BSO - Visceral Osteopathy 2011-2012 Session 3&4

1. BSO - Visceral Osteopathy 2011-2012Session 3&4 Lecturer: Valeria A Ferreira DO MScOst PGCAP

2. Above the Diaphragm Mobility & Motility(after J.P. Barral and P. Mercier) Many thanks to J P Barral for verbally agreeing with the use of the text, drawings and extracts of his book “The Thorax” ” (3rd edition, 1994).

3. Thorax Learning Outcomes • Revision of the palpation/ location of: • Thoracic inlet and Mediastinum • Pleural ligaments • Thoracic outlet and Diaphragm • Lungs • Heart • Introduction to the concept of the different visceral restrictions (adhesions, fixations, ptosis, viscerospasm, rhythmic alterations) • Assessment techniques of mobility and motility tests (inspir/expir)

4. Thorax Revision of Concepts • Healthy organ has a normal physiological motion or Motility • Altered motion can be caused by: • Variations of the axis or the amplitude • Alterations to the motility • Alterations to the mobility of the organ caused by surrounding articular structures Valeria Ferreira

5. Thorax Possible clinical presentations • According to Barral,visceral motion can change if: • Local pathology with symptoms • Early stages of local pathology without symptoms • A local sequaela to an old pathology, with successful adaptation • Viscera having “articular” relations with a adjacent pathologic tissue/organ • A pathology in a structure having vascular, nervous and fascial relations with the viscera Valeria Ferreira

6. Thorax Revision of Concepts • Healthy organ has a normal physiological motion or Motility • Altered motion can be caused by: • Variations of the axis or the amplitude • Alterations to the motility • Alterations to the mobility of the organ caused by surrounding articular structures Valeria Ferreira

7. Thorax Possible clinical presentations • According to Barral,visceral motion can change if: • Local pathology with symptoms • Early stages of local pathology without symptoms • A local sequaela to an old pathology, with successful adaptation • Viscera having “articular” relations with a adjacent pathologic tissue/organ • A pathology in a structure having vascular, nervous and fascial relations with the viscera Valeria Ferreira

8. Thorax Terminology of Visceral restrictions • Visceral restrictions = any reduction in motion caused by restrictions of the sliding surrounding surfaces, connecting ligaments, muscles, etc. • Scar tissues - mechanical irritation leading to decreased motion and change in the axis of movement of the organ(s).

9. Thorax • Articular restrictions - involves loss of Mobility & Motility • Adhesions - Reduced Motility but normal Mobility • Fixations - Both Motility and Mobility are compromised (partial/total), causes may include sequelae of pathological infection, pleurisy, peritonitis, surgery, etc

10. Thorax • Ligamentous Laxity/ Ptosis = loss of elasticity in the ligament from prolonged overstretching, usually secondary to adhesions (Barral) • Muscular restrictions / Viscerospasms = • Hollow organs with double smooth musculature (longitudinal and transverse fibers) are exclusively affected. Irritation of a group of these fibers can result in viscerospasm, reducing amplitude of its motility. Local restriction that usually only affects part of the organ. Various causes. • Rhythmic problems = Compromised vitality with changes of the axes of motion resulting in a longer resting period or slowing down/irregularity of the rhythm.

11. Thorax • Assessment • Mobility tests • Mobility test or Listening

12. Thorax - RevisionThoracic Inlet • Also called the superior diaphragm. • Composed by muscles and ligaments fibers that join the 1st ribs, clavicles and T1. • The thoracic cavity is separated by the Mediastinum. • The mediastinum contains the Heart, Esophagus, Trachea and Vagus nerve.

15. Pleura • Pleura • Parietal layer lines whole thoracic cavity. • Inferiorly - Adheres to the diaphragm. • Anteriorly and laterally- lies the Sternocostal wall, connecting with the Endothoracic fascia. • Posteriorly- the pleura is thick and fibous, easy to dettach and it can fix part of the lung or the rib cage. • The pleura is very affected by the diaphragmatic motion (> superior attach’s). • Pleural restrictions are quite common. The superior attachments are area of myofascial tensions and changes in pressure, which makes it vulnerable to restrictions.

16. Thorax Pleural dome • Pleural dome • The apex is found at level of T1 • Posterior and medial to 1st rib • Lateral to Subclavian artery • Dome moves inferiorly on inhalation

17. Thorax Pleura • Suspensory ligaments • Parietal pleura is attached to a connective tissue dome - (intermediary to the hard skeletal frame). • Pleural dome is formed by myofascial fibers and ligaments such as: • the Pleurovertebral lig. • Costopleural ligaments - thick connective fibers that connects the dome to the neck of the 1st rib. It runs along the anterior edge of the 1st rib, ending close to the anterior scalenes. • Some fibers of the scalenus minimus or the transverse cupular ligament (when scalenus minimus is absent). • The Scalenus minimus is only present in 35-65% of people. Often replaced by fibrous tissue with contractile fibers. It originates from the pleural dome, running superiorly along the edge of the 1st rib, against the anterior scalenes. It inserts on the Tps C6-7. • The suspensory ligaments of the pleura and pericardium are inserted particularly on the deep cervical aponeurosis over C7-T1.

20. Thorax Pleural dome attachments • Fascial connections: • Fascial extensions of the middle and deep cervical aponeuroses are in contact with the pleura. They help to attach the pleura to the Csp, neck of the 1st rib and to the Esophagus and Trachea. • These fasciae are divided into 2 parts: • C4-7 and attaching to the Pleural dome. • From the mid cervical aponeurosis to the inferior part of the dome.

21. Thorax Cervicothoracic diaphragm • Loosely organized area with openings/ passages for the pleura, thymus, large vessels, trachea and esophagus. • The bounderies of this cervicothoracic diaphragm is formed by: • Anteriorly - sternum and clavicular insertions of the cervical aponeurosis. • Laterally - vascular sheaths. • Posteriorly - visceral sheaths and fibromuscular pleural apparatus.

22. Thorax 2 Mediastinum

23. Thorax Thoracic Viscera • The lungs • The apex extends from the upper aperture of the thorax and rises ventrally above the 1st rib in front • The base rests on the diaphragm • The flat mediastinal surface faces the medial connective tissue space in the thorax - the mediastinum • Its costal surface (curved surface) faces the ribs and vertebral column

25. Thorax Landmarks of R & L Bronchus • Trachea - bifurcates at inferior border of the Manubrium • R of the Sternum between the 2nd and 4th ribs (2nd rib connects at the munubrium/sternal junction) • R Bronchus is at 25 degrees off the Trachea • L Bronchus is at 45 degrees off the Trachea

26. Thorax The articulations of the Lungs • Sliding surface: • Oblique fissure (L) and Horizontal fissure ® • Posterior articulation: • Ribcage via parietal pleura • Anterior articulation: • Ribcage via parietal pleura • Lateral articulation: • Ribcage via parietal pleura • Superior articulation: • Scalenes and Cervicobrachial structures via pleural dome and Sibson’s fascia • Inferior articulation: • Diaphragm via parietal pleura

29. Thorax The Heart • Heart • The apex points forwards to the L and downwards • The base points backwards to the R and upwards

31. Thorax Pericardium • Separated from the Sternum by loose connective tissue that thickens at the top and botton ( the superior and inferior sterno-pericardial ligaments). • The degenerated Thymus (±age 8) becomes a fibrous-adipose mass that separates the pericardium from the sternum (ribs 1-3), transforming into pericardial lig’s • Posteriorly - connects with organs found in the posterior mediastinum (T4-T8). • Close connective tissue linkage with the esophagus (difficult to differentiate between esophageal and cardiac complaints).

32. The thorax Pericardium • Pericardial ligaments: • Superior sternopericardial or sternocostalpericardial lig • Inferior sternopericardial lig. or xiphopericardium ligament • Vertebropericardial lig

33. Thorax Pericardium • Superior sternopericardial (sternocostalpericardial) lig. • Helps to suspend the pericardium in the vertical and supine positions. • Triangular shape lig, which inserts on the manubrium and 1st sternocostal joint. • Replaces the degenerated Thymus. • Some fibers goes to the manubrium and others to the middle cervical aponeurosis.

34. Thorax Pericardium • Inferior sternopericardial lig. (or xiphopericardium ligament) • It helps to suspend the Heart in the supine position. • ± triangular shaped lig. • Originates from the xiphoid process, exchanges several fibers with the diaphragm and inserts into the middle part of the diaphragm.

35. Thorax Pericardium • Vertebropericardial lig. • Inserts into a thickened portion of the deep cervical aponeurosis bet. C4 - T4. • Better developed on the L side. This could explain why some of the cardiac pathologies are felt predominantly on the L side. • Some fibers run anteriorly to form aponeurotic sheaths for the Aorta and large vessels at the base of the neck.

37. Thorax The Heart • Superior: • R 2nd- 3rd intercostal space • L 2nd intercostal space • Inferior • R 5th intercostal space • L 5th-6th intercostal space • Left margin • 2 fingers medially R of left nipple line • Right margin • 2 cm R from the Sternum

38. Thorax The articulations of the Heart • Sliding surface: • Pericardium • Posterior articulation: • Bronchi pulmonary ligament • Anterior articulation: • Sternum, via sterno-pericardium ligament • Lateral articulation: • Lungs, via mediastinal pleura • Superior articulation: • Hilum of lungs and great vessels • Inferior articulation: • Diaphragm via the pericardial sac

40. Thorax • References • Visceral Manipulation- The Thorax, Barral, J.P.: Mercier, P, 1994 • Netter, F H (1989), The thorax in Atlas of Human Anatomy, CIBA-GEICY, USA • Lungs and Mediastinum lecture notes from Robert McCoy (BSO)