Abdominal and Diaphragmatic Mobility in Adults With Chronic Gastritis: A Cross-Sectional Study

Abstract

Objective

The purpose of this study was to assess abdominal and diaphragmatic mobility in adults with chronic gastritis compared with healthy individuals and to analyze the impact of chronic gastritis on musculoskeletal signs and symptoms of the cervical and thoracic spine.

Methods

This was a cross-sectional study conducted by the physiotherapy department at the Universidade Federal de Pernambuco in Brazil. Fifty-seven individuals participated, 28 with chronic gastritis (gastritis group [GG]) and 29 healthy individuals (control group [CG]). We assessed the following: restricted abdominal mobility in the transverse, coronal, and sagittal planes; diaphragmatic mobility; restricted cervical vertebral segmental mobility; restricted thoracic vertebral segmental mobility; and pain on palpation, asymmetry, and density and texture of the soft tissues on the cervical and thoracic spine. The measure of diaphragmatic mobility was assessed with ultrasound imaging. The Fisher exact and χ² tests were applied to compare the groups (GG and CG) in relation to the restricted mobility of the abdominal tissues near the stomach on all planes and diaphragm, and the independent samples t test to compare the mobility measurements of the diaphragm. A significance level of 5% was considered for all tests.

Results

Restricted abdominal mobility in all directions (P < .05) was greater in GG when compared with CG except for the counterclockwise direction (P = .09). In GG, 93% of the individuals presented restricted diaphragmatic mobility, with a mean mobility of 3.1 ± 1.9 cm, and in the CG, 36.8% with a mean of 6.9 + 1.7 cm (P < .001). The GG presented a higher occurrence of restricted rotation and lateral glide mobility of the cervical vertebrae, pain to palpation, and density and texture dysfunction of the adjacent tissues when compared with CG (P < .05). In the thoracic region, there was no difference between GG and CG regarding musculoskeletal signs and symptoms.

Conclusion

Individuals with chronic gastritis presented greater abdominal restriction and lower diaphragmatic mobility, in addition to a higher occurrence of musculoskeletal dysfunction in the cervical spine when compared with healthy individuals.

Introduction

A recent study has attempted to establish relationships between visceral gastrointestinal disorders and musculoskeletal disorders of the spine.¹ It has been hypothesized that an organ, due to malfunction, may present restricted intrinsic (motility) and extrinsic (mobility) movements. The loss of this mobility and motility may be associated with tension in the connective, supporting tissue of the organ, which may also influence the nearby structures. These structures may include other viscera and musculoskeletal structures, which are connected by the same underlying ligaments, fascia and other connective tissues.^2,3

Hypotheses suggest the following 3 main mechanisms in which the movement relationship between organs and connective tissues may be manifested: visceral referred pain, central sensitization, and local fascial changes. Through these mechanisms, it is plausible that visceral disorders may result in musculoskeletal complaints.^{1, 2, 3, 4, 5, 6}

Recent studies have suggested relationships between intestinal and uterine visceral dysfunctions with dysfunctions of the spine and pelvic girdle. These studies have presented proposals for manual therapy to improve the mobility and motility of the involved structures.^{7, 8, 9, 10}

The digestive system and related structures may also be subject to similar relationships.^{11, 12, 13} However, there are currently no studies that assess this relationship to chronic gastritis, which is an infiltration of inflammatory cells in the gastric mucosa¹⁴ and may cause gastric atrophy.¹⁵ It is estimated that in chronic gastritis, there is mobility restriction of the abdominal tissues near the stomach and connected organs, such as the lesser omentum, the greater omentum, and the gastrophrenic ligament, which are connected to the liver, intestine, and diaphragm, respectively.³

The cervical and thoracic spine may have direct and indirect relationships with gastrointestinal disorders.^1,2,4,5,16 These relationships raise questions concerning changes with musculoskeletal repercussions due to anatomical, nerve, and fascial relationships.¹⁷ One hypothesis is that the muscles and joints that have the same innervation and are connected by the same body fascia may generate tension, which may then have repercussions on tissue restrictions throughout the body.^{18, 19, 20} Another hypothesis suggests that decreased visceral mobility may impair organ function,²¹ thus generating afferent stimuli for the phrenic nerve, which innervates the diaphragmatic muscle, subdiaphragmatic peritoneum, coronary ligaments, and liver capsule. Hence, it is hypothesized that the restricted mobility of abdominal tissues near the stomach may affect the mobility of the diaphragm muscle since the gastrophrenic ligament directly connects these 2 structures.^{19, 20, 21}

Other hypotheses have suggested that tissue restrictions are due to inflammation, and visceral restrictions may lead to increased muscle tension in innervated structures at the corresponding spinal level through viscerosomatic reflexes.^6,22 Sensory nerves enter the spinal cord, where they produce local segmental responses, such as excitation, facilitation, and reflex actions. Thus, a sensory stimulus may directly affect a motor or sympathetic nerve or may do so through an intermediate interneuron. These interneurons may be excitatory or inhibitory. Therefore, the continuous afferent stimulation produced from the restricted mobility of the innervated tissues by the phrenic and vagus nerves may promote the facilitation (irritability) of the internuncial neurons at the levels where their neural roots are found, between C3 and C5 and T5 to T9, respectively.²¹ It may also influence the response to pain sensitivity for areas without demonstrable dysfunctions.^10,17,22,23

These hypotheses suggest there may be a relationship between chronic gastritis and musculoskeletal disorders of the spine and adjacent organs, especially the diaphragm. If this is correct, it may be possible to improve organ function and prevent and treat associated musculoskeletal disorders through manual therapies, such as osteopathy, chiropractic, or others. Through integrating body systems, a more global approach to patient care would include the visceral and musculoskeletal systems.^1,5,8,18

Therefore, the aim of this study was to assess the abdominal and diaphragmatic mobility in adults with chronic gastritis compared with healthy individuals and to analyze the impact of chronic gastritis on musculoskeletal signs and symptoms of the cervical and thoracic spine.

Method

Study Design

This was a cross-sectional study conducted between October 2018 and December 2019 that followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Sample

The study consisted of 57 adults, 28 with chronic gastritis (gastritis group [GG]) and 29 healthy adults (control group [CG]), with no gastric symptoms and no diagnosis of gastritis, of both sexes and aged between 18 and 59 years. There were no losses to participation in the study.

A sampling power greater than or equal to 95% was obtained using G*Power (Kiel University), considering the total sample of 14 individuals and using the mean of the variables related to the main outcome of this study (diaphragmatic mobility)

Inclusion and Exclusion Criteria

Adults were included in the chronic gastritis group by volunteer recruitment and also from the Hospital das Clínicas at the Universidade Federal de Pernambuco through the Learning and Motor Control Laboratory. Individuals with a medical diagnosis and evidence of chronic gastritis through endoscopic examination (performed over the previous 2 years) were included in the study. Exclusion criteria were as follows: another gastrointestinal disorder; pregnant women; preexisting rheumatic diseases, except osteoarthritis; relevant decompensated comorbidities (cancer, diabetes, thyroid disorders); hypotension; limiting respiratory diseases (chronic obstructive pulmonary disease, asthma); arterial or venous, cardiac, renal or hepatic failure; presence of chronic postural deformities (scoliosis, kyphoscoliosis, and any differences between the limbs); presence of thoracic surgery or abdominal; neurological dysfunction; changes in skin integrity in the thoracoabdominal region; and vestibular change.

Those in the healthy group were recruited by invitation through social media and from volunteers and included adults aged between 18 and 59 years, of both sexes, with no gastric symptoms and no diagnosis of acute or chronic gastritis; exclusion criteria were those used for the chronic gastritis group.

Measures

Personal, Clinical Information and Intensity of Gastric Symptoms

After recruiting the chronic gastritis and healthy groups, individuals were assessed through questionnaires produced by the researchers regarding personal information and clinical and/or gastric symptoms, with symptom intensity from 0 to 10. Following this, the International Physical Activity Questionnaire (IPAQ) long form²⁴ and the Perceived Stress Scale²⁵ were applied.

Assessment of Abdominal Tissue Mobility Restriction

Abdominal tissue mobility was assessed according to the palpation protocol described by Barral,³ who assessed the patient while seated. However, this was modified in relation to the position of the patient, who was assessed in the supine position, and to the evaluator, who remained in the contralateral position to the organ.

Abdominal tissue mobility was assessed with palpation through the skin surface in the region between the liver and the left costal margin, obliquely limited by the left side of the sternum, at its lower part, and at the higher part through an oblique line of the sixth costal cartilage to the lower part between the eighth and ninth rib. For palpation, the evaluator's hand was placed obliquely with the fingers pointing towards the region of the ribs with the palm remaining close to the sternum region, performing deep compressions until reaching the threshold of skin elasticity.²⁶

During inspiration and expiration, the tissues near the stomach are expected to move together with the diaphragm in a 3-dimensional movement. On inspiration, it is considered normal when the organ, on palpation, moves in a medial, inferior direction and performs a clockwise rotation. During expiration, abdominal mobility is considered normal when there is lateral and superior movement with counterclockwise rotation.²⁶

For this study, the movements of the abdominal tissues during palpation were divided into coronal (cranial-caudal and caudal-cranial directions), sagittal (medial-lateral and lateral-medial directions), and transverse (clockwise and counterclockwise rotations) planes, where a lack or decrease of movement was identified on each plane in each direction and classified as being restricted.²⁶

Currently, there are no studies that assess the validity of being able to detect the mobility of abdominal organs with palpation. However, assessing abdominal tissue mobility through palpation in visceral osteopathy is an assessment procedure used in clinical practice²⁶; thus, it is a practical, rapid, and low-cost parameter for assessing visceral mobility. Osteopathic manual therapy has been described by the World Health Organization regarding visceral symptoms.²⁷ In the present study, palpation was used to verify tissue malleability and elasticity, density, or tension. Palpation was located midway between the body surface and the physical rejection zone (applied pressure rejection), better known as the “work zone.”²⁶

For the reproducibility of this technique, the intrarater agreement was performed from 3 assessed measurements (time between assessments).

Ultrasound Assessment of the Diaphragmatic Mobility Measurement

The ultrasound assessment of the diaphragmatic mobility followed the criteria of Cardenas et al,²⁸ using an ALOKA 500 Pro series (GE Medical Systems).²⁹ Dysfunctions were characterized according to mobility. Diaphragmatic mobilities below 6.3 cm were described as restricted and above that as normal.

Assessment of the Presence of Musculoskeletal Signs and Symptoms of the Cervical and Thoracic Spine

The Tenderness, Asymmetry, Restriction of Motion, Tissue Texture Change (TART) tool was used to assess the presence of musculoskeletal signs and symptoms of the cervical and thoracic spine.^1,30 The TART is an assessment method used in osteopathy.²⁹ It characterizes a somatic dysfunction that may manifest as a localized area of palpable change in the muscles and fascia adjacent to the spine. These changes include tissue swelling or edema, increased or decreased temperature, and stiffness or loss of tone.^1,31 Through TART, the thoracic spine (T5 to T9) was assessed for the presence of pain on palpation of the vertebral segment (pain on palpation), dysfunction in posterior vertebral positioning (vertebral asymmetry), tenderness of adjacent soft tissues (density and texture dysfunction of adjacent soft tissues), and blockage in vertebral segmental movement (vertebrae with reduced rotation mobility). For the cervical spine, in addition to the above-mentioned findings, a vertebral segmental lateral glide movement was palpated. For the TART tests related to the cervical spine, the participant was positioned in the supine position, with the head slightly bent and resting on the evaluator's sternum. To assess the thoracic vertebrae, the participant was positioned in the prone position, using a band covering the nipple region, with the arms relaxed parallel to the body and the evaluator standing one foot positioned in front of the other, at the height of the participant's pelvis, facing towards the cranial region.

Pain on palpation of the vertebrae was assessed through palpation of the spinous processes, and the patient was instructed to report the presence or absence of pain.³⁰

The density and texture of the soft tissues adjacent to the occipital region (suboccipital muscles) and to the C1 to C4 and T5 to T9 vertebrae (paravertebral muscles) were assessed by palpating the soft tissues immediately lateral to the spinous processes of the spine and occipital bone. The presence or absence of tenderness in the adjacent soft tissues was also recorded.^32,33

The symmetry of the occipital and vertebral region was assessed with the evaluator resting the fingers on the region to be assessed and identifying whether there was any dysfunction in the vertebral positioning in the vertebral posteriority.³³

Vertebral mobility of C1 to C4 was performed by assessing 2 main movements, lateral glide and vertebral rotation. For lateral glide, with the fingers resting on the transverse processes, the movement was performed, and it was observed whether there was any lateral glide restriction on one of the sides. For rotation, also with the fingers on the transverse processes, rotation movements of the vertebrae were performed, alternately directing the fingers in the posteroanterior direction, seeking the restriction of this movement towards one of the sides. For vertebral mobility from T5 to T9, the vertebral rotation was assessed, also with the fingers on the transverse processes, performing rotational movements of the vertebrae, alternately directing the fingers in the posteroanterior direction, seeking any restriction of this movement towards one of the sides.^1,34

Ethics

All individuals included in the research signed the Informed Consent Forms, according to resolution 466/12 of the National Research Ethics Commission of the Ministry of Health. This study obtained prior approval from the Research Ethics Committee at the Universidade Federal de Pernambuco, CAAE: 98862718.3.0000.5208, Report No. 3,267,353.

Statistical Analysis

A descriptive analysis was performed to characterize the study patients of the 2 groups (Table 1) based on the mean measurements, the standard deviation for continuous or discrete quantitative variables (age, body mass index, and Perceived Stress Scale), and frequency for qualitative variables (sex, IPAQ, gastritis symptoms and type of gastric symptoms). For a comparison between groups in relation to nonparametric variables (age and body mass index), the Mann-Whitney U test was used, and for the parametric variable (perceived stress), the independent t test was used. For the categorical variable, sex, and IPAQ, the χ² test was used.

Table 1.

Clinical, Anthropometric, and Basic Characteristics

Characteristics of the Sample	GG (n = 28)	CG (n = 29)	P Value
Age (y), mean (range)	24.5 (23.7-31.4)	24 (22.5-28.1)	.08a
Sex, n (%)  Female  Male	26 (92.9) 2 (7.1)	20 (71) 9 (29)	.05b
BMI (kg/m2), mean ± SD	23.6 ± 4.7	24 ± 3.7	.45a
IPAQ, n (%)  Low  Moderate  High	1 (3.7) 7 (25.9) 20 (70.4)	2 (6.7) 10 (33.3) 17 (60)	.4b
Perceived stress, mean ± SD	32.1 ± 8.5	28.6 ± 8	.118c
Gastric symptoms, n (%)  Less than 3 symptoms  More than 3 symptoms	4 (14.3) 23 (82.1)	–	–
Type of gastric symptoms, n (%)  Feeling of gastric fullness  Pyrosis Pain in the upper abdominal region  Epigastric pain  Nausea  Eructation  Vomits	25 (89.2) 24 (85.7) 23 (82.1) 23 (82.1) 22 (78.5) 20 (71.4) 6 (21.4)	–	–

BMI, body mass index; CG, control group; GG, chronic gastritis group; IPAQ, International Physical Activity Questionnaire; SD, standard deviation.

^aMann-Whitney U test.

^bχ² test.

^ct Test for independent samples.

To compare the categorical variable, mobility restriction between the groups (Table 2) through the coronal (cranial-caudal and caudal-cranial), sagittal (lateral-medial and medial-lateral), and transverse (clockwise and counterclockwise rotation) planes, the Fisher exact test was used. This test was also used to compare the categorical variable of diaphragmatic mobility dysfunction.

Table 2.

Comparison of Restricted Abdominal Mobility (By Direction), Measure of Mobility, and Dysfunction of Diaphragmatic Mobility (Hypomobility) Between Healthy Individuals and Those With Gastritis

	Total Sample (N = 57)
Restricted Abdominal Mobility (By Direction) and Diaphragmatic Mobility	GG (n = 28)	CG (n = 29)	P Value Gastritis × Control	Intrarater Agreement (Kappa/ICC)
Restricted abdominal mobility, n (%)
Coronal plane
Cranial-caudal direction  Yes  No	19 (67.9) 9 (32.1)	4 (16.7) 20 (83.3)	.00a	0.947b
Caudal-cranial direction  Yes  No	11 (39.3) 17 (60.7)	2 (8.3) 22 (91.7)	.01a	1.0b
Sagittal plane
Lateral-medial direction  Yes  No	13 (46.4) 15 53.6)	1 (4.2) 23 (95.8)	.00a	1.0b
Medial-lateral direction  Yes  No	10 (35.7) 18 (64.3)	2 (8.3) 22 (91.7)	.02a	1.0b
Transverse plane
Clockwise rotation  Yes  No	12 (42.9) 16 (57.1)	2 (8.3) 22 (91.7)	.01a	1.0b
Counterclockwise rotation  Yes  No	20 (71.4) 8 (28.6)	11 (45.8) 13 (54.2)	.09a	1.0b
Diaphragmatic mobility dysfunction, n (%)
No  Yes	26 (92.9) 2 (7.1)	7 (36.8) 12 (63.2)	.001a	1.0b
Diaphragmatic mobility (cm)
Mean ± SD	3.4 ± 1.9	6.9 ± 1.7	.001c	1.0d

CG, control group; GG, chronic gastritis group; ICC, intraclass correlation coefficient; SD, standard deviation.

^aFisher exact test.

^bKappa intrarater (>0.95).

^ct Test for independent samples.

^dICC intrarater (>0.99).

The numerical variable “diaphragm mobility” was expressed as a mean and standard deviation, and the groups were compared with the independent samples t test.

The level of intrarater agreement was assessed to decrease the limiting factor by calculating the Kappa index for the outcomes of abdominal mobility restriction and diaphragmatic mobility restriction. In order to analyze the reproducibility of the values obtained for diaphragm mobility, the intraclass correlation coefficient (ICC) was used. The ICC and Kappa were classified as follows: <0 = no agreement; 0 to 0.50 = poor agreement; 0.50 to 0.75 = moderate agreement; 0.75 to 0.90 = good agreement; <0.90 = excellent agreement.³³

To compare the categorical variables related to musculoskeletal signs and symptoms in the cervical region (vertebrae with reduced rotation mobility, vertebrae with reduced lateral glide mobility, pain on palpation in the vertebral segment, vertebral asymmetry, and density and texture dysfunction of adjacent soft tissue) and in the thoracic region (reduced rotation mobility, pain on palpation, vertebral asymmetry, density and texture dysfunction of adjacent soft tissue), the Fisher t test was used (Table 3).

Table 3.

Characteristics of the Musculoskeletal Signs and Symptoms of the Cervical, Thoracic, and Occipital Region in the Chronic Gastritis and Healthy Groups

	Total Sample (N = 57)
Musculoskeletal Signs and Symptoms of the Spine	GG (n = 28)	CG (n = 29)	P Valuea
Occipital and cervical joint (C1-C4)
Vertebrae with reduced rotation mobility	26; 96.3	15; 65.2	.013
Vertebrae with reduced lateral glide mobility	27; 100	18; 78.3	.037
Pain on palpation	22; 81.5	9; 39.1	.005
Vertebral asymmetry	27; 100	21; 91.3	.401
Density and texture dysfunction of adjacent soft tissue	27; 100	16; 69.9	.007
Thoracic region (T5-T9)
Rotation mobility reduced	22; 81.5	12; 52.2	.056
Pain on palpation	21; 77.8	12; 52.2	.108
Vertebral asymmetry	27; 100	21; 91.3	.401
Density and texture dysfunction of adjacent soft tissue	27; 100	22; 95.7	.935

CG, control group; GG, chronic gastritis group.

^aFisher exact test.

The analyses were performed using SPSS 25 (IBM Corporation, Armonk, NY), adopting a significance level of P ≤ .05. The Shapiro-Wilk test was used to analyze the normality of the data.

Results

A total of 57 individuals participated in the present study, with 28 in the chronic gastritis group (GG) and 29 in the healthy (control) group (CG). Table 1 presents a comparison between the groups regarding clinical, anthropometric, and basic information.

The 2 groups presented a mean age of 24 years. In GG, around 93% were women, and in the CG, 71% were women. In GG, more than 71% presented with gastric symptoms, such as pain in the upper abdominal region, pyrosis, gastric fullness, nausea, and epigastric pain.

The groups also presented similarities regarding the level of physical activity (IPAQ). In GG, 70% of the individuals presented a high level of activity, and in CG, 60%. The stress level according to the Perceived Stress questionnaire was 32 points for the GG and 28 for the CG, demonstrating no significant difference between groups for this study.

All individuals in GG were either undergoing or had undergone treatment for gastritis (n = 28). Eighty-two percent of the individuals in GG presented more than 3 symptoms of gastritis. The frequency of all symptoms was above 71% among these individuals, with the exception of vomiting, which presented a frequency of 21%.

Table 2 presents a comparison between the restricted mobility of the abdominal tissues, the measurement and the restricted diaphragmatic mobility in those with chronic gastritis and the healthy adults, and the intrarater agreement.

The GG presented a greater occurrence of restricted abdominal and diaphragmatic mobility in all directions when compared with the CG in all directions, except for the counterclockwise direction in the transversal plane.

The mean measurement of abdominal mobility was lower in GG (3.4 + 1.9 cm) when compared with CG (6.9 + 1.7 cm), P < .001. The degrees of intrarater agreement of the 3 measurements for each assessment of the restricted abdominal and diaphragmatic mobility (Kappa >0.97) and the measurement of diaphragmatic mobility (ICC = 0.99) were classified as excellent.

Table 3 presents a comparison between those with chronic gastritis and healthy individuals in relation to the presence of musculoskeletal signs and symptoms of the spine (pain on vertebral palpation, density and texture of adjacent tissues, vertebral asymmetry, reduced rotation mobility, reduced lateral glide mobility).

In relation to the occipital and cervical segments, GG presented a greater occurrence of restricted rotation (93.3%) and lateral glide (100%) mobility of the cervical vertebrae, pain on palpation (81.5%), and density and texture dysfunction of the adjacent tissues (100%) in this region, when compared with CG (65.2%, 78.3%, 39.1%, and 69.9%, respectively, P < .05). No difference was observed in relation to vertebral asymmetry in the cervical segment. There was no difference in the thoracic region between GG and CG in relation to musculoskeletal signs and symptoms.

Discussion

The results of this study have demonstrated that there was a greater restriction in abdominal tissue and diaphragmatic mobility in individuals with chronic gastritis, in addition to a higher frequency of musculoskeletal dysfunction in the cervical spine when compared with healthy individuals.

There is a hypothesis that visceral dysfunction may affect visceral mobility.³ In chronic gastritis, it is thought that function may be compromised and associated with delayed gastric emptying and decreased visceral mobility, which may result in abdominal pain, nausea, vomiting, pyrosis, loss of appetite, and other digestive problems.³⁵

The decreased mobility of abdominal tissues near the stomach, associated with inflammation of this mucosa, may be related to tension in the cranial-caudal and caudal-cranial directions, and it is possible that this is mainly due to the gastrophrenic ligament and its relationship with the diaphragm, as well as the spleen, transverse colon, greater omentum, and phrenocolic ligament, and in the lateral-medial, medial-lateral, clockwise, and counterclockwise directions, mainly related to the lesser omentum, gastrosplenic ligament, and greater omentum.²⁶ This restriction of visceral mobility was observed in the present study. The GG presented lower abdominal tissue mobility in all directions when compared with the CG.

Another hypothesis is that visceral ligament and fascial tensions may favor a restriction of the related musculoskeletal structures and may possibly cause mechanical and physiological effects. These effects depend on the freedom of the visceral 3-dimensional movement with the visceral-peritoneal anatomo-functional relationship (between the viscera and the peritoneum), visceral-visceral (between viscera), and viscero-somatic (between viscera and spine). This may restrict the mobility of the diaphragm muscle and the movement of other viscera associated with the stomach through its topography in the upper left quadrant of the abdomen, which may possibly suggest a direct anatomical relationship between the diaphragm and the stomach and its possible relationship with mobility restriction.^18,26,36

In the present study, the diaphragm of individuals with gastritis presented less mobility when compared with healthy individuals. However, these interpretations need to be undertaken with caution since they have all been based on cross-sectional studies. No cause-and-effect studies have thus far been found.

In addition, the possible relationship between visceral disorders and musculoskeletal signs and symptoms may be due to viscero-somatic convergence of shared pathways between afferent nerves in the spinal cord. Thus, visceral disorders may cause hypersensitive or hyperreactive muscle, skin, and joints, which share the same innervation and may contribute to an increased sensitivity to pain and, consequently, muscle and joint restrictions.^1,37

In the present study, dysfunctional relationships were observed in patients with chronic gastritis, with a higher proportion in the cervical spine, especially in the spinal rotation.

The phrenic nerve corresponds to roots originating from the somatic segments of C2 to C4, which innervate the diaphragm muscle. Cervical dysfunctions could hypothetically impair the neural command of the diaphragm, which may result in less mobility,^38,39 as observed in the present study. With regard to the vagus nerve, neural changes in the sympathetic somatic segment from T5 to T9 may alter the functioning of the muscles and viscera that it innervates.³³

Intervention studies of individuals with gastrointestinal diseases have demonstrated the influence of visceral mobilization on gastrointestinal symptoms and diaphragmatic mobility.^{33,39,40, 41, 42} The results of these intervention studies suggest that there is a possible relationship between the visceral and musculoskeletal systems. Until the present moment, only the abovementioned studies have been conducted in patients with gastric dysfunction. However, other studies^7,8,37 have reported the relationship between visceral and musculoskeletal symptoms and the effect of osteopathy, which also reinforces the hypothesis of a possible relationship between the stomach and the musculoskeletal system.

Study Limitations

One of the limitations of this study is that the sample was made up of young adults, mostly women. We, therefore, suggest that more studies be conducted with an older population, and the sample between men and women is balanced.

It is also important that subsequent studies consider the duration of drug treatment undertaken by the population in order to assess the degree to which medication may influence the symptoms and abdominal mobility.

Another limitation was the measurement of stomach mobility since it was undertaken with a palpatory method and may not be as reliable compared with diagnostic ultrasound analysis, which can provide qualitative and quantitative information about gastric motility.⁴³ Therefore, the results of this study must be analyzed with caution; it has not yet been validated for detecting abdominal organ mobility.

We also emphasize that this study is cross-sectional, which has limitations in its ability to make generalized statements about differences between groups. Thus, studies with appropriate methods are needed to establish this relationship and associations between variables. No statements should be made about how the present study should guide treatment because the cross-sectional design does not investigate treatment.

Conclusion

Individuals with chronic gastritis, when compared with healthy individuals, presented with greater restrictions in abdominal and diaphragmatic mobility. They also demonstrated more musculoskeletal dysfunctions of the cervical spine (reduced rotation and lateral glide vertebral mobility, pain on palpation, and dysfunction from disjunction and texture of the adjacent tissue).