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The case report presents a patient with a possible neuropathic sternal pain associated with a recent heart transplant procedure. The patient could not breathe deeply and move the upper limbs, with a trunk torsion, feeling a sharp pain under and around the left breastbone. A fascial osteopathic approach in the treatment of the pelvic floor, the respiratory diaphragm, the thoracic outlet, the tongue and the tentorium cerebelli allowed the patient to access to a cardiovascular rehabilitation program. In osteopathic medicine, these anatomical parts of the body are called the five diaphragms. To our best knowledge, this is the first case report that uses osteopathic treatment in a patient with sternal pain associated with an undergoing cardiac transplantation. The clinical importance of the case report is added to other osteopathic research with patients undergoing cardiac surgery (coronary artery bypass graft) and with multiple benefits, without side effects. One of the main goals of osteopathic treatment is to provide the patient with well-being, from many clinical points of view, allowing the person to be discharged from the hospital more quickly and/or with less pain.

Bruno Bordoni, 1, 2 Bruno Morabito 3 1Foundation Don Carlo Gnocchi IRCCS, Department of Cardiology, Institute of Hospitalization and Care with Scientific Address, S Maria Nascente, Milan 20100, Italy; 2Department of Osteopathy, Asomi, Torino, Italy; 3Foundation Polyclinic University A. Gemelli University Cattolica Del Sacro Cuore, Rome, ItalyCorrespondence: Bruno Bordoni Tel +39 02 3496300617Email bordonibruno@hotmail.comAbstract: A great many articles discuss the histological aspects of fascial tissue in detail, but at the same time, there are many contradictions within the literature. In addition, there is a paucity of scientific data that allow straightforward classification of what tissue the fascia truly is. More precise classification of fascial tissue is essential in improving clinical care and effectively framing patient needs. Embryology is an indispensable starting point for understanding the many functions of the fascial tissue. This scientific discipline allows us to observe the relationships and adaptability of fascia both at local and systemic levels. This article reflects on modern scientific knowledge concerning the classification of fascia from an embryological standpoint with the aim of improving our understanding of connective tissue.Keywords: fascia, myofascial, embryology, anatomy, surgery, fibroblast

The present article comprehensively reviews the thoracic outlet syndrome (TOS), its etiology and assessment, with reference to the usual conservative treatment and surgical therapy, highlighting new definitions and reporting obsolete tests. The syndrome affects about 8% of the population, with higher prevalence in females, and rarely affects the children. Conservative, non-surgical treatment produces good results, and it becomes important to know which specific areas need to be treated. Currently, there is no rehabilitation scheme, either osteopathic or chiropractic, considered as a valid tool for a precise localization of the pathologic condition, probably due to the lack of a manual assessment process to evaluate bones and muscular components of the thoracic outlet. In this situation, the manual treatment performed is usually generic. The present article proposes a manual evaluation that can be used to identify the anatomical area which needs to be treated. This hypothesis of assessment should be carried out after the clinician has ruled out the necessity of surgery with instrumental examinations.

Bruno Bordoni,1 Fabiola Marelli,2,3 Bruno Morabito,2,3 Beatrice Sacconi,4,5 Paolo Severino6 1Department of Cardiology, Foundation Don Carlo Gnocchi, IRCCS, Institute of Hospitalization and Care, S Maria Nascente, Milan, Italy; 2CRESO, School of Osteopathy Centre for Research and Studies, Castellanza, Italy; 3CRESO, School of Osteopathy Centre for Research and Studies, Falconara Marittima, Italy; 4Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy; 5Center for Life Nano Science at Sapienza, Istituto Italiano di Tecnologia, Rome, Italy; 6Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy Abstract: 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. Keywords: post-sternotomy pain syndrome, osteopathic, fascia, chronic pain, cardiac surgery

Bruno Bordoni,1–3 Fabiola Marelli,2,3 Bruno Morabito,2–4 Beatrice Sacconi5 1Foundation Don Carlo Gnocchi IRCCS, Department of Cardiology, Institute of Hospitalization and Care with Scientific Address, Milan, 2CRESO, School of Osteopathic Centre for Research and Studies, Gorla Minore, 3CRESO, School of Osteopathic Centre for Research and Studies, Falconara Marittima, 4Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, 5Center for Life Nano Science, CLNS@Sapienza, Istituto Italiano di Tecnologia, Rome, Italy Abstract: This study deals with an osteopathic approach used for a patient with left-ventricular assist device (L-VAD) affected by left brachialgia. Clinical examination revealed the presence of thoracic outlet syndrome and pectoralis minor syndrome, with compression of the left proximal ulnar nerve, related to the surgical sternotomy performed. The osteopathic techniques used can be classified as indirect and direct, addressed to the pectoralis minor and the first left rib, respectively. To our knowledge, this is the first text in literature with an osteopathic treatment in a patient with L-VAD. Keywords: osteopathic, L-VAD, thoracic outlet syndrome, TOS, myofascial, fascia