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Pérez-Montalbán M, García-Domínguez E, Oliva-Pascual-Vaca Á. Subdiaphragmatic phrenic nerve supply: A systematic review. Ann Anat 2024; 254:152269. [PMID: 38692333 DOI: 10.1016/j.aanat.2024.152269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE The aim of this systematic review is to study the subdiaphragmatic anatomy of the phrenic nerve. MATERIALS AND METHODS A computerised systematic search of the Web of Science database was conducted. The key terms used were phrenic nerve, subdiaphragmat*, esophag*, liver, stomach, pancre*, duoden*, intestin*, bowel, gangli*, biliar*, Oddi, gallbladder, peritone*, spleen, splenic, hepat*, Glisson, falciform, coronary ligament, kidney, suprarenal, and adrenal. The 'cited-by' articles were also reviewed to ensure that all appropriate studies were included. RESULTS A total of one thousand three hundred and thirty articles were found, of which eighteen met the inclusion and exclusion criteria. The Quality Appraisal for Cadaveric Studies scale revealed substantial to excellent methodological quality of human studies, while a modified version of the Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias Tool denoted poor methodological quality of animal studies. According to human studies, phrenic supply has been demonstrated for the gastro-esophageal junction, stomach, celiac ganglia, liver and its coronary ligament, inferior vena cava, gallbladder and adrenal glands, with half of the human samples studied presenting phrenic nerve connections with any subdiaphragmatic structure. CONCLUSIONS This review provides the first systematic evidence of subdiaphragmatic phrenic nerve supply and connections. This is of interest to professionals who care for people suffering from neck and shoulder pain, as well as patients with peridiaphragmatic disorders or hiccups. However, there are controversies about the autonomic or sensory nature of this supply.
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Affiliation(s)
- María Pérez-Montalbán
- Universidad de Sevilla. Facultad de Enfermería, Fisioterapia y Podología, Departamento de Fisioterapia, Spain
| | | | - Ángel Oliva-Pascual-Vaca
- Instituto de Biomedicina de Sevilla, IBiS, Departamento de Fisioterapia, Universidad de Sevilla, Spain; Escuela de Osteopatía de Madrid, Madrid, Spain.
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Silveri OC, Dunemann G, Woo C, Gutman J, Palazzi J, Canestrino J, Luke B, Millard JA, Breiner M. Rare case of divided phrenic nerve variation: a cadaveric case report. Surg Radiol Anat 2024; 46:825-828. [PMID: 38597949 DOI: 10.1007/s00276-024-03341-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/01/2024] [Indexed: 04/11/2024]
Abstract
The phrenic nerve innervates the respiratory diaphragm, the primary muscle active during ventilation. The canonical path of the phrenic nerve originates from the cervical spine at C3-C5 spinal nerves and travels inferiorly through the neck and thoracic cavity to reach the diaphragm. During a cadaver dissection, a variation of the phrenic nerve was discovered in a 93-year-old male specimen. A traditional origin of the phrenic nerve was noted; however, the nerve branched into medial and lateral components at the level of the superior trunk of the brachial plexus. The branches reconnected at the apex of the aortic arch and continued inferiorly to innervate the ipsilateral diaphragm. This case study describes a rare type of branching of the phrenic nerve and explores its potential impact on clinical procedures.
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Affiliation(s)
- Olivia C Silveri
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA.
| | | | - Christian Woo
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | - Jacob Gutman
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | - Joseph Palazzi
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | | | - Benita Luke
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | | | - Michael Breiner
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
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3
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Bordoni B, Escher AR, Duczyński M. Proposal for Manual Osteopathic Treatment of the Phrenic Nerve. Cureus 2024; 16:e58012. [PMID: 38606024 PMCID: PMC11007451 DOI: 10.7759/cureus.58012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 04/13/2024] Open
Abstract
The article reviews the anatomical path of the phrenic nerve and its anastomoses, with the most up-to-date knowledge reported in the literature. We have briefly reviewed the possible phrenic dysfunctions, with the final aim of presenting an osteopathic manual approach for the treatment of the most superficial portion of the nerve, using a gentle technique. The approach we propose is, therefore, a theory based on clinical experience and the rationale that we can extrapolate from the literature. We hope that the article will be a stimulus for further experimental investigations using the technique illustrated in the article. To the authors' knowledge, this is the first article that takes into consideration the hypothesis of an osteopathic treatment with gentle techniques for the phrenic nerve.
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Affiliation(s)
- Bruno Bordoni
- Physical Medicine and Rehabilitation, Don Carlo Gnocchi Foundation, Milan, ITA
| | - Allan R Escher
- Anesthesiology/Pain Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
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Verlinden TJM, Lamers WH, Herrler A, Köhler SE. The differences in the anatomy of the thoracolumbar and sacral autonomic outflow are quantitative. Clin Auton Res 2024; 34:79-97. [PMID: 38403748 PMCID: PMC10944453 DOI: 10.1007/s10286-024-01023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/12/2023] [Indexed: 02/27/2024]
Abstract
PURPOSE We have re-evaluated the anatomical arguments that underlie the division of the spinal visceral outflow into sympathetic and parasympathetic divisions. METHODOLOGY Using a systematic literature search, we mapped the location of catecholaminergic neurons throughout the mammalian peripheral nervous system. Subsequently, a narrative method was employed to characterize segment-dependent differences in the location of preganglionic cell bodies and the composition of white and gray rami communicantes. RESULTS AND CONCLUSION One hundred seventy studies were included in the systematic review, providing information on 389 anatomical structures. Catecholaminergic nerve fibers are present in most spinal and all cranial nerves and ganglia, including those that are known for their parasympathetic function. Along the entire spinal autonomic outflow pathways, proximal and distal catecholaminergic cell bodies are common in the head, thoracic, and abdominal and pelvic region, which invalidates the "short-versus-long preganglionic neuron" argument. Contrary to the classically confined outflow levels T1-L2 and S2-S4, preganglionic neurons have been found in the resulting lumbar gap. Preganglionic cell bodies that are located in the intermediolateral zone of the thoracolumbar spinal cord gradually nest more ventrally within the ventral motor nuclei at the lumbar and sacral levels, and their fibers bypass the white ramus communicans and sympathetic trunk to emerge directly from the spinal roots. Bypassing the sympathetic trunk, therefore, is not exclusive for the sacral outflow. We conclude that the autonomic outflow displays a conserved architecture along the entire spinal axis, and that the perceived differences in the anatomy of the autonomic thoracolumbar and sacral outflow are quantitative.
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Affiliation(s)
- Thomas J M Verlinden
- Department of Anatomy & Embryology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands.
| | - Wouter H Lamers
- Department of Anatomy & Embryology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Andreas Herrler
- Department of Anatomy & Embryology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - S Eleonore Köhler
- Department of Anatomy & Embryology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
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Lohse A, Deininger MM, Loeser J, Roehren F, Ziles D, Breuer T, Leonhardt S, Walter M. A physiological model of phrenic nerve excitation by electrical stimulation. Biomed Phys Eng Express 2024; 10:025017. [PMID: 38232399 DOI: 10.1088/2057-1976/ad1fa3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/17/2024] [Indexed: 01/19/2024]
Abstract
Mechanical ventilation is essential in intensive care treatment but leads to diaphragmatic atrophy, which in turn contributes to prolonged weaning and increased mortality. One approach to prevent diaphragmatic atrophy while achieving pulmonary ventilation is electrical stimulation of the phrenic nerve. To automize phrenic nerve stimulation resulting in lung protective tidal volumes with lowest possible currents, mathematical models are required. Nerve stimulation models are often complex, so many parameters have to be identified prior to implementation. This paper presents a novel, simplified approach to model phrenic nerve excitation to obtain an individualized patient model using a few data points. The latter is based on the idea that nerve fibers are excited when the electric field exceeds a threshold. The effect of the geometry parameter on the model output was analyzed, and the model was validated with measurement data from a pig trial (RMSE in between 0.44 × 10-2and 1.64 × 10-2for parameterized models). The modeled phrenic nerve excitation behaved similarly to the measured tidal volumes, and thus could be used to develop automated phrenic nerve stimulation systems for lung protective ventilation.
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Affiliation(s)
- Arnhold Lohse
- Chair for Medical Information Technology, Faculty of Electrical Engineering and Information Technology, RWTH Aachen University, Aachen, 52074, Germany
| | - Matthias Manfred Deininger
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, 52074, Germany
| | - Johannes Loeser
- Institute of Automatic Control, Faculty of Mechanical Engineering, RWTH Aachen University, Aachen, 52074, Germany
| | - Felix Roehren
- Chair for Medical Information Technology, Faculty of Electrical Engineering and Information Technology, RWTH Aachen University, Aachen, 52074, Germany
| | - Dmitrij Ziles
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, 52074, Germany
| | - Thomas Breuer
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, 52074, Germany
| | - Steffen Leonhardt
- Chair for Medical Information Technology, Faculty of Electrical Engineering and Information Technology, RWTH Aachen University, Aachen, 52074, Germany
| | - Marian Walter
- Chair for Medical Information Technology, Faculty of Electrical Engineering and Information Technology, RWTH Aachen University, Aachen, 52074, Germany
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Li D, Li Z, Zhang Z, Liu Y, Wang C, Cheng A. Effect of respiratory training on respiratory failure secondary to unilateral phrenic nerve injury: A case report. Medicine (Baltimore) 2023; 102:e32566. [PMID: 36800600 PMCID: PMC9936005 DOI: 10.1097/md.0000000000032566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
INTRODUCTION Diaphragm is one of the most important respiratory muscles dominated by the phrenic nerve. Phrenic nerve injury would induce a series of clinical symptoms, including respiratory failure. Respiratory training could assist in regular treatment in improving the respiratory function and daily ability of respiratory failure patients. CASE PRESENTATION A 71-years-old female was enrolled for the disorders of consciousness of 4.5 hours observed by her family and was diagnosed with respiratory failure secondary to unilateral phrenic nerve injury. The patient received basic therapy combined with rehabilitation training, including the training of aspirate muscle, limb resistance, thoracic loosening, aerobic training, electrical stimulation on respiratory nerves, and airway clearance. The combining therapeutic strategy significantly improved the daily ability and respiratory of the patient. The ultrasound showed that after therapy, the diaphragmatic muscles were thickened and the range of diaphragmatic movement was also enhanced. The pulmonary function was also improved after therapy. CONCLUSION The combination of rehabilitation is suitable for the treatment of respiratory failure patients with clear causes of phrenic nerve injury. For patients with unexplained causes, rehabilitation could also be performed before the diagnosis. Patients with irreversible injury need long-term and family rehabilitation prescriptions.
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Affiliation(s)
- Dawei Li
- Neurorehabilitation Department, Shengli Oilfield Central Hospital, Dongying, Shandong, China
| | - Zhendong Li
- Neurorehabilitation Department, Shengli Oilfield Central Hospital, Dongying, Shandong, China
| | - Zhiyou Zhang
- Neurorehabilitation Department, Shengli Oilfield Central Hospital, Dongying, Shandong, China
| | - Yueyang Liu
- Neurorehabilitation Department, Shengli Oilfield Central Hospital, Dongying, Shandong, China
| | - Congcong Wang
- Neurorehabilitation Department, Shengli Oilfield Central Hospital, Dongying, Shandong, China
| | - Aixia Cheng
- Neurorehabilitation Department, Shengli Oilfield Central Hospital, Dongying, Shandong, China
- * Correspondence: Aixia Cheng, Neurorehabilitation Department, Shengli Oilfield Central Hospital, No.31 Jinan Road, Dongying 257000, Shandong, China (e-mail: )
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7
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Diaphragm Neurostimulation Mitigates Ventilation-Associated Brain Injury in a Preclinical Acute Respiratory Distress Syndrome Model. Crit Care Explor 2022; 4:e0820. [PMID: 36601565 PMCID: PMC9788975 DOI: 10.1097/cce.0000000000000820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In a porcine healthy lung model, temporary transvenous diaphragm neurostimulation (TTDN) for 50 hours mitigated hippocampal apoptosis and inflammation associated with mechanical ventilation (MV). HYPOTHESIS Explore whether TTDN in combination with MV for 12 hours mitigates hippocampal apoptosis and inflammation in an acute respiratory distress syndrome (ARDS) preclinical model. METHODS AND MODELS Compare hippocampal apoptosis, inflammatory markers, and serum markers of neurologic injury between never ventilated subjects and three groups of mechanically ventilated subjects with injured lungs: MV only (LI-MV), MV plus TTDN every other breath, and MV plus TTDN every breath. MV settings in volume control were tidal volume 8 mL/kg and positive end-expiratory pressure 5 cm H2O. Lung injury, equivalent to moderate ARDS, was achieved by infusing oleic acid into the pulmonary artery. RESULTS Hippocampal apoptosis, microglia, and reactive-astrocyte percentages were similar between the TTDN-every-breath and never ventilated groups. The LI-MV group had a higher percentage of these measures than all other groups (p < 0.05). Transpulmonary driving pressure at study end was lower in the TTDN-every-breath group than in the LI-MV group; systemic inflammation and lung injury scores were not significantly different. The TTDN-every-breath group had considerably lower serum concentration of homovanillic acid (cerebral dopamine production surrogate) at study end than the LI-MV group (p < 0.05). Heart rate variability declined in the LI-MV group and increased in both TTDN groups (p < 0.05). INTERPRETATIONS AND CONCLUSIONS In a moderate-ARDS porcine model, MV is associated with hippocampal apoptosis and inflammation, and TTDN mitigates that hippocampal apoptosis and inflammation.
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Motoda A, Matsubara T, Tanei Z, Sakashita Y, Yamazaki M, Kawakami I, Sengoku R, Arai T, Maruyama H, Saito Y, Murayama S. Morphological study of the phrenic nerve to determine a reference value for the myelinated fiber density in elderly individuals. Neuropathology 2022; 43:129-134. [PMID: 37005009 DOI: 10.1111/neup.12856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 12/01/2022]
Abstract
Phrenic nerves (PNs) play an important role in respiration; however, very few morphological studies have assessed them. This study aimed to provide control reference values, including the density of large and small myelinated PN fibers, for future pathological studies. We assessed a total of nine nerves from eight cases among consecutive autopsy cases registered to the Brain Bank for Aging Research between 2018 and 2019 (five men and three women, mean age 77.0 ± 7.0 years). The nerves were sampled distally, and their structures were analyzed using semi-thin sections stained with toluidine blue. The mean and standard deviation of the density of each myelinated fiber of the PN was 6908 ± 1132 fibers/mm2 (total myelinated fiber), 4095 ± 586 fibers/mm2 (large diameter myelinated fiber; diameter ≥7 μm), and 2813 ± 629 fibers/mm2 (small diameter myelinated fiber; diameter <7 μm). There was no correlation between myelinated fiber density and age. This study provides the density measurement of the human PN myelinated fiber, and these findings can be used as reference values for the PN in elderly individuals.
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Affiliation(s)
- Atsuko Motoda
- Department of Neuropathology (the Brain Bank for Aging Research) Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
- Department of Pathology Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
- Department of Clinical Neuroscience and Therapeutics Hiroshima University Graduate School of Biomedical and Health Sciences Hiroshima Japan
| | - Tomoyasu Matsubara
- Department of Neuropathology (the Brain Bank for Aging Research) Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
- Department of Clinical Neuroscience and Therapeutics Hiroshima University Graduate School of Biomedical and Health Sciences Hiroshima Japan
| | - Zen‐ichi Tanei
- Department of Neuropathology (the Brain Bank for Aging Research) Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
| | - Yasuhiro Sakashita
- Department of Neuropathology (the Brain Bank for Aging Research) Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
- Department of Pathology Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
| | - Mikihiro Yamazaki
- Department of Neuropathology (the Brain Bank for Aging Research) Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
| | - Ito Kawakami
- Department of Neuropathology (the Brain Bank for Aging Research) Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
| | - Renpei Sengoku
- Department of Neuropathology (the Brain Bank for Aging Research) Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
| | - Tomio Arai
- Department of Pathology Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics Hiroshima University Graduate School of Biomedical and Health Sciences Hiroshima Japan
| | - Yuko Saito
- Department of Neuropathology (the Brain Bank for Aging Research) Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
| | - Shigeo Murayama
- Department of Neuropathology (the Brain Bank for Aging Research) Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Tokyo Japan
- The Brain Bank for Neurodevelopmental, Neurological and Psychiatric Disorders United Graduate School of Child Development, Osaka University Osaka Japan
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Fuller DD, Rana S, Smuder AJ, Dale EA. The phrenic neuromuscular system. HANDBOOK OF CLINICAL NEUROLOGY 2022; 188:393-408. [PMID: 35965035 PMCID: PMC11135908 DOI: 10.1016/b978-0-323-91534-2.00012-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The phrenic neuromuscular system consists of the phrenic motor nucleus in the mid-cervical spinal cord, the phrenic nerve, and the diaphragm muscle. This motor system helps sustain breathing throughout life, while also contributing to posture, coughing, swallowing, and speaking. The phrenic nerve contains primarily efferent phrenic axons and afferent axons from diaphragm sensory receptors but is also a conduit for autonomic fibers. On a breath-by-breath basis, rhythmic (inspiratory) depolarization of phrenic motoneurons occurs due to excitatory bulbospinal synaptic pathways. Further, a complex propriospinal network innervates phrenic motoneurons and may serve to coordinate postural, locomotor, and respiratory movements. The phrenic neuromuscular system is impacted in a wide range of neuromuscular diseases and injuries. Contemporary research is focused on understanding how neuromuscular plasticity occurs in the phrenic neuromuscular system and using this information to optimize treatments and rehabilitation strategies to improve breathing and related behaviors.
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Affiliation(s)
- David D Fuller
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States; McKnight Brain Institute, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States.
| | - Sabhya Rana
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States; McKnight Brain Institute, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States
| | - Ashley J Smuder
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States; Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, United States
| | - Erica A Dale
- McKnight Brain Institute, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States; Department of Physiology and Functional Genomics, University of Florida, Gainesville, FL, United States
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10
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Dempsey JA, Neder JA, Phillips DB, O'Donnell DE. The physiology and pathophysiology of exercise hyperpnea. HANDBOOK OF CLINICAL NEUROLOGY 2022; 188:201-232. [PMID: 35965027 DOI: 10.1016/b978-0-323-91534-2.00001-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In health, the near-eucapnic, highly efficient hyperpnea during mild-to-moderate intensity exercise is driven by three obligatory contributions, namely, feedforward central command from supra-medullary locomotor centers, feedback from limb muscle afferents, and respiratory CO2 exchange (V̇CO2). Inhibiting each of these stimuli during exercise elicits a reduction in hyperpnea even in the continuing presence of the other major stimuli. However, the relative contribution of each stimulus to the hyperpnea remains unknown as does the means by which V̇CO2 is sensed. Mediation of the hyperventilatory response to exercise in health is attributed to the multiple feedback and feedforward stimuli resulting from muscle fatigue. In patients with COPD, diaphragm EMG amplitude and its relation to ventilatory output are used to decipher mechanisms underlying the patients' abnormal ventilatory responses, dynamic lung hyperinflation and dyspnea during exercise. Key contributions to these exercise-limiting responses across the spectrum of COPD severity include high dead space ventilation, an excessive neural drive to breathe and highly fatigable limb muscles, together with mechanical constraints on ventilation. Major controversies concerning control of exercise hyperpnea are discussed along with the need for innovative research to uncover the link of metabolism to breathing in health and disease.
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Affiliation(s)
- Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, United States.
| | - J Alberto Neder
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, ON, Canada
| | - Devin B Phillips
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, ON, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, ON, Canada
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11
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The terminal segment of the human phrenic nerve as a novel implantation site for diaphragm pacing electrodes: Anatomical and clinical description. Ann Anat 2021; 239:151835. [PMID: 34562604 DOI: 10.1016/j.aanat.2021.151835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/04/2021] [Accepted: 09/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diaphragm pacing allows certain ventilator-dependent patients to achieve weaning from mechanical ventilation. The reference method consists in implanting intrathoracic contact electrodes around the phrenic nerve during video-assisted thoracic surgery, which involves time-consuming phrenic nerve dissection with a risk of nerve damage. Identifying a phrenic segment suitable for dissection-free implantation of electrodes would constitute progress. STUDY DESIGN This study characterizes a free terminal phrenic segment never fully described before. We conducted a cadaver study (n = 14) and a clinical observational study during thoracic procedures (n = 54). RESULTS A free terminal phrenic segment was observed on both sides in 100% of cases, "jumping" from the pericardium to the diaphragm and measuring 60 mm [95% confidence interval; 48-63] and 72.5 mm [65-82] (right left, respectively; p = 0.0038; cadaver study). This segment rolled up on itself at end-expiration and became unravelled and elongated with diaphragm descent (clinical study). Three categories of fat pads were defined (type 1: pericardiophrenic bundle free of surrounding fat; type 2: single fatty fringe leaving the phrenic nerve visible until diaphragmatic entry; type 3: multiple fatty fringes masking the site of penetration of the phrenic nerve) that depended on body mass index (p = 0.001, clinical study). Hematoxylin-eosin and toluidine blue staining (cadaver study) showed that all of the phrenic fibers in the distal, pre-branching part of the terminal segment were contained within a single epineurium containing a variable number of fascicles (right: 1 [95%CI 0.65-4.01]; left 5 [3.37-7.63]; p = 0.03). CONCLUSION Diaphragm pacing through periphrenic electrodes positioned on the terminal phrenic segment should be tested.
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12
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Rasulić L, Lepić M, Samardžić M. Commentary: Nerve Graft Length and Recovery of Elbow Flexion Muscle Strength in Patients With Traumatic Brachial Plexus Injuries: Case Series. Oper Neurosurg (Hagerstown) 2021; 21:E165-E166. [PMID: 34097737 DOI: 10.1093/ons/opab177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/04/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lukas Rasulić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery, Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Milan Lepić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
| | - Miroslav Samardžić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery, Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
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13
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Cabanas-Valdés R, Toro-Coll MD, Cruz-Sicilia S, García-Rueda L, Rodríguez-Rubio PR, Calvo-Sanz J. The Immediate Effect of Informational Manual Therapy for Improving Quiet Standing and Bodily Pain in University Population. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094940. [PMID: 34066393 PMCID: PMC8124965 DOI: 10.3390/ijerph18094940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 12/25/2022]
Abstract
Background: The Informational Manual Therapy (IMT) is a therapeutic touch. This study aims to assess the effect of IMT on quiet standing, pain and health status in university population. Methods: An experiment was conducted on subjects utilizing a comparative paired analysis both before and after the intervention. One IMT session was performed on 57 healthy individuals aged from 18 to 65 years. The primary outcome was quiet standing assessed by the Satel 40 Hz stabilometric force platform. Secondary outcomes were bodily pain assessed by the 36-Item Short Form Survey (SF-36) and health status by EQ-5D-3L. The primary outcome was evaluated before and immediately after treatment. Results: The individuals were divided into 3 age groups, 18–35 (52.6%), 35–50 (29.8%) and 51–65 (17.6%). Statistically significant differences were immediately observed after the session ended when comparing the pre-post quiet stance scores in a number of length parameters: L, Lx, Ly and stabilometry amplitude on Y-axis with eyes open and closed. Significant differences were also found when testing bodily pain (SF-36) and anxiety (5Q-5D-3L). Conclusion: One session of IMT produced positive effects when testing quiet standing with eyes open and eyes closed, as well as a significant reduction in pain and anxiety for those tested. Further research is suggested.
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Affiliation(s)
- Rosa Cabanas-Valdés
- Physiotherapy Department, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallés, Spain; (M.D.T.-C.); (L.G.-R.); (P.R.R.-R.)
- Correspondence:
| | - Mª Dolores Toro-Coll
- Physiotherapy Department, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallés, Spain; (M.D.T.-C.); (L.G.-R.); (P.R.R.-R.)
| | | | - Laura García-Rueda
- Physiotherapy Department, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallés, Spain; (M.D.T.-C.); (L.G.-R.); (P.R.R.-R.)
| | - Pere Ramón Rodríguez-Rubio
- Physiotherapy Department, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallés, Spain; (M.D.T.-C.); (L.G.-R.); (P.R.R.-R.)
| | - Jordi Calvo-Sanz
- Physiotherapy Department, School of Health Sciences, Tecno Campus, Mataró-Pompeu Fabra University (TCM-UPF), 08302 Barcelona, Spain;
- Hospital Asepeyo Sant Cugat del Vallès, 08174 Barcelona, Spain
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14
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Effects of Manual Therapy on the Diaphragm in the Musculoskeletal System: A Systematic Review. Arch Phys Med Rehabil 2021; 102:2402-2415. [PMID: 33932362 DOI: 10.1016/j.apmr.2021.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/14/2021] [Accepted: 03/23/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To analyze the effects at the musculoskeletal level of manual treatment of the diaphragm muscle in adults. DATA SOURCES Systematic review using 4 databases: PubMed, Science Direct, Web of Science, and Scopus. STUDY SELECTION AND DATA EXTRACTION Two independent reviewers applied the selection criteria and assessed the quality of the studies using the Physiotherapy Evidence Database scale for experimental studies. A third reviewer intervened in cases where a consensus had not been reached. A total of 9 studies were included in the review. DATA SYNTHESIS Manual therapy directed to the diaphragm has been shown to be effective in terms of the immediate increase in diaphragmatic mobility and thoracoabdominal expansion. The immediate improvement in the posterior muscle chain flexibility test is another of the most frequently found findings in the evaluated studies. Limited studies show improvements at the lumbar and cervical level in the range of motion and in pain. CONCLUSION Manual diaphragm therapy has shown an immediate significant effect on parameters related to costal, spinal, and posterior muscle chain mobility. Further studies are needed, not only to demonstrate the effectiveness of manual diaphragm therapy in the long-term and in symptomatic populations, but also to investigate the specific neurophysiological mechanisms involved in this type of therapy.
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15
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Haenssgen K, Herrmann G, Draeger A, Essig M, Djonov V. The Contribution of the Left Phrenic Nerve to Innervation of the Esophagogastric Junction. Clin Anat 2020; 33:265-274. [PMID: 31625208 PMCID: PMC7027871 DOI: 10.1002/ca.23502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/25/2019] [Accepted: 10/12/2019] [Indexed: 01/16/2023]
Abstract
The contribution of the left phrenic nerve to innervation of the esophagogastric junction. The esophagogastric junction is part of the barrier preventing gastroesophageal reflux. We have investigated the contribution of the phrenic nerves to innervation of the esophagogastric junction in humans and piglets by dissecting 30 embalmed human specimens and 14 piglets. Samples were microdissected and nerves were stained and examined by light and electron microscopy. In 76.6% of the human specimens, the left phrenic nerve participated in the innervation of the esophagogastric junction by forming a neural network together with the celiac plexus (46.6%) or by sending off a distinct phrenic branch, which joined the anterior vagal trunk (20%). Distinct left phrenic branches were always accompanied by small branches of the left inferior phrenic artery. In 10% there were indirect connections with a distinct phrenic nerve branch joining the celiac ganglion, from which celiac plexus branches to the esophagogastric junction emerged. Morphological examination of phrenic branches revealed strong similarities to autonomic celiac plexus branches. There was no contribution of the left phrenic nerve or accompanying arteries from the caudal phrenic artery in any of the piglets. The right phrenic nerve made no contribution in any of the human or piglet samples. We conclude that the left phrenic nerve in humans contributes to the innervation of the esophagogastric junction by providing ancillary autonomic nerve fibers. Experimental studies of the innervation in pigs should consider that neither of the phrenic nerves was found to contribute. Clin. Anat. 33:265-274, 2020. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
| | | | | | - Manfred Essig
- Department Gastroenterology, Tiefenau HospitalUniversity of BernBernSwitzerland
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16
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Chikata A, Kato T, Usuda K, Fujita S, Maruyama M, Otowa KI, Takashima SI, Murai H, Usui S, Furusho H, Kaneko S, Takamura M. Coronary sinus catheter placement via left cubital vein for phrenic nerve stimulation during pulmonary vein isolation. Heart Vessels 2019; 34:1710-1716. [PMID: 30972550 DOI: 10.1007/s00380-019-01402-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/05/2019] [Indexed: 01/07/2023]
Abstract
Phrenic nerve (PN) stimulation is essential for the elimination of PN palsy during balloon-based pulmonary vein isolation (PVI). Although ultrasound-guided vascular access is safe, insertion of a PN stimulation catheter via central venous access carries a potential risk of the development of mechanical complications. We evaluated the safety of a left cubital vein approach for positioning a 20-electrode atrial cardioversion (BeeAT) catheter in the coronary sinus (CS), and the feasibility of right PN pacing from the superior vena cava (SVC) using proximal electrodes of the BeeAT catheter. In total, 106 consecutive patients who underwent balloon-based PVI with a left cubital vein approach for BeeAT catheter positioning were retrospectively assessed. The left cubital approach was successful in 105 patients (99.1%), and catheter insertion into the CS was possible for 104 patients (99.0%). Among these patients, constant right PN pacing from the SVC was obtained for 89 patients (89/104, 85.6%). In five patients, transient loss of right PN capture occurred during right pulmonary vein ablation. No persistent right PN palsy was observed. Small subcutaneous hemorrhage was observed in eight patients (7.5%). Neuropathy, pseudoaneurysm, arteriovenous fistula, and perforations associated with the left cubital approach were not detected. Body mass index was significantly higher in the right PN pacing failure group than in the right PN pacing success group (26.2 ± 3.2 vs. 23.8 ± 3.8; P = 0.025). CS catheter placement with a left cubital vein approach for right PN stimulation was found to be safe and feasible. Right PN pacing from the SVC using a BeeAT catheter was successfully achieved in the majority of the patients. This approach may prove to be preferable for non-obese patients.
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Affiliation(s)
- Akio Chikata
- Division of Cardiology, Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan.,Department of System Biology, School of Advanced Preventive Medical Sciences, Kanazawa University Graduate, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Takeshi Kato
- Department of System Biology, School of Advanced Preventive Medical Sciences, Kanazawa University Graduate, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Kazuo Usuda
- Division of Cardiology, Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Shuhei Fujita
- Department of Pediatrics, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Michiro Maruyama
- Division of Cardiology, Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Kan-Ichi Otowa
- Division of Cardiology, Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Shin-Ichiro Takashima
- Department of System Biology, School of Advanced Preventive Medical Sciences, Kanazawa University Graduate, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Hisayoshi Murai
- Department of System Biology, School of Advanced Preventive Medical Sciences, Kanazawa University Graduate, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Soichiro Usui
- Department of System Biology, School of Advanced Preventive Medical Sciences, Kanazawa University Graduate, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Hiroshi Furusho
- Department of System Biology, School of Advanced Preventive Medical Sciences, Kanazawa University Graduate, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Shuichi Kaneko
- Department of System Biology, School of Advanced Preventive Medical Sciences, Kanazawa University Graduate, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Masayuki Takamura
- Department of System Biology, School of Advanced Preventive Medical Sciences, Kanazawa University Graduate, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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