Doris Newman, DO, FAAO Newman Osteopathic and Wellness [email protected] The Interstitium is m an organ? FSACOFP Orlando, FL July 2018
Disclosures
Dr. Newman has nothing to disclose
Quote by A.T. Still, MD; Photo from presentation by Donald Hankinson, DO Tonight’s discussion includes
Fluid Dynamics: • New concepts about: • Fascia - Interstitium – submucousa • Fascia reconceived as a “fluid body” • Palpatory assessment of fluid or “Tide”
Midline: • Neurodevelopment process • Palpatory assessment of midline NEW CONCEPTS IN “FLUID-BODY” Early Osteopathic thoughts on treating the “fluid” of the body.
A.T. Still, MD William Garner Southerland, DO The Philosophy and Mechanical Teaching in the Science of Principles of Osteopathy, 1892 Osteopathy “As blood and other fluids of life are Edited by Ann Wales, DO as ponderable bodies of different adapted from AAO’s 1949 Yearbook consistencies, “The potency of the cerebrospinal and are moved through the system fluid Tide is the “highest known to construct, purify, vitalize, and element” furnish power necessary to keep the “You can direct that Tide…” machinery in action, “The CSF is in command and controls we must reason on the different the Tide” powers necessary to move those bodies……”p59 Jane Carreiro, DO An Osteopathic Approach to Children, 2nd ed, Elsevier Page 136 Describes a typical strain “A cone-shaped, rotational strain seen at the site of vacuum extracted infants.”
Interpreted by many as a fluid-type motion treated by identifying two ends of the strain and organizing the fluid strain along a midline; the spiral becoming a linear flow distal to proximal Isn’t interstitium the same as fascia or connective tissue??
Interstitium Connective Tissue A small area, Fibrous type of body tissue, containing Collagen but few cells space, or Variety of functions gap Supports and connects internal organs Forms bones and the walls of blood vessels in the substance of an organ or tissue. Attaches muscles to bones (tendons) Mainly long fibers embedded in noncellular matter, the ground substance The space between cells in Fiber density and chemical content varies tissue Soft and rubbery Hard and rigid
Can develop in any part of the body so the See also connective tissue body uses connective tissue for repair (ie scar tissue)
https://medical- dictionary.thefreedictionary.com/connective+tissue Connective tissue…..further classified
Supporting A major constituent of which is extracellular matrix or ground substance Glycoproteins Derived from the mesenchyme Many classifications: Matrix proportion – loose or dense Arrangement of fibers – regular dense vs irregular dense Fiber type – collagenous, elastic Embedded cell types – adipose, lymphoid, hemopoietic Degree of differentiation – mesenchymal, mucous
Location – subcutaneous, periosteal, perichondria http://www.gstbody.com/important- Appearance – areolar, granulation discovery-related-fascia/ Nature of matrix = cartilaginous, osseous, liquid (blood, lymph)
https://medical-dictionary.thefreedictionary.com/connective+tissue Where does the term “Fascia” fit in?
A term so vague in use that it signifies little more than assemblages of connective tissue large enough to be visible to the unaided eye
Structure is highly variable
Collagen fibers tend to be interwoven: seldom compact, parallel orientation (tendons)
http://matrix-myofascial.abmp.com/what-is- Takes many forms fascia-and-why-is-it-important Surface or investing Loose connective tissue Provides a degree of mechanical isolation Gray’s Anatomy, 38th ed., page 782 Churchill*Livingstone Fascia constitutes the loose packing of connective tissue around peripheral nerves, blood and lymph vessels as they pass between other structures, often linking them together as a neurovascular bundle It forms a dense connective tissue layer investing some large vessels such as the common carotid tissue layer and femoral arteries Fascia may be functionally significant aiding venous return by approximating large veins to pulsating arteries or could represent a primary tissue response to the pulsatile forces created by neighboring arteries Superficial Fascia Functions: As adipose between skin and muscles can decrease friction and Provide increased mobility of skin Contribute to thermal insultation Constitutes a store of energy for metabolic use
https://learnmuscles.com/blog/2017/11/16/the-frictionless- skin-fascia-interface-with-underlying-bone-theory/ Subcutaneous tissue of the skin UKyOrtho “Strolling Under the Skin” on youtube Published on Aug 28, 2014 Basic Science https://www.youtube.com/watch?v=eW0lvOVKDxE Dr. Jean-Claude Guimberteau
THE “NEW ORGAN” DISCOVERY…… “Structure and Distribution of an Unrecognized Interstitium in Human Tissue”
Open Access article Published: 27 March 2018 https://www.nature.com/articles/s41598-018-23062-6 Authors: Petros C. Benias, Rebecca G. Wells, Bridget Sackey-Aboagye, Heather Klavan, Jason Reidy, Darren Buonocore, Markus Miranda, Susan Kornacki, Michael Wayne, David L. Carr-Locke & Neil D. Theise Scientific Reports Volume 8, Article number: 4947 (2018) Icahn School of Medicine, Mount Sinai
Illustrator: Jill Gregory’s blog, Mount Sinai Health Systems https://www.ami.org/press/press-releases/2018/386- the-story-behind-my-viral-interstitium-illustration
12 patients IV fluorescein with direct in situ visualization at 60-70 micrometers deep Confocal laser endomicroscopy (pCLE) Submucosal reticular pattern 20 micrometers wide dark branching bands Surrounding large flouorescein-filled polygonal spaces (fluid-filled)
Which persisted upon immediate ex vivo pCLE visualizatioin
Immediately froze the resected bile duct
Samples were cut to an equal depth as the in vivo and ex vivo pCLE = 60 micrometers
Perpendicular cuts to the lumen
Flourescent microscopy
The same reticular pattern was seen
Masson’s trichrome stain: Blue collagenous bands separating open, formerly fluid- filled spaces
Compared from samples of the same patient
Normally fixed specimen: Described as a compacted and dense submucousa Due to loss of the fluid and collapse of the collagen
Additional microscopy and staining revealed
Fluid filled spaces and collagen bundles Lined by cells staining for CD34 (stem cells) Submucous of multiple organs and tissues: entire digestive tract, urinary bladder, peribronchial tissue, fascia and stroma of arteries and veins of all sizes epidermis
Continuity bw interstitium and lymph
Then they further stained submucosa Colonic (A-C) gastric (D-F) epidermal carcinomas (G-I)
Observed the “tattooed” markers drain into respective lymph nodes Article Discussion: “In sum, while typical descriptions of the interstitium suggest spaces between cells, we describe macroscopically visible spaces within tissues – dynamically compressible and distensible sinuses through which interstitial fluid flows around the body.”
“A submucosa subjected to directional peristaltic flow is not the previously envisaged wall of dense connective tissue, but a potential conduit for movement of injurious agents, pro- fibrogenic signaling molecules, and tumor cells.” Woosup Park, MD Doximity.com
“New interest in the interstitium is like people suddenly obsessing about the stuffing in sofas.”
https://opmed.doximity.com/new-interest-in-the- interstitium-is-like-people-suddenly-obsessing-about- the-stuffing-in-sofas-308b1336a317 How many organs does the human body have?
10 “systems” with “Vital” organs = 5 (brain, heart, liver, lungs, kidneys) Total organs = 78-80
According to new research out of Mount Sinai Health Center https://www.inverse.com/articl e/42886-interstitium- dscovered-new-organ-cancer- lymph-system
The interstitium may be the newest body organ https://ipfs.io/ipfs/QmXoypizjW3WknFiJnKLwHCnL72vedxjQkDD P1mXWo6uco/wiki/List_of_organs_of_the_human_body.html THE OSTEOPATHIC CONTEXT: So, what does it mean PALPATORILY? Two important concepts in Osteopathic Medicine are involved in this discussion:
Midline Fluid Flow Dynamics
Developmentally Fluid dynamics occur on a midline about Midline of neurodevelopment a fulcrum in multiple axes (planes) 3 parts of the developing brain Every joint, suture, extremity and organ, must align to develop has a midline (biomechanically and in appropriately the fluid body) that can be palpated MOTOR and treated with OMT SENSORY Balancing of the membranes, ligaments or fluid occur when the physician holds COGNITION the midline and allows the inherent One fails, they are all at risk of mechanism to shift and change until the delay/failure motion is restored
DEVELOPMENT OF MIDLINE Concepts in Midline
Fluid dynamics organized along the midline
Embryologic development is full of symmetry and each piece of the machine has a midline Neurodevelopment of Midline
Motor Milestone
Sensory Milestone
Cognitive Milestone Neurodevelopment of Midline
Motor Milestone
Sensory Milestone
Cognitive Milestone Motor Development
Proceeds cephalad to caudad and proximal to distal
Muscle tone dictates motor development process Intrauterine Birth Infancy In motor control:
POSTURE primary
CONTROLLED MOVEMENT secondary
“Stability before Mobility” Gross Motor, Posture and Balance
Posture is the ability of the The maintenance of posture and balance body to control its position depends upon information in space against the forces from all three systems of the external world. 1. Vestibular (Shumway-Cook, 2. Visual Woollacott, 2000). 3. Somatosensory Sense of Balance Posture is the product of an Sense of spatial integrated orchestration orientation between the sensory and Coordinated motor systems of the body. movement with balance
Vestibular System
Auditory system Eye movements Trunk Muscles and proprioceptors Sends signals to the CNS
ORGANS: Vestibular Organs Semicircular Canals Anterior Horizontal Posterior Otolith organs Utriculus Sacculus
Extrapyramidal - Vestibular System
Lateral vestibular nucleus mediate: extensors of the legs flexors of the arms/ upright stance Upright Stance vestibulospinal reflex
Medial and superior vestibular nuclei mediate: vestibulo-ocular reflex Maintains eye fixation w/head turning
Superior vestibular nucleus fibers terminate: On motor neurons of cervical musculature Influence neck position Stabilizes the head in space vestibulocollic reflex Visual System
The maintenance of posture and balance depends upon information from all three systems Visually activated muscle 1. Vestibular synergies
2. Visual precedes 3. Somatosensory Sense of Balance Somatic sensory activated Sense of spatial systems orientation
Coordinated movement with balance
Visual System stimulates motor control
3 days of age: Newborns will orient their eyes to a visual stimulus and Track it even though muscle synergies are too immature to support coordinated head movement
2 months of age: Early signs of postural control can be recognized An infant lying on her back will turn her head to look at something An infant lying on his stomach will begin to lift his head. These are visually triggered activities. 3 month Improved thoracic control but not lumbar control 6 months of age Commando crawl with sinusoidal motions Motor response from head, neck, torso Hips and leg flexors are relaxed
ATNR involves motor, vestibular and visual activities
Birth to 6 months Must “turn off” or integrate to develop midline
If persists can see problems with: Handwriting skills Reading Laterality
Midline development depends on neurological integration of primitive reflexes
STNR (6m-3yr) allows the quadruped position and reciprocation. The visual system is leading the neurological progress through the developmental milestones. Neurodevelopment of Midline
Motor Milestone
Sensory Milestone
Cognitive Milestone Somatosensory System
Neurodevelopmental Milestones Organs Muscles Joints Proprioceptive mechanoreceptors Motion – alignment, glide, flex, extends Skin Sensory nerves Receptive Fields Hypo or Hypertonia (ie motor issues) will alter proprioceptive information and biomechanical motion
Children with spastic paraplegia have altered postural strategies secondary to biomechanical factors rather than neurological
Neurodevelopment of Midline
Motor Milestone
Sensory Milestone
Cognitive Milestone Three components of cognitive function
Ability to attend (and record the function) Sensory
Ability to integrate (from the context of all other experiences) Contextual
Ability to interpret (the important of the response) Derive meaning and respond Object Representation
Attention Spatial Position
Visual Motion Cortex Color
Use Name Cognitive awareness of shapes
• Attend • Integrate • Interpret Becomes awareness of language.
• Attend • Integrate • Interpret MIDLINE development can be affected by all 3
Motor Developmental Milestone
Sensory Developmental Milestone
Milestones of Cognitive Development Integrating MIDLINE and FLUID into your OMT practice.
Identifying the flow Slower than the cranial rhythm Only about 4 cycles per minute
More like a slow flowing brook Your job is to find the obstructions in the flow Midline Fluid Palpation Location Follows the primitive streak and remnant noto chord Along the “line” of the nucleus pulposis Deep and posterior in the body Flow Distal to proximal Palpation Supine patient Physician seated head of bed Hands flat and under the upper back Thorax & Ribs Midline Fluid Palpation In the areas of the ribcage
Flow Medial to lateral Laterally from spine Equal bilaterally
Palpation Hands under thorax Seated at head of supine patient
Midline of the spine: Mechanical axis passes through embryologic axis primitive streak – notochord – nucleus pulposis
PALPATION Starting at the tip of the coccyx (“Henson’s node”) embryological origin of endpoint is located on the dorsal wall of the saphenous sinus. Henson’s Node @ Tip of Coccyx
Midline Fluid Palpation in the LEs
Flow: Fluid flows from proximal to distal Should line up with the “embryological origin” of the extremity = L3-L5 Palpation Seated at the foot of the bed Cradle both extremities in your hands Do not grip or apply any force Midline Fluid Palpation in the UEs
Flow: Fluid flows from proximal to distal Should line up with the “embryological origin” of the extremity = C5-C8 Palpation Seated at the side of the ext Distally, grasp the patient’s hand and align your middle finger with his midline (C7) Proximally, place your hand at the C5-C8 region Midline of Fluid Axes of the upper extremities It is sometimes necessary to treat the midline of a portion of the extremity first
Always finish with the midline of the entire extremity Distal Hand Position
May need to “get the wrist out of the treatment” initially. Midline Theory - Potency
When balancing the mechanical and embryologic axis in an optimal setting, there is a “potency” (powerful movement) in two, sometimes in three waves.
This “potency” is only noticeable when the axes harmonize itself.
Treatment depends on interactions between patient and physician and is dependent on the own state, circumstances, situations.
Sutherland: “be still and know!” Amplified MRI (aMRI) human brain motion
“The brain moves slightly with each heartbeat, but these motions are tiny: on the order of ten to 180 micrometers, less than a width of a single human hair.” https://medicalxpress.com/news/ 2018-05-magnify-brain-motion- heartbeat.html
Original online source: Magnetic Resonance in Medicine, May 29.
Itamar Terem, Stanford University research assistant and first author