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Osteopathic Considerations of the Pelvis in Lower GI Complaints

Developed for OUCOM CORE


By the CORE Osteopathic Principles and Practices Committee Session #3 Series A

CORE OMM Curriculum for Students, Interns, & Residents

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?

CORE OMM Curriculum for Students, Interns, & Residents

2006

Lower GI Complaints

Devise a treatment plan encompassing:


Psychosocial issues Diet modifications if applicable

Manipulative treatments
Pharmacotherapy

Exercises to be done at home by patient

CORE OMM Curriculum for Students, Interns, & Residents

2006

Somatic Dysfunction

Osteopathic manipulative treatment is directed toward: Improving blood flow

Improving lymphatic flow


Balancing autonomic impulses to and from the bowel

CORE OMM Curriculum for Students, Interns, & Residents

2006

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

CORE OMM Curriculum for Students, Interns, & Residents

2006

Sympathetic Innervation of the GI tract


Autonomic Names Group Innervation Collateral Sympathetic Ganglion Celiac Ganglion

Greater Splanchnic Nerve

T5-9

Stomach, Liver, Pancreas, Duodenum Small Intestines and Right Colon

Lesser Splanchnic Nerve

T10-11

Superior Mesenteric Ganglion

Lumbar Splanchnic Nerve

L1-2

Left Colon and Pelvic Organs

Inferior Mesenteric Ganglion

CORE OMM Curriculum for Students, Interns, & Residents

2006

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

Source: British Grays, p. 1306


CORE OMM Curriculum for Students, Interns, & Residents

British Grays Anatomy 38th Ed., p.1293


2006

Inferior Collateral Sympathetic Ganglion w/ Sympathetic Hyperactivity

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

CORE OMM Curriculum for Students, Interns, & Residents

2006

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

CORE OMM Curriculum for Students, Interns, & Residents

2006

Parasympathetic Activity

Hyperactivity:
Increases bowel motility and glandular secretions Associated with diarrhea

Hypo activity:
Decreased bowel motility and glandular secretions Associated with constipation

CORE OMM Curriculum for Students, Interns, & Residents

2006

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

Colon Chapmans Reflexes:


GI Group

Located between the ASIS & the Greater Trochanter Specific for Atonic Constipation Evaluate thyroid, liver & spleen, as well

CORE OMM Curriculum for Students, Interns, & Residents

Owens, An Endocrine Interpretation of Chapmans Reflexes


2006

Colon Chapmans Reflexes:

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

Colon Chapmans Reflexes:

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)

CORE OMM Curriculum for Students, Interns, & Residents

p. 1053, Foundations, 2nd Ed.


2006

Irritable Bowel Syndrome

Manifestation of hyperactivity of both parasympathetic and sympathetic systems

CORE OMM Curriculum for Students, Interns, & Residents

2006

Lymphatics

Somatic Dysfunction leads to:


Increased interstitial fluids and tissue congestion Edema in tissue of the mesentery can exert pressure on the thin walls of the lymphatic and venous channels Results in accumulation of waste products, reduced oxygenation, and decreased nutrition to cells

CORE OMM Curriculum for Students, Interns, & Residents

2006

Lymphatics

Potential Consequences:
Increases the colons susceptibility to inflammation and infection Increases the healing time in stress phase of colon Increases likelihood of scarring

Can worsen the prognosis in colitis or Crohns disease

CORE OMM Curriculum for Students, Interns, & Residents

2006

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

CORE OMM Curriculum for Students, Interns, & Residents

2006

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

CORE OMM Curriculum for Students, Interns, & Residents

2006

Pelvic Dysfunction

Pelvic diaphragm function can be influenced by sacral and pelvic function.


Today we will focus upon pelvic dysfunction and its contribution to fluid congestion, as well as sub-optimal parasympathetic function. Pubic & Innominate dysfunction change tensions in the urogenital diaphragm and the levator ani. Thus fluid congestions may be augmented by decreased tissue motion

CORE OMM Curriculum for Students, Interns, & Residents

2006

Pubic & Innominate Dysfunction

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

OMT with Hip Joint

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

CORE OMM Curriculum for Students, Interns, & Residents

2006

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.

The monitoring finger can feel the pubes ascend.


CORE OMM Curriculum for Students, Interns, & Residents

2006

Innominate: Rotated Anterior

Caudad Hand: Holds knee to maintain eversion at the hip.

Cephalad Hand: Directs force on the ASIS superior and posterior


Patient: Gently and slowly carries the foot along the medial aspect of the opposite leg until straight.

CORE OMM Curriculum for Students, Interns, & Residents

2006

Innominate: Rotated Posterior

Same technique, except


Cephalad Hand: contacts the ischial tuberosity and carries it superior/posterior

CORE OMM Curriculum for Students, Interns, & Residents

2006

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

CORE OMM Curriculum for Students, Interns, & Residents

2006

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

CORE OMM Curriculum for Students, Interns, & Residents

2006

Innominate Inflare

Forces are reversed In both cases the accuracy of force localization is key Knee flexion/extension adjustment will help the localization process

CORE OMM Curriculum for Students, Interns, & Residents

2006

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

CORE OMM Curriculum for Students, Interns, & Residents

2006

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.

Moore, Clinically Oriented Anatomy, 4th Edition, 1999, p.400

CORE OMM Curriculum for Students, Interns, & Residents

2006

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