You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

Introduction and background
===========================

The approach to the five diaphragms in osteopathic manipulative medicine (OMM) is part of the respiratory-circulatory model, whose principle is the free movement of body fluids to maintain or improve patient health \[[@REF1]-[@REF2]\]. The OMM philosophy is based on patient-centred care, applying scientific knowledge and clinical experience \[[@REF3]-[@REF4]\]. The use of the five-diaphragm model is part of the OMM philosophy and represents one of the many manual therapeutic choices to guide the patient towards his maximum expression of well-being. Treating one or more body diaphragms is an osteopathic therapeutic option: tentorium cerebelli; tongue; thoracic outlet; diaphragm; pelvic floor. Other diaphragms are not considered, such as the sole of the foot or the posterior area of the knee or other body portions reminiscent of a diaphragm, because the five diaphragms are vital for survival; without the limbs, a person can live but, without the five diaphragms, a person risks death. Not surprisingly, working with this orientation can make a difference in the patient\'s clinical picture \[[@REF5]-[@REF9]\]. The article reviews the anatomy of the anterolateral myofascial relationships of the five diaphragms, continuing and concluding the path of the first part of the previous article.

Review
======

Systemic myofascial relationships of the five diaphragms: anterolateral area

There are several ligamentous and fascial structures not always studied and understood at a sub-occipital level, such as the sub-occipital ligament (between the occipital condyles) or Gerber\'s ligament (near the cruciform ligament) \[[@REF10]-[@REF11]\]. Probably, because they are not always present and found during anatomical dissections. Other internal ligaments at the base of the skull are poorly studied due to the difficulty of access but they are always present and connected to the meningeal structures, such as bridges between the posterior and anterior portion of the tentorium cerebelli: interclinoid; caroticoclinoid or anterior interclinoid; posterior petroclinoid; petrosphenoid or Grüber's ligament; pterygospinous or Civinini ligament; pterygoalar or Hyrtl-Calori or innominate ligament \[[@REF12]\]. Another element that connects the dural system is the optic nerve. Its coating is dural and bilaminar (in adults) \[[@REF13]\]. The diaphragma sellae derives from the dural continuation of the tentorium cerebelli; the optic chiasm passes over the diaphragma sellae, sharing dural fibers (Figure [1](#FIG1){ref-type="fig"}) \[[@REF14]\]. There is a close dural relationship between the tentorium cerebelli and the optic nerve.

![The images show the close relationship between the optic chiasma, the optic nerve, and the diaphragma sellae\
Figure A shows the presence of the optic chiasm covering diaphragma sellae; figure B shows the foramen of the diaphragma sellae.\
Images reproduced with permission of Dr. Doris George Yohannan \[[@REF14]\].](cureus-0012-00000007795-i01){#FIG1}

In its path, the optic nerve merges with the Tenon capsule which, as previously described, is in continuum with the myofascial system that leads to the sub-occipital area and to the dura mater \[[@REF2]\]. The extraocular muscles attach themselves to the Tenon capsule and for myofascial continuity they communicate with the neighboring muscles, involving the contractile districts of the face: procerus; orbicularis oculi; levator labii superioris alaeque nasi; zygomatic muscles (upper and lower); levator labii superioris; malaris; levator anguli oris; depressor labii inferioris; depressor anguli oris \[[@REF15]\]. All the muscles of the face act in perfect coordination and fascial continuity. The anterolateral area of the face, the cheek, involves some of the muscles mentioned (orbicularis oculi with its lower portion, levator labii superioris alaeque nasi, levator labii superioris, zygomatic muscles, risorius, levator anguli oris); the masseter muscle stands out among the cheek muscles, partially covered by the buccinator muscle. There is a link of myofascial continuity of the buccinator muscle with the tendinous area of the temporalis muscle (Figures [2](#FIG2){ref-type="fig"}-[3](#FIG3){ref-type="fig"}) \[[@REF16]\].

![1, Superior oblique muscle; 2, optic nerve; 3, superior rectus muscle; 4, tendinous ring of Zinn; 5, inferior rectus muscle; 6, inferior oblique muscle; 7, lateral rectus muscle; 8, superioris levator palpebrae muscle.\
Reproduced with permission from Anastasi G, et al., Anatomia dell'uomo, fourth edition \[Human Anatomy\], vol 3, 2010, Milan: Edi-Ermes, p. 174.](cureus-0012-00000007795-i02){#FIG2}

![1, Frontal muscle; 2, orbicularis oculi muscle, part of the eyelid; 3, procerus muscle; 4, medial palpebral ligament; 5, nasal muscle; 6, levator muscle of the upper lip and of the wing of nose muscle; 7, levator of the upper lip muscle; 8, small zygomatic muscle; 9, great zygomatic muscle; 10, orbicularis oris muscle; 11, risorio muscle; 12, squared muscle of the inferior lip; 13, mentalis muscle; 14, triangular muscle; 15, platysma muscle; 16, parotid fascia; 17, fascia masseter; 18, anterior auricular muscle; 19, occipital muscle; 20, temporoparietal and upper auricular muscles; 21, aponeurotic galea.\
Reproduced with permission, from Anastasi G, et al., Anatomia dell'uomo, fourth edition \[Human Anatomy\], 2010, Milan: Edi-Ermes, p. 127.](cureus-0012-00000007795-i03){#FIG3}

The buccinator muscle via the pterygomandibular raphe is in myofascial communication with the tensor veli palatini, with the superior pharyngeal constrictor, the masseter and the mylohyoid (or buccal floor) \[[@REF17]-[@REF18]\]. The interpterygoid fascia or temporopterygoid fascia arises from the base of the skull (sphenoid) and connects the pterygoid muscles, involving the insertion of the muscle temporalis, playing an important role for the delimitation of the pterygomandibular space, which ends above the hyoid bone \[[@REF19]-[@REF20]\]. The interpterygoid fascia merges with the main muscle of the tongue (styloglossus) and with the fascial system of the internal carotid artery \[[@REF21]\]. The interpterygoid fascia is in direct contact with the sphenomandibular and stylomandibular ligaments \[[@REF19]\]. The muscles of the face, including the chewing muscles, are interconnected with each other, with the base of the skull, with the hyoid bone and the lingual complex (Figure [4](#FIG4){ref-type="fig"}).

![The alar fascia is identified behind the buccopharyngeal fascia below the C1 level and fuses to the fascia of the longus capitis lateralis muscle above the C1 level. The tongue is seen in its most proximal portion in the figure, on the far right.\
The image is reproduced with permission of Dott Noritaka Komune \[[@REF21]\].](cureus-0012-00000007795-i04){#FIG4}

The superficial facial and cervical connective tissue forms the parotid fascia (with the masseteric fascia, temporal fascia), involving the styloid muscles (stylopharyngeus, stylohyoid, styloglossus), the platysma and digastric muscle, the sternocleidomastoid muscle (SCM) \[[@REF22]\]. The anatomy demonstrates the myofascial continuity between the anterior and posterior parts of the body, involving the tentorium cerebelli, the lingual complex and the thoracic outlet. The superficial and deep cervical fascias surround the viscera and the suprahyoid and infrahyoid muscles, to flow anterolaterally to the superficial muscles of the neck (SCM, subclavian muscle, platysma), to the clavicle, the sternal body; at the thoracic outlet level the fasciae divide to cover the anterior (fascia thoracis superficialis) and deep chest area (as described in the previous first part \[[@REF23]\]. The thoracis superficialis fascia covers the pectoralis major muscle, the pectoralis minor, the serratus, the sternalis (when present), and is connected to the lateroposterior musculature since the superficial fascia is the same \[[@REF24]-[@REF25]\]. The deep fascia of the neck before entering the mediastinum, at the cervical level, covers the thyroid posteriorly, while anteriorly and laterally the superficial fascia covers the thyroid, the thyroid muscles, the Berry ligament (between the thyroid and the laryngeal-tracheal complex); the superficial fascia builds the lingual frenulum (between the arch of the jaw and the buccal floor), involving the sublingual glands and submandibular ducts \[[@REF26]-[@REF27]\]. The sternothyroid muscle covers the surface of the lateral fascia of the thyroid while, anteriorly, the thyroid comes into contact with the proximal portion of the omohyoid muscles and the sternohyoid; the SCM stands between the latter two muscles in its anterior portion. Returning to the thoracic outlet, the fascial continuum covering the pectoral and thoracic muscles involves the deltoid and posterior musculature (infraspinatus fascia, deltoid fascia), as well as the fasciae of the upper limb \[[@REF28]-[@REF29]\]. The pectoralis fascia that covers the pectoralis major muscle continues, covering the sternum and passing to the contralateral muscle; distally at the level of the xiphoid process, the fascia pectoralis continues to merge with the abdominal fascia, on the same side and on the contralateral side \[[@REF29]\]. There is no fascial discontinuity between the superficial and deep bands of the neck with the fascia pectoralis and the lateral and posterior muscles of the trunk (deltoid muscles, serratus anterior muscles, pectoralis minor muscles, teres major muscles, subscapularis muscles, trapezius muscle, latissimus dorsi muscles) \[[@REF29]\]. The pectoralis major continues with the abdominal fascia, including the aponeurosis of the external oblique; the abdominal fascia covering the rectus abdominals involves the rib cartilages (V-VII) and the pubic symphysis. The abdominal fascia and the underlying abdominal muscles (rectus abdominis, obliques and transversus abdominis), together with the transversalis fascia, communicate with fascial continuity with the thoracolumbar fascia (Figure [5](#FIG5){ref-type="fig"}) \[[@REF25]\].

![Muscles of the anterior wall of the trunk; view from inside\
1: sternum; 2: first rib; 3: internal intercostal muscle; 4: sternal part of the diaphragm; 5: sternocostal trigon; 6: costal part of the diaphragm; 7: tendinous sign of the rectus abdominis muscle; 8: transversus abdominis muscle; 9: arcuate line; 10: inguinal ligament; 11: spermatic cord; 12: iliopsoas muscle; 13: the femoral vessels; 14: deep inguinal ring; 15: semilunar line; 16: umbilicus; 17: linea alba; 18: transverse muscle of the chest.\
Reproduced with permission, from Anastasi G, et al., Anatomia dell'uomo, fourth edition \[Human Anatomy\], 2010, Milan: Edi-Ermes, p. 174.](cureus-0012-00000007795-i05){#FIG5}

The transversalis fascia (TF) is the continuation of the endothoracic fascia and stands between the epimysium of the diaphragm muscle and the underlying viscera. In its path, TF is found under the epimysium of the transversus abdominis and above the parietal peritoneum; behind the TF there is also the renal lodge, where it merges with the Gerota fascia (anterior) and with the Zuckerckandl fascia (posterior to the kidney) \[[@REF30]-[@REF31]\]. TF contacts the Zuckerckandl fascia and through the latter, comes into contact with the prevertebral fascia; laterally, TF comes into contact with the quadratus lomborum muscle \[[@REF31]\]. TF forms the connective tissue where the rectus abdominis and the oblique muscles rest and envelop themselves, as well as the transversus abdominis. The outermost portion of the TF is the alba line where, at the level of the umbilical area, it merges with some fascial structures connected to the liver: round ligament or ligamentum teres hepatis; medial umbilical ligaments; median umbilical ligament or urachus \[[@REF32]\]. The urachus at the inguinal ring merges below to strengthen the spermatic cord in the inguinal canal or to contribute to the formation of the common vaginal tunic \[[@REF33]\]. Vestigial fascial folds or lateral umbilical folds can also be found \[[@REF29]\]. TF encounters another structure called ligamentum venosum (between left portal vein and left hepatic vein) \[[@REF34]\]. TF merges in part with the iliac fascia (deriving from the psoas and iliacus muscles) in its anteroinferior and anteromedially portion; near the inguinal ligament; TF and iliac fascia merge with pectineal fascia \[[@REF33]\]. The pectineus muscle is in close contact with the pectineal ligament (ventrally and superiorly), which is connected to the inguinal ligament via the lacunar ligament; TF binds in the iliopubic portion to this complex \[[@REF35]\]. At the iliopubic level, TF and its more superficial expansions bind to Henle\'s inguinal falx, which acts as a bridge to the inguinal ligament \[[@REF36]\]. A fascial thickening of TF that passes medially through the deep inguinal ring is known as the Hesselbach ligament or semilunar fold of the transverse fascia or interfoveolar ligament \[[@REF37]\]. The posterior face of the inguinal ligament (IL) binds frontally to TF by means of a fascial Thompson layer. There is a strong link between TF and IL. This relationship drags TF to involve the contralateral lower limb; the medial portion of the fascia lata derives from IL, whose fibers derive from TF \[[@REF33], [@REF38]\]. The connective tissue system of TF is contacted caudally with the adductor longus muscle; the pyramidalis muscles are below the TF attack (which covers the anterior pubic ligament) at the level of the pubic symphysis and merge with the adductor longus muscle \[[@REF38]\]. The thoracolumbar fascia continues with the lower and upper limbs, as well as the anterior fascias from the skull to the pelvis and vice versa, making the human body a continuum without interruption; each body segment seen as a diaphragm (pelvis, respiratory diaphragm, thoracic outlet, tongue, and tentorium cerebelli) with their myofascial connections and with different vectors influence local and / or distant movements \[[@REF39]\]. The subdivision into fascial layers is only an anatomical and didactic convention but, in reality, all the tissues are interconnected: \" . . . unreasonable to apply the terms the superficial layer and deep layer, which are for the two-dimensional concept, to the three-dimensional clinical use \[[@REF40]\]".

Clinical reflections

The five diaphragms and the OMM remind us that the symptom must be seen in the whole body and not only as a localized anatomical structure. In fact, a chronic physical disorder also leads to dysfunctions in the psychological sphere \[[@REF41]\]. There are many chronic pathologies where a disturbance of one of the diaphragms leads to multiple comorbidities, and hence the clinical motivation in manually treating the diaphragm(s) with an osteopathic approach \[[@REF1]-[@REF2],[@REF7]-[@REF8], [@REF41]-[@REF43]\]. We also remember the nervous system, which not only communicates with the whole body but passes through the myofascial system. The vagus nerve is wrapped in the deep cervical fascia, the same fascia that involves the suboccipital muscles \[[@REF23]\]. The vagus nerve innervates the subtentorial portion and the crural area of the diaphragm (esophageal hiatus) and with the presence of parasympathetic nerve endings to the pelvic tissues \[[@REF1]-[@REF2]\]. Considering that nervous tissue is a highway of electrical and biochemical information, capable of moving this information both towards the periphery and towards the medulla or the central nervous system, a dysfunction of the myofascial system can be one of the causes of chronic pain that involves more diaphragms: headache, alteration of the relationship between esophagus and diaphragm, impaired swallowing, brachialgia, pelvic pain \[[@REF44]-[@REF48]\]. The phrenic nerve and the sympathetic trunk near the vertebral bodies are enveloped by the prevertebral fascia \[[@REF49]\]. The sympathetic system and phrenic nerve are able to carry somatic and visceral nociceptive afferent information; their structural and functional alteration, such as an abnormal compression of the cervical tract that affects the fascial system, or in other anatomical areas where they pass, can trigger multiple symptoms \[[@REF1]-[@REF2], [@REF43], [@REF50]\]. The five diaphragms are a strategy that can be used, as for other osteopathic medicine strategies, which is based on the fascial continuum and the neurological continuum. When we inhale the tongue it performs a retrusion action where the diaphragm is lowered as well as the pelvic floor; this happens thanks to the intervention of the supramedullary centres of the breath (nucleus retroambiguus), which govern the mentioned structures \[[@REF1]-[@REF2]\]. A correct level crossing of the thoracic outlet is fundamental for the nerve structures that will affect the remaining diaphragms, and a correct dural tension of the tentorium cerebelli will be important to avoid cascade disturbances as well \[[@REF1]-[@REF2]\].

Conclusions
===========

The second part of the article illustrated the myofascial connections of the anterolateral area of the body, showing continuity with the posterolateral myofascial system. OMM has several manual strategies to deal with the multiple disorders of patients, and the five diaphragm approach is one of these strategies. The article, divided into two parts, contains scientific information on myofascial body connections that have never been collected and mentioned in a single work. The hope is that the text will become an excellent reference point for clinicians who study and work with osteopathic medicine.

The authors have declared that no competing interests exist.