Osteopathic Considerations of the Pelvis in Lower GI Complaints

1. Osteopathic Considerations of the Pelvis in Lower GI Complaints Developed for OUCOM CORE By the CORE Osteopathic Principles and Practices Committee Session #3 – Series A

2. What is the autonomic nerve supply to the lower GI tract? Somatic dysfunction of what areas of the body have the greatest impact on dysfunction of the gastrointestinal system? Does the patient have short leg syndrome? Lower GI Complaints

3. Devise a treatment plan encompassing: Psychosocial issues Diet modifications if applicable Manipulative treatments Pharmacotherapy Exercises to be done at home by patient Lower GI Complaints

4. Osteopathic manipulative treatment is directed toward: Improving blood flow Improving lymphatic flow Balancing autonomic impulses to and from the bowel Somatic Dysfunction

5. Usually associated with facilitated segments at T10 – T11 for right half of colon T12 – L2 for left half of colon Produce viscerosomatic reflexes which increase thoracolumbar para spinal muscle tension Sympathetic Hyperactivity

6. Sympathetic Innervation of the GI tract

7. Autonomic Innervation • Innervation of each viscus • generally follows the course of • the arterial supply. • Sympathetic supply: • Prostate & Prostatic Urethra: T11-L1 • Testis & Ovary: T10-11 • Ureter: T11-L2 • Urinary Bladder: T11-L2 • Uterus: T12-L1 • Uterine Tube: T10-L1 • Source: British Gray’s, p. 1306 British Gray’s Anatomy 38th Ed., p.1293

8. Sympathetic Ganglion Located in midline of abdomen, superior to the umbilicus Indicates sympathetic hyperactivity to the colon Sympathetic Hyperactivity Ileus Constipation Abdominal distention Flatulence Inferior Collateral Sympathetic Ganglion w/ Sympathetic Hyperactivity

9. Normalization of parasympathetic activity may be useful to treat: Colitis Crohn’s disease Irritable bowel syndrome Idiopathic diarrhea Parasympathetics

10. Parasympathetic Innervation • Left side of Colon • Supplied by pelvic splanchnic nerves • Origin from cord segments S2,3,4 • Right side of Colon • Supplied by the vagus nerve • Also lesser curvature of stomach, liver, gallbladder and all of the small intestine

11. Parasympathetic Activity • Hyperactivity: • Increases bowel motility and glandular secretions • Associated with diarrhea • Hypo activity: • Decreased bowel motility and glandular secretions • Associated with constipation

12. Chapman’s Points • Viscerosomatic Myofascial Tenderpoints • Anterior Chapman’s points are used to diagnose colon dysfunction: • Tender, palpable fascial ganglioform nodulations • Initiated by tissue inflammation or irritation • Located on lateral side of the thighs in the anterior half of the iliotibial bands • From greater trochanters to the lateral epicondyles of the femur

13. Colon Chapman’s Reflexes: GI Group • Located between the ASIS & the Greater Trochanter • Specific for Atonic Constipation • Evaluate thyroid, liver & spleen, as well Owens, An Endocrine Interpretation of Chapman’s Reflexes

14. Colon Chapman’s Reflexes: GI Group • Along the anterior aspect of the iliotibial band distribution: • Trochanter to • Within 1” (2.5 cm) of the patella Fig. 67.2, p.1053, Foundations 2nd Ed., 2003

15. One or both thighs - ‘Just superficial to the deep fascia or slightly adherent to it.’ Presentation: Single Multiple ‘Coalescent mats or even ‘strings of pearls’ (chronic or severe cases) Colon Chapman’s Reflexes: p. 1053, Foundations, 2nd Ed.

16. Manifestation of hyperactivity of both parasympathetic and sympathetic systems Irritable Bowel Syndrome

17. Somatic Dysfunction leads to: Increased interstitial fluids and tissue congestion Edema in tissue of the mesentery can exert pressure on the thin walls of the lymphatic and venous channels Results in accumulation of waste products, reduced oxygenation, and decreased nutrition to cells Lymphatics

18. Potential Consequences: Increases the colon’s susceptibility to inflammation and infection Increases the healing time in stress phase of colon Increases likelihood of scarring Can worsen the prognosis in colitis or Crohn’s disease Lymphatics

19. Visceral lymph nodes lie close to the organ which they drain • Then drain through chains of parietal nodes along the path of the major arteries & veins Clemente, Fig. 235

20. Thoracic diaphragm function should be evaluated and treated because it can restrict the thoracic duct Pelvic diaphragm must be evaluated and treated Moves passively and synchronously with thoracic diaphragm Lymphatic Congestion

21. Pelvic diaphragm function can be influenced by sacral and pelvic function. Today we will focus upon pelvic dysfunction and its contribution to fluid congestion, as well as sub-optimal parasympathetic function. Pubic & Innominate dysfunction change tensions in the urogenital diaphragm and the levator ani. Thus fluid congestions may be augmented by decreased tissue motion Pelvic Dysfunction

22. Parasympathetic changes occur with suboptimal sacral motion and the increased tensions in the pelvic tissues Sympathetic changes for the same reasons especially around the sacral sympathetic chain and the ganglion impar at its end. In summary, innominate dysfunction can influence: Fluid congestion Parasympathetics Sympathetics Pubic & Innominate Dysfunction

23. The treatments that follow all have in common the use of the hip joint. Corrective force is brought into the innominate via the accumulation of focused tension through the capsular ligaments of the hip joint. This creates the vector of force to normalize the dysfunction. OMT with Hip Joint • Participants can evaluation and treat their partners taking turns with the techniques that follow. • Practice can immediately follow the review of each slide.

24. Superior and Inferior shearing mechanics seen with pubic dysfunction Seen post partum Also seen in strenuous use of adductor muscles of thighs or trauma Symphysis Pubis

25. Superior Pubes • Physician uses the shoulder to compress from the knee toward the acetabulum • Physician internally rotates the lower extremity • The monitoring finger can feel the pubes descend

26. Inferior Pubes • Compression is again the first step • Followed by external rotation of the lower extremity to carry an inferior pubes superior. • The monitoring finger can feel the pubes ascend.

27. Innominate: Rotated Anterior • Caudad Hand: Holds knee to maintain eversion at the hip. • Cephalad Hand: Directs force on the ASIS superior and posterior • Patient: Gently and slowly carries the foot along the medial aspect of the opposite leg until straight.

28. Innominate: Rotated Posterior • Same technique, except • Cephalad Hand: contacts the ischial tuberosity and carries it superior/posterior

29. Innominate Outflare • Compress through the knee toward the hip • Carry the knee medially and the ankle laterally • Vary the flexion at the knee and hip to localize the force toward the ASIS

30. Innominate Outflare • Compress through the knee toward the hip • Carry the knee medially and the ankle laterally • Vary the flexion at the knee and hip to localize the force toward the ASIS

31. Innominate Inflare • Forces are reversed • In both cases the accuracy of force localization is key • Knee flexion/extension adjustment will help the localization process

32. Assess for spasm or asymmetry related to prior surgery involving lower sigmoid, rectum and anal areas Funnel shaped muscle attaching to lateral walls of the true pelvis Angles inferior and medially to attach to the urogenital diaphragm and midline structures of the urogenital and anal triangles Innervated by pudendal nerve originated from sacral roots S2,3,4 Pelvic Diaphragm

33. Pelvic Diaphragm • Looking forward from the posterior right aspect • View of the ischiorectal fossa – • Reasonably direct access to one hemi-diaphragm of the pelvic diaphragm. • The thoracic diaphragm can be monitored for synchrony of motion between the two – • pelvic & thoracic Moore, Clinically Oriented Anatomy, 4th Edition, 1999, p.400

34. Osteopathic treatment of the lower GI tract involves evaluating the patient’s entire health - Nutritional status, psychological stress Somatic influences on the pelvis must be evaluated and treated - Short leg syndrome, lumbar & sacral strain/sprain, post-partum considerations, innominate upslip The potency of further therapy hinges on the manipulative treatment. - For antibiotics to be fully effective, blood flow and lymphatic drainage must be optimized Summary

35. Kuchera, Michael L. and Kuchera, William A., Osteopathic Considerations in Systemic Dysfunction. 2nd Edition, 1994. p 94 – 116. Ward, Robert C., ed. Foundations For Osteopathic Medicine. Lippincott Williams & Wilkins. 2003. p 762-783. Yates, Herbert A. Counterstrain: A Handbook of Osteopathic Technique. Y Knot Publishers. 1995. References