Visceral Dysfunction OMT

Question 1

How is visceral pain developed?

Answer 1

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

Question 2

What are the 4 parts of the body that visceral diseases affect?

Answer 2

Autonomic nervous system

Blood circulation

Lymphatic circulation

MSK system

Question 3

What is the difference between mobility and motility of the viscera?

Answer 3

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

Question 4

How does the diaphragm and viscera move with inhalation vs exhalation

Answer 4

Inhalation:

• diaphragm descents
• thoracic/ab contents descend and compress
• increases SVC blood flow but decreases portal vein blood flow

Exhalation:
- exact opposite above

Question 5

How is the motility of organs affected with inspiration and expiration

Answer 5

Inspiration = moves away form midline

Expiration = moves towards the midline

rate is 7-8 cycles per minute and occurs even when breath is held

Question 6

Visceral ligaments

Answer 6

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

Question 7

How to test for visceral dysfunctions?

Answer 7

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

Question 8

Motion testing with viscera

Answer 8

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

Question 9

Beginners visceral protocol

Answer 9

• 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

Question 10

Celiac ganglia controls what organs?

Answer 10

Distal esophagus

Stomach

Proximal duodenum

Liver

Gallbladder

Spleen

Proximal pancreas

Question 11

Superior mesenteric ganglia affects what organs?

Answer 11

Distal duodenum

Portions of the pancreas

Ileum

Jejunum

Ascending colon

Proximal 2/3 of the transverse colon

Question 12

Inferior mesenteric ganglia controls what organs?

Answer 12

Distal 3rd of the transverse colon

Descending colon

Sigmoid colon

rectum

Question 13

Indications for visceral OMT

Answer 13

Visceral dysfunctions with a known medical diagnosis or somatic dysfunction

Question 14

Contraindications of visceral OMT

Answer 14

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)

Question 15

Where do the ganglia of the GI viscera lie?

Answer 15

• 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**

Question 16

What are the two ways to do the superior lines alba/celiac superior and inferior mesenteric ganglia release?

Answer 16

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

Question 17

Superior lines alba release steps

Answer 17

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

Question 18

Median umbilical ligament release indications

Answer 18

UTIs

Chronic cystitis

Release of abdominal musculature

Supra Pubic pain

Urinary frequency

Question 19

What is the median umbilical ligament a remnant of?

Answer 19

Prenatal urachus

Question 20

Medial umbilical release steps

Answer 20

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

Question 21

Mesenteric lifts

Answer 21

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

Question 22

Mesenteric lift: sigmoid colon steps

Answer 22

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

Question 23

Mesenteric lift: descending colon steps

Answer 23

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

Question 24

Mesenteric lift: ascending colon steps

Answer 24

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

Question 25

Mesenteric lift: cecum steps

Answer 25

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

Question 26

Mesenteric lift: small intestine

Answer 26

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

Question 27

What regions of the thoracic and abdomen get parasympathetic reflexes from the S2-S4

Answer 27

Distal 1/3 of transverse colon through rectum

Ureters

Bladder

Ovaries/testicles

Uterus

Prostate

**everything else gets vagus Parasympathetic reflexes