Accepted Manuscript

Title: Diaphragm: a vital respiratory muscle in mammals

Author: Thais Borges Lessa Dilayla Kelly de Abreu Bruno

Machado Bertassoli Carlos Eduardo Ambrósio

PII: S0940-9602(16)30040-1
DOI: http://dx.doi.org/doi:10.1016/j.aanat.2016.03.008
Reference: AANAT 51031

To appear in:

Received date: 28-1-2016

Revised date: 11-3-2016
Accepted date: 14-3-2016

Please cite this article as: Ambrósio, T.B.L., </sup>; Dilayla Kelly de
Abreu, ; Bruno Machado Bertassoli, ; Carlos Eduardo,
Diaphragm: a vital respiratory muscle in mammals, Annals of Anatomy (2016),
http://dx.doi.org/10.1016/j.aanat.2016.03.008

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 1

Diaphragm: a vital respiratory muscle in mammals

1* 1* 2* 3*
Thais Borges Lessa ; Dilayla Kelly de Abreu ; Bruno Machado Bertassoli ; Carlos Eduardo Ambrósio
1*
Department of Surgery at the School of Veterinary Medicine and Animal Science of University of Sao
Paulo, FMVZ/USP - Prof. Dr. Orlando Marques de Paiva, n. 87, Cidade Universitária, Zip code 05508-
000, São Paulo/SP, Brazil

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2*
Departamento of Morphology at Biologic Science Institute of Federal University of Minas Gerais

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(UFMG), Avenue Presidente Antônio Carlos, 6627 - Pampulha, Belo Horizonte, MG CEP 31.270-010,
Brasil.

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3*
Department of Veterinary Medicine, Faculdade de Medicina Veterinária e Zootecnia, Universidade de
São Paulo – FMVZ/USP – Av. Duque de Caxias Norte 225, Pirassununga, Zip code 13635-900,
Pirassununga/SP, Brazil

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Corresponding author: Thais Borges Lessa. Av. Prof. Dr. Orlando Marques de Paiva 87, Cidade
Universitária, São Paulo, SP 05508 270, thaisblessa32@gmail.com

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Abstract

The diaphragm is a respiratory muscle that is primarily responsible for the respiratory
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function in normal individuals. In mammals, the diaphragm muscle has been studied
from the early days of zoology, comparative and experimental anatomy, physiology,
medicine, physics, and philosophy. However, even with these early advances in
knowledge pertaining to the diaphragm, comprehensive morphological data on the
d

diaphragm are still incomplete. In this review, we summarize the beginnings of the
morphological description of the diaphragm, and we describe the current status of the
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known morphological and embryological features. In addition, we correlate how the

impairment of the diaphragm muscle in Duchenne Muscular Dystrophy (DMD) can lead
to patient deaths. DMD is the most common X-linked muscle degenerative disease and
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is caused by a lack of dystrophin protein. Dystrophin is an important muscle protein that

links the cellular cytoskeleton with the extracellular matrix. In the absence of
ce

dystrophin, the muscle becomes susceptible to damage during muscle contraction. This
review allows researchers to obtain an overview of the diaphragm, transcending the
morphological data from animals described in conventional literature.
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Key words: history, mammalian diaphragm, muscular dystrophies, respiratory muscle

1. Introduction

The diaphragm is a respiratory muscle required for breathing and primarily

responsible for respiratory function in normal individuals, corresponding to 70% of the
total function and 40% of the tidal volume at rest (Unal et al., 2000; Dos Santos
Yamaguti et al., 2008 and Huang et al., 2011). In addition to other respiratory muscles,
its contraction during the respiratory cycle changes the anatomical configuration of the
chest and moves its components by causing gas exchange in the lungs (Roussos and
Macklem, 1982; Rochester, 1985 and Huang et al., 2011). The respiratory function of
the diaphragm muscle expands the lungs and pleural cavity, thereby balancing the
difference between abdominal and pleural pressure, which results in thoracic expansion

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(Wilson and Troyer, 2009). Anatomically, the diaphragm is shaped like a dome, with a
convex surface directed to the abdomen and a concave face directed to the chest cavity,
separating the abdominal cavity from the thoracic one. (Getty, 1986 and Dyce et al.,
1987). However, gastrointestinal physiologists are becoming increasingly aware of the
value of this muscle in helping to stop gastric contents from refluxing into the
esophagus. The activities of the diaphragm can diverge during certain events such as
swallowing and emesis, suggesting that the diaphragm muscle has two physiological

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functions (Mark and James, 2002).

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Here, we present the research results on the diaphragm's embryological and
historical aspects, and cite the existing morphological data of the diaphragm in
mammals. In addition, an analysis of the impairment of the diaphragm muscle in

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Duchenne Muscular dystrophy (DMD) is performed. DMD is the most severe and
common X-linked muscle disorder, affecting 1 in each 3,500 male births (Nakamura
and Takeda, 2011). It is caused by a mutation in the DMD gene that encodes a 427-kDa

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protein, called dystrophin, that is located on the short arm of chromosome X at locus
Xp21 (Caromano, 1999). Dystrophin is responsible for stabilizing the myofiber
membrane during muscle contraction through the link that it provides between the

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cytoskeleton and the extracellular matrix (Nakamura and Takeda, 2011). In DMD
patients, limb muscles are severely affected. However, these patients usually die of
cardiac and respiratory failure, but not due to muscle degeneration in the limbs.
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2. Embryology of the diaphragm muscle

The diaphragm muscle originates from the mesoblast during the third week.
These muscles are considered a musculotendinous septum and are formed from four
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embryonic components: the septum transversum, the pleuroperitoneal membranes, the

dorsal mesentery of the esophagus, and the sidewalls of the body. The septum
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transversum, or tendon center, is the source of the central tendon of the diaphragm and
grows dorsally to the ventrolateral wall of the body, forming a semicircular structure
that separates the heart from the liver. Initially, it is located inferior to the pericardial
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cavity and does not separate the abdominal cavity. During the fourth week, after the
head bends ventrally, the septum transversum expands and merges with the ventral
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mesenchyme of the esophagus membranes and with the pleuroperitoneal membranes.

The pleuroperitoneal membranes, in turn, merge with the dorsal mesentery of the
esophagus and the septum transversum to form the primitive diaphragm. After this
merger, the dorsal mesentery of the esophagus constitutes the middle portion of the
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diaphragm, which is called the diaphragmatic pillar. From the ninth to the twelfth
weeks, the lungs and pleural cavities increase in size within the side walls of the body;
during this process, there is a division into two layers: an outer one, which forms the
definitive abdominal wall, and an inner layer, which becomes part of the peripheral
portion of the diaphragm. As further extensions of the developing pleural cavities occur
towards the inner walls of the body, the right and left diaphragm recesses are formed,
which establish the configuration of the diaphragm's dome shape. Through the
development of the pleural cavities in the mesenchyme, an invagination of myoblasts
originates from the third, fourth, and fifth cervical metameres, forming the muscular
portion of the diaphragm innervated by the phrenic nerve (Scheer and Linville, 1965;
Shouchard, 1989 and Moore and Persaud, 2004).
During the fetal developmental stages, the lungs are filled with fluid and do not
participate in gas exchange. Thus, to ensure an effective transition during birth, the

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respiratory system undergoes major changes that include the removal of fluid from the
airways and the alveoli as well as the formation of a functional residual capacity (Bland,
1980; Olver et al., 2004; Siew et al., 2009 and Cannata et al., 2011). These changes
promote increased pulmonary blood flow, decreased intrapleural pressure, lung
compliance, and functional closure in parts of the ductus arteriosus due to increased
blood oxygenation (Rudolph, 1985; Hooper and Harding, 2005; Crossley et al., 2009
and Cannata et al., 2011).

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For these changes to occur, muscular contractions take place that are almost

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fully dependent on the diaphragm muscle, which must, in turn, adapt to the change in
the chest wall and the compliance of the lungs, which are filled with fluid. This change
leads to an increase in the trans-diaphragm pressure to ensure that this adaptation is

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sufficient to inflate the lungs during delivery and to maintain a regular breathing
rhythm. Thus, the muscular fibers of the diaphragm are activated to expel the fluid from
the lungs and stimulate the respiratory function of inspiration and expiration and to

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maintain the negative pressure within the chest cavity (Guslits et al., 1987; Mantilla and
Sieck 2008; Cannata et al., 2011).
However, little is known about the impact of birth itself on the activation

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properties of the fibers within the diaphragm. Maxwell et al. (1983) reported that in
baboons, the phenotype of respiratory muscular fibers changes gradually over the last
trimester of pregnancy and continues into postnatal life. In a study of sheep fetuses,
Cannata et al. (2011) reported that, due to the transition from the fluid-filled to the air-
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filled lung at birth, physical changes in proteins may determine the activation of the
elastic properties of the diaphragm. Thus, this suggests that the initiation of air
breathing at the moment of birth is what produces the rapid change in the force-
generating capacity of the diaphragm muscular fibers, ensuring the perfect perfusion of
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air into the lungs.

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3. The beginnings

From ancient times, Greek philosophers showed a great interest in investigating which
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muscles were responsible for breathing. However, despite this enthusiasm, the earliest
Greek writings on the diaphragm were lost, and much of their historical record was
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reported by followers of the scientists, leading to inconsistencies in the accounts

(Derenne et al., 1994).
The history of the physiology of the diaphragm has been closely linked to the
development of zoology, comparative anatomy, experimental physiology, medicine,
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physics, and philosophy during the Roman Empire. By that time, the Greeks had
managed to achieve an amazing understanding of respiratory mechanics (Derenne et al.,
1994). Aristotle was the first to recognize that breathing involved a specific organ and
mechanism. The concept introduced by Aristotle was that the “use” of respiration was
to cool the innate heat of the body and that the heart was the site of innate heat.
Therefore, Aristotle presented a “cardiocentric” theory, explaining that the lungs expand
due to the heating produced by the heart. As a consequence, the lungs dilated the thorax,
thereby allowing space for the incoming air. According to Aristotle’s theory, the
diaphragm continued to be described as only a division between the upper and lower
parts of the body, without a role in respiration (Harris, 1973; Furley and Wilkie, 1984;
Derenne et al., 1994).
When Alexander’s empire later broke apart, the cultural center was moved to
Alexandria, where medicine enjoyed remarkable progress through the dissection of

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animals and human beings. During this period, Herophilus and Erasistratus (340 B.C.)
introduced two new ideas. The first idea introduced the brain as the center of the
nervous system and suggested that the brain was connected by nerves to different
organs. The second idea introduced the concept of the muscles as being responsible for
force generation (Furley and WilKie, 1984; Derenne et al., 1994).
According to Herophilus, the respiratory cycle consisted of the following components:
expansion of the chest and lungs and contraction of the lungs and thorax, which

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promoted the inflow and outflow of air. Importantly, Erasistratus recognized the

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diaphragm as a muscle that acted in respiration (Derenne et al., 1994).
Later, the Greek physician Claudius Galen (131-120 A.D.) reported that the action of
the diaphragm allowed for the opening of the lower ribs and described that there were

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extraordinary expiratory movements. Vesalius (1514-1564) also supported Galen's
theory, assuming Galen's idea for the role of the diaphragm in the opening of the lower
ribs and adding the idea that during inspiration, the diaphragm muscle rises and then

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falls during expiration. Colombo (1593) reported that the diaphragm muscle allowed
inspiration to occur when the diaphragm moved downwards and that its contraction
occurred on rising. Magendie (1833) then became the main proponent of Galen’s theory

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until Duchenne de Boulogne (1867). Duchenne de Boulogne (1867) established the role
of the diaphragm in breathing and the importance of visceral mass for the diaphragm's
biomechanics, clarifying the function of the diaphragm in breathing (Shouchard, 1989;
Derenne et al., 1994) (Figure I).
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Figure I – Diaphragm history time line

4. Diaphragm in mammals
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In mammals, the diaphragm is covered by peritoneum on the abdominal face

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and by pleura on the endothoracic fascia. During each respiratory cycle, this muscle
changes shape to increase the size of the chest cavity to allow air to enter the lungs.
Therefore, when the contraction of the diaphragm occurs, the dome curvature is reduced
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and its caudal part moves caudally, thus allowing air to enter the chest cavity (Getty,
1986 and Dyce et al., 1987). The respiratory function of the diaphragm is to expand the
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pleural cavity and the lungs, thereby balancing the difference between abdominal
pressure (abP) and pleural pressure (plP), which results in the expansion of the chest
such that the magnitude of the diaphragm descent will result from the interaction among
the diaphragm, lungs, thoracic cage, and abdomen (Wilson and Troyer, 2010).
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Comparing the diaphragm to other skeletal muscles, one can observe that the
other muscles exert a force along an axis, whereas the diaphragm combines muscle
tension and muscle curvature, balancing a pressure load directed perpendicularly to the
muscle axis of the muscle (Kim et al., 1976; Hubmayr et al., 1990; Leduc et al., 2008
and Wilson and Troyer, 2010).
Another point concerns the necessary function of the diaphragm for life, which
is uninterrupted, especially during sleep. Compared to other muscles, one can observe
that the diaphragm is more resistant and recovers from fatigue up to 10 times faster than
other muscles (Gandevia et al., 1983 and McKenzie et al., 2009). Because the
diaphragm muscle has a high oxidative capacity, O2 has a short capillary-to-
mitochondrial diffusion distance in the diaphragm, and the diaphragm muscles have a
velocity of shortening between that of fast-twitch and slow-twitch muscles, all of which

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aid in metabolism during breathing to prevent muscle fatigue (Mizuno, 1991 and Romer
and Polkel, 2008).
The fatigue of inspiratory or expiratory muscles can be produced using resistive
loads, whereas global respiratory muscle fatigue can be achieved using voluntary
hyperpenea. Factors such as a reduction of blood flow in the diaphragm may promote an
insufficient transport of O2, thereby increasing the probability of fatigue (Romer and
Polkel, 2008).

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Morphologically, one can observe that the diaphragm differs between mammals.

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Gordon et al. (1989) and Boriek et al. (2001; 2002) reported that in small mammals,
such as dogs and cats, the diaphragm muscle has short, muscular fibers that are arranged
into fascicles, with a discontinuous architecture and a large number of intermediate

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fibers between the insertion tendons near the tendon center ("V" shaped).
In white-eared opossums (Didelphis albiventris), the anatomical features
observed in the diaphragm are similar to those present in domestic and laboratory

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animals. Laboratory animals display a “V”-shaped tendon center and symmetry of
muscle fascicles similar to those of rabbits (Oryctolagus cuniculus), the common
marmoset (C. jacchus) and albino rats (Pompeu et al., 1992; Amorim Júnior et al., 1993,

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Cassel et al., 2001 and Lessa et al., 2012).
Lessa et al. (2012), in a morphological study of the common marmoset, reported
that these muscles are dome-shaped and, in transverse section, they separate the
abdominal from the chest cavities. Structurally, the central part could be seen to contain
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the “V”-shaped tendon center and the vena cava caudal foramen. The authors reported
that the muscular portion was at the periphery with the presence of two openings; i.e.,
the esophageal hiatus and the aortic gap, for the passage of the aorta, azygous vein, and
thoracic duct. Microscopically, the same authors described that the muscle fibers were
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organized, with a preserved diameter and basal ganglia. In a comparative study of the
common marmoset C. jacchus and the white-headed marmoset, Lessa et al. (2012)
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reported that the white-headed marmoset (C. geoffroyi) presented the same
morphological characteristics of the common marmoset. The authors also noted that
these fibers had a cylindrical shape following examination by scanning electron
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microscopy. In the fascicle count, they found no significant difference between males
and females. In C. jacchus, a discontinuous and tortuous architecture can be observed
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arranged into rows perpendicular to the longitudinal axis and grouped into fascicles,
which ensure even timing in the contraction of the long muscle (English and Weeks,
1987; Loeb et al., 1987 and Gaunt and Gans, 1990).
Unlike the above animals, the species Trichechus manatus latirostris (manatee)
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presents an "I"-shaped tendon center. This center attaches to the epiphysis of the bone
and extends ventrally into the vertebral bodies, forming two elongated hemi diaphragms
that are located at the dorsal section. Another species that also differs from the other
mammalian species is Cavia porcellus (guinea pig), which presents an "U"-shaped
tendon center (Rommel and Reynolds, 2000; Cassel et al., 2001 and Lessa et al., 2013).
However, the vast majority of mammals present a "V"-shaped tendon center,
while few animals have the "I" and "U" shapes, indicating that there can be variations in
the shape of the diaphragm in different mammals.
The contractile properties of the respective diaphragm muscle determine their
characteristic function of inspiration. Their contractions are rhythmic and counter the
elastic and resistive forces of the diaphragm muscle. After ceasing contraction, the
diaphragm relaxes and returns to a relative resting position, which is determined by the
equilibrium of forces of the lung and the chest wall. In contrast to limb muscles, which

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also rhythmically contract during locomotion to overcome the forces of inertia in the
resting position, the diaphragm stands out because it contracts in a manner similar to the
heart, which is rhythmically repetitive throughout life (Rochester, 1985). Such
contractions are performed because of the composition of their muscle fibers, which are
more resistant to fatigue. Mammals generally possess 55% slow contraction fibers,
which are oxidative and are highly resistant to fatigue; 25% fast contraction fibers,
which are glycolytic oxidative and intermediate but are relatively resistant to fatigue;

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and 20% glycolytic fast contraction fibers, which are susceptible to fatigue. In dogs and

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rats, the glycolytic fast contraction fibers are absent, whereas in other mammals, these
fibers represent 20 - 40% of all diaphragm fibers (Faulkner et al., 1979; Rochester,
1985).

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In laboratory animals, such as the mouse and rat, the proportion of fast fibers in
the respiratory muscles is greater than that in human beings or in large mammals, thus
reflecting the idea that volume can decrease from small to large animals (Blank et al.,

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1988; Hodge et al., 1997 and Polla et al., 2004).
The diaphragm muscle fibers generally have a smaller cross section than limb
muscles do. Because the number of capillaries around each fiber is similar, the diffusion

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distance is reduced, thus making oxygen delivery in the diaphragm more efficient than
in the other muscles (Mizzuno, 1991).

5. Muscular dystrophies
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Some muscular diseases result from mutations in the genes encoding sarcolemic,
sarcomeric, and cytosolic muscle proteins, which initiate a process of progressive
muscular degeneration and, consequently, a progressive loss of motor skills (Bergman
et al., 2002 and Vainzof et al., 2008). Among the muscles that are affected in muscular
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dystrophies, the diaphragm ends up taking prominence because the late respiratory
failure observed in patients with Duchenne muscular dystrophy (DMD), Becker
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muscular dystrophy (BMD), and waist-limb dystrophy is considered the main "causa
mortis". In fascio-scapular-humeral dystrophies and in Ulrich's congenital myopathy,
respiratory failure occurs earlier, due to the more rapid death of muscle fibers (Gozal,
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2000; Mercuri et al., 2002; Padberg et al., 2002 and Polla et al., 2004). In human beings,
a mutation in the dystrophin gene can cause two clinical phenotypes, which differ in the
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age at which the patient loses her/his ability to walk, as in DMD and BMD. In DMD,
boys become wheelchair users prior to 14 years of age, whereas in BMD, patients
become wheelchair users after 16 years of age (Malhotra et al., 1988; Hoffman et al.,
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1998; Prior and Bridgeman, 2005 and Kornegay et al., 2012). In these patients, muscle
hypertrophy is attributed to the deposition of fat and connective tissue, and is thus
named pseudo-hypertrophy. However, some imaging studies have demonstrated true
hypertrophy in some individuals (Jones et al., 1983; Cros et al., 1989; Kornegay et al.,
2012).
DMD has been described as the most severe and common X-linked disorder,
affecting 1 in 3,500 male births (Nakamura and Takeda, 2011). It is caused by a
mutation in the DMD gene that encodes a 427-kDa protein called dystrophin, which is
located on the short arm of chromosome X at locus Xp21 (Caromano, 1999).
Dystrophin represents 0.002% of the striated muscle cell mass and is localized
to the sarcolemma, where it forms a dystrophin-glycoprotein complex (DGC) composed
of dystroglycan, sarcoglycan, and syntrophin - dystrobrevin complexe. The DGC is
responsible for membrane stabilization during contraction; however, this complex
(DGC) has not been elucidated in the literature, though it may transduce signals from

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the extracellular matrix to the muscle cytoplasm via intracellular signaling molecules
(Yeung et al., 2005; Shelton and Engvall, 2005; Nakamura and Takeda, 2011 and Lessa
et al., 2013).
The dystrophin gene contains 79 exons, and its full length comprises four
domains: the N-terminal domain, the rod domain, a cysteine-rich domain and a C-
terminal domain (Koenig et al., 1988 and McGreevy et al., 2015). These domains of
dystrophin bind to filamentous (F)-actin via its N-terminus and to a cluster of basic

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repeats 11–17 in its rod domain. Dystrophin binds dystroglycan via its cysteine-rich

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domain, and it binds α-dystrobrevin and α-syntrophin via its C-terminal domain (Jung et
al., 1995; Yang et al., 1995; Sadoulet-Puccio et al., 1997; Amann et al.,1999; Nakamura
and Takeda, 2011 and Fairclough, Bareja and Davies 2011). It has been proposed that

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dystrophin acts to protect the myofibers from contraction-induced stress due to the
elasticity and flexibility of dystrophin's large central rod domain (Petrof et al., 1993).

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In DMD, muscle degeneration occurs because the absence of dystrophin makes
the sarcolemma vulnerable to damage-inducing factors (Petrof et al. 1993). The stress
factors of the continuous degeneration and regeneration of muscle tissue have been
suggested to be responsible for elevated levels of fibrosis (Morrison et al. 2000;

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Fairclough, Bareja and Davies 2011).
In mammals, it is possible to observe a spontaneous mutation in the dystrophin
gene in 3 animals with distinct muscular dystrophy phenotypes: the X-linked muscular
dystrophy (mdx) mouse, the canine model of the Golden Retriever muscular dystrophy
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(GRMD), and the feline model of hypertrophic muscular dystrophy (FHMD) (Bulfield
et al., 1984; Winand et al., 1984; Vos et al., 1986; Sharp et al., 1992; Duclos and Straub,
1998; Gillis, 1999 and Kornegay et al., 2012).
The most common dystrophin-deficient animal model used for DMD research is
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the mdx mouse (Bulfield et al., 1984). A mutation in these animals occurs in exon 23.
However, though they are dystrophin deficient, these animals have a mild DMD
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phenotype. In mdx mice, the peak of degeneration occurs from 3-6 months. After this
period, the limb muscles exhibit a great regeneration. However, the diaphragm muscle
shows a progressive degeneration (Stedman et al., 1991 and McGreevy et al., 2013).
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At 3 months of age, the mdx diaphragm and intercostal muscles have mild
multifocal inflammation in endomysium and fibrosis. At 6 months, this inflammation
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stabilizes in the intercostal muscles and becomes noticeable in the diaphragm, which
indicates that although there is a milder clinical phenotype, the mice present a severe
involvement of the diaphragm, being the main “causa mortis” in DMD (Ishizaki et al.
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2008; Huang et al. 2011).

Canine GRMD (Sharp et al. 1992) is a widely used model for presenting
progressive muscular weakness and the subsequent atrophy caused by a mutation in
exon 7, which results in the absence of dystrophin, a significant increase in creatine
kinase (CK) in these animals at 1 and 2 days of life and severe damage to the diaphragm
muscle that results in respiratory failure (Sharp et al. 1992; Nakamura and Takeda
2011). Although GRMD is a useful model for DMD, it requires a high cost of
maintenance and treatment. The large size of these animals hampers their manipulation,
and when these animals are used in experiments, they engage emotionally with the
handler and vice versa.
Feline FHMD presents as persistent hypertrophy and other deleterious
consequences due to difficulties with eating. In these animals, the hypertrophy of the
tongue base and regurgitation compromise the function of this organ due to the hypo-

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motility of the esophagus or obstruction at the level of the hypertrophied diaphragm

(Winand et al., 1984; Vos et al., 1986 and Kornegay et al., 2012).
Microscopically, the diaphragm muscles in these three animal models of DMD
present with robust perimysial inflammatory infiltrates, and the muscle cells display
central nuclei and fibers with various diameters (Winand et al., 1984; Vos et al., 1986;
Kornegay et al., 2012; Abreu et al., 2012 and Lessa et al., 2012).
Morphologically, the diaphragm muscles in the DMD animal models have

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similar characteristics, such as hypertrophy of muscle fibers, regeneration and necrosis

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of fibers, mild endomysial fibrosis and severe muscle atrophy (Bergman et al., 2002;
Nguyen et al., 2002 and Abreu et al., 2012).
Although muscular dystrophy severely affects a number of different limb

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muscles, humans and animals that are affected by DMD do not die from a failure of
limb muscles. Instead, they die due to diaphragm and/or cardiac failure, which clearly
shows the importance of the diaphragm muscle as a vital muscle for all mammals.

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Conclusion

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The diaphragm muscle in mammals has been studied since the early days of
zoology, comparative and experimental anatomy, physiology, medicine, physics, and
philosophy. Many diverse morphological and functional theories on the diaphragm have
been proposed throughout history, until the true role of the diaphragm was defined.
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However, despite the evolution of our knowledge on the morphology and the
importance of the diaphragm as a unique and vital respiratory muscle, descriptive data
and information about the morphological changes related to age are still missing. For
example, it was observed in this review that the diaphragms of many mammals have not
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been described. This fact suggests that the enthusiasm for the study of the diaphragm
that we have observed since the research of Aristotle has waned, despite advances in
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science, such as improved dissection and processing techniques, as well as greater

knowledge and access to animals for investigation. We observed that there are more
morphological descriptions of the diaphragm muscle in animals that are typically used
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in scientific studies. These data can help researchers because this muscle is directly
linked to respiration, which is a vital process in the life of mammals. This information
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about the mammalian diaphragm has great value and contributes data patterns that
researchers can use as references to validate studies using animals as clinical models.
Regarding DMD, this review provides researchers with an overview of the
morphological data of the diaphragm in combination with a description of this muscle
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because these morphological data transcend the animal morphological data described in
the conventional literature.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All of the authors contributed equally to the production of this work.

Acknowledgments

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We acknowledge the assistance of the Foundation for Support for Research of the State
of São Paulo (FAPESP) and CAPES for scholarship for Lessa TB.

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