Osteopathic Medicine The Kidneys and Adrenals - E

Osteopathic Medicine
The Kidneys
and Adrenals
Grégoire Lason & Luc Peeters
The Kidneys and Adrenals
Grégoire Lason & Luc Peeters
All rights reserved. Osteo 2000 bvba © 2013. No part of this e-book may be reproduced or made
public by printing, photocopying, microfilming, or by any means without the prior written permission of
the publisher.
Contact: Osteo 2000, Kleindokkaai 3-5, B – 9000 Ghent, Belgium
Mail: [email protected]
Web: http://osteopedia.iao.be and www.osteopathie.eu
Tel: +32 9 233 04 03 - Fax: +32 55 70 00 74
ISBN: 9789074400343
The International Academy of Osteopathy – I.A.O.
2
Content
Content ....................................................................................................................... 3
1. Introduction ............................................................................................................ 7
2. Anatomy ................................................................................................................. 8
2.1. Position ............................................................................................................ 8
2.2. Anatomical Fixations .................................................................................... 17
2.3. Innervation ..................................................................................................... 18
2.3.1. Sympathetic .............................................................................................. 18
2.3.2. Parasympathetic ....................................................................................... 18
2.3.3. Afferent Supply ......................................................................................... 19
2.3.4. Renorenal Reflex ...................................................................................... 20
2.3.5. Interaction between the Sympathetic Nervous System and the Kidneys in
Relation to the Blood Pressure ........................................................................... 20
2.3.6. Adrenal ..................................................................................................... 20
2.4. Blood Supply ................................................................................................. 21
2.4.1. The Kidneys .............................................................................................. 21
2.4.2. The Adrenals ............................................................................................ 21
2.5. Size and Consistency of the Kidneys ......................................................... 23
2.6. Size and Consistency of the Adrenals ........................................................ 25
3. Physiology ......................................................................................................... 26
3.1. Functions of the Kidney ............................................................................... 26
3.1.1. Filter and Resorption Function ................................................................. 26
3.1.2. Endocrine Function ................................................................................... 26
3.2. Regulation of the Blood Volume .................................................................. 26
3.3. Regulation of the Chemical Constituents of the Blood ............................. 27
3.3.1. General ..................................................................................................... 27
3.3.2. Filtration .................................................................................................... 28
3.3.3. Reabsorption ............................................................................................ 30
3.3.4. Secretion .................................................................................................. 30
3.3.5. Saturation ................................................................................................. 30
3.3.6. Dehydration .............................................................................................. 31
3.3.7. Diuretics .................................................................................................... 31
3.4. Regulation (hormonal) of Blood Pressure in Kidneys and Adrenals ....... 32
3.5. Function of the Adrenals .............................................................................. 33
3.5.1. The Cortex (Stress Organ) ....................................................................... 33
3.5.2. The Medulla .............................................................................................. 34
3.5.3. General Function of the Adrenals ............................................................. 34
3.5.4. Note Related to Stress ............................................................................. 35
3.6. Function of the Ureters ................................................................................. 36
4. Mobility ................................................................................................................. 38
5. Patient History and Physical Examination ........................................................ 41
3
5.1. Kidney Ptosis ................................................................................................ 41
5.2. Trauma ........................................................................................................... 42
5.3. Kidney Stones ............................................................................................... 44
5.4. Glomerular Conditions ................................................................................. 46
5.4.1. Glomerulonephritis ................................................................................... 46
5.4.2. Nephrotic Syndrome ................................................................................. 47
5.5. Tubular and Interstitial Conditions .............................................................. 48
5.5.1. Acute Kidney Failure ................................................................................ 48
5.5.2. Chronic Kidney Insufficiency or Uremia .................................................... 50
5.5.3. End Stage of Kidney Insufficiency: Disruption of Homeostasis ................ 51
5.6. Pyelonephritis ............................................................................................... 51
5.7. Renal Cysts/Polycystic Kidneys .................................................................. 52
5.8. Renal Cancer ................................................................................................. 52
5.9. “Nutcracker” Syndrome ............................................................................... 54
5.10. Adrenals ....................................................................................................... 55
5.10.1. Conditions of the Cortex ......................................................................... 55
5.10.1.1. Hyperadrenocorticism ...................................................................... 55
5.10.1.2. Hypoadrenocorticism ....................................................................... 57
6. Clinical Examination ............................................................................................ 59
6.1. Provocation Tests ......................................................................................... 59
6.1.1. Provocation Test for Pyelonephritis .......................................................... 59
6.1.2. Provocation Test for Pyelonephritis .......................................................... 60
6.1.3. Valsalva Test ............................................................................................ 60
6.2. Palpation ........................................................................................................ 61
6.2.1. Palpation of the Inferior Pole of the Kidney .............................................. 61
6.2.2. Palpation with the Fingertips .................................................................... 62
6.2.3. Palpation with Thenar - Hypothenar ......................................................... 62
6.2.4. Anteroposterior Palpation ......................................................................... 63
6.2.5. Palpation of the Ureter .............................................................................. 63
6.2.6. Palpation of the Pulse of the Posterior Tibial a. ........................................ 64
6.3. Mobility Tests ................................................................................................ 65
6.3.1. Mobility Test,Ppatient laying on Side ........................................................ 65
6.3.2. Mobility Test of the Superior Pole, Patient Sitting .................................... 66
6.3.3. Mobility Test with the Thumbs .................................................................. 67
6.3.4. Mobility Test with the Fingertips ............................................................... 67
6.3.5. Mobility Test with Thenar/Hypothenar ...................................................... 68
6.3.6. Mobility Test to Medial .............................................................................. 68
7. Osteopathic Techniques ..................................................................................... 69
7.1. Relaxation of the Kidney Zone and Fascial Techniques ........................... 69
7.1.1. Relaxation of the Posterior Side ............................................................... 69
7.1.2. Relaxation of the Posterior Parietal Peritoneum ....................................... 70
7.1.3. Fascial Stretch under the Kidney .............................................................. 71
7.1.4. Stretch of the Perirenal Fascia ................................................................. 72
4
7.1.5. Relaxation of the Kidney area .................................................................. 73
7.2. Mobilisations ................................................................................................. 74
7.2.1. Mobilisation to Cranial with the Thumbs ................................................... 74
7.2.2. Mobilisation to Cranial with the Fingertips ................................................ 75
7.2.3. Mobilisation to Cranial with Thenar/Hypothenar ....................................... 76
7.2.4. Bilateral Mobilisation of the Kidneys ......................................................... 77
7.2.5. Mobilisation of the Superior Pole .............................................................. 78
7.2.6. Mobilisation and Drainage of the Centro-Superior Retroperitoneal Region
............................................................................................................................ 79
7.2.7. Mobilisation upon the Psoas M. ................................................................ 80
7.3. Stretch of the Ureter ..................................................................................... 81
7.4. Stretch of the Ureter ..................................................................................... 82
7.5. Neurolymphatic Reflex Points ..................................................................... 83
8. Bibliography ......................................................................................................... 84
9. About the Authors ............................................................................................... 87
10. Acknowledgements ........................................................................................... 88
11. Visceral Osteopathy .......................................................................................... 89
11.1. Introduction ................................................................................................. 89
11.2. Motion Physiology ...................................................................................... 90
11.2.1. The Motions of the Musculoskeletal System .......................................... 90
11.2.2. The Motions of the Visceral System ....................................................... 90
11.2.2.1 The Diaphragm ................................................................................. 90
11.2.2.2. The Heart ......................................................................................... 91
11.2.2.3. Peristalsis ......................................................................................... 91
11.3. Visceral Interactions ................................................................................... 91
11.3.1. General ................................................................................................... 91
11.3.2. Relationships .......................................................................................... 92
11.3.2.1. Gliding Surfaces ............................................................................... 92
11.3.2.2. Ligamentous Suspensory System ................................................... 92
11.3.2.3. The Mesentery ................................................................................. 92
11.3.2.4. The Omenta ..................................................................................... 93
11.3.2.5. The Turgor Effect and the Intracavitary Pressures .......................... 93
11.4. Mobility Loss ............................................................................................... 93
11.4.1. Diaphragm Dysfunction .......................................................................... 93
11.4.2. Adhesions ............................................................................................... 93
11.4.3. Retractions ............................................................................................. 94
11.4.4. Trophic Tissue Changes ......................................................................... 94
11.4.5. Congestion ............................................................................................. 94
11.4.6. Postural Disorders .................................................................................. 94
11.4.7. Visceral Mobility Loss ............................................................................. 95
11.5. Visceral Hypermobility ............................................................................... 95
11.6. Osteopathic Visceral Examination ............................................................ 96
5
11.7. Bibliography Visceral Osteopathy ............................................................. 97
12. General Abbreviations ...................................................................................... 98
13. Specific Terms ................................................................................................... 99
14. All Videos ......................................................................................................... 100
6
1. Introduction
It is well recognised by classic medicine that kidney problems can lead to
musculoskeletal complaints. Renal colic most commonly begins with pain in the flank.
Functional problems of the kidneys are a frequent source of complaint, which is not
always immediately associated with the kidney. The reason for this is that the kidney
plays an important role in filtration and therefore purification of the blood and
regulation of the blood pressure.
An osteopath can significantly influence the kidney function by improving mobility of
the organ under influence of the diaphragmatic respiration, by providing optimal
neurovegetative supply and by improving the venous and arterial blood supply.
Anatomically the adrenal glands are closely related to the kidney, with a predominant
endocrine function. The medulla produces adrenaline while the cortex hormones are
implicated in fat, sugar and mineral metabolism.
Osteopathic consideration of the kidney segment can therefore have different aims.
On one hand kidney and/or adrenal dysfunctions can lead to complaints in the
related segments but on the other hand kidney and/or adrenal dysfunctions can also
be involved in complaints, which are not directly related to the segment.
Blood pressure problems, oedema, stress management, fluid balances, pH balance
problems, bone metabolism, fatigue, weight-loss, immune depletion and many other
problems are often associated with the kidney and/or adrenal segment.
The first sign for the osteopath that would indicate that treatment of the kidney is
required would be somatic dysfunction in the zone T10 to T12.
This e-book deals with both the kidney and adrenal organs even though they have
completely different functions. The reason for this is that the adrenal gland cannot be
mobilised specifically on its own. In other words the anatomical unity between kidney
and adrenal means that the visceral tests and techniques cannot be differentiated for
each organ.
The vertebral segments are also the same.
This e-book discusses the anatomy, neurology and physiology of the kidney and the
adrenal but also provides instruction as to how the osteopath can examine and treat
these organs.
The osteopath must be capable of recognising structural kidney and adrenal
problems and refer the patient appropriately.
For readers who are unfamiliar with the osteopathic visceral approach, please refer to
Chapter 11 at the end of this e-book.
7
2. Anatomy
(Grant & Boileau 2004, Gray 1995, Hallgr’msson et al 2003, Netter 1997, 2006,
Sobotta 2001)
2.1. Position
The kidneys are bean-shaped and are located in the retroperitoneal space in the
superior lumbar region.
The right kidney is approx. 2cm lower than the left kidney due to the presence of the
liver, which effectively pushes the right kidney downwards.
The lateral side is convex and the medial concave.
On the medial side of each kidney is the hilum: the aggregation of the arteries, veins,
lymph vessels and nerves, which run to and from the kidney.
The pyelum is also medial; this is from where the ureters run towards the
posterior/inferior side of the bladder.
The adrenals sit upon the kidneys (Figures 1 and 2) surrounded by a common fatty
tissue layer and capsule. They are also retroperitoneal.
They are in contact with:
•
•
•
Right: liver and inf. vena cava.
Left: pancreas and stomach.
Posterior: diaphragm.
Figure 1 - Position of the right adrenal in the frontal plane
8
Figure 2a - Position of the kidneys in the frontal plane
9
Figure 2b - Position of the kidneys in the frontal plane
The kidney is found lateral to the spine and retroperitoneal (Figure 3).
Figure 3 - Upper horizontal section of the kidney
The kidney is found lateral to the spine and retroperitoneal (Figure 4).
10
3. Physiology
(Ganong 2005, Guyton & Hall 2005, Marieb 1988, Vander 1995)
3.1. Functions of the Kidney
3.1.1. Filter and Resorption Function
•
•
•
Regulation of the blood volume and blood pressure.
Regulation of the chemical composition of the blood: sodium (Na+) and
potassium (K+) balance and pH balance.
Transport of waste products such as nitrogen and sulphur-bonds which result
from protein metabolism.
3.1.2. Endocrine Function
•
Hormone production:
o Erythropoetin, or EPO, stimulator of the bone marrow to produce red
blood cells.
o Renin as blood pressure regulator.
3.2. Regulation of the Blood Volume
Each influx of blood into the kidney leads to a certain volume of fluid being pressed
into the renal tubuli via specialised capillaries (glomerular capillaries). These renal
tubuli run along the peritubular capillaries. The majority of the water is reabsorbed
through these renal tubuli into the blood vessels. The water, which remains in tubuli,
is excreted.
The quantity of water which is reabsorbed regulates the blood volume.
Figure 18 - Reabsorption and secretion
26
3.3. Regulation of the Chemical Constituents of the
Blood
3.3.1. General
The kidney regulates the chemical composition of the internal environment by way of
a combination of filtration, reabsorption and secretion (Figures 18,19, 20 and 21).
The filter process in the kidney is initially non-discriminatory. This means that
anything small enough to be filtered will be filtered including products which the body
does not wish to excrete (glucose, amino acids, vitamins etc.). These molecules are
then reabsorbed via the renal tubuli into the bloodstream while other molecules are
not reabsorbed (creatine, toxins). These are waste products.
It is important to realise that 20% of the plasma leaves the blood vessels and enters
the renal tubuli meaning that waste products actually remain in the bloodstream.
These waste products need to be secreted.
By the regulation of the reabsorption and the secretion the kidneys can determine
Na+, K+, hydrogen and bicarbonates levels in the plasma. In this way the kidney
regulates the chemical composition of the blood.
Figure 19 - Regulation of the chemical constituents of the blood
27
Figure 20 - Filtration – reabsorption - secretion
3.3.2. Filtration
80% of the plasma enters the glomerulus. Due to the high blood pressure in the
afferent arterioles and the high permeability in the glomerular endothelium 20% of
that plasma is filtered.
The remaining blood flows further into the efferent arterioles, which run along the
renal tubule to the renal vein where the blood pressure is lower. These veins are also
porous which allows easy reabsorption of the watery solution from the renal tubule.
Only plasma enters into the renal tubule; the blood cells and proteins larger than
albumin do not pass. The filtrate in the renal tubule consists therefore of plasma
without proteins larger than albumin.
Glucose, small cations Na+, K+, H+ and small anions Cl-, HCO3- do enter into the
renal tubule.
The balance between the pressure in the afferent arterioles, the pressure in the
glomerulus and the pressure in the peritubular capillaries decide how much filtrate is
produced per unit of time.
99% of the plasma that enters the kidney re-enters the circulation.
1% of the volume is excreted.
The kidneys filter approx. 180 litres of fluid per day.
28
4. Mobility
(Schwartz et al 1994, Sörnsen the Koste 2006, Vasbinder 2002)
The kidney is a very mobile organ.
The motor of this mobility is the diaphragm and the respiration.
During inhalation the kidney descends; during exhalation it ascends (Figure 27).
Per day the bladder moves approx. 800 m due to respiration alone.
The amplitude between inhalation and exhalation is 4 to 5 cm in an adult.
During the descend and return (ascent) the kidney follows a curved trajectory which
results from the length of the vascular pedicle.
The inferior pole of the kidney descends 1 cm more than the superior pole. This
means that the kidney itself stretches under influence of the respiration, which leads
to an even better blood flow.
The left and the right kidney are evenly mobile.
In boys up to the age of 15 it has been noted that the right kidney is more mobile.
When body weight reaches 60 to 70 kg. left and right mobility becomes even and the
gender difference disappears.
During apnoea the kidney ascends spontaneously by 0.5 cm.
During these motions of the kidney the renal artery will bend but also alter its angle
with the kidney.
During inhalation the kidney also bends 1 to 2 cm forwards and rebounds backwards
during the exhalation (Figure 28).
The adrenals follow the motions of the kidney.
38
Figure 27 - Mobility of the kidney
Figure 28 - Mobility of the kidney in the horizontal plane
39
5. Patient History and Physical Examination
(Bickley 1999, Coresh et al 2007, Fogo et al 2006, Fogo & Kashgarian 2005, Kern &
Silva 1999, Laporte et al 1990, Levey et al 2003, Longmore et al 2004, Lote 2000,
National Kidney Foundation 2002, Sapira 1990, Simon et al 2004, Teichman 2004,
Toto 2004)
5.1. Kidney Ptosis
The kidney can be found in ptosis (Figure 29).
Three grades of ptosis are described:
•
•
•
Lateral descent of the kidney, following the lateral edge of the psoas m..
Further descent of the kidney so that it rests upon the psoas m., and tilts
inwards.
Further descent into the pelvis and complete tilting.
When in ptosis the kidney loses normal mobility under influence of the diaphragm
leading to decreased function.
Serious ptosis can lead to congestion due to kinking of the ureter and interruption to
the peristalsis.
Grade 3 ptosis (Figure 29) position cannot be corrected by the osteopath. However,
mobilisation is still important to help drain some of the congestion and aid the good
function of the ureter.
A light grade of ptosis is not necessarily pathological. More serious ptosis can lead to
dysfunction (Barber & Thompson 2004, Boccardo et al 1994, Clorius et al 1987).
70% of kidney ptosis occurs on the right side.
Kidney ptosis will significantly decrease the blood supply to the organ.
41
Figure 29 - Three grades of ptosis
5.2. Trauma
(Smith et al 2007)
The kidneys are found between the 12th rib and the 3rd lumbar vertebra. The upper
part is quite well protected by the lower ribs but are otherwise relatively exposed,
especially the right kidney as it sits lower.
The kidneys are often actually lower than described topographically meaning that the
musculoskeletal system provides less protection than implied. Both kidneys are
therefore vulnerable to trauma and this is also more so for the right than the left.
Classic medicine describes motor vehicle accidents as the most notable cause of
kidney trauma but even an ‘innocent’ fall can lead to problems in the region.
Classically 95% of kidney traumas are expected to present with haematuria; this is
not really the case especially if the injury is to the renal pedicle. Furthermore, the
patient does not always notice haematuria.
Measuring the blood pressure after trauma is therefore indicated.
42
6. Clinical Examination
6.1. Provocation Tests
6.1.1. Provocation Test for Pyelonephritis
The osteopath places the flat hand over the Grynfelt zone. This is lateral to the
paravertebral muscles and under the 12th rib. In this region the muscular layer is at its
thinnest.
Using the fist of the other hand several percussions are given to ventral with
increasing intensity.
If a dull pain occurs which continues to ache after the percussion has stopped, this is
a sign of pyelonephritis. Of course, this finding must be found along with other clinical
signs from the patient history and with ventral palpation pain.
Video 1 - Provocation test for pyelonephritis
59
7. Osteopathic Techniques
7.1. Relaxation of the Kidney Zone and Fascial
Techniques
7.1.1. Relaxation of the Posterior Side
The patient is placed in the “lumbar roll” position with the lumbar spine in light
lordosis.
The osteopath places the thumb in the Grynfelt zone, pointing into the angle between
the paravertebral muscles and the 12th rib.
A progressive pressure is given with the thumb to ventral/medial, in the direction of
the kidney.
During this progressive pressure the lumbar roll position is used to help find the
position of maximum relaxation of the region where the thumb is placed.
The technique is an example of a more advanced mobilisation technique of the
kidney most notably because the kidney moves ventrally during inhalation and any
posterior adhesions can limit this motion.
This means that the pressure to ventral should be held while several deep abdominal
inhalations are done. During these inhalations the kidney moves ventrally.
At the beginning of this technique this region will feel hard but the combination of the
progressive thumb pressure and the relaxation via the lumbar roll position will result
in slow relaxation of the region.
The technique is deemed successful if less resistance is felt in this zone afterwards.
It is not fully understood how the technique works but the effect is very clear by way
of the palpable relaxation of the region. It is possible that posterior adhesions are
stretched; possibly the over-stimulated sympathetic tone of the tissue in this posterior
region is inhibited.
It is a good preparation for further mobilisation of the kidney.
69
Video 16 - Relaxation of the posterior side
7.1.2. Relaxation of the Posterior Parietal Peritoneum
The patient is supine with both legs bent.
The osteopath stands opposite to the side to be mobilised.
The fingers of both hands are placed in the Grynfelt space and this zone is lifted
ventrally and medially.
A progressive pressure is given against the resistance and then held for a certain
time.
The technique is successful if a more relaxed region is felt after 30 seconds to a
minute.
It is not fully understood how the technique works but the effect is very clear by way
of the palpable relaxation of the region. It is possible that posterior adhesions are
stretched; possibly the over-stimulated sympathetic tone of the tissue in this posterior
region is inhibited.
It is an essential preparation for further mobilisation of the kidney most importantly
because the kidney moves ventrally during inhalation and any posterior adhesions
can limit this motion.
The ventral lift can even be held and - during a deep inhalation - suddenly released
so as to stretch posterior adhesions.
70
9. About the Authors
Grégoire Lason
Gent (B), 21.11.54
Luc Peeters
Terhagen (B), 18.07.55
Both authors are holders of university degrees, namely the Master of Science in
Osteopathy – University of Applied Sciences, and are very active with the promotion
and academic structuring of osteopathy in Europe. In 1987 they began The
International Academy of Osteopathy (IAO) and are, to this day, the joint-principals of
this academy. The IAO is since several years the largest teaching institute for
osteopathy in Europe. Both osteopaths are members of diverse professional
organisations, including the American Academy of Osteopathy (AAO), the
International Osteopathic Alliance (IOA), the World Osteopathic Health Organisation
(WOHO), as part of their mission to improve osteopathic development.
This osteopathic encyclopaedia aims to demonstrate the concept that a proper
osteopathic examination and treatment is based upon the integration of three
systems: the musculoskeletal, visceral and craniosacral systems.
87
This e-book is a product of Osteo 2000 bvba.
If you are interested in publishing an e-book or if you have questions or suggestions,
please contact us:
Mail: [email protected]
Fax: +32 55 70 00 74
Tel: +32 9 233 04 03
Web Osteopedia: http://osteopedia.iao.be
Web The International Academy of Osteopathy – IAO: http://www.osteopathie.eu
101