As an manipulative therapist, on day to day clinical practice, addressed numerous spinal dysfunctions. On my clinical practice, when I encounter a ERS dysfunction (Extended, Rotated & Side bent) in osteopathic term (most commonly type 2 somatic dysfunction) or Opening dysfunction in Physiotherapy term. I had observed that some of this ERS dysfunction or Opening dysfunction had re-occured after it correction with in a week of time or more. It had been challenging to re-address it. after ruling out possible mechanical cause, Couldn’t able to find out the reason for re-occurrence. This made me to explore the cause of re-occurrence of the dysfunction, finally found out the reason for re-occurrence after refering to various literatures , Now going to discuss about it.
What is this ERS or Opening Dysfunction ?
Either of the one, of the two facets joints,of the vertebral segment gets strucks in extended position, vertebral segment side bends and rotates in the same direction. This dysfunctional vertebral segment will not allow the facet joint of that side to open while the spine flexing. The physiological law of spinal motion will explain it clearly.
Physiological Law of Spinal Motion -
According to physiological laws of spinal motions, which was stated by Harrison H.Fryette DO (1918). There are two types of mechanism, Type 1 Mechanics and Type 2 Mechanics.
Type 1 Mechanics – Is an neutral mechanics, usually it occurs in neutral range, in which two or more vertebrae’s side bends and rotates in opposite directions.
Type 2 Mechanics – Is an non-neutral mechanics, in which with sufficient flexion or extension, the vertebral side bending and rotation are coupled in the same direction.
NON-NEUTRAL or Type 2 Dysfunction –
In thoracic and lumbar spine when sufficient flexion or extension beyond the neutral range occurs, sidebending and rotation will be coupled to the same side. The vertebral segment is flexed or extended and sidebent right, rotated right or sidebent left, rotated left. This is called as Type 2 mechanics. If a dysfunctional vertebral segment held in this position is referred to as a Type 2 dysfunction or non-neutral dysfunction.
This ERS or Opening dysfunction is an Type 2 somatic dysfunction or Non-Neutral Dysfunction according to osteopathic terms. Which occurs when the spine is extended beyond the neutral range.
Somatic dysfunction replaces old terms such as osteopathic lesion,chiropractic subluxation,joint blockage,joint lock,loss of joint play,or minor vertebral derangement. Somatic dysfunction is an Impaired or altered function of related components of the somatic (body-framework) system: skeletal, arthrodial and myofascial structures, and related vascular, lymphatic, and neural elements. Somatic dysfunction is a distinctly osteopathic diagnosis.
The osteopathic medicine literatures is explaining,That this ERS or Opening dysfunction are frequently a product of segmental muscle contraction,that results from viscerosomatic reflex as a consequence of visceral disease.
Viscero-somatic reflex is an representation of somatic reflection of the visceral pathology,through autonomic nervous system. Spinal segmental facilitation plays the role.
The viscerosomatic reflex will cause somatic dysfunction, but this dysfunction is secondary due to segmentally related visceral inflammation and they are mediated through visceral afferent neurons.
Mechanism of viscerosomatic reflex in causing somatic dysfunction -
The irritation from the inflammation associated with visceral pathology, will trigger the activation of visceral afferent neurons.
This afferent neurons enters the spinal cord and synapse in dorsal horn with interneurons.
The ongoing afferents from site of irritation will cause facilitation of interneurons of that spinal segment.
Seems that Additional afferent activity,from any source,results in spinal segmental response, this results in tenderness, tissue texture abnormality proportionate to the degree of visceral pathology when area of the associated dermatome and myotome is palpated.
The amount of afferent activity is sufficient from the organ, cause internuncial firing with activation of ascending spinal pathways,referred pain results.
The activity from the interneurons that synapse with ventral horns motor neurons,results in segmentally related myospasticity, as seen in primary somatic dysfunction. The myospasticity/spasm would be seen in the deep paravertebral muscles especially in multifidi and rotatores,this will be the product of segment muscle contraction which causing ERS or Opening dysfunction as discussed.
The ERS or Opening dysfunction,due to the consequence of visceral pathology via viscerosomatic reflex,is an secondary dysfunction.Even Phillip Greenman DO had presented and discussed about this in Research Workshop in Neurobiologic Mechanisms in Manipulative Therapy,michigan state university 1977. Louis Burn DO had did extensive work in viscerosomatic reflex and somatovisceral reflex.
This types of dysfunction will gets corrected only if the visceral pathology gets appropriate treatment.On my experience this type of somatic dysfunctions can be addressed by manipulative techniques (direct & indirect techniques) but results will be temporarily.
This type of ERS or Opening Dysfunctions,which re-occurs with in a short period of time after addressing it, is an good indicator to consirder about visceral pathology.Can be cross-referred to an General Physician.because we physiotherapist cannot address visceral issue.
On my experience, I had seen among the some patients in whom the correction of ERS or Opening dysfunction re-occurred after addressing it, they had co-morbidities like reflux oesophagitis, gastritis, peptic ulcer and etc. but these thing had been diagnosed by a general physician when I cross-referred back and These things had been diagnosed after the failure of my attempt in correction of the ERS or Opening dysfunction. At that time im not much aware about viscerosomatic reflex induced vertebral dysfunction. Even the quadrant examination sign too been negative in those patient, but the reason for negative sign is unclear. My manual therapy school of thoughts is a mixture of osteopathy and traditional orthopaedic manual physio therapy, hence im familiar with osteopathic terminologies, diagnosis and techniques. This made my exploration easier, on the search of causative factor of re-occurrence of the dysfunction, through referring to the works of pioneers like Harrison H.Fryette DO, Phillip Greenman DO, Louis Burns DO, and Irvin M.Korr DO.
This viscerosomatic reflex induced vertebral dysfunction from an osteopathic origin, will be really helpful for manual physiotherapist too, in cross-referring patient to General Physician, if they encounter a re-occurence of ERS or Opening dysfunction with in a short period of time after correcting it appropriately and ruling out the mechanical cause.
The diagnosis of ERS or Opening dysfunction can be made by following osteopathic structural diagnosis eg. For lumbar spine By placing the both thumbs on lumbar tranverse process its symmetry is noted on neutral position , subject is asked to bend his trunk forward in sitting position, now symmetry of transverse process is checked,if the transverse process is posterior on one side during forward bending then that side of facet is strucked in extension, same method is applied to thoracic spine too, for upper thoracic spine the subject is asked to look down the floor by bending upper thoracic spine,for lower thoracic spine the subject is asked to slump the back and forward bend the trunk.
The diagnosis can also be made using Passive Accessory Intervertebral Motion (PAIVM) testing. Because this ERS or Opening dysfunction is an arthrokinematic restriction.
Let the orthopaedic manual physiotherapy practioner belong to any school of thoughts such as Kalternborn,Maitland,Cryiax,Mulligan and etc. its doesn’t matter. Consirdering this viscerosomatic reflex induced vertebral dysfunction, will helps in timely cross-referral, helps in avoiding failure of intervention and saves the time of clinician.
Greenman’s Principles of Manual Medicine,4th Edition,Lisa DeStefano DO.
Somatic Dysfunction in Osteopathic Family Medicine,2nd Edition,Kenneth E.Oslon,Thomas Glonek
Foundation of Osteopathic Medicine,3rd Edition,Antony Chila
Principles of Manual Therapy,2nd Edition,Deepak Sebastian DPT,PhD,FAAOMPT,OCS.
The Neurobiological Mechanisms in Manipulative Therapy,Irvin M.Korr.
Manual Physical Therapy of Spine,2nd Edition Kenneth S.Olson