2006
Lower GI Complaints
What is the autonomic nerve supply to the lower GI tract? Somatic dysfunction of what areas of the body have the greatest impact on dysfunction of the gastrointestinal system? Does the patient have short leg syndrome?
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Lower GI Complaints
Manipulative treatments
Pharmacotherapy
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Somatic Dysfunction
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Sympathetic Hyperactivity
Usually associated with facilitated segments at T10 T11 for right half of colon T12 L2 for left half of colon Produce viscerosomatic reflexes which increase thoracolumbar para spinal muscle tension
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T5-9
T10-11
L1-2
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Autonomic Innervation
Innervation of each viscus generally follows the course of the arterial supply.
Sympathetic supply: Prostate & Prostatic Urethra: T11-L1 Testis & Ovary: T10-11 Ureter: T11-L2 Urinary Bladder: T11-L2 Uterus: T12-L1 Uterine Tube: T10-L1
Sympathetic Ganglion
Located in midline of abdomen, superior to the umbilicus Indicates sympathetic hyperactivity to the colon
Sympathetic Hyperactivity
Ileus Constipation Abdominal distention Flatulence
CORE OMM Curriculum for Students, Interns, & Residents
2006
Parasympathetics
Normalization of parasympathetic activity may be useful to treat: Colitis Crohns disease Irritable bowel syndrome Idiopathic diarrhea
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Parasympathetic Innervation
Left side of Colon Supplied by pelvic splanchnic nerves Origin from cord segments S2,3,4
Right side of Colon Supplied by the vagus nerve Also lesser curvature of stomach, liver, gallbladder and all of the small intestine
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Parasympathetic Activity
Hyperactivity:
Increases bowel motility and glandular secretions Associated with diarrhea
Hypo activity:
Decreased bowel motility and glandular secretions Associated with constipation
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Chapmans Points
Viscerosomatic Myofascial Tenderpoints Anterior Chapmans points are used to diagnose colon dysfunction: Tender, palpable fascial ganglioform nodulations Initiated by tissue inflammation or irritation
Located on lateral side of the thighs in the anterior half of the iliotibial bands From greater trochanters to the lateral epicondyles of the femur
CORE OMM Curriculum for Students, Interns, & Residents
2006
Located between the ASIS & the Greater Trochanter Specific for Atonic Constipation Evaluate thyroid, liver & spleen, as well
GI Group
Along the anterior aspect of the iliotibial band distribution: Trochanter to Fig. 67.2, p.1053, Within 1 (2.5 cm) of the patella Foundations 2nd
Ed., 2003
CORE OMM Curriculum for Students, Interns, & Residents
2006
One or both thighs Just superficial to the deep fascia or slightly adherent to it. Presentation: Single Multiple Coalescent mats or even strings of pearls (chronic or severe cases)
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Lymphatics
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Lymphatics
Potential Consequences:
Increases the colons susceptibility to inflammation and infection Increases the healing time in stress phase of colon Increases likelihood of scarring
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Visceral lymph nodes lie close to the organ which they drain
Then drain through chains of parietal nodes along the path of the major arteries & veins
Clemente, Fig. 235
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Lymphatic Congestion
Thoracic diaphragm function should be evaluated and treated because it can restrict the thoracic duct
Pelvic diaphragm must be evaluated and treated Moves passively and synchronously with thoracic diaphragm
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Pelvic Dysfunction
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Parasympathetic changes occur with suboptimal sacral motion and the increased tensions in the pelvic tissues Sympathetic changes for the same reasons especially around the sacral sympathetic chain and the ganglion impar at its end. In summary, innominate dysfunction can influence: Fluid congestion Parasympathetics Sympathetics
CORE OMM Curriculum for Students, Interns, & Residents
2006
The treatments that follow all have in common the use of the hip joint. Corrective force is brought into the innominate via the accumulation of focused tension through the capsular ligaments of the hip joint. This creates the vector of force to normalize the dysfunction. Participants can evaluation and treat their partners taking turns with the techniques that follow. Practice can immediately follow the review of each slide.
CORE OMM Curriculum for Students, Interns, & Residents
2006
Symphysis Pubis
Superior and Inferior shearing mechanics seen with pubic dysfunction Seen post partum Also seen in strenuous use of adductor muscles of thighs or trauma
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Superior Pubes
Physician uses the shoulder to compress from the knee toward the acetabulum
Physician internally rotates the lower extremity The monitoring finger can feel the pubes descend
CORE OMM Curriculum for Students, Interns, & Residents
2006
Inferior Pubes
Compression is again the first step Followed by external rotation of the lower extremity to carry an inferior pubes superior.
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Innominate Outflare
Compress through the knee toward the hip Carry the knee medially and the ankle laterally Vary the flexion at the knee and hip to localize the force toward the ASIS
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Innominate Outflare
Compress through the knee toward the hip Carry the knee medially and the ankle laterally Vary the flexion at the knee and hip to localize the force toward the ASIS
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Innominate Inflare
Forces are reversed In both cases the accuracy of force localization is key Knee flexion/extension adjustment will help the localization process
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Pelvic Diaphragm
1. Assess for spasm or asymmetry related to prior surgery involving lower sigmoid, rectum and anal areas 2. Funnel shaped muscle attaching to lateral walls of the true pelvis
3. Angles inferior and medially to attach to the urogenital diaphragm and midline structures of the urogenital and anal triangles
4. Innervated by pudendal nerve originated from sacral roots S2,3,4
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Pelvic Diaphragm
The thoracic diaphragm can be monitored for synchrony of motion between the two pelvic & thoracic
Looking forward from the posterior right aspect View of the ischiorectal fossa Reasonably direct access to one hemi-diaphragm of the pelvic diaphragm.
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Summary
1. Osteopathic treatment of the lower GI tract involves evaluating the patients entire health - Nutritional status, psychological stress 2. Somatic influences on the pelvis must be evaluated and treated - Short leg syndrome, lumbar & sacral strain/sprain, post-partum
considerations, innominate upslip
3. The potency of further therapy hinges on the manipulative treatment. - For antibiotics to be fully effective, blood flow and lymphatic
drainage must be optimized
CORE OMM Curriculum for Students, Interns, & Residents
2006
References
Kuchera, Michael L. and Kuchera, William A., Osteopathic Considerations in Systemic Dysfunction. 2nd Edition, 1994. p 94 116.
Ward, Robert C., ed. Foundations For Osteopathic Medicine. Lippincott Williams & Wilkins. 2003. p 762-783. Yates, Herbert A. Counterstrain: A Handbook of Osteopathic Technique. Y Knot Publishers. 1995.
CORE OMM Curriculum for Students, Interns, & Residents
2006