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Patricia Kooyman, D.O.

OMM Department August 16, 2011

Viscerosomatic Reflexes
Inflammation is a powerful stimulator of local nociceptors. The convergence of visceral nociceptors with the nociceptors from all somatic tissues produces several clinical effects:
Referred pain Segmental facilitation at the spinal cord level

Primary Afferent Nociceptors (PANs)


Can be activated by stretch or by chemicals in the surrounding media

Factors activating PANs:


Bradykinins Histamines Prostaglandins Serotonin H+ and K+ Cytokines ATP Neuropeptides

Neurosecretoy Function of: Primary Afferent Nociceptors(PANs) They release these (dilatory) peptides: Substance P Calcitonin Gene-Related Polypeptide Somatostatin Normally, a basal release of these peptides; they are targeting the resistance arterioles, to act as a counterbalance to the SNS (since NO PNS to the extremities) However, can have a Neurogenic Inflammatory Response, if a lot of these are released vs. the basal release.

Primary Afferent Nociceptors (PANs)


Can be activated by stretch or by chemicals in the surrounding media

Factors activating PANs:


Bradykinins Histamines Prostaglandins Serotonin H+ and K+ Cytokines ATP Neuropeptides

Neurosecretoy Function of: Primary Afferent Nociceptors(PANs) They release these (dilatory) peptides: Substance P Calcitonin Gene-Related Polypeptide Somatostatin Normally, a basal release of these peptides; they are targeting the resistance arterioles, to act as a counterbalance to the SNS (since NO PNS to the extremities) However, can have a Neurogenic Inflammatory Response, if a lot of these are released vs. the basal release.

Primary Afferent Nociceptors (PANs)


Can be activated by stretch or by chemicals in the surrounding media

Factors activating PANs:


Bradykinins Histamines Prostaglandins Serotonin H+ and K+ Cytokines ATP Neuropeptides

Results of PAN activation: Lowering thresholds Clinically, the development of hyperalgesia

Neurosecretoy Function of: Primary Afferent Nociceptors(PANs) They release these (dilatory) peptides: Substance P Calcitonin Gene-Related Polypeptide Somatostatin Normally, a basal release of these peptides; they are targeting the resistance arterioles, to act as a counterbalance to the SNS (since NO PNS to the extremities) However, can have a Neurogenic Inflammatory Response, if a lot of these are released vs. the basal release.

Then TART findings occur: muscle spasm, sensitivity to touch

Primary Afferent Nociceptors (PANs)


Can be activated by stretch or by chemicals in the surrounding media

Factors activating PANs:


Bradykinins Histamines Prostaglandins Serotonin H+ and K+ Cytokines ATP Neuropeptides

To spinal cord: increased afferent drive, due to this sensitization of the primary afferent fibers

Results of PAN activation: Lowering thresholds Clinically, the development of hyperalgesia

Descriptive model from Frank Willard, PhD

Spinal cord facilitation/ Segmental facilitation


Reduced threshold for firing of the interneurons receiving nociceptive input
interneurons = a neuron between a primary sensory neuron and a final motorneuron, or any neuron whose processes are entirely confined within a specific area internuncial neurons = transmitting impulses between two different parts.

Then - a change occurs at the level of the genes of those interneurons/internuncial neurons. Exaggerated segmental autonomic and alpha-motor response occurs; produces boggy spasm, increased temperature, increased sweat. Exaggerated ascending tract input to higher centers, produces hyperasthesia, and referred pain Alters autonomic outflow to viscera

From Frank Willard, PhD discussion of: Research by and Mary F. Anderson and Barbara J. Winterson of UNECOM Brain Research 678:140-150, 1995. After making a cut at the area of the green pointer, 85% of the facilitation remained. Therefore, the muscle spindle alone isnt sustaining the somatic dysfunction. The smallcaliber system is necessary for the initiation of this spinal facilitation, but then once initiated, this afferent drive is not needed to sustain the spinal /segmental facilitation.

Visceral Sympathetics
Thyroid T1-4 Mammary T1-6 Esophagus T1-6 Lung T1-6 Heart T1-6 Stomach T5-9 Left Liver T5-9 Gallbladder T5 Right Pancreas T7 Right Spleen T7 Left Small intestine to right colon T10-11 Left colon to rectum to pelvic organs T12-L2 Appendix T10 (T9T12) Ovary/Testes T1011 Kidney T10-11 Uterus T12-L2 Bladder T12-L2

Levels cited from Kuchera, Osteopathic Considerations in Systemic Dysfunction

Osteopathic treatment considerations - Diagnosis


First and foremost is to treat the underlying pathology responsible for the reflex. Somatic dysfunction resulting from a visceral pathology generally has an acute, boggy, rubbery end feel. Reflexes can be palpated and distinguished through tissue texture changes. (+ red reflex secondary to inc. erythema, + skin drag secondary to inc. moisture ) Beals compression test gently lift up in the paravertebral area bilaterally to detect changes to tissue texture

Osteopathic treatment considerations


Prolonged hyperactivity of the autonomic nervous system can lead to facilitation of the spinal cord and lower thresholds for autonomic firing. Treatment is directed towards breaking the facilitation, and restoring balance between the sympathetic and parasympathetic systems. Understanding the anatomy of the SNS and PSNS will assist in treatment. Reflexes are acute changes. Treatments are generally more effective and better tolerated utilizing gentle, indirect and passive techniques.

Treatment techniques - SNS


Addresses T1-L2 along sympathetic chain ganglion corresponding to the level of the reflex - Inhibitory pressure - Soft tissue myofascial release - Rib raising

Rib Raising
initially stimulates regional sympathetic efferent activity to organs related to that level of sympathetic innervation, but in the long run, rib raising results in a prolonged reduction in sympathetic nervous system outflow from the area treated.
p. 53 Nelson

Treatment techniques - PSNS


Vagus CN X Address the occipital and upper cervical region as reflex can lead to dysfunctions of the OM suture, OA, C1-3.

Treatment techniques - PSNS


Parasympathetic fibers arise from roots S2,3,4 and are distributed as the pelvic splanchnic nerves to the pelvic viscera. Treatment to address PSNS of the lower GI and GU systems target the sacrum and pelvis.

Treatment techniques - PSNS


For Vagus OA decompression, sub-occipital release techniques, balanced ligamentous tension (BLT), FPR, myofascial releases, inhibition For Pelvic splanchnics (S2-4) lumbosacral myofascial, sacral rock, BLT, inhibition The above list is just a sample of techniques; as long as the treatment is gentle, indirect, and passive it would be better tolerated.

Chapmans Reflexes
Chapmans reflexes are a system of reflex points originally used by Frank Chapman, D.O. These reflexes present as predictable anterior and posterior fascial tissue texture abnormalities. Gangliform contraction that blocks lymphatic drainage. Sympathetic nervous system dysfunction and lymphatic pathology following viscerosomatic reflexes.

Chapmans Reflexes
On palpation, Chapman reflexes are located deep to the skin, most often lying on the deep fascia or periosteum. Usually found paired on both the dorsal and ventral parts of the body. Small, smooth, firm nodules approximately 23mm in diameter and exquisitely tender to palpation but non-radiating.

Key Chapmans Points


Tip of the 12th rib for appendix reflex. Colon reflex reflected onto the iliotibial fascial tract. Upper respiratory system (pharynx/nasal sinuses) points around the clavicle and 1st intercostal space. Myocardium point in 2nd intercostal space. GI and GU points to help differentiate causes or source of visceral pain.

Chapmans Reflexes Treatment


Primarily a diagnostic tool. Find the dysfunction anteriorly but treat posterior points since they are generally less tender. Treat somatic dysfunctions of the pelvis first. Apply firm pressure with finger pad of one finger in a circular fashion, and attempt to flatten the mass. Treatment usually requires 10 to 30 seconds. Treatment ends when the mass disappears.

Application of OMM
Diagnostic

Therapeutic

Adjunctive

Treatment
Hospital based any disease state will have an effect on the sympathetic tone and respiratory excursion of the patient. Gentle manipulation can help facilitate the body towards recovery. Ambulatory care osteopathic physicians have a unique qualification to utilize osteopathic manipulation as a therapeutic or adjunctive treatment for many disease states.

Effects of Osteopathic Treatment


Develop a unique relationship with the patient by taking the time to talk, listen, and touch them. Provide pain relief and increased range of motion for musculoskeletal dysfunctions. Break viscerosomatic cycles to facilitate healing. Reduce the need for medication and potential side effects. Improve circulation to enhance healing by removing tissue restrictions and allowing proper circulatory and lymphatic flow. Treating dysfunctions of the body to promote optimal functioning, and permit the bodys inherent ability to heal itself.

Questions???
"To find health should be the object of the doctor. Anyone can find disease." - Dr. A.T. Still