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Journal of
Bodywork and
Movement Therapies
www.intl.elsevierhealth.com/journals/jbmt
CLINICAL PHYSIOLOGY
Edgecliff Physiotherapy Sports and Spinal Centre, Suite 505 Eastpoint Tower, 180 Ocean Street, Edgecliff,
N.S.W. 2027, Australia
Received 18 January 2007; received in revised form 14 April 2007; accepted 17 April 2007
KEYWORDS Summary An integrative functional model largely based upon the observation and
Clinical classification analysis of the more common features of neuromusculoskeletal dysfunction
LBP; encountered in clinical practice was presented as a working hypothesis in Part 1.
Diagnosis LBP; The functional inter relationships between these regional and general features
Neuromusculoskeletal and their contribution to the development and perpetuation of local and or referred
dysfunction; spinal pain syndromes was explored.
Movement Here we look more closely at clinical patterns of presentation.
dysfunction; A simple classification system of clinical subgroups with back pain and related
Back pain; disorders is offered. These more commonly observed dysfunctional postural and
Posture; movement strategies have been distilled into a number of dysfunction syndromes
Motor control which will have predictable consequences.
In beginning to provide a map of the tendencies towards, or actual, changed
postural and movement responses seen in people with spinal pain and related
disorders, this model provides a valuable reference for those working in the body
work and movement therapies realm. It is a practical and useful clinical tool to assist
1360-8592/$ - see front matter & 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2007.04.006
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106 J. Key et al.
diagnosis and help better understand the development and perpetuation of most
spinal pain and related disorders. In so doing, more rational, functional and effective
therapeutic and research interventions can ensue.
& 2007 Elsevier Ltd. All rights reserved.
Muscle hypoactivity/lengthened:
Hyperactivity/adaptive shortness:
Patchy extensor synergies tend to dominate in Figure 3 Pure Posterior Pelvic Crossed Syndrome: lateral
most movements—particularly thoracolumbar view.
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108 J. Key et al.
Figure 8 Pure Anterior Pelvic Crossed Syndrome: ante- Figure 10 Pure Anterior Pelvic Crossed Syndrome:
rior view. posterior views.
Hyperactivity/adaptive shortness:
o Hamstrings.
o Piriformis.
o Upper abdominal group including lateral internal
oblique.
o Hip external rotators 4 internal rotators.
o +/ T/L erector spinae (Figs. 8–10).
the tendency is for the patient to flip to using a that this is probably the more common under-
more primitive gross extensor synergy—princi- lying clinical presentation (O’Sullivan et al.,
pally utilising the thoracolumbar extensors (CPC) 2006a).
in association with their retained upper abdom- Posterior Pelvic Crossed Syndrome shows fea-
inal CAC pattern. The lower thorax then becomes tures in common with his Extension Pattern.
functionally converted to a cone shape. We have We see that O’Sullivan’s other directional pat-
termed this a ‘‘central conical cinch’’ (CCC) terns are variations on these basic two patterns
whereby the anterior, posterior and lateral at differing stages of neuromusculoskeletal
thoracolumbar junction becomes hyperstabilised. dysfunction.
Control of the pelvis is attempted from this
habitual thoracolumbar strategy. The reflex re-
active response becomes the postural set from Mixed Syndrome: display features of
which they move. APXS and PPXS—usually with a dominant
Van Wingerden et al. (2004) presented a study
tendency towards one or the other
that supports the concept of the two Pelvic
Crossed Syndromes. They examined forward
Clinically, this is perhaps the more common
bending motion patterns of the lumbar spine
presentation. Appreciating each syndrome sepa-
and pelvis in patients with chronic pelvic girdle
rately helps see the composite presentation and
pain and chronic low back pain (CLBP). They
the relative dominance of one.
found those with pelvic girdle pain demonstrated:
We are finding that the effects of some of the
increased posterior rotation of the pelvis; a
currently popular yet poorly conceived and admi-
decreased lumbar lordosis in standing and when
nistered exercise programmes (therapeutic, gyms,
forward bending, used more lumbar flexion than
personal trainers, Pilates and some forms of Yoga)
hip flexion, i.e. APXS. Those with low back pain:
are further creating and compounding this picture
maintained more lordosis when forward bending,
of dysfunction.
i.e. they could not let their extensors (? thor-
The combination of features of a CPC in PPXS
acolumbar), lengthen. They clearly belong to the
with those of a CAC seen in APXS creates a CCC (see
PPXS group. Predictably we can expect symptoms
above) in posture and movement function.
to differentially occur in both groups over time.
Common to all is the tendency to posturally align
O’Sullivan (2005, 2006) proposes three broad
and move predominantly in the more primitive,
clinical subgroups of CLBP patients, based on
gross, bilateral flexion/extension synergies which
the mechanism underlying the disorder. Within
disallow:
one of these groups he proposes an underlying
defective motor control problem—primarily as
either movement impairments or control impair-
Appropriate patterns of axial setting and control
to support limb movement.
ments. Under the control impairments subgroup
he further defines his five clinical directional
The important rotary and lateral shifts and
adjustments needed for weight shift and to
patterns based on subjective history and symp-
maintain axial alignment and equilibrium and
tom behaviour. (O’Sullivan P.B., 2000; O’Sullivan,
control.
2004, 2005; Dankaerts et al., 2006a.)
There is a close affinity between our approach
and that of O’Sullivan. We feel our two primary
pelvic syndromes provide a simpler yet elegant, Shoulder Crossed Syndrome (Janda
integrated understanding of the underlying in- 1980, 1988)
herent tendency to dysfunction in us all, and
importantly, the commonly observed, magnified, Common to all three pelvic syndromes is the
motor control dysfunctions seen in CLBP. We see variable coexistence of this syndrome.
that movement and control impairments coexist It is an expression of the typical changes in
though in different proportions, depending on the posture and movement function seen in the upper
primary underlying pelvic postural and movement torso. It will also affect related function in the
syndrome and the presenting stage of the lower torso.
disorder. Importantly however, we observe similar It is characterised by:
patterns of clinical presentation (O’Sullivan P.,
2000; Dankaerts et al., 2006b, c) namely: Altered posture—round shoulders; increased
Anterior Pelvic Crossed Syndrome shows features upper thoracic kyphosis including a ‘‘dome’’;
in common with his Flexion Pattern. We agree forward drawn head.
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Therapeutic care in spinal pain and related musculoskeletal syndromes: Part 2 113
Increased activity and tightness of—the anterior drome and upper body tension. Cervical pain
chest and shoulder muscles, long cervico-thor- syndromes inevitable.
acic extensors, sternocleidomastoid and scaleni. Neuromuscular patterns triggered in response to
Related hypoactivity of—the deep neck flexor stress, tension and anxiety (cringing, protection)
group, the lower scapular stabilisers and related are more upper body global muscle system
spinal intersegmental muscles (Figs. 14 and 15). dominant and associated with disturbed breath-
ing (see Hanna, 1988).
Contributing factors to this syndrome are vari-
Most occupations require sustained forward arm
use in predominant flexor synergies e.g. manual
able combinations of the following:
physiotherapist, computer operator.
Adverse training effect, e.g. poorly conceived gym
Dysfunctional breathing patterns. and exercise routines which over emphasise
J Breath holding and central cinch in posture contemporary aesthetics over function—the de-
and movement (either CAC, CPC or CCC). sire for ‘good pecs’ and ‘a six pac’ abdominals
J Adaptive SGMS strategy of upper chest which further stiffen the thorax and reinforce the
breathing in both low and high demand tendency to dominant upper body flexor synergies.
situations. Related Hyperventilation Syn- Overuse of upper limb ‘fixing strategies’ (parti-
cularly in the elderly) to compensate for
decreased lumbo-pelvic control and equilibrium
reactions within the body. Watch even young
people in the train clinging and hanging off the
bars instead of resolving the perturbations
through the legs and trunk!
two in PPXS (psoas over active; iliacus under Improving lumbo-pelvic-femoral control includ-
active). Future primary research should help ing better Diaphragmatic breathing will help lessen
confirm this. the need for so much mid—upper body global
The pelvic floor muscles function closely muscle activity.
with lower Tr. A. and I.O, iliacus and L.M. Interestingly, Urquhart (2004) reported transver-
Given their common underactivity, it is sus abdominis in a normal population, consists of
tempting to assume related pelvic floor three regions which differ structurally and function-
dysfunction to some extent. Control of ally. Activation of the middle and lower region was
intrapelvic movement is fundamental to independent of the upper region, demonstrating
controlling the pelvis in space, on the lumbar independent activation above and below the belt.
spine and the hips. The entire neuromusculoskeletal system is
affected by the muscle system imbalance creating
Lee and Vleeming (2000) suggested imbalance in a complex multi system dysfunction—‘a functional
the pelvic floor with a tendency to under-activation pathology of the locomotor system’ (Lewit, 1985);
of the anterior pelvic floor and over activation of Janda, 1978, 1982, 1984)—will result in altered
the posterior pelvic floor. This may be associated alignment and control of the joints which in time
with ‘butt clenching’ and overactivity of the will create:
external rotators of the hip.
Pool-Goudzwaard and Stoeckart (2000) noted
Segmental dysfunction resulting in local and or
hypertonicity of the pelvic floor in certain patient
referred pain syndromes—both somatic and/or
populations complaining of low back and pelvic
dermatomal, e.g. back pain, hip pain, sciatica.
pain. Clinically, we are seeing some patients with
Altered quality of afferent information going to
dysfunction related to poor therapeutic interven-
the CNS, thus further changed efferent (motor)
tions which have emphasised ‘‘pulling it up and
output.
holding on’’. The muscles supplied by those irritated segmen-
Clinically, we see a relationship between pelvic
tal nerves will be affected in two basic ways:
floor dysfunction syndromes and CPC and CCC
(i) Inhibition/weakness—principally of SLMS
muscle activation patterns which hyperstabilise
muscles, e.g. lumbar multifidus (Hides et al.,
the thoracolumbar region, creating segmental joint
1996)—most have segmental innervation.
dysfunction and resultant autonomic effects.
(ii) Facilitation/increased tonus—principally of
Adequate antigravity support for the torso comes
SGMS muscles, e.g. hamstrings, thoracolum-
from below via effective control of the pelvis on
bar erector spinae.
the legs. We see that in the dysfunctional state, We observe a tendency to patterns of tightness
muscle activation patterns seem to be somewhat
and imbalance within the SGMS related to:
upside down. The lower torso is underactive and
(i) The primary pelvic crossed syndromes:
poorly controlled on the legs while excess SGMS
PPXS—psoas, rectus femoris, tensor fascia
activity occurs in the upper body, as the patient
lata, gastro soleus—i.e. over active/tight
attempts to ‘‘hold himself up’’. Similarly, the
anterior pelvic, hip and thigh muscles.
breathing pattern is upside down—inadequate
APXS—hamstrings, piriformis—tight/over-
diaphragmatic excursion and central expansion
active posterior pelvic, hip and thigh
with an excess of accessory muscle respiration muscles.
and upper body tension.
(ii) The shoulder crossed syndrome where the
O’Sullivan et al. (1997) partly observed this
upper limb girdle flexors are generally
tendency in altered patterns of abdominal activa-
stronger and tighter than the extensors.
tion in patients with CLBP—difficulty preferentially
activating the deep abdominals with a tendency to
higher levels of upper rectus abdominis activity. The Neuro-myo-articular dysfunction becomes
Therapeutically, he also cautions the importance of self-perpetuating.
correct and selective activation of the wanted
patterns without reinforcing faulty patterns of
muscle recruitment. The current overemphasis on
abdominal strengthening is misunderstood and mis- Summary of inappropriate antigravity
applied ‘‘core control’’. Particularly in those with and axial control strategies
APXS where this potentially leads to: a further loss
of the lordosis; further imprinting the tendency to a The patient, to a greater or lesser extent, adopts
CAC; and disturbed breathing amongst other things. more primitive and stereotyped strategies for
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118 J. Key et al.
antigravity postures, stability and movement con- Reduced initiation and control of rotary pat-
trol as follows: terns in the axial spine contributes to segmental
‘blocks’, restricts movement transmission up the
Changed timing of activation between the SLMS spine, as well as rendering some regions vulner-
and SGMS—delayed and reduced activation from able in movement.
the SLMS (Hodges and Richardson, 1996; Hun- Increased use of the anterior chest shoulder and
gerford et al., 2003). Early SGMS activity arm muscles in abnormal gripping and ‘fixing
(Hungerford et al., 2003) providing poor axial strategies’ as a response to perturbations in the
alignment, control and stability, thus creating a system. This contributes to propagation of a
‘yanking’ torque on various spinal tissues—par- ‘dome’ and further stiffening of the thorax and
ticularly in the cervical and lumbar spines. cervico-thoracic problems.
Abnormal ‘feed forward’ postural presetting The habitual neuromuscular strategy creates
prior to movement. It seems a habituated reflex the joint dysfunction over time, which in turn
overcontraction of the SGM’s around the body’s influences and perpetuates the neuromuscular
centre of gravity with associated disturbed strategy.
breathing, creates the abnormal postural set/
stability strategy from which they attempt to
move. Much of the current over applied approach
Over-activation of the SGM’s around the body’s to core stability training risks becoming ‘core
centre of gravity with hyperstabilisation of the rigidity training’ and inducing further central
thoracolumbar junction either as: CAC seen in fixing behaviour around the body’s centre of gravity
APXS; CPC seen in PPXS; or more often a with associated dysfunctional breathing patterns
combination of both—CCC intermittently in (O’Sullivan, 2005; Comerford, 2001b; Thompson
APXS and in the Mixed Syndrome. et al., 2004; Hanna, 1988).
Breathing is affected by this central cinch that
disallows effective descent of the diaphragm and
is associated with breath holding and poor basal
expansion. The patient utilises the accessory Conclusion
muscles of respiration in low load situations and
becomes an upper chest breather. This creates This practical model endeavours to integrate
unnecessary tension in the neck shoulder mus- clinical pattern recognition and analysis with
cles, hyper stabilising the cervico-thoracic junc- current research, and the influence of respected
tion and upper thorax with attendant effects on thinkers in the field.
the cervical spine and shoulders. It invites primary research to further validate the
Relative mobility of lumbar spine and poor clinical patterns commonly observed.
lumbo-pelvic-femoral control because of re- Appreciation of the model poses significant
duced deep system activity—patient attempts implications for a shift in our thinking in the way
to control pelvis in space from thoracolumbar we approach assessment, diagnosis and therapeutic
fixing strategies using global muscles (CAC: CPC: intervention in spinal pain and related disorders.
CCC). This further stiffens the thoracolumbar Diagnosis based upon local, regional and systemic
junction and thorax. functional neuromusculoskeletal deficits rather
Active spinal extension is defective and than structural changes and local symptoms alone,
achieved unevenly and primarily from abnormal is more likely to lead to improved therapeutic
SGMS activity. outcomes.
The patient finds it difficult to activate and An improved understanding of the common
modulate activity between the deep flexors and dysfunctional neuromuscular patterns of response
extensors in order to align and control the spine. and their effect on joint function helps delineate
He frequently employs more primitive, global fundamental principles of therapeutic approach—
system dominant flexor/extensor ‘holding pat- both manual and movement therapies—which
terns’. Stiffness, hyperstabilisation, lack of movement patterns we want to facilitate and gain
movement initiation and control from within improved control, and those which we need to
the thorax means attempts to do so will tend to modify or avoid.
increase thoracolumbar ‘shunt’ or ‘cinch’ e.g. Unfortunately, it has been our experience that
attempts in trying to align spine and /or open many of the programmes being offered in gyms and
chest will evoke a lower anterior rib thrust with work hardening programmes are in fact compound-
or without anterior ‘cinch’. ing the patient’s underlying dysfunction. Hopefully,
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Therapeutic care in spinal pain and related musculoskeletal syndromes: Part 2 119
this model helps us understand why, and predict affect the sagittal lumbar spine, pelvic tilt, and thoracic
why, some patients benefit and why many do not. kyphosis? European Spine 11, 287–293.
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