GENERAL SURGERY: diagnostics and surgical therapy of diseases of the gastoenteric tract.

This technique consists in injecting small quantities of homeopathic and homeotoxilogical medicines into particular zones of the patients body.  In this way it is possible to combine the stimulating effect on specific zones of acupuncture with the therapeutic action of the medicines, and the reciprocal boosting effects of both the techniques.  This is ideal for the treatment of:

• CELLULITE
• LOCALISED ADIPOSITY
• ACNE
• VENO-LYMPHATIC INSUFFICIENCY
• HAIR LOSS

LIPODISSOLVE METHOD
Electro-lipolysis and homeopathic products for the treatment

• LOCALISED ADIPOSITY AND DOUBLE CHIN

MEDICINAL GASES

LOCALISED AND GENERAL ANTI-AGE PROTOCOL AND BIO-REVITILISATION OF THE FACE, NECK, DECOLTE AND HANDS

• BIO-STIMULATION: for rejuvenation with vitamins and homeopathic products
• PEELING:  Glycolic acid
• FILLERS:  Collagen and hyaluronic acid

Postural re-education refers to all the techniques that  utilise resistance, with the auxiliary of insoles if necessary, in order to correct the patient’s posture and cancel all the adaptations and incorrect positions which lead to pathologies.

Self awareness exercises

Aim at the recuperation of  postural muscles through the use of unstable surfaces on which the patient is positioned.  The two instruments used are referred to as Daedalus and Semelles à boule and they are utilised to recuperate, in static and dynamic states, after the Sagittal and helicoid deviation of the rachid.  Their function is based on neuro physiological principles which are at the root of  dynamic anti-gravitational orthostatism.  The dedalus and Semelles a boule are the fruit of years of study and experimentation of the methods of R.J. Bourdiol and his team on the many factors that affect the regulation and  static equilibrium in human kinetics.  Dedalus (photo) the name Dedalus makes reference to a “circular labyrinth of concentric corridors” positioned on the anterior part of the implement which moves a ball.  The posterior part of the implement is made up of a foot plate.  The platform is sustained by a mechanical frame which forms two parallel tracks that have the scope to hold a medical ball which can move forwards and backwards inflated or deflated.  Even though the Dedalus is based on the same principles as an equilibrium axis on an elastic base, can combine  involuntary  exercises (with sub cortical reflex control) and voluntary exercises (with cortical control) which entail  moving of the ball in the labyrinth till the centre is reached.  the playful component makes the exercise more enjoyable.  This method  progressively results in a double phenomenon which have till now never been paired:

1) Reacquisition of self awareness, various parts of the body, muscles participate in a purely reflexive way to ortostatism,  gently improving the equilibrium of the altered and unbalanced structures.

2)Reacquisition of baro-sensitivity which is deeply linked to the participation of the various articular and somatic baro-receptors induced during the pneumatic oscillation on the  medical ball at variable pressure.  The Dedalus cannot be used for the rehabilitation of other muscular chains which are not controlled by ortostatism.   Procubit with the weight forward is the ideal exercise to regain muscular tone of the neck.  Procubit with the weight forward for the shoulder muscles and back.  Semelles à boules (board with ball) photo are applied to the patients shoes on condition that the heels are no more than two centimetres. On the inferior part the support has a metal blade onto which the ball is anchored which is lodged on a spring of variable resistance.  The ball can be moved backward or forward with respects to the  centre of the foot.  Walking is the most practical sport, because it allows us to use all the reflexes of all the sub cortical cerebral systems and synergic muscular groups agonistic and antagonistic.  R.J. Bourdiol identified two muscular systems based on their podial origin, calling them extensor  origin chains and flexor origin chains.  These are complementary and unconsciously alternatively regulate anti-gravitational erectness, in both immobile orthostatism and during walking, running and jumping.  The scope of the semelles à boule is therefore to solicit the activity of these chains.

Resistance Techniques
The patient can perform these alone using a ball as a resistance element or with the help of another person.

Exercise with elastic resistance:  This exercise harnesses an elastic resistance (ball, fender) to activate an antagonistic and synergic muscular mechanism.

Exercise with a rubber band: In this method elastic bands of varying rigidity,  depending on specific needs, are attached on one side to a fixed element ( radiator, table leg, handle etc) while on the other side it is attached  to the limb which needs to be worked. Successively specific exercises are prescribed to the patient which use the opposite resistance of the elastic band.

Exercise in adapted contro-resistance: this method harnesses the opposite resistance  of a second person on a defined  body segment in order to relax contracted hypotonic muscle groups favouring the reacquisition of articular mobility.  This method conceived and systemised by R.J. Bourdiol has three phases.

• Positioning: which is characterised by the correct positioning  of the segment in question.
• Tension:  the scope of this phase is to de-contract  the contracted muscles responsible for the blockage of the articular function by activating the inhibitory circuit.

Re-education in adapted contro-resistance.  From the phase of maximum patient the patient is asked to return to the starting position while the therapist applies dynamic and calibrated resistance which should be variable and have sudden releases to maximise the automatic mechanism that regulates the relationship between different muscle groups defined “agonistic-antagonistic”.  If the patient activates a particular body segment while the therapist applies resistance which is suddenly decreased because the therapist has suddenly released, a gamma  circuit is re-launched putting into play the agonistic- antagonistic system which is normally useful and necessary for re-equilibrating and maintaining normal motor function.  Thanks to this manoeuvre in adapted  contro-resistance  good results can be obtained in cases of  muscular imbalance bodily regions because of static alteration or in the post-traumatic form (whip lash, sprained ankles and because of  surgery etc.).  It is important to highlight that this re-educative technique  bases its action mechanism on  a neurological circuit which regulates muscle tone called the “gamma circuit”, which is a binary system which pairs an extension sensitive baro-receptor  with a baro-receptor positioned in  the osteo-tendinous insertion of the same muscle which impedes the risks of dis-insertion by cancelling the contraction.  All violent manipulative manoeuvres which characterise many  schools of manipulation are excluded from this re-educative technique because they are considered traumatic and anti-physiological.

Active Lumbar Traction (ALT)

Active lumbar traction or ALT is the direct descendant of the Swedish technique of (auto-traction” , a mechanical treatment of  lumbar- sciatic pain resulting from benign causes.  Spondylolysis and spondylothesis are not among the symptoms (in that the pain cannot be traced to a compressive mechanism, nor neo-plastic pathologies, major inflammation such ankylosing spondylitis or rheumatoid arthritis.  It is indicated for  radicular protrusion syndrome or disk hernia, lateral or median, contained or bulging, single or multiple, just like the insidious slow channel syndrome where the lumbar-sciatic pain is associated with  “lameness” forms that are like the vascular forms.  With this method patients with a history of relapses and regression after previous surgical procedures can be treated successfully.  The  patient lies in a supine position on a table (photo) half the length of which is divided transversally.  The inferior half of the body, pelvis included, is sustained by the caudal part of the table.  This part can then be slowly lowered or raised and rotated to the left or right using an electric mechanism controlled by the therapist, so as to position or tri-dimensionally mobilise the lumbar-sacral column.

Instrumental Physiotherapy

Super pulsed diode laser:  Its therapeutic properties are based on the biostimulation obtained from the deep release of  electromagnetic energy in the form of laser light.  At medium frequencies the effect is antiflogistic and antalgic.  At high frequencies the effect is anti-inflammatory, anti-oedemigenic, and bio-stimulant.

CO2 LASER: a gas laser utilised at a reduced potential 10-15W

Super pulsed ultrasound: these are acoustic vibrations that are not perceptible to the human ear.  They spread in the form of compressed and decompressed wave particles transmitted from the means of transmission parallel to the direction of the propagated waves.

Electro therapy:  Electric energy in its various forms is utilised for therapeutic purposes.  It produces differing effects on the organisms and has diverse clinical applications: transcutaneous electrical nerve stimulation (TENS) for pain therapy, pharmaceutical “propelling” electrotherapy (Iontophoresis).

Hi Top (High Tone Power):  Is a high frequency therapy, which utilises sinusoidal waves at a medium frequency.  This therapy allows for the activation of the metabolism and has a stimulating effect.

Magnetotherapy: High frequency magnetic fields are used to obtain analgesic effect.  Low frequency magnetic fields are used for a bio stimulating effect

SCENAR: an acronym for Self-Controlled Energy Neuron Adaptive Regulation.  This is an non-invasive medical method of  stimulating and activating the bodies self-healing properties.  SCENAR was invented for a Russian military and spatial programme about 20 years ago.  The astronauts could not take any medicines during the mission and as a result, as part of the strategic planning of the mission an instrument to care for and improve the immune system was created.  SCENAR can be referred to as an interactive neuro-regulator which transmits very low bi-phase and bi-frequency electrical impulses which can be programmed in relation to the pathology being treated.  Uses of SCENAR: pain, results of trauma and sports trauma, muscular inflammation, muscular lesions, capsulo-ligamentary sprains, calcifications, arthrosis, bursitis and tendonitis.  SCENAR helps to resolve inflammation and above all pain very quickly.

McKenzie Method

This technique  deals with the rehabilitation of mechanical disturbances of the locomotive apparatus, utilising the diffusion of pain as a guide line for both the diagnosis and treatment.  This is one of the elective techniques for the conservative treatment of discopathies (protrusions and hernias) that can evolve into cervicobrachalgia and lumbar sciatalgia, and above all patients with histories and relapses after surgery can be treated.  The objectives of this technique are:

1. The treatment of current pain episodes;

2. The prevention of future episodes;

achievable through static positions and specific repetitive movements that are taught to the patient  to show them how they themselves can modify the symptomology.  By inserting the concept of auto treatment, we try to make the patient accept their responsibility and give them a measure of autonomy thereby reducing their reliance on the physiotherapist.

Kinetic Control Method

This method allows for  re-education in cases of mechanical motion dysfunctions resulting from functional instability thus contributing to the reduction of  pain  in the region of the muscular skeletal apparatus.  Functional instability of the  locomotory apparatus refers to the incapability of the locomotory apparatus to control the static position and the correct execution of  functional movements.  The organs that fundamentally regulate  functional stability are the muscles.  These are re-educated by means of excercises  performed under the strict control of the physiotherapist.

Masso Physiotherapy

This involves manual manoeuvres performed on the skin and underlying tissues (muscles) that explicit a localised action and a reflex action on the nervous system.

• Connectival massage:  neuro-reflex technique, principally deep cutaneous applied on the sub-cutaneous tissues using the fingers.  The massage develops on the reticular sympathetic terminal of the skin inhibiting reflexogenic areas corresponding with deep organs affected by pathological processes.
• Deep Massage MTP: a massage technique invented by Dr. J.M. Cyriax and prescribed in cases of ligament, muscle and tendon pain.  The method is performed using transversal mobilisation, performed by the therapist with one or more fingertips, along the anatomic course of the affected tendon, muscle or ligament.
• Lymphatic massage: Manual lymphatic drainage speeds up the lymphatic flow, improving the re-absorption of oedemas and favouring the unblocking of  functionally closed lympho-venous connections under normal conditions.  It also boosts the immune system and renews the intercellular or interstitial fluid allowing a portion of lymph to reach all the tissues.
  

Hallux valgus (Bunion)
Hallux valgus is an outward deviation of the  first toe and can be classified in two big sub-categories: Simple Hallux valgus  and complex Hallux valgus.

The  outward deviation of the first toe results in reduced support and consequently the weight is transferred to the smaller metatarsals which are not capable of supporting all the body weight; this results in hallux vagus, “collapsed metatarsal arch” and hammer toes. Hallux valgus is therefore not only an aesthetic problem, it is a real bio-mechanical problem.

Surgical Treatment
By correcting hallux valgus early we prevent that the condition degenerates from  simple hallux valgus to complex hallux valgus.  Surgery for simple hallux valgus is performed under loco-regional anaesthetic, by means of a simple injection in the region of the knee which numbs the entire leg.  Surgery of simple hallux valgus has a duration of about 30 minutes, and ambulation is immediate with the auxillary of special shoes (called “talus”) which shift the weight to the heel.

Hallux Rigidus
Consists in the loss of movement of the first toe either because of trauma or because of congenital reasons resulting in sharp pain when walking.  Many operations have been described depending on the gravity of the condition, ranging from a simple cleaning of the bone to complex corrective osteotomies (bone re-section)

Metatarsalgia
Metatarsalgia is a generic term for  pain in the forefoot, the cause of which can be determined through instrumental examination.  The most frequent causes of metatarsalgia are, hallux valgus, Mortons Neuroma, metatarsalphalangeal dislocation and hammer toes.

Metatarsal collapse
Metatarsal collapse is usually a complication of hallux valgus and it involves the collapse of the transverse arch of the foot which initially causes a partial dislocation of the metatarsal phalanges (second, third and fourth) and then a complete dislocation.  Corrective surgery is called metatarsal re-alignment.

Surgical Treatment
Metatarsal re-alignment consists in the shortening of the second and third metatarsals and more rarely the fourth via a small incision using the Weil osteotomy technique with micro screws drilled into the bone itself.  This is how metatarsal alignment optimum support is repristined.  Usually this operation is performed under loco-regional anaesthetic  and is associated with the surgery to correct hallux valgus and as a result the recovery period is greater compared to that of hallux valgus.

Rheumatoid arthritis of the foot
The foot can be seriously affected by rheumatoid arthritis and other rheumatic diseases, and it can literally become deformed because of the  attack on the cartilage by the disease.  For rheumatoid arthritis and other rheumatic diseases of the foot there are  specific surgical techniques which allow ambulation and prevent ulterior serious deformities.

Surgical Treatment
The usual tendency is to correct the deformity as in hallux valgus and matatarsalgia while trying to eliminate cartilage so as to prevent ulterior degeneration.

Tendinopathy of the Achilles tendon
The most frequent pathologies of the Achilles tendon are acute breakage – which represents a surgical emergency, usually occurs because of sudden stress and requires immediate hospitalisation and a reconstruction of the tendon; tendonitis with peri-tendonitis is the most frequent pathology in which the elastic tissue of the tendon is substituted by fibrous tissue which is not elastic and can be the forerunner of a breakage.  If  physiotherapy  does not give good results (laser, ultrasound and general physiotherapy) a surgical solution is available

Surgical Treatment
The operation involves the insertion of small muscular grafts taken from the twin muscle through a small incision of about 5mm in the region of the Achilles tendon.  The operation does not entail immobilisation but a tutor is used for a period of about 20 days.  This operation which is performed und loco--regional anaesthetic takes about 40 minutes and requires a night of hospitalisation, after which any sport can be performed even traumatic sport.

Lesion of the ankle ligaments
After a violent ankle sprain or repeated ankle sprains which normally occur in athletes, one or more of the ankle ligaments can get torn.  The ligament usually involved is the anterior peroneus astragalo and the peroneus calcanean ligaments.  These ligaments have the function of stabilising the foot and the ankle, and in the event of a sprain the ankle manifests instability which causes pain, more sprains and weariness.

Surgical Treatment
In the case of chronic instability (from a long time ago)  it is possible to perform  surgical correction by reconstructing the  torn ligaments using a tendon (usually the peroneus brevis) to substitute the torn ligament.  This operation, which is performed under loco-regional anaesthetic, entails a maximum of 2 days hospitalisation and immediate ambulation with a tutor for 25 days but without the auxiliary of crutches.

Traumatic Pathology (the foot of the athlete)
The most frequent foot pathologies among athletes are:

• lesions of the ankle ligaments
• tendinopathies of the Achilles tendon
• stress fractures of the metatarsals: do not represent a complete fracture of the metatarsal bones but rather a partial fracture which occurs suddenly after strain. 

Congenital malformations
There are many congenital malformations of the foot, among the principal ones we find syndactylia (two or more toes webbed together) polydactylism; axial deviation  of the toes which can be studied singularly and eventually treated surgically if necessary.                         

Calcaneal spurs and plantar fasciitis
Calcaneal spurs and plantar fasciitis are two very closely related pathologies.  Calcaneal spurs are in fact a calcification under the plantar fascia on the heel.  The symptoms are severe pain when weight is placed on the heel, which is most accentuated when the first steps are taken in the morning or after walking for long periods.  Medical therapy consists in  the use of  soft inserts or insoles, physiotherapy, use of medicine and only in the case of  frequent recurrence or constant pain lasting more than 6 months you resort to surgery.

Surgical Treatment
The technique performed is called a fasciotomy according to Steindler and is performed percutaneously: through an incision in the region of the heel the plantar fascia are punctured. One suture is applied.  Surgery is performed under loco-regional anaesthetic, in a day hospital and takes a few minutes.  Ambulation is immediate but caution should be practiced as the initial pain when walking can be accentuated.

Hammer toes
Usually associated with hallux valgus or metatarsal collapse and more rarely isolated.

Surgical Treatment
The operation is performed under  local anaesthetic via a small incision made on the back of the toe regulating the phalange.  The operation does not entail hospitalisation and is performed in the doctors rooms.

Insufficiency of the first ray
The insufficiency of the first ray syndrome is frequent and very often unrecognised.  It has a symptomology similar to that of simple hallux valgus, but unlike hallux valgus, there is n deviation of the first toe.

The causes
The causes of the syndrome are predominately of an anatomic nature.  The symptoms are severe pain when the foot is placed with the sensation of walking on stones.

Surgical Treatment
The operation represents a definitive solution of the syndrome.  The operation performed is metatarsal realignment using the Weil technique,  which entails the shortening of the second and third and more rarely the fourth metatarsal via a small incision on the top of the foot and then clamping  it to the bone with a micro screw.  The operation is performed under loco-regional anaesthetic. Ambulation is immediate.

Flat feet in adults
It is normally a result of untreated serious childhood flatfeet.  The therapy for painful flat feet in adults is initially of a rehabilitive (soles, medicines, physiotherapy and physical therapy) If, however, this is not sufficient it is possible to perform surgery in select cases.

Surgical Treatment
The operation consists in the realignment of the internal arch using the Miller technique modified with the transporisation of the anterior tibial tendon to the posterior.  This operation lifts the collapsed arch and reduces the painful symptoms and repristines  the correct step.  It is perfomed under loco-regional anaesthetic with a 2 day hospitalisation period. Ambulation is immediate with a dedicated tutor.

Mortons Neuroma
Mortons Neuroma are a benign thickening of the plantar nerve in the regionof the  second and third intermetatarsal space.(this being the more frequent condition which occurs in 90% of cases)  It mainly affects females by a ratio of 7:1. The symptoms of Morton’s Neuroma consist of severe pain like an electric  charge  radiated to the second, third and fourth toes.  Non surgical treatment of Morton’s Neuroma usually has a temporary effect.

Surgical Treatment 
Surgery consists in making an incision of about 1.5 cm on the ball of the foot in the passage between the toes and the ball of the foot.  The neuroma is removed and three or four stitches are made.  Immediate ambulation is allowed and the operation is performed under loco-regional anaesthetic in day hospital.

PAEDIATRIC OTRHOPEDIA AND TRAUMATOLOGY

Infantile Hallux valgus
Infantile hallux valgus is aesthetically similar to adult hallux valgus, but it is almost always a result of flat feet with the consequent strain on the medial region and a successive outward deviation of the foot.  It usually does not require treatment and surgery is not performed except in very rare cases. It usually corrects itself spontaneously or with the correction of the flat foot.  In more serious cases, however, infantile hallux valgus can be an expression of neurological disease (infantile cerebral palsy)

Club Foot (Talipes equinovarus)
Club foot in newborns is a  serious malformation which is present at birth and affects 1 in 1.000.  The foot appears “equinus, inverted and adducted” as in the image.

Surgical Treatment
The most used treatment currently, is started at birth and consists in the use of the Ponseti Method which I utilise.  In this method many progressive corrective plaster casts are made and used in conjunction with a tendinotomy of the Achilles tendon which can be perfomed under sedation and local anaesthetic.   This form of treatment is non invasive and gives optimal results.

Varus or Valgus Knees
In children an angular deformity of the lower limbs is a serious cause of worry for parents even though the evolution is almost always benign. Angular pathologies are referred to as varus or valgus knees in varus kneed the legs look like two brackets and the knees do not touch, and vice versa in valgus knees which are commonly known as knock knees, the knees touch but the feet remain separated from each other.  In the first years of life there is a gradual passage from varus knees to valgus knees; the orthotist has to exclude the presence of pathological conditions like infantile tibial varus, rachitism and so forth, and evaluate whether the actual  alignment of the lower limbs is physiological for the childes age.  Children are born with varus knees, which straighten at about 20 months after which the knee becomes valgus and this becomes most evident at two to three years of age.   In rare and pathological cases the underlying disease has to be identified and  orthopaedic support or surgical correction.

Scoliosis
Scoliosis is an abnormal curvature of the spine. In children it is identifiable when you look at them from behind and there are one more pathological curvatures.  Scoliosis affects 2% of women and 0.5% of men.  The are many causes, the most common of which being, congenital deformities of the spine, genetic conditions, and neuro-mascular disorders, and disparity of the length of the lower limbs, but also cerebral palsy, spina bifida, muscular dystrophy, and spinal muscular atrophy and some tumours.  In more than 80% of cases, scoliosis is idiopathic, or in other words has no known cause; this common form of scoliosis is found in subjects who are otherwise completely healthy.  Idiopathic scoliosis  can be sub-divided into four categories depending on age: (1) infantile: children till age 3; (2) juvenile: children between ages 3 to 9; (3) adolescent; 10-18 years of age; (4) adult: after skeletal maturity.

Signs and symptoms
These can include uneven alignment of the shoulders, prominence of one shoulder blade, uneven hip alignment, one side higher than the other and the tendency to curve toward one side. When untreated scoliosis worsens the spine tends to turn and curve laterally, eventually causes, in serious cases, pain and difficulty breathing.

Treatment
Treatment can be medical or surgical depending on the case and it’s complexity and it is adapted to each patient.

PATHOLOGIES OF THE HIP

PERIODIC GROWTH ASSESMENT

The system that governs balance is in fact found between the ear and the brain, part of which being in the periphery or in other words inside the ear and is composed of the balance receptor from where the signal is then conducted to the central nervous system via the balance nerve (cranial nerve VIII or the vestibulochoclear nerve)

This simple diagram can help us to understand the complexity of the system and its localisation from outside (periphery) and inside (brain):

In our rooms Dr Roberto Bassani deals with this very interesting field using the most modern methods available todayThe evaluation of a patient with vertigo or who  suffers from disturbances of the balance first goes through a clinical evaluation where the complex neurological semeiotic is integrated with a series of  trials aimed at the vestibular function.Then, using special infrared video cameras and other instruments we try to fine tune the research revealing signs that otherwise may not have been evident to the naked eye.If we discover that the situation is complicated and we therefore have a suspected  diagnosis of grave pathology we proceed with further examination.  In the case of a definable clinical situation, however, we can then proceed to physical therapies or with the aid of pharmaceuticalsGiven the close vicinity and collaboration with th  physiatrist and physiotherapists as in few other places the interdisciplinarity can be of great help to the patient who can therefore make use of more competencies.

Some information on the vestibular system
Vestibology is the science that studies diseases that affect the vestibular system. The vestibular system is a sophisticated system that processes information relative to the position and maintenance of the head and body in space. This information, which we are unconscious of, except in cases of illness, is fundamental to the maintenance of posture and of uprightness. The vestibular system is made up of all the peripheral organs found in the inner ear and that are used for the analysis of both movement (acceleration receptors) and the force of gravity.  The organs that compose it are called semi-circular canals (perception of movement of the head in space) and the otolithic organs (particularly interesting for their unique function of perception of the force of gravity, and therefore important for the maintenance of the upright position).  All together, therefore, the peripheral receptor serves for the good maintenance of static and dynamic equilibrium.  When we take ill, for various reasons (infective, traumatic etc) this causes a series of very fastidious symptoms, among which vertigo, that is the false perception (a hallucination) of rotation in a way similar to someone who tries to stop suddenly after having spun around and around rapidly ( or on a roundabout) and with the aggravation of intense nausea and vomiting. Following, an image of the structure of the semi-circular canals and the otolithic organs.  The first look like differently oriented rings in various points in space while the otolithic organs (the utricule and saccule) are practically two bags found below and in contact with the semi-circular canals.

The mass of information received by the peripheral system has to be conducted to a centre or in other words a switchboard where signals are interpreted correctly and where motor responses are elaborated  for the maintenance of posture.  The electrical cable used for the transmission of these impulses is the vestibular nerve.  The vestibular nerve is connected to the brain and conducts signals up to the vestibular nuclei  and the cerebellum which as noted has the function of co-ordination and maintenance of equilibrium.  In summary this system has a peripheral part, a nerve and a central part.  It is, therefore, a circuit, whose optimal functioning allows us to move, even rapidly without losing our balance.

Diseases that cause vertigo
The most frequently encountered diseases of the vestibular system, in day to day medicine which cause vertigo are vestibular neuritis, Menière’s  disease and even more frequently, parossistic vertigo.

• Vestibular neuritis is characterised by intense vertigo that lasts for about a week.  In the first days it is impossible for the patient to stand upright and they, therefore, have to stay in bed, disturbed by spinning vertigo and intense nausea and vomiting.  The cause seems to be viral and the diagnosis has to be made using good clinical evaluation and with a test (vestibular test) which proves and quantifies the damage caused by the virus to the vestibular nerve.  Therapy is both medical and rehabilitative.  The latter, in particular, has to be commenced as soon as possible in order to minimise the damage caused to the patients balance.
• Menière’s disease is a relapsing vertigo determined by the swelling of the peripheral organs, the liquid normally present in which is called endolymph and is clinically found to be susceptible to increments in pressure which in the long run cause permanent damage to the structure.  Even for Mernière’s disease apart from a clinical exam a series of laboratory tests are recommended in order to determine the entity of the problem.
• Parossistic vertigo is the third entity but the most frequent.  It consists of episodically recurring vertigo which in some instances can last for very long and undermine particularly the balance of elderly people.  Vertigo in this case, typically manifests itself during the night or in the morning on awakening when turning to one side or trying to get up.  The cause seems to be caused by the movement of crystalline microstructres which are normally found in the otolitic organs, which become dislocated and freely fluctuate consequently  giving inadequate signals.  Unlike the other two causes of vertigo, that we have listed, this is treated with specific exercises without there really being a need for further exams apart from those clinical (that is medical examination).

Our Vestibology Centre 
The Vestibology centre found in our practice evaluates, other causes of vertigo and balance disturbances apart from the main causes and recommends other centres that perform major instrumental tests in order to identify the causes of vertigo and balance disturbances where possible.  We utilise a videonystamography machine that allows us to observe and evaluate the main and most visible exit of the vestibular system and the index of its health and if the nystagmus, the rapid rhythmic movement of the eye, which appears as follows under video observation:

Our management of the problem, however, is different of that at other centres.
Our viewpoint is neurological and the centre is in fact run by a neurologist, who has studied neuro-otological problems for many years and the most senior collaborates with many public  hospitals in the diagnosis of neurological vertigo.  Since the most serious causes of vertigo are, in fact, those that affect the central nervous system, it seems important, first of all to guarantee the possibility of excluding the presence of so called central problems to the patient and we believe that nothing is more important than pluriannual experience of a specialist in this field.  Once the most serious diseases are excluded, pathologies of the ear or in the case of vestibular neuritis those of the nerve are treated.  We also need to remember that not always and actually quite frequently the patient remains with the disturbance and without the possibility of a diagnosis ….. why?  The reason is simple because the terms of the problem are in reality very complex. Balance is a black box that receives a lot of information, vestibular, auditive, visusal, from even more peripheral structures like the muscles, ligaments, joints etc etc … It elaborates on this information and generates a response which is the health of balance itself, good posture and the capacity to adapt in the most diverse situations of day to day life and in the most adverse or challenging  or arduous situations (climbing a tree or hike till 8000m, adjust a halyard at the top of a mast while the boat is on a bowline, skateboard or perform acrobatics etc).  How is it possible to find your way in a forest so full of possibilities if we consider only one point of view no matter how noble. Otorhino or neurological?  The only possible solution (and to be honest the situation still remains difficult) is to render the complex observation and multiply the points of view which should then include physiatrists or better still orthopaedic medicine (not orthopaedics which is a different thing) which studies the most intimate mechanisms of articular function above all the vertebral column and then using complementary therapies like prolothrapy, and neraltherapy to press the smallest regulation buttons.  But even most sophisticated investigative methods require a postural approach with avant guarde dynamic and static stabilometres.

In conclusion we hope to have given an idea even though it is inevitably a summary of what in our view should be the correct approach to a frequent problem which is often resolvable or improvable but which always merits study and probing.

Jerome Bosch, "il giardino delle delizie"

In the history of humans there are traces of rudimentary auricolotherapy.  It seems that the Egyptians calmed certain pains by stimulating certain zones of the ear.  Hippocrates reveals the resolution of some forms of impotence by marking certain points of the ear.  Even Avicenna spoke about auricular therapies for the treatment of headaches.  In 1637, a portugese doctor described the auricular cauterisation for the treatment of sciatic neuralgia.  In 1717 Valsalva spoke about burns on the ear for the treatment of toothaches.  In 1810, a doctor called Ignaz Colla spoke about the observation of a man who could not walk for a period  after being bitten by a bee on the anthelix.  In 1850 Doctor Lucciani di Bastia spoke about the cauterisation of the ear as a radical cure for sciatalgia.  Near the mid 900’s doctor Nogier focused attention on patients treated for sciatalgia using auricular cauterisation.  He then had the genial intuition that the point was nothing other than an  element of a vast cartography that represented the total sum.  From there on auricolotherapy was born

The therapy
Even in antiquity the auricular pavilion was known as the seat of reflex therapy and certain points were cauterised to heal certain disturbances. This, elementary,  process had some fame in the last century even within the ambient of official medicine but was then abandoned because of its empiricism. Auriculotherapy, in existence for more than fourty years, is based on serious scientific experimentation and on precise investigative methods. The pavilion appears with a more precise somatotopy. Each region of the body seems to have a correspondent in the pavilion and a peripheral disturbance modifies the corresponding point in the pavilion.  Inversely the stimulation of the point can have an effect on the disturbance produced. This way a system was gradually constituted for the detection and treatment of the altered points in the pavilion. The anatomical study of the ear is performed with a  pressure “palpeur”  which allows for the exploration of the details of the structure of the pavilion  but also using a bracket that helps with the identification of  the cartilaginous grooves. Because the auricular points present a decrease in  electrical resistance when they are active, the search for the pathological point can be undertaken with an electrical probe. The range of uses for  auriculotherapy is very vast and includes functional pathologies of the spinal column and joints, problems of visceral function (gastritis, colitis, cystitis etc) neuro-vegetative dystonia etc. The action mechanism of auriculothrapy is based on the stimulation of pathological points, which can be done in various ways methods: needles, laser, electricity, magnets and cauterisation.  It has no contra-indications.

(From Nogier)

Other notable aid in the control of pain was the development of infiltrative techniques that allow that the pharmaceutical goes directly to the seat where the pain originates, using minimal doses, but with an extraordinary efficacy.  Today we also have at our provision extremely sophisticated tools for diagnosis and monitoring: from radiology to ultra sound to electro stimulation etc.  Using these  we can identify, through the skin and with very high precision, the structures that need to be infiltrated and operate on these  very safely.  Algology, today, is a scientific reality which often allows, even independently of the root disease, for the recuperation of an good quality of life adapted to the needs of the patient.

1) Manipulative medicine: Manipulative medicine is a branch of orthopaedic medicine which  is comprised of a series of well codified and precise manoeuvres aimed at the resolution of diverse painful pathologies of the spinal column and the peripheral joints: vertigo, migraines, headaches, backaches, lumbalgia, lumbar-sciatalgia, pain in the shoulders, elbows, hips, knees, feet etc.

2) Auricular reflex therapy. Works through the application of needles in differing zones of the ear for various types of  pathologies.  It is electively chosen for the treatment of many painful functional disturbances of the spinal column and peripheral joints, minor visceral disturbances, anxiety forms and headaches.

3) Infiltration

a) Mesotherapy. Is an infiltration technique based on the introduction of specific products in the dermal zone corresponding with the affected organ or structure.  In physiotherapy it is indicated for all the various painful pathologies of the spinal column and peripheral joints.

b) Prolothrapy.  The term prolotherapy was first used by George Hackett in 1950 and he defined it “the rehabilitation of an incompetent structure through the generation of new cellular tissue”.  The prefix prolo means to proliferate.  Prolotherapy is an infiltrative method of treating tendons and ligaments damaged as a result of degenerative or traumatic events with the scope of healing the affected structures. The theory of prolifotherapy is based on the fact that chronic muscular skeletal pain results from an inadequate reparative process of the fibrous tissues that results in  the poor vascolisation of the ligamentary  and tendinous structures. The sprain of a ligament or distraction of a tendon become the cause of chronic pain when the  healing process does not result in sufficient contractile or tensive force.  A condition referred to as  “insufficiency of the connective tissue” is characterised by a very weak structure that initially sends irregular and then continuous  nociceptive  signals under stress which results in chronic pain.  Prolifotherapy utilises soluble drugs that are infiltrated into the osteo-ligamentary gaps, which in the first phase create a localised inflammatory reaction  and then successively stimulates the repair and tension of the damaged tissues (tendons and ligaments).

c) Oxygen-ozone therapy through auto haemo-transfusion.  Oxygen-ozone therapy exerts a very useful anti-inflammatory and analgesic  action  for the treatment of arthro-rheumatic ailments.   Oxygen-ozone therapy has been demonstrated to have a high success rate in the treatment of lumbar or cervical disc hernias.  Oxygen-ozone through auto-haemo transfusion has a general revitalising effect and is therefore useful for treating asthenia,  after effects of influenza, anxiety and rheumatic disturbances

d) Neural therapy. Neural therapy is an infiltrative technique of treating scars  in chronic arthro-rheumatic diseases and postural imbalances utilising procaine and lidocaine.

e) Bio-therapies.  The term biotherapy refers to all pharmaceuticals of vegetal, mineral or animal origin which with different dilutions and action mechanisms can help with the resolution of various problems

f) Epidural
An epidural is an infiltrative method which has the scope of emitting a local anaesthetic with or without the addition of cortisone into the peridural space. The function of an epidural is both anti-inflammatory and neuro reflexive. The access point is either sacral or intervertebral.

4) Study and correction of posture.

Chronic benign skeletal pain, be it of traumatic origin or degenerative origin, characterised by an arthro-tendino-ligamentous dysfunction is a pathological situation that often tends to auto-maintain itself. The question posed is why painful rachialgia in certain subjects manifests itself  violently, lasts some days or maximum some weeks and then it resolves itself  and yet in other individuals once installed, despite variable intensities, it tends to auto-maintain itself. Perhaps the key can be researched in the presence of postural alterations which determine abnormal mechanical reactions of the skeleton during traction,  compression, rotation, twisting and yawning which cause articular imbalances and instability showing a predisposition to pathological painful rachialigia. If the subject has postural imbalances of plurifactoral genesis (feet, eyes, mastication, scars, anxiety, food intolerances etc) they progressively tend to assume an anti-physiological posture which comports an ever increasing  contractile state of the tonic muscles and successively that of the phasic muscles. This continuous situation of  postural imbalance also affects the osteo-articular  system particularly the capsuloligamentous support structures which slowly decline towards scleroses because of micro-circulatory alterations that follow giving way to fibrous degeneration which can result in laxity and consequent situations of articular instability. The tendino-ligamentous structures cover a very important role in the economy of the skeleton, exercising not only an articular sustaining and stabilising  function but also an externo-proprioceptive type action because of their important sensitive orthosympathetic innervation.  If, these structures, in a subject with an altered orthostatism because of pluri-receptorial disorderliness, are wounded as a result of any traumatic event, this can cause a chain reaction which leads first to structural weakening and then pain.  In this abnormal situation any pathogenic agent, which would have a limited effect in an individual with good posture, could result in the insurgence of persistent contractile-pain conditions mistakenly defined as “fibromyalgic”.

Diagnosis
In the presence of chronic skeletal pain a detailed anamnesis has to be executed to investigate, the type of pain, it’s duration, the seat and the timing of it’s insurgence, whether it is matutinal, afternoon, vespertine or nocturnal.  Pain according to the Bourdiol concept can be classified as mechanical, ligamentary and inflammatory.  Mechanical pain has the characteristic of  worsening with movement. Ligamentary pain: generally has the characteristic of  worsening while at rest and improving with movement (ankylosis pain). Inflammatory pain:  worsens in the second half of the night forcing the subject to awaken but without the immediate remission of the pain as happens in a ligamentary syndrome. For a correct  diagnostic picture, the doctor should ask the subject to undress and then after making them climb onto the podoscope , evaluate the bearing of the feet and the position of the rachid according to the frontal and horizontal sagittal planes. According to the teachings of  Dr. Bricot the evaluation with string hanging  perpendicular to arrows can reveal important information on diverse pathological postures and the resulting correlation between the foot and the rachid, between dental classes and the rachid, etc.  The  evaluation of the scapular belt and the bisiliac plane can highlight  postural imbalances which correlate with alterations of the eye, the foot or of both stabilometric. Postural examination successively continues with the evaluation of  temporomandibular articulation, the dental classes, swallowing, pathogenic scars and eventual micro-galvanisms according to the classical dictates of global postural re-education  according to Bricot. The integration of the static and dynamic stabilometric exam for the evaluation of  strategies in the study of the technical postural system is very important. After a classical neurological examination the doctor proceeds with a palpation of the spinal column to locate segmentary vertebral dysfunctions.  While the patient lies prone with a pillow under their stomach, the doctor exerts pressure on the interspinal gaps, on the articular spinal facets to localise the painful zone. The “palper rouler” technique then follows for the localisation of  dermalgic zones which mirror pain of the posterior brancha or visceral problems. At the end of this phase we have available a general picture that includes the plurifactoral origin of the pathology along with it’s  postural, mechanical, neurological and orthopaedic components

Treatment
Treatment in the case of pain of the rachid or the peripheral joints should be characterised by a) correction of the posture, b) miotensive manipulative treatment, c) proprioceptive re-education of the tonic muscles (daedalus and semelles) d)capsule-tendinoligamentous recuperation using prolotherapy e) ozone therapy f) epidural g) biological mesotherapy h) neural therapy i) biotherapy

Postural correction
Consists in the evaluation and correction of dysfunctional receptors using external -proprioceptive soles for the feet,  correction of non-compensated refractive disturbances like astigmatism for the eye or in the correction of convergence disturbances with orthotic exercises along with the use of magnets and eye drops for scars and neutralisation using infiltrations of procaine,  for occlusal problems using bites, for micro-galvanisms by eliminating endoral currents caused by poly metalism etc.

The physiatrist in collaboration with physiotherapists perform the following therapies:

• Lind Natchev table (auto-traction), a therapy utilised in the treatment of disc pathologies of the lumbar-sacral rachid
• Cervical traction: indicated for the treatment of cervico-brachalgia  of disc origin.
• Kinetic therapy: comprises multiple techniques, passive and active, finalised at the recuperation of movement and the normalisation of altered functions.
• Clinical massotherapy: for muscular-skeletrical pain.
• Specialised massotherapy: reflexogenic, zonal reflex of the ear, Cyriax deep transverse massage, lymphatic drainage