Optimizing Core Stability In Pediatric Therapy: Looking At The Diaphragm, Ribcage, and Breath

Assessing the core, ribcage, and breathing patterns in children is a crucial component of pediatric physical and occupational therapy. These elements directly influence overall functional movement and stability. By addressing these aspects, you can help improve kids’ motor skills, balance and coordination, and functional activities that depend on core stability. You can even help kids with bowel and bladder issues.

In this blog post, we will explore key considerations and techniques for assessing and treating the diaphragm, ribcage, and pelvic floor to improve the quality of life in your pediatric patients.

Let’s first take a look at the connection between the diaphragm and pelvic floor. In my previous blog post, I discussed the structural and neurological connections of the diaphragm throughout the body. Now, let’s delve deeper into understanding how the diaphragm works with the pelvic floor to stabilize the core.

The diaphragm and pelvic floor share a symmetric relationship, with their coordinated movements playing an integral role in core stability and respiratory function. When assessing breathing, you should normally notice that as the child inhales, the diaphragm descends, which increases intra-abdominal pressure, and the pelvic floor mirrors this movement by also descending.

With exhalation, the diaphragm and pelvic floor should return to their resting positions. This rhythmic movement ensures the stability of the trunk and helps maintain urinary continence during breathing and functional tasks such as coughing.

When further assessing a child’s breathing, you should notice the diaphragm is positioned parallel to the pelvic floor. This allows for optimal function of both the diaphragm and pelvic floor.

Postural dysfunction often presents as a posteriorly rotated ribcage. This misalignment compromises the diaphragm’s ability to modulate intra-abdominal pressure and the pelvic floor’s activation. This positioning leads to compensatory patterns, leading to core instability and other movement or bladder/bowel dysfunction.

Next, you must assess the ribcage and infrasternal (rib) angle to fully understand the level of a child’s core stability. A normal rib angle falls between 80-90 degrees. A child with dysfunction may start with an even wider rib angle, but what’s most important is how the ribs move during activity.

To evaluate this, you can have the child lie supine and lift their head and shoulders. Ideally, the rib angle should remain consistent, with no widening. If the rib angle widens, this may indicate muscle imbalances, including anterior muscle weakness and/or posterior muscle and fascial tightness.

Another critical assessment involves observing ribcage position in relation to the diaphragm. When the child lifts both arms overhead while lying supine, the ribcage should maintain a neutral position.

If you see the ribcage rotate posteriorly with reaching overhead, this indicates a lack of thoracic spine and ribcage stability. Since children typically do not have restrictions in the shoulder girdle (unless they have increased muscle tone or spasticity), this compensatory movement is often a sign of core instability.

Children with core dysfunction—often observed as abdominal distension, constipation, incontinence, or diastasis recti—can benefit from exercises that target the upper transverse abdominals. These muscles are essential for stabilizing the lower six ribs, which are responsible for responding to postural perturbations and maintaining core stability. I’ll walk you through some progressions.

To begin, start with anticipatory core exercises in a supportive supine position. Have the child lift their head and shoulders while focusing on maintaining a stable rib angle. Focusing on stabilizing the rib angle is key!

Depending on the child’s strength, you may need to position them in a more flexed supine position, using a pillow for support, before gradually advancing to overhead weight exercises. Once the child demonstrates adequate strength and ribcage control, you can progress their position to a more extended supine posture without a pillow.

To further challenge the core, progress exercises by moving the extremities outside of the sagittal plane and incorporating rotational movements to engage the obliques. Ensure the thoracic spine and rib angle remain stabilized before advancing to more complex exercises. Eventually, progress from supine to standing activities to challenge core stability and balance, enabling the child to apply these skills to functional activities.

When progressing core exercises, go slowly and prioritize correct technique, without letting the child rush through exercises. And always ask the child if they are holding their breath. As you know, proper breathing during core exercises is essential. A child’s breathing patterns provide insight into whether a child is using their diaphragm and core muscles effectively.

Some kids may compensate by holding their breath to create stability. They hold their breath to close the glottis, which increases abdominal pressure and therefore, increases stability. While this can be an effective compensatory strategy during challenging tasks, it may indicate that the task is too difficult and that alternative core muscles should be strengthened.

For children with cerebral palsy, this breath-holding pattern is common. They may struggle to coordinate breathing with movement because they rely heavily on closing their glottis for stability.

Kids with core weakness often exhibit weakness in other parts of their body, especially the scapulothoracic region. Strengthening the serratus anterior and latissimus dorsi can enhance ribcage stability by supporting the scapulae, which reinforced the overall core control. When you focus on improving their scapulothoracic stability, your kids will have a solid foundation for the upper body. This helps optimize their posture, breathing mechanics, and functional movement.

For children with low muscle tone, tactile input from you or a parent can be beneficial. Applying gentle compression to the ribcage helps to increase the engagement of the abdominals. By improving the length-tension relationship of these muscles, you can enhance their activation and provide stability to other muscle groups. Some children may also benefit from using an abdominal brace to reduce lower rib flare and provide additional support during core exercises.

Lastly, assessing pelvic floor function is another critical aspect when treating core stability. In my PDFC course, you can learn how to palpate the pelvic floor externally through the coccyx in various positions, including:

• prone
• child’s pose
• supine with child’s legs rested on pillow, supine knees to chest or side lying or butterfly position
• seated position upright or criss cross to minimize activation of the glutes (especially in kids who sacral sit) with an anterior pelvic tilt or neutral spine
• standing with neutral spine position
• functional exercises such as squat and lunging

When working with children on pelvic floor exercises, begin by teaching the child to hold a contraction for five seconds and relax for five seconds. Once they can perform this consistently, you can progress the exercise to more challenging positions and activities.

By focusing on the relationship between the diaphragm, ribcage, and pelvic floor, and incorporating targeted exercises, you can help children in bigger ways than you ever imagined possible!

The strategies outlined here are just the beginning—further exploration and training through my virtual course like the Pediatric Pelvic Floor Diaphragm and Postural Development (PFDC) provides video tutorials and case studies that demonstrate the progression of exercises and practical applications.

If you are looking to deepen your understanding of pediatric core assessment and pelvic floor therapy, join me live next week on September 29, 2024 , where I will give you valuable tools and insights for working with children to optimize their core function and pelvic floor function.