By Wayne Oliver, M.OMSc and Lee Jarvis, M.OMSc. Proofreading and editing by Alison Brazeau.
On June 13, 2024 I met with Wayne Oliver, M.OMSc. I greatly appreciated him taking the time to speak with me as he is very busy for numerous Osteopathic and non-Osteopathic reasons. I also appreciated speaking with him simply for the reason that his no nonsense and at times boisterous attitude makes Wayne enjoyable to discuss anything with. Wayne graduated from the Canadian Academy of Osteopathy (CAO) in 2017 and started teaching shortly after. Currently Wayne is the Director of Labs at the CAO.
We got down to business quite rapidly, which is standard for Wayne, and discussed numerous topics in our time together. One topic that came up immediately was the idea of retained fluid in the body and how that affects patients that we see.
When we talk about fluid in the Osteopathic world, we must say that we are talking about the idea that a person could be holding onto an excess amount of fluid in the body, more than what is necessary/functional. Looking back to Osteopathy historically, Dr. Still would use the word “stagnation” when talking about fluid in this context. It’s important to remember in the current or historical case, despite the potential for excess fluid in the body that fluid is still circulating to some degree (even in a pond the water still moves). Completely motionless fluid in the body is typically fatal and so would not be the type of patient we are referring to here.
Excess fluid in the body should normally be reduced or removed by the circulatory and lymphatic system. This fluid is then removed by the kidneys and voided by the bladder.
Note: Sweat also plays a factor in fluid excretion but less so and not the subject of this article.
The idea that any form of manual therapy could have an effect on the fluid system may seem a foreign concept to some, but it is a fairly reasonable statement when one knows the anatomy and physiology of the complete bodily fluid transport system. The Venous and Lymphatic systems are together responsible for returning fluid from tissue to the heart. Both the Venous and Lymphatic systems have valves and small amounts of musculature to make fluid movement possible within their vessels. However, both the venous and lymphatic are partially assisted by changes in pressure outside of their vessels. These external pressure changes on the venous and lymphatic vessels come in part from pulsations where there is overlap from arteries but as well contractions of muscles and general fascial changes within the area. Some readers may be familiar with the pedal pump, but also understand this happens many other places in the body.
Muscles and the general connective tissue around venous and lymphatic vessels create this pressurization through both adding compression to the area of the vessel but as well by adding pressures through lengthening. This means that contractions of tissue as well as taking a tissue through lengthening/range also assist in this pressure generation. Optimally any area of the body is going through regular and intermittent on and off pressurization to assist fluid flow, which, in many ways can just be said to be a capacity for full range of motion, along with regular full-body movement of the person. This type of on and off pressure allows the fluid to get to the next set of valves in the venous and lymphatic vessels (and nodes in the case of the lymph) and so it must increase pressure regularly, but also decrease pressure enough to allow more fluid to come into the region. Though there is arguably a good start and direction in the Osteopathic and manual therapy research related to manual fluid movement (see reference section), I don’t feel that I have seen enough to satisfy the requirements for anything close to certainty yet (or a supportive systematic review). I very much hope that in the future this research continues as it seems it would be valuable for the Osteopathic community as well as the understanding of the function of the human body.
Part of what has interested Wayne in understanding fluid movement and Osteopathic treatment is that (at the time of this interview) he is in end-stage kidney failure. At the time of this interview, he was waiting on both a kidney and heart transplant*. Despite this, it is well worth noting that during our interview Wayne was not only in good spirits, but looked to be in great shape. We can of course attribute this good shape and attitude to an excellent medical team, but also, I’d like to believe that it is because he takes great care of himself. Another part of me believes, knowing Wayne as I do, that he is just too stubborn to suffer completely from having several failing organs. It’s also well worth noting that Wayne is still currently seeing 10 to 12 patients a day when possible (medical care and appointments aside). Which, in Wayne’s words, is “a small amount, and I feel terrible for only seeing that many.”
When it comes to treating the patient who is holding onto extra fluid, it is important to be able to treat and see the response in real time during your treatment. This would mean that determining areas to assess for that fluid is of key importance so that you can notice it changing (or not) as you go.
The back of the neck, the stomach, and feet tend to be the most observable regions of fluid buildup in the human body and so make for good areas to assess and re-assess throughout the treatment.
Wayne‘s opinion is that it’s best to work on every other area in the body first and then come back to that fluid-related area and see how it responds to the changes made elsewhere. We had discussed a similar methodology in reference to addressing the neck region but this will be followed up in a future article.
At the outset of the explanation, Wayne wanted to be clear that there isn’t a “fluid treatment”, in that there is no one treatment to exclusively follow that just works on fluid. As always in Osteopathy you will have to be capable of determining the work that needs to be done, doing that work, and then determining how much more needs to be done after. Meaning that, it always takes some level of awareness of the process and readiness for methodology adjustment to move fluid (or treat in general) around effectively. That being said, even though this is no singular fluid treatment, there are places in the body that are more worth looking related to the movement of fluid. Understanding anatomy and physiology we can then investigate the areas leading into or most closely connected with those excess fluid prone areas.
Wayne also wanted to point out that this is not just a “treat as you go” situation. Those who graduated from the CAO may be familiar with the concept of a “running diagnosis” versus a planned-out treatment. Both methodologies have their value where in the “treat as you go” (aka running diagnosis) you simply find whatever you happen to find and work on that at the time. “Treat as you go” is a perfectly valid way of working however in this case when we’re considering moving fluid, we want to make sure there are regions we have assessed and made improvements upon. These areas are at junctional zones and likely where fluid is going to have the most trouble getting through based on pressure and tension.
The regions around junctional zones are a fairly simple model that goes back to the early days of Osteopathy where the early Osteopaths talked about five major regions to assess for fluid; two in the Axilla, two in the Inguinal, and the Respiratory Diaphragm. Historically this is often attributed to Frederic Millard (Chikly, 2005) but this was talked about by other Osteopaths at the time.
The inguinal region is located at the junction between the anterior abdominal wall and the anterior thigh. It has a large region of lymph nodes divided into the superficial and deep inguinal lymph nodes. These nodes are found inferior to the inguinal ligament which runs between the Anterior Superior Iliac spine of the Iliac bone, and the Pubic Tubercle of the Pubic Bone. There are superior and inferior superficial inguinal lymph nodes which all drain into the deep inguinal lymph nodes located within the Femoral Sheath. The femoral sheath is a tube of fascia that surrounds important vessels which pass below the inguinal ligament. The lymphatic vessels of the lower limb collect excess fluid and transport it to the inguinal lymph nodes which will eventually drain into the central lymphatic drainage site of the lower body (Cisterna Chyli).
The major vein in the inguinal region is the Femoral Vein. The femoral vein is found within the femoral sheath beside the deep inguinal lymph nodes. It travels under the inguinal ligament to eventually drain into the Inferior Vena Cava. The femoral vein is important because it is where all venous structures of the lower limb will drain blood into. The Saphenous vein is also substantial here because it spans the entire lower limb from the foot all the way up to the inguinal region where it drains into the femoral vein. The Saphenous vein is a superficial vein within the lower limb, which means it will drain blood from closer to the surface. The saphenous vein drains into the femoral vein within the inguinal region.
This particular area is a point of on and off pressure largely because of the leg swing in gait. The pressure is arguably largely derived from the leg/hip going into an extended position/lengthening the local tissues. Certainly, there can be a compression effect when the hip flexes but it is rare that the leg is fully brought up into full “knee to chest” flexion in gait (unless mimicking John Cleese). Therefore, we can assume that in the leg extension portion of gait (the back leg) the lengthening tissue on the front side of the leg where the inguinal region is located is where a good deal of pressure alteration is occurring.
The axillary region is located inferior to the shoulder joint, between the shoulder girdle and the thorax. It is the region known to most as the “armpit”. There are many groups of lymph nodes in the axillary region, they include the anterior axillary lymph nodes, the central axillary lymph nodes, the lateral axillary lymph nodes, and the posterior axillary lymph nodes. The lymphatic vessels of the upper limb and thoracic wall drain into these nodes, which then drain into the central axillary lymph nodes before the fluid moves towards the Right Lymphatic Duct or Thoracic Duct on the left.
The main venous contribution to the axillary region is the axillary vein. It is a continuation of the brachial veins and basilic vein, running through the axillary region and below the clavicle. It receives venous drainage from all blood vessels in the upper limb, providing a central drainage point to the whole shoulder girdle and arm.
In the case of the arm, it is always hanging and in a position of slight (but normal) compression. This is because the inside of the arm and lateral side of the thorax are typically touching in a resting, hanging position. As the arm swings forward and backward in gait (or in any other movement) the pressure increases and decreases regularly.
The respiratory diaphragm sections the body roughly in half by attaching to the first, second and third Lumbar Vertebrae, the internal surfaces of the Costal Chondral Cartilages of ribs seven to twelve, the Xiphoid Process of the Sternum, and the central Tendon Sheath. There are numerous vessels that transport fluid through the respiratory diaphragm including the Abdominal Aorta, Inferior Vena Cava, Azygous and Hemiazygos Veins, and the thoracic duct.
The importance of the above vessels cannot be understated as they act as the fluid transportation system between the upper and lower halves of the body. The abdominal aorta brings fresh blood from the heart to soft tissue structures of the abdomen, thorax, pelvis, and lower limbs, and to the abdominal and pelvic organs. The inferior vena cava drains deoxygenated blood from the abdomen, pelvis, lower limbs and the organs of the abdomen and pelvis (via the hepatic portal system). The azygous and hemiazygos veins drain blood from the abdominal and thoracic walls. The thoracic duct is where all fluid in the lymphatic vessels and nodes of the lower half of the body will drain through.
The action of the respiratory diaphragm in breathing is a very well-known air pump but it is as well a fluid pump. With the respiratory diaphragm’s location in the trunk and the up and down pressure many times per minute that it creates, it assists in fluid propulsion. Typically, in explanations of the fluid propulsion that the respiratory diaphragm assists with, it is limited to the visceral (digestive) region. However, based on the vessels that pass through the respiratory diaphragm, it is quite likely that there is some amount, a small but meaningful amount, of fluid propulsion of the lower body that happens because of the respiratory diaphragm. Based on its position, we could also argue that the lymphatic area above the respiratory diaphragm and the rib cage is enhanced by breathing. As well the inferior vena cava’s passage through a mobile region of the respiratory diaphragm is likely purposeful.
To simplify the concept as much as possible; the areas mentioned above must all move as effectively as possible to move fluid as effectively as possible. As Osteopathic practitioners we must be capable of determining how well these areas move as a part of our assessment(s). Assessing this movement accurately involves a thorough understanding of all of the anatomy and mechanics listed above (and usually a great deal of experience motion testing these things). If we are capable of restoring full movement capacity (or even close to it) to an affected area then we make it easier for that area to move fluid through it.
After this explanation of the central parts of the body Wayne then talked about following the pathways of the arteries and/or major vascular bundles through the arms, legs, and neck. We follow the arteries through palpation and treatment because the arteries have venous and lymphatic structures that tend to wrap around the arteries. In many cases the veins and lymphatics are wrapped around arteries to utilize the pulsation of the arteries for enhancing fluid flow through them. As well, like in the five regions we talked about previously the movement of the surrounding tissues also enhances fluid movement. The presence of valves in the veins and lymphatic vessels ensure that pressure changes whether from artery pulse or fascia movement keep the fluid moving in the right direction. Along the lengths of the appendages these areas of fluid movement are much smaller contributors to fluid flow but are still contributors nonetheless. The major areas of interest in the appendages to fluid movement would be around the joints, in particular the knees and elbows if we were looking to narrow down the most significant influences. Though any area of restriction can be seen as sub-optimal if not moving to its full capacity in the appendages.
From there Wayne performed a hands-on demonstration which will be covered in our next article.
*I am pleased to report that at the time of posting this article Wayne has had his heart transplant and is waiting on his kidney transplant.
References
Adams, J., Parikh, S., Goodwin, B. & Noll, D. (2023). Does the osteopathic pedal pump reduce lower limb volume in healthy subjects?. Journal of Osteopathic Medicine, 123(4), 201-206. https://doi.org/10.1515/jom-2022-0127
Castillo, R., Schander, A. & Hodge, L. (2018). Lymphatic Pump Treatment Mobilizes Bioactive Lymph That Suppresses Macrophage Activity In Vitro. Journal of Osteopathic Medicine, 118(7), 455-461. https://doi.org/10.7556/jaoa.2018.099
Chikly, B. (2005). Manual Techniques Addressing the Lymphatic System: Origins and Development. Journal of Osteopathic Medicine, 105(10), 457-464. https://doi.org/10.7556/jaoa.2005.105.10.457
Franzini, D., Cuny, L. & Pierce-Talsma, S. (2018). Osteopathic Lymphatic Pump Techniques. Journal of Osteopathic Medicine, 118(7), e43-e44. https://doi.org/10.7556/jaoa.2018.112
Kilgore, T., Malia, M., Di Giacinto, B., Minter, S. & Samies, J. (2018). Adjuvant Lymphatic Osteopathic Manipulative Treatment in Patients With Lower-Extremity Ulcers: Effects on Wound Healing and Edema. Journal of Osteopathic Medicine, 118(12), 798-805. https://doi.org/10.7556/jaoa.2018.172