9-2 CV Cases Flashcards
What are the limits of Osteopathy?
No one knows the limits of Osteopathy.”
John Martin Littlejohn
(except peer-reviewed literature)
Is Osteopathy only useful for treating musculoskeletal pain and injuries?
No - viscerosomatic reflexes, and somatovisceral input
Also, use of lymph techniques and other circulatory enhancing tachniques to improve venous return, possibly preload if necessary
Where does the sympathetic innervation of the heart have its origins? Where are the synapses?
Cord segments T1-5(6)
Synapses occur in the upper thoracic and/or cervical chain ganglia
Does SNS fiber distribution to the heart have something unusual about it? Is it perfectly symmetrical?
Sympathetic fibers to the heart do have a right- and left-sided distribution
Right sided fibers pass to the right deep cardiac plexus - innervate the right heart and sinoatrial (SA) node
Left sided fibers pass to left deep cardiac plexus – innervate left heart and atrioventricular (AV node)
What is the result of hypersympathetic activity (tone) to the right side of the heart (SA node)?
Supraventricular tachyarrhythmias
Sinus tachycardia
Paroxysmal supraventricular tachycardia (PSVT)
What is the result of hypersympathetic activity (tone) to the left side of the heart (AV node)?
Ectopic foci
Ventricular tachycardia
Ventricular fibrillation
What type of somatic dysfunction can increase sympathetic activity (tone) to the heart?
Upper thoracic dysfunction (especially extended segments)
Upper rib dysfunction, many times associated with upper thoracic dysfunction
Cervical dysfunction – affecting the superior, middle and inferior cervical ganglia
Where does the parasympathetic innervation of the heart have its origins?
Vagus nerves (cranial nerve 10)
Also have ipsilateral distribution:
Right vagus – innervates the sinoatrial (SA) node
Left vagus – innervates atrioventricular (AV) node
What is the result of hyperparasympathetic activity (tone) to the right side of the heart (SA node)?
Sinus Bradycardia
What is the result of hyperparasympathetic activity (tone) to the left side of the heart (AV node)?
AV Blocks
What is the course of the vagus nerve (cranial nerve 10)?
Originates on the medulla
Exits the skull via the jugular foramen between the occipital and temporal bones
Has connections with the first 2 cervical somatic nerves
Enters the chest via the thoracic inlet
What types of somatic dysfunction can affect the vagus nerves?
Occipitomastoid compression affecting the jugular foramen
Occiput, atlas and axis (upper cervical spine)
Thoracic inlet:
Upper thoracics
Upper ribs
Clavicles
Lower cervicals
Cervical fascia
ECT.
How is lymph drainage from the heart and lungs taken care of? Where does it drain, and what is the course of the lymph vessels? What drives this movement?
Lymphatic drainage from heart and lungs primarily carried back to the heart via the right lymphatic duct
Courses through the thoracic inlet on the way back into the heart
Driven by synchronized diaphragmatic function and muscle activity – overall body movement
Describe the relative dist of the body in terms of what each lymph vessel drains:
right lymphatic duct
left lymphatic duct
right lymphatic duct
- heart and lungs, right half of neck and head, right arm and shoulder
left lymphatic duct
- everything else
What 2 treatment modalities (other than drugs) that can improve lymph flow, and by how much?
OMM, in dog studies, can improve lymphatic flow by 4-5 times
Exercise can improve lymphatic flow by 30+ times
We can combine both for the benefit of the patient
What are some areas of somatic dysfunction that can negatively affect lymphatic flow?
Thoracic inlet
Respiratory diaphragm
Lower thoracics
Lower ribs
Upper lumbars (psoas major muscle)
Sympathetics
What are Chapman’s reflexes?
Chapman’s Reflexes
A viscerosomatic reflex mechanism
Associated with palpable nodules deep to skin and subcutaneous tissue
Can be used for diagnosis and treatment
Can be used to affect heart, renal and adrenal function
What can take a patient closer to threshold of sx and disease?
Allostatic load
- SD anywhere affects the individual locally and globally
Stressors/imbalance that takes them closer to the threshold of symptoms and disease-activates SNS-HPA couple
SD is frequently associated with what type of activity?
Hypersympathetic activity
Example – upper thoracic dysfunction may be associated with local hypersympathetic tone to innervated structures but also a global increase in sympathetic tone throughout the body
Overall, the entire individual is closer to their threshold for firing , more susceptible to imbalance and closer to the threshold for symptoms and disease
What is increased allostatic load associated with?
Increased allostatic load may contribute to breakdown of the cardiovascular, immune, renal, gastrointestinal and central nervous systems
How should osteopaths treat allostatic load - what is the philosophy?
Our job – to work knowingly with the system to allow health to manifest itself
As a result, multiple layers of dysfunction are removed to allow the underlying health to shine through
It is not a sequence of wresting holds to mindlessly apply to disease conditions
Osteopathy is art and science integrated into one
The overall result of a competently applied Osteopathic treatment is to improve the health, function and motion of the individual
Do our genes/DNA just randomly think for themselves?
Probably not! Epigenetics look at the genes as responding to multiple environmental signals that go into them
Positive signals may produce positive epigenetic expression and vice versa
Epigenetic abnormalities may be passed on for multiple generations unless the environmental signals are altered
What are some negative environmental signals that may have a negative impact on gene expression?
Poor nutrition
Toxic thoughts/mental stress
Physical stress
Environmental toxins
Somatic dysfunction
Others???
How common is HTN? What is it a risk factor for?
Affects a significant amount of the US population
Is a risk factor for:
coronary heart disease,
congestive heart failure,
ischemic and hemorrhagic stroke,
renal failure and
peripheral arterial disease
What determines arterial pressure?
Cardiac output
and
peripheral resistance
What determines cardiac output?
stroke volume
heart rate
What determines peripheral resistance?
vascular structure
vascular function
What is the most common cause of hypertension?
Essential
We don’t know what causes it
Harrison’s Principles of Internal Medicine describes multiple contributing factors including increased sympathetic activity
Some antihypertensive medications work by reducing sympathetic effects
Renin-angiotensin-aldosterone system – involved in the regulation of arterial pressure via:
Angiotensin II (vasoconstrictor)
Aldosterone (sodium retention)
Renin is synthesized by what in response to?
synthesized by juxtaglomerular cells
In response to:
Decreased pressure or stretch within the renal afferent arteriole (baroreceptor mechanism)
Sympathetic nervous system stimulation of renin-secreting cells
How can somatic dysfunction contribute to elevated blood pressure and hypertension?
Upper thoracic dysfunction can facilitate increased sympathetic tone to the heart
Increased heart rate
Increased stroke volume
What SD can affect the kidneys?
Somatic dysfunction in the thoracic and lumbar regions (especially T6-L2) can facilitate increased sympathetic tone to the adrenal gland and kidney
HTN and SD can work together to make each other worse. How is this done?
Will facilitate catecholamine release from adrenals – resulting in increased cardiac output and peripheral resistance
Will activate renin-angiotensin-aldosterone system – resulting in vasoconstriction (increased vascular resistance) and sodium and fluid retention via aldosterone
What techniques can reduce sympathetic tone?
thoracolumbar junction
chapman’s reflexes
What can decrease ADH’s effect of increasing aldosterone in treating HTN?
Free SB symphysis
What techniques are helpful in treating retained fluids and electrolytes?
Fascial techniques
What types of SD can also alter carotid receptor fxn and contribute to alterations in BP?
Somatic dysfunction affecting the:
cranium (SBS compression, occipitomastoid compression affecting jugular foramen),
occiput,
atlas and
remainder of cervical spine
- may alter carotid receptor function and contribute to alterations in blood pressure
What treatments can affect CN IX, X effect on baroreceptors, decreasing peripheral resistance?
OA
Cervical tissues
What can reduce ANS contributions to increased peripheral resistance (what treatments)?
Decrease Sympathetics
ribs
chain ganglion
How can you reduce allostatic load in the patient?
Treat the entire patient Osteopathically to overall reduce the allostatic load
What areas should you pay special attention to in HTN and CV cases?
Pay special attention to the cranial mechanism, cervicals, upper thoracics and thoracolumbar junction
Don’t forget Chapman’s reflexes
A 30 year old male presents for an initial routine physical. He has not seen a physician for 12 years and has no complaints.
Review of systems negative
Medical histories noncontributory
Vitals Temp 99.0F, BP 145/95, Pulse 70, Respirations 14
Physical exam – normal
What is the diagnosis?
MI
A 30 year old male presents for an initial routine physical. He has not seen a physician for 12 years and has no complaints.
Review of systems negative
Medical histories noncontributory
Vitals Temp 99.0F, BP 145/95, Pulse 70, Respirations 14
Physical exam – normal
How will you manage it?
What is the common COD?
Most common cause of death within the 1st 24 hours is ventricular fibrillation (50% occur within 1st hour)
Treat them sooner versus later
MI is associated with what SD?
Many demonstrate autonomic imbalance
Dysfunction at T2-3 on left in patients with anterior wall MI
Dysfunction at C2 and cranial base (vagus) with inferior wall MI
What is the OMM treatment goal with an MI?
Goals:
Bring autonomic balance back to the cardiovascular system
Prevent ventricular fibrillation
Reducing sympathetic tone will cause dilation of the coronary arteries – improved myocardial perfusion
Improve arterial supply and venous and lymphatic drainage to heart
What techniques should you not use with a suspected MI?
Avoid HVLA technique (especially to the upper thoracics) during the initial management.
Why should you not use HVLA with a suspected MI?
HVLA can cause a short-term increase in sympathetic activity
May result in vasoconstriction of coronary arteries and extend infarct
When treating a patient for MI:
Again, treat the whole patient Osteopathically to improve function and motion but pay special attention to the
Cranial mechanism (CV 4 helps balance autonomics)
Cervical spine (Vagus)
What are some more good techniques for using OMM to treat an MI?
Upper thoracic spine and upper ribs
Thoracolumbar junction
Chapman’s reflexes affecting heart, adrenals and kidneys
Gentler techniques are initially a better option!
A 48-year-old male is brought to your emergency department via ambulance with chest pain of 45 minutes duration. A 12-lead EKG is suggestive of an inferior wall MI
What do you do?
MONA, no HVLA
What is CHF associated with?
Clinical syndrome associated with:
Intravascular and interstitial volume overload
Inadequate tissue perfusion
What are the symptons of CHF?
Fatigue and SOB most common
Also see anorexia, nausea, early satiety associated with abdominal pain/fullness, confusion, disorientation, sleep/mood disturbances and nocturia
What is the pathogenesis of CHF?
Pathogenesis – progressive disorder
Something damages the heart muscle or reduces its ability to generate force (contract)
Many causes including coronary artery disease, MI, hypertension, toxic damage (excessive alcohol), viral infection, etc.
Regardless of cause, result is overall decline in pumping capacity of heart
Vicious downward spiral develops due to activation of neurohormonal systems
What is the spiral of CHF?
Decreased CO
– unloading of high-pressure baroreceptors in left ventricle, carotid sinus and aortic arch
Afferent signals to CNS – releases ADH (antidiuretic hormone)
Reabsorption of free water
Activation of sympathetic efferents to heart, kidney, peripheral vasculature and skeletal muscles
In the ‘spiral’ of CHF, sympathetic stimulation of the kidney is associated with?
Release of renin and activation of renin-angiotensin-aldosterone pathway
Salt and water retention
Vasoconstriction and increased vascular resistance
Myocyte hypertrophy
Myocyte death
Myocardial fibrosis
What is the goal of OMM in treating CHF?
Goal is to break into the downward spiral
Reduce intravascular and interstitial volume overload (improve renal function)
Improve tissue perfusion
Optimize cardiac function
When treating CHF osteopathically what should you pay special attention to?
Treat entire patient Osteopathically but especially pay attention to:
Cranial mechanism
Cervical spine
Upper thoracics
Thoracolumbar junction (kidneys and adrenals)
Lymphatics (thoracic inlet, respiratory and other diaphragms)
Proceed slowly - these patients can be very fragile!
Exercise is a key treatment for CHF. What does it improve?
Autonomic nervous system function
Regional blood flow
Endothelial function
Skeletal muscle function
Quality of life
Exercise training can improve exercise duration by how much?
Exercise training can improve exercise duration as much as pharmaceutical agents (digoxin and ACE inhibitors)
What can an osteopath combine to help provide the best outcome for CHF?
We combine exercise, pharmacologic management and OMM for best possible outcomes
Manage other comorbid conditions including hypertension, diabetes, thyroid disease, etc.
