Correlation of Somatic Dysfunction With …pylorus VS, sphincter of Oddi VS, duodenojejunal junction...

ORIGINAL CONTRIBUTION

The Journal of the American Osteopathic Association June 2016 | Vol 116 | No. 6358

From the A.T. Still Research

Institute at A.T. Still University

in Kirksville, Missouri

(Dr K. Snider, Dr E. Snider,

and Ms Johnson);

the Departments of Family

Medicine, Preventive Medicine,

and Community Health

(Dr K. Snider) and Osteopathic

Manipulative Medicine

(Dr Schneider, Dr E. Snider,

and Dr Danto) at the A.T. Still

University-Kirksville College

of Osteopathic Medicine in

Missouri; the Department

of Family Medicine at the

University of Massachusetts

Medical School in Worcester

(Dr Lehnhardt); Osteopathic

Horizons in Belleville, Illinois

(Dr Ngo); and Northeast Regional

Medical Center in Kirksville,

Missouri (Dr Sheneman).

Financial Disclosures:

None reported.

Support: The current study was

supported by a grant from the

A.T. Still Research Institute’s

Strategic Research Fund.

Address correspondence to

Karen T. Snider, DO,

Departments of Family Medicine,

Preventive Medicine, and

Community Health,

A.T. Still University-

Kirksville College of

Osteopathic Medicine,

800 W Jefferson St,

Kirksville, Missouri

63501-1143.

E-mail: [email protected]

Submitted

January 14, 2016; revision

received February 19, 2016;

accepted March 15, 2016.

Correlation of Somatic Dysfunction With Gastrointestinal Endoscopic Findings: An Observational StudyKaren T. Snider, DO; Robert P Schneider, DO; Eric J. Snider, DO; Jay B. Danto, DO; Charles W. Lehnardt, DO; Christopher S. Ngo, DO; Jane C. Johnson, MA; and Timothy A. Sheneman, DO

Context: Gastrointestinal (GI) endoscopy provides a novel means of correlating visceral abnormalities with somatic dysfunction.

Objective: To assess the correlation of palpatory findings of somatic dysfunction with GI abnormalities determined by endoscopy and to identify which types of so-matic dysfunction were most commonly correlated with GI abnormalities.

Methods: In this observational, cross-sectional study, participants who were sched-uled to receive an esophagogastroduodenoscopy (EGD), colonoscopy, or both were examined by 2 osteopathic physicians immediately prior to endoscopy for the pres-ence of vertebral tenderness, asymmetry, restricted range of motion, and tissue tex-ture abnormalities (TART findings); tenderness of anterior Chapman reflex points; and tenderness of visceral sphincters. Each type of somatic dysfunction and the somatic dysfunction burden (sum of findings) were compared with the type of endo-scopic procedure and abnormal endoscopic findings.

Results: Sixty-six adults participated: 43 received an EGD, 40 received a colonos-copy, and 17 received both. The incidence of vertebral TART findings ranged from 70% at T12 to 98% at the sacrum. Participants who received only EGD had a higher somatic dysfunction burden than those who received only colonoscopy and those who received both procedures (P=.002). The incidence of abnormal endoscopic findings ranged from 98% in the stomach to 0% at the ileocecal valve. Statisti-cally significant positive associations were found between specific vertebral TART findings and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, and sigmoid colon; specific Chapman reflex point tenderness and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending co-lon, descending colon, sigmoid colon, and rectum; and specific visceral sphincter tenderness and abnormalities of the duodenum, ascending colon, and sigmoid colon.

Conclusions: The current study found numerous associations between somatic dysfunction and abnormal endoscopic findings. However, the high incidence of vertebral TART findings and the lack of normal controls for many GI regions made establishing meaningful relationships between specific somatic dysfunc-tion and specific GI abnormalities challenging. Future investigations should include more participants to ensure a higher number of normal endoscopic find-ings and limit the physical examination to elements of somatic dysfunction with a high level of variability between vertebrae within an individual participant and between participants, such as tenderness and tissue texture abnormalities. (ClinicalTrials.gov number NCT01394198)

J Am Osteopath Assoc. 2016;116(6):358-369

doi:10.7556/jaoa.2016.076


The Journal of the American Osteopathic Association June 2016 | Vol 116 | No. 6 359

hiatus VS, pylorus VS, sphincter of Oddi VS, duodeno-jejunal junction VS, and ileocecal valve VS.13 Any inflammatory abnormalities affecting these anatomical areas should result in visceral fascial dysfunction diag-nosed as palpable tenderness. In the United States, more than 14 million GI endos-copies are performed yearly to assess for GI abnormali-ties,14 which provides an opportunity to compare the relationship between GI abnormalities and musculoskel-etal physical findings. Esophagogastroduodenoscopy (EGD) allows visualization of the luminal surface of the upper GI system (epiglottis to duodenum) and is per-formed primarily for evaluation of active upper GI symp-toms.15,16 Colonoscopy allows visualization of the lower GI system (anal sphincter distally to the ileocecal valve and the terminal ilium) and is performed for both active symptoms as well as asymptomatic screening for colorectal cancer in asymptomatic individuals aged 50 years or older.15,16 Therefore, colonoscopies can provide asymptomatic controls. The objective of the current study was to correlate palpatory findings of somatic dys-function with objectively confirmed GI abnormalities and to identify which types of somatic dysfunction were most commonly correlated with GI abnormalities. We hypothesized that GI abnormalities would be associated with somatic dysfunction diagnosed as vertebral TART abnormalities; tenderness of anterior Chapman reflex points; and VS tenderness.

MethodsParticipants

Between March 2011 and September 2013, we recruited participants aged 21 years or older who were scheduled to receive an EGD, colonoscopy, or both. Prior to enroll-ment, potential participants were screened by telephone to determine eligibility. Potential participants were ex-cluded if they had any history of spinal fractures or sur-gical intervention of the spine that could alter palpatory findings of the spinal and paraspinal regions. Participants

The osteopathic profession has long stressed structure-function relationships between the musculoskeletal and visceral systems, allowing

diagnostic clues of visceral abnormalities to be found within musculoskeletal structures. These relationships are partly due to viscerosomatic convergence of shared pathways between visceral and somatic afferent nerves within the spinal cord.1-3 The structures sharing innerva-tion (musculoskeletal and visceral) become hypersensi-tive or hyperreactive when disease is present in either. Visceral irritation, such as that induced experimentally through the topical administration of capsaicin to the mucosa of the gastrointestinal (GI) tract in healthy peo-ple, can manifest as burning somatic pain in predictable areas.4-6 These areas of referred pain are accompanied by somatic tissue hyperalgesia, locally increased skin temperature and blood flow,4-6 and subcutaneous and musculartrophic changes in the deep somatic tissues indicative of sympathetic nervous system excitation.7 These findings are also consistent with physical find-ings of somatic dysfunction, which include palpable ten-derness, asymmetry, restricted spinal motion, or tissue texture abnormalities (TART findings).1,8 Because the GI system receives sympathetic innervation from the thoracic and lumbar regions of the spinal cord, with the upper GI system receiving parasympathetic innervation from the vagus nerve and the lower GI system receiving innervation from the pelvis splanchnic nerves,9,10 somatic dysfunction in the corresponding spinal levels may be indicative of underlying GI abnormalities. In addition to spinal TART findings, other types of somatic dysfunction findings have been proposed to cor-relate with GI abnormalities. Chapman reflex points are discrete points of fascial tenderness and tissue texture abnormalities believed to reflect specific areas of visceral abnormalities, including GI abnormalities.11,12 Palpable areas of tenderness and fascial tissue texture abnormali-ties within the abdomen, known as visceral sphincters (VSs), are believed to be associated with the following GI transitional areas: gastroesophageal (GE) junction–



assessed on the right, left, and midline of each spinous process of C1-S1 and on the right, left, and midline of the inferior nuchal line of the OA. Vertebral segmental rotational asymmetry and motion restriction were as-sessed by noting the static asymmetry of the transverse processes and then applying alternating anterior pres-sure on the transverse processes. The preference for vertebral rotation was noted as right, left, or none. Vertebral segmental sagittal asymmetry and motion restriction were assessed by noting the static asym-metry of the spinous processes and then applying ante-rior pressure on the spinous processes. The preference for vertebral flexion, extension, or none was deter-mined by the presence of either static asymmetry or motion restriction. Paraspinal tissue texture abnormali-ties were recorded as boggy, muscular tension, or both with the location noted as right, left, or bilateral. Sacral asymmetry was recorded using the classic Mitchell terminology.20 Thirty-seven Chapman reflex points were assessed and noted as tender on the right, left, or bilateral, except for the sternal midline, which was ei-ther present or none. Abdominal VS tenderness was noted as tender or not tender for each of the 5 VS loca-tions as follows: the hiatus VS was immediately infe-rior and deep to the xiphoid process; the pylorus VS was just right of midline, 4 to 5 cm superior to the umbilicus; the sphincter of Oddi VS was palpated as a small projection at the right midclavicular line, 2 to 3 cm superior to the umbilicus; the duodenojejunal junction VS was at the left midclavicular line, 2 to 3 cm superior to the umbilicus; and the ileocecal valve VS was 3 cm wide and palpated medial to the ilium at the level of the cecum.13,21 For each physical examination, the first physician palpated for somatic dysfunction findings, and the second physician then confirmed those findings. When the examiners disagreed on the findings, the area was reexamined by both examiners and discussed until agree-ment was reached. The consensus of the physical find-ings was recorded on a data collection form.

who were wards of the state or unable to sign the consent form on their own behalf were also excluded. All partici-pants were scheduled to receive a GI endoscopy as part of their standard medical care; no participants received an endoscopy for research purposes. All aspects of the study protocol were approved by the local institutional review board, and all participants provided informed consent prior to study enrollment.

Somatic Dysfunction Determination

Just prior to their scheduled endoscopy, participants received a physical examination in the preoperative area performed by 2 physicians (either 2 neuromuscu-loskeletal medicine/osteopathic manipulative medicine [NMM/OMM] specialists or 1 NMM/OMM specialist and 1 NMM/OMM resident) who were blinded to the participant’s medical history and type of endoscopic procedure the participant would receive. Participants were told not to reveal their medical history or sched-uled endoscopic procedure to the physicians performing the physical examination. In the seated position, the participant was evaluated for tenderness and paraspinal tissue texture abnormalities at T1-L5 and the sacral base; rotational asymmetry, motion restriction, and re-stricted flexion and extension of T1-L5; and sacral asymmetry. In the supine position, the participant was evaluated for tenderness, rotational asymmetry, re-stricted flexion and extension, and paraspinal tissue texture abnormalities of the occipitoatlantal joint (OA) through C7; anterior Chapman reflex point tenderness of reflex points located on the anterior chest and lateral thighs11,12; and abdominal tenderness of the hiatus VS, pylorus VS, sphincter of Oddi VS, duodenojejunal junction VS, and ileocecal valve VS. When evaluating vertebral, Chapman reflex point, and VS tenderness, the participant was asked to indi-cate when he or she felt pain or tenderness with local-ized palpatory pressure sufficient to result in blanching of the examiner’s fingernail, which is considered to be approximately 4 kg/cm2.17-19 Vertebral tenderness was



Endoscopic Findings

Participant demographics, type of procedure(s), indica-tions for the procedure(s), participant symptoms, and endoscopic abnormalities were collected from the outpa-tient surgical record and histologic reports (if applicable). The following endoscopic findings, if reported on the operative visual report or the histologic report, were considered abnormal: inflammation such as erythema, erosions, ulcerations, or eosinophilia, and abnormal growths such as polyps, metaplasia, or dysplasia. The presence of a hiatal hernia, diverticula, or hemorrhoids on the visual report or Helicobacter pylori on the histo-logic report was also considered abnormal. For analysis, endoscopic findings were grouped according to the following regions: esophagus, GE junction, stomach, pylorus, duodenum, terminal ileum, ileocecal valve, as-cending colon (including the cecum and hepatic flexure, transverse colon), descending colon (including the splenic flexure), sigmoid colon, and rectum and anus.

Statistical Analysis

The data for participant demographics, type of procedure(s), indications for the procedure(s), partici-pant symptoms, endoscopic abnormalities, and types of somatic dysfunctions were tabulated. The relationship of the somatic dysfunction burden with the type of endo-scopic procedure and the presence of GI symptoms were assessed using the Kruskal-Wallis test. Mann-Whitney tests were used to compare the somatic dysfunction burden, vertebral TART findings, vertebral tenderness, regional TART findings, and regional spinal tenderness between those participants with abnormal vs normal en-doscopic findings. Somatic dysfunction burden was cal-culated as the sum of the number of individual vertebral TART findings (0 to 233 points), tender Chapman reflex points (0 to 37 points), and tender VS (0 to 5 points) and had a possible range of 0 to 275 points. Vertebral TART findings were calculated as the sum of the individual TART findings (tenderness, rotational asymmetry or mo-tion restriction, sagittal asymmetry or motion restriction,

and tissue texture abnormalities) for each vertebral seg-ment and could range from 0 to 9 points for the OA through L5 and from 0 to 8 points for the sacrum (1 point for each TART finding present). Vertebral tenderness was calculated as the sum of the individual tenderness find-ings for each vertebra and could range from 0 to 3 points (1 point for tenderness at each location). Regional TART findings were calculated as the sum of the individual vertebral TART findings for the cervical (OA-C7), tho-racic (T1-T12), lumbar (L1-L5), and sacral regions. Re-gional tenderness was calculated as the sum of the individual vertebral tenderness findings for the cervical, thoracic, lumbar, and sacral regions. χ2 tests were used to compare the percentage of tender Chapman reflex points and tender VS between those participants with abnormal or normal endoscopic findings. P≤.05 was considered statistically significant. The data were analyzed using SAS statistical software (version 9.4, SAS Institute, Inc).

ResultsSixty-six participants (39 [59%] women; mean [SD] age, 53 [15] years) completed the current study. One participant dropped out after receiving the physical examination because the scheduled endoscopy was not performed. Forty-three participants (65%) received an EGD, 40 participants (61%) received a colonoscopy, and 17 participants (26%) received both. Forty partici-pants (93%) received an EGD for a diagnosis of active symptoms and 3 (7%) for surveillance of previously diagnosed problems. Twenty-nine participants (73%) received a colonoscopy for health screening, 9 (23%) for diagnosis of an active problem, and 2 (5%) for sur-veillance; 14 (33%) reported GI symptoms at the time of their colonoscopy. The most common GI symptoms among the 40 symptomatic participants receiving an EGD were GE reflux (26 [65%]) and abdominal pain (23 [58%]), and the most common symptoms among the 14 symptomatic participants receiving a colonos-copy were constipation (6 [43%]) and abdominal pain



malities were positively associated with sacral ten-derness (P=.03). No other significant associations were found between abnormal endoscopic findings and vertebral tenderness. When regional TART findings were examined, py-loric abnormalities were positively associated with TART findings in the lumbar and sacral regions (both P≤.04). No other significant correlations were found be-tween abnormal endoscopic findings and regional TART findings. When only regional tenderness findings were examined, ascending colon abnormalities were posi-tively associated with tenderness in the thoracic region (P=.02). Sigmoid colon abnormalities were positively associated with tenderness in the cervical, thoracic, lumbar, and sacral regions (all P≤.05). Rectal and anal abnormalities were positively associated with tenderness in the lumbar region (P=.05). No other significant cor-relations were found between abnormal endoscopic find-ings and regional tenderness. The incidence of tender Chapman reflex points ranged from 9% at the anterior proximal 3rd and the posterior middle 3rd of the iliotibial band to 53% at the 5th intercostal space and the anterior tip of the 12th rib (Table 3). The differences between the per-centage of tender Chapman reflex points for those with abnormal and normal endoscopic findings is presented in Figure 2. Tenderness was present at the hiatus VS in 29 par-ticipants (44%), the pylorus VS in 29 (44%), the sphincter of Oddi VS in 25 (38%), the duodenojejunal junction VS in 26 (39%), and the ileocecal valve VS in 34 (52%). Significant negative associations were found between GE junction abnormalities and hiatus, pylorus, sphincter of Oddi, and duodenojejunal junction VS tenderness (all P≤.05). Significant positive associations were found between duodenal abnormalities and duo-denojejunal junction VS tenderness (P=.04); ascending colon abnormalities and sphincter of Oddi VS tender-ness (P=.05); and sigmoid colon abnormalities and hiatus and pylorus VS tenderness (both P=.03).

and diarrhea (each 5 [38%]). The incidence of abnormal endoscopic findings ranged from 98% in the stomach to 0% at the ileocecal valve (Table 1). Because only 1 participant had no stomach abnormalities, the gastric region was not included in any comparisons with mus-culoskeletal findings. Participants who received an EGD had a higher mean (SD) somatic dysfunction burden (97 [31] points) than those who received a colonoscopy (68 [28] points) and those who received both procedures (69 [29] points, P=.002). Symptomatic participants who re-ceived only EGD or only colonoscopy had a higher mean (SD) somatic dysfunction burden (95 [32] points) than symptomatic participants who received both pro-cedures (77 [36] points), participants symptomatic for 1 procedure who received both procedures (65 [19] points), or asymptomatic participants who received 1 procedure or both procedures (63 [25] points, P=.005). No significant associations were found between ab-normal endoscopic findings of any single GI region and somatic dysfunction burden (all P≥.07). The incidence of 1 or more vertebral TART findings ranged from 70% at T12 to 98% at the sacrum (Table 2). The differences between the mean number of vertebral TART findings for those with abnormal and normal en-doscopic findings is presented in Figure 1. When only vertebral tenderness was examined, GE junction abnormalities were negatively associated with tenderness at T8 and T12 (both P≤.03). Pyloric abnormalities were positively associated with tender-ness at T11 (P=.01). Duodenal abnormalities were negatively associated with tenderness at T2 and L2 (both P≤.03). Ascending colon abnormalities were positively associated with tenderness at T5, L2, and L5 (all P≤.02). Descending colon abnormalities were positively associated with tenderness at T5 and T7 (both P≤.05) and negatively associated with tender-ness at C2 (P=.05). Sigmoid colon abnormalities were positively associated with tenderness at C2, L4, and the sacrum (all P≤.03). Rectal and anal abnor-



tion,22,23 the somatic dysfunction of our participants may have been of somatic or visceral origin. However, mus-culoskeletal pain can also affect visceral structures via viscerosomatic convergence. Noxious stimulation of somatic tissues in animal models has been shown to cause visceral hyperalgesia and altered contractility, as well as altered muscular activity in structures receiving innervation from the same spinal levels.24-26 For the cur-rent study, we looked solely at the relationship between somatic dysfunction and GI abnormalities. Our results suggested that participants receiving an EGD had a sig-nificantly higher somatic dysfunction burden than par-

DiscussionThe current study found numerous significant associa-tions between somatic dysfunction and abnormal endo-scopic findings. However, the high incidence of vertebral somatic dysfunction findings combined with a lack of normal controls for many GI regions made it difficult to establish meaningful relationships between specific GI abnormalities and somatic dysfunction in the various body regions. Additionally, the methods of the current study allowed the inclusion of participants with chronic musculoskeletal pain. Because patients with back pain are more likely to have significant somatic dysfunc-

Table 1. Incidence of Visual and Histologic Abnormalities Reported on Endoscopic Operative and Pathology Reports in Patients With Somatic Dysfunction (N=66)

Region Total Visual Region Histologic

Gastrointestinal Visualized, Abnormalities, Abnormalities, Biopsied, Abnormalities,

Regiona No. No. (%) No. (%) No.b No. (%)

EGD 43 … … 41 …

Esophagus 43 24 (56) 24 (56) 3 3 (100)

Gastroesophageal 43 38 (88) 38 (88) 27 20 (74) junction

Stomach 43 42 (98) 42 (98) 36 28 (78)

Pylorus 43 20 (47) 20 (47) 0 NA

Duodenum 42 33 (79) 32 (76) 17 15 (88)

Colonoscopy 40 … … 28 …

Terminal ilium 5 3 (60) 2 (40) 3 2 (67)

Ileocecal valve 14 0 0 0 NA

Ascending colon 39 17 (44) 11 (28) 15 14 (93) including cecum and hepatic flexure

Transverse colon 40 9 (23) 7 (18) 6 6 (100)

Descending colon 40 17 (43) 12 (30) 9 9 (100) including splenic flexure

Sigmoid colon 40 23 (58) 22 (55) 12 9 (75)

Rectum and anus 40 28 (70) 28 (70) 14 10 (71)

a No operative reports identified visual or histological findings at the sphincter of Oddi or the duodenojejunal junction.b Some regions biopsied were visually normal.

Abbreviations: EGD, esophagogastroduodenoscopy; NA, not applicable.



not predict what type of visceral disease patients had using only palpation and visual clues. The current study positively correlated vertebral TART findings with ab-normal endoscopic findings in the esophagus, GE junc-tion, pylorus, ascending colon, and sigmoid colon. However, these correlations did not seem to follow a pattern such as dermatomal or autonomic innervation of the associated GI region. Negative correlations were

ticipants receiving a colonoscopy or both an EGD and colonoscopy. This finding may be explained by the 93% of EGD participants who reported active upper GI symp-toms; only 33% of colonoscopy participants reported active lower GI symptoms. Several studies27-31 have positively correlated a his-tory of visceral disease with spinal TART findings. How-ever, Tarr et al31 found that osteopathic physicians could

Table 2. Incidence of Vertebral TART Findings in Patients Undergoing Gastrointestinal Imaging (N=66)a

Asymmetry/ Tissue Texture

Spinal Level Any TART Tenderness Restricted ROM Abnormalities

OA 63 (95) 33 (50) 61 (92) 34 (52)

AA 61 (92) 36 (55) 57 (86) 34 (52)

C2 62 (94) 38 (58) 45 (68) 50 (76)

C3 63 (95) 43 (65) 54 (82) 49 (74)

C4 59 (89) 41 (62) 48 (73) 45 (68)

C5 56 (85) 36 (55) 44 (67) 40 (61)

C6 58 (88) 37 (56) 42 (64) 47 (71)

C7 59 (89) 37 (56) 49 (74) 44 (67)

T1 59 (89) 27 (41) 47 (71) 46 (70)

T2 60 (91) 27 (41) 43 (65) 52 (79)

T3 58 (88) 34 (52) 46 (70) 47 (71)

T4 59 (89) 35 (53) 43 (65) 45 (68)

T5 57 (86) 31 (47) 44 (67) 44 (67)

T6 60 (91) 29 (44) 52 (79) 45 (68)

T7 56 (85) 27 (41) 46 (70) 43 (65)

T8 48 (73) 20 (30) 37 (56) 38 (58)

T9 50 (76) 18 (27) 40 (61) 36 (55)

T10 51 (77) 18 (27) 37 (56) 37 (56)

T11 48 (73) 17 (26) 31 (47) 37 (56)

T12 46 (70) 14 (21) 28 (42) 34 (52)

L1 55 (83) 24 (36) 34 (52) 36 (55)

L2 57 (86) 29 (44) 32 (48) 45 (68)

L3 55 (83) 33 (50) 39 (59) 40 (61)

L4 53 (80) 36 (55) 35 (53) 33 (50)

L5 58 (88) 42 (64) 38 (58) 36 (55)

Sacrum 65 (98) 37 (56) 64 (97) 27 (41)

a Data are given as No. (%).

Abbreviations: AA, atlantoaxial joint; OA, occipitoatlantal joint; ROM, range of motion; TART, tenderness, asymmetry, restricted range of motion, tissue texture abnormalities.



Figure 1. Difference between the mean vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings) for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from the Mann-Whitney test comparing the number of TART findings between those with abnormal vs normal findings. Positive values indicate that participants with abnormal endoscopic findings had higher mean vertebral TART findings at the indicated levels, and negative values indicate that participants with normal endoscopic findings had higher mean vertebral TART findings at the indicated levels. Blue bars indicate significantly more TART findings for those with abnormal endoscopic findings. Red bars indicate significantly more TART findings for those with normal endoscopic findings (P≤.05). Abbreviations: AA, atlantoaxial joint; GE, gastroesophageal junction; OA, occipitoatlantal joint.

A

B

OAAAC2C3C4C5C6C7T1T2T3T4T5T6T7T8T9T10T11T12L1L2L3L4L5Sacrum

Spinal Level

.55 .48

.84 .05

.18 .91

.18 .39

.49 .77

.84 .28

.03 .54 .56

.97 .05

.56 .67 .79

.34 .22 .29

.80 .43

.92

-3.0-2.0-1.00.01.02.03.0

Esophagus Normal Abnormal (n=19) (n=24)

.68 .55 .86

.82 .32 .68

.27 .40

.64 .54 .92

.05 .40

.02 .83

.38 .71

.55 .12 .18

.50 .04

.94 .70 .55

.79

-3.0-2.0-1.00.01.02.03.0

GE Junction Normal Abnormal (n=5) (n=38)

-3.0-2.0-1.00.01.02.03.0

Stomach Normal Abnormal (n=1) (n=42)

.45 .21

.22 .96

.29 .32

.04 .78

.17 .66 .40 .22 .46

.84 .45

.97 .36

.45 .23

.97 .04 .02

.38 .08

.03 .07

-3.0-2.0-1.00.01.02.03.0

Pylorus Normal Abnormal (n=23) (n=20)

OAAAC2C3C4C5C6C7T1T2T3T4T5T6T7T8T9

T10T11T12

L1L2L3L4L5

Sacrum

Spin

al L

evel

.42 .50

.06 .99 .90 .96

.63 .93 .54

.52 .005

.19 .80 .53

.32 .49

.89 .19 .47 .25

.08 .95

.89 .34 .50 .79

-3.0-2.0-1.00.01.02.03.0

Duodenum Normal Abnormal (n=9) (n=33)

OAAAC2C3C4C5C6C7T1T2T3T4T5T6T7T8T9T10T11T12L1L2L3L4L5Sacrum

Spinal Level

-3.0-2.0-1.00.01.02.03.0

-3.0-2.0-1.00.01.02.03.0

-3.0-2.0-1.00.01.02.03.0

-3.0-2.0-1.00.01.02.03.0

OAAAC2C3C4C5C6C7T1T2T3T4T5T6T7T8T9

T10T11T12

L1L2L3L4L5

Sacrum

Spin

al L

evel

-3.0-2.0-1.00.01.02.03.0

Ascending Colon Normal Abnormal (n=22) (n=17)

Transverse Colon Normal Abnormal (n=31) (n=9)

Descending Colon Normal Abnormal (n=23) (n=17)

Sigmoid Colon Normal Abnormal (n=17) (n=23)

Rectum and Anus Normal Abnormal (n=12) (n=28)

.34 .18

.77

.87 .55

.003 .20 .20

.27 .74

.19 .28

.65 .21 .10 .05

.15 .14

.88 .07

.99 .57

.27 .87 .94 .66

.48 .75

.88 .50

.95 .68

.57 .77

.05 .77

.62 .28

.78

.35 .72 .50 .70

.12 .16

.15 .58 .62 .57 .96 .67 .40

.73 .26 .43 .43 .83

.94 .68 .59 .69

.70 .90

.91

.93 .63

.17 .23

.31 .32 .25

.34 .85 .63 .82

.56 .30 .27

.68 .48

.08 .97 .50

.88 .32 .36

.007.17

.41 .02

.15 .27

.77 .42

.60

.52 .84

.13 .62 .88

.16 .32 .14

.25

.48 .77 .95 .90

.75 .11 .08 .21

.70

.51 .12 .15

.98 .68 .31

>.99 .10

.28 .56

.51 .58

.65 .79

.72 .75

.10



While palpation is inherently subjective and prone to interobserver reliability errors, it is still used and encour-aged as part of clinical assessment, and its relationship to pathology needs to be studied.32-36 The current study used a consensus of palpatory findings identified by 2 physician examiners, but future studies could utilize research tools, such as algometers or ultrasonography,

found in the esophagus, GE junction, duodenum, and transverse colon. Together these findings suggest a need for additional studies that would include more partici-pants for better powered statistical analyses of the dif-ferent TART elements of somatic dysfunction. The current study had several limitations. Foremost, this study used palpation to identify TART findings.

Table 3. Incidence of Tender Chapman Reflex Points in Patients With Somatic Dysfunction Undergoing Gastrointestinal Imaging (N=66)

Chapman Classic Visceral Associationa Tender Points

Reflex Point Right Left Any Right Left

1st Rib, at manubrial Pharynx Pharynx 31 (47) 20 (30) 24 (36) attachment

2nd Rib, at superior Larynx Larynx 31 (47) 22 (33) 21 (32) aspect of sternal attachment

2nd Intercostal space Esophagus Esophagus 24 (36) 19 (29) 17 (26)

3rd Intercostal space Right upper lung Left upper lung 25 (38) 17 (26) 18 (27)

4th Intercostal space Right lower lung Left lower lung 29 (44) 24 (36) 23 (35)

5th Intercostal space Liver Stomach 35 (53) 27 (41) 26 (39)

6th Intercostal space Liver/gallbladder Stomach 30 (45) 20 (30) 25 (38)

Sternal midlineb Pylorus Pylorus 31 (47) NA NA

7th Intercostal space Pancreas Spleen 30 (45) 21 (32) 27 (41)

8th Intercostal space Small intestines Small intestines 25 (38) 20 (30) 18 (27)



12th Rib, anterior tip Appendix NKA 35 (53) 23 (35) 29 (44)

ITB, anterior proximal third Cecum Sigmoid 6 (9) 3 (5) 3 (5)

ITB, anterior middle third Ascending colon Descending colon 9 (14) 4 (6) 5 (8)

ITB, anterior distal third Hepatic flexure Splenic flexure 14 (21) 8 (12) 7 (11) and proximal and distal transverse colon transverse colon

ITB, posterior proximal third Right broad ligament Left broad ligament 9 (14) 6 (9) 4 (6) (F)/prostate (M) (F)/prostate (M)

ITB, posterior middle third Right broad ligament Left broad ligament 6(9) 6 (9) 4 (6) (F)/prostate (M) (F)/prostate (M)

ITB, posterior distal third Right broad ligament Left broad ligament 7 (11) 5 (8) 3 (5) (F)/prostate (M) (F)/prostate (M)

a Classic visceral associations of Chapman reflex points were defined according to Fossum et al.12

b Sternal midline includes tenderness located anywhere along the vertical midline of the sternum.

Abbreviations: F, female; ITB, iliotibial band; M, male; NA, not applicable; NKA, no known association.



1st Rib

2nd Rib

2nd ICS

3rd ICS

4th ICS

5th ICS

6th ICS

Sternum

7th ICS

8th ICS

9th ICS

10th ICS

12th rib

ITB AP

ITB AM

ITB AD

ITB PP

ITB PM

ITB PD

Chapm

an Reflex P

oint

-50-40-30-20-10 0 10 20 30 40 50

1st Rib

2nd Rib

2nd ICS

3rd ICS

4th ICS

5th ICS

6th ICS

Sternum

7th ICS

8th ICS

9th ICS

10th ICS

12th rib

ITB AP

ITB AM

ITB AD

ITB PP

ITB PM

ITB PD

Cha

pman

Ref

lex

Poi

nt

RightLeft

RightLeft

-50-40-30-20-10 0 10 20 30 40 50

-50-40-30-20-10 0 10 20 30 40 50

-50-40-30-20-10 0 10 20 30 40 50

-50-40-30-20-10 0 10 20 30 40 50

Stomach Normal Abnormal (n=1) (n=42)

Esophagus Normal Abnormal (n=19) (n=24)

GE Junction Normal Abnormal (n=5) (n=38)

Pylorus Normal Abnormal (n=23) (n=20)

Duodenum Normal Abnormal (n=9) (n=33)

.11

.44

.24

.84

.81

.39

.09

.55

.03

.96

.44

.04

.14

.87

.42

.56

.42

.03

.42

.50

.69

.92

.90

.76

.61

.81

.43

.07

.02

.37

.92

.69

.25

.45

.69

.06

.11

.32

.16

.61

.52

.84

.84

.80

.89

.32

.40

.71

.43

.84

.60

.51

.68

.22

.53

.51

.89

.80

.43

.16

.98

.76

.84

.14

.12

.80

.52

.21

.51

.39

.39

.51

.45

.51

.49

.75

.98

.08

.92

.92

.99

.72

.95

.32

.75

.54

.92

.12

.64

.11

.64

.76

.09

.11

.99

.94

.32

.57

.02

.05

.45

.05

.53

.33

.30

.47

.52

.52

.64

.88

.09

.30

.43

.32

.19

.42

.12

.34

.54

.78

.22

.43

.16

.48

.45

.60

.76

.35

.28

.60

.03

.03

.16

>.99

.62

.48

.51

.20

.86

.54

.004

.48

.60

.28

.28

.60

.14

.35

1st Rib

2nd Rib

2nd ICS

3rd ICS

4th ICS

5th ICS

6th ICS

Sternum

7th ICS

8th ICS

9th ICS

10th ICS

12th rib

ITB AP

ITB AM

ITB AD

ITB PP

ITB PM

ITB PD

Chapm

an Reflex P

oint

.10

.65

.48

.22

.39

.20

.42

.11

.68

.11

.39

.71

.22

.25

.71

.43

.78

.85

.78

-50-40-30-20-10 0 10 20 30 40 50

Ascending Colon Normal Abnormal (n=22) (n=17)

.82

.02

.11

.23

.36

.88

.64

.41

.23

.95

.97

.39

.37

.20

.71

.37

.25

.71

1st Rib

2nd Rib

2nd ICS

3rd ICS

4th ICS

5th ICS

6th ICS

Sternum

7th ICS

8th ICS

9th ICS

10th ICS

12th rib

ITB AP

ITB AM

ITB AD

ITB PP

ITB PM

ITB PD

Cha

pman

Ref

lex

Poi

nt

RightLeft

RightLeft

.67

.95

.98

.51

.69

.50

.67

.95

.38

.98

.28

.33

.13

.06

.33

.90

.90

.33

.90

-50-40-30-20-10 0 10 20 30 40 50

Transverse Colon Normal Abnormal (n=31) (n=9)

.38

.69

.38

.85

.45

.21

.51

.83

.26

.51

.57

.56

.59

.43

.64

.59

.59

.64

.09

.75

.89

.85

.82

.48

.39

.31

.37

.89

.18

.74

.04

.24

.74

.46

.75

.38

.75

-50-40-30-20-10 0 10 20 30 40 50

Descending Colon Normal Abnormal (n=23) (n=17)

.75

.63

.37

.75

.72

.23

.58

.58

.63

.58

.41

.94

.38

.83

.74

.38

.24

.74

.10

.08

.53

.85

.63

.19

.10

.30

.16

.53

.14

.74

.85

.38

.38

.75

.17

.12

.75

-50-40-30-20-10 0 10 20 30 40 50

Sigmoid Colon Normal Abnormal (n=17) (n=23)

.72

.63

.89

.63

.72

.23

.02

.02

.75

.36

.41

.44

.24

.83

.12

.38

.38

.38

.93

.16

.56

.43

.08

.11

.32

.16

.56

.16

.76

.24

.43

.12

.90

.17

.17

.24

.82

-50-40-30-20-10 0 10 20 30 40 50

Rectum and Anus Normal Abnormal (n=12) (n=28)

.51

.82

.80

.23

.03

.08

>.99

.43

.73

>.99

.41

.23

.51

.34

.15

.12

.51

.90

Figure 2. Difference between the percentage of tender Chapman reflex points for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from χ2 test comparing the percentage of tender Chapman reflex points between those with abnormal vs normal endoscopic findings. Positive values indicate that participants with abnormal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations, and negative values indicate that participants with normal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations. Blue and green bars indicate a significantly higher percentage of tender Chapman reflex points on the right and left sides, respectively, for those with abnormal findings. Orange bars indicate a significantly higher percentage of tender Chapman reflex points on the left side for those with normal findings (P≤.05). Abbreviations: AD, anterior distal third; AM, anterior middle third; AP, anterior proximal third; GE, gastroesophageal junction; ICS, intercostal space; ITB, iliotibial band; PD, posterior distal third; PM, posterior middle third; PP, posterior proximal third.

A

B



tionships between the endoscopic findings and smaller groups of vertebral TART findings such as those associ-ated with sympathetic innervation. Future investiga-tions should focus on elements of somatic dysfunction with a high level of variability between vertebrae within an individual participant and between partici-pants, such as tenderness, and evaluate more partici-pants to ensure a sufficient number of participants with normal endoscopic findings.

AcknowledgmentsWe thank Deborah Goggin, MA, from Research Support at A.T. Still University, for her editorial assistance. We extend our gratitude to Matthew R. Hardee, DO, and to the other participating endoscopists.

Author ContributionsAll authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and Dr K. Snider agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correlation of Somatic Dysfunction With …pylorus VS, sphincter of Oddi VS, duodenojejunal junction...

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