The most common and well-known diaphragm, which separates the thoracic cage from the abdomen. This diaphragm controls the pressures between the thorax and the abdomen. The diaphragm is the major respiratory muscle of the body. The torso consists of two cavities, the thoracic and the abdominal. Theses cavities share some properties, and they have an important distinction as well as containing organs. The thoracic houses the heart and lungs, and the abdominals house the stomach, liver, gall bladder, spleen, liver, kidneys.
Both share the diaphragms by the abdominals having it as a roof and the thoracic area having it as the floor thoracic cavity. They also both open at one end to an external environment and both mould and change shape via movement and breath. However there is an important structural difference in how they do so.
The abdominal cavity is a fluid flexible sac like structure like that of a balloon. When you squeeze one end the pressure or bulge increases in another area and vice versa This is because fluid is non compressible.
Also, in processes other than breathing when we eat or drink a big meal, the volume will expand as a result of the expanded organs stomach, intestines and bladder. If you have inflammation of the gut? Any increase in abdominal pressure will result in a decrease in the thoracic.
We talk about three-dimensional breathing in both Yoga and Pilates and emphasize diaphragmatic breathing in Pilates. Farfan, ; Grillner et al. However one cannot happen with out the other.
Thoracic shape change is linked to abdominal shape change. You can also say the abdominal cavity also changes shape not volume in three dimensions. It is also where the powerful muscles of the upper extremities and shoulder girdle insert [2]. The thoracic inlet diaphragm covers the superior thoracic aperture the superior opening of the thoracic cavity.
Anatomically it is referred as the thoracic inlet and clinically as the thoracic outlet. This is also where the brachial plexus passes. Impingement of the plexus in the region of the scalenes, ribs, and clavicles is responsible for thoracic outlet syndrome. At the thoracolumbar junction spinal function changes abruptly as is seen in the differences in the upper thoracic and lower lumbar joints. Somatic dysfunction in this area can be associated with hypertonus of the iliopsoas, quadratus lumborum, thoracolumbar erector spinae and inhibition of the rectus abdominus muscles [2].
The respiratory diaphragm or called thoracic diaphragm in anatomy , is found in this transitional zone Fig. Contraction and relaxation of this diaphragm provide the function for breathing and it also produces alternating intrathoracic and intra-abdominal pressure gradients which provide the pumping mechanism for the venous and lymphatic circulation.
Licensed under CC BY 3. The lumbosacral junction forms the base of the spinal column and is therefore a major determinant of body statics.
Movement from the legs is transmitted through this junction to the spine. The pelvic diaphragm or pelvic floor is associated with this junction Fig. The two articles highlight the most up-to-date scientific information on the myofascial continuum for the first time.
Knowledge of myofascial connections is the basis for understanding the importance of the five diaphragms in osteopathic medicine. In this first part, the article reviews the systemic myofascial posterolateral relationships of the respiratory diaphragm; in the second I will deal with the myofascial anterolateral myofascial connections.
OMM provides five models for the clinical approach to the patient, which act as an anatomy physiological framework and, at the same time, can be a starting point for the best healing strategy [ 1 ]. The five models are: biomechanical-structural; respiratory-circulatory; neurological; metabolic-nutritional; behavioral-biopsychosocial [ 1 ].
In the five models were also recognized by the osteopathic international alliance OIA [ 1 ]. In clinical practice there will always be a subjectivization in the choice of the model, with interchangeability of the same models; the models are not limits but rather non-binding reference points [ 1 ].
The metabolic-nutritional model highlights how cellular metabolism works, as well as the assimilation of nutrients, the immune and reproductive systems; the behavioural-biopsychosocial model controls and regulates the circadian rhythms of sleep, daily behavior with respect to physical activity, food choice and lifestyle in general [ 1 ].
The respiratory-circulatory model, the theme linked to the vision of the five diaphragms, takes into account the homeostasis of the extracellular and intracellular environment with the aim of ensuring that no obstacles prevent either the supply of oxygen and nutrients, or the elimination of cell metabolism waste [ 1 ]. The rationale of the respiratory-circulatory model is based on the fact that body fluids must have the ability to circulate freely and the OMM approach will be oriented towards those anatomical structures that can facilitate the objective, including the respiratory diaphragm muscle [ 1 ].
The first osteopath who spoke of the treatment of the three diaphragms was Viola Frymann diaphragm, tentorium cerebelli, and pelvic floor in [ 2 ].
From the anatomical point of view, a diaphragm is considered as such on the basis of its "horizontal" body position [ 3 ]. In reality, in the living, there are no such demarcated and linear structures on one plane, since each macroscopic and microscopic structure is three-dimensional, involving infinite axes and planes of movement, with different tissues that influence each other [ 4 - 5 ].
Talking about diaphragm and diaphragms is a convention. In the late seventies, another osteopath made palpatory observations involving four diaphragms. Gordon Zink evaluated the position of the respiratory diaphragm, the thoracic outlet or high thoracic diaphragm, the pelvic floor or pelvic diaphragm, and the tentorium of the cerebellum or cerebellar diaphragm.
Its assessment was based on movements induced by the operator, to look for any restrictions on rotation; while inducing a movement, if the tissue presents an abnormal tension, the slight push of the operator is slowed down by the tissue or anatomical area taken into consideration during the evaluation [ 1 ]. By comparing the different assessed diaphragms, the osteopath decides which anatomical structure needs more attention, depending on the greater restriction of palpated movement.
In daily clinical practice, a restriction is referred to as "inspiration restriction" or "internal rotation", if one or more palpated diaphragms have a preferentially caudal attitude [ 1 , 6 ]. On the contrary, a restriction found palpatory in "expiratory restriction" or "external rotation" is called if one or more palpated diaphragms have a preferentially cranial attitude [ 1 , 6 ].
In , the first scientific article came out which highlighted the relationship of the diaphragm muscle with an additional diaphragm the fifth , that is, the tongue, through fascial and neurological connections [ 7 ]. In a second article was published on the five diaphragms, with the hypothesis of manual treatment; in the first clinical article appeared with the five diaphragms and OMM [ 2 , 8 ].
The article briefly reviews the anatomy of the body diaphragms and the myofascial systemic anterolateral relationships of the same diaphragms. The diaphragm muscle is the main respiratory muscle. The sternal portion of the diaphragm involves the xiphoid process of the sternum from its posterior area with small bundles of fibers [ 9 ].
The rib portion arises from the posterior and upper area of the last six ribs, merging with the transverse muscle of the abdomen [ 9 ]. The diaphragm involves the dorsal DD12 and lumbar L1-L4 vertebrae. The diaphragmatic portion of the dorso-lumbar area consists of the right and left medial pillars MPs , deep and posterior to the sternal and costal anterolateral portion; MPs form an "eight" with anterior inclination, for the passage of the abdominal aorta and then of the esophagus [ 10 ].
The right medial pillar is longer and wider DL4 , while the left medial pillar is shorter and thinner DL2 [ 9 - 10 ]. The vena cava passes through the phrenic center at about D11 [ 9 ].
The intermediate pillars with the medial pillars form the medial arcuate ligaments, while the lateral pillars will form the median and lateral arcuate ligaments involving the vertebral body of L1 and L2 and the transverse process, as well as the transverse process with the last rib, respectively [ 7 ]. The median arcuate ligament will merge with the large psoas muscle and the lateral arcuate ligament with the quadratus lumborum muscle [ 7 ]. Reproduced with permission, from Anastasi G, et al.
The innervation of the diaphragm muscle comes from the left and right phrenic nerves as well as the vagus nerves; the latter involves the portion of the esophagal hiatus Figure 2 [ 7 ]. The pelvic diaphragm, first named in , is made up of the levator ani muscle made up of the iliococcygeus, pubococcygeus and puborectal muscles , and a second muscle referred to as the coccygeal or ischiococcygeal [ 11 ].
The triangular ligament or urogenital diaphragm or Carcassonne fascia or middle perineal aponeurosis is the most caudal portion of the pelvic floor, placed externally and horizontally [ 11 - 12 ].
The triangular ligament includes the deep transverse muscle of the perineum; the anterior portion of the ligament is crossed by the urinary and genital ducts, stretched between the two ischio-pubic branches and turned with the apex towards the pubic symphysis [ 11 - 12 ]. The levator ani extends from the internal surface of the pubis to the side of the symphysis, up to the ischial spine; in its path, it involves the internal obturator muscle with a myofascial connection tendon arch of the levator ani.
The pubococcygeus and puborectal muscle form the anococcygeal ligament posteriorly; the iliococcygeal portion originates from the tendon arch of the levator ani, moving medially up to the coccyx forming a connective raphe or anococcygeal ligament [ 11 - 12 ].
The ischiococcygeal muscle constitutes the posterosuperior portion of the pelvic diaphragm and originates from the lateral margin of the last sacral segments and coccyx, ending with a thinned portion on the ischial spine and on the neighbouring portion of the sacrospinous ligament [ 11 - 12 ].
The upper portion of the pelvic floor is covered with the endopelvic fascia. Another muscle is an integral part of the pelvic muscle complex, that is, the gluteus maximus. The gluteus maximus muscle is connected via a connective tissue strip at the level of the ischioanalis fossa to the muscle complex of the levator ani; a contraction of the latter is equivalent to a contraction of the gluteus maximus, as demonstrated by electromyographic and magnetic resonance assessments [ 13 ].
The innervation of the pelvic musculature is complex, as smooth muscle fibers not just skeletal muscle fibers can be found in the levator ani muscle group; these smooth fibers are found mainly in the central and medial area [ 14 ]. This area rich in smooth muscle fibers is innervated by the sympathetic nerves of the inferior hypogastric plexus; the remaining muscular area of the pelvic floor is innervated by the levator ani nerve and the pudendal nerve [ 15 ].
Anatomists define the thoracic opening or upper thoracic diaphragm as a thoracic inlet, giving the motivation that it is an orifice where air and food passes; for clinicians, it is defined as thoracic outlet, as the passage of blood vessels is emphasized [ 16 ].
The upper thoracic diaphragm consists of the sternal bone and the joints between the first two ribs and the clavicle; the clavicle and the first two ribs will involve the scapula and the first two thoracic vertebrae, respectively [ 16 ]. The muscle components are the trapezius muscle, the three scalene muscles, the subclavian muscle and the pectoralis minor muscle; to remember, the presence of the scalene minimus muscle, which may contain a muscular or purely connective structure [ 17 ].
Different vascular-nervous and visceral structures cross the area. The lower roots and trunks of the brachial plexus with the artery and subclavian vein cross the muscular space, between the anterior and middle scalene, with the base consisting of the first rib; this passage is defined as an interscalene triangle [ 16 ]. The nervous and vascular pathways continue, to cross a space between the clavicle and the first rib costoclavicular space [ 16 ]. The sub-coracoid tunnel, below the tendon of the pectoralis minor muscle, is the third passage portion of the vascular-nervous package [ 16 ].
Inside the upper thoracic diaphragm, we find the pleural dome and the Sibson fascia [ 18 ]. The lingual complex is made up of intrinsic and extrinsic muscles. The intrinsic muscles are: transversalis, verticalis, inferior longitudinalis and superior longitudinalis [ 19 ].
The extrinsic muscles, unlike the previous ones, involve the mandibular bone in particular the genioglossus muscle and the hyoid bone: genioglossus, styloglossus, hyoglossus and palatoglossus. The intrinsic and extrinsic muscles are in pairs right and left , for a total of 16 muscles [ 19 ]. Some authors consider two other muscles forming the lingual complex, which are part of the extrinsic musculature: glossopharyngeus and chondroglossus.
The first is a muscle strip from the superior pharyngeal constrictor muscle, while the second is a small contractile district, which derives from the hyoglossus muscle [ 19 ].
The innervation of the tongue comes from the lingual nerve and the hypoglossal nerve; the two nerves communicate before reaching the lingual complex [ 20 ]. The hypoglossal nerve with the lateral and medial branches enters the ventrolateral area of the tongue and innervates the genioglossus muscle of the right and left in its posterior portion , building a cross innervation [ 21 ].
The image shows above some portions of the meninges, while the following image below shows the venous sinuses and some arteries. Figure A shows the tentorium cerebelli, occipital bone, corpus callosum, lateral ventricle and cerebellum. Figure B shows the superior sagital sinus, vein of Galen, internal cerebral vein, inferior sagital sinus, pericallosal artery, cortical veins, straight sinus, ophthalmic artery, confluence of sinuses, superior petrosal sinus, occipital sinus, inferior petrosal sinus, internal carotid artery, internal jugular vein, sigmoid sinus and transverse sinus.
The tentorium cerebelli is located in the posterior cranial fossa with a semilunar shape; it is a transverse septum or tentorial diaphragm.
It covers the cerebellum and acts as a support for the occipital lobes of the brain mass. Along with strengthening your diaphragm, diaphragmatic breathing can also reduce stress and lower blood pressure. The thumb is the first of the hand's five digits, but it is typically not referred to as a finger.
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