Visceral OMT

OPSC February 2017

Kenneth Lossing DO

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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

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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

• 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 4

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 5

Planes of Motion

Atlas of Human Anatomy, Sobbatta 6

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.

Sagittal Transverse Coronal

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 7

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 8

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

Detection and mapping of intraabdominal adhesions by using functional cine MR imaging: preliminary results, Lienemann, radiology 2000 10

The viscera all slide with their neighbors. When this ability is compromised, it is visible with either ultrasound or MRI.

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 11

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 12

Respiratory Diaphragm

• Right and left hemi-diaphragms 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 13

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 14

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 15

Lung Mobility, Deep Breathing

Imaging tumor motion for radiotherapy planning using MRI, Kacczor and Plathow, Cancer Imaging 2006 16

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.

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 17

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) 21

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 inter-

cycle 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

Cranio-caudal Movements of the Liver, Pancreas and Kidneys in Respiration, Acta Radiological Diagnosis, 1984 25

Liver: 28 cases Pancreas: 70 cases Kidneys: 25 cases All organs seen to move S/I, A/P, L/R

Meta Analysis of Visceral Respiratory Motion

The Management of Respiration Motion in Radiation Oncology, AAPM Task Force 2006 26

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

• 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.

Phase Locked parallel movement of the diaphragm and pelvic floor during

breathing 30

Pelvic Floor and Resp. Diaphragm

Phase Locked parallel movement of the diaphragm and pelvic floor during

breathing 31

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 33

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 34

Stomach: Abnormal

• Lack of full descent, poor motility

Deltadyn 35

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 36

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 37

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

• Indirect/exaggeration • Direct • With respiratory assistance • Lymphatic • Vascular • Counterstain • Spinal/cranial

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Visceral OMT Contraindications

• 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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