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Firstpublished2003 Reprinted2003,2005,2007,2008 ISBN9780443063602 British LibraryCataloguingin PublicationData Acataloguerecord forthisbookisavailable fromtheBritishLibrary LibraryofCongressCataloguinginPublicationData Acataloguerecord forthisbookisavailable fromtheLibraryof Congress Note Medicalknowledgeisconstantlychanging.Asnew information becomesavailable, changesintreatment,procedures,equipmentand theuseofdrugsbecomenecessary. Theeditors,contributorandthe publishershave taken caretoensurethat theinformationgiveninthis textisaccurate and uptodate. However,readersarestronglyadvised toconfirmthat theinformation,especiallywithregardtodrugusage, complieswith thelatestlegislationandstandardsofpractice. yoursourceforbooks. ELSEVIER journalsandmultimedia inthehealthsciences www.elsevierhealth.com Working together to grow librariesin developingcountries www.elsevier.com \ www.bookaid.org 1www.sabre.org ELSEVIER "H",t"K,,,,I1K11A111I,I,,I1 The publishers policyistouse pipermlnullClurld "omsuslllnlbil'o'lsls I Printed inChina Preface Thistextisacomposite ofinformationdrawnfrommany immunesystem, the respiratory/circulatory system, and and varied sources. It is the culmination of research, the bioenergetic model. Although a discussion of these study and practice in the science and art of osteopathy models isintegratedthroughoutthetext,ashortsynopsis and its application to children. Along the way I have isprovidedhere. learned much frommycolleagues andteachers,butmost One ofthe primarydiagnostic clues garnered from an ofwhatIhave learnedhas been from my patients. From osteopathic examination is the spinal facilitation. This is the tiniest seventeen-week gestation newborn to the a localized area of palpatory change in the muscles and eldest in her ninth decade, their bodies and minds and fasciaadjacent to the spine. Thesechanges include tissue spirits have taught me how to be still and listen. In my swelling or edema, increased or decreased temperature, somewhat naive opinion, much of the art of osteopathy and stiffnessorlossoftone. Thesetissue texture changes isthe ability tointegrate the indescribable,perhaps even represent localized areas of inflammation that occur in incomprehensiblebutpalpable,informationthepatient's response to direct local insult. They may also arise in body isprovidingwith whatis scientificallyknown and responsetodamageorirritationtodistal tissues through understood. One type ofinformation does not negate or visceral-somatic reflexes. Visceral-somatic reflexes were diminish the value ofthe other.They dovetailtoprovide first describedby osteopathsin the early partofthis cen amorecomplete,amoreunified pictureoftheindividual. tury. Recent scientific investigation into the mechanism Thisbook ismy attempttodojustthat. and effectsoftheseinteractionshas shednew lightonthe Thebook is arranged in two parts. The first discusses intimate relationship between the musculoskeletal sys basic concepts of physiology from the perspective of an temand theviscerathroughthesympatheticnervoussys osteopathic clinician. The second describes the more tem. Chapman's reflexes are superficial areas of tissue common pathophysiological processes seen in children. texture change thathave a high correlation with visceral Severalrecurring themes are woventhroughoutthe text: pathology. These pea-sized areas of fibrosous are found the mechanisms by which pathophysiological processes on the anterior and posterior torso. The site of location influenceeachother;thenormalchanges and adaptations and presence of both anterior and posterior findings instructureand function thatoccurthroughoutchildhood suggests a visceral problem (Owen 1963). Chapman's and how the changes can be affectedby these processes; reflexeswere first discussed in the early part of the 20th andarationaleforosteopathictreatment.Acommonbelief centurybyFrankChapman,D.O.Theyareveryeasilyinte inUSosteopathicpracticeisthat'theindicationforosteo gratedin the general physical exam and provideanother pathic manipulation is somatic dysfunction'. While that tool in developing a differential diagnosis. A general may be true, different pathophysiological processes understandingofthevisceral-somaticmap andChapman's often require different osteopathic approaches especially reflexes can give the clinician clues about what may be in the very young, the very old and the very sick.With causingthe patient's symptoms andcan provide a path that in mind, somatic dysfunction is discussed from the way fortherapeuticapproach. perspective of the findings in different tissues, i.e.fluid, Theneuroendocrine-immuneconnection isa term that membranous, articular, osseous, and neural findings. has been coined to refer to the complicatedinterdepend Osteopathic treatmentis discussed within the context of ency between the nervous system, hormone balance physiological models: somato-visceral interactions, pos and immune function. Basically speaking, the human tural or biomechanical influences, the neuroendocrine- bodymaintainsinternalbalance orhomeostasis, through viii PREFACE rhythmicchemical secretions from thebrain(neurotrans of the muscles of the back, thorax, neck and upper mitters),immuneorgans (immunoregulators),andglands extremities playa role in respiratory mechanics. Altered (hormones). The chemicals that are secreted interact to respiratorymechanics cancontributetotissue congestion stimulate and suppresseach other, thus coordinatingthe and decreased clearance;alteredventilationandincreased internal chemistry ofthe body. Potentiallyharmfulstim energy expenditure; and altered lymphatic and venous ulifromboth external andinternalsources canalter these return pressures. Factors that can affect respiratory rhythmical patterns,thusaffectingthehomeostasisofthe mechanics include, butare not limited to, respiratory ill internal body chemistry and creating a general adaptive nesses, scoliosis, thoracic or abdominal surgery, obesity, response. Normally, once the stress is removed the adap andposturalchanges. tive response resolves and homeostasis isre-established. The human body requires a balance between energy Howeverunderlong-termorseverestress,theentirephys expenditureandenergysupplytomaintainhomeostasis. iology of the neuroendocrine-immune system can alter, Efficient operation of internal body systems conserves creating a permanent condition of adaptive response. energythatcanbeused toadapttoexternalstressorssuch Brain chemistry, immune system function and hormone asnutritional deficiencies,trauma, infection, nociceptive balance will alter. Not only is this person more suscep stimulation and others. When several stressors occur tible to disease, he or she will have a much harder time simultaneously, their influence may become cumulative adapting to any new stress. Many studies have demon orsynergistic, furthercompromisingthe body'sability to stratedchangesinimmunecells,hormonelevelsandnerv maintain homeostasis. Changes in the musculoskeletal oussystem function understress (McEwan1987,Ganong systemmay increase the body's energy requirement. For 1988,Gold & Goodwin 1988a,1988b,Keicolt Glaser & example, restriction in joint motion because of somatic Glaser 1991,Esterly 1992,Sternberg1992).Stressful stim dysfunctionwillalterbiomechanicsandreduce efficiency uli may include psychological and physiological influ ofmotion. Itwillrequiremore worktouse thejoint- this ences.Pain, ornociceptivestimuli, isconsideredapotent increasesthemetabolicdemandsplaceduponthepatient. stressor. From an osteopathic perspective, somatic dys Now imagine there are many restricted joints, all in the function or other strains in the patient's body may thorax, and the patient is a four-month-old infant with adverselyinfluence the neuroendocrineimmunesystem. respiratorysyncitialvirus.Anyprocessthatinterfereswith The postural/biomechanicalmodel views the body as localorsystemichomeostasishas thepotentialtoincrease an integration ofsomatic components. Stresses or imbal thebody'senergyrequirements. ances between these components result in increased Inmy view these fivephysiologicalmodelsinterweave energy expenditure, changes in joint structure, impedi to form the fabric of the osteopathic approach. There is ment ofneurovascular function and altered metabolism. one other component that, when added, turns osteo Inveryyoungchildrenbiomechanicalorposturalstresses pathic approach into osteopathic treatment. That is the may influence the developmentofmotorskills, and per relationshipbetweenthe osteopathicpractitionerand the haps even cognitive processes. Furthermore,altered pos patient. Bythis I do not mean the personalities - most turalmechanicswillinfluenceconnectivetissueand fascia, two-week olds don't have much personality! I refer to potentially affecting vascular and lymphatic drainage. an acknowledgement that must take place between These changes can contribute to the accumulation of the practitionerandthe patient. Though perhaps lacking cellular waste products, altered tissue pH, changes in in conversational skills, even the youngest patient is an osmotic pressure, and impediment of oxygen and nutri individual, a complete human being, with no less or no ent delivery. This is important in cases of infection, car greater bearing in Life than the physician. Osteopathic diopulmonary problems, and metabolic diseases such treatmentrequirestwothings tobesuccessful-thepatient asdiabetes. Posturalimbalancesmay alsocauseirritation andthepractitioner.Osteopathsarenot abjecthealers. We to paraspinal tissues, including the articular tissues of are facilitators. The patientprovides the clues thatallow the vertebrae. Irritation to these tissues will stimulate us touseour knowledgeandskilltofacilitatechange. But somatosympathetic fibers, resulting in sympathetically the patient'sbody, the patient's mechanism has to make mediated changes in the involved tissues and potential that change. The osteopathic practitioner must have a changes inassociatedviscera. human relationship with the child. You cannot come The respiratory/circulatory model concerns itselfwith along andjust do thingstothe tissues. themaintenanceofextracellularandintracellularenviron Throughout this book I have tried to incorporate the ments through the unimpeded delivery of oxygen and most commonly practiced techniques and approaches nutrientsand theremovalofwasteproducts.Theintegrity used by the osteopathic profession. However, because oftherespiratory/circulatorysystem isinfluencedbypos much of the book deals with very young children, the tural changes on a microscopiclevelthroughtissue stress teachingsofWilliamSutherland,D.O.figure prominently and macroscopicallythroughrespiratorymechanics.Most inthetext.Itisimportanttorememberthat DrSutherland PREFACE ix always maintained that his teachings were not his con me know whenthe information isunclear,incomplete or cept, but his understanding of Dr Still's principles of (heavenforbidit)justplainwrong.Itgoeswithoutsaying osteopathy.Likewise,whatis written withinthese pages thatpats onthebackarealways welcome. arenot my ideas, myinventionsormy discoveries.They DrAnneWalesisfondofsaying, 'Weosteopathsareon arebutan attempt toexplain mystillfeebleunderstand afrontier'- Ilookforward tojourneyingwith you. ing of the principles of osteopathy in the treatment of children.Withthatinmind, Iencourage eachreader tolet Je,2003 REFERENCES Esterling B1992Stress-associatedmodulationofcellularimmunity. Keicolt-GlaserJK,GlaserR1991Stressand immunefunctionin In:Willard FH,PattersonM(eds)Nociceptionand the humans.In:AderR,Felton DL,CohenN (eds) neuroendocrine-immuneconnection.AmericanAcademyof Psychoneuroimmunology,2nd edn. AcademicPress,SanDiego, CA, Osteopathy:275-294 pp 849-895 GanongW1988Thestress response- adynamicoverview. McEwan B1987Glucocorticoid-biogenicamineinteractionsin relation HospPrac23:155-171 tomoodandbehavior. BiochemPharm36:1755-1763 Gold P,GoodwinF1988aClinical andbiochemicalmanifestationsof OwenC1963AnendocrineinterpretationofChapman'sreflexes, stress:Part I.New EnglandJournalofMedicine319:348-353 2nd edn.AmericanAcademyofOsteopathy,Colorado Gold P,GoodwinF1988bClinical and biochemicalmanifestationsof SternbergE,ChrousosG1992Thestress responseandtheregulation depression:PartII.New EnglandJournalofMedicine319:41~20 ofinflammatorydisease.AnnInternMed 117:854-866 Acknowledgements Thisbookwouldnever have cometofruition ifitweren't friends and teachers who eachhelped me open adoor to for the support, patience and encouragement of Mary my vocationandheart'sdelight. Iwould alsoliketo pay Law, Katrina Mather and Derek Robertson of Elsevier myhighestrespect toViolaFrymann,D.O.and Edna Lay, Science.Tothem loweadebtofgratitude.Alsogenerous D.O.Although they may not know it, each has been an intheirsupportand encouragementwereSteveShannon, inspiration and force in my professional development. D.O.and BoydBuser,D.O.,Dean andAssociate Dean of IwouldliketothankJayneAlexander,D.O.,MaryBayno, the CollegeofOsteopathic Medicine at the Universityof D.O., Michael Burraunno, D.O., Hugh Ettlinger, D.O., New England. Andrew Goldman, D.O., Sabine Schmidt, D.O., and Iwould like to thank the members ofmy department, Lynette Bassett, D.O. for critical reading and discussion Ann Nielsen and Nancy Goulet; George Pasquarello, throughoutthe productionofthe text.Inaddition, Susan D.O.,CharlieCarr,D.O.,and RalphThieme,D.O.;and the Winer graciously provided edititorial advice in the early residents and fellows for supporting me and putting up stages forwhich Iamvery grateful. Icannotend without with my frequent periods of pre-occupation with this acknowledgingmy respectedfriend and colleague Frank endeavor. Likewise,Iwouldliketoacknowledgethestu H. Willard,PhD.Formanyyears Ihave been very fortu dentsatthe RoyalMelbourneInstituteofTechnology,the natetoworkwithhim.Thedissectionphotographsinthis Winer Schule fur Osteopathie, the European School of textarepartofacollectionthat wehave evolvedover the Osteopathyand especiallytheUniversityofNewEngland pastdecade. Dr Willard isa gifted anatomist and photo College of Osteopathic Medicine for their infectious grapher. enthusiasm, probing questions and insistence on clarity. Last and most importantly I would like to thank my Youhave taughtmemuch. family,especially FrancisandJessewho have supported, However,even moreimportantly,Iamindebtedinper encouraged, cajoled, bribed and fed me through this petuitytoAnne Wales,D.O.andJamesJealous,D.O.,two process. 1 CHAPTERCONTENTS Introduction 1 Embryologicaldevelopmentofthenervoussystem The nervous Myelination 3 Spinalreflexes 3 system - a Spinalsegmentation 4 Primaryafferentfibres 5 Neurogenicinflammation 5 clinician's Convergence 6 Spinalfacilitation 6 Viscera-somaticintegration 7 perspective Viscera-somaticreflexes 10 Facilitationandemotions 10 Conclusion 11 INTRODUCTION Thephysiologyanddevelopmentofthe nervoussystem is avastand complicatedsubject,which Icannotdojusticeto inthespaceofthischapterorthedepthofmymind. Rather, Ihopetoprovidethereaderwith aclinician's viewofsome fundamental processes in the nervous system and their potential rolein osteopathic evaluation and management. Formore information,readersare directed totheexcellent textsandessays referenced attheendofthischapter. EMBRYOLOGICAL DEVELOPMENT OF THE NERVOUS SYSTEM The cellular development of the nervous system can be divided into sevenstages: proliferation,migration, aggre gation, differentiation, synaptogenesis, remodelling, and myelination (Moore & Persaud 1993,Kandel et al 2000). The first three, proliferation, migration and aggregation, happen early in embryological development. They are completedby birth. The latter four are not finished at the time of birth; in fact, some of them are just starting and will continuethroughoutlife.Early ingestation,neuronal cellsmigrate and arrange themselves into groups, which share a common function. In the primitive brainstem, neuronal cells cluster into nuclei. In the spinal cord, theyorganizethemselvesinto elongatedcolumns.Wecan thinkofthe earlyembryoasasegmented columnwith an opening at the most anterior aspect: the anterior neural pore. The most anterior aspect will grow, elongate and tumposteriorly, inferiorlyandanteriorlylikearam'shom toform the cortical hemispheres (Fig.1.1).The remaining segmentedcolumnwillform the spinalcord. Thiscolumn is surrounded by the somites of the body. Each somite will cluster a group ofaxons from the adjacent neural cells.Thesomites giverise toallthe somatic tissues ofthe body; skin, muscle, periosteum, fascia,etc.As the somite developsintothese tissues, itusuallydragsitsinnervation 2 ANOSTEOPATHICAPPROACHTOCHILDREN Figure1.1 (A)Lateralviewoftheexternalsurface ofthebrain.Thearachnoid hasbeenremoved fromthesurface oftherighthemisphere.but isstillinplace(arrows)ontheleft.(B)Sagittalsectionthrough midlineofbrain.CC.corpus callosum; M.midbrain; Pit,pituitary stalk. Usedwith permission oftheWillard&CarreiroCollection. C8 L4 Figure 1.2 Mapofdermatomes. fromthe adjacent spinalsegment. Within the thorax, this C3-C5 could present as pain in the area of the scapula arrangement ofstacked segmented innervationis readily (sclerotome)orinthetrapezius(myotome). evident in the dermatomalpattern (Fig.1.2).However, in Dermatomes, myotomes and sclerotomes are areas of the extremities, where the somatic tissue was dragged sensory innervation associated with a common nerve out along the axis of the appendage, the organization is root. These areas were first described at the tum of the distorted. Thestacked arrangementislostand in itsplace centuryby Dr Head and are called the 'zones ofHead'. is left a hodgepodge of overlapping tissues such that A zone of Head represents the summation of the der the motor innervation from C3-C4-C5 is found in the matome, myotome and sclerotome patterns which have diaphragmbutthesensoryinnervationfrommusculartis thesameembryological origin,i.e.patternofinnervation. sue (themyotome) isfound in the trapezius, the sensory Nociceptivestimulationtotissueinanyoftheseareaswill innervation from skin (thedermatome) is found over the activatecellsinthedorsalhomofthespinalcord.Inmany top ofthe shoulderandforearm,and the sensoryinnerv situations,the same neuralcellsmay receiveinformation ation from bone (the sclerotome) is found in the scapula fromthree different kinds oftissue: skin, bone, and mus (Fig. 1.3).Irritationofnerve cellsinthespinal cordareaof cle.Thisinformationwillbe relayed tothe brain. Cellsin THENERVOUSSYSTEM- ACLINICIAN'SPERSPECTIVE 3 people, the brainis initially exposed to pain signals from somatic rather than visceral tissue. The brain learns to interpretnociceptivesignals from most areas ofthe spinal cordascomingfromsomatictissue.Thussymptomsofvis ceralpathologyarereferred tothemusculoskeletalsystem. However,whenchildrensufferearlyvisceral diseasesuch asreflux,intussusceptionorsurgical correctionofcongen ital heartdisease, the brainlearnsto interpretnociceptive inputfrom those areas ofthe spinalcord as visceral rather thansomatic irritation. Later,whensomatic irritationdoes develop, the child may complain of symptoms similar to those associatedwiththeearly visceral pathology. MYELINATION The embryological processes of proliferation, migration and aggregation can be thought of as laying down the paths.Youcan drive on a road thatisnotpaved,butyou havetodriveslowly.Pavingthe roadcan becomparedto myelinatingthe nerves. Myelination allows the signal to travelveryquickly.However,anervedoes notneed tobe myelinated in order to function. In a fully functioning nervous system, the pain system is unmyelinated, yet it functions appropriately. But, as would be expected, the conduction time is slower than in other systems. The amountofmyelinationdetermineshowquicklycommu Figure1.3 Schematicdiagramdepictingthedermatome(Derm), sclerotome(Seier),myotome(Myo),andmotorinnervationfrom nication will occur. For example, the large-calibre fibres C3-C5. involved in proprioceptive input are heavily myelinated and have rapid conduction times. Myelination initially the cortex learn to interpret signals from the spinal cord startsin peripheralnerves, the spinalcordand the brain as comingfrom specific tissues,baseduponthe qualities stem. Consequently, spinal reflexes are established very of the signal and location of the activated cell. Cortical early and are present at birth. Later, maturation of the cells learn to distinguish between nociceptive, proprio cortical spinalconnectionswill dampenthese reflexes. ceptive and discriminative touch stimuli. Cells in the cortex learn to associate activity in a certain level of the SPINAL REFLEXES spinalcord withirritationto aspecifictissue. However,if theincitingspinalcord cellreceives inputfrommorethan Reflexescanbedividedinto twocategories: spinalreflexes one kind oftissue, the cortex maynotbe able todifferen and supraspinal reflexes. Spinal reflexes are segmental tiate between them. This is one of the mechanisms of andmonosynaptic.Forexample,tappingapatellatendon referredpain.Anirritationorinjurytooneareaofthebody withareflexhammercausesthe tendontostretchrapidly, is interpreted as coming from a different tissue because exciting muscle spindles within the quadratus muscle the two havea commoninnervation. Clinically,we often (Fig.1.4).Thesignalfrom the musclespindleiscarriedto associate this processwithvisceralpathology. thespinalcord, whereitisrelayedthroughinterneurones Most sensory cells in the spinal cord receiving input to the alpha motor neurones of the ventral hom. The from somatic tissue will also receive input from viscera. alphamotorneuronessignalextrafusalmusclefibres that Whenthebrainreceivesasignalfromthatareaofthespinal causethe quadratusmuscletocontract.Thisisaspinalor cord,itcannotdistinguishbetweenthevisceralandsomatic stretchreflex. tissue. If, during life, the cortex has learned to interpret Thestretchreflexcanbebrokendownintotwocompon pain stimulation from the T4 area as arm or shoulder ents: a dynamicstretchreflex,whichrespondsquicklyto injury, thenwhenT4becomes stimulatedby myocardial rapid changes in muscle length, and a weaker static injury, the brain maycontinue to interpretthat signal as stretchreflex,whichcontinuesto maintaincontractionof shoulder pain. Many incidents of referred pain, such as the muscleaslongas the stretchforcepersists.Theentire shoulder irritation with gallbladder disease, and back circuitisrunwithinthespinalcord.Theinterneuronemay painwithurinarytractinfections,canbeaccountedforby alsosendasignaltothe braintoletitknowwhathas hap the convergencepatternsofthe zonesofHead. For most pened,butthe reflex isnotdependenton inputfrom the