Journal of Paramedical Sciences & Rehabilitation

Journal of Paramedical Sciences & Rehabilitation

Does Adding Diaphragm Myofascial Release Improve Pain, Disability and quality of life in Patients with Chronic Shoulder Pain?

Document Type : Original Article

Authors
Fatemeh Ghaderi Varkani 1
Khadijeh Otadi 1
Siamak Bashardoust Tajali 1
Kazem Malmir 1
Monire Motaqi 2
1 Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Basic Sciences, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran
10.22038/jpsr.2026.92415.2752
Abstract
Purpose:
Shoulder pain is the third most common musculoskeletal disorder, and impaired diaphragmatic function may lead to altered arthrokinematics and contribute to symptom development in patients with shoulder pain. This study aimed to investigate the effect of adding myofascial release of the diaphragm muscle to routine physiotherapy on pain, functional disability, and quality of life in these patients.
Methods:
This double-blind randomized clinical trial included 25 patients allocated into two groups: a control group (routine physiotherapy + sham diaphragm release) and an intervention group (routine physiotherapy + active diaphragm myofascial release). Both groups received six treatment sessions over two weeks. Pain intensity, functional disability, and quality of life were assessed using the Visual Analogue Scale (VAS), Shoulder Pain and Disability Index (SPADI), and Short Form-12 Health Survey (SF-12), respectively. Paired and independent t-tests were used for within- and between-group comparisons, and Cohen’s d was calculated to determine effect sizes.
Results:
Pain intensity at rest, during activity, and during night sleep, as well as SPADI scores, significantly decreased in both intervention and control groups from pre- to post-treatment (p < 0.001); however, the effect size was greater in the intervention group. The mental component score (MCS) of quality of life significantly improved in the control group (p < 0.001), with an effect size of 0.78. The physical component score (PCS) also showed a significant increase in the control group (p = 0.01), with a large effect size of 1.1.
Conclusion:
Active myofascial release of the diaphragm combined with routine physiotherapy and sham manual contact can effectively reduce pain and disability in patients with chronic shoulder pain. However, no sufficient evidence was found to support a differential effect between active and sham diaphragm release on pain and disability outcomes. In the present study, the sham-contact group demonstrated greater improvements in quality of life.
Keywords
Chronic shoulder pain
Myofascial release
Diaphragm
Physiotherapy
Quality of life
Shoulder Pain and Disability Index
  1. Martín-Rodríguez A, Gostian-Ropotin LA, Beltrán-Velasco AI, Belando-Pedreño N, et al. Sporting Mind: The Interplay of Physical Activity and Psychological Health. Sports 2024; 12(1): 37.
  2. Malliaras P, Cridland K, Hopmans R, Ashton S, et al. Internet and telerehabilitation-delivered management of rotator cuff–Related shoulder pain (INTEL trial): Randomized controlled pilot and feasibility trial. JMIR mHealth and uHealth 2020; 8(11): e24311.
  3. Holmes RE, Barfield WR, Woolf SK. Clinical evaluation of nonarthritic shoulder pain: Diagnosis and treatment. The Physician and sportsmedicine 2015; 43(3): 262-268.
  4. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment. American family physician 2008; 7(4):493-497.
  5. Sergienko S, Kalichman L. Myofascial origin of shoulder pain: a literature review. Journal of bodywork and movement therapies 2015; 19(1): 91-101.
  6. Donatelli R.A. Physical Therapy of the Shoulder. Fifth Edition. PhD, PT, OCS National Director of Sports Rehabilitation, Physiotherapy Associates. Las Vegas, Nevada. 2012.
  7. Fernández-López I, Peña-Otero D, de los Ángeles Atín-Arratibel M, Eguillor-Mutiloa M. Influence of the phrenic nerve in shoulder pain: A systematic review. Int J Osteopath Med 2020; 1(36): 36-48.
  8. Bordoni B, Zanier E. Anatomic connections of the diaphragm: influence of respiration on the body system. Journal of multidisciplinary healthcare 2013; 25: 281-291.
  9. Donatelli RA. Physical Therapy of the Shoulder-E-Book. Elsevier Health Sciences; 2011.
  10. Tang A, Bordoni B. Anatomy, Thorax, Muscles. In: Stat Pearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 30855905.
  11. Bordoni B, Pellegrini MV. Osteopathic manipulative treatment: 5 diaphragm procedures. InStatPearls [Internet] 2022. Stat Pearls Publishing.
  12. Sueki DG, Cleland JA, Wainner RSJJom, therapy m. A regional interdependence model of musculoskeletal dysfunction: Research, mechanisms, and clinical implications. J Man Manip Ther 2013; 21(2): 90-102.
  13. Zeinab M. Abd El-Rahem, Abeer A. Yamany;  Mariam O, et al. Effect of diaphragmatic release on neck pain and chest expantion in patients with upper crossed syndrome. Egypt J Appl Sci 2023; 38(1): 9-21.
  14. Ajimsha MS, Al-Mudahka NR, Al-Madzhar JA. Effectiveness of myofascial release: systematic review of randomized controlled trials. J Bodyw Mov Ther 2015;19(1):102-112.
  15. Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 1983; 16(1): 87-101.
  16. Martins J, Napoles BV, Hoffman CB, Oliveira AS. The Brazilian version of Shoulder Pain and Disability Index: translation, cultural adaptation and reliability. Braz J Phys Ther 2010; 14: 527-536.
  17. Ebrahimzadeh MH, Birjandinejad A, Golhasani F, Moradi A, et al. Cross-cultural adaptation, validation, and reliability testing of the Shoulder Pain and Disability Index in the Persian population with shoulder problems. Int J Rehabil Res 2015; 38(1): 84-87.
  18. Jenkinson C, Layte R. Development and testing of the UK SF-12. J Health Serv Res Policy 1997; 2(1): 14-18.
  19. Sharif-Nia H, Fatehi R, Hosseini L, Nowrozi P. Psychometric Properties of the Short-form-12 Questionnaire of Quality of Life Among Iranian Hemodialysis Patients. J Mazandaran Univ Med Sci 2024; 34(237): 100-114.
  20. Rocha T, Souza H, Brandão DC, Rattes C, et al. The manual diaphragm release technique improves diaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease: A randomised trial. J Physiother 2017; 63 (4): 240-245.
  21. Marizeiro DF, Florêncio AC, Nunes AC, Campos NG, de Paula Lima PO. Immediate effects of diaphragmatic myofascial release on the physical and functional outcomes in sedentary women: a randomized placebo-controlled trial.  Bodyw Mov Ther 2018; 22(4): 924-929.
  22. Fernández-López I, Peña-Otero D, Eguillor-Mutiloa M, Bravo-Llatas C, de los Ángeles Atín-Arratibel M. Manual therapy on the diaphragm is beneficial in reducing pain and improving shoulder mobility in subjects with rotator cuff injury: A randomized trial. Int J Osteopath Med 2023; 50:100682.
  23. Menek B, Ceylan A, Tayboğa Uİ, Erayata BN. Effects of breathing exercises on pain and functionality in rotator cuff tears. A randomized controlled traial. Karya J Health Sci 2025; 6(1): 7-13.
  24. Poojari S, Kamani NC. The influence of fascial manipulation on shoulder range of motion, pain, and function in individuals with chronic shoulder pain. J Bodyw Mov Ther 2024; 40: 53-60.
  25. Chen Z, Wu J, Wang X, Wu J, Ren ZJCtim. The effects of myofascial release technique for patients with low back pain: A systematic review and meta-analysis. Complement Ther Med 2021; 59: 102737.
  26. Paulo LR, Lacerda AC, Martins FL, Fernandes JS, et al. Can a single trial of a thoracolumbar myofascial release technique reduce pain and disability in chronic low back pain? A randomized, balanced crossover study. J Clin Med 2021; 10(9): 2006.
  27. Boff TA, Pasinato F, Ben ÂJ, Bosmans JE, et al. Effectiveness of spinal manipulation and myofascial release compared with spinal manipulation alone on health-related outcomes in individuals with non-specific low back pain: randomized controlled trial. Physiotherapy 2020; 107: 71-80.
  28. Şahin O, Kocamaz D. Effects of diaphragmatic mobilization and diaphragmatic breathing exercises on pain and quality of life in individuals with shoulder pain: A randomized controlled trial. International Int J Disabil Sports Health Sci. 2021; 4(2): 113-123.
Journal of Paramedical Sciences & Rehabilitation
Volume 15, Issue 1
Spring 2026
Pages 71-79