Somatic dysfunction (SD) is considered a key idea within the theory and practice of osteopathy. However, a closer inspection of this concept reveals it is outdated, and bears little relevance to the paradigms of person-centred care and evidence-informed practice. It is time to re-evaluate such key terms and concepts within osteopathic discourse, and make them compatible with
modern day healthcare.
Somatic dysfunction, diagnosis, facilitated-segment
Somatic dysfunction: an osteopathic conundrum (Fryer, 2016)
Gary Fryer has been engaged in osteopathic education and research since 1997. He has published extensively, and has a particular interest in advocating an evidenced informed approach to the teaching and practice of osteopathy.
This master-class paper suggests that the central concept of somatic dysfunction (SD) within osteopathy is no longer relevant. The conceptual framework of SD is critiqued in relation to “its unclear pathophysiology and poor reliability of detection.” Palpation as a diagnostic tool is critiqued and found to be wanting. Fryer provides a brief historical summary including Korr’s facilitated segment theory which attempted to explain the neurological basis for SD. However, a thorough review of Korr’s research has revealed serious flaws, and that it cannot validate the notion of SD. A more compelling explanation for palpatory findings and patient experience of pain in the osteopathic setting is the one of central sensitisation, in which all pain is perceived in the higher centres, not the local tissues. Fryer urges us as a profession to widen our perspectives and integrate the ever increasing knowledge from current pain and chronic pain research. He suggests a more plausible explanation for the palpable findings, we as osteopaths experience on a daily basis, could be attributable to “nociceptive-driven functional changes.” These produce changes in tissue quality, texture and alter pain sensitivity.
It is suggested that SD now lacks relevance within modern day health studies. As a theory it is too unspecific, lacks reliability and validity, and dramatically undermines the claim that it is a useful concept in health and disease. Fryer deepens his critique by suggesting that the term dysfunction is also unhelpful, potentially producing a negative picture of the body for the patient (see also Darlow, 2016). He particularly points to Fryette’s biomechanical model which perpetuates the “bone out of place” concept, which may leave the patient believing they have a serious structural problem. Fryer states quite clearly “positional terminology is anachronistic and potentially harmful.
The use of this type of negative language is also heavily critiqued in the placebo research literature (Benedetti and Amanzio, 2011) and may induce a nocebo response. The words and concepts we use with are patients are highly loaded with meanings both positive and negative. It is therefore important that our language should be considered with care.
The article also provides an alternative model for understanding the palpatory findings without referring to SD, which he suggests we as a profession need to rethink in the light of current research findings on the nature of pain. The paper ends with a clear message that as a profession we need to examine our theoretical concepts in the light of the best available evidence.
Benedetti, F. and Amanzio, M., 2011. The placebo response: How words and rituals change the patient’s brain. Patient Education and Counseling, 84(3), pp.413-419.
Fryer, G., 2016. Somatic dysfunction: An osteopathic conundrum. International Journal of Osteopathic Medicine, 22, pp.52-63.
Darlow, B., 2016. Beliefs about back pain: The confluence of client, clinician and community. International Journal of Osteopathic Medicine, 20, pp.53-61.
Robert Shaw PhD
Robert has worked as an osteopath for over 30 years and a psychotherapist for over 25 years. He obtained his PhD in 2000 exploring the concept of embodiment within the therapeutic encounter. He has written many journal articles, a book, and lectured throughout Europe on the subject.
He has a specialised training in dealing with the physical and psychological aspects of post traumatic stress disorder. He moved to Sweden in 2010 and currently has a private practice as an osteopath, integrative psychotherapist, and supervisor, and is the program leader for the Skandinaviska Osteopathögskolan.
He is on the international editorial board for The International Journal of Osteopathic Medicine, and a member of the European School of Osteopathy International faculty. He is an Honorary Research Fellow at University of Technology Sidney (ATS), Australia, which has organised the first International Osteopathy Research Leadership and Capacity Building Program for osteopathy.