Visceral OMT

AAO Convocation
March 2018

Kenneth Lossing DO

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 Who First Described
Visceral OMT?
 AT Still- Osteopathy,
Research and Practice
 Carl McConnell- Clinical
Osteopathy
 Elmer Barber- Osteopathy
Complete
 Edward Goetz- A Manual
of Osteopathy
 William Garner Sutherland-
Teaching in the Science of
Osteopathy

2
 Definition of Visceral
Dysfunction
“Impaired or altered mobility or motility of the
visceral system and related fascial, neurological,
vascular, skeletal, and lymphatic elements”.
American Osteopathic Association glossary, 2009

”Dr. Still stressed the necessity of structurally adjusting

all lesions; that is of both the spinal and ventral (
visceral) planes.” Dr Carl McConnell
3
Dr. Barber’s List of Osteopathic
Treatment Indications in 1898
 Pulmonology: Asthma, tuberculosis, bronchitis, bronchiectasis, pneumonia, pulmonary
congestion, empyema, pleurisy,

 Cardiology: endocarditis, pericarditis, myocarditis

 Gastroenterology: constipation, gastritis, gastric ulcer, enteritis, chronic diarrhea, dysentery,

appendicitis, intussusception, intestinal obstruction, acute biliousness, jaundice, acute
hepatitis, inflammation of glisson’s capsule, gall stones, hepatic colic, acute pancreatitis

 Urology: anuria, hematuria, lipouria, pyuria, oxaluria, uremia, renal congestion, acute
nephritis, diabetes insipidus, pyletis, nephroliaasis, renal abscess, floating kidney, cystits,
prostatic hypertrophy, prostatitis

 General Medicine: acute peritonitis, ascities, splenitis, splenic hypertrophy, floating spleen,
proctitis, hemorrhoids, prolapsed ani, fistula in ano

 Gynecology: displacements of uterus, prolapse, amenorrhea, oligomenorrhea,

dysmenorrhea, acute metritis, cervical stenosis, salpingitis, ovarian prolapse, vaginitis,
prolapses vaginae

Osteopathy Complete, Elmer Barber 1898 4

 Mobility-Diaphragm
Movement
 All of the viscera
move with each
breath (mobility).
This movement is
necessary to keep
fluid and pressure
distribution within
normal limits.

Atlas of Human Anatomy, Sobbatta 5

 Planes of Motion
The motions of
mobility occur 3
dimensionally.
The largest visceral
motion is in the
sagittal plane, and
is largest near the
Transverse diaphragm.
Sagittal Coronal

Atlas of Human Anatomy, Sobbatta 6

Real Time MRI Shows All of the Viscera
Move With Respiration.
During inhalation
the lungs expand and
the respiratory
diaphragm contracts,
moving the
pericardium at least
1.5cm inferior and
medial, during tidal
breathing.

Fredricson,J. Radiology.1995 195:169-175 7

 Medicine is changing!
 In the time of Dr. Still, almost all diagnosis were based
on the traditional physical examination.

 Today, modern technology plays a much larger

diagnostic role.

 “Evidence-based” physical diagnosis, principally

addresses those diagnosis defined by technology
standards.

 Visceral respiratory motion has been measured.

Evidence based Physical Diagnosis, McGee 8

 Evidence Based Visceral
Motion
 The science of the last 20 years has confirmed what
Carl McConnell DO. told us over 100 years ago. “The
viscera ride in the tide of respiration”. Some, such as
the prostate, move less than a centimeter. Some, such
as the kidneys , can move up to 9 cm with maximal
inhalation.

 Visceral motion measurement comes from research

done in English, French and German languages. The
visceral movements have been measured with MRI,
CT, ultrasound, x-rays, and fluoroscopy.
 9
 What is normal?
 Normal:
 There is only 1 normal

 Visceral dysfunctions
show as decreased
motion.
 What Has Been
Measured?
 Movement of the organs with respiration by ultrasound, CT,
MRI, Fluoroscopy, which are 3D.

 Normal motion, decrease/alteration in dysfunction.

 Movement of the organs with posture changes.

 Visceral volume changes with posture change.

 Visceral density changes in dysfunction.

 Visceral density changes are palpable.

 Viscera sliding relative to their neighbors, and when this has

been compromised, as evidenced 11 by MRI and ultrasound.
 Visceral Slide

The viscera all slide with their neighbors.

When this ability is compromised, it is
visible with either ultrasound or MRI.
Detection and mapping of intraabdominal adhesions by12using functional cine MR imaging:
preliminary results, Lienemann, radiology 2000
 Respiration
 In quiet/tidal respiration the
diaphragm moves about 1.5cm,
the chest circumference changes
1.2 cm when erect and 0.7 cm
when supine.
 In deep respiration the
diaphragm moves from 7-13 cm,
and the chest circumference
changes between 5-11cm.
 In a full vital capacity breath, one
quarter of the ventilation is due
to chest expansion and three
quarters to diaphragm
displacement.
Movements of the Thoracic Cage and Diaphragm
13 in Respiration, Wade, J
Physiology 1954
 Mobility
 During inhalation the
respiratory diaphragm
descends ( 1.5-7cm), the
costo-diaphragmatic recess
opens, the pericardium
descends, the tension of the
pulmonary ligaments,
parenchyma, and vessels
increase.

 Therefore, tension in any

ribs, pleura, pericardium, or
lungs can all decrease
respiratory volume.
Anatomy: Development Function, and Clinical
14 Correlations, William Larson
2002
Respiratory Diaphragm
 Right and left hemi-diaphragms
move nearly the same
 Superior/inferior motion for liver,
spleen, diaphragm is 1.3cm for
tidal breathing, 3.9cm for deep
breathing
 Visceral motion is in 3 dimensions
 Liver dilates about 3%

Respiratory Kinematics of the Upper Abdominal

15 Organs A qualitative Study, H.
Korin, Magnetic Resonance in Medicine 1992
Diaphragmatic Motion
with MRI
 Fast Gradient recalled
echo MRI
 10 volunteers
 Patient supine
 Approximate vital
capacity breathing
 Rate of 4-10
respirations per
minute

Diaphragmatic Motion: Fast Gradient-recalled Echo MR

Imaging in healthy Subjects, Radiology 1995, Gierada
 Diaphragm Displacement
 Posterior
 Dome
 Anterior
 2,6 : mid dome
 4: mid sagittal
 Shows greatest motion at the
domes and posteriorly!

Gierada
 Diaphragm

 A: midsagittal , left exhalation, right inhalation

 B: mid dome, left exhalation, right inhalation

GIerada
Diaphragm
Motion

Diaphragmatic Motion, Gierada

 Diaphragm Motion

Gierada
 Test of Diaphragm
Mobility
 With the patient supine,
place your thumbs 2-3 cm
below the costal margins
bilaterally at about the
nipple line. Press your
thumbs through the
abdominal wall to the
abdominal contents. Have
your patient take a deep
breath.

Foundations of Osteopathic Medicine 21

 Lung Function Declines with Age
 FEV1 starts declining at
about 30 years old.

 Dyspnea without exertion

is common in 80 plus year
olds, and in smokers much
earlier.

Cecil Textbook of Medicine, 2004 22

 Lung Mobility, Deep Breathing

During deep vital capacity breathing the motion of the lung

regions was significantly greater in the lower regions that in
the upper regions (5+/- 2cm vs 0.9+/- 0.4).
Tumor bearing lung regions showed a significantly lower
mobility than the corresponding23
non-involved regions.
Imaging tumor motion for radiotherapy planning using MRI, Kacczor and Plathow, Cancer Imaging 2006
 Oxygenation Changes with Age
 Resting pO2- arterial
decreases even for healthy
people with aging.
 This trend was found to be
reversible using something
called Oxygen Multistep
Therapy in Germany.

Oxygen Multistep Therapy, M. Von Ardenne,

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Theme Medical Publishers, 1990
The Lungs
 Larger posteriorly than
anteriorly

 Accessible through the

lateral ribcage.

 Normal parenchyma soft,

firmer in COPD.

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 Layer Palpation
 To palpate a layer or an
organ: palpate to the skin,
then superficial fascia,
superficial adipose, etc.. noting tissue
texture and consistency at
Middle each layer. Does it feels like
there is tension? Continue
Deep through the tissues layers
to an appropriate depth.

 Explore the walls of the

body cavities (superficial),
the things inside the
26 cavities ( middle), and the
posterior cavity ( deep).
 Newton’s 3rd Law
 If 2 bodies are in contact,
and body 1 exerts a force
on body 2, then body 2
will apply a force on
body 1 in such a way that
the 2 forces will have
Action force Reaction force equal magnitude but
opposite directions.
1 2  Useful in layer
palpation, when you
press down to a layer, it
will press back.

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Fascial Pull
 While you are identifying
layers, pay attention to the
tissue texture and consistency.
 When you are on a fascial layer,
Dysfunction you may feel it being pulled in a
certain direction, towards a
dysfunction.
 Lift your hand off the body, and
move the base of the palm to
somewhere further along the
tension line. When you are at a
dysfunction, the tissue will pull
in. Confirm with motion testing
the structure.

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Lung

 The patient is in the lateral

recumbent position.
 Palpate through the skin and
ribcage to the lung tissue itself
(Layer Palpation).
 Motion test the lung superiorly
and inferiorly, also medial and
lateral rotation.
 Also compress into lung, and
appreciate its return (Texture
palpation and viscoelasticity).
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 Clinical
Correlation/Application
 Asthma: reduction in need
for break though meds
 Chronic pain patients:
almost all of them don’t
exercise enough
 Elderly patients
 Multiple medical problem
patients
 Chronic fatigue syndrome
patients
 History of pneumonia
 Bronchitis
 After smoke inhalation

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 Cardiac
Motion
 The inferior wall of the
heart was found to move
1.5 cm during tidal
respiration, in the coronal
plane.
 Left pictures: during
exhalation, top: end
systole, bottom: end
diastole
 Right pictures: During
inhalation
Simultaneous temporal resolution of Cardiac and
Respiratory Motion in MR Imagining, Radiology
1995, Fredrickson
 Breathing Affects
Circulation!
 Blood flow in the descending aorta
and superior vena cava increases
during inspiration because the
increased negative pressure increases
venous return, and decreases during
exhalation.
 In the abdomen, blood flow in the
portal vein is highest during
expiration, lowest during inhalation,
due to increased positive pressure
reducing blood flow. In healthy
subjects, cardiac pulsititiy of portal
venous flow is usually minimal, with
larger flow variations seen with
respiration!

Simultaneous temporal Resolution of Cardiac and

Respiratory Motion in MR Imagining, Radiology
32 1995,
Fredrickson
 Portal Vein
 Pulsatility or cardiac inter-
cycle variability is the
difference between the
minimum and maximum
values during a cycle. This
study shows a average flow
rate of the portal vein to be
about 970 mL/min, with the
respiration varying the flow
on average 539mL/minute,
and cardiac cycle varying an
average of 296mL/minute. In
other words about half of
portal vein blood flow is
respiration dependent.

Simultaneous temporal Resolution of Cardiac33and Respiratory

Motion in MR Imagining, Radiology 1995, Fredrickson
 Cardiac Output
 Free breathing and breath
hold.
 During free breathing, the
right side of the heart
maximizes cardiac output
during peak inspiration (
1.36) of breath hold), and the
left heart maximizes CO
during expiration (1.22)

Respiratory Resolved Cine Phase Contrast MRI: Measurement of

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Right and Left Heart Cardiac Output During Inspiration and
Expiration, B Thompson, Proc. Intl Soc. Mag. Reson. Med (2002)
 Ultrasound

Liver: 28 cases
Pancreas: 70 cases
Kidneys: 25 cases
All organs seen to move S/I, A/P,
L/R
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Cranio-caudal Movements of the Liver, Pancreas and Kidneys in
Respiration, Acta Radiological Diagnosis, 1984
 Meta Analysis of Visceral
Respiratory Motion

The Management of Respiration Motion in

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Radiation Oncology, AAPM Task Force 2006
 Renal ptosis
 A kidney can drop
(ptosis), lose it’s
mobility, and create
symptoms such as:
recurrent urinary tract
infections, renal lithiasis,
low back pain, knee pain,
flank pain, or groin pain.

Atlas of Anatomy, Sobotta 37

 The kidney, when stuck inferiorly can:
 Kink the ureter, restricting
urine outflow.
 Irritate the 12th intercostal
nerve, iliohypogastric
nerve, ilioinguinal nerve,
lateral femoral cutaneous
nerve, genitofemoral nerve,
or femoral nerve.

Atlas of Anatomy, Sobotta 38

 Kidney Position

 Right kidney is lower than the left, relates with R 12th rib,
right psoas, quadratus lumborum, transversus abdominis,
liver, ascending and transverse
Atlas of Anatomy, Netter 39
colon, duodenum.
 The Left Kidney
 Higher, it's inferior border is
1-2cm above naval.
 Mechanically relates with
left 11th and12th ribs, left
psoas and quadratus
lumborum muscles,
tranversus abdominus,
spleen, tail of pancreas,
transverse colon and
mesocolon, descending
colon, and stomach.
 Normal mobility of both
kidneys with deep
respiration is between 5cm
and 10cm.
Atlas of Anatomy, Netter 40
Kidney Ptosis, 1st Degree
 The kidney drops
inferior 0-1cm, feels
frozen, there is no
rotation.

 May irritate 12th

intercostal ( subcostal)
nerve- rib/back pain.

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 Kidney Motion
“Motion characteristics of kidneys with
visceral somatic dysfunction”, Heller,
Manual Medicine 2013 Germany
Normal: 4.4-5.9 cm with deep
respiration
With visceral dysfunction pre treatment:
3.5-4.5 cm
Post treatment: 4.5-6.5 CM
 Normal : 1-4 cm with shallow
breathing*
2-7 cm with deep breathing*
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*Surmo, 1984, Cranio-caudal movements of the liver, pancreas, and kidney, Acta
Radiol Diag
Kidneys
 Palpated through
abdominal wall and
Grynfeld’s space, check
with motion testing.

 Indications: abdominal
pain, flank pain, low back
pain, groin pain, UTI’s

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 Clinical Correlations
 Urinary stress incontinence
 Benign prostatic
hypertrophy
 Pelvic pain
 Pudendal neuralgia
 Low back pain

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 Stomach and Diaphragm:
Normal  The dome of the
diaphragm and the
fundus of the stomach
are clearly seen to
displace inferiorly during
inhalation, and
superiorly during
exhalation, on the order
of 1-2 vertebral
segments.
 Fundus displacement
measures 2.9 CM
inferior, 2 cm anterior,
right shift .6cm
Treating Visceral Dysfunction, Finet and
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William, Deltadyn
 Stomach Body and
Duodenum: Normal
 Stomach body: descends .8cm,
advances anteriorly .95cm, and
shifts to the left or right.

 Duodenum: Descends
 .53- .97 cm, closes on itself,
advances .64cm, shift to the left
.014cm

Treating Visceral dysfunction, Finet and

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William, Deltadyn
 Stomach: Abnormal
 Lack of full
descent, poor
motility

Deltadyn 47
 Stomach: Frontal Plane
 65 cases
 In Inhalation the gastric
fundus: moves from
superior to inferior an
average of 2.9cm,
posterior to anterior 2cm,
shifts to the right .6cm, it
tends to incline to the left.

Treating Visceral Dysfunction, Finet and

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Williame
 Gastroesophageal Reflux Disease
 Experienced 1x/month by 44% of US population.
 Experienced 1x/day by 7% of US population.
 Standard medical treatment often fails to ameliorate
symptoms.
 Many self medicate.
 Endosopy-50% normal, 30% mild changes, 20% severe
changes. (10-12% already have Barrett's).
 “Reflux disease, however, is associated with considerable
morbidity as a result of its propensity to produce
complications such as esophageal ulceration (5%), stricture
formation (4-20%), Barrett's esophagus (8-20%), and more
rarely gastrointestinal hemorrhage (<1%)”.
Textbook of Gastroenterology, Yamada,3rd
49
ed, 1999
GERD: Longitudinal Muscle
Contraction
 Tenting of fundus
 Barium in distal
esophagus is reflux
 The hiatus is widened
by LM force
 This is the only
book/article on
GERD that implicates
the LM. This is what
we find
osteopathically.
The Longitudinal Muscle in Esophageal
50
Disease, Stiennon
Evaluation of Upper
Esophageal Sphincter
 Palpate hyoid bone,
thyroid cartilage, cricoid
cartilage, trachea.
 At cricoid: palpate
posteriorly to find the
area of the lower
pharyngeal constrictor
muscle, motion test it
superiorly. In
symptomatic GERD, it
will not distend well.
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Test of Esophagus and LES
 Do layer palpation
through: skin,
adipose, abdominal
wall, peritoneum, to
stomach. Then bring
stomach inferior and
lateral to the left,
noting distance and
ease of distensability.

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 Sutherland Technique
 Addresses the crus of the
diaphragm and the LES
 Find the left 12th rib
 Place right fingers on it, left
hand under right.
 Traction laterally with left
hand, monitor with the right,
until you feel everything
soften.
 This tractions-12th rib, crus,
diaphragm, GE junction

Foundations for Osteopathic Medicine,2nd ed,

53
chapter 69
 Sutherland Technique
 12th rib

 arcuate ligament

 Crus of diaphragm

 Gastroesophageal
ligaments, junction

 Also celiac plexus

Atlas of Human Anatomy, Netter 54

 Treatment of Exhalation Dysfunction-
Stomach

 Stand to the left of the patient. Your left hand on the

area of the body of the stomach. Your right hand
under the left costal margin near the cardia of the
stomach. Induce a tension with both hands toward
the feet. Right hand-incline the ulnar edge to the left.
Left hand-incline the ulnar edge to the right.
Treating Visceral dysfunction, Finet, Williame,
55
2000
 Still Technique
 The patient is in a right lateral
recumbent position.
 You stand behind them, and place
your hands on their stomach.
 Traction inferior and laterally to
engage the tension.
 Take out the slack with each
exhalation, feeling the tissues
release, until you can feel the
traction all the way through the
esophagus.
 If done properly after the
presiding 2 techniques, will allow
you to stretch the longitudinal
muscle of the esophagus.

Foundations for Osteopathic Medicine, 2nd

56
ed, ch 69 Lossing
Visceral OMT Approaches
 Indirect/exaggeration
 Direct
 With respiratory assistance
 Lymphatic
 Vascular
 Counterstain
 Spinal/cranial

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 Visceral OMT
Contraindications
 High fever of unknown origin

 Traumatic internal bleeding

 Non medically treated cancer

 Infectious diseases not medically controlled

 Unstable medical problems without a proper diagnosis

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Kenneth Lossing DO
1748 Lincoln Ave.
San Rafael, CA 94901
(415) 454-8979
lossingaao@gmail.com

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