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.