Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model

Avastin-Loaded 3D-Printed Alginate Scaffold as an Effective Antiadhesive Barrier to Prevent Postsurgical Adhesion Bands Formation

Postoperative adhesion can cause complications, such as pain and organ blockage, in the abdominal regions. To address this issue, surgical techniques and antiadhesive treatments are applied. Given the significant role of vascularization in adhesion band formation, Avastin (Ava) that targets vascular endothelial growth factor (VEGF) can be applied to prevent peritoneal adhesion bands. Moreover, Alginate (Alg), a natural polysaccharide, is a promising physical barrier to prevent adhesion bands. Incorporating Ava into Alg hydrogel in a form of 3D-printed scaffold (Alg/Ava) has potential to suppress inflammation and angiogenesis, leading to reduce peritoneal adhesion bands. Following physical, morphological, and biocompatibility evaluations, the efficacy of Alg and Ava alone and their combination in Alg/Ava on the formation of postsurgical adhesions is evaluated. Upon confirming physical stability and sustained release of Ava, the Alg/Ava scaffold effectively diminishes both the extent and strength of adhesion bands. Histopathological examination shows that the reduction in fibrosis and inflammation is responsible for preventing adhesion bands by the Alg/Ava scaffold. Additionally, the cytokine assessment reveals that this is due to the inhibition in the secretion of VEGF and Interleukin 6 suppressing vascularization and inflammatory pathways. This study suggests that a 3D-printed Alg/Ava scaffold has great potential to prevent the postsurgical adhesion bands.

Nerve transfer for restoration of lower motor neuron-lesioned bladder, urethral and anal sphincter function. Part 4: Effectiveness of the motor reinnervation

In pilot work, we showed that somatic nerve transfers can restore motor function in long-term decentralized dogs. We continue to explore the effectiveness of motor reinnervation in 30 female dogs. After anesthesia, 12 underwent bilateral transection of coccygeal and sacral (S) spinal roots, dorsal roots of lumbar (L)7, and hypogastric nerves. Twelve months postdecentralization, eight underwent transfer of obturator nerve branches to pelvic nerve vesical branches, and sciatic nerve branches to pudendal nerves, followed by 10 mo recovery (ObNT-ScNT Reinn). The remaining four were euthanized 18 mo postdecentralization (Decentralized). Results were compared with 18 Controls. Squat-and-void postures were tracked during awake cystometry. None showed squat-and-void postures during the decentralization phase. Seven of eight ObNT-ScNT Reinn began showing such postures by 6 mo postreinnervation; one showed a return of defecation postures. Retrograde dyes were injected into the bladder and urethra 3 wk before euthanasia, at which point, roots and transferred nerves were electrically stimulated to evaluate motor function. Upon L2-L6 root stimulation, five of eight ObNT-ScNT Reinn showed elevated detrusor pressure and four showed elevated urethral pressure, compared with L7-S3 root stimulation. After stimulation of sciatic-to-pudendal transferred nerves, three of eight ObNT-ScNT Reinn showed elevated urethral pressure; all showed elevated anal sphincter pressure. Retrogradely labeled neurons were observed in L2-L6 ventral horns (in laminae VI, VIII, and IX) of ObNT-ScNT Reinn versus Controls in which labeled neurons were observed in L7-S3 ventral horns (in lamina VII). This data supports the use of nerve transfer techniques for the restoration of bladder function.NEW & NOTEWORTHY This data supports the use of nerve transfer techniques for the restoration of bladder function.

Practice of Peritoneal Adhesions in Osteopathic Medicine: Part 2

Peritoneal adhesions are an unwanted and frequent event following abdominal surgery, with a response rate that can reach 100%. The adhesions can be symptomatic, becoming a source of pain and discomfort for the patient, or asymptomatic, with possible chronic or acute visceral dysfunction. The article reviews what the diagnostic strategies are and discusses what could be the causes that lead to chronic pain in the presence of adhesions. The text reports the knowledge of the literature on the manual treatment of adhesions and illustrates possible symptoms that are not easily recognized by the clinician. To conclude, the article proposes osteopathic manual approaches derived from clinical experience and from what has been explained about the formation of peritoneal adhesions. Research must make further efforts to identify not only the causes triggering the formation of peritoneal neogenesis but also seek the most appropriate non-invasive treatments to help the patient.

Peritoneal Adhesions in Osteopathic Medicine: Theory, Part 1

Peritoneal adhesions form as a result of trauma to the abdomen, injuries resulting from surgery, and infections. These tissutal neoformations are innervated and vascularized, and with lymphatic vessels, adherence becomes a new and independent structure, capable of negatively influencing visceral functions. Adherent neogenesis can be asymptomatic or can be a source of pain, limiting the patient's quality of life. Although adhesiolysis remains the elective approach to eliminate adhesions, this therapeutic route prepares the peritoneal anatomical area to recur. The article reviews information on adhesion formation and peritoneal anatomy, probable subjective predispositions, and pathways that carry nociception. The text aims to be a theoretical basis for making new treatment suggestions for non-invasive osteopathic medicine, through a second part will be discussed in another article.

Chemical Scalpel: An Experimental Collagenase-Based Treatment for Peritoneal Adhesions

(1) Background: Abdominal adhesions are a common disease appearing after any type of abdominal surgery and may prolong surgical time and cause intestinal obstruction, infertility, or chronic pain. We propose the use of intraperitoneal collagenase to perform chemical adhesiolysis based on the pathophysiology and histology of adhesions. (2) Methods: We generated an adhesion model with intraperitoneal polypropylene meshes. Four months later, we evaluated the efficacy of the treatment in blinded form, i.e., 0.05% collagenase vs. placebo at 37 °C for 20 min. Protocol 1: Ten rats with ten mesh fragments, in which an attempt was made to remove the maximum number of meshes in a 5-min period. Protocol 2: Six rats with four mesh fragments in the sides of the abdominal cavity in which adhesiolysis was performed using a device that measures burst pressure. (3) Results: Protocol 1: 42% efficacy in the collagenase group versus 8% in the control group (p < 0.013). Protocol 2: 188.25 mmHg (SD 69.65) in the collagenase group vs. 325.76 mmHg (SD 50.25) in the control group (p < 0.001). (4) Conclusions: Collagenase allows for the safe and effective chemical adhesiolysis in this experimental model of adhesions.

Abdominal massage: A review of clinical and experimental studies from 1990 to 2021

OBJECTIVE

To systematically review the current state and holistic application of abdominal massage (AM).

DESIGN

A systematic review of qualitative evidence was conducted. All English articles exploring the topic of AM that had been published until the end of June 2021 were retrieved.

DATA SOURCES

The PubMed, Cochrane library, and Embase databases were accessed. Some original texts were obtained from Google Scholar.

DATA EXTRACTION AND SYNTHESIS

Two authors independently evaluated all search data to identify relevant studies. Disagreements were settled by discussion with a third author. Results were independently extracted into standardized sheets and checked for accuracy.

MAIN RESULTS

A total of 107 full-text reports were eligible for inclusion. Adult digestive disorders, pediatric disorders, gynecological disorders, obstetric disorders, metabolic disorders, psychological disorders, the side effects of AM, and animal experiments accounted for 49.53%, 14.02%, 7.48%, 7.48%, 4.67%, 4.67%, 5.61%, and 6.54% of all these papers, respectively, with most reports focusing on clinical studies.

CONCLUSION

The variety of diseases treated with AM is gradually increasing, and the treatment programs of AM for many diseases are being gradually optimized. Different forms of AM, especially mechanical AM, have been widely studied; the side effects of AM have also been considered; and the possible mechanisms of AM therapy continue to be discovered. In general, AM is an effective and safe therapy and can be widely used in various diseases, but further studies are necessary to clarify the mechanism of AM for different diseases. In the future, AM could become an even safer, more popular, and more modern therapy.

Osteopathy and Mental Health: An Embodied, Predictive, and Interoceptive Framework

Globally, mental and musculoskeletal disorders present with high prevalence, disease burden, and comorbidity. In order to improve the quality of care for patients with persistent physical and comorbid mental health conditions, person-centered care approaches addressing psychosocial factors are currently advocated. Central to successful person-centered care is a multidisciplinary collaboration between mental health and musculoskeletal specialists underpinned by a robust therapeutic alliance. Such a collaborative approach might be found in osteopathy, which is typically utilized to treat patients with musculoskeletal disorders but may arguably also benefit mental health outcomes. However, research and practice exploring the reputed effect of osteopathy on patients with mental health problems lack a robust framework. In this hypothesis and theory article, we build upon research from embodied cognition, predictive coding, interoception, and osteopathy to propose an embodied, predictive and interoceptive framework that underpins osteopathic person-centered care for individuals with persistent physical and comorbid mental health problems. Based on the premise that, for example, chronic pain and comorbid depression are underlined by overly precise predictions or imprecise sensory information, we hypothesize that osteopathic treatment may generate strong interoceptive prediction errors that update the generative model underpinning the experience of pain and depression. Thus, physical and mental symptoms may be reduced through active and perceptual inference. We discuss how these theoretical perspectives can inform future research into osteopathy and mental health to reduce the burden of comorbid psychological factors in patients with persistent physical symptoms and support person-centered multidisciplinary care in mental health.

The effect of visceral manipulation on Diastasis Recti Abdominis (DRA): A case series

BACKGROUND

Diastasis recti abdominis (DRA) is a condition that affects many postpartum and older women, often due to pregnancy-related issues and heavy lifting. Published research on nonsurgical DRA treatment has primarily focused on exercise to correct or prevent this dysfunction. A survey of women's health physical therapists identified that visceral manipulation and other interventions are utilized to treat DRA. No literature exists to identify the specifics of visceral manipulation or its effect on DRA.

STUDY DESIGN

This case series is a retrospective chart review of three female patients with DRA who received visceral manipulation.

CASE DESCRIPTION

The ages of the patients were 33, 37, 39 years old and all were positive for DRA based on inter-rectus distance (IRD) described as greater than two finger-width measurements at one of three measurement sites. Patients presented with chief complaints of low back pain, abdominal pain, and vulvar burning and itching. All women were gravida two and para two. Each patient received at least four treatments of visceral manipulation (VM).

OUTCOMES

VM decreased the IRD, decreased numeric pain rating scores, and improved functional activities in three women with DRA. Improvements were also seen in bladder and bowel symptoms.

DISCUSSION

Four treatments of visceral manipulation appear to be effective in decreasing DRA measurements in three women. DRA measurements improved to two finger-widths or less above, at, and below the umbilicus. The changes remained stable for six to sixteen months.

Physiological Responses Induced by Manual Therapy in Animal Models: A Scoping Review

Background: Physiological responses related to manual therapy (MT) treatment have been investigated over decades using various animal models. However, these studies have not been compiled and their collective findings appraised. The purpose of this scoping review was to assess current scientific knowledge on the physiological responses related to MT and/or simulated MT procedures in animal models so as to act as a resource to better inform future mechanistic and clinical research incorporating these therapeutic interventions.

Methods: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, and Index of Chiropractic Literature (ICL) were searched from database inception to August 2019. Eligible studies were: (a) published in English; (b) non-cadaveric animal-based; (c) original data studies; (d) included a form of MT or simulated MT as treatment; (e) included quantification of at least one delivery parameter of MT treatment; (f) quantification of at least one physiological measure that could potentially contribute to therapeutic mechanisms of action of the MT. MT studies were categorized according to three main intervention types: (1) mobilization; (2) manipulation; and (3) massage. Two-phase screening procedures were conducted by a pair of independent reviewers, data were extracted from eligible studies and qualitatively reported.

Results: The literature search resulted in 231 articles of which 78 met inclusion criteria and were sorted by intervention type. Joint mobilization induced changes in nociceptive response and inflammatory profile, gene expression, receptor activation, neurotransmitter release and enzymatic activity. Spinal manipulation produced changes in muscle spindle response, nocifensive reflex response and neuronal activity, electromyography, and immunologic response. Physiological changes associated with massage therapy included autonomic, circulatory, lymphatic and immunologic functions, visceral response, gene expression, neuroanatomy, function and pathology, and cellular response to in vitro simulated massage.

Conclusion: Pre-clinical research supports an association between MT physiological response and multiple potential short-term MT therapeutic mechanisms. Optimization of MT delivery and/or treatment efficacy will require additional preclinical investigation in which MT delivery parameters are controlled and reported using pathological and/or chronic pain models that mimic neuromusculoskeletal conditions for which MT has demonstrated clinical benefit.

Active Visceral Manipulation Associated With Conventional Physiotherapy in People With Chronic Low Back Pain and Visceral Dysfunction: A Preliminary, Randomized, Controlled, Double-Blind Clinical Trial

OBJECTIVE

The purpose of this study was to generate data for conduction of a power analysis to investigate short-term effects of visceral manipulation associated with conventional physical therapy on pain intensity, lumbar mobility, and functionality of people with chronic low back pain and visceral dysfunctions.

METHODS

This was a double-blinded, randomized, controlled, clinical trial preliminary study. A blinded evaluation was conducted involving 20 people with chronic low back pain with visceral dysfunction. Pain perception, lumbar mobility, and functionality were assessed in 3 moments: evaluation 1 (1 week before the intervention), evaluation 2 (immediately after the last intervention), and evaluation 3 (1 week after the last intervention). The protocol consisted of 50-minute session of conventional physical therapy and visceral manipulation. The participants were randomly allocated to 2 groups: 10 for the experimental group (conventional physical therapy and visceral manipulation) and 10 for the control group (conventional physical therapy and placebo visceral manipulation).

RESULTS

Significant reductions were found in the experimental group for lumbar mobility and specific functionality in comparison with the control group (P < .05). There were no significant differences for pain perception and global functionality.

CONCLUSION

The combination of visceral manipulation and conventional physical therapy program demonstrated significant between-groups differences over time for lumbar spine mobility and specific functionality. These gains occurred after 5 sessions, once a week, and were maintained 1 week after the end of the treatment. This study generated data for conduction of a power analysis to inform the design for future clinical research in this line of inquiry.

Osteopathic Manipulative Medicine Consultations for Hospitalized Patients

Context

Although osteopathic manipulative treatment (OMT) is predominantly known for its benefits in improving musculoskeletal pain, many studies have examined the effects of OMT on hospitalized patients with a variety of conditions, showing improved outcomes in conditions such as pneumonia, postoperative and postpartum recovery, preterm newborn recovery, and newborn feeding dysfunction.

Objective

To determine the reasons osteopathic manipulative medicine (OMM) consultations are being ordered at a tertiary care teaching hospital.

Methods

This descriptive study was conducted at an academic medical center with a well-established electronic health record system. A retrospective review examined data on all OMM consultations between January 1, 2015, and June 30, 2015. Reasons for consultations in a free text field were grouped into categories of "primary reason for consult" by a single reviewer. Demographics and patient location were also assessed.

Results

Of 1310 total consultations included in the study, 620 (47.0%) listed a musculoskeletal complaint as the primary or only reason for a consultation, 231 (18.0%) of which were for back pain, followed by neck pain (69 [5.0%]) and headache (46 [4.0%]). The next most common reason for consultation was for newborn feeding difficulty (352 [27.0%]) or other newborn consultation (66 [5.0%]). A total of 272 consultations (21.0%) were not limited to musculoskeletal complaints and included general nonspecific discomfort (96 [7.0%]) or respiratory complaint (53 [4.0%]). A total of 209 (16.0%) consultations noted patients to be postoperative; 124 (9.5%) to be postpartum; 57 (4.4%) to have cystic fibrosis; and 21 (1.6%) to have constipation.

Conclusion

The majority of inpatient OMM consultations were placed for musculoskeletal complaints, followed by newborn feeding problems. Although it is clear that some physicians think that OMT will help their patients for the aforementioned conditions, the number was still quite low, suggesting that many physicians may be unaware that OMT can help patients with conditions such as respiratory disorder, postoperative recovery, and constipation. There are many opportunities for treatment teams to be ordering OMM consultations as a way to reduce morbidity in their patients.

Battling adhesions: from understanding to prevention

Adhesions represent a major burden in clinical practice, particularly following abdominal, intrauterine, pericardial and tendon surgical procedures. Adhesions are initiated by a disruption in the epithelial or mesothelial layer of tissue, which leads to fibrin adhesion sites due to the downregulation of fibrinolytic activity and an increase in fibrin deposition. Hence, the metabolic events involved in tissue healing, coagulation, inflammation, fibrinolysis and angiogenesis play a pivotal role in adhesion formation. Understanding these events, their interactions and their influence on the development of post-surgical adhesion is crucial for the development of effective therapies to prevent them. Mechanical barriers, antiadhesive agents and combination thereof are customarily used in the battle against adhesions. Although these systems seem to be effective at reducing adhesions in clinical procedures, their prevention remains still elusive, imposing the need for new antiadhesive strategies.

Effect of soft tissue mobilization techniques on adhesion-related pain and function in the abdomen: A systematic review

OBJECTIVE

To systematically review the effects of soft tissue mobilization (STM) on both surgical and non-surgical abdominal adhesion-related symptoms.

STUDY DESIGN

Systematic Review.

BACKGROUND

It is known that abdominal adhesions can cause a variety of symptoms with one of the most common being abdominal pain. To date, there is no known systematic review that documents the effects of STM on adhesion-related abdominal symptoms.

METHODS AND MEASURES

A systematic review of literature was indexed in the following databases: PubMed, Cochrane, Google Scholar, OVID, and EBSCO. The quality of the studies was assessed using the MINORS scale.

RESULTS

Nine studies satisfied the eligibility criteria for this systematic review. The studies' population age ranged from 10.7 to 89.4 years. Four articles were nonrandomized and had scores ranging from 3 to 14 out of 16 total on the MINORS scale. Five articles were randomized controlled trials or comparative studies and scores ranged from 16 to 23 out of 24 total on the MINORS scale. There were five articles that used pain as an objective measure and all of them reported a decrease in pain after treatment. Two studies looked at quality of life and function and both saw objective improvements following abdominal adhesion treatment. Collectively, there were also improvements seen in scar mobility, infertility, posture, a reduction in medication, increased pressure tolerance and decreased postoperative ileus.

CONCLUSION

The results of this review indicate preliminary strong evidence for the benefits of STM on symptoms relating to acute post-surgical adhesions, preliminary moderate evidence for the benefits of STM on symptoms relating to chronic non-surgical related adhesions (fertility and SBO) and moderate evidence for the benefits of STM on symptoms relating to chronic post-surgical adhesions.

Decreasing recurrent bowel obstructions, improving quality of life with physiotherapy: Controlled study

AIM

To compare (1) quality of life and (2) rate of recurrent small bowel obstructions (SBO) for patients treated with novel manual physiotherapy vs no treatment.

METHODS

One hundred and three subjects (age 19-89) with a history of recurrent adhesive SBO were treated with a manual physiotherapy called the Clear Passage Approach (CPA) which focused on decreasing adhesive crosslinking in abdominopelvic viscera. Pre- and post-therapy data measured recurring obstructions and quality of life, using a validated test sent 90 d after therapy. Results were compared to 136 untreated control subjects who underwent the same measurements for subjects who did not receive any therapy, which is the normal course for patients with recurring SBO. Comparison of the groups allowed us to assess changes when the physiotherapy was added as an adjunct treatment for patients with recurring SBO.

RESULTS

Despite histories of more prior hospitalizations, obstructions, surgeries, and years impacted by bowel issues, the 103 CPA-treated subjects reported a significantly lower rate of repeat SBO than 136 untreated controls (total obstructions P = 0.0003; partial obstructions P = 0.0076). Subjects treated with the therapy demonstrated significant improvements in five of six total domains in the validated Small Bowel Obstruction Questionnaire (SBO-Q). Domains of diet, pain, gastrointestinal symptoms, quality of life (QOL) and pain severity when compared to post CPA treatment were significantly improved (P < 0.0001). The medication domain was not changed in the CPA treated group (P = 0.176).

CONCLUSION

CPA physical therapy was effective for patients with adhesive SBO with significantly lower recurrence rate, improvement in reported symptoms and overall quality of life of subjects.

Effect of Emodin on Preventing Postoperative Intra-Abdominal Adhesion Formation

BACKGROUND

Postoperative intra-abdominal adhesions are a major complication after abdominal surgery. Although various methods have been used to prevent and treat adhesions, the effects have not been satisfactory. Emodin, a naturally occurring anthraquinone derivative and an active ingredient in traditional Chinese herbs, exhibits a variety of pharmacological effects. In our study, we demonstrated the effect of emodin treatment on preventing postoperative adhesion formation.

MATERIALS AND METHODS

A total of 48 rats were divided into six groups. Abdominal adhesions were created by abrasion of the cecum and its opposite abdominal wall. In the experimental groups, the rats were administered daily oral doses of emodin. On the seventh day after operation, the rats were euthanized, and blood and pathological specimens were collected. Abdominal adhesion formation was evaluated by necropsy, pathology, immunohistochemistry, Western blot, and enzyme-linked immunosorbent assay analyses.

RESULTS

Abdominal adhesions were markedly reduced by emodin treatment. Compared with the control group, collagen deposition was reduced and the peritoneal mesothelial completeness rate was higher in the emodin-treated groups. Emodin had anti-inflammatory effects, reduced oxidative stress, and promoted the movement of the intestinal tract (P < 0.05).

CONCLUSION

Emodin significantly reduced intra-abdominal adhesion formation in a rat model.

Attenuation of postoperative adhesions using a modeled manual therapy

Postoperative adhesions are pathological attachments that develop between abdominopelvic structures following surgery. Considered unavoidable and ubiquitous, postoperative adhesions lead to bowel obstructions, infertility, pain, and reoperations. As such, they represent a substantial health care challenge. Despite over a century of research, no preventive treatment exists. We hypothesized that postoperative adhesions develop from a lack of movement of the abdominopelvic organs in the immediate postoperative period while rendered immobile by surgery and opiates, and tested whether manual therapy would prevent their development. In a modified rat cecal abrasion model, rats were allocated to receive treatment with manual therapy or not, and their resulting adhesions were quantified. We also characterized macrophage phenotype. In separate experiments we tested the safety of the treatment on a strictureplasty model, and also the efficacy of the treatment following adhesiolysis. We show that the treatment led to reduced frequency and size of cohesive adhesions, but not other types of adhesions, such as those involving intraperitoneal fatty structures. This effect was associated with a delay in the appearance of trophic macrophages. The treatment did not inhibit healing or induce undesirable complications following strictureplasty. Our results support that that maintained movements of damaged structures in the immediate postoperative period has potential to act as an effective preventive for attenuating cohesive postoperative adhesion development. Our findings lay the groundwork for further research, including mechanical and pharmacologic approaches to maintain movements during healing.

Post-sternotomy pain syndrome following cardiac surgery: case report

Over 2 million people undergo sternotomy worldwide for heart surgery each year, and many develop post-sternotomy pain syndrome (PSPS) which persists in the anterior thorax. In some patients, PSPS lasts for many years or suddenly reappears a long time after the sternotomy. The exact etiology of PSPS is unknown. This article presents a case report of a patient with a diagnosis of PSPS (after cardiac surgery 4 years prior) for whom an osteopathic approach was used, which successfully eliminated the pain. In a previous study, we demonstrated that this osteopathic procedure could reduce sternal pain associated with a recent surgical wound. Further efforts are needed to understand the reasons for PSPS. In light of new scientific data, these osteopathic techniques could contribute to a multidisciplinary approach to solve the problem.

Microscopic anatomy of the visceral fasciae

The term 'visceral fascia' is a general term used to describe the fascia lying immediately beneath the mesothelium of the serosa, together with that immediately surrounding the viscera, but there are many types of visceral fasciae. The aim of this paper was to identify the features they have in common and their specialisations. The visceral fascia of the abdomen (corresponding to the connective tissue lying immediately beneath the mesothelium of the parietal peritoneum), thorax (corresponding to the connective tissue lying immediately beneath the mesothelium of the parietal pleura), lung (corresponding to the connective tissue under the mesothelium of the visceral pleura), liver (corresponding to the connective tissue under the mesothelium of the visceral peritoneum), kidney (corresponding to the Gerota fascia), the oesophagus (corresponding to its adventitia) and heart (corresponding to the fibrous layer of the pericardial sac) from eight fresh cadavers were sampled and analysed with histological and immunohistochemical stains to evaluate collagen and elastic components and innervation. Although the visceral fasciae make up a well-defined layer of connective tissue, the thickness, percentage of elastic fibres and innervation vary among the different viscera. In particular, the fascia of the lung has a mean thickness of 134 μm (± 21), that of heart 792 μm (± 132), oesophagus 105 μm (± 10), liver 131 μm (± 18), Gerota fascia 1009 μm (± 105) and the visceral fascia of the abdomen 987 μm (± 90). The greatest number of elastic fibres (9.79%) was found in the adventitia of the oesophagus. The connective layers lying immediately outside the mesothelium of the pleura and peritoneum also have many elastic fibres (4.98% and 4.52%, respectively), whereas the pericardium and Gerota fascia have few (0.27% and 1.38%). In the pleura, peritoneum and adventitia of the oesophagus, elastic fibres form a well-defined layer, corresponding to the elastic lamina, while in the other cases they are thinner and scattered in the connective tissue. Collagen fibres also show precise spatial organisation, being arranged in several layers. In each layer, all the fibrous bundles are parallel with each other, but change direction among layers. Loose connective tissue rich in elastic fibres is found between contiguous fibrous layers. Unmyelinated nerve fibres were found in all samples, but myelinated fibres were only found in some fasciae, such as those of the liver and heart, and the visceral fascia of the abdomen. According to these findings, we propose distinguishing the visceral fasciae into two large groups. The first group includes all the fasciae closely related to the individual organ and giving shape to it, supporting the parenchyma; these are thin, elastic and very well innervated. The second group comprises all the fibrous sheets forming the compartments for the organs and also connecting the internal organs to the musculoskeletal system. These fasciae are thick, less elastic and less innervated, but they contain larger and myelinated nerves. We propose to call the first type of fasciae 'investing fasciae', and the second type 'insertional fasciae'.

Work of separation - A method to assess intraperitoneal adhesion and healing of parietal peritoneum in an animal model

BACKGROUND

Adhesion grades and adhesion breaking strength are widely used to assess severity of intraperitoneal adhesion in animal models. However, the results of adhesion grades have the large deviations due to vary personal experience. Adhesion breaking strength ignores the details of adhesion. This study introduced work of separation, the energy consumption during breakage of adhesion, to better evaluate intraperitoneal adhesion.

METHODS

The intraperitoneal adhesion was induced by traumas created at rat cecum and adjacent abdominal wall. The wounds were coated with or without sodium hyaluronate. On day 14 after surgery, the intraperitoneal adhesion was assessed by adhesion density grade, adhesion area grade, adhesion breaking strength and work of separation. The healing of parietal peritoneum was evaluated with histology, adhesion breaking strength and work of separation.

FINDINGS

The severity of adhesion evaluated with work of separation was consistent with those obtained from the grades of adhesion density, adhesion area and adhesion breaking strength. Work of separation had a linear correlation with adhesion breaking strength. Furthermore, the results of histological examination and work of separation demonstrated that adhesion significantly delayed healing process of abdominal wall muscles.

INTERPRETATION

Work of separation can quantify all intraperitoneal adhesions rather than the major one by other methods. It is a more precise method to evaluate postoperative adhesions, especially those including adipose tissue. This study proved that work of separation could be a reliable method to assess intraperitoneal adhesion and tissue healing.

Preventive Effects of the Intestine Function Recovery Decoction, a Traditional Chinese Medicine, on Postoperative Intra-Abdominal Adhesion Formation in a Rat Model

The intestine function recovery decoction (IFRD) is a traditional Chinese medicine that has been used for the treatment of adhesive intestinal obstruction. In this study, the preventative effects and probable mechanism of the IFRD were investigated in a rat model. We randomly assigned rats to five groups: normal, model, control, low dose IFRD, and high dose IFRD. In the animal model, the caecum wall and parietal peritoneum were abraded to induce intra-abdominal adhesion formation. Seven days after surgery, adhesion scores were assessed using a visual scoring system, and histopathological samples were examined. The levels of serum interleukin-6 (IL-6) and transforming growth factor beta-1 (TGF-β1) were analysed by an enzyme-linked immunosorbent assay (ELISA). The results showed that a high dose of IFRD reduced the grade of intra-abdominal adhesion in rats. Furthermore, the grades of inflammation, fibrosis, and neovascularization in the high dose IFRD group were significantly lower than those in the control group. The results indicate that the IFRD can prevent intra-abdominal adhesion formation in a rat model. These data suggest that the IFRD may be an effective antiadhesion agent.

A Novel Method for Evaluating Postoperative Adhesions in Rats

Purpose/Aim: Postoperative adhesions remain an undesirable and commonly symptomatic side effect of abdominopelvic surgeries. Animal models of postoperative adhesions typically yield heterogeneous adhesions throughout the abdominal cavity and are not easily quantified. Here we present a novel method of postoperative adhesion assessment and report its reliability and measurement error.

MATERIALS AND METHODS

A model of cecal abrasion with partial sidewall attachment was performed on female rats. After 1, 2, 4, or 7 days of recovery, the rats were euthanized and their abdominopelvic cavities were systematically evaluated for postoperative adhesions. The necropsy was recorded through the surgical microscope. Four raters were trained to use a ballot to capture key factors of the adhesions as they viewed the recordings. Their ratings were compared for measurement error and reliability (using Bland-Altman plots and intraclass correlation coefficients, respectively) and for the ability to discriminate differences in experimental groups. A subset of the data was analyzed to determine practical utility.

RESULTS

The rating system was shown to have low measurement error and high inter-rater reliability for all parameters measured. Applied practically, the system was able to discriminate groups in a manner that was expected.

CONCLUSIONS

We have developed and validated a rating system for postoperative adhesions and shown that it can detect group differences. This method can be used to quantify postoperative adhesions in rodent models.

Treating Small Bowel Obstruction with a Manual Physical Therapy: A Prospective Efficacy Study

Small bowel obstructions (SBOs) caused by adhesions are a common, often life-threatening postsurgical complication with few treatment options available for patients. This study examines the efficacy of a manual physical therapy treatment regimen on the pain and quality of life of subjects with a history of bowel obstructions due to adhesions in a prospective, controlled survey based study. Changes in six domains of quality of life were measured via ratings reported before and after treatment using the validated Small Bowel Obstruction Questionnaire (SBO-Q). Improvements in the domains for pain (p = 0.0087), overall quality of life (p = 0.0016), and pain severity (p = 0.0006) were significant when average scores before treatment were compared with scores after treatment. The gastrointestinal symptoms (p = 0.0258) domain was marginally significant. There was no statistically significant improvement identified in the diet or medication domains in the SBO-Q for this population. Significant improvements in range of motion in the trunk (p ≤ 0.001), often limited by adhesions, were also observed for all measures. This study demonstrates in a small number of subjects that this manual physical therapy protocol is an effective treatment option for patients with adhesive small bowel obstructions as measured by subject reported symptoms and quality of life.

Clinical relevance of fascial tissue and dysfunctions

Fascia is composed of collagenous connective tissue surrounding and interpenetrating skeletal muscle, joints, organs, nerves, and vascular beds. Fascial tissue forms a whole-body, continuous three-dimensional viscoelastic matrix of structural support. The classical concept of its mere passive role in force transmission has recently been disproven. Fascial tissue contains contractile elements enabling a modulating role in force generation and also mechanosensory fine-tuning. This hypothesis is supported by in vitro studies demonstrating an autonomous contraction of human lumbar fascia and a pharmacological induction of temporary contraction in rat fascial tissue. The ability of spontaneous regulation of fascial stiffness over a time period ranging from minutes to hours contributes more actively to musculoskeletal dynamics. Imbalance of this regulatory mechanism results in increased or decreased myofascial tonus, or diminished neuromuscular coordination, which are key contributors to the pathomechanisms of several musculoskeletal pathologies and pain syndromes. Here, we summarize anatomical and biomechanical properties of fascial tissue with a special focus on fascial dysfunctions and resulting clinical manifestations. Finally, we discuss current and future potential treatment options that can influence clinical manifestations of pain syndromes associated with fascial tissues.

Skin, fascias, and scars: symptoms and systemic connections

Every element or cell in the human body produces substances that communicate and respond in an autocrine or paracrine mode, consequently affecting organs and structures that are seemingly far from each other. The same also applies to the skin. In fact, when the integrity of the skin has been altered, or when its healing process is disturbed, it becomes a source of symptoms that are not merely cutaneous. The skin is an organ, and similar to any other structure, it has different functions in addition to connections with the central and peripheral nervous system. This article examines pathological responses produced by scars, analyzing definitions and differences. At the same time, it considers the subcutaneous fascias, as this connective structure is altered when there is a discontinuous cutaneous surface. The consequence is an ample symptomatology, which is not limited to the body area where the scar is located, such as a postural or trigeminal disorder.

Manual Physical Therapy for Non-Surgical Treatment of Adhesion-Related Small Bowel Obstructions: Two Case Reports

Background: Adhesion formation is a widely acknowledged risk following abdominal or pelvic surgery. Adhesions in the abdomen or pelvis can cause or contribute to partial or total small bowel obstruction (SBO). These adhesions deter or prevent the passage of nutrients through the digestive tract, and may bind the bowel to the peritoneum, or other organs. Small bowel obstructions can quickly become life-threatening, requiring immediate surgery to resect the bowel, or lyse any adhesions the surgeon can safely access. Bowel repair is an invasive surgery, with risks including bowel rupture, infection, and peritonitis. An additional risk includes the formation of new adhesions during the healing process, creating the potential for subsequent adhesiolysis or SBO surgeries. Objective: Report the use of manual soft tissue physical therapy for the reversal of adhesion-related partial SBOs, and create an initial inquiry into the possibility of nonsurgical lysis of adhesions. Case Reports: Two patients presenting with SBO symptoms due to abdominal adhesions secondary to abdominal and pelvic surgery were treated with manual soft tissue physical therapy focused on decreasing adhesions. Conclusions: Successful treatment with resolution of symptom presentation of partial SBO and sustained results were observed in both patients treated.

Prevention of adhesion formation in Wistar-albino rats by increased bowel movements achieved with oral Ricinus oil use for 8 days postoperatively: an experimental study

OBJECTIVE

Adhesion formation frequently occurs after abdominopelvic surgery and can cause significant morbidity for patients. Meticulous hemostasis, minimal access surgery and utilization of surgical adjuvants intraoperatively are clinically useful measures to minimize adhesion formation. We investigated the clinical efficiency of oral Ricinus oil treatment for 8 days postoperatively to decrease adhesion formation in this case-control study in a rat model.

STUDY DESIGN

Following computer-generated randomization, 24 female Wistar-albino rats were operated on, with 10 standard cautery lesions on the right uterine horn and two simple suture lesions on left uterine horn generated with absorbable material. Half (n=12) the rats received 0.13 g (0.2 ml) Ricinus oil emulsion (40 g/60 ml) via the oral route during the first 8 days postoperatively, and the remaining rats (n=11) were considered as controls. The extent, severity, degree, total adhesion scores and histopathological features of the adhesions were the main outcome measures.

RESULTS

The degree and total adhesion formation scores in the Ricinus oil group and control group revealed significant differences in adhesion extent and severity. The total adhesion scores of the Ricinus oil and control groups were 3.00 ± 2.21 and 5.18 ± 2.78 respectively (P<0.05). Differences in type of inflammation, extent of inflammation and vascularization were statistically insignificant for suture and cautery lesions individually (P>0.05).

CONCLUSIONS

Ricinus oil treatment following abdominopelvic surgery for the 8-day period that covers the completion of tissue healing process may be a promising, cheap and cost-effective treatment strategy for patients.

Visceral massage reduces postoperative ileus in a rat model

OBJECTIVE

Abdominal surgery invariably causes a temporary reduction of normal intestinal motility, called postoperative ileus. Postoperative ileus extends hospital stays, increases the costs of hospitalization, and may contribute to the formation of postoperative adhesions. We designed experiments to determine if visceral massage affects postoperative ileus in a rat model.

MATERIAL AND METHODS

Forty female Long Evans rats were assigned to 4 groups in a 2 (surgery) × 2 (treatment) factorial design. Twenty rats were subjected to a small intestinal manipulation designed to emulate "running of the bowel." Transabdominal massage was performed upon 10 operated and 10 control rats in the first 12 h following surgery. Ileus was assayed after 24 h using fecal pellet discharge and gastrointestinal transit. Intraperitoneal inflammation was assayed using total intraperitoneal protein and inflammatory cell concentrations.

RESULTS

The surgery consistently caused ileus. Compared to the operated group with no treatment, the operated with treatment group showed increased gastrointestinal transit and reduced time to first fecal pellet discharge. Similar group comparisons revealed that the treatment decreased total intraperitoneal protein and numbers of intraperitoneal inflammatory cells.

CONCLUSIONS

In this rat model, visceral massage reduced experimental postoperative ileus. The data suggest that the effect was through the attenuation of inflammation. A similar study could be designed and performed in a hospital setting to assess the potential role of visceral massage as part of the integrated care for postoperative ileus.

Training principles for fascial connective tissues: scientific foundation and suggested practical applications

Conventional sports training emphasizes adequate training of muscle fibres, of cardiovascular conditioning and/or neuromuscular coordination. Most sports-associated overload injuries however occur within elements of the body wide fascial net, which are then loaded beyond their prepared capacity. This tensional network of fibrous tissues includes dense sheets such as muscle envelopes, aponeuroses, as well as specific local adaptations, such as ligaments or tendons. Fibroblasts continually but slowly adapt the morphology of these tissues to repeatedly applied challenging loading stimulations. Principles of a fascia oriented training approach are introduced. These include utilization of elastic recoil, preparatory counter movement, slow and dynamic stretching, as well as rehydration practices and proprioceptive refinement. Such training should be practiced once or twice a week in order to yield in a more resilient fascial body suit within a time frame of 6-24 months. Some practical examples of fascia oriented exercises are presented.

The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine

Visceral manual therapy is increasingly used by UK osteopaths and manual therapists, but there is a paucity of research investigating its underlying mechanisms, and in particular in relation to hypoalgesia. The aim of this study was to investigate the immediate effects of osteopathic visceral mobilisation on pressure pain thresholds. A single-blinded, randomised, within subjects, repeated measures design was conducted on 15 asymptomatic subjects. Pressure pain thresholds were measured at the L1 paraspinal musculature and 1st dorsal interossei before and after osteopathic visceral mobilisation of the sigmoid colon. The results demonstrated a statistically significant improvement in pressure pain thresholds immediately after the intervention (P<0.001). This effect was not observed to be systemic, affecting only the L1 paraspinal musculature. This novel study provides new experimental evidence that visceral manual therapy can produce immediate hypoalgesia in somatic structures segmentally related to the organ being mobilised, in asymptomatic subjects.