Reflection on a new paper to be published in IJOM

Somatic dysfunction:  An osteopathic conundrum

Gary Fryer

IJOM (2016)

I am something of a pedant in examining the literal origins of words.  This is a little bit jarring if you work in osteopathy, which sounds like it should be about diseases of bones.  Another phrase used extensively in my training was disappointing, not in that it had the “wrong” meaning, more in its lack of meaning.   “Somatic dysfunction” never had a ring of anything very much to me – the word, deconstructed, seemed to mean only that something in the body wasn’t working quite right.  It seemed more vague than its predecessor, “osteopathic lesion”, which had a poetic, substantial sound, albeit  reminiscent of dusty secondhand bookshops.   But I dutifully wrote the abbreviation “sd” in my notes for a while after graduating, and even used it as a standalone diagnosis as I had been taught. It seemed to imply that this was the bit of the spine that needed manipulating, or releasing, or normalising in some way.  I was never totally sure of the difference between that and a ‘facet lock’, but I thought I pretty much knew what one felt like.  It was a bit of the spine that felt to varying degrees stiff, resistant, or even puffy and sore.  People often had a few of them, some asymptomatic.

A link with the viscera

I had also been informed that it would be linked to substandard function, or pathology, of an associated organ e.g. people with hepatitis should have somatic dysfunction around T7-8.  I gathered that a problem in one would cause a problem in the other, whichever came first, and this is how our musculoskeletal system was linked to our general health, each able to affect the other for good or ill via the nerve roots.  According to which came first you could describe the link, (or even more confusingly, the “reflex”),  viscero-somatic or somato-visceral.  On entering practice, whenever I found a somatic dysfunction, I diligently enquired as to whether the associated organ was troubled.  Dozens of my low back pain patients endured thorough quizzing on their bowel movements and their urinary and reproductive health.  It wasn’t long before I stopped doing that (it hadn’t seemed to serve much purpose) and after a couple of years I had begun to write “stiff” instead of “sd”.  Now this often gets abbreviated further to a cross.  My notes are still littered with references to L2R x or C2L x, or just upper thoracic x.  I find this enormously useful, in keeping a record of areas that feel “locked” or “tight” or “restricted”, and I might add a descriptor: “p”, “tender” or “inflamed”, depending on the precise feel of it.  Without realising, I have relegated it to a mere finding relating to the spinal joints, to be noted along with hypertonic traps or shallow breathing or stiff sacrums, all of which together contribute to my understanding, familiarity and documenting of the terrain of that person’s body.

It’s the same as subluxation

I had realised at college that somatic dysfunction was the modern name for osteopathic lesion.  Being a poor student, I had only vaguely grasped that it comprised four characteristics, summed up in the mnemonic TART (tenderness, asymmetry, range of motion abnormality and tissue texture abnormality) but in practice to me it simply meant the bit of the spine that didn’t feel healthy and flexible. I’ve since learnt that some people regard hypermobile segments as somatically dysfunctional, but that’s new to me.  One of our lecturers was keen on someone called Irvin Korr, who was not an osteopath, but who had come up with a concept called the facilitated segment, back in the 40s and 50s, which seemed to mean the same sort of thing, but had a lot of dense neurological explanation behind it.

Enormously slow on the uptake, the thing I have only just realised,  is that the chiropractic concept of subluxation is basically the same thing.   They substitute the ‘tenderness’ for ‘pain’, and thus abbreviate the characteristics to PART.  Not so long ago I sent off a slightly huffy message to a physio who dared to associate osteopathy with subluxation.  I dissociated our profession ABSOLUTELY from the term, and explained sniffily that subluxation was nothing to do with osteopathy.  Yet now I have to eat my words as I have come to realise that osteopathic lesion = somatic dysfunction = facilitated segment = subluxation.  And here’s the rub.  Chiropractors are abandoning this concept in large numbers.   In 2010 the General Chiropractic Council issued the following statement:

The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.

Arguably they needed to do this more than we do for several reasons.  Subluxation is a slightly weird and distinctive word,  which sounds a bit pseudoscientific, which does have a real but different meaning in medicine,  and which is highly identified with the chiropractic profession and is its underlying rationale for treatment.  It is harder to mount an attack on somatic dysfunction.  By virtue of its blandness the phrase is totally forgettable, almost porous in fact.  It doesn’t sound particularly “quackish”, and has a less prominent role in the principles which underpin osteopathy and rationalise our treatment.

Gary Fryer questions the concept of somatic dysfunction

Gary Fryer is someone who is way ahead of me on this one.  Back in 1999 he was already writing an article claiming that the concept was out of date.  Then in 2003 he wrote a paper exploring the “manipulable spinal lesion”.  He was faced with the same confusing gaggle of labels that I have come across, and settled on “intervertebral dysfunction” as the most accurate and useful.  But 13 years on he evidently still feels that “somatic dysfunction”needs discussion, and has written a new paper titled “Somatic Dysfunction: the osteopathic conundrum”.  I imagine that anyone with as many results as he has in the IJOM search engine has chosen words with care, so it seems he regards somatic dysfunction as a “a confusing and difficult problem or question”.  (Back in the 16th century conundrum was a term of abuse for a crank or pedant. Make of that what you will.)

Fryer questions whether the model many of us learnt at undergraduate level is accurate, useful or relevant to life in practice today.  The crucial question is, as he puts it, whether it is

a useful, real clinical entity, or an anachronistic, obsolete concept from the earliest 20th century..?

Fryer runs through a few possible causes of the findings which lead us to diagnose somatic dysfunction.  There could be facet joint injury, synovial fold entrapment, articular connective tissue changes, disc degeneration or nociceptive-driven functional changes.  No conclusion is reached as the evidence is patchy.  He says that Korr’s idea of the facilitated segment has been largely superseded by the now established concept of central sensitization, in which increased afferents sensitize the dorsal horn neurons and facilitate nociceptive pathways.

After examining the research, he suggests we stop thinking of somatic dysfunction as a single entity, but realise that

numerous neurological or comorbid tissue factors are involved in a cycle of minor injury, degenerative change and resultant nociceptive and neurological consequences. 

He takes a look at what might cause the individual components.

TART – the somatic dysfunction deconstructed

• Tenderness and pain – could be caused by inflammation, degeneration or neuroplastic changes, nociceptive driven functional changes, peripheral sensitization.
• Asymmetry – there might be uneven tissue or motor changes, but asymmetry in landmarks can also be a red herring, and due to poor palpatory reliability fryer seems to suggest you can discount it
• Range of motion abnormality – from inflammatory changes, such as tissue fluid congestion, neurogenic inflammation, degenerative changes in the disc and facet joints, remodelling of capsule and connective tissues, neuroplastic changes in the dorsal horn and higher CNS
• Tissue Texture abnormality – inflammation/guarding, nociceptive driven functional changes.

note: not all of these are amenable to osteopathic treatment.

There is a place for somatic dysfunction in osteopathy

You might suspect that Fryer’s answer to the question (of whether we should throw this concept out) from all of this is yes, but you’d be wrong.

Fryer concludes that somatic dysfunction as a concept is useful as a broad model when using palpation to help clinical reasoning in a physical examination, but is of no use for formulating a diagnosis or describing findings to other practitioners.

So the answer to my question is no, not completely.  This is a useful concept, but maybe we need to think about how we use it a bit more.

Practical Recommendations

Fryer makes several suggestions for osteopaths to use in practice on the basis of this research

• Use “restricted motion” or “tenderness” as descriptors, because somatic dysfunction is too generic
• Don’t use somatic dysfunction in a written diagnosis
• Consider tissue, neurological and biopsychosocial factors in clinical reasoning
• Remember that diagnostic reliability is poor
• Remember that relevance to health or disease is not established
• Do not use the term somatic dysfunction (have I already said this?)
• Do not use language implying a bone is out of place with patients.  They might imagine something really wrong.  It is better to use motion restriction terminology.
• It would be interesting to find out how osteopaths use the concept in practice.
• We need to discuss this concept collectively as a profession.
• We can regard it as a useful model to help in our treatment.

 

Thanks for reading.

I believe that the full article will be published in IJOM, but it’s possible you can get a copy from Austin Plunkett at NCOR if you just can’t wait.

Osteopaths registered with the GOsC can access it via the ozone.

Monica Noy has written an excellent and scholarly piece on the osteopathic lesion here, which is apparently a term still widely used in Canada.  Can’t insert the link right now so please just cut and paste this address  https://www.monicanoy.com/osteopathic-lesion/