Gathering place for osteopaths
The Facilitated Segment–Fact or Fiction?
The idea of what constitutes a facilitated spinal segment (FSS), has dominated osteopathic and chiropractic theory(Gatterman, 2004), for over seventy years. It has been at the heart of osteopathic teaching practice and used in clinical diagnosis, to rationalise the need to treat different musculoskeletal and visceral conditions.
This important subject has rarely been criticized within the profession. There have been many critics outwith, including Mirtz & Perle (2011). (The existence of what is commonly described as a facilitated segment comprises: localised sensory hypersensitivity of segmental soft tissue to palpation; local vasomotor changes; reduced vertebral motility of active and passive ranges; suggested visceral links via the ANS. Its relevance to osteopathic medicine should perhaps be re-examined in contrast to alternative biomedical models, which dispute the reality of the FSS.
In Leon Chaitow's book Modern Neuromuscular Techniques (2002), he discussed Beal's (1985), work. These are some extracts:
One 5-year study involving more than 5000 hospitalized patients (Beal, 1985), concluded that most visceral disease appeared to influence more than one spinal region, and that the number of spinal segments involved seemed to be related to the duration of the disease. Beal, described this phenomenon as resulting from afferent stimuli, arising from dysfunction of a visceral nature. The reflex is initiated by afferent impulses arising from visceral receptors, which are transmitted to the dorsal horn of the spinal cord, where they synapse with interconnecting neurons. The stimuli are then conveyed to sympathetic and motor efferent impulses, resulting in changes in the somatic tissues, such as skeletal muscle, skin and blood vessels. Beal (1985) notes that, when the voluminous research into segmental associations with organ dysfunction is compounded, three distinct groups of visceral involvement are found relating to particular sites:
1. T1-T5: heart and lungs
2. T5-T10: oesophagus, stomach, small intestine, liver, gall bladder, spleen, pancreas and adrenals
3. T10-L2: large bowel, appendix, kidney, ureter, adrenal medulla, testes, ovaries, urinary bladder, prostate gland, uterus.
Beal suggests that the diagnosis of a paraspinal viscerosomatic reflex be based on two or more adjacent spinal segments showing evidence of somatic dysfunction, and being located within the specific autonomic reflex area. There should be deep confluent spinal muscle splinting, and resistance to segmental joint motion. Skin and subcutaneous tissue changes that are consistent with the acuteness or chronicity of the reflex should be noted.
Specific identification of the origin of the reflex is, he suggests, is difficult.
The usefulness of understanding the nature of these complex reflexes can involve clinical frustration when localised soft tissue dysfunction fails to respond to treatment. Suspicion may then be alertedto possible underlying visceral activity maintaining the muscular or joint dysfunction (Korr, 1975).
Early in my own training at BNOA (now BCOM), I was taught the clinical usefulness of what is termed the facilitated segment, which is defined as an abnormal reflex pattern. This is probably synonymous to the 'subluxations', commonly identified by chiropractors. These phenomena have been extensively described, and the physiology that underpins their characteristics well documented in both orthodox as well as chiropractic and osteopathic literature (Hoag, 1969; DiGiovanni, 2005).
Viscerogenic Reflex. A reflex which is produced by stimuli which arise in internal viscera.
Visceromotor Reflex. A reflex commonly recognized as a spasm of muscles, produced by afferent impulses which come from an inflamed organ and go to the spinal cord over the sympathetic, sensory nerves and there mediate with the spinal nerves which supply the skeletal muscles.
Viscerosensory Reflex. A reflex usually recognized as pain in the superficial tissues skin, subcutaneous tissue, and muscles, which is produced by inflammation of internal viscera. The stimulus passes to the cord over sensory sympathetic neurons and is there transferred to adjacent cell bodies which give origin to the spinal sensory nerves which supply the superficial soft tissues.
Viscerotrophic Reflex. A degeneration of the skin, subcutaneous tissue and muscles resulting from a stimulus which is due to inflammation in internal viscera. The stimulus passes from the inflamed organ over the sensory sympathetic neurons to the cord and is there transferred to the spinal sensory and motor nerves which supply the superficial tissues. The viscerotrophic reflex results from long-continued nerve stimulation.
These descriptions are taken from Marion Pottenger's classic (1919) Symptoms of Visceral Disease, and illustrate somatic structural links to other somatic or visceral tissues. Many other more recent texts discuss the same material, but interestingly (most other reference points in human physiology have rapidly increased in number and scope), it has remained standard over the last 70 years or so. Pottenger could well be described as the father of Functional or Integrated Medicine (Nicolle & Woodriff Beirne, 2010), and predated other innovators such as Roger Williams (Biological Individuality), by a generation. (Anyone not acquainted with Pottenger’s work is strongly recommended to read his interpretation of symptom presentation and its significance–you will not be disappointed). Many DO’s believe these reflex patterns are identifiable in daily practice, being used to locate a patient’s potential and actual spinal weakness and mechanical dysfunction. This diagnostic method is not done in isolation. It is included together within the patient's overall case history, functional assessment and physical presentation.
So, friends of the forum, does the FSS exist, or is it an illusion?
References
Beal, M., (1985), Viscerosomatic reflexes: a review. Journal American Osteopathic Association 85(12):786-801
Chaitow, L., (2002), Modern Neuromuscular Techniques (2nd edition), Elsevier: London/Edinburgh
DiGiovanna, E., (2005), An Osteopathic Approach to Diagnosis and Treatment (3rd edition), Lippencott, Williams & Wilkins:Philadelphia.
Gatterman, M.,(2004), Foundations of Chiropractic: Subluxation (2nd edition), Elsevier Mosby
Hoag, J., Cole, W., & Bradford, S., (1969), Osteopathic Medicine, McGraw Hill:New York.
Korr, I., (1975), Journal of the American Osteopathic Association (JAOA), Vol. 74, March 1975.
Mirtz, T., Perle, S. (2011), The prevalence of the term subluxation in North American English-Language Doctor of Chiropractic Programs Chiropractic & Manual Therapies 2011, 19:14
Nicolle,L., Woodriff Beirne, A.,( 2010), Biochemical Imbalances in Disease-A Practitioners Handbook, Singing Dragon Publishers
Pottenger, M., (1919), Symptoms of Visceral Disease, Mosby: St. Louis
Tags: ., Functional Medicine, Integrative Medicine, Marion Pottinger, facilitated segment, osteopathic philosophy, viscerosomatic reflexes
Replies to This Discussion
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Permalink Reply by Quatermass on -
Three telegraphic observations (which will remain unreferenced!):-
1) Observable signs of a localised alarm response, like any other physiological abnormality, may have complex multifactorial aetiology, and complex, interactive repercussions.
2) Reflexly, the viscerosomatic direction is much more facilitated in pathophysiology than is the somatovisceral direction.
3) Never forget the overarching modulatory influence of the higher centres!
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Permalink Reply by Hume O'Rous on -
Thanks for your reply.
1) Observable signs of a localised alarm response, like any other physiological abnormality, may have complex multifactorial aetiology, and complex, interactive repercussions.
Aren't all cellular reactions 'genera'l rather than 'local' in complex multi-cellular organisms?
2) Reflexly, the viscerosomatic direction is much more facilitated in pathophysiology than is the somatovisceral direction.
How do you know this? Where does immune function influence your understanding of it all?
3) Never forget the overarching modulatory influence of the higher centres!
What do you mean?
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Permalink Reply by Quatermass on
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(1) Yes and no. If you break your large toe there are physiological checks to the extent of the general reaction to stop you dying, for example, of acute cerebral inflammation! The theory of "facilitated segments" surely derives from the common observation of local responses, e.g. paraspinal areas of hyperaemic skin reaction to stimulation.
(2) Sorry, I should have expressed myself differently - I don't know it, I just believe it.
Firstly, it seems to me that viscerosomatic reflexes have been well documented, while firm demonstration/confirmation of the pathophysiological importance of somatovisceral reflexes remains elusive.
Secondly, I think from an evolutionary perspective it makes sense that vital organ function is maintained and unaltered by the repercussions of accumulated physical trauma on the musculoskeletal system.
I am not saying I do not believe in somatovisceral reflexes, just that again, I think there are physiological checks to the extent and significance of their influence, much more so than with viscerosomatic ones.
(3) I mean that pure short-arc reflexes of this kind probably do not exist. Afferent signals enter the spinal cord. Information goes upstairs and other information comes downstairs to produce a response. Upstairs lots of information from other sources determines the signals going downstairs. For example, information regarding nociception from other sources, the sum nociceptive load, allostatic demands of other sorts, the sum allostatic load. The psychological milieu in which this processing takes place is of the utmost importance: emotions, mood, attitudes, thoughts, beliefs, attentional and cognitive patterns. All this makes the difference between acute activation (local and/or general) and water off a duck's back.
My Dry Bones said:Thanks for your reply.
1) Observable signs of a localised alarm response, like any other physiological abnormality, may have complex multifactorial aetiology, and complex, interactive repercussions.
Aren't all cellular reactions 'genera'l rather than 'local' in complex multi-cellular organisms?
2) Reflexly, the viscerosomatic direction is much more facilitated in pathophysiology than is the somatovisceral direction.
How do you know this? Where does immune function influence your understanding of it all?
3) Never forget the overarching modulatory influence of the higher centres!
What do you mean?
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Permalink Reply by Small Fry on -
Well a broken toe immediately causes a total shift in the attention of the CNS. The gross postural changes are visible to the observer, the sufferer feels immediate involuntary tensioning of both voluntary and involuntary muscle, and it's likely to wipe the smile off the face very quickly. The organs are hardly spared this influence - there is an immediate alteration of the balance of circulation between deep and superficial, and lunch is not high on the agenda at this point, in fact it may be harmful.
If anyone doubts that a somatic stimulus can alter the function of every cell in the body, pop round and I'll kick you in the shin.
But what about the segmental or specific effect on a viscus? (Even if we ignore the local changes in blood supply - and their corresponding DEEP reflection - as viscus). Well, Burns, Korr, Denslow etc produced a wealth of work on this throughout most of the 20th century, and even by today's standards it's impressive in its rigour. Specific visceral responses were observed in-vivo in conscious and unconsious dogs, guinea pigs, rabbits to specific spinal mechanical disturbance, and were not observed when specific nerves were cut. If you want to know how to reliably give a stomach ulcer to a dog, read Burns.
This is all poo-pooed by many of our colleagues, but how many have even read it? Certainly none - none - working in our current institutions have re-tested it for repeatability (although ethically this may be a good thing). So it is arbitrarily dismissed because it is 'old work'. But what has actually changed about the dog nervous system (or ours) in 40 years?
We do not have so much as an up-to-date systematic review of the literature, just some wafty dismissal, which isn't good enough.
We pin too much on this dismissal because it suits us. This is lazy thinking at institutional level, most of us have no choice but to take it at face value. Yet there are those in clinic for whom this 'out of date' work is bread and butter. As far as I am concerned, this is a case of 'those who say it can't be done should catch up with those who are doing it'.
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Permalink Reply by Quatermass on
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Small Fry said:
"Well a broken toe immediately causes a total shift in the attention of the CNS."
Of course it does. The point is, responses at different levels and in different domains are different, depending on proximity, functional roles and priorities. So the answer to My Dry Bones' question: "Aren't all cellular reactions 'genera'l rather than 'local' in complex multi-cellular organisms?" is "no, they are not". I am a bit bemused by this. My Dry Bones introduced a discussion about the facilitated segment. I called it a localised alarm response, which is how I understand it. Shall I sacrifice brevity for pedantry by calling it an "integrated response with specific characteristics manifest locally"? We were, after all, discussing segmental phenomena, which by definition must display characteristics specific to their segments at the time they occur. Can my terminology really be so controversial?!
"Specific visceral responses were observed in-vivo in conscious and unconsious dogs, guinea pigs, rabbits to specific spinal mechanical disturbance, and were not observed when specific nerves were cut."
For the record, let me just point out something I said before: "I am not saying I do not believe in somatovisceral reflexes"; and I have read Burns, Denslow, Korr.
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Permalink Reply by Small Fry on
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You are right. Somatic afferents are just one field of influence on disease. Similarly, the influences on the soma are so many and varied that in treatment we need to take into account the entire environment of the problem.
For these two reasons and many others, specific treatment is a doomed approach, but one that has been tried time and again.
Naive practitioners have hoped that finding the right combination of segments and hitting them will cure a problem, and they are nearly always disappointed. What evidence we have of effectiveness is obtained by extreme narrowing of outcome measures until an effect appears - segmental back pain relieved for 2 days in healthy patients age 26-28 and no long-term distant effects taken into account.
In practice, somatic pain is a staging post between the many things irritating the body, and the many outcomes that can arise. In electing to become modern osteopaths, we have chosen this particular point of convergence as the one thing we all agree on. Back pain is the only thing that currently defines us all.
And because the role of structural alteration in disease is so commonly overlooked, this is what Still focussed on a lot. But if our primary interest is in helping our patients find health then we should be interested in anything whatsoever that can obstruct health, and I'm sure Still would agree.
However, while disease may normally be caused by many factors, one single overwhelming factor may be sufficient, eg injury, poisoning, shock, blockage, deficiency etc. What our 20th century research points to is that segmental lesioning IS sufficient on its own to cause disease in a lab context, even though we must acknowledge the reality in life is usually more complicated. And we should never infer that specific segmental treatment is the cure; that approach seems to have failed.
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Permalink Reply by Hume O'Rous on
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One suggestion may be of the facilitated segment is that it has an academic value, but little clinical application?
By isolating one segmental level and studying it (in a sense), outside its 'real world' existence, are we not suggesting that fragmentising cells makes little difference to their adaptative function? Isn't the entire body's capacity to exist greater than the sum of its parts.....
Another thing: I asked for your further ideas on....
2) Reflexly, the viscerosomatic direction is much more facilitated in pathophysiology than is the somatovisceral direction.
How do you know this? Where does immune function influence your understanding of it all?
3) Never forget the overarching modulatory influence of the higher centres!
What do you mean?
Any thoughts?
Quatermass said:Small Fry said:
"Well a broken toe immediately causes a total shift in the attention of the CNS."
Of course it does. The point is, responses at different levels and in different domains are different, depending on proximity, functional roles and priorities. So the answer to My Dry Bones' question: "Aren't all cellular reactions 'genera'l rather than 'local' in complex multi-cellular organisms?" is "no, they are not". I am a bit bemused by this. My Dry Bones introduced a discussion about the facilitated segment. I called it a localised alarm response, which is how I understand it. Shall I sacrifice brevity for pedantry by calling it an "integrated response with specific characteristics manifest locally"? We were, after all, discussing segmental phenomena, which by definition must display characteristics specific to their segments at the time they occur. Can my terminology really be so controversial?!
"Specific visceral responses were observed in-vivo in conscious and unconsious dogs, guinea pigs, rabbits to specific spinal mechanical disturbance, and were not observed when specific nerves were cut."
For the record, let me just point out something I said before: "I am not saying I do not believe in somatovisceral reflexes"; and I have read Burns, Denslow, Korr.
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Permalink Reply by Quatermass on
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Any facilitated segment exists within a context that encompasses the whole organism and its environmental and social relations. Disturbance is likely to be multifaceted including different spheres within this context, each of which will contain "concentrations" analogous to any concentrated areas which draw the attention in the body (like the facilitated segment). I agree with Small Fry that one must look to and address the whole context to help the patient in a deep and long lasting way. Personally, I also like to address "concentrations", or specifics if you like, as they can have powerful maintaining factors in vicious cycles, and I see no harm in it if one doesn't become fixated on them to the exclusion of the rest. So to me, evidence of physiological activation whether locally, regionally or globally is clinically valuable.
You write:
Another thing: I asked for your further ideas on....
2) Reflexly, the viscerosomatic direction is much more facilitated in pathophysiology than is the somatovisceral direction.
How do you know this? Where does immune function influence your understanding of it all?
3) Never forget the overarching modulatory influence of the higher centres!
What do you mean?
If you scroll back, you'll see that I answered points (2) and (3), except your question about immune function.
Uhm... I'm not sure what you're getting at really. Obviously it is part the network of communication which controls our physiology along with the psyche, neural function, and hormonal responses. But immunology is not a forte of mine. Maybe I haven't considered it deeply enough. Immune function is amazingly complex and so I don't think generalised answers would be satisfactory. I think its functional relationship to states of physiological activation probably depends on the nature, intensity and duration of the "stressor" agent(s). Can you give me a clue about where you want to go?
My Dry Bones said:One suggestion may be of the facilitated segment is that it has an academic value, but little clinical application?
By isolating one segmental level and studying it (in a sense), outside its 'real world' existence, are we not suggesting that fragmentising cells makes little difference to their adaptative function? Isn't the entire body's capacity to exist greater than the sum of its parts.....
Another thing: I asked for your further ideas on....
2) Reflexly, the viscerosomatic direction is much more facilitated in pathophysiology than is the somatovisceral direction.
How do you know this? Where does immune function influence your understanding of it all?
3) Never forget the overarching modulatory influence of the higher centres!
What do you mean?
Any thoughts?
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Permalink Reply by Small Fry on
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Of course specifics are important, but it took us a century to realise that this information alone does not help us to treat them. It is the context that creates the specific obstruction, and if context is maintained, then direct technique to the lesion creates a bigger problem for our patient. However, we may not recognise this bigger problem as related, so our conscience is clear, but more importantly, how will the patient be one year from now? (forget 20 minutes from now).
How often do we get asked the difference between a chiropractor and an osteopath? The answer I now give is that the chiropractors see the body as a collection of specifics joined together. We see the specific as a feature within the whole. It is fanciful to treat an isolated segment and expect the rest of the universe to de-rotate around it. Chiropractors have got it inside out, therefore I am an osteopath.
Medicine also believes if all the parts of a system are working, then the system will work. AT Still saw that quite the contrary, when the system is working properly, then the parts will have what they need. How else can you repair a liver? A disc? A mind? If the system is not supplying the needs of those elements? There is no other way.
Finally, taking the spine and its segments as an example, it is like a piece of string - twist it from both ends and kinks will form along its length (rib strain, facet lock, disc, scoliosis). To deal with these problems, we need to understand the pattern of the whole system, this is many times more important than the right technique for a 12th rib or whatever.
Untwist the string and the kinks take care of themselves, with perhaps a little local help at most. Go straight to the kink, and you put MORE strain into the area, not less. If we don't learn this, then four years at the BSO has been completely wasted.
Quatermass said:
Any facilitated segment exists within a context that encompasses the whole organism and its environmental and social relations. Disturbance is likely to be multifaceted including different spheres within this context, each of which will contain "concentrations" analogous to any concentrated areas which draw the attention in the body (like the facilitated segment). I agree with Small Fry that one must look to and address the whole context to help the patient in a deep and long lasting way. Personally, I also like to address "concentrations", or specifics if you like, as they can have powerful maintaining factors in vicious cycles, and I see no harm in it if one doesn't become fixated on them to the exclusion of the rest. So to me, evidence of physiological activation whether locally, regionally or globally is clinically valuable.
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Permalink Reply by Hume O'Rous on
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It's always problematic when a proposal is made across the board:
'Go straight to the kink, and you put MORE strain into the area, not less'. This approach doesn't produce results in all cases. I would go as far as to suggest that it doesn't work in most cases. It may work sometimes, but not for long.
Most patients attend osteopaths with pain as a primary presenting symptom (PPS), and to consider the spine and its function out with the biochemistry that underpins it, is missing a trick.
Mazur, et al.,(2006), in their paper 'Magnesium and the inflammatory response: Potential physiopathological implications,' writes:
Experimental magnesium deficiency in the rat induces after a few days a clinical infammatory syndrome characterized by leukocyte and macrophage activation, release of inflammatory cytokines and acute phase proteins, excessive production of free radicals. Increase in extracellular magnesium concentration, decreases inflammatory response while reduction in the extracellular magnesium results in cell activation. Because magnesium acts as a natural calcium antagonist, the molecular basis for inflammatory response is probably the result of modulation of intracellular calcium concentration. Magnesium deficiency induces a systemic stress response by activation of neuro endocrinological pathways. As nervous and immune systems interact bidirectionally, the roles of neuromediators have also been considered. Magnesium deficiency contributes to an exaggerated response to immune stress and oxidative stress is the consequence of the inflammatory response. Inflammation contributes to the pro-atherogenic changes in lipoprotein metabolism, endothelial dysfunction, thrombosis, hypertension and explains the aggravating effect of magnesium deficiency on the development of metabolic syndrome.
See attached file for entire paper.
I take from this, (and all the other voluminous research showing pain to be a highly complex issue with many potential mediators), that the manual approach is but one of many potential methods ....
Does the BSO really promote increasing the perceived mechanical factors when addressing spinal lesions, whilst ignoring all the other equally important ones? I'm sure they don't.
The only way that really works is a holistic (Jan Smuts, 1870-1950) approach. That's why we do CAM, and that's what they teach at BCOM. I hope.
Small Fry said:Of course specifics are important, but it took us a century to realise that this information alone does not help us to treat them. It is the context that creates the specific obstruction, and if context is maintained, then direct technique to the lesion creates a bigger problem for our patient. However, we may not recognise this bigger problem as related, so our conscience is clear, but more importantly, how will the patient be one year from now? (forget 20 minutes from now).
How often do we get asked the difference between a chiropractor and an osteopath? The answer I now give is that the chiropractors see the body as a collection of specifics joined together. We see the specific as a feature within the whole. It is fanciful to treat an isolated segment and expect the rest of the universe to de-rotate around it. Chiropractors have got it inside out, therefore I am an osteopath.
Medicine also believes if all the parts of a system are working, then the system will work. AT Still saw that quite the contrary, when the system is working properly, then the parts will have what they need. How else can you repair a liver? A disc? A mind? If the system is not supplying the needs of those elements? There is no other way.
Finally, taking the spine and its segments as an example, it is like a piece of string - twist it from both ends and kinks will form along its length (rib strain, facet lock, disc, scoliosis). To deal with these problems, we need to understand the pattern of the whole system, this is many times more important than the right technique for a 12th rib or whatever.
Untwist the string and the kinks take care of themselves, with perhaps a little local help at most. Go straight to the kink, and you put MORE strain into the area, not less. If we don't learn this, then four years at the BSO has been completely wasted.
Quatermass said:
Any facilitated segment exists within a context that encompasses the whole organism and its environmental and social relations. Disturbance is likely to be multifaceted including different spheres within this context, each of which will contain "concentrations" analogous to any concentrated areas which draw the attention in the body (like the facilitated segment). I agree with Small Fry that one must look to and address the whole context to help the patient in a deep and long lasting way. Personally, I also like to address "concentrations", or specifics if you like, as they can have powerful maintaining factors in vicious cycles, and I see no harm in it if one doesn't become fixated on them to the exclusion of the rest. So to me, evidence of physiological activation whether locally, regionally or globally is clinically valuable.
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Magnesium+Inflamation.pdf, 314 KB
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© 2012 Created by Ronan O'Brien.
