Back Pain - A Movement Problem by Josephine Key

Common features of posturomovement dysfunction CHAPTER 8 Fig 8.26  This patient does ‘physical culture’ yet cannot weight shift through the pelvis, instead she is trying to do it from higher up. This then also limits appropriate lateral elongation in the torso. The reason is apparent in Figs 8.8, 9.18 & 11.4. Fig 8.25  Despite the fact this person ‘works out’ he finds becoming so prevalent for people to habitually stand it hard to adopt dynamic antigravity postures choosing to this way – just stand on a station platform or any hang between abducted legs. public place and note this – particularly in the young! The deep system becomes rustier from lack the pelvis falls back and the spine collapses. When of demand and disuse. When perturbations do overactive the pelvis tilts forward and the spine is occur, rather than resolving the postural challenge ‘held’ as reduced eccentric lengthening does not let through a flexible torso on a dynamic base of the spine posturally adjust. Attempted weight shifts support, he tends to react by stepping to widen his predictably occur higher up via CCP behavior base of support, stiffening his trunk and grabbing around the mid torso (Fig. 8.26). The spine is not with his arms. Importantly disallowing freedom of free to adjust and breathing is compromised. Axial the ‘ischial swing’ means that capability in the large collapse is not conducive to active weight shifts sagittal pelvic weight shifts needed in bending and either. An inactive base of support for sagittal lifting becomes reduced. weight shift helps explain incidents such as ‘I did my back in when all I was doing was putting on my Lateral weight transfer also suffers. Reduced sagittal shoes!’ control of the ‘ischial swing’ correspondingly limits • In standing. Apart from the wide base of control of lateral weight shift through the pelvis. support through the feet, the person locks their Again iliacus-psoas activity tends to be either inade- knees into extension and habitually positions the quate or increased with predictable effects in the pelvis forward or back from the midline. This spine and pelvis. Unilateral limb activities involve defacilitates active pelvic control and the readiness lateral weight shift whatever the posture. The for balance reactions and weight shifts. It is patient is disinclined to shift his weight onto one leg and if he does, it is usually a passive strategy of lateral pelvic shift and passive ‘hanging’ with the hip in relative adduction. The de-tuned pelvis–hip myomechanics mean actively shifting his weight onto one leg through the pelvis with ‘postural lift’ and flexible control through the kinetic chain is not good. He has to hold himself up from higher up (Figs 8.27 & 8.28). There may be asymmetry in 193

Back Pain: A Movement Problem Fig 8.27  Disability in frontal plane pelvic rotation limits Fig 8.28  Defective control of pelvic rotation in the sagittal lateral weight transfer through the pelvis and creates the need and frontal planes again reduces weight shift through the for compensations higher up. The patient is 21 years old and pelvis and the need for ‘holding strategies’ higher up. complaining of right sacroiliac joint pain. Poor proprioceptive, spatial, kinesthetic awareness the action. Not surprisingly balance on one leg is dif- Effective SLMS activity is dependent upon good ficult and involves sag and grip in the kinetic sys- afference. Reduced perceptual awareness is variably tem. He may move into a slight crouch in an apparent in subjects with spinal pain. In general attempt to lower his centre of gravity and also try their ‘senses’ appear to be less well attuned to and grab and ‘fix’ with his arms to compensate both their intrinsic and extrinsic state. This may through his upper body for that stability and control be due to subtle CNS dysfunction (Ch.7) or sub- which his lower body is not providing. Clinical tests sequently ‘acquired’. This compromises effective such as the Trendelenberg and Gillet may/not test motor planning and control, the appreciation of var- positive.32 Even if the pelvis remains level reduced ious spatial relationships of the limbs to the torso as spatial shift and central cinch behavior shows the well as spatial positioning of the pelvis and torso. poor quality of LPU support. When the postural system is ‘on’, the small oscillat- ing adjustments serve to continually recharge the sys- To recap, poor control of multiplanar weight tem. The adoption of sustained collapsed or ‘held’ shift from the base of support and the adoption of postures subverts the system. Sitting slouched for central cinch patterns stops movement sequencing 5 minutes has been shown to alter lumbar spine through the torso, thus affecting equilibrium. 194

Common features of posturomovement dysfunction CHAPTER 8 therapy’ difficult as the patient ‘thought they were doing it right’ when their performance frequently indicates otherwise. Diminished use of space can mean they ‘have no idea’ how to do an unfamiliar movement (Fig. 8.29). Low back pain research has demonstrated proprio- ceptive deficits in the form of significantly degra- ded lumbosacral position sense in sitting.147,148,149 Similar difficulties with spinal repositioning have been shown in standing and four point kneeling.150 Lumbar fatigue further impairs ability.148 Evidence suggests that reduced sensory feedback particularly diminishes eccentric muscle control151 and is also reflected in dif- ficulties with sustaining antigravity postures, motor impersistence, the ability to selectively move parts of the body, force modulation and fine tuning of move- ments. Movement control becomes more primitive (Ch.7). At times they appear the ‘motor moron’. ‘Sen- sation seekers’ in exercise classes may be trying to redress their deficits. The importance of head control in postural con- trol is frequently overlooked. Sensorimotor distur- bances in neck disorders can affect postural stability, head and eye movement control.152 Previ- ous trauma can wield insidious effects shown by subjects who had suffered QTF grade II whiplash injuries and demonstrated postural control deficits despite not complaining of symptoms, indicating that when postural control disturbances become clinically symptomatic, several subsystems involved with balance control fail.153 Fig 8.29  The same patient in Fig. 8.1 & Fig. 8.10 has been Movement quality reflects asked to move her pelvis back in space in order to bend excess effort and stress/tension forward and instead she initially does what she ‘knows’ which patterns (see Ch. 6, Part A) is to bring it forward and into posterior tilt. While there is generally ‘emptiness’ in the SLMS, reposition sense in pain free subjects,145 thus the muscular patterns of stress, tension and ‘holding’ habitual adoption of collapsed postures in LBP sub- are usually apparent. These are SGMS dominant jects can be expected to significantly limit their abil- and are more active around the centre of the body, ity in appreciating and finding a neutral alignment of the neck jaw and shoulder area. Patients can exhibit the pelvis spine and head. Hyperkyphosis in young signs of hyper-arousal, are often tense, reflexley subjects has been associated with disturbed integra- overactive and find it difficult to ‘let go’ and tion of proprioception and in sensory interaction relax.154 Asking for an action invariably results in which may result in postural instability especially in ‘overkill’ – they have lost the sense of discrete a mediolateral direction.146 The abnormal state is movement. When stress is a chronic event, the perceived as normal which often makes ‘exercise patient tends to posture and move with a strong underlying influence from these patterns. He tends to move in a more gross explosive way, using too much unnecessary effort and breath holding. 195

Back Pain: A Movement Problem He wants to move quickly as he finds sustained low thorax87, hence posterior basal expansion is poor as load from activity of the systemic deep muscles dif- is the postural support from the diaphragm towards ficult to achieve. Grading and modulating the motor patterns of axial stabilization and control response is difficult as he is relying more on the (Fig. 8.30). The thoracic spine shows little or no superficial system whose actions are more characterized by quick, large and strong actions. Underactivity in the SLMS is probably in part due to reduced afferent input.155–157 He does not have much experience of soft sequential pleasur- able and easy movement but instead his postur- omovement control ricochets between collapse and trying too hard with evident superficial muscle activity. Dysfunctional breathing patterns (DBP) emerge (see Ch. 6, Part A) In essence, breathing is altered both in where the Fig 8.30  Internal support and activity from the diaphragm is patient breathes and also how he breathes in terms wanting. of the pattern of breathing, his ability to coordinate breathing with moving and an altered rate and volume. In a study of 38000 women, Smith et al.158 found that disorders of continence and respiration had a stronger association with frequent back pain than obesity and physical activity. Clinically, patients with spinal pain disorders always have some form of DBP – a fact that most are surprised to hear and resistant to embrace. Breathing and movement are inextricably intertwined hence disturbed move- ment control will also be reflected in dysfunctional breathing. Inadequate SLMS control of axial align- ment and the ‘internal cylinder’ means a poor ‘spa- tial ring’ to support effective function of the diaphragm. This is compounded by the adoption of consistently poor sitting postures with passive collapse of the thorax towards the pelvis. Other- wise, active holding via the CCPs serve to restrict the torso and render diaphragmatic descent and consequent basal expansion more difficult. Stiffness within the thorax itself also further hampers dia- phragm activity with related reduced intercostal action. These factors all contribute to the person beginning to display various altered breathing char- acteristics as follows: • Inefficient activity of the diaphragm with consequent reduced opening and widening of the lower pole of the thorax on inspiration159,160 and an inability to breathe into the posterior wall of the 196

Common features of posturomovement dysfunction CHAPTER 8 respiratory wave.87 In fact the breathing wave is Fig 8.31  Reduced activity in the diaphragm is associated reduced throughout the spine and pelvis. with increased use of the accessory breathing muscles and neck tension and pain syndromes. • Lifting of the whole thorax on inspiration is considered by Lewit87,160 to be a most serious the fasciae related to any of the above structures. finding. Imbalance between the primary and Frequently after the primary problem is cleared secondary accessory breathing muscles where the the diaphragm autonomously maintains and secondary predominate results in upper chest continues the asymmetrical tension patterns and breathing and can result in the thorax being abnormal hypertonus created within it interfering chronically held in the inspiratory position.159 In not only the breathing patterns but also with those with insufficient or no activity in the craniosacral system function and freedom of fascial abdominal muscles, the spinal column loses the mobility support from the diaphragm.87 • Respiration can be so badly coordinated that trying to ‘deep breathe’ can instead result in The poor breathing stereotype is thus too much lift- ing and too little widening of the lower pole of the thorax. • Habitual upper chest breathing can be observed at rest, while the subject gasps as they talk or when asking them to inhale. The contours of the sternocleidomastoidei, upper trapezius and scalenii are variably prominent with noticeably increased activity, the upper clavicular grooves are deep and during inspiration the clavicles are lifted too87 (Fig. 8.31). In marked cases of secondary accessory muscle dominance, the scapulae can be seen to protract from pectoral activity. While this method of breathing is a useful short term solution in states of high demand and arousal such as in ‘running away from the tiger’, if habitually adopted in low demand situations it comes with a high energy cost and stresses the cervical and shoulder structures. Upper chest breathing occurs both when there is insufficient abdominal activity to anchor the inferior thorax to provide stability for the diaphragm and in cases of overactivity of the abdominals which disallows proper diaphragm descent. It is common in those who have learned to hold in their abdomen through vanity or fashion161 – as Farhi162 suggests: ‘feeling bad in order to look good’; those who are habitually stressed and anxious,163 or who have over trained their abdominals in the misguided pursuit of ‘core control’. • Upledger53 notes an abnormal state of hypertonus or contracture of the respiratory diaphragm may occur unilaterally or bilaterally as a result of problems with the lower four thoracic nerves and/or the phrenic nerve which collectively innervate the diaphragm. Dysfunction of the diaphragm may also occur secondary to somatic dysfunction which involves the lower six ribs, the sternum, xiphoid, the upper three lumbar vertebrae, psoas, quadratus lumborum and/or 197

Back Pain: A Movement Problem paradoxical breathing where the patient will draw in muscle tension where the patient invariably the abdomen on inspiration and push it out while works against himself –‘central intelligence’ breathing out.87,160 and control is more often than not, fundamentally disturbed. • During movement, an altered breathing rate is frequently adopted at different times in the • The habitual upper chest breathing pattern is following manner: generally associated with hyperventilation syndrome (HVS) or over breathing. Chronic HVS is an • The patient will often initiate a movement insidious condition which may not be readily with a ‘central cinch’ or breath hold and related central fixing by the global muscles apparent, is more prevalent in females and deemed around the body’s centre in association with responsible for a plethora of medical symptoms165 unnecessary effort which further favors mid- and has been estimated to affect 10% of the upper torso global muscle activation. The American population.166 The altered breathing abdominals are accessory muscles of patterns are caused by physical, environmental, expiration in high respiratory demand behavioral or psychological stimuli which override situations yet are often over employed in low the automatic activity of the respiratory centers demand situations. We have noted that resulting in over breathing at rest161 or where the attempts to control the pelvis are frequently breathing depth and rate are in excess of the attempted by abnormal global system activity metabolic needs.165 This leads to a reduction in the around the body’s centre. This superficial arterial partial pressure of carbon dioxide known as muscle overactivation creates a central hypocapnia. Bradley165 states that hypocapnia ‘squeeze’ effect which hampers diaphragm reduces blood flow to the brain in the order of 2% descent and its valuable contribution in decrease in flow per 1 mm Hg reduction in arterial control of torso stability. Breath holding thus CO2, causing a multitude of symptoms including becomes a compensatory postural control poor concentration and memory lapses, headaches, strategy in the case of deficient SLMS control sympathetic dominance, tingling, paresthesia, which includes the diaphragm. O’Sullivan weakness dizziness, tremor and confusion. Further, et al.77 nicely showed decreased according to Chaitow,167 the evidence points to diaphragmatic excursion, altered breathing breathing pattern disorders (BPD) causing a variety patterns and pelvic floor descent during the of negative psychological, biochemical, neurological ASLR test in subjects with sacroiliac pain. and biomechanical influences and interferences Thompson et al.164 describe the negative effects of global abdominal bracing combined capable of modifying neuromuscular control with an increase in chest wall activity and mechanisms and low back function in general. breath holding, on effective pelvic floor Chaitow166 also includes HVS as causing an function. automatic increase in levels of anxiety and apprehension, affecting balance, heightened pain • Variable increase in breathing rate and volume perception, speeding up of spinal reflexes, increased inappropriate to the level of activity. This is excitability of the corticospinal system, associated with a shorter expiratory phase and hyperirritability of motor and sensory axons, little if no post expiratory pause. This can be changes in serum calcium and magnesium levels and observed when subjects are working out new encouragement of the development of myofascial motor patterns and particularly so when trigger points. Addressing our patient’s breathing redressing movement restrictions in stiff regions or ‘stretching’ tight muscles. They problems will clearly help right many of their ills! often find it difficult to disassociate the action McLaughlin and Goldsmith168 reported a case from the breathing – to organize the dual roles series of 24 patients with low back/pelvic pain who of breathing and movement in a harmonious all showed lower than normal end tidal carbon way. It is widely held that muscular activity is dioxide levels via capnography. Breathing retraining facilitated during inspiration and inhibited improved CO2 levels to normal in all but one during expiration.87 ‘Stretching’ is often patient, as well as improvements in pain, functional accompanied by short inspiratory gasps, activity and breathing with decreased anxiety. breath holding and a general increase in Clinically, the state of chronic hypocapnia appears to create hypertonus in the diaphragm and 198

Common features of posturomovement dysfunction CHAPTER 8 secondary expiratory muscles – the abdominals – from T1 to L2.172 Both somatic and autonomic dys- which can make it very difficult for the subject to function are implicated in many and varied bodily reduce the inspiratory rate and volume during symptoms possibly accounting for a significant pro- breathing retraining. This can be seen on the portion of the complaints presenting to the general capnograph as spikes in diaphragm activity when medical practitioner. Generally, as a basic underly- attempting to lengthen the exhalation and ing functional problem, its role needs to be under- expiratory pause. stood and addressed for effective therapeutic outcomes. Demonstrating the close link between SLMS activ- ity, diaphragmatic breathing and postural stability, Common clinically observed Cumpelik169 describes a pilot study where those features of thoracic dysfunction who were upper chest breathers took longer to help provide a functional working restabilize their posture in response to external per- model turbation than those who were abdominal breathers. Lee173 describes rotational instability of the mid ‘Breathing is the link between motion and emo- thoracic spine after trauma, however in clinical tion’.170 It is important to recognize the potent practice this is a relatively uncommon event. Gener- influence of emotional stress and anxiety on the ally the thorax as a whole is found to be functionally development and maintenance of DBP. However stiff and in time, becomes structurally stiff. The DBP further serve to increase arousal states and a coexistence thoracic stiffness and chronic low back vicious cycle risks being activated. If you don’t pain is clinically known.174 An under active deep breathe well, you can’t move well. If you don’t system, antigravity collapse and imbalanced overac- move well, you can’t breathe well. Lewit87 consid- tivity of the large SGMS muscles attaching to the ers DBP the most disastrous of all faulty patterns thorax, serve to functionally convert it to a ‘dis- and if allowed to remain, may jeopardize any treat- torted semi-rigid barrel’. This means that postural ment of the locomotor system. shifts, selective movement and segmental control within the thorax are reduced. These must be com- Thoracic dysfunction pensated for elsewhere in the spine and usually occur in the cervical and lumbar spine127,171,175 The thoracic spine represents somewhat of an which helps explain the high clinical incidence of enigma in that it comprises the largest region of both lumbar and cervical pain and related syn- the axial spine yet accounts for the smallest propor- dromes in the one patient. Achieving a proper neu- tion of published studies on the spine as a whole.171 tral lumbar and cervical lordosis is difficult. This is probably due to the focus on pain rather than dysfunction as the principal driver of much of the Characteristic changes are apparent and fall into research to date. certain patterns further affecting thoracic and related bio and myomechanics. They are best In general, thoracic musculoskeletal pain com- understood examining the thorax as a whole unit plaints are not disabling, do not significantly occa- as well as regionally. sion absence from work and so are not seen as such a cost burden. Local thoracic joint dysfunction The thorax as a whole. The shape and function is not necessarily highly pain producing, but often of the thorax is partly dependent upon the inherent seen as a relatively unimportant associated com- myomechanics operating through it. The large plaint (‘just’ tightness or stiffness) to another more axioscapular and thoracopelvic muscles have exten- flagrant presenting pain symptom. This ignores the sive rib attachments and if their function changes enormous biomechanical influence of the thorax have the propensity to significantly alter thorax on the functional movement control of the rest of function. In particular the abdominal muscle group the axial spine. Clinically, posturomovement dys- has a significant effect on the lower pole of the tho- function of the thorax is always implicated in some rax as they extend as high as the 5th rib, while the degree to presenting spinal pain syndromes and anterior shoulder girdle muscles significantly affect related disorders including many of those in the the upper pole of the thorax as they extend down upper and lower limb. Thoracic function plays a to the 7th rib with serratus going as low as the 9th large role in healthy function of the autonomic ner- (see Ch.6, Part C). vous system as the sympathetic outflow extends 199

Back Pain: A Movement Problem The more common features can be generally Fig 8.33  A thoracic ‘dome’ is evident when doing the attributed to imbalanced activity between the flexor “Allah” stretch. and extensor systems: • The thorax tends to be spatially postured either extension.171,180 Al-Eisa et al.181 describe an forward or back relative to the pelvis and the line of ‘incidental finding’ of significantly reduced range gravity: of thoracic lateral flexion and axial rotation in LBP subjects! Energy efficient walking requires a • when more anterior, increased activity of derotation between the pelvis and shoulder posterior erector spinae is evident girdle. Normally, most segmental rotation occurs at T6/7182. Gracovetsky40 and Kapandji183 cite a • when more posterior relative to the forward normal study performed by Gregerson and Lucas in (sway) of the pelvis, upper abdominal activity 1967 which impressively shows that this derotation rather than lower is more prevalent. occurs maximally at T7 (Fig. 8.34). The presence of a ‘dome’ limits this movement occurring which must • An increase in the thoracic kyphosis both then be compensated for somewhere else – usually functional and structural (Fig. 8.32) is clinically very the lumbar or cervical spine, which in function are common and strongly influences the alignment of then required to become the site of relative the rest of the spine, patterns of load bearing and flexibility.68 Addressing the dome in management is segmental movement171 and trunk muscle necessary in lessening CCP behavior. forces.176 Hyperkyphosis has been associated with lowered static and dynamic postural stability.146 A ‘dome’ appears to result from and be maintained • Clinically, the patient commonly demonstrates by a combination of factors: a ‘dome’. This describes an increased local kyphosis with stiff reactive segments around T6/7/8 • passive axial collapse and ‘hinging’ between the (Fig. 8.33). While this region represents the apex of upper and lower poles the thoracic curve177,178 it also the functional junction between the upper and lower poles of the • imbalanced activation of the myofascial fan which thorax – the ‘dorsal hinge’ between regions 2 and 3 anchors the shoulder girdle to the thorax (Ch.6, (Ch. 6, Part C). Loading studies in those with an Part C) – increased activity and shortness in the increased kyphosis showed the peak mean flexion anterior chest muscles and moment occurred at T8.176 A significant decrease in the range of thoracic rotation has been shown in • related poor medial scapular and adjacent deep flexion compared with neutral and extended intersegmental muscle activity postures in pain free subjects.179 Mid thoracic hypomobility disorders are the most common • changed muscle activation strategies acting thoracic presentation, the primary movement around the lower pole of the thorax restriction is rotation and to a lesser extent • altered breathing patterns (see Fig. 8.36). Fig 8.32  A thoracic kyphosis effects the alignment of the rest of the spine. 200

Common features of posturomovement dysfunction CHAPTER 8 Axial rotation of the Thoracolumbar Spine Absolute rotation Segmental rotation Shoulder Counter Shoulder T1 Clockwise Clockwise T1 T2 84048 T2 T3 T3 T4 Degrees T4 T5 T5 T6 T6 T7 T7 T8 T8 T9 T9 T10 T10 T11 T11 T12 T12 L1 L1 L2 L2 L3 L3 L4 L4 L5 L5 Pelvis Pelvis 0 1 2 Degrees Fig 8.34  Gregerson and Lucas 40,183 showed that maximal segmental rotation occurred around T7 when walking. Alterations in the spatial and extensive costal attachments from all ribs in movement properties of each region this region and those of the upper ring with some slips also extending down as far as rib 8 or While regional distinctions are somewhat arbitrary, even 10.94 Shortening of these large shoulder functional differences can be observed to commonly girdle protractors and depressors results in the occur: shoulder girdle hanging more down and forward with ‘stretch weakness’68 and a 1. The vertebromanubrial region or ‘upper ring’ drops anteriorly and assumes more vertical reduction in the activity of the lower scapular orientation with less flexibility within it. This stabilizers and associated spinal intrinsics. affects regional segmental function and Balance in the axioscapular force couples is posturomovement control of the head and neck and disturbed. This results in related increased shoulder girdle. activity in the levator scapulae upper trapezii. Szeto et al.184 found increased upper trapezius 2. The vertebrosternal region becomes stiffer. activity preceded the onset of neck and This appears to be a consequence of: shoulder discomfort in keyboard operators and was also associated with increased head neck • sustained static postures involving axial and shoulder flexion angles.185 In a healthy collapse associated with population Crosbie et al.186 found decreased • repetitive bilateral arm use in the forward and upward rotation of the scapula in all planes on down position primarily involves the anterior the dominant side. Scapulothoracic chest muscles being over activated in their neuromyofascial imbalance also limits spinal shortened position. The axial attachments segmental movements, costovertebral of these muscles are significant: pectoralis movements, and movements of the ribs minor attaches to the 3rd – 5th rib (and independent of the scapula and spatial frequently between ribs 2 and 494); pectoralis positioning of the shoulder girdle over the chest major from the medial clavicle, sternum wall. The kyphosis increases and the sternum and ribs 2 – 6 or 7;94 serratus anterior has drops and is recessed. Movements of the 201

Back Pain: A Movement Problem upper limb into elevation, extension and retraction become reduced. Thoracic and shoulder girdle ‘opening’ and movement options are hampered and become the genesis of many shoulder pain syndromes including many of the increasingly prevalent so called ‘rotator cuff’ problems. Together, the two regions above constitute the upper Fig 8.35  Postural collapse and a ‘dome’ can lead to pole of the thorax and when stiff create local pain deformation of the thorax and anterior ‘shunters’ (the photo is syndromes as well as exerting significant biomechan- ical influences on adjacent functionally interdepen- post treatment hence the skin reaction). dent structures. The segmental dysfunction can lead to clinical patterns such as T4 syndrome187 contrib- lower ring of the thorax is diminished ute to headaches and symptoms emanating from (Fig. 8.36B). autonomic irritation simulating visceral disease such as palpitations.188 Reduced adaptive postural adjust- • Overactive antigravity strategies generally involve ments of the vertebrae and ribs within the upper pole hyperactivity in the erector spinae and serratus directly affect load bearing and movements of the posterior inferior with either related underactivity in cervical spine175 and orienting and control of the head the whole abdominal wall or overactivity. on the neck. Cervical pain syndromes are a predict- able consequence. When shoulder stiffness and pain  Abdominal underactivity particularly of upper develop this serves to further limit movements external oblique, results in the anterior ribs in within the upper pole. this region flaring out with a wide infra-sternal angle and more open inferior thoracic outlet 3. The vertebrochondral region begins to show or ‘ring’ which is more oblique and variable deformation of its internal cavity and hyperstabilized posteriorly and hypostabilized external shape due to the combined effects of anteriorly. (Figs 8.36C & 8.37) either passive or overactive antigravity postural strategies and related changed activation patterns of  Abdominal overactivity combined with the thoraco-pelvic muscles. Essentially two main overactivity in the extensors acts to patterns appear to result: ‘squeeze’ or constrict this region including narrowing the infra-sternal angle and • Passive antigravity collapse particularly in especially the lower thoracic aperture. The sitting, results in an increased kyphosis around lower pole of the thorax is hyperstabilized the midpoint of the curve from the ‘dome’ and and becomes more conical in shape. The down through this region to the thoracolumbar ‘body cylinder’ resembles an hourglass. junction. This is associated with the anterior Diaphragmatic descent is really hampered ribs from about the 7th, being shunted forward (Figs 8.36B & 8.38) at around the level of the xiphoid where the strut effect of the sternum terminates. There is a 4. The thoracolumbar junction. Clinically, the recess below the breasts. Observing the lateral importance of segmental dysfunction in this region wall of the thorax, a ‘windswept appearance’ of as a contributor to lumbar pain and a variety of ribs 7–10 can result where their anterior part diffuse pain syndromes 180,189,190,194 cannot almost resemble the ‘shunters’ on the front of a be overestimated. Its functional disturbances and train (Fig. 8.35). The infra-sternal angle is often altered joint kinematics exert a biomechanical narrower and there is also a reduction in the influence over joints in the lumbar spine while pain anterior-posterior volume of the cage. Rotary from here is also usually referred distally and can and lateral movements become even more extend to the low back, buttocks, hip groin, and difficult. Postural collapse and overactivity or lateral thigh.189 Segmental dysfunction in this adaptive shortening of the upper abdominal region is particularly implicated in the really nasty muscles means that diaphragmatic descent is and severe acute back pain presentations including hampered and its postural and respiratory support is reduced. The circumference of the 202

Common features of posturomovement dysfunction CHAPTER 8 Angle of ribs Underactivity in Infero-medial scapula = Tight overactive Ribs the lower scapula stabilisers and adjacent muscles stabilisers spinal intrinsics = Long underactive underactive muscles Intercostal spaces Depressed Anterior chest sternum muscles Dome hyperactive Overactivity and Whole extensor shortness in the Abdominals system relatively anterior chest muscles underactive and upper abdominals under active Hyperactivity in Costal cartilage thoracolumbar extensors A Normal shape of the thorax B Anterior shortening & C Thorax X syndrome posterior lengthening Fig 8.36  The upper and lower poles of the thorax can become differently ‘deformed’ through postural collapse and altered myofascial length / tension relationships. Both scenarios explain the development of a ‘dome’. Fig 8.37  Open lower anterior pole of the thorax. primarily posterior facet joint degeneration (Fig. 8.39). those with a trunk list. The region is vulnerable to both compressive and torsional forces and in Collapsed sitting postures place a lot of imbalanced particular T12 as it checks and marries rotation compression loading on these levels. Clinically, in the thorax above with a relative lack of it below regional erector spinae hyperactivity is usual. This in the lumbar spine. Singer180 and Stokes182 probably results for two reasons. Local or regional describe a study by Malmivarra et al. which found joint dysfunction will result in ‘firing up’ the adjacent particular patterns of degenerative pathologies muscles and those which receive innervation from through the region no doubt in response to the these segments. Secondly, the habitual strategies loading stresses incurred at each level: at T10/11 adopted in posturomovement control act to further there was primarily anterior degeneration hyperstabilize the region. Depending upon the pro- characterized by disc degeneration, vertebral body clivity for flexor or extensor system dominance, the osteophytosis and Schmorl’s nodes; the T11/12 region is functionally ‘held’ or hyperstabilized in more segment showed both anterior and posterior flexion or extension or ‘straight-jacketed’ between degeneration involving the facet and costovertebral both. The joints become more symptomatic and a joints; while the T12/L1 level was characterized by vicious self generating cycle is set in train. Regions 3 and 4 together constitute the lower pole of the thorax. While selective movement con- trol is deficient within this region it is also subject to external deformation as it compensates for inade- quate movement in the upper pole. This is appre- ciated when trying to move or stretch the shoulders towards their end range which invariably results in a reflex SGMS dominant ‘cinch’ of mus- cles acting around the lower pole posteriorly, ante- riorly or both. This central ‘cinch’ also occurs in response to inadequate lumbopelvic control further splinting the thorax and serving to increase the load on lumbar segments. 203

Back Pain: A Movement Problem T10 T11 T12 L1 Degeneration Least Moderate Severe Fig 8.38  Closed lower anterior pole of the thorax. Fig 8.39  Pattern of segmental degeneration over thoracolumbar levels. A schematic depiction of the transition Disturbance in the form and function of the lower (arrow) in degeneration from anterior elements at T10, to a pole from an over reliance on various SGMS domi- posterior element pattern of degeneration at T12–L1. Vertebral nant cinching, gripping holding and fixing strategies body osteophytes and disk degeneration were more prevalent in in the mid torso compromises important functions: the T10–T11 and T11–T12 levels, in contrast with costovertebral • the central postural support and respiratory role joint reactive changes which was least at T12–L1, where the of the breathing mechanism zygapophysical joints acted to constrain torsion. • alignment of the body wall and ‘core’ central stability mechanisms including IAP Largely, the movement restrictions within the thorax • connecting and sequencing movements between tend to render it a functional ‘carapace’ and to com- the upper and lower pole of the body cylinder pensate, the patient is further obliged to employ var- including that between the limbs iable increased global muscle activity around the • equilibrium responses and weight shift through thoracolumbar junction as he attempts to control the torso. Importantly the bilateral ‘cinch’ responses movements of the upper torso and limb girdle; the limit lateral bending and lateral weight shift and ‘thoracic barrel’ on the lumbar spine; while at the segmental adjustments through the region same time trying to control the pelvis in space. This • lower limb function is compromised because of helps explain why treating and improving function poor adaptive support for control of the in the thorax deloads the lumbar spine and usually lumbopelvic complex – lumbar, hip and lower limb contributes towards pain relief. pain syndromes are a predictable consequence. Biomechanical and articular changes become predictable over time Dysfunctional posturomovement control creates predictable changes in skeletal alignment and func- tion over time. Sagittal plane postural collapse is probably the most pernicious influence: 204

Common features of posturomovement dysfunction CHAPTER 8 Change in the normal physiological spinal curves Altered pelvic position; reduced lumbar lordosis; Fig 8.41  Functionally, when the thoracic spine becomes a increased thoracic kyphosis; altered alignment of ‘block’ the lumbar spine becomes more of a ‘hinge’ in the head and neck and shoulder girdle eventually function. become apparent. Depending upon the stage of dis- order, functional problems become structural and mobile segment(s) act like ‘hinges’ in posture and begin to mutually reinforce one another. Altered movement (Fig. 8.41). They feed off one another. loading stress on the joints and soft tissues predict- Inadequate deep system and regional control means ably lead to neural irritation and pain syndromes. the patient finds it difficult to get movement into the stiff regions and he can’t adequately control General/regional loss of extension the relatively mobile segments or regions. This cre- through spine ates further compensations up and down the spine. Clinically, symptomatic joints occur in both the stiff Most of our activities are axial flexor pattern domi- regions and the relatively over mobile regions. nant and extension loss is significant in spinal pain disorders. This is particularly prevalent in the tho- This phenomenon plays out in many clinical pre- racic spine and while the cervical and lumbar spines sentations e.g. ‘spinal stenosis’ where segments are required to compensate, they too generally show become symptomatic because of the abnormal load- reduced passive and active intersegmental move- ing stress placed upon them over time. Frequently ment into extension. Protocols advocated by patients are ill advised to avoid extension and McKenzie191,192 partly address this aspect. Consis- undertake passive flexion maneuvers which only tently adopted flexed postures can so stretch the serve to further bother levels which are already superficial tissues that when assuming an extended struggling and iatrogenic perpetuation of the prob- position there is puckering of the tissues lem. Gaining function, in particular extension, (Fig. 8.40). One can easily guess the joint problems! rotation and side bending through the kinetic chain - through the thorax, and hip/pelvis/lumbosacral The development of functional junction and the symptomatic levels usually amelio- ‘hinges’ and ‘blocks’ rates symptoms despite significant radiological changes. (Fig. 8.42) Regions of segmental stiffness can act like ‘blocks’, while the abnormally, relatively flexible/hyper Clinically observed and found regions of stiffness Fig 8.40  Simple observation reveals a lot about this Stiffness is a general feature, however some regions person’s potential or actual joint problems. are consistently found to be more hypomobile and so in function, shunt the movement responsibility to adjacent structures creating regions of compensa- tory relative flexibility.68 Sahrmann also coined the term ‘directional susceptibility to movement’ if this compensatory movement or applied stress is in a consistent specific direction.68 Both are exemplified in the tendency for the lumbar spine to flex early in 205

Back Pain: A Movement Problem Fig 8.42  This physician was diagnosed with spinal stenosis The junctional regions and told to avoid extension! He had been doing ‘flexion exercises’. He could not walk the length of a ward to do his Ideally the line of gravity passes through each of rounds. Restoring intersegmental movement into ‘closing these regions, but when spinal alignment and patterns’ and addressing ‘function around the junctions’, control changes, these transitional regions are particularly the lumbosacral, allowed him to walk 8km without more vulnerable and prone to develop hypomo- pain 10 days after presentation. bility. Experienced practitioners note problems in these regions.87,190 In general, there is an movement relative to the hip and thoracic spine. altered flexion/extension relationship and a signifi- Sahrmann believed that the site of compensatory cant loss of rotation and side bending through the movement was the site of pain. However, this junctions. By and large, all clinical presentations author would argue than in respect to the spine can be found have some ‘defective function in the while this may be so, it is certainly not necessarily junction(s)’ which produces compensations in adja- so. For instance pain felt over the mid lumbar spine cent functional segments or regions e.g. cervical may emanate from T12/L1 or higher. We are never and lumbar spines, shoulders etc. Sahrmann193 absolved from the responsibility to fully assess all reminds us to consider ‘what are the sources, and structures. what are the causes of the pain’– the ‘criminals’ and the ‘victims’. Thoracic spine and rib cage • Craniocervical junction – C0/1/2/3 – is To generalize, the common findings include a var- complex biomechanically and has an important iable segmental and regional reduction of mobility functional role in mediating postural tone into extension, rotation and side bending, the throughout the body. The most common articular presence of a ‘dome’ and related myofascial restrictions are reduced flexion/extension (0/1); tightness. rotation (1/2); side bending (2/3). • Cervicothoracic junction – C7/T1/2 and ribs 1 and 2 – most commonly lose extension (widow’s hump); rotation and side bending in these levels. • The dome – T/6/7/8. While not strictly a junction as described, it is clinically significant with a common loss of extension, rotation and side bending. • Thoracolumbar junction – T10/11/12 /L1/2 – usually hyper stabilized which can be in flexion, neutral or extension; variable loss of flexion, extension, and notable loss of rotation, lateral shift / side bending. In particular, T12 is a segment of frequent dysfunction.189,194 Dysfunction in various of these levels can refer to the abdomen hip and pubis195 as well as the groin, scrotum and into the leg. • Lumbosacral junction – L5 and sacrum are closely linked to sacroiliac function. Clinically most lumbopelvic pain disorders are associated with some loss of extension and ‘swivel’ between L5/S1 with related loss of freedom in sacral nutation and torsion. Note three of the five junctional regions relate to the thorax. A cervical or lumbar problem will usually show local and regional neuromuscular dysfunction with attendant symptomatic joint restrictions at the superior and inferior junction, although usually one will be dominant. 206

Common features of posturomovement dysfunction CHAPTER 8 Intrapelvic joints: principally sacroiliac common and has been described as Hip-Spine Syn- joint drome.197 However, restriction in the hip is usually sub-clinical and painless yet exerts significant bio- While cases of sacroiliac instability occur, these are mechanical effects upon the sacroiliac and lumbar usually related to trauma or post partum. The bio- joints because of their close functional interdepen- mechanical effects of a stiff sacroiliac are clinically dence. Commonly the hips show restriction into compelling. In most ‘developmental’ back pain syn- flexion, internal rotation and extension. The func- dromes, it is common to find a somewhat counter- tional interrelationship between low back pain and nutated sacrum with reduced mobility which may/ hip dysfunction has increasing recognition.198,199 not be stuck in torsion and related contrarotation Recurrent lateral hip pain and conditions such as of the innominates. trochanteric bursitis have been correlated with lum- bar degenerative disease.200 Early intraarticular hip The large ball and socket joints are disease may present with similar symptoms to that often the criminals of posterior pelvic pain attributable to SIJ dysfunc- tion201 or referred from the lumbar spine. McGill202 The importance of the shoulder and hip joints in states ‘sufficient hip and knee flexibility is imperative providing the biggest source of rotation in the body in sparing the spine excessive motion during tasks of and allowing multiplanar movements in all three daily living’. Forward bending studies have found dimensions is generally not appreciated. However, altered patterns of flexion motion with reduced hip they are always stiff in varying degrees in those with motion and increased lumbar motion.203–206 Positive spinal pain and related disorders and require correlations were found between loss of hip internal compensations which significantly impact upon pos- rotation lumbar extension and back pain in a cohort turomovement control of the torso. A pattern gen- of professional golfers.207 Associations between erating cycle appears to prevail: changed shoulder/ reduced hip internal rotation and low back pain have hip function requires compensations in the spine. been found65,208 as have decreased passive hip exten- Over time, segmental irritation begins to occur sion mobility.209,210 Subjects with unilateral sacroil- and further affects change in the facilitation /inhibi- iac dysfunction had significantly more external tion of muscles controlling these large joints. This than internal rotation of the hip on the side of the may not include somatic pain referral. The stiffer posterior innominate.65 Artificially increasing hip the hip/shoulder, the more the axial stress and so stiffness in normal subjects caused profound changes on. Habitual provocative movement strategies in the profile of trunk movements and balance become further modified and so the dysfunction control.211 becomes more entrenched. The increasing amount of hip and shoulder surgery attests to the extent The lower kinetic chain of the dysfunction in contemporary sedentary society. The legs need both flexibility and strength in order to provide an adaptable yet stable base from which Shoulder stiffness not only changes cervical and pelvic control can be executed. While there is often thoracic and kinematics but ipso facto through its joint restriction in the hip and ankle, the stiffness in affect upon the thorax also significantly impinges the lower kinetic chain is more ‘neural pattern rust- on proper function in the low back. Many cannot iness’. Generally the feet resemble dead little pad- even elevate their arms above their head and dles with poor intrinsic myomechanics, stiffness of attempts to do so invariably result in compensatory the ankle joints and imbalance in the mediolateral cervical movements and thoracolumbar cinching stirrup between peroneus longus and tibialis poste- strategies which affect the lumbar spine (Fig. 4.5). rior. The common habit of standing with the legs Clinically one also finds an impressive incidence of abducted, externally rotated with hyperextended coexisting shoulder and low back pain syndromes. knees and hips mean the feet tend to pronate with When large shoulder girdle muscles such as latissimus collapse of the medial arch. There is poor grounding and serratus are tight, adaptive lengthening of the through the feet to provide and active base of sup- lateral body wall is compromised affecting standing port. This is particularly evident through the heel on one leg and reach patterns. where reduced push from here affects the ability to direct and control movement from the ischia. Rolf196 stated ‘it is impossible to overemphasize the importance of a free hip joint’. The clinical inci- dence of concurrent hip and spine symptoms is 207

Back Pain: A Movement Problem Dynamic control of closed chain hip, knee and ankle The prime role of the lower unit is weight flexion is difficult. Trussing the feet up in orthotics support, groundedness through the feet and the further robs the SLMS of the valuable propriocep- crucial role of weight shift which centers the body tive and kinesthetic inputs that would otherwise at any moment and provides an anchor for the help to fire it up. upper unit. The pelvis houses the centre of gravity in the body and is fundamentally the base of The brain weight support.51 While this may appear a fatuous inclusion it is actu- The upper unit contains our principal organs of ally the heart of the problem and the most complex perception and its principal role is manipulative and difficult to change. Feldenkrais212 said ‘the and communicative. Nowadays, man has become stiffness is only in the head’ – our brains are stiff absorbed with the upper unit in intellectual pursuits to change. Posturomovement control is largely and in the development of skill of hand and reflex and automatic with the option for voluntary speech;51 the brain and the hands have become control. Habitual patterns of response become the most predominant ‘workers’.213 Work generally ingrained and require focus, perceptual awareness happens in sitting and function changes. application and determination to change them. Whether psychological, emotional or physical, ‘old In people with back pain and poor movement habits, habits die hard’. Knowing what the bad habit is the lower unit is underactive. They show a distinct dis- and its deleterious effect to ones being is the first inclination and disability in effectively controlling their task. However, making change is more difficult pelvis for physiological support and weight shift. This but necessary if sustained improvement is to occur: includes loading the lower limb in patterns of flexion. ‘You can’t fix the problem with the same bad habits Conversely the upper unit is overactive and the arms that created it’. are used more for antigravity support, and grab to regain balance. The ‘centre’ has become maladaptive and the Role reversal in aspects of sense of power has been transferred from the base to upper and lower body function the top of his structure. As Todd51 says: ‘to a great extent he has also lost both the fine sensory capacity Bartenieff125 describes ‘distinctively diverse roles’ of the animal and its control of power centered in between the upper and lower body which when the lower spinal and pelvic muscles . . . the crouch integrated into one unit, provide for effective move- muscles which should still be employed for spring or ment function. take off and for shock absorption’. This is readily appar- ent – even in a yoga class! It inevitably leads to an over reliance on ‘pushing down’ with the arms when ‘coming up’ from sitting or from the floor. We need to truly find and stand on our own two feet! References [1] O’Sullivan PB, et al. The effect of response of transverse abdominis [7] Callaghan JP, Dunk NM. different standing and sitting and internal oblique muscles to Examination of flexion relaxation postures on trunk muscle activity different postures. Man Ther phenomenon in erector spinae in a pain free population. Spine 2006;11:54–60. during short duration slump 2002;27(11):1238–44. sitting. Clin Biomech 2002;17 [5] Snijders CJ, et al. Biomechanics (5):353–60. [2] O’Sullivan PB, et al. Evaluation of of the interface between spine flexion relaxation phenomenon of and pelvis in different postures. [8] O’Sullivan P, et al. Trunk the trunk muscles in sitting. Spine In: Vleeming A, et al., editors. kinematics and EMG during static 2006;31(17):2009–16. Movement, stability and low back and dynamic sitting. In: Proc. 5th pain: the essential role of the Interdisciplinary World Congress [3] O’Sullivan PB, et al. Effect of pelvis. New York: Churchill on Low Back and Pelvic Pain. different upright sitting postures Livingstone; 1997. p. 103–13. Melbourne; 2004. on spinal-pelvic curvature and trunk muscle activation in a pain [6] Dolan P, Adams MA, Mutton WC. [9] Gallagher S, et al. Torso flexion free population. Spine 2006;31 Commonly adopted postures and loads and the fatigue failure of (19):E707–12. their effect on the lumbar spine. human lumbosacral motion Spine 1988;13(2):197–201. segments. Spine 2005;30 [4] Ainscough–Potts AM, (20):2265–73. Morrissey MC, Critchley D. The 208

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Chapter Nine 9 The two primary patterns of torso dysfunction Altered function in the posturomovement system is dysfunction is central to the approach of this model observable in the manner in which we relate to grav- and is one shared by Sahrmann,2,3 O’Sullivan,4,5 ity. The pelvis, in housing the centre of gravity of and Dankaerts et al.6 Based upon this premise, the body plays a central role in posturomovement those authors have argued for a clinical classification control and its position when standing is the key system to assist in the diagnosis and management to good or faulty postural alignment.1 Small shifts of chronic non specific low back pain disorders can exert significant changes throughout the body. (CNSLBPD). They advocate classification into clinical subgroups which are determined by ‘the While each person with back pain has an individ- alignment, stress, or movement direction that most ual presentation; in general, the altered neuromus- consistently reproduces pain.3 When the mecha- cular responses fall into certain predictable, nism or cause of a disorder is known treatment of common patterns of response which can be distilled the cause is usually considered more effective.6 into the two primary pictures of torso dysfunction. These are characterized by a changed sagittal plane Sahrmann3 arrived at five diagnostic categories spatial position of the pelvis in standing and for CNSLBP based upon the direction of movement corresponding alterations in the postural alignment causing the pain, which in order of her observed fre- of the body in relation to the line of gravity (see quency are: Ch. 8). They afford a simple clinical classification system and underlie a working model or paradigm • rotation–extension to help understand the development and perpetua- tion of posturomovement disorders responsible for • extension many musculoskeletal pain syndromes. Before examining these two proposed primary patterns • rotation more closely, it is useful to consider clinical classifi- cation systems suggested by other authors. • rotation–flexion The case for a clinical • flexion syndromes. classification based upon underlying motor control Sahrmann says: ‘The diagnosis is designed to direct impairments the intervention. The primary strategy for an inter- vention program is eliminating the alignment stress The premise that impairments in the way people or movement in the symptom producing direction. posture and move are the underlying factor driving The program does not emphasize movement in the the patient’s presenting musculoskeletal pain and opposite direction, except where the alignment impairment is excessive’.3 Similarly, O’Sullivan7,8 and Dankaerts et al.,6 no doubt influenced by Sahrmann, suggest a mecha- nism based classification in the diagnosis and treat- ment of CNSLBPD. They also proposed five distinct yet different clinical patterns based upon a specific direction of motor control impairment which

Back Pain: A Movement Problem aggravated the pain, and the hypothesized mecha- This author concurs with O’Sullivan’s three broad nism underlying the pain disorder6. These patterns subgroups and that maladaptive movement patterns were originally described by O’Sullivan in relation are responsible for chronic abnormal tissue loading to ‘instability’ of the lumbar spine:7,8 and ongoing pain. However, this author considers that movement and control impairments are not nec- • flexion pattern – this appears to be most essarily exclusive, but generally co-exist in some common pattern8 measure, albeit with one dominating, depending upon the subgroup classification to be presented in • lateral shift pattern this chapter (see also Ch. 8). The patterns of altered neuromuscular response (movement impairments) • active extension pattern may well be the heightened responses of chronically dysfunctional movement pattern behavior and indic- • passive extension pattern ative of the severity of pain, tissue irritability as well as the stage of the disorder. It is suggested that clini- • multidirectional pattern. cally, symptom reproduction with movement is not O’Sullivan4,5 further elaborated his classification necessarily always achieved nor a reliable guide to based upon the mechanism underlying the disorder, the underlying reason why that person’s movement proposing that three broad subgroups of NSCLBP problems have developed and are further feeding disorders exist. The directional patterns appear to his pain picture. Nor is it necessarily always desirable be a subgroup of Group 3. to reproduce the pain as the testing in doing so can be potentially very provocative. 1. In this group, the underlying pathological processes drive the pain and the patient’s motor This proposed model, while resonant with O’Sulli- responses are secondary and adaptive to this, van’s work, offers a somewhat different view around e.g. inflammatory pain disorders, severe the notion that maladaptive movement patterns result structural disorders, neuropathic or centrally in chronic abnormal tissue loading and ongoing pain. mediated pain. Rather than rely upon symptom provocation, it offers a simple clinical classification system which initially 2. In this, a dominance of psychological and/or relies upon observation of the quality of movement. social factors represents the primary mechanism Concerned with basic function, it delineates the more underlying the disorder. Altered central processing, common postural and related movement impairments and amplification of pain result in disordered which appear to constitute the underlying mechanism movement and motor dysfunction. The patient’s responsible for the development and perpetuation of coping and motor control strategies are maladaptive most axial and related pain syndromes including those in nature. of the lumbopelvic region. It would appear that there is an inherent tendency for these maladaptive motor 3. In this large group, maladaptive movement responses to develop in us all under certain conditions. patterns result in chronic abnormal tissue loading Various elements can be fairly consistently observed in and ongoing pain. They present in either of two the young and old, from the elite sportsman, yoga ways: practitioner to the office worker and the ‘couch potato’. The maladaptive responses are just more • Movement impairments characterized by numerous, developed and obvious in people with frank avoidant pain behavior associated with a loss musculoskeletal pain disorders. of normal physiological lumbopelvic mobility in the direction of pain. They present with Appreciating the features of the model as out- abnormally high levels of muscle guarding and lined not only provides a clinical classification but cocontraction of the lumbopelvic muscles and also guides the assessment process and provides a fear of movement. The neuromuscular functional diagnosis based on the pattern of neuro- splinting and pain avoidance behavior is myoarticular dysfunction responsible for the pain considered to be the mechanism which drives disorder. It also provides predictive and preventa- the pain. tive insights – the presenting symptom picture usually being an acute or subacute episode on a • Control impairments demonstrate no variable picture of underlying neuromusculoskeletal impairment to mobility of the symptomatic dysfunction at various stages of disorder. spinal segment in the direction of pain provocation. This is associated with inability to effectively control the neutral zone. The pain provocation behavior is considered to represent the mechanism driving ongoing symptoms. 218

The two primary patterns of torso dysfunction CHAPTER 9 The two primary pictures Roussouly et al.12 comment ‘the majority of of torso dysfunction degenerative disease occurs in spines that are well aligned in the coronal plane but exhibit highly Observing the habitual standing posture provides a variable morphology in the sagittal plane’. They per- convenient ‘road map’ of the way in which the patient formed a significant radiographic study examining has adaptively organized herself against gravity. the sagittal alignment of the lumbar spine in a cohort of 160 asymptomatic subjects. They found In the sagittal view optimal posturomotor control that ‘normal’ varied, and classified these variations has the pelvis balanced within the line of gravity, into four groups. These subgroups resonate well but when disturbed, the pelvis is postured either with clinical impressions and so the features of each more anteriorly or posteriorly from the line of are described: gravity (Fig. 9.1 & also Fig. 8.4). • Type 1 lordosis. The sacral slope is less than This constitutes the basis of the two primary pic- 35; the apex of the lordosis is centered in the tures of dysfunction – the pelvic crossed syndromes. middle of the L5 body; the lower arc of lordosis is When pelvic alignment changes so do the spinal minimal decreasing toward zero as the sacral slope curves in a predictable fashion. The thoracolumbar approaches horizontal; the inflection point junction is considered the inflexion point between (transition between the upper kyphosis and lumbar the thoracic kyphosis and the lumbar lordosis and lordosis) is low and posterior creating a short through which the line of gravity passes.9 Its posi- lordosis with a negative lordosis tilt angle; the upper tion has a marked effect on the distribution of the spine has a significant kyphosis of the intersegmental rotations of the lumbar vertebrae thoracolumbar junction and thorax (Fig. 9.2). and upon the magnitude of the sagittal moments • Type 2 lordosis. The sacral slope is less than 35; carried by the passive spine.10 When more anterior, the apex of the lordosis is located at the base of the a constant extension torque ensues; when more pos- L4 body; the lower arc of the lordosis is relatively terior, a flexion torque results.11 flat; the inflection point is higher and more anterior decreasing the lordosis tilt angle but increasing the Logf Logf Logf number of vertebral bodies included in the lordosis; the entire spine is relatively hypolordotic and A posterior pelvis/ ‘Neutral’ An anterior pelvis/ hypokyphotic. anterior thorax tends flexor/extensor posterior thorax tends • Type 3 lordosis. The sacral slope is between 35 to extensor dominence to flexor dominence and 45; the apex of the lumbar lordosis is in the balance centre of the L4 body; the lower arc of the lordosis is more prominent; the inflection point is at Fig 9.1  Schematic sagittal view: altered pelvic position the thoracolumbar junction and the lordosis tilt influences the body’s neuromuscular response to the angle is nearly zero; an average of four vertebrae gravitational ‘line of force’. constitutes the arc of the lordosis. The spine is well balanced. • Type 4 lordosis. The sacral slope is greater than 45; the apex of the lordosis is located at the base of the L3 vertebra or higher; the lower arc of the lordosis is prominent and the lordosis tilt angle is zero or positive; the number of vertebrae in lordotic orientation is greater than 5; a state of segmental hyperextension exists. While demonstrating that sagittal alignment ‘nor- mally’ varies significantly, the authors found the least common was Type 2 and the most common was Type 3 (construed as normal); where the apex of the lordosis was located on average in the centre of the L4 body. They also confirmed that the characteristics of the lumbar lordosis are most 219

Back Pain: A Movement Problem Lordosis tilt angle Type 1 L1 Thoracic Upper arc of lordosis kyphosis Apex Lower arc of lordosis Sacral slope Inflection point Upper arc of lordosis Type 2 Lordosis tilt angle apex L1 Lordosis tilt angle Upper arc of lordosis Lower arc of lordosis Sacral slope Apex Lower arc of lordosis Sacral slope Type 3 Type 4 Lordosis L1 Lordosis L1 tilt angle tilt angle Upper arc of lordosis Upper arc of lordosis Lower arc of lordosis Apex Apex Lower arc of lordosis Sacral slope Sacral slope Fig 9.2  The four lordosis types according to Roussouly et al. 2005. Change in the sacral slope effects reciprocal change in the lordosis. 220

The two primary patterns of torso dysfunction CHAPTER 9 dependent on the orientation of the sacral slope and however it often underlies a Mixed Syndrome the pelvis. They comment that there appears to be presentation (see Ch. 10). It resembles a ‘kyphosis- an association between loss of lordosis and an ante- lordosis posture.1 rior shift of the vertical axis and the development • Anterior Pelvic Crossed Syndrome (APXS). of symptomatic back pain. Further, they comment This appears to be the more common presentation that they have noticed that patients with symptom- within this author’s clinical practice population atic disc herniations are most commonly classified either as the pure form or underlying the mixed as Type 1or 2; patients with spinal stenosis are most syndrome (see Ch. 10). It resembles a ‘sway-back commonly classified as type 4 and that they rarely posture’.1 see patients with significant complaints who are classified as Type 3! A further study13 compared These two syndromes form the basis of a proposed the native sagittal alignment of patients with spon- clinical classification system. dylolysis and low grade spondylolisthesis against a control group. They found increased lumbar lordo- It is important to appreciate that not all patients sis, but less segmental extension between L5 and will demonstrate the pure pelvic and related pic- S1 than in the normal population. Reporting a later ture. Some will show some tendency, and others related study14 in patients with lumbar degenerative will exhibit a variable mixture of the two with a diseases, they commented that previous data dominant tendency. Understanding the features of suggested that patients demonstrated less distal lor- each helps understand the patient in front of you – dosis, more proximal lordosis and a more vertical possibly a Mixed Syndrome (see Ch. 10). sacrum; while that particular study found the loss of lordosis and a decreased sacral slope were signifi- Posterior Pelvic Crossed Syndrome cant. Their findings are important in corroborating (PPXS) the clinical impressions which underpin the pelvic crossed syndromes. Of particular significance are The pelvis is back Type 1 with a reduced lordosis and Type 4 with an increased, albeit more cephalad or high lordosis. Here the neuromuscular system is generally more switched on but in an abnormal manner of relative sys- In addition, Smith et al.15 reported a photo- temic global muscle system (SGMS) ‘overdrive’, with graphic study examining sagittal alignment in 235 a tendency for axial extensor muscle system domi- adolescents and also identified four subgroups – nance. However, this extensor hyperactivity is region- neutral, hyperlordotic, flat and sway. A higher ally patchy and associated and related under activity of proportion of the adolescent group that had never the deep system (SLMS). In its purest form it may be had back pain was in the ‘neutral’ subgroup. more common in males. The patient ‘looks up’– the ‘pseudo warrior’ although he is tense, unyielding, gen- The Pelvic Crossed Syndromes erally tight and stiff, with poor selective control of movement within the torso (Figs 9.3–9.6). These paradigms have elaborated upon the model of Sagittal alignment characterized by: the Pelvic Crossed Syndrome described by Profes- sor Vladimir Janda.16–18 Attempts to validate the • Pelvis is posteriorly shifted with increased relationship between The Pelvic Crossed Syndrome anterior sagittal rotation or tilt. This appears to as described by Janda and back pain have not been result from both psoas and erector spinae successful.19 While the Pelvic Crossed syndrome as hyperactivity. he described it certainly applied to some of this author’s patients, it did not completely fit the picture • Trunk – anterior translation of the thorax for many, or at all for others. It took some time for via thoracolumbar ‘shunt’ from increased this author to recognize the other patterns. thoracolumbar (T/L) extensor muscle activity creates a forward loaded trunk and associated • Posterior Pelvic Crossed Syndrome (PPXS). compensatory anterior pelvic rotation. The line of This fairly much equates to Janda’s original ‘pelvic gravity passes behind the thoracolumbar junction or lower crossed syndrome’. In its pure form it does and the posterior wall of the body cylinder is not appear to be as prevalent as might be expected, shortened. An important normative study by 221

Back Pain: A Movement Problem Fig 9.3  PPXS: lateral view. Fig 9.4  PPXS: posterior view. Harrison et al.20 showed that trunk muscle activity extensor muscle activity associated with an can also influence pelvic position. Anteriorly anterior thoracic posture significantly increased the translating the thorax at the level of T12 without disc loads and stresses for all levels below T9. The restraining the pelvis resulted in it anteriorly tilting IVD compressive and shear loads and the (and shifting posteriorly as shown, though not corresponding stresses were most marked at L5/S1 and L3/4 level. commented upon). The sacral base angle increased, the T12/L1 and L1/2 segments extended on • Hips are in relative flexion in the pure form as average a total of 5 from the neutral position Janda originally described it. However, in the mixed while L4/5 and L5/S1 flexed by a combined total syndrome (see Ch. 10) it is also common to see of 6. The flexing of the lower lumbars and the some patients lock their knees, externally rotate the extension in the upper lumbars around the lumbar hips, ‘butt grip’22 and hang the torso forward off the curve apex at L4 is interesting. In a later study,21 pelvis by holding with sustained activity of the they calculated that the increased thoracolumbar thoracolumbar extensors. 222

The two primary patterns of torso dysfunction CHAPTER 9 et al.20 with regard to reduced segmental extension of the lower levels in response to thorax position somewhat confirm this clinical impression. The chest is held more in the inspiratory position. Quick appraisal reveals a big belly, bottom and calves and bulky thoracolumbar extensor groups. Puffy superficial tissues and poor definition of the bony landmarks over the low lumbar levels and lumbosacral junction are usual. • The altered length/tension relationships of the various muscles contributing towards this picture are shown in Table 9.1, Fig. 9.6. As Janda17 described the ‘cross‘, there is an oblique relationship between the iliopsoas/hip flexors and erector spinae which are overactive/tight with poor Fig 9.5  PPXS: anterior view. The patient is 17 years old. Also see Figs 9.8 and 9.9. • Cursory glance shows they look ‘extended’ with an increased lordosis. This is principally high lumbar and over the thoracolumbar junction. The Roussouly12 Type 4 lordosis is extant. However, closer inspection generally reveals that the lower lumbar levels in fact show some relative flexion and are poorly controlled. The further findings reported by Roussouly et al.13,14 and those of Harrison Table 9.1 Altered myofascial length/tension contributing to PPXS Muscle hypoactivity/ Muscle hyperactivity/ Thoracolumbar lengthened adaptive shortness extensors Lower pelvic unit synergy Thoracolumbar erector Whole Lumbosacral (LPU) in particular: spinae þþþ abdominal extensors • transversus and internal Serratus posterior inferiorþ wall Gluteii oblique Anterior hip flexor groups: Diaphragm +/- Piriformis +/- • lumbosacral multifidus • primarily psoas þþ Hip flexors • iliacus in controlling • RF TFL Obturator group including Overactive intrapelvic movement and piriformis? Underactive anterior pelvic rotation AT Hamstrings? the lumbosacral junction ? hip internal Fig 9.6  Schematic view of PPXS. • probably pelvic floor rotators > external Entire abdominal wall þþþ rotators? Glutei – medius þ ?? lateral fibres of: Inefficient diaphragm activity • internal oblique and • latissimus dorsi 223

Back Pain: A Movement Problem control of eccentric lengthening. The spatially oblique spinae EMG and a lack of flexion relation gluteals and abdominals are weakened resulting in an phenomenon25–27 in forward bending. anterior pelvic tilt, increased lordosis and a slightly flexed position of the hip (Fig. 9.3; Fig. 9.6). If the lor- • Trunk extension is generally reduced dosis is deep and short the imbalance is principally particularly through the thorax. In attempting located in the pelvic musculature. If it is shallower extension, both poor spatial prepositioning of the but longer extending into the thoracic area the imbal- pelvis and poor hip and intra-thoracic extension ance is more marked in the trunk musculature.17,23 leads to further over activation of the extensor Clinically, the latter appears more common and many muscle groups over thoracolumbar junction (T/L/J) also have quite bulky buttocks. Janda noted that those and upper lumbar levels. who stand with an opened lower thoracic aperture have a shortened diaphragm in association with under- • Thoracolumbar region becomes active abdominals with decreased excursion in breath- hyperstabilized by overactive erector spinae ing.23 Janda also noted that hamstrings could be tight in groups, serratus posterior inferior and psoas this syndrome either as a compensatory mechanism to producing a ‘Central Posterior Cinch’ (CPC; Fig. lessen pelvic tilt or possibly as a functional compensa- 9.4). This reflex response begins to become the tion for the inhibited glutei.17 He also noted that an postural set that supports the ensuing movements. imbalance can exist in the lateral pelvic muscles where CPC hyperactivity over-anchors the lower thorax a weak gluteus medius can be compensated for by over- posteriorly, further reducing movement within the activity and tightness in the ipsilateral quadratus lum- thorax and over the thoracolumbar junction to the borum and tensor fascia latae. An increased thoracic upper lumbar spine. This then creates a tendency kyphosis and further compensatory increase in the cer- for a compensatory functional ‘break’ in the mid/ vical lordosis develop in efforts to balance the body and low lumbar spine – these levels become relatively keep the head and eyes in the upright position.17 over stressed in movement with less intersegmental control. Examining the mechanics of lifting in a Toppenberg and Bullock24 examined lumbopel- group of power lifters who clearly hyper develop vic muscle lengths and their interrelationships in their erector spinae, McGill reports a chance healthy adolescent females and found significant recording by video fluoroscopy of a segmental positive correlations between shorter (by implica- buckling/instability injury at L3/428 (later reported tion overactive) erector spinae and iliopsoas and at L2/329,30) (see Ch. 6, p. 134; and Ch. 13, rectus femoris with a tendency for longer abdom- p. 335). CPC activity can be so entrenched that it is inals (by implication weaker) in association with even evident when recumbent (Fig. 9.7). longer gluteals and shorter iliopsoas muscles. They concluded that the pattern of length relationships • Poor control of the pelvis in space, on the which constitute the pelvic crossed syndrome as lumbar spine and hips in posture and movement described by Janda can be seen in normal pain free because of inadequate control of the lower pelvic adolescent females. This study lends weight to the unit (LPU) and hence the fundamental pelvic premise that movement dysfunction is present and observable before pain appears. A prospective study would be nice in determining which subjects went on to develop pain syndromes. As a consequence we can expect or Fig 9.7  Segmental irritation can further drive central predict that in movement: posterior cinch behavior such that it is evident ‘at rest’. • Patchy extensor synergies tend to dominate in most movements – particularly T/L extensors. Inhibition of the overactive muscles can be difficult and they often can’t let them go, e.g. in standing forward bending the T/L extensor muscle groups keep holding instead of eccentrically lengthening. This helps explain why some though not all patients with back pain demonstrate increased erector 224

The two primary patterns of torso dysfunction CHAPTER 9 patterns. Instead, sagittal pelvic rotation control is to support hip extension is interesting. Psoas is indirectly attempted by an abnormal strategy which overactive in synergy with thoracolumbar extensors, utilizes his CPC – anterior rotation primarily from and iliacus seemingly underactive in concert with the T/L extensors and the anterior pelvic femoral the abdominals. The observed imbalance between muscles – particularly psoas. The apparent anterior psoas and iliacus activity in this group will hopefully pelvic rotation is not controlled at the lumbosacral interest future researchers. junction. This group has more difficulty shifting the pelvis anteriorly. When shifting it posteriorly, poor • The important standing forward bending abdominal control to support anterior alignment in pattern. The pelvis is already posteriorly shifted and the body cylinder is evident. anteriorly rotated, and so a reasonable contribution • Decreased hip extension range because of tight/ of hip flexion is more often seen. The better overactive psoas/anterior hip muscles and related developed buttocks seen in this group is evidence underactive glutei (Fig. 9.8). Difficulty performing that they are using them somewhat! Poor control of the 2nd fundamental pelvic pattern (FPP2) means the ‘body cylinder’ with imbalance between the shifting the pelvis anteriorly/posterior rotation and underactive abdominals and the dominant posterior control of closed chain hip extension is deficient cinch patterns is the key deficient component with particularly in kneeling (see Fig. 11.8). Difficulty diminished dynamic adjustments in the legs. with the 1st fundamental pelvic pattern (FPP1) Reduced control of the FPP1 coupled with poor makes open chain hip extension control more control of the anterior wall of the body cylinder is difficult. Active hip extension movements are compensated by increased thoracolumbar extensor associated with increased CPC activity. The poor activity. This leads to. . . contribution and control of the lumbosacral region towards anterior pelvic rotation/low lumbar lordosis • Relatively increased intersegmental flexion over the mid/low lumbar levels occurs during spinal Fig 9.8  Difficulty achieving closed chain hip extension is flexion (and other movements) as the thoracolumbar associated with disturbed patterns of axial alignment. contribution to movement is reduced from CPC hyperactivity. This becomes exacerbated by the frequent therapeutic misdirective to ‘tuck the tail under’ in a misguided attempt to decrease thoracolumbar extensor hyperactivity. • Sitting postures will further stress the low lumbar levels into flexion if a collapsing strategy is adopted (see Ch. 8). Conversely they may ‘sit up’ by locking in with a CPC strategy and inadequate lumbopelvic contribution. • Abnormal axial rotation – lack of general and rotary mobility in the thorax and over the thoracolumbar junction because of CPC activity and a ‘dome’ (Ch. 8) and diminished mobility and control in the hip–pelvic unit, means any rotation imposed on the system tends to occur abnormally in the mid/low lumbar spine. • Walking further increases the altered loading patterns. Decreased hip extension and poor triplanar control pelvic rotation leads to further stress in the lumbar spine. Lateral weight shift (Ch. 6, Part B) is further compromised by the CPC fixing strategies holding the spine more centrally and limiting lateral shift of the thorax over the base – the lumbar spine becomes stressed in both the sagittal and frontal planes. When dysfunction is marked walking is characterized by a waddling gait as the mass of the thorax is heaved over the standing leg and the lumbar 225

Back Pain: A Movement Problem spine is observed to both side bend and rotate. The incidence of foot pain symptoms and the wearing of orthotics as well as chronic knee symptoms are common to see – both related to chronic somatic and autonomic influences resulting from compromised segmental dysfunction. • Dysfunctional breathing patterns – Poor abdominal tone does not provide the stability for effective diaphragm activity which is further hampered by CPC strategies reducing posterior basal expansion. The thorax is frequently held in the (abnormal) inspiratory position31–33 where its lower pole and the diaphragm assume a more oblique position. Liebenson34 notes this position will inhibit the postural function of the diaphragm (Fig. 9.9). In very general terms the prognosis for this group is perhaps more limited. Inhibiting the dominant CPC neuromuscular behavior can be really difficult and can represent a real therapeutic challenge. Chronic- ity is more likely and particularly so in those who have spinal surgery. Surgery may be more likely in this group. Anterior Pelvic Crossed Syndrome (APXS) The pelvis is forward! Fig 9.9  The thorax appears to migrate more cephalad because of decreased inferior stability from the abdominals. Here, the neuromuscular system is more ‘switched off’ – both the deep SLMS and the superficial sys- and they passively hang relying on their tems (SGMS). However, while less dominant, the iliofemoral ligaments. This requires little superficial system is still abnormally used though postural demand in the LPU. The poor pelvic more intermittently. Those with generally low control is primary. muscle tone fall into this group and sensory system dysfunction seems more apparent. These people rely • Trunk. The thorax is shifted more posteriorly and more on passive strategies for antigravity support – the line of gravity passes anterior to the thoracolumbar hanging on the iliofemoral ligaments, adopting a wide junction. The axial posture is one of more general base of support, hyperextending the knees and gener- flexion, creating more loading stress on the anterior ally limiting the opportunity for postural perturba- structures throughout the spine. The anterior wall of tions to influence the system (see Ch. 8). the body cylinder is shortened. There is loss of the lumbar lordosis and in some, lumbar kyphosis is In its purest form, it is probably more common in apparent. This equates to the Roussouly12 Type 1 females. The patient appears somewhat collapsed lordosis (p. 219–220). Adaptive shortening and/or and exhausted while ‘up’. The tail bone is ‘tucked overactivity of the upper abdominals with under’ and aspects of posturomovement patterns underactivity in the lower region is evident. tend to reflect elements of ‘psychological with- drawal’ (Figs.9.10–9.13). Sagittal alignment is characterized by: • Pelvis is anteriorly shifted with an increased posterior rotation or tilt. Psoas is underactive 226

The two primary patterns of torso dysfunction CHAPTER 9 Fig 9.10  APXS: lateral view. Her buttocks and calves are Fig 9.11  APXS: posterior view. more developed than usual as she is a marathan runner! • Hips are in extension with adaptively tight posterior hip structures. This can vary between reliance on the passive structures or active holding with the obturator group – the hips are externally rotated and the buttocks usually poorly developed. Active ‘butt-gripping’22 is more a feature of the mixed syndrome (see Ch. 10). 227

Back Pain: A Movement Problem Fig 9.12  APXS: anterior view. Upper abdominals Thoracolumbar Diaphragm extensors Table 9.2 Altered myofascial length/tension contributing to APXS Lower abdominals Lumbosacral extensors Muscle hypoactivity/ Hyperactivity/ Iliopsoas lengthened adaptive shortness Hip extensors Pelvic floor Piriformis Lower pelvic unit synergy: Hamstrings þþþ Hamstrings • Lower abdominal group Obturator group including • Lumbar multifidus – Overactive particularly over lower piriformisþþþ Underactive levels Upper abdominal group Fig 9.13  Schematic view of APXS. • Diaphragm – reduced excursion þþ including lateral internal upper abdominal group and the lower obturator/pir- • Iliacus and psoas þ obliqueþ iformis group with the posterior pelvic floor and • ? weakness of anterior Hip external rotators i hamstrings. The other ‘diagonal’ is under activity/ pelvic floor internal rotators weakness of the lower abdominal group, iliacus þ/À T/L erector spinae and psoas with lumbar multifidus. In standing this Glutei – reduced postural and Posterior pelvic floor: creates a posterior tilt of the pelvis, loss of the lum- movement demand and anterior? bar lordosis and hip extension. Active neuromuscu- often adaptively shortened lar synergies for lumbopelvic support and control are in short supply. • Quick appraisal shows poorly developed buttocks; forward loaded head posture; thoracic As a consequence we can expect that kyphosis and the thorax is collapsed towards pelvis in in movement: the expiratory position. Calf development is poor. • Patchy flexor synergies tend to dominate in The altered myofascial length/tension relationships posture and movement – e.g. upper abdominals observed in this picture of dysfunction are shown and pectorals coactivate in antigravity trunk in Fig. 9.13 and Table 9.2. In this presentation, the ‘cross’ consists of the oblique relationship between the hyperactive/tight 228

The two primary patterns of torso dysfunction CHAPTER 9 Fig 9.14  General loss of extension is evident when prone on elbows. flexion. Insufficient SLMS activity means the Fig 9.15  Chronic CAC: the thorax is pulled down anteriorly; initiation and sustaining of appropriate postures to note the inactivity in the lower abdominal wall, anteriorly support movement is wanting. shifted pelvis and wide base of support. • Generalized loss of extension through the LPU means poor spatial pre-positioning of the spine is marked – both in the thorax and lumbar pelvis to provide support to the ‘body cylinder’ as spine. Loss of lordosis is marked through the lumbar well as for lower limb movement. The tendency to spine (Fig. 9.14). Most active extension is achieved readily shunt the pelvis forward in movement by intermittent thoracolumbar extensor activity means shifting it posteriorly is particularly disabled and/or further swaying pelvis forward and hyper and ‘unknown’ (Fig. 8.29). A healthy study showed extending the hips to compensate. that if posterior shift of the pelvis was prevented when bending forward, inhibition of erector spinae • Thoracolumbar junction hyperstabilized in occurred earlier in range than that normally given flexion. Upper abdominal overactivity or ‘cinch’ for the flexion–relation response.36 The creates a ‘central anterior cinch’ (CAC) which underactivity in psoas/iliacus is further reflected in holds the anterior thorax down, inhibiting good difficulty in anteriorly rotating the pelvis, descent of the diaphragm, increasing the thoracic controlling sacral nutation and the low lumbar kyphosis and ‘dome’ and further reducing the lordosis. The development of lumbopelvic girdle contribution of the thorax in axial movement. This pain syndromes including the so called ‘instability’ reflex action invariably becomes the postural set syndromes of the lumbar spine and sacroiliac joint adopted for axial stability to support limb (SIJ) become a predictable eventuality. movement. It can be acute (Fig. 4.9), or a chronic Incidentally, Mens et al.37 note the possible intrinsic problem (Fig. 9.15); or result from excessive ‘training’ (Fig. 9.16). • Poor spatial control of the pelvis, pelvis on the hips and lumbar spine. When standing, particular underactivity in psoas/iliacus means the pelvis shifts forward and they passively hang off the iliofemoral ligaments. The patient utilizes the CAC with the hamstrings/obturators to bring the pelvis forward. Increased vertical loading stresses on the pelvic floor are more likely and Spitznagle suggests this risks stretch weakness of the PFM.35 Clinically the posterior floor often appears tight. Delay, underactivity and imbalanced activity of the 229

Back Pain: A Movement Problem Fig 9.17  The subject is attempting closed chain hip flexion in the ‘Allah’ stretch. Note the loss of axial alignment and poor anterior pelvic rotation. Fig 9.16  CAC from overtraining. increased risk of developing peripartum pelvic pain Fig 9.18  Neurologically the patient is asleep. Passive when delivery positions involved a flexed spine. collapse without directing the stretch from the W ischium means the lumbar spine is the victim. The subject is the same • Decreased hip flexion due to underactivity in as that in Figs 8.8, 8.26 and 11.4 who cannot initiate lateral iliacus-psoas and disordered LPU synergies with weight shift through the pelvis in sitting. corresponding tight posterior pelvic and hip muscles which show poor eccentric lengthening – the combination of holding with the hamstrings while obturator group including piriformis, posterior engaging the upper abdominals (CAC) and ‘folding’ pelvic floor gluteus maximus and particularly forward in a pattern of generalized flexion (Figs. hamstrings. Difficulty with FPP1 means anterior 9.19 & also 8.6 & 8.9) The spinal flexion–relaxation rotation of the pelvis and active control of closed response is likely to occur early in range. In fact chain hip flexion is particularly deficient and is ‘hanging off the hamstrings’ allows one to rely more compensated by further increased low lumbar on the passive tissues and the hamstrings may not flexion in movement (Figs 9.17 & 9.18). Hip achieve flexion–relation at the end of flexion which extension becomes associated with posterior pelvic is deemed to occur38 (Fig. 9.20). This habitual tilt. Poor control of the fundamental patterns means initiation of forward bending by actively ‘tucking open chain hip movements particularly extension, the tail’, creating posterior pelvic tilt and flexion of are built on a poorly controlled pelvic base of the spine has been alluded to as the ‘click-clack support hence the movement is not well localized to phenomenon’39 – an unfavorable loading state for the hip but is transferred to the lumbar spine. ‘Hip the lumbosacral and sacroiliac structures. Poor stretches’ invariably become stretches to the lumbar control of FPP2 means the lifting/return phase is spine (Fig. 9.18) and may also create altered characterized by poor coactivation within the LPU patterns of axial alignment higher up (Figs. 8.15 & and the ‘body cylinder’ with little contribution 9.17) because of inadequate control of the LPU from gluteus maximus, the hamstrings being synergies. • The important pattern of forward bending in standing. Instead of the sagittal axis of rotation being in the hips it becomes more the spine. Deficient control of the FPP1 & FPP2 is particularly evident in this action. The bending action is initiated more from relying on a 230

The two primary patterns of torso dysfunction CHAPTER 9 Fig 9.19  Forward bend pattern with axial ‘folding’. dominant throughout the movement. The pelvis is Fig 9.20  Forward bend pattern relying upon ‘hanging off hyperstabilized inferiorly thus held in posterior tilt the hamstrings’ & the posterior axial ‘passive system’. through both phases and hyper flexion of lumbar segments occurs (Fig. 9.21). Adherence to the including control of the lumbar lordosis. Any advice to ‘bend the knees’ generally results in more attempts ‘to sit up’ are achieved by the adoption of posterior pelvic rotation and lumbar flexion a transient CPC in concert with their habitual CAC (Fig. 9.22) (see Ch. 6, Part B.). The key component which serves to constrict the lower pole of the is the lack of pelvic-hip control, and poor control of thorax in a ‘central conical cinch’ (CCC). alignment in the ‘body cylinder’. Lumbopelvic • Abnormal axial rotation – a general reduction control suffers. in extension and rotation because of the dominant CAC patterns and thoracic ‘dome’, in addition to • Relatively increased intersegmental flexion deficient lumbopelvic control and relative over low lumbar levels occurs as a result of poor hypomobility in the hip and pelvic joints means any lumbopelvic control as well as compensation for imposed rotation will abnormally occur in the associated posterior hip and pelvic tightness. lumbar spine. (Fig. 9.23). Lumbar joints and intersegmental • Walking. Gracovetsky40 suggests that loss of structures including the disc are used in untenable, control of psoas has a major effect upon locomotion more unstable and vulnerable end range flexion. Disc, as lordosis control is lost. Similarly, Rolf41 facet and the plethora of other various ‘diagnoses’ are considered that grace and efficiency in walking a predictable consequence over time. requires the psoas not the erector spinae as the primary antagonist of the rectus abdominus. Rather • Sitting generally involves passive collapse than walking with ‘a spring in the step’ and the easy (Ch. 8) with little initiation and control from the oscillatory rhythm inherent in contralateral LPU, with minimal weight shifts and an inappropriate sacral position for ‘axial column lift’ 231

Back Pain: A Movement Problem Fig 9.22  Basic pattern tendencies are carried forward into other actions (Fig. 9.20). ‘Bending the knees’ in forward bending often results in increased posterior pelvic rotation. Fig 9.21  Forward bend pattern from behind with poor Fig 9.23  Viewed from above. Segmental ‘break’ can occur eccentric lengthening in the postero-inferior pelvi- in hyper-flexion of the lumbar spine. femoral muscles – “inferior tether”. themselves’, bringing the body to the weight pelvis–shoulder rotation, walking appears an effort bearing leg rather than over and past it where and lacks vitality. Reduced range and control of push off can be more effectively achieved through rotation and weight shift through the kinetic system an extended hip in ipsilateral backward pelvic means that walking becomes more sagittal and two rotation. dimensional. Some ‘pull themselves along’ with • Dysfunctional breathing patterns. The thorax their arms rather than push off well through the tends towards the more collapsed ‘expiratory’ feet. Others appear to ‘walk up to, but not past position and becomes distorted by the effects of the hyperactive CAC responses and the more transient 232

The two primary patterns of torso dysfunction CHAPTER 9 It is also important to recognize that during acute severe bouts of pain, marked muscle spasm can transform an APXS individual into one resembling a PPXS picture as their spine is held in extension with the pelvis more posteriorly placed. As joint irritability settles they revert to form. Discussion: pelvic position and flexor or extensor proclivity Fig 9.24  General collapse and central anterior cinch Altered pelvic shift and associated tilt has received diminishes adequate support function from the diaphragm. almost no attention in the literature. Myers43 men- tions, ‘the pelvis is commonly described as being CPC activity which serve to externally compress anteriorly or posteriorly shifted relative to the mal- and reduce the dimensions of the inferior aperture leoli with the understanding that “some tilts must (Fig. 9.24). This hampers diaphragmatic descent occur along the way for that to happen”.’ A personal and the widening and opening out of the centre article by Schleip44 describes ‘The structural typol- creating the internal support so important for axial ogy of Hans Flury’; however, this author found stability and control (Ch. 6, Part A). When the Flury’s work difficult to locate. According to Schleip, diaphragm loses its dynamic function the action of Flury arrived at four combinations of pelvic tilt and transversus is also lost and the resting tone of the shift. The two related to an anterior tilt he called pelvic floor muscles is potentially reduced.42 ‘internal’. This may be because clinically, the hip Diminished basal breathing is compensated by tends more to internal rotation in anterior pelvic tilt, increased upper chest breathing with sympathetic although this is not stated. Similarly, those with a dominance and related upper body tension. Cervical posterior tilt were termed ‘external’ – again not pain syndromes can also be expected to occur. stated, but presumably because clinically, external hip rotation and posterior pelvic tilt certainly ‘go It is important to note that when attempting to be together’. It appears Flury felt that an anterior and ‘up’, performing certain movements, trying too posterior tilt can occur in both an anterior and a hard, or being over challenged, the tendency for posterior shift of the pelvis. However, at this stage, this subgroup of patients is to flip to using a more it is this author’s clinical impression that posterior primitive gross extensor synergy – principally uti- pelvic shift is coupled with anterior rotation and lizing the thoracolumbar extensors (CPC) in asso- anterior shift with posterior rotation. Try it for your- ciation with their retained upper abdominal self! Importantly, Schleip mentions that the two ‘central anterior cinch’(CAC) pattern. The lower types with a posterior shift are considered to be thorax then becomes functionally converted to a ‘tensional types’ in which the fascial and muscular cone shape. We have termed this a ‘central conical holding patterns are considered to be more apparent. cinch’ (CCC) whereby the anterior, posterior and This directly applies to the picture seen in the PPXS lateral thoracolumbar junction becomes hyperst- subgroup in the model presented here. Those with abilized. Control of the pelvis is attempted from an anterior shift are considered ‘compressional types’ this habitual thoracolumbar strategy. The reflex and this author interprets this as ‘internal collapse’ reactive response becomes the postural set from from inadequate SLMS activity – APXS as presented. which they move. Schleip hints that the emphasis for these names is in relation to the posterior trunk. Brumagne et al.45 recently found that persons with recurrent LBP showed a significant more for- ward inclination of their body when vision was occluded or in anticipation of postural instability. They noted however other studies have shown a tendency to more posterior inclination. 233

Back Pain: A Movement Problem The important significance of the pelvic shifts flexed with extended hips. Perhaps the pelvis is the and tilts is the real effect they have on the distribu- primary dysfunction in APXS and the trunk is tion of extensor and flexor muscle system activity primary in PPXS. However, practically they are inter- throughout the torso: dependent as trunk muscle activation patterns affect the pelvis and conversely pelvic activation patterns • When the pelvis is anterior, flexor system influence those in the trunk. dominance tends to prevail (APXS) O’Sullivan described6–8 five clinical patterns • When the pelvis is posterior extensor system which are principally flexion or extension dominant, dominance is more apparent (PPXS) (Fig. 9.1) based upon pain behavior with movement. It appears that we are observing similar patterns of • When the pelvis is neutral balance between the clinical presentation6,50,51 namely: flexors and extensors is likely. • the APXS shares features in common with his Rock42 defines the functionally normal neutral pel- flexion pattern which he thought was the more vic position as having a slight anterior tilt where common underlying clinical presentation.7,8,50 the anterior superior iliac spines move slightly in front of the symphysis. In this position the reflex • posterior pelvic crossed syndrome shares features postural muscle chains are better activated and in common with his extension pattern sacroiliac joint shear stress is minimized. This can be readily felt in standing. • O’Sullivan’s other directional patterns can be viewed as variations on these basic two patterns at Schleip46 also offers a structural typology based differing stages of neuromusculoskeletal on the effects of primary reflex behavior upon the dysfunction. functional relationship between the flexors and extensors (Ch. 7). This typology also shares many Van Wingerden et al.52,53 presented a study features in common with the crossed syndromes. which lends support to the concept of the two pel- Clinically, he notes a ‘short extensor pattern’ which vic crossed syndromes. They examined forward equates to the PPXS and a ‘short flexor pattern’ – bending motion patterns of the lumbar spine and either contracted or collapsed, which equates to the pelvis in two subgroups of patients with chronic pel- APXS. Like this author, he has also been influenced vic girdle pain and chronic LBP against a control by the work of Feldenkrais47,48 and Hanna49 and group. While they described the position of the notes the associated psychological temperaments trunk in standing as similar in all three groups, they which tend to accompany each state. Feldenkrais found that those with pelvic girdle pain demon- saw that negative emotions and the ‘the body pattern strated a significantly increased posterior pelvic tilt of anxiety’ were flexor dominant. The APXS/flexor and decreased lumbar lordosis in standing. When tendency group does appear more inclined to nega- this group bent forward, lumbar flexion was signifi- tive emotions, tension, depression, and anxiety, etc. cantly increased initially and through range while The PPXS/extensor dominant individuals appear hip motion was significantly reduced (a common extroverted yet are stiff and rigid. Importantly his strategy adopted by those classified as APXS). two typologies are not exclusive of one another, which Those with LBP initially maintained more lordosis is also the case in the crossed syndromes and further when forward bending, but had more lumbar explored in the mixed syndrome in Chapter 10. motion in the final stage of flexion i.e. they initially However, Schleip believes the ‘key indicator for the ‘held’ more with their thoracolumbar extensors and reflex patterns is not in the pelvis position in standing compensate at the end of range with increased (like Flury’s model), nor in the femur rotation (like in motion probably over the lower levels. This group Sultan’s), but the tonus balance between trunk- can clearly be sub-classified in the PPXS group. Pre- flexors and trunk-extensors specially (sic) around dictably we can expect symptoms to differentially the rib cage’.46 occur in both groups over time. The paradigm of the two crossed syndromes Other forward bending studies of subjects with embraces the significant role that both the trunk and CLBP have also shown early and increased lumbar pelvis play and importantly, their ability to mutually movement with reduced hip movement,54 especially influence one another. Essentially in the pure form, when fatigued.55 Porter and Wilkinson56 found an those with PPXS are axially hyperextended with rela- overall reduction in the mean total range and mean tive hip flexion while those who are APXS are axially maximum lumbar flexion in all symptomatic subjects 234

The two primary patterns of torso dysfunction CHAPTER 9 with a subgroup showing a significant decrease in hip exercises have been a common therapeutic directive flexion. Sub classification as proposed would help but this is hard to justify, when it is understood that explain the various findings. the pelvis is usually found to readily tilt back but not forward. Posterior tilt places the lumbosacral If some show flexor dominance junction in flexion57 with well documented deleteri- why work their abdominals so? ous effects on the viscoelastic tissues and related neuromuscular responses.58–60 Snook et al.61 demon- It has been exciting for this author to find resonance strated significant reductions in pain intensity in in the work of others who are describing similar clini- CNSLBP when subjects completely avoided early cal patterns with a certain common theme – some morning lumbar flexion for the first two hours after subjects show the influence of more dominant reflex rising. While not a particularly functional solution flexor activity while for others it is extensor. This has the benefits of reducing the flexion stress are shown. important implications. The abdominal muscles receive a lot of attention in therapy and fitness pro- While abdominal function is generally deficient grams in the pursuit of ‘good core control’. However in subjects with back pain, so are a lot of other different presentations require different solutions. things. Rather than muscle weakness, the problem is more usually inadequacy in the automatic reflex In general those who are classified as APXS lack activity of groups of muscles cooperating in various extension are flexor dominant and ‘collapsed’ when synergies, to provide certain functionally important up. They generally show increased activity patterns patterns of postural control and movement. The in the upper abdominals and consistent underactivity importance of this reflex behavior is attracting of the lower abdominal region. The combination of increasing research interest. There is recognition reduced deep system activity and the adoption of the that attempting to consciously voluntarily alter ‘holding’ and ‘folding’ strategies result in the axial trunk muscle coactivation might constitute a non spine becoming relatively shortened. The anterolateral optimal motor scheme and result in a drop in stabil- abdominal wall bulges and they ‘have a tummy’. Janda ity in demanding situations.62 Reeves et al.63 felt the lateral waist bulge was indicative of transversus showed that increasing trunk muscle recruitment hypoactivity. Unfortunately being told to ‘hold their by ‘bracing’ degrades postural control. Brown and stomach in’ has the effect of pulling them down into McGill62 recently showed that the ability to more flexion, shortening the torso increasing the increase spine stiffness by abdominal bracing is par- ‘dome’ and further constricting function around the tially dependent upon trunk posture and it would body’s centre of gravity. These people need to develop appear reflex mechanisms. Normal subjects were control of their pelvis, the synergies for which require placed in a set up which eliminated gravity and activation of the lower abdominals. Control of poste- reflex responses and asked to voluntary brace the rior pelvic tilt and achieving anterior tilt is difficult. abdominals and trunk muscles while being slowly Coactivation between the flexors and extensors for passively moved into different positions. In exten- low load activities is also reduced, hindering control sion, spine stiffness increased with successive of alignment between the related segments in the increases in voluntary muscle activation through kinetic chain. Consistently working them more into range. However, in flexion and lateral bending, flexion compounds their problems and therapeutic (the most commonly adopted trunk postures for misadventure is becoming a more common presenta- ADL activities) spine stiffness increased between tion in the clinic. neutral and approximately 40% and 60% of maxi- mum range respectively. After that, subjects Those who are classified as PPXS do need to became unaccountably less stiff despite maximal achieve better abdominal control, as they show voluntary abdominal coactivation. The apparent underactivity in both the upper and lower regions. ‘yielding’ phenomenon is being further researched. However, activation strategies also need to control the pelvis to prevent it punching into posterior tilt Understanding the primary differences in presen- which is usual and serves to perpetuate the lumbo- tation affords clearer insights into the specific pelvic dysfunction. movement problems of the presenting patient. This is further understood by examining the related clin- All abdominal activation strategies need to allow ical syndromes which ensue from these two primary proper diaphragmatic breathing. Posterior tilting patterns of movement dysfunction. 235

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Chapter Ten 10 Clinical posturomovement impairment syndromes Changed muscle activation patterns produce altered describes the common posturomovement alignment of the body segments against gravity. dysfunction in the upper body and is usually always Observing the patient provides information about present albeit in varying degrees. the more common patterns of posturomovement dysfunction. Chapter 9 dealt with the two primary Coronal view pictures of torso dysfunction which underlie all the clinical syndromes. These provide a clinically Layer or Stratification Syndrome. Described by useful classification system guiding assessment, Janda3–5 this describes the commonly altered mus- diagnosis and therapeutic care. The presence of cle activation patterns in the flexor and extensor these syndromes result in altered stresses on the systems. joints and soft tissues and the predictable develop- ment of various pain syndromes in time. Diagnosing Composite view the ‘underlying mechanism driving the disorder’1 rather than the often spurious diagnosis based upon The Belted Torso Syndrome. This describes the pathology helps inform more rational treatment observed dysfunction around the central torso and interventions. the body’s centre of gravity which results from the combined influences of the pelvic crossed syn- Observing the subject in different planes affords dromes and the layer syndrome. different information. The clinical syndromes are listed and further explored below. The ‘pure’ form of the pelvic crossed syndromes is not necessarily always present, yet the patient will Sagittal view generally display features which merit classification into one group or the other, and is then described The three pelvic syndromes and the common upper for example as a ‘mixed syndrome on a primary body posturomovement dysfunction: APXS picture’. • The Posterior Pelvic Crossed Syndrome (PPXS) (see Ch. 9) Mixed Syndrome (MS) • The Anterior Pelvic Crossed Syndrome (APXS) (see Ch. 9) Clinically, this is perhaps the more common pre- • The Mixed Syndrome: display features of both sentation. Appreciating each primary syndrome PPXS and APXS with a dominant tendency towards separately helps see the composite presentation one or the other and the relative underlying influence of one. The • The Shoulder Crossed Syndrome. Described two basic pictures of dysfunction in the pelvic Janda,2–4 this is also known as the upper crossed syndrome or the proximal crossed syndrome: it

Back Pain: A Movement Problem crossed syndromes are reflective of the develop- Table 10.1 The cardinal features of altered function in the mental prowess or otherwise of the individual two primary pictures of dysfunction which not only includes the early developmental history but also subsequent influences. Psycholog- PPXS APXS ical occupational and recreational factors all impact upon the primary picture of dysfunction Pelvis position re line of Posterior Anterior and variously contribute to the development of gravity the MS pictures in some patients. Unfortunately, Posterior poorly conceived therapeutic interventions and Thoracolumbar Anterior fitness industry programs appear to be responsible position re line of Flexor for the increasing prevalence and most flamboyant gravity examples. The important role that the systemic CAC ! CCC local muscle system (SLMS) plays in the proper Flexor/extensor system Extensor Pelvic > control of movement is generally not well under- tendency thoracolumbar? stood. Instead, many myths abound and in particu- Posterior > lar with regard to ‘core control’ (see Ch. 6, Part B). Central cinch pattern CPC anterior In pursuit of this, many are entrenching central torso ‘cinch patterns’ and dysfunctional breathing Suspected principal Thoracolumbar patterns – a ‘gym junkie syndrome’ is becoming regional dysfunction > pelvic? apparent (see Ch. 11, Sport and Recreation; Train- ing and the fitness industry). Pattern of hip/thigh Anterior > muscle restrictions posterior Regarding the mixed syndrome, it is useful to firstly reconsider the salient aspects of each of the Central cinch patterns (CCPs) two primary dysfunction pictures in order to more clearly see its genesis. CCPs refer to the seemingly reflexive and some- what obligatory bilateral neuromuscular responses In general terms, the shared common dysfunc- which are observed to occur in posture and move- tion in the primary pictures consists of: ment around the central torso. In most instances, their early activation means they become the pos- • Imbalanced activity between the SLMS tural set which initiate and support the ensuing and systemic global muscle system (SGMS) movements. They hyperstabilize the central torso with general underactivity of the deep system in one or more planes. They appear to be a response to reduced SLMS control and a compen- • Altered co-activation patterns between the axial sation for inadequate proximal girdle control par- flexors and extensors ticularly in the pelvis. They are further magnified in the presence of a ‘dome’ (Ch. 8, Thoracic dys- • Poor lumbopelvic control providing function). For whatever reason, the response is inadequate support around the body’s centre more dominant above the belt line than below. of gravity The patient finds it difficult to inhibit these responses and in essence only learns how to when • Increased SGMS activity occurs around better SLMS control is established, including con- the central and upper torso disturbing trol of the proximal limb girdles along with proper postural alignment and control including diaphragmatic breathing and better co-activation equilibrium, stability and breathing between the axial muscles. mechanisms. Central posterior cinch (CPC) However, within the common patterns above, varia- tions occur in accordance with each primary syn- CPC refers to the observed pattern of bilateral drome and are summarized in Table 10.1. reflex overactivation of the superficial muscle groups which form a dense ‘fan’ which spans ‘Central conical cinch’ (CCC) behavior and ‘butt-gripping’6 are probably the most consistent distinguishing traits which unite the two primary pelvic syndromes in the MS. This results in a hyperstabilized central torso yet poorly stabilized lumbopelvic region with variable patterns of inferior pelvis/hip restriction. These aspects are further explored. 240

Clinical posturomovement impairment syndromes CHAPTER 10 posteriorly from approximately the level of the Erector spinae mid/upper lumbar spine extending upwards to - Spinalis thoracis cover the lower pole of the thorax (Fig. 10.1). - Longissimus thoracis These work in synergy as a reflex ‘mass response’ - Iliocostalis lumborum with associated underactivity in the abdominals. Janda7 considered that a clinically found muscle Serratus posterior inferior imbalance between different muscle groups is probably the result of a combination of both reflex A and mechanical mechanisms. Regional extensor Psoas major system hyperactivity may serve to inhibit the abdominals mediated by Sherrington’s Law of Quadratus lumborum reciprocal inhibition2 or conversely, SLMS system Rib 12 dysfunction, abdominal underactivity and changed axial alignment creates the loading torque such Iliocostalis that the CPC activity is necessarily facilitated. Serratus posterior inferior The presence of a ‘dome’ and generally reduced extension can mean that the CPC represents the Longissimus thoracis Transversospinal muscles region of ‘active’ extension. This can be readily B Spinalis observed when the patient simply lifts his head Fig 10.2  Schematic conceptual view of the muscles up in prone (see Fig. 8.18). The response is also a involved in a central posterior cinch. Posterior view (A); cross- common compensation in forward bending when section around T12/L1 (B). lumbopelvi-femoral control is decreased. Clinically, the superficial posterior thoracolum- bar muscle groups are usually but not always bulky, tender and tense with trigger points commonly found. Clinical impressions suggest they include (Fig. 10.2): Fig 10.1  Central posterior cinch: note the demarcation • Those sections of the erector spinae which act over between the tension in the muscles above the waist and the this region – the medially placed spinalis thoracis, atonic puffy, overworked tissues below. longissimus thoracis pars thoracis and particularly the more lateral iliocostalis lumborum pars thoracis attaching to the angles of the lowest six or seven ribs.8 • Serratus posterior inferior extending from the spinous processes T11–L3 upwards and laterally to the posterior surfaces of ribs 9–12 lateral to their angles.8 • Psoas. Clinically one readily observes the activity of the superficial muscles but it is possible that the upper fascicles of psoas are also active in the response. Bogduk et al.,9 suggest the upper fascicles tend to extend the upper lumbar spine while the lower fibres flex the lower lumbar levels. Penning10 agrees and further considers psoas probably also functions as a stabilizer. Lateral weight shift requires eccentric contraction of one psoas and 241

Back Pain: A Movement Problem concentric in the other but when bilaterally active the column becomes hyperstabilized centrally. In particular the thoracolumbar junction is pulled forward and ‘fixed’. • Similar involvement from the upper fibres of quadratus lumborum and lateral fibres of internal oblique and latissimus is also a probability. This tethers the lower pole of the thorax and limits elongation of the lateral wall of the body cylinder. To a greater or lesser extent, practically all patients with spinal pain and related disorders can be observed to activate extensor dominant CPC pat- terns in posturomovement control. They are obliga- tory and particularly evident in the PPXS group, less so in the MS and intermittent in the APXS group. This is a reasonably constant response which the patient finds hard to inhibit. Eccentric lengthen- ing is poor hence little adaptability/variability for postural control. The bilateral activation serves to ‘fix’ the lower pole of the thorax and the thoraco- lumbar spine in a ‘central’ position holding the region in a sagittal orientation and importantly, lim- its flexion, lateral and rotary movements and weight shifts through this region of the torso (Fig. 10.3). Neural irritability through segmental hypomobility further increases the tonus of the thoracolumbar extensors feeding into a vicious pattern generating cycle as the mid/low lumbar levels are further required to compensate. Central anterior cinch (CAC) CAC refers to the observed pattern of bilateral Fig 10.3  A central posterior cinch fixes the spine centrally reflex overactivation of the anterolateral abdominal limiting lateral weight shift. The subject is attempting to ‘grow group above the level of the umbilicus. Given their one elbow to the ceiling (see Ch. 13). Note the lack of superior attachments extend over the entire ante- adaptive eccentric lengthening in the (L) erector spinae and rolateral surface of the inferior pole of the thorax; probably psoas and the poor weight shift through the pelvis. their overactivity has a significant influence. The bilateral activation creates a flexor torque, holding activity of the abdominal muscles. However, in those the central torso in a more flexed sagittal orienta- spastic children with a hypotonic trunk and bad pos- tion thereby limiting extension, lateral and rotary ture, the activity of the abdominal muscles increased weight shift and movements. Most significant is considerably in sitting during this test. Questioning the narrowing of the inferior thoracic opening and whether this was the result of an altered reflex mech- limitation of the diaphragm’s important functional anism or due to possible mechanical stabilization role (Fig. 10.4). This ‘reflex withdrawal’ action is also initiated with anxiety, stressful states and fear (see Ch. 6, Part A). Janda11 found that in healthy children and spastics with good postural develop- ment, unresisted and resisted knee extension in supine and sitting produced only slight or no 242

Clinical posturomovement impairment syndromes CHAPTER 10 et al.12 found that patients with CLBP had difficulty preferentially activating the deep abdominals with a tendency to higher levels of upper rectus abdominis activity. The CAC postural response is the obverse of that found in the normal state where the EMG onset of the upper region of transversus abdominus has been shown to occur later than that of the lower and middle regions in response to perturbation.13 CAC strategies are obligatory in ‘pure’ presenta- tions in the APXS group and also predominant in those in the MS group but do not occur in the ‘pure’ PPXS group. See Figures 4.9, 8.28, 8.38, 9.12, 9.15. Central conical cinch (CCC) Fig 10.4  Central anterior cinch: the anterior thorax is CCC refers to the combined activation of the anchored inferiorly. Note the difference in abdominal tone CPC and CAC strategies and can subsequently above the umbilicus compared to that below. develop in both primary pictures of dysfunction to create a MS. This simultaneous increased dysfunction in these children, he examined healthy reflex activation serves to ‘squeeze’ the inferior children with evident hypotonia of the trunk and also region of the lower pole of the thorax and concep- found a remarkable increase in their abdominal activ- tually convert it into a conical shape. The lower ity in sitting. The entire pattern of knee extension in pole of the thorax extending into the upper lum- this group was accompanied by a ‘simultaneous back- bar spine is hyperstabilized in all three planes. ward tilt of the pelvis and a pronounced lumbar This is akin to a self inflicted functional ‘straight kyphosis and a curling movement of the whole trunk’. jacket’. Rather than the ‘body cylinder’ (Ch. 6, He surmised that altered reflex mechanisms were p. 93) being open in the centre, it becomes con- operant. It is interesting to note that low tone, pos- stricted in posturomovement like squeezing a tural collapse, CAC strategies and a tendency for tube of toothpaste in the centre – the body cylin- ‘total flexion patterns’ (Ch. 8, p. 181) are all features der now resembles an ‘hourglass’ (Figs. 10.5 & observed in those classified as APXS. O’Sullivan 8.38). This regional hyperstabilization coupled with inadequate and imbalanced lumbopelvic con- trol renders the mid/low lumbar spine levels more vulnerable. CCC strategies are seen intermittently in those classified as APXS and consistently in those in the MS based on either a primary underlying APXS (Fig. 10.6) or PPXS (Fig. 10.7). Co-contraction of the superficial muscles was described by Radebold et al.14 in 2000 and is being increasingly reported in the literature.15,16 In an edi- torial on muscle function and dysfunction in the spine, Cholewicki et al.17 note that while there is consensus that the muscle activation patterns exhib- ited by patients with low back pain are different to healthy subjects, the interpretations of such findings are divergent. Van Die¨en et al.18 analyzed the litera- ture with respect to the changed activation of the lumbar extensor muscles derived from studies adopt- ing the pain–spasm–pain model and the pain 243

Back Pain: A Movement Problem Fig 10.5  Central conical cinch: the lower pole of the thorax Fig 10.6  Central conical cinch on a primary APXS is drawn in. picture. Note the asymmetry in the pelvis and the reaction around the thoracolumbar junction. adaptation model. They found neither of the two Overall effect of CCPs models was unequivocally supported in the literature and proposed an alternate model which suggested The CCPs create significant impediments to that the altered trunk muscle recruitment is a func- healthy torso control as follows: tional adaptation to limit noxious tissues stress by • The transmission of the segmental movement limiting range and providing stabilization to the spine wave between the proximal limb girdles through (Ch. 7 ‘Is the altered motor behavior observed in the spine is variably impeded in three people. . .’ p. 160) An appreciation of the central dimensions – flexion/extension, side bending cinch patterns may help provide explanations for and rotation. the diverse findings in the literature. They represent • The small oscillating segmental shifts and evolving maladaptive responses which contribute to adjustments necessary for equilibrium are blocked. the development of pain syndromes and which become Balance control begins to suffer. further enhanced and entrenched in the presence of • The bilateral activation hyperstabilizes the pain. Pain tends to facilitate activity in SGMS mus- column ‘centrally’ compromising weight shift and cles and inhibit activity in SLMS muscles. 244