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BSO - Visceral Osteopathy 2011-2012
Session 3&4
Lecturer: Valeria A Ferreira DO MSc Ost PGCAP
+ Above the Diaphragm
Mobility & Motility
(after J.P. Barral and P. Mercier)
Many thanks to J P Barral for verbally agreeing with the use of
the text, drawings and extracts of his book “The Thorax” ” (3rd
edition, 1994).
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Thorax
Learning Outcomes
 Revision





of the palpation/ location of:
Thoracic inlet and Mediastinum
Pleural ligaments
Thoracic outlet and Diaphragm
Lungs
Heart
 Introduction
to the concept of the different
visceral restrictions (adhesions, fixations, ptosis,
viscerospasm, rhythmic alterations)
 Assessment techniques of mobility and motility
tests (inspir/expir)
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Thorax
Revision of Concepts
 Healthy
organ has a normal physiological
motion or Motility
 Altered



motion can be caused by:
Variations of the axis or the amplitude
Alterations to the motility
Alterations to the mobility of the organ caused by
surrounding articular structures
Valeria Ferreira
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Thorax
Possible clinical presentations
 According
change if:
 Local
to Barral,visceral motion can
pathology with symptoms
 Early stages of local pathology without symptoms
 A local sequaela to an old pathology, with
successful adaptation
 Viscera having “articular” relations with a
adjacent pathologic tissue/organ
 A pathology in a structure having vascular,
nervous and fascial relations with the viscera
Valeria Ferreira
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Thorax
Revision of Concepts
 Healthy
organ has a normal physiological
motion or Motility
 Altered



motion can be caused by:
Variations of the axis or the amplitude
Alterations to the motility
Alterations to the mobility of the organ caused by
surrounding articular structures
Valeria Ferreira
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Thorax
Possible clinical presentations
 According
change if:
 Local
to Barral,visceral motion can
pathology with symptoms
 Early stages of local pathology without symptoms
 A local sequaela to an old pathology, with
successful adaptation
 Viscera having “articular” relations with a
adjacent pathologic tissue/organ
 A pathology in a structure having vascular,
nervous and fascial relations with the viscera
Valeria Ferreira
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Thorax
Terminology of Visceral
restrictions
 Visceral
restrictions = any reduction in motion
caused by restrictions of the sliding surrounding
surfaces, connecting ligaments, muscles, etc.
 Scar
tissues - mechanical irritation leading to
decreased motion and change in the axis of
movement of the organ(s).
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Thorax
 Articular
Motility
restrictions - involves loss of Mobility &
 Adhesions
Mobility
 Fixations
- Reduced Motility but normal
- Both Motility and Mobility are
compromised (partial/total), causes may
include sequelae of pathological infection,
pleurisy, peritonitis, surgery, etc
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Thorax

Ligamentous Laxity/ Ptosis = loss of elasticity in the ligament
from prolonged overstretching, usually secondary to
adhesions (Barral)

Muscular restrictions / Viscerospasms =
 Hollow organs with double smooth musculature
(longitudinal and transverse fibers) are exclusively
affected. Irritation of a group of these fibers can result in
viscerospasm, reducing amplitude of its motility. Local
restriction that usually only affects part of the organ.
Various causes.

Rhythmic problems = Compromised vitality with changes of
the axes of motion resulting in a longer resting period or
slowing down/irregularity of the rhythm.
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Thorax
 Assessment
 Mobility
tests
 Mobility
test or Listening
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Thorax - Revision
Thoracic Inlet
 Also
called the superior diaphragm.
 Composed
by muscles and ligaments fibers
that join the 1st ribs, clavicles and T1.
 The
thoracic cavity is separated by the
Mediastinum.
 The
mediastinum contains the Heart,
Esophagus, Trachea and Vagus nerve.
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Pleura
 Pleura
 Parietal layer lines whole thoracic cavity.
 Inferiorly - Adheres to the diaphragm.
 Anteriorly and laterally- lies the Sternocostal wall,
connecting with the Endothoracic fascia.
 Posteriorly- the pleura is thick and fibous, easy to dettach
and it can fix part of the lung or the rib cage.
 The pleura is very affected by the diaphragmatic motion
(> superior attach’s).
 Pleural restrictions are quite common. The superior
attachments are area of myofascial tensions and changes in
pressure, which makes it vulnerable to restrictions.
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Thorax
Pleural dome
 Pleural
 The
dome
apex is found at level of T1
 Posterior and medial to 1st rib
 Lateral to Subclavian artery
 Dome moves inferiorly on inhalation
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Thorax
Pleura
 Suspensory ligaments
 Parietal pleura is attached to a connective tissue dome (intermediary to the hard skeletal frame).
 Pleural dome is formed by myofascial fibers and ligaments such as:





the Pleurovertebral lig.
Costopleural ligaments - thick connective fibers that connects the dome to
the neck of the 1st rib. It runs along the anterior edge of the 1st rib, ending
close to the anterior scalenes.
Some fibers of the scalenus minimus or the transverse cupular ligament
(when scalenus minimus is absent).
The Scalenus minimus is only present in 35-65% of people. Often
replaced by fibrous tissue with contractile fibers. It originates from
the pleural dome, running superiorly along the edge of the 1st rib,
against the anterior scalenes. It inserts on the Tps C6-7.
The suspensory ligaments of the pleura and pericardium are
inserted particularly on the deep cervical aponeurosis over C7-T1.
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Thorax
Pleural dome attachments
 Fascial
connections:
 Fascial
extensions of the middle and deep
cervical aponeuroses are in contact with the
pleura. They help to attach the pleura to the Csp,
neck of the 1st rib and to the Esophagus and
Trachea.
 These fasciae are divided into 2 parts:


C4-7 and attaching to the Pleural dome.
From the mid cervical aponeurosis to the inferior part of
the dome.
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Thorax
Cervicothoracic diaphragm
 Loosely
organized area with openings/
passages for the pleura, thymus, large
vessels, trachea and esophagus.
 The
bounderies of this cervicothoracic
diaphragm is formed by:
 Anteriorly
- sternum and clavicular insertions of
the cervical aponeurosis.
 Laterally - vascular sheaths.
 Posteriorly - visceral sheaths and fibromuscular
pleural apparatus.
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Thorax 2
Mediastinum
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Thorax
Thoracic Viscera
 The
lungs
 The
apex extends from the upper aperture of the
thorax and rises ventrally above the 1st rib in front
 The base rests on the diaphragm
 The flat mediastinal surface faces the medial
connective tissue space in the thorax - the
mediastinum
 Its costal surface (curved surface) faces the ribs
and vertebral column
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Thorax
Landmarks of R & L Bronchus
 Trachea
- bifurcates at inferior border of the
Manubrium
R
of the Sternum between the 2nd and 4th ribs
(2nd rib connects at the munubrium/sternal
junction)
R
Bronchus is at 25 degrees off the Trachea
L
Bronchus is at 45 degrees off the Trachea
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Thorax
The articulations of the Lungs

Sliding surface:
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Posterior articulation:
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Ribcage via parietal pleura
Superior articulation:


Ribcage via parietal pleura
Lateral articulation:
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
Ribcage via parietal pleura
Anterior articulation:

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Oblique fissure (L) and Horizontal fissure ®
Scalenes and Cervicobrachial structures via pleural dome and Sibson’s fascia
Inferior articulation:

Diaphragm via parietal pleura
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Thorax
The Heart
 Heart
 The
apex points forwards to the L and
downwards
 The
base points backwards to the R and upwards
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Thorax
Pericardium

Separated from the Sternum by loose connective tissue that
thickens at the top and botton ( the superior and inferior
sterno-pericardial ligaments).

The degenerated Thymus (±age 8) becomes a fibrousadipose mass that separates the pericardium from the
sternum (ribs 1-3), transforming into pericardial lig’s

Posteriorly - connects with organs found in the posterior
mediastinum (T4-T8).

Close connective tissue linkage with the esophagus (difficult
to differentiate between esophageal and cardiac
complaints).
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The thorax
Pericardium
 Pericardial
ligaments:
 Superior sternopericardial or
sternocostalpericardial lig
 Inferior
sternopericardial lig. or
xiphopericardium ligament
 Vertebropericardial
lig
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Thorax
Pericardium
 Superior
sternopericardial
(sternocostalpericardial) lig.
 Helps to suspend the pericardium in the
vertical and supine positions.
 Triangular shape lig, which inserts on the
manubrium and 1st sternocostal joint.
 Replaces the degenerated Thymus.
 Some fibers goes to the manubrium and others
to the middle cervical aponeurosis.
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Thorax
Pericardium
 Inferior
sternopericardial lig. (or
xiphopericardium ligament)
 It helps to suspend the Heart in the supine
position.
 ± triangular shaped lig.
 Originates from the xiphoid process,
exchanges several fibers with the diaphragm
and inserts into the middle part of the
diaphragm.
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Thorax
Pericardium
 Vertebropericardial
 Inserts
lig.
into a thickened portion of the deep
cervical aponeurosis bet. C4 - T4.
 Better developed on the L side. This could
explain why some of the cardiac pathologies
are felt predominantly on the L side.
 Some fibers run anteriorly to form aponeurotic
sheaths for the Aorta and large vessels at the
base of the neck.
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Thorax
The Heart
 Superior:


R 2nd- 3rd intercostal space
L 2nd intercostal space
 Inferior

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R 5th intercostal space
L 5th-6th intercostal space
 Left

margin
2 fingers medially R of left nipple line
 Right

margin
2 cm R from the Sternum
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Thorax
The articulations of the Heart

Sliding surface:


Posterior articulation:
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
Lungs, via mediastinal pleura
Superior articulation:

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Sternum, via sterno-pericardium ligament
Lateral articulation:


Bronchi pulmonary ligament
Anterior articulation:


Pericardium
Hilum of lungs and great vessels
Inferior articulation:

Diaphragm via the pericardial sac
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Thorax
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References

Visceral Manipulation- The Thorax, Barral, J.P.: Mercier, P, 1994

Netter, F H (1989), The thorax in Atlas of Human Anatomy, CIBAGEICY, USA

Lungs and Mediastinum lecture notes from Robert McCoy (BSO)