Viscerosomatic Reflexes Science of Osteopathy

John M. Lavelle, OMSIV, OMM Fellow

Objectives:1. Describe the anatomic and physiologic characteristics

of the autonomic nervous system.2. Describe the concept of facilitation and its importance

to somatic dysfunction.3. Describe the concept of viscero-somatic and somato-

visceral reflexes.4. Describe Chapman’s Reflexes.5. Explain specific reflex patterns commonly seen with

organ system dysfunction.6. Explain what causes somatic dysfunction.

CASE: KH CC: 48 y/o C FM with abd pain, SOB, N/V, dec appetite. HPI: Pt states that for the past day she has been unable to eat.

She has intense pain located in upper abd with extreme nausea and emesis x2. She has had difficult walking more than 10 ft due to SOB, fatigue and pain.

PMHx: Hypertryglyceridemia, Hyperlipidemia, HTN. SocHx: Smoker (40pack/yr), ETOH (6beers/night),no ellicits PSHx: Cholcystectomy PFHx: M) dec, MI(66); D) Alive(68) - HTN, Inc Chole; No children.

PHYSIOLOGY

Reflex Mechanisms

Viscerosomatic reflexes:

“Localized visceral stimulation produces patterns of reflex response in segmental related somatic structures.” – Glossary

Spinal Physiology Visceral inflammation activates general visceral

afferent neurons (through the dorsal horn). The effect, of which, upon ventral horn motor

neurons, results in segmentally related tissue texture change, a viscero-somatic reflex.

The degree of the intensity of the paravertebral response is directly proportionate to the severity of the visceral pathology.

Reflex Mechanisms Louisa Burns, D.O. performed studies on animals in various stages

of pregnancy. Electrical stimulation of the body of the uterus caused contraction of

the muscles near the second lumbar vertebra. Furthermore, electrical stimulations at the second lumbar vertebra

caused uterine contractions which were regular and strong. These stimulations were accompanied by contraction of the uterine vessels and rigidity of the uterine cervix.

Inhibition of the tissues near the lumbo-sacral junction caused the dilatation of the cervical vessels and relaxation of the cervix

Repeated by Irvin Korr, Ph.D. in dogs; showed that there is a mechanism by which the sensory afferent neurons from the viscera convey impulses through the spinal cord, and INTERNUNCIAL CONNECTIONS with gamma efferent motor nerves, to the paraspinal muscles18.

Reflex Mechanisms In a double labeling study performed at MWU by Ross

Kozinski and our OM Fellows, OMM fellows (Greg Collins and Jay Miller), a mouse gallbladder and intercostal nerve were injected with two different color axonally transported dyes. The dorsal root ganglion of the effected segmental level was studied. It was found that there were “double labeled” DRG cell bodies showing viscero-somatic convergence. There were approximately 1.8 axons per nerve cell body. One axon innervating the viscera and one to the soma.

Reflex Mechanisms Viscerosomatic convergence does not only

occur in the spinal cord or brain, it also occurs in the dorsal root ganglion.

Reflex Mechanisms Dr. Burns showed, in humans, that electrical

stimulation of the tissues near the fourth thoracic vertebrae caused an increase of as much as fifteen beats per minute in the pulse rate. 

Stimulations to the tissues near the fourth and fifth thoracic vertebrae caused a decreased amount of blood in the hands.

Therefore, it is possible through OMT to the thoracic spine to cause change within the upper extremities and upon the heart18.

Reflex Mechanisms Single organs project a response to

multiple cord levels. Clinically, the palpable response is much

more focal. Beal8 does an excellent job of describing the palpatory quality.

The palpatory findings are skin and sub-cutaneous puffiness.

Reflex Mechanisms Dr. Larson looked for the center of intensity

of the tissue texture change; and he tended to report single segments.

Therefore, a basic scientist/neuroanatomist might report reflex at T1 – T6 from lung. Dr. Larson would report T3.

Reflex Mechanisms The mechanical nature of somatic

dysfunction produced by viscerosomatic reflexes centers around muscle hypertonicity. However, the palpatory motion is described as RUBBERY/ ELASTIC. No firm barrier to the motion.

Nocioception helps maintain the VSR.

Reflex Mechanisms The purpose of understanding and

palpating viscerosomatic reflexes is clinical problem solving, not didactic.

Those clinicians who use viscerosomatic reflex information in clinical problem solving have a wealth of experience.

Not just DO’s: right shoulder pain with cholecystitis.

Reflex Mechanisms

Somatovisceral reflexes

 

“Localized somatic stimulation produces patterns of reflex response in related visceral structures.” – Glossary

Reflex Mechanisms MR. X case: X was involved in a MVA about 4 weeks

prior to this presentation. She suffered whiplash and minor soft tissue injuries. Dr. X was evaluated in my office for a chief complaint of shortness of breath, dry cough, more severe at night, and occasional wheezing. She was found to have a severely extended upper thoracic dysfunction. Her peak flows ranged from 210-230. She was diagnosed with an exacerbation of asthma. She was treated with OMT, inhaled corticosteroids and B2 agonists. How would an upper thoracic “sprain” cause bronchospasm?

Reflex Mechanisms Sato in 1975 demonstrated changes in

heart rate in response to skin stimulation. Cats with intact cord and brain showed cardiac changes with stimulation of any dermatomal level. Cord transection caused the cardiac response only to upper thoracic skin stimulation.

Reflex Mechanisms Whiting et al showed a decrease in the time of labor in

223 women between prenatal women who received OMT versus prenatal women whom had OMT withheld from their treatment regimen20.

Hart et al also documented a decrease in labor time in 100 women when comparing women who received OMT to the lumbar vertebrae versus those who did not17.

Apparently, by manipulating the lumbar spine, it is possible through somato-viscero feedback to affect the pelvic viscera and induce uterine contractions.

Reflex Mechanisms

Somatosomatic reflexes

 

“Localized somatic stimulation produces patterns of reflex response in segmental related somatic structures.” – Glossary

WHAT MAKES UP TISSUE TEXTURE ABNORMALITY?

Tissue Texture Change: Palpable Evidence of Disturbed Physiology

Weiss and Hiscoe7 showed in the late 1940’s that there is continual flow of axoplasm from the cell body down the entire length of the axon. The rate of flow was estimated at about 1 mm per day.

Tissue Texture Change: Palpable Evidence of Disturbed Physiology Substance P is released from central and peripheral

sensory neurons, and plays an important role in the propagation of the local inflammatory response. Its effects in the dorsal horns may contribute to spinal facilitation seen in chronic pain.

In response to Substance P and local cytokines, the sympathetics release Norepinephrine and the adrenal gland releases cortical hormones. Tissue texture abnormality is not just a local phenomenon!

Tissue Texture Change: Palpable Evidence of Disturbed Physiology

There is more to a “muscle knot” than you think! Palpable muscular tension may be related to sympathetic influences! A viscous cycle between inappropriate mechanoreceptor reporting and exaggerated muscular response can maintain an inappropriate spinal reflex.

FACILITATION? The facilitated segment is the physiologic

cornerstone of somatic dysfunction. In segmental facilitation, a spinal segment receives exaggerated input from somatic or visceral structures.

Facilitation is the maintenance of a pool of neurons (internuncial) in a state of partial or sub-threshold excitation. Facilitation involves the general somatic nerves as well as the autonomics.

The Response The external response is generally inappropriately

exaggerated. Findings may include muscle hypertonicity, skin sensitivity and diffuse severe tenderness. The tissues of this type of patient are generally reactionary to treatment and more prone to “flare”.

Local sympathetic hyperactivity exaggerates the spindles response to changes in length3,4. Muscles innervated by these segments are kept in a hypertonic state with subsequent impediment to spinal motion.

Local Processing: Peripheral Nervous System

The peripheral nervous system can be divided into two separate divisions. (sympathetic and parasympathetic)

Sympathetic Nervous System The sympathetic nervous system adjusts

the internal environment of the organism to EXTERNAL environmental stressors. The sympathetic nervous system is involved in the “fight or flight” response to an external stressor.

Sympathetic Nervous System The sympathetic nervous system

innervates its peripheral structures via thoraco-lumbar outflow (T1-L2,3).

Enhances or accelerates the activity of organs

Sympathetic Nervous System The sympathetic chain ganglia (paravertebral) lie

on either side of the spine, anterior to the costotransverse articulations.

It is hypothesized that somatic dysfunction of the ribs may affect the paravertebral ganglia due to their anatomic proximity to the costotransverse articulations.

Parasympathetic Nervous System The parasympathetic nervous system

adjusts the internal environment of the organism to the needs of INTERNAL environment. The parasympathetic nervous system innervates a majority of visceral structures via the vagus nerve.

Parasympathetic Nervous System It has cranial and sacral outflow (cranial No. III,

VII, IX and X and S2-S4). Palpatory findings of abnormal function of the

vagus nerve are found at C2. Consider that C0,1,2 are a functional unit when treating your patients.

Cranial or sacral somatic dysfunction can affect parasympathetic tone to related viscera.

Inhibits or decelerates the activity of organs

Spinal Facilitation S.D. leads to prolonged inappropriate

sympathetic bombardment

The maintenance of a pool of neurons in a state of partial or subthreshold excitation…less stimulation is required to trigger the discharge of impulses (A.P.)

Spinal Facilitation May be due to sustained increase in

afferent input, or changes within the affected neurons themselves

Can lead to alterations in muscle tone resulting in myofascial connective tissue stiffness, contracture and pain.

Palpation of VSR Special attention to costotransverse area. Skin and subcutaneous tissue texture

changes (acute or chronic). Resistance to segmental motion with

ambiguous barrier.

Acute Reflexes Increased skin temperature

Increased sweating

Increased subcutaneous fluid

Chronic Reflexes Decreased skin temperature Decreased sweating Subcutaneous fibrosis Muscles are hard and tense with

hypersensitivity to palpation

CHAPMAN’S REFLEXES

Chapman Points System of reflex points originally used by Frank

Chapman, D.O. Definition:

Small points of increased tenderness and sensitivity found in the deep fascial layers that correlate with increased sympathetic tone to a particular area of the body

Anterior and posterior points used to be used for diagnosis and treatment, respectively

Today, these points are used more as diagnostic indicators for dysfunction of a particular organ

Chapman’s ReflexesPhysiology Increased sympathetic tone as well as

blockages in the lymphatic system lead to myofascial nodules

Follow sympathetic afferent pathways; manifest along the dermatome, sclerotome, and myotome segmental lines.

These points are less specific due to the fact that one spinal segment innervates several organs, not just one.

Chapman’s RefelxesPhysical Findings Location: deep in the fascia Palpation: small, smooth, firm, 2-3 mm, “string of

pearls” Tissue Texture Change (just like VSR)

Acute reflexes: boggy, edematous Chronic reflexes: ropy, thickened, feels like a pea

Very sensitive and very tender but does not radiate away from the specific point (Travell’s Trigger Points)

Not necessarily associated with SD

Chapman’s ReflexesAnterior upper quarter

Chapman’s ReflexesITB points

OMT OMT works well for reflex points.

Short term: There is a short- term effect of improved range of motion, less pain and less muscle tension.

Long Term: “Consider the long- term change to be ‘watering the lawn’. You continue to do it however the fruits of your efforts are not seen right away, but before long the lawn is green!”

Clinically

Hypertension In the hypertensive patient, OMT has been postulated to

lower blood pressure by affecting neurogenic, humoral and vascular factors. OMT is felt to break the cycle of increasingly frequent episodes of sympathicotonia and delay the stage of fixed hypertension11.

Serum aldosterone levels have been shown to decrease 36 hours post-OMT12.

In a study of 100 hypertensive patients treated with OMT only, there was an average drop in pressure of 33mmHg systolic (199-166mmHg) and 9mmHg diastolic (123-114mmHg).13

Cardiac Sympathetics

T1-T5 left>right (T2 on the L, most common for MI)

Parasympathetics

C0, C1, C2 Clinical Cases - Arrhythmias:

Bradycardia – C2 left

Sinus tachycardia, SA node – T2 right

PVC’s, AV node – T2 left

URI Increased sympathetic tone to the head and neck will cause

vasoconstriction and will thicken mucus. Osteopathic treatment has been reported to decrease the

symptoms and the duration of the common cold and to prevent complications and recurrence14.

Research using rhinomanometry has shown that following OMT there is a reduction in the amount of work required by the nose during breathing15.

Patients report draining of the sinuses following manipulative techniques specifically addressing somatic dysfunction of the cranium.16

HEENT Sympathetic

T1-T4 Bilateral

Parasympathetic

CN V, C0, C1,C2

Pulmonary Sympathetics

T1-T4 bilateral

Parasympathetics

C0, C1, C2

Clinical Cases: asthma, COPD, pneumonia

Asthma – T2 left, specifically

**Vagal stimulation can exacerbate bronchospasm; don’t treat

C2 during an acute asthma attack

G.I. - Sympathetics Esophagus: T3-T6 right Stomach: T5-T10 left Duodenum: T6-T8 right Appendix: T9-T12 right Liver and Gall Bladder: T6-T9 right Pancreas: T5-T9 bilateral Spleen: T7-T9 left Small Intestine: T8-T10 bilateral Colon and Rectum: T10-L2

- Ascending colon in right sided, descending colon is left sided

G.I. - Parasympathetics From esophagus to transverse colon - C0,

C1, C2.

From transverse colon to anus – S2-S4 (pelvic splanchnics)

G.I. Common GI Pattern:

- C2 left

- T3 right

- T5 left

- T7 right

G.U. - Sympathetics

Kidneys - T9-L1 bilateral

Ureters and Bladder - T10-L2

Prostate - T10-L2

Ovaries (testes) and Fallopian Tubes - T9-T11

Uterus and CervixT10-L1

G.U. - Parasympathetics Kidneys - C0, C1, C2 Ureters and Bladder - S2-S4 Prostate - S2-S4 Ovaries (testes) and Fallopian Tubes - S2-

S4 (for Fallopian Tubes) Uterus and Cervix - S2-S4

Endocrine Pituitary gland: C1-2 mid cervical,

upper thoracic, cranial

Thyroid: T2, C2 (Vagus), upper thoracic flexion hump.

Thymus: upper thoracic, C2 Vagus

Adrenal glands: T9-T10 lateralized

Review of VSR

RegionSympathetics Parasympathetics

HEENT T1-T4 C2 Heart T1-T5 C2 Lungs T1-T4 C2 GI T5-L2 C2, S2-S4 GU TL junction C2, S2-S4

Summary Experienced osteopathic physicians detect

palpable change in muscles and tissues. These changes appear to result from increased sympathetic tone and local inflammatory mediators.

Osteopathic researchers feel that aberrant reporting of information to and from muscle spindles and viscera induce the facilitation and tissue texture changes (S.D.).

Summary Visceral dysfunction may be produced via somatic

dysfunction (somato-visceral reflex).

The mechanisms behind these reflex arcs are complex. The autonomic nervous system is not strictly an efferent system. Reflex arcs, local mediators, and the release of stress hormones are involved in the bi-directional communication between the somatic and visceral systems.

CASE:KHPE: V/S: Tm:101.2, P:112, RR:28, BP:110-133/78-96, O2sat:94% Gen: A&Ox3, Anxious, restless HEENT: perrla, eomi, mmm, TM”s: + cone of light, no erythema,

turbinates: no swelling/erythema, neck supple, CNII-XII intact CV; tachy, RRR, noS3S4 murmur Lung: + B/L rales lower lobes, tachypneic Abd: diffuse Abd TTP, worse in epigastric, dec BS, + guarding EXT: 2+ pulse(radial,PT), trace LE edema, Neuro: CNII-XII intact, 3/4 DTR’s B/L U&LE, sensatoin intact to

touch/pinprick, muscle strength: 5/5 B/L U&LE. OM: C2: FSRL , T3 ESRR,T5-T9: B/L boggy, wollen, warm, tender

SUGGESTED READINGS1. Beal, Myron C., D.O., "Viscerosomatic Reflexes: A Review",

JAOA, 185:12, December 1985, pp. 786-801.2. Larson, Norman J., D.O., "Functional Vasomotor

Hemiparesthesia Syndrome". OMM Selected Papers, Section X pp. 63-68.

3. The Collected Papers of Irvin M. Korr. Pgs. 77-87.4. Foundations for Osteopathic Medicine, Robert C. Ward, D.O.,

Executive Editor. Williams & Wilkins, 1997 pgs 53-136.5.  An Osteopathic Approach to Diagnosis and Treatment,

DiGiovanna and Schiowitz, pg. 12 -19.

REFERENCES1. Patterson, M.M., “A Model Mechanism For Spinal Segmental Facilitation.” JAOA, Vol. 76, 4-14,

1976.2. Patterson, M.M., Louisa Burns Memorial Lecture 1980: “The Spinal Cord Active Processor Not

Passive Transmitter.”3. Passatore M., Filippi G. M., Grassi C.: Cervical Sympathetic Nerve Stimulation Can Induce an

Intrafusal Muscle Fiber Contraction in the Rabbit. In: The Muscle Spindle (Boyd, I.A. and Gladden, M.H. Eds), 221-226, Macmillan, Basingstoke & London, 1985.

4. Passatore M., Grassi C., and Flippi G. M.: “Sympathetically-induced Development of Tension in Jaw Muscles; the Possible Contraction of Intrafusal Muscle Fibers.” Pflugers Arch. 405: 297-304, 1985.

5. Korr, I. M., “Somatic Dysfunction, Osteopathic Treatment and the Nervous System: A Few Facts, Some theories, Many Questions.” J Am Osteopath Assoc 86 (2): 109-114.

6. Korr, I. M.: “Sustained Sympathicotonia as a Factor in Disease.” In: The Collected Papers of Irvin M. Korr. Edited by Barbara Peterson. Copyright 1979, A.A.O., second printing, 1988, pp.77-89.

7. Weis, P., Hiscoe, H.B.: Experiments on the Mechanism of Nerve Growth”. J. Exp Zool 107: 315-95, Apr. 48.

8. Beal, M.C.: “Viscerosomatic Reflexes: A Review.” Journal of the A.O.A.. 85, (12): 786-801, 1983.

9. Willard, F, Lecturer AAO Convocation 1991.

REFERENCES10. Larson, N.J., “Osteopathic Manipulation for Syndromes of the Brachial Plexus,” JAOA, vol. 72, Dec.

1972, pp.378-384.11. Kuchera M., Kuchera, W., Osteopathic Considerations in Systemic Dysfunction. Kirksville: KCOM

Press, 1991.12 Mannino, J.R.; “The Application of Neurologic Reflexes to the Treatment of Hypertension.” JAOA, Dec.

1979, 79, pp. 225-231.13. Northup, T.L.; “Manipulative Management of Hypertension.” JAOA, Aug. 1961; 60, pp. 973-978.14. Schmidt, I.C., “Osteopathic Manipulative Treatment as a Primary Factor in the Management of Upper,

Middle, and Pararespiratory Infections.” JAOA, Feb 1982; 81: 382—8.15. Kaluza, S.M.; “The Physiologic Response of the Nose to Osteopathic Manipulative Treatment:

Preliminary Report.” JAOA, May 1983, 82, pp. 654-660.16. Magoun, H.I., Osteopathy in the Cranial Field. Kirksville , Journal Printing Co, 3rd Ed, 1976, pp. 289-

291.17. Foundations for Osteopathic Medicine, Robert C. Ward, D.O., Executive Editor.

Williams & Wilkins, 1997 pgs 53-136.18. Hart LM. Obstetrical practice. J Am Osteopath Assoc. 1918; 609-614.19. King et al. Osteopathic manipulative treatment in prenatal care: a retrospective case control study. J Am

Osteopath Assoc. 2003; 103(12): 577-58220. 16) Whiting, LM. Can the length of labor be shortened by osteopathic treatment? J Am Osteopath

Assoc. 1911; 11: 917-921.