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ProActionClinic a mené plusieurs années de recherches et de synthèse de nombreux travaux scientifiques et a mis au point le coussin extensit.

Extensit est la bases d’une nouvelle stratégie d’approche des troubles posturaux et des maux de dos qui y sont probablement liés.

 


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SACROILIAC SHEARS: A NEW CONCEPT FOR UNDERSTANDING AND TREATING LUMBAR, SACRAL AND SCIATIC PAIN

The physiological movement of the sacroiliac joint has been widely documented[1] [2] [3] [4]. Pressures exerted on this joint are likely to contribute to the development of lumbosacral pain, but the full effects have probably been underestimated [5] [6] [7] [8] [9] [10]: "The Sacro Iiliac Joint is a potential pain generator that must be considered within the differential diagnosis of low back pain. Failure to recognize and treat SIJ-mediated pain will result in unsatisfactory outcomes in a subset of patients who suffer low back pain"[11].

The sacroiliac joint is a little like a suspension bridge, with the sacrum being suspended between the two iliac bones[12] [13]. Other than the typical nutation and counter-nutation movements, the sacrum has a tendency to descend between the iliac bones, generating a vertical shearing force known as an upslip or a downslip[14].

This shear would normally be controlled by the congruity of the joint margin, the sacroiliac ligament system and certain muscles which are physiologically able to exert a transverse force sufficient to close the sacroiliac joint, mainly the pelvic floor and transversus abdominis (Snijder's Theory)[15].

When functioning normally and subjected to short-term load, these muscles, working in synergy with the diaphragm, stabilise the pelvis and spine by exerting intra-abdominal pressure that they can temporarily increase when required, for example during effort[16].

The sacroiliac joint is therefore able to open and close, a physiological function necessary for transmitting forces from the torso to the legs, especially during load-bearing or walking[17] [18].

The intra-abdominal pressure is transferred to the lumbar spine and improves the closure of the vertebral facet joints. This temporarily stabilises the lumbar spine and allows it to resist these additional forces which, in the short term, is beneficial[19].

However, excessive and chronic shear can lead to instability and friction between the joints, a possible cause of sacroiliac pain.

This excessive force can be avoided by contracting the same muscles, namely the transversus abdominis and pelvic floor, in a transverse direction[20].

In the long term, this increased intra-abdominal pressure can become permanent[21] [22] and have an undesired compressive effect; in fact, the permanent contraction of these muscles can have a composite effect and result in a chronic increase in muscle tension and the permanent compression of the sacroiliac and vertebral joints [23] [24] [25] [26] [27] [28]. The consequences can be deep compensation within these muscles and unwanted friction within the sacroiliac joint spaces[29].

In addition, this hypertension of the transversus abdominis and pelvic floor muscles increases the intra-abdominal pressure[30].

This increased pressure again stiffens the lumbar spine but instead of being temporary, this change is long-term and can chronically effect the disc and facets[31] [32]. This plays a non-negligible role in the development of lumbosacral pain.

We therefore enter a vicious circle, whereby the increase in intra-abdominal pressure disrupts the disc hydration phase which in turn encourages disc degeneration[33] and chronically increases facet joint pressure[34] (“…There are many structures in the lumbar spine that can serve as pain generators and often, the etiology of low back pain is multifactorial. Since being described  as a potential pain generator (…), the facet joint has been increasingly recognized as an important cause of low back pain...”)[35] - the abdominal hypertension worsens the sacroiliac shear and increases the upslip or downslip, a movement that is compensated by the transverse force of the transversus abdominis and pelvic floor[36] muscles, resulting in even greater abdominal pressure... Eventually, the visco-elastic properties are severely effected making the overall structure become stiffer and more rigid as a whole.

These circumstances can create mechanical conditions that alter the chemistry of the joint[37], resulting in the appearance of acute and chronic pain.

In addition, sacroiliac and lumbar stability are closely linked: "Due to their contribution to modulation of intra-abdominal pressure (IAP) and stiffness of the sacroiliac joints, the pelvic floor muscles (PFM) have been argued to provide a contribution to control of the lumbar spine and pelvis"[38].

It seems that, in order to be significant, disc degeneration must be associated with partial destruction of the adjacent end plates ("...Signal changes on MRI in the vertebral body marrow adjacent to the end plates also known as Modic changes (MC) are common in patients with Low Back Pain (18-58%) (….) In asymptomatic persons the prevalence is 12-13%)"…"A mechanical cause: Degeneration of the disc causes loss of soft nuclear material, reduced disc height and hydrostatic pressure, which increases the shear forces on the endplates and micro fractures may occur")[39] [40].

On the other hand, any chronic intra-abdominal hypertension triggers eccentric contractions of the diaphragm, forcing exhalation[41]. This places yet more pressure on the intervertebral disc and fact joints, which further stiffens the spine ("...Tetanic stimulation of the diaphragm increased Intra Abdominal Pressure by 27-61% of a maximal voluntary pressure increase and increased the stiffness of the spine by 8-31% of resting levels. The increase in spinal stiffness was positively correlated with the size of the Intra Abdominal Pressure increase")[42], aggravating, in the long-term, the vicious circle...

 

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Questo indirizzo e-mail è protetto dallo spam bot. Abilita Javascript per vederlo. [20] Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J. The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain. Spine. 2002 Feb 15;27(4):399-405. Institute of Rehabilitation, University Hospital Rotterdam, the Netherlands[21] O'Sullivan PB, Beales DJ, Beetham JA, Cripps J, Graf F, Lin IB, Tucker B, Avery A .Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine. 2002 Jan 1;27(1):E1-8.School of Physiotherapy, Curtin University of Technology, Shenton Park, Western Australia, Australia. Questo indirizzo e-mail è protetto dallo spam bot. Abilita Javascript per vederlo. [22]Beales DJ, O'Sullivan PB, Briffa NK Motor control patterns during an active straight leg raise in chronic pelvic girdle pain subjects. Spine (Phila Pa 1976). 2009 Apr 20;34(9):861-70.Curtin University of Technology, Perth, Western Australia, Australia 6164. Questo indirizzo e-mail è protetto dallo spam bot. Abilita Javascript per vederlo. [23] . Van Wingerden JP, Vleeming A, Buyruk HM, Raissadat K.Stabilization of the sacroiliac joint in vivo: verification of muscular contribution to force closure of the pelvis. Eur Spine J. 2004 May;13(3):199-205.Spine & Joint Centre, Westerlaan 10, 3016 CK, Rotterdam, The Netherlands. Questo indirizzo e-mail è protetto dallo spam bot. Abilita Javascript per vederlo. [24] Amarenco G et al. Cough anal reflex: strict relationship between intravesical pressure and pelvic floor muscle electromyographic activity during cough. J Urol. 2005 Oct;174(4 Pt 1):1502-3. Department of Neurologic Rehabilitation, Urodynamic and Neurophysiology Laboratory, Rothschild Hospital, Assistance Publique-Hopitaux de Paris, 33 boulevard de Picpus, 75571 Paris Cedex 12, France.[25] O’sullivan PB, Beales DJ. Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: A case series.. Man Ther. 2006 Aug 16.  Curtin University of Technology, School of Physiotherapy, GPO Box U1987, Perth, WA 6845, Australia.[26] Tsao H, Galea MP, Hodges PW. Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain. 2008 Aug;131(Pt 8):2161-71. NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Qld 4072, Australia.[27]Brain. 2004 Oct;127(Pt 10):2339-47. Moseley GL, Nicholas MK, Hodges PW. Does anticipation of back pain predispose to back trouble? Brain. 2004 Oct; 127(Pt 10):2339-47.  Prince of Wales Medical Research Institute, Randwick, Sydney, Austalia. Questo indirizzo e-mail è protetto dallo spam bot. Abilita Javascript per vederlo. 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Spine. 1996 Feb 15;21(4):434-8.Comparative Orthopaedic Research Unit, University of Bristol, United Kingdom.[32] Thompson RE, Pearcy MJ, Barker TM.The mechanical effects of intervertebral disc lesions. Clin Biomech (Bristol, Avon). 2004 Jun;19(5):448-55.School of Mechanical, Manufacturing and Medical Engineering, Queensland University of Technology, Brisbane 4001, Australia.[33] Luoma K, Riihimaki H, Luukkonen R, Raininko R, Viikari-Juntura E, Lamminen A. Low back pain in relation to lumbar disc degeneration. Spine. 2000 Feb 15;25(4):487-92. Finnish Institute of Occupational Health, Helsinki, Finland[34]Rannou F, Lee TS, Zhou RH, Chin J, Lotz JC, Mayoux-Benhamou MA, Barbet JP, Chevrot A, Shyy JY. Intervertebral disc degeneration: the role of the mitochondrial pathway in annulus fibrosus cell apoptosis induced by overload.  Am J Pathol. 2004 Mar;164(3):915-24. Division of Biomedical Sciences, University of California, Riverside, California 92521-0121, USA.[35] Yang KH, King AI.. 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Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362-71.Division of Physiotherapy, the University of Queensland, Brisbane, Queensland, Australia. Questo indirizzo e-mail è protetto dallo spam bot. Abilita Javascript per vederlo. [40] Albert HB, Kjaer P, Jensen TS, Sorensen JS, Bendix T, Manniche C. Modic changes, possible causes and relation to low back pain. Med Hypotheses. 2008;70(2):361-8.  The Back Research Center, Part of Clinical Locomotion Science, University of Southern Denmark, Lindevej 5, 5750 Ringe, Denmark.[41] Tue S Jensen, Tom Bendix*, Joan S Sorensen*, Claus Manniche,* Lars Korsholm*, Per Kjaer. 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