LIVING ANATOMY: IMPLICATIONS OF RESPIRATION CONVOCATION MARCH 16, 2019 PAMELA L. WILSON, D.O.

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1 LIVING ANATOMY: IMPLICATIONS OF RESPIRATION CONVOCATION MARCH 16, 2019 PAMELA L. WILSON, D.O.

2 I believe you are taught anatomy in our school more thoroughly than any other school to date, because we want you to carry a living picture of all or any part of the body in your mind. Andrew Taylor Still, MD,DO

3 RESPIRATORY VOLUME CURVE

4 ELASTIC RECOIL

5 TENSION PTX

6 CHEST WALL Semi-rigid cylinder Allows body movement Protects organs Prevents tissue collapse during pressure gradient development within thoracic cavity Anchor against which diaphragm can work

7 THORACIC CAGE Ribs, spine, sternum, costal cartilage 105 articulations Costovertebral Costotransverse Costochondral Chondrosternal Sternomanubrial facet

8 BONEY THORAX Ribs spine sternum Costal cartilage

9 COSTOVERTEBRAL JOINTS Ribs 2-11 articulate with two vertebral bodies and the intervertebral disc Each rib articulates with the transverse process of a vertebrae

10 COSTAL CARTILAGE

11 STERNUM

12 STERNUM

13 STERNUM

14 STERNUM

15 SCALENES Initiate respiration Anterior, middle, posterior Origin: transverse process C3 C7 Insertion: ribs 1 and 2

16 TRANSVERSUS ABDOMINIS Exhalation Fibers horizontally oriented, like a belt Origin: inner surface cartilage last six ribs Thoracolumbar fascia Iliac crest / inguinal ligament Insertion: Rectus aponeurosis

17 EXTERNAL OBLIQUE ABDOMINIS Exhalation Origin: lateral boarders of lower eight ribs Insertion: rectus aponeurosis, anterior iliac crest Fibers oriented diagonally downward

18 INTERNAL OBLIQUE ABDOMINIS Exhalation Origin: cartilage lower three ribs, rectus aponeurosis Insertion: iliac crest and inguinal ligament Fibers run diagonally upward

19 QUADRATUS LUMBORUM Inserts on 12 th rib Transverse process of L1-L4 Iliac crest Lateral to psoas Complex muscle: -vertical fibers -2 sets of oblique fibers Acts against upward pull of diaphragm on12th rib Holds 12 th rib down Activates in response to diaphragm, after beginning of inspiration

20 DIAPHRAGM Primary muscle of respiration Separates abdomen and thorax Allows abdominal contents to function like a piston

21 DIAPHRAGM Global influence on body: Muscles of mouth, pharynx Abdominal and thoracic organ motion Postural effects Has continuous anterior and posterior fascial connections with pelvis and skull

22 DIAPHRAGM Central tendon Flexible aponeurosis designed to resist pulling forces Attachment site for muscle fibers Hiatus for Inferior vena cava Anterior attachment to pericardium

23 DIAPHRAGM Costal fibers Innervation: Phrenic nerves (2) Origin: central tendon Shortest anteriorly Longest posteriorly Insertion: Sternum, Inner surface lower six ribs, Posterior arcuate ligament, 12th rib Psoas Quadratus lumborum

24 DIAPHRAGM Crural fibers Pillars of diaphragm Derivative dorsal esophageal mesentery Innervation: Vagus Hiatus: Aorta esophagus Insert on L3 to L4 vertebrae

25 DIAPHRAGM POWER

26 DIAPHRAGM POWER

27 DIAPHRAGM POWER

28 ABDOMINAL ORGANS SUSPENDED FROM SPINE

29 MOTION IMPORTANT FOR CANCER TREATMENT Tumors decrease motion of tissue Respiration moves tumor in and out of treatment field Must decrease dose to tumor to prevent damage to healthy tissue

30 RESPIRATORY MOTION Inhalation moves abdominal organs Superior Inferior Posterior Anterior

31 HYSTERESIS Organ does not exactly retrace its path during a respiratory cycle

32 INSPIRATORY EFFECT ON KIDNEY MOTION [15]

33 ORGAN HYSTERESIS [12]

34 ORGAN HYSTERESIS [12]

35 ORGAN HYSTERESIS [12]

36 AVERAGE ORGAN MOTION 4-D CT: superior/inferior [12] LIVER 1.3 cm SPLEEN 1.3 cm RIGHT KIDNEY 1.3 cm LEFT KIDNEY 1.1 cm

37 KIDNEY LESIONS ULTRASOUND EVALUATION [15] Normal / Right: Left: less than 1 cm: 2.5cm 1.8cm Lesion 1-2 cm: 2.3cm 1.5cm Lesion 2+ cm: 1.9cm 1.3cm

38 Keep your minds full of pictures of the normal body all the time while treating the afflicted Andrew Taylor Still, MD, DO

39 REFERENCES: 1. Willard, F. Foundations of Osteopathic Medicine, 3 rd ed. 2011; Lippincott, Williams and Wilkins; pg A.T. Still, Philosophy of Osteopathy; 1899, 4 th reprint, AAO 3. Blandine, C. Anatomy of Breathing, Eastland press, Barral, J.P. The Thorax, Eastland Press, Barral, J.P. Visceral Manipulation, Eastland Press, Bordoni, B., Anatomic connections of the diaphragm: influence of respiration on the body system. J Multidisp Health. 2013: McCool, F.D., Dysfunction of the Diaphragm, N Engl J Med 2012;366: De Troyer, A., Functional Anatomy of the Respiratory Muscles, Clinics in Chest Medicine-Vol 9, No 2 June Cappello, M. On the respiratory function of the ribs, J Appl Physiol 92: , Kenyon: Rib cage mechanics during quiet breathing and exercise in humans; J Appl Physiol 83(4): , Ingber, D.E. The Architecture of Life, Scientific American, 1998, 278:48-57

40 REFERENCES 12. Brandner, E.D.; Abdominal organ motion measured using 4D CT; Int. J. Radiation Oncology and Biol. Phys., Vol. 65,No.2, pp Boyd, W., Sequence of action of the Diaphragm and quadratus lumborium during quiet breathing.; Anat. Rec., 151: Chiti, L., Scalene muscle activity during progressive inspiratory loading under pressure support ventilation. Respiratory Physiology & Neurobiology 164(2008), Rakkuneeth, H., Quantitative study on the effect of abnormalities on respiration-induced kidney movement. Ultrasound in Medicine & Biol., Vol.42, No. 7, pp , Chuhan,C. The lymphatic vascular system in liver diseases: its roke in ascites formation. Clinical and Molecular Hepatology, 2013: 19 :99-104