Download Diaphragms/ Fluid Model/Lymphatics

OMM 3 Diaphragms/ Fluid Model
Wednesday Oct 29, 2003 2-3pm
Kate Gadberry
Paul Giles
Page 1 of 6
Diaphragms/ Fluid Model/Lymphatics
•Human Body
–Approximately 70% water
–Self contained
–All biochemical processes are dependent on the universal solvent, water.
•oxygen
•nutrition
•growth
•communication
•A.T. Still’s Fluid Model
–Controlled by neurologic model
–Essential for proper nutrition on a cellular level
–All aspects of supply and return must function effectively to allow viscera to
function and assist in the prevention of disease
“The human body will sicken and die from imperfect drainage just as certainly as
the inhabitants of a great city would become extinct by collapse or any method
that would block the sewage main, the vena cava, of a great city.” – A.T. Still
•Poor Circulation Implies:
–decreased oxygen tension
–decreased nutrients
–decreased reticuloendothelial elements
–stasis
•sets the stage for infection and disease
If circulation  then waste products build up and stasis results
Lymphatic System Overview
•The lymphatic system is a vascular system separate from the cardiovascular
system. It is primarily composed of vessels and nodes but is also closely
associated with the spleen, thymus, and bone marrow.
•Lymphatic vessels usually begin as dilated tubes with closed ends. They are
larger than blood capillaries and they lack a basal lamina. Unlike most blood
capillaries, their endothelium is quite permeable to colloidal material, cells & cell
debris, and microorganisms from tissue spaces.
•Obstruction of the lymphatic vessels causes edema. The surrounding tissues
distend with protein rich fluid.
•Lymphatic capillaries are present in most tissues. They are absent from central
nervous tissue, bone marrow, epidermis, hair, nails, cornea, and cartilage.
•Most lymphatic vessels drain into lymph nodes before joining with larger trunks.
•Lymphatics have many more valves than veins and the vessel walls between
the valves expand into a sinus. This gives the vessels a “beaded” appearance
when they become distended. The valves are very important to prevent backflow.
OMM 3 Diaphragms/ Fluid Model
Wednesday Oct 29, 2003 2-3pm
Kate Gadberry
Paul Giles
Page 2 of 6
Lymphatic Anatomical Structures
•Lymphatic Vessels- Capillaries to trunks.
•Lymph Nodes- Encapsulated centers where lymphocyte differentiation and
proliferation occurs. Lymph nodes have an indentation on one side called the
hilum which contains the artery & vein supplying the node and contains the
efferent lymphatic vessel. There are approximately 400-450 lymph nodes in an
adult.
Function of the Lymphatic System
•Return Fluid to the vascular system. Most fluid formed at the arterial ends of
capillaries returns to the circulation by the venous ends, but 10-20% of fluid is
returned by the lymphatics.
•Removal of cell debris and foreign matter.
•Critical to the immune response.
•Transport fats absorbed from the small intestine.
Propulsion of Lymph
•Filtration pressure from fluid under pressure in the blood capillaries. (water from
a fire hose picture)
•Contraction of muscles, whether active or passive. Very little lymph flows from
an immobilized limb. Massage will increase the flow of lymph from edematous
tissue. (squeezing a toothpaste tube picture)
•Pulsations of adjacent arteries.
•Pulsatile contractions of smooth muscle in the thoracic duct (and probably other
large vessels). Sympathetic stimulation will also cause smooth muscle in the
wall of lymphatic trunks to contract.
•Movement of the respiratory diaphragm and negative pressure in the
brachiocephalic veins. (sucking through a straw picture)
Fluid Model
•Diaphragms:–The primary contribution to the propulsion of lymph involves the
thoracoabdominal diaphragm.
•Pressure differences created with respiratory cycle allow the lymph to be drawn
along the lymph vessels.
•Descent of diaphragm squeezes and massages the sinusoidal tissue of the liver
and spleen and compresses the viscera of the abdomen.
–Other diaphragms also affect lymphatic flow:
•Pelvic diaphragm
•Sibson’s fascia
OMM 3 Diaphragms/ Fluid Model
Wednesday Oct 29, 2003 2-3pm
Kate Gadberry
Paul Giles
Page 3 of 6
Importance of Fluid Flow
•Somatic Dysfunction is accompanied by localized inflammation and edema due
to alteration in blood and lymphatic circulation.–Contributes to mechanical
restriction in affected tissues
–Hypoxia secondary to arterial restriction has negative consequences
•Restriction in venous or lymphatic flow at one location will back up fluid flow at
more distal sites–creates a spreading locus of dysfunction
Sites of terminal lymphatic drainage dysfunction
(letters match picture in ppts)
A) Head &Neck……………...Supraclavicular
Space
B) Arm…………………………Posterior Axillary
Fold
C) Lower Abd & Chest…...….Epigastric Area
D) Lower Extremity……….….Inguinal Area
E) Leg……………………...….Popliteal Space
F) Ankle & Foot………………Achilles Tendon
•The most common area for lymphatic restriction, regardless of what tissue
region is congested, is the CERVICOTHORACIC DIAPHRAGM (In the
supraclavicular space. This is the location of Sibson’s fascia.)
Osteology of the Thoracic Inlet
Manubrium, First Ribs, Body of T1, clavicles
Key Structures in the head and neck
•Manubrium
•Clavicals
•First Ribs
•Body of T1
•Sibson’s Fascia
•Thoracic Duct
•Internal Jugular vein
•Brachiocephalic vein
•Strap Muscles
Lymphatic Anatomical Structures:
Lymphatic Trunk and What They Drain:
**KNOW THIS**
Right Jugular trunk: responsible for draining the right side of face and neck
Right Subclavian: right upper extremities
Right bronchomediastinal trunk: lungs, heart, liver
Left Jugular: left side of face and neck
Left Subclavian: left upper extremities
OMM 3 Diaphragms/ Fluid Model
Wednesday Oct 29, 2003 2-3pm
Kate Gadberry
Paul Giles
Page 4 of 6
Left Bronchomediastinal: Grays says it exists, not MENTIONED in our required
text though.
-Our book says that most of the mediastinal visceral organs are drained to the
right Subclavian.
•Thoracic Duct- A large lymphatic vessel beginning at around L1 or L2 and
extending to the base of the neck. The thoracic duct usually begins in the
abdomen as a confluence of lymphatic trunks but in a number of instances a
saccular dilation is formed called the cisterna chyli.
•Lymph is returned to the venous circulation via the right and left lymphovenous
portals (generalized term). There are multiple trunks on each side and there is a
great variation of the termination of these vessels.
•Sometimes the trunks will converge to form a right and left lymphatic duct but
more often they open independently into either the internal jugular, subclavian, or
brachiocephalic veins.
•These “portals” are located at the base of the neck in the region where the
brachiocephalic vein bifurcates into the internal jugular vein and the subclavian
vein.
•Right lymphatic duct: heart, lungs, liver, right upper limb, head and neck
–right brachiocephalic approximately 80% but much variation to this
–head and neck = right jugular trunk
–heart, lungs, liver = right bronchomediastinal trunk
–right limb = right subclavian trunk
•Left lymphatic duct: rest of body
–left jugular, left subclavian, left bronchomediastinal, left thoracic duct
Technique: Thoracic Inlet: dir. Myofascial release of Sibson’s fascia
Sitting at patients head, palpate the supraclavicular area/Sibson’s fascia to
determine if one is restricted. When diagnosed, move to the ipsilateral side of
the patient.
•Caudal fingers on the superior aspect of the supraclavicular fossa, apply an
inferior/anterior traction to the pt’s wrist. The caudal fingers apply gentle anterior
pressure against the clavicle.
•Move the pt’s arm into flexion, abduction, and then extension. Follow the rotation
of the clavicle posteriorly until tension develops. Hold this until some relaxation
is noted this allows stretching of the thoracic inlet.
•Repeat two or three times.
Technique: Thoracic Inlet: Articulatory tx for elevated 1st Rib
How to find and diagnose the first rib:
Find the spinous process of T1- attached to T1 is the posterior portion of the first
rib. On the anterior surface it attaches to the manubrium just to each side of the
sternal notch. Then feel if one is elevated or restricted.
OMM 3 Diaphragms/ Fluid Model
Wednesday Oct 29, 2003 2-3pm
Kate Gadberry
Paul Giles
Page 5 of 6
When first rib is diagnosed, the doctor puts his foot up on the table and the
patient puts his arm over the doctor’s leg, resting the axilla contralateral to the
dysfunctional side on the doctor’s thigh.
•Doc holds the 1st rib with thumb lateral to the costotransverse joint with a finger
on its anterior end.
•Doc uses the head and neck to move T1 through its full range of motion until the
best possible motion is obtained.
Thoracoabdominal Diaphragm: Attachments, Openings, Penetrations
Attachments:
Right crus to L1,2,3,(4- depending on anatomical variation)
Left crus to L1,2,(3- depending on anatomical variation)
Arcuate ligaments- Between the two crus is the median arcuate ligament- it
arches around the aorta. The medial arcuate ligament connects with the body of
L2 and the SP of L2. Just lateral to that is the lateral arcuate ligament that
connects the SP of L2 to rib 12.
Xyphoid process
Ribs 6-12
Openings/penetrations
Esophageal hiatus- Muscles form the esophageal hiatus.
Vena caval foramen- As the diaphragm contracts the hole opens.
Azygous/hemiazygous v.
Aortic foramen
Neutral Control of Breathing
Vagus nerve: involved in nocioreceptors from the bronchi of the lungs
Phrenic nerve: C3,4,5 (to keep you alive)
Intra/Extrafusal fibers in intracostal muscles – reflex arc involved there in stretch
and strain of those muscles, synapse with lumbar spine.
Technique: Thoracoabdominal diaphragm: supine indirect respiratory force
•Doc grasps pt’s rib cage A/P or laterally. A/P – “feel like piano wire between your
hands" The bottom hand is monitoring.
•Carries the rib cage into right or left rotation with side bending and
flexion/extension to the point of balanced ligamentous tension. Take it the way it
likes to go.
•Pt is instructed to hold his breath as long as possible in the phase that provides
the best ligamentous balance.
•Recheck
Technique: Thoracoabdominal diaphragm: supine direct respiratory force
•Doc grasps the lateral side of the pts ribcage.
•Carries the rib cage into right or left rotation with side bending and
flexion/extension to the point of maximum ligamentous tension.
OMM 3 Diaphragms/ Fluid Model
Wednesday Oct 29, 2003 2-3pm
Kate Gadberry
Paul Giles
Page 6 of 6
•Pt’s respirations are observed to determine which hemi-diaphragm is most
restricted.
•Doc maintains the diaphragm at the fascial barrier in all three planes while
resisting the inhalation effort on the side that has the best motion, forcing the
restricted side of the diaphragm to move. You are using the patients own
musculature and respiratory drive to get it to move.
Technique: Thoracoabdominal diaphragm: Direct mechanical
•Grasp the inferior lateral rib cage. With thumbs pointed towards each other and
lateral/caudad to the xiphoid process.
•Follow the diaphragm motion as the pt. exhales. (posterior/anterior) Hold the
end position and resist movement during inhalation.
•During exhalation follow the diaphragm to a new barrier.
•Repeat three times, then move thumbs laterally along the costochondral margin
to a new restriction and repeat.
Seven Degrees of Osteopathy
How to Connect the Body to the Thoracoabdominal Diaphragm
The Pelvic Connection:
Urogenital diaphragm  pelvic diaphragm  piriformis (which attaches to
sacrum and greater trochanter of femur)  anterior sacrococcygeal ligament
(also attaches to sacrum)  interdigitates with anterior longitudinal ligament 
interdigitates with left and right crus of the diaphragm
Superior Connections:
•transversus abdominis
•transversus thoracis
•internal intercostals
•thoracic inlet
Clavicle  thoracic inlet  1st rib and sternum  ribs, internal intercostals mm.
Cardiothoracic Lymphatics:
•retrocardiac nodes
•infracardiac nodes
•thoracic duct
Pericardium- direct connection to diaphragm so when diaphragm contracts, it
changes the shape of the heart and function.
Technique: Lymphatic pump VS. posterior diaphragm release
•Doc stands at head of table
•Pt. reaches around the Doc and grabs his waist.
•Doc reaches under the Pt. contacting the posterior diaphragm attachments
•Doc carries the Pt’s thorax into extension using his elbows as a fulcrum – apply
anterior pressure and traction
•LVMA (springing) rib raising is continued until desired fluid response is obtained.