**5. Vertebral dysfunction in relation to internal organ disease**

Vertebral dysfunction is caused by a combination of morphological and functional disorders. The musculoskeletal system has passive components (bones, joints, ligaments) and active components (muscles, fascia). These components create static and dynamic spinal function. Vertebral disorders should not be considered as only morphological disturbances. Functional disorders of the intervertebral joints, movement problems, altered muscle tone status and abnormalities may also be classified as vertebral disorders. Morphological and functional disorders should therefore be considered simultaneously, as symptoms for both dysfunctions frequently appear together (Lewit, 2010)

Vertebrovisceral relations are determined by segmental somatic and autonomic innervation. Myotome, dermatome, viscerotome, and sclerotome are innervated in each spinal segment. Failure in one of the reflex arc sectors often causes dysfunction in parts or the entire segment. In terms of etiopathogenesis, two types of functional disorders are generated. If there is a primary spinal defect which reflexively induces changes in viscerotom, we can simply, although not precisely, refer to vertebrovisceral syndromes. Reflective changes in the spine lead to a number of significant clinical manifestations-primarily pain along with

Non-obstructive swallowing disorders: Neuromuscular diseases (pseudobulbar syndrome, bulbar syndrome, lower motor neuron dysfunction, neuromuscular disorders, muscle disease), autoimmune disease, achalasia, idiopathic spastic dysphagia, psychogenic and

 Scleroderma – an autoimmune disease that causes weakening of the esophagus tissues. Achalasia – with the loss of ganglion cells in the wall, increases the tone of the lower sphincter at first (loss of inhibitory stimuli), followed by the loss of peristalsis in the proximal parts of the esophagus with subsequent accumulation of food and dilation of

 Primary esophageal spasm with unclearly identified pathophysiology – diffuse spasms that block the transport of food and fluids through the esophagus, leading to an

Sometimes, globus pharyngicus (hystericus) is classified as a functional swallowing disorders. Patients describe sensation of a lump in the throat with a characteristic absence of dysphagia. The food does not stick in the throat and fluids pass freely when swallowing, this condition can alleviate symptoms. Some studies suggest an increase in upper esophageal sphincter pressure or abnormal mobility of the hypopharynx. The occurence of these problems is usually associated with psychosocial factors, especially depression and anxiety. Medical treatment usually does not bring relief, although patients may benefit from

Vertebral dysfunction is caused by a combination of morphological and functional disorders. The musculoskeletal system has passive components (bones, joints, ligaments) and active components (muscles, fascia). These components create static and dynamic spinal function. Vertebral disorders should not be considered as only morphological disturbances. Functional disorders of the intervertebral joints, movement problems, altered muscle tone status and abnormalities may also be classified as vertebral disorders. Morphological and functional disorders should therefore be considered simultaneously, as symptoms for both

Vertebrovisceral relations are determined by segmental somatic and autonomic innervation. Myotome, dermatome, viscerotome, and sclerotome are innervated in each spinal segment. Failure in one of the reflex arc sectors often causes dysfunction in parts or the entire segment. In terms of etiopathogenesis, two types of functional disorders are generated. If there is a primary spinal defect which reflexively induces changes in viscerotom, we can simply, although not precisely, refer to vertebrovisceral syndromes. Reflective changes in the spine lead to a number of significant clinical manifestations-primarily pain along with

increase in lower esophageal sphincter tone and nonspecific motility disorders. Functional and psychogenic dysphagia – no signs of organic impairment, it may be

The most common types of non-obstructive swallowing disorders are:

Age-related changes in motor function of the esophagus.

Inflammation associated with gastroesophageal reflux.

dysfunctions frequently appear together (Lewit, 2010)

Inflammation associated with the use of drugs (pill esophagitis).

**5. Vertebral dysfunction in relation to internal organ disease** 

Motility disorders in diabetic neuropathy, alcoholism, psychiatric illness.

functional disorders.

the esophagus.

psychotherapy.

associated with stress.

other symptoms (Nansel & Szalazak, 1995). The musculoskeletal system can cause problems that mimic symptoms of visceral organ disorder.

We refer to viscerovertebral syndromes when there are primary defects in the visceral organ which can cause segment changes and changes in the functional state of the axial organ. The internal organ problems may cause changes, such as changes in muscle tone, tendons, fascia, subcutaneous tissue, and skin. Often it is difficult to establish a differential diagnosis that distinguishes the primary cause, and inaccurate or erroneous treatment could be the consequence.

In very broad terms, the four possibilities should be envisaged:


The first two points highlight the necessity for precise differential diagnosis and the problems associated with this. The spinal column with its motion segments can in fact produce symptoms that may mimic symptoms arising in the viscera. If such symptoms stem from the motor system, it is not surprising that drug treatment aimed at organic visceral disease fails. This causes frustration in many patients as the true cause of symptoms is not recognized (Nansel & Szalazak, 1995; Hülse, 1991).

If the mechanism causing visceral dysfunction is disturbed function of the motor system, better understanding of this would be of great practical interest, as more effective treatment by the technique of musculoskeletal (manual) medicine would be more widely applied.

Point 2 is the warning that pain perceived in the locomotor system may be a deceptive sign masking serious underlying visceral disease. This suspicion is strengthened if the symptoms of spinal segmental disturbance tend to relapse repeatedly without obvious cause. While the error in point 1 is more common, that in point 2 is all the more fraught with danger.

Point 3 is of major theoretical significance and demonstrates that visceral disease is actually one of the possible causes of dysfunction in the motion segment. Clinical experience teaches that certain visceral diseases are associated with characteristic patterns in the locomotor system. They are so specific that their recurrence is in all probability predictive of a recurrence of the visceral disease.

Point 4 it would seem justifiable to assume that lesion in a motion segment of the spinal column may impair function in the corresponding internal organs. This is borne out by the vasomotor response in the whole segment to which pain is referred. In such cases we can see the disorder clearing up as soon as we treat the motion segment. Reactions of this kind have been noted particularly in connection with the cervicocranial syndrome, especially at the craniocervical junction, including disturbances of equilibrium. Similar phenomena have been observed in connection with certain cardiac arrhythmias. A motion segment dysfunction may activate latent disease in an internal organ. Multiple pathogenic factors

Swallowing Disorders Related to Vertebrogenic Dysfunctions 181

sternothyreoideus, that are innervated mainly from segments C2 and C3. M. cricothyreoideus and m. laryngopharyngeus are also innervated by n. laryngicus cranialis of cervical segments C 1-4. The treatment using musculoskeletal (manual) medicine techniques

Inclusion of functional dysphagia as a vertebrovisceral disorder is generally recognized, but this conditon has not been studied extensively. This is because functional dysphagia borders with four fairly distant branches of medicine—gastroenterology, neurology, otorhinolaryngology, and musculoskeletal medicine. And an objective assessment of this

Conventional radiology, computed tomography, ultrasound scans, and magnetic resonance imaging facilitate visualization of gastrointestinal tract organ morphology, but these scans cannot precisely quantify their function. In the diagnosis of esophagus disease, fluoroscopy has been used with non-physiological contrast materials, and this is not a quantitative evaluation either. The use of endoscopy or manometry is an invasive way of investigating the organ condition. The use of nuclear medicine can quantify gastrointestinal organ function assessment by measuring the passage of isotope-labeled material (Russel et al., 1981). At the investigation of patients with dysphagia and normal manometric and endoscopic findings, 50% of them presented dysmotility when dynamic scintigraphy was used (Kjellen et al., 1984). A positive diagnoses of functional gastrointestinal disorders are a result of an expert gastroenterologist´s work. Usually, this diagnosis is determined after

However, it is necessary to take into account the importance of psychological factors that may be the cause of motility disorders of the esophagus. Studies using sophisticated psychometric instruments, dealing with the importance of psychological factors in patients with painful esophageal motility disorders, identified a number of mutual relations. Groups of patients with esophageal spasm, with irritable colon, with benign abnormalities of the impaired esophagus were compared with a control set of healthy persons. Patients with esophageal motility and irritable colon had significantly higher scores than other groups with somatic anxiety and gastrointestinal susceptibility. This shows that certain patients tend to have a significant interest in the somatic function and have more frequent and severe

When 50 referred patients with pathogenic esophageal manometry underwent a psychiatric examination, abnormalities were detected in 21 out of 25 patients with motility disorders of the distal esophagus. On the contrary, abnormalities were found in only 4 out of 13 patients with normal manometric findings. The most common findings were somatization disorders,

In addition to patients with clearly defined pathomorphological esophageal changes, a group of patients without obvious morphological variations had functional spinal disorders. The positive effect of manipulation therapy to relieve pain of the spine and affected organs

**8. Treatment of esophagus functional disorders caused by vertebral** 

lead to an improvement of laryngeal difficulties (Hulse, 1991).

**7. Diagnosis of functional swalloving disorders** 

exclusion of all other potential causes of dysfunction.

gastrointestinal symptoms due to stress (Waterman et al., 1989).

anxiety, and depression. (Clouse & Lustman, 1983).

**dysfunction** 

disease is a complicated issue as well.

may also need to be considered in terms of their cumulative impact. As well as those that affect the locomotor system, other factors may be important in terms of their influence on the organism as a whole, for example infections, metabolic disturbances, diet, etc. None of these individual factors on its own would be sufficient to provoke disease but it is legitimate to refer to them as risk factors (Lewit 2010).

Motor system statics and dynamics are dependent on the physiological state of central regulatory mechanisms. Pain and stress play important roles. Chronic state pattern and disability severity are not represented with an individual musculoskeletal disorder, and the clinical picture is affected by the patient psychological condition. Vertebrovisceral relations are very complex. In many cases pathogenesis is due to more than one factor, and it is better to speak of disease with vertebrogenic factor (Lewit 2010).

In the medical literature the spinal column is mainly mentioned as a cause of dysphagia in the form of a possible mechanical obstacle causing compression of the esophagus by anterior osteophytes: they are believed to produce both dysphagia and dysphonia and even difficulty in breathing (Kodama et al, 1995; Krause & Castro, 1994, Richter et al., 1995; Valadka et al., 1995). Hughes (Hughes et al., 1994) even described patients in whom osteophytes caused dysphagia combined with apnea during sleep. Fuhrmann (Fuhrmann & Neufang, 1994) described similar cases due to disk protrusion. In such cases even surgical treatment was considered. Retropharyngeal hematoma, too, has been described, causing dysphagia and hoarseness (Shaw, 1995). Therefore it is mandatory to have the patient thoroughly examined clinically and by X-ray, ultrasound and esophageal endoscopy, etc.
