OMT Considerations for Neurologic Presentations

00:00 So when we apply osteopathic treatment in the neurologic model, it's important to treat the underlying pathology responsible for the reflex. We want to treat somatic dysfunctions that result from a visceral pathology. The response of a viscero-visceral reflex has an acute boggy, rubbery end feel. Reflexes could be palpated and distinguished through tissue texture changes. For example, you could have a positive red reflex because of increased erythema, you may have a positive skin drug test secondary to increased moisture. So, prolonged hyperactivity of the autonomic nervous system can lead to facilitation of the spinal cord and lower thresholds for autonomic firing as we've discussed. Treatment is directed towards breaking that facilitation. We want to try to restore balance between the sympathetic and parasympathetic systems. If we understand the anatomy of the sympathetic system and parasympathetic system, that will help assist us with directing our treatment. Reflexes are acute changes, so treatments that you want to use and are more effective are usually gentle, indirect and passive techniques. So, let's take a closer look at the sympathetic innervation to our organs. So, our sympathetic chain ganglion, which lies anterior to the rib heads along T1 down to L2 provide sympathetic innervation to our organs. So remember back to the map that we discussed before each of these different organs have a specific level that correspond to the sympathetic chain ganglion and the nerve roots that innervate it and so when we want to treat the sympathetic nervous system, we want to address any sort of somatic dysfunctions that may impair proper rib motion that may affect the structures in that area including the musculoskeletal structures in that area. So techniques that we could use include inhibitory pressure, soft tissue myofascial release and also rib raising to try to decrease any sort of musculoskeletal restrictions along the sympathetic tract and also to treat any viscerosomatic reflexes where there are acute changes to those paraspinal muscles. So, rib raising is a very gentle technique. Initially, it will stimulate regional sympathetic efferent activity to the organs to that level of sympathetic innervation but in the long run rib raising will result in prolonged reduction of sympathetic nervous system outflow from the treated area. So let's take a look at parasympathetic innervation. So parasympathetic innervation in our body is provided by 2 main structures, our vagus nerve or cranial nerve X and also our parasympathetic nerves, the pelvic splanchnics which is supplied from S2 to S4.

02:57 So the vagus nerve exits the cranium from the jugular foramen. So, the jugular foramen is a key area to try to address. Also it traverses down passing the neck and enters the thoracic cavity to innervate the thoracic organs and also the abdominal organs. And so treating areas like the upper cervical region can also help decrease any possible restrictions on that vagus nerve as it traverses from the base of the skull down through the rest of the body. Parasympathetic innervation from most the organs in the pelvis arise from S2 to S4. So, these are the pelvic splanchnic nerves. What we want to do is to take a look at possible compression of the nerves as it exits the sacrum. So we definitely want to take a look and treat the sacrum, treat the pelvis, treat anything that might be possibly compressing those nerves that would cause problems with potentially the GI and GU systems. So, again, reviewing some of the treatments that we could utilize for treating and balancing the parasympathetic nervous system, for the vagus, techniques such as OA decompression, suboccipital release, balanced ligamentous tension or FPR myofascial release or inhibition are good techniques to utilize to try to decrease any sort of hypertonicity that you might find in the cervical region. Again, the pelvic splanchnics could be treated by utilizing lumbosacral myofascial. Sacral rock is a good technique to gently articulate the sacrum, balance ligamentous tension. Lumbosacral decompression using balance ligamentous tension is a good technique so is SI gapping and then also just using gentle inhibition in the region will also help. So the above list is just a sample of techniques. As long as the treatment is gentle, indirect and passive and well tolerated by the patient, they could be very effective techniques to help balance parasympathetic tone. Chapman reflexes is another form of viscerosomatic reflexes. Chapman reflexes are a system of reflex points originally used by Dr. Frank Chapman. He described these predictable anterior and posterior fascial tissue changes that corresponded with different organs and so these ganglia form contractions. He felt blocked the lymphatic drainage and there are viscerosomatic reflexes from sympathetic nervous system dysfunction. So, Chapman reflexes are located deep to the skin often lying on the deep fascia or periosteum. Usually they are found paired on both the dorsal and ventral parts of the bodies so you will usually find the anterior point and their corresponding posterior point. What you will palpate are the small, smooth, firm 2mm to 3mm nodules that are really tender to palpation but when you push on it they generally do not radiate. So, here are some examples of Chapman reflex points. Again, these points correspond with specific regions and so if a patient presents with ENT complaints you could try to screen for these points anteriorly. Usually they are palpated and found anteriorly and then you will treat the anterior point and then the corresponding posterior point if present. There are also additional key points to be really familiar with. Tip of the 12th rib is one for the appendix reflex. The colon reflex is reflected upon the IT band. So patients with GI issues you might find these Chapman points along the lateral aspect of the IT band. Upper respiratory points will be found around the clavicle and the first intercostal space. The myocardial point is in the left second intercostal space. GI/GU points are surrounding the lower rib cage, the costal margins, the umbilicus and around the pelvis. And so if you have a vague complaint of abdominal pain, pelvic pain sometimes these points could help you with differentiating the possible cause. So, Chapman reflexes primarily you utilize it to help diagnose but they are viscerosomatic reflex so when you find the dysfunction anteriorly it will help you confirm a diagnosis but you could also treat the points. Generally, you want to treat the posterior points since they're usually less tender. You always have to treat the pelvis first prior to treating the points. So how you treat the points is you apply a firm pressure of a finger and place a circular fashion on that point until you flattened the mass but you don't want to push as hard as you can. You want to put gentle pressure to match the tissue texture change there and usually if you do this for about 10 to 30 seconds at the end the mass will disappear. So, we see how utilizing the neurologic model of osteopathic manipulative medicine it could be diagnostic in looking at our somatic clues that may tie in with viscerosomatic reflexes or Chapman reflexes. We could also utilize the neurologic model to apply adjunctive and therapeutic treatment to our patients to help break viscerosomatic reflexes, decrease facilitation and to balance their autonomic tone to help them heal better.