SINTESI: il modello delle "Colonne di pressione"©

Trattamento del dolore acuto e cronico
evidence based data

MODELLO FUNZIONALE

A PROPOSITO DELLA "SERIE MUSCOLARE”

Muscles arranged in serie : if one muscle were to contract alone, it would stretch the other (in serie) along its passive length-tension so that the tension in each would be identical
Macklem PT, Macklem DM, De Troyer A. A model of inspiratory muscle mechanics. J Appl Physiol Respir Environ Exerc Physiol. 1983 Aug;55(2):547-57.

DIAFRAMMA, RESPIRAZIONE, POSTURA E MUSCOLI DELLA SERIE

IL DIAFRAMMA, IL TRASVERSO ADDOMINALE, IL PAVIMENTO PELVICO, GLI INTERCOSTALI, SCALENI, STERNOCLEIDOMASTOIDEO E TRAPEZIO SONO MUSCOLI COINVOLTI IN MODO INESTRICABILE IN UNA “SERIE MUSCOLARE POSTURO RESPIRATORIA”. (Finet&Williame)
Macklem PT, Macklem DM, De Troyer A. A model of inspiratory muscle mechanics. J Appl Physiol. 1983 Aug;55(2):547-57.De Troyer A, Kirkwood PA, Wilson TA. Respiratory action of the intercostal muscles. Physiol Rev. 2005 Apr;85(2):717-56.Vostatek P,  Novák D,   Rychnovský T, Rychnovská S. Diaphragm Postural Function Analysis Using Magnetic Resonance Imaging. PLoS One. 2013; 8(3): e56724.Hodges PW, Sapsford R, Pengel LH. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362-71.Masubuchi Y, Abe T, Yokoba M, Yamada T, Katagiri M, Tomita T. Relation between neck accessory inspiratory muscle electromyographic activity and lung volume. Nihon Kokyuki Gakkai Zasshi. 2001 Apr;39(4):244-9.

IL MODELLO DELLE «COLONNE DI PRESSIONE» © FINET & WILLIAME

- Contraction of the diaphragm is unique in which it  produces a fall in negative pleural pressure that is synchronous with a rise in positive intra abdominal pressure (IAP)
- Increase of IAP during postural task is the result of activation of diaphragm, abdominal and pelvic floor muscles
Perry SF, Similowski T, Klein W, Codd JR. The evolutionary origin of the mammalian diaphragm.Resp.Phys. and neurobiology.171(2010)1-16 .
- Increase in negative Thoracic Pressure TP provokes a reflux in jugular veins and an increase in intra-cranial pressure (ICP)
Dabrowski W.Changes in intra-abdominal pressure and central venous and brain venous blood pressure in patients during extracorporeal circulation. Med Sci Monit. 2007 Dec;13(12):CR548-54.Bloomfield GL, Ridings PC, Blocher CR, Marmarou A, Sugerman HJ.A proposed relationship between increased intra-abdominal, intrathoracic, and intracranial pressure. Crit Care Med. 1997 Mar;25(3):496-503.
- Modified Monroe-Kellie doctrine recognizes four main contents in the cranial space (osseous, vascular, cerebrospinal fluid and parenchyma) the volume of each reciprocally affecting each other
Athanasios Marinis. Ischemia as a possible effect of increased intra-abdominal pressure on central nervous system cytokines, lactate and perfusion pressures.Crit Care. 2010; 14(2): R31.
- « PRESSURE COLUMN » IS THE RESULT OF ABSOLUTE INTERDEPENDANCE BETWEEN RESPIRATORY-POSTURAL SERIE AND IAP, TP, ICP
Finet&Williame

PRESSIONE INTRA ADDOMINALE E COLONNA VERTEBRALE

Il diaframma e i muscoli addominali insieme creano un effetto idraulico nella cavità addominale, che aiuta la stabilizzazione vertebrale irrigidendo la colonna lombare attraverso una maggiore pressione intra-addominale
Kolar P et al. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol . 2010     Oct;109(4):1064-71

VISCERALE E UROGENITALE

- Diaphragm is a visceral organizer
Perry SF1, Similowski T, Klein W, Codd JR. The evolutionary origin of the mammalian diaphragm. Respir Physiol Neurobiol. 2010 Apr 15;171(1):1-16.
- Visceral slide isrepetitive (around 25000 x a day) and  show a common pattern for a largepopulation. Visceral slide and visceral homeostasis depend on Intra AbdominalPressure
Finet G, Williame C. Visceral osteopathy : a space of discussion with the medical world. 2012.
- There can be no problems with the pelvic statics for as long as equilibrium exists between the strength of abdominal pressure and the strength of perineal restraint
Kujas A. Coussement A Villet R editors. Imagerie dynamique des troubles pelvi-péritonéaux de la femme. Vigot, 1998

ADATTAMENTI POSTURALI ANTICIPATI (APA’s) E ABILITÀ POSTUROCINETICA (PKC): CHIAVI PER UN APPROCCIO OSTEOPATICO GLOBALE

in ambito digravita’

- Humans  evolve in a gravity field that permanently tends to induce postural destabilization
- To keep the body (or part of it) steady, these disturbing forces must be compensated by “postural adjustments”
Yiou E, Hamaoui A, Allali G. The Contribution of Postural Adjustments to Body Balance and Motor Performance. Front Hum Neurosci. 2018; 12: 487.

ADEGUAMENTI POSTURALI ANTICIPATI: APAS

- Anticipatory postural adjustments APAs are mechanisms triggered by sensory feedback signals and used by the central nervous system (CNS) to deal with body perturbations internally generated or externally generated
Kanekar N, Aruin A. Aging and balance control in response to external perturbations: role of anticipatory and compensatory postural mechanisms. Age (Dordr). 2014 Jun; 36(3): 9621.
- APAs are organized according to a reproducible pattern for a given movement and for every subject
- APAs are postural movements and do not consist in a simple rigidification of some joints
Hamaoui A, Alamini-Rodrigues C. Effect of Experimentally-Induced Trunk Muscular Tensions on the Sit-to-Stand Task Performance and Associated Postural Adjustments. Front Hum Neurosci. 2017; 11: 32.
- Consequently, ANY PREVISIBLE MOVEMENT (= i.e FOCAL  - refers to the voluntary movement itself, (Bouisset and Do, 2008)) IS PRECEEDED BY A POSTURAL MOVEMENT
Yiou E, Hamaoui A, Allali G. The Contribution of Postural Adjustments to Body Balance and Motor Performance. Front Hum Neurosci. 2018; 12: 487.
- The stability of spine, shoulder girdle, and pelvic girdle is established before execution of a postural task by a central mechanism of anticipatory postural adjustments, which occur independently from the respiratory activity of the diaphragm. Proper stabilization is critical for all dynamic activities ranging from simple functional tasks to skilled athletic maneuvers. Moreover, some studies suggest that coactivation between the diaphragm, abdominal muscles, and pelvic floor musculature is necessary to create the sensorimotor control that is of great clinical importance and is often lacking in conditions such as vertebrogenic disorders
Kolar P et al. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol . 2010     Oct;109(4):1064-71

oscillazioni posturali (POSTURALSWAY)

- Postural sway represents the net result of both the disturbing postural forces and their compensation by postural adjustments
Hamaoui A, Hudson AL, Laviolette L, Nierat MC, Do MC, Similowski T. Postural disturbances resulting from unilateral and bilateral diaphragm contractions: a phrenic nerve stimulation study. J Appl Physiol (1985). 2014 Oct 15;117(8):825-32
- Human body permanently sways : this could help to alternate the supports to prevent or delay the occurrence of both mechanical and physiological fatigue and also contribute to the resting of the structures responsible for postural maintenance.
Péninou G,  Colné. LA POSTURE DEBOUT. Biomécanique fonctionnelle, de l'analyse au diagnostic.Elsevier Masson 2018.

BECCHEGGIO E ROLLIO: CONTROLLO DELL’OSCILLAZIONE POSTURALE

- Anterior-posterior (pitch) plane postural sway is mainly controlled by ANKLE muscles
- Mediolateral (roll) plane postural sway is mainlycontrolled by HIP AND TRUNK muscles
Henry S, Fung J, and Horak F. Control of stance during lateral and anterior/posterior surface translations. IEEE Trans Rehabil Eng 6: 32–42, 1998.
- Control of the trunk and limbs can involveinteraction with key respiratory muscles, such as the diaphragm
Gandevia SC, Butler JE, Hodges PW, Taylor JL. Balancing acts: respiratory sensations, motor control and human posture. Clin Exp Pharmacol Physiol. 2002 Jan-Feb;29(1-2):118-21.

Giunto sacroiliaco (sij)

- to overcome the forces of gravity and shear,« force closure » ideally generates a perpendicular compressional reactionforce to the SIJs
- TRANSVERSUS ABDOMINIS close the pelvis superiorlyand PELVIC FLOOR MUSCLES close the pelvis inferiorly and are involved in forceclosure of the SIJs
- When this mechanism works efficiently in thepelvis, the shear forces between the iliac bones and sacrum are adequatelycontrolled, and loads can be effectively transferred between the trunk, pelvisand legs
Pel J.M. Spoor C. W, Pool-Goudzwaard A. L,. Hoek van Dijke G. A, Snijders C.J.. Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces. Ann Biomed Eng. 2008 March; 36(3): 415–424.
- TRANSV ABD AND PELVIC FLOOR EXHIBIT ANTICIPATORYSTABILIZING ABILITY (APAs) WHICH IS A KEY FOR SIJs STABILITY
Richardson CA, Snijders CJ, Hides JA, et al. The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain. Spine (Phila Pa 1976) 2002;27:399–405.
- TRANSV ABD AND PELVIC FLOOR CONTRACTIONNECESSARILY SUPPOSE AN INCREASE IN IAP
Neumann P1, Gill V. Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(2):125-32.
- TRANSV ABD AND PELVIC FLOOR ARE PART OF THE «RESPIRATORY POSTURAL MUSCULAR SERIE » AND ( due to «  in serie »mechanics) « PRESSURE COLUMN » IS THEN ACTIVATED
Finet G, Williame C. Traité d’ostéopathie. 2016. www.publier-un-livre.com

«CAPACITA’ POSTURO CINETICA» ( PKC )

- As a modern view of postural adjustments, the“Posturo-Kinetic Capacity” (PKC) has been defined as the capacity of anindividual to generate efficient postural adjustments in response to aperturbation (internal or external).
- PKC emphasized the importance of postural jointmobility to ensure an efficient postural counter perturbation.
Yiou E, Caderby T, Hussein T. Adaptability of anticipatory postural adjustments associated with voluntary movement. World J Orthop. 2012 Jun 18; 3(6): 75–86.
- Focal and  postural movements are usuallylocated in distinct parts of the musculo-skeletal system. For example, abimanual isometric push task involves the mobility of the pelvis
Le Bozec S., Bouisset S. (2004). Does postural chain mobility influence muscular control in sitting ramp pushes? Exp. Brain Res. 158, 427–437.

MODello Disfunzionale

MATRICE EXTRACELLULARE (ECMS)

- On the level of organs, external mechanical forces largely influence the control of tissue homeostasis
Chiquet M, Gelman L, Lutz R, Maier S. From mechanotransduction to extracellular matrix gene expression in fibroblasts. Biochim Biophys Acta. 2009 May;1793(5):911-20.
- Extracellular matrices (ECMs) transduce mechanical signals into changes in tissue structure, a process termed  mecanotransduction 552
- Diseases of extracellular matrices involve pathological levels of mechanical forces that impact the gene expression repertoires and function of bone, cartilage, and soft connective tissues.
Chan MW1, Hinz B, McCulloch CA. Mechanical induction of gene expression in connective tissue cells. Methods Cell Biol. 2010;98:178-205.
- AS A CONSEQUENCE, « PRESSURE COLUMN » MUST BE ACTIVATED IN A TRANSIENT AND NOT PERMAMENT WAY, OTHERWISE, JOINT STABILITY AND TISSUE MECANOTRANSDUCTION I.E. HOMEOSTASIS, WILL BE COMPROMISED
Finet G, Williame C. Traité d’ostéopathie. 2016. www.publier-un-livre.com

EPIDEMIOLOGIA

DIVERSI STUDI MOSTRANO CHE DIVERSI GRUPPI DI PERSONE PRESENTANO UN AUMENTO CRONICO DELLA PRESSIONE ADDOMINALE:

Gruppo 1. Lombalgie o lombo-sacralgie
Gruppo 2. Stato post chirurgico (laparoscopia)
Gruppo 3. Obesità
Gruppo 4. Post-parto
Gruppo 5. Gonfiore addominale
Gruppo 6. Malattia polmonare ostruttiva cronica [BPCO]
Gruppo 7. Pesisti, atleti e lavoratori che portano regolarmente dei pesi

CONSIDERANDO CHE LA “COLONNA DI PRESSIONE” © È IL RISULTATO DI UN'ASSOLUTA INTERDIPENDENZA TRA LA SERIE MUSCOLO RESPIRATORIO-POSTURALE E LE PRESSIONI ADDOMINALI, TORACICHE, INTRA-CRANICHE, QUESTI GRUPPI MOSTRERANNO UN'ATTIVAZIONE DI PRESSIONE PERMANENTE UNI O BILATERALE»© Finet G, Williame C. Trattato di osteopatia. 2016.  www.publier-un-livre.com

QUESTO PORTA A:
- maggiore tensione muscolare lungo il tronco con conseguente APA più lunghi - la rigidità muscolare nella catena posturale può rallentare i movimenti di compenso necessari per mantenere il corpo stabile e renderli meno efficaci
- la rigidità muscolare attiva lungo il tronco, quando supera un determinato livello, rischia di modificare la capacità posturo-cinetica, il che può avere implicazioni per le strategie di trattamento.
Hamaoui A, Alamini-Rodrigues C. Effect of Experimentally-Induced Trunk Muscular Tensions on the Sit-to-Stand Task Performance and Associated Postural Adjustments. Front Hum Neurosci. 2017; 11: 32

VARIABILITA’

- Mature motor skills and healthy states are associated with an optimal amount of movement variability  
- LESS than optimal movement variability characterizes biological systems that are overly rigid and unchanging
- whereas GREATER than optimal variability characterizes systems that are noisy and unstable.
- Both situations characterize systems that are less adaptable to perturbations
Stergiou N, Harbourne R, Cavanaugh J. Optimal movement variability: a new theoretical perspective for neurologic physical   therapy. J Neurol Phys Ther. 2006 Sep;30(3):120-9.
- altered diaphragm function leads to core muscles instability, which will further lead to other systemic and musculoskeletal disorders including spinal instability
Hamayun Zafar,  Ali Albarrati, Ahmad H. Alghadir, Zaheen A. Iqbal. Effect of Different Head-Neck Postures on the Respiratory Function in Healthy Males.Biomed Res Int. 2018; 2018: 4518269.
- Persons with recurrent low back pain exhibit a rigid postural control strategy
Simon Brumagne,1 Lotte Janssens,1 Stefanie Knapen,1 Kurt Claeys,1 and Ege Suuden-Johanson. Persons with recurrent low back pain exhibit a rigid postural control strategy .Eur Spine J. 2008 Sep; 17(9): 1177–1184.

IL MODELLO DELLE «COLONNE DI PRESSIONE» ©

QUALSIASI AUMENTO FISIOLOGICO DELLA PRESSIONE ADDOMINALE (Pab) DOVREBBE ESSERE SOLO TRANSITORIO.

Qualsiasi aumento cronico della pressione addominale (Pab) si tradurrà in un'attivazione permanente della serie muscolare posturo-respiratoria: le colonne di pressione si attivano quindi dal processo mastoideo temporale al pavimento pelvico!

L'aumento cronico della pressione porta a cambiamenti nelle proprietà dei tessuti circostanti. Questa risposta provoca rigidità che porta alla perdita delle proprietà viscoelastiche di questi tessuti, della qualità delle matrici extracellulari, della mobilità di questi tessuti, degli scambi di fluidi e della risposta neurovegetativa.

Come corollario, l'omeostasi di questi tessuti può essere compromessa.Un aumento permanente della pressione addominale (Pab) comporta l'applicazione di pressioni permanenti sulle articolazioni sacroiliache e sulla colonna vertebrale, coinvolgendo tutti i muscoli del cilindro pelvico-lombare-addominale: questi muscoli generano e dipendono dalla pressione addominale (Pab). Questi muscoli striati, lavorando continuamente, si indeboliscono e perdono i loro APA - aggiustamenti posturali anticipatori: la capacità posturo-cinetica sarà quindi compromessa.

La “variabilità” del movimento sarà piuttosto “rigidità”, e verificabile controllando la postura attraverso l'applicazione PROSYM © su smartphone. (www.prosymetrical.com)

Queste colonne di pressione permanentemente attive aumenteranno notevolmente la pressione in tutte le sfere: ripercussioni sul torace, sul forame giugulare, che possono limitare il flusso venoso giugulare centripeto e influenzare la pressione intracranica. Il sovraccarico permanente avrà effetti nocicettivi sulle pressioni trasferite dalle articolazioni sacro-iliache che sovraccaricheranno gli arti inferiori, compromettendo eventualmente l'omeostasi della colonna vertebrale e delle articolazioni sacroiliache, della sfera viscerale e urogenitale, riducendo il movimento dei visceri ed esercitando un carico eccessivo su questi visceri.

Tutto ciò porta a un modello disfunzionale notevolmente globale.

TRATTAMENTO OSTEOPATICO

Il trattamento osteopatico dovrebbe includere il motivo del consulto del paziente nella metodologia delle "Colonna della pressione" ©, ovvero:

- L'anamnesi dovrebbe concentrarsi sulla determinazione del gruppo epidemiologico del paziente.

- La diagnosi palpatoria dovrebbe valutare le conseguenze delle pressioni intra-addominali, toraciche e craniche, la rigidità della serie muscolare posturo-respiratoria al fine di definire la "colonna di pressione".

- Gli aggiustamenti posturali anticipatori - APA’s, la capacità posturo-cinetica e la variabilità vanno studiati con l'applicazione PROSYM © su smartphone

- La "Procedura Finet & Williame" © (tecniche osteopatiche globali e specifiche) sarà applicata tenendo presente che "I movimenti focali e posturali sono generalmente localizzati in parti distinte del sistema muscolo-scheletrico", il che può spiegare perché e come l'osteopata deve rispettare un approccio globale al paziente

- Il trattamento osteopatico mira a ridurre le conseguenze della disfunzione delle "colonne di pressione" al fine di guadagnare capacità e variabilità posturo-cinetica.

- Gli effetti positivi del trattamento devono essere valutati mediante diagnosi palpatoria, miglioramento della mobilità, controllo della variabilità con l'applicazione per smartphone PROSYM © e valutazione del miglioramento del disturbo del paziente.