The Osteopathic Lesion: Why is this still a thing?

So as not to set myself up to be accused of creating a strawman in another blog I’m writing, I attempted to find a definition of the osteopathic lesion, a term used consistently in Canada to describe all manner of osteopathically diagnosed causes of pain and dysfunction.

According to the American Association of Colleges of Osteopathic Medicine Glossary of Osteopathic Terminology the term osteopathic lesion is archaic and has been replaced by somatic dysfunction. The definition given below is the basis for several sub categories of somatic dysfunction including acute, chronic, primary, secondary, type I and type II that can be applied to all regions of the body:

“Somatic dysfunction: Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment. The positional and motion aspects of somatic dysfunction are best described using at least one of three parameters: 1). The position of a body part as determined by palpation and referenced to its adjacent defined structure, 2). The directions in which motion is freer, and 3). The directions in which motion is restricted. See also TART. See also STAR”

Somatic dysfunction was brought into use because the term lesion in medicine^[1]1. Essentially injury – Late Middle English: via Old French from Latin laesio(n-), from laedere ‘injure.’ had different connotations and could be confusing for the patient, but osteopathically the terms osteopathic lesion and somatic dysfunction essentially mean the same thing.

In 1935 George MacDonald and W Hargrave-Wilson wrote a book entitled The Osteopathic Lesion. Shortly after its publication there was a review by the Journal of the American Medical Association (JAMA) that I have summarized below:

“Even after reading it, one cannot obtain an entirely clear understanding of just what the authors mean by the “osteopathic lesion.” The effect of the lesion may be localized, peripheral, visceral or general. … Even attempting an attitude of fairness, there does not appear to be any justification for this book.”^[2]1. http://jama.jamanetwork.com/article.aspx?articleid=1155975

And a review in the British Journal of Medicine that followed with:

“These authors, though they have no doubt of the actual existence and immense importance of the lesion, yet agree that search for it has been inadequate and unconvincing … and that it is proved by the success of those who base their treatment on the supposition that it constitutes the predisposing or exciting cause of every morbid condition. Happily, empirical success may accompany a false pathology, or what would have been the reputation of Hippocrates?”^[3]1. The British Medical Journal, Vol. 2, No. 3897 (Sep. 14, 1935), pp. 503-504

Since then, and despite the resounding trouncing of the osteopathic lesion as an actual phenomena it is still used, and not sparingly, by Canadian osteopathic institutions and subsequently by the average Canadian osteopathic practitioner.

Though there are more studies or papers from historical perspectives in support of the osteopathic lesion they can be characterized by an overarching factor of belief stated by Denslow in 1940:^[4]1. Denslow, J.S., Analyzing the osteopathic lesion. JAOA • Vol 101 • No 2 • February 2001

“To the osteopathic physician the osteopathic lesion is a demonstrable entity. He perceives it with his sense of touch and often with his muscle sense as he moves the parts … .”

In a more recent book from 2006, Osteopathy: Models for Diagnosis, Treatment and Practice, the authors introduce the osteopathic lesion in a way that does not give it any more substance than it had in 1935:^[5]1. Parsons, J. & Marcer, N. Osteopathy: Models for Diagnosis, Treatment and Practice. 2006, Elsevier Limited. London.

“Defining the osteopathic lesion, like defining osteopathy itself, is difficult. … When he later asked the students to define an osteopathic lesion one wit replied, ‘That which osteopaths find!’

“There is in fact much truth in this statement, as the definition appears to be dependent on one’s perception or understanding of osteopathy.” p. 17

There are many more papers on the osteopathic lesion and still more on the facilitated segment that emerged from it  and was made osteopathically famous by Korr and Denslow. Most of the papers appear to be the property of the Journal of the American Osteopathic Association (JAOA) and not easily accessible without subscription, even through the university libraries. So though peer reviewed by a journal that is “particularly interested in research articles that reflect osteopathic medicine’s traditional emphasis on the role of the musculoskeletal system in health and disease“, the articles themselves are not widely distributed for interdisciplinary review.

Though several of the papers authored by Korr and found in the JAOA are nervous system related, at least suggested by title,^[6]1.(1975) Proprioceptors and somatic dysfunction; (1976) The spinal cord as organizer of disease processes: some preliminary perspectives: (1979) The spinal cord as organizer of disease processes: … Continue reading there is also significant critique of the facilitated segment theory that suggests its presence and the overarching reason for its necessity within osteopathic education – the high velocity adjustment – has in fact retarded osteopathic knowledge of continuing neuroscientific progress.

“The concept of the facilitated segment provides the justification for performing a very accurate HVT on particular segments. It gives the HVT a physiological depth beyond the biomechanical structural fixing of the spine. The osteopath is now able to reach deep into the interior of the patient to affect visceral pathologies. This was done at a great cost to osteopathy – osteopathic understanding of neurophysiology has starts (sic) and ended at the facilitated segment.”

In 2002 a now archived discussion on Soma Simple on the facilitated segment had a comment by David Butler of the Neuro Orthopaedic Institute^[7]1. https://www.somasimple.com/forums/showthread.php?t=1473 who suggested the facilitated segment could be “completely explained by central sensitization”. So if current neuroscience, in its inevitable progression, is able to offer an encompassing explanation of a segmental phenomena that up until now cannot be shown to exist as a thing in and of itself, should we not jump on that bandwagon? After all, along with the art of osteopathic practice there is also the science. The art is creative, but the science is, by its nature, progressive. The tenants of central sensitization within which the initial concept of the osteopathic lesion and its offspring, the facilitated segment, now likely reside are not proprietary.

So not essentially osteopathic or lesional at all, but relevant to anyone with a nervous system.