1. BELOW THE DIAPHRAGM SPECIFIC TECHNIQUES FOR THE VISCERA AND ASSOCIATED SOMATIC STRUCTURES DURING PREGNANCY Dr. Steve Sandler PhD DO

2. Mobilisation within the peritoneal cavity The usual Barrall techniques rely on a very specific ability to detect the anatomical position of the organs. In pregnancy, because of the drift away from the normal position due to the compression of the rising gravid uterus, we simply don’t know exactly where points such as the pyloric sphincter, the D/J junction and the colonic flexures are to be found with accuracy. This means that for the most part, the motility techniques used in the non pregnant are simply not available for use during pregnancy.

3. Visceral Osteopathy and Pregnancy, During pregnancy when the growing and expanding uterus pushes the other abdominal organs away to allow room for the foetus to grow, these fascial attachments need to be stretched and relaxed, which is another function of the hormone Relaxin during pregnancy. However adhesions between the sliding surfaces are common and can lead to visceral dysfunction.

4. Visceral Osteopathy and Pregnancy Osteopathic visceral manipulations at this time to release any adhesions and to facilitate these changes can be very beneficial to the mother's changing structure and function and can have a part to play in the function and dysfunction of the organs during pregnancy

5. Visceral Osteopathy and Pregnancy As the gravid uterus rises it turns to the right guided by the mass of the sigmoid colon, this is known as dextrorotatation., and it causes a displacement and a compression of the organs in the abdomen and the pelvis.

6. Visceral Osteopathy and Pregnancy The normal anatomy is arranged for the organs to slide on each other, but they are anchored to the bony skeleton or to fascial attachments, and obviously the movement of the organs will be limited by the muscles of the abdominal walls, the diaphragm and ribs and the pelvic floor.

8. The ligaments anchor the organs allowing mobility around a fixed point. The most important bony structures for this process are the ribs and the diaphragm. Directly or indirectly all of the abdominal organs are guided in this way.

9. The mesocolon and Toldt's fascia guide and support the intra abdominal organs in a similar fashion. How the supporting structures change during pregnancy either in position or in action is fundamental in understanding just what does happen to the abdominal contents during pregnancy.

10. Fixation of the Ascending Colon If we take the ascending and descending colons as an example, they are anchored by the transverse meso colon medially and by Toldt's fascia laterally. The lateral attachments are much stronger.

11. The mesocolon itself is attached to a number of other organs as can be seen in figure large chart, however the attachments to the organs is thinner and more elastic than Toldts fascia, and the mesentary being full of blood is naturally more mobile

12. The transverse mesocolon is attached to the ribs and diaphragm and as it rises during the pregnancy so the transverse mesocolon and all that is attached to it rises too. The diaphragm becomes increasingly more domed shaped as the pregnancy continues.

13. The height of the fundus at different stages in pregnancy At the end of the pregnancy she engages in more upper rib breathing than diaphragm or abdominal breathing.

14. The fate of the liver in pregnancy The liver cannot ascend more than the diaphragm allows and is therefore forced around the right abdominal wall so that at the end of the pregnancy it lies high up and lateral and the usual mobility is greatly restricted.

15. The fate of the stomach during pregnancy The stomach is compressed and rotates to the left around the abdominal wall.

16. The increased pressure together with the relaxation of the lower oesophageal sphincter under the influence of the pregnancy hormones means that the compression from below and the restriction in the diaphragm above results in a squeezing of the stomach thought to be responsible for the symptoms of gastro oesophageal reflux.

17. Osteopathic Treatment of GOR in pregnancy CAUSED BY Increase weight and pressure on stomach from below by baby and fat in mesentary Loosening of cardiac sphincter Small stomach size with the same size meals Poor posture ii.e.. Slumping in chairs after a meal

18. GASTRO OESOPHAGEAL REFLUX Not caused by –Hairy baby ! –Pressure on a nerve –Poor diet –Toxaemia of pregnancy

19. GASTRO OESOPHAGEAL REFLUX Treatment principles should include –Dietry advice –C2 on the left –The importance of the diaphragm and it’s attachments –The rib flare –Direct techniques for the reflux itself –Viscero somatic reflections in the thoracic spine treated with direct or functional techniques

20. Advice re Diet Raw foods such as cucumber especially if unpeeled, raw tomatoes, raw union, and radishes will all need more time to be digested. If the cucumber is peeled,the tomatoes poached and skinned, and the onions gently cooked before eating them, reflux is less likely. Meat and fish that is casseroled or poached instead of fried or roasted again will digest easier and quicker. Avoid all gassy drinks including bottled water with gas and she should limit herself to a small glass of plain water with each meal. Avoid all gassy drinks and acid containing fruit juices if possible too. Small meals more often Eat main meal at midday

21. The Diaphragm Lift Technique The aim of this technique is to release the trapped LOS by applying gentle traction to the rib margins whilst the patient leans back against you, Gravity then allows the abdominal contents to settle back below the diaphragm.

23. Here we can see her leaning back with her head against my shoulder. My hands are “gathering flesh” in preparation for the movement forward over my fingers

24. Here we see her forward and the ulnar borders of my hands are actually deep under the rib margins my fingers moving towards her spine and back stimulating contraction of the central tendon of the diaphragm

25. The C2 T2 Pattern “Osteopathic Lesions “ found in nearly every case of upper gastric irritation. Caused by contraction of spinal muscles linking the two regions

26. Irritation of the lower oesophageal sphincter causes reflex contraction in the associated spinal muscles at T2/3. This in turn causes a secondary lesion at C1/2. At this level there is a small nerve running to the Vagus nerve (Xth) which encourages secreto motor impulses to the gastric mucosa, therefore excess acid combined with a weak lower oesophageal sphincter can cause vagal stimulation which produces a viscous circle

27. A Plan of the Superior Cervical Plexus

28. A Plan of the cervical Plexus after Grays Anatomy

29. The C2 T2 pattern seen in GOR The classic C2 on the left lesion is palpated under the skull beneath the mastoid and at the beginning of the cervical column in cases of upper gastric discomfort

30. Sitting Technique to mobilise C2 on the left during pregnancy Here we can see the classic sitting minimal leverage technique done as part of the C2 T2 pattern very commonly seen with patients with Gastro Oesophageal Reflux. For T2 use any sitting lift off technique

31. The Treatment of Constipation during pregnancy Caused by Relaxation of gut smooth muscles by Relaxin Longer transit time for food residue therefore more time for water re absorption Hormones such as Calcitol increase the absorption of calcium increased iron deposits cause constipation Ptosis of the caecum Poor diaphragm excursion

32. Constipation Treatment Protocol Don’t forget the diaphragm and the ribs, especially because of the attachments of the colon at the hepatic and splenic flexures Release adhesions with “visceral Thrust” techniques Functional Techniques and the caecum

34. The Visceral Thrust Techniques Not thrust techniques at all more techniques that create shock waves to separate the adhesions that form between the caecum or the sigmoid and the wall of the greater pelvis.

35. Adhesions and Visceral Motion A – viscera is mobile with no adhesions. 1 – GIT. 2 – Mesentary. 3 - Root of the Mesentary. 4 – Posterior Parietal Peritoneum. 5 – restroperitoneal vessels. 6 – Beginning of an adhesion B – The adhesions builds. C – A fully bound down organ

36. The Visceral Thrust Techniques

37. Functional Techniques and the caecum NB I should be standing on the right side of the patient. Use the usual parameters for F/T and the diagnostic wait, and release stages and follow the release to the end.

38. The Kidney and Pregnancy The Fascia around the kidney

39. Normal motion of the kidneys should remain unchanged as they are retro peritoneal and their position is not greatly affected by the rise of the gravid uterus, they slide superiorly and inferiorly around the rib cage with each breath taken very much as before. However it is always worth checking the mobility of the kidneys and the pre renal fascia as restrictions can occur and should be dealt with using a myofascial release technique.

41. The same parameters of Flexion Extension, Rotation and side bending etc as used before will apply. However the change here is to the feeling of the volume of the tissues under the hands rather than the tissues themselves. The kidney is not a hollow viscus and so it will feel different to say a caecum or a lung mass.

42. The patient is sitting which allows the kidneys to fall under the effects of gravity and so caudal motion is easier felt here. The volume is palpated towards the ease of each parameter, stacking them to achieve the minimal possible tension. Then the position is held for up to twenty seconds until a global release is felt. This again is followed passively until the motion stops. The biggest difference between this myofascial release and any other functional technique release is the depth of relaxation gained by waiting for longer.

43. Structural Techniques and Pregnancy HVLA techniques are suitable with modifications up to and including the onset of labour. There have been no reported or documented cases of a manipulation causing an abortion or the onset of labour.

44. Modifications include –No rotation techniques applied to the lumbar spine that can cause abdominal compression –Side bending techniques are better with a small “body drop” –Care with the shoulder and the pectoral girdle as you can cause an overstrain here –Minimal levers and specific very short and very crisp amplitudes

45. THE REVERSE UPPER LUMBAR THRUST FOR T/L JUNCTIONS

47. Set her up for the technique in the usual way –Start from the three sided square –Place the lower limb knee in extension at the bottom corner of the table –Place her hand and upper extremity of the uppermost arm along the length of the body to avoid early rotation. –“Sit down” and introduce flexion down to the lesion. –Take up the slack and feel the tension. –Turn your feet to face down the table but keep your arms as they were. –Now introduce force by minimal compression and side bending and rotation of the top lever away from the bottom

48. Modification of the lumbar roll technique in pregnancy Modification of the Side bending HVLA technique with “Body drop ”

49. Modification of the lumbar roll technique in pregnancy Body drop means a very small impulse from the osteopath into side bending and directly into the lesion. It is a very controlled movement and is very safe as long as it is momentary and crisp, i.e. Short lever and high amplitude

50. Modification of the lumbar roll technique in pregnancy The set up is as before The three sided square Flexion is introduced down to the lesion again but not beyond the lesion. Minimal rotation

51. The Lumbar Spine MLT The weight is towards the back foot

52. The Lumbar Spine MLT The fingers are palpating the spinous processes to feel the response to the motion

53. The Lumbar Spine MLT Here we can see that the osteopath’s right arm is being used to stabilise the shoulder girdle whilst the left applies the thrust in rotation towards the pelvis. The fingers of the right hand are employed in palpating the segment concerned