Modificazione della tensione muscolare della muscolatura del cingolo scapolo omerale in pazienti affetti da rachialgia mediante utilizzo della Tecnica Tone control®

Abstract

Lo studio controllato randomizzato in cieco si propone di verificare l’efficacia del metodo Tone-Control® nell’indurre una riduzione tensionale della muscolatura del cingolo scapolo-omerale e quindi una normalizzazione posturale del distretto.

Si è analizzata la modificazione posturale, correlata alla tensione muscolare del Gran Pettorale e del Trapezio, indotta dalla somministrazione di un programma di esercizi codificati denominati metodo Tone Control®.

Sono stati coinvolti 70 Pazienti affetti da rachialgia posturale, con età compresa tra i 25 ed i 81 anni di età e con una media di 61.9 anni, 11 pazienti maschi e 59 pazienti femmine, divisi in un gruppo studio di 40 paz. ed un gruppo di controllo di 30 paz. Le sessioni  riabilitative di un’ora si sono svolte in gruppi di quattro o cinque paz. per un ciclo di almeno 10 sedute, fino ad un massimo di 15 sedute. Sono stati esclusi pazienti in fase acuta, pazienti in trattamento farmacologico antiinfiammatorio e pazienti con ernie o protrusioni improntanti il sacco durale.

Il gruppo di studio ha eseguito una sequenza codificata di esercizi attivi del metodo Tone Control®, mentre il gruppo di controllo ha eseguito esercizi di mobilizzazione attiva e stretching del distretto analizzato. Entrambi i gruppi hanno integrato tale lavoro con la medesima sequenza di esercizi attivi di mobilizzazione polidistrettuale, rinforzo segmentario, stretching attivo e rieducazione propriocettiva.

In prima ed ultima seduta sono state rilevate misurazioni angolari tramite goniometro delle articolazioni del distretto scapolo-omerale, nello specifico l’elevazione della spalla sul piano sagittale, l’angolo sterno-claveare e l’anteposizione di spalla sul piano trasversale. E’ stata somministrata la scala NSR  per il dolore all’inizio e alla fine del ciclo di sedute.

I dati ottenuti sono stati analizzati mediante pacchetto SPSS.

Conclusioni

I pazienti del gruppo studio hanno riportato miglioramenti delle misurazioni proporzionalmente maggiori rispetto al gruppo di controllo, insieme ad una apprezzabile  riduzione del dolore percepito, con miglioramento globale della postura e della funzionalità del cingolo scapolare.

Keywords

Tone control®, muscle tone change, improvement in muscle contraction, shoulder girdle rehabilitation.

INTRODUZIONE

Lo scopo del lavoro è testare l’efficacia della tecnica Tone Control®.

La tecnica ha trovato il suo inizio quando, ricercando nella pratica lavorativa un miglioramento posturale ed un’armonizzazione del tono muscolare all’interno dell’unità psicosomatica individuale, si è provato a fondere l’applicazione dei principi dell’eutonia (1) con facilitazioni biomeccaniche articolari (2),(3). Nella pratica si è notato che il fornire un fulcro esterno alle articolazioni prese in esame e contemporaneamente aumentare gli input propriocettivi (4) di quel comparto produceva risposte positive. Se poi l’input percettivo veniva fornito da una superficie elastica, il guadagno in termini di riadattamento tonico e posturale sembrava superiore all’aspettativa.

Ci si è quindi riproposto di codificare delle procedure che potessero essere sufficientemente versatili da adattarsi alla necessaria personalizzazione del trattamento allo specifico del paziente, ma contemporaneamente fossero riproducibili con uniformità di tecnica, così da prestarsi ad una verifica.

La ricerca di un adattamento del tono della muscolatura (5) è uno degli aspetti su cui si concentra il lavoro del terapista, quando affronta la postura e le sue alterazioni. E’ possibile  adottare quale definizione di postura, utile seppur non esaustiva, quella scelta da F. Scoppa (6) “ Per postura possiamo intendere la posizione del corpo nello spazio e la relazione spaziale tra i segmenti scheletrici, il cui fine è il mantenimento dell’equilibrio (funzione antigravitaria), sia in condizioni statiche che dinamiche, cui concorrono fattori neurofisiologici, biomeccanici, psicoemotivi e relazionali, legati anche all’evoluzione della specie”. Le parole di Scoppa ci permettono di evidenziare alcuni aspetti che sono a fondamento dell’idea del Tone Control, cioè la spazialità e la concorrenza di più fattori.

Per verificare l’efficacia dell’approccio con il trattamento Tone Control® si è deciso quindi di valutare in questo studio i cambiamenti ottenuti applicando questa tecnica alla riabilitazione del cingolo scapolo-omerale, ponendo attenzione alle variazioni posturali relative a diversi stati di tono muscolare di alcuni dei muscoli del cingolo, nelle loro azioni principali.

Nello specifico si è scelta la correlazione tra tono della muscolatura toracica anteriore (Muscolo pettorale) e atteggiamento anteposto di spalla, insieme alla correlazione tra tono di Trapezio (superiore e medio) + Elevatore della scapola ed elevazione dell’intero cingolo sul piano frontale. Per indagare la possibilità di movimento articolare, si è scelta per praticità di approccio la flessione di spalla sul piano sagittale. Come parametro soggettivo si è poi tenuto conto dell’autovalutazione del dolore da parte del soggetto.

I fondamenti neurofisiologici e biomeccanici ai quali si è fatto riferimento sono: la stimolazione propriocettiva (7), il riflesso da stiramento ed il principio dell’inibizione reciproca (3). Si ricorda il concetto di fissazione e facilitazione già studiato dal Dr. Irvin Korr nel 1975. (2),(4),(7).

La scarica afferente dei motoneuroni gamma dal fuso neuromuscolare produce un riflesso contrattile e blocca la mobilità articolare in una determinata posizione . Controllando la contrazione delle fibre intrafusali attraverso la stimolazione dei gamma motoneuroni, il sistema nervoso centrale è in grado di resettare il grado di lunghezza muscolare, il tono e la sensibilità dei fusi allo stiramento (8). Questo meccanismo crea uno stato di preallerta nel muscolo, il quale è così in grado di rispondere anche a piccole variazioni di allungamento. In più, maggiore è la stimolazione gamma, maggiore è la sensibilità dei fusi allo stiramento (4). Uno stiramento del muscolo con stimolazione gamma elevata produce una scarica più intensa da parte dei fusi e di conseguenza un maggiore riflesso di contrazione muscolare. In un tessuto disfunzionale (7), con un’alterazione del tono muscolare, i fusi muscolari continuano a scaricare (6). Gli esercizi del metodo Tone Control® mirano a diminuire la contrazione muscolare riducendo la scarica aberrante d’origine fusale e quindi il tono muscolare (9).

Le misurazioni sono state così rilevate (10):

1)    anteposizione di spalla: valutata in cm dal piano frontale posizionando il paziente seduto e appoggio dorsale alla parete, misurando la distanza perpendicolare tra prominenza acromiale e parete di appoggio

2)    elevazione del cingolo scapolo-omerale: si è scelto di misurare l’angolo formato dallo sterno, nella sua verticale e la linea che collega l’articolazione sterno-claveare e la prominenza acromiale, con paziente seduto.

Questa misurazione goniometrica fornisce informazioni sull’elevazione del cingolo e, indirettamente, sulle strategie di adattamento del tono muscolare in risposta antigravitaria.

3)    flessione di spalla: valutata in gradi con goniometro, con paziente seduto e appoggio dorsale a parete.

4)    dolore: autovalutazione del soggetto mediante scala NRS

Tali misurazioni, indubbiamente indirette rispetto ad una valutazione diretta del tono dei muscoli presi in esame, si sono rese necessarie ed inevitabili a causa del peculiare limite del test di valutazione del tono attraverso la scala di Asworth, che è estremamente operatore-dipendente.

Uno strumento più specifico risulta essere il miometro, strumento purtroppo non diffuso nell’attuale pratica clinica (11).

MATERIALI E METODI :

I pazienti partecipanti allo studio sono arrivati alle cure riabilitative di gruppo a seguito di visita fisiatrica e con diagnosi di rachialgia (criterio di inclusione) senza irradiazioni periferiche in atto e in assenza di patologie neurologiche centrali (criteri di esclusione).

I pazienti sono stati selezionati tra gli utenti afferiti al Servizio Ambulatoriale dell’Azienda Servizi alla Persona IMMeS e PAT di Milano che hanno usufruito di un ciclo di ginnastica riabilitativa nel periodo tra settembre 2012 e settembre 2014, nel rispetto dei criteri di inclusione ed esclusione.

La distribuzione dei pazienti nei gruppi di lavoro, gruppo studio e gruppo controllo, è derivata dal meccanismo automatico di gestione dei pazienti in lista di attesa che venivano indirizzati in maniera casuale verso i due gruppi di lavoro.

I trattamenti sono stati svolti presso l’Azienda Servizi alla Persona IMMeS e PAT di Milano da settembre 2012 al novembre 2014, in regime ambulatoriale di piccolo gruppo, massimo cinque persone, ex articolo 26 fascia 2, per un massimo di 15 sedute ed un minimo di 10, di durata di 60 minuti l’una e di frequenza bi o trisettimanale.

Nel gruppo di studio l’età è compresa tra i 47 anni e gli 81 anni , con una media di 63,1 anni.

Nel gruppo di controllo l’età è compresa tra i 25 anni e gli 81 anni, con una media di 60,3 anni.

Ai pazienti in sede di prima visita fisiatrica, a seguito della prescrizione di fisioterapia in piccolo gruppo, è stato spiegato dal medico lo scopo del percorso riabilitativo, informando il paziente che avrebbe eseguito esercizi attivi per il miglioramento dell’articolarità globale, della funzionalità rachidea e globale, per la contenzione delle algie e per didattica posturale.

Il paziente è stato messo a conoscenza che vi era in atto uno studio sull’efficacia della tecnica Tone Control®, ma senza venir informato se era facente parte del gruppo di studio o di quello di controllo.

Lo studio ha avuto l’approvazione del Direttore UOC della Struttura ed il consenso informato dei pazienti partecipanti allo studio.

PROGRAMMA RIABILITATIVO DEL GRUPPO DI STUDIO

Gli esercizi di Tone Control® sono stati inseriti nel programma riabilitativo di alcuni gruppi di lavoro con pazienti affetti da rachialgia, proponendo solo alcune delle sequenze di esercizi attivi previsti dal metodo Tone Control® e incentrate sulle dinamiche del cingolo scapolo-omerale e della colonna cervico-dorsale.

Gli esercizi somministrati ai pazienti sono stati i seguenti:

1) Esercizio dell’inventario: si chiede al paziente, supino a terra di focalizzare l’attenzione sulla percezione della superficie corporea di contatto con il terreno. Si chiede di eseguire una pressione a terra dei vari segmenti dell’arto superiore (mano, gomito, spalla) in sequenza da distale a prossimale per entrambi i lati corporei, terminando con una pressione dell’appoggio della zona occipitale. La pressione va mantenuta per 5 secondi ed è seguita da un rilascio e da una finestra di ascolto percettivo di 5 secondi, da ripetersi per tre volte. Tale esercizio costituisce l’inizio e la fine del trattamento Tone Control®.

2) Pressioni contro resistenza elastica: il terapista posiziona tra il corpo del paziente e il terreno una palla di circa 15 cm. di gomma gonfia d’aria, avente pressione proporzionata al peso del soggetto e tale da consentire un sostegno della zona senza collabire, ma garantendo una superficie d’appoggio cutaneo di almeno 5 cm. Si chiede al paziente di eseguire in fase espiratoria una spinta in direzione posteriore, comprimendo la palla contro il pavimento. La pressione va mantenuta per 5 secondi ed è seguita da un rilascio e da una finestra di ascolto percettivo di 5 secondi, da ripetersi per tre volte.

La palla andrà posizionata in sequenza sotto le seguenti sedi anatomiche, monolateralmente:

  1. fossa sottospinata scapolare
  2. tra il margine mediale scapolare ed i processi spinosi dorsali tra D3 e D5

Si ripeterà per l’arto controlaterale.

c.   Si posizionerà poi la palla centralmente sulle spinose tra D3 e D5, con gli arti superiori in extrarotazione.

d.   Si posiziona la palla sotto la protuberanza occipitale esterna, dall’appoggio occipitale, si chiede di eseguire una torsione della testa con inclinazione laterale fino ad arrivare ad un appoggio limitato dal processo mastoideo temporale. Da lì si chiede al paziente di eseguire una pressione con gli stessi parametri precedenti per entrambi i lati.

3) Si termina la sequenza di esercizi di Tone Control® con la ripetizione dell’esercizio dell’inventario, per consentire al paziente di percepire eventuali differenze tra l’immagine corporea precedente al trattamento e quella attuale.

Queste sequenze sono state inserite all’interno di un percorso che prevede una sequenza di esercizi di mobilizzazione attiva della colonna lombare e degli arti inferiori, di rinforzo segmentario della muscolatura del torchio addominale, dei muscoli quadricipiti e degli stabilizzatori del bacino, di stretching della catena posteriore degli arti inferiori e di stimolazione propriocettiva in carico con esercizi di equilibrio sia statico che dinamico.

PROGRAMMA RIABILITATIVO DEL GRUPPO DI CONTROLLO

Gli esercizi relativi alla mobilizzazione e stimolazione propriocettiva del cingolo scapolare somministrati ai pazienti del gruppo di controllo sono stati i seguenti:

  1. Flessione anteriore del capo passiva, da supini a terra, guidati dalle mani. La posizione viene mantenuta per 5 secondi e ripetuta tre volte.
  2. Torsione con inclinazione laterale del capo, sempre passiva guidata dagli arti superiori. La posizione viene mantenuta per 5 secondi e ripetuta tre volte.
  3. Scivolamento scapolo-toracico, con braccia conserte e spinte avanti in fase espiratoria. La posizione viene mantenuta per 5 secondi e ripetuta tre volte.
  4. Stretching della muscolatura dell’avambraccio, del muscolo pettorale e dell’intera catena anteriore dell’arto superiore, mantenendo le posizioni 30 secondi e ripetendole due volte.
  5. Trazione attiva verso il basso degli arti superiori extraruotati ed aderenti al pavimento. La posizione viene mantenuta per 5 secondi e ripetuta tre volte.

Come per i pazienti del gruppo di studio, gli esercizi descritti sono stati inseriti nella medesima sequenza di mobilizzazione attiva della colonna lombare e degli arti inferiori, di rinforzo segmentario della muscolatura del torchio addominale, dei muscoli quadricipiti e degli stabilizzatori del bacino, di stretching della catena posteriore degli arti inferiori e di stimolazione propriocettiva in carico con esercizi di equilibrio sia statico che dinamico.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ELABORAZIONE DATI STATISTICI

DOLORE

La figura 1 mostra la relazione tra i valori di autovalutazione del dolore, ottenuti somministrando una NRS in prima seduta ed in ultima seduta.

In prima seduta il gruppo di studio (cerchi) presentava valori di partenza compresi tra 8 e 3, con una media di 5; il gruppo di controllo (triangoli) ha riportato valori di partenza tra 7 e 2, con una media di 4,7.

In ultima seduta il gruppo di studio presentava valori compresi tra 0 e 6, con una media di 2,4; il gruppo di controllo presentava valori compresi tra 0 e 5, con una media di 2,6.

Entrambi i trattamenti raggiungono quindi lo scopo di ridurre il dolore, con miglioramento sostanzialmente uguale.

Figura 1 Valutazione soggettiva del dolore prima e dopo il trattamento, nel gruppo studio ( cerchi) e in quello di controllo ( Triangoli)

p < 0.0000

L’effetto principale è significativo: entrambi i trattamenti raggiungono lo scopo di modificare significativamente la valutazione del dolore, diminuendolo.

Conclusione: entrambi i trattamenti raggiungono quindi lo scopo di ridurre il dolore, con miglioramento sostanzialmente uguale, anche se comunque il guadagno per il gruppo con trattamento speciale è 1.25 volte quello del gruppo standard.

GRADI DI ELEVAZIONE DI CLAVICOLA

La figura 2 mostra i gradi misurati con goniometro tra l’asse verticale passante per l’articolazione sterno-clavicolare e l’asse della clavicola stessa.

Gli angoli rilevati sui pazienti del gruppo di studio (cerchi) partivano da valori simili a quelli del gruppo di controllo (triangoli), ma la riduzione di tale angolo in ultima seduta risulta essere maggiore nel gruppo di studio che in quello di controllo.

Nell’analisi posturale la spalla appariva quindi meno rilevata sul piano frontale.

Figure n. 2 Angolo di elevazione della clavicola prima e dopo il trattamento, nel gruppo studio (cerchi) e in quello di controllo ( triangoli)

L’effetto del trattamento, considerato dal punto di vista del risultato che emerge dal confronto fra prima e dopo, è significativo in entrambi i gruppi (entrambi i gruppi ricevono un beneficio significativamente diverso/superiore al nulla, considerati separatamente):

p < 0.0000   (eta quadrato parziale)  = 0.350

Il guadagno del gruppo studio è il doppio  rispetto a quello del gruppo di controllo.

Conclusione: partono dallo stesso livello, il gruppo con trattamento standard arriva a un buon livello, ma il gruppo con trattamento speciale arriva ad un livello significativamente diverso, migliore.

FLESSIONE DI SPALLA

 

La figura n° 3 mostra la flessione di spalla, che è stata rilevata con goniometro a paziente in ortostatismo con appoggio dorsale al muro ed è un dato significativo perché la possibilità di elevare l’arto superiore è rappresentativa delle capacità funzionali della spalla e del cingolo scapolare. I pazienti del gruppo di studio partivano da valori inferiori (cerchi) rispetto quelli dei pazienti di controllo (triangoli) e al termine del trattamento sono arrivati a valori inferiori rispetto a quelli raggiunti dai pazienti del gruppo di controllo, ma il guadagno è stato maggiore per il gruppo di studio

Figure n. 3 Flessione di spalla prima e dopo il trattamento, nel gruppo studio (cerchi) e in quello di controllo ( triangoli)

L’effetto del trattamento è significativo in entrambi i gruppi:

p < 0.0000    (eta quadrato parziale)  = 0.320

Il guadagno del gruppo studio è 1.38 rispetto a quello del gruppo di controllo.

Conclusione: partono da livello diverso (gruppo con trattamento speciale livello peggiore) ed arrivano allo stesso livello, ma il miglioramento è maggiore nel gruppo con trattamento speciale.

ANTEPOSIZIONE DI SPALLA

 

La figura n° 4 mostra l’anteposizione di spalla è stata valutata in cm. di distanza dalla superficie di riferimento, con paziente in ortostatismo e tratto dorsale in appoggio alla parete. Nell’analisi posturale questo dato è in relazione diretta con la chiusura anteriore del cingolo scapolare e lo scivolamento in fuori della scapola sulla superficie di contatto dorsale.

I valori dei pazienti nel gruppo di studio partivano peggiori (cerchi) rispetto i valori del gruppo di controllo (triangoli), raggiungendo in ultima seduta un miglioramento importante con superamento dei valori ottenuti -sempre in ultima seduta- dal gruppo di controllo.

Figure n. 4 Anteposizione di spalla di spalla prima e dopo il trattamento, nel gruppo studio (cerchi) e in quello di controllo ( triangoli)

Effetto principale significativo (il trattamento è efficace):

Le differenze nel guadagno tra i due gruppi sono significative

F(1,68) = 33.14             p < 0.0000      (eta quadrato parziale)  = 0.328

 

L’entità della differenza è notevole:

il guadagno del gruppo studio è 3.15 volte rispetto a quello del gruppo di controllo.

1 dolore      F(1,68) = 1,961            p < 0.166 (eta quadrato parziale)  = 0.028

2 antepos.  F(1,68) = 36,550          p < 0.000 (eta quadrato parziale)  = 0.350

3 flessione  F(1,68) = 32,065          p < 0.000 (eta quadrato parziale)  = 0.320

4 spalla       F(1,68) = 33,140          p < 0.000 (eta quadrato parziale)  = 0.328

Le differenze di guadagno sono significative per le tre grandezze “oggettive”.

RISULTATI

I risultati descritti evidenziano globalmente un significativo miglioramento dei parametri scelti in apertura del lavoro e consentono di metterli in relazione ad un effettivo miglioramento posturale dei pazienti in trattamento. Il quadro generale vede infatti un adattamento della postura dei pazienti con riduzione dell’elevazione del cingolo scapolare, riduzione dell’anteposizione di spalla e un miglioramento della funzionalità dell’arto superiore nel gesto fisiologico della flessione.

Si può quindi concludere che il metodo Tone-control® risulta efficace quanto la mobilizzazione attiva tradizionale nella contenzione del dolore, mentre si mostra più efficace nel miglioramento posturale conseguente ad una più efficace normalizzazione del tono muscolare nei distretti esaminati.

Il lavoro svolto ha permesso di ottenere dei primi dati relativi alla proposta di Tone-control® in situazione di riabilitazione di gruppo, implicando quindi la partecipazione completamente attiva del paziente. Sarebbe di interesse confrontare i risultati ottenibili con pazienti di tipologie diverse, quali ad esempio giovani sportivi, così da poter estrapolare informazioni utili sulla compliance del paziente.

Inoltre sarebbe di grande interesse poter testare ulteriormente il metodo in situazione riabilitativa di trattamento individuale, così da poter sfruttare anche le tecniche di Tone control® di stimolazione operatore-dipendenti, che necessitano di un contatto diretto tra il terapista ed il paziente e consentono di associare il lavoro attivo all’ascolto del movimento passivo indotto dal terapista.

 

BIBLIOGRAFIA:

  1. Alexander Gerda: Eutonia, Paidos, 1991
  2. Korr IM The Segmental nervuos system as mediator and organizer of disease process The physiological basis of osteopathic medicine ,1970
  1. Kandel, Schwartz, Jessell. (2003), Principi di neuroscienze, Ambrosiana, 36: 702-712.
  2. Korr IM Proprioceptors and somatic dysfunction J AM Osteopath Assoc 1975; 74:638-50.
  3. Physiopathology & clinical manifestations of skeletal muscle tone, Arch Phys Ther (Leipz) [0376-1630] 1958 Jul-Aug;10(4) Pages: 276-86.
  4. Scoppa F. Posturologia e schema corporeo. Attualità in Terapia Manuale e Riabilitazione 2001; 4:5-16
  5. Korr IM Proprioceptors and somatic dysfunction J AM Osteopath Assoc 1975; 74:638-50
  6. D. Radovanovic, K. Peikert, M. Lindstrom and F. P Domellof  Sympathetic innervation of human muscle spindles; J. Anat. (2015) 226, pp542-548
  7. Controversial aspects of skeletal muscle tone. Hník P.Biomed Biochim Acta [0232-766X] 1986;45(1-2) Pages: S139-43.

10.  On the problem of the technic of measurement of skeletal muscle tone]. PANFILOV BK, Klin Med (Mosk) [0023-2149] 1962 Jul;40() Pages: 65-9.

11.  G. Ianieri, R. Saggini, R. Marvulli, G. Tondi, A. Aprile, M. Ranieri, S. Altini, L. Goffredo, M. Megna, G. Megna “Tono, elasticità e stiffness: valutazione miometrica delle proprietà muscolari”  EUR MED PHYS 2008;44(Suppl. 1 to No. 3)

 

 

 

 

 

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