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Treating the Five Diaphrams of the Body, Part I

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Treating the Five Diaphrams of the Body, Part I 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 bone 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 lumbar vertebrae 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 rib. 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 sacrum. 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.
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