Part 1: Holes in the Paradigm

3/9/09

     Somatic dysfunction has been explicitly but broadly defined by The Educational Council on Osteopathic Principles (ECOP) of the American Association of Colleges of Osteopathic Medicine. This collaborative evolutionary work has served to legitimize a wide range of Osteopathic therapeutic models and techniques. Some of the things it does not address are:

  1. Frequency;  prevalence or incidence.
  2. Reversability.
  3. Intensity.
  4. Functional ROM < Physiologic ROM < Anatomic Range of Motion

     We propose the following Grade system:

     Grade 1 is the most frequent grade of somatic dysfunction. It tends to present as a relative asymmetry of motion within the Functional Range of Motion. It is fully reversible and the least intense; tender points are often latent, or conscious pain is intermittent. Cranial, MyoFascial Release, Balanced Ligamentous Tension and Counterstrain are effective treatment styles.

     Grade 2 somatic dysfunction implies a loss of FROM up to the Physiologic ROM. In axial joints one of the facets may be stuck; release produces a cavitation sound that is audible to the patient and the physician, as with Type I and Type II somatic dysfunctions. Articular joints feel stuck or tight, and release can also produce cavitation sounds. It is mostly reversible. It is less often latent, more often acute or constant. Based on published back pain studies  , its incidence is ≥ 5?% of the population per year.  It is described by three orthogonal vectors of Flexion/Extension, Sibebending and Rotation. Muscle Energy and HVLA are added effective treatment styles.

     In Grade 3 somatic dysfunction, joints are pushed past the Physiologic ROM up to and sometimes beyond the Anatomic ROM. There is some tangible translation of the joint beyond the Physiologic ROM. It is most commonly found as Bilateral compression of a joint, with the gradual accumulation of degenerative disc and joint changes that tend to accumulate with age and are loosely described as osteoarthritis. Other clear examples are spondylolysthesis and laterolysthesis. Reversability is sometimes possible, but much less frequently so. Pain is typically chronic, latent and low grade; commonly the body responds reflexively using descending inhibitory pathways to supress pain creating an  often ignorable chronic pain.  Incidence and prevalence increase with age, obesity and chronicity of vitamins C and D deficiency. Treatment sequence becomes critical, and patient’s state of mind and their physiologic reserve play larger parts in the rehabilitation process. Triggerpoint injections may facilitate recovery of lost range of motion due to translation; prolotherapy (sclerotherapy, platelet rich plasma regenerative therapy) may facilitate the strengthening and tightening of chronically lax joints.  

     Typically,constellations of somatic dysfunction include Grade I and Grade II somatic dysfunctions in people under 40, and Grade III, II and I constellations in persons over 40, that reflect or run counterpoint to the gravity powered patterns of scoliosis and leg length inequality.

Parts 2 - 4: Four discontinuities in the Osteopathic paradigm

2/28/09

     The vertebral unit used by Fryette to describe axial articular somatic dysfunction is defined with regard to the vertebrae directly below it; so a thoracic vertebrae in the lower  middle of a large type I scoliotic convexity to the Right would be defined as Sidebending the Left even though the position of that vertebrae in the universal standing position might well be sidebent to the Right according to absolute coordinates.

     The description of sacral sidebending is in absolute coordinates, not relative to the adjacent structures below. Most Osteopathic descriptions of sacral motion describe sacral flexion as a nutation except for the Cranial model which describes sacral flexion as a counternutation.

     In thoracic Type II extension mechanics, e.g., T12E RSlt, Sidebending and Rotation occur to the named side and are exaggerated during flexion; the closed restricted lower  facet is on the named side. In T12F RSlt, the Right Lower facet remains opened  during extension motion testing, contralateral to the named side, while quite commonly the T11 Right lower facet remains in a relatively Closed position during extension testing of T12F RSlt. The description of Type II somatic dysfunction at one vertebral level excludes its effect on the vertebrae immediately above it, and we miss the Janus like effect of a dysfunction along a semi-rigid rod above and below the point of desription.

     To say that a Type II somatic dysfunction "occurs when the spine or region is in the non-neutral position" (p19) is NOT to say that those positional characteristics carry over into the neutral position. In fact the definition of "neutral" is circular and has only a relative meaning.

     In our case of T12F RSlt in the neutral position, T11 may well conform to T12 adopting a similar congruent position, but it would be described as SB right and Rot Lt fitting the description of Type I mechanics. The convention whereby somatic dysfunction of one spinal segment is defined only with regard to the segment below it obscures the mechanics of Type II flexion somatic dysfunction.

     On the planet Beetlejuice, a more ideal osteopathic system would define the vertebral unit of somatic dysfunction as the relation of the vertebral unit to the structure immediately below and above it.

 

Part 6: Holes in the Paradigm

     With regard to the rib lab exercises, the apparent hole in the paradigm was that of the "elevated 1st rib". We managed to retain coherency using the pump handle paradigm to explain the depressed 1st rib (defined as depression of the most anterior superior part), but extending it to the three treatments[1] for an "elevated 1st rib" was problematic.

     What the techniques actually treat, and what we think of as an elevated 1st Rib is one where some posterior aspect is elevated, but this would be a natural counterpart to a depressed 1st Rib in the pump handle paradigm. Consider the following:

  1. The first rib is atypical.
  2. The tubercle is larger, longer and flatter.
  3. The head of the first rib has only one facet, on the first thoracic vertebra.
  4. Unlike the typical rib costochondral joints, the first rib actually forms a syndesmosis with the manubrium[2] In Grant's Atlas[3] there is no synovial joint between the sternum and the first rib as there are with the typical true ribs 2 thru 5.

     Above the first rib anterior attachment are sternoclavicular ligaments surrounding the synovial sternoclavicular joint. The cumulative effect is that outside of trauma, the anterior first rib can respond to movements of the thoracic spine and rib cage around it, but probably does not initiate movement: "its movement is in unison with the sternum".[4] The posterior aspect on the other hand has two individual synovial joints capable of articular somatic dysfunction. Bearing in mind our arborial past, the costotransverse joint must provide for the widest range of pump handle motion, as the 1st Rib is the major, and only articular attachment of the upper extremity to the axial skeleton. We would expect that Type I and II somatic dysfunction of the first thoracic vertebra would have an enhanced effect on the costotransverse joint, the elevated tubercle of which we can refer to as an "elevated 1st Rib". This understanding makes the admonition to treat thoracic somatic dysfunction before rib dysfunction all the more practical.

     It is interesting to note that Fryette (~’54) arrives at the same conclusion (bottom of pg 135, attached) through a similar line of logic. The Kimberly terminology seems to be from a middle period of Osteopathic thinking and terminology. I would be interested in any thoughts you may have on this subject.

 

John H. Juhl, D.O.

 

 

[1] Kimberly Paul E, Outline of Osteopathic Procedures, The Kimberly Manual 2006, Walsworth Publishing Company, Marceline Missouri, pp 135-38.

[2] Greenman, Phillip E, Principles of Manual Medicine 2nd Ed, Williams & Wilkins, Baltimore,1996, p 240.

[3] Anderson James E, Grant’s Atlas of Anatomy 8th Ed., Williams and Wilkins, Baltimore, 1983.

[4] Fryette, Harrison H, Principles of Osteopathic Technic, Harry L Chiles Memorial Publ., AAO, Carmel, CA, 1966 2nd Ed.