Somatic dysfunction

In osteopathic medicine and osteopathy, somatic dysfunction is the impaired or altered function of bodily structures (most often of the musculoskeletal system, nervous system, or lymphatic system) treated by osteopathic manual therapy (OMT). Though a distinct concept, it is related to (and perhaps the forerunner) of the chiropractic idea of vertebral subluxation.

Diagnosis

Somatic dysfunction is diagnosed by physical examination. The osteopathic physician looks for symptoms commonly represented by the mnemonic device "TART" (Tissue texture change, Asymmetry, Restriction, and Tenderness). The physician uses techniques such as layer-by-layer palpation and intersegmental range of motion testing to make the diagnosis. Diagnosis usually requires only the use of the physician's hands and fingertips, though instruments such as a goniometer can be used to detect a diminished range of motion.

The hallmark of a musculoskeletal somatic dysfunction diagnosis involves the detection of a "restrictive barrier" related the structure in question. The language of "barriers" refers to the point at which a structure cannot move further in a given direction. For example, a natural "physiologic barrier" of the arm represents the farthest that a person can naturally move their arm before it cannot be comfortably moved further. The "anatomic barrier," then, is how far the arm can be pushed or pulled by an outside force before the arm becomes physically injured. A "pathological" or "restrictive" barrier represents the shortened range of motion to which the arm is confined because of an injury, spasm, or some other somatic dysfunction. The goal of treatment, then, is to restore the arm's range of motion (or that of whatever structure is in question).

Other types of somatic dysfunctions may include occlusions or mutilations of vasculature or lymphatic vessels, which can impair cardiovascular or lymphatic circulation. This may also occur secondary to organ pathology, a factor which theoretically allows the detection of visceral dysfunction by examining surface structures. It is by this explanation that Chapman's Points are said to be used in identifying problems with deep tissue structures. A Chapman's Point is an area of bunched tissue or vasculature that is said to occur as a result of fluid backup or another dysfunction at a portion of the vasculature more proximal to a pathological organ. For example, damage to an organ such as the appendix may cause lymphatic back-up that produces a palpable nodule in distal lymphatic vessels near the tip of the 12th (floating) rib. By feeling for this Chapman's Point, the physician may be able to noninvasively detect appendicitis. The evidence for these points remains controversial, though some studies suggest modest sensitivity and specificity for their use in diagnosis .

Significance

The physical manifestation of somatic dysfunction is frequently associated reciprocally with visceral illness, generally related to the vertebral level associated with the organ in question. E.g., T-6 (the sixth thoracic vertebra) is associated with the stomach. Similarly, the resolution of either can aid in the resolution of the other. For example, an infection may be associated with edema (causing a tissue texture change). Lymphatic drainage aids in clearing the infection while, conversely, resolution of the infection causes clearing of associated edema. Thus the physician attempts to aid the resolution of visceral disease by eliminating its associated manifestation in the musculo-skeletal system. The two reflex effects just discussed are generally referred to as the somatovisceral and viscerosomatic reflexes, and these are routinely encountered in regular clinical work. What is perhaps of particular interest is that it does not matter if the spinal lesion was caused by nociceptic (pain) inpulses from the organ, or by biomechanical forces. The result is the same...a reciprocal neurological phenomenon between the viscus and the vertebra wherein the status of the vertebra has been altered, which will generally persist in the absence of treatment, and will create trouble unless treated.

When this "vicious cycle" is broken, by the application of osteopathic manipulation (or chiropractic adjustment), a return to normal physiological status, both in the spinal tissue and the organ tissue generally ensues, baring complications, such as the presence of major infection or significant physical trauma. The clinical picture will vary from patient to patient, naturally, but the phenomena discussed above are based on sound neurologial principles.

The founder of osteopathy, Dr. Andrew Still, held that spinal lesion effects were based on the compromise of vascular supply not on neurological effects. In recent years, most osteopathic physicians agree that neurological effects are primary, while vascular changes may play some part.

Research

Research in somatic dysfunction and the use of OMM has resulted in mixed conclusions. In a famous article published the New England Journal of Medicine in November 1999, researchers concluded that OMM and traditional drug therapy resulted in equivalent resolution of lower back pain in a nearly identical time frame. The difference was that those receiving OMM required less pharmaceutical intervention. The advantage of OMM was diminution of adverse drug reactions while the disadvantage was the greater amount of physician time required for each patient.

However, a meta-analysis of six randomized controlled trials of OMT that involved blinded assessments of low back pain in ambulatory settings found from computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and the Cochrane Central Register of Controlled Trials, found that OMT significantly reduces low back pain. It also concluded that the level of pain reduction is greater than expected from placebo effects alone and persists for at least three months.

Sources

• Ward, Robert (2003). Foundations for Osteopathic Medicine (2nd ed.). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-3497-5. 

• Leach, Robert (1986). The Chiropractic Theories: A Synopsis of Scientific Research (2nd ed.). Baltimore, MD: Williams & Wilkins. ISBN 0-683-04906-2. 

• Gatterman, Meridel I. (1995). Foundations of Chiropractic subluxation (2nd ed.). St. Louis, MO: Mosby-Year Book, Inc. ISBN 0-8151-3543-2. 

^ Kevin Washington, DO; Ronald Mosiello, DO; Michael Venditto, DO; John Simelaro, DO; Patrick Coughlin, PhD; William Thomas Crow, DO; Alexander Nicholas, DO. Presence of Chapman reflex points in Hospitalized Patients with Pneumonia. JAOA. Oct 2003.

Licciardone JC, Brimhall AK, King LN (2005). "Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials". BMC Musculoskelet Disord. 6: 43. doi:10.1186/1471-2474-6-43. PMC 1208896 Freely accessible. PMID 16080794. CS1 maint: Multiple names: authors list (link)