The Pelvic Girdle: An approach to the examination and treatment of the lumbopelvic-hip region, 3 ed

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The Pelvic Girdle

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The Pelvic Girdle An approach to the examination and treatment of the lumbopelvic-hip region

Diane Lee

BSR MCPA FCAMT

Instructor/Examiner for the Orthopaedic Division of the Canadian Physiotherapy Association

Foreword by

Paul Hodges

MD PhD BPhty

NHMRC Senior Research Fellow and Professor. Department of Physiotherapy' The University of Queensland, Brisbane, Australia

THIRD EDITION

This book has been endorsed by the MACP MANIPULATION ASSOCIATION OF CHARTERED PHY SlOTH ERAPISTS

��\ �.A

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v

Contents

Foreword Preface

vii

7. Pain, dysfunction, and healing

ix

Acknowledgments Abbreviations

8. Diagnosing the lumbopelvic-hip

xiii

dysfunction

xv

1. A historical review

9. Defining the impairment

1

2. Evolution and comparative anatomy

dysfunction 7

function and its application to the lumbopelvic-hip region

References Index

259

41

6 . Biomechanics o f the lumbopelvic-hip region

163

Linda-Joy Lee, Diane Lee

15

5. Principles of the integrated model of

133

10. Treating the lumbopelvic-hip

3

3. The pelvis - its anatomy through time 4. Anatomy

81

Diane Lee, Linda-Joy Lee

55

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249

73

vii

Foreword

Bridging the gap between science and clinical prac­

straight leg raise test developed by Mens. Rather

tice presents enormous challenges. Often we are

than simply use the test to evaluate load transfer

faced with clinical techniques that develop with little

through the pelvis Diane has taken the test to the

consideration of biomechanical and neurophysiol­

next level, with multiple variants to establish the spe­

ogical findin gs Ol� conversely, basic science that con­

cific pattern of muscle activity that is problematic

tributes little to the progression of clinical practice.

or beneficial. Another example is Diane's inter­

What Diane Lee and her colleagues have attempted

pretation of the neutral zone hypothesis of Panjabi.

and largely achieved here is a successful collabora­

Panjabi's model was specifically designed to explain

tion between science and practice. The r-esult is an

the behaviour of motion segments and provide a

integrated clinical approach that incorporates a

model to explain changes in control of intervertebral

blend of concepts that are underpinned by research

motion that may contribute to the development of

and clinical ideas that are based on observation of

pain and disability. Diane has extended this model to

countless patients. Diane's clinical reasoning, based

include additional dysfunctions, such as intermittent

on observation of patterns of function and dysfunc­

loss of stability and subluxation. A final example is the extrapolation of the con­

tion, is attractive and thought-provoking. A major feature that is obvious in the progres­

cept of failed load transfer to urinary incontinence.

sion of each new edition of this book is how new

Recent data from my group has defined the pos­

advances

tural function of the pelvic floor muscles and has

in

science

and

practice

have

been

embraced, molded, challenged and refined into a

identified

working clinical model. It would appear that no

increased risk of low back pain (Smith et ai, unpub­

that

incontinence

is

associated

with

new challenge or idea goes vvithout notice. A great

lished data). The integration of this data and the

strength of the book is its open discussion of the evo­

concept of failed load transfer is likely to lead to

lution of ideas.

improved management of incontinence. Although

A multitude of people have developed and refined clinical techniques for the assessment and

all of these developments require validation and support, they provide fuel for future research.

management of the pelvic girdle system. This book

1 have been fortunate for several years to collabo­

presents an amalgamation of these ideas into an

rate clinically with Linda-Joy Lee. Her take on my

integrated package. A strength of the book is how

group's approach to assessment and training of the

it flows from one approach to the next. The only

muscle system has been faithfully described and

weakness of this method is possible confusion

integrated along

regarding what comes from who and what has been

address specific issues of the pelvic girdle. Linda-Joy

adapted and progressed.

is currently taking the critical step to understand the

with

additional

techniques

to

A major strength is the extrapolation and exten­

'other side' and is completing her PhD in my labora­

sion of established models. For instance, Diane has

tory investigating motor control of the trunk and

introduced a new level of complexity to the active

interaction of the lumbopelvic systems. If this book is

Copyrighted Material

viii

FOREWORD

any indication, I

am

convinced that this will lead

many new extrapolations

to

into clinical practice.

clinical practice. I am sure the developments will progress clinical practice and look

In summary I commend Diane Lee and her col­ laborators for their intelligent summary of the field

next steps.

and their thoughtful clinical take on science and

Brisbane 2004

Copyrighted Material

forward to the

Paul Hodges

Preface

When I was approached by the publishers about

This text focuses on the assessment and treatment of

writing the third edition of this text I didn't think

the first three components of this model (form clos­

there was enough material to warrant a new edition

ure, force closure, and motor control) and its appli­

at this time. After completing this update, I now

cation to the lumbar spine, pelvic girdle, and hip.

realize that there have been significant advances in

The biomechanics of the lumbopelvic-hip region

our understanding of the low back and pelvis over

are updated in Chapter 6. Of significance is the recent

the past 5 y ears and a major revision to the second

PhD work of Barbara Hungerford, physiotherapist,

edition has occurred' As before, Chapters 1--4 review

from Sydney, Australia. Hungerford confirmed some

the history of interest in the pelvic girdle, its phys­

of

ical evolution through time both in the species and

arthrokinematics) proposed in the second edition;

the

biomechanics

(both

osteokinematics

and

individually, and the relevant anatomy necessary

in particular, those that occur on the non-weight­

to lmderstand the subsequent material in the text.

bearing side of the pelvis during one-leg standing in

There are new anatomical figures in Chapters 4 and

healthy individuals. Her research also revealed that

9, which Frank

during one-leg standing a different arthrokinematic

DeRosa, Lance Twomey, and James Taylor have

glide (previously unknown and Lmpredicted) occurs

kindly allowed me to use. Thank you for sharing

at the sacroiliac joint on the weight-bearing side when

your beautiful work.

the force closure mechanism is effective. She went on

Chapter 5 is a brand new chapter for this text and

to show that this 'locking-in' glide at the sacroiliac

presents in greater detail the integrated model of

joint does not occur when there is insufficient com­

function that was developed in collaboration with

pression (ineffective force closure) of the pelviS. This

Andry Vleeming through our many hours of discus­

research has been clinically developed into specific

sion and teaching together. I

am,

as always, indebted

to him for his confidence in me as I share this work with you. This model was originally derived from

tests (Ch.

8) for analyzing load trartSfer through the

pelvis and hip. The assessment of the lumbopelvic-hip region

anatomical and biomechanical studies of the pelvis,

(Ch.

as well as from the clinical experience of treating

had the pleasure of working and teaching with

patients

approach

Linda-Joy for the last 3 years and she continues to

addresses why the lumbopelvic-hip region is painful

amaze me with her brilliance and clinical wisdom far

with lumbopelvic pain.

This

8) is co-written with Linda-Joy Lee. I have

and no longer able to sustain and transfer loads, as

beyond her graduate years. She gently challenges

opposed to an approach that seeks to identify pain­

my long-held paradigms; she improves my writing

generating structures. It has long been recognized

and my PowerPoint presentations and, through the

that physical factors impact on joint function. The

results she achieves with her patients, encourages

model suggests that joint mechanics can be influ­

me to explore areas of clinical practice that at times

enced by multiple factors, some intrinsic to the joint

frighten me (dry needling). Together, we have learned

itself, while others are produced by muscle action

how to teach others to achieve mobile stability through

which is in turn influenced by the emotional state.

touch, imagery, and movement - a different way to

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x

PREFACE

exercise. Thank you Linda-Joy for sharing this part

test alone and the significance of Panjabi's inter­

of your journey with me; I look forward to watching

dependent concept of stability (1992b) . It is indeed a

you fly.

complex concept, which we often attempt to sim­

The assessment presented in Chapter 8 follows the integrated model and includes tests for func­

plify for study.

It has also become clear that the global system is

tional analysis (load transfer) as well as specific

essentially

regional tests for analysis of form closure, force

several muscles, which produces forces. A muscle

closure, and motor control. The work of Vleeming,

may participate in more than one sling and the slings

an

integrated sling system, comprised of

Buyruk, and Darnen has had a significant impact

may overlap and intercormect depending

on our knowledge regarding the interpretation of

being demanded. It is proposed that the slings have

joint play tests for form closure. Individually, their

no beginning or end but rather cormect to assist in

on

the task

research has shown that we cannot predict how

the transference of forces . It is possible that the slings

much mobility an individual's sacroiliac joint should

are all part of one intercormected myofascial system

have and therefore we cannot reliably diagnose

and the particular sling that is identified during any

'hypomobility' or ' hypermobility' from joint play

motion is merely due to the activation of selective

tests alone. Perhaps this is why intertester reliability

parts of the whole sling. This leads us to question the

has been so poor for motion analysis in vivo. What

validity of 'specific' testing for

they have shown is that, in health, mobility of the left

whether this is indeed possible. A different

and right sacroiliac joint should be symmetric and

analyzing effective force transfer through slings as

muscle strength and way of

that asymmetry is predictive of dysfunction and

well as analyzing the extensibility of a sling is pre­

pain. The clinical significance of this research is

sented in Chapter 8.

expanded further in both Chapters 8 and 9. The active straight leg raise

In 2002, Jackie Whittaker joined our team

and has

(ASLR) test is a validated

shared her clinical experience using real-time ultra­

clinical test for measuring effective load transfer

sound imaging both for assessment and treatment

between the trunk and lower limbs. It was originally

of the muscles of the lumbopelvic local system. In

introduced by Mens & Vleeming and has been fur­

Chapter 8, she presents her clinical interpretation

ther developed in this edition, based on clinical experi­

of the research in this field; it has certainly opened

ence over the last 5 years. It is proposed that, by

my eyes and hands to another dimension for clinical

varying the location of manual compression during

assessment and treatment. Thank

the

ASLR, further information can be gained, which

taking this on and tolerating my multiple edits. Your

assists the clinician when prescribing manual ther­

enthusiasm is contagious and I think I even under­

you, Jackie, for

apy and/or exercises to improve mobility, stability,

stand it when I can slow you down just a bit. Which

and motor control (Ch. 10).

way does the green dot go again?

A major change in this edition is the classifica­

Chapter 9 considers the clinical findings from the

tion, assessment, and treatment of the muscles of

subjective and objective examination for specific

the local and global sy stems. This is in response to

lumbar, pelvic girdle, and hip impairments accord­

the proliferation of research in this area, notably by

ing to the integrated model. The chapter concludes

Paul Hodges, Lorimer Moseley, Peter

with a discussion of stress urinary incontinence,

O'Sullivan,

or

and others. We have been fortunate to learn directly

ineffective force closure of the urethra. I believe that

from these leaders during their visits to our clinic

orthopedic manual therapists who focus on restoring

(and ours to theirs) and by the opportunity of one of

function to the local system of the low back and pelvis

us (Linda-Joy Lee) to assist Paul Hodges on his

and therapists who specialize in pelvic floor dysfunc­

courses

in North America. We are indeed indebted

tion are treating the same condition: failed load trans­

to them for their trust and confidence that we will

fer through the lumbopelvic region, including the

represent their material well in a clinical text such

organs. The dysfunction is manifested either through

as this. The neuromuscular research pertaining to

a loss of effective force closure of the joints of the low

the local system has impressed upon us the sensi­

back and pelvis (pain and loss of mobility / stability),

tivity of the lumbar, sacroiliac, and hip joints to

or loss of effective force closure of the urethra (incon­

compression (or lack thereof) and the impact that

tinence). The research clearly suggests that we

variable compression can have on function of the

merging to a common understanding of both function

low back, pelvis, and hip. We now understand that

and dysfunction of the whole pelvis and not just

a diagnosis of 'stability' cannot be reached by one

its parts.

Copyrighted Material

are

Preface

Treatment for specific impairments of the lumbo­

closure, motor control, and emotions. Ultimately,

pelvi c hip region is the challenge of Chapter 10 and

function requires stability with mobility (not rigid­

is also co-written with Lind a Joy Lee. Treatment for

ity) of the joints and organs for any endeavor the

-

-

the impaired lumbopelvic-hip region must be pre­

individual chooses to do. This chapter presents spe­

scriptive since every individual has a unique clin­

cific manual therapy techniques and exercises for

ical presentation. Rarely will on ly one dysfunction

restoring mobile stability for the l urnbopel v ic hip

be present (one stiff joint or one poo rly controlled

region. The role of external supports and the indica­

joint); more commonly, mu ltiple problems coexist

tions for prolotherapy are discussed.

-

such that the most effective treatment consists of a

In closing, I hope you enjoy the changes in this

unique combination of techniques and exercises

edition and feel, as I now do, that it was time to

specific for each p a tient The effective management

update the second edition.

.

of lumbopelvic-hip pain and dysfunction requires attention to all four components: form closure, force

Canada, 2004

Copyrighted Material

Diane Lee

xi

xiii

Acknowledgments

In addition to the contribution of the clinicians men­

portray the goal of this book: restoring confident

tioned in the Preface, I would like to acknowledge

stability with mobility. Lisa Davies (the dancer on

the support of those who helped see this project to

the right) is a principal soloist with Les Grands

its completion. All of the clinical photographs are

Ballets and Linda-Joy and I truly enjoyed the oppor­

new thanks to Goran Basaric (photographer) and

tunity to work with her. Finally, I would also like to

Melanie Coffey (model) and several of the anatom­

thank Mary Law and Churchill Livingstone for their

ical and biomechanical line drawings are improved

patience and support while waiting for the comple­

or new thanks, once again, to Frank Crymble. The

tion of this edition.

anatomical figures in Chapter 9 are from Primal Pictures.

Thank you,

Sloan Hickman, for your

As alway s, I am especially grateful for my family, Tom, Michael, and Chelsea, who allow me the time,

generous corporate vision and for allowing me to

and provide the encouragement, so necessary to

use them here. The picture for the cover of this edi­

complete

tion is provided courtesy of Roland Lorente, who

cated to my mother, whose life's journey gave her

a

project such as this. This edition is dedi­

is the official p hotographer for Les Grands Ballets

the challenge of Alzheimer's disease, and my father,

Canadiens de Monh·eal. He holds the copyright for

whose life's journey gave him the challenge of her

this photo and has kindly allowed me to use it here.

care. The lesson for me has been to take the time to

The dancers captured in this wonderful pose clearly

remember them both.

Copyrighted Material

xv

Abbreviations

ASIS

anterior superior iliac spine

MUI

mixed urinary incontinence

ABLR

active bent leg raise

PAVM

passive accessory vertebral motion

ASLR

active straight leg raise

PICR

path of the instantaneous center of rotation

CT

computed tomography

PHS

posterior inferior iliac spine passive intervertebral motion

DISH

diffuse idiopathic skeletal hyperostosis

PIVM

EMC

electromyogram

PNF

proprioceptive neuromuscular facilitation

EO

external oblique

PSIS

posterior superior iliac spine

ERSL

extended, rotated/sideflexed left

RSA

roentgen stereophotogrammetric analysis

ERSR

extended, rotated /sideflexed right

RTUS

real-time ultrasoLmd

FRSL

flexed, rotated/sideflexed left

SIJ

sacroiliac joint

lAP

intraabdominal pressure

SUI

stress urinary incontinence

ILA

inferior lateral angle

TA

transversus abdominis

lMS

intramuscular stimulation

UI

urinary incontinence

TO

internal oblique

UUI

urge urinary incontinence

Copyrighted Material

Chapter

1

A historical review

I

According to Weisl

l

I

,

,

(1955) the first medical practi­

,

.

.

I

I'

,I l :

. �

.

•"

..t

11

....1 I

•

,

1\' ,

Interdisciplinary World Congress on Low Back and

tioners to express an interest in the pelvic girdle

Pelvic Pain (Vleeming et al

(460-377 Be), Vesalius (AD 1543) and Pare (AD 1643). According to the historical records (reported by Weisl 1955), Hippocrates and

rent state of knowledge in this area; most was empir­ ical. It was clear that more research was necessary to

Vesalius both felt that the sacroiliac joints were

assessment tests and to determine the best way to

inunobile, whereas Pare believed that motion of this

treat lumbopelvic dysfunction. Three years later,

were Hippocrates

joint could occur in women during pregnancy. Then in

1698 De Diemerbroeck demonstrated that mobil­

Lmderstand

1992b) exposed the cur­

the biomechanics, to

develop valid

the second World Congress (Vleeming et al

1995c)

brought forth a wealth of irLformation, validated

ity could occur apart from pregnancy. It appears that

through research, that has become part of the foun­

from the seventeenth century until today, a contro­

dation for rehabilitation of the lumbopelvic region.

versy has existed as to the classification and compo­

Two more World Congresses (Vienna 1998, Montreal 2001) have occurred since the second edition of this

sition of the SI}, the quantity,

if any,

of motion, and

the specific biomechanics which accompany move­

text was published and each has helped to consoli­

ment of the lower extremities and trunk.

date the scientific basis for the diagnosis and treat­

The joint has been implicated as the cause of many symptoms including sciatica; in fact, at the turn of the twentieth century Albee Osgood

(1909) and Goldthwait &

ment of the impaired lumbopelvic region. The integrated function of the low back, pelvic girdle, and lower extremity is becoming clear. The

(1905) proposed that sciatica developed

most reliable, sensitive, and specific diagnostic

from direct pressure on the lumbosacral plexus as

tests/procedures and treatment techniques/exer­

it crossed the anterior aspect of the SIJ. This pressure

cises are still open to debate; however, we now

was thought to be caused by "subluxed, relaxed or

have evidence to support sound inclusion criteria

1911). Treat­

for defining the impairment and thus investigating

ment consisted of manipulative reduction of the

it independently from the pain it can produce. Once

sacrum followed by immobilization, in plaster, in

again, it is appropriate to record the current thoughts

spinal hyperextension for 6 months. Following the

on the anatomy, biomechanics , assessment, and

diseased sacroiliac joints" (Meisenbach

classic paper by Mixter & Barr

(1934) on prolapsed

intervertebral disks and the clinical ramifications of pressure on the lumbosacral nerve roots intraspinally,

treatment of the lumbopelvic-hip complex. The integrated model of function (Lee & Vleeming

1998, 2003) continues to be the foundation for this work.

the SIJ was felt to be less significant and lesions of

Some parts of this model are firmly supported by

this articulation were regarded as rare (Cyriax

1954).

research while others remain to be validated. With

Research over the last 50 years has revealed

each passing year, today's ideas become historical

Significant information pertaining to the anatomy

reviews - this edition attempts to bridge the histor­

and function of the pelvic girdle. In

ical gap from

1992, the first

Copyrighted Material

1998 to 2004.

3

Evolution and comparative anatomy In collaboration with

James Meadows

MCPA MCSP FCAMT

Instructor for the Orthopaedic Division of the Canadian Physiotherapy Association and the North American Institute of Orthopedic Manipulative Therapy. Founder and director of Swodeam Consulting

INTRODUCTION

CHAPTER CONTENTS Introduction

The human lumbopelvic-hip region, while in many

3

Evolution of the pelvic girdle Comparative anatomy

4

3

respects unique in the animal world for its evolution­ ary adaptation to orthograde bipedalism, is based on a design originating almost half a billion y ears ago. The absence of fossils of human pelves older than five million years supports the assumption that the adaptation to bi pedali s m is recent. This chapter will

briefly outline the evolutionary steps which have fac ilitated human gait. Subsequently, the changes in h um a n structure and posture as a re s ult of bipedal­ ism will b e described.

EVOLUTION OF THE PELVIC GIRDLE The pelvic gi rdl e first appeared as a pair of small cartilaginous elements lying in the abdomen of primitive fish (Romer 1959, Encyclopedia Britannica

1981, Young 1981, Stein & Rowe 1982, Nelson & Jurmain 1985, Gracovetsky & Farfan 1986). The "fin fold" theory maintains that lateral folds formed in ancient fish to prevent rolling and buckling of the undulating

bod y

.

As

the

folds

contributed

to

propulsion and steering, they gradually began to fragment From this fragmentation, two paired lat­ .

eral fins were formed, the pectoral and p elvi c fins. The pectoral fin was the primary propeller and was the largest and the most stable of the two. Since sta­ bility was not a functional requirement of the pelvic girdle, there was no need for a x ial attachment nor attachment between the two sides. With migration on to land, the pelvic fin r api dly developed into the powe rhouse of locomotion and consequently increased stabiljty o f the pelvic gi rdle

Copyrighted Material

4

THE PELVIC GIRDLE

was required. The pectoral fin (and its later devel­ opment, the forelimb) was relegated to the role of steering - a reversal of the original roles.

1966, Tuttle 1975, Farfan 1978, Goodall 1979, Rodman & McHenry 1980, Stein & Rowe 1982, Swindler & Wood 1982, Basmajian & Deluca 1985, Nelson & Jurmain 1985, Williams 1995) (Fig. 2.1). Brumlik

STABILIZATION OF THE PELVIC GIRDLE

The surface area of the ilia has increased whereas the

The pelvic girdle has evolved towards increased

The posterior muscles have lost some bulk second­

stability both at the pubic symphysis and at the

ary to the increased stability of the sacroiliac joint.

sacroiliac joints.

Sufficient mobility of the sacroiliac joint has been

length of the ischium and the pubis has decreased.

The original

innominate bone

contained two elements which together formed the

maintained for bipedalism.

puboischium. Ouring the stabilization process, the puboischium enlarged and tmited with the oppos­ ite side via the puboischial symphysis. Intrapelvic stability was subsequently increased; however, stabil­ ity between the primitive innominate bone and the ax.ial skeleton was also required. A dorsal projection developed on the puboischium (ultimately forming the ilium) directed towards the axial skeleton. Simultaneously, the costal element of the axial skel­ eton enlarged and fused with one (or more) preanal vertebra to form the sacrum. The iliac projection of

SACRUM The sacrum has increased in size, thus accommo­ dating the increased osseous attachment of the gluteus maximus muscle. The articular surface of the sacroiliac joint has also increased in size and facili­ tates the increased compression produced in bipedal stance. The surface itself has become more incongm­ ous

(Ch. 3)

and facilitates inh'apelvic stability.

the primitive innominate bone and the enlarged costal process of the primitive sacrwn formed the

INNOMINATE

first sacroiliac joint. The initial union was ligament­ ous. Thus, direct articulation between the axial and

The

appendicular skeletons occurred. At this stage, the

response to bipedalism. The bone has twisted (Fig.

ilia have

undergone dramatic changes in

pelvic girdle had a full inventory of the elements

2.1)

present today in all tetrapods.

anteriorly. The gluteus medius and minimus muscles

such that the lateral aspect is now directed

The number of vertebrae which contribute to the

have migrated anteriorly and their function has

sacrum varies from species to species and depends

subsequently changed. In the ape, the gluteus medius

on the degree of stability or mobility required at

and minimus muscles are femoral extensors, while

the sacroiliac joint. Many amphibians and reptiles

in humans they act as femoral abductors (Fig.

have only one or two sacral vertebrae whereas higher

and thus prevent a Trendelenburg gait.

2.2)

marrunals have five. The extreme of sacral develop­

In addition to the reorientation of the ilium, a fossa

ment is fo und in the bird where the synsacrum

has developed (the iliac fossa) which increases the

includes the fusion of the sacral, lumbar, and caudal

surface area available for the attachment of the

thoracic vertebrae. This, together with the huge

gluteal and iliacus muscles. The reduction in extensor

sternum, provides the stability necessary to anchor

power caused by the anterior migration of the gluteus

the muscles which move the wings.

medius and minimus muscles is therefore compen­

As the locomotive pattern of vertebrates pro­

sated for. The iliac fossa also facilitates the enlarge­

gressed from crawling to the linear-limb quadri­

ment of the iliacus muscle, which plays a significant

pedal and bipedal gait of advanced mammals, the

role in the maintenance of erect hwnan posture.

role of the ilium became more Significant. The bone

The anatomical changes apparent in the ischium

provided the major pelvic attachment for the limb

reflect the alteration in function of the hamstring

musculature as well as the articular surface for the

muscle group (see below). Although these muscles have continued to be involved in femoral extension,

sacroiliac joint.

constant activity is not a requirement of bipedal stance in humans. Subsequently, the ischial body and tuberosity have become reduced in both length and

COMPARATIVE ANATOMY

width (Fig.

2.1).

The vertical dimension of the pubic

The structure of the human pelvic girdle reflects

symphysis has also decreased with the evolution of

the adaptation required for bipedal gait (Keagy &

efficient bipedal gait.

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Evolution and comparative anatomy

Gorilla

Macaque Figure

2.1

Human

Comparative a n a tomy of the pelvic girdle. ( Redrawn from Stein Et Rowe

the angle of

1982.)

inclination, ensures that the leg adducts

at heel strike to place the foot beneath the acetabulum. The ligaments of the hip joint (Figs

4.23 and 4.24)

are extensive in comparison to those of the ape, where they are almost non-existent.

POSTURE The hwnan vertebral column, in comparison to other primates, differs primarily in its posture. The human vertebral column and innominates have rotated

90° to bring the head above the 2.3). The sacral base is no longer horizontal as it is in non-human mammals, but neither has it rotated through 90° (AbitboI1995, 1997). The angle of the sacral promontory with the fifth lumbar ver­ tebra is acute. Consequently, the spine organized into a vertical column even though the orientation of the sacrum facilitated a more horizontal row. posteriorly through feet (Fig.

Gorilla Figure

2.2

Caudally, the lumbosacral angle and lumbar lordo­

Human

The gluteus medius and minimus muscl e s in the

gorilla function as femoral extensors while in humans they act as femoral abductors.

sis developed. This curve was compensated for

by

the development of a thoracic kyphosis. In all non-human primates, the lumbar spine is kyphotic. However, it is possible for a non-human

ACETABULUM

primate to achieve a lumbar lordosis, as was wit­ nessed

by

Goodall

(1979) in

her Gombe Stream

The acetabul um has become deeper as well as reori­

Reserve study. One ape in this study contracted

ented in an anterolateral direction. llis reorientation

poliomyelitis as an infant, which affected the function

projects the femoral neck anteriorly and, together with

of one arm. Since the characteristic "knuckle walk"

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5

6

THE PELVIC GIRDLE

attachments of the posterior muscles in the ape are widespread and the ischial body and tuberosity are

massive. Conversely, in humans, the line of gravity falls slightly posterior to the coronal axis of the hip joint (Fig.

8.1)

and therefore the requirements for

postural balance are both reduced and reversed. According to Abitbol

(1997),

erect posture can be

effortless when the center of the sacroiliac joint (biau­ ricular line) and the center of the acetabulum (biac­

etabular line) form a vertical line when the sagittal plane of the pelvis is viewed laterally. The body weight is more efficiently balanced and tends to

extend the pelvic girdle on the femora. To prevent this, slight recruitment of the psoas major muscle

is required to maintain the optimal bipedal posture. Only intermittent activity is required from the hamstring muscle group and consequently the ischial

body and tuberosity have become considerably Gorilla Figure 2.3

Human

reduced in size.

Posterior rotation of the vertebral column and the

innominates has led to the development of the lumbosacral

Summary

lordosis and the thoracic kyphosis.

The human lumbopelvic-hip complex has developed from the primate pelvic girdle which evolved for an

was not possible, the animal had developed a bipedal

arboreal lifestyle. The current vertebral curvatures

gait for locomotion. To facilitate this, a marked lum­

are relatively recent; the early hominids and even

bar lordosis had developed. However, the attach­

Neanderthals had different vertebral curvatures. The

ment of the gluteal muscles in the ape prevents

curves are interdependent a nd any factor which

simultaneous extension of the lumbar spine and the

causes a change in one results in a compensatory

femur and since neither the osseous nor the myofas­

change in all others. The major structural changes in

cial structure had changed, an increase in both hip

Homo sapiens appear to have evolved to facilitate

and knee flexion had to occur in order to maintain

the most bioenergetically efficient gait among

the line of gravity within the base of support.

terrestrial tetrapods.

The bipedal posture of the ape depends on the massive

gluteal and hamstring muscles whose

major role is to stabilize the pelvic girdle and the trunk on the flexed hips. Constant activity in both

ACKNOWLEDGMENT

muscle groups is re quired since the line of gravity of the bipedal ape falls consider a bly anterior to

For

the coronal axis of the hip joint. Consequently, the

Meadows.

this

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contribution,

I

am

indebted

to

Jim

7

The pelvis - its anatomy through time

EMBRYOLOGY AND DEVELOPMENT

CHAPTER CONTENTS

DEVELOPMENT OF BONES

Embryology and development

7

The sacroiliac joint and aging

10

The pubic symphysis and aging

13

Sacrum The sacrum derives its name from the Latin word saeer,

meaning sacred. It is thought that the sacrum

was the only bone to be preserved following the burning of a witch and as such must have been sacred. Fryette credits the "ancient Phallic Worshipers [for naming] the base of the spine the Sacred Bone" (Fryette 1954). The bone is derived from the fusion of five mesodermal somites. During the 4th embry­ onic week, 42-44 pairs of somites arise from the paraxial mesoderm. Although not consistently, the sacrum evolves from the 31st to the 35th somites, each of which divides into three components - the sclerotome, myotome, and dermatome (Fig. 3 .1). The sclerotome multiplies and migrates both ventrally and dorsally to surround the notochord and the evolving spinal cord. Subsequently, each sclerotome divides into equal cranial and caudal components

�--- Myotome .�iI.'-- Dermatome 7'"5;';':-:'--� Sclerotome

Figure 3.1

Differentiation of the mesodermal somite into

sclerotome, myotome, and dermatome. ( Redrawn from Williams

1995.)

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8

THE PELVIC GIRDLE

separated by a sclerotomic fissure which in the sacrum progresses to develop a rudimentary inter­ vertebral disk composed of fibrocartilage. The adja­ cent sclerotomic segments then fuse to form the centrum of the sacral vertebral body. The dorsal aspect of the sclerotome, which has migrated poster­ iorly, forms the vertebral arch (the neural arch is part of this), while the ventrolateral aspect becomes the costal process (ala of the sacrum) (Fig. 3.2). This process appears only in the upper two or three sacral segments and is responsible for forming the auricu­ lar sacral surface.

Vertebral Arch

Costal Element

Centrum

Fi gure 3.2 The sclerotome of the future sacrum differentiates into three parts: the centrum, the vertebral arch, and the costal element or process.

Chondrification of the sacrum precedes ossifica­ tion and begins during the 6th embryonic week (Rothman & Simeone 1975). The primary ossification centers for the centrum and each half of the vertebral arch appear between the 10th and the 20th week, while the primary centers for the costal elements appear later, between the 6th and the 8th month. The three components of the sacral segment (Fig. 3.2) - the costal element, the vertebral arch, and the centrum - remain separated by hyaline cartilage up lffitil 2-5 years of age when the costal element (ala of the sacrum) unites with the vertebral arch. Th.is unit then fuses to the centrum and to the other vertebral arch in the 8th year. The conjoined costal element, vertebral arch, and centrum of each sacral segment remain separated from those above and below by hyaline cartilage laterally and by fibrocartilage medially (Fig. 3.3). A cartilaginOUS epiphysis extends the entire length of the lateral aspect of the sacrum. Fusion of the sacral segments occurs after puberty in a caudocranial direction with the simultaneous appearance of sec­ ondary ossification centers for the centrum, spinous process, transverse processes, and costal elements. The adjacent margins of the sacral vertebrae OSSify after the 20th year; however, the central portion of the intervertebral disk can remain lffiossified even after middle life.

2 3 2

3

4

Figur e 3.3 O ssifi c ati on of the sacrum. Left: Posterior aspect: note the centrum (1), the vertebral arch (2), the lateral ep ip hysis ( 3 ) . and the sacral canal (4). Right: Anterior aspect: note the c ent rum (1), the lateral epiphysis (2), and the intervertebral disk (3). (Reproduced with permission from Rohen 8 Yokochi 1983.)

Copyrighted Material

The pelvis

Innominate

its anatomy through time

8th week of intrauterine life. As in other synovial

The innominate has a Latin derivation, innominatu5, meaning having no name. It appears during the 7th embryonic week as three bones - the ilium, the ischium, and the pubis - which are derived from a small proliferating mass of mesenchyme from the somatopleure in the developing limb bud. Three primary ossification centers appear before birth, one for the ilium above the sciatic notch dunng the 8th intrauterine week, one for the ischium in the body of the bone during the 4th month , and one for the pubis in the superior ramus between the

-

4th and 5th

months. At birth, the iliac crest, the acetabular fossa, and the inferior ischiopubic ramus are cartilaginous (Fig. 3.4). The inferior ischiopubic ramus ossifies dur­ ing the 7th to 8th year. The iliac crest and the acetabu­ lar fossa develop secondary ossification centers during puberty but can remain unossified until 25 years of age. When treating adolescents, it is pertinent to recall the stage of development before applying vigorous mobilization or manipulation techniques.

joints, a trilayer structure initially appears in the mesenchyme between the ilium ent of the sacrum. Cavitation begins both peripher­ ally and centrally by the 10th week and by the 13th . week the enlarged cavities are separated by flbrous septa.

These

findings

are

not

consistent

with

Walker's ( 1984, 1986) study of 36 fetuses in which she noted that cavitation did not begin until the 32nd week (Fig. 3.5). The stage at which cavitation is complete and the fibrous bands disappear is c�n­ troversial. Bellamy et al ( 1983) state that the cavity is fully developed by the 8th month and that the fibrous septa soon disappear whilst Walker (1986) notes that, unlike most synovial joints which show complete cavitation by the 12th week, the SIT remains separated by fibrous bands at birth and she questions their persistence in some joints into adult­ hood. Bowen & Cassidy ( 1981) report that the 10 specimens studied in this age group did not contain . ill late fetal life.

the fibrous septa previously noted

Schunke (1938) was the first to describe these intraarticular bands and felt that they disappeared

DEVELOPMENT OF JOINTS

in the first year of life. The synovium of the joint develops from the

Sacroiliac joint

mesenchyme at the edges of the primordial cavity, as

According to Bellamy et al ( 1983), the development

does the articular capsule which is thin and pliable at

of the sacroiliac joint (SIJ) commences during the

this stage (Bowen & Cassidy 198 1). All investigators

2

6

5 4

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Figure 3.4 The medial (left) and lateral (right) aspect of the left innominate bone and the ossification process. Note the cartilage of the iliac crest (1), the ilium (2), the cartilage separating the ilium, pubis and ischium (3), the pubis (4), the ischium (5) and the acetabulum (6). (Reproduced with permission from Rohen Et Yokochi 1983.)

9

10

THE PELVIC GIRDLE

Figure 3.5

Cavitation of the

sacroiliac joint. Top: Sacroiliac joint of a fetus at 16 weeks of gestation. Note the proximity of the iliac bone to the joint surface, the partial cavitation of the joint, and the presence of a fibrous band connecting the two surfaces. Bottom: Sacroiliac joint of a fetus at 34 weeks of gestation. Note that cavitation is almost complete except for a few loose fibrous bands. (Reproduced with permission from Walker 1986.)

note (Schunke 1938, Bowen & Cassidy 1981, Walker

thin layers of hyaline cartilage. The sym ph y sis

macroscopic

is present by the end of the second month of gesta­

and microscopic differences between the cartilage

tion (Gamble et al 1986) wit h thick cartilaginous

which lines the articular surfaces of the ilium and

end-plates at birth (9-10 mm) that become thin

1986, Kampen & TiJ lmann 1998) the

(200-400

the sacr um. The ilium is lined with a type of fibrocartilage which

/-lm)

with skeletal maturity. The s econda ry

ossification centers appear in early puberty and, by

is bluer, duller and more striated than the hyaline

mid-adolescence, the joint has reached its mature

cartilage which lines the sacrum (Plates 1 and 2) and

size. It is beyond the scope of this text to describe

this difference is noted r ight from birth (Kampen &

the detailed embryology of the hip joint; however,

Tillmann 1998). The depth of the cartilage is also

several references are included for the int e re s ted

different. Accor d ing to Bowen & Cassidy (1981), the

reader (Str ayer 1971,

sacral hyaline cartilage is three to five times thicker

Feldman 1980, Walker 1980a, b, 1981).

Watanabe

1974, Siffert

&

than the iliac fibrocartilage. This is consistent with the

fin d ings of Schunke (1938), Ma cDon a ld &

HtU\t

(1951) and Kampen & Tillmann (1998), but differs from the studies of Walker (1986), who fOlmd that the sacral hyaline cartilage was 1.7 times thicker than the iliac fibrocartilage, although this f inding may var y

depending upon which aspect of the joint was being s tudied All agree that the corresponding articular .

surfaces were smooth and flat at this stage, although Walker (1984) fotU\d elevations and depressions on her full-term infants as well. Bowen & Cassidy (1981) note that during handling of the fetal pelves, the joint

was capable of gliding in a multitude of directions.

developmentally. A

m ajor

part of the unit is carti­

laginous and the articular anatomy contributes little

to intrapelvic stability. The changes

which

occur

within the SIJs over the next seven decades are sig­ nificant for the biomechanics, assessment, and treat­

ment of the pelvic girdle in the var ying age groups.

THE FIRST DECADE (0-10 YEARS)

this age group and report that the surfaces of the

The pubic symphysis is a non-synovial joint which

th ick

At bir th, the pelvic girdle is far from complete

Bowen & Cassidy (1981) studied seven pelves in

Pubic symphysis and hip joint contains a

THE SACROILIAC JOINT AND AGING

fibrocartilaginous disk between

SIJ remain primarily flat (Pl ate

rest ra int

Copyrighted Material

2),

with the major

to passi ve motion being provided by the

The pelvis - its anatomy through time

Figure 3.6

A coronal section through two embalmed male specimens: the left aged 12 years and the right over 60 years. Note the

planar nature of the sacroiliac joint in the young an d the presence of ridges and grooves (arrows) in the old. S, sacrum. (Reproduced with permission from Vleeming et al 1990a.)

formation and

very strong interosseous ligaments. The articular

and some crevice

cartilage remains as noted prenatally.

the end of the third decade. The sacral hyaline carti­

erosion occurs by

lage takes on a yellowish hue, although macroscopic changes are not evident at this stage. The collagen

THE SECOND AND THIRD DECADES (11-30 YEARS)

cing its The availability of cadavers for investigation in this age group is limited; the data obtained is, therefore, based on few specimens. Sashin's (1930) investigation of age-related intraarticular changes is perhaps the most extensive;

42 specimens in his study

fibrous extenSibility.

content of the

belonged

to this age group. The study of Resnick et al (1975)

capsule increases, thus redu­ Passive articular

motion

is

limited to a small angular motion coupled with a few millimeters of translation. Shibata et al

(2002)

inves­

tigated age-related changes (joint space narrowing, sclerosis, osteophytes, cysts, and erosion) of the via

computed tomography

51}

(CT) and found changes

beginning in the third decade.

included only two specimens, MacDonald & Hunt's (1951) seven, Bowen & Cassidy'S (1981) seven, and Walker's (1986) none. Early in the second decade the

51} appears planar; third decade all

THE FOURTH AND FIFTH DECADES (31-50 YEARS)

however, by the beginning of the

Several investigators

specimens manifest a convex ridge which runs along

Cassidy 1981, Walker 1984, 1986, Faflia et al 1998,

a12002)

(Schunke 1938,

Bowen

&

the entire length of the articular surface of the ilium

Shibata et

apposed to a corresponding sacral groove (Bowen &

articular surfaces during this stage represent a degen­

Cassidy 1981, Vleeming et al 1990a) (Fig. 3.6). The

erative process. The changes occur earlier in males

feel that the changes noted in the

(fifth decade). Vleeming

iliac fibrocartilaginous surface is duller, rougher,

(fourth decade) than females

and

et al (1990a, b) feel that since these changes are

intermittently coated with fibrous plaques

3). The deep articular cartilage is microscopic­

asymptomatic in most, they reflect a functional

ally normal, but the superficial layers are fibrillated

adaptation secondary to an increase in body weight

(Plate

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11

12

THE PELVIC GIRDLE

Figure 3.7 Sacroiliac joint of a male, 60 years of age. Note the variability in the depth of both the sacral (5) and the iliac cartilage at different sites. (Reproduced with permission from Walker 1986.)

Figure 3.8 Left: This rad iograph of a coronal section through the sacroiliac joint of a cadaver over 70 years of age illustrates narrowing of the joint space (Jl. sclerosis of the bone (5) and osteophyte formation (0) secondary to the degenerative process. Note the space for the interosseous ligament (UG). SAC ind icates the sacrum and IL the ilium. Right: This photomicrograph reveals the thickened trabeculae in the sclerotic region (5), an area of fibrous intraarticular fusion (FUS) and the previously noted osteophyte (0). (Reproduced with permission from Resnick et al (1975) and the publishers J. B. Lippincott.)

during puberty and not a degenerative process. They studied the effects of the cartilage texture on the friction coefficient of the joint (Vleeming et al 1990b) and found that, together with the develop­ ment of ridges and grooves, the fibrillated sw-face increased friction and thus stability of the SIJ. This was felt to reflect an adaptation to bipedalism. The articular surfaces increase in irregularity, with marked fibrillation occurring on the iliac side by the end of the fourth decade (Plate 4). Plaque for­ mation and peripheral erosion of cartilage progress to subchondral sclerosis of bone on the iliac side. The joint space contains flaky, amorphous debris. The articular capsule thickens but still permits the translatory motion noted in the second and third decades (Bowen & Cassidy 1981). Bony hypertrophy with some lipping of the sacral articular margins was noted in some specimens in the fifth decade. Shibata et al (2002) found degeneration to be more frequent in this age group and found sclerosis to be common on the upper and middle anterior of the articular surface of the ilium whereas osteophytes

were common on the anterior surface of the sacrum. Women showed more advanced signs of degener­ ation and parous women tended to progress faster than nulliparous women.

THE SIXTH AND SEVENTH DECADES (51-70 YEARS) At this stage (Figs 3.7 and 3.8), the articular surfaces become totally irregular with deep erosions occa­ sionally exposing the subchondral bone. Peripheral osteophytes enlarge and often bridge the anterior margin and inferior lip of the joint. Fibrous inter­ connections between the articular surfaces are com­ monplace; however, "when stressed, all specimens maintained some degree of mobility, although this was restricted when compared with the younger specimens" (Bowen & CaSSi dy 1981). Vleeming et al (1992a) found that even in old age small move­ ments of the SIJ are possible and ankylOSiS of this joint is not normal. Faflia et al (1998) also note that ankylosis of the SIJ was rare and, like Shibata et al

Copyrighted Material

The pelvis

-

its anatomy through time

Figure 3.9 Sacroiliac joint of a female, 81 years of age. Note the erosion of the articular cartilage and the intraarticular fibrous connection (arrow). (Reproduced with permission from Walker 1986.)

Figure 3.10 This radiograph of a transverse section (ANTER. is the anterior aspect of the pelvis and POST. is the posterior aspect) through the sacroiliac joint (J) illustrates the intra­ articular ankylosis (A) of ankylosing spondylitis. Note the ossification of the interosseous ligament (UG). SA C indicates the sacrum and IL the ilium. (Reproduced with permission from Resnick et al (1975) and the publishers J. B. Lippincott.)

(2002), found joint changes in all subjects imaged this age group. Interestingly, Faflia et al (1998) fOlmd a higher prevalence of asymmetric non­ uniform SlJ narrowing and extensive subchondral sclerosis in obese and multiparous women when age-matched to men, normal-weight women, and non-multiparous women.

in

ankylosis is rarely reported and usually thought to be associated with ankylosing spondylitis (Fig. 3.10). Schunke (1938) reports that the average age of the specimens with bony ankylosis is considerably less than those without fusion, confirming a probable pathological cause. In Walker's study (1986), 15 adult cadavers between 49 and 84 years of age were investigated for age-related changes. "Changes observed in adult specimens were similar to those of previous reports, but from examination of the entire joint, this report emphaSizes the inherent variability of the SI}, both within and between joints, at any of the ages studied." THE PUBIC SYMPHYSIS AND AGING

In the fourth decade, smooth undulations appear along the margins of the joint and the bone begins to compact. This process continues and in the sixth decade the superior and inferior edges of the symph­ ysis are clearly demarcated on X-ray and a dense sclerotic streak is present. This sclerosis continues and marginal osteophytes may appear (Gamble et aI1986). Summary That the SIJ degenerates with time is not unique to

THE EIGHTH DECA DE (OVER 70 YEARS)

this articulation. The significance of this degeneration

Intraarticular fibrous connections are more often the rule, with some periarticular osteophytosis present (Plate 5, Fig. 3.9). Cartilaginous erosion and plaque formation is extensive and universal, filling the joint space with debris. Consequently, the joint space is markedly reduced. Intraarticular bony

advancing age does not mean the loss of mobility.

for function is unknown. Clinically, it appears that Current evidence supports the view that the presence or absence of SIJ mobility and its significance to the patient's presenting complaints are best judged by clinical evaluation.

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13

15

Chapter 4

Anatomy

HISTORY

CHAPTER CONTENTS History

15

16

Osteology: the bones Arthrology: the joints

Myology: the muscles Neurology: the nerves

Angiology: the blood

20

28

37

supply 39

The following historical data comes from Lynch (1920). The earliest record of anatomical data per­ taining to the pelvic girdle is credited to Bernhard Siegfried Albinus (1697-1770) and William Hunter (1718-1783). According to Lynch (1920), these anatOrrDsts were the first to demonstrate that the sacroiliac joint (SIJ) was a true synovial joint, a find­ ing apparently confirmed by Meckel in 1816. Von Luschka, in 1854, was the first to classify the joint as diarthrodial (Lynch 1920). Further anatomical stud­ ies conducted by Albee in 1909 on 50 postmortem specimens confirmed that the joint was lined with a synovial membrane and contained by a well-formed articular capsule. His findings were confirmed by Brooke in 1924. It wasn't until 1938 (Schunke 1938) that the variations in the articular cartilage lining the iliac surface were noted. In 1957, Solonen conducted a comprehensive study of the osteology and arthrol­ ogy of the pelvic girdle, from which some findings will be reported later in this chapter. The pelvic girdle as a unit supports the abdomen and the organs of the lower pelvis and also pro­ vides a dynamic link between the vertebral column and the lower limbs. It is a closed osteoarticular ring composed of six or seven bones which include the two innominates, the sacrum, the one or two bones which together form the coccyx and the two femora, as well as six or seven joints which include the tvvo sacroiliac, the sacrococcygeal, often an intercoccygeal, the pubic symphysis, and the two hip joints. Copyrighted Material

16

THE PELVIC G I R DLE

which are essential to the descrip tion and evaluation

O STEO LOGY: THE B O N ES

of function will be described here. The cranial a spect of the first sacral vertebra

SACRUM

(Fig. Little wonder tha t the a ncient Phallic Worshipers named the base of the spine the sa cred bone. It is the seat of the transverse center of gravity, the keys tone of the p elvis, the founda tion of the spine. It is closely a ssocia ted w i th our grea test abilities and disabilities, with our greate s t romances and tragedies, our grea t­ est p l e asure and pains (Fryette

1954).

The sacrum is a large tr ian g ular bone situated a t the base of the spine wedged between the tvvo innom­ inates. It is formed by the fusion of five sacral verte­ bra e (see Fig .

3.3), and the vertebral equiv alents a re

easily recognized. The sacrum is highly va riable both between individuals and between the left and right sides of the s ame bone.

In spite of this,

certain

a na tomical features are consis tent and only those

4.1),

the sacral base, consists of the vertebral

body an teriorly (the anterior projec ting edge being the sa cra l promon tory) and the vertebral arch pos­ teriorly. Laterally, the transverse processes of the first sacral vertebra are fused wi th the costal elements (see Fig. 3.2) to form the alae of the sacrum. Variations have been noted (Grieve

1981)

in the height of the

sacral alae as well as the body of the

51 vertebra.

The orienta tion of the superior articula r processes of the

51 vertebra is also variable (see below).

The pos terior surface of the sa crum (Fig.

4 . 2) is

convex in both the sagittal and the transverse planes. The spinou s processes of the

51-54 vertebrae are

fused in the midline to form the median sa cral crest. La tera l to the median sacra l crest, the inte rmediate sacral cres t is formed by the fused l aminae of the

51-55 vertebrae. The laminae and inferior artic ular 55 (and occasionally the 54) verte­

processes of the

Superior Articular

bra remain unfused in the midline . They projec t

Process

cau d ally t o form the sacral cornua, and together with the pos terior aspect of the ver tebral bod y of the

Sacral Ala

55 v erte b ra, form the s acral hia tus. The la teral s a cral crest represents the fused transverse processes of the

51-55 vertebrae. Between this crest and the inter­ mediate sa c ral crest lie the dors a l sa cral foramina

F i g ure 4.1

which transmit the dorsal sacral ramus of each

<

Vertebral Body

s a c ral

spina l nerve. There are three deep depressions in

Sacral Promonlory

The cran i a l aspect of t h e first sacral vertebra - the

the lateral s a cral cre s t at the levels of the

51, 52, and

53 ver tebrae. These depressions contain the strong

sacra l base.

Deep Depressions for

Attachment of the

-----1r4.'"""'"",ffi)

Dorsal Interosseous

&/,;.---11'>-

Ligament

�-+-'--"�Median Sacral

Crest

-""",",,4-..i!-/c-..

Lateral

Sacral

Crest

Dorsal Sacral Foramen

���Ifm+- Intermediate Sacral Crest

Unfused Spinous

Process of S4

&

Inferior Lateral Angle

S5

(Sacral Hiatus)

Sacral Transverse Process

Cornua

Coccygeal Cornua

Figure 4.2 The posterior a s p ect of the sacrum and coccyx. Inset: the o rientation of the th ree components of the aUricular surfac e a re sha ped like a p rope l l er. (Re drawn from V l eem i ng et a l 199 7 .)

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Anatomy

attachments of the interosseous sacroiliac ligament (Fig. 4.2 and see Fig. 4.13). The lateral sacral crest fuses with the costal element to form the lateral aspect of the sacrum (Fig. 4.3). S uperiorly, the lateral aspect of the sacrum is wide, while inferiorly the anteroposterior dimension nar­ rows to a thin border which curves medially to join the S5 vertebral body. This angle is called the mferior lateral a ngle of the sacrum (Figs 4.2 and 4.4). The articular surface of the sacrum is auricular in shape (L-shaped) and is contained en t i rely by the costal elements o fthe first three sa cral segments. The short arm of the L-shaped surface (Fig. 4.3) lies in the vertical plane and is contained within the first sacral segment. The long arm lies in the antero­ posterior plane within the second and third sacral segments. The contours of the articular surface are

Figure 4.3

The lateral aspect

of the

reported (WeisI1954, 1995, Solon en 1957, Kapandji 1970, Vleeming et al 1990a) to be highly variable and depend on the age of the individual studied (see Ch. 3) . Investigators have reported (Kapandji 1974) the presence of a curved furrow bordered by two longitudinal crests corresponding to a convex longitudinal crest on the articular surface of the ilium. However, Solonen (1957) in his study of 30 skeletons concluded that there were "numerous depressions, elevations and other irregularities ... In no case was there a distinct ridge-furrow or eminence-depression formation. On the contrary, the impression was gained that great irregularity prevails in respect to the surface formations" (Solonen 1957). His study; however, did not consider the age-related changes which may have been present in his specimens. The anterior surface of the sacrum (Fig. 4.4) is concave in both the sagittal and the transverse planes. In the midline, four interbody ridges represent the sclerotomic fissures which are not always c ompletely fused. Lateral to the fused vertebral b odies are four ventral sacral foramina which transmit the ventral ramus of each sacral spinal nerve as well as the seg­ mental ventral sacral artery. The costal elements pro­ ject laterally from the middle of each vertebral body between the ventral sacral foramina and fuse with those above and below as well as with the transverse processes p osteriorly to form the lateral aspect of the sacrum. The orientation of the articular surface of the sacrum in b oth the coronal and the transverse planes has been studied by Solonen (1957) and a summary of his findings is presented in Table 4.1. These obser­ vations represent the common findings but variations

sacrum.

Table

4. 1

Orientation of the articular surface of

the sacrum in the coronal and transverse planes Superior Articular Process

-I.=---"':?...�.u-'!4.1.P

Ala

as described by Solonen

(1957) and

Coronal plane 900/0 of the specimens narrowed

Costal Element

BOOfo of the specimens examined narrowed superiorly at 53

Coccyx---�

Transverse plane 51 and 52 narrow posteriorly 53 narrows anteriorly

The anterior aspect

Fig.4.SB

narrowed inferiorly at 52

Sacral Foramen

Inferior Lateral Angle

Figure 4.4

Fig. 4.SA and B

inferiorly at 51 BSOfo of the specimens examined

Ventral

as shown

graphically in Figure 4.5

of

the sacrum and coccyx.

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Fig.4.SA

17

18

THE PELVIC G I R DLE

Fig ure 4.5

Stereometric drawings of two pelves studied by Solonen

(1 957)

illustrating the variation found in the

orientation of the sacral articular surface. (Redrawn with permission from Solonen

Figure 4.6 Figu res 4.6-4.8

Figure 4.8

Fig u re 4.7 Sacrum types

A, B,

1957.)

and C.

were noted. The stereome tric drawings of two pelves studied by Solonen are illustrated in Fig ure 4.5. Vleeming et al (1997) describe the orienta tion of the three components of the auricular surface as resem­ bling those of a propeller (Fig. 4.2 inset). Fryette (1954) examined 23 sacra and subsequently classified the bone into three types: A, B, and C (Figs 4.6-4.8). This classification depends on the orienta­ tion of the sacral articular surface in the coronal plane, which he found to correlate with the orientation of the superior articular processes of the Sl vertebra. The type A sacrum narrows inferiorly at Sl and S2 and superiorly at S3. The orientation of the superior articular processes in this group is in the coronal plane. The type B sacrum narrows superiorly at Sl and the orientation of the superior articular processes in this group is in the sagittal plane. The type C sacrum narrows inferiorly at Sl on one side (type A) and superiorly a t S1 on the other (type B). The orien­ tation of the superior articular processes is in the

coronal plane on the type A side and in the sagittal plane on the type B. In conclusion, there is a high incidence of vari­ ability in the plane of the SIJ, in both the coronal and the transverse planes as well as in the shape of the articulating surfaces. Grieve (1981) has noted that "Each joint exhibits at least two planes slightly angu­ lated to one another and often three - their dispos­ ition and area are no t always similar when sides are compared in the same individual." As clinicians, we are never relieved of the necessity for accurate cl.inical evaluation given the anatomical uncertainty of the individual being assessed.

C O C CYX

The coccyx (Figs 4.2 and 4.4) is represented by four fused coccygeal segments although the first is com­ monly separate. The bone is roughly triangular;

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Anatomy

Iliac Crest Iliac Cresl

Anicular Surface Attachmenl of Ihe Inlerosseous Ligamenl Posterior Superior iliac Spine

Poslerior Superior Iliac Spine Poslerior Inferior Iliac Spine

"l'-\,p---Arcuale Line

"'!/f---- lIiopeclineal Eminence

....�--Ischial Spine

Superior Pubic Ramus

Ischial Tuberosity

Ischial Tuberosily

Inferior Pubic Ramus

Ischial Ramus

Ischial Ramus

Figure 4.9 Figures 4.9 and 4.10

Figure 4.10 The medial and lateral aspects of the innominate.

the base bears an oval facet which articulates with the inferior aspect of the S5 vertebral body The first coccygeal segment contains two rudimentary transverse processes as well as two coccy geal cor­ nua which project superiorly to articulate with the sacral cornua.

INNOMINATE There are three parts to the innominate, the ilium, the ischium and the pubis, w hich in the adult are fused to form one bone, the innominate (Figs 4.9 and 4.10 and see Fig. 3.4). Only the anatomical features pertin­ ent to the description and evaluation of function will be described here.

Ilium The ilium is a fan-like structure forming the superior aspect of the innominate and contributing to the superior portion of the acetabulum. The iliac crest is convex in the sagittal plane and sinusoidal in the transverse plane such that the anterior portion is concave medially whjle the posterior portion is con­ vex medially The curve reversal occurs in the same coronal plane as the short arm of the L-shaped articu­ lar surface. The anterior s uper ior iliac spine (ASIS)

and the posterior superior iliac spine (PSIS) are at either end of the iliac crest. Inferior to the PSIS, the ilium curves irregularly to end at the posterior inferior iliac spine (PHS). This is often the site of an accessory srJ (Trotter 1937, SoIonen 1957). Several anatomical points are worthy of note on the medial aspect of the ilium. The articular surface lies on the posterosuperior aspect of the medial sur­ face. Like the sacrum, the articular surface is L-shaped with the axis of the short arm in the cralliocaudal plane, while the long arm has an anteroposterior axis. A variety of elevations, depressions, ridges, and furrows have been reported and develop with age (see Ch. 3). Superior to the articular surface, the medial aspect of the ilium is very rough and affords attachment to the strong interosseous sacroiliac liga­ ment which has been noted (Colachis et al 1963) to remain intact when the sacrum and the innominate are forced apart in cadavers. The SrT cannot be pal­ pated given the depth of the articulation and this point should be noted when studying the anatomy. Anteriorly, the arcuate line of the ilium appears at the angle between the short and the long arms of the articular surface and projects anteroinferiorly to reach the iliopectineal eminence, a point at which the ilium and the pubis ullite. This line between the SrI and the iliopectineal eminence represents a line of force transrrussion from the vertebral column to the lower

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19

20

THE PELVIC GIRDLE

and is reinforced by subperiosteal trabeculae (Kapandji 1974).

limb

Pubis

The inferomedial aspect of the innominate is formed by the pub i s which articulates with the pubis of the opposite side via the pubic symphy sis. It joins the il ium superiorly via the superior p ubic ramus which constitutes the anterior one-fifth of the acetab u lum. Inferiorly, the inferior pubic ramus projects postero­ lateraUy to join the ischium on the medial aspect of the obturator foramen. The lateral surface of the p u bis is directed towards the lower limb and affords attachment for many of the medial muscles of the thigh . The pubic tubercle is located at the lateral aspect of the pubic crest appro x imatel y 1 em lateral to the mid symphyseal line. Ischium

The inferolateral one-third of the innominate is fo rmed by the ischium. The upper part of the body of the ischium forms the floor of the acetabulum as well as the posterior two fifths of the articular surface of the hip joint. From the lower part of the bod y, the ischial ramus projects anteromedially to jOin the inferior ramus of the pubis. The ischial tuberos­ ity is a roughened area on the posterior and inferior aspect of the ischi al body and is the site of strong muscular and ligamentous attachments. Superior to the tuberosity, the ischial s p ine projects medially. This process is also the site of ligamentous and muscular attachments (see Figs 4.12 and 4.18).

femur, as well as the angle of anteversion between the femoral neck and the coronal plane, are hi g hly variable. This variability will be reflected in both the pat ter n and the range of motion available at the hip j oint (Kapandji 1970).

ARTHROLOGY: T HE JOINTS SACROILIAC JOII'JT

The SIT (Fig. 4.11) is classified as a synovial joint or diarthrosis (Bowen & Cassidy 1981). According to Bowen & Cassidy (1981), A lb inus and Hunter were the first to note the presence of a synovial mem­ brane w it hin the joint. In 1850, Koelcher identified synovial fluid within the joint on dissection (Bowen & Cassidy

1981).

The shape, as well as the articular cartilage, have been previously described (see Ch. 3). To summar­ ize, the sacral surface is covered with hyaline cartil­ age while the iliac srnface is covered with a type of fibrocartilage (see Ch. 3, Plates 1--4). The de p th of the articular cartilage differs both within the same

-

Acetabulum

The acetabulum (see Figs 4.10 and 4.22) is formed from the fusion of the three bones which make up the innominate (see Fig. 3.4). It is roughly the shape of a hemisphere and projects in an anterolateral and inferior direction. The lunate surface represents the articular portion of the acetabulum while the non­ articular portion constitutes the floor, or the acetabu­ lar fossa. This fossa is continuous w ith the acetabular notch located betvveen the two ends of the l un ate surface.

FEMORA Clinically, it is important to note that the angle of inclination of the femoral neck to the shaft of the

Figure 4." A computed tomography scan (top) with a photograph of the c o r re s po n d i n g anatomical section (bo tt o m) through the synovial portion of a cadaveric sacroiliac joint (arrows). (Reproduced with permission from Lawson et al (1982) and the publishers Raven Press.)

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Anatomy

articular surface and on apposing sides (see F ig . 3.7). Most inv es tigator s report

(MacDonald

& Hunt 1951,

Solonen 1957, Bow en & Cassidy 1981) a ratio of 1:3 between the iliac and sacral surfaces. The joint cap sule is composed of two layers, an external fibrous layer which contains abundant fibroblasts, blood vessels, and collagen fibers, and an

inner synovial layer. The chronological chan ges

in the articular ca p sule have been described (Ch. 3). Anteriorly, from

the capsul e is clearly distinguished

the overlying ventral

sacroiliac li gament,

while posteriorly the fibers of the capsule and the deep inte rosseous liga ment are intimately blended. I n ferio rly, the c a p su l e blends with the perioste u m of the contiguous sacrum and innominates. Like other sy novial jOints, the S1I capsule is sup­

Interosseous sacroiliac ligament The in terosseo u s sacroiliac liga m ent is the strongest of the gro up and completely fi l ls the space between the lateral sacral

crest and

the iliac tuberosity (Figs 3.8

and 4.13). The fibers are multidirectional and can be divided into a deep and a superficial group. The deep layer attac h es medially to three fossae on the lateral

4.2)

aspect of the dorsal sacral surface (Fig.

and lat­

erally to the adj acent iliac t uberosity. The supe r fici a l layer of this ligament is a fibrous sheet which attaches to the latera l sacral crest at Sl and S2 and to the medial aspect of the iliac crest. This structure is the primary barrier to direct palpation of the

S1}

in

its superi or pa rt and its density makes intraarticular i n jections extremely difficult.

ported by overlying ligaments and fascia, some of which are the st ron gest in the bod y. They include the ventral sacroiliac, interosseous sac r oiliac, lon g dorsal sacroiliac, sacrotuberous, sacrospinous, and iliolumbar ligaments.

Long dorsal sacroiliac ligament The dorsal sacroiliac ligamen t (Fig .

4 14) .

attaches

medially to the lateral sacral crest at S3 and 54 and

and the inner lip of the iliac crest. and is separated from it by the emerging d orsal branches of the sacral spinal nerves and blood vessels. It can be palpated directly caudal to the PSIS as a thick band and at this point it is covered by the fascia of the glu­ teus maximus muscle. Med ially, fibers of this liga­ ment attach to the deep lamina of the posterior layer

laterally to the PSIS

It lies posterior to the interosseous ligament

Ventral sacroiliac ligament The ventral sacroiliac ligament (Fig.

4.12)

is the

weakest of the group and is little more than a thick­ ening of the anterior and inferior parts of the joint c a p sule (Bowen & Cassidy 1981, Williams 1995). I lio l u m b a r L igam e nt

Sup Ant

Ventral

Sacroi liac -+--++---/.....,-./ Ligament Sacrotuberous -\-',..-T----... Ligament

Sacrospinous

Ligament -----1&-�-�'7����.. II iofem ora Ligament

,

l+--'LLJ+.rf

Ligament Figure 4.12

The ligaments of the pelvic girdle viewed from the anterior aspect.

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21

22

THE PELVIC GIRDLE

Figure 4.13 A computed tomography scan (top) with a photograph of the corresponding anatomical sect i o n (bottom) through the sacroiliac joint. Note the depth of the synovial portion [SYN) of the join t and the interosseous ligament (LlG). (Reproduced with permission from Lawson et al (1982) and the publishers Raven Press.)

of the thoracodorsal fascia and the aponeurosis of the erector spinae muscle (Vleeming et aI 1996). At a deeper level, connections have been noted between the long dorsal ligament and the multifidus muscle (Willard 1997). Laterally, fibers blend with the super­ ior band of the sacrotuberous ligament. Tension can be increased in this ligament during motion of the sacrum and contraction of the muscles which blend with it. During counternutation of the sacrum, the ligament tightens (Fig. 4.15) (Vleeming et aI 1996). During nutation of the sacrum, the liga­ ment slackens. Contraction of the erector spinae mus­ cle as well as loading of the sacrotuberous ligament will also increase tension in this ligament, whereas contraction of the latissimus dorsi and the gluteus maximus muscles has been found to reduce the tension (Vleeming et aI1997). The skin overlying the ligament is a frequent area of pain in patients with lumbosacral and pelvic girdle dysfunction (Fortin et a11994a, b, 1997, 1999). Tenderness on palpation of the long dorsal sacroiliac ligament does not neces­ sarily incriminate this tissue, given the nature of

Figure 4.14 A dorsal view of the female pelvic g irdle. LPSIL, the long d orsal sacroiliac ligament, 4/5, the zygapophyseal Joint between L4 and L5; ST, the sacrotuberous ligamen t. (Reproduced with permission from Willard (1997) and the publishers Churchill Livingstone.)

pain referral from both the lumbar spine and the SIJ. Chapter 8 outlines specific stress tests for this structure. Sacrotuberous ligament This ligament is composed of three large fibrous bands, the lateral, medial, and superior (Fig. 4. 16) (Willard 1997). The lateral band connects the ischial tuberosity and the PITS and spans the piriformis muscle, from which it receives some fibers. The medial band (inferior arcuate band) attaches to the transverse tubercles of S3, 54, and S5 and the lateral margin of the lower sacrum and coccyx. These fibers run anteroinferolaterally to reach the ischial tuberos­ ity. The fibers of this band spiral, such that those

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Anatomy

23 ;

(

Long Dorsal Ligament

Figure 4.15 Countern utation of the sacrum tightens the long dorsal ligament. This increase in tension can be pa l p ated just inferior to the posterior superior iliac spine. (Redrawn from Vleeming et al 1 996.)

arising from the lateral aspect of the ischial tuberosity insert into the caudal part of the sacrum while those from the medial aspect of the ischial tuberosity attach cranially (Vleeming et al 1996). The superior band runs superficial to the interosseous ligament and connects the coccy x with the PSIS. The gluteus maximus also attaches to the sacrotuberous ligament and its contraction can increase the tension in the sacrotuberous ligament (Vleeming et a11989a, b). Phylogenetically, the sacrotuberous ligament rep­ resents the tendinous insertion of the biceps femoris muscle in lower vertebrates (Williams 1995). In some humans, this ligament still receives some fibers from the biceps femoris muscle (Fig. 4.17) (Vleeming et al 1989a, 1995b). The fibers of the biceps femoris muscle can bridge the ischial tuberosity completely to attach directly into the sacrotuberous ligament. The tendons of the deep laminae of the multifidus muscle can also blend into the superior surface of the sacrotuberous ligament (Fig. 4 16) (Willard 1997). The ligament is pierced by the perforating cutaneous nerve (52, 53) which subsequently winds around the inferior border of the gluteus maximus muscle to supply the skin covering the medial and inferior part of the buttock, perhaps a source of paresthesia when entrapped.

.

J

Figure 4.16 A dorsal view of the male pelvic girdle, ligaments in tact and al l but the dee pest laminae of multifidus (Mu) removed. The arrowheads mark the long dorsal l igame n t beneath the lateral band (LB) of the sacrotuberous ligament. The medial band (MB) of the sacrotuberous ligament traverses the ischial tuberosity [1sT) an d the coccyx. The superior band of the sacrotuberous ligament [5B) runs superficial to the long dorsal ligament to connect the coccyx with the p oster i or superior iliac spine. Tendons of the multifidus (Mu) pass between the superior band and the long dorsal ligament to insert into the body of the sacrotuberous ligament. (Re p rodu ced with permission from Willard (1997) and the p u b l i shers Churchill Livingstone.)

innominate. Proximally, fibers blend with the cap­ sule of the SIJ (Willard 1997). It is closely connected to the coccygeus muscle, of which it may represent a degenerated part (Williams 1995).

Sacrospinous ligament The sacrospinous ligament (Figs 4.12 and 4.18) attaches medially to the lower, lateral aspect of the sacrum and the coccyx. Laterally, the apex of this tri­ angular ligament attaches to the ischial spine of the

Iliolumbar ligament

Bogduk (1997) describes five bands of the iliolum­ bar ligament: anterior, superior, inferior, vertical (Fig. 4.12), and posterior (Fig. 4.19). The anterior

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u:

24

THE PELVIC GIRDLE

Figure 4.17

The biceps femoris muscle

(BFM) has been found to a l ter tension in the sacrotu berous ligame n t (STL) throug h its indirect (attaching to the i sc h ia l tuberos i ty first), and in some, d irect (bypassing the isch i a l t u berosity) connection to the l igament. (Reprod u ced with permission from V l eeming et al 1995b)

-

STL

.

..

�i

r.

\

BFM

DORSAL VIEW

-,

BFM

LATERAL VIEW

Posterior band Iliolumbar Ligament

Sacrospinous Ligament

Sacrotuberous

Figure 4.19

A t ransverse section of the l umbosa cra l junction i llustra ting the attac hment of the posterior band of the i lio lumba r l i gament.

Ligament

Figure 4.18 A sag ittal section of the pelvic g i rd le i l l u strat ing the a n c hori n g effec t of the sacrotu be rous l i gament o n the sacra l base.

band attaches to the anteroinferior aspect of the entire length of the transverse process of the L5 vertebra. It blends with the superior band anterior to the quad­ ratus lumborum muscle to attach to the anterior margin of the iliac crest. The superior band arises from the tip of the transverse process of the L5 verte­ bra. Laterally, the band divides to envelop the quad­ ratus lumborum muscle before inserting on to the iliac crest. The posterior band also arises from the tip

of the transverse process of the L5 vertebra. Laterally, it inserts on to the iliac tuberosity posteroinferiorly to the superior band. The inferior band arises both from the body and the inferior border of the trans­ verse process of the L5 vertebra. Inferiorly, the fibers cross the ventral sacroiliac ligament obliquely to attach to the iliac fossa. The vertical band arises from the anteroinferior border of the transverse process of the L5 vertebra. These fibers descend vertically to attach to the posterior aspect of the arcuate line. Willard (1997) reports that the individual bands of the iliolumbar ligament are highly variable in number and form, but consistently arise from the transverse processes of the L4 and L5 vertebrae, blending inferiorly with the sacroiliac ligaments

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Anatomy

and laterally with the iliac crest. Previous descrip­ tions of the evolu tion of this ligament from the quadra tus lumborum muscle in the second decade of life (Luk et al 1986) have been refu ted with the discovery of this ligament in the fetus (Uhtoff 1993, Hanson & Sonesson 1994). Both Bogduk (1997) and Willard (1997) specula te that these ligaments are re s ponsible for ma intaining the stability of the lumbosacral junction in both the coronal and the sagi ttal planes. SACRO C O C CYGEAL J O I NT

The sacrococcygeal joint is classified as a symphysis altho u gh synovial j oints have been fOl.md at this articulation. Maigne (1997) examined nine specimens and found one fibrocartilaginous disk, four synovial joints, and four mixed (part syno vial and part fibro­ cartilaginous). it is not known if the sacrococcygeal joint can change from one form to another during a life time. The sup­ porting ligaments include the ventral sacrococcygeal ligament, dorsal sacrococcygeal ligament, and the lateral sacrococcygeal ligament. The ventral sacrococcygeal ligament represents the continuation of the anterior longitudinal ligament of the vertebral column. The dorsal sacrococcygeal ligament has two layers The deep layer a ttaches to the posterior aspect of the body of the S5 vertebra and the coccyx (analogous to the posterior longi t udinal ligament), whereas the superficial layer bridges the margins of the sacral hiatus and the posterior aspect of the coccyx, thus completing the sacral canal. Lat­ erally, the intercomual ligaments, or the la teral sacro­ coccygeal ligaments, connect the sacral and coccy geal cornua. INTER C O C CYGEAL JO I NT

The intercoccygeal j o in t is classified as a symphysis in the young since the first two segments are sep­ ara ted via a fibrocarti laginous disk. With time, the joint usually ossifies; however, it occasionally remains synovial. PUB I C SYM PHYS I S

This joint contains a fibrocartilaginous disk ( Fig. 4.20a), has no synovia l tissue or fluid, and therefore is classified as a symphysis - a Greek term for "growing together" ( Gamble et aI1986). The osseous

surfaces a re covered by a thin layer of hya line cartil­ age; however, they are sep arated by the fibrocarti­ laginous disk. The posterosuperior aspect of the disk often contains a cavity which is not seen before the age of 10 years (Williams 1995). This is a non­ synovial cavity and may represent a chronological degenerative change. The supporting ligaments of this a rticulation (Fig. 4.20a-c) include the superior pubic ligament, inferior arcuate ligament, pos terior pubic ligament, and the anterior pubic ligamen t. The superior p ubic ligament is a thick fibrous band which runs transversely between the p u b i C tubercles of the p ubic bones. Inferiorly, the arcuate lig a ment b lends with the fibrocartilaginous disk to attach to the inferior pubic rami bilaterally. According to Gamble et al (1986), this ligament provides m os t of the joint s stabi lity. The poste r ior p ub ic ligament (Fig . adj acent periosteum while the anterior l i gamen t of the pubiC symphysis is very thick and contains both tra nsverse and oblique fibers (Kapandji 1974). It receives fibers from the aponeurotic expansion of the abdominal muscula ture as well as the a dductor longus muscle which decussa tes across the joint (Fig. 4.20c). '

H I P J O I NT

The hip jOint (Fig. 4 21a ) is classified as an unmodi­ fied ovoid synOVial joint ( M acC o n ai l l & Basmaji a n 1977). The head o f the femur forms roughly two­ thirds of a sphere, and except for a s ma ll fovea it is covered by hyaline cartil a ge which decreases in depth toward the periphery of the surface (Fig. 4.21b). The acetabulum has been described (see Os teology: The Bones section, above). The luna te surface of the acetabu l um (Fig. 4.22) is lined wi th hya line cartil­ age while the non-articular portion, the acetabula r fossa, is filled with loose areolar tissue and covered w ith sy novium. The acetabulum is deepened by a fibrocartilaginous labrum which on cross-section is triangular in shape. The base of the labrum a ttaches to the rim of the acetabulum except inferiorly where it is deficient at the acetabular notch, which is bridged by the transverse acetabular ligamen t. The a pex of the labrum is lined with articular cartilage and lies inside the hip joint as a free border; the capsule of the joint attaches to the labrum at its peripheral base, thus creating a circular recess. The articular capsule encloses the joint and most of the femoral neck. Medially, it attaches to the base

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25

26

THE PELVIC G I R D LE

c::::: S u p e r i o r P u b i c Lig am e n t

Acetabu l a r L a b r u m Femoral A r c u a t e Ligament

(a)

A rcu a t

e Lig a m e n t (a)

I s c h i o fe m o ral Ligament

Anterior Pubic

-+--#.If/'

L i g a m e n t --�.,\

I l iofemoral Ligament

Fe mo ra l

Ligament

Arcuate

Li g a m e n t

(b)

I n f e r i o r Arcuate Ligament

R e c t u s A bd o m i n i s

\t

(b) F i g u re 4. 21

(a) A coro n al sec t i o n

thro u g h the hip joint. [ b )

M ed i al view of t h e proximal fem ur. ( R ed rawn from H ewitt e t al

2002.)

a l o n g the entire extent of the trochan tericline, pos­ teriorly to the femoral neck above the

trochanteric superiorly to the b a se of the femor a l neck, and inferiorly to the fe mora l neck above the lesser crest,

. Adductor Lo n g u s

(c) Fig ure 4.20

[b) A

The pubic symphysis.

[a) A

coro n al secti o n .

sag ittal secti o n t h ro u g h t h e fi brocarti laginous d is k .

an ter i or aspect. ( R edrawn from Kapandji

trochanter. The s u perficia l bands of the capsular

[c) The

1 974.)

fibers are pred ominantly longi tudinal while the deep bands

are circular (Hewitt et aI 2002) . The ligaments

which are in tim a tely blended w i th, and s u ppo r t, the capsule incl ude the i l i o fe m o r a l lig a m en t, pubo­ femoral liga ment,

of the aceta b u lar labrum and extends 5-6 em beyond thi s p oint on to the innominate. Inferi o r ly, the medial a tta chmen t is

to the trans v erse acetabular ligament.

La tera Uy, the capsule inserts on to the femur anteriorly

the ischiofemora l ligament, and ligament. There are two intra ar­

the femoral a rc u a te

ticular ligaments, the ligamen tum teres and the trans­ verse acetab u l a r ligament. Hewitt et al

(2002) tes ted

some of these ligaments to fail u re in tension and also

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Anatomy

Iliofemoral Ligament

Articular ( Luna t e ) S u rface Acetabular Fossa

'��ff��;;:;;;;:�r Lig a m e n tu m Teres """�-t---'l--

Transverse Acetabular Ligament

Fig u re 4. 2 2

The acetab u l um. F i g u re 4.2 4 I I l e l e m eral ligam e n t

Iliofe m o r a l L i g am e n l :

Pube l e m e ral

Iliot rochan teric Band

Ligam ent

The l igaments of the poster ior aspect o f the

hip joint.

form an inverted Y, the center o f which i s filled with weaker ligamentous tissue. Hewitt e t al (2002) noted that both bands of the iliofemoral ligament resisted a greater tensile force than the ischiofemoral and femoral arcuate ligaments and failed with the least amount of displacement. This ligament exhibited the greatest stiffness. The iliofemoral ligament res tricts extension of the hip .

I,

P u bofe m o ra l l i g a m e n t

Fi g u re 4.2 3

h i p j oi n t.

T h e l i gaments o f the a n terior aspect o f t h e

noted the stiffness value (force / displacement) at the point of failure. I l i o fe m o r a l l i g a m e n t

The i liofemo r a l ligament (Figs 4. 1 2, 4 . 23, and 4.24) is extremely strong and reinforces the anterior aspect of the hip jo in t . It is triangula r in shape and attaches to the a nt erio r inferior iliac spine a t its apex. Infero­ laterally, it di v erges into two bands, the lateral i l i o trochanteric band which inserts on to the super­ ior aspect of the trochanteric line and the medial inferior band which inserts on to the inferior aspect of the trochanteric line. Together, th ese two bands

The p ubofemora l ligament (F igs 4 . 1 2 and 4 .23) attaches medially to the iliopectineal eminence and the superior pubic ramus as well as to the ob tu ra tor crest and membrane. La tera lly, it attaches to the anterior surface of the trochanteric line. The capsule of the hip join t is unsupported by any ligamen t between the pubofemoral ligament and the inferior band of the iliofemoral ligament; however, the ten­ don of the psoas major muscle crosses the joint at this point, contributing to its dynamic support. A bursa is located here between the tendon of the psoas muscle and the capsule and occasionally w ill com­ municate directly with the synovial cavity of the hip joint. Hewitt et al (2002) did not test this ligament in their study. I s c h i ofe m o ra l l i g a m e n t The ischiofemoral ligamen t (Fig. 4 . 2 4 ) arises medi­ ally from the ischial rim of the acetabulum and its

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28

T H E P E LV I C G I R D L E

labru m. La te ra ll y, the fi b ers s pira l s u p ero a n te r i or l y over the back of the femora l neck to insert an terior to the troc h a nteric fossa deep t o the i liofemoral liga m en t . Some fi bers from this l igament also run t ran sv erse ly to b lend w i th those forming the fe m or a l a rc u a te l iga m e n t , fo rm erl y called the zona orbicu­ laris (Hewi tt et aI 2002) . The ischiofemoral l iga m en t p rimarily restricts in ternal ro ta tion of the hip as well as adduction of the flexed hip. This l i ga men t failed under l o w e r tensi le loads than the ili o fe m o ra l li g a ­ ment and exhibi ted grea ter displacement at the point of fail ure ( l e s s s tiff) (Hewitt et al 2002) .

Fe m o ra l a rc u a te l i g a m e n t

This l ig a m e n t w a s p rev i o u sl y called th e zon a orbic­ ularis and some c h a ng e s in its an a to my have been noted (Hewitt et aI 2002). The fibers a re c i rc u l a r and loca ted in the dee p p o s te r io r cap s u l e ( F i gs 4 . 2 1 and 4 .24) . It originates a t the grea ter t ro c h a n te r and passes deep to the ischiofemoral liagment posteriorly to insert infe ri o rl y at the lesser trochan ter. It does not cross th e hip joint; however, it functions to tense the caps ule at the l imits of extension and fle xion. In tension studies (Hewitt et a l 2002), this l i ga m en t exhibi ted the least amOLmt of stiffness and fa iled a t the lowest force.

M YO L O GY : THE M U S C L E S There are 3 5 m u s cl e s which a t tac h d i rec tl y t o the sacrum and / or innominate and hmc ti on w i th the li gaments a nd fa s cia to pro d uce synchrono u s mo tion and s tab ility of the trunk and e x tem ities . It is not the intent of this text to describe the a n a tomy of each of these muscles b u t ra ther to hi ghl i ght certain mu sc le s which will be d i s cu s se d in grea ter depth in l a te r chap ters of this text.

T R A N SV E R S U S A B D O M I N I S The tra nsversus ab do min i s (Fig. 4.25) is the deepes t a b domina l m uscle a nd arises from the la teral one­ third of the ing uina l liga ment, the anterior two-thi rds o f the inner lip of the i l ia c cres t, th e latera l ra p he of the tho r aco d or s a l fa scia, and the internal as p e ct of the lower six costal ca r ti l a g e s in terd igi ta ting with the costal fibers of the diaphragm. From th i s b ro a d

Li g a m e n t u m te res

The l ig amen tum teres (Figs 4.2 1 a and 4 . 22) attaches la ter a l l y to the anterosuperior part of t he fovea of th e femora l head and medi a l l y v ia three bands to either end of the lunate surface of the a c e ta b u l um inferiorly and to the u p p e r border of the transverse a c e t ab u l ar l i g a m e nt .

Tra nsverse a ceta b u l a r l i g a m e n t

o f the ac e ta b u l a r labrum i nfer i or l y and c o n v er ts the ac e tab ul a r no tch into a fo r a m en thro ugh which the intraa rticular ves­ sels pass to supply the head of the femur ( Fig. 4 . 2 2 ) . In a d d i t i o n to the ligamentous support, the hip j oint is dyna m ically s tabilized by numerous muscles, in c l u din g the iliacus, rec tus femoris, pectineus, gl u te u s m i ni m us, pi r ifo rmi s , obtura tor ex ternus, ob turator intern us, superior a nd inferior gemellus muscles, as well a s the fa scia latae of the th i g h , all of w hic h par tial ly i ns e r t into the articular capsule. This li g a m e n t i s a c on tinu a t i on

F i g u re 4.2 5

A l a te ra l v i e w of t h e tra nsversus a b d o m i n is.

( R e p rod u ce d w i th perm i ss i o n fro m D e R osa 2001 )

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Anatomy

a t tachment, the muscle runs tra n s v er se ly a ro und the

in feri o r l y with the a n terior l amina passing a n ter io r

trunk where i ts upper and middle fib ers blend w i th

to the rec tus abdominis and the po s teri o r la mina

th e fa scial en velope of the rectus abd ominis, rea ch­

p a ssing posterior to the rectus abd ominis . C a u d a lly,

ing the l inea a lb a in the m i d l i n e thro u gh a c o m p le x

the posterior lam in a r fibers grad u a l l y pass a n terior

and v a riable b i l a minar a pon e uro s is (Fig . 4 . 26) . S uper­

to the rectus abdominis along with the anterior lam­

ior to the umbilicus, the aponeuro tic fibers of trans­

inar fibers (Rizk 1 980) (Fig. 4 . 2 6 b bottom) . Inferiorly,

versus a b d om ini s pass poste rior to rec tu s abdominis

the ing u in a l fibers of transversus ab d o mini s blend

in ei ther a s uperior or infer ior direction to blend w i th

with the insertion o f the internal ob l i qu e muscle to

the a p one u r o ti c fi bers of the contra la tera l transver­ sus abdominis and in t e rn a l obl iq ue

(Fig . 4.26b

form the co nj o int tendon to a ttach to the p ubic cre s t

to p ) .

posteri or t o the s up e r fic i a l inguinal ring. Urquhart

Below the LUubilicus, a l l of the apone uro tic fi bers run

et a l (200 1 ) h a v e noted di fferences in the fiber orienta tion of the upper, middle, and lower regions of transversus abdominis . The upper fibers w e re oriented superomedially, middle region inferomedi­ ally, and the l owe r region inferomedially (more s o tha n the middle re g i on) . The transversus abdominis

is innerv a ted by the anterior pri mary rami of T7-T 1 2 a n d Ll .

M U LT I F I D U S The deepest fibers of the m u l ti fid us muscle in the lumbar spine ( th e l a min a r fi bers) a r ise from the p os teroinferio r aspect of the l a m i n a a n d a rticula r

capsule of the z y gapophysea l j Oin t and i nsert on to the mammillary process tvv o levels below

( B ogd u k

1 99 7) (Fig. 4 . 2 7 and see Fig. 4 . 3 3 ) . The re m a ind e r of the m uscle a rises medially from the sp in o us process, blend ing la tera lly w i th the lam inar fibers. Inferiorly, the s uperficial fasc icles of

multifidus insert three

levels below, such tha t those a rising from the Ll ver­ tebra insert on to the mammillary p ro c e ss es of the L4, L5, and Sl ve r teb ra e a s well a s the medi a l aspect of

(a)

the iliac cres t. Inferiorly, the fibers from the spino us

Exlernal Ob l i q u e

Inlernal O b l i q u e Transverslis Abdomi n i s

Exlernal Oblique

Internal Oblique Transversus

Abdo m l n i s

�c:g:>;;;;:;

�s

Abdominis

<::::==::::3

�

�S2"" � c=::s

Reclus Abdo m i n i s

(b) ( a ) The a n teri o r fascia of transvers u s a b d o m i n i s is b i l a m i n a r. Ab ove the u m b i l i c u s the decussa t i n g f i b e rs pass e i t h e r s u p e ro m e d i a l l y o r i n fero m ed i a l l y a n d create a cross- h atched patte r n , w h e reas b e l o w t h e u m b i l ic u s a l l t h e fi b e rs travel i n fe ro m ed i a l l y. ( R e d ra w n fro m R i c h a rd s o n e t al 1 999 ) ( b ) The pattern o f decussati on o f t h e a n te r i o r fascia o f the extern a l o b l i q u e , i n t e rn a l o b l i q u e , a n d transversus a b d o m i n is a bove [ top ) a n d below t h e u m b i l icus [botto m). [ Red ra w n from W i l l i a m s 1 99 5.) Fi g u re 4.2 6

Fi g u re 4 . 2 7 R i g h t : s u p e rfic i a l fi bers of t h e l u m ba r m u l t i fid u s . Left : t h o ra c o d o rs a l fasc i a . Cou rtesy o f G ra covetsky [perso n a l

l i b ra ry) .

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30

T H E P E LV I C G I R D L E

process o f the L 2 ver tebra (superficial multifi d u s )

L5 51 vertebrae a n d the P5I5 o f t h e innominate. The fibers from the spinous process of the L3 vertebra insert on to the 51 articular process, the superola teral a spect (costal element) of the 51 and 52 segments, insert on to the mammillary processes of t h e

and

a nd the iliac c rest. The fibers from the spinous process of the

l4 verte bra insert on to the l a teral the area of b one between this cre s t

sacral cres t and

and the dorsal s a cral foramina, while those from the

L5 vertebra insert on to the intermed i a te sacra l crest i n feriorly to 53. Within the pelvis, the m u l ti fi d u s muscl e a l s o a ttaches to the deep laminae o f the pos terior thoracodorsal fa scia at a raphe which sep­ a ra tes i t from the glu teus maxim u s m uscle (Willard

1 997) . Here, fibers from the multifidus pass beneath the pos terior sacroiliac li gaments to blend with the sacrotu bero u s

ligament

(Fi g .

4 . 1 6) . A t the l u mbo­

sacra l j unc tion, the multi fi d u s is the largest muscle. In the lumbar spine, the superfic ial (and more lateral) multisegmental fibers are known (Moseley e t a1 2002)

Vagina F i g u re 4.28

org a n s ( tra nspare n t ) of the pelvic fl oor.

to be phasic in func tion (responsible for an gu l ar mo tion) whe rea s the deep fibers have

a more tonic

fLmction (are non-direction-sp ecific and responsible fo r s tabilization) . The

fascicles

are

innerva ted

b y the medial

1/'1 I', , f l. ,/I, (((I' · Vagma 1

j /l

l JfI'

/1/' 'I

'I

'j U rethra

�

J

Endopelvic Fascia

! ill

branch of the dorsal ramus s u c h tha t all of the fas­ c icles which a rise from

Rectum

T h e relati o n s h i p betw e e n the m u scl es, fasci a, and

the same spinous process a re

inn e rvated by the same nerve regardless of the infer­ ior

ex tent of their insertion (Bogduk 1 983, 1997).

T H E D EEP B A C K WALL A N D FLO O R O F T H E P ELV I S The deep back w a l l of the pelvis is comprised of the ischi ococcygeus muscle which l i e s in the same plane as the piriform is, ano t her muscle of the deep back w a U . The pelvic floor is comprised of the leva tor ani mu scle (pubore c talis, pubococcygeus, and i L iococcygeus) and the fascia from which i t arises (Figs

4.28 and 4.29), also known collectively

Figure 4 . 2 9

effective ly force-clos i n g t h is structure. Atte n u atio n of the fascia l suppo rt system is o n e cause of lost u reth ral force c l osure a n d s t ress urinary i n co n t i n e nce. ( Redraw n from Delancey

as the " leva tor pla te . "

T h e p e l v i c fa s c i a

T h e " fu nctio n al h ammock." Dow n w ard pressu re

com p resses the urethra agai n st the e n dopelvic fascia ,

1994.)

the a rc u s tendineus fascia is a well-d efined tendon

The pelvic floor takes origin from the osseus perimeter

which a ttaches

of the interna l

mid l ine of the inferior border of the p ubic symphy­

1 c m above and 1 cm lateral to the

pelvis as well as from certa in fascial struc ture s . The a rcus tendineus fascia (Fig. 4.28) is

sis ( De lancey

a thick fascia l band (often called the white line)

the arcus i s to the ischial spine. As t he arc us pro­

which i s s u spended between its a nterior and pos­

ceeds pos teriorly from i ts ten d inous a t tachment to

1 994). The pos terior a t tachment of

terior a t t a chmen ts. It is located med ial to the fascia

the p u bic bone, it fuses with surrounding struc tu res

overly ing the o b tura tor in ternus

and becomes a broad aponeurotic band blen d ing

m uscle. Anteriorly,

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Anatomy

wi th the endopelvic fasci a . The endopelvic fascia

lateral to the ure thra, va gina (fema les), and rec tum to

is

u n i te w i th i ts cOlm terpart to form a m uscu lar sling

a

dense horizonta l fa scial aponeu rosis which lies

between the anterior vaginal w a l l and the u rethra

at the anorec tal flexure; there is no posterior osseus

(Fig. 4.29) and provides support to these s tructures.

a t tachmen t . The i liococcygeus originates from the

La tera lly, the endopelvic fascia a t taches to the arcus

media l aspec t of the i schial sp ine and the posterio r

tendineus fascia bilaterally, prov iding a hamrnock­

p a r t o f the arcus tend in eus fascia. Fibers from this

l i ke support for the u re thra and vagina (Fig . 4 . 29)

muscle a ttach to the anterior aspect of the coccyx .

( DeLancey 1994) . Pos teriorly, the endopelvic fa scia

The ante romedial p ortion of the leva tor ani is sup­

blends w ith the in tern a l s u rfa ce o f the pubococ­

plied b y branches of the pudendal nerve while the

cygeus, p uborec tal is, and i liococcygeus m u scles.

posterola teral region is sup plied direc tly from the

These m uscles support the endopelvic fa scia and

sacral ple x u s S3 and S4 (Williams 1995) .

thus the u re thra and vagina by sti ffening the func­ tional "hammoc k . "

D I AP H RAG M

I sc h i ococcyge u s

The dia phragm is a modified ha l f-dome which sep­

The ischiococcygeus a rises from the ven tral aspec t

4.30). It has

of the sacrospinous ligamen t and the ischial spine and inserts into the apex of the sacrum between 54 and 55 . Together with the piriformis, ischiococcygeus form s the deep back w a l l of the pelvis. This musc l e is supplied b y ventral r a m i of the sacral plexus, 53 a n d 54 .

arates the thorax from the a b dominal cavity (Fi g . an

e x tensive a t tachmen t to the xyphoid,

interna l s u rface of the lower six ribs (interdigita tes w i th the transversus abodm inis), and lumbar spine . The crura of the diaphragm arise from the an tero­ lateral a spect o f the bodies and intervertebra l d isks of U-L3 on the right and U-L2 on the left. La teral ly, fibers arise from the medial and l a teral a rc u a te liga­ ments, which a re thick bands of fa scia which a rc h over the psoas major and quadratus lumborum .

P i r i for m i s The p i rifo rmis m u scle arises

From this circumferen tial origin, fibers converge o n from

the a n terior

aspect of the 52, 53, and 54 segments of the sacrum as well as the ventral capsule of the SII, the an terior aspec t of the PIlS o f the ilium, and o ften the upper part of the sacrotuberous ligament. Its exit from

t o a central ten don - a thin, strong aponeurosis o f collagen fibers. The motor fibers to t h e d ia phragm a re from the phrenic nerve (C3 and C4) while the sen­ sory supply comes from the lower six or seven inter­ cos tal nerves (T6-T l 2) .

the pelv is is thro ugh the grea ter scia tic fo ramen and it a ttaches to the g reater troch a n ter of the fem ur. The nerve supply is from the ven tral rami of

L5

and S l .

EXTERNAL O B L I QUE The external obl ique is the largest abdom ina l muscle w i th eight d igi ta tions a rising from the e x ternal surfaces and inferior borders of the lower eigh t ribs.

Leva tor a n i

This or igin interdigita tes with fibers of serratus anter­

The levator a ni i s part o f the pelvic floor and i s

ior and latissimus dors i . The upper attachmen ts of

comprised o f three muscles, the pubococcygeus, pub­

the ex terna l oblique arise close to the cos tochond r a l

orec tali s, and iliococcygeus. The pubococcyge us and

joints, th e mid dle a ttachments t o t h e b o d y of t h e ribs,

p uborecta l i s arise from the inn e r s u rface of the pubic

and the lowest to the tip of the cartilage of the 1 2 th

bone 2 . 5-4 cm above the arcus tend ine us fascia (Fig.

rib . Inferiorly, the pos terior fibers descend vertically

4.28) . Posterior fibers of the pubococcygeus arise

to a ttach to the ou ter lip of the a n terior h a l f o f the

from the an terior half of the arcus tendineus fasci a .

iliac c res t. The upper a n d middle fibers end i n the

Pubococcygeus passes posteriorly, inferior t o the

a n terior ab d o m inal aponeurosis (Fig . 4 . 3 1 ) . Ri zk

p uborec talis, and a ttaches to a midline raphe pos­

( 1 980) investig a ted this structu re in 41 speci mens

terior to the rec tum . Thro ugh this raphe, fibers unite

and d iscovered tha t the aponeurosis of the e x terna l

and con tinue pos teriorly from the anorec tal flexure

oblique was bilaminar (Fig. 4.26b) . The tvvo layers

to a ttach to the anterior aspect of the l a s t two coc­

cross the midline to blend w i th the fascia o f the

cygeal segmen ts. The p ubore c ta l i s passes p osteriorly

opposite side with the deep layer being continuous

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T H E PE LV I C G I R D L E

Fi g u re 4 . 3 1 Th e i n sertion o f t h e extern a l o b l i q u e i n to the a n te r i o r a b d o m i n a l a p o n e u rosis. ( R e p ro d u ced with perm i ss i o n from De Rosa 2001 .)

with the c o n tra l a ter al internal oblique . The super­ fici a l layer merges with the s u pe rfi cia l l a y er of the c on tr al a tera l sid e . The deep and superfi ci a l l ayers p ro du ce a c ro ss - ha tc h ed appea rance as their o r i e n­ ta tion is 90° to one another. The ex ternal oblique m u sc le is innervated by the ventral rami of the

T7-T12 spinal nerves . I NT ERNAL O BL I QUE

The internal oblique l i es between the externa l oblique and the transversus abdominis and a rises from the la tera l two-thirds of the in g uinal l iga men t,

(e) ( a ) An a n a to m i c a l d i ssect i o n o f the d i a p h ra g m viewed fro m b e l ow. ( R e p r o d u c e d w i th p e r m i s s i o n fro m Pri m a l Pictu res. ) ( b ) A n a n a to m ica l d i ssection of t h e d i a p h ra g m viewed fro m a bove. ( R e p rod u ce d w i t h p e r m i ss i o n fro m Pri m a l Pictu res. ) ( c ) A th ree-d i m e n s i o n a l g ra p h i c re p rese n ta t i o n of t h e res p i ra t o ry d i a p h ra g m . F i g u r e 4.30

anterior two-thirds of the intermediate line of the iliac cre s t, and the la teral r a phe of the thoracodorsa l fascia. The p os te ri o r fibers ascend la terally to reach the tips of the 1 1 th and 12th ribs and the 10th rib nea r the costochondral junction. The an terior fibers arising from the in gu in a l ligament arch inle ro me d i a l l y to blend with the aponeurosis of t r a ns ve r sus abdo­ minis a n d attach to the p ub ic crest. The intermediate fi be rs pass s u pe r ome d i a lly to insert into a bilaminar ap o neuro s i s (Ri zk 1980), b le n d in g with the aponeu­ rosis of the external o b l i qu e a nd transversus abdo­ minis, fo rming a decussa ting network of fa s c i a across the m i d l in e of the b od y (Fig. 4.26b) . The internal

Copyrighted Material

An atomy

a p oneuros is

of the transversus

abdominis.

The

med ial borders of the rectus abdominis connect thro ugh this bilaminar aponeurosis, collectively known as the linea alba. The nerve su pply is through the ventral rami of the lower six

seven thoracic

or

spinal nerve s .

PY R A M I D A L I S This tri angular muscle i s loca ted anterior to the infe r i or aspect of the rec tus abd ominis muscle and is enclosed w i thin its sheath (Fig. 4 20c) The base .

.

atta ches to the os pubis as well as to the symphysis while the apex blends with the linea alba midway between the umbilicus and the pubis . This mu scle is inn e rvated by the subcostal nerve which is the ventral ramus of the T12 spina l ne r ve

.

E R E CTO R S P I N A E Lo n g i s s i m u s t h o r a c i s p a rs l u m b oru m F i g u re 4 . 3 2

This muscle arises from five muscle fascicles, the

R e c t u s a b d o m i n i s . N ote t h e th r e e h o r i z o n t a l

t e n d i n ou s b a n d s w h i c h receive atta c h m e n t fro m t h e exte r n a l

deepest of w hi ch is from the L5 vertebra overlapped

o b l i q u e m u s c l e . ( R e p ro d u ce d w i t h p e r m is s i o n fro m D e Rosa

by those from L4, then L3, then L2, and finally L 1

200 1 .)

(Bogduk 1997) . Medially, these laminae arise from the accessory and the medial end of the dorsal su r­

o b liq u e muscle is inne rva te d by the ven tral rami of the T7-T l 2

a nd

L1 sp in a l nerves.

face of the transverse p rocesses . The fibers from the

L 1 -L4 vertebrae in ser t via a common tendon into the medial aspect of the lumb ar intermusc ular aponeurosis which a t taches infe riorly to the medial

R E CT U S A B D O M I N I S

aspect of the PSIS just la teral to the fascicle from L5.

The rec tus a bd o mini s muscle is a lon g musc ul a r s tr a p and is j ust latera l to the an terior midline of the

Lo n g i s s i m u s t h o r a c i s p a rs t h o ra c i s

abd omen . It arises from th e pubic crest and tubercle

The thoracic component o f longissimus thoracis i s

as well as the l ig a ment s

of the symphysis pub is The aponeurotic e xp a ns io n s of th i s muscle, a l ong with .

those of the transversu s abdomini s, internal obliq u e, p y r a mid a l is, a n d add uctor longus muscles, inter­

d igitate a n terior to the symphysis to form a dense ne twork of fibers and thus con trib u te to the stab il ity

of this

articulation

(see Fig. 4 . 20c)

(Kapa ndji

1974,

Wi lliams 1 995) . The muscle in serts in to the fi fth to seven th costal ca r tila ge s (sometimes as hi g h as the thi rd costal ca rtilage) and xyphoid process . Rec tus

ab dominis is sepa r ate d by three horizontal tendinous bands (Fig . 4 . 32) which recei ve a tta chment from the

external o bl iq u e muscle (DeRosa 200 1 ) . The re c tus a b dom inis is enclosed in

a

fa scial sheath formed by

the decussa ting aponeurosis of th e ex ternal and interna l

o bli que

m uscles as well as the bila minar

the largest part of the erector spinae gro up in the thoracic spine and forms the bulk of the parav erte­ bral m uscle mass adjacent to the spine . It arises from the ribs and transverse processes of T1 T12 -

and descends to a ttach via the aponeurosis of the e r ect o r spinae to the spinous processes of the lumba r

spine a

and sacrum (Fig . 4.33). Each fascicle descends

variable length with those from the upper thorax

reaching to L3 while the lower fascicles bridge the lumbar s p in e completely.

I l i o costa l i s l u m b o r u m p a rs l u m b o r u m This m uscle ari s es as fo ur overlapping fascicles from the tips of the transverse processes of the L1-L4 ver tebrae (l a tera l to the lumbar longissimus)

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a nd

33

34

T H E P E LV I C G I R D L E

and

iliocosta lis

lumborum

pars

thoracis.

This

muscle is innerv a ted from the l a teral and intermed i ­ a te bran ches of the segmen tal dors a l spina l ra m i .

T HO RA C O D ORSAL FAS C I A The thora codorsal fascia i s a critica l s truc t u re when considering transference of load from the trunk to the lower ex tremi ty (Vleeming e t a I 1 995a ) . Severa l m uscles, impor tant in p rov i d ing stability to the pelvic g irdle, a ttach to this fascia and can a ffec t tension within i t . They include the tran svers us abdo­ minis, internal oblique, g l u teus maximus, latissimus dorsi, erector spinae, multi fidus, and biceps femoris . Its ana tomy is complex (V leeming et al 1995a, Bogd uk 1 99 7, Barker & Briggs 1999). There are three la yers to the fascia : the a n te rior, middle, and pos terior. The anterior layer is thin and covers the anterior aspect of the quadratus lumborum muscles . It a ttaches medially to the transverse processes and blends

w i th the in tertransverse

l i gaments .

The

middle l ayer is posterior to the quad ratus l umbonm1. It a rises media l ly from the tips of the

transverse

p rocesses and p rovides origin to the a pone u rosis of the transversus a b d o m i n i s . There are tvv o l a minae which comprise the poster­ F i gure 4 . 3 3

Longis s i m u s t h o racis pars t h orac i s ( Lo) . iliocos tal i s

lum borum pars t horacis ( Lc) a n d s u perficial fi b ers of m ulti fidus ( M u ) can b e clearly seen in this beautifu l d i ssec t i o n of W i llard. S, spin alis. (Re p rod uced w i t h pe rm i ssio n from Willard

( 1 997)

ior layer of the thoracodorsal fascia. The supe rfici a l lamina is predominantly derived from the aponeu­ rosis o f the la tissim u s dorsi m uscle (Fig. 4.34) and conta ins obli q u e fi bers which run cau dome dia lly.

a n d t h e p u bli s h ers C h u rch ill L i v i n gsto n e . )

In the m i dline, s trong connec tions exist to a t ta ch the

fro m t h e middle layer o f t h e thoracodorsal fa s c i a .

processes of the l u mbar vertebrae cran ial to L4 .

Inferi orly, the m u scle inserts o n t o the i l i a c cre s t

Accord ing to Wil l a rd (1997), the pos terior border of

fa scia to the supraspina l l i gaments a nd the spinous

la teral to the PSIS.

the ligamentum flavum becomes the sup raspinous ligament, w h ich in t urn is a nchored to the thora­ codorsal fascia (Figs

I l i o costa l is l u m bo r u m pa rs t h o racis

a ttachments,

4.35 and 4.36) . Th ro ugh these

tension

of

the

thoracodorsal fascia

The thoracic component of iliocostalis lumboru m i s

is transmitted to the ligamentum flav um and, accord­

la rge and the m o s t la teral p art o f the erector spinae

ing to Wil l a rd ( 1 997), assists in the a lignme n t of

m u scle gro u p . Fascicles from the inferior borders of

the l um b a r verteb rae. The s u p e r ficial laminae also

the angles of the lower seven to eight ribs origina te

receives some fibers from the external oblique and

la teral to the a ttachmen t of iliocostalis thoracis a n d

the lower

descend t o a t tach to t h e i l i u m and s a c r u m with the

trapezius

muscles ( V leem ing e t al 1 995a ) .

Caudal t o L4, midline connec tions are v e ry loose

midline

thoracic component of the l o ngissimus thora cis to

and actually cross the

form the aponeurosis of erector spinae (Fig. 4.33) .

iliac cre s t and sacr u m . Over the sacrum, the s u per­

to reach the opposite

These thoracic fascicles have no a t tachment to the

fic ial lamina blends w i th the fascia of the gluteus

lumbar ver tebra brid ging the gap between the

maxim u s . These fibers run in a caud olateral direction

thorax an d the pelv i s .

from a me d i a l a t tachmen t to the med i a n sacral

The e r e c t o r spinae aponeu ros is is deri ved from the tendons of the longissimus thora cis pars thoracis

crest and occasionally as far cranial a s the L4 spinou s p rocess (Fig. 4.37).

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Anatomy

1

1 "" TLF

F i g u re 4.3 5 Dorso l a te ra l view o f t h e l u m b a r s p i n e . The t h ora­ c o l u m b a r fascia (TLF) blends with t h e s u p raspinous l ig a m e n t (55) a n d i ntersp i n o u s l i g a m e n t ( I S) , l i ga m e n t u m fl a v u m ( LF) a n d the facet joint ( FJ) ca psu l e . I C is t h e i l i a c crest. ( R e prod u ced fro m Wi l l a rd ( 1 997) w i t h p e r m i s s i o n of C h u rch i l l Liv i n gsto n e . )

Mu�rtidus

Compa rt m e n t

Fig u re 4.34 A posteri o r v i e w of t h e t h o raco l u m b a r fascia (TLF) i l l u st ra tes the attac h m e n ts of l a tiss i m u s d o rs i ( Ld) a n d g l uteus maximus [G m ) i n to t h e s u perfi c i a l l a m i n a of t h e poste rior l a ye r. N o te t h e sma l l attac h m e n t of t h e l o w e r fi bers of t h e tra p e z i u s m usc l e (Tp). [Reproduced fro m W i l l a rd ( 1 997) w i t h perm issi o n o f C h u rc h i l l Livi n gstone.)

The de ep l am i n a

of t h e po s t e r i o r l a y e r of the

s e v e ra l 4.38). The fibers run in a caud ola te r a l d irection a ttaching media l ly to the in te r­ s p in o u s ligamen ts and ca udally to the PSIS, iliac crest, and posterior sa croil iac ligaments. Above the p elvis , the d e e p lamina a t taches to the lateral raphe and b l e nds w i th the m i d d l e layer of the thora codorsal fascia. The internal o bl i q u e and the transversus abdom inis muscles a t t a ch to this l a te r a l raphe . Ove r the p e l v is, some fibers blend with the d eep fa scia of the e re c to r s p i na e m u scle (forming the roof over the sacra l m u l ti fi d u s : see Fig . 7.1) and the s a cro ­ t ub e ro us l ig a m e n t. Tension of the thora codors a l f a sc i a can b e t hor a codor s a l fascia is a lso complex with

muscular c onne c t i on s (Fig.

i ncreased th r o u gh m o tion of th e a rms, trun k, a n d

Figure 4.3 6 H o r i zo n ta l view of the l u m b a r reg i o n i l l ustra t i n g t h e l i g a m e n t u m fl a v u m / i n te rs p i n o u s l i g a m e n t/su p ra s p i n o u s l i g a m e n t/ t h o ra c o d o rsa l fascia c o n n e c t i o n s . Th i s m e c h a n i s m p l ays a sig n i fi ca n t ro l e i n sta b i l iz a t i o n tra i n i n g of t h e l u m bo ­ pelvic- h i p reg i o n . ( R e d r a w n f r o m W i l l a rd ( 1 997) w i t h perm i s s i o n of t h e p u b l i s h e rs C h u rc h i l l Li v i n gsto ne.)

l ower ex tremi ty.

or lengthening of a t t ach into the fa scia can

Contra c tion

the many muscles which

influence its tension . Coupled with the a n te rior

musculature a nd the a n terior abdomin a l fa sc ia (Fig. 4.39), a " c i rcle of integri ty i s cre a te d . " In this manner,

s tabili ty of the pelvic gird le and low back is enhanced

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35

36

T H E P E LV I C G I R D L E

(a)

Fi g u re 4 . 3 7

T h e s u p e rfi c i a l l a m i na o f t h e thora c o d o rsal fa sci a . ( R e d ra w n fro m Vlee m i n g e t a l ( 1 997) w i t h p e r m i ss i o n of t h e p u b l ishers C h u rch i l l Livi ngston e.)

is effectively transferred from the trunk to the lower e x trem i ty.

and load

T H E FAS C I A O F TH E L E G The fascia o f the lower ex tremity envelops the muscles and via i ts extensive a ttaclunents to the pe lv ic gird le can influence its func tion and subse q uently become sym p tom a ti c in d y s functi o n The fascia encircles the pelvic girdle by a t ta ching to the sacrum, coccyx, iliac crest, ing uin al ligament, s uperior pubic ra mus, inferior p u bi c ramus, ischial ramus, ischi a l tuberosity, and s a cro tub erous ligament. Superiorly, .

it blends w i th the thoracodorsal and abdominal

fa sci a of the trunk. F r o m the iliac crest, the fascia descend s over the g l u te us medius muscle before spli tting to e n ve lo p the gluteus max im u s muscle. The two bands me e t a t the lower b or d e r of thi s muscle

(b) F i g u re 4.38 ( a ) The deep l a m i n a of the t h o racod orsa l fas c i a . ( R e d ra w n fro m Vlee m i n g et a l ( 1 997) with permission o f t h e p u b l ish ers C h u rch i l l Livi n gs to n e . ) (b) The d e e p l a m i n a of t h e t h o ra c o d o rsa l fascia for m s t h e roof o f m u l ti fi d u s a n d b l e n d s w i t h the sacrot u bero u s l i g a m e n t . (Cou rtesy of A. Vlee m i n g . )

Copyrighted Material

Anatomy

A ltered

a fferen t

inp u t

from

the

articular

mechanorecep tors can have p r ofo un d infl u ences on

both static and d ynamic pelvic gi r dle func tion. Sev­ eral studies (Mattila e t al 1986, Bullock-Sax ton e t al 1994, Uhl ig e t a l 1 995, Hides e t a l 1996, Hodges & Richardson 1 996, Danga ria & Naesh 1998, Ho d ge s & Moseley 2003) have shown tha t c ha n ges in m uscle fiber type, mu scle b u l k, and recrui tment patterns occur w i th pain and p a thology. However, si m ply relievin g p a in does not neces s a r i l y res tore op timum function; these changes can remain even when p a in s ubsides (Bulloc k-Saxton et al 1 994, Hides et a I 1996) . F i g u re 4 . 3 9 A g ra p h i c r e p r e s e n t a t i o n of t h e co m p o n e n ts o f c i rc l e of i n t eg r i ty.

the

Changes in the proprioceptive and m o tor con tr ol systems a l ter movement p a tterns and s trategies of load tra nsfer. The resul t is less efficient movement,

and fac i l i t a te its insert ion in to the i l io t ibial tra ct which rep resents a l a teral thi ckening of the fasci a . The

i l i o tibial

tract

a ttaches

inferiorly

t o the

condyles of the fem u r and the tibia, and to the

suboptimal function, a higher risk for rec u rrence of p a in and

inj ury

(Hides et al 200 1 ) , and a l tered j o in t

forces (due to al tered axes of j oin t rot a tion) tha t may lead to earlier de g enera tive cha nges and pain.

he a d of th e fibu la, blend ing with the crural fascia and aponeuro tic exten sions of the quadriceps muscle. The fascia i s continuous in the thigh with two inter­

M A C R O S C O P I C A RT I C U LA R N E U R O L O G Y

musc u l a r septa which a ttach to the linea aspera . The ten sor fa scia la tae muscle inserts in to the ili­

The

most

ex tensive

s t u dy

o f the

macroscopic

o tibia l trac t a n terior to the attachmen t o f the gluteus

innerva tion of the SIJ was d one in 1 957 by Solonen.

max imus muscl e . Thi s m u s cle is a lso enveloped

He examined 1 8 j o ints in nine cadavers and found

by two layers of the fa scia . The supe rfic ial la yer

tha t posteriorly all of the join ts were innerva ted

reaches the iliac crest l a tera l to the muscle whi le the

from branches of the pos terior ra mi of the 51 a n d

deep l ayer blend s media l l y with the capsule of the

5 2 spinal nerves. Bra dlay ( 1 985) reported tha t the dorsal sa croil iac l igaments receive supply from the

hip joint.

l a ter a l divisions of the dorsal rami of the L5, 5 1 , 52, and 53 spinal nerves. Th is was l a ter confirmed by Grob e t al ( 1 995) . According to Willard e t a l ( 1 998),

N E U R O LO G Y : TH E N E RVES

the d orsal sacral plexus ( 5 1 , 52, 53) forms in the Unders tand i ng the n e u rology o f the lumbopelvic­

sacral gutter infe rior to the sacral a t tachment of mul­

hip region is essential since rehabil itation involves

tifidus and superficial to the sacro tuberous liga ment

func tion.

and divides into med i a l an d l a teral divisions. The

Muscle control in postu re and locomotion depends

medial divisions s upply m u l tifidus while the lateral

d i rec tly on both the central and peripheral nervous

div isions pass either through or under the long d or­

the restora tion of op tima l

n e u ro l o g i cal

systems. Janda (1 986) notes tha t " I t is alm ost impos­

sal li gament where they a re fla ttened to a very thin

sib le clin ically to differentia te the primary changes

la y er. These branches innerv a te the pos terior a spect

in muscle from the i r secon d ary reaction d ue to an

of the SIJ. An teriorly, Solonen ( 1 957) found tha t the

regula ti o n, as the

artic u lar innerva tion w a s not always consistent nor

a l tered or impaired cen tra l

n ervo u s

q u a l i ty of muscle func tion depends directly on the

necessarily sym m e trical. Of the 18 specimens exam­

central n ervous syste m activity. " In a d d i tion, e mo­

ine d, all o f the joints were inn erva ted by branches

tional sta tes are kno w n to infl uence basic muscle

from the ven tral rami of the L5 spinal nerve, 17 from

tone and pa tterning (Hols tege e t a I 1 996) . Wy ke (1981,

L4, 11 from 5 1 , four from 52, one from L3, and 15

1985) has shown that a rtic u lar neurology has both

received innerva tion from the superior gl u teal nerve.

d irec t and reflex infl uences on muscle tone locally

Grob e t al

and glo ba l ly. In a d d i tion, a fferent input from articular

iIU1erv a tion from the ventral rami . Fortin e t a l ( 1 999)

structures contribu tes to perception of posture and

concur wi th G rob e t a l and feel tha t the SIJ is only

motion.

innerva ted from the dorsal rami 51-54 . They sugges t

Copyrighted Material

( 1 995)

were

unable to confirm any

37

38

T H E P E LV I C G I R D L E

that the inves tigators who have reported innerv­

velOCity ) . The recep tors w h ich h a v e a h i gh thresh­

ation of the joint from ventral ra mi have m is taken

old for discharge adap t very slowly and are pro­

blood vessels for nerves since both a re imaged

w it h

tective. The effec t of these receptors is refle x i vely to

the same s taining technique. The wide di s tri b u tion

inhibit further muscle con trac tion

of innerv a t i o n is reflected c l inica lly in the variety o f

further stretch o f the j oint caps ule. Both myelina ted

pain patterns reported b y patients w i t h 5IJ dysfunc­

and non-myelinea ted a xons a re fo u n d in the ven tral

tion (Fortin e t aI 1994a ) .

portion of the SlJ caps ule (Fortin e t al 1999 ) .

The pubic symphysis is innerva ted from branches from

the

puden d a l

and

geni tofemora l

nerves

(Gamble et aI 1986) .

a nd

p revent

Nocicep tors are loca ted throughou t t h e a r ti c u l a r and myofascial system. They res pond to ex trem es o f mechanical d eformation and / o r chemic a l i rri ta­

The hip j oin t is innerv ated by branches from the

tion (potassi um ions, lac tic acid, polypeptide kinins, 5 -hydroxy tryp tamine, ace tylcholine, nore pinephrine

ratus femoris

(L2, L3, L4), the nerve to the quad­ (L2, L3, L4), and the s uperior glu teal

(LS, 51)

(Grieve 1986) . As well, the joint recei ves

high- threshold, non-adap ting recep tors. These recep­

b ranches from the nerves which supply the muscles

tors contrib u te to the percep tion of p a in (noc icep­

ob turator nerve nerve

( norad renaline), pros taglandins, histamine) and a re

c rossing the j oin t. The hip j oin t is p rincipally derived

tion); however, the afferent inpu t can be signi fican tly

from the L3 segment of mesod erm with contri b u­

a l tered b o th peripherally and centra l l y.

t ions from L2 to S 1 , hence the po tential for a v a riety of patterns of pain referral.

According to Wy ke ( 1 9 8 1 ) the cen tra l effec ts of a r ti c u lar mechanoreceptor activ ity a re threefo l d :

The o u te r one- third of the lumbar i n tervertebral

re flex, percep tual, and pai n s u p p ression.

d isk is innervated pos teriorly by the sinuver teb r a l n e r v e (Bogduk 1 9 83, 1997) and latera lly b y the v e n ­ tral ram i a n d gray ra m i communicantes of t h e spina l

R E F L E X E F F E CTS

nerve. Nociceptors (see below) have been located here, th us the ana tomic a l po tential for pri mary d i s k

Depola rization of the afferen t fibers from the low ­

51

threshol d a r ti c u lar mechanoreceptors reaches the

v e r tebra e are innervated via the medial branch o f

fusimotor neurons polysynap tical ly, thus contrib u t­

pain . T h e zygapophy seal j oints o f the L 5 and

t h e d orsal ramus of the L 4 , L5, and 5 1 s p in a l nerves .

ing to the gam m a feedback loop from the muscle s pindle both a t res t and d u ring join t motion. " By th is means the a r tic u l a r mechanoreceptors exert

M I C R O S C O P I C A R T I C U LA R N E U R O L O G Y

recip rocally coordina ted reflexogenic influ ences on

Accurate info rmation from mechanoreceptors in

in all the striated muscles" (Wyke 198 1 ) . When this

the j oint is req u i red by the cen tral nervous system so

capsular reflex is activa ted, the d i scharging recep­

muscle tone and on the exci tability of s tretch reflexes

tha t the ac tivi ty of the m o tor uni ts essen tial for pos­

tors facil i tate the muscles anta gonistic to the occ u r­

i tion, mo tion, and s ta b i l ity of the j oin t is coordina ted

r ing movemen t . When the high- threshold artic u lar

(Hod ges & Moseley 2003) . This mechan ism pro tec ts

mec hanorecep tors are d i scha rged, the reflex effec t

t he j o in t from excessive mo tion and coordinates the

is p rojec ted polysynaptica l ly to the a lpha motoneu­

timing of motor recruitmen t such that habitual move­

rons and this resu l ts in loc a l m usc u lar inhibition.

ments are produced in an efficient and biomechani­

Nocicep tors affect the d ischarge from the a l pha­

cally safe ma nner.

mo tone uron pool and can distort the normal, coord ­

There is m ore than one cla ssification of joint recep­ tors (Wyke 1 9 8 1 , Rowinski 1985) . Essentially, there

ina ted, mechanorecep to r reflex system (Gandevia

1992).

a re receptors in all lay ers of the cap s u l e , in a l l liga­ ments and fascia, and wi thin all pa rts of the muscles. Some have a low threshol d for d i scharge and are slow in adap ting . They rep ort on s ta tic posi tion o f

Pe rce ptu a l effects Afferent inp u t from the artic ular mechanorecep tors

t h e join t, muscle length a n d tone, a n d in traartic u l a r

travels polysynap tica lly v ia the posterior a nd dorsal

pressure. O thers have a l o w threshold for discharge

spina l c olumns to reach the pa racentra l and parietal

a nd adap t very qu ickly. These recep tors report

regions of the ce reb ral cortex, thus contributin g

d y n a mic cha nges in the environment, inc l u d ing

Significa n tly, though not solely, to b o th pos tural

c hanges in j oin t position (direc tion, quantity, a n d

and kinesthetic awareness.

Copyrighted Material

..,

Anatomy

The

observa t ion that capsu lectomy of the hip jo i n t

performed in the course ofh i p replacement s u rgery does not res u l t in to tal l o s s of p os t ura l sensa tion at

leaves

the hip

n o doubt that while joi n t capsule m echa no recep­

to rs co ntrib u te to awareness of s tatic join t p os i t ion,

39

experience of p a in (Butler 2000, Butler & Moseley 2003 ) . The p resence of pain and the fear of p a in are kno w n to impact m o t or c on t r o l ( H o d g e s & Moseley 2003) .

thelj are not the sole sou rce of pe rc ep t ual e xp er ien ce, and other rec e n t s tudies suggest tha t their contribu­ t ion in this

rega rd is su pplementary to and coordinated

with tha t p rov ided by the i n p u ts from cutaneo us and

myo tactic [ m us c l e

spindle] meclza no receptors !

( Wyke 198 1 )

Pa i n According to

G rieve (1981 ) :

No ma tter where i t is fe l t i n t h e body, and n o m a tter

from what ca us e , pain

- which

is the c om m one s t of all

clinical symptoms enco u n te red in medical p ra c t i c e rep resents

a

d is t u rba nce of neurolog ica l fu nc tion .

Unlike taste, t o u ch , or sme l l , p a in is not a primary neu ro l og ic a l sensation b u t ra ther a c om ple x ne u r ologi c a l p heno me n o n influenced by patterns of activ i ty in sp e c ifi c a fferent systems as well as by past and p resen t experiences. I m p u l s e s s ub se r v ing p a in are not transmitted centra lly by small-d iameter fibers o nl y. The entire spec tru m of a fferent fi bers may be stimulated b y periphera l n o x io u s s ti mu l i, depend ing upon the intens i ty of the s tim ulus. The experience of p a in depend s upon mechanisms of c on ve rg en ce , summa­ tion, and m o d u la t i on bo th p eri phe r al l y in the s pinal cord a n d ce n tr a J l y in t h e bra ins tem and cortex. The th e o ry of peripheral modula tion, or sp inal ga ting, was o r igi n a l ly p ro p os ed by Melzak & Wa l l ( 1 965) . Briefly, the gate c on t rol mechanism depends on l a rg e- fi b e r activ i ty (mechanorecep tor) which pre s ynap ti c ally inhibits the transmission of impulses from the s m a l l -fi ber noc i cep t o rs a t the s ubs t anti a gelatin o sa . Thus "by rhythmic movement of the bod y, or a body part, a nd by cu taneous contact and s oft tissue com p re s s i on, i.e. stroking, holding a nd by rhy thm i c manual or mechanical mobilization tecl1l1iques, th e l a r ge d i a meter (6-12 and 13-17 fLm) mechanorecep tors a re sti m u l a ted" (Grieve 1981) and s ubs e q ue n t ly mod u l a te the transmi ssion of n o c i c ept or activity. Centra l ly, the percep tion of p a in can be influenced b y psycho l og ic a l fac tors, including p a st experience, anx i e ty, and culture, and d rugs such as caffeine, a l c ohol , and b arbiturates, all of which increase the -

-

A N G I O LO G Y : THE B L O O D S U P P LY The hip j o int is s u ppli ed by the obtura tor, the medial and l a teral femoral circumflex, and the su pe ri o r and inferior gl u tea l arteries and ve ins (Singleton & LeVeau 1 975, Crock 1980, Grieve 1981). The ace tab­ ular fossa, its conten ts as well as the head of the femur, receive s u pply from the ace tabular branch of the obturator and medial femoral circumflex vessels via the ligamentum tere s . The vascular a na t o m y is inconsistent and rarely sufficient to sustain the vi a­ bi l i ty of the head of the femur fol l o win g interrup­ tion of other sou rces of s upply.

Experimental findings (Astrom 1 9 75)

po i n t to a con­

nec tio n b e tw e e n ach i ng pain, eleva tion of in traosseo us press u re a n d impa i red

[ven o u s ]

drainage of spon­

giosa. Rhythmic mobiliza t ions of this articu lation a re

extremely effect ive in re l iev ing p e rs ist e n t aches asso­

ciated with o s teo ar t h r i t is Toge t he r with the effe c ts of .

mecha noreceptor discharge during these t e c hni q u es

perhaps i mp ro v ed circula tion plays a role in pa in

s u p p ress i on

.

(Grieve 1981)

The n u tr i en t arteries a nd veins fo r the sa crum a r ise from the la teral and median sacral system. The l a t­ eral sacral vessels arise from the p o s te rio r trunk of the internal iliac and descend over the anterola tera l aspect of the sacrum . The two lo n g itudina l a r teries give off anterior central branches which course medially to anastomose with the median sacral artery. The anterior centra l branches send feeder vessels into the centrum of the sacru m . At the level o f the ven­ tral sacral foramin a , s p ina l b r a n ch e s s u pp l y the cauda eq u in a as weJl as the conten ts of the sacral canal. The fora minal branch, after p a ss in g th ro u g h the dorsal s a c r a l foramina, s u pp l i e s the posterior aspect of the medial and intermed i a te sacra I crests as well as the pos terior m u sc u l a ture . Venou s d r a ina g e is via vessels which accompany the a rteries and subsequently drain into the common iliac syste m . The n u tr i e n t supply for the inn o m in a te is derived fro m the iliac b ranc hes of the obtura to r and il i o l um bar vessels as well as th e superior gl ut e a l vessels ( Wi l l i a m s 1 995) .

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5

Chapter

Principles of the integrated model of function and its application to the lumbopelvic-hip region

INTRODUCTION

CHAPTER CONTENTS Introduction

The integrated mod e l of function Form closure

43

Force closure

46

Motor control Emotions Conclusion

This chapter introduces the principles of an inte­

41

54 54

53

42

grated model for managing impaired function. This model comes from anatomical and biomechanical studies of the pelvis, as well as from the clinical experi­

pain 2001b, Lee & Vleeming 2003). This approach

ence of treating patients with lumbopelvic (Lee

addresses why the pelvis is painful and no longer able

to sustain and transfer loads as opposed to one

which seeks to identify pain-generating structures. Several studies have sought to understand pelvic function. The anatomical research on the sacroiliac

and the 1995b, 1996, Snijders et al1993a) led to conclusions regard­ ing the role the passive and active elements play joint (SIJ) and the connections between it

lumbopelvic muscles (Vleeming et a11990a, b,

in stabilization of the pelvis (form and force closure of joints). The timing of specific muscle activation (Hodges

1997, 2003, Hodges & Richardson 1997, 1999, 2001a, 2003b, Hungerford 2002) and the p at tern of muscular co-contraction (or lack Hodges et al

thereof) in patients with low back pain (Hides et al

1994, 1996, Hodges & Richardson 1996, O'Sullivan 2000, Hungerford 2002, O'Sullivan et a12002, Hodges 2003, Hodges & Moseley 2003) further enhanced the force closure theory and suggested a crucial role for motor control. Based on this knowledge, fLU,ctional tests for the pelvis were developed (Buyruk et al

1995a, b, 1999, Lee 1999, Mens et al 1999, 2001) and established (Lee 1999, Richardson et al 1999, O'Sullivan 2000). Clinically,

treatment protocols were

it was soon apparent that the patient's emotional state could significantly influence the outcome. Over time, the integrated model of fLllction oped (Lee & Vleeming

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1998, 2003).

was devel­

42

THE PELVIC GIRDLE

THE INTEGRATED MODEL OF FUNCTION The integrated model of function (Fig. 5.1) has four components - three that are phy sical:

through

the pelvis effectively

is dynamic and

depends on: 1. optimal function of the bones, joints, and

ligaments (form closure or joint congruency) (Vleeming et al1990a,

b)

1. form closure (structure) 2. force closure (forces produced by myofascial action)

Body weight

3. motor control (specific timing of muscle action/inaction during loading) and one that is psychological: 4. emotions.

The proposal is that joint mechanics can be influenced by multiple factors (articular, neuromuscular, and emotional) and that management requires attention to all. Managi ng dy sfunction requires an understand­ ing of function. A primary function of the lumbo­ pelvic-hip region is to transfer the loads generated by body weight and gravity during standing, walk­ ing, and sitting (Snijders et al 1993a, b) (Fig. 5.2). How well this load is managed dictates how effi­ cient function will be. According to Panjabi (1992a, b), stability (effective load transfer) is achieved when the passive, active, and control systems work together (Fig. 5.3). Snijders et al (1993a, b) believe that the passive, active, and control systems produce approx­ imation of the joint surfaces, which is essential if stability is to be insured. The amount of approxima­ tion required is variable and difficult to quantify

Ground reaction forces

since it is essentially dependent on an individual's structure (form closure) and the forces they need to control (force closure). The term "adequate" has been used (Lee & Vleeming 1998, 2003) to describe how

Figure 5.2

The orientation of the bony trabeculae within the

pelvic girdle corresponds to the lines of force met during load transfer through the pelvic girdle. (Redrawn from Kapandji 1970.)

much approximation is necessary and reflects the non-quantitative aspect of this measure. Essentially, it means "not too much" and "not too little"; in other words, just enough to suit the existing situa­ tion.

Consequently, the ability to transfer load

Form closure Bones, joints, ligaments

Force closure Muscles, fascia

Motor control

Emotions

Neural patterning

Awareness

Figure 5.1 1998).

The integrated model of function (Lee ft Vleeming

Figure 5.3

Conceptual model from PanJabi (1992bl.

illustrating the components which provide stability.

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The integrated model of function

2. optimal function of the muscles and fascia (force closure) (Vleeming et a11995b, Richardson et al 1999,2002, O'Sullivan 2000, Hungerford 2002) 3. appropriate neural function (motor control, emotional state) (Bo & Stein 1994, Holstege

et a11996, Hodges 1997, 2003, Hodges et a11999, 2001c, 2003b,

Hodges &

Gandevia 2000b,

Compression Compression of

an

object results when two forces act

towards each other. The main restraint to compression

in the lumbar spine is the vertebral body / annulus­ nucleus unit, although the zygapophyseal joints have been noted (Farfan 1973, Kirkaldy-Willis 1983, Gracovetsky et a11985, Gracovetsky & Farfan 1986,

Hungerford 2002).

Bogduk 1997) to support up to 20% of the axial com­ pression load (Fig. 5.5). Both the annulus and the nucleus transmit the load equally to the end-plate

FORM CLOSURE

of the vertebral body. The thin cortical shell of the

The term "form closure" was coined by Vleeming & Snijders (Vleeming et a11990a, b, Snijders et a11993a,

b)

and is

used

to describe how the joint's structure,

orientation, and shape contribute to stability and

potential mobility (Fig. 5.4). All joints have a variable amount of form closure and the individual's inher­ ent anatomy will dictate how much additional force (force closure) is needed to ensure stabilization when loads are increased. The "form" of the lumbar spine, pelvic girdle, and hip (the bones, joints, and liga­

ments) has been described in detail in Chapter 4. The potential mobility (biomechanics) for each region will be discussed in Chapter 6.

vertebral body provides the bulk of the compres­ sion strength, being simultaneously supported by a hydraulic mechanism \vithin the cancellous core, the contribution of which is dependent upon the rate of loading. When compression is applied slowly (static loading), the nuclear pressure rises, distribut­ ing its force on to the annulus and the end-plates. The annulus bulges circumferentially and the end­ plates bow towards the vertebral bodies. Fluid is squeezed out of the cancellous core via the veins; however, when the rate of compression is increased, the small vessel size may retard the rate of outflow such that the internal pressure of the vertebral body rises, thus increasing the compressive strength of the unit. In this manner, the vertebral body sup­ ports and protects the intervertebral disk against

THE LUMBAR SPINE

compression overload (McGill 2002) The anatom­ .

The "form" of the lumbar spine contributes to its abil­

ical structure which initially yields to high loads of

resist compression, torsion, and posteroanterior

compression is the hyaline cartilage of the end-plate,

shear, forces encountered during activities of daily

suggesting that this structure is weaker than the

living, in the following ways.

peripheral parts of the end-plate (Bogduk 1997).

ity to

Figure 5.4

Schematic representation of form closure

[Vleeming et a11990a, b, Snijders et aI1993a}.

Figure 5.5

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Compression of the lumbosacral junction.

43

44

THE PELVIC GIRDLE

Figure 5.6

Supe r i or and i n fe rior end-plate fractures (Schmorl's

nodes) detected via a diskogra m. Note the penetration of the dye into bot h the superior and inferior vertebral bodies through the end-plate (arrows). (Reproduced with pe r mission fro m Farfan

1973)

Figure 5.7

Right axial torsion of the L5 vertebra is resisted

by osseous impaction of t he left zygapophyseal joint and

capsular distraction of th e right zygapophyseal joint as well as the segmental ligaments, the intervertebral disk, and the

The fracture appears radiographically as a Schmorl's node (Fig. 5.6) (Kirkaldy-Willis et a11978, Kirkaldy­ Willis 1983). This lesion is commonly seen at the higher lumbar levels. McGill states that the vertebral bony elements fail at the higher load rates whereas the end-plate (no specification as to which part) fails first at low rates (McGill 2002). The zygapophyseal joints do not contribute to weight-bearing when in the neutral position, given that their sagittal and coronal components are oriented vertically. When the segment is extended, the inferior articular process of the superior vertebra glides inferiorly and impacts the pars interarticularis. When axial compression is applied in this lordotic position, load can be trans­ ferred through the inferior articular process to the lamina (Bogduk 1997).

Torsion or rotation

When a force is applied to an object at any location other than the center of rotation, it will cause the object to rotate about an axi s through this pivot point. The magnitude of the torque force can be calculated by multiplying the quantity of the force by the dis­ tance the force acts from the pivot. Axial rotation of the lumbar vertebra occurs when the bone rotates about a vertical axis through the center of the body (Fig. 5.7) and is resisted by anatomical factors located within the vertebral arch (65%) as well as by the struc­ tures of the vertebral body /intervertebral disk unit (35%) (Gracovetsky & Farfan 1986, Bogduk 1997).

myofascia.

At the lumbosacral junction, the superior articu­

lar process of the sacrum (see Fig. 4.2) is squat

and

strong in comparison to the inferior articular process of the L5 vertebra which is much longer and receives less support from the pedicle. Consequently, the inferior process is more eaSily deflected when the zygapophyseal joint is loaded at 90° to its articular surface. This process can deflect 8-9° medially during axial torsion beyond which trabecular fractures and residual strain deformation will occur (Farfan 1973, Bogduk 1997). The structure and orientation of the annular fibers are critical to the ability of the intervertebral disk to resist torsion. "The concentric arrangement of the collagenous layers of the annulus ensures that when the disk is placed in tension, shear or rotation, the individual fibers are always in tension" (Kirkaldy­ Willis 1983). Under static loading conditions, injuries occur with as little as 2° and certainly by 3S of axial rotation (Gracovetsky & Farfan 1986). The iliolumbar ligament (see Figs 4.12 and 4.19) plays an important role in minimizing torque forces at the lumbosacral junction. The longer the transverse process of the L5 vertebra and consequently the shorter the iliolumbar ligament, the stronger is the resistance of the seg­ ment to torsion (Farfan 1973). Axial compression also increases the segmental torque strength by 35% (Gracovetsky & Farfan 1986). During forward flexion of the lumbar spine,

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The integrated model of function

the myofascial components (force closure) are required to balance the moment of a large external load.

THE PELVIC GI R DLE How does the "form" of the pelvic girdle contribute Posteroanterior Shear

to stab i lity of the SIJs? The SIJs transfer large loads and

their shape is adapted to this task. The articular

surfaces are relatively flat and this helps to transfer compression forces and bending moments (Vleeming et a11990a, b, Snijders et a11993a, b). However, a rela­ tively flat joint

is theoretically more vulnerable

to shear forces. T he SIJ is anatomically protected from shear in three ways. First, the sacnun is wedge­ shaped in both the anteroposterior and vertical Figure 5.8 sacrum.

planes (Figs 4.1 and 4.2) and thus is stabilized by the

Posteroanterior shear of the L5 vertebra on the

innominates. The articular surface of the SIJ is com­ prised of two to three sacral segments and each is oriented

differently (Fig. 4.5) (Solonen 1957). Second,

the instanta n eous center of rotation moves forward

in contras t to other synovial joints, the articular car­

(see Fig. 6.3), thus increasing the compressive load

tilage is not smooth but irregular, especially on the

and co nseq u ently the ability of th e joint to resist torsion (Farfan 1973, Gracovetsky & Farfan

1986).

ilium (Sashin 1930, Bowe n & Cassidy 19 81 ) (Plates 1-5, Ch. 3). Third, a frontal dissection through the SIJ reveals cartilage-covered bony extensions protrud­ ing into the joint (Vleeming et aI1990a), ridges, and

Posteroanterior translation

grooves (Fig. 3. 6 ). T hey seem irreg ul a r, but are in

applied force produces

fact complem entary. All three factors enhance stabil­

sliding between two planes. Posteroanterior transla­

ization of the SIJ when compression (force closure) is

tion occurs in the lumbar spine when a force a ttempts

applied to

to displace a superior vertebra anterior to the one

closure) and the myofascial components (force clos­

5.8). The anatomical factors which resist

ure) are required to balance the moment of a la rge

Translation occurs when an

below (Fig.

posteroanterior shear at the lumbosacral junction are

primarily the impaction of the inferior articul a r processes

of

L5

against

the

superior

articular

processes of the sacrum and the iliolumbar ligaments

the pelvis. Again, both the articular (form

external load. The pubic s y mphys i s has less form the SIJ in that the

closure th an joint surfaces are relatively flat.

The joint surfaces are bound by a fibrocartilatinous

(Bogduk 1997). Secondary factors include the inter­

disk which is supported externally by superior, infer­

vertebral disk, the anterior longitudinal ligament, the

ior, anterior, and pos terior ligaments. T he pubic sym­

posterior longitudinal ligament, and the midline pos­

physis is vulnerable to shear forces in both the

terior ligamento us system (Twomey & Taylor 1985) .

vertical and horizontal plane and relies on dynamic

Dynamically, the posterior midline ligaments, the thoracodorsal fascia, and the muscles which generate

elements (myofascia), in addition to the passive struc­ tures, for

tension within this system are impor t ant in balancing the anterio r shear forces which occur when large

stabili ty.

THE HIP

loads are lifted (force closure) (Gracovetsky & Farfan 1986, Vleeming et a11990a, b, 1995a, 1997, Hides et al

T he hip is subjected to forces equal to m u lt i ples of

1994, 1996, Richardson

the body weight and requires osseous, articular, and

& Jull 1995, Hodges

&

Richardson 1996, Adams & Dolan 1997, Bogduk 1997,

myofasc ia l integ ri ty for stability. T he form

Hodges et al 2003b). The op timal method of loading

factors which contribute to stability at the hip include

closure

the spine should balance both compression and

the anatomical configuration of the joint as well as

translation

such that the magnitude of the resultant

the or ientatio n of the trabeculae and the orientation

force does not exceed the stre ngth of the joint.

of the capsule and the ligaments during habitual

Consequently, both the articular (form closure) and

movements.

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45

46

THE PELVIC GIRDLE

During erect standing, the superincumbent body weight is distributed equa lly through the pelvic girdle

(Vleeming b). For the zygapophy­

friction between the articular surfaces et a11990b, Snijders et a11993a,

to the femoral heads and necks. Each hip joint sup­

seal joints of the lumbar spine this position is end­

ports approximately 33% of the body weight which

range extension, for the sacroiliac joints full nutation

subsequen tly produces a bending moment between

of the sacrum or pos terior rotation of the innominate

the neck of the femur and its shaft (Singleton &

(Vleeming et a11989a, b, van Wingerden et al 1993),

LeVeau 1975). A complex system of bony trabeculae

and for the hip joint extension combined with abduc­

exists within the femoral head and neck to prevent

tion and internal ro ta tion.

superoinferior shearing of the femo ral head during

Studies have shown (Egund et a11978, Lavignolle

erect standing (Fig. 5.2) (Kapandji 1970). The hip

et a11983, Sturesson et a12000, Hungerford 2002) that

joint is an unmodified ovoid joint, a deep ball and

nutation of the sacrum occurs bilaterally whenever

socket, and its shape precludes significant shearing in any direction yet facilitates mo tion

(Ch. 6).

the lumbopelvic spine is loaded. The amOLmt of

sacral nutation varies with the magnitude of the load. Full sacral nutation (self-locking or close-packing) occurs during fonvard and backward bending of the

FORCE ClOSURE

trunk (Sturesson et al 2000). Countemutation of the sacrum, or anterior ro tation of the innominate, is

If the a r ticu lar surfaces of the lumbar spine, pelvic

thoug ht to be a relatively less stable position for

girdle, and hip were cons tantly and completely com­

the SIJ. The long dorsal ligament becomes taut

pressed, mobility would not be possible. However,

during this motion (Fig. 4.15); however, the other

compression during loading is variable and therefore motion is possible

(Ch. 6) and s tabilization required.

This is achieved by increasing compression across

major ligaments (sacrotuberous, sacrospinous, and interosseus) are less tensed (Vleeming et al 1996)

.

The orientation of the capsule and the articular

hip joint (see Figs 4.23 and 4.24) con­ h ip during functional

the joint surface at the moment of loading (force

ligaments of the

closure - Fig. 5.9). The amount of force closure

tribute to force closure of the

required depends on the individua l's form closure

motions (Table 5.1). Extension of the femur winds all

and the magnitude of the load. The ana tomical struc­

of the extraarticular ligaments around the femoral

tures responsible for force closure are the ligaments, muscles, and fascia. For every join t, there is a position ca l led the close-packed, or self-locked, position in which there is maximum congruence of the articular surfaces and maximum tension of the major liga ments.

In this

position, the joint is under Significant compression and the ability to resist shear forces is enhanced by the tension of the passive structures and increased

Table 5.1

Force closure secondary to tension of the

liga m ents of th e hip joint during motion of the femur Femoral motion

Ligament

Tension

Extension

All extraarticular

Taut

l i g am e n ts Flexion/adduction

All ligaments

Sl a ck

Lateral rotation

lIiotrochanteric

Taut

Pubofemoral

Taut

Ischiofemoral

SI<Jck

Iliofemoral

Slack

Medial rotation

Abduction

Adduction

Figure 5.9

PubofemoraI

Slack

Isch iofemora I

Taut

Pu bofe m o ra l

Ta ut

Inferior banda

Taut

I sc h iof e mo ra l

Taut

Iliotrochanteric

Sla ck

II iotrochanteric

Taut

Inferior banda

Slack

Ischiofemoral

Slack

Pubofemoral

Slack

Schematic representation of force closure

(Vleeming et al 1990a, b, Snijders et al 1993a).

°lnferior band of iliofemoral ligament.

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The integrated model of function

neck and renders them taut. The inferior band of the

1997, Hodges et al 1999, Moseley et al 2002, 2003)

iliofemoral ligament is under the greatest tension in

whereas the global system contracts later and is

2000, 2001,

extension. Flexion of the femur unwinds the liga­

direction-dependent (Radebold et al

ments, and when combined with slight adduction,

Hodges 2003). While some researchers have embraced

predisposes the femoral head to posterior disloca­

this classification (Richardson et

tion if sufficient force is applied to the distal end of

Mottram

the femur (e.g., dashboard impact). During

lateral

rotation

of

a11999, Comerford & 2001), others have not (McGill 2002).

The research is still lacking which enables classi­ fem ur,

the

fication of all muscles according to this system and

iliotrochanteric band of the iliofemoral ligament and

clinically it appears that parts of some muscles may

the

the pubofemoral ligament become taut while the

belong to both systems. With respect to the lum­

ischiofemoral ligament becomes slack. Conversely,

bopelvic region, the following muscles fit the cri­

during medial rotation of the femur, the anterior

teria for classification as local stabilizers - the muscles

ligaments become slack while the ischiofemoral

of the pelvic floor (Constantinou & Govan 1982, Bo &

the end of abduction, the neck of the femur impacts

1994, Sapsford et al 2001, Hodges 2003), the 1997, Hodges 2003), the diaphragm (Hodges & Gandevia 2000a, b, Hodges 2003), and the deep fibers of multifidus (Moseley et al 2002, 2003) (Fig. 5.10). As

on to the acetabular rim, thus distorting and evert­

research continues, more muscles will likely be

ligament becomes taut (Hewitt et al

2002).

Stein

Abduction of the femur tenses the pubofemoral lig a ment and the inferior band of the iliofemoral ligament as well as the ischiofemoral ligament. At

ing the labrum (Kapandji

1970). In this manner, the

transversus abdominis (Hodges & Richardson

added to this list. The deep (medial) fibers of psoas

2002), the medial fibers of quadratus 1989, McGill 2002), the lum­

acetabular labrum deepens the articular cavity

(Gibbons et al

(improving form closure), thus increasing stability

lumborum (Bergmark

without limiting mobility. Adduction results in ten­

bar parts of the lumbar iliocostalis and longissimus

sion of the iliotrochanteric band of the iliofemoral

(Bergmark

ligament while the others remain relatively slack.

internal oblique (Bergmark

1989), and the posterior fibers of the 1989, O'Sullivan 2000)

Adduction of the flexed hip tightens the ischiofemoral

are some likely candidates. This text will focus on

2002). The ligamentum teres

those in which the research clearly indicates that

ligament (Hewitt et al

is under moderate tension in erect standing as well

they are local stabilizers; however, it is not the

as during medial and lateral rotation of the femur.

intent to state that they are the only muscles that fit

Function would be significantly compromised if

this role.

joints could only be stable in the close-packed pos­ ition. In the neutral spinal position, an osteoligamen­

(T1 to sacrum with no muscles attached) 4.4 lb) of compression load (Lucas & Bresler 1961, Panjabi et a11989, Panjabi 1992a, b). Stability for load transfer tous spine

Multifidus

will buckle l.mder approximately 20 N (about

Diaphragm

is required throughout the entire range of motion and this is proVided by the active, or neuromyofascial, system. In

1989, Bergmark proposed that muscles

could be classified into two systems - a local and

a

global system. 111e local system pertains to those muscles essential for segmental or intrapelvic stabil­ ization while the global system appears to be more responSible for regional stabilization (between the thorax and pelvis or pelvis and legs) and motion (Bergmark

1989, Richardson et a11999, Comerford &

Mottram 2001). There is a significant neurophysiolog­ ical difference in the timing of contraction of these two muscle systems. When loads are predictable, the local system contracts prior to the perturb­

(in anticipation) regardless of the direction of movement (Hodges 1997,2003,Hodges & Richardson

ation

Sac ru m Figure 5.10

The local system of the lumbopelvic region

consists of the muscles of the pelvic floor, the transversus abdominis, the diaphragm, and the deep fibers of multifidus. (Reproduced with permission from © Diane G. Lee Physiotherapist Corp.)

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47

48

THE PELVIC GIRDLE

THE ROLE OF THE LOCAL MUSCLE SYSTEM The function of the lumbopelvic local system is to stabilize the joints of the spine and pelvic girdle in preparation for (or in response to) the addition of extemalloads. This is achieved through several mech­ anisms, some of which include: •

•

•

increasing the intraabdominal pressure (McGill & Norman 1987, Cresswell 1993, Hodges & Gandevia 2000a, b, Hodges et al 2001a, 2003b, Hodges 2003) increasing the tension of the thoracodorsal fascia (Cresswell 1993, Vleeming et a11995a, Willard 1997, Hodges 2003, Hodges et a12003b) and/or increasing the articular stiffness (Hodges et al 1997a, Richardson et a12002, Hodges 2003).

Research has shown (Constantinou & Govan 1982, Eo & Stein 1994, Hodges 1997, 2003, Hodges & Gandevia 2000a, b, Sapsford et a12001, Hungerford 2002, Moseley et a12002, 2003) that when the central nervous system can predict the timing of the load, the local system is anticipatory when functioning optimally. In other words, these muscles should work at low levels at all times and increase their action before any further loading or motion occurs.

Transversus abdominis Dr. Paul Hodges' first PhD focused on the role of transversus abdominis in healthy individuals and the response of this muscle in patients with low back pain (Hodges & Richardson 1996, 1997). He was able to show that transversus abdominis is an anticipa­ tory muscle for stabilization of the low back and is recruited prior to the initiation of any movement of the upper or lower extremity. He also showed that this anticipatory recruitment of transversus abdo­ minis is absent or delayed in patients with low back pain. Dr. Paul Hodges has just completed his second PhD (2003: Neuromechanical control of the spine). This series of studies prOVides further information on how lumbopelvic stability is achieved. According to Hodges (2003), a key finding from this research is that: When the upper limbs were moved rapidly in response

to a light, the anticipatory postural adjustment did not stiffen the trunk, but rather there was a consistent pattern of trunk

tion of limb

motion

movement.

that was specific to the direc­

Stability is achieved through motion, not rigidity. Small angular displacements of the vertebra pre­ ceded the limb movement and occurred in the opposite direction (preparatory movement) to the predicted movements of the segment (resultant movement). In other words, during rapid bilateral flexion of the upper limbs, a small amount of seg­ mental extension occurred in the lumbar spine (preparatory movement) before the arms moved (flexed). After the arms flexed, the lumbar segments flexed (resultant movement) a small amount. The opposite preparatory and resultant movements were noted during bilateral extension of the upper limbs. Transversus abdominis was the first trunk muscle recruited in all of these experiments yet did not render the trunk rigid . Hodges (2003) proposes that movement is used to diSSipate or dampen the imposed internal and external forces which occur as a result of the perturbation . Therefore optimal stabil­ ity requires mobility and a finely tuned motion con­ trol system. The clinical application of this research (Ch. 10) supports exercise programs which foster mobile stability (movements with control) as opposed to rigidity and bracing. As part of a very interesting study with pigs, Hodges et al (2003b) differentiated the role of first, the intraabdominal pressure (lAP); second, the vertebral attachments of the crura of the diaphragm; and third, the fascial attachments of the middJe layer of the tho­ racolumbar fascia on stability (resistance to flexion and extension) at L3-L4. The pigs were anesthetized and pins inserted into the spinous processes of L3 and L4. The resistance to segmental flexion and extension of L3-L4 was measured under different conditions. 1. The phrenic nerve was stimulated and the impact of an isolated contraction of the diaphragm on lAP and consequential stiffness (resistance to flexion/extension) at L3-L4 was noted. The JAP increased approximately 5 cm H20 and the resistance to flexion at L3-L4 increased approximately 10%. There was no difference in the resistance to extension at L3-L4. 2. Transversus abdominis was electrically stimu­ lated bilaterally. The intensity of the stimulus was set such that the lAP increased to similar levels as those in the phrenic nerve stimulation trials (#1: see below). The impact of this stimulation on stiffness (resistance to flexion/extension) at L3-L4 was noted. Again, resistance increased to flexion at L3-L4 but not statistically to extension (although a trend was noted). When transversus abdominis was stimulated

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The integrated model of function

unilaterally there was no change in the resistance to either flexion or extension at L3-L4. Therefore a bilateral contraction of transversus abdominis is required for stiffness at L3-L4 to be increased. 3. To differentiate the role of JAP from the mechanical role of the crura of the diaphragm and the fascial attachments of transversus abdominis three further experiments were done: a. A small incision was made in the abdominal wall and the phrenic nerve was stimulated to produce an isolated contraction of the diaphragm. It was noted that the lAP decreased to 17% of the lAP that occurred when the abdomen was closed. Subsequently, the resistance to flexion and extension was measured at L3-L4 (the diaphragm was stimulated through the phrenic nerve) and no change was noted. Therefore, the IAP is a significant contributor to resisting flexion at L3-L4 (contraction of the diaphragm increased the lAP which in turn produces an extensor moment). b. The crura of the diaphragm were then cut and the abdomen closed. When a contraction of the diaphragm occurred through stimulation via the phrenic nerve, the IAP had returned to 87% of the previous measures (#1 above). Subsequently, the resistance to flexion and extension was measured at L3-L4 and, as previously observed, there was an increase in the resistance to flexion. However, in addition, the resistance to extension was significantly decreased, suggesting that the crura of the diaphragm provide some mechanical control for extension at L3-L4. c. The middle layer of the thoracolumbar fascia was cut from the transverse processes at L2-LS first unilaterally and then bilaterally. In both trials, the resistance to flexion and extension was measured at L3-L4 following bilateral stimulation of transversus abdominis. Although the IAP increased with the contraction of transversus abdominis, there was no difference in the stiffening effect in flexion and there was a reduction in the stiffness of extension. Trans­ versus abdominis appears to play a mechanical role (along with the crura of the diaphragm) through its fascial attachments in resisting extension at L3-L4. In conclusion, the IAP, the fascial attachments of transversus abdominis, and the crura of the diaphragm play a significant role in controlling

flexion and extension in the lumbar spine (measured only at L3-U). T he JAP is increased through con­ traction of both the diaphragm and transversus abdominis and produces an extension moment (resistance to flexion). Extension is resisted by the fascial attachments of transversus abdominis and the crural attachments of the diaphragm. Although it does not cross the SIJ directly, the transversus abdominis has an impact on stiffness of the SIJ (Richardson et al 2002) through, in part, its direct pull on the large attachment to the middle layer and the deep lamina of the posterior layer of the thoracodorsal fascia (Barker & Briggs 1999) (Figs 4.37 and 4.38). Richardson et al (2002) propose that contraction of the transversus abdominis pro­ duces a force which acts on the ilia perpendicular to the sagittal plane (i.e., approximates the ilia anteri­ orly) (Fig. 5.11). They also propose that the "mechan­ ical action of a pelvic belt in front of the abdominal wall at the level of the transversus abdominis corres­ ponds with the action of this muscle." At this time, the specific direction of force produced by an isolated contraction of transversus abdominis (i.e., without co-activation of multifidus) has not been validated through research but this hypothesis has been devel­ oped clinically as a means for diagnosis and exercise prescription (see active straight leg raise, eh. 8). In a study of patients with chronic low back pain, a timing delay or absence was found in which trans­ versus abdominis failed to anticipate the initiation of arm and /or leg motion (Hodges & Richardson 1997a, 1999, Hodges 2001,2003). Delayed activation of transversus abdominis means that the thoracodor­ sal fascia is not pretensed and the joints of the low

Figure 5.11 Contraction of the transversus abdominls is proposed to produce a force which acts on the ilia perpendicular to the sagittal plane (i.e., approximates the ilia anteriorly: arrows). (Reproduced with permission from © Diane G. Lee Physiotherapist Corp.)

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T H E P E LV I C G I R D L E

F i g u re 5. 1 2

W h e n t h e d e e p fi b e r s o f t h e m u l t i fi d u s c o n t r a c t ,

t h e m u s c l e ca n b e fe l t to b roa d e n o r sw e l l (re p re s e n ted b y t h e a rr o w s i n t h e d e e p l a y e r s of t h e m u s c l e ) . Th i s hyd ra u l i c a m p l i fyi n g m e c h a n i s m ( p r o posed b y G ra c ovetsky

1 990)

" p u m ps

u p " t h e t h o ra c o d o rsa l fa s c i a m u c h l i ke b l o w i n g a i r i n to a b a l l o o n (V l e e m i n g et

a l 1 9 95a).

( R e p ro d u ced w i t h p e r m i s s i o n

Fi g u re 5 . 1 3

fro m © D i a n e G . Lee P h ys i o t h e ra p i s t Cor p.)

back and pelvis are there fore not st iffened (com­

p resse d ) in preparation for ex ternal loa di n g al1d are po tentially v u ln erable to losing in trinsic s tab ili ty

To g e t h e r, m u l t i fi d u s a n d t r a n s v e r s u s a b d o m i n i s

fo r m a co rs e t o f s u p p o r t fo r t h e l u m b o p e l v i c reg i o n , co l l e c t i v e l y c a l l e d t h e "c i rc l e of i n t e g r i ty . " ( R e p ro d u c ed w i t h p e r m i s s i o n fro m © D i a n e G. Lee Physi o t h e ra p i s t C o r p .)

.

et a l 2002) have s tudied the response of mul tifid us

D e e p fi bers of m u l t i fi d u s

in low back and pe l vic pain p a t i ents and note tha t

Moseley e t a l (2002) have shown tha t the deep fib er s of the mul tifidus muscle a re a lso anticip a tory for sta­

mul tifid us becomes

bi li za tion of the lumbar region and are recrui ted prior

multifidus on the thor a co do rs a l fascia, and therefore

to the initi a tion of any m ove m ent of the upper extrem­

i ts abil ity to compress the pelv is, is lost when the size or func tion of this muscle is i m p a ire d . Rehabili tation

.

ity when the timing of the load is predictable (Moseley et a l 2002) . In contrast, the su p e r ficial and l a te r a l fibers of the mul tifidus m u scle were shown to be direction-de p endent. In the p e l v is, this muscle is con­ tained between the dorsal aspect of the sacrum and the deep l a yers of the thoracodorsal fascia ( Fi gs and

4.16 4.27) . When the deep fibers of the multifidus con­

tract, the mu scle can be felt to broaden or swell (Fig.

5 . 12). As the d eep fibers of multifidus broaden, they "pump up" the thoracodorsa l fascia much like blo w ­ ing air in to a balloon (Gracovetsky 1990, Vleeming et al 1995a) . Using the Doppler imaging syste m Ri chardson et al (2002) noted tha t a co-contrac tion of m ul tifid us and transvers u s abd ominis increased the s ti ffness of the SJ}. These au thors state that " Under ,

grav itational load, it is the tr an s v e rse ly oriented mus­ cles tha t m us t act to compress the sacrum between the ilia and maintain st a bili ty of the

SIJ . " Althoug h

mul ti fid us is not oriented tr ans ve rsely, its contraction tenses the thoracodorsal fascia and i t is likely this

inh ibited and red uced in size in

these individuals. The n o rm al " p u mp-up" effect of

re q u i res

both retraining (Hides et a 1 1996, O'Su lliv a n a1 1997) and hyp ertrophy of t h e m uscle (Danneels et a 1 200 l ) for the res tora tion of proper force closure of the lumbopelvic region. Toge ther, m u l t i fi d us and tr a nsv ersu s abdominis (a l o n g with thei r fascia) form a corset of support for the l u mbopel vic re g ion (Fig. 5.13) the "circle o f integr i t y

et

-

. "

The p e l v i c fl o o r The "roof and floor" o f this local sys tem ( Fig .

5. 10) m u scles of the pel v ic floor and the respira tory d iaphragm. The mu s cles of the pelvic floor (Figs 4.28 and 4 2 9 ) p lay a critical rol e in both s tabiliza tion of the pelvic g i rdl e and in the m ainten ance of urinary and fec a l contine n ce ( Constan tino u & G ova n 1982, Bo & S tein 1 994, Ash ton -Mi l ler et al 2001, Peschers et a 1 200 1 a , Sapsford et a 1 2001 , Dietz et a I 2003 ) . Co ns t an tino u & G o v a n ( 1 9 82) meas ured a re s u ppor ted by the

.

­

s truc h.lre which imparts compression to the posterior

the intra u re thral

pelv is. This has yet t o be scien tifica lly verified; ho w

he a l th y conti nent w omen durin g co u gh ing and

­

ever, thi s hypothesi s has been de v eloped cli.nical ly as a means for diagnosis and exercise prescription (Lee

in trabladder p ressu res in

Va lsa lva (bea ring down) and foun d tha t during a cough the in tr a u re thra l pressure increases approxi­

8). Several inves tiga tors (Hides e t al 1994, Danneels

m ate l y

e t a1 2000, O'Sullivan 2000, Hungerford 2002, Moseley

cipa tes

2002) (see active s traight leg raise, Ch.

and

250 ms before any p ressure increase is de tec ted anti­

in the bladder. This su ggests that the u re th r a

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the

i m pendi ng

load

d u r i ng

coughing.

The integrated mode l of fu nction

The increase in urethral pressure occurred simultane­ ously with the increase in bladder pressure d uring a Valsalva (no urethra l an ticipation) . Constantinou & Gova n suggest tha t the timing difference in pressure generation within the urethra and bladder during a cough versus a Valsalva may be due to the contrac­ tion of the pelvic floor during a cough and relaxa tion of the pelv ic floor during a Valsalv a . Sapsford et al (2001) investigated the co-activation pa ttern of the pelvic floor and the abdominals via nee­ dle electromyogram (EMG) for the abdominals and surface EMG for the pelvic floor. In two subjects, fine­ wire needle EMG was used to detect activation of the right pubococcygeus through the lateral vaginal wall. They found that the abdominals contract in response to a pelvic floor contraction conunand and that the pelvic floor contracts in response to both a "hollow­ ing" and "bracing" abdomina l conunand . The results from this research s uggest tha t the pelvic floor can be facilitated by co-activating the abdomina ls and vice versa. Constantinou & Govan's suggestion tha t there may be a reflex connection between the pelvic floor and the urethra is supported by this research.

1 Dia

EMG

(a)

(b)

(c)

(d)

� 15

(EMG) a c t i v i ty o f t h e d i a p h ra g m repetitive t r u n k l o a d i n g v i a u p p e r - l i m b fl e x i o n w i t h a n d w i t h o u t res p i ra t i o n . ( a ) Si n g l e - l i m b move m e n t ( s h o u l d e r fl e x i o n ) w i t h o u t brea t h i n g . (b) R e pe t i tive u p p e r- l i m b F i g u re 5 . 1 4

E l e c t romyog ra m

d u ri n g si n g l e a n d

m o ve m e n t w i t h o u t b rea t h i n g . T h i s tra c i n g s h o w s a n i n crease i n t h e to n i c a c t i v a t i o n o f t h e d i a p h ra g m a l o n g w i t h t h e re p e t i t ive p h a s i c b u rsts in response to the re p e t i t i v e arm m o v e m e n ts.

( c)

Co m b i ned ton i c and p h a s i c

EMG

mod u l at i o n of the d i a p h ra g m

d u r i n g re p e t i t i v e a r m m o ve m e n t w h i l e breath i n g . T h e d a s h e d

T h e diaph ragm The diaphragm is traditionaJly considered to be a respiratory muscle. Hodges (2003; Hodges et al 1997a, b; Hodges & Gandevia 2000a, b) investigated the role of the diaphragm as a s tabilizer of the trunk during perturba tion studies involving rapid, single (Hodges et al 1997b, 2001 c) and rapid, repetitive (Hodges & Gandevia 2000b, Hodges et al 2001c) shoulder flexion . They found that EMG activity in both the costal and cru ral portions of the d iaphragm occurred simultaneously with the transversus abdo­ m inis and approx imately 20 ms prior to any EMG activity noted in the deltoid. They a lso note d tha t the anticipa tory activity of th e diaphragm depends on the magni tude of the per turbation and occurred regardless of the phase of respiration in which the shoulder was rapidly moved (Hodges et al 1 997b). This research supports the classification of the diaphragm acting as a local s tabilizer of the trunk in addi tion to its respira tory responsibili ties. Hodges & Gandevia (20 ooa b) also noted that when loads to the trunk are sustained, the diaphragm responds tonically tlu'oughout the respiratory cycle for postural support of the trunk and simultaneously mod ulates this tonic activa tion to control the intratho­ racic pressure necessary for breathing. An interesting pa ttern between the amplitude of activation of the ,

l i n e r e p rese n ts t h e i n s p i ra t o ry d i a p h ra g m E M G w i t h o u t l i m b move m e n t a n d t h e l i n e a b ove i s t h e p h a s i c m o d u l a t i o n w h i c h o c c u rs w h e n r e p e t i t ive a r m m ove m e n t i s a d d e d . ( d ) EMG a c t i v i ty o f the d i a p h ra g m d u ri n g res p i ra t i o n w i t h o u t a n y l i m b m o ve m e n t. ( R e d ra w n fro m H o d g es & G a n d e v i a 2000b.)

diaphragm and the transversus abdominis was noted the initial study (Hodges & Gandevia 2000a).

in

The amp litude of d iaph ragm E M C w a s h igh e r in ins pi ra t io n than expira tion. The opposite pattern of activity modulation was fo u n d for both the right and left TrA [transversus abdo m in isl . Similar to the diap h ragm, TrA wa s active throughou t the respira tory cycle and was modula ted with res p i ra t ion , but the amplitude of TrA EMC was higher during exp iration.

( Hodges

&

Gandevia 2000a )

When repetitive and sustained (lO s) perturbation of the trunk wa s added to the experiment (Hodges & Gandevia 2000b), another modulation of diaphragm activity was seen. There was a phasic modula tion of activity which occurred at the fre­ quency of the limb movement superimposed on the respiratory and tonic /postural activa tion (Fig . 5.14) ! Our data sugges t

tha t

diaphragm EMC h a s three

components; i n cre a s e d tonic activity, p hasic modu la­ tion

with

mo ve m e n t .

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respiration and phasic

( H odges

m o du la tio n &

wi th

Gandevia 2000b)

51

52

T H E P E LV I C G I R D L E

In a subsequen t stud y (Hodges et al 200lc), the authors no ted that the ton ic func tion (as well as the phas ic mod ulation associa ted with arm movement) of both the diaphragm and transversus abdominis was red uced or absent after only 60 s of hypercapnea. Blaney & Sawyer (1997) measured the amplitude of descent of the diaphragm from fLmctional residual capaci ty to maximal inspiration jll subjects who were about to undergo upper abdominal surgery and found the average displacement of the crura l p o r tion to be 5.5 :!:: 1 . 1 cm preoperatively. No significant dif­ ference was noted between abdominal versus lateral costa l expansion breathing patterns. Postoperatively, the amplitude of the diaphragm descent decreased to 2.0 :!:: 1.0 cm (58% decrease) and again no significant d i.fference was noted between the two breathing pat­ terns. However, the authors did note that when the subject was instructed just to take a deep breath, the amplitude of descent was much less and they con­ cluded that the propriocep tive input from the ther­ apist's hands can play a significant role in the excu rsion of the diaphragm. Blaney et al (1999) s ubse­ quently measured diaphragmatic displacement dur­ ing tidal breathing maneuvers (quiet breathing - not forced, not full) and noted that the excursion of the diaphragm varied with the pattern of brea thing. They measured diaphragm displacement during upper chest, abdominal, and lateral costal breathing and found the mean amplitude to be 2.2, 3 . 1 , and 2.4 cm respectively. Op timally, DeTroyer (1989) has found tha t quiet breathing should consist of 60% lateral costal expansion and 40% upper abdominal motion.

F i g u re 5 . 1 5 incl udes the

i n te rv e n i n g t h o ra c o d o rs a l fasc i a . ( R e d r a w n fro m Vl e e m i n g

et a l

1 995a.)

T H E R O L E O F T H E G L O B A L M U S C L E S Y ST E M the past, four slings of muscle sys tems which s t a ­ bilize the pelvis regionally (between the thorax and legs) have been described (Vleeming et al 1995a, b, Snij ders et aI 1 993a). The posterior oblique sling (Fig. 5. 15) contains connections between the latissimus dorsi and the gluteus maximus through the thora ­ codorsal fascia. The anterior oblique sling (Fig. 5. 16) contains connec tions between the external oblique, the anterior abdominal fascia, and the contralateral internal oblique abdominal muscle and adductors of the thigh . The longitud inal sling (Fig. 5 . 1 7) connects the peroneu, the biceps femoris, the sacrotuberous ligamen t, the deep lamina of the thoracodorsal fas­ cia, and the erector spinae. The lateral sling contains the primary stabilizers for the hip joint, namely the gl u teus medius / minim us and tensor fascia latae and the lateral stab ilizers of the thoracopelvic region. These muscle slings were initially classified to gain a better lmderstanding of how local and global In

Su m m a ry I n co n c l u s i o n , w h e n t h e l oca l system is fu n ct i o n i n g o pt i m a l ly, i t p rov i d es a n t i c i pato ry i n te rseg m e nta l stiffness of t h e j o i nts of t h e l u m b a r s p i n e ( H o d g es et a l 2003b) a n d p e l v i s ( R i c h a rd s o n et a l 2002 ) . T h i s extern a l fo rce (force c l o s u re) a u g m e n ts t h e fo rm cl osu re (sha pe of t h e j o i n t) a n d h e l p s to p reve n t excessive s h e a r i n g a t t h e t i m e o f l o a d i n g . Th is stiffn ess/co m p ress i o n o cc u rs prior to t h e onset of a n y movement and p re p a res t h e l o w b a c k and p e l v i s fo r a d d i ti o n a l l o a d i n g fro m t h e g l oba l syste m . S i m u l ta n e o u s l y, t h e d i a p h ra g m m a i n ta i n s res p i ra t i o n w h i l e t h e p e l v i c fl o o r a s s i sts i n m a i n ta i n i n g t h e p o s i t i o n o f t h e p e l v i c org a n s (co n t i n e n c e) a s l o a d i s tra n sfe rred t h ro u g h t h e p e l v i s.

T h e p o s t e r i o r o b l i q u e s l i n g of t h e g l oba l sys t e m

latissi m u s dorsi, g l uteus m a x i m us, and the

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The i n te g r a ted mod el of function

Fi g u re 5 . 1 6

T h e a n t e ri o r o b l i q u e s l i n g of t h e g l o b a l system

i n c l u d es t h e e x t e r n a l o b l i q u e , t h e c o n t ra l a t e r a l i n ter n a l o b l i q u e ,

F i g u re 5 . 1 7

t h e a d d u c t o rs o f t h e t h i g h , a n d t h e i n t e rv e n i n g a n te r i o r

b i c e p s fe m o r i s , t h e s a c r o t u b e r o u s l i g a m e n t, t h e d e e p l a m i n a of

T h e l o n g i t u d i n a l s l i n g co n n ects t h e p e ro n e i i , t h e

the t h o r a co d o rsa l fa s c i a , a n d the e re c t o r s p i n a e . ( R e p r o d u c e d

a b d o m i n a l fa sc i a .

w i t h p e r m i ss i o n fro m © D i a n e G . Lee Phys i o t h e ra p i s t C o r p . )

stabi lity of the p e l v is c o u l d be achieved by specific muscles . It is now recognized tha t, although indi­ vidual muscles a re i mp o r t ant for regional stabiliza­ tion as well as for mobi l i ty, it is critical to understand how they connect and function together. A muscle contrac tion produces a force that spreads b ey ond the origin and insertion of the active m uscle. This force is transmitted to other muscles, tendons, fasciae, ligamen ts, capsules, and bones that lie both in series and in p a r a l lel to the active muscle. In this manner, forces are prod uced quite distant from the origin of the ini tial muscle contraction. These integra ted muscle systems p rod uce slings of forces th a t assist in the tra nsfer of load. Van Wingerden et a l (200 1 , s ub­ mi tted) used the Doppler imaging system to ana­ lyze the effec t of contraction of the biceps femoris, erector spinae, gluteus maximus, and la tissiumus dorsi on compression of the SIJ. N o ne of these muscles directly crosses the S1J yet each was found to effect comp ression (increase sti ffness) of the SIJ . The glob a l system of muscles is essentially an integra ted sling system, comprised of several mus­ cles, which prod uces forces. A muscle may participate in more than one sl ing and the sl ings may overlap

and interconnect depend ing on the task being demanded. The hypothesis is tha t the slings ha ve no beginning or end but ra ther connect to assist in the transference of forces. It is possible that the slings a re all p a r t of one interconnec ted myofascial system and the particular sling (anterior o blique, posterior obliq ue, la tera l, longitudina l), which is iden tified d uring any motion, is merely due to the activation of selective parts of the whole sling. The identification and treatment of a specific m uscle dysfunction (weakness, inappropriate recrui t­ ment, tightness) is important when restoring global stabi liza tion and mobility (between the thorax and pelvis or between the pelvis and legs) and for under­ standing why parts of a sling may be inex tensible ( tigh t ) or too fl e x i bl e (lacking in s u pp ort) .

MOTOR CONTRO L Motor control pertains to p attern ing of muscle a c ti­ vation (Hodges & Richardson 1996, Hodges 2000, O'Sullivan et al 1997, Richardson et a1 1999, O'Sullivan 2000, Comerford & Mottram 2001, Danneels et al 2001,

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T H E P E LV I C G I R D L E

Moseley e t a l 2002, Hodges 2003), in other words,

the timing of specific muscle action and inaction. Efficient movemen t requires coordina ted muscle action, such tha t stability is ens ured while motion is con trolled and not restrained (Hodges et al 2001b, Hodges 2003 ) . With respect to the Iwnbopelvi c region, it i s the coordinated action between the local and global systems that ensures stability withou t rigid i ty o f posture and without episodes o f collapse. Exercises tha t focus on sequencing muscle acti va hon are necessary for restoring motor control (Richardson et a1 1999, Lee 200 1 a, Lee DG 2003 ) . The exercises in Chapter 10 focus on balancing tension and releasing compression within the slings of muscle systems and involve an extensive use of imagery. Imagery has been shown (Yue & Cole 1 992, Franklin 1996, Gandevia 1999) to be effective in restoring neural pat­ terning and increasing streng th Using im agery and specific sequencing of muscle activation, individual muscles are strengthened, lengthened, and appropri­ ately timed /patterned during functional tasks. .

Emotional states (fight, flight, or freeze reactions) are physically expressed through muscle action and, when sustained, influence basic muscle tone and patterning (Holstege et al 1996) . If the muscles of the pelvis become hypertonic, this sta te will increase compression of the SIJs (van Wingerden et a l 200!, Richardson e t aI 2002 ) . It is important to u nderstand the pa tient's emotional state since the detrim ental mo tor pattern can often only be changed by a ffe ct ing the emotion al s ta te. Sometimes, it can be as Simple as r esto r ing hope through education and aw areness of the underlying mechanical problem ( Bu tle r & Moseley 2003, Hodges & Moseley 2003). Other times, professional cognitive-behavioral ther­ apy is required to retra in m ore positive thought pa tterns. A basic requiremen t for cogni tive a nd p hys i c a l learning is focused, or a t tentive, training in o ther word s, not being absent-minded . Te a chi n g individuals to be "mindful" or aware of wha t is happening in their body d u rin g times of phYSical and / or emo tional loading can reduce sustained, unn e cessary muscle tone and therefore joint com­ pression (Murphy 1 99 2). ­

�

E M OT I O N S

Dr. A n d ry Vl ee m i ng (from Le e Et Vleem i n g 2003)

CO N C L U S I O N

Emotional states can play a s ignifi c an t role in human function, including the function of the neuromuscu­ loskeletal system. Many chronic pelvic pain pa tients present with trawna tized life ex p erie nc e s in add­ ition to their fLmc tional comp laints. Seve ral of these patients adopt motor pa tterns indicative of defensive posturing which sugges t a negative past experience. A negative emotional s ta te leads to further s tress . Stress is a normal response intended t o energize our system for quick flight and fight reac tions. When this response is sustained, high levels of epineph­ rine ( a d ren a l ine) and cortisol remain in the system (Holstege et al 1996), in p art due to circulating s tress­ related neuropep tides (Sapolsky & Spencer 1 997, Sapolsky e t al 1 997) whi ch are released in a n tic i p a tion of defensive or offensive behavior. ­

I t has long been recognized tha t phYSical fac tors impact joint function. The model presen ted here suggests tha t joint mechanics can be influenced by multiple fa c tors, some in trinsic to the joint i tself, while o thers are produced by muscle action which in tum is influenced by the emotional state . Th e effective managemen t of pain in the lumbopelvic­ hip region which is associa ted with d ysfunc tion requires atten tion to all fou r components - form clos­ ure, force closure, motor control, and emo tions with the goal be in g to guide pa tients towards a hea l thier way to live and move. This text w i l l focus on the assessment a nd treatment of the first three componen ts of this model an d its application to the lumbar spine, p e l vic gi rdl e , and hip .

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55

Chapter

6

Biomechanics of the lumbopelvic-hip region

The primary function of the lower quadrant is to move and simultaneously to provide

CHAPTER CONTENTS Terminology

56

Kinematics within the lumbar spine Kinematics within the pelvic girdle Kinematics of the hip

64

Integrated biomechanics of the lumbopelvic-hip region Lifting

a

stable base

from which the upper extremity can fUl1Ction (trans­

65

56 59

fer load). Together, the trunk and the lower extrem­ ities have the potential for multidirectional movement with

a

minimum of energy expenditure (Abitbol1995,

1997, McNeill 1995, 1997). Neuromusculoskeletal harmony is essential for optimal lumbopelvic-hip function. In 1911, Meisenbach stated that:

71

Pregnancy

72

When the trunk is moul'd to

one side quickly there direct opposing forces of the lumbar and spinal mLiscles agains t the pelvic and leg muscles. Normally Ihese work in harmony and are resisted by the strong pcloic ligamenb and fascia to a certain extcnt. if the hannolHj of these muscles is distllrbed from SOllie cause or another, or if the ligamentoLis :5l1jJjJort is weakened, other points of fixation must nccc,;stlrily are

yield. It is traditional to study both anatomy and biomech­ anics in a regional manner. For example, the lumbar spine is often considered separately from the pelvic girdle which in turn is investigated separately from the hip. This approach yields information as to how the parts function but not

as

to how the parts

work together. While it is necessary to consider the fLULCtion of the individual parts, rehabilitation is unsuccessful without consideration of how the;!.: parts achieve the harmonious action noted Meisenbach almost

a

by

century ago. After studying

individually the biomechanics of the lumbar spine, pelvic girdle, and hip, the collective biomechanics will be presented. Hopefully, a more integrated per­ spective of the biomechanics of the lumbopelvic-hip region can be achieved. First, a description of the terminology used is required.

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56

THE PELVIC GIRDLE

with the movement of one articular surface upon

TERMINOLOGY

another ... Articular surfaces can spin and/ or slide

T he terms kinematics (the study of movement) and kinetics (the study of forces) come from the science of kinesiology, the study of biomechanics. The pre­ fixes os teo and arthro are Greek derivatives meaning bone and joint respectively. Osteokinematics refers to the study of motion of bones regardless of the motion of the joints. These motions are named according to the axis about which they occur. F1exion/extension occurs when one or more bones rotate about a coronal axis. This terminology is consistent throughout the spinal col­ umn and peripheral joints. When the trunk bends forward/backward in a sagittal plane about a cor­ onal axis, this is called forward/backward bending.

upon each other" (MacConaill & Basmajian

1977).

These motions are referred to as pure spins and pure and impure swings. A pure spin occurs when the only motion of a point on the articular surface is a rotation around the mechanical axis of the bone. A pure swing occurs when the only motion of a point on the articular surface is a slide along the shortest possible line (the chord) behveen two points. An impure swing occurs when a point on the articular surface slides along any other curved line (an arc) behveen hvo points such that an element of spin also occurs. Arthorkinetics refers to

the study of forces met

by the joint during static and dynamic function.

Within the pelvic girdle, the accepted terms for flex­ ion and extension of the sacrum are nutation and counternutation respectively. Forward rotation of the innominate about a coronal axis is termed ante­ rior rotation, backward rotation is termed posterior rotation. Nutation/counternutation and anterior/ posterior rotation of the innominate should be reserved to describe motion between the sacrum and the innominate. When the hvo innominates and the sacrum rotate as a unit (pelvic girdle) about a

coronal axis through the hip joint, this is called an

anterior or posterior pelvic tilt. Abduction/adduction occurs when one or more appendicular (peripheral) bones rotate about a sagit­ tal axis. Within the spinal column, sideflexion occurs when an axial bone (skull, vertebral column) rotates about a sagittal axis. Motion of the trunk in the coronal plane about

a

sagittal axis is called lateral

bending. When the hvo inn 0 minates and the sacrum rotate as a unit (pelvic girdle) about a sagittal axis, this is called a lateral pelvic tilt. Medial/lateral or internal/external rotation occurs when one or more appendicular (peripheral) bones rotate about a vertical or longitudinal axis. Axial rotation occurs when

axial bone (skull, vertebral

an

column) rotates about a vertical or longitudinal axis. A hvist of the body about

a

vertical axis is also

called axial rotation.

KINEMATICS WITHIN THE LUMBAR SPINE Newton's second law states that the motion of an object is directly proportional to the applied force and occurs in the direction of the straight line in which the force acts. Translation occurs when

a

sin­

gle net force causes all points of the object to move in the same direction over the same distance (Bogduk

1997). Rotation occurs when hvo unaligned and opposite forces cause the object to move around stationary center or axis (Bogduk

a

1997).ln mechan­

ical terms, the lumbar vertebrae have the potential for 12 degrees of freedom (Levin

1997) (Fig. 6.1), as

motion can occur in a positive and negative direction along and about three perpendicular axes. However, this model does not accolmt for the anatomical fac­ tors which modify and restrict the actual motion which can occur. Clinically, the lumbar spine appears to exhibit four degrees of freedom of motion: flexion, extension, rotation/sideflexion right, and

1984, 1993, Bogduk 1997). through­

rotation/sideflexion left (Pearcy & Tibrewal Vicenzino & Twomey

out the spine, flexion/extension is an integral part of forward/backward bending of the head or trunk while rotation/sideflexion occurs during any other motion.

The bones can also translate along the same axes resulting in posteroanterior, anteroposterior, medi­ olateral,

lateromedial,

and

vertical

FLEX I 0 Nt EXTE IIJ SI 0 IIJ

(distraction­

compression) translation.

In the lumbar spine, the coronal axis is dynamic

Arthrokinematics refers to the study of motion of

rather than static and moves forward with flexion

joints regardless of the motion of the bones. "Intra­

such that flexion couples with a small degree

articular kinematics or arthrokinematics has to do

(1-3mm) of anterior translation (Figs

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6.2 and 6.3)

Biomechanics of the lumbopelvic-hip region

Figure 6.1

vD

Distraction

In mechanical terms,

there is the potential for 12 degrees of motion of the lumbar vertebrae

Compression

(Bogduk 1997, Levin 1997).

Translation

Coronal

Sagittal Axis

Axis

Vertical Axis

75

Flexion angle (degrees)

Center of rotation Figure 6.3

The coronal axis for flexion/extension moves

anteriorly with increasing degrees of flexion.

along the superior articular processes of the inferior Figure 6.2

1997). Durin g extension, processes of the s upe rior verte­ bra glide inferiorly and posteriorly along the s u perior vertebra/sacrum (Bogduk

Flexion/anterior translation at LS-S 1.

the inferior articular

(White & Panjabi

1978, Gracovetsky et al 1981, 1986, Bogduk 1997). Con­

Gracovetsky & Farfan

versely, extension couples with posterior translation

articular processes of the inferior vertebra / sacrum. The total amplitude of thi s glide is about

5-7 mm.

during backward bending of the trunk. At the zygapophyseal joints, the arthrokinemat­ ics of flex.ion and extension are impure

During flexion, the inferior articular processes of the

superior

vertebra glide

s uperio rly

ROTATI 0 NISI D EFLEXI 0 N

swings.

and anteriorly

Motion coupling of the vertebral rotation or lateral bending of the

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column during trunk was fi rst

57

58

THE PELVIC GIRDLE

recorded by Lovett in

1903. He noted that a flexible

provided by the intervertebral disk and

65% by the

rod bent in one plane could not bend in another

posterior elements of the neural arch.

without twisting. The direction of this motion coup­

Bogduk (1997) supports Pearcy & Tibrewal's (1984) model of motion coupling and concurs that

ling has been a controversial issue.

1984, Pearcy & Tibrewal reported on a three­

for the upper three segments axial rotation is accom­

dimensional radiographic study of lumbar motion

panied by contralateral sideflexion. This motion is

In

10 men under

unidirectional about an oblique axis and also involves

30 years of age. Their findings of coupled motion (Fig. 6.4) were consistent with those of Gracovetsky & Farfan (1986) except at the lumbosacral junction

6.5). L5-S1 the pattern tends to be ipsi­ lateral (Fig. 6.6) and that L4-L5 is variable. In add­

where lateral bending coupled with ipsilateral axial

ition, he notes that individual variation exists and

rotation. L4-L5 was noted to be transitional and

resists any rules for segmental motion patterning .

du r ing rotation and lateral bending of

followed the movement pattern of either

L3-L4 or

L5-Sl. This study did not investigate the coupling

slight flexion or extension of the segment (Fig. He agrees that at

Vicenzino & Twomey

(1993) investigated the

conjunct rotation which occurred during lateral

of motion when lateral bending was introduced from a position of flexion or extension. According to Bogduk

(1997),3° of pure axial rota­

tion of a lumbar motion segment is possible. At this point, all of the fibers of the annulus fibrosus that a re aligned in the direction of the rotation are under stress, the sagittal component of the contralateral zygapophyseal joint is compressed, and the ipsilat­ eral zygapophyseal joint capsule is tensed. The axis

L3

of motion is vertical through the posterior part of the vertebral body. After

3° of rotation , the axis

shifts to the impacted zygapophyseal joint and the upper vertebra pivots about this new axis. The ver­ tebral body swings posterolaterally, imposing

a

L4

lat­

eral translation force on the intervertebral disk. The impacted inferior articular process swings backwards and medially, further stretching the capsule and liga­ ments. Further rotation can result in failure of any of the stressed or compressed components. According to Bogduk

Figure 6.5

Left rotation of the L3-L4 joint complex couples

with contralateral sideflexion.

(1997),35% of the resistance to torsion is

TWIST TO THE RIGHT

TWIST TO THE LEFT

I L1/2 IL2/3 IL3/4 IL4/S IL5/S11

I LI/2'L2/31L3/4 IL4/S ILS/SII

Cil UJ UJ a: (j UJ

J I

e. >-

2 UJ :> UJ > 0 :>

-I -2 -3 -4

Figure 6.4

D

- A XIA L ROTATION

f%j �

_ ACCOMPANYING LATERAL BEND

Findings of coupled motion of rotation and lateral

bending in the lumbar spine. At the lumbosacral junction, lateral bending occurs in the same direction as the induced rotation. (Redrawn from Pearcy Et Tibrewal

1984.)

Figure 6.6

During right rotation, the LS vertebra rotates/

sideflexes to the right.

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Biomechanics of the lumbopelvic-hip region

bending of the lumbar spine

an d noted that in 64% of their specimens no conjunct rotation occurred at L5-Sl In the remainder, the d irection of rotation was always the same as sideflexion. This coupling .

of motion was consistent when the segment was side flexed from a flexed, neutral, or

extended pos­ an inter est in g pattern emerged. In extension, Ll-L2 and L3-L4 rotated opposite to the direction of sideflexion. In flexion, L1-L2 and L3-L4 rotated in the same direction as the sideflexion. Conversely, in extension, L2-L3 and L4-L5 rotated in the same direction as the sideflexion and in flexion L2-L3 and L4-L5 r otated in the opposite direction! The conclusion from this study was that the coupling ition. Above L 5 -S1

1990a, b, Kissling & Jacob 1997, Sturesson 1997, 2002). The investigative methods include: manu a l ma nip u la ti on of the SlJ both at surgery and in a cadaver (Jarcho 1929, Chamberlain 1930, Lavignolle et al 1983); X ray analysis in various postures of the trunk and lower extremity (Albee 1909, Brooke 1924); roentgen stereophotogrammetric and stereo­ radiographic imaging after the insertion of tantalum balls into the innominate and sacrum (Egund et al 1978, Walheim & Selvik 1984, Sturesson et al 1989, 2000, Sturesson 1997); and after the attachment of Hungerford et al2001, Hungerford

-

surface markers to the femur, sacrum, and innom­

displaced with degeneration, resulting in excessive

(H unger ford et al 2001, Hungerford 2002), measurements in various postures of the trunk and lower extremity, after the insertion of Kirschner wires into the innominate and sacrum (Pitkin & Pheasant 1936, Colachis et a11963, Jacob & Kissling 1995, Kissling & J acob 1997), and computer­ ized analysis using a Metrecom skeletal analysis system (Smidt 1995). Clinica l theories (DonTigny 1985, 1990, 1997, Hesch et al 1992, Lee 1992, 1999, Hesch 1997) have also contributed significantly

posteroanterior and/or lateral translation during

towards the research in this region. The results of

of motion in the lumbar spine was indeed complex. The biomechanics of the lumbar spine have been

shown (Farfan 1973, Kirka ldy Wil l i s et al 1978, White & Panjabi 1978, Kirkaldy Willi s 1983, Gilmore 1986, Grieve 1986, Stokes 1986, Twomey & Taylor 1986) to change with both age and degeneration. The -

-

instantaneous center of rotation for flexion/ exten­ sion and/or rotation/ sideflexion can

be signi ficantly

inate

inclinometer

physiological motion of the tnmk (White & Panjabi

these studies have led to proposals concerning both

1978, Stokes 1986). Consequently, "on the interseg­ mental level ... normal loads may in fact be acting about a displaced IAR [instantaneous axis of rota­ tion], thus locally producing abnormal motion" (Gilmore 1986).

function and

In summary, even if the biomechanics of the lum­ bosacral junction were confirmed and conclusive, the

p otential for altered biomechanics to exist is "perceptive clinical observation of a p atien t [as] the most direct way to assess spine motion clinically, despite its lack of obj e c tivity (Stokes 1986). high, rendering

"

KINEMATICS WITHIN THE PELVIC GIRDLE

Mobility

of the sacroiliac joint (SIJ) has been recog­

dy sfunction of the pel v ic girdle. T he detail the current status of the

followin g section will

biomechanics of the pelvic girdle. Motion of the pelvi c girdle

as a unit can occur in body planes: anterior and posterior pelvic tilt in the sagittal plane, lateral tilt in the coronal plane , and axial rotation in the transverse pl ane. A combination of all of these motions occurs d u ring the normal gait cycle (Greenman 1990, 1997). In addition, motion occurs within the pelvis. W hile m ob ility of the SIJ is small, movement has been shown to occur (WaJheim & Selvik 1984, Miller et al 1987, Sturesson et al 1989, 2000, Sturesson 1997, Hungerford et a12001, H unger ford 2002) throughout life (Vleeming et al 1992b, 1997). In the past, the quantity of motion available at the SIJ has been debated. In 1983, Lavignolle et al reported 10-12° of all three

nized since the seventeenth century. Since the middle

posterior rotation of the innominate (coupled with

of the nineteenth century, both postmortem and in viv o studies have been done in an at temp t to clar­ ify the movements of the SIJs and the pubic symph­ ysis and the axes about which these movements occur (Meyer 1878, Goldthwait & Osgood 1905, Albee 1909, Sashin 1930, Weisl 1954, 1955, Colachis et al 1963, Egund et al 1978, Wi l d er et al 1980, L a vignol le et aJ 1983, Walheim & Selv ik 1984, Miller et a11987, Sturesson et a11989, 2000, Vlee min g et al

6 mm of anterior translation), and 2° of anterior rota­ tion (coupled with 8 mm of anterior translation), in an in vivo study of two women and three me n under 25 years of age. This study was conducted in the non-weight-bearing position and Vleeming et al (1990a) note that this is probably a significant factor in the quantity of motion reported. Sturesson et al

(1989, 2000) used roentgen stereophotogrammetric 21

analYSis (RSA) to inv e stigate SI] mobility in

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59

60

THE PELVIC GIRDLE

women from 19 to 45 years of age and four men from 18 to 45 years of age. They found only 2S of innominate rotation (coupled with 0.5-1.6mm of translation). This in vivo study was conducted in the weight-bearing position Sturesson et al (2000) felt that the other authors (Weisl 1954, 1955, Colachis et al 1963, Lavignolle et al 1983) had overestimated the mobility of the SIJ. Jacob & Kissling's (1995) findings of S1] mobility using the RSA technique supported those of Sturesson et al (1989, 2000). The average values for rotation and translation were low, being 1.8° of rota­ tion (coupled with 0.7mm of translation) for the men and 1.9° of rotation (coupled with 0.9mm translation) for the women. No statistical differences were noted for either age or gender. They postulated that more than 6° of rotation and 2 mm of translation should be considered pathologic (Jacob & Kissling 1995). In 1995, Buyruk et al (1995a, b ) established that the Doppler imaging system could be used to meas­ ure stiffness of the SIJ. This research has recently been repeated and confirmed by Leonie Damen et al (2002a). Doppler imaging of vibrations across the SI] has shown (Buyruk et a11995a, b, 1997, 1999, Damen et a12002a) that stiffness of the SII is variable between subjects and therefore the range of motion is potentially variable. This research has also revealed that stiffness of the SIJ is symmetric when the left and right sides are compared in subjects without pelvic pain and asymmetric in subjects with pelvic pain. These studies will be discussed in greater depth later. In conclusion, we know that the SUs are capable of a small amount of both angular (1-40) and transla­ toric motion (1-3 mm), that the amplitude of this motion is variable between subjects; however, within one subject it should be symmetric between sides. NUTATION!COUNTERNUTATION OF THE SACRUM

Sacral Nutation

Inferoposterior Glide

Figure 6.7

When the sacrum nutates, its articular surface

glides inferoposteriorly relative to the innominate.

� .�

Sacral counter­ Nutation

Figure 6.8

'

When the sacrum counternutates, its articular

surface glides anterosuperiorly relative to the innominate.

Nutation and countemutation are osteokinematic terms that describe how the sacrum moves relative to the innominates regardless of how the pelvic girdle is moving relative to the lumbar spine and femora. Nutation of the sacrum occurs when the sacral promontory moves forward into the pelvis about a coronal axis through the interosseous ligament (Fig. 6.7). Conversely, countemutation of the sacrum occurs when the sacral promontory moves backward about this coronal axis (Fig. 6.8). The sacrum is countemutated in supine lying (Sturesson et al 2000) and nutates in sitting or standing (Sturesson

et aI2000). In other words, whenever an individual is vertical, the sacrum is nutated relative to the innominates. The amount of sacral nutation depends on how the individual is sitting or stand­ ing. In an optimal posture, the sacrum should be suspended between the two innominates in slight nutation but not completely nutated (Levin 1997). During the initial stages of forward or backward bending, the sacrum completely nutates between the innominates and should remain there throughout the full range of motion. On returning to standing, the

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61

Biomechanics of the lumbopelvic-hip region

sacrum rem ains nutated between the innominates

until the erect posture is reached. At this point, the sacrum counternutates slightly (remaining relatively

nutated) to become suspended once again between the two innominates. When an indi vidu al stands in a col l a ps ed posture (excessive kypholordosis or sway back), the sacrum can be completely nutated between the innominates. No further nutation will occur during forw ard or backward b en ding since the total available range of motion has been exhausted. When an in dividual sits in a co l lapsed posture (slouched) , the sacrum can be completely counternu­ tated (forced by weight- bearing through the coccyx). Arthrokinematically, when the sa crum nutates relative to the innominate, a linear motion or transla­ tion between the two joint surfaces can occur. To date, there have been no studies to validate the following arthrokinematics proposed to occur when the sacrum nutates relative to the innominate. Durin g nutation, the proposal is that the the sacrum g l ides inferio rly down the short arm (51) and posteriorly along the lo ng arm (52, 53) of the ar tic ular surface (Fig. 6.7). The amplitude of this transl ation is ex tremely small yet can be p alp a ted . This motion is resisted by the wedge shape of the sacrum, the r idges and depres­ sions of the articular surface, the friction coefficient of the j oint surface and the integrity of the inter­ osseous and sacrotuberous ligament s (Vleeming et al 1990a, b) (Fig. 6.9). This is the close-packed or self­ braced position of the SIJ the most stable position for transferring intermittent, high loads. The inter­ osseous and sacrotuberous lig am ents are s upported during nutation by the muscles which not only insert into them but compress the pelvic girdle transversely. D ur ing counternutation, it is p ropos ed that the sacrum glides a nter i o rly along the long arm and superiorly up the short arm (Fig. 6.8). This motion is resi sted by the l o n g dorsal sacroi l iac li ga ment (Fig. 4.15) ( V leemin g et aI1996). This ligament is sup­ ported by t he contraction of the multifidus which acts to nutate the sacrum. The m ul tifidus and le vator ani appear to act as a force couple to control sacral nutation/ counternutation (Snijders et al 1997). -

FLEXION/EXTE NSION OF THE COCCYX

Figure 6.9

Sacral n u tat ion i s the fo rward motion o f the sacral

promontory into the pelvis. This motion is resisted by t h e interosseous and sacrotuberous ligaments. (Redrawn from Vleeming et al

1997.)

POSTERIOR ROTATION OF THE IN NOMINATE Posterior rota tion of the innominate is an osteo kine­ matic term used to describe motion of the innomin­ ate relative to the sacrum and OCClli'S about a coronal axis through the interos seous ligament of the SIJ. Using reflective surface markers on 15 bo ny land­ marks of the femur, innominate, and sacrum and a sophi st icated imaging sy stem (six- ca mera Expert vision motion analy sis hi res 5.0 system), Hungerford (2002) noted that when an ind ividual transferred weigh t through one leg and flexed the contralateral femur (Fig. 6.10), the s u pporting innominate ( weight bearing side) either pos terior ly rotated or remained poster iorly rotated relative to the sacrum (sac rum is therefore relativ ely n u tate d ). The SIJ is thus close­ packed in preparation for load transfer. T he non­ weight-bearing innominate (sid e of h ip flexion) also posteriorly rotated relative to the sacrum ( Figs 6.10 and 6.11) during this motion. 5turesson et al (2000) initially reported this osteokinematic pattern of intrapelvic motion dur in g one leg stan ding and this research confirms their findings. Hungerford also descri bed a conjunct osteokinematic motion which occurred in association with posterior rotation of the innominate. On both the n on weight bea r ing a nd we ig ht bea ri n g sides, posterior rotation of the innominate was associated with sideflexion ­

-

Bo et al (2001) used MRI to investigate the function of the pelvic floor muscles and in this s tudy noted that a contraction of the pe l vic floor caused the coccyx to move in a ventral and cr anial direction (flex ion) During a Valsalva, or strainin g, t hey noted that the coccy x moved caudal and dorsal (extension). .

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-

-

-

62

THE PELVIC GIRDLE

(Fig. 6.12a, b) and rotation (Fig. 6.12c, d) of the innom­ Sideflexion and rotation of the innominate were coupled in a c oun tralater a l sense, although some va riability was n o ted Hungerford also investi g a ted the translatoric

inate.

.

mo tion (a rthrokinematics) between the innominate and sacrum during pos terior rotation of the

innom­ inate on both the non-weight-bearing and weigh t­ be a rin g sides. She w a s able to confirm part of what was o ri ginally proposed in the second edition of this text (Lee 1999); th at is, during pos terior rotation of the non-weight-bearing innominate (side of hip flex­ ion), the innominate glides anterosuperiorly rela tive

weight-bearing side, posterior and super­ ior relative to the sacrum (Fi g 6.l3). Co n c urre n tly, a medial translation was no ted, which may reflect increased a r ticular compression during loading In other w ords, when the pelvic girdle is self-bra ced and compressed by the passive a nd active elements, the direc tion of the translation is no t as predic ted (Lee 1999). Pos terior and superior translation of the articula r surface of th e iImominate relative to the sacrum would effectively "lock in" the S1J similar to the engagement of gears in a bicycle. Motion would be prevented and stability ensured for load transfer to the s acrum (Fig. 6.11). On the

the relative translatoric glide was .

.

Figure

6.10

The one-leg standing test (Gillet): the indivi dual

transfers weight through one leg and flexes the contralateral hip joint to approximately 90'.

when the articular surfaces engage in this ma nner.

ANTERIOR ROTATIO N OF THE II'.JNOMINATE Anterior ro ta tion of the innominate is an osteokine­ matic term used to describe motion of the inn omina te rela tive to the sa crum and occurs about a coronal axis through the interosseous ligament of the SIJ (Fig 6.14). Hung erford did not inves tigate anterior rota tion of the innomina te in healthy subjec ts; con­ sequent ly the follo wing is s till a p r opo sal In health, .

rotation of the innominate occurs d u ring extension of the fr eely swinging leg. When the innominate anteriorly rota tes, it glides inferiorly down the short arm and posteriorly along the long arm of the SIJ (Fig. 6.14). In conclusion, we now know that in non­ weight-bearing an arthrokinematic glide between anterior

Figure

6.11

When an individual transfers weight through one

leg and flexes the contralateral hip, the innominate on the non-weight-bearing s i de rotates posteriorly (dotted lines) relative to the sacrum (osteokinematics). The innominate glides anterosuperior and lateral (possibly reflects decompression of the joint) relative to the sacrum (arthrokinematics) (Hungerford

2002).

Note the dotted line of the articular surface. The amplitude

of the osteokinematic and arthrokinematic motion has been exaggerated in this illustration for visual purposes. In reality, the amplitude of osteokinematic motion is less than 5° coupled with

2-3 mm of translation.

the innominate and the sacrum occurs during pos­

terior rotation of the innominate and is physiological (i.e., f ollows the articular surfaces). In weigh t­ b ea ring, the close-packing of the SI} precludes this physiological glide. The rest is still hypothesis. Sacral nutation produces the same rela tive arthrokinematic glide as posterior ro tation of the innominate

Copyrighted Material

Biomechanics of the lumbopelvic-hip region

Figure 6.1 2

(2002)

Hungerford

describes a conjunct

osteokinematic motion which occurs in association with posterior rotation of the in nominate on both the n on-weight-bearing and weight-bearin g sides. The posterior rotation motion was associated with side­ flexion (a: left sid eflexion, b: right sid eflexion) an d rotation (c: left rotation, d: right rotation ). The combined pattern was often contralateral (the rotation occurred con tralateral to the direction of sideflexion) although this find in g was variable. The amplitud e of the osteokinematic motion has been exaggerated in these illustration s for visual purposes.

(d)

(c)

I . . .......

. I

I

I I

Figure 6.13

When an ind ividual transfers weight through

Figur e 6.1 4

the weight-bearing sid e either remain s posteriorly rotated

relative to the sacrum (note d otted lin e of the articular surface)

2002).

.'

/

An terior rotation of the innominate occurs d uring

extension of the freely swinging leg. When the innominate

posteriorly rotates (d otted line) relative to the sacrum

(osteokinematics). The in nominate glides posterior an d superior (Hun gerford

-

....... _ -" ._--.

one leg and flexes the con tralateral hip, the innominate on or

,

..

The amplitud e of the osteokinematic and

anteriorly rotates (dotted line), it glides inferiorly d own the short arm and posteriorly along the lon g arm of the sacroiliac joint (note d otted line of the articular surface). The amplitud e

arthrokinematic motion has been exaggerated in this illustration

of the osteokin ematic and arthrokinematic motion has been

for visual purposes.

exaggerated in this illustration for visual purposes.

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63

64

THE PELVIC GIRDLE

(inferoposterior motion of the sacrum is the same as

Os teokinematically,

flexion/extension

occurs

anterosuperior motion of the innominate); sacral

when the femur rotates about a coronal axis through

counternutation produces the same arthrokine­

the center of the femoral head and neck. Although

matic glide as anterior rotation of the innominate

variable, approximately

(anterosuperior motion of the sacrwn is the same as

possible, following which motion of the SIJ and inter­

100° of femoral flexion is

inferoposterior motion of the innominate). Further

vertebral joint occurs to allow the anterior thigh to

findings from Hungerford's research on how these

approximate the chest (Williams

biomechanics are impacted in patients with pelvic

mately 20° of femoral extension is possible (Kapandji

pain and failed load transfer will be discussed later.

1970). When rotation of the femoral head occurs purely

about this axis

(i.e.,

1995). Approxi­

without conjOined

abduction/ adduction or medial/ lateral rotation), the motion is arthrokinematically described as a

KINEMATICS OF THE HIP

pure spin. The femur articulates with the innominate via a

Abduction/adduction is an osteokinematic term

ball-and-socket joint, the hip, which is capable of

used when the femur rotates about

circumductive motion. The hip is classified as an

through the center of the femoral head. Approxi­

unmodified ovoid joint and in mechanical terms is

mately

capable of

adduction are possible, following which the pelvic

a

sagittal axis

45° of femoral abduction and 30° of femoral

12 degrees of freedom of motion along and about three perpendicular axes (Fig. 6.15). This

girdle laterally tilts beneath the vertebral column

classification does not account for the anatomical

(Kapandji 1970). When the femur rotates purely about

factors which influence the coupling of motion

this sagittal axis, the head of the femur arthrokine­

which actually occurs at the joint.

matically transcribes a superoinferior chord within Figure 6.1 5

u

compreSSlon

The osteokinematic

motion of the femur. In mechanical

terms, the femur is capable of 12 degrees of freedom of motion along and about three perpendicular axes.

Medial Lateral ! Rotation

Copyrighted Material

Biomechanics of the lumbopelvic-hip region

the ace t abulum (i.e., the shortest distance between two poi nts); therefore this mo tion is described as a pure swing. Medial/lateral rotation is an o steo kin ema ti c term used when the femur rotates about a l ongi tudin al axis. The location of this axis depends o n whether the foot is fixed on the grOlmd. When the pelvic girdle rotates a bou t a firmly p l an ted foot, the l ongitudin al axis of rotation runs from the center of the femoral head thro ugh to t he

l ater al fem oral condy le. When

the foot is off the ground, the femur can ro tate about a va ri e ty of longitudin a l a xes, all of which pass

through the femoral head and the foot (Williams

1(95). A pproximately 30-40° of m edial rota tion and 60° of lateral rotation are possible (K apan dji 1970). Pu re femoral rotation about this axis causes the femoral head arthrokinematically to tra n scribe an anteroposterior chord within the acetabulum a n d this m otion is described as a pure s w in g . Functionally, movement of the femur relat iv e to the innominate does not produce pure arthrokine­ matic motion.

Rather, combinations of movement

are the norm. The habitual pattern of motion for

the non - wei ght-bear ing lower extremity is a co mbin ­ ation of

flexion, abduction, and lateral ro tation and

Fig ur e 6.1 6

Forward bending of the trunk. Optimally, the apex

of the forward bending curve should be in the mid-buttock. This model demonstrates a lack of anterior tilt of the pelvic girdle

extension, adduction, an d medial rotation. Arthro­

on the femoral heads due to insufficient lengthening of the

kinematically, b oth motions are impure swings. The

hamstrings. ( Reproduced with permission from © Diane G. Lee

cl ose - p ac k position (most

stable) of the hip is exten­ sion, abduction, and i nter na l rotati on .

Physiotherapist Corp. )

INTEGRATED BIOMECHANICS OF THE LUMBO PELVIC-HI P REGION Functional movements

of the lumbopelvic-hip part of the clinical examination, conse­ quently the in te gra ted biomechanics need to be region are

understood.

FO RWARD BEN DI NG Forward bending of the trunk results in a posterior dis p lacement of the pel v ic girdle as a unit. This

motion shifts

the center of gravi ty behind the pedal 6.16 and 6.17). The pelvic girdle anteri­ orly tilts on the femoral heads about a t ransv e r s e axis throu gh the hip joints (hip joint flexes). The base (Figs

lumbar spine flexes in a superoinferior direction until L5 flexes on the sac ru m .

Within the pelvic ante rior or

girdle itself, there is no re lativ e

posterior rotation between the innomi­

nates during

forward b end ing . Both inno m inat es

Figure

6.17

The osteokinematic motion of the lumbopelvic­

hip region during forward bending of the trunk.

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65

66

T H E P E LV I C GIRD LE

shou ld travel an equal distance as the pelvic girdle a n teriorly tilts on the femoral head s . Du ring the ini­ tial stages of forward bend ing, the sacrum comp le tely n u tates between the innom ina tes and should remain there thro ugho u t the

full

range of motion . On

returning to standing, the sacru m remain s nu ta ted between the innominate s until the erec t pos ture is reache d . At this point, the sacrum COLmternutates slightly (remaining rel a tively n u t a ted) to become su spended once again be tween the two inn o rninates. The m uscles which eccen trically control forward bend ing of the trunk and the pelvic girdle include the ere c tor spinae, mul tifidus, qu a dratus lumborum, and the hip joint e x tensors (gluteus m a x im u s and the hamstrings) . Contributions from the hip joint rota tors, a b d u c tors, and a d duc tors a s well a s from the deep back mu scles function to s ta bi l i ze and coordin a te the motion between the lum b a r spine, pelvic gird l e , and hip . Prior to this motion, stabil­ iza tion of the l u mb a r segments and the pel v ic girdle is required from the loc a l s tabilizing system, in par­ ticu lar, the transversus a b dominis, m u l tifid us, and Fig u re 6. 1 8

pe lvic floor.

t h e i l i o fe m o r a l l i g a m e n t o f t h e h i p j o i n t . ( R e p ro d u ce d w i t h

B A C K WA R D B E N D I N G Backward bending of the trunk (Figs

B a c k w a rd b e n d i n g of t h e t r u n k . O p t i m a l l y, t h e

a p e x o f t h e b a c kwa r d b e n d i n g c u rve s h o u l d b e a t t h e l eve l o f p e r m i s s i o n fro m © D i a n e G . L e e P h ys i o t h e ra p i s t Co r p . ]

6.1 8 and 6. 19)

res u l ts i n an anterior displacemen t of the pelvic gir­ dle and a shift o f the cen ter of gra v i ty anterior to the ped a l base. The pelvic girdle poste riorl y til ts on the femoral hea d s abou t a transverse axis thro ugh the hip join ts (hip joint e x tends) . The thoracolumbar sp ine e x tends in a s uperoinferior direction

u n ti l

L5

ex tends on the sacrum. Wi thin the pe lvic girdle i tsel f, the re is no relative a n terior or posterior ro ta tion be tween the innomi­ nates d u ring b a ck w a rd bending. Both innomina tes should travel an equ al d i s tance as the pelvic girdle posteri orly ti l ts on the femoral hea d s . The sacru m sho u l d rema in in its n u ta ted position re l a tive to the inn o m in a te s . The muscles which eccentrically control backward bending of the trunk include the abdomin a l s, the quadricep s, the tensor fa scia la tae, and the psoas maj or. Con tribu tions from the hip j oint ro ta tors, ab d u c tors, and add uctors a s well as the deep back muscles fun c tion to s t a b i l i ze and coordina te the mo tion between the lumbar spine, pelvic g i rdle, and hip. Prior to this mo tion, stabil iza tion of the l u m b a r segmen ts a n d the pelvi c gi rdle is req u ired from the local s tabil izing system, in particular the tran sver­

Fi g u re 6. 1 9

sus abdominis, m ul tifid us, and the pelv ic floor.

h i p reg i o n d u r i n g b a c k w a rd b e n d i n g o f t h e t r u n k .

Copyrighted Material

T h e o s te o k i n e m a t i c m o t i o n o f t h e l u m b o p e l v i c ­

B i o m e c h a n i cs of the l u mbope lvic-h i p reg i o n

LAT E R A L B E N D I N G

t o the left. The segmenta l c onj u n c t rota t i on i s va ri­

Left la tera l ben d ing of the trunk is initia ted by dis­

gruen tly w i th the sacrum .

m a i n ta ining the line of gravity central wi thin the ped a l base ( F i g . 6. 20) . The a pex o f this l a teral bending c u rve

bending of the

able. Clinically, L5 appears to placing the upper legs to the right, thus

rota te/ sideflex con­

The muscles which eccentrically control la tera l

tnmk in c lude the contra l a tera l abdom­ q u ad r a t u s l u mbo­

inals, erec tor spinae, m u l tifi d us,

sho uld be a t the level of t h e grea ter trochanter. Th e

rum, i l iacus,

pelv ic girdle as a uni t l a te r a l ly til ts to the left s u ch

medius, gluteus minimus, and the ipsila teral a d d u c t­

tha t the left femur abd ucts and the right femur add ucts. Wi thi n the pelvis a sligh t right intrapelv i c

ors of the hip . Con trib utions from the hip j o i n t ro ta­

torsion c an occ ur. The right innomin a te posteriorly

s ta bil ize a nd coordinate the motion between the

psoas, tensor fa scia la tae, gl uteus

tors a s well as the deep back muscles func tion to

rota tes rela ti ve to the left innominate and the sacrum

l u m b a r spine, pel v ic girdle, and hip . Prior to this

ro tates to the right. The l u mb a r spine l a te r a l ly bends

m o ti on, s tabiliza tion of the lumb a r segments and

the

p elvi c girdle is re q uired from the local sys tem .

AX I A L R O TAT I O N Axial ro ta tion o f the pelvic girdle, toge ther with

a x i a l rotation of the vertebral c o l u mn, knees, and feet, a l lows the eyes to scan

3600 from a s t a tiona ry point. Du ring left axial rota tion, the femora twist to the l eft abou t a midline vertical axis, res u l ting

in an antero medial displacement of the proximal right femur

and a pos terome d i a l d ispla cemen t of

the p r o x i m a l left femur. Simu l ta neously, the pelvic gi rdle as a uni t rota tes to the left on the displaced femoral heads, resul ting in extension and lateral rota t i on of the right fem u r and flexion and media l rota t i o n of the left femur. The tw ist contin ues in an inferosuperior direction, producing in trapelvic torsion. The righ t inn o mina te ante riorly rota tes rel­ a tive to the left innomin a te and the sacru m rota tes to the left. The l u mb a r s p i n e rota tes to the left; th e s eg m e n t a l conj un c t r o ta t i o n is variab l e . C l inic­ ally, L5 appears to ro tate / sideflex c o ng ru e n tly w i th the sacrum.

WA L K I N G Wa lking is

an excellent e xampl e of the integra ted

model in mo tion. W11en func tion is optimal and one's mood is l igh t and confident, walking

is effo rtless glides through space w i th min­ imal displacemen t of the ce nter of g r a vity. This re qu i res op timal for m closure, force clo s u re, and

and the ind iv id u al

motor control of multiple regions. The ind ivid ual' s F i g u re 6 . 2 0

Late ra l bending of the tru n k. O p tim all y, the apex

of the lateral bendi n g curve should be at the leve l of the greater trochanter. ( R e p r o d uced with permissio n from © D i a n e G. Lee Physio thera p i st Co rp. )

emo tional s t a te can be reflected in

a n individ ual's

gait p a t tern. This se c ti on will review the os teokinema tics of the lurnbopelvic-hip region d u ring one cycle of g a i t . The

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67

68

THE PELVIC G I RDLE

integra ted biomechanics presented here comes from

the path of femoral motion is in the pure sagittal

clinical extrapolation

plane.

(Greenman 1997, Gracovetsky

1997, Lee 1999) since detailed osteokinematic research

During the stance phase of the right lower

is lacking, especially for motion between the sacrum

extremity (heel strike to toe-off), the femur moves

and the inn ominate (intrapelvic motion). During gai t,

from a flexed to an extended position. Again, this

there is motion within the lumbar spine and pel vic

motion is not a pure spin at the hip joint b u t ra ther

girdle as well as motion of the pelvic girdle as

unit

an arcuate or im p ure swing. The conjoined mo tion

ampli­

incl udes med ial rotation, althou gh as mention ed

rela tive to the lumb ar spine

and femur. The

a

tude and patterning of each mo tion are individual;

above, the medial femoral rotation is d ue to right

however, optimal gait requires the following compo­

transverse rotation of the pelvic girdle and therefore

nents (Table

the pa th of femoral

6. 1).

motion is in the pure sa gittal

plane. Adduction/ abduction d u ring this motion is va riable . The ligaments are progressively wound

Fe m o ra l motion During

around the femoral neck as the body weight passes

the swing phase o f the right lower extremity

anterior to the hip joint. Through the mid-stance

(toe-off to heel strike), the right femur moves from

position, the winding of the ligaments of the hip joint,

a n ex tended to a fl exed position. The habi tual

together with the myokinetic forces, increases com­

femora l movement p a ttern is not an arthrokine­

pression of the femoral head into the acetabula r fossa.

ma tic p ure spin at the hip j oint but rather an arc u a te

This increa se in force clos ure augments the form

(impure) swin g and therefore conj oined osteokine­ m a tic mo tions also occur. At toe-off, the femu r is

closure of the hip joint as the load transfer requi re­

med ially rotated

optimal mobility of the hip joint which requires a

ex tended

and

relative

to the

ments increase. A d equa te s tride leng th

re quires

innominate (abduction / adduction is variable) and

centered femoral head (neither d isplaced anteriorly

some of the ligaments of the hip joint are taut. As

nor posteriorly)

the

femur flexes, it rotates lateral ly relati ve to the

d uring al l motion. Effective load and

transfer requires harmonious action of the local

innominate due to the left transverse rotation of

glob a l systems of the enti re lumbopelvic - hip region

the pelv i c gi r d le as

(force clos ure and motor control) .

Ta b l e 6. 1

a

uni t (see below); consequen tly,

One g a i t cycle fo r t h e ri g h t lower extre m i ty Right h e e l st r i k e (Fig. 6.22)

Right toe-off (Fig. 6.2 1 ) Fe m ora

Pe l v i c

g i rd l e

as

a unit

Right m i d -sta nce (Fig. 6.24)

Right

Le ft

Right

Left

R i g h t a n d l eft a re

e xte n d e d

s l i g h tly flexed

flexed a n d

exte n d e d

a p proa c h i n g verti ca l

a n d i n te rn a l

a n d extern a l

extern a l

a n d i n te rn a l

b e n e a th the p e l v i c g i rd l e

rota t i o n a t

rota t i o n a t

rotation at

rota t i o n at

hip joint

hip joint

hip joint

hip joint

Rotated i n tra nsve rse p l a n e

Rotated i n tra nsve rse p l a n e

N e i t h e r rotated l eft o r

t o the right

t o t h e l eft

rig h t

A n t e r i o r rota te d r e l a tive

Poste r i o r rotated r e l a tive

A n t erior rota ti n g

to sacru m and l e ft

to sacru m a n d l e ft

re l a t ive to sacru m

i n n o m i n a te

i n n o m i n ate

Poste r i o r ro ta te d

A n t e r i o r rotated re l a tive

re l a t ive to t h e r i g h t

to the ri g h t i n n o m i n a te

Intra pelvic motion Right i n n o m i n ate

Left i n n o m i n ate

i n n o m i n a te

Poste ri o r rota t i n g re l a tive to t h e s a c r u m a n d ri g h t i n no m i nate

Sa c r u m

Left rotated between

R i g h t rotated b e t w e e n

Left ro t a t i n g between

t h e i n n o m i n a tes

t h e i n n o m i n a tes

t h e i n n o m i n a tes

Copyrighted Material

Biomechanics of the lumbopelvi c-h i p region

Pe l v i c g i rd l e motion

increases compression through the SI} and thus its

At r i g h t toe-off, the pelvic girdle as a uni t is rota ted

in the transverse plane to the right. Thro ugh the right swing phase, the pelvic g irdle as a uni t rota tes

s tabi l i ty. Inman e t a l

( 1981) have shown tha t the

hams tri ngs become active j u s t before heel strike. Contraction o f the biceps femoris mu scle increases

transversely to the left. A t right heel s trike, the pelvic girdle as a unit is rotated in the transverse plane to the left. Thro ugh the righ t stance phase, the pelvic girdle as a uni t rotates transversely to the right. Wi thin the pelvis, a n al terna ting i n trapelvic tor­ sion occurs . At rig h t toe-off (Fig.

6.21), the right

innomina te is anteriorly rota ted rela tive to the sacrum and the left innomina te . The sacrum is left­ rotated between the innomina tes. Through the righ t sw ing

phase,

th e

righ t

innomin a te

posteriorly

ro ta tes rela tive to the sacrum and a l so rela tive to the left innominate. The sacrum ro ta tes to the right between the innomina tes . A t right heel s trike (Fig.

6.22), the righ t inn om­

inate is posteriorly rota ted rel a tive to the sa crum. The sacrum is righ t-ro ta ted between the innom­ ina tes . The sacrum is nuta ted on the righ t rela tive to

F i g u re 6.2 2

the right innomina te (right innominate is posteri­

pelvic gi rdle at heel strike phase of the right lower ext rem i ty.

Wal king : osteokinema t i c s of t h e femora and

orly rota ted) and also nutate d on the left rela tive to the left innominate ( d ue to the right s acra l rota tion) . Therefo re b o th SUs a re self- b raced ( the left one is already under load and the right one is p rep aring for loa d ) . Posteri or rotation of the right innominate (or sacral n u ta tion) increases the tension of the sacrotuberous and interosseous ligament and prepares the j O int for heel s trike (Fig.

6.23) . The increase in

ten sion contributes to the force closure mech a nism, a ugments the form closure mechanism, and therefore

F i g u re 6 . 2 3

At heel s t r i ke, posterior rotation of the right

innomina te increases the ten sion of the right sacrot u be ro u s ligamen t. Con t raction of t h e biceps femor i s f u rt h e r i n c reases

Fi g u re 6.2 1

Wal k i n g : osteokinematics of the femora and

pelvic gi rdle at toe-off phase of the rig h t lower extremity.

tension i n this l i g ament, p repari n g the sacroil iac joint for impact. ( R e d rawn from V l eem i n g et al

Copyrighted Material

1 997.)

69

70

THE PELVIC GI R DLE

F ig u re 6 . 2 4 p e l v i c g i rd l e

Wa l k i n g : o s t e o k i n e m a t i c s of t h e fe m o ra a n d

a t m i d -s t a n c e p h a se o f t h e r i g h t l ow e r e x t re m i ty.

the tension in the sacrotuberous liga ment, fu rther contribu t i ng to the force c l osure mechanism . From heel s trike to m i d-s tance (Fi g . right innom ina te a n teri orly rota tes sacrum.

Simul taneously,

the

6. 24), the relative to the

sacrum

left-rotates

between the two innomina tes . It i s possible for the sacru m to left-ro ta te a s the right inn o m i na te

anteri­

orly rotates, thus ma intainin g sacr a l n u tation on the right s i d e . As the body moves from double support

F i g u re 6 . 2 5

Co m p e n sa t e d Tre n d e l e n b u rg .

to single-leg support, force closure of the pelvis is

travel along a smooth sinusoida l curve b o th ve rtically

e x tre m ely im p o r tan t

a nd l a teral ly and the d i splacement

and the system relies on effect­

ive motor con trol (both within the loca l and global systems) for s tabi l i ty.

should be no m ore than S c m

in both p l a nes (Inman et al 1 9 8 1 ) .

This d ispla cemen t is exaggerated when the pelvic

From m id-sta nce to toe-o ff, the right innominate

girdle

is

unable

to

transfer load ( insu fficient 1997a ) .

continues to rotate a n teri orly rel a tive to the sacrum.

in either form clos ure or force closure) (Lee

This motion unlocks the righ t SIT and a l l ows the

The p a t i en t attemp ts t o compensate b y reducing the f orces through the pelvic girdle . In a ful l y compen­

sacrum to con tinue to left-rota te between the innom­ in a tes.

Thro ugh the m id-stance phase, the hamstring

m uscles relax and

the gluteus ma x im u s muscle

s a ted ga i t, the

p a ti en t transfers weight l a te rally over

the involved limb (compensated Trendelenb urg) ,

becomes more active (Inman et a l 1 9 8 1 ) . This occurs

thus reducing the vertical shea r forces th rough the

in conj lmc tion with a counterro ta tion of the trunk

SI] (Fig.

6. 25). In a non-compensa ted gait pattern, the

firing of the contrala teral la tissimus dorsi muscle

patient tends to de m onstr a te a true Trendelenb u rg

(Gracove tsky 1997, Vleeming et al 1997) . Toge ther,

6.26) . The pelvic g i rd le adducts excessively (on The femur abducts rela tive to the fo o t, th us bri nging the cen ter of grav i ty closer to the SI}, wh i c h re duces the vertical she a r force .

and

these two muscles tense the thoracodors a l f a sci a a n d fac i li t a te the force closure mechanism thro ugh the

SIJ (Fig. 5 1 4) .

.

(Fi g .

the weigh t - bea rin g leg) .

In op tim al ga i t, the unlocking of the SUs allows

for sLight mobili ty which d issip a tes some of the rota ­ tion force away from the lu mbosacral j unction and

Lu m ba r m o t i o n the

facilita tes shock a bsorp tion within the pelvis . The

During gait, the lower lumb ar vertebrae rotate in

locki ng of the SUs fa c i l i ta tes sta bi li ty du ring times

same direction as the posteri orly rotating iIUlo mi­

of gravity should

nate. The axis abou t which l umbar rota tion occurs is

of h i gh load. Op ti m a l l y, the center

Copyrighted Material

Biomechan i cs of t h e lumbopelv i c- h ip region

li fting techniq u e is often resp onsible for the onset of low back and / or pelvic pain (Mc G i l l Moving an

object

2002) .

from the floor to a h i gh er s u r­

face ini tially req u i res fOIVv a rd bending. Op tim a l ly, full spi.ne flexion should be avoided to minimi z e p a ssi v e tissue tension.

Fo rward bending o f the

trunk should occur by flexing the hip j oints and the spine should b e ma intained in neu tra l . This requires the coordinated a c tion of b o th the local and glob a l systems. The p a rs thoracis extensors are po w erful e x tenders and when combined w i th activa tion of the oblique abdominals (po w e r fu l fle x o rs) help to maintain the prope r thoracopelvic positi on . In add­ ition, they have

a

s trong pos terior shea r moment on

the l u m b a r sp ine and this coun teracts the anteri or shear force produced by gra vity and the lifted load (McGi l l

2002) . Undernea th this, the local system

functions to con tro l inte rsegmental motion, particu­ larly shear wi thin the neu tral zone. The tension of the thoracodorsal fascia (generated by activa tion of the muscles which insert into it as well a s the hydra ulic amp lifica tion mechanjsm of those benea th it) contribu tes to force closure of the low back and SIJs and the maintenance of stability during loading. The moment the

tnmk

inclines for­

ward , the sacrum completely nutates betvveen the innomina tes (Sturesson et al F i g u re 6.2 6

oblique (see Fig.

6.5)

taut. These ligaments are supported

such that sideflexion occurs in

conj unc tion w i th th e rotation (Gracovetsky & Farfan

1 986,

Bogdu k

1997) . The d irection of sideflexion can

be va riable: common ly L5-S1 rotates and sideflexes in

an

ipsila tera l direc tion (Fig.

2000)

(SIJs self-locked),

and the interosseou s and sacrotuberous liga ments are

Tru e Tre n d e l e n b u rg .

6 . 6) and L4-LS

contra lateral d irection (Pea rcy &

in a

TibrewaI 1984).

by the activation

of the local and glob al muscles which insert into the m . McGill

(2002) considers " m o t o r con trol errors" to

be the most common cause of inj ury during l i fting . Cholewicki noted tha t the risk of such a n event was

grea tes t when high fo rces were developed by the la rge m uscles

and

mu s cles

(a possibility with o u r power lifters) or wILen

low fo rces by t h e small in tersegmental

all m uscle fo r ce s were low s uch as during a low-level

exer t ion. Th us

L I FT I N G Lifting is ano the r exa mple of the in tegrated model

d u ring potentia l l y high loading. McGill (2002) has q u a n ti fie d the mo ments and loads for

in motion

both the active a n d p a ssive elements of the spine d u ring a squa t l i ft

inj u ry from quite low in tensity be n d ing (1 995) no ted that passive

is poss ible. Adams and Dolan

of 27 kg ( 59 . 5 l b ) . The forces

necessary to support the load can ind uce a com­ p ressive load on th e sp ine of over 700 0 N ( 1568 lb) ! Therefore, optimal techni que which ba lances tension and red uces compression is essential for

inj ury pre­

tissues beg in to experience da mage with ben ding

moments of 60 N m . Th is can occu r simply

fro m a muscular s up po r t when bending over. This mechanism of motor con trol error res u lting in tempo rary i n app rop r ia te neural activation e xp l a i n s

te m po ra ry loss of

how inj u ry m ight occ u r during extremely l o w load situations, for exa mpl e p icking up a pencil from the floor fo l l o wing

demanding job.

a

long day at work perform ing

a

very

(McG i l l 2002)

vention. This will requi re optim a l form closure,

Re t u r n ing to ere c t s tanding is imt i a ted by backward

force clos u re, and motor control if loads are to be

rota tion of the pelvis. This mo tion is produced b y

tra nsferred and moved safe ly. Repetitive inc orrect

t h e concentric contraction of t h e g l u teus ma x i m u s .

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72

T H E P E LV I C G I R D L E

Load trans ference through the tr unk i s maintained

pubic s y m p h ys i s has been no ted r a d i olog i ca l ly

b y a co or d i n a ted a c tion of the loca l and globa l sys­

remain nu ta ted between

(Brooke 1 930, Hagen 1974), w i th the average increase being 5 m m . Whereas wi d e nin g of the

the illilom inates and supp orted . Pelvic s ta bi lity for

p ubic sy mphysis is universally found in pos tpar­

te m s . The sacrum should

is maintained b y the force closure

tum wo men (Wurdinger e t al 2002), a corre l a ti on

mecha nism prov ided by the tensi on in the tho r a ­

widening and pelvic p a in ei ther dur­ ing p regna ncy or in the p ostpa rt u m phase has not been fo u nd ( O s t g a a r d 1997, W u r d inge r et a l 2002) . Si mila rly, Damen et al (2002b) h av e shown th a t there is no s tat i s ti cal co rrelation between increase d

load tra nsference

codorsa l fascia ca used by con tr a ct i on of the la tis­ sim us dorsi, the tr a nsv e r sus abdominis, interna l oblique , mul tifidus, a n d g l u teus maximus . T h e glu­ teus maximus muscle h a s a c ons i d er a ble

mechanical

between this

adva n ta ge in humans as compared to o the r prima tes,

la xi ty of the SlJs and pelvic p a in in pregnancy.

given the inc r e a sed a n te r opo s te ri or d ep th of the

There is a co rrela tion; however, be tween asymmet­

human pelv i S . In addi tion, m ore than half of the

ric laxi ty o f th e SlJ and pelvic pain

m uscle inse r ts into the iliotibial band d i s ta l ly which

( D a m en et al 2001 ) .

increases its levera ge on the hip j o int, espec i a l l y w he n the b a n d is ta u t . The size a n d a n a tomy of thi s

muscle render i t an excellent " l i fter. " In summary, op ti ma l and therefore safe loading

and unloading of the Itunbopelvic-hip re gi o n during

in pregnancy

(1974), rela x a tion o f the in p reg n anc y is d ue to the p resence of a specific high-molecula r-weigh t hormone, r e l a x in, According to Ha gen

pelvic gird le

which toge ther w i th oes trogen ca uses " depoly m er iza tion of

­

hyal uronic acid . . C o mp re s s i ve, s h e a rin g .

ac tiv ities of d a i ly l i v ing can onl y occur when the

and

force

closure I motor con trol mechanisms s up p ort the bones and j oints (form clos ure) they stabi lize and

i n creas ing the concen tra tion of h y a l u r oni da se . . .

move. The co ord inated muscle response depe nds on

Thi s in terferes with the humoral conditions need ed for pe l v ic stab i l i ty and very l i k ely a l s o pl a ys a cer­

tensile forces

cons ti tute

a

ch ronic

tr a uma

complex peripheral a n d central feedback a n d feed­

tain role a s a p a thogenetic fa c t or in pe lvic relax­

forward m echa ni s m s which integra te the oss eo us,

a tion . " This has been con firmed by Kristia nsson

articular, and m u scula r fu nc tion .

( 1 997) . C onseq u en tly, the self-b raci ng mech anism of the pe l v i c gird le is less effective, th us inc re asing the stra in on the ligaments of both the SIJ s

pubiC

P R E G N A N CY

symphysis.

The

morp hological

and the ch a n ges

w i thin the pe lvic girdle associa ted w i th p regnancy The impact of pregnancy on the biomechanics of the

are

pel vic gird le warrants considera tion. The j o in ts of

(D a men et a1 2001, 2002b ) .

u n iv ersa l and often occur w itho u t s y mp to m s

the pe l vi c gir d l e b ecome l a x second ary to rel axation

OccaSiona lly, wome n present b e tween the 26th

of the l i g a m en t s of the SlJs and the p ubic sy mphysis

and 28th weeks with increasing tenderness over the

d u ring pregna ncy ( Brooke 1930, Yo un g al

1 940, H a gen 1 999, Damen

SlJ and l or p ubic symphysis seco n d ary to loss of

1974, Kristia nsson 1997, Buyruk et et a l 200 1 ) . Thi s process beg ins

d uring the 4th

if a woman presents a t this time with modera te to

month a nd con ti n ues until the 7th mon th of p reg

­

na nc y, followi ng which on l y a slight increase in

force closure. Damen et a l (2002b) h a v e show n th a t severe

(7/ 10 on a v i sual ana l og sca le) pe l vic pain a sym m e tric lax i ty of the SIJs, then this can

and h a s

mobility occ u r s . G re a t varia tion in the degree of

be predictive of ongoing pelvic p a in into the post­

both trans v erse and s up er oi nfe r io r widening of the

pa rtu m period

Copyrighted Material

(8 weeks p os tp a r t um) .

Chapter

7

Pain, dysfunction, and healing

MANUAL THERAPY AND PAIN

CHAPTER CONTENTS Manual therapy and pain

In the late 1970s and early 1980s, the emphasis of

73

Manual therapy and dysfunction Pain, dysfunction, and healing The soft-tissue healing process

74

75 75

manual therapy was on the detection and treatment of painful joints. Using specific manual techniques, Jull was able to identify painful cervical zygapophy­ seal joints 100% of the time in a b l inded study in w h ich

the painful joints were confirmed with anes­

thetic joint blocks (J ul l et al 1988). JuH was able to verify that the manual therapy techniques she used during this study were valid and specific. To date, a similar study has not been conducted for painful sacroiliac joints (SlJs); in fact, up until the mid-1990s, there was still debate regarding the ability of the SII to cause low back or pelvic pain. This issue was laid to rest in 1994 when Fortin et al (1994a, b) investigated the location of pain which resulted when healthy SIJs were injected with

an

irritant solution. From

these two studies, the SIJ is now known to cause pain directly over the posterior aspect of the joint and tends to refer pain down the posterolateral but­ tock and thigh (Fig. 7.1). Rarely does the p a in refer below the knee. Schwarzer et al (1995) and Maigne et al (1996) demonstrated, via formal studies using intraarticular SIJ anesthetic blocks, that 15-21% of people with low back p a in had a contribution from the SlJ. Maigne et al (1996) also investigated the validity of certain manual techniques thought to provoke pain from the SIJ. Of 67 participants, 54 had at least 75% of their pain relieved when the SIJ was injected under fluoroscopy. All participants had suffered from their pain for more than 50 days. These subjects then had several SI] pain provocation tests applied

Copyrighted Material

74

THE PELVIC GIRDLE

little support to proponents of the use of physical examination for diagnosis." This belief was sup­ ported internationally by respected authors in this subject (Laslett & Williams 1994, Bogduk 1997, Buyruk et al 1997, Laslett 1997, Mooney 1997). Bogduk's (1997) interpretation of this work is that "although SII pain is common in patients with chronic low back pain, it can only be diagnosed using diagnostic local anesthetic blocks."

MANUAL THERAPY AND DYSFUNCTION Fortunately, the last 5 years have seen the develop­ Figure 7.1

The pattern of pain produced when the

joint is irritated

(Fortin

permission from

© Diane G. Lee Physiotherapist Corp.)

et al 1994a,

b).

sacroiliac

(Reproduced with

Gaenslen, Patrick, pain on resisting external rotation of the hip, pressure directly over the pubic symphy­ sis, distraction); the response was noted and correl­ ated with the findings from the joint block. The authors note:

There was no statistically s ignifican t association between response to blocks and any single clinical dicto r of sacro il i ac joint pain.

a

useful pre­

(Ma.gne et aI1996)

Dreyfuss et al (1996) were also unsuccessful in identifying either

a

consistent medical history or

relevant SlJ test (as determined by a multidisciplinary expert panel) for detecting individuals who had 90% of their pain relieved with anesthetic joint blocks. The tests in this study included: 1. pain drawing depicting pain over the

physical examination tests for identifying those indi­ viduals with impaired function of the lumbar spine

to their pelvic girdle (compression, sacral pressure,

parameter. No pain provocatioll test was

ment of some reliable, valid, sensitive, and specific

SIJ

and pelvis

(Ch. 8).

When these tests are used as inclu­

sion criteria for investigating pelvic pain patients; reliability, sensitivity, and specificity can be found. Vleeming et al (2002) have confirmed that the long dorsal ligament is a significant pain generator in patients with peripartum pelvic pain (sensitivity

76%).

When a combination of pain severity, pain

provocation tests, and functional tests was applied to tighten the inclusion criteria (severe pelvic pain coupled with a positive posterior pelvic pain provo­ cation test (Ostgaard et al 1994, Ostgaard 1997) and a positive active straight leg raise test (Mens et al 1999,2001,2002; see Ch.

8)

the sensitivity was 98%.

In 1999, it was proposed (Lee 1999) that:

we have 110t yet "discovered" the right man­ llal tests for the 51/. How cal l we be so accurate with

Perhaps

respect to the cervical spill!' and so inaccurate in the

pelvic girdle? Dreyfuss et al (1996) put forth this

2. pain drawing depicting pain into the buttock

challCllge: "If proponents of other tests bclir(J(, tlwt

3. pain drawing depicting pain into the groin

the ir tests are superior, they have tit!' rrsponsibili ty a I1d

4. pointing to within 5 em

(2

measured inches)

of the posterior superior iliac spine to indicate the site of maximal pain 5. sitting with partial elevation from the chair of the buttock on the affected side

6.

the means to validate those tests by challel1�ing titem

with diagnostic, intra-articular Sl] blocks as rbcrihed in this stlldy." Slowly but surely we are doing just that

(Ch. 8).

Manual therapists have long advocated"joint play"

Gillet test

tests (passive accessory mobility tests) for analyz­

7. thigh thrust

ing joint mobility/stability. Recently, Doppler stud­

8. Patrick's test

ies (Buyruk et al 1999, Damen et al 2001, 2002a-d,

9. Gaenslen's test

Richardson et al 2002) have established stiffness

10. midline sacral thrust

values for the SIJ under different conditions

11. sacral sulcus tenderness

(Ch.

It is only a matter of time until we can test our

12. joint play

8).

man­

ual tests of "joint play" (the" manual Doppler" test)

They emphatically state that "The results of the

against this technology. However, these tests evalu­

present study vindicate [these 1 reserva hons and offer

ate function, not pain, and this is where the integrated

Copyrighted Material

Pain, dysfunction, and healing

model of function differs from those which seek to

joints. Others have ap parentl y full function in terms

identify pain generators. Pain is not predicatible

of mobility and stability and yet intraarticular joint

because it is an emotional experience and depends

pain (Buyruk et al 1997). Stiff on those above and below them, and over time symptoms may appear. Maigne et al (1996) do concede that "It remains possible that a major part of the so-called SII pathology is a path­ ology of the soft tissues surrounding the j o int " Or maybe, the joints above and/or below the ones which are dysfunctional are responsible for the pain.

on both mechanical and biopsychosocial factors. Those which initiate the pain response (mechanical and/or chemical deformation of nociceptors in

pain­

sensitive tissues) can be quite different from those which maintain the perception (Butler 2000, Moseley 2003, Hodges &

Butler &

Moseley 2003).

blocks relieve their

joints put extra stress

.

When treating dysfunction, it is important to restore optimal form closure (mobi l ity an d stability) , force

PAIN. DYSFUNCTION. AND HEALING

closure, and motor control so that the injured

Pain disabil ity is a form of pain behavior (Vlaeyen et al

1997, Waddell 1998, Butler 2000) constantly by social and psychol ogical conditions. According to Vlaeyen et al (1997) pain disability shifts from a structural/mechanical control to a cognitive/environmental control over a period of influenced

soft may be responsible for some of the nociceptio n can heal, while re maining cognizant of other factors (emotions and psychological state) which can impact the pain experience and rate of tissue which

recovery.

4--8 weeks. It is inte restin g to note that all of the sub­

jects in the Maigne et al (1996) a nd Dreyfuss et al (1996) studies had low back pain for l on ger than 8 weeks. With respect to low back pain, Moseley has been able to show that a combination of physiother­ apy (as outlined in this text) and education regarding the neu ro physio logy of pain

is effective in produ­

cing both symptomatic and functional change in the moderately disabled chronic group (Moseley 2002). He also notes that health professionals often believe that patients will not understand the

ne u roph y si ology of chronic pain and therefore hold back this valuable information (M oseley 2003). A new book, Explain Pain, co-authored by Lorimer Moseley and ­

THE SOFT-TISSUE HEALING PROCESS W hen an injury has occ u rred

either directly (macro­ a short period of time) or indirectly (microtrauma over a long period of time) to the soft

trauma over

tissues of the body, the principles of treatment follow those of

the body's natural he a ling process. Since it doubtful that any thin g can be done to accelerate the normal response for wound repair, the intent of the rapy is to prevent and/or reverse the factors is

which tend to retard recovery and facilitate the fac­ tors which restore the neurophysiology that accom­ pani es the inju r y. The aim is to restore

the function

David Butler ( www .noigroup.com). intends to bridge

and treat the soft tissue according to the stage of its

this gap.

recovery.

The prefix "dys" is Greek for abnormal, the word "function"

is Latin for performance. Abnormal

Approximately three billion years ago when liv­ ing organisms were unicellular, death of the cell

performance has little to do with pain perception,

meant death of

although it is known that pain and fear of pain have

multicellular organisms, so followed the process of

a negative impact on motor control (Hides et al

repair after inju ry. Ultimately this repair process was

1994, Hodges & Richardso n

the organism. With the evolution of

1996, Danneels et a12000,

perfected so th at complete regeneration of an ampu­

Hodges & Moseley 2003). Several studies (Mattila et al 1986, Bullock-Saxton et al 1994, U hl ig et al 1995, Hides et al 1996, Hodges & Richardson 1996, Dangaria & Naesh 1998) have shown that changes in muscle fiber type, muscle bulk, and recruitment patterns occur with pain and pathology. It is clear that relieving pain does not necessarily restore opti­ mum function (Bullock-Saxton et al 1994, Hides et al 1996, Hodges & Moseley 2003). Many people

tated limb was possible. Some lower vertebrates such as lizards and newts have retained this capability. The evolution of more complex life forms (e g., the .

mammal) has occurred at the expense of total regen­ erative

ability. For example, in humans, cardiac

muscle does not regenerate after infarction, neural tissue does not

regenerate after cellular death, skin

does not regenerate after full-thickness injury, and an amputated finger does not grow back. With few

have abnormal joint function (stiffness - arthro­

exceptions, mammalian tissue responds to injury

desis, looseness - instability ) and no pain from these

by repair rather than regeneration.

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7S

76

THE PELVIC GIRDLE

In most tissues, repair occurs by fibrous tissue

remains constant or even decreases after the stage

proliferation regardless of which tissue has been

of fibroplasia, the wound continues to gain in ten­

damaged. Although the healing process is not a state,

sile strength. This strength gain is due to two factors:

it can be divided into three phases: the substrate

the intramolecular/intermolecular cross-linking of

phase, the fibroblastic phase, and maturation.

the collagen fibers, and remodeling of the wound by the dissolution and reformation of the collagen fibers to give a stronger weave. The quantity of col­

SUBSTRATE PHASE

lagen is constant; it is the organization that is under­

The substrate phase (also called the lag, latent, or productive phase) extends from the time of the 4th to 6th day.

It is

injury to

going change. This process of remodeling may require

6-12

months for completion.

characterized by the inflam­

matory response which prepares the wound for sub­

CLINICAL APPLICATION TO TREATMENT

sequent healing by removing the debris, necrotic tissue, and bacteria. At the same time, fibroblasts

Following

migrate to the wound site. Exactly how these cells are

ability can be caused by the synthesis and depos­

attracted to the wound is unknown; however, sev­

ition of scar tissue and the way in which the physical

an

acute soft-tissue injury, functional dis­

eral investigators (Bassett 1968, Kappel et al 1973,

properties of collagen differ from the Lillwounded

Peacock 1984) feel that an electric potential exists

tissue it replaces.

at the injury site which influences their migration.

motor control must be considered. The aim of treat­

In addition,

the impact of pain on

During this phase, the wound is held together by the

ment, therefore, must be to control and guide the

gluing action of fibrin which has a very low break­

repair process such that optimal structure and func­

ing strength.

tion are restored. During the stage of fibroplasia, the tensile strength of the wound is proportional to the rate of collagen

FIBROBLASTIC PHASE

accumulation. Webster et al

The fibroblastic phase begins between the 4th and 6th day after inj ury and can last up to (Peacock

1984).

4-10

weeks

At this time, the proliferating fibro­

blasts begin to synthesize collagen, mucopolysacchar­ ides, and glycoproteins. Regardless of the location of the wound, the fibroblasts carry on the process of wound repair by replacing the damaged structures with fibrous tissue. Tropocollagen is secreted from the fibroblasts and quickly aggregates into collagen fibers. The orientation of the fibers at this stage has been shown (Bassett 1968, Peacock 1984) to be influ­ enced by the mechanical forces existing at the wound site. The tensile strength of the wound during the fibroblastic phase is proportional to the quantity

(1980)

have shown that

ultrasound can increase the quantity of collagen synthesized, thereby increasing the tensile strength of the scar. Research (Mester 1971, Abergel 19 84) on the effects of lasers indicates that facilitation of the optimal rate of healing is possible with this modal­ ity. However, whether it is possible to shorten the total length of time required for maturation of the scar is controversial. What can be done; however, is to prevent the undesirable factors which tend to retard the healing process. The fibrosis can also be controlled and directed during the stages of synthe­ sis, deposition, and remodeling, such that a more functional scar subserves the tissue it replaces as best it can.

of collagen present rather than the cross-linking behveen the collagen fibers.

Tendon

MATURATION PHASE

of the tendon of the piriformis muscle with those of

To illustrate, compare the structural characteristics the peroneus longus muscle. The tendon of piri­ These is no sharp demarcation between the end of

formis is relatively short and is not enclosed in a

the fibroblastic phase and the beginning of the

synovial sheath (Fig. 7.2). The collagen fibers within

maturation phase. Peacock (1984) states that the

the tendon are oriented in a longitudinal regular

quantity of collagen within the wound ceases to

manner (Fig.

7.3),

consistent with the lines of stress

injury.

produced when the muscle contracts. Since the type I

Although the collagen content within the wound

collagen which is present in tendon is inelastic, this

increase between the 3rd and 4th week after

Copyrighted Material

Pain. dysfunction. and healing

/

r'"

'/

\ r-,-r-'-,,"+- Piriformis

Figure 7.2

The piriformis muscle and its tendon.

Figure 7.4

The peroneus longus muscle, its tendon and

synovial sheath.

Figure 7.3

Both tendons and ligaments are composed of a

regular longitudinal arrangement of collagen fibers. ( Redrawn from Williams

1995.)

arrangement allows the force generated by contrac­ tion of the muscle to be efficiently transmitted to the bony insertion on the greater trochanter. Minimal gliding of the tendon on the adjacent structures is required for normal fWlction. Conversely, the tendon of the peroneus longus muscle is long and is enclosed within a sy novial sheath passing beneath several fibrous tunnels on the lateral aspect of the ankle as well as within the sole of the foot (Fig. 7.4). The collagen fibers within the tendon are also oriented in a longitudinal man­ ner consistent with the lines of stress produced when the muscle contracts. Aga in, this arrangement

facilitates the transmission of force from the muscle belly to the bone efficiently. However, when the muscle contracts, the tendon is required to glide extensively between the adjacent structures and the restoration of this fWlction is critical to the success of treatment. The repair process following injury to either of these tendons is the same. The inflammatory response of the substrate pha se is followed by the prolifer­ ation of fibroblasts and the production of collagen, mucopolysaccharides, and glycoproteins. The orien­ tation of the new collagen fibers at this stage of repair is influenced by mechanical deformation of the wound. Exactly how tension affects the orien­ tation process is controversial; however, research (Bassett 1968, Kappel et al 1973) suggests that the electrical field surroWlding the injury site may influence both healing and regeneration of tissue. In 1880, Pierre and Jacques Curie discovered that when a quartz crystal was stressed, a potential dif­ ference was produced across its faces. This was called the piezoelectric effect. It is felt (Bassett 1968, Kappel et a1 1973, Peacock 1984) that since collagen is crys­ tal lin e in nature, a potential difference, or fieJd of electricity, is produced when the fibers are deformed. Perhaps this deformation produces the piezoelec­ tric current which subsequently directs the newly formed collagen fibrils. Bassett (1968) has described the cellular effects of electrical current and believes

Copyrighted Material

77

78

THE PELVIC GIRDLE

these to be the trigger of wound repair. Clinically, this appears to be the most effective stage in which to implement electrical, ultrasonic, light, and/ or

man­

ual therapy if optimal function is to be achieved.

This information can be

a pplie d

to healing tissue

in the following manner. If the injured tendon is stressed repetitively dilling the therapeutic exercise program, an excellent environment will be created

The tendons of the piriformis and peroneus longus

for lateral intertissue cross-linking. This facilitates

muscles contain type I collagen fibers which lie in a

tensile strength but a restrictive adhesion will also

longitudinal direction in series with the muscle fibers.

be encouraged.

Therefore, during the fibroblastic stage of healing,

(or frictions) of the tendon are also incorporated into

If, however, transverse mobilizations

treatment should be directed towards orienting the

the therap y session, elongation of the enti re adhesion

coll a gen

longitudinally.

will be promoted as the col lagen fibers are "teased"

Passive physiological mobilizations and exercise

apart and longitudinal slippage of the fibers occurs.

fibers

of

programs which

both

gently

tendons

stress the tendon should be

started at this stage. Vigorous exercises or aggres­

The adhesion is therefore non-restrictive and both tensile strength and mobility are encouraged.

sive passive mobilizations will prevent the revascu­

To summarize, tendon tensile strength can be

larization of the tendon and retard the healing

effectively restored by exercise programs which

process, so "gentle" is the key word at this time. As

apply stress to the tendon. These programs can be

well, since there is minimal intramolecular or inter­

graduated from gentle passive stretching to vigor­

molecular cross-linking of collagen fibers at this

ous eccentric loading depending upon the stage of

stage, strong stretchi.ng or forcing of the wound is

healing. If tendon mobility is also required, atten­

contraindicated. More pain will definitely lead to

tion must be directed to the lateral attachments which

less gain. Both ultrasound and laser can facilitate

bind the tendon down, otherwise the stage is set for

the synthesis of collagen and are useful adjunctive

chronic repeated microtears of scar tissue such

modalities.

those seen in chronic tennis elbow or chronic

The maturation phase is the stage when things can defi n itely go wrong. The structure may be

as

pero­

neal tendinitis following old inversion injuries of the ankle.

restored and extremely resistant to tensile forces but the

function may be completely devastated. Consider peroneus longus tendon in the foot. Collagen

the tom

Ligament

cannot differentiate between the tendon, the syn­

Ligaments structurally resemble tendons and there­

ovium, and the fibrous tunnel. The new collagen

fore the tensile requirements are the same. They

fibers uniting the tendon will indiscriminately cross­

must, however, be free to move on the bones they

link with those restoring the structure of the sheath

cross. If a restrictive adhesion is allowed to develop,

or the fibrous tunnel beneath which it passes.

chronic repeated microtears will occur. If the adhe­

Stability is thus restored at the expense of mobility.

sion can be elongated via transverse frictions, the

Since this tendon must glide extensively for normal

mobility and the elasticity of the ligament will be

function, a 50% reduction in gliding ability will have

restored. Manipulation of adhesions is a destructive

profound effects on the function of the foot. By

con­

treatment

technique

since

the

adhesion

r a rely

trast, the tendon of the piriformis muscle requires

releases where it is intended. More co mmon ly, a

struc­

fresh tear between the adhesion and normal tissue

little mobility between itself and the adjacent

tures, and loss of this mobility will have less effect

occurs which sets up

on the overall fLmction.

If the fibroblastic phase and the maturation phase

another

inflammatory response.

There are two kinds of adhesions which can

of collagen synthesis, deposition, and remodeling

occur subsequent to the healing process - restrictive

are now treated appropriately, a new elongated

and

adhesion will be formed which allows the necessary

non-restrictive. Restrictive adhesions are regu­

larly organized with a compact arrangement of

mobility.

collagen fibers oriented in a longit u dinal manner. Non-restrictive adhesions are randomly organized with small-fiber bundles. Although the evidence is not conclusive, it is felt (Peacock

1984)

that longitu ­

dinal slippage or friction-induced instability of lagen fibers and

fibrils is

col­

the most probable method

by which additional length in the scar is gained.

Fibrous joint capsule The structural characteristics and fLmctional require­ ments of a fibrous joint capsule are from those of either a tendon

or

quite

different

ligament. The outer

layer of the joint capsule is composed of an irregular

Copyrighted Material

Pain. dysfunction. and healing

random arrangem ent of c ol l agen

fibers

(Fig.

7.5)

permitte d

(Fig . 7.6).

This anatomi cal arrangement

unlike the tendon or ligament which di sp la y s a

promotes m ob ili ty while the physi c al characteristics

regular longitudinal a rrangemen t . This is a good example of function governing s tru c ture . The pri­

of

mary fun ct ion of a ligament is to resist tensile forces between two bones, and the ana tom y suits its needs

ideally. The fibrous caps ule; however, must be exten­ sible to allow m ob il i ty

of the joint, and

since

collagen

is inextensible, a l ongi tudinal arrangement would

inhibit m obil ity. The random, irreg ular orientation of the collagen fibers

perrriits mobility. When the capsule is stre tche d , the fibers orient themselves along the lines of ten­ sion produced by the stretch. Ul timate ly, the colla­ gen fibers set the limit to the amount of extensibility

the collag en fiber itself a fford end-range stability. The repair proce ss following capsular injury is identic al to the one previously des cr ibe d . The initial inflammatory response is c lini c ally appare n t as traumatic ar t hrit is . Fibr opl a si a and co lla ge n synthe­ sis follows 4--6 days after injury. The orientation of the new fibers will not automatically assume a ran­ dom arrange ment if ten sil e forces are applied to the w o u nd . If the patient is s tar ted on an ex erci se program designed to res tore full range of m oti on, and that exe rci se program puts tension through the wound, l on gi tudin al orientation of ne w collagen fiber s will be promoted, leading to increas ed la teral cross-linking and restricted mobility. This is not

adhesion,

an

but rather the r estoration of s tructure

with tissue that does not su bs e rve the joint cap­ sule's fun ction . The treatment given

governed by the

functional

to

any tis sue is

requirements of the

d amage d tissue. L. this instance, bo th ex tensib i l ity

and tensile strength The c hallenge is the joint c ap s ule by

require restoration.

to preserve the ex tensi bi li ty of c rea ting a random arr ange men t

of small-fiber col lage n bundles while Simultaneously increasing the tensile s trength. An extensible scar is more likely to develop a

if

stresses are induced in

multitude of directions across the wound. Three­

d im e nsion al exercise programs, together with phYSio­ logical active and passiv e mobiJization will theo ret icall y facilitate the Figure 7.5

The outer layer of the joint capsule is composed of

an irregular random arrangement of collagen fibers. from Williams

1995.)

Figure 7.6

[ Redrawn

of the new

techniques, random a r ra nge m ent

colla gen fibe rs.

The princ ipl e s and instruction will be

progressions for exe rcise

covered

in detail in Chapter 10.

The orientation of the co l lage n fibers within the joint capsule influences the degree of extensibility

permitted. The random irregular orientation initially permits mobility [ left ) . When placed under tension the reorientation of the fibers [right) ultimately restricts the motion.

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80

THE PELVIC GIRDLE

Summary Left alone, wounded tissue will repair. However, wound repair is not necessarily accompanied by the restoration of function . Recent research has increased our understanding of the impact of low back and pelvic pain on both articular function (form closure) and neuromyofascial function (force closure and motor control). Changes in the proprioceptive and motor control systems alter movement patterns and strategies of load transfer. The result is less efficient movement, suboptimal function, a higher risk for recurrence of pain and injury, and altered joint forces (due to altered axes of joint rotation) that may lead to earlier degenerative changes and pain. The effective management of low back and/or pelvic pain requires assessment of the impact of the injury and consequences of the subsequent pain state on the form closure, force closure, motor control, and emotional state of the patient.

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Chapter

8

Diagnosing the lumbopelvic-hip dysfunction Linda-Joy Lee

Diane Lee

CHAPTER

CONTENTS

Subjective examination Objective examination

81 83

Real-time ultrasound analysis of local system function

120

When the int egr a te d model is used to treat patients with dysfunction, the primary focus is the restora­ tion of function: the location and behavior of pain become less relevant to the assessment and subse­ quent treatment. However, to i gnore completely the patient's complaints is to fail to a dd re ss the psychosocial factors of the patient's experience. Dreyfuss et al (1996) note: "Patients with sacroiliac j oint (SIn pain exhibit no characteristic feature such as aggravation or relief of their pain by sitting, walk­ ing, standing, flexion, or extension." This research is not consistent with clinical experience; however, it is not s urpri sin g if pa in was used to indicate dysf u nc­ tion. Clinically, activities which aggravate or relieve sy m ptom s tend to follow common patterns when patients with similar pelvic impairments, and not pain patterns, are considered. Thus, it is im portan t to investigate the sy mptom behavior as this will address the patient 's psychosocial needs as well as provide a preliminary in dication of the w1derlying impai rm ent once clinical ex pertis e is attained. Therapists who take the time to develop a disci­ plined examination technique will be rewarded later with the ability to recognize similar patterns of impairment quickly. The purpose of this section is to describe and illustrate the basic subjective and objective examination for the lu mb a r spine, pelvic girdle, and hip. Chapter 9 will elaborate further on the significance of the findings from these tests.

SUBJECTIVE EXAMINATION (Table 8.1) MODE OF ONSET •

How did

the problem be gin - suddenly or to wound re pair

insidiously? With respect Copyrighted Material

82

T H E P E LVIC G I R D LE

Table 8.1

Subjective examination

N a me

I

Do ctor

Age

M o d e of o n set Past h i story

Past trea t m e n t

Pai n / d ys e s the s i a l ocati o n A g g ravating a c t i vities Reliev i ng a ctivi ties S l e ep surfa ce/po s i t i o n

S t a t u s i n a . m.

Occu p a t i o n/Ie i s u re activi t i e s/spo rt Genera l hea l t h

M e d i cati o n

Resu lts of adj u n c t i ve tests

7), is the pati ent presenting during the mat urati on ph ase of healing? Was there an elem ent of trauma? If so, was there a m aj or traumatic event o ve r a short per iod of time, such as a fal l, or was ther e a series of minor traumatic events ov er a pro longed p e r iod of time, such as the habitual use of i m p rop er lifting techniq u e? Is this the first episode re qu i rin g treatment or has there been a similar past history of e ven ts ? If this is a repeat episode, how long did it take to recover from the previous one and was therapy necessary a t that time? If so, what (Ch.

•

How far down the limb o r limbs do the sympto ms r adi a te? Which activities (including how much) will a ggr av a te the symptoms? Wha t effect does p r olonged si tti ng , standing, walking, stair-climbing and descent, rolling over in bed, getting in/ out of a chair/car, cough, and/or sneeze have on the pain/dysesthesia? Does th e a gg r av ating activity ind uce more

•

What activities

•

substrate, fibroblastic, or

•

•

•

vertical or horizontal loading (or both)?

(inc luding

how

much) prOVide

relief?

SLEEP

therapy was beneficial, if any? •

Is the p roblem a consequence of a pregnancy delivery? If so, when did the symptoms begin, what was the na ture of the delivery, and how much trauma occ u r re d to the pelvic floor?

•

and/ or

PAIN/DYSESTHESIA •

Exactly

OCCU PATION/LEISU RE ACTIVITIES/SPO RT

where is the p a in/d y ses th esia? Is or diffuse and can its quality be

locali z e d

described?

•

Are the s ym p tom s i nterfe rin g with sleep? Does rest provide relief? What kind of bed is being slept in and what posi tion is most fre q u ently adopted?

it

•

level of p h y s ical activity does th e p a tien t and essential for ret urn to full function?

What

consider normal

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D iag nosing the lumbopelvic-h ip dysfunction

•

Wha t are the pa tient's goals from therapy?

1997, Herrington 2000, Damen et a12002a) that tester

l11e specifics of both the patient's occupa tion

experience and standardization of testing are strong

and sport are required if rehabilitation is to be

variables which influence the reliability of any test. The tests for spinal and SIJ function (i.e., mobility/

successful and complete.

stabili ty, not pain) continue to evolve and as we understand more about the factors which influence

GENERAL INFORMATION

the test findings, hopefully they will be able to with­ •

What is the status of the patient's general health?

•

Is the patient currently taking any medication for this or any other condition?

•

a

clinical evalua tion which follows

an

grated model of function. The tests presented

inte­

in this

chapter follow this model and are presented with

What are the results of any adjunctive

good intention, recognizing thei.r failure to respond

diagnostic tests (i.e., X-ray, computed

in isolation to reliability and validi ty studies. They

tomography (CT) scan, magnetic resonance

remain the best we have and when a clinical reason­

imaging, laboratory tests, e tc.)? •

stand the scrutiny of scientifi.c research and take their place in

Is there any urinary incontinence? If so, is it stress, urge, or mixed?

ing process is applied to their findings, a logical diag­ nosis can be made with respect to load transfer through the low back, pelvis, and hip. The objective examination is divided into tests for func tion, form closure (lumbar spine, pelvic girdle,

OBJECTIVE EXAMINATION

and hip), force closure, and motor control, specific Bogduk

(1997) sta tes tha t biomechanical diagnoses

neurological conduction and mobility tests, vascular

require biomechanical criteria. He notes tha t "Pain

tests, and adjunctive imaging tests (Table

on movement is not that criteria." Tests which aim

chapter will outline the details of how to perform

8 2) This .

.

to analyze the mobility and stability of a joint are

these tests. The clinical interpre ta tion of the test

required to fu]fiJI these cri teria. Several biomechan­

findings will be discussed in Chapter

9.

ical tests of the S1] have been criticized with regard to their reliability, validity, and specificity (Po tter &

1985, Carmichael 1987, Herzog et a 1 1989, Dreyfuss et al 1994, 1996, Laslett & Williams 1994, Paydar et al 1994, Maigne et al 1996, Bogduk 1997, Buyruk et a11997, Lasle tt 1997) . From this research, it has been suggested that manual testing of the SIJ

FUNCTION: GAIT

Ro thstein

Careful observa tion of the patient's gait can be informative since walking requires optimal lurnbo­ pelvic-hip function (see Ch.

6). Initially, deviation of

the top of the head in the vertical and/or coronal

is unreliable and therefore should be abandoned.

planes is no ted. When gait is optimal, there is min­

This conclusion has not been rea ched wi th o ther

imal deviation of the head in either plane. Failed load

joints of the body. Stability tests for the knee joint

transfer through the pelvis and/or hip joint mani­

(Lachman's and the anterior drawer tests) are com­

fests as

monly accepted amongst both physio therapists and

entire body (TrendeJenburg gait: Fig.

orthopedic surgeons (Reid

1992) even though their

reliability, validity, and specificity have been ques­ tioned (Cooperman et

aI 1990 ) . The results from the

a

deviation in the coronal plane of either the

6.25) or of the

pelvis rela tive to the lumbar spine and hip (subtle

6.26) . Alterations in stride length and timing can be indicative of

hip drop/Trendelenburg sign) (Fig.

latter intertester reliability study clearly showed

mobility or stability dysfunction within the lurnbo­

poor agreement in all areas. In spite of this research,

pelvic-hip complex.

the Lachman's test remains widely used for evalu­ ation of stability at the knee joint. Wurff et al

FU NCTION: POSTURE

(2000) conducted a systematic literature

review of the reliability studies for both pain provoca­

Postural asymme try is not necessarily indicative of

tion and mobility tests for the SIJ. They conclude that

pelvic girdle dysfunction; however, pelvic girdle

individually there is no reliability for any test' T hey

dysfunc tion is often reflec ted via postural asym­

suggest that a multitest score would likely be more

metry. The impact of a specific impairment (intrinsic

reliable and a valid method for detecting SIJ pain and

or extrinsic to the pelvic girdle) is often reflected in

dysfunction. Intertester reliability has long been an

the patient's posture. Optimal posture requires the

is some suggestion (Strender et al

following. In the sagittal plane, a vertical line should

issue and there

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84

THE PELVIC GIR DLE

Table 8.2

Objective examination

Function

Abduction/adduction

Gait

Lateral/medial rotation

Posture

Combined movement test (in flexion)

Regional movement tests

Combined movement test (in extension)

Forward bending in standing

Hip: passive tests of arthrokinematic and arthrokinetic

Backward bending in standing

function (PAVM)

Lateral bending in standing

Lateral/medial translation

Axial rotation in standing

Distraction/compression

One-leg standing

Anteroposterior/posteroan terior translation Hip: pain provocation and global stability

Form closure - lumbar spine

Torque test

Lumbar spine: positional tests

Inferior band of the iliofemoral ligament

Flexion

lIiotrochanteric band of the iliofemoral ligament

Extension Lumbar spine: passive tests of osteokinematic function (PIVM) Flexion/extension Sideflexion/rotation Lumbar spine: passive tests of arthrokinematic function (PAVM) Superoanterior glide - zygapophyseal joint

Pubofemoral ligament Ischiofemoral ligament Force closure and motor control Anterior abdominal fascia - test for diastasis of the linea alba

Inferoposterior glide - zygapophyseal joint

Deep fibers of multifidus

Lumbar spine: passive tests of arthrokinetic function

Active straight leg raise test

Compression

Simulation of the local system

Rotation

Simulation of the global system

Anterior translation

Active bent leg raise test

Posterior translation

Local system - co-contraction analysis

Lateral translation

Local system and the neutral zone Real-time ultrasound analysis

Form closure - pelvic girdle

Global system slings - strength analysis

Pelvic girdle: positional tests

The posterior oblique sling

Innominate

The anterior oblique sling

Sacrum Pelvic girdle: passive tests of osteokinematic function (PIVM) Anterior/posterior rotation - innominate

The lateral sling Global system slings - length analysis The posterior oblique sling and the latissimus dorsi

Nutation/counternutation - sacrum Pelvic girdle: passive tests of arthrokinematic function (PAVM) Inferoposterior glide - sacroiliac joint

The anterior oblique sling and the oblique abdominals The longitudinal sling and the erector spinae The longitudinal sling and the hamstrings

Superoanterior glide - sacroiliac joint

Psoas major. rectus femoris, tensor fascia latae,

Pelvic girdle: passive tests of arthrokinetic function Horizontal translation - sacroiliac joint and pubic symphysis Vertical translation - sacroiliac joint and pubic symphysis Vertical translation - pubic symphysis Pelvic girdle: pain provocation tests

adductors Piriformis/deep external rotators of the hip Pain provocation tests - contractile lesions Neurological conduction and mobility tests

Long dorsal ligament

Motor conduction tests

Sacrotuberous ligament

Sensory conduction tests

Anterior distraction - posterior compression

Reflex tests

Posterior distraction - anterior compression

Dural/neural mobility tests

Form closure - hip

Femora I nerve

Hip: positional tests

Sciatic nerve

Hip: passive tests of osteokinematic function (PIVM) Flexion

Vascular tests

Extension

(Contd over column)

Adjunctive tests

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Diag n osi ng t h e l u m bo pel vic-hip dysfu nct i o n

pass through the external auditory meatus, the bod­ ies of the cervical vertebrae, the glenohumeral joint, slightly anterior to the bodies of the thoracic verte­ brae transecting the vertebrae at the thoracolumbar junction, the bodies of the lumbar vertebrae, the sacral promontory, slightly posterior to the hip joint and slightly anterior to the talocrural joint and naviculo-calcaneo-cuboid joint (Fig. 8.1) . The primary spinal curve should be maintained, i.e., lumbar lor­ dosis, thoracic kyphosis. The innominates should not be rotated excessively relative to one another and the sacrum should not be rotated between them. The anterior superior iliac spine (ASIS) of the innominate should lie in the same coronal plane as the pubic symphysis such that the innominate is vertical over the femoral shaft. In the coronal plane, the clavicles should be sym­ metrical and slightly elevated, the manubrium and sternum vertical (with the manubriosternal junc­ tion in the same plane as the pubic symphysis and ASISs of the innominate), and the scapulae should rest in slight upward rotation (abduction) with the inferior angle on the chest wall.

FUNCTION: REGIONAL MOVEMENT TESTS These tests examine the integrated biomechanics (Ch. 6) of the low back, pelvis, and hip. Effective load transfer requires optimal function of the pas­ sive (form closure), active (force closure), and neural systems (motor control). Forward bending in standing

Initially, the patient is instructed to forward bend and the ease with which the patient does so is noted (Fig. 6.16). Repeat the test three to four times. Note the apex of the sagittal curve for the whole body and then specifically note:

1. the relative intersegmental mobility of the lum­ bar spine (segmental kyphosis/lordosis or rotation). The spinal segments should flex symmetrically with­ out shifting or hinging. 2. the paravertebral fullness. It should be equal on the left and right sides of the spinal col umn. 3. the relative mobility of the pelvic girdle on the femoral heads (the hip joint can be palpated anteri­ orly for this). The pelvic girdle should anteriorly tilt symmetrically over the femoral heads. 4. any intrapelvic rotation. Palpate both innomi­ nates at the inferior aspect of the posterior superior iliac spine (PSIS) and at the iliac crest (Fig. 8.2). No intrapelvic rotation or torsion should occur.

Fig u re 8.2

Forw a rd b e n d i n g test in sta n d i n g. The i n n o m inates

are p a l p a t e d a t the p o steri or sup erior i l iac s p ine a n d the i l i a c crest. There should be n o r e l a tive r o t a t i o n b etween t h e t w o

F igur e 8.1

Opti m a l posture in sta n d i n g. [ Repro d u ce d with

permi ssio n fro m Lee & Walsh

1996.)

inn o m ina tes, i.e., t h e pelvic g irdle sho u l d a n t e r i orly ti lt a s a u n i t

o n the fe m ora l hea d s bi l atera l l y. ( Repro d u c e d with perm i ss i o n

fro m © Di ane G. L e e Phys i othera pist Corp. )

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85

86

THE PELVIC GIRDLE

Figure 8.3

Forward bend i n g test i n stand ing. The i n n o m i n a te

i s p a l pated w i t h one ha n d and t h e sacr u m w i th t h e o t h e r (either

at the median sacra l crest at 52 o r the infe r i or l a teral an gle). In t h e fi rst few d e g rees of fo r w a rd bend ing t h e sacrum n utates re l ative

to

the inno m i nate ( m ay o r m ay no t be fe lt) and s h o uld

rem a i n nutated thro u g h o u t the full fo rw a rd bend. ( Repro d u ced with per m i ssion from © Diane G. Lee Phys i o t h erapist Corp.)

5.

the maintenance of sacral nutati.on throughout

the full fo rward bend. Palpate the innominate with one hand (as in #4 above) and the median sacral

52, or the inferior lateral angle (ILA) of the 8.3 ) . As the trunk bends forward there is an increase in the activation of m u l crest at

sacrum, with the other (Fig.

­

tifidus. If the sacral base is palpated directly parallel to the PSIS (lateral to the median sacral crest), the bulging of the sacral multifidus pushes your thumb posteriorly (Fig.

5 . 12) and it is easy to interpret this

as counternutation of the sacrum when in fact deep to the multifidus the sacrum is actually nutating. Therefore, the median sacral crest at

52, or the ILA,

is a more reliable point to palpate the sacrum sin ce there are no muscle fibers here to confuse the tester. The sacrum may be felt to nutate during the first

Fi gure 8.4

Back w a rd bend i ng test i n sta n d i ng. The i n n ominates

are palpated at the poste r i o r supe r i o r i l iac spine a n d the i l ia c crest. There s h ould b e no re lat i ve rotation between the two inno m i n ates, i .e., the pe lvic g i rdle s h ould poste r i o r l y t i l t as a unit on the fem o ra l h eads bi latera l l y. (Reprod uced w i th permiss ion fro m © Diane G. Lee Phy s i o therapi st Corp.]

few degrees of the forward bend (depending on the starting position of the sacrum) and should remain nutated throughout the forward bend. Note the consistency /inconsistency of any positive findings during the repeated testing and the ease with which the patient is able to forward bend repeatedly.

orly for this). The pelv ic gi rdle should posteriorly tilt symmetrically on the femoral heads.

3 . any intrapelvic rotation. Palpate both innomi­ nates at the inferior aspect of the PSIS and at the iliac crest (Fig.

8 .4).

No intrapelvic rotation or tor­

sion should occur.

Ba ckward be n d i n g i n sta n d i n g I nitially the patient is instructed to backward bend ,

and the ease with which the patient does so is noted (Fig.

2. the relative mobility of the p elvic girdle on the femoral heads (the hip j oin t can be palpated anteri­

6.18). Repeat the test three to four times. Note

the apex of the sagittal curve for the whole body

Note the consistency /incon si s ten cy of any pos itive findings d uring the

p eated

re

testing and the ease

with which the patient is able to backward bend repeatedly.

and then specifically note:

1 . the relati v e intersegmental mobility of the lumbar spine (segmental kyphosis/lordosis or rota­

Late ral be n d i ng in sta n d i n g Initially, the patient i s instructed to laterally bend

6.20) and the ease with which the patient does

tion). The spinal segments should extend symme­

(Fig.

trically without shifting or hinging.

so is noted. Repeat the test three to four times. Note

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D i a g nos i ng t h e lu m bopelv i c- hip dysf u n ction

the apex of the coronal curve for the whole body and then specifically note: 1. the relative intersegmental mobility of the lumbar spine (segmental sideflexion/rotation). The spinal segments should sideflex symmetrically. 2. the relative mobility of the pelvic girdle on the femoral heads (the hip joint can be palpated). The pelvic girdle should laterally translate and laterally tilt relative to the femora. 3. any intrapelviC rotation. Palpate both innomi­ nates at the inferior aspect of the PSIS and at the iliac crest. In a mobile individual some intrapelvic motion occurs during lateral bending in standing such that in left lateral bending the right innomi­ nate posteriorly rotates relative to the left and the sacrum rotates slightly to the right. Relatively, both sides of the sacrum remain nutated compared to the left and right innominate and therefore stability is ensured for load transfer.

Repeat the test and note the consistencylinconsis­ tency of any positive findings and the ease with which the patient is able to lateral bend repeatedly.

Axial rotation in standing Initially, the patient is instructed to rotate and the ease with which the patient does so is noted. Repeat the test several times and note:

Figure 8.5

O n e - l e g sta ndi n g test : h i p f l ex i o n p h a se . T h e

i n no m inate shou l d poster iorly rot a te re l a tive t o t h e s a c r u m. Art h ro k i nema t i c a l l y this requ i res an a n te ros u perior g l i d e of t h e i n no m i n a te r e l ative to t h e sa crum ( Hung erford

( See

a l so F i g s

6.10 a n d 6.11.) ( R eprod uced

2002).

w i t h pe r miss i o n

1. the relative intersegmental mobility of the lumbar spine (segmental sideflexionl rotation). The spine should rotate without "kinking." 2. the relative mobility of the pelvic girdle on the femoral heads (the hip joint can be palpated anteri­ orly for this). The pelvic girdle should rotate such that there is relative internal rotation of the ipsilat­ eral hip joint and external rotation of the contralat­ eral hip joint. 3. any intrapelvic rotation. Palpate both innomi­ nates at the inferior aspect of the PSIS and at the iliac crest. In a mobile individual some intrapelvic motion occurs such that in left axial rotation the right innominate anteriorly rotates relative to the left and the sacrum rotates slightly to the left. Relatively, both sides of the sacrum are nutated compared to the left and right innominates and therefore stability is ensured for load transfer.

This test is also known as the Gillet test, stork test, or kinetic test and examines the ability of the low back, pelviS, and hip to transfer load unilaterally (support phase) as well as for the pelviS to allow intrapelvic rotation (Ch. 6) (Hungerford 2002). Initially, the patient is instructed to stand on one leg and to flex the contralateral hip and knee towards the waist (Fig. 6.10). The ability to perform this task is observed. The pelvis should not anteriorly I posteriorly Ilaterally tilt nor rotate in the transverse plane as the weight is shifted to the supporting limb. The test is repeated on the opposite side. Subsequently, the intrapelvic motion which occurs during this task can be examined as follows:

Repeat the test and note the consistency /inconsis­ tency of any positive findings and the ease with which the patient is able repeatedly to rotate axially.

1. Hip flexion phase (ipsilateral kinetic test) (Fig. 8.5): With one hand, palpate the innominate at the inferior aspect of the PSIS and at the iliac

from © D i a n e G. L e e P h y s i ot h e rapi st Corp. )

On e-leg standing

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87

88

TH E PE LVIC G I R D L E

Fig u re 8.6

One-leg sta n d ing test: s u pport phase. The

Figure 8.7

innominate shou l d rem a i n poste r i orly r o t a ted relative t o t h e

One- leg stand ing test: s u pport phase. The

innomina te sh o u l d extend rel a t i ve to t h e fem u r [a rrow) o r rema i n

s a c r u m . [Repro d u ced w i t h perm ission fro m © Diane G . Lee

verti ca l . Th i s i s a sta ble posit ion for l oad t ransfer t h roug h th e

P h y s i otherapist Co rp.)

h i p jo i n t. [Reprodu ced w i th per m i ssio n fro m © Diane G. Lee P h y s i o thera pist Co rp.)

crest on the non-weight-bearing side . With th e other hand, pa lpate either the median sacral crest at or the

ILA of the sacrum

on

S2

the same side as the

innominate being pa lpated . In struc t the patien t to flex the i psilateral and

note

hip (same side you are palpating)

the posterior rotation of th e innominate

the amplitude and ( resistance) of this movement to the con­ tralateral side. Thi s is not a test for mobilit y of the 51! bu t rather a test of osteokinematic motion of relative to the s a crum. Compare

quality

the low lumbar vertebrae, the innominate, and the

sacrum. Many factors can imp e d e osteokinematic motion: the SIJ is one. 2. Support phase : a. On the weight-bearing side, with one hand,

p alpa te the innominate at the inferior aspec t of the PSIS and at the iliac crest. With the other hand, p a lp a te either the median s acral crest at S2, or the ILA of the sacrum, on the same side as the innomina te being p a lp ated (Fig. 8.6). Instruct the p at ient to flex the contralateral hip ( side you are

not pa l p a ting) and note the motion of the innom­ inate rela tive to the sacrum ( con tra la ter al kin etic tes t) . Especially note the movement that occurs as the weight is t rans ferred on to the support ing leg

(initial loading) and the contralateral leg is

com ing off the ground . The innominate should either posteriorly rotate or re mai n still relative to the

sacrum

(in

a poste riorl y rota ted position; what

is observed will depend on the starting pos i tion of the innominate). b. On the weight- bearing side, p al pate the inn om­

and the femur wi th the other 8.7). In struct the patient to flex the contralat­ hip ( s ide you are not palpating) and note the

inate with one hand (Fig. eral

motion of the innominate relative to the femur.

either move towards the (extend) or remain v e rtica l rela­

The innominate should vertical position tive to the femur.

A posit ive test occurs when the innominate anteri­ orly rotates or internally rotates relative to the sacrum

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D i a g n osing the l u mbo p e l v i c- h i p d ysfunction

Load R2 ,,"

.... .... ..

.. .. "

..

..

.. "

Elastic zone

....

•

.....

..

.. "

....

.. ..

o

R1

Range of motion Displacement Figure 8.8 The zones of articular motion: the neutral zone (O-R1) and the elastic zone (R1-R2) (Panjabi 1992b).

(H\.mgerford et al 2001, HLmgerford 2002) or Hexes

Figure 8.9 The ball and bowl concept introduced by Panjabi ( 1992b) to represent differences in neutral zone motion. The distance the ball can roll represents the amplitude of the neutral zone of motion under varying conditions.

relative to the femur (failed load transfer through the hip joint). This is a less stable position for load transfer through both the pelvis and the hip.

(Fig. 8.1Oa-f). Each of the situations illustrated in Figure 8 . 1 0 will be discussed in Chapter 9.

(failed load transfer through the pelvic girdle)

Lumbar spine: positional tests

FORM CLOSURE: LUMBAR SPINE The following tests examine the mobility and pas­ sive stability of the joints of the lumbar spine. Form closure analysis requires an evaluation of two zones of motion: the neutral zone and the elastic zone (Fig. 8.8) (Panjabi 199 2b) . The neutral zone is a small range of movement near the joint's neutral position where minimal resistance is given by the osteoliga­ mentous structures (joint p lay from 0 to R1 or first resistance). The elastic zone is the part of the motion from the end of the neutral zone up to the joint's physiological limit (end-feel from R1 to R2). Panjabi (1992b) noted that joints have non-linear load-displacement curves. The non-linearity results in a high degree of laxity in the neutral zone and a stiffening effect toward the end of the range of motion. He found that the size of the neutral zone may increase with injury, articular degeneration, and/or weakness of the stabilizing musculature and tha t this is a more sensitive indicator than angular range of motion for detecting instability. He used a ball and bowl illustration to represent this change in the ne u tral zone (Fig . 8.9) . Lee & Vleeming (1998, 2004) suggest that the neutral zone is not only affected quantitatively (bigger or smaller), but also qualitatively (more or less resistance) when com­ pression is increased or decreased across the joint

To determine the position of L5 relative to the sacrum, the posteroanterior relationship between the transverse processes of the L5 vertebra and the sacral base is noted in neutral, full Hexion, and full extension. The inHuence of muscular hypertonicity and/or atrophy should be considered when inter­ preting the positional findin gs . Fl exion With the patient sitting, feet supported, and the lumbar spine fully Hexed, the lateral aspect of the L5 segment and the sacral base are palpated bilaterally (Fig. 8.11) . The posteroanterior relation­ ship of the articular pillar of L5 relative to the sacra I base is noted. A posterior right articular pillar of L5 relative to the sacral base is indicative of a right rotated position of LS-S1 in hyperflexion. Exte n sion W ith the patient prone and the lumbar spine fully extended, the LS and then the sacral base are palpated laterally (Fig. 8.12). The posteroanterior relationship of the articular pillar of L5 relative to the sacral base is noted. A posterior right articular pillar of L5 relative to the sacral base is indicative of a ri ght rotated position of LS-S1 in hyperextension. Lumbar spine: passive tests of osteokinematic function (passive intervertebral motion: PIVM) Flexio n/exte nsion With the patient sidelying, hips and knees flexed and supported on the therapist's

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T H E PELV I C G I RDLE

(a)

(d)

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Figure 8.10

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(b)

(c)

n 0

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(e)

(f)

The n eutral zone can be affe c t e d by a l teri n g c o m pres s i o n a c ross t h e joint. (a) A grap h i c i l lustra tio n of t he n eutral z o n e

o f m o t i o n i n a hypothet i cal l y n ormal joi n t. (b) A j o i n t w h i c h i s i n suffic i e n tly com pressed due to the l o ss of either form o r force clo sure w i l l have a rel ative i n crease in t he n e u tral z o n e of m o t i o n . (c) A j o i n t w h i ch i s excess i v e l y com pressed d ue to fi b ro sis will have a rel ative d e crease i n the n eutral zo n e of m o t i o n . ( d ) A j o i n t w h i c h is excessi v e l y compressed d u e to ove rac tivat i o n of t he gl obal system wil l also have a re l a t i ve d e c rease in the neu tral z o n e o f m o t ion. (el When there is an i n term i ttent m o tor control d e f i cit. passive m ot i o n w i th i n the n eutral z o n e can be normal s i n ce t h e d ysfun c t i o n is dynam i c . The b o u n c i n g ball refl ects the i n te r m i t t e n t loss of c o m press i o n du r i n g fu n ctional act i v i t i e s (dynam i c i n s tab i l ity).

(f)

A joi n t which is fixate d (sub luxed) is exces s i v e l y compressed an d n o

n e u tral zo n e of m o t i o n c a n be palpated (co m p l ete jo i n t blo ck).

Figure 8.12

Po s i t i o n al t es ti n g of LS-Sl in exten s i on.

( R e p ro d u ce d with p e r m i s s i o n from © Diane G. Lee

Physiotherapist C o r p.)

the interspinous space of the lumbar segment b eing tested (Fig. 8.13). With your caudal arm and hand, s upp ort the patient's legs. Passively flex/extend the lumbar segment and note abdomen, palpate

the quantity and quality of intersegmental motion. Repeat the test

for the other

Sidefiexio n/rotat i o n : L3-L4

Fig ure 8.11 Pos i t i o nal test i n g of LS-Sl in f l ex i o n . (Re pro d u ce d with p e r m i ss i o n fro m © D i a n e G. Lee Physiotherapist Corp.)

lumbar segm e nts. With the patient side­

l ying , top hip and knee slightly flexed, bottom hip and knee extended, weave y o u r cranial ann between the patient's arm and thor a x and palpate lateral to the interspinous space of L3-L4 with the index and middle fingers . Your cranial hand should

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D i a g nos i n g t h e l u m bopelvi c-h i p dysfunction

Fi g ur e 8.15

Figure 8.13

Passive test for o ste o k i n e m atic fl exi o n /exte n s i o n

o f the l umbar spi ne. (Reprod uced w i th permiss i o n fro m

i s p u r e l y s i d ef l exed (arrow i n d i c a t e s t h e dire c t i o n o f t h e i n d u ced s idefl e x i o n ) to pro d uce t h e superoanterior gli d e. (Reprod uced

© D i ane G. Lee Phys i o t h erapist Corp.)

F i gure 8.14

Passive test fo r t h e a rt h roki n e matic supe roan terior

g l id e of t h e left zygapoph yseal join t at L4-L5. The l u m bar s p i n e

w i t h perm i s s i on from © Di a n e

Pass i ve test f o r osteoki n e matic l eft s i defl e x i on

c o m b i n ed w ith right rotat i on at L3-L4. The a rrow indicates the d i re c t i o n o f force app l ie d by the t h era p i st s ca u d a l h a n d . '

(Repro duced w i t h pe r m i ssion fro m © Dia n e G . Lee P hysio the rap i s t Corp.)

be dire ctly dorsal to the L3-L4 zygapophysealjoint (Fig. 8.14). P a lp a te the pelvic g i rdle in an obl iqu ely distolateral direction with the caudal arm. With the index and middle fing ers of this ha n d, palpate L4. Passively sideflex and contralaterally rotate L3-L4 using an obli q ue force th ro ug h both a rm s Note the quantity and quality of segm en ta l motion. Repeat the test for the other lumbar segments and then tes t sideflexion/rotation in the op p os i te direction by laying the patient on the op p osi te si de .

.

G.

Lee Phys i o t h e ra p i s t Corp.)

Jomt occurs dur ing flexion and ri ght sideflexion L4-LS. With the pa tient in righ t sidely ing, left hip and knee sli ghtly flexed, right hip and knee extended, weave your cranial arm between the patien t's left arm and thorax. This will giv e you good control of the thoracolumbar region d uring this test. With the cra­ nial hand, palpate lateral to the interspinous space of L4-LS. With th e caudal hand, p alp ate LS (Fig. 8.15). Passively sideflex the segment to the ri ght (i.e., pro­ duce a su p eroanterior gli de of the left z ygapop hyseal joint). Analyze the two zones of motion (neu tral zone from 0 to R1, and el as tic zone from R1 to R2) for amplitude, resistance to motion, and end-feel. I n feroposterior g l i d e: rig ht zyga pophyse a l joint L4-L5 An inferoposterior glide of the right zygapophyseal joint occurs d urin g extension and ri ght sideflexion L4-LS. With the patien t in left side lying, right hip and knee sli ghtly flexed, left hip and knee extended, weave your cr anial arm between the patient's right arm and thorax. This will give you good control of the thor acol umbar regi on during this test. With the index finger of the cranial hand, palpate lateral to the inter­ spinous space of L4-LS (Fig. 8.16). P ass ively sideflex the segment to the right (i.e., produce an inferoposte­ rior g lide of the right z ygapophyseal joint). An a lyze the two zones of motion (n e u tra l zone, from 0 to R1, and elastic zone, from Rl to R2) for amplitude, resist­ ance to motion, an d end-feel.

Lumbar spine: passive tests of arthrokinematic function (passive accessory vertebral motion: PAVM)

Lumbar spine: passive tests of arthrokinetic funct io n

L4-L5 A superoanterior glide of the left zyg ap ophyseal

hips

Su pe roanterio r glid e : l eft zyga pop hysea l joi nt

With th e pa tient lyin g supine and the and knees flexed, the lower extremities are

Co m p ressio n

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TH E P E LV I C G I R D L E

F i g u re 8. 1 6

F i g u re 8. 1 8

Pa s s i ve test fo r the a rt h rokine m a t i c

inferoposte rior g l i d e o f t h e r i g h t zyg a p o p hysea l j o i n t a t L 4 - L 5 . The pe l v i c g i rd le is pu rely s i d eflexed benea t h t h e l u m b a r s p i ne to p ro d u ce the infe ro p oste r i o r g l i d e. The a rrow ind i c a tes the d i re c t i o n o f the ind u ced s i de fl e x i o n . ( Re p rod u ce d with

Arth rokine t i c test of co m p res s i on of t h e l u m b a r

s p i ne . The a rr o w ind i ca tes the fo rce p r o d u ced b y the t h e ra pist's h a n d s . ( Rep rod u ced w i t h pe rm i ssion fro m © D i a n e G. Lee Phys i o t h e ra p i st C o rp.)

cra d le d C ompressio n is ap p lied to the lumbar seg­ ments by applying a crani a l force p aral l el to the table through the flexed lower extremi ties (Fig. 8 . 1 7 ) . Note the provoca tion o f pain and / o r spasm d u ring .

compression loading.

Rotati o n : left rotation L4-L5 Wi th the p a tien t in right sidelying, left hip and knee slightly flexed, right hip and knee extended, palpate th e left side o f the spinous process of L4 with the cranial h an d . With the long a nd rin g fingers of the ca udal hand, palpate the right side of the spinous process of l..5 (Fig. 8. 18). Left rota ti on, or left segmental torsion, is tested by fixin g L4 and ri ght ro ta ting L5 about a pure vertical axis beneath the L4 vertebra ( the L4-L5 segment re l a tively left-ro tates) . Note the a mplitu d e o f the neutral zone, the resistan c e t o motion wi thin the neut r a l and the elastic zones, the qual i ty of the -

is a b o u t a p u re v e rt i c a l a x i s a n d is t h e re fo re u n p h ys i o l o g i ca l . T h e a rrow i n d i cates t h e d i rect i o n o f force a p p l ied by t he the ra p ist'S c a u d a l h a n d . ( Re p ro d u ce d w i t h pe r m i ssion fro m © D i ane G. Lee Phys i ot h e r a p i s t Corp.)

pe r m i ss i on fro m © D i a ne G. Lee Phys i ot h e ra p i s t C o r p .)

F i g u re 8. 1 7

A rth roki net i c test of left seg me n t a l ro t a t i o n a t

L4 - L 5 . N o te t h a t t h e ro t a t i o n i n d uced a t t h e l u m b a r seg ment

F i g u r e 8. 1 9

Arth rokine t i c test o f ante r i o r t rans l a t i o n a t

L4-L5. T h e a rrows i n d i c a tes the d i rection of fo rce a p p l ie d b y the the ra p is t ' s h a n d s . ( Re p ro d u ce d w i t h pe rm i s s i o n fro m © D i a ne G. Lee Phys i o t h e ra p i s t Co rp.)

end-feel of the elastic zone, and the provocation of p ain or spasm . Ante r i o r tra n slati o n : L4-L5 With the patient lying prone, palpate the spinous p ro cess of L4 with the p isi ­ form of one hand. With the other hand, stabilize the sacrum and l..5 with a c auda l force ( to prevent exten­ sion of the spine) (Fig. 8.19). Apply an an te rior trans­ la ti on force to the L4 vertebra . Note the amplitude of the neutra l zone, the resistance to motion within the neutral and the elastic zones, the q u a li ty of the end­ feel of the ela stic zone, and the prov oca t io n of p a in or sp a s m . This test may also be done in the si d elying posi ti on by fixing the spinous process of the superior vertebra and takin g the inferior vertebra p osteriorl y by applying compression al on g the flexed femurs. Poste r i o r tra n s l a ti o n : L4-L5 Wi th the pa tien t sit­ ting in a neu t ral lumbar sp ine p os i tion, arms crossed,

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D i a g nosing t h e lu m bopelv i c- h ip dysfu nction

Figu re 8 .2 0

L4-L5. L4-L5

Art h ro k i n et i c test of p o st e r i o r t ra n s l a ti o n a t i s i n n e u t ra l a n d t h e l u m b a r s p i n e i s fl exed above.

R i g h t h a n d : t h e i n d e x fi n g e r pa l pa tes t h e i n t e rs p i n o u s s p a c e a n d t h e m i d d l e a n d r i n g fi n g e rs f i x

LS.

Left h a n d : a p p l i e s a p o s te r i o r

t ra n s l a t i o n fo rce t h ro u g h t h e l u m b a r s p i n e . ( R e p ro d u ce d w i th p e r m i s s i o n fro m © D i a n e

G. Lee

F i g u re 8 . 2 1

A r t h ro k i n e t i c test of l a te ra l t ra n s l a t i o n a t L3 - L4.

R i g h t h a n d : t h e th u m b and i n d e x fi n g e r fix L4. Left h a n d : a p p l i es a l a te r a l tra n s l a t i o n fo rce ( a rro w i n d i c a tes t h e d i r e c t i on o f the a p p l i e d fo rce ) . ( R e prod u ced with p e r m i ss i on fro m © D i a n e

G.

Lee P h y s i o t h e ra p ist C o r p . )

P h ys i o t h e ra p i s t C o r p . )

palpa te the interspinous space of L4-L5 . To localize the force, flex the lumbar spine dovm to L3-L4, ensuring tha t L4-L5 remains in a neutral position. Fix L5 ,;vith the caud a l hand and ap pl y a pure posterior tra nslation force through the trunk with the other arm / hand (Fig. 8.20). The ampli tud e of the neu tral z on e, the resis tance to motion within the neu tral and the elas tic zones, the q u a l ity of the end­ feel of the elastic zone, and the p rovoca tion of pain or spasm are no ted . Late ra l tra nsl ation : L3- L4 With the patient si tting in a neutral lumbar spine position, arms crossed, pa l­ pate and stabiJjze L4 w i th an open web space grip. Fix L4 with this hand and apply a pure lateral transla tion force through the trunk wi th the o ther arm / hand (Fig. 8.21). The ampli tude of the neutra l zone, the resistance to motion within the neutral and the ela s tic zones, the q uality of the end-feel of the elastic zone, and the provoca tion of pain or spasm are noted.

F O R M C L O S U R E : P E LV I C G I R D L E The following tests examine the mobility and pas­ sive stabili ty of the joints of the pelvic gi rdle . Form closure ana lysis requires an evalua tion of two zones of motion, the n e u tral zone and the elastic zone (Fig. 8.8) (Panj abi 1992b), but fi rst, p ositional ana l y ­ sis is req uired. W h e n interpreting the mobility find­ ings, the position of the bone at the beginning of the test should be correla ted w i th the subsequent mobility, since altera tions in j oint m ob ili ty m a y m e r el y be a reflection of an a ltered s tar ting position . If the innomina te is posteriorly ro t a te d rela tive to the sacrum, then the a mpli tude of the neutral zone w i l l be red uced compared to the other side. Buyruk et al ( 1997) and Damen et al ( 200 2b ) have shown tha t asymmetrical stiffness (or laxity ) of the SIJs cor­ rela tes with and is prognos tic for pelvic impa irment and pain. Since it is not possible to know exactly

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T H E PE LV I C G I R D L E

F i g u re 8.2 3

(a,

b) Po ints of p oste r i o r pa l pa t i on a n d h a n d

pos i t i on fo r positi onal testing o f t h e in n o m i n ate. T h e arrows ind i cate the resting point o f the h e els o f t h e h ands. ( R e p ro d u c e d w i t h p e r m i ss i on fro m © D i ane G . L e e Physi o t h e ra p i s t C o r p . )

Figure 8.22

( a , b ) Po ints o f ante r i o r pal p a tion and hand

pos i t i on fo r pos i t i o n a l testing of t h e inno m i nate. Cup the i n n o m inate by resti n g t h e heels of yo u r h a n d s o v e r t h e ante r i o r s u p e r i o r i l iac s p ines (do ts). ( R e p ro d u ce d w i th p e r m i s s i o n fro m © D i ane G. Lee Phys i o t h e ra p i s t C o r p . ) m o v e m e n t an individual should have, form closure analysis relies on comp aring one side to the o th e r. If considera tion isn't given to the start­ ing posi tion of the j oint, then the findings from the m o b ili ty tes ts a re e asi l y misinterpreted.

how much

Pe l v i c g i rd l e : positi o n a l tests I n n o m i n ate When analyzing the posl hon of the innom ina te bones, it is m o re rel iable to us e the entire

hand to gain informa tion ra ther than visualizing one point of the bone (i.e., ASIS or PSIS). With the patient lying supine, legs extended, pa lp ate the ASIS of both inn o min a tes with the heels of your hands. Let the rest of your hand "mold " to the innominate (Fig. 8.22a, b) and with your eyes ini tially closed, gain an impres­ sion as to whe ther the pe lv is feels twisted (intrapelvic torsion) or sheared in a craniocauda l or an te r op o st e ­ rior plane . Then, open your eyes and palpate the infer­ ior aspect of the ASIS bil a terally and / or the su p erior aspect of the pubic tuberc les to confirm or negate your initial impression. Make sure that you ke ep your head and neck very still while making this j u dgm en t Sideflexion of your own crani overtebral j o in ts will change your percep tion and cou ld alter your visual find ings. Wi th the p a tient lying p rone, p a lpa t e the in fe rior aspect of the PSIS of both innominates with your thumbs. Let t h e res t of your hand "mold" to the innomina te and repeat your analysis from this pos­ ition (Fig. 8.23a, b). To confirm a s u p e ri or shear of the inn o m in a t e , p a lpate the inferior a spect of the

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D i a g nosi ng t h e l u m bopelvi c- h i p dysfu n ction

Fi g u re 8. 2 5 F i g u re 8.24

( a , b) Po i n ts of p a lpa t i o n and h a n d pos i t i on fo r

pos i t i o n a l testi ng of t h e s a c r u m . ( Reprod u ced w i t h p e r m i ssio n

Po si t i o n a l testi n g of t h e isch i a l t u b e ro s i t i es.

E n s u re that t h e most i n fe r i o r a s p e ct of t h e i sch i a l t u b e ro s i ty i s

fro m © D i a n e G. Lee P h ys i o t h e ra p i st Cor p.)

pa l p a ted. ( R e p ro d uced w i t h perm iss i o n from © D i ane G . Lee Physi otherapist Corp.)

tuberosi ty b ila terally. Ini t i al ly use the heels hands and then p a l p a te the ischia l t u b e r os­ ity w i th the thumbs (Fig. 8.24) . Ens u re tha t you are on the mos t inferior as p ec t of th e tuberosity since a ro ta ted inno min a te can c h a ng e the apparent cranio­ caudal rela tionship between the left and right sides i f you are p a lp a ting the dors a l aspec t of the ischial tuberosity. Sacrum The mos t re liable p l a c e f o r pOSi tional tes ting of the sacrum is the d o rsal aspect of the ILA (Fig. 8.25a, b) since a t the sacral base the size and tone of multifidus can influence the find ing s . To determine the position o f the sac rum, a comparison is made o f the posteroanteri or rela tio ns h i p of th e ILA b i la te r a ll y. To find the ILA, begin by p a l p a ting the med ian sacral crest. Follow the crest inferiorly un ti l you reach the sacral hia tus (unfused spino us processes of 54 and 55). From this point, palpate lat­ erally u ntil you feel the lateral edge of the sacrum : thi s i s th e ILA . A pos terior l e f t I LA is indica tive of

ischial

of both

a left rota ted sacrum .

Pe l v i c g i rd l e : pa ssive tests of osteo k i n e m a t i c fu n ct i o n ( P IVM) Anter i o r/p oste r i o r rotati o n : i n n o m i n a te Wi th the pa tient in side lying, hips and knees sligh tly flexed, palpate the A515 of th e innominate w i th the cranial hand. Le t the fin g er s of this hand mold around as much of the innomina te as p os s ib l e . With the heel of the other hand, palpate the ischial tuberosi ty. Let the fingers of this hand mold around as much of the inno minate as p o ssible (Fig . 8. 26) . Passively ante­ rio rly and pos teriorly rotate the innominate relative to the sacrum (remember the amplitude of Sl] move­ ment is very small) and note the quantity and qual­ i ty of the mo tion . N utatio n/co u nter n u tatio n : sacr u m Wi th the patient l yin g prone, palpate the apex of the sacrum with one hand and the midline of the sacral base wi th the o ther (Fig. 8.27). Passively nu tate and coun ternutate the

sacrum relative to the innomina tes and note the

quantity and Copyrighted Material

quality

of the motion.

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T H E P E LV I C G I R D L E

Fi g u r e 8 . 2 6

Pa ssive t e s t fo r osteo k i n e m a t i c a n te r i o r/ p o s t e r i o r

rota t i o n o f t h e i n n o m i n a te . ( R e p ro d uced w i t h p e r m i s s i o n fro m

© Diane

G.

lee P h y s i oth e ra p i s t Corp.)

Fig u re 8 . 2 8

Pos i t i o n of t h e p o s t e r i o r h a n d fo r p a l p a t i o n of

m o b i l ity a n d s t a b i l i ty o f t h e S U . ( R e p ro d u c e d w i th p e r m i s s i o n fro m © D i a n e G . L e e P h ys i o t h e ra p i s t Corp.)

2002). The goal is to have the lumbopelvic Check to ensure tha t the pubic symphysis i s level with the ASISs (no posterior pelvic tilt) and gently move the ri b c age la terally from side to side to ensure the oblique abdomina Is and erec tor sp inae muscles are not overactive. Onc e you e t al

region in a neu tral posi tion .

F i g u r e 8.27

Passive test fo r osteo k i n e m a t i c n u ta ti o n a n d

c o u n t e r n uta t i o n o f t h e s a c r u m . T h e a rrows i n d icate t h e d i recti o n o f force a p p l i e d by t h e t h e ra p ist's h a n d s to p roduce n u ta t i o n (a rrow o n t h e r a p i st's l e ft h a n d ) a n d co u n te r n u ta t i o n (a rrow o n t h e t h e ra p i st's ri g h t h a n d) . ( R e p rod u ced w i t h p e r m i ss i o n fro m © D i a n e

G. L e e

Phys i o t h e ra p i s t Corp.)

are sure that the p a tien t is relaxed, p a l p a te the medial p o sterior i liac cres t U ust above and

aspe c t of the medial

to the PS IS ) (Fig. 8.28) by sliding your cranial

hand benea th the pelvi s Do not press too deeply into .

the multifidus muscle to avoid n u ta ting the sacrum.

Pe lvic g i rd l e : passive tests of arth ro k i n e matic fu nctio n (PAV M) I n fe roposte r i o r g l i de : SIJ

An inferoposterior glide

of the inno minate rela tive to the s a c rum occurs at the SIJ durin g non-weight- bearing anterior rota tion of the innominate (see Fig. 6 . 14). The p a ti en t is in crook lying w i th the knees comfortably s u p p o rted

With the heel of the o ther hand,

pal p ate the ipsilat­ eral ASIS and wi th the res t of this hand, the i liac cres t. The first step is to determine the plane of the join t since there is a high degree of indiv idua l variance ( C h. 4) . Apply a gentle oscilla tory force in an an tero ­ p o sterior direc tion varying the inclina tion from sligh tly medi al to sl igh tly la tera l . One of those pl ane s will meet with the least amount of resistance: this is

over a bolster and arms b y the sides. It is im por t an t

the joint plane. Once the plane of the joint is fo und,

to ens u re tha t the patient is as relaxed as po ssib le (as well a s a c tivation of the longi t u d in a l and

8.29) to the an inferopos terior glide of the innomina te rela tive to the sacrum at the SlJ . Analyze

oblique slings) can change the stiffness

the two zones of mo tion (neu tral zone from 0 to R l ,

since even m ini m a l ac tiva tion of the loca l sys tem

value of the SIT. This has been c onfi rmed via Doppler ima ging under v a rying cond i tions of mu sc le contraction (Van Wingerden e t a l 2001, s u bm i tted Ri c h a rds on ,

a pp l y a sma ll anterior rota tion force (Fig.

innomina te to prod u ce

and elastic zone from R1 t o R2) for ampli tude, resis t­ ance to mo tion, and end-feel. Compare the findings to the opposite s i d e : symme try is the norm, while

Copyrighted Material

D i a g nos i n g the l u mbo pelvic-h i p dysfu n ct i o n

to produce a superoanterior glide of the inn o mina te rela tive to the sacrum at the SIJ . Analyze the two zones of motion (neutral zone - from 0 to R1, and elastic zone - from R1 to R2) for amplitude, resist­ ance to motion and end-feel. Compare the findings to the opposite side; symmetry is the norm, asym­ metry of stiffness, or laxi ty, is indicative of dysfunc­ tion (Buyruk et a1 1997, Damen et al 2002b). Pe l v i c g i rd l e : passive tests of a rt h ro k i n et i c fu n ct i o n Figure 8.29

An i n fe ro p oste r i o r g l i d e of t h e i n n o m i n a te

r e l a tive to t h e sacru m occ u rs w h e n t h e i n n o m i n a t e is a n te r i o rl y r o t a t e d . T h e a r row i n d i c a tes t h e d i re c t i o n of fo rce a p p l i e d b y t h e t h e r a p i s t ' s h a n d . ( R e p r o d u c e d w i t h perm i s s i o n fro m

© D i a n e G. Lee Phys i o t h e r a p i s t Corp. )

F i g u re 8 . 3 0

A s u p e r o a n t e r i o r g l i d e of t h e i n n o m i n a te re l a tive

to the sacrum oc c u rs w h e n the i n n o m i n a te i s poste r i o r l y rota te d . T h e a r row i n d i c a t e s t h e d i re c t i o n o f fo rce a p p l i e d b y t h e t h e r a p ist's h a n d . ( R e p rod u c e d w i th perm i ss i o n fro m © D i a n e G. Lee Physi o t h e r a p i s t C o r p . )

asymmetry of stiffness, or laxity, is indicative of dysfunction (Buyru k et a1 1997, Damen et aI 2002b). S u p ero a n te r i o r g l i d e : S IJ A superoan terior glide of the innominate rela tive to the sacrum occurs at the SlJ during non-weight-bearing posterior rota­ tion of the innomina te (see Fig. 6 . 1 1 ) (Hungerford 2002) . The pa tient's position and therapist's palpa­ tion points are identical to tha t described for testing the inferopos terior glide at the SIJ. The fi rst s tep is to determine the plane of the joint since there is a high degree of individual variance (Ch. 4). Apply a gentle osci llatory force in an anteropos terior direc­ tion, varying the inclina tion from sligh tly medial to slightly lateral. One of those planes will meet with the least amount of res istance; this is the joint plane. Once the plane of the joint is found, apply a small posterior rota tion force (Fig. 8.30) to the innominate

These tests are also used t o detect a change in the neutral zone of motion of the SIJ or the pubic sym­ physis. They specifically evaluate the ability of the SlJ and pubiC symphysis to resist vertical and hori­ zontal plane translation (Lee 1992, 1997b, Lee & Walsh 1996). Individually, neither vertical nor hori­ zonta l transla tion occur physiologically, therefore these are unphysiological translatoric tests of stabil­ i ty. Clinically, they appear to be more sensitive to changes in the neutral zone than angular motion (anterior / posterior ro ta tion ) . Horizontal tra nslati o n : SIJ a n d p u b i c sym physis The patient's position and therapist's palpation points are identical to that described for testing the infero­ posterior glide at the 51]. The first step is to deter­ mine the plane of the SIJ since there is a high degree of individual variance (Ch. 4). Apply a gentle oscilla­ tory force in an anteroposterior direction, varying the inclina tion from slightly medial to slightly la teral. One of those p lanes will mee t with the least amount of resistance: this is the 51] plane. Once the plane of the joint is found, apply a small posterior transla tion force (Fig. 8.31a, b) to the innominate. Analyze the two zones of motion (neutral zone from 0 to R1, and elastic zone from R1 to R2) for amplitude, resistance to motion, and end-feel. Compare the findings to the opposite side : symmetry is the norm, while asym­ metry of stiffness, or laxity, is indicative of dysfunc­ tion (Buyruk et a1 1997, Damen et aI 2002b). Ve rtica l tra n s l atio n : SIJ a n d p u b i c sym p hysis The patient's posi tion and therapist's posterior palpa­ tion points are identical to tha t described for tes ting horizontal transla tion at the SII. The therapist'S cau­ dal hand p alpates the distal end of the femur or knee (Fig. 8.32a, b) . The firs t s tep is to determine the plane of the joint s ince there is a high degree of indi­ vidual variance (Ch. 4). Apply a gentle oscillatory force through the femur in a cranioca udal direction, varying the inclina tion from directly cranial to cranial and slightly lateral. One of those planes wilJ

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97

98

THE P E LV I C G I R D L E

Stabil ity Tests

Sta b i l ity Tests - P u re Plane

-

P u re P l a n e

S.1. J o i n t : I n n o m i nate Sacrum Superior

Translation

5.1. Joint: ---i=:::= I n n o m i nate

(a)

Posterio r Translation

Anterior Tra n slation Sacrum

I n nominate --1'=::l'

(a)

F i g u re 8.3 1

s a c ro i l i a c

(a, b) Th i s test exa m i n e s the a b i l ity of t h e

(5. 1.) j o i n t

t o r e s i s t a h or i zo n t a l p o s te r i o r t ra n s l a t i o n

fo rce. T h e a rrow i n d i c a t e s t h e d i recti o n o f fo rce a p p l i e d b y t h e t h e ra p i st's h a n d . ( R e p ro d u c e d w i t h p e r m i ss i o n fro m © D i a n e G . L e e P h ys i o t h e ra p i s t Corp.)

least amount of resistance: this is the SIJ pla n e. Once the pla n e of the joint is found, apply a small cra ni a l and then caudal translation force to the innomina te through the femur. Analyze the two zones of m otion ( neu tral zone from 0 to R1, and elastic zone from R1 to R2) for am plitude, res i s t an c e to motion, and end-feel. Compare the findi ngs to the op posi te side: symmetry is the norm , while as ym­ metry of stiffness, or l a x i t y, is indicative o f dysfunc­ tion (Bu yruk et al 1 997, D a me n et aI 2002b) . Stabil i ty is not about how much mov e ment there is or is not but ra th er about the sy mmetry of s tiffness . B u y ru k et al (1995b) as well as Damen et al (200 1 ) found that u ns tab le SlJs had lower sti ffn ess values and tha t symptoma tic indi v id ua ls demonstrated asymmetry in the values between t he ir left and righ t sides. While t he D opp ler studies s uggest that the stiffness value for the SIJ should be sy mmetric, they do not determine if the amount of stiffness in the vertical plane should e qu al tha t in the hori­ z o ntal plane. C lini c a ll y, it appears tha t an individ­ ual c an have more or less stiffness in one plane than the other and yet s ti ll be sy mme tri c when th e pl an es are com p a red For ex ample , the stiffness found on meet w i th the

.

Fi g u re 8.3 2

(5. 1.) j o i n t

(a,

b)

This test exa m i n es t h e a b i l i ty of the sacro i l i a c

to resist a v e rt i c a l tra n s l a t i o n fo rce. The a rrows

i n d i c a t e the resu l t a n t force o n the i n n o m i n a te p rod u ce d t h roug h " p u s h i n g a n d p u l l i n g" t h e fe m u r. ( R e p rod u ced w i t h p e r m i s s i o n fro m © D i a n e G. Lee Phys i o t h e r a p i s t C o r p.)

tes ti ng vertical translation is comparable left and right and the stiffness found on testin g horizontal tra nsla tion is comparable left and r ight ; however, the stiffness found on vertical transla tion is more or less than tha t found on horizontal translation. It appears tha t an individual can have differing amo unts of form closure for different directions of force . Therefore, when app ly ing these tests, the ther­ ap ist should compare the stiffness value le f t and right for a parti c ular direction of tran sla tion and not compare the stiffness value for vertical translation with horizontal translation on the same Side; they ma y not nec es saril y be the same, yet may be quite normal and function a l for th at in d i vid u a l The neutral zone is a n aly z ed by c omp a rin g the sense of ease w i th whi ch the innominate glides in a p aral le l manner rel a tiv e to the sac ru m u ntil the

Copyrighted Material

.

D i a g n os i n g t h e l u m bo p e l v i c- h i p d ysfu n ct i o n

F i g u re 8 . 3 3

F i g u re 8 . 3 4

Th i s t e s t exa m i n e s t h e a b i l i ty of t h e p u b i c

Pa i n provo c a t i o n test fo r t h e l o n g d o rs a l l i g a m e n t ,

sy m p hysis t o res i s t a d i re c t v e rt i c a l tra n s l a t i o n fo rce. T h e a rrows

co u n te r n u ta t i o n of t h e sacru m . I n t h i s p h o t o , t h e m o d e l ' s a r m s

i n d i c a t e the d i re c t i o n o f fo rce a p p l i e d by t h e t h e r a p i s t ' s h a n d s .

a re ove r h e a d t o fa c i l i t a t e v i e w i n g o f t h e t e c h n i q u e . C l i n i c a l l y,

(Reproduced

w i t h p e r m i ss i o n from © D i a n e G . L e e

t h e a r m s s h o u l d be by t h e s i d e s to re d u ce a n y te n s i o n i n t h e p o s t e r i o r o b l i q u e s l i n g s. T h e a rrow i n d i ca t e s t h e d i re c t i o n o f

Phys i o t h era p i s t C o r p . )

fo rce a p p l i e d by t h e t h e r a p i st's h a n d . ( R e p ro d u c e d w i t h p e r m i ss i o n fro m © D i a n e G. Lee P h ys i o t h e ra p i s t C o r p . )

point of fi rst resistance. The elastic zone is analyzed from R1 to R2 and the q uality of the resistance is assessed as well as the provocation of any pain or muscle spasm. The findings are then compared to the patient's opposi te side, comparing the antero­ posterior glide left and right and the craniocaudal glide left a nd right. We cannot make any j udgments regarding amplitude of mo tion (stift loose, normal) with this test since it has been shown that the range of mo tion a t this joint is highly variable and making a sta tement regarding the amplitude implies know­ ledge of what is "norma l . " It is not possible to know what the patient's normal should be. We can only compare the left to the right side of the pelvis and look for symmetry. Vertical tra nslati o n : p u b i c sym physis The pubiC symphysis can be speci fically tested for vertical sta­ bility. With the heel of one hand, palpate the super­ ior aspect of the superior ramus of one pubic bone. With the heel of the other hand, palpate the inferior aspect of the superior ramus of the opposite pubic bone (Fig. 8.33 ) . Fix one pubic bone and apply a slow, steady vertica l translation force to the other. Analyze the two zones of motion (neutral zone from o to R1, and elastic zone from R1 to R2) for ampli­ tude, resistance to motion, and end-feel as well as the reproduction of any symptoms.

Pe lvic g i rd l e : pa i n p rovocat i o n tests Pain p rovoca tion tests have shown good intertester rel iability (Laslett & Wil liams 1 994, Laslett 1 997), although their validity and specificity have been questioned ( Dreyfuss et al 1994, 1996, Wurff e t al

2000) . When combined with tests of function, cer­ tain provoca tion tests are useful when developing inclusion criteria for research (Vleeming et a I 2002) . They can a lso help to explain to pa tien ts why cer­ tain ac tivities / exercises may be p rovocative to their cond i tion . On occasion, it is necessary to treat the painful structure before function can be restored, particularly if the exercises being taught are aggra­ va ting a painful, inflamed structure . Lo ng do rsa l l i g a m e nt This structure is commonly tender to palpation in patients with pelvic pain (Vleem ing et al 2002) . The pa tient is lying p rone with the head neutral and arms by the sides. With one hand, palpate the iliac crest at approxima tely the level of L3. Follow the iliac crest posteriorly until you drop off the PSIS. A t this point, you should be dorsal to the long dorsal ligament, which can be felt as a vertically oriented band (Fig. 4. 14) . Note any tenderness to palpation. Continue to p alpa te the liga­ ment with one hand and apply a counternutation force to the sacrum (Fig. 8 34 ) . You should feel an increase in tension in the long dorsal ligament. If this is associa ted with increased pain, then this structure is a likely pain genera tor. Sacrotu berous l i g a ment Although the sacro­ tuberous ligament can be inj ured d uring a fa ll on the buttock, this structure is less often a source of pelvic pain. The pa tient is lying prone with the head neutral and arms by the sides. Palpa te the ischial tuberosi ty with one thumb. From this point, palpate medially and cranially until you reach the inferior arcuate band (medial band) of the sacrotuberous ligament (Figs 4 . 1 6 and 8.35a, b). I t should feel like

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99

1 00

T H E P E LV I C G I R D L E

F i g u re 8.36

l i g a m e n t,

Pa i n provoc a t i o n test fo r t h e s a c ro t u b e ro u s

nu tation

of t h e s a c r u m . I n t h i s p h o t o , t h e m o d e l 's

a rm s a re o v e r h e a d to fa c i l i t a t e v i e w i n g of t h e te c h n i q u e . C l i n i c a l l y, t h e a r m s s h o u l d b e b y t h e s i d e s t o red u c e a n y t e n s i o n

i n t h e poste r i o r o b l i q u e s l i n g s . The a rrow i n d i c a tes t h e d i re c t i o n of force a p p l i e d by t h e t h e r a p i s t ' s h a n d . ( R e prod uced w i t h p e r m i s s i o n fro m © D i a n e G . L e e Phys i o therapist Corp.)

Fig u re 8 . 3 7

T h i s p a i n p rovocati o n t e s t st resses t h e a n te r i o r

stru c t u res o f t h e p e l v i c g i rd l e a n d c o m p resses t h o s e poste r i o r. T h e a rrows i n d i c a t e t h e d i re c t i o n of fo rce a p p l i e d by t h e t h e ra p ist's h a n d s. ( R e p r o d u c e d w i t h p e r m i s s i o n fro m © Diane G. Le e P h ys i o t h era p i s t C o rp.)

F i g u re 8 . 3 5

( a , b ) Pa l pa t i o n o f t h e i n fe r i o r a rc u a te b a n d

( m e d i a l b a n d) of t h e s a c ro t u b e r o u s l i g a m e n t . ( R e p ro d u ced w i t h p e r m i ss i o n fro m © D i a n e G . L e e P h ys i o t h e r a p i s t C o rp.)

p o s te ri o rly and distracted If the SIJ is inflamed and an in traa r t ic u la r synovitis is p resent, this tes t m a r kedl y increases the girdle i s compressed anteriorly.

pa tien t's p a in . With the pa tient lying supine, the

and s u p in a te your fo re a r m Continue to p a l p a te the lig a m ent and apply a n u ta tio n force to the sacrum (Fig. 8 .36) . Yo u s h o u l d feel an increase in tension in the sacro tuber­ ous l i g a m e n t . If this is associa ted with increased

medial aspect of th e ASIS is p a lp a ted

p a i n, then th is structure is a likely pain genera tor.

terior struc tures. The force is mainta ined for 5 s an d

a

ta u t g u i t a r s tring w hen you pronate .

Ante r i o r d i stracti o n : p oste r i o r com press i o n b u t rather tes ts for p a in

This

p a r ticula r

s tructure

p rov oc a tion when

the pelvic

test is not intended to s tress a

b i l a te ra ll y 8.37) . A

with t he heels of the crossed hands (Fig.

slow, s teady, posterola teral force is applied thro ugh the ASISs, thus distra c ting the anterior aspect of the

SI} and pubic symphysis

and compressing the

the p r ovocatio n and loca tion of

pain are

po s

­

note d .

Posterior d i stract i o n : a nter i o r compress i o n

This test

is not intended to s tress a p a r t i c u l a r s truc ture but

Copyrighted Material

D i a g n o s i n g t h e l u m b o p e l v i c- h i p dysfu nction

Fig u re 8 . 3 8

T h i s pa i n p rovo c a t i o n test s t resses t h e poste ri o r

s t r u c t u res o f t h e p e l v i c g i rd l e a n d c o m p resses t h ose a n te r i o r. E n s u re t h a t t h e a p p l i e d fo rce is a n te ro m e d i a l t h u s g a p p i n g t h e sa c ro i l i a c j o i n t poste r i o r l y a n d c o m p ress i n g i t a n te r i o rly. T h e a rrow i n d i ca te s t h e d i re c t i o n o f force a p p l i ed by t h e t h e ra p i s t 's ha n d s . ( R e p ro d uced w i t h perm issi o n fro m © D i a n e G . Lee Phys i o t h era p i st Corp.)

rather tests for p a in provoc ati on when the p e lvi c gir­ dle i s compressed anteriorly and distracted posteri­ orly If an intra arti cu lar synovitis of the S1] is pr esent, .

this tes t a lso increases the pa tient's p a in. patien t sidelying, hi p s

and

With the flexed, iliac crest

knees c om f orta b ly

the an terol a tera l aspect of the u p permost is palpa ted (Fig. 8.38) . A slow, steady, medial force is appbed through the pelv ic g i rd l e, thu s distra ct in g the posterior structures of the Sl] and compressing the anterior. The force is maintained for 5 s and the

provocation and loca tion of p a in a re note d .

F i g u r e 8.3 9

Posi t i o n a l t es t i n g of t h e fe m o r a l h e a d re l a tive to

t h e i n n o m i nate i n w e i g h t- b e a r i n g . W h e n t h e fe m o r a l h e a d i s p o si t i o n e d a n t e r i o r l y i n t h e a c te b u l u m t h e re is p o s t e ro l a t e ra l b u t t o c k ( F i g .

a

" d ivot" i n t h e

t h e h e a d o f t h e fe m u r i s

easi l y p a l p a t e d a n te r i o r l y. ( R e p ro d uced w i t h p e r m i s s i o n fro m

FO R M C L O S U R E : H I P

© D i a n e G. Lee P h ys i o t h e ra p i s t Corp.)

The following tests examine th e mob i li ty and passive

stab ility of the hip join t A s with the .

lumbar

spine

and pel v i c girdle, form closure analysis req uires an eva l u a tion of two zones of motion: the neu tral zone

a nd the elastic

8.40) a n d

zone ( F i g

.

8.8); however, before any

interp re tati on of mobili ty can be made, the posi tion of the femoral hea d wi th respect to the acetab ulum must be determined. The hip joint is W1der the infl u­

ence of sev eral la rge muscles and imbalance can cause a displa c emen t of the femora l head

and

thus

gi ve the appearance of res tricte d articular range of motion .

pos terola teral b u t tock (Fig.

hip

8.40) a nd the a n te ri or

structures feel like they are W1der considerable

tension, it is lik e ly tha t this individual is gripping

with

the deep external rota tors of the

hip. Over­

activa tion o f these m u scles forces the femoral head ant

e riorly

and has

marked consequenc es for mobil­ and pelvis (Fig. 8.41). We c a l l

i ty a t the hip, low back,

these p eop le "butt grippers

. "

Try this s imple experi ­

ment. Stand with your feet u nder your hips and with one hand, p a l p a te j u s t pos terior to the grea ter tro c han te r. Wi th the other hand, pa lpa te the an terior aspect of the hip at the level of the ingu ina l l igament. Keep your fee t fi rmly pl an te d on the floor and

Hip: posi tional tests

a c tively externa lly rota te your femora l head in the

Wi th the patient standing, pa lp a te the conto ur

of the

ace tab ulum b i l a tera l l y. You

will

feel the develop­

pos tero l a teral b u t tock behind the gre a ter trochanter

ment of th e

and the a n te rior hip joint a t the level of the

inguina l

ior di spla c ement of the femoral h ea d . You have

If there is a la rge " d ivot" in the

become a butt gripper too ! Maintain this contrac tion

l igamen t (Fig.

8.39) .

Copyrighted Material

"

d ivo t

"

po ster i orly as well as the a n ter­

1 01

1 02

T H E P E LV I C G I R D L E

F i g u re 8.40

Overa ctiva t i o n of t h e exte r n a l rotato rs of t h e

h i p c a u ses " b u tt g r i p p i n g , " N o te t h e l a rg e "d ivots" ( a r rows )

i n t h e p o s t e ro l a tera l b u t t o c k . ( R e p r o d u c e d with p e r m i ss i o n fro m © D i a n e G . Lee P h ys i o t h e ra p i s t C o r p . )

Fig u re 8 . 4 1

Overactiva t i o n of t h e d e e p exter n a l ro t a t o rs o f

t h e h i p p u l l s t h e g re a t e r t ro c h a n te r posteri o r l y ( l a rg e a r row ) a n d fo rces t h e fe m o ra l h e a d a n te r i o rly. ( R e p ro d u ced w i t h perm i s s i o n

fro m L e e 2001 a . j

and try to fo rward bend . It's no wonder tha t the pelvic girdle and low back become sore when this method of stabiliza tion i s used. Wi th the patient s up ine, note the res ting position

H i p : p a ss i ve tests of osteo k i n e m a t i c fu n ct i o n

(PIVM) Flexion

With the pa tient lying supine, the flexed

of the legs . Overactiva tion of the external ro t a tors of

knee of the l ower ex trem i ty to be tested is palpated

the hip w i l l cause the legs to lie in ext e rn a l rota tion

with the caudal hand. The femora l head is p a l p a ted

8.42) . The femur

at rest. Palp a te the a n terior femoral head in this

an teriorly with the o the r hand (Fig.

p osition. If the femoral head is displaced anteriorly,

is p assively flexed a t the hip joint un til posterior

be very superfic ial and the

rota tion of the ipsilateral innomina te begins. At tha t

struc tu res b e tween your hand and the fem oral head

p oin t, the limit o f a v a ilab le range for femoral flex­

can be qu ite tender. It is no t uncommon for individ­

ion has occ urre d . Both the quantity of mo tion and

i ts prominence will

ua ls to have a bi l a ter a l pa ttern of overactiva tion of

the end-feel are no ted . The tes t i s repea ted on, and

the external rota tors, therefore comparing to the

compared to, the other side .

Exte n s i o n

opposite side is not always an option.

Wi th the pa tient supine lying at the

Since there is a wide ind ividual varia tion of coxa

end of the table, one fem ur is flexed, held b y the

vara, coxa valga, and angle of inc lina tion of the

pa tien t, and supp orted against the therapist's lateral

femoral neck, specific measurements of where the

thora x .

greater trochan ter is in rela tion to the ASIS is not

occurred . The anterior aspect of the iliac cre s t and

Ens ure

tha t

no

in trapelvic

tors ion

has

a lways a re liable indica tor of displacement of the

the ASIS of the limb being tested are palpa ted with

femoral head . C linically, considera tion must be given

the cranial hand . Wi th the ca udal hand, the therapist

to b o th th e mo b ility findings and the pOSi tion a l

guides the femur into ex tension until anterior ro ta­

findings t o understand

tion of the ipsila teral innominate begins (Fig.

pOS i tional tes t .

t h e significance of this

8.43) .

At tha t po int, the limit of ava ilable range for femoral

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D i a g nosi n g the l u m bo p e l v i c- h i p dysfu n c t i o n

Fig u re 8 .44 Passive test for osteo k i n e m a ti c abd uction of the h i p. La teral t i l t i n g of the pelvic g i rd l e beneath the l u m ba r s p i n e i n d icates a l l a va i l a b l e ra n g e o f m o t i o n a t the h i p j o i n t h a s occu rre d . ( R e p rodu ced w i t h p e r m i s s i o n fro m © D i a n e G . Lee Phys i o t h e ra p ist Corp.)

la teral thora x . The anterior aspect of the i liac cres t and the ASIS of the limb being tested are pa lpated with the c rania l hand. With the caudal hand, the therapis t guides the fem u r into ab d u c ti on / add uc­ tion (Fig.

8 . 44) until lateral bending of the pelvic

girdle bene a th the vertebral col umn begins. At tha t point, the limit of femoral abduction / a dduction has F i g u re 8.42 Passive test fo r oste o k i n e m a t i c flexion of the h i p . ( R e p rod u ced with permiss i o n fro m © Diane G . Lee

been reached. Both the quantity of motion and the

Physiothera p i s t Corp.)

pared to, the opposite side.

end-feel are noted . The test is repeated on, and com­ Late r a l/med i a l

rotation

With the patient lying

supine, the lower ex tremi ty to be tested is palpate d above the ankle with the c a u d a l hand. The tes t can be performed in v a rying degrees of hip flexion / e x ten­ sion to assist in the d i fferentiation between an articu­ lar and myofascial restric tion. The anterior aspect of the iliac cres t and the ASIS are palpa ted w i th the cra­ nial hand . The femur is passively la terally /medially rota ted (Fig.

8.45) un ti l rota tion of the inn o minate

begins . At tha t point, the lim i t of available range for femoral rotation has occurred. Both the quanti ty of motion and the end-feel are noted . The tes t is repeate d on, and compared to, the opposite side .

Figure 8.43 Passive test fo r oste o k i n e m a t i c exte n s i o n o f the h i p. ( R e p ro d u ced with perm i s s i o n fro m © D i a n e G . Lee Physioth era p i s t Corp.)

Co m b i ned

m ovement test ( i n fl ex i o n )

With the

p a tient lying supine, the flexed knee of the lower extremity to be tested i s palpa ted with the c a uda l hand . The anterior aspect of the i l ia c c rest and the

extens ion has occ urred. Both the quantity of moti on

ASIS are palpated w i th the c ranial hand. The femur

and the end-feel are note d . The test is repeated on,

is passively flexed, adducted, and medially rota ted

and compa red to, the opposite side. Abduction/a d d u ct i o n

Wi th

the

(Fig. pa tient

supine,

8.46) . If the femoral head is d i splaced anteriorly

second ary to overactive ex terna l rota tors, impinge­

lying a t the end of the table, one femur is flexed, held

ment w il l occur, and the patient will likely complain

by the pa tient, and supported against the therapist's

of an terior groin pain.

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T H E P E LV I C G I R D L E

F i g u re 8.47

A rth ro k i n e m at i c tests a t t h e h i p : a n i n fe ro l ate ra l

fo rce g l i d es t h e s u p e ri o r a n d i n fe r i o r

aspects

of t h e fe m o ra l

h e a d l a t e ra l l y a n d d istra cts t h e fove a . T h e a rrow i n d i c ates t h e d i re c t i o n of force a p p l i ed by t h e t h e ra p ist's F i g u re 8.45

Pa ssive test fo r o s t e o k i n e m a t i c m e d i a l rota t i o n

h a nds. (Reprod uced

with p e r m i s s i o n from © D i a n e G . Lee P h y s i o t h e ra p i s t Corp. )

o f t h e h i p. T h e a r row i n d ic a t e s t h e d i re c t i o n of fo rce a p p l i e d by t h e t h e ra p ist's h a n d . ( R e p ro d u ced w i t h p e r m i ss i o n fro m

© D i a n e G. Lee Phys i o t h e r a p i s t Corp. )

movemen t a na lys iS of linear translation (arthro­ kinema tics: PAVMs) will be less informa tive than analysis of the os teokinematic mo tion (PIVMs) . With respe ct to stability, it is the elastic zone analysis which reveals the most informa tion (qua lity of the end -feel).

Latera l d i stractio n/co m p ress i o n

Wi th the pa tient

lying supine and the femur flexed to position of the rup joint), the proximal

30° (res ting tru gh is pal­

p a te d . The j oin t is transla ted la teral ly by applying an inferolateral force parallel to the neck of the femu r (Fig.

8.47) . The superior and infe rior aspects

of the head of the femur translate latera lly in relation to the acetabulum while the fovea is distrac ted . F i g u re 8,46

Co m b i ned m o ve m e n t test fo r a n te r i o r i m p i n g e m e n t

h i p. ( R e p r o d u c e d Phys i o t h e ra pi s t Corp. )

of t h e

w i th p e r m i ss i o n from © D i a n e G . Lee

C o m b i n ed m ovement test ( i n extension)

Compression is applied by approxima ting the femu r superomedially into the medial aspect of the acetab­ u la r fossa . Analyze the two zones of mo tion (neutral zone fro m

With the

pa tient l ying prone, the ex tended knee of the lower ex tremity to be tes ted is palpated with the caudal hand. The pos terior aspect of the greater trochanter is

palpated w i th the cranial hand. The femur is pas­ sively extended, medially rotated, and then adduc ted or abducted. If the femoral head is displaced anteri­ orly and the joint is stiff, a res triction of extension will occur. I f the femoral head is displaced anteriorly and the anterior aspect of the capsule / labrum is lax, excessive extension will occur.

0 to Rl, and el astic zone from Rl to R2)

for a mplitude, resis tance to motion, and end-feel .

Su peroi nferior g l i d e

Wi th the pa tient lying supine

and the fem ur flexed to

30°, the proximal trugh is pal­

pated. The superior aspect of the join t is distracted ( the inferior aspect is compressed) by a pplying

an

inferior force along the longitudinal a xis of the femur

8.48). The superior aspec t of the j oint is com­ approxi­ m a tin g the femur superiorly into the superior aspec t (Fig.

pressed ( the inferior aspect is d istracted) by

of the ace tabular fossa . Analyze the two zones of motion (neu tra l zone from

0 to R l , and elastic zone

from Rl to R2) for amplitude, resis tance to motion, and end-feel.

H i p : p a ssive te sts of a rth ro k i n e m a t i c a n d

Ante ro poste r i o r

a rt h ro k i n et i c fu n ct i o n ( PAV M )

g l ide

With

supine and the fem ur flexed to

lyin g 30°, the proximal

the pa tien t

Linear translation is rela ti vely limi ted a t the hip j oin t

thigh

due to i ts high degree of form closure . Consequently,

i nduced by applying a pos terola teral force in the

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is

p a l p a ted.

An

ante roposterior

glide

is

D i a g n o s i n g the l u m bo p e l v i c- h i p dysfu nction

Fig u re 8 .48

A r t h r o k i n e m at i c tests at t h e h i p : a n i n fe r i o r fo rce

F i g u r e 8.50

Pa i n p rovoca t i o n test fo r a l l t h e l i g a m e n ts of t h e

d i stracts the s u p e r i o r aspect o f the fe m o ra l head. T h e a rrow

h i p j o i n t : t o rq u e test. T h e fe m u r i s h e l d exte n d e d a n d m ed i a l l y

i n d i ca t e s the d i re c t i o n of force a p p l i e d by the t h e ra pi s t ' s

rota t e d (a rrow) a s a p o s t e ro l atera l fo rce i s a p p l i e d t o t h e

h a n d s. ( R e p r o d u c e d w i t h p e r m i s s i o n fro m © D i a n e G . L e e

p rox i m a l fe m u r. ( R e p ro d u ced w i t h p e rm i s s i o n fro m © D i a n e G .

P h ys i o t h e r a p i s t C o r p . )

L e e Physi o t h e r a p i s t C o r p . )

a

slow, s teady, pos terola teral force is applied along

the line o f the neck of the femur to s tress the lar liga m en ts

further

( Fig

.

8.50) .

capsu­

The a mpl i tude of

the neutra l zone (should be zero), the resis tance to m o tion within the e la s t ic zone (should be very fi rm), the quality of the end-feel of the elas tic zone, and the provoca tion of p a in or spasm a re noted . I n fe r i o r b a n d of the i l i o femora l l i g a m e n t

Thi s liga­

ment is taut when t he femur i s fully ex tend ed. If pas­ sive femoral ex tension elicits the

greatest a mount of

pain, this ligament ma y be a nocicep tive source. l I i otroc h a nte r i c

F i g u r e 8.49

Arth ro k i n e m a t i c t e s t s a t t h e h i p : a postero l a te r a l

band

of the

i l iofe m o r a l

l i g a m ent

With the patient supine, lying close to the edge of the table, the ipsilateral femu r is sligh tly ex tended,

fo rce d i stracts t h e a n teri o r a s p ect o f t h e fe m o ra l h e a d . (Re prod u ced w i t h p e rm issi o n fro m © D i a n e G . Lee

adduc ted, and fully l a terally rota ted . The distal fem u r

P h ys i o t h e ra p i st Corp.)

i s fixed against the therapist's thigh a n d the proximal

plane perpendicular to the line of the femoral neck

applied

fem ur is p a l p a ted A slow, steady distraction force is .

(Fig.

8.49). Analyze the two zones of mo tion (ne u tral 0 to R l , and elastic zone from Rl to R2) for

zone from

a m p l itude, resis tance to mo tion, and end-feel.

alon g

th e p rovoca tion of local p a in is noted . Pubofe m o r a l

pa tient

lying

'

This is a glo b a l tes t of p a ssiv e stabil i ty

aU

the

and f ul ly la tera lly ro tated . The distal femur

femur is palpated. A sl ow,

and a pain provoca tion tes t for the ligamen ts of the The inten t is to stress

With

is fixed a ga ins t the ther apist s thigh and the p roxima I

H i p: pain provocati on and g l obal stabil ity

hip joint.

l i g a ment

s up ine, the ipsila teral femur is sl igh tly extended, a bduc ted,

To r q u e test

the line of the neck of the femur and

of the ca psular

steady distraction force is

applied along the line of the neck of the fem u r and the p rovoca tion of local p a in is note d . Isch iofemora l

l ig a m e n t

This

ligament prima rily

liga m ents S imu l taneou sly. If the tes t is painless, then

l imits interna l rota tion as well as adduction of the

the subseq u en t tests which help to d i fferentia te

flexed hip (Hewi tt et al 2002) . With the patient lying

the individual ligaments a re not require d . With the

supine, the ipsilateral femur is flexed, adducted, and

patient supine, lying close to the edge of the table,

fully medially rota ted. A slow, s te ad y distraction force

the ipsila tera l femur is extended until a n terior rota­

is applied along the line of the neck of the femur and

tion of

the inn ominate begins .

The femur is then

the provoca tion o f local pain is note d . This posi tion

medially rota ted to the limit of the phy siologica l

can also cre a te an terio r impingement so noting the

range of motion. T h e proximal thigh is palpa ted and

loca tion of the pain is critical for differen tia ti on .

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T H E P E LV I C G I R D L E

Fig u re 8 . 5 1

A l a rg e th ree-fi n g e rw i d t h post p a r t u m d i a s t a s i s o f

t h e l i n e a a l ba . ( R e p ro d u c e d w i t h p e r m i s s i o n fro m © D i a n e G . Lee P h y s i o t h era p i st C o r p . )

Fig u re 8 . 5 2

Pa l pa t i o n o f t h e d e e p fi b e rs of the m u l t i fi d u s .

I n t h i s fi g u re t h e t h e ra p ist's i n d ex fi n g e r i s p a l p a t i n g t h e s p i n o u s p rocess a n d t h e m i d d l e fi n g e r i s s i n k i n g i n to a " h o l e " o n t h e

F O R C E C L O S U R E A N D M O TO R C O N T R O L

r i g h t s i d e i n t h e g u tt e r b e t w e e n t h e s p i n o u s p rocess a n d t h e

The foll o w ing tests examine the in tegrity of the myofascial systems which provide d ynamic stability

fo r the lumbopelvic-hip region . Force clos ure and evaluate the pa tient s a b il i ty specifically to recru i t both the local and glo b a l sys­ tems appropria tely ( the righ t a mount at the righ t time: see Chs 5 and 6) . In addition, tests a re requ i red to assess the impact of the force clos ure mechani sm on form closure in both the lum b ar sp in e and pelvic mo tor conh'ol analysis

effective contra c tion of the l ocal system on force clos ure of the lumbar sp ine and pelvic gi rd le depends on an in tac t a n t erior and p os ­ terio r fa sci a l connection. Anteriorly, this req u ires integrity of the abdomina l fascia and p os teriorl y, The im p a c t of a n

m u l tifidus m us t be of suffi cient bulk to genera te ten­

the thoracodorsa l fa scia when it contra cts.

An terior abdomin al fasci a - test for d iastasis of the l in ea a l ba Pregnancy is a common, but not the only, cause for diastasis of the linea alb a . The fascial ana tomy (see Ch. 4) renders the abdomen v ulnerable j ust below the wnbilicus, although se p ara tion of the fascia can occur along the entire length of the midline from the

p ubiS

to the xyphoid (Fig .

8.51 ).

With the p a tient

in

crook lying, p a lp a t e the linea alba in the mid line . Ask the p a t ient to do a slow curl-up (activ a te the

inals

anyw ay

the

of m u l t i fi d u s. ( R e p ro d u c e d w i t h p e r m i s s i o n fro m © D i a n e G. Lee P h ys i o t h e r a p i s t C o r p . )

'

gird l e .

sion in

t ra n sve rse p rocess. Th i s h o l e i s d u e to a t r o p h y o f t h e d e e p fi b e rs

abdom­

p a tien t knows how) and p a l pa te

et a1

(1998),

it is normal to

feel 1-2 cm separation in

the linea alba above the wnbilicus and less below.

Deep fibers of mul tifid u s The deep fibers of m u l tifidus are pa lp a ted with the patient in prone lying, he ad in neutral . In the lumbar spine, the "gu tter" between the spinous process and the transverse process is p a l p a ted (Fig . 8.52) . In the pel v i s the deep fibers of the m ultifidus are palpa ted j us t l a teral to the median sacral cres t. T h e sup e r ficial and la tera l fibers of mul tifi d us belong to the global system (Moseley e t al 20 0 2 ) and in the pel vis a ttach to the p oste rio r iliac crest la teral to the deep fibers (Figs 4.27 and 4.33). Press firmly but gently into the tissue and note the quality of the tissue (firmness) a nd the size of the m uscle. Compare the firmness / ,

size to the contralateral side and to levels above and

find atrophy hypertoni c i ty of the

below. In dysfunc tion, i t is common to of the deep (medial) fibers and

superfici a l or lateral fibers of mu l t i fidus.

Active straig h t le g raise test leg raise (ASLR) tes t et al 1997, 1999, 200 1, 2002) has been v a l ­

The supine active straight ( M ens

for sep a r a tion of the

ida ted as a clinical t e s t for measu ring effec tive load

i s measured in

transfer between the trunk and low er l i m bs . When

midline fascia . The separation fingerwid ths . According to Sapsford

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D i a g n os i n g the l u m bo p e l v i c- h i p d ysfu n cti o n

Fi g u re 8 . 5 4 F i g u re 8 . 5 3

An o p t i m a l a c t i ve s t ra i g h t l e g ra i s e . T h e o n ly j o i n t

m o v i n g i s t h e h i p j o i n t. T h e t h o r a x , l u m b a r s p i n e , a n d p e l v i c g i rd l e re m a i n s ta b l e d u e to co-a c t i v a t i o n o f t h e l oca l a n d g l o b a l syst e m s ; t h i s i s o p t i m a l tenseg r i ty.

the lumbopelvic-hip region is functioning optimally, the leg should rise effortlessly from the table (effort can be graded from 0 to 5) (Mens et a1 1999) and the pelvis should not move (flex, extend, laterally bend, or rotate) rela tive to the thorax and / or lower ex tremity (Fig. 8.53). This requires proper activation of the muscles (both in the local and global systems) which stabilize the thorax, low back, and pelvis. Several compensa tion s trategies have been noted (Lee 1999, 2001a, Richardson et al 1999) when stabi­ lization of the lumbopelvic region is lacking. The ASLR test can be used to identify these strategies . The application of compression to the pelvis has been shown (Mens et al 1999) to reduce the effort necessary to lift the leg for patients with pelvic pain and instability. It is proposed (Lee 2002) that by varying the location of this compression during the ASLR (see below), further information can be gai.ned which will assist the clinician when prescrib­ ing exercises to improve motor control and stability (see Ch. 1 0 : restoring force closure / motor control) . The supine patient is asked to lift the extended leg off the table and to note any effort difference between the left and right leg (does one leg seem heavier or harder to lift?) . The strategy used to sta­ bilize the thorax, the low back, and the pelvis d uring this task is observed. The leg should flex at the hip joint and the pelvis should not rota te or laterally, anteriorly or posteriorly tilt relative to the lumbar spine (Fig. 8.54 and see Fig. 8.56) . The ribcage should not draw in excessively (overactivation of the exter­ nal oblique muscles) (Fig. 8.55a-c), nor should the lower ribs flare out excessively (overactiva tion of the internal oblique muscles). Overactivation of the external and internal oblique will result in a braced, rigid ribcage tha t limits lateral costal expansion on

Active stra i g h t l e g ra ise w i t h l o s s of l u m b o p e l v i c

s t a b i l i ty - n o t e t h e a b d o m i n a l b u l g i n g , a n te r i o r p e l v i c t i lt , a n d t h o ra c i c e xte n s i o n a s w e l l a s t h e ext r e m e effo rt re q u i re d to l i ft t h e l e ft l e g . ( R e p ro d u ced w i t h p e r m i s s i o n fro m © D i a n e G. Le e P h ys i o t h e r a p i s t Corp.)

inspiration. The thoracic spine should not extend (overactiva tion of the erector spinae) (Fig. 8.56), nor should the abdomen bulge (breath-holding: Valsalva) (Fig. 8.57) . ln addition, the thorax should not shift lat­ erally relative to the pelvic girdle. The provocation of any pelvic pain is also noted at this time. S i m u l ation of the local syste m The pelvis is then compressed passively and the ASLR is repeated; any change in effort and / or pain is noted . The location of the compression can be varied to simula te the force which would be produced by optimal function of the local system. Although still a hypothesis, clinically it appears that compression of the anterior pelvis a t the level of the ASISs (Fig. 8.58) simulates the force pro­ duced by contraction of lower fibers of transversus abdominis and compression of the posterior pelvis at the level of the PSISs (Fi g 8.59) simulates that of the sacral multifidus. Compression of the anterior pelvis at the level of the pubic symphysis (Fig. 8.60) simu­ lates the action of the anterior pelvic floor whereas compression of the posterior pelvis at the level of the ischial tuberosities simulates the action of the poste­ rior pelvic wall and floor. Compression can also be applied to one side anteriorly and simultaneously to the opposite side posteriorly (Fig. 8 . 6 1 ) . You are look­ ing for the location where more (or less) compression reduces the effort necessary to lift the leg - the place where the patient notes: "That feels marvelous ! " S i m u l ation o f t h e g l o b a l system The thorax and pelvis are compressed obliquely to simulate the action of the oblique slings of the global syste m . Compression of the right anterola teral thora x towards the left side of the pelvis (Fig. 8 . 62) simu­ lates the action of the left rotators of the trunk which include (bu t are not l imited to) the right externa l oblique and the left internal oblique. Alternately,

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Figu re 8 . 5 6 Active s t ra i g h t leg ra ise w i t h excessive a c t i va t i o n of t h e erector s p i n a e c a u s i n g t h e th orax to exte n d re l a tive to the l u m ba r s p i n e a n d p e l v is. This m o d e l has a l so l o s t t h e rota t i o n co n t ro l of t h e p e l v i c g i rd l e ( p e lvis is l e ft - ro t a t e d ) . A com b i n a t i o n of p a tterns is com m o n l y see n . ( R e p r o d u c e d with permission fro m © D i a n e G . Lee Phys i o t h e ra p i s t Co rp.)

F i g u r e 8 . 5 7 Ac tiv e s t ra i g h t leg raise with excessive a b d o m i n a l b u l g i n g ( a rrow) a n d bre a t h - h o l d i n g : a Va l s a lva m a n e uver. ( R e p r o d u c e d w i t h p e r m i s s i o n from © D i a n e G. Lee Physi o th e ra p i s t Corp.) leng thening of a partic u la r sling may be required . Decompression of the left anterol a tera l thora x a w a y Fig u re 8 .5 5 Active stra i g h t leg ra ise (ASLR) w i th excessive activation of the extern a l o b l i q u e m us c l e s resu l t i n g in n a rrow i n g of the i n fra stern a l a n g l e of the ribcage. (a) A b d o m e n at res t ; (b) a b d o m e n d u ri n g the ASLR : note the n a rro w i n g of the i n fra ste r n a l a n g l e a n d the tra n sverse a b d o m i n a l crease w h i ch occu rs a s t h e t h o ra x fl exes rela tive to the p e l vis. [ R e p ro d u ced w i t h permission fro m © Diane G . Lee Phys i o therapist Corp.) (c) Schematic d raw i n g refl e c t i n g t h e conse q u e nces o f overactiva ti n g t h e externa l o b l i q u e d u ri n g l o a d i n g . N o t e t h e d e press i o n of t h e u p p e r a b d o m e n , b u l g i n g o f t h e l o w e r a b d o m e n , fl ex i o n o f t h e thoraco l u m b a r s p i n e , a n d poste r i o r p e l v i c ti l t. (Co u rtesy o f D r. Pa u l H o d g es.)

from the right s i d e o f the p e l v i s ( F i g .

8.63) simu la tes

a release of the righ t ro ta to r s of the trunk . Once a gain

,

you are looking for the loca tion where more (or less) compression reduces the effo r t necessa ry to lift the leg.

Active bent leg rai se test Further analysis of both muscle recrui tment an d tim­ ing is necessa ry to confirm the find ings of the

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ASLR

D i a g n os i n g the l u m bo p e l v ic- h i p dysfu n c t i o n

F i g u re 8 . 5 8

C o m p ression of t h e a nterior pelvis at the l evel of the ASISs s i m u l a tes the action of t h e tra nsve rs u s a b d o m i n is. ( R e p rod uced with p e r m i s s i o n fro m © D i a n e G. Lee Physiothera p i s t Corp. )

F i g u re 8 . 5 9

Com p ress i o n of t h e posterior pelvis a t t h e l evel of the PS ISs s i m u l a tes the a c t i o n of t h e sacra l m u l tifi d us. ( Reproduced with permission fro m © D i a n e G . Lee Phys i o t h e ra p ist Corp. )

F i g u re 8 . 6 1 Com press i o n of the r i g h t a n t e r i o r pelvis a n d l eft poste rior pe lvis s i m u l a tes t h e a c t i o n of t h e r i g h t t r a n svers u s a b d o m i n is a n d t h e l eft s a c ra l m u l tifi d u s. ( R e p r o d u c e d w i t h p e r m i ss i o n fro m © D i a n e G . L e e P h ysi o t h e ra p i s t Corp. )

F i g u re 8 . 6 2 Com p ress i o n a p p l ied o b l iq u e l y between t h e t h o ra x a n d pe l v i s s i m u l ates t h e a c t i o n o f t h e o b l i q u e s l i n g system . T h e a r rows i n d i c a te t h e d i rection of fo rce a p p l ied by t h e t h e r a p ist's h a n d s. ( R e p r o d u c e d w i t h p e r m i ss i o n fro m © D i a n e G. Lee Physi o t h e r a p i s t Corp. )

Deco m p ress i o n ( l e n g t h e n i n g ) a p p l i ed o b l i q u e l y between the t h o ra x a n d p e lvis s i m u l a tes releas i n g t h e o b l i q u e s l i n g syst e m . T h e a rrows i n d icate t h e d i rect i o n of fo rce a p p l i e d by t h e t h e ra p i st's h a nds. ( R e pro d u ce d w i t h permiss i o n from © D i a n e G. Lee Phys i o t h e ra p i st Corp. ) F i g u re 8 . 6 3

F i g u re 8 . 60

Co m p ress i o n of t h e a n te r i o r p e l v i s at t h e l evel of t h e pubic sym p hys i s s i m u l ates the action of t h e ante ri o r p e l v i c floor m u s c l es. ( R e p rod u ced w i th perm i ss i o n fro m © D i a n e G. Lee Phys i o t h e ra p i s t Corp. )

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With the patient in crook lying, palpate the transver­ sus abdominis deep in the abdomen approxima tely 2.5 cm (1 in.) medial to the ASIS. With the other hand, palpate multifi dus at the level where atrophy was noted (Fig. 8.64). To test the integrity of the neural pathway to transversus abdominis, multifidus, and the pelviC floor the following verbal cues are given and the response of the local system is noted:

Fig u re 8 . 6 4

Po i n ts o f p a l p a t i o n fo r tra nsve rsus a b d o m i n i s

a n d m u l t i fi d u s fo r eva l u a t i n g c o - c o n t ra cti o n d u r i n g l o w l o a d i n g . ( R e p r o d u ced w i t h p e r m i ss i o n fro m © D i a n e G . P h ysi o t h e ra p i s t

Corp.)

Lee

and to plan an effective exercise program . With the pa tient in crook lying, palpa te the transversus abdo­ minis deep in the abdomen approxima tely 2.5 cm (1 in.) med ial to the ASIS. v\Then the transversus abdo­ minis contrac ts, an increase in tension (not bulging) is felt at this point. When the internal oblique con­ tracts, a distinct bulging is felt. With the other hand, palpate multifidus at the level where atrophy was noted (Fig. 8.64). Ask the patient to lift the foot off the table, keeping the hip and knee flexed . Note the impact of this lesser load on the motor control stra t­ egy used to stabilize the lwnbopelvic region. Note the ability to maintain a s table low back and pelvic girdle and, in addi tion, note the recruitment pattern of the lower abdominals (deep tension of transversus abdominis versus a fast bulging of internal oblique) and deep (slow tonic swelling) versus superficial (fast phasic bulging) multifidus . Both the local and global systems are required to achieve this task; how­ ever, in dysfunction the global sys tem commonly dominates over the local. Loca I syste m : co-contract i o n a n a l ys i s

In health, the local system should co-contract in response to a command which begins with intention. This system is anticipatory (for the resea rch, see Ch. 5) and should respond prior to the activation of the global system. Global muscles do things (move joints) whereas the local muscles prepare the region for the impending load and respond to the thought of doing something. Therefore imagining or thinking abo u t (preparing), but not actually doing a move­ ment, appears to be a more effective way of accessing the appropria te neural pathways to the local system.

1. "Slowly and gently draw your lower abdomen in . " 2. "Slowly and gently squeeze the muscles around your urethra as i f to s top your urine flow. " 3. "Slowly and gently draw your vagina (or testicles) up into your body. " 4. "Imagine there is a wire connecting your hip bones an teriorly [ASISsj from the left to right side. Think about genera ting a force which would draw these two bones together. " 5. "Imagine there is a wire connecting your hip bones posteriorly [PSISsj from the left to right side. Think about genera ting a force which would draw these two bones together. " 6. See Chap ter 10 for further verbal cues which can help to activate the local system - there are an infinite number, you just have to find the cue tha t works for your patient! If the p a tient is able to connect and to co-con tract the muscles of the local sys tem, you should feel a deep, light tension develop in the transversus abdo­ minis and a slow, tonic swelling posteriorly in the deep fibers of multifidus . You should not feel a fast, phasic bulging of the internal oblique, nor a rapid superficial contraction from the superficial fibers of multifidus. The lumbopelvic region should remain still - no motion should be seen. Palpate both sides and look for equal contraction and timing for both sides of the transversus abdominis and multifidus in resp onse to these verbal cues. This is the analysis of the "circle of integri ty" (see Ch. 5, Fig. 5 . 13). The functional pelvic floor (muscles and the fascia) can only be properly assessed with internal palpation techniques; however, the impact of the functional floor on bladder position and support can be assessed via real-time ultrasound (RTUS) imaging. RTUS (see below) is a useful way to visualize some of the abdominal m uscula ture (internal oblique, transversus abdominis), multifidus, and pelvic floor during verbal cuing (using inten tion) as well as dur­ ing functional load transfer activities (ASLR). If the patien t is able to isola te the muscles of the local sys tem appropriately, the endurance of the local

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D i a g n o s i n g the l u m bo p e lvic-h i p d ysfu ncti o n

system can be assessed. The patient should be able to maintain the co-contraction for 10 s repea ted 10 times while brea thing normally. The co-contraction should also be maintained when loads a re added; this ability can be assessed by adding leg loading (i.e., heel slides, hip flexion) while palpa ting trans­ versus abdominis and multifidus and ensuring that co-contraction is maintained. Further de tail regard­ ing loading progressions for assessment and treat­ ment will be covered in Chapter 10. Local system and t h e n eutra l zone

When the force closure mechanism is effective, co­ contrac tion of the muscles of the local system should compress the j oints of the lumbar spine (Hodges e t al 2003b) and the SII s (Richardson et al 2002), thereby increasin g stiffness. To tes t the status of the active force closure mechanism, the pa tient is first ins tructed to recrui t the local system ( trans­ versus abdominis, multifidus, and pelvic floor) (see Ch. 10: restoring force closure / motor control) . This instruction may take a few sessions to master. Once the patient is a ble to sustain a tonic co-contraction of the local system, the e ffect of this contraction on the stiffness of the l umbar zygapophyseal/ SIJ is assessed by repea ting the form closure tes ts for trans­ lation while mainta ining a gentle co-contraction of the local system. The joint stiffness should increa se and no rel a tive mo tion betvveen the innominate and sacrum should be felt (the neu tral zone of motion should be red uced to zero). This means tha t an ade­ q uate amount of compression has occurred and the force closure mechanism is effective. If the local sys­ tem is contracting appropria tely and has no effect on the stiffness of the joint, then the active force closure mechanism is ineffective for controlling shear. This is a poor prognostic sign for successful rehabilitation with exercise. Global system sl ing s: strength a n a l ysis

The global sys tem of muscles is essentially an inte­ grated sling system, comprising several m uscles, which produces forces . A muscle may particip a te in more than one sling and the slings may overlap and interconnect depend ing on the task being demand e d . The hypo thesis is tha t the slings have no beginn ing or end b u t rather connect to assist in the transference of forces. It is possible tha t the slings are all part of one interconnected myofascial system a nd the particular sling (anterior oblique,

posterior oblique, lateral, longitudinal), which is identified during any motion is merely due to the activa tion of selective parts of the whole sling. The identification and treatment of a specific muscle dysfunction (weakness, inappropriate recruit­ ment, tightness) is importan t when restoring global stabilization and mobility (between the thorax and pelvis or between the pelvis and legs) and for under­ standing why parts of a sling may be inextensible (tight) or too flexible (lacking in s upport). It is impor­ tant to tes t for muscle strength and length; the reader is referred to Kendall et al (1993) for a detailed review of how to test specific m uscles not covered in this text. Remember, j us t because a muscle seems weak to specific testing does not mean that the muscle is weak. It merely implies tha t the sling is not able to resist the force you are applying and it could be due to weakness (or lack of recruitment) of any muscle along that sling or an insufficient recruitment of the local system . Four slings speci fic to the lumbopelvic region are described below. They reflect the anatomical cormec­ tions observed by V1eeming et al (1995a, b) and are commonly involved in patients with lumbopelvic dysfunction. However, these are not the only slings which require consideration. Remember, the globa l system of muscles is essentially an integra ted sling system, comprising several muscles, which produces forces. A muscle may participate in more than one sling and the slings may overlap and interconnect depending on the task being demanded . The poste r i o r o b l i q u e s l i n g This sling consists, in part, of the gluteus maximus and the contralateral latissimus dorsi and the intervening thoracodorsal fascia (Fig. 5 . 15). The lower part of this sling is tested by resisting extension of the leg (Fig. 8.65a). Wa tch, and feel, for the give in the sling; where the loss of control occurs. The upper part of this sling is tested by resisting terminal eleva tion of the a rm (Fig. 8 . 65b) . Wa tch, and feel, for the give in the sling; where the loss of control occurs. When the gluteus maximus is weak, the buttock appears flattened and the gluteal fold may be lower on the weak side. The gluteus ma ximus is specifically tested in the prone position. The p atient is asked to squeeze the bu t­ tocks together and the ability to do so is palpa ted . If the patient is able to isolate an effective contraction, he or she is then asked to perform a concentric contraction by extending the femur with the knee flexed (Fig. 8.65c) . Resistance is then applied to the ex tended femur. Careful observa tion of the effects of this contraction on the position of the lumbar spine

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Fig u re B . 6 S a Tes t fo r t h e lower pa rt o f t h e poste r i o r o b l i q u e s l i n g . N o te t h e l o ss of control i n t h e l u m b a r s p i n e ( a rrow i n l u m b a r s p i n e ) . ( R e p ro d u c e d w i t h p e rm i ss i o n fro m © D i a n e G . Lee Physi o t h e ra p i s t C o r p . )

Fig u re B . 6 S e C o n c e n t r i c con tracti o n of g l u te u s m a x i m us i n a s h o rte n e d positio n . I n t h i s m o d e l , t h e g l u te u s m a x i m u s is h o l d i n g w e l l ; however, as noted i n Fi g u re 8.65a, h e r reg i o n of give o r l oss o f c o n trol i s i n t h e l u m b a r s p i n e ( a rrow ) . ( R e p ro d uced w i th p e r m i ss i o n fro m © D i a n e G . Lee Phys i o t h e r a p i s t Corp. )

F i g u re B . 6 S b Test fo r the u p per p a rt of t h e posteri o r o b l i q u e s l i n g . T h e a rrow i n d icates t h e d i re c t i o n of fo rce a p p l i e d b y t h e th era p ist's h a n d . Th is m o d e l i s d e m o n s tra t i n g fa i rl y g o o d sca p u l a r, t h o ra c i c , l u m b a r, a n d p e l v ic c o n trol d u r i n g t h i s test. ( R e p ro d u ced with p e r m i s s i o n fro m © D i a n e G . Lee Phys i o t h era p ist Corp. )

and pelvic girdle gives the examiner further infor­ mation on muscles in the res t of this sling. It is not uncommon to find positional weakness of the glu­ teus maxim us m uscle in pa tients with a chronically anteriorly rota ted innominate. This position length­ ens the gluteus maxirnus muscle and , when thi s m uscle is tested in its shortened posi tion (Fig. 8.65c), a marked weakness will be found and the femur wi ll "give" relative to the pelvic gird le. The latissimus dorsi is isolated by resis ting adduction of the extended, medially rotated arm . This muscle tends to tighten or become hypertOnic and i ts length test will be described below. The a n te r i o r o b l i q u e s l i n g This sling consists, in part, of the oblique abdominals and the contrala tera l adductors of the thigh (Fig. 5 . 1 6 ) . When the anterior system is weak, the ribcage appears "posteriorly rotated" in standing and extended in supine lying, especially when the trunk is loaded during the ASLR (Fig. 8.56) . The anterior slings can be tes ted bila terally during a sequenced cu rl-up (Fig. 8 . 66) . The therapist monitors the infrasternal angle and observes the ability of the patient to flex the thorax sequentially. The patien t is then asked to continue flexing the lumbar spine through to a full sit-up. When this s ling is weak (or excessively resisted by hypertonicity of the posterior slings), there is an absence of seq uential spinal movement (parts of the spine remain ex tended) and the lower extrem­ ities tend to abduct and ex ternally ro ta te. Unila tera l weakness presents as a thoracolumbar rota tion (often associated w i th the lateral shift of the thorax du ring the c url-up ) .

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D i a g n o s i n g the l u m bo p e l v i c- h i p dysfu nct i o n

F i g u r e 8.66 A seq u e n ced c u rl - u p tests t h e o b l i q u e a b d o m i n a l portion of t h e a n terior o b l i q u e s l i n g s b i l a t e ra l l y. T h i s m o d e l w a s o n l y a b l e se q u e n t i a l ly to fl ex t h e thorax to t h e thoraco l u m b a r j u n c t i o n . She was not a b l e to s i t u p fu r t h e r w i t h o u t exte n d i n g h e r t h oraco l u m b a r s p i n e. ( R e prod u ced w i t h p e r m i ss i o n fro m © D i a n e G. Lee Physi o t h e ra p i st Corp . )

The gluteus m edi us / m ini m u s the te ns or fascia la tae a re s ig nifican t muscles of this sling and work together to s tabilize the pelvic gird le at the hip j oint. Traditionally, gluteus medius is thought to be an abductor of the hip; however, Gottschalk et al (1 989) revi s ted the anatomy and p o tential a c tion of this muscle a n d propose a differ­ ent functional role. They note that the gluteus m e d i u s m u scle is comprised of three segments, each with its own innervation. The posterior fibers run parallel to the neck of the femur (horizontal) whereas the a n terior and middle fibers are oriented more vertically. Their electromyogra m (EMG) stud­ ies showed tha t the three parts of glu teus medius function phasic a Uy; the onse t o f action was sequen­ tial from posterior to a nterior; the posterior fibers fire firs t at heel strike while the anterior fibers show the grea tes t a mp l i tu d e of activity during stance a nd single-leg support. They propose tha t the pri m ary function of the posterio r part of the gluteus medius (and the entire glu teus minimus) is to stabilize the The l a te r a l s l i n g

and

F i g u re B . 6 7 (a) Wea k n ess d u ri n g l o a d i n g of the l a t e ra l s l i n g m a y be i n d ica t ive o f i n s u ffici e n t recru itm e n t of m a n y m u scles : the g l u te u s m e d i u s is o n e of t h e m . Loo k a n d fe e l fo r t h e l o c a t i o n of g ive (sp i n e . p e l v i s . h i p) d u ri ng t h i s test to g a i n a c l earer u n d e rsta n d i n g of exactly which m u sc l e i s a t fa u l t . Th e a r row i n d ica tes the d i re c t i o n o f fo rce a p p l i e d by the t h e ra p ist's h a n d . ( b ) T h e poste r i o r fi b e rs of g l u t e u s m e d i u s a re pa l pated d u ri n g l a tera l l o a d i n g o f t h e l e g i n a b d u c t i o n a n d exte r n a l rota t i o n . T h e a rrow i n d i ca tes t h e d i re c t i o n o f force a p p l i ed b y t h e t h e ra p ist's h a n d . ( R e p rod u ced with p e rm i s s i o n fro m © D i a n e G . Lee P h y s i o t h e ra p i s t Corp. )

femoral head (by co m pres s in g it into the acetabu­ lum) during different posi tions of femoral / pelvic rotation during ga i t . They also propose that the anterior and middle parts (ha v e a more vertica l p u ll) help to in i tiate abduction; however, the ma in abd uctor of the hip is the te n sor fascia latae. To test the left l a ter a l sLing, the p a tient is right sidelying. The pa tient is requested to abduct the left leg, maintaining ne u tral alignment of the lumba r spine, p elvis, and hip (Fig. 8.67a) . A n adduction force is applied to the limb and the response observed. Watch, and feel, for the give in the sling; where the

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F i g u re 8 . 6 8 a , b Le n g t h test fo r l a ti ss i m u s d orsi a n d t h e rig h t poste rior o b l i q u e s l i n g . ( a ) T h e a m p l i t u d e o f leh rota tion is n o t e d w i t h t h e a r m s a t t h e s i des. ( b ) Te n s i o n i s i n creased t h ro u g h t h e r i g h t l a t i ssi m u s d o rs i b y a d d i n g fl e x i o n , externa l rota t i o n , a n d a d d uction of t h e s h o u l d e rs . When t i g h t (or hyperto nic), rota t i o n of t h e t ru n k w i l l be red uced w i t h t h e a rm s m a i n ta i n e d i n this pos i t i o n . ( R e p rod uced w i t h perm ission fro m © D i a n e G. Lee Physiothera pi s t Corp.)

loss of control occurs. Look for any compensa tion

(exte rn ally rotate the hip ) . Resis ta.nce to external ro ta­

way.

tion

To tes t the pos terior fibers of gluteus medius the

(Fig.

strategies which indicate which region is giving

patient is sid elying wi th the leg to be tested upper­

is applied through the la teral aspect of the femur B.67b). When t he p os terior fibers of gluteus

medius are weak, the leg gives way easily and the

most. With the knee ex tended, the hip is positioned in

patient a ttemp ts

slight ex tension, abduction, and external rotation.

backwards to facilitate the use of the tensor fascia

to compensate by rotating the pelvis

The patient is req ues t ed to hold the hunk and the leg

l a tae. Alternatively, the patient may sideflex the spine

still, as support is released . The response is then

in

obsenred.

sacral multifidus a re

The pa tient with weak posterior fibers of

gluteus medius will tend to ro ta te the pelvis back­

an

attemp t to hold the leg.

If the deep fibers of the not func tion a l, thi s test may be

positive and yet gluteus med ius is relatively strong.

wards to facilita te the use of the tensor fascia latae. Alterna tively, the patient may sideflex the spine in an a ttempt to hold the leg.

In both ca ses, stabiliza tion

of

G l obal system sl i n g s : l eng th analysi s

sacral multifidus a re no t functional, this test may

can a d v e rsely a ffe c t the bio­ lumbopelvic-hip region . The m u sc les which tend to tighten in the presence of

be positive and yet the p osterior fibers of gluteus the posterior

bili ty. These muscles incl ude latissi m u s d orsi, e rec­

the lumbar sp ine has been lost in an a ttemp t to achieve the ta sk demanded . If the deep fibers of the

medius are rela tively strong. Al ternately,

Muscle shor tening mechanics

of

the

dysfunc tion should be assessed for their ex tensi­

fibers of gluteus med ius are tested as follows. The

tor spinae, oblique a b d omina Is, hamstrings, psoas

p a tien t is sidelying with the hips and knees slightly

maj or, rectus femoris, tensor fasci a la tae, short a nd

flexed . The patient is ins tructed to main tain contact

long a d d u c tors, and p i ri formis / deep ex terna l ro ta ­

between the ankles and then to

lift

the

top knee

tors of the

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hip.

D i a g n osing the l u m bo p e l v i c- h i p dysfu n c t i o n

Fig u re 8.68c, d Len g t h test for latiss i m u s d o rs i a n d the ri g h t poste rior o b l i q u e s l i n g . (c) Exte n d i n g t h e l e ft k n e e w h i l e seated i n c reases the tension o f the h a mstri n gs. I f t i g h t or hyperto n i c , the pelvis w i l l p oste riorly t i l t a n d the l u m b a r spine w i l l flex to a l l o w fu l l k n ee extension. (d) The fu l l - l e n g t h test fo r the ri g h t poste rior o b l i q u e s l i n g. Note t h e l oss of n e u t ra l s p i n e ( l u m b a r s p i n e is fl exed, t h o r a c i c s p i n e is ext e n d ed) a n d t h e excessive d ra w i n g i n of t h e ri g h t l o w e r r i b c a g e . A l l t h e s e fi n d i n gs i n d icate i nsufficie n t l e n g t h of the posteri o r o b l i q u e s l i n g . The spine is respo n d i n g b y b u c k l i n g . ( R e p rod u ced w i t h permission fro m © D i a n e G . Lee Physiothera p i s t Corp.)

The posterio r ob l iq u e s l i n g and the l a t i ssim u s d o rs i

sling. In the sitting posi tion, the p a tient is ins truc ted

The p a tient is s i tting in a neu tral lu mbar spine pos­

to extend the left knee (Fig. 8.68c) . The ability to d o

i tion with the a rms res ting by the sides. Instruct the

s o withou t posteriorly ti lting the pelvis is observed.

pa tient to rota te the trunk to the left (Fig . 8 . 68a) and

From this posi tion, the a rms are flexed to 90°, ful l y

then to the right and note the quantity and qua l i ty

ex ternally rotated a n d a d d uc ted, and the trunk i s

of motion th rough the thoracic and lumbar spin e .

rotated t o the l e f t (Fig. 8 . 68d ) . This is a fu l l s tretch

Subsequently, instruct the p a tient to fl e x the arms

for the right pos terior ob lique sling.

to 90°, and fully externally rotate and adduct the

The a n te rio r o b l iq u e sling a n d the o b lique a b d o m i n a l s

shoulders such tha t the hypothenar em inences are

I n the supine lying position, the rel a tive position o f

approxima ted . This posi tion increases the tension

t h e thorax t o the pelvic girdle is noted. When the

throu gh the la tissimus dorsi muscle . From this pos­

oblique abdominals are overac tive, the lumbar lor­

i tion, instruct the patien t to rotate the trunk to the

dosis is absent and the pelvis rests in a posteriorly

left (Fig. 8 . 68b) and then to the right. The quan ti ty

til ted position. In addi tion, the infrasternal angle

mId qua lity of the motion a re noted and compared

(Fig. 8 . 69) is na rrow ei ther b i la ter a lly or uni latera ll y.

to that ob served w i th the a rm s by the side. The

Isola ted overactiva tion of the internal oblique is less

motion is markedly reduced in this posi tion when

common and tends to widen the infrasternal angle.

the l a tissimus dorsi m uscle is tight . The length of

The l o n git udin a l s l ing a n d t h e e recto r s p i n a e

Wi th

the full posterior ob lique sling can be tested b y

the pa tient sitting, fee t supported a n d the verte­

added tension t o the inferior components o f the

bral column

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in a neu tra l position, the pa tient is

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Fig u re 8 . 6 9

B i l a t era l overa ctiva t i o n of t h e o b l i q u e a b d o m i n a l s

w i l l n a rrow t h e i n fraste r n a l a n g l e . I s o l a ted a ctiva t i o n o f t h e i n t e r n a l o b l i q u e w i l l w i d e n t h e i n frast e r n a l a n g l e . Asy m m e t ry is com m o n . ( R e p ro d u c e d w i t h p e r m i s s i o n fro m © D i a n e G. lee P h y s i o t h e r a p i s t Corp.)

instructed to forward bend . The quantity of the avai lable motion, the sy mmetry / asymmetry of the paravertebra l muscles, and the p resence/ absence of a multisegmental rotoscoliosis may be indicative of unilateral tightness of the erec tor spinae m uscles. The long itud i n a l s l i n g and t h e h a mstri ngs The extensibility of the longi tudinal sling can be assessed in stand ing (Fig. 8.70a) or sitting (Fig 8.70b ) . Optimally, the p a tient should be able t o touch the toes and, with the knees extended, anteriorly tilt the pelvic girdle to a t least a 90° angle rela tive to the femurs . Insufficien t extensibility of the ha mstrings is a common cause of tightness in this sling. To assess the length of the hamstrings specifica lly, the pa tient is lying supine with the lower extremity to be tested flexed at the hip joint to 90°. While ma intaining the fem ur in this position, the knee is extended until the first resistance from the hamstrings is encoun­ tered (Fig. 8.70c) . Med ial and latera l rota tion of the lower e xtremi ty will bias the test towards the lateral (Fig. 8.70d) or medial (Fig 8.70e) hamstring. Both the quantity and the end-feel of motion are noted. The test is repea ted on and compared to the opposite extremity. What is normal length for a func tional hamstring? According to Kendall et al (1993), when hamstring length is measured with the lumbar spine in a neutral position and no motion of the pelvic gir­ dle is allowed, the femur should flex at the hip joint to 70° . Clinically, one needs to consider the patient's functional demands. This quantity of motion would be insufficient for a dancer or for a person who works in repe titive trunk flexion or who drives a car with a low sea t. If the patient presents with

F i g u re 8 . 70a, b

Test fo r exte n s i b i l i t y of t h e l o n g i tu d i n a l s l i n g

a n d t h e h a m s t r i n g s. ( a ) I n s ta n d i n g

and

(b) in sitting.

lumbopelvic-hip pain and the p a in provocation tests have revealed tha t the pelvic ligaments are a poten­ tial source of this pain, then the hamstrings need to be extensible enough to allow full forward bending while maintaining sacral nutation betvveen the innominates. If the biceps femoris is unable to lengthen suffiCiently, it will p roduce a force through the sacrotuberous ligament which resists the sacral nutation. As the innomina tes con tinue to flex on the femoral heads a rela tive counternuta tion of the sacrum occurs. The SIJ is now vulnerable since it is in a less stable position.

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F i g u re B. 70c, d,

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( d ) The test can b e biased tow a rd s t h e b i ce p s fe m o ris by m e d i a l ly rota t i n g ( R e p rod u c e d w i t h p e rm i s s i o n fro m © D i a n e G. Le e P h y s i ot h e ra p ist Corp.)

h a m st ri n g s. (c) The h a mstri n g e x t e n s i b i l i ty t h e fem u r/t i b i a and (e) towards the m e d i a l

is tested by exte n d i n g t h e k n e e w i t h t h e fe m u r flexed to 90°. h a mstri n g g ro u p by l a t e ra l l y rota t i n g the

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F i g u re 8 . 7 1

( a ) Test fo r exte n s i b i l i ty

of i l i a c u s. The a rrow i n d i cates t h e d i re c t i o n of m o t i o n of t h e fe m u r i n d u c e d by t h e t h e ra p ist. ( b ) Test fo r ext e n s i b i l ity of rect u s fe m o ris.

T h e a rrow i n d ica tes t h e d i re c t i o n of motion of the t i b i a i n d u ce d by the t h e ra p i st . ( c) Test fo r e x t e n s i b i l i ty of t h e a n te r i o r b a n d o f t h e tensor fa s c i a l a t a e . T h e a rrow i n d i c a t e s t h e d i r e c t i o n of m o t i o n of t h e t i b i a i n d u c e d b y t h e t h e ra p i st. ( R e p r od u c e d w i t h p e r m i ss i o n fro m © D i a n e G . L e e Phys i o t h e ra p i st Corp. )

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D i a g n o s i n g t h e l u m b o pe l v i c - h i p d ysfu n cti o n

I l i acus, rectus fe moris, tensor fascia l atae, adductors the patient supine, lying at the end of the table, one femur is flexed and supported against the ther­ apist's lateral thorax. The anterior aspect of the iliac crest and the ASIS of the limb being tested are pal­ pated. With the other hand, the therapist guides the femur in to extension, avoiding full knee flexion to test the length of the iliacus muscle (Fig. 8.71a) and then with the knee flexed to test the length of the rec­ tus femoris muscle (Fig. 8 .71b) . Both the quantity of femoral extension and knee flexion as well as the end-feel ofmotion are noted . The test is repea ted on, and compared to, the opposite extremity. l\n inextensible iliacus muscle will restrict ex ten­ sion of the femur regardless of the p osition of the knee whereas an inextensible rectus femoris muscle w ill only restrict extension of the femur if the knee is flexed. According to Kendall et al ( 1 993), in this pos­ ition the thigh should reach the table and the knee should flex to 80° . If the anterior band of the tensor Wi th

F i g u re 8 . 7 2

fascia la tae muscle is tight, full femoral extension will only occur if the hip is allowed to abduct. In addition, knee flexion with femoral extension results in la teral tibial rotation when the muscle is tight. If the tibial rotation is passively blocked d uring the test (Fi g . 8 . 71c), knee flexion will be restricted. The length of the add uctors is tested with femoral abduction. The short adductors are tested with the knee flexed (Fig . 8 . 72), the long adductors with the knee extended . Both the quantity and the end-feel of motion are note d . The test is repea ted on, and compared to, the opposite extremi ty. Pi rifo r m i s/deep exte r n a l rotato rs of the h i p The p atient is supine, the lower extremi ty comfortably flexed at the hip a nd knee. The latera l aspect of the iliac crest and the ASIS are palpa ted w i th the cranial hand, while the caudal hand flexes the femur to 90° of flexion . From this point, the femur is guided into adduction and in ternal rotation with the ca udal hand while the cranial hand mon itors the subse­ q uent medial rota tion of the innomina te (Fig. 8 . 73 ) . The extensibility of the piriformis muscle h a s been

Test fo r exte n s i b i l i ty of t h e s h o rt a d d u c t o rs of

the t h i g h . The a r r o w i n d i cates t h e d i re c t i o n of m o t i o n of t h e

F i g u re 8 . 7 3

fe m u r i n d u ced b y t h e t h e ra p i s t . ( R e p r o d u c e d w i t h p e r m i s s i o n

( R e p ro d u ce d w i t h p e r m i s s i o n fro m © D i a n e G. Lee

fro m © D i a n e G . L e e P h ys i o t h e ra p i st C o r p . )

Te s t fo r exte n s i b i l i ty o f the p i r i fo r m i s m u sc l e .

P h ys i o t h e ra p i s t Co r p . )

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T H E P E LV I C G I R D L E

reached when the inn o mina te is felt to rotate medi­ ally. Both the q uantity and the end-feel of this c o m­ bined motion ( fl e xion adduction, and internal rotation) are no ted . The tes t is repea ted on, and compared to, the o p posite extremity. Piriformis, together with the d ee p external rotators of the h i p (obturator in ternus, ex ternus, and qu ad ratus fe m or i s ), can produce an anterior displacement of the femoral head ( F i g 8.41) s uc h tha t adduction from the posi tion of 90° of femoral flexion causes marked impin ge men t pain in the gro in In addition, internal ro ta tion from this posit i o n can be redu ce d to 0°. The ex ternal rota tors are then s p ecifi c al l y palpated for tender t ri g ger p oin ts . When the ischio­ coccygeus is h y pertoni c and supersensitive, the range of mo tion of the femur is not a ffec ted ; how­ ever, a trigger point can be pa l pa te d jus t inferior to the s uperior a ttachment of the inferior arcua te band of the sacrotuberous ligament (Fig. 10.43a ) . Hyper tonicity o f the obturator intemus (toge ther w i th piriformis) has a marked impact on the femoral head position and conse qu en tl y the range of femoral mo tion . A tender t r i g g er poin t is o ften ,

.

.

found medial to the inferior attachment of the infe­ rior a rcuate band o f the sacrotuberous ligamen t (Fig. 10.45) . Pa i n p rovoca t i o n tests : co n t r a ct i l e l e s i o n s

The presence and the location o f p a in evoked d ur ing resistance testing a re correlated with the muscle's strength, thus enabling the the r a p i s t to reach a d iag­ n osi s of muscle "sprain" and / or rup ture. Grades 1 and 2 muscle spra ins are painfu l l y strong when resisted iso m e tric a lly, as opposed to gr a d e 3 spra ins (i.e., complete ruptures), which are relatively pain­ free and weak when resisted isome tr i c a l l y. Of c ou rse, there exists an entire spectrum of dysfunction between the two ex tremes. It must be reme m be re d that con trac tions of muscles induce comp ression forces across join t s and also inc re as e tension in the v a riou s ligaments to which th e y attach . Therefore, a pain response may not be indicative of a muscle strain at all, but ra ther the pain may be coming from a joint which reacts to c ompress i on or from a li g a­ ment which is painful to stretch.

Rea l -ti m e u l tra so u n d a n a lys i s of l oca l syste m fu n cti o n J a c k i e W h i tta ke r

UltrasOLmd imagin g has been established as a safe, cost-effec tive and accessible method for visualizing a nd measuring the deep muscles of the trunk (Bernstein et al 1991, Hides e t al 1995a, Blaney et al 1 999, Bunce e t a1 2002, Hodges et aI 2003a). The local system is c omp r is e d of muscles that lie d e ep inside the body; as such their contraction cannot be viewed d i re c tly from the surface . The value o f ultrasound i ma ging is that it allows for d y n a mi c stu dy (real­ time i mages) of these deep muscle groups as th e y co n tr a c t (Hi d es et al 1995b). The co mplemen ta ry use of u l trasound i m agin g can enhance the clinical

o f these muscles and has been a dvo c a te d by various a u thors (Hides et al 1992, McKenzie et al 1994, Richa rdson et a1 1999, Dietz e t a l 2001) . RTUS h a s been used for assessment of four of the loc al system muscles ( McK e nzi e et al 1994, Hid e s et a1 1995b, Richardson et a1 1999, Dietz et a1 2001). This section will outline the assessment p roced u re s for three: transversus abdominis, the deep segmen tal fibers of multifidus, and the pelvic floor. A l l applica ­ tions use a diagnostic ultrasound imaging unit set in B-mod e (brilliance/ brightness) and a 5 MHz curved (conv e x ) array transd ucer (Fig. S . 74a, b). analysiS

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D i a g n os i n g t h e l u m bo p e l v i c- h i p d ysfu n ct i o n

displayed on a digital screen . The

density of the tis­

sue and the angle at which the sound encounters

it determine the a mplitude of reflection and conse­ quently the brightness of t he d i sp layed image . A medium that lacks density, s uch as fluid (bl ood, urine), creates minimal reflection and a ppears black on the screen (see Fig. 8 . 83a) . Denser medium s su c h as internal organs, perioste um, muscle, and fascia generate greater reflection and appear a s varying shades of gray to white (see Fig . 8 . 76a) . E x tremely dense mediums such as bones do n o t perm i t wave p enetr a tio n, and reflect 100% of the s ound waves at their interface. Consequently they appear as a very bright white outline wi t h a b l a c k shadow behind (see Fig . 8 . 8 0a ) . Despite th e d ensity o f the medi um, the reflection crea ted is la rgely d e termined

by the a ngle at which

the sound waves encounter the tissue interfa c e . The an gle o f the transd ucer, as well a s knowledge of the anatomy of the structure being imaged, is c ri t ic a l for su ccessful image genera tion . Placing the t r a n sd u cer perpendicu l a r to the target tissue wil l optimize the reflection and enhance the quality of the image; placing the transducer p a ra l lel to the target tissue wil l minimize the reflection and reduce the quality o f the image. Ima g e i nterp re ta tion is unique for each m uscle and will be d is c ussed individua lly. Further discus­ sion on image interpretation can be fo u nd

in

Chapter 1 0 . The collect ive objective is to determine if the p ati e nt can produce, and maintain, an i so­ l a ted, isom etric , low-level con tra c tio n which tenses its associa ted fascia . This suggests tha t the speci fi c motor control p a thway to the targe t muscle i s hea l thy. Subsequen tly, RTDS can be used to a ssess co-contraction wi thin the loca l sys tem and c oo rd i ­ n a ti on with respi rat i o n It is importan t to unders tand tha t the amount of change seen in a muscle's arc h i tecture ( thickn e ss and length) d u ring a contraction do es n o t represent the in tensi ty or a m o u n t of actual m uscle activi ty. Hodges e t a l (2003a) note tha t, d u r in g an isometric contraction of transversus abdom inis and internal ob lique, the inc rea se in thic k n ess and dec rease in length seen via RTUS has a non-linear rela tionship to actua l m u scle activity measured by indwel l ing e lect rom yog raphy. This study de termined tha t ultra sound is sensi tive for low -level contractions (less tha n 20-30% m a x imal voluntary contract i o n) .

(b) Fi g u re 8.74

(al D i a g nostic u l traso u n d i m a g i n g u n it (Fa l co m od e l , Esaote P i e - M e d i ca l ) ; (b) 5 cm c u rved a rray u l traso u n d tra n s d u c e r.

The use of RTU S for the assessment of t he mus­ c u loskelet a l sys tem requires two steps: i mage gen­ eration and image i n terp re t a t ion ( C h . 10) .

As with

therapeutic uJ trasound, sound w a v es a re generated

within the tran sd ucer and the n enter the bo dy t hrough a gela tino us medi um . As the waves p rop a ­ gate they encounter a n d reflec t off v a ri o us tissues. This echo is captured by the transd ucer and then

of transversus abdominis and internal

oblique. The

significance of these findings i s tha t ultrasound imaging canno t be used to discrimina te between

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T H E P E LV I C G I R D L E

F i g u r e 8 . 7 5 U l traso u n d t ra n s d u c e r p l a c e m e n t fo r i m a g i n g t h e a n te ro l a te r a l a b d o m i n a l w a l l .

moderate and s t rong con trac tions . Compara tively, they found no relationship between muscle thick­ ness on ultrasound and EMC activity for the exter­ nal oblique.

sc EO 10 TA

Tran sve rsu s abd ominis Goal The primary goal is to de termine if transver­ sus abdominis can be activated in isolation from the superficial abd ominal muscul a ture (internal oblique, external oblique, and rectus abdominis) and ma intained as an isometric, low-level contrac­ tion w hich results in fascia l tensioning and co-contraction of other local system muscles (Richardson et aI 1999) . Pati e n t positi o n To standardize the technique and to facilitate access to the abdomen, the supine, crook lying posi tion is used . The abdomen should be exposed from the xiphoid to below the umbilicus (preferably to the symphysis p ubis ) . Realize that this posi tion is not always the op tima l position for training transversus abdominis (see Ch. 10) . U l trasound tra n s d u cer p l acement Place the ultra­ sound transducer transversely j ust superior to the iliac crest, on the anterolatera l aspect of the abdomen (Fig. 8.75). Manipulate the angle of the transducer unti l there is a clear transverse image of aU three abdominal muscles (Fig. 8 . 76a, b) and the anterior midline fascial connection of transversus abd ominis (Fig. 4.26a, b) . Most tra nsducers have a light or marker on one side tha t corres p onds with a marker on the left side of the ultrasound screen to help orient the viewer. In this application, use the marker to orient patient left (i.e., keep the ma rker facing the left side of the pa tien t) . Adjust the depth con trol

(b) F i g u re 8 . 7 6 Lateral a b d o m i n a l wa l l u l traso u n d i m a g i n g . ( a ) Resti n g tra n sverse i m a g e o f t h e a n tero l a te r a l a b d o m i n a l w a l l . ( b ) La b e l e d o u t l i n e of t h e sa m e i m a g e . M , m i d l i n e ; SC, su b c u ta n e o u s tissu e ; EO, e x tern a l o b l i q u e ; 10, i n te r n a l o b l i q u e ; TA, t ra n sv e rsus a b d o m i n is.

to focus on the more superficial s truc tu res such tha t the muscle layers fill approximately 40-50% of the screen. Due to the cunfed shape of the ultrasound transducer, mild pressure may be needed to increase the visual ized a rea; adequate use of ul tra­ sound gel increases the a rea of contac t and mini­ mizes this need. I d e a l res p o n se Note the movement of the muscle layers as the pa tient breathes quietly. Hodges & Candvevia (2000a) note tha t ac tivity of the trans­ versus abd ominis should be minimal du ring quiet brea thing. The y also note that when there is an increase in the chemical drive (increased carbon dioxide levels) or the elastic loa ding through the thorax (due to a thoracic joint fixation, d isease process, or bracing with the global muscles), transversus abdominis is the first abdominal m uscle recruited to assist expira tion . A modulated contrac tion of transversus abdominis (or the oblique abdominals) corresponding with expiration is a likely ind icator of dysfunction .

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After monitoring the abdominal muscula ture during quie t breathing, the pa tient is asked to pro­ duce a transversus abdominis contraction using one of the following verbal commands: "Slowly and gently draw your lower abdomen in." " Slowly and gently squeeze the muscles around your urethra as if to stop your urine flow. " "Slowly and gently draw your vagina (or testicles) up into your body." "Imagine there is a wire connecting your hips bones anteriorly [ASISs] from the left to right side. Think abo u t genera ting a force which would draw these two bones toge ther. " "Imagine there is a wire connecting your hip bones posteriorly [PSISs] from the left to right side . Think abou t generating a force which would draw these two bones together. " An ideal response (Fig. 8.77a) produces a slow and controlled increase in the thickness and decrease in the length of the transversus abdominis with no change in the internal oblique. It is import­ ant tha t the transversus abdominis corsets, or arcs in its lateral aspect, and that the tension in the midline fascia increases as the transversus abdominis slips under the internal oblique (Richardson e t al 1999 ) . Correlate the response noted on imaging with tha t noted on clinical palpation (see section Local system ­ co-con trac tion analysiS, above). If an isola ted con trac tion occurs then the p atient is asked to repeat the contraction and hold it while b rea thing normal ly. Concurrently, the examiner palpa tes for a co-contraction of the lumbosacral m ultifidus (Fig. 8.64) . This w ill establish the m uscle's endurance capacity, as well as its abili ty to coor­ dinate and co-contract with the o ther muscles of the local system. It is critical tha t the patient is observed and tha t t h e transversus abdominis is palpa ted during the RTUS assessment. There is a tendency with this technol ogy to focus on the d igital screen; RTUS is on ly an adjunct to the examina tion process. A b n o rm a l responses Abnormal responses of transversus abdominis can include an absent or insu fficient recruitment with or withou t substitution of the global system (hypoactive) or an inabi lity to con tract in isola tion from the global system. The response is often asymmetrical, therefore both sides of the abdomen should be imaged . It is important to note that ultrasound imaging carul0t be used to make a conclusion regarding external oblique muscle activi ty (Hodges et a l 2003a) as its thickness

Fi g u re 8 . 7 7 (a) U l traso u n d i m a g e s h o w i n g a n i s o l a ted res p o n se of tra n sv e rs u s a b d o m i n i s : note the i s o l ated i n c rease i n g i rt h o f t ra n sversus a b d o m i n i s (arrows) a n d l a t e ra l c o rse t i n g a s i t s l i d es u n d e r i n te r n a l o b l i q u e (curved l i n e) . ( b ) U l tras o u n d i m a g e s h o w i n g a hyperactive res p o n se fro m t h e a n te r o l a t e ra l a b d o m i n a l m u s c l e s : n ote t h e i n crease i n g i rth o f both i ntern a l o b l i q u e ( 1 0 ) a n d tra nsvers u s a bd o m i n i s (TA).

does not change consistently with muscle contrac­ tion. Consequently an increase in activity wi ll require palpa tion or use o f supplementary surface electro­ myography. An absent or insu fficient response resu l ts in inef­ fective force closure of the lumbopelvic region and is seconda ry to a deficiency of the contractile com­ ponent (absent or hypoactive contraction, altered length tension or a trophy), and/or a loss of integrity of the fascial system (diastasis of the linea alba or another breakdown in the "circle of integrity " ) . When the contractile component i s insufficien t, the anterior and / or posterior fascia is not sufficien tl y tensed and little change will be seen between the resting and contracted images.

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T H E P E LV I C G I R D L E

Co-contraction of transversus abdominis with the oblique abdominals or rectus abdominis (global system) (inability to isolate a separate contraction) results in inappropriate force closure of both the pelvis and thorax. The ultrasound image will demonstrate a concurrent phasic increase in thick­ ness and decrease in length of the transversus abdo­ minis and the internal oblique (F i g 8.77b). This simultaneous contrac tion will not produce the slip­ ping of the transversus abdominis and the medial fascia under the internal oblique. In addition, depres­ sion of the ribcage towards the pelvis will be observed (thoracopelvic flexion) (Fig. 8.55b). .

The mid line a bd omi n a l fasc i a The integrity of the fascial extensions of th e local muscles is critical for their function. With respect to the transversus abdominis, it is common to see a loss of the fascial integrity in the linea alba. A quick screen of the integrity of this structure can be made by pla­ cing the ultrasound transducer transversely at vari­ ous sites along the linea alba (Fig. 8.78a) . Initially, the width is assessed and then the structure is observed for any widening with activation of the rectus abdo­ minis (i.e., lifting of the head) (Fig. 8.51). Sapsford et al (1998) state that above the umbilicus the width of the linea alba is betvveen 1 and 2 cm, while below it is narrower. A normal linea alba is seen in the ultra­ sound image in Figure 8.78b. The medial edges of the rectus abdominis muscle come together and resemble "ca t eyes." Abnormalities can be structural (loss of fascial architec ture: see Fig. 8.78c), and this allows a separation greater than 2 cm between the medial edges of the rectus abdominus, or functional (a sep­ aration of the medial edges with activa tion of the rectus abdominis) .

M u l ti fid us The goal is to determine if the deep fibers of the lumbar multifidus can be activa ted in isolation from the superficial fibers and maintained as an iso­ metric, low-level contraction which res ults in fascial tensioning and co-contraction of other local system muscles . Pat i e n t pos i t i o n To standardize the technique and to optimize the patient's feedback from the ul trasound screen, the side lying position with the hips and knees comfortably flexed is used. The lum­ bar spine shoul d be pOSitioned in neutral and, i f there i s large discrepancy between th e hip and waist Goal

F i g u re 8 . 7 8

M i d l i n e rectus a b d o m i n i s u l t ras o u n d i m a g i n g .

( a ) U l t raso u n d t ra n s d u c e r p l a ce m e n t fo r m i d l i n e a ssess m e n t o f t h e re c t u s a b d o m i n i s s h e a t h . ( b ) N o r m a l u l traso u n d i m a g e of t h e m i d l i n e rect u s a bd o m i n i s s h e a t h . R A , rec t u s a b d o m i n i s ;

M , m i d l i n e . ( c ) U l t r a so u n d i m a g e o f a n a b n o r m a l r e c t u s abdom i n i s sheath.

circumference, a folded towel / pillow should be placed at the waist angle. The trunk should be exposed so that the abdomen, lower ribcage, and vertebral column from the m i d thoracic spine to the

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D i a g n os i n g t h e l u m b o p e l v i c- h i p d ysfu n cti o n

Fi g u re 8 . 7 9

U l t raso u n d t r a n sd u c e r p l a c e m e n t fo r l o n g i t u d i n a l

i m a g i n g of t h e l u m b a r m u l t i f i d u s .

sacrum are visible. Realize tha t t hi s posi tion is not

sMF

always the op tima l posi tion for training multifidus (see Ch.

10) . U ltraso u n d tra nsducer p l a cement

dMF

Place the ultra­

sound tra nsducer longi tudinally j us t latera l to the

A P L4

spinous p rocesses (over the articular pillar), angl ed slightly med i a l . Orient the m arker on the trans­ ducer (ind ica ting the left side of the screen) towards the p a tien t's

head

(Fig.

8 .79) . Manip u l a te the

s

A P L5

(b) Fig u re 8 . 8 0

Lo n g i t u d i n a l m u l t i fi d u s u l t raso u n d i m a g i n g .

angle of the transd ucer until a clear longitudinal

( a ) Lo n g i t u d i n a l res t i n g i m a g e o f l u m b a r m u l t i fi d u s j us t l a t e ra l

view of the lumbar multi fidu s, sacrum, and a rticu­

t o t h e s p i n o u s p rocesses a n d over t h e L3 -S 1 a rt i c u l a r c o l u m n .

p rocesses

lar

achieved (Fig.

of

LS-Sl,

L4-LS, and L3-L4 is

8 . 8 0 ) . Once the view is identified,

a d j us t the dep th con trol so tha t the mul tifidus and spinal column make

up

fidus will b e obtained w i th a linear a rray transducer

higher

frequency

(7.S MHz) (Hides e t al

1 995a ) . The delinea tion between the d eep (local) and sup erfi.cial (glob a l ) fibers of the lumbar mul tifidus is not as defined as the layers of the abdominal m uscles. The deep fibers of m u l tifidus a re loca ted near

the a rticula r pillar and the superficial fibers

a re nea r the top o f the screen and the subcu taneous tissue. This delinea tion will become more obvious as the contrac tion is observed.

I d e a l res ponse

The p a tie n t is a sked to produce a

con tra ction of the deep segme n ta l portion of the lumbar multifidus

u s in

g one of the following verba l

commands: " I magine there is

s M F, s u p e rfi c i a l m u l t i fi d u s .

the m aj ority of the i m a g e

d i s played on the s c reen . The best image of multi­ of slightly

( b ) O u t l i n e o f t h e s a m e i m a g e. A P L4 , a rt i c u l a r p ro c e s s L4 ; A P L 5 , a rt i c u l a r p ro c ess L5 ; S, s a c r u m ; d M F, d e e p m u l t i fi d u s ;

Th ink ab out generating a force wh i c h

w o u ld

draw these two b ones toge ther. "

"Imagine there

is a wire c onnec ting your inner

thigh (or p ubic bone) to your low b a c k [ therapist presses d e e p l y o v e r the dysfunc tiona l segment] . Think about genera ting a force

which would

draw these

tw o points toge ther. " " Slowly and gently squeeze the muscles around yo u r urethra a s i f to s top your urine flow. " " Slowly and gently draw your vagina (or testicles) up into your b o d y. " "Imagine there i s a w ire connec ting your hips bones an teriorly [ASISs ] from the left to right side. Think about gene r a ting a

a

wire connecting your

h ip bones

pos teri orly [ PSISs] from the l e ft to r i gh t side.

force which w o uld draw these tw o bones together. "

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T H E P E LV I C G I R D L E

A b n o r m a l resp o n ses Abnormal responses of mul­ tifidus can include an absent or insufficient recruit­ ment with or without substitution of the global system (hypoactive) or an inability to contract in isoi­ ation from the global system . The response can be segmental, multisegmental, or asymmetrical (Hides et aI 1994), hence imaging should be repeated at vari­ ous levels b i la ter a lly. An absent insu fficient response results in inef­ fective force closure of the lumbopelvic region sec­ ondary to a deficiency in the contractile component (absent or hypo a ctiv e contraction, altered length ten­ sion, or atrophy), and / or a loss of integrity of the fas­ c ia l s ystem (loss of li g amentous or fascial integrity) . When the contractile componen t is insufficien t, the thoracodorsal fascia is not sufficiently tensed and little change will be seen between the resting and con tracted images. Co-contra ction of both the deep and superficial fibers of multifidus (as well as the erec tor spinae) (inability to isolate a sep a ra te contraction) results in inappropria te force closure of both the pe lv is and tho­ ra x. The ul trasoLmd image will demonsh'ate a concur­ rent phasic increase in thickness of the entire muscle from the subcutaneous interface to the articular p illa r (Fig. 8 . 8 1 b ) In addition, spina l extension will occur. .

F i g u r e 8.8 1

( a l U l t ra so und i ma g e i n d i c a t ing t h e l o c a t i o n for

an i so l a ted respo n se of t h e dee p fi ber s of l u m b a r m u l t i f i d u s. (b) U l tras o u n d imag e ind i cating t h e l o c a t i o n fo r a hyperactive res p o nse fro m the s u p e rfi c i a l fi ber s of l um b a r m u l t i fi d u s .

An ideal response (Fig . 8 . 8 1 a ) produces a slow thickness of the deeper part of the muscle as the fibers increase in girth. Carefully note where the increase in muscle girth occurred (deep versus su perficial) as both will increase the thick­ ness; however, only a deep contraction is the ideal response. It is critical tha t the patient is observed a nd tha t the mul tifidus is palpated throughout the RTUS assessmen t. There is a tendency with this technology to focus on th e di g ital screen; RTUS is only an adj unc t to the objective examina tion . If a n i s o la ted contraction occurs, then the pa tient is asked to repea t the contraction and hold it while brea th ing normally. Concurrently, the exam iner palpa tes for a co-con traction of the transvers us abdominis (Fig. 8 . 64). This will es tablish the muscle's en d ur a n c e capacity, as well a s its ability to coor­ dina te and co-con tra ct with the other muscles of the loca l system. in c re as e in

The pelvic

fl o o r

G o a l The primary goal is t o de termine i f the pelvic floor muscles can be activated in isolation from the surrounding musculature (glutei, adduc tors, in te rna l ! ex ternal oblique, rectus abdominis) and maintained as an isometric, low-level contraction which results in fascia l tensioning (capable of sup­ porting the blad der) and co-contraction of other local system muscles. Pati e n t position To s tandardize the technique and to facilitate access to the lower abdomen, the pa tient is supine with the legs straigh t and the hips relaxed. The p a tie n t s abdomen should be exposed from the xiphoi d to the symphysis p ubis. U ltraso u n d tra n sd u cer placement Assessment of the pelvic floor muscles can be achieved through either a parasagittal or transverse abdominal view of the pos­ teroinferior aspect of a moderately full bladder. Pa rasa g i tta l a p p l ica t i o n Orient the transducer in a s uperola teral to inferomedial sagittal plane on the abdomen just s uperior to the pubic symphysis, slightly la teral to midline (Fig. 8 . 82a ) . Orient the m a rker on the transducer (ind icating the left side of the screen) towards the pa tient's head . Manipulate

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'

D i a g n o s i n g t h e l u m bo p e l vi c - h i p d ysfu n cti o n

F i gu re 8.82

(a) U l traso u n d t r a n s d u c e r p l a ce m e n t fo r p a r a s a g i tta l a b d o m i n a l i m a g i n g of t h e u ri n a ry b l a d d e r. ( b ) U l t r a s o u n d

t r a n sd u c e r p l a c e m e n t fo r t ra n sverse a b d o m i n a l i m a g i n g o f t h e u r i n a ry b l a d d e r.

us

I n fe r i o r

S u p e ri o r

(b) F i g u re 8 . 8 3

Pa rasag i t t a l a b d o m i n a l u l traso u n d i m a g i n g . (a) R e s t i n g p a ra sa g i t t a l a b d o m i n a l

o u t l i n e of t h e

same i mage.

i m a g e o f t h e u ri n a ry

b l a d d e r. (b) La b e l e d

U B , u r i n a ry b l a d d e r ; N . n e c k o f t h e b l a d d e r.

the a n g l e of the transducer, pointing it inferior and posterior to the symphysis pubis and u n til it p roduces a clear i m a ge of the urina ry bladder and the u rethrovesical neck (Fig. 8 . 83a, b) (Whi t taker 2004) . Tra n sverse a p p l i cati o n Orient the transd ucer transversely across the midline just superior to the pubic symphysis and angle it approximately 60° from the vertical; aim towards the gluteal region (Fig. 8.82b) . Orien t the marker on the transducer towards the pa tient's left side. Manipulate the angle of the transducer u ntil there is a clea r image of the urinary bladder (Fig . 8 . 84a, b) (Whi tta ker 2004). As with a l l abdomina l i maging, gas (ei ther between the transducer and the skin, or within the abdomen) and / o r excessive a dipose tissue can interfere with image genera tion as both sca tter the sound waves and obli terate the echo. Care must be ta ken when genera ting the image ( wi th adequate

use of gel as well as manipula ting the transducer) and i n i ts interpreta tion. I d e a l response Once the appropriate im a g e has been generated, the transducer is held s teady and the pa tient is asked to perform a con traction of the pelvic floor muscles (squeeze the m uscles arOl.md the urethra or lift the vagina l testicles) . The bladder is supported b y the pelvic floor muscles and the endopelvic fascia (leva tor pla te) ( Wi l lia ms 1995, Ashton-Miller e t al 200 1 ) . When the pelvic floor muscles contract, there is a consequential tension­ ing of the endopelvic fa scia as well as a broadening of the l eva to r ani muscle. This res ults in encroach­ ment of the bladder wall which is seen as a slow indenta tion of i ts pos teroinferior aspect a nd is accompanied by cranioventra l motion of the bladder (Christensen et al 1995, Howard et al 2000, Bo et al 200 1 , Prana thi Reddy et al 2001, Whi ttaker 2004) (Fi g . 8 . 85a, b ) .

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T H E P E LV I C G I R D L E

UB

Right

Left

(b) F i g u re 8 . 8 4

Tra n sverse a b d o m i n a l u l traso u n d i m a g i n g . ( a ) Res t i n g t r a n sv e r s e a b d o m i n a l i m a g e o f t h e u r i n a ry b l a d d e r. (bl La b e l ed

o u t l i n e of t h e s a m e i m a g e . U B , u r i n a ry b l a d d e r.

F i g u re 8 . 8 5

( a l U l t ra so u n d i m a g e s h o w i n g a n i s o l a ted r e s p o n s e of t h e p e l v i c fl o o r m u s c l e s fro m a p a ra s a g i t ta l abdo m i n a l vi ew. The

a r row n o tes w h e re t h e b l a d d e r ca n b e s e e n to i n d e n t w i t h a p r o p e r p e l v i c fl o o r con tracti o n . (b) U l traso u n d i m a g e s h o w i n g an i so l a ted c o n t ra c t i o n of the p e l v i c fl o o r m u sc l e s a s seen fro m

a

tra nsverse a b d o m i n a l v i e w. Once a g a i n , the a rrow n otes w h ere the b l a d d e r c a n

b e s e e n t o i n d e nt w i t h a p r o p e r p e l v i c f l o o r c o n trac t i o n .

The indentation of t h e posteroinfe rior

aspect of

A b n o r m a l responses

An abnorm a l response gene r­

the bladder can be seen with b o th the pa ra s a git ta l

ally involves one of two p a tterns

an d t r a ns ver s e

cient recruitment (hypoactive) of the pelvic floor

a pplica tion s; how ever, Christensen et al (1995) state tha t the displacement is best seen in the para s a gi tta l plane. The cranioventral motion can only be v i ew e d using the pa ra s ag i t tal technique. The va lue of the tra nsver s e a b d omi.nal v i ew is that i t allows for e v a l u a tion of both s id e s o f the pelvic floor at once. This is critic a l as clinical exper i ­ ence h a s shown that the resp o n s e is often asymmet­ r i ca l an d, therefore, the para s ag i t tal image should be o b ta ined b i la ter a lly. If an isola ted contraction occurs then the pa tient is asked to repe a t the contraction and hold it while

brea thing

norma lly. Concurren tly, the examine r p a l ­

pa tes for a co-con traction of the transversus abdo­ minis (Fig. 8.64) . This will e s ta bli sh the muscle's endurance capacity, as we ll as its abili ty to coordinate and co-contract wi th the o ther muscles of the local system.

muscles, with or witho u t

an

- absent or insuffi­

exce ss ive

activa tion of the

abdorninal s resultin g in a Valsalva (bearing-down) mane uver. Alterna tely, an isola ted contraction may occur

and

then fa tigue ve ry quickly (lack

of

endurance) . The response is o fte n asymmetrical, there­

fore both sides of the abdomen should be ima ged . An ab s ent or insufficient response res u lts in inef­ fec tive force clos ure of the lurnbope lvic region sec­ ondary to

a

defic iency in the contrac tile component

(a bsent or hypoactive contra c tion, altered length

te n si on, a t ro phy, or impaired nerve s u pp l y ) and / or a loss of inte gr i ty of the fascial s y stem. Several fa c­ tors can lead to s truc tural deficits in the endopelvic fascia: childbir th, repe titive use of a Va l s a lv a maneu­ ver for load trans fer, and surgical p roce d u re s. For an y of these clinical s cena r i o s , the u l tr as ound im ag e will be sim ilar to the resting view.

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D i a g n os i n g the l u m bo p e l v i c- h i p d ysfu n ct i o n

d e gree of ca udodors a l mo t ion of the neck of the bla d ­ der occurs with a cou gh or Va lsalva in b o th norma l a nd pa t i ent popula tions . Cons e quen tly, al thou gh the bladder will rem a in relatively s t a tiona ry, a sma l l amount of c a u dodorsal motion should be considered norma l .

Abnormal response Bo th the litera ture (O'Sullivan 2002) and clinical experience suggest tha t if the

et al

local system fails to a c t in a coo rdina te d fashion, the most common comp e ns a t ory motor con t r ol pattern will be a Valsalva or bracin g s trategy. This causes sig ­ nificant ca udodorsal motion of the bladder (Fig. 8 . 8 6) .

Vari ous loa d ing s t ra te g i e s

can be used in place of

the ASLR: bent knee l e g l ift, bent knee fa l l o ut, arm

eleva tion. In all situa tions, signi ficant caudodors a l motion o f the bladder i s consid ered a b norma l . An Lmob trusive method for im ag ing l umbopelv i c muscle function

in ind iv i d u a ls with l o w b a c k and

pe lv i c pain has been p resente d and s upp o r te d by the exis ting evidence . S tudies are still re quired in b o th

normal

and

mine re li a bili ty,

Fi g u r e 8 . 8 6

(a) Pa rasa g i t t a l u l traso u n d i m a g e of a Va lsa lva

s t ra te g y and i ts i n fl u e n c e o n the b l a d d e r : a rrows n o te m o t i o n s e e n i n rea l t i m e . ( b ) Tra nsa b d o m i n a l u l traso u n d i m a g e o f a seen

to

d e te r­

speci fic i ty for lum­

bopel vic myofasci al impairments. Ul tima t e ly, the use of rea l - time u l traso Lmd ima gin g in conj u nc tion and b i omec han i ca l

w i th a vi gi lan t his to r y, physical,

Va l s a l v a stra tegy a n d its i n fl u e n c e on t h e b l a d d e r : a rrows

note m o t i o n

p a ti e n t pop ula tions

s ens i tiv i ty, and

examination w i ll r e sul t in a more comp re hen s iv e

in rea l t i m e .

a ssessmen t of lumbopelvic func tion in indiv i d u als w i th low back and pe l v ic

Whe n the p a tie nt uses a Va l sa l v a ma neuver (Fig . 8 .57), a c t i v a t i on of the a b d o min a l musc u l a tu re results in a c a u d o d orsal m o tion of the bl a dd e r (Fi g . 8 . 86) . T his may or m a y not be acco m panied b y a contrac tion of the pelvic floor mu sc l es ( ide n tifi ed by enc ro a chmen t of the bla dd e r ) .

pain.

N E U R O L O G I CA L C O N D U CT I O N A N D M O B I L I TY T E ST S These tests examine the conduc tivity o f the motor and sensory nerv e s relative to the lumbosacra l pl exus as well as the mobility of the d ma throu gh the inter­ fora mina. The reader is refe rred to Bu tler

B l a d d e r sta b i l i ty d u ri n g l o a d i n g

ve r teb ra l

Goal The pr i mar y g o a l i s to d e termine i f the loc a l sys tem muscles tha t form t h e muscular bound­

(2000) for a

a r i e s of the ab d om e n ( the transv ersus abdominis,

m o re indep th review o f this topi c .

Motor co n d u ct i o n tests

the diaphra gm , a nd the p e l v i c floor) can con trol the pos i t i o n of the bla d d e r d u rin g trunk loading . The

The L2 to S2 mo tor nerve roots are evalua ted clin­

position

ical l y via the p e rip h e r a l m uscles they innerv a te.

of the pa tien t,

t rans d uce r

p lace m ent, and

the p rocess of im a g e gene r a ti on are the same as d e sc ribe d fo r the parasa gi ttal p e l v ic floor a p p l ica ­

Although th e re are no tr u e peripheral

tion abov e . Both sides of the bladder should be

one nerve root), specific muscles known as key

assessed .

are

myo tomes in

the lower qua d rant (one muscle solely innervated by

muscles

prim a rily innerva ted by o ne motor nerve and

Once the a p p ropriate image has

their func tion is a reflection of the neurological innerv­

been genera ted (Fig . 8 . 83a) the p a tient i s asked to p er form an ASLR (see Ch. 8). Id e a l l y, the local system

a tion. Initia lly, a maxima l contraction is elicited

Ideal response

sho u ld co-contra c t and the bladder remain sta tion­ a ry. How ard e t a l

(2000)

d e monstra ted tha t some

from the key muscle and the quantity and qua l i ty of strength are comp a re d to the op p osi te side. If th e muscle tests are s trong, six s ub ma x irn a l

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1 29

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T H E P E LV I C G I R D L E

are elicited to detect accelera ted fatigability - a com­ mon find ing of neurological impedance. The m o tor nerves and the key m u scles which are eva l u a ted include:

L2

psoas major, a d d u c tors

L3

a d d u c tors, quadriceps

L4 L5 51 52

quadriceps, tib ialis anterior

Femoral nerve

the stra igh t leg

Wi th the pa tien t prone, t he lower

leg i s passively flexed a t t h e kn e e j oin t a n d the

Ll-52 sensory nerve roots are ev a l u a ted derma tomes

L2-52 nerve roots is eva luate d b y two tes ts : the femoral nerve s tretch test a nd

e x tremity is p a l p a ted above the ank l e . The lowe r

S e n s o ry co n d u c t i o n tests

the

plantar response test.

raise test.

hams trings, glu teus m a x imus

via

The integri ty of the spinal cord is eva luated by the

The mobility of the d u r a m a ter surrounding the

hamstrings, gas trocnemius

clinica lly

gas trocnemius (i . e . , ank le jerk) .

D u ra l/ n e u r a l m ob i l i ty tests

ex tensor hallucis, extensor d igjtorum, peronei

The

L5, 51, 52

they

innerv a te .

Derma tome m a p s can be confusing s ince varia tions

quantity and end -feel of motion a re noted. When the mobili ty of the dura ma ter of the L2, L3, and / or L4 nerve roots is res tricted, hip e x tension and knee

i n derma tome distrib u tion exist from individual

flexion are restricted by pain fel t pos teriorl y in the

to individual. Furthermore, impedance of sensory

lumbar spine.

con d u c tivi ty may be reflected in a range of dyses­ thesia from slight h yperesthesia to complete anes­

Sciatic nerve

With the p a ti e n t lying s upine, the

lower e x tremi ty is palpated above the ankle. While

thes i a . Deta i led exa mina tion of the d i s tal e x tent of

m a intaining the knee in ex ten sion and the fem u r

the derma tome is useful in detecting early neuro­

i n slight a d d uction / med i a l rota tion, the fem ur is

logical interference. One of the firs t signs of sensory

flexed a t the hip joint. The qua n t i ty and end-feel of

dysfunction is hyperesthesia w i thin a specific d er­

mo tion a re noted . When the mobili ty of the d ura

m a tome. This sign tends to occ u r lon g before sensa­

m a ter of the

tion becomes reduced or obli te r a ted comple tely and

restricted, hip flex ion i s limi ted to

its exis tence is often a s urprise to the pa tient .

p a in a n d m uscle spasm.

L4, L5, 5 1 , and / or 52 nerve roots is 30-60" by both

Although indiv i d u a l v a riabili ty is recognized, the following descrip tion of derma tom e d istribu­

VAS C U LA R T E STS

tion is one commonly seen :

L1 L2

u p p e r posterior buttock, a nterior groin m i d d l e posterior b u ttock, a n terior thigh to the knee

L3

lower posterior b u t tock, a nterior thigh to

the medial knee

and occasionally d istal to

the medial malleolus

L4

la teral thigh, m e d i a l leg, dorsum of the foo t to the gre a t toe

LS

l a te r a l leg, dorsum of the foot to toes

2, 3,

4, sole of the foo t (excluding the heel) to toes 1, 2, 3 51

posterior thigh, leg, l a teral border of the foot to dorsum and sole, to toes

52 53, 54

4 and 5

posterior thi gh, leg to heel perineal region.

These tests screen the ci rcula tory s ta tus of the lower ex tremi ty. C a refu l observation of the skin color, tex­ ture, response to dependency and eleva tion, and the length of time for s uperfic i a l wounds to heal sho u l d be noted . The fem oral, p o p l i teal, and dor­ salis pediS arteries are p a lp a ted a nd ausc u l ta ted in the fe mora l triangle, pop l i te a l fossa , and dorsum of the foo t resp ectively. If a d eep vein throm­ bophlebitis is suspected, the response to p assive dorsiflexion of the a nkle sho u l d be noted (Homans sign) and the region carefu l l y p a l p a ted for hea t and / or tenderness .

A DJ U N CT I V E T E STS X-rays make good policemen b u t p o o r cou nselors, in that while the straight radiography ma y exclude ser­

R efl ex tests

ious bone disease and sig n ifica n t mechan ical defect, it

The spinal reflexes are evalu a ted via the myotac tic

does not ofte n p rovide m uch gu ida nce abo u t how to

response to s tretch of the key m uscle innerva ted by

treat th e patien t.

the roo t

L3, L4

in question. They include the fol lowing: q u a d riceps ( i . e . , knee j erk)

(Grieve 1981)

The prim ary reason for ob ta in ing the resu lts of adj unc tive tests i s to rule out serio us pa thology and to

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D i a g n o s i n g the l u m bo p e l v i c- h i p d ysfu n ct i o n

F i g u re 8 . 8 7

A c o m p u t e d t o m o g ra p h y s c a n ( t ra n sverse p l a n e)

of a p a t i e n t w i t h R e i te r' s d i se a s e . Th i s t e c h n i q u e c l e a r l y revea l s

Fig u re 8 . 8 8

A c o m p u t e d to m o g ra p h y sca n (verti c a l p l a n e ) of a

p a t i e n t w i t h R e i t e r' s d i s e a s e i l l u s t ra t i n g n a rrow i n g , e ros i o n , a n d

t h e foca l s c l e ros i s (a rro w s) , n a rrow i n g , a n d eros i o n o f t h e

fo c a l sc l e r o s i s (a rrows) o f t h e a rt i c u l a r s u rfa c e s of t h e s a c ro i l i a c

s a c ro i l i a c j o i n t asso c i a t e d w i t h t h i s d i seas e. T h e d e p th o f t h e

j o i nts.

j o i n t is clearly v i s u a l ized.

d i scover the presence of ana tomical anomalies prior to trea tment. The

adj unc tive

tests

avail able

incl ude

the

fol lowing: 1. radiography ( X -rays) 2 . d iskography 3. myelog raphy 4 . radic ulogra phy

5. ep i d u rography 6 . tomography

7. transverse a x i a l tomogra phy 8 . comp u ted transverse axial tomog raphy 9 . radiographic s tereoplotting 1 0 . interosse o u s spina l venogra phy

F i g u re 8.89

A c o m p u te d to m o g ra p hy scan o f a p a t i e n t w i t h

11. cinera diog raphy and fluoroscopy

a n ky l o s i n g s p o n d y l i t i s . N o te t h e tota l a n ky l os i s of t h e r i g h t

12. thermogra p h y

s a c r o i l i a c j o i n t ( o p e n a r rows) .

1 3 . nerve roo t infil tration 14. electrodi agnosi s

j oint space. Thus the d iagnosis of infl amma tory

1 5 . intervertebral d i s k manome try

s acroil iitis, which i s based on the identification of

1 6 . cystome try

join t n arrowing, sclerosis, ankylos is, or erosion, w a s

17. radioactive isotope s tu d ies 18. ul trason ogra phy 19. nuclear magnetic resonance . With respect to the

facil i ta ted . Fig ures portions of the

SIt Lawson et al (1 982) reported

on the benefits of compu ted a x ial

8 .87-8 . 9 1 ill u s tra te t h e v i s u a l iza­

tion of both the synovial and the l igamento u s

SIT th a t is possible w i th this a dj u nc­

tive tes t .

tomography

CT sca nning techn iques can reve a l congenita l

(CT scanning techni ques) as opposed to conven­

and / or acqu i red a n a tomical changes in the lumbar

tiona l radiography in the d e tection of mild erosions

spine (Fig .

and narrowing of the joint. Bec ause of the three­

spinal canal as well as the l a teral recess a re clearly

dimensional spatial orien ta tion of the

SIt CT scan­

ning was s u p erior in ob ta i ning vis u a liza tion of the

8 . 78 ) . The dimensions of the centra l

visualized and often confirm or deny the clinica l find ings of physical trespass.

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131

1 32

T H E P E LV I C G I R D L E

F i g u re 8.90

A c o m p uted to m o g ra p h y sca n of a pa t i e n t w i t h

a n ky l o s i n g s p o n dy l i ti s . N o te t h e b i l a tera l b o n y a n ky l osis of t h e s a c ro i l i a c j o i n ts. ( F i g u res 8.87-8.90 a re re prod uced w i t h permission fro m La w s o n e t a l ( 1 982) and t h e p u b l i s h e rs Raven Press. )

Fig u re 8 . 9 1

A c o m puted t o m o g r a p h y sca n of t h e LS- S 1

s e g m e n t i l l u s t ra t i n g c e n t r a l ste n o s i s seco n d a ry t o e n l a rg e m e n t o f t h e zyg a po p hysea l j o i n ts b i l a te ra l l y. ( R e p r o d u c e d w i t h p e r m i ss i o n fro m Ki rka l d y- W i l l i s

The lumbosacral junc tion is often the site of con­ geni tal anomalies which may or may n ot be signifi­ cant to the clinical picture. Their presence, however, should be ascertained . The anomalies which are seen at this level include: 1. asymmetry of the posterior zygapophyseal joints 2 . congenital absence of a pedicle 3 . accessory l a minae 4. osseous bridging of the transverse processes 5 . dysplasia or absence of the spinou s process of the L5 or S l verteb rae (spina bifida ) 6. dysplasia of the pars interarticularis 7. spina magna of the L5 vertebra 8 . trapezoidal LS vertebra, l umbarized Sl vertebra - p a rti a l or complete

1 983 )

9. sacralized LS ve r teb ra - pa rtial or complete anomalous adventitious joint between the transverse process of the LS vertebra and the ala of the sacrum 11. asymmetric height of the a la of t h e sacrum with one side hi gher tha n the o ther, creating a sacra I tilt 1 2 . calcified iliolumbar l i g a m e n t (Grieve 1981 ) . 10.

The findings noted o n adj unctive testing o f the lumbopelvic-hip complex m u st b e correla ted w i th the findings noted on clinical examination if their significance is to be understood. Rarely can trea tment be directed by the results of these tests al one .

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Chapter

9

Defining the impairment

CLASSIFICATION: MEDICAL MODEL

CHAPTER CONTENTS medical model 133 functional model 134 Excessive articular com press ion 135 Excessive articular compression with an underlying in st ab i l it y 144 Insufficient articular compression 146 Insuffic i ent urethral compression: stress urinary

Classification:

Classification: integrated

incontinence

157

In the medical model, disorders of the low back have been classified (MacNab 1977) as visceral, vas­ cular, neurogenic, psychogenic, sociogenic, and/ or spondylogenic in origin. Disorders of the pelvic vis­ cera can refer pain to the lumbar region and are eas­ ily confused with benign mechanical dysfunction. Insufficiency of the peripheral vascular system can secondarily give rise to backache and/ or symptoms resembling sciatica. Neurogenic disorders include benign and/ or malignant tumors of the central or peripheral nervous system. A central lesion at the lumbosacral junction can mimic a cauda equina compression lesion. Pure psychogenic or sociogenic backache is not often seen, although emotional states do playa significant role in the experience of pain (Holstege et a11996, Butler & Moseley 2003, Hodges & Moseley 2 003). Spondylogenic disorders have been further classified (MacNab 1977) as: 1. Pathologic soft tissue and bony a. Scheuermann's disease - vertebral os teochondritis b. Infective - pyogenic vertebral osteomyelitis c. Systemic inflammatory - rheumatoid arthritis, ankylosing spondylitis d. Metabolic - osteoporosis, Paget's disease, tuberculosis, Calve's disease, diffuse idiopathic skeletal hyperostOSis (DISH) 2. Traumatic soft tissue and bony a. Fractures b. Contusions c. Spondylolisthesis/ spondylolysis

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THE PELVIC GIRDLE

Table 9.1

Conditions affecting the sacroiliac joint

(Bellamy et al

1983)

Table 9.2

Classification of hip disorders according to

age group (Cyriax 1954)

Inflammatory disorders

Newborn

Ankylosing spondylitis Reiter's syndrome Inflammatory bowel disease Psoriatic spondylitis Rheumatoid arthritis Juvenile rheumatoid arthritis Pustulotic arthroosteitis Familial Mediterranean fever Beh�et's synd rome Relapsing polychondritis Whipple's disease

Congenital dislocation of the h ip Ages 4-12 years Perthes

disease

Tuberculosis

Transitory arthritis Ages 12-17 years

Slipped femoral epiphysis Osteochondritis dissecans Yaung adults Muscle

lesion s

Bu rsit is

Joint infection

Pyog e n i c

Adults

Brucellosis

Arthritis

Osteoarthritis Rheumatoid arthritis Ankylosing spondylitis

Tuberculosis Metabolic disorders

Gout Calcium pyrosphosphate deposition disease Hyperparathyroid ism

Bursitis

Loose bod i es

Miscellaneous

Osteitis condensans ilii Paget's disease Acroosteolysis in polyv i n yl chloride workers Alkaptonuria Gaucher'S disease Tuberous sclerosis

3.

as lifting, being the two most common forms of injury.

Attitudes or pos tu res are also of importance in causing or predisposing to jo i n t weakl1ess or displacemel1t.

(Goldthwait & Osgood 1905)

Aging, adaptation, degeneration a. Arthrosis of the posterior zygapophyseal joints b. Spondylosis of the intervertebral disk.

At the turn of this century, practitioners believed tha t the sacroiliac joint (SI.o was the major source of scia tica, admitting that, as well as sciatica, "lumbago [and] backache ... were frequently caused by an abnormal amount of motion in the pelvic joints, espe­ ci a lly the sacroiliac synchondrosis" (Meisenbach 1911). Aside from trauma, the influence of poor pos­ ture as well as lumbopelvic adap tation to extrinsic fac tors were recognized as being integral to the eti­ ology of decompensa tion. The etiologtj of the pel vic g irdle dysfunction is not

always clear, but there are many features of definite importance. At times, the lesion apparently represents s i mp l y

an excess of

a

n orm al

physiological process.

At otiler times, trauma is a definitefactor, "sitting down hard," or the "giving way" under severe strains, such

The causes of mechanical pelvic girdle dysfunc­ tion remain the same today. Aside from mechanical impairments, there are a number of sy ste mi c dis­ eases which can affect the pelvic girdle. The major­ ity of these are listed in Table 9.1 and the reader is referred t o Bellamy et al (1983) for a further descrip­ tion of each. In the medical model, hip disorders are commonly classified according to the age group in which they occur (Table 9.2) or, alternately, disorders have been classified as articular or non-articular (Table 9.3).

ClASSIFICATION: INTEGRATED FUNCTIONAL MODEL

The medical models of classification rarely enhance the ability of the therapist to trea t the patient. Functionally, mobility of the lumbopelvic-hip region can become either restricted or poorly controll ed due to either excessive or insufficient articular com­ pression, regardless of the underlying etiology. In keeping with the integra ted model of function

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Defining the impairment

Table 9.3

Articular versus non-articular disorders of

the hip (Adams

1973)

Articular disorders of the hip

Congenital deformities Con gen ita l dislocation of the

hip

Arthritis Transient arthritis of children Pyogenic arthritis Rheumatoid arthritis

Tuberculous arthritis Osteoarthritis Ankylosing spondylitis Osteochondritis Perthes disease

(pseudocoxalgia)

Mechanical disorders

THE LUMBAR SPINE

Slipped upper femoral epiphysis Osteitis deformans

(Paget's disease )

Non-articular disorders in the region of the hip

Deformities Coxa vara Infections Tuberculosis of the trochanteric bursa

(Fig. 5.1), the causes for impairment can be due to dysfunction of: • •

•

form closure (structure) force closure (forces produced by myofascial action/ inaction) motor control (specific timing of muscle action/inaction during loading).

In addition, force closure and motor control can be affected by the emotional state of the patient. This chapter will consider the clinical findings from the subjective and objective examination for specific lumbar, pelvic girdle, and hip impairments accord­ ing to this model. The chapter will conclude with a discussion of stress urinary incontinence; or ineffec­ tive force closure of the urethra.

EXCESSIVE ARTICULAR COMPRESSION

Excessive articular compression can result from articular pathology which: •

•

•

In addition, the jo ints can be compressed by overac­ tivation of muscles which become hypertonic (Janda 1978, Bergmark 1989, Richardson et a11999) and are often supersensitive (Gunn 1996). The fuse d joints cannot be mobilized whereas the fibrosed j Oin ts require specific mobilization. Manual therapy techniques (see Ch. 10) help to restore the articular mobility and osseous aligrunent; motor con­ trol retraining is necessary to retain the benefit gained. When the excessive compression is secondary to muscle hypertonicity and supersensitivity, appropri­ ate motor control training which emphasizes optimal stabilization strategies (see Ch. 10) will be required.

ultimately fuses the joint (SIJ - ankylosing spondylitis or DISH) ca u se s fibrosis of the articular capsule (secondary to joint sp rain) or fixates the joint.

The impact of excessive compression on the struc­ tures of the low back has been d escribed and illus­ trated by Kirkaldy-WilLis et al (1978), Kirkaldy-Willis (1983) and Taylor & Twomey (1986, 1992) (Table 9.4). The cause for the joint restriction may be either articular, myofascial, or both and is often the result of an excessive rotation or compression force which exceeded the physiological range of the joint either suddenly (traumatic event) (Farfan 1973, Kirkaldy­ Willis et al 1978, Gracovetsky et al 1981, Kirkaldy­ Willis 1983, Gracovetsky & Farfan 1986, Twomey et al 1989, Taylor et al 1990, Bogduk 1997) or over time (impact of altered posture) (O S u ll i van et aI2001). The specific anatomical changes include: '

1. synovitis of the posterior zygapophyseal joints (grade 1-2 sprain) 2. minor circumferential tears of the outer layers of the annulus and the associated anterior and posterior longitudinal ligaments (Fig. 9.1) 3. minor joint subluxations ( trapped intraarticular meniscoid) 4. end-plate fractures (compression overload) (Farfan 1978, Kirkaldy-Willis 1983, Bogduk 1997) 5. tears of the capsule and ligamentum flavum as well as subchondral fractures of the superior articular process (in more severe injuries) (Taylor et aI1990). These injuries were not evident on X-ray. Subjective findi ngs

The mode of onset may be either insidious (postural) or sudden (trauma). The pain may be unilateral or bilateral and is u s ua lly localized to the low back (region between TI2/12th rib and the iliac crest) with Copyrighted Material

135

136

THE PELVIC GIRDLE

The degenerative process of the lumbar spine (Kirkaldy-Willis 1983)

Table 9.4

INTERVERTEBRAL DISK

ZYGA POPHYSEAL JOINTS Sy n ov i ti s

DYSFUNCTION

Ci rcumfe rential tears

-L

-L

F i brill ati o n of

a rt ic u la r

cartilage

Ra d i a l tea rs (her n i a tion)

J,

-L

Capsular laxity a nd cont i n u e d cart i lag e dest ru ction

INSTABILITY

Int erna l d is ru pt io n

Subl u x a tion

Lateral ne rve entra p m ent

Disk resorption

STABILIZATION

Osteophytosis

J,

-L

Enlarg e ment of ar ticu lar p rocess

One-level stenosis

-L Multilevel spondylosis and s tenosis occur as a resu l t of recu rrent strains

Figure 9.1

A tr a ns v erse circu mfere ntial tear in the annulus

fibrosus (arrow).

occasional radiation to the buttock. D y sest hesia

is

not often reported. The aggravating activities include

extremes of range of motion (forward/backward prolonged s tandin g, and lifting. Rest in the supine lying position (knees over a bolster) the

bending, rotation),

usually affords relief.

Figure 9.2

This young dancer's posture reflects her musc le

i m ba lance. The tight calves are p u ll ing her l egs posteriorly (arrows on leg and foot) (restricting dorsiflexion at the talocrural joint); the domi n a n t erecto r spinae coupled with a relatively w e a ker a nte ri o r abdominal wall result in an anterior pe lvic tilt (arrow on pelv is) and excessive thora columbar

lordosis (arrow posterior to the lumbar spine). ( R e prod uced with

Objective findings

permission from © Di ane G. Lee Physi otherapist Corp.)

In the first few d ays after a traumatic injury (substrate phase), the acute patient presents with marked difficulty walking since pelvic rotation beneath the lumbar s pine is r e quired for optimal stride length. Once the acute pain has settled, gait Gait

may no longer be provocative unless long distances are attempted. Posture

A

wide

variation

of

postures will be

noted when there is excessive com pressi on of the

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Defining the impairment

Figure 9.3 This posture reflects overactivation of the internal oblique and lengthening of the external oblique (note the vertical lateral abdominal crease: small arrow) , overactivation of the upper portion of the rectus abdominis, coupled with underactivation of the transversus abdominis ( depressed upper abdomen and bulging lower abdomen ) . Note also the lengthening of the erector spinae and the long thoracolumbar kyphosis. The pelvis is posteriorly tilted (curved arrow) and the thighs are displaced anterior to the line of gravity. ( Reproduced with permission from © Diane G. Le e Physiotherapist Corp. )

lumbar spine, pelvic girdle, or hip. In the lumbar spine, overactivation of a segmental muscle may manifest as a segmental rotation in standing which becomes magnified with motion. Regional multiseg­ mental global muscle imbalance is more obvious on postural examination. Four common patterns are: 1. Posterior displacement of the legs relative to the foot (plantarflexion at the talocrural joint) asso­ ciated with an anterior pelvic tilt and increased tho­ racolumbar lordosis (Fig. 9.2). Overactivation of the erector spinae coupled with underactivation of the abdominal wall occurs with this postural pattern. 2. Anterior displacement of the legs relative to the foot (dorsiflexion at the talocrural joint) associ­ ated with a posterior pelvic tilt and decreased tho­ racolumbar lordosis (flat back). Overactivation of the anterior abdominal wall (thoracopelvic flexors­ external oblique, internal oblique, or rectus abdo­ minis) and lengthening of the erector spinae occur with this postural pattern (Fig. 9.3).

Figure 9.4 When both the abdominal wall and the erector spinae are ove ractive, bracing occurs. This posture dramatically increases compression th rough the lumbar spine. ( Reproduced with permission from © Diane G. Lee Physiotherapist Corp. )

3. Overactivation of both the anterior abdominal wall and the erector spinae (bracing). This pattern of stabilization excessively compresses the lumbar spine without a resultant displacement between the thorax and the pelvis or the lower extremity and the foot (Fig. 9.4). 4. Unilateral overactivation of either of the above muscle groups causes a multisegmental roto­ scoliosis of the thoracolumbar spine coupled with a lateral shift of the thorax relative to the pelvis (Fig. 9.5a). Rarely is the asymmetry confined to the vertebral column; intrapelvic torsion of the pelvis and internal rotation of one hip and external rota­ tion of the other are frequently seen with this pos­ tural pattern (Fig. 9.Sb). Regio n a l movement tests In the first few days after an injury to the lumbar zygapophyseal joint, the patient with acute symptoms will present with marked restriction of all ranges of motion. The range of motion is bilaterally limited when the sprain is bilateral, and unjJateraIly ]jmited when the path­ ology is unilateral. As the acuity of the pain subsides (4-6 days) the pattern of segmental restriction

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138

THE PELVIC GIRDLE

Figure 9.5 Asymmetric activation of either the abdominals and/or erector spinae causes a multisegmental rotoscoliosis of the thoracolumbar spine. This can result in a lateral shift of the thorax relative to the pelvis and lumbar spine (aJ. The arrow indicates a left lateral shift of the thorax relative to the pelvic girdle. (b) Note the external rotation of the right lowe r extremity. This is coupled with a left transverse plane rotation of the entire pelvis and right lateral shift of the thorax (arrow). (Reproduced with permission from © Diane G. Lee Physiotherapist Corp.)

becomes more evident and localized to the trauma­ tized joint. One-leg stand i n g If the restriction involves the L4-L5 or L5-S1 joint, the hip flexion phase of this test may reveal asymmetry since LA and L5 must be free to rotate to the side of the non-weight-bearing lower e x t r em it y (sid e of hip flexion) during this test. Load transfer d urin g the support ph ase may be

impacted

if the pain is severe.

(fibrotic stiff joint), the neutral zone for arthrokine­ matic motion of the su peroante r ior and/or postero­ inferior glide will be reduced and the elastic zone will rev eal a very firm end-feel. If the joint is com­ pressed by overactivation of the global system (myofascially compressed joint) the neutral zone of motion will also be reduced; however, the elastic

zone will feel very resistant (like pushing a boat up a strong current), unlike the firm stop end-feel of a fi bro tic stiff joint. The passive tests for art hro k i net i c s tabi l ity are normal. Force c l o sure/m otor co ntrol Several investigators (Hides et al 1994, Danneels et al 2000, O'Sullivan 2000, Htmgerford 2002, Moseley et al 2002) have studied the response of multifidus in low back and a ri ver with

Form c l o sure: positi o n a l tests/mobil ity/sta bi l ity

The

sever ity of the pai n usual ly restricts a detailed form

closure analysis in the acute phase; however, with resolution over time, the passive physiological tests for osteokinematic m obi l ity confirm the restricted motion. If restri c t ive capsular adhesions deve lop

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,

Defining the impairment

pelvic pain patients and note tha t the deep fibers of multifidus become inhibited and reduced in size in these individuals. The a trophy of multifidus can be found both segmentally and mul tisegmentally.

In addition, it is common to find a timing delay or absence of contrac tion of the transversus abdo minis muscle (Hodges & Richardson

L3

1997, Hodges et al

1999, Hodges 2001, 2003) either unil aterally or bilat­ erally. When the local stabilizing system is ineffec tive, the ac tive straight leg raise (Figs

(ASLR) tes t is positive 8.55-8.57) and lumbopelvic control is lacking.

L4

Palpation of the segmenta l multifidus and transver­ sus ab dominis during the active bent leg raise and also

during

cueing (see

the co-contraction response to verbal

Figure 9.6 Flexed, rotated/sideflexed left L3-L4: left rotates/sideflexes at the limit of extension.

Ch. 8) will reveal the individual's spe­

cific pattern of local system d ysftillc tion.

A segmental restriction of the lumbar spine can be subclassified according to the position in which the vertebra is held. For example, a flexed L5 verte bra exhibits an

a

bilateral restriction of extension, whereas

extended L5 vertebra exhibits a b ilateral restriction

of flexion. The

unilateral

lesions produce a segmental

rotation of the vertebra as well as a compensa tory

A flexed, (FRSL) L3 vertebra exhibits

multisegmental curve above and below. rotated/sideflexed left a

restriction of extension and righ t rotation/side flex­

ion

(and

sideflexes/rotates left in extension: Fig.

9.6),

whereas an extend ed, ro tated/sideflexed left (ERSL)

L3 vertebra exhibits a restric tion of flexion and right rotation/sideflexion (and sideflexes/rotates left in flexion: F i g .

9.7). Note that this terminology does

not identify the cause of the res tric tion.

THE PELVIC GIRDLE S1] can result from

systemic articular pathology such as ankylosing spondy litis (fusion) or from mechanical articular pathology which causes fibrosis of the capsule (fibrotic stiff joint) . Excessive compression of the

SIJ

also occurs when there is overactivation of certain global muscles (myofascially compressed joint). an

individual develops a s tabilization strat­

egy that uses predominantly the deep external rota­ tors of the hip joint as well as the ischiococcygeus, the constant ac tivation of these muscles compresses the inferior aspect of the SIJ

Extended, rotated/sideflexed left L3-L4: left rotates/sideflexes at the limit of flexion.

response to the joint sprain a nd the pa tient usually

Excessive compression of the

When

Figure 9.7

(butt gripping: Fig. 8.40).

presents several months later complaining of pain in the opposite

Sl], lumbar spine, or groin. The fibrotic

joint is rarely the current source of pain, The mode of onset for the

SIJ compressed by

myofascia is usually altered mo tor control pattern­ ing. This may be sec ond ary to spo rts which repeti­ tively induce external rotation of the hip such as ballet, soccer, hockey, or a compensa tory strategy which developed subsequent to loss of mo tor con­ trol in the local system. The l ocation of the pain is variable and depends on which tissues are being stressed as a conse quence of the altered biomechan­ ics produced by this compression.

Subjective findings

a ltho u gh

patients may report that their symptoms began there.

from the

SII,

If the pain is

it will be pelv ic pain (within the limits

The mo de of onset for the SIJ compressed by fibro­

of the iliac crest and gluteal fold ) and may rad iate

sis (stiff) is usually trauma tic. The joint stiffens in

down the pos terola teral thigh to the knee (Fig.

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7.1).

139

140

THE PELVIC GIRDLE

The aggravating activities include walking and any acti v ity which requires intrapelvic torsion. O bjective find i n g s G ait When the SlJ i s stiff due to cap su lar fibrosis, the stride length for the hip joint is not affected; how ever, there is a noticeable lack of intrapelvic motion during gait. When the SIJ is myofascially compressed by over­ activation of the external rotators of the hip joint (Figs 8.40 and 8.41), the individual tends to walk with the legs externally rotated (Char lie Chaplin gait). Since the femoral head is held anteriorly in the acetabulum (Figs 8.41 and 9.8) , flexion and extension of the hip join t is limited and the stride length (mid­ stance to toe off) is s hor te n ed. The pelvis cannot rotate transversely relative to the femoral head and the pelv is resembles a block moving through space. Posture The fibrotic, stiff SIJ is not evident in pos­ tural analysiS; however, the myofascially compressed SIJ (secondary to overactivation of the external rotators of the hip) has a classic appearance (Fig. 8.40 and see Figs 9.10b and 9.13). Normally, the lumbopelvic region should resemble the shape of a pyramid (Fig. 9.9) with a wide pelvic base narrow­ ing superior! y at the waist. The bilateral "butt grip­ per" has a buttock which resembles an inverted -

Figure 9.B Overactivation of the external rotators of the hip joint displaces the femoral head anteriorly in the acetabulum and restricts femoral flexion and extension, as well as anterior rotation of the pelvic girdle. (Reproduced with permission from © Diane G. Lee Physiotherapist Corp.)

pyramid (Fig. 9.lOa, b) and in standing, a large divot posterior to the greater trochanter can be pal­ pated. These intrapelvic postur al changes can occur in addition to the gen eral postural changes noted in the lumbar spine section above (Figs 9.2-9.5). The bilateral "butt gripper" tends to stand with the pelvic girdle posteriorly tiJted and the L4-LS and LS-S1 joints flexed. The unilateral "butt gripper" often stands with a twisted pelvis (intrapelvic tor­ sion) and the L4-L5 and LS-Sl joints tend to rotate away from the side of excessive compression. Regio n a l movement tests In both forvvard and backward ben din g the fjbrotic, stiff SlI will create an intrapelvic torsion and the asymmetry will be consistent each time the individual moves in the sagittal plane. Axial rotation will be limited towards the side of the restriction and lateral bending will be limited away from the side of the restriction. A SIJ w hi ch is myofascially compressed unilaterally by the external rotators of the hip j oin t will al so create the above findings; however, in addition there will be a marked limitation of anterior tilt of the pelvic girdle in forw ard bending. The apex of the forward­ ben ding curve will be in the thorax (Fig. 9.11).

Figur e 9.9 The optimal lumbopelvic pyramid. (Reproduced with permission from © Diane G. Lee Physiotherapist Corp.)

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141

Defining the impairment

One-leg standing

hip flex­ will reveal of the innominate.

In both ins tanc es the

ion phase of the one-leg s tanding test asymm e try o f pos t erior rotation

The

ind ivid u al with the f ibrotic,

stiff SII will have

no difficulty tra nsferring load through

either leg during the s uppor t phase; however, th e myofas ci a ll y com p re ssed 51] may have difficulty trans fer­ ring load through the hip join t due to the anterior ­

displacement of the femoral head. Form closure: positional tests/mobility/stability

the f ibroti c, s tiff

SIJ and

Both

the unila t eral myofascially

51} have a reduced neutral zone of 8.1Oc, d) for both inferoposterior glid e (anterior rotation of the innom ina te) and antero­ superior glide ( pos t erior rotation of the innominate); the findings on testing the el a stic zone differen­ tiate between the two. The fibrotic , stiff joint has a consis tent hard end-feel whereas the myofascially compressed

m otion

(Fig.

(a)

Figure 9." Figure

9.10

(a) The inverted pyramid. (b) The pelvis appears

very compressed inferiorly and resem ble s the shape of an

the pe l v ic gi rdle to tilt anteriorly relative to the femoral heads

(butt gri pping) . Note the open hip angle (minimal hip joint

inverted pyramid. Note the flexion of the lower lumbar segments. ( Reproduced with permission from Physiotherapist Corp.)

This is the pattern of fo rw ar d bending commonly

seen in an individual who cannot release the hip joints to allow

© Diane G. Lee

flexion) and the excessive thoracolumbar flexion. (Reproduced with per mi ssi on from © Diane G. Lee Physiotherapist Corp.)

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THE PELVIC GIRDLE

compressed joint has a muscular resistance feeling. The quality of the end-feel varies with the speed of the test when the compression is due to overactiva­ tion of the muscle system. The passive tests for arthrokinetic stability are normal. Force closure/motor control Often poor motor control accompanies both the fibrotic, stiff SI] and the myofascially compressed SIJ. The dysflmctional patterns used for lumbopelvic stabilization during the ASLR test are highly variable and may include abdominal bulging and breath-holding (Fig. 8.57), excessive oblique abdominal activation with thora­ columbar flexion and posterior pelvic tilt (Fig. 8.55), excessive erector spinae activation with thoracolum­ bar extension, and anterior pelvic tilt or lumbopelvic rotation (Figs 8.54 and 8.56). A lateral shift between the thorax and the pelvis may also occur. Palpation of the segmental multifidus and transversus abdo­ minis during the active bent leg raise and also dur­ ing the co-contraction response to verbal cueing (see Ch. 8) will reveal the individual's specific pat­ tern of local system dysfunction. When the external rotators of the hip are overactive, femoral flexion and adduction combined with internal rotation are markedly limited (Fig 9.12). Subsequent palpation of the obturator internus and piriformis is required to determine the location of the trigger point. Ischio­ coccygeus will also compress the SIJ but will not impact the range of motion of the femur. Real-time ultrasound imaging often reveals the patient's inability to isolate a contraction of trans­ versus abdominis without a co-contraction of the internal oblique (Fig. 8.77b). A marked descent of the bladder is commonly seen when the stabiliza­ tion strategy is a Valsalva (Fig. 8.86a, b). .

THE HIP The hip joint degenerates secondary to traumatic disruption of the articular surfaces or as a conse­ quence of too much compression during loading. When the hip joint functions with the femoral head anterior in the acetabulum (Fig. 8.41), the afferent input from the mechanoreceptors within the joint capsule can be disturbed. This adversely affects the perceptual component of static joint position, dynamic proprioception, and stability as well as the resting tone of the muscles about the hip joint. The patient may state that the limb feels weak and tends to give way rather than be restricted in range, particularly during athletic endeavors. If the hip is continuously loaded in this non-centered pOSition,

Figure 9.12

When the femoral head is held displaced

anteriorly, there will be a marked limitation of femoral flexion combined with adduction and internal rotation. The femoral head impinges on the anterior structures of the hip joint and

often causes groin pain. (Reproduced with permission from © Diane G. Lee Physiotherapist Corp.)

and the patient is unable to release the muscles which are holding the femoral head anterior, the range of motion becomes restricted (flexion, adduc­ tion, and internal rotation) (Fig. 9.12) and the posterior capsule can become stiff. Over time, degenerative changes of the superoanterior aspect of the joint may result. Excessive compression of the hip may initially be secondary to myofascial causes which ultimately lead to fibrosis of the capsule in the absence of any significant trauma. Subjective findi ngs In the early stages, the compressed hip joint which is secondary to muscle imbalance produces symptoms which are usually not local. Even minor restrictions of femoral motion can cause compensatory hyper­ mobility of the S1I, the lumbosacral junction, and/ or the knee/patellofemoral joint and these articulations are more commonly the source of pain. With time,

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Defining the impairment

Table 9.5

Pain patterns in 89 patients with

osteoarthritis of the hip joint (Wroblewski 1978) Number of patients

Area of pai n Greater tro chan ter

71

Medial buttock

40

Groin

47

Anterior thigh

63

Knee

70

Shin

40

from the L3 mesoder m can refer pain an ywhere within the L3 dermatome and/or sclerotome. With moderate a rt icu la r degeneration, the aggra­ vating activities include walking, stair climbin g/ descent, and weight-bearing in flexion (i.e., squat). In the early stages, more demanding activities such as sport may be req ui red to aggravate the condition. ,

Figure 9.13

Backward bending of the trunk in the presence of

restricted femoral extension. This person is butt gripping (note how his shorts go up the gluteal cleft - a sure sign of gripping!) His pelvic girdle is already posteriorly tilted relative to the femoral heads and further backward bending is occurring at the expense of his low back, which is developing a translatoric

Objective findings

instability (arrow). (Reproduced with permission from © Diane G. Lee Physiotherapist Corp.)

Gait Excessive compression of the hip joint results in decreased mobility and this is refl ected in the

patient s gait pattern. The stance phase is often shortened, creating a vertical li mp If the altered m echanoreceptor input from the articular capsule si gnificantly alters the streng th of the lateral system (stabilizers of the hip), there will be a loss of dynam ic st a bility (force closure) compensated for by a lateral limp (compensated Trendel enburg : Fig. 6.25). The center of gravity deviates la teral l y in order to reduce the muscle requirements of unilateral stance. Posture A wide variety of postures can be found: the bu tt gripping posture is very common ( Figs 8.40 and 9.13, and see lum bar spine above, Figs 9.2-9.5). Regional movement tests When the hip joint is restricted in fl ex i on/e x tensi on unilaterally, full forward/backward bending of the trunk produces a rotation of the pelvic girdle on top of the femoral heads as well as in trapel vic torsion. A compensa­ tory, multisegmental rotoscoliosis of the lower lum­ bar spine also occurs. Lateral bending of the trunk will be restricted such that the pelvic girdle cannot translate in the coronal plane without deviation when abduction or adduction is limited. Axial rotation of the trunk is limited in both directions when the femoral head is compressed anterio r ly. One-leg standing The hip flexion phase is not impacted tmless the range of hip flex i on is m a rked ly limited, at which p oint posterior rotation of the innominate will occur much earlier in th e range. The '

the patient begins to complain of anterior groin pain and impingement with leg crossin g When trauma is not a factor, the onset of symptoms is insidious. Co mpens atory pain from the SlJ and/or the lum­ bosacral j unction is aggravated by any activity which requires excessive motion from the low back/pelvis in compensation for restrictions of the femur. For example, backward bending of the tnmk often elicits pain at the lumbosacral j unction when L5-S1 over­ extends to compensate for restricted femoral exten­ sion secondary to an anteriorly displaced femoral head. Since the pelvic girdle is already posteriorly tilted, further hip extension is not available during backward bending and the L5-S1 compensates (Fig. 9.13). A painful, long dors a l ligament is aggravated in forward bend ing of the trunk when b iceps femoris cannot sufficiently lengthen. The tension which devel­ ops in the sacrotuberous ligament (through the attach­ ment of biceps femoris) prevents the sacrum from remaining nutated relative to the innominate when the pelvic girdle anteriorly tilts in forward bencting. When the hip joint itself becomes sy m pto matic, the location of pain can be variable. Wroblewski (1978) studied the p a in patterns in 89 patients with osteoarthritis of the hip joint and the variation noted is tabulated in Table 9.5. The hip joint, bein g derived .

.

-

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143

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T H E P E LV I C G I R D L E

support phase i s often posi tive ( the irmomina te tend s

3 . ischiorecta l abscess

to rotate anteriorly) when the femoral head is held

4. 5. 6. 7. 8.

anterior since the weigh t-bearing line is affec te d .

Form closure : positi onal tests/mobil ity/stabi l ity

Posi­

tionally, the femoral head is easily p a lpated anteri­ o rly in the groin in both standing and supine lying.

septic b u rsitis rheuma tic fever w i th bursi tis neoplasm at the upper fem ur i l iac neop lasm fra c tured sacr u m .

The patient tends to stand with the lower extremi ty

Force closu re/motor contro l

externally ro ta ted and the leg rests in external rota­ tion when supine. The passive physiological tests for

Janda

(1978, 1986) has

observed tha t very early in the degenerative process

osteokinema hc mobility of the femur reveal the p a t­

of the hip joint certain muscle groups respond by

tern of res triction. The fully established capsular p a t­

tightening (hamstrings, rectu s femoris, iliopsoas,

tern of restriction (Cyriax

1954) of the hip join t is:

1. 50-55° limi ta tion of femoral abd uc tion 2. 0° of femoral med i a l ro ta tion from neu tral 3. 90° lim i ta tion of femoral flex ion 4. 10-30° l i m i t a tion of femoral ex tension 5. femora l la teral rotation and adduction (in supine) i s fully maintaine d .

tensor fa scia la tae, adductors, and piri f ormis) while others respond by becoming weak (gluteus max­ imus, medi us, and minimus). This is one example of changes ( lengthening / shor tening) in the longitu­ d inal and lateral global sling systems and a wide variety

of p a tterns

are

observed

clinically.

The

femoral head remains anterior d uring the A SLR test and posterior rotation of the innominate occurs early

However, as w a s previously men tioned, the degen­

in the range ( a t approxima tely

50° of femoral flexion ) .

erative p rocess of the hip joint occurs over time such that, in the p resence of early pa thol ogy, the only objective finding may be a slight limita tion of med i a l rota tion, flex ion, a n d adduc tion in

90° of femoral

flexion (posi tive combined movement tes t) . As the

EXCESS IVE ART I CULAR COMPRESS I O N W I T H A N U N DER LY I N G I N STAB I L I T Y

p a thology progresses, the full capsular p a ttern of re s tric tion emerge s . Ar throkinema tically, the neutral

When a force is appl ied to the j o i n t sufficien t to

zone of mo tion is red uced in all d i re c tions . The elas­

a tten uate the articular ligaments, the muscles will

tic zone analysis helps to differen tia te a fibro tic, stiff

respond to p revent disloca tion and further tra u ma

j o i n t from one which is myofascially compressed .

to the joint. The resul ting spasm hol d s ( fixa tes) the

A very hard end - feel i s indicative o f a n a rticular

joint in an abnormal resting position and marked

restriction whereas a softer end-feel is usually mus­ c u l a r. C linic al ly, the two are usually seen

in com­

asymmetry of the bones is present. This is Fig.

an teriorly if these str u c tures are p ainfu l .

manip ula tion techni q u e (see Ch.

According to Cyriax

(1954), a l l major lesions or

an arresting pat tern of physical signs that draws immediate attent ion to the but tock. Passive hip flexion with the knee held extended . . is slightly limited and .

painfu l. Pass ive h ip flexion, this time with the knee flexed too, is again limited and more painful. Further

exa m ina tion reveals a non-cap s u lar pa tt ern of limita­ tion of movemen t at the hip joint.

(ey riax 1 954)

The end - feel of motion is e m p ty ( i . e . , limited by p ain) as opposed to tha t of a r ticular or myofascial tissue resistanc e . This "sign of the b u t tock" should a lert the e x a m iner to the po tential presence of seri­ ous p a thology s uch a s :

1. os teom yeli tis of the u p p e r femur 2. chronic sep tic s acroi liac arthritis

unstable

8.10£) . Treatment usually requires a high-velocity 1 0 ) to distract a n d

bina tion. The torqu e tes t may provoke symp toms

serious p a thology in the b u t tock presen t w i th:

an

join t under excessive compression (j oint fixa tion:

reposi tion t h e j oint. These techni ques w i l l reduce the articular compression and res tore the rest­ ing posi tion o f the bones . Repea t a na lysis of the

in 8.1Ob ) .

form closure tests will now rev eal a ' decrease s tiffness compared to the opposi te side (Fig.

Restoration o f the force clos ure mechanism through an

appropria te exercise program (see eh .

10) must

foll ow. This is an imp a i rment of both fo rm and force closure in tha t the re lati onsh ip between the articular su rfaces has been d i s turbed and the muscle response is excessive. Tre a tmen t of th is individual which foc uses on exercise w i th o u t fi rst addressing the posture, posit ion, and a lignment of the joint tends to be i neffec tive and commonly increases symp toms . Conversely, i f trea tment only inc ludes manual the rapy (mobiliza tion, mani p u l a tion, or muscle energy) for correc tion o f posture, posi tion,

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Defi n i n g t h e i m p a i r m e n t

and alignment, relief tends to be temp ora ry and d ependence on the health ca re prac ti tioner prov i d ­

ing the manual correction is common. Trus i mpair­ ment requires a combin a tion o f m a nu al therapy, exercise, and educa tion for a s uccessfu l outcome in o ther word s, an inte g ra ted approach .

Su bj e ct i ve fi n d i n g s The mode o f onset is usua lly s udden: the p a tien t

v i vidly reca l ls the prec ipita ting event. The pa in i s often Lmi la teral l o w b a c k p a in wruc h is s h a rp l y a gg ra va ted b y an y motion which in feriorly g l i d es the imp a ire d zyga p op hyse a l j oint. The p a tie n t has gre a t d ifficu l ty acrueving o r m a i n t a i n i n g a neu­ tral lumbar spine p ostu re . Over time, the p a i n may

TH E LU M BA R S P I N E

ra d ia te distally down the b uttock and p os tero l a te r al

An intraar ticular meruscoid (Fig.

9 . 14) of a moder­

a tely de g enera ted zy g ap ophyseal j O int can become trapped d u ring a flexion / rota tion load (lift and twist) in the p resence of insufficient stabilization of the j oint. The res u lting s p asm fi xa tes the lumb a r segment in wha t

a ppe a rs

to be

a

"locke d " posture and the find ­

in gs are a s follows.

thigh. Rest in the flexed, l a tera l ly transla ted pos t u re (away from the s i d e of p a in) u s ually affords relief.

O bj ective fi n d i n g s Gait

In the first few d a y s a fter

a

tra uma tic inj ury

( s ubs tra te pha se) , the a c ute pa tien t presents with ma rked

d i ffi c u l ty w alkin g since pelv ic rotat ion

benea th the l umbar spine is required for opti m a l

s tride length. Postu re

The pa tien t presents with a c l assic flexed

and la ter a l ly transla ted p o s tu re . Segm enta l ly, the imp aired j oint is kypho tic and ro t a t ed a wa y from the impa ired side. The pelvis is posteriorly til ted and the rup j o in ts flexed . Reg i o n a l move m e n t tests

Any a ttemp t t o correc t

the pos tu r a l deformity meets w i th marked increase in p a i n . All movemen ts are pa infu l O n e - l e g sta n d i n g

a nd li mi ted .

If the res triction involves the

L4-LS or LS-S 1 j o in t, the hip flexion phase of thi s test m a y reveal a symme try since L4

a nd LS m u s t

be free to ro ta te to the side of the p oste riorly ro tat­

ing irmominate d urin g trus tes t. Load tr ans fer d u r­ in g the supp or t pha se may be impacted i f the p a in i s sev ere . Form c l o s u re : positi o n a l tests/ m o b i l ity/sta b i l i ty

Posi­

ti on a l ly, the i mp ai red j o int is he l d in flex ion and cOLmtra l a teral r o ta ti on (away from the side of pain) . Passive os teokinema tic mobili ty tests for ex tensi on, sidefl ex ion, and ro ta tio n towards the impa i red side are res tric ted . The neu tra l zone for a r throkinem a tic motion o f posteroinferior gl idin g is completely b l oc k e d (Fig. S . 1 0£) and the end -feel is s p ringy. Prior to

manipula tin g the join t (see Ch. 10) the tes ts for

a rthrokine t i c s tabili ty are norma l since the joi n t is under excessive compression d ue to rea c tiv e F i g u re 9 . 1 4

This i s a c o ro n a l s e ct i o n

t h ro u g h

muscle sp a s m a

lumbar

zyg a p o p h yse a l j o i n t s h o w i n g a h e a l t h y m e n i s c o i d i n c l u s i o n . W i t h d e g e n e ra t i o n ,

these i n c l u s i o n s c a n b e c o m e t h i c k a n d pa t i e n t

fi b r o t i c a n d o c c a s i o n a l l y " s t u c k " o u t s i d e t h e j o i n t. T h e

t h e n p rese n ts w i t h a f l e x e d a n d l a t e ra l l y t ra n s l a t ed p o s t u re .

.

Force c l o s u re/m otor c o n tro l

The AS L R is positive

since fur ther a c tiva tion of the local a nd g l ob al sys­ tems further increases compression and pain . A u g ­ men ting the loc a l system w i th specific compression

T h i s b e a u t i fu l d i s s e c t i o n i s r e p ro d u c e d w i t h p e r m i s s i o n

of the pe lv i s has no i mpa c t on the p a tient's abi l i ty to

from D rs . La n c e Tw o m ey a n d J a m es Tayl o r, C u r t i n U n i v e rs i ty.

lift the leg.

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T H E P E LV I C G I R D L E

T H E P E LV I C G I R D L E

the affected side is

significan tly imp ac ted in both lesions, thus the s upp o r t phase is p osi t iv e for failed load transfer. shear

S u bj e ctive fi n d i n g s

The mode o f onset i s a lw a ys trauma tic and com­ monly involves a fall on the b u t to c k s (e x c e ssi ve v er t i c a l loa d ) or a l if ti n g, twis ting even t (e xc essi ve horizon tal lo a d ) . The pain and in a b i l i ty to l oa d th ro ugh the p e l v i c girdle are immed iate . The lo c a ­ tion of the pain is local to the p el v i c g ird l e and u s u all y uni la te r a l ( F or tin ' s d i st ri b u ti on ( F or tin e t al 1994a, b ) - wi th in the limits of the iliac c re s t and gluteal fol d ) and m a y ra dia te down the po stero ­ l a te ral thi gh to the knee. After a vertical load inj ury, the a g g ra va ting a c ti v i ti es inc lud e any we i ght­ b e a r ing thr o u gh the affected si de (standing, walking, s i t tin g ) . After a horizontal load inj u r y, the agg r a v a t ­ i n g a c ti v i ti es in c l u d e fo r w a rd b e n d in g or rota tion. The p a tient ofte n sta tes tha t no p osi t ion a ffo rds relief. It is common for them to state th at they h a ve "put the i r hip out. "

O bjective fi n d i n gs Gait Thes e impairments lea d to a ma rked d ys ­ function of gait. The p a t ien t who has s ust a in e d a vertica l load inj u ry may use cru tches or a cane to fa c ilita te load transfer through the pelv is. The patient who has sustained a horizontal load inj u r y walks in a forwa rd-flexed, l a te ral l y shifted manner. It is read­ i l y a ppa ren t to even a c as u a l observer that some­ th ing is very wrong ! Po stu re Verti c a l shear l esi o n s : the pe l v i c g i r d le appea rs to h ave been sheared verticaUy with or with­ out an terior or p osteri. or ro ta tion of the i nn o mi n a te . Horizon tal shear l e si o n s : th e pe l v i c girdle appears to have been she a re d horizontally with or w itho u t a n te r io r or p os te r i o r ro ta tion of the innominate or sa cra l rota tion. The lumbar spine a nd hip joi n ts compensate for th is she a r such that a m ul ti s e g m en ­ ta l ro to s co l i o si s is p resen t in the lumbar spine a n d the hip p os tur e is in in te rna l ! external rota tion. Reg i o n a l m ove m e n t tests In bo th forw a rd and b a c k w a rd b en ding the fi xated S1] ( v er t ic al or hori­ zontal shear l esi on ) will crea te an i n tr a p elv i c tor­ sion and the asymme tr y will be c o nsi s te n t each time the individual moves in the sagi ttal p l ane . O n e - l e g sta n d i n g Th e hip flexion phase of the o ne -l e g sta nd ing test will reveal a symmetry of pos­ terior rota tion of the innomina te . The fixa ted SIJ w i l l not permit a ny po ste ri o r rota tion of the inno m ­ inate on the impaired s i d e . Lo a d t rans fer thr o u g h

Form c l o s u re : positi o n a l tests/ m o b i l ity/sta b i l ity

The

pOSi tiona l tests d i fferentiate the sh ea r lesions. In the

su p er io r

vertical shear lesion, the anterior and pos­ il iac crest, and ischial tu b e ro s i ty are all crania l on the imp a ir e d side. The infer i o r arcua te band (med ial b a nd ) of the sa cro­ tu b e ro u s li g a me n t is rela tively slack on the i mp a i red s i d e . In th e horizontal shea r lesion, the sacral base and inferior l ater a l a n gl e are e i th e r an terior or pos­ terior on the imp a ired side (anterior or p o s te r or sacral shear l es i o n) . The passive tests for both os teokine­ ma tic and arthro kinematic function reveal a total block to a ny motion ana l ysis . I t is not p o s s i ble to find the jo i n t plane for te st ing when the SI] is fix­ a ted. Th e s tab i l ity tests are n e g a ti ve unt i l the j o in t has been d e c om presse d w i t h a m a ni p u l a ti v e tech­ ni qu e . A fte r thi s, th e s tab ili ty tests reveal an exces­ sive neutral zone o f motion in ei ther the vertica l or a n tero p os te r io r pl ane (o r both) . Fo rce c l o s u re/m oto r control The pa tie n t has m a r k e d difficulty liftin g e i th er l e g when the SI} is fix a t e d . A u g m e n tin g the loc a l system via s p ec i fi c compression of the p e l vi s o f ten ma kes the ASLR m o re difficult. After the joint has been manipulated and th e un d er l y in g in sta bili ty revealed, sp ec ifi c c o mp res sio n of the pelvis w ill revea l which part of the local system re qu i res a ttention for stabilization of the p elv i s (see below) . terior s u per i o r i l i a c s p in es,

i

INSU FFICIENT ARTICU LAR CO M PRESSION This situa tion a r i se s when there is either in a deq u at e or ina p p ropria te motor control and /or li gam ento us lax i ty such tha t there is ins u fficient a r ti cu l a r c om ­ pressi on d u r ing movement a nd lo a d in g .

TH E LU M BA R S P I N E R ep e a te d trauma to th e

lumba r

spine

can

result in

p r og ress iv e ana tomical and physiolo gic a l cha n ges lea d ing to s e gm ental ins tab i li ty (Tabl e 9.4) ( Kirk a ldy­ Willis 1983, Panjabi 1992a , b, Bogduk 1997) . The a n a to mi c a l a n d p h ysiolog i c a l c ha ng es i ncl ud e :

1. fib ri l l a ti on and subsequent loss of the a rti c u ­ lar c artil a ge of the z y g ap o ph ysea l join t (s) (Figs 9. 15 and 9 . 1 6 ) (Taylor & Tw om e y 1986, B o gd u k 1997) 2. laxity of the a rticular ca p s u le ( s) and a tte n u a ­ tion of the i liolumbar l i g a men t

Copyrighted Material

Defi n i n g the i m pa i rm e n t

F i g u re 9 . 1 5

H i s t o l o g i c a l s e ct i o n of t h e zyg a p o p h ys e a l j o i n t .

N o te t h e t h i n n i n g a n d fi bri l l a t i o n o f t h e a rt i c u l a r c a rt i l a g e (a rro ws) . ( R e p ro d u ced w i t h p e r m i s s i o n fro m K i rk a l d y - W i l l i s

1 98 3 .) F i g u re 9 . 1 7

M a crosco p i c t ra n sve rse s e ct i o n o f the L4- L5

seg m e n t . N o te t h e co a l e s c e n c e o f seve ra l ra d i a l fi s s u res a n d t h e e a r l y s t a g e s of i n t e rn a l d is r u pti o n . ( Reprod u ced w i t h p e r m i s s i o n fro m K i r k a l d y - W i l l i s

Fig ure 9 . 1 6

1 983.)

M a cros c o p i c tra n sv e rse s e c t i o n of t h e L5-S 1

s e g m e n t. N o te t h e m a r k e d d e g e n e r a t i o n of t h e l eft zy g a p o p hysea l j o i n t (a rrow). ( R e p ro d u ce d w i t h p e r m i s s i o n fro m K i r k a l dy - W i l l i s

1 9 83.)

3 . fractu re of the

a r ticu lar

process with resu l ta n t

strain deforma tion o f t h e neura l arch (Tw omey et al

1989, Taylor e t al 199 0 ) 4. coalescence of the c i rcu mferenti a l annu l a r tears i n to a radial fissure ( F i g . 9. 17) with or witho ut subsequent herniation of the nucleu s pulposus,

F i g u re 9 . 1 8

M a c rosc o p i c s a g i t t a l sec t i o n o f t h e l u m b a r s p i n e .

N o te t h e s c l e rosis o f t h e verte b ra l b o d i e s a b ove a n d b e l o w t h e c e n t ra l i n te rv e rt e b ra l d i s k , w h i c h i s m a r k e d l y r e s o r b e d . ( R e p r o d u ced w i t h p e r m i s s i o n fro m K i rka l d y - W i l l i s e t a l

5 . sclerosis (Fig.

of

th e

adj acent

vertebral

1 978.) bod ies

9 . 18 ) .

ul ti m a tely progressin g to m a rked in terna l disrup­

At

ti on of the d i sk, loss of disk height, circumfe ren ti al

changes allow the s u pe rior a rticular p rocess of the

the

b u lging, a nd res orption

sacrum to sub lux upwards and forwa rds during

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lumb osacral j lUlction,

these

anatom ical

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T H E P E LV I C G I R D L E

a x ial rotation o f the tru nk (Fig. 9 . 1 9 ) . Th is m o tion c o n s e q u e n tl y

na rrow s the l a teral recess of LS-S 1 ,

Wi th time, the pos terior zygapophysea l joints e nl a rge to d ev elop o st e op hyt e s , the in tervertebral

p o t en t iall y impeding the vascular a n d neu r o l ogic a l

d i sk becomes fibrotic,

function of the s tructures w i thin the intervertebral

de v e lo p on the an terior and / or po s te r io r

fo ra m e n (Sunderland 1 978) .

the v e r te b ra l body, occasion a l ly lead ing to spon­

and

traction sp urs

may

a sp ec t

of

ta neOLlS fusion (Figs 9 . 20 and 9 . 2 1 ) . These cha nges

occur d uring the third stage of the degenera tive p ro c e s s , osseous stabili z a tion, and the p a tien t is often pa infree (as well as hypo mobile and no longer

unstable!) (Kirkaldy-Willis stage is the

1 983) . The risk at thi s d ev e l op m ent of fi xed cen tral a n d / or 1a t­

eral stenosis d u e to osseOLlS trespass on the spinal canal and / or late ral re c e ss w i th attendant peripheral symp toms

of

ne urogenic

vascular

cla u d ication

(Sunderl and 1978).

F i g u re 9 . 1 9

Dy n a m i c s t e n os i s of t h e l a te r a l rec ess of the

l u m bosa cra l j u n c t i o n ass o c i a t e d with i n s ta b i l i ty. In t h i s s p e c i m e n t h e s p i n o u s p rocess of t h e LS v e r te b ra h a s b e e n ro t a t e d t o w a r d s t h e o b s e rver. The zyg a p o p h ys e a l j o i n t h a s o p e n e d (a rro w ) , a n d t h e s u p e r i o r a rt i c u l a r p ro cess h a s a p prox i m a t e d t h e p o s t e r i o r a s p e c t o f t h e i n t e rvert e b ra l d i s k , s u b s e q u e n t l y n a rrow i n g t h e l a tera l recess. [ R e p r o d u ce d w i t h p e r m i s s i o n fro m R e i l l y J e t a l

Fig u re 9 . 2 0

1 9 78.)

M a crosco p i c tra nsverse secti o n of t h e

LS-S1

seg m e n t i l l u s t ra t i n g f i x e d c e n tra l a n d l a t era l s te n os i s . T h e c e n tra l a n d l a t e r a l c a n a l s a re m a r k e d l y n a r r o w e d b y

F i g u re 9.21

o s t e o p h y t o s i s . [ R e p ro d u c ed w i t h p e r m i s s i o n fro m

i l l u s t ra t i n g m u l t i l ev e l s p i n a l s t e n o s i s . [ R e p ro d u c ed w i t h

K i r ka l dy - W i l l i s

1 983.)

M a crosco p i c sa g i tta l s e c t i o n o f t h e l u m ba r s p i n e

p e r m i s s i o n fro m K i r k a l dy-W i I l i s

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1 983.)

Defining the impa i rment

Subject ive findi ngs

Clinically, the patient with insufficient articular compression (instabili ty) of a lumba r segment often presents w ith a long history of intermittent low back pain with repeat episodes of exacerbation and res olution. Alterna tely, this may be their first episode. The low back pain may be tmilateral or bilateral and can refer as far as the distal extent of the segmental dermatome. Dysesthesia is common due to the potential for neurovascular impedance a t the intervertebral foramen. The aggrava ting activi­ ties frequently include sustained end-ra nge pos­ tures (flexion and/or extension of the lumbar spine wi th or wi thout rotation) and those activities which induce them (prolonged stand ing or sitting out of neutral spine, prolonged forward or backward bending of the trun k). Res t in the supine lying posi­ tion with the knees supported over a bolster usually affords rel ief. See Tables 9.6-9.9 for findings specific to the segmental impairment.

Posture/reg ional movement tests In ad d i tion to the general postural changes noted under excessive articular compression: lumbar spine, above (Figs 9. 2-9.5), specific segmental deviations from the neu­ tral posi tion can be noted when instability is present in the lumbar spine. O'Sull ivan (2000) has developed a very useful way of classifying these instabilities according to the posture/ position they present with and the movement that is impa ired (see Tables 9. 6-9.9) . (Thi s is a wonderful article which "rang so true" for me and I high! Y recommend tha t every clin­ ician obtain a copy of this paper: O'Sullivan 2000 .)

Object ive fi ndi ngs G a i t Wal king often rel ieves the pa i n as long as the dista nce attempted is not too far.

I n s u ff i c i e n t arti c u l ar com p ression - c l i nica l c l a ss ifi cation for t h e l u mba r spine ( adapted from

Ta b l e 9.6 O ' S u l l ivan

Common to all patien t presen tations is t h e rep o r t ed and observed lack of movemen t control and related symptoms within the neu tral zone. This is associa ted with the inability to initiate co-contraction of the local sys tem within this zone. It appears that these patients develop compensa tory movement s tra t­ egies which "stabilize " the m.otion segment out of the neutral zone al1.d towards an end-range positioll (such as flexion, lateral shift or e xtens io n) . Th is is achieved by rec ruitment of global system m uscles and by generating high levels of intra-abdo minal pressure (bracing) during low load tasks, in wha t appea rs to be a sub-optimal attempt to preserve seg men t a l s ta b i l i t y. (O'Su l l i van 2000) v u l nerability

2000)

F l e x i o n patte rn - poste ri o r tra n s l ation i nsta b i l i ty O n set

F l e x i o n /rota t i o n activ i t i es , s u d d e n o r repeti t ive

A gg r a va t i n g

S u sta i n e d or repetitive flexi o n (shove l i n g , g a rd e n i n g , ro w i n g , etc . )

a ct iv i ti e s Po stu re

Loss of seg m e n ta l l o rdosis w h i c h is a c ce n t u a ted in si tti n g . Poste r i o r p e l v i c t i l t in s i tti n g . I n c reased t o n e i n t h e e rector s p i n a e i n t h e l o w e r t h o ra x a n d u p p e r l u m b a r s p i n e

R eg i o n a l

H i n g i n g a t u n sta b l e seg m e n t i n creases i n fo rwa rd b e n d i n g . M a y req u i re t h e u s e o f t h e h a n d s to

move m e n t tests

fo rwa rd b e n d a n d / or re t u rn to erect sta n d i n g . Decreased seg m e n ta l e x te n s i o n i n b a c k w a rd b e n d i n g U n a b l e t o a c h ieve a n e u tra l s p i n e p o s i t i o n i n st a n d i n g s i t t i n g , o r fo u r- p o i n t k n e e l i n g ,

Form c l os u r e tests

PIVM - i n creased osteo k i n e m a t i c fl e x i o n a n d rota t i o n a t u n sta b l e seg m e n t

( m o b i l i ty/sta b i l ity)

PAVM

-

i n creased a rt h ro k i n e tic a n teroposterior tra n s l a t i o n w i t h a ssocia ted i n crease i n t h e n e u t r a l

z o n e a n d a softer e n d -fee l i n t h e e l a stic z o n e Force c l o s u re a n d motor c o n t ro l tests

ASLR - l oss o f l u m bo p e l v i c c o n tro l - p e l v i s t e n d s to rotate t o t h e s i d e of e l eva t i n g l e g . N o c h a n g e i n effort w h e n c o m p ress i o n i s a p p l i ed to t h e p e l v i s ( t o s i m u late t h e loca l syste m ) u n l ess t h e u n sta b l e seg m e n t i s L S - S 1 A B L R - pa l p a b l e a troph y of m u l t i f i d u s b i l a te r a l l y at t h e u n sta b l e se g m e n t U n a b l e to co-activate tra nsversus a b d o m i n is w i t h m u l t i fi d u s Va r i a b l e c o m p e n sa t o ry strategies - ofte n t e n d t o brace l o w b a c k i n to fl ex i o n usi n g extern a l a n d i n te r n a l o b l i q ues a n d erecto r s p i n a e . T h i s c o m p resses t h e l o w t h o ra x , p reve n t i n g l a t e ra l cost a l ex pa n s i o n b reath i n g ( espec i a l l y a n t e r i o r)

PIVM,

passive i n te rv e rt e b ra l mov m e n t ;

PAV M ,

passive accessory verte b r a l m o v e m e n t ;

ASLR,

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a c t i v e stra i g h t l e g ra i se ;

ABLR,

a c tive b e n t l e g

r a ise.

1 49

1 50

THE P E LV I C G I RDLE

I n s u ffi c i e n t a rti c u l a r co m p ress i o n - c l i n i ca l c l a s s i f i c a t i o n fo r t h e l u m ba r s p i n e ( a d a pted fro m

Ta b l e 9.7 O ' S u l l i va n

2000)

Exte n s i o n pattern - a n te r i o r tra n s l at i o n i nsta b i l ity

Onset

Exten sion/rotation a ctivities. sudden or repetitive

Aggravating activities

Sustained or repetitive exten sion (standi ng. throwi n g . runnin g . da ncing. swimming . etc.) Increased segme n t a l lordosis. Anterior pe lvic tilt in standing . Increased tone in the erector spi nae in the spine

Posture

e n t i re t h o ra c o l u m b a r

loss of segmenta l extension

Regional movemen t tests

Hinging at u n sta ble seg ment increases in backward bending associated with at levels above insta bility. Often an obvious skin crease at unsta ble segment

Form closu re tests (mobil ity/sta bi I i ty)

PIVM - increased osteokinematic extension and rotation at unsta ble segment PAVM - increased a rthrok i n etic posteroanterior tra nslation with associated increase in the n eut r a l z o n e a nd a softer end -feel in the elastic z o n e

Force closure a n d motor control tests

ASLR

loss of l umbopelv i c control - pelvis tends to rota te to the side of e l e v a ti n g leg. N o ch ange i n when com pression i s a p pli e d t o t h e pelvis (to simulate the local system) unless the u n sta ble segment is LS-S 1 ABLR - pa lpable a trophy of mu ltifid us bilaterally at the u nstable segment. U n a ble to co-activate tra n sversus a bdominis with multifid u s Va ria ble compensatory stra teg ies - often ten d t o bra ce l o w b a c k i n to extension using t h e e rector spina e. This compresses the low poste rior thorax preventing lateral costa l ex p a n sion breath ing (especia lly posterior) . Ribca ge appears elevated whe n the patie n t lies supine -

effo rt

PIVM. PAV M . ASLR, a c t i v e s t ra i g h t leg r a i s e ; A B L R , active b e n t

leg

raise.

I n s u ffi c i e n t a rt i c u l a r co m p ressi o n - c l i n i ca l c l a ss i fi c a t i o n fo r t h e l u m b a r s p i n e ( a d a pted fro m

Ta b l e 9.8 O ' S u l l iva n

a

2000)

Late r a l s h i ft pa tte rn

- latera l

tra n s l a t i o n i n sta b i l ity

Onset

Rotation i njury usu ally in flexion

Aggravating activities

Susta ined or repetitive rotation even

Posture

Loss o f segmental lordosis which is accentuated i n sitting. Posterior pelvic t i l t i n sitting w i t h a rela tive lateral s h i ft of th e tru n k relative to t h e pelvis. I ncreased t o n e in the e rector spinae u nilatera lly

Reg ional movement tests

Deviation of the tru n k la tera lly throu g h the mid-ra nge of fo rwa rd bending Ma rked lateral shift of the tru nk during one-leg sta nding

Form closure tests ( m o b i l ity/st a b i l ity)

PIVM increased osteok i n ematic rotation at unsta ble segment PAVM - i n creased a rthrokinetic lateral tra nslation and unilateral posteroa n terior translation with associated increase in the neutral zone and a softer end -fe e l in the el astic zone

Force closure a n d motor control tests

ASLR - loss of thoracopelvic con trol - tend to shi ft the thorax latera lly relative to the pelvic girdle during elevation of the leg. No change in effort when compression i s a pplied to t h e pelvis (to simulate the loca l system) ; however. there is often a reduction in effort when the thoracopelvic shift is manually controlled ABLR - pa l pa b l e atroph y of m u ltifidus unila tera l l y at the u n sta b l e segment Una ble to co-activate transversus a bdominis with mu ltifidus uni la teral pattern Va riable com pensatory strategies - often tend to brace low back i n to rotation a n d sideflexion using quadratus lumborum. superfici a l erector spinae on ipsilateral side of t h e shift

in neutra l

-

P IV M , PAVM. A S L R . a ct i ve s t ra i g h t l e g ra i s e ; A B L R . a c t i ve b e n t l e g ra i s e .

Copyrighted Material

Defi n i n g t h e i m p a i r m e n t

I n s u ffi c i e n t a rt i c u l a r c o m p ress i o n - c l i n i c a l c l a s s i f i c a t i o n fo r t h e l u m b a r s p i n e ( a d a p t e d fro m

Ta b l e 9 . 9 O ' S u l l i va n

2000)

M u ltid i recti o n a l pattern O n se t

M u l t i p l e recu rre n t e p isodes of t ra u m a w i th i n crea s i n g l ev e l s of d i s a b i l i ty a fter ea c h e p i sode

Agg rava ti n g

Eve ryth i n g - n o w e i g ht-bea r i n g p os i t i o n i s t o l e ra b l e

a ctiv i t i es

Postu re

Vu l n e ra b l e to l o ck in fl ex i o n , exte n s i o n , or l a t e ra l shift p o s i t i o n

Re g i o n a l

A l l ra n g e of m o t i o n i s d e c rea sed in every d i recti o n . A l l mov e m e n t is asso c i a te d w i t h s p a s m a n d s h a rp pa i n

m ove m e n t tests a c c u ra te l y - a l l passive move m e n ts, w h e t h e r a n g u l a r o r tra n s l a t o r i c , a re assoc i a ted w i t h

Fo rm c l osu re tests

D i ffi c u l t t o

( m o b i l i ty /sta bi I i ty)

m a rk e d sp a s m a n d p a i n

Force c l os u r e a n d

ASLR

motor con trol tests

C o m p re ssi o n ofte n i n c re ases p a i n

-

a ssess

m a rked d i ffi c u l ty l i ft i n g t h e l e g at al i , m a y n o t be a b l e to p e rfo r m test

A B L R - p a l p a b l e a t ro p h y of m u l t i fi d u s b i l a t e ra l l y, ofte n m u l tiseg m e n ta l l y U n a b l e to a ct i va t e t ra n sversus a b d o m i n is or m u l t i fi d us. M a rk e d su bsti t u t i o n w i th t h e g l oba l syst e m M a g n et i c res o n a n c e i m a g i n g - o f t e n rev e a l s e x c e s s i v e fa tty i n fi ltra t i o n of m u l t i fi d u s

( F i g . 9.25)

P I V M , PAV M , A S L R , a c t i v e stra i g h t l e g ra i s e ; A B L R , a c t i v e b e n t l e g ra i s e .

(a) F i gu re 9 . 2 2 A p a t i e n t w i t h a s eg m e n ta l fl e x i o n i n st a b i l i ty a t L5- S 1 . N o t e the seg m e n t a l ky p h os i s a t LS-S 1 i n s t a n d i n g ( a rro w ) ( a ) a n d i ts a c ce n t u a t i o n i n s i tti n g (b). I n a d d i ti o n , n ote t h e p oste ri o r p e l v i c t i l t ( a rro w) a n d l oss of t h e l u m ba r l o rdosis i n s i tti n g . A n indiv idual

with aflexion instability presents with a segmenta l kyph os is (Fig. 9 .22a) which is exagger­ a ted i n fl e x i on (forwa rd bending) . The seg mental kyphosis is a lso evident in sitting (Fig 9.22b)

and four-point kneeling and the ind ividual tends to rotate the pelvis posteriorly and ex tend the upper lu mbar a nd lower thora cic spine in both positions.

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151

1 52

T H E P E LV I C G I R D L E

An individ ual

w i th an ex tension ins ta bi l i ty pres­

ents with an excessive segmen tal lordosis which is

When

a

lumbar j oint i s uns table, the osteokine­

ma tic motion often co uples with a n unphysiol ogical

exaggerated in extension (backward bending) (Fig.

arthro kinema tic gl ide . For exa mple, flexion is nor­

9.23) . The pelv i s can be ei ther anteriorly tilted (Fig. 9.23a, b) or pos teriorly til ted (Fig. 9 . 13) and remain the re durin g backward b ending . The upper lumbar

m a ll y co u pled w i th a nterior tra nslation. When tl te segmen t is uns table , i t is not unco mmon to see flex­ ion couple ,",v i th p os terior tra nsla tion and extension

spine and lower thora x often remain flexed d uring

co uple w i th anterior translation (Fig .

ba ckward be nding such th a t the motion hinges

skin crease). Typical ly, an indiv id u a l w i th a flexion

a round the u ns table segment .

instability forward-bends by

A unila teral fl e xion in s t a bi l i ty results in a seg­ mental latera l shift . The se gmen t is kypho tic and

shifted la terally (Fig .

9.24) . The lateral shi ft becomes

exa ggera ted d u ri ng the one-leg s tand tes t and othe r unila t er a l l o a d in g tasks

-

see

below (O'Sullivan

2000) . The

d own the thi ghs (Fig. erect

s tanding .

9 . 25)

9 . 13:

wa lking

no te the

the hands

a nd back u p to re turn to

An individ u a l

with

a

p a infu l ex ten­

sion instabili ty backward-bends by flexing

at

the

talocrural j oin t s, a VOiding a ll extension ' The less p a inful pa tien t may ex tend the low back, maintain­ ing e i ther an ante riorly or pos terioriy til ted pelvic

s egment which

is uns t a b le

in m u l t i ple

direc­

tions (multidirectional instability) is severel y impaired. E xcessive s e g m enta l transla tion is evide n t in a U m ovement d ire c tions a n d estab l i shing con tro l i s

d ifficult.

gird le . In this situa tion, a deep skin crease appears a t the uns ta b le level (usua lly One-leg

sta n d i n g

The

L4

or

l a teral

L5) . shj ft instability

be c o m es

more evident d uring single-leg loa ding (Fig. 9.26a, b ) . With respect to in trapelvic motion, the

hip flexion phase of this test is n ot often impaired or

as y mmetric

in the

presence

of a l u mbar segme n t a l

ins tabil i ty; however, the sup p ort

ph a se

is often pos­

i tive. Lumbar segm e n t a l ins tabilities dramatica l ly impact the function of the deep fibers of multifi d u s

F i g u re 9 . 2 3

(a, b)

A p a t i e n t w i t h a seg m e n t a l exte n s i o n

i n s ta b i l i ty. N o t e t h e h i n g i n g of t h e t h o ra x i n t h e m i d l u m b a r reg i o n a n d t h e m a i n t e n a n c e o f t h e a n t e r i o r p e l v i c t i l t d u ri n g b a c k w a rd b e n d i n g .

F i g u re 9 . 2 4

A p a t i e n t w i t h a s eg m e n t a l l a tera l t ra n s l a t i o n

i n s t a b i l i ty t o t h e , l eft a t L4- L 5 .

Copyrighted Material

Defi n i n g the i m p a i r m e n t

and this imp a i rmen t is often mul tisegmenta l . If the

sacra l fibers of mu l ti fidus are im pa ired, then force clos u re of the pos terior p el v i s is reduced, l ea ding to a loss of the self-b racing mechanism for load trans­

fer through the pelvis (see The pel vic

girdle, below) .

Form c l o s u re : posi t i o n a l tests/m o b i l i ty/sta b i l i ty

In

the neutral res ting posi tion (lying p rone) the pos­ i tional fa u l t no ted in s t an d in g (postu re) may or m ay

not be eviden t . The passive os teokinema tic tests of mob il i ty (PlVMs) revea l the rel a tive excessive

angu­

lar motion (flex ion /ex tension); the arthrokinema tic

tes ts rev ea l a rela tiv el y la rger ne utral zone of motion and the elastic zone is often "softer. " Pain may or may not be p rovoked at the end of the elas tic zone depending on the irri tabil i ty of the local tiss ues . The pa ssive tests for a r throkinetic stabili ty rev ea l

the di rec tion of the t ranslatoric ins t ab ilit y (excessive an terior, pos terior, latera l transl a t ion, or rota tion) . Fo rce c l o s u re/moto r contro l

ment, the

a troph y

At the impaired seg­

of the deep fibers of m u l tifid us is

rea d ily pa lpated. Fi g ure

9.27 is a magnetic resonance

F i g u re 9 . 2 6

A patient with

a

postsu rg i c a l s e g m e n ta l l a te ra l

t ra n s l a t i o n i n sta b i l i ty a t L4- L5. N o t e t h e l eft l a t e ra l sh ift of t h e s e g m e n t d u r i n g ( a ) t h e l e ft o n e - leg s ta n d i n g test. H e is a b l e t o F i g u re 9 . 2 5

A p a t i e n t w i t h a seg m e n ta l f l e x i o n i n s ta b i l i ty typ i c a l l y fo rwa r d - b e n d s by w a l k i n g t h e h a n d s d o w n t h e th i g h s.

reta i n a v e r t i ca l o r i e n ta t i o n of h i s t r u n k to h i s p e l v i s d u r i n g ( b ) t h e r i g h t o n e - l e g sta n d i n g t e s t .

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1 53

1 54

T H E P E LVI C GIRDLE

the lateral recess. The relevan t dural ! neu ral mobil­ ity test would then be positive.

The spectrum

of

n eurol og ical impedance is variable and depends on

the degree of p athology. The pati e nt may present with minimal motor weakness or sensory dysesthe­

si a

in the ea rly stages, and la ter with a co mp lete

motor nerve block and sensory anesthesia. Ca reful obj ectiv e evaluation is manda tory to detect the ea rly neurolog ical decompensation.

T H E P E LV I C G I R D L E Repetitiv e trauma to the pelvic gird le can also res ult in a natomical cha nges w h ich lead to insta b i lity of

the SIJs and pubic symphysis. Unlike the lumbar spine, very lit tle anatom ica l Fig u re 9 . 2 7

A m a g n e t i c reso n a n c e i m a g e of t h e l u m bosa c r a l

j u n c ti o n . N o te t h e d a rk " h o l e s" i n t h e dee p fi b e rs of m u l t i fi d u s . T h i s i s l i k e l y d u e t o fa tty i n fi l t ra t i o n of t h e m u s c l e .

imaging image which shows m a rke d

fatty infiltra­ LS-Sl .

The

impaired function of m u l ti fidu s often coex ists wi th a ti ming delay or a bsence of co-con traction of the transversus abdominis unil aterally or bilateraIly. The ASLR test is positive and l umbopelvic control is lacking . The dysfunctiona l pattern used for lum­ bopelvic sta bili zation is highly variable and may include abdominal b ulgin g a nd breath-holding, excessive ob liq u e abdominal activation with thora­ columba r flexion and posterior pelvic tilt, excessive erector spinae activation with th or acolwn b a r exten­ sion, and anterior pelvic tilt or lumbopelvic la teral tilt and lor rotation. P a lp a ti o n of the seg menta l m u l tifidus and transversus abdominis d u ring the active bent leg raise and also during the co-con trac­ tion response to verbal cueing (see Ch.

8)

will reve al

the individua l's specific pattern of local system dy s­ function . If the local system is functioning opti­ m a lly and the force closure mechanism is intact, the neutral zone of motion can be s tabilized (reduced to

z ero) . If

the local system is functioning opti m ally

been done

insufficient articular compression of the pelvic j O in ts . The consequences of the hormonal changes of preg­ nancy have been disc ussed in Chapter

tion of the multifidus in an individual who demon­ strated m ul tidirectional instability at

research has

to docwnent the structural changes which occur with

6.

See Tab le s

9 . 1 0-9 . 1 2 for findings specific to each impairment .

S u bj ective fi n d i n g s

SIJ

The

and l o r p ubic symphysis can become unsta­

ble due to pregnancy, major trauma, minor repeti­ tive tra uma, or as a consequence of co m pe nsa t i n g for hypomobility of the hip or contralatera l

SIJ .

Consequently, the history can be quite v a riable . The pelvic pain is often, though not always, uni lateral in Fo r t n s distrib ution (Fortin et al 1994a, b) and ca n i

'

refer distally to the knee. The a ggravating activities fre quently include unila teral wei ght-bearing ( v e r ­ tical inst ability ) , bending forw ard or lifting (hori­ zonta l instabil ity), lyin g supine (especial ly if the long dorsal ligament is a pain gene r a to r) , and rolling

over from this position . The most comforta ble posi­ tion for the painful

SIJ

is sid e l ying in the sem i­

Fowler position with the p a inful side uppermos t. Comfort is enhanced with a body pillow that al lows the flexed hjp and knee to be s up ported

.

Obj ective fi n d i n g s

and the force closure mechanism is not in tac t, the

Gait

neutral zone of motion will remain excessive. This

exaggera ted when the

is a poor prognostic sign for s uccessful rehabilita­

a t t empts to compensate for the lack of stabi li t y by

tion through exercise .

The displacement of the center of gravity i s

reducin g

SIJ

i s unstable . The pa tie n t

the shear forces through the SIJ . In the

Impedance of neurologica l

compensated gait pattern, the p a tie n t transfers his

fu nction (motor, sensory, reflex) and neural mobil­

or her weight la terally over the in volved l i m b (com­

N e u ro l o g i c a l

tests

i ty can occ ur with this impairment since the transla­

pensated Trendelen b u rg sign), thus

toric insta b ilit y can interfere w i th the dimensions of

vertical shear forces through the joint (Lee

Copyrighted Material

re d

u cing the 1997a)

Defi n i n g the i m p a i r m e nt

Ta b l e 9 . 1 0

I n s u ffi c i e n t a rt i c u l a r c o m p re ss i o n - c l i n i ca l c l a ss i fi ca t i o n fo r t h e s a c ro i l i a c j o i n t ( S I J )

Vert i c a l patte rn - cra n i oca u d a l i n sta b i l i ty

-

SIJ

Onset

S u d d e n o r repe t i t ive vertica l l o a d i n g t h ro u g h the l o w e r extre m i ty o r isch i a l t u b e rosity

Agg rava t i n g a c t iv i t i es

S u sta i n e d verti ca l l o a d i n g (si tti n g , w a l k i n g , sta n d i n g , etc.)

Post u re/g a i t

U n eq u a l l o a d i n g t h ro u g h the l o w e r extre m i t ies. Co m p e n sated or true Tre n d e l e n b u rg g a i t

R eg i o n a l movem e n t

I n tra p e l v i c a sy m m etry prod u ced d u r i n g fo r w a rd b e n d i n g ; h o w ever, t h i s fi n d i n g m a y be i n co n s i s t e n t

tests

w h e n re p e a t e d . O n e - l eg sta n d i n g - h i p fl e x i o n p h a se reve a l s a sy m m et r i c m o t i o n betw e e n l eft a n d r i g h t s i d es. S u p port phase - m a y hav e g re a t d iffi c u lty w e i g h t - b e a r i n g u n i l atera l l y a n d w h e n t h i s i s possi b l e , t h e p a t i e n t i s u n a b l e t o fo rce c l ose t h e S I J s u c h t h a t t h e i n n o m i n a te rotates a n te r i o rly re l a t i ve t o t h e s a c r u m a n d flexes a t t h e h i p j o i n t

Fo rm c l osu re tests ( m o b i l i ty/sta b i I i ty)

P I V M - i n creased osteo k i n e m a t i c i n n o m i n a te rota t i o n o n s i d e o f i nsta b i l i ty PAVM - i n c reased a rt h r o k i n e t i c c r a n ioca u d a l t ra n s l a t i o n of t h e S I J w i t h associated i n c rea s e in t h e n e u tra l z o n e a n d a s o ft e r e n d -fe e l i n t h e e l ast i c z o n e A S L R - l o s s of l u m bo p e l v i c co n t ro l - t e n d to rotate to s i d e of e l eva t i n g l e g . M a y h a ve m a rked d i fficu lty

Fo rce c l o s u re a n d m o t o r co n t ro l tests

l i fti n g leg off the ta b l e. Effort d ecreases w h e n co m p ress i o n i s a p p l i e d to p e l v i c g i rd l e , oft e n both a n te r i o r and poste r i o r A B L R - pa l p a b l e a t ro p h y of sacra l m u l t i fi d u s u n i l a te ra l l y. U n a b l e to co-activate tra nsversus a bd o m i n is w i t h m u l t i fi d us. Va ria b l e loca l syst em dysfu n ct i o n a n d v a r i a b l e c o m p e n sa t o ry strate g i es

PIVM, PAVM, ASLR,

Ta b l e 9 . 1 1

a c tive stra i g h t l eg r a i s e ;

ABLR,

a c t i v e b e n t l e g ra i se.

I n suffi c i e n t a rt i c u l a r c o m p ress i o n - c l i n i ca l c l a ss i fi c a t i o n fo r t h e s a c ro i l i a c j o i n t ( S I J )

H o r i z o n t a l pattern - a n te r o p oste r i o r i n sta b i l ity - SIJ Onset

Tra u m a t i c - l i ft i n g/twist i n g i nj u ry

Ag g rava t i n g a c t i v i t i e s

Susta i n e d fo rwa rd b e n d i n g

Po stu re/ g a i t

Pe l v i s a p pea rs tw i sted - sacru m a p pe a rs rota ted i n sta n d i n g s u c h t h a t t h e i n fe r i o r l a te ra l a n g l e s a re n o t l eve l . M i n i m a l i n t ra pe l v i c m o t i o n d u ri n g g a i t

Reg i o n a l movem e n t

I n t ra pe l v i c asy m m e t ry p rod u ced d u ri n g fo rwa rd b e n d i n g ; h o w ev e r, t h i s fi n d i n g m a y b e i n co n s iste n t

tests

w h e n repe a t e d . Pa t i e nts te n d t o w a l k w i t h t h e i r h a n d s d o w n t h e t h i g h s a n d b a c k u p t o ret u rn to s ta n d i n g . O n e - l e g sta n d i n g - h i p flex i o n p h a s e revea l s asy m m e tric m o t i o n bet ween l eft a n d r i g h t s i des. Su p p o r t p h a se - m a y h av e g re a t d i ffi c u l ty w e i g h t - b e a r i n g u n i l a t e ra l l y and w h e n this i s poss i b l e , t h e pati e n t is u n a b l e t o fo rce c l ose t h e S I J s u c h t h a t t h e i n no m i n ate rotates a n te r i o rly re l a tive to t h e sa c ru m a n d fl exes at t h e h i p j o i n t

Form c l osu re tests

PIVM - i n creased oste o k i n e m a t i c s a c r a l n u t a t i o n/co u n tern u ta t i o n o n s i d e of i n sta b i l i ty

( m o b i l i t y/sta b i l i ty)

PAVM - i n c reased a rt h r o k i n e t i c a nt e ro poste r i o r t ra n s l a t i o n of t h e S I J w i t h assoc i a t e d i n c rea s e i n t h e n e u t ra l z o n e a n d a softer e n d -fe e l i n t h e e l as t i c z o n e

Force c l o s u re a n d

A S L R - l o s s o f l u m bo p e l v i c co n t ro l - t e n d to rotate to s i d e of e l eva t i n g l e g . M a y h a v e m a rked d i ffi c u l ty

m o t o r c o n trol tests

l i fti n g l e g off t h e ta b l e . Effo rt d e c reases w h e n co m p ress i o n is a p p l i ed to p e l v i c g i rd l e, oft e n best poste r i o r

ABLR

-

p a l p a b l e a t ro p h y of sac ra l m u l t i fi d u s u n i latera l ly. U n a b l e to c o - a ctivate tra n sversus a b d o m i n i s

w i t h m u ltifi d u s often u n i l a te ra l ly. Va ria b l e loca l syst em dysfu n ct i o n a n d t e n d t o c o m p e n s a t e by activa t i n g p i r i fo r m i s and isch i ococcyg e u s , w h i c h may excess i ve l y co m p ress t h e j o i n t : the u n d e r l y i n g stab i l i ty i s o n l y rev e a l e d o n ce t h ese m uscles a re re l eased

PIVM, PAV M , ASLR,

a c t i ve stra i g h t leg r a i s e ;

ABLR,

a c t i ve b e n t l e g r a i s e .

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T H E P E LVIC GIRD LE

Ta ble

I n s u ffi c i e n t a rt i c u l a r com p ressi o n - cl i n i ca l c l a ss i f i ca t i o n fo r t h e p u b i c sy m p h ysis

9.1 2

Vert i ca l pattern - cran i o c a u d a l i nst a b i l i ty - p u b i c sym p h ysis O n set

Tra u m a o r p reg n a n cy

Agg rava t i n g

Su sta i n ed vertica l l o a d i n g (sitti n g , w a l k i n g , sta n d i n g , e t c . ) , o r a b d u c t i o n /exte rna l ro t a t i o n of t h e h i p .

activities

Ro l l i n g over i n b e d a n d/or g e tti n g o u t o f a ca r a re t w o c o m m o n a g g ra v a t i n g activities

Pos tu re/g a i t

U n eq u a l l o a d i n g t h ro u g h the l o w e r extre m i t i e s. Com p e n s a t e d or tru e Tre n d e l e n b u rg g a i t

Re g i o n a l

I n tra p e l v i c a sy m m etry p rod u ced d u r i n g fo rwa rd b e n d i n g ; h o w ever, t h i s fi n d i n g m a y be i n co n s i ste n t w h e n

m ove m e n t tests

repea ted. O n e - l e g sta n d i n g - h i p fl e x i o n p h ase rev e a l s sym m e tri c m o t i o n between l e ft a n d r i g h t s i d es . S u p p o rt p h ase - m a y have g rea t d i ffi c u l ty w e i g h t -bea r i n g o n e i t h e r l e g a n d w h e n t h i s i s possi b l e , t h e p a t i e n t i s u n a b l e t o fo rce cl ose t h e p u b i c sy m p h ysis s u c h t h a t t h e i n n o m i n ate rotates a n te r i o r l y re l a t ive t o t h e sacru m a n d flexes re l a t i ve to t h e fe m u r b i l a t e ra l l y

F o r m c l o s u re t e s t

PIVM - i n creased oste o k i n e m a t i c i n n o m i n a t e rota t i o n on both i n n o m i n a tes

( m o b i l i ty/sta b i I i ty)

PAVM - i n creased a rth ro k i n e t i c cra n i o ca u d a l tra n s l a t i o n of the p u b i c sy m p hy s i s w i th associa ted i n crease in the n e u t r a l zone and a softer e n d -fe e l i n t h e e l as t i c zone. Th i s l e s i o n i s often assoc i a t ed w i t h m a rked local pa i n

Force c l o s u re a n d

ASLR - loss o f l u m b o p e l v i c con trol - t e n d t o rota te t o s i d e o f e l evati n g l e g . M ay have ma rked d i fficu l ty l i ft i n g leg off t h e t a b l e . Effo rt decre a ses w h e n com p ressi o n i s a p p l i e d a n teriorly to p e l v i c g i rd l e a t t h e l ev e l

m o t o r con trol tests

of t h e p u b i c sy m p h ys i s A B L R - m u l ti fi d u s is o f t e n n o r m a l ; h o w ever, t h e co-activa t i o n of t h e p u bo coccyg e u s a n d tra nsvers u s a b d o m i n i s i s l a c k i n g . M a y o r m a y n o t be a ssoc i a t ed w i t h a d i asta s i s of t h e l i n e a a l b a

PIVM, PAVM, ASLR, a c t i v e st ra i g h t l e g ra ise ; A B LR , a c tive b e n t l e g ra i s e .

(Fig.

6 . 25) .

In the non-compensa ted g a i t p a t tern, the

p a tient tends to demons tra te a true Tre ndelenb urg sign (Fig.

6.26) .

The pelvic girdle adduc ts exces­

si vely (on the unstable weight-bearing side) . The femu r abducts rela tive to the fo ot, thus bringing the center of g r a V i ty closer to the SI] , and reduces the vertical shear force. Posture

I n s tand ing and

tends to adopt

a

s i tting, the p a tient

res ting posture w h ich unloads the

a ffec ted SIJ . Reg i o n a l

inconsistent

m ove m e n t tests

fin d ings

I n forward bending,

p reva i l .

D uring

one

test,

asymme try ( intrapelvic torsion) may be presen t. In

to meet the following c ri teri a : 1 . unil a teral pelvic pain w hich was a ggrava ted b y

vertical load ing acti v i ties 2 . positive fo rward ben ding tes t in standin g

( intrapelvic torsion) 3 . positive

hip flexion phase of the

one-leg standing

tes t (asymme try of motion be tween sides) 4. positive ASLR 5 . asymmetric stiffness va lues for the SIJs on joint

play tes ting . Hungerford noted the fo llo wing:

the next, i t m a y be absen t and in a s ubsequent test

1. Hip flexion phase: posterior ro tation of the

the asymme try may re turn. This is consis ten t w i th

inno minate occ urred on the non -weight-bea ring

ineffec tive force closur e of the pelvic gird l e . If the

side (side of hip fle x i on) and was associa ted w i th an

sacrum is u nable to stabi lize

between the

innomi­

a n terosuperior a r throkinematic glide (Fig.

6 . 1 1 ) . An

na tes a l l movements may be inconsis tently a ffec ted

a symme tric amoLm t of movement occurred between

w i th or w i thou t pain .

the two sides and the unstable side did not a lways

O ne-leg sta n d i n g

HLmgerford

(2002) investiga ted

present with the greatest amoun t of movement in tru s

the osteokinem a tic and a rthrokinema tic mo tion of

test. This finding confirms Sturesson et a J's impres­

the i nnomina te rel a tive to the sacrum in both men

sion

and women who clinically mani fes ted signs of fa iled

mine mobi lity of the SIJ .

(2000)

tha t this tes t sho uld no t be used to d e ter­

l oad tra nsfer throu gh the pelvis (ineffec tive force

2. Support phase: anterior rota tion of the support­

closure ) . For inclusion in this study the s u bj e c t had

ing innomin a te occ urred on the weigh t-bea ring side

Copyrighted Material

Defi n i n g t h e i m p a i rm e n t

(side away from hip flexion) and was associa ted

mechanism is intact, the neu tral zone of mo tion can

w i th all.

be s ta bil ized (reduced to zero ) .

inferior and

pos teri or a r throkinema tic gl i d e

of the innominate re la tive to the sacrum ( F i g .

6.14).

If the l o c a l syste m is

functioning op tima lly and the force closure mecha­

This s uggests tha t there was insuffi cent compression

ni sm is

to effectively "lock" the S1] d u ring load trans fer. In

remain excessive. This i s a poor prognos tic sign for

a prev ious study of norm a l s ubjects, Hungerford

s uccessful rehab ilitation through exercise.

not

intact, the neutral zone of m o tion wi l l

(2002) found tha t the inn o mina te posteriorly ro tated

N e u ro l o g i c a l tests

rela tive to the sacrum and glided posteriorly and

func tion of the L5 and

superiorly

d uring weight-bearing ( see Ch. 6).

SI nerve roots when the SIJ

h a s been unstable for some time. Table

Form c l o s u re : p o s i t i o n a l tests/m o b i l i ty/sta b i l ity

the absence of a fix a ti on of the

I t is common to see loss of

In

S1], the positional find­

ings are often unrema rkable. The passive osteokine­

9 . 1 3 summarizes the fin dings, imp a irment

classifi c a tion and subseque n t trea tment require­ ments for d ysfunc tion according to the in tegrated model of function.

ma tic tes t s of mobility (PIMVs) reveal a s ymme tric a ngular motion for a n terop o s terior rotation of the inn ominate and / or n u tatio n / counternutation of the sacrum; the unstable side has rela tively more motion. The a r throkinema tic tests reveal asymmetry of neu­ tral zone motion ( less s t i ff on the uns table side). The end - feel of the elastic zone is often so fter and p a in may or may not be provoked depending on the i rritabili ty of the local tissues . The passive tests for a r throkinetic

s tabi l i ty

of e i ther

the

SIJ or the

p u b l i c symphysis reveal the d i rec tion of the transla­ toric ins tability (excessi ve hor i zontal or vertica l transla tion) . Fo rce c l o s u re/motor c o n tr o l

Force clos ure of the

pelvic girdle relies on o p t i m a l func tion of the deep fibers of the sacral m u l ti fi d us, transversu s abdo­ minis, and the pelvic floor. Dysfunc tion o f the local system (e.g., l i nea a l b a d iasta sis, a trophy of the deep fibers of m u ltifi d us, timing del ay, or absence of recruitment of transversus abd ominis and the pel vic floor) can be fo und in any combination and c re a te

sub tle

malal ignmen t (Scha mberger

2002)

I N S U F F I C I E N T U R ET H R A L C O M P R E S S I O N : S T R E S S U R I N A RY I N CO N T I N E N C E Urina r y inc ontinence

(UI) i s defined a s the involun­

tary lea kage of urine w hich is o bjec tiv ely demon­ stra b l e . Stress urin a ry incontinence

(SUI: leak age

which occurs d u ring physic a l exertion) i s the most common type. Urge urinary

incontinence (UUl) is

defined as leakage which i s

precipitated by a

sud den s trong urge or desire to void and often occurs a long w i th sur (m ixed or MUI) . Accordin g t o DeLancey

( 1994):

Du ring a co ugh urethral clos u re press u re is known to rise sim ulta neously

w i th

abdominal p ress u re to keep

the u reth ra closed in spite of grea t increases in i n t rav­ esical press u re. S t ress u rinary incol7 linence occurs beca use this normal tran smission of abdo m inal p res­ sure to the urethra is lo s t .

Essenti ally, ineffective force closure of the u rethra and

(all. terior / posterior innomin a te rotati on, inflare /

failed load transfer thro ugh the o rgans of the pelv i s

o u tflare of the innomina te, sacral torsions - forward

lead to S U I . H o w common is this? The prevalence o f

or b a c k w a rd) . The ASLR tes t is p o s i tive and lum ­

this condition v aries according t o age, study design, and definition. Ash ton-Mi ller e t al (2001) sta te tha t 8.5-38% of women experience SUI . Nyga ard et al (1994) note that this c ondition is not limi ted to women bea ring children and tha t in a s tudy of 144 nulliparous fema le a thletes aged 18-21 years, 28% suffered from SUI. 60 & Borgen (2001) found that 41 % of elite female a thletes experience SU I . Carr iere quotes Fant! et al ( 1996) and s ta tes that incontinence affects four out of 10 women, about one ou t of 1 0 men, and about 1 7 % o f child ren below the age of 1 5 .

bopelvic con trol is lacking. The dysfunc tion a l p a t­ tern u sed for l u m bopelvic stabiliza tion is highly va riable a nd may include abdo mina l b u lging and brea th-ho ld ing, excessive oblique a b d om in a l a c ti­ v a tion w i th thoracolumbar flexion and posterior pel vic t i l t, excessive erector spinae a c t i v a tion with thoracol umb a r ex tension, and an terior pelvic ti l t or l umbopel v ic l a teral ti l t a nd / or rotation. Palp a tion o f the segmental m u l tifi d u s a n d tra nsvers us abdo­ m inis d u rin g the active bent l e g raise and also d ur­ ing the co-con tra c t i o n response to verbal c ueing

Clearly, this is a Significant problem b u t is it a

dif­

8) will re veal the individual's specific p a t­ tern of loc a l system dysfunction. If the l o c a l system

ferent

is

common to hear women complain of both low back

(see Ch.

fu nc tio ning

o p tima lly

and

the

force closure

problem than

a

loss of effective force c los ure

of the musculoskeletal elements of the pelvis?

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It is

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T H E P E LV I C G I R D L E

Ta b l e 9 . 1 3

I m p a i red l u m b o p e l v i c- h i p fu n c t i o n Excessive a rticu l a r compress i o n Arti c u l a r p a t h o l ogy c a u s i n g c a p s u l a r

Overa c t i v i ty of g l oba l syste m - u n i l a te ra l

fi bros i s - u n i l a tera l

Fu n ct i o n a l fi n d i n g s

Fo rward b e n d test - a sy m m e t r i c

Fo rwa rd b e n d test - a s y m m e t r i c

O n e - l eg sta n d i n g

O n e- l e g st a n d i n g

H i p fl e x i o n - asy m m et r i c

H i p fl e x i o n

S u p p o rt - v a r i a b l e

S u p p o rt - i m p r o p e r patt ern i n g

..l. Active + p a ssive osteo k i n e m a t i c moti o n ..l. Arth ro k i n e m a t i c m o t i o n ¥ " H a rd e n d -feel e l a st i c z o n e ..l. N e u t ra l z o n e

Form c l o s u re fi n d i n g s

F o r c e c l o s u re motor c o n t r o l fi n d i n g s

Tre a t m e n t

-

asym m e t r i c

..l. A c ti ve + passive osteo k i n e m a t i c ..l. Arth ro k i n e m a ti c m o t i o n ..l.

¥ N e u t ra l z o n e

motion

�

Resi sta n t e l a s t i c z o n e

Co n s i st e n t - d o e s n o t

Resista nce v a r i e s w i t h

v a ry w i t h s p e e d

s p e e d of test

i n creases

A S L R - effo rt to l i ft l e g i n c reases

ASLR - effo rt to l i ft leg

when co m p ress i o n a p p l i e d to p e l v i s

w h e n com p re s s i o n a p p l i e d to p e l v i s

Pass ive a rt i c u l a r m o b i l i z a t i o n Su sta i n e d g ra d e

N e u ro myofa s c i a l r e l ease

• m u s c l e e n e rgy

4

• fu n cti o n a l • t r i g g e r poi n t r e l e a se •

I M S a c u p u nct u r e

Resto re l o ca l

ASLR,

a c t i v e s t ra i g h t l e g ra i s e ;

I M S,

+ g l oba l system fu n c t i o n

i n tra m u s c u l a r s t i m u l a t i o n .

and pelvic pain as well as ur and therapists com­

continence is achieved during physical exert ion.

monly

Essentially, continence relies on o p ti m a l func tion of

note

tha t

trea ting

one

component often

impacts the o ther. Minima l resea rch has been done

h-v o systems - the u rethral support sys tem and the

on

sphinc teric closure system .

the

correla ti on

between

the

two

functional

impairments. In reviewing the li terature, it ap pears tha t Panj abi's stabil i ty model (Fig.

5 .3) can be applied

to the u rethra as well as to the muscul oskeletal system.

U reth ra l s u p po rt system The structures 'which provide suppor t for the urethra include:

U R I NARY CONTI NENCE •

In

an

excel len t review ar ticle, Ash ton-Mi ller et al

(2001) clearly explain the mecha nism by which

the passive system : this includes the endopelvic

fascia which is anchored to

a

thick fascial band

called the arc us tendineus fasc i a e which a rises from

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Defining the i m p a i r m e n t

Ta b l e 9 . 1 3

1 59

Con t 'd

I n sufficient a rticu l a r com pression ---+--J o i n t fixa tio n

Articu l a r pa t h o l o gy c a u s i n g

U n d e ra c t i v i ty of l o c a l syst e m

I

l i g a m e n to u s l ax i ty - u n i l a te ra l

Forw a rd b e n d test

- a sy m m e t r i c

O n e - l e g s ta n d i n g

Fo rward b e n d t es t - i n consistent + va r i a b l e

Fo rw a rd b e n d t es t - i n co n si sten t l y va ri a b l e

O n e - l e g sta n d i n g

O n e - l e g sta n d i n g

H i p f l ex i o n - a sym m e t r i c

S u p p o rt

-

u n a b l e to we i g h t bear

H i p flex i o n S u p po rt

t h ro u g h a ffected side

Co n s i st e n t fi n d i n g i s i n co n s i stency

M a rked pos i t i o n a l c h a n g es

J, Act ive + ¥

passive osteok i nematic m otion

�

B l ocked n e u t ra l

C a n ' t fi n d j o i n t

zo n e

p l a n e to test

J, Active osteoki n e m a t i c m o t i o n i Passive oste o k i n e m a t i c m o t i o n i A rt h ro k i n e m a t i c i

e l a stic zone ASLR - m a rked d i ffic u l ty to l i ft l e g

- va ries - va ries

H i p flex i o n - asym m e t r i c S u p p o rt - i m pro p e r p a tt e r n i n g

/

N e u t ra l z o n e

motion

......

i Ac t i ve + p a s s i v e osteo k i n e m a t i c i Art h ro k i n e m a t i c m ot i o n i

/ Neutral zone

motion

...... N or m a l e l a s t i c zo n e

Soft n o n - resiste n t e n d fe e l i n e l a st i c z o n e

+

ASLR - effort to l i ft l e g d ra m a t i ca l ly

A S L R - effo rt to I i ft l e g d e creases

e ffo rt d r a m a t i c a l l y i n c reases w h e n

d e c reases w h e n co m p ress i o n a p p l i e d

w h e n co m p ress i o n s p e c i fi c a l l y

c o m p r e ss i o n a p p l i e d t o p e l v i s

t o p e l v i s ofte n a nyw h e re

a p p l i e d t o p e l v i s t o si m u l a te w h e re m o re c o m p re s s i o n is n e e d e d

Art i c u l a r d i stracti o n m a n i p u l a t i o n

P r o l o t h e ra py a n d / o r m otor control

M o t o r co n t r o l retra i n i n g of l o ca l +

Re -eva l u a t i o n us u a l l y rev e a l s a n

retra i n i n g of loca l + g l o b a l sys t e m s

g l o b a l sys t e m s

u n d e rly i n g i nsta b i l i ty ( see l i g l a x i ty )

I

the p u bic bone a nteriorly and inserts into the ischial sp i n e ( Fi g s 4.28 and 4.29) • the active system for thi s fascial hammock o r s l ing: this inc ludes the levator ani muscle which c o n ta i n s p r i m ar i l y type 1 fibe rs and exhibi ts con­ stant tone • the control system : th i s includes th e pudendal nerve which innervates the levator ani as well as the c e ntr a l con trol of reflex fun c t i o n b e tween the detru­ sor m uscle and th e p e l v ic floor. To g e th er, the p a s si v e and a ctive sys tems form a hammock of support for the urethra (Fig. 4. 29) and th e i ntegri t y/ fu n c ti o n of these tissues is essential if

force closure of the ure thra is t o be effe c tiv e. If this system gives w a y e a s ily, it c annot prov id e a back­ s t op a gains t which the urethra c a n be compressed . A useful anal o gy ( Ashton-Miller e t al 2001) is to im a gine a garden hose (urethra), with ,v at e r [LID­ n in g thr o u gh it (urine), l y in g on a tr a mp o line be d (the p e lv ic floor) . S tep p ing on the hose will b l o c k the flow of wa ter if the bed is very s tiff and p ro v i de s an equa l and o pp os i t e c o un t e rfo rc e ( fun c t i o nal pelvic fl oo r ). If however, the bed is v e ry flexible (i.e., there is loss of myofascial support), the do w n wa rd pressure on th e hose will ca use the bed to stretch and allow the hose to indent the bed. The flow of w a ter will c on tinue uni n t e r rup t e d .

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T H E P E LV I C G I R D L E

S p h i n ct e r i c cl osu re syste m

In ad d i t i on, the ure thra is closed by a system of both intrinsic and extrinsic m uscles: • The striated muscles w i thin the wall of the ure­ thra (intrinsic) c on tra ct prior to any pressure received by the b ladder, s u gg es t ing an a n t ic i p at ory neural re spo n se mecha nism (media ted by the p u dend a l nerve?) • The s tria ted urethral sphincter muscles (extrin­ sic compressor urethra and u r ethro v a ginal sphinc­ ter mu sc l es) are also c om p ri se d of type 1 fibers and are well s uited to mainta in co n s tan t ton e . .

(1 9 8 2) measured the intra­ ure thral and in trabladder pressures in he al th y conti­ nen t wo men during the Valsalva m ane uv er a n d c o u ghin g and fo un d tha t d u rin g a cough the in tra­ u re thral pressure increases before any press ure increase is detec ted in the blad der by a ppro x i ­ ma tely 250 ms. This did not occur du ring a Va l s a lv a (bearing down or stra ining) . Thi s suggests an an tici­ p a to ry reflex between the pelvic floor a nd urethra ( the pelvic floor is active d urin g a c o u gh and inac­ tive during a Va lsa l v a ) . This an tic i p a to ry closure of the urethra w a s confirmed in a subsequent stu d y by Thind et a l ( 1 99 1 ) . They also noted tha t the urethra l pressure rema ined eleva ted fo r a short time a fter the pressure normalized in the bladder. Bo & Stein ( 1 994) used needle e lectr o m yogra m (EMG) to measure a cti v i t y in the urethral wall dur­ in g a c o u gh and Valsalva as well as during ac ti­ va tion of the hip adductors, abdominals, and gl u te al muscles . They fo und tha t the urethral wall con­ trac ted synergis tically with the pelv ic floor, hip a dd u c to r s and g l u t e a l s a nd also d u ring a co u g h They conclude tha t s trengthening the pe lv iC floor will also strengthen the urethral wall, but w i l l it restore the a ntic i p a t o ry reflex mechanism? Sapsford et al (200 1) investiga ted the co-activa tion p attern of the pelv ic fl o or and abdominals via nee­ dle EMG fo r the abdominal wall and s u rface EMG for the pelvic floor and found tha t the abdomina Is c o n t r a ct in res p o nse to a pelvic floor c on tr a c ti on command and tha t the pelvic floor contracts in both a ho ll o wing and "bracing" abdominal comman d . They a l s o fo u nd tha t a s u b m a x i m al command of pub o c o ccy g e Lls elicited the greatest re spo n s e in tran s­ versus abdom inis . The results from this resea rch sugges t tha t the pelvic floor can be fac ilita ted by co-activa ting the deep abdominals a nd vice versa . H o we v er ; it is wrong to assume that all pa tien ts will Cons t a n tinou & Govan

,

"

.

"

be able to contract the m uscles of the pelvic floo r thr o ugh verbal c o mm an d s alone, ei ther through the abdomen or the pe l v i c floor. Bump et al (199 1 ) found that only 50% of wo men could actually perform a pelvic floor muscle contra cti o n wi th j us t a verbal ins tru c ti o n Careful analysis (see Ch. 8) is required to ensure that the reflex connection between the trans­ versus abdominis and the pelvic floor is intac t before this s tra tegy is used . .

ST R E S S U R I N A R Y I N C O N T I N E N C E SUI can res u l t when there is loss of the in te g rit y, or function, of the pelvic floor ( muscles a nd fasc i a) sec­ on da ry to a major tra uma or m i c ro tra uma over pro­ longed periods of time. Inefficient load transfer s tra te gi es through the low back and pel v i s p a r ti cu ,

­

larly those which excessively increase the intra­ a b d om inal pressme and res ult in the bladder b e in g re p e ti tively compressed inferiorly, can lead to inc on tine n ce. Some of these s tra tegies have a lre a dy been mentioned and include ab d o m i na l bulging and breath-holding, excessive ob l i que abdomina l activa tion with th o r aco l u mb a r flexion and po s t e r ior pelvic tilt, excessive erector spinae ac t i va ti o n w i th thoracolumba r extension, a n d a n t er i o r pel v i c tilt. When the bladder is observed wi th rea l-time ul trasound imaging, it can be seen that these s t r a tegies ca use the bladder to descend ( F i g s 8.S5b and S.86b ) . In a g ro u p of pelvic pain patien ts, O'Su ll ivan et a l (2002) noticed via real-time u l t r a s o und i mag­ ing th a t the bladder tended to descend during an ASLR tes t. When compression was ap pl ied to the pelvic gir d le , this descent was minimi zed. How m uch descent of the bladder i s op timal, o r normal, d u ring fu nctional activi ties? Peschers e t al (2001b) measured the mobi l i ty of the b la d d e r neck via perineal u l trasound d u r i n g co u gh in g and Vals a lva in 39 he a l th y, nu l lip a r o u s women. They found tha t the bladder neck descended a v a ri a b le amount (2-32 m) in both a c o u gh a nd Valsa lva and questioned th e l o n g h e l d view th a t SUI was associ­ ated wi th ure thra l mobili ty. Like th e SIJ ( Buyruk et a l 1995b), there appears to be a w i d e variation in the a m O Lm t of motion possible and con tinence (effec tive force closure of the urethra) relies mo re on control and urethral c l osure ra ther than a mp l i t u de of motion of the urethra . Howard et al (2000) inves tigated descent of the bladder neck durin g a c o u gh and Valsa lv a in three groups of w om en : nulli p a ro us continen t ( 1 7 s u bj ec ts ) ,

Copyrighted Material

­

­

-

Defi n i n g t h e impa i rm e n t

pri m ipa ro u s contin e n t

( 1 8 s ubj ec ts ) , and pri m i­ (23 subjects ) . There was no s ta­

can

pa rous incontinent

end opelvic fasc i a . Th i s effectively re d uces the s t i ff­

tistical

occur

which

causes

a

sepa r a tion

in the

difference in the amount of b l a d d er neck

ness of the fasci a l layer which s up p o rts the urethra

mobility between the groups, a gain s u ggest in g tha t

and can occ ur uni l a terally or bila terally. When this

moveme n t o f the ure thra is

not w h a t de term ines

occurs, the pelvic floor must take over to supp ort

one 's continence status . When they com p a re d t h e amOLm t of bladder neck movement which occurred

ure thra. However, they note: "if the muscle is com­

cough compa red with a Valsalva, they

ple tely de tached from the fascia l tissues, then it

du ring

a

the organ p o s i tion and provid e active closure to

the

no t e d tha t in the two continent groups there was

may be able to contract; but tha t contrac tion may

less movement

co ugh. The incon tinent

not be effective in eleva ting the urethra or stabiliz­

g roup c onve r sely demons tra ted n o difference in the when the subjec ts co ughed or

ing i ts position " ( A sh ton-Miller e t aI 2001 ) . B o e t a l ( 1 990) demonstra ted in a randomized clini c a l trial tha t ret ra ini ng the fu n c tion of the pel v ic floor ( a w a reness tra ining coupled with s trength a n d end u rance tra ining: see Ch. 10) is effec tive for some women (60%) in the treatme n t of SUI . Their program i s c o up led w i th exercises w hich a im to

during a

am ount of move m en t

did

a

Va lsa l v a . Clearly,

s o me thing was happe ning

d u ring a co u g h in the continent women th at waS no t hap p e n ing in the incontinent group. All th ree groups generated the same a mo u n t of cough pres­ sures; however, the stiffness value (press ur e change d ivided by b l a d d e r neck mobi l i ty ) was the g rea te s t

res tore force closure of the pelv ic girdle ( transver­

in the null i p a rous c o n t inen t

s us ab dominis and m u l t i fi d u s ) .

group, next highes t

in the p r i m ip a rou s con tinen t group, and lowest in the primi p a ro u s inc ontinent gro u p . How a rd et al hypothes ize th a t the re ason for these d ifferences is a functional p e lvic Thind et a l

floor in

(199 1 ) no ted tha t t h e a m p l i t u d e of the

an ticipa tory p ressure rise in th e u r e thra was less in

women with SUI

and s uggest tha t this

is due to

et a l ( 1 990) in ves t i g a ted 96

nulliparous

w o m e n both pr e n a ta ll y and postpartum to d e ter­ mine if childbirth caused damage to the pelvic flo o r

muscles a

and/ or its nerve s upply.

va g ina l

I b e l i eve t h a t o rt h o p e d i c m a n u a l t h e ra p ists w h o

foc u s o n resto ri n g fu n c t i o n t o t h e l oca l syste m o f t h e l o w b a c k a n d p e l v i s (tra nsversus a b d o m i n i s , m u l ti fi d u s, a n d t h e p e l v i c fl o o r) a n d t h e ra p ists w h o

weakness of the pelvic floor. Allen

Summary

the c on ti nen t wome n .

They sho w ed tha t

delivery impa irs the s trength of the pelvic

speci a l ize i n p e l v i c fl o o r dysfu n ct i o n a re tre a t i n g t h e sa m e co n d i t i o n - fa i l ed l o a d tra n sfer t h ro u g h t h e l u m b o p e l v i c reg i o n , m a n i fested e i t h e r t h ro u g h a l oss of effective force c l osu re of t h e j o i nts of t h e l o w b a c k a n d p e l v i s , o r l oss of effective fo rce c l o s u re o f

floor and no ted tha t recov ery had not occu rred at

t h e u re t h r a . T h e resea rch c l e a rly s u p p o rts t h a t w e

2 mon ths postp a r t u m . They also demonstra ted via

a re m e rg i n g to a co m m o n u n d e rsta n d i n g o f b o t h

need le EMG tha t vagina l delivery

caused a p a rtial denervation of the pelvic floor in 80% of these

fu n c t i o n a n d dysfu ncti o n of t h e w h o l e pe l v i s a n d n o t j u s t i ts pa rts. Tre a t m e n t of the i m pa i re d l u m b o p e l v i c ­

women. Women who had a long, ac tive second

h i p reg i o n m u st fo c u s o n a n i n teg ra t e d a p p ro a c h -

stage of la b or

o n e w h i c h c o n s i d e rs t h e restora t i o n of fo rm c l o s u re.

showed the most EMG e vi d e nc e of d enerv a tion. Ash ton-M i l le r et a l (200 1 ) feel tha t if the nerve to the l e v a tor ani is d a maged, the dener­ v a ted m uscles wi l l a trophy, thus pla cin g more s tress

force c l o s u re, a n d motor c o n t r o l of a l l the structu res co n ta i n e d w i t h i n t h e reg i o n . U l t i m a t e l y, fu n c ti o n req u i res m o b i l i ty w i t h sta b i l i ty ( m o b i l e s ta b i l i ty -

on the p a ssive sup porting s truc tures (endopelvic

n o t ri g i d i ty) of t h e j o i nts a n d o rg a n s, fo r a ny

fa s cia ) which over ti m e

e n d e a v o r t h e i n d iv i d u a l c h o o ses to d o .

will s tretch

and result in

organ p ro l ap s e. Alterna tely, a p a r a v a gina l defe c t

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1 61

1 63

Treating the lumbopelvic-hip dysfunction Linda-Joy Lee

;----:- .' ••�. -. -.....

1.

,

.

.,.

Diane Lee

>- I

-

l'

"

....

I

,"

\ ,

166

Restoring form closure (mobility) - sacroiliac joint

170

Restoring form closure (mobility) - hip joint

177

Sacroiliac belts and taping Prolotherapy

180

unique cl inical presenta tion. Rarely will only one dysfunction be present (one stiff join t or one poorly controlled joint); m ore commonly, m u l tiple prob­ lems coexist such tha t the most effec tive treatmen t consis ts of a un i que combina tion of techniq ues and

the therapis t who is inexperienced in working wi th this model. The fir s t step is to analyze th e findings

18 1 182

Techniques to correct alignment

must be prescriptive since e very individual has a

are some principles for tre a tment which help guid e

18 1

Reducing rigidity - downtraining the global system

195

from the assessment (Ch.

•

196

Adding proprioceptive challenge Addressing specific global muscle 24 1

Addressing specific global muscle 245

under too little compression due to

recruitment and timing of the local system (force clos ure / motor control), or •

2 15

"tightness"

primarily

neutral zone of mo tion, and / or insuffi cient

214

Coordinating the local and global

"weakness"

too much compression from stiff

loose joints (form closure), a poorly controlled

Co-contraction and endurance training for

systems

primar i l y under

globa l system (force closure / m otor control)? •

199

the localsystem

Does the individ ual

joints (form closure) or hyper tonicity of the

Isolation and awareness training for the local system

8).

appear to be:

Decompression via intramuscular stimulation

I

exercises specific for each patient. Howe ver, there

Restoring force closure and motor control

- .!

Treatment for the impaired lumb opelvic-hip region

163

Restoring form closure (mobility) - lumbar zygapophyseal Joints

. t

GENERAL PRINCIPLES

CHAPTER CONTENTS General principles

,

240

a combination of both too

much

and too

little

compression in different areas of the

lumbopel vic-hip co mpl e x? In the first instance, the therapis t may decide to use manual techniques and exercises which decom­ press the joints (in c rease mobility) and follow this with an exercise p l an that re-establishes a more optimal s tabiliza tion s trategy which emphasizes s tability with m obility. In the second instance, the therapist may decide to s tart a program whi c h emphasizes retraining of the local sys tem

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right

1 64

T H E PELVIC G I R DLE

away (increase stability) and then add decompres­ sion techniques/exercises (increase mobility) later as necessary. The most common scenario is the third, where a combination of decompression and stabilization is required. Continual assessment of form closure (mobility/stability of the joints) and force closure/motor control helps direct the ther­ apeutic plan from treatment to treatment. T he effective management of lumbopelvic-hip pain and dysfunction requires attention to all four components - form closure, force closure, motor control, and emotions. Ultimately, the goal is to teach the patient a healthier way to live and move such that sustained compression and/or tensile forces on any one structure are avoided. The ther­ apist uses manual skills to facilitate this process; however, the primary role is to educate and coach the patient through the recovery process since only the patient can make the changes necessary for opti­ mal function. If the clinical findings suggest that decompres­ sion is necessary, the treatment principles are:

R ESTOR I N G JO I NT M OB I L I TY Th e fib rotic stiff jo i n t

For the stiff joint, passive articular mobilization techniques are the most effective. The technique is graded according to the irritability of the articular tissues. Long-standing fibrosis requires a sustained grade 4+ passive mobilization. The myofascia l l y comp ressed jo i nt/regio n

For joints which are compressed due to overactiva­ tion of muscles (myofascially compressed) there are many neuromuscular techniques which decrease hypertOnicity in the global system (red uce rigidity). For the lumbopelvic-hip region they include:

1. restore the zygapophyseal, sacroiliac, and/or hip joint mobility (form closure - mobility) 2. correct the osseous alignment within and between the lumbar spine, pelvic girdle, and femur 3. restore optimal force closure and control of the neutral zone through training of the local system (force closure/motor control) 4. retrain integration of the local and global systems, including functional movements (rehearse activities of daily living, work- or sport-specific movement patterns - functional integration).

1. active mobilization or muscle energy techniques (Mitchell & Mitchell 2001, Schamberger 2002) 2. functional or craniosacral techniques 3. trigger point techniques (Travel! & Rinzler 1952) 4. intramuscular stimulation (IMS - dry needling) (C unn 1996) 5. using imagery during a combination of active mobilization, trigger point release, and exercise (Franklin 1996, Lee 2001a, Lee DC 2003, Lee LJ 2003) 6. techniques to restore an optimal breathing pattern (Chaitow et a12002, Lee DC 2003, Lee LJ 2003) 7. exercises which encourage movement with awareness (Feldenkrais, Hanna somatics, Pilates), finding neutral spine (Lee LJ 2003) and the optimallumbopelvic pyramid (postural re-education) (Lee 2001a).

If the clinical findings suggest that more com­ pression is necessary, the treatment principles are:

The fixated joi n t

1. correct the osseous alignment within and between the lumbar spine, pelvic girdle, and femur 2. restore optimal force closure and motor control through training of the local system (force closure/motor control) 3. provide an external support (not always necessary) to augment the training being taught (sacroiliac belt, taping) 4. restore articular mobility/stability to extrinsic joints (knee, foot, thorax) since their dysfunction may be contributing to compensatory patterns that put excessive stress on the joints of the lumbopelvic-hip region (form closure - mobility).

For the joint which is fixated, a passiv€ articular manipulation technique (Hartman 1997) is neces­ sary to restore the joint position and mobility before stabilization exercises can be prescribed.

COR R ECTI N G AL I G N M E N T

Loads are transferred more effectively through joints which are properly aligned such that the compres­ sion and tension forces induced are shared amongst all structures. Malalignment can create excessive stress on individual structures (tension or compres­ sion) which ultimately leads to tissue breakdown

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Treat i n g the lu m bope l vic-hip dysfu n ct i o n

(inflammation and pain). Therefore, techniques which correct aligrunent and restore the path of the instantaneous center of rotation (PICR) for joint movemen t (Hall & Brody 1999, Sahrmann 2001) are necessary in most treatment p lans. They include: 1. active mobilization/ alignment techniques (muscle energy) (Mitchell & Mitchell 2001, Schamberger 2002) 2. movement with awareness exercises - finding neutral spine (Lee LJ 2003) and the optimal lumbopelvic pyramid (postural re-education) (Lee 2001a).

RESTORING FORCE CLOSURE AND MOTOR CONTROL Recent research has increased our understanding of muscle and joint function and consequently changed the way exercises for back pain and dysfunction are prescribed (Bergmark 1989, Bullock-Saxton et al1993, 1994, Hides et al 1994, 1996, Hodges & Richardson 1996, 1997, O'Sullivan et al 1997, Richardson et al 1999, Danneels et al 2000, Hodges 2000, 2003, Jull & Richardson 2000, Moseley et al 2002). New concepts of how joints are stabilized and how load is trans­ ferred through the body highlight the importance of proprioception, automatic muscle activity, and motor control for regaining optimal movement after injury. It is clear from this body of evidence (see Ch. 5) that successful rehabilitation of back pain and dysfunc­ tion requires exercises that differ from those used for conditioning and training the healthy, non-painful, non-injured population. When planning injury rehabilitation, exercises should be prescribed as part of an integrated treat­ ment plan, not as a stand-alone treatment. If exercise is prescribed without firs t restoring joint mobility (form closure), the patient's pain and d ys­ function often get worse. This may lead to the conclusion that certain exercises are "bad" or "unsuccessful" for treating back pain, when it may merely be a problem of inappropriately timed exercise intervention. Similarly, the type of exercise prescribed is of utmost importance. For back and pelvic pain, the evidence cited above supports correcting deficits in motor control rather than focusing on strength and power of individual muscles. Patients who go mind­ lessly through a routine of exercises will have lim­ ited success in retraining motor patterns and may get worse with exercise if poor patterns and control

are reinforced, resulting in irritation of joint s truc­ tures and symp tom exacerbation. The problem may not be which exercise was prescribed, but how the exercise was performed. Three people performing a squat can do so with three different movement strategies, with three different combinations of mus­ cle recruitment and timing. Therefore, when plan­ ning exercise intervention clinicians must remember that "exercise A" does not guarantee the use of "mus­ cle A" It is up to the clinician to observe, assess, and decide if"exercise A" is reaching the goal of training "muscle A" (with appropriate recrui tment, timing, endurance, etc .) for each patient. The key to correct­ ing dysfunctional patterns of muscle activation is teaching awareness of movement; this requ ires mindfulness on the part of both the thera pist and the patient. The goal of restoring force closure and motor control for the lumbopelvic-hip region is to restore stabilization strategies and movement patterns such that load transfer is optimized through all joints of the kinetic chain. Optimal load transfer occurs when there is precise mod ulation of force, coordination, and timing in the local and global sy stems, ensuring control of the neutral zone for each joint (segmental control), the orientation of the spine (spinal curva­ tures, thorax on pelvic girdle, pelvis in relation to the lower extremity ), and the control of postural equilib­ rium with respect to the environment (Hodges 2003). The resul t, and our goal for our patients, is stability with mobility, where there is stability with­ out rigidity of posture, without episodes of collapse, and with fluid ity of movement. The exercises pre­ sented in this chapter are prescribed in the context of this goal; the focus is to balance compression and tension forces by using manual cues, imagery, and movement to address alterations in the motor control system. Op timal coordination of the local and global sys­ tems will produce optimal stabilization strategies. These patients will have: • the ability to find and maintain control of neu tral spinal alignment both in the lumbopelvic region and in relationship to the thorax and hip • the ability consciously to recruit and maintain a tonic, isolated contraction of the local stabilizers of the lumbopelvis to ensure segmental control (con­ trol of the neutral zone) • the ability to move in and out of neutral spine (flex, extend, laterally bend, rotate) without seg­ mental or regional collapse

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166

TH E P E LVIC G I R D L E

•

th e ability t o maintain a ll the above in coordi­

•

exercises for training awareness of the neutral

nation with the thorax and the extremities in func­

spine position to decrease global rigidity,

tional, work - specific, and sport-specific postures

facilitate poshlral re-education, facilitate

and movements.

performance of local system recruitment exercises, and facilitate balanced activity in the global system

Su b o p t i m a l sta bi l i za t i o n strateg i es In the lumbopelvic region, it

is

•

e x erci ses for isolation and recruitment of the

•

protocols to train precision, endurance, and

individual local system muscles

common to see

segmental inhibition of the local system associated

coordination of the local system muscles

with a mulbsegmental overactivation of the global

(Arendt-Nielsen et al 1996, Kaigle et al 1998, Richardson et al 1999, Radebold et al 2000, 200l, Comerford & Mottram 2001). Restoring motor control system

•

•

exercises to target specific global muscle

•

exercises to maintain/ restore global muscle

•

exercises for integration of local and global

weakness and imbalance

to the region needs to address dysfunction in both the local and global systems. Inhibition of the local sys­

length

tem results in poor control of the neutral zone; over­ activation of the global muscles produces increased compression and often results in pain, loss of range of motion, and rigidity of movement. Excessive activity and tone in the global muscles of the trunk can also inhibit the recruitment and training of the local sys­ tem muscles, as well as prevent retraining of proper functional

movement patterns.

insufficient lumbar lordosis, and scoliosis are com­

9.2-9.5) and usually result from dysfunc­ tional patterns in the global system. The objective examination tests described in Chapter 8 will reveal

mon (Figs

levels

instability

and

direction

muscles into functional movements and activities. Specific exercises for each

of

these components will

be addressed in this chapter.

Multisegmentally,

postural changes such as excessive lumbar lordosis,

specific

exercises to integrate coordination and timing of the local and global systems

of

hypermobility /

in the lumbar spine and pelvis; these

findings will direct where and how to cue the correc­ tion of segmental control during exercise. The assess­ ment process will also reveal the patient's specific pattern of global substitution and dominance, espe­

RESTORING FORM CLOSURE (MOBILITY) LUMBAR ZYGAPOPHYSEAL JOINTS The following section outlines the specific therapy indicated for restoring mobility of the zygapophy­ seal joints of the lumbar spine durin g each stage of repair (i.e., substrate, fibroblastic, maturation) following a traumatic

joint

sprain. During the first

4-6 days after injury (substrate phase), the goal of treatment is hemostasis of the wound. At home, the

cially during functional movements and motor con­

frequent application of ice together with rest is

tests (one-leg standing, active straight leg raise (ASLR), active bent leg raise (ABLR)). The dominant

lumbar spine is supine with the hips and knees

trol

muscles involved in the suboptimal stabilization strategies need to be monitored throughout the exer­ cise process, especially when more difficult exercises

and progressions are introduced. Janda (1986) and Sahrmann (2001) have observed common patterns of imbalance in the global system and described tech­ niques and exercises that are useful for correcting global dysfunction. However, it should be noted that purely treating global muscle imbalance is unlikely to correct deficits in the local system. Thus, the exercise rehabilitation program for restoring force closure and motor conh·ol is multifaceted and should include: •

the treatment of choice. The resting position for the semiflexed and supported over a wedge. The surface should be firm, but not rigid. At the clinic, elec­ trotherapeutic analgesic modalities such as transcu­ taneous nerve stimulation and interferential current therapy can afford relief from pain; however, the patient should not attend at this stage if the physical stresses induced are greater than the relief gained. With the resolution of some active range of move­ ment, the specific segmental osteokinematic restric­ tion

(extended

right (ERSR), (FRSL): see Ch. 9)

rotated/sideflexed

flexed rotated sideflexed left

becomes apparent. During the fibroblastic stage of

repa ir (up

to 4-6 weeks postinjury), the goal of treat­

exercises and imagery to downtrain dys­

ment is to restore the segmental articular mobility,

functional patterns in the global system

ensure optimal alignment and then restore force

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Treating the lumbopelvic-hip dysfunction

closure and motor control segmentally and region­ ally. Passive and active mobilization teclmiques are effective in restoring the articular kinematics. In addition, specific home exercises help to maintain the increased articular mobility gained in the treat­ ment session. The manual therapy treatment tech­ niques and home exercises for three specific lwnbar segmental dysfunctions will be described.

LS-Sl: FLEXED ROTATED/SIDEFLEXED LEFT The individual

with this

segmental

restriction

presents with a limitation of extension, rotation/ sideflexion of LS-S1 to the right (osteokinematics), and a loss of the inferoposterior glide of the right

Figure 10.1

Passive mobilization - specific traction of the

lumbosacral junction. The arrows indicate the direction of force applied to the patient's pelvic girdle and thorax. (Reproduced with permission from © Diane G. Lee Physiotherapist Corp.)

LS-S1 zygapophyseal joint (arthrokinematics). The following manual therapy techniques are used to restore mobility.

Correct i o n techn ique - mobilization

Specific trac­

tion is applied to the lumbosacral junction via a straight caudal force from the therapist's lower lateral

Specific traction - passive mobilization technique

thorax against the patient's pelvic girdle (Fig.

10.1).

The therapist's cramal arm simultaneously stabilizes

This is a useful preliminary mobilization technique

the patient's upper thorax. The grade of the teclmique

which can be graded according to the irritability of

is dictated by the joint/ myofascial reaction.

the joint and surrounding soft tissues. Initially, grade

2

and 3 techniques are indicated, keeping

well within the range of pain and reactive muscle spasm. The large afferent fiber input from the

Rotation/sideflexion - passive and active mobilization techniques

mechanoreceptors located in the articular capsule

In

inhibits the centripetal transmission of the small­

rotation/ sideflexion restriction is usually muscular

fiber input (nociception) at the

spinal

cord, thus

reducing the perception of pain via the spinal gat­ ing mechanism (see Ch.

4).

The stimulation of these

the

early

stages of healing, the cause of the

since restrictive capsular adhesions have not had time to form. A grade

sideflexion

2 or 3 (Grieve 1981) rotation/

passive mobilization technique can be

neurophYSiological

mechanoreceptors also reduces the gamma efferent

used for a

discharge to the intrafusal muscle fibers of the seg­

segmental muscles. The technique yields the best

effect on the multi­

mentally related global muscle, which is often

result when it is used in combination with the active

hypertonic.

mobilization technique (see below). If the injury is

Pati e n t a n d the r a p ist p o s i t i o n

With the patient

sidelying, hips and knees slightly flexed, the inter­ spinous space between the

L4 and

the LS vertebra is

palpated with the caudal hand. The thoracolumbar spine is rotated lmtil rotation of L4-LS occurs. The

long-standing and adhesions have formed (capsu­ lar fibrosis), a grade

4+

sustained technique is the

most effective . Pa t i e n t a n d the r a p i st positio n

With the patient in

left sidelying, hips and knees slightly flexed, the

cranial hand now palpates the interspinous space

interspinous space between the L4 and the LS verte­

between the LS vertebra and the sacrwn while the

bra is palpated with the caudal hand. The thora­

caudal hand flexes the patient's uppermost hip and

columbar spine is rotated until rotation of L4-LS

knee, thus posteriorly

occurs.

rotating the innominate;

ensure that LS-S1 remains neutral. Simultaneously,

Comfort is assured if the technique is

focused and localized and full articular locking is

1997). The cranial hand now pal­

the patient should extend the lower leg to the end

avoided (Hartman

of the table. The foot of the upper leg is allowed to

pates the interspinous space between the LS verte­

rest against the popliteal fossa of the lower leg. The

bra and the sacrum while the caudal hand flexes the

therapist's lower lateral thorax contacts the patient's

patient's uppermost hip and knee, thus posteriorly

uppermost innominate.

rotating the innominate; ensure that LS-S1 remains

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1 67

168

THE PELVIC GIRDLE

Figure 10.2

Passive mobilization for extension and right

Figu re 10.3

An anterior pelvic tilt (white arrows) coupled

rotation/sideflexion of the lumbosacral junction (flexed rotated/

with right lateral tilting (black arrows) facilitates extension

sideflexed left lesion). The arrow indicates the direction of force

and right rotation/sideflexion of the lumbosacral junction.

applied by the therapist. (Reproduced with permission from

[Reproduced with permission from © Diane G. Lee

© Diane G. Lee Physiotherapist Corp.)

Physiotherapist Corp.)

neutral. Simultaneousl y, the pa tient should extend the lower leg to the end of the table. The foot of the upper leg is allowed to rest against the popliteal fossa of the lower leg. The therapis t's cranial arm supports the patient's thorax while the caudal arm supports the pelvic girdle. Correction technique - passive mobilization From this position, LS-S1 is mobilized passively into exten­ sion and right rotation/sidefiexion (osteokinematic motion) through either the thorax o r the pelvic girdle (Fig. 10.2). Simultaneously, the right zygapophyseal joint is mobilized inferiorly and posteriorly (arthro­ kinematic motion). The technique is graded according to the joint/myofascial reaction. Correction technique - active mobilization LS-S1 is initially mobilized pa ssively into extension and right rota tion/ sideflexion. From the point of first resistance, the patien t is ins truc ted to resist further motion while the therapist applies a gentle rotation force to the pelvic girdle or the thorax . The isomet­ ric contrac tion is held for up to 5 s, followed by a period of c omplete relaxation. The joint is then pas­ sively taken to the new physiological range of exten­ sion and righ t rotation/sideflexion. The technique is repea ted three times followed by re-eva luation of the regional movement tes ts, positional tests, and arthrokinema tic mobility test (inferopos terior glide of the right LS-S1 zygapophyseal joint). Home exercise Home exercises which ma intain the segmental motion rega ined during the treat­ ment session are paramount to successful rehabili­ ta tion . Since wound repair occurs continuo usly, the orienta tion of the newly formed c ollagen fibers should be direc ted as often as possible (see Ch. 7).

In the early fibroblas tic stage of repair, the exer­ cises should be kept well within the painfree range. For this impairment, the patient is taught to do an anterior pelvic tilt in the supine, crook lying pos­ ition ( this faci litates extension). This can be coupled with lateral tilting of the pel vis beneath the lu mbar spine to facilitate unilateral extension (Fig. 10.3).

LS-S 1: EXTENDED ROTATED/SIDEFLEXED RIGHT Specific traction - passive mobiliza t i on techniq ue

As with the FRSL lesion, specific trac tion is a useful preliminary mobil ization technique which can be graded according to the irritability of the j O int. The details and the in tent of this technique are identical to those described above. Rotation /sideflexion - pa ssive and a ctive mobiliza tion technique Patien t and therapist position Wi th the pa tient in right sidelying, hips and knees slightly flexed, the interspinous space between the L4 and the LS verte­ bra is palpa ted with the cauda l hand. The thora­ columbar spine is ro tated until ro tation of L4-LS occurs. Comfort is assured if the technique is foc used and loc a li z e d and full articular locking is avoided (Hartman 1997). The cranial hand now pal­ pa tes the interspinous space between the LS verte­ bra and the sacrum while the caudal hand fl e xes the patient's uppermos t hip and knee, thus pos teriorly rotating the innominate; ens ure that LS-S 1 remains ne u tral. Simultaneously, the patient should extend

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Treating the lumbopelvic-hip dysfunction

169 ]

Figure 10.4

Passive m o biliza t i o n fo r fl exi o n a n d l eft rotati o n /

sid e flexion of t h e l u m b o sa c ral ju n cti o n (e x te n d e d rotate d /

Fig u re 10.5

A p o s ter i o r p e l v i c t i l t (wh i t e a r r o ws) c o u p l e d wi th

l eft l at e ra l ti lti ng (b l a c k a r ro w s) fac i l i ta tes flexio n a n d left

s id efl exed r i g ht les i o n) . Th e r i g h t zyg a p o p h ys e al jo i n t is m o b i l ized

rota ti o n /s i d e fl e x i o n o f t h e l u m b o s acra l jun c ti o n . ( R e p roduced

s u peroa n te r i o rly w i t h t h i s te c hni q u e . The a rro w i n d i c a tes the

w i th p e r m i ss i o n fro m © D i a n e G. Le e Phys i o th e ra p i st Co r p . )

d i re cti on of fo r ce a pp l ie d by the t he r ap i st. ( R e p ro d uced wi t h pe rm i s s i o n from © D i ane G . Lee Phys i o t h e ra p i st Corp.)

the lower leg to the end of the table. The foot of the leg is allowed to rest against the popliteal fossa of the lower leg. The therapist's cranial arm supports the patient's thorax while the caudal arm supports the pelvic girdle. Co rrection tech n i que - passive mobilizatio n From this position, LS-S1 is mobilized passively into flex­ ion and left rotation/sideflexion (osteokinematic motion) through either the thorax or the pelvic girdle (Fig. 10.4). Simultaneously, the right zygapo­ physeal joint is mobilized superiorly and anteriorly (arthrokinematic motion). The technique is graded according to the joint/ myofascial reaction. Correctio n techniq ue - active mo b i l izati on LS-S1 is initially mobilized passively into flexion and left rotation/sideflexion. From the point of first resist­ ance, the patient is instructed to resist further motion while the therapist applies a gentle rotation force to the pelvic girdle or the thorax. The isomet­ ric contraction is held for up to S s followed by a period of complete relaxation. The joint is then paSSively taken to the new physiological range of flexion and left rotation/sideflexion. The technique is repeated three times followed by re-evaluation of the regional movement tests, pOSitional tests, and arthrokinematic mobility test (superoanterior glide of the right LS-S1 zygapophyseal joint). Home exercise Home exercises which maintain the segmental motion regained during the treat­ ment session are paramount to successful rehabili­ tation. Since wound repair occurs continuously, the orientation of the newly formed collagen fibers should be directed as often as possible (see Ch. 7). upper

In the early fibroblastic stage of repair, the exercises should be k ept well within the painfree range. For this impairment, the patient is taught to do a posterior pelvic tilt in the supine, crook lying position (this facilitates flexion). This can be coupled with left lateral tilting of the pelvis beneath the lumbar spine to facilitate unilateral flexion on the right (Fig. 10 .5). L4- L5: ZY G APO PHYSEALJO I N T F I X AT I O N - LEFT Distra ction ma n i pulatio n An intraarticular meniscoid of a moderately degen­ erated zygapophyseal joint can become ent rapped during a flexion/rotation load in the presence of insufficient stabilization of the j oint. The following distraction manipulation is useful for relocati n g the meniscoid. Segmental neuromuscular retraining (see below) must follow if recurrences are to be prevented. Patient a n d thera p ist positio n With the patient i n right sidelying, hips and knees slightly flexed, the interspinous space between the L3 and the L4 verte­ bra is palpated with the caudal hand. The thora­ columbar spine is rotated until rotation of L3-L4 occurs. The cranial hand now palpates the inter­ spinous space at L4-LS while the caudal hand flexes the patient's uppermost hip and knee, thus poster­ iorly rotating the innominate and flexing LS-Sl; L4-L5 should remain in neutral. Simultaneously, the patient should extend the lower leg to the end of the table. The foot of the upper leg is allowed to rest against the popliteal fossa of the lower leg.

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170

THE PELVIC GIRDLE

should not attend at this stage if the physical stresses induced are greater than the relief gaine d . Weight-bearing activities such as walking, stand­ ing, and sitting sho u ld be minimized during the first few days. Using a cane can help to reduce the loading through the pelvis when vertical. With the resolution of some active range of movement, the specific osteokinematic restric ti on ( u s u ally p osterio r rotation of the innominate/ nutation of the sacnun) becomes app arent . During the fibroblastic stage of repai r (up to 4-6 weeks post in jury), the goal of trea tment is to restore the articular mobility, ensure op t i m al a lignmen t, and then to restore force closu re and motor control of the entire pelvic gi rdle . Passive and active mobilization tech­ niques are used to restore the articular kinematics. In addition, specific home exe rcise s help to main­ tain the increased articular mobility gained in the treatment session. If the inj u ry is long- sta ndin g and adhesions have for me d (ca psu l a r fibrosis), a gr ade 4+ sustained technique is the most effecti v e. ­

Figure 10.6

Distraction manipulation to reduce a fixation of the

left zygapophyseal joint at L4-L5. The force is pure axial rotation of the pelvic girdle and L5 beneath the L4 vertebra. [Reproduced

with permission from © Diane G. Lee Physiotherapist Corp.)

The the rapist ' s cranial arm supports the patient ' s thorax while the caud a l arm supp o rts the p elvic gi rdle. The cranial hand/thumb fix es the sp inous process of L4 firmly. Correction technique - manipulation From this position, the sagittal component of the left zyga p o­ physeal joint at L4-LS is distrac ted with a hi gh ve locity, low - a mplit u d e thrust by app lying a pure a x i a l rotation force through the pelvic g i rdle with LS-Sl stabi l i z ed in flex i on (Fig. 10.6). The regional movement tests confirm the success of the tech­ nique since the range of motion is often dramat­ icall y resto red . However, the underlyi ng arti cular i n stab i lity ( i nsu ff ic i ent a rt i cular c om press i on) and the lack of force closure/motor control become evident on subsequent retes ting . ­

RESTORING FORM CLOSURE (MOBILITY) SACROILIAC JOINT

The individual with this restriction presents with a limitation of posterior rotation of the right innom­ inate (nutation of the sac nun) ( osteo kinema tics) and a loss of the anterosup erior gli de of the ri ght SI] (described as the innominate moving on the sacrum). The f ollow ing manual therapy techniques are used to restore mobility.

Distra ctio n of the

SIJ - passive mobi l ization

technique

the specifi c therapy indicated for restoring mobility of the sacroiliac joint (SI]) d u ring each stage of repai r (i . e . , substrate, fibroblas­ tic, maturation) f ollowin g a traumatic joint spr a in. During the first 4-6 days after injury to the SI] ( sub strate p hase) the goal of treatment is hemostasis of the wound. At home, the fre quent appl ic ation of ice together with rest is the treatment of choice. The resting position for the painful S1] is sidely ing with the painful side upper m os t and the hip and knee supp orted on a p illow. At the clinic, electro thera­ pe u ti c a n a l gesi c modalities such as transcutaneous nerve stimulation and interferential curren t therap y can afford relief from pain; however, the patien t This section describes

­

,

SIJ: ANTERIORLY ROTATED RIGHT INNOMINATE!COUNTERNUTATED RIGHT SACRUM

a useful preliminary mobilization techn iq ue be graded a ccordin g to the irr itability of the joint and su r rounding soft tiss ues. I nitia ll y grade 2 or 3 techniques are indicated, k eeping well within the range of pain and reactive muscle spasm. The l arge afferent fiber input from the mechano­ receptors located in the articular capsule inhibits the centr ipet al transmission of the small-fiber input ( noc i cept ion) at the spin al cord, thus reduc in g the p ercep ti on of pain via the s pin al gating mechanism (see Ch. 4). The stimulation of these mechanorecep tors also reduces the gamma efferen t discharge to the intrafusal muscle fibers of the related hyper­ tonic muscles. This i s

which can

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,

­

Trea t i n g t h e l u m bo p e l v i c- h i p dysfu n ct i o n

F i g u re 1 0 . 8 Passive m o b i l i z a t i o n for poste r i o r rota t i o n of t h e r i g h t i n n o m i nate. T h e a rrow i n d i cates t h e d i rect i o n of fo rce a p p l ied by t h e t h e ra p i st. ( R e p ro d u ced w i t h permission fro m © D i a n e G. Lee P h ys i o t h e ra pist Corp.)

Poste rior rotat i o n of the i n n o m i n ate or n u tation of the sacru m - passive and active m o b i l izati on tech n i q u es In the early stages of healing, the cause of the pos t­ erior rotation restriction of the

SII is usually myo­

fascial since restrictive caps ular a d hesions have not had time to form . A grade

2

3 (Grieve 1981) pas­

or

sive mobilization technique can be utilized for a neurophysiological effect on the myofascia. The technique yiel d s the best result when it is used in

Passive m o b i l ization fo r d i stract i o n of the left sacro i l i a c joint (51J) i n the n e u tral 51J pos ition. The a rrow i n d ica tes the d i rectio n of fo rce a p p l i e d by the thera p ist. ( R e p roduced w i t h p e r m i s s i o n from © Dia n e G. Lee Physiotherapist Corp.) F i g u re 1 0. 7

combination w ith the active mobilization tech­

n iqu e .

If the injury is long-standing and adhesions

have formed (caps ular fibros is),

a

grade 4 + sus­

tained technique is the most effective . Pati ent

and

t h e r a p i st

positi o n

The patien t is

s upine, with the hips and knees flexed . Wi th the Pa t i e n t

and

t h e ra p i st

positi on

The patien t is

long and ring finger of one hand, palpa te the sacral

supine, w i th the hips and knees flexed . With the

s u lcus j us t med ial to the

long and ring finger of one hand, palpate the sacral

other hand, palpate the ipSilateral anterior s uperior

s ulcus j u s t medial to the posterior s uperior iliac

il iac spine

sp ine (PSIS)

(Fig.

8.28) .The flex ed hip and knee are

(Fig.

PSIS

8.28) .

Wi th the

(ASIS) and the iliac crest.

Correct i o n

te ch n i q u e

-

p a s s i ve

m o b i l iza t i o n

A

sup ported against the therapist's shoulder and arm.

grade

The femur is flexed, adducted, and internally rotated

right inn o minate to prod uce an anteros u perior

to the motion barrier of the hip j oint. Dis traction can be app lied from either the neutral from the limit of posterior

SIJ

rota tion of

position or the innomi­

2--4 pos terior rota tion force is app l ied to the

g lide at the

SlJ

(Fig.

1 0 . 8) .

This glide is al so associ­

ated with nutation of the sacrum . If the j oint is sti ff, the force is sus tained (grade

4 + ) for up to 3 m i n,

nate. This is reached by passively flexing the femur

during which time the connective tissue can be felt

un ti l the motion barrier for posterior rotation of the

to gi ve and subsequent arthrokinematic mobility

innominate is perceive d .

testing confirms the restoration of articu lar motion.

Co rrect i o n tech n i q u e - passive m o b i l iza t i o n

this posi tion, distraction of the

SIJ

From

is achieved by

applying a dorsolateral force along the length of the fe mur

(Fig. 10.7). The SIJ can be felt to distract pos­

The

SIJ

can be mobilized through the sacrum by

applying a grade 2--4 nutation force unilaterally to the right s acral base (Fig.

1 0 .9) .

Correct i o n tech n i q u e - a ctive m o b i l i zati o n

The

teriorly. The degree of force appl ied is d ictated by

p atien t is s up ine, with the hips and knees flexed.

the joint/ myofascia l reaction .

With the long and ring finger

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of

one hand, pal pate

1 71

1 72

T H E P E LV I C G I R D L E

Figu re 1 0.9

Pass ive m o b i l i za t i o n fo r n u ta t i o n o f t h e r i g h t s a c r a l

b a s e . T h e a rrow i n d i c a tes t h e d i r e c t i o n of fo r c e a p p l i e d by t h e t h e ra p i st . ( R e p ro d u c ed w i t h p e r m i s s i o n fro m © D i a n e G. Lee P h ys i o t h e ra p i st C o r p . )

th e sacral su lcus j u s t me d i a l to the PSIS

(Fig . 8.28) .

Th e limit of posterior ro tation of the innom ina te is reached by p a ssiv ely flexing the femu r u n til the

m o tion b a rr i e r for p os teri o r ro ta tion of the innomi­ na te is pe rcei v e d (Fi g .

p a ti en t

which is

g en tl y

inc reased by the th er a p i st . The i so­

metric con tra c t i o n is a

1 0 . 10). From this pos i t i on, the

is in s tr u cte d to resis t fur ther hip fl e x i on,

hel d

for

up to 5 5, fol l ow e d by

pe ri od o f complete rel axa tion. The inn ominate is

th en p a ss i ve l y taken to the new ba rrier o f pos terior rota tion. The techni q u e i s repea t e d three times fol­ lowed by re - ev a l u a t ion

of the re g iona l movemen t

te s ts , po siti ona l tests, and a r thro kinema tic mo b i l ity

Active m o b i l i za t i o n fo r p o s t e r i o r rota t i o n of t h e

a p p l i e d by t h e t h e r a p i s t w h i c h the p a t i e n t is to resist. ( R e p ro d u ced w i t h p e r m i s s i o n fro m © D i a n e G. Lee P h y s i o t h e ra pist Corp. )

tes t ( a n terosuperior joint glide) of the SIJ.

H o m e exercise

Fig u re 1 0. 1 0

ri g h t i n n o m i n a te . T h e a rrow i n d ica tes t h e d i re ct i o n o f g e n t l e fo rce

Th is exercise can be ta u gh t as a

self-a ctive mobiliza tion t e c hnique

usin g a

tow el .

The p a tient engages the motion ba rrier of p os terio r rota tion of the inn o m ina te by flexing the fem ur and

then

gent l y contracts the hi p ext e ns o rs a g a i ns t the 1 0 . 1 1 ) . The contrac tion

res i s t a n c e of the to w e l (Fig.

is held for up to 5 s fol lowed by

a

p eriod of com­

p le te rela xa tion. The fe mur is then flexed fur ther thus ta kin g the innomi nate to the new mo tion b a rrier of po s ter i o r rota tion .

SIJ : POST E R I O R LY R OTAT E D R I G H T I N N OIVI I I\J AT E / N U TATED R I G H T SA C R U M

Fig u re 1 0. 1 1

H o m e e x e r c i s e - s e l f- a c t ive m o b i l i z a t i o n exercise

to m a i n ta i n the ra n g e o f m o t i o n ( p o s t e r i o r rota t i o n o f the

The ind ividual with this

res tri c tio n presen ts with a right inn o min a t e

lim i ta tion of anterior rota ti on of the (osteo kinematics) a nd

a

loss of the infe ropo s terior

gli d e of the ri gh t SIJ . This is not a common a rticu lar res tric tion s ince the injure d Sij usually pos tures , and su b s equ en t l y s tiffen s, in anterior rota tion. However,

it is common to find the innomina te held pos teriorly

i n n o m i n a t e ) g a i n e d in the trea t m e n t ses s i o n . T h e p a t i e n t e n g a g e s t h e m o t i o n b a r r i e r o f p o s t e r i o r r o ta t i o n o f t h e

i n n o m i n a te by fl ex i n g t h e fe m u r a n d t h e n g e n t l y c o n t r a c ts t h e h i p exte n s o rs a g a i n s t t h e re s i s t a n ce o f t h e t o w e l . T h e n e w m o t i o n b a r r i e r fo r poste r i o r rota t i o n of t h e i n n o m i n a te i s e n g a g e d after a p e r i o d o f re l a x a t i o n . T h e a rr o w i n d ica tes the d i re c t i o n of g e n t l e fo rce a p p l i e d by the p a t i e n t . ( R e p r o d u c e d w i t h p e r m i ss i o n fro m © D i a n e G. L e e P h ys i o t h e r a p i s t C o r p . )

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Tre a t i n g t h e l u m bo p e l v i c- h i p d ysfu nct i o n

F i g u re 1 0 . 1 2 Passive m o b i l ization fo r a n te r i o r rota t i o n o f the rig h t i n n o m i n a te . The a rrow i n d i c a tes th e d i re c t i o n of fo rce

a p p l ied by the thera pi st. ( R e p ro d u ce d w i t h p e r m i s s i o n fro m © D i a n e G. L e e Phys i o t h e rap ist Corp. )

Fi g u re 1 0 . 1 3 Pa ssive m o b i l i z a t i o n fo r c o u n t e r n u t a t i o n o f t h e ri g h t sacra l base. The a rrow i n d i c a tes t h e d i rection of fo rce a p p l ied by the th e ra pist. ( R e p ro d uced with permiss i o n fro m © D i a n e G . Lee Phys i o t h e r a p i s t Co rp. )

rotated by an imb a l an c e in the global system (see Techniques to correc t a lignm e nt : Intrapel vi c torsions : Posterior rotation innomina te, below). Ante r i o r rota t i o n of t h e i n n o m i n at e o r co u n te rn u t a t i o n of t h e s a c r u m - p a s s i ve a n d a ct i ve m o b i l i za t i o n tech n i q u es

Pati ent and therapist position The p a t i e nt is supine, hips and knees flexed. Wi th the lo ng and ring finge r of one hand, pal p a te the sacra l su leus just me di a l to the PSIS (Fig. 8 . 28). Wi th the other hand, palp a te the ipSila tera l ASIS an d the iliac crest. Co rrection tech n i q u e - passive m o b i l ization A grade 2-4 anterior rot a t i on force is a pplied to the inno mina te to p roduce an inferoposte rior glide a t the SIJ (Fig. 1 0 . 1 2) . Th is glide is also assoc i a ted with countern uta tion of the s a c rum . If the j oint is stiff, the force is sustained (grade 4 + ) for up to 3 min, during which time the connec tive tissue can be fel t to give a nd subse q uent a r thr o kin e m a ti c mobi l i ty tes ting confirms the re sto r a ti on of articular motion. Th e SIJ can be mobilized through the sa crum by applying a grade 2-4 counternu ta tion force unilaterally to the inferior lateral angle of the sacrum (Fig. 10.13). Correctio n tech n i q u e - active m o b i l izati on With th e pa tient prone, lying close to the edge of the table, the a nterior aspect of the d istal t h i gh is p a l­ p a te d with the caudal hand, while the PSIS of the inno mina te is palp a ted w i th the heel of the cranial hand . The lim i t of a n terior rotation of the innom­ ina te is reached by p aSS iv ely extending the femur with the c a u d a l hand and app l y in g an anterior rotation force to the innomina te w i th the c ranial hand (Fig . 10.14). From this position, the pa tient is w i th the

F i g u re 1 0. 1 4

Act ive m o b i l iza tion for a n terior rotation of the right i n no m i n a te. From the m o t i o n b a rrier, t h e therapist a p p l i e s a g e n t l e exte n s i o n force w h i c h the patient resists. The a rrows i n d i cate the d i rection of force a p plied by the thera pist. ( Reproduce d with permission fro m © Diane G . Lee Physiothera pist Co rp. )

instructed to resist fu r th er h i p ex tension w h i ch is gently increased by the thera p ist. The isometric contraction i s h e l d for u p to 5 s fol lowed by a period of c o mple te relaxa tion. The innom inate is then pas­ Sively t a k e n to the new b arrier of a n terior rotation. The technique i s repeated three times followed by re-ev alua tion of the regional movement tes ts, pos­ itional tests, and arthrokinematic m ob i li ty test (inferopos terior joint gl ide) of the SIJ. H o m e exe rcise A modified unilatera l lunge with the anterior leg res ting on a foot stool or chair and the other correctly aligned (nei ther i ntern a l ly nor externa lly rota ted at the hip jOint) in extension w i l l fac i litate anterior rota tion o f the inn o m in a te on the ex tended side (Fig. 1 0 . 1 5 ) . Ens u r e that the patient does not posteriorly til t the pelvis by "butt gri p­ ping" on the ex tended leg side.

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F i g u re 1 0. 1 5 H o m e exercise - specifi c u n i l a te ra l h i p exte n s i o n e x e r c i s e to fa c i l itate a n t e r i o r rota t i o n ( a rrow ) of t h e i n n o m i n a te. ( R e p rod uced with p e rm i s s i o n fro m © D i a n e G. Lee Phys i o t h e ra p ist Corp. )

S I J : S U P E R I O R S H EA R F I XAT I O N - I N N O M I N A T E

When a force is applied to th e SIJ s u fficie n t t o a ttenu­ a te the a r t i c u l a r ligaments (fal l on the b uttocks or a lift / tvvist inj u r y ) , t he muscles will resp o nd to pre­ vent disloca ti on and further trauma to the j o in t . The resu l t ing spa sm may fix the j o in t in an abnormal rest in g pos i t i o n and marked asymme try of the p elvic girdle ( inn o m in a t e and / or sacrum) can b e p resent. This is an uns table j o in t under excessive co m p re ss i on (Fig. 8 . 1 Of) and decompression as well a s a l ignm en t correction is required be fo re s tabiliza­ tion exercises a re gi v en . A s up e ri or shear fi xa ti o n of the SIJ ca n occur when a vertical force t hro ugh the p el v i c g ird l e (a fall on the inferior pelvis) exceeds the ability of the SIJ to resist. On positiona l te s ting, the ASIS, PSIS, and ischial tub e r osi t y are s u p e rior on the imp a i r ed side ( the s a crum is rela tively infe r ior) . In additi on, the innom in a te may be either an teriorly or pos t e r ior ly

F i g u re 1 0 . 1 6 M a n i pu l a t i o n to deco m p ress a verti c a l s h e a r fixa t i o n of the l eft i n n o m i n a te i n poste r i o r rota t i o n . T h e arrow i n d i c a tes t h e d i rection of force a p p l ied b y t h e t h e ra pist. ( Repro d u ced with perm i ss i o n fro m © D i a n e G. Lee Phys i o t h e ra p ist Corp. ) rota ted .

If

the iLmominate i s anteriorly rotated and

ipsila tera l sacrotuberous ligament will be slack. The neu tral zone of motion o f the SIJ cann o t be loca ted for te s ting until a fter the joint is decompresse d . superior,

the

I nfe r i o r d i st r a ct i o n of t h e S I J m a n i p U l atio n

Pati ent a n d therap ist position

-

passive

If the innominate is

anteriorly ro ta t e d and superiorly fi xa ted, the pa tient

is prone. If the innomina te is p o s t er i orl y rota ted and su p eriorl y fi x a ted, the p a t i e n t is s upine. The

lower leg is g r a sp ed prox im a l to th e talocru ral j oin t . The hip j o in t is ex tended (if the i nnominate is a n te­ riorly rotated) or flexed

(if inn o mina te i s poste riorly

ro ta ted ) a n d m ed i a l l y ro ta ted . The manip u l a tion

ba rrier is reached by a p p lying a l on g i t u d in a l p u l l through the l e g ( F i g . 10.16).

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Treati n g t h e l u m bo p e l v i c- h i p d ysfu n c t i o n

Correct i o n

tech n i q u e

-

A high­

m a n i p u lation

veloc i ty, low-a m p l i tude tug i s applied through the leg to distract the inferior aspect of the

SIJ. After

the

fixa tion is reduced, the a r thro k ine tic s tabil i ty tes t of the

SIJ

will reveal an incre ased neutral zone of

mo tion in the craniocaudal direction . Any residual malalignment between the innomin a te and sacrum should be correc ted

(see Techniques

to correct

alignment, below ) , fol lowing which the pelvic gir­ dle i s supported w i th a proper bel t (see b elow) or taped. Trea tment to restore force closure / mo tor control (s tabiliza tion e xercise therapy) then follow s .

S I J : A N T E R I O R S H E A R F I X AT I O N I N N O M I N AT E An anterior shear fixa tion of the innomin a te at the SIJ can occur when

a pos teroanterior force through the

pelvic girdle (a fall on the posterior pelvis) exceeds the ability of the

SIJ

to resist. On pOSi tional testing,

the ASIS and p ubis are anterior on the impaired side ( the pelv is feels like it has been torqued into a rhom­ boid shape) . In addi tion, the inno minate may be either anteriorly o r pos teriorly rotated. The neutral

zone of motion of the SIJ canno t be loca ted for testing until a fter the joint is decompressed .

Poste r i o r d istracti o n of the SIJ m a n i p u l at i o n

-

passive

The p a tient i s supine,

Pa t i e n t a n d t h e ra p i st p o s i t i o n

w ith the hips and knees fle xed . With the long and ring finger o f one hand, palpate the sacral sulcus j us t me d i a l to the

hip

PSIS

(Fig.

8 .28).

The flexed

F i g u re 1 0. 1 7 M a n i pu l a t i o n to d e co m p ress a horizo n t a l a n te r i o r s h e a r fi xati o n of t h e rig h t i n n o m i n a t e (posteri o r s a c ro i l i a c j o i n t d istra c t i o n i n n e u tra l rota t i o n ) . The a rrow i n d i ca tes t h e d i re c t i o n of force a p p l i e d by t h e t h e r a p ist. ( R e p ro d u ced w i th perm iss i o n fro m © D i a n e G . L e e Physiothera p i s t Corp.)

Trea tment to restore force closure / motor con trol (stabiliza tion exercise therapy) then follo w s .

and knee are s u pported by the therapist's

sho u l der and a rm . The fem ur is flexed, a d d uc ted, and in terna l l y rotated to the m o tion barrier o f the

S I J : P O S T E R I O R R O TAT I O N F I XAT I O N I N N O M I N AT E

hip j oin t. The manip u l a tion barrier for d i s traction of the pos terior aspect of the

SIJ is

reached by apply­

Th is fixa tion usually occurs i n a you ng, a thletic

ing a dorsola tera l force along the length of the

individual. The mode o f onset is usually tra u m a tic,

fem u r.

commonly a rota ry force th rough the leg. A n over­

Correct i o n

tech n i q u e

-

m a n i p u l at i o n

A

high­

zea lous kick against a mi ssed ta rget is a common

10.17)

cause. When the innominate i s fix a ted in pos teri o r

is applied through the femur to the SII - After the

ro tation, t h e ASIS i s s uperior, the PSIS i s inferior, the

fixation is reduced, the arthrokine tic s tabil i ty test SIJ will reveal an increased neu tral zone of

ischial tuberoSi ty i s ven tra l but lev e l in the c ranio­

velocity, low-ampli tude dorsolateral thrust (Fig.

of the

ca udal plane, and the sacro tuberous l iga ment is

motion in the anteropos terior direction. Any residual

und er marked ten s i on on the side of the fix a ti on.

mal alignment be tween the innomina te and sacrum

The

should be correc ted (see Techniques to correct align­

rota ted toward s the side of the dysfunc tion. The

men t, below), follow ing which the pelvic g i rdle is

neutra l zone o f motion of the

supported w i th a p roper belt (see b elow) or taped .

for testing until a f ter the j o in t is decompressed .

L5 vertebra a s well as the sacrum ten d s to be

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cann ot be loca ted

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THE

P E LV I C G I R D L E

Fi g u re 1 0 . 1 8

M a n i p u l a t i o n t o d e co m p ress a pos t e r i o r rota t i o n

fixati o n o f t h e r i g h t i n n o m i n a te . T h e a r ro w s i nd i cate t h e d i re c t i o n o f fo rce a p p l i e d b y t h e t h e r a p i s t . ( R e p ro d u c e d w i t h p e r m i ss i o n fro m © D i a n e G. L e e P h y s i ot h e ra p i st C o r p . )

Poste r i o r d i st r a ctio n/a n t e r i o r rota t i o n of the SIJ p a ssive ma n i p u l a tion

-

Patient and therapist position With the patient prone, lying close to the edge of the table , the anterior aspect of the distal thigh is palpated with the caudal hand, while the PSIS of the innominate is palpated with the heel of the cranial hand. The manipulation bar­ rier for anterior rotation of the inn ominate is reached by p a ss i ve ly ex tending the femur with the caudal hand and applying an anterolateral force to the innominate with the cranial hand (Fig. 10.18). Correct i o n tech n i q u e - m a n i p u lation A high­ veloci ty, low-amplitude thrust is applied through the innominate in an anterolateral direction while the other hand simultan eously extends the femur, thus anteriorly rotating the innominate. The lateral pressure on the PSIS d is tracts the posterior aspect of the SlJ. After the fixation is reduced, the arthroki­ netic stabi lity tes t of the S1J will reveal an increased neutral zone of motion in the anteroposterior direc­ tion. Any residual malalignment between the innominate and sacrwn should be corrected, fol­ lowing which the pelvic girdle is supported with a proper belt (see below) or taped. Treatment to restore force closu re/motor control (stabilization exercise therapy) then follows. SI J : A N T E R I O R R O TAT I O N F I X AT I O N I N N O M I N AT E

The mechanism o f injury i s trauma tic, with hyperex­ tension of the leg being a significant factor. On p osi­ tional testing, the ASIS is inferior, PSIS superior, ischial tuberosity is dorsal but level in the craniocaudal

F i g u re 1 0 . 1 9

M a n i p u l a t i o n to d e co m p ress a n a n te r i o r rota t i o n

fixa t i o n of t h e r i g h t i n n o m i n a te ( p o s t e r i o r rota t i o n a n d d i s t r a c t i o n o f t h e s a c ro i l i ac j o i n t) . T h e a r rows I n d i c a t e t h e d i re c t i o n of fo rce a p p l i e d b y t h e t h e ra p ist. [ R e prod u c e d w i t h p e r m i s s i o n fro m

©

D i a n e G. Lee P h y s i o t h e ra p i s t Corp )

plane, and the sacrotuberous ligament, althou gh still palpable, is less ta u t than normal on the side of the dysfunction. The L5 vertebra and the s a c r u m tend to rotate away from the a ffected side. The ne u­ tral zone of mo tion of the SU cannot be l o c a t e d for testing until after the joint is decomp ressed. Poste rior d i straction /poste rior rotation of t h e - p a s s i v e ma n i p u l at ion

SIJ

Patient and thera pist position The patient is supine, with the hips and knees flexed . With the long and ring finger of one hand, palpate the sacral sulcus just medial to the PSIS (Fig. 8.28) .The flexed hip and knee are supported over the therapist's shou lder and arm. The femur is flexed and adducted to the motion bar­ rier of the hip joint. The manipulation ba rrier for dis­ traction of the posterior aspect of the SlJ is reached by applying a dorsolateral force coupled with posterior rotation of the inno minate (Fig. 1 0 . 19).

Copyrighted Material

Treating the

Correcti on

tech n iq u e

-

m a n i p u lati o n

A

l u mbope l v i c- h i p

dysfunct ion

high­

veloci ty, low-amplitude dorsola tera l thru st is applied through the innominate to distract the sacroiliac j oin t. After the fixation is red uced, the arthrokinetic stability test of the SIJ w i l l revea.l an increased

neutral

zone of motion in the anteroposterior direc tion. Any residual malaligrunent between the inn omina te and sacrum should be corrected, fo llowing which th e pelvic girdle is supported wi th a proper belt (see below) or taped . Trea tment to res tore force clos ure / motor control (s tabilization exercise the r apy) then follows. F i g u re 1 0.20

S I J : H O R I Z O N TA L S H E A R F I X AT I O N (A N T E R I O R O R POSTE R I O R) - R I G HT S I D E O F SAC R U M The mode of onset is commoruy a lifting, twisting inj ury. The p a ti en t often repor ts hearing and feeling a pop and a sharp pain localized to the SIJ at the time

M a n i p u l a t i o n to d e c o m p ress a h o r i z o n t a l s a c ra l

s h e a r fi x a t i o n of t h e rig h t s a c ro i l i a c j o i n t . T h e a rrow i n d i c a tes

t h e d i re c t i o n o f fo rce a p p l i e d by t h e t h e ra p i s t . ( R e p rod u c e d

w i t h perm i ss i o n fro m © D i a n e G . Lee P h y s i o t h e r a p i s t Corp. )

closure /mo tor control (s tab iliza tion exercise th erapy) then follows.

of the inj ury. On posi tional tes ting, the sacral base and the inferior lateral angle

(ILA) are ei ther an terior a rti c u.lar restriction

or pos terior on the side of the

a nd this displacement persists in all positions of the

trunk - hyper flexi on, neu tral, and hyperextension . The ne utr a l zone of mo tion of the SIJ cannot be loca ted for testing unh.! a fter the joint is decompressed .

R E ST O R I N G F O R M C L O S U R E ( M O B I L I TY) H I P J O I NT Limited range of mo tion of the hip is extremely common a nd often p a inless. I t can lead to second­ ary hypermobil i ty of the s a c r oili a c and / or l u m b a r j o in ts which then bec ome p a infu l . T h e hip j o i n t can

Poste rior distraction of t h e S I J pa ssive

a l s o be m a l a l igned by muscle imb alance of the

m a n i p u lation

glob a l muscle slings (Fig.

Pa tient a n d thera p ist positi o n

With t h e p a tient in

left sidel yin g and the l ower leg e x tended and the upper hip a nd knee flexed, the thoraco l u mbar spine is rotated un til LS-S l is fe l t to be fully rota ted to the

L5 ver tebra is firmly s t a b i l ized with one hand to m a intain the rota t ion at the l u mbo s ac ra l

righ t . The

j Lmction . With the o ther hand, t h e righ t innom ina te is in tern a l l y ro ta ted

about a p u re vertical axis through pelvic Kirdle to gap or d i s tr a c t the pos terior aspect of the SI] (Fig. 10.20 ) . The tec hnique can be foc u sed the

to the Sl, S2, or S3 segment.

Co rrection tech n i q u e - ma n i p u l ation

From this

positio n , a high- v el o city, low-amp l i tude thrust is a pplied through the righ t

innomina te

to distract the

SIJ . This technique is e ffectiv e for ei ther an a n terior or pos terior shear fi x a tion

posterior aspec t of the

8.41 ) . Both the sti ff j o int

and the m ala lign e d (non-cen tered ) j oin t w i l l have significant consequences for mobili ty. The fol l o w ­ ing passive

mobiliza tion techniques a re u s e d t o

restore the articular kine matics whe n t h e j o in t i s s tiff.

S pec ific h o m e exerc ises help t o m a in t a in the

increased mobility gained in the trea tment session. See Res toring force closure

a nd motor con trol,

below, for techniques to rea lign the femo ral head a n d release the "bu tt gripper. /I

T H E F I B R O T I C H I P J O I I\J T La te ra l d i stracti o n of t h e h i p - p a s s i ve a n d a ctive mob i l izatio n This is

a

useful p reliminary mob i liza tion technique

which can be graded acco rd i ng to the irritab i l i ty of

SI] will reveal an

the j oin t and surroun d in g soft tis s u es . A grade 2 or 3 technique is indica ted for the p a infu l joint . If the

increased neutra l zone of mo tion in the a n teropos te­

joint is s tiff, a grade 4+ technique susta ined for up

rior direc tion . Any resid ua l malal ignmen t be twee n

3 min is indica ted . Pa ti ent a n d thera pist position With the p a tien t lying s upine, hip and knee fl exed, a m o b i l i za tion

of the sacrum. After the fixa tion is reduced , the arthrokine tic s t a bili ty test for the

the innomina te and sacrum should be corrected (see below) or taped . Trea tment to res tore force

to

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T H E P E LV I C G I R D L E

Fig u re 1 0 . 2 1

Pa ssive m o b i l iza t i o n fo r d i s t r act i o n of the hip j o i n t. The a rrow i n d ic a tes t h e d i re c t i o n of fo rce a p p l i e d by the t h e ra p ist. ( R e prod uced w i t h p e r m i s s i o n fro m © D i a n e G . Lee Phys i o t h e ra p i s t Corp.)

belt is placed around the proximal thigh and secured a ro und the therapist's pelvis (Fi g. 10 .2 1). Corre cti o n tech n i q u e - passive m o b i l izati o n The h ip joint is dis tra cted by applying a l a tera l force pa rallel to the neck of the femur. The pos teroante­ rior orienta tion of the applied force will vary and depends on the degree of femoral a ntev ersion p re­ sen t. The techni que is graded accord ing to the j oint/ myofascial reaction. Correction tech n i q u e - M u l l i g a n m o b i l izati o n An active mob iliza tion with movement technique (M u lligan) can be a dded by maintaining the la teral distraction described above and having the patient actively move into the direction of the restriction (flexion, e xtension, abduction, adduc tion, in terna l, or ex ternal rotation) . Home exercise Range of motion exercises (general flex ion, ex tension, abd uction, adduction, internal rota ti on, ex ternal rota tion) which maintain the movemen t gained in the treatment session sho uld be ta ught.

F i g u re 1 0. 2 2 Pa ssive m o b i l i za t i o n fo r poste r i o r g l ide of the fe m o r a l head in fl ex i o n . E n c o u ra g e re l a xa t i o n o f the exte r n a l rota tors of the h i p b y te l l i n g the pa t i e n t t o i m a g i n e t h e fe m u r i s s i n k i n g i n to soft so i l ( a rrow o n fem u r) . T h e fe m u r i s d o rsa l ly g l i d e d t h ro u g h th e m o b i l i z a t i o n b e l t as t h e t h e ra p i s t b e n d s the knees; d i stra c t i o n of t h e h i p j o i n t can be added to t h i s tech n i q ue. T h e a r row o n t h e patien t's fe m u r reflects t h e "si n k i n g fe m u r" a n d t h e a rrow o n t h e m o b i l i z a t i o n b e l t i n d ica tes the d i rect i o n of force a p p l i e d by the t h e ra pist. ( R e p rod uced w i t h perm i ss i o n fro m © D i a n e G . L e e Phys i o t h e ra p i s t Corp.)

Poste rio r g l i d e of the fe m o ra l h e a d - in fe m o ra l fl exio n

Susta ined overac tiva tion of the external rota tors of the hip can ca use the posterior capsule to tighten . The following technique can be used after the deep external rota tors have been released (see Reducing rigidity - down training the global sys tem, below) . Patient a n d thera p i st position With the patien t lying supine, hip and knee flexed, a mobi liza tion belt is placed around the proximal thigh and secured around the the rapist's pelv is. Flex / adduct the fem ur to the motion barrier wi tho ut impinging the anterior aspect of the join t . Correction tech n i q ue - passive m o b i l izati o n The motion ba rrier of fem oral flexion and adduc tion is maintained and an anteroposterior gli d e of the femoral head is applied through the mobil iza tion belt by slightly bending your knees (Fig. 10.22) .

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Treati n g t h e l u m bo p e l v i c- h i p d ysfu ncti o n

F i g u re 1 0. 2 3 H o m e exercise to reseat t h e fe moral head posteriorly. The ba l l (note the sma l l black a rrow) p rovides p ressu re to the m uscles of the posterior bu ttock. With a consc i o u s re lease o f the posterior bu ttock m u scles, gravity a l lows t h e fe m u r to " s i n k" dorsa l l y ( l a rg e w h i te a rrow) thus resea t i n g the fe m o ra l head and a p p l y i n g a gentle stretch to t h e poste rior caps u l e of the h i p j o i n t. (Reprod uced w i t h permission from © D i a n e G . Lee Physiothera p i s t Corp.)

Instruct the patient to i magine the femur as a telephone pole sinking in to soft soil or mud and to try to allow the femoral head to release posterior into the acetabu­ l u m. This im age will facilita te further relaxa tion of the ex ternal rotators of the hip and allow a deeper posterior capsular s tretch. Lateral distraction of the joint can be added to this technique. Home exercise The pa tient is lying on the floor with the a ffected leg supported on a foot s tool or the foot supported on the wall. A small ball can be placed poste riorly j ust behind the greater trochanter or over a tender trigger point (Fig. 10.23) . The exercise is to relax the posterior buttock (let the ball sink in to the muscles of the buttock) and allow gravity to take the leg dorsa lly such that the femoral head disengages from the an terior acetabulum and provides a stretch to the posterior capsule. Patients often find tha t the image of the telephone pole sinking in to mud is help­ fu l to fac i l ita te this relaxation and stretch. A four­ point kneeling rock (Fig. 10.24) or rock'n'roll on a gym ball (Fig. 10.25) are also useful exercises for this. Thera p i st fa c i l itat i o n - v e rb a l cues

Poste r i o r g l i d e of the fe m o ra l h e a d exte n s i o n

-

i n fe m o ra l

The follo w ing technique i s useful for resea ting the femoral head in extension, which is a requirement of the terminal stance phase of gait. Pat i e n t a n d thera p i st positi o n With the pa tient lying prone w i th the knee flexed, palp a te the distal end of the femur with one hand and the posterior aspect of the grea ter troch a n ter with the other.

F i g u re 1 0 . 2 4 H i p rock i n t h e fou r- p o i n t k n ee l i n g pos i t i o n . The p a t i e n t i s ta u g h t to positi o n t h e t h o raco l u m ba r s p i n e i n a n e u t ra l p os i t i o n w i t h t h e p e l v i c g i rd l e a n teriorly ti lted 9 0 ° . W h i l e m a i nta i n i n g t h i s p o s i t i o n t h e pati e n t i s i n structed to r o c k d i rectly poste r i o r, t h u s i n creas i n g t h e a n g l e o f h i p fl ex i o n . The t e n d e n cy w i l l be to t i l t t h e p e l v i s posteri o r l y (fl e x t h e h i ps) a n d l ose the l u m ba r l o rdosis. T h e therap ist s u p p o rts t h e ribca g e to assist i n t h e m a i n t e n a n c e o f t h e t h o r a c i c ky p h o s i s w h i l e o n e h a n d c u e s l e n g t h e n i n g i n t h e l u m ba r s p i n e to m a i n ta i n t h e l o rdosis. ( Re p rod u c e d w i t h p e r m i s s i o n fro m © D i a n e G . Lee Physiot h e r a p ist Corp ) ,

.

Rock' n ' ro l l on a g y m b a l l . The b a l l s u p ports t h e p ri m a ry t h o r a c i c c u rve, t h e t h e ra p i s t e n s u res t h a t t h e l u m b a r l o rdosis a n d a nterior p e l v i c ti l t a re m a i nta i n e d as t h e p a t i e n t rocks b a c k w a rd s a n d t h e n ro l l s fo rwa rds. T h e te n d e n cy w i l l b e fo r t h e p a t i e n t t o t i l t t h e p e l v i s poste r i o r l y a n d fl ex t h e l u m b a r s p i n e d u ri ng t h e backwa rd r o c k a n d re m a i n fl exed a n d poste riorly t i l ted d u r i n g t h e fo rwa rd ro l l . The p e l v i s c a n be rocked d i a g o n a l l y backwa rds to i n co rp o ra te rotat i o n with h i p fl e x i o n . (Re pro d u ced w i t h permission fro m © D i a n e G. Lee Phys i o t h e ra p i s t Corp.) F i g u re 1 0 . 2 5

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T H E P E LV I C G I R D L E

Correction tech n i q u e - pa ssive m o b i l ization

The

mo tion b a rrier of femoral ex tension / inte rnal rota­ tion is main tained with the caudal hand and an an terop osterior glide of the femora l head is applied by gl iding the grea ter trochanter anterio rly and medially. Instruct the

Therap ist fac i l itat i o n - verbal cues

pa tient to relax the hip to aUow the femoral head to seat posteriorly into the ace tab u lum.

S A C R O I L I A C B E lTS A N D TA P I N G Subsequent

to manipula ting

underlying

inc rease

in

SIJ fixa tion,

a

neu tral

becomes apparent. A t this time

an

zone

the

m o tion

ex ternal support

can help to control the excessive translation un til s uch time as force clos ure and motor control c an be res tore d . The ex ternal support ( taping or a belt) is used onl y as an a dj unc t to the re storation of force closure. Damen et al (2002c, d) were able to show using Doppler imaging that the stiffness of the

S1]

inc reases when a belt is applied to the pelvi s . There are many sacroiliac belts on the marke t and most will b e effective in providing some degree of com­ pression (Vleeming e t al 1992c ) . Howev er, pa tients sometimes require more or less compression than a genera l belt can supply and often it is d ifficult to specify the location of the compression (b ila tera I anterior,

bila teral

posterior,

unila teral

anterior,

and / or unil a teral pos terior) . Th is led to th e devel­ opment o f a new sacroiliac belt - the CompressorT"1 (Lee 2002) (Fig. 1 O . 26a, b ) . Essentia lly this belt con­ sists of a light fabric m a teria l which is wrapped a round the pelvic girdle and secured with Velcro. The compression s traps are then a ttached to the belt specifying the loca tion of compression. The straps can be overlapped (doubled up) to increase the a m o unt of compression at tha t location. Four straps of two differen t lengths are included with the belt. The ASLR tes t

(eh. 8) is used to determ ine exactly

Fig u re 10.2 6

[a)

T h e Compressor" i s a b e l t d e s i g n e d fo r t h e

p e l v i c g i rd l e w h i c h a l l o w s fo r s p e c i fy i n g b o t h t h e a m o u n t a n d l o c a t i o n o f t h e co m p ressi o n b y va ry i n g t h e n u m be r a n d l o c a t i o n o f t h e co m p r ess i o n s t r a p s . [ b ) I n t h i s a p p l i c a t i o n , t h e co m p res s i o n stra ps a re a p p l i e d t o co m p ress t h e r i g h t a n te r i o r

where and how much c ompression is neede d . If

p e l v i s a n d t h e l e ft p o s t e r i o r p e l v i s . [ R e p ro d u c e d w i t h p e r m i s s i o n

b i l a teral an terior compress ion of the pelvis (app rox­

fro m

ima te the ASISs: Fig.

8.58)

©

D i a n e G . Lee Phys i o t h e ra p i s t

Corp.)

a llows the p a tient to li ft

the leg with less effo rt, then two straps are applied

One b a nd is applied a t a time. If unila tera l an te rior

b y anchoring each band laterally and p ulling them

compression and unila teral posterior compression

to the an teri or midline (pubic

symphysis) . One

are the mos t effective, then one ba nd is applied

band is applied at a time . If bila teral posterior com­

anteriorly and one band pos teriorly (Fig .

pression of the pelvis ( approx ima te the PSISs: Fig.

Once the bands a re applied, the ASLR i s repea ted .

8 . 59) allows the pa tient to lift the leg with less effo rt,

The pa tien t should notice a marked difference in the

then tw o s traps are applied b y anchoring each band

abili ty to transfer load th rough the pelvic gi r d le

p u lling them to the pos terior midline.

throu gh a reduc tion in the effort required to lift the

la tera lly and

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1O .26b ) .

Trea t i n g the l u m bo p e l v i c- h i p dysfu nction

leg when either supine or in stand ing.

principles and

The same

tests a re applied if tape is used

instead of the Compresso rTM . Initially, the pelvis shou ld be tap e d or supported by a belt whenever the pa tien t is vertical ( i . e . , stand­ ing, si tting, or during any a c tiv ity of daily living) . As force closure returns, the pa tient should wean off the belt by red u c ing the a motmt of compression (loosen the tension in the compression s traps) and fina lly

remov ing

the

belt

al together

periods of time (begin with

30 m in) .

for

short

Ultima tely,

the pa tient sho uld be a ble to e l imina te the need for any ex terna l sup port.

RESTORING FORCE CLOSUR E AN D MOTOR CONTROL Be fore specific exercises can be described, it is important to disc uss some key considerations for developing the p rogram. The thera pist should: •

E d u ca te the p a ti ent a s to the importance of a

new approach to exercise. Discuss wha t happens to the brain's program ming of m uscle coordina tion with p a in and inj ury (Ch. 5) and the importance of practice, mind ful movement,

and

incorpora tion

into daily a c tivities. It i s helpfu l to remind patients tha t th i s is not really exercise but ra ther "cha nging the way you l ive in your body. "

PROLOT H ERAPY Prolotherapy

•

(Dorm an

1 9 94,

1997)

is indica ted

when there has been a loss of form closure ( articular instabili ty) and the local sys tem canno t supply s u f­ ficient comp ression to compensate a nd force close th e join t under load . When the force closure mech­ anism is effective, co-contra ction of the muscles of the local system shou ld compress the j o int and thereby increase its stiffness. The neutra l zone of mo tion is subsequen tly re d uced to zero . If the local sys tem is con tra c ting appropria tely

and

yet is

ineffec tive for con trol l ing shear.

This is a poor prog­

nostic sign for success ful rehabil ita tion w i th exer­

cise

and the primary ind ica tion for prolo therapy.

In

inj ected with

an

i rritant solu tion w hich crea tes an

of the ligament. Typ ically, the ligaments a re inj ected every

2 weeks and

•

p rocess is to ensure tha t the joint is s tabi l i ze d w i th an ex ternal su pport or tape to prevent e xcessive shearing of the j oint and to ensure tha t op timal alignment is m a inta ined through the use of a c tive mobil ization

techniques.

Since

prolotherapy

is

"prac tice

ma kes

En sure tha t the e xercise p rogram is speci fie to

that fa ulty movement p a t terns are i dentifie d . The therapist should ha ve identifie d : - the levels o f p o o r con trol ( C h .

8:

Region a l

movement tests) - the d i rection(s) of poor con trol

(Ch. 8 :

Regional move ment tests a n d form clos ure analysis) - the levels or regions of res tricted mobility (Ch.

8:

Form closure a n a lysis)

- the overactiv e / domin a n t global muscles or slings of muscles (Ch.

8:

Force cl osure / motor

c ontrol analysis) - the inactive / underrecruited muscles (local stabilizers) or slings of muscles (global muscles)

(Ch. 8: Force closure / motor con trol analysis) - any specific m uscle length / s tren gth imbalances

the trea tmen t is repeated for fo u r

t o s i x sessions . The role of the therapist d u ring thi s

tha t

the p a tient's needs and not generic . Thi s requi res

of fibroblasts into the inflamed tissue promotes the prod uction o f collagen whi c h increases the stiffness

p a tient

of qualit y of movemen t, ra ther than quantity of

pro lotherapy, the ligaments of the unstable jOint a re inflam m a tory rea c tion. The subsequent migra tion

the

e x ercise.

unable to increase the s ti ffness (stability) of the joint, then the ac tive force closure mechanism is

Remind

permanent, not perfect" to reinforce the importa nce

(Ch. 8: Force closure / motor

control analysis) . •

Design

and

modify

the

exercise

program

b a sed on tissue health, tissue irritability, and stage of healing ( C h . 7) . Speed of p rogression will depend on a number of fac tors, including the capacity of the p a tient for learning new tasks.

often painful, the thera pist should be prepared to

Strength, endurance, and power of the global trurtk

p r ov ide

muscles are important componen ts of muscle func­

emotiona l support d uring this process .

Once the force

closure

mechanism begins to a ffec t

tion tha t should be assessed and trea ted when identi­

the neutral zone of motion ( th e j oin t glide can b e

fied as deficits . However, it is not the intent of this

red u ced by a co-contrac tion o f the l o c a l system),

cha p ter to cover exercises or pro tocols for these

biomechanical recovery has begun. Force closure

components as several sources e xis t on these topics

and motor control retra ining can now begin.

(McArd le et a1 1991, Farrell et al 1994, Brukner & Khan

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T H E PELV I C GIRDLE

2002,

2002) . Instead, the focus of the exercis es is the restoration of motor control where­ by un d e r re cru i te d muscles are reactiva ted through m ind bod y a wa reness a nd ima ge ry. This connec tion and activa tion of underrecruited local and global muscles is essential prior to pres c r ibin g exercises for s tre ngth, as unless the br a in is using the muscle, exercises for s treng thening that muscle will only serve to strengthen alterna te muscles being subs titu ted for the action (e.g., hip ex tension exercises for gl u te u s maximus can be performed using the hamstrings) . Thus, the focus o f the e xerc i ses here i s control of movement, with optimum techni que, and wi th an a w a rene s s of the segments and areas of poor control that ne ed to be correc ted . Once the bra in has "found" the muscle, protocols for endurance, strength, and power can be used if needed for p a tien t s pec ifi c goa l s Following the presentation of the lumbop el v i c stabi bza tion program, exercises for streng thening spec ific m us cl es c ommonl y affected in p a tien ts wi th lumb o p elvi c - hip dysfunction are p re s ente d Al tered m u scle l ength has imp li c a t ion s for strength (due to l en gth tensi on rela t ion ships) and for restriction of mobili ty. As s es smen t of the under­ lying ca use of a ltered m u sc l e leng th is cruci al for c orre c tin g the dysfu n ct ion in the muscle. I t is rarely a ma tter of simply s tre tchin g a ti gh t mu s c le C ha p te r 8 described tests for common patterns of m uscle leng th restrictions (see Global sys tem slings: len gth ana lysis ) . These test p o s i tions can be ad a p te d in to thera pist-assisted stretching t e chn i que s or home exercises . Often, a technique tha t inc o rp o ra t es acti­ va tion of neu ral pa thways is more effec tive for rel e a s ing the m uscle; these include active m ob i l i z a ­ tion or m uscle energy, re c ip ro ca l inhib i tion, and IMS. It is beneficia l to follow these te c hnique s with home exercises tha t maintain ex ten si bility in the rele ased muscles. So m e ex a m ple s of these exercises are presented la ter in this c hapte r The reader is referred to o ther sources ( Ke nda l l et a l 1993, Stark 1997, Hall & Brod y 1999) for a more comprehensive covering of s tretching and flex ibility exercises. McGill

p resen t e d

-

-

.

.

-

.

.

RE DUCING RIG I D ITY - DOW N TRAI N ING T H E G LOBAL SYSTEM

c or re c tin g breath i n g patterns, a nd re l eas in g the hip. Sap sfor d e t al (200 1) investigated spinal po s i ti on and the effect of p osi ti on on abdominal m u s c le re c ru i t m e n t d u r in g " hollowing" ( a imed to recruit p ri m arily transversus a b d ominis (TA) and in ternal ob lique (10» ), and " br a cin g (a contrac tion of all the abdominal m u s c le s) maneuvers. The spina l pos­ ition found to pro d u c e the gre a test increase in TA a c ti v i t y was t he neutral spin e position. In the flexed position the ex terna l obli que ( EO) mu s c le had the greatest increase in a c tivity. Al though the s tu dy was p erformed with a sma l l number of su bje c ts, the find ing s are consisten t with wha t we observe in the clinical s ett in g Notably, a common substi tu tion stra tegy for pa tients w i th l u mbope lvic dysfunc ti o n is a "bu tt grip p i ng " (Fig. 8.40) or an abdominal b ra c i n g (Fig. 9.4) s t ra te g y to transfer load. These pa tterns of activa tion res ul t in a posterior pelvic til t, a fle xe d lumbar sp in e, and a braced hip j o int. A t tem p ting to te a c h exercises tha t isola te the loca l mu s c les (TA, deep fi bers of m u l t i fid us) wi tho u t f i rst c o rr ec t ing the spinal po s i t i o n can often lead to frus tration for both the the ra p i s t and the pa tient. Two m e thod s for postural correction can be used : "

.

­

1 . po s itio ning the pa ti en t passively in to a n e u tral spine position and then te a c hing the p a tie n t how to perform self-positioning a t home (see side­ lying posi tion below) or 2. te a ching the pa tien t to find neutral s p in e with an active exercise but without excessive global activity, ­

esp eciall y in the erector spinae and s up erficial multifidus

muscles .

It has been our clinical exp erie nc e tha t by address­ ing s p in a l po s i t ion, cues for r ec rui tmen t and isola­ tion of the local muscles are more effe c t ive and efficient. Usually both passive positioning for exer­ cises as well as active exercises to learn ne u tr al sp ine are included i n a p a ti en t s program; however, ini tia l ly they may be separa te exercises performed in two different posi t io ns . For example, a patient who lies in a p os ter io r pelvic tilt in crook lyi.ng ma y be giv en the roll-up-roll-down exercise (see below) to learn how to find the neutral spin e position and rel e ase ho l d ing in the global muscles of the trunk and hip . This m a y take a fai r amount of mental concentra ti on; the pa tie n t s spin a l posi tion will improve w i th p ractice of the exercise and with the concurrent manual release a nd mobilization tech­ niques being pe rfor med by the the r a pi s t . If the p a tient cannot ful1y release into neu tr a l spine in this exercise ( i . e . , remains in some p o s te rior pel v i c tilt '

'

P O ST U R A L R E - ED U CAT I ON, NEUT R A L S P I N E , AND R E LEAS I NG T H E " B U TT G R I P PER"

This sec tion will in trod uce exercises tha t emph a si z e movement with awa reness in finding neutral s p in e,

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Tre a t i n g t h e l u m bo p e l v i c- h i p dysfu nction

b u t to a less d eg re e ), the a ddi tion of cues to r e c r u i t TA in th i s posi tion will still bias recruitment of the EO. Thu s, recruitment and isola tion of TA a re ta u g h t in a di ffe re n t position. By ch ang in g the po si tio n for p rac t ic in g TA i so la tio n exercises, the brain is given a short c o n c en t ra ti on break, which is imp o r t an t w i th exerc ises tha t re train m o to r learn­ ing. Th e a l ternate posi tion c ho se n is the one where the p a ti e n t c a n e a s ily find neutral and thus will have the easiest ti m e re cr u i ting TA Si d el yin g or prone are the most co mm on al te rna t e p o si t i ons for p a tien ts who have dif fi c u l ty moving out of pos ter­ ior pel v ic til t (see below) . It sho u l d be noted that there a r e o ther benefits and effects of neutral s p ine exercises . Notably, by us ing active exercise to retra in n e u tral s pine , the pa ti en t is learning a new p l a c e to live in the body, which then reinforces new stabilization s tra tegie s a s the y are learned . C o rre c ting a s ymme tri e s in the s pin a l c urves and in thor a cop elv ic a lignm e n t fa cil i t a te s mo re s ym ­ m e tr i ca l ac ti v i ty in the gl ob a l s l in g s a n d p la c e s restricted portions of the glob al slings on c ontinu­ ous stretch. Furthermore, a k ey rehabilitation goal is to p rogress the s t a b il i zatio n exercise program to upright, func tional p o siti o n s and ac ti v i ti e s . When p e r for ming exercises in the s tan din g p os i ti o n the pa tient often reverts to a habitual poor posture or an ov ere rect pos ture tha t simply in cre a s e s a lr ea dy dom­ inant gl ob a l musc l e activi ty, moves throu gh existing hypermobilities, and a v o id s movement through typ­ ica lly stiff j oin ts . In the ini tia l st a ge s of rehab ilita tion, it is often diffi c u l t for the pa ti en t to assume a neutral sp inal p o s ition in s tand in g, even with verbal and ta c t­ ile c ueing. Supine and fom-point kneeling over a ball a re less loaded positions where this skill can be d ev el op e d and then a pp l i e d to more up r i gh t pos­ i tions as th e exercise program is pro g re s s e d . Thus, training of neu tra l spine is an e sse ntia l p a rt of the postural re-educa tion process and ad dre ssin g dys­ function in both the local and g l ob a l systems. The ne utral sp ine p os iti o n is d e fin ed as the pos­ ition where the normal s pi n a l curves are p res en t and the thora x is centered o v e r the p e lvi s . In e a c h different body pos i ti on (s upine , fo u r- p oin t kneel­ ing, s i t t ing, s tan d in g), the s a me s p in a l orien ta tion is desired: gra d u a l , even curve s with a neutral pe lvic tilt (ASISs a n d pub i c sy mph y si s in the same corona l plane), l u mbar lo rd os i s, thoracic kyphosis, and cer­ vi c a l lo rd os i s . Kendall et al (1 993) p ro v i d e a fo u n ­ da tion from which to cla ss i fy different postures; however, often a more s p e c i fic s e g m e n ta l ana ly si s and sp e c i fic pa lp a ti o n a re needed. In each r e g i on ,

we are not only looking for a n inc re a s e or decrease th e normal c urv e, but a l so fo r sp eci fi c levels of ab no rmal curvature. A common p re se n t a ti o n is excessive lordosis in t he upper lumbar levels, the thoracolumbar j unc ti on, and l o we r thoracic spine, while t he lower l u mb a r s pin e h a s a l o s s o f lordosis (L4-L5 and L5-Ll levels re main flexed) with a pos­ terior p e l v ic til t (F ig . 9 .22a) . Th e pa ti en t with a spondylolisthesis ofte n has a d ec re a se d lordosis or flexed s eg m e n ts above and below the level o f exces­ sive anterior shea r. Thus, a se gme n t a l ana l y s is of s p ina l posture / cu rves is req u i re d du ring a ssess­ me n t , and l ev e l s of excessive flexion or ex tension should be t a r g et e d for correction with manual and verbal c u e s d uring the exercises below. in

N e u t ra l s p i n e - p a ss i ve p os i t i o n i n g s i d e l y i n g

Pat ient a n d therapist position The patient i s si dely ­ the ra p i s t with the knees bent. Stand faCing the p a tie n t w i th your body at the level of the p a ti en t ' s lumbar s p ine . With you r c ranial h a nd , p a l ­ p a te the lumbar c urve . Iden tify l e v e l s of excessive flexion or extension. The c a u d a l hand slides under the pa tien t' s ankles and the w e i gh t of the le g s is su p ­ po rte d by the t h er ap is t ' s c a u d a l thigh (Fig. 10.27) . Correction tech nique The legs are pass iv ely moved into flexion and ex tension as the llunb ar spine is pal­ pa ted fo r chan g es in th e cu rve . When a gentle, even lordosis is achieved, p la c e th e l e g s on the plinth a t tha t p os i t i on . Note the p o si ti on o f the fe e t rela tive to the rest of th e body. The neu tral spin a l po s i ti o n is often obtained where the soles of the fee t lie in the s am e p l a ne as the trunk . Instruc t the p a tient how to find this p osi ti on at home. The i d e a o f p r e tendin g to lie aga ins t a wall with the soles of th e feet and ing facin g the

F i g u re 1 0. 2 7 N e u tra l s p i n e : s i d e lyi n g , p a ss iv e p os i t i o n i n g . ( R e p ro d uced w i t h perm i s s i o n fro m © D i a n e G. Lee Phys i o t h e ra p ist Corp.)

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T H E P E LV I C G I R D L E

touching the wall i s a helpful c u e . palpate the lumbar s p in a l cu rve both in the habitual sidelying position and in the new position. En s u re tha t the pati en t can find the neu tral position w it ho u t your assistance . the

back

both

H a v e the pa ti ent

N e u tra l s p i n e - crook lyi n g ro l l - u p - ro l l - d o w n

Pa tient a n d thera pist positi o n The p a t ient i s s u p ine with the hips and knees c o mfor ta b l y flexed. Stand at the patient's sid e . Slide one hand under the lum­ bar spine, sp re a d in g the fingers to allow p a l p a t io n

several interspinous spaces. Make note of the lumbar spine orientation. Observe the ribcage a n d look for a lifted s ternum or space under the lower thoracic s p in e . While in this position, use your fingers to give tac tile feedback as you ed ucate the p a tient abo u t the goa l of the exercise ("your low back is very fl a t / the curve is uneven here, this is where we need to change the curve " ) . In order to help the patien t learn the exercise movement, th e p a t i en t s h a n d s a r e plac ed on th e upper and lower of

re s t ing

'

F i g u re 1 0. 2 8

sternum, and th e therapist's hands are placed so that one hand p a lp a t e s at one hip, and the other hand p a l p a te s in the lower abdomen (Fig. l O .28a). During th e exercise a nd in subsequent repe titions of the m o v e ment the therapist's hands will move to p a l p a te and fa ci lita te a t sev e r a l key points of con trol, depending on the correction needed for

op timal exercise exec u tion. Correction tech n i q u e - ve rba l a n d m a n u a l cues

p a tient

The

abdomen to the be d , then to push through the feet and lift the hips off the be d , rol l in g the spine gen tly into a " C " (p os t e rio r p e l vic tilt and spina l flexion), lifting up to the level of the lower thoracic spine ( F i g. 10. 28b). H o w high the hip s a n d lumbar sp ine are lifted d e p end s on the pa tien t's ability to m a int a in a flexed s pine Lifting is not permitted beyond a point where spina l ex tension and / or ac tivity in the erec tor s p inae muscles occur. Next, ask the patient to lie th e spine b ack down on the bed, starti ng from the ribcage . The thorax is kept hea vy on the bed to m a in tain the thoracic k yp ho s i s , a nd the vertebrae is asked to draw the lower

.

N e u t ra l s p i n e : crook l y i n g ro l l - u p - ro l l - d o w n .

[ a ) T h e p a t i e n t p a l p a te s t h e st e r n u m t o s e l f- c u e a h e a vy, re l a x e d t h o rax [verti ca l a r row) d u r i n g t h e m ove m e n t . N o l i ft i n g o f t h e s t e r n u m i s p e r m i tte d . T h e t h e ra p i s t pa l pa tes a t t h e l o w e r a b d o m e n to c u e a g e n t l e d ra w i n g - i n of t h e l o w e r a b d o m e n a n d a ro u n d t h e h i p to fa c i l i ta t e a poste r i o r t i l t ( c u rved a r row) of t h e p e l v i s a n d fl e x i o n o f t h e l u m b a r s p i n e [a rrow). ( b ) T h e h i p s a n d p e l v i s a re l i ft e d off t h e bed to con t i n u e t h e f l e x i o n m o ve m e n t i n t o t h e u p p e r l u m b a r a n d l o w e r t h o ra c i c l ev e l s . T h e h i ps a re l i ft e d o n l y t o t h e p o i n t t h a t s p i n a l fl e x i o n ca n b e m a i n ta i n e d ; i n t h i s exa m p l e t h e l i ft i s s to p p ed a t t h e t h o ra c o l u m b a r j u n c t i o n . (c) R e l e a s e i n t o l u m b a r l o r d o s i s . T h e t h e r a p i s t p ro v i d e s g e n t l e poste r i o r p ress u r e on t h e l o w e r s t e r n u m [verti c a l a r row) to p reve n t t h o r a c o l u m b a r e x te n s i o n a s t h e p e l v i s fa l l s fo rwa rd i n to a n a n te r i o r t i l t . T h e t h e ra p i st's l e ft h a n d i s pro v i d i n g a c u e t o re l ea s e t h e a n teri o r h i p as w e l l as d ra w i n g the p e l v i s a n t e r i o r l y a n d i n fe ri o r l y (c u rv e d a rr o w ) . O n s u b s e q u e n t r e p e t i t i o n s o f the e x e rc i s e the t h e r a p i s t c a n pa l p a t e t h e l u m b a r s p i n e to fa c i l i t a t e t h e l o rd os i s a n d e n s u re t h a t t h e s u p e rf i c i a l m u l t i fi d u s a n d e r ecto r s p i n a e re m a i n r e l a x e d d u ri n g t h e ro l l - u p a n d a t t h e fi n a l r e l e a s e i n to n e u t ra l l o r d o s i s . [ R e p ro d u c e d w i t h p e r m i s s i o n fro m

Copyrighted Material

©

D i a n e G . L e e Physi o t h e r a p i s t Corp.)

185

Trea t i n g the l u m b o p e l v i c- h i p dysfu n ct i o n

are unrolled one segmen t at a time . Once the lum­

the roll-down component, the thorax rema ins in

bar spine is flat on the bed, ask the pa tient to "let the

flexed position as the lu mbar spine passively falls

tai lbone fall to the bed" or " l et the pelvis roll for­

in to a lordosi s . The anterior and pos terior hip

a

ward" and allow a small curve in the low back to

muscles are relatively rela xed (no areas of marked

occ u r (Fig. 1 0 . 28c) . Observe and palpate for where

hypertonicity) .

the lordosis occ urs - watch for a s ternal lift ( thoracic

Prog ressions/other co nsi derations

Support the legs

extension) and feel for excessive segmental lor­

at the knees with a bo lster i f the patient canno t relax

dosis (e. g . , L3) . The goa l is

the bu ttocks and perform the exercise through a

a

lumbar lordosis shared

by all lumbar segmen ts. Have the pa tient repe a t the

sma l ler range of motion.

movement several times, each time using your hands and cues to improve the end released pos­ ition. Do not let the pa tien t force the spine into lum­ bar ex tension. This active movement will cause a

Postu ra l re-ed u ca t i o n of n e u tra l s p i n e i n s i tt i n g - setti n g t h e o p t i m a l pyra m i d base

The patient sits o n a

strong thoracic erec tor spinae contra c tion or super­

Patient and thera p i st p o s iti o n

ficial multifidus contract ion (parts of the global

chair or plinth . The therapist stands or kneels beside

slings) , and wil! inhibit recru itment of the deep

the p a tient on the same side as the " b u t t gripping"

local stabilizing muscles (as well as po tentially

hip . Place one hand under the ischial tuberoSi ty,

increasing back pain and soreness due to excessiv e

and the o ther hand along the top of the iliac cres t

comp ression ) .

(Fig. 1 0 . 2 9 ) .

Correction tech n i q u e - verbal a n d m a n u a l cues

Key points of control for hands: •

Fingers can provide propriocep tion a t levels that need to leng then into a lord osis - glide your fingers along the spin ous processes in a vertic al l ine.

•

Hand on s tern um to prevent li fting of ches t ­

•

Hands in hip creases to fa c i l i tate " folding"

Ask

t h e p a tient t o f o c u s on the amount o f weight on each b u ttock, and to decide if the weight is evenly distrib u ted between the left and right sides. Instruct the patient to lean away from you slightly, ta king

keep "heavy. " of hips and "opening" of pelvis (anterior tilt) (Fig. 1 0 28c) . •

Use small wiggles (gen tle rota tion) of the ribcage, pelvis, and / or hips to facili ta te decreased global muscle contraction and rigidity. Verbal / visua l cues :

•

" Rela x y o u r buttocks, and l e t your sitz bones go wide as the tai lbone fa l l s to the b ed . "

•

"

Le t your h i ps go heavy as they sink to

the bed . " •

" Let yo u r low back lengthen a s you let your pel vis fa ll forward . "

•

"Im agine a line between the bottom o f the sternum and the pubic bone; the line shou l d get longer d uring the release pha se; the length comes from the pubic bone fa lling forwa rd, whi l e the stern u m point stays s till . "

•

" Keep the ches t heavy, relax the back . "

Idea l response

A s the rol l-up portion i s per­

formed, there is a relaxation of the lumbar and thor­ acic ex tensor muscles and segmen tal flexion occ urs from the pelvis to the lower thora x . At the end of

Fi g u re 1 0 . 2 9 N eutral s p i n e in s i tti n g : setti n g the o pti m a l pyra m i d base. H e re, t h e p a t i e n t l e a n s t o t h e rig h t w h i l e t h e t h e ra p i s t resets t h e l e ft i n no m i n a te posi t i o n [a rrow). T h e fo rce u s e d is determ i n e d by how m u c h " b utt g r i p p i n g i s p resen t . T h e f i n a l positi o n s h o u l d revea l a l evel p e l v i s a n d e q u a l w e i g h t­ bea r i n g t h ro u g h t h e l e ft a n d ri g h t b u ttocks. [ R e p rod u ce d w i t h p e r m i s s i o n fro m © D i a n e G . L e e Phys i o t h e ra p i s t Corp . )

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T H E P E LV I C G I R D L E

the weigh t o ff the a ffec ted buttoc k . Now, lift and pu l l the ischi a l tu b e ro si ty la terally and posteriorly,

and apply a gen tle medial counterforce to the iliac c rest a s the p a tien t slowly retu rns the b u ttock back down to the cha i r. Use the cue, "As you lower your buttock, think of letting the s i tz bone on this side go wide a n d o p e n b eh ind yo u " In .

the new posi tion,

th e p a tient sho uld feel more equal weigh t distribu­ tion b e tw een the two ischial tuberosi ties; this pro­ vides the wide, stable base of the opti mal p y r a m id.

Ideal response

In the new position, the pelvis

should be in a neu tral rota tion in

the tran sv e rse plane and the iliac crests should be level . Compared to the

ini tial sitting position (precorrec tion), la teral bending and rota tion curves in the lumbar sp ine

are often less

pronounced or comple tely correcte d . The anterior

on the a ffec ted side a re softer and more equal in tone to the other hip, and the and posterior hip mu s cles

femoral head sea ts more pos teriorly in the acetab u­ l um ( there will be a deeper crease in the anterior hip).

The p a tient can ta ught how to set the pyramid base independ­

Progressions/other co nsiderations be

ently for exercises and functional ac ti v i tie s in sitting. The patient's ipsilateral han d is used to p u ll the ischial tuberosity out and back as the weigh t is shifted and re p lac e d The patien t may need to per­ .

form a few re p etition s of this movement to get an equal p l acement o f the i s chial tuberosities. Exercises

F i g u re 10,30

N e u tra l

spi n e

i n s i tti n g : setti n g t h e s p i n a l

c o r re c t i n g a fl attened L5 a n d L4. t h e p a t i e n t create a " s i n k i n g " o r faci l i tate a n i n c r e a s e i n t h e

p o s i t i o n . I n t h i s exa m p l e t h e t h e ra p i s t i s

t h o ra c i c kyp h o s i s a n d a d ec r e a s e d l u m b a r l o r d o s i s a t The t h e r a p i s t ' s l eft h a n d h e l p s

" h e a v i n ess" o n t h e s t e r n u m to

and techniques to release the p oste ri o r hip mu scles

t h o r a c i c kyp h o s i s i n t h e u p p e r t h o ra c i c s p i n e a n d b r i n g t h e

should be conc urrently p erforme d , w i th the even tual

r i b c a g e p o s t e r i o r l y o v e r t h e p e l v i s . Th e t h e ra p i st's r i g h t h a n d

goal tha t the p a tient can assume the wide pyramid base position w i tho u t needing man ual self-correction. Pa tients with limited hip fl e x io n should initially sit on

a

hi ghe r chair or stool for this exercise so tha t the

p e l v is can move

into a

an terio

rly over the femoral heads

p r o d u c es a g e n t l e cra n i a l a n d

g e n t l e l u m b a r l o rd o s i s , a n d t i l t i n g

l i fti n g

of t h e

sacru m ,

p e l v i s fo rward

D i a n e G. Lee P h ys i o th e r a p i s t Corp.)

Th e p a t i e n t sits o n a flexion e i ther

uni l a terally or bi laterally, increase the heigh t of the sitting surface so tha t the p e lv i S is able

decreased

thora cic

"Let the ches t sink" or "go

chair or a ball, with the o ptimal py ra mid base (see a b ove) . If the patient has l i mited hi p

of

ky p hos i s

For

(usua lly

accompanied b y excessive erec tor s pi n a e activity ) :

Po stu ra l re-ed u c a t i o n of n e u t ra l s p i n e i n s i tt i n g - setti n g t h e s p i n a l pos i t i o n

to move

anteriorly over the fe murs ( to a l l ow the crea tion of a n e u t r a l lordosis in the lumbar s p in e ) . The therapi s t stands or kneels beside t he p a tient (Fig.

10.30).

H a n d placement wi l l d epen d o n which levels of the sp ine need co rrec tion (see verb al and manual cues).

the thoracic c urve fi r s t, then the l u m bar head/ cervical p os i ti on .

c u rve, and fi nally the

of t h e

and u n d e r t h e r i b c a g e . ( R e p ro d u c ed w i t h p e r m i ss i o n fr o m

©

a reas

Correct

p re s s u r e t h r o u g h t h e a

Correction tech n i que - ve rbal and m a n u a l cues

neutral tilt posi tion.

Patient a n d thera p i st positi o n

a n te r i o r

l u m b a r s p i n o u s processes to fa c i l i ta t e

heavy under my

hand . " " As your c he s t sinks, imagine your back openi ng between your shoul der b l a d e s . "Imagine

"

tha t th e distance from your sternu m

t o your b elly bu tton i s decreasing as y o u l e t the chest go heavy. "

For a reas of

increased thoracic kyphosis:

"I m ag in e a strin g a t tached to your back (palp a te

a t level of increased c u rve); the string is ge n tly up to heaven . " "Imagine tha t your s ternum i s b ei n g gently b e ing pulled

li fted . "

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Tre a t i n g t h e l u m bo p e l v i c- h i p dysfu nction

For a de crea s e d

l u mbar lord osis (flexed lumbar

sp ine ) :

"Im agine a s tring a ttached to y o u r ta i l b one, and someone else i s g en tl y p u lling the s tring up to heaven . " "Grow t a l l from the tailbon e . "

"Let y o u r pe l v i s fal l forward a s y ou g r o w tall fro m my fin g er s. " " I m a gin e th a t your p e lvis i s a bowl, and th a t i t is tipping forw a rd as y o u let yo u r si tz bones go wi de. "

"Let your buttocks go wide, let your hips fol d . " " A llow the b a l l t o roll und e rnea th y o u a s the pelvis rocks forward . " For an increased lumbar lord osis (hyperextended lumbar s p ine a t one or m u l tilevels) :

"Relax and let yo u r back round o u t, then as yo u grow tail, th ink of lengthening your l o w b a c k . " " R a the r th a n a r c hin g y o u r back, th i n k of the spine b ei ng long and tall, with a g e n tl e ev en c u rv e . " M a n u a l c ues

placement •

and o p t i o n s

fo r ther a pis t h a n d

(po in ts of con t ro l ) :

up p e r s tern u m (for loss of upper thoracic kyphosi s)

lower sternum (for loss of lower th or ac i c kyphosis and / or a n te ri orly sh i f t e d ribc a ge) • pos t e ri o r t ho r ax / ribc a g e ( fo r excessive thora c ic

•

kyphosis) •

l um ba r s pin e spino us processes

(at level w here lordosis is

more lord osis i s r e q u i re d or wh e re excessive)

m anubrioste rn a l sy m phys i s an d sup eri or p ub ic bone ( to cue vertica l alignmen t of these points) • bi l a ter a l l y around the anterol a teral or pos terol a ter a l l o w e r ribcag e ( to draw the thorax as a whole posteriorly, a nt e r i o r l y, or v e r ti ca ll y ) • ili a c crests and hip fold s ( to f acilita te a n te ri or pe l vi c til t ov e r hi ps ) . •

As the verbal c u e s a re giv e n , t he ther a pis t uses the poin t s of control to crea te the ideal cu rv a t u re s . To faci l i ta te increased thoracic kyphosis, the hand on the s ternum crea tes an inferior and p o s terior pres­ s u re . To d e cre ase a n excessive ky p h os i s, the hands l ift the ribcage from the sides or gi.ve a s u p e r i or and sl ightly an t e r i or pressure at the levels of excessive curve. To c orrec t a fla t lumbar s pine, th e fingers p us h gen tly anterior and su p e r i o r, cr ea ting a l i fting sensa t ion . For an e xc ess i v e l u mbar lordosis at one

or two segments, focus on f a cil i ta t in g a lord osis at levels above or below tha t are flexed, and th en l e n g then i n g or s tre t chin g the curve at the hyp er ­ ex tend e d segme n t (s ) by spre a din g t he fing e r s an d appl ying a vertical p ressu re .

I d e a l response T he crea tion of the l u m b a r lordosis be a release into an optimum c u rve , not a forc ed effort with contrac tio n of the e rec t or spinae. As sitting is an uprigh t positi on , there will be some tone in the erec tor sp inae and sup e rfi C ia l mul tifidus, but i t should be symmetrical and not exce ssiv e . Ri g i d i ty between the th o rax and pelvis ( in a bil i ty to dissociate the thorax from the p elvi s) is a sign of excessive er ec tor spinae a c tivi t y (p al pa te for tone and c hec k la teral mobility of the rib cage - see Rib wiggle, bel ow) . Once the thora cic curve h as been cor­ rec ted, as the l u mb a r lordosis is fa c i l i t a ted the sternal hand sh o uld not move superior or an terior ( the thor­ acic k yph os i s shou ld b e m a in ta ined ) . The goal is to crea te a ge n tle , even kyphosis in the th ora cic spin e, a g ent l e , even lordosis in the lumbar spine, and a gen­ tle lordosis in the cerv ical spine; p a lp a te and obs erve to ensure th a t one or two s egme n ts d o not rema in e x ce SSively flexed or extended. The pa t i ent ' s wei ght should be ce nte re d e q u a ll y over the ischia l tuberosi­ ties ( the op ti m a l pyramid base), the pubic sy mphys i s and the ASISs sho uld be in the same plane, and the m anu b rios ternal symp hys i s should be v e r ti c all y in line with the pub ic symphys is. If the ribca ge i s shifted an terior o r p o s te r i or to the pelvis ( i . e . , th e manu b r i os te rna l s y mphy si s is anterior or p os te rior to the p u bic symphysis) , use these two points a s p ati ent p a lp a tion poin t s for l ea rnin g and correc tin g thoracopelvi c alignment . The the ra p i s t uses a c ombin­ a tion of the ab o v e poin ts of control to maintain cor­ rect th oracic position as the p e lv is is b rought under the ri b c age or ma in tain the op tima l pyra mid base a s the thor ax is mo v e d into alignment over the p e l vis . Prog ress i o ns/oth e r co n s i d e ra t i o n s The bre a th ca n b e used to facil itate the proper curves. " Breathe deeply and a llow the a i r to fil l the space " : shou ld

b e t w een your shoulder blades (if mid-thorax is lord o tic) • ben eath y o u r st e rn u m ( i f mid-thorax is k yph o ti c) • be tw e en your l o we s t ribs - p o s t eri o r l y ( i f l ordo t ic) - an t er i orly ( i f k y ph ot ic) . •

Once the spinal cu rv es have been corrected in the sa gi t t a l plane, corrections c a n then be ma d e to any rot a t ion and / or s id eben d in g fa ults. Thes e

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1 88

T H E P E LV I C G I R D L E

asynunetries will correlate w i th imbalances of length

"comfortable pos ition ha lfway between the two

and recruitment in the global slings, especially in

positi ons . " C a re must be taken w i th this kind of

those tha t control thoracopelvic aligrunent. Scapular

exercise if given withou t specific manual or verb a l

position and the muscle balance relationships of the

cues. In a pop u l a tion w i th lu mbopelvic dysfunc­

scapulothoracic muscles can also impact thoraco­

tion, the "comfortable" posi tion will be one that

pelvic aligrunent. Correc tion techniques include:

avo ids restrictions and moves into areas of a l ready

•

Bi l a teral l y p a lpating the ribcage a t the levels of

rotation and sidebend to corre c t the asymme try manually while providing gentle traction through the thorax ( this allows the pa ti ent to re lax). For exa mple, i f the thorax is right-rota ted and right lat­ erally bent, the therapist provides a p osterior and inferior force to the left lower ribcage while provid­ ing an a n terior and superior force to the right lower ribcage . •

A " d umped" scapula (depressed a nd down­

ward l y rotated) can contrib u te to thoracolumbar latera l bending to the same side. Manual or tape support to the scapula w i l l assist in spinal position correction. •

Verbal cues such a s "open the ribcage in the

fron t on the right side" and "imagine the space b e tween your ribcage and pelvis on the right side

excessive movemen t or poor con trol . It cannot be assumed that this is true ne u tral spine . It is essenti a l tha t segmenta l p a l p a tion a n d observa tion o f subs ti­ tution p a tterns are performed by the therapist whi le giving this exercise. However, with specific correc­ tions, the pelvic rock can be a useful method for tea ching thoracopelvic movement dissocia tion and facil i ta te awareness of w here the center of gravity falls in rel a t ion to the sitz bones. In a posterior pelvic til t the p a tient can be made aware tha t the center of gravity falls behind the si tz bones, and in an an terior pelvic tilt the pa tient can be made a w a re tha t the center of gra v i ty falls in front of the sitz bones . The goal is tha t the cen ter of gra vity fa lls in line with the sitz bones, and this awa reness can be used as a self-check for the patient when prac ticing the exercise independen tly.

increasing or lengthening " provide the patient with i ma ges to self-correct the asy mme try. •

La tera l costal exp ansion and breathing p a t ­

N e u tra l s p i n e i n fo u r- po i n t k n ee l i n g The patient is

four­

terns will b e asy nunetric al; u s e retra ining of l a teral

Patient a n d thera p i st positi o n

costal expansion (see below) Lmila tera lly to re lease

point kn eeling on the floor or on a plinth, shoulders

tone in muscles con trib u t ing to the asymme trical

over the hands, hips over the knees . If there is a uni­

spinal position.

l a teral or bila teral restric tion of hi p flexion, the hips

Once

you have fa cili tated a neutral spine posi tion,

ask the pa tient to maintain the new posi tion and brea the norma lly. Observe what happens to spinal position ca uses

w i th b reathing excessive

(apical brea thing often

thora col umb a r

ex tension);

use

re-educa tion of the brea thing p a ttern (la teral costal expansion, see below) to fa cilita te maintenance of neu tr a l spine position. Note that small devia tions of trunk and lower-limb posi tion will occur in sync w i th the brea thing cycle (Hodges

2003) but these

sh ould not be e xcessive nor resul t in high levels of global m uscle a ctivity and postural rigid i ty. Check internal and external rotation mob ility of the hip s; if the pa tien t is u n able to move the hips actively or allow passive rota tion this is an indication of exces­ sive glob a l m uscle a c tivity and "b u tt gripping" (see checkpoints for global rigidity belo w ) .

should be a llowed to rock forw a rd of the knees (otherwise the pa tient w il l be unable to a t tain a lumbar lordosis) . The thera pist kneels or stands beside the pa tien t . Therapist hand placemen t and fa cilita tion will depend on the a reas of tho racic and

lumbar

curvature

tha t

need

correction

(Fig.

10.31). Correcti o n tech n i q ue - ve rbal a n d m a n u a l cues

Verbal c ues for decreased thora cic kyphosi s : " L e t me h a v e your ribcage; l e t y o u r b a c k open as I lift your ches t. " "Take a breath and bring the air into your back . " For decreased lumbar lordosis: " Keep your upper back open as you lengthen under m y finge rs . " "Let you r b u ttocks g o wide a nd the low back

A common exercise technique f o r find ing neu tral i s some form of pelvic rock. The p a tient s i ts on a ball

fa ll i n to a gentle a rch . " " Stay supported and open in y o u r ribcage

as

or chair, and is taught to roll the pel vis in to an an ter­

you let the pelvis fall fo rward towards the floor,

ior ti l t, then a posterior ti l t, and then resume a

letting the hips fol d . "

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Tre a t i n g the l u m bo p e l v i c- h i p dysfu n ct i o n

Figure 1 0 . 3 1 N e u t ra l s p i n e : fo u r - po i n t k n ee l i n g . I n t h i s exa m p l e , the t h e ra p ist u s e s t h e c ra n i a l a r m u n d e r t h e r i b c a g e t o resto re the t h o rac ic ky p h osis a n d b ri n g t h e r i b c a g e i n l i n e w i th the pelvis ( vertica l a rrow ) . The c a u d a l h a n d fac i l i ta tes t h e l u m b a r l o rd o s i s w i t h a cra n i a l a n d a n terior p ressu re ( h o rizonta l a rrow ) w h i l e verba l cues a re g iv e n . ( R e p ro d uced w i t h perm iss i o n f r o m © D i a n e G . L e e Phys i o t h erapist Corp. )

For increased thoracic kyphosis: "Len gthen your spine under my hands as you let you r ribs fall to the floor. " For increased lumbar lordosis: "Round ou t your back to the ceiling (reverse the c u rve into flexion ) . Now let the low back a rch again but think long a nd gentle (manual cueing is i m port an t here; see below) . " Key points o f control and options for therapist h a nd plac e m ent : •

•

•

•

•

•

man ub ri os tern al

symphysis (for loss of upper thoracic kyphosis) support under lower ribcage (for loss of lower thoracic kyphosis) posterior thorax a l o n g the spinous processes (for excessive thoracic kyphosis) lumbar spinous processes (at level(s) where more lordosis is requi red or where the curve need s lengthening) iliac crests (to facilitate more symmetrical lumbar lordosis/ lengthening thro u gh spine, a n terior pel v ic tilt over hips) hip creases (to facilita te hip fold ing an d w i dening of buttocks) .

As the verbal cues are given, the therapist uses the points of control to create the ideal curvatures. To facil i ta te an increased thoracic kyphosis, the fingers under the sternum can press gen tly posteriorly

(up to the ceiling), or the whole arm can support the ribcage and lift it posteriorly to open up the poster­ ior thorax . To decrease an excessive kyphosis, one hand on the posterior thorax p rod u ces an anterior and slightly cranial pressure while the o ther hand on the sacrum provides an inferior distrac tion to create a sensa tion of lengthening to go with the verbal cue. To correct a fla t lumbar spine, the fingers push gently an terior and superior, creating a length­ ening sensa tion as the pelvis falls forward but the thoracic spine stays supported into a neutral kyphosis. For an excessive lumbar lordosis a t one or two segmen ts, have the patient reverse the entire l um ba r curve into flexion, then foc u s on faci l i ta ting a lordosis at levels above or below the excessive lordosis as the p a tient returns into a lordosis . Use a light "wiggle" through the iliac cres ts with a ca udal pull to create the sensation of lengthening or stretching the curve a t the hyperextended segment(s). The head and neck position are corrected a fter releas ing the s upport for the trunk . Note tha t asym­ metries are common and that manual and verb a l c u e s m a y need to be focused more t o o n e si de to cre­ a te the op tima l neutral spine position . For example, when one hip is " b u tt gripping," rota tion and lat­ eral bending will be induced in the pelvis and spine . When c ueing the neutral spine posi tion, direct the pa tient's a ttention to release the specific hip involved and lengthen between the ribcage and pelvis on the affected side . I d e a l response As you release your manual sup­ port, the patient should be able to maintain the new position of gentle thoracic kyphosis and l u m b a r lor­ dosis, withou t excessive bracing w i th the abdom­ inals or brea th-hold ing . Ask the p a tient to maintain the position and breathe norma lly. If there is a n anterior collapse of the upper thorax, loss of control through the scapulae, loss of the l umbar lordosis, or bracing and brea th-holding (the entire trunk becomes sti ff) , the pa tient is not ready for exercises in this position. Progressio ns/other co nsi derations Have the pa bent breathe in, breathe o u t, then gently connect to the deep lumbopelvic s tabilizers (see below) . Grad­ ually release your s upport as you ask the patient to hold the new position. Ask the patient to come out of the position into kneeling, then go back into four­ point knee l in g and see if the p a tient can find the optimal po si tion independently. Repeat the m an u a l ! verbal cueing a s needed, but reduce the manual support to train the p a tient to find the correct posi­ tion w ithout a ssistance.

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Idea l response lumbar

lordosis

As per sitting, the g o a l is and

a gentle

thoracic k yp ho sis w ithout

excessive erec tor spinae

or s up erfi c ial m u l ti f id us

m uscle a c tiv i ty. It is impor t an t to p a lpa te the l um­

b a r c u rve a s wel l a s the muscle tone i n the l u m b a r s p ine and thoraco lumbar j un c t ion. The re shou ld be no butt gripping and the hips should remain free to m o ve . Progressions/other considerations The l umb ar spine can be fl a tte ne d a gains t the wall and then released in to a lo rd o sis by cueing, "Relax the buttocks and let the pub i c bone fall forwa rd . " Teach the patient how to pa lp at e the lumb ar curve so th a t the new correct pos­ i tion is achieved independently. Direct the pa tient's attention to the p ress ure of the bu ttocks a g ains t the wall and ensure that the pressure rema ins equal be tween the righ t and left sides; simila rly, there should be equ al press ure of the p os t e ri o r r ib c age on the wall. Unequal pressu re will occur when r o ta tion a l as y mme tries in th or a copel vi c alignm ent have not been correcte d . Use intern al and external rota tion of the hips (see C he ckp O ints for g l oba l muscle rigidi ty, below rigidity) to check for "butt gripping. " R e l e a s i n g t h e h i p (t h e " b u tt g r i p p er") i n s u p i n e F i g u re 1 0. 3 2 N e u tra l s p i n e : s u p p o rted s ta n d i n g . The p a t i e n t i s u s i n g self-pa l pa t i o n poi nts to perfo r m correct i o n of s p i n a l postu re i n de p e n d e n t l y. T h e c ra n i a l h a n d p a l pa tes t h e m a n u brioste r n a l j u nction a n d t he ca u d a l h a n d p a l pa tes t h e p u b i c sym p hysi s . W h e n p ra c t i c i n g setti n g n e u tra l s p i n e i n t h i s pos i ti o n , t h e p a t i e n t a i ms to h a v e t h e t w o h a n d s i n t h e s a m e ve rtica l l i n e . [ R e prod u ce d w i t h p e r m i s s i o n fro m © D i a n e G . Lee Phys i o t h e ra p i s t Corp.)

N e u t ra l s p i n e in s u p p o rted sta n d i n g

Pati ent a n d therap ist position

The p a t ient stand s

with the back again s t a wall, fee t a pp ro xim a te ly I S-30 cm

(6-I 2 in.)

aw ay fro m the wall. The knees

a re bent and the prima r y point

of c on ta c t and sup­ head should be positioned over the thorax, n o t res ti n g agains t the wall, as this usually resu l ts in poor cerv i­ c o th o ra cic po s i tion. The thera p is t stands beside the p o r t is the p o ste ri o r pelvis (Fig. 10.32 ) . The

patient and palpa tes the lumb ar curve and s ternum,

or o ther ke y p oin ts

of control a s desc ribed abo ve,

Ov era c ti v a tion o f the pi ri for mis (pi ri fo rm i s syn­ d rome) and i schio c o cc y ge u s resu l ts in excessive compression of the SIJ . In a d d i tio n, overactivation of the obtura tor in ternus and e x ternus, gemel li, and q u a d r a t us fem o r is increases c o mp ress i on of t he p o s t eri o r aspect of the hip j o i n t. The fol lowing teclmi q ue is usef u l for r e l e a s in g the m u scles and d ec o mp re s sing the h i p and SII. Pati ent a n d t h e ra p ist position The pa tient is su p in e w i th the h ip s and knees c o mfo r ta b l y flexed . With the crania l h a n d , p a l pa te the i li ac crest as wel l as the transversus abdominis or m u l t i fidus. Thi s ch o ice w i l l be based on the find ings fr o m the force closu re / motor control ana l y s is; pal p a te t h e m uscle the pa tient ha d the mo s t d i ffi c u l t y is o la ting . Wi th the caudal hand, palpate the musc l e(s ) in the pos ter­ ior pe l vi c wall or the external ro ta tor of the hip which is overa c t i v e (look fo r a ten d e r trig ger p oint ) . Co rrection tech n i q ue - ver b a l a n d m a n u a l cues In struct the pa tient to brea the in a nd on the bre a th o u t l ightly and gen tl y to contract the TA or multi­

d ependin g on where the cu r ves nee d cor recting .

fidus ( see isola tion a nd awareness tra ining for the

Correction tech n i q u e - verba l a n d m a n u a l cues The c u es described above for the s i t ting p o s i ti o n can be u sed in this p os i ti on . Again, correct the th o ra ci c curve first, and then the l u mbar c u rve .

muscle system for use fu l verbal c ues) . Have the pa tient maintain a ver y low level of contrac tion of TA a n d m u l ti fid us and on the next b re a t h out fo cus a ttenti o n on to t h e tri g ger point you a re local

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Trea t i n g t h e l u m bo p e l v i c - h i p dysfu n cti o n

F i g u re 1 0 . 3 3 R e l eas i n g t h e muscles of t h e posteri o r pelvic wa l l and t h e extern a l ro tators of t h e h i p. I n this exa m p l e , t h e t h e ra p i st"s r i g h t h a n d is m o n i to r i n g the co n t ra c t i o n o f tra nsversus a bd o m i n is a n d a p p l y i n g a v e ry g e n t l e m e d i a l fo rce [a rrow o n the r i g h t forearm) to the i l i u m [propriocep tive c u e) w h i l e t h e left h a n d is m o n i to r i n g t h e t r i g g e r po i n t i n t h e poste r i o r p e l v i c fl oor / wa l l a n d a p p l y i n g a g e n t l e l a t e ra l fo rce [arrow on the left h a n d ) to t h e isch i a l t u b e rosity. ( Repro d u ced with permiss i o n fro m © D i a n e G . Lee Phys i o t h e ra p i st Corp. )

pa lpa ting ( ge n tly a pply press u re to the p o in t ) . On the next b reath out, p ro v id e the cue, "A llow the sitz bones to relax and move apart . " "Focus on making the m uscle u nder my fi n g e rs mel t . " Very gen tl y, apply a med i a l pres s u re to the ilium s u p e r i orly and a l a tera l pressure to the ischiwn i n fe ri o rly (a b d u c t the inn o m in a te) (Fig. 10.33) . M on i t o r the muscle response; do not force the innomina te or evoke a reflexive muscle contrac tion, m e rely p ro vid e a pro­ prioce p t i ve cue to the nervous system as to the direction of release y o u are loo kin g for. Repeat this for three to fou r b rea ths, ensuring tha t the TA and multifid u s re m ai n en ga ge d thro ughout the breath. Then, move your caudal h a n d to the distal femu r (Fig. 10.34) . A pp l y a very gentle force pa rallel to the

F i g u re 1 0 . 3 4

H a n d posi t i o n fo r rese a t i n g t h e fem o ra l h e a d .

A very g e n t l e fo rce is a p p l i ed para l l e l to the l e n g t h of t h e fe m u r [ w h ite a rrow o n fe m u r) t o fac i l i ta te t h e re laxa tio n o f t h e extern a l rot a t o rs o f t h e h i p. I f t h e tec h n i q u e i s s u ccessfu l , i n te r n a l a n d exte r n a l rota t i o n of t h e h i p ( b l a c k a rrow) w i l l fee l very free a n d easy ( n o resista nce). (Re prod uced w i t h perm issi o n from © D i a n e G. Lee P h ysi o t h e ra p i s t Corp.) l en g th of the fe m u r (again to ad d a proprioceptive input into the nervous sys tem) a n d on the next breath o u t ask the p a tient to imagine the femur a s a te lephone p ole slowly sinking into mud . C ue, " A l low the weight of the l e g to take the femur back into the pelvi s . " If the p a tient has been successful in fo l low in g your verbal cues and has released the muscles of the p o s te r ior p e lv i c wall a n d ex terna l rota tors of the hip, internal and ex ternal rota tion of the hip in this p o s i ti o n will feel very free and easy. If this mo tion sti l l meets with res istance, the bu tt is still gripping !

R e l e a s i n g the h i p ( " b u tt g ri p per") i n sta n d i n g . postu ra l re-ed ucat i o n Pa t i e n t

and

t h e r a p ist

p o s i ti o n

I n standing,

the

p a t i en t p a l p a te s t h e p o s t eri o r aspect of the gre a ter

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aligned under the thorax such tha t the pubic sym­ physis is vertical l y aligned under the manubrioster­ nal j unction (Fig. 8 . 1 ) . If the hip has released but the pelvis is still not fully under the thorax, the alter­ nate palpation points at the p ubic symphysis and the manubrios terna l j unc tion can be used to correct the alignment further (Fig. 10.32) . If further correc­ tion of the spinal curves is necessary, the cues previ­ ously described above can be used; at this point in the postural educa tion process, the cues tha t are most effec tive for the patient will have been iden ti­ fied in other posi tions and simply need to be applied in the st a nd in g position.

RES T O RATION O F B R E ATHI N G PATT E R N S

Fig u re 1 0. 3 5

Releasing t h e " bu tt g rippe r" in s tand i ng. The

thera pist i ns t r u cts t h e pati ent how to palpate the position of the femoral head a nteriorly in the groin and posteriorly be hind t h e greater troc h a nter. The therapis t provid es an image t h a t facili tates relaxa tion a n d opening o f th e posterior b u ttock and

a

deepen ing of t h e a n terior hip fol d . ( R ep ro d u ced w i t h perm ission from © D iane G. Lee Physioth erapist Corp.)

The diaphragm has m ul tiple func tions including maintaining respira tion while contribu ting to increa sed intraabdominal pressure for segmental spinal stabiliza tion (see Ch. 5) . Altered breathing pa tterns a re commonly seen in pa tien ts with lumbo­ pelvic dysfunc tion, resul ting in compromised effi­ ciency of both respira tion and spina l stabilization. By assessing and retraining suboptima l breathing pa tterns, several goals can be a ddressed simul tane­ ously. First, there is improved function of the dia­ phragm. Second, unwanted excessive global m uscle activity (rigidity) can be reduced, especially in the superficial abdomina Is (obliq ues, rec tus abd ominis), erector spinae, and hip m uscles. Finally, since resp i­ ra tion is a primary drive for surviv al, the need for spinal stabi lity will be a secondary priority to bre a thing By firs t retraining breath ing, the stage is set for successful recrui tment and end urance train­ ing in the other local sys tem muscles (TA, deep fi bers of multifidus, and pelvic floor) . When the respira tory muscles are working opti­ mally, there is three-dimensional movement of the ri bcage. Op timal diaphragmatic brea thing invol ves both abdomina l and lower ribcage expansion dur­ ing inspira tion (DeTroyer 1989) . The most common component lost in pa tients with lumbope lvic dys func tion is la teral and posterola tera l costal ex pansion. When la tera l / posterolateral expansion is absent, excessive excursion occ urs in the abdomen (making it difficul t to a ttain a functional TA contrac­ tion) or in the upper chest (a ssocia ted with excessive accessory respira tory m uscle activity) . Sever a l fac­ tors can contribute to the loss of la teral / pos tero­ la tera l expansion. These include, b u t a re not lim i ted to, joint restric tions in the thorax (spin a l or costal), .

trochanter in the deepest part of the "divot." The other hand palpates the anterior hip at midpoint a long the inguinal ligament. Kneel in fron t of the pa tien t a nd palpa te the a ffec ted hip and the con­ tral a tera l side of the pelvis (Fig. 1 0 .35) .

Correction

tech n i q u e - verba l

and

manual

cues

"Focus on the muscle under your fingers and my fingers . Feel the tension there, and imagine the muscle melting as your hip opens at the back. Feel your hip coming back into your f inge rs Imagine the groove in the fron t of your hip is ge tting deeper and softening as the hip moves bac kwards . " Use your hands on the patient's hips to provide a gentle force backwards and facilita te moving the pelvis underneath the thora x . I d e a l re s p o n se The d i v o t should become less p a lpable (less deep ) . The innominate should be vertically aligned over the femur and the pelvis .

Copyrighted Material

Treati n g t h e l u m bo p e l v i c- h i p d ysfu n c t i o n

hyper tonicity of the th oracic por tions of the erector spinae, serra tus pos terior inferior a nd / or oblique abdominal muscles, a nd excessive recruitment of these global muscles d u ring the respira tory cycle . During the obj ec tive assessment the a r ticular res tric­ tions and m uscular hypertonicity should be noted . Abdomina l muscle recruitment du ring respira tion should a lso be assessed (described below ) . If the abdominal mu scles are recruited d uring inspira tion, ribcage expansion will be restricted to the apic a l regi on . Expira tion in the supine position during rela xed breath ing should be a passive event, with no activity in the supe rficia l abdomin a l m uscle s . It is crucia l tha t the c linician identifies and correc ts these patterns prior to teachin g a volunta ry exercise to iso­ late TA . An isolated con traction of TA cannot occur if e xcessive abdominal muscle a c tivi ty persists; fur­ thermore, using this p a ttern during p rogressions of

F i g u re 1 0 . 3 6 Fa c i l itati o n of l a tera l costa l expa n s i o n in s u p i n e . The t h e ra p i st's h a n d s p rovi d e a w a r e n ess o f w h e re t h e p a t i e n t n e e d s to red i rect i n s p i ra t i o n . F u r t h e r fa c i l i ta t i o n c a n b e a d d e d w i t h r i b s p ri n g i n g . I n t h i s exa m p l e t h e p a ti e n t u s e s o n e h a n d t o m o n itor fo r excessive a p i ca l c h e s t move m e n t. ( R e p ro d u ce d w i t h p e r m i s s i o n fro m © D i a n e G . L e e Phys i o th e ra p ist Corp. )

the exercise program pre vents the o p timal anticipa­ tory contraction of TA (inap propria te timing occu rs) .

O bservat i o n a n d fa ci l i ta ti o n of l ate ra l costa l expa n s i o n Patient a n d thera p i st p o s i t i o n

The p a tient i s s upine

w i th the legs s tra ight or in crook ly ing (whichever is more comfortable for the pa tient) . The abdomen and lower ribcage should be exposed as much as possi­ ble. S tand at the p a tient's side. Before placing your hands on the p a tient, firs t observe the chest, lateral ribcage, and abdomen over severa l in sp ira tory and expiratory phases. Look for movement

in the upper

chest (apical b rea thing), the l a teral lower ribcage ( l a teral costal expansion), and the abdomen ( upper and lower abdomen) . Note the area where mos t

Fi g u re 1 0. 3 7 H a n d posi tion for co rrecti n g a u n i latera l restriction of costa l expa n s i o n . O n i n s p i ra t i o n d ra w the posteri o r ribs l a te ra l ly ( bottom a rrow ) ; on e x p i ra t i o n p rovide a postero la t e ra l press u re to t h e a n terior t h o ra x ( top a rro w ) . ( R e p ro d uced w i t h perm i ss i o n fro m © D i a n e G. L e e Phys i o t h e ra p i s t Corp. )

movement occurs. N e x t, place your hands on the lateral aspect of the lower ribcage to monitor move­

when you brea the in the bo ttom of the u mbrella is

ment. Check fo r th e amount of movement a nd the

opening up . " " With each brea th open your rib s into

symme try between the left and right sides . Make

my hands . " Wi th b o th hands, a p p l y a sl ow, gentle,

note of any exp i ra tory abdominal a c tiva tion. Keep

inw ard p ressure a t the end o f expiration and release

your han d s on the lateral aspect of the lower ribcage

this press u re slightly after the start of the inspiration

and give the p a tient a n i mage to red i rect the insp ira­

p h a se (rib springing) . A llow your hands to follow

tion (Fig . 10.36) .

the ribcage opening and then apply the gentle p res­

If posterolateral excursion is the

most restricted movemen t, move your hands more

s ure again at the end of expira tion . With the unilat­

posteriorly on the ribcage . For a unilatera l res tric­

eral restri c tion, provide gentle press ure into the

tion, s ta nd on the same side as the restri c tion . Place

erector spinae and draw the ribs l a teral ly with the

one hand pos teriorly under the ribcage, and the

p o s terior hand as you cue op ening into you r hand

other on the anterior ribca ge at the same level

w i th inspira tion . As the p a tient exhales, apply a pos­

(Fig. 1 0 . 3 7 ) .

terior pressure to sim ulate a heavy feeling w i th your

Correct i o n tech n i q u e - ve r b a l a n d m a n u a l cues "As

an terior hand ( to facili ta te thorac i c flexion) .

you b reathe in, ima gine bringing the a ir into my

For m uscle activity on expiration: "As you b reathe

hand s . " " Ima gine y o u r ribs are like an umbrella, and

out, let the air fall out of you and relax your stomach. "

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"Imagine I am slowly pulling the a ir out of you . " "Sigh a s y o u breathe out - ahhh1hl . " "Let your chest and sternum go heavy to the floor as you exhale." "Let your ribcage sink into my hand (s) as you breathe out." Ge n tl y w iggl e the ribcage a small amoW1t to release the muscle, hol d ing as the patient expires. P ro g ress i o ns/o t h e r co n s i d e ra t i o n s The p a tie n t should perform focused breatrung pattern retraining two to three times a d a y, using both normal and deeper breaths, for several min u tes. The patient uses his or her own hands on the sides of the ribcage to provide sel f-feedback. Al tern a tely, resistive exercise band (e.g., Theraband ) can be used aroW1d the lower ribcage for proprioceptive feedback (Fig. 10.38a); use the lowest resistance of band to allow flexibility and ribcage expansion. This technique is especially help­ ful for pa tients w i th decreased posterola teral expan­ sion, excessive erec tor spinae ac tivity, �d excessive thoracolumbar ex tension. Alternate positions should be a ss es s ed as optimal breathing patterns may be easier for pa tients to perform in different positions. To facilitate posterolateral costal expansion, the prayer position can be used (Fig. 1O.38b). The patient kneels with the elbows bent on the floor, the hip s resting back over the heels, and the head resting over the hands. This flexed spinal position opens the pos­ terior rib cage and helps release excessive erector spinae tone, while inhibiting excessive lower abdom­ ina l breatrung. For patients with a large abdomen, b reatrung exercises in s u pine are often W1comfort­ able; moving to the side lying position allows for greater ease and success. To encourage the transfer of the new breatrung pattern into a more automatic stra tegy, have pa tients "check-in" on their pattern a t d iffe ren t poin ts throughout the day, in different pos­ tures and during different activities (si tting, stand­ ing, walking, etc . ) . Breath i n g . postero l atera l costa l e x p a n s i o n a n d e recto r s p i n a e re l ease

Patient and thera p i st position The patient is s upine with the legs straight or in crook lying (whichever is more comfortable for the patient). Stand a t the pa tient's side . Scoop your hands bilate r a l ly under­ nea th the tr unk and ribcage and palpa te for hyper­ tonic areas in the thoracic erec tor spinae muscles. Start at L2 and the thoracolumbar j W1c tion and move up into the middle / upper thoracic spine to find the mos t hypertOnic area. I f there is p r im a ri l y a w1ila teral restriction, use the unil a teral hand position as shown in Figure 10.37.

Fig u re 1 0. 3 8 Te c h n i q u e s to fa c i l i tate postero l a te ra l costa l expa n s i o n . ( a ) U se o f a res i s t ive e x e rc is e b a n d fo r propri oceptive fe e d b a c k l a te ra l ly a n d postero l a tera l l y. W i t h every b r e a t h i n , t h e p a ti e n t t h i n ks o f o p e n i n g t h e r i b c a g e i n to t h e b a n d . I n t h i s exa m p l e the th e r a p i s t c u e s t h e p a t i e n t to open the ribs poste r i o rly. (b) P r a y e r posi t i o n . T h e t h e r a p i s t s h a n d s give a g e n t l e press u re o n t h e poste r i o r ribcage, c u e i n g t h e p a t i e n t t o b r e a t h e i n a n d op e n t h e r i bc a g e i n t h e b a c k . " ( R e p r o d u ce d w i t h p e r m i s s i o n fro m © D i a n e G. L e e Phys i o t h era p i s t Corp. ) '

"

Co rrectio n tech n i q u e - v e r b a l a n d m a n u a l cues Whi l e using the brea thing techniques described above, p ro v id e a deep s i n king press ure into the hypertonic muscles as the patient exha les and then add the fol low ing v e rb a l cue: "Imagine tha t yo ur back is a n ink blot tha t has been dropped on the

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Trea t i n g the l u m b o p e l v i c- h i p dysfu ncti o n

floor. Im a g ine that with every exhale the ink blot is

can be used to ensu re th a t the glob a l sys tem is n o t

spreading on the floor and getting bigger and bigger. "

b eing overly recruited. Th i s test can be easily per­

As the patient exhales, apply press ure to the trigger

form ed in s upine, crook lying, sit ting, supported

point in the muscles with your finger pads as you

stand ing, and o ther functiona l positions. The ther­

use the whole hand to draw the ribcage l a teral ly, as

apist l ightly grasps the p a tient's lower thigh and

if opening the pos terior ribcage . If using the uni lat­

a ttemp ts to move the hip pa ssively in to intern a l

eral hand posi t ion, use pos terior p ressure with your

rota tion a nd t h e n e x ternal rota tion w i th a gen tle

anterior hand to s i m u la te the heavy feeling as the

force . A l terna tely, the p a tient can perform a self­

patient exha les.

check by a t temp ting to move the hips actively i n to interna l and e x tern a l ro tation ( see the chicken exer­ cise Maintaining neutra l spine with loading: trunk

C H E C K PO I NTS FO R G LO B A L M U S C L E

R I G I D I TY

Througho u t the rehabilita tion process our goal is to reduce rigidi ty and promo te stabili ty w i th mob i l i ty. There are severa l areas to observe in the p a tient w i th lumbopelvic-hip dysfunc tion . As discussed previously, excessive activi ty in the global system wiU reduce ribcage mobili ty, l a tera l costal expan­ sion, spina l m obil i ty, and hip mobili ty. The follow­ ing a re techniques to use at any time du ring trea tment an d ex ercise ins truction to moni tor for excess ive globa l m uscle a c ti v a tion .

a nd leg dissoc i a tion - supported s tan d ing, below ) .

Toe w i g g l e A s the exercises are progressed to an up righ t, weight­ bea ring p osi tion, alignment of the lower ex tremity and a c tiv a tion of the global slings of mu scles must be considere d . G rippin g the toes into flexion indi­ ca tes an imbalance in global sl ing a c tiv a tion in the lower leg; asking the patient to " keep the toes relaxed" d u ring exercises and to " wiggle the toes" b e tween exercise repetitions i s an effec tive s tra tegy to correc t foo t rigi d i ty.

Rib wiggle

T E C H N I Q U ES TO CO RR ECT A LIGN M E N T

Place you r hands b i l a tera lly o n the la tera l aspect of the ribcage . Wi th one hand, apply a gentle la tera l

Once the j oin ts of the lumbar spine, p elvic girdle,

transla tion force in one d i rection followed by an

and hip have been decompressed , the osseous align­

opposite l a teral tra n sl a t ion force wi th the other

men t should be addressed . Often, the decompres­

h a n d . Repeat several osci l l a tory translations to the

sion techniques restore the alignment; however, if

left and right and note the amo unt of resis tance to

mala lignme n t pers i s ts, the following techniques can

the applied force. There should be a symmetrical

balance the tension forces in the slings of the global

amoun t of la teral movement with only a small

systems. The fol lowing techniques a re used to

a mou n t of force. A loss of this l a teral j oin t play is an

correct a m ultisegmental rotoscoliosis in the l um b a r

ind ication of a res triction of movement.

spine and intrapelVic torsions (innomina te rota tions / flares and sacra l torsions ) . Subsequen tly, exercises are required to main tain optimal a l ignment and p re­

B reath i n g pattern

ven t relapse into the old h a bitual pa ttern s .

Observe the ribcage d u ring respiration. I f there i s excessiv e g l o b a l m uscle ac tiv i ty the re w i l l be a non­ opti m a l p a ttern of ribc age expansion, b i l a tera lly or unila tera l ly.

M u ltiseg m e n ta l rotosco l io s i s l u m b a r s p i n e - s i d efl exed l eft/rotated r i g h t Pat i e n t a n d t h e r a p ist p o s i ti o n

The patien t is sitting

wi th the arms crossed to opp osite shoulders and the fee t s u pported on the floor. The thera p i s t sits on the

I nte r n a l/exte rn a l rotation of t h e h i p

pa tient's left side. With the d o rs a l hand, palpa te the

A decrease in the range of in ternal o r e x ternal rota­

lumb a r s p ine at the apex of the sideflexion curve .

hip c a n be an ind ica tion of excessive

The ventra l hand is placed on the con tra la teral

tion of the

globa l m u scle ac tivi ty. When the local sys tem is

shoulder. The mo tion barrier i s localized b y side­

recru i ted there should be n o change in the ease of

flexing the lumbar spine to the righ t and rota ting

hip rota tion . Th us, in many exercises hip ro tation

the l u mb a r spine to the left (Fig .

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reached by passiv ely flexing the ad ducted an d in te rn a l ly rota ted femur unti l the motion barrier for posterior rotation of the irmominate is pe rcei v ed (F i g . 10. 10) . Correction tech n i q u e - active m o b i l izati on From this posi tion, the pa tient is instructed to resist fur­ ther h ip flexion which is gently increased by the therapist. The isometric contraction is held for up to 5 s, followed by a period of complete relaxa tion. The irmominate is then paSSively taken to the new bar­ rier of posterior rota tion and the technique is repea ted three times.

I n tra p e l v i c tors i o n s - poste r i o r rota t i o n i n n o m i n a te

F i g u re 1 0 . 3 9 Active m o b i l i z a t i o n tec h n i q u e to co rrect a m u l t i seg m e n ta l rotosco l i os i s of the l u m ba r s p i n e w h i c h i s sid eflexed l e ft a n d rota ted r i g h t. ( R e p ro d u ced w i th p e r m i s s i o n fro m © D i a n e G . Lee Phys i o t h e ra pist Corp. )

Correcti o n tech n i q u e - a ctive m o b i l izati o n From this posi tion, the pa tient is instruc ted to hold s till while the therapist applies gentle resista nce to righ t rota tion of the trunk. The isome tric contrac­ tion is hel d for up to 5 s, following which the patient is ins tru c ted to relax completely. The new side­ flexion / rotation b arri er is l oc alized and the mobiliza­ tion repe a t e d three times. I n tra p e l v i c t o rs i o n s - a n t e r i o r rota t i o n i n n o m i n ate

Patient and thera pist position The p a t ien t is supine, with the hips and knees flexed. With the long and ring finger of one hand, palpate the sacral sulcus j ust medial to the PSIS. The flexed hip and knee are supported against the therapist's shoulder and arm. The femur is flexed, adducted, and intern ally rota ted to the motion barrier of the hip joint. The lim i t of pos terior ro ta tion of the irmomina te is

Pa tient a n d thera p i st position With the p a tient prone, lying close to the edge of the ta ble, the a nter­ ior aspect of the distal thi g h is p a lpated with the caudal hand, while the PSIS of the irmomina te is palpa ted with the heel of the cranial hand. The limit of anterior rota tion of the innom inate is reached by passively ex ten ding the femur with the caudal hand and applying an ante rior rot a ti on force to the irmomina te wi th the cranial h and (Fig. 1 0 . 1 4) . Correcti on tech n i q u e - active m o b i l izatio n From this position, the pa tient is instructed to res ist fur­ ther hip ex tension which is gently increased by the therapis t. The isome tric contraction is held for up to 5 s fol lowed by a period of complete relaxation. The innomina te is then passively taken to the new bar­ rier of anterior rota tion and the technique is repea ted three times. Inflares (internal rota tion) and outflares (ex ternal ro tation) of the innominate reflect a loss of function of the mu l tifidus and TA muscles and are correc ted by r e s tor ing the balance and function of these two muscles of the local system (see below ) . Sacral tor­ sions (forward L l C R / R, backward R/C L / R) reflect a loss of func tion of the pelvic floor and mul­ tifidus and a re corrected by res toring the balance be tween these two muscles .

DECOMPRESSI ON VIA I NTRAMUSCU LA R ST I MU LAT I O N

IMS or dry needling is a technique developed by Dr. Chan Gunn (Gunn 1996) and is extremely effective for releasing hypertonic global muscles. According to Gunn (1996), S hor te nin g in muscles acting across

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Trea t i n g the l u m bopelvi c - h i p dysfu n ct i o n

Fig u re 1 0.40

(a, b) An in tramu scula r

sti mula tion poi n t ( a rrows) for releas ing one hyperton i c fa sc i c l e of the external obl i q u e m u s cle d irectly over the anterior a s pect of t h e rib. N ote how the the ra p i s t ens ures t h a t t h e needle stays anterior t o t h e rib b y fix ing t h e r i b between the fin g e rs. Clinically, c o n trol of the needle is mainta i n e d at all ti mes w i th the other hand a n d has only b e e n released here for illustra tion pur poses. ( ( a ) R e p rod uced with permi s s i on from Primal Pic tures © 2003. ( b ) Reprod u ced w i th p er mission from © Diane

G. Lee Physiotherap i s t Corp.)

Fig u re 1 0.41

( a , b) An i n tramuscular

s t i m u l a t i o n poi n t for releas ing one hypertonic fascicl e of the i n ternal obliq u e m u s cle along the ili a c crest. ( (a) R e produ ced with permi ssion from P rimal Pict u res © 200 3 . (b) Repro d u ced wi th permiss i on from © D i a ne G . Lee Physiothera p i s t Corp.)

a jo in t increases joint pressu re, upsets alignmen t, and can precipitate p a in in the join t, i.e. arthralgia . " Dry needling of the shortened m uscle band causes an immediate relaxation which is palpable. A sense of release and increased range of motion is often experienced by the pa tient. When used in conjunc­ tion w ith neuromusc u l a r retraining of the local and global s ys te ms , the release obtained from IMS can be long-lasting. Dr. G unn a dvoca tes t rea t in g both the spinal seg­ ment of inn e rvation for the a ffec ted m us c l e as well as the hyperton ic trigger points wi thin the m uscle. When decompressing the lumbopelvic-hip region,

the following m u scles (and their rela ted spinal segments) can b e tre a ted with IMS: ex ternal oblique - segmental innervation T7-T12 (Fig. 1 0 .40a, b) 2. internal obl ique - segmental innerva tion T7-U (Fig . 10.41a, b) 3 . erector spinae - dorsal rami all spinal segmen ts (Fig. 1 0 .42a, b) 4. s uperficial mul tifidus over the sacrum - dorsal r ami a ll spinal segments (Fig. 10.43a, b) 5 . ischiococcygeus - sacral plexus S3, S4 (Fig. 1O.43a, c) 1.

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T H E P E LV I C G I R D L E

Fi g u re 1 0.42

(a , b) An i n t ra m u s c u l a r

s t i m u l a t i o n po i n t fo r r e l e a s i n g o n e hyperto n i c fa sc i c l e of t h e i l iocost a l i s l u m b o r u m ove r t h e p o s t e r i o r a s p e ct o f t h e r i b. N o t e h o w t h e t h e ra p i s t e n s u res t h a t t h e n e ed l e stays posterior to the rib by fixi n g the rib between t h e fi n g e rs . C l i n i c a l l y, con tro l of t h e needle i s m a intained a t a l l times with the other hand a n d h a s o n l y b e e n re l ea s e d h e re fo r i l l u s t ra t i o n p u rposes. ((al R e p rod uced w i t h p e r m i ss i o n fro m P ri m a l Pi ctu res

© 2003. © Diane

( b ) R e p ro d u ce d w i t h p e r m i s s i o n fro m

G . L e e Phys i o t h e ra p i st Co r p.)

F i g u r e 1 0 .43

(a) I n t r a m u s c u l a r

sti m u l a t i o n p o i n ts fo r re l e a s i n g o n e h y p e rto n i c fa s c i c l e of t h e s u p e rfi c i a l ( l a te r a l ) s a c ra l m u l t i fi d u s a n d i s c h i ococcyg e u s . ( R e p ro d u ced w i t h p e r m i s s i o n fro m P ri m a l P i c t u res

© 2003.) ( b )

S u p e rfi c i a l m u l t i fi d us.

(c) I s ch i ococcy g e u s . ( ( b, c) R e p ro d u c e d w i t h permission from

©

D i a n e G . Lee

P h ys i o t h e ra p ist C o r p . )

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Trea t i n g t h e l u m b o p e l v i c- h i p dysfu n ct i o n

F i g u re 1 0 . 4 4 ( a ) I n tra m u scu l a r sti m u l a t i o n poi n ts fo r releas i n g hyperto n i c fa sc i c l e s w i th i n t h e p i rifo r m is, t h e d e e p exte r n a l rotators of t h e h i p , a n d g l u te u s m e d i us. ( R e p ro d u ced w i t h p e r m i ss i o n fro m P ri m a l Pictu res © 2000.) (b) Pi rifo r m i s , o b t u ra t o r i ntern us / g e m e l l i , a n d q u a d ra tus fe m o r i s . ( c) G l u te u s m e d i us. ((b, c ) R e p ro d u ce d w i t h p e r m i s s i o n fro m © D i a n e G . L e e Phys i o t h e ra p i s t Corp. )

F i g u re 1 0 . 4 5 A co m m o n t r i g g e r p o i n t a n d t h e refo re a n effective i n tra m u scu l a r sti m u l a t i o n p o i n t fo r o b t u r a t o r i n t e r n u s . ( R e p r o d u ced w i t h perm i ss i o n f r o m Pri m a l Pictu res © 2000.)

F i g u re 1 0 . 4 6 ( a , b) La tissi m u s d o rs i i s a powerfu l c om p resso r o f b o t h the t h o rax and l o w back. Th is i s a n e ffective re l ease point with i n tra m u s c u l a r sti m u la t i o n . ((a) R e p ro d u ce d w i t h p e rm ission fro m Pri m a l P i c t u res © 2003. ( b ) R e p ro d u ced w i th p e r m i ss i o n fro m © D i a n e G . Lee Phys i o t h e ra p ist Corp. )

6. piriform is, gemel li, obturator internus, qua dratus femoris, and gluteus medius ­ ven tra l rami L4, L5, 51 (Fig. 1 0 . 44a-c) 7. obturator internus - L5, 51, 52 (Fig. 1 0 .45) S . la tissi mus d o rsi - C6, C7, C S (Fig. 1 0 .46a, b) 9 . glu teus maximus L5, 51 52 (Fig. 1 O .47a, b) 1 0 . tensor fascia l a tae L4, L5 (Fig . 1 0 . 48a, b ) . -

-

ISO LATIO N A N D AWAR E N E S S T RAI N ING FOR T H E L O CA L SYST E M

I n ord er to re t r a in the local system, pa tients are first ta ugh t to i sol a te and main tain a tonic contrac tion of the deep muscles, sep a ra te from the global m uscles. This is a r tificial since in normal hmction the local muscles work in conj unction with th e global muscles.

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T H E P E LV I C G I R D L E

However,

a lth o u g h both m u scle systems

work

toge the r in func tional movements, the cen tral ner­

con trol is lost; in ord e r to

a dd ress

the change in

mo tor control s t r a te gy the local sys tem mus t be

vous sys tem con trols the local system ind ependently

trained separately. This p ro tocol of isola tion, train­

of the global system. In dysfunc tion, this independent

ing tonic holding ability, training co-contrac tion of the local muscles, and then in tegra tion w i th global muscles and in to fun c tio na l ac tiv i ties is an effective means of retraining the co ord inated function of the local system (Hides et a1 1 996, 200 1, O'Sullivan et al 1997, Ri cha rd s on e t a l 1 9 99 ) .

The assessment o f co-contrac tion of the loc a l sys­ tem described in Ch a pter 8 includes instruc tions and images that sh o uld ac tiva te the local m u scles in the hea l thy motor system. In the pa tient with dysfunc­ tion these cues alone are often inadequate to facili tate recrui tment of the desired muscles, re s ultin g in: •

no activ a tion of one or more of the local muscles (TA, deep fib e r s of the m u ltifidus, p e lv i c fl oor

m u s cles) and / or •

asymme trical ac tiv a t ion (in timing or amount of response) of one or more of the loca l mus cles

and / or •

phasic ac tivity in one or more of the local m u scles and / o r

•

proper activation but a n in abili ty to main tain a proper dia phragmatic b r eat hing p a t tern d uring the contrac tion and / or

•

any of the above combined w i th

a

p a t t ern of

excessive glob a l m uscle ac ti v i ty. Figu re 1 0.47

(a, b) A n

intramuscular sti m u l a t i o n i n g l uteus m a x i m us.

re l e a s i n g a h y p e rt o n i c fasc i c l e

p o i n t for ((a) R e prod u ced

wi th p e r m i ssio n fro m Pri m a l P i c t u res © 2000. (b) R e p rod u ced with p e r m i S S i o n fro m © Diane G. Lee PhYS i o th e ra p i s t

C o rp } .

These incorrect activa tion p a t terns are eviden t d ur ­ ing pa lp a ti o n , observation, and real-time u l tra­ sound imaging (Ch. 8). Any deficiencies in the local sys tem need to be add ressed in treatment; however,

F i g u re 1 0.48 ( a , b) An i n t ram u sc u l a r s t i m u l a t i o n p o i n t fo r re l e a s i n g a hyper­ to n i c fasc i c l e

((a)

in

te nso r fa s c i a l a la e .

R e p ro d u ce d w i th p e r m i ss i o n fro m

Pr i m a l P i c t u res © 2000. (b) R ep rod u ced with p e r m i ss i o n fro m © D i a n e G . Lee Phys i o t h e r a p i s t

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Corp.}

Treati n g t h e l u m bo p e l v i c- h i p d ysfu n cti o n

as there is often dysfunction in more than one of the local system m uscles, the clinician needs to decide which muscle to start with firs t. Clinically, we have found tha t the pa ttern of manual compression tha t maximally changes the ease of the ASLR test (Ch. 8) indicates which of the loca l muscles should be trained first. These muscles will have the most signi ficant impact on functional tests such as the support phase of the one-leg standing test (Ch. 8 ) . It i s important t h a t the ASLR and manual compres­ sions be retested at each trea tment session as the pat­ tern o ften · changes depending on the amount and loca tion of compression from the global system and the improvement in function of the local system. The first step in teaching recruitment of the local system involves educa ting the patient about the ana tomy, location, and function of the muscles. Once the patient understands the difference betvveen exer­ cises for the local muscles (the dysfunction is in the way the brain uses the muscle, so we use cues for the brain), versus exercises for s trength and power (using weights and movements), tra ining for recruit­ ment of the dysfunc tional muscle(s) can begin. Techniques to retrain the diaphragm have been covered above. Specific facilita tion cues and tech­ niques for the pelvic floor muscles, TA, and deep fibers of m u ltifidus wilI be covered below. However, there are some general guidelines that apply to training any of the local muscles . • The goal is a symme trical con trac tion and co-contraction of the local muscles whi le maintain­ ing an o p timal breathing pa ttern. • Encourage a m inimal contraction, that is, 10-1 5% of max imal volu ntary con trac tion. Often simply asking the pa tient to perform less of a con­ trac tion can p roduce the desired resul t. • There should be no activity in the global system. • There should be no spina l or pelvic movement w i th the contraction. • Encourage the patient to contract the muscle as slowly as possible; speaking your cues slowly and provid ing slow tactile cues will faci litate the proper speed of contraction. This is a key modification whenever a phasic response is present or if activity in the global sys tem is observed. • Choose the position tha t best relaxes the global muscles, faci l i ta tes an op timal breath ing pattern, and facilitates a neutral s pine position. • Use images and menta l intent instead of move­ ment to re-establish the brain-body connection: think instead of do.

• Palpa te the muscles bilaterally in order t o detect asyrrunetries in activ i ty; encourage the patient to use a small ammmt of extra palpation pressure and extra men tal energy for the dysfunctional side. No te tha t the position chosen for exercise practice can have a marked effect on the patient's ability to recruit the dysfunctional side (e. g ., left sidelying versus right sidelying).

T H E P E LV I C F L O O R

Sapsford et al (2001 ) have shown that activa tion of the abdominal muscles should accompany contrac­ tion of the pelvic floor muscles and vice versa. Images and explanations tha t involve contraction of the anterior pelvic floor (pubococcygeus) are useful facilita tion techniques for obtaining an isolated TA contraction and are described below. This research supports using a submaximal contraction of the pelvic floor in a position of neu tral pelvic tilt to facilita te best contraction of TA . Palpa tion of the abdominal wall is a useful indica tor of pelvic floor function; the p resence of a bulging or braCing contrac tion is con­ sistent with depression of the leva tor pla te (func­ tional pelvic floor) on ultrasound (O'Sullivan et al 2003). However, if a successful isola ted TA contrac­ tion occurs with verbal cueing of the pelvic floor, it cannot be guaranteed that a proper contraction of the pelvic floor muscles has occurred. Bump et al (1991 ) found tha t only 49% of female patients presenting in a gynecological and urodynamic laboratory could perform a correct pelvic floor contraction when given verbal or written instructions. Dyshmction in the pelvic floor muscles can exist in p a tients with SIJ dysfunction (O'Sullivan et a l 2002) as well as in pa tients with lumbosacral dysfunc tion (O'Sullivan et al 2003 ) . Thus, specific assessment of the hmction of the pelv ic floor muscles is necessary. A non-invasive method to assess the function of the pelvic floor using real-time ultrasound imaging has been described in Chapter 8 . In both transverse and p arasagittal views of the bladder, contraction of the pelvic floor muscles results in a slow indenta­ tion and encroachment of the bladder wall (Fig. 10.49a, b ) . When the contraction is absent or a Valsalva response is observed with real-time ultra­ sound, the patient is given different cues to try and facilitate a proper response on the screen. To retrain the tonic stabilizing function o f the pelvic floor m uscles, the focus is on ob taining a slow, gen tle, submaximal contrac tion, with concentration on a

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T H E P E LV I C G I R D L E

the p ro t o c o ls for training the h old ing ab ility of t h e p elv i c floor m uscles with those for s tre ng th t rainin g and hy pe rt rop h y (86 et al 1990) . The a p p ro ach p resented here is d es i g n e d to add r e s s the imp a i rm ent in motor control and stabilizing function o f the p el v i c floor mu s c l e s , both in is o l ation and in conj un c tion with the other local muscles . Real- time ul tr a s oun d i m a g in g can be used in conj unction with abdominal w a ll p a lp a t i on a n d observ a tion t o assess the func tion o f the p e lvi c floor muscles. C o m m o n c l ini c a l pa t t e rn s of abnormal resp onses a re l is ted below w i th fa ci l i t a t i on and cor­ rec tion stra teg i e s may need to c o u p l e

tonic

.

U l traso u n d i m a g e - n o i n d e n t a t i o n of the b l a d d e r, n o l ift observed The bl add e r sh a p e d o es n o t c h an ge at the p os t e roin ­ ferior as p e c t and there is no cranioven t r a l mo tion on the parasagittal view (Fig. 10 .49a ) . Some movement may be e v id en t d u rin g th e b r e a thin g cycle, but the re is n o change when the patien t think s of s q ueezin g the ure thra or li fting the v a gina l tes tic les. Pa l p a t i o n of a b d o m i n a l w a l l There is usua lly no ch ang e in the a b d o min a l w a ll tensi o n . The finge rs can sink into th e so ftness of the abdomen . O b s e rva t i o n There may be c on c urre n t brea th­ ho l d in g w ith the effor t t o r ec ru i t th e p el v ic floor or superficial a b d o m in a l muscle a c ti v i ty on ex p ira tion but u s ua ll y no o th e r a c ti v ity in the su p erficial ab d om in a l muscles is evident on a n a ttempt to p e rform a contrac tion.

F i g u re 1 0.49 U ltraso u n d I m a g e s : b l a d d e r, p a rasag i tta l v i e w. (a ) I m a g e a t rest. U B , u ri n a ry b l a d d e r ; N , n eck of t h e b l a d d e r ; S U P, s u perior; I N F, i n ferior. If t h e re i s a n i n a b i l i ty t o produce a pelvic fl oor c o n tracti o n , the i m a g e w i l l n o t c h a n g e ; n o l i ft or i n d e n ta t i o n o f the bladder wa l l is seen. ( b) Recru i t m e n t of the p e l v i c floor m uscles res u l ts i n a slow i n dentation of t h e poste roi n feri o r aspect of the b l a d d e r (a rrows ) a n d a cra n iove ntral sh i ft. (c ) A Va lsa lva m a n e uver resu l ts i n a defo r m a t i o n of t h e b l a d d e r shape a n d a ca u d o d o rsa l s h i ft (a rrows) . ( R e p rod uced w i t h permissi o n fro m © D i a n e G. L e e Physiothera p i st Corp.)

Co r r ecti o n tech n i q u e - v e r b a l cues

u l trasound . Verbal cue e x a m p les: •

an t

(rectal) activation. I t is

-

For wome n : "Instead of thinking of squeezing,

imagine that y o u a r e l i ftin g a tampon . "

e ri or ( va g inal or u reth ral ) tha n p o s t erior i mp orta n t tha t the p a ti e nt unders tands tha t the fina l g o a l is a 1 0 s con trac tion, repe a te d 10 times, but tha t the d ura tio n and num­ ber of con trac t ions p e r form e d c or re c tl y on a gi v en day may vary. This informa tion all ows the p a t ie n t to se lf p ro g r ess th e e x e rc i s e pro to c o l . Certain s u b

m o re

In this case

does not have a n in t a c t neural p a thway b e tween thinking a b out a contraction and the con­ tra c ti o n occurrin g . In or de r to obta in a c on tra c tion, di fferent cues a re used and the response noted on . the p a ti e nt

­

groups of pa tients with stress urinary incontinence

• F o r men: " I ma g ine that y o u a re sl o wly walk­ ing into a c ol d lake, and the wa ter is s ta r t ing to come u p b e tween y o u r inner thi g h s . " • "Connect a s t ring between y o u r p u b ic bone and your tai lbone, then be tween your right and left sitz b o n e s Now dra'w the string u p i nto the cen ter .

like a draws tring . " • A l terna tively, cues for TA o r deep fibers o f multifidus (l isted below ) c a n b e used to p ro d u ce a

contraction.

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Treating the l u mbopelvic- h i p dysfu n ction

b re a thing pa tterns are noted, then i t to teach correct d i a phra gma ti c b re a thing; restoring the function of the p e l v i c floor muscles i s c l os e l y linked w i th th e func tion of the di ap hr a gm and its effects on in t ra a b d o mina l pre ssur e . •

If incorrect

is es s e n t i a l

An a b s ent response may also res u l t from nerve dam­ age, in s u fficie n c y in the fascial connec ti ons of the p e lv i c floor muscles, or h yp e r toni c ity of the pelvic floor muscles. If no res p ons e is observed after the above c ues and corrections in brea thing p atte rn have been tried, biofeedback tools such as the Pelvic Floor Educator (www.neenhealth.com) can be use d . These too ls p rovide some p r op ri o c ep ti v e feedback and a l low p a tie n ts to practice contrac tions with the assurance t h a t they a re p e r fo rmin g the correc t ac ti­ vation. Pelvic floor func ti on can then be reassessed with real-time ultrasound in 1-2 weeks . If there i s s till no ch an g e evid ent, a re fe r r a l to a ther a pi s t spe ­ c i a l izin g in pelv ic floor d y s func ti on a nd manual assessment of the floor is rec o m mended.

U l t rasound imag e - no in d e n tation of the b lad d e r. caudodorsal move m e n t

(Valsalva )

observed

the p a r a s a g i t ta l view the bladder ma y m o v e c a u ­ (Fig . 10.49c). In the transverse a b d om­ inal v i e w, the dorsal c o m p on e n t will be observed and any asymmetry wil l be apparent. Pa lpation of abdom i n a l wall A b u lge and/ or b ra ­ cing tension occurs; it may d e v e l op s low l y or quic kly. Observati on A c t i v i ty in the sup e rfi c i al a b d om in al musc l e s i s n oted , e speci all y in the I O and E O m us c l e s . Flexion of the ri bc a ge may occur if th ere is no co-contraction of the thoracic portions of the erec to r sp inae muscle to c o un te r a c t the flexion m o m en t of the obli qu e abdom ina Is. The abdomen may bulge w i th c o nc u rren t n a r r O\v in g of the r ibc ag e . Co rrect i o n techn ique - verbal c u es The goal in this scena rio is to reduce the g l ob a l m us cl e a ctivi ty tha t is causing the Va lsa lva maneuver and then tra in a proper lift of the p e l v i c floor muscles. Draw th e pa tie nt ' s attention to the screen, and point out the movement an d d efo rm ati on of the bl a d d er sh a p e that oc curs w hen a contrac tion is a ttemp ted. Cue proper brea thing w ith a s pe C i a l focus on abdominal relaxa tion d u r ing exhalation . Palp a te the inner thi g h s bi l a te r ally to fo c u s th e pa ti ent 's attention away from the abdomen. The same cues can b e used, with some modifications. Verb a l c ue ex ampl e s: In

d od or sa l l y

• " I ma g i n e a tension tha t is corning up from your inner th igh s into the front of yo u r p e l v i c floor and then lif ting your p e l v i c floor. "

• " Really focus l o w down i n your pelv ic floor. Now i m agine slowly and g e ntl y li f ting a tampon . " • Wh en a Va lsalva is p re s e nt it is es sen ti al to encourage a slower c o n tr ac tio n ("This time contract at 1 0 % of the sp ee d of the la s t c on trac t i on . " ) a n d a l i g h ter con traction ("This ti me I want you to think of c on t ra cti ng o nly 10% of the las t contrac tion . " ) . • Cues for TA or d ee p fibers of m u l t i f i d u s can be u s e d .

O f t en

a ft e r the fi rs t s es s i on th e p a tie n t will go horne with an i ma g e to pr a c tic e tha t ensures no Va lsalva but only prod uces minimal or no l i f t . The p a t ie n t is ta ugh t to pa lp a te bila terally in the abdomen (j ust medial to the ASISs) to ensure that no b u lge is felt. A t s ub s e quen t t r ain i n g sessions the lift c o m pon en t c a n th en b e e ffe c ti v ely t r a ine d .

U ltrasou nd image - i nd e n tation a n d lift of t h e blad d e r. followed by a Valsa lva

i d e a l response of the bla d der wall is observed but then q ui c kl y fol lowed b y a ca u d o do rs a l move­ men t of the blad der. The Valsalva may a lso o c c u r sl o w l y as the patient attempts to m a i nta in a tonic c o n t racti on . Pa l pati o n of abd o m i n a l w a l l A te nsi on in the abdominal wall consistent wi th a TA c on t ra c t i o n is followed b y a bulge and / or b r a c in g . Observa t i o n A sma ll fla ttening of the l o w e r abdominal wall is fo ll o wed by a c ti v i ty in the s uper­ ficial abdominal muscles, e sp ec i a l l y in the IO and EO muscles. Flexion of the ribcage may occur if t he re i s no co-contraction of the thoracic p o r t io n s of the erec tor sp in a e muscle to counteract the flexion moment of the ob liqu e abdomina Is. A bu l ge in the lower abd omen is u su al l y presen t; there may be concurrent na rro w ing of the ribc a ge . Co r r e ct i o n techn i q u e Thi s response is best cor­ rected b y cues tha t focus on d e c rea s in g the speed and effort of the contraction (see v e rba l c ues as a bo v e) . The correct neural pa t h w ay exis ts but is overridden b y the incorrect Valsalva. It is v ery effect­ ive to have the p a t i ent observe the screen and to le a rn to stop the contrac tion before the Val sa l v a occurs and pushes the bladder c au d o d or s a l l y. Before the p a t i e n t goes home to p rac ti c e the exer­ cise, it is important to have the patient try several c o n tr a c ti o n s w i th o u t w a tch ing the screen wh i le s to p p ing before the Valsalva. This ensure s interna l­ ization of the n ew m o to r s tr a te gy. It is also i mpor t­ ant to assess how long the pa tient can hold a An

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2 04

T H E P E LV I C G I R D L E

contraction before a Valsalva starts to occur. Note the number of seconds the isolated contraction is main­ tained. Teach the patient to palpate the abdominal wall to moni tor for bulging; the patient is instructed to practice holding the correct contraction as long as possible without the Valsalva occurring. U l t r a so u n d i m a g e - i n d e n t a t i o n a n d l i ft of t h e b l a d d e r, s l o w re l ea s e o f c o n t r a ct i o n w h e n atte m pt i n g to i n crease t h e d u ra t i o n o f h o l d ( d e c reased e n d u ra n ce )

Pa l p ation of abdom i n a l w a l l A tension in the abdominal wall consistent with a TA contraction occurs but slowly releases as the patient attempts to maintain the contraction. Observation A small fla ttening of the lower a bdominal wall occurs b u t releases as the pa tient a ttempts to maintain the contraction. Co rrection tech n i q ue Often the patient thinks that they are maintaining a contraction but it is evident from the ulh'asound image and palpation of the abdominal wall tha t the contraction has been released. The key in this case is to make the patient aware of when the contraction is truly occurring and the point at which it starts to let go. Teaching the patient to pal­ pate the abdomen while wa tching the screen and then repea ting contractions without wa tching the screen will internalize the new awareness.

erector spinae; however, there is little stretch on the abdomi.nal wall to provide feedback for the pa tient of where the "drawing-in" ac tion of TA should occur. The sidelying position provides more stretch on the abdominal wall due to the pull of gravity on the abdomen. When a rolled towel is placed under the waist and a pillow inserted between the knees, the sidelying position can be supportive to allow global muscle relaxation. The four-pOint kneeling position provides the grea test amount of pull on the abdomen and is a good starting place to help the patient understand the feeling of "drawing-in" the lower abdomen. However, it is not often the easiest posi­ tion to perform an isola ted contraction. Substitution strategies occur due to the greater loading and pos­ tural challenge in this position, and are often more easily identified in this position. A more supported posi tion for training an isolated contrac tion can then be chosen based on the global substitution pattern observed. Ideally, a neutral position for the lumbar spine should be attained since this position is known (Sapsford et al 2001) to facilitate the isola tion of TA, especially in patients exhibiting a dominance of the oblique abdominal muscles (avoid a flexed, fla t lum­ bar spine and posterior pelvic tilt) . Palpa te the abd omen 2.5 cm (1 in.) medial to and slightly inferior to the ASIS bilaterally ( Fig. 10.50) . The pa tient should be taught how to palpa te here for a proper con trac tion . In side lying, the therapist

U l traso u n d i m a g e - a sym m et ri c a l a ct i v a t i o n An asymmetrical activa tion is usually corrected by having the patient direct extra focus and attention to the side of the abnormal response . However, if there are neural, fascial, or muscle tone impairments then retraining of symmetrical function is facilitated by referral to a therapist who specializes in internal palpation and trea tment of the pelvic floor.

T R A N SV E RSU S A B D O M I N I S Pa t i e n t a n d t h e ra p i st p o s i t i o n

The initial position chosen to teach this exercise will depend on which position encourages relaxation of the global muscles while ideally providing some s tretch on the abdominal wall for proprioceptive feedback. The best position for each patien t will vary depend ing on their substitu tion s tra tegies . For example, s upine crook lying is most supportive and allows relaxa tion of global muscles such as the

Figure 1 0.50

The ova l c i rc l es j u st m ed i a l to the a n te r i o r su perior

i l i a c spine o n each s i d e i n d i c a te t h e p o i n ts fo r pa l pa t i n g a con tract i o n of t ra nsve rs u s a b d o m i n i s. An i s o l a ted co n t raction w i l l b e fe l t a s a sl ow, g e n t l e f l a tt e n i n g a n d te n s i o n i n g u n d e r t h e fi n g e rs . A b u l g e o r ra pid c o n t ra c t i o n i s e v i d e n c e o f co n t ra c t i o n of the i n t e r n a l o b l i q u e m u s c l e . The c i rc l e around the pelvis rep rese n ts the "c i rc l e o f i n teg r i ty" p ro d u c e d by t h e co-co ntraction of tra nsvers u s a b d o m i n i s a n d t h e d e e p fi b e rs o f m u l t i fi d us. ( R e prod u ced w i t h p e r m i ss i o n fro m © D i a n e G. Lee Phys i o t h e r a p i s t Corp.)

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Trea ting t he lumbopelvic-hip dysfu n ction

can also gen tly cup the lower ab domen w ith the

abdominis

p a l m to provide feedb ack o f where the contraction

remain relaxed. If the ribc a ge is d epressed and

shou l d be initia ted . Observe the abdominal wall and

drawn

trunk for signs o f p roper isolation w i thout g l o b a l

small "wiggle" of the ribcage by p ushing it gently

muscle activ a tion.

l a tera lly; i f there is a lot of resis tance to your pres­

in,

and

the

oblique

abdominals

should

this is a sign of EO a c ti v a tion. Perform a

sure this means the ribcage is being braced by over­

Cor rect ion tech n i q u e - ve rbal and m an ual cues

active global muscles and an isol a ted TA contraction has not been achieved . The ribcage should still move

Several v e rbal cues can help to facilitate an isolated

easily in response to the lateral pressure in the pres­

con traction of transversus abdominis:

ence of an isolated TA contraction .

" Breathe in, brea the o u t, then d on ' t brea the as

•

you slowly, gently d raw your lower abdomen away from my fingers (or hand) . " "Imagine tha t there i s a slow tension coming

•

up

fro m the inner thighs into the front of your

pelvic floor, then ex tend tha t tension up into my fingers in your lower a bd omen . " •

" Imagine

tha t you

are slowly

and

gently

The common abnormal responses a re lis ted here and ca tegorized according to p a tterns seen w i th real-time ultrasound i maging . The reader shou ld note tha t real- ti me u l trasound is a n adj unct to pal­ pation and observation skil l s and is no t a n essenti al tool for teaching local muscle activation; however, it is often a useful tool for providing feedback to p a tients and obj ec tive assessment of dysfunction.

dra wing these tw o bones [ASISs] toge ther. " •

" Imagine

that you

are

slowly

and

gently

•

U lt rasound i mage - no TA rec r u it m ent , no s u bstit u tion w i t h

d rawing these two b ones [ASISs] apart. " "Imagine drawing y o u r s tomach away from

your pub ic bone . " "Very l i gh tly and slowly think of l ifting up in your pelvic floor" ( w omen can imagine lifting the vagina, while men can do a small lift of

I m ag i n g

10

O n the rea l - time u l trasound image, the

following is seen (Fig.

10.51 ) :

•

n o widening (change in thickness) o f the TA

•

no corse ting of TA l a terally or la tera l slide o f the

•

no change in thickness in the 10 muscle la yer.

muscle layer

the testes ) . Provide a sinking pressure into the ab domen as you give the verbal cues slowly and gently. Ta c tile pres­ sure can also be gi ven just above the p ubic bone or

medial fa scia of TA

with the hand c upping the a b domen; sink in to the tissue slowly to encourage a slow, tonic c on tra c tion instead of a fast, phasic response . If there is exces­ sive u pper abdominal ac tivi ty, the pa tien t can con­ tinue to palpate a t the ASIS points while the thera pist provides gentle ta c tile p ress u re bila terally in to the upper medial thighs to take the focus away from the s tomach. The patient is then encouraged to ima gine the contra c tion starting lower.

Ideal and abn orma l responses A slow developmen t of gentle tensioning under the fingers should be felt. It sho u l d be remembered tha t only

a

10-15% con traction of this muscle is require d .

If the patient uses t o o m u c h effort or performs a fast contraction, a b ulge into the fingers will be felt, pushing the fingers away from the abdomen; this is the 10 m uscle. A similar 10 b ulge can often be felt with a cough or with li fting the head from the floor.

Fig u re 1 0. 5 1

Ultrasound image of the lateral abdomi nal wall,

t ra n sv e rs e v i ew. M, media l ; SC, subcu taneous tiss u e ; EO, external obli q u e ; 1 0, i nte rnal oblique ; TA , tra n sv e r s u s abd om i n is.

The ultrasou nd image appears t h e same as a n i m ag e ta k e n of the relaxed abdo m i n al wall. T h i s i s consiste n t w i t h an abse n t tra n sv e r s u s abdominis con traction without i n tern al obliq u e

There should be no movement of the pelvis or spine,

s u bsti t u tion. (Reprod u c e d w i t h p e rm i s s i o n from © Dia n e G . Lee

and little movement in the upper ab domen. Rectus

P h ys i o t h e ra p i s t Corp.)

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On p a l p a tion, the follow ing is felt:

Pa l p a t i o n •

The lower abdomen remains soft and no ten­

sioning or con trac tion is felt j u s t medial to the ASIS, or •

A tensioning in the s u perficial fascia is p a l­

pated ra ther than

a deep tension. This can occur due to a con trac tion of the EO muscle and the res u l tan t tension in the EO fascia tha t occurs over the p a l pa ­ tion point. The ulh'asOlmd image confirms th a t TA is not a c t i v e . The re may be no change in EO observed on the ultrasound image as the c orrela tion b e tl,veen activity in

the EO and change in the th ickness of the

muscle on the u l trasound screen is poor (Hodges e t al 2003a ) .

Activ i ty in the EO can be p a lp a ted a t

the lower rib a t tachments o f the muscle (Fig.

10 .52).

If there is n o spinal movement then concu rrent activ­ ity c a n be palpated in the ere c tor spinae m uscles. The rib w iggle tes t will be restricte d .

w a i s t ) . La teral cos ta l expansion wi ll b e red uced . If the erec tor sp in ae m u sc l e s rema in relaxed there w i l l be thoracolumbar fle xion a nd na r rowing of the infrasternal angle (Fig. 855b) . •

B rea th-holding -

the

upper ab domen

move s uperiorly a n d p u ll in; and may l i f t

w i ll

the ri bcage w i l l fla re

if there is a concurrent contra c tion of

the erector s pinae . Correct i o n

tech n i q u e

Sev era l

fa cilita tion tech­

ni ques c a n b e used. •

Change p a tien t position: if there is no

activity in

TA or any o ther abdominal muscle on cueing, choose a position that w ill prov ide more gra v ity pull on the abdomen s uch as sidelying (Fig. 10.53), fou r-point kneeling, or supported

sta nding (Fig. 1 0 . 3 2 ) . The

inc reased prop rioceptive input is often sufficient to prod uce the desired response .

If

the response is

On ob servation, t h e following i s note d : if TA does not contract there will be no fla t­

pri m a rily in the

tening or drawing in of the lower abdomen; how­

Sidelying or prone a re good positions for allowing

ever, there may be substitution p a tterns tha t a re n o t

relaxa tion of the abdomin a l walL • F o r EO dominance: check for EO a c tiv i t y o n e xp i ra t i on . Add the c u e , " B rea the i n , brea the o u t,

O b s e rvati o n

observa ble from the ultrasound i m a g e . The possible scenarios inclu d e :

EO contrac tion - movem e n t o f the abdomina l w a l l is ini tiated from the upper a b d omen and activ­ i t y in the EO m u sc l e fi bers a t their rib cage a t tach­ men ts will be observed . There may a lso be a •

horizon ta l skin crease in the abdomen j us t a b ove the umbi licus, as well as an increase in the diameter of the abd ominal w a ll (widening

EO (EO-dominant pa ttern), make s ure tha t t he p a tient is pOSitioned in ne u t ra l spine.

now

really relax

yo ur stolnach, d o n ' t b re a the, and gen­

tly think of lifting y o ur lower your hand (or a n other

abd omen away fro m

image) . "

Use verb a l cues tha t

draw foc u s away from the abdomen; for example, thinkin g of the pelvic floor, tension coming

up

fro m

la tera l at the

F i g u re 1 0 . 5 2 Pa l pa t i o n p o i n ts fo r transvers u s a b d o m i n i s (TA) a n d extern a l o b l i q u e (EO). The p a t i e n t is pa l p a t i n g j u st m ed i a l a n d i n fe r i o r t o t h e a n terior s u p e r i o r i l i a c s p i n e b o n e s b i l a tera l ly to fee l a contra c t i o n of t h e TA ; t h e t h e ra p ist pa l pates fo r s u bstit u t i o n by t h e EO as t h e m u s c l e co m es off i ts a ttach m e n t a t t h e a n te r i o r s u rfa ces o f t h e l o w e r ri bs. ( R e p ro d u ced w i t h p e r m i s s i o n fro m © D i a n e G . L e e Physiothera pi s t Corp.)

F i g u re 1 0. 5 3 Fac i l i ta t i o n of t ra n svers u s a b d o m i n i s iso l a t io n : s i d e l y i n g positi o n . I n t h i s exa m p l e, t h e p a t i e n t p a l pates fo r l a tera l costa l e x p a n s i o n w i t h t h e l eft h a n d a n d tra nsve rs u s a b d o m i n i s c o n t ra c t i o n w i t h t h e rig h t h a n d ; t h e t h e r a p i s t s i m i l a rly p a l pa tes a n d provi des m a n u a l fa ci l i ta t i o n . N o te t h a t p a t i e nts o ften have m o re a w a re ness of t h e l o w e r a b d o m e n l i ft i n g fro m t h e b o t t o m s i d e ( i n t h i s c a s e , t h e l e ft s i d e ) ; fo r p a t i e nts w i t h a n asym m etri c a l t ra n svers u s a b d o m i n i s con t ract i o n s i d e lyi n g o n th e side o f poor a c tiva tion c a n fa c i l i tate m o re sym m e tri c a l rec ru i t m e nt. ( R e p ro d u ced w i th perm ission fro m © Diane G . Lee Phys i o t h e r a p i s t Co rp. )

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Trea t i n g t h e l u m bo pe l v i c - h i p dysfu n ct i o n

the

For no abdominal mus c l e ac t ivi ty: try th e ver­ cues l isted above, st a r tin g firs t w i th those tha t u s e palpa tion a nd focus on the lowe r abdomen to

downw a rd bu lge (into the a b d omen) at th e medial edge of the 10 will often be observed. This b l u rs the fas c i a l lines medi­ al l y. When the p a tie n t is asked to d o the contraction slowly, the same p a t ter n will be evident b ut occurs

i ncrease awareness of the area.

more slowly.

inner

thighs, or a m ul t i fi d u s (d eep fibers)

c o n tra c ti o n . •

bal

D u e to the lack of fascial tension a

On p a l p a t ion , the f ollo w in g is felt:

Pa l p ati o n

U l traso u n d i m a g e - n o TA , su bstitu t i o n w i t h 10 w i t h or w it h o u t EO a n d rectus a bd o m i n is Imaging On the real-time ultrasound ima ge, th e f ollow in g is seen (Fig . 1 0 . 54a, b)

10

with a fa st, with a sl ow, gra d u a l increa se. No inc rease in th i ckne s s of the TA l ay e r i s seen underneath, no la teral g l i de of the fascia is observed, a n d there is no c o rse tin g of the TA layer l a terally. •

The

phasic

layer inc reases in thi c kness

response or

• A fast or slow b ul g e (ra ther than a tensioning) can be fe l t medial to the ASIS. • In order to de termine if EO or rec tus abdo­ minis i s also be ing recru i ted with the 10, p a l p a te a long the lower ribcage ( b elo w the eighth rib) and inferior to the s ternum .

O bs e rv a t i o n

On

observa tion, the

follow i n g is

note d : •

Bilatera l contraction of onl y the 10 wil l r es u l t

in fl aring (wi d e nin g ) of the infrasternal an g l e; in lean individuals the upper an terior fibers may be p alp able and

v isible as an ob lique band

i ng to the

runn

s u p ero me d i a lly from the a n terior iliac crest

rib s . If both the 10 and EO a re active, ribc age bra ­ cing and decrea se d lateral costal expansion will be observed a l on g w i th lo wer a b d ominal bulging. • Rectu s a b dominis a c ti v i ty will result in thora­ c o l u mb a r flexion and / o r a pos ter ior pelvic tilt. • Co-con traction of the erec tor spin a e m u scles will reduce the amolm t of thoracolumbar flexion observed but w ill res u l t i n trunk rigidity and a res tric ted " rib w i gg le • I f the d y sf unc tion a l s u b s ti tu ti on p att e rn is primarily uni l a teral, a la tera l shift in the ribca ge will O C C llf w i th the con tra c tion. . "

Correct i o n

niques can

tec h n i q u e

Several faci l i t a tion tech­

be used .

C h an ge p a tient position: choose a posi t ion tha t facilita tes relaxation of the trunk. This may be supine / crook lying (as long as the pelviS i s not poster­ iorl y tilted) or prone lyin g (Fig. 10.55). If the erec tor spinae are be ing recruited al o ng with the sup erfic i a l •

best

F i g u re 1 0. 5 4 U l t raso u n d i m a g e of t h e l a te r a l a b do m i n a l w a l l , tra nsverse vi ew. M , m ed i a l ; SC, s u b c u ta n e o u s t i ss u e ; EO, exter n a l o b l i q u e ; 1 0 , i n t e rn a l o b l i q u e ; TA, tra n sversus a b d o m i n is. D o m i n a n t 1 0 w i t h o u t p reco n tract i o n o f TA. f a ) R e l a xed a b d o m i n a l w a l l . ( b) I n c reased t h i c k ness in the 10 layer is evi d e n t ( d o u b l e - h ea d a rrow ) a n d t h e m ed i a l e d g e o f t h e m us c l e b u l g e s i n to t h e abdo m e n , w i t h a resu l ta n t b l u rri n g o f the fasci a l l i n e s m ed i a l ly ( s m a l l a rrows) . I n t h is exa m p l e a s m a l l TA contra ct i o n i s occurri n g w i t h t h e 1 0 c o n tract i o n , a s evi d e n ced by a c h a n g e i n t h i c k n ess i n the TA layer. H o wever, t h e re i s n o lateral c o rse t i n g o f TA a n d i n rea l t i m e t h e c o n tra c t i o n d i d not occ u r befo re t h e 1 0 contract i o n . ( R e p r o d u ced w i t h perm i s s i o n fro m © D i a n e G . Lee Physi oth era p i s t C o r p . )

abdominal muscles a pillow can be p laced under the s tomach in prone to encollfage re l a xa ti on .

Start w i th ver b a l and tac tile c ues tha t d raw away from the abdomen (ac t i v a t i ng the pelvic floor, tension coming u p from the inner thighs, con­ •

focus

trac ting mul tifidus (deep fibers)) . •

Check for s u pe r fi ci a l

abdominal activ ity on

e x p i r at ion. Add the c u e , " B rea the in, b rea th e o u t, now reall y relax y our s tomach, d on ' t brea the, and gently think of l i ftin g in your p elvic floor. "

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F i g u re 1 0. 5 5 Fa c i l itati o n of tra n sversus a b d o m i n is (TA ) i s o l a t i o n : p ro n e lyi n g positi o n . To faci l i tate r e l a xati o n of the a b d o m i n a l wa l l , ask t h e pati e n t to "let t h e sto m a c h relax o n t h e b e d " p ri o r to a t te m p t i n g recru i t m e n t of t h e TA. T h e p a t i e n t p a l pates fo r a T A c o n tracti o n b i l a t e ra l l y w h i l e t h e t h e ra p i st m o n i t o rs t h e t h o r a c i c erecto r s p i n a e a n d t h e l a te ra l p o rt i o n s o f t h e extern a l o b l i q u e m us c l e fo r a c t i v i ty. ( R e p rod u ced w i t h p e r m i s s i o n fro m © D i a n e G . Lee Phys i o t h era p i st Corp.)

U l tra so u n d i m a g e i n isolation

-

TA co ntracti n g but n ot

When TA comes o n first, followed b y 1 0 and the o ther abd o m in a ls (may occur quickly or more g r a d u a ll y ) , this indicates that proper timing of th e muscles is o c cu r ring ; however, the r ec ru i tm ent of the global system i s h a p pening too early and needs to be eliminated to ge t an is ola ted TA contraction . Imaging On the real- time u l trasound image, the follo w ing is seen (Fig. 1 0 .56a, b ) : • The TA layer increases in t hic knes s and moves l a te r a l l y, draw ing the med ial fascial connection lat­ e ra lly. This is fol lowed by an in c r ea s e in thic kn e s s in the 10 layer. T h e r e is less in te r na l b ulging and less fascial b l u rring of the medial portion of 10 (as com­ p a red to an 10 c ontr a c ti on without an underlying TA) due t o the p r et en si onin g of the underlying fa sc i a by the TA contrac tion .

Pa l p a t i o n

On palpa tion, the following is felt:

A deep t e nsi onin g fol lowed by a fast or slow b u l g e can be felt med ial to the ASIS. • In or d e r to d ete rmin e if EO or rectu s a b do ­ m inis is also being re c mi te d wi th the 10, palpa te a l ong the lower ribcage (below the eighth rib, Fig. 1 0 .52) a nd inferior to the s ternum . •

O b s e rva t i o n

On observation, the fo ll ow in g is

noted: • The lower ab d o m en will gently flatten fol­ lowed by signs of s upe r fic ia l abdominal muscle activi ty ( de sc ribe d in s e c ti ons above) .

F i g u re 1 0 . 5 6 U l traso u n d i m a g e s of t h e l a t e ra l a b d o m i n a l wa l l , tra nsverse v i ew. M , m e d i a l ; 10, i n te rn a l o b l i q u e ; TA, tra nsvers u s a b d o m i n is. ( a ) R e l a xed abd o m i n a l wa l l . (b) TA contraction fo l l ow e d by 1 0 co n t racti o n . When viewed i n rea l t i m e, a n i n c rease i n t h i c k n ess o f the TA layer occu rs fi rst ( s m a l l d o u b l e ­ h e a d arrow ) , w i t h a l a t e ra l s l i d e o f t h e m e d i a l fasc i a l a t t ac h m e n ts ( h o ri zo n ta l a r ro w ) a n d s o m e c o rse t i n g of TA l a tera l ly. T h i s is q u i c k l y fo l l owed b y a l a rg e i n c rease i n t h e t h i c kness o f t h e 1 0 l a y e r ( l a rg e d o u b l e- h e a d a rrows ) . Note t h a t t h e m e d i a l fasc i a l l i nes a re s ti l l d i s ti n g u i s h a b l e , as co m p a red to t h ose i n Fi g u re 1 O. 54b. ( R e p ro d u ced w i t h p e r m i ss i o n fro m © D i a n e G . Lee Phys i o t h e r a p i s t Corp. )

Co r recti o n

tech n i q u e

Several faci l i t a ti on tech­

niques can be used . • E nc o ur a g e a slower contrac tion; start with 50% of curren t speed, then 50% of the new sp ee d, and so on . • Encourage a lighter contraction; start w i th 50% of current effor t, then 50% of th e new effort, and so on. Remind p a tie n ts that o nly 1 0-15% of m a x i m a l vollmtary c o n t racti on i s req u i red and that they sh o ul d be imagining a c on t r a c t i on ra the r tha n doing a con traction. • If decrea sing the s p e e d and e ffo r t s till re s u l ts in g l o b a l m uscle ac tivi ty, try changing the p a tien t's p o si ti on s uch tha t the global muscles a re more relaxed. • Direct the p a tie n t ' s attention to the ultrasound scree n . Ask the patient to s top the c o n t rac tio n before m o ve m e n t in the global musc le layers ( n o ta b l y 10) o cc u rs . Once this is mastered, have the patient p erform th e contraction without looking a t the screen so tha t the n e w s ki l l i s internalized.

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Trea t i n g t h e l u m b o p e l v i c- h i p dysfu n ct i o n

When the TA and 10 (wi th or withou t EO and rectus abdominis) come on together, this indicates tha t there is incorrec t timing and no separation of control of the local and global systems. I m a g i n g On the real-time ul trasound image, the fol lowing is seen : • The TA layer increases in thickness and moves la terally, drawing the medial fascial cormection l a t­ erally, but there is a concurrent increase in thickness in the IO layer. Often there is less lateral slide of the TA layer than usually observ ed w i th an isolated TA contraction and blurring of the medial fascia cormec tions can occur depending on the amount of contraction in the TA (Fig. 1 0 .54a, b). The lateral corseting occurs but there is concurrent inwa rd movement of both the TA and IO layers.

Pa l p a t i o n

On

pa lpa tion, the following is felt:

• A fast or slow bulge can be fel t medial to the ASIS (in this scenario palpa tion carmot identify if the re is TA activity underneath or not as the bulge domina tes the palpa tion result) . • In order to determ ine if EO or rectus abdo­ m inis is also being recruited w i th the 10, palpate along the lower ribcage (below the eighth rib, Fig. 1 0 .52) and inferior to the sternum.

O b s e rvati o n

On

observa tion, the following is

noted : • The signs of superficial abdomin a l muscle activity w i ll be evid ent and dependent on which globa l m uscles are activa ted (see above) .

Correct i o n

tech n i q u e

Several facilitation tech­

niques can be tried . Consider using manual or other techniques to downtrain the global muscle a c tivity (muscle energy, lateral costal brea thing, treating thoracic joint restrictions, IMS, electromyogram biofeedback) prior to another attempt a t TA isolation exercises. • Change the patient position to one tha t maxi­ mizes relaxation of the abdomina l wall. • Encourage a slower contraction; start with 50% of current speed, then 50% of the new speed, and so on. • Encourage a lighter contrac tion; start with 50% of current effort, then 50% of the new effort, and so on. Remind pa tients tha t only 1 0-15% of maximal voluntary contraction is required and tha t they should be imagin ing a contraction rather than do ing a contraction. •

F i g u re 1 0. 5 7 Faci l i ta t i o n of t ra nsversus a b d o m i n is isola t i o n : s i d e lyi n g . I n t h i s exa m p l e , t h e patient pa l pates fo r l a tera l costa l expa n s i o n w i t h t h e l e ft h a n d a n d tra n sversus a b d om i n i s (TA) contra c t i o n w i t h t h e ri g h t h a n d . The t h e r a p i s t p a l pates t h e rig h t TA fo r ev i d e n ce o f a n i d e a l contraction w h i l e t h e ca u d a l h a n d provides g e n t l e s i n k i n g press u re i n to t h e i n n e r t h i g h s b i l a te ra l l y. W h i l e s l i d i n g t h e fi n g e rs u p t h e t h i g h s a s h o r t d ista nce ( a rrows) , give t h e c u e , " I ma g i n e te n s i o n co m i n g u p from my fi n g e rs i n you r i n n e r t h i g hs, m ovi n g u p i n to t h e fron t of you r pelvic flo o r." The i m a g e can be exte n d e d up to the l o w e r a b d o m e n if n ecessa ry. (R e p ro d u ced with p e r m i ss i o n from © D i a n e G . Lee Physiothera p i s t Corp. )

• Start with verbal and tactile cues that draw focus away from the abdomen (activa ting the pelvic floor, tension coming up from the imler thighs (Fig. 1 0 .57), contracting multifidus) . • C heck for superficial abdomina l activity on expira tion. Add the cue, "Brea the in, brea the out, now really relax y o u r s toma ch, don ' t breathe, and gently think of l i fting in your pelvic floor. "

U l t raso u n d i m a g e - a sym m etrica l p a tte rns This is the most common clinical presentation and is often present with asymmetries in multifidus and / or pelvic floor function. Any of the above scenarios can occur asymmetrically, with one side producing an ideal response and the other side producing one of the abnormal responses, or with both sides showing abnormal but different responses. Correction of asymmetry will require a combination of the above facilita tion techniques. The sidelying position (Figs 1 0 .53 and 10.57) is useful for facilita ting the TA on the side that the patient is lying. Successful correction of the asymmetry is often achieved by simply adding a small increase in p atient focus and a ttention to the dysfunc tional side when the isolation exercise is a ttempted . Images to address asymmetry in TA/ multifidus will be addressed la ter under co-con traction s tra tegies.

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T H E P E LV I C G I R D L E

deep m ultifidus, i t can be described as a loss of the

D E E P F I B E R S O F M U LT I F I D U S

connec tion in the wire, a llowing rota tion and col­

Pati e n t a n d t h e r a p i st pos i t i o n

lapse of the spine on tha t side. The i mage of energy

Choose the position where the patient c a n atta in a neu tral spine position and the global muscles a re m o s t relaxed, especially the erec tor spinae, the deep hip e x ternal rota tors, and the posterior pelvic floor. Prone is a useful position for comparing right / left recruitment symmetry, but is n o t often the easiest posi. tion fo r pa tients fi rst to prac tice isolation exer­ cises. Sidelying is a use ful position a s it allows easy p a lp a tion of the muscle and relaxation into a neu­ tra l spine position. Positions such a s supine a n d c rook lying c a n also be beneficial for s o m e p a tien ts. P a lp a te multifidus j ust l a teral to the spinous processes of the l umbar spine or sacrum b i l a terally at the level o f atrophy. To moni tor the deep fibers, the muscle must be palpated close to the spine; in the lower l u mb ar and sacral segments the lateral muscle bu] k consists o f th e more superficial fi bers . Teach the p a tient how to find the dysfun c tional seg­ ment ( " feel for the soft part of the muscle") and how to sink i n to the muscle with the fingers .

coming up ver tically a l ong the wires to support the sp ine helps to cre a te the sense of s uspension . In each case, the deep multifidus is pa lpated bilat­ erally a t the dys func tional level; this i s where the " guy wires" a t tach to . The inferior a tta chment of the wire can vary; the image u l ti m a tely chosen is the one tha t prod u ces the best response in the deep m u l tifid us. The timing o f the tac tile press ure from the therapist's hands crea tes the image and p ro­ v i des feedback as to how quickly the m uscle shou ld be contra cted. The fingers should sink into the m u l­ tifidus and prov ide a cranial pres s u re to encou rage a lifted or s u spe nded

feeling. The i n ferior a ttach­

ment of the wire can be j us t medi a l to the ASISs (Fig.

1 O .58a), sup erior to the pubic bone (Fig.

l 0 .58b), or fro m the pelvic fl oor

(Fig. l O .S8c); the

sequence of tactile feedback is from the an terior palpa tion point firs t, then up i.n to the multifi d u s palpa tion point. Finally, c ues t o activate

a

TA or

pelvic floor contra c t ion can be used to a c tivate a contrac tion in the deep m ul ti fi d u s .

Correct i o n tec h n i q u e - verba l a n d m a n u a l c u e s

I d ea l a n d a b n o rm a l res po nses

Se vera l verbal c ues c a n help to faci litate a n iso l a ted

A s l ow development of firmness in the muscle will

contraction of the deep fibers of mul tifidus.

be fel t as a deep swelling and indenta tion of the

•

"Feel the m u scle under my finger and think o f

a tension coming f r o m inside y o u r b o d y to make this m uscle bulge into my fingers . " •

"Feel these tw o bones (palpate the PSISs) and

imagine drawing them toge ther. " •

" Im a gine tha t y o u are a Barbie doll, and tha t

someone has p ulled your leg off and left it lying a t y o u r pelvis, b u t disconnecte d . Ima gine an energy from insi de your spine tha t will draw the leg in to your body and reconnect it. " Or, "Imagine there is a s tring connec ted from the spine to the hip

(in the

groin); if you p u l l on thi s s tring from the muscle in your back you c a n connec t the leg back into your body. "

pads of the palpa ting fingers. A fas t contraction is indica tive of the superficial multifid us and / or l um ­ bar erector spinae a c tivation; the fingers

wil l be

quickly pushed o ff the body. A fas t gene ra tion of su perfic ia l tension can also be palpated if the thor­ a cic ere c tor spinae a re contracting. The common tend on of the erector spinae m uscle overlies the lumb a r mul tifidus (Fig.

4 .33) and ac tivity in the

muscle w i l l change tension in the tendon, espec ially in indiv i duals where this muscle is well-developed . It is important to teach the p a ti e n t how easy it is to p ush the fingers into the muscle when it is relaxed ( " feels l i ke a mushy banana"), as compa red to when the deep fibers of multifi dus con tra c t ( " feel how it is firmer and h arder to sin k your fingers into the

Images tha t crea te the idea of the spine being sus­

muscle " ) . There should be no pelvic or spin a l motion

pended are also effec tive for fa c i lita ting a con­

observed, and no activi ty in the globa l abdom i n a l

traction of the deep fibers of mu ltifi d u s . Va rious

m u scles or i n the hip m uscul a tu re . A co-con traction

descrip tions can be used, but the common theme is

of TA is accep table and desired.

tha t the spine is a central pole tha t needs to be sus­

The common abnormal resp onses tha t occur are

pended b y tension wires from both sides. The ten ­

l i s ted here and ca tegorized according to p a t terns

sion in the wires needs to be equal on the right and

seen w i th real-time ultrasound i ma g ing. The reader

left s ides; i f there is loss a c tivity in one side of the

should no te tha t rea l- time u l trasound is an adjunct

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Tre a t i n g t h e l u m bo p e l v i c- h i p dysfu n c t i o n

(a)

(b) F i g u re 1 0. 5 8 Descri b e t h e i ma g e to t h e pat i e n t : " I m a g i n e t h a t t h e re i s a t e n s i o n w i re o r stri n g t h a t is g o i n g to s u s p e n d yo u r s p i n e . W e a re g o i n g t o con n ect t h e w i re fro m t h e fro n t of y o u r b ody, u p a n d i n th ro u g h y o u r body d i a g o n a l l y to my fi n g e rs i n yo u r s p i n e . [The a rrows i n t h ese i l l u s t ra t i o n s rep rese n t t h e t e n s i o n w i re.] Bre a t h e i n , b r e a t h e out, n o w s l o w l y c o n n ect a w i re fro m t h i s fi n g e r h e re [ g i v e p ress u re a t a n te r i o r p a l pa ti o n po i n t] to t h i s fi n g e r h e re [g ive p ressu re i n to m u l ti fi d u s] . " O p t i o n s fo r a n te r i o r atta c h m e n ts i n c l u d e : [a) t h e t h e ra p i s t s i n ks t h e fi n ge rs a n d th u m b j u s t m e d i a l to t h e a n te r i o r s u p e r i o r i l ia c s p i n e [AS IS) o n e a c h s i d e , w h i l e t h e p a t i e n t i m a g i n e s two w i re s asce n d i n g d i a g o n a l ly a n d m e d i a l ly from t h e ASISs t o t h e ri g h t a n d l e ft s i d e o f the verte b ra b e i n g p a l pated. [ b ) T h e t h e ra p ist p a l pates j ust s u p e r i o r to the p u b i c bone a n d the p a t i e n t i m a g i n e s one w i re asce n d i n g c e n t ra l l y a n d t h e n s p l i ts to a t t a c h to t h e ri g h t a nd l eft sides of t h e s p i n e a t t h e pa l p a t e d poi n ts. (c) T h e t h e ra p is t u ses press u re i n to the i n n e r t h i g h s b i l a t e ra l ly to c u e a w i re sta rt i n g in t h e p e l v i c fl o o r. [ R e p ro d u c e d w i t h perm i s s i o n from © D i a n e G . Lee Phys i o t h e ra p ist Corp.)

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21 2

•

Alterna tely, r ap i d tension in the s uperficial l a yers may be fel t from the tensioning of the long tend ons of the thorac i c erector s p ina e musc l e s .

•

•

Palpation of the abdomen may reveal a TA contraction or the TA may remain inactive. Activity is felt in any m uscles being used in substitu tion (e.g., the oblique abdominals) . Observati o n

On

observa tion, the following i s

noted:

is com mo n ly observed, as • Breath-holding well as pos terior ti l ting of the pe lvis or segmental l umbar flexion as the pa tient attemp ts to p ush the muscle into the therapist's fingers . Abdominal brac­ ing m ay also be evident. • If the thoracic erector sp ina e muscles are active, the tone will be evident up into their o rigi ns in th e thoracic spine, either symmetrically or asym­ metrically, and spinal e x tension w i ll occur unless there is co-contraction of the abdominal s . Co rrecti o n

tech n i q u e

Se vera l facilita tion tec h­

niques can be tried. Fig u re 1 0 . 5 9

U l traso u n d i m a g es o f l u m bosacra l m u l ti fi d us. l o n g i tu d i n a l view. APL4, a rt i c u l a r p rocess L4 ; A P L5, a rticu l a r p rocess L5 ; S , sacru m ; d M F, d e e p m u l tifi d u s ; s M F, s u perfi c i a l m u l t i fi d us. The a rro ws i n b o t h i m a g es i n d i cate w h e re m u sc l e activi ty is s e e n w h e n e i t h e r t h e d e e p o r s u p e rfi c i a l m u l ti fi d u s m u sc l e co n t ra cts. [ a ) W h e n n o acti v i ty o cc u rs i n e i t h e r t h e d e e p o r s u perfi c i a l fi b e rs o f m u l t i fi d u s o n a c u e t o recru i t t h e m u sc l e , t h e i ma g e does not c h a n g e [ t h e re is n o c h a n g e i n t h e t h i c k n ess o f t h e m us c l e layers ) and rese m b l es a n i ma g e taken a t rest. [ b ) Co n c u rre n t recru i t m e n t of t h e deep a n d s u p e rfi c i a l fi b e rs of m u l tifi d u s res u l ts i n a c h a n g e in t h i c k n ess of t h e e n t i re m usc l e fro m t h e la m i na t o t h e most s u p e rfi c i a l fi b e rs. [ R e p ro d u ced w i t h p e r m i ss i o n fro m © D i a n e G . L e e P h ys i o t h e ra p i s t Corp. )

to palpa tion and ob se rvation skill s and is not an essen­ tial tool for teaching local muscle activation; however, i t is often a useful tool for p rov i d ing feed bac k to p a ti en ts and objective assessment of dysfunc tion .

U l traso u n d i m a g e - no recr u i t m e n t of t h e deep o r su perfi c i a l fi bers of m u l tifi d u s Imaging

On

fo ll o w in g is •

No change in the th ickness of the muscle l a y ers is seen on the ul trasound. Pa l p a t i o n

•

the real-time u l trasound i mag e , th e (Fig. 1 0 .59a) :

seen

On

palpa tion, the following is felt:

The muscle remains s o f t a n d no tension is felt in the mu ltifidus.

• Tr y a variety of images u n ti l one is found tha t enables the patient to find the musc le. If l u m b a r flexion is occurring, use cues tha t emphasize a su s pended or lifted feeling rather than "make the m uscle swell . " • Check the posterior pelvic floor (ischiococ­ cyge us) and poste rior hi p for hypertonicity (Fig 10 .33); if there is "butt grip ping" it will i nhi b i t acti­ vation of the multi fidu s . Change the p a tien t pos­ ition or use release techniques to decrease the tone prior to faCilitating a multifidus contraction. • If the thoracic erector sp i n ae are active, choose a position tha t will ma ximize relaxa tion in these m uscles, such as p ro ne l y ing (Fig. 10.60). • Check the b re a th ing pattern and ensure there are no p eri od s of breath-hold ing. Use the exhalation phase to encourage relaxation of the erector spinae m u s cle s . ­

U l traso u n d i m a g e - no recru itment of t h e deep fi b e rs of m u ltifi d us. activ ity i n the s u perfici a l l ayers I m a g i ng On the real-time ultrasound image, the following is seen: • No change in the w i d th o f the muscle la y ers is seen in the d eep layers of multifidus. An increase in

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Trea t i n g t h e l u m bo pe l vi c - h i p dysfu n c t i o n

move i t") as these feed into the pred isposi tion to recrui t the sup e rficia l fi be r s . • C h e c k the brea thing p a t tern and ensu re there are no p erio d s of b reath-holding. Use the exhalation phase to encourage relaxation of the erector spin ae and sup er fi c i a l m u l t i fi d u s . • Change the p a tie n t s p OSition to one where there is best relaxa tion of the superficial m u l t i fidus. A pillow under the abdomen is often effective. '

Fi g u re 1 0 . 6 0

Fa ci l i ta t i o n of d e e p fi b e rs of m u l t i fi d u s : prone. Th i s posi t i o n ca n red u ce excessive activity i n the thoracic erector s p i n a e ; p l a c i n g a p i l l o w u n der t h e sto m a c h ca n i ncrease s u p p o rt and fu rth e r fa c i l i ta te r e l a xa t i o n of the tru n k. The p a t i e n t p a l p a tes t h e m u l t i fi d u s b i l a tera l ly to m o n itor t h e con tracti o n w h i l e the therapist c h ecks fo r co-co n tracti o n o f t h e tra nsvers u s a b d o m i n is. The t h e ra p ist's pa l pa t i o n p o i nts ca n b e u s e d to cue a " g u y w i re" i m a g e fro m t h e a n te r i o r a b d o m e n . [ Reprodu ced w i t h perm i s s i o n fro m © D i a n e G . Lee Phys i otherapist Corp. )

width of the superficial layers is observed, often fa s t , p h a s i c re s p on s e .

Pa l p a t i o n

a

On pa lpa tion, the follow ing is felt:

• The fin g e rs will be r a p i d l y p ushed o u t from the muscle, without any p a l p a tion of deep tension p rior to the ra p id con trac tion . • A l te rn a t e l y, a fast contrac tion in th e m ultifidus fibers la teral to the p a l p a t io n p o in t will be fe l t while the med i a l p a l p a t i o n p o i n t (deep fibers) stays soft and inactive.

O bserva t i o n

On

observation, the fol lowing is

noted :

tech n i q u e

Severa l

facilita tion tech­

niques can be tri e d . manual o r other tec hn i qu e s to the tone and sensi tivity in the s u p erfic ia l fibers p rior to another a ttemp t a t is ola ti on exercises •

Cons ider u s in g

d ec r e a s e

for the deep l a yers .

A change i n t h i c kne s s o f the superficial and a fast, phasic response. •

d ee p l a y ers occurs s imu l t a n e o u s l y in

Pa l p a t i o n

On p a lp a tion, the fo l l ow in g is felt:

• The fin ge r s will be r a p i d l y p u s he d out from the m uscle, without any p a l p a t i on of d eep tension prior to the ra p i d contraction.

O b serva t i o n

On observa ti on,

the following is

noted: •

If

the multifidus is ac tive witho u t concurren t

a b d o m ina l a c t ivity then a n inc rease in the l u m b ar lord osis w ill

b e evident. No change in the l u m b ar is concurren t abd ominal

curve w i l l occur if there

b racing. Correct i o n

tech n i q u e

Several facilitation tech­

n i q ue s can be tried . Consider u s ing manual or o ther techniques to tone and sensi tivity in the s u p erfic i a l fibers p rior to another a ttempt a t isola tion exercises for the d eep layers. • Encourage a much slower contraction, with much less effort. Often by re p ea te dly reducing spee d and effort the pattern of ac tivation can be altered such that the tension develops primarily in the deep l a y ers of mul tifidus first. Use the ul tr a sound and manual cueing to teach the patient the point at which to stop the contraction (before the large bulge occurs). • Try a va r iety of images unti l o n e i s found that enables the pa tient to find the m u scle Av oi d i m a ge s that encourage an ex tension movement (e . g . , " p re tend you are arching your b ack but don't a c tu a l l y move it") as these feed into the p redisposition to recr u i t the superficial fibers. decrease the

.

Try a variety of images until one is found tha t enables the pa tient to find the muscle. Avoid images tha t encourage a n e x t e n s i on movement (e.g., " pre­ tend you a re a rching your back but don't actually •

I m a g i ng On t h e real-time ul trasound ima ge, the following is seen ( F i g . 1 O .59b ) :

•

If the s up e rf i c i a l m u l tifidus is active w i thout concurren t abdominal activity then an increase in the l u mb a r lordosis will b e eviden t . No change in the l u mbar curve will occur if there is concurrent abdominal bracing. •

Correcti o n

U l traso u n d i m a g e - co ncu rrent ph a s i c contract i o n of t h e d e e p a n d su perfi c i a l fi bers o f m u l t i fi d u s

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214

T H E P E LV I C G I R D L E

• Check the b re a trung pattern and ensure there a re no periods of brea th-hold ing. Use the exha l ation phase to encourage relaxa tion of the erector spinae and superfic ial mul tifid us.

U l tr a so u n d i m a g e - deep then s u p e rfi c i a l fi b e rs of m u l t i fi d u s ( cor rect ti m i n g b u t n o t i s o l ated )

Trus is an accep table recrwtment pattern; however, the contraction of the s uperficial multifidus should be down trained so tha t i t is not excessive or phasic. The ultrasound image, palpa tion, and observation will be si milar to that described above for the con­ current contraction of deep and s uper ficia l; however, the deep contraction can be observed on ultrasound and palpated prior to being overlaid with the super­ ficial contraction . Cues for d ecrea s in g speed and effort are effective for reducing the activity in the s uperficia l multifidus a n d th us bias the contraction to occur primarily in the deep l a y e rs . U l t r a so u n d i m a g e - a sy m m e t r i ca l a ctivat i o n

This i s the most common clinical presenta tion and i s often presen t with asymmetries in TA and I o r pelvic floor func tion. The deep fibers of multifid us on one side will be poorly recruited, often in conj unction wi th excessive super fi c ia l multi fidus activity on the ipSi lateral or con tralateral side. Correc tion of asym­ metry will require a combina tion of the above facili­ tation techniques for all the local muscles. Using unilateral pa tient focus and attention is a key com­ ponent. Images to address asymme try in TA l multi­ fidus will be a dd re s se d in the next section with co-contrac tion s trategies .

C O - C O N T R A C T I O N A N D E N D U RA N C E T R A I N I N G FO R T H E L O CA L SYS T E M

Once a s uccessful s tra tegy for crea ting a n isola ted contraction in the targe t local muscle has been i d en ­ tifi e d, th e p a t ien t is encouraged to work toward s increasing the duration of the tonic contrac tion whi le maintaining normal breathing. It is important tha t the patient is ta ught how to recognize when the muscle s tops working and l or when substitution pa tterns start (e.g., TA gradually fades and 10 turns on). In this way, pa tients can monitor and progress their own program on a day-to-d ay basis, working towards 10 repetitions of 10-s holds, but vary in g the duration and nu mber of contractions at each

practice session depending on how accurate the performance of the skill is at tha t time. Remind the patient tha t more p r ac ti ce sessions in a da y, wi th smaller numbers of repeti tions (e.g., 5-s holds, five repeti tions, 10 times a day) is more effective a t retraining the skill than one session o f large n u m ­ bers of re peti tions ( e .g . , 5-s holds, 50 repetitions, once a day) . As the skill is mastered in s up po rte d positions, more upright pOSitions and activities are a dded to the program. The pa tient is instructed to perform the same contrac tion, but in positions suc h as si tting, supported standing, s t a n d ing , and walk­ ing. The therapist must check the qua lity of the con­ tr a ct i on in these new positions and ens ure tha t a c tivity in the global muscles is not excessive (use the checkpOints for global rigidity) More ideas on func tional progressions are presen ted in the sec­ tions tha t follow. If the p atien t presents with an asymmetric con­ trac tion, the verb a l cueing and images can be altered such that more foc us is directed towards the dysfunctional side. Careful palpation and observa ­ tion by the therapist are crucia l, as it is common to have one side with an ideal response in the muscle (isolated TA contraction), and a substitution response on the other side (10 contraction) . In some cases, a bilatera l contraction is cued first, and then the patient is ins tructed to think "a li ttle b i t more" about the side of the poor response ("pull the left tummy in a bit more," " think of d rawing the left ASIS farther to the center, " "crea te more tension in the guy wire to the righ t side o f your low back" ) . I n other cases, the best result is pro d u ce d when only the d ysfun c tion a l side is cued ( "just think of p ulling in the left side of your tu m m y," "draw only the left ASIS to the center," "crea te a guy w i re that only connects to the right side of your low back") . Although the pa tien t is thinking o f a unilateral con­ traction, a bilateral contraction is prod uced and p al ­ pated by the the r a p i s t . Usually this c u eing needs to be progressed to a b i l a te ra l c ueing as the globa l muscles on the d y s f un c ti o n a l side become less active and the isola ted contrac tion more precise. Ultima tely the goal is a co-contrac tion of the loca l m uscles - the pelvic floor, TA, a nd the deep fibers of m u l ti fidus - with norma l brea thing pa tterns (nor­ mal modulation of the d iaphragm) . I ma ge s can be combined or modified to prod uce co-contra ction. The image of the guy wire for mul ti fid us isola tion often res u l ts in a co-contraction of TA and deep m u l ti fidus . C ues can be combined in many ways, for example, "Gently connect your h-vo ASISs

Copyrighted Material

Treating the lumbopelvic-h i p dysfun ction

It has very li ttle ability to con trol the orien ta tion of the ribcage in re la tion to the pelviS, o r the limbs in rel a tion to the trunk . It is essential to control spinal orienta tion, fun c tional limb movement, and postural equilibri um o f the global system. This section will cover e xercises tha t promo te opti m a l recru itment of the global m uscles w i th a precontr a c ti on base of the local s tabilizers. The goal is to m a intain the co­ contraction of the deep local system w hile sustaining positions and controlling movemen ts tha t require glob al muscle a c tiv i ty. Care must be taken n o t to F i g u re 1 0. 6 1

C u e i n g fo r c o r r ec t i n g asym m e tries i n t h e d e e p

l o c a l s ta b i l i z i n g syste m . T h e t h e ra p i st p ro v i d e s d e e pe n i n g press u re a t t h e p a l p a t i o n p o i nts a s t h e ve r b a l c u e i s g iv e n .

I n t h i s ex a m p l e , t h e l eft t h u m b p a l p a tes t h e t ra n sv e r s u s a b d o m i n i s a n d t h e ri g h t h a n d

(under the

t ru n k ) p a l p a tes t h e

progress global e xercises too quickly, and the ability vo luntarily to isolate and tonically hold a segmenta l contrac tion should be reassessed often to ensure that control of the local system has not been lost. The spe­ cific exercise program used will vary depending on

d e e p m u l t i fi d u s . T h e a rrow i n d i c a t e s t h e d i re c t i o n of t h e

each p a tient's p resenta tion, but a general protocol

d i a g o n a l s u s p e n s i o n w i re. T h e p a ti e n t p a l pa tes t h e r i b c a g e

for progression is presented in Figures

b i ! a te ra l l y to s e l f- c u e a p r o p e r b r e a t h i n g p a t t e r n w h i l e t h e co n t ra c t i o n i s h e l d . ( R e p r o d u c e d w i t h p e r m i s s i o n fro m © D i a n e

G . l e e P h y s i o t h e ra p i s t C o r p . )

1 0 . 63.

10.62

and

This protocol is a d ap ted from the guidelines

d eveloped by Richardson et a l

(1999) .

Exercises can be designed to chal lenge con trol of flexion, ex ten sion, or rota tion through the lumb a r

together [for

TA J , and i magine tha t they a re con­

spine a n d pelvis depend ing on the d irec tion tha t

nec t i ng in the center a t your pubic bone. Now con­

the limb is moved or the d irection of the application

nect a l ine from your p ub ic bone, thro ugh your

of ex terna l forces (w eights, resistive exercise b a nds,

bo dy, a n d up in to your spine on b o th sides w here

pulleys) . Upright positions and movement o f the

my fingers a re [fo r m u l ti fidus] . " In some cases pal­

limbs requ ire a c tiva tion of the global musc les and

p a tion w i l l revea l tha t c u eing one m uscle is suffi­ cient to p rod uce co-contraction in the o thers ( the

should be fi rst on movement control; in p a tients w i th

pa tien t thi n ks of l i fting in the pelvic floor and a co­

l u mbopelvic-hip d ysfunc ti on it is o ften m o s t crucial

thus the global slings . For each progression foc us

contra c t i on i s felt in the TA and deep m u l tifid u s ) .

to m a s ter dissocia tion of hip movemen t from tru n k

F o r pa tterns of asymmetry, crea t ing d iagonal l ines

moveme n t . Focus is o n a ttaining pro x i m a l con trol

or guy "vires can a ddress a dysfunc tional left TA

fi rst, and then a d d in g the rest of the limb in func­

and [ight m u l t i fi d us simultaneously: "Think of con­

tional p a t terns .

necting a w i re from your right ASIS (or right pelvic

the exercises can b e p rog ressed to resis ted movements

As m ovemen t control is m a s tered,

floor) to the l e ft low back where my finger is"

to s trengthen the m u scles in fLmcti onal p a t terns. It

(Fig.

is important to identify the direc tion of loss of con­

1 0 . 6 1 ) . When the ASLR indica tes t h a t asym­

metrical compression i s most beneficial, s ta rting

trol and the area of loss of control

with

bar sp ine j oints) s o th a t the exercise program c a n be

asymmetr ical

Images

for

asym m e trica l

(SUs versus l u m ­

co-contraction can often y ield beneficial func tional

specific and not i nvolve so m any exercises tha t

res ults (improved

p a t ient compliance is u n likely.

ASLR, improved s ta nce p h a se of

one- leg s tandi ng) more q u i c kly than w o rking on

When the glob al muscles are ac tivated in a coord­ inated, properly timed m anner with a p recontrac­

the muscles separately.

tion of the deep local stabil izers, the resul tan t movemen ts will be performed with o p timal a l i gn ­

C O O R D I N AT I N G T H E L O C A L A N D

m e n t a n d fl uidity o f movement . Palpa tion o f the

G L O B A L S Y ST E M S

poorly controlled segmen t w i l l reveal main tained control o f the neu tra l zone b y the local s tab ilizers .

Coord in a tion o f the local and glob a l sys tems is

Observa tion of the relative positions of the limbs in

essential for func tiona l movement. Local system

rela tion to the trunk and of the thorax in rela tion to

function can only con trol the segmental re la tion­

the pelvis w i l l rev eal maintained a l ignment of a l l

ships of the joints and prevent excessive shearing.

j oin ts in the kinetic cha in such tha t the entire body

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21 5

216

T H E P E LV I C G I R D L E

R educe rigidity: downtra i n t h e g l obal system Self-release

R etrain brea t h i n g

exercises

p a tt e r n s Isolate a n i n d e p e n d e n t contraction of t h e d e e p l o c a l l u m bo p e l v i c sta b i l i z e rs ; a i m f o r co-co n t ra ct i o n , foc u s o n i n d i v i d u a l m us c l e s a s necessary Maintain global

N e u t ra l s p i n e

syste m m o b i l i ty/

st rate g i e s

length Practice f o r precision and e n d u ra n c e : i n t e g rate with brea t h i n g G oa l : 1 0-seco n d h o l d , 1 0 re p s

Adj u nctive s u p p o rt : sacro i l iac belt/taping

Coord i nate with t h e g l o b a l syst e m

(

I

S u pported

t

U p right/f n c t i o n a l pos i t i o n s

.,-----#

(see F i g . 1 0 . 6 3 )

F i g u re 1 0.62

Pro g ra m fo r sta b i l i z a t i o n of the l u m b a r s p i n e and p e l vis .

expected o r unexpected cha llenges to balance w i l l

Mainta i n neutral spine with load i n g

I

•

T r u n k-arm dissociation

•

Tru n k-leg d i ssoc iation

reveal control of postural equilib rium wi thou t long

\

Add i n g

Adding

periods of excessive global muscle activa tion a n d trunk rigidi ty (Hodges

2003 ) .

I t is critical tha t fo r each n e w exercise the ther­ apist palpates the segment(s) where failed load \

trans­

fer was iden tified on assessme n t . This will revea l

I proprioceptive

p ro p rioceptive

whether or not the local s ta bilizing system is continu­

challenge

challenge

ing to function in the new moveme n t and / or load­

Functional

Functional

i n tegration

i n teg ra t i o n

I

I

\

/

Moving out of neutral spine •

T h o racopelvic

•

I n t e g rated kinetic c h a i n

ing environme n t . Palpation p o in ts include: •

For the pelvic girdle, the inn o minate and the

sacrum a re p a l p a te d on the a ffec ted side to ensure tha t anterior ro tation ( o r shearing) of the inn o m­ ina te d oes not occur with limb loading (Fig. •

8.7).

F o r t h e l umbar spine, t h e artic ular pillars o r

interspinous spaces are palpated t o check for l o s s o f con trol i n the relevant direction (flexion, ex tension, rota tion, or shea ring) .

F i g u re 1 0 . 6 3

Coord i n a t i n g the loca l a n d g l ob a l systems.

•

For the hip, the innominate and the grea ter

trochanter of the fem u r are palpate d to check for i s posi tioned to share an d transmit forces equal ly.

a n terior d isplacemen t of the fem oral head or loss of

This overall body alignment is sustained by bal­

rota tional control (change in hip position often

anced length, s trength, and timing in the global

reflects an al tered s tabilization s tra tegy such tha t

sling systems. Observation of the

quality

of muscle

reac tions d uring a c tivities on uns table s u rfaces with

the hip m u scles substitu te f o r the lumb opelvic loca l stabil izers) (Fig.

Copyrighted Material

8.6).

Treat i n g t h e l u m bo p e l v ic-h i p d ysfu n ction

As exercises are added tha t include full limb move­ ment, each joint in the kinetic chain should be observed/pa lpa ted for control of the optimal a xis of movement and j o in t position. The position of the thorax in relation to the pelvis is monitored for altera tions in the an teroposterior (sagittal), l atera l (corona l), and rota tional (transverse) planes. The femoral head should remain seated (centered in the acetabulum) withou t loss of control into internal! ex ternal rota tion, abduction / a d duction, flexion or extension. The knee shou ld not excessively rota te or abduc t / adduct (fa ll in to a va lgus or v a rus position); the foot should not excessively supinate or pronate . In c losed kinetic chain exercises, the knee should stay aligned such that mid-patella is in line with the m idpoint of the inguinal ligament and tracks over the second toe . By correc ting devia tions of alignment d uring the exercises with tactile c ues, imagery, or proprioceptive inpu t (e.g., via resis tive exercise bands), the appropriate comp onents of the global slings will be activated for total body movement control . When add ing the global m uscles to the loca l sta­ bilizers, the discerning c linician may ask, "How much is too m uch global ac tivi ty?" It is evident tha t there needs to be enough global activ i ty to con trol the imposed forces. However, excessive global activity is best a voided as i t perpetuates too much comp ression through the j oints and res tricts mobiJ­ ity. Th us, the clinician needs to be able to identify when the added global muscle activity crosses over from "j ust enough" to " too much . " Each pa tient will present with a specific pa ttern of glob a l muscle hyperac tivity; this pa ttern will have been identified d uring the assessment tests. By spec i fi c ally palpat­ ing and observing these m uscles du ring exercise progressions, the cl inician will ge t an idea of how much activity is present; comparing for symmetry of activa tion between affected a nd non-affec ted sides is often revealing. Furthermore, the check­ poin ts fo r global rigidity as described above should be used often and even between repe ti tions of exer­ cises; whenever rigidity is p resen t there is " too much" glob al m uscle ac tivi ty. The pa tient can be ta ught how to moni tor the specific muscles and p a t­ tern of substi tu tion for the home exercise program . G E N ERAL PR I N CI PLES • Connect firs t - teach the p a tien t to perform a precontraction of the deep local stabi lizers as the starting point for each exercise .

• Initially the p a tient may need to relax the 10caJ s tabilizer co-contraction a fter each repeti tion of movement; however, the goal is to encourage a maintained local muscle co-contraction for several repetitions of movement, as long as substitu tion stra tegies are not observed . The number of repeti­ tions possible w i th one local muscle activa tion will increase as con tro l improv es. • Palp a te and monitor the loca l mu scle recruit­ ment and control o f the join t position d u ring the exercises, especially when adding a new p rogres­ sion. Ensure that the muscles do not turn off and tha t there a re no signs of loss of control into the direc tion of hypermobility. • Focus on low load and contro l of movement. • Aim for high repetitions . Start with only as many repetitions as the p a tient can perform w i th an effective local system co-contraction and con trol of the movemen t (sometimes as low as three to five repe titions), and progress to 15-20 repetitions wh ere the exercise is easy and req uires minimal concen tration to con trol the movement. • Use the manual cues and key points of control described above for a ttaining neutral spine and isol­ a ting the local stabilizers to prov ide tac tile feedback and assist con trol a t the levels where segmen tal hypermobility or multisegmental collapse occ u rs

during the exercise movements. Avoid fast ballistic movements. Progress from stable to un stable su rfaces to increase propriocep tive input and challenge. • Check for excessive global muscle ac tiv ity by monitoring the breathing pa ttern (sho uld continue to see la teral costal and abdominal expansion) a nd by monitoring for bracing/ rigidity (see check points for global rigidi ty) . • Incorporate local muscle co-contraction into daily func tional activities as early and as often as possible; break down func tional tasks into compon­ ent movements and use sep a ra te components as an exercise. • Focus on co-contraction and control of posi tion instead of single m u scle strengthening. • For S1} dysfunction exercises that address rota­ tional con trol need to be included in the program in order to res tore full fun c tion . • If high-load and high-speed activities a re required for work or sport, a dd these at the end­ stages of rehabilita tion and ensure tha t low-load, slow-speed control is present for the same move­ ment pa ttern fi rst. High-speed / high-load activities should be only one part of the pa tient's exercise •

•

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T H E P E LV I C G I R D L E

program; low-load exercises shou l d be continued concurrently to ensure continued ftmction of the local system. • There are many v aria tions and op tions pos­ sible for e a ch of the fo llow ing c a tegories. For each

sec tion, severa l progressions are p resented, but the reader is encouraged to use the princip les and g u i d e l ines in this chap ter to gu ide the crea tion of other exercise progressions tha t may be necessary for a specific p a tient presen tation.

M A I N TA I N I N G N E U T R A L S P I N E W I T H L O A D I N G The g o a l for a l l of the exercises in this section is to m a in t a in co-contrac tion of the deep loca l stabilizers and control of the ne u tr a l spine posi tion while a d d in g the challenge o f limb loa ding. The spinal curves should be moni tored and the rela tionship be tween the l u mbopelvic region and the thorax should be mainta ined thro ughout the exercises. The movements should be slow and controlled in both the concentric and eccen tric phases of movemen t. Two types of exercises can be used: those tha t con­ trol d issocia tion of the arm from the t runk, a n d those tha t con trol dissociation of t h e leg from the trunk .

F un c tiona l

integra tion ex ercises

are

dis­

c u ssed l a te r in the chap ter. Palpa tion of the poorly controlled joints and the loc a l

stabi l i zing

muscle

a c t i v a tion

will

reveal

whether or not con tro l of the neu tra l zone is main­ taine d . Ob ser v a tion of the orien tation of the pelvis,

F i g u re 1 0 . 6 4 I ma g e s fo r correc t i n g t h o racopelvic a l i g n ment. I n t h i s exa m p l e , t h e pa t i e n t i s u n a b l e t o m a i nta i n a n e u tra l s p i n e posi t i o n d u ri n g l e g l o a d i n g . T h e t h o ra x moves i n to e x t e n s i o n a n d ri g h t rota t i o n w h i l e t h e p e lvis rota tes t o t h e l eft. Th e a rrows i n d icate the d i re c t i o n and c o n n ec t i o n s o f the s u s p e n s i o n w i res crea ted w i t h i m a g e ry fo r t h o r a c o p e l v i c c o n t ro l . ( R e p roduced with p e r m i ss i o n fro m © D i a n e G . Lee Physi o t h e ra p i s t Corp. )

•

If the pelvis is rota t ing left ( F i g .

1 0 . 64), use the

cue: "Ima gine th a t there is a pin going th ro ugh your right ASIS tha t i s holding the right side of your pelvis down on the bed and keep ing i t s till while you move your leg" ( this faci l i ta tes con trala teral anterior oblique sling and / or i p s ilateral posterior oblique sling ) . These cues a re added after the i n i tial co-contrac tion

the orienta tion of the ribcage, and th eir rel ative

of the deep local stab i l izing

a lignment will reveal whe ther or not b a l a nced and

emphasized

symme tric a l activi ty in the glob a l sys tem is occur­

tha t con tinued ac tiva tion of the appropria te g l ob a l

ring. To correct loss of glob a l m uscle control, images

sl ing occurs d u ring inc rea sed l i mb loading .

during

s y s tem

occurs, and

movement of the a rm

or

leg so

of keeping connec tions of parts or of keeping ten­ sion a long lines of force are used to cue correc t a lignment of p a rts of the k inetic chain . For thora­ copelvic control d uring these e x ercises, the follow­ ing cues c a n be used: •

If there i s ex tension and right rota tion of the

th orax (Fig .

1 0 . 64), use the cue: "Keep the bot tom of

your ribcage on the right side connected to the left ASIS d u ring the exercise" ( this facili tates the anter­ ior oblique sling) . •

If there is flexion and rota tion of the thorax to

the right, use the c u e : "Ima gine tha t there is a line going from your left bottom rib at the back to yo u r righ t hip (or PSIS) ; kee p tension in tha t line through­ out

the

exerc ise"

oblique sling) .

( this

facil ita tes

the

pos terior

Tru n k a n d a rm d i ssoc i a t i o n - su p i n e or crook l y i n g Pa t i e n t p o s i t i o n Crook lying i n neutr a l s p ine on a fl a t surface. Arms a re flexed to 90° so tha t the h a n d s

a r e vertically o v e r t h e shou lder join ts. Exercise i n struct i o n

C ue the image tha t facil i ta tes

a co-contrac tion of the lum bopel v i c local s tabi l izers . Palpa te the TA and mul tifidus a t the d ysfu nc tional leve l(s), ensuring th a t recrui tmen t occ urs with your cue. Ask the patient to keep b rea thing

and

ma in tain

the spinal position w h i le performing various arm movements :

1 . Triceps p ress (ex tension control) (Fig . 10.65) : bend the elbows and bring the hands towards the

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Treat i ng t h e l u mbopelv i c- h i p dysfunction

in neutral spine posi tion (optimal lumbopelvic pyramid) . If an exercise band is being used as resist­ ance, secure it such that when the patient moves the arm the band has a line of pull in the opposite direc­ tion to the movement. Exercise i n struct i o n Cue the image tha t facilita tes a co-contraction of the lumbopelvic loca l stabilizers . Palpate the TA and multifidus at the dysfunc tional level(s) , ensuring tha t recruitment occurs with your cue. Ask the patient to keep brea thing and mainta in the spinal position while performing various arm movements: Fi g u re 1 0. 6 5

M a i n ta i n i n g n e u tra l s p i n e w i t h l o a d i n g : t ru n k a n d

a rm d i sso c i a t i o n - c r o o k l y i n g t r i c e p s p ress ( e x te n s i o n c o n tro l ) . T h e t h e ra p i s t pa l p a tes fo r t h e recru i t m e n t a n d to n i c co n t ra c t i o n o f t h e tra n svers u s a bd o m i n i s w h i l e p r ov i d i n g g e n t l e press u re o n t h e s t e r n u m to c u e m a i n t e n a n c e of t h e t h o ra c i c ky p h o s i s a n d to p reve n t l o s s o f n e u t ra l s p i n e i n to t h o ra co l u m ba r e x t e n s i o n . ( R e p rod u ced w i t h p e r m i s s i o n fro m © D i a n e G . Lee P h ys i o t h e ra p i s t C o r p . )

head. The elbows a re then straightened (triceps press movement) . The shoulders should not flex or ex tend; movement occurs only at the elbow joints. 2. Overhead flexion (ex tension control): keep the arms straight while eleva ting the arms through flex­ ion . The patient will require adequa te length in the latissim us dorsi m uscles to perform this progres­ sion with good control of the lumbar lordosis. The exercise can also be s ta r ted w i th the arms at the sides instead of at 90° flexion. 3. One-arm fly (rotation control) : keep the arm straight while l owering the arm through horizontal abduction one arm at a time. Palpate the dysfunc­ tional area (l umbar spine, SI]s) to ensure no loss of control of the neu tral position. Prog ress i o n s/ot h e r co n s i d erations Progress to lying on a ha lf-roll or other unsupported surface. Hand weigh ts can be added to increase the challenge to the spine whi le concu rrently streng thening the arm muscles. These exerc ises can be performed in sit­ ting, sitting on a ball, and standing. The upright positions require more awareness and spinal con­ trol. I f the triceps press and overhead flexion exer­ cises are performed uni laterally wi th alternating arm movements, both ex tension and rotational con­ trol of the spine will be challenged.

T r u n k a n d ar m dissociat ion - sitting Pa t i e n t p o s i t i o n Sitting on a firm surface, fee t flat on the floor, pelvis centered over the sitz bones,

1. Bila teral arm ex tension ( flexion control ) : the hands are a t shoulder level in front of the body, holding a resistive exercise band on slight tension . Both arms are pulled down to the sides as neu tral spine i s maintained ( the tendency will be to flex the spine and posteriorly tilt the pelvis to pull the arms down). Use the rib wiggle and the hip interna l and external rota tion tests to ensure that there is no trunk bracing and no "bu tt gripping. " 111e arms are returned smoothly to the starting position, control­ ling the movement against the pull of the resistive exercise band. This exercise can also be performed using pulleys . Unila teral movements will add a rota tiona I challenge. 2 . Diagonal arm extension: (flexion and rotation con trol) : start with one arm in ful l flexion and adduction (across the body), holding a resistive exercise band a ttached above and la tera l to the con­ trala teral shoulder. The arm is pulled down into extension and across the body into abduction ( to the ipsila teral hip) . The tendency will be for the pa tient to flex and rotate the spine and pelvis to facilita te the arm movement. The therapist uses manual and verbal cues to prevent this substi tu tion pattern. 3. Bila teral arm flexion w i th facil i ta tion from a resistive exercise band (extension control) : the patient starts with the elbows bent a t the sides and palms facing . A l ight resis tive exercise band is wrapped around the hands so that there is l ight tension pres­ ent (Fig. 1 0 .66) . Instruc t the pa tient to p ush gently into the band with the hands (5% abduction force), and then lift both arms into flexion as high as possi­ ble while controlling the spinal posi tion. The arms are then lowered to the side. The light resistive exercise band is thought to increase proximal pro­ prioceptive inpu t and assist in learning movement con trol. The start position for this exerc ise i s the same as that used in adding thoracopelvic rota tion control (moving out of neu tral spine, see below) .

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Fig u re 1 0. 6 6

M a i n ta i n i n g n e u t ra l s p i n e w i th load i n g : tru n k a n d a rm dissoci il t i o n - s itt i n g . B i l atera l a rm fl exion ( exte n s i o n control ) . The thera pist mon itors t h e r ig h t tra n sversus a b d o m i n i s co ntraction a n d p a l pa t es m u ltifidus b i l a te ra l l y a t t h e dysfu n c t i o n a l seg m e n t ; a co-contraction of the l oca l system s h o u l d be performed fi rst a n d t h e n to n i ca l l y m a i n ta i ned thro u g h o u t t h e a r m movemen ts. Th e sm a l l a rrows i n d icate the d i recti o n of the h a n d s press i n g i n to the resistive exercise band and the l a rg e a rrows i n d i cate t h e fl exion move ment of the a rms. (Repro d u ced w i th p e r m i ss i o n fro m © D i a n e G. Lee Ph y si o t h e ra p i s t C o r p .)

Prog ressions/othe r consid erations

Progress to sitting

on a ball or sissel, sitting with the feet on a ha lf-roll , or using other

llilS upp orted

surfaces to increase proprio­

c eptive cha llen ge . These exercises can be pe rformed in kneeling, s u p p orted s tanding, and standing. Dia gonal

arm pa tte rns can be p erform ed starting from either hip (Fig.

10.67)

and either shoulder (four p rop rio cep­

tive neurom uscular fa cili t a ti on are

(PNF) pa tterns) and

good for func tional integra tion and con trol of

combined extension/ rota tion and flexion /rota tion .

Fig u re 1 0. 6 7 Ma i nt a i n i n g n eutra l s p i n e w i th loa d i n g : tru n k and arm d i ssoc i a t i o n - s i t t i n g . U n i l a tera l fl e x i o n d i a g o n a l ( combi ned e x t e n si on and rota t i o n contro l ) . The p at i e n t m o n i to rs t h e l e ft tra nsversus a b d o m i n i s c o n traction t h ro u g h o u t t h e exercise. T h e r i g h t h a n d sta rts just l a t e r a l to t h e l e ft h i p and then p u l ls a g a i nst th e resistive exercise band d i a g o n a l ly i n to fl exion a n d a b d u ct i o n t o t h e e n d p o s i t io n , a s s h o w n . N o t e t h a t t h e re is a l o ss of t h e n e u t ra l p o s i t i o n of t h e thorax over t h e p e l v i s i n t o t h o raco l u mb a r exte nsion a n d ri g h t rota t i o n ( s h o r t arrow ) . This s h o u l d be corrected w i t h a cue to c o n n e ct the rig ht ribca g e to the l e ft hand ( d i a g o n a l a rrow ) . ( R e p ro d u c e d w i t h p e r m i s s i o n from © D i a n e G . L e e Physi o t h e ra pi s t Corp.) a b al l , 10.68). It is i mp o r ta n t to pr o gre s s

s t and in g, supported s tanding a g a in s t

or

s tanding (Fi g .

to

these func tional positions as ea rl y as possible. For the p a t ie nt with lwnbopelv ic-hip d y sf unc t io n,

a rm

movements in s upp ort ed s tanding are a useful

int e r m ed ia te s tep before standing trunk-hip d i s so ­ cia tion exercises such as a s q u a t can be pe rfor med . Once the

arm

m o v e ments are mas tered, the patien t

can be p rogr e s s e d t o

a

squa t (lower-ex tre m i ty exer­

cises). A t t h e la ter s tages of the rehab i l i ta tion e x e r ­ cise prog ram, ann movemen ts ca n be c o m bi ned

Tru n k a n d a r m d i ssoci a t i o n - sta n d i n g

with modified leg positions to ch a l l e n g e the base of

The same arm mov emen ts d esc ri b ed above and o ther v a riations can be performe d in supported

support fu r th e r a nd integra te a rm and le g move­ ment with sp in al contro l . For examp le, a spli t-squ a t

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Treating the l u m bopelvic-h i p dysfunction

Fi g u re 1 0. 6 9

M a i n ta i n i n g n e u t ra l s p i n e w i t h l o a d i n g : t r u n k

a n d a rm d i ss o c i a t i o n - fo u r - p o i n t k n e e l i n g . T h e t h e r a p i st's h a n d p a l p a tes the l u m bo p e l v i c s p i n e to e n s u re t h a t t h e l u m b a r l o rd o s i s i s m a i n ta i n e d d u ri n g t h e a r m l i ft a n d c a n a l so p rovi d e s p e c i f i c t a c t i l e fe ed b a c k a t the l e ve l s of p o o r c o n t ro l .

( R e p ro d u c ed

w i t h p e r m i s s i o n fro m © D i a n e G . Lee

P h y s i o t h e r a p i st C o r p . )

facilita tes

maintenance

of

the

neu tra l

thoracic

kyphosi s . The pelvis and lumb a r spine should be unsupported and free to move into

a

neutral posi tion

over the hips. If there is a res tric tion of hip flexion range of mo tion, p lace the knees farther away from the b a l l so tha t they are not directly under the hips. Exerci se i n structi o n

Cue th e linage that facilitates

a co-con traction of the l umb opelvic loc a l s tabilizers. Palp a te the TA F i g u re 1 0 . 6 8

M a i n ta i n i n g n e u tra l s p i n e w i t h l o a d i n g : tru n k

a n d a r m d i ssoc i a t i o n - sta n d i n g . U n i l a te r a l e x t e n s i o n d i a g o n a l

( c o m b i n ed

flex i o n a n d rota t i o n c o n t r o l ) . T h e p a ti e n t p a l pates

the l u m b osa c r a l m u l ti fi d u s b i l a te ra l l y at the dysfu n c t i o n a l seg m e n t to m o n i t o r p re c o n t r a cti o n a n d c o n ti n u ed ton i c a c t i v i ty d u r i n g t h e p e rfo r m a n ce of t h e a r m m o ve m e n t. T h e r i g h t a rm sta rts i n a b d u c t i o n a n d e l eva t i o n a n d p u l l s t h e res i s t i ve e x e r c i s e ba n d a c ross t h e b o d y to t h e l e ft h i p. ( R e p ro d u ce d w i t h

c u e . Ask the p a tient to keep breathing, and main tain a s ti l l spine as the a rm is lifted off the b a l l . This movement will chall enge e x tension control of the spine. Prog ress i o n s/ot h e r co n s i d e rati o n s

Progress to p er­

forming the exercise withou t support (Fig.

p e r m i s s i o n fro m © D i a n e G . L e e P h y s i o t h e ra p i s t C o r p . )

and multifidus at the dysftmctional

level(s), ensuring tha t recruitment occurs w i th your

from the b a l l 1 0 . 6 9 ) . Adding the challenge of a concu rre n t

contr a l a teral leg l i f t is a high-level exercise a n d requires significant con trol . Often t h e p a tient w il l s ta nce or unila teral s tanding against a ball on the

be able to pe rform e xercises in s upported standing

w a ll can be mainta ined while the a rms move in

and s ta n d ing posi tions before leg movements in

diagonal p a t tern s . Finally, the lower ex tremity and

fo ur-point kneeling are possible. Decisions abou t

the arms move together (a dyna mic l unge while the

how fa r to challenge control in any posi tion w i l l

performs a d iagonal pull) while continu in g to

depend on the pa tien t's functional demands a n d

arm

rec rea tional g o a l s (for example, i f the p a tien t per­

maintain neutral spinal a lignment.

forms a c tiv ities that requ i re prolonged forward­

Tru n k and a r m dissoc i ation - fou r- poi n t k neeli n g . fou r- poi n t k n eeli n g ove r a ball If p erformed correctly, these posi tions are useful for tra i n ing stability of the lumbopel vic region w h i l e

posi tions

then progressions

in

fo ur-point

knee l ing will likely b e i mporta n t ) .

Tru n k and leg dissociation - c rook ly ing

KneeUng p rone over a b a l l with

and their progressions by several a u thors (Hall & Brody 1999, Richardson et a l 1999, Sahrm a nn 200 1 ) .

positioned so tha t the c urve of the ball

Presented here a re some spec i fic examples a n d

m a in ta ini ng a n a w a reness of an o p e n b u ttock (pre­ Pati e n t position

Va rious leg loading exercises

have been descri b e d

ven ting " bu t t grippi ng" ) . the thora x

bent

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mod ified examples tha t w e find useful in trea ting patients w i th lumbopelvic-hip dysfunction. Pati e n t position Crook lying in neutral spine on a fla t s u rface . Exerc i s e i n st ruct i o n Cue the image tha t facili­ ta tes a co-contrac tion of the lumbopelv ic l ocal stabi­ lizers ("connect" to the local system). Palpate the TA and multifidus a t the dysfunctional level(s), ensur­ ing that recruitment occurs with your cue. Ask the p a tien t to keep breathing and m a intain the neutral position of the lumbar spine and pelvis while per­ form ing various leg movemen ts: l. Heel slides (ex tension/ rota tion and flexion / rotation control) : ens u re tha t the feet can slide on the s urface easily (have the patient wear socks) . Ask the p a tient slowly to slide one heel away from the trunk (Fig. 1 0 . 70a), straigh tening the leg as far as possible without losing control of the neutral lumbopelv ic position. P a lp a te the segment(s) of poor control to ensure tha t no rotation occurs in the lumbar spine or pel v iS. This phase of the exercise

challenges extension and rotation control; the re turn of the leg back to the flexed position chal­ lenges flexion and rotation control. The easies t pos­ ition to sta r t the slide from is the crook lying position; to increase the challenge, have the patient start the slide with the leg straigh t. The exercise can also be changed from a Single-leg slide to a lterna t­ ing slides (from moving one leg at a time to mov ing both legs at the same time, one sliding down while the other slides up) . 2. Bent knee fall-o u t (rota tion con trol) : from the crook lying position one knee is slowly taken to the side so tha t the hip abducts and externally rotates (Fig. 1 0 . 70b, a rrow ) . The other leg stays sta tionary. C a reful observ a tion and palpation is necessary to ensure tha t the pa tient is no t "butt gripping" and pushing the femoral head anterior. Palpa te at the A SISs or in the lumbar spine in terspinous spaces for rota tion con trol. To progress the exercise, straighten the non-moving leg (Hall & Brody 1999 ) . 3. Heel drops from 9 0 ° (extension control) : to attain the s tarting position, the pa tien t requires 90°

M a i n ta i n i n g n e u tra l s p i n e w i t h l o a d i n g : t ru n k a n d l e g d i ssoci a t i o n - crook l y i n g exerci ses. ( a ) H e e l s l i des i n croo k l y i n g . The thera pist pa l pates t h e l u m b osacra l m u l t i fi d u s b i latera l ly w i th t h e h a n d u n d e r the l o w back w h i l e t h e p a t i e n t pa l p a tes t h e tra n sversus a bd o m i n is (TA) b i l a te ra l ly. The heel s l i d es d o w n t h e bed ( w h i te a rrow) as fa r as the neutral s p i n e posit i o n ca n be m a i n t a i ned and then returns to the sta rt positi o n . Th e therapist's hand on the k n ee g u i d es t h e leg m ov e m e n t a n d perio d i ca l ly " w ig g l es" the knee l a tera l ly (hip i n tern a l and exte r n a l rotati o n , sma l l b l ack a rrows) to check fo r hip b ra c i n g . (b) Bent k n ee fa l l o u ts. The t h e ra pist pa l pa tes in the l u mba r i n te rs p i n o u s spaces to ensu re t h a t neutral i s m a i n ta i n ed (n o rotation occu rs) ; a l ternately t h e d e e p m u l ti fi d u s ca n be pa l pated. I n t h is exa m p l e the p a t i e n t pa l pa tes t h e p o i nts to fa c i l i ta t e the i m a g e of a d i a g o n a l con nection between the left TA a n d the r i g h t deep fi b e rs of m u l ti fi d us. (c) H e e l d rops fro m 90·. The thera p i s t p a l pates the TA and m u l tifi d u s o n the rig h t sid e ; the p a ti e n t pal pa tes t h e left TA and the stern u m . As t h e foo t is lowered tow a rds t h e ta b l e t h e te n d en cy w i l l be to l ose the n e u t ra l s p i n a l posi t i o n a n d m ove i n to exte n s i o n . Th e h a n d on t h e stern u m h e l ps to p reve n t thoraco l u m b a r extension. ( R e p ro d u ced with permission fro m © D i a n e G. Lee Physiothera p i s t Corp.) F i g u re 1 0. 7 0

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Trea t i n g t h e l u m bo p e l v i c- h i p dysfu n ct i o n

of hip flexion (any articular or myofascial restric­ tions need to be addressed fi rs t) . The pa tient lies w i th the hips flexed to 900 such that the knees a re v e r ti cally over the hip joints . The lumbar lordosis should be checked for a neu tral position . Cue a relaxation of the abdomina l wall and b re a thin g, and then ins truct t h e patient to "connect" to the local sta­ bilizers . Th e patient is then asked slowly to lower one foot, keeping the knee flexed, until the foot is p l a ce d on the floor (or until the spinal control is lost) (Fi g . 1 O . 7 0 c) . The foot is then l ifted from the floor and re tumed t o 90° hip flexion. Using the image "Keep the fold in the front of the hip deep and con­ trol the lowering of the knee from deep inside your groin" helps to prevent excessive activation of the tensor fascia latae and rectus femoris muscles. Progress the exercise by ha v in g the p a tient extend the knee as the foo t is lowered (increa se the lever arm ) . Th is exerc ise is a usefu l precursor to any

exercise that involves lifting one foot off the grOLmd in supine or si t ting . It is also a key exercise to prescribe for those patients who have poor eccentric control in the hip flexion phase of the one-leg s tanding tes t. 4. Hip join t control progressions: these progres­ sions are aimed at reducing tensor fa scia la tae, rec­ tus femoris, and sa rtorius activity du ring h i p flexion, and facilitate the underlying iliopsoas for con trol of the joint axis during mov emen t. The ther­ a pist and pat i en t shou ld palpate around the grea ter trochan ter and feel the activity in the l a teral muscles during the exercise. The first level begins with the foot supported on a wall, w ith the hip flexed approxima tely 70-8 0 ° . The local system is precon­ tracted, and then the patient is asked to " imagine an energy deep in your groin tha t is deepening your hip groove, and then fold the h i p so tha t your knee comes towards your body" ( F i g . 1O.71a). Ankle plantarflexion ( heel l i ft) can be used as a n assis t to

Fig u re 1 0. 7 1 M a i n t a i n i n g neu tra l s p i n e with loa d i n g : tru n k a n d leg d issoci a t i o n - h i p c o n t ro l p rog ressions. (a) I n n er-ra n g e h i p fl e x i o n o f f wa l l . The p a t i e n t pa l p a tes i n t h e a n terior g ro i n w h i l e t h e thera p ist p a l pa tes t e n s o r fascia l a ta e , rectu s fe m o ris, a n d sa rt o r i u s la tera l ly. The pa t i e n t's l eft h a n d p a l pates tra n sversus a b d o m i n i s (TA). T h e i d ea of t h e fe m u r s i n k i n g (ve rtica l a rrow) a n d t h e h i p h i n g i n g w i l l fa ci l i ta te proper rec r u i t m e n t a n d pa ttern i n g . (b) A resistive exercise b a n d assist d e c reases t h e a m o u nt o f l o a d t o c o n t r o l . I n t h i s exa m p l e t h e t h e ra pist i s p a l pa t i n g TA b i l a te ra l l y to m o n i to r t h e to n i c a ctiva t i o n d u ri n g t h e exercise. (c) M o v i n g i n t o o u te r ra n g e. I n this exa m p l e t h e p a t i e n t p a l pates a co-con tract i o n o f t h e l e ft TA a n d ri g h t m u l t i fi d u s w h i l e t h e t h e ra pist m o n itors s p i n a l pos i t i o n . A s the l e g m oves i n to t h i s o u t e r - ra n g e positi o n , t h e s u pe rfi c i a l h i p fl exors w i l l t u rn o n to s o m e d e g ree b u t t h i s a ctiv i ty s h o u l d n o t res u l t i n rig i d i ty of the h i p j o i n t. ( R e p ro d u c e d with p e r m i ss i o n fro m © D i a n e G . L e e Phys i o t h e r a p i s t Corp.)

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T H E P E LV I C G I R D L E

get the

foo t off the wall. Alte rna t el y, i f there i s exces­ sive tensor fascia l a tae, rectus femoris, or sartorius a c tivi ty then use a resistive exercise b a n d around the thigh to act as an assist to the hi p flexion move­ ment (Fig. 10.71b) . At this inner range with the knee vertically over the hip the re should be l i ttle need for a l a r g e contribu tion by the g lob a l hip muscles. The exercise is progressed by mo v in g the p a t ient fa rther and farth er away from the w a l l . Final ly, the exercise is pe r for med o v e r th e e dg e of a table so tha t th e foo t c an be lowered past the level of the table and the h ip can move into full extension (Fig . 1 0 .7 1 c) . Pro g ressions/other co nsi derati ons P rogre ss to lying on a half-roll or other unsu ppor te d surface. Initially th e patient will onl y be able to move the l eg through a sma ll range of motion. As control improves, the leg can move through a l a rge r range of motion. It is important to te a ch p a tients what it feels like when they lose control so tha t the exercise can be monitored and progressed at home . Be sure to use the rib wi ggle, hip in te ma l and ex ternal rota tion, and to monitor l a t­ eral costal expansion b re a thing d uring the exercises to prevent excessive activation of the global muscles. Lifting the wei gh t of the le g off the fl oo r and l owe ring the l eg into a fully ex te nde d position are hi gh-l e v el exercises, especially in those pa tie n ts with muscular legs. In these cases, exercises in more uprigh t pos­ itions such as Si tting and su pp o rt e d s tand ing can be added to the exercise pro gr am before the higher pro­ gressions of le g lo a d ing in supine are achieved . Tru n k a n d l eg d i ssoci a t i o n - p ro n e Patient positi o n Prone ly ing, with the lumbar spine in neu tral p o s i tion . Pillows or towels under the abdomen or thorax can be used to obtain the c or re ct a lignme n t. Exercise i n struction Instruct the patient to think of the i ma ge that facili t a te s the desired l o c a l muscle co-contraction, p a lp a tin g the TA and multifidus to provide feedback and check recruitment. Ask the pa tient to bend one knee t o 90° flexion, l i f tin g the foot and then l ow er i ng it to the table (Fig. 10.72). Repeat on the other s i d e . Oth e r consi derations This movement can a ls o be used as a test for effective load transfer. Before cue­ ing a local system contrac tion, ask the p a tien t to bend the knee (wi thou t thinking of controlling the pelv i s or sp ine) . Palpate the inn ominate and the s a c r u m as the movement is p e r fo r m e d . If the innom­ ina te an te ri o r l y rotates rela tive to the sacrum, espe­ ci a lly in the early stages of the movemen t as the and p e lv is

F i g u re 1 0 .72

M a i n t a i n i n g n e u tra l s p i n e w i t h l o a d i n g : tru n k a n d

l e g d i ss o c i a t i o n - p r o n e k n e e b e n d . I n t h i s e xa m p l e t h e th e ra p i s t i s p a l p a t i n g t h e s a c ra l m u l t i fi d u s b i l a te ra l l y to e n s u re t h a t

a

preco n t r a c t i o n a n d co n t i n u e d to n i c a c t i v i ty of t h e d e e p fi b e r s i s m a i n t a i n e d w h i l e t h e pa t i e n t l i fts t h e r i g h t fo o t fro m t h e ta b l e a n d b e n d s t h e k n e e . T h e t h e ra p ist a l so m o n i to rs m e d i a l a n d l a t e r a l h a m s t ri n g a c t i v i t y fo r e q u a l recru i t m e n t . T h e pa t i e n t c u e s a n d m o n i to rs t h e tra nsversus a b d o m i n i s a n t e r i o r ly. ( R e p rod uced w i t h p e r m i ss i o n from

©

D i a n e G. Lee Phys i o t h era p i st C o r p . )

of the leg is m o ve d and before tension occurs the rectus fe m o ri s muscle, this is considered a positive test for failed load transfer of the SIJ. Palpa tion of the medial and la teral h a m strings often reveals a s ymm etr ical activation. Manual stabiliza­ tion of the srJ (nutate the sacrum ) often makes the movement easier to initiate a nd ch an ge s the balance in the recruitment of the medial / lateral hamstrings. If this tes t is positive, the S1] m u s t be monitored d W"­ ing the performance of the exercise to ens ure th a t the local muscle co-contraction controls the neutra l zone; the pa tient can moni tor the innominate anteri­ o r ly with a hand under the ASrS to feel for any ante­ rior rota tion. For this specific p a tien t, exercises s u ch a s r e si ste d h am st ring curls without conscious local control of the SIJ us ua l ly increase and perpetuate symp toms . These p ati e n ts often c omp l a in of vague medial or la teral h a ms t rin g a ching or insertional ham str ing p a in unrela ted to a tra umatic incident. A sp ec i fi c hamst rings muscle test may rev e a l "weak­ ness"; however, on retes ting the hamstrings s tren g th with the SIJ manua lly stabilized ( n uta ted), the strength will be normal. This i llus tr at e s the impor­ tance of monitoring for proxima l c on t rol as the lower l imb is a d de d in exercise pro g ress i on s . we ight in

Tr u n k a n d l e g d i ssoci a t i o n - s i tt i n g

In this position exercises can foc us on ei ther move­ ment of the trunk on the hips or movement of the legs un der the trunk.

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Tre a t i n g t h e l u m b o p e l v i c- h i p d ysfu n ct i o n

ability to control spinal position dming the sitting lean-forward movement in s ubjects with and with­ out low back pain. They found that low back pain pa tients showed a consistently earlier loss of control of the neu tral position, and that the displacement of the curvature between TI2 and S2 in low back pa in subjects was almost twice the displacement in non­ low back pain s ubjects. Sitti n g

knee exte n s i o n

o r h i p flex i o n

-

patient

Si tting in neutral spine (optimal lumbo­ pelvic pyramid), fee t supported on the floor; to progress the exercises have the patient sit on a ball or other uns table surface. Exercise i n st r u ct i o n "Connect to the d eep loca l s tabilizers, then slowly let the foot slide on the floor a s you straighten one knee. Keep the curve in your low back and you r spine still as you move the leg . " Or, a s k the pa tient t o palpate the anterior hip i n the groin and lift the heel (ankle planta rflexion), feeling the anterior hip fold, keepin g the "ou tside mu scles " ( tensor fascia latae) relaxed, and keeping the weight equal on the b u t tocks as the hip flexes. Alterna te with the other foot. This exercise can be progressed to li fting the toe off the ground, which is a much higher load, especially in pa tients with long or mus­ cular legs. I f training hip flexion / ex tension control is an important component for the p a tient, this e xer­ cise should be used in conj unction with progres­ si ons in the s upine position above. positi o n

F i g u re 1 0.73

leg

d i ssoc i a t i o n

tru n k

and

- s i tti n g l e a n -forward. T h e thera p ist pa l p a tes

the

M a i n ta i n i n g

neutra l

spine

with

load i n g :

lordosis posteriorly a n d t h e ri g h t h i p c rease ( n o t v i s i b l e ) . N e u tra l spine posi t i o n s h o u l d be m a i n ta i n e d as the p a t i e n t a n terio rly t i l t s the p e l v i s fo rwa rd over t h e fem u rs ( w h i te a rrow) ; i n this exa m p l e the p a t i e n t h a s mov ed i n to exte n s i o n in the l o w e r thorax as the exercise is atte m pted ( b l a c k arrow) . (Re p rod u ce d w i th per m is s i o n from © D i a n e G. Lee Phys i o t h e rapist Corp.) l u mbar

S i tti n g l ea n -fo rward - patient p o s i t i o n Sitting on the edge of a plinth, cha i r, or ball. If there is a restric­ tion of hip flexion, the s u rface should be high enough to allow the p elvis to flex over the femoral heads. The fee t are supported on the floor. Exe rci se i n str uct i o n C ue a neutral sp ine position (optimal lumbope lvic pyramid) and palpate the a nterior hip crease (unila terally or bilatera lly). Have the pa tien t "connec t" to the local system, and then instruct the p a tient to hinge at the hips to bring the trunk forward over the hips while keeping the spine neutral (Fig. 10.73) . Onl y allow movemen t through a range of motion where there is no loss of neutral spine. Start with smal l amounts of movement and progress to larger ranges. This exercise can be pro­ gressed to standing (Sahrmann's "w aiter 's bow" (2001)) . Ha milton & Richardson (1998) studied the

Tru n k and l eg d i ssoc i a t i o n - fo u r- p o i n t k n ee l i n g I f performed correc tly, these posi tions are useful for training s tability of the lumbopelvic-hip region while main taining an a wareness of an open b u ttock (preven ting "butt gripping") . The "hip rock" exer­ cise (Fig. 1 0 . 24) and the "hip rock' n ' roll" exercise (Fig. 1 0 . 25) for mainta ini.ng hip m obility can be combined with a co-con trac tion of the deep s tabil­ i zers to incorpora te mobi lity tra ining w i th l umbo­ pelv ic s tability training . Exercises involving li fting one leg from this posi tion require Significantly higher levels of stability and should be added la ter in the rehabilita tion p rogram . Examples include one-leg lifts, a lterna ting a rm / l e g lifts, and leg press into ex tension against a resistive exercise band (Fig. 1 0 . 74) . The lumbopelvic position must be ca reful ly moni tored to ensure no til ting o r rota tion .

Tru n k a n d l eg d i ssoc i a t i o n - su pported sta n d i n g Standing in neu tral spine against a The feet are approximately 1 5 c m (6 in.) away

Pa t i e n t p o s i t i o n

w a ll .

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F i g u re 1 0 . 7 4 M a i n ta i n i n g n e u tra l s p i n e w i t h l o a d i n g : tru n k a n d l e g d i ssoci a t i o n - fou r-po i n t k n ee l i n g . Resi stive exercise b a n d l e g p ress. T h e p a t i e n t fi rst fi n d s a n e u tra l s p i n e pos i t i o n . A resistive exercise b a n d is w ra p ped a ro u n d t h e h e e l a n d a rch o f t h e worki n g foo t ; t h e o t h e r e n d i s h e l d secu re w i t h t h e i psi l a te ra l h a n d . W i t h a p reco n t ra c t i o n o f t h e loca l sta b i l izers , h i p exte n s i o n a n d k n e e exte n s i o n a re penfo r m e d b y p ress i n g back i nto t h e resistive exercise b a n d . H e re , the t h e ra p i s t c u es t h e ma i n te n a nce o f t h e t h o racic c u rve and e n s u res a co n ti n u e d con tra c t i o n of the l u m bosacra l m u l t i fi d us thro u g h o u t t h e exercise. T h e p a t i e n t has lost s o m e of the u pper l u m ba r l o rd o s i s ( a rrow ) d u e to overrec u i t m e n t of the o b l i q u e a b d o m i n a Is. ( R e p roduced w i t h perm issi o n fro m © D i a n e G . Lee Physio t h era p ist Corp. )

from the w all. The hips should be in approx imately

20° flexion, so tha t the pelvis and spine are inclined fonv a rd o n the hips and the upper thora x and head a re a way from the wall. The hi ps should be in neu ­ tra l rota tion, the knees flexed under the hips, the second toe of each foo t in line w i th the

mi ddle of the

p a tell a, and equal bod y weight distrib u ted over each foo t . In correcting techniq ue and posi tion in the s tanding posi tion, i t is importa n t to use all of the

F i g u re 1 0 . 7 5

M a i n ta i n i n g n e u t r a l s p i n e with load i n g : tru n k a n d l e g d isso c i a t i o n - s u p po rted sta n d i n g . T h e c h i c ken : t h e p a t i e n t sta rts by fi n d i n g n e u t ra l s p i n e i n s u p ported sta n d i n g . I n t h i s exa m p l e t h e pati e n t i s pa l pa t i n g a n d s e l f- c u e i n g t h e tra n sversus a b d o m i n is c o m p o n e n t b i l a te ra l ly. T h e a r rows i n d icate move m e n t of t h e kn ees fo r t h e c h i c k e n exerc i se. ( R e p rod uced w i t h p e r m i s s i o n fro m © D i a n e G . L e e Phys i o t herap ist Corp. )

c heckpoints for global rigid i ty from the ribcage to the toes .

both knees are moved in the same direc tion simultan­

Exercise i n struct i o n

Advise the p a tient th a t move­

ment is to occur only in the legs; the spine stays still and suspended by the

"guy

wires. " Have the patient

" connect" to the local sys tem, and then continue brea thing while

m oving

the knees

in and

out (hip

in ternal and e xternal rotation) . For the chicken exer­ cise the righ t

and

left knees a re moved away from

1O.75) . lf the pa tient will be a restric tion of the

eously. This p roduces more rota tional challenge to the lumbopelvic position . The pa tient should feel equal pressure on both sides of the b uttock during both of these exercises,

indica ting that there is no rota­

tion of the pelvis occurring. Both the chicken and the skier can be

performed

in v a rying amounts of knee

and hip flexion (deeper squat posi tion) .

each other and then together (Fig . is "butt gripping " there

movement. Al ternately, the patient may have more difficu lty controlling one hip than the other (sh udd ers

Tru n k a n d l eg d issoc i a t i o n - sta n d i n g fl exion control

of movement, uneven speed of movement) . The focus

Pa t i e n t

should be on smooth, even movement of the legs

shoul der- wi d th a p a r t .

under a s table lumbop elvis and spine. The fee t are

exercise the w eight of the upper body and trunk can

a llowed to roll in and out as needed, but not exces­

be su pported by res ting the hands on the back of

sively.

a cha i r or counter.

111e exercise is progressed to the skier, where

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position

S t anding in neu tra l spi ne, feet

In

the ini tial s tages of this

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Tre a t i n g t h e l u m b o p e l v i c- h i p dysfu n ct i o n

::J

Exercise

Adv ise

instruction

p a tien t

the

tha t

movemen t is to occ u r only a t the hi p s; the spine

s tays still and sus pended by the

"guy

wires . " Have

the p a tient connec t" to the loc a l system, then imagine "

ben d i ng forvvard " l ike

hips

the

as

a

Barbie doll," hinging a t

the buttocks move b ackwards a n d the

forvvards ( wai ter

s bow

Sahrmann

trunk

moves

2001) .

Only al low forwa rd inclina tion of the trunk as

far

the lumbar lordosis can be maintained. The

as

trunk then retu rns to the

palpa tion

'

upright

-

position . Useful

points for the pa tien t are in the l um ba r

lord osis, or aro und the greater trochanters to feel t he hips

"

fo lding

"

and moving bac kwa rd s . Ensure tha t

t here i s s ymme tr i ca l flexion o f th e hips .

Tru n k a n d l e g d i ssoc i a t i o n - sta n d i n g rota t i o n control Pa t i e n t po sition

S t and in g in neutr a l spine,

with

the

legs in sta nce p osi t i on The back leg is supported on .

the ball o f the foot ( heel l i fted ) . Wei ght is

the

foc used on

front leg. Ens ure tha t the knee faces anterior

w i th t he mi d d le of the pa tella in line

with

the hip

join t and the second toe. Exerci se

Cue

in struct i on

recrui tment

the

l u m b opel v i c local muscles . Instruct

keep the leg still

and the

of

the

p a tie nt to

knee forward w hile ro t a t

­

ing the pelv i s and trunk as one unit over the leg

F i g u re 1 0. 7 6

M ain tain i n g n e u t ral spine w i t h loading :

(spin the pelvis over the femoral hea d ) . C ue the

tr u n k and leg di ssociation - standi n g rotation con tro l ,

ini tia tion of the ro ta tion movement to corne from

unila teral weight - b earing. Th e t h era p i s t mon i tors t h e

just ins ide p e l vi s ) .

fe m ur and rest o f the lower extre mity should rem ain still as

the ASIS

Progress i o n s/othe r

(the

move ment comes from the

considera tion s

Do not

a llo

w

any l a teral or pos terior pelvic til ting as the pe lvis rota tes. Monitor the knee and g i ve tac tile c ues to

keep the knee fac ing forward, a n d the hip centered (no "butt grip pin g " ) . M onitor the seg men ts

of

poor

at the SIJ (sacrum and inn ominate) or the l u mb a r spine. Progress the exercise to weight­ bea ring only on the fron t leg (Fi g . 10.76) . Al terna tely, l a teral con trol of the pelvis on the innominate can be tra ined by h a v i n g the p a t ie n t perform a con trolled

m ain ten ance o f the pos i tion of t h e wei gh t-bearing l eg ; t h e the pelvis rotates to t h e right ( arrow) an d to the left. In this exa mple, for rig h t rotati on of t h e pelvis the pat ient thinks of a po int m edial to the right anterior s u perior iliac spi n e and i magines drawing t h e pelvis back fro m that poi n t ( w h ite circle )

( Re produc ed with

perm ission from © Dian e G. Lee

Phys i otherapist Corp. )

control, either in

drop of the pelv is on the front hi p, then return the pelvis t o neutral la teral ti l t by

u s in g

the gluteus

medius. This mo vement should be carefu lly moni­ tored to ensure t h a t the opposite rum

is not perfoffiling

qu a d r a tu s lumbo­

the movement.

i n ter ve r te (innominate / fem ur) rela ­

The therapist must carefully moni tor the bral,

in tr a p elv i c,

and hip

tionships d uring these there is equal

­

m ove m e n ts to ensure tha t

m o vemen t

and l o a d ing occ urring

at

each segment and from e a c h component in the kinetic

chain

o f movement. For fu nc t i ona l load

tra nsfer, the hy perm o bil e segmen t(s) must be con­ trolled during c ha nges in

thoracopelvic o rie n ta t i o n integrated functional

and as a c o m p onen t part of an kinetic

chain

movement.

Changes in the thora copelvic o r i e n ta ti o n

MOVI N G OUT O F NEUT R A L S P I N E

will

res u l t in movemen t in the l u m b a r spine: flex ion, Control o f movemen ts o u t o f n e u tr a l spine i s essen­ tia l fo r s tability

d u r i ng

ma ny functional activ i ties .

ex tension, l a tera l bending, rota ti on, o r comb in­ a tions of these mo vemen ts . The ability to control

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T H E P E LV I C G I R D L E

thoracopelv ic movement is an e s sentia l re q uire m en t of many fu nc tiona l a c tivi tie s , from tho se a s b a s ic a s w a lking to more compl ex sport maneuvers. Exercises can be des i gne d such tha t the thorax moves on th e pelvis or the p e l v is moves under the thorax. These e x erci s e s focus on tra ining the abili ty t o d issoci a te movement of the thora x from the p el v is and vice ve r sa . Some e x a m ple s are pro v i d ed here, and then the concept is app lied t o re tr ainin g the p elv ic co m p one n t of a func t i o n a l m o v e m en t ( th e golf sw ing) . U l ti m a t el y, re storin g op ti m a l movement specific to a p a t ien t s a c t ivi tie s re q u ire s bre a king do w n com ­ p le x functional, work, o r sport m o v emen t s i to comp onen t p a r t s Once a b a s e of isola tion / recruit­ ment and co-con traction endurance has been e s t a b ­ l ished for the l umb opel vi c loca l s ta bili ze r s and in t eg r a ti on of the gl o b a l s y ste m h a s p ro g re ss ed to the po in t where func tiona l p o si tion s can b e a tt a ine d, training of componen t p a r t s of work- or s po r t s peci f i c mo v e m ents can be g in The first s tep for thi s ca t e g or y o f movement re tra ining inv ol v e s teaching control of the tho r acopelv ic movemen t co mponen t ­

'

n

.

-

.

.

Thoracopelvic control - rowin g bac k Pat i e n t positi o n

The p a t ient s t a r t s si tting

knees bent on a plinth o r be placed b e tween

the

with the

floo r. A small b a ll can

the upper inn er thighs t o faci l i ­

ta te a "connection" t o th e a nter i o r p e lvic floor and ma in tenance of neutr a l

hip a li gnm e n t s q ueeze d,

exercise. The b a l l is not to be

d u rin g the but merely

hel d in pl a ce by the thi ghs sink ing into the sides of the ba ll . Co rrec t for neutral sp ine p o s i t ion (op timal l u m b opelvic p yramid), then c ue a re c ru i tmen t of the l u mbo p e l v ic l o c a l stabilizers. Exercise i n st r u cti o n Ask the pa tient to m ain ta in the po s i ti on of the thorax and sho ulders a nd g entl y ro l l s l i gh tl y back on the pel v i s ( p os te r ior l y tilt) (Fig. 1 0 . 77) . Only a sm a ll movement is re quired . The p a ti en t is then asked s l ow ly to ro tate the thorax to the right and then to the left, i ma gining tha t the ribcage is a lid on a jar tha t is t u rnin g w hile the j a r (pelvis) stays s t i l l The thera p is t p ro v id e s manual feedback to ensure tha t the dis tance between the rib c age and iliac c rests d o e s no t c h a n g e and tha t no lateral shift o r collapse o f the thorax occ ur s d ur ing the ro tation. The pelvis should not ro tate as a uni t or underg o any intr a p e l v i c torsions. This exercise trains flexion and rota tion control; a l te rna tel y cue­ ing p u re rota tion only ( n o p e lv i c til t ) will train ro ta­ tion i n n e u tral spin e . .

,

F i g u re 1 0 . 7 7

M o v i n g o u t o f n e u tra l s p i n e : t h o ra c o p e l v i c

c o n t ro l . R o w i n g b a c k . T h e p e l v i s i s s l i g h t l y ro l l ed b a c k p r i o r t o rota t i n g t h e a rm s a n d t h ora x t o t h e ri g h t a n d l e ft. T h e p e l v i s re m a i n s fa c i n g fo rwa rd t h ro u g h o u t t h e e x e r c i s e ( n o rota t i o n i n t h e tra nsverse p l a n e ) . ( R e p ro d u ced w i t h p e r m i s s i o n fro m

© D i a n e G. Le e P h ys i o t h e ra p i st C o r p . )

T horacopelvic con trol - bridg e and rotate Pat i e n t p o s i t i o n

The p a ti e n t s ta r ts in crook l y i n g

.

C h ec k fo r la t era l co s tal

ex p an s i on d u rin g b rea t h i n g. E x e r c i se i n structi o n At the end o f a b reath out, cue a co-con tra c tion of the deep local s ta b i l i z e r s , th en in s t ru c t the p a tien t t o roll the p el vis back into a p o s t eri or p e lv ic tilt by p u sh ing throu g h the feet a n d li f t in g the hi p s off the fl oor. C u e a con tin ued lumb a r s pine flex io n a s the hip s are lifted. The m i d - thorax rem a in s on the floor. A t the top of the "bridge" pos­ i t ion, the p a tie nt is a s ked to release the hips and p elvi s into a neu tral p elv i c tilt position ( "let the b u t­ to ck s drop a n d the h i p c reases fold " ) , crea t in g a neutral l u mba r lord osis. Once th is is m a s tered, rota­ tion of the pel v i s under the thorax is a dded ( rotate the j a r under the lid") (Fig. 1 0 . 78 ) . Cue fold in g of the hip as the pelvis is slowly rotated to one s ide; to re turn t o neu tra l , ha v e th e p a tien t think of d rawing the pe lv i s u p from j us t inside the ASIS. Repeat th e rota tion to the opposite s id e . Movement must be "

controlled th rou g h both p hases

of the rota tion. s tarting po s i ti on by flex in g the thorax net the c h es t go heavy"), then flex ing the lumb a r s pin e ( "bring your low back down to the bed"), and fina lly relea s in g into a ne utr a l lumba r lordo s is ("let the pelvis tilt fo r w ard and t h e bu ttocks go w i de " ) . M o d i fi cati o n s/co n s i d e ra t i o n s In p a tien ts with a poor connection to the i r a n ter io r ob li q ue s l in g (oblique abdomina Is and co n trala tera l ad d uc tor s ) , a ball b e tween the upper inner thi g h s can be used to fac i li t a te control d uring the exercise. If the r i bca ge extends uni l a te r a l l y d u ring the movements (loss of Re tu rn to the

Copyrighted Material

Tre a t i n g the l u m bo p e l v i c- h i p d ysfu n cti o n

F i g u r e 1 0. 7 8 M o v i n g o u t of n e u tral s p i n e : t h o ra c o p e l v i c con tro l . B r i d g e a n d r o t a t e . From n e u tra l s p i n e i n a b r i d g e posi t i o n , t h e patient i s rota t i n g t h e pelvis to t h e ri g h t ( a rrow ) w h i l e m a i n ta i n i n g the thoracic pos i ti o n . Th e therap ist c u e s control of t h e rig h t fe m u r i n n e u t ra l a l i g n m e n t a n d pa l pates the l u m b a r m u l ti fi d us. The pelvis retu rns to n e u tra l by p u l l i n g t h e l eft a n terior su perior i l i a c s p i n e back. ( R e p ro d u ced w i t h perm i s s i o n from © D i a n e G . Lee Phys i o t h e ra p ist Corp. )

neu tra l thoracic spine position),

then

the EO com­

ponent of the an terior oblique sling needs to be

of tens i on your l ef t r ibcage and the right ASIS throughout t h e exercise" ) . Al t ern a tely, for p a tients with a poor connection to the i r la teral s l in g (es p e­ c i a l l y the gl u t eu s medius portion), a r es is ti ve exer­ cise b a n d can be tied aro und the th ighs to facilitate better con trol d ur i ng the exerci s e . cued on th a t side ( " th ink of keeping a line

between

Thoracopelvic contro l - l a tera l be n d i n g The patient sits o n a b a l l in n eu tr a l w e ig h t centered over the sitz bones and the sp ine s u spe n ded by co-contraction of the lo c a l sta bil izers. Exercise i n structi o n The p a ti en t is a sked to k e ep the thorax s t i l l and s uspended in space, while the p elvis is rocked la tera l ly side to si de, ind ucing l a t­ eral ben d ing of the lumbar s pine . Ens ure that la t e r a l costa l ex p ansio n con tinues with bre a th ing, and that the movement is smoo th in b o th the concentric a n d eccen tric phases in both d i rec ti o n s . Pat i e n t p o s i t i o n

spine, with the

Tho r a co p e l v i c control - sta n d i n g tru n k rota t i o n posit i o n The p a t ie n t s tands i n ne u tral with the fee t hip - w id th apart. A ligh t- resis t ance exerc ise band is w rappe d aro und the hands with the palm s facing each o ther and shoulder- w i d th apar t. The hands s ta r t re laxed in front of the pa tient . Pa tient

spine

F i g u re 1 0. 7 9 M ovi n g o u t o f n e utra l s p i n e : t h o ra co p e l v i c c o n tro l . Sta n d i n g tru n k rota t i o n . The t h e ra p i s t p a l pates t h e tra n sversus abd o m i n i s b i l a te ra l ly w h i l e a lso p rovi d i n g fe edback to keep the pelvis sti l l and fa c i n g fo rward d u r i n g t h e t h o r a c i c rota t i o n . ( R e p ro d u ced w i t h p e r m i ss i o n from © D i a n e G . Lee Phys i ot h e r a p i s t Corp. )

a gainst the resistive exerci se band (5% e ffort), then raise the arms w i th the elb ows bent until the ha nds

a re a t approximately eye leveL The s p i ne should remain neu tra l d u ring this mov ement. E x e r c i s e i n st r u c t i o n The p a t ie n t is then asked to rotate the thorax to the right (Fi g . 1 0 . 79) a n d to the left while brea thing and m ain t a ining the d i s ta nce b e tw ee n th e ribc a g e and pelv i s . The use of the resist­ ive exe rcise b a n d and a rm eleva tion i s tho u gh t to increase p r o x i m a l proprioce p ti on and p reven t c ol ­ l a p s e of the ribcage or over a c t iva t i o n of the l a tis­ sim u s d orsi du ring th e trunk ro t a tio n.

T h o ra co p e l v i c contro l - sta n d i n g p e l v i c rota t i o n with lumbopelvic d y sfunc ti on often have dissocia ting pelvic rota tion from the

Cue a connection to the loca l stabilizers, then a s k

Patien ts

the p a t ie n t gently t o abd u c t the sho ul d e r s to push

d iff ic u l ty

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229

230

T H E P E LV I C G I R D L E

t hora x . This affects performance of many func tional and sport activities . This exercise can be applied to a variety of sport maneuvers; the s tarting position may vary but the principles are the same. For golfers, thjs exercise re tra ins the use of the pelvis for rota tion d u ring both phases of the swing by first isola ting the m ovement a n d then in tegrat ing i t into p roper timing of the swing. Pat i e n t position The p a tient starts standing in a neutral spine position. Cue a connec tion to the lumbopelvic local s tabilizers, then have the patient assume the position of the s tart of a golf sw ing (the approach to the ball, holding an imaginary golf club). The therapist checks for e q ual flexion of the hips an d maintenance of the neutra l lumbopelvic curve. Exe rcise i n structi o n Main taining the local stabi­ lizer co-contraction and brea thing norma lly, the p a tient is then asked to rotate the pelvis under the thorax in the direction of the backswing, inj tiating the movement from j us t inside th e ASIS on the same sid e (Fig. 10.80) . The movemen t will be smail, and no movement in the thorax should be noted. The patient is then asked to rotate the pelvis in the opposite direc­ ti on fully, again, initiating from j ust inside th e ASIS on the same side as the rotation (into the swing and follow- through d irec tion). The pa tien t then returns to the neutral starting posi tion. This pel vic movement is practiced at slow speeds to begin w i th and then the other components of the golf swing are added . For the backswing portion, the sequence would proceed as follows: pelvis rotation, then thorax rota tion but no a rm back swing � pelvis rota ti on, thorax rota tion, then arm back swing � aU three movements toge ther at slow pace � a Ll three movements at fa ster speeds. The other p a r ts of the swing are simi­ larly broken down, practiced, and reintegra ted .

I n teg rated fu n cti o n a l k i n et i c c h a i n A t this stage in the rehabilitation exercise progra m the p a tient should be performing several of the functiona l integra tion exercises (see below) tha t involve maintaining the neutral spine position and mov ing the trunk over th e h ip s or moving the arms i n rel ation to the trunk. As the pa tient lea rns to perform exercises moving out of neutral spine suc­ cessfully (above), exercises tha t incorpora te an increa sing number of j o ints in a movement chain are added . The previous gol f simula tion exercise is an exa mple of this p rogression for one specific a c tivity. O ther exercises a re described below, b u t t h e rea der sho u l d recognize that by following the

Fi g u re 1 0. 8 0 M ovi n g o u t of n e u t ra l s p i n e : t h o racopelvic c o n t ro l . Sta n d i n g p e l v i c rota t i o n . The t h era pist s u p po rts t h e ribcage to i n h i b i t m ovem e n t o f the t h o ra x as t h e c u e i s g i ven t o " d r a w t h e rig h t h i p b o n e [ a nt e ri o r s u peri o r i l i a c s p i n e ] b a c k " to s p i n t h e p e l v i s u n d e r the t h o ra x ( a rrow ) . The ri g h t h i p u n d e rgoes fl e x i o n and rela tive i n te r n a l ro t a t i o n d u r i n g t h i s movement. To re t u rn to n e u t ra l and move i n to left rota t i o n , a s i m i l a r i m a g e is used fro m j ust m ed i a l t o t h e l eft a n terior s u p e r i o r i l i a c s p i n e . ( R e p rod uced w i t h perm i ssi o n from © D i a n e G . Lee Phys i o t h e ra p i s t Corp. )

princip les p resented in this chapter, many more exercises can be create d tha t a re speci fic to each p a tient's work, sport, a nd recrea tional goa ls.

F U N CT I O N A L I N T E G R A T I O N Many func tional activities req u i re the a b i li ty to ma intain neutral s p ine "vh i le moving the trunk on the hips (squa tting to si t down), mov ing the arms on the trunk (driving), or both of these movements simul taneously (li fting) . In addi tion, activities of daily li fe, work, and sport re q uire the abi l i ty to con­ trol movemen ts of the spine in and out of ne utral while the a rms and legs a re moving. Certain activ­ i ties may require prolonged positions such as si tting

Copyrighted Material

Treati ng the lumbopelvi c - h ip dysfunction

at a desk or kneeling whi l e leaning forw ard to work

w i th excessive bracing in the glob a l sys tem is

w i th the hands. These d ifferent func tional condi­

unable to use these small dampening movements to

tions illus tra te th a t b o th dynamic and sta tic control

maintain s tability and postural equilibrium. Pa tients

of the spine need to be tra ined, in both the neutral

can use the checkp o ints for global rigidity period­

and non-neutra l position of the spine .

ica lly while in prolonged positions to ensure main­

In order to facilita te the au toma tic and toruc

tenance of mobile stab i l i ty.

func tion of the local s tabili zing muscles, it is import­

The exercises tha t follow are examples of tra in­

ant to include functional integra tion exercises in the

ing control o f neutral spine du ring dynam ic a c tiv­

rehabilita tion program as ea rly as possible. Every

i ties involving the low er-ex tremity kinetic chain .

few treatmen t sessions, a functional a c tiv i ty tha t is

They a re progressed to movements tha t require

challenging or uncomfortable for the p a tien t should

spinal con trol while mov ing in and o u t of neu tral

Two

spine. D u ring the exercise performance, areas of

a pproaches can be use d : first, educate and p rovide

poor control or give will become app a rent, either a t

cues to change the way the p a tient performs a spe­

a segmental level or a t a global orien tation level.

be

identi fied

and

targeted

for

tra ining .

cific func tional a c tivi ty, so tha t whenever the a c tiv­

Loss of segmen tal

i ty is performed, the patien t "checks in " and spends

c ueing and a ttention to the local system p recontrac­

control

will req u ire specific

a moment thinking a b o u t the position of the spine,

tion and endurance; these techniques have been

brea thing, and the contrac tion of the local sys tem,

described extensively above. A loss of global orien­

and second, design a n exercise tha t breaks the activ­

ta tion ( thorax on pelvis, pelvis on hip, hip on knee,

ity down into components a n d practice the base

knee on foot) w ill require speci fic cueing and a t ten­

the

tion to m uscles of the glob a l slings tha t a re being

pa tient's a b i l i ty and movement control i mp rove .

ins ufficiently activate d . This is performed by using

components

first,

then

add

complexity

as

Depending on the pa tient's level of control, choose

imagery and manual cues to facilitate proper a l ign­

approp riate ac tiv ity to modify. For example, for

ment d u ring the exercise move men t . Some of these

a p a tient who is a t the level of prac ticing neutra l

have been described previously in rel a tion to the

an

spine a nd exercises in the si tting position, ed uca tion

thoracopelvic alignmen t (see section C oordinating

of d riving position can be ini tia ted . The patient is

the local and global sys tem s : Main ta ining neutral

instructed how to s i t equally on both sitz bones,

spine

rela x the b u ttocks, and l ightly contra c t the deep

ex tremity, the imagery is ex tended to incl ude all

local s tabili zing m uscles while driv ing. This is per­

j oints in the movemen t. For example, a common

formed whenever possible: before s t a r ting the car,

pattern is a decrease in a c tiva tion in the a d d u c tors

w i th

loading ) .

When

a d ding

the

lower

at s top ligh ts, or whenever the pa tien t thinks about

and / or v a s tus medialis obliquus, evidenced b y a

i t . This same p a tient may not be ready for integra­

p a lp a ble decrease in tone and often observable a tro­

tion of new s tabili z a tion s trategies into lifting or

phy. This c reates a de ficiency in the a nterior obli que

more complex movements in s tandin g . These can

s ling and the con tinuation of the connections o f this

be in troduced l a ter in the reha b i l i ta tion process as

sling into the lower leg and foo t ( tibialis pos terior

new levels of contro l a re gained . The key i s tha t

and the media l arch) . Excessive in terna l ro t a t ion of

func tiona l in tegra tion activi ties a re introduced a t

the tib ia and prona tion of the foo t can be o bserve d .

each s tage o f the stabiliza tion program .

Ra ther tha n prescribing a specific exercise for each

Training of static positions follows the guidelines and uses the techniques described above in the

muscle in this med ial

s l ing

( a d d uc tors,

vastus

medialis obliquus, tibialis p o s terior, foot intrinsics),

sec tion Postural re-educa tion, neutral spine and

an image of a suspension wire coming up from the

releas ing the " b u tt gripper" to apply ne u tral spine

medial a rch, to the medial knee, and into the groin

awareness to pa tien t-specific func tional tasks. The

is used ( F i g .

key is to educa te the patient on ways to avoid rig id­

placed between the upper inner thighs and the

i ty when m a in t a ining prolonged postu res. Norma l

p a tient is ins t m c ted gently to "connec t" to the b a ll,

1 0 .81 ) . In the early s tages a small b a l l is

func tion in s tatic pos t ures involves small rea c tive

lightly squeezing it and increasing facili tation to the

movements in response to limb movemen ts ( arm

add u c tors . Manual palpa tion is used as t he image is

the

cre a ted for the p a tient, a nd a new position and

center of gravi ty due to trunk movements ( e . g . ,

a l ignment will be observed . The p a tien t can then

movements while sitting at a desk), to shifts

in

turning o r shi fting the tru nk) and t o p ostu ral effects of resp ira tion (Hod ges

2003 ) . A

spine made rigid

think about tension and support along the tension w i re d u ring any standing exercise. In some cases,

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232

T H E P E LV I C G I R D L E

inclined

fonvard on the hips and the upper thorax and head are a w ay from the w a l l . The hi ps sh o u l d be in ne u tr al rota tion, the knees under the hips, the se co n d toe of each f oo t in line with th e m iddle of the p a tella, with eq u a l b o d y weight d i s trib u ted over each foot. In c o r re c ting techni que and p o si ti o n in the s t a n d in g p o si ti o n, it is imp or ta n t to use all of the checkpoints for glo b a l rigi d i ty from the ribcage to the toe s ,

i n structi o n Advise the patient tha t occur onl y in the legs; the spine s tays stil l and suspe nd e d by the "guy wires , " The pa tient is asked to sq u at " a s if sitting in a cha i r, " flexing a t t h e hips, knees, and ankles, while ma in­ ta ining the neutral spine p o s i ti on and sliding the b uttocks equally down the w a l l . The thera p i s t can palpa te in the lumb a r spine, or at the s a c ru m and innomina te to ensure tha t there is no loss of control during the m o ve m ent . For patients with fa iled lo a d transfer of the SIJ the innom i n a te will be felt to rotate anteriorly rel a t ive to the sa c rum on the side of fa iled load transfer. D u ring the re tu rn to s tarting p o s i t ion , watch for and c o rre c t any "butt gri pp ing " Exercise

movement is t o

as the hips extend .

Prog reSS i o n s/oth e r considerations T h e w a ll p r o vi d es feed back for m a in ta ining the pelvis in the same frontal plane; if any ro t a ti o n occurs, th e pressure on one b u ttoc k will change , The even t u a l goal is to h a ve the p a tient per fo rm this squa tting exercise in a free-standing p os i ti o n , • The d ep th of the squ a t m o vemen t is va ried depend ing on the control of the m o veme n t b u t is not usually p r o g res s ed to lower than 90° knee flex­ ion (unless s p o r t or w o rk d e ma n d s require i t ) . • The wall squa t is p rogressed t o a sling squat: the pa tie n t squ a ts d own, then li fts both heels to s tand on the b a l ls of the feet (Fig. 10 ,82), then s t raightens the knees and h i ps to come up to stand­ ing but re ma in ing on the toes, then lowers the heels to return to the e xerci se s ta r ting posi tion. This pa t­ tern can be perfo r m e d in re verse to ch a l lenge eccen­ tric control. Using a ball b e tween the thighs and c u ein g the med i a l l eg s l ing i m a ge is he l p f ul for opti­ mal exercise perfo rm a n ce . • Other p ro gress io ns in c l ud e p erfo rming the squ a t and the s l ing squ a t against a ball. The b a ll s h o u ld be placed such th a t it s upp o r ts the lumbar lordosis and d o es n o t res tri c t the m o veme n t of the th o ra x into a neutral kyphosis. As t he squ a t occurs the l umb a r lordosis sho u l d be m a i n t a ine d a n d the hips sho u l d move posteriorly u nder the b a l l . •

F i g u re 1 0 . 8 1 F u n c t i o n a l i n tegrati o n : i m a g e ry fo r fa c i l i ta t i n g opti m a l a l i g n m e n t d u ri n g a step-d o w n , I n t h i s case, to c u e t h e m e d i a l s l i n g a n d i ts c o n n e cti o n s i n to t h e l o w e r l e g a n d foot, a s k t h e p a t i e n t to " i m a g i n e a s u s p e n s i o n w i re com i n g from u n d e r t h e i n s i d e of yo u r a rc h , tra c i n g u p t o t h e i n side of t h e k n ee a n d i n n e r t h i g h , a n d i n to t h e g r o i n " [ a rrow ) , From t h e g ro i n , t h e s u s p e n s i o n w i re ca n c o n t i n u e me d i a l ly u p t o t h e l u m ba r m u l tifi d u s , o r l a te ra l ly t o t h e posterior g l u teus m e d i u s, d e pe n d i n g o n w h e re the p at i e n t is losi n g c o n t ro l , ( R e p ro d u ce d w i t h p e r m i ss i o n fro m © D i a n e G , L e e Physioth e rapist Corp, )

espe c ia lly where

the re has been peripheral inj u ri e s a spra ined a n k le), a d d i tional s treng thening e x e r c i ses will be necessary. In c a ses where p roximal con trol is the primary p rob l e m, rest o r in g lumbo­ pelvic control and then in tegra ting the new mo tor pa ttern into functional patterns with cu e in g of proper alignmen t is often su ffi c ie n t. (e.g.,

Sq u ats

S ta nd ing in neu tr a l spine aga ins t appro xim a te ly 15 cm (6 in. ) away fr o m the wall, The hips sho ul d b e in a p pro xi ­ ma tely 20° flexion, s o tha t the pe l v i s and spine a re

Pati e n t positi o n

the w a l l . The fee t a re

Copyrighted Material

Trea t i n g the lumbopelvi c - h ip dysfunction

Fi g u re 1 0. 8 3

F u n ct i o n a l i n te g ra t i o n : s p l i t sq u a t. T h e b a s e o f

s u p p o rt i s red u c e d by p l a c i n g o n e fo ot fo rw a rd a n d o n e foo t b a c k w i t h t h e h e e l l i ft e d ( a s c o m p a red t o a b a s i c sq u a t) . Th e b o d y w e i g h t s h o u l d b e d i st r i b u t e d e q u a l l y o v e r b o t h le gs a s t h e h i ps a n d k n e e s f l e x . In th i s e xa m p l e t h e t h e r a p i s t p ro v i d e s t a c t i l e fe ed b a c k a t t h e a n te r i o r h i p c r e a s e s t o fa c i l i ta t e fo l d i n g (fl e x i o n ) of t h e h i ps e q u a l l y a n d m a i n t e n a n c e of p e l v i c p o s i t i o n d u r i n g t h e m o ve m e n t. ( R e p r o d u c e d w i t h p e r m i s s i o n fro m

© D i a n e G . L e e P h ys i o t h e ra p i s t C o r p . ) F i g u r e 1 0.82

F u n ct i o n a l i n t e g r a t i o n : s l i n g sq u a t , p r o g ress i o n

o f w a l l sq u a t . T h e s t a rt i n g p o s i t i o n i s n e u t ra l s p i n e i n s u p p o rt e d s ta n d i n g a g a i n s t a w a l l . I n t h i s exa m p l e t h e p a t i e n t i s pa l pa t i n g

knee w i th

a

5 % effort during the e x ercise. The re

should be no visible extern a l ro ta tion movement of

tra n sversus a b d o m i n i s b i l a te ra l l y fo r a sym m e t r i ca l c o n t ra c t i o n .

the hip or c hange in a lignmen t of the knee and foot;

T h e b a l l i n t h e m ed i a l t h i g hs i s t h e n g e n t l y s q u eezed w i t h o u t

however, a n increase in the a c ti v i t y of the posterior

a n y h i p i n t e rn a l o r e x t e rn a l rot a t i o n ; t h i s p ress u re i s s u st a i n e d t h ro u g h o u t t h e e x e r c i s e . ( R e prod u c e d w i t h p e r m i s s i o n fro m

© D i a n e G. Lee P h ys i o t h e r a p i s t C o r p . )

fibers of gluteus medius will be palp a te d . The e x er­ cise is progressed

by removing

the b a n d and h a v i ng

the p a tient m a in tain the control and a c ti v i ty in the gluteus med ius .

•

S q u a ts

with the ball can then be p r ogressed to

sp li t squats (Fig. be

p ra c ti ced •

10.83) . Again, this ex ercise should

b o t h free-standing a nd a gainst the bal l .

Using a resistive exerc ise ba n d tied a round the

lower thigh d u r ing the ini tia l in troduc tion of these

•

The p a tient's a rm position depends on w h e re

tactile feedb ack is re quire d for correct exercise per­ formance. Initia lly the m u l ti fidus and

TA may

need

to be p alpated. Al terna tely, palp a tion at the hi p c a n faci lita te folding an teriorly a n d main tenance o f

exercises will provide fa cilit a ti on to the pos terior

the axis f o r h i p m ovemen t d ur i ng t h e exercise. A s

fibers of the g l u teus

musc l e . The p a tien t is

the m ovement p a t tern becomes more a u tomatic,

asked to maintain p ress ure against the band a t the

use less tactile feedback and have the p a tient swing

m edi u s

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F i g u re 1 0 . 8 4 F u n c ti o n a l i n te g r a ti o n : step fo rward, ste p back. (a) Poo r p e rfo r m a n c e of w ei g h t s h i ft c o m p o n e n t . The pati e n t i s l o s i n g con trol of t h e r i g h t s a c ro i l i a c j o i n t a n d h i p a s we i g h t i s t a k e n o n t h e r i g h t l e g . Note t h e Tre n d e l e n b u rg o n the r i g h t s i d e . (b) Co rrect tech n i q ue. P r i o r to s h i ft i n g w e i g h t o n to t h e fro n t l e g , t h e p a t i e n t p a l pa tes a n d "co n n ects" to t h e r i g h t d e e p m u lt i fi d u s w i t h a n i ma g e , t h e n c o n t i n u es t o k e e p t h e m u s c l e a ctive a s w e i g h t i s ta k e n o n t o t h e ri g h t l eg. T h e c u e t o " k e e p t h e pelvis vertica l l y ove r t h e h i p" is a l s o h e l p fu l to co n t ro l t h e h i p a n d co rrect t h e Tre n d e l e n b u rg . ( R e p ro d uced w i t h perm i ss i o n fro m © D i a ne G . Lee P h ys i o t h e ra p i s t Corp.)

the arms while moving the legs . During squa tting motions, the arms are l i fted bi l a terally in fr on t of the body. In s p li t squa ts the arms move in a con­ tralateral p a ttern to the legs (if the left leg is for­ w a rd, as the left knee bends, the left a rm extends behind the body a nd right a rm flexes forward ) .

Step fo rw a rd , ste p back The goal of these ex erc i ses is to s i m ulate comp o n­ en ts of th e g a i t cycle in a progress iv e ma nner. Initially, the exercise is perfo rmed in stride sta ndi ng as a w e igh t shift from front to back (Fig . 1 O . 84a, b) . The p a t i ent pa lpa tes the key mu scles to focus on (mul ti fid u s, p osterior fibers gluteus medius, TA, e tc . ) . The exercise is repea ted w i th the oppo s i te l e g forward . The exerc ise is p r ogressed from b il a ter a l we i gh t-bearing to uni l a t era l weight-bearing as fol­ lows. The same w e ig h t shift exercise is performed,

but the back foo t is lifted from the gro u n d at the end of the weight sh i ft forward, held for a fe w secon ds, and th en a step back is perfo r me d and the front foot is l ifted from the g ro und at the end of the we i gh t shi ft b ac k w a rd s . The next p rogression involves p e r formin g a s wing phase with one leg; from bilateral s tr ide stance the w e i gh t is sh ifted for­ w a rd on to the front leg, the back foo t is lifted, and the h i p flexes to bring the leg fo rwa r d into a new step. The same l eg is then swung back and a backward s tep i s t a k e n . Arm sw ings are added a s l ess tactile fee dback is requi red . The size o f t he steps is grad u a lly inc reased to a functional stride leng th . In the first stages of this exerc ise, the goal is to ma i.n tain a neu tral spine as we igh t is transferred forward and bac k , but as the exercise progresses to become more like normal g a it, the s p ina l p os iti o n w i l l m o v e in a n d out of neu tral p os i t i o n (b ut n o t exces s i v e l y s o) .

Copyrighted Material

Treati n g t h e l u m bo p e l v i c- h i p dysfu ncti o n

Lu nges a n d va riations position Standing in neutral spine. The palpa tes the muscles that need extra cueing and a ttention for correct performance; this may be the TA a nd lor multifidus, or the posterior glu teus medius, or the anterior hip (to cue relaxa hon and fold ing) . The therapist initially palpa tes the area of dysfunctional load transfer (sacrum and innom­ ina te, lu m bar spine, around the greater trochanter, etc . ), and then uses different palpa tion points as needed to correct the exercise technique . Exe rcise i n struct i o n Cue a co-contraction of the lumbopelvic local stabilizers . The p atient s teps for­ ward with one foot, landing heel first, and a llowing the heel of the back foot to come off the ground so tha t weight-bearing is performed through the b all of the b a c k foot. Ask the pa tient to bend both knees so that the body drops down between the legs, whi l e keepi ng the weight equally distributed between both legs . The front knee should b e verti­ cally in line with the ankle joint as the knee bends. C u e folding of both hips and maintenance of the neutral lumbopelvic curve as the hips bend . To return to the s tarting position, the hips and knees a re s tra ightened as the pa tient pushes backwards off the heel of the front foot and brings the legs back toge ther into a neu tral standing pos ture . Prog ress i o n s/ot h e r c o n s i d e r a t i o n s The dep th o f the l unge can be varied depend ing o n the patient's control. Watch for any la teral tilting or excessive rotation of the pelvis. During the step forward, observe the s ta tionary leg ( the back leg) . Poor load transfer at the SIJ or decreased gluteus medius acti­ va tion in the bac k leg is often a cause for compensa­ tory hip stra tegies in the other leg s uch as hip hiking and pel vic ro tation because of the unstable base for movement. Using a resistive exercise band tied around the lower thigh d u ring the initi a l intro­ duction of these exercises w i l l provide facilitation to the pos terior fibers of the gluteus medius muscle ( Fig. 1 0.85) . The p a tient's a rm position depends on where tac ti le feedback is requ ired for correct exer­ cise performance. As the movement pa ttern becomes more au tomatic, use less tactile feedback and have the patien t sw ing the arms while moving the legs. Du ring forward and dia gonal lunges use the a rms in a contralateral sw ing pattern; during side l unges both a rms can move toge ther in front of the body as for squats (see above). Progressions i nclud e a l unge with one knee lift progressing to walking lunges. The basic l u nge is Pa tient

patient

F i g u re 1 0 . 8 5 Fu n cti o n a l i nt e g ra t i o n : fo rw a rd l u n g e w i th resistive exe rcise ba n d fa c i l i ta t i o n . I n n o r m a l sta n d i n g , t h e b a n d i s sec u red a ro u n d the pati e n t ' s t h i g h s ; t h e p a t i e n t t h e n p e rfo r m s a va riety of fu n c t i o n a l exercises, fo r exa m p l e a fo rwa rd l u n g e . Prog ress i o n o f the exerc i s e i s a c h i eved by re m ovi n g the b a n d ( re d u c i n g p r o p r i o c e p t i ve i n p u t) . ( R e p ro d u ced w i t h p e r m i s s i o n fro m © D i a n e G . Lee Physiothera p i st Corp.)

performed to the point where the body drops between the two legs . Now, instead of p ushing back off the front leg to re turn the legs togethe r, the body moves forward on to the front leg while l i fting the back knee and hip forward into flexion (unila teral weight-bea ring on the fro n t leg) . This end p osition resembles the one-leg standing test and is held for a few seconds to challenge control of b a lance. To return to the s tart position, a s te p backwards is per­ formed by the non-\veight-bearing leg. The e xerci se is then performed on the o ther side. A fu rther p ro­ gression is to remove the fina l s tep backward s and link alternating lunge knee li fts together so tha t the p a tient moves forward with each lunge. These a re novv walking lunges . Using brief holds where the p a tien t stops with the knee lifted in between severa l walking l unges adds proprioceptive challenge to the exercise.

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T H E P E LV I C G I R D L E

• Backward lunges: one leg moves into exten­ sion to land on the ball of th e foot so that the squa t­ ting m o tion is performed in the same position as the forward squat, but the initiation of the exercise requires d i fferent muscle p a tterning. I t is useful to ta rge t eccentric glu teus maximus control in one-leg s tand in g . • Side or d iagonal lunges : the stepping leg moves in a side s tep, and a squat is performed so tha t the body weight is equal between the legs. Alterna tely, the st epping leg moves in a forward a n d diagonal line or a backwards and diagonal line. Correct the body position when the foo t lands to teach the p a t ient how to land with the weight already equally dis trib u t ed between b o th fe et ; this retraining helps to correct and facilitate better awareness of body center, which is often altered in p a tients wi th lumbopelvic-hip dysfunc tion. The body centre awareness exercise can be performed a t d ifferent speeds t o increase au toma tic reactions. • Lunge against a r esis tive exercise band: a piece of resistive exercise band is secured behind the pa ti en t at shoulder level. The pa tient stands in neu­ tral spine, hold ing the ban d with one hand a t the ipsila teral shoulder (elbow is bent) . With a precon­ trac tion of the local stab ilizing system, the p a tien t performs a d ynamiC lu.nge against the u nila teral resis tance of the band (Fig. 10.86) . The l unge can be performed on the leg ipsila ter a l or contralateral to the arm holding the band . I n b o th cases a rotational force is imparted to the tnmk. The patient is instruc ted to keep the spine in neutral throughou t the performance of the mov e m en t. l u nges : these exercises are • Cross- tubing adapted from Alex McKechnie and Rick Celebrini's Hard Core S trength exercise protocol . These clin­ icians have i ncorporated the use of light-weight resistive exercise bands in a cross pa ttern (Fig . 1 0 . 87a) to facilitate proper m o to r p a t terns and exer­ cise performa nce in end-stage rehabilita tion train­ ing programs. Two long pieces o f bands are used for the a rm connections. Each piece is tied toge ther a t the ends, forming one large circle. A loop i s formed in one end and the p a tient s teps into the loop so tha t it can be slid up the leg and secured around t he thig h . The other end of the circle is placed around the contra la teral hand. The same pattern is repeated on the o ther leg w i th the second piece of exercise band; this completes the upper-body cross-tubing s e t- u p . Another smaller c i rcul a r piece of exercise band is used a round the ankles. For these lunge variation e xercises, the sta r t posi tion is a supported

F i g u re 1 0 . 8 6 F u n ct i o n a l i n te g r a ti o n : fo rwa rd l u n g e a g a i nst a resi stive exercise band. As t h e l u n g e is performed t h e p a t i e n t is c u e d to m a i n ta i n t h e n e u tra l s p i n a l po s i t i o n a n d n o t a l low rota t i o n towa rds t h e band. Th i s tra i n s i s o m e t r i c c on trol th ro ug h the a n te ri o r o b l i q u e s l i n g s ( a g a i nst rota t i o n a n d exte n s i o n ) . I n t h i s exa m p l e t h e t h e r a p i s t i s p a l pa t i n g t h e l e ft i n n om i n a te a n d sacru m to e n s u re c o n t ro l of t h e l e ft sa c ro i l i a c j o i n t d u r i n g t h e move m e n t. ( R e p r o d u c e d w i t h p e r m i s s i o n fro m © D i a n e G. Lee Phys i o t h e r a p i s t Corp .)

s tand ing posi tion aga inst a ball on the wall with the knees bent. The l umba r spine lordosis is s upported by the ba ll and the thorac ic kyphosis is ma in tained . The pelviS should be in n e u tr al position w i th the hips folded symmetrically; do not a l l ow any poste­ rior tilt, flexion of the lumb a r spine, or " b u tt grip­ ping . " The hands are together in fron t of the mid- thorax (Fig. 1 O . 87a) . Cue a co-con traction of the deep local s t abilizi ng muscles, and then ask the pa tient to perform a side squat to one side, transfer­ ring the weigh t so tha t i t remains equally d istrib­ u ted between both legs . As the leg moves laterally, the arms a re moved up and out in a diagonal flex­ ion pattern (Fig. 10.87b). Depend ing on the patient's con trol and balance, the heigh t the a rms are ra ised can be increased to above the shou lders ( h ands

Copyrighted Material

Trea t i n g the lumbopelvic-h i p dysfunction

F i g u re 1 0 . 8 7

F u n c ti o n a l i n teg ra t i o n : cross-tu b i n g l u n g es . ( a ) Li g h t - w e i g h t y e l l ow res i s t ive e x e r c i s e b a n d i s u s e d fo r t h e u p p e r - b o d y

cross- tu b i n g s e t - u p ; red res i s t i v e e x e r c i s e b a n d fo r t h e a n k l e t u b i n g (fro m M c Kec h n i e 8: Ce l e b ri n i ) . T h e s ta rt p o s i t i o n i s a n e u t r a l s p i n a l c u rv e i n s u p p o r t e d s ta n d i n g w i t h t h e l o rd o s i s s u p p o rt e d a g a i n s t t h e b a l l . ( b ) A p re c o n t r a c t i o n o f t h e d e e p l o c a l s t a b i l i z e r s i s p e rfo rm e d a n d t h e ri g h t l e g s t e p s to t h e s i d e to pe rfo r m a sq u a t. T h e a r r o w s i n d i c a t e t h e d i rect i o n of a r m m o ve m e n t ; a s t h e p a t i e n t g e ts b e t t e r c o n t r o l , t h e a rm s ca n b e l i fted h i g h e r. ( R e p ro d u ced w i t h p e r m i s s i o n fro m © D i a n e G . Lee P h y s i o t h e r a p i s t C o r p . )

level wi th t h e top of the head ) a nd the d ep th of the squa t movemen t can be va ried . A p rog r e ss i o n of th e

righ t l eg and l ift the le f t

side step is a d i a gonal lunge, where one leg moves

band down ac ro ss the body in the direc tion of th e left hip ( exte nsion and abduction diagonal) a nd the thor a x is ro t a ted to the left (Fig. 1 O . 8 8 b ) .

back in to ex tension a nd a b d uc tion in a d i agona l p a t t er n to land on the

b all of the foo t . C oncurrentl y,

h ip and knee into fle xion . the left arm draws the

As the r i gh t l e g is s traigh tene d

the ip s i la te r a l a r m moves into an e x t en sion d i a go­ nal ( d own, b a c k a nd out, fol low i n g th e

leg) a nd the

contra l a t era l arm l i fts into a flexion / a bduction diagona l ( a s •

before).

One-leg sq u ats

in neutral s p i ne . Th e tha t need ex tra c u e ing and a tten tion for correct p e rfo rma n c e . Th e th e ra p i s t ini tia l ly p alp a tes the area o f d ysfunc tion a l load Pa t i e n t

Lunge w i th contrala teral t r un k rotation : this

exercise i n te g r a te s i n co n gru en t ro ta tion b e tween the th or a x a nd the pelvis d uring m ovemen t of the

position

Standing

p a t i e n t p a lp a tes the muscles

fu l l

transfer (sacrum and innomina te, lumbar spine,

the l ow e r

around gre a t e r trochanter, etc. ) , a nd the n uses dif­

k inetic c h a in . The p a t i en t p e r form s a l ung e w i th extremity while simu l taneously ro t a ti n g the trunk a ga ins t a resi s tiv e exercise b a n d . For

lunges with the right leg, the band is secured ab ove and a nterior to the right shou ld er.

The left arm

holds the band i n eleva tion across t he bod y (Fig.

1 0 . 88a ) .

The p a tient is in s tr ucted to s tep forw ard

and lunge w i th the right foo t, then s traig h te n th e

fe r en t pa lpa tion poin ts as needed to

correct the More cueing and a t tention w i l l b e needed for the wei ght-b e a r ing leg. Exercise i n st r u ct i o n Cue a co-contra c tion of the exercise techni q u e .

lumbopelvic local s tabilizers . The p a tient lifts one foot,

b en d ing the knee a n d hip to c l e a r the foo t off

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T H E P E LV I C G I R D L E

(a) Fu n c t i o n a l i nt e g ra t i o n : l u n g e w i th c o n t ra l a tera l tru n k ro ta ti o n . r a j T h e p a t i e n t p e rfo rms a c o - c o n tract i o n of t h e deep l oca l sta b i l i z e rs, steps fo rward w i th t h e r i g h t leg, and perfo r m s a l u n g e . (b) The fi n a l p h a se of t h e exercise i n vo l ves r i g h t pelvis rota t i o n a n d left t h o ra c i c rota t i o n , t h u s c h a l l e n g i n g c o n t r o l o f co n tra l a t e r a l t h o r a c o p e l v i c moti o n . T h e t h e r a p i s t i s m o n i t o r i n g p e l v i c con tro l. ( R e p r o d u ced w i t h p e r m i s s i o n fro m © D i a n e G . Lee Phys i o t h e r a p i s t Corp. ) Fi g u re 1 0 . 8 8

the ground. The pelv i s shou ld re m a in level a n d in

fea therweight-bearing role . The p a tie n t's

rotation . A sq u a t is performed on the other leg. The hip sho uld fold and the pelv is move anteri­ orly over the femu r. Cue, "]ma gine you are d rop­ ping down to s i t in a cha i r a nd your hip is moving back to the ch a i r. " The knee s h o u l d track in l ine

ition depends on where tactile feedb a c k i s

ne u tral

for

correct exerc ise performance .

As

arm

pos­

re quired

the movement

pa ttern becomes m ore automa tic, use less tactile fee d b a ck

and

h a ve the p a tie n t

swin g

the a rms in

a

con tral a tera l swing p a t tern with the s q u a t .

w i th the second toe and the fem u r should not exces­ sively in te r n a l l y or e x te rn a l l y rota te. Wa tch for toe grippin g and tru n k b r a C ing. The exercise rep e tition

is c o m p l e te d by s traigh tening the leg; fu r the r sq u a t rep e ti tions c a n b e repeated on the s a me leg o r the

Ste p u p

body, in line w i th the

S t a n d ing in neu tral sp in e in fron t a s tep . The p a ti en t pa lpa tes the muscles that need extra cueing and a t ten tion fo r correct p erform ance . The the r a pi s t ini ti a l ly palpates the a rea of dysfunc­ tional load transfer (sacrum and innom i n a te, lum­ bar sp i ne , around greater trochan ter, etc.) d u ring subsequen t exercise r ep e ti tio n s ; different pa l p a ti on p oin ts a re used as n ee d e d to correct th e exercise techn i q u e .

bea ring, the n on-weigh t-bea ring toe can be p l a ced

l u mbopelvic local s ta b i l izers . Th e p a ti e n t s teps for­

legs can be a l ternated . Prog ress i o ns/oth e r

considerations

The dep th of

squ a t can be va ried depending on the pa tient ' s con trol. Wa tc h for a n y l a teral t i l ting or rota tion o f the p e l v iS . The p os ition of t h e non-weight-bearing the

leg ca n be varied so tha t the foo t is in front of the

b o d y, or behind the b o d y. ]f the pa tient canno t control full unilateral we i gh t­

o n the floor

sli ghtly

behind the o ther foo t in

a

Pa t i e n t p o s i t i o n

of

Exercise i n str u cti o n

Cue

a

co-contraction of the

ward on to the s tep w i th one foot, l and ing heel first,

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Trea t i n g t h e l u m bo p e l v i c- h i p dysfu n ct i o n

F i g u re 1 0 . 8 9 Fu n c t i o n a l i n te g ra ti o n : ste p - u p . (a) Good exercise tech n i q u e . T h e pelvis i s level a n d t h e re i s m i n i m a l l atera l s h i ft o f t h e tru n k . ( b ) Po o r c o n tro l . T h e tru n k i s excessive l y s h ifted to the r i g h t , t h e l e ft h i p is h i ke d , a n d t h e ri g h t b u ttock is " g ri p p i n g " ( n ot e t h e d ivot poste r i o r t o t h e g rea ter troc h a n te r ) . ( R e p ro d u ced w i t h perm i ssion from © D i a n e G . Lee P h ys i o t h e ra p i st Corp.)

and then transfers the body-weight forw ard to per­ form the full step-up. The other leg lifts from the ground and i s then brought forwa rd into hip and knee flex ion to si m u l a te s tepping up on to another s tep (Fig. 1 O . 89a) . The exercise is co mp l e te d reach­ ing the non-weigh t-bea ring leg backwards into extension and stepping back down off the step . The exercise is repea ted on the o ther leg. Prog ress i o n s/oth e r co n s i d e rati o n s Wa tch for s ub­ stitution s tra tegies on both legs (e.g., Trendelenbu rg or hip hiking), on the back leg as the pa tient li fts the foot to place it on the step and on the front leg as weight is transferred on to the step into unila teral weight-bea ri ng (Fi g 1 0 . 89b) . Wa tch for any lateral tilting or excessive rota tion of the pelvis. "Bu t t grip­ ping" will result in an i n abi l it y to dissocia te hip movement (e.g., flexion as the leg moves f orw a rd ) from pelvic movement. If th is occurs un ila terally, a p os t e rior til t, latera l tilt, and / o r rota tion of the pelvis wil l occur when an a ttemp t to flex the hip is made. Check alignment and monitor the check­ p o in t s for global rigidi ty throughou t the kine tic .

cha in . Wea k links in the global slings will res ult in a l tered alignment in the l ow er e x tre m ity during the m ovemen t. Use manu a l p a l p a tio n a nd imagery to correct any devia tions. Encourage a rm swing as d u ring a norma l gait pattern; initially the h a nds may need to b e placed on the iliac crests or pa lpa te specific muscles to ensure optimal exercise per­ formance. Progressions incl ude s t ep ping up on a di agonal (to a corner on the step) and add ing thoraco­ pelvic rota tion (as in the lunge with con tra lateral trun k rota tion, see above) .

Step d o w n Pa t i e n t positi o n Sta nding in neutral spine o n a step. The pa tient palpates the m uscles tha t need extra c u eing and a ttention for correct performance; having both hands on the iliac crests provides good feed back for m ain ta inin g pe l vi c po s i tio n The ther­ ap is t ini tially palpa tes the area of dysfunc tiona l load transfer (sacrum and innomina te, l um bar spi ne, around grea ter trochanter, e tc . ) , then uses different

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T H E P E LV I C G I R D L E

palpa tion points as needed to correct exercise tech­ n ique . To correct a lignmen t it is helpful to kneel or s tand on the same side as the leg tha t will be unilat­ erally weight-bearing. Exe rcise i n structi o n Cue a co-contraction of the lumbopelvic local stabilizers and then cue any sling imagery that is needed to maintain thoracopelvic and lower-extremity a lignment. The pa tient lifts one foot off the step, and then bends the weight-bearing hip, knee, and ankle to lower the foot to the ground (Fig. 1 0 . 8 1 ) . The center of gravity is slowly moved forvv a rd as the foot is lowered. The ball of the foot should contact the ground first, then the rest of the foot. As weight is transferred on to the fron t leg, the knee and hip are allowed to flex as part of the shock­ absorbing mechanism and in simulation of continu­ ing to proceed down stairs. The repetition can be completed by bringing the feet together on the floor, then stepping back up on to the step. The exercise is then repeated on the other leg. Prog ress i o n s/ot h e r co n s i d e r a t i o n s Start with a small step, as low as a phone book. Progress by increasing the height of the step. The exercise can be broken up into s tages and performed as progres­ sions: at fi rst just the hip and knee flexion compon­ ent a re practiced without the shift in the center of gravity, then the s hift is a dded with a small lower­ ing of the foot, then the foo t is lowered completely to the ground b u t only the toe touches, then finally the ful l weight transfer is allowed . Watch for any l a teral til ting or excessive rota tion of the pelvis. Palp a te the femur for internal or external rota tion, observe for medial knee tracking, medial a rch col­ lapse, and toe gripping. Using a resistive exerc ise band tied around the lower thigh will provide faci li­ tation to the posterior fibers of the gluteus medius muscle and help correct excessive internal rota tion of the fem ur.

Low to h i g h p u l l eys This exercise integrates congruent rotation through multip le joints in a functional kinetic chain. The movement can be performed from low to high (flex­ ion to extension) or from high to low (extension to flexion). The feet need to be able to pivot to allow movement through the whole chain; start with the feet facing the pulleys and then finish the move­ ment with the feet pointing 1800 from the sta rt pos­ i tion. Aim to maintain the norma l sagittal curves of the spine throughout (flexion and extension should occur at the hips and knees) . The arms s ta rt low at

the p ulleys by flexing at the hips and knees, and then rota tion occurs through the legs, pelvis, and thorax as the a rms are taken in a diagonal ex tension and elevation pattern, the front hip and knee e xtends and weight is tra nsferred to the other leg. There should be no segmental shifting or an tero­ posterior loss of curves in the spine. The goal is a smooth controlled transition and in tegra tion of the rotation and extension a t a l l joints along the cha in. Use only light resistance as the focus is on control. Many work and sport activi ties require con trol along with power and speed. The exercises pre­ sented in this chapter can be modi fied and per­ formed at varying speeds, and many can be ada pted to add jumps and coord inated with plyometric exer­ cise protocols to address these func tional goals. Howevel� there is evidence tha t performing ballis tic forms of exercise increases activity preferentially in the superficial global muscles and may be inhibitory to the deep local stabilizing system (Richardson et a l 1999). Thus, care should b e ta ken whenever ballis tic exercises are used. Slow-speed and low-load exer­ cises for motor recrui tment and control should be continued throughout the exercise p rogram and the therapist should check the ability to isola te and maintain a tonic contrac tion in the local sys tem muscles on a regu lar basis.

A D D IN G P R OPRIO C E PTIVE C H A L LE N GE

Using u n even su rfaces and equ ipmen t tha t chal­ lenge proprioception and balance is an important component in the rehabilita tive exercise program . When combined with a conscious co-contrac tion of the loca l stabilizers and cues to prevent long periods of global rigidity, adding p roprioceptive cha llenge facilitates the retraining of the a u tomatic recru it­ ment of the local sys tem and trains the ab ility to maintain postural equi librium. In general, the patien t should be able to maintain co-contraction of the deep local stabilizers, providing neu tral zone control, and maintain low-load activity in v ario us postural global muscles depending on the direc tion of change of the center of gravity. Thus, the previ­ ously described checkpoints for global rigi d i ty can be used. However, brief periods of high levels of activity in the global muscles are to be expected when there are large d evia tions in the center of grav­ i ty such that muscles are activated to preven t a fall. Many different variab les can be used and combined to crea te proprioceptive challenges. Some of these

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Tre ating t h e lumbopelv i c- h i p dysfunction

include: removing visual inp u t (close the eyes), ch a nging the base of s upport ( single- or doub le-leg s tance, Lmeven s u rfaces) , moving o ther body pa r t s

while on an a l tered base of s up port (hea d , arms, one leg), performing a rm acti v i ties concurrently with an

a l te red base

of support (boun cin g

a ball, throw ing /

ca tchin g a medicine b a l l, resistive exercise band d ia go n a l s )

,

a nd

holding s ta tic po s i tion s in between

dynam ic activities (perform hops on one foo t and then hold a one-leg s tance posi tion between

n umbers

varying

of rep e ti tions) . The fol low ing exercises

ideas for a dding p rop ri ocep tive chal­ func tional positions, b u t many more adap­ and op tions can be use d by combining

provide some lenge in

ta ti ons

differen t variables in light of the p a tien t's goa ls.

Rocker board squats

stands on a r ocker hips in some flex ion The b oard can be po s i tioned so tha t the unstable direction is in a n an teroposterior d i re c tion or in a m e d io la te ra l direc tion. The p a tient holds on to a sup por t to find a still b alance poin t and pre­ connect to the local s tabilizin g muscles, and then The p a tien t

Pa t i e n t p o s i t i o n

boa rd in neu tra l sp ine w i th the knees and .

­

releases the supp or t . Exercise i n struct i o n

Mainta ining con trol o f the is a sk ed to per­

ne u tr al spi ne posi ti on , the p a ti en t

form a squat, kee pi n g the b oa rd in the horizontal p o si ti on (Fig. 1 0 . 9 0 ) . General ly pa tien ts with poor flexion / ex tension control w il l have more d ifficu l t y w ith the ante roposterior control and pa tients with poor rotational control will have more diffi c u l ty w i th the med iola te ral control. Both di rec t ions sho u l d be c hecked; often s t a r ting w i th the posi tio n of b e tter con trol bui lds confidence and reinforces good motor control s tra tegies to apply in the more ch a l lengin g p osi tion

Lu n g e on

"c i r c l e o f i n t e g r i t y " t h a t s h e rec r u its p o o r l y. ( R e p ro d u c e d w i t h p e r m i s s i o n fro m © D i a n e G . L e e P h ys i o t h e r a p i s t C o r p . )

K neeling on t h e ball The p a tien t holds on to a stable obj ec t w i th the hands while positioning the

legs

bal l

in a

the neutral spine while exerc i s e provides a larg e

works on maint a ini ng

d egree of cha l leng e to the trun k c ontrol system, a n d the fron t foo t p l aced on a sissel s u rfa ce. In s t r u c t the p a tient to co­

is highly

beneficial i f p erform ed witho u t

prov ide c lose su pervision and su pport in the e a rly s tages, a n d the p a tient sho u l d

range hip in te r n a l a nd ex tern a l rotation to check for "b u t t gripping, " espec i a lly in the front leg. Exercise i n struct i o n Have the p a ti en t p erform a

checkpOints for glob a l rigi d ity.

l unge, d ropping the b ody be t w e en the legs and keep i ng e qua l w eight between the front and back

" b u t t grip­

p ing" and trunk rigid i ty. The the r apist needs to

contract the lumbopelvic s ta b ili ze r s and use small­

legs (Fig.

on a

kneeling pos i tio n . Th e hands then let go and knee ling on the b a l l . This

A s tatic lunge (split s q u a t) position

a ssu med with or othe r unstable

Ad d i n g p r o p r i o c e p t i v e c h a l l e n g e : r o c k e r b o a rd

a n d ri g h t t r a nsve rs u s a b d o m i n i s a s t h ese a re t h e p o rt i o n s of t h e

pa tient

a sissel

Pat i e n t p o s i t i o n

is

.

Fig u re 1 0.90

sq u a ts . H e re t h e p a t i e n t is m o n i to r i n g t h e l eft d e e p m u l t i fi d u s

be remind ed of

A D D R E S S I N G S P E C I F I C G LO B A L M U S C L E " W EA K N E S S "

1 0 .9 1 ) . A resis tive exercise band around

the th ighs can be used for ex tra facilitation tro l and gluteus med i us activ a tion.

of con­

Often

by

proper

al

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using

func tion a l

mov emen ts,

i gnme n t and using imagery ,

cueing

to "connect"

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T H E P E LV I C G I R D L E

the therapist to mod i fy p atien t position and move­ ment to ensure tha t the targe t muscle is the prime mover. These exercises a re ea rly-stage isolation and strengthening exercises. They should be progressed to func tiona l integra tion exercises as soon as the movemen ts can be controlled, providing tha t activity is monitored and mainta ined in the dysfunctiona l muscle d uring the ftmc tional exercise .

G L U T E U S M E D I U S - POST E R I O R F I B E RS Cla mshel l

Patient positi o n

Sidelying w i th the target limb fac­

ing u p . The spine is pa ssively posi tioned into neu­ tral spine, and the top hip is rolled slightly fo rward . The p a tien t is reminded to relax the h.ip a n d let the sitz bones go wide. The the rapist palpa tes posteri­ orly in the pos terior fibers o f gluteus m e d i u s and anterola terally in the tensor fascia latae muscle on the uppermost hip .

Exercise i n structi o n

C u e a contrac tion of the

deep local s tabi lizers, checking p articula rly for a contrac tion in the deep fibers of m u l t i fidus. Ask the p a tien t gen tly to lift the top knee from the b o t tom knee, opening the knees like a clamshell (Fig.

10.92 ) .

Figu re 1 0. 9 1 Add i n g p ropri oceptive cha l l e n g e : l u n g e on sissel. I n th i s exa m p l e t h e p a t i e n t has deve l o ped a n i n te r n a l sense of t h e

Wa tch for ac tivity in the deep h i p ex tern a l rota tors

i m a g es req u i re d to a c h ieve recru i t m e n t of t h e l u m bo p e l v i c loca l sta b i l izers to t h e poi n t w h ere m a n u a l fac i l i ta t i o n i s n o l o n g e r req u i re d . T h e a rm s a re a l l o w e d t o s w i n g i n a n o r m a l fu n c t i o n a l c o n t ra l a tera l p a ttern as t h e l u n ge is perfo r m e d . ( R e p rod u ced with permissi o n from © D i a n e G . Lee Physi o t h e ra p ist Corp. )

groove behind the gre a te r trochanter w i l l appear or

( the

fem oral

head

w i l l move anteriorly and a

deepen) . Palpate for acti v i ty in the tensor fascia latae. If ac tivity i s noted in ei ther of these muscles, try the following cues: "Imagine there is a s tring connecting the top of your hip [palpa te in the pos­ terior g l u teus medius] to your knee: try to lift the

the p atient to inac tive muscles in the sling, under­

knee by shor tening the s tring. "

recruited global mu scles will be properly recrui ted

(a long the fem u r) into your body to lift the leg

and s trengthened. On some occasions, however, s p e­ c i fic foc us is required for some of the global muscles.

ra ther than j us t thinking of li fting the knee . "

The following exercises a re for m uscles of the lumbo­

fid u s is fe l t prior to the leg l i ft. A con traction in the

Co rrect response

" Draw the leg

A swelling in t h e d e e p multi­

pelvic-h.ip region tha t may require specific a ttention.

pos terior fibers of gluteus med i u s is palpated and

The goal is to prescribe

no a c tivity

an

exercise that targets isol­

a tion and awareness of the dysfunc tiona l muscle. Of

in the tensor fa scia l a tae is present. The

femora l head stays cen tered in the acetabul um. If

course, th.is is not true isolation, as first, the deep

the exercise cannot be p erformed w i thout tensor

local stabi lizers need to be cued and activated under­

fascia la tae dominance, an a l terna te exercise should

neath these global muscles, and second, movemen t

b e used for gluteus medius (see be low) .

synergists need to be active to perform the exercises.

Pro g ressio ns/oth e r considerations

The clamshell

However, certain exercises can facilita te activity pre­

is a n excellent progression for p a tients w i th marked

dominan tly in cer tain key agonists. Once recruitment

a trophy of the d eep fibers of mu ltifid us. The pa tient

is successful, movements to strengthen the m uscle

is taught to pa lpa te for a maintained deep ten sion

a re performed with protocols for s trength (increased

the mul tifidus as the leg is li fted and to keep the leg

resistance,

two to three sets ) . Aga in,

lifted for up to 10 s as long as the m u l tifid us con­

identifica tion of subs titution p a t terns will ena ble

trac tion is held . The exercise is p rogressed by lifting

8-12 repe titions,

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2 43

Tre a t i n g t h e l u m bo pe l v i c- h i p dysfu n ct i o n

up the wall so tha t the hip a b d u c ts, while the ex ten­ sion push

into the wall is maintained . Wa tch tha t

the trunk does not shi ft or twist during any part of the exercise. Co r rect respo n se

A con trac ti on in the posterior

fibers of the

gluteus medi us is p a l p a ted and no activity in the tensor fascia la tae is present. Prog ress i o n s/co n s i d e r a ti o n s If the p a tient carmot m a inta in tru n k con trol or excessive global a c ti v i ty is noted, the exercise can be performed in the stand­ ing posi tion against a wall. The key components a re e x ternal rotation a n d ex tension of the hip . Poles can be used to help s upport the weight of the trunk. This exercise is then progressed b y using resis tive exercise bands or p u l leys for resis tance ins tead of the wall; this option req u ires more trunk control and balance.

Lu n g e with i so m etric exte r n a l rota t i o n I n standing, a resis tive exercise tied around the pa tient's lower thighs. The patient then moves into a s t a tic lunge position (also known a s a split squat posi tion) . The b ody weight is d i s tri b u ted equa l ly be tween the front and back legs. The back foo t is plantarflexed such tha t the weight is supported on the ba l l of the foo t . Check tha t the hip, knee, and foot are in corre c t alignment for both the front and back legs (described previously) . Pati e n t p o s i t i o n

band is

F i g u re 1 0 . 9 2 A d d ressi n g s p e c i fi c g l o b a l m u scle " w e a k n ess" : c l a m sh e l l . T h e p a t i e n t i s m o n i tori n g l a t e ra l costa l expa n s i o n a n d pa l p a t i n g m u l tifi d us. T h e t h e ra p ist p a l p a tes m u l tifi d u s a n d t h e r i g h t posterior fi b e rs o f g l u te u s m ed i us w h i l e c u e i n g t h e k n e e l i ft . (Repro d u ced w i th p e r m i ss i o n fro m © D i a n e G . Lee Phys i o t h e ra pist Corp. )

Exe r c i se i n st r u ct i o n

think of w i th o u t

the foot a fter

lifting

the knee, or b y a d d ing resist­

ance w i th exercise bands a round the knees .

gently pushing b o th knees into the band ing t h e knees ( F i g 1 0 .85) . This first

m ov

stage of the exercise should res u l t in a palpable of glu­ te us medius b i l a te r a l ly. The patien t is shown how to

increase in the activity of the pos terior fibers

feel the m u scle, and instructed to keep the a c ti v i ty

I so m etric wa l l press Pa t i e n t positi o n

C u e a co-contra c tion o f the

deep local stabi lizers, and then ask the p a tient to

in the muscle (and the press ure

Sidelying w i th the back to the

cons tant a s the body i s lowered

against the ba nd) fa rther into a lunge

wall, the head and sho u l d ers fa rther away from the

(both knees an d hips flex ) , th en returned to the

wall than the hips. The pelvis is rolled slightly for­

s tarting p osition.

w ard and the upp ermost rota t i on and ex tended so

h ip is placed in ex terna l that the heel res ts agains t

Correct respo n se

Activ i ty in the posterior fibers

of gluteus med ius is ma intained

th rou gh o u t the

the w a l l . Chec k tha t the l u mb a r spine is n o t exces­

l u nge mov ement, a n d a c ti vi ty in the tensor fascia

sively lord osed (as close to neu tra l posi tion as pos­

l a tae i s

sible) . The the ra p i s t pa lpates the pos terior

hip flexion component of the exerci se.

fibers of

gluteus medius and the tensor fascia latae m uscle on the uppermos t h i p . E x e r c i s e i n str ucti o n

deep

not excessive to the p oint of res tric t ing the

Prog ress i o n s/co n s i d e rat i o n s

This exercise works

b o th to increase glu teus medius ac tivi ty and to C u e a co-contrac tion of the

local stabi li zers, and then ask the p a tient gen­

integra te the m uscle in to func tional movement.

It

is

important to monitor the lower-extremity alignment

tly to p ush the heel in to the wall ( isometric ex ten­

and a l l checkpoints for

sion ) . The exercise is p rogressed by sliding the heel

exercise a nd teach the pa tien t how to self-moni tor

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global rigi dity during the

244

T H E P E LV I C G I R D L E

the wide pyra mid

base. Do no t a llow

technique. For p atients who are "butt grip pers , " use

spine position and

ta c tile and verbal cues to facilita te flexion of the hip

the pelvis to roc k backward s . This is L'ssential; if the

d u ring the lunge portion. Flexion should occ u r b i l a t­

pa tien t performs a pos terior p elvic til t w i th the acti­

(" think of fol d in g the hip in the fron t and s ti cking the b u ttock backw ard s ) The p r inciples

va tion of the gl u te us maxim us, symp toms can be

used in this exercise can be applied to o ther func­

va te d in a func tiona l posi ti on .

tiona l in tegr a ti on exercises tha t have been described

for equal a c tivation a n d use tactile fe edback to

( s tep fonva rd, s tep up or step down, e tc . ) .

increase re crui tment .

er ally

"

.

exacerba ted. Furthermore, the m uscle is not

Progress i o n s/oth e r

If the pa tien t

co n s i d erati o n s

positi on c a n be used. Again, neu tra l spine must be

Prone lying i n neu tra l spine . A

moni tore d . The sitting exercise is progresse d from

resis tive exercise band can be tied around the lower

an

thi ghs; in some cases this m a kes the exercise h a rder

co ncen tric / eccentric

to increased resis tance

for the p a tient ( d u e

acti­

the m uscle

has di fficul ty with the sit ting recru i tment, the p rone

Pro n e h i p exte n s i o n a n d a bd uct i o n Pati e n t p o s i t i o n

Pa lpa te

to

isome tric recru i tment exercise to a functional con tra c tion

pa t i en t slowly to perform

a

by

asking

the

sit- to-sta nd m oveme n t .

a b d u c tion) and in o ther cases it makes the e xercise

T h e fee t are moved back u nder the s i t ting surfa ce,

easier for the p a tient (due to increased prop riocep­

the trunk inclines forward a t the h ips, a nd the

tive feedba ck ) .

pa tien t

thinks

of using the b u t tocks to p ush off from

co-con tra c tion of the

the seat and rise to s tanding. The re turn to s i t ting

d eep loca l stabilizers, and the n ask the pa tient to l i f t

sho uld also be slow and con trolled, with both hips

Cue

Exe rcis e i nstruction

a

t h e l e g off the floor (hip ex tension) a s fa r

a s p oss i ble

with o u t losing the lumbopelvic position. Then, the

during

fle xing equa l l y and smoo thly

the move­

men t . It is p a rticu la rly impor tan t to m on i to r the las t

lift o f the le g is m a in tained while the leg i s a b d uc ted

phase as the p a tient comes close to s i t ting; this ou ter

( " take your leg out to the side " ) . Pro vide feedback

ra nge often rev eals eccen tric weakness (wa tch for

to ensure tha t the lumbopelvic pos ture does not

fa s t drop into the sea t) . Do n o t

a l l ow

a

the use o f

change and th a t the leg does n o t d r op as abduction

momentum

is performed.

Start w i th a hj gh s u r fa ce a nd progress to a lower

or s p eed

d uring the l i f t from the sea t .

e xerc ise

surface . A b a l l can also be used instead of a stable

re qu ires si gnifi can t lumbop elv ic s tab i li ty in order

surface. I f the pa tient has w e a kness o f b o th the

Progress i o n s/other

co n s i d erati o n s

111is

to con trol the spine whi le the weigh t of the le g is

gl u teus

l i fted . I t is a usefu l p rogression of the previo us gl u ­

resistiv e e x e rcise band

teus medius exercises and u su al ly p rescribed when

ex tra faci l i ta tion.

med ius

a nd

g l u te us

around

ma x i m u s,

use a

the lower th ighs for

i ncreased s treng th is requi red for functional inte­ gra tion exercises in one-leg weight-bearing pos i­ ti ons . By t h is s tage of the stab iliza tion program the p a tient sho uld have sufficient l umbopelvic con trol to be able to per form th e exe r cise correc tl y.

Bridging The

bridge position

in the

Moving out o f ne utral

spine : Thoracopelvic control

bridge and ro ta te

-

exercise, above, can b e used to inc rease the load ing of an

isome tric gl uteus ma x imu s contr a c t ion in

tral spine position. The exerci se can b e

G L U TE U S M A X I M U S

a ne u ­ p rog re ss ed b y

lifting one foo t off the gro und a n d w eight-bea ring o n

Seated g l uteus m a x i m u s sq u eeze a n d s i t to sta n d Pa t i e n t positi o n

Si t ting on a

firm

s urface w i th the

fee t planted on the floor, in an op tima l lu mbopelvic p yramid and neu tral sp ine . If there is any restric tion of hip flex ion (common in "butt grip pers " ) a raised s u r face sho u ld be used s o that the hips d o not res tric t a ne u tra l ti l t of the pelvis on the femurs. As the pa tient progresses E x e rcise i n st r u ct i o n

a

low er su rface is used . C u e a co-contrac tion o f the

one l e g a t

a

tim e . The neutral spine and h i p posi tion

m us t be ca refu lly moni tored to prevent " b u t t grip­ ping" and p oste rior pelvic til ting.

Pro n e h i p exte n s i o n - knee fl exed To increase l oa d ing in concen tric a n d eccen tric con­ trac tions, the test posi tion d escribed in Chap ter (Fig.

8.65c) can

8

be modified so tha t t h e p a tien t per­

form s the bent-knee hip ex tension mov ement over

i ncreased range

deep l ocal s tabi l i ze rs, and then ask the p a tient to

the end of

squeeze th e b u t tocks while maintain ing the neu t ra l

m o tion . Again, as for the prone gl u teus med i us

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a

bed . Thi.s a llows

of

Treat i n g t h e l u m b o p e l v i c- h i p d ysfu n c t i o n

exercise,

th is

progression

requi res

l u mbopelvic s t a bi l i ty. I t is not always

s ignificant a

I L I O PSOAS

necessary

and a c tiva tion

of

p rog r ession if s u ccessful a c tiva tion of the m uscle is

Exercises tha t fa cili ta te hip control

occ u rring d u r in g functional i n tegra tion exercises

the i l i opsoas (and down train the domin a nce of the

a nd their progressions . However, in cases where

tensor fascia l a tae) have been d escribed a b ove in

m a rked a trophy is p resent, the prone h ip ex tension

Ma i n ta ining neutral spine with loading: Trunk a n d

exercise m a y be ind ic a ted .

leg dissocia tion - Crook lying. S e e Figure l O . 7 1 a -c . The crook l ying progressions c a n b e used in s i t t i n g

A D D U CTO R S A N D V A ST U S M E D I A L I S O B L I Q U U S

and s tanding to cha llenge s trength a n d control o f il iopsoas fu rth er.

I t is co m m on to observe poor a c ti v a tion unila tera lly or bila tera l l y in the a d d uc tors a n d / or v a stus medi­ alis obl iquus d uring func tional tests, evidenced b y a p a lp a b l e d ecrease in tone a t rophy.

This

ob liq u e s l i ng

creates and the

and

often observable

a d e ficiency in the anterior contin ua tion of the connec­

tions of this s l ing i n to the lower leg and foo t (tibia l i s posterior

and

medial

the

p o o r recruitment pa t tern

c an

a rch) .

Usua l l y

th i s

be fac i litated d u ring

func tional in tegra tion exercises by simply placing a

s m a ll

compressi ble

ball

between

th e

upper

inner thi ghs and a s k ing the p a tient to " connect" to the ball w i th the thighs, lightly squeezing i t w itho u t

any

i n ternal or extern a l rota tion a t the

h i p s . Ac tiv i ty 'vvi l l be p a l p a te d in the adductors a n d v a s tu s medialis ob l i qu u s and should be main­ tained d ur ing exercise movem e n ts . Tn some cases a d d i t ional streng the ning is req u ired . Pa t i e n t p o s i t i o n

Sidelying w i th t h e top

hip

a nd

knee flexed so tha t the knee or foo t c a n b e placed in fro n t of the b o t tom leg. The b o t tom leg is flexed a t the knee s o tha t the exercise targets the sho r t add uct­ ors o f the thigh (Comerford M - Kine t i c Con trol,

unpublished

c o u rse notes ) .

Exercise i n structi o n

C ue a co-con trac tion o f the

deep loc a l stabili zers, and then ask

the p a tient

to lift

the b o t to m th igh whi le maintaining the posi tion of the spine and pelv iS ( n o til ting or rotation ) . Allow o nly the ra nge of mo tion where the lumbopelvic posi tion can b e controlled. Prog ress i o n s/oth er co n s i d erati o n s

A lift w ith the leg

s traight w i ll ac tiva te the lon g add uctors. Both move­ men ts can be tested

and

the position prescribed

based on the weaker component. Alternate e xercise

H A M ST R I N G S The m e d i a l and la teral h a m s tring muscles have d i f­ ferent fa scial and l i g a mentous connections to the pelvis, and asymme try in activa tion and s trength is often p resent in

p a tien ts w i th l u mbopelvic-hip

dysfuncti o n . Th is a ffec ts torsiona l forces th ro u g h the knee

joint.

Palpa tion of the

medial

(sem i tendi­

nosu s / semimembranosus) and la tera l h a m s t rings (b iceps femor i s )

d u ri ng

the prone knee-bend exer­

cise (see Ma i n t a inin g neutral spine w i th lo a d i ng:

Trunk and leg dissociation - prone,

Fig . 10.72)

will

reveal t h e a symme try. Resisting k n e e fle xion i n this p osition comb ined with med ia l or la teral ro ta ti on of the tibia will p rovide a measur e o f s tre n gth. Howev er,

if

the

SIT

is poorl y con trol led, this dys­

function needs to be a d d ressed firs t . Only then can hams tring re training begin. Several op tions are a v a i lable for s t rengthening the hams trings: closed­ c ha in exercises such a s squa ts, spl i t s q u a ts, and lunges pro v i d e the bes t environmen t to train sym­ m e tric a l med i a l / l a tera l recruitment. To u p tra in t he less recru i ted hams tring muscle(s) , use ta c t i l e cues ( " find this muscle ") and verbal cues ( " I m a gine the re i s a w i re from the ou tside of your knee [ touch p a tien t's fibula] to the o utside of your hip : ke ep ten­ sion in the

wire

througho u t

the exerci se . " )

to

increase a c tivi ty in the m u scle d uring movemen t. I f o p e n -cha in hams tring c u rls a re used, the m u scles m ust be p a l p a ted to ens u re equal a c tivity, and the tibia m u s t stay neu tral ( the foo t sho uld no t turn in or o u t) d u ring the exerc ise.

op tio n s include s tand ing add uc tion w i th p u lleys ( or a dd uc tion a g a inst resistive exercise band ) . The sta nd in g posi t ion requires su fficient lum b opelvic s tabi l i ty

and hip control in the unaffected leg

(weight-bearing leg ) . In b a ck or pelvic pa in i t is

AD D R ES SING SPECI F I C G L O BAL M U SCL E " TI G H T N ESS "

p a tients w i th chronic low common for load tra nsfer

As previously disc llssed, lumbopelvic-hip d ysfLmc­

performance to be a ffe c te d bila tera lly, consequently

tion often results in hyper tonicity a nd / or s h o rten­

exercises in one- leg s ta n d i n g are less op ti m a l .

ing

of the glob a l muscles, w i th resu l tan t li m itations

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245

246

T H E P E LV I C G I R D L E

of movement through speci fic glob a l slings . Careful assessmen t (Ch.

8)

w ill reveal whe ther there is true

muscle shor tening or a neurological sensitivity / hyper tonicity in the m uscles,

and subsequently

d i rect the type o f manual intervention required . In both cases, s upplemen tary home exercises should b e prescribed w i th the goa l of increasing the ex tensi­ bili ty of a shortened muscle and/ or maintaining the mob i l i ty gained in a hypertonic muscle. This sec tion covers

home

exercises

for

the

lumb opelvic-hip

muscles tha t a re often short / hypertonic. The rea der is reminded tha t many of the muscle length tes t posi tions (Ch.

8)

c a n be modified into home exer­

cises . The exercise parameters prescribed will vary depend ing on the goal of the exercise; to mai.ntain and increase length in a short muscle, a prolonged hol d of at least

20-30 s (up to a min u te), repeated

two to three times, is necessary. This can be com­ bined w i th slow, range w i th

rhy thmic movements

F i g u re 1 0. 9 3 Ad d ress i n g specifi c g l oba l m u s c l e "ti g h t n ess" : erector s p i nae. The t h e ra p ist c a n provide a g e n t l e tract i o n fo rce with both h a n d s and encou rage " l e n g th e n i n g or o p e n i n g " of the back a s the l e g s hang fro m the b a l l . ( Re prod u ced w i th perm i ss i o n fro m © D i a n e G. Lee Physi othera p ist Corp. )

through

10 s holds to teach the p a tient new move­

ment p a t terns with fu ll muscle leng thening. Severa l i ma ges have been described thus fa r with the tech­ niques to release the "butt gripper," to res tore neu­ tral spine, and to restore op timal brea thing p a t terns; these can be used in conj unc tion w i th these exercises

the spine while the arms rest on the floor and pro­ vide

some lateral stability.

expansion " melting"

Posterola teral costal

brea thin g i s encoura g ed

and a conscious

of the mu scles is cued

du ring each

exhale .

to optimize results.

O B L I QU E A B D O M I NALS LAT I S S I M U S D O R S I

Asymmetries

The patient s tarts in fo ur-point kneeling with the hands together. The spine is allowed to flex as the pati e n t sits back on the fee t and walks the hands fo rward, farther away from the body. The thoracic and l u mbar spines should rema in flexed as the arms a re ex tended overhe a d , a n d the hands kep t close toge ther. To bias one side more than the o ther, the hands can be walked to the right or left, indu­ cing l a te r a l bending of the spine. Thi s exercise wil l also lengthen components of the quadra tus l u mbo­ rum

muscle.

in

the o b l i que abdorninals w i l l result

in a l tered thoracopel v ic a l ignmen t; correc tion of the n e u tral spine posi tion and main tenance of this position using imagery d uring the progression of s tabilization exercises is an

effec tive

way

to

acti v a te

the weak or p oorly rec r u i ted o b l ique a b dominal mu scles while providing a n active s tre tch of the opp osing oblique muscles

(Fig. 1 0 .64) .

La tera l costal

breathing is another usefu l techni que tha t re quires leng thening in the obl ique muscles (Fig.

1 0 .36) .

Lying p rone with the trunk ra ised into extension a n d supported on the elbows opens the an te rior ribcage and can be combined with breathing tech­ niques to stretch the e x tern al obliq u e abd ominals

E R E CTO R S P I N A E

and rec tus abd ominis bi latera lly. S u p ine trunk r o ta­

If the p a t ient has more restric tion in the erector

knees rock gently to one side a n d then the other)

tion stretches can a lso be prescribed (crook lying, above

but must be ca refu l l y moni tored. If there is a ro ta­

s tre tch will b e an e ffec tive technique for the erec tor

spinae

tha n in the l a tissimus d orsi, the

tional hypermobility of the lumbar spine or hyper­

spina e . An al ternate exercise

10 .93) .

is

the "ball hang " (Fig .

The p a t ie n t kneel s p rone over a large b a l l ,

mobil ity of the SII, a co-con trac tion o f the local sta bilizers should be c u ed prior to ro ta ting the hip s

hypermobilities

The

then p u shes from the fee t a nd rolls forw a rd on the

so tha t the

ball so tha t the spine is p a ra llel to the floor. The

th orax should also be o bserved for compensa tory

weight of the legs provides a gentle flexion force to

move ments (unil a tera l flex ion, ex tension, la tera l

Copyrighted Material

a re control led .

Treati n g the l u m bo p e l v i c- h i p dysfu n ct i o n

F i g u re 1 0 . 9 5

Add ress i n g specific g l oba l m u scle " ti g h t n ess" : rectus fe m o r i s a n d t e n s o r fascia l a ta e . T h e t h e ra p is t e n s u res t h a t t h e p e l v i s re m a i ns sti l l a s the ri g h t h i p i s moved i nto exte n s i o n . ( R eproduced w i t h perm i ss i o n from © D i a n e G . Lee P h ys i o t h era p i s t Corp.)

( see Maintaining neutral spine wi th l o a d in g :

Tru n k

an d leg d issociation - sitting) i s a n e ffec tive active stretch of the hams trings, w i th the added benefi t of rec ip roc a l inhibition due

to the a cti v ity in the

q u adriceps muscle . If the foot is kep t in neutra l ro ta tion, b o th the medial and la teral hamstrings

will b e required to leng then equa lly.

F i g u re 1 0 . 9 4 Add ress i n g specifi c g l o b a l m us c l e " t i g h t n ess" : h a m s t r i n g s w a l l stretch. (R e p ro d u ced w i t h p e r m i s s i o n fro m © D i a n e G. Lee P h ys i o t h e ra p ist C o r p .)

R E C T U S F E M O R I S A N D T E N S O R FA S C I A LATA E Several variations of this ex ercise can be pe rformed . The key component is control of the pelvic posi tion

shi ft, or rota tion) that take the res tri c ted muscles o ff s tretch and thus render the exercise ineffec tive.

as the hip and leg are moved into ex tension . For

is cued to stabil­ pull of the rectus

b o th musc les, a pos terior pelvic ti l t ize the pelvis a nd re sist the

femoris and tensor fasc ia l a tae muscles . To s tretch

H A M ST R I N G S

the rectus femoris, the patient

is

s i d e lying w i th the

botto m hip and knee flexed to 90°. The pa tient This exercise is a modifica tion o f the tes t described

bends the top knee to grasp the ankle.

in Chapte r 8 (Fig. 8 . 70c-e ) . The pa tien t lies on the

p e lv i c tilt is p erformed, the n the patient pulls the

floor with the h i p flexed, knee bent, and the foot

leg into hip ex tension and knee flexion u n ti l a gen­

s u p p orted on a wall or doorframe. The other leg lies

tle s tretch along the front o f the thigh is fel t . Th e

A posterior

through the door, w i th the knee slightly b ent or

therapis t monitors the pelviS for any signs of anter­

straight. The s tretch is pe rformed b y slowly sl i d i n g

ior tilt (Fi g . 1 0 .95) . To bias the stretch into the ten­

the foot up the wall, straightening the knee until

sor fascia latae muscle, the knee flex ion is sligh tly

a

released, the h ip is e x ternally rota ted (while the

stretch is fe l t in the pos terior thigh . Alterna tely,

the

patien t places

the

s tra ight leg

against

the

wall. The amoun t of s tre tch is va ried by how close the body moves towards the wall (Fig. 10 .94) . The

p e l v is remains ne u tra l -

no

rolling back) a nd the leg

is adducte d while maintaining the hip ex tension com­ ponent. If the hip i s allowed to flex or the pelvis rolls

med ia l or lateral hamstring is biased by rotating the

back the s tre tch will be removed from the tensor

tib ia / fibula and

fascia l a ta e . A stre tch sho u l d be felt in the muscle

foot into ex ternal rota tion (for

medial hamstrings) a nd in ternal

rotation ( for the

belly a t the i lium or may b e felt a l ong the fascial

lateral hamstring) . The seated knee extension exercise

connections of the i l ioti bia l band . The tensor fa s c i a

the

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247

L

248

T H E P E LV I C G I R D L E

in a kneeling posi tion,

abduc ting t h e l e f t thigh, the patient can v a r y the

with one foot on the ground a nd the o ther knee on

abduc tion and adduction of the right hip and fi nd

the grolmd behind and in line with the heel of the

the position where the mos t res tric tion is percei ved.

latae can also be s tretched

foo t .

The kneeling leg

is positioned in hip adduc­

tion a nd e x ternal ro tation. The pelvis is posteriorly til ted and then the body sways fo rward on to the front foot to move the hip into ex tension . Again, it is importa n t for an effective tensor fascia la tae s tre tch tha t the pelvic tilt and hip ex tension comp onents a re maintained as the body moves forward .

S u m m a ry A p ri m a ry req u i re m e n t of t h e l u m bo p e l v i c- h i p reg i o n i s t o tra n sfe r l o ad a n d t h i s d e p e n d s o n :

1 . opti m a l fu n cti o n of t h e b o n es, j o i n ts, a n d l i g a m e nts (fo rm c l o s u re)

2 . o p t i m a l fu n c t i o n of the m u scles a n d fa s c i a (force

P O ST E R I O R B U TTO C K - P I R I F O R M I S / D E E P E XT E R N A L R O TATO R S O F T H E H I P

c l o s u re)

3. a p p r o p r i ate n e u r a l fu n c t i o n ( m o t o r c o n t ro l , e m ot i o n a l sta te) .

The fo ur-point kneeling rock exercise has been described p reviously (Fig.

10.24) and can b e per­

formed a s a motor p a t terning exercise (to teach trunk-hip

dissoc i a tion)

a nd

held

at

the

end­

T h e effect ive m a n a g e m e n t of l u m bo p e l v i c- h i p pa i n a n d d ysfu ncti o n req u i res t h o ro u g h a n a l y s i s (Ch. 8 ) a n d t rea t m e n t of fo rm c l os u re , fo rce c l o s u re , m o t o r

position of hip flexion to s tre tch the m uscles of the

c o n t ro l , a n d a n u n d ersta n d i n g of t h e i m pa ct of t h e

pos terior b uttoc k . A fu rther stretch is ob tained

e m ot i o n a l s t a t e o n m o t o r c o n t ro l a n d p o st u re .

by positioning the hips into some intern a l rotation

U l t i m a te ly, the g o a l i s to t e a c h the p a t i e n t a hea l t h i e r

at the s tart o f the e x ercise ( " s l ightly tur n the knees in" ) . Altern a te l y, s l ightly d ifferen t fibers of the

w a y t o l i ve a n d m ove such t h a t su sta i n ed co m pression

muscles will be targeted w i th the pretzel s tretch. The

a v o i d e d . T h e key is to resto re confi d e n t sta b i l ity w i t h

pa tient l ies supine w i th the knees b ent. To s tretch

m o b i l i ty. The t h e ra p ist u ses m a n u a l sk i l l s ( m o b i l ization,

th e

right

posterior hip muscles, the right a nkle i s

c rossed over the left knee, pla cing the right hip in to ex ternal rota tion a nd flexion. "let the righ t

buttock

go wide and let the hip sink"

up

m a n i p u l a t i o n , and t o u c h ) , e d u ca t i o n , and exercise t o fa c i l i t a t e t h i s process. If yo u a re i n te rested in l e a rn i n g m o re a b o u t t h i s

The pa tient then

grasps the left p o s terior thigh. Ask the pa tient to as the left knee i s p u l led

a n d/ o r t e n s i l e fo rces o n a ny o n e s t r u c t u re a re

towards the chest

m o d e l a n d t h e i n te r n a t i o n a l rese a r c h e rs a n d c l i n ic i a n s w h o e m b race i t , p l ease j o i n u s at t h e I n te rd isci p l i n a ry World Co n g ress o n Low Back a n d Pe l v i c Pa i n

w i th the hand s . This movement is s topped when a

(www. w o r l d co n g ressl b p.co m ) . Fo r c o u rses a n d o t h e r

gentle s tretch is fel t in the pos terior b uttock. There

e d u ca t i o n p ro d u cts re levant to t h i s text c h e c k

sho u l d be no sensa tion of pinching or imp ingemen t

www.d i a n e l ee.ca a n d www. lj ptco n s u l t i n g .ca.

in the

g roin

of either hip .

By

gen tly a d d u c ting a n d

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249

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B a s m a j i a n J V, Delu ca C J 1 985 M u scles a l i v e : th e i r f u n ctions re v e a led by electromyography. W i l l ia m s & Wi l k i n s, Ba l t i more

A b i tbol M

M 1995 Energy storage in the vertebra l col u m n . In: V leem i ng A, Mooney V, D o r m a n T. Sn i j d e rs C (eds)

B a s s e t t C A L 1968 B iologic significa nce of p iezoe lec t r i c i ty.

Seco nd i n terd i s c i p l i n a ry world c o ngress on low b a c k

Bel l a m y N, Park

pa in: t h e in tegra ted function o f the l wn b a r s p ine and sacro i l ia c j o in t. P a r t 1 . Sa n Diego, C a l i fo r n i a , p 257

W, Rooney P J 1 983 Wha t do

we

know

a bo u t the sacroil i a c join t ? Se m i n ars i n A r thritis a n d Rheu m a t i s m 1 2 :282

A b i tb o l M M 1997 Q u a d ru p ed a l is m , b ipeda l is m, and h u m a n pregna ncy. I n : Vleem ing A , Mooney

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V, Dorman T,

Berg m a rk A 1989 Stab i l i ty o f the l u m b a r s p i n e . A s t u d y in mech a n i c a l e n g ineering. A c ta O r t hoped ica S c a n d i n a v i ca

Sn ijders C S toeckart R (eds) Move m e n t, s ta b i l i ty a n d l o w b a c k pa i n . C h u rch i l l Liv ings tone, E d i n b u rg h , p 3 9 5

23 0(60) : 20 Bernstein 1, J u u l N, C ro nva l l S, Bonde B, K1ars kov P 1 9 9 1

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Wingerd en J P, S n ij d e r s C J 1 995 a The po s t e r i o r layer of the thoraco l u mba r fasc i a : its function i n load transfer from sp i n e to l e g s . S p in e 2 0 : 753 V l e e m i n g A, S n ij d e rs C J , Stoeckart R, M e ns J M A 1995b A new l ig h t on low b a ck p a i n . In: P roc e ed ings from the 2nd interd is c i pl i na ry w o r l d congress on low back pain. San Diego, C a l i fornia Vleem ing A, Mooney V, D o r m a n T, S ni j der s C (eds) 1 995c Se c on d in terdisci plinary wo rld c o n g re s s on low b a c k p a in : t h e i n t e g r a te d function o f th e l u mb a r sp ine and sac roi l i a c j o int, pa rts 1 and 2. San Diego, Ca l i fornia V leem ing A, Pool-G o u d zwaard A L, Ha m m u d o g h l u 0, Stoe c k a r t R, Snijders C J, Mens J M A 1 996 The func t i on of the long d o rsa l s a c ro i .l ia c li g a m e n t: i ts i m p l i c a t i o n fo r unde r s t a nd in g l o w back p a in . Spine 2 1 ( 5 ) : 5 5 6 V l ee min g A , Sn.ijders C J , S toec k a r t R, Mens J M A 1997 The role o f the sac roi liac jo i n t s i n coupl ing between s p i n e, pelv is, legs a nd a r m s . in: Vlee m ing A, M oo n e y V, D o rm a n T, S n ij de rs C , Stoeck a r t R (eds) Movement, s tability and lo w back p a in . Ch u rc hi l l L i v ing s t on e , Edin b u rgh, p 53 Vleeming A , de Vries H L M e n s J M, van Wi n gerden J P 2002 P o ss i b l e role of the l o n g d o rs a l s a c ro i l i a c l iga m e n t in women w i th perip a r tum pelvic p a i n. Acta Obstetrica G ynec o l ogic a Scand i n a v ic a 8 1 (5 ) :430 Wa dde l l G 1998 The bac k p a i n revo l u ri o n . C h urchi l l Liv i ngston e , E d i n b u rgh Walheim G G, Sel v i k G 1 984 M o b ili ty o f th e p u bic s y m p hysis. C linic a l O r th opaed i cs a nd Rela ted Res ea rc h 1 9 1 : 1 29 Wa lker J M 1980a Morp hologica l v a r i a n ts in the h u m a n fetal hip j oint. J o urn a l o f Bone a nd Join t S u rgery 62A : 1 073 Wa lker J M 1980 b G rowth cha racteristics of the feta l l i g a m e n t of th e head of fem u r : signifi c a n ce in con g e n i t a l hip d isease. Ya le J o u rna l of Biology a nd M edic i ne 53:307

Wa lker J M 1981 Hi s tologica l study of the feta l d e v e lo p m e nt o f the human aceta b u lum and l a b r um : s i gni f i c a nc e i n

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c o ng eni t a l hip d i se a s e . Ya le J o u r n a l o f B i o lo g y and Med i c ine 54: 255 Wa lker J M 1984 Age ch a n g e s in the sacro i l i a c joint. Proceedings of the 5th Interna hona l Federa tion of O rth o p a e d i c M a n i p u l a t iv e Thera p ists. Vanc o u v e r, p 250 Wa l ker J M 1 9 8 6 Age-rela ted d i f fe rence s in the h u ma n s a cro i l i ac j o i n t : a h i s t o l o gi ca l s t u dy ; imp l i ca ti o n s fo r t he r a p y. Journ a l of O r tho p a ed i c a nd Sports Ph y sic a l T he r a p y 7:325 Wa tanabe R S 1974 E mb r y o l o g y of the h u m a n hi p . C l ini c a l Orthopaed ics 98:8 Webster D F, H a rv e y W, Dyson M, Pond J B 1 9 80 The role of u l tr a so un d -indu ce d cavita tion in t he "in vitro" s tim u l a t io n o f c o l l a g e n s y n the s i s in h u m a n fi brobl a s ts. Ul trasonic 1 8 :33 Weisl H 1 954 The a r t i c u l a r s u rfaces of the sa cro-iliac j oint and their r e l a t i o n to the moveme nts of t h e sacrum. A c ta A na to m ic a 22 : 1 Wei s l H 1 955 The movements of the sacro-i l i ac j o int. Acta Ana tomica 23 :80 W h ite A A , Panj a b i M M 1 9 78 The basic kine m a tics of the h u m a n spine . Spine 3 : 1 2 Whittaker J L 2003 Abdominal u l t r a s o u n d i ma gi n g of pelvic floor muscle function in ind i v i d u a l s w i th low back p a in . Journal o f Man u a l and M anip u lative Therapy (submi tted) Wi l d e r D G, P ope M H, F r ym oye r J W 1 980 The f u n c t i o n a l topogra phy of t he sacroiliac joint. Spine 5:575 Wi l l a rd F H 1 997 The muscu l a r, l i g a m e n to u s and ne u r a l s truc t u re of the low back a nd i ts re l a h o n to back p a in. In: Vleeming A, M o o ne y V, Do r m a n 1, Snijders C, Stoeckart R ( e d s ) Movement, stab i l i ty a n d low back p a in. C h u rc h i l l Livi ngstone, Ed inburgh, p 3

Willa rd F H, C a rre i ro J E, Ma nko W 1998 The lo n g pos te rio r the s acro c occ y g ea l p l e x u s . In: P rocee d in gs from the 3 rd inte rd isciplinary world congress on low back and p e lv i c p a i n . Vienna,

i n terosseo u s l i g a m e nt a nd

A u s t ri a, p 207

Wil l iams P L 1995 Gra y ' s ana tomy, 38th e d n . Chu rchi l l L i v i n g s to n e , N e w Yo r k Wrobl ewski B M 1 978 Pa in i n osteo a r throsis o f t h e hip. Pract i t ioner 1 3 1 5 : 1 40

S, H u m b s ch K, Reichenback J R, Pe i ke r G, Seew a l k H J, K a i se r W A 2002 MRJ of the p e l v i c r ing joints postpartu m: no r m a l and pathological find ings. Journ a l of Magnetic R e so n a n c e Imaging 15(3) :324 Wurff P, H agme ij e r R, M eyne W 2000 Cl in ica l tests of the s a c r o i l i a c j O in t . A s y stem a ti c methodological r ev ie w : p a r t 1 : rel iabil i ty. Manual T h e r a p y 5 ( 1 ) :30 Wy ke B D 1 9 8 1 The neuro logy of joints : a rev iew of gene ral p rinc iples. Clinics i n Rhe uma tic Diseases 7:223 Wyke B D 1985 A r t i c u l a r ne u ro logy a nd man i p u l a tive t h era p y. I n : Glasgow E F, Tw o me y L 1, Scu l l E R, Kley nhans A M (eds) Aspects of m a n i p u l a tive th e r a p y, 2n d e d n . C h u rchill Liv ings tone, M e l bo u rn e , p 72 Yo ung J 1940 R el a x a ti o n of the pelvic j oints in p reg n a n c y : pelvic a rthropath y of p regna ncy. Journal of Obste trics and G yne c o l o g y 47:49 3 Yo u n g J Z 1 98 1 The l i fe o f vertebra tes, 3 rd edn. C l a re n d o n Press, Ox ford Yu e G , Cole K J 1 99 2 St r en g th increase fro m the motor p ro gr a m m e : c o m p a r i s o n of tra ining w i t h m a x imal voluntary a n d imagined muscle con tractions. Journ a l of Neurophysiology 67(5 ) : 1 1 1 4 Wu rdi n g e r

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2 59

I n d ex

A b d u m in a l b ra c ing postu re, 137, 182 A b d o m in;] 1 m usc les p elvic

fl oo r con t r'l C tion and, 201, 202, 203, 204 use d u ri n g bre a t h i n g , 19 2- 1 9 3 , <,c 17/,0 E x te rna l o b l i q u e muscle; ln tcrn � 1 o b l i q ue mu s c le; Rec t u s 'l b d o min is m uscle; Tr,1 11 sV lTSUS abdom i ni s A b d u c ti o n , "ill, 64-65 Acel'1 b u l u m a na tom y, 1 9 , 2 0 , 25, 2 7 blood s u p p l y, 3 9 evolu tion, 5 Active: bent leg raise test, 1 08-1 1 0 Active m o b i l ization techn i q u e s co rrec t i o n o f a l i gn ment, 1 96 fibrotic hip joint, 1 77-178 lumba r segmenta .l dysfunc tion, 1 67-1 69 sacro i liac j o int res t r i c t i on, 1 7 1 - 1 72, 1 73 A c t i v e s traight leg r a i se test (ASLR), 1 06-108, 1 09 b la dd e r s ta b i l i ty d uring, 129, 160 w i th 111'1 n u a l comp ression, 107-lO8, 201 A d d u c tion, 56, 64-65 Ad d u ctors, thigh length tes ting, s t rengthening

Adhesions, 78

Ba l a n c e ,

h is t o ry, 1 5 j o i n ts, 20-28

A

119 e xe r c is es, 245

Adj u n c t ive te s ts , 130- 1 32

Agi ng, 10-13

l u m b a r spine b i o me c ha n i c s a n d ,

p ubic symp hysis, 1 3

sa c ro i l i a c join t,

1 0-13, Plates 3-5 A l ignm e n t , tec hniqu e s to c o r rect, 164-165, 1 95-1 9 6 Ana tomy, 1 5-39 age-re l a ted c ha nge s , 7-13 b l o o d s u pp ly, 39 bones, 1 6-20 com para t i ve, 4-6

59

c h a l l engi n g , 240-241

Ball

muscles, 28-37

nerves, 37-39 A n g i o l o g y, 39 Ankylosing s p o n d y l i tis CT s c annin g , 131, 1 3 2 sacroiLiac jo i n t c h a n ge s, 1 3 Ank y l o si s , sacroiliac j o in t , 1 2-13 Annul us, clrcumferentia l tears, 135, 136 A nterior a b d o min a l a p o ne u ro s is ( fascia), 29, 31-32, 33 objective exa min a tion, 1 06 rea l-time ultrasound i m aging, 124 see also Linea a lba Anterior dis trac tion : p o s t e r i o r co m p re ss i o n pain p rovoca tion test, 100 A n terior obli q u e s l ing, 52, 53 length tes ti ng, 1 1 5, 1 1 6 strength a na lYSi S , 1 1 2, 1 1 3 A n t e ri o r pelvic ti l t, 56, 59, 1 88 Ante rio r ro tation, 56 A n terior s u p e ri or i l iac spine (ASrS), 1 9 Arc u a te l iga m e n t, infe rior, 2 5 , 2 6 Arcus tend i ne u s fa scia, 30-3 1 , 158-159 A r t ltr o k in em a tics, 56 Art hrokinetics, 56 A r thro l o g y, 20-28 A r t i c u la r co m p re s si on excessive, 1 35-1 44, 1 5 8-159 with un d e rl y i n g insta b i l i ty, 144-146 i n s u ffi c i e n t, 1 46-157, 1 59 s t r a tegies for red u c ing, 164 s t rate g i es f o r restor i ng , 164 Ax i a l ro t a t ion , 56 bio mechanics, 58, 59, 67 in s tan d ing test, 87

kn e e l i ng o n , 2 4 1 pos terior g li d e of femora l hea d

exerc ise, 1 79 roc k'n'roll exercise, 1 79 s q u a t s w i th, 232-233 trunk and arm d is s o c i a t i o n s i t ti n g on, 220 B a l l a nd bowl c once p t ( P a nj a bi ' s stabi lity mod el), 89, 158 "BaJ I h a n g " ex e rc ise, 246 B a l listic exe r c is es , 240 B e n d in g movements, 56 B en t knee fa l l- o u ts , 222 B e n t leg raise test, a c ti v e , 1 08-1 1 0 B i c e p s femoris musc le, 23, 24 Biofeedback, 203

Biomec h a ni cs, 55-72 h i p , 64-65 in te g r a ted model, 65-72 l i fting, 7 1 -72 l u mbar spine, 56-- 5 9 p e l v i c g i rd l e , 59-64 p regn a n c y, 72 t e rm ino l o gy, 56 w a J k ing, 67-71 B i p e d a l is m, 3, 4, 5-6 B l a dder desce n t d u r ing fu nc ti o na l acti v i ty, 1 29, 160-1 61 p el v i c fl o o r re t r a inin g , 202-204 s tability d u ri n g tru nk loadi ng, 129 u l trasound i m a ging, 1 27-1 29, 201-204 B l ood s u p p l y, 39

Bo n es

a n a tomy,

1 6-20 development, 7-9

B rea th- holding

m u l t i fid u s contracti on, 2 1 2, 213,

B

214

Backwa rd b e n d ing

(in s ta nd ing ) , 56

b iomecha ni cs, 66 tes t, 86

Copyrighted Material

p e l vic floo r con t rac ti o n , 202 transversus a b d o m i ni s iso l a t i o n,

206

...

260

I N DEX

B r e a th in g d ia p hra g m excu rsion, 5 2

observ i n g / fa c i l i ta ting l a te ra l costal e x p a ns ion, 1 93 -1 9 4 p a t t e rns m o n i t o rin g, 1 9 5 restoring, 192-195 pelvic floor ret r a ining and, 202, 203

exp a n s i o n spinae rel e a s e ,

posterol a te r a l costal e rector

a nd

1 94-- 1 95

s e tt i n g spina l p o s i t i o n , 1 8 7, 188 tra n svers u s a b do m ini s m o v e men t ,

122 Bridge a n d ro ta te e x e r ci s e ,

C o u g hi n g b l a d d er m o b i li ty, 1 29, u re thra l closure , 1 60 Co untern u t a tion, 5 6,

Electromyography

1 60 - 1 6 1

60-6 1

Crook ly in g p o s i ti o n n e u t r a l s p i n e , 1 84-1 85 trans versus abdominis isolat ion, 204

and a rm d issocia tion exerc ise, 2 1 8-21 9 trunk a nd leg d issoci a tion exercise, 221-224 see also S u p ine p o s i ti o n Cro s s - tu b in g l u n g es , 23 6-2 37

d i a p h ra g m , 5 1

pe l v i c floor, 5 1 , 1 60, 1 6 1 urethra l, 160

E m b r y olo g y, 7-1 0 Emotions, 43, 54 E n dopelvic fa scia, 3 0 , 3 1 , 1 58-1 59 ca uses of d a m a ge , 1 28

trunk

c hi ld b i r th-re l a ted da mage, 1 6 1

1 8 1 -1 8 2, 2 1 4-215 33-:14 ap o n eu ro s is , 34 intra m u sc u lar s t i m u la tion, 1 9 7, 1 9 8 l en g th tes ting, 1 1 5-116 m u l t i fi d u s contrac tion and, 2 1 0 , 212 release, b re a th i ng techn i q ues,

E n d ur a nc e tra ining, Erector spin ae,

22 8- 2 2 9

Bri d g i n g e x e rc i se, 244

p u b o fe m o r a l , 27 " B u tt gripping", 1 40, 1 4 1 , 1 8 2 m u l t i fi d u s con trac tion a n d , 2 1 2 p o s i t i o n a l t es t in g, 1 0 1 - 1 02 re l e a s i n g techn iques, 185-1 86, 189, 1 9 0- 1 9 2

B u rsa,

step up exercise, 239

B u ttoc k s

fa l l o n to , 146, 1 74 of s e r i o u s pa tho logy, 1 44

signs

c Cen ter of g r a v i ty, 70, 1 8 8 Child ren, sacroil iac j o in t, 1 0- 1 1 , Pla te 2 C i r c l e of in te g r i ty, 35-36, 3 7, 50, 204 C l a m s h e l l exerci se, 242-243 C la u d i c a tion, n e u ro ge n i c vasc u l a r, 148 C lose- p a c ke d p o s i t i o n , 46 C o - c o n t ra c t i on analysis, local s y s te m , 1 1 0- 1 1 1 Co-co n t raction tra in i n g , l o c a l system, 21 4-- 2 15 C o c cy g e u s m u scle, 23 C occ yx ana tomy, 18-19

fl ex i o n / e x te n s i o n , 6 1 Cognitive-behav ioral thera py, 5 4 Co l l a ge n fibers exercise p rogra ms and, 78, 79

j o i n t c a ps u l e,

79

in tendon hea l ing, 77-78

ten dons, 76-77 in W O UJ1 d h ea l in g , 76 C o m p re s s i o n, ar ti c u l a r see A r ti c u l a r

c o m p re s s i o n Co m p re s so r, 1 8 0 - 1 8 1 Com p u ted tomograp hy (CT sc anning), 131 Co n j oin t t e n d o n , 2 9 Coord i n a t i n g l oc a l and g lob a l sy s te m s , 1 65-166, 215-240 fu nction a l in t e gr a t i o n , 230-240 g e ne ra l p r in c i p l es , 2 1 7- 21 8 m a in t a i n i n g ne u t r a l sp ine with lo a d ing, 218-227 moving o u t of ne u t ra l spin e ,

227-230 subop t i ma l, 1 6 6

(EMG)

D

1 94-1 95

Deep b a c k w a l l 30-31

of pelv is, m uscles,

Deep vein th rombophleb itis, 130 Degeneration, l u m b a r s p ine

biom echanics and, 59

Derma tomes, 1 3 0 De v e l o p m en t , 7-1 0 bones, 7-9

j o in ts , 9-10 D i a gnosis, 81-132 obj e c t i v e ex a m i n a t i o n see O b j e c t i v e e x a m in a t i o n s u bje c ti ve e x a m i n a tio n, 8 1 -83

stretch e x e rc i s e , 246

Evol u t i on, p e l v i c gird le, 3-4 Exa mina tion o bj e ctiv e see O bj e c t i v e e x a m i n a t i o n s u bj e c t i v e , 8 1 -83 E x e r cis e p rogra ms, 1 65, 1 8 1 - 1 82 c o o r d i n .:l t in g g l o b a l and loca l s y s tems, 215, 2 1 6 j o i n t c a p s u l e he a l ing , 79 tend on h e al in g , 78 see a lso Home e xe r c i se s ; specific exe rcises E x tended rota ted / s i d eflexed left

(ERSL) lumbar s eg m en t a l

Diaphragm, res p i ra to ry, 3 1 , 32, 192

d ys f u n c t i o n , 139, 166-167

fu nc ti on , 49, 5 1 -5 2

p a s s i v l' .:l nd ac t iv e mob i l iza tion

re t ra in i n g, 1 9 3-1 9 4

D i s t r a c t i o n m an i p u l a t i on hi p j o in t mob i l iza tion, 1 77-1 78 s a c roi l i a c j o i n t re s t r i c t i o ns, 170- 1 7 1 , 1 74--175 zygapophysea l

j o in t fixa tion,

1 69-170 D o r s a l s a crococ c y g e a l l i g a m en t , 25 Dmvn t ra ining the globa l sys tem,

1 8 2 - 1 95 Dri v ing p o s i t i o n , 23 1 Dry n eed l ing ( i ntra musc u l a r

techn i que, 1 68-169

tr a c tion/ pass i v e mob i l i z a t i o n t eclmiq u e , 1 68 E x ten s i on , 56 E x te rn a l o b l i q u e ( EO) m uscle, 3 1 -32 intra m u sc u l a r s ti m u l a tion , 1 9 7 le n g th tes t i ng , 1 1 5 , 1 1 6 post u ra l re-ed u c a tion, 1 82, 1 8 3 t r a nsversus a b d o m i n i s i s o l a tion

a nd , 205, 206-207 Ex tern a l rota tion, 56

s t i m ula tion), 1 96-199

D u ra l / ne u r a l m o bi l i ty Dysesth e s i a

tests, 130

i n l u mbar s e g m enta l i ns ta b il i ty,

1 49, 154

s u bj e c t i v e e x a m i n a tion, 82

Dy s f u n c t i o n , l um b o pel vi c -hi p , 75 c l a ss i f i c a tio n of causes, 1 33-1 3 4 d i a g n o si s , 8 1 - 1 3 2 e t i o logy, 1 34 hea l i n g p rocess, 75-80

manu a l the r a p y tes t s , 7 4--7 5

tre a t m ent ,

1 63 - 2 4 8

F Fasci a , leg, 36-37

Fec a l co n t in e nc e , 50-5 1 F e m o r a l a r c u a te l i ga m e n t, 26, 27 Femora l head, 25, 26 an t e r i o r d isp l a c em e n t , 1 02, 142 blood s u p p ly, 39 pOSi tional tes ts, 1 0 1 - 1 02 p o s te r i o r g l i d e in fe moral e x te n s i o n , 1 79-180

i n fem o r a l flexio n, 1 78-1 79

F e m o ra l ne rve s t retch test, 1 3 0

Fem u r

E

abd uction / adduc tion, 64--6 5

Educa tion, p a t i ent , 1 8 1 , 231 E l a s tic zone o f j oint

motion, 89

Elec t r i c a l therapy, te n d o n inj u ry, 78

Copyrighted Material

a na to m y, 20 fl e x i o n / e x tension, 64 medi a l / lateral rota t i o n , 64, 65 mo t io n d ur i n g w a l k i ng, 68

I n dex

F ibrob l a s ts, 76

Fibroc a r t i l a ge, s a c r o i l iac j o i n t, 1 1 ,

230-240 low to h igh p u l l e ys, 240

20-2 1 , P l a te s 1 -5

is, 25, 26 F i b rotic s t i ff j o in t, 164 sym p hy.

Fin fo l d theo ry, 3

Fla t b a c k

1 64

insu fficient Flexed rota ted / s i d e fJexed left (FRSL) l u mba r segmen t a l d y s f u n c t i o n , 1 39, 1 66-1 67 p assi v e a nd a c t i v e mob i l i z a tion techn iques, 167-168 tracti o n / passive mobil i za tion techni q u e , 167

F l e x i b i l i t y exercises, 1 82 F l e x i o n, 56 Force c l os u r e, 42, 43, 46-53

restori ng, 1 65-166, 181-182 Force closure / motor co n t ro l ana l y si s , 106-1 29

i n ex c e ss i ve

h i p j o i n t c o m p re s s i on ,

1 44

in excessi ve l u m b a r s p i n e

l u nge w i t h i s o me tric e x t e rn a l

s te p u p , 238-239

rot a t ion, 243-244 p ro n e hip e x tension and a b d u c t ion, 244

F u n c t i o n a l tests, 83-89

G l u te u s mi n i m us, c o mpa r ativ e

a n a to m y, 4, 5, 6

G

G o l f s i m u la t i o n e x e rci se, 230 G unn, Dr.

a s sessment, 83 i n e x ce ss i ve

hip j o in t compression, 143 in e x c e ss i v e l u m ba r s p ine com p res s i o n, 1 3 6 in excess i v e l u m b a r sp i n e

c o m p res s ion w i t h ins ta b i l i ty,

145

in excessi v e pel v ic gi rdle c o m p r es s i o n with ins ta b i l i ty,

146

1 45

in l u mba r s e g me n ta l i n s t a b i l i ty, 149

c omp ress i o n w i t h i ns ta b i l i ty,

1 46

in e x ce ss i v e S[J comp rL'ss i o n , 142

l u m b a r se
in p e l v i c gi r d l e insta b i l i ty, 1 5 7 F o r m closu re, 42, 41 46 a n J l y s i s, 89-105

in excessi w hip j o i n t com p ression, 144 in excessive lumba r sp i n e compress ion, 138

in L' xcessive l u mb a r s p i n e comprL'ssion w i th

Chan, 196-1 99

Galt, 67-71

in excessive SlJ c o m p r e ss io n , 140 fe mo ra l motion, 68 l u m bar mot ion, 70-71

in exces s i v e pe l v i c g i rd l e

in

s tep down, 239-240

c o m p ressi o n , 13&-1 39

in excessive l u mb a r s p i n e com p re s s i o n w i th ins ta b i l i ty,

c l a mshell exerc ise, 242-24 3 i so me t ric w a l l p ress, 243

step forwa rd, step back, 234

L u m b a r lordosis,

see

strength te s t in g, 1 1 3 , 1 1 4 s tre ng t heni ng o f p o s t e r i o r f i bers, 242-244

l u ng es and v a r i a tions, 235-237 one-leg squa ts, 237-238 squa ts, 232-234

Fib roca rt-i lagenous d i sk, p ubic

Fixated j O in t,

s ta b i l iz ing f un c t i o n , 1 1 3

Functional in tegr a ti o n exercises,

in pe l v ic gi rd l e in s ta b ili t y, 154-1 56 p e l v i c gi rd l e motion, 69-70 see also Wa l k ing Ga mma fe ed b a c k loop, 38

CJ te-control th e o r y, 39

Geni tofemoral n erv e , 38 G i llet tes t see On e - l egge d sta nd in g test Global m u s c le system, 52-53 add ress i n g s pe cif ic " tigh tness " , 245-248 a d d res s in g spec i fi c " wea kness " , 241-245 coord i n a t ion w i th local s y stem see

H Ha m m o c k , fu n c t i ona l, 30, 31, 1 58-1 59

H a m s tring m u sc les com p a r a tive

a na

t o m y, 4, 6

length tes ting, 1 1 6, 117

s t reng thenin g exercises, 245

s tretch exerci ses, 247 H a rd Core S t re ng th exercise, 236 Hea l i ng, 75-80 fibro blastic p h a se, 76 f i b ro u s j o in t c a p s u l e, 78-79 l ig a m en t, 78

m a tu ra tion phase, 76

relevance to trea t ment, '76-79

s u b s t r a te p h ase, 76 tendon, 76-78 Heel d rops, 222-223 Heel slid es, 2 2 2

H ee l -st r i k e p ha se , 68, 69-70 H ip j o i n t

a n a tomy, 25-28 an te r i o r i m p i n gement tes ting, 1 03, 1 04 blood sup p l y, 39

c a p s ul a r pa ttern o f r e s tr i c t i o n , 1 42,

Coord in a t ing lo c a l and

144 capsu le, 2 5-26

glo b a l systems

c l assi fic a t io n of d iso rd e r s, 1 34, 1 3 5

correction o f a li gnment, 1 95-1 96

c l o s e -p a c k e d

p os i ti on , 4 6 , 6 5 5 contro l prog re s s ions, 223-224

i n s ta b i l i t y, 145

dec o mp ress i o n via intra m uscu la r s tim u l a ti o n , 1 96-1 9 9 downtra i n ing, 1 82-195

c o mp a r a ti v e a na tomy,

insta b i l i ty, 146

length a na lysis, 1 1 4- 1 2 0

degeneration, 1 42, ] 43 , 144

in excess i vc' p e l v i c g i r d l e com p rL'ss ion w i th in e x c e s s i ve Sl] com p ression, 141-142 i n l u mba r segme n ta l insta b i l i ty,

ri gi d ity c h eckpoints , 1 9 5 re d u c ing, 18 2-1 95 si m u l a t i on tes t i n g , 1 0 7-1 08, 1 09

in p e l v ic girdle i n s ta b i l i ty, 1 5 7

s t re n g th ana lysiS, 1 1 1 - 1 1 4

1 53

res tori ng, 166-180

see also Linder

spccific joints

Fortin's distr i b u tion, p e l v i c pa in, 73,

74, 1 46 , 1 5 4

Forward b e n d i n g ( i n s t a n d i n g ) , 5 6 b i omec h a n ics, 65-66

tes t, 85-86 Fo u r- p o i n t kn ee lin g see Knee l ing, fo u r - p o in t Fourth a nd fi fth d ec a de , sacroi l ia c j o i n t, 1 1 - 1 2, Pla te 4

G l u te u s maxim us, 3 4 , 3 5 , 36-37 in tra m u s c ul a r s ti m u l a t i o n , 1 9 9 s t rengthe n i n g exercises, 244-245

d e c o m pres s i on , 190- 1 9 2

d evelopment, 1 0

excess ive co m p res s io n , 142-144 o b j e c t i v e find ings, 1 43-144 s u bj ec t i v e find i ngs, 1 42-143

externa I

ro ta tors

I.en gth testing, 1 1 9-120 overactiva tion, 1 0 1-1 02, 140, 1 42

bridgin g, 244

r e le as ing o v e r a c t i v e , 1 9 0-192

prone hip e x tens ion - knee

s tretch exercises, 248

f le x e d , 244-245

sea ted sq ueeze and si t to s ta n d ,

244 G l uteus medius com p a ra t i ve ana to m y, 4, 5, 6 intra m u s c u l a r s t i m u l a tio n, 1 99

Copyrighted Material

tr i g ge r p o in ts, 1 2 0 fibrotic, mob i l i z a tion, 1 '77-1 78 force c l os u re, 46-47 fo rm c l o s u re, 45-46 tests, 101-105 innerv a tion, 3 8

261

2 62

I N D EX

H i p joint

(eo11 ld)

llio l u mbar v e s s e l s,

I l i o p s o a s exercises, 245

k i n e m a tics, 64--65

I liotibial tract, 37

I l i um

l i g a m e nts, 26-27

o s teo a r thritis, p a in pa tte rn s , 1 43 p a in p ro v o c a t i o n

Interna I r ot a t i o n , 5 6 In terosseo us sacroi l ia c liga ment, 2 1 , 2 2 I n te r s p i n o u s l ig a m e n ts , 35

39

interna l / externa l rota tion test, 1 9 5

and gl ob a l

s t a bi l i ty tests, 1 05

p a l p a t io n points, 2 1 6 p a s s i v e tes ts o f arthrokine matic

I n tervertebra l d is k

a na tom y, 1 9-20

com pression, 43-44

arcua te line, 1 9-20

d e gL'nera tio n, 136, 147, 148 i nner va tion, 38

I magery, 231-232

I m p a i rm e n t, 81, 158-159 c l a ssifica tion

an d a r t h ro ki ne t ic function,

i n t e g r a ted func tiona l m o de l ,

a n te roposterior glide, 1 04--105 l a teral d i s tracti o n / c o m p re ss i on ,

104

med ical mod e l, 1 33-1 34

defin i ng, 1 33-161

s u p e ro inferior g lide, 1 04, 1 05 f un c ti o n, 1 02-104 a b d u c t i o n / add u c t i o n, 1 03

c o m bi n e d movement tes t in e x te n s i o n, 1 0 4

1 3 5-144, 1 58-159

w i th Lm d e r l y ing i n s ta b i l i t y,

c o m b i ned movement test in fl ex i o n, 1 03, 1 04

I n t ra p e l v ic torsions, correc t i on,

Ischia l s p ine, 1 9 , 20

i n s u fficien t u rethral 1 57-1 6 1

com p ression,

196

Isch i a l t u be r os i ty, 19, 20 Isch iococcygeus m u sc le, 30, 3 1

1 44-- 1 46

in s u f f i c i e n t a r tic u l a r c o m p re s s i o n, 146-157, 159

OMS),

196-199

e x ce s s i v e ar ti c u l a r co m p re s s ion ,

passive t e s t s of o s teo k inem a tic

stabi l izing f un c t i o n , 48-49

In t ra m u s c u la r s t i m u l a t i o n

1 34--135

1 04-- 1 05

to rsi on or ro t a t i on , 44, 58 I n t r a ,l b d omina l p re ss u re ( lAP),

i n t r a m u sc u l a r stim u l a t i o n , 1 9 7 , 198

Isc h i o femo ri1 1

liga ment, 26, 27-28

p a i n p r ov o ca t ion test, 1 05

Ischiu m an a to my, 19,

20

e x te n s i on, 1 0 2-1 03

I nc o n t ine n c e ,I'e Urina ry i n continence I n ferior gluteal vessels, 39

flex ion, 1 02, 103

Infl a m matory re s p on se , 76

4, 6 Is o me t r ic ex terna l ro tCi t i on, l u nge w i th, 243-244

l a tera l / me d i a l r o t a t i o n , 103, 104

lnnomi.nate

Isomet ric w a l l p ress, 243

p o si t i o na l tests, 1 0 1 -1 0 2

a natomy, 19-20

re s t o r i n g fo rm closure

a n terior ro t a t io n , 62-64

(mobili ty),

1 77-1 80

m o b i l i z a t i on techni ques,

H i p rock exercise, 1 79 , 225, 248

1 70-172, 1 73, 196

p a ss i v e test, 95, 96

Hip roc k ' n ' rol l e x e rc ise, 1 79 , 225

History, 1 , 1 5 H om a n s s i gn ,

J j o i nt(s)

a n terior shea r fixation, 1 75

H i p po c ra te s , 1

compa ra t i v e a n a t o m y,

a lign m e n t, c o r r e ct i ng , 1 64--165,

blood s u p p ly, 39

Home exerc i ses h i p joint m o b i l i z a t i o n , 1 78, 1 79

l u mba r s eg me n t a l

1 95- 196

c o m p a r a t i v e a n a to m y, 4

130

d y s f un c t io n,

168, 169

s a c r o i l i a c j o i n t res triction, 1 70 , 1 72,

H y a l in e c a r t il a g e

aceta b u l u m , 25

sacroi l i a c j o int, 1 1 , 20-2 1 , P l a tes 1 -5

c lo s e - pa c k ed ( s e l f - l o c k e d ) po s i t io n ,

evol u tion, 4

46

ossifica tion, 9

com p ress ion

p o s i t i o n a l a n a l y s i s , 94-95

decomp ress i o n s trateg ies, 164

fi x a tion, 1 75-1 76

d e v elo p m e n t, 9-1 0

mob i l ization te chn i q ue s ,

elastic zone of m o t ion, 89 fibrotic s t i ff, 164

171 -1 73, 1 96

p a s s i ve tes t, 95, 96 superior shea r f i x a t i on , 1 74-- 1 75 see

fixa ted, 1 64

inne rva t i o n, 37-38

also I l i u m; I s c hi u m ; P u b i s

Integr a ted functional kine tic chain, 230

see also F un c tion a l integ ra tion

my o fa s cia l l y

I l i a c us muscle

c o m p a ra t i v e anatomy, 4 length te s ting, 1 1 8, 1 1 9

re s t o r i n g m ob i l i ty, 1 64, 1 6 6-1 80

J l i o c o c c y g e u s musc le, 3 1 I l iocosta l i s l u mborum in tr a m u s c u l a r stim ula tion, 198

c a u ses of i mp a i r m e n t , 134-135

fo rce c l o s u re, 46-53

"j o in t p la y "

form c l o s ur e, 43-46 motor

p a i n pr o v o c a ti o n t e s t , 1 05

I l i o l u m b a r li ga m e n t, 2 1 , 23-25 function, 44

74-75

K

In terd iscip linary Wo rld Co n g re ss on Low Back an d Pe l v i c Pa in, 1

infe r io r b a n d , 2 7

tests,

c o n t rol , 53-54

Inte r c o c c yg ea l joint, 25 In tercorn u a l l igaments, 25

p a in p ro vo ca t i o n test, 1 0 5

Mechan o recep tors, a r t i c u l a r also H i p j o i n t; P u b i c symp h ys i s; Sacroil i a c Joi nt;

Zygapophyse'l l j o in ts j o i n t ca p sule, f i b ro us, 7H-79

e m o tions, 54

p a rs th oracis, 34 i liot rochanteric band, 27

see

components, 42

p a rs lumborum, 33-34 I l i o femora l ligament, 2 1 , 26, 27

sen sory re c e p to r s see

b iomech a n ics, 65-71

d e v e l o p me n t , 41

N e u tra l

zone of j o i n t m o tion

I n te g r a te d model o f f unch on, 1 , 41 -54

Wac crest, 1 9

c o m p res sed , 164

ne u tra l zone of m oti o n see

exercises

l I i a c fossa, 4

see Art i c u l a r

c o m p re s s i o n

p o s ter i o r rotation, 61-62, 63

173, 1 74 s tretc h ing, 246 see a lso E x e r c i se programs H unte r, William, 15

a n a to m y, 20-28

d e v e l op me n t, 9

In te rn a l o b l iqu e

( 10)

m u sc l e , 32-33

int ra m u s c u l a r stimu lation, l e n g th t es tin g , 115, 116

197

pos t u r a l re - ed uc a t i on , 1 82 tra n s v e rsus a bdominis is o l a t i o n and, 205, 207, 208, 209

Copyrighted Material

K i nematics, 5 6

hip, 64-65 in t r a a rti c ular, 56

l um b a r sp i ne, 56-59 pel vic g i rd le , 59-64 Kinesthe t i c awa reness, 38-39 K inetic cha in, integr,l ted

f un c t i o n a l , 230

I n d ex

Ki netic test see One-l egged s t a nd i ng test

K i ne tics, 56

rea l - ti me u l tra sound i m aging,

m u l tisegmental rotoscolio sis, 137,

s i m u la tion tests, 107, 109

pa lpa tion poin ts, 216

1 20-129

Long dorsal s a cro i liac l i g a m e n t, 2 1 -22 ,

Kneel ing, fo u r-point

hip rock exercise , 1 7 9, 225, 248

138, 1 95-196

pass i v e tests of a rthrokinema tic fLm c tion, 91, 92

23, 6 1

la tissim u s d o r s i s tretch, 246

n e u t r a l s p i ne p o s i ti o n , 1 88-1 89 transversus abdominis is o l a t ion, 204

p a i n genera tion, 74

p a s s i v e tes ts of a r thro k i netic function, 91-93

p a ln p rovoc a t i on test, 99

a n terior translation, 92

Lon g i s s i m u s thoracis

p a rs ILLffi b orum, 33

compression, 91-92

p a rs thoracis, 33, 34

t r Lm k and a rm d issociation exercise, 221

l a tera l transla tion, 93 posterior transla tion, 92-93

Long itud i n a l s l ing, 52, 53

trunk and leg d issoc ia tion exel'cise,

l e n g th testing, 115- 1 1 6 , 1 1 7

rota t ion, 92

p a s s i v e tests of osteo ki.nema tic

Low back see Lumbar sp ine

225, 226 Kneelin g on th e b a ll, 241

function, 89-91

Low back p a in

Kyp hos i s, 137, 151, 190 correcting, 186-1 87, 1 8 8, 189

a c u te trauma tic, 136, 137-138

s i d e flex i o n / ro t a t ion, 9 0-9 1

a c u te unilateral, 1 4 5

positional tes ts, 89, 90

c h ronic, 75 multifidus fun c t ion, 50

L

fle x ion / ex tension, 89-90, 91

extension, 89, 90

in seg mental l u m b a r i n s ta b i l i ty, 1 49

tran s v e rsus a b d ominis func tion, 48,

Laser therapy, tendon i nj u ry, 78 Later� l bend i ng (in s tan d ing), 56 biomech a n ics, 57-59, 67

49-50

tes t,

H6-tO

La tera l fe mora l circ u m flex a r tery,

La tera l pel v ic t i l t, 56, 59

L u m b a r l ordosis

c o r rec tin g, 1 86, 1 87,

39

La tera l l'cccss stenosis, 1 48

sacra l vesse l s, 39

Latc r�l sacrococcygCi) I liga ment, 25 Late r a l s l i n g, 52

s t rength a na lysis, 1 1 3-1 1 4

Latissi m us dors i, 34 , 3 5

in tra musc u b r sti m u l a tion, 1 99 length test,

114, 115

stretch excrcises, 246 Leg, h; c i a , 36-37

Li fting, b i o m ec h a n i cs, 71-72

Ligaments, 21-25, 26-27

18]

Liga mentum fl av u m, 34,

5-6

35

d i a stasis, test, 106 rea l - t i m e u l t raso und imaging, 1 24

also Ante rior a b d o m i n a l a p on e u rosis

42

Loc a l m u sc le system, 47, 48-52

co-con traction an a l y s i s , 1 1 0--111

co-con traction and end u r a nce tra ining, 214-215 coord ina tion w i th global s y s tem

classification o f d isorders, 1 33-1 34

excessive a r ticular co m p ression, 1 35-139

with i n s ta bi l i ty, 145

obj e c t i v e find ings, 136-139

passive and a c t i v e mob il ization technique,

1 68-169

199-214

L u m b o p e lv i c pyra m i d see Py ra m i d ,

b i o mecha n ics, 58--59

compress ion, 43

con geni ta l a n o m a l ies, 1 32

d e gene r a t i v e cha nges, 1 47-148 postero a n terior t r a n s l a t i o n, 45 to rsion or ro t a t i o n,

Lunges, 235-2 37

44, 58-59

b a c k w a rd, 236 w i th contra l a tera l trunk rota t i o n ,

t r a c t ion/passive mobi lization technique, 168

237, 238

cross- t u b ing, 236-237 w i th isometric extern a l rotatio n , 243-244

p a s s i v e a n d a c tive mob i l ization techn iques, 1 6 7- 168 trac tion / p a ssive mobilization techni que, 1 6 7

a g a in s t resistive exercise band, 236

or d iagona l, 236 o n a sissel, 2 4 1 , 242 side

flexio n / e x tension, 56-57

v a ria tions, 235-237

form c l o s u re, 43--45

wa l king, 235

tests, 89-93

i n s u fficie n t ar tic ula r co mpres sion (segme nta l in s ta b ili ty),

M

1 46-154

a n a tomica l / ph y s i o logic a l cha nges, 1 46-1 48

ex tension p a ttern,

1 50, 152

flexion pattern, 149, 151

mu ltid irectiona l pattern,

ne u tra l zone a n d , 111

see also Zyga pophys e a l j o i n ts

L umbosacral j unc tion

g lo b a l systems 20 0-- 2 01

res torin g m o b i li ty, 1 66-1 70

s ubc l a ss i fication, 139

l u m b o p e l v ic

degene r a t ion, 1 3 6 , 1 4 6- 1 48

l a tera l s hjft p a t tern, 1 5 0 , 1 52

isola t ion and a W i Heness t r a i n ing,

segmental res triction

compression, 43--44

see Coord ina ting l oc a l and

incorrec t a c t i v a ti o n p a t terns, 1 66,

spine, ins u fficient a rt i c u l a r c o m p ression (above)

tors ion o r ro tation, 44-45

(FRSL), 139, 1 66-1 6 7

Liga mentu m teres, 26, 2 7 , 2 8

Lo ad trans fer,

non-hLuna n prima tes,

flexed rota ted / s i deflexed left

L inea albJ, 2 9 , 33

see

1 6 6 , 183

(ERSL), 139, 1 6 6-1 67

Leva tor ,1 [li m uscles, 30, 31, 159

heal ing, 78

1 3 7, 1 5 1 ,

in s u fficient ( fl a t back),

s u bjective find ings, 1 35-1 36

Leva tor p l a te, 3 0

p r o l o ther,lpy,

excessive, 1 3 6 , 137, 166, 1 83

e x te n d ed rota ted / s i d e flexed left

Leisll fl' acti v i ties, 82-83

segmen ta l insta bi l i ty see L u m b a r

1 88, 1 89, 1 90

L u m b a r spine

La tera l rota t i o n, 56 Lil tera I

rotation /sid e fl e x i o n, 57-59

Low to h i gh pulley exercise, 240

E'xl' rc i sl', 229

flex ion, 89, 90

poste roante rior t r a n s l a tion, 45

1 5 2 , 153

objective find i ngs,

151,

1 49-154

s u bj ective find ings, 149

k inema tics, 56-5 9

motion d u r ing wa l king, 70-71

Copyrighted Material

Mechanorece p tors, a r tic u l a r, 37, 38 perce p tu a l e ffec ts, 38-39

reflex e ffec ts, 38

Med ia l fe m o r al c i rc u m flex ve ssels, Med ia l ro ta tion, 56

39

Median sa c r a l a r te ry, 39

Med ica l model, 133-134

Mid-stance phase, 68, 70

M id l ine a b d o m in a l fa s c i a see Anterior a b d o m ina l a p o n e u rosis

Mobil ity tests, d u ra l / ne u ra l , 130

2 63

2 64

I N D EX

Mob i l i za t i o n techniques, 1 64, 166-1 80

h i p j oint, 1 77-1 80 l umbar zygapop hysea l j o i nts, 1 6 6-1 70

s a c ro i l ia c j o in t, 1 6 7-1 77

in pelvic g i rd le in s ta bi l i ty, 1 5 6-157

Neutral spine, 1 8 2-1 9 2 c rook l y in g ro l l - u p-ro ll-down, 1 8 2 , 1 84-185

s u p p ort p h a se, 88 Onset, mode of, 8 1 -82

defined, 183

Ossifica tion cen ters, 8, 9

in

Os teokinema tics, 5 6

four- p Oint kneel i n g, 1 88-1 89

Mode of onset, 8 1 -82

m a i n tena nce w i t h l o a d ing, 2 1 8-227

Osteology, 1 6-20

Motor cond u c tion tests, 1 29-130

moving out of, 227-230

Osteop h y tes, 1 2 , 13, 148

Motor control, 43, 53-54

p a ssive position in g s i d e l y i n g ,

restoring, 1 65-166, 1 8 1 - 1 8 2 tests s e e Force c l os u re / motor

183-184 in s i tting setting o p t im a l pyramid base,

con trol a na l y s i s Mov e m e n ts

1 85-1 86

se tting spinal pos i t i on , 1 8 6-1 88

controL 2 1 5 resis ted , 2 1 5

in supported s tand ing, 190

tests, regional s e e Reg ional

t ransvers u s a b d o m in i s isolation

movement tests Mul liga n mob i li z a t i on, fibrotic hi p

and, 204 N eutra l zone of j o in t m o tion, 89, 90

j o int, 1 78

local m uscle s y s tem a nd , 1 1 1

M u l t i fidus m us c l e

Nociceptors, 38 , 39

ana to m y, 29-30

N u t a tion, 56, 60-61

co-contr a c t ion and e n d u r a nc e

isolation and a w a reness of deep fibe rs, 21 0-2 1 4

p a tient and thera p i s t position,

sacro tuberous l i ga m e n t a n d , 23, 3 0 s ta b i l izing f u n c ti o n o f d e e p fibers, 50 u l t r a s o Lmd i m a g ing, 124-1 26, 2 1 0-2 1 4 a d d res sin g s peci fic " ti g h tness " , 1 8 2, 245-248 add ressing s pecific "wea kness " , 241-245

1 06-1 29 form c l o s u re, 89-105 func t i o n , 83-89 mobil i ty, 1 29-1 30 v ascu la r tests, 1 3 0 O b l i q u e abdominal m u scles

1 64

see

also Ex ternal oblique m uscle; Intern a l oblique muscle tes ting, 120

O b t u ra tor internus muscle i n tram u sc ula r s t i m u l a tion, 199 l e n g th tes ting, 1 2 0

P l a te

4

reflex effec ts, 38-39

Neu ro l ogic a l cond uction tests, 1 29-130

in l u m b a r segmenta l i n s ta b i lity, 154 in p e l v i c g i rd le ins ta b i lity, 157 Neu ro logy, 37-39

u J /drr L u m b a r

spine p e l v i c g i rdle, 97-99 Passive tests o f osteokinematic function (passive i n terverteb ral motion;

hip j o i nt,

PIVM)

1 02-104

l u mb a r spine, 89-9 1

p e l v i c g i rd l e, 95, 96 Pe l v i c fa scia, 30-31

One-legged s t a n d in g test, 87-89

Pel v i c floor

c o m p ression, 1 3 8

a r tic u l a r, 37-38

l u m b a r spine ,1'1'

One-leg squats, 237-238

i n excessi ve lumba r spine

m icrosco p i c a r ticular, 38

hip j o i n t, 1 04-1 05

fle x i o n / ex tens ion, 89-90, 9 1

143-144

macrosco pic

Passive tL' s ts of a rt h ro k i netic func tion

s i d e fl ex ion / rota t ion, 90-91

i n excessive lum b a r spine

Nerves, 37-39

9 1 , 92

Older peop le, sacroi l i a c j o int, 1 2-13,

in exces s i v e hip j o in t comp re ssion,

N

PAV M)

Oestrogen, 72

b iomecha nics, 6 1 -62

Myology, 28-37

v e r tebra l m o tion; h ip j o int, 1 04-1 05

p e l v i c gi rd le, 96-97

Occ u p a tion, 82-83

Myofa s c i a l l y com pressed j oin t / region,

f u n c t i o n ( p a ssive accessory

l u m b a r s p i ne,

loca l a nd g l obal class i fica tion, 47

pa i n prov oca tion tests, 1 20

1 73, 1 74-1 75, 1 76-1 77 Passive tes ts of a r t h ro k i n e m a t i c

length testing, 1 1 5, 116

Obtura tor vessels, 39

s p r a in s / r u p t u res, 1 20

1 6 7-1 69 s a c ro i l iac j o i n t restri ctions, 1 70-1 72,

s t retch exerc i ses, 246-247

key, 1 29-130

Loca l m u scle system

m o de l, 89 , 1 5 8

Passive mob i l i /. J t i o n te chniq ues, 1 64

hip j o i n t, 1 77- 180

O b t u r a tor n e r v e , 38

also G lobal m uscle system;

S a c ro ili ac Jo int (SlJ), p a in P a i n prov oca tion tes ts

l u m b a r segmenta l dys function,

anatomy, 28-37

see

a lso Low b a c k pa i n; Pe l v i c pa in;

fo rce clos ure a n d m o tor con tro l,

Ob t u r a to r e x temus muscle, l e n g th

M u scles

s u bj e c tive exa m in a tion, 82 see

a dj unc t i v e t e s t s , 130-132

v e r b a l and manual c u es, 2 1 0 pa l p at ion o f deep fibers, 1 0 6

m a n u a l therapy a n d , 73-74 perce p t ion, 39

Panj a b i ' s s ta b i l ity Objective e x a m i n a tion, 83-1 3 2

n e urolog i c a l conduction a n d

210

75

hea l ing p rocess, 75-80

p e l v i c gird le, 99-1 0 1

i dea l an d a b n o r m a l respo nses, 2 1 0-2 1 4

c h ronic,

h i p join t, 1 05

o

t r a ining, 214-2 1 5 i n t ra m u sc u la r s t i m u l a tion, 1 97, 1 9 8

Pain, 39

contracti Ie lesions, 1 20

a trop hy, 1 38-139, 153-154 c la mshel l exercise, 242-243

p

co mpression w i th instab i l i ty, 1 45 in excessive pelvic girdle compression w i th in sta b i l i ty, 146

in excessive S IJ com pres s ion, 141 hip flexion phase, 87-88 in l um b a r segm e n t a l instability, 152-153

Copyrighted Material

a n a tomy, 30-3 1 a ssess m e n t of function, 1 1 0, 1 2 6-1 29, 201-202 c h i ld b i r th-rela ted inj u ry, 1 61 co-con t ra c t i on a n d e n d u ra nce t r a in ing, 2 1 4-215

func t i o n, 50-51

h a mmock f un c t i o n , 30, 3 1 , 158- 159 m u scles, 30, 3 1 a b normal res ponses, 128 i n coc c y x fle x io n / e x tens ion, 61 fa ciJ i t a t i n g con tra c t ion, 1 6 0 nerve d a ma ge, 1 6 1 re t r a ining, 1 6 1 , 2 0 1 -204

I n d ex

u l trasound i m a ging, 1 26--1 29 , 201-204 u rin ary con ti nence and, 160-1 6 1 Pelvic F loor Educator, 2 03 Pelvic g i rdle age� related c h a n g e s , 1 0-13 ana tomy see A n a tomy embryology a nd development, 7-1 0 evolu tion, 3-4 excessi ve compress ion see Sacroi l ii1c joint (51)), excessive compression fo rm closu re, 45 tests, 93-1 0 1 i ns u fficien t compression (in s ta b i l i ty), 154-157 k i nematics, 59-64 mo tion

p a in

during

w a l ki n g , 69 -7 0

p rov oca tion

tests,

99-101

poi nts, 2 1 6 pa ssi v e tests o f a rthro kinema tic

p a l p a tion

function, 96-97

passive' te'sts of Mthrokinetic func tion, 97-99 p o s s i v e tests of osteokinema tic function, 95, 96 positional tes ts, 94 -95 Pel vic p a in ch ronic, emotional influences, 5 4 in excessi ve p e lv i c g ird l e compression w i t h instabili ty, 146 in excessiH' SIJ com pression, 1 3 9 For t i n ' s d istrib u tion, 73, 74, 1 46, 154

man u a l thera py tests, 74-75 m u l t ifi d u s f u n c tion, 50

p regnancy, 72 also Sacro i l iac j o i n t (Sf]), pain Pel v ic rock ex erc i s e, 1 8 8 Pel vic tilt an terior, 56, 59, 1 88 latera l, 56, 59 po:-terior s ec Posterior pelvic t i l t Pe l vic w a l l , musc les of deep back, 30-31 Peroneus lon g u s muscle tendon, 76-77 tendon hea l ing, 78 Piezoelectric effect, 77-78 Pi rifom1 i s m uscle, 30, 31 i n t ra m u s c u l a r sti m u l a tion, 199 length testing, 1 1 9-1 2 0 stretch exercises, 248 tendon, 76-77 t end on h e a l i n g , 78 Pos i tional tests h ip joint, 101-1 02 l umba r s p i ne, 89, 90 pe lvic g i rd l e, 94-95 Posterior b u ttock s t r e tc h exerc ises, 248 Posterior distraction: a nterior compression p a in p ro v ocat i on test, 1 00-1 0 1 in

see

Posterior oblique s lin g , 52 l e ng th testing, 114, 115 stren g th ana lysis, 11 1-1 1 2 Posterior pelvic ti l t, 56, 59 m a nagement, 1 82-1 83, 1 88 Pos terior p ubic ligament, 25, 26 Pos terior ro t a ti o n , 56 Posterior s u p e rio r iliac s p i n e (PSIS), 19

Pos teroan terior tra nslation, 45 Pos t u re ossessment, 83-85 a wareness, 38-39

in excessive hip joint co m p res s io n , 1 43

in e x c ess iv e l u mb a r spine comp ression, 1 36-- 1 37, 138 in excessive l umba r spine

compression with ins ta bi l i ty, 145 in e xcessi ve pe l v i c gi rdle compression with i n s ta b i l i ty, 146 in excessive 51) c o m p ression, 140 h u ma n vs non-human, 5-6 in lumbar segmenta l instability, 1 49-152

neutra l spine see Neu tra l s p ine in pelvic gird le ins t abi l ity, 156

re-education, 182-192 Power tra ining, 1 8 1- 18 2 Prayer posi tion, b reathing exercises, 194 Pregnancy diastasis of l i nea alba, 1 0 6 effects on pel v i c gird l e biomechanics, 72 p e l v i c floor d a m a ge , 1 6 1 s u bjective exa m i na tion , 8 2 Pretzel s tretch, 248 Pri ma tes, n on - h um a n , 4, 5-6 Prolotherapy, 1 8 1 Prone h i p ex tension - knee flexed exercise, 244-245 Prone hip ex tension a nd a b d u c tion exercise, 244 Pro ne lying positio n glu teus m a x i mus squeeze and s i t to s ta nd exercise, 244 m u l t i fid us isola tion and a wa reness, 210

tra nsversus abdominis isola t i o n ,

207, 208 tru n k and leg d issocia tion exercise, 224 Proprioceptive cha llenge, adding, 240-24 1 , 242

P u bic symphysis aging, 13 anatomy, 25, 26 co m p a ra t ive anatomy, 4 develop ment, 1 0 evol u tion, 4 form closure, 45 horizonta l tra n s l a tion test, 97, 98 innerva tion, 38

Copyrighted Material

ins u fficient com pression

(insta b i li ty), 1 54-157 clinic a l classi fica tion, 1 5 6 obj ect i ve findings, 154-157 subjective find ings, 154 vertica l tra ns l ation test, 99 w ide ni n g , in pregna ncy, 72 Pubic tubercle, 20 Pubis, ana tomy, 1 9 , 2 0 Pubococcygeus muscle, 30, 3 1 Pubofemoral lig a me n t, 2 1 , 2 6 , 2 7 p a in p rovoca tion test, 1 0 5 Puboischi u m, 4 Puborectalis m u sc le, 31 Pudendal nerve, 3 1 , 38, 1 5 9 Pulleys, l o w t o high, 240 Pulses, periphera 1, 130 Pyra m id , l u mbopelvic, 140, 141 setting optimal, 1 85-186 Pyra midalis

m uscle, 33

Q

Quad ratus femoris m uscle intramusc u l a r stim u la tion, 199 length tes t i ng, 120 nerve to, 38 Q u a d ratus l u mbor u m muscle, 24, 25

R

Rad iogra phy, 131

Ra m i communicantes, 38

Rea l-time u l trasound see Ul tra sound real-tim e

i m a g ing

ima g i n g,

Rectus abdomin is m u sc le, 33 transvers u s abdom ini s isola tion and , 2 0 5 , 207 Rectus femoris muscle length testing, l l 8, 119 stretc h e xercises, 247-248 Reflexes, 38-39 te s ti n g, 130 Region a l movement t e s t s , 85-89 in excessive h i p joint compression, 143 i n excessive l um b a r s p ine compression, 1 37-1 38 in excessive I umba r spine compression with in s t a b i l ity, 1 45

in excessive pelvic g i rd le co m p re ssion with insta b i l i ty, 1 46

in excessive 51] compression, 1 40, 141

i n l umbar segmenta l instab i l i ty, 1 49-1 52

in pelvic g i rd le ins t a b i l i ty, 156 Reite r ' s d isease, 1 3 1 Re l a x i n, 72 Resisted movements, 2 1 5

265

266

I N DEX j

Resistive exerc ise band, 1 94 f u nctional integra tion ex ercises, 233, 235, 236

trunk a nd arm dissoc i a tion exercises, 219, 221 trun k and leg d issocia tion exerc i s e , 223, 224

Ri b w i ggle, 195, 205 Rib c a ge resp i r a to ry movemen ts, 192-195 se t t ing position, 1 8 7, 188 Ri g i d i ty, glob a l muscle chec kpoin ts, 1 95 re d u c in g , 182-195

Roc ker board squa ts, 241 Rock' n ' ro l l exercise, 1 79, 225 R o l l - up-rol l - do w n exercise, 1 82, 184-1 85 Rota t i o n movemen ts, 56 Rotoscoliosis, m u ltisegmenta l l umb a r spine, 13 7, 1 38, 195-1 96 Rowing bac k exerc ise, 228

l a x i ty, in pregna ncy, 72 m a n u a l the rapy tests, 74-75 m ob i l i ty, 59-60 m y ofascial l y compressed, 139, 140, 141-142

p a in, 73-74, 139 s e e also Pe l v i c p a in poster ior ro ta tion fixation, 1 75-176 restoring form c l o s u re ( mob i l i ty ) , 1 70-177

a n te rior rota tion f i x a tion ­ innomina te, 1 76-1 77 a n terior she a r fixa tion innominate, 1 75 a n teriorly ro tated right

Sacral a lae, 1 6 Sacral ple x u s , 3 1 , 3 7 Sacrococcygeal j oint, 25 S a c rococcygea l l igaments dorsal, 25 l a tera l, 25 v e n t r a l, 25 Sacroi liac belts, 1 8 0- 1 8 1 S a c roi l iac j o in t (SIJ) a ge-relil ted cha nges, 1 0-13, Pla tes 1 -5 ana tomy, 20-25 ank y losis, 1 2-13 a n terior shea r fi x a t i on, 1 75 caps ule, 2 1

counternuta ted r ig h t sacrum, 1 70-172

horizontal s h e a r fi x a tion - r i g h t s i d e of s a c r u m , 1 77 posterior rota tion f i x a tio n ­ llu10min a te, 1 75-1 76

sacrum, 1 72-173 s u pe r i o r shear fi x a t ion innomina te, 1 74-1 75

sensory recepto rs, 38 st a bil i ty tes ts, 97-99 s t a b i l i z ing m u scles, 49, 50, 53 sti ffness, 60, 98 fibrotic, 139, 140, 1 4 1 - 1 4 2 s u p e r i o r s h e a r fixa ti on, 1 74-175 superoa n terior glide test, 97 tes ts, 83

t ra u m atic s p ra in, 1 70 vertica l transl a t i o n test, 97-99 Sacro i l i a c ligamen t s i n terosseo us, 2 1 , 22 long do rsa l see Long dorsa l sacroi l ia c l ig ame n t

c lose-p a c ked p OSi t ion, 4 6 , 6 1 c o m p a r a t i v e anatomy, 4

ventra l, 21 Sacro i l i a c taping, 1 80- 1 8 1 Sa c roiliit is, infl a m m a to ry, 1 3 1 , 132

cond i tions a ffec ting, 134

Sacrospin o u s ligament, 21, 23, 24 Sacrotuberous ligament, 21, 22-23, 24, 30

computed tomography, 1 3 1 , 132

decompression, 1 90-192 develop ment, 9-10, Plates 1 -2 d istraction/ passive mobi l i za tion techn ique, 1 70-1 7 1 e v o l u tion, 4 excessiv e com press ion, 1 39-1 42 w i th insta b i l i ty, 146 obj e c tive find ings, 140-1 4 2 s ubjective findings, 1 39-140 fo rce clos ure, 46, 53 form closure, 45

Sc i a t i c n er ve s tretch test, 130

Scia tica, 1 Sclerotome, 7-8 Scol iosis, 1 66 Sea ted g l u teus m a x imus squeeze a n d sit to s ta n d exerc ise, 244 Senso r y cond uction tests, 130 Sensory receptors, join t see Mecha norecep tors, a rticula r S i d e flex ion, 56, 57-59 S i d e l yi ng position m u l t ifi d u s isol a t ion and a w areness , 210

inno m inate/

posteriorly rotated right innomin a te / n u t a ted righ t

s

Sca p u la, setting position, 188 Sca r tissue, 76 Schmorl's node, 44

p a in p rovoca tion test, 99-100

tri gg er p o in ts near, 1 2 0 Sacrum a na tomy, 1 6- 1 8

a rtic u l a r s u r face orientation, 1 7-18 b lood s u p p ly, 39 class i fication ( t yp es ) , 1 8 c o mp a ra tiv e ana to my, 4

cou n te rn u tated, m ob i l ization

techniques, 1 70-1 72, 1 73

neu t ral spine, 1 83-184

transversus abdominis isola tion , 204, 209

Siegfried, Bernh a rd , 15

S lJ ,ec Sacro i l i a c joint S in uv e rteb ral nerve, 38 Sissel, l unge on a , 241 , 242 Si t ting posi tion g lu teus m ax i m u s s q ueeze and s i t to

s ta n d e x ercise, 244 p o s tu ra l re-ed uca tion se tting op ti mal pyra m id base,

1 85--1 86 setting spin a l position , 1 86-1 88 trun k and a rm d issocia tion ex erci se, 21 9-220

trun k a nd leg d issoc i a hon exercise, 224-225

S l e e p , 82

SI i d e, a r t i c ula r su rfaces, 56 S p in, a r t ic u lar surfil ces, 56 S p in a l nerves, 37-38, 38 S p ina l pos i tion neu tr a l see Ne u tra l s p ine setti ng, 1 86-188 Spinal reflexes, tes ting, 130

Sp ina l s te n os i s, 1 4 8 Sport, 82-83 Squa ts, 232-234

a ball, 232-233 one-leg, 237-238

w i th

rocker board, 241 s l i ng, 232, 233 s p l it, 233

S ta b i l iza tion of pelvic g irdle, evolution, 4 St a n d in g flexion contro l , t runk and leg d issoc i a hon exercise, 226-227

development, 7-8

one-legged see One-legged s t a n d in g tes t

inferoposterior g lid e test, 96-97 innerv a ti o n , 37-38

e volu tion, 4 inferior la teral angle (ILA), 16, 1 7, 95 n u ta te d , mobi l i za tion techni ques,

1 9 1 -192 rota tion control, t runk and leg

insu fficie n t compression ( insta b i l i ty ) , 154-157 ho rizontal p a t ter n , 1 5 5 o bjective find ings, 154- 1 5 7 subjec t i v e f i n d in gs, 1 54

n uta ti o n / c oun t e r n u tation, 56, 60-61 p ass i v e tes ti ng, 95, 96 ossifica tion, 8

historical aspects, 1 , 15, 59 h o r i zonta l tran s l a tion tes t, 97, 98

vertica I pattern, 1 5 5 k i ne m a tics, 59-60

1 71 - 1 73

positional analysis, 95 Sa hrmann's "wa i ter 's b o w " , 225

Copyrighted Material

re l e a s ing th e hi p ( " b u tt g r i pper"),

d i ssociation exercise, 227 trun k and arm d issocia tion

exercise, 220-221 see also Supported s ta nding Standing pelvic rotation exercise,

229-230 S t a n d ing trunk rota t i on exe rcise, 229

I n dex

iso l a tion a nd a w a reness tra ining,

S tep d o w n exercise, 239-240

Step fo rward, step b a c k e x erc i s e , 234

u p ex e rc i se, 238-239 see O n e -l e gge d s t and in g test S tra i g h t leg raise t e s t , 1 30 a c t i v e see A c t i ve s tra ight leg ra i se Stork t e s t

pa t ie n t and the ra pi s t p osi ti o n, 204-205 postural re-ed u c a ti o n , 1 8 2, 1 83

s ta b i l i z in g func tion, 48-50

(SUI),

u ltraso und

1 5 7-158, 1 60- 1 6 1 pe l v i c fl oo r re t r a ining , 20 1-204 tre a t m e n t a pp roa c he s , 1 6 1 S t re t ching exerc ises, 1 8 2 , 245-248 Subj ec t ive exa min a t ion, 8 1-83 Su per i o r gl u t ea l nerve, 37, 38

g l ute a l vessels, 39 S u pt'rior p ubi c l iga men t , 25, 26 S u pine p osi t io n rC'lC'il s i n g the h ip , 190-191 trunk a n d at'm dis s o c i a t io n

Tr a pe z i u s

imaging, 1 2 2-1 24,

205-209

m u sc l e, 34, 35

co m p e n s a t e d , 70

rrue, 70, 71 120

Trunk and

arm d i s so c i a t i o n e x e rc i s e s

fo u r - p oin t kneeling, 2 2 1

si tti ng, 2 1 9-220 s ta n d i n g , 220-2 2 1

fo u r- po int kne el ing, 225, 226

e x e rci se, 220-221

p rone, 224

22S-22ti

s i t t ing, 224-225 s ta n ding fle x i o n con trol, 226-227

trun k il n d leg d i ssocia tion e xerc is e, S u p r a s p i n o u s l iga ment, 34, 35

" Wa i te r ' s b o w " ,

Sahrma nn's, 225

Wa l k i n g b iomecha n i cs, 67-71

also Gait

Wa l l p re s s, i s o metric, 243 Women, s a c ro i l i a c j o in t a g i ng, 1 2

World Co n g re ss o n L o w Ba ck a n d Pelvic Pain, 1

Wo u n d

re p a i r see Hea l i n g tens ile s tre n g t h, 76

s t anding rota tion control, 227

s upp o r t e d s t and ing, 225-226

Syn silcrum, 4

Trunk movements see Backw ard be n d ing; Forwa rd bend ing;

T

Late r a l b en d i n g

Tendon hea l in g , 76-78 Tens i le strength, healing w o u n d , 76 Tensor fascia la tae m u scle, 37 i n tril m uscula r s t i m u la tion, 199

il'ng t h ll's t i n g, 1 1 8 , 1 1 9

u U l t r a s oni c thera p y, tend o n inj u ry, 78 Ultra s o u n d i m a g ing, re a l t i m e (RTUS), 110, 1 20-129

Tho raco-pe l v ic con trol b r i d g e
1 29, 1 60- 1 6 1 im a ge in terpre ta tion, 1 2 1

rowing ba c k e x e rc ise, 228

m id l ine a b d o m i na l fasc ia, 1 24 mu l ti fid us, 1 24-1 26, 2 1 0-214

s ta nd ing p el v i c ro tat i o n e x e rc i s e, 229-230

p e l v ic floor, 1 26-1 29, 201-204 transversus abdo m inis, 1 2 1 -1 24, 205-209

trunk ro ta tion exe r ci se , 229

U rethra

" p u m p i n g u p " , 50 s t a b i l i / i ng f un c ti on, 48

Toe-o ff p h a se, 68 , 69 Toe w iggle, 195

To rque lL'st, hi p j o in t, 1 05 To r s i on s , co r rec t i o n o f in t ra pe lv i c 196 ,

Tra b e c u l a e, bo n y, o r ie n ta tion, 42, 46 Trac tion- p
t ec hniq u e , l u m b a r s eg m e n ta l

dys func t i o n, 1 67, 1 68 Tra nsla tion, 56 Tran sverse aceta b u l a r l i g a m e n t , 26-27,

(TA), 28-29

y Yo ung p eo p le, s a c ro i l i a c j o in t, 1 1 , P l a te

b la d d er sta b i l i ty d u ring load ing,

late r a l be nd i n g exercise, 229

Th o ra c odorsa l fa scia, 34-36

x X-rays, 130, 1 3 1

-

s tretch l' xl'rcisl's, 247-248

b rea thing re tra in i ng and, 1 93 co-contrac tion a n d e nd u rance t r a i n i n g , 2 14- 21 5

w

sec

supine o r crook l yi ng, 2 1 8-21 9 Trun k a n d l eg d i ssoc i a t i o n e x e rc ises c rook ly ing, 2 2 1 -224

nt' u t r,l l spi ne, 190 S q U il ts, 232 tru n k J nd a rm d issoc i a ti o n

Ve r te b ra l body

degenera tive c h a nge s , 147, 148

Trig g er po i n t s , extern a l rota tors of h ip,

S u p p o r ted stand ing

25

Ve ntra l sa croi l i a c l i g a men t, 2 1

Trendelenburg g a i t

exerc ise, 2 1 8-21 9

a b d om inis

s t rengthening exercises, 245 Ven tra l sa c rococcygea l l iga m e n t ,

Vesa l i us, A n d re a s , 1

Tre a tm ent, 1 63-248

also C rook ly i ng p o s i ti on

Tra nsversus

Va s t u s media l i s o b l iq u u s,

com pression, 43-44

Tra u ma , 82

S u p e r i or

28

Va s c u l a r tests, 130

verb a l a nd m an u a l c ues, 205

S t re n g t h t r a i n i ng, 1 81-182

stand ing

u re thra l closu re, 1 6 0

205-209

tes t

.' 1'(

1 29, 203-204

i d e a l a n d a bnorm a l res ponses,

Step

Stress, em o t i on a l , 54 S tress u rina ry in co n t i n e nce

b l a d der descen t, 1 29, 160- 1 6 1 p el v i c floor co n t r a c t i on w ith, 1 2 8 ,

2 0 1 , 204-209

3

z Zona o r b ic u l a r i s see Femora l a rc u a t e ligament

Zyga p o phy s ea l j oi n ts close-pa c ked position, 46

ins u ffi c ient com pression, 1 57-1 6 1

co m p re ss ion , 43, 44

s p hi nc te r i c clos u re system, 1 6 0

degenera tio n , 136, 145, 146, 1 47,

suppo r t system, 1 58-159 U rge

u rina r y in co ntin e n ce (UUI), 157

U rina ry c o nt i ne n ce, 50-5 1 , 1 5 8-160

Urinary i nco n t inen c e (UI), 1 5 7-1 6 1 m ixed ( M ULl, 1 5 7 s tress s e e S tr e ss u rina ry incon tinence urge ( U UI), 1 57

148

fixation, d i s trac tion m a ni p u l a t ion, 1 69-1 70 inferopos terior g l i d e of right, 9 1 , 92 innerva tion, 3 8

kinema tics, 5 7 , 5 8 pa in, 73

re s t o ri n g form clo s ure

( m ob i l i ty ) ,

1 66-1 70

v

s u p e ro ante rio r g l id e of l e f t , 9 1 synovi tis, 1 3 5

Va lsalva maneuver a c tiv e straigh t l e g raise wi th , 1 07, 1 08

Copyrighted Material

torsion or ro t a tion, 4 4

t r a u m a tic s p ra in , 1 66-167

267

Pl ate sect i o n

Plate 1

S a c r o i l i a c j o i n t of a fe t u s a t

3 7 w e e k s of g esta t i o n . N o t e

t h a t t h e fi b roca rti l a g e l i n i n g t h e a rt i c u l a r s u rfa ce of t h e i l i u m i s b l u e r t h a n t h e h y a l i n e ca rt i l a g e l i n i n g sacru m .

P l ate 2 S a c ro i l i a c j o i n t o f a m a l e , 3 yea rs o f a g e ( t h e s a c ra l s u rface is on t h e r i g h t ) . N o te t h e b l u e , d u l l fi b ro c a r t i l a g e l i n i n g t h e a rt i c u l a r s u rfa c e o f t h e i l i u m .

Copyrighted Material

t h e a rti c u l a r s u rfa ce o f t h e

P LATE S E CT I O N

S a c ro i l i a c on

the arti c u l a r

P l ate 4

su rface

S a c ro i l i a c j o i n t o f a t h e ri g h t! .

m a l e,

4 0 y e a rs o f a g e

j o i n t o f a m a l e , 1 7 yea rs of a g e ( t h e sacra l t h e ri g h t) . N o te t h e d u l l , ro u g h fi b r o c a rti l a g e l i n i n g su r fa c e o f t h e i l i u m .

P l ate 3

s u rfa c e is

( t h e s a c ra l

is o n

P l ate 5 S a c r o i l i a c j o i n t o f a fe m a l e , 7 2 yea rs o f a g e ( t h e s a c r a l s u rfa c e is o n the l eft) . N o te t h e m a rked l o s s of a r t i c u l a r c a r t i l a g e o n both s i d es o f th e j o i n t a s w e l l a s t h e p rese n c e o f a n a c c es s o ry s a c r o i l i ac j o i n t [a r ro w s ) . [ P l a tes 1 - 5 a re re p ro d u ced w i t h p e r m i s s i o n fro m B o w e n Et C a ss i d y ( 1 98 1 ) a n d t h e p u b l i s h e rs H a rp e r a n d R o w e )

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