a single case allows one to describe in detail the clinical presentation , therapeutic approach and outcome evaluation through internationally adopted tools avoiding the loss of data intrinsic to the selection of a representative pool of subjects . on the other hand ,
even if it is felt that what reported is a common feature of the clbp population , these observations are intended at stimulating a different perspective on the problem and possibly promote a new direction of investigation .
our subject is a 34 year - old man ( 1.83 m , 71.5 kg ) reporting a 6 years history of progressive low back pain with sporadic radiation to the left lower limb .
his symptoms become noticeably worse during physical workout limiting heavily his activity as an amateur runner of intermediate distances . a lumbosacral spine mri ( 2007 ) showed degenerative changes and disk protrusion with a median - para median herniation compressing the homologous nerve root at the l5-s1 level ( figure 1 ) .
he then consulted with a physiatrist that addressed him to the neurosurgeon ; the latter excluded neurological deficits indicative of surgery .
after a five months course of conservative treatment including specific core stability exercises the clinical picture improved globally so that the subject participated in a competitive 8.5 kms run with a final time of 3825  and an average running pace of 431  min / km . due to persistent debilitating symptomatology he repeated an mri study in may 2011 that showed the persistence of the herniation with neither a free fragment nor any sign of congestion .
he then presented for a consult with the corresponding author . upon inspection a loss of the physiological lumbar lordosis
local pain on palpation at the lumbosacral area and weakness in the rectus femoris and gluteus medium bilaterally were present .
mild tenderness and bloating of the abdomen on palpation were not supported by a positive history of major gastrointestinal disorders .
based on the author experience a restrictive diet ( table 1 ) was discussed and introduced together with a 20 day course of probiotics , homeopathic and herbal remedies .
after the resolution of all symptoms the restrictions were lifted with the exception of gluten and of milk derivatives .
the subject reported a progressive regression of the symptoms as displayed in the scales and questionnaires ; ( table 2 ) these results are maintained to date .
there were no confounding factors ( besides placebo s effect ) that could explain the outstanding clinical result since the inception of the dietary regimen .
the subject was instructed not to change his habits in terms of physical activity and did not participate in any additional physical or rehabilitative program .
the outcome was not limited to the primary therapeutic goal : as a matter of fact other sources of physical and mental distress improved as evidenced by the sf-36 forms ( figure 2 ) .
the influence of a limited therapeutic intervention at the gastrointestinal level on a variety of apparently unrelated symptoms is not surprising when considering clbp as comorbidity , hence one finding among the others . in this perspective
other subjects might express a more evident symptomatology at the digestive level ( irritable bowel syndrome ) whether emotional , energy related ( chronic fatigue syndrome ) or diffused pain  muscle pain like in  fibromyalgia  . at present , these subjects are managed by professionals with a different background including gastroenterologist , orthopedist , rheumatologist , neurologist , psychiatrist not to mention a slew of individuals under the umbrella of  alternative medicine  .
clbp is indeed a condition that challenges the diagnostic and therapeutic capabilities of the professionals involved . to date
the rehabilitative and cognitive approaches do not demonstrate fully satisfactory results especially when the treatment plan is not individualized .
a systematic review on the effectiveness of physical and rehabilitation interventions for chronic non - specific low back pain showed that unusual approaches like neuromotor oriented patient education ( rather than anatomically oriented ) , acupuncture and yoga provide greater effectiveness on disability than any of the commonly proposed treatments .
 vague  diagnoses like chronic fatigue syndrome , anxiety and fibromyalgia and what has been deemed the  functional somatic syndrome  might be overlooked .
functional gastrointestinal and gluten related disorders are seldom self - reported or under investigation in clbp patients . yet
the literature clearly associates gut related dysfunction with pain and sensory - motor abnormalities that in the end could explain spine dysfunction .
a vast array of neurological symptoms are related to gluten sensitivity , and gastrointestinal neuromuscular abnormalities observed in animal models seem to justify the symptomatology of gluten sensitive subjects . in both animal models and humans
there is now evidence that chronic visceral pain leads to somatic hypersensitivity and not the opposite as previously described . specifically in ibs
this hypersensitivity is not limited to the colon but displays a vast diffusion and a variety of clinical symptoms representative of alteration in central pain processing .
this observation is supported by the discovery of nmda receptors in the enteric nervous system and their role in central and peripheral sensitization and plasticity , as well as the acknowledged notion of convergence of sensory pathways at the spinal level . these abnormalities or even only pain in the gut in response to a trigger event , whether perceived or not , are associated with visceral hypersensitivity .
this in the end could be the explanation , through plasticity and viscerosomatic convergence of stimuli , of the motor response s alteration as we see in conditions like clbp .
neural plasticity is not only the adaptive response of the central nervous system to learning , structural damage or sensory deprivation , but also an increasingly recognized common feature of the gastrointestinal nervous system changes during pathological states .
neural plasticity in the peripheral nervous system and specifically in the enteric nervous system drives neural plasticity in the central nervous system ( specifically in the cortex ) .
clbp as a central cortical disturbance featuring motor neurons activity suppression in the primary motor cortex was recently proposed .
visceral stimulation activates the cerebellum and the dorsolateral prefrontal cortex , a critical point of the sensorimotor integrator network . through connections to the limbic system and cortical associative
areas it can affect the integration of motor responses to the stimulus at the cortical level .
motor training induction of cortical maps reorganization in clbp brings further evidence of the interconnection of these pathophysiologic events .
interestingly meridian therapy procedures like acupuncture and acupressure are particularly supported in both ibs ( irritable bowel syndrome ) and clbp .
two apparently unrelated complaints could be a different manifestations of the same chronic visceral hypersensitivity leading to central plastic changes in sensory motor organization and perception .
clbp has been positively associated in cross - sectional studies to cardiovascular disease , headache , respiratory problems , anxiety , depression and ibs .
given that it is a multifaceted issue , it should be considered in terms of comorbidity where the prevalence of other symptoms could be irrelevant or unreported .
the visceral and metabolic aspects of this problem have been overlooked so far as most studies focused on anatomy and abnormal mechanics .
food as a source of inflammation , pain related symptoms and motor impairment should be considered as primarily .
tools in the field of complementary medicine provide a different insight , a chance both for managing the symptoms of a disabling condition and possibly preventing the occurrence of more aggravating disorders .
clbp could be an epiphenomenon of a complex neural plasticity syndrome related to gastrointestinal and/or autonomic dysfunction .
 chronic low back pain ( clbp ) is a disabling condition affecting both quality of life and performance in athletes . 
 several approaches have been proposed in the field of physiotherapy , manual therapy , physical exercise and counseling . 
 none apparently is outdoing the other with the exception of trunk stability exercises in specific conditions . 
 the present paper describes a clinical success in managing a clbp runner affected by mri documented disk herniation via dietary change . 
 dietary changes allowed our patient that had failed with previous standard therapeutic approaches , to regain an optimal pain - free condition . 
 we advance the hypothesis that a visceral - autonomic concomitant or primary disturbance possibly generating mild gastrointestinal discomfort in clbp patients should be ruled out as a possible cause of pain and disability at the somato - motor level . 
Materials and Methods
Results and Discussion