The Goal of Therapy

by Tyler Cymet, DO, FACOFP

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    00:01 So the big goal of therapy is that we can move and function freely.

    00:05 So the fascial strains can affect ones well-being.

    00:09 Each transitional zone in the body is associated with a horizontal diaphragm where many structures are going to go through and it allows for functioning.

    00:18 You can diagnose restrictions by identifying changes in the fascial pattern and how the fascial patterns relate to each other.

    00:26 And OMT is useful in promoting health by affecting the lymphatic drainage and the functioning of the diaphragm.

    00:32 A.T. Still brought our attention to the fascia as well and he said, “The fascia is the place to look for the cause of disease and the place to consult and begin the action of remedies in all diseases.” The body is a single unit. It’s all connected and the fascia is the thing that connects it.

    00:50 So let’s go ahead with an example.

    00:52 Here’s a case where we’re going to talk about respiratory issues and this is a 3-year-old male, who was brought into the office by his mom, with difficulty breathing and wheezing for 3 hours.

    01:02 What questions do you have for this patient? And what things do you think about? So a 3-year-old with difficulty breathing and wheezing for 3 hours.

    01:11 Big differential.

    01:12 You’re scared they may have swallowed something.

    01:14 It could be an obstructed airway.

    01:16 It could be an infection.

    01:17 It could be something congenital still. They’re still young.

    01:20 It could be that they’ve got some genetic disorder.

    01:23 So we’ve got a broad differential.

    01:25 What tests do you want to do to further narrow your differential and start focusing? Well, you want to know how serious it is.

    01:32 You want to get a measure of the oxygenation.

    01:35 You want to get a peak flow.

    01:36 You want to see if it’s anatomic, if it’s functional, and where you are.

    01:40 You may want to get an x-ray run, peak flow, or pulmonary function testing.

    01:44 And here’s a schematic representation.

    01:48 Because you’re going to look, listen, and feel.

    01:50 You’re going to test for functioning.

    01:52 You’re going to see if the breathing is something that’s affecting the musculoskeletal system as well as if oxygenation is occurring.

    01:59 Is there bronchospasm? Can you hear anything out of the ordinary? Are you seeing a lot of secretions coming out? Could this possibly be secondary to nervous activity, in the vagus, or sympathetic or parasympathetics? Is inflammation going on? And what do the secretions look like? Does it look infectious? Does it look dehydrated? What is going on? And you can actually look at the fluids you’re seeing to get a better sense.

    02:25 From a muscular aspect, you want to see which muscle the patient is using.

    02:31 Is the breathing normal and healthy? Is the diaphragm going out in the normal pump handle and bucket handle motion of the ribs occurring? Is there an excessive work of breathing? Have they started using the accessory muscles, or the sternocleidomastoid, and the rib muscles? Are they splinting or doing other mechanical aids to breathing? Does it look like the diaphragm is working well or does it look like the diaphragm is out of sync with the body? So what is going on that’s helping increase interthoracic pressure so breathing occurs or hurting interthoracic pressures? That’s what the examination of the musculoskeletal system is going to tell you.

    03:17 And I want you to stop and take a look at the muscles of respiration— the intrinsic muscles, the extrinsic muscles, the accessory muscles and what’s going on.

    03:27 So if you look at the chest cavity, what’s going to be expected and what’s going to be recruited when things are not going well? So take a moment and check out this image.

    03:45 One thing that I want to talk about is the diaphragm—huge muscle, many attachments, front and back, and a huge player in respiration.

    03:55 All of the muscular portions are going to converge in the aponeurotic central tendon.

    04:00 And it’s going to be a dome-shaped muscle with 2 lateral hemidiaphragms on each side.

    04:06 And the shape is going to be influenced by the viscera, the weight, and other things as well.

    04:10 It’s also important in other functioning of the body as well.

    04:13 So, it’s an important muscle.

    04:15 And it helps aid in the return of blood and lymph.

    04:19 So from a mechanical perspective, what are we focusing on? We’re focusing on the interaction of the muscles and the viscera, and what happens to the muscles of respiration when the patient starts having trouble breathing.

    04:34 This is a viscerosomatic issue.

    04:37 If you’re having trouble breathing, what does it do to the muscles? Could it be a somatovisceral issue? Sure, it could be.

    04:45 You could have a disruption of the diaphragm that’s causing the breathing not to occur.

    04:50 But in this situation, where you have a 3 year old who’s having trouble breathing, we’re going to look more at the viscerosomatic, and what happens to thoracic compliance when the muscles go out of sync, and when the ribs are no longer able to function.

    05:05 And what happens to the diaphragm early and late in this kind of problem and how it differs with different issues.

    05:13 So as we take a deep breath in, the diaphragm comes down.

    05:17 It pulls the ribs up a little bit.

    05:20 It creates a negative interthoracic pressure that helps pull the air in through the mouth and breathing occurs.

    05:28 So there are going to be some viscerosomatic signs you can find when a patient is having difficulty breathing.

    05:35 And you can relate these to the sympathetics and parasympathetic innervations.

    05:40 So what happens with increased sympathetic tone? We’ll see that in just a minute.

    05:45 And what structures do you have to focus on? This is relating ourselves to the connection of the viscera and the musculoskeletal system and how the autonomics are going to be that bridge.

    06:00 So when we talk about viscerosomatic reflexes, inflammation is what is going to be mediating what is going on.

    06:07 It’s going to be the communication that’ll be both positive communication because it’s communication—let’s people know what’s going on— but also can affect the functioning itself.

    06:17 So the convergence of the visceral nociceptors and the nociceptors from the somatic tissues are going to be found distally to the spinal cord.

    06:29 And this will also affect other feelings as well.

    06:33 So we’re going to talk a little bit about sympathetic innervation and how the lungs are going to be effecting the body because you’re going to get input from the upper thoracics which are then going to effect some of the functioning of the thorax as well.

    06:49 And viscerosomatic findings in pulmonary disease— once you have one system going wrong, other systems are going to follow.

    06:58 You can have early indicators in the musculoskeletal system.

    07:02 We talk a lot about Chapman’s points which are fibrous findings deep to the muscles—small, and can refer you back to certain areas.

    07:13 So if you find heart points or lung points, you can get a sense that that’s where you’re going to have to look for disease.

    07:21 And these are going to be important areas to remember, both so you can refer yourself and have clues and foreshadowing to problems, and also give you a full sense of what’s going on with the person’s health.

    07:36 When a person has increased sympathetic tone, you’re going to notice that there’s increased mucus production, thicker mucus production, and you’re going to start to have congestion occurring.

    07:48 You may have an overall decrease in lung secretions but you’re going to have an increase in the vasoconstriction to the lung tissue.

    07:57 So this is an important concept to be aware of.

    08:01 We also always relate the sympathetic to the parasympathetic activity and see whether they’re antagonistic and what they’re doing to each other.

    08:11 What happens when you have increased parasympathetic tone to the lungs and how it differs from increased sympathetic tone, and which is going to effect which organs? So with the lung, you do have some parasympathetic innervation which is going to occur through the vagus nerve.

    08:27 And that’s where the information is going to occur.

    08:31 In the normal state, the parasympathetic is going to be happening continuously and with feedback to the lung.

    08:39 In the increased parasympathetic nervous system tone, thinning of secretions, but profuse secretions, and you may have some constriction of the bronchi.

    08:51 And here’s a diagram giving you all of the parasympathetic effects on the body.

    08:57 Take a minute, study this, and go through it, make sure you read all of them.

    09:03 We will hit the major ones later on.

    09:05 When you’re examining this patient, we’re doing a lot of checking of the musculoskeletal system looking for somatic dysfunctions and looking at the transitional zones and the diaphragms.

    09:17 You want to pay attention as well to the jugular foramen and C2 where the vagus is going to enter.

    09:26 And here’s an anatomic orientation of the vagus nerve.

    09:30 It exits the skull through the jugular foramen.

    09:33 And this is going to be treated through OA and C2 treatment.

    09:39 What role does lymph drainage play in this case? We know that the lymph is getting congested.

    09:45 We know that there are zones filling with lymphatic fluid and there’s some impediment to return of the lymph into the circulatory system.

    09:53 And how is the lung tissue affecting this? Is it going to be more affected on one side or the other? And what findings are going to affect lymphatic drainage to point you in that direction? Well here’s an example of the lymphatics and lymphatic drainage different vascular system.

    10:12 It is extrapleural so you’re having the lymph occur in the body and then dump into the central circulation.

    10:18 And we do notice that the right lymphatic duct is going to be a key piece of what’s going on because it runs above the apex of the lung and is an area that can get occluded.

    10:30 The thoracic ducts from below because of the lymph flows up with a majority of lymphatics being in the top part of the body and draining back in through the cisterna chyli into the circulation.

    10:42 Restrictions in the lymphatic system are going to cause congestion which, when you get good, you can tell when there is lymphatic congestion from the musculoskeletal exam with different depths of pressure on the body.

    10:54 Some doctors like to examine the areas of entry of the lymph back into the circulation.

    11:00 I have trouble feeling those but it is an area to focus— once people are very sick it becomes a lot easier.

    11:07 Increased sympathetics are going to cause constriction of the large lymph vessels and decrease the drainage in the return.

    11:14 Just something to be aware of.

    11:17 And again, the lymph drains from peripheral and distal towards the central region.

    About the Lecture

    The lecture The Goal of Therapy by Tyler Cymet, DO, FACOFP is from the course Introduction to Osteopathic Treatment.

    Included Quiz Questions

    1. This is the reflex that results from the convergence of visceral inputs (viscera) which stimulates the somatic structures and causes clinical effects, including referred pain and segmental facilitation at the spinal cord level
    2. This is the reflex of the convergence of somatic inputs which stimulates visceral structures that cause clinical effects, including referred pain and segmental facilitation at the spinal cord level
    3. When an injury to somatic structures causes stimulation of the somatic nociceptors that reflex and stimulate other adjacent somatic structures
    4. When an injury to somatic structures causes stimulation of the somatic nociceptors that reflex and stimulate other adjacent visceral structures
    1. Bronchiole dilation
    2. Increased heart rate
    3. Increased vasoconstriction of the pulmonary vasculature
    4. Decrease in respiratory rate
    1. Decrease in respiratory rate
    2. Bronchiole constriction
    3. Increase in secretions
    4. Increased heart rate
    5. Bronchiole dilation
    1. OM sutures
    2. AO
    3. AA
    4. C2
    5. L2

    Author of lecture The Goal of Therapy

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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