ABCs of Osteopathic Medicine

ABCs

autonomics, biomechanics, circulation, screening

5 Osteopathic Models

- biomechanical

- respiratory/circulatory

- neurologic

- metabolic energy

- behavioral

autonomics

- regulates key processes without conscious effort

- parasympathetic and sympathetic nervous system provide regulatory balance

- balance maintains homeostasis of the body

- targets smooth muscle of organs and sweat glands to regulate physiology

parasympathetics

- rest, digest, heal

- cranial (CN III, VII, IX, X; synapse in brainstem)

- sacral (splanchnic; synapse in lateral horn of S2-S4)

what percent of parasympathetic outflow is provided by the vagus nerve?

75%

sympathetic nervous system

- flight, fight, freeze, forget

- T1-L2

- each organ has a specific thoracolumbar region that relates to sympathetic nervous system

segmental faciliation

- creates physiology imbalance that interferes with body's response to challenge

- occurs in response to majority of disease processes and hurts body's ability to respond to a disease

head and neck sympathetic innervation

T1-T5

head and neck parasympathetic innervation

vagus nerve (also CNIII, VII, IX)

heart sympathetic innervation

T1-T5

pneumonic: 1 to 5 keeps the heart alive

heart parasympathetic innervation

vagus nerve

lung sympathetic innervation

T2-T5 (the slides say T5 but a study guide from elsewhere says T6 so idk)

pneumonic: you need 2 lungs for sex (T2-T6)

lung parasympathetic innveration

vagus nerve

lower esophagus/stomach sympathetic innervation

T5-T10

pneumonic: pump the stomach 5-10x

lower esophagus/stomach parasympathetic innervation

vagus nerve

liver and gallbladder sympathetic innervation

T6-T9

pneumonic: drink too much, bad decisions - 69 lol

liver and gallbladder parasympathetic innervation

vagus nerve

small intestine sympathetic innervation

T9-T11

pneumonic: two Ls in "small" make 11

small intestine parasympathetic innervation

vagus nerve

ascending/transverse colon sympathetic innervation

T11-L1 (the slide says this; a study guide says T12-L1 so idk)

pneumonic: 12 months in a year, 1 egg per month (T12-L1)

ascending/transverse colon parasympathetic innervation

vagus nerve

descending and sigmoid colon/rectum sympathetic innervation

L1-L2

pneumonic: helps you go #2 not #1 (L1-L2)

descending and sigmoid colon/rectum parasympathetic innervation

S2-S4

kidney sympathetic innervation

T10-L1

pneumonic: "10" looks like one kidney is gone lol (and you can still live with one kidney)

kidney parasympathetic innervation

vagus nerve

ovary/testes sympathetic innervation

T9-T11

pneumonic: call 911 if they touch you there

ovary/testes parasympathetic innervation

S2-S4

uterus sympathetic innervation

T12-L1

pneumonic: 12 months in a year, 1 egg per month

uterus parasympathetic innervation

S2-S4

cervix sympathetic innervation

T10-L2

pneumonic: labor time is 10 hours for twins (T10-L2)

is this true? prob not but if it helps it helps

cervix parasympathetic innervation

S2-S4

primary afferent nociceptors (nociceptors detect pain)

- widely distributed throughout tissues of the body

- chemical, thermal, and mechanical (proprioceptors)

- synapse in spinal gray matter

- through interneurons, can upregulate sympathetic efferents

autonomics: pneumonia and respiration sympathetic innervation effects

vasoconstriction -> hypoperfusion (reduced blood flow) of alveoli

increase in goblet(makes mucus)/ciliated(moves mucus out of the way) cell ratio -> thick, sticky secretions (because there are more goblets than ciliated cells)

relaxes bronchiole smooth muscle -> bronchodilation

rib raising activates sympathetic chain ganglia -> reduces sympathetic outflow

autonomics: pneumonia and respiration parasympathetic effects

decreases number of goblet cells -> enhances thin secretions and clearance

contracts bronchiole smooth muscle -> bronchoconstriction

biomechanics

- mechanical and structural connections throughout the body

- restrictions on muscles, fascia, bones, joints can lead to restriction in vasculature, innervation, and organ function

- posture, injury, surgery, activity, motion, gait

- restriction in visceral motion

- removing the mechanical restriction leads to improved structure and thus function

biomechanics: pneumonia and breathing

thoracic cage motion

- spine, cervical, thoracic, lumbar

- ribs

- thoracic inlet

- sternum

respiratory musculature

- diaphragm (redoming), intercostals

- secondary

lung parenchyma

biomechanical applications of omt

- asthma

- CHF

- GERD

- UTI

circulation

arterial, venous, CSF, lymphatic fluid

- implications on oxygenation energy, immune function

choke points

- diaphragms: thoracic inlet, thoracic diaphragm, pelvic diaphragm

- other: OA, tentorium cerebelli, inguinal region; extremities: plantar fascia, popliteal fossa, antecubital fossa, axilla

circulation: lymphatic pump

- in addition to antibiotics, it decreases bacterial load at 72 and 96 hours after infection

- mobilizes bioactive lymph and suppresses macrophage activity

circulation: pneumonia

arterial supply

- bronchial arteries from systemic circulation

venous drainage

- considerable variation

lymphatic drainage

- thoracic inlet

- thoracic diaphragm

- pelvic diaphragm

detoxification

- liver pump

WBC (white blood cell) circulation

- splenic pump

for lymphatic drainage, always open the ___ first

terminal drain

___ governs the flow of lymph

autonomic innervation

lymphatic flow dramatically increased with ___

thoracic/abdominal pumps

pneumonia screening: chapman's points

anterior:

- bronchus: 2nd intercostal space

- lungs: bilateral 3rd and 4th intercostal

posterior

- lungs: between SP and TP of T3 posteriorly

counterstrain points:

- ribs

- thoracic

- sternum

screening for pneumonia

- upper extremities: fascial and muscle attachments into thorax

- lumbar/sacrum/pelvis: influence on breathing; diaphragm and other muscular attachments

- mind-body-spirit: relieve stressors, lifestyle changes (yoga), breathing techniques

screening methods

- Zink

- Mitchell Model

- Tenderpoints

- Fascial pull

- Mind, body, spirit

Autonomics: low back pain sympathetics

- T10-L2: mechanical, thermal, and chemical input from lower extremities, pelvis, sacrum, lumbar, and thoracic spine and somato-somatic facilitation

- compromises blood flow to and reduces nutrient/medication delivery to muscles, ligaments, bones, synovium, fascia

Autonomics: low back pain parasympathetics

- S2-S4: mechanical, vascular, and lymphatic congestion/dysfunction can increase norciceptive input

Biomechanics: low back pain

lumbar spine

- somatic dysfunction can sensitize interneurons leading to facilitation

- muscle may spasm as an initially protective mechanism

- trauma

sacrum/pelvis

- intricately related to low back pain

- trauma

thoracic spine motion

- group dysfunctions causing lumbar strain

- fascial and muscular connections

diaphragms

- thoracoabdominal and pelvic and diaphragms through direct/indirect connections

Circulation: low back pain

arterial supply

- dorsal branches of the embryonic intersegmental somatic arteries

venous drainage

- vertebral column veins from intricate plexuses along the entire column, external and internal to the vertebral canal

lymphatic drainage

- deep lymphatic vessels tend to follow the arteries

- brain to cisterna chyli and thoracic duct

Zink Screen

consider places where fluid may become restricted at mechanical diaphragms

Tenderpoints Screen for low back pain

anterior lumbar, posterior lumbar, sacrum/pelvis points

Mitchell Model Screen for low back pain

improving metabolic efficiency and decreased energy requirements and increases exercise capacity via normalizing proper alignment and function of the sacrum and pelvis

mind, body, spirit

SMART goals (specific, measurable, attainable, relevant, time-sensitive)

Autonomics: asthma sympathetics

- T2-T6: sympathetic chain ganglia lie anterior to rib heads

- vasoconstriction -> hypoperfusion of alveoli

- epithelial hyperplasia (increase in Goblet cell, sticky secretions)

- initially, dilation of bronchial tubes, effect eventually wanes

Autonomics: asthma parasympathetics

- vagus nerve

- bronchodilation

- because of congestion/obstruction, shallow rapid breathing

Biomechanics: asthma

rib motion

- often restricted globally

- with hyperinflation, may see many inhaled ribs

thoracic spine motion

- dysfunctions with sticky end-feel

sternum motion

- typically motion is very limited

thoracoabdominal diaphragm

- may be flattened and needing to be re-domed

cervical spine

- especially C3-C5 (phrenic)

- hypertonic scalene muscles

Circulation: asthma

arterial supply

- bronchial arteries from systemic circulation

venous drainage

- considerable variation

lymphatic drainage

- superficial and deep plexuses

- no lymph vessels in alveoli

Chapman's points screen for asthma

anterior

- 2nd intercostal space -> bronchus

- 3rd intercostal space -> upper lung

- 4th intercostal space -> lower lung

posterior

- between SP and TP of T3 posteriorly

Mitchell model screen for asthma

ipsilateral innominate for unilateral

this was confusing to me so here's what chatgpt had to say about it: The innominate bones are parts of your pelvis, kind of like the foundation of a house. If one side of your foundation isn't working well (that's the "ipsilateral innominate" part), it can affect how the whole house stands up.

Now, when you have asthma, your lungs have a hard time breathing because the airways get tight, like a balloon that won't blow up. If the foundation (your pelvis) isn't stable, it can make it harder for your muscles, like your diaphragm (the muscle that helps you breathe), to work properly.

mind, body, spirit screen for asthma

journaling, breathing exercises, yoga

Autonomics: CHF sympathetics

- T1-T6: right side SA node, left side- AV node

- can lead to coronary vasospam, increased heart rate, atrial fibrillation, vasoconstriction

Autonomics: CHF parasympathetics

vagus

- slow heart rate

- constrict coronary arteries

Biomechanics: CHF

rib motion

- improves respiratory effort

- improves diaphragm movement for respiration and fluid movement

thoracic spine motion

- improves respiratory effort

- improves viscerosomatics

sternum motion

- improves respiratory effect

Circulation: CHF

arterial supply

- coronary arteries

venous drainage

- pericardial and myocardial veins: drain to coronary sinus

lymphatic drainage

- subendocardial, myocardial, and subepicardial plexuses

Chapman's points screen for CHF

2nd intercostal space anteriorly, between SP and TP of T3 posterioly

Upper Crossed Posture screen for CHF

inhibited or facilitated muscles could be upregulating sympathetic innervation to the heart

mind, body, spirit screen for CHF

significant cardiac effects from anger, stress, anxiety, loneliness

more MIs in AM, mondays, winter

religious involvement: less cardiovascular disease and cardiovascular mortailty

Autonomics: UTI sympathetics

- T10-L1: lowest thoracic and first lumbar splanchnic nerves

- vasoconstriction of afferent arterioles, decreased GFR, decreased urine volume, decreases ureteral peristaltic waves (can cause ureteral spasm)

Autonomics: UTI parasympathetics

kidney

- vagus nerve

proximal ureter

- vagus

distal ureter

- S2-S4 via pelvic splanchnics

bladder

- S2-S4 via pelvic splanchnics

effect is unclear (counterbalance sympathetics?)

Biomechanics: UTI

kidney motion

-

Circulation: UTI

arterial supply

- renal arteries

venous drainage

- renal veins

lymphatic drainage

- renal lymphatic vessels: coalesce at hilum drain to thoracic duct and vessels can dilate 300% to protect renal capsule and parenchyma

- synchronous motion of thoracoabdominal diaphragm and thoracic inlet is vital to drainage

Chapman's points screening for UTI

Anterior

- Kidney: 1 in lateral and 1 in superior to umbilicus bilaterally

- Bladder: inverted triangle around umbilicus

Posterior

- Kidney: intertransverse space between T12 and L1 (between TP and SP)

- Bladder: upper edge of the transverse process of L2

mind, body, spirit for UTI

behaviors thought to increase UTI risk: intercourse, tight clothing, holding urine, irritants (douche, soaps, etc)

biofeedback decreases incidence of recurrent UTIs

Autonomics: GERD sympathetics

- T5-T12: via grater and lesser splanchnic nerve, celiac plexus

- decreases mucosal defenses against digestive acids via vasoconstiction

- nociceptive signals are conveyed by sympathetic and vagal afferents

Autonomics: GERD parasympathetics

vagus nerve

- left = greater curvature

- right = lesser curvature

increases secretion of glands

Biomechanics: GERD

stomach/esophagus

- exhaled (superior); pulls cardiac portion of stomach through sphincter -> hiatal hernia

thoracoabdominal diaphragm

- crura intricately related to esophagus

thoracic spine motion

- restriction can be "sticky" in quality suggesting viscero-somatic reflex

Circulation: GERD

arterial supply

- left gastric artery branches, thoracic aorta (branch directly from aorta)

venous drainage

- left gastric, short gastric, azygous/hemiazygous

- GE junction -> anastomosis of portosystemic systems

lymphatic drainage

- small channels into cisterna chyli, between right crus and aorta

- cisterna chyli drains to thoracic duct

Chapman's points for screening for GERD

anterior

- esophagus: intercostal space between 2nd and 3rd ribs, close to sternum

- stomach (acidity): 5th intercostal space (between 5th and 6th rib)

posterior

- esophagus: T2 -> midway between SP and TP

- stomach (acidity): intertransverse space between T5-T6 -> midway between SP and TP

mind, body, spirit screen for GERD

- lifestyle modifications

- avoid foods that relax LES (lower esophageal sphincter)

- avoid large meals/meals too close to bedtime

- increase HOB (head of bed) by 4-6 inches

- exercise -> weight loss, but also direct effects improving digestion