Gastroparesis and Autonomic Dysfunction


saltzman25
 

I recently saw a new patient who has a very complex medical history. I feel that I can help her, but I am new to VM and do not have the experience or knowledge that many of you have. 
A quick summary: she has not been able to eat solid food for 12 years. She has gone through extensive testing at Cedars-Sinai and Stanford, and eventually dx with gastroparesis, IBS, and 2cm hiatal hernia. She eats only protein shakes, cream of wheat, Ensure, and apple sauce. She has chronic nausea which she manage with sublingual zoltan 3x/day. She lives with the nausea, but no longer vomits. 
She did not respond to botox to pylorus. She has been on antibiotics multiple times. Most recent was 3 wks of Erythromycin because this was shown to stimulate motility during one of her procedures. 
She has since developed autonomic dysfunction and faints regularly. She has seen multiple cardiologists and neurologist and has been told everything from sick sinus syndrome, prinzmetal's angina, POTS, and EDS connective tissue disorder.
She fainted during tilt table test. She faints when getting soft tissue work done. She is currently on a protocol of Mididrine, Florinef, and salt tablets. (oh boy!)
She also recently discovered that she has scoliosis, found on x-ray taken of her lungs. It is pretty significant and starts high up in her thoracic region (I have no idea how this was never noticed before now). She is 30 years old.

She also had a traumatic experience as a child and has struggled with separation anxiety since pre-school. She was put on Paxil in middle school, and was on it for 10 years! Trouble weaning off, including "brain zaps", in which other antidepressants were used to transition her off of Paxil. (10 years as a child on this stuff!)

There is obviously vagus nerve dysfunction at play here- and I will go back and review treatment ideas from prior functional medicine and functional neurology courses I have taken. What I would like some input on are your thoughts regarding VM treatment with her.

1. I suggested wearing thigh high TED hose to her first VM session, to prevent orthostatic hypotension upon standing. Thoughts?
2. Any input in regards to her scoliosis? My thoughts are that this alignment could be playing a role in vagus nerve activity. Anything specific I should be feeling for in regard to her scoliosis (R thoracic dextroscoliosis), and how it relates to organ alignement. I have not done the thoracic class yet.
3. Should I be of concern if she does actually have Ehlers-Danlos Syndrome, as this is a connective tissue disorder (her MD suspects this based on white fatty deposits on her heels, and "velvety skin". No genetic testing has been done).
4. Is there anything that should be avoided in her case?
5. Are there any VM techniques that I may not be aware of that may support function of her vagus nerve, and/or be avoided to avoid over activation of her sypathetic nerve ganglion. 
6. Areas to avoid? Suggestions for number of techniques in one session (I am trying to keep the session short as to not overstimulate her system).
6. Anything I have not thought of yet in regard to initiating hands on treatment with her?

I feel that I may be over my head in terms of both visceral manipulation skills and functional medicine treatment-- but she is truly at the end of the rode with traditional treatments, and I have hope that the appropriate VM treatment could be a catalyst for healing.

I would love input from any experienced visceral therapists, and especially from anyone that work with patients in a holistic manner (ie: Naturopaths).
Bob, are you out there? I am channeling your widsom and experience!!

Thank you all in advance for any advice you provide.

Sheila DPT, IFMCP
VM1


drmariotti@...
 

Hi Sheila;

 

Wow, anyone, regardless of their years of practice would be overwhelmed by such a patient as this. 

 

It seems to me, from the details of your case that you are looking for a kind of algorithm to help you approach this patient. From the conventional perspective, who could blame you!

 

Unfortunately, you won't find that with Jean Pierre Barral's work. His work is not based on the symptoms of the patient, which this patient has numerous. Of course, we do not ignore the patient's symptoms but we are not ultimately dictated or guided by those symptoms, or the disease or pathology the patient is presenting with. The work of Jean Pierre Barral is truly a paradigm shift. Try as you might to fit his work into the conventional model and you will only find yourself becoming frustrated. Believe me, in the beginning, when I was learning this work I did just the same thing. But try as I might it was a bit like trying to shove a square peg into a round hole….uggh!

 

The symptoms of the patient, the disease, the pathology, no matter how long the list, can provide you with a kind of roadmap to the underlying systems that may be compromised. But ultimately, the body dictates, the body determines, what is to be the best treatment. And this is not some mysterious energetic, or psychic force that delivers this information to you. It is not based on your intuition or your years of practice or how many books you have read or classes you have taken. 

 

It is pure and simple. It is the listening. 

 

Now, I understand only have VM1 under your belt. And as a teacher of this work, I confess that we do not spend much time teaching you how to do general listening and local listening. There just simply is not enough time to bring that into the curriculum courses. And this is the reason we have devoted 2 classes just to the listening. 

 

That being said, you have it in your hands to do this. Of course, you don't have it in your head. And who needs it to be there anyway. It is not you who decides the treatment plan. It is not the patient who decides the treatment plan. It is not the symptoms of the patient that decides the treatment plan. 

 

It is the patient's body that decides the treatment plan. 

 

As JP says "let the body speak". Another quote I absolutely love from him; “Better the most inapt technique at the location the body chooses than the most perfect technique at the place the therapist decides.” Wow, now doesn’t that bring a flood of sweet relief. 

 

The only thing you lack is confidence. But this comes with experience. Having patients like this will take your confidence to a completely different universe. Trust me, I've been there. Many of us have already walked this road and have realized that if we simply trust our hands, and trust the listening, the body will dictate the treatment.

 

And everything you learned in VM1 is sufficient!  All you need to do is clear your mind, review your notes on how to do general listening, and let the body tell you the area in the body that is the most important. And without allowing the demons of self-doubt to cloud your mind, have the patient lying on the table and do local listening in the area of the general listening. And then treat what you find. 

 

I’m excited to hear how things go. 

 

Ron


Robert Minkowsky
 

Sheila; Great case. Thank you for sharing it. 
Ron your comments are inspirational. Thank you.
Best regards.
Robert Minkowsky

On Sun, Aug 1, 2021, 12:24 PM drmariotti via groups.io <drmariotti=mac.com@groups.io> wrote:

Hi Sheila;

 

Wow, anyone, regardless of their years of practice would be overwhelmed by such a patient as this. 

 

It seems to me, from the details of your case that you are looking for a kind of algorithm to help you approach this patient. From the conventional perspective, who could blame you!

 

Unfortunately, you won't find that with Jean Pierre Barral's work. His work is not based on the symptoms of the patient, which this patient has numerous. Of course, we do not ignore the patient's symptoms but we are not ultimately dictated or guided by those symptoms, or the disease or pathology the patient is presenting with. The work of Jean Pierre Barral is truly a paradigm shift. Try as you might to fit his work into the conventional model and you will only find yourself becoming frustrated. Believe me, in the beginning, when I was learning this work I did just the same thing. But try as I might it was a bit like trying to shove a square peg into a round hole….uggh!

 

The symptoms of the patient, the disease, the pathology, no matter how long the list, can provide you with a kind of roadmap to the underlying systems that may be compromised. But ultimately, the body dictates, the body determines, what is to be the best treatment. And this is not some mysterious energetic, or psychic force that delivers this information to you. It is not based on your intuition or your years of practice or how many books you have read or classes you have taken. 

 

It is pure and simple. It is the listening. 

 

Now, I understand only have VM1 under your belt. And as a teacher of this work, I confess that we do not spend much time teaching you how to do general listening and local listening. There just simply is not enough time to bring that into the curriculum courses. And this is the reason we have devoted 2 classes just to the listening. 

 

That being said, you have it in your hands to do this. Of course, you don't have it in your head. And who needs it to be there anyway. It is not you who decides the treatment plan. It is not the patient who decides the treatment plan. It is not the symptoms of the patient that decides the treatment plan. 

 

It is the patient's body that decides the treatment plan. 

 

As JP says "let the body speak". Another quote I absolutely love from him; “Better the most inapt technique at the location the body chooses than the most perfect technique at the place the therapist decides.” Wow, now doesn’t that bring a flood of sweet relief. 

 

The only thing you lack is confidence. But this comes with experience. Having patients like this will take your confidence to a completely different universe. Trust me, I've been there. Many of us have already walked this road and have realized that if we simply trust our hands, and trust the listening, the body will dictate the treatment.

 

And everything you learned in VM1 is sufficient!  All you need to do is clear your mind, review your notes on how to do general listening, and let the body tell you the area in the body that is the most important. And without allowing the demons of self-doubt to cloud your mind, have the patient lying on the table and do local listening in the area of the general listening. And then treat what you find. 

 

I’m excited to hear how things go. 

 

Ron


saltzman25
 

Thank you for replying Ron. I appreciate the reminder to always trust the local listening. 

I suppose my question here was less about having algorithm, and more about learning from those more experienced than me in terms of possible adverse reactions to the treatment, or possible contraindications based upon patient diagnosis.

Since the sympathetic trunk is in the thoracic cavity, and I have not yet taken the thoracic course, I was hoping to gain some insight into whether there are techniques that should be avoided that could inadvertently trigger a vaso-vagal response.

Thanks again for your inspirational reply!

Sheila


Anne Sotelo
 

Hi Sheila,

Ron showed us a great “avoid a vagovasal response technique: using a Pulse Ox ( allow it to give you a steady reading before starting to treat - a few seconds of the same rate ) while treating. If your gentle cause no pain treatment evokes an increase in pulse rate, the vagus is noticing what you are doing = you are done or you are not as light/ specific and precise/ doing an induction into ease, as you thought, you may be getting a validation that you are working in the wrong place/ level/tissue. The pulse should slow if the vagus is eased. 

Anne Sotelo
CMT
VM 1-6, L1,2, NM 1-5,  and a few more.


On Aug 7, 2021, at 7:53 AM, saltzman25 via groups.io <saltzman25@...> wrote:

Thank you for replying Ron. I appreciate the reminder to always trust the local listening. 

I suppose my question here was less about having algorithm, and more about learning from those more experienced than me in terms of possible adverse reactions to the treatment, or possible contraindications based upon patient diagnosis.

Since the sympathetic trunk is in the thoracic cavity, and I have not yet taken the thoracic course, I was hoping to gain some insight into whether there are techniques that should be avoided that could inadvertently trigger a vaso-vagal response.

Thanks again for your inspirational reply!

Sheila



Mindy Marantz
 

Hi Sheila,

Regarding your question about compression for dysautonomia, many patients find an abdominal binder more effective than compression stockings. 
You could suggest trying that. Banana Bag enzyme packets are also terrific!

I am always worried about microbiome health with gastroparesis since there is so much information carried along the vagus back to the brain. I worry about the long term consequence of that. So I pull out ALL my tools to help improve function here.

For treatment, I am faithful to balancing anything orthopedic through the pelvis and trunk, (respectful of her scoliosis) and I usually check in on dural tightness and try to ease that before going on to follow my listening for visceral treatment. I “always” teach these patients to treat their own digestive sphincters at least 
3-5x/day which is VERY empowering for the patient. I also investigate (in severe cases such as this) my patients medical care to see if they are  with a “Mast Cell knowledgable physician”, especially if they concurrently have the combination of Hypermobile Ehlers Danlos Syndrome (hEDS), Dysautonomia, and SIBO.  If it is not already in the diagnostic compendium, I try to encourage  exploration of MCAS. Just in case you’d like a reference on this, here is a suggested reading:



The other thing I treat manually with Dysautonomia and hEDS is  Barral’s left sidelying compression of the heart to the pericardium. I do this because hEDS patients LOVE compression in their body. 
I used to just compress the boney structures a la Feldenkrais, but now with Barral’s visceral training, I compress organs (gently of course) and I frequently compress the heart to it’s sac which seems to reduce sympathetic tone. It’s also a very good technique to use during Covid since the respiratory system is so vulnerable, and the heart is cradled between those structures. (Valuable to remember is the body’s hierarchy of importance: the heart is one of the body’s top priorities, up there with the Artery rules supreme!.)

Viscosity is another one of the most valuable Barral tools that I use  with nearly every hEDS patient. hEDS patients are typically apical breathers, and this again, reduces sympathetic tone and helps them breathe into their diaphragm providing space for all the structures that bisect it.

Good luck. You’ve presented a challenging case, one that is perfect for adjunctive visceral treatment!

Best,
Mindy VM 1-6, NM 1-5 +++


Mindy Marantz PT MS GCFP
Founder/Director
Healthwell Physical Therapy Group
1200 Gough Street
San Francisco, Ca 94109
www.healthwellpt.com


On Aug 7, 2021, at 8:33 AM, saltzman25 via groups.io <saltzman25@...> wrote:



Thank you for replying Ron. I appreciate the reminder to always trust the local listening. 

I suppose my question here was less about having algorithm, and more about learning from those more experienced than me in terms of possible adverse reactions to the treatment, or possible contraindications based upon patient diagnosis.

Since the sympathetic trunk is in the thoracic cavity, and I have not yet taken the thoracic course, I was hoping to gain some insight into whether there are techniques that should be avoided that could inadvertently trigger a vaso-vagal response.

Thanks again for your inspirational reply!

Sheila