1/11/2015

NEUROMIOTERAPIA SEGMENTAR: ESTUDOS DE ERIC KANDEL, PRMIO NOBEL DE FISIOLOGIA, MOSTRAM A POSSIBILIDADE DE R

19th March 2011

NEUROMIOTERAPIA SEGMENTAR: ESTUDOS DE

ERIC KANDEL, PRMIO NOBEL DE FISIOLOGIA,
MOSTRAM A POSSIBILIDADE DE REVERSO DA
SENSITIZAO SEGMENTAR ALIADA DA
FISIOTERAPIA BASEADA EM EVIDNCIAS!

Vejaaapresentao do Prof Kandel [http://nobelprize.org/nobel_prizes/medicine/laureates/2000/kandel-lecture.html] diante

do comit do Prmio Nobel e compreenda um pouco mais sobre uma tcnica simples e efetiva no combate s
doresmusculoesquelticas,deacordocomartigodoDrGianpaolodeSena.

SegmentalNeuromyotherapy:basicconceptsandpracticalapplications
Objectives:
Understand the clinical application of the concepts of peripheral and central sensitization in the most
commonpainconditionsinPhysicalandRehabilitationMedicinepractice
Overviewthebasicconceptsofperipheralandcentralsensitizationofthedorsalhornneuronsandtheir
correlationtoclinicalfindingsonphysicalexam
Identifythespinalsegmentlevelofinvolvement
Applydesensitizationtechniquesforfunctionalandqualityofliferecovery
Presenttheimmediateandlongtermeffectsachievedbythisapproach
BACKGROUNDANDOVERVIEWOFTHESEGMENTALNEUROMYOTHERAPYMODEL

Spinal Segmental Sensitization (SSS) is a hyperactive state of the spinal cord caused by irritative foci sending
nociceptiveimpulsesfromasensitizeddamagedtissuetodorsalhornneurons.Theclinicalmanifestationofdorsal
horn sensitization includes hyperalgesia of the dermatome, pressure pain sensitivity of the sclerotome and
myofascial trigger points within the myotomes, which are supplied by the sensitized spinal segment. Shah et al.
(2005)foundthatactivemyofascialtriggerpointspresentlowerpressurepainthresholdwhencomparedtopeople
withnopainorthepresenceofonlylatenttriggerpoints.Theyalsodemonstratedthedistinctinvivobiochemical
milieu of muscle with significant elevated levels of substance P, calcitonin generelated peptide (CGRP),
bradykinin,tumornecrosisfactor(TNF)andinterleukin1(IL1),serotonin,andnorepinephrineinthevicinity
oftheactivemyofascialtriggerpointattheuppertrapeziusmuscle.Overall,pHwassignificantlowerintheactive
trigger point. Treatment rationale and techniques may evolve from this information, and should be taken into
accountwhendealingwithchronicpatientswithamplifiedpainresponses.Irritativefociintheformofmyofascial
trigger points (MTrPs) located within the associated myotomes and tender spots in the supra/interspinous
ligaments (SSL/ISL) of the segment frequently lead to SSS. The mechanism consists of the nociceptive stimuli
generated in the sensitized areas bombarding the dorsal horn of the spinal cord. This causes central nervous
systemsensitizationwithresultanthyperalgesiaofthedermatomeandsclerotomeandspreadsfromthesensory
component of the spinal segment to the anterior horn cells, which control the myotome within the territory of the
SSS.TheimportanceofSSSisemphasizedbythefactthatitisconsistentlyassociatedwithmusculoskeletalpain.
For example, thoracic SSS facilitates and perpetuates abdominal pain and somatovisceral symptoms commonly
mimickingGIdisorders.ThedevelopmentoramplifiedactivityofMTrPsisoneoftheclinicalmanifestationsofSSS.
FailuretorecognizeanddiagnoseSSSoftenleadstoonlytemporarydeactivationofMTrPs,sincephysicaltherapy
andtriggerpointinjectionproceduresareaimedattreatingtheperipheralMTrPswithoutaddressingthesegmental
dysfunction. This may lead to transient benefit rather than long term relief because MTrPs and their associated
symptomsfrequentlyrecur.
Eradication of the sensitized spinal segment by the technique of paraspinous block (PSB) with 1% Lidocaine
effectively desensitizes (reverses to normal sensitivity) the SSS by blocking the nociceptive impulses from the
SSL/ISL and prevents afferent bombardment of the dorsal horn. Subsequent needling and infiltration of the
SSL/ISL with 1% Lidocaine as well as needling and infiltration of MTrPs in the myotome of the territory of the
sensitizedspinalsegmentleadstolongtermreliefofneuromusculoskeletalpainanddysfunction.
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NEUROMIOTERAPIA SEGMENTAR: ESTUDOS DE ERIC KANDEL, PRMIO NOBEL DE FISIOLOGIA, MOSTRAM A POSSIBILIDADE DE R

Because Spinal Segmental Sensitization (SSS) is a hyperactive state of the spinal cord caused by irritative foci
sendingnociceptiveimpulsesfromasensitizeddamagedtissuetodorsalhornneuronsisimportanttotakeaway
theprymaryirritaitvefoci.
Ifisnotpossibletodeliverneedlingandinjectionsothertherapiescanbeusedtodesensitizethesegmentandto
treatit.
That can be possible i.e. if the patient has some specific allergies, if needling and injection are not covered by
insuranceorbythenationalhealthsystem,orifthepatientdoesntlikeordoesentwanttobeinjected.
ThesetherapiesmustbeusedfollowingtheprofFischersconceptofthesensitizedsegment.
Afterthesensitizedsegmentisdiagnosedanditisdetectedtheimmediatecauseofpain,wecantreatboththe
vertebralsegmentandtheirritativefociwiththeseothertherapies.Therapiesalreadybeenprooventobeeffective
innonspecificpainare,spinalmanipulation,acupuncture,massage,andantiinflammatorydrugs.Otherthanthis
wecantforgetthatoneofthemostimportantdesensitizationisduetoantinflammatoryagents.

A.Identificationoftheimmediatecauseofpain:
Askpatienttopointwithonefingerwherethemostintensivepainis.
Findthepointofmaximumtenderness.
Reproduction(recognition)ofpain:Pressoverthemaximumtenderpointandask:isthisthepainyou
arecomplainingabout?
Quantifythetenderness(degreeofsensitization)byalgometer.

B.DiagnosisofSensitizedSpinalSegment(SSS):
I.DermatomalHyperalgesia:
Paindiagram
Paperclipscratchtest(useofsensorydiagnostictracks)
Skinpinchandroll:Testsensitizationofsubcutaneoustissue.
Electricskinconductance:Objectivequantitativetesting.
Dorsalandventralprimaryramushyperalgesianeedstobediagnosed
II.SclerotomalHyperalgesia:
Palpationfortendernessofsupraspinous/interspinousligaments
Palpationfortenderspots(TsP)andMTrPsatattachmentsites,andenthesopathies
C.Myotomaldistributionof:
Triggerpoints/tenderspotsbypalpationandalgometry
Taut bands by palpation and tissue compliance meter which renders quantified, objective
results
Musclespasm/reducedstretchrangebypalpation
D.Sympathetichyperactivity:
Microedema
Increasedelectricalskinresistance
OrangePeelskin

3. Treatment: Concentrate on the sensitized spinal segment corresponding to the

immediate cause(s) of pain (MTrPs, TsP, and muscle spasms) and the associated
supraspinous/interspinous ligament nociceptive irritative focus. The injection techniques
tobedescribeddesensitizethedorsalhorn,eliminatetheSSSanderadicatetheperipheral
paingenerators.
INJECTIONS:forimmediateandlongtermrelieveofpain:
PARASPINOUSBLOCKtodesensitizetheSSS.
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NEUROMIOTERAPIA SEGMENTAR: ESTUDOS DE ERIC KANDEL, PRMIO NOBEL DE FISIOLOGIA, MOSTRAM A POSSIBILIDADE DE R

PREINJECTIONBLOCKtoanesthetizethepainfulsensitiveareatobeinfiltrated.
NEEDLING & INFILTRATION OF THE ENTIRE TAUT BAND (TB), to break up the entire underlying
pathologyoftheTrPs/TSs.
Alternativemethodstodesensitizethesegment
spinalmanipulationoftheidentifiedsegment,
needlingoftheidentifiedsegment,
specificandselectiverangeofmotionmovementtomobilizetheidentifiedsegment.
postinjectionphysicaltherapy:
A.Modalitiesheatorcoldelectricstimulation(sinusoidsurgingandtetanizingcurrents)
B.ExercisesRelaxationexercisesfollowedbystretching:
General(eyemovement+expiration+pullinginofbellyandholdingfor2seconds)
Specific for the involved myotome, in which the pain generating TrPs/TSs and MSp are located
relaxationbyactivationofantagonistmuscle(s)(RAA).Activerelaxation:eliminationofgravity.Stretch
onlywhenmuscleisrelaxed+stretchingbygravity.Dryneedling,postisometricrelaxation,spretchand
spray,deeptransersefriction,
C.Specificposturalcorrection:Lossofcervicaland/orlumbarsacrallordosis,extensionandflexiondeficiencies.

4.Diagnosisandremovalofperpetuatingandetiologicalfactors:
PHYSICALEXAMINATIONreveals:
Mechanicaloverloadofbodyparts,overuse,andcumulativetraumadisorders,
Deficiencyofmusclefunction(lossofflexibility,weakness).(Kraus)
Posturaldeficienciessuchaslossofcervicalorlumbarlordosis.(RobinMcKenzie)
The Pentad of discopathy radiculopathy paraspinal spasm and supraspinous ligament sprain: Spinal
segmental sensitization., that consist of segmental hyperalgesia, and TrPs/TSs and MSp in the
myotome.
LABORATORYRESULTS:
Endocrinedisorders,particularly,lowthyroidorestrogensupplytothemuscles(normalbloodlevelsare
sometimesinsufficient)
Metabolicorelectrolytedisordersand
Vitamindeficiencies.
ByCMCVCentroMdicodaColunaVertebral

Postado h 19th March 2011 por Fisioterapia & Cincia

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