The word ‘dysfunction’ chosen by Mennell to describe the loss of movement commonly known as ‘joint play’ or ‘accessory movement’ seems infinitely preferable to the terms ‘osteopathic lesion’ and ‘chiropractic subluxation’, neither of which means anything and both of which mean everything.
‘Dysfunction’ or ‘not functioning correctly’ at least acknowledges that something is wrong without going through the sham procedure of pretending that only those who belong to the club really understand the terminology. For years osteopaths and chiropractors have claimed that only the people, properly trained in their particular calling, have the necessary knowledge to understand their terminology. There may be some truth in that.
Although I believe that the term ‘dysfunction’ as used by Mennel does not strictly cover the loss of movement caused by adaptive shortening, I have chosen to use this term instead of repeatedly referring to ‘adaptive shortening’. Essentially, the mechanism of pain production in dysfunction is the same as in normal tissues — that is, when overstretching of soft tissues causes sufficient mechanical deformation of the free nerve endings in these tissues, pain will arise. In dysfunction soft tissues in or around the segment involved are shortened or contain contracted scar tissue. When normal movement is attempted these structures are placed on full stretch somewhat prematurely. While normally movement in the joint would take place over a certain distance before being stopped by ligamentous tension, it is now brought to a halt after only part of that distance is completed. Attempts to move further towards end range will result in overstretching and produce pain. The pain is felt at the end of the existing range and ceases immediately after end range stretch is released. Repeated uncontrolled stretching of contracted soft tissues will lead to further micro-traumata and pain. The patient then avoids the movement which is painful, and adaptive shortening of the scar reduces the existing range of movement even more.
Developed as a result of poor postural habit, spondylosis, trauma or derangement, the dysfunction syndrome is the condition in which adaptive shortening and resultant loss of mobility causes pain prematurely — that is, before achievement of full normal end range movement. Essentially, the condition arises because movement is performed inadequately at a time that contraction of soft tissues is taking place.
There are two possibilities regarding the cause of dysfunction. When dysfunction develops following trauma or derangement, the patient will be aware of the onset. He will describe the symptoms from the date of trauma or derangement, but the pain produced by trauma or derangement will no longer be present and the symptoms are now related to the resultant loss of mobility and function. When dysfunction is the result of poor posture or spondylosis the patient will be unaware of the onset. He will be unable to relate the cause of the pain to a particular incident and usually describes a gradual slow onset of pain commencing for no apparent reason.
Patients in the dysfunction category are likely to be over thirty years of age. However, younger patients may well present, who have had previous low back pain or trauma which resulted in loss of function that has not been detected or treated.
The pain is felt at the end range of certaincmovements, or before end range is achieved, and this may interfere with the performance of simple tasks. For example, loss of function in the neck is often first noticed when the motorist turns the head while reversing the car; in loss of function in the low back it is often difficult to put stockings on the feet or to get into the trousers.
Initially patients with dysfunction are stiff first thing in the morning, loosening as the day progresses. But as time passes flexion and extension become reduced and the morning stiffness does not pass. In extension dysfunction lying prone for any length of time — for example, on the beach — cannot be tolerated. Due to inadequate extension in the lumbar spine the ligamentous structures are placed on full stretch prematurely while lying prone and pain is produced.
Often the patient with dysfunction states that he feels better when he is active and moving about than when at rest. The reasons for this are obvious: during regular and not excessive activity end range of movement is seldom required and, if so, only momentarily; on the other hand, during resting end positions are readily assumed and as soon as they are maintained they may prove painful. In dysfunction the pain is intermittent, occurring only when periarticular structures are placed on full stretch. This happens much sooner in a patient with dysfunction than in a normal person, hence the much more frequent provocation of pain in dysfunction. The greater the loss of function, the more often will the pain occur.
Pain from dysfunction sometimes develops in an episodic manner and appears to resemble derangement. This episodic pain is triggered by excessive use, for example a vigorous afternoon in the garden. Overstretching of contracted soft tissues causes minor traumata and produces or increases pain. If the patient rests for a few days the pain subsides, but further scarring and healing contractures will increasingly limit the available range of movement. This becomes a vicious circle which will only be broken by treatment procedures as described for dysfunction.
Generally, the posture of the patient with dysfunction will be poor. In the absence of trauma or previous back pain episodes, often only poor posture is to be blamed for the development of dysfunction. This is confirmed by merely correcting the posture which relieves the patient of a significant amount of pain. Except in the elderly with dysfunction, deformity is not commonly seen.
However, there is always a loss of movement or function. Often the loss of movement is a capsular pattern type of restriction. This is clearly described by Cyriax for spinal as well as peripheral joints. When dysfunction in the spine is the result of poor posture or spondylosis, there tends to be a symmetrical movement loss in all directions and group lesions are commonly seen.
However, when dysfunction is the result of trauma and derangement there is more often an asymmetrical movement loss, some movements remaining full range and others being partially or completely lost. Group lesions may or may not develop following trauma depending on the extent of the damage sustained, and are hardly ever seen following derangement.
If there is a significant loss of extension, the lordosis may be reduced or the patient may be unable to produce the lordosis, even if he strains to do so. If there is a loss of flexion, the patient may have difficulty in reaching his toes and on bending forwards the lumbar spine may remain in slight lordosis. Alternatively, the loss of flexion may become apparent midway through the flexion excursion by a deviation of the body to one side or other of the midline. Many variables are possible and all must be noted in order to determine the pattern of movement restriction of each patient individually.
Fig. Loss of extension.
Fig. Loss of flexion.
Fig. Loss of flexion with deviation.
The test movements
It will not be difficult to reproduce the symptoms with the test movements. Due to the reduced end range of some movements pain is elicited readily as soon as stretching of these movements is performed, and each time the stress is released the pain subsides quickly.
Following the test movements the patient should be allowed to move about and perhaps have a short walk. The object of this is to determine the effect of the test movements on the general pain pattern. A patient with dysfunction may be slightly more aware of his pain after the examination, but he will never remain significantly worse, provided tissue damage due to overstretching of shortened structures has not taken place. Following the test movements the movement pattern will not have altered — that is, if we were to repeat the whole sequence the same movements would produce the same pain as in the first session.
Let us look at the example of a typical patient with dysfunction. In particular we must assess the effects of the test movements on the pain. In this patient pain is produced at the point of full stretch in flexion and extension, which are both restricted in range of movement. Repetition of the test movements does not make the symptoms better or worse, and on release of the stress the pain subsides leaving the patient no worse than before testing. Rapid changes of symptoms do not occur in dysfunction. It takes weeks for soft tissues to become contracted and adaptively shortened and, likewise, it will take a long time for them to lengthen again.
Treatment of the dysfunction syndrome
Patients who fall in the dysfunction category will still require postural instruction. When planning treatment we must include from the first day all the procedures laid down for the patient with postural pain. The patient with dysfunction can learn quickly to control those symptoms which are caused or enhanced by bad posture.
The symptoms of dysfunction are more related to movement and become evident in the difficulty or inability of the patient to accomplish end range of movement, most noticeable in the extremes of flexion and extension. These symptoms will remain present until the length of the shortened tissues is increased and the range of movement is improved. This will be achieved in about four to six weeks, provided the treatment procedures are used in a precise and clearly defined manner. The very nature of adaptive shortening of soft tissues adjacent to articular structures prohibits the rapid recovery of function in a few days.
Stretching must be performed in such a way that it allows elongation of ligamentous structures and scar tissue without causing micro-traumata. Pain produced by stretching should stop shortly after the stress is released. When pain persists long after stretching has occurred overstretching has taken place. To achieve lengthening of soft tissues it is not sufficient to perform stretching once a week, neither is it sufficient to do this once a day. Too many physiotherapy clinics make their patients return daily for ten minutes of mobilisation or, worse still, one minute of manipulation with the express purpose of restoring mobility. This concept of treatment may well be acceptable, if the patient is given adequate exercises to perform regularly in between treatment sessions. However, often enough this is not done; or else, when the patient is instructed in a self-treatment programme he is carefully warned not to do the exercises if they cause pain, thus defeating the purpose of the stretching.
If a patient receives manipulation in an attempt to lengthen contracted structures, minor trauma must follow and the dysfunction cycle will be perpetuated. If the patient receives only mobilisation procedures and does not perform exercises, the stretching that occurred during the ten minutes of treatment will be entirely lost by the contraction that is allowed to take place over the next twenty-three hours and fifty minutes, or whatever time period separates the treatment sessions. Even if exercises are given, no benefit will result unless the patient is instructed to move to the extreme range where some, but not great, discomfort or pain should be experienced. If no strain pain is produced during the performance of exercises for the recovery of lost movement, the contracted soft tissues are not being stretched enough to enhance elongation of the shortened structures. Furthermore, if the stretching procedures are not performed often enough, no benefit will result either. If the rest periods between the stretching procedures are too long, the length of time when no stretching takes place negates the effect of stretching.
We can have a significant influence on the remodelling of tissue expecially during the process of repair.
In all dysfunction situations exercises for the restoration of movement and function must be performed about ten times per day from first thing in the morning to last thing at night. On each of the ten occasions a minimum of ten movements will be performed. In other words, the patient will perform one hundred stretches per day in groups of ten. The following instructions must be given to the patient:
- if the exercises do not produce some minor pain, the movement has not been performed far enough into the end range;
- the type of discomfort aimed at is not unlike the pain felt when bending the finger backwards beyond the normal position;
- the pain should have subsided within ten to twenty minutes after completion of the exercises;
- when pain produced by the stretching procedures lasts continuouly and is still evident the next day, overstretching — that is, too much stretching;
- has taken place; in this case the number of exercises in each sequence or the frequency of the sequences must be reduced.
It is accepted that due to circumstances many patients will be unable to strictly follow the recommended frequency of exercising. Where it is not possible to perform stretching as often as instructed, recovery of full function is likely to take a little longer.
During the course of one treatment session we should not use more than one new procedure; nor should that procedure, if it is a manipulative thrust technique, be performed more than once. Following the application of a new procedure or a manipulation we must wait, if necessary twenty-four hours, to assess the response of the patient.