07 Nov The Heart
(Anderson & Wilcox 1998, Baert et al, Dalley & Agur 2004, Grant & Boileau 2004, Gray 2000, Kirklin & Barratt-Boyes 1993, Netter 2003, Schlant & Silverman 1986, Sobotta 2001, Spence 1986, Tortora & Grabowski 2000, Zimmerman 1966)
- Is approximately the size of a fist and is in the thorax, above the diaphragm and left of the sternum.
- Is in the middle mediastinum (Figure 1).
- Is a hollow organ that weighs approximately 300 g and has 4 chambers.
Due to the fact that caudal surface of the heart is strongly related to the diaphragm, it will also follow the cranio-caudal movements of the diaphragm (Figure 2). (Holland et al 1998, Mc.Leish et al 2002, Peeters 2005, Porat et al 2000, Wang et al 1995)
The movement of the heart as influenced by respiration is a global translation.
During inhalation the diaphragm descends. The heart follows this displacement caudally (Figure 2).
This results in traction along the vertebropericardiac, bronchopericardiac and tracheopericardiac ligaments and along the superior sternopericardiac lig.
If these ligaments are trophically changed and their elasticity is reduced, this caudal force will be directly transferred to the spine at T2-T4, the sternum and the trachea and the bronchi (Figure 2). This is most likely why periostial sensitivity is so frequently found at T2-T4. Such vertebropericardiac traction could play an important role in complaints of the trachea, bronchi and thyroid (Figure 3).
The “thoracic outlet” is significantly influenced and “thoracic outlet” symptoms are likely to result.
3 . Palpation
Palpation of the cardiac pulse is done with the right hand flat upon the left hemithorax; thenar and hypothenar on the sternum and the index finger under the nipple. For female patients the right hand is placed under the left breast.
The osteopath pays attention to:
- Is there a point of maximum pulsation that can be localised at the height of the apex of the left ventricle? Try to localise this point with the fingertip.
- Normally this point is the size of a coin along the midclavicular line at the height of the 5th intercostal space.
- In cases of left ventricle enlargement (previous infarct(s)) this point will be displaced laterally. An obvious enlargement can mean that the point is found along the axillary line.
- If this pulse point is not readily found this does not always indicate pathology. Palpation of the point with the patient lying on the left side can aid the palpation.
Palpation of the apex:
4. Osteopathic Techniques
Stretch of the Intrathoracic Fascia
(Figure 4 )
The patient is supine, the legs straight and with the level of T2-3 on the edge of the table. The head is supported in the hands of the osteopath.
The osteopath applies traction from the occiput, protecting the cervical spine by avoiding lordosis, and asks the patient to breath in deeply – first via the abdomen, then via the thorax.
The patient is requested to breath in as deep as possible, to hold the shoulders against the table and to avoid any lumbar lordosis.
This is repeated until less caudal resistance is felt via the head.
The osteopath brings the head of the patient into opposite sidebending (C7) and ipsilateral rotation (C6), gives traction on the occiput, protecting the cervical spine by avoiding lordosis, and asks the patient to breath in deeply – first via the abdomen, then via the thorax while holding the shoulders against the table.
This is repeated until less caudal resistance is felt via the occiput.
If, after four repetitions, the fascias are not loosening there are musculoskeletal lesions that are limiting the motion. These must be corrected.