2025 GI Related Viscerosomatic and Chapman's Reflexes PDF

G.I. related Viscerosomatic and Chapman’s Reflexes Krista Lund DO Ed Goering DO January 2025 The presenters have no conflict of interest related the material presented in this lecture/lab financially or any other way. Learning Objectives Differentiate V...

G.I. related Viscerosomatic and Chapman’s Reflexes Krista Lund DO Ed Goering DO January 2025 The presenters have no conflict of interest related the material presented in this lecture/lab financially or any other way. Learning Objectives Differentiate Viscerosomatic (VS) reflexes and Chapman’s reflex points. Explain the theorized underlying mechanism behind Chapman’s reflexes. Identify somatic levels related to the GI system Describe the location and treatment of Chapman’s Reflexes for GI pathology. Develop a palpatory sensitivity necessary to identify, assess, and treat visceral tissue texture changes and their associated viscerosomatic reflexes and Chapman’s reflex points. Required Reading Elentra - OMS II OPP Department Textbook Chapter GI System Review and recall prior required reading assignments: Chapman’s Reflexes Viscerosomatic Reflexes Review and recall prior OPP sessions: 1. FOM 5: Viscerosomatic Reflexes and Chapman’s Reflex Points 2. FOM 5: Somatic Dysfunction, Functional Techniques, and Linkage 3. FOM 2: Dr. Frank Willard’s Expanding Osteopathic Concepts – 12/8/2023 Terminology Review Visceral dysfunction: Impaired or altered mobility or motility of the visceral system and related fascial, neurological, vascular, skeletal and lymphatic elements. Reflex: An involuntary nervous system response to a sensory input. − The sum total of any particular involuntary activity. Spinal facilitation: 1. The maintenance of a pool of neurons (e.g., premotor neurons, motor neurons or preganglionic sympathetic neurons in one or more segments of the spinal cord) in a state of partial or subthreshold excitation; in this state, less afferent stimulation is required to trigger the discharge of impulses. 2. A theory regarding the neurophysiological mechanisms underlying the neuronal activity associated with somatic dysfunction. 3. Facilitation may be due to sustained increase in afferent input, aberrant patterns of afferent input, or changes within the affected neurons themselves or their chemical environment. Once established, facilitation can be sustained by normal central nervous system (CNS) activity. - Glossary of Osteopathic Terminology, 3 rd ed. Terminology Review Somatosomatic reflex: localized somatic stimuli producing patterns of reflex response in segmentally related somatic structures Somatovisceral reflex: localized somatic stimuli producing patterns of reflex response in segmentally related visceral structures Viscerosomatic reflex: localized visceral stimuli producing patterns of reflex response in segmentally related somatic structures. Viscerovisceral reflex: localized visceral stimuli producing patterns of reflex response in segmentally related visceral structures. (Preferred term is autonomic reflex) Chapman Reflex Points: A system of reflex points that present as predictable anterior and posterior fascial tissue texture abnormalities (plaque-like changes or stringiness of the involved tissues) assumed to be reflections of visceral dysfunction or pathology. - Glossary of Osteopathic Terminology, 3 rd ed. Lippincott® Atlas of Anatomy, 2e Plate 1-19 Somatic Response To Visceral Pathology 1. Segmental related findings Vertebral asymmetry Muscle hypertonicity/tenderness Temperature changes Skin moisture content 2. Organ findings Abnormal organ and surrounding tissue findings 3. Chapman Reflex Points present Integrated GI Exam Inspection General Anterior view Posterolateral view Posterior view Palpatory Exam of Spinal Regions Viscerosomatic Reflexes Heart Lungs Abdomen Inspect Auscultate Percuss Palpate 9 regions Lift structures at cecal and sigmoid regions Compress the linea alba Bates’ 13e, Figures 19-4 and 19-5 in animation Chapman’s Points … Lippincott® Atlas of Anatomy, 2e Plate 1-13, 14, 15, 16, and 19 in animation  Sympathetic Nervous System Parasympathetic Nervous System The Autonomic Nervous System Fig 16.38, Gilroy Atlas 4th ed. Autonomic Nervous System Distribution as listed in the NMM/OMM Department Textbook Of note, the Educational Council on Osteopathic Principles (ECOP) generated an updated ANS chart in September 2024. It is a simplified chart created from the sources listed in the notes section on the next slide. The new chart does not reflect the complexity and variability of the autonomic nervous system. It is meant for testing purposes for osteopathic medical students. It has NOT yet been adopted by the NBOME. Viscera Sympathetic Nervous System (Spinal cord levels) Parasympathetic Nervous System Head and neck T1-4 CN III, VII, IX, X Heart T1-5 Vagus Lung T2-7 Vagus Esophagus T3-6 Vagus Stomach T5-9 Vagus Liver T5-9 Vagus Gallbladder T5-9 Vagus Spleen T5-9 Vagus Pancreas T5-9 Vagus Duodenum (before ligament of Treitz) T5-9 Vagus Jejunum T10-11 Vagus Ileum T10-11 Vagus Ascending Colon & proximal 2/3 of transverse colon (between ligament of Treitz and splenic flexure) & appendix T10-11 Vagus Distal 1/3 of transverse colon T12-L2 S2-4 Descending colon & Sigmoid colon (after splenic flexure) T12-L2 S2-4 Rectum T12-L2 S2-4 Kidneys T10-L1 Vagus Adrenal medulla T10-11 Vagus Upper Ureters T10-11 Vagus Lower Ureters T12-L1 S2-4 Bladder T11-L2 S2-4 Gonads T10-11 S2-4 Uterus and cervix T10-L2 S2-4 Erectile tissue of penis and clitoris T11-L2 S2-4 Prostate T11-L2 S2-4 Upper extremities T2-7 none Lower extremities T10-L2 none Viscera Sympathetic Nervous System Parasympathetic Nervous (Spinal cord levels) System Head and neck T1-4 CN III, VII, IX, X Heart T1-5 Vagus Lung T2-7 Vagus Esophagus T3-6 Vagus Stomach, Liver, Gallbladder, Spleen, Pancreas, and Duodenum (before T5-9 Vagus ligament of Treitz) Jejunum, Ileum, Ascending Colon & proximal 2/3 of transverse colon T10-T11 Vagus (between ligament of Treitz and splenic flexure) & appendix Distal 1/3 of transverse colon, Descending colon & Sigmoid colon (after T12-L2 S2-4 splenic flexure) & Rectum Adrenal medulla, & Upper Ureters T10-T11 Vagus Kidneys T10-L1 Vagus Lower Ureters T12-L1 S2-4 Bladder T11-L2 S2-4 Gonads T10-T11 S2-4 Uterus and cervix T10-L2 S2-4 Erectile tissue of penis and clitoris, & Prostate T11-L2 S2-4 Upper extremities T2-7 none Lower extremities T10-L2 none  Collateral Ganglia Celiac ganglion: Receives fibers from T5-T9 via the Greater Splanchnic nerve Innervates what? Superior mesenteric ganglion: Receives fibers from T10-T11 via the Lesser Splanchnic nerve Innervates what? Inferior mesenteric ganglion: Receives fibers from T12- L2 via the Least Splanchnic and lumbar splanchnic nerves Innervates what? Adapted from Bate’s Fig 11-1 Gustowski Osteopathic Techniques Fig 14.9  Chapman Reflex Points: A type of a viscerosomatic reflex response thru facilitated segments Thought to arise from “gangliform contractions” that block lymphatic drainage and cause sympathetic nervous system dysfunction neurolymphatic in origin Each point represents specific organ pathology Generally, found at the end of spinal nerves, or associated tissue (i.e., dermatomal distribution pattern) Size varies: “BB” pellet to pea sized with central density Texture: edematous, ridge-like, ropy, fibrospongy, or shotty Tender  Comparing Chapman Reflex Points, Trigger Points, & Tender Points Clinical Location Palpatory Quality Pain Association Classic Treatment System Characteristics Soft tissue structures: Gangliform, Tenderness: Viscerosomatic Rotary stimulation for subcutaneous tissue, fascia, contracted, slightly painful to tissue reflex 20-60 seconds muscle, ligament, & edematous, ridge- almost Chapman perichondral or periosteal like or ropy, shotty, unbearable Reflexes tissue fibrospongy Well localized Mostly in deep fascia or Varying size: pinhead Sharp quality periosteum to almond No pain radiation Central TrP in mid-muscle fibers Distinct nodules Localized pain Local muscle Injection, dry needling, Attachment TrP in (contraction knots) Taut muscle band pathophysiology ischemic compression, Trigger myotendinous junction Rope-like induration Referred pain to Stimulation of post-isometric Point (TrP) Depth varies with muscles (taut band) distant region point often causes relaxation MET, spray taut band twitch and stretch, Counterstrain Musculotendinous junctions Discrete, small, Exquisitely tender Specific muscle or Counterstrain attachments tense, edematous Very localized joint SD Tender Muscle belly rarely, esp in Size of a fingertip No pain radiation postural muscles Point Ligaments associated with a joint dysfunction, believed to be related to the spindle mechanism Adapted from: Table 40E.3, FOM 4 th ed  Chapman Reflex Anterior Points Points Posterior Points Figures 40E.1 & 40E.2, FOM, 4th ed. Treatment of Chapman’s Anterior Chapman Reflex Points – Quick Screening Points with Direct Inhibition 1. Locate the Chapman’s point. 2. With finger pad or thumb, push firmly in a circular manner around (but tolerably) the point, using a gentle rotary motion. May also resolve with linear traction through the point 3. Keep pressure on the point until it palpably recedes, and the point becomes non-tender. ~15-60 seconds, don’t overtreat Figure 40E.5, FOM, 4th ed.  Organ/System Parasympathetic Sympathetic 1 Ant. Post. Innervation Table Chapman's Chapman's HEENT Cr Nerves (III, VII, IX, X) T1-T4 Mult. pts. Mostly in Occipital, Suboccipital, 1st ICS & C1-C7 Heart Vagus (CN X) T1-T5 2nd Intercostal T2-4 2 Space (ICS) Lung Vagus (CN X) T2-T7 3rd & 4th ICS T3-5 Esophagus Vagus (CN X) T3-T6 2nd ICS T2 Stomach Vagus (CN X) T5-T9 (Greater Splanchnic) 5th & 6th ICS on L 3 T5-6 & T6-7 on L 3 Liver Vagus (CN X) T5-T9 (Greater Splanchnic) 5th-6th ICS on R T5-6 on R Foregut Gallbladder Vagus (CN X) T5-T9 (Greater Splanchnic) 6th ICS on R T6-7 on R Spleen Vagus (CN X) T5-T9 (Greater Splanchnic) 7th ICS on L T7-8 on L Pancreas Vagus (CN X) T5-T9 (Greater Splanchnic) 7th ICS on R T7-8 on R 8th–10th ICS T8-11 Small Intestine 4 Vagus (CN X) T5-T11 (Greater and Lesser Splanchnic) & btwn ASIS and greater and Rib 11 CT jxn (peristalsis) troch. (peristalsis) Midgut Appendix Vagus (CN X) T10-T11 (Lesser Splanchnic) Tip of 12th Rib T11-12 on R Ascending Colon Vagus (CN X) T10-T11 (Lesser Splanchnic) R IT band Vagus (CN X) (first 2/3rd) & T10-T11 (Lesser Splanchnic) (first 2/3 rd) L2-L4 Triangle, Transverse Colon B distal IT band (Quad Lumb) Pelvic Splanchnic (last 1/3rd ) & T12-L2 (Least Splanchnic) (last 1/3rd ) Hindgut Descending & Sigmoid Pelvic Splanchnic (S2-4) T12-L2 (Least Splanchnic) L IT band Colon Rectum Pelvic Splanchnics (S2-4) T12-L2 (Least Splanchnic) Lesser trochanter Lower IS joint GI related Chapman’s Reflex Points Stomach Gallbladder – Acidity (think E-G junction) – Ant: Right ICS 6 Ant: Left 5th ICS – Post: Right T6-7 IT Post: Left T5-6 IT Pancreas – Peristalsis (think celiac ganglion) – Ant: Right ICS 7 Ant: Left ICS 6 – Post: Right T7-8 IT Post: Left T6-7 IT Pylorus Small Intestines – Ant: medial 8th-10th ICS – Pyloric sphincter (think motility) https://www.picfair.com/pics/08998472-male-abdominal-organs-illustration Ant: along center portion of – Post: T8, T9, T10 IT sternum (sternalis muscle) Appendix Post: T10 TP/Rib 10 jxn – Ant: distal tip of right rib 12 Key: Ant = anterior Liver – Post: Right, T11 IT Post = Posterior – Ant: Right ICS 5 and 6 Intestinal Peristalsis/Colonic Atony ICS = intercostals space – Post: Right T5-6 IT IT = intertransverse space between – Ant: btwn ASIS and greater troch the spinus and transverse processes – Post: Rib 11 costotransverse jxn TP = transverse processes GI related Chapman’s Reflex Points (cont.) Colon – Post: Triangle of L2-L4 TP and iliac crest – Ant: iliotibial bands (ITB) Anatomic location of Chapman’s reflexes on iliotibial band correlate with specific portions of the colon Right Colon = Right ITB – Upper 1/5th = Iliocecal area – Middle 3/5ths = ascending colon & hepatic flexure – Distal 1/5th = proximal transverse colon Left Colon = Left ITB – Distal 1/5th = distal transverse colon Fig 67.2, Illustration by W.A. Kuchera, FOM 2nd ed. Ward. – Middle 3/5th = splenic flexure & descending colon – Upper 1/5th = Sigmoid area & rectosigmoid junction Rectum – Post: Lower edge of iliosacral joint – Ant: Lesser trochanter (bilateral) Why upside down? Midgut Rotation  Viscerosomatic Reflexes (Recall Dr. Willard’s Lectures during FOM1) Viscerosomatic reflexes are objective changes in somatic structures resulting from visceral injury, trauma, or nociception. They are mediated through the spinal cord and are a form of somatic dysfunction. Considering the specific organ, can help with understanding the paraspinal regional spasms and where they can refer to. Cardiosomatic reflex Paraspinal muscle spasm, upper thoracic segments especially T3 to T5 Referred pain to the upper thoracic region and upper extremity especially on the left Gastrosomatic reflex Paraspinal muscle spasm, Midback to thoracolumbar junction Referred pain, Torso, midthoracic spine to thoracolumbar junction Nephrosomatic reflex Paraspinal muscle spasms, Low back region L1-L2 Referred pain, Flank pain, L1-L2 distribution, Testicular pain in a male Uterosomatic reflex Paraspinal muscle spasms, Thoracolumbar junction and sacrum Referred pain, Thoracolumbar junction and sacrum  Fig 1.36 , Moore’s Clinical Anatomy, 8e. GI Sympathetic Innervation, Foregut: T5-T9 Midgut: T10-11 Chapman’s, and Dermatomes Hindgut: T12-L2 Anterior Points Figures 40E.1 & 40E.2, FOM, 4th ed. Posterior Points Putting it all Together GI system may be affected by several mechanisms Primary organ disease can cause viscerosomatic reflexes resulting in somatic dysfunction Somatic dysfunction can produce somatovisceral reflexes influencing organ irritation and dysfunction Treatment of the primary organ problem will not always resolve the somatic dysfunction, so both should be treated  GI Dysfunction Treatment Goals Address asymmetries, motion restrictions, and tissue texture abnormalities that are viscerosomatic reflections of homeostatic disturbances Decrease or eliminate pain Remove segmental motion restrictions Improve altered skeletal vertebral unit and myofascial motion arising from aberrant visceral and autonomic activity Decrease or eliminate segmental facilitation Decrease or eliminate trigger point and tender point activity Decrease pathophysiologic musculoskeletal and neuroreflexive factors influencing circulation Enhance musculoskeletal and neuroreflexive-mediated circulatory functions Improve organ function Meeting these goals not only improves the current dysfunction or pathology but can also assist with preventing future health problems that could occur from that dysfunction Treatment Approach Dependent on patient condition – what can the patient tolerate? Diaphragms Thoracic Inlet (Sibson’s fascia) Thoracoabdominal diaphragm Pelvic diaphragm Parasympathetic Vagus (OA, AA and C2) and Pelvic Splanchnics (S2, S3, S4) Sympathetic Posterior spinal segments, Chapman’s points, Abdominal ganglion Viscera Mesenteric or colonic lift MFR for various abdominal viscera Liver and Spleen pumps Recall prior Lymphatic and Viscera techniques learned to improve gut motility Constipation – Infrequent or incomplete bowel movements Physiology and Associated Somatic Dysfunctions OMT Treatment Parasympathetics 2-minutes: – Increased tone → increased peristalsis – Sacrum – articulation and distraction – Vagus nerve: OA, AA, C2 and cranial somatic – Abdomen – Collateral ganglia release dysfunctions 5-minutes: Vagus nerve (CN X) exits the jugular foramen (composed of – Head – OA release occiput and temporal bones) so compression of – Abdomen – Colonic stimulation occipitomastoid sutures can affect parasympathetic tone – Pelvic splanchnics: Sacral (S2–S4) somatic dysfunction Extended Treatment: Innominate somatic dysfunction can also affect tone – Cervical – AA, C2: FPR or HVLA – Thoracic – MET or HVLA Sympathetics – Lumbar – MET or HVLA – Increased tone → decreased peristalsis – Ribs – Rib raising – Thoracic and lumbar (T5-L2) somatic dysfunction – Pelvis – Innominate MET and direct pelvic floor muscles – Superior and inferior mesenteric ganglion – fascial release restrictions – Sacrum – MET and sacral rocking Other Somatic Dysfunction Findings – Abdomen – mesenteric lift – Thoracoabdominal diaphragm dysfunction – Abdomen viscerosomatic – anterior Chapman’s reflex – Pelvic diaphragm dysfunction – Lower extremity – Iliotibial band Chapman’s reflex for colon Channell M, Mason D. The 5-Minute Osteopathic Manipulative Medicine Consult. 2 nd ed, Wolters Kluwer, 2020 Diarrhea – Abnormally high frequency and volume of bowel movements; may have functional, inflammatory, or infectious etiology. Channell M, Mason D. The 5-Minute Osteopathic Manipulative Medicine Consult. 2nd ed, Wolters Kluwer, 2020 Physiology and Associated Somatic Dysfunctions OMT Treatment Parasympathetics 2-minutes: – Thoracic and Lumbar – Soft tissue or MFR – Increased tone → increased peristalsis – Vagus nerve: OA, AA, C2 and cranial somatic dysfunctions 5-minutes: – Thoracic and Lumbar – MET or HVLA – Pelvic splanchnics: Sacral (S2–S4) somatic dysfunction – Abdomen – Collateral Ganglia Release Sympathetics – Head – OA release – Increased tone → decreased peristalsis Extended Treatment: – Thoracic and lumbar (T5-L2) somatic dysfunction – Head – V spread – Celiac ganglion, superior mesenteric ganglion and/or inferior – Cervical – FPR and/or HVLA mesenteric ganglion – fascial restrictions – Ribs – Rib raising and MET or HVLA Other Somatic Dysfunction Findings – Sacrum – MET – Associated rib dysfunctions – Innominate – MET – Thoracoabdominal diaphragm dysfunction – Abdomen/other/viscerosomatic – Chapman’s – Pelvic diaphragm dysfunction reflex References Giusti R, Ex ed. Glossary of Osteopathic Terminology. 3rd ed. AACOM; 2017 Seffinger M. et al. Foundations of Osteopathic Medicine: Philosophy, Science, Clinical Applications, and Research, 4th Ed. Lippincott Williams & Wilkins, 2018. (Chapters 10, 31, and 12, 30, 31, 40E, 40K) The Back. In: Gest TR. eds. Lippincott® Atlas of Anatomy, 2e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2020. Abdomen. In: Bickley LS, Szilagyi PG, Hoffman RM, et al. eds. Bates' Guide to Physical Examination and History Taking, 13e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2021. Gilroy A, MacPherson B, Schünke M et al., Atlas of Anatomy. 3rd Ed. Thieme; 2016. doi:10.1055/b-005-148856 Gustowski S, Budner-Gentry M, Seals R, Osteopathic Techniques: The Learner's Guide. 1st Ed. Thieme; 2017. Chapter 14 doi:10.1055/b- 005-148866 Capobianco JD. Chapman’s Reflex Points. In: DiGiovanna EL, Amen CJ, Burns DK. eds. An Osteopathic Approach to Diagnosis and Treatment, 4e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2021. The Gut Tube and the Body Cavities (Chapter 7) and Digestive System (Chapter 15). In: Sadler TW. eds. Sadler T. Langman’s Medical Embryology. 15e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2024. Overview and Basic Concepts. In: Dalley AF, II, Agur AMR. eds. Moore’s Clinically Oriented Anatomy, 9e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2023 Common Clinical Problems of the Lower Quarter. In: DeStefano LA. eds. Greenman's Principles of Manual Medicine, 5e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2017 Channell MK, Mason DC. The 5-Minute Osteopathic Manipulative Medicine Consult, 2e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2020. Check out the amazing collections of textbooks available in the Pumerantz Library https://www.westernu.edu/library/ Here’s the textbooks available on the Osteopathic Medicine page Here’s some of the Anatomy And you can navigate between collections with the textbooks available on the the “More Collections” tab Premium Basic Sciences page