Week_9_-_Visceral_Somatic_Reflexes_student.pdf

The connection between viscera and soma JENNIFER WILSON D.O. CLINICAL ASSOCIATE PROFESSOR OKLAHOMA STATE UNIVERSITY FEBRUARY 28, 2024 Objectives  Discuss Autonomic Nervous System in regards to viscerosomatic reflexes.  Define viscerosomatic, somatovisceral, viscerovisceral, and somatosomatic refle...

The connection between viscera and soma JENNIFER WILSON D.O. CLINICAL ASSOCIATE PROFESSOR OKLAHOMA STATE UNIVERSITY FEBRUARY 28, 2024 Objectives  Discuss Autonomic Nervous System in regards to viscerosomatic reflexes.  Define viscerosomatic, somatovisceral, viscerovisceral, and somatosomatic reflexes  Describe pathophysiology of facilitation – why is all of this important?  Describe how to diagnose and treat a viscerosomatic reflex  Review Clinical Cases and practice questions Nervous System  The nervous system is divided into central and peripheral.  The peripheral nervous system (PNS)  Consists of spinal nerves, cranial nerves, and their associated ganglia (groups of nerve cells outside the CNS).  Informs the brain of what is going on with the physical environment and allows it to respond.  Somatic (Sensory and Motor)  Autonomic (Sympathetic & Parasympathetic) Two parts of PNS: 1. Somatic:  Sensory: Provides CNS with information from the body via afferent nerves. Examples include temperature from thermoreceptors, light from photoreceptors, chemicals from chemoreceptors, pressure from mechanoreceptors, and nociceptors for pain.  Motor: efferent nerves involved in voluntary motor functions, such as the contraction of skeletal muscles 2. Autonomic: branch of the PNS that regulates functions of internal organs and controls smooth muscle, cardiac muscle, and glands  Inputs are constant and there is continuous feedback  Changing body temp, blood supply, increasing or decreasing heart rate, changing stomach secretions  Effects change depending on situation and which division is in charge at that moment.  Goal is to maintain a constant internal body environment (homeostasis).  Consists of 2 parts: Sympathetic and Parasympathetic   Sympathetic (thoracolumbar)  Parasympathetic (craniosacral) Require 2 neurons in order to work: pre and post ganglionic  Ganglion: cluster of cell bodies that house millions of synapses Sympathetic Fight or flight Excitatory, exercise, emergency Preparing for activity Originates from the thoracics and lumbars Ganglia close to spine so able to send wide spread messages 080 quickly 1010 Short preganglioinic fibers Long post ganglionic fibers Called sympathetic because network quickly coordinate many organs at once. Greek for “feeling together” One small stress signal can trigger multiple responses at once Parasympathetic Rest and digest Calming Digestion, defecation, diuresis Ganglia far from spine, often very near organ Uses more specific signals Long preganglionic fibers Short postganglionic fibers Originate craniosacral “next to sympathetic” Sympathetic  Originating from T1- L2/3  Fight or flight system    Physiologic response to stress Sympathetic Stimulation leads to:  Mydriasis and Lens relaxation  Decreased gland (nasal/lacrimal) secretion and increases sweating  Increased HR and contractility  Relaxes bronchial smooth muscle  Relaxes GI lumens and contracts sphincters, decreases motility  Contracts arterioles and relaxes skeletal muscle  Relaxes bladder wall and contracts sphincter  Constricts uterine body and relaxes cervix  Ejaculation  Stimulates glycogenolysis Loss of sympathetic is the opposite  Eg – Horner Syndrome (interruption of sympathetic) : ptosis, miosis, loss of sweating. Parasympathetic  CN 3, 7, 9,  CN 10 (vagal, OA, C1-2)  S2-4 (Pelvic Splanchnic)  Rest and Digest  Parasympathetic stimulation leads to  Miosis and lens contraction  Nasal, lacrimal, gastric secretion  Sweating of palms  Decreases HR and contractility  Contracts bronchiole smooth muscle and thins secretions  Contracts GI lumens and dilates sphincters, increases motility  No effect on arterioles  Contracts bladder wall and relaxes trigone  Erection  Uterine relaxation and cervix constriction ECOP (Education Council on Osteopathic Principles) Board Resource On Leo NBOME follows ECOP recommendations How is this all connected?  Visceral afferent neurons and somatic afferent neurons relay information from the viscera to the body. The afferent neuron from the viscera has a cell body located in the dorsal root ganglia, and a central process that terminates in the dorsal horn of spinal cord.  This central process terminates on interneurons that, in turn, innervate the effector neurons in the gray matter of the spinal cord or brainstem causing change in many areas elsewhere in the body.  Visceral pain can be referred to a somatic structure that is innervated by the same segments that receive input from the visceral organ.  The afferent fibers from diseased visceral organ excite the spinothalamic tract cells that receive convergent input from related somatic structures.  In general, afferents from viscera may cause somatic change via interconnecting neurons. This may lead to pain and somatic dysfunction.  Common examples include:  Shoulder pains associated with cholecystitis  Pains of the left arm or throat associated with myocardial ischemia What type of reflexes are there?    Through autonomic reflex activity, a connection is made between the somatic and autonomic components of the peripheral nervous system.  viscerosomatic  somatovisceral  viscerovisceral  somatosomatic Naming  First component is primary source and causation  Second component describes included effect For example  Viscerosomatic: Organ stimulation leads to somatic change. Chronic gastritis leading to somatic dysfunction of T5-9 Viscerosomatic Reflex tested  yes Organ info leading to somatic change.  Afferent stimuli from viscera travel through the dorsal horn of the spinal cord, synapse on interconnecting neurons, and convey a stimulus to autonomic and somatic efferents.  This results in sensory and motor change in somatic tissues of muscle, blood vessels, and skin.  Each organ has a specific associated level for which somatic change can occur.   Visceral afferent input has a preference for affecting rotatores muscle  Creates sidebending and rotation toward the side of dysfunctional organ Most tested type of reflex on boards!  You will be expected to memorize the levels of the spine at which TART changes are expected from each organ.  BOTH sympathetic and parasympathetic Organ Sympathetic Parasympathetic Head & Neck T1-4 Specific cranial nerves Upper extremities T1-8 Heart T1-5 Respiratory tree T1/2-6/7 Esophagus T2-7/8 Stomach, GB, Liver, Spleen T5-9 CN X, Occiput, C1-2 Small intestine T10-11 CN X, Occiput, C1-2 Pancreas CN X, Occiput, C1-2 Colon & rectum T5-9 (head) T10-11 (tail) T8-L2 Appendix T12 Occiput, C1-2 Kidneys & up. ureter T10-L1 CN X, Occiput, C1-2 Lower ureter & bladder T11-L2 S2-4 Gonads T10-11 S2-4 Uterus T10-L2 S2-4 Prostate L1-2 S2-4 Lower extremities T10-L2 (3) CN X, Occiput, C1-2 r CN X, Occiput, C1-2 CN X (lower 2/3), Occiput, C1-2 CN X (ascending; 2/3 transverse to proximal splenic flexure) S2-4 (1/3 transverse colon, sigmoid, rectum) For example: A patient is having an MI, you would expect multiple somatic effects including pain and tissue texture change of T1-5, and near OA. Detailed and complicated graph provided by ECOP – 2021 Impossible to read on power point. Available on LEO Levels  Gwirtz, et al (2007) used EMG and palpation of T2-5 and T11-12 (control). Induced coronary ischemia led to increase in muscle tension, texture, and firmness of T2-5 on the left. (not right or control area). EMG noted increased activity T4-5. After sympathectomy, muscle changes were absent.  Heart: T1-5 (SNS)& Occiput/vagal (PNS) Boadquest. o A 43 year old woman presents with RUQ abdominal pain, nausea, fever, and leukocytosis. At what level would you treat sympathetically mediated somatic dysfunction?  T2-5  o  L1-2  OA  T5-9 T7-11 A patient presents with RUQ abdominal pain, nausea, fever, and leukocytosis. At what level would you treat expected sympathetic induced somatic dysfunction?  T2-5  T5-9 right  T7-11    Organ Sympathetic Parasympathetic Head & Neck T1-4 Specific cranial nerves Upper extremities T1-8 L1-2 Heart T1-5 CN X, Occiput, C1-2 OA Respiratory tree T1/2-6/7 CN X, Occiput, C1-2 Esophagus T2-7/8 CN X (lower 2/3), Occiput, C1-2 Stomach, GB, Liver, Spleen Small intestine T5-9 CN X, Occiput, C1-2 T10-11 CN X, Occiput, C1-2 Pancreas T5-9 (head) T10-11 (tail) T8-L2 CN X, Occiput, C1-2 T5-9 and OA would be acceptable answers for areas to treat in a patient with cholecystitis, however this question asked for sympathetic dysfunction treatment  Sympathetic: T5-9  Parasympathetic: vagus Colon & rectum CN X (ascending; 2/3 transverse to proximal splenic flexure) S2-4 (1/3 transverse colon, sigmoid, rectum) Studying tips  Sympathetic  Ligament of Treitz – divides duodenum and jejunum   Organs before this ligament = T5-9 (Eg. Stomach, gallbladder, liver) Parasympathetic  All organs above the diaphragm = vagus  GI  tested  Ascending colon and 2/3 of transverse = vagus  Descending colon and 1/3 of transverse = Pelvic splanchnic GU  Kidneys and upper ureters = vagus  Lower ureters and bladder = pelvic splanchnic Organ Sympathetic Parasympathetic Head & Neck T1-4 Specific cranial nerves Upper extremities T1-8 Heart T1-5 CN X, Occiput, C1-2 Respiratory tree T1/2-6/7 CN X, Occiput, C1-2 Esophagus T2-7/8 CN X (lower 2/3), Occiput, C1-2 Stomach, GB, Liver, Spleen T5-9 CN X, Occiput, C1-2 Caution : don’t forget about parasympathetic Small intestine T10-11 CN X, Occiput, C1-2 Colon & rectum T5-9 (head) T10-11 (tail) T8-L2 CN X, Occiput, C1-2  Reference “Chapmans points” – these are discussed March 6th Pancreas  https://www.youtube.com/watch?v=B 8Tnmtvhbto Appendix T12 Occiput, C1-2 Kidneys & up. ureter T10-L1 CN X, Occiput, C1-2 Lower ureter & bladder T11-L2 S2-4 Gonads T10-11 S2-4 Uterus T10-L2 S2-4 Prostate L1-2 S2-4 Lower extremities T10-L2 (3) You Tube  Videos for memorization    https://www.youtube.com/watch?v=N -r_QriTMSc Additional video  https://www.youtube.com/watch?v=7 1pCilo8k4M CN X (ascending; 2/3 transverse to proximal splenic flexure) S2-4 (1/3 transverse colon, sigmoid, rectum) Craniosacral Outflow (Parasympathetic) Thoracolumbar Outflow (Sympathetic) Main Ganglia Name of Nerve Organ(s) Innervated CN III — Ciliary Oculomotor Pupils CN VII — Pterygopalatine (sphenopalatine) Facial Lacrimal and salivary glands CN IX — Inferior petrosal to otic Glossopharyngeal Sinuses CN X — Ambiguus to dorsal motor of vagus nerve. Vagus Carotid bodies, carotid sinuses, thyroid, heart, lungs, liver, gall bladder, spleen, pancreas, kidneys, upper ureters, right side of colon S2–S4 — Pass through sacral paraspinals Spinal → visceral Left side of colon, sigmoid, rectum, lower ureters, bladder — T1–T4 Cervical paraspinal Spinal → visceral Head and Neck — T1–T5 Spinal → visceral Heart — T1–T6 Thoracic paraspinal — T5–T9 Celiac Greater splanchnic Liver, gall bladder, spleen, stomach, duodenum, pancreas — T10–T11 Superior mesenteric Lesser splanchnic Small intestines, right side of colon, kidneys, adrenal, upper ureters, gonads — T12–L2 Inferior mesenteric Least and Lumbar splanchnics Left side of colon, sigmoid, rectum, lower ureters, uterus or prostate, bladder Lungs VS Ganglia questions  A 43 year old woman presents to the ER with RUQ abdominal pain, nausea, fever, and leukocytosis. Tissue texture changes are found at the OA and from T7-9 on the right. Which of the following ganglia is likely involved in this viscerosomatic reflex?  Ciliary  Cervical paraspinal  Thoracic paraspinal  Celiac  Superior mesenteric Craniosacral Outflow (Parasympathetic) Thoracolumbar Outflow (Sympathetic) Main Ganglia Name of Nerve Organ(s) Innervated CN III — Ciliary Oculomotor Pupils CN VII — Pterygopalatine (sphenopalatine) Facial Lacrimal and salivary glands CN IX — Inferior petrosal to otic Glossopharyngeal Sinuses CN X — Ambiguus to dorsal motor of vagus nerve. Vagus Carotid bodies, carotid sinuses, thyroid, heart, lungs, liver, gall bladder, spleen, pancreas, kidneys, upper ureters, right side of colon S2–S4 — Pass through sacral paraspinals Spinal → visceral Left side of colon, sigmoid, rectum, lower ureters, bladder — T1–T4 Cervical paraspinal Spinal → visceral Head and Neck — T1–T5 Spinal → visceral Heart — T1–T6 Thoracic paraspinal — T5–T9 Celiac Greater splanchnic Liver, gall bladder, spleen, stomach, duodenum, pancreas — T10–T11 Superior mesenteric Lesser splanchnic Small intestines, right side of colon, kidneys, adrenal, upper ureters, gonads — T12–L2 Inferior mesenteric Least and Lumbar splanchnics Left side of colon, sigmoid, rectum, lower ureters, uterus or prostate, bladder Lungs Ryan, Colton, Peyton, Evelyn – cousins or what!? Somatovisceral Reflex  Somatic irritant causes visceral change  Sato 1989 – pinching of skin of mouse led to increased sympathetic activity and decreased gastric motility.  A somato-autonomic reflex is a reflex elicited by stimulation of somatic tissue and manifesting as an alteration in autonomic nervous system function.  How can we apply this?  Treat constipation by increasing sacral parasympathetic activity with sacral rocking A 3 month old infant presents with her mother who reports issues with hard stools. Which technique would be most appropriate in this situation to affect the parasympathetics?  OAD  Soft Tissue to T10-L2  Rib raising O  Sacral rocking A 3 month old female presents with her mother reporting issues with hard stools. Which technique would be most appropriate in this situation to affect the parasympathetics?  OAD  Soft Tissue to T10-L2 Organ Sympathetic Parasympathetic  Rib raising Small intestine T10-11 CN X, Occiput, C1-2  Sacral rocking Pancreas CN X, Occiput, C1-2 Colon & rectum T5-9 (head) T10-11 (tail) T8-L2  The descending and sigmoid colon is under sympathetic control from T8-L2 and parasympathetic control from S2-4. Appendix T12 Occiput, C1-2 Kidneys & up. ureter T10-L1 CN X, Occiput, C1-2 Lower ureter & bladder T11-L2 S2-4 Gonads T10-11 S2-4 Uterus T10-L2 S2-4 Prostate L1-2 S2-4 Lower extremities T10-L2 (3)  Rocking of the sacrum can stimulate balance to the parasympathetic nervous system and improve constipation. CN X (ascending; 2/3 transverse to proximal splenic flexure) S2-4 (1/3 transverse colon, sigmoid, rectum) Viscerovisceral reflex  Viscera affecting viscera  A reflex in which stimulation of visceral receptors results in activation of visceral motor phenomena.  Viscerovisceral reflexes likely play a role in coordinating the activity between various organs. May not be purely neurological but also humoral.  For example, gastric distention causing increased lower intestine motility. Somatosomatic reflex  Soma affecting soma.  Afferent, dorsal horn, interneurons, efferent via ventral root to motor end plate of another soma. Facilitation  Something that makes something else easier to occur  Definition: The maintenance of a pool of spinal neurons in a state of lowered threshold for activation (a central sensitization)   Less afferent stimulation needed to trigger discharge of impulses  Hyperexcitable neural state  i.e. we become more sensitive May be involved in creating or maintaining  allodynia (non-painful stimulus evoking painful response),  hyperalgesia (pain out of proportion to painful stimulus),  hyperpathia (greater stimulus is required to get a neural response but once evoked, response goes to max intensity),  Referred pain (pain in one area of body caused by different area that is neurally connected) Diagnosis and Treat Diagnosis of Viscerosomatic Reflex  2 or more adjacent spinal segments that show evidence of somatic dysfunction within reflex section  Evaluate the skin for changes in texture, temperature, & moisture.  Evaluate the subcutaneous tissue for changes in consistency and fluid.  Evaluate the superficial and deep musculature for tone, irritability, consistency, and elasticity.  Evaluate the fascia for texture change. Possible findings  Segmental musculoskeletal changes     Acute:  Increased temp and moisture,  Bogginess,  Articular restriction without firm stiff endpoint.  Prolonged red reflex. Chronic: Rubbery Visceloamotic endfeel  Thickened skin,  Increased muscle tension and tone, muscles hard and sensitive to palpation.  Stiff joints with motion restriction with firm definite end feel.  Rapid fading red reflex Intensity may be proportional to severity of visceral path. Have a higher index of suspicion for viscerosomatic reflex if a somatic dysfunction is resistant to OMM.  If you treat a dysfunction and it returns in a few hours, especially with a rubbery end feel, think viscerosomatic. Treatment  Goals  Reduce somatic dysfunction  Reduce facilitation and risk of developing facilitation  Interrupt viscerosomatic reflexes  Acute – break the arc. Gentle, short duration, more frequent treatments. Focus on relaxation of tissues. Do not over treat.  Chronic – Effectiveness less established. May be more aggressive. Things to keep in mind…..  Autonomic System    Parasympathetic  Vagal  Sacral Sympathetic  Thoracic 1-12  Lumbar 1-2/3 Ganglia Boards!  Know your levels.  For EVERY level!  Some laterality may be involved. You are expected to memorize all levels however the following are popular. Organ Head & Neck Upper extremities Heart Respiratory tree Esophagus Sympathetic T1-4 T1-8 T1-5 T1/2-6/7 T2-7/8 Parasympathetic Specific cranial nerves Stomach, GB, Liver, Spleen Small intestine Pancreas T5-9 CN X, Occiput, C1-2 CN X, Occiput, C1-2 CN X, Occiput, C1-2 Colon & rectum T10-11 T5-9 (head) T10-11 (tail) T8-L2 Appendix Kidneys & up. ureter Lower ureter & bladder T12 T10-L1 T11-L2 Gonads* Uterus Prostate Lower extremities T10-11 T10-L2 L1-2 T10-L2 (3) CN X, Occiput, C1-2 CN X, Occiput, C1-2 CN X (lower 2/3), Occiput, C1-2 CN X (ascending; 2/3 transverse to proximal splenic flexure) S2-4 (1/3 transverse colon, sigmoid, rectum) Occiput, C1-2 CN X, Occiput, C1-2 S2-4 S2-4 S2-4 S2-4 FYI Parasympathic Origins DMU Vagus Sensory heart, lungs, organs of trachea, liver, head gallbladder, esophagus, stomach, pancreas, spleen, kidneys, small intestine, ascending and transversion colon Pelvic sex organs, Organs external genitalia, bladder and sphincters DMU DiGiovanna 3rd ed. S2, 3, 4  There is some variability in levels Sympathetic Organ Sympathetic Parasympathetic Head & Neck T1-4 Specific cranial nerves Upper extremities T1-8 Heart T1-5 CN X, Occiput, C1-2 Respiratory tree T1/2-6/7 CN X, Occiput, C1-2 Esophagus T2-7/8 CN X (lower 2/3), Occiput, C1-2 Stomach, GB, Liver, Spleen T5-9 CN X, Occiput, C1-2 Small intestine T10-11 CN X, Occiput, C1-2 Pancreas T5-9 (head) T10-11 (tail) CN X, Occiput, C1-2 Colon & rectum T8-L2 CN X (ascending; 2/3 transverse to proximal splenic flexure) S2-4 (1/3 transverse colon, sigmoid, rectum) Appendix T12 Occiput, C1-2 Kidneys & up. ureter T10-L1 CN X, Occiput, C1-2 Lower ureter & bladder T11-L2 S2-4 Gonads T10-11 S2-4 Uterus T10-L2 S2-4 Prostate L1-2 S2-4 Lower extremities T10-L2 (3) DiGiovanna 3rd ed., 40 FOM2 96-7,112 Goetz Neurology 2nd Chapter 21 Sympathetic Outflow heart, lungs, trachea, liver, gallbladder, esophagus, stomach, pancreas, spleen, small intestine, ascending and transversion colon heart, lungs, trachea, liver, gallbladder, esophagus, stomach, pancreas, spleen, kidneys, small intestine, ascending and transversion colon Reproductive organs, bladder, pelvic colon, and rectum Kidneys, bladder and sex organs FOM 2 FOM 2 Pages PGH OMM Manual T1-5 T1-4 FOM2 100 T1-5 T2-4 T2-5 T5-6 T6-10 T1-5 T2-5 T5-7 FOM2 111 FOM2 98 FOM2 98 T1-4 C6-T1 T5-9 FOM2 111 T3 R, C3-C5 T5-9 L T7-9 T7-9 T5-11 T6-9 FOM2 111 FOM2 111 T6-9 BL T5-9 R Page 47 Head and Neck Thyroid Heart Lung UE Esophagus Lower Esophagus and Stomach Spleen and Pancreas Liver and Gallbladder T1-4 T1-4 BL T1 - T5 L T1 - T6 BL T2 - T8 T5-T9 L T7 L,/ R T5 R & T6-9 R Adrenal T10-T11 B/L T8-10 T2-5 B/L T1-4 T2-6 T10-11 Small Intestine T10 - T11 Ovary/Testes T10 - T11 Kidney T10-T12 T9-10 T10-11 T10-L1 T9-11 T9-T10 T10-L1 FOM2 111 FOM2 111 FOM2 111 T10-12 R T10-L1 T10-L1 Ureters T10 -T11; T12-L1 Bladder T12 - L2 Prostate and Prostatic T12 - L2 Urethra Cervix T11-L2 T10-L1 FOM2 111 T10-L1 T11-L2 T11-L2 T10-L1 L1-2 FOM2 111 FOM2 111 T10-L1 L1-2 FOM2 111 LE T 11 - L 2 T10-T11 R T11-L2 T11-L1 T10-L2-3 T10-12 FOM2 98 FOM2 110 L3-5 L1-2 (pelvic organ) L1-2 (pelvic organ) L1-2 T12 - L2 T10 - L2 L T12 T12-L1 L1-2 T10-L1 L1-2 FOM2 111 FOM2 110 Ascending and Transverse Colon Genital Organs Uterus Descending and Sigmoid Colon and Rectum Goetz Neurology 2nd Chapter 21 Sympathetic Outflow T1-3 L1-5 R L4, 5 L4, L5 L1-5 L T11-L2 T12-L2/T9-L2 How would I approach this in clinic other than just treating viscerosomatic spinal dysfunction? or low itnormotz.es  OAD: Normalize vagal tone tohigh  Correcting SD from T1-L3: Normalize sympathetic tone  Active Rib raising: Increase sympathetic tone  Inhibitory pressure to thoracolumbar paraspinals: Decrease sympathetic tone  Sacral Rocking: Normalize parasympathic tone Io VIII L Porosimpots c tone Patient with asthma  What organ: Lungs Organ Sympathetic Parasympathetic  What do I want to do: Head & Neck T1-4/5 Specific cranial nerves Upper extremities T2-8 Heart T1-5 CN X, Occiput, C1-2 Respiratory tree T1/2-6/7 CN X, Occiput, C1-2 Esophagus T2-7 CN X (lower 2/3), Occiput, C1-2 Stomach, GB, Liver, Spleen Small intestine T5-9 CN X, Occiput, C1-2 T8-11 CN X, Occiput, C1-2 Pancreas CN X, Occiput, C1-2 Colon & rectum T5-9 (head) T10-11 (tail) T8-L2 Appendix T12 Occiput, C1-2 Kidneys & up. ureter T9-11 CN X, Occiput, C1-2  Decrease/normalize parasympathetic input to lungs to decrease bronchoconstriction   Increase sympathetics input to lungs to increase bronchodilation   As the parasympathic input would contracts bronchiole smooth muscle and thins secretions As the sympathetic input would relax bronchial smooth muscle How would I achieve this CN X (ascending; transverse) S2-4 (descending, sigmoid, rectum)  OAD – normalize parasympathetic  Rib raising – stimulate sympathetic Lower ureter & bladder T11-L2 S2-4  Remove any SD of OA, T1-7 Gonads T9-11 S2-4  Treat SD or ribs, diaphragm, lymphatics, C35 keeps the diaphragm alive Uterus T10-L2 S2-4 Prostate L1-2 S2-4 Lower extremities T11-L2 S2-4 References  References  M Seffinger; Foundations of Osteopathic Medicine, 4th Edition; Copyright © 2018 Wolters Kluwer Health / Lippincott Williams & Wilkins  A Chila; Foundations of Osteopathic Medicine, Third Edition; Copyright © 2011, 2003, 1997 Lippincott Williams & Wilkins  SG Waxman; Clinical Neuroanatomy, Twenty-Seventh Edition; Copyright © 2013 by McGraw-Hill Education  RG Saverese; OMT Review, 3rd Edition; Copyright 1998 John D. Capobianco  ECOP