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GREENMAN’S PRINCIPLES OF MANUAL
MEDICINE
Fifth Edition

Lisa A. DeStefano, D.O.

Associate Professor and Chairperson
Department of Osteopathic Manipulative Medicine
College of Osteopathic Medicine
Michigan State University
East Lansing, Michigan
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Fifth Edition

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Library of Congress Cataloging-in-Publication Data

DeStefano, Lisa A., author.
Greenman’s principles of manual medicine / Lisa A. DeStefano. — Fifth edition.
p. ; cm.
Principles of manual medicine
Includes bibliographical references and index.
ISBN 978-1-4511-9390-9
I. Title. II.Title: Principles of manual medicine.
[DNLM:1. Manipulation, Osteopathic.2. Manipulation, Orthopedic.3. Osteopathic Medicine—methods.WB 940]
RM724
615.8'2—dc23
2015035146

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LWW.com
This edition is dedicated to Philip Erwin Greenman, DO, who passed away on February 5,
2013, 20 days shy of his 85th birthday.
In 1952, Dr. Greenman earned his Doctor of Osteopathy degree from the Philadelphia
College of Osteopathy in Pennsylvania. He then went on to complete an internship at
Osteopathic Hospital of Philadelphia and postdoctoral training in radiology and osteopathic
general practice. He was in private practice near Buffalo, New York, from 1956 until 1972,
before he was recruited to chair the Department of Biomechanics by Myron S. Magen, DO,
founding dean of Michigan State University College of Osteopathic Medicine (MSUCOM). He
subsequently served as associate dean for academic affairs and then senior associate dean.
During his 60-year career, he authored 4 books, 68 peer-reviewed medical journal articles, 10
book chapters, and 11 educational modules. He also served on the editorial advisory board of
10 professional journals.
Dr. Greenman also led the Continuing Medical Education Manual Medicine series. Faculty
of the inaugural course, Principles of Manual Medicine, included non-osteopaths John
Bourdillion, MD, and John Mennell, MD; then later Mark Bookhout, MS, PT, and Ed Isaacs,
MD. Dr. Greenman ultimately formed a diverse team of manual therapists and thinkers who
would cause many to rethink the conventional wisdom of musculoskeletal pain syndromes.
Committed to challenging the status quo to address the patients’ needs, he sought to connect the
great minds that could go toe-to-toe with conventional therapies for syndromes such as low
back pain. Philip E. Greenman, DO, was a standard-setter, an artist, an alchemist, a heretic,
and the most authentic wholehearted human being I have ever had the privilege to meet.
Preface

This book was originally designed as course material used to support the Continuing Medical
Education courses offered through Michigan State University College of Osteopathic
Medicine. Since that time, this publication has been used nationally and internationally in a
number of colleges of osteopathic medicine, chiropractic colleges, schools of physical therapy,
and schools of massage therapy. With an energized commitment to making the text clinically
focused; the fifth edition of Greenman’s Principles of Manual Medicine continues to help the
learner look beyond the general application and pursue the “how” and the “why” manual
medicine techniques can improve neuromusculoskeletal system function.
This edition has many new additions starting with my version of Dr. Greemnan’s “walking
around the temporal bone” diagnostic and sutural approach to the head. Proven to make cranial
treatment fun, easy, and effective, this algorithm is invaluable. Cervical mobilization with
impulse has been rewritten for ease and consistency. These techniques are simple and safe,
defining them as such was greatly needed. Finally, thanks to the expertise of Clarence
Nicodemus, DO, PhD, terminology for normal lumbosacral and sacroiliac motion has been
modified and clarified.
Basic science research continues to improve our understanding of how ones
musculoskeletal system is stabilized in three-dimensional space. Fascial continuity continues
to be a main focus, in particular of the implications of myofascial force transformation. In this
edition, I added a chapter on clinical correlations of the upper quarter. This chapter capitalizes
on Frank Willard and Andry Vleemings’ conclusions as to the stabilizing roles of the
specialized layers of the thoracolumbar fascia beyond the trunk into the thorax, cervical spine,
and cranium. Call me genius or call me reckless, this is a conceptual chapter that is genuinely
meant to start a conversation.
Acknowledgments

Michigan State University College of Osteopathic Medicine has been my home since
matriculating in 1988; I would like to thank the staff and faculty, present and past, for their
tenacious pursuit of excellence in osteopathic education. I would especially like to
acknowledge my colleagues in the Department of Osteopathic Manipulative Medicine, Jennifer
Gilmore, Jacob Rowan, Mark Gugel, Sherman Gorbis, Jon Bruner, Matt Zatkin, Chris Pohlod,
Catherine Donahue, Peter Blakemore, Vincent Cipolla, William Pintal, and Timothy Francisco;
I am very fortunate to have such a great team. I am particularly grateful to our Dean William
Stampel, DO; thank you, Bill, for all your continued support and leadership.
The Continuing Medical Education Program in Michigan State University College of
Osteopathic Medicine has been providing the highest quality manual medicine education in the
country for more than 30 years. To be given the opportunity to participate as a faculty member
in this program is one of greatest joys in my career. Over the years, I have learned from the
very best students, faculty, and staff; to you all, I owe a great deal of gratitude.
My greatest teachers in life have been my parents, Jim and Joanne DeStefano. Thank you
for providing me with all the tools necessary to excel while allowing me the freedom to use
them in a fashion that is uniquely mine; I admire and love you both so very much. I am
especially appreciative to my husband Keith; thank you, my love, for your enduring support and
encouragement during this adventure.
Contents

Preface
Acknowledgments
Reviewers

PART I PRINCIPLES AND CONCEPTS

1 Structural Diagnosis and Manipulative Medicine History

2 Principles of Structural Diagnosis
3 Barrier Concepts in Structural Diagnosis
4 The Manipulative Prescription
5 Normal Vertebral Motion
6 Concepts of Vertebral Motion Dysfunction

PART II PRINCIPLES OF TECHNIQUE

7 Principles of Soft-Tissue and Other Peripheral Stimulating Techniques
8 Principles of Muscle Energy Technique
9 Mobilization With and Without Impulse Technique
10 Principles of Indirect Technique
11 Principles of Myofascial Release and Integrated Neuromusculoskeletal
Technique

PART III TECHNIQUE PROCEDURES

12 Cranial Technique
13 Cervical Spine Technique
14 Thoracic Spine Technique
15 Rib Cage Technique
16 Lumbar Spine Technique
17 Pelvic Girdle Dysfunction
18 Upper Extremity Technique
 19 Lower Extremity Technique

PART IV CLINICAL INTEGRATION AND CORRELATION

20 Common Clinical Problems of the Lower Quarter

21 Common Clinical Problems of the Thorax, Upper Quarter, and Neck
22 Adjunctive Diagnostic Procedures

Index
Reviewers

Rachel Johnson, DO
Associate Professor of Clinical Science
West Virginia School of Osteopathic Medicine
Lewisburg, West Virginia

Daniel Lee, DO
Family Medicine
Miami, Florida

Randy G. Litman, DO
Kentucky Osteopathic Medical Association
Pikeville College
Pikeville, Kentucky

Michael P. Rowane, DO, MS, FAAFP, FAAO

Associate Clinical Professor of Family Medicine and Psychiatry
Case Western Reserve University
Director of Medical Education
University Hospitals Regional Hospitals
Director of Osteopathic Medical Education
University Hospitals Case Medical Center
Cleveland, Ohio

Marc Sibella, DO
Clinical Instructor
School of Medicine
Tufts University
Boston, Massachusetts
 PART I

PRINCIPLES AND CONCEPTS

1 Structural Diagnosis and Manipulative
Medicine History

HISTORY
Manual medicine is as old as the science and art of medicine itself. There is strong evidence of
the use of manual medicine procedures in ancient Thailand, as shown in statuary at least 4,000
years old.1 The ancient Egyptians practiced the use of the hands in the treatment of injury and
disease. Even Hippocrates, the father of modern medicine, was known to use manual medicine
procedures, particularly traction and leverage techniques, in the treatment of spinal deformity.
The writings of such notable historical figures in medicine as Galen, Celsus, and Oribasius
refer to the use of manipulative procedures.2 There is a void in the reported use of manual
medicine procedures corresponding to the approximate time of the split of physicians and
barber–surgeons. As physicians became less involved in patient contact and as direct hands-on
patient care became the province of the barber–surgeons, the role of manual medicine in the
healing art seems to have declined. This period also represents the time of the plagues, and
perhaps physicians were reticent to come in close personal contact with their patients.
The 19th century found a renaissance of interest in this field. Early in the 19th century, Dr.
Edward Harrison, a 1784 graduate of Edinburgh University, developed a sizable reputation in
London utilizing manual medicine procedures. Like many other proponents of manual medicine
in the 19th century, he became alienated from his colleagues by his continued use of these
procedures.3
The 19th century was a popular period for “bonesetters” both in England and in the United
States. The work of Mr. Hutton, a skilled and famous bonesetter, led such eminent physicians
as James Paget and Wharton Hood to report in such prestigious medical journals as the British
Medical Journal and Lancet that the medical community should pay attention to the successes
of the unorthodox practitioners of bone setting.4 In the United States, the Sweet family
practiced skilled bone setting in the New England region of Rhode Island and Connecticut. It
has also been reported that some of the descendants of the Sweet family emigrated west in the
mid-19th century.5 Sir Herbert Barker was a well-known British bonesetter who practiced
well into the first quarter of the 20th century and was of such eminence that he was knighted by
the crown.
The 19th century was also a time of turmoil and controversy in medical practice. Medical
history of the day was replete with many unorthodox systems of healing. Two individuals who
would profoundly influence the field of manual medicine were products of this period of
medical turmoil. Andrew Taylor Still, MD, was a medical physician trained in the preceptor
fashion of the day, and Daniel David Palmer was a grocer-turned- self-educated manipulative
practitioner.

Osteopathic Medicine
Still (1828 to 1917) first proposed his philosophy and practice of osteopathy in 1874. His
disenchantment with the medical practice of the day led to his formulation of a new medical
philosophy, which he termed “osteopathic medicine.” He appeared to have been a great
synthesizer of medical thought and built his new philosophy on both ancient medical truths and
current medical successes, while being most vocal in denouncing what he viewed as poor
medical practice, primarily the inappropriate use of medications then in use.6
Still’s strong position against the drug therapy of his day was not well received by his
medical colleagues and was certainly not supported by contemporary osteopathic physicians.
However, he was not alone in expressing concern about the abuse of drug therapy. In 1861,
Oliver Wendell Holmes said, “If all of the MATERIA MEDICA were thrown into the oceans, it
will be all the better for mankind, and worse for the fishes.”7 Sir William Osler, one of Still’s
contemporaries, stated: “One of the first duties of the physician is to educate the masses not to
take medicine. Man has an inborn craving for medicine. Heroic dosing for several generations
has given his tissues a thirst for drugs. The desire to take medicine is one feature which
distinguishes man, the animal, from his fellow creatures.”8
Still’s new philosophy of medicine in essence consisted of the following:

1. The unity of the body.

2. The healing power of nature. He held that the body had within itself all those things
necessary for the maintenance of health and recovery from disease. The role of the
physician was to enhance this capacity.
3. The somatic component of disease. He felt that the musculoskeletal system was an integral
part of the total body and alterations within the musculoskeletal system affected total body
health and the ability of the body to recover from injury and disease.
4. Structure–function interrelationship. The interrelationship of structure and function had
been espoused by Virchow early in the 19th century,9 and Still applied this principle
within his concept of total body integration. He strongly felt that structure governed
function and that function influenced structure.
5. The use of manipulative therapy. This became an integral part of Still’s philosophy because
he believed that restoration of the body’s maximal functional capacity would enhance the
level of wellness and assist in recovery from injury and disease.

It is unclear when and how Dr. Still added manipulation to his philosophy of osteopathy. It was
not until 1879, some 5 years after his announcement of the development of osteopathy, that he
became known as the “lightning bonesetter.” There is no recorded history that he met or knew
the members of the Sweet family as they migrated west. Still never wrote a book on
manipulative technique. His writings were extensive, but they focused on the philosophy,
principles, and practice of osteopathy.
Still’s attempt to interest his medical colleagues in these concepts was rebuffed,
particularly when he took them to Baker University in Kansas. As he became more clinically
successful, and nationally and internationally well known, many individuals came to study with
him and learn the new science of osteopathy. This led to the establishment in 1892 of the first
college of osteopathic medicine at Kirksville, Missouri. In 2014, there are 35 osteopathic
training sites (including five branch campuses) in the United States graduating more than 4,500
students per year.10 Osteopathy in other parts of the world, particularly in the United Kingdom
and in the commonwealth countries of Australia and New Zealand, is a school of practice
limited to structural diagnosis and manipulative therapy, although strongly espousing some of
the fundamental concepts and principles of Still. Osteopathic medicine in the United States has
been from its inception, and continues to be, a total school of medicine and surgery while
retaining the basis of osteopathic principles and concepts and continuing the use of structural
diagnosis and manipulative therapy in total patient care.

Chiropractic
Palmer (1845 to 1913) was, like Still, a product of the midwestern portion of the United States
in the mid-19century. Although not schooled in medicine, he was known to practice as a
magnetic healer and became a self-educated manipulative therapist. Controversy continues as
to whether Palmer was ever a patient or student of Still’s at Kirksville, Missouri, but it is
known that Palmer and Still met in Clinton, Iowa, early in the 20th century. Palmer moved
about the country a great deal and founded his first college in 1896. The early colleges were at
Davenport, Iowa, and at Oklahoma City, Oklahoma.
Although Palmer is given credit for the origin of chiropractic, it was his son Bartlett Joshua
Palmer (1881 to 1961) who gave the chiropractic profession its momentum. Palmer’s original
concepts were that the cause of disease was a variation in the expression of normal neural
function. He believed in the “innate intelligence” of the brain and central nervous system and
believed that alterations in the spinal column (subluxations) altered neural function, causing
disease. Removal of the subluxation by chiropractic adjustment was viewed to be the
treatment. Chiropractic has never professed to be a total school of medicine and does not teach
surgery or the use of medication beyond vitamins and simple analgesics. There remains a split
within the chiropractic profession between the “straights,” who continue to espouse and adhere
to the original concepts of Palmer, and the “mixers,” who believe in a broadened scope of
chiropractic that includes other therapeutic interventions such as exercise, physiotherapy,
electrotherapy, diet, and vitamins.
In the mid-1970s, the Council on Chiropractic Education (CCE) petitioned the U.S.
Department of Education for recognition as the accrediting agency for chiropractic education.
The CCE was strongly influenced by the colleges with a “mixer” orientation, which led to
increased educational requirements both before and during chiropractic education.
Chiropractic is practiced throughout the world, but the vast majority of chiropractic training
continues to be in the United States. The late 1970s found increased recognition of chiropractic
in both Australia and New Zealand, and their registries are participants in the health programs
in these countries.11

MEDICAL MANIPULATORS
The 20th century has found renewed interest in manual medicine in the traditional medical
profession. In the first part of the 20th century, James Mennell and Edgar Cyriax brought joint
manipulation recognition within the London medical community. John Mennell continued the
work of his father and contributed extensively to the manual medicine literature and its
teaching worldwide. As one of the founding members of the North American Academy of
Manipulative Medicine (NAAMM), he was instrumental in opening the membership in
NAAMM to osteopathic physicians in 1977. He strongly advocated the expanded role of
appropriately trained physical therapists to work with the medical profession in providing
joint manipulation in patient care.
James Cyriax is well known for his textbooks in the field and also fostered the expanded
education and scope of physical therapists. He incorporated manual medicine procedures in
the practice of “orthopedic medicine” and founded the Society for Orthopedic Medicine. In his
later years, Cyriax came to believe that manipulation restored function to derangements of the
intervertebral discs and spoke less and less about specific arthrodial joint effects. John
Bourdillon, a British-trained orthopedic surgeon, was first attracted to manual medicine as a
student at Oxford University. During his training, he learned to perform manipulation while the
patient was under general anesthesia and subsequently used the same techniques without
anesthesia. He observed the successful results of non–medically qualified manipulators and
began a study of their techniques. A lifelong student and teacher in the field, he published five
editions of a text, Spinal Manipulation. Subsequent to his death in 1992, a sixth edition of
Spinal Manipulation was published with Edward Isaacs, MD, and Mark Bookhout, MS, PT,
as coauthors.
The NAAMM merged with the American Association of Orthopaedic Medicine in 1992
and continues to represent the United States in the International Federation of Manual Medicine
(FIMM).

PRACTICE OF MANUAL MEDICINE

Manual medicine should not be viewed in isolation nor separate from “regular medicine” and
clearly is not the panacea for all ills of humans. Manual medicine considers the functional
capacity of the human organism, and its practitioners are as interested in the dynamic processes
of disease as those who look at the disease process from the static perspective of laboratory
data, tissue pathology, and the results of autopsy. Manual medicine focuses on the
musculoskeletal system, which constitutes more than 60% of the human organism, and through
which evaluation of the other organ systems must be made. Structural diagnosis not only
evaluates the musculoskeletal system for its particular diseases and dysfunctions but can also
be used to evaluate the somatic manifestations of disease and derangement of the internal
viscera. Manipulative procedures are used primarily to increase mobility in restricted areas of
musculoskeletal function and to reduce pain. Some practitioners focus on the concept of pain
relief, whereas others are more interested in the influence of increased mobility in optimizing
joint stability and function of the musculoskeletal system. When appropriately used,
manipulative procedures can be clinically effective in reducing pain within the
musculoskeletal system, in increasing the level of wellness of the patient, and in helping
patients with a myriad of disease processes.

GOAL OF MANIPULATION
In 1983, in Fischingen, Sweden, a 6-day workshop was held that included approximately 35
experts in manual medicine from throughout the world. They represented many different
countries and schools of manual medicine with considerable diversity in clinical experience.
The proceedings of this workshop represented the state of the art of manual medicine of the
day.12 That workshop reached a consensus on the goal of manipulation: The goal of
manipulation is to restore maximal, pain-free movement of the musculoskeletal system in
postural balance.
This definition is comprehensive but specific and is well worth consideration by all
students in the field.

ROLE OF THE MUSCULOSKELETAL

SYSTEM IN HEALTH AND DISEASE
It is indeed unfortunate that much of the medical thinking and teaching look at the
musculoskeletal system only as the coat rack on which the other organ systems are held and not
as an organ system that is susceptible to its own unique injuries and disease processes. The
field of manual medicine looks at the musculoskeletal system in a much broader context,
particularly as an integral and interrelated part of the total human organism. Although most
physicians would accept the concept of integration of the total body including the
musculoskeletal system, specific and usable concepts of how that integration occurs and its
relationship in structural diagnosis and manipulative therapy seem to be limited.
There are five basic concepts that this author has found useful. Since the hand is an integral
part of the practice of manual medicine and includes five digits, it is easy to recall one concept
for each digit in the palpating hand. These concepts are as follows:

1. Holism
2. Neurologic control
 3. Circulatory function
4. Energy expenditure
5. Self-regulation

Concept of Holism
The concept of holism has different meanings and usage by different practitioners. In manual
medicine, the concept emphasizes that the musculoskeletal system deserves thoughtful and
complete evaluation, wherever and whenever the patient is seen, regardless of the nature of the
presenting complaint. It is just as inappropriate to avoid evaluating the cardiovascular system
in a patient presenting with a primary musculoskeletal complaint as it is to avoid evaluation of
the musculoskeletal system in a patient presenting with acute chest pain thought to be cardiac in
origin. The concept is one of a sick patient who needs to be evaluated. The musculoskeletal
system constitutes most of the human body, and alterations within it influence the rest of the
human organism; diseases within the internal organs manifest themselves in alterations in the
musculoskeletal system, frequently in the form of pain. It is indeed fortunate that holistic
concepts have gained increasing popularity in the medical community recently, but the concept
expressed here is one that speaks of the integration of the total human organism rather than a
summation of parts. We must all remember that our role as health professionals is to treat
patients and not to treat disease.

Concept of Neural Control

The concept of neurologic control is based on the fact that humans have the most highly
developed and sophisticated nervous system in the animal kingdom. All functions of the body
are under some form of control by the nervous system. A patient is constantly responding to
stimuli from the internal and external body environments through complex mechanisms within
the central and peripheral nervous systems. As freshmen in medical school, we all studied the
anatomy and physiology of the nervous system. Let us briefly review a segment of the spinal
cord (Fig. 1.1). In this figure are depicted the classic somatosomatic reflex pathways with
afferent impulses coming from the skin, muscle, joint, and tendon. Afferent stimuli from the
nociceptors, mechanoreceptors, and proprioceptors all feed in through the dorsal root and
ultimately synapse, either directly or through a series of interneurons, with an anterior horn cell
from which an efferent fiber extends to the skeletal muscle. It is through multiple permutations
of this central reflex arc that we respond to external stimuli, including injury, orient our bodies
in space, and accomplish many of the physical activities of daily living. This figure also
represents the classical viscerovisceral reflex arc wherein the afferents from the visceral
sensory system synapse, in the intermediolateral cell column, with the sympathetic lateral chain
ganglion or collateral ganglia, which then terminate onto a postganglionic motor fiber to the
target end organ viscera. Note that the skin viscera also receive efferent stimulation from the
lateral chain ganglion.
Figure 1.1 Cross section of spinal cord segment.

These sympathetic reflex pathways innervate the pilomotor activity of the skin, the vasomotor
tone of the vascular tree, and the secretomotor activity of the sweat glands. Alteration in the
sympathetic nervous system activity to the skin viscera results in palpatory changes that are
identifiable by the structural diagnostic means.13 Although this figure separates these two
pathways, they are in fact interrelated, so somatic afferents influence visceral efferents and
visceral afferents can manifest themselves in somatic efferents. This figure represents the
spinal cord in horizontal section, and it must be recalled that ascending and descending
pathways—from spinal cord segment to spinal cord segment as well as from the higher centers
of the brain—are occurring as well.
Another neurologic concept worth recalling is that of the autonomic nervous system (ANS).
The ANS is made up of two divisions, the parasympathetic and sympathetic. The
parasympathetic division includes cranial nerves III, VII, VIII, IX, and X and the S2, S3, and
S4 levels of the spinal cord. The largest and most extensive nerve of the parasympathetic
division is the vagus. The vagus innervates all of the viscera from the root of the neck to the
midportion of the descending colon and all glands and smooth muscle of these organs. The
vagus nerve (Fig. 1.2) is the primary driving force of the cardiovascular, pulmonary,
neuroimmune, endocrine, and gastrointestinal systems14,15 and has an extensive distribution.
Many pharmaceutical agents alter parasympathetic nervous activity, particularly that of the
vagus.
Figure 1.2 Autonomic nerve distribution.

The sympathetic division of the ANS (Fig. 1.2) is represented by preganglionic neurons
originating in the spinal cord from T1 to L3 and the lateral chain ganglion including the
superior, middle, and inferior cervical ganglia; the thoracolumbar ganglia from T1 to L3; and
the collateral ganglia. Sympathetic fibers innervate all of the internal viscera as does the
parasympathetic division but are organized differently. The sympathetic division is organized
segmentally. It is interesting to note that all of the viscera above the diaphragm receive their
sympathetic innervation from preganglionic fibers above T4 and T5, and all of the viscera
below the diaphragm receive their sympathetic innervation preganglionic fibers from below
T5. It is through this segmental organization that the relationships of certain parts of the
musculoskeletal system and certain internal viscera are correlated. Remember that the
musculoskeletal system receives only sympathetic division innervation and receives no
parasympathetic innervation. Control of all glandular and vascular activity in the
musculoskeletal system is mediated through the sympathetic division of the ANS.
Remember that all these reflex mechanisms are constantly under the local and central
modifying control of excitation and inhibition. Conscious and subconscious control
mechanisms from the brain constantly modify activity throughout the nervous system,
responding to stimuli. The nervous system is intimately related to another control system, the
endocrine system, and it is useful to think in terms of neuroendocrine control. Recent advances
in the knowledge of neurotransmitters, endorphins, enkephalins, and materials such as
substance P have enlightened us as to the detail of many of the mechanisms previously not
understood and have begun to provide answers for some of the mechanisms through which
biomechanical alteration of the musculoskeletal system can alter bodily function.16
Emphasis has been placed on the reflex and neural transmission activities of the nervous
system, but the nervous system has a powerful trophic function as well. Highly complex protein
and lipid substances are transported antegrade and retrograde along neurons and cross over the
synapse of the neuron to the target end organ.17 Alteration in neurotrophin transmission can be
detrimental to the health of the target end organ.18–20

Circulatory Function
The third concept is that of circulatory function. The concept can be simply described as the
maintenance of an appropriate cellular milieu for each cell of the body (Fig. 1.3). Picture a
cell, a group of cells making up a tissue, or a group of tissues making up an organ resting in the
middle of the “cellular milieu.” The cell is dependent for its function, whatever its function is,
upon the delivery of oxygen, glucose, and all other substances necessary for its metabolism
being supplied by the arterial side of the circulation. The arterial system has a powerful pump,
the myocardium of the heart, to propel blood forward. Cardiac pumping function is intimately
controlled by the central nervous system, particularly the ANS, through the cardiac plexus. The
vascular tree receives its vasomotor tone control through the sympathetic division of the ANS.
Anything that interferes with sympathetic ANS outflow, segmentally mediated, can influence
vasomotor tone to a target end organ.21,22

Figure 1.3 The cellular milieu.

The arteries are also encased in the fascial compartments of the body and are subject to
compressive and torsional stress that can interfere with the delivery of arterial blood flow to
the target organ or cell. Once the cell has received its nutrients and proceeded through its
normal metabolism, the end products must be removed. The low-pressure circulatory systems,
the venous and the lymphatic systems, are responsible for the transport of metabolic waste
products. Both the venous and lymphatic systems are much thinner walled than the arteries, and
they lack the driving force of the pumping action of the heart, depending instead on the
musculoskeletal system for their propelling action.23 The large muscles of the extremities
contribute greatly to this activity, but the major pump of the low-pressure systems is the
diaphragm (Fig. 1.4).
Figure 1.4 Thoracoabdominal diaphragm.

The diaphragm has an extensive attachment to the musculoskeletal system, including the upper
lumbar vertebra, the lower six ribs, the xiphoid process of the sternum, and, through
myofascial connections with the lower extremities, the psoas and quadratus lumborum muscles.
The activity of the diaphragm modulates the negative intrathoracic pressure that provides a
sucking action on venous and lymphatic return through the vena cava and the cisterna chyli.
Because of the extensive attachment of the diaphragm with the musculoskeletal system and its
innervation via the phrenic nerve from the cervical spine, alterations in the musculoskeletal
system at a number of levels can alter diaphragmatic function and, consequently, venous and
lymphatic return. Accumulation of metabolic end products in the cellular milieu interferes with
the health of the cell and its recovery from disease or injury. It should be pointed out that the
foramen for the inferior vena cava is at the apex of the dome of the diaphragm. There is some
evidence that diaphragmatic excursion has a direct squeezing and propelling activity on the
inferior vena cava.24,25
Another circulatory concept related to musculoskeletal function concerns the lymphatic