OMM: Treatment Options

00:00 There are some clinical presentations where osteopathic manipulation could be applied to in order to treat them. So, one thing to consider is anterior or posterior chest wall pain and costochondritis.

00:14 So costochondritis is an inflammation where the ribs and the sternum attach and usually there is localized chest pain that is reproducible by pressure or motion or movement. So, if a patient has costochondritis or anterior chest wall pain, it's a really good place to consider the application of counterstrain. So remember counterstrain is a technique where we are folding and holding over the point. So if you get to isolate a specific tender point that a patient might have with costochondritis or with anterior chest wall pain, counterstrain might be applicable technique to utilize. You could also utilize muscle energy, facilitated positional release, articulatory technique to try to mobilize the rib cage. If there is a rib that is stuck in inhalation or exhalation, that could potentially cause rib pain. Also rib raising could also help to remove any restrictions along the area and also direct inhibition sometimes can help with softening and loosening that muscle so it could decrease the level of pain in the region. Patients who have post-sternotomy usually will complain about chest pains. Pretty much post-sternotomy, the healing of the ribs and sternum sometimes may not be necessarily symmetric that could put an increased strain on the tissue in the ribs and the fascia underneath. So these strains could often extend above and below the incision site. So it's important to really look at the tissue and the fascia and to see how the strain extends beyond the incision site. So, if things are not really addressed or lined up correctly in the healing process, treatment could be very difficult. So, there has been several studies looking at the use of OMT in different cardiac patients and OMT was shown to really help in the recovery and with decreasing pain for patients after heart surgery. What they did was daily postoperative OMT was utilized to treat patients after their operation and they observed that the patients had decreased pain and improved hemodynamic effects post-surgery.

02:58 We could utilize osteopathic manipulation in treating cardiac presentations especially focusing on circulatory and lymph treatments. Lymphatic dysfunction has been found to be implicated in post-MI complications, congestive heart failure and even atherosclerosis. So we want to take a look at the cardiac lymphatics and see how we could promote lymphatic flow. So, the cardiac lymphatics are found in the fascia behind the heart and we discussed how all those fascias are intricately attached and tied into the thoracic cage. When we look at the thoracic cage, remember that lymphatics are moved primarily from breathing and so if we have any sort of restrictions, that's going to prevent that proper intrathoracic pressure change. So when we take a deep breath in, we create a negative pressure in the thoracic cage and when we exhale that creates rebound return to normal pressure and so every time we breathe, that helps to pump venous and arterial flow.

04:03 So, when applying osteopathic manipulative treatment to our patients to try to improve lymphatic flow, there are key areas that we have to look at to check for somatic dysfunction and treat.

04:14 So, remember we need to look at the upper rib cage, the clavicles, the sternum. Remember the relationship of the heart and its fascial connections to the thoracic cage. We want to try to make sure that there are no restrictions there that might be limiting lymphatic flow. You want to treat the spinal junctions especially the cervicothoracic and thoracolumbar. You have attachments of the abdominal diaphragm to the thoracolumbar spine. You also have the heart sitting right on the diaphragm and so addressing and treating somatic dysfunctions of the thoracolumbar spine will help with motion and movement of the diaphragm and looking at the cervicothoracic junction and the thoracic inlet is key. So, looking at the thoracic inlet, making sure that there are no restrictions there to allow for proper terminal drainage of the lymphatics and also again the abdominal diaphragm to try to promote lymphatic flow and then treating the upper extremities. This is something that we're looking at to really treat the pectoralis muscles. So when the pectoralis muscles are spasmed that can compress on the lymphatic vessels and the lymph nodes lying underneath the muscle.

05:25 So it's key to treat the shoulder joints and the muscles attaching to the shoulder to try to promote and increase lymphatic flow. So congestive heart failure is a condition that we could apply osteopathic treatment for. So, heart failure is a sign where there is decreased perfusion to meet the body’s metabolic demands. Somatic dysfunctions can contribute to the restriction of circulation in lymphatic flow. So, in congestive heart failure, we want to target potential regions of restriction and then augment lymph flow when appropriate to help the patients recover. You want to make sure that you don't overload the patient with lymphatic pumps if they're in acute state and wait for maybe medications to kick in first so they are not so fluid overloaded. The diaphragm is an important structure that we look at when considering the circulatory and lymphatic model of treatment. So, diaphragm is important for respiration, it flattens and contracts enlarging the thoracic cage and reducing intrathoracic pressure allowing for increased circulatory and venous return to the thoracic cage. So, here you could see an image when the diaphragm is contracting. It descends, thus creating a negative pressure allowing for air to come into the lungs and then it relaxes and then becomes a dome shape when the patients exhale. So, when we look at the diaphragm, we have to think about treating its attachments. So we have to think about its attachments to the thoracolumbar region, also to the 11th and 12th rib posteriorly and anteriorly on the sternum and the xiphoid and also the costal margins ribs 6 through 10. So the diaphragm has strong attachments to all these structures and it's important to address those areas for somatic dysfunction.

07:22 When we look at the diaphragm, it's important to note the different structures that pass through the diaphragm and where they pass. So, when you look at the diaphragm, it has a central tendon and then a muscular portion around it. So, in the central tendon region, it prevents contraction and so you have the inferior vena cava passing through at the level of T8. It's important to note that it really is more in that central tendon because when the diaphragm contracts and ascends and descends it doesn't compress on the vein and so the passage of the vein through that central tendon is an important placement whereas the esophagus passes through the esophageal hiatus and that is more at the level of T10 and you could see how the right crus kind of circles around the esophagus.

08:18 Why is it designed that way is that whenever we inhale or take a deep breath in, that will actually constrict at that sphincter preventing stomach acids from refluxing into the esophagus which makes sense because if we have a negative pressure in the thoracic cage we don't want the stomach acids to reflux up through the diaphragm and so the positioning of the esophageal hiatus is outside of the central tendon more within the musculature because we want that area to contract when we take a deep inhalation. Finally, the aortic hiatus is more in the posterior aspect. It is supported by the spine and again here when the diaphragm descends, since there is a support with the spine, it does not compress on the aorta because you don't want to compress on the aorta every time you take a breath in. Again, the aorta hiatus is more at the level of T12. So when we apply osteopathic treatment for promoting circulation in lymphatics, the first step is to remove any sort of restrictions, looking at the inlets, looking at the diaphragm and then trying to improve the function by improving respiration, improving the thoracic cage and then finally applying a lymphatic pump if indicated.

09:43 It's important to remember the drainage for the heart actually goes to both sides. The right side of the heart drains through the right lymphatic duct and the left side through the thoracic duct and so it's important to address both sides when you are trying to improve lymphatic drainage of the cardiac system. So when considering the circulatory lymphatic model, what we want to do is to utilize different treatments to treat our patients and optimize their lymphatic flow. So we start off again with the thoracic inlet, trying to remove any restrictions in the structures surrounding the inlet like the first rib, the clavicles and the pectoralis muscles. We want to optimize motion and breathing by treating thoracic cage and diaphragm restrictions and also utilizing lymphatic pumps if indicated. Keep in mind trying to avoid fluid overload and congestive heart failure and to make sure that our patients do not have any fractures or thrombotic events or acute fever that may promote sepsis. So in summary, applying this osteopathic treatment and diagnosis could potentially help with treating patients with cardiac presentations and to help them with balancing the autonomics, removing biomechanical strains and also promoting lymphatic flow and healing.