In the high-stakes environment of the intensive care unit (ICU), respiratory physiotherapy plays a pivotal role in managing patients on invasive mechanical ventilation (IMV). One of the most persistent challenges in this setting is ventilator-induced diaphragm dysfunction (VIDD), a condition that complicates weaning and prolongs hospital stays. While manual therapy is a staple in orthopedic settings, its application in critically ill, neurocritical patients remains a developing frontier. A recent pilot randomized controlled trial, published in December 2025, investigates the feasibility and safety of the Manual Diaphragm Release Technique (MDRT) in this delicate population.
Bridging Manual Therapy and Critical Care
The study, conducted by de Oliveira and colleagues, sought to answer a primary question regarding safety and feasibility. Neurocritical patients often present with complex physiological instability, making manual interventions around the thoracic cage potentially risky. The researchers aimed to determine if MDRT could be applied without causing adverse events or hemodynamic instability, while also exploring preliminary data on diaphragmatic kinematics via ultrasound.
This pilot RCT enrolled 20 adult neurocritical patients undergoing pressure-support ventilation (PSV). The participants were randomized into two groups: one receiving a single session of MDRT plus standard physiotherapy, and a control group receiving a sham maneuver plus standard care. The primary focus was not just efficacy, but whether the protocol could be successfully delivered in a real-world ICU setting.
High Feasibility and Safety Profile
For practitioners hesitant to apply manual techniques to intubated patients, the results of this study are encouraging. The trial demonstrated a high feasibility profile with an 80% recruitment rate and 100% adherence to the protocol. The intervention, which lasted approximately 6 minutes, resulted in zero adverse events during or immediately after the therapy. This suggests that MDRT is a safe addition to the physiotherapist’s toolkit for neurocritical patients, provided they are hemodynamically stable enough for standard rehabilitation.
Immediate Effects on Diaphragm Kinematics
While safety was the primary endpoint, the study also utilized ultrasound to measure immediate changes in diaphragm mechanics, specifically contraction velocity, relaxation velocity, and excursion. It is important to note that this was a pilot study involving a single treatment session. The adjusted analyses revealed no detectable statistical differences in diaphragmatic kinematics between the MDRT and sham groups immediately following the intervention.
However, the lack of immediate kinematic change does not necessarily negate the potential clinical value of the technique. Manual therapy often requires cumulative sessions to effect tissue change, particularly in patients with prolonged immobility or neurological deficits. The authors note that these findings simply provide the baseline effect size estimates needed to power future, larger-scale trials.
Implications for Future Practice
This study represents a crucial step forward for orthopaedic and respiratory manipulation in critical care. By establishing that MDRT is feasible and safe, it opens the door for larger longitudinal studies to investigate if repeated sessions can improve weaning outcomes or reduce VIDD. For the practicing physiotherapist, this evidence supports the notion that manual diaphragm techniques can be integrated into neurocritical care plans without compromising patient safety.
References
de Oliveira, E. F. A. L., de Souza, H. C. M., Cavalini, H. F. S., Dantas, F. M. N. A., Neves, V. R., Lemos, F. A., Gama de Abreu, M., & Magalhães, P. A. F. (2025). Feasibility of the Manual Diaphragm Release Technique in Neurocritical Patients on Mechanical Ventilation: A Pilot Randomized Controlled Trial. Medical Sciences (Basel, Switzerland).
