{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T03:24:30Z","timestamp":1791516270797,"version":"4.3.4"},"reference-count":34,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,3,17]],"date-time":"2026-03-17T00:00:00Z","timestamp":1773705600000},"content-version":"unspecified","delay-in-days":16,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,2,25]]},"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Non-specific low back pain (NSLBP) is one of the leading causes of disability worldwide. Emerging evidence suggests that altered diaphragmatic function may be associated with lumbar pain, impaired trunk stabilisation and functional disability. Manual diaphragmatic techniques have been proposed as an intervention to modulate diaphragmatic tension, mobility and neuromyofascial relationships; however, their effectiveness has not yet been synthesised using rigorous systematic review methods.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>This protocol follows Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidance and has been prospectively registered in PROSPERO. Randomised controlled trials evaluating manual techniques specifically applied to the diaphragm in adults with NSLBP will be eligible. The primary outcomes will include pain intensity and functional disability; secondary outcomes will include lumbar mobility, respiratory function, quality of life and adverse events. Searches will be performed in PubMed\/MEDLINE, Cochrane CENTRAL, PEDro, CINAHL, Scopus, Embase and clinical trial registries without language or date restrictions. Two reviewers will independently perform study selection, data extraction and risk-of-bias (RoB) assessment using the Cochrane RoB 2 tool. Where appropriate, a random-effects meta-analysis will be conducted; the certainty of evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation approach. Substantial clinical and methodological heterogeneity is anticipated across trials, which may limit the feasibility of quantitative data pooling.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>As this study uses data from previously published trials, ethical approval is not required. Findings will be disseminated through peer-reviewed publication, conference presentations and a plain-language summary for clinical stakeholders.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>PROSPERO registration<\/jats:title>\n                    <jats:p>CRD420251172616.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-114709","type":"journal-article","created":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T21:56:05Z","timestamp":1773870965000},"page":"e114709","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Effectiveness of manual diaphragmatic techniques in adults with non-specific low back pain: a systematic review and meta-analysis protocol"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-6989-487X","authenticated-orcid":false,"given":"Francisco Jos\u00e9","family":"Vera\u2011Serrano","sequence":"first","affiliation":[{"name":"Physiotherapy Department, Faculty of Physiotherapy and Podiatry, University of Seville, Seville, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4589-4442","authenticated-orcid":false,"given":"Maria Jesus","family":"Vinolo-Gil","sequence":"additional","affiliation":[{"name":"Department of Nursing and Physiotherapy, University of Cadiz, Cadiz, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1956-3087","authenticated-orcid":false,"given":"Rub\u00e9n","family":"Arag\u00f3n\u2011Mart\u00edn","sequence":"additional","affiliation":[{"name":"MOVE\u2011IT Research Group, Department of Physical Education, Faculty of Education Sciences, University of C\u00e1diz, C\u00e1diz, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlos","family":"P\u00e9rez-P\u00e9rez","sequence":"additional","affiliation":[{"name":"Grupo PAIDI CTS1152 Fisioterapia, University of Cadiz, C\u00e1diz, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0701-079X","authenticated-orcid":false,"given":"Pedro Alfonso","family":"Dom\u00ednguez-Vera","sequence":"additional","affiliation":[{"name":"Physiotherapy Department, Faculty of Physiotherapy and Podiatry, University of Seville, Seville, Spain"},{"name":"Rehabilitation Clinical Management Unit, Interlevels-Intercenters Hospital Puerta del Mar, C\u00e1diz, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0855-9557","authenticated-orcid":false,"given":"Juan Antonio","family":"D\u00edaz-Mancha","sequence":"additional","affiliation":[{"name":"Physiotherapy Department, Faculty of Physiotherapy and Podiatry, University of Seville, Seville, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,3,18]]},"reference":[{"key":"2026031814553629000_16.3.e114709.1","doi-asserted-by":"publisher","DOI":"10.14245\/ns.2448372.186"},{"key":"2026031814553629000_16.3.e114709.2","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2022-064119","article-title":"Clinical and economic burden of low back pain in low- and middle-income countries: a systematic review","volume":"13","author":"Fatoye","year":"2023","journal-title":"BMJ Open"},{"key":"2026031814553629000_16.3.e114709.3","doi-asserted-by":"publisher","DOI":"10.1016\/S2665-9913(23)00098-X"},{"key":"2026031814553629000_16.3.e114709.4","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)30480-X"},{"key":"2026031814553629000_16.3.e114709.5","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(20)30925-9"},{"key":"2026031814553629000_16.3.e114709.6","doi-asserted-by":"crossref","first-page":"1913","DOI":"10.1016\/j.apmr.2023.02.022","article-title":"A systematic review of clinical practice guidelines for persons with non-specific low back pain with and without radiculopathy: identification of best evidence for rehabilitation to develop the WHO\u2019s package of interventions for rehabilitation","volume":"104","author":"Zaina","year":"2023","journal-title":"Arch Phys Med Rehabil"},{"key":"2026031814553629000_16.3.e114709.7","doi-asserted-by":"publisher","DOI":"10.1111\/j.1469-7580.2012.01511.x"},{"key":"2026031814553629000_16.3.e114709.8","doi-asserted-by":"publisher","DOI":"10.1007\/s00276-010-0757-7"},{"key":"2026031814553629000_16.3.e114709.9","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0208697","article-title":"Impact of diaphragm function parameters on balance maintenance","volume":"13","author":"Kocjan","year":"2018","journal-title":"PLoS One"},{"key":"2026031814553629000_16.3.e114709.10","doi-asserted-by":"crossref","first-page":"281","DOI":"10.2147\/JMDH.S45443","article-title":"Anatomic connections of the diaphragm: influence of respiration on the body system","volume":"6","author":"Bordoni","year":"2013","journal-title":"J Multidiscip Healthc"},{"key":"2026031814553629000_16.3.e114709.11","unstructured":"Moore KL , Dalley AF . Clinically oriented anatomy. 4th edn. Philadelphia: Lippincott Williams & Wilkins, 2001:119\u201323."},{"key":"2026031814553629000_16.3.e114709.12","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1089\/end.2012.0152","article-title":"Medial arcuate ligament: a new anatomic landmark facilitates the location of the renal artery in retroperitoneal laparoscopic renal surgery","volume":"27","author":"Cai","year":"2013","journal-title":"J Endourol"},{"key":"2026031814553629000_16.3.e114709.13","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1148\/radiology.185.1.1523290","article-title":"Lateral arcuate ligaments of the diaphragm: anatomic variations at abdominal CT","volume":"185","author":"Silverman","year":"1992","journal-title":"Radiology"},{"key":"2026031814553629000_16.3.e114709.14","doi-asserted-by":"crossref","first-page":"937","DOI":"10.3171\/2021.10.SPINE21793","article-title":"Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction","volume":"36","author":"Xu","year":"2022","journal-title":"J Neurosurg Spine"},{"key":"2026031814553629000_16.3.e114709.15","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1007\/s00276-007-0291-4","article-title":"Anatomy and biomechanics of the vertebral aponeurosis part of the posterior layer of the thoracolumbar fascia","volume":"30","author":"Loukas","year":"2008","journal-title":"Surg Radiol Anat"},{"key":"2026031814553629000_16.3.e114709.16","first-page":"273","article-title":"Morphologic variation of the diaphragmatic crura: a correlation with pathologic processes of the esophageal hiatus?","volume":"67","author":"Loukas","year":"2008","journal-title":"Folia Morphol (Warsz)"},{"key":"2026031814553629000_16.3.e114709.17","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1016\/j.jbmt.2020.11.008","article-title":"Effect of releasing quadratus lumborum muscle on hip and knee muscle length in asymptomatic individuals","volume":"26","author":"Jairakdee","year":"2021","journal-title":"J Bodyw Mov Ther"},{"key":"2026031814553629000_16.3.e114709.18","first-page":"421","article-title":"Mechanical Low Back Pain","volume":"98","author":"Will","year":"2018","journal-title":"Am Fam Physician"},{"key":"2026031814553629000_16.3.e114709.19","unstructured":"World Health Organization . Package of interventions for rehabilitation: module 2 musculoskeletal conditions. Geneva: WHO, 2023."},{"key":"2026031814553629000_16.3.e114709.20","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1123\/jsr.2023-0207","article-title":"The efficiency of respiratory exercises in rehabilitation of low back pain: a systematic review and meta-analysis","volume":"33","author":"Zhai","year":"2024","journal-title":"J Sport Rehabil"},{"key":"2026031814553629000_16.3.e114709.21","doi-asserted-by":"crossref","first-page":"13","DOI":"10.3233\/BMR-230054","article-title":"Effects of breathing exercises on chronic low back pain: a systematic review and meta-analysis of randomized controlled trials","volume":"37","author":"Jiang","year":"2024","journal-title":"J Back Musculoskelet Rehabil"},{"key":"2026031814553629000_16.3.e114709.22","doi-asserted-by":"crossref","first-page":"97","DOI":"10.2147\/JMDH.S101208","article-title":"A review of analgesic and emotive breathing: a multidisciplinary approach","volume":"9","author":"Bordoni","year":"2016","journal-title":"J Multidiscip Healthc"},{"key":"2026031814553629000_16.3.e114709.23","doi-asserted-by":"publisher","DOI":"10.1016\/j.jmpt.2009.03.003"},{"key":"2026031814553629000_16.3.e114709.24","unstructured":"Oscoz Mu\u00f1oa GA . La influencia de la t\u00e9cnica de stretching de la parte anterior del diafragma en los valores espirom\u00e9tricos en fumadores [thesis]. Madrid, Escuela de Osteopat\u00eda de Madrid, 2005"},{"key":"2026031814553629000_16.3.e114709.25","unstructured":"M\u00e1rquez Ambite JE , Cortijo S\u00e1nchez C . Efectividad de la t\u00e9cnica de estiramiento del diafragma tor\u00e1cico objetivada con radiograf\u00eda de t\u00f3rax [thesis]. Madrid, Escuela de Osteopat\u00eda de Madrid, 2006"},{"key":"2026031814553629000_16.3.e114709.26","doi-asserted-by":"crossref","first-page":"924","DOI":"10.1016\/j.jbmt.2017.10.008","article-title":"Immediate effects of diaphragmatic myofascial release on the physical and functional outcomes in sedentary women: a randomized placebo-controlled trial","volume":"22","author":"Marizeiro","year":"2018","journal-title":"J Bodyw Mov Ther"},{"key":"2026031814553629000_16.3.e114709.27","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1590\/0102-6720201600s10011","article-title":"Evaluation of the thoracoabdominal mobility of obese subjects in pre-bariatric surgery","volume":"29Suppl 1","author":"Veloso","year":"2016","journal-title":"Arq Bras Cir Dig"},{"key":"2026031814553629000_16.3.e114709.28","first-page":"1","article-title":"Manual therapy in diaphragm muscle: effect on respiratory muscle strength and chest mobility","volume":"14","author":"Braga","year":"2016","journal-title":"Man Ther Posturology Rehabil J"},{"key":"2026031814553629000_16.3.e114709.29","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1016\/j.jbmt.2022.09.029","article-title":"Effects of diaphragmatic and iliopsoas myofascial release in patients with chronic low back pain: a randomized controlled study","volume":"33","author":"S\u0131\u011flan","year":"2023","journal-title":"J Bodyw Mov Ther"},{"key":"2026031814553629000_16.3.e114709.30","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: an updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"2026031814553629000_16.3.e114709.31","doi-asserted-by":"crossref","DOI":"10.1186\/2046-4053-4-1","article-title":"Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement","volume":"4","author":"Moher","year":"2015","journal-title":"Syst Rev"},{"key":"2026031814553629000_16.3.e114709.32","unstructured":"Higgins JPT , Thomas J , Chandler J , et al . Cochrane handbook for systematic reviews of interventions. Version 6.4. London: Cochrane, 2023."},{"key":"2026031814553629000_16.3.e114709.33","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.l4898","article-title":"RoB 2: a revised tool for assessing risk of bias in randomised trials","volume":"366","author":"Sterne","year":"2019","journal-title":"BMJ"},{"key":"2026031814553629000_16.3.e114709.34","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.39489.470347.AD"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-114709","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T21:56:10Z","timestamp":1773870970000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-114709"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3]]},"references-count":34,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3,18]]},"published-print":{"date-parts":[[2026,3]]}},"alternative-id":["10.1136\/bmjopen-2025-114709"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-114709","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3]]}}}