Back Pain - A Movement Problem by Josephine Key

Back Pain: A Movement Problem Rolf1 considered that psoas provides a unique link body cylinder. Rather than the erector spinae being between the legs and the upper torso. Psoas prever- the prime antagonist to the rectus abdominus, psoas tebrally and rhomboids postvertebrally connect the and rectus abdominus need to be balanced as do two girdles to the spine. Functionally, however, psoas and rhomboids/lower trapezius. Rolf says: lower trapezius is also important in the functional ‘the focus of rhomboid–psoas balance is at the lum- synergy with rhomboids and should be included par- bodorsal junction which is what gives this area its ticularly as both it and psoas attach to T12 (Fig. unique importance in body mechanics’.1 6.52). Balance between them all ensures stability though flexibility of the girdles without disturbing The extensor mechanism the axial vertical. It also ensures correct function of of the body the diaphragm which is fundamental to the ‘open’ Occipital bone Superficial to the erector spinae is an auxiliary Intrinisic extensor system which has interesting myofascial extensor system geometry for distributing the load between the upper and lower movement systems (Fig. 6.53). Rhomboids • The three sections of the trapezius extend from Diaphragm Trapezius: the occiput to T12. upper middle Rectus T12 and lower • Latissimus dorsi arises from the spines of T7–12, abdominis the spines of all the saccral and all lumbar vertebrae and other Extensor via the thoracolumbar fascia; as well as the posterior abdominals system iliac crest; the lateral aspect of ribs 9–12; the inferior angle of the scapula. All the fibres converge Psoas Pelvis into a narrow tendon to attach superiorly on the humerus. Note the trapezius and latissimus overlap Fig 6.52  Schematic concept of sagittal alignment. between T7–12 to reinforce the mid back. Through Balanced activity between the lower scapula stabilizers, the it, the arms and the low back are functionally extensors and psoas with the diaphragm and abdominals connected. No wonder Janda222 considered it one of provides support and marries function between the upper the most significant muscles in the body! and lower body. • Gracovetsky37 considers the thoracolumbar fascia is the most important structure insuring the integrity of the spinal machinery as the viscoelastic properties of its collagen directly impacts upon the way the muscles are used and forces are channeled from the ground to the upper extremities. Its direct attachment to the spinous processes allows the powerful action of the hip extensors to be directly transmitted to the spine.131 The ability to dynamically alter the lumbar lordosis is important in force transfer. • Gluteus maximus extends from the iliotibial tract of the fascia lata and the femur and attaches superiorly to the iliac crest, thoracolumbar fascia, sacrum and coccyx. Its ability to bring the trunk upright has been described as the defining attribute of man.10 Coupled motion between it and the contralateral latissimus has been shown.223 • Raising the body. With gluteus maximus acting over the hip, hamstrings action raises and lowers the base of the body cylinder from the ischia as though the pelvis were a draw bridge. 142

Salient aspects of normal function of the torso CHAPTER 6 Trapezius External oblique Overlapping of Iliac crest latissimus dorsi Anterior superior by trapezius iliac spine Fascia of Gluteus maximus latissimus dorsi Sartorius Thoraco- Tensor fascia lata lumbar fascia Fascia of gluteus Rectus femoris maximus Vastus lateralis Biceps femoris, long head Iliotibial tract Ilio-tibial tract Semimembranosus Fig 6.53  The superficial myofascial extensor matrix. Biceps femoris, short head Patella Patellar ligament Head of fibula Plantaris Gastrocnemius, lateral head • The lower limb extensor mechanism. From the Fig 6.54  The lower limb extensor mechanism. ground reaction force through the feet, antigravity ‘lift’ is further achieved from coordinated interplay ischial tuberosity and the lower border of the between the one and two joint leg muscles (see sacrotuberous ligament.10 Ch. 4). The quadriceps mechanism and tensor fascia lata tense the fascial envelope around the The main functional roles of the thigh and help promote optimal function in the hip upper and lower body joint224 including stability for gluteus maximus7 and hamstring activity in raising and lowering the ‘pelvic Helped by Bartenieff’s observations148 one can swing’ (Fig. 6.54). Farfan7 notes that by increasing delineate the essentially different roles between external rotation at the hip, the hip extensors gain the upper and lower units of the body. mechanical advantage. The extensive fascia lata with • The lower unit as the controller of the centre of the reinforced iliotibial tract is distally attached to weight essentially ‘grounds’ the ‘base of support’ for the lateral tibial condyle, fibula head and femoral condyles and extends proximally to attach to the back of the sacrum and coccyx, iliac crest, inguinal ligament and superior and inferior pubic rami, 143

Back Pain: A Movement Problem antigravity control and postural changes for advantage of a lordotic spine that compresses and locomotor activity. twists driving rotation of the pelvis and counter rotation in the shoulder. This counter rotation • ‘The upper unit essentially serves exploring, between the limb girdles enables the connecting manipulating gesturing activities. It initiates and link – the spine and its viscoelastic tissues, to store extends reach space, communicates through spatial and release kinetic energy – the body becoming an gesture, body touch grasp, enveloping dispersing and oscillator resonating in the gravitational field. The intertwining’. viscoelasticity of the spinal tissues and the inertia of the limbs are important features of the system. It is common to see a certain ‘role reversal’ in many In his model, psoas is the controller of the spine of our patients which is associated with a ‘central enhanced by the combined action of the erectors, disconnect’ between the upper and lower poles of latissimus and trapezius.130 ‘In this model, the the body cylinder. arms and legs need to be evenly developed, smoothly interrelated’.226 Overdevelopment and Walking imbalance of superficial SGMS muscles in the proximal girdles and body wall including the Locomotion is basic to survival. A fundamental abdominals, will limit freedom of movement in physiological movement, walking involves integra- axial rotation in the limb girdles and the spine ted function of the legs, both proximal limb girdles reducing the rhythmical movement and energy and the axial spine while allowing independent transfer. As Newton suggests, the result will be motion of the head in order to focus the senses. ‘visible homologous (sagittal) or homolateral (lat- Many in the world still walk many miles a day to eral flexion) patterns of spinal motion226 during gather food and work. ‘Exercise’ is a matter of walking’. course. Studies on walking have confirmed that the pel- The greatest amount of motion occurs at the vic and shoulder girdles rotate in the transverse pelvis.225 Pelvic motion is initiated by the base of plane. This is initially synchronous in the same the trunk mass (sacroiliac joint) being eccentric direction and evolves toward counterrotation with to the centre of the supporting hip joints. Pelvic increasing walking velocity.227 Bruijn et al.228 found movement is restrained by the hip muscles while this is due to the pelvis beginning to move in-phase the axial muscles control trunk alignment over with the femur while the thorax continued to the pelvis.225 During each stride, the pelvis rotates counter rotate with respect to the femur. Moreover, asynchronously in three directions: sagittal 4, cor- pelvic and thoracic contributions to total body angu- onal 7 and in the transverse plane 10.225 This lar momentum were low, the contributions of the involves ‘distorsion’. With increasing stride, ‘the legs and arms being much larger. Crosbie et al.229 horizontal components become greatly increased. found small but definite segmental axial rotation The backward leg develops a forward, and the for- and lateral flexion movements occur through the ward leg a backward, rotating thrust creating a lower thorax during walking. Lumbopelvic move- force couple which rotates the pelvis in the trans- ments were greatest in the sagittal and frontal verse plane. These forces are essential to producing planes which led them to suggest that spinal seg- the propulsion and restraint of human gait’.132 ments move more in response to the lower limbs, Transverse plane rotation thus occurs at the hip due in large part to iliopsoas activity. They also joint, sacroiliac joint and the lumbosacral joint. showed that the amplitude of spinal motion Lumbar motion occurs in all segments, is triaxial increased with increased walking speed particularly and although small, the complex multiplanar in the sagittal plane. Significant reduction in spinal motion allows the lower extremities to remain in range of motion occurred with advancing age.230 a largely planar pattern.13 However, they did find that thoracic spine axial rotation was less in males. Walking on an incline Gracovetsky130 has proposed the spine as an exerts major influences on the thoracic spine by engine which drives the primary movement of the increasing the amplitudes of the axial rotations.231 pelvis.131 Walking is possible without legs – the legs only amplify movements of the pelvis. How- Ideally walking is effortless and flowing because of ever, in energy efficient walking the extensor a coordinated sequence of interconnected functions power from the legs is transmitted by the hip between the proximal limb girdles and spine. extensors through the pelvis to the spine taking 144

Salient aspects of normal function of the torso CHAPTER 6 References [1] Rolf IP. Rolfing: the integration of [13] Rozumalski A, et al. The in vivo editors. Clinical anatomy and human structures. New York: three dimensional motion of the management of thoracic spine Harper and Row; 1977. human lumbar spine during gait. pain. Oxford: Butterworth Gait Posture 2008;28(3):378–84. Heinemann; 2000. [2] Gracovetsky S. Stability or controlled instability? In: [14] Pearcy MJ. Twisting mobility of [25] Boyle JJW, Milne N, Singer KP. Vleeming A, Mooney V, the human back in flexed Influence of age on Stoeckart R, editors. postures. Spine 1993;18 cervicothoracic spinal curvature: Movement, stability & (1):114–9. an ex vivo radiographic study. lumbopelvic pain: integration Clin Biomech 2002;17(5): of research and therapy. 2nd ed [15] Burnett A, et al. Lower lumbar 361–367. Churchill Livingstone; 2007. spine axial rotation is reduced in end range sagittal postures when [26] McCouch GP, Deering ID, [3] Gracovetsky S. Linking the spinal compared to a neutral spine Ling TH. Location of receptors engine with the legs: a theory of position. Man Ther 2008;13 for tonic neck reflexes. human gait. In: Vleeming, et al., (4):300–6. J Neurophysiol 1951;14:191–5. editors. Movement, stability and low back pain: the essential role [16] Kapandji IA. The physiology of [27] Bergmark A. Stability of the of the pelvis. New York: the joints. Vol.3: the trunk and lumbar spine: a study in Churchill Livingstone; 1997. the vertebral column. 2nd ed, mechanical engineering. Acta p. 243–51. Edinburgh: Churchill Livingstone; Orthop. Scand. Suppl. 1989;230 1974. (60):1–54. [4] Janda V. Introduction to functional pathology of the motor [17] Franklin E. Pelvic power: mind/ [28] Hackney P. Making connections: system. In: Proc. V11 body exercises for strength, Total body integration through Commonwealth and International flexibility, posture and balance. Bartenieff Fundamentals. New Conference on Sport Physical New Jersey: Princeton Book York: Routledge; 2002. Education, Recreation and Dance Company; 2002. vol. 3; 1982. [29] Twomey L, Taylor J. Flexion [18] Lee D. The pelvic girdle: An creep deformation and hysteresis [5] White AA, Panjabi MM. Clinical approach to the examination in the lumbar vertebral column. biomechanics of the spine. and treatment of the lumbo- Spine 1982;7(2):116–22. Philadelphia: J. B. Lippincott pelvic-hip region. 3rd ed Company; 1990. Edinburgh: Churchill Livingstone; [30] Bogduk N, Twomey LT. Clinical 2004. anatomy of the lumbar spine. [6] Todd ME. The thinking body. Melbourne: Churchill Hightstown: Dance Horizons- [19] Twomey L. The effects of age on Livingstone; 1987. Princeton Book Company; 1937. the ranges of motions of the lumbar region. Aust J Physiother [31] Granhead H, Jonson R, [7] Farfan H. The biomechanical 1979;25(6):257–63. Hansson T. The loads on the advantage of lordosis and hip lumbar spine during extreme extension for upright activity. [20] Rock C-M. Reflex incontinence weight lifting. Spine 1987;12 Spine 1978;3(4):336–42. caused by underlying functional (2):146–9. disorders. In: Carri`ere B, Markel [8] McGill SM. Ultimate back fitness Feldt C, editors. The pelvic floor. [32] Adams MA, Dolan P, Hutton WC. and performance. Waterloo: Stuttgart: Thieme; 2006. The lumbar spine in backward Wabuno Pub.; 2004. bending. Spine 1988;13(9): [21] Levine D, Whittle MW. The 1019–26. [9] Norkin CC, Levangie PK. Joint effects of pelvic movement on structure and function: A lumbar lordosis in the standing [33] Claus A, et al. Sitting versus comprehensive analysis. 2nd ed position. J Orthopaedic & Sports standing: Does intradiscal Philadelphia: F.A. Davis Physiotherapy 1996;24(3): pressure cause disc degeneration Company; 1992. 130–135. or low back pain?. J Electromyogr Kinesiol 2008;18(4):550–7. [10] Williams PL, Warwick R. [22] Black KM, McClure P, Gray’s Anatomy. 36th ed Polansky M. The influence of [34] Solomonow M. Ligaments: Edinburgh: Churchill Livingstone; different sitting positions on a source of work related 1980. cervical and lumbar posture. musculoskeletal disorders. Spine 1996;21(1):65–70. J Electromyogr Kinesiol [11] Indahl A, et al. Interaction 2004;14:49–60. between the porcine lumbar [23] Lewit K. Manipulative therapy in intervertebral disc, zygapophysial rehabilitation of the motor [35] Solomonow M. Ligaments: a source joints, and paraspinal muscles. system. London: Butterworths; of musculoskeletal disorders. J of Spine 1997;22(24):2834–40. 1985. Bodywork and Movement Therapies (IN PRESS). [12] Neumann DA. Kinesiology of the [24] Singer KP, Malmivarra A. musculoskeletal system: Pathoanatomical characteristics of [36] Solomonow M, et al. The Foundations for physical the thoracolumbar junctional ligamento-muscular stabilising rehabilitation. Mosby; 2002. region. In: Giles LGF, Singer KP, system of the spine. Spine 1998;23(23):2552–62. 145

Back Pain: A Movement Problem [37] Gracovetsky S. Is the [48] Gracovetsky S. Is the ed. Edinburgh: Churchill lumbodorsal fascia necessary? lumbodorsal fascia necessary? In: Livingstone; 2006. J Bodywork and Movement Fascia Research: basic science and Therapies 2008;12(3):194–7. implications for conventional and [61] Kippers V, Parker AW. Posture complementary health care. related to myoelectric silence [38] Findley T, Schleip R, editors. Elsevier; 2007. of erectors spinae during Fascia Research: basic science and trunkflexion. Spine 1984;9(7): implications for conventional and [49] Gandevia SC, McCloskey DI, 740–5. complementary health care. Burke D. Kinaesthetic signals and Elsevier; 2007 Introduction. muscle contraction Trends. [62] Toussaint HB, Winter A, de Haas Y, Neurosci 1992;15:62–5. et al. Flexion relaxation during [39] Levin SM. A suspensory system lifting: implications for torque for the sacrum in pelvic [50] Dolan KJ, Green A. Lumbar spine production by muscle activity and mechanics: biotensegrity. In: reposition sense: the effect of a tissue strain at the lumbo-sacral Vleeming A, Mooney V, ‘slouched’ posture. Man Ther joint. J Biomech 1995;28:199–210. Stoeckart R, editors. Movement, 2006;11:202–7. stability and lumbopelvic pain: [63] Bogduk N, Macintosh J, integration of research and [51] Swinkels A, Dolan P. Spinal Pearcy MJ. A universal model of therapy. New York: Churchill position sense is independent of the lumbar back muscles in the Livingstone; 2007. the magnitude of movement. upright position. Spine 1992;17 Spine 2000;25(1):98. (8):897–913. [40] Bond M. The new rules of posture: How to sit stand and move in the [52] Brumagne S, et al. Effect of [64] Andersson, et al. EMG activities modern world. Rochester: Healing paraspinal muscle vibration on of the quadratus lumborum and Arts Press; 2007. position sense of the lumbosacral erector spinae muscles during spine. Spine 1999;24 flexion-relaxation and other [41] Schultz RL, Feitis R. The endless (13):1328–33. motor tasks. Clin Biomech web: Fascial anatomy and physical 1996;11:392–400. reality. Berkeley: North Atlantic [53] Janda V. Muscles as a pathogenic Books; 1996. factor in back pain. In: Proc. [65] Gupta A. Analyses of myo- IFOMPT. New Zealand; 1980. electrical silence of erectors [42] Robertson S. Integrating the fascial spinae. J Biomech 2001;34 system into contemporary concepts [54] Cholewicki J, Panjabi MM, (4):491–6. on movement dysfunction. The J of Khachatryan A. Stabilising Manual and Manipulative Therapy function of trunk flexor extensor [66] O’sullivan P, et al. Evaluation of 2001;9(1):40–7. muscles around a neutral spine the flexion relaxation posture. Spine 1997;22 phenomenon of the trunk [43] Guggenheimer KT, Barker PJ, (19):2207–12. muscles in sitting. Spine 2006;31 Briggs CA. Effects of tensioning (17):2009–16. the lumbar fascia on segmental [55] Potvin JR, O’Brien PR. Trunk sagittal motion and instability muscle co-contraction increases [67] Enoka RM. Neuromechanics of factor during flexion and during fatiguing isometric lateral human movement. 3rd ed Human extension. In: Fascia Research: bend exertions: possible Kinetics; 2002. basic science and implications for implications for spine stability. conventional and complementary Spine 1998;23(7):774–80. [68] Trew M, Everett T. Human health care. Elsevier; 2007. movement: an introductory text. [56] Radebold A, et al. Muscle 5th ed Edinburgh: Elsevier; 2005. [44] Langevin HM, Sherman KJ. response pattern to sudden Pathophysiological model for trunk loading in healthy [69] Bradley D. Hyperventilation chronic low back pain integrating individuals and in patients with Syndrome: breathing pattern connective tissue and nervous low back pain. Spine 2000;25 disorders. 3rd ed New Zealand: system mechanisms. Med (8):947–54. Tandem Press; 1998. Hypotheses 2007;68:74–80. [57] Quint U, et al. Importance of the [70] Chaitow L, Bradley D, Gilbert C. [45] Schleip R, Klingler W, Lehmann- intersegmental trunk muscles for Multidisciplinary approaches to Horn F. Fascia is able to contract the stability of the lumbar spine: a breathing pattern disorders. in a smooth muscle like manner biomechanical study. Spine Edinburgh: Churchill Livingstone; and thereby influence 1998;23(18):1937–45. 2002. musculoskeletal mechanics. In: Fascia Research: basic science and [58] Reeves NP, et al. The effects of [71] Chaitow L. Breathing and altered implications for conventional and trunk stiffness on postural control motor control. In: 5th complementary health care. during unstable seated balance. Interdisciplinary Congress on Elsevier; 2007. Exp Brain Res 2006;174: Low Back and Pelvic Pain: 694–700. Effective diagnosis and treatment [46] Smith J. The oscillatory of lumbopelvic pain. Melbourne; properties of the structural body. [59] McGill S. Low back disorders: 2004. IASI Year Book; 2006. evidenced based prevention and rehabilitation. Champaign: [72] Hanna T. Somatics: reawakening [47] Upledger JE, Vredevoogd. Human Kinetics Publ.; 2002. the mind’s control of movement, Craniosacral therapy. Seattle: flexibility and health. Eastland Press; 1983. [60] Adams M, et al. The Cambridge MA: Da Capo biomechanics of back pain. 2nd Press; 1988. 146

Salient aspects of normal function of the torso CHAPTER 6 [73] Laban R, Lawrence FC. Effort: sudden perturbations on trunk muscles associated with Economy of human movement. muscle activity and intra- movement of the lower limb. 2nd ed London: Macdonald and abdominal pressure while Phys Ther 1997;77:132–44. Evans Ltd; 1974. standing. Exp Brain Res 1994;98:336–41. [96] Hodges PW, Richardson CA. [74] Feldenkrais M. The Elusive Feedforward contraction of Obvious. California: Meta [86] Richardson C, et al. Therapeutic transversus abdominis is not Publications; 1981. exercise for spinal segmental influenced by the direction of stabilisation in low back pain: arm movement. Exp Brain Res [75] Shumway Cook A, scientific basis and clinical 1997;114(2):362–70. Woollacott MH. Motor control: approach. Edinburgh: Churchill Theory and practical applications. Livingstone; 1999. [97] Hodges P. Abdominal 2nd ed. Philadelphia: Lippincott mechanism and support Williams and Wilkins; 2001. [87] Richardson C, Hodges P, Hides J. of the lumbar spine and pelvis. Therapeutic exercise for In: Richardson C, Hodges P, [76] Gruneberg C, et al. The influence lumbopelvic stabilisation: Hides J, editors. Therapeutic of artificially increased hip and A motor control approach foe exercise for lumbopelvic trunk stiffness on balance control the treatment and prevention stabilisation: A motor in man. Exp Brain Res of low back pain. 2nd ed control approach foe the 2004;157:472–85. Edinburgh: Churchill Livingstone; treatment and prevention of 2004. low back pain. 2nd ed [77] Mok NW, Brauer SG, Edinburgh: Churchill Hodges PW. Hip strategy for [88] Hodges PW, Gandevia S. Livingstone; 2004. balance control in quiet standing Changes in intra-abdominal is reduced in people with low pressure during postural and [98] Hodges PW. Low Back Pain and back pain. Spine 2004;29(6): respiratory activation of the the Pelvic Floor. In: Carri`ere B, E107–12. human diaphragm. J Appl Physiol Markel Feldt C, editors. The 2000;89:967–76. pelvic floor. Stuttgart: Thieme; [78] Panjabi MM. The stabilising 2006. system of the spine. Part 1. [89] Hodges PW, Gandevia SC. Function, dysfunction, adaptation Activation of the human [99] De Troyer A, et al. and enhancement. J Spinal Disord diaphragm during a repetitive Transversus muscle function in 1992;5:383–9. postural task. J Physiol humans. J Appl Physiol 2000;522:165–75. 1990;68:1010–6. [79] Panjabi MM. The stabilising system of the spine. Part 11. [90] Hodges PW, et al. In vivo [100] Newton A. Breathing in the Neutral zone and stability measurement of the effect of gravity field. Part 1. Rolf Lines hypothesis. J Spinal Disord intra-abdominal pressure on the 1997; Fall. 1992;5:390–7. human spine. J Biomech 2001;34 (3):347–53. [101] Wildman F. The brain as the [80] Bartelink DL. The role of core of strength and stability. abdominal pressure in relieving [91] Hodges PW, Heijnen, Sydney: Feldenkrais workshop; the pressure on the lumbar Gandevia SC. Postural activity 2003. intervertebral discs. J Bone Joint of the diaphragm is reduced in Surg 1957;39B:718–25. humans when respiratory demand [102] Bartley J. Breathing matters: a increases. J Physiol New Zealand guide. New [81] Thompson J, et al. Motor control 2001;537(3):999–1008. Zealand: Random House; 2006. strategies for activation of the pelvic floor. In: Proc. 5th [92] Hodges PW. Is there a role for [103] Cumpelik J. Breathing Interdisciplinary World Congress transversus abdominis in lumbo- mechanics in postural on Low Back and Pelvic Pain. pelvic stability? Man Ther stabilisation. Sydney: Course Melbourne; 2004. 1999;4(2):74–86. notes; 2008. [82] Marras WS, Mirka GA. Intra- [93] Allison G, et al. The role of the [104] De Troyer A, Kirkwood PA, abdominal pressure during trunk diaphragm during abdominal Wilson TA. Respiratory action of extension motions. Clin Biomech hollowing exercises. Aust J the intercostal muscles. Physiol 1996;11(5):267–74. Physiother 1998;44(2): Rev 2005;85:717–56. 95–102. [83] Cholewicki, et al. Lumbar spine [105] Hodges, et al. Contraction of the stability can be augmented with [94] Hodges PW, Sapsford RR, human diaphragm during rapid an abdominal belt and/or Pengel HM. Feedforward activity postural adjustments. J Physiol increased intra-abdominal of the pelvic floor muscles 1997;505:539–48. pressure. Eur Spine J precedes rapid upper limb 1999;8:388–95. movements. In: Proc. VIIth. [106] Netter FH. Atlas of Human International Physiotherapy Anatomy. 4th ed Philadelphia, [84] Hagins M, et al. The effects of Congress. Sydney, Australia; Pennsylvania: Saunders Elsevier; breath control on intra-abdominal 2002. 2006. pressure during lifting tasks. Spine 2004;29(4):464–9. [95] Hodges PW, Richardson CA. [107] Calais-Germain B. Anatomy of Contraction of the abdominal breathing. Seattle: Eastland [85] Cresswell AG, Oddsson L, Press Inc; 2006. Thorstensson A. The influence of 147

Back Pain: A Movement Problem [108] De Troyer A, et al. The essential role of the pelvis. [129] Kendall FP, McCreary EK, diaphragm: Two Muscles. New York: Churchill Provance PG. Muscles: Science 1981;213:237–8. Livingstone; 1997. testing and function. 4th ed Baltimore: Williams and [109] Shirley D, et al. Spinal stiffness [121] Grieve GP. The sacro-iliac joint. Wilkins; 1993. changes throughout the Physiotherapy 1976;62(12): respiratory cycle. J Appl Physiol 384–400. [130] Gracovetsky S. An hypothesis 2003;95:1467–75. for the role of the spine in [122] Vleeming A, Stoeckart R. The human locomotion: a challenge [110] Clifton smith T. Breathe to role of the pelvic girdle in to current thinking. J Biomed succeed. New Zealand: Penguin; coupling the spine and the legs: a Eng 1985;7:205–16. 1999. clinical anatomical perspective on pelvic stability. In: [131] Gracovetsky S. The Spinal [111] Ameisen P. Every breath you take; Vleeming A, Mooney V, Engine. Austria: Springer- Facts about the Buteyko Method. Stoeckart R, editors. Movement Verlag/Wien; 1988. Sydney: Lansdowne; 1997. stability and lumbopelvic pain: integration of research and [132] Steindler A. Kinesiology of the [112] Farhi D. The breathing book: therapy. Edinburgh: Churchill Human Body under Normal and good health and vitality through Livingstone; 2007. Pathological conditions. essential breath work. New Springfield Illinois: Charles C York: Henry Holt and [123] Snijders CJ, et al. Biomechanics Thomas; 1955. Company; 1996. of the interface between spine and pelvis in different postures. [133] Claus A, et al. Activity of the [113] Janda V. Sydney: Course notes; In: Vleeming, et al. editors. paraspinal muscles is 1995. Movement, stability and Low differentially affected by Back Pain: The essential role of changes in spinal curves in [114] Massery M. Breathing: is it really the pelvis. New York: Churchill sitting in people with and necessary? – Integrating Livingstone; 1997. without low back pain. In: cardiopulmonary and postural Proc. 6th Interdisciplinary control strategies (paediatric and [124] Bendov´a, et al. MRI based World Congress on Low Back adult populations) In: Sydney: registration of pelvic alignment and Pelvic Pain. Barcelona; Course notes; 2008. affected by altered pelvic floor 2007. muscle characteristics. [115] Kolar P. Facilitation of agonist- Clin Biomech 2007;22(9): [134] Mitchell FL, Moran PS, antagonist co-activation by 980–7. Pruzzo NA. An evaluation and reflex stimulation methods. In: treatment manual of osteopathic Liebenson C, editor. [125] Hungerford B, Gilleard W. muscle energy procedures. 1st Rehabilitation of the spine: a Sacroiliac joint angular rotation ed. Valley Park Mo: Mitchell, practitioner’s manual. 2nd ed during the stork test and hip Moran and Pruzzo Assoc. Philadelphia: Lippincott drop test in normal subjects: Publishers; 1979. Williams and Wilkins; 2007. pilot study results. In: Proc. 3rd Interdisciplinary Congress on [135] Fritsch O. Anatomy and [116] Panjabi MM, White AA. Low Back and Pelvic Pain. Physiology of the Pelvic Floor. Biomechanics in the Vienna; 1998. p. 332–4. In: Carri`ere B, Markel Feldt C, musculoskeletal system. New editors. The pelvic floor. York: Churchill Livingstone; [126] Hungerford B, Gilleard W. The Stuttgart: Thieme; 2006. 2001. pattern of intrapelvic motion and lumbopelvic muscle [136] Spitznagle TM. Musculoskeletal [117] Putz R, Pabst R, editors. recruitment alters in the chronic pelvic pain. In: Sobotta: Atlas of Human prescence of pelvic girdle pain. Carri`ere B, Markel Feldt C, Anatomy. Volume 2: Thorax, In: Vleeming A, Mooney V, editors. The pelvic floor. Abdomen, Pelvis, Lower Limb. Stoeckart R, editors. Movement, Stuttgart: Thieme; 2006. 12th English ed. Baltimore, Stability & Lumbopelvic pain: Philadelphia: Williams & Integration of research and [137] Pool-Goudzwaard A, et al. Wilkins; 1997. therapy. Edinburgh: Churchill Contribution of pelvic floor Livingstone; 2007. muscles to stiffness of the pelvic [118] Putz R, Pabst R. (Eds). Sobotta ring. Clin Biomech 2004;19(6): Atlas of Human Anatomy Vol. 2. [127] Wilson M, Ryu J-H, Kwon Y-H. 564–71. 12th English-Edition. Williams & Contribution of the pelvis to Wilkins; Baltimore, 1997. gesture leg range of motion in a [138] Kelly M, et al. Healthy adults complex ballet movement. can more easily elevate the [119] Harrison DE, et al. Upright J Dance Medicine & Science pelvic floor in standing than in static pelvic posture as rotations 2007;11(4):118–23. crook lying: an experimental and translations in 3-dimensional study. Aust J Physiother from three 2-dimensional digital [128] Lee D. The pelvic girdle: an 2007;53(3):187–91. images: Validation and approach to the examination and computer analysis. treatment of the lumbo-pelvic- [139] B´ K. Evidence-based Physical J Manipulative Physiol Ther hip region. 2nd ed. Edinburgh: Therapy for stress and urge 2008;31(2):137–45. Churchill Livingstone; 1999. incontinence. In: Carri`ere B, Markel Feldt C (Eds). The Pelvic [120] Smidt GL. Interinnominate floor. Stuttgart: Thieme; 2006. range of motion. In: Movement, stability and low back pain: the 148

Salient aspects of normal function of the torso CHAPTER 6 [140] Sapsford RR, Hodges PW. [151] Andersson E, et al. The role of [163] Snijders CJ, Vleeming A, Contraction of the pelvic floor psoas and iliacus muscles for Stoeckart R. Transfer of muscles during abdominal stability and movement of the lumbosacral load to iliac bones manoeuvres. Arch Phys Med lumbar spine, pelvis and hip. and legs. 1. Biomechanics of self Rehabil 2001;82:1081–8. Scand J Med Sci Sports bracing of the sacroiliac joints 1995;5:10–6. and its significance for treatment [141] Sapsford RR, et al. Co-activation and exercise. Clin Biomech of the abdominal and pelvic [152] Porterfield JA, DeRosa C. 1993;8:285. floor muscles during voluntary Mechanical low back pain: exercises. Neurol Urodyn perspectives in functional [164] Pool-Goudzwaard AL, et al. 2001;20:31–42. anatomy. 2nd ed. Philadelphia: Inefficient lumbopelvic stability: Saunders; 1998. a clinical, anatomical and [142] Hartley L. Wisdom of the biomechanical approach to Body Moving: An introduction [153] Harrison DE, et al. How do ‘a-specific’ low back pain. Man to Body-Mind Centering. anterior/posterior translations of Ther 1998;3(1):12–20. Berkeley: North Atlantic Books; the thoracic cage affect the 1995. sagittal lumbar spine, pelvic tilt, [165] Bogduk N. The morphology and and thoracic kyphosis? Eur Spine biomechanics of latissimus dorsi. [143] Norton PA, Baker JE. Postural J 2002;11:287–93. Clin Biomech 1998;13(6): changes can reduce leakage in 377–85. women with stress urinary [154] Bogduk N, Pearcy M, incontinence. Obstet Gynecol Hadfield G. Anatomy and [166] Myers TW. Anatomy trains: 1994;84:770–4. biomechanics of psoas major. myofascial meridians for manual Clin Biomech 1992;7: and movement therapists. [144] Umphred D. The nervous system 109–19. Edinburgh: Churchill and motor learning. Livingstone; 2001. In: Carri`ere B, Markel [155] Santaguida PL, McGill SM. Feldt C, editors. The pelvic floor. The psoas major muscle: a [167] Akuthota V, Nadler SF. Core Stuttgart: Thieme; 2006. three dimensional geometric strengthening. Arch Phys Med study. J Biomech 1995;28(3): Rehabil 2003;85(1):86–92. [145] Sapsford R. Rehabilitation of the 339–45. pelvic floor muscles utilising [168] Hodges PW, Cholewicki J. trunk stabilisation. Man Ther [156] Penning L. Psoas muscle and Functional control of the spine. 2004;9(1):3–12. lumbar spine stability: a concept In: Vleeming A, Mooney V, uniting existing controversies. Stoeckart R editors. Movement, [146] DonTigny RL. Mechanics and Critical review and hypothesis. stability & lumbopelvic pain: treatment of the sacroiliac joint. Eur Spine J 2000;9:577–85. integration of research and In: Vleeming A, et al., editors. therapy. 2nd ed. Churchill Movement, stability and low [157] Gibbons SGT. The model of Livingstone; 2007. back pain: the essential role of psoas Major stability Function. the pelvis. New York: Churchill In: Proc. 1st International [169] Richardson CA, Jull GA. Muscle Livingstone; 1997. Conference on Movement control – pain control. What Dysfunction. Edinburgh; 2001. exercises would you prescribe. [147] DonTigny RL. A detailed Man Ther 1995;1(1):2–10. and critical biomechanical [158] Vleeming A, et al. Relationship analysis of the sacroiliac joints between form and function in [170] Hodges PW, Jull GA. Spinal and relevant kinesiology: the the SI joint part 11. Spine segmental stabilisation training. implications for lumbopelvic 1990;15:133–6. In: Liebenson C, editor. function and dysfunction. Rehabilitation of the spine: a In: Vleeming A, Mooney V, [159] Sims K. The development of hip practitioner’s manual. 2nd ed. Stoeckart R, editors. osteoarthritis: implications for Philadelphia: Lippincott Movement, Stability & conservative management. Man Williams and Wilkins; 2007. Lumbopelvic Pain: Integration Ther 1999;4(3):127–35. of research and Therapy. [171] Beith ID, Synnott RE, Edinburgh: Churchill [160] Janda V. The role of the thigh Newman SA. Abdominal muscle Livingstone; 2007. adductors in movement patterns activity during the abdominal of the hip and knee joint. hollowing manoeuvre in the four [148] Bartenieff I, Lewis D. Body Courrier 1965;(Sept):563–5. point kneeling and prone movement: coping with the position. Man Ther 2001;6(2): environment. Australia: Gordon [161] Hungerford B, et al. Altered 82–7. and Breach Science Publishers; lumbo-pelvic muscle recruitment 2002. occurs in the prescence of sacroiliac [172] O’sullivan PB, Twomey LT, joint pain. In: Proc. 5th Allison GT. Evaluation of [149] Basmajian JV. Muscles Alive. Interdisciplinary World Congress specific stabilising exercise in 4th ed. Baltimore: Williams and on Low Back and Pelvic Pain. the treatment of chronic low Wilkins; 1978. Melbourne; 2004. back pain with radiologic diagnosis of spondylolysis or [150] Nachemson A. Electromyographic [162] Vleeming A, et al. The posterior spondylolisthesis. Spine studies on the vertebral portion layer of the thoracolumbar 1997;22(24):2959–67. of psoas muscle. Acta Orthop fascia: its function in load Scand 1966;37:177–90. transfer from spine to legs. Spine 1995;20:753. 149

Back Pain: A Movement Problem [173] McGill SM. Lumbar spine State of the art reviews [193] Sparto PJ, et al. The effect of stability: Mechanism of injury 1995;9:419–32. fatigue on multijoint kinematics and restabilisation. In: and load sharing during a Liebenson C, editor. [183] Moreside JM, Vera-Garcia FJ, repetitive lifting task. Spine Rehabilitation of the spine: a McGill SM. Neuromuscular 1997;22(22):2647–54. practitioner’s manual. 2nd ed. independence of abdominal wall Philadelphia: Lippincott muscles as demonstrated by [194] Van Die¨en JH. Effects of Williams and Wilkins; 2007. middle-eastern style dancers. repetitive lifting on the J Electromyogr Kinesiol 2008;18 kinematics, inadequate [174] Stanton T, Kawchuk G. The (4):527–37. anticipatory control or adaptive effect of abdominal stabilisation changes? J Motor Behaviour contractions on postero-anterior [184] Mens J, et al. The active straight 1998;30(1):20–32. spinal stiffness. Spine 2008;33 leg raise test and mobility of the (6):694–701. pelvic joints. Eur Spine J [195] Van Die¨en J, Hoozemans MJM, 1999;8:468–73. Toussaint HM. Stoop or squat: [175] Feldenkrais M. Body and Mature a review of biomechanical Behaviour; A study of anxiety, [185] O’Sullivan PB, et al. Altered studies on lifting technique. sex, gravitation and learning. motor control strategies in Clin Biomech 1999;14 New York: International subjects with sacroiliac joint (10):685–96. Universities Press Inc; 1949. pain during the active straight leg raise test. Spine 2002;27(1): [196] Burgess-Limerick R. Squat, [176] Bainbridge-Cohen B. Sensing, E1–8. stoop or something in between? Feeling and Action; The Int J of Industrial Ergonomics experiential anatomy of [186] Beach P. The contractile field: a 2003;31(3):143–8. body-mind centreing. new model of human Northampton MA: Contact movement. J Bodywork and [197] Dionisio VC, et al. Kinematic, Editions; 1993. Movement Therapies 2007;11 kinetic and EMG patterns (4):308–17. during downward squatting. [177] Beith ID, Harrison PJ. Reflex J Electromyogr Kinesiol 2008;18 control of human trunk muscles. [187] Norris CM. Spinal stabilisation: (1):134–43. In: Proc. 1st International stabilisation mechanisms of the Conference on Movement lumbar spine. Physiotherapy [198] Panjabi MM, White AA. Dysfunction. Edinburgh; 2001. 1995;81(2):72–9. Biomechanics in the musculoskeletal system. New [178] Hodges PW, Richardson CA. [188] Zetterberg C, Andersson GB, York: Churchill Livingstone; Transversus abdominus and the Schultz. The activity of 2001. superficial abdominals are individual trunk muscles during controlled independently in a heavy physical loading. Spine [199] Gracovetsky S, et al. The postural task. Neurosci Lett 1987;12(10):1035–40. importance of pelvic tilt in 1999;265:91–4. reducing compressive stress in [189] Hodges PW, Richardson CA. the spine during flexion and [179] Urquhart DM, et al. Regional Inefficient muscular stabilisation extension exercises. Spine morphology of transversus of the lumbar spine associated 1989;14(4):412–6. abdominis and internal oblique. with low back pain: a motor In: Proc. Musculoskeletal control evaluation of transversus [200] Rantanen P, Nykvist F. Optimal Physiotherapy Australia Twelfth abdominus. Spine 1996; sagittal motion axis for trunk Biennial conference. Adelaide; 21:2640–50. extension and flexion tests in 2001. chronic low back trouble. Clin [190] V´ezina MJ, Hubley-Kozey CL, Biomech 2000;15(9):665–71. [180] Urquhart D. Regional variation Egan DA. A review of the in the morphology and muscle activation patterns [201] Gracovetsky S, et al. Analysis of recruitment of transversus associated with the pelvic tilt spinal muscular activity during abdominus: implications for exercise used in the treatment flexion/extension and free control and movement of the of low back pain. The J of lifts. Spine 1990;15 lumbar spine. In: Proc. 5th Manual and Manipulative (12):1333–9. Interdisciplinary World Therapy 1998;6(4):191–201. Congress on Low Back and [202] Pope M. Giovanni Alfonso Pelvic Pain. Melbourne; 2004. [191] Arjmand N, Shirazi-Adl A. Borelli- The father of Biomechanics of changes in biomechanics. Spine 2005;30 [181] Urquhart DM, Hodges PW, lumbar posture in static (20):2350–5. Story IH. Postural activity of the lifting. Spine 2005;30 abdominal muscles varies (23):2637–48. [203] Sihvonen T. Flexion relation of between regions of these the hamstring muscles during muscles and between body [192] McClure PW, et al. Kinematic lumbar-pelvic rhythm. Arch positions. Gait Posture 2005;22 analysis of lumbar and hip Phys Med Rehab 1997;78 (4):295–301. motion while rising from a (5):487–90. forward flexed position in [182] Snijders CJ, et al. Biomechanical patients with and without [204] McGorry R, et al. Timing of modelling of sacroiliac stability a history of low back pain. activation of the erector spinae in different postures. Spine: Spine 1997;22(5):552–8. and hamstrings during a trunk flexion and extension task. Spine 2001;26(4):418–25. 150

Salient aspects of normal function of the torso CHAPTER 6 [205] Gallagher S. Trunk extension [214] Lee LJ, Coppieters M, [222] Janda V. Sydney: Course notes; strength and muscle activity Hodges PW. Differential 1995. in standing and kneeling activation of the thoracic postures. Spine 1997;22 multifidus and longissimus [223] Mooney V, et al. Coupled motion (16):1864–72. thoracis during trunk rotation. of the contralateral latissimus Spine 2005;30(8):870–6. dorsi and gluteus maximus: its [206] Perry J. Gait analysis: normal role in sacroiliac stabilisation. In: and pathological function. New [215] Harrison D, et al. Lumbar Vleeming A, et al., editors. Jersey: Slack Incorp; 1992. coupling during lateral Movement, stability and low back translations of the thoracic cage pain: the essential role of the [207] Beach P. The contractile field: relative to a fixed pelvis. Clin pelvis. New York: Churchill a new model of human Biomech 1999;14(10):704–9. Livingstone; 1997. movement – Part 2. J of Bodywork and Movement [216] Grieve GP. Common Vertebral [224] Fairclough J, et al. Is iliotibial Therapies 2008;12(1):76–85. Joint Problems. Edinburgh: band syndrome really a friction Churchill Livingstone; 1981. syndrome? J Sci Med Sport [208] Pinto RZA, et al. Bilateral and 2007;10(2):74–6. unilateral increases in calcaneal [217] Keller TS, et al. Influence of eversion affect pelvic alignment spine morphology on [225] Perry J. Gait analysis: Normal and in standing position. Man Ther intervertebral disc loads and Pathological Function. New 2008;13(6):513–9. stresses in asymptomatic adults: Jersey: SLACK Incorporated; implications for the ideal spine. 1992. [209] Lee D. Manual therapy for the Spine J 2005;5(3):297–309. thorax: a biomechanical [226] Newton A. Gracovetsky on approach. DOPC Delta; 1994. [218] Stokes IAF. Biomechanics of the walking. Structural Integration thoracic spine and rib cage. In: 3003, February:4–8. [210] Edmondston SJ, Singer KP. Giles LGF, Singer KP, editor. Thoracic spine: anatomical and Clinical anatomy and [227] Lamoth CJC, et al. Spine biomechanical considerations for management of thoracic spine 2002;27(4):E92–9. manual therapy. Man Ther pain. Oxford: Butterworth 1997;2(3):132–43. Heinemann; 2000. [228] Bruijn SM, et al. Coordination of leg swing, thorax rotations, [211] Willems JM, Jull GA, Ng JK-F. [219] Travell JG, Simons DG. and pelvis rotations during gait: An in vivo study of the primary Myofascial pain and dysfunction: the organization of total body coupled rotations of the thoracic The trigger point manual. angular momentum. Gait spine. Clin Biomech 1996;11 Baltimore: Williams and Posture 2008;27(3):455–62. (6):311–6. Wilkins; 1983. [229] Crosbie J, Vachalathiti R, [212] Theodoridis D, Ruston S. The [220] Kolar P. In: Dynamic Smith R. Patterns of spinal effect of shoulder movements neuromuscular stabilisation: motion during walking. Gait on thoracic spine 3D motion. according to Kolar. Presented by Posture 1997;5:6–12. Clin Biomech 2002;17 Safarova M. Conducted by C E (5):418–21. A Ltd. Sydney: Course notes; [230] Crosbie J, Vachalathiti R, 2008. Smith R. Patterns of spinal [213] Flemons T. A biotensegrity motion during walking. Gait explanation for structural [221] Crosbie J, et al. Scapulohumeral Posture 1997;5:13–20. dysfunction in the human torso. rhythm and associated spinal http://www.intensiondesigns. motion. Clin Biomech 2008;23 [231] Vogt L, Banzer W. Measurement com. (2):184–92. of lumbar spine kinematics in incline treadmill walking. Gait Posture 1999;9(1):18–23. 151

Chapter Seven 7 Changed control of posture and movement: the dysfunctional state Cholewicki and van Die¨en1 comment that while A pattern generating mechanism can be set in train. there is an emerging consensus in the literature that The systems are: muscle activation patterns are different in people with back pain, the interpretations of these findings • The corticosubcortical motor regulatory are divergent. By and large the scientific community centers of the CNS. Phylogenetically the youngest has little considered whether altered motor control and most fragile part of the motor system. Impaired might be significant in causing back pain. function at this level results in defective and uneconomical movement patterns,10 poor Some 30 years ago Janda,2,3 Lewit4 and others in adjustment of fine movements, and the progressive the Prague school of manual medicine introduced switch from complicated movement patterns to the the concept of ‘functional pathology of the motor more primitive ones regulated at the subcortical system’ to explain the development and perpetua- level.2 tion of pain in the musculoskeletal system. Some more recent studies have implicated pre existing • The muscle system. This represents perhaps the functional changes in the development of later most exposed part of the motor system, having to pain5–8 or in the recurrence of low back pain.9 ‘extensively respond to changes due to civilization or more exactly to the technicalization of our living Functional pathology of the conditions’.11 As the main movement effectors, motor system2 they must respond quickly to all stimuli coming from the neural system, reacting to changes in the Excluding insidious pathology, Janda2 considered periphery especially from the articular system.2 that most musculoskeletal pain syndromes are the Clinically, evident changes in the muscle system are result of impaired motor system function. This func- generally apparent for some time before the onset tional pathology of the motor system and its interac- of pain. The presence of pain further compounds tions with the whole organism, mainly of a reflex the muscle dysfunction creating further change nature,3 is regularly involved in many organic diseases throughout the whole motor system. and underpins most spinal pain and related disorders. • The articular system. The welfare of the joints In essence, the motor system comprises three is dependent upon balanced neuromuscular control. functionally interdependent systems. Dysfunction ‘Joint dysfunctions are only one expression of in any one system will influence function in the impairment of motor system as a whole i.e. of both other systems, perpetuating further impairment. neuromuscular and osteoarticular systems’.3 Further, any changes in the joints will be reflected in changes in both the neural and muscle systems.

Back Pain: A Movement Problem Motor control impairments precede Importantly, recognizing the significance of these the onset of pain ‘rules’ allows the clinician to predict the develop- ment of functional impairments and introduce pro- The quality of muscle function depends directly on phylactic and rational therapeutic interventions. the central nervous system activity.12 While func- tional impairment of the motor system is the most The muscle system mirrors frequent cause of pain in the motor system it is the state of sensory motor not identical with pain and may remain clinically integration silent. Depending upon the primary locus, the impairment is generally clinically discernable either Movement patterns are one of the basic elements of in palpable changes at the spinal joint and observ- movement. The patterning process is the most able changes in movement patterns, the early onset important way that movement develops. According of fatigue and faster switch into more primitive to Janda,14 these involve a chain of conditioned movement patterns in fatigue of the motor system.2 and unconditioned reflexes which are constant over Gregory et al.7 demonstrated altered motor control a short period of time but change, sometimes con- characteristics that can distinguish the likelihood of siderably, over life. Changes occur in response to an individual developing back during common tasks changing conditions of the ‘inner milieu’ as well as such as standing. the outer environment. ‘The degree of activity and time synchronization of various muscle groups Significantly, Janda says, ‘the high incidence of within the movement are thus characteristic of such functional impairment makes it extremely difficult patterns’.14 to estimate the borders between the norm and evi- dent pathology’.2 Hodges15 remarks that with regard to lumbopel- vic pain, ‘two relatively consistent research findings According to Janda,2 the development of impair- have been observed: increased activity in the super- ment follows two basic rules as follows: ficial muscles and decreased activity of the abdomi- nal canister’. 1. The rule of vertical generalization. A local impairment, for instance in a joint, provokes Clinical observation of patients with spinal pain reaction and adaptation processes in all other syndromes, supported in part by frank and extrapo- parts of the motor system i.e. in the muscular or lative research findings, demonstrates changes in neural system. Similarly, any alteration in motor the typical activation patterns and altered functional regulation as in stress, depression and neurotic roles of muscles in each of the two proposed princi- reactions involves simultaneously and preferably the pal muscle systems. This results in imbalanced activ- muscles and then the joints. In this respect, the ity between the two systems which is reflected in limbic system has particular relevance in motor altered motor control responses to perturbation control. and for organizing body alignment, postural control and movement. 2. The rule of horizontal generalization. Impaired function in one joint or muscle provokes a In time this leads to structural changes and reaction and adaptation in related other joints or changes in other co-dependent systems. muscles and spreads so that finally the whole system, articular or muscular will be involved. Altered qualities of function This is particularly evident in the axial spine and in each muscle system proximal limb girdles. Restriction of a spinal segment or a number creates relative flexibility at Conceptually and generally speaking, we tend to see adjacent segments. A stiff hip joint creates a a change in the timing and level of activity – too lit- compensatory relative flexibility13 in the low back. tle activity and more phasic activity in the deep sys- Clinically it is common to see the coexistence of tem and too much, more tonic activity of certain back pain with a plethora of other overt or covert muscles in the superficial system. However, mus- symptoms such shoulder and neck symptoms, hip cles in the deep system can be overactive and those and knee pain etc. in the superficial system underactive. A local pain symptom is generally the expression of a regional and general neuromyoarticular problem. 154

Changed control of posture and movement CHAPTER 7 Systemic local muscle system (SLMS; foundation tending to create yanking stresses within see Ch.5) the axial skeleton. Altered responses which variably occur in muscles • Muscles within this system become variably classified within this system as muscles of the overactive and dominant in movement patterns7,29 irrespective of pain.30 In the presence SLMS demonstrate: of underlying irritable segmental joint restrictions and/or frank pain they are predictably overactive. • Delayed feedforward postural responses have Normal studies have indicated that these muscles been demonstrated in transversus abdominus,16,17 become more active in situations involving reduced internal oblique and transversus,18 internal oblique, gravitational loading and related decreased sensory multifidus and gluteus maximus.19 Transversus input.31,32 activity changes from direction independent to direction specific activity in the control of reactive • These muscles are easily strengthened, forces of the trunk.16 Mok et al.20 found decreased hypertrophy and become tight and short33 – preparatory movement of the lumbopelvis and the functional ‘bullies’, they are generally over increased corrective movements in response to active and those that everyone is obsessively perturbation from rapid arm movement. stretching! • Inadequate. Relative underactivity, inhibition, • SGMS muscles become more tonically active weakness has been shown in the abdominals;18 rather than phasic, a changed role from phasic transversus abdominus;21 multifidus;22,23 the activity to more tonic activity as the system diaphragm.24 Functionally they act like ‘shy becomes co-opted into a more postural role.34 muscles’. Also, arthrogenic inhibition, e.g. of When abnormally activated for antigravity control35, multifidus due to pain or directly impaired the patient ‘holds himself up’ against gravity rather proprioception of an injured joint is clinically like scaffolding holding up a building. He then often common. Isolated segmental wasting of multifidus can’t voluntarily let them go, particularly around the ipsilateral to symptoms has been shown.25 body’s centre of gravity, and evidenced in a lack of Simulated microgravity/spinal un-loading/bed rest the flexion–relaxation response seen in many people studies have also shown selective atrophy of with back pain.36,37 Muscles such as external multifidus.26 oblique and thoracic erector spinae form part of this system.38 • Diminished patterns of coactivation in the SLMS affect spinal support and control mechanisms. In general terms, Janda39 considered that at least O’Sullivan et al.24 found poor coactivation of the five types of increased muscle tone can result from diaphragm and pelvic floor in subjects with sacroiliac either: pain. During the active straight leg raise test diaphragm splinting, respiratory disruption and • Dysfunction of the limbic system pelvic floor descent occurred. • Impaired function at the segmental • Muscle system activity is poorly sustained. (interneuronal) level Low load sustained postures become difficult as the more usual SLMS tonic yet variable activity • Impaired coordination of muscle contraction becomes more phasic. Subjects with back pain have (trigger points) also demonstrated more phasic activity in • As a response to pain irritation transversus while walking27 and a shift from locomotor to primarily respiratory activity.28 • Overuse of the muscles – this is as a rule combined with changed elasticity of the muscle and usually described as muscle tightness. Systemic global muscle system (SGMS) Muscle imbalance In conjunction with the changed activity in the Janda proposed that clinically developed imbalance SLMS, altered timing and degree of activation between different muscle groups was probably the occurs inversely in muscles within this system as result of both reflex and mechanical mechanisms.3 follows: He was initially more interested in the effect of the tight overactive muscles (SGMS) and their inhibi- • Early onset of activity precedes SLMS tory action upon their antagonists e.g. overactive muscles.19 This means that these muscles are activated from a non stable, poorly controlled 155

Back Pain: A Movement Problem erector spinae may inhibit abdominal activity.3 • Reduced endurance in antigravity posture and Stretching and other inhibitory techniques applied movement because of poorly organized and to the tight muscles often spontaneously improved the weakened antagonist. With respect to the imbal- sustained synergies of low grade tonic activity from anced muscle system response, he questioned whether there was any difference of innervation muscles within the SLMS. While some studies have between the two systems and noted that the tight muscles were often those involved in flexor reflexes shown that people with chronic back pain develop a and those with a tendency to be underactive or weaken were those mainly participating in extensor higher ratio of fast to slow twitch fibres and reflexes.3 Importantly, pain, injury, fatigue or extensor muscle activity becomes more phasic,41 it stress and the working out of new movement pat- terns tends to reduce activity in the SLMS and is suggested that clinically this inability to organize increase activity in the SGMS. appropriate patterns of underlying response also Clinically, in the dysfunctional state, a reciprocal relationship evolves whereby reduced deep system contributes to reduced staying power in movement. activity necessitates the adoption of more superficial system strategies, which in turn inhibits or disallows • Reduced, imbalanced and delayed patterns of effective deep system activation. The dysfunction SLMS coactivation affects joint protection and becomes reinforced, perpetuated and entrenched. control of spinal support mechanisms such as low The poorly coordinated activity between the two muscle systems creates muscle imbalance through- load IAP; jeopardizes effective weight shift and out the body. This can occur in a number of ways: • Between the two systems which begin to work appropriate adaptive postural presetting of the limb counter to one another instead of in a mutually supportive relationship girdles necessary to facilitate the ensuing pattern of • Within each system, particularly the SGMS e.g. between the rectus femoris and hamstrings movement. Ineffective deep system coactivation • Between the axial flexor and extensor systems. diminishes effective SGMS activity. When overactive, the global muscles of the trunk can act to shorten, compress and constrict parts of • Effective postural control and precisely the torso acting rather like very tight outer clothing, coordinated and discrete movements are highly while the behavior of the SLMS resembles loose old underwear! dependent upon adequate proprioception. Imbalanced activity between Diminished proprioception in subjects with back the two muscle systems: direct pain has been reported.42,43 Taimela et al.44 found ramifications for underlying control of NPRM reduced ability to sense rotational position change in Research interest is increasingly concerned with the the lumbar spine when sitting, particularly when quality of postural and movement control in the fatigued. O’Sullivan et al.45 found significant presence of back pain. However, to date, Dankaerts et al.40 are one of the few who have suggested that deficits when patients attempted to reposition the inherent postural control faults may predispose one to the development of pain syndromes.40 lumbar spine into a neutral lordosis when sitting. The main features of dysfunction in the postural Postural and gait stability is reduced in astronauts reflex mechanism can be summarized as: following in-flight adaptation of CNS processing of altered sensory inputs from the vestibular, proprioceptive and visual systems.46 Bed rest studies involving reduced antigravity sensory input demonstrate reduced activity in certain SLMS muscles particularly the one joint extensors26,47 and increased activity in certain SGMS muscles.31,32 • Poorer balance has been found with greater postural sway,48 the predominant use of the hip strategy over the ankle strategy.49 Mok et al.50 found inability to initiate and reduced control of the hip strategy for balance. Conversely, increased trunk muscle stiffening has been shown to degrade postural control51 as it limits adaptive segmental adjustments. This has been shown in sitting52 and particularly so in the sagittal plane.72 • Disturbed motion patterns become more stereotyped and show predictable change in kinematics e.g. back pain subjects used increased lumbar flexion when forward bending.9,53,54,67 156

Changed control of posture and movement CHAPTER 7 • Variably increased patterns of SGMS co- reduce muscle force . . . after the onset of sustained contraction act to splint some regions of the physical activity’. Fatigue involves a variety of ele- spine. Reduced postural support from the deep system and increased SGMS activity leads to the ments throughout the motor system and Neu- adoption of coarse central holding or ‘cinch’ mann58 suggests it is useful to consider fatigue as patterns in posture and movement. These have also been described by O’Sullivan as fixing and splinting primarily occurring centrally or peripherally. Cen- strategies.24,29 Radebold et al.55 found increased co-contraction of the superficial trunk muscles in tral fatigue can involve the limbic system, activation response to multidirectional sudden load release while subjects were generating isometric forces of of the primary motor cortex, or descending CNS 20%–30% maximal exertions. SGMS activity typically increases with load, exertion and speed. control over neurons and motoneurons in the spinal Incidentally subjects were semi seated and the pelvis was restrained allowing no postural cord. Peripheral fatigue relates to neurophysiologic adjustment of the pelvis in controlling the perturbation to the torso – hardly a functional factors related to action potential propagation in pattern and co-contraction can be expected. Gregory7 found greater responses of the superficial motor nerves and transmission of activation to mus- trunk extensors and flexors in response to cle fibres.58 Normally the nervous system compen- unexpected perturbations in subjects who developed back discomfort when standing for sates for muscle fatigue by either increasing the 2 hours. After 8 weeks of bed rest simulating a microgravity environment, Belavey et al.32 found rate of activation or recruiting assistive motor units increased activity but decreased co-activation of the thereby maintaining a stable force level.58 Slow superficial lumbopelvic muscles in stabilizing the pelvis during a repetitive leg movement. Clinically, twitch motor units can sustain an isometric force patterns of both increased and decreased SGMS co- activation are found and better understood when longer than fast twitch. Slow twitch muscle can sus- patients are sub grouped into the two principal clinical pictures. This helps explain the variance in tain a greater force during isovelocity shortening the various research studies (see Ch. 9). • Altered performance of other functionally contractions, while fast twitch muscle is able to sus- related systems such as continence, breathing and cardiovascular deconditioning. Studies by Smith56 tain greater power production. have shown that people with respiratory disease and Janda59 maintained 40 years ago that fatigue incontinence have increased activity of the superficial trunk muscles, restricted rib expansion increased the differential timing and activity level and diaphragm descent. in the two muscle systems adversely affecting Further findings in back pain research influencing motor coordination and the quality of the motor patterns control (see Ch.5). Muscle fatigue More recent research on fatigue has shown vari- The subject of fatigue has attracted a lot of research interest. Enoka57 describes fatigue as ‘the activity ous effects on neuromuscular performance; in brief: related impairment of physiological processes that altered latency of the stretch reflex;60 the loss of force generation of the back muscles61,62 and the subsequent effect on the bending moments acting on the lumbar spine.63 Fatigue occasions a preferen- tial loss of fast twitch fibres in the shift to lower fre- quencies and so increases the muscle reaction time and reduces the magnitude of the EMG, potentially affecting the response to sudden loads.64 Other studies have looked at the effects of isodynamic fatiguing on movement patterns and trunk motor output but restrained the subjects into equipment such as triaxial dynamometers.65 Research design such as this does not allow for the natural kinematic patterns which should accompany trunk forward bending. Van Die¨en et al.66 and Sparto et al.67 examined the kinematic patterns of motion during repetitive lifting, importantly allowing free body movement which equate more to activities of daily living. Both groups found that with increasing fatigue, hip and knee motion decreased, the legs becoming more extended while the lumbar spine became increasingly flexed. Postural stability is also reduced under fatigue conditions68 particularly when more proximal muscles are fatigued.69,70 Lumbar fatigue impairs lumbar spatial position 157

Back Pain: A Movement Problem sense and so the ability to anticipate and respond to experimental pain has also been shown to delay pos- altered postural events.44 Some studies have indi- tural adjustments with decreased activation of deep cated that fatigue experienced with eccentric mus- system muscles such as transversus abdominus.79,80 cle contractions is less than during concentric Lund et al.81 proposed a ‘pain adaptation’ model contractions particularly if performed slowly.57 This which proposed that pain reduces the activation of is interesting as clinical impressions seem to indicate muscles when active as agonists and increases their a disinclination for people with spinal pain and activation when antagonistically active. Van Die¨en related disorders to perform slow eccentric move- et al.82 point out that the theory is somewhat aspe- ments when weight bearing through the limbs, cific and interpret antagonists as those eccentrically while fast concentric actions appear much easier. lengthening muscles and agonists as those that are shortening. This serves to reduce the velocity and Delayed reaction times range of motion and prevent mechanical provoca- tion of sensitive tissues. In a review of the literature Hodges16–18 found direction independent delayed on the effect of pain on the activation of the lumbar responses in deep system muscles, and direction spe- extensor muscles, van Die¨en et al.82 conclude that cific delay in superficial trunk muscles.17 Most other neither model is unequivocally supported by the lit- studies have only examined responses in the superfi- erature. High pain-related fear of movement has cial trunk muscles. Radebold55 showed longer reaction been shown to alter movement strategies in limiting times in response to sudden load release both in lumbar motion while reaching.83 Hodges et al.79 switching muscles on and off. Descarreaux et al.71 showed that experimental pain delayed feedforward found low back pain subjects could generate flexion postural responses and that these changes persist and extension forces equal to controls however some after the resolution of the pain leading them to con- of their sample took longer time to reach peak clude that the changes in motor control were more force. Longer latencies were also correlated with complex than simple inhibition and include changes reduced balance.72 In a prospective study, Cholewicki in motor planning. Leinonen et al.84 also demon- et al.5 found delayed muscle reflex responses appear strated impaired anticipatory feedforward control to be a pre-existing risk factor that significantly in subjects with sciatica. Significant in this study increases the risk of sustaining a low back injury. was the fact that the impairment was only apparent when subjects stood unsupported as against sup- Luoto et al.73,74 found deficits in information ported standing. processing and delayed psychomotor speed in chronic low back pain patients and among women. It is proposed that in general terms pain will tend This was also related to impaired postural control. to inhibit SLMS function and increase SGMS func- tion. Hodges and Moseley85 report consistent dif- Effect of pain on altered ferential effects of pain on the deep and superficial motor control lumbopelvic muscles. Mosely et al.86 showed that the anticipation of experimental back pain delayed Altered motor control leads to spinal joints and activity in the deep trunk muscles and augmented related soft tissues including the nerves to become at least one of the superficial muscles. pain producing over time. Once pain is present – whatever the source, further changes in motor con- Clinically an acute, irritable and ‘hot’ spinal joint trol can be expected. Janda75 maintained that ‘trunk will certainly fire up the local intersegmental as well muscle activity can be inhibited to prevent motion as the long multisegmental muscles. This is what into a painful posture or direction and to avoid often makes effective assessment and treatment of stresses on motion segment pathology. Conversely, spinal joints especially difficult as the joint becomes the trunk muscles may go into spasm to fulfil a hard to access, particularly in some regions. In more similar protective role’. Pain has been shown to subacute or chronic states, pain may be more increase the amplitude of the stretch reflex76 and related to chronic neural irritation from either a muscle activity77 which in turn will increase pain blocked or relatively over mobile joint and local and has led to the ‘pain-spasm-pain model78 pro- and long muscle spasm may not be so apparent. In posed for perpetuating spinal disorders. However, all stages, marked local reactive changes are appar- ent in the surrounding soft tissues and over the joint itself. The irritability, complexity and stage of disor- der thus affect the responses found. 158

Changed control of posture and movement CHAPTER 7 Back pain patients appear • Poor fine motor coordination with frequent to demonstrate features of less tremor, uncertain timing, and overshooting well integrated sensorimotor with reduced visual-perception ability and perceptuomotor behavior • While no intellectual deficits were found, The quality of mature motor behavior is variable. In subjects displayed poor sustained attention some, full integration and transformation of the and concentration and had difficulty changing primitive reflexes and early responses fails to occur, from one working method to another and despite normal development in other areas, result- abstracting from simple sensory ideas. ing in less effective proprioceptive and motor integration. In addition to the motor and perceptuomotor dys- functions, two other characteristics stood out: Janda3 performed a detailed analysis of 100 • Wide variations in the general activation level. A patients who were ‘therapeutic failures’ and found higher activation level with medium or poor control subtle sensorimotor dysfunction attributable to was evident in some e.g. superfluous movements. ‘minimal brain dysfunction’. Three striking findings Another group was evidently slower with delayed emerged: reactions, long reaction times and slow in pace and language. 1. In the neurological examination, subtle ‘soft’ • Low tolerance to stress was a striking finding in neurological symptoms were evident which while more than half the subjects, living in high tension, often combined, could be divided into three groups: worrying over trifles and coping with daily problems with undue strain. “Some might be said to even • Microspasticity: with increased muscle tonus, produce these stresses by their own ‘over- tendon reflexes, a decreased threshold for reactivity’, ‘over-excitability’”.3 provoking spastic phenomena and slight developmental asymmetries such as slight Janda summarized these patients as ‘unable to hemipareisis adjust or adapt themselves adequately to altered physiological conditions’.3 • Hypotonia: usually asymmetrical with irregular tendon reflexes mostly decreased, Altered muscle tonus and evident instability in static functions, lack of flexor/extensor proclivity coordination and evidence of involuntary movements similar to that in slight In local terms, Janda11 maintained that one of the choreoathetoid syndrome factors influencing the irritability of muscles in the vicinity of a joint is change in the intraarticular pres- • Proprioceptive deficits: with failure in tests sures. Traction or separation facilitates the flexor requiring greater demand upon afferent muscle groups whereas compression in the longitu- pathways such as standing on one leg, dinal axis of the joint facilitates the extensors. especially if the eyes were closed; and alterations in discriminative sensitivity In more global terms, we have noticed in our spi- nal pain population, a tendency for two main forms 2. Evaluation of the ability to work out new of basic muscle tonus – those who have ‘lower tone’ movement patterns.14 Clinically, assisted by and are ‘looser’ who tend more to antigravity col- multichannel EMG, he found they had difficulty lapse, and those whose tone is more hyperactive with: with general tightness, tension and stiffness. Those with low tone were often ‘hyper mobile’ as children. • Alterations in the ability to work out finely These differences in tone could be an expression adjusted coordination so that they activated of subtle primary CNS dysfunction alluded to more muscles than expected above3,33 – the clumsy kid. Janda has also drawn attention to the similar patterns of excess ‘postural • Inability to activate one side of the body only muscle’ (SGMS) activity seen in postural problems with a tendency to mirror movements and those with spastic syndromes.14,33,87 Further, in agreement with Janda33,59 secondary, subtle CNS 3. Psychological evaluation. Besides examining dysfunction appears to also result from altered the usual personality characteristics he evaluated perceptuomotor coordination, visual and space orientation and motor memory and learning. He found: 159

Back Pain: A Movement Problem demand and inadequate sensory input and proprio- Clinically, flexor dominance appears more appar- ceptive control related to modern living, resulting ent in those with low tone while extensor domi- in imbalanced action between the SLMS and the nance is associated more with higher tone. This SGMS. helps explain the increased extensor EMG findings in some and not all low back pain patients.36,37 Whatever the cause, adequate muscle coactiva- tion is more difficult in those with a tendency to Hanna89 felt that a person’s structure was influ- low tone, while inhibition of overactive muscles is enced by neuromuscular adaptations in response to more difficult in the higher tone group. All will have chronic stress which resulted in primary flexor or difficulty with activation of the deep system and extensor activity (see Ch. 6). Sustained negative inhibition of the superficial system albeit to varying stress (distress) provoked a flexor withdrawal degrees. response which activated muscles on the front of the body. Sustained positive stress (eustress) acti- Clinically it is also apparent that some show a vates the extensors for ‘get up and go’ and is related tendency for flexor muscle system dominance while to assertion. Both responses are basic adaptive others are more robust in their extensor systems reflexes necessary to survival. They involve the entire impeding balanced co-activation. body musculature and the whole nervous system in a specific orientation of either negative withdrawal or Schleip88 ruminated upon the evolution of an positive action and mobility. individual’s structure or posturomovement patterns from a neurobiological perspective and noted two The presence of the two primary flexor and primary reaction patterns involving two opposing extensor patterns are not exclusive of one another sets of muscles – the genetic flexors and the genetic and can overlap in the one individual. This is a com- extensors. These differ neurologically, functionally mon finding in people with back pain (see Ch. 9). and morphologically and are innervated from sepa- rate areas of the spinal cord, as seen in Table 7.1. Is altered motor behavior observed in people with back In the process of development, balance between pain functional or dysfunctional – the flexors and extensors needs to be achieved for adaptive or maladaptive? optimal posturomovement control (see Ch. 3). If this does not occur, one of the genetic extensor/ In a very comprehensive presentation, Van Die¨en90 flexor patterns will tend to dominate and can act argues a theory of ‘contingent adaptations’ to help as a basis for chronic muscle shortening and so influ- explain the changed motor behavior seen in patients ence adult human structure. The integrity of the with back pain. Many aspects of his theory are com- body cylinder is altered (see Ch. 6). pelling and concur with clinical experience of people with back pain. In particular this author agrees with Table 7.1 Classification of genetic extensors and flexors his contention that patients adhere to preferred according to Schleip88 motor strategies, are less responsive to changing task constraints and that these altered strategies involve Genetic extensor Genetic flexor muscles costs relative to other constraints that negatively muscles affect outcome (Fig. 7.1). Also the relationship between the disorder and adaptive motor behavior • Mainly tonic muscles with • Mainly phasic with a lot of is non deterministic. However, he also states: a lot of slow twitch Type 1 fast twitch type 11 fibres. fibres. Red meat color White meat color 1. ‘A (pain) disorder triggers adapted motor strategies that help cope with the new situation (my • Innervated from the • Innervated from the dorsal italics)’.90 ventral part of the anterior part of the anterior horn of horn of the spinal cord – spinal cord 2. ‘The adaptive changes in motor behavior are gen- either the dorsal primary erally aimed at increasing ‘more robust (i.e. resistant to ramus or by a dorsal • Located on the ventral side internal and external perturbation) control over motion ramus of the plexi of the trunk and arms, on of afflicted joints or body parts is a common goal of the dorsal leg and dorsal adaptive strategies in musculoskeletal disorders’.90 • Located on the dorsal side of the foot trunk and arms and on the ventral leg and plantar side of the foot 160

Changed control of posture and movement CHAPTER 7 Therapy Pain, injury, fear 2. The patient now has ‘acute’ or ‘sub-acute’ back Re-weighting of constraints pain which in van Die¨en’s terms requires a further re-weighting of constraints. Depending upon the Adequate Inadequate No stage of disorder, learning effect, and the adaptation adaptation adaptation neuromyoarticular status of the person, responses accounted for in the ‘pain-spasm-pain’ and ‘pain Resolution Therapy adaptation’82 models variably become apparent. The of disorder Therapy patient brings into play the best ‘functional adaptive changes’ in motor behavior that he can muster, Adaptation Adaptation many of which are in fact provocative. The problem resolved not resolved is that he is trying to ‘functionally adapt’ on a platform of already substandard quality motor Optimal Sub-optimal control and he has limited choices based on the outcome outcome experience of prior motor learning history. He still needs to get up against gravity and move as best he Fig 7.1  Van Diee¨ n’s depiction90 of the potential role of can as he shops, walks and dresses etc. He will motor behavior adaptations in outcome of musculoskeletal habitually do so in the ‘way that he knows’ and is disorders. familiar with – even though it may be detrimental to his musculoskeletal well being. He now In other words in response to pain, he says: ‘the demonstrates a combination of ‘functional adaptive’ alterations in trunk muscle recruitment in patients and ‘dysfunctional maladaptive’ motor behavior. are functional as they reduce the probability of The sensorimotor dysfunction becomes noxious tissue stresses by limiting range of motion perpetuated. Van Die¨en’s model appears to assume and stabilizing the spine’.82 that prior to the onset of pain, motor control was’normal’. While the motor system is highly However, this author would like to enter the debate redundant, it would appear that many who develop and build upon van Die¨en’s model in suggesting that back pain utilize fewer motor pattern options. Their the altered motor behavior seen in people with back motor behavior is more ‘primitive’. The ‘more pain is principally dysfunctional (albeit with functional robust strategies’ have usually been already been aspects) as it both causes and serves to further perpetuate brought in to play before pain is apparent, serve to the patient’s problem. To expound this further in ‘bring it to the surface’, and then perpetuate it. response to points 1 and 2 above: Clinically one finds different responses in different regions of the spine – some are hyperstabilized 1. Low back pain is in general, a developmental while others are hypostabilized. What seems to be disorder. The pain is not necessarily ‘new’ but generally unaccounted for is the influence of the develops over time as a result of habitual altered ‘facilitated segment’ as described by Korr91 in postural control and more primitive and facilitating (or inhibiting) local and regional muscle stereotyped movement patterns which jeopardize responses further affecting motor control. Altered spinal support and control mechanisms and alter the afference to the CNS even further changes motor spinal joint kinematics over time. This represents a behavior. The neuromyoarticular dysfunction dysfunctional maladaptive response to the patient’s becomes compounded and the patient now wears internal and external environment over time. the label of ‘chronic non specific back pain’. Clinically there are always the early warning signs which herald developing pain. These are usually Movement behavior quality: unaccounted for and their significance ignored until characteristic of more primitive finally ‘the straw that breaks the camels/patient’s and coarse motor control back’ comes into play (Fig. 7.2). The quality of movement patterns is dependent upon the cerebral cortex. Fine motor coordination is needed to prevent damage of a joint and especially 161

Back Pain: A Movement Problem The quality of mature motor behaviour (M/B) is variable and influences the development and perpetuation of back pain and therapeutic outcomes A.'More primitive' M/B B. 'Ordinary' M/B C. 'Good' M/B D. Advanced M/B • Less ideal motor • Normal development • Well developed • Dedicated pursuit and • Subsequent altered development sensori-motor skills practice improves • Minimal brain demand: • Imbalanced abilities beyond usual - Sensory input e.g. committed yogi dysfunction - Altered M/B responses neuromuscular activity • Clumsy become habitual develops from: • 'Motor moron' - Training effect - Sports specific - Occupational eg.shearer Most likely to develop Many possibly develop A few develop M/S Rarely present to clinician musculoskeletal (M/S) M/S problems, may/not Problems resolve generally overt traumatic pain syndromes • Present early and be ongoing more quickly incident • Symptoms are variably ongoing Back pain and related syndromes Further changes in M/B Group A & B Group C&D Require more intense and individualised therapy Quickly assimilate programmes - entrenched habitual maladaptve patterns - therapeutic exercise directives require considerable application to make change and need little supervision Spectrum of outcomes from Resolution usual poor to reasonably good Fig 7.2  Building upon van Diee¨ n’s model90: suggested prior influences on the development and subsequent perpetuation of back pain syndromes. so during a fast movement.3 At the end of a fast they did not develop normally, but for some reason movement, the active inhibition of the antagonist or other their current motor behavior shows the switches into rapid facilitation and contraction in hallmarks of less well integrated control. order to slow down the movement and prevent injury. If this reciprocal interplay is altered, the joint These features have mostly emanated from clini- is endangered. This reciprocal reflex mechanism cal observation; however researchers such as van occurs at the spinal segmental level.3 Die¨en90 are recognizing the importance of quality of response in motor control. Clinical observation of how people with spinal pain syndromes move can reveal certain quite subtle Altered features of movement yet typically common altered qualities in the organi- zation of their movement behavior. In some The motor system is deemed to be highly redundant respects their responses resemble those attributable in that there are an infinite number of different to a more primitive state of development or less muscle activity patterns that can be drawn upon to well integrated development. This is not to say that satisfy mechanical requirements.90,92 However, the 162

Changed control of posture and movement CHAPTER 7 movements of many with back pain can display variable • More symmetrical limb use and tendency to subtle combinations of the following less ideal qualities: remain within the body’s centre of mass; reciprocal • Certain responses are stereotypical and more limb movements are often not automatically well obligatory e.g. central cinch patterns. organized • Less flexibility and adaptability in responses to • Reduced distal initiation – head, tail bone, hands internal and external perturbation. Responses fall and feet into more predictable patterns. • Limited use of reaching actions away from the • Reduction in movement pattern abilities. A more body and exploration of movements into the limited movement repertoire93 with less variety in surrounding space those used. Responses are less differentiated. • Predominance of upper body over lower body • Adherence to the motor strategies they know90 muscle activity which may in fact be provocative • Movements are heavy, laboured ‘bound’ rather • In limiting the repertoire of movement options, than light, easy and free flowing they further reduce sensorimotor learning • Reduced stability/mobility element interaction experience and stimulation. means weight shift suffers in all positions • Reduced internal body awareness and ability to Altered qualities of movement discretely modulate movement • Increased use of protective and defensive Examining movement quality more closely reveals responses either learned through habit, pain95 or an array of possible strategies: emotionally driven • Adopt a more fixed and less flexible use of the • Some difficulty with actions requiring vertical antigravity eccentric muscle control in the trunk • Altered alignment of head and pelvis as they and limbs. balance on the occipital and femoral condyles alters alignment of whole spine in relation to the vertical Altered patterns of motor • Poor integration of flexor/extensor balance with a control become habitual tendency of one to dominate over the other and learned • Tendency to more mass movements in ‘more total flexor/extensor pattern response’ As posture and movement control is largely an auto- • Movements tend to be more jerky, are grosser, matic function, the repeated adoption of the abnor- coarser and clumsier; less differentiated, less refined mal strategies means they become habitual, • Use of unnecessary movements and effort – being learned and begin to feel normal. ‘Habituation is upright and moving is often hard work the simplest form of learning – a slow, relentless • Importantly, see reduced use of lateral and rotary adaptive act, which ingrains itself into the functional movements which affects weight shift and balance patterns of the central nervous system’.89 Their • The increased use of central fixing, holding or repeated use means that over time, subjects simply cinch strategies with a functional ‘disconnect’ forget to draw upon and maintain the array of other between the upper and lower body and poor available motor pattern options. Many of these sequencing of movements from the limbs to torso become relegated to the functional archive depart- and torso to limbs94 ment and rust away from disuse while they continue • Tendency to ‘propping’ when weight bearing to use those few they ‘know’. through limbs References [1] Cholewicki J, van Die¨en JH. [2] Janda V. Introduction to Education, Recreation and Dance; Muscle function and dysfunction functional pathology of the motor 1982. in the spine. Editorial J system. In: Proc. Vol. 3. V11 Electromyogr Kinesiology Commonwealth and International [3] Janda V. Muscles, central nervous 2003;13:303–4. Conference on Sport, Physical motor regulation and back problems. In: Korr IM, editor. 163

Back Pain: A Movement Problem Neurobiologic Mechanisms in Markel Feldt C, editors. [25] Hides JA, et al. Evidence of Manipulative Therapy. New York: The Pelvic Floor. Stuttgart: lumbar multifidus muscle wasting Plenum Press; 1978. p. 27–41. Thieme; 2006. ipsilateral to symptoms in patients with acute/Subacute low [4] Lewit K. Manipulative Therapy in [16] Hodges PW, Richardson CA. back pain. Spine 1994; Rehabilitation of the Motor Inefficient muscular stabilisation 19(2):165–72. System. Butterworths; 1985. of the lumbar spine associated with low back pain: a motor [26] Hides JA, et al. Magnetic [5] Cholewicki, et al. Delayed trunk control evaluation of transversus resonance imaging assessment of muscle reflex responses increase abdominus. Spine 1996; trunk muscles during prolonged the risk of low back injuries. 21(22):2640–50. bed rest. Spine 2007; Spine 2005;30(23):2614–20. 32(15):1687–92. [17] Hodges PW, Richardson CA. [6] Sihvonen T, et al. Functional Delayed postural contraction of [27] Saunders S. Lumbo-pelvic control changes in back muscle activity transversus abdominus in low back during human bipedal correlate with pain intensity and pain associated with movement of locomotion. Doctoral thesis prediction of low back pain during the lower limb. J Spinal Disord abstract. In: MPA Intouch pregnanc. Arch Phys Med Rehabil 1998;11(1): 46–56. magazine. 2 Publication of 1998;79(10):1210–2. Musculoskeletal Physiotherapy. [18] Hodges PW, Richardson CA. Australia; 2008. [7] Gregory DE, Brown SHM, Altered trunk muscle recruitment Callaghan JP. Trunk muscle in people with low back pain with [28] Saunders SW, et al. Reduced responses to suddenly applied upper limb movements at tonic activity of transversus loads: Do individuals who develop different speeds. Arch Phys Med abdominus muscle during discomfort during prolonged Rehabil 1999;80(9):1005–12. locomotion in people with low standing respond differently? back pain. In: Proc. 5th J Electromyogr Kinesiol 2008; [19] Hungerford B, Gilleard W, Interdisciplinary World Congress 18(3):495–502. Hodges P. Evidence of altered on Low Back and Pelvic Pain. lumbopelvic muscle recruitment Melbourne; 2004. [8] Moseley GL. Impaired trunk in the prescence of sacroiliac pain. muscle function in subacute neck Spine 2003;28(14):1593–600. [29] Silfies SP, et al. Trunk muscle pain: etiologic in the subsequent recruitment patterns in specific development of low back pain? [20] Mok N, Hodges P, Brauer S. low back pain populations. Clin Man Ther 2004;9:157–63. Different range and temporal Biomech 2005;20(5):465–73. pattern of lumbopelvic motion [9] McClure PW, et al. Kinematic accompanies rapid upper arm [30] Arena J, et al. Electromyographic analysis of lumbar ad hip motion flexion in people with low back recordings of low back pain while rising from a forward, pain. In: Proc. 5th subjects and non pain controls in flexed position in patients with Interdisciplinary World Congress six different positions: effect of and without a history of low back on Low Back and Pelvic Pain. pain levels. Pain 1991; pain. Spine 1997;22(5):552–8. Melbourne; 2004. 45(1):23–8. [10] Janda V. Muscles as a pathogenic [21] Ferreira PH, Ferreira ML, [31] Belavey D, et al. Long term over factor in back pain. In: Proc. Hodges PW. Changes in the activity in the oblique muscles I.F.O.M.P.T. New Zealand; recruitment of the abdominal after 8 weeks of bed rest – 1980. muscles in people with low back implications for inactivity, lumbar pain: ultrasound measurement spine stability and sedentary [11] Janda V. Muscle and joint of muscle activity. Spine 2004; lifestyle. In: Proc. 14th Biennial correlations. In: Proc. 1Vth 29(22):2560–6. Conference MPA. Brisbane; Congress F.I.M.M. Prague; 1975. 2005. p. 154–8. [22] Hides JA, Richardson CA, Jull GA. Multifidus muscle [32] Belavey DL, et al. Superficial [12] Janda V. Muscle weakness and recovery is not automatic lumbopelvic muscle overactivity inhibition (pseudoparesis) in back following resolution of acute first and decreased cocontraction after pain syndromes. In: Greive G, episode low back pain. Spine eight weeks of bed rest. Spine editor. Modern manual Therapy 1996;21:2763–9. 2007;32(1):E23–29. of the vertebral column. Edinburgh: Churchill; 1986. [23] Danneels LA, et al. Differences in [33] Janda V. Muscles and motor Electromyographic activity in the control in low back pain – [13] Sahrmann SA. Diagnosis and multifidus muscle and the assessment and management. In: treatment of movement iliocostalis lumborum between Twomey L, editor. Physical impairment syndromes. St Louis: healthy subjects and patients with Therapy of the low back. 1st ed. Mosby; 2002. sub-acute and chronic low back New York: Churchill Livingstone; pain. Eur Spine J 2002;11:13–9. 1987. [14] Janda V, Stara V. Comparison of movement patterns in healthy [24] O’Sullivan PB, et al. Altered [34] Gleeson MG. The alexander and spastic children. In: Proc. motor control strategies in technique. In: Proc. 1st 2nd International Symposium subjects with sacroiliac joint pain International Conference on on Cerebral Palsy. Prague; 1987. during active straight leg raise Movement Dysfunction. p. 119–22. test. Spine 2002;27(1):E1–8. Edinburgh; 2001. [15] Hodges PW. Low back pain and the pelvic floor. In: Carri`ere B, 164

Changed control of posture and movement CHAPTER 7 [35] Dankaerts W, et al. Differences in low back pain population. Spine Magazine.Issue 2. Australia: sitting postures are associated 2003;28(10):1074–9. A.P.A; 2008. with non specific low back pain disorders when patients are sub [46] Speers RA, Paloski WH, Kuo AD. [57] Enoka RM. Neuromechanics of classified. Spine 2006; Multivariate changes in human movement. 3rd ed. 31(6):674–98. coordination of postural control United States: Human Kinetics; following spaceflight. J Biomech 2002. [36] Ahern DK, et al. Comparison of 1998;31:883–9. lumbar Paravertebral EMG [58] Neumann DA. Kinesiology of the patterns in chronic low back pain [47] Belavy DL. (F)lying to Mars: how musculoskeletal system: patients and non patient controls. spaceflight research helps Foundations for physical Pain 1988;34(2):153–60. healthcare. In: MPA Intouch rehabilitation. St Louis: Mosby; magazine. Issue 2. Australia: 2002. [37] Watson PJ, et al. Surface National APA; 2008. electromyography in the [59] Janda V. Postural and phasic identification of chronic low back [48] Mientjes MIV, Frank JS. Balance muscles in the pathogenesis of pain patients: the development of in chronic low back pain patients low back pain. In: Proc: X1th the flexion relaxation ratio. compared to healthy people Congress I.S.R.D. Dublin; 1968. Clin Biomech 1997; under various conditions in p. 553–4. 12(3):165–71. upright sitting. Clin Biomech 1999;14(10):710–6. [60] Jackson ND, Gutierrez GM, [38] O’Sullivan P. Motor control and Kaminski T. The effect of fatigue the lumbo-pelvic region. Proc. [49] Byl NN, Sinnott P. Variations in and habituation on the stretch 5th Interdisciplinary World balance and body sway in middle reflex of the ankle musculature. Congress on Low Back and Pelvic aged adults: subjects with healthy J Electromyogr Kinesiology Pain. Melbourne; 2004. backs compared with subjects (IN PRESS). with low back dysfunction. Spine [39] Janda V. Differential diagnosis of 1991;16(3):325–30. [61] Mannion AF, et al. The influence muscle tone in respect to of muscle fibre size and type inhibitory techniques. In: [50] Mok NW, Brauer SG, distribution on electromyography Paterson JK, Burn I, editors. Back Hodges PW. Hip strategy for measures of back muscle pain, an international review. balance control in quiet standing fatigability. Spine 2395: London: Kluwer Academic Press; is reduced in people with low 1998;576–84. 1990. p. 196–9. back pain. Spine 2004;29(6): E107–12. [62] Ng JK, et al. Fatigue related [40] Dankaerts W, O’Sullivan P, changes in torque output and Burnett A, Straker L. Differences [51] Reeves NP, et al. The effects of Electromyographic parameters in sitting postures are associated trunk stiffness on postural control of trunk muscles during with non-specific chronic low during unstable seated balance. isometric axial rotation exertion: back pain disorders when patients Exp Brain Res 2006;174: an investigation in patients are subclassified. Spine 2006; 694–700. with back pain and healthy 31(6):698–704. subjects. Spine 2002;27(6): [52] Hamaoui A, et al. Does postural 637–646. [41] Mannion AF, et al. Fibre type chain stiffness reduce postural characteristics of the lumbar steadiness in a sitting posture? [63] Dolan P, Adams MA. Repetitive paraspinal muscles in normal Gait Posture 2007;25(2): lifting tasks fatigue the back healthy subjects and in patients 199–204. muscles and increase the bending with low back pain. J Orthop Res moment acting on the lumbar 1997;15:881–7. [53] Esola M, et al. Analysis of lumbar spine. J Biomech 1998;31(8): spine and hip motion during 713–21. [42] Gill KP, Callaghan MJ. The forward bending in subjects with measurement of lumbar and without a history of low back [64] Wilder DG, et al. Muscular proprioception in individuals with pain. Spine 1996;21(1):71–8. response to sudden load: a tool to and without low back pain. Spine evaluate fatigue and rehabilitation. 1998;23(3):371–7. [54] Porter J, Wilkinson A. Lumbar- Spine 1996;21(22):2628–39. hip flexion motion: a comparative [43] Brumagne S, et al. The role of study between asymptomatic and [65] Parnianpour M, et al. The triaxial paraspinal muscle spindles in chronic low back pain in 18 to 36 coupling of torque generation of lumbosacral position sense in year old men. Spine 1997;22(13): trunk muscles during isometric individuals with and without low 1508–13. exertions and the effect of back pain. Spine 2000; fatiguing isoinertial movements 25(8):989–94. [55] Radebold A, et al. Muscle on motor output and movement response pattern to sudden patterns. [44] Taimela S, Kankaanp¨a¨a M, Luoto S. trunk loading in healthy The effect of lumbar fatigue on the individuals and in patients with [66] Van Die¨en JH, et al. Effects of ability to sense a change in lumbar chronic low back pain. Spine repetitive lifting on kinematics: position: a controlled study. Spine 2000;25(8):947–54. Inadequate anticipatory control or 1999;24(13):1322–7. adaptive changes? J Motor Behav [56] Smith M. Competing demands on 1998;30(1):20–32. [45] O’Sullivan PB, et al. Lumbar the trunk muscles: effects repositioning deficit in a specific consequences and mechanisms. [67] Sparto PJ, et al. The affect of Thesis abstract. In: MPA Intouch Fatigue on Multijoint Kinematics 165

Back Pain: A Movement Problem and Load Sharing During a [77] Arendt-Nielson L, et al. The trouble? Brain 2004; Repetitive Lifting Test. Spine influence of low back pain on 127(10):2339–47. 1997;22(22):2647–54. muscle activity and coordination during gait: a clinical and [87] Janda V. Comparison of spastic [68] Sparto P, et al. The effect of experimental study. Pain 1996; syndromes of cerebral origin with fatigue on multijoint kinematics, 64(2):231–40. the distribution of muscular coordination and postural stability tightness in postural defects. Int. during a repetitive lifting task. [78] Roland MO. A critical review of Symposium on Rehabilitation in J Orthopaedic & Sports Physical the evidence for a pain-spasm- Neurology Rehabilitacia Suppl. Therapy 1997;25(1):3–12. pain cycle in spinal disorders. Clin 1977;14–5. Biomech 1986;1(2):102–9. [69] Gribble PA, Hertel J. Effect of [88] Schleip R. Primary reflexes and hip and ankle muscle fatigue on [79] Hodges PW, et al. Experimental structural typology. Sourced at unipedal postural control. muscle pain changes feedforward http://www.somatics.de/ J Electromyogr Kinesiol 2004; postural responses of the trunk flexextens/primrefl.html 14(6):641–6. muscles. Exp Brain Res 2003;151:262–71. [89] Hanna T. Somatics: reawakening [70] Salavati M, et al. Changes in the mind’s control of movement, postural stability with fatigue of [80] Moseley GL, Hodges PW. Are flexibility and health. Cambridge lower extremity frontal and the changes in postural control MA: Da Capo Press: Perseus sagittal plane movers. Gait associated with low back pain Books; 1988. Posture 2007;26(2):214–8. caused by pain interference? Clin J Pain 2005;21(4):323–9. [90] Van Die¨en JH. Low back pain and [71] Descarreaux M, Blouin JS., motor behavior: contingent Teasdale N. Force production [81] Lund JP, et al. The pain adaptations, a common goal. In: parameters in patients with low adaptation model: a discussion of Proc. 6th Interdisciplinary World back pain and healthy control the relationship between chronic Congress on Low Back and Pelvic participants. Spine 2004; musculoskeletal pain and motor Pain. Barcelona; 2007. p. 3–14. 29(3):311–7. activity. Can J Physiol Pharmacol 1991;69:683–94. [91] Korr IM. The facilitated segment. [72] Radebold A, et al. Impaired In: Korr IM, editor. Neurobio- postural control of the lumbar [82] Van Die¨en JH, Selen LPJ, logic Mechanisms in Manipulative spine is associated with delayed Cholewicki J. Trunk muscle Therapy. New York: Plenum muscle response times in patients activation in low-back pain Press; 1978. p. 27–41. with chronic idiopathic low back patients, an analysis of the pain. Spine 2001;26(7):724–30. literature. J Electromyogr [92] Bergmark A. Stability of the Kinesiol 2003;13:333–51. lumbar spine: a study in [73] Luoto S, et al. Psychomotor mechanical engineering. Acta speed and postural control in [83] Thomas J, France C. Pain-related Orthop Scand 1989;230(60 chronic low back pain patients: a fear is associated with avoidance Suppl.):2–54. controlled follow-up study. of spinal motion during recovery from low back pain. Spine [93] Edwards I, Jones M, Hillier. The [74] Luoto S, et al. Mechanisms 2007;32(16):E460–66. interpretation of experience and explaining the association its relationship to body between low back trouble and [84] Leinonen V, et al. Disc movement: A clinical reasoning deficits in information processing: herniation-related back pain perspective. Man Ther a controlled study with follow up. impairs feedforward control of 2006;11:2–10. Spine 1999;24(3):255–61. paraspinal muscles. Spine 2001;26(16):E367–72. [94] Hackney P. Making Connections: [75] Jull G, Janda V. Muscles and Total body Integration through motor control in low back pain: [85] Hodges PW, Moseley LG. Pain Bartenieff Fundamentals. New assessment and management. In: and motor control of the York: Routledge; 2002. Twomey LT, editor. Physical lumbopelvic region: affect and Therapy of the low back. New possible mechanisms. J [95] Moseley LG, Hodges PW. York: Churchill Livingstone; Electromyogr Kinesiol 2003; Reduced variability of postural 1987. 13(4):361–70. strategy prevents normalization of motor changes induced by back [76] Matre DA, et al. Experimental [86] Moseley LG, Nicholas MK, pain: a risk factor for chronic muscle pain increases the human Hodges PW. Does anticipation of trouble? Behav Neurosci stretch reflex. Pain 1998;75(2–3): back pain predispose to back 2006;120(2):474–6. 331–9. 166

Chapter Eight 8 Common features of posturomovement dysfunction The imbalanced activity between the deep and super- against the kitchen bench when standing, or the ficial muscle systems and between the flexor and back of the seat when sitting. Relaxing becomes extensor systems is expressed in a number of clinically more a state of collapsing. The spine tends towards observable altered features of postural and movement a functional ‘buckling’ or ‘folding’. ‘Hanging the control, which appear to be more or less common in head’ is common. those with spinal pain and related disorders. • Overactive strategy: he ‘holds himself up’ principally utilizing superficial SGMS muscles It is important to appreciate that these features particularly those around the body’s centre, such as are interrelated and variable in their presence, the thoracolumbar erector spinae. Usually this effect and mutual reinforcement of one another. quickly becomes tiring and so he collapses again. However, some have developed such entrenched Defective antigravity support ‘holding’ or ‘fixing’ strategies that they then ‘cannot and control let go’. ‘Holding strategies’ create constant regional muscle tension in the torso and hyperstabilization of A general or regional lack of axial the underlying joints. extension control Poor pelvic base of support The manner in which the spine is postured when upright highly influences patterns of trunk muscle The requirement for any column ‘to be up’ is an activity.1 Conversely, patterns of muscle activity appropriate and well grounded foundation and the determine how the spine is postured. By and large spinal column is no exception. Effective support people with spinal pain syndromes can move but comes from below and yet most have a ‘dead tail- they can’t ‘posture’ very well: if they manage to bone’ and poor control of the base of the spine. align the spine in neutral they have difficulty main- As the sacrum is part of the pelvis it is this that taining it in movement. provides the important active base of support for the entire axial spinal column. Inadequate deep Poor control of a ‘dynamic antigravity neutral’ system activity, particularly of the Lower Pelvic means the patient finds sitting or standing difficult Unit, reduces the ability of the pelvis to spatially to do in an easy non effortful way. He will tend to adapt and provide an appropriate and effective base adopt either of two extremes – passive collapse or of support to initiate, lift and direct control of the overactive ‘holding’. Both affect function around spine from its base – the sacrum and coccyx. the body’s centre: • Passive strategy: he hangs/sags/collapses relying The alignment and control of the spine in sitting, more upon passive ligamentous support and where standing and bending forward is compromised, jeopar- possible seeks external support such as leaning dizing its safety. See defective pelvic control (p.170)

Back Pain: A Movement Problem Common altered strategies for sitting and standing The habitual adoption of poor sitting positions is probably the single most significant instigator and perpetuator of the postural and related movement dysfunction associated with the development of spinal pain and related disorders. In a modern industrial society long periods of sitting and relatively reduced general activity levels begin with schooling. The advent of computers and increasing sedentary work and leisure practices mean we do even more of it. The- central nervous system (CNS) is relatively starved of decent proprioceptive inputs and automatic respon- sesbegin to suffer (see Ch.11). Altered alignment changes the motor memory, affects muscle activation demand, the line of pull of muscles, creates the need for ‘holding patterns’ and leads to changes in the myo- fascial matrix. Passive strategy Fig 8.1  Passive collapse in sitting creates eccentric loading in the spine of a 15 year old (also in Fig 8.10). Sitting. The common strategy involves rolling back onto the posterior ischia and staying there. dramatic impact of increased segmental flexion on Repeated enough, the person begins to lose options fatigue failure.9 Solomonow et al.10 showed induced for varied position change in sitting. Poor initiation flexion creep in feline viscoelastic tissues desensi- and control of the base of support through the tized the mechanoreceptors and dramatically dimi- ischial tuberosities compromises the ability of the nished muscular activity in multifidus. Later studies11 axial spine to adjust and move. This is particularly showed prolonged flexion results in tension-relaxation so when the commonly habitual strategy of crossing and laxity of viscoelastic structures, loss of reflexive the legs is adopted. Even worse is ‘putting the feet muscular activity within 3 minutes and EMG spasms up’ on stools or similar, often advised when the ‘cir- in multifidus and other posterior muscles. The spasms culation is bad’ which only serves to worsen it! The and muscular hyperexcitability in response to 20 min- alignment and control of the whole spinal column is utes static loading even when very light loads were affected (Fig. 8.1). applied were still evident after 7 hours of rest12 and lasted for more than 24 hours.13 In addition, the Collapsed sitting switches off demand in the sys- micro-damage from sustained loading of the viscoelas- temic local muscle system (SLMS), rendering the tic tissues results in time dependent development of joints and soft tissues vulnerable. In ‘normal’ pain free inflammation14 setting the stage for chronic neural irri- subjects, slump sitting has been shown to decrease tation and a plethora of referred symptoms of which activity in the internal oblique and multifidus1–3 trans- pain is just one. versus and internal oblique,4 particularly if the legs are crossed5 or higher than the pelvis. Some normative Usually, any attempts to ‘sit up straight’ are not studies have reported increased lumbar extensor mus- initiated from the pelvic base of support but by cle activity6,7 in slump sitting, yet the subjects shown in the study by Callaghan and Dunk7 are not in the position that most potentially or actually symptomatic subjects commonly adopt. The posterior pelvic tilt creates hyper flexion of the spine8 – particularly over the lower levels, includ- ing the lumbosacral junction with well documented detrimental consequences. Cadaveric studies of lum- bosacral motion segments have demonstrated the 168

Common features of posturomovement dysfunction CHAPTER 8 intermittent systemic global muscle system Fig 8.2  An ineffectual pelvic base of support requires (SGMS) activity of the muscle groups over the ‘holding oneself up’. Note the poor lateral abdominal tone. thoracolumbar junction.15 O’Sullivan2 draws atten- tion to the critical role of pelvic position in deter- to do so. This is generally achieved by more consis- mining spinal muscle activation patterns. ‘Holding tent over activity of SGMS muscles – particularly oneself up’ is tiring and poorly sustained and so the extensor groups over the thoracolumbar shortly the patient collapses again. In ‘normal’ sub- junction.3,15 However, control of the pelvis as an jects, significantly less superficial lumbar multifidus effective and adaptable base of support for the axial and internal oblique activity has been demonstrated skeleton is still deficient. Dankaerts et al,23 using in this postural strategy.16 an electromagnetic measuring device, examined sit- ting postures in those low back pain subjects who The work of Solomonow and colleagues clearly actively extend in sitting and reported an increased demonstrates that a cumulative neuromuscular lumbar lordosis. While the low lordosis was disorder develops because of repetition of static reported as greater than the controls, it is lumbar flexion, the severity of which is magnified suggested that clinically, even this group usually by the number of repetitions. Full recovery of creep demonstrate reduced intersegmental joint play into may not occur.17 O’Sullivan et al.18 showed a rela- extension over the lower levels when assessed by tionship between flexed sitting postures, reduced skilled palpation. Appearances can be deceptive. In back muscle endurance, physical inactivity and a radiographic study, Roussouly et al.24 showed that flexion provoked low back pain. In sitting, twisting while lordosis was increased, segmental extension mobility significantly increases when the spine is between L5 and S1 was reduced. In the main, flexed further increasing vulnerability of the poster- reduced extension over the lower levels (relative ior annulus to injury.19 to the upper levels) and associated deficient inter- segmental neuromuscular control is clinically Importantly, collapse of the lumbopelvic spine apparent. will affect the alignment of the rest of the spine including the head and neck, a fact which is often overlooked in some studies on cervicothoracic posture.20 It also contributes to the development of the shoulder crossed syndrome21 (see Ch.10). In standing, the same postural pattern of poster- ior pelvic rotation is invariably carried through from sitting – the tendency being, to shift the pelvis for- ward with posterior rotation, hang off the iliofemoral ligaments in hip external rotation, with hyperex- tended knees and a collapsed spine. The sacrum is counternutated and L5 in relative flexion – an unfavorable loading state of the lumbosacral and SIJ region. This ‘locking’ of the lower limb kinetic chain limits the pelvis’ ability to be an adaptable and appro- priate base of support for movement control of the spine. Further, when the pelvis is shunted forward, there is reduced lumbopelvic SLMS demand. Snijders et al.22 showed posterior pelvic rotation decreased activity in internal oblique. There is little buoyancy or ‘lift’ in the axial column or through the pelvis-leg base of support– the whole SLMS is relatively ‘switched off. Overactive strategy Sitting. The person ‘holds himself up’ (Fig. 8.2) – from extensor system dominance and often also as a result of a mistaken belief that it is ‘good posture’ 169

Back Pain: A Movement Problem The superficial muscle overactivity reduces the beginning and end of the standing period with fur- ability to posturally adjust and shift weight over the ther increased responses to sudden trunk perturba- support base. Intentionally stiffening the trunk by tions. After discomfort developed, the superficial co-activating the superficial muscles has been shown abdominal activity also increased. to degrade postural control in unstable sitting.25 Defective pelvic control Standing. The standing overactive patterns are again a reflection of the sitting posture patterns – In the clinical setting, it is an almost universal primarily relying upon dominant activity of thoraco- finding that those people with spinal pain and lumbar extensor groups and related considerable related disorders demonstrate to a greater or lesser underactivity of the anterior abdominal wall. The extent, inadequate neuromotor control of the pelvis thorax is shunted forward in relation to the pelvis. in many, if not all, of the different aspects of its In an important and really nice ‘normal’ study, functional movement repertoire. This affects pelvic Harrison et al.26 demonstrated that anterior transla- joint kinematics and transmission of forces and tion of the thorax resulted in posterior displace- loads through the pelvis. Joint findings generally ment and anterior tilt of the pelvis with extension reflect the movement difficulties. Mechanical of the upper lumbars and flexion of the lower lum- dysfunction of the pelvic joints is generally in the bars. Reduced SLMS activity in the lower pelvic form of a ‘functional biomechanical block’ where unit means that the dynamic base of support through ‘distorsion’ is reduced or fixed. This may not neces- the pelvis-leg kinetic chain is still inadequate. sarily be directly pain producing but is accompanied by associated signs when palpating the ligaments The superficial muscle hyperactivity splints the and myofascia and for joint ‘play’. This ‘functional spine and further disallows it to adequately prepare block’ may be symmetrical or asymmetrical and for, dissipate and dampen the forces created by head affects segments higher up and down the kinetic movement breathing and particularly in response to chain. Pelvic asymmetry has been shown to create limb movements. Reduced segmental adjustments functional kinematic compensations not only in the mean balance suffers. Mok et al.27 showed decreased lumbar spine but also in the thoracic region.31 Pelvic preparatory and resultant increased correctional dysfunction acts as a potent and important contrib- lumbopelvic movements in response to rapid arm utor to the development and perpetuation of many movements. Smith et al.28 experimentally induced lumbopelvic and related pain disorders including low back pain and found reduced motion of the hip and knee pain as well as underpinning a lot of trunk associated with breathing. mid and upper torso dysfunction syndromes. Thus in upright activities, some regions of the Pelvic control is core control. It is the lack of this spine are subjected to collapse, compression and a core control which needs to be better appreciated functional ‘buckling’– they become relatively uncon- and more appropriately addressed in many treat- trolled or ‘unstable’ while other regions become ment interventions. stiff or ‘over stable’ and fixed. This interrupts or damps the transference of the movement wave up Understanding the various aspects of altered pel- through the spine. vic control which will be present in varying degrees is assisted by examining each separately. They are as The tendency to uneven patterns of control is also follows: apparent in the asymptomatic population as Gregory and Callaghan29 found when ‘university population’ Defective intrapelvic control subjects stood for 2 hours as they performed four (refer to Ch. 6 Part B) light manual tasks. 13 of the 16 subjects developed some level of low back pain during that time. One Inadequate control of Lower Pelvic Unit (LPU) mus- of only three variables to significantly change was an cle synergies result in difficulty performing the Fun- increase in lumbar spine flexion. When central sup- damental Patterns of Pelvic Control. Attempts to do port is reduced because of inadequate deep local so invariably utilize strategies involving a lot of muscle system activity, the person is forced to rely SGMS activity – either from large pelvi-femoral more on abnormal SGMS activity in low load activi- muscles and/or those higher up the torso normally ties. Gregory et al.30 had a group of college students stand for 2 hours and found that those who devel- oped substantial back discomfort showed greater superficial extensor trunk muscle activity at the 170

Common features of posturomovement dysfunction CHAPTER 8 responsible for controlling the relationship between in the force couple producing the movement. Prin- the thorax and pelvis. Manual movement testing pre- cipal activity involving the pelvic floor and obturator dictably reveals patterns of joint hypomobility which group including piriformis, is augmented by the ten- are also reflective of the motor control difficulties. dency to create the habitual ‘dysfunctional posterior pelvic tilt’ by pushing through the feet, clenching Fundamental Pelvic Pattern 1 (FPP1) the buttocks or ‘butt gripping’32 with associated overactivity from hamstrings. The underactivity of FPP1 is consistently the pattern that most if not all the lower abdominals is associated with over activity have little idea of the action and the most difficulty of the upper abdominals in some subgroups performing. Low lumbar segmental movement into (Fig. 6.30). extension is generally reduced with underactivity in multifidus, lower transversus, internal oblique, Difficulty performing these two fundamental iliacus and probably psoas. The prime movers patterns means that spatial modulation of the two responsible for FPP2 are generally hyperactive and pelvic bowls is deficient. This affects the myome- do not adequately eccentrically lengthen further chanics of the pelvic floor and the ability of the hindering the proper performance of this pattern. pelvic ring to adapt its internal shape as well as the Instead the action is more likely attempted by acti- whole unit in space in order to provide a stable base vating the thoracolumbar erector spinae, serratus of support for torso and lower limb movements. posterior inferior higher up around the mid torso – a bilateral ‘posterior cinch’ which serves to ‘fix’ Fundamental Pelvic Pattern 3 (FPP3) the thoracolumbar segments, thrust the lower ante- rior pole of the thorax forward and limit diaphragm Deficient control of FPP1 and FPP2 accordingly activity and basal chest expansion. This may be affects the ability to perform FPP3 and achieve and overt or subtle yet readily discernable by palpation modulate pelvic ring ‘distorsion’ necessary for contra- (Fig. 8.3). Because of difficulty with or habitual lateral innominate rotation in the sagittal plane and non use of this pattern, the pelvis is generally more pelvic rotation in the transverse plane, both involved posteriorly rotated, the sacrum counter-nutated and in walking and most movements. This further affects posterior hip opening is reduced as is low lumbar the ability to control movements of the pelvis such extension and control. that it is a spatially adaptable yet stable platform to support movements in the hips and torso. Fundamental Pelvic Pattern 2 (FPP2) Defective spatial control Generally this movement seems easier though of the pelvis appearances can be deceptive. Commonly, poor eccentric co-activation from those muscle groups Normally, the lumbopelvic stabilizing muscles with a prime role in FPP1 means there is imbalance including the pelvic floor are active when maintain- ing optimally aligned erect postures.1,3,33 Hodges34 Fig 8.3  Rather than initiate the FPP1 movement with a states ‘there is considerable debate as to whether subtle anterior pelvic rotation, there is just discernable central pelvic and lumbar positions are different in low back posterior cinch pattern activity. and pelvic pain although changes have been identi- fied in specific subgroups’. Clinical observation reveals definite patterns of altered spatial position and control and this is described. Reduced intrapelvic control compromises the ability to spatially align and adjust the pelvis when weight bearing. Rather than control the pelvis around a ‘dynamic neutral’, the tendency is to assume postures in more passive, end range posi- tions. The motor control difficulties are apparent in all three planes of spatial pelvic control, but are particularly obvious in the sagittal plane. 171

Back Pain: A Movement Problem Sagittal plane literature except in a personal article by Schleip on the structural typology of Hans Flury.35 In a very Here the observed preference is to posture and initi- recent paper, Brumagne et al.36 discuss the inconsis- ate subsequent movement from either an anteriorly tent results in the small amount of studies which or posteriorly shifted spatial relationship to the verti- report altered body inclination in relation to postural cal neutral. The habitual preference for either forms control. Two studies found a more anterior centre of the basis for a clinical classification system based on mass36,37 with related increased back muscle activ- altered function (see Ch. 9). While whole synergies ation, while two others reported a more posteriorly of muscles control the spatial position of the pelvis, located centre of mass.38,39 Clinical classification into psoas appears to play a large role. When underactive the two primary pictures of dysfunction may help the pelvis shifts forward and when overactive it shifts explain these diverse findings (Ch. 9). back. The postural shift is always accompanied by a coexistent sagittal rotation as shown in Figure 8.4: Coronal plane • Anterior shift and related posterior pelvic The postural habit of passively ‘hanging’ the body rotation with a corresponding diminished ability to predominantly on one leg is common and partly posteriorly shift and counter rotate the pelvis into contributes towards the high incidence of hip ‘bursi- anterior pelvic rotation tis’ (Fig. 8.5). Reduced LPU activity subsequently • Posterior shift and related anterior pelvic rotation – with corresponding difficulty in anteriorly shifting and counter rotating the pelvis into posterior sagittal rotation. While the anterior and posterior pelvic shifts and associated sagittal rotations are clinically apparent, there is little acknowledgement found in the Logf Logf Logf Posterior shift ‘Neutral’ Anterior shift with anterior rotation with posterior rotation Lumbar spine: Balance around Lumbar spine: relatively flexed relatively extended the line of Hips: relatively Hips: relatively flexed gravitational force extended Fig 8.4  Conceptual schematic sagittal view showing pelvic Fig 8.5  Passive lateral ‘hang’ in standing – the deep shifts and associated rotations (exaggerated for clarity). system is ‘off’. 172

Common features of posturomovement dysfunction CHAPTER 8 affects the ability to laterally shift weight through Altered control of sagittal pelvic tilt the hip joints; either the pelvis over the weight bear- generally reflects imbalanced ing leg, or the leg medially under the pelvis. Instead activity between the iliopsoas and control is attempted higher up via a bilateral ‘cinch’ obturator/hamstrings groups which then affects the spines ability to posturally adapt in the coronal plane and maintain three Sagittal tilting movements of the pelvis on the femur dimensional control of its alignment. are the largest and most employed in functional movement. It is necessary that each muscle in the Horizontal plane LPU synergy works enough but not too much so each can effectively contribute to the synergy and co coor- Diminished control of backward and forward pelvic dinated movement patterns ensue (see Ch. 6). rotation affects adaptive postural pre- positioning of the pelvis to support lower limb movements as well The ability to readily tilt or swing the pelvis as rotation in the horizontal plane and related spinal forward and back on the femoral heads is influenced rotation. Gracovetsky draws attention to the impor- by the habitual posturomovement patterns used tance of pelvic rotation in walking.40 Tightness and/ which in turn affects balance in the length/tension or imbalance in the hip rotators, particularly tighter relationships between the obturator/hamstrings external rotators, limit transverse plane pelvic rota- and iliopsoas groups. Unfortunately imbalance in tion. A combination of reduced intrapelvic rotation the ‘ischial swing’ is clinically common. The obtura- or ‘distorsion’ and reduced rotation of the pelvis as tor/hamstrings group is generally tight and the iliop- a whole on the hips means that the mid lumbar soas group can show underactivity, overactivity or spine becomes the site of relative rotary flexibility. imbalance between iliacus and psoas activity. Because of the poor spatial control, the pelvis is eas- ily shunted around and movements of the hips The imbalance is reflected in the pattern of the invariably end up being movements of the low back. standing posture and contributes to clinical func- tional classification which is covered in the next Poor pelvic control affects the ability chapter. of the sacrum to direct alignment and control of the rest of the spine The relationship between back pain syndromes and hypo or hyper tonus of iliacus and psoas is Regional or general reduction of the lumbar lordosis understood by clinicians yet there is a dearth in is universally common clinically,41 and as noted by the literature. Mostly considered as open chain hip Adams et al.42 particularly in the lower lumbar flexors,45 a postural stabilizing role is increasingly spine. Poor control of anterior pelvic rotation and accorded to psoas46–49 particularly if hip flexion the habitual adoption of posterior pelvic rotation is part of the movement.50 Except for inclusion or tilt means the sacrum is carried into flexion and with psoas as the ‘iliopsoas’, iliacus barely rates a the lumbosacral region moves more into relative mention. However the two muscles differ anatomi- flexion in posture and movement. Generally, closed cally, neurally and functionally.50 Andersson et al.47 chain hip flexion and open chain hip extension are demonstrated individual and task specific activation more difficult. Both rely on control of sagittal anter- patterns between iliacus and psoas which varied ior pelvic rotation which is coupled with lordosis in according to the particular demands for stability the lumbar spine. The importance of being able to and movement at the lumbar spine, pelvis and hip. control posture and movement around the neutral The scant attention paid to iliacus in the literature lordosis for a healthily functioning spine is acknow- is indicative of paucity in the understanding of func- ledged by clinicians and has been stressed by noted tional movement control around the lumbopelvic researchers such as McGill43 and Adams.42 Loss of region. Both these muscles provide important inter- control of the neutral lumbosacral position jeopar- nal bracing of forces and movements within the pel- dizes local segmental control,44 and also transmis- vis51 including stability of the sacroiliac joint as well sion of the movement wave and control up and as controlling the pelvis on the femur and the align- down the whole axial spine, including coupled rota- ment and stability of the spine over the legs. Unilat- tion and side bending amongst other things. eral spasm of iliacus and psoas can contribute to a fixed intrapelvic ‘distorsion’.52,53 The influence of the deep external hip rotators on modulating pelvic tilt control is practically 173

Back Pain: A Movement Problem nowhere to be found in the literature. Their influ- Sagittal plane ence is also important in transverse plane rotation of the pelvis on the fixed femur. Related to control of sagittal pelvic tilt movements, patients generally demonstrate poor alignment and The myomechanics of the pelvic floor muscles control of the segments when executing the two (PFM) are dependent upon the reciprocal relation- most functionally significant patterns used in ship between the ilio/psoas and the obturator performing usual everyday activities: groups as they balance and modulate the dimensions of the superior and inferior pelvic bowls. Because of Forward bend pattern the close functional synergism between the PFM and the obturator group, dominance of the latter Ideally this is achieved from a ‘pelvic swing and shift renders the PFM likely to overactivity and shortness pattern’ based upon FPP1 (see p.127). However, also. When the more superiorly spatially placed ilia- habitual buttock clenching and not ‘letting go’ of cus/transversus synergy is sufficiently active to bal- the posterior pelvic floor60 and pelvi-femoral mus- ance the obturator group, the PFM are functionally cles contribute to difficulty initiating and controlling required and better able to both concentrically and this action from the pelvis. Instead the pelvis eccentrically contract and lengthen. commonly rolls into posterior rotation where the sacroiliac joint and the mid/low lumbar spine levels Imbalance in the ‘swing’ is also reflected in the are the victim as they are pulled into hyper flexion position of the hips. When the obturator group to compensate (Fig. 8.6). This is common and has dominates, the hips are more externally rotated also been described as a ‘click-clack’ movement.5,61 and internal rotation is reduced. When the iliacus/ psoas are tighter (less common), the hips move more freely into internal rotation and less into external rotation. Both groups can be tight where the neutral rotation position is more balanced but range into rotation, flexion and extension is more limited (see Ch.10 ‘Mixed syndrome’). When adaptive pelvic tilt support for functi- onal spinal movement is insufficient, compensatory regional hyperactivity around the centre of the body is seen, serving to further limit spinal control me- chanisms as the region becomes hyperstabilized. Increased activity in the superficial abdominals is increasingly reported30,54–57 as well as extensor hyper- activity30,58,59 (see Ch. 10, ‘Central cinch patterns’). Difficulty controlling closed chain movements of the hip joint and subsequent effect on lumbar spine (see Ch. 6, Part B) It is interesting to ponder the manner in which we Fig 8.6  Habitual poor forward bend pattern – note the use personally and conceptually view dysfunction. The of the arms. noted researcher McGill states ‘I am continually surprised at the number of people with back trou- bles who also have hip troubles’.50 They are always interrelated; and emanate from defective pelvic control. The huge numbers of people with back pain and those increasingly undergoing hip replacement surgery attest to the extent of the communal dysfunction. 174

Common features of posturomovement dysfunction CHAPTER 8 The sacroiliac joint is especially prone to shear Coronal plane forces if loaded in the counter-nutated position.71 In the coronal plane, reduced control of the LPU Roussel et al.62 described a study which found and lateral and medial weight shift at the hip that reduced control of this pattern in dancers as a engenders the need for holding patterns higher basis for performing open and closed chain hip flex- up in the torso or for excess activity in the large ion was predictive of risk for developing future pelvi-femoral muscles. Underactivity in iliacus- musculoskeletal injuries. A large epidemiology study psoas reduces control of lateral weight shift while by Ving˚ard et al.63 found the strongest risk factor overactivity disrupts the neutral pelvic position for LBP of biomechanical origin in men was working and feeds into central ‘cinch posterior cinch’ in a forward bent position. It makes no sense to behavior (Ch.10; Fig. 8.7). Reduced intrapelvic attempt to ‘stabilize’ the lumbar spine – or the sacroiliac joint for that matter, if they are being con- stantly forced to abnormally compensate for move- ments which should be initiated from the pelvis during our many and varied activities of daily living. The disinclination to shift the pelvis posteriorly and weight bear through a flexed hip is also apparent in kneeling, all fours and variations of these positions. In fact loading weight through a flexed hip in any position such as supine is usually challenging e.g. ‘bridging’ is generally only achieved by posterior pel- vic rotation. Achieving functional lengthening in the hamstrings and obturator group can only occur when the pelvis can be controlled in anterior rotation.64 Lifting or return from forward bend pattern Ideally this is based upon control of FPP2 which brings the pelvis forward and extends the hips while balanced activity of the flexors and extensors con- trols the ‘body cylinder’ alignment. When control is defective, the patient tends to principally rely upon the hamstrings and passive tension in the posterior myofascial structures with the spine in flexion and posterior pelvic rotation or conversely, he excessively relies upon the back extensors (see Ch.9). Transverse plane Fig 8.7  Defective control of lateral weight transfer in standing becomes ‘hanging’ and ‘holding’. In the transverse plane it is common to see: Decreased ipsilateral backward pelvic rotation, hip internal rotation and lumbosacral ‘closing’. This is usually more compromised than: • Decreased ipsilateral forward pelvic rotation and associated hip external rotation and lumbosacral ‘opening’. Cibulka et al.65 found subjects with sacroiliac joint pain has significantly more hip external rotation with a limitation of internal rotation on the side of the posterior innominate. 175

Back Pain: A Movement Problem control provides a less stable base to support Fig 8.8  This common stretch perpetuates her problem. well controlled activity of the large SGMS pelvife- Note the axis of movement in the stretch is the lumbo pelvic moral muscles – in particular the adductors and junction rather than the hip. See Fig 8.26 and text. hamstrings both of which are notorious for ‘sprains’. Mens66,67 draws attention to the fact Impaired movements of the femur that ‘adduction-related groin pain’ in the athlete on a stable pelvis may not be caused by adductor tendonitis but by instability of the pelvic ring. In a study of 44 ath- Movements at the hip are generally better under- letes with groin pain clinically elicited by resisting stood and considered in terms of ‘open chain’ move- the adductors in crook lying, he then applied a ments – the pelvis providing a stable platform for pelvic belt placed inferior to the iliac spines and the moving femur. This is also an important compo- just above the greater trochanter. Subsequent nent of pelvic function and most contemporary retesting generally but variably improved adductor rehabilitation strategies do focus on this aspect. force and lessened pain during the maneuver. It is However attention to the ability to control sagittal suggested that the pelvic belt is performing the pelvic rotation and the neutral lumbar lordosis, as action that would otherwise be provided by the well as isolating the movement to the hip is synergy of the LPU in performing the first funda- frequently overlooked in practice. Reduced lumbo- mental pelvic pattern. In particular the lower pelvic or intra/extra pelvic control means that the abdominals and iliacus provide intrinsic medial pelvis is an ineffectual platform to support open stability of the upper pelvic bowl and ipso facto chain hip movements. This is particularly important mediolateral stability of the inferior bowl to sup- with large long lever actions of the leg such as the port actions of the large pelvifemoral muscles. ASLR test and particularly so if they are ballistic He notes the strong association between groin pain as in kicking a football. The lumbar spine again and abdominal wall weakness. He also describes67 becomes overstressed setting up a vicious cycle two other studies where cases of osteitis pubis, where the dysfunction is perpetuated. Tightness of instability of the symphysis and adduction related the pelvifemoral muscles further compounds the groin pain were treated either by surgical fusion of problem. This helps explain the prevalence of vari- the symphysis or intraarticular injections into the ous ‘diagnoses’ of hamstring problems in the sport- symphysis with improvement in the adductor ing arena – pulls, tightness, tears, tendinopathies related groin pain. Increased adductor tension/ etc. is (see ‘The hamstrings conundrum’ Ch.12). activity possibly not only causes tendonitis but overstress of the ligaments of the joints of the The close functional relationship pelvic ring. between hip–pelvis myomechanics Three-dimensional control of closed chain move- The more common patterns of habitual posturo- ments of the hip is not only critical in being able to movement tend to underutilize available hip range functionally move at the hips but is also particularly of movement and control and certain patterns of important when ‘stretching the hips’. The ‘catch 22’ is that the hips are tight because of poor control of the fundamental patterns, yet often, subsequent hip stretching is performed as ‘stupid stretches’ (Fig. 8.8) with no attention paid to initiation and control from the pelvis. The lumbar spine is gener- ally pulled into end range flexion or extension and rotation and becomes the site of relative flexibility68 and even more vulnerable, setting up a vicious cycle where the dysfunction is perpetuated. This is particularly so in the case of tightness of the ham- strings and piriformis (see the ‘hamstrings/hip conundrum’ (Ch.12). Reduced pelvic control at the hip particularly during dynamic single leg exertions has also been associated with patellofemoral pain syndromes.69 176

Common features of posturomovement dysfunction CHAPTER 8 movement become more prevalent. Reduced activity Fig 8.9  Neuromyofascial restriction in the external hip and imbalance within the LPU and an over reliance rotators and hamstrings act to inferiorly ‘tether’ the pelvis on the outer SGMS muscles affects intrapelvic sta- during forward bending. The axis of movement becomes the bility and control e.g. dominance of rectus femoris low lumbar spine. over psoas for hip flexion; of TFL over gluteals for abduction. The tendency is to ‘hang’ relying on the ‘outer’ muscles rather than find ‘inner’ support. The neuromuscular predominance of closed chain hip extension, abduction external rotation patterns with reduced antagonist activity, causes the inferior pelvic bowl to become hyperstabilized and more ‘closed’ and the sacrum counternutated. Altered loading stresses and reduced ‘distorsion’ in the pelvic ring ensue. Articular and neuromuscular freedom of patterns of hip movement into various combinations of flexion, internal rotation and adduction and related opening of the inferior bowl begin to show restriction. This limits closing of the superior bowl and control of the lumbar lordosis. Clinically, this is more common (Fig. 8.9). If there is then a requirement for sudden or explosive muscular activity involving patterns of hip flexion, internal rotation and particularly adduc- tion such as in kicking, the decreased eccentric lengthening in the extensor/external rotators/ abductors can potentially lead to ‘tears’ as they are forced to lengthen. On the other hand, any of the flexor/internal rotator/adductors may also poten- tially ‘tear’ as they are forced to contract against antagonists which do not ‘let go’. Particularly in the sportsman, actions that suddenly require large opening hip/leg movements or those requiring a sudden change of direction on a fixed leg, risk yank- ing the proximal muscle attachments and the pelvic bones themselves at the inferior pubic ramus and ischial tuberosities. This jeopardizes the stability of the pelvic floor and the syndesmosis of the SIJ. Clinically, the association between adductor hyper- activity ‘osteitis pubis’ and other related ‘unstable’ conditions of the symphysis become probable. In likewise manner the incidence of ‘groin pain’ syn- dromes can be partially explained. The influence of altered segmental function and related ‘facilita- tion’ in these muscles should also not be overlooked. Sacroiliac Instability? across the joints, they were potentially unstable. They introduced the notion of a self locking or self Vleeming et al.70,71 considered that the articular bracing mechanism which acted to stabilize the surfaces of the sacroiliac joint (SIJ) were relatively joint. This model comprised a combination of ‘form flat and as large forces needed to be transferred closure’– the specific anatomic features of the joint, 177

Back Pain: A Movement Problem and ‘force closure’ – compression generated by lat- bone seen on X-ray was possibly caused by an anterior eral muscle forces and ligaments with friction, in rotation of the innominate about a horizontal axis near order to withstand potential shear at the joint from the sacroiliac joint. However, normally, weight bearing gravitational forces and during load transfer. Nuta- is considered to produce a posterior rotation of the tion of the saccrum is crucial in this self locking weight-bearing innominate while the superincumbent mechanism and tensions most SIJ ligaments.70 The body weight causes the sacrum to nutate.79,80 It can be four muscles they listed as specifically important reasoned that hanging the contralateral leg will pro- in providing joint compression were erector spinae, duce further physiological ‘distorsion’ in the pelvic gluteus maximus, latissimus dorsi and biceps ring. If the pelvic ring is unstable at the symphysis, this femoris. Through their attachments including those will ‘appear to be’ excessive anterior rotation of the to the thoracolumbar fascia, they were considered free innominate. While this study does show instabil- to form part of three muscle slings: the longitudinal, ity at the symphysis it does not necessarily show it at posterior oblique and anterior oblique slings the SIJ. However, largely through it, a positive ASLR (see p.121) which acted to compress the joint70and has somehow become construed as indicative of ‘SIJ provide support. Van Wingerden et al.72 managed to instability’. show that sacroiliac joint stiffness did increase when individual muscles were activated, especially the Furthermore, clinically there is also a danger erector spinae. Failure in the system is said to occur that pelvic girdle pain and the associated finding when erector spinae and gluteus maximus become of a positive ASLR test have become readily inter- weak with an increase in hamstrings tension which preted as confirming ‘sacroiliac instability’. This serves to hold the sacroiliac joint in counternuta- author agrees with O’Sullivan56 who suggests many tion, and so more vulnerable to shear forces in load- clinicians hold confused beliefs that the pelvis is ing.70 Note that practically all these muscles belong unstable or displaced, which are then transferred within the SGMS and are not intimately related to to their patients with unfortunate consequences. pelvic ring myomechanics, hence are unlikely to While Mens et al.78 found a strong correlation provide a truly effective postural pre- between positive ASLR and actual demonstrated stabilizing role to support integrated load transfer pubic joint laxity in PPPGP, the test can also be through the pelvis. As those authors suggest, the positive in cases of pelvic joint stiffness. Clinically superficial slings will play an important role in gross in a general population, the joint is more often motor activities such as walking and running, but it symptomatic because of stiffness which may or is suggested only if they are able to act on a stable not be directly pain producing. Pain provocation base of support provided by deep system preactiva- tests are not necessarily clinically reliable and it is tion. With the benefit of more recent evidence by generally necessary to apply composite tests to Australian researchers73–77 into function of various arrive at a diagnosis.81 Examining the quality muscles within the deep system, the authors later and ‘feel’ of the tissues and specific movement suggested including the contribution of ‘core mus- testing of the spinal, hip and pelvic joints including cles’ to the self bracing mechanism.71 control of key functional movement patterns without necessarily reproducing ‘the pain,’ gener- The instability model was further developed ally delineates the source and reasons for the pain when in 1999 Mens et al.78 published a paper which and informs appropriate treatment direction. showed that impairment of the active straight leg O’Sullivan et al.77 identified altered motor control raise test (ASLR) correlated strongly with instabi- in subjects who had pain over the sacroiliac joint, lity of the pelvic ring in patients with peripartum positive pain provocation tests and a positive pelvic girdle pain (PPPGP). The increased mobility ASLR. During the active ASLR test, not only did was demonstrated on X-ray and occurred at the the pelvic floor descend but this was associa- symphysis pubis and was most evident when pas- ted with bracing and decreased descent of the sively hanging the symptomatic leg while standing diaphragm and alterations in respiration which on a raised box. The ASLR was improved by the appli- improved with external pressure over the ilia. cation of a pelvic belt either just below the anterior Rather than necessarily indicating ‘sacroiliac insta- superior iliac spines or at the level of the symphysis bility’, this study nicely showed that it is the oper- pubis. This external compression provides pelvic ring ant suboptimal motor control strategies of the stability either above or below the hip joint. The whole torso that are ‘unstable’ in many with pelvic researchers surmised that the caudal shift of the pubic girdle pain syndromes. 178

Common features of posturomovement dysfunction CHAPTER 8 The Netherlands model of ‘sacroiliac instability’ loaded40 with oscillating load sharing roles between has been popular and adopted by clinicians 32,82,83 the passive and active tissues. and researchers.84–86 An improved understanding of function in the deep system has led to the inclu- This proposed model is appealing both clinically sion of those muscles responsible for generating and in terms of function allowing the pelvic ring to IAP, also considered to have a role in maintaining slightly twist or distort (‘distorsion’) in the basic func- pelvic stability and respiration (transversus, internal tional movement – walking, as well as numerous other oblique diaphragm and pelvic floor).77 However, activities involving the lower limbs. Dysfunctional highly significant is that apart from the pelvic floor spatial and particularly intrapelvic control as described and piriformis muscles, the influence of the very will disrupt the kinematic chain controlling and trans- functionally important ‘other internal pelvic mus- ferring forces and movements between the hips and cles’ – the iliacus and obturator group have to date spine through the pelvis. not yet been well considered. Andersson et al.47 showed that during ASLR, moderate to high activity Neuromyo-articular dysfunction of was present for both psoas and iliacus. Clearly they the spinopelvic–hip complex contribute to providing internal support for load underlies most pelvic girdle pain transfer through the pelvis. Eminent clinicians87,88 and related disorders describe spasm of iliacus as a potent factor in main- taining sacroiliac dysfunction. In the Mens study the Pain in the pelvic girdle can either arise from the raised leg was ‘relaxed in lateral rotation’.78 Clini- local joints or myofascia including the hip, or be cally, preactivation of the FPP1 with the hip in neu- referred from the spine or manifest from a combin- tral rotation can impressively change the ASLR test ation of the above. Groin pain in the sporting popu- result. Interestingly, in an earlier paper document- lation can be associated with pathology in the hip, ing the results of a survey of 518 women with pubic symphysis91 and associated dysfunction in PPPGP, Mens et al.89 noted the high frequency of the lumbar spine and SIJ. While traumatic injuries delivery positions with a bent spine. They con- including childbirth can precipitate the develop- cluded a flexed position during delivery may ment of symptoms, more often than not their onset enhance the risk for PPPGP. Post partum tasks is insidious, seemingly occurring for no apparent involve constant flexion patterns, undoubtedly fur- reason. The pelvic organs receive sympathetic sup- ther feeding the dysfunction. ply from the thoracolumbar outflow while the para- sympathetic is via the sacral outflow. It should also Gracovetsky90 refutes the Netherlands ‘instabil- be borne in mind that psoas is innervated by ity model’ suggesting that there is an evolutionary L12394 and iliacus by L2394, and the adductors by advantage to instability – function drives the anat- L234.94 Spasm in iliacus can result from L23 and/ omy and not the other way around; ‘the viscoelas- or SIJ dysfunction. Palpation of joints over the thora- tic nature of biomechanical material precludes columbar spine can reproduce scrotal, haunch, hip straightforward application of these engineering and pelvic pain. The functional relationship between concepts’. Even a steady erect stance is maintained the thoracic and pelvic diaphragms means that clini- by cycling through a sequence of different but cally, thoracolumbar dysfunction is usually part of closely related postures so that no one structure the dysfunction picture in many pelvic girdle pain is continuously loaded. He proposes a ‘SG ridge’ disorders. Clinical assessment readily delineates on the sacrum locks into a corresponding shape in underlying patterns of neuromyo-articular dysfunc- the innominates allowing coupled motion similar tion precipitating and perpetuating symptoms. In an to that seen in the lumbar facets, but of smaller excellent review synthesizing current evidence with magnitude though greater force. The SG ridge acts clinical observation, O’Sullivan and Beales56,92 make as a fulcrum transferring the vertical loads, leaving the case for clinically classifying and diagnosing pelvic the SIJ relatively free to rotate around the hinge in girdle pain disorders based upon the dysfunctional two planes, thus allowing axial rotation of the pel- mechanisms underlying the disorder. Currently, vis and nutation. The joint surfaces are warped theories about the sacroiliac joint are popular yet and so do not slip past each other; the ligaments confused and poorly validated, and these authors are strong and the geometry of the joint is such attempt to clarify the known facts. Importantly they that there is no need for additional force closure to keep it together. The spine needs to be impulse 179

Back Pain: A Movement Problem suggest that ‘directional strain’ may be more signifi- generated in pelvic floor function stems from the cant than positional changes. In agreement with problem of stress urinary incontinence (SUI). these authors, clinical findings generally delineate A recent longitudinal study by Smith et al.93 prov- patterns of both neuromuscular hyperactivity and ides evidence of a relationship between back pain, hypoactivity with a tendency for two main clinical incontinence and respiratory problems, suggesting subgroups. Those they classify as having ‘reduced a common underlying mechanism. force closure’ fairly much equates to the anterior pelvic crossed syndrome group (APXS; see Ch. 9) Pelvic floor and continence while those with ‘excessive force closure’ bear similarity to the mixed syndrome (MS; see Ch.10). Good coordination is required between the pelvic Assessing and redressing joint function and activa- diaphragm (levator ani and coccygeus94) and the tion and control of the fundamental pelvic move- urogenital diaphragm as the floor may need to open ments and functional patterns generally ensures spatially in movement such as the dancer’s high kick, symptom amelioration. while the sphincters remain closed. Pelvic posturomo- tor control dysfunction is likely to have consequences Postural asymmetry of the pelvis for the continence mechanism.34 When the pelvic floor muscles (PFM) lose their automatic coordinated Clinically this is quite common87,88 even in chil- function, it is the timing of muscle recruitment, as well dren, where Lewit found approximately 40% preva- as the endurance and strength which is deficient95 and lence in children from nursery school age onwards. activation may be asymmetrical.99 The asymmetry may be directly or indirectly respon- sible for the patient’s symptoms. Lewit87 considers The incidence of stress incontinence is, or appar- that pelvic distortion is always secondary to some ently was, low in Chinese women and cadaver studies other lesion which must be found and treated, have shown better developed levator ani muscle mass atlanto-occipital joint dysfunction being common, when compared to occidentals. This was attributed particularly in children. As Lewit87 describes it: to hard work, minimal obesity and squatting.95 viewed from behind, the pelvis deviates slightly to Altered spatial control of the pelvis and its inclination one side (usually the right) and is slightly rotated affect the gravitational forces acting on the floor33,96 (usually to the left). There is a fixed ‘distorsion’ and the line of pull of the muscles. When habitually where one innominate is anteriorly rotated against forward and posteriorly tilted, postural demand is the other (usually the right) where the PSIS is higher reduced. Increased sustained vertical loading on the and the ipsilateral ASIS is lower. Related to this is the PFM and increase stretch weakness is likely.97 ‘overtake’ phenomenon where in forward bending in sitting or standing, the lower PSIS (usually the left) A close functional interrelationship exists between overtakes the other becoming more cranial for about the PFM and the abdominals and co-activation has 20s after which the two spines return to a symmetri- been shown.98 Given the underactivity of the entire cal position. There is usually muscle imbalance in the abdominal wall in some groups reasoning suggests pelvic region and spasm of iliacus is frequent on the probable associated underactivity of the PFM. side of the lower PSIS, gluteal muscle bulk and activ- ity is usually asymmetrical as is PFM activity. Clini- An association between uterovaginal collapse and cally, the side of the lower PSIS is usually the decreased lumbar lordosis has been described.99 painful side.88 When torsion is present the leg lengths Similarly, postural collapse has been shown to relate appear unequal.88 to decreased PFM activity.100 Lordosis facilitates activation.57,95,100 Incompetent PFM response to Pelvic floor dysfunction sudden increases in IAP have been observed to be Effective function of the pelvic myofascial floor greater in spinal flexion in both sitting and stand- requires the ability to coordinate the static, ‘open- ing.95 Poor tonic PFM activity is likely if tonic hold- ing’ and ‘closing’ actions appropriate to the com- ing ability in transversus is reduced.33 Carri`ere101 bined situational demands of breathing, continence notes weakness of the PFM can occur from damage and posturomovement control. Much of the interest to the pudendal nerve from heavy falls onto the bot- tom, and if the parasympathetic nerves are also injured, various pain syndromes can also occur. SUI has a general connotation of a ‘weak pelvic floor’ and the need to strengthen it. While low muscle tone, reduced or delayed activity may relate to pro- lapse102 and defective sphincter control,32 subjects 180

Common features of posturomovement dysfunction CHAPTER 8 with SUI can also have EMG-demonstrated tone between the two sides. Local PFM pain from increased activity of all the PFM.57,95 This is related trigger points cleared after 2–5 inspirations which to problems in the coordination and timing of activity focused upon ‘pushing the palpating finger away’. between the abdominals and PFM57,103 The abdomi- Improving diaphragm activity can thus change the nal activity can be either decreased or increased. tonus of the PFM. Clinical correlations between pel- When decreased, the increased PFM activity is prob- vic myo-articular dysfunction, PFM dysfunction and ably more likely in those who attempt to control the thoracolumbar dysfunction are common and treating pelvis by the posterior inferior pelvic force couple either can affect the other.106 The complex innerva- (see Altered control of sagittal pelvic tilt p.173) with tion to the pelvic organs and pelvic floor includes or without buttock clenching and related underactiv- somatic nerve fibres from S234, sympathetic nerves ity of the lower or entire abdominal wall. The obtura- which originate T10 – L2, and parasympathetic sup- tor group is hyperactive and shortened and the pelvic ply originating in spinal segments S2-S4.107 Trigger diaphragm is in the ‘closed’, shortened position and points, altered muscle tone, SUI and various pain hyperactivity more likely. The coccyx becomes syndromes are often associated with disturbed hyperstabilized creating an inferior ‘tether’ of the syn- related spinal segmental function and associated desmosis part of the SIJ which restricts nutation of irritation of the spinal nerve roots supplying that par- the sacrum and the lumbar spine moving into lordosis. ticular pelvic muscle or tissue. The clinical findings When abdominal activity is increased, particularly the of symptomatic segmental dysfunction can extend external oblique,95,103,104 the associated PFM hyper- higher than the thoracolumbar junction and certainly activity may be in response to the increased intra- appears to implicate autonomic contributions to abdominal pressure so created. Retraining diaphrag- PFM dysfunction and symptoms. matic breathing is indicated as a first step.33 The cur- rent fad of inappropriate overtraining the abdominals Pelvic floor and posturomotor control as ‘core muscles’ is compounding a lot of spinopelvic girdle dysfunction syndromes and probably contribut- Because the PFM forms part of the ligamentous/ ing to SUI incidence. Furthermore, there is a sub- myofascial syndesmosis119 contributing to the group of patients with SUI who have diligently mechanics of the sacroiliac joint, their altered length/ performed ‘PFM exercises’ only to experience increas- tension relationships and coordination will affect intra- ing leakage. Freeing the sacrum-coccyx and mastering pelvic alignment and control and moderation of the the 1st fundamental pelvic pattern which opens the dimensions the inferior pelvic bowl. Electrical stimula- floor, coupled with complementary postural advice tion of one side of the PFM demonstrated altered can lead to dramatic improvement in one treatment. pelvic alignment with significant displacement of the coccyx, femur and innominate on the stimulated Importantly, Rock105 draws attention to ‘reflex side.108 During the ASLR test, PFM hypoactivity has incontinence’ whereby changes in PFM tone occur been demonstrated77 while others have reported from reflex changes which occur in response to dis- increased activity.103 Unfortunately many sufferers orders of neuromyo-articular function elsewhere in have been taught to activate the PFM by ‘pull up and the body e.g. functional disorders of the diaphragm in’ in isolation without incorporation into appropriate can result in a reduction in both the elasticity and synergistic and functional patterns of posturomove- strength of the PFM due to diminished eccentric ment control. This risks further imprinting the and concentric contractility respectively. tendency for axial ‘holding patterns’, further disturb- ing motor control in the torso. Pelvic floor and breathing Movement control becomes The close functional synergy between the diaphragm coarser resembling more and PFM is disturbed when diaphragmatic breathing primitive and total flexion/ is compromised and can be further reflected in extension movement patterns altered tone in the pelvic floor.105,106 Chaitow102 draws attention to the effects of PFM trigger points In Chapter 7 we noted features of more primitive which in the main serve to increase PFM tone. movement behavior, which can be variably apparent Rock105 describes a study where external palpation in subjects with spinal pain disorders and this is of the PFM in continent male and female phy- siotherapists found all cases were hypertonic with painful trigger points and clear cut differences in 181

Back Pain: A Movement Problem further explored. Instead of an infinite variety of e.g. computer use; knitting. More total axial flexion adaptable postural sets, and movements, the patient then becomes the postural set for initiating often demonstrates a reduced repertoire, tending to movement such as initial forward weight shift in adopt more primitive and stereotyped postur- sitting in order to stand up. omovement strategies reminiscent of aspects of ear- lier developmental stages and possibly reflecting less • Standing forward flexion frequently becomes a than ideal integration; the early postural reflexes. pattern of ‘more total flexion’ of the trunk and shou- The person tends to posture and move from say a lder girdle with poor pattern break up of hip flexion, pattern of more dominant flexion and will have lumbosacral neutral / and axial extension with upper some difficulty achieving pattern break up into limb girdle posterior engagement and control. The combinations of flexion and extension such as hip person adopts an ‘axial folding pattern’ initiated from flexion with spinal extension. This is associated the centre rather than the hip. (Fig. 8.11) with imbalanced muscle co-activation in the proxi- mal limb girdles with poor regional or general axial • Limb movements also show a total pattern control and patchy SGMS dominance. For example: tendency e.g. hip flexion is generally associated with excess lumbar flexion with loss of control of Flexor pattern influence A common tendency is for both proximal limb gir- dles and the spine to contribute towards more ‘total pattern synergies’ probably as a result of habitual postures and use and perhaps also reflecting devel- opmental aspects e.g: • Habitual sitting postures often reflect a generalized flexion pattern which is maintained by a combination of gross flexor activity and collapse of the whole spine instead of hip flexion with spinal extension in the normal curves (Fig. 8.10). Sustained forward arm use compounds the picture Fig 8.10  Habitual ‘more total flexor’ collapse in sitting. Fig 8.11  Axial folding pattern in forward bending. The 182 patient is 9 years old.

Common features of posturomovement dysfunction CHAPTER 8 Fig 8.13  Tendency to collapse into more total flexion in ‘Allah’ on all fours with marked posterior pelvic rotation and lumbosacral flexion (also see Fig.13.71). Fig 8.12  Hip flexion also becomes lumbar flexion (side bending). the neutral lordosis. Arm flexion is associated with Fig 8.14  Observable more total flexion pattern in all fours excess shoulder girdle flexion. Limb stretches with dominance of ‘pectoral cinch and propping’. become axial flexion (Fig. 8.12) • Supine activities. Care needs to be exercised • When on all fours there is often a tendency when working for activation of transversus as towards posturing in a more total flexion pattern, advocated by Richardson et al.109 not to reinforce either tonus shift or overt posture. This may be the tendency for more total flexion responses with intrinsic (Fig. 8.13) or increased through training increased proximal girdle flexion seen in effect (Fig. 8.14). The pelvis is posteriorly rotated unnecessary pectoral overactivity and posterior on the femora and lumbar spine in relative flexion. pelvic tilt. Asking for weight bearing through the hands will • Many so called ‘hip stretching’ activities become generally be actioned by ‘propping’ through the arms total flexion patterns of both proximal limb girdles with the elbows usually locked in extension. This is and the spine (Fig. 8.8) and/or often involves more a reflection of pectoral and anterior chest general collapse into flexion (Fig. 8.15). muscle ‘flexor lock in’ which does not allow for balanced co-activation of the shoulder girdle needed Extensor pattern influence for good stable weight bearing control. The patient finds it difficult to break up this pattern and achieve While torso flexion patterns can be more ‘total’, proximal girdle control and proper axial alignment extension is patchier but can be ‘mega’ when and with elongation between the head and the tail bone. where it occurs: Similar difficulty maybe encountered in the kneeling alignment and control test (Ch.13). 183

Back Pain: A Movement Problem Fig 8.15  ‘Total flexion’ collapse during stretching. The stretch is in the back rather than the legs. In standing, the patient tends to adopt a more Fig 8.16  Locking the legs and ‘hanging’. total extension pattern in the lower limb locking the knees into extension with a disinclination for flexible control between the ankles, knees pelvis– hip36 (Fig. 8.16). This is particularly so if the pelvis is carried forward and/or he ‘butt grips’ (see Ch.10). Janda110 likened the subtle changes which are seen, to the more obligatory synergies seen in lesions of the upper motor neuron – for example, movements of the upper limb tend to favor over activation of the flexors and internal rotators and those of the lower limb the extensors and external rotators and this is clinically apparent. Locking the legs limits postural shifts of the pelvis (see Ch. 6, Part B). In the torso, more patchy yet coarse extensor activity is seen in consistent patterns of cervical hyperextension and especially thoracolumbar exten- sor ‘fixing’ which respectively shunt the chin and the lower rib cage forward. When on all fours, because of poor pelvic con- trol, attempts to anteriorly rotate the pelvis on the femora are generally attempted by a dominant thor- acolumbar strategy (Fig. 8.17). Attempts at hip extension again result in a thoracolumbar fixing or a central posterior cinch (CPC) (see Ch. 10) with movement poorly isolated to the hip joint and asso- ciated poor patterns of axial alignment and control. In prone the hyperactivity in the cervicothoracic and particularly the thoracolumbar extensors is readily apparent e.g. lifting the head results in CPC behavior with little activity in the upper tho- rax to support the movement (Fig. 8.18). Therapist 184

Common features of posturomovement dysfunction CHAPTER 8 Fig 8.17  The same patient as in Fig.8.13 attempting to Fig 8.19  Central posterior cinch activity when entrenched anteriorly rotate the pelvis does so from a dominant central can still prevail when the patient is in the supine ‘relaxed’ posterior cinch strategy. The patient is aged 17. The same position. difficulty is seen in Fig. 9.17. Patterns of upper limb weight bearing can suggest lingering influences from the tonic neck reflexes (see Figs 3.6 & 3.7). Upper limb weight bearing often involves ‘propping’ associated with either hyperex- tension of the head or hanging the head possibly further indicating incomplete integration of the tonic labyrinthine reflex (see Ch. 3) and adequate develop- ment of the Landau reaction. Habitual head forward posturing may also contribute (Fig. 8.20). More primitive control is also seen in the ten- dency for bilateral activation in the limbs. Elements of reduced crossed pattern ability where dissocia- tion between them is required, shows up as diffi- culty in seemingly simple tasks such as flexing one hip while extending the other with a neutral lumbo- pelvic posture or alternate plantar and dorsiflexion. Fig 8.18  Central posterior cinch behavior as a result of lifting the head in prone. Note the ‘dead space’ in activity over the mid thorax. skill is required in directing motor relearning in Fig 8.20  The tendency for retracting the neck or order to counter and not further reinforce these hanging the head on all fours. Notice the different tonus patterns. in the arms in relation to head position. In supine, hyperactivity in the cervicothoracic and thoraco lumbar extensors can be so fixed as to be operative in supine e.g. ASLR test may involve an increase in CPC behavior and cervical hyper- extension. This can even be present at rest (Fig. 8.19) and could partly represent influences from incomplete integration of the tonic labyrin- thine reflex (see Ch. 3). 185

Back Pain: A Movement Problem The person becomes more of what we have Table 8.1 Altered muscle activation patterns in the torso termed a ‘Primary A-P mover’– a rather crude extensor system flexer/extender in posture and movement. He finds it difficult to modulate co-activation of the deep Hyperactive Underactive extensors flexors and extensors to achieve balanced alignment, extensors elongation and discrete movement control of his torso in a multitude of different actions. These reflex • Cervicothoracic • Mid/upper dorsal erector responses resulting in variations in muscle tonus and extensors to T2 spinae T2–7 more obvious flexor/extensor proclivity are subtle • Upper trapezius, • Shoulder girdle medial and yet quite apparent in more loaded situations and levator scapulae lower scapular stabilizers those requiring greater antigravity response, the use • Thoracolumbar • Middle trapezius of effort and upper limb use (See Ch. 7). extensors T8–L2 or so • Lower trapezius þþþ • Rhomboids Importantly, the proclivity for the more bilateral • ?obturator group • Lumbosacral extensors: flexor/extensor response limits use of the lateral including piriformis multifidus significantly underactive and rotary components of movement needed for • Hamstrings in all weight shift and balance and which provide for • Glutei three-dimensional control. Further changed muscle Table 8.2 Altered muscle activation patterns in the torso activation patterns within the flexor system dominant flexor/extensor patterns reduce selective Hyperactive flexors Underactive flexors movement control in the torso and affect alignment • Sternocleidomastoid • Craniocervical/deep neck • Scaleni flexors Underactivity in the deep systemic system and • Shoulder girdle flexors: • Whole abdominal wall in altered control of the postural reflex mechanism is pectorals; serratus anterior?; some groups (see PPXS) associated with uneven patterns of torso muscle lateral latissimus dorsi • Lower abdominal wall in activation between the two systems and within the • Upper abdominals in all groups is significantly superficial system which can be further mapped. some subgroups (see APXS, underactive Janda110,111 was the first to clinically observe a ten- Ch.9) • Iliacus underactive in most dency to alternate layers or strata of muscle hyper • Hip flexors: psoas; rectus and psoas in some groups and hypo-activity in the extensor and flexor systems femoris in some subgroups of the body. He termed this the layer or stratification (see PPXS, Ch.9) syndrome (Ch.10). Best seen in the extensor muscle system it is evidenced by changes in the muscle bulk faster, longer and more often, then a number of and contours and changed sequence and particularly the underlying joints are not free to move properly degree of muscle activation. The following classifica- but are functionally ‘straightjacketed’– they become tion of the torso flexor and extensor systems in hyperstabilized. Segmental movement becomes Tables 8.1 and 8.2 is extrapolated from Janda’s clas- limited in one or more planes. Over time this will sification110–112 with some additions, based upon the result in these joints becoming stiff from lack of clinical patterns consistently recognized. variety in their movement repertoire. We start to see regions or ‘blocks’ of stiff segments forming. The imbalanced development between the flex- Movement tends to be shunted into more mobile ors and extensors leads to imbalanced co-activation regions e.g. the lumbar spine. At the same time we in the proximal limb girdles and axial spine. see a consistent pattern of underactivity over the This uneven patterning of torso muscle activity has lumbosacral junction – of both the deep and super- significant consequences for spinal health and well- ficial systems (Figs 8.21 & 8.22). The lumbar spine being. When any of these superficial muscle groups becomes even more vulnerable. The SLMS is gener- e.g. the thoracolumbar extensors, work harder, ally underactive throughout the axial spine and loss 186

Common features of posturomovement dysfunction CHAPTER 8 of SLMS co-activation with uneven superficial mus- cle activity pulls the spine ‘off centre’ creating eccentric loading states and altered stresses through the spine. The person then finds it difficult to get intersegmental movement in the stiff regions, e.g. the thoracic spine while at the same time he finds it hard to control movement in the relatively mobile regions, e.g. lumbar and cervical spines. This is a really important concept to grasp and will be dis- cussed further on in relation to O’Sullivan’s work (see p.188). Imbalanced activity between the two systemic muscle systems occurs in differing proportions Fig 8.21  Posterior view of the Layer Syndrome in standing. It was noted in Ch.7 that there are two basic scenar- ios in the picture of systemic muscle system imbal- Fig 8.22  Layer Syndrome in the prone patient. Even at rest, ance. Both display a reduction in SLMS activity and note dominant neuromuscular activity over the thoracolumbar an increase in SGMS activity although in differing region with ‘emptiness’ over the posterior proximal limb proportions as follows: girdles. • Flexor inclined: here the reduced SLMS system activity is probably more pronounced. These demonstrate more flexion pattern proclivity and their increased extensor SGMS activity is more intermittent. • Extensor inclined: here the increased SGMS extensor activity is more pronounced and constant with still evident decreased SLMS contribution to movement. Both pictures play into the layered patterns of altered torso muscle response and in particular around the central torso we see a significant increase in muscle activity – a dominance of thoracolumbar extensor activity albeit more intermittent in the flexor inclined group. We see a predominance of upper abdominal activity in the flexor inclined groups. When these extensors and flexors are regionally activated it appears that it is more in the manner of a ‘bilateral total response’ pattern – likened to a ‘cinch’ which serves to anchor or somewhat immobilize the thoracolumbar region towards extension or flexion keeping it in a more sagittal orientation. We have termed the regional extensor hyperactivity around the thoracolumbar junc- tion a ‘Central Posterior Cinch’ (CPC); the regional flexor hyperactivity over the lower thorax a ‘Central Anterior Cinch’ (CAC) and when both are hyperac- tive, a ‘Central Conical Cinch’ (CCC) (see Ch.10). During everyday functional activities, the adop- tion of these Central Cinch Patterns (CCPs) will 187

Back Pain: A Movement Problem tend to shunt the movement that should occur in provocative are not avoided, thus subjects maxi- this region more into the lumbar region. At the same mally stress their pain sensitive tissues and are time, we also see a significant reduction in lower unaware of their role in perpetuation of the prob- abdominal and lumbosacral extensor activity across lem. Pain onset is gradual and associated with spe- all groups. Control of the pelvis is diminished and cific functional segmental control deficits and the lumbar spine is under controlled or ‘under pro- more chronic pain states. The non compensations tected’ and becomes more vulnerable still (see for the pain become the mechanism that drives ‘Belted torso syndrome’, Ch.10). the disorder. It becomes apparent then, that in the spinal col- O’Sullivan’s classification rests on a movement umn as a general principle, a pattern emerges where response to pain. However, it is suggested that most there are regions of muscular over control, or spinal pain patients develop their pain because of the hyperstability whereby the underlying joints pre-existing underlying posturomotor problems the become stiffer; and adjacent regions which are nature of which is partly the subject of this book. under controlled or hypostable (or relatively ‘unsta- Spinal pain syndromes are usually a developmental ble’ to use the contemporary parlance). Here, the disorder, and over time as a result of altered muscle joints and soft tissues become more vulnerable to activation patterns and enough attrition to the joints the effects of attrition because of the relatively and soft tissues, pain develops. If it is severe enough excess and changed movement. A plethora of vari- and acute enough splinting behavior is always pres- ous clinical ‘diagnoses’ begin to develop. ent. Inflamed and angry spinal joints effectively facil- itate or inhibit the muscle system. Clinically the local Are movement impairments and SLMS muscles are more prone to inhibition e.g. control impairments co-related? multifidus,117 although not always. Depending upon the stage of disorder and joint irritability, the local While there is increasing evidence that subjects muscles can be in spasm. Those of the SGMS are with chronic low back pain have associated motor more prone to facilitation and hyperactivity in pain control impairments, these are generally seen as a states e.g. lack of flexion relation phenomenon in the response to pain. O’Sullivan113–115 proposes that erector spinae. The presenting stage of disorder again painful movement will be reflected in altered motor becomes a significant element. If the joint problem is control as either adaptive (protective) or maladap- not addressed, the muscle activation patterns risk tive (provocative) responses producing excessive or becoming entrenched and fear of movement, psycho- reduced spinal stability respectively. Adaptive logical sensitization etc all begin to kick in. Once pain behavior serves to splint the injured tissue and is is present it can certainly drive the motor control in synonymous with the pain-spasm-pain model. Van the manner O’Sullivan suggests. However, this is a Die¨en et al116 would argue that this adaptive motor superimposition on underlying defective control. behavior is functional in order to reduce the proba- Clinically, most patients demonstrate a variable bility of noxious tissue stress by limiting range of mixture of both movement and control impairments; motion and providing stabilization of the spine. they exist together, each influencing the other According to O’Sullivan,114,115 the maladaptive and creating the tendency to regions of hyper- movement patterns present as either: stability and hypostability in the spine. A pattern generating mechanism is set in train and will continue ‘Movement impairment’: movements which are in the absence of effective therapeutic interventions painful are avoided and are associated with an exag- which address the underlying pain producing gerated reflex withdrawal motor response, high mechanisms. levels of cocontraction and guarding resulting in high levels of compressive joint loading, muscle Deficient initiation and fatigue hypervigilance and fear of movement. This sequencing of axial rotation appears to fit the acute stage of disorder and severe pain states. He argues that the compensations for It is well acknowledged that most functional activ- the pain become the mechanism that drives the ities require transverse plane motion.118 Rotation disorder. is an important component of all movement, and ‘Control impairments’: more common clini- cally, postures and movements which are pain 188

Common features of posturomovement dysfunction CHAPTER 8 particularly in functional control of the torso. Nor- demands require long hours of head down and mally, it is variously initiated through the eyes and forward postures with related eye hand activities. head and the proximal limb girdles, the movement Neurologically we begin to habituate to these pos- sequencing though the spine – yet in movement tures and ‘forget’ to utilize all the other available dysfunction it is lacking. movement options of which rotation is an important one. In particular, eye movements as initiators of In 1955 Steindler119 wrote ‘we know from clinical head movements are neglected. Conversely the experience that it is particularly the length rotary hunter gatherer is constantly varying his head movements of the trunk which, when blocked in postures to orient his prime organs of sense towards their purpose of carrying through visible motion by survival. an intrinsic rigidity of the body or by external resis- tance, are most apt to lead to structural damage’. Shoulder girdle Clinically, the reduced axial rotation is not con- Most contemporary occupations involve bilateral stant throughout the spine, but observed as too arm use low down in front of the body with a rela- little in some regions and too much in others – both tive paucity of outer spatial reaching actions. This a reflection of inadequate neuromuscular control. leads to common patterns of neuromuscular While the morphology of the cervical and thoracic dysfunction seen in the shoulder girdle with over regions indicates that rotation should be greatest activity and related shortening of the large anterior here, thoracic rotation is universally somewhat woe- SGMS chest muscles with associated underactivity ful, cervical is reduced and the lumbar region is in the shoulder girdle extensors creating a conse- forced into a major role for which it is not suited. quent bias for protraction and depression of the A number of factors play out to adversely affect shoulder girdle in posture and movement. Over rotary control in the torso as follows: time the girdle may lose freedom into elevation, and rotating forwards and particularly backwards • Sahrmann drew attention to the notion of on the thorax. ‘compensatory relative flexibility’ 120 and Janda121 to the Rule of Horizontal Generalization (Ch.7). Limited backward and forward shoulder girdle Both concepts involve the notion that in a rotation control will affect a number of torso segmented structure such as the human functions: musculoskeletal system, if some structure or regions are stiff, then adjacent or further removed • These movements are coupled with structures or regions will be required to intersegmental thoracic rotation and their compensate with a relative increase in movement. limitation also limits movement in the thorax and This concept is evidenced in altered control of vice versa. This compromises the function of the rotation in the torso. upper limb and underpins the genesis of many developmental shoulder problems which are • The combination of passive sagittal collapse and often given the dubious diagnosis of ‘rotator cuff’ coarse more general flexor/extensor synergies in tear, etc. posturomovement and has the effect of shortening and mal aligning the axial spine, limiting spinal • Restricted rotation in the shoulder-thorax unit control to a more sagittal orientation e.g. CPC requires compensatory movement in the cervical behavior holds that region of the spine in more spine above and the lumbar spine below e.g. actions extension limiting flexion, lateral flexion and requiring body patterns of rotation such as hitting a rotation through the thoracolumbar region of the forehand or back hand tennis shot or a golf swing spine. When rotation is required in the system it then become a potential or actual problem for the will generally occur below this hyperstabilized low back and neck. region – the mid-low lumbar levels. • Reduced shoulder girdle rotation and arm The component parts are examined more closely swing interferes with the natural counter rotation below. between the proximal girdles when walking. Normally, the viscoelastic properties of the Head tissues and the counter rotary oscillation between the girdles affords an energy storing The head initiates rotation from the top of the and releasing mechanism and ensures no one spine. Disturbed axial alignment impedes the rotary structure is continuously loaded such that freedom of the head. Contemporary occupational 189

Back Pain: A Movement Problem walking can be done for a long time.90 The energy junction/pelvic block and associated chronic low load of walking increases while endurance grade L3/4 nerve irritation producing somatic pain decreases. referral syndromes to the knee. This is a common • McGill122 notes the important role of arm swing cause of much non traumatic knee pain and often in assisting counter rotation between the girdles, not recognized as back and or pelvic pain is not nec- which effectively decreases the actual loading essarily a feature. Conversely, the altered pelvic stress in the lumbar spine by up to 10%. myomechanics also helps explain why some people notice increased back pain when they walk. • Latissimus dorsi is an important member of the synergy forming part of the posterior oblique Axial spine muscle sling30,70,82 deemed an important factor in helping stabilize the lumbar spine and pelvis during The flexibility of the spine is crucial to all torso load transfer between the upper and lower body. movement.125 Regions of segmental hyper and When its line of pull is altered and/or its shoulder hypostability interfere with the even sequencing of firing patterns change, the effectiveness of this rotation through the spine. posterior system begins to decrease. Cervical spine Neuromuscular imbalance in the shoulder girdle has far reaching effects through the torso as it impedes The common clinical presentation of the head for- the transference of movement between the upper ward posture creates relative hype flexion of the limb and the spine and interferes with movement joints over the cervicothoracic junction and relative within the whole spine. extension in the joints in the cervicocranial com- plex. Invariably this is associated with a pattern of Pelvic-hip girdle restricted rotation at the C1/2 joint (where 50% of cervical rotation is deemed to occur)126 and The initiation of axial rotation from the base of the restricted movement in the joints over the cervi- spine occurs through pelvic ‘distorsion’ rotating the cothoracic junction. The mid cervical spine then sacrum, the movement then sequencing up the becomes the site of relative flexibility, with rela- spine. Distorsion is part of axial rotation of the pel- tively excess segmental movement. Restriction in vis, a key functional component of many movement the shoulder girdle and upper thoracic spine as patterns. Gracovetsky40 notes: ‘In its elementary noted above compounds the picture of dysfunction. form, human gait can be reduced to rotating the pel- vis in the horizontal plane’. In dysfunction there is Thoracic spine always some reduction in the ability to accomplish forward and particularly backward pelvic rotation Despite anatomy favoring side bending and particu- in the transverse plane. Reduction in the multipla- larly rotation here, clinically, the thoracic spine is nar range and control of hip movements, particu- predictably stiff in these movements with exten- larly the deep hip rotators is an important factor in sion. Posterior or anterior translation can also be limiting transverse plane pelvic rotation. Experi- reduced.127 The axial movement wave is damped mentally fixating the pelvis in the horizontal plane or blocked through the thorax further shunting the has been shown to result in altered gait and exces- movement into the lumbar and cervical regions sive trunk rotation.123 Lumbar spine morphology (Fig. 8.23). renders it less suited to this role. If the sacrum is blocked, so will the lumbosacral junction levels, Fig 8.23  Reduced and uneven rotation through the spine owing to their corresponding functional relation- with evident ‘wind’ over the low lumbar levels. ship. The movement will then tend to occur more around the mid lumbar levels – the lumbar spine again becomes the site of ‘relative flexibility’. This is particularly likely in sports which require repeated rotary actions.124 Grieve88 notes ‘that it is not rare for a sacroiliac problem to be accompa- nied by abnormalities at L3’. Clinically, many of those presenting with knee pain yet minimal local signs, are found to have a functional lumbosacral 190

Common features of posturomovement dysfunction CHAPTER 8 Lumbar spine Reduced use of lateral movements The collective influences of restricted function within the thorax–shoulder girdle, the hip–pelvic Lateral spinal movements are an important feature girdle and over the thoracolumbar junction, and in the development of our patterns of spinal control corresponding inadequate SLMS activity shunts (Ch. 3). They help achieve balance between the the movement into the lumbar spine, particularly flexors and extensors, control of all the sagittal over the mid/low lumbar levels. Caution needs to curves while lengthening the side of the body cylin- be exercised in the manner of guiding improved der for frontal plane weight shift. Gracovetsky136 torso rotation as the patient will tend to reflexley suggests the phylogenetic importance of lateral initiate the action through ‘central cinch’ strategies bending and its role in coupled motion of the spine ‘wringing the waist’, limiting the diaphragm and helping drive axial rotation of the spine and pelvis. requiring the lumbar spine to further accommodate the movement. The tendency for more predominant postur- omovements in the sagittal plane including ‘fixing Farfan128 postulated that loss of the lumbar lor- strategies’ from the CCPs means that in general, dosis and excess torsion or rotation of the lumbar spinal pain subjects show disinclination and poor spine were a provocative cause of disc pathology. ability for lateral weight shift/transfer and ‘body He was correct – the low back being forced to half’ activities where the weight bearing occurs unfairly bear the brunt for example in lifting and through one side of the body and the other side is twisting actions because other functional links free to move e.g. in all fours or standing on one in the kinetic chain do not adequately contribute leg. Weight bearing through one side involves adap- to the pattern of movement. However, he also tive ipsilateral eccentric activity in the ‘lateral con- pointed out129 that upright and lifting activities tractile field’137 of the body cylinder to allow were subserved by a strong hip extensor mechanism ‘lengthening the side’, in particular from erector spi- which helped protect the integrity of the lordosis. nae, psoas, quadratus lumborum, lateral latissimus However, somehow the message was lost and the and the anterolateral abdominals. CCP behavior trend in therapeutic advice to patients became to limits this. The difficulty is in both initiating and limit or avoid flexion and rotation activities of the controlling the shift through the pelvic base trunk. This is unrealistic as so many ordinary activ- and allowing adaptive lateral shift through the torso ities of daily living involve aspects of trunk flexion including the thorax (Fig. 8.24). In addition, imbal- and rotation. When thoracic and pelvic postur- ance between the flexors and extensors jeopardizes omovement dysfunctions are addressed, the lumbar able control of the sagittal alignment between tho- spine can align and function more normally, only rax and pelvis with anterior ‘rib shunt’ of the lower having to take its fair share of the movement load pole of the thorax common. (see Ch. 6). Reduced weight shifts over the In more general terms, loss of rotary ability base of support and through makes is difficult to roll over in lying and transition the spine affect equilibrium through postural sets e.g. getting up and down from control the floor. It also compromises the ability for pos- tural adjustments needed in balance control. Being The SLMS (Ch.5) in its role of moderating the nor- able to control rotation through all links in the func- mal postural reflex mechanism is the primary agent tional kinetic chain is necessary for walking. Studies of weight shift and equilibrium control in the body. have shown that people with back pain walk at a Its relative underactivity, the consequent over use slower pace with shorter steps,130,131 with a of more superficial SGMS activity towards the reduced ability to adapt trunk pelvis coordinationto coarse flexor and extensor synergies and the conse- changes in velocity.132 The altered motor control quent reduced ability for lateral and rotary control, showed a more rigid, less flexible pelvis-thorax coordination133,134 which was also less variable and showed irregular movements of the thorax131 and increased fluctuations in dynamic thoracic and pel- vic oscillations.135 191

Back Pain: A Movement Problem Fig 8.24  The patient has been asked to grow the right the limbs (Ch.3). The person’s balance suffers. ‘Falls elbow to the ceiling to facilitate ipsilateral weight shift. Note in the elderly’ become more likely in the future. poor spatial shift through the pelvis and reliance upon central posterior cinch behavior which stops ipsilateral lengthening in Research has variously shown defective equilib- the torso. Note how she also compensates in the neck. rium control in chronic low back pain subjects. In standing, significantly increased anteroposterior serve to limit effective weight shifts over the per- postural sway 138,139 is apparent and more so when son’s base of support and through their proximal combined with task complexity and removal of limb girdles and spine – whatever position they are visual cues.39 The internal perturbation of respira- in. Most spinal pain patients are loathe to shift the tion exerts a greater disturbing effect on standing body over and around the particular base of support. equilibrium in back pain subjects140 with a tendency The base of support is in general poorly ‘grounded’ to less hip motion to counteract the postural distur- with resultant collapse or ‘propping’. Control of bances.141 During bilateral and single leg stance bal- weight shift is control. Weight shifts underpin all ance control tasks, Mok et al.142 found decreased movements of the body and particularly those of ability to initiate and control the anteroposterior hip strategy responses with increased visual depen- dence. Luoto et al.143 found a relationship between impaired psychomotor speed and impaired postural control among females. In another study Luoto et al.144 found a strong relationship between severe low back pain and poor ability to balance on one leg. When standing, it is common for spinal pain sub- jects to adopt a wide base of support and ‘lock in’ with the obturator group/buttock clench. Rather than stand over the legs they stand between them which is much more stable, limiting perturbations to the system which otherwise help to refuel the sensorimotor apparatus (Fig. 8.25). Lack of oppor- tunity and ‘practice’ in equilibrium responses reduces system smartness. If weight shifts and equi- librium are not well integrated – particularly the ability to initiate the shift from and through the base of support, the person will compensate by combina- tions of propping through his limbs, and utilizing collapsing and/or ‘holding’ strategies in his body. Clinically, the ability to control weight shift even in prone and supine is frequently so impressively reduced that some patients find it hard to turn over! Needless to say, subsequent positions such as all fours, kneeling etc. also show poor control. The pelvis is the base of support for the ‘body cylinder’. When upright, the prime centre of weight shift is through the pelvis – of itself in sitting or through the legs when standing. • In sitting. It’s all about what the sit bones do or don’t do – the person’s ability to direct and control how the ischial tuberosities present and change the base of support and so direct movement of the torso. Reduced intra and extra pelvic control makes this more difficult. Doing it improves control. Balanced activity in iliacus-psoas is critical to sagittal and lateral weight shift control. When underactive 192