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