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A common variant of accessory muscles in the anterior forearm is the Gantzer's muscle (GM). GM arises as a muscle belly from flexor digitorum superficialis (FDS) or ulnar coronoid process to merge distally with the flexor pollicis longus (FPL) muscle. In the present case report, we describe a novel accessory muscle in the flexor compartment of the forearm. The proximal attachment was tendinous and came from three sources: FDS muscle, ulnar coronoid process, and the medial aspect of the proximal radius. The distal tendon of the novel accessory muscle ran parallel to FPL, passed through the carpal tunnel, and entered the palmar aspect of the hand. In the hand, the tendon thinned out and blended with the tenosynovium of the FPL, contributing to the sheath around the FPL tendon. This accessory muscle of the FPL is comparable to the frequently documented Gantzer muscle (GM); however, the present case exhibited fundamental nuances that distinguish it from the previously described iterations of the GM in the following ways: 1) The novel accessory muscle is tendinous from its proximal origin and throughout the upper one-third of the forearm, and one component of its origin arose from the medial aspect of the radius. Gantzer muscles with an origin on the radius have not been previously reported. 2) In the middle one-third, the tendinous proximal attachment transitioned to a muscle belly that passed through the carpal tunnel and entered the hand. 3) In the hand, the novel tendon widened, thinned, and merged with the tenosynovium of the FPL. Accessory muscles are a common finding in the anterior forearm during cadaveric dissection. In patients, they can be the cause of neuropathies due to compression of the anterior interosseous nerve. Awareness of variations is also important for clinicians who examine the forearm and hand, as well as hand and surgeons.

A mass or a tumor may not always be an underlying cause for a clinically apparent swelling. A wide range of myotendinous disorders can present as pseudomasses. These include muscle/myofascial hernia, tendon tears, benign hypertrophy, accessory muscles, tendon xanthomas, diffuse myositis, and exertional compartment syndromes. We have briefly reviewed these lesions highlighting their typical radiological findings and have also highlighted the role of different imaging modalities and the role of dynamic imaging. Although rare, radiologists should be aware of these entities to avoid mislabeling a pseudomass as a mass or malignancy and to detect the abnormality in not-so-apparent masses.

Background: The anterior belly of the digastric muscle (ABDM) presents highly variable and frequent anatomical variations. Since the ABDM functions as a landmark for clinical procedures involving the submental region, it is important to have a comprehensive understanding of its variations. In this study, we sought to improve our knowledge of ABDM variations in the ethnically diverse whole-body donor population in Northern California. Specific aims were: (1) to determine the frequency of ABDM and anterior belly (AB) accessory muscle variations in cadavers donated to the UC Davis Body Donation Programme, (2) to classify these variations identified in this population using the previously proposed nomenclatures by Yamada (1935) and Zlabek (1933), and (3) to investigate the innervation and arterial supply to the representative ABDM and AB accessory muscle variations. Materials and methods: During the 2018 and 2019 gross anatomy dissection laboratories at the UC Davis School of Medicine, the submental regions of 48 cadavers were examined and classified. Results: Fifteen (31.2%) cadavers presented ABDM and AB accessory muscle variations. These variations were clearly categorised using the morphology of the ABDMs and attachments of the AB accessory muscles. We also identified three previously unreported types of variations, two of which presented the fusion of right and left ABDMs and one presenting an ectopic tubercle beneath the mandibular symphysis to which a pair of AB accessory muscles were attached. Conclusions: Anterior belly of the digastric muscle variations were found in 1 in 3 individuals in the local Northern California population. Knowledge of the prevalence and common patterns of ABDM variations in the general population would be valuable information when an operation or examination is performed in the submental region.

Quantitative functional anatomy of amniote thoracic and abdominal regions is crucial to understanding constraints on and adaptations for facilitating simultaneous breathing and locomotion. Crocodilians have diverse locomotor modes and variable breathing mechanics facilitated by basal and derived (accessory) muscles. However, the inherent flexibility of these systems is not well studied, and the functional specialisation of the crocodilian trunk is yet to be investigated. Increases in body size and trunk stiffness would be expected to cause a disproportionate increase in muscle force demands and therefore constrain the basal costal aspiration mechanism, necessitating changes in respiratory mechanics. Here, we describe the anatomy of the trunk muscles, their properties that determine muscle performance (mass, length and physiological cross‐sectional area [PCSA]) and investigate their scaling in juvenile Alligator mississippiensis spanning an order of magnitude in body mass (359 g–5.5 kg). Comparatively, the expiratory muscles (transversus abdominis, rectus abdominis, iliocostalis), which compress the trunk, have greater relative PCSA being specialised for greater force‐generating capacity, while the inspiratory muscles (diaphragmaticus, truncocaudalis ischiotruncus, ischiopubis), which create negative internal pressure, have greater relative fascicle lengths, being adapted for greater working range and contraction velocity. Fascicle lengths of the accessory diaphragmaticus scaled with positive allometry in the alligators examined, enhancing contractile capacity, in line with this muscle's ability to modulate both tidal volume and breathing frequency in response to energetic demand during terrestrial locomotion. The iliocostalis, an accessory expiratory muscle, also demonstrated positive allometry in fascicle lengths and mass. All accessory muscles of the infrapubic abdominal wall demonstrated positive allometry in PCSA, which would enhance their force‐generating capacity. Conversely, the basal tetrapod expiratory pump (transversus abdominis) scaled isometrically, which may indicate a decreased reliance on this muscle with ontogeny. Collectively, these findings would support existing anecdotal evidence that crocodilians shift their breathing mechanics as they increase in size. Furthermore, the functional specialisation of the diaphragmaticus and compliance of the body wall in the lumbar region against which it works may contribute to low‐cost breathing in crocodilians., The figure shows the head and upper torso of an American alligator.

Background: COPD leads to airway obstruction, hyperinflation, mechanical disadvantage of respiratory muscles which places accessory muscles in shortened position, leading to increase resistance to chest wall expansion, this causes decrease in pulmonary function. Breathing exercises assist by decreasing dyspnea. Diaphragmatic breathing aims to improve chest wall motion and distribution of ventilation. In Inverse ratio breathing, the ra­tio of I:E becomes 2:1. This study aims to compare the immediate effects of diaphragmatic and inverse ratio breathing in patients with COPD. Method: Study was conducted on 60 patients having COPD. Subjects were randomly selected to perform diaphragmatic or inverse ratio breathing first on day 1, and other technique on day 2. Diaphragmatic breathing was performed for total duration of 5 minutes within 10 minute interval at 6-8 breathes/minute. Washout period of one day was given. Next day, subject was asked to perform inverse ratio breathing using visual video feedback (inspiration for 4 seconds and expiration for 2 seconds) for 10 minutes. Outcome measures: Pulmonary functions (FVC, FEV1, FEV1/FVC, MVV) and thoracic expansion at 2nd, 4th, 6th intercostal space Results: Result showed significant improvement for FVC, FEV1 and MVV, but FEV1/FVC shows no significant difference after diaphragmatic breathing. There was no significant difference for pulmonary functions after inverse ratio breathing. Results showed no significant difference for thoracic expansion after either of two breathing techniques. Conclusion: Diaphragmatic breathing showed significant improvement in pulmonary functions, however no improvement was observed in thoracic expansion. Inverse ratio breathing showed no improvement in pulmonary functions or thoracic expansion. Key words: COPD, diaphragmatic breathing, inverse ratio breathing, pulmonary functions, thoracic expansion

Introduction Nerve compression by anomalous masses located at the wrist and distal forearm is an infrequent condition. They may compress underlying structures in the carpal tunnel region, causing pain and paresthesias, which leads to the wrong diagnosis of carpal tunnel syndrome. Clinical cases We present three cases of patients with symptomatology and clinical tests compatible with compression of the median nerve in the carpal tunnel but whose physical examination showed a soft mass in the distal region of the forearm which was compressing the median nerve, as demonstrated by ultrasound evaluation. Discussion The reported cases of accessory muscles or lipomas described in the literature as causes of median nerve compression clinic are mainly described only after the surgical decompression of the carpal tunnel, due to the maintenance of residual symptoms. Conclusion Careful examination with an ultrasound evaluation prior to surgery may help to identify these cases and help planning surgical treatment.

This case report presents a 21-year-old male construction worker with ipsilatcral inferior shoulder and posterior elbow dislocations. accompanied with other injuries. Such a combination of injury undoubtedly occurs: however, to the best of our knowledge. this is the first reported case. The prompt closed reductions without waiting for anesthesia were accomplished without the help of an assistant using a novel technique. The patient returned to his job with considerable recovery of motion and strength despite his permanent paralysis of the deltoid muscle and he was still employed as a worker after four years. He was abducting his arm by using his accessory muscles, which contribute to abduction when arm is externally rotated. The maneuver described in the report can be used to reduce all inferior shoulder dislocations and it is worth to know that working at a job requiring high level of activity is still possible despite a permanent loss of axillary nerve function. WOS:000573941100031 2-s2.0-85091562966 PubMed: 32962598

The trapezius muscle is one of the large muscles of the back and is innervated mainly by the accessory nerve. This muscle is generally divided into three parts composed of ascending, middle and descending fibres. During a study of the course of the accessory nerve, a series of back dissections were initiated by incision of the skin along the dorsal midline between the occipital protuberance and the first lumbar vertebrae. We report a previously unidentified accessory muscle of the back. During dissection of the back of a male cadaver, the skin, underlying fat and fascia were reflected laterally and revealed an accessory muscle superficial to the inferior segment of the left trapezius muscle. The accessory fibres originated from the spinous process of thoracic vertebra 12 and projected superiorly with supero-laterally oriented fibres. It terminated at the level of thoracic vertebra T5. Upon examination of the inferior surface of the accessory muscle, a nerve originating from the thoracic spinal nerve 11 was identified travelling along the medial border of the muscle. All dissections were performed in accordance with the laws regulating anatomic dissection in Ireland. Several surgical procedures are carried out at the inferior portion of the trapezius muscle; therefore, variation of this region is of clinical importance, and the presence of accessory muscles may have an influence on outcomes.

The temporomandibular muscle dysfunction is characterized by myofascial pain and is more prevalent in women of reproductive age. Sex steroid hormones are hypothetically involved in the dysfunction, but few are the studies of steroid receptors in masticatory and mastication-related muscles. Our aim was to determine estrogen and testosterone receptor expression in rat masticatory and mastication-related muscles within the context of age and gender. Twelve rats were equally divided into four groups: (a) 10-month-old females; (b) 10-month-old males; (c) 24-month-old females; and (d) 24-month-old males. Euthanasia of the females was performed in the proestrous phase (vaginal smears) and the masticatory and accessory muscles were removed for immunohistochemical analysis. Statistical analysis was performed with ANOVA and the Tukey test. Estrogen receptor expression was similarly low in all muscles and groups. Testosterone receptor expression in the Masseter muscle of the 24-month-old male rats was higher than that in the other groups and significantly superior to its expression in the Posterior Digastric muscle. In short, testosterone receptor expression was highest in old male rats. If we generalize to humans, this fact could indicate age- and sex-related hormonal influence on temporomandibular muscle dysfunction. Further studies, however, are necessary to strengthen this hypothesis.

Airway obstruction is a common component in Chronic Obstructive Pulmonary Disease (COPD). Detection of obstruction and its grading is very essential. Obstruction in the airways, forces the accessory muscles like sternomastoid muscle (SMM) of respiration to work. Normally, only essential muscles of respiration work. In the said paper electromyographic (EMG) analysis of SMM is done for COPD and Normal subjects. We have developed improved slope based onset detection algorithm to detect the onset and offset timing of EMG. Time domain features are extracted for COPD and normal subject. The onset detection algorithm reduces the number of computations by 32.96% and increases accuracy of feature calculation by 40.19%. Dominant time domain features are selected and applied to Support Vector Machine Classifier. The SVM classification algorithm is compared with Threshold and Naïve Bayes classification algorithm. SVM gives the highest accuracy of 87.80%, sensitivity of 89.65% and specificity of 83.33%. Results are also compared with previously used FEV1/FEV6 and Forced Oscillation Technique. The activity of SMM has a significant role in the classification of Normal and COPD subject. Further analysis of SMM can be done to find different grades of COPD. Keywords: Electromyography, Onset, Obstruction, COPD

Background: The diaphragm is one of the most important muscles of respiration in the body separating the abdomen from the thorax. Abnormalities of the diaphragm could be congenital or acquired, morphological or functional while pulmonary infection e.g. pulmonary tuberculosis, is implicated in its etiology. Case presentation: A 63-year- old man with six weeks history of cough productive of yellowish sputum. Chest X-ray showed a uniform well-circumscribed opacity in the right lower lobe abutting on or in continuum with the right diaphragm consistent with a diaphragmatic hump. Sputum Gene Xpert was positive for Mycobacterium tuberculosis. Chest CT scan revealed bilateral lymph node enlargement with hyperdense lesions in the anterior basal segment of the right lower lobe and medial bronchopulmonary segments of the right middle lobe. He was treated for 6 months with first-line anti-tuberculosis drugs. Discussion: The incidence of the diaphragmatic hump on chest radiograph worldwide and among Nigerians is unknown. The association of diaphragmatic hump with chest infection has been well document. The association of diaphragmatic hump with pulmonary tuberculosis is uncommon. Conclusion: A high index of suspicion is needed to diagnose pulmonary tuberculosis with atypical clinical and radiological presentations. Such prompt diagnosis will aid the treatment of the disease.

Background: The present study aims to summarise the accessory muscles of the anterior thoracic wall and axilla that can be encountered during breast and axillary surgery and record their incidence and clinical significance. Moreover, the laterality of the atypical muscles is highlighted and possible gender dimorphism is referred. Accessory anterior thoracic wall muscles include: Langer’s axillary arch, sternalis muscle, chondrocoracoideus, chondroepitrochlearis, chondrofascialis, pectoralis minimus, pectoralis quartus and pectoralis intermedius. Materials and methods: The anatomical, surgical and radiological literature has been reviewed and an anatomical study on 48 Greek adult cadavers was performed. Results: Literature review revealed the existence of accessory muscles of the anterior thoracic wall and axilla that have a significant incidence that can be considered high and may, therefore, have clinical significance. For the most common of these muscles, which are axillary arch (Langer’s) and sternalis muscle, the cadaveric incidence is 10.30% and 7.67%, respectively. In the current cadaveric study, accessory thoracic wall muscles were identified in two cadavers; namely a bilateral sternalis muscle (incidence 2.08%) extending both to the anterior and posterior surface of the sternum and a left-sided chondrocoracoideus muscle (of Wood) (incidence 2.08%). Conclusions: Despite the fact that accessory anterior thoracic wall and axillary muscles are considered to be rare, it is evident that the incidence of at least some of them is high enough to encounter them in clinical practice. Thus, clinicians’ awareness of these anatomical structures is advisable.

The respiratory muscles encompass a variety of functions and roles, their action during exercise facilitates arterial blood-gas and pH regulation. Exercise hyperpnea is the first line of defense to meet increased metabolic demand. In so doing, the muscles of respiration encounter several challenges, which may lead to respiratory muscle fatigue and impaired exercise tolerance. The focus of this brief review is to summarize recent developments in the study of respiratory muscle mechanics, energetics, and fatigue during exercise. Advances in the field are highlighted and directions of potential future research identified.

Accessory anatomical structures in the ankle and foot usually represent incidental imaging findings; however, they may also eventually represent a source of pathology, such as painful syndromes, degenerative changes, be the subject of overuse and trauma, or appear as masses and cause compression syndromes or impingement. This review aims to describe and illustrate the imaging findings related to the presence of accessory ossicles and muscles in the midfoot and forefoot through different techniques, with special attention on those variants that associate factors of clinical relevance or that would trigger challenges in the differential diagnosis.

Background: Breathing is the essential step of Pilates exercise and can be used to activate core muscles. Although the effects of breathing exercise on pain, breathing muscles, and cervical posture have been extensively studied, little is known about the impact of Pilates breathing on spinal posture and alignment. Purpose: To determine the effect of 3D-Pilates breathing exercise on spinal curvature and alignment of healthy adults during corrected to normal alignment. Design: One group pre-post test design Methods: Eighteen participants were given a 3D-pilates breathing exercise twice a week (20 minutes per session) for three weeks and warmed up for 10 minutes before each exercise session. To examine spinal curvature and alignment of each subject, this study used radiation free rasterstereography (Formetric Ⅲ, Germany). Paired t-test and Wilcoxon signed rank test were performed to determine the difference between pre and post exercise. Results: There were statistically significant differences in height (p

Background and Aim Supernumerary muscles and tendons from extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) are sometimes encountered during hand surgery. They include accessory muscles like extensor carpi radialis intermedius (ECRI), intertendinous slips (ITS) between the two muscles, or simple birfurcated tendons. Awareness of these variations is crucial for preoperative planning for tendoplasty. This study was conducted with the aim of studying their prevalence since there is limited literature on its variations. Materials and Methods The study was carried out on 80 free upper limbs from the human cadavers, in the Anatomy Department of Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala. The radial carpal extensors were studied in detail. The length and width of the accessory muscles and tendons were measured. The percentage of different variations was also calculated. Results ITS from ECRL were seen in 20 of the limbs. ECRI was identified in 7 cases. Bifurcated tendon from ECRB was observed in two limbs. Absent ECRB was also noted in a specimen. In one specimen, ECRL and ECRB fused to form a single muscle and tendon, that later split into two for insertion into second and third metacarpal. The proximal attachment of both radial extensors was normal in all cases. Conclusion A total of 37.5% of variations was observed, among which supernumerary tendons accounted for 35%. Knowledge of these variations is essential in planning for tendon grafting and finger deformity correction surgeries.

Purpose This case report describes the identification and treatment of costochondritis with suspected neural entrapment in a 14-year-old individual diagnosed with cystic fibrosis. Summary of key points The individual discussed in this report had resolution of his chest pain with additional improvement in pulmonary function test results. Statement of conclusion and recommendations for clinical practice This case supports the need for musculoskeletal and neuromuscular screening and intervention for patients with cystic fibrosis. The success of the intervention suggests that when traditional approaches to treatment of costochondritis fail, use of myofascial release at the accessory muscles of breathing could be beneficial.

Objectives: Pompe disease is a rare genetic disease produced by mutations in the GAA gene leading to progressive skeletal and respiratory muscle weakness. T1-weighted magnetic resonance imaging is useful to identify fatty replacement in skeletal muscles of late-onset Pompe disease (LOPD) patients. Previous studies have shown that replacement by fat correlates with worse results of muscle function tests. Our aim was to investigate if fat replacement of muscles involved in the ventilation process correlated with results of the spirometry and predicted respiratory muscle impairment in LOPD patients over time.Materials and Methods: We studied a cohort of 36 LOPD patients followed up annually in our center for a period of 4 years. We quantified muscle fat replacement using Mercuri score of the thoracic paraspinal and abdominal muscles and the pillars of the diaphragm. We correlated the combined Mercuri scores of these areas with spirometry results and the need of respiratory support.Results: We found a statistically significant correlation (Spearman test, p < 0.05; coefficient of correlation > 0.6) between forced vital capacity seated and lying and fat fraction score of all muscle groups studied. The group of patients who needed respiratory support had higher fat fraction scores than patients not requiring ventilatory support. Higher fat replacement in these areas correlated with worse progression in spirometry values over time.Conclusions: Fat replacement of paraspinal, abdominal, and trunk muscles correlates with results of spirometry and is able to predict worsening in respiratory muscle function tests that could lead to an emerging ventilatory dysfunction. Therefore, the identification of fat replacement in these muscle groups should lead to a closer monitorization of patients. Radiologic evaluation of diaphragm pillars in T1-weighted imaging axial sequences could also be helpful to predict respiratory insufficiency.

Root nerve surgical exploration and grafting is technically more demanding than nerve transfers, but mastering it is mandatory to optimize the outcomes of brachial plexus reconstruction. For preoperative planning for BPI, we recommend combining Tinel’s sign, the protraction sign (in complete palsies), and a CT-myeloscan to verify C5-C6 availability for grafting. The C7 to T1 roots are not explored, even if not avulsed, because grafting yields very poor results. For C5-C6+/-C7 upper-type BPI, we recommend, when possible, combining nerve grafting with a triple nerve transfer. This strategy provides better elbow flexion and shoulder abduction outcomes than isolated nerve transfer, owing to the reinnervation of accessory muscles acting as joint stabilizers. For a T1 hand, grafting of the C5-C6 roots is also recommended, when available. For complete BPI, the presence of a graft-able root occurs in almost 90% of patients. Available roots are connected to the musculocutaneous nerve using long grafts. Benefits of these reconstructions are neuropathic pain control in 50% of patients, functional elbow flexion reanimation in 90% of cases, and protective sensory restoration of the radial forearm and hand in all instances.

During a heavy exercise, energy requirement increases, causing insufficiency of inspiratory muscles to overcome the elastic recoil of the lungs. Respiratory accessory muscles are in charge during forced inspiration or expiration. Muscles elevating chest cage during respiration are referred to muscles of inspiration, while muscles depressing chest cage are termed as muscles of expiration. In case of high cervical spinal injury, sternocleidomastoid muscle remains intact and is the objective of physiotherapy. Expiratory muscle strength is significant in patients suffering chronic obstructive pulmonary disease. Involvement of bulbar muscles in patients with neuromuscular diseases presents a deterioration of the disease.

The ventromedial portion of the spinal trigeminal nucleus, together with the nearby lateral reticular formation in the pons and medulla, is the neuroanatomical regions responsible for sneezing. These areas apparently control several groups of muscles which work together to produce sneezes: those in the pharynx, those within the larynx proper and the muscles of respiration. Sexually induced sneezing is not triggered by irritation of the nasal cavity nor by allergenic stimulation. It may happen at any stage during sex. One term to describe the phenomenon is “honeymoon rhinitis”. Honeymoon rhinitis thus refers to the situation where sexual activity leads to nasal symptoms, including sneezing, rhinorrhoea and stuffiness (i.e. congestion). Potentially, honeymoon rhinitis may be present in both males and females for their whole lives, but patient reticence about mentioning bizarre and embarrassing symptoms to their clinician results in under-reporting. Internet chat rooms and forums are often valued for their anonymity, and in such places the symptoms may be more readily disclosed. In this chapter, we presented honeymoon rhinitis.

The activity of the trapezius muscle is reportedly higher than that of other neck accessory muscles under a condition of increased inspiratory pressure in the standing position. The present study aimed to compare the activity of the trapezius muscle with those of the scalene and sternocleidomastoid muscles under a condition of increased inspiratory pressure in the supine position. This study included 40 subjects, and the muscle activity was measured using surface electromyography. Regarding the results, there was a significant difference in the muscle activity between the trapezius muscle and the scalene and sternocleidomastoid muscles (p = 0.003) in both men and women. Post-hoc analysis showed significant differences between trapezius and the other muscles. Moreover, there was no difference between the scalene and sternocleidomastoid muscles (p = 0.596). The increase in the change in electromyography activity of the muscle is greater in the trapezius muscle than in other muscles when the level of inspiratory pressure increases in the supine position., 論文

Minimizing the energy required for breathing muscles is based on the adaptation of the respiratory muscles which is reflected in the reduction of breathing frequency (BF) and tidal volume (VinfT/inf) increase. This may be influenced through a targeted BE and the quality of breathing may be linked to endurance performance. Aim of this study was assess dynamic ventilation parameters at different load intensities and their changes due to the systematic breathing exercise (BE).Study recruit 36 runners of both sexes with a mean age 16.8±1.6 years. A random distribution was performed. The intervention program consisted of a set of BE aimed at the activation of the diaphragm. We monitored the dynamics of ventilation parameters at intensities 2, 3, 4 W/kg during a stepped test on a bicycle ergometer.The BE was focused on the activation of the diaphragm for a 12.2±3.6 minutes per day, sixteen weeks. After eight weeks, there were significant changes in VinfT/infand BF (P0.05). After sixteen weeks there was a significant increase in VinfT/infof 5.7-18.3% (P0.01), depending on the load level, BF values decreased significantly by 5.4-14.4% (P0.01). VinfE/infand VOinf2/infvalues were without changes. There were no significant changes in the control group.It was confirmed that the two-month BE intervention focused on the activation of the diaphragm is sufficient and resulted in a significant change in the values of dynamic ventilation parameters. After four months of intervention, the changes are significantly greater compared with values found after a two-month intervention period.

After stroke, limited ribcage movement may lead to impaired respiratory function. Combining threshold inspiratory muscle training with rib cage joint mobilization has been shown to enhance the recovery of respiratory function in patients with stroke. The present study investigated whether the combination of rib cage joint mobilization and inspiratory muscle training would improve chest expansion, inspiratory muscle activity, and pulmonary function after stroke. Thirty stroke patients were recruited and randomly assigned to one of the two groups, namely 6-week rib cage joint mobilization with inspiratory muscle training (experimental group) or inspiratory muscle training alone (control group). Outcome measures included upper and lower chest expansion, activity of accessory inspiratory muscles (latissimus dorsi (LD) and upper trapezius (UT)), and pulmonary function (forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and peak expiratory flow (PEF)). All evaluations were conducted at baseline and after 6 weeks of inspiratory muscle training. Significant increases were observed in upper and lower chest expansion, LD and UT muscle activity, FVC, FEV1, and PEF in both the groups. Upper and lower chest expansion and muscle activity of UT and LD were significantly higher in the experimental group than in the control group. No significant differences were observed in FVC, FEV1, and PEF between the groups. Inspiratory muscle training is effective in improving chest expansion, inspiratory muscle activity, and pulmonary function after stroke. The addition of rib cage joint mobilization further increases chest expansion and inspiratory muscle activity.

Background Approximately 30 to 50% of women are unable to correctly perform pelvic floor muscle (PFM) contractions. For women to benefit from a pelvic floor muscle training (PFMT) programme for stress urinary incontinence (SUI), the awareness phase of PFMT cannot be omitted. The purpose of this study is to evaluate whether vaginal palpation together with verbal instructions about PFMs and body awareness techniques helps women with SUI learn how to correctly contract the PFMs and improve their functions. Methods This single-centre, double-blind randomized controlled trial with two intervention groups was designed following the standard protocol items for randomized interventional trials (SPIRIT). The results will be reported in a manner consistent with the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Patients with SUI (n = 172) will be recruited. The experimental group will receive verbal instructions about PFM function and body awareness techniques together with vaginal palpation; the control group will receive similar protocol without vaginal palpation. The primary outcome includes the number of fast-twitch muscle fibres assessed by vaginal palpation and visual observation. Secondary outcomes include power and muscular endurance that will be assessed by visual observation and vaginal palpation (Oxford scale), the use of accessory muscles during the voluntary contraction of PFMs, and the self-efficacy and the expectations for the results using the self-efficacy scale of pelvic floor exercises. Discussion This study will determine whether vaginal palpation can help women with SUI to correctly perform PFM contractions and improve their functions. Trial registration ClinicalTrials.gov NCT 03325543. Registered on 30 November 2017. Study protocol version 1; 30 November 2020. Prospectively registered.

Persons older than 60 with hypertension, diabetes, COPD, cardiovascular, cerebrovascular, liver, kidney, and gastrointestinal...

Accessory and atypical muscles of the upper limb are common, whereas symptomatic variations presenting with carpal tunnel syndrome (CTS) are rare. A rare unilateral accessory transverse carpal muscle located palmar to the transverse carpal ligament is described. The accessory muscle, associated with CTS clinical manifestations in a 38-year-old Greek male worker, can be quite problematic during CTS operation. The current case emphasizes the importance of meticulous knowledge of the variable anatomy of the carpal tunnel (CT) area, since the accessory muscles may be accompanied by ectopic motor branches and a high risk of iatrogenic injury. Recognition and careful evaluation of accessory muscles may enhance a surgeon’s ability to carry out a safer and successful CT approach.

The primary function of the respiration is the gas exchange of oxygen and carbon dioxide between the lungs and the blood. Respiration includes ventilation, which takes place in the lungs within the interaction which sternum, ribs, vertebrae, and muscles surrounding the thorax. The nose, pharynx, and larynx are the parts of the upper airways. Upper airways are responsible for warming, moistening, and filtering of the air. The lower respiratory tract includes conducting airways and the respiratory zone. Thoracic cage expands, and the air enters into the lungs as the diaphragm, external intercostals, and the scalenes contract during quite inspiration. The expiration is passive during rest. Accessory muscles of respiration contract during forced expiration. Compliance, airway resistance, and surface tension affect ventilation. The children have different anatomical and physiological features of lungs and thorax compared to adults. The mechanical properties of the lungs and thoracic cage differ according to the diseases. In this chapter, the kinesiology of respiration is discussed.

Objectives: to evaluate the evolution of clinical indicators that characterize airway permeability in patients in the postoperative period of thoracoabdominal surgeries and to analyze their relationship with the occurrence of the diagnosis “ineffective airway clearance”. Methods: descriptive, quantitative, longitudinal research with 60 patients who were followed for five consecutive days. Eleven indicators of the nursing outcome “respiratory status: airway permeability” were used. Results: on the first day of evaluation, the most compromised indicators were: respiratory rate, cough, depth of breath and use of accessory muscles. During follow-up, most of the indicators presented a slight deviation from normal variation and, in the last evaluation, there was a predominance of indicators with some degree of impairment. Conclusions: with the aid of the Nursing Outcomes Classification, it was observed that patients submitted to thoracoabdominal surgeries may present compromised airway permeability even days after surgery.

The control of rate, rhythm and depth of different phases of respiration is required not only for exchange of gases but also during non-respiratory motor behaviours and emotional states. A network of rhythm-generating and pattern-generating neural groups in the ponto-medullary region of brain controls the activity of inspiratory, expiratory and accessory muscles of respiration. This network is intricately connected to the higher subcortical and cortical regions of the brain for state and behaviour-specific modulation respiration. The network also receives afferent information from periphery to modulate the ongoing respiratory activity to match the respiration with the metabolic needs. This chapter details the most recent information regarding neural substrate and models that underlie the control of respiration.

Introduction Several structures liable to compress the median nerve have been described around the elbow and proximal forearm. Signs of deficit justify surgical exploration and decompression by exoneurolysis. Better knowledge of the locations of these structures would ensure reliable and effective exploration. Hypothesis The study hypothesis was that compressive structures show precise topography, with few variations in distance along the median nerve course. Material and methods The study was performed on 36 upper-limb cadaver specimens. The measurement reference level was the humeral bi-epicondylar line. Proximal-to-distal dissection located: (1) Struthers’ ligament, (2) the pronator teres bellies (PT) with their anatomic particularities of structure and insertion, (3) the lacertus fibrosus, (4) the fibrous arcade of the flexor digitorum superficialis (FDS), (5) the accessory muscles, (6) the origin of the anterior interosseous nerve (AIN), (7) and the vascular arches. Results Struthers’ ligament was not located, but 1 case of medial bicipital fibrous arcade was found. The lacertus fibrosus crossed the median nerve at +1.5 ± 0.6 cm. PT insertion was high in 19 cases (53%). The humeral PT belly was thin in 21 cases (58%), crossing the median nerve more distally (+1.8 ± 0.8 cm) than the thicker muscles (+1 ± 1.1 cm) (p = 0.016). The ulnar PT belly was fibrous in 14 cases (39%). A fibrous arcade was found between the 2 PT bellies in 23 cases (64%). The FDS arcade was located at 4.5–7 cm from the bi-epicondylar line. An accessory flexor pollicis longus belly was found in 11% of cases. The AIN origin was at +4 ± 1.6 cm from the reference. A vascular pedicle crossed the median nerve in 3 cases. Discussion The present study inventoried and mapped 6 potentially compressive structures neighboring or crossing the median nerve. Except for the FDS arcade, they showed very precise proximal-to-distal location, with variations of 0.5 to 1.5 cm. Level of evidence IV; case series.

A 57-year-old woman nursing home patient with diabetes, hypertension, and a prior haemorrhagic stroke presented to our emergency department with progressive dyspnoea, cough with white sputum and low-grade temperature. On arrival, the patient was tachypnoeic, using accessory muscles and oxygen desaturation was noted. Physical examination showed no jugular vein engorgement, trachea was not deviated and auscultations revealed bilateral equal breath sounds with bi-basilar rales. Despite supplemental oxygen, the patient required intubation and was admitted to the intensive care unit (ICU). However, in the ICU, the patient’s saturation continued to fluctuate despite varying ventilation settings. The postintubation X-ray …

International audience; In this chapter, we evaluate the 3D tumor trajectories from patient-specific biomechanical model of the respiratory system, which takes into account the physiology of respiratory motion to simulate irregular motion. The behaviour of the lungs, driving directly by simulated actions of the breathing muscles, i.e. the diaphragm and the intercostal muscles (the rib cage). In this chapter, the lung model is monitored and controlled by a personalized lung pressure-volume relationship during a whole respiratory cycle. The lung pressure is patient specific and calculated by an optimization framework based on inverse finite element analysis. We have evaluated the motion estimation accuracy on two selected patients, with small and large breathing amplitudes (Patient 1 = 10.9 mm, Patient 10 = 26.06 mm). In this order, the lung tumor trajectories identified from 4D CT scan images were used as reference and compared with the 3D lung tumor trajectories estimated from finite element simulation during the whole cycle of breathing. Over all phases of respiration, the average mean error is less than 1.8 ± 1.3 mm. We believe that this model, despite of others takes into account the challenging problem of the respiratory variabilities and can potentially be incorporated effectively in Treatment Planning System (TPS) and as lung tumor motion tracking system during radiation treatment.

Johnson, CD, Whitehead, PN, Pletcher, ER, Faherty, MS, Lovalekar, MT, Eagle, SR, and Keenan, KA. The relationship of core strength and activation and performance on three functional movement screens. J Strength Cond Res 32(4): 1166-1173, 2018-Current measures of core stability used by clinicians and researchers suffer from several shortcomings. Three functional movement screens appear, at face-value, to be dependent on the ability to activate and control core musculature. These 3 screens may present a viable alternative to current measures of core stability. Thirty-nine subjects completed a deep squat, trunk stability push-up, and rotary stability screen. Scores on the 3 screens were summed to calculate a composite score (COMP). During the screens, muscle activity was collected to determine the length of time that the bilateral erector spinae, rectus abdominis, external oblique, and gluteus medius muscles were active. Strength was assessed for core muscles (trunk flexion and extension, trunk rotation, and hip abduction and adduction) and accessory muscles (knee flexion and extension and pectoralis major). Two ordinal logistic regression equations were calculated with COMP as the outcome variable, and: (a) core strength and accessory strength, (b) only core strength. The first model was significant in predicting COMP (p = 0.004) (Pearson's Chi-Square = 149.132, p = 0.435; Nagelkerke's R-Squared = 0.369). The second model was significant in predicting COMP (p = 0.001) (Pearson's Chi-Square = 148.837, p = 0.488; Nagelkerke's R-Squared = 0.362). The core muscles were found to be active for most screens, with percentages of "time active" for each muscle ranging from 54-86%. In conclusion, performance on the 3 screens is predicted by core strength, even when accounting for "accessory" strength variables. Furthermore, it seems the screens elicit wide-ranging activation of core muscles. Although more investigation is needed, these screens, collectively, seem to be a good assessment of core strength.

Muscles of flexor compartment of forearm have a common origin from medial epicondyle of humerus. Additional bellies of flexor muscles are commonly reported but presence of supernumerary muscles is an infrequent phenomenon. The present study describes an unusual muscle mass in flexor compartment of forearm simulating pronator teres. During routine dissection the upper limb of a 50 years old male cadaver, a supernumerary muscle was found on left side of the upper limb in the flexor compartment. The origin of the muscle was 2cm wide and aponeurotic in nature and attached to an oblique line extending from the inferior surface of the medial epicondyle and the medial surface of the trochlea. It was inserted on an oblique line 2.5cm wide on the radius in area between supinator superiorly and flexor digitorum profundus inferiorly. Existence of accessory muscles, which connect flexor muscles, could be explained embryologically by incomplete cleavage of flexor mass during development. The flexor muscles of the forearm develop from the flexor mass which subsequently divides into two layers: superficial and deep. The deep layer gives rise to flexor digitorum superficialis, flexor digitorum profundus and flexor pollicis longus. These supernumerary muscles are extremely rare entities and probably represent deranged embryological development or the process of atavism in which the anomalous part persist for a longer time in the tree of evolution.

Skeletal muscle has diverse mechanical roles during locomotion. In swimming fish, power-producing muscles work in concert with the accessory muscles of the fins which augment and control power transfer to the water. Although fin muscles represent a significant proportion of the locomotor muscle mass, their physiological properties are poorly characterized. To examine the relationship between muscle metabolism and the differing mechanical demands placed on distinct muscle groups, we quantified the aerobic and glycolytic capacities of the myotomal, pectoral and caudal muscles of bluegill sunfish. These were indicated by the activities of citrate synthase and lactate dehydrogenase, rate-limiting enzymes for aerobic respiration and glycolysis, respectively. The well-established roles of slow and fast myotomal muscle types in sustained and transient propulsive movements allows their use as benchmarks to which other muscles can be compared to assess their function. Slow myotomal muscle had the highest CS activity, consistent with meeting the high metabolic and mechanical power demands of body-caudal fin (BCF) swimming at the upper end of the aerobically supported speed range. The largest pectoral adductors and abductors had CS activities lower than the slow myotomal muscle, in line with their role supplying thrust for low-speed, low-power swimming. The metabolic capacities of the caudal muscles were surprisingly low and inconsistent with their activity during steady-state BCF swimming at high speeds. This may reflect adaptation to the observed swimming behavior in the field, which typically involved short bouts of BCF-propulsive cycles rather than sustained propulsive activity.

TOPIC: Pulmonary Physiology TYPE: Fellow Case Reports INTRODUCTION: Respiratory muscle weakness is known to occur in neurodegenerative disorders, including Huntington's disease (HD), and causes 25% of deaths in this population. Though diaphragmatic dystonia has been described in some neurodegenerative diseases, it has not been in HD. In general, little published data exists on overall respiratory function and diaphragmatic movement in HD. CASE PRESENTATION: We describe a 58-year-old male with HD, presenting with progressive dyspnea over 1 year and an accompanying choking sensation upon awakening. Cardiac evaluation with echocardiogram and dobutamine stress test revealed only left ventricular hypertrophy. Family history includes HD in his mother, diagnosed at autopsy age 72;an older brother with HD onset at 53 that died at 62;a maternal aunt with onset in her 50s that died in her 70s. His maternal grandmother and 2 other family members also had involuntary movements believed to be chorea. Most died from respiratory complications. Physical exam showed adequate air entry bilaterally, with clear breath sounds and decreased chest wall expansion. No abdominal paradox or diaphragm dysfunction was appreciated in supine or seated position. On walking oximetry, he became tachypneic and dyspneic after 2 minutes of walking, prompting him to stop. His saturation on room air did not drop below 96%. Heart rate increased to 110 beats per minute. Laboratory panel revealed hemoglobin 13.8 g/dl. A venous blood gas revealed pH 7.38 and pCO2 of 49.A dynamic digital chest radiography (DDR) was performed during two tidal breaths and a forced inspiratory and expiratory maneuver. This revealed decreased bilateral lung inflation. Diaphragmatic contours were elevated bilaterally with a mildly reduced excursion. During the breathing cycle multiple independent diaphragmatic contractions were appreciated on forced inspiration and exhalation resulting in paradoxical motion and dyssynchrony. There was exaggerated use of accessory muscles in the shoulder girdle as a compensatory mechanism. Spasms in the upper airway were also noted throughout the test. Because of covid restrictions, the patient is awaiting pulmonary function tests. DISCUSSION: DDR uniquely provides the opportunity to interrogate respiratory physiology and identify diaphragmatic abnormalities, such as coordination impairments and dyssynchrony compared to static chest radiography;with lower levels of radiation as used in video fluoroscopy. As previously described1, we suggest that the understanding of dyspnea in patients with neurologic disease is enhanced using DDR. CONCLUSIONS: We report the first case of diaphragmatic chorea in a patient with HD using DDR. Future studies are needed to better understand this newly recognized phenomenon of diaphragmatic discoordination and its association with shortness of breath. REFERENCE #1: O'Sullivan M, Singh A, Prime D, Moore J, Zink S. A Whole New Chest X-Ray. ATS 2019 ePoster Viewing Site. Published May 2019. Accessed April 28, 2021. https://cslide-us.ctimeetingtech.com/ats2019_eposter/attendee/eposter/poster/6529 DISCLOSURES: No relevant relationships by Norma Braun, source=Web Response No relevant relationships by Jose Concepcion, source=Web Response No relevant relationships by Natasha Garg, source=Web Response No relevant relationships by Mary O Sullivan, source=Web Response No relevant relationships by Valeria Santibanez, source=Web Response

Key points Respiratory failure is a leading cause of mortality in Duchenne muscular dystrophy (DMD), but little is known about the control of breathing in DMD and animal models. We show that young (8 weeks of age) mdx mice hypoventilate during basal breathing due to reduced tidal volume. Basal CO2 production is equivalent in wild-type and mdx mice. We show that carotid bodies from mdx mice have blunted responses to hyperoxia, revealing hypoactivity in normoxia. However, carotid body, ventilatory and metabolic responses to hypoxia are equivalent in wild-type and mdx mice. Our study revealed profound muscle weakness and muscle fibre remodelling in young mdx diaphragm, suggesting severe mechanical disadvantage in mdx mice at an early age. Our novel finding of potentiated neural motor drive to breathe in mdx mice during maximal chemoactivation suggests compensatory neuroplasticity enhancing respiratory motor output to the diaphragm and probably other accessory muscles. Abstract Patients with Duchenne muscular dystrophy (DMD) hypoventilate with consequential arterial blood gas derangement relevant to disease progression. Whereas deficits in DMD diaphragm are recognized, there is a paucity of knowledge in respect of the neural control of breathing in dystrophinopathies. We sought to perform an analysis of respiratory control in a model of DMD, the mdx mouse. In 8-week-old male wild-type and mdx mice, ventilation and metabolism, carotid body afferent activity, diaphragm muscle force-generating capacity, and muscle fibre size, distribution and centronucleation were determined. Diaphragm EMG activity and responsiveness to chemostimulation was determined. During normoxia, mdx mice hypoventilated, owing to a reduction in tidal volume. Basal CO2 production was not different between wild-type and mdx mice. Carotid sinus nerve responses to hyperoxia were blunted in mdx, suggesting hypoactivity. However, carotid body, ventilatory and metabolic responses to hypoxia were equivalent in wild-type and mdx mice. Diaphragm force was severely depressed in mdx mice, with evidence of fibre remodelling and damage. Diaphragm EMG responses to chemoactivation were enhanced in mdx mice. We conclude that there is evidence of chronic hypoventilation in young mdx mice. Diaphragm dysfunction confers mechanical deficiency in mdx resulting in impaired capacity to generate normal tidal volume at rest and decreased absolute ventilation during chemoactivation. Enhanced mdx diaphragm EMG responsiveness suggests compensatory neuroplasticity facilitating respiratory motor output, which may extend to accessory muscles of breathing. Our results may have relevance to emerging treatments for human DMD aiming to preserve ventilatory capacity.

Postural control and breathing are mechanically and neuromuscularly interdependent. Both systems- of spinal stability and respiration- involve the diaphragm, transversus abdominis, intercostal muscles, internal oblique muscles and pelvic floor muscles. The aim of the study was to evaluate the effect of exercises activating deep stabilizer muscles on postural control and quality of breathing movements. Eighteen volunteers (25,7 ± 3,5) were recruited from the general population. All the subjects implemented an exercise program activating deep muscles. Head, pelvic and trunk positions in the sagittal and frontal planes were assessed with the photogrammetric method. Breathing movements were estimated with the respiratory inductive plethysmography. The results indicate that the use of deep muscle training contributed to a significant change in the position of the body in the sagittal plane (p = 0.008) and the increase in the amplitude of breathing (p = 0.001).

Aberrant accessory muscles are rare entities in the hand. The extensor digitorum brevis manus (EDBM) muscle is amongst them and may be seen in association with dorsal ganglion cysts. Distinguishing an EDBM muscle is relevant in the diagnostic consideration of a dorsal ganglion in order to facilitate and guide its proper treatment. To date, there have been only few reports of an EDBM in association with a dorsal ganglion cyst. We report our experience with an incidental intraoperative finding of an intramuscular EDBM dorsal ganglion cyst and follow with a literature review and guide to management.

Accessory muscles around the ankle are commonly encountered as incidental findings on cross-sectional imaging. Mostly asymptomatic, accessory muscles sometimes mimic mass lesions. They have been implicated as the cause of tarsal tunnel syndrome, impingement of surrounding structures, and chronic pain. Distinguishing these muscles can be challenging, because some travel along a similar path. This article describes these accessory muscles in detail, including their relationships to the aponeurosis of the lower leg. An imaging algorithm is proposed to aid in identification of these muscles, providing a valuable tool in diagnostic accuracy and subsequent patient management.

Crests, bands, chords, and membranes can be seen within the different cardiac chambers, with variable clinical significance. They can be incidental or can have clinical implications by causing hemodynamic disturbance. It is crucial to know the morphology and orientation of normal structures, aberrant or accessory muscles, and abnormal membranes to diagnose the hemodynamic disturbance associated with them. Newer generation computed tomographic scanners and faster magnetic resonance imaging sequences offer high spatial and temporal resolution allowing for acquisition of high resolution images of the cardiac chambers improving identification of small internal structures, such as papillary muscles, muscular bands, chords, and membranes. They also help in identification of other associated complications, malformations, and provide a road map for treatment. In this article, we review cross-sectional cardiac imaging findings of normal anatomical variants and distinctive imaging features of pathologic bands, chords, or membranes, which may produce significant hemodynamic changes and clinical symptomatology.

The northern tamandua (Tamandua mexicana) is a xenarthran mammal with a distribution from Mexico to Peru. This species arrives to wildlife care centres due to illegal trafficking and attacks by domestic dogs, both of which are situations where the northern tamandua's thoracic limbs (forelimbs) can be affected. As such, it is necessary to have anatomical studies that allow us to perform better medical and surgical procedures. Among these, studies about the musculoskeletal system also aid in the muscular reconstructions of extinct species. The aim of this study was to characterize the craniolateral muscles of the forearm in Tamandua mexicana and compare them with other Xenarthrans to determine their gross adaptations. Six dead specimens were used, and none were sacrificed for the purpose of this investigation. In five specimens, arterial repletion was done. Four were fixed with 10% formaldehyde and 5% glycerin, and two were dissected in fresh. All were dissected in the Veterinary Anatomy Laboratory of the Universidad del Tolima. The weights of the muscles from seven forearms were taken and divided in three functional groups for comparison with non-parametric statistics. Two muscular groups were found: one superficial formed by the brachioradialis, brachioradialis accesorius, extensor carpi radialis, extensor digitorum communis, extensor digitorum lateralis and extensor carpi ulnaris; and one deep muscular group formed by the supinator, extensor digiti III et IV, abductor digiti I longus, and extensor digiti I et II. They were supplied by different branches of the cranial interosseous, transverse cubital and superficial brachial arteries, which had the shape of rete mirabile; and all muscles were innervated by the deep branch of the radial nerve. The presence of the brachioradialis accesorius muscle in this species allows its hand to remain in semi-supination when it is mobilized in a quadrupedal manner. It must also support elbow flexion together with the action of the brachioradialis and the extensor carpi radialis muscles. All the antebrachial digital muscles sent tendons for the digit III making it the most functional for different grip activities such as climbing trees and searching for its food, however, the most strength was directed to supination and carpal extension, and therefore also to the flexion of the elbow.

INTRODUCTION: Acute Flaccid Myelitis (AFM) is a recently recognized, polio-like illness of children that can be functionally devastating. Severe cases can lead to ventilatory failure. Incomplete phrenic nerve injuries in other populations has been shown to respond to diaphragmatic stimulation. We therefore proposed an early assessment for incomplete denervation by laparoscopic direct stimulation of the diaphragm and placement of a diaphragmatic pacing system to enhance diaphragm function. CASE PRESENTATION: A 3 year-old girl presented with AFM with clinically and electrodiagnostically severe involvement of all four limbs and muscles of respiration. Direct stimulation of the diaphragm demonstrated contraction and a diaphragmatic stimulator was placed at 3 weeks post presentation. The patient was immediately able to tolerate short bouts of reduced ventilation settings. Electromyography via the pacing wires demonstrated intact motor units consistent with partial denervation/reinnervation in the left hemidiaphragm, and no motor units in the right hemidiaphragm. At three months, she tolerated 6 h of pacing on pressure support setting. At 5 months she demonstrated larger tidal volumes with active pacing than without. DISCUSSION: In our experience, AFM patients who require chronic ventilator support are rarely able to be weaned. Despite clinical and surface electrodiagnostic evidence of complete phrenic nerve involvement, the patient’s diaphragm responded to direct stimulation. The patient preferred pacing over non-pacing times and showed improved ventilatory ability with pacing as opposed to without, though remains ventilator-dependent. These findings support augmentation of diaphragm function and possible enhanced recovery of spontaneous function.

Respiratory muscles are located at multiple sites of the upper airway and are the effectors for the respiratory, alimentary, and communicative roles of the upper airway. The upper airway contains multiple muscles at each of five major sites. Their major respiratory functions are to optimize airway patency during inspiration, regulate the rate of airflow during expiration, and partition ventilation between nasal and oral routes. Accessory muscles of the neck act to assist the thoracic respiratory muscles mainly by stabilizing the upper rib cage. There are five groups of upper airway muscles, based on their anatomic location: regulating the pharynx, soft palate, larynx, nose, and mouth. The muscles of the upper airway are rhythmically active during the respiratory cycle, and have several influences on airflow under normal circumstances and in the presence of disease. An appreciation of the high prevalence of obstructive sleep apnea has led to a wealth of new information about the structural and contractile properties of pharyngeal muscles.

Cervical muscle weakness in amyotrophic lateral sclerosis (ALS) indicates a poor prognosis.1 Cervical weakness has several implications, not only disturbing posture and gait, but also affecting speaking and swallowing leading to drooling, reducing respiratory and cough efficacy and impairing social interactions. Cervical orthotics can improve some of these problems.2 Cervical muscles are important accessory muscles of respiration.3 The sternocleidomastoid is usually only recruited during greater respiratory efforts in healthy individuals, but is activated to support resting ventilation when the diaphragm is weak.3 Cervical extensor and other axial muscles can contribute to ventilation in ALS, when the diaphragm is weak.3 We have studied the association of cervical muscle strength and respiratory function in ALS. We included consecutive ALS patients followed in our ALS clinic in Lisbon (2010–2017). Clinical assessment of flexor and extensor cervical strength was performed by one evaluator (MdC), using a standard clinical method. We recorded the revised functional ALS rating scale (ALSFRS-R) on the same day. Phrenic nerve studies and forced vital capacity (FVC) were performed within 3 months. Inclusion criteria were: definite, probable and probable laboratory-supported disease (revised El Escorial-criteria); evaluation of neck strength; disease progression. Exclusion criteria included: incomplete data; signs of dementia; severe respiratory symptoms; inability to tolerate the recumbent position; neck pain during cervical testing; associated neurological disorders; refusal of consent. ### Cervical muscle strength Strength of neck …