Received 27 May 2016; accepted 17 July 2016; published 20 July 2016
1. The Regional Interdependence in Clinical Practice
Figure 1. Legend: Regional Interdependence (RI), Lower Quadrant (A); Front Quadrant (B); Upper Quadrant (C).
2. Lower Quadrant
2.1. Data Collection
A 52-year-old male patient went to consultation for LBP with rear side radiation to the gluteus, which propagates in the groin from the right side since almost three months. This continuous pain, except during the nighttime, increases in the early morning and then after few steps fades and reappears more pronounced in the evening. After having consulted the Family Practitioner (FP) and the Orthopedical doctor, was referred to have lumbar Nuclear Magnetic Resonance (NMR), which showed disc protrusion of L5S1 highlighting a wide-ranging that non-imprints the dural sac. Also after the recommendation to rest and use if necessary not Steroidal Anti-Inflammatory Drugs (NSAIDs), nothing changed. At the remote anamnesis, he reported having had 20 years ago a surgery on his right knee with meniscus-external excision and reconstruction of the anterior cruciate ligament (ACL), with the presence of almost −10˚ extension deficit. The trauma took place during a game of football. Moreover, he reported having pneumonia two years ago.
2.2. Musculoskeletal Assessment
The lumbar spine showed a recti linearization of the curve with a limited stiffness. The right hip has a lower internal rotation of 20 degrees compared to the contralateral. Patrick’s test, Scour tests, Hip Flexion Test, Thomas Test to the right psoas were positive, as well as the performance of the hip abduction test (motor control) of the right side were positive. At the end of evaluation was carried out the Visual Analogic Scale (VAS) and Oswestry Disability Index Scale (ODI) as well as at the end of the last session.
2.3. Functional Diagnostic Conclusions
The lower back pain of right side with groin irradiation it is due to the hip, which causes loss of mobility during rotation and extension movements.
2.4. Therapeutic Proposal
Osteopathic Manipulative Treatment (OMT) and home exercise program. OMT protocol consists in Long-axis distraction with hip thrust, anterior-posterior directed force to the proximal femur non-thrust, poster-anterior directed force to the proximal femur non-thrust, right Hip caudal glide mobilization with the belt support, Muscle energy technique (Me) Psoas right. The home exercise program consists of: Aerobic exercise (up to 10 minutes cycle or walk); Strengthening (3 sets of 10 repetitions of hip abduction (Abd), hip extension, hip lateral rotation); Knee extension; Stretching (60 seconds passive stretch of the hip flexors, knee extensors, hip extensors, knee flexors, hip abductors and lateral rotators, ankle plantar flexors).
There have been five OMT sessions. The first two sessions were in the first week of treatment, in the second week was made the third session where at the end the patient was trained to home exercise program to do every other day until the end of the treatment protocol (5 Weeks). The last session, the fifth, was done 15 days after the fourth session. Each of OMT treatment session lasted around 25 - 30 minutes. The home-exercise program took about 30 - 40 minutes.
The patient had significantly improved the symptoms already after the first week of treatment and decreased during the treatment sessions. The symptoms went from an initial VAS score of 8 in the first assessment, to a VAS of 2 at the end of the five weeks treatment. In the performance of the Oswestry Disability Index scale (ODI) scale the percentage scored from 8%, (equivalent to moderate disability) to a percentage of 10% (equivalent to minimum disability) at the end of the five weeks treatment protocol. Symptoms and the score of the scales improved and the patient reported that he had a better hip mobility and had less difficulty to get on the bike by lifting the right leg.
3. Front Quadrant
3.1. Data Collection
A 41-year-old nulliparous female patient, which had a medical consultation for constant pain with a sense of constant lumbar heaviness during the daytime, with increased symptoms after eating or when constipation were present. Symptoms present since returning to Italy after a period of 5 months abroad for work purposes. She also reported that once in Italy after meals she swelled. The FP investigated the symptoms with negative results, and excluded any problem through a gynecological specialist examination. The anamnesis did not reflected comorbidities and systemic diseases as well as the absence of surgeries, not use drugs (including birth control pills).
3.2. Musculoskeletal Evaluation
Stiffness of the lumbar spine is enhanced. No mobility limitations in the lower back and the spring test were negative, with no radiation of pain to the gluteus or below the knees. To abdominal palpation was present muscles’ tension in all the quadrants, with sensation of pain radiating posteriorly above the right iliac fossa and even more pain in the mesogastrium area. The Thomas test scored positive on the right side. At the end of the evaluation was carried the ODI as well as at the end of the last session.
3.3. Functional Diagnostic Conclusions
The low back pain, based on the functional assessment, is thought to be due to an anterior visceral-somatic irradiation caused by the bowel. For this reason, were done specific sessions of OMT and the patient was directed to consult a specialist in nutrition, in order to follow a nutritional protocol to treat gastrointestinal dysfunction (Table 1).
3.4. Therapeutic Proposal
Consisted in following the OMT: Me and CS (counterstrain treatment) Psoas Muscle, Lower Thoracic cage Release (for Diaphragm release), Me Transitional D12L1 area, Mid Thoracic Extension/Closing Manipulation, Maneuver VIS (visceral manipulative treatment) of the ileoceale tract, and “Mesenteric Lift Manouver” and high velocity low amplitude (HVLA) Sacral Iliac Transitional to the root of the mesentery.
Were done five OMT treatment sessions: the firsts two during the first week, one section during the second week,
Table 1. General dietary advice for patients with IBS.
Prebiotics: psyllium and inulin; Probiotic: combinations of Lactobacilli, Bifidobacteria, and Streptococci. N.B.: assess tolerance to gluten, fructose, and low-lactose dairy products by means of a breath test.
than a week off, a section in the fourth week, three week off, and the last session on the eighth week. So the session was carried within two months. During the last session was carried the ODI scale. The duration of each session ranges from 20 to 40 minutes, depending on the patient’s tolerance and response of the tissues. Nutritional regimen was followed starting from the second OMT session and had to be followed for at least 6 months.
The patient already improved after the first week of treatment (after 2 sessions of OMT), presenting less lower back pain and less feeling of heaviness, even if it remained some bloating after eating and hive’s irregularities, but the constipation decreased. At the end of the last session of the treatment protocol, the patient no longer presented the initial symptoms, and the abdominal bloating was almost disappeared after meals and the bowel function returned almost entirely legitimate. In the ODI scale the percentage changed from the initial 28% (equivalent to moderate disability), to 8% (equivalent to mild disability) at the end of the two months of treatment.
4. Upper Quadrant
4.1. Data Collection
A 38-year-old male patient went to consult for right anterior shoulder pain, which was present since almost two months and arising after having lifted a tarpaulin cover. Pain was continuously present, except at nighttime and in the intermediate position of the elevation of the shoulder. During the anamnesis, he reported that 15 years ago had a surgery for an appendectomy, and two years ago he had a fracture of the right fibula which was treated with pinstripe valve for 20 days.
4.2. Musculoskeletal Assessment
The patient resulted positive to the Hawkins Kennedy Test, Arc Sign in painful Abd between 60 - 120 degrees, weakness detected during the infraspinatus muscle test. During the functional examination of the cervical-dorsal junction and upper thoracic spine and medium, was present hypo mobility during extension, flexion and rotation movements through application of an anteroposterior pressure on the spinous processes and the transverses. It was also detected hypomobility of costovertebral joint of the first right rib. Shoulder active ROM evaluation included flexion (F), Abd, external rotation (ER) and internal rotation (IR). The VAS scale was assessed at the beginning and the end of treatment.
4.3. Functional Diagnostic Conclusions
The anterior shoulder pain perceived on the right was due to the cervical/dorsal junction, due to the first coast and the middle-upper thoracic spine.
4.4. Therapeutic Proposal
The patient received OMT treatment of soft tissue (ST) of the upper trapezius sitting, SCOM and muscle paravertebral upper dorsal, one maneuver of HVLA to the cervical/dorsal junction, one maneuver of HVLA to the right coast while supine, one HVLA maneuver to the middle dorsal spine from the supine position.
Three sessions were carried to the patient. The first OMT treatment was carried out after the initial assessment. Other 2 treatments were carried out after 1 week and after 3 weeks. Each session lasted for 25 - 30 minutes and the treatment protocol had a total duration of 1 month (4 weeks).
At the initial assessment, the patient had a score in the VAS scale of 8 and the active range of motion (ROM) was F: 100˚, Abd: 95˚, ER: 110˚. Right after the first week of treatment, the patient has significantly improved shoulder mobility to F: 115˚ Abd: 115˚ ER: 120˚ and does not report feeling of pain. Before the second session, the patient reported that the week after the first treatment session, the pain significantly decreased from a VAS of 8 to a VAS of 5. Mobility remained the same of the first session. After the second session, the shoulder mobility improved to F: 130˚, Abd: 130˚, ER: 135˚; the VAS remained unchanged. At the third treatment session, the patient reported that the pain was almost disappeared and reported VAS of 2, describing to feel more “light” and to have reached greater mobility at the cervicodorsal level as well as preserved the shoulder mobility reached after the second session. With the third treatment further improved, the shoulder mobility reached F: 145˚, Abd: 145˚, ER: 160˚, with the resolution of the pain (VAS = 0).
Despite the lack of healthy control data, the three case reports support the concept of a functional assessment and treatment oriented towards a framework concept  .
The fallout that could happen during the clinical practice applying the RI model offered greater support and integration in the rehabilitation activities and a better patient management in functional terms (improving signs and symptoms), but also improving quality of life, containment of health care costs  . In this way, it would be possible to take consciousness of the resources available, not only from management and evaluation of the output point of view (measurable products of the individual activities provided by the treatment), but with an evaluation of the outcomes (i.e. measuring only users’ health status, quality of life). Nowadays the professional skills are essential both to improve the quality of service offered and to optimize the resources, taking into account the patient care experience that continues to be underestimated. The direction of research in the reliability and the application of the RI model is promising and is trying to improve the methodological aspects of the studies as well as the clinical impact as a classification tool, providing, in this way, accurate strategies in the implementation of the rehabilitation practice.
ACL: Anterior Cruciate Ligament
ANS: Autonomic Nervous System
CS: Counterstrain Treatment
ER: External Rotation
FP: Family practitioner
HVLA: High Velocity Low Amplitude
ICD-10 CM: International Classification of Disease V. 10
IR: Internal Rotation
LBP: Low Back Pain
M 99.09: Code Segmental and somatic dysfunction of abdomen and other regions (ICD-10CM)
Me: Muscle Energy
NMR: Nuclear Magnetic Resonance
NSAIDs: Non Steroidal Anti-Inflammatory Drugs
ODI: Oswestry Disability Index
OMT: Osteopathic Manipulative Treatment
PFPS: Patellofemoral Pain Syndrome
PNS: Peripheral Nervous System
RI: Regional Interdipendence
ROM: Range Of Motion
SD: Somatic Dysfunction
ST: Soft Tissue
VAS: Visual Analogic Scale
VIS: Visceral Manipulative Treatment
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