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Visceral osteopathy


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this presentation explains anatomical and physiological basis for visceral osteopathic techniques

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Visceral osteopathy

  1. 1. Visceral Osteopathy Hossein Khorrami, Ph.D. DOMP
  2. 2. Cavities
  3. 3. Diaphragm • Dome-shaped muscle with central tendinous portion(phrenic center) • 2-4mm thick • Right crus (pedicle) insert onto L2-L3(L4)- body and disc • Left crus insert onto L2-L3- body and disc
  4. 4. Diaphragm, costal portion • Insert into lower 6 ribs • Crossing QL muscle and attach to TVP of L1 (lateral lumbocostal arch) • Sternal portion attach to xiphoid process
  5. 5. Diaphragm, arcuate ligaments • Medial, aorta • Median, psoas muscle • Lateral, quadratus lumbarum • All are fibrous and non muscular • But Esophageal hiatus(T10) contracts during inhalation, so prevents reflux
  6. 6. Lower Esophageal Sphincter(LES) • Epiphrenic ampulla – Dilate with inhalation(compliance) • Area of sphincter – Diaphragmatic(hiatal anulus) – Lower esophegeal
  7. 7. Esophageal motor innervation by the vagus nerve; Auerbach’s and Meissner’s plexuses. The striated muscle of the proximal esophagus is directly innervated by the somatic efferent cholinergic fibers of the Vagus nerve originating from the nucleus ambiguous In contrast, the smooth muscle of the distal esophagus is innervated by the preganglionic vagus nerve fibers from the dorsal motor nucleus. The preganglionic vagus fibers release Ach, that affects two types of postganglionic neurons in the myenteric plexus, the excitatory cholinergic neurons and the inhibitory nitrinergic neurons
  8. 8. Esophagogastric Junction • Diaphragmatic sphincter • Lower Esophageal Sphincter Complex – LES – Cardiac opening
  9. 9. Lower Esophageal Sphincter • LES involves the distal 3-4cm of the esophagus and at rest is tonically contracted • Resting LES pressure: 10-30mmHg • LES maintain a high-pressure zone by the intrinsic tone of its muscle and by cholinergic excitatory neurons • Lowest pressure after meal & highest at night • Also influenced by circulating hormones, peptides, foods(esp fats) and drugs
  10. 10. LES Contracts • In response to: • Gastrin • CCK • Secretin • Glucagon • Acid
  11. 11. Pressures • Intra-esophageal: -5cmH2O • Gastric: 8cmH2O and more(27) • LES: 14-55cmH2O – Variable, related to the gastric pressure – initial pressure <14 reflux • Pressure inversion point at LES-Diaphragm • Importance of air pocket in fundus area, pushes esophagus up and stomach down
  12. 12. During inhalation • Decrease esophageal pressure • Increase abdominal pressure GERD: GastroEsophageal Reflux Disease
  13. 13. Reflux • Pyrosis(heartburn): burning sensation from xiphoid toward sternum, rarely radiate to neck and/or between shoulder blades • Regurgitation: bitter and burning acidic liquid to mouth without vomiting
  14. 14. Reflux, other signs • Tracheobronchial irritation, esp nocturnal • Asthmatiform crisis • Pharyngeal pain • Hiccup • Otalgia(ear pain) • Burping(Eructations)
  15. 15. The Vestibule • The esophageal segment between diaphragm and cardia • Passes into abdomen During inhalation and into the thorax during exhalation
  16. 16. Cardiac Orifice • Opening of esophagus to stomach • 2cm left of the midline • At T11 • Ventral and left to aorta • Connect with left lobe of liver, makes a groove • Corresponds to the left 7th costal cartilage
  17. 17. Phrenicoesophageal ligament
  18. 18. Achalasia • Results from a malfunction of the nerves controlling the rhythmic contractions of the esophagus • Viral and autoimmune or.. • Certain tumors
  19. 19. Hiatal Hernia • A hiatal hernia occurs when the upper part of stomach bulges through diaphragm
  20. 20. Hiatal Hernia, Symptoms • Heartburn • Regurgitation of food or liquids into the mouth • Acid reflux • Difficulty swallowing • Chest or abdominal pain • Shortness of breath • Vomiting of blood or passing of black stools, which may indicate gastrointestinal bleeding
  21. 21. Hiatal Hernia, Causes • Age-related changes in diaphragm • Injury to the area, for example, after trauma or certain types of surgery • Being born with an unusually large hiatus • Persistent and intense pressure on the surrounding muscles, such as vomiting, coughing, straining during a bowel movement, exercising or lifting heavy objects
  22. 22. Mesenteries In Saggital Plane
  23. 23. Gastric Hcl Secretion Gastric HCl Secretion Proton Pump (H,K-ATPase) Na+ Pump (Na,K-ATPase) ATP Na+ K+ HCl Lumen of gastric gland Fig. 21-6
  24. 24. Pancreatic juice
  25. 25. Endopeptidases • Pepsin (stomach), cleaves at amino side of aromatic A.A.'s • Trypsin (pancreas), cleaves at COOH side of basic A.A.'s, i.e., lys & arg • Chymotrypsin (pancreas), cleaves at COOH side of aromatic A.A.'s, also leu and met • Enteropeptidase (duodenum) cleaves at COOH side of Lys that is preceded by 4 Asp and followed by non-Pro
  26. 26. Exopeptidases • Carboxypeptidase (pancreas), C-terminal peptidase • Aminopeptidase (intestine), N-terminal peptidase
  27. 27. Digestive enzymes
  28. 28. (from duodenal epithelial cells) CCK works on acinar cells #-Amylase Lipase (no activation needed) b. Secretion/Activation of Pancreatic Enzymes secreted by duodenal epithelium (Enterokinase) (cholecystokinin)
  29. 29. Surface anatomy of abdomen
  30. 30. Duodenum
  31. 31. Liver Functions • Filter: bacteria, antigens, damaged cells, proteins, hormones and drugs • Detoxification: ammonia, alcohol., etc – alcohol to acetaldehyde(carcinogen) • Blood reservoir • Nutrient processor • Protein synthesis: albumin, binding proteins, transferrin, globulins, blood clotting factors, fibrinogen, prothrombin, v, vii, ix, x.., apolipoproteins, angiotensinogen • Glucose, lipid homeostasis, gluconeogenesis, • Minerals, Iron & vitamin storage • Bile synthesis by destruction of old Rbcs
  32. 32. Hepatic Ligaments • R triangular • L triangular • Falciform • Round, – remnant of L umbilical vein • Hepatogastric • Coronary(to diaphragm)
  33. 33. Liver Referred Pain
  34. 34. Intestines • Small: 7meters • Large: 1.5 meters
  35. 35. The Large Intestine The Large Intestine
  36. 36. Spleen, Position
  37. 37. Referral pain
  38. 38. Liver, ligaments • Round ligament (ligamentum teres) • Coronary ligament • Right triangular ligament • Left triangular ligament
  39. 39. Liver ligaments
  40. 40. Liver, treatment, side • Push the liver on both sides With Every Breath • Push the liver WEB, finish with vibration • Do the same, finish with rebound • Stretching on R side, using one elbow on pelvic, the other below arm + move back & forth + stretching • Do the same with leg stretch • Do the same with hand stretch
  41. 41. Gallbladder, treatment, sitting • Midclavicular line, below rib8 • Push post+sup
  42. 42. Stomach, attachments • Liver • Transvers colon • Descending colon
  43. 43. Sympathetic nerve • Greater splanchnic and Lesser splanchnic nerves join to celiac ganglion • Between crura of diaphragm and expansion of psoas arch
  44. 44. Pneumogastric (Vagus ) nerve • 10th cranial nerve, from medulla • Passes through jugular foramen, at middle part of temporal-occipital suture
  45. 45. Vagus, functions • Sensory – Skin of posterior auricular area + part of external auditory meatus • Motor – With 9th & 11th cranial nerve innervate palatal & pharyngeal muscles, in deglutition – Innervate larynx, role in phonation • Vegetative – Taste from base of tongue – Proprioception of larynx & pharynx, protective role for airways – Carotid baroreceptors
  46. 46. Vagus, pneumogastric portion • A visceral nerve • Extending to thoracic and abdominal viscera • Proprioception of lungs, GI tract, heart and great vessels (carotid sinus) • Controls SM of lungs, esophagus, intestine • Stimulate bile and gastric secretions
  47. 47. Vagal system
  48. 48. Second Brain • We know the basic steps to keeping a young, healthy brain: eat healthy, exercise, and get a good night’s sleep • Our brain health may also be influenced by an unexpected source, our second brain • Within the walls of our digestive system, the gut, or the “second brain,” which contains bacteria that could help our brain structure, possibly influencing our moods, behavior, and mental health, such as the likelihood of developing Alzheimer’s disease
  49. 49. • The gut is able to communicate with the brain via the vagus nerve, a cranial nerve extending from the brainstem to the abdomen via the heart, esophagus and lung, known as the gut- brain axis • Ninety percent of the fibers in the vagus carry information from the gut to the brain
  50. 50. Colon: net absorption of salt and water, but also some secretion of K+ (Colon participates with kidneys in regulating body K+.) HH22OO NaNa++ ClCl--
  51. 51. NaCl Secretion by the Colon (minor, except when pathological)
  52. 52. Colonic bacteria There is very little nutrient absorption by the colon, however: Short-chain fatty acids produced by colonic bacteria: 1) taken directly across apical membrane of colonocytes 2) many used by colonocytes as preferred metabolic substrate Vitamin K and biotin: absorbed in small intestine from dietary sources, but also produced by colonic bacteria and absorbed across colonic epithelium
  53. 53. Crohn’s Disease • inflammatory bowel disease (IBD) • 3-3.5/1000 • It causes inflammation of the lining of digestive tract – Abdominal pain – Severe diarrhea – Fatigue – Weight loss – Malnutrition • Inflammation caused by Crohn's disease can involve different areas of the digestive tract from mouth to the rectum in different people
  54. 54. • The inflammation caused by Crohn's disease often spreads deep into the layers of affected bowel tissue • Crohn's disease can be both painful and debilitating, and sometimes may lead to life- threatening complications • In some people with Crohn's disease, only ileum is affected • In others, the disease is confined to the colon
  55. 55. Symptoms • Diarrhea is a common problem • Fever and fatigue due to inflammation or infection • Abdominal pain and cramping • Nausea and vomiting • Night sweats • Blood in stool, visible or occult blood • Mouth sores • Reduced appetite and weight loss • Perianal disease (fissures and fistula) • Inflammation of skin, eyes and joints • Inflammation of the liver or bile ducts • Delayed growth or sexual development, in children
  56. 56. • Immune system. It's possible that a virus or bacterium may trigger Crohn's disease – Mycobacterium – Listeria – … • Heredity. Crohn's is more common in people who have family members with the disease, so genes may play a role in making people more susceptible. However, most people with Crohn's disease don't have a family history of the disease
  57. 57. • Age. Crohn's disease can occur at any age, but most people who develop Crohn's disease are diagnosed before they're 30 years old • Ethnicity. Although Crohn's disease can affect any ethnic group, whites and people of Eastern European (Ashkenazi) Jewish descent have the highest risk • Family history. As many as 1 in 5 people with Crohn's disease has a family member with the disease • Cigarette smoking is the most important controllable risk factor • NSAIDS, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, Anaprox), diclofenac sodium (Voltaren, Solaraze). While they do not cause Crohn's disease, they can lead to inflammation of the bowel that makes Crohn's disease worse • Live in an urban area or in an industrialized country. This suggests that environmental factors, including a diet high in fat or refined foods, play a role in Crohn's disease. People living in northern climates also seem to be at greater risk
  58. 58. Crohn’s disease • file://localhost/Users/Home/Downloads/Croh n_disease_video.webm.480p.ogv
  59. 59. Coeliac disease • Autoimmune disease, not a food allergy • Affects small intestine • Any age • Reaction of gut to gluten • Gluten in wheat, barley and rye • Intestinal villi become flattened as a result of the inflammation • Food and nutrients are not so readily digested by the body
  60. 60. Symptoms • Abdominal pains, tiredness and weight loss • In babies starting solid foods, – pale stool, smelly diarrhea – Vomit repeatedly – Fail to grow or poor growth – In adults • Weight loss • Anemia because of poor iron absorption • Diarrhea, abdominal bloat • Mouth ulcer
  61. 61. Sugar hurts liver • The organ uses one type of sugar, called fructose, to make fat • Too much refined sugar and high-fructose corn syrup causes a fatty buildup that can lead to liver disease • Some studies show that sugar can be as damaging to the liver as alcohol, even if you’re not overweight • It’s one more reason to limit foods with added sugars, such as soda, pastries, and candy
  62. 62. Herbal supplements • Even if the label says “natural,” it may not be OK for you. For instance, some people take an herb called kava kava for menopause symptoms or to help them relax • Studies show that it can keep the liver from working right • That can lead to hepatitis and liver failure • Some countries have banned or restricted the herb, but it’s still available in the U.S.
  63. 63. Over weight • The extra fat can build up in your liver cells and lead to non-alcoholic fatty liver disease (NAFLD) • As a result, your liver may swell • Over time, it can harden and scar liver tissue (cirrhosis) • You are more likely to get NAFLD if you are overweight or obese, middle-aged, or have diabetes
  64. 64. Vitamin A • Your body needs vitamin A, and it’s fine to get it from plants such as fresh fruits and vegetables, especially those that are red, orange, and yellow • But if you take supplements that have high doses of vitamin A, that can be a problem for your liver
  65. 65. Soft drinks • Research shows that people who drink a lot of soft drinks are more likely to have non- alcoholic fatty liver disease (NAFLD)
  66. 66. Acetaminophen • Be sure to take the right amount! If you accidentally take too much of anything that has acetaminophen -- for instance, a pill for your headache and something else for your cold, and both have acetaminophen in it -- it can harm your liver. Check the dose and how much is OK to take in one day. Stick to those limits, and you should be fine
  67. 67. Trans fats • Trans fats are a man-made fat in some packaged foods and baked goods • A diet high in trans fats makes you more likely to gain weight • That’s not good for your liver. Check the ingredients list • Even if it says “0” grams of trans fat, it may still have a small amount, and that adds up
  68. 68. Alcohol • You probably already know that drinking too much is bad for your liver • But you might not realize that “too much” can happen without you being an alcoholic or addicted to alcohol. It’s easy to drink more than you think. Many glasses can hold a lot more than one standard serving, which is 5 ounces of wine (that’s a little more than half a cup), 12 ounces of regular beer, or 1.5 ounces of liquor • If you drink, be sure to keep it moderate -- that’s one drink a day for women and up to 2 per day for men
  69. 69. Lymph nodes • Lymphatic vessels lead into lymph nodes • The body has around 600 to 700 of lymph nodes in the groin, neck, armpits, around the heart, lungs, and intestines • The largest concentration of lymph tissue called gut-associated lymphatic tissue (GALT) surrounds the intestines
  70. 70. • Lymphatic fluid flows primarily upwards towards the neck • The lymphatic system has no pump of its own and must rely on the movement of the body’s musculoskeletal system to circulate
  71. 71. Ways to activate lymphatic system • Movement/ Exercise • Deep diaphragmatic breathing • Rebounding – Rebounding is the equivalent to jumping up and down on a mini-trampoline • Dry Skin Brushing or Effleurage
  72. 72. • Circular muscular fibers • Gastrophrenic ligament • Coronary falx of the stomach
  73. 73. Coronary falx of the stomach • Peritoneal fold formed by gastric artery • Concave below, stretched out between celiac trunk and posterior flank of lesser curvature
  74. 74. Lungs, evaluation, supine • Push on shoulder + Breathing • Push scapula and anterior of ribs + breathing • Push sides of sternum with knife hand + breathing • Push both hands on sternum + breathing • Push diaphragm + breathing • Hold trapezius muscle + push rib1
  75. 75. Description Vertebral level Contents Caval opening T8 The caval opening passes through the central tendon of the diaphragm. It contains the inferior vena cava and some branches of the right phrenic nerve Esophageal hiatus T10 The esophageal hiatus is situated in the posterior part of the diaphragm, located slightly left of the central tendon through the muscular sling of the right crus of the diaphragm. It contains the esophagus, and anterior and posterior vagal trunks Aortic hiatus T12 The aortic hiatus is in the posterior part of the diaphragm, between the left and right crus. It contains the aorta, the azygos vein, and the thoracic duct two lesser apertures of right crus greater and lesser right splanchnic nerves two lesser apertures of left crus greater and lesser left splanchnic nerves and the hemiazygos vein
  76. 76. Description Vertebral level Contents behind the diaphragm, under the medial lumbocostal arch sympathetic trunk areolar tissue between the sternal and costal parts (see also foramina of Morgagni) the superior epigastric branch of the internal thoracic artery and some lymphatics from the abdominal wall and convex surface of the liver areolar tissue between the fibers springing from the medial and lateral lumbocostal arches This interval is less constant; when this interval exists, the upper and back part of the kidney is separated from the pleura by areolar tissue only
  77. 77. Goal of treatment • Liberate all tension restraining the original diaphragmatic dynamic imposed on the intra- abdominal organs and to restore the plasticity and elasticity of those organs in order to maintain their homeostasis
  78. 78. Subjects • Lungs and Diaphragm • Liver • Gallbladder • Pancreas • Stomach • Intestine • Kidney • Bladder • Uterus
  79. 79. Visceral Osteopathy • Evaluation techniques • Treatment techniques
  80. 80. Contraindications • Bone fracture • Tumor • Infection • Pregnancy • Scar/bleeding
  81. 81. Treatment techniques • Push • Mobilization • Vibration • Recoil/Rebound (Lymphatic Technique) • Scooping
  82. 82. Lungs, active evaluation, sitting • Compare 2 sides • Put both hands over shoulder girdle+ breathing • Put hands around ribs below arm on each side • Put hands on both sides + breathing • Hands below diaphragm(from back) • Hands over chest (upper ribs) from back • Push rib 1 on both sides • Push hands over sternum and thoracic vertebra
  83. 83. Lungs, passive evaluation, sitting • Similar to active, but try to move chest from different areas • Push cartilaginous parts of chest