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 Small Fry on -
What decostelium does illustrate is the broad principle that there are no conditions that just attach themselves to an otherwise ideally functioning individual - everything is coming from somewhere and going to somewhere else, and exists within the physiology of the body. Florence NIghtingale recognised this, and observed painstakingly the progression of 'unrelated' diseases through various stages of a whole lifecycle towards recovery. She concluded 'there are no diseases, only disease conditions'.
People don't come to us with only one problem, there is always something else, and I tend not to treat them until I have dug far enough to find it. That's because I am always looking for a change in the overall pattern - this is what tells us what's really going on. Isolated expressions of the pattern are not enough to assess a case. When a symptom goes, we don't really know if the situation has got worse, or better, or if the individual is just expending more resources on coping with it at the expense of something else, unless we are aware of the whole pattern at all times.
Interestingly, many GPs will only allow you to bring one problem at each appointment, which must make it very hard to spot important patterns. There must be whole diseases that are very easily missed thanks to this policy. The joke is that if you break five fingers in a car door, you have to make five appointments. Presumably a fever, rash, stiff neck, headache and photophobia would take five different appointments also...
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Permalink Reply by Hume O'Rous on -
Please read the attached paper on the usefulness of the FS in a clinical setting. It's taken from BMJ Vol 291 6 July,1985.
Sixty two subjects were studied. Twenty five patients (myocardial infarction group) had had acute myocardial infarction confirmed clinically three to five days before transfer from the hospital's in- tensive care unit to the "step down" unit. Twenty two patients without known cardiovascular disease were selected to serve as controls.
The authors claim to have established that somatic changes in the thoracic dorsum can be detected by routine palpation of soft tissue in patients with acute myocardial infarction. These observations may provide the osteopath with a simple bedside manoeuvre to aid in diagnosing an acute myocardial infarction or predicting an impending myocardial infarction.
Anyone care to critique this work?
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Permalink Reply by dictostelium on -
No - first para not completely serious, and no, not an Osteopath.
So, why should a baby cry unconsolably for such a long period of time if not in distress? Single Aetiology or Multiple Aetiologies aside, the 3 hour definition is just a statement that "the baby cries - we don't know why - nobody can stop it, whatever they do - we think that if this happens for longer than 3 hours, something must be wrong, and we'll call it 'colic'... ". The term Colic is a throwback to the time when babies were thought to be non-human and insensitive because their neurology was not yet connected up in a way that made them capable of feeling pain the way that adults were thought to feel pain. Therefore the crying was not pain - because it couldn't be - it was something else. I am not ascribing colic to any one cause, merely saying that sometimes in some circumstances it is accompanied by an example of one form of facilitation. if you read the sentence carefully, you'll see that it's shot full of caveats and does not say that facilitation is a cause of colic.
indikate said:I am asuming the first paragraph is not entirely serious.
Infantile Colic is not what you attempt to describe. It is inconsolable crying of three hours or more in a 24 hour period and is of multiple aetiologies. To regard this as some segmental restriction is also trying to reduce a complex presentation down to the improbable. I notice that you are not an osteopath.
dictostelium said:The baby burps, wriggles and fills its nappy - description of thermodynamic conservation of energy. When you manage to calorify colic in, say Joules/Kg, then we can look for that slightly hotter poo and then scientifically measure the change in entropy.
Colic is essentially some form of pain. Babies are very fluid in their presence and in their internal experience, and they respond very quickly to touch "as if" they are fluid. And that kind of touch is also safe, whereas a manipulation is not recommended. If the baby curls up and screams it's probably got a painful belly. Babies with really bad head and neck aches scream and move their hands round their heads (when theyre old enough to move their arms - before that they just scream). And if it's the AO or upper cervical area that's causing the pain (either in the head/neck directly or in the belly via CN X), then maybe 60% of the time that is indicated by a spotty red patch of skin - a facilitated segment no less.
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Permalink Reply by dictostelium on
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A critique - well, first is why not also look at Phrenic nerve roots? Why stop at T1?
Other than that, the research is good - it shows a correlation between the state of the soft tissue in the upper thoracic area and heart disease.
I'm still not sure how chickens and eggs can be separated. Did the soft tissue abnormalities result from heart condition or did they cause it? Or a mixture of the two? The causality link is missing, and it's very difficult to set up any kind of causality. We treat, something happens, and we have no idea what illness we might have prevented by whatever action we took. Or caused for that matter. A retrospective health study of patients might give some idea on a statistical level, but there would be no way of tying that back to the individual.
Hume O'Rous said:Please read the attached paper on the usefulness of the FS in a clinical setting. It's taken from BMJ Vol 291 6 July,1985.
Sixty two subjects were studied. Twenty five patients (myocardial infarction group) had had acute myocardial infarction confirmed clinically three to five days before transfer from the hospital's in- tensive care unit to the "step down" unit. Twenty two patients without known cardiovascular disease were selected to serve as controls.
The authors claim to have established that somatic changes in the thoracic dorsum can be detected by routine palpation of soft tissue in patients with acute myocardial infarction. These observations may provide the osteopath with a simple bedside manoeuvre to aid in diagnosing an acute myocardial infarction or predicting an impending myocardial infarction.
Anyone care to critique this work?
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Permalink Reply by indikate on -
That's interesting I have never heard colic referenced like that, do you have any more info with links to this development in neurology
dictostelium said:So, why should a". The term Colic is a throwback to the time when babies were thought to be non-human and insensitive because their neurology was not yet connected up in a way that made them capable of feeling pain the way that adults were thought to feel pain. .
less.
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Permalink Reply by dictostelium on
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Neurology links - unfortunately no
Good book by Michel Odent "The Scientification of Love" is worth reading as a general look at childbirth. Just watching babies is very instructive - they have a full range of emotions and their brains work pretty well - its just that they need 20 seconds or more to react. If given that time they know very well what is happening around them. Good general links here http://birthpsychology.com/ and http://www.beba.org/
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