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The respiratory–circulatory model of osteopathic care
RUNNING HEAD RECTO PAGES
Chapter 8
The respiratory–circulatory model of osteopathic care
CHAPTER CONTENTS Introduction 159 Movement of fluids 160 The respiratory–circulatory model of osteopathic care 161 Conclusion 163 References 164 Recommended reading 164
INTRODUCTION ‘The rule of the artery is supreme’ is one of Still’s most often cited principles. It was later modified to the more globally inclusive ‘The movement of the body fluids is essential to the maintenance of health’. Fluid bathes our whole body. Many of us tend to think initially of the blood in the arterial and venous system as the major fluid system in the body. This, however, accounts for only 8% of the total body fluid. Body fluid accounts for 60% of the total body weight of a human, which is 42 L of fluid. Of this, 40%, or 28 L, is intracellular fluid and 20%, or 14 L, extracellular fluid. The blood represents just 5 L.1 The fluids serve a multiplicity of tasks. They carry the nutritional requirements such as oxygen and glucose to all of the tissues of the body, and then bear away the waste products such as lactic acid and carbon dioxide. They can be seen as the mediator of the humoral communication systems that are essential for the defence of the body and the maintenance of homeostasis. The cellular elements of the immune system are conveyed within the vascular system and can pass into the extracellular fluid when required. The humoral communication messengers of the neuroendocrine immune system, the hormones, neurotransmitters, cytokinins, etc., are all transmitted via the fluid systems. The lymphatic system, though often seen as a separate entity, is also a part of the total fluid system. It has two major roles. It transmits the fatty fluids from the gastrointestinal tract (GIT), and the interstitial fluid that escapes from the capillaries, back into the
159
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OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS
cardiovascular system. It also has a major role in the defence of the body, with mobile ‘surveillance’ elements, such as the lymphocytes, circulating the body and destroying or producing antibodies to any foreign substances; and static organs through which the fluids have to pass and through which medium foreign substances are removed. It also has a role in support and protection. Fluid fills the fascial cavities, ‘inflating’ them, and thereby offering structural support to the area both locally and to the body globally. These fluid-filled cavities act as tensegrity structures, offering protection by causing any forces acting on them to pass equally to the entire surrounding structure, diminishing the overall effect. It can also be seen as a hydraulic support system which can buffer the supported structures from any external forces, such as the cerebrospinal fluid (CSF) protecting the central nervous system.
MOVEMENT OF FLUIDS Fluid passes to every cell, even when there are no vessels or obvious passageways for it to get there. The only obvious pump for the circulation of the fluids is the heart, which acts on the arterial system. Circulation of the extra- and intracellular fluids, lymph, venous blood and CSF depend on a complex interplay of the soft tissues and the resulting pressure changes in the body. On a gross scale the contraction and relaxation of the thoracic diaphragm in respiration creates a constant cycle of pressure changes throughout the body. As the diaphragm moves inferiorly on inspiration there will be a relative increase in pressure below the diaphragm and a relative decrease above. Increase in pressure tends to ‘squeeze’ fluids out of tissues; as the pressure is decreased it will cause fluids to be ‘sucked’ into the tissues. This helps the perfusion of these tissues. Similarly any movement of the body will be transmitted through the extracellular tissue matrix, torsioning and shearing the planes of the tissues, creating ‘wringing out’ effects on the tissues right down to a cellular and intracellular level. To aid these two actions the body is organized into a series of fascial compartments on both a local level, creating multiple small spaces, and a global level with the cranial, thoracic and abdominopelvic cavities. Transmission between these fascial compartments, or even from extracellular to intracellu-
lar, is dependent on pressure gradients. Where the appropriate pressure gradient is disturbed there will be a disturbance in the flow of fluids, resulting in a relative decrease in perfusion in areas of high pressure, and stasis in areas of low pressure. Thus an increase in the pressure of the abdominopelvic cavity will result in a relative hypoperfusion in the organs and tissue contained therein, but as the pressure gradient between the lower extremities and the pelvis has increased, there may be insufficient pressure within the lower extremity return mechanisms to overcome this gradient. Consequently, fluids will tend to pool in the lower extremities, both in the venous system and in the tissues and extracellular spaces, and stasis will ensue. With decrease in perfusion there will also be a reduction in all of the physiological effects of the fluid: nutrition, communication, elimination, etc. Other mechanisms of aiding the return of fluids are the contraction and relaxation of striated muscles and of the smooth muscle of the alimentary canal in peristalsis. As they are contained in a fascial envelope, this will cause an alternating pressure within the envelope, moving the fluids along. There will also be an effect on the neighbouring soft tissue structures in their envelopes, creating similar changes in the fluids. The movement of fluid is assisted by the valves in the lymphatic system and parts of the venous system. When the pressure is increased in a cavity, fluid will be pushed along the vessel, but it will be prevented from dropping back with the following decrease in pressure, by the action of the valves. The inherent motility of cells, tissues and organs will also have an effect on the fluid dynamics. The various diaphragms are also thought to have a great influence on the circulation of fluids. The thoracic diaphragm has already been mentioned. The plantar fascia is thought by some to act as a gentle pump, being active when walking. The remaining diaphragms, the pelvic floor, the thoracic inlet (Sibson’s fascia), and the tentorium cerebellae with or without the diaphragma sella, are more generally seen as possible areas of restriction to fluid flow if dysfunctioning. It will be noted that fluid movement is dependent on pressure and movement of tissues. If a local somatic dysfunction occurs, it will often result in local hypomobility and an increase in tension in the associated soft tissues. This will automatically result in a local decrease in tissue perfusion which will result in relative hypoxia and decrease in all of the
The respiratory–circulatory model of osteopathic care
physiological functions mediated by the constituents carried in the fluid. Gross disturbances of the body, such as postural problems, will disturb the balance of pressure between the cavities and will therefore have a dramatic effect on the circulation of all of the fluids of the body, and consequently a global physiological effect. This is described by Littlejohn in the anterior and posterior weight types, Goldthwait in Body Mechanics and Kelman in Emotional Anatomy.2,3,4 Pressure and mobility are not the only factors affecting fluid exchange. Others include osmolar gradients and the electrical potential of particles,5 to mention just two; however, the obvious importance of the factors discussed earlier and their accessibility to manual therapists make them predominantly important. Inherent in many treatment approaches is the concept of restoring mobility and thereby restoring fluid exchange. The general osteopathic treatment (GOT) is an approach that cites this as one of its key aims, and this is discussed in the next section. Some of the approaches within the involuntary mechanism are based on fluid movement, such as the CV4 which is thought of as a compression of the fourth ventricle which encourages CSF exchange, amongst other stated benefits. The osseous structures themselves may be visualized as being composed of a sea of molecules rather than as a rigid structure, permitting work on an intraosseous level; again the rationale behind involuntary approaches is discussed in Section 3. Another approach that is perhaps more conceptual than practical is that of Gordon Zink’s Respiratory–Circulatory Model of Osteopathic Care. The practical application of this draws on a series of approaches including articulation, high velocity thrust (HVT) and indirect work such as fascial unwinding, or cranial techniques. It can be seen as a conceptual model, the application of which can be adapted by the practitioner depending on the patient’s needs, biotype, state of health and the practitioner’s abilities.
It would appear that he was influenced by the strong emphasis that AT Still placed on the role of the body fluids and particularly the lymphatics: ‘your patient had better save his life and money by passing you by as a failure, until you are by knowledge qualified to deal with the lymphatics’.6 Another great influence was FP Millard who developed a systematic approach to evaluate and treat the lymphatic system.7 Zink’s respiratory and circulatory model can be seen as an expansion of Millard’s work. The other major influence was WG Sutherland, most notably his work on the primary respiratory mechanism and fluid fluctuations. The key feature of Zink’s model is that for health (or homeostasis) there must be good circulation of all of the body fluids; this will ensure that there is proper nutrition and drainage of the tissues right down to a cellular level. This represents the circulatory part of the name. In order to achieve this, the respiratory processes must be working efficiently. Of prime importance is the ‘respiratory suction pump’, by which he means the action in respiration of the thoracic diaphragm, the thorax and the lungs. He describes it as a ‘three way’ suction pump; air, venous blood and lymph being aspirated by it.8 This pump is therefore working synergistically with the ‘pressure pump’ of the heart to ensure the circulation of the body fluids. This is the respiratory aspect of the title. The concept as a whole is best described in Zink’s own words.
THE RESPIRATORY–CIRCULATORY MODEL OF OSTEOPATHIC CARE
Respiration and circulation are unifiable functions. The need for establishing ‘normal respiration’, which is diaphragmatic when the patient is resting in the supine position, is obvious when we consider the fact that most of the volume of blood is found in the venous reservoir. This low pressure system is dependent on pressure differentials in the body cavities for effective flow, because there is no assistance from the muscles, which are aptly called ‘peripheral pumps’. The cardiogenic aspect of circulation depends on the respirogenic aspect of circulation to complete the circuit. But that is not all; the most important feature is the fact that the ‘terminal’ lymphatic drainage into the venous system is also dependent on the effective diaphragmatic respiration when the patient is resting.9
J Gordon Zink was an American osteopath and educator based at the Des Moines College of Osteopathic Medicine and Surgery in Iowa (until he died in 1982).
Another element that was thought by Zink to be essential to the body’s physiological respiratory mechanisms was the primary respiration described by Sutherland. Particular attention was paid to the
161
162
OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS
freedom of movement of the cranial and pelvic diaphragms, and their relationship with the thoracic diaphragm, and articular mobility of the sacrum between the ilia. The primary respiration is therefore supporting the secondary respiration and its thoracoabdominal pelvic pump, these two working in synergy with the heart.
THE COMMON COMPENSATORY PATTERN (CCP) The pattern as described by Zink and BA TePoorten10 is based on the junctional areas between the three body parts, the cranium, thorax and pelvis. These junctions are the upper cervical complex, the thoracic inlet, the thoracic outlet or thoracolumbar junction, and the lumbosacral complex. These areas are mobile and vulnerable to dysfunction and they each have a diaphragm associated with them and a relationship with the ANS. This is shown in Table 8.1. The four diaphragms are, as already mentioned, important in the movement of both body fluids and air by producing pressure differentials within the body cavities. They are considered the main rotational/torsional components in the body’s compensatory pattern. Besides being connected to the junctional areas of the spine, the diaphragms are also linked with the longitudinal connective tissue continuity of the body. Distortion of the diaphragms would introduce a myofascial torsioning of the longitudinal fascial continuity, and their function as a vascular pathway of the body would be disturbed.
Thus any fascial torsion will affect the fluid circulation of the body and therefore compromise its health. The common compensatory pattern (CCP) represents a series of myofascial torsions that are compatible with physiological function. Simply stated, if the diaphragms are rotated in alternating directions it indicates compensated physiological function (Fig. 8.1). Zink also described another physiological pattern which is a series of myofascial torsions that are rotated in alternating directions but opposite to that of the CCP; it is also compatible with physiological function. As it is relatively rare it is termed the uncommon compensatory pattern (Fig. 8.2). If the fascial torsions are found on testing not to be rotated in alternately opposite directions it indicates a non-compensatory pattern. This is not physiological and therefore compromises the respiratory– circulatory integrity of the body and its normal function, predisposing the individual to disease. This should be resolved to restore a physiological compensatory pattern. This can be achieved by addressing the osseous attachments of the diaphragm utilizing a direct approach, or by addressing the fascia by an indirect approach, or by a combination of the two.
Right
Left OA
Table 8.1 The relationship between the junctions in the common compensatory pattern in Zink’s respiratory–circulatory model Junction The upper cervical complex
C/D
Spinal level
Related diaphragm
C0–C3
The tentorium cerebellae PSNS and the falx cerebri (also part of the RTM)
D/L
The thoracic inlet diaphragm (Sibson’s fascia)
L/S
The thoracic C7–T1 inlet
Autonomic action
SNS
The thoracic T12–L1 The thoracoabdominal outlet diaphragm
SNS
Lumbosacral L5–S1 complex
PSNS
The urogenital or pelvic diaphragm
Figure 8.1 The common compensatory pattern (CCP), the specific finding of alternating fascial motion at the diaphragms of the junctional areas of the body as described by Zink. (Modified after Glossary of osteopathic terminology. Chicago: American Association of Colleges of Osteopathic Medicine; 2002.)
The respiratory–circulatory model of osteopathic care
A BRIEF DISCUSSION OF THIS MODEL Right
Left OA
C/D
D/L
L/S
Figure 8.2 The uncommon compensatory pattern: the specific finding of alternating fascial motion at the diaphragms of the junctional areas of the body opposite to that of the CCP. (Modified after Glossary of osteopathic terminology. Chicago: American Association of Colleges of Osteopathic Medicine; 2002.)
BA TePoorten describes the structural pattern of dysfunction that is to be found in the CCP.10 He advocates that these dysfunctions should be resolved and suggests that, once this is achieved, most of the associated problems should be resolved. 1. Pelvic torsion with the left inominate being posterior and the right anterior with a consequent left elevated pubic tubercle. 2. The sacrum is in a left on left torsion. 3. Right rotation and left side-bending of the lumbosacral articulation. 4. The thoracolumbar junction is left rotated and side-bent. 5. The tenth rib is held in inspiration, being inferior and posterior. 6. Rib five is in inspiration and anterior to its left equivalent. The fifth thoracic vertebra is in extension and right rotation. 7. The third thoracic vertebra is right rotated causing the left rib to be anterior. 8. The first rib is elevated on the left. 9. The first and second thoracic vertebrae are rotated to the right. 10. The upper cervical complex (C2) is in sidebending right and left rotation.
Using Zink’s (and TePoorten’s) compensatory and non-compensatory patterns in evaluation and management of patients has many advantages. First of all, it is inclusive, which means that your approach to the patient is global, not focal. It is relatively descriptive: the sequencing allows you to approach patients who are acutely ill or hospitalized. Where, after your examination, you do not understand the chaos of findings, following the descriptors will take care of approximately 80% of the body’s dysfunction. The model focuses on respiration and circulation, crucial factors in restoring and maintaining health. It acts as a sort of American GOT.11 Within Europe many would find this prescriptive treatment approach anathema. However, that does not invalidate the fascial torsion patterns and the consequences that this will have on the fluid exchange. Perhaps a more flexible treatment approach will enable this useful conceptual model to be applied more widely.
CONCLUSION This is a very short section, in essence dealing purely with Zink’s Respiratory–Circulatory Model of Osteopathic Care. This is included here as the model has at its roots a very simple concept, that of correct breathing being of great importance in completing the cardiac cycle and thus ensuring the optimum perfusion of the body’s tissues. At first glance it appears to be somewhat naïve and, with TePoorten’s model, prescriptive. However, if you take on board the concept underpinning the model, and then incorporate it into the conceptual models that you already have, it becomes an interesting and important and perhaps different perspective that will add to the efficacy of your treatment. An immediate example that is cited about Zink’s treatment is that he utilizes a HVT to ring the fluid out of the tissues, not a thought that would immediately have sprung to mind. Little has been said here about CSF circulation and cranial treatment. It is addressed slightly in Section 3, but as there is a plethora of articles currently available on this subject, and the concepts are changing very rapidly, a search on the web for the most recent concepts would be more appropriate than anything written here.
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OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS
References 1. Guyton AC, Hall JE. Textbook of medical physiology. In: Royder JO. Fluid hydraulics in human physiology. J Am Acad Osteopath 1997; 7(2):11–16. 2. Wernham J, Hall TE. The mechanics of the spine and pelvis. Maidstone: Maidstone College of Osteopathy; 1960. 3. Goldthwait JE, Lloyd T, Loring T et al. Essentials of body mechanics in health and disease, 5th edn. Philadelphia: JB Lippincott; 1952. 4. Keleman S. Emotional anatomy. Berkeley: Center Press; 1985. 5. Royder JO. Fluid hydraulics in human physiology. J Am Acad Osteopath 1997; 7(2):11–16.
6. Still AT. Philosophy and mechanical principles of osteopathy. Kirksville: Journal Press; 1902: 105. 7. Millard FP. Applied anatomy of the lymphatics. Kirksville: Journal Printing; 1922. 8. Zink JG. Applications of the holistic approach to homeostasis. AAO Yearbook; 1973. 9. Zink JG. Respiratory and circulatory care: The conceptual model. Osteopathic Annals 1997; March: 108–112. 10. TePoorten BA. The common compensatory pattern. The Journal of the New Zealand Register of Osteopaths 1988; 2:17–19. 11. Fossum C. Personal communication; 2003.
Recommended reading Little is written on Zink’s model other than the articles referenced here; these are of interest. For an historical perspective Millard’s book makes interesting reading.
Millard FP. Applied anatomy of the lymphatics. Kirksville: Journal Printing; 1922.
Chapter 8
The respiratory–circulatory model of osteopathic care
CHAPTER CONTENTS Introduction 159 Movement of fluids 160 The respiratory–circulatory model of osteopathic care 161 Conclusion 163 References 164 Recommended reading 164
INTRODUCTION ‘The rule of the artery is supreme’ is one of Still’s most often cited principles. It was later modified to the more globally inclusive ‘The movement of the body fluids is essential to the maintenance of health’. Fluid bathes our whole body. Many of us tend to think initially of the blood in the arterial and venous system as the major fluid system in the body. This, however, accounts for only 8% of the total body fluid. Body fluid accounts for 60% of the total body weight of a human, which is 42 L of fluid. Of this, 40%, or 28 L, is intracellular fluid and 20%, or 14 L, extracellular fluid. The blood represents just 5 L.1 The fluids serve a multiplicity of tasks. They carry the nutritional requirements such as oxygen and glucose to all of the tissues of the body, and then bear away the waste products such as lactic acid and carbon dioxide. They can be seen as the mediator of the humoral communication systems that are essential for the defence of the body and the maintenance of homeostasis. The cellular elements of the immune system are conveyed within the vascular system and can pass into the extracellular fluid when required. The humoral communication messengers of the neuroendocrine immune system, the hormones, neurotransmitters, cytokinins, etc., are all transmitted via the fluid systems. The lymphatic system, though often seen as a separate entity, is also a part of the total fluid system. It has two major roles. It transmits the fatty fluids from the gastrointestinal tract (GIT), and the interstitial fluid that escapes from the capillaries, back into the
159
160
OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS
cardiovascular system. It also has a major role in the defence of the body, with mobile ‘surveillance’ elements, such as the lymphocytes, circulating the body and destroying or producing antibodies to any foreign substances; and static organs through which the fluids have to pass and through which medium foreign substances are removed. It also has a role in support and protection. Fluid fills the fascial cavities, ‘inflating’ them, and thereby offering structural support to the area both locally and to the body globally. These fluid-filled cavities act as tensegrity structures, offering protection by causing any forces acting on them to pass equally to the entire surrounding structure, diminishing the overall effect. It can also be seen as a hydraulic support system which can buffer the supported structures from any external forces, such as the cerebrospinal fluid (CSF) protecting the central nervous system.
MOVEMENT OF FLUIDS Fluid passes to every cell, even when there are no vessels or obvious passageways for it to get there. The only obvious pump for the circulation of the fluids is the heart, which acts on the arterial system. Circulation of the extra- and intracellular fluids, lymph, venous blood and CSF depend on a complex interplay of the soft tissues and the resulting pressure changes in the body. On a gross scale the contraction and relaxation of the thoracic diaphragm in respiration creates a constant cycle of pressure changes throughout the body. As the diaphragm moves inferiorly on inspiration there will be a relative increase in pressure below the diaphragm and a relative decrease above. Increase in pressure tends to ‘squeeze’ fluids out of tissues; as the pressure is decreased it will cause fluids to be ‘sucked’ into the tissues. This helps the perfusion of these tissues. Similarly any movement of the body will be transmitted through the extracellular tissue matrix, torsioning and shearing the planes of the tissues, creating ‘wringing out’ effects on the tissues right down to a cellular and intracellular level. To aid these two actions the body is organized into a series of fascial compartments on both a local level, creating multiple small spaces, and a global level with the cranial, thoracic and abdominopelvic cavities. Transmission between these fascial compartments, or even from extracellular to intracellu-
lar, is dependent on pressure gradients. Where the appropriate pressure gradient is disturbed there will be a disturbance in the flow of fluids, resulting in a relative decrease in perfusion in areas of high pressure, and stasis in areas of low pressure. Thus an increase in the pressure of the abdominopelvic cavity will result in a relative hypoperfusion in the organs and tissue contained therein, but as the pressure gradient between the lower extremities and the pelvis has increased, there may be insufficient pressure within the lower extremity return mechanisms to overcome this gradient. Consequently, fluids will tend to pool in the lower extremities, both in the venous system and in the tissues and extracellular spaces, and stasis will ensue. With decrease in perfusion there will also be a reduction in all of the physiological effects of the fluid: nutrition, communication, elimination, etc. Other mechanisms of aiding the return of fluids are the contraction and relaxation of striated muscles and of the smooth muscle of the alimentary canal in peristalsis. As they are contained in a fascial envelope, this will cause an alternating pressure within the envelope, moving the fluids along. There will also be an effect on the neighbouring soft tissue structures in their envelopes, creating similar changes in the fluids. The movement of fluid is assisted by the valves in the lymphatic system and parts of the venous system. When the pressure is increased in a cavity, fluid will be pushed along the vessel, but it will be prevented from dropping back with the following decrease in pressure, by the action of the valves. The inherent motility of cells, tissues and organs will also have an effect on the fluid dynamics. The various diaphragms are also thought to have a great influence on the circulation of fluids. The thoracic diaphragm has already been mentioned. The plantar fascia is thought by some to act as a gentle pump, being active when walking. The remaining diaphragms, the pelvic floor, the thoracic inlet (Sibson’s fascia), and the tentorium cerebellae with or without the diaphragma sella, are more generally seen as possible areas of restriction to fluid flow if dysfunctioning. It will be noted that fluid movement is dependent on pressure and movement of tissues. If a local somatic dysfunction occurs, it will often result in local hypomobility and an increase in tension in the associated soft tissues. This will automatically result in a local decrease in tissue perfusion which will result in relative hypoxia and decrease in all of the
The respiratory–circulatory model of osteopathic care
physiological functions mediated by the constituents carried in the fluid. Gross disturbances of the body, such as postural problems, will disturb the balance of pressure between the cavities and will therefore have a dramatic effect on the circulation of all of the fluids of the body, and consequently a global physiological effect. This is described by Littlejohn in the anterior and posterior weight types, Goldthwait in Body Mechanics and Kelman in Emotional Anatomy.2,3,4 Pressure and mobility are not the only factors affecting fluid exchange. Others include osmolar gradients and the electrical potential of particles,5 to mention just two; however, the obvious importance of the factors discussed earlier and their accessibility to manual therapists make them predominantly important. Inherent in many treatment approaches is the concept of restoring mobility and thereby restoring fluid exchange. The general osteopathic treatment (GOT) is an approach that cites this as one of its key aims, and this is discussed in the next section. Some of the approaches within the involuntary mechanism are based on fluid movement, such as the CV4 which is thought of as a compression of the fourth ventricle which encourages CSF exchange, amongst other stated benefits. The osseous structures themselves may be visualized as being composed of a sea of molecules rather than as a rigid structure, permitting work on an intraosseous level; again the rationale behind involuntary approaches is discussed in Section 3. Another approach that is perhaps more conceptual than practical is that of Gordon Zink’s Respiratory–Circulatory Model of Osteopathic Care. The practical application of this draws on a series of approaches including articulation, high velocity thrust (HVT) and indirect work such as fascial unwinding, or cranial techniques. It can be seen as a conceptual model, the application of which can be adapted by the practitioner depending on the patient’s needs, biotype, state of health and the practitioner’s abilities.
It would appear that he was influenced by the strong emphasis that AT Still placed on the role of the body fluids and particularly the lymphatics: ‘your patient had better save his life and money by passing you by as a failure, until you are by knowledge qualified to deal with the lymphatics’.6 Another great influence was FP Millard who developed a systematic approach to evaluate and treat the lymphatic system.7 Zink’s respiratory and circulatory model can be seen as an expansion of Millard’s work. The other major influence was WG Sutherland, most notably his work on the primary respiratory mechanism and fluid fluctuations. The key feature of Zink’s model is that for health (or homeostasis) there must be good circulation of all of the body fluids; this will ensure that there is proper nutrition and drainage of the tissues right down to a cellular level. This represents the circulatory part of the name. In order to achieve this, the respiratory processes must be working efficiently. Of prime importance is the ‘respiratory suction pump’, by which he means the action in respiration of the thoracic diaphragm, the thorax and the lungs. He describes it as a ‘three way’ suction pump; air, venous blood and lymph being aspirated by it.8 This pump is therefore working synergistically with the ‘pressure pump’ of the heart to ensure the circulation of the body fluids. This is the respiratory aspect of the title. The concept as a whole is best described in Zink’s own words.
THE RESPIRATORY–CIRCULATORY MODEL OF OSTEOPATHIC CARE
Respiration and circulation are unifiable functions. The need for establishing ‘normal respiration’, which is diaphragmatic when the patient is resting in the supine position, is obvious when we consider the fact that most of the volume of blood is found in the venous reservoir. This low pressure system is dependent on pressure differentials in the body cavities for effective flow, because there is no assistance from the muscles, which are aptly called ‘peripheral pumps’. The cardiogenic aspect of circulation depends on the respirogenic aspect of circulation to complete the circuit. But that is not all; the most important feature is the fact that the ‘terminal’ lymphatic drainage into the venous system is also dependent on the effective diaphragmatic respiration when the patient is resting.9
J Gordon Zink was an American osteopath and educator based at the Des Moines College of Osteopathic Medicine and Surgery in Iowa (until he died in 1982).
Another element that was thought by Zink to be essential to the body’s physiological respiratory mechanisms was the primary respiration described by Sutherland. Particular attention was paid to the
161
162
OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS
freedom of movement of the cranial and pelvic diaphragms, and their relationship with the thoracic diaphragm, and articular mobility of the sacrum between the ilia. The primary respiration is therefore supporting the secondary respiration and its thoracoabdominal pelvic pump, these two working in synergy with the heart.
THE COMMON COMPENSATORY PATTERN (CCP) The pattern as described by Zink and BA TePoorten10 is based on the junctional areas between the three body parts, the cranium, thorax and pelvis. These junctions are the upper cervical complex, the thoracic inlet, the thoracic outlet or thoracolumbar junction, and the lumbosacral complex. These areas are mobile and vulnerable to dysfunction and they each have a diaphragm associated with them and a relationship with the ANS. This is shown in Table 8.1. The four diaphragms are, as already mentioned, important in the movement of both body fluids and air by producing pressure differentials within the body cavities. They are considered the main rotational/torsional components in the body’s compensatory pattern. Besides being connected to the junctional areas of the spine, the diaphragms are also linked with the longitudinal connective tissue continuity of the body. Distortion of the diaphragms would introduce a myofascial torsioning of the longitudinal fascial continuity, and their function as a vascular pathway of the body would be disturbed.
Thus any fascial torsion will affect the fluid circulation of the body and therefore compromise its health. The common compensatory pattern (CCP) represents a series of myofascial torsions that are compatible with physiological function. Simply stated, if the diaphragms are rotated in alternating directions it indicates compensated physiological function (Fig. 8.1). Zink also described another physiological pattern which is a series of myofascial torsions that are rotated in alternating directions but opposite to that of the CCP; it is also compatible with physiological function. As it is relatively rare it is termed the uncommon compensatory pattern (Fig. 8.2). If the fascial torsions are found on testing not to be rotated in alternately opposite directions it indicates a non-compensatory pattern. This is not physiological and therefore compromises the respiratory– circulatory integrity of the body and its normal function, predisposing the individual to disease. This should be resolved to restore a physiological compensatory pattern. This can be achieved by addressing the osseous attachments of the diaphragm utilizing a direct approach, or by addressing the fascia by an indirect approach, or by a combination of the two.
Right
Left OA
Table 8.1 The relationship between the junctions in the common compensatory pattern in Zink’s respiratory–circulatory model Junction The upper cervical complex
C/D
Spinal level
Related diaphragm
C0–C3
The tentorium cerebellae PSNS and the falx cerebri (also part of the RTM)
D/L
The thoracic inlet diaphragm (Sibson’s fascia)
L/S
The thoracic C7–T1 inlet
Autonomic action
SNS
The thoracic T12–L1 The thoracoabdominal outlet diaphragm
SNS
Lumbosacral L5–S1 complex
PSNS
The urogenital or pelvic diaphragm
Figure 8.1 The common compensatory pattern (CCP), the specific finding of alternating fascial motion at the diaphragms of the junctional areas of the body as described by Zink. (Modified after Glossary of osteopathic terminology. Chicago: American Association of Colleges of Osteopathic Medicine; 2002.)
The respiratory–circulatory model of osteopathic care
A BRIEF DISCUSSION OF THIS MODEL Right
Left OA
C/D
D/L
L/S
Figure 8.2 The uncommon compensatory pattern: the specific finding of alternating fascial motion at the diaphragms of the junctional areas of the body opposite to that of the CCP. (Modified after Glossary of osteopathic terminology. Chicago: American Association of Colleges of Osteopathic Medicine; 2002.)
BA TePoorten describes the structural pattern of dysfunction that is to be found in the CCP.10 He advocates that these dysfunctions should be resolved and suggests that, once this is achieved, most of the associated problems should be resolved. 1. Pelvic torsion with the left inominate being posterior and the right anterior with a consequent left elevated pubic tubercle. 2. The sacrum is in a left on left torsion. 3. Right rotation and left side-bending of the lumbosacral articulation. 4. The thoracolumbar junction is left rotated and side-bent. 5. The tenth rib is held in inspiration, being inferior and posterior. 6. Rib five is in inspiration and anterior to its left equivalent. The fifth thoracic vertebra is in extension and right rotation. 7. The third thoracic vertebra is right rotated causing the left rib to be anterior. 8. The first rib is elevated on the left. 9. The first and second thoracic vertebrae are rotated to the right. 10. The upper cervical complex (C2) is in sidebending right and left rotation.
Using Zink’s (and TePoorten’s) compensatory and non-compensatory patterns in evaluation and management of patients has many advantages. First of all, it is inclusive, which means that your approach to the patient is global, not focal. It is relatively descriptive: the sequencing allows you to approach patients who are acutely ill or hospitalized. Where, after your examination, you do not understand the chaos of findings, following the descriptors will take care of approximately 80% of the body’s dysfunction. The model focuses on respiration and circulation, crucial factors in restoring and maintaining health. It acts as a sort of American GOT.11 Within Europe many would find this prescriptive treatment approach anathema. However, that does not invalidate the fascial torsion patterns and the consequences that this will have on the fluid exchange. Perhaps a more flexible treatment approach will enable this useful conceptual model to be applied more widely.
CONCLUSION This is a very short section, in essence dealing purely with Zink’s Respiratory–Circulatory Model of Osteopathic Care. This is included here as the model has at its roots a very simple concept, that of correct breathing being of great importance in completing the cardiac cycle and thus ensuring the optimum perfusion of the body’s tissues. At first glance it appears to be somewhat naïve and, with TePoorten’s model, prescriptive. However, if you take on board the concept underpinning the model, and then incorporate it into the conceptual models that you already have, it becomes an interesting and important and perhaps different perspective that will add to the efficacy of your treatment. An immediate example that is cited about Zink’s treatment is that he utilizes a HVT to ring the fluid out of the tissues, not a thought that would immediately have sprung to mind. Little has been said here about CSF circulation and cranial treatment. It is addressed slightly in Section 3, but as there is a plethora of articles currently available on this subject, and the concepts are changing very rapidly, a search on the web for the most recent concepts would be more appropriate than anything written here.
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References 1. Guyton AC, Hall JE. Textbook of medical physiology. In: Royder JO. Fluid hydraulics in human physiology. J Am Acad Osteopath 1997; 7(2):11–16. 2. Wernham J, Hall TE. The mechanics of the spine and pelvis. Maidstone: Maidstone College of Osteopathy; 1960. 3. Goldthwait JE, Lloyd T, Loring T et al. Essentials of body mechanics in health and disease, 5th edn. Philadelphia: JB Lippincott; 1952. 4. Keleman S. Emotional anatomy. Berkeley: Center Press; 1985. 5. Royder JO. Fluid hydraulics in human physiology. J Am Acad Osteopath 1997; 7(2):11–16.
6. Still AT. Philosophy and mechanical principles of osteopathy. Kirksville: Journal Press; 1902: 105. 7. Millard FP. Applied anatomy of the lymphatics. Kirksville: Journal Printing; 1922. 8. Zink JG. Applications of the holistic approach to homeostasis. AAO Yearbook; 1973. 9. Zink JG. Respiratory and circulatory care: The conceptual model. Osteopathic Annals 1997; March: 108–112. 10. TePoorten BA. The common compensatory pattern. The Journal of the New Zealand Register of Osteopaths 1988; 2:17–19. 11. Fossum C. Personal communication; 2003.
Recommended reading Little is written on Zink’s model other than the articles referenced here; these are of interest. For an historical perspective Millard’s book makes interesting reading.
Millard FP. Applied anatomy of the lymphatics. Kirksville: Journal Printing; 1922.