BMC Sports Sci Med Rehabil 15, 112 (2023). https://doi.org/10.1186/s13102-023-00729-w
5. Seo, H., Jeong, G., & Chun, B. (2024). Impact of Diaphragm-Strengthening Core Training on Postural Stability in High-Intensity Squats. Life, 14(12), 1612. https://doi.org/10.3390/life14121612