Download Visceral OMT

Visceral OMT
OPSC
February 2017
Kenneth Lossing DO
1
Who First Described Visceral OMT?
• AT Still- Osteopathy,
Research and Practice
• Carl McConnell- Clinical
Osteopathy
• Elmer Barber- Osteopathy
Complete
• Edward Goetz- A Manual
of Osteopathy
• William Garner
Sutherland- Teaching in
the Science of Osteopathy
2
Definition of Visceral Dysfunction
“Impaired or altered mobility or motility of the
visceral system and related fascial, neurological,
vascular, skeletal, and lymphatic elements”.
American Osteopathic Association glossary, 2002
”Dr. Still stressed the necessity of structurally
adjusting all lesions; that is of both the spinal
and ventral ( visceral) planes.” Dr Carl
McConnell
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Dr. Barber’s List of Osteopathic
Treatment Indications in 1898
•
•
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•
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Pulmonology: Asthma, tuberculosis, bronchitis, bronchiectasis, pneumonia,
pulmonary congestion, empyema, pleurisy,
Cardiology: endocarditis, pericarditis, myocarditis
Gastroenterology: constipation, gastritis, gastric ulcer, enteritis, chronic diarrhea,
dysentery, appendicitis, intussusception, intestinal obstruction, acute biliousness,
jaundice, acute hepatitis, inflammation of glisson’s capsule, gall stones, hepatic
colic, acute pancreatitis
Urology: anuria, hematuria, lipouria, pyuria, oxaluria, uremia, renal congestion,
acute nephritis, diabetes insipidus, pyletis, nephroliaasis, renal abscess, floating
kidney, cystits, prostatic hypertrophy, prostatitis
General Medicine: acute peritonitis, ascities, splenitis, splenic hypertrophy,
floating spleen, proctitis, hemorrhoids, prolapsed ani, fistula in ano
Gynecology: displacements of uterus, prolapse, amenorrhea, oligomenorrhea,
dysmenorrhea, acute metritis, cervical stenosis, salpingitis, ovarian prolapse,
vaginitis, prolapses vaginae
Osteopathy Complete, Elmer Barber 1898
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Mobility-Diaphragm Movement
• All of the viscera move
with each breath
(mobility). This
movement is necessary
to keep fluid and
pressure distribution
within normal limits.
Atlas of Human Anatomy, Sobbatta
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Planes of Motion
Sagittal
Transverse
Coronal
Atlas of Human Anatomy, Sobbatta
The motions of
mobility occur 3
dimensionally, in
all of the cardinal
planes of
existence.
The largest
visceral motion is
mostly in the
sagittal plane.
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Real Time MRI Shows All of the Viscera
Move With Respiration.
During inhalation
the lungs expand
and the respiratory
diaphragm
contracts, moving
the pericardium at
least 1.5cm inferior
and medial, during
tidal breathing
Fredricson,J. Radiology.1995 195:169-175
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Medicine is changing!
• In the time of Dr. Still, almost all diagnosis were
based on the traditional physical examination.
• Today, modern technology plays a much larger
diagnostic role.
• “Evidence-based” physical diagnosis, principally
addresses those diagnosis defined by technology
standards.
• Visceral respiratory motion has been measured.
Evidence based Physical Diagnosis, McGee
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What Has Been Measured?
• Movement of the organs with respiration by
ultrasound, CT, MRI, Fluoroscopy, which are 3D.
• Normal motion, decrease/alteration in
dysfunction.
• Movement of the organs with posture changes.
• Visceral volume changes with posture change.
• Visceral density changes in dysfunction.
• Visceral density changes are palpable.
• Viscera sliding relative to their neighbors, and
when this has been compromised, as evidenced
by MRI and ultrasound.
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Visceral Slide
The viscera all slide with their neighbors.
When this ability is compromised, it is
visible with either ultrasound or MRI.
Detection and mapping of intraabdominal adhesions by using functional cine MR imaging:
preliminary results, Lienemann, radiology 2000
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Respiration
• In quiet respiration the
diaphragm moves about 1.5cm,
the chest circumference
changes 1.2 cm when erect and
0.7 cm when supine.
• In deep respiration the
diaphragm moves from 7-13
cm, and the chest
circumference changes between
5-11cm.
• In a full vital capacity breath,
one quarter of the ventilation
is due to chest expansion and
three quarters to diaphragm
displacement.
Movements of the Thoracic Cage and Diaphragm in Respiration, Wade, J Physiology
1954
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Mobility
• During inhalation the respiratory
diaphragm descends ( 1.5-7cm),
the costo-diaphragmatic recess
opens, the pericardium descends,
the tension of the pulmonary
ligaments, parenchyma, and
vessels increase.
• Therefore, tension in any ribs,
pleura, pericardium, or lungs can
all decrease respiratory volume.
Anatomy: Development Function, and Clinical Correlations, William Larson 2002
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Respiratory Diaphragm
• Right and left hemidiaphragms move nearly
the same
• Superior/inferior motion for
liver, spleen, diaphragm is
1.3cm for tidal breathing,
3.9cm for deep breathing
• Visceral motion is in 3
dimensions
• Liver dilates about 3%
Respiratory Kinematics of the Upper Abdominal Organs A qualitative Study, H. Korin,
Magnetic Resonance in Medicine 1992
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Test of Diaphragm Mobility
• With the patient
supine, place your
thumbs 2-3 cm below
the costal margins
bilaterally at about
the nipple line. Press
your thumbs through
the abdominal wall to
the abdominal
contents. Have your
patient take a deep
breath.
Foundations of Osteopathic Medicine
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Lung Function Declines with Age
• FEV1 starts declining
at about 30 years
old.
• Dyspnea without
exertion is common
in 80 plus year olds,
and in smokers much
earlier.
Cecil Textbook of Medicine, 2004
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Lung Mobility, Deep Breathing
During Deep vital capacity breathing the motion of the lung
regions was significantly greater in the lower regions that in the
upper regions (5+/- 2cm vs 0.9+/- 0.4).
Tumor bearing lung regions showed a significantly lower mobility
than the corresponding non-involved regions.
Imaging tumor motion for radiotherapy planning using MRI, Kacczor and Plathow, Cancer Imaging 2006
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Oxygenation Changes with Age
• Resting pO2- arterial
decreases even for
healthy people with
aging.
• This trend was found
to be reversible
using something
called Oxygen
Multistep therapy in
Germany.
Oxygen Multistep Therapy, M. Von
Ardenne, Theme Medical Publishers, 1990
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The Lungs
• Larger posteriorly
than anteriorly
• Accessible through
the lateral ribcage.
• Normal parenchyma
soft, firmer in COPD.
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Lung
• The patient is in the lateral
recumbent position.
• Palpate through the skin and
ribcage to the lung tissue itself.
• Motion test the lung superiorly
and inferiorly, also medial and
lateral rotation.
• Also compress into lung, and
appreciate its return
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Clinical Correlation/Application
• Asthma: reduction in
need of break though
meds
• Chronic pain patients:
almost all of them don’t
exercise enough
• Elderly patients
• Multiple medical
problem patients
• Chronic fatigue
syndrome patients
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Cardiac Output
• Free breathing and
breath hold.
• During free breathing,
the right side of the
heart maximizes
cardiac output during
peak inspiration (
1.36) of breath hold),
and the left heart
maximizes CO during
expiration (1.22)
Respiratory Resolved Cine Phase Contrast MRI: Measurement of Right and
Left Heart Cardiac Output During Inspiration and Expiration, B Thompson,
Proc. Intl Soc. Mag. Reson. Med (2002)
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Cardiac Motion
• The inferior wall of the
heart was found to
move 1.5 cm during
tidal ( normal)
respiration, in the
coronal plane.
• Left pictures: during
exhalation, top: end
systole, bottom: end
diastole
• Right pictures: During
inhalation
Simultaneous temporal Resolution of Cardiac and
Respiratory Motion in MR Imagining, Radiology 1995,
Fredrickson
Breathing Affects Circulation!
• Blood flow in the descending aorta
and superior vena cava increases
during inspiration because the
increased negative pressure
increases venous return, and
decreases during exhalation.
• In the abdomen, blood flow in the
portal vein is highest during
expiration, lowest during
inhalation, due to increased
positive pressure reducing blood
flow. In healthy subjects, cardiac
pulsititiy of portal venous flow is
usually minimal, with larger flow
variations seen with respiration!
Simultaneous temporal Resolution of Cardiac and Respiratory
Motion in MR Imagining, Radiology 1995, Fredrickson
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Portal Vein
• Pulsatility or cardiac intercycle variability is the
difference between the
minimum and maximum
values during a cycle. This
study shows a average flow
rate of the portal vein to be
about 970 mL/min, with the
respiration varying the flow
on average 539mL/minute,
and cardiac cycle varying an
average of 296mL/minute. In
other words about half of
portal vein blood flow is
respiration dependent.
Simultaneous temporal Resolution of Cardiac and Respiratory Motion
in MR Imagining, Radiology 1995, Fredrickson
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Ultrasound
Liver: 28 cases
Pancreas: 70 cases
Kidneys: 25 cases
All organs seen to move S/I, A/P, L/R
Cranio-caudal Movements of the Liver, Pancreas and Kidneys in
Respiration, Acta Radiological Diagnosis, 1984
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Meta Analysis of Visceral Respiratory
Motion
The Management of Respiration Motion in
Radiation Oncology, AAPM Task Force 2006
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Diaphragmatic Motion with MRI
• Fast Gradient
recalled echo
MRI
• 10 volunteers
• Patient supine
• Approximate
vital capacity
breathing
• Rate of 4-10
respirations per
minute
Diaphragmatic Motion: Fast Gradient-recalled Echo MR Imaging in
healthy Subjects, Radiology 1995, Gierada
Liver
• Palpated below the
right costal margin
• Check density, and
motion test inferior
and superiorly.
Indications: dietary,
polypharmacy,
alcohol.
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Kidneys
• Palpated through
abdominal wall and
Grynfeld’s space,
check with motion
testing.
• Indications:
abdominal pain, flank
pain, low back pain,
groin pain, UTI’s
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Pelvic Floor and Resp. Diaphragm MRI
Phase Locked parallel movement of the
diaphragm and pelvic floor during
breathing
• 8 cases
• Right and left
diaphragm, 1.5cm
in quiet breathing,
3.2 and 2.8 during
forced breathing
and coughing.
• Both Respiratory
diaphragm and
pelvic floor moved
caudally during
inhalation and
cephalic during
exhalation.
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Pelvic Floor and Resp. Diaphragm
Phase Locked parallel movement of the
diaphragm and pelvic floor during
breathing
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Clinical Correlations
• Urinary stress
incontinence
• Benign prostatic
hypertrophy
• Pelvic pain
• Pudendal neuralgia
• Low back pain
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Stomach and Diaphragm: Normal
• The dome of the
diaphragm and the
fundus of the stomach
are clearly seen to
displace inferiorly
during inhalation, and
superiorly during
exhalation, on the
order of 1-2 vertebral
segments.
• Fundus displacement
measures 2.9 CM
inferior, 2 cm anterior,
right shift .6cm
Treating Visceral Dysfunction, Finet and
William, Deltadyn
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Stomach Body and Duodenum:
Normal
• Stomach body: descends
.8cm, advances anteriorly
.95cm, and shifts to the
left or right.
• Duodenum: Descends
• .53- .97 cm, closes on
itself, advances .64cm,
shift to the left .014cm
Treating Visceral dysfunction, Finet and
William, Deltadyn
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Stomach: Abnormal
• Lack of full
descent, poor
motility
Deltadyn
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Stomach: Frontal Plane
• 65 cases
• In Inhalation the
gastric Fundus:
moves from superior
to inferior an
average of 2.9cm,
posterior to anterior
2cm, shifts to the
right .6cm, it tends
to incline to the left.
Treating Visceral Dysfunction, Finet and
Williame
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GERD: Longitudinal Muscle Contraction
• Tenting of fundus
• Barium in distal
esophagus is reflux
• The hiatus is widened
by LM force
• This is the only
book/article on GERD
that implicates the LM.
This is what we find
osteopathically.
The Longitudinal Muscle in Esophageal
Disease, Stiennon
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Evaluation of Upper Esophageal
Sphincter
• Palpate hyoid bone,
thyroid cartilage, cricoid
cartilage, trachea.
• At cricoid: palpate
posteriorly to find the
area of the lower
pharyngeal constrictor
muscle, motion test it
superiorly. In
symptomatic GERD, it
will not distend well.
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Test of Esophagus and LES
• Do layer palpation
through: skin, adipose,
abdominal wall,
peritoneum, to
stomach. Then bring
stomach inferior and
lateral to the left,
noting distance and
ease of distensability.
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Visceral OMT Approaches
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Indirect/exaggeration
Direct
With respiratory assistance
Lymphatic
Vascular
Counterstain
Spinal/cranial
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Visceral OMT Contraindications
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High fever of unknown origin
Traumatic internal bleeding
Non medically treated cancer
Infectious diseases not medically controlled
Unstable medical problems without a proper
diagnosis
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