visceral manipulation. dr. jac k dol bin dc ses sion 1

Visceral Manipulation

Dr. Jack Dolbin DC Session 1

How we heal/ Why we fail

Patient: All tissue heals relative to oxygen delivery/ circulation

Dr. Jack Dolbin DC Session 1

Well vascularized tissues are in general resistant to infection and capable of localizing and containing offending agents.

Robbins Pathology: third edition: Pg 51

Motivation

Work Comp Study: Cassidy

Number one predictor: Physical condition of patient.

Employer relationship

Dr. Jack Dolbin DC Session 1

Cardinal Principles

DietRestExerciseBlood SupplyNerve SupplyStress Management

Dr. Jack Dolbin DC Session 1

Fitness in Children

Decrease in absentismDecrease in drugs and gang activityGrades improved ass fitness improvedA. 50% increase in fitness=50%

improvement in gradesChildren obese at age 4 had a 30% lower

IQ scores in adolescenseBrain of fit children has a bigger

hippocampus

Dr. Jack Dolbin DC Session 1

Fitness ( cont )

Adults who exercise 4x wk/40 mimutes delayed onset of cognitive decline by 20-25 years.

Women who walk 8 hours/wk. lower Fx risk by 67%

Obesity in toddlers:Lower IQ scoresCognitive delaysBrain lesions

Increase fitness decrease violence by 67%

Dr. Jack Dolbin DC Session 1

Dr. Jack Dolbin DC Session 1

Mobility: Movement related to outside forces. IE: Diaphram

Motility: Internal Movement of a structure. IE: Peristalsis

Turgor: Viscera will totally occupy the available space.

Donald Ingber MD, Ph. D

The current focus on molecular genetics

ignores the physical basis of disease even though many of the problems that lead to pain and morbidity and bring patients to the doctors office result form changes in our tissue structure and mechanics.

Donald Ingber MD, Ph.D

….A wide range of diseases included within all fields of medicine share

a common feature: Their etiology or clinical presentation result from abnormal biomechanics

Ingber ( Cont.)

Most of the clinical problems that bring a patient to the doctors office result from

changes in tissue structure and mechanics

Motion is Life

Ingber

Abnormal cell and tissue responses to mechanical stress may actively contribute to the development of many diseases and ailments.

Thus it may be wise to search for a physical cause when chemical or molecular forms of investigation do not suffice

When properly utilized, manipulative procedures have been noted to reduce pain, Increase the level of wellness, and in helping

the patient with a myriad of disease processes.

Philip Greenman DO, Professor of Biomechanics

Michigan State University School of Osteopathic Medicine

The musculoskeletal system comprises most of the human skeleton and alterations within it influence the rest of the human organism.

Our role as physicians is to treat patients and not disease.

Deep Fascia: Three diminsional sensory organ. 10 times the concentration of nerve endings as muscle tissue.

Holistic Man

Most highly developed nervous system in the animal kingdom.

All functions of the human body are under some form of neurologic control.

Control of all glandular and vascular activity is under the control of the ANS.

Neuroendocrine Control: Substance P, endorphines, enkephalines, and neurotransmitters can be altered by biomechanical alterations

Alterations in neurothropin transmission can be detrimental to the health of target cells.

Neurologic Man

Formed by lower motor neurons in the lateral horns of C2-C4

Ascends through the foramen magnum, receives fibers from the nucleus ambiguous and decends along the jugular foramen.

Sends branches to the Vagus Nerve

Has SVE and GSE. Thoracic branches matched to vagus innervation of the embryonic heart.

Spinal Accessory Nerve

Anything that interfered with with sympathetic autonomic nervous system

outflow, segmentally mediated, can influence vasomotor tone to the target end organ.

Maximal function of the musculoskeletal is important to the efficiency of the circulatory system and maintainance of a normal cellular milieu.

Circulatory man

Restriction of one major joint in the lower extremity increase the energy expenditure in walking by 40%, two major joints in the same extremity 300%.

Multiple minor restriction of movement, especially in the lower extremity gait can have a detrimental effect on the total body function

Energy expending man

The goal of the physician should be to enhance all the body’s self regulating mechanisms to assist in the recovery from disease. ( injury).

One in seven hospital days are the result of adverse reactions to pharmaceuticals.

The drug eventually becomes the disease.

Anything placed with in the body alter the self regulating mechanism.

Self-Regulating Man

Silent Killer

Chronic Stress: hypothalamus increase ACTH from Pituitary. ACTH causes increase catecholamines( Epinephrine-Cortisol).

Increase Cortisol: decrease immune system, decrease DNA repair, increase autoimmune mechanisms.

Increase cateholamines damages HT muscle, damages vessel walls, increase CHO, increase platelet clumping.

Damages neurons in Hippocampus

Dr. Jack Dolbin DC Session

Increased hippocampal atrophy is seen in patients who:

A. abused as childrenB. long term depression or prolonged griefC. PTSD

Bottom Line: Not the stressor but the individuals response to the stressor.

Effects function of Viscera

Dr. Jack Dolbin DC Session 1

The physiological process where cells sense and respond to mechanical loads.

Various forms of exercise and or movement prescription promote repair and remodeling of tendon, muscle, articular cartilage and bone.

Mechanotransduction: Maintains normal musculoskeletal structure in the absence of injury. Homeostasis

Mechanotherapy: Treatment of injuries using exercise prescription or manual therapy

Mechanotherapy

The process where the body converts mechanical loading into cellular response.

Three phases:A. Mechanicalcoupling: TriggerB. Cell-Cell communication:communication

throughout a tissue to distribuite the loading message.

C. Effector response:Response at the cellular level to effect the response that will produce the necessary materials to correct alignment.

Mechanotherapy

Fascia: Three dimensional Sensory Organ

What does manipulation really do?

Philosophy or Science ?

Philosophy based on Science

Soapbox Exaggeration

If a suitable kind of stimulation of the skin or muscle at the appropriate spinal segment level is selected, all these visceral functions can be reflexly affected by cutaneous or muscle stimulation

Scott Haldeman DC, Ph.D, MD

Dr. Jack Dolbin

DC Session

1

Or Science

When properly utilized, manipulative procedures have been noted to reduce pain, Increase the level of wellness, and in helping the patient with a myriad of disease processes.

Philip Greenman DO, Professor of Biomechanics

Michigan State University School of Osteopathic Medicine

The Adjustment

Is it local or global?

1. Activates Mechanoreceptors: Activates Primary sensory neurons, motor control system, pain processing. Reflexly elict sympathetic nerve activity

2. Releases Deep Fascial Adhesions: Mechotherapy.

3. Reverse Central Pathway Changes4. Increase Nerve Root Firing

What does the Adjustment Really do.

Mobilize1. Activates the Kinesthetic Receptorsa. Ruffini Type Joint Receptors: Stimulates

strongly when the joint is suddenly moved. Thereafter a steady signal

B. GTO type receptors in the Ligaments: same receptor qualities as Ruffini Corpusles.

C. Pacinian: Rapid response to detect rate of movement: Proprioceptive afferents= Muscle response.

Increase TNF alpha: Immune system: Homeostasis.

Reduction of proinflammatory cytokinesIncrease immune system responseStimulates areas in the CNS: hypoalgesiaPositive changes in HT rate: BP: Resp:Skin

conductivity

Dr. Jack Dolbin DC Session 1

Spine J Sept- Oct. 2002 Neurophysiological Effects of Spinal manip.

J. Electmyog. Kinesio 2012 )ct.22 Spinal Manipulative therapy and Somatosensory Activation

Clin Biomech. 2006 Mar Spinal Manipulation and duration affect vertebral movement and neuromuscular responses

Man Ther 2008, Oct 13: Evidence for a Central Nervous System component in the response to passive cervical joint mob.

References

Leon Chaitow DO, ND

Any modality that incorporates application of pressure, shear forces, movement and stretching is working on fascial structures whether the therapist is aware of this or not.

Gentle and precise manipulation elicits an internal sensory feed back response designed to stimulate the body’s self correcting mechanism.

Speak to the brain through the joint or tissue.

Jean- Pierre Barral, DO

Causes of Organ Movement

Mobility

Diaphramatic movement: Most important driver of mobiity

Kidney moves 2.5-3cm. In a day 600-700 meters/day

Articulate against each other

Example Liver

The liver articulates with the upper pole of the kidney

Ist part of duodenum

Assending colon

Diagnosis: Rule out major pathologies

Tests for mobility and motility

Mobility: movement in response to outside forces: tested in all three planes

Motility: Intrinsic movement of organ. Independent of diaphramatic action

Four Major Cavities

Cranium +15 cm/water

-Thorax – 5cm/water

Abdomen +15cm of water

Pelvis +30cm/water

Due to negative Thoracic pressure the abdominal organs are pulled superiorly.

Liver weights 1.5-2KG: effective weight 400g

Reasons for visceral restrictions

Trauma

Infections

Surgery

Emotional reactions

Organ Systems

Composed of highly differentiated tissue and require an elaborate support system for their maintanance.

A. connective tissue composed of

irrregularly arranged collagen and elastin embedded in a glycoprotein matrix…….Fascia.

Four Fascial Layers

Pannicular fascia: Superficial

Axial and Appendicular: Deep or muscular

Meningeal: Investing the CNS

Visceral or Splanchnic: Surrounding body cavities and packing around internal organs.

Continuity of visceral fascia

Nasopharyngeal fascia

Cervical

Thorax and abdominal

Levator ani and pelvic region

Function of Visceral fascia

Provides the packing tissue for the midline structures of the body.

A. Forms a column from the 1. Cranial Base2. Through the cervical region3. Into the thorax4. Occupies the mediastinum

Visceral Fascia

Extends from the cranial base to the pelvic basin

Most complex of the four layers

Into this layer the pleura, pericardial, and peritoneal expand in size- Turgor.

As expansion occurs the visceral fascia becomes compressed against the body wall and consolidated medially.

Invested in Fascial layers

A. Mediastinal region:1. Major vasculature: Aorta, Vena

cava,Thoracic duct, Great abdominopelvic plexus of autonomic nerves.

These structures and their branches become invested in fascial layers which accompany neurovascular bundles as they extend outward to reach individual organ systems.

At the Diaphram:A. Passes through the aortic and

esophageal openings to enter the abdomen.

B. Decends through the abdomen into the pelvic basin to form a continuation of the mediastinum.

Pelvic Basin: Visceral fascia surrounds midline structures.

Visceral Fascia

Four Layers

1. Muscular layer ( parietal layer)2. Neurovascular sheath3. Organ Fascia4. Fascia underlying pleura and peritoneal

linings.

Lesional Chains

A restriction: Detrimental Effect on all surrounding structures and affects the axis of motion and force lines in the body.

Does not remain isolated: Loses its distensibility and, gives rise to membranous restriction.

Trauma or inflammatory disease.

Restriction

Affects the axes of motion of organs

Affects the directions of force lines in the body

These tissue restrictions are the beginning of lesional chains

Injured tissue doesnot remain isolated

Membranous Restrictions

Organs attachments lose their usual distensibility and give rise to membranous restriction or lesions

Cause: Direct or indirect trauma or inflammation

Result of Restrictions

Pressure, Mobility, Motility and other forces are poorly transmitted through a restriction.

Result: Disturbance in both local and whole-body membrane systems

Replacement of orderly process with mechanical problem.

Result of Imbalances

Follow the Laws of Compensation and adaptation.

When all the adaptive process have been exhausted symptoms appear.

Due to lesional chains symptoms can appear at distant sites

Excretion/Secretion

Best results on organs with an excretory canal

Gallbladder, common bile duct, pylorus, Bladder, uterine tubes

Best Technique: Stretch along longitudinal axis

Anchor proximal-Push distal.

Reflex Zones

Junction Zones between different parts of the digestive tract. Sphincter Zones

Manipulation of these junction zones has a rapid effect on spasms and visceral pain.

Rapidly affects the digestive systemEx: Pylorus

Sphincter Zones

1. Upper Esophageal Sphincter2. Gastroesophageal Junction3. Pyloris4. Sphincter of Oddi/ Gall Bladder5. Duodenaljejunal Flexure6. Ileocecal juncture7. Sigmoid Colon

Nervous System

Without the nervous system manipulations will not work.

Manipulation transmit messages via sensory nerves.

Tension, pressure, volume

Diagnostic Tests

General Listening

Tissue that loses its elasticity becomes the new axis or pivot point for motions of mobiltiy and motility.

On Palpation hand will be drawn to dysfunctional area.

Listening

Example: Liver Tense as in hepatitis it will

attract the right pleura. Right lung,

attachment to right cervical spine

Diagnostic Angle

Adams Position

Side Bending

Angle is the area of restriction

Correlate this will associated viscera

Inhibition Points

Gently pressing on a restriction will inhibit its effect on the rest of the body.

Glenohumeral Articulation Test

Example C5/C6 or R7 with Shoulder abduction/external rotation

Liver: abduction/external rotation of shoulderBirth control pills, alcohol abuse, hepatitis

Shoulder

Often reflects visceral pathologies

Right side: Hepato-biliary system, Head of pancreas

Left Side: Heart – body and tail of pancreas

Local Listening

Restriction in inspiration: Organ

Restriction in Expiration: Problem of fluid evacuation

Identify lower extremity restriction by palpating abdomen

Dorsiflexion of foot: side of faster dorsi flexion is side of restriction

Pressure, Mobility, Motility

Poorly transmitted through a restriction with resulting disturbance of the balance of both local and whole body membrance systems.

Lost tissue elasticity: causes general mechanical problems.

Adaptations

When adaptive process has been exhausted symptoms appear

Due to lesional chains symptoms can appear at distal sites.

All restriction whether articular or soft tissue have a global effect

Treatment

Direct contact in the supine position with the goal of freeing the fixed planes identified in the examination.

Take to barrier and use the inspiration and exhalation to free the restriction.

May also use indirect method

Finish with induction technique

Critical Zones

Gall Bladder

Sphincter of Oddi, Pancreatic Ducts

Esophogeal and Pyloric Sphincter

Duodenal Jujunal/Iliocecal Junction

Sigmoid

Critical because when they are tight the function of the body is significantly impaired

Goal of Visceral Manipulation

Emphasis is not on alignment but on mobility

The goal is to restore normal motion around the normal axis of rotation.

This translates into normal function

Treatment Methods

Direct Manipulation

Indirect Manipulation

Recoil Manipulation

Induction

Law of Least Action

Maupertius: The quantity of action necessary to effect any change is the least possible, the decisive amount is always the minimal, the infintesimal.

Maximum precision/ Minimal force

Dr. Jack Dolbin DC Session 3

Diagnosis

After we eliminate pathology look for functional disorders.

All visceral examination begin with the spine.

A. Segmental DysfunctionB. Altered Tissue Texture

Begin Exam with the spine

Palp for alterted tissue texture: Viscerosomatic reflex

Note angulations in lateral flexion

Make corrections:

Co/C1-C7/T1-T12/L1-L5/S1 Major areas

Diagnostic Angle

Spinal Evaluation

Palpation: Highest intertester evaluation for subluxation

Range of Motion: Look for angulation.A. Bending form an angulation at the site of

restrictionB. Angle between Cervicothoracic and

thoracolumbar

Evaluation

Head and Neck.

Look for restriction in Cranial motion: Inspiration/ Exhalation: Spehnoid bone.

Suboccipital: GlabellaCarotidsLigments that attach to lung pleuraOmohyoid Muscle: Hyoid BoneErbs PointAdsons-Wrights Test

Cranial Region

Includes the pharyngealbasilar and pharyngealbuccal fascia

Fuses at the cranial baseCranial visceral fascia extends inferiorally

into the neck, nasopharynx, oropharynx, and cervical visceral.

Summary: A continuous visceral sleave from the hyoid muscles, anterior to the longus muscles, extending into the thorax.

Omohyoid Muscle

Treatment

Sphenoid Bone to release Cranial Fixations

Glabella Contact to facilitate Internal/external cranial rotation.

Hyoid Bone and tracheal mobilty Technique

Thoracic Viscera

Acomodates the two pleural cavitiesViscerally fascia expands to form the

packing substance of the mediastinumSurrounds the great vessels and becomes

the pericardium anteriorlyPosteriorly surrounds aorta, esophagus,

trachea, primary bronchi and thoracic ductSurrounds the bronchi and septa of lung

Access motion from pleural ligaments

Inferior border of lung at 6 th rib

Costodiaphramic 6-8th rib

T 12 most important: Where peritoneum and pleura joint.

Palp and mobility tests:

Supra clavicular region: Rotate patients head to side bring tested

Look for side with maximal tension: use inhalation/exhalation

In seated position: Evaluate elasticity of movement. Look for side of limited mobility.

Use inhalation/exhalation

Adsons/Wrights test.

Test for mediastinal space

Side posture: Hands on sternum and posterior T – spine.

Use Inhalation / exhalation to determine motion deficit

Supine: Hands in opposition on sternum.A. Recoil Tech.

Consists of hard frame and internal organs

First treat external parts of thorax

Only then treat internal organs

Techniques

Supine: Head in Flexion-Hand on Sternum. Treating cervical/pleural ligaments.

Hands on posterior Occiput and Clavicle. Use inhalation/exhalation.

Sternal Recoil Tech

Recoil

Abdominal Visceral Fascia

Visceral fascia spreads out to surround the peritoneum: endoabdominal fascia posteriorly and transversalis fascia anterioraly.

Endoabdominal fascia forms a vertical column analogous to the mediastinum.

Covers the major vascular and neural channels such as the abdominal aorta, inferior vena cava.

Peritoneum

Greater Omentum

Parietal Peritoneum: Restriction will disrupt the cohesion and functioning of the abdominal organs.

Extensions of the abdominal mediastinal fascia pass into the mesogastrium, mesentary, and mesocolon to reach the visceral organs of the abdomen.

Along this pathway blood supply, innervation, and lymphatic channels reach the peritoneal organs of the abdomen,

Posterior Abdominal Fascia

Surrounds the kidneys

Gerota’s fascia

Perirenal fascia blends with the axial fascia of the Psoas muscle and Quad Lumborum

Pelvic Visceral Fascia

Endoabdominal fascia is contiinuous with the endopelvic fascia: surrounds the inferior region of the peritoneum.

Inferior border is the pelvic diaphram.PD lines with axial fascia from the

somatic wall.Anterior and posterior border of the

Endopelvic fascia fills the retropubic space and bladder.

Visceral endopelvic fascia surrounds the midline organs, rectum, reproductive organs, and bladder.

At the sacral prominence it surrounds the hypogastric plexus, common iliac artery and lymphatic channels

Surrounds midline organs.

Serves as a conduit from which the major organ systems receive their blood supply.

Visceral fascia envelops the core of the broad ligament and tranverse cervical ligament of the uterus.

Posterior lateral bands then reach the sacro uterine ligaments that reach the back to the sacrum and underlie the prominent rectrouterine folds

Visceral Ligaments

Function to carry blood supply and innervation to an organ system or to loosly anchor an organ in the body cavity.

Visceral ligaments need to be distinguished from fibrous adhesions that develop secondary to irritation and inflammation.

Ligaments

Fibrous Adhesions

Derive from areas of chronic inflammationImmune system cytokines generate

additional collagen. Irregular collagen and when excessive

form adhesions in viscera of the abdomen and pelvis and may obstruct movement withing its lumen.

Can interfere with reproductive function

Summary

Visceral fascia can be traced from the cranial base into the pelvic cavity.

Forms the packing surrounding the body cavities where it is compressed against the somatic wall.

Forms the packing around visceral organs by passing along suspensory ligaments.

Forms a conduit for the neuro vascular and lymphatic bundles as they radiate outward from the thoracic, abdominal, and pelvic mediastinum.

Referal Patterns

Liver

Liver

Liver

Liver

Upper part of abdominal cavity

Situated behind Rib Cage

Largest gland in digestive system

Produces Bile

2KG

Containes 500-1000 grams of blood

Major organ for detox

Moves in relation to diaphramatic action

Superior border diaphram ,inferior border pelvic cavity

Right to left hypochondria

Mobilize Liver in side posture, Supine Position, Seated Position.

Move in all planes using the inspiration exhalatiion

Finish with recoil Tech.

Indications for Liver treatment

Trauma

Affects the suspensory mechanism of the liver

Spinal Relationships: C4/C5 T8/T9 Right

Recurrent Thoracic problems

Muscle fatigability

Problems associated with digestive problems

Headaches

General Fatigue

Immune system: Cronic bronchitis, Colds, Chronic diseases

Gall Bladder and Bile Ducts

G

Manipulate the Gall Bladder under the intercostal margin.

Common Bile duct in midline

Sphincter of Oddi

Indications for Gall Bladder

C4/C5-T7 with 7th rib

Reflex point at the superior angle of right scapula

Pain in Rt Hypochondrium

Fat and sugar intolerance

Chronic Headache, Fatigue, Depression

Pancreas and Spleen

Spleen

Location

Left upper quadrant of the abdomen at the level of the 9th to 11th rib

Axis parallel to 10th rib

Articulates with the stomach

Left Kidney

Left decending Colon

Function of spleen

Important component of immune system

Forms antibodies, lymphocytes, plasma cells

Filters out erythrocytes

Stores blood to be released if necessary

Spleen cannot be palpated unless diseased

Look for ligamentous tension

Treat in Seated position using medial and lateral motion

Supine position: Knees flexed using lateral motion.

Combined Manipulation in supine.

Knees bent, Contact spleen and move in rotation

Relation T9-T10

Non specific digestive problems

Fatigue related to anemia

Indication:

T 9-10 on left

Lethargy and fatigue: anemia

Pancreas

Most important digestive gland

Head, body, tail

Positioned with sphincter of oddi in a posterior angle

Located transversely in retroperitoneal space of the upper abdomen

Functions

Secretes enzymes for digestion, primarilly proteins.

Islets of Langerhans manufacture and secrete insulin

Indications for treatment

Severe Trauma

MVA’s

Blow to back

Falls on back

Relationship to T9

Type 1 diabetic Study

Treat by treating sphincter of Oddi, Common Bile duct

Never use a direct technique on the Pancreas

Use induction technique

Adjust T-9.

Esophogeal/ stomach

Stores food

Secreates gastric juices

Destroy bacteria

Prepares food for digestion

Palpate for mobility

Superior gastric entrance

Gastric Fundus

Pyloris

Treat to mobilize in left lateral recumbent position.

Mobilize in all planes: Mobilize at costal margins

Mobilize at Pyloris

Adjust C5/6, T5/6 T11/T12

Stomach and duodenum

Pyloric Flexure

Treat at Esophageal/ Stomach and Pyloric Sphincter

JeJunoileum and Colon

Kidneys

Located Retro peritoneal

Connected to diaphram, Liver, duodenum,Ascending and tranverse colon

Related to Psoas Muscle

Locate Rt Kidney at line with umbilicus at 3 finger widths above.

Hypothenar eminence move in superior and inferior direction

Lt Kidney a bit higher.

Treat in lateral recumbent position using a/p movement

Recoil Tech in supine position

Adjust T12-L1 SI Jts T7