An Integrated Approach for Treating the OB Patient: Treating the Five Diaphrams of the Body, Part I

by Ken Johnson, DO Introduction ratory rate is unchanged. The tidal helpful and detrimental from a struc- regnant volume increases by 40% and the tural point of view. Women who have women are a residual volume (which is the volume pre-existing somatic dysfunction be- joy to treat. aftermaximum exhalation) decreases fore pregnancy may be helped greatly They seem to by 20%. The expiratory reserve vol- during pregnancy. The relaxation of be tied di- ume (the amount that can be expired the ligaments allows for a greater, as rectly into the at the end of normal exhalation) in- well as easier, mobilization of a re- primary life creases by 20% and the functional stricted joint. There is also a negative force of the residual capacity decreases. The tho- effect in that the relaxation of the universe. Pregnancy is a time of racic cage also flares, increasing the ligaments can promote somatic dys- change; anatomically, physically, subcostal angle from 68° to 103°. The function occurring at a joint; a com- mentally and emotionally. Part 1 of diaphragm, due to the changes of mon example is an acute pubic sym- this paper will discuss the physiologi- pregnancy, must increase in its excur- physis shear. This can be an excruci- cal as well as anatomical changes that sion to oxygenate the increased blood atingly painful somatic dysfunction. occur during pregnancy. Part 2 will volume. discuss diagnosis and use treating the A common complaint of preg- five diaphragms of the body (the foot nancy is a subjective feeling of dys- arches, the pelvis, the respiratory dia- pnea. Dyspnea is possibly due to the ANATOMY phragm, Sibson's fascia covering the increase in blood volume to be oxy- There are many anatomical thoracic inlet and the tentorium cer- genated, and the anatomic changes changes that occur during pregnancy. ebelli) as a model for treatment. which lead to altered respiratory The growing fetus within the uterus function. causes an overall anterior shift in the center of gravity of the pregnant PHYSIOLOGY woman with a compensatory poste- Cardiovascular System Renal System rior shift in the shoulders - the so- The blood volume increases by Because there is more blood to be called "pride of pregnancy stance". approximately 40-55%. There are in- circulated by the cardiovascular sys- There is an increase in the lumbar creases in stroke volume by 30%, tem, there is more blood to purify. lordosis. These shifts cause changes heart rate by 10-20% and possibly an Therefore, the glomerular filtration in the thoracoabdominal pelvic cavi- increase in the cardiac volume by rate increases by approximately 50% ties which impede function and will 10%. The changes in the cardiovas- with a corresponding increase in so- be discussed in the following sec- cular system indicate that there is dium retention. tions. more blood for the cardiovascular system to circulate. Endocrine System First Diaphragm - There are numerous vascular The corpus luteum of pregnancy Arches of the Feet changes that occur as well. The uter- produces a polypeptide hormone The navicular is like the key- ine blood flow changes from approxi- called "relaxin". Also, there is an stone of the medial arch. With the mately 30-50 rril up to 500-1000 ml increase in the production of estro- postural changes that occur during per minute. There is also an increase gen. These hormonal changes cause pregnancy, it is common to find a in the breast blood flow. relaxation of the pelvic ligaments and functional pes planus or "flatfoot". also a general relaxation of many The arch, especially the navicular Respiratory System ligaments throughout the body. bone, drops inferiorly. There is a It has been proposed that the respi- These endocrine changes are change in the relationship of the talus

/A Atop Journal 6 Winter 1991 to the tibia and fibula, which will the uterus, bladder and rectum. The Third Diaphragm - change the orientation of the knee bladder is suspended in the pelvis by Respiratory Diaphragm joint and, in return, will be reflected the median umbilical ligament (em- The pelvic and the respiratory dia- into the pelvis. bryonic remnant of the urachus) as phragms are connected anteriorly, The tibialis anterior attaches to the well as its lateral and posterior at- posteriorly, radially and laterally. medial cuneiform and base of the first tachments of endopelvic fascia. The Posteriorly, the quadratus lumborum metatarsal. The tibialis posterior at- cardinal ligaments containing the is attached to the taches to the navicular, cuneiforms, uterine artery forms a lateral suspen- and the iliac crest. Superiorly, the cuboids and bases of 2-4 metatarsals. sion for the uterus. There is a direct quadratus lumborum is attached to Together these muscles form a sling connection between the bladder and the twelfth . The quadratus lum- for the longitudinal arch. As the arch the uterus, running anterior to poste- borum could be viewed as a functional drops, there is an increased tone and rior, forming the vesicouterine pouch. extension of the diaphragm. The tension noticed in the tibialis muscles. The bladder is also suspended by the quadratus lumborum has, as its action, The tibialis anterior attaches on lateral pubovesicular ligaments. The both postural as well as respiratory the lateral anterior portion of the tibia rectum is suspended by the presacral motion. The quadratus lumborum acts and the approximate region where the fascia as well as the vaginal rectal as an anchor for the twelfth rib during iliotibial band attaches. When the arch fascia. respiration. Restriction in either he- drops, there is a change in the ten- The fascia of the pelvis and the midiaphragm can be seen reflected in sions of the tibialis anterior, reflect- endopelvic fascia basically suspends the quadratus lumborum and through ing into the iliotibial band which, in these three organs -the bladder, uterus the tensor fascia lata into the iliotibial turn, will affect the pelvis. As the arch and rectum within the pelvic cavity, band all the way to the peroneal drops, the talus changes the relation- allowing them to float within the muscles of the lower extremity. ship with the tibia and the fibula; the content of the pelvic cavity. The names fibula being an attachment for the of the fascial ligaments are somewhat POSTERIOR long and short head of the biceps. misleading, creating the idea that there Therefore, the change in orientation are a number of separate ligaments The diaphragm is attached to the of the fibula and tibia will have an within the pelvis. In reality, the liga- twelfth rib posteriorly via the lateral effect on the long and short head of ments are thickenings of fascia, which and medial arcuate ligaments. The the biceps. The biceps femoris attaches are continuous with each other and lateral arcuate ligament attaches from from the fibula head to the ischial with the fascias of the rest of the body. the twelfth rib to the transverse pro- tuberosity as well as the sacrotuber- Any kind of twist in the pelvis, any cess of T12. The medial arcuate liga- ous ligaments. restriction in the pubic symphysis or ment attaches from the transverse These changes in the anatomical either sacroiliac joint can have a large process of T12 to the body and the relationships of the arches (first dia- effect on the endopelvic organs. A anterior longitudinal ligament at T12. phragm) to the second diaphragm (the twist within the pelvis will impede The medial and lateral arcuate liga- pelvic diaphragm) of the body can be the organs and the vessels leading to ments form what could be thought of enough to impede both the postural as a stasis of fluid in the pelvic organs as as caves for the quadratus lumborum well as respiratory motion of the pel- well as the lower extremity. One pro- and the psoas. These ligaments are vis and lower extremity. posed mechanism of swelling in the basically thickenings of the fascia, covering the muscles in this region. lower extremities is that the fetus will Medially, the crura of the dia- Second Diaphragm - impinge on the inferior vena cava phragm attaches to Ll, 2 and 3 on the Pelvic Diaphragm somewhat and cause a back pressure right and Ll and 2 on the left. This is The pelvis is made up of the two within the venous system, leading to how it is described in most anatomy innominates and the . It is venous stasis. Another possible books. In reality the crura attaches to heavily invested with muscle and mechanism is somatic dysfunction of the anterior longitudinal ligament and neurovascular structures, as well as the pelvis, impairing the ability of the blends to this ligament. It is impossible fascial structures. The endopelvic pelvic diaphragm to move in con- to separate the crura from the anterior fascia attaches anterior to posterior, junction with the respiratory dia- longitudinal ligament at their attach- as well as medial lateral, forming phragm leading to stasis of lymphatic ments. Looking at specimens in the what could be thought of as support and venous fluid. anatomy lab, the crura basically blend bridges for the pelvic organs; namely into the anteriorlongitudinal ligament

MO Journal Winter 1991 A 7 and functionally become a portion of Reciprocal Function of the coabdominopelvic cylinder will im- it. The anterior longitudinal ligament Respiratory and Pelvic Diaphragm pede the return of fluid centrally. continues down through the lumbar (There is a functional relationship The growing fetus will displace vertebrae and can be shown to con- between the pelvic diaphragm through the abdominal contents superiorly, tinue into the anterior sacral coccygeal the median umbilical ligament to the pushing the diaphragm into the tho- ligaments and then directly into the umbilicus and then the falciform liga- racic cavity. Affectively, there is a pelvic musculature, thus forming the ment through to the diaphragm.) The decrease in the superior to inferior posterior connection between the pelvic diaphragm works in a recipro- length of the . There- pelvic and respiratory diaphragms. cal relationship with the respiratory fore, the diaphragm must work at an The lateral connection between the diaphragm. As the respiratory dia- increased rate of contraction against a pelvic and respiratory diaphragm are phragm contracts, the pelvic dia- stronger resistance to maintain oxy- through the muscles of the abdominal phragm must relax to allow the ab- genation of the circulating blood vol- wall. dominal and pelvic contents to shift ume. inferiorly. If there is any restriction in Not only is there an effect on the ANTERIOR the respiratory or pelvic diaphragms, superior to inferior length of the tho- The organs and muscles of the this physiological phenomenon will racic cavity, the growing fetus shift- pelvic cavity connect with the en- not occur. It may be that there are ing the center of gravity anteriorly dopelvic fascia. The endopelvic fas- neuronal pathways which reflexively will increase the lumbar lordosis. This cia is connected to the median umbili- relax the pelvic diaphragm when the creates a larger tension on the crura of cal ligament and to the medial umbili- respiratory diaphragm contracts and the diaphragm posteriorly, impeding cal ligaments which go to the umbi- vice versa. diaphragmatic function. The pelvis is licus and linea alba of the rectus sheath. With each inspiration, the dia- tilted anteriorly, greater tension is Continuing superiorly from the um- phragm acts on the lumbar vertebrae. placed on the anterior abdominal wall bilicus, the falciform ligament and There is a general flattening of all and the A-P diameter is de- ligamentum teres (round ligament) spinal A-P curves. The diaphragm, creased. attach to the liver as well as the inferior acting through the crura moves the ante riorlongi tudinal ligament and has surface of the diaphragm. Therefore, Fourth Diaphragm - there is a direct anterior connection a far reaching effect throughout the Sibson's Fascia cardiovascular system. Blood is from the pelvic diaphragm to the The thoracic inlet, which is com- pumped from the heart out to the respiratory diaphragm. The falciforrn prised of T I , the first and manu- extremities throughout the cardio- ligament basically cuts the liver in brium, work as a functional unit. Any vascular system. Blood is returned half anterior to posterior. rotation of T1 will be reflected through through the venous and lymphatic The combination of the falciform the first ribs and the manubrium, channels by the action of the pumping ligament with the ligamentum teres changing the diameter of the superior of the peripheral muscles. The return (round ligament) embedded within it thoracic aperture. Sibson's fascia is system (venous and lymphatic) is and the ligamentum venosum form attached to the inferior border of the highly pressure-gradient dependent. an anterior to posterior fascial con- first ribs and the posterior border of When the return of blood enters the nection. So there is not only an infe- the manubrium and going posteriorly pelvic cavity and abdominal cavities, rior to superior connection from the to the region of the seventh cervical it is solely dependent on the pressure pelvic diaphragm to the respiratory and the first . It has diaphragm, but there is also an ante- differentials between the , ab- imbedded within it the scalenus mini- dominal and pelvic cavities. The lym- rior to posterior connection of the mus which when contracted, tenses phatic system returns 10% of the cir- anterior abdominal wall to the poste- Sibson's fascia. This fascia acts as a culatory fluid from the periphery with rior abdominal wall under the dia- diaphragm covering the cupula of the each cycle. It has been estimated that phragm. . Sibson's fascia is also respon- The diaphragm interdigitates with in a 24-hour period, we turn over sible for maintaining a pressure gra- 100% of the circulating serum blood the transversus abdominus at a 90° dient between the and the tho- volume through the lymphatic sys- angle. This relationship with the rax. Without this gradient, the neck tem. The peripheral muscles act to transversus abdominus blending into viscera would be sucked into the tho- pump the lymphatic fluid into the the linea alba medially can be useful rax with each inspiration. lymphatic channels and back cen- in treatment. The fascial connection of the peri- trally. Any disturbance in the thora-

Winter 1991 A AAO Journal 8 cardium to the is called the nected to the Sibson's fascia through the pelvic diaphragm and Sibson's "pericardial ligament".The pericar- the prevertebral as well as pretrachael fascia work together to create pres- dium is basically pretracheal fascia, fascias. The pretracheal and preverte- sure differentials which promote cir- which has extended down from the bral fascias as cylinders extending culation of venous and lymphatic neck and embedded itself into the from the thorax into the neck region. fluid. As the respiratory diaphragm diaphragm. This pretracheal fascia The prevertebral fascia invests the contracts, the pelvic diaphragm re- continues from the diaphragm being ribs. It continues from 1st ribs superi- laxes, allowing the contents to drop the covering of the heart, connecting orly to cover the bodies of the verte- into the pelvic cavity. A relative to the sternum and into the neck. The brae as well as the anterior and poste- negative pressure is established in the ribs are covered by the prevertebral rior cervical vertebral muscles. This thorax with positive pressure in the fascia, which travels superiorly to the column of fascia is a direct connec- abdomen and pelvis. On exhalation, base of the skull. tion between the first ribs, the manu- the respiratory diaphragm rises by Just as there is a relationship be- brium and Tl, to the base of the skull. elastic recoil and pressure gradients tween the thoracic and pelvic dia- The insertion of the muscles of the reverse. phragms with respiration, Sibson's neck onto the skull, effectively con- The tentorium um cerebelli and pelvic fascia acts as a diaphragm in a recip- necting Sibson's fascia to the skull. diaphragm work in synchrony as well. rocal relationship with the thoracic The tentorium cerebelli, being re- As the primary respiratory mecha- diaphragm. Any distortion of the tho- flections of dura, is directly connected nism goes into its flexion phase, the racic inlet will lead to passive conges- through the foramen magnum to the tentorium moves inferiorly, the sa- tion of venous and lymphatic fluids spinal dura to C2 and C3 and then to cral base moves posterior with the throughout the whole body. The tho- the second sacral segment, forming a apex moving anterior. The innomi- racic inlet is approximately 4-1/2" continuous connection to the sacrum nates move into external rotation. The wide by about 2-1/2" long. Within (cranial to pelvic diaphragm). There reverse occurs in extension. There is this space is a great number of vital is evidence that the dura has firm a relationship of the primary respira- structures. The thoracic duct empties attachments to most vertebrae tory mechanism (cranial rhythmic into the left in the throughout the column as well. impulse) to the secondary respiratory region of the thoracic inlet as well as The tentorium cerebelli has em- mechanism (breathing) in which they the right thoracic duct. The thoracic bedded within it the venous sinuses. tend to augment each other. duct drains most of the lymphatic (The root of venous drainage from the The arches have an effect on the fluids of the body minus the right skull is through the venous sinuses.) other diaphragms through their role portion of the thorax, the right head The tentorium cerebelli is attached to in posture. A functional pes planus and the right upper extremity. Any the petrous ridges of the temporal (dropped arch) will restrict motion of distortion of the thoracic inlet will bone (enclosing the superior petrosal the pelvis during respiratory and pos- lead to passive congestion of venous sinus) and the internal surface of the tural motion, thus affecting the four and lymphatic fluids throughout the occiput. As the sphenobasilar junc- remaining diaphragms. How this is whole body. tion goes into flexion, the tentorium seen clinically will be discussed in There are a great number of struc- is brought inferior and spreads out. In Part 2. tures that traverse the thoracic inlet extension, the opposite occurs. The The full functioning of the five besides the thoracic duct. These tentorium cerebelli aids in the circu- diaphragms must be maintained to structures include the , the lation of venous as well as cerebro- prevent symptoms of pain, passive , the , the sym- spinal fluid. The tentorium cerebelli congestion of fluid, dyspnea and oth- pathetic chain ganglion, carotid arter- is part of the dural structures that form ers. As described, the five diaphragms ies, subclavian arteries, and subcla- the "core link" connecting the sphe- are related to each other anatomically vian veins. The brachial plexus rests nobasilar junction to the sacrum. The and therefore, functionally. on the superior borderof the first ribs. reciprocal function of both areas is The diagnosis and treatment of the Based on these anatomical relation- important in maintaining health. obstetrical patient using these prin- ships, this becomes a very important ciples will be discussed in Part 2 of area to examine. Function of The Five Diaphragms this series, which will be published in the Spring issue of this journal, along Together with the complete reference list for Fifth Diaphragm - There is a synchronous motion of both articles. Tentorium Cerebelli the five diaphragms of the body. As The tentorium cerebelli is con- the respiratory diaphragm contracts,

A AAO Journal Winter 1991 9