Resumo: O modelo “Colunas de Pressão” ©

Tratamento da dor aguda e crônica
DADOS BASEADOS EM EVIDÊNCIAS

FUNCTIONAL MODEL

SOBRE "MÚSCULOS EM SÉRIE"

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.

DIAFRAGMA, RESPIRAÇÃO, POSTURA E MÚSCULOS EM SÉRIE

DIAPHRAGM, TRANSVERSUS ABD, PELVIC FLOOR AND INTERCOSTAL, SCALENES, STERNOMASTOID and TRAPEZE MUSCLES ARE INEXTRICABLY INVOLVED IN A « RESPIRATORY POSTURAL MUSCULAR SERIE » (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.

O MODELO DE “COLUNAS DE PRESSÃO” © 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 COLUMNS » IS THE RESULT OF ABSOLUTE INTERDEPENDANCE BETWEEN RESPIRATORY-POSTURAL SERIE AND IAP, TP, ICP
Finet&Williame

PRESSÃO INTRA-ABDOMINAL E COLUNA

The diaphragm and abdominal muscles together create a hydraulic effect in the abdominal cavity, which assists spinal stabilization by stiffening the lumbar spine through increased intra-abdominal pressure
Kolar P et al. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol . 2010     Oct;109(4):1064-71

VISCERAL E URO-GENITAL

- 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 is repetitive (around 25000 x a day) and  show a common pattern for a large population. Visceral slide and visceral homeostasis depend on Intra Abdominal Pressure
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

ANTICIPATED POSTURAL ADJUSTMENTS (APAs) AND POSTURO-KINETIC ABILITY (PKC): KEYS FOR A GLOBAL OSTEOPATHIC APPROACH

THE GRAVITY FIELD

- 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.

ANTICIPATED POSTURAL ADJUSTMENTS: 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

postural oscillation (postural sway)

- 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.

PITCH AND ROLL :  POSTURAL OSCILLATION CONTROL

- Anterior-posterior (pitch) plane postural sway  is mainly controlled by ANKLE muscles
- Mediolateral (roll) plane postural sway is mainly controlled 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 involve interaction 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.

Sacroiliac joint (sij)

- to overcome the forces of gravity and shear, « force closure » ideally generates a perpendicular compressional reaction force to the SIJs
- TRANSVERSUS ABDOMINIS close the pelvis superiorly and PELVIC FLOOR MUSCLES close the pelvis inferiorly and are involved in force closure of the SIJs
- When this mechanism works efficiently in the pelvis, the shear forces between the iliac bones and sacrum are adequately controlled, and loads can be effectively transferred between the trunk, pelvis and 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 ANTICIPATORY STABILIZING 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 CONTRACTION NECESSARILY 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

« POSTURO-KINETIC CAPACITY» ( PKC )

- As a modern view of postural adjustments, the “Posturo-Kinetic Capacity” (PKC) has been defined as the capacity of an individual to generate efficient postural adjustments in response to a perturbation (internal or external).
- PKC emphasized the importance of postural joint mobility 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 usually located in distinct parts of the musculo-skeletal system. For example, a bimanual 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.

DYSFUNCTIONAL MODEL

EXTRACELLULAR MATRICES (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

EPIDEMIOLOGY

EPIDEMIOLOGIA VÁRIOS ESTUDOS MOSTRAM GRUPOS DE PESSOAS COMAUMENTO CRÔNICO DA PRESSÃO ABDOMINAL:  
Grupo 1. Dor lombar ou lombossacralgia Grupo
2. Condição pós-cirúrgica(laparoscopia)) 
Grupo 3. Obesidade 
Grupo 4. Pós-parto 
Grupo 5. Inchaço abdominal 
Grupo 6. Doença Pulmonar Obstrutiva Crônica[BPCO] 
Grupo 7. Fisiculturistas, atletas etrabalhadores que regularmente carregam pesos pesados  

UMA VEZ QUE AS "COLUNAS DE PRESSÃO" ©SÃO O RESULTADO DE UMA INTERDEPENDÊNCIA ABSOLUTA ENTRE A SÉRIE MÚSCULORESPIRATÓRIO-POSTURAL E AS PRESSÕES ABDOMINAL, TORÁCICA, INTRACRANIANA, ESTESGRUPOS MOSTRARÃO UMA ATIVAÇÃO UNI OU BI-LATERAL PERMANENTE DAS “COLUNAS DEPRESSÃO" 


Finet G, Williame C. Treatise on osteopathy. 2016. www.publier-un-livre.com

TIsto leva a: 

- maior tensão muscular ao longo do troncolevando a uma modificação dos APAs

- a rigidez muscular da cadeia postural podedesacelerar os movimentos contra-perturbadores necessários para manter o corpoestável e torná-los menos eficazes 

- a rigidez muscular ativa ao longo do tronco,quando ultrapassa um determinado nível, pode modificar a capacidade posturo-cinética, o que pode ter implicações nas estratégias detratamento. 
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

VARIABILITY

- 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.

The "pressure columns" model ©

ANY PHYSIOLOGICAL INCREASE IN ABDOMINAL PRESSURE (Pab) SHOULD ONLY BE TRANSITORY.

Any chronic increase in Pab will result in permanent activation of the respiratory-postural muscle series: the pressure columns then apply from the temporal mastoid process to the pelvic floor!

The chronic increase in pressure leads to changes in the properties of the surrounding tissues. This response causes rigidity which leads to the loss of the viscoelastic properties of these tissues, the quality of the extracellular matrices, the mobility of these tissues, the fluid exchanges and the neurovegetative response.

As a corollary, the homeostasis of these tissues may be altered. A permanent increase in Pab leads to the application of permanent pressure on the sacroiliac joints and on the spine, involving all the muscles of the pelvic-lumbar-abdominal cylinder: these muscles generate Pab and also depend on it. These striated muscles, when they work permanently, weaken and lose their APAs: the Posturo-kinetic Capacity will then be compromised.

The "variability" of the movement would become rather "rigidity", which could be verified by the posture control, which is possible with the PROSYM© application on smartphone. (www.prosymetrical.com)

These permanently active pressure columns will significantly increase the pressure in all spheres: repercussions on the thorax, on the jugular foramen, which can limit the centripetal jugular venous flow and influence the intracranial pressure. The permanent overload will have nociceptive effects on the pressures transferred by the sacroiliac joints which will overload the lower limbs, possibly compromising the homeostasis of the spine and sacroiliac joints, the visceral and urogenital sphere, reducing the movement of the viscera and exerting an excessive load on them.

All this leads to a remarkably global dysfunctional pattern.

OSTEOPATHIC TREATMENT

Osteopathic treatment should include the patient's complaint in the "Pressure Column" © methodology, i.e. :

- The anamnesis should focus on determining the patient's epidemiological group.
- The palpation diagnosis should evaluate the consequences of intra-abdominal, thoracic and cranial pressures, the rigidity of the respiratory-postural muscle series in order to define the "pressure column".
- ABSs, posturokinetic capacity and variability should be studied with the PROSYM © application on smartphone
- The "Finet & Williame Procedure" © (global and specific osteopathic techniques) will be applied keeping in mind that "Focal and postural movements are generally located in distinct parts of the musculoskeletal system", which may explain why and how the osteopath must respect a global approach to the patient - The osteopathic treatment aims at reducing the consequences of dysfunction of the "pressure columns" in order to gain in posturo-kinetic capacity and variability.
- The positive effects of the treatment should be assessed by palpatory diagnosis, improvement of mobility, control of variability with the PROSYM © smartphone application and evaluation of the improvement of the patient's complaint.