Clinical Osteopathic Observation of Patients with Left-Ventricular Assistance Device ©2017 Bordoni Et Al

International Journal of Complementary & Alternative Medicine

Clinical Osteopathic Observation of Patients with Left- Ventricular Assistance Device

Objective Clinical Paper

The objective of the study was to investigate the presence and location of

Volume 8 Issue 2 - 2017 osteopathic dysfunctions in this patient population, through palpation by qualified andpersonnel buccal such diaphragms. as qualified An osteopaths evaluation D.O. of theMethods: craniosacral The palpation rhythm evaluation was also 1Department of Cardiology, Institute of Hospitalization and concerned the spine, the respiratory diaphragm, the thoracic diaphragm, pelvic undertaken. Manual osteopathic evaluation was completed by the department Care with Scientific Address, Italy 2CRESO, School of Osteopathic Centre for Research and Studies, Italy on the second day after taking charge of the patient, before starting the cycle of 3Department of Radiological, Oncological and havecardiovascular thoracic outletrehabilitation. syndrome. Results: The dysfunction We detected of hypertonia the respiratory of the diaphragmparaspinal Anatomopathological Sciences, Italy 4 reflectsmuscles aat dysfunction the level of of C1-C2, the same C3-C4 side and of C7-T4, the buccal and highlightedand pelvic floors.that all Palpation patients Center for Life Nano Science@Sapienza, Istituto Italiano di Tecnologia, Italy hoped that the information highlighted is used in choosing the type of therapy by

of craniosacral rhythm showed a slowing of the cranial pulse. Conclusions: It is *Corresponding author: and that it will encourage other researchers to conduct further research in the Bordoni Bruno, Foundation Don manual fieldpractitioners, and patients such with as osteopaths, L- VAD. physical therapists and chiropractors, Carlo Gnocchi IRCCS, Department of Cardiology, Institute of Hospitalization and Care with Scientific Address, S Keywords: Maria Nascente, Via Capecelatro 66, Milan 20100, Italy, Tel: Received:0039.02.3496300617; Email:| Published: Osteopathic; Left ventricular assist device; Fascia; Diaphragm; Rehabilitation July 14, 2017 August 01, 2017

Abbreviations: CHF: Chronic Heart Failure; EBM: Evidence- Based Medicine; L-VAD: Left Ventricular Assist Device specialists.day, put under Since electric the system charge. is Thecarried patient out mustwith thelearn ultimate to manage aim Introduction the device and its management, thanks to the training provided by

Chronic heart failure (CHF) is a condition characterized by of having a transplant, it is referred to as “bridge therapy”, while the inability of the heart to ensure proper supply of oxygen to the if the use of L-VAD becomes a definitive therapeutic solution, it is body tissues [1]. The prevalence of this disease is found mainly described as a “destination therapy” [5,8], (Figure 1). in patients over 50 years of age.1 Heart disease from chronic age of the population and medical treatment that guarantees longerinsufficiency survival is for increasing, the cardiac due patient to the [1-3]. average When increase heart failure in the is in an advanced stage and the clinical condition allows, the Anotherpatient can treatment be put onoption the transplant in advanced list. heart However, failure the is mechanical number of organs available for transplant is lower than the demand [4,5]. pre-determined criteria for inclusion [6]. The most commonly surgicallyventricular implanted support, whichdevice can is left-ventricular be offered to patients assistance who device. meet

(L-VAD), a mechanical pump that supports the cardiac pump function, intervening in support of left ventricle in severe Figure 1: Patient with L-VAD. dysfunction, and which, in the newer models, provides a continual instrumentation with a display where every day the medical staff theflow apex [7]. Connectedof the left ventricle.to a pump; A therepackage is a ofcannula external for batteries the outflow for To his left the machinery that carries replacement batteries, and thethat operation exits from of the the aorta, pump and is put one into for connectionthe inflow whichby means enters of anin connectionevaluates the with values the ofmain the control patient, unit as theor cyclescontroller per minute(front) and the batteries speed of on the either flow. Theside wireof the comes patient out with of thea special peritoneum, belt. The in electric wire, called the drive line, which exits at the level of the subcutaneous tissue of the chest or peritoneum [7]. The system of external battery has a limited duration, approximately 12 hours in controller receives data from the continuous flow pump, and using a the newer models, and must be changed periodically during the link, can be transmitted the data to the computer.

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Methods with a previous history of sternotomy cardiac surgery and thePatients positioning undergoing of a pacemaker implantation / ofimplantable L-VAD, usually cardioverter present Setting and study partecipants mustdefibrillator be stable (PM and / ICD) they (Figure must be 2 able& 3). toThese handle patients the replacement are subject In our centre, Don Carlo Gnocchi Foundation IRCCS S. Maria ofto veryexternal long batteries periods ofbefore hospitalization, being discharged because to their home. condition These Nascente, during the time period between January 2011 and patients have to undergo strict medical supervision and can August 2016, 60 patients with L-VAD continuous flow implants access the cardiovascular rehabilitation programs; the results interventionwere hospitalized, patients of werewhich from 55 were an inpatient male and hospital. five women, with a minimum age of 23 years and a maximum age of 69. The post- patient with L-VAD system is subject to a number of complications Interventions of functional recovery are very slow but verifiable [6,9-11]. The both during the hospital stay, and at home, in particular anemia, During their hospitalization, they followed a cardiovascular respiratory problems, recurrent infections in the insertion of the we evaluated the presence of osteopathic dysfunctions in patients rehabilitation program, and an osteopathic evaluation for the VAD cable, and on rare occasions, thrombosis [5-7]. In this study detection of possible faults, using an identical palpation approach issues is missing from the existing literature. for each patient. The osteopathic somatic dysfunction is defined with L-VAD, as we have verified that a text citing osteopathic as an “impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural asymmetryelements [12]. and Thethe diagnosticrestriction criterionof movement for defining and the a increase somatic dysfunction must include abnormalities in tissue palpation, the

beforein muscular starting tone the [12].1 cycle The of assessmentcardiovascular was rehabilitation. performed by The the patientdepartment was onevaluated the second in daysupine after and taking standing charge positions. of the patient, The

the patient was comfortable. evaluation areas were chosen for ease of access, while ensuring All patients who underwent osteopathic evaluation displayed

wasa respiratory performed diaphragm by placing dysfunction,the hands under with the a range diaphragm of limited and Figure 2: movement. With the patient in the supine position, palpation (Figure 4). Small lateral offsets were actively induced to evaluate side the tubeFrom to the apexx-ray of can the be left observed ventricle. the The pump, patient where also to has the a theat the elasticity same time, of tissueswrapping and the whether fingers aroundthere were the costal preferential arches left there is the tube which will arrive to the aorta, while on the right movement vectors. Evaluating the respiratory diaphragmatic area device of ICD-PM. possibleusing active restrictions. stimuli, the structure was listened to see if breathing had any cranial-caudal limitations, assessing the existence of

Figure 4 Figure 3: From the x-ray can be observed the pump above the performed by placing the hands under the diaphragm and at the : With the patient in the supine position, palpation was

diaphragm muscle, and the close connection with the heart. same time, wrapping the fingers around the costal arches.

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Bordoni B, Marelli F, Morabito B, Sacconi B (2017) Clinical Osteopathic Observation of Patients with Left-Ventricular Assistance Device. Int J Complement Alt Med 8(2): 00255. DOI: 10.15406/ijcam.2017.08.00255 Copyright: Clinical Osteopathic Observation of Patients with Left-Ventricular Assistance Device ©2017 Bordoni et al. 3/8

For the pelvic floor the operator positioned his hands areasPalpating which thestood paravertebral out as having muscles hypertonia as a whole, and byhypomobility placing the understandbilaterally on the the elastic iliac bones, response resting of the on tissues the anterior-superior and whether or iliac not open palm on the muscles, had the effect of highlighting specific spine. Perpendicular pressure was applied towards the bed, to of vertebral segments, when solicited to passive movement. there were preferential movement vectors (Figure 5). Once the Palpation was performed with open palm on the column, by active areas are assessed, the structure was listened to in order pressing gently on the muscles, with the patient standing pelvicto understand diaphragm how area. diaphragmatic breathing is reflected on the (Figure 7). The joint motion was evaluated with small passive pelvic area, assessing the existence of possible restrictions in the smallmovements; lateral movements; for the cervical the thoracic spine, the portion patient was was assessed supine with and the operator kept the cervical spine in the hands, soliciting with operator’s hand on each vertebral segment; the lumbar and sacral the patient standing, with small trunk passive rotations and the operator under the corresponding section and passive rotation of was evaluated with the patient supine, with one hand of the

the operatorlegs with placedknees benthis hands with onthe both other sides hand so (Figures that the 8-10).index andFor the thoracic outlet area, with the patient in the supine position,

middle involved the clavicle (the bone between two fingers), the thumb was directed toward the C7-D1 level, and the remaining fingers on the area under the clavicular area.

Figure 5

: For the pelvic floor the operator positioned his hands understandbilaterally on the the elastic iliac bones,response resting of the on tissues the anterior-superior and whether or iliac not therespine. were Perpendicular preferential pressure movement was vectors. applied towards the bed, to

Applying light pressure to the cranial vector, the elasticity howof the the buccal tissues floor behaved was tested while the(Figure patient 6). breathed.In passive evaluation, always using the same palpatory approach, the operator assessed

Figure 7

: Palpation was performed with open palm on the column, by pressing gently on the muscles, with the patient standing.

General palpation of the craniosacral rhythm, by placing hands in open palm on the skull (little finger on the corner infero-lateral occiput, a middle finger on the asterion, the other middle finger theon thesacral tragus bone of with the the ear, patient the index supine. on the pterion, and thumbs resting on the parietal bone), and later a hand palm open under Outcome measurements

Figure 6 apply uniform pressure on both sides. comparingThe practitioner the two was sides instructed of the to reportbody. tissueThe comprehensive abnormalities, : Place the fingertips in a medial position to the jawline and restriction of movement in passive solicitation or listening,

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palpation examination was carried out by more practitioners for each patient, without interchange evaluation.

Figure 10: The lumbar and sacral was evaluated with the patient

Figure 8 section and passive rotation of the legs with knees bent with the othersupine, hand. with one hand of the operator under the corresponding lateral movements.: For the cervical spine, the patient was supine and the operator kept the cervical spine in the hands, soliciting with small The research is observational. All patients were informed and allowed the osteopathic evaluation voluntarily. The patient was never in danger during the evaluation; all patients of our clinic

to the Declaration of Helsinki - Ethical Principles for Medical are evaluated and are subjected to standard treatment, according was obtained from all patients. Research Involving Human Subjects. Written informed consent Results

Of a total of 60 patients, 55 had a more pronounced left thediaphragmatic side of the motordome in dysfunction, diaphragmatic while dysfunction the remainder is related showed to a major issue on the right. Osteopathic evaluation indicated that

the hypertonia of the ipsilateral muscle of the pelvic floor. In palpating the floor of the mouth, and externally the medial branch of the mandible, we see the same phenomenon, that is to say an increase of tone that reflects the diaphragmatic side which is moreThe in tonedeficit. of the paravertebral muscles of the dorso-lumbar

mobility. All patients were found to have the same phenomenon ofpassage increased always muscle appears tone to and be inhypomobility hypertonia, ofwith the reduced facet joints spinal at Figure 9: The thoracic portion was assessed with the patient there was a level of C3-C4 hypertonia. Another dysfunction which on each vertebral segment. standing, with small trunk passive rotations and the operator’s hand the level of C7-T4 and the occipital area sub-C1-C2. In 55 patients always presents in all patients is thoracic outlet syndrome, with

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varying clinical intensity. Fifty five of the patients evaluated right side. With the patient in the supine position, palpation for displayed paresthesia in the last two fingers of the hand with the thoracic outlet, highlighted an elevation of the first rib, a subjective intensity, especially the left little finger. The remaining hypertonia of the subclavius muscle and of the pectoralis minor, numberTable 1: Somatic of patients dysfunction. reported the same disturbance, but to the in the side that had the disorder (Figures 11-13), (Table 1 & 2). Thoracic Outlet Patients Diaphragm Pelvic Floor Floor of the Mouth Spine Syndrome

Left somatic Left somatic Left somatic 55 Left dysfunction dysfunction dysfunction Hypomobility C1-C2, C3-C4, C7-T4 5 dysfunction dysfunction dysfunction Right somatic Right somatic Right somatic Hypomobility C1-C2, Rigth C7-T4

Figure 11 Figure 12 : The operator evaluates the first rib, following with your positionfingers the according posterior to areathe breath. of the neck, until the root of the neck; the : Under the axilla, the operator places the thumb with examiner palpates the medial border of the first rib, which varies its cranial direction towards the coracoid insertion of the muscle, with oblique vector. Table 2: Graphic representing the major somatic dysfunction in 65 patients. slowing of the cranial rhythmic impulse in all patients tested (FigureGeneral 14). palpation of the craniosacral rhythm, displayed a Discussion This manual evaluation is based on our experience comprising

respiratory and cardiac diseases. The osteopathic dysfunctions more than 20 years of clinical practice with patients affected by implantation of L-VAD concerned an issue of diaphragmatic motor that we found more frequently in patients undergoing

Theand causesa hypertonic are many. muscles People of withthe pelvic CHF have floor an and altered the floor position of the of mouth, mirroring the side of the diaphragmatic dome dysfunction.

the diaphragm, in expiratory behaviour, with a non-physiological

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contractility rate [13]. Patient studies show a decrease in the along the left side of the pericardium [16]. The nerve may suffer mechanical and ischemic damage by extracting the internal highlight a situation of myopathy with phenotypic changes of the strength of the diaphragm muscle and, in animal research, often have a previous history of sternotomy intervention. The literaturethoracic mammary that the artery,functional because electrophysiological of its proximity andrecovery is often is contractile fibres [14,15]. People arriving at the point of L-VAD used for bypass procedures [16]. Normally, we know from the to the side of the diaphragmatic dome or greatly reducing its surgical approach may injure the phrenic nerve, causing paralysis conductivityrecorded as of occurring the phrenic within nerve 6-12 in subjects months who of the have procedure.16 undergone However, there is no data on the restoration of electrical betweenmobility. Duringthe phrenic the sternotomy and pericardium. procedure, This theevent temperature is registered drop in patients with L-VAD. causes a cooling lesion to the nerve, due to the close relationship the procedure, in conjunction with chronic heart failure, or in greater proportion to the left nerve, in that the cooling is mainly

Figure 13 Figure 14 experiencing: Thea small operator strip of putscompact the tissue. fingers below the clavicle, slowing of the cranial rhythmic impulse in all patients tested. particularly in the portion of the middle third of the bone, : General palpation of the craniosacral rhythm, displayed a

The diaphragm muscle with its fascia and neurological relationships forms a network of afferent and efferent information that can affect the whole body. From a neurological point of studies point out that the cell bodies of sympathetic afferent fibres view the contraction of the diaphragm muscle is preceded by are found in the dorsal root ganglia of C8-T9; these then run up the Lissauer track, progressing using the spinothalamic pathway [20]. Within this upward path somatic afferents can also be found the contraction of the floor of the mouth, and is synchronous [20]. Other studies with cardiovascular patients showed an with pelvic floor muscles [17]. The fascia connections to the aosteopathic strong muscle dysfunction tension in and the hypomobilityspinal area.21 joint For the ratio. sub-occipital From the diaphragm muscle, allows communication with the entire body tract and the relationship between spinal C1 and C2, we noticed network [17,18]. We can reasonably assume that a dysfunction of the diaphragm, will lead to functional alteration of the pelvic and neurological point of view, electrophysiology studies involving buccal floors. The tone of the paravertebral muscles of the dorso- the stimulation of cardiac nerves, suggest a close relationship lumbar area is always in hypertonia, with reduced passive spinal between myocardial afferents, neck, jaw and spinal tract of C1- mobility, probably as a result of the presence of a diaphragmatic C2 [20]. Other osteopathic research highlighted a dysfunction at indysfunction. hypomobility Our articulation.palpation evaluation We hypothesize highlighted that hypertoniathis feedback of the level of the cervical spine with high cardiovascular disease, the cervical muscle in 55 patients, at the level of C3-C4, resulting probably caused by a visceral-somatic reflex via the afferent vagal nerve [21]. The vagal nerve has a close relationship with is in relation to the suffering of the phrenic nerve, as a somato- the aortic arch, particularly to the left [22]. We can also speculate somatic reflex [19]. In all patients, we noticed these phenomena as to the cause of such problems found, not only at the cervico- at the level of the cervicodorsal track, in particular C7-T4, and dorsal area, in the area of C1 and C2 but also of the related the sub-occipital area, C1-C2. The change in muscle tone at muscles, is immobilization. These patients undergo a long period cervicodorsal level could be a visceral-somatic reflex since several of bed rest, which can last for several months, before cardio

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outlet syndrome; the causes of which remain speculative. The comfortablesurgical intervention bed rest towith position the neck the andL-VAD, dorsal and track also inelevated the post- to surgical phase. The posture adopted by the patient, to allow for craniosacral rhythm is slow, probably as a result of the clinical and This could cause structural and functional alterations of the Disclosurepathological history specific to the patient population evaluated. cervicala height musculature.of 45 degrees, Another is something dysfunction which thatshould we bedetected considered. in all

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