Chiropractic Care and the Situs Inversus Patient: Modifying Technique to Match Anatomy

Zablotney J, Blum CL.WFC’S 10th Biennial Congress. International Conference of Chiropractic Research, Montreal, CanadaApr 30 – May 2, 2009: 235-7

Introduction: Matthew Baillie described situs inversus in the mid 1700s. In situs inversus totalis the heart chambers, lung lobes, abdominal organs and colon are all found in a mirror image arrangement of normal. Situs inversus is a congenital condition affecting genders and races equally [1] and found in less than 1 in 10,000 people. Literature reviewed on situs inversus was from searching PubMed, MANTIS, ChiroIndex.org, and GoogleScholar which did not find any papers discussing chiropractic and situs inversus. Many patients with situs inversus totalis are unaware of their unusual anatomy until they seek medical attention for an unrelated condition. The reversal of the organs may then lead to some confusion, and for example, with appendicitis a patient might have left lower abdominal pain [2] or left upper quadrant pain could be associated with a biliary cholic [3]. The purpose of this paper is to present a novel case report of a patient with situs inversus treated by chiropractic care involving chiropractic manipulative reflex (visceral) techniques (CMRT) modified to the patient’s condition.

Case Report The Assessment: This patient was a 60 year old mother of 4 who has been a chiropractic patient for over 20 years receiving spine-only chiropractic care. She had a long history of upper respiratory problems such as asthma and allergies. Her gallbladder was removed at 22 years of age and during the surgery it was discovered she had situs inversus. She had been coping with a spastic colon for 35 years and an anal fissure following a traumatic labor and delivery for her second child during which she iatrogenically dislocated her hip joint. The patient noted numerous neck and back injuries and her radiographs demonstrated advanced cervical degeneration and pelvic imbalance. As a result of her injuries she reported chronic neck, upper back, right shoulder, and low back pain; necessitating chiropractic care for nearly 20 years. She had been under the care of family physicians and specialists, taking a large number of medications.

The patient began care in this office in January of 2007 and was seen for 16 office visits utilizing Blair Upper Cervical (BUC) x-ray spinography protocols, Sacro OccipitalTechnique (SOT) categorization, and CMRT procedures. Some outcome assessment measures were utilized for clinical measurements which included an algometry exam that revealed an above average pain threshold. Range of motion testing found her lumbosacral and cervical range of motions significantly decreased with the exception of lumbosacral flexion. The initial rolling thermal exam revealed sympathetic dystonia in her lower cervical spine and would be performed at the start of each visit in order to establish a cervical subluxation pattern. The occipital fiber analysis involves palpation for pain at of suboccipital muscles, specific related vertebra, and associated reflex/referred pain points. The CMRT protocol uses palpation of painful regions associated with viscerosomatic reflexes and their reduction following treatment. The patient’s diagnosis involved multiple parameters but focused on cervical intersegmental dysfunctions, sacroiliac joint hypermobility, and multiple viscerosomatic/somatovisceral reflex imbalances.

Treatment/Intervention: BUC treatment using three dimensional lateral stereoscopic x-rays of her cervical spine revealed multiple misalignments. SOT categorization procedures revealed a Category II. Her response to Blair and SOT protocols was good and as expected however CMRT protocols needed to be modified in novel ways to compensate for her situs inversus presentation. Occipital fiber analysis, an assessment process used with CMRT protocols, was performed on each visit, and an active visceral reflex was identified on 13 out of her 16 visits. CMRT involved occipital fiber neutralization, vertebral adjustment and reflex manipulations to balance reflex arcs between the organ, spine, and the autonomic nervous system. CMRT’s 7 occipital fibers are located on each side along the nuchal line, from the occipitomastoid junction (number 1) to the most medial number seven, lateral to the external occipital protuberance number 7). These muscle fibers are located in 7 vertical fibers on each side of the occiput and are near the aponeurosis of the cervical musculature where they attach to the occiput. Generally there will be swelling at the fiber along with sensitivity when active.

CMRT diagnosis involves testing for occipital fiber analysis and vertebral transverse process sensitivity as well as, referred pain patterns associated with the dysfunctional organ. Once the occipital reflex is determined and corroborated by, history, examination, and possibly laboratory tests, then treatment can begin. Fiber neutralization is accomplished by cross fiber manipulating the specific occipital fiber at line two while contacting the sensitive vertebral transverse process, in the reflex arc. Once moisture or warmth is palpated at the transverse process the occipital fiber manipulation is ceased and the vertebra is adjusted. Following the vertebral adjustment the visceral reflex arc is treated with CMRT procedures. On one office visit, the patient noted three consecutive days of constipation. Tenderness to palpation was found at occipital line fiber 3, right L1 transverse process, over the ileocecal valve region and left anterior shoulder [4]. Normally CMRT reflexes for ileocecal syndrome would be in the right inguinal region and right shoulder. The CMRT procedure for ileocecal valve was performed opposite to the normal pattern with stimulation to her left shoulder and left lower abdomen. At another office visit, occipital fiber 4 was tender and she had sensitivity at her left T6 transverse process. While the usual CMRT reflex pattern for an active pancreas reflex is a tender right thenar pad, this patient had a tender left thenar pad [5]. Typically there are two CMRT pancreas referred pain reflexes at the base of the rib cage, one on the left just above the lower border of the costal cartilage, and one on the right just below the lower border of the costal cartilage. This patient demonstrated the opposite reflex pattern.

Results: Following each treatment the patient noted a reduction in neck pain and an increase in range of motion. After 5 visits, SOT protocols indicated an improved capability in bilateral supine leg lift capacity. The arm fossa test results were continually improving. Also, her right shoulder pain subsided completely and her thoracolumbar junction pain subsided. Following CMRT treatment for the L1/ileocecal reflex the patient experienced “gurgling and rumbling” within her abdomen. Ten minutes later she experienced a large and urgent bowel movement, which was significant based on her prior three days of constipation. Following CMRT treatment for T6/pancreas reflex the patient noticed global symptomatic improvement. Of significance, for one month following this office visit, the patient was able to sleep through the night without having to rise to urinate, which had not been the case for years.

Short-term outcome to treatment involved reduction in pain and increased function as well as reduction of sleep disturbances and constipation. Due to her long-term disabilities and complex presentations it may not be reasonable to anticipate a “permanent” long-term solution to her conditions. Ideally infrequent treatment that allows her to function at home and maintain a good quality of life might be her best long-term option.

Discussion: While the response to BUC and SOT Category Two protocols were as anticipated, the CMRT evaluation and treatment was unusual based on the patient’s situs inversus presentation. Referred appendix and gallbladder pain patterns of patients with situs inversus (totalis) have been found opposite to what is seen with normal human organ anatomy. Therefore it was assumed that treatment of this patient’s ileocecal and pancreas visceral reflex pattern would be the opposite of what is commonly seen.A possible mechanism for the observed changes could be related to CMRT, a method of treating vertebral visceral syndromes associated with viscerosomatic/somatovisceral reflexes, spinal joint complex dysafferentation, and visceral mimicry type somatic relationships. If indicated, when a vertebral dysfunction is chronic or unresponsive to chiropractic spinal manipulation then a viscerosomatic or somatovisceral component is evaluated.

Conclusion: The purpose of the case report was to present an unusual patient presentation of situs inversus and how treatment was modified for the patient’s condition. While CMRT referred pain and reflex patterns need greater study it is of interest that their opposite presentation and related treatment appeared to affect a positive outcome. Future studies could compare a blinded evaluation of patients with situs inversus and normal organ anatomy to determine if side of CMRT reflex and referred pain patterns is consistent. Greater research is needed to investigate what subset of patients may respond to viscerosomatic/somatovisceral chiropractic reflex treatment.

References:

Wilhelm A, Holbert JM. Situs Inversus. Dec 5, 2007. http://www.emedicine.com/radio/topic639.htm [Last Accessed 8-20-08].
Nelson MJ, Pesola GR. Left lower quadrant pain of unusual cause. J Emerg Med. 2001 Apr;20(3):241-5.
Janchar T, Milzman D, Clement M. Situs inversus: emergency evaluations of atypical presentations. Am J Emerg Med. 2000 May;18(3):349-50.
Blum CL, Globe G, Angina visceral mimicry syndrome: A proposed collaborative integrative treatment model Journal of Chiropractic Education, Spr 2006;20(1): 51-2.

5. Blum CL, Visceral Mimicry Syndrome and Cholecystectomy: A Chiropractic Case Study, FCER’s Conference on Chiropractic Research, Sep 15-16, 2006 – Chicago, Illinois.

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