Viscerosomatic Reflexes in the Diagnosis of a Patient with ...

Viscerosomatic Reflexes in the Diagnosis of a Patient with Abdominal Pain
Kristie Petree, DOAssistant Professor of Osteopathic Manipulative MedicineGeorgia Campus – Philadelphia College of Osteopathic Medicine
Review osteopathic tenets and definitions.Defineviscerosomaticand Chapman’s reflexes.Integrateviscerosomaticand Chapman’s reflex findings into a standard differential diagnosis for abdominal pain.
Learning Objectives
The human being is a dynamic unit of function.The body possesses self-regulatory mechanisms that are self-healing in nature.Structure and function are interrelated at all levels.Rational treatment is based on these principles.
Tenets Of Osteopathy
Osteopathic Manipulative Treatment
“OMT”“The therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.”Considered a medical procedure, and is indicated for treatment of somatic dysfunction
“Impaired of altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and their related vascular, lymphatic, and neural elements.”
Somatic Dysfunction
Diagnostic Criteria “TART”T–Tenderness to PalpationA – AsymmetryR – Restricted Range of MotionT – Tissue Texture ChangesAt leastTWOof the four must be present to make a diagnosis of somatic dysfunction.
Diagnosing Somatic Dysfunction
Biomechanical ModelRespiratory-Circulatory ModelNeurologic ModelMetabolic-Energy ModelBehavioral Model
Five Models Of Osteopathy
Biomechanical ModelViews the patient from a structural or mechanical perspectivePhysiologic functions: posture and motion
Five Models Of Osteopathy
Respiratory-Circulatory ModelFocuses on respiratory and circulatory components of the homeostatic response in pathophysiological processesPhysiologic functions: respiration, circulation, venous and lymphatic drainage
Five Models Of Osteopathy
Neurological ModelViews the patient’s problems in terms of aberrancies or impairments of neural function that are caused by or cause pathophysiologic responses in structural, respiratory-circulatory structures and functions, metabolic processes, and behavioral activities.Physiologic functions: control, coordination, and integration of body functions; protective mechanisms; sensation
Five Models Of Osteopathy
Metabolic-Energy ModelFocus is placed on the metabolic and energy-conserving aspects of the homeostatic adaptive responsePhysiologic functions: efficient posture and motion, arterial supply, venous and lymphatic drainage, CSF fluid mechanics, neurologic, endocrine and immune functions, and prudent behaviors, balanced emotions, and proper nutrition are the keystones of energy conservation and efficiency of metabolic functions
Five Models Of Osteopathy
BehavioralModelRecognizes that the assessment of a patient’s health includes assessing his or her mental, emotional, and spiritual state of being as well as personal lifestyle choices.Physiologic functions: psychological and social activities, e.g., anxiety, stress, work, family; habits
Five Models Of Osteopathy
How does this information apply to stomach pain?
Shoulder painThat turned out to be gallbladder disease or a MIFlank painThat turned out to be a kidney stoneBack painThat turned out to be a peptic ulcer or pancreatitis
Have You Ever Had A Patient With…
Why does this happen?
Viscerosomatic reflexes (definition): localized visceral stimuli producing patterns of reflex response in segmentally related somatic structuresVisceral pathology can lead to somatic dysfunction at the neurologically associated spinal levels.These palpable findings can be very helpful diagnostically in complicated case presentations.
Viscerosomatic Reflexes
Viscerosomatic Reflexes
Viscerosomatic Reflexes
A 44-year-old male presents to the outpatient clinic four weeks post-hospitalization for acute diverticulitis with continued left lower quadrant pain and intermittent low back pain. Non-invasive treatment was successful and surgical intervention was not required for the diverticulitis, and this was his first episode. He has no chronic medical problems and no previous surgical history. He states that the his belly pain is constant, dull, and achy. It has no aggravating or alleviating factors. He denies nausea, vomiting, constipation, or diarrhea and has been consistent with the diet given to him by GI. He noticed the back pain seems to wax and wane with the belly pain and began shortly after leaving the hospital. The pain has the same features and is non-radiating.
Case Study
Physical Exam:Vitals: BP 121/78 P 80 R 12 Weight: 215lbsHeight: 6’0”General: AAOx3, no acute distressCardiac: RRR, no rubs, gallops, clicks or murmurs appreciatedPulm: lungs clear to auscultation bilaterally, no accessory muscle useAbdomen: bowel sounds present in all quadrants, no hepatosplenomegaly, no bruits, no distention, rebound or guarding, mild tenderness to deep palpation in the LLQMusculoskeletal: myofascial restrictions in LLQ, +TTA T8-L2 on the left
Case Study
What is the treatment plan?
Treatment Plan:OMT to address somatic dysfunctionThe previous/residual inflammation and irritation of the colon are likely causing the continued LLQ painViaviscerosomaticreflex, the colonic irritation is causing segmental issues at the shared innervation levels of the thoracic and lumbar spine
Case Study
“A system of diagnosis and treatment directed to the viscera to improve physiologic function; typically the viscera are moved toward their fascial attachments to a point of fascial balance; also called ventral techniques. ” - ECOP, 2006
OMT: Visceral Technique
Myofascial Release of the Colon
What About The Back Pain?
Viscerosomatic dysfunction has a distinctivepalpatoryfeelParaspinalmuscles often described as “rubbery”Difficult to treat until the underlying cause is addressedOnce the diverticulitis has cleared, and the colonic fascia is released, these somatic dysfunctions should be more amenable to OMT
Back Pain
Somatic dysfunction of the soft tissues of the body as characterized by asymmetry, restriction of motion, tissue texture changes, and tendernessHypertonic musclesExcessive tension infascialstructuresAbnormalsomatosomaticandviscerosomaticreflexesClinical benefits of soft tissue techniques:Improved local tissue nutrition, oxygenation, removal of metabolic wastes, local and systemic immune responsiveness
OMT: Soft Tissue Techniques
Gentle, repetitive pressure used to stretch the soft tissuesRelaxes muscles and connective tissueUsually performed for 3-5 minutes, or until desired tissue relaxation is reached
OMT: Soft Tissue Technique
Soft Tissue - Thoracolumbar Region
Questions?
Chapman’s Reflexes
Another palpableviscerosomaticmanifestation
Originally described by Frank Chapman, DO in 1928.“A system of reflex points that present as predictable anterior and posterior fascial tissue texture abnormalities (plaque-like changes or stringiness of the involved tissues) assumed to be reflections of visceral dysfunction or pathology.” – ECOP, 2006Chapman’s reflexes areganglioformcontractions found in the fascia believed to be from lymphatic stasis/congestion secondary to visceral pathology.
Chapman’s Reflexes
Dr. Chapman meticulously mapped over 200 areas of lymphatic stasis and matched them to underlying visceraPoints located deep to the skin and subcutaneous tissue, most often lying on the deep fascia or periosteumPoints are fixed in their anatomical position and mostly found in pairs on the anterior and posterior surface of the bodyAnterior points are often more tender than expected when palpated
Chapman’s Reflexes
Anterior Chapman’s Reflex Points
Posterior Chapman’s Reflex Points
Distinguishing Characteristics
Palpation will reveal:Small (2-3mm in diameter)SmoothFirmDiscretely palpable“Small pearls of tapioca, partially fixed, on the deep fascia”
Pain elicited from palpation is described as:Pinpoint, non-radiatingSharp“Exquisitely painful”
Clinical Application
The process:Perform history and physical exam, create differential diagnosisUse Chapman’s Reflexes to help navigate underlying visceral pathologyUsing the mapped chart, look for the presence or absence of a Chapman’s ReflexDiagnosis is made based on the presence of the anterior point and confirmed with the presence of the posterior point
Osteopathic Manipulative Treatment
Treatment:To treat a Chapman’s reflex, firm, rotary pressure is initiated to the point for 15-60 seconds.Treat the anterior point first.The treatment is completed once the reflex point has palpably changed, not when the pain is alleviated.
Osteopathic Manipulative Treatment
Treatment order:It is most important to treat the anterior point first, however…If the point is too tender to treat:Address the posterior point first, then reassess the anterior pointApply other osteopathic manipulative techniques to the surrounding tissues to try and obtain some tissue texture change
To completely alleviate a Chapman’s Reflex, the underlying visceral pathology must be addressed using standard medical care!!!Using OMT on Chapman’s ReflexesMay help the underlying condition improve by improving lymphatic drainage, etc.Help track patient progressIf the visceral pathology is improving, the Chapman’s Reflex should improve/disappear
Remember!!!
A 24-year-old female presents to the ER with pain that starts in her right flank and wraps around to her umbilicus. She states that the pain is intermittent and has been getting more frequent over the last two weeks. When the pain occurs, it is severe and makes her double over in pain. When the pain occurs, nothing makes it better; however she has noticed it gets worse with eating sometimes. She has irregular menstrual cycles and is unsure of her last period.
Case Study
Current Medications:MirenaIUD, vitamin DAllergies:cipro– rashSurgicalHx: wisdom teeth at 18, right inguinal hernia repair at 19SocialHx: current grad student, in long term monogamous relationship with boyfriend, denies alcohol, tobacco, or illicit drug use, admits to 3-5 cups of coffee/dayFamilyHx: mother has long history of kidney stones and HTN
Case Study
Physical Exam:Vitals: BP 132/89 P 87 R 15 Weight: 165lbsHeight: 5’7”General: AAOx3, visibly uncomfortableCardiac: RRR, no rubs, gallops, clicks or murmurs appreciatedPulm: lungs clear to auscultation bilaterally, no accessory muscle useAbdomen: mild tenderness in RUQ and RLQ, no rigidity, + CVA tenderness on the right, bowel sounds present in all quadrants
Case Study
Labs: CBC / COMP – normalU/A: +2 proteinUrine and serum ß-hcg(negative)CT scan abdomen/stone protocol (-)
Case Study
…now what?
Patient was referred to outpatient OB/GYNOB/GYN does own H & P including pelvic ultrasound in officeDoes U/A and culture (negative)Urine and serum ß-hcg(negative)Confirms thatMirenais properly in place, no ovarian or uterine pathology
Case Study
Patient is still having pain…
Patient was referred to primary care providerPCP does own H & PConfirms CVA tenderness and mild upper right quadrant tendernessReferred to urology to rule-outstruvitestonesSuggested that this may be musculoskeletal pain
Case Study
While Waiting For The Urology Appointment…
Patient follows up with OMM clinic for musculoskeletal pain.NMM/OMM does his own H & P including an osteopathic structural exam which revealed:Acute tissue texture changes from T7-9 on the rightAnterior and posterior gallbladder Chapman’s Reflex pointsAddressed somatic dysfunction with OMT, and referred for HIDA scan.HIDA scan revealed gallbladder ejection fraction of 2%.
Case Study
The original ER physician had screened for Chapman’s Reflexes?
What if…
Questions?
Ward, Robert DO, FAAO (2003).Foundations of Osteopathic Medicine, 2nd edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.Chila, A. G. (2011).Foundations of Osteopathic Medicine, 3rdedition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
References