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Chapman's points are viscerosomatic reflexes discovered by Frank Chapman. These reflexes, or "gangliform" contractions, or excessive tissue congestion, reflect visceral dysfunction and are mediated by the sympathetic arm of the autonomic nervous system. Excessive sympathetic tone from an irritated, diseased, or stressed organ leads to lymphatic stasis manifesting as myofascial nodules, which may feel boggy, ropy, shotty, and/or thickened. These points almost always exhibit tenderness on palpation (DiGiovanna, Schiowitz, & Dowling, 2005).. Chapman's reflexes are excellent diagnostic tools to the osteopathic physician and they may also be used to break positive feedback cycles through somatovisceral pathways to restore health (DiGiovanna, Schiowitz, & Dowling, 2005). There are approximately 50 distinct Chapman's reflexes, ranging from points for the eye to the prostate. These points are bilateral and are located on the anterior and posterior regions of the body. This would account for nearly two hundred separate neurolymphatic reflexes. Anteriorly, these gangliform contractions, or excessive tissue congestion, which manifest as edematous or ropy, are usually located in the intercostal space "between the anterior and posterior layers of the anterior intercostals fascia." These rib segments are associated with the corresponding sympathetic innervations of the involved viscera. For example, the sympathetic fibers to the sinuses originate in the cell bodies of the first through fourth thoracic spinal segments. Sinusitis, or any ear, nose, or throat pathology, therefore, would manifest as altered tissue texture along the clavicle and first two ribs (DiGiovanna, Schiowitz, & Dowling, 2005).. The principles of Chapman's reflexes are based on anatomy and physiology. These gangliform contractions may feel hard, boggy, and tender and are usually the size of a "BB" pellet or a pea that has been split in half. These tissue
texture changes may be felt on the periosteum of the rib or clavicle. An acute reflex point is more likely to feel boggy or edematous. A more chronic gangliform contraction will likely feel ropy or stringy. Chapman's reflexes do not radiate pain like trigger points and are not necessarily associated with remote somatic dysfunction, as are Jones's counterstrain points. Although these neurological reflexes exhibit pain on palpation, tenderness is not the sole criterion for a Chapman's point; rather, it is lymphatic congestion and altered myofascial texture (DiGiovanna, Schiowitz, & Dowling, 2005). Posteriorly, Chapman's reflexes are located in the soft tissues between the spinous process of a vertebra above and the transverse process of a vertebra below. For example, the posterior Chapman's point for the heart is located between the spinous and transverse process of the second and third thoracic vertebrae. The posterior points have the feel of a classic viscerosomatic reflex; the operator will palpate what feels like a rubbery nodule. If the physician attempts to articulate a vertebral somatic dysfunction and the spine "bounces" away from the force, the possibility of a viscerosomatic reflex should be considered (DiGiovanna, Schiowitz, & Dowling, 2005). Chapman's reflexes are also located along the extremities. This is because of the fact that the upper and lower extremities are innervated by T2-8 and T11-L2, respectively. The arm and leg share sympathetic fibers with the viscera. For example, the colon and thigh are innervated by the sympathetic cell bodies of T11-L2. If the patient has colitis, the resulting Chapman's reflex will manifest as quarter-sized or half-dollar-sized "shotty plaque(s)" along the outer thigh. Likewise, disorders of the eye may exhibit tissue texture changes along the anterior superior aspect of the humerus (DiGiovanna, Schiowitz, & Dowling, 2005). Appendicitis Diagnostic Point (good for DD workup) One anterior point of interest in surgical diagnosis is the reflex for appendicitis. This is located along the tip of the right twelfth rib. This reflex may help the osteopathic physician in the emergency department to distinguish appendicitis from a different surgical problem such as a ruptured ovarian cyst, mesenteric adenitis, or ureterolithiasis. However, because one spinal cord segment innervates more than one organ, Chapman's reflexes are considered to be more sensitive than specific indicators of disease (DiGiovanna, Schiowitz, & Dowling, 2005). TREATMENT Owens (Endocrine Interpretation of Chapman's Reflexes) stresses the importance of first treating the pelvis. Arbuckle explains that the pelvis houses not only the ganglion impar, the most distal aspect of the sympathetic nervous system, but also the ovaries and testes. Owens emphasized the role of hormones on total body homeostasis. When the operator is ready to approach specific Chapman's points, a gentle rotary motion is induced over each point, using the finger pad, for a period of approximately 15 seconds. Treatment, however, may take a few seconds or last 2 minutes. The pressure should be firm, although not enough to elicit a sustained grimace from the patient. The end point of a reflex treatment by the physician's "thinking, knowing, feeling, sensing" fingers is the dissolution of edema and lessening of tension in the myofascial tissues. A decrease in pain is more the result, rather than the aim, of treatment (DiGiovanna, Schiowitz, & Dowling, 2005). NEUROENDOCRINE—IMMUNE CONNECTION To Chapman and Owens, the thyroid was the master gland of immunity. As previously mentioned, treating the pelvis was vital because of the proximity of the ganglion impar to the coccyx. Moreover, the ovaries and testes produce sex steroid hormones, specifically estrogen, progesterone, and testosterone. These hormones interact not only with immunocytes but also with the adrenal and thyroid glands. The sex hormones have receptors in the thyroid gland, influence thyroid stimulating hormone (TSH), and may increase thymocyte proliferation. The thyroid in turn enhances reproductive function. Thyroid hormone not only permeates every cell in the body but also is important in myelin production for the nerves. Proper thyroid function is necessary for immunocyte proliferation. Moreover, thyroid hormone has a sympatheticomimetic effect (DiGiovanna, Schiowitz, & Dowling, 2005). Excess adrenergic tone may lead to organic vasoconstriction. Cortisol, secreted by the adrenal gland, may affect the thyroid by inhibiting TSH secretion. On an immune cellular level, lymphocytes are miniature producers of endocrine substances evidenced by the fact that they can secrete TSH in addition to progesterone, corticotrophin-releasing hormone (CRH), and adrenocorticotrophic hormone (ACTH). Each aspect of the neuroendocrine triad functions on a metabolic stillpoint, which promotes homeostatic balance; for example, excess Cortisol production is an immunosuppressant (DiGiovanna, Schiowitz, & Dowling, 2005). Various Points Chapman's reflexes for gonads can be located anteriorly along the upper border of the pubic bone, just lateral to the symphysis. Posteriorly, reflexes for the gonads are found between the spinous and transverse processes of T8 and T10, and T10 and Tl 1, respectively. The anterior reflex for the adrenal gland is found 1 inch lateral and 2.5 inches superiorly from the umbilicus. The thyroid reflex resides in the second intercostal space, along the sternal border. The posterior point for the adrenal is located between the spinous process of T11 and the transverse process of T12. The posterior Chapman's reflex for the thyroid can be found along the transverse process of T2 (DiGiovanna, Schiowitz, & Dowling, 2005).
Chapman's reflex treatment is easy to administer; it is delivered rapidly and safely. Most importantly, Chapman's reflexes are effective in many of the systemic disorders encountered in the general practice of osteopathic medicine (DiGiovanna, Schiowitz, & Dowling, 2005).
Anterior Chapman Points (DiGiovanna, et al., 2005)
Posterior Chapmans Points (DiGiovanna, et al., 2005) Lecture Notes On Chapman's Lymphatic Reflexes C. Haddon Soden, D.O., M.Sc. (1949 Yearbook page 201-211) Chapman's reflexes is the term given the hypercongestions manifest by soreness or tenderness at the distal ends of spinal nerves. These hypercongestions vary in size according to location, and to the proportion of pathology present. Chapman charted over two hundred separate and distinct reflexes, each one having a definite and specific effect upon the endocrine. gland or viscus with which it is in association. When he found a given combination of tender areas he always found a given disease entity or organ pathology present, or vice versa with the manifestation of a certain disease entity or pathology there would always be present a definite combination of tender areas. These reflexes are located in the lymphoid tissue in the fascia and are manifested in the acute stage by soreness or tenderness at the distal ends of the spinal nerves. The sympathetic fibres we know are passing with the lymphatics which are continuous with those lymphatics of the deeper structures so that treatment of these reflexes or receptor organs will effect all structures so connected. A Chapman reflex lesion is the result of a lymph stasis in the viscus or glands. This lymph stasis is responsible for the dysfunction of that organ or gland. Both the lymph stasis and the resultant dysfunction are reflexly responsible for the Chapman lesion due in part to nerve impulse and to a chemical reaction of the lymphatic tissue in which the reflex lesion is found. Head's law states that "when a painful stimulation is applied to a part of low sensibility in close central connection with a part of much greater sensibility, the pain produced is felt in the part of high sensibility rather than in the part of lower sensibility to which the stimulus was actually applied." Head formulated this law of the location of visceral pain because he recognized two types of sensation in Internal viscera, one in the organ itself which is more that of discomfort and uneasiness and one on the surface of the body which is a true painful sensation.
The significance of these reflex or receptor organs is two fold--they are a reliable index to the nature of the disturbance within their associated organs or glands and they are a specific means of correcting the disturbances. By the stimulation of these receptor organs both the afferent and efferent vessels draining the surrounding tissues will be affected, as will also the entire lymph system of this area. These receptor organs are easy to palpate because of the edema or congestion localized around the area. Thyroid Dysfunction Any lesion which disturbs the bony pelvis interferes with the blood and nerve supply to the gonads which in turn directly affect the thyroid, whose function it is to influence the oxygen content of the blood. All the blood passes through the thyroid gland at least twice an hour and there receives thyroxine, the secretion of the thyroid, which is carried to every tissue cell. Thus with a pelvic lesion is started the imbalance to the endocrine system which in turn interferes with nutrition to body structures. Examples –of Specific Chapman Reflexes Retinitis or Conjunctivitis Anterior: Front of humerus. Middle aspect surgical neck. Posterior: Occipital bone. sub-occipital nerve. Retinitis. Occipital bone. Ant. br occipital nerve. Conjunctivitis. Cerebellar Congestion Anterior: Tip corocoid process of scapula. Posterior: Across transverse processes Atlas. Cerebral Congestion Anterior: Posterior: Torticollis Anterior: Posterior: Otitis Media Anterior: Posterior: Pharyngitis Anterior: Posterior:
Laterally from spinous processes 3-4-5 cervical vertebrae. Between the transverse processes l-2 cervical vertebrae near their tip ends.
Inner aspect, upper end of humerus, surgical neck downward. Posterior aspect transverse processes 3-4-5-6-7 cervical vertebrae.
Upper edge of clavicle, just beyond where it crosses 1st rib, Upper edge posterior aspect, tip of transverse process 1st cervical vertebra.
The front of the first rib for a matter of three quarters of an inch to an inch toward the sternum from where the clavicle crosses the rib. Midway between the spinous process and the tip of the transverse process of the second cervical vertebra, on the posterior aspect of TP
Tonsillitis Anterior: Posterior: Laryngitis Anterior: Posterior: Sinuses Anterior: Posterior: Arms Anterior: Posterior: Bronchitis Anterior: Posterior:
1st intercostal space near sternum. Transverse process 1st cervical, midway between spinous process and tip of TP.
Upper surface 2nd rib 2-3 inches from sternum. Midway between spinous and tip of transverse process. 2nd Cx.
Upper edge 2nd rib--3 l/2 inches from sternum. 2nd cervical--TP midway between spinous and tip of transverse.
Muscular attachment Pectoralis minor muscle to 3-4-5 ribs. Superior angle of scapula--1-2-3 ribs along inner margin of scapula.
Intercostal space between the second and third ribs close to the sternum. Across the face of the transverse process of the second dorsal vertebra, midway between the spinous process and the tip of the transverse process.
Intercostal space between the second and third ribs close to sternum.
The space between the transverse process of the second and third dorsal vertebra, midway between the spinous process and the tip of the TP.
Upper Lung Anterior: Posterior:
A gangliform contraction between the third and fourth ribs near the sternum. Between the third and fourth transverse processes, midway between the SPs and the tips of the TPsof the third and fourth dorsal vertebra.
Lower Lung Anterior: Posterior: Hemorrhoids Anterior: Posterior: Sciatic Neuritis Anterior:
A gangliform contraction between the 4 and 5 ribs, close to the sternum. Fourth intertransverse space.,
Just above the tuber ischii. On the sacrum, close to the ilium, at the lower end of the SIJ.
A gangliform contraction starting one fifth of the distance below the trochanter and for a space of from two to three inches downward on the posterior outer aspect of the femur. Second--A gangliform contraction commencing one fifth of the distance above the knee, and continuing upward for a matter of two inches on the posterior outer aspect of the femur. Third--A gangliform contraction in the mid-posterior region of the femur and one third of the distance upward from the condyles.
Supplemental Points 1. Both sides of the fibula from its upper articulation with the tibia to the outer malleolus. (b) Midway between the trochanter & the tuber ischii and above the trochanter, transversely. (c) Just below the posterior superior spine of the ilium. Note: Loosen up the initial or principal contractions first, before touching the supplemental points. Posterior: Upper part of the sacrum inside of the sacro-iliac articulation.
An innominate lesion will usually be found in such conditions. Atonic Constipation Anterior: Posterior: Prostate Anterior: Posterior: Ovaries Anterior: The round ligaments from the upper border of the pubic bone downward to the attachment of the muscles on the lower border. A gangliform contraction in or along the round ligament or at the bony attachment of the muscles in relation to it at the lower pubic border indicates ovarian congestion or probably inflammation. A gangliform contraction, between the ninth and tenth dorsal intertransverse space, indicates th an involvement of the inner half of the ovary, while a gangliform contraction between the 10 th & 11 dorsal intertransverse space, indicates an involvement of the outer half of the ovary
A gangliform contraction of the muscle tissue between the anterior superior spine of the ilium and the trochanter of the femur. On the face of the eleventh rib at the end of the transverse process of T11.
From the trochanter downward on the outer aspect of the femur to within two inches of the knee, & laterally on either side of the symphysis, identical with the uterine center in females. Between the posterior superior spine of the ilium and the SP of the fifth lumbar vertebra.
Uterus Anterior : Posterior: Broad Ligament Anterior: Posterior : Rectum Anterior: Lesser trochanter of the femur downward. At the upper edge of junction of ramus of pubes and ischum. Between posterior superl or spine of ilium and spine of the fifth vertebra.
From the trochanter down ward on the outer aspect of the femur to within 2 inches of the knee Between the posterior superior spine of the ilium and the spinous process of L5.
Posterior: Cystitis Anterior: Posterior: Kidneys Anterior: Posterior:
On the sacrum close to the ilium, at the lower end of the ilio-sacral articulation.
You will find a gangliform or seemingly callous state of the tissues around the umbilicus. Upper edge of the transverse process of the second lumbar vertebra.
Laterally on an area located about an inch on either side of the medial vertical line of the abdomen and one inch above the horizontal plane of the umbilicus. Intertransverse space between the twelfth dorsal and the first lumbar vertebra, midway between the spines and the tips of the transverse processes processes.
Adrenals Anterior: Posterior:
An area from two to two and a half inches above and one inch on either side of the umbilicus. Intertransverse spaces on both sides of the eleventh and twelfth dorsal vertebra, midway between the spinous processes and the tips of the transverse processes when both adrenals are involved and on the affected side where only one is at fault.
Small Intestines Anterior: Posterior:
Intercostal spaces between the eighth and ninth, ninth and tenth and tenth and eleventh ribs near the cartilages on both sides of the body. Intertransverse spaces of the eighth and ninth, ninth and tenth, tenth and eleventh dorsal vertebra on both sides-, midway between the SPs and the tips of the TPs.
Pyloric Stenosis Anterior: Posterior:
On the front of the sternum at the junction of the manubrium with the gladiolus, down to the ensiform cartilage. On the face of the tenth rib at its juncture with the tip of the transverse process of the tenth dorsal vertebra on the right side.
Congestion of the Liver and Gall Bladder Anterior: A gangliform contraction of the tissues in the intercostal space from the mid-mammillary line up to the-sternum on the right side between the sixth and seventh ribs. Posterior: Between the transverse processes of the sixth and seventh dorsal vertebra, midway between the spinous processes and the tips of the transverse processes, on the right side. Examination Patient supine 1. Before starting examination of the anterior and posterior reflex centers, stand at the foot of the table. Place both hands under the calcaneal bones, slightly elevate the legs and forcibly invert the feet. Note difference in muscular tension, by resistance to inward rotation, for indications of innominate lesion 2. Have the patient flex thighs and legs, the feet resting on the table. The physician facing the foot of the table places the thumbs about two inches medial to the anterior superior spines and presses downward on Pouparts ligaments. The ligament will be thickened on the affected innominate side and the area will be sensitive to pressure. Place the fingers over the flare of the iliac crests and extending down over the glutius minimus and medius to see which of these areas is prominent or depressed. Place the index fingers on the abdomen close to the pubic bones and later. al to the symphysis. Press toward the pubic bones and feel which is high or low. Treatment Hypercongestions of any part of the body for which the reflexes centers have been worked out may be greatly reduced by a brief treatment of the anterior and posterior reflex centers and in this order. For spectacular, convincing results and one that would affect a more lasting reflex effect and so hasten recovery, first correct the pelvic lesions and then treat the anterior and posterior reflexes, particularly the anterior with the terminal phalanx of the index or middle finger with a light rotary movement for about 15 to 30 seconds. The pressure must be light. Sacro-iliac Lesions Diagnosis: If there is more unilateral muscular tension when inverting one foot than the other, Poupart's ligament is thickened on that same side, the pubic bone is higher and the crest and gluteal area is depressed or less prominent than the opposite side, we are then dealing with a posterior innominate lesion on that side. If it is an anterior innominate, the pubic bone will be higher, the iliac crest will be more prominent lateralward. Various Iliac Positions 1. One innominate (usually the right) rotated backward. 2. One may be rotated backward and the other forward. 3. Either one may be rotated forward.
4. Either one may be down at the symphyseal articulation. 5. Either one may be up at the symphyseal articulation. 6. Both may be down or up at the sacrum. Sacro-iliac Lesion Correction Right Posterior Rotation Position patient on left side, knees drawn up toward the body. Standing behind the patient, slip your right arm between the patient's thighs, until the bend of your right elbow is even with the front of the patient's right thigh, your arm resting close against the crotch of the patient, with weight of leg supported upon your arm and foot extending beyond the edge of the table. By this procedure the weight of the leg acts as a fulcrum to spread the lesioned joint. Next rest the elbow of your left arm against your left side just in front of the anterior superior spine of your left innominate, with heel of your left hand resting against the posterior superior spine of the patient's ilium, and your forearm as a prop, ease the innominate back into normal position by the weight and rotation of your own body. Left Posterior Rotation To correct a left posterior rotation the procedure is the same as for right posterior rotation, except you reverse the position of patient and of your hands. Right Anterior Rotation To correct a right anterior rotation, place patient or left side and stand facing patient. Place heel of right hand against the front of the anterior superior spine, left hand back of the tuberosity of the ischium, with patient's knee against your abdomen. Exert equal pressure with both hands, 'pushing away from you with right hand and pulling toward you with left hand. Left Anterior Rotation To correct a left anterior rotation place patient on right side. Place the left hand in front of the anterior superior spine and right hand back of the ischium, with patient's knee against your abdomen. Exert equal pressure with both hands, pushing away from you, with your left hand pulling toward you with right hand. Ma1 Position at the Symphysis When the innominate is down at the symphysis, place patient on back. Stand opposite side of table from the lesioned innominate. Flex the leg on lesioned side and bring it toward you across the patient's body at an angle of 45 degrees. If it is a right innominate down place your right hand on patient's knee and your left beneath the tuberosity of the ischium. Bring the leg on lesioned side toward you and press down on the knee to spread the sacral articulation and lift with your left hand on the tuberosity. If it is a left innominate that is down, stand on right side of table and with left hand resting at patient's knee and your right hand beneath the patient's tuberosity bring the leg on the lesioned side toward you and press down on the knee to spread the sacral articulation and lift with your right hand on the tuberosity. If either innominate is up at thesymphysis place patient on opposite side from the lesion. Stand behind then 'slip your arm between the patient's thighs and grasp the top side of the lesioned innominate, with the weight of patient's leg resting upon your arm, pull down with the innominate- engaged hand and push forward with your free hand against the posterior superior spine. This will easily rotate the joint into position. Once the pelvic lesion has been detected and corrected attention should be turned to relieving the congested lymphatic drainage. Relaxing the Thorax The patient is prone. Place pillow under the patient's chest and one under the frontal bone, arms hanging loosely on either side of table. Place thumbs above the ribs lateral to the transverse processes of the first dorsal vertebra on either side using heavy pressure. Have patient extend or swing his arms toward the head of the table and inhale. On reaching the limit of extension have the patient exhale and return arms to their original position, move the thumbs to the same position 2nd dorsal vertebra and proceed as before, vertebra by vertebra until the entire thorax has been relaxed. This method of relaxing the thorax, stimulates the sympathetics through the splanchnit area, expands the chest and lungs, and if vertebral or rib motion are present, it makes their replacement much easier to accomplish. Warning - Prescribe a plain water enema before retiring, as the detritus, present in the colon will cause the patient to become very toxic if not removed.
References DiGiovanna, E., Schiowitz, S., & Dowling, D. (2005). An osteopathic approach to diagnosis and treatment (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Kuchera, M., & Kuchera, W. (1994). Osteopathic considerations in systemic dysfunction. Dayton, Ohio: Original Works.