Muscle - Dr Sanjana ravindra

Dr.Sanjana.Ravindra

Rajarajeswari Dental College

Bangalore

SESSION 1 SESSION 2

Introduction

Embryology

Types

Skeletal muscle

Smooth muscle

Cardiac Muscle

Muscles of Head and Neck.o Embryologyo Muscles of tongueo Muscles of masticationo Muscles of pharynx and

Larynxo Muscles of Soft palate.o Muscles of Facial Expressiono Muscles of Neck Applied Aspect Treatment Modalities Pharmacological Management.

Muscle-Tissue that is characterized by aggregation of

cells, whose primary function is to produce contraction and

allow the movements of parts and organs of the body.

The term muscle is derived from the Latin musculus meaning

"little mouse" perhaps because of the shape of certain

muscles or because contracting muscles look like mice

moving under the skin

Nearly half of body weight is

muscle weight.

The 206 bones of skeletal

framework are covered by nearly

650 muscles.

Muscles are connected to

bones by tendons - tough

elastic type bands of

connective tissue.

Bones are connected -

ligaments

TENDON : Fibrous cord of connective tissue continuous with the fibres of a muscle and attaching the muscle to bone or cartilage.

CARTILAGE : Specialized flexible connective tissue including the joints between bones, the rib cage, the ear, the nose, the

bronchial tubes and the intervertebral discs. It is not as hard and rigid as bone, but it is stiffer and less flexible than muscle.

Myogenesis

Muscle tissue

Derived from

Paraxial Mesoderm

Divided along the embryo’s lenght

Somites

Sclerotome Dermatome Myotome

Myotome

Epimere Hypomere

Epiaxial muscles Hypaxial muscles

Dorsal rami of the spinal nerves

Innervated by

Ventral rami of the spinal nerves

Innervated by

Depending On The Striations-

1. Striated

2. Non- Striated

Depending Upon The Nature of Control-

1. Voluntary

2. Involuntary

Depending Upon the Distribution-

1. Skeletal

2.Smooth

3. Cardiac

Summary of the above classification

1. Skeletal – striated, voluntary

2. Cardiac – striated, involuntary

3. Smooth – non-striated, involuntary

SKELETAL MUSCLE

Gives shape and structure to

the body

Enables to maintain erect

posture

Brings about movement

Helps to communicate

feelings/expressions

Determines the flow of

blood in the arteries

Move the food through the

digestive tract

Regulates air flow in lungs

In excretion and

reproduction

Soft and fragile, yet can exert

tremendous power- its because thousands

of their fibers are bundled together by

connective tissue which provides

strength and support to the muscle as a

whole.

Mainly made up of 75% of water, 20%

proteins and 5% organic substances.

Involuntary muscles which are attached

to the bones of the skeleton .

Derived from somites, somatomeres and from

mescenchyme of the region.

In embryonic development each skeletal muscle fiber

arises from the fusion of a million mesodermal cells

called as myoblasts, of which few cells called satellite

cells which persists later in life fuse and cause

regeneration.

The outermost layer encircling the whole muscle is the epimysium.

Perimysium surrounds groups of 10-100 individual muscle fibers separating them into bundles called as fascicles which are large enough to be seen with the naked eye.

Each individual muscle fiber is separated from one another by the endomysium.

Made up of many fibrils called Myofibrils.

Each myofibril is 1-2 micrometer in diameter, lies parallel

to one another and are ‘striated’.

Long, cylindrical fibres.

Diameter 10-60 um.

Multinucleated.

Nuclei are elongated and lie periphery of the fibre, just under sarcolemma.

The cytoplasm called as sarcoplasm contains glycogen which can be split into glucose used for ATP synthesis.

Sarcoplasmic reticulum are fluid filled sacs encircling each myofibril.

Inside each myofibril -

filaments -thick and thin

filaments.

They are arranged in

compartments called as

sarcomeres which are the basic

functional unit of a myofibril.

Filaments overlap causing zones

and bands .

The various bands are present in Myofibrils.

The dark band ‘A’ and light band ‘I’.

Middle of ‘A’ band is transvered by a lighter band called

‘H’ band.

Running across the middle of each of ‘I’ band is ‘Z’

band.

Running through ‘H’ band a thin dark line ‘M’ band.

Contractile proteins consists of Thin and thick filaments.

Thin Filaments: Actin in its monomer form is globular and has sites for

attachments witho Myosino Troponino Various ionso ATP.On actin :1. Troponin - attached.2. Tropomyosin - attached.3. head of the myosin - attached - muscle contracts

Thick Filament:

Myosin has a head and a tail.

Myosin functions as a motor protein, push and pull

their cargo to achieve movement by converting

chemical energy in ATP to mechanical.

Nerve impulses traveling down the motor neurons of

the sensory-somatic branch of the nervous system

cause the skeletal muscle fibers to contract.

Neuromuscular junction - The junction between the

terminal of a motor neuron and a muscle fiber.

Motor nerve stimulated – Action

Potential – approaches NMJ –

increased permiability of Ca++

ions – penetrates prejunctional

membrane.

Causes bursting of Ach – Ach released.

Ach crosses pjm – Ach + receptors = End Plate Potential.

Action Potential develops –Muscle contraction.

To ilustrate the relaxed and contracted states of muscle. Note : the H

zone has almost disappeared in the contracted state

Isotonic contraction : Contraction occurs when the

tone or tension within a muscle remains the same but

the length of the muscle changes.

Isometric contractions: Contraction occurs when a

muscle is stimulated adequately but is prevented to

shorten.

Here, muscle becomes hard,hot and expands but does

not shorten.

Its used to evaluate the activity of an orofacial

muscle on an electromyogram.

The electrical activity is the easiest to record.

Electrodes are inserted into the skin surface or into

the body of a muscle.

They record the membrane potential from several

fibers in a single motor unit which arrives at

different times.

This gives useful information

about when a muscle is active

and defines when activity begins

and ends but its impossible to

know how much activity is being

missed.

Irritability : ability of the muscle to respond to stimulus either mechanical, electrical or thermal.

Contractility and relaxation : capacity of the muscle to develop tension between its ends “in contraction” and can release its tension “in relaxation”

Distensibiity : Ability of muscle to be lengthened or stretched when an outside force is applied to it upto certain limit(physiological limit)

Elasticity : Ability of the muscle to recoil to its original length when an outside force is released or removed.

The name “Smooth muscle” - lacks

the visible striations that are

noticeable characteristic of other 2

muscle.

Also called as Plain Muscle

Located in the walls of internal organs.Hence, called as “VISCERAL MUSCLE”.

Seen in the walls of :

Stomach

Intestine

Urinary bladder

Uterus

Ateries

Veins

Base of hair follicle

Iris of the eye

Elongated in shape with

tapering ends .

The ends overlap, so that they

form bundles, sheets or cords

The cell membrane of each smooth

muscle fiber is called Sarcolemma.

Each cell contains a single rod-

shaped nucleus which is located in

the central thick portion.

The sacrcoplasm contains a

contractile apparatus of thick and

thin filamentus

The sarcoplasm contains :

Mitochondria

Endoplasmic reticulum

Ribosomes

Golgi apparatus

Glycogen granules.

Made up of small bundles of interdigitating thick and

thin filaments that are irregularly shaped and randomly

arranged.

Therefore, under EM individual myofibrils are striated

but striations do not form a regular pattern.

Myofibril

Thick filament Thin filament

Myosin Actin (fundamental)

Tropomyosin

The contractions in smooth muscle have a longer

duration – more variable – produce less tension than in

skeletal muscle.

Types :-

1. Single unit Smooth muscle

2. Multi unit Smooth muscle

Does not occur in smooth muscle.

Instead the autonomic nerves make diffuse junctions

that secrete neurotransmitter into the matrix coating of

smooth muscle a few micrometers away from the

muscle fiber.

Also the axons supplying them do not have terminal

buttons but varicosities on their terminal axons that

contain the vesicles containing the Neurotransmitter

Apart from Ach, norepinephrine can also be released.

Instead of synaptic clefts, smooth muscles have contact

junctions

Tone or Tonus - Shows continuous irregular

contractions.

It contracts when stretched in the absence of any

extrinsic innervation.

Denervation Hypersensitivity

Involuntary, striated muscle that is found in the walls

of the heart

Called as “ELECTRICAL SYNCYTIUM”

Muscular wall of the heart - myocardium

Forms a thick middle layer between the outer

epicardium layer and the inner endocardium

layer.

Each cell is about (100 * 10)

micrometer size, cell membrane –

sarcolemma

Single nucleus.

Cells- cross striated – branched –

interdigitate with each other

Each cell, at the end – intercalated

disc – sarcolemmas of two muscle

cell come very close to each other.

S K Chaudhari.Concise Medical Physiology 6th

edition NCBA; 2011

Intercalated disc

Fascia adherens /

Desmosomes.

Gap junction

Highly vascular.

Shows well developed Sarcoplasmic reticulum with

cytoplasam

mitochondria

rich in glycogen

Same as Skeletal muscle.

S K Chaudhari.Concise Medical Physiology 6th edition NCBA; 2011

S K Chaudhari.Concise Medical Physiology 6th edition NCBA; 2011

Myofibril

Thick filament Thin filament

Myosin Actin (fundamental)

Tropomyosin

Troponin

Development:

1.Muscular system develops

from intra-embryonic

mesoderm.

2. Around 4th wk of IUL, the

neural crest cells migrate into

the future head & neck

regions and pharyngeal arches

begin to develop.

Inderbir Singh. Human Embryology 5th edition Jaypee

Brothers Medical Publishers;2009

3. 1st pair of pharyngeal arches serves as the primordium of the jaws and develops into two prominences-

a. maxillaryb. mandibular

4. Maxillary prominence gives rise to upper jaw, zygomatic bone and squamous part of the temporal bone.

5. Mandibular prominence forms the lower jaw.

Inderbir Singh. Human Embryology 5th edition Jaypee Brothers

Medical Publishers;2009

ARCH MUSLES OF ARCH NERVES OF ARCH

1st arch or mandibular arch • Muscles of mastication

• Tensor tympani

• Tenor palati

• Mylohyoid

• Anterior belly of digastric.

Mandibular nerve.

2nd arch or Hyoid arch • Muscles of face.

• Platysma.

• Stapedius.

• Stylohyoid.

• Auricular muscle.

• Occipito frontalis.

• Posterior belly of digastric.

Facial nerve

3rd arch • Stylopharyngeus. Glossopharyngeal nerve

4th arch Muscles of pharynx

Soft palate

cricothyroid

Superior laryngeal

6th arch Muscles of larynx Recurrent laryngeal

Action

Open the glottis or abductors of vocal cord

Close the glottis or adductors of vocal

cord

Tense the vocal cords

Relax the vocal cord

Open the inlet of larynx

Close the inlet of larynx

It is a movable , muscular fold, suspended from the

posterior border of the hard palate.

Muscles include :

1. Tensor palati (tensor veli palatini)

2. Levator palati (levator veli palatini)

3. Musculus uvulae

4. Palatoglossus

5. Palatopharyngeus

ORIGIN INSERTION INNERVATION FUNCTION

Scaphoid fossa of

sphenoid bone

Palatine

aponeurosis

Mandibular nerve Tightens the soft

palate

Opens the auditory

tube to equalize air

pressure between

the middle ear and

the nasopharynx

Muscles of Soft Palate


Petrous part of

temporal bone

anterior to opening

of carotid canal

Superior surface of

palatine aponeurosis

Vagus nerve Elevatessoft palate

and closes the

pharyngeal isthmus



Superior surface of


Pharyngeal wall Vagus nerve Pulls up the wall of

the pharynx and

shortens it during

swallowing



Inferior surface of


Lateral margin of

tongue

Vagus nerve Depresses palate,

moves palatoglossal

arch towards

midline, elevates

back of the tongue



Posterior nasal

spine

Mucous membrane

of uvula

Vagus nerve Elevates uvula


Each half of the tongue contains two types of muscles i.e., four intrinsic and four extrinsic muscles.

EXTRINSIC MUSCLES :

Genioglossus M

Styloglossus M.

Palatoglossus M.

Hyoglossus M.

INTRINSIC MUSCLES :

Superior longitudinal M.

Inferior longitudinal M.

Verticalis M.

Transverse M.

Origin. Insertion. Artery. Nerve. Actions.

Symphysis

mentii

Dorsum of

tongue and

body of hyoid.

Lingual artery Hypoglossal

nerve

Protrudes tongu

Depress centre

of tongue

TONGUE MUSCLES

Origin Insertion. Artery. Nerve. Actions.

Hyoid bone Side of tongue Lingual artery Hypoglossal Depresses and

retracts the

tongue.

TONGUE MUSCLES


Styloid process

of temporal

bone

Tip and sides of

tongue.

Lingual. Hypoglossal. Retraction and

elevation of

tongue.

TONGUE MUSCLES


Palatine

aponeurosis.

Tongue Lingual. Vagus nerve. Raising the

back part of the

tongue.

TONGUE MUSCLES


Close to the

epiglottis from

the median

fibrous septum.

Edges of the

tongue.

Lingual. hypoglossal Retracts the

tongue with the

inferior

longitudinal

muscle,making

the tongue

short and thick.

TONGUE MUSCLES


Root of the

tongue

Apex of the

tongue.

Lingual Hypoglossal Shortens the

tongue and

turns the apex

under.

TONGUE MUSCLES


Median fibrous

septum

Sides of

tongue.

Lingual. Hypoglossal Makes the

tongue narrow

and elongated.

TONGUE MUSCLES


Submucosal

fibrous layer of

dorsum of

tongue.

Inferior surface

borders of

tongue

Lingual Hypoglossal Flattens and

broadens the

tongue.

TONGUE MUSCLES

Principle muscles

Masseter

Temporalis

Medial Pterygoid

Lateral Pterygoid

Accessory muscles

Anterior digastric

geniohyoid

mylohyoid

Origin Insertion Nerve

Supply

Actions

a. Superficial layer: from anterior

2/3 of lower border of

zygomatic arch and adjoining

zygomatic process of maxilla

b. Middle Layer: from anterior 2/3

of deep surface and posterior

1/3 of lower border of

zygomatic arch

c. Deep layer : from deep surface

of zygomatic arch.

a. Superficial layer:

into lower part of

lateral surface of

ramus of

mandible

b. Middle layer:

into upper part of

ramus.

c. Deep part: into

upper part of

ramus and

coronoid process

of the mandible.

Massetric

nerve

Elevates

the

mandibl

e to

close the

mouth to

bite.

Origin Insertion Nerve Supply Actions

a. Temporal fossa,excluding

zygomatic bone

b. Temporal fascia.

a. Margins

and deep

surface of

coronoid

process.

b. Anterior

border of

ramus of

mandible.

Two deep

temporal

branches from

anterior

division of

mandible nerve

a. Elevates

mandible.

b. Posterior

fibres

tetract the

protruded

mandible.

c. Helps in

side to side

grinding

movement.


a. Upper hand: from

infratemporal surface and

crest of greater wing of

sphenoid bone.

b. Lower head: from lateral

surface of lateral pterygoid

plate.

a. Pterygoid

fovea on

the anterior

surface of

neck of

mandible.

b. Anterior

margin of

articular

disc and

capsule of

TMJ

A branch from

anterior

division of

mandibular

nerve

a. Depress

mandible to

open

mouth,

b. Protrude

mandible

c. Left Lateral

pterygoid

and right

medial

pterygoid

turn the

chin to left

side as part

of grinding

movements.


a. Superficial head : from

tuberosity and adjoining

bone.

b. Deep head : from medial

surface of lateral pterygoid

plate and adjoining process

of palatine bone.

Roughened

area on the

medial surface

of angle and

adjoining

ramus of

mandible,

below and

behind the

mandibular

foramen and

mylohyoid

groove.

Nerve to

medial

pterygoid,

branch of the

main trunk of

mandibular

nerve.

a. Elevates

mandible.

b. Helps

protrude

mandible.

c. Right

medial

pterygoid

with left

lateral

pterygoid

turn the

chin to left

side.

Origin – anterior belly from digastric fossa of mandible ,

posterior belly from mastoid notch of temporal bone.

Insertion – intermediate tendon

Innervation –

• anterior belly by mylohyoid nerve ,

• posterior belly by facial nerve.

Action – depresses the mandible , elevates the hyoid bone

Origin – mylohyoid line of mandible

Insertion – hyoid bone , median raphe.

Innervation - mylohyoid nerve

Action – elevates the floor of the mouth , depression of

mandible

Origin – inferior mental spine (genial tubercle) of the

mandible

Insertion – anterior surface of the body of hyoid bone.

Innervation – first cervical nerve

Action – elevates the hyoid bone , depress the mandible when

hyoid is fixed

Facial Muscles. Muscles Involved.

Smiling and Laughing Zygomaticus major.

Sadness Levator labii superioris

Levator anguli oris.

Grief Depressor anguli oris.

Anger Dilator nares

Depressor septi.

Frowning Corrugator supercelli

Procerus.

Horror,terror,fright Platysma

Surprise Frontalis

Doubt Mentalis

Grinning Risorius

SMILING AND

LAUGHING

Zygomaticus major: Draws

cheek back and corner of mouth

open

Muscles of Facial Expression

Platysma: Raises skin

of neck and lowers

corner of mouth


Mentalis: Raises chin,

protrudes lower lip,

and decreases depth of

lower vestibule.


Corrugator supercilii:

Draws eyebrow

medially


Frontalis :Raises

forehead, pulls scalp

backward


Muscle dystrophy- primary progressive

degeneration of skeletal muscles

Myotonia – failure of muscle relaxation after cessation

of voluntary contraction

Myositis- inflammation of muscle tissues

Muscle hypertrophy – increase in size of individual

muscle fibres ( macroglossia, masseter hypertrophy)

Applied Anatomy

Is an autoimmune disorder, results in abnormality at

the neuromuscular junction, resulting in prevention of

muscle fibre contraction which in turn causes weakness

of skeletal muscle.

Usually occurs in masseter and muscles of face neck.

Initial symptoms are weakness of eye muscles, later

difficulty in chewing, talking and swallowing occur.

Applied Anatomy

DEFINATION :

Disease of the CNS characterized by intense activity of the motor

neuron, resulting in SEVERE MUSCLE SPASM.

ETIOLOGY:-

CLOSTRIDIUM TETANI.

Applied Anatomy

CLINICAL FEATURE :

Pain and stiffness in the jaws and neck muscles. Causing

muscle rigidity, trismus and dysphasia.

TREATMENT –

1. antimicrobial drugs

2. active & passive immunization

3. anticonvulsants if indicated.

Applied Anatomy

Defination

Prolonged tetanic spasm of the jaw muscles by which normal opening of the

mouth is restricted.

Causes

a. INTRACAPSULAR : condylar fracture

arthritis

b. PERICAPSULAR : dislocation

infection

inflammation

irradiation

c. MUSCULAR : tetanus

tmj – dysfunction syndrome

d. OTHERS : OSMF

systemic sclerosis

fractures

Applied Anatomy

C/F : 1. spasm of the jaw muscles2. difficulty in opening the mouth3. difficulty in eating and swallowing4. difficulty in maintaining good oral hygiene.

TEST : THREE FINGER TEST……….

TREATMENT : 1. remove the cause2. apply moist heat to masticatory muscles

during rest breaks3. gently massage the masticatory muscles4. NSAIDs5. Warm saline rinses

Applied Anatomy

Defination :

subconscious nocturnal clenching or grinding of the teeth

There is a brief rhythmic–strong contraction of the jaw muscles during eccentric lateral jaw movements ; or in maximum intercuspation.

Cause : 1.emotional disorders

2. stressful events

3. anxiety

C/ F :

facial pain, headache, earache and pain in the region of M.O.M which is worse in the mornings.

wearing away of tooth.

lead to masseter muscle hypertrophy and hyperactivity of lateral pterygoid muscle.

Applied Anatomy

TREATMENT :

1. evaluate / render psychological counseling and remove the cause of stress.

2. occlusal splints worn during sleep to reduce the signs of bruxism.

3. coronoplasty

4. application of moist heat

Applied Anatomy

Responsible principal factor – masticatory muscle

spasm

Signs and symptoms – pain ,muscle tenderness ,

clicking noise in TMJ and limitation of jaw opening

Negative characteristics – absence of evidence of

organic changes in joint, lack of tenderness in joint

Applied Anatomy

involuntary tonic muscle contraction associated with

local metabolic conditions within the muscle tissue.

CAUSE : 1. continued deep pain input

2. muscle fatigue

3. idiopathic

Applied Anatomy

Clinical feature :

1. structural dysfunction : marked reduction in movements

2. pain at rest which increases with function

3. affected muscle is firm and painful to palpate

4. general feeling of muscle tightness.

Treatment :

1. manual massage

2. inj of LA into the muscle and then passively stretch to the

fullength

3.correct the cause e.g. FATIGUE

4. injection of BOTULINUM TOXIN as it is a

NEUROTOXIN which causes irreversible presynaptic blockade

and thus muscles no longer contract.

5. deep massage

6. muscle conditioning

7. relaxation techniques

Applied Anatomy

Several hours after the death the muscles are stiffened.

Fresh supply of ATP becomes impossible and

detachment of myosin from actin cannot take place.

Muscle remains in rigor, until muscle proteins are

destroyed which results from autolysis caused by

enzymes.

Applied Anatomy

chronic, continuous muscle pain originating predominantly from the CNS and effects are felt peripherally on the muscle tissue, secondary to neurogenic inflammation.

CAUSE : 1. prolonged presence of pain substances in the muscle tissue.

2. local muscle soreness3. MPDS

C / F: 1. structural dysfunction2. significant pain at rest which increases with function3. general feeling of muscle tightness4. on prolonged duration, it may induce muscle atrophy.

TREATMENT :NSAIDs, Moist heat application.

Applied Anatomy

General acute painful condition associated with swelling

of Muscles of mastication, decreasing the range of

movements.

CAUSE : trauma, infection, repeated mandibular

block – myositis of the medial pterygoid.

TREATMENT : 1.treat the underlying cause

2. restore the range of movements

after pain and swelling decreases.

Applied Anatomy

It is recognized as UNILATERAL PARESIS OF

FACIAL NERVE.

It begins with slight pain around one ear, followed by

abrupt paralysis of facial muscles on that side of the

face.

There is MASSETER WEAKNESS and thus the

FOOD IS RETAINED IN THE SULCUS.

Applied Anatomy

Facial expression changes .

Creases of the forehead are flattened.

Impaired blinking

Loose of taste, drooling of saliva on one side of the face.

TREATMENT;

1. Systemic corticosteroids.

2. Physiotherapy.

3. PLASTIC SURGERY- create anastomosis between facial nerve and hypoglossal nerve.

Applied Anatomy

Beginning at about 30 years of age,

Progressive loss of skeletal muscle mass that is largely

replaced by fat.

Accompanying the loss of muscle mass, there is a

decrease in maximal strength and a diminishing of

muscle reflexes

Applied Anatomy

Drugs that reduce the muscle tone.

Classification :

Drugs acting peripherally at NMJ :-

Gallamine, Pancuronium, Atracurium.

Drugs acting centrally :

Diazepam, Baclofen, Mephenesin

Drugs acting directy on muscle :-

Dantrolene.

Uses of Peripherally Acting Relaxants :

Adjuvant to anaesthesia.

In electroconvulsive therapy

In Spastic disorders :overcome spasm of tetanus,

athetosis and status epilepticus.

Uses of Centrally acting Muscle Relaxant :

Musculoskeletal disorders like

Muscle strain,sprains,myalgias

Uses of Directly acting Muscle Relaxant

In spastic disorders and Malignant hyperthermia.

Heat and ice are the two most common types of

passive, non-invasive, and non-addictive therapies.

Induces vasodilation: drawing blood into the target tissues. Increased blood flow delivers needed oxygen and nutrients, and removes cell wastes. The warmth decreases muscle spasm, relaxes tense muscles, relieves pain, and can increase range of motion.

Superficial heat is available in many forms, including hot and moist compresses, dry or moist heating pads, hydrotherapy, and commercial chemical/gel packs.

Heat packs in any form should always be wrapped in a towel to prevent burns. Punctured commercial heat packs should be immediately discarded, as the chemical agent/gel will burn skin.

Cold therapy produces vasoconstriction, which slows

circulation reducing inflammation, muscle spasm, and

pain.

Superficial cold is available in many forms, including a

variety of commercial cold packs, ice cubes, iced

towels/compresses, and forms of hydrotherapy.

The duration of cold therapy is less than heat therapy;

usually less than 15 minutes. The effect of cold is

known to last longer than heat.

Cold or ice should never be applied directly to the skin.

A barrier, such as a towel, should be placed between

the cold agent and the skin's surface to prevent skin and

nerve damage.

Punctured commercial cold packs should be

immediately discarded, as the chemical agent/gel will

burn skin.

use of electric current produced by a device to

stimulate the nerves for therapeutic purposes.

TENS devices available to the domestic market are

used as a non-invasive nerve stimulation intended to

reduce both acute and chronic pain.

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http://teachmeanatomy.info

Inderbir Singh. Human Embryology 5th edition Jaypee Brothers Medical Publishers;2009.

Inderbir Singh.Textbook of Human Histology 5th edition Jaypee Brothers Medical Publishers;2009.

S K Chaudhari.Concise Medical Physiology 6th edition NCBA; 2011.

Grays anatomy: Peter L Williams, Roger Warwick, 37th edition

B.D Chaurasias; Human Anatomy; regional and applied volume three, 3rd edition

Greenberg MS, GlickMicheal, Ship JA eds Buerkets Oral Medicine 11th edition 2008

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http://teachmeanatomy.info/

Health & Medicine

Muscle - Dr Sanjana ravindra