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