Somatic dysfunction

The term somatic dysfunction has been adopted by the osteopathic profession as a substitute for the older designations, osteopathic lesion or Still lesion. Somatic dysfunction is a condition of the musculoskeletal system that is recognized solely by the osteopathic profession and was first defined by Ira Rumney, D.O. The accepted definition in the Glossary of Osteopathic Terminology is as follows ... 

Somatic dysfunction is an impaired or altered function of related components of the somatic (body framework) system skeletal, arthrodial, and myo-fascial structures, and related vascular, lymphatic, and neural elements. 

Not all somatic lesions are somatic dysfunctions. Fractures, sprains, degenerative processes, and inflammatoiy processes ate not somatic dysfunctions. Fred Mitchell, Sr has given a useful observation "Implicit in the term somatie dysfunction is the notion that manipulation is appropriate, effective, and sufficient treatment for it"... 

A somatic dysfunction is a change in the normal functioning of a joint and is diagnosed by using specific criteria. These criteria of diagnosis may be remembered as the mnemonic T-A-R-T. 

T denotes tenderness. Although not an objec five finding, tenderness is produced during palpation of the tissues where it should not occur if there was no somatic dysfunction. 

Tissue textme changes vary somewhat between acute and chrorric somatic dysfunctions. In the spirral area, the changes tend to occm at the artic-ulatiorrs of the vertebrae, over the transverse processes, and over the spinous process. (Table 1)... 

On palpation of a joint involved in somatic dysfunction, the bony stmcture involved with the related joint will be formd to lie in an asymmetric position with respect to its normal position and to the position of bones contiguous to it. For example, the spinous process of a vertebra involved by somatic dysfunction may lie to one side of the line formed by the spinous processes of other vertebrae (which should he in the mid-line), or one transverse process rrray be more posterior than the ones superior arrd inferior to it and the corrtralateral one of the same vertebra. There may be an approxirrtation of one transverse process to the vertebra below while the opposite transverse process is separated from the one below it. A spinous process may be found... 

TABLE 4-1 FINDINGS IN ACUTE AND CHRONIC SOMATIC DYSFUNCTIONS... 

A joint involved by somatic dysfunction has a restricted range of motion. It is said to meet an abnormal "barrier" to motion. In the normally functioning joint, there are two barriers to motion (Fig. 4-1) ... 

In somatic dysfunction, a joint is restricted, or meets a restrictive barrier, in one or more planes of motion. Motion in the opposite direction will appear normal or relatively free. For example, a vertebra may move more freely into flexion but not be able to move all the way to the physiologic motion barrier of extension. Because... 

Restriction Neutral I FIG. 4-3 Somatic dysfunction with illustration of rotational restricti... 

Tenderness is the subjective sensation of pain or soreness that is reported by the patient in response to palpation of tissues by the physician. Tenderness is the most likely subjective finding. This sensation is almost always present in tissues surrounding a somatic dysfunction when the physician exerts no more than normal pressure. Pressing too firmly on soft tissues will almost always cause pain or tenderness. Pressure that should not normally cause pain will do so in tissues around a dysfunctional joint. 

It is important to be aware that because tenderness is a subjective finding, not all patients report it as such at the site of somatic dysfunction. Some other subjective sensation may be reported, or none at all may be reported. If the other criteria are present, they are sufficient for the diagnosis to be made. Tenderness and other subjective sensations indicate the likelihood of a problem but are not a diagnosis in and of themselves. The physician must use these findings as part of a larger picture when making the diagnosis of somatic dysfunction. 

A tenet of osteopathic medicine is that visceral reflexes to the soma are an important cause of somatic dysfunction and are of major diagnostic significance. Dysfunctions caused by these reflexes may be either acute or chronic. 

Acute viscerosomatic reflex dysfunctions are probably indistinguishable from any other acute somatic dysfunction. Chronic viscerosomatic dysfunctions have a few characteristics that may aid in differentiating them from somatic dysfunctions of other causes. 

Spinal somatic dysfunctions are classified as type I or type II dysfunctions. Type I dysfunctions follow Fryette s first principle of physiologic motion, which states that when the vertebrae are side-bent from a neutral position, rotation will occur in the opposite direction from the side-bending. These are group curves in the thoracic or lumbar regions involving more than... 

Type I and type II dysfunctions refer only to somatic dysfunctions in the thoracic and lumbar vertebrae because Fryette s principles only apply to these areas. However, in common usage, somatic dysfunctions in the typical cervical spine are often referred to as type II, Motion characteristics of the cervical region dictate that the typical cervical vertebrae side-bend and rotate toward the same side regardless of dysfunction or normal functioning. The distinction is the involvement of a flexion or extension component in the dysfunctional unit. 

Somatic dysfunctions in other areas of the body, such as the extremities, are still named for their freedom of motion. For example, the radial head may move anteriorly or posteriorly. If it moves freely posteriorly and is restricted in anterior motion, it is named a "posterior radial head." Likewise, when it moves freely in an anterior direction and is restricted in posterior motion, it is named an "anterior radial head."... 

Certain factors that predispose to the development of a somatic dysfunction are as follows ... 

Transitional areas (areas are especially prone to the development of somatic dysfunction)... 

The exact cause of somatic dysfunction is often debated. Some feel there is a true facet "locking." Most believe that muscle dysfunction is the major factor operating in the creation and/or maintenance of joint restrictions. Abnormal neural impulses, probably arising as a result of nociceptive activity and muscle spindle stretch responses, to the muscle, mediated through the muscle spindle, are probably the most significant cause of joint restriction and pain. Trauma (pain and force) is probably the major factor triggering an abnormal neural impulse. 

Mitchell F, Jr. Towards a definition of "somatic dysfunction." Osteopath Manual Medicine. 1979. 

Rumney I. The relevance of somatic dysfunction. Yearbook cf the American Academy f Osteopatl. Colorado Springs American Academy of Osteopathy, 1976. 

All bones that have freedom of movement will move on other bones at their respective joints. Several factors influence these motions. Knowledge of why, when, and how joint motion is induced is essential for the understanding of functional anatomy and for the diagnosis and treatment of osteopathic somatic dysfunctions. 

Articular stabihty is a cortrbined furrction of the shape of the joint, its hgamerrtous and muscular attachments, the strength of its capsule, and the balance of joint pressine to atmospheric pressure. Variation in any of these factors may contribute to somatic dysfunctions. 

The addition of force to joint motions may bring into play accessory motions. Accessory motions cannot be performed voluntarily they can only be activated against resistance or by an outside force. An example is long-axis traction on the phalangeal articulations. The restriction of small accessory motions is a major factor in the creation of somatic dysfunctions, especially in the articulations of appendages. 

The motion found at transitional interveitebral segmental levels is unpredictable. The additional stress created by changes in curve directions and the osseoirs shape variations create a climate for the development of somatic dysfunctions. 

The muscular attachments are commonly described as bilaterally mmetric. Unfortunately, this is not the case. Everyone has asymmetric development. This causes unstable lypotonic or lypertonic muscular development. Even simple spmal motions would become imbalanced if not for the synergistic or stabilizing assistance of other groups of muscles. All motions are susceptible to dysfunction because of these factors. The greater the imbalance, the greater the tendency for the development of somatic dysfunction. 

A diagnosis of somatic dysfunction, T4ESrRr, indicates that the motion of the foiuth thoracic vertebra on the fifth thoracic vertebra is greater in the directions of extension, right lateral flexion, and right rotation. These three coupled motions occur in three planes simultaneously on a helical axis of rotation (Fig. 5-12). The barriers to freedom of the described motion would all be in the opposite directions, but on a similar helical axis of rotation. 

For example, on palpation, the transverse process of the fourth thoracic vertebra is more prominent posteriorly on the right. Is it part of a somatic dysfunction complex involving three planes and six motions on a helical axis The vertebra is placed into a position of flexion. The right transverse process becomes more prominent posteriorly. It is assumed that this has happened because there is a barrier preserrt to the motion of flexion, and the vertebra is resporrding according to the rale of the effect of resistance on linear motion. That is, on meeting this flexion barrier, the vertebra turns away from and arotmd it in the direction of allowable freedom of motion, or right rotation. 

In essence, osteopathy is based on the concepts of stractnre and function. At its simplest interpretation, stracture is anaton and fimction is physiology. An understanding of plysiology and neurophysiology in particular is essential to un-deistanding the mechanisnis of somatic dysfunction and the logical apphcation of osteopathic manipulation. Some basic terminology needs to be clarified ... 

York Science Publishing, 1985. Korr IM. Somatic dysfunction. Osteopathic manipulative... 

Localized thoracic flattening may also be caused by chronic somatic dysfunction in two contiguous vertebrae. The examiner should look for a segmentally related visceral-somatic reflex pattern as the imderlying cause. Chronic visceral pathology can cause this condition. 

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