1、( (意大利整骨膈肌中英意大利整骨膈肌中英文文2The diaphragm is a thin muscular and tendinous septum that separates thorax & abdominal cavities. It is pierced by the structures that pass between the chest and the abdomen.膈肌是別離胸腔和腹腔的肌肉肌腱薄組織膈膜。它被胸腔和腹腔之間的組織結構穿過。The diaphragm is the most important muscle of respiration. I

2、t is dome shaped and consists of a peripheral muscular part, which arises from the margins of the thoracic opening, and a centrally placed tendon. The origin of the diaphragm can be divided into three parts:Diaphragm膈肌膈肌膈肌是最重要的呼吸肌肉。它呈穹窿狀，由胸腔開口邊緣上升的肌肉組織構成其邊部，而中心部為腱膜。膈肌的起源可以分為三局部。3ORIGIN OF THE DIAPHR

3、AGM膈肌的起源膈肌的起源A sternal part arising from the posterior surface of the xiphoid process胸骨部起源于劍突后骨面A costal part arising from the deep surfaces of the lower six ribs and their costal cartilages forms the right and left domes 肋部起源于下六對肋骨和肋軟骨的內側面，組成了左右的膈肌隆起A vertebral/lumbar part arising from upper three

4、lumbar vertebrae; forms the right and left crura and the arcuate ligaments脊柱/腰部起源于上3腰椎，組成左右膈腳和弓形韌帶4SHAPE OF THE DIAPHRAGM膈肌形狀膈肌形狀It is studied as 可以被分為Central tendon中心腱Right & left crus 左右膈腳Right & left dome 左右膈肌隆起5 INSERTION OF THE DIAPHRAGM膈肌附著點膈肌附著點The diaphragm is inserted into a central

5、 tendon. The superior surface of the tendon is partially fused with the inferior surface of the fibrous pericardium. Some of the muscle fibers of the right crus pass up to the left and surround the esophageal orifice in a slinglike loop. These fibers appear to act as a sphincter and possibly assist

6、in the prevention of regurgitation of the stomach contents into the thoracic part of the esophagus.膈肌肌束止于中心腱。中心腱的上外表與纖維性心包膜局部膈肌肌束止于中心腱。中心腱的上外表與纖維性心包膜局部性地融合在一起。右膈腳的一些肌纖維越至左邊，吊帶似地性地融合在一起。右膈腳的一些肌纖維越至左邊，吊帶似地包圍食管形成裂孔。這局部肌纖維起到了括約肌的作用，防包圍食管形成裂孔。這局部肌纖維起到了括約肌的作用，防止胃部物體返流至胸腔食管。止胃部物體返流至胸腔食管。6The right crus ari

7、ses from the sides of the bodies of the L 1-3 & IV discs; the left crus arises from the sides of the bodies of the L 1-2 & IV disc.右膈腳起自于1-3腰椎和椎間盤側部，左膈腳起自于1-2腰椎和椎間盤側部Lateral to the crura the diaphragm arises from the medial & lateral arcuate ligament. 在膈腳的兩側，膈肌起自于中部和側部的弓狀韌帶The medial arc

8、uate ligament extends from the side of the body of the second lumbar vertebra to the tip of the transverse process of the first lumbar vertebra. 中部的弓狀韌帶由第2腰椎體側部延伸至第1腰椎橫突末端The lateral arcuate ligament extends from the tip of the transverse process of the first lumbar vertebra to the lower border of t

9、he 12th rib. 側部的弓狀韌帶由第1腰椎橫突末端延伸至第12肋的下緣The medial borders of the two crura are connected by a median arcuate ligament which crosses over the anterior surface of the aorta兩個膈腳的中部邊緣由中部弓狀韌帶覆蓋著主動脈前方連接著Pillars & Arcuate Ligaments柱形與弓形韌帶柱形與弓形韌帶7The caval opening lies at the level of the T 8 vertebra i

10、n the central tendon. 腔靜脈裂孔位于T8水平的中心腱Inferior vena cava & branches of the right phrenic nerve.下腔靜脈與右側膈神經分支The esophageal opening lies at the level of the T 10 vertebra in a sling of muscle fibers derived from the right crus at the left of median plane.食管裂孔位于T10水平，由左中心平面的右膈腳發出的吊帶肌纖維Esophagus, the

11、 right and left vagus nerves, the esophageal branches of the left gastric vessels, & the lymph vessels. 食管，右側和左側迷走神經，胃部左血管的食管分支和淋巴管The aortic opening lies anterior to the body of the T 12 vertebra between the crura. 主動脈裂孔位于T12椎體前方，兩個膈腳之間Aorta, thoracic duct, & azygos vein.主動脈，胸導管與奇靜脈The diap

12、hragm has three main openings:膈肌有膈肌有3個主要的裂孔：個主要的裂孔：8Nerve Supply of the Diaphragm膈肌的神經支配膈肌的神經支配Motor nerve supply:運動神經支配運動神經支配The right and left phrenic nerves (C3, 4, 5)右邊和左邊的膈神經右邊和左邊的膈神經C3,4,5Sensory nerve supply:感覺神經支配感覺神經支配The parietal pleura and peritoneum covering the central surfaces of the d

13、iaphragm are from the phrenic nerve and the periphery of the diaphragm is from the lower six intercostal nerves.覆蓋于膈肌中心面的胸膜與腹膜由膈神經分出，膈肌的周覆蓋于膈肌中心面的胸膜與腹膜由膈神經分出，膈肌的周圍神經那么由下圍神經那么由下6對肋神經分出對肋神經分出9Functions of the Diaphragm膈肌功能膈肌功能 Muscle of inspiration: On contraction the diaphragm pulls its central tendo

14、n down and increases the vertical diameter of the thorax. The diaphragm is the most important muscle used in inspiration.呼吸肌：收縮時膈肌下拉中心腱增加胸腔的垂直徑長。呼吸肌：收縮時膈肌下拉中心腱增加胸腔的垂直徑長。膈肌是最重要的吸氣肌膈肌是最重要的吸氣肌Muscle of abdominal straining: The contraction of the diaphragm assists the contraction of the muscles of the a

15、nterior abdominal wall in raising the intra-abdominal pressure for micturition, defecation, and parturition. 腹部緊張肌：膈肌收縮時幫助腹前部肌肉收縮，促進腹腹部緊張肌：膈肌收縮時幫助腹前部肌肉收縮，促進腹內排尿、通便及分娩活動內排尿、通便及分娩活動Weight lifting muscle: In a person taking a deep breath and holding it (fixing the diaphragm), the diaphragm assists the

16、muscles of the anterior abdominal wall in raising the intra-abdominal pressure. Before doing this make sure that a person have adequate sphincteric control of the bladder and anal canal under these circumstances.提舉肌：當人深吸氣抱住重物時固定膈肌，膈肌幫提舉肌：當人深吸氣抱住重物時固定膈肌，膈肌幫助腹前部肌肉收縮提升腹壓在這個活動之前，需要確保助腹前部肌肉收縮提升腹壓在這個活動之前，

17、需要確保人有在這種情況下控制膀胱和肛門括約肌的能力人有在這種情況下控制膀胱和肛門括約肌的能力10Functions of the Diaphragm膈肌功能膈肌功能 Thoraco-abdominal pump: The descent of the diaphragm decreases the intrathoracic pressure & increases the intra-abdominal pressure. This compresses the blood in the inferior vena cava and forces it upward into the

18、 right atrium of the heart. Within the abdominal lymph vessels is also compressed, and its passage upward within the thoracic duct is aided by the negative intrathoracic pressure. The presence of valves within the thoracic duct prevents backflow.胸腹泵：膈肌的下降減少胸內壓，提高腹內壓。這會擠胸腹泵：膈肌的下降減少胸內壓，提高腹內壓。這會擠壓下腔靜脈，

19、使血液泵回右心房。同時腹部淋巴管也受壓下腔靜脈，使血液泵回右心房。同時腹部淋巴管也受到擠壓，它在胸導管處閥門阻止倒流的通行也受到到擠壓，它在胸導管處閥門阻止倒流的通行也受到胸腔腹壓的幫助胸腔腹壓的幫助11 THORACIC DIAPHRAGM connections: 胸部膈肌的聯系：胸部膈肌的聯系：HEART by phrenic-pericardial ligament; also from the pericardium to the vertebrae we find vertebral-pericardial ligaments (from C6 to T4); from the p

20、ericardium to the sternum we have sternal- pericardial upper & lower ligaments.心臟，膈-膜心包韌帶；同時從心包膜到椎骨我們可以看到脊椎-心包韌帶；從心包到胸骨還有胸骨-心包上下韌帶12 THORACIC DIAPHRAGM connections: 胸部膈肌聯系：胸部膈肌聯系： LUNGS, by phrenic-pleural ligaments; we also have costal-pleural (from K1-2 to pleura), vertebral-pleural and transv

21、erse-pleural (from C7 to pleura) ligaments that connect directly to the cervical spine.肺，膈肺，膈-胸膜韌帶；同樣還有肋胸膜韌帶；同樣還有肋-胸膜從肋胸膜從肋1、2到胸到胸膜，脊椎膜，脊椎-胸膜和橫突胸膜和橫突-胸膜從肋胸膜從肋7到胸膜韌帶，直到胸膜韌帶，直接聯系著脊椎接聯系著脊椎13 THORACIC DIAPHRAGM connections: 胸部膈肌聯系：胸部膈肌聯系： LIVER, by coronal ligament (under the right dome of the diaphragm

22、), triangular ligament under the left dome and falciform ligament.肝，由冠狀韌帶位于膈肌右圓頂下方，位于左圓頂下肝，由冠狀韌帶位于膈肌右圓頂下方，位于左圓頂下方的三角韌帶和鐮狀韌帶肝圓韌帶方的三角韌帶和鐮狀韌帶肝圓韌帶On the right side, we have also the right phrenic-colic ligament(between lower right part of liver and right colic corner).在右側，同樣有膈-結腸韌帶位于肝右下部和右結腸角14THORACIC

23、DIAPHRAGM connections:胸部膈肌聯系：胸部膈肌聯系：On the right side, with the right colic flexure, we have also the right phrenic-colic ligament(between right dome and right colic flexure).在右側，與右結腸屈曲，有右膈在右側，與右結腸屈曲，有右膈-結腸韌帶位于右圓頂和右結腸結腸韌帶位于右圓頂和右結腸屈曲之間屈曲之間15 THORACIC DIAPHRAGM connections: 胸部膈肌聯系：胸部膈肌聯系： STOMACH (and

24、 esophagus), by gastro-phrenic ligament (under the left dome of the diaphragm), SMALL INTESTINE by Treitz muscle, SPLEEN by phrenic-spleen ligament, COLON by left phrenic-colic ligament.胃和食管，通過腸胃和食管，通過腸-膈膜韌帶位于左圓頂下方，膈膜韌帶位于左圓頂下方，通過韌帶肌與小腸連接，通過膈通過韌帶肌與小腸連接，通過膈-脾韌帶與脾連接，通過脾韌帶與脾連接，通過膈膈-結腸韌帶與結腸連接結腸韌帶與結腸連接16T

25、HORACIC DIAPHRAGMOsteopathic approch胸部膈肌整骨方法TakeCare Osteopathic AcademyMilano - Italy17THORACIC DIAPHRAGM dysfunction: 胸部膈肌的功能失常胸部膈肌的功能失常 The movement of the diaphragm is a compromise between its descent, its support visceral and the tension of the aponeurotic axis.膈肌的運動是在收縮下降、支撐內臟和維持腱膜軸張力的膈肌的運動是在收

26、縮下降、支撐內臟和維持腱膜軸張力的綜合效果綜合效果Malfunctions can be uni-bilateral, at level of the domes or of the pillars. Well talk then of dysfunction in inspiration low or high功能失常可以存在于單功能失常可以存在于單-雙側，位于隆起或者膈腳韌帶水雙側，位于隆起或者膈腳韌帶水平。我們以吸氣高平。我們以吸氣高/低來命名低來命名DYSFUNCTION OF LOW INSPIRATION: In this injury the diaphragm is contr

27、acted and keeps a relatively low position with respect to its neutral point, ie reduces the excursion epiratory.吸氣低功能失常：這種情況中，膈肌在縮緊狀態時保持相吸氣低功能失常：這種情況中，膈肌在縮緊狀態時保持相對于中立位較低的位置，減少了呼氣時運動的程度更弱對于中立位較低的位置，減少了呼氣時運動的程度更弱呼氣呼氣DYSFUNCTION OF HIGH INSPIRATION: In this dysfunction the diaphragm is contracted and m

28、aintains a relatively high position with respect to its neutral point, in other words reduces the inspiratory excursion. The lower ribs remain closed during the inspiratory time.吸氣高功能失常：這種情況中，膈肌在縮緊狀態時保持相吸氣高功能失常：這種情況中，膈肌在縮緊狀態時保持相對于中立位較高的位置，換句話說減少了吸氣時運動的程對于中立位較高的位置，換句話說減少了吸氣時運動的程度更弱吸氣。而在吸氣過程中下肋骨褒詞閉合狀態

29、度更弱吸氣。而在吸氣過程中下肋骨褒詞閉合狀態18How to name a dysfunction? 如何命名功能失常？如何命名功能失常？Hands covering rib cage, on the projections of the diaphragm:雙手置于胸廓膈肌的突起處density test密度測試Which side is in trouble?哪一側失常？If during breathe-in goes down, but during breathe-out doesnt go back, I have a dysfunction of “low inhalation.

30、 Also the rib cage on that side is first to open.如果在吸氣時向下但呼氣時沒有回去，那么是有“低吸氣功能失常。同樣胸廓在這一側是最開始翻開的。Opposite sensations for “high inpiration dysfunction“高吸氣功能失常那么是相反的情況19 INSPIRATION DYSFUNCTION 吸氣功能失常吸氣功能失常Operator on the opposite side of the dysfunction. Patient supine.In the first phase, exaggerate dy

31、sfunction.Same side arm of the patient under the head.Caudal hand of the operator under the costal arch to be treated with the palm of the hand. Cranial hand on the costal ipsilateral rib cage.整骨師位于與功能失常相反一側，患者仰整骨師位于與功能失常相反一側，患者仰臥。首先進行的是將功能失常臥。首先進行的是將功能失常“擴大。患擴大。患者同側手置于頭下方。整骨師遠端手置于肋者同側手置于頭下方。整骨師遠端手置

32、于肋角下方，以手掌進行技術調整。近端手置于角下方，以手掌進行技術調整。近端手置于胸廓同側肋骨處。胸廓同側肋骨處。During inspiration, Move body weight to the top to exaggerate the parameter inspiratory. Hold rib cage opening during expiration and with the caudal hand vibrate.吸氣時，將身體重量都移至頂部來擴大吸氣吸氣時，將身體重量都移至頂部來擴大吸氣的運動程度。呼氣時保持胸廓處于翻開狀的運動程度。呼氣時保持胸廓處于翻開狀態，遠端手作振動

33、手法態，遠端手作振動手法Then fix the dysfunction: arm of the patient relaxed. Move body weight to the foot, keeping rib cage closing during inspiration and closing more during xpiration (also with vibrations).然后調整功能失常：患者手臂放松，將身體然后調整功能失常：患者手臂放松，將身體重量移向足部，保持胸廓在吸氣時關閉，在重量移向足部，保持胸廓在吸氣時關閉，在呼氣時關閉更多同樣配合振動手法呼氣時關閉更多同樣配合振動手法20 EXSPIRATION DYSFUNCTION 呼氣功能失常呼氣功能失常Operator in the same position as before.整骨師處于同樣位置整骨師處于同樣位置Start exaggerating dysfunction, by accompanying the grid rib in closing during exhalation and holding it during the inspiration phase s