Female age 67 with upper abdominal pain, reflux, bloating, excessive belching, and mid-thoracic pain. She is in relatively good physical health, and does some exercise. She has eliminated gluten and dairy from her diet. She has no particular physical trauma history. She did have what she describes as a difficult childhood. She was referred by her physician for visceral mobilization.
On exam, she presented with mild mid-thoracic and rib dysfunction at the level of T4-5 and the 5th rib on the left. The cranial exam was fairly unimpressive, with good mobility. A cervical spine exam revealed restriction at the C4-5 levels. A visceral exam revealed restrictions of the stomach, lesser omentum, sphincter of Odi, 1st part of the duodenum, and a moderate superior strain of the esophagus. The respiratory diaphragm was restricted and inefficient in its range of motion.
Treatment involved manual therapy for the above-referenced structures, including the visceral and musculoskeletal elements. The patient achieved a 90% improvement in her symptoms, and she maintained this over time. I showed her the technique that she could perform at home to pull her esophagus inferiorly through the diaphragm so that she could self-treat and maintain this for the long term. I also had her elevate the head of her bed using 4×4″ blocks under the headposts of the bed.
Important considerations: C4-5 was important to normalize as the phrenic nerve to the diaphragm takes its innervation from those levels. The mid-thoracic vertebral and rib dysfunction improved considerably by treating the visceral structures. The T4 vertebra is the reflex point for the cardiac sphincter at the junction of the esophagus and stomach, so that was important to verify. Remember that the greater splanchnic nerve that goes to the stomach and the upper GI tract has cell bodies in the T5-9 levels, so that can also be some interplay. The sphincter of Odi is SO important as it controls the digestive enzymes coming from the pancreas into the duodenum and the flow of bile here, too. Restriction at Odi can cause gut digestive issues.
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