Download Hypertension

Clinical Integration of Osteopathic Manipulative Medicine
Internal Medicine/Family Medicine – Osteopathic Considerations in Patients with Hypertension
Authors: Daria Abolghasemi OMS IV and Sheldon C. Yao, DO
Introduction: Hypertension (HTN) is one of the most common chronic diseases affecting adults in the
United States. Treatment of hypertension is the number one most common reason for office visits in nonpregnant adults as well as for the use of prescription medications.1 HTN is a primary risk factor for
myocardial infarction, stroke, renal failure, and death if not treated and controlled.
Based on the JNC 8 in 2013, HTN is defined under the following parameters in two or more visits
after the initial screening2:
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Normal BP is systolic <120 mmHg and diastolic <80 mmHg.
Prehypertension is defined as 120-139 systolic or 80-90 diastolic.
Stage 1 HTN: systolic of 140-159 and diastolic at 90-99.
Stage 2 HTN: systolic >160 and diastolic >100
HTN can be classified as either primary or secondary. Primary HTN is idiopathic, with no
underlying cause. The pathogenesis of primary HTN is poorly understood. Secondary HTN is elevated
blood pressure that is attributed to another medical condition. Examples of secondary HTN include
pheochromocytoma, hyperaldosteronism, Cushing syndrome, thyroid disease, and renovascular disease.
Although an estimated 29 to 31% of adults in the U.S. are considered hypertensive, many patients
are not properly controlled. Data from the NHANES surveys of 2005-2008 reported that only about half
of those patients diagnosed with HTN are actually appropriately controlled3, with control defined as BP
<140/<90 mmHg.
Patient presentations:
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Asymptomatic – found on screening
If BP is severely elevated patients can present with
o Headache
o Blurred vision
o Dizziness
o Nervousness/anxiety
o Facial flushing
Differential diagnosis10:
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Anxiety disorder
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Sleep apnea
Cocaine-induced cardiomyopathy
Hypertrophic cardiomyopathy
Congestive heart failure and pulmonary edema
Primary hyperaldosteronism
Hyperthyroidism/thyroid storm
Myocardial infarction
Stroke
Drug toxicity (amphetamine, phencyclidine)
Clinical pearls and diagnostic tools:
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Alcohol use4, obesity, physical inactivity, vitamin D deficiency5, and excess sodium intake are all
factors that increase risk of developing hypertension
More common and often more severe in black patients6
Hypertension is the major risk factor for premature cardiovascular disease. It is more common
than tobacco use, DM, and dyslipidemia7.
Major complications of untreated or uncontrolled HTN include: myocardial infarction,
intracerebral hemorrhage, left ventricular hypertrophy with associated enhanced incidence of
congestive heart failure, chronic kidney disease/ end stage renal failure
OMM Integration: Many hypertensive patients, despite pharmacologic therapy, are inadequately
controlled. This may be due to a number of factors including noncompliance and lack of adherence to
long-term therapy, especially when patients are asymptomatic3. Other potential reasons for poor control
include limited access to healthcare and adverse reactions to antihypertensive agents. Osteopathic
Manipulative Therapy (OMT) can be an important tool in the arsenal to achieve blood pressure control,
especially in addition to pharmacotherapeutic agents.
While the pathogenesis of essential hypertension is incompletely understood, several factors have
been implicated. Increased sympathetic neural activity is one of the factors that can be targeted in using
OMT as treatment in addition to medications. OMT can be used to normalize the sympathetic outflow and
remove restriction to the parasympathetic nervous system. Sympathetic innervation to the heart is
through the stellate ganglia from T1-T5. The effect of sympathetic activity on the peripheral circulation is
vasoconstriction, and an increase in total peripheral resistance1. Another consideration in treatment of
hypertensive patients with OMM is targeting the kidneys and adrenals, which both play a role in
maintenance of BP.
Many different osteopathic techniques can be employed to normalize the autonomic nervous
system (ANS). In a study done by Roman Schneider, cranio-sacral treatment was performed on patients
who were monitored for the effects of OMT on the ANS. The results of blood pressure regulation on the
subjects who received OMT showed a decrease of 16.8% in systolic mean value and 10.3% decrease in
the diastolic mean value versus the control group. This study demonstrates there is an effect on balancing
the ANS, which indicated a shift from the sympathetic to parasympathetic control1.
Henley et al showed that treating patients with cervical myofascial can produce a strong enough
vagal response to overcome sympathetic tone2. Normalizing sympathetic tone can aid in reducing blood
pressure, since the overall effect of sympathetic innervation on the circulation is vasoconstriction and
increased TPR.
Osteopathic Structural Examination: A short-term study done by Johnston and Kelso showed there is
an association between somatic dysfunction and the regulation of blood pressure. A specific pattern of
segmental motion dysfunction was found at C6T2T6 using a standardized palpatory examination. This
pattern was present repeatedly in a statistically significant number of subjects with a history of HTN3.
Other areas of somatic dysfunction that should be considered in patients with HTN include
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Cranial Vault, examination of the CRI
Occipital-atlantal joint – Vagal control of parasympathetic input to the heart
Cervical Spine
Thoracic Outlet
Thoracic spine
Ribs
Chapman’s Points to the kidneys (T10-T11) and adrenals (T11-T12)
Possible Treatments Options:
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Rib Raising 8
Cranio-sacral membrane and fluid balancing 1
C2-C3 9
Cervical myofascial 9
Atlas adjustment 9
CV4 8
Parietal lift 8
Posterior Chapman’s points to the adrenals (T11-T12)8
Thoracolumbar junction 8
Evidence Based Medicine Articles
1. Schneider, Roman. “The effect of cranial-sacral membrane and fluid balance technique on the
autonomic nervous system using pulse rate, breathing frequency and blood pressure as
indicators” 2006. http://www.osteopathic-research.com/paper_pdf/SchneiderRoman.pdf
2. Henley, C., Ivins, D., Mills, M., Wen, F., & Benjamin, B. (2008). Osteopathic manipulative
treatment and its relationship to autonomic nervous system activity as demonstrated by heart
rate variability: a repeated measures study. Osteopath Med Prim Care, 10.1186(1750),
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18534024
3. Johnston, W., Kelso, A., & Babcock, H. (1995). Changes in presence of a segmental
dysfunction pattern associated with hypertension:part 1. a short term longitudinal study.
JAOA, 95(4), Retrieved from http://www.jaoa.org/content/95/4/243.full.pdf
Citations:
1. Egan BM, Zhao Y, Axon RN. “US trends in prevalence, awareness, treatment, and control of
hypertension” 1988-2008. JAMA 2010; 303:2043.
2. James PA, Oparil S, Carter BL, et al. 2014 “Evidence-based guideline for the management of
high blood pressure in adults: report from the panel members appointed to the Eighth Joint
National Committee (JNC 8)”. JAMA 2014; 311:507.
3. Wang TJ, Vasan RS. “Epidemiology of uncontrolled hypertension in the United States”.
Circulation 2005; 112:1651.
4. Ronksley PE, Brien SE, Turner BJ, et al. “Association of alcohol consumption with selected
cardiovascular disease outcomes: a systematic review and meta-analysis.” BMJ 2011;
342:d671.
5. Larsen T, Mose FH, Bech JN, et al. “Effect of cholecalciferol supplementation during winter
months in patients with hypertension: a randomized, placebo-controlled trial”. Am J
Hypertens 2012; 25:1215.
6. Carson AP, Howard G, Burke GL, et al. “Ethnic differences in hypertension incidence among
middle-aged and older adults: the multi-ethnic study of atherosclerosis”. Hypertension 2011;
57:1101.
7. de Simone G, Devereux RB, Chinali M, et al. “Risk factors for arterial hypertension in adults
with initial optimal blood pressure: the Strong Heart Study”. Hypertension 2006; 47:162.
8. Kuchera, M.L., Kuchera, W.A. (1994). Osteopathic Considerations in Systemic Dysfunction.
(2.Auflage), Columbus, OH: Greyden Press.
9. Downing, J. (1913-1914). Observations on effect of osteopathic treatment on blood pressure.
Journal of the American Osteopathic Association, 13, Retrieved from
http://books.google.com/books?id=edgVAQAAIAAJ&pg=PA257&lpg=PA257&dq=Observa
tions on effect of osteopathic treatment on blood pressure downing&source=bl&ots=i28VrM_8H&sig=HNrJCGPNa97D0wnc81IVyL_tys&hl=en&sa=X&ei=7fUUU9D_ONGdkQf3kIHYAQ&ved=0CC
YQ6AEwAA
10. http://www.mayoclinic.org/diseases-conditions/secondary-hypertension/basics/causes/con20033994