OMM: Surgery - Autonomic considerations

00:01 So the next step to approaching our surgical patient is B for breathing.

00:06 So it's vitally important for patients to be able to breathe, it helps to decrease post-op complications.

00:14 So some potential post op complications include: Wound infection, Respiratory complications, Bleeding, Thrombo-embolism, Urinary complications and Ileus.

00:25 So, the mnemonic to remember for patients that present with post-op fever are the 5 W's.

00:32 So if someone has a fever post-operatively, you have to think of potential problems with their lungs.

00:40 Perhaps they have developed atelactasis or pneumonia.

00:44 This is common because the post-op patient was intubated.

00:48 Also, after surgery, especially if there's abdominal incision, patients tend to splint and not want to take a deep breath in.

00:56 So atelectasis is when the alveola collapse or potential complication with pneumonia.

01:03 You have to consider possible UTI's.

01:06 So water stands for a possible infection of the urinary tract infection, especially with patients that had a foley catheter introduced for the surgery.

01:16 The 3rd W stands for Walking.

01:19 It reminds you that patients may develop deep vein thrombosis, especially post-operatively.

01:24 Patients are pretty immobile.

01:26 Usually they are stuck in bed and immobility increases their risk for a DVT.

01:33 The 4th W is Wound.

01:35 Surgical wound infection potentially could cause a post-op fever.

01:40 And the last W is Wonder drug.

01:43 So anesthetic medication sometimes could induce a drug fever.

01:48 So patients that present with a post-op fever, you have to think of these 5 things.

01:55 Out of these 5 things, OMT potentially could help patients with preventing some and also help treating some of these issues.

02:06 So, there's a major importance of optimizing breathing mechanics.

02:10 If we are able to optimize breathing mechanics, we are gonna be able to improve the amount of oxygen being delivered to our tissues, release and give off more CO2.

02:20 It discourages atelectasis and prevents pulmonary infections.

02:24 This alternating intrathoracic pressurewill help return of venous return and also promote lymphatic flow.

02:32 The sympathetic chain ganglion actually will be massaged or pumped with our breathing.

02:38 And important structures that enter or pass through or reside within the thorax also will have proper motion and function.

02:46 So, postsurgical complications are major cause of morbidity and mortality.

02:54 Pulmonary complications include atelectasis, bronchospasm, pneumonia and exacerbation of chronic lung disease.

03:01 Post-op atelectasis is usually caused by decreased compliance of a lung tissue, impaired regional ventilation, retained airway secretions, and/or postoperative pain that interferes with spontaneous deep breathing and coughing.

03:14 In fact, most post operative patients are given incentive spirometer.

03:17 This is a device where they have a little ball inside the tube and they use the tube and they have to inhale really deeply to keep the ball elevated.

03:27 And so, this device helps patients to expand their airway and to take deep breaths in.

03:37 So in postsurgical patients, we want to optimize the patient's recovery by addressing musculoskeletal structural findings to help them with thoracic cage mobility.

03:47 We wan to improve lymphatic drainage to decrease inflammation and to promote healing.

03:51 And we want to decrease post-op pain and to improve the body's structure to help restore normal function and promote healing.

03:58 So in order to prevent pulmonary complications, there are some key areas we need to diagnose and treat.

04:03 So it's really important to look at the thoracic rib cage.

04:06 When we breathe, we need proper mobility and motion of the rib cage.

04:09 The rib cage will articulate with the thoracic spine and all the muscles of respiration that attach to it.

04:17 So if there's restriction in the rib cage, the muscles that attach to it or the spine itself that could prevent proper expansion and movement.

04:25 We also have to look at the abdominal diaphragm.

04:27 The abdominal diaphragm is a major muscle that attaches to the lower rib cage and posteriorly to the 12th rib and it attaches also to the thoracolumbar junction.

04:36 So we wanna look at the abdominal diaphragm and it's excursion.

04:39 If the diaphragm is restricted, it's also gonna restrict the lungs, prevent proper inhalation and will not allow for proper changes in interthoracic pressure.

04:52 So again, our rib cage is a structure that surrounds the lungs and the heart.

04:58 Breathing is required to change the shape of the thoracic container.

05:01 The container changes shape.

05:04 And then when it changes shape, it also changes pressures.

05:07 These changing pressures ventilate the lung and also, help to bring fluids and lymphatics back into the thoracic cavity.

05:15 So in order to assess rib dysfunctions, what we're going to do is we're going to screen for rib restrictions based on the ability of the patient to breathe and also with motion testing.

05:26 So what we're going to do is we're gonna place our hand on the rib cage and three different areas: the lower rib cage, the middle rib cage and the upper rib cage.

05:34 You could use translation to see if you could detect restrictions in rib motion.

05:39 Or you could also place your hands there passively, have the patient take deep breaths and out and see if there's regions where the ribs do not move or expand as much comparing right and left sides.

05:53 So remember, the change and shape of the thorax helps to augment venous and lymphatic return.

05:59 In order to try to augment that shape change, we want to treat the diaphragm.

06:04 And also, we could perform oscillation throughout the thorax to allow for improved motion of the fluids.

06:12 So doming done on the diaphragm, here what we want to do, is with the patient supine, get your thumbs underneath the costal margin on both sides, you're gonna have the patient take a breath in and when the patient exhales, you're gonna follow the diaphragm into exhalation.

06:29 So most of the time when the diaphragm is restricted, it's gonna be restricted in inhalation because that's when the diaphragm contracts.

06:36 The diaphragm will descend, so you're trying to treat the diaphragm by doming it, bringing your thumbs underneath it, trying to restore it's natural shape on exhalation.

06:46 So you do this for several cycles, you resist on inhalation and gently follow with exhalation.

06:52 You don't wanna push really hard, this is a very sensitive area.

06:56 Patients would complain if you put too much pressure and it could cause pain.

07:01 So again, when the patient exhales, you keep following inhalation and exhalation and you continue this until you feel like the diaphragm domes easily at the end of exhalation.

07:11 So there are techniques that we could utilize to help treat the thoracic cage and improve it's compliance and also, it balances sympathetic tone.

07:19 So we could use soft tissue techniques to try to treat the different muscles that might be spasmed.

07:25 And try to relax those muscles to allow the rib cage to move and expand better.

07:29 You could utilize rib raising which helps to articulate the ribs and also helps to treat any viscerosomatics and remove any restrictions that might be blocking proper sympathetic tone.

07:42 And you can also use Myofascial release to help with reducing tension throughout the thoracic cage.

07:49 So, movement of the diaphragm is vital to a patient's ability to heal.

07:55 If the diaphragm is restricted, you then cut off the pump for lymphatics.

08:00 And so, we need to ensure that there is proper motion and movement of the diaphragm to allow for venous and lymphatic flow.

08:08 The abdomen and pelvis is a container which holds all of the abdominal pelvic viscera.

08:14 Any sort of diaphragmatic dysfunction will limit it's excursion and thus the ability to move fluids and allow for healing.

08:22 Here's a closer look at tha abdominal diaphragm.

08:26 The diaphragm is of upmost importance to treat and make sure that it is functioning well.

08:32 the aorta and the cisterna chyli pass through the medial arcuate ligament between the crura.

08:39 The right crus also forms the major portion of the gastroesophaegeal junction.

08:45 The sympathetic chain passes through the medial arcuate ligament.

08:49 And so there's a lot of important structures that pass through the diaphragm, and if there's restriction of the diaphragm, that could potentially cause issues in functioning of the structures that pass through there.