13/01/14
What does visceral help to do? Well it was explained today that visceral should be used like any other technique whenever it is best suited to the patient. There is not a visceral osteopath but an osteopath that performs visceral. Visceral techniques affect the surrounding musculoskeletal system as well as the vascular and nerve supply.
Motility and mobility of the viscera was discussed today and from my understanding, motility is how one organ and moves in relation to another and mobility is how an organ is in relation to the musculoskeletal neighbouring structures.
The visceral elective today began with the diaphragm - recapping the anatomy and learning new techniques.
Anatomy:
L1-3 - Crura
I found the lesson really interesting and the diaphragm fascinating. I am going to watch the recommended dissection in preparation for next weeks session.
What does visceral help to do? Well it was explained today that visceral should be used like any other technique whenever it is best suited to the patient. There is not a visceral osteopath but an osteopath that performs visceral. Visceral techniques affect the surrounding musculoskeletal system as well as the vascular and nerve supply.
Motility and mobility of the viscera was discussed today and from my understanding, motility is how one organ and moves in relation to another and mobility is how an organ is in relation to the musculoskeletal neighbouring structures.
The visceral elective today began with the diaphragm - recapping the anatomy and learning new techniques.
Anatomy:
- Embryological: occurs from week 4-8 and derived from 4 precursor tissue (septum transversum, pleuroperitoneal membranes, paraxial mesoderm, oesophageal mesentery).
- Nerve supply: Phrenic nerve (C3-5)- Inner ring and central tendon
L1-3 - Crura
- Diaphragm muscle derives from C3-5 therefore it starts there and when the viscera descends it drags this innervation with it.
- Blood supply: Superior and inferior phrenic artery and vein.
- At level of T8 = Vena cava opening
- At level of T10 = Oesophageal opening
- At level of T12 = Aortic opening
- The right (psoas major) and left (QL) blend with the ALL of the vertebral column.
- Connection between Transversus Abdominus (TA) muscle fibres and the diaphragm - work at a right angle to one another with TA muscle fibres going more horizontal and diaphragm fibres going more vertical.
- Patient supine, place confident hands onto either side of the costal margin and lower part of diaphragm standing with your dominant hand furthest away. Really sink through the skin with your palpation. Ak the patient to breathe through their nose deeply and out, do this a few times and feel the rise and fall of their diaphragm with your hands. Be aware of the movement on both sides and it elevating and descending. One side will probably feel different and may rise but not descend (exhale) as well as the other.
- Patient sitting, stand behind them with a pillow in-between you and the patient. Place your hands preferably your thumb onto their restricted area e.g. under costal margin and ask the patient to slouch forward and breathe in as they exhale bring their body weight back onto you so they are sitting straight and slightly backwards and move into the restricted position. Add the patients arm into abduction and ask them to arch their back to reinforce this stretch even more. Re test and there should be a noticeable change to the diaphragm tone.
- Patient side lying, stand behind patient with body aiming more to the patients head, place cranial hand on their iliac crest and roll them over quickly towards you and place your other hand underneath their abdomen midway between their ASIS and umbilicus. Once the restricted area is found you can alter the levers by using cranial hand, body weight and caudal hand.
I found the lesson really interesting and the diaphragm fascinating. I am going to watch the recommended dissection in preparation for next weeks session.
20/01/14
In the visceral class today we practiced what we had learnt last week with the diaphragm techniques and then learnt some new techniques focusing on the crura and then subclavius.
On reflection:
In the visceral class today we practiced what we had learnt last week with the diaphragm techniques and then learnt some new techniques focusing on the crura and then subclavius.
- Patient sitting, use your thumb locked and at an oblique angle find the patients 12th rib then move laterally passed LES and QL to find the softer skin and then fix lightly there and with your other arm place across patients upper back and use this arm as a lever to move them left and right and then ask them to slump forward. To cause a tissue change will last no longer than 20 seconds and may feel like a needle on the patients side but only for a few seconds so patient must be pre warned. This technique helps the effect the crura.
- Patient side lying, get them to place their upper arm at a 90 degree angle with a loose fist resting on the plinth. Using pads of fingers scoop above the patients clavicle with thumb underneath it and pull downwards. Place your other arm on patients shoulder and use body weight to compress here. Use anterior and compression as levers and ask patient to take elbow away from their body to increase stretch. This technique works on subclavius and affecting SC, AC and GH.
On reflection:
- Never underestimate the importance of fascia and how it can help contribute to muscle tension.
- Position of body and feet when performing a technique, get them to help you move with little effort.
- Left crus originates from L1 & L2 and the right crus originates from L1-3 (is larger and longer).
- Both attach from the diaphragm to the vertebra.
- How working on the crura can cause a tissue change, allowing the diaphragm to work better as well as affect the movement of the rib cage.
27/01/14
On reflection, I found todays visceral lesson hard today and struggled with the evidence behind the techniques. We covered the pericardium and the 'hard thorax' looking at the clavicle, ribs, sternum and thoracic cage. The techniques shown were recoil techniques working on the surrounding pericardial ligaments. A lot of the technique was lead my palpation and where the tension was however, there is no evidence or physiology behind this technique and it was hard for the tutors to explain the concept fully. I understand that palpation is key to osteopathy and that our hands are a guide but I do like to try and have an understanding of the techniques I am trying to apply to patients and be able to explain them. I do not feel from today that I would be able to do this well and I do not feel effective in my palpation and technique to influence the pericardial ligaments. I felt the session was too advanced today for me and my level of palpation.
I revised the pericardial ligaments and their attachments:
On reflection, I found todays visceral lesson hard today and struggled with the evidence behind the techniques. We covered the pericardium and the 'hard thorax' looking at the clavicle, ribs, sternum and thoracic cage. The techniques shown were recoil techniques working on the surrounding pericardial ligaments. A lot of the technique was lead my palpation and where the tension was however, there is no evidence or physiology behind this technique and it was hard for the tutors to explain the concept fully. I understand that palpation is key to osteopathy and that our hands are a guide but I do like to try and have an understanding of the techniques I am trying to apply to patients and be able to explain them. I do not feel from today that I would be able to do this well and I do not feel effective in my palpation and technique to influence the pericardial ligaments. I felt the session was too advanced today for me and my level of palpation.
I revised the pericardial ligaments and their attachments:
- superior sternopericardial ligaments; anterior surface of fibrous pericardium to superior body of the sternum.
- inferior sternopericardial ligaments; anterior surface of fibrous pericardium to inferior body of the sternum.
http://etc.usf.edu/clipart/53900/53952/53952_heart.htm
03/03/14
I thoroughly enjoyed the visceral elective this week as we focused on the oesophagus and the throat which are very new areas for me in revising my anatomy but also in learning new techniques.
The two techniques we learnt were:
I thoroughly enjoyed the visceral elective this week as we focused on the oesophagus and the throat which are very new areas for me in revising my anatomy but also in learning new techniques.
The two techniques we learnt were:
- Oesophagus motility - place hand on left of sternum and away from manubrium and 'sink through the tissues' until you can 'feel' the oesophagus and ask the patient to swallow and follow the movement. Use your body weight to assert the pressure. Can follow movement of ease and use patients breathing.
- Hyoid, Thyroid and Cricoid Cartilage - Place hands on different parts of the hyoid, thyroid and cricoid and feel the resistance by moving each area to one side and back. Can make the movements quite large with patients consent.
10/02/14
The liver is such an amazing organ! That is what I took away with me from todays visceral class as well as many other very useful and powerful tips and techniques:
Functions:
The techniques today were so effective and I really felt today I really got an understanding of the effective visceral treatment can have on a patient. The liver techniques were sitting but mainly side lying and it aimed to encourage movement of the liver by following the position of ease and at the end put providing a quick strong impulse to further encourage movement. As the practitioner and patient is was great to treat and be treated as you could really notice as the patient a warm runny sensation when the liver released.
http://www.liverpoolgastroenterology.nhs.uk/Library/patientservices/billarysystem.gif
The liver is such an amazing organ! That is what I took away with me from todays visceral class as well as many other very useful and powerful tips and techniques:
- It relationship between the stomach, gall bladder, pancreas, diaphragm and duodenum.
- The blood supply: Hepatic artery from the aorta and Portal veins from the GIT to the liver and Hepatic veins from the liver to the inferior vena cava. Important to understand this as the stomach can heavily influence the liver health due to this blood supply.
- Situated around T5-Rib 12 on the right hand side and can greatly vary in size.
Functions:
- Amino acid synthesis
- Produces and excretes bile which s used to emulsify fats and this goes to the duodenum or is stored in the gallbladder
- Helps with absorption of Vitamin K in the diet
- Plays a part in lili and carbohydrate metabolism
- Breaks down or modifies toxic substances e.g. alcohol and are 'drug metabolised' so they are excreted in bile or urine.
- Removal of bilirubin (yellow part of haem catabolism of RBC) excreted through bile. If bilirubin levels build then patient will present with yellow skin, eyes, stools etc.
The techniques today were so effective and I really felt today I really got an understanding of the effective visceral treatment can have on a patient. The liver techniques were sitting but mainly side lying and it aimed to encourage movement of the liver by following the position of ease and at the end put providing a quick strong impulse to further encourage movement. As the practitioner and patient is was great to treat and be treated as you could really notice as the patient a warm runny sensation when the liver released.
http://www.liverpoolgastroenterology.nhs.uk/Library/patientservices/billarysystem.gif
17/02/14
'Last night a DJ saved my life.' That was the song from todays visceral class in regards to the duodenal-jejunum sphincter (DJ junction). We looked at the sphincters today which was extremely interesting;
Reflection:
'Last night a DJ saved my life.' That was the song from todays visceral class in regards to the duodenal-jejunum sphincter (DJ junction). We looked at the sphincters today which was extremely interesting;
- Pyloric sphincter - found centrally in line with the xiphoid process and three fingers approximately from the umbilicus.
- Sphincter of Oddi - mid clavicular on the right obliquely to the umbilicus and then three fingers approximately from the umbilicus in the same angle.
- Cardiac - found lateral to the xiphoid process to the left hand side.
- Ilio-caecal valve - found one third between the ASIS and the umbilicus on the patients right hand side.
- D-J junction - found mid clavicular line on the left obliquely to the umbilicus and then three fingers approximately from the umbilicus in the same angle.
Reflection:
- Must sink through the tissues and feel the surrounding areas to feel the difference between the soft and hard barriers.
- The sphincter areas are often tender and painful for the patient and there should be a palpable 'pea' shape underneath your palpating hand.
- Soft pads of fingers that sink through the tissues with your body not force from your hands.
- Know the anatomy under your fingers so you can focus on palpation and switch off from your brain and really feel the structures beneath your fingers.
- Keep heel of hands upwards and sink into tissues at an oblique angle using your body weight.
24/02/14
We covered the stomach and different techniques for it as well as the lesser and greater omentum in Visceral today which was really interesting and I felt that I could use this on my patients (where appropriate) and could have a positive effect on their symptoms. The class today made me reflect on the role of the stomach, surrounding structures, blood and nerve supply. I also realised that you can feel the difference between the structures in what you palpate and feel underneath your fingers and you need to be firm and sink through the skin to influence the stomach and lesser omentum.
We covered the stomach and different techniques for it as well as the lesser and greater omentum in Visceral today which was really interesting and I felt that I could use this on my patients (where appropriate) and could have a positive effect on their symptoms. The class today made me reflect on the role of the stomach, surrounding structures, blood and nerve supply. I also realised that you can feel the difference between the structures in what you palpate and feel underneath your fingers and you need to be firm and sink through the skin to influence the stomach and lesser omentum.
03/03/14
It was the turn of the small intestines today with understanding the embryology, anatomy and function of this fundamental organ. I reflected that you must say to the patient about the effect treatment may have on their bowel habits as often the small intestine techniques help to get things moving and the patient must be told beforehand so that they are not worried if this happens to them after treatment. It was also touched upon today that these techniques may not have direct effect on helping other organs or structures but by helping treat constipation symptoms can really make a difference to the patients quality of life. I liked in todays session when you understand what the techniques are trying to achieve you can adapt them to each patient and develop your own modification. I found the direct technique onto the small intestine worked best for the colleague I was working with.
It was the turn of the small intestines today with understanding the embryology, anatomy and function of this fundamental organ. I reflected that you must say to the patient about the effect treatment may have on their bowel habits as often the small intestine techniques help to get things moving and the patient must be told beforehand so that they are not worried if this happens to them after treatment. It was also touched upon today that these techniques may not have direct effect on helping other organs or structures but by helping treat constipation symptoms can really make a difference to the patients quality of life. I liked in todays session when you understand what the techniques are trying to achieve you can adapt them to each patient and develop your own modification. I found the direct technique onto the small intestine worked best for the colleague I was working with.
10/03/14
We went through the anatomy and techniques for the uterus and the surrounding ligaments today in visceral. We palpated for the pubis, bladder, uterus, and obturator membrane.
On reflection:
We went through the anatomy and techniques for the uterus and the surrounding ligaments today in visceral. We palpated for the pubis, bladder, uterus, and obturator membrane.
On reflection:
- Patient must understand and agree to each technique as they can be in intimate areas.
- Differentiating between the superior pubic ramus which had a hard bone end feel and the obturator membrane that was a lot softer on palpation.
- Really connecting between both hands when one is on the sacrum and the other on the uterus and bladder.
- Know the anatomy under your palpating hand so that if there is restriction there you know what structures might be implicated.
- Practice the techniques so that you build up confidence and believe in what you are dong and trying to achieve.
17/03/14
It was the last visceral elective today which I am really sad about as I have found it a very useful yet challenging elective. We covered the kidney today and I felt this technique had the most effect on my colleagues that I practiced on. At the beginning of each session we cover embryology which really helps to understand the organ and how and why it is there in the body. I found that my embryology is not up to scratch and this is something that I must put some time into to gain a better understanding. The kidneys function are outstanding and they help to maintain and control many things including blood pressure, vitamin D and calcium levels. The main technique involved finding each kidney e.g. the right one you look for the canal between the ascending colon and the duodenum and sink through the tissues to feel a harder surface which is the kidney, the other hand fixes around the posterior part of the kidney and with two hands working together you can feel if the kidney wants to go superior, inferior and medial or lateral. The technique involves taking the kidney into the position of ease and trying to enhance its movement and therefore function. The patient will often say this technique feels weird and can sometimes feel the release and heat around the kidney area.
I think it is important to be aware of all the structures you can influence when performing this technique on the kidney to be able to justify why you are using on this patient with low back pain.
The visceral classes have been excellent and I feel I have learnt a lot that I can take away with me into clinic however, I do believe that much more time and practice is needed to fully understand and ensure the techniques are performed effectively. I will want to do some more classes on visceral techniques and this can be part of my CPD when I am a fully qualified osteopath.
It was the last visceral elective today which I am really sad about as I have found it a very useful yet challenging elective. We covered the kidney today and I felt this technique had the most effect on my colleagues that I practiced on. At the beginning of each session we cover embryology which really helps to understand the organ and how and why it is there in the body. I found that my embryology is not up to scratch and this is something that I must put some time into to gain a better understanding. The kidneys function are outstanding and they help to maintain and control many things including blood pressure, vitamin D and calcium levels. The main technique involved finding each kidney e.g. the right one you look for the canal between the ascending colon and the duodenum and sink through the tissues to feel a harder surface which is the kidney, the other hand fixes around the posterior part of the kidney and with two hands working together you can feel if the kidney wants to go superior, inferior and medial or lateral. The technique involves taking the kidney into the position of ease and trying to enhance its movement and therefore function. The patient will often say this technique feels weird and can sometimes feel the release and heat around the kidney area.
I think it is important to be aware of all the structures you can influence when performing this technique on the kidney to be able to justify why you are using on this patient with low back pain.
The visceral classes have been excellent and I feel I have learnt a lot that I can take away with me into clinic however, I do believe that much more time and practice is needed to fully understand and ensure the techniques are performed effectively. I will want to do some more classes on visceral techniques and this can be part of my CPD when I am a fully qualified osteopath.