Blum Cl, Visceral Mimicry Syndrome and Cholecystectomy: A Chiropractic Case Study. Proceedings on the 2006 Conference on Chiropractic Research, Chicago, Illinois, September 15-16, 2006: 161-3.
INTRODUCTIONThis case study reports on a patient presenting with pain she believed to be associated with her gallbladder. The patient reported having gallbladder surgery ( cholecystectomy) approximately 2 weeks prior to chiropractic evaluation and treatment.
The incidence of gallbladder related conditions in the USA is approximately 1 in 438 or 0.23% or 620,031 Americans with 2,830 deaths reported in the United States in 1999 for cholelithiasis and other gall bladder conditions.
There is a paucity of published studies (reviewed through PubMed and MANTIS) evaluating spinal manipulative therapy for gastrointestinal and gallbladder related dysfunction with none characterizing the treatment of post-surgical visceral dysfunction by spinal manipulation or reflex techniques.
The purpose of this case report is to investigate chiropractic's purported ability to treat visceral conditions, in this case pain related to the gallbladder, with spinal manipulative therapy using a method of treatment called sacro occipital technique (SOT) and chiropractic manipulative reflex technique (CMRT). Chiropractic treatment of patients with purported organ related symtomatology is not clearly understood. Theories suggest conditions might be helped due to somatovisceral - viscerosomatic autonomic balancing, decreasing nociceptive activity relating to a referred pain reflex pattern, balancing a somatically induced visceral mimicry syndrome, [1,2] or with this case, an effect similar to ameliorating aberrant reflexes associated with "phantom organ pain."
Assessment
The patient was a 40-year-old female who presented two weeks post-surgically after cholecystectomy . She reported good health until approximately 6 months previously when she had a series of what she described as 3 "gallbladder" attacks. Her allopathic doctor diagnosed the etiology of her complaint as most likely secondary to a "blockage in her bile duct, which caused the area to become inflamed" and recommended surgery.
Within a few days following the surgery the patient reported experiencing an increase of the pain, which became constant, severe and sharper. The pain region expanded from the right costal margin to a generalized area inferior of the xiphoid to superior of the umbilicus. The patient was taking over-the-counter NSAIDs recommended by her allopathic physician, but these did not provide her relief.
Prior to her being seen for chiropractic treatment her surgeon assured her the surgery was a success but that occasionally there can be pain that follows due to the "healing process." Due to the severity of the pain, her lack of responsiveness to medication, and the absence of a further allopathic care pathway; the patient sought alternative care with a chiropractor experienced in treating visceral dysfunction. The patient was examined and it was determined safe to begin a brief trial of sacro occipital technique (SOT) diagnostic and treatment.
The SOT procedures included evaluating the patient using chiropractic manipulative reflex technique (CMRT) and found that she did have congruent findings related to the gallbladder. CMRT diagnosis involved testing for occipital fiber analysis and vertebral transverse process sensitivity as well as, referred pain patterns associated with the evaluated organ, such as in this case right shoulder and lower costal margin pain .
Treatment/Intervention:
The initial treatment procedure focused on "neutralizing the occipital fiber vertebral reflex arc." This was accomplished by cross fiber manipulating the specific occipital fiber at line two while contacting the right transverse process of T4. Once moisture or warmth is palpated at the vertebra the occipital fiber manipulation the procedure is discontinued. This is then followed by vertebral adjustment, if indicated.
Next, this patient's right thumb reflex was manipulated until palpatory pain subsided in the thumb-index finger web. Very gentle pressure was applied to a sensitive region at the left 8 th rib costal margin relaxing her related tissues and diaphragm.
The next step in the procedure utilized a "Gallbladder Control Technique" involving two procedures: (1) Contact was made to the right thumb web while another hand contacted a reflex point approximately 1-1/2 inches to the right of the umbilicus and 3 inches inferior. Both the "abdominal reflex" and the right thumb web were contacted with 2 pounds of pressure and this contact was held for 3 minutes. (2) Following the thumb web reflex contact the doctor's hand moved so that, while there was still contact at the abdominal reflex point, the other hand contacted the gallbladder reflex on the plantar aspect of the right foot.
The conclusion to the CMRT gallbladder procedure is called the "postganglionic technique." This was accomplished using the doctor's left hand contacting the patient's right shoulder while the doctor's other hand contacts the "abdominal reflex" point. This contact was held until warmth or tissue relaxation was felt under the abdominal reflex point. Then the abdominal reflex was released and the hand moved to the anterior 8 th rib costal margin and was held until relaxation of the tissues was palpated
Immediately following treatment the patient noted that her epigastric pain felt about 50% reduced, was able to stand, and walk with a normal gait, which she was unable to accomplish prior to the treatment. Within 15 minutes following care, on her drive home, the patient experience complete abatement of all pain. Over the past fifteen years the patient has returned for treatment of two other unrelated conditions and reports no return of her 'gallbladder' symptomology.
DISCUSSION
There are various possible explanations for the patient's response to treatment for her constant, severe, and unremitting pain, although it is significant to note the timing of the symptom abatement coincided almost immediately with the onset of chiropractic treatment. While improvement in symptoms may have been secondary to placebo response or with the boundaries of the natural history of post-surgical symtomatology, the temporal aspects of her pain relief minutes following treatment, at least suggest a relationship.
Conceptually, what could explain this relationship? Various theories suggest somatovisceral influences but the literature on this relationship is not conclusive. In an attempt to understand what might have possibly occurred during the treatment of this patient, three theories are offered:
1. Visceral pain syndrome leading to autonomic imbalance and subsequent referred pain,
2. Post surgical irritation or "Phantom" visceral pain, and
3. Visceral Mimicry or Dysafferentation.
In 1996 Nansel and Szlazak determined that "somatic dysfunction is notorious in its ability to create overt signs and symptoms that can mimic, or simulate (rather than cause), internal organ disease "[ 1 ] Complicating the picture it can also be the case that nociceptive input from dysfunctional somatic structures may act to exacerbate the symptoms of pre-existing visceral disease. [ 1 ] Seaman and Winterstein later noted that joint complex dysfunction should be included in the differential diagnosis of pain and visceral symptoms because joint complex dysfunction can often generate symptoms which are similar to those produced by true visceral disease. [ 2 ]
Scott and Scot have attributed a form of visceral mimicry syndrome to "painful rib syndrome" in some cases of "non-curative cholecystectomy." Their description of "painful rib syndrome" consists of three features: pain in the lower chest or upper abdomen, a tender spot on the costal margin, and reproduction of the pain on pressing the tender spot. They determined that painful rib syndrome is common yet underdiagnosed.
A concern for the practitioner is that numerous visceral diseases can masquerade as musculoskeletal pain that can easily be misdiagnosed and mistreated. [ 3 ] "Obviously, doctors must take care not to confuse somatic problems with true visceral disease because mistakes can be catastrophic for the patient. Adding to this diagnostic conundrum is the fact that musculoskeletal problems can often masquerade as visceral disease. "[ 1,2,4 ]
CONCLUSION
The patient's response to specific chiropractic care for the gallbladder was significant and various possibilities to the patient's presenting symptoms might be related to visceral or referred pain pathway dysfunction, phantom organ pain, post-surgical pain, and visceral mimicry syndrome. Chiropractors involvement in the somatovisceral reflex environment necessitates openness for co-treatment. "The existence of these somatic visceral disease mimicry syndromes obviously justifies a highly important mandate for increased cooperation between the medical physician and those who specialize in the evaluation and treatment to various aspects of primary somatic dysfunction." [ 1 ].
The visceral mimicry and referred pain patterns "need to be appreciated by all portal-of-entry health care providers, to insure timely referral of patients to the health specialist appropriate to their condition." [ 1 ] Of concern for chiropractors is the "possibility that manipulation of the spine may mask the pain of an ongoing pathology." [ 5 ] Consequently, it is possible spinal adjustments could reduce the somatic-induced symptoms of visceral pathologic conditions or mimicry syndromes. [ 4 ] Further study is indicated into chiropractic's possible effect on visceral and post-surgery visceral related pain syndromes to determine whether this case was an anomaly or other patients with similar conditions might benefit from chiropractic care.
1. Nansel D, Szlazak M.] Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manipulative Physiol Ther. 1995 Jul-Aug;18(6):379-97.
2. Seaman DR, Winterstein JF Dysafferentation: a novel term to describe the neuropathophysiological effects of joint complex dysfunction. A look at likely mechanisms of symptom generation. J Manipulative Physiol Ther . 1998 May;21(4):267-80.
3. Grieve GP. The masqueraders . In: Boyling JD, Palastanga N, editors. Grieve's modern manual therapy: the vertebral column . New York: Churchill Livingstone; 1994: 842-56.
4. David R. Seaman, DC, MS Can spinal adjustments and manipulation mask ongoing pathologic conditions? J Manipulative Physiol Ther . 1999 Mar-Apr;22(3):171-9
<>5. Dyck VG, Embree BE. The enigma of referred abdominal pain in chiropractic practice: a literature review and case report . J Manipulative Physiol Ther 1981;4:11-4.