5 OPP Somatic Dysfunction

8/2/2019 5 OPP Somatic Dysfunction

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SOMATIC DYSFUNCTION


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Kirksville, 1920s-30s, experimented in producing lesionsin the vertebral segments of rabbits, guinea pigs, dogs,by pushing the vertebra 40 X a minute in one directionuntil its position altered

Acute lesionsFound

Chronic lesionsAcute:

Altered position of vertebraeLocal oedema - felt 'doughy'Swelling of periostium

DiscsLigamentsSmall deep muscles wereLess striatedHad areas of rigorOedema

Muscle fibres appeared damagedBv's of deep muscles engorged and haemorrhaged'Putty-like' areas in otherwise soft tissueFlinched when touched - exquisite hypersensitivity


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Chronic (ie present for more than 2 years)Areas of connective tissue hyperplasia in the muscleAtrophy of muscle fibresHard 'knotty' areas - achy but not hypersensitiveSynovial membranes round joints thickeningSynovial fluid diminuishingReduced joint mobilityReduced disc thicknessSmaller and less elastic nucleus pulposusSkin above dry and scaly and maybe hypersensitive

to touch, pain, heat I cold

so we had empirical observations of what you'd find at alesioned area.Observing this, Denslow and Korr started to look at whatwas happening neurologically in the lesioned area, to seeif they could explain these empirical findings

Before we look at their experimental results, need alittle divergence to remind ourselves of relevantanatomy ...


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Nerve fibres in a single segment of the spinal cord

I.{. - ~ ti 't- lekp, . .n(A.~~

V(f~ . } VI~C-~Mf1:..4U I'JT'C'"'-J[g~ )

l( _ hl~ V.t,..V~J.l . 5 f -~/L~ (j,. M~

$:~Vl~ --piJ~ \. k :..~ .

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The previous diagram shows the neurons going into andout of the spinal cordBut there are other neurons in these pathways .......he interneurones, and the tracts going up and downthe spinal cord

Because of this layout I theoretically every nerve fibre(efferent, afferent, somatic or autonomic) in the bodycan connect wth and influence every other nerve fibre (remember I 'the body is a unit')This is the PRINCCIPLEOF RECIPROCITYit follows that ....


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..... if the stimulus is large enough, orthe threat is great enough, orthe dysfunction is severe enough,

then large parts of neural control can be disrupted

THIS CONCEPT UNDERLIES MUCH OF OSTEOPATHICUNDERSTANDING OF THE DISEASE PROCESS, ANDWE'LL SEE WHY IN A MINUTE

We know that the NS works largely on the basis ofreflexes, ie pre- programmed 'wirings up' of neurons

But although many of these reflexes arepre-programmed, they can under some circumstances bere-programmed

One of the ways they can become re-programmed is bythe synapses becoming more sensitive to stimuli (ie neurotransmitters)Another way is by more connections being made betweenparticular neurons


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You'llremember that in order to fire, a nerve must reacha threshold level of depolari zction, through either spatialor temporal summation

Temporal spatial

: . .'. t.'..'~.

The level of readiness of any neurone(s) to fire at anyone time is a result of the summation and is called thedegree of facilitation of the nerve(s)The greater the degree of facilitation (ie the greaterthe level of temporal or spatial summation, the moreeasily the nerve w i l l fire

END OF D IVERSION - BA CK TO DENSLOW ANDKORR


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Denslow and Korr looked at the neural activity going on ina segment that was showing all the signs of alteredactivity (see previous list)

They deliberately stimulated the dysfunctional segmentsby applying increasing amounts of pressure to them. Asthey increased the pressure on a segment I they measuredthe reflex response of the surrounding muscle

They found that segments showing the signs of somaticdysfunction required less stimulation to cause themusc les to contractWhy? .....


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...the increased responses could have been due toeither increased responsiveness of local sensory

receptors in the segmentor increased level of readiness of the motor

neurons at that segment to fire le increasedfacilitation in those neurons that have synapsesat that level

further experiments showed that it was the second ofthese - somehow, somatic dysfunction increased the levelof readiness of the motor nerves with synapses at thatlevel to fireso any nerve I somatic or autonomic # from anywhere inthe body which synapses at the level of the somaticdysfunction, may cause a neurone, sensory or motor Ito be more highly faeil itated and therefore to firewhen it otherwisw wouldn't have


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Korr called this phenomenon the Neurological Lensbecause it appeared to focus or concentrate stimuli atthis level(in fact, what's happening is that because the neurons atthat level are already more highly stimulated than theyshould be, it only takes a small extra amount ofstimulation to fire them. To push the lens metaphorfurther than it probably ought to goI you could say ittakes less sun through the lens to ignite paper that ismore combustible than usual)These experiments looked at somatic structures-skeletal musclesBut empirical cliniccl observations suggested that somaticdysfunction affected visceral function alsoQ: if these clinical observations were right I which partof the N5 must have been influenced in some way?

A: the Autonomic N550 Korr and co started experimenting to find out whateffect somatic dysfunction had on the ANS, and inparticular the sympathetic part of the ANS


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Q; which unpleasant feature of bodily functioning doesthe sympathetic NS affect that is easy to measure?

A : sweat (sudomotor function)Inc SNS activity causes increased sweating which causesan electric current to pass more easily, and increasedskin temperature .. which is easy to detect

As you might expect, experiments showed that theelectrical conductivity and temperature of the skin wereraised over areas of somatic dysfunction I

SubsequentlyI Korr & co encouraged further areas ofsomatic dysfunction by putting subjects in eg high heels

Not surprisingly, they found further areas of raised skinconductivity and temperature 2 . .

So what? ..


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....f we Assume that the whole sympathetic efferentoutflow (ie smooth muscle of viscera, bv walls etc) areaffected in the same way as the outflow to the sweatglands are, then, we can hypothesise that:

mechanical dysfunction may exaggerate neurologicalactivity, both somatic and autonomic, at a particularspinal cord level (the neurological lens),andthat this exaggerated neurological activity maycause inappropriate responses in an otherwisenormal reflex physiological activity at that level,

andsince these otherwise normal physiological reflexeswould normally be maintaining the finely balancedhomeostatic.mechanisms that maintain the normalitythat we call health"

thenthe inappropriate response caused by theexaggerated neurological activity set off by themechanical dysfunction, may predispose to ill health(disease) by disrupting the homeostaticmechanisms that maintain health

SO NOW WE HAVE A POSSIBLE MECHANISMLINKING A PHYSICAL/MECHANICAL DYSFUNCTIONTO A VISCERAL OUTCOME


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Arguably, this has all sorts of implications for thepotential for osteopathic treatment, which is oftenthought of as a purely mechanical/physical therapy

So far so good, but we hoven't yet explained why aparticular segment may end up in a state of long termincreased facilitation .


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Sdys620Causes of increased facilitation at a segment

Remember I some degree of facilitation (level of readinessto fire) is normal and necessaryAn increased degree of facilitation may also be a normalresponse to an abnormal stimulusThis normal and appropriate increase in readiness to fireis called sensitizationEg, suppose you sprain your wrist. This will cause all sortsof insults to the tissues eg overstretch of muscle,tendon,capsule/etcThe immediate response would be a vastly increasedafferent surge to- the spinal cord from the damagedtissue - this would be normal, and would result in:Reflex withdrawal of limb

) somaticInhibition of muscles (local paralysis)Constricted local bv's to reduce blood lOSS)

autonomicDilated bv's in sk muscle to aid F & FPain sensation via long tracts


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I repeat t this immediate response is a normal response toabnormal circumstances (sprained wrist in this case).What's abnormal (and what we call somatic dysfunction)is when this increase in response is greater than thestimulus warrants, ie the circumstances are not thatabnormal but you still get a big response

ndThe response is long term

S_ummaryof terminologyUsual stateOf readinessTo fire

appropriate increasedstate of readiness

to fireinappropriatestate of

read iness to fireFacilitation sensitization somatic dysfunction

What sort of damage can cause this inappropriateresponse? .


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Sdys640Possible causes of somatic dysfunction

Classified according to the site of entry into the spinal cord, ieeither by the posterior or anterior division of the dorsal root

1. SOMATIC1.1 Posterior Division1.1.1 AcuteAcute Joint Sprain (traumatic synovitis)Eg by sudden uncoordinated movement or impact causing tearof capsuleEg 2. overloading joint, especially in a position of mechanicaldisadvantage,

Eg a) flexion + lifting + torsionb) prolonged semiflexion overloading joints

Muscle strainEg 1. tearing of muscle fibres leading to spasmEg 2. inappropriate turning up of gamma gain (see later lecture)Ligament overstretch ingOften cssoc with hypermobile segment - maybe due to overuse ofHVTDisc DegenerationHerniation of annular fibres (which are pain sensitive)


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Sdys6501.1.2 ChronicChronic joint sprainEg 1 . unresolved acute joint sprainEg 2. mechanical occupational stresses, especially if asymmetric

Eg repetitive movementsMaintained position

Eg 3. Postural adaptationAlP plane eg 'reversed' curves, spondylolisthesis,

exaggerated curvesLateral plane eg PSLE, scoliosis, hip or kneedegeneration, sr problem

Temporary adaptation eg knee meniscus problem,sprained ankle etc

1.2 Anterior Division

1.2.1 Acuteperiheral Joint sprainsaffecting capsule, muscles, ligaments, cartilage or meniscimuscle tearof larger muscles acting over jointsligament overstretch1.2.2 ChronicDegenerate changes in jointsPostural adaptation or habit

Eg 1. joint eg hip knee held in flexionEg 2. ligament stretch or shortening


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2. AUTONOMICincreased afferent impulses from nocicepters in pathological orirritated visceral structures

Any of these may be responsible for initiating alocal spinal increase in facilitation (sensitization)by bombarding the cord with afferent impulsesUsually, these increases in facilitation areappropriate and short term

So how do they become long term and. .t ?Inapproprla e .


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...several possible ways - it's not dear, but:the wiring of the NS is not fixed - it's plastic. Neuronescan make new connections with other neurons and severexisting connections. How?Sensory stimuli actually affect the DNA of neurons theytravel down and cause them

a) to make or break connections and therefore makeor break pathways

b) release more neurotransmitter

Pain is a very powerfu l sensory stimulus, so a damaged orstrained tissue which does not heal, eg because it iscontinually irritated or opened by movement I may over along period develop a very strong and secure set ofcoonections (pathwy) to the spinal cord

These pathways are, in effect, a very strongly learnedresponse causing a big stimulus (inappropriately big)message to the spinal cord from a relatively smallstimulusWe have our conditions for somatic dysfunction


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But, if sensory stimuli can change the NS pathways 'forthe worse', in principle it might be possible for differentsensory stimuli to change them 'for the better'.

Soft tissueHvtFunctionalEtc


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"The nervous system controls and co-ordinates all organs and structures of the human GraysAnatomy 29th edition pA Mis-alignments of spinal and discs may cause irritation to the nerves

which could affect areas listed.V erteb ra A reas C on tro lled Ne rves ' P o ss ib le E ffe cts of a Malfunction

Blood to th esca lp , bones o f t he f ace , andm i dd le e a r, s ym pa th e ti c n e r v o u s system

o headaches , 0 ne rvousness , 0 insomnia ,o head colds,0 h ig h b lo o d p re s su re ,om i gr ai ne h e ad a c he s , 0chron ict i redness, 0d izz iness.A TLA S __ --- ,. .., ..- - ;::;;:AX IS ---~~Jrl I--------------z--------------C h ee ks , o ute r e ar , fa ce b on es , te eth . t r i o Qf ac i al n e r ve ff j 0 n eu ra lg ia . 0 n eu ritisr-------------------~----------------:::.::: 0 r unny n os e, 0 hear ing lossr-----------------~------------------z 0la ryng i t is , 0h o ar se n es s , O l hr oa tc on ditio ns s uc h a s s ore th ro at

E yes , op tic ne rves , nerves ,s in u se s .r na s to id b o ne s , t on g ue , f or eh e ad

CERV I CA LSPINE1 s tTH 0 RA C IC -----,~-;.,;=~

pharynx

o stiff neck , 0pa in in upp er arm ,o t on s ill it is , O c h ro n ic c o ug hhou lders, t o n s i l s

o s in us tro ub le , 0 a lle rg ie s, 0 p ain a ro un deyes , 0earache, 0f a in t in g sp e ll s ,Odeaf l1ess

o bursit is, o t h yr o id co n d it io n sh yr oid g la nd , b urs ae in th e s ho uld ers ,e lbow s .o cough , 0d ih ic u lt b re a th in g o r s h or tn e sso f b re ath , O pa in in lo wer a rm s a nd h an ds

O liv e r c o n d s io n s , 0 b lood p r e s s u r e1-- C _ i , _ . C _ U I _ o t _ i o _ n _ ( 9 _ ' e _ n _ e _ r a _ l l _ p rob lems , 0poo r c i r cu la t ion

;ii 0s tom a ch t rc u bl es o r n e rv o us s tom a ch ,o O in dig es tio n, O b ea rtb um , o dy sp ep siaI - - - - - - - - - - - - - - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - - - - - -

A r m s fro m Ih e e lb ow s d ow n, in du din ghands , and finge rs ; esophagusa n d t ra c he awZ0..(J)oo0 : : :o. J . . .l-

o f un c tio n al h e ar t c o nd it io n s a n d c e rta inc h e s t c o n d it io n so b ro nc hitis , 0 p le ur is y, 0 p ne um o nia ,o o in f luenzao g a ll b la d de r c o nd it io n s

O i ow e re d r es is ta n ceo a ile rg ie s, 0 h iveso k id n ey t ro u bl es , 0ch ro n ic t ir e dn e s s ,o n e ph ri ti s, 0 p y el it is

.," o s kin c on ditio ns s uc h a s a cn e, 0 p im p le s,o eczema , 0boilso rh eu ma tis m, 0 9a s p ain s

o const ipa t ion , 0c o li ti s, 0 d ia rr ho e aLUMBARSPINE

Ocramps , o d i ff ic u lt b r e at h in g , Om i n o rv ar ic os e v ein sS ex o rg an s, u te ru s, b l a d d e r , knees

o b la dd er tr ou ble s, 0 m e ns tru al tr ou ble s~ su ch a s p ain fu l o r i rre gu la r p erio ds ,: 0 c ha ng e o f l if e s ym pt om s , 0 m a ny k ne e1-- ~ pa insg o s ci at ic a , l um b a go , O d iff ic u lt . o pa in fu l ,! or fr eq ue nt u rin atio n, 0 b ac ka ch esP ro sta te g la nd , m u sc le s o f th e lo we rba ck , s c ia ti c n e r ve

a n kl es , f ee t o p oo r c ir cu la tio n 1 n th e le gs , 0 s w olle nankle s . 0 w eak ankle s and a rches, 0 co ldfee t , ow ea kn es s in th e legs, oleg c ramps~ ( ~ ~ ~ r~ ; ~ ~ 2 Co n di ti on s , 0

I!' I---------------u--------------\j:\~... ~ Coccyx Rectum , anus o, 0 pa in a t end of sp ine oner .> ..COCCYX ''''-i~ . D irec tly or ind ire c tly con tro lled Source : Unknown


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Sympathetic Efferent Cell Locations of Selected VisceraAccording to Various Authors

V i s c e r a 1937 1944' 1953 1953Chapm an Po tte nqe r G illi lan K un tz 1966Cra f t 1969E l l i n t l 1978 1988G ray Kuche raS in us es , E u sta ch ia n T ub es T1-4

P u pil D ila tio n C7 -T3 T1 11-3 C8 -T3 T1-4 -4la cr im a flS aliv ary G la nd s T1-3 T1 -4 T1 -4

Thy ro id T2 T1-4 T1-4Trachea/Bronch i T1-6

Esophagus ! Lowe r 2/3 T2 T5 -10 T1 o - u T6- l1 T5-6" " AD ria TI-5Hear l T1 T1 -4 -5 T1-6 n -5 T1

LungsN isce ra l P leu ra T3 -4 Tl-6 _ T 1 - 4 T2-5 12-4 T1-6S tomach T5-6 T5 -9 (12 ) T5 -8 T5 -9 T5 -10 T6-10 TS-9LDuodenum TS-9 T5 -9 T5-9

l iver T5 R T5 -9 T7 -10 T5 -9 T5 -6 T7-9 T5RG all B la dd er a nd D ucts T6 R T5 -9 19 -10 T5 -11 T7-9 T6R

Spleen L T6-8 TS -9 T6 -8 T6-10 T7 lPanc reas T7 R T5-9 T5-9 T5-6 T6-10 T7R

Sm a il In tes tines T8 -10 T5-9 TIO11 T5 -9 1510 T9 -10 T10 -11Colon T10-L2 T11 -12 T5 -10 T11 -L2 T10 -L2

R ig ht C o lo n TjO-11Append ix T11 T12L ett C o lo n T1Ad rena l T11 TS -9 T8 -11 T5-11 T8 - L1 T10-11K idney T12 T 6-L 1 T12 T8-12 T12- l2 T100r11 T l O -L 1 T10-11

Uppe r Ure te r T10 -11low e r Ure te r T12 -l1

" B ladde r (Body ) L2 L2-5 l1-2 T12-L2 T11 -l2 T11 -L2 T12-L2B l adde r T r igone /Sph inc te r T11- l3 L2

O va ry a nd Te ste s T9-10 T9-11 T9-10 T10 -12 T10 -11 T10-11 T10-11U te rin e B od y 11 O -LS Tt1 -12 T10-11 T12-L2(2) T12- l2

Prosta te ", U-2 T11-U T12-L2G e nita l C a ve rn ou s T is su e L2

Mamm ary G lands T4 6 T1-6A rms T2 -5 T2 -8legs T10 -L2 T11- l2


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vyWplUIII:::::> VI e prnat IVllsalignment"The nervous controls and co-ordinates all and structures of the human GraysAnatomy 29th edition pA Mis-alignments of spinal vertebrae and discs may cause irritation to the nerveswhich could the areas listed.

Vertebra A re a s Co nt ro lle d b y Nerves" Poss ib le Effects o f a M a lfu n ct io n

A TLA S __ - .. - , ,- :: ;: : :; ;:_ ~A XIS _ _ ,. . . , ,~ ;. ; . ;{

B lo od s up ply to th e h ea d, p itu ita ry g la nd ,s ca lp , b on es o f th e fa ce , b ra in , in ne r a ndm id dle e ar , s ym p ath etic n erv ou s s ys te m

E y es , o p tic n e rv es , a u dito ry n e rv es ,s in us es , m a sto id b on es , to ng ue , fo re he adr - - - - - - - - - - - - - - - - - - - - - - - - - - z - - - - - - - - - - - - - - - - - - - - - - - - - - - - -C he ek s, o ute r e ar, fa ce b on es, te eth , tri- gf a ci al n e rv e U l 0neuralgia, 0neuri t isr - - - - - - - - - - - - - - - - - ~ - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Nose, lips , m ou th , eustach ian tube ::.:: 0 r un ny n os e, 0h e ar in g lo ssr - - - - - - - - - - - - - - - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - -z 0 laryngi t is, 0hoarseness , 0 throatc on ditio ns s uc h a s so re th ro at

CERV I C A LSP I N E1s tT HORAC I C - -,~ , .:; . . ;: V oc al c ord s, n ec k g la nd s,

o headaches, 0nervousness , 0 i nsomnia,o h ea d co ld s, 0 h ig h b lo od p re ss ure ,omigra i n e head ac hes , 0chronict i redness, 0 dizziness.o s in u s t ro ub le , 0al lergies, 0p a in a ro u ndeyes , 0earache. 0f ai nt in g s pel ls ,o deafness

Ne ck mu sc le s, s ho u ld e rs , t on sils o s tiff ne ck, 0 p ain in u pp er a rm ,o tonsil l i tis, o c hr on ic c ou g hT hy ro id g la nd , b urs ae in th e s ho uld ers ,e lbows o bursi t is, 0colds, 0 t hy ro i d cond it ions

o cough, 0d if fi cu lt b r ea th in g o r s hor tn e s so f b reath , D pain in low er a rm s and handsA rm s fro m the e lb ow s dOVIn , includinghands, wrists, a n d fin g er s; e s op h ag u sa n d tr ac he awZ0..Cf)oo


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Sympathetic Efferent Cell Locations of Selected VisceraAccording to Various Authors

, V i sc e r a 1937 1944' 1953 1953C h a p m a n P o U e n g e r G i l l i l a n K u n t z 1966G r a f t 1969a n e n 1978 1988G r a y K u c h e r aS in us es , E us ta ch ia n T ub es T1-4

Pu p il D i la tio n C7 -T3 T1 T1-3 C8 -T3 T1-4 T1-4L ac rim a l/ Sa liv a ry G la nd s T1-3 T1-4 T1-4

Thyro id T2 T1-4 T1 -4Trachea /Bronch i T2 T2-4 T1-4 T2-4 T1-6

E so ph ag us lL ow er 2 /3 T2 T5-10 T 1 O - L1 rs-u T5-6- A o r t a T1-5Hear t T2 T1-7 -4 -5 T1-6 T1-5 T1-6

Lungs iV isce ra l P leu ra T3 -4 T1-6 T1-4 T2-5 T2-4 T1-6Stom ach T5-6 T5-9 (12 ) T5 -8 T5-9 Hi-10 T6 -10 TS-9 l

Duodenum T5 -9 T5-9 T5 -9Live r TS R T5 -9 T7-10 T5 -9 T5-6 T7~9 TSR

G all B lad der a nd D uc ts T6 R T5-9 T9-10 TS-11 T7-9 T6RSp leen T7 l T68 T5 -9 T6-8 T6-10 T7 l

P ancreas T7 R T5-9 T5 -9 TS-6 T6-10 T7RSma ll In te s tin e s I T8-10 T5-9 T10-11 TS-9 T5 -10 T9-10 T10-11Co lon T10 -l2 1 -12 15-10 T11-L2 T10-L2R igh t C o lon T10-11

Append i x T11 I IT12

L eft C o lo n I 2-l2Adrena l T11 T5-9 T8-11 T5-11 T8-L 1 T10-11K idney T12 T6L1 T12 T8-12 T12-L2 T10o r11 T1 O -L 1 T1 0-11U pp e r U re te r I T10-11L ow e r U re te r T12L1_ B ladd er (B ody) L2 L2-5 L1-2 T12-L2 T11-L2 T11-L2 T12-L2

B l adde r T r ig one /Sph in c t er T11-l3 L2 T12-L2O va ry a nd T es tes T9-10 19 -11 T9 -10 T10-12 T1 O~11 T10-11 T10-11

U te rin e B od y TI0- lS T 1 , 1 - 1 2 T10-11 T 12-L2 (2 ) T 12 -l2Prostate " L1-2 T11-l1 T12-l2

G e nita l C a ve rn ou s T is su e L2M am m ary G land s 14-6 T1-6

A rms 12-5Legs 110-L2 T11-L2

5 OPP Somatic Dysfunction

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