An Integrated Approach forTreating the OB Patient: Treating the

Five Diaphrams of the Body, Part I

Introductionregnantwomen are ajoy to treat.They seem tobe tied di-rectly into theprimary lifeforce of the

universe. Pregnancy is a time ofchange; anatomically, physically,mentally and emotionally. Part 1 ofthis paper will discuss the physiologi-cal as well as anatomical changes thatoccur during pregnancy. Part 2 willdiscuss diagnosis and use treating thefive diaphragms of the body (the footarches, the pelvis, the respiratory dia-phragm, Sibson's fascia covering thethoracic inlet and the tentorium cer-ebelli) as a model for treatment.

PHYSIOLOGYCardiovascular System

The blood volume increases byapproximately 40-55%. There are in-creases in stroke volume by 30%,heart rate by 10-20% and possibly anincrease in the cardiac volume by10%. The changes in the cardiovas-cular system indicate that there ismore blood for the cardiovascularsystem to circulate.

There are numerous vascularchanges that occur as well. The uter-ine blood flow changes from approxi-mately 30-50 rril up to 500-1000 mlper minute. There is also an increasein the breast blood flow.

Respiratory SystemIt has been proposed that the respi-

by Ken Johnson, DO

ratory rate is unchanged. The tidalvolume increases by 40% and theresidual volume (which is the volumeaftermaximum exhalation) decreasesby 20%. The expiratory reserve vol-ume (the amount that can be expiredat the end of normal exhalation) in-creases by 20% and the functionalresidual capacity decreases. The tho-racic cage also flares, increasing thesubcostal angle from 68° to 103°. Thediaphragm, due to the changes ofpregnancy, must increase in its excur-sion to oxygenate the increased bloodvolume.

A common complaint of preg-nancy is a subjective feeling of dys-pnea. Dyspnea is possibly due to theincrease in blood volume to be oxy-genated, and the anatomic changeswhich lead to altered respiratoryfunction.

Renal SystemBecause there is more blood to be

circulated by the cardiovascular sys-tem, there is more blood to purify.Therefore, the glomerular filtrationrate increases by approximately 50%with a corresponding increase in so-dium retention.

Endocrine SystemThe corpus luteum of pregnancy

produces a polypeptide hormonecalled "relaxin". Also, there is anincrease in the production of estro-gen. These hormonal changes causerelaxation of the pelvic ligaments andalso a general relaxation of manyligaments throughout the body.

These endocrine changes are

helpful and detrimental from a struc-tural point of view. Women who havepre-existing somatic dysfunction be-fore pregnancy may be helped greatlyduring pregnancy. The relaxation ofthe ligaments allows for a greater, aswell as easier, mobilization of a re-stricted joint. There is also a negativeeffect in that the relaxation of theligaments can promote somatic dys-function occurring at a joint; a com-mon example is an acute pubic sym-physis shear. This can be an excruci-atingly painful somatic dysfunction.

ANATOMYThere are many anatomical

changes that occur during pregnancy.The growing fetus within the uteruscauses an overall anterior shift in thecenter of gravity of the pregnantwoman with a compensatory poste-rior shift in the shoulders - the so-called "pride of pregnancy stance".There is an increase in the lumbarlordosis. These shifts cause changesin the thoracoabdominal pelvic cavi-ties which impede function and willbe discussed in the following sec-tions.

First Diaphragm -Arches of the Feet

The navicular bone is like the key-stone of the medial arch. With thepostural changes that occur duringpregnancy, it is common to find afunctional pes planus or "flatfoot".The arch, especially the navicularbone, drops inferiorly. There is achange in the relationship of the talus

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to the tibia and fibula, which willchange the orientation of the kneejoint and, in return, will be reflectedinto the pelvis.

The tibialis anterior attaches to themedial cuneiform and base of the firstmetatarsal. The tibialis posterior at-taches to the navicular, cuneiforms,cuboids and bases of 2-4 metatarsals.Together these muscles form a slingfor the longitudinal arch. As the archdrops, there is an increased tone andtension noticed in the tibialis muscles.

The tibialis anterior attaches onthe lateral anterior portion of the tibiaand the approximate region where theiliotibial band attaches. When the archdrops, there is a change in the ten-sions of the tibialis anterior, reflect-ing into the iliotibial band which, inturn, will affect the pelvis. As the archdrops, the talus changes the relation-ship with the tibia and the fibula; thefibula being an attachment for thelong and short head of the biceps.Therefore, the change in orientationof the fibula and tibia will have aneffect on the long and short head ofthe biceps. The biceps femoris attachesfrom the fibula head to the ischialtuberosity as well as the sacrotuber-ous ligaments.

These changes in the anatomicalrelationships of the arches (first dia-phragm) to the second diaphragm (thepelvic diaphragm) of the body can beenough to impede both the postural aswell as respiratory motion of the pel-vis and lower extremity.

Second Diaphragm -Pelvic Diaphragm

The pelvis is made up of the twoinnominates and the sacrum. It isheavily invested with muscle andneurovascular structures, as well asfascial structures. The endopelvicfascia attaches anterior to posterior,as well as medial lateral, formingwhat could be thought of as supportbridges for the pelvic organs; namely

the uterus, bladder and rectum. Thebladder is suspended in the pelvis bythe median umbilical ligament (em-bryonic remnant of the urachus) aswell as its lateral and posterior at-tachments of endopelvic fascia. Thecardinal ligaments containing theuterine artery forms a lateral suspen-sion for the uterus. There is a directconnection between the bladder andthe uterus, running anterior to poste-rior, forming the vesicouterine pouch.The bladder is also suspended by thelateral pubovesicular ligaments. Therectum is suspended by the presacralfascia as well as the vaginal rectalfascia.

The fascia of the pelvis and theendopelvic fascia basically suspendsthese three organs -the bladder, uterusand rectum within the pelvic cavity,allowing them to float within thecontent of the pelvic cavity. The namesof the fascial ligaments are somewhatmisleading, creating the idea that thereare a number of separate ligamentswithin the pelvis. In reality, the liga-ments are thickenings of fascia, whichare continuous with each other andwith the fascias of the rest of the body.

Any kind of twist in the pelvis, anyrestriction in the pubic symphysis oreither sacroiliac joint can have a largeeffect on the endopelvic organs. Atwist within the pelvis will impedethe organs and the vessels leading toa stasis of fluid in the pelvic organs aswell as the lower extremity. One pro-posed mechanism of swelling in thelower extremities is that the fetus willimpinge on the inferior vena cavasomewhat and cause a back pressurewithin the venous system, leading tovenous stasis. Another possiblemechanism is somatic dysfunction ofthe pelvis, impairing the ability of thepelvic diaphragm to move in con-junction with the respiratory dia-phragm leading to stasis of lymphaticand venous fluid.

Third Diaphragm -Respiratory Diaphragm

The pelvic and the respiratory dia-phragms are connected anteriorly,posteriorly, radially and laterally.Posteriorly, the quadratus lumborumis attached to the lumbar vertebraeand the iliac crest. Superiorly, thequadratus lumborum is attached tothe twelfth rib. The quadratus lum-borum could be viewed as a functionalextension of the diaphragm. Thequadratus lumborum has, as its action,both postural as well as respiratorymotion. The quadratus lumborum actsas an anchor for the twelfth rib duringrespiration. Restriction in either he-midiaphragm can be seen reflected inthe quadratus lumborum and throughthe tensor fascia lata into the iliotibialband all the way to the peronealmuscles of the lower extremity.

POSTERIORThe diaphragm is attached to the

twelfth rib posteriorly via the lateraland medial arcuate ligaments. Thelateral arcuate ligament attaches fromthe twelfth rib to the transverse pro-cess of T12. The medial arcuate liga-ment attaches from the transverseprocess of T12 to the body and theanterior longitudinal ligament at T12.The medial and lateral arcuate liga-ments form what could be thought ofas caves for the quadratus lumborumand the psoas. These ligaments arebasically thickenings of the fascia,covering the muscles in this region.

Medially, the crura of the dia-phragm attaches to Ll, 2 and 3 on theright and Ll and 2 on the left. This ishow it is described in most anatomybooks. In reality the crura attaches tothe anterior longitudinal ligament andblends to this ligament. It is impossibleto separate the crura from the anteriorlongitudinal ligament at their attach-ments. Looking at specimens in theanatomy lab, the crura basically blendinto the anteriorlongitudinal ligament

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and functionally become a portion ofit. The anterior longitudinal ligamentcontinues down through the lumbarvertebrae and can be shown to con-tinue into the anterior sacral coccygealligaments and then directly into thepelvic musculature, thus forming theposterior connection between thepelvic and respiratory diaphragms.The lateral connection between thepelvic and respiratory diaphragm arethrough the muscles of the abdominalwall.

ANTERIORThe organs and muscles of the

pelvic cavity connect with the en-dopelvic fascia. The endopelvic fas-cia is connected to the median umbili-cal ligament and to the medial umbili-cal ligaments which go to the umbi-licus and linea alba of the rectus sheath.Continuing superiorly from the um-bilicus, the falciform ligament andligamentum teres (round ligament)attach to the liver as well as the inferiorsurface of the diaphragm. Therefore,there is a direct anterior connectionfrom the pelvic diaphragm to therespiratory diaphragm. The falciforrnligament basically cuts the liver inhalf anterior to posterior.

The combination of the falciformligament with the ligamentum teres(round ligament) embedded within itand the ligamentum venosum forman anterior to posterior fascial con-nection. So there is not only an infe-rior to superior connection from thepelvic diaphragm to the respiratorydiaphragm, but there is also an ante-rior to posterior connection of theanterior abdominal wall to the poste-rior abdominal wall under the dia-phragm.

The diaphragm interdigitates withthe transversus abdominus at a 90°angle. This relationship with thetransversus abdominus blending intothe linea alba medially can be usefulin treatment.

Reciprocal Function of theRespiratory and Pelvic Diaphragm

(There is a functional relationshipbetween the pelvic diaphragm throughthe median umbilical ligament to theumbilicus and then the falciform liga-ment through to the diaphragm.) Thepelvic diaphragm works in a recipro-cal relationship with the respiratorydiaphragm. As the respiratory dia-phragm contracts, the pelvic dia-phragm must relax to allow the ab-dominal and pelvic contents to shiftinferiorly. If there is any restriction inthe respiratory or pelvic diaphragms,this physiological phenomenon willnot occur. It may be that there areneuronal pathways which reflexivelyrelax the pelvic diaphragm when therespiratory diaphragm contracts andvice versa.

With each inspiration, the dia-phragm acts on the lumbar vertebrae.There is a general flattening of allspinal A-P curves. The diaphragm,acting through the crura moves theante riorlongi tudinal ligament and hasa far reaching effect throughout thecardiovascular system. Blood ispumped from the heart out to theextremities throughout the cardio-vascular system. Blood is returnedthrough the venous and lymphaticchannels by the action of the pumpingof the peripheral muscles. The returnsystem (venous and lymphatic) ishighly pressure-gradient dependent.When the return of blood enters thepelvic cavity and abdominal cavities,it is solely dependent on the pressuredifferentials between the thorax, ab-dominal and pelvic cavities. The lym-phatic system returns 10% of the cir-culatory fluid from the periphery witheach cycle. It has been estimated thatin a 24-hour period, we turn over100% of the circulating serum bloodvolume through the lymphatic sys-tem. The peripheral muscles act topump the lymphatic fluid into thelymphatic channels and back cen-trally. Any disturbance in the thora-

coabdominopelvic cylinder will im-pede the return of fluid centrally.

The growing fetus will displacethe abdominal contents superiorly,pushing the diaphragm into the tho-racic cavity. Affectively, there is adecrease in the superior to inferiorlength of the thoracic cavity. There-fore, the diaphragm must work at anincreased rate of contraction against astronger resistance to maintain oxy-genation of the circulating blood vol-ume.

Not only is there an effect on thesuperior to inferior length of the tho-racic cavity, the growing fetus shift-ing the center of gravity anteriorlywill increase the lumbar lordosis. Thiscreates a larger tension on the crura ofthe diaphragm posteriorly, impedingdiaphragmatic function. The pelvis istilted anteriorly, greater tension isplaced on the anterior abdominal walland the thoraxes A-P diameter is de-creased.

Fourth Diaphragm -Sibson's Fascia

The thoracic inlet, which is com-prised of T I , the first ribs and manu-brium, work as a functional unit. Anyrotation of T1 will be reflected throughthe first ribs and the manubrium,changing the diameter of the superiorthoracic aperture. Sibson's fascia isattached to the inferior border of thefirst ribs and the posterior border ofthe manubrium and going posteriorlyto the region of the seventh cervicaland the first thoracic vertebrae. It hasimbedded within it the scalenus mini-mus which when contracted, tensesSibson's fascia. This fascia acts as adiaphragm covering the cupula of thelung. Sibson's fascia is also respon-sible for maintaining a pressure gra-dient between the neck and the tho-rax. Without this gradient, the neckviscera would be sucked into the tho-rax with each inspiration.

The fascial connection of the peri-

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cardium to the sternum is called the"pericardial ligament".The pericar-dium is basically pretracheal fascia,which has extended down from theneck and embedded itself into thediaphragm. This pretracheal fasciacontinues from the diaphragm beingthe covering of the heart, connectingto the sternum and into the neck. Theribs are covered by the prevertebralfascia, which travels superiorly to thebase of the skull.

Just as there is a relationship be-tween the thoracic and pelvic dia-phragms with respiration, Sibson'sfascia acts as a diaphragm in a recip-rocal relationship with the thoracicdiaphragm. Any distortion of the tho-racic inlet will lead to passive conges-tion of venous and lymphatic fluidsthroughout the whole body. The tho-racic inlet is approximately 4-1/2"wide by about 2-1/2" long. Withinthis space is a great number of vitalstructures. The thoracic duct emptiesinto the left subclavian vein in theregion of the thoracic inlet as well asthe right thoracic duct. The thoracicduct drains most of the lymphaticfluids of the body minus the rightportion of the thorax, the right headand the right upper extremity. Anydistortion of the thoracic inlet willlead to passive congestion of venousand lymphatic fluids throughout thewhole body.

There are a great number of struc-tures that traverse the thoracic inletbesides the thoracic duct. Thesestructures include the trachea, theesophagus, the vagus nerve, the sym-pathetic chain ganglion, carotid arter-ies, subclavian arteries, and subcla-vian veins. The brachial plexus restson the superior borderof the first ribs.Based on these anatomical relation-ships, this becomes a very importantarea to examine.

Fifth Diaphragm -Tentorium Cerebelli

The tentorium cerebelli is con-

nected to the Sibson's fascia throughthe prevertebral as well as pretrachaelfascias. The pretracheal and preverte-bral fascias as cylinders extendingfrom the thorax into the neck region.The prevertebral fascia invests theribs. It continues from 1st ribs superi-orly to cover the bodies of the verte-brae as well as the anterior and poste-rior cervical vertebral muscles. Thiscolumn of fascia is a direct connec-tion between the first ribs, the manu-brium and Tl, to the base of the skull.The insertion of the muscles of theneck onto the skull, effectively con-necting Sibson's fascia to the skull.

The tentorium cerebelli, being re-flections of dura, is directly connectedthrough the foramen magnum to thespinal dura to C2 and C3 and then tothe second sacral segment, forming acontinuous connection to the sacrum(cranial to pelvic diaphragm). Thereis evidence that the dura has firmattachments to most vertebraethroughout the column as well.

The tentorium cerebelli has em-bedded within it the venous sinuses.(The root of venous drainage from theskull is through the venous sinuses.)The tentorium cerebelli is attached tothe petrous ridges of the temporalbone (enclosing the superior petrosalsinus) and the internal surface of theocciput. As the sphenobasilar junc-tion goes into flexion, the tentoriumis brought inferior and spreads out. Inextension, the opposite occurs. Thetentorium cerebelli aids in the circu-lation of venous as well as cerebro-spinal fluid. The tentorium cerebelliis part of the dural structures that formthe "core link" connecting the sphe-nobasilar junction to the sacrum. Thereciprocal function of both areas isimportant in maintaining health.

Function of The Five DiaphragmsTogether

There is a synchronous motion ofthe five diaphragms of the body. Asthe respiratory diaphragm contracts,

the pelvic diaphragm and Sibson'sfascia work together to create pres-sure differentials which promote cir-culation of venous and lymphaticfluid. As the respiratory diaphragmcontracts, the pelvic diaphragm re-laxes, allowing the contents to dropinto the pelvic cavity. A relativenegative pressure is established in thethorax with positive pressure in theabdomen and pelvis. On exhalation,the respiratory diaphragm rises byelastic recoil and pressure gradientsreverse.

The tentorium um cerebelli and pelvicdiaphragm work in synchrony as well.As the primary respiratory mecha-nism goes into its flexion phase, thetentorium moves inferiorly, the sa-cral base moves posterior with theapex moving anterior. The innomi-nates move into external rotation. Thereverse occurs in extension. There isa relationship of the primary respira-tory mechanism (cranial rhythmicimpulse) to the secondary respiratorymechanism (breathing) in which theytend to augment each other.

The arches have an effect on theother diaphragms through their rolein posture. A functional pes planus(dropped arch) will restrict motion ofthe pelvis during respiratory and pos-tural motion, thus affecting the fourremaining diaphragms. How this isseen clinically will be discussed inPart 2.

The full functioning of the fivediaphragms must be maintained toprevent symptoms of pain, passivecongestion of fluid, dyspnea and oth-ers. As described, the five diaphragmsare related to each other anatomicallyand therefore, functionally.

The diagnosis and treatment of theobstetrical patient using these prin-ciples will be discussed in Part 2 ofthis series, which will be published inthe Spring issue of this journal, alongwith the complete reference list forboth articles.

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