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CORE OMM Curriculum

for Students, Interns, & Residents ©2006

Osteopathic Considerations of the

Pelvis in Lower GI Complaints

Developed for OUCOM CORE

By theCORE Osteopathic Principles and Practices Committee

Session #3 – Series A





CORE OMM Curriculum


Lower GI Complaints

Devise a treatment plan encompassing:

– Psychosocial issues

– Diet modifications if applicable

– Manipulative treatments

– Pharmacotherapy

– Exercises to be done at home by patient



CORE OMM Curriculum


Somatic Dysfunction

Osteopathic manipulative treatment is directed toward:

– Improving blood flow

– Improving lymphatic flow

– Balancing autonomic impulses to and from the bowel



CORE OMM Curriculum


Sympathetic Hyperactivity

• 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



CORE OMM Curriculum


Sympathetic Innervation ofthe GI tract

Autonomic

Names

Group Innervation Collateral

Sympathetic

Ganglion

Greater Splanchnic

Nerve

T5-9 Stomach, Liver,

Pancreas,

Duodenum

Celiac Ganglion

Lesser Splanchnic

Nerve

T10-11 Small Intestines and Right

Colon

Superior Mesenteric

Ganglion

Lumbar Splanchnic

Nerve

L1-2 Left Colon and Pelvic

Organs

Inferior Mesenteric

Ganglion



CORE OMM Curriculum


Autonomic Innervation

Innervation of each viscusgenerally 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



CORE OMM Curriculum for Students, Interns, & Residents ©2006

Inferior Collateral Sympathetic Ganglion

w/ Sympathetic Hyperactivity

Sympathetic Ganglion

• Located in midline of abdomen, superior to the umbilicus

• Indicates sympathetic hyperactivity to the colon

Sympathetic Hyperactivity

Ileus

Constipation Abdominal distention

Flatulence




Parasympathetics

Normalization of parasympathetic activity may

be useful to treat:

– Colitis – Crohn’s disease

– Irritable bowel syndrome

– Idiopathic diarrhea




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




Parasympathetic Activity

Hyperactivity:

•Increases bowel motility

and glandular secretions

• Associated with diarrhea

Hypo activity:

•Decreased bowel motility

and glandular secretions

• Associated with

constipation




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




Colon Chapman’s Reflexes:

•Located between the ASIS

& the Greater Trochanter

•Specific for AtonicConstipation

•Evaluate thyroid, liver &

spleen, as well

Owens, An Endocrine Interpretation of

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

GI Group





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)

p. 1053, Foundations, 2nd Ed.




Irritable Bowel Syndrome

Manifestation of hyperactivity of both

parasympathetic and sympathetic systems




Lymphatics

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

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




• Visceral lymph

nodes lie close to

the organ which

they drain

• Then drain through

chains of parietal

nodes along the

path of the majorarteries & veins

Clemente, Fig. 235




Lymphatic Congestion

• 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




Pelvic Dysfunction

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 tissuemotion




Pubic & Innominate Dysfunction

• Parasympathetic changes occur with suboptimal sacralmotion and the increased tensions in the pelvic tissues

• Sympathetic changes for the same reasons especially

around the sacral sympathetic chain and the ganglionimpar at its end.

In summary, innominate dysfunction can influence:

Fluid congestionParasympathetics

Sympathetics




OMT with Hip Joint

• 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 capsularligaments of the hip joint. This creates the vector of

force to normalize the dysfunction.

• Participants can evaluation and treat their partnerstaking turns with the techniques that follow.

• Practice can immediately follow the review of each slide.




Symphysis Pubis

• Superior and Inferior shearing mechanics seen

with pubic dysfunction

• Seen post partum

• Also seen in strenuous use of adductor muscles

of thighs or trauma




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




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.




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 ofthe opposite leg until straight.




Innominate: Rotated Posterior

Same technique, except

Cephalad Hand: contacts the

ischial tuberosity and carries it

superior/posterior




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




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




Innominate Inflare

•Forces are reversed

•In both cases the

accuracy of force

localization is key

•Knee flexion/extension

adjustment will help the

localization process




Pelvic Diaphragm

1. Assess for spasm or asymmetry related to prior surgeryinvolving lower sigmoid, rectum and anal areas

2. Funnel shaped muscle attaching to lateral walls of thetrue pelvis

3. Angles inferior and medially to attach to the urogenitaldiaphragm and midline structures of the urogenital andanal triangles

4. Innervated by pudendal nerve originated from sacralroots S2,3,4




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 ofmotion between the two –

pelvic & thoracic

Moore, Clinically Oriented Anatomy, 4th Edition, 1999, p.400




Summary

1. Osteopathic treatment of the lower GI tract involves

evaluating the patient’s entire health

- Nutritional status, psychological stress

2. Somatic influences on the pelvis must be evaluated and

treated

- Short leg syndrome, lumbar & sacral strain/sprain, post-partum

considerations, innominate upslip

3. The potency of further therapy hinges on the

manipulative treatment.

- For antibiotics to be fully effective, blood flow and lymphatic

drainage must be optimized



CORE OMM Curriculum for Students Interns & Residents © 6

References

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.

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