Visceral Dysfunction OMT Flashcards
How is visceral pain developed?
Facilitation increases neural excitability at the level of viscera
- this triggers supernumerary impulses from afferent/efferent signals passing through the point of disturbance “cross-talk”
Common visceral pain areas:
- liver = back right kidney
- gallbladder = right scapula and back right shoulder
- stomach = upper middle back (T1-4 roughly)
- appendix = middle abdomen radiating to McBurney point
What are the 4 parts of the body that visceral diseases affect?
Autonomic nervous system
Blood circulation
Lymphatic circulation
MSK system
What is the difference between mobility and motility of the viscera?
Mobility:
- how organs move in response to forces generated outside the organ (peristalsis/cardiac movement)
- example: moves in the 3 planes (sagittal/coronal/transverse) with respect to respiration
Motility: (Barral)
- observation of organs moving in 3 planes with OWN rhythm (not induced by outside forces)
- is controversial and not much evidence backs this up
How does the diaphragm and viscera move with inhalation vs exhalation
Inhalation:
- diaphragm descents
- thoracic/ab contents descend and compress
- increases SVC blood flow but decreases portal vein blood flow
Exhalation:
- exact opposite above
How is the motility of organs affected with inspiration and expiration
Inspiration = moves away form midline
Expiration = moves towards the midline
rate is 7-8 cycles per minute and occurs even when breath is held
Visceral ligaments
Are considered viscoelastic
- when stress is present: deform and creation heat
- when stress is removed: return to normal shape, dissipation of heat and movement of fluid occurs
- increased mechanical tension causes fluid vessels to get compressed in the following order (needs more stress as you move down):*
1) lymphatics = edema
2) veins = congestion and edema
3) arteries = hypoxia
How to test for visceral dysfunctions?
Observation
Auscultation
Percussion
Palpation
- toxicity of cavity wall
- ease-bind of visceral articulations and fascia
- inherent rhythmic motion
- assessment of fascial strain
osteopathic screening exam
- go and treat the AGR area first
Motion testing with viscera
the greatest motion in the viscera is superior-inferior “cardinal movement”
Find ease of direction in superior-inferior
- once its found move the tissues to the “balance” point and then check tissues in left-right plane
- do this again but with counterclockwise-clockwise
Beginners visceral protocol
- narrow the differential down to a specific target organ*
1) treat the appropriate ganglia that corresponds to the organ in question
2) treat any viscerosomatic reflex by working on the vertebral dysfunction associated with the corresponding sympathetic spinal reflex level
3) treat the corresponding Chapman’s point for the viscera if present
4) treat the organ itself with MFR or other techniques
Celiac ganglia controls what organs?
Distal esophagus
Stomach
Proximal duodenum
Liver
Gallbladder
Spleen
Proximal pancreas
Superior mesenteric ganglia affects what organs?
Distal duodenum
Portions of the pancreas
Ileum
Jejunum
Ascending colon
Proximal 2/3 of the transverse colon
Inferior mesenteric ganglia controls what organs?
Distal 3rd of the transverse colon
Descending colon
Sigmoid colon
rectum
Indications for visceral OMT
Visceral dysfunctions with a known medical diagnosis or somatic dysfunction
Contraindications of visceral OMT
Abdominal aneurysm
Visceral ruptures
Internal bleeding
Infections uncontrolled by antibiotics
Severe pain induced by palpation or manipulation
Friability (acute inflammation)
- CD/UC, appendicitis, diverticulitis, hepatitis, pyelonephritis, infectious diarrhea
Non-healed incision or open wound
Pregnancy (uterus or round ligaments only)
Ventral hernias (Linea alba and ganglion releases)
Where do the ganglia of the GI viscera lie?
- all are behind (deep) the superior lines alba
1) celiac = below the xyphoid process
2) inferior mesenteric = just superior to the umbilicus
3) superior mesenteric = half way between the celiac and inferior mesenteric
** if any of the ganglia are dysfunctional, TTA is often appreciated**
What are the two ways to do the superior lines alba/celiac superior and inferior mesenteric ganglia release?
1) release the anterior abdominal musculature and thus improve the function of the muscles
- very indicated when trying to improve breathing mechanics or direct abdominal injuries
2) physically palpate and release the ganglia
- very indicated for visceral disorders where you want to inhibt the nerve activity
cant do either in the cases of ventral hernia presence
Superior lines alba release steps
1) patient supine with doctor standing beside the patient at the level of the epigastric area
2) place hands and fingers perpendicular to the ab muscles (fingertips align the complete middle of the abdomen)
3) keep hands flat, fingers straight and radial deviated wrists while applying increasing posterior pressure until resistance is met
4) once resistance is met, rotate wrists closer together with fingertips spread apart and rapidly -> ulnar deviation
5) wait until tissues relaxed then release
must do this before median umbilical release if you want to do median umbilical release
Median umbilical ligament release indications
UTIs
Chronic cystitis
Release of abdominal musculature
Supra Pubic pain
Urinary frequency
What is the median umbilical ligament a remnant of?
Prenatal urachus
Medial umbilical release steps
1) patient supine doctor at side of table at level of median umbilical ligament
2) place hands and fingers perpendicular to ab muscles and line fingertips along the lines alba halfway between the pubic symphysis and the umbilicus
3) keep hands flat, fingers straight and radial deviation While pressing posteriorly with increasing pressure until resistance is met
4) once resistance is met, rotate wrists to be closer together, fingertips spread apart and ulnar deviation
5) hold until tissues relax and then release
Mesenteric lifts
Remove obstruction in mesentary
Indications:
- bloating
- constipation
- diarrhea (non-infectious
- pelvic/abdominal pain
Contraindications:
- acute bowel obstructions
- acute infectious diarrhea
- ab infections
- tumors
- pregnancy
- patient intolerance
- IBD
Mesenteric lift: sigmoid colon steps
1) patient is supine and physician on patients right side
2) bend patients knees with feet on table to relax abdomen
3) gently apply the heel of your right hand to the inferior portion of the left lower quadrant of the abdomen near sigmoid colon
(Near ASIS just superior to inguinal ligament
4) gently lift sigmoid colon superiorly away from any pelvic entrapment by pushing cephalad and towards hepatic flexure of colon
(Often requires slight clockwise/counterclockwise motion)
5) hold tissues for 90 seconds or until a sense of relaxation is palpated
Mesenteric lift: descending colon steps
1) stand behind the left lateral recumbent patient
2) have patient flex knees and hips slightly
3) use ulnar aspect of your little fingers and press gently into the left lower quadrant of the abdomen
4) gently scoop the abdominal wall and underlying descending colon towards its mesenteric attachment by leaning slightly backwards
- don’t force and if pain is noted stop
- sometimes need to apply slight clockwise/counterclockwise fashion
5) hold tissues gently for 90 seconds or until tissues relax
Mesenteric lift: ascending colon steps
1) stand behind the right lateral recumbent patient
2) patient flexes knees and hips slightly
3) gently apply the ulnar aspect of your little fingers into the right lower quadrant of the abdomen
4) gently scoop the abdominal wall and underlying ascending colon by leaning slightly backward
- dont force tissues and if pain is present stop
- sometimes apply clockwise/counterclockwise motions
4) hold tissues gently until sense of relaxation is palpated or 90 seconds pass
Mesenteric lift: cecum steps
1) patient supine, physician on right side
2) patient flexes knees with feet placed on table to relax abdomen
3) gently apply the heel of your hand to the inferior portion of the right lower quadrant of the abdomen
4) gently lift cecum superiorly away from pelvic entrapment by pushing towards hepatic flexure
5) hold tissues for 90 seconds or until release is palpated
Mesenteric lift: small intestine
1) patient supine, physician at patients right side
2) flex patients knees with feet placed on table to relax abdomen
3) gently apply the ulnar aspect of little fingers into right lower quadrant (NOT DEEP, should be more superficial than descending colon lift)
4) gently scoop the abdominal wall and underlying loops of small intestine toward their mesenteric attachment (direction of umbilicus and hepatic flexure)
5) hold tissues for 90 seconds or until relaxation is palpated
What regions of the thoracic and abdomen get parasympathetic reflexes from the S2-S4
Distal 1/3 of transverse colon through rectum
Ureters
Bladder
Ovaries/testicles
Uterus
Prostate
**everything else gets vagus Parasympathetic reflexes
