What is abdomino-phrenic dyssynergia?

Hello Friends.  I love getting into the science around here–so here I go again. Today’s topic is abdomino-phrenic dyssynergia. Sounds like a low key subject, right? Ha! After I did a post on bloating a while back, readers asked for more information on this condition.

Let’s start with the basics. What is abdomino-phrenic dyssynergia (APD)?  APD describes the failure of the abdominal wall muscle to contract and the diaphragm to relax after a meal.  Instead, the anterior abdominal wall relaxes and the diaphragm contracts and this redistributes gas which can lead to the sensation of bloating and visible belly distention. Why this happens in some people is poorly understood.

Abdominal bloating can occur via a number of different conditions, including chronic constipation, small intestinal bacterial overgrowth, gastroparesis (delay in stomach emptying) or impaired stomach accommodation to food, and even in life threatening conditions such as ovarian cancer. This is why it is important to visit with a doctor and to not self diagnose. For those of you in the back row, let me say this again, ALWAYS discuss your symptoms or change in symptoms with your doctor!

For more on causes and treatment of bloating, check out my previous post here .

Please note, low grade bloating after eating a meal is normal for humans. When bloating, however, impairs quality of life or is more than low grade bloating, I encourage you to work with your GI team to guide your treatment. This may include your trusted gastroenterologist, registered dietitian with a GI expertise, GI psychologist, and possibly, a physical therapist specialized in managing bloating. A dietitian may trial a reduction in foods rich in fermentable carbohydrates (FODMAPs) which can reduce bloating for some people.

Physical therapist, Jenna Leader, PT, DPT, from Boston-based Beth Israel Deaconess Medical Center’s Pelvic Floor Program and Megan Riehl, PsyD, GI psychologist, from University of Michigan, weigh in on this topic.

Kate: When do you suspect APD is a potential problem in a patient? What symptoms would you call ‘red flags’? Are there risk factors?

Jenna: If a patient comes in for their first visit with complaints of severe abdominal distention that occurs quickly after eating, I will suspect APD. However, if other diagnoses such as SIBO or food intolerances, which can also cause similar symptoms, have not been ruled out, I will not suspect APD right away. Abdominal distention is one of the largest complaints I hear from my patients and it is often one of the more difficult things to treat. There are many things that can cause distention. In order to properly treat it, we have to know the cause. There are breath tests and elimination diets to help diagnose SIBO or food intolerances but there is no way to formally test for APD. Usually it is a diagnosis that is eventually given when nothing else has worked but it is possible that certain symptoms may be helpful in identifying APD.

Patients with APD may report looking pregnant after eating or having a flat stomach in the morning that progressively distends as the day goes on.  Patients may also report feeling full quickly with meals. Objectively, abdominal distension will likely be visible, especially later in the day or after meals.

Kate: What are some potential risk factors for abdominal phrenic dyssynergia (APD)?

Jenna: I have not identified specific risk factors for developing APD. However, stress seems to play a role as well as the pelvic floor due to its close relationship with the diaphragm.

Kate: Does APD commonly occur with other conditions?

Jenna: APD typically occurs with pelvic floor dysfunction, specifically outlet constipation, which is when the pelvic floor does not relax appropriately to allow for emptying. APD and pelvic outlet constipation likely occur together because the pelvic floor and diaphragm have a pressure relationship. Meaning, when the diaphragm descends during inspiration, the pelvic floor also descends. During exhalation, the diaphragm passively recoils upwards and the pelvic floor also recoils upwards. With APD, there is uncoordinated movement of the diaphragm which will lead to the same within the pelvic floor.

Kate: For those recommended to your practice with APD- can you walk through in laymen’s terms what they might expect from a pelvic floor physical therapy appointment?

Jenna: My treatments are highly focused on regaining muscle coordination between the diaphragm and the pelvic floor. I start with patient education to give them an understanding on how these muscles work together. I will use biofeedback for retraining proper pelvic floor relaxation while bearing down during bowel movements. I also use the biofeedback to achieve proper pelvic floor activating during diaphragmatic breathing. I do not use biofeedback on the diaphragm as this would require a sensor that goes down into the esophagus.

I’d like to take a moment to explain biofeedback because there is a lot of misinformation out there.  Biofeedback only tells us if a muscle is contracting or relaxing, it cannot grade muscle strength and it is not actively helping a muscle contract or relax. The sensors only detect muscle activity. The patient is still doing all the work. It is a helpful visual tool but if patients rely on the visual feedback and cannot replicate without it, it ultimately is not helpful. For retraining the diaphragm, it is just as easy to have a patient place their hands on their stomach and feel for abdominal expansion and pelvic floor relaxation. This would still be considered feedback, it is just tactile feedback.

I do use biofeedback often but it is not the only treatment I do. I focus on gaining the patients awareness of their body. You can feel the pelvic floor muscles relax and contract and you can feel for proper diaphragmatic breathing. I give my patients the tools they need to know if they are doing this correctly. Body awareness is a large focus of treatments. I may also spend time with different stretches for the pelvic floor and hips. Poor mobility in the spine can also contribute to poor movement of the diaphragm so we may also do spinal mobility exercises.

Going beyond just the body, as I stated earlier, stress also plays a role in how we breathe. The mind and body are always connected. I will typically recommend restorative yoga or meditation as ways to manage stress, both also happen to help with breathing mechanics. Stress may not be the cause of APD but may be the result of dealing with APD. It is not easy to feel misunderstood or misdiagnosed but there is help out there. I encourage anyone dealing with this to stay strong and motivated.

What about GI psychologist-based behavioral interventions for bloating? Here, Megan Riehl, PsyD from University of Michigan, Michigan Medicine weighs in:  “The research has shown that bloating can be a difficult symptom to treat from a behavioral perspective using hypnotherapy and/or cognitive behavioral therapy (Foley et al, 2014). However, a GI psychologist can work with the patient to identify better coping strategies for the discomfort of this symptom. Treatment may include relaxation training in the form of diaphragmatic breathing, passive muscle relaxation, guided imagery, and gut-directed hypnotherapy.  A psychologist may also explore body image with the patient to determine if the subjective experience of bloating is hindering a person’s self-esteem or creating unrealistic expectations for their body image. At times, unconscious clenching of the abdominal region due to poor body image can exacerbate the issue and this can be addressed in behavioral therapy.”  Dr. Riehl describes commonly used behavioral therapies in gut disorders here.

References:

Foley A, Burgell R, Barrett JS, Gibson PR. Management Strategies for Abdominal Bloating and Distension. Gastroenterol Hepatol (N Y). 2014;10(9):561–571. Free access to PDF of this paper here.