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Original Contribution  |   June 2016
Correlation of Somatic Dysfunction With Gastrointestinal Endoscopic Findings: An Observational Study
Author Notes
  • From the A.T. Still Research Institute at A.T. Still University in Kirksville, Missouri (Dr K. Snider, Dr E. Snider, and Ms Johnson); the Departments of Family Medicine, Preventive Medicine, and Community Health (Dr K. Snider) and Osteopathic Manipulative Medicine (Dr Schneider, Dr E. Snider, and Dr Danto) at the A.T. Still University-Kirksville College of Osteopathic Medicine in Missouri; the Department of Family Medicine at the University of Massachusetts Medical School in Worcester (Dr Lehnhardt); Osteopathic Horizons in Belleville, Illinois (Dr Ngo); and Northeast Regional Medical Center in Kirksville, Missouri (Dr Sheneman). 
  • Support: The current study was supported by a grant from the A.T. Still Research Institute’s Strategic Research Fund. 
  •  *Address correspondence to Karen T. Snider, DO, Departments of Family Medicine, Preventive Medicine, and Community Health, A.T. Still University-Kirksville College of Osteopathic Medicine, 800 W Jefferson St, Kirksville, Missouri 63501-1143. E-mail: ksnider@atsu.edu
     
Article Information
Gastroenterology / Neuromusculoskeletal Disorders
Original Contribution   |   June 2016
Correlation of Somatic Dysfunction With Gastrointestinal Endoscopic Findings: An Observational Study
The Journal of the American Osteopathic Association, June 2016, Vol. 116, 358-369. doi:10.7556/jaoa.2016.076
The Journal of the American Osteopathic Association, June 2016, Vol. 116, 358-369. doi:10.7556/jaoa.2016.076
Abstract

Context: Gastrointestinal (GI) endoscopy provides a novel means of correlating visceral abnormalities with somatic dysfunction.

Objective: To assess the correlation of palpatory findings of somatic dysfunction with GI abnormalities determined by endoscopy and to identify which types of somatic dysfunction were most commonly correlated with GI abnormalities.

Methods: In this observational, cross-sectional study, participants who were scheduled to receive an esophagogastroduodenoscopy (EGD), colonoscopy, or both were examined by 2 osteopathic physicians immediately prior to endoscopy for the presence of vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings); tenderness of anterior Chapman reflex points; and tenderness of visceral sphincters. Each type of somatic dysfunction and the somatic dysfunction burden (sum of findings) were compared with the type of endoscopic procedure and abnormal endoscopic findings.

Results: Sixty-six adults participated: 43 received an EGD, 40 received a colonoscopy, and 17 received both. The incidence of vertebral TART findings ranged from 70% at T12 to 98% at the sacrum. Participants who received only EGD had a higher somatic dysfunction burden than those who received only colonoscopy and those who received both procedures (P=.002). The incidence of abnormal endoscopic findings ranged from 98% in the stomach to 0% at the ileocecal valve. Statistically significant positive associations were found between specific vertebral TART findings and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, and sigmoid colon; specific Chapman reflex point tenderness and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, descending colon, sigmoid colon, and rectum; and specific visceral sphincter tenderness and abnormalities of the duodenum, ascending colon, and sigmoid colon.

Conclusions: The current study found numerous associations between somatic dysfunction and abnormal endoscopic findings. However, the high incidence of vertebral TART findings and the lack of normal controls for many GI regions made establishing meaningful relationships between specific somatic dysfunction and specific GI abnormalities challenging. Future investigations should include more participants to ensure a higher number of normal endoscopic findings and limit the physical examination to elements of somatic dysfunction with a high level of variability between vertebrae within an individual participant and between participants, such as tenderness and tissue texture abnormalities. (ClinicalTrials.gov number NCT01394198)

The osteopathic profession has long stressed structure-function relationships between the musculoskeletal and visceral systems, allowing diagnostic clues of visceral abnormalities to be found within musculoskeletal structures. These relationships are partly due to viscerosomatic convergence of shared pathways between visceral and somatic afferent nerves within the spinal cord.1-3 The structures sharing innervation (musculoskeletal and visceral) become hypersensitive or hyperreactive when disease is present in either. Visceral irritation, such as that induced experimentally through the topical administration of capsaicin to the mucosa of the gastrointestinal (GI) tract in healthy people, can manifest as burning somatic pain in predictable areas.4-6 These areas of referred pain are accompanied by somatic tissue hyperalgesia, locally increased skin temperature and blood flow,4-6 and subcutaneous and musculartrophic changes in the deep somatic tissues indicative of sympathetic nervous system excitation.7 These findings are also consistent with physical findings of somatic dysfunction, which include palpable tenderness, asymmetry, restricted spinal motion, or tissue textture abnormalities (TART findings).18 Because the GI system receives sympathetic innervation from the thoracic and lumbar regions of the spinal cord, with the upper GI system receiving parasympathetic innervation from the vagus nerve and the lower GI system receiving innervation from the pelvis splanchnic nerves,9,10 somatic dysfunction in the corresponding spinal levels may be indicative of underlying GI abnormalities. 
In addition to spinal TART findings, other types of somatic dysfunction findings have been proposed to correlate with GI abnormalities. Chapman reflex points are discrete points of fascial tenderness and tissue texture abnormalities believed to reflect specific areas of visceral abnormalities, including GI abnormalities.11,12 Palpable areas of tenderness and fascial tissue texture abnormalities within the abdomen, known as visceral sphincters (VSs), are believed to be associated with the following GI transitional areas: gastroesophageal (GE) junction–hiatus VS, pylorus VS, sphincter of Oddi VS, duodenojejunal junction VS, and ileocecal valve VS.13 Any inflammatory abnormalities affecting these anatomical areas should result in visceral fascial dysfunction diagnosed as palpable tenderness. 
In the United States, more than 14 million GI endoscopies are performed yearly to assess for GI abnormalities,14 which provides an opportunity to compare the relationship between GI abnormalities and musculoskeletal physical findings. Esophagogastroduodenoscopy (EGD) allows visualization of the luminal surface of the upper GI system (epiglottis to duodenum) and is performed primarily for evaluation of active upper GI symptoms.15,16 Colonoscopy allows visualization of the lower GI system (anal sphincter distally to the ileocecal valve and the terminal ilium) and is performed for both active symptoms as well as asymptomatic screening for colorectal cancer in asymptomatic individuals aged 50 years or older.15,16 Therefore, colonoscopies can provide asymptomatic controls. The objective of the current study was to correlate palpatory findings of somatic dysfunction with objectively confirmed GI abnormalities and to identify which types of somatic dysfunction were most commonly correlated with GI abnormalities. We hypothesized that GI abnormalities would be associated with somatic dysfunction diagnosed as vertebral TART abnormalities; tenderness of anterior Chapman reflex points; and VS tenderness. 
Methods
Participants
Between March 2011 and September 2013, we recruited participants aged 21 years or older who were scheduled to receive an EGD, colonoscopy, or both. Prior to enrollment, potential participants were screened by telephone to determine eligibility. Potential participants were excluded if they had any history of spinal fractures or surgical intervention of the spine that could alter palpatory findings of the spinal and paraspinal regions. Participants who were wards of the state or unable to sign the consent form on their own behalf were also excluded. All participants were scheduled to receive a GI endoscopy as part of their standard medical care; no participants received an endoscopy for research purposes. All aspects of the study protocol were approved by the local institutional review board, and all participants provided informed consent prior to study enrollment. 
Somatic Dysfunction Determination
Just prior to their scheduled endoscopy, participants received a physical examination in the preoperative area performed by 2 physicians (either 2 neuromusculoskeletal medicine/osteopathic manipulative medicine [NMM/OMM] specialists or 1 NMM/OMM specialist and 1 NMM/OMM resident) who were blinded to the participant’s medical history and type of endoscopic procedure the participant would receive. Participants were told not to reveal their medical history or scheduled endoscopic procedure to the physicians performing the physical examination. In the seated position, the participant was evaluated for tenderness and paraspinal tissue texture abnormalities at T1-L5 and the sacral base; rotational asymmetry, motion restriction, and restricted flexion and extension of T1-L5; and sacral asymmetry. In the supine position, the participant was evaluated for tenderness, rotational asymmetry, restricted flexion and extension, and paraspinal tissue texture abnormalities of the occipitoatlantal joint (OA) through C7; anterior Chapman reflex point tenderness of reflex points located on the anterior chest and lateral thighs11,12; and abdominal tenderness of the hiatus VS, pylorus VS, sphincter of Oddi VS, duodenojejunal junction VS, and ileocecal valve VS. 
When evaluating vertebral, Chapman reflex point, and VS tenderness, the participant was asked to indicate when he or she felt pain or tenderness with localized palpatory pressure sufficient to result in blanching of the examiner’s fingernail, which is considered to be approximately 4 kg/cm2.17-19 Vertebral tenderness was assessed on the right, left, and midline of each spinous process of C1-S1 and on the right, left, and midline of the inferior nuchal line of the OA. Vertebral segmental rotational asymmetry and motion restriction were assessed by noting the static asymmetry of the transverse processes and then applying alternating anterior pressure on the transverse processes. The preference for vertebral rotation was noted as right, left, or none. Vertebral segmental sagittal asymmetry and motion restriction were assessed by noting the static asymmetry of the spinous processes and then applying anterior pressure on the spinous processes. The preference for vertebral flexion, extension, or none was determined by the presence of either static asymmetry or motion restriction. Paraspinal tissue texture abnormalities were recorded as boggy, muscular tension, or both with the location noted as right, left, or bilateral. Sacral asymmetry was recorded using the classic Mitchell terminology.20 Thirty-seven Chapman reflex points were assessed and noted as tender on the right, left, or bilateral, except for the sternal midline, which was either present or none. Abdominal VS tenderness was noted as tender or not tender for each of the 5 VS locations as follows: the hiatus VS was immediately inferior and deep to the xiphoid process; the pylorus VS was just right of midline, 4 to 5 cm superior to the umbilicus; the sphincter of Oddi VS was palpated as a small projection at the right midclavicular line, 2 to 3 cm superior to the umbilicus; the duodenojejunal junction VS was at the left midclavicular line, 2 to 3 cm superior to the umbilicus; and the ileocecal valve VS was 3 cm wide and palpated medial to the ilium at the level of the cecum.13,21 
For each physical examination, the first physician palpated for somatic dysfunction findings, and the second physician then confirmed those findings. When the examiners disagreed on the findings, the area was reexamined by both examiners and discussed until agreement was reached. The consensus of the physical findings was recorded on a data collection form. 
Endoscopic Findings
Participant demographics, type of procedure(s), indications for the procedure(s), participant symptoms, and endoscopic abnormalities were collected from the outpatient surgical record and histologic reports (if applicable). The following endoscopic findings, if reported on the operative visual report or the histologic report, were considered abnormal: inflammation such as erythema, erosions, ulcerations, or eosinophilia, and abnormal growths such as polyps, metaplasia, or dysplasia. The presence of a hiatal hernia, diverticula, or hemorrhoids on the visual report or Helicobacter pylori on the histologic report was also considered abnormal. For analysis, endoscopic findings were grouped according to the following regions: esophagus, GE junction, stomach, pylorus, duodenum, terminal ileum, ileocecal valve, ascending colon (including the cecum and hepatic flexure, transverse colon), descending colon (including the splenic flexure), sigmoid colon, and rectum and anus. 
Statistical Analysis
The data for participant demographics, type of procedure(s), indications for the procedure(s), participant symptoms, endoscopic abnormalities, and types of somatic dysfunctions were tabulated. The relationship of the somatic dysfunction burden with the type of endoscopic procedure and the presence of GI symptoms were assessed using the Kruskal-Wallis test. Mann-Whitney tests were used to compare the somatic dysfunction burden, vertebral TART findings, vertebral tenderness, regional TART findings, and regional spinal tenderness between those participants with abnormal vs normal endoscopic findings. Somatic dysfunction burden was calculated as the sum of the number of individual vertebral TART findings (0 to 233 points), tender Chapman reflex points (0 to 37 points), and tender VS (0 to 5 points) and had a possible range of 0 to 275 points. Vertebral TART findings were calculated as the sum of the individual TART findings (tenderness, rotational asymmetry or motion restriction, sagittal asymmetry or motion restriction, and tissue texture abnormalities) for each vertebral segment and could range from 0 to 9 points for the OA through L5 and from 0 to 8 points for the sacrum (1 point for each TART finding present). Vertebral tenderness was calculated as the sum of the individual tenderness findings for each vertebra and could range from 0 to 3 points (1 point for tenderness at each location). Regional TART findings were calculated as the sum of the individual vertebral TART findings for the cervical (OA-C7), thoracic (T1-T12), lumbar (L1-L5), and sacral regions. Regional tenderness was calculated as the sum of the individual vertebral tenderness findings for the cervical, thoracic, lumbar, and sacral regions. χ2 tests were used to compare the percentage of tender Chapman reflex points and tender VS between those participants with abnormal or normal endoscopic findings. P≤.05 was considered statistically significant. The data were analyzed using SAS statistical software (version 9.4, SAS Institute, Inc). 
Results
Sixty-six participants (39 [59%] women; mean [SD] age, 53 [15] years) completed the current study. One participant dropped out after receiving the physical examination because the scheduled endoscopy was not performed. Forty-three participants (65%) received an EGD, 40 participants (61%) received a colonoscopy, and 17 participants (26%) received both. Forty participants (93%) received an EGD for a diagnosis of active symptoms and 3 (7%) for surveillance of previously diagnosed problems. Twenty-nine participants (73%) received a colonoscopy for health screening, 9 (23%) for diagnosis of an active problem, and 2 (5%) for surveillance; 14 (33%) reported GI symptoms at the time of their colonoscopy. The most common GI symptoms among the 40 symptomatic participants receiving an EGD were GE reflux (26 [65%]) and abdominal pain (23 [58%]), and the most common symptoms among the 14 symptomatic participants receiving a colonoscopy were constipation (6 [43%]) and abdominal pain and diarrhea (each 5 [38%]). The incidence of abnormal endoscopic findings ranged from 98% in the stomach to 0% at the ileocecal valve (Table 1). Because only 1 participant had no stomach abnormalities, the gastric region was not included in any comparisons with musculoskeletal findings. 
Table 1.
Incidence of Visual and Histologic Abnormalities Reported on Endoscopic Operative and Pathology Reports in Patients With Somatic Dysfunction (N=66)
Gastrointestinal Regiona Region Visualized, No. Total Abnormalities, No. (%) Visual Abnormalities, No. (%) Region Biopsied, No.b Histologic Abnormalities, No. (%)
    EGD 43 41
        Esophagus 43 24 (56) 24 (56) 3 3 (100)
        Gastroesophageal junction 43 38 (88) 38 (88) 27 20 (74)
        Stomach 43 42 (98) 42 (98) 36 28 (78)
        Pylorus 43 20 (47) 20 (47) 0 NA
        Duodenum 42 33 (79) 32 (76) 17 15 (88)
    Colonoscopy 40 28
        Terminal ilium 5 3 (60) 2 (40) 3 2 (67)
        Ileocecal valve 14 0 0 0 NA
        Ascending colon including cecum and hepatic flexure 39 17 (44) 11 (28) 15 14 (93)
        Transverse colon 40 9 (23) 7 (18) 6 6 (100)
        Descending colon including splenic flexure 40 17 (43) 12 (30) 9 9 (100)
        Sigmoid colon 40 23 (58) 22 (55) 12 9 (75)
        Rectum and anus 40 28 (70) 28 (70) 14 10 (71)

a No operative reports identified visual or histological findings at the sphincter of Oddi or the duodenojejunal junction.

b Some regions biopsied were visually normal.

Abbreviations: EGD, esophagogastroduodenoscopy; NA, not applicable.

Table 1.
Incidence of Visual and Histologic Abnormalities Reported on Endoscopic Operative and Pathology Reports in Patients With Somatic Dysfunction (N=66)
Gastrointestinal Regiona Region Visualized, No. Total Abnormalities, No. (%) Visual Abnormalities, No. (%) Region Biopsied, No.b Histologic Abnormalities, No. (%)
    EGD 43 41
        Esophagus 43 24 (56) 24 (56) 3 3 (100)
        Gastroesophageal junction 43 38 (88) 38 (88) 27 20 (74)
        Stomach 43 42 (98) 42 (98) 36 28 (78)
        Pylorus 43 20 (47) 20 (47) 0 NA
        Duodenum 42 33 (79) 32 (76) 17 15 (88)
    Colonoscopy 40 28
        Terminal ilium 5 3 (60) 2 (40) 3 2 (67)
        Ileocecal valve 14 0 0 0 NA
        Ascending colon including cecum and hepatic flexure 39 17 (44) 11 (28) 15 14 (93)
        Transverse colon 40 9 (23) 7 (18) 6 6 (100)
        Descending colon including splenic flexure 40 17 (43) 12 (30) 9 9 (100)
        Sigmoid colon 40 23 (58) 22 (55) 12 9 (75)
        Rectum and anus 40 28 (70) 28 (70) 14 10 (71)

a No operative reports identified visual or histological findings at the sphincter of Oddi or the duodenojejunal junction.

b Some regions biopsied were visually normal.

Abbreviations: EGD, esophagogastroduodenoscopy; NA, not applicable.

×
Participants who received an EGD had a higher mean (SD) somatic dysfunction burden (97 [31] points) than those who received a colonoscopy (68 [28] points) and those who received both procedures (69 [29] points, P=.002). Symptomatic participants who received only EGD or only colonoscopy had a higher mean (SD) somatic dysfunction burden (95 [32] points) than symptomatic participants who received both procedures (77 [36] points), participants symptomatic for 1 procedure who received both procedures (65 [19] points), or asymptomatic participants who received 1 procedure or both procedures (63 [25] points, P=.005). No significant associations were found between abnormal endoscopic findings of any single GI region and somatic dysfunction burden (all P≥.07). 
The incidence of 1 or more vertebral TART findings ranged from 70% at T12 to 98% at the sacrum (Table 2). The differences between the mean number of vertebral TART findings for those with abnormal and normal endoscopic findings is presented in Figure 1. 
Table 2.
Incidence of Vertebral TART Findings in Patients Undergoing Gastrointestinal Imaging (N=66)a
Spinal Level Any TART Tenderness Asymmetry/Restricted ROM Tissue Texture Abnormalities
OA 63 (95) 33 (50) 61 (92) 34 (52)
AA 61 (92) 36 (55) 57 (86) 34 (52)
C2 62 (94) 38 (58) 45 (68) 50 (76)
C3 63 (95) 43 (65) 54 (82) 49 (74)
C4 59 (89) 41 (62) 48 (73) 45 (68)
C5 56 (85) 36 (55) 44 (67) 40 (61)
C6 58 (88) 37 (56) 42 (64) 47 (71)
C7 59 (89) 37 (56) 49 (74) 44 (67)
T1 59 (89) 27 (41) 47 (71) 46 (70)
T2 60 (91) 27 (41) 43 (65) 52 (79)
T3 58 (88) 34 (52) 46 (70) 47 (71)
T4 59 (89) 35 (53) 43 (65) 45 (68)
T5 57 (86) 31 (47) 44 (67) 44 (67)
T6 60 (91) 29 (44) 52 (79) 45 (68)
T7 56 (85) 27 (41) 46 (70) 43 (65)
T8 48 (73) 20 (30) 37 (56) 38 (58)
T9 50 (76) 18 (27) 40 (61) 36 (55)
T10 51 (77) 18 (27) 37 (56) 37 (56)
T11 48 (73) 17 (26) 31 (47) 37 (56)
T12 46 (70) 14 (21) 28 (42) 34 (52)
L1 55 (83) 24 (36) 34 (52) 36 (55)
L2 57 (86) 29 (44) 32 (48) 45 (68)
L3 55 (83) 33 (50) 39 (59) 40 (61)
L4 53 (80) 36 (55) 35 (53) 33 (50)
L5 58 (88) 42 (64) 38 (58) 36 (55)
Sacrum 65 (98) 37 (56) 64 (97) 27 (41)

a Data are given as No. (%).

Abbreviations: AA, atlantoaxial joint; OA, occipitoatlantal joint; ROM, range of motion; TART, tenderness, asymmetry, restricted range of motion, tissue texture abnormalities.

Table 2.
Incidence of Vertebral TART Findings in Patients Undergoing Gastrointestinal Imaging (N=66)a
Spinal Level Any TART Tenderness Asymmetry/Restricted ROM Tissue Texture Abnormalities
OA 63 (95) 33 (50) 61 (92) 34 (52)
AA 61 (92) 36 (55) 57 (86) 34 (52)
C2 62 (94) 38 (58) 45 (68) 50 (76)
C3 63 (95) 43 (65) 54 (82) 49 (74)
C4 59 (89) 41 (62) 48 (73) 45 (68)
C5 56 (85) 36 (55) 44 (67) 40 (61)
C6 58 (88) 37 (56) 42 (64) 47 (71)
C7 59 (89) 37 (56) 49 (74) 44 (67)
T1 59 (89) 27 (41) 47 (71) 46 (70)
T2 60 (91) 27 (41) 43 (65) 52 (79)
T3 58 (88) 34 (52) 46 (70) 47 (71)
T4 59 (89) 35 (53) 43 (65) 45 (68)
T5 57 (86) 31 (47) 44 (67) 44 (67)
T6 60 (91) 29 (44) 52 (79) 45 (68)
T7 56 (85) 27 (41) 46 (70) 43 (65)
T8 48 (73) 20 (30) 37 (56) 38 (58)
T9 50 (76) 18 (27) 40 (61) 36 (55)
T10 51 (77) 18 (27) 37 (56) 37 (56)
T11 48 (73) 17 (26) 31 (47) 37 (56)
T12 46 (70) 14 (21) 28 (42) 34 (52)
L1 55 (83) 24 (36) 34 (52) 36 (55)
L2 57 (86) 29 (44) 32 (48) 45 (68)
L3 55 (83) 33 (50) 39 (59) 40 (61)
L4 53 (80) 36 (55) 35 (53) 33 (50)
L5 58 (88) 42 (64) 38 (58) 36 (55)
Sacrum 65 (98) 37 (56) 64 (97) 27 (41)

a Data are given as No. (%).

Abbreviations: AA, atlantoaxial joint; OA, occipitoatlantal joint; ROM, range of motion; TART, tenderness, asymmetry, restricted range of motion, tissue texture abnormalities.

×
Figure 1.
Difference between the mean vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings) for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from the Mann-Whitney test comparing the number of TART findings between those with abnormal vs normal findings. Positive values indicate that participants with abnormal endoscopic findings had higher mean vertebral TART findings at the indicated levels, and negative values indicate that participants with normal endoscopic findings had higher mean vertebral TART findings at the indicated levels. Blue bars indicate significantly more TART findings for those with abnormal endoscopic findings. Red bars indicate significantly more TART findings for those with normal endoscopic findings (P≤.05). Abbreviations: AA, atlantoaxial joint; GE, gastroesophageal junction; OA, occipitoatlantal joint.
Figure 1.
Difference between the mean vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings) for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from the Mann-Whitney test comparing the number of TART findings between those with abnormal vs normal findings. Positive values indicate that participants with abnormal endoscopic findings had higher mean vertebral TART findings at the indicated levels, and negative values indicate that participants with normal endoscopic findings had higher mean vertebral TART findings at the indicated levels. Blue bars indicate significantly more TART findings for those with abnormal endoscopic findings. Red bars indicate significantly more TART findings for those with normal endoscopic findings (P≤.05). Abbreviations: AA, atlantoaxial joint; GE, gastroesophageal junction; OA, occipitoatlantal joint.
When only vertebral tenderness was examined, GE junction abnormalities were negatively associated with tenderness at T8 and T12 (both P<.03). Pyloric abnormalities were positively associated with tenderness at T11 (P=.01). Duodenal abnormalities were negatively associated with tenderness at T2 and L2 (both P<.03). Ascending colon abnormalities were positively associated with tenderness at T5, L2, and L5 (all P<.02). Descending colon abnormalities were positively associated with tenderness at T5 and T7 (both P<.05) and negatively associated with tenderness at C2 (P=.05). Sigmoid colon abnormalities were positively associated with tenderness at C2, L4, and the sacrum (all P<.03). Rectal and anal abnormalities were positively associated with sacral tenderness (P=.03). No other significant associations were found between abnormal endoscopic findings and vertebral tenderness. 
When regional TART findings were examined, py-loric abnormalities were positively associated with TART findings in the lumbar and sacral regions (both P<.04). No other significant correlations were found between abnormal endoscopic findings and regional TART findings. When only regional tenderness findings were examined, ascending colon abnormalities were positively associated with tenderness in the thoracic region (P=.02). Sigmoid colon abnormalities were positively associated with tenderness in the cervical, thoracic, lumbar, and sacral regions (all P<.05). Rectal and anal abnormalities were positively associated with tenderness in the lumbar region (P=.05). No other significant correlations were found between abnormal endoscopic findings and regional tenderness. 
The incidence of tender Chapman reflex points ranged from 9% at the anterior proximal 3rd and the posterior middle 3rd of the iliotibial band to 53% at the 5th intercostal space and the anterior tip of the 12th rib (Table 3). The differences between the percentage of tender Chapman reflex points for those with abnormal and normal endoscopic findings is presented in Figure 2. 
Figure 2.
Difference between the percentage of tender Chapman reflex points for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from χ2 test comparing the percentage of tender Chapman reflex points between those with abnormal vs normal endoscopic findings. Positive values indicate that participants with abnormal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations, and negative values indicate that participants with normal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations. Blue and green bars indicate a significantly higher percentage of tender Chapman reflex points on the right and left sides, respectively, for those with abnormal findings. Orange bars indicate a significantly higher percentage of tender Chapman reflex points on the left side for those with normal findings (P≤.05). Abbreviations: AD, anterior distal third; AM, anterior middle third; AP, anterior proximal third; GE, gastroesophageal junction; ICS, intercostal space; ITB, iliotibial band; PD, posterior distal third; PM, posterior middle third; PP, posterior proximal third.
Figure 2.
Difference between the percentage of tender Chapman reflex points for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from χ2 test comparing the percentage of tender Chapman reflex points between those with abnormal vs normal endoscopic findings. Positive values indicate that participants with abnormal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations, and negative values indicate that participants with normal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations. Blue and green bars indicate a significantly higher percentage of tender Chapman reflex points on the right and left sides, respectively, for those with abnormal findings. Orange bars indicate a significantly higher percentage of tender Chapman reflex points on the left side for those with normal findings (P≤.05). Abbreviations: AD, anterior distal third; AM, anterior middle third; AP, anterior proximal third; GE, gastroesophageal junction; ICS, intercostal space; ITB, iliotibial band; PD, posterior distal third; PM, posterior middle third; PP, posterior proximal third.
Table 3.
Incidence of Tender Chapman Reflex Points in Patients With Somatic Dysfunction Undergoing Gastrointestinal Imaging (N=66)
Chapman Reflex Point Classic Visceral Associationa Tender Points
Right Left Any Right Left
1st Rib, at manubrial attachment Pharynx Pharynx 31 (47) 20 (30) 24 (36)
2nd Rib, at superior aspect of sternal attachment Larynx Larynx 31 (47) 22 (33) 21 (32)
2nd Intercostal space Esophagus Esophagus 24 (36) 19 (29) 17 (26)
3rd Intercostal space Right upper lung Left upper lung 25 (38) 17 (26) 18 (27)
4th Intercostal space Right lower lung Left lower lung 29 (44) 24 (36) 23 (35)
5th Intercostal space Liver Stomach 35 (53) 27 (41) 26 (39)
6th Intercostal space Liver/gallbladder Stomach 30 (45) 20 (30) 25 (38)
Sternal midlineb Pylorus Pylorus 31 (47) NA NA
7th Intercostal space Pancreas Spleen 30 (45) 21 (32) 27 (41)
8th Intercostal space Small intestines Small intestines 25 (38) 20 (30) 18 (27)
9th Intercostal space Small intestines Small intestines 27 (41) 19 (29) 21 (32)
10th Intercostal space Small intestines Small intestines 21 (32) 12 (18) 18 (27)
12th Rib, anterior tip Appendix NKA 35 (53) 23 (35) 29 (44)
ITB, anterior proximal third Cecum Sigmoid 6 (9) 3 (5) 3 (5)
ITB, anterior middle third Ascending colon Descending colon 9 (14) 4 (6) 5 (8)
ITB, anterior distal third Hepatic flexure and proximal transverse colon Splenic flexure and distal transverse colon 14 (21) 8 (12) 7 (11)
ITB, posterior proximal third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 9 (14) 6 (9) 4 (6)
ITB, posterior middle third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 6(9) 6 (9) 4 (6)
ITB, posterior distal third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 7 (11) 5 (8) 3 (5)

a Classic visceral associations of Chapman reflex points were defined according to Fossum et al.12

b Sternal midline includes tenderness located anywhere along the vertical midline of the sternum.

Abbreviations: F, female; ITB, iliotibial band; M, male; NA, not applicable; NKA, no known association.

Table 3.
Incidence of Tender Chapman Reflex Points in Patients With Somatic Dysfunction Undergoing Gastrointestinal Imaging (N=66)
Chapman Reflex Point Classic Visceral Associationa Tender Points
Right Left Any Right Left
1st Rib, at manubrial attachment Pharynx Pharynx 31 (47) 20 (30) 24 (36)
2nd Rib, at superior aspect of sternal attachment Larynx Larynx 31 (47) 22 (33) 21 (32)
2nd Intercostal space Esophagus Esophagus 24 (36) 19 (29) 17 (26)
3rd Intercostal space Right upper lung Left upper lung 25 (38) 17 (26) 18 (27)
4th Intercostal space Right lower lung Left lower lung 29 (44) 24 (36) 23 (35)
5th Intercostal space Liver Stomach 35 (53) 27 (41) 26 (39)
6th Intercostal space Liver/gallbladder Stomach 30 (45) 20 (30) 25 (38)
Sternal midlineb Pylorus Pylorus 31 (47) NA NA
7th Intercostal space Pancreas Spleen 30 (45) 21 (32) 27 (41)
8th Intercostal space Small intestines Small intestines 25 (38) 20 (30) 18 (27)
9th Intercostal space Small intestines Small intestines 27 (41) 19 (29) 21 (32)
10th Intercostal space Small intestines Small intestines 21 (32) 12 (18) 18 (27)
12th Rib, anterior tip Appendix NKA 35 (53) 23 (35) 29 (44)
ITB, anterior proximal third Cecum Sigmoid 6 (9) 3 (5) 3 (5)
ITB, anterior middle third Ascending colon Descending colon 9 (14) 4 (6) 5 (8)
ITB, anterior distal third Hepatic flexure and proximal transverse colon Splenic flexure and distal transverse colon 14 (21) 8 (12) 7 (11)
ITB, posterior proximal third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 9 (14) 6 (9) 4 (6)
ITB, posterior middle third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 6(9) 6 (9) 4 (6)
ITB, posterior distal third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 7 (11) 5 (8) 3 (5)

a Classic visceral associations of Chapman reflex points were defined according to Fossum et al.12

b Sternal midline includes tenderness located anywhere along the vertical midline of the sternum.

Abbreviations: F, female; ITB, iliotibial band; M, male; NA, not applicable; NKA, no known association.

×
Tenderness was present at the hiatus VS in 29 participants (44%), the pylorus VS in 29 (44%), the 
sphincter of Oddi VS in 25 (38%), the duodenojejunal junction VS in 26 (39%), and the ileocecal valve VS in 34 (52%). Significant negative associations were found between GE junction abnormalities and hiatus, pylorus, sphincter of Oddi, and duodenojejunal junction VS tenderness (all P<.05). Significant positive associations were found between duodenal abnormalities and duo-denojejunal junction VS tenderness (P=.04); ascending colon abnormalities and sphincter of Oddi VS tenderness (P=.05); and sigmoid colon abnormalities and hiatus and pylorus VS tenderness (both P=.03). 
Discussion
The current study found numerous significant associations between somatic dysfunction and abnormal endoscopic findings. However, the high incidence of vertebral somatic dysfunction findings combined with a lack of normal controls for many GI regions made it difficult to establish meaningful relationships between specific GI abnormalities and somatic dysfunction in the various body regions. Additionally, the methods of the current study allowed the inclusion of participants with chronic musculoskeletal pain. Because patients with back pain are more likely to have significant somatic dysfunction,22,23 the somatic dysfunction of our participants may have been of somatic or visceral origin. However, musculoskeletal pain can also affect visceral structures via viscerosomatic convergence. Noxious stimulation of somatic tissues in animal models has been shown to cause visceral hyperalgesia and altered contractility, as well as altered muscular activity in structures receiving innervation from the same spinal levels.24-26 For the current study, we looked solely at the relationship between somatic dysfunction and GI abnormalities. Our results suggested that participants receiving an EGD had a significantly higher somatic dysfunction burden than participants receiving a colonoscopy or both an EGD and colonoscopy. This finding may be explained by the 93% of EGD participants who reported active upper GI symptoms; only 33% of colonoscopy participants reported active lower GI symptoms. 
Several studies27-31 have positively correlated a history of visceral disease with spinal TART findings. However, Tarr et al31 found that osteopathic physicians could not predict what type of visceral disease patients had using only palpation and visual clues. The current study positively correlated vertebral TART findings with abnormal endoscopic findings in the esophagus, GE junction, pylorus, ascending colon, and sigmoid colon. However, these correlations did not seem to follow a pattern such as dermatomal or autonomic innervation of the associated GI region. Negative correlations were found in the esophagus, GE junction, duodenum, and transverse colon. Together these findings suggest a need for additional studies that would include more participants for better powered statistical analyses of the different TART elements of somatic dysfunction. 
The current study had several limitations. Foremost, this study used palpation to identify TART findings. While palpation is inherently subjective and prone to interobserver reliability errors, it is still used and encouraged as part of clinical assessment, and its relationship to pathology needs to be studied.32-36 The current study used a consensus of palpatory findings identified by 2 physician examiners, but future studies could utilize research tools, such as algometers or ultrasonography, to better objectify the physical findings. Similarly, we did not use objective identifiers of location, so palpatory and endoscopic locations must be considered approximate rather than absolute. The endoscopic procedures were unable to assess extraluminal abnormalities (eg, gallbladder disease), small bowel abnormalities distal to the duodenum, and functional disorders that did not cause visible changes in mucosa (eg, slow-transit constipation).15 Future studies using ultrasonography or computed tomography may be better for assessing correlations with these types of abnormalities. To minimize examiner bias during the physical examination, the current study investigated both EGD and colonoscopy procedures to ensure asymptomatic patients were screened. However, because EGD procedures are not performed for general health screening, there were no asymptomatic controls for these comparisons. Additionally, because of the high incidence of somatic dysfunction in our participants, the current study was statistically underpowered to correlate GI regions with a high incidence of abnormalities, such as in the stomach, with somatic dysfunction. Future studies should use a larger patient population to ensure more participants with normal findings are assessed or consider a lower risk GI evaluation, such as capsule endoscopy, that would allow enrollment of asymptomatic participants. 
Conclusion
The current study found numerous statistically significant associations between somatic dysfunction and abnormal endoscopic findings. Symptomatic participants receiving an EGD had a significantly higher somatic dysfunction burden than asymptomatic participants. However, because of the high incidence of vertebral TART findings and the lack of normal controls for many GI regions, we were unable to establish meaningful relationships between somatic dysfunction in the various body regions and specific GI abnormalities. Additional analyses of the current data are planned for future publications to assess for relationships between the anterior and posterior TART findings and for relationships between the endoscopic findings and smaller groups of vertebral TART findings such as those associated with sympathetic innervation. Future investigations should focus on elements of somatic dysfunction with a high level of variability between vertebrae within an individual participant and between participants, such as tenderness, and evaluate more participants to ensure a sufficient number of participants with normal endoscopic findings. 
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Figure 1.
Difference between the mean vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings) for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from the Mann-Whitney test comparing the number of TART findings between those with abnormal vs normal findings. Positive values indicate that participants with abnormal endoscopic findings had higher mean vertebral TART findings at the indicated levels, and negative values indicate that participants with normal endoscopic findings had higher mean vertebral TART findings at the indicated levels. Blue bars indicate significantly more TART findings for those with abnormal endoscopic findings. Red bars indicate significantly more TART findings for those with normal endoscopic findings (P≤.05). Abbreviations: AA, atlantoaxial joint; GE, gastroesophageal junction; OA, occipitoatlantal joint.
Figure 1.
Difference between the mean vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings) for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from the Mann-Whitney test comparing the number of TART findings between those with abnormal vs normal findings. Positive values indicate that participants with abnormal endoscopic findings had higher mean vertebral TART findings at the indicated levels, and negative values indicate that participants with normal endoscopic findings had higher mean vertebral TART findings at the indicated levels. Blue bars indicate significantly more TART findings for those with abnormal endoscopic findings. Red bars indicate significantly more TART findings for those with normal endoscopic findings (P≤.05). Abbreviations: AA, atlantoaxial joint; GE, gastroesophageal junction; OA, occipitoatlantal joint.
Figure 2.
Difference between the percentage of tender Chapman reflex points for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from χ2 test comparing the percentage of tender Chapman reflex points between those with abnormal vs normal endoscopic findings. Positive values indicate that participants with abnormal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations, and negative values indicate that participants with normal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations. Blue and green bars indicate a significantly higher percentage of tender Chapman reflex points on the right and left sides, respectively, for those with abnormal findings. Orange bars indicate a significantly higher percentage of tender Chapman reflex points on the left side for those with normal findings (P≤.05). Abbreviations: AD, anterior distal third; AM, anterior middle third; AP, anterior proximal third; GE, gastroesophageal junction; ICS, intercostal space; ITB, iliotibial band; PD, posterior distal third; PM, posterior middle third; PP, posterior proximal third.
Figure 2.
Difference between the percentage of tender Chapman reflex points for those with abnormal and normal endoscopic findings in the (A) upper gastrointestinal system and (B) lower gastrointestinal system. Data are given as P values from χ2 test comparing the percentage of tender Chapman reflex points between those with abnormal vs normal endoscopic findings. Positive values indicate that participants with abnormal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations, and negative values indicate that participants with normal endoscopic findings had a higher percentage of tender Chapman reflex points at the indicated locations. Blue and green bars indicate a significantly higher percentage of tender Chapman reflex points on the right and left sides, respectively, for those with abnormal findings. Orange bars indicate a significantly higher percentage of tender Chapman reflex points on the left side for those with normal findings (P≤.05). Abbreviations: AD, anterior distal third; AM, anterior middle third; AP, anterior proximal third; GE, gastroesophageal junction; ICS, intercostal space; ITB, iliotibial band; PD, posterior distal third; PM, posterior middle third; PP, posterior proximal third.
Table 1.
Incidence of Visual and Histologic Abnormalities Reported on Endoscopic Operative and Pathology Reports in Patients With Somatic Dysfunction (N=66)
Gastrointestinal Regiona Region Visualized, No. Total Abnormalities, No. (%) Visual Abnormalities, No. (%) Region Biopsied, No.b Histologic Abnormalities, No. (%)
    EGD 43 41
        Esophagus 43 24 (56) 24 (56) 3 3 (100)
        Gastroesophageal junction 43 38 (88) 38 (88) 27 20 (74)
        Stomach 43 42 (98) 42 (98) 36 28 (78)
        Pylorus 43 20 (47) 20 (47) 0 NA
        Duodenum 42 33 (79) 32 (76) 17 15 (88)
    Colonoscopy 40 28
        Terminal ilium 5 3 (60) 2 (40) 3 2 (67)
        Ileocecal valve 14 0 0 0 NA
        Ascending colon including cecum and hepatic flexure 39 17 (44) 11 (28) 15 14 (93)
        Transverse colon 40 9 (23) 7 (18) 6 6 (100)
        Descending colon including splenic flexure 40 17 (43) 12 (30) 9 9 (100)
        Sigmoid colon 40 23 (58) 22 (55) 12 9 (75)
        Rectum and anus 40 28 (70) 28 (70) 14 10 (71)

a No operative reports identified visual or histological findings at the sphincter of Oddi or the duodenojejunal junction.

b Some regions biopsied were visually normal.

Abbreviations: EGD, esophagogastroduodenoscopy; NA, not applicable.

Table 1.
Incidence of Visual and Histologic Abnormalities Reported on Endoscopic Operative and Pathology Reports in Patients With Somatic Dysfunction (N=66)
Gastrointestinal Regiona Region Visualized, No. Total Abnormalities, No. (%) Visual Abnormalities, No. (%) Region Biopsied, No.b Histologic Abnormalities, No. (%)
    EGD 43 41
        Esophagus 43 24 (56) 24 (56) 3 3 (100)
        Gastroesophageal junction 43 38 (88) 38 (88) 27 20 (74)
        Stomach 43 42 (98) 42 (98) 36 28 (78)
        Pylorus 43 20 (47) 20 (47) 0 NA
        Duodenum 42 33 (79) 32 (76) 17 15 (88)
    Colonoscopy 40 28
        Terminal ilium 5 3 (60) 2 (40) 3 2 (67)
        Ileocecal valve 14 0 0 0 NA
        Ascending colon including cecum and hepatic flexure 39 17 (44) 11 (28) 15 14 (93)
        Transverse colon 40 9 (23) 7 (18) 6 6 (100)
        Descending colon including splenic flexure 40 17 (43) 12 (30) 9 9 (100)
        Sigmoid colon 40 23 (58) 22 (55) 12 9 (75)
        Rectum and anus 40 28 (70) 28 (70) 14 10 (71)

a No operative reports identified visual or histological findings at the sphincter of Oddi or the duodenojejunal junction.

b Some regions biopsied were visually normal.

Abbreviations: EGD, esophagogastroduodenoscopy; NA, not applicable.

×
Table 2.
Incidence of Vertebral TART Findings in Patients Undergoing Gastrointestinal Imaging (N=66)a
Spinal Level Any TART Tenderness Asymmetry/Restricted ROM Tissue Texture Abnormalities
OA 63 (95) 33 (50) 61 (92) 34 (52)
AA 61 (92) 36 (55) 57 (86) 34 (52)
C2 62 (94) 38 (58) 45 (68) 50 (76)
C3 63 (95) 43 (65) 54 (82) 49 (74)
C4 59 (89) 41 (62) 48 (73) 45 (68)
C5 56 (85) 36 (55) 44 (67) 40 (61)
C6 58 (88) 37 (56) 42 (64) 47 (71)
C7 59 (89) 37 (56) 49 (74) 44 (67)
T1 59 (89) 27 (41) 47 (71) 46 (70)
T2 60 (91) 27 (41) 43 (65) 52 (79)
T3 58 (88) 34 (52) 46 (70) 47 (71)
T4 59 (89) 35 (53) 43 (65) 45 (68)
T5 57 (86) 31 (47) 44 (67) 44 (67)
T6 60 (91) 29 (44) 52 (79) 45 (68)
T7 56 (85) 27 (41) 46 (70) 43 (65)
T8 48 (73) 20 (30) 37 (56) 38 (58)
T9 50 (76) 18 (27) 40 (61) 36 (55)
T10 51 (77) 18 (27) 37 (56) 37 (56)
T11 48 (73) 17 (26) 31 (47) 37 (56)
T12 46 (70) 14 (21) 28 (42) 34 (52)
L1 55 (83) 24 (36) 34 (52) 36 (55)
L2 57 (86) 29 (44) 32 (48) 45 (68)
L3 55 (83) 33 (50) 39 (59) 40 (61)
L4 53 (80) 36 (55) 35 (53) 33 (50)
L5 58 (88) 42 (64) 38 (58) 36 (55)
Sacrum 65 (98) 37 (56) 64 (97) 27 (41)

a Data are given as No. (%).

Abbreviations: AA, atlantoaxial joint; OA, occipitoatlantal joint; ROM, range of motion; TART, tenderness, asymmetry, restricted range of motion, tissue texture abnormalities.

Table 2.
Incidence of Vertebral TART Findings in Patients Undergoing Gastrointestinal Imaging (N=66)a
Spinal Level Any TART Tenderness Asymmetry/Restricted ROM Tissue Texture Abnormalities
OA 63 (95) 33 (50) 61 (92) 34 (52)
AA 61 (92) 36 (55) 57 (86) 34 (52)
C2 62 (94) 38 (58) 45 (68) 50 (76)
C3 63 (95) 43 (65) 54 (82) 49 (74)
C4 59 (89) 41 (62) 48 (73) 45 (68)
C5 56 (85) 36 (55) 44 (67) 40 (61)
C6 58 (88) 37 (56) 42 (64) 47 (71)
C7 59 (89) 37 (56) 49 (74) 44 (67)
T1 59 (89) 27 (41) 47 (71) 46 (70)
T2 60 (91) 27 (41) 43 (65) 52 (79)
T3 58 (88) 34 (52) 46 (70) 47 (71)
T4 59 (89) 35 (53) 43 (65) 45 (68)
T5 57 (86) 31 (47) 44 (67) 44 (67)
T6 60 (91) 29 (44) 52 (79) 45 (68)
T7 56 (85) 27 (41) 46 (70) 43 (65)
T8 48 (73) 20 (30) 37 (56) 38 (58)
T9 50 (76) 18 (27) 40 (61) 36 (55)
T10 51 (77) 18 (27) 37 (56) 37 (56)
T11 48 (73) 17 (26) 31 (47) 37 (56)
T12 46 (70) 14 (21) 28 (42) 34 (52)
L1 55 (83) 24 (36) 34 (52) 36 (55)
L2 57 (86) 29 (44) 32 (48) 45 (68)
L3 55 (83) 33 (50) 39 (59) 40 (61)
L4 53 (80) 36 (55) 35 (53) 33 (50)
L5 58 (88) 42 (64) 38 (58) 36 (55)
Sacrum 65 (98) 37 (56) 64 (97) 27 (41)

a Data are given as No. (%).

Abbreviations: AA, atlantoaxial joint; OA, occipitoatlantal joint; ROM, range of motion; TART, tenderness, asymmetry, restricted range of motion, tissue texture abnormalities.

×
Table 3.
Incidence of Tender Chapman Reflex Points in Patients With Somatic Dysfunction Undergoing Gastrointestinal Imaging (N=66)
Chapman Reflex Point Classic Visceral Associationa Tender Points
Right Left Any Right Left
1st Rib, at manubrial attachment Pharynx Pharynx 31 (47) 20 (30) 24 (36)
2nd Rib, at superior aspect of sternal attachment Larynx Larynx 31 (47) 22 (33) 21 (32)
2nd Intercostal space Esophagus Esophagus 24 (36) 19 (29) 17 (26)
3rd Intercostal space Right upper lung Left upper lung 25 (38) 17 (26) 18 (27)
4th Intercostal space Right lower lung Left lower lung 29 (44) 24 (36) 23 (35)
5th Intercostal space Liver Stomach 35 (53) 27 (41) 26 (39)
6th Intercostal space Liver/gallbladder Stomach 30 (45) 20 (30) 25 (38)
Sternal midlineb Pylorus Pylorus 31 (47) NA NA
7th Intercostal space Pancreas Spleen 30 (45) 21 (32) 27 (41)
8th Intercostal space Small intestines Small intestines 25 (38) 20 (30) 18 (27)
9th Intercostal space Small intestines Small intestines 27 (41) 19 (29) 21 (32)
10th Intercostal space Small intestines Small intestines 21 (32) 12 (18) 18 (27)
12th Rib, anterior tip Appendix NKA 35 (53) 23 (35) 29 (44)
ITB, anterior proximal third Cecum Sigmoid 6 (9) 3 (5) 3 (5)
ITB, anterior middle third Ascending colon Descending colon 9 (14) 4 (6) 5 (8)
ITB, anterior distal third Hepatic flexure and proximal transverse colon Splenic flexure and distal transverse colon 14 (21) 8 (12) 7 (11)
ITB, posterior proximal third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 9 (14) 6 (9) 4 (6)
ITB, posterior middle third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 6(9) 6 (9) 4 (6)
ITB, posterior distal third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 7 (11) 5 (8) 3 (5)

a Classic visceral associations of Chapman reflex points were defined according to Fossum et al.12

b Sternal midline includes tenderness located anywhere along the vertical midline of the sternum.

Abbreviations: F, female; ITB, iliotibial band; M, male; NA, not applicable; NKA, no known association.

Table 3.
Incidence of Tender Chapman Reflex Points in Patients With Somatic Dysfunction Undergoing Gastrointestinal Imaging (N=66)
Chapman Reflex Point Classic Visceral Associationa Tender Points
Right Left Any Right Left
1st Rib, at manubrial attachment Pharynx Pharynx 31 (47) 20 (30) 24 (36)
2nd Rib, at superior aspect of sternal attachment Larynx Larynx 31 (47) 22 (33) 21 (32)
2nd Intercostal space Esophagus Esophagus 24 (36) 19 (29) 17 (26)
3rd Intercostal space Right upper lung Left upper lung 25 (38) 17 (26) 18 (27)
4th Intercostal space Right lower lung Left lower lung 29 (44) 24 (36) 23 (35)
5th Intercostal space Liver Stomach 35 (53) 27 (41) 26 (39)
6th Intercostal space Liver/gallbladder Stomach 30 (45) 20 (30) 25 (38)
Sternal midlineb Pylorus Pylorus 31 (47) NA NA
7th Intercostal space Pancreas Spleen 30 (45) 21 (32) 27 (41)
8th Intercostal space Small intestines Small intestines 25 (38) 20 (30) 18 (27)
9th Intercostal space Small intestines Small intestines 27 (41) 19 (29) 21 (32)
10th Intercostal space Small intestines Small intestines 21 (32) 12 (18) 18 (27)
12th Rib, anterior tip Appendix NKA 35 (53) 23 (35) 29 (44)
ITB, anterior proximal third Cecum Sigmoid 6 (9) 3 (5) 3 (5)
ITB, anterior middle third Ascending colon Descending colon 9 (14) 4 (6) 5 (8)
ITB, anterior distal third Hepatic flexure and proximal transverse colon Splenic flexure and distal transverse colon 14 (21) 8 (12) 7 (11)
ITB, posterior proximal third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 9 (14) 6 (9) 4 (6)
ITB, posterior middle third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 6(9) 6 (9) 4 (6)
ITB, posterior distal third Right broad ligament (F)/prostate (M) Left broad ligament (F)/prostate (M) 7 (11) 5 (8) 3 (5)

a Classic visceral associations of Chapman reflex points were defined according to Fossum et al.12

b Sternal midline includes tenderness located anywhere along the vertical midline of the sternum.

Abbreviations: F, female; ITB, iliotibial band; M, male; NA, not applicable; NKA, no known association.

×