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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.