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TECHNIQUES THAT MAY ENHANCE THE GLYMPHATIC

SYSTEM AND THE CLEARANCE OF THE BRAIN

AAO CONVOCATION MARCH 14, 2019

DR. A. HOPE TOBEY DO C-NMM/OMM FACOP FAAP

ASSISTANT PROFESSOR OF OMM AND PEDIATRICS

EDWARD VIA COLLEGE OF OSTEOPATHIC MEDICINE - VIRGINIA

TODAY’S GOALS:

• DESCRIBE THE CURRENT KNOWLEDGE OF THE

ANATOMY OF THE GLYMPHATIC SYSTEM

• DISCUSS POSSIBLE IMPLICATIONS FOR

RESTRICTION OF FUNCTION OF THE

GLYMPHATICS

• REVIEW A SEQUENCE OF LYMPHATIC

TECHNIQUES AND TECHNIQUES THAT MAY

HELP WITH GLYMPHATIC DRAINAGE

GENERAL LYMPHATIC ANATOMY REVIEW

“No space is so small as to be out of

connection with they lymphatics…” – AT

Still - Philosophy of Osteopathy

“ ….This great river of life must be tapped

and the withering field irrigated at once, or

the harvest of health be forever lost.” - AT

Still - The Philosophy And Mechanical

Principles of Osteopathy.

“THE LYMPHATICS ARE CLOSELY AND UNIVERSALLY CONNECTED WITH THE

SPINAL CORD AND ALL OTHER NERVES, LONG OR SHORT, UNIVERSAL OR

SEPARATE, AND ALL DRINK FROM THE WATERS OF THE BRAIN.”

– AT STILL - PHILOSOPHY OF OSTEOPATHY

“.... THUS THE SYSTEM OF LYMPHATICS IS COMPLETE AND UNIVERSAL IN THE WHOLE BODY,…. FROM THE BRAIN TO

THE SOLES OF THE FEET.” – AT STILL - PHILOSOPHY OF OSTEOPATHY http://www.dynamicpotency.com/words-and-wisdom-osteopathic-quotes-2/

THE GLYMPHATIC SYSTEM

• A PERI-ARTERIAL SPACE ALLOWS CSF TO ENTER THE BRAIN AND BE TRANSPORTED

THROUGH THE AQUAPORIN 4 (AQP4) CHANNELS THAT ARE PRESENT IN THE END

FEET OF THE ASTROCYTE (ASTROGLIAL) CELLS INTO BRAIN PARENCHYMA.

• THE CSF COMBINES WITH INTERSTITIAL FLUID AND SWEEPS ACROSS THE

PARENCHYMA TOWARDS THE VEIN COLLECTING SOLUTES AND WASTE PRODUCTS

ALONG THE WAY. IT LEAVES THE PARENCHYMA THROUGH AQP4 CHANNELS

ENTERING THE PERI-VENOUS SPACE, TAKING THE SOLUTES WITH IT

THE GLYMPHATICSYSTEM

• DURAL SINUSES AND MENINGEAL ARTERIES

HAVE TRUE LYMPHATIC VESSELS THAT

PARALLEL THEM

• THUS CONNECTING THE GLYMPHATIC

SYSTEM TO THE BODY’S LYMPHATIC SYSTEM

AND ALLOWING DRAINAGE TO THE DEEP

CERVICAL LYMPH NODES

• CLEARANCE IS MORE ACTIVE WITH

INCREASED INTERSTITIAL SPACE VOLUME

SUCH AS DURING SLEEP AND WITH

CERTAIN ANESTHETICS

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THE GLYMPHATIC SYSTEM- WHAT IF IT ISN’T WORKING WELL?

• DECREASED GLYMPHATIC FLOW CAN LEAD TO DECREASED CLEARANCE

OF WASTE PRODUCTS WHICH COULD LEAD TO AGE-RELATED

PATHOLOGY SUCH AS ALZHEIMER'S DISEASE AND POSSIBLY OTHER

NEUROCOGNITIVE DISORDERS.

• EXPERIMENTS IN GENETICALLY MODIFIED MICE SHOWED

• THAT A FUNCTIONING GLYMPHATIC SYSTEM WAS NECESSARY TO REMOVE

AMYLOID-BETA FROM THE BRAIN INTERSTITIUM.

• IN MICE THAT DID NOT HAVE THE AQP4 GENE, AMYLOID-BETA CLEARANCE IS

REDUCED BY APPROXIMATELY 55%

SO WHAT DO WE KNOW ABOUT THE EFFECTS OF OMT ON LYMPHATICS AND

GLYMPHATICS?• HODGE ET AL – LYMPHATIC PUMP

• 1) INCREASES LYMPH FLOW (?IN THE BRAIN TOO?)

• 2) INCREASES THE CONCENTRATION OF LEUKOCYTES IN LYMPH.

• 3) MOBILIZED INFLAMMATORY MEDIATORS INTO CIRCULATION

• 4) STIMULATES MESENTERIC IMMUNE CELLS TO ENTER CIRCULATION

• COSTA/TOBEY – CV4 - NATURALLY AGED RAT MODEL

• 1) A SIGNIFICANT IMPROVEMENT IN SPATIAL MEMORY

• 2) IMMUNOASSAY ANALYSIS AND LIVE ANIMAL PET IMAGING REVEAL REDUCED AΒ LEVELS

• 3) ACTIVATION OF ASTROCYTES

• 4) IMPROVED EXCITATORY NEUROTRANSMISSION IN AGED RAT BRAIN.

TREATMENT SEQUENCE

“ A thought strikes him that the

cerebrospinal fluid is one of the

highest known elements that are

contained in the body, and unless the

brain furnishes this fluid in abundance,

a disabled condition of the body will

remain.”

– A T Still - The Philosophy And

Mechanical Principles of osteopathy

THORACIC INLET MFR (STEERING WHEEL TECHNIQUE)

• PATIENT IS SUPINE. PHYSICIAN STANDS AT THE HEAD AND USES WHOLE HAND TO

CONTACT THE THORACIC INLET BY PLACING PALMS OVERTOP OF THE 1ST RIB AND

CLAVICLE WITH FINGERS OVER UPPER RIBS ANTERIORLY AND THUMBS POSTERIORLY.

• CONTACT DOWN TO THE LAYER OF THE FASCIA AND MOTION TEST THE FASCIA

– COMPRESSION/DISTRACTION, ANT/POST, CLOCKWISE/COUNTERCLOCKWISE.

• STACK MOTIONS DIRECTLY (OR INDIRECT) AND WAIT FOR A RELEASE 20-60 SECONDS.

RIB RAISING – UPPER RIBS

• PATIENT SUPINE PHYSICIAN SEATED AT THE HEAD

• SLIDE BOTH HANDS UNDER THE PATIENT WITH FINGER

PADS CONTACTING THE PARAVERTEBRAL TISSUE OVER

THE COSTOTRANSVERSE JOINTS

• LEAN DOWN ON THE ELBOWS TO INTRODUCE AN ANTERIOR,

CEPHALAD AND LATERAL PRESSURE

• MAY BE DONE AS AN INTERMEDIATE KNEADING TECHNIQUE OR

SUSTAINED DEEP PRESSURE FOR 2-5 MIN

YOU CAN THEN GO ON TO TRADITIONAL RIB RAISING B/L

DIAPHRAGM LIFT

• TREATMENT GOAL - TO DRAW THE DIAPHRAGM CRANIALLY, ELEVATING THE FLOOR OF THE THORAX,

DRAWING UPWARD ON THE ABDOMINAL CONTENTS AND PROMOTING VENOUS AND LYMPHATIC

DRAINAGE FROM THE LOWER HALF OF THE BODY.

• WITH THE PATIENT SUPINE THE OPERATOR INTRODUCES HIS FINGERTIPS UNDER THE COSTO-JUNCTIONS. IF

THAT AREA IS PARTICULARLY SENSITIVE THE PATIENT HOOKS HIS OWN FINGERS UNDER THEM AND THE

OPERATOR LIFTS AS THE PATIENT EXHALES.

• THE OPERATOR LIFTS THE LOWER RIM OF THE THORAX IN A CRANIAL AND SLIGHTLY LATERAL DIRECTION. THE

ADVANCEMENT THAT IS MADE IS HELD DURING INSPIRATION AND IS INCREASED ON EXHALATION.

• AFTER SEVERAL RESPIRATORY CYCLES THERE IS NO FURTHER UPWARD PROGRESS AND THE PATIENT IS TOLD

TO BREATHE OUT, CLOSE THE THROAT AND ATTEMPT TO EXPAND THE CHEST.

The Osteopathic Techniques of W. G. Sutherland DO

- by H. A. Lippincott DO 1949 AOA Yearbook

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CISTERNA CHYLI TREATMENT

• PATIENT SUPINE. PHYSICIAN STANDS ON THE PATIENTS RIGHT SIDE FACING THEIR HEAD

• LIGHTLY PLACE ONE INACTIVE HAND FLAT ON THE ANTERIOR ABDOMEN OVER THE REGION OF

THE CISTERNA CHILI (L2)

• THE PHYSICIANS ACTIVATING HAND IS PLACED ON TOP OF THE FIRST HAND AND USING THE

PALMAR ASPECT OF THE FINGERS MAINTAINS CONSTANT CONTACT.

• WITH THE PADS OF THE FINGERS THE ACTIVATING

HAND INTRODUCES A GENTLE RHYTHMIC PULSE

DIRECTED TOWARDS THE CISTERNA CHILI

• YOU AND/OR THE PATIENT WILL FEEL A GENERAL

HEAT AND SOFTENING WHICH SIGNALS

COMPLETION OF THE TREATMENT.

PELVIC MYOFASCIAL RELEASE - ANTERIOR APPROACH

• INDIRECT TECHNIQUE HELPFUL FOR PELVIC FLOOR AND

PELVIC FASCIA BALANCING.

• PATIENT SUPINE. PLACE HANDS OVER ASIS CONTACT DOWN

TO THE FASCIA

• CHECK PLANES OF MOTION ( SUP/INF, RT/LT,

CLOCKWISE/COUNTERCLOCKWISE)

• TAKE EACH MOTION INTO THE FREEDOM JUST TO THE

EDGE OF THE BARRIER.

• YOU MAY FEEL THE TISSUE UNWINDING UNDER YOUR HANDS IF SO

FOLLOW THE FASCIA FURTHER INTO THE NEW EASE DYNAMICALLY.

THERE MAY BE PERIODIC PAUSES AS THE TISSUE PAUSES. THE END IS

SIGNALED BY A GLOBAL SOFTENING OF THE PELVIC FASCIA/FLOOR.

TREAT TYPICAL CERVICALS, AA AND OA

• TREAT TYPICAL

CERVICALS, AA AND OA

WITH YOUR PREFERRED

STYLE OF TREATMENT

CERVICAL CHAIN DRAINAGE• PATIENT SUPINE PHYSICIAN SITS/STANDS NEAR THE HEAD

• PHYSICIAN USES CEPHALAD HAND TO STABILIZE THE HEAD BY EITHER HOLDING FOREHEAD OR

PLACING UNDER THE PATIENTS HEAD

• PHYSICIANS CAUDAD HAND WITH THE FLAT PADS OF THE FINGERS MAKE A BROAD CONTACT

OVER THE ANTERIOR EDGE OF THE SCM NEAR THE ANGLE OF THE MANDIBLE.

• FROM CEPHALAD TO CAUDAD ROLL YOUR FINGERS ALONG THE MUSCLE IN A MILKING

FASHION. MOVE YOUR HAND INFERIOR AS NEEDED TO AFFECT WHOLE ANTERIOR CERVICAL

CHAIN

• THEN MOVE TO THE CEPHALAD POSTERIOR ASPECT OF THE SCM AND REPEAT TO AFFECT THE

POSTERIOR CERVICAL

Preauricular

Supraclavicular

Posterior

Cervical

Submandibular

Anterior

Cervical

Anterior Cervical Chain Drainage Posterior Cervical Chain Drainage

VENOUS SINUS DRAINAGE

• A

Sinus Released Finger Pad Contact

1) Confluence Of Sinuses One finger pad either side of Inion

2) Occipital Sinus Finger pads midline occiput from inion down to opistion.

Hands parallel to each other.

3) Jugular Foramen &

Internal Jugular Veins

Bilateral condylar portions of the occiput – Condyler

decompression

4) Confluence of Sinuses &

Transverse Sinus

With pinkies on either side of Inion, finger pads line up

along the superior nuchal line

5) Anterior Transverse Sinus Unilaterally Middle finger pad over Asterion – Treat

Both

6) Confluence of Sinuses &

Straight Sinus

One finger pad from each hand at the inion and thumbs

at the vertex

7) Sagittal Sinus Thumbs crossed with pads on either side of Sagittal

suture from inion to bregma

8) Anterior Sagittal Sinus Finger Pads Parallel on either side of metopic suture

from bregma to nasion

1

2

3

4

VENOUS SINUS DRAINAGE

Sinus Released Finger Pad Contact

1) Confluence Of Sinuses One finger pad either side of Inion

2) Occipital Sinus Finger pads midline occiput from inion down to opistion.

Hands parallel to each other.

3) Jugular Foramen &

Internal Jugular Veins

Bilateral condylar portions of the occiput – Condyler

decompression

4) Confluence of Sinuses &

Transverse Sinus

With pinkies on either side of Inion, finger pads line up

along the superior nuchal line

5) Anterior Transverse Sinus Unilaterally Middle finger pad over Asterion – Treat

Both

6) Confluence of Sinuses &

Straight Sinus

One finger pad from each hand at the inion and thumbs

at the vertex

7) Sagittal Sinus Thumbs crossed with pads on either side of Sagittal

suture from inion to bregma

8) Anterior Sagittal Sinus Finger Pads Parallel on either side of Metopic suture

from bregma to nasion

5

6

7

8

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CV4

• PATIENT LAYS SUPINE

• PLACE HANDS ONE PALM WITHIN THE OTHER AND THEN UNDER THE

PATIENTS CRANIUM.

• THE THENAR EMINENCES HOLD THE LATERAL ANGLES OF THE OCCIPUT.

(BELOW THE INION AND MEDIAL TO THE OCCIPITAL MASTOID SUTURE)

• THE WEIGHT OF THE HEAD COMPRESSES THE LATERAL ANGLES MEDIALLY

AND INITIATES POSTERIOR TENSION IN THE TENTORIUM CEREBELLI.

• FIRST MONITOR THE CRI FOR A COUPLE CYCLES AND THEN VERY GENTLY

DISCOURAGE FLEXION WITH EACH CYCLE.

• AMPLITUDE OF CYCLE WILL DECREASE UNTIL A “STILL POINT” IS REACHED. (BRIEF MOMENT OF INTENSE, LOW

AMPLITUDE ACTIVITY OR TRUE STILLNESS.)

• A SOFTENING WILL FOLLOW, OFTEN WITH PALPABLE WARMTH, AND WITH THIS COMES A GENTLE, FREE, MORE

SYMMETRIC, STRONGER CRI RHYTHM.

• OVER A COUPLE CYCLES ALLOW THE CRI TO SLOWLY, GENTLY PUSH YOU AWAY AND REMOVE YOUR HANDS.

MILLER THORACIC PUMP• PATIENT SUPINE WITH HEAD TURNED TO ONE SIDE.

• PHYSICIAN AT THE HEAD PLACES THENAR EMINENCES

OR PROXIMAL EDGE OF THE PALM JUST INFERIOR TO

THE CLAVICLE WITH FINGERS ALONG UPPER RIBS (IN

FEMALE PATIENTS KEEP FINGERS ELEVATED OR MOVE

HANDS MORE MIDLINE OVER STERNUM)

• PATIENT TAKES A DEEP BREATH AND AS THEY EXHALE

PHYSICIAN PLACES AN INFERIOR AND CAUDAD

PRESSURE ON THE ANTERIOR RIB CAGE

EXAGGERATING THE INHALATION.

• AT THE END OF EXHALATION PHYSICIAN IMPARTS

VIBRATORY 2/SEC COMPRESSIONS FOR SEVERAL

MINUTES (OK TO RELAX PRESSURE A BIT TO ALLOW

PATIENT TO BREATHE)

ARBUCKLE’S PRONE THORACIC LYMPHATIC PUMP

• PATIENT LIES PRONE WITH A PILLOW UNDER THEIR CHEST AND

ARMS HANGING OFF THE SIDES OF THE TABLE.

• PHYSICIAN STANDING AT THE HEAD FACING CAUDAD AND PLACES

THEIR THUMBS OVER SPACES BETWEEN TRANSVERSE PROCESSES

BILATERALLY STARTING AT C7- T1 SPACE.

• PHYSICIAN APPLIES AN ANTERIOR PRESSURE WITH THEIR THUMBS

BILATERALLY WHILE THE PATIENT SWINGS THEIR ARMS ANTERIOR

AND CEPHALAD.

• THE THUMBS ARE MOVED PROGRESSIVELY DOWN THE SPINE WITH

THE ARM SWING REPEATED EACH TIME UNTIL THE WHOLE

THORACIC REGION IS TREATED

REFERENCES:

• APPLIED ANATOMY OF THE LYMPHATIC SYSTEM – P. F. MILLARD

• FOUNDATIONS OF OSTEOPATHY 2ND ED – CHILA????????

• MANIPULATIVE LYMPHATIC THERAPY – MILLIARD – 1939 AAO YEARBOOK

• PHILOSOPHY OF OSTEOPATHY – AT STILL (2ND BOOK)

• SOFT TISSUE MANIPULATION – LEON CHAITOW ND DO

• THE OSTEOPATHIC TECHNIQUES OF WM. G. SUTHERLAND DO - BY H. A.

LIPPINCOTT DO 1949 AOA YEARBOOK

• THE PHILOSOPHY AND MECHANICAL PRINCIPLES OF OSTEOPATHY - A T

STILL (1ST BOOK)

• VERHEGGEN ET AL. ; INTERACTION BETWEEN BLOOD BRAIN BARRIER AND GLYMPHATICSYSTEM

IN SOLUTE CLEARANCE NEUROSCIENCE AND BIOBEHAVIORAL REVIEWS 90 (2018) 26–33 HTTPS://WWW.SCIENCEDIRECT.COM/SCIENCE/ARTICLE/PII/S014976341730773X

• ILIFF JJ, WANG M, LIAO Y, PLOGG BA, PENG W, GUNDERSEN GA, BENVENISTE H, VATES GE,

DEANE R, GOLDMAN SA, NAGELHUS EA, NEDERGAARDM (AUGUST 2012). "A PARAVASCULAR

PATHWAY FACILITATES CSF FLOW THROUGH THE BRAIN PARENCHYMA AND THE CLEARANCE OF INTERSTITIAL SOLUTES, INCLUDING AMYLOID Β". SCIENCE TRANSLATIONAL MEDICINE. 4 (147):

147RA111. DOI:10.1126/SCITRANSLMED.3003748. PMC 3551275. PMID 22896675.

• LOUVEAU A, SMIRNOV I, KEYES TJ, ECCLES JD, ROUHANI SJ, PESKEJD, DERECKI NC, CASTLE D,

MANDELL JW, LEE KS, HARRIS TH, KIPNIS J (JULY 2015). "STRUCTURAL AND FUNCTIONAL

FEATURES OF CENTRAL NERVOUS SYSTEM LYMPHATIC VESSELS". NATURE.523 (7560): 337–41. DOI:10.1038/NATURE14432. PMC 4506234. PMID26030524.

• ^ JUMP UP TO:A B ASPELUND A, ANTILA S, PROULX ST, KARLSEN TV, KARAMAN S, DETMAR M,

WIIG H, ALITALO K (JUNE 2015). "A DURAL LYMPHATIC VASCULAR SYSTEM THAT DRAINS BRAIN

INTERSTITIAL FLUID AND MACROMOLECULES". THE JOURNAL OF EXPERIMENTAL MEDICINE.212 (7): 991–9. DOI:10.1084/JEM.20142290