OMM: Clinical Application in the GI System

00:00 So, there are different clinical applications that we could apply osteopathic manipulation to in terms of GI presentations. So, irritable bowel syndrome is one. Irritable bowel syndrome is a presentation where patients come in with complaints of potential abdominal pain, nausea, alternating diarrhea, constipation. The etiology tends to be not very clearly defined but there are some neurologic and possible muscular components to the disease process. There definitely are effects to the autonomic nervous system. There are increased risk factors with patients with anxiety, depression, personality disorders, there may be history of childhood sexual abuse or domestic abuse in women. So, irritable bowel syndrome is a set of symptoms. It really needs to be a diagnosis that you make after you excluded all the potential causes. There are autonomic nervous system effects. Sympathetic nervous system tends to shut down the GI system and so there is potential for parasympathetic rebound, overcompensation so there is pretty much an unbalance of the sympathetic and parasympathetic systems and this then leads to varying symptoms that the patient may have. So, remember to take a thorough history with your physical exam, osteopathic structural exam to help you with finding the potential somatic dysfunctions that could help in these cases. So, with potential osteopathic structural findings you want to check for any possible facilitation especially in the thoracic spine, upper lumbar. Looking for Chapman points could also potentially help. You also want to check for proper functioning of the lymphatic system and checking the different diaphragms. Different treatments that could potentially help with irritable bowel syndrome include trying to balance the sympathetic and parasympathetic. Remember we said how irritable bowel presents with varying symptoms of what seems to be hypersympathetic tone and then at times a rebound hyperparasympathetic tone. So potentially if we remove any sort of restrictions to try to balance autonomic tone, that might help these patients. So, for parasympathetic balance, checking the OA and upper cervical for the vagus nerve and also checking the sacrum for the pelvic splanchnics. We also want again to check for Chapman reflexes. Remember Chapman reflexes for the small intestines anteriorly are in the bilateral intercostal spaces of ribs 8 to 10, and also for the colon it is bilaterally along the IT bands. You could also check the spinal junctions and check for Zink patterns to promote lymphatic drainage and help with improving lymphatic flow from the GI tract and also check for any sort of postural dysfunctions. Again, spinal dysfunctions on a posture could affect the entire abdominal container and treating those could help our patients. So, overall with treatment, you want to apply osteopathic treatment to the different dysfunctions that you may find. Treating facilitated segments first could be helpful in treating irritable bowel syndrome. So, some possible treatments that you could utilize include utilizing gentle inhibitory pressure, using indirect fascial release, taking a look at different somatic dysfunctions of the spine and utilizing facilitated positional release or utilizing balanced ligamentous tension on those spinal restrictions. Balancing the spine sometimes will also help with the muscular attachments to it and the diaphragms. You could screen for counterstrain points. Patients with irritable bowel may have corresponding counterstrain points especially the anterior lumbar points near the anterior ASIS and posteriorly in the lumbar region. One could use muscle energy, soft tissue, articulatory techniques again to the different somatic dysfunctions that you may find. Ganglion inhibition might have a good role here so ganglion inhibition, remember we talked about the different ganglion of the abdomen that supplies sympathetic innervation to the gut and so we could apply some gentle inhibition over the ganglion to try to normalize sympathetic tone and again looking at Chapman reflexes to break that visceral somatic cycle and to decrease facilitation. Here is a chart looking at the different Chapman points of the lower GI tract and so again with these Chapman points there are visceral somatic reflexes and usually what you are looking for is your feeling for a tissue texture change underneath your fingers at these different locations and if you do find it then treatment starts with treating the pelvis and then applying a gentle inhibitory pressure, circular pressure on that point for 30 seconds until the nodule kind of dissolves. So, looking at these different points, it is important to remember that the anterior ones are easier to diagnose and then treatment, usually you treat the anterior and sometimes also the posterior points if present. So, here is a schematic of the Chapman points for the large intestine. So an easy way to remember how the Chapman points lie for the large intestine is that you are kind of cutting at the transverse colon and then reflecting the large intestine onto the IT bands on both sides and so you are kind of reflecting downwards. So my hepatic flexure on the right side will be more closer to my right knee whereas my ileocecal valve will be more towards my right hip and then on the opposite side my splenic flexure will be reflected down closer to the left knee and my sigmoid and anal region will be more reflected by the left hip and so when you are trying to identify the Chapman points you may feel a little bit of a nodular tissue texture change along the lateral aspect of the IT bands along the legs on either side. So colic is another GI presentation that potentially could be treated with osteopathic manipulation. Colic usually has no cause or etiology. It's important to rule out other potential causes for babies to be uncomfortable, perhaps they have an allergy to the formula or something else that potentially be irritating their GI tract but if there is any other pathology ruled out, colic really is just a symptom having increased crying and irritability.

07:03 There are a lot of different factors that could play a part and usually the onset is about 2 to 3 weeks and usually there is resolution by 3 months. Treatment usually includes trying to pacify, nurse, support the baby until they stop crying. So, with osteopathic manipulation, first we want to take a thorough history especially birth history, development to see if there are any birth traumas, perform a thorough physical exam looking at potential regions that may contribute to colic. Key areas to diagnose include the cranium especially the cranial base and the upper cervical. So in our pediatric patients, our babies, the craniums undergo a lot of stress and trauma during development in the womb where there may be certain pressures on the head and also through delivery if there was a vaginal delivery then the head goes through a lot of molding and compression and so these are some key areas to take a look at with infants especially if there was some sort of trauma related to the birth itself whether or not they had to vacuum or if there was a prolonged labor. This may cue you in to potential somatic dysfunctions being more present in the cervical and cranial region. So, definitely take a look at the occiput, the occipitomastoid suture. Remember that the jugular foramen lies along that suture and cranial nerves IX, X and XI are in that region. Also, the hypoglossal passes by the occiput and the occiput undergoes a lot of different forces during delivery. The occiput at birth is in 4 parts and so those condylar parts can potentially be compressed. So it is really important to take a look at those specific regions because those cranial nerves are ultimately responsible for the ability to suck and swallow and also provides parasympathetic innervation to the GI. You also want to take a look at the thoracic cage and diaphragm and also looking at these rib restrictions, that may potentially affect the diaphragm and also scan and screen for possible viscerosomatic reflexes. So, when treating, you want to treat what you find,take a look at the thoracic cage and to the cervical biomechanic, look at potentially utilizing treatments to resolve any somatic dysfunctions in those regions. For the cranial treatments, you could do some gentle OA decompression, suboccipital release. Base spread is a good technique to try to really release the condyles and also the OM suture. So, in general, colic cases may have potential contributions from mechanical causes. So, these osteopathic somatic dysfunctions usually go unrecognized and there is a potential improvement that patients can have with the incorporation of osteopathic manipulation to the treatment of colic.