OPP considerations in CV

Question 1

Where does the sympathetic innervation of the heart have its origins?

Answer 1

Cord segments T1-5(6)
Synapses occur in the upper thoracic and/or cervical chain ganglia
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)

Question 2

What is the result of hypersympathetic activity (tone) to the right side of the heart (SA node)?

Answer 2

Supraventricular tachyarrhythmias
Sinus tachycardia
Paroxysmal supraventricular tachycardia (PSVT)

Question 3

What is the result of hypersympathetic activity (tone) to the left side of the heart (AV node)?

Answer 3

Ectopic foci
Ventricular tachycardia
Ventricular fibrillation

Question 4

What type of somatic dysfunction can increase sympathetic activity (tone) to the heart?

Answer 4

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

Question 5

Where does the parasympathetic innervation of the heart have its origins?

Answer 5

Vagus nerves (cranial nerve 10)
Also have ipsilateral distribution
Right vagus – innervates the sinoatrial (SA) node
Left vagus – innervates atrioventricular (AV) node

Question 6

What is the result of hyperparasympathetic activity (tone) to the right side of the heart (SA node)?

Answer 6

Sinus Bradycardia

Question 7

What is the result of hyperparasympathetic activity (tone) to the left side of the heart (AV node)?

Answer 7

AV Blocks

Question 8

What is the course of the vagus nerve (cranial nerve 10)?

Answer 8

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

Question 9

What types of somatic dysfunction can affect the vagus nerves?

Answer 9

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.

Question 10

Lymphatics

Answer 10

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

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

Question 11

What are some areas of somatic dysfunction that can negatively affect lymphatic flow?

Answer 11

Thoracic inlet
Respiratory diaphragm
- Lower thoracics
- Lower ribs
- Upper lumbars (psoas major muscle)
Sympathetics

Question 12

Reflexes and cardio

Answer 12

Larson, Beal and Nicholas have reported palpatory changes at T2-T4 on the left with cardiac problems

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

Question 13

Dr Frank Willard – allostatic load

Answer 13

Somatic dysfunction anywhere affects the individual locally and globally (entirely)
Stressors/imbalance that takes them closer to the threshold of symptoms and disease-activates SNS-HPA couple
Somatic dysfunction is frequently associated with 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

Question 14

Epigenetics - do our genes (DNA) just randomly think for themselves?

Answer 14

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

Question 15

What are some negative environmental signals that may have a negative impact on gene expression?

Answer 15

Poor nutrition
Toxic thoughts/mental stress
Physical stress
Environmental toxins
Somatic dysfunction
Others???

Question 16

Hypertension (HTN)

Answer 16

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

Question 17

What determines arterial pressure?

Answer 17

CO, TPR

Question 18

What is the most common cause of hypertension?

Answer 18

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)

Question 19

Renin is synthesized by the juxtaglomerular cells of the kidney in response to

Answer 19

Decreased pressure or stretch within the renal afferent arteriole (baroreceptor mechanism)
Sympathetic nervous system stimulation of renin-secreting cells

Question 20

How can somatic dysfunction contribute to elevated blood pressure and hypertension?

Answer 20

Upper thoracic dysfunction can facilitate increased sympathetic tone to the heart
Increased heart rate
Increased stroke volume

Somatic dysfunction in the thoracic and lumbar regions (especially T6-L2) can facilitate increased sympathetic tone to the adrenal gland and kidney

Question 21

HTN and SD

Answer 21

Will facilitate catecholamine release from adrenal – 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

Question 22

Somatic dysfunction affecting the cranium (SBS compression, occipitomastoid compression affecting jugular foramen), occiput, atlas and remainder of cervical spine may alter

Answer 22

carotid receptor function and contribute to alterations in blood pressure

Question 23

Myocardial Infarction (MI)

Answer 23

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
Most common cause of death within the 1st 24 hours is ventricular fibrillation (50% occur within 1st hour)
Treat them sooner versus later

Question 24

OMM goals with MI

Answer 24

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

Question 25

avoid HVLA after MI

Answer 25

HVLA can cause a short-term increase in sympathetic activity
May result in vasoconstriction of coronary arteries and extend infarct
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)

Question 26

OMM integration after MI

Answer 26

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)
Upper thoracic spine and upper ribs
Thoracolumbar junction
Chapman’s reflexes affecting heart, adrenals and kidneys
Gentler techniques are initially a better option!

Question 27

Heart Failure (CHF)

Answer 27

Clinical syndrome associated with:
Intravascular and interstitial volume overload
Inadequate tissue perfusion
Symptoms
Fatigue and SOB most common
Also see anorexia, nausea, early satiety associated with abdominal pain/fullness, confusion, disorientation, sleep/mood disturbances and nocturia

Question 28

CHF pathogenesis

Answer 28

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

Question 29

The Spiral (CHF)

Answer 29

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

Sympathetic stimulation of kidney 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

Question 30

OMM Integration- the CHF spiral

Answer 30

Goal is to break into the downward spiral
Reduce intravascular and interstitial volume overload (improve renal function)
Improve tissue perfusion
Optimize cardiac function

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!

Question 31

Exercise is a key and improves:

Answer 31

Autonomic nervous system function
Regional blood flow
Endothelial function
Skeletal muscle function
Quality of life
Exercise training can improve exercise duration as much as pharmaceutical agents (digoxin and ACE inhibitors)
We combine exercise, pharmacologic management and OMM for best possible outcomes