횡격막근(diaphragm muscle)과 늑간근

[문형철]

1. 폐렴, 폐결핵, 늑막염, 폐암, 심부전, 만성위궤양 등 횡격막 근육이 제대로 못 움직이는 상황이 오랫되었다고 가정

2. 근육을 싸고 있는 근막은 섬유화되고, 근위축이 발생하고 TrP가 발생하여 근육의 길이가 부분적으로 짧아지고, Size principle에 의하여 근육을 순서적으로 동원하지 못하고

3. 어떤 방법으로 횡격막 근육이 정상회복할 수 있도록 도와줄 것인가? 깊은 심호흡, 복식호흡, 코어운동 등

4. 어떻게 촉진할 것인가? 침치료는 가능한가? 

5. C3, 4, 5 phrenic nerve 지배 - 목디스크, 길랑바레증후군, 루푸스, 폐암 등으로 만약 횡격신경이 마비된다면? 

6. 참고로 횡경막근, 내외늑간근의 기능이 떨어지면 부호흡근인 "사각근과 SCM"을 사용함. - 어지러움, 미식거림, 두통의 원인

7. 사람 횡격막 근육은 42%가 type 1 느린 연축섬유, 58%가 2형 빠른 연축섬유. 

8. 완전한 흡기시에 배를 내밀면 복횡근 신장, 완전한 호기시 배를 밀어 넣으면 횡격막 신장. 

호흡과 관련된 근육 움직임

얕은 호흡과 심호흡, 재채기 상황이 다르다.

얕은 호흡에서 흡기시 횡격막 근육이 제일 먼저 전기적 활성이 일어남. 늑간근의 근육이 미미하게 움직임. 호기시 횡격막근육 미미하게 움직임. 사각근은 조용한 호흡동안에 항상 활동하고, 늑간근전에 활성화됨. 

심호흡에서 흡기시 관여하는 1차근육은 횡격막 근육, 흉골주의 내측늑간근, 사각근, 외측늑간근, 늑골거근임. 횡격막은 인간 호흡에서 가장 중요한 근육으로 전체 흉벽을 확장시키지 않고 복부와 아래쪽 흉곽만을 확장함. 흉곽 위쪽의 확장은 사각근이 작용함. 

조용이 숨을 내뱉는 과정은 페의 탄성에 의한 수동적인 과정임. 호기에 대한 노력이 필요할때 주로 작용하는 호기근은 복근, 내측 늑간근, 

panic bird...

In human anatomy, the thoracic diaphragm, or simply the diaphragm, is a sheet of internal skeletal muscle^[2] that extends across the bottom of the rib cage. The diaphragm separates the thoracic cavity containing the heart and lungs, from the abdominal cavity and performs an important function in respiration: as the diaphragm contracts, the volume of the thoracic cavity increases and air is drawn into the lungs.

The term "diaphragm" in anatomy can refer to other flat structures such as the urogenital diaphragm or pelvic diaphragm, but "the diaphragm" generally refers to the thoracic diaphragm. Other mammals have diaphragms, and other vertebrates such as amphibians and reptiles have diaphragm-like structures, but important details of the anatomy vary, such as the position of lungs in the abdominal cavity. 

횡격막 근육의 구조

The diaphragm is a dome-shaped structure of muscle and fibrous tissue that separates the thoracic cavity from the abdomen. The dome faces upwards. The superior surface of the dome forms the floor of the thoracic cavity, and the inferior surface the roof of the abdominal cavity.^[3]

As a dome, the diaphragm has peripheral attachments to structures that make up the abdominal and chest walls. The muscle fibres from these attachments converge in a central tendon, which forms the crest of the dome.^[3] Its peripheral part consists of muscular fibers that take origin from the circumference of the inferior thoracic aperture and converge to be inserted into a central tendon.

The muscle fibres of the diaphragm emerge from many surrounding structures. At the front, fibres emerge from behind the xiphoid process and the cartilages of the floating ribs, ribs 7-12. At the sides, fibres emerge from the sides of the ribs themselves, including the two false ribs ribs 11-12. At the back, fibres emerge from the abdominal wall and lumbar vertebrae.^[3] There are two lumbocostal arches, a medial and a lateral, on either side.

The left and right crura (Latin: legs) are tendinous in structure, and blend with the anterior longitudinal ligament of the vertebral column. The central tendon of the diaphragm is a thin but strong aponeurosis situated near the center of the vault formed by the muscle, but somewhat closer to the front than to the back of the thorax, so that the posterior muscular fibers are the longer.

Innervation[edit]

The diaphragm is primarily innervated by the phrenic nerve which is formed from the cervical nerves C3, C4 and C5.^[3] A useful mnemonic to remember this is, "C-3, 4, 5 keeps the diaphragm alive." While the central portion of the diaphragm sends sensory afferents via the phrenic nerve, the peripheral portions of the diaphragm send sensory afferents via the intercostal (T5-T11) and subcostal nerves (T12).

Blood supply[edit]

Arteries and veins above and below the diaphragm supply and drain blood.

From above, the diaphragm receives blood from branches of the internal thoracic arteries, namely the pericardiophrenic artery and musculophrenic artery; from the superior phrenic arteries, which arise directly from the thoracic aorta; and from the lower internal intercostal arteries. From below, the inferior phrenic arteries supply the diaphragm.^[3]

The diaphargm drains blood into the brachiocephalic veins, azygos veins, and veins that drain into the inferior vena cava and left suprarenal vein.^[3]

Variation[edit]

The sternal portion of the muscle is sometimes wanting and more rarely defects occur in the lateral part of the central tendon or adjoining muscle fibers.

Development[edit]

The thoracic diaphragm develops during embryogenesis, beginning in the third week after fertilization with two processes known as transverse folding and longitudinal folding. The septum transversum, the primitive central tendon of the diaphragm, originates at the rostral pole of the embryo and is relocated during longitudinal folding to the ventral thoracic region. Transverse folding brings the body wall anteriorly to enclose the gut and body cavities. The pleuroperitoneal membrane and body wall myoblasts, from somatic lateral plate mesoderm, meet the septum transversum to close off the pericardio-peritoneal canals on either side of the presumptive esophagus, forming a barrier that separates the peritoneal and pleuropericardial cavities. Furthermore, dorsal mesenchyme surrounding the presumptive esophagus form the muscular crura of the diaphragm.

Because the earliest element of the embryological diaphragm, the septum transversum, forms in the cervical region, the phrenic nerve that innervates the diaphragm originates from the cervical spinal cord (C3,4, and 5). As the septum transversum descends inferiorly, the phrenic nerve follows, accounting for its circuitous route from the upper cervical vertebrae, around the pericardium, finally to innervate the diaphragm.

횡격막 근육의 기능

The diaphragm functions in breathing. During inhalation, the diaphragm contracts and moves in the inferior direction, thus enlarging the volume of the thoracic cavity (the external intercostal muscles also participate in this enlargement). This reduces intra-thoracic pressure: In other words, enlarging the cavity creates suction that draws air into the lungs.

Cavity expansion happens in two extremes, along with intermediary forms. When the lower ribs are stabilized and the central tendon of the diaphragm is mobile, a contraction brings the insertion (central tendon) towards the origins and pushes the lower cavity towards the pelvis, allowing the thoracic cavity to expand downward. This is often called belly breathing. When the central tendon is stabilized and the lower ribs are mobile, a contraction lifts the origins (ribs) up towards the insertion (central tendon) which works in conjunction with other muscles to allow the ribs to slide and the thoracic cavity to expand laterally and upwards.

When the diaphragm relaxes, air is exhaled by elastic recoil of the lung and the tissues lining the thoracic cavity. Assisting this function with muscular effort (called forced exhalation) involves the internal intercostal muscles used in conjunction with the abdominal muscles, which act as an antagonist paired with the diaphragm's contraction.

The diaphragm is also involved in non-respiratory functions, helping to expel vomit, feces, and urine from the body by increasing intra-abdominal pressure, and preventing acid reflux by exerting pressure on the esophagus as it passes through the esophageal hiatus. In some non-human animals, the diaphragm is not crucial for breathing; a cow, for instance, can survive fairly asymptomatically with diaphragmatic paralysis as long as no massive aerobic metabolic demands are made of it.

Paralysis[edit]

If either the phrenic nerve, cervical spine or brainstem is damaged, this will sever the nervous supply to the diaphragm. The most common damage to the phrenic nerve is by bronchial carcinoma, which usually only affects one side of the diaphragm. Other causes include Guillain-Barre syndrome and systemic lupus erythematosis.^[4]

Herniation[edit]

Main articles: Hiatus hernia and Congenital diaphragmatic hernia

A hiatus hernia is a hernia common in adults in which parts of the lower esophagus or stomach that are normally in the abdomen pass bulge abnormally through the diaphragm and are present in the thorax. These hernias are implicated in the development of reflux, as the different pressures between the thorax and abdomen normally act to keep pressure on the oesophageal hiatus. Hernias are described as rolling, in which the hernia is beside the oesophagus, or sliding, in which the hernia directly involves the esophagus. With herniation, this pressure is no longer present, an the angle between the cardia of the stomach and the oesophagus disappear. Not all hiatus hernias cause symptoms however, although almost all people with Barrett's oesophagus or oesophagitis have a hiatus hernia.^[4]

Hernias may also occur as a result of congenital malformation, a congenital diaphragmatic hernia. When the pleuroperitoneal membranes fail to fuse, the diaphragm does not act as an effective barrier between the abdomen and thorax. Herniation is usually of the left, and commonly through the posterior Foramen of Bochdalek, although rarely through the anterior foramen of Morgagni. The contents of the abdomen, including the intestines, may be present in the thorax, which may impact development of the growing lungs and lead to hypoplasia.^[5] This condition is present in 1 out of 2,000 births. A large herniation has a mortality rate of 3/4 and requires immediate surgical repair.^{[citation needed]}

늑간근

Intercostal muscles are several groups of muscles that run between the ribs, and help form and move the chest wall. The intercostal muscles are mainly involved in the mechanical aspect of breathing. These muscles help expand and shrink the size of the chest cavity when you breathe.

There are three principal layers;

1. external intercostal muscles aid in quiet and forced inhalation. They originate on ribs 1-11 and have their insertion on ribs 2-12. The external intercostals are responsible for the elevation of the ribs, and expanding the transverse dimensions of the thoracic cavity.
2. internal intercostal muscles aid in forced expiration (quiet expiration is a passive process). They originate on ribs 2-12 and have their insertions on ribs 1-11. The internal intercostals are responsible for the depression of the ribs decreasing the transverse dimensions of the thoracic cavity.
3. innermost intercostal muscle, the deep layers of the internal intercostal muscles which are separated from them by a neurovascular bundle. This in turn is composed of:
   • transversus thoracis muscle
   • intercostal space
   • subcostalis muscle

Innervation[edit]

Both the external and internal muscles are innervated by the intercostal nerves (the ventral rami of thoracic spinal nerves), are supplied by the intercostal arteries, and are drained by the intercostal veins. Their fibers run in opposite directions.

Function[edit]

The scaleni, which also move the chest wall and have a function in inhalation, are also intercostal muscles, just not one of the three principal layers.

외늑간근

The Intercostales externi (External intercostals) are eleven in number on either side. They extend from the tubercles of the ribs behind, to the cartilages of the ribs in front, where they end in thin membranes, the anterior intercostal membranes, which are continued forward to the sternum. These muscles work in unison when inspiration (inhalation) occurs. The intercostal muscles relax while external muscles contract causing the expansion of the chest cavity and an influx of air into the lungs.

Each arises from the lower border of a rib, and is inserted into the upper border of the rib below. In the two lower spaces they extend to the ends of the cartilages, and in the upper two or three spaces they do not quite reach the ends of the ribs.

They are thicker than the Intercostales interni, and their fibers are directed obliquely downward and laterally on the back of the thorax, and downward, forward, and medially on the front (the example is often used of sticking one's hands in their pocket and noting the direction of the fingers pointing downward and medially).

내늑간근

The internal intercostal muscles (intercostales interni) are a group of skeletal muscles located between the ribs. They are eleven in number on either side. They commence anteriorly at the sternum, in the interspaces between the cartilages of the true ribs, and at the anterior extremities of the cartilages of the false ribs, and extend backward as far as the angles of the ribs, whence they are continued to the vertebral column by thin aponeuroses, the posterior intercostal membranes.

Each arises from the ridge on the inner surface of a rib, as well as from the corresponding costal cartilage, and is inserted into the inferior border of the rib above. The internal intercostals are innervated by the intercostal nerve.^[1]

Their fibers are also directed obliquely, but pass in a direction opposite to those of the external intercostal muscles.

For the most part, they are muscles of expiration. In expiration, the interosseous portions of the internal intercostal muscles, (the part of the muscle that is between the bone portion of the superior and inferior ribs), depresses and retracts the ribs, compressing the thoracic cavity and expelling air.^[2] The internal intercostals, however, are only used in forceful exhalation such as coughing or during exercise and not in relaxed breathing.^[3] The external intercostal muscles, and the intercartilaginous part of the internal intercostal muscles, (the part of the muscle that lies between the cartilage portion of the superior and inferior ribs), are used in inspiration, by aiding in elevating the ribs and expanding the thoracic cavity.^[4]

최내늑간근

The innermost intercostal muscle is a layer of intercostal muscles deep to the plane that contains the intercostal nerves and intercostal vessels and the internal intercostal muscles. These are divided into:

1. transversus thoracis anteriorly
2. lateral muscle slips laterally (which cross a single intercostal space)
3. subcostalis posteriorly (which often cross more than one intercostal space)

^{늑골근육과 횡격막 근육의 Trp}

에반스의 늑간근 isolated stretching

[heoss]

감사합니다.^^