Myofascial Pain and TreatmentGlobal physiotherapy approach to thoracolumbar junction syndrome. A case report
Introduction
Low back pain is currently the leading cause of disability in the world (Hartvigsen et al., 2018; GBD, 2015; 2016). It is estimated that 80% of people will suffer from it at least once in their lifetime (Andersson, 1999). It represents a real public health challenge. The diagnosis, often influenced by medical imaging, and treatment are usually planned around the lower lumbar area. This neglects the role of the thoracolumbar junction, which, according to Maigne is considered as a contributor to low back pain cases (Maigne, 1980; Akgun et al., 2006). Thoracolumbar junction syndrome or Maigne's syndrome (TLJS) is characterized by referred pain originating in a minor intervertebral dysfunction (MID) of the thoracolumbar junction. Maigne called it segmental cellulotenoperiosteomyalgic syndrome. They defined MID, as “a vertebral segmental dysfunction, benign and reversible, of mechanical and reflexive nature, which tends to be self-sustaining” (Maigne, 1981).
The posterior thoracic joint alignments in the frontal plane and posterior lumbar joint alignments in the sagittal plane produce powerful mechanical stresses in the thoracolumbar junction zone, especially during rotational movement. The ribs also limit thoracic rotation, reinforcing stress in this transitional zone. This results in interapophyseal joint pain at this level, causing referred pain in the cutaneous areas of the posterior or anterior branches of the T12 and L1 vertebral nerves (Maigne et al., 1989).
Symptoms include lumbosacral area, lumbogluteal area, or sacroiliac pain from the posterior nerve root. They cause supratrochanteric hip pain arising from the lateral perforating branch of the anterior nerve root and pseudo-visceral (colon irritation), inguinal, or pubic pain arising from the anterior nerve root. These signs can be isolated or concomitant (Maigne, 2006).
The most commonly used therapies published in various studies are vertebral manipulations (Maigne, 1980; Kim et al., 2013; Proctor et al., 1985; DiMond, 2017; Sebastian, 2006), joint infiltration (Maigne, 1980; Kim et al., 2013; Alptekin et al., 2017), exercises and proprioceptive re-education (Alptekin et al., 2017; Aktas et al., 2014; Fortin, 2003). A global physiotherapy approach has not been proposed, although there are methods widely used in the clinical field, such as the Mézières (Paolucci et al., 2017a, Paolucci et al., 2017b) and Godelive Denys-Struyf methods (Arribas et al., 2009) or Global Postural Re-education (Ferreira et al., 2016).
The Mézières Method (MM) created by Françoise Mézières in 1947, is based on the concept of muscular and functional bodily unity (Table 1) (Mézières, 1984). A recent article describes how the MM application has evolved since its discovery (Ramírez Moreno and Revilla Gutiérrez, 2018). The MM is held to reduce pain and improve functionality in cases of neuro-musculoskeletal disorders, as part of a biopsychosocial approach to wellbeing. It is based on stretching the myofascial chains. It includes manual techniques (MT), symmetrical and asymmetrical therapeutic exercises, sensorimotor re-education and breathing exercises.
The aim of this study is to report on the effectiveness of the MM in reducing pain and improving posture in a patient diagnosed with TLJS.
Section snippets
Description of the patient and her history
A 42-year-old Caucasian female with a body mass index of 17,9 kg/m2, presented herself for consultation with a two-year history of right inguinal fold pain. She has an ectomorphic somatotype possibly associated with hereditary factors. She does not practice sport regularly. She is married and health worker about 8 h a day. She was sent by her osteopath who diagnosed her with TLJS but whose intervention was not effective in improving her pain. During the process of anamnesis, red flags
Intervention
Treatment consisted of ten weekly sixty-minute MM sessions, performed by the same practitioner (Table 3), and following some therapeutic exercises as reported in the published literature (Patté, 2009, 2018; Sider, 2013a, Sider, 2013b; Godelieve Struyf-Denys, 1995). These different Mézières therapeutic exercises always took care to avoid any compensation. Additionally, a range of concomitant MT were performed, consisting of myotensive, articular and neuromuscular techniques, palpated-rolling and
Results
Tests for pain at (t1), performed under the same conditions, were all negative with a NRS of 0. Table 4 shows the biometric measurements at (t0), (t1) and (t2), using the ADiBAS system, as well as the reference values of certain parameters reported in the literature. During the three treatment periods, each parameter was measured twice, giving a Pearson reliability coefficient (R) > 0.9. In the vertebral sagittal plane at (t1), the PTA (pelvic tilt angle) and LSLA (Lumbosacral lordosis angle)
Discussion
TLJS is one of the common causes of lower lumbar and proximal lower limb pain, which is diagnosed clinically. Because it is not well understood, its symptomatology is often confused with other origins, such as sciatica, lower back pain, pain of sacroiliac origin or tendinopathies of the psoas muscle, supratrochanteric and pubic (Delavierre et al., 2010). Medical imaging does not provide a conclusive diagnosis (Ren et al., 1999). On the other hand, the anaesthetic infiltration of the
Conclusion
Presenting a single case report does not provide a definitive treatment for TLJS. However, short and medium term pain reduction, as well as a slight normalization of posture in the frontal and sagittal planes, combined with improved extensibility of the myofascial chains, justify other clinical trials demonstrating the validity of the Mézières Method in patients with TLJS.
Limitations
Treatment in this case report was performed by a physiotherapist experienced in the fields of manual therapy and osteopathy. His short experience (one year) in the practice of the MM may contribute to the variability of results, especially in postural changes.
Ethical guidelines
The entire protocol followed the recommendations for human research provided in the Declaration of Helsinki. The patient signed an informed consent form.
CRediT authorship contribution statement
Yvan Ségui: Conceptualization, Investigation, Writing - review & editing. Jose Ramírez-Moreno: Methodology, Formal analysis, Validation, Project administration.
Declaration of competing interest
The authors declare no conflict of interest.
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