The first part of the study illustrates the main clinical and epidemiological characteristics of the main disorder treated in the report, the so-called non-specific Low Back Pain. In the second part I described all the structures from the anatomical point of view, whose treatment will be described later, first of all the lumbar portion of the spine, then the diaphragm, the small intestine (in particular the duodenum and the root of the mesentery) and the colon (particularly Toldt's fascia and sigmoid colon). In particular, their connection with the lumbar spine and the various modalities through which they can cause painful symptoms was also analyzed: these are the mechanisms of referred pain, the mobility limitations of the visceral fascia or the phenomenon of central awareness raising. In the third part of the study the practical modalities of the rehabilitation treatment are explained: a case of non-specific Low Back Pain was selected, and it was subjected to a treatment of 5 sessions (plus one follow-up) which include diaphragmatic maneuvers and manipulations visceral to the structures previously described. The purpose of these treatments is to reduce lumbar pain, ensure greater flexibility of the lumbar spine and decrease the tension of the domes and diaphragmatic pillars; consequently, the purpose of this study is to demonstrate the efficacy of a visceral and diaphragmatic treatment to reduce the symptoms affecting the spine. Once the 3 parameters have been improved with the rehabilitation sessions, the long-term goal is to improve the patient's quality of life. The work was measured through universally recognized scales, such as: pain assessment scale (VAS), which aimed to monitor improvements in terms of painful symptoms in the lumbar region, and lumbar mobility assessment scale (Schober Test), which was intended to record the improvements in terms of flexibility. To verify the improvements from the point of view of diaphragmatic mobility, the MED (Manual Evaluation of Diaphragm) scale, recently in the validation phase, was considered in the study, which provides for a manual evaluation of this muscle and its parts. Finally, a questionnaire was also used, the Eq-5d to measure the improvement from the point of view of the patient's general health. The results showed that visceral manipulation had excellent results, both in improving the mobility of the lumbar spine and in reducing pain: in particular, it was seen how pain gradually decreases from session to session, while lumbar flexibility definitely go to increase and reach more than good levels already from the second session. This is combined with a significant final improvement in diaphragmatic mobility, an indication of a detensioning of the diaphragm and therefore of a further reduction in pain at the level of the lumbar vertebrae in which it is inserted. Finally, the quality of life after the treatment is totally restored, through the data recorded in the questionnaire: it should however be specified that for an improvement in the quality of life and long-term well-being it is also necessary to manage low back pain through a correct lifestyle and correct posture during the main activities of daily life, therefore ergonomic advice is also provided at the end of the treatment. The improvement after the rehabilitation cycle shows, however, that the work carried out has proved to be effective and consistent with the lumbago clinical picture, and that therefore both the nerve pathways reflected from the viscera to the lumbar metamers, and the fascial interactions, can have a strong influence on the dysfunctions of the lumbar spine.
Nella prima parte dello studio vengono illustrate le principali caratteristiche cliniche ed epidemiologiche del disturbo principale trattato nell’elaborato, il cosiddetto Low Back Pain aspecifico. Nella seconda parte sono state descritte dal punto di vista anatomico tutte le strutture di cui verrà successivamente descritto il trattamento, quindi innanzitutto la porzione lombare della colonna vertebrale, poi il diaframma, l’intestino tenue (in particolare il duodeno e la radice del mesentere) e il colon (in particolare la fascia di Toldt e il colon sigmoideo). È stato analizzato anche il loro collegamento con il rachide lombare e le varie modalità attraverso le quali possono far scaturire la sintomatologia algica a suo carico: esse sono i meccanismi di dolore riferito, le limitazioni di mobilità della fascia viscerale o il fenomeno della sensibilizzazione centrale. Nella terza parte dello studio vengono spiegate le modalità pratiche del trattamento riabilitativo: è stato selezionato un caso di Low Back Pain aspecifico, ed è stato sottoposto ad un trattamento di 5 sedute (più una di follow-up) le quali includono manovre diaframmatiche e manipolazioni viscerali alle strutture precedentemente descritte. Lo scopo di questi trattamenti è quello di ridurre il dolore lombare, garantire una maggiore flessibilità del rachide lombare e diminuire la tensione diaframmatica; di conseguenza, il fine di questo studio è dimostrare l’efficacia di un trattamento a livello viscerale e diaframmatico per ridurre la sintomatologia a carico della colonna. Una volta migliorati i 3 parametri con le sedute riabilitative, l’obiettivo a lungo termine è quello di migliorare la qualità di vita del paziente. Il lavoro è stato misurato attraverso scale universalmente riconosciute, quali: scala di valutazione del dolore (VAS), che ha avuto lo scopo di monitorare i miglioramenti dal punto di vista della sintomatologia dolorosa a livello lombare, e scala di valutazione della mobilità lombare (Schober Test), che ha avuto lo scopo di registrare i miglioramenti dal punto di vista della flessibilità. Per verificare i miglioramenti dal punto di vista della mobilità diaframmatica, è stata considerata nello studio la scala MED (Manual Evaluation of Diaphragm), recentemente in fase di validazione, che prevede una valutazione manuale di questo muscolo e delle sue parti. Infine è stato anche utilizzato un questionario, l’Eq-5d per misurare il miglioramento dal punto di vista della salute generale del paziente. I risultati hanno dimostrato che la manipolazione viscerale ha avuto ottimi risultati, sia nel miglioramento della mobilità del rachide lombare, sia nella riduzione del dolore: in particolare, si è visto come il dolore venga gradualmente a diminuire di seduta in seduta, mentre la flessibilità lombare vada decisamente ad aumentare e a raggiungere livelli più che buoni già dalla seconda seduta. Ciò si unisce a un notevole miglioramento finale anche della mobilità diaframmatica, indice di un detensionamento del diaframma e dunque di un’ulteriore riduzione del dolore a livello delle vertebre lombari in cui esso si va a inserire. La qualità della vita infine dopo il trattamento risulta totalmente ripristinata, tramite i dati registrati nel questionario: va comunque specificato che per un miglioramento della qualità di vita e un benessere a lungo termine occorre anche gestire la lombalgia attraverso un corretto stile di vita e una corretta postura durante le attività principali di vita quotidiana, quindi a fine trattamento vengono forniti anche consigli ergonomici. Il miglioramento post ciclo riabilitativo dimostra comunque che il lavoro svolto si è rivelato efficace e coerente con il quadro clinico lombalgico, e che quindi sia le vie nervose riflesse dai visceri ai metameri lombari, sia le interazioni fasciali, possono avere una forte influenza sulle disfunzioni del rachide lombare.
La manipolazione viscerale nel trattamento della lombalgia persistente Case Report
DE ROSA, LEONARDO
2020/2021
Abstract
The first part of the study illustrates the main clinical and epidemiological characteristics of the main disorder treated in the report, the so-called non-specific Low Back Pain. In the second part I described all the structures from the anatomical point of view, whose treatment will be described later, first of all the lumbar portion of the spine, then the diaphragm, the small intestine (in particular the duodenum and the root of the mesentery) and the colon (particularly Toldt's fascia and sigmoid colon). In particular, their connection with the lumbar spine and the various modalities through which they can cause painful symptoms was also analyzed: these are the mechanisms of referred pain, the mobility limitations of the visceral fascia or the phenomenon of central awareness raising. In the third part of the study the practical modalities of the rehabilitation treatment are explained: a case of non-specific Low Back Pain was selected, and it was subjected to a treatment of 5 sessions (plus one follow-up) which include diaphragmatic maneuvers and manipulations visceral to the structures previously described. The purpose of these treatments is to reduce lumbar pain, ensure greater flexibility of the lumbar spine and decrease the tension of the domes and diaphragmatic pillars; consequently, the purpose of this study is to demonstrate the efficacy of a visceral and diaphragmatic treatment to reduce the symptoms affecting the spine. Once the 3 parameters have been improved with the rehabilitation sessions, the long-term goal is to improve the patient's quality of life. The work was measured through universally recognized scales, such as: pain assessment scale (VAS), which aimed to monitor improvements in terms of painful symptoms in the lumbar region, and lumbar mobility assessment scale (Schober Test), which was intended to record the improvements in terms of flexibility. To verify the improvements from the point of view of diaphragmatic mobility, the MED (Manual Evaluation of Diaphragm) scale, recently in the validation phase, was considered in the study, which provides for a manual evaluation of this muscle and its parts. Finally, a questionnaire was also used, the Eq-5d to measure the improvement from the point of view of the patient's general health. The results showed that visceral manipulation had excellent results, both in improving the mobility of the lumbar spine and in reducing pain: in particular, it was seen how pain gradually decreases from session to session, while lumbar flexibility definitely go to increase and reach more than good levels already from the second session. This is combined with a significant final improvement in diaphragmatic mobility, an indication of a detensioning of the diaphragm and therefore of a further reduction in pain at the level of the lumbar vertebrae in which it is inserted. Finally, the quality of life after the treatment is totally restored, through the data recorded in the questionnaire: it should however be specified that for an improvement in the quality of life and long-term well-being it is also necessary to manage low back pain through a correct lifestyle and correct posture during the main activities of daily life, therefore ergonomic advice is also provided at the end of the treatment. The improvement after the rehabilitation cycle shows, however, that the work carried out has proved to be effective and consistent with the lumbago clinical picture, and that therefore both the nerve pathways reflected from the viscera to the lumbar metamers, and the fascial interactions, can have a strong influence on the dysfunctions of the lumbar spine.| File | Dimensione | Formato | |
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TESI LEONARDO DE ROSA.pdf
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Descrizione: Tesi di Leonardo De Rosa
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https://hdl.handle.net/20.500.12075/744