Sophie, born on April 20, 2002<\/p>\n
Spastic diparesis, predominantly right-sided, primarily affecting the lower extremity Mother 37 years old, first pregnancy, pregnancy complicated by premature contractions at 24 weeks of gestation and bleeding; subsequently ceased work as IT systems administrator. Family History<\/strong>: Open, friendly child. Sophie demonstrates understanding of her environment, has been moving independently and purposefully in her wheelchair since 2007, partially understands conversation content. She vocalizes, has spoken individual words since age 2, four-word sentences since early summer 2007 (with poor oral motor function). Since osteopathic treatment has been ongoing since January 2005, only the (subjectively) most significant palpation findings are listed below as an interim assessment.<\/p>\n Sophie has been receiving osteopathic treatment since January 2001. Daily stretching of the lower extremities by the parents. According to the Educational Council on Osteopathic Principles (ECOP), the primary somatic dysfunction maintains the global pattern of dysfunction (ECOP Glossary, 2002). Embryologically, close interrelationships between mesoderm\/skull and ectoderm are of great importance for development (e.g., Rohen, L\u00fctjen-Drecoll, 2006). However, no significant findings were obtained through palpation of the bony skull. Rather, attempts were made through indirect palpation to influence cerebral tension patterns. <\/p>\n Diaphragmatic tensions could hypothetically be associated with several dysfunction complexes: e.g., cervical spine (origin of the phrenic nerve). The mediating or lever function of the diaphragm for the anterior\/posterior chain and gravity line could also play a role, not to mention the tensions of the right psoas muscle at the arcuate ligament of the diaphragm. The strong fascial tensions are thus transmitted to the diaphragm. <\/p>\n Spasticity arises because the spinal reflex arc can no longer be adequately modulated cortically. The result is excessive muscle contraction upon tendon stretch. Not only abnormal muscle spindle-based reflexes are considered responsible, but also by some the disturbed integration of perception and motor function, or the disturbance in the physiological mechanisms that serve the acquisition of motor skills (O’Dwyer, Nelson 1988, Vaughn et al., 1988). In all conditions of impaired well-being, but even more so in Sophie’s case, it seems particularly important to align all therapeutic and family social contexts toward avoiding additional burdens in the sense of allostatic load, e.g., through optimal harmony in daily rhythms, through resolution or reduction of nociceptive somatic, visceral, and emotional stimuli, through loving attention, etc. According to this model, development is the result of interactions of many subsystems of the body that arise through environment and specific demands (Thelen, 1996). Motor development is not to be considered in isolation, but in interaction with sensory, cognitive, and emotional development. Thus, altered visual function leads to altered perception of the environment and one’s own positioning and location in space and the development of arm\/hand motor function. Sophie’s altered perception and development is in turn to be understood not only due to cerebral organic pathologies, but also due to altered motor function, e.g., the grasping function of the hand, hand-mouth coordination, etc. Internal maps (mapping) of spatial dimensions and orientation arise through somatosensory inputs that reach the CNS from the entire body. According to Lin (2005), distortions of this sensory cartography can impair the body’s interaction with its spatial environment. Therefore, it is important to also treat somatic dysfunctions. <\/p>\n The spastic and hypotonic patterns in Sophie also manifest in the body according to the tensegrity model. It seems conceivable that osteopathic treatments improve the reciprocal tension system, both cellularly and musculoskeletally. Thus, the tension patterns in the thorax, in which the ribs and vertebrae of the thorax as rigid discontinuous components connected via continuous tension cables of myofascial chains, are co-responsible for tension patterns in the upper lung lobes. <\/p>\n Sophie’s case illustrates a further aspect very clearly, namely the holarchic structuring of regulatory organization. This is characterized by the fact that each level of regulation maintains integrity in its own specific manner. Each higher organizational level encompasses and integrates the lower one. Thus, in Sophie’s case, for example, the partial failure of the inhibitory capacity of central neural structures causes spasticity of the lower extremity. Even if we palpate very strong tissue tensions in the lower extremity, it is by no means sensible to focus all attention solely on local treatment of the leg musculature. So-called holistic approaches that make no hierarchical distinction in the development-related manifestation of certain organizational principles are unable to appropriately appreciate the different development-related meanings. <\/p>\n Correction of somatic and visceral dysfunctional tension patterns, taking into account the holarchic regulatory organization (e.g., through tension reduction in the thoracic and cerebral regions, but also through stretching exercises of the lower extremities, etc.) reduces uncontrolled feedback mechanisms, improves mapping and homeostasis, and thus the state of health and developmental potential. Effects of cerebral organic pathologies cannot be completely eliminated. The homeostatic dynamics adapt to these conditions and attempt to manifest under these prerequisites. Sophie is making great progress, and it would be conceivable that she could one day walk independently with walking aids. However, it must be considered that during growth phases, regression of symptoms is very likely to occur. Regular treatments should continue into adulthood. <\/p>\n In osteopathy, treatment is primarily based on an understanding of structure-function relationships, i.e., the main focus is directed toward external tissue expression. However, if a person and their discomfort are understood only from an understanding of their tissue patterns, the treatment approach becomes inadequate. Sophie’s case makes it clear that for the most “holistic” treatment possible, it is not only about considering the interaction of cranial, visceral, and musculoskeletal systems, i.e., quasi-objective tissue relations, nor is the exclusive application of the model of primary dysfunction sufficient to explain Sophie’s condition. Equally, her subjective experiential sphere, her intersubjective and interobjective realities must be considered in the treatment process. Beers MH, Porter RS, Jones TV, Kaplan JL (2007) The MSD Manual. 7th edition. Munich, Elsevier, 2771. 1 Patient Presentation Sophie, born on April 20, 2002 1.1 Diagnoses Spastic diparesis, predominantly right-sided, primarily affecting the lower extremity Periventricular leukomalacia (=PVL:<\/p>\n","protected":false},"author":2,"featured_media":2591,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_seopress_titles_title":"Spastic Diparesis: Cranial-Visceral Case Study","_seopress_titles_desc":"Pediatric case study linking cranial, visceral and musculoskeletal systems in spastic diparesis with PVL. 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\nPeriventricular leukomalacia (=PVL: damage to the white matter<\/a> in the brain<\/a> caused by severe oxygen deficiency<\/a>; occurs particularly frequently in premature infants<\/a> during infancy<\/a> (Beers et al., 2007)). <\/p>\n\n
1.2 Medical History<\/h2>\n
\nPremature infant at 33 weeks of gestation, following premature rupture of membranes, partial placental abruption
\nLength: 48 cm, weight: 2345 g, head circumference 33 cm
\nAPGAR score: 8\/9\/9
\nPostpartum<\/strong>:
\nImmediately postpartum cyanosis, crying, muscular hypotonia.
\nDevelopment of respiratory distress syndrome and transfer to intensive care unit; with brief resuscitation.
\nShort-term ventilation (5 days) with subsequent uncomplicated weaning from ventilation.
\nDischarge without further complications after 3 weeks.
\nNotable were low muscle tone and noise sensitivity.
\nNutrition<\/strong>:
\n(Initially expressed breast milk given by bottle. After several weeks, breastfeeding commenced, continuing until 10 months of age). Sophie drank slowly. Later, feeding was only possible with finely pureed foods.
\nMotor Development:<\/strong>
\nProne position not possible, head could not be lifted. KISS syndrome in the first year of life, treated multiple times; no\/minimal motor development
\nVojta therapy initiated at 9 months due to muscular hypotonia and stagnating statomotor development: twice weekly
\nRolling preferentially to the left and crawling (with pathological pattern: left arm active, right with fisted hand under the body, legs stretched and dragged) at 1 year of age. Crawling: at nearly 2 years with abducted legs, non-elevated pelvis, carpal support on left and supported fist on right. Bilateral toe-walking.) Despite treatment, minimal improvement in lower extremity motor function; however, further progress was achieved in 2007 through additional therapeutic measures (Galileo, Botox).
\nLanguage Development<\/strong>:
\nFirst vocalizations from 1 year of age, increasing linguistic progress since 2005.
\nPsychological Development:<\/strong>
\nSocial smiling from 9 months. Stranger anxiety from 1 year.
\nSince early 2007, increasing awareness of own disability.
\nVisual Function<\/strong>:
\nPartial optic atrophy bilaterally, alternating divergent strabismus, myopia, discrete
\nVaccination according to STIKO recommendations, no vaccination reactions
\nSeptember 2004: hemolytic uremic syndrome occurred
\nMedication<\/strong>: <\/p>\n\n
\nMother: allergic to antibiotics, pollen, and slightly to house dust
\nFather: myopia <\/p>\n1.3 Examination Findings<\/h2>\n
1.3.1 Inspection<\/h2>\n
\nIntermittent head reclination. Thoracic kyphotic posture. Left-sided tone weakness with tendency for thorax to tilt to the left.
\nIncreased muscle tone in both legs (right more pronounced) and right hand.
\nAble to pull herself up on objects with both legs since early 2007. Independent walking not possible. During supported standing: head reclined, forward-bent posture, pelvic alignment not completely achieved, legs internally rotated and adducted, right more than left, valgus foot position, forefoot weight-bearing.<\/p>\n1.3.2 Reflex Status: increased reflex response<\/h2>\n
Palpation<\/h2>\n
\n
2 Osteopathic Management<\/h2>\n
\nThe long-term goal is to enable Sophie to achieve the greatest possible independence, including in mobility.
\nNote:
\nThe following are osteopathic explanations and approaches, whereby it is by no means certain whether these osteopathic interventions actually treat the mentioned structures or make contact with these structures (e.g., midline, brainstem, etc.).<\/p>\n\n
3 Additional Management<\/h2>\n
\nDaily training with an alternating powerplate “Galileo” for alternating gait mode, loosening, proprioception, muscle building (spasticity is avoided).
\nBobath ongoing since 2006, occupational therapy since spring 2007.
\nBotox treatment.
\nNo longer current: Vojta (discontinued June 2007, as Sophie rejected this treatment), early intervention, vision therapy.<\/p>\n4 Discussion of the Concept of the Patient’s Primary Dysfunction<\/h2>\n
4.1.1 Primary, Secondary, Tertiary Dysfunction<\/h2>\n
\nIt represents the most significant or longest-standing somatic dysfunction of the body, is usually traumatic in nature, and is caused by exogenous influences. According to ECOP, this refers primarily to impaired or altered function of interrelated components of the musculoskeletal system: skeletal, articular, and myofascial structures, as well as the associated vascular, lymphatic, and neural elements (ECOP Glossary, 2002). Somatic dysfunctions are amenable to manual osteopathic treatment.
\nEven though cerebral structures are explicitly not understood as somatic dysfunction according to the ECOP definition, the cerebral origin of Sophie’s symptoms (periventricular leukomalacia, reduction of brain substance) can be considered the primary dysfunction, as palpation revealed the most pronounced tissue findings in these regions. This could also still be largely consistent with the traditional model of somatic dysfunction according to Korr\/Denslow. They assume that harmful effects of a structural disturbance arise through the generation of altered outflows from spinal regions\u2014only that in this case the altered outflow originates directly in central nervous tissue. The altered outflow to neurally associated somatic and visceral structures subsequently impairs their function and simultaneously the entire body homeostasis (Korr, 1979, 1976).
\nCertainly, these pathologies are only partially accessible to osteopathic approaches. However, an attempt was made to create optimal tissue tension in the cerebrum, in the hope that cerebral function would also improve. Remarkably, the parents reported a brief improvement in visual function following treatment of the optic nerve and the associated visual field.
\nSecondary sequelae of the cerebral organic origin are the spastic manifestations primarily of the lower extremity, muscular hypotonias, e.g., in the oral and thoracic regions, as well as visual disturbances.
\nFurther tertiary sequelae are visceral dysfunction patterns of the right upper lung lobes, e.g., as consequences of thoracic parietal problems.
\nLikewise, psychological developmental delays could be considered part of cerebral organic disturbances.<\/p>\n4.1.2 Meso-ectodermal Interactions<\/h2>\n
4.1.3 Diaphragm<\/h2>\n
4.1.4 Spasticity<\/h2>\n
\nEvery attempt to walk causes the muscles to shorten with cumulative effect. This additive effect impairs the ability to learn to walk or to develop a functional gait pattern (Carreiro, 2005). Additionally, with an existing altered joint position, this also affects posture and balance.
\nTreatment to promote proprioception and muscle relaxation was performed regularly (osteopathy, physiotherapy, powerplate, daily stretching), while avoiding triggering increased reflex activity.<\/p>\n4.1.5 Allostatic Load<\/h2>\n
\nAny additional negative stress would lead to further burdens, e.g., via the hypothalamic-pituitary-adrenal axis (HPA axis), the sympathetic nervous system, and the immune system (cytokines).<\/p>\n4.1.6 Dynamic-Systemic Model of Development<\/h2>\n
\nThe delayed uprighting and the inability to stand and walk independently influences the exploration of the environment and thus modifies psychological cognitive developmental steps that occur in close interaction with motor and cerebral organic maturation processes. These relationships could perhaps be considered so-called neurovisceral-psychological dysfunction patterns.
\nThis is also therapeutically important to consider in Sophie’s case; Sophie was not only treated locally, e.g., the primary dysfunction, but all developmental areas were included, e.g., parental interaction, through continuous appropriate support, etc. This approach follows the idea that disturbed proprioceptive and nociceptive information includes all aspects. <\/p>\n4.1.7 Mapping<\/h2>\n
4.1.8 Tensegrity Model<\/h2>\n
4.1.9 Holarchic Structuring of Regulatory Organization<\/h2>\n
4.2 Treatment Potentials<\/h2>\n
\nThese could be possible explanations for why, for example, Sophie’s speech as well as her language comprehension progressively improve during treatment (taking into account inherent healing tendencies). The goal of osteopathic treatment is to maximize potential, improve quality of life, and enhance independence. <\/p>\n4.3 Prognosis<\/h2>\n
5 Further Considerations<\/h2>\n
\nThe disease designation (periventricular leukomalacia, reduction of brain substance as objective tissue realities) and the palpable tissue patterns in the brain as a quasi-primary dysfunction as well as causal etiologies (e.g., prenatal oxygen deficiency) provide only limited insight into the inner experience (subjective experiential world) and her integration into the family (intersubjective reality).
\nThe support of the family (intersubjective experiential world), through loving acceptance and her integration into the family as a quasi-“normal” child who simply shows different needs due to her symptoms, is a very significant factor in Sophie’s healing-developmental process.
\nLikewise, interobjective factors play a role, such as the family’s financial resources, the parents’ educational level, which enabled Sophie to receive the best possible medical and paramedical care, e.g., osteopathic care, training with “Galileo” powerplate, etc.
\nThe combination of all these factors, in my view, explains the enormous healing progress far more adequately than the exclusive discussion of osteopathic cranial, visceral, and musculoskeletal interactions, which, as a reflection of quasi-objective structure-physiological realities, are only able to describe a small part of being human\/embodied existence.<\/p>\n6 References<\/h2>\n
\nCarreiro JE (2004) Pediatrics from an osteopathic perspective. Munich, Elsevier, 251.
\nLiem T (2006) Morphodynamics in Osteopathy. Stuttgart, Hippokrates, 302-311, 448.
\nECOP Glossary (2002) Educational Council on Osteopathic Principles. The Educational Council on Osteopathic Principles (ECOP) of the American Association of Colleges of Osteopathic Medicine (AACOM) defined osteopathic terminology in collaboration with the international teaching commission of the AAO. Presented at the AAO convocation 2003.
\nKorr IM: The spinal cord as organizer of disease processes: some preliminary perspectives. Journal of the American Osteopathic Association, 1976; 76(1):35-45.
\nKorr IM: The spinal cord as organizer of disease processes: III. Hyperactivity of sympathetic innervation as a common factor in disease. Journal of the American Osteopathic Association, 1979; 79(4):232-7.
\nKorr IM: The spinal cord as organizer of disease processes: II. The peripheral autonomic nervous system. Journal of the American Osteopathic Association, 1979;79(2):82-90.
\nLim KW Infantile Cerebral Palsy. In: M\u00f6ckel E, Noori M (2006) Handbook of Pediatric Osteopathy. Munich, Elsevier, 408f., 414.
\nRohen JW, L\u00fctjen-Drecoll E (2006) Functional Embryology. 3rd ed. Stuttgart, Schattauer, 45.
\nO’Dwyer NJ<\/a>, Neilson PD<\/a> (8\/1988) Voluntary muscle control in normal and athetoid dysarthric speakers. Brain, 111 (Pt 4):877-99.
\nThelen E (1996) The improvising infant-learning about learning how to move. In: Merrens MR, Brannigan GG. The developmental psychologists-Research adventures across the life span. New York, McGraw Hill, 21-35.
\nVaughan CW<\/a>, Neilson PD<\/a>, O’Dwyer NJ<\/a> (4\/1988) Motor control deficits of orofacial muscles in cerebral palsy. Journal of neurology, neurosurgery and psychiatry. 51(4):534-9.<\/p>\n","protected":false},"excerpt":{"rendered":"