OPP considerations in CV Flashcards
Where does the sympathetic innervation of the heart have its origins?
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)
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.
Lymphatics
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
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
Reflexes and cardio
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
Dr Frank Willard – allostatic load
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
Epigenetics - 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???
Hypertension (HTN)
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?
CO, TPR
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 the juxtaglomerular cells of the kidney 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
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
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
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
Myocardial Infarction (MI)
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
OMM goals with MI
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
avoid HVLA after MI
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)
OMM integration after 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)
Upper thoracic spine and upper ribs
Thoracolumbar junction
Chapman’s reflexes affecting heart, adrenals and kidneys
Gentler techniques are initially a better option!
Heart Failure (CHF)
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
CHF pathogenesis
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
The Spiral (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
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
OMM Integration- the CHF spiral
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!
Exercise is a key and improves:
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
