Pelvic
girdle and low back pain have fallen under the diagnostic umbrella
of non-specific low back pain (NSLBP). Consequently,
a misconception that any exercise is good exercise was created.
It is true that low back pain can have it's etiology in pelvic
girdle mal-alignment, and similarly low back pain with neural
irritation can lead to inco-ordination of muscles causing pelvic
mal-alignment. However, clinically there appears to be very
little non-specific about such problems. Traditionally,
manual therapists have viewed impairment as loss of range of motion
and/or perceived stiffness on joint mobilization. However,
when considering low back pain and pelvic girdle dysfunction,
the effects of muscular force transduction are becoming more evident
as being an important impairment variable. The clinician
needs to be aware of Newton's third law of 'action-reaction',
the effects of inverse dynamics and
the desire for symmetrical and appropriately timed force dissipation
by supporting muscles. Essentially, efficiency of movement
is the desired outcome of any movement strategy, whereby muscles
are considered as a series of slings acting across joints with
differing movement functions. Most of us have experienced
the stiffness and awkwardness of movement when learning a novel
task. Pain and dysfunction and/or inappropriate physiotherapy
can result in excessive stiffness, which compromises the 'fluidity'
and range of movement. Hence, such stiffness is the result of
non-optimal neuro-muscular firing, rather than passive stiffness
based on adhesions, scar tissue or degenerative changes.
Good clinical assessment with the application of appropriate muscle
energy, manual therapy, soft tissue massage and dry needling techniques
for reduction of pain and muscle spasms, as well as appropriate
exercise prescription can ascertain the 'cause of the cause' of
dysfunction. Therefore, don't just
rush into a Swiss Ball regime.
It is important to understand that motor inco-ordination
in the pelvic girdle can be the result of peripheral and/or central
mechanisms. Peripheral mechanisms include reflexogenic muscle
spasms or cortical inhibition of muscles and/or delayed central
transmission due to noxious input. Altered proprioceptive input
can result in an inaccurate 'virtual body concept of self' resulting
in inaccurate feedback during the execution of motor tasks. Attention,
stress and fear can inpact motor planning through altered perceptions
of task demand and the environment where the execution of the
task is to take place.
Build strength and flexibility
in stages. The deeper the foundations of motor learning
the stronger and greater the scope of adaptation during recovery.
Remember there are 3 stages of learning, where the first stage
is the cognitive stage in which fundamental movement patterns
need to be learnt in the most basic positions of neutral. Then
comes the associative stage whereby more dynamic activity or prolonged
static postures can be practiced before arriving at the autonomous
stage of learning (Fits & Possner 1967, Gentile 1972). Activation
of low threshold muscles first, small movements and lots of cognitive
motor control. Additionally, deactivation
of global muscles and improved timing are frequently early priorities.
Later goals may include performance enhancement for return to
sport, whereby intramuscular and intermuscular control between
and deep stabilising and superficial ballistic muscles is trained
using functional exercises which may include the Swiss Ball.
Importantly, determine whether the person is
inherently a 'floppy', 'stiffy' or 'flippy-floppy'. The
goal with stiff people will be to improve range of motion and
acquire control of global muscle timing. Hereby, reducing
intra-abdominal and intra-discal pressure. The goal
with floppy people will be to enhance stability through co-ordination
and improved endurance. Hereby, improving cognitive motor
control. Don't get trapped by exacerbating a persons condition,
who appears to be stiff, yet has an underlying functional instability.
Ask them whether they used to be really flexible as a child or
prior to the onset of dysfunction. Also screen for
trauma which could have resulted in some functional instability
such as hyper-flexion-extension from a 'whiplash type' injury
such as skiing, marshal arts, etc. Ultimate aims will be
to improve lumbo-pelvic dynamics by optimising
'form & force closure' around the symphasis pubis & sacro-iliac
joints.
Joint Hypermobility Syndrome (JHS) includes
conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome
and Osteogenesis imperfecta. These people are thought to have
a higher proportion of type III to type I collagen, where type
I collagen exhibits high tensile strength, whilst type III collagen
is much more extensible and disorganised and occuring in organs
such as the gut, skin and blood vessels. The predominant presenting
complaint is widespread pain lasting from day to decades. Additional
symptoms associated with joints, such as stiffness, 'feeling like
a 90 year old', clicking, clunking, popping, subluxations, dislocations,
instability, feeling that the joints are vulnerable, as well as
symptoms affecting other tissue such as paraesthesia, tiredness,
faintness, feeling unwell and suffering flu-like symptoms. Autonomic
nervous system dysfunction in the form of 'dysautonomia' frequently
occur. Broad paper like scars appear in the skin where wounds
have healed. Other extra-articular manifestations include ocular
ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal
and carpal tunnel syndrome, alterations in neuromuscular reflex
action, development motor co-ordination delay (DCD), fibromyalgia,
low bone density, anxiety and panic states and depression. Age,
sex and gender play a role in presentaton as it appears more common
in African and Asian females with a prevalence rate of between
5% and 25% . Despite this relatively high prevalence, JHS continues
to be under-recognised, poorly understood and inadequately managed
(Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309)
Assessment of the Sacro-iliac
Joint should include
Patrick - FABER test : the patient lies
supine on the table, and the examiner stands next to him/her.
The examiner brings the ipsilateral hip into flexion, abduction,
external rotation so the heel is on the contralateral knee. The
examiner fixates the contralateral ASIS and applies pressure on
the subjects flexed knee. The test is positive when similar buttock
or groin pain below L5 is reproduced (Kokmeyer et al JMPT 2002,
25, 1, 42-8)
ThighThrust or posterior shear test :
the subject lies supine on the table. The examiner flexes the
hip and knee so that the hip is at approx 90degrees flexion and
slight adduction and the thigh is at right angles to the table
with the knee remaining relaxed. One of the examiners hands cups
the sacrum and the other arm wraps around the flexed knee. The
axial pressure applied is directed through the long axis of the
femur, which causes anterior ot posterior shear to the SIJ. The
test is positive when familiar pain is provoked over the posterior
aspect of the SIJ below L5 (Kokmeyer et al 2002, Laslett et al
2003, 2005)
Restricted abduction test
: the subject is positioned in supine with the leg fully extended
and abducted to 30degrees. The examiner holds the ankle and pushes
medially while the subject pushes laterally. The test is positve
when similar pain is produced over the SIJ below L5 (Broadhurst
& Bond, J Spinal Dis, 1998, 11, 4, 341-5). These
authors claimed 87% sensitivity and 100% reliability for this
test.
Standing flexion test
: is performed by palpating the PSISs whilst the subject is bending
forward from the standing position. The test is negative where
both PSISs move the same amount and positive where one PSIS moves
further cranially than the other which means limited movement
of the sacrum on the ilium on the side of the superior PSIS (Potter
& Rothstein. Physical Therapy,1985, 65, 11, 1671-5)
Sitting flexion test : is performed as
in standing
Gillet Test : is performed in 1 leg standing
whilst the subject pulls their knee up to their chest. A normal
result would be for the PSIS to move inferiorly. If the PSIS remains
at the same level or drops only slightly or even moves superiorly
this is considered as a positive test
Prone Knee Flexion test : is performed
with the patient prone. While the examiner holds both heels, the
patients knees are flexed to 90degrees. The leg lengths are compared
by examining the left and right soles of the feet in the prone
extended and flexed positions. If one leg appears shorter in extension
and lengthens in flexion implies an hypothesised posterior ilial
rotation (Potter & Rothstein 1985)
Arab et al (Manual Therapy, 14, 213-221) demonstrated
fair to substantial inter and intra-rater reliability for individual
tests, moderate to excellent reliability for clusters, and substantial
to excellent reliability for composites of the above motion palpation
and provocation tests
Stork test : is performed standing on
1 leg as the subject moves the 90 degree flexed knee into hip
flexion and hip extension. The PSISs are palpated w.r.t the sacrum
and L4. With the hip moving into flexion, inferior movement of
the PSIS and ipsilateral rotation of the L4 is expected. With
the hip moving into extension, superior movement of the PSIS and
contralateral rotation or no movement of the L4 is expected. Hip
hitching can also be tested in this position.
Active Hip Extension test : involves the
client prone and extending their straight leg at the hip. The
addition of compression anteriorly or posteriorly can glean information
w.r.t force closure. A positve result would be improved timing
of contraction of the Gluteus Maximus over the hamstrings. Additionally,
a reduction in pain and/or the movement feeling easier 'lighter'
to do may also occur. Takasaki et al (Manual Therapy, 2009, 14,
484-489) found that the addition of 50N and 100N anterior compression
resulted in the gluteus maximus coming on sooner (263+-99.5ms
vs 183.5+-77.9ms vs 91.5+-49.7ms)
Prone Figure of 4 Test: involves the client
in prone. The knee is bent to 90degrees and the hip is rotated
externally, the hip can also be abducted and finally a combination
of abduction and external rotation can be made with the knee at
90degrees flexion. These manouvres result in saggital and transverse
iliac rotation in 18-35 year olds (Bussey et al, Manual Therapy,
2009, 14, 520-525)
Gaenslen's Test : useful test for psoas
major length and with some adaptation rectus femoris length.
It should be noted that people
who have medial knee pain on hip extension may have referred pain
from an irritated pubic symphasis
Supine -> Sitting Test
: originally described by DonTigny (1997) it involves assessing
leg lengths in supine and in long sitting. The patient is aided
to sitting by puling up with their outstretched hands, so as not
to involve the abdominal muscles and to avoid pelvic twisting.
Outflares and Inflares should remain unaffected by this test.
Leg length discrepency should also remain unchanged from either
supine or sitting. During an 'upslip' the affected side will appear
to be shorter in either position. The reverse will be true fo
a 'downslip'. With rotational malalignment the pelvis no longer
moves as a unit. With anterior rotation on the right and posterior
rotation of the innominate on the left, the pelvis rotates in
the transverse plane to the right creating an apparent shorter
right leg in sitting. Note that it is the relative shortening
which is important. (Shamberger 2002)
Generally there is little evidence to support the
use of the Gillet test, standing flexion test, sitting flexion test,
or supine-to-sit test to differentiate between subjects with and
without static innominate torsion (Pamela K Levangie 1999, PHYS
THER Vol. 79, No. 11, November 1999, pp. 1043-1057). However, these
tests in my opinion are easy to do and may provide some useful information
when examined in the context of the entire clinical picture. Certainly,
in some sports such as cycling and rowing the supine -> sit may
provide very useful information when exmined in that context.
Assessment of peripheral
strength and flexibility is essential before commencing any Swiss
Ball exercises or any other training regime. Symmetry in alignment
and muscle balance (endurance versus strength) are important aspects
for attaining motor control -
remember the analytical physiotherapist should
use their 'clinical
reasoning' skills to take into account the entire
clinical picture
are the muscles short and weak
and therefore require strengthening, stretching and power ( i.e.
bulk)?
are the muscles long and
weak and therefore require endurance for stability ?
are there muscles which are over-dominant
and therefore require enhanced timing and co-ordination?
for example the static
assessment of the influence of the hamstrings, tensor fascia lata
and rectus femoris on the pelvic tilt (anterior, posterior and
lateral),
in terms of motor
control, Bernstein's perspective suggests that the constraints
of movement are the 'degrees of freedom'
which the central nervous system allows for safe and efficient
movement to take place. When considering neuro-linguistic programming
(NLP), this tautology of words presents an interesting aspect
of communication and goal setting for the physiotherapist.
An adapted Geoff Maitland approach
to stability and function, incorporating a modified concept of
'degrees of freedom', where the clients reaction to pain determines
functional ability.
note the excessive scoliosis from
the TFL stretch!!!!!
note the excessive posterior pelvic tilt from
the hamstring stretch!!!
are the hamies and quads tight because they
are weak?
- remember the peroneals, the lateral hamstrings (biceps), the
sacrotuberous ligament, erector spinae and deep thoracolumbar
fascia are functionally continuous (Dianne Lee 1999)
Following a static assessment,
dynamic movement analysis should occur. How does
the client walk, run, lift, swim? What is the lumbo-pelvic
control and what is the timing between the muscles? For
example, do the hamstrings activate before the gluteus maximus?
This is frequently the case in hamstring
dominant people or people with an anterior iliac rotation whereby
counternutation of the SIJ seems to inhibit the gluteus maximus.
On the other hand posterior pelvic tilt may be the result of excessive
hamstring and rectus abdominis - external oblique activity and
a dysfunctional kyphotis low lumbar spine (flexion impairment)
whilst anterior pelvic tilt is the result of excessive erector
spinae activity (active extension impairment). What
is the timing between the erector spinae muscles with arm movements
and rocking movements? Can this timing be enhanced by activation
of pelvic floor muscles? Is there reduced hip extension
(due increased Iliopsoas activity) causing ipsilateral pelvic
rotation (in the horizontal plane) resulting in shortening of
the contralateral piriformis muscle? This latter scenario may
be accompanied with ipsilaterally reduced Prone Knee Bend (PKB)
and reduced contralateral Straight Leg Raise (SLR). When extending
the hip in prone with a flexed knee does the lumbar spine hyperextend
at an unstable segment or rock to one side as can occur with an
'active extension impairment' with it's mal-adaptive spinal stabilising
coactivation of erector spinae and iliopsoas?
Any movement discrepancy observed , should be
confirmed using special tests such as one leg standing - pelvic
control. Additionally, manual muscle testing as well as
muscle energy techniques, myofascial dry-needling and joint mobilisations
can confirm or negate the 'working hypothesis' of what is causing
the dysfunction. The physiotherapist
needs to engage the client, thereby educating them to a point
where they are able to do their own assessment of the efficacy
of any exercise regime or treatment intervention.
reinforcement of shoulder rotation
(throwing action) with transverse abdominis activation
- note pelvic tilt and external rotation
of stance leg: ?due to tight piriformis and weak gluteus maximus?
?due to hip stiffness? ?due to weak gluteus medius and weak hip
rotators?
muscle energy techniques {MET} (gentle
[<20%max] and only 3 reps for approx 10 secs)
rectus femoris and iliopsoas
The iliopsoas is frequently
regarded as a key player in the compromise of hip extension, lumbar
spine lateral flexion, flexion and/or extension. Although clinically,
MET's to the iliopsoas can be very useful for restoring lumbar
range of movement, there is little evidence to suggest that the
iliosoas is tight, too strong or too weak. Similarly, in the abscence
of an 'upslip' there is little evidence to suggest it's involvement
in anterior pelvic tilt, rather it is more likely to be a posterior
pelvic tilter. When separating the two muscles, the iliacus has
an anterior rotation affect on the ilium (counternutation), whereas
the psoas major has a posterior rotating affect on the ilium.
Additionally, the iliacus muscle and posterio-medial aspect of
the psoas major are more linkley to have stabilising functions
as they are close to the joint and hence axis of rotation, whereas
the antero-lateral psoas major may have a largely mobilising-power
generating function. If this is the case, then the iliopsoas may
be involved with functional synergies which involve the superficial
abdominal muscles in maintaining the pelvic neutral position.
When a forward/backward rocking motion is performed in standing,
the erector spinae and superficial abdominal muscles exhibit reciprocal
timing suggesting that the duration of the considerable compressive
force generated by the erector spinae can be reduced in the lumbar
spine through enhanced superficial abdominal muscle timing. Similarly,
reduced erector spinae and enhanced superficial abdominal activity
may reduce the amount of compressive forces (excessive
force closure) generated on the lumber intervertebral
discs. However, more ideally, it is the non-torque producing muscles
of the abdominal cavity such as the horizontal fibres of interanl
oblique and transverse abdominis as well as the deep fibres of
multifidus which maintain lumbar spine neutral posture. By reducing
the activation of both superficial abdominals and erector spinae
it may be possible for the low threshold muscles to function during
postural and endurance activities. During high threshold dynamic
exercise such as running, transverse excursion of the diaphragm
becomes essential to efficient movement as abdominal expansion
may lead to loss of pelvic control. Since the oblique abdominal
muscles arise from the lower 6 ribs, the oblique abdominal muscles
require adequate length for inferior lateral chest expansion to
take place. Notably, the low thoracic spine is covered by the
pars thoracic aspect of the erector spinae and hence these muscles
require sufficient relaxation for rib excursion to take place.
Therefore, it makes sense for the iliopsoas to provide powerful
hip/lumbopelvic stability, in a functional synergy with the gluteal
muscles during activities such as sprinting and hill running.
Despite these paradoxes, it is highly likely that the clinical
effect of MET's on the iliopsoas is a proprioceptive one, rebalancing
the stabilising synergies of the hip and lumbar spine. Importantly,
by including inferior lateral breathing in an iliopsoas release,
the therapist will be able to glean the importance of incorrect
breathing to the dysfunction. Realistically, the clinical reasoning
process allows for such areas of uncertainty by using the correlation
between the impairment and disability measures to assess the validity
of involving the iliopsoas muscle in the treatment process.
Myofascial dry needling techniques can also
be used to reduce muscle tension (spasms) in the superior gluteus
maximus, rectus femoris, vastus lateralis/ITB/Tfl, adductor and
piriformis muscles.
Additionally, the ilium should be examined for outflares and
a tight piriformis, or inflares and a tight iliacus. If both piriformi
are contracted then forward flexion may be very difficult. Muscle
energy techniques can be used on these muscles. Additionally,
adductor longus should be assessed together with the medial hamstrings.
Remember, what is tight may also be weak. Therefore, do
not increase ROM at the expense of stability. Adductor
longus and contralateral external oblique form a functional sling
(Diane Lee 1999). Don't forget that the adductor muscles have
trigger points which can refer pain into the anus and genital
areas (see Travel & Simmons).
Lumbar Spine - Pelvic Kinematics
Sacral nutation & counternutation
Sacral nutation and counternuation
are considered normal events during flexion and extension in
standing. It should be noted that counternutation of the sacrum
generally occurs beyond 45degrees flexion (some variation between
individuals and pathology) and is a movement of the innominates
relative to the sacrum. In extension the reverse occurs whereby
the ilia rotate posteriorly w.r.t the sacrum resulting in nutation.
During extension in sitting, initially the ilia do not rotate
whilst the sacrum nutates until all the slack is taken up by
the ligaments and pelvis floor muscles at which point the ilia
will begin to rotate anteriorly.
Gait Cycle and Pelvic Rotation
Posterior and lateral view of gait - rotation and counter-rotation
of the sacrum/pelvis and spine
Posterior view of innominate anterior and posterior rotation
Anterior innominate rotation with
hip extension coincides with ipsilateral pelvic rotation, and
ipsilateral lumbar spinelateral flexion (with contralateral rotation
above L5). Anterior innominate rotation also encourages contralateral
L4 rotation through attachments of the ilio-lumbar ligaments,
which is in turn countered by the posterior ilial rotation of
the opposite side.These movements occur around an oblique axis.
In the above example rotation around the left oblique axis results
in a 'counter-rotation' action whereby the right posterior ilial
rotation is accompanied by a 'counterlocking' left anterior ilial
rotation. Additionally posterior rotation of the right ilia stabilises
the right SIJ joint in preparation for heel strike through the
tightening of the right sacrotuberous, sacrospinous and interosseous
ligaments. The continuation of the biceps femoris mechanism with
the sacrotuberous ligament may also act as a mechanical stabiliser.
Alternatively, it may be that the sacrotuberous ligament provides
powerful proprioceptive input for the biceps muscles. Furthermore,
in cases of dysfunction, mechanical hyperalgesia of the sacrotuberous
ligament may contribute to reflexogenic muscle spasms in the biceps
femoris. This can set up a viscious cycle whereby one perpetuates
the other, as shortening and/or incorrect timing of the biceps
femoris may result in increased mechanical input (tension) on
the sacrotuberal ligament. This can create additional problems
elsewhere such as the posterior lateral knee, peroneal nerve,
both SIJ's and the spine.
The sacrotuberous ligment also has strong connections with the
posterior thoracolumbar fascia, and muscular attachments of gluteus
maximus and piriformis. Hereby, the biceps femoris, the GM and
the piriformis can increase ligamentous tension.
L4 rotation can be tested during
'the stork' test through palpation of the spinous process of L4
and sacral sulcus during long striding. Additionally, control
over lateral pelvic tilting on the stance leg can also be tested
in various positions of flexion and extension whilst palpating
the L4 in order to ascertain any mal-rotation suggesting some
unstable L4 element. The L5 can almost be considered the 'meat
in the sandwich' of sacral torsions (especially backward ones
: left on right, right on left), ilial anterior rotations and
L4 mal-rotations affect the bood vessels, nerves and articular
processes of the L5.
Pelvic Ring Distortion
Frequently, these people present
with an apparent or real leg length discrepency and are sometimes
confused for an upslip. Examine people in standing from the
front and behind. Make sure you are symmetrical to the persons
landmarks. Also be certain which is your dominant eye - use
the photographers square fingers technique and determine with
which eye there is least movement from the centre of the square
when both eyes are open compared to one eye shut. Additionally,
try to glide the hip anteriorly and posteriorly with more and
less weight bearing. The hip will appear to glide further posteriorly
on the side of anterior innominate rotation. Generally, the
entire pelvis will look like it is rotated.
Upslips and Downslips
Upslips: can be the result of a sudden
vertical force through the outstretched leg for example when
stepping into a pot hole, landing awkwardly during a jump
or when running. car accidents where the persons foot is on
the brake and the force goes up longitudinally through the
thigh is also a common mechanism of an upslip. Upslips are
generally accompanied by counternutation of the sacrum (anterior
rotation of the innominate) which results in tension of the
long dorsal sacroiliac ligament. Tightness in the quadratus
lumborum and psoas major may contribute to an upslip.
It should be noted that the attachment of
the biceps femoris muscle is intimately linked with the continuation
of the sacrotuberous ligament and hence can be considered
a stabilizer of the SIJ. An MET of the hamstrings are often
used to posteriorly rotate the innominates, thereby reducing
the counternutation of the sacrum
Downslips: are generally the result
of a traction injury such as a rider falling off a horse with
the foot caught in the stirrups. I consider these injuries
to be exceedingly rare. In theory these are accompanied by
sacral nutation (posterior rotation of the innominate) and
tension on the sacrotuberal, sacrospinal and interosseous
ligaments.
Anterior rotation of the innominate
Anterior rotation of the innominate
may the the result of an injury. However, activation of the
iliacus which is an important hip stabiliser will also anteriorly
rotate the ilium. Therefore, it may be equally important to
have the counterbalancing stabilising muscles such as the
horizontal fibres of internal oblique and transverse abdominis
acting to stabilising the anterior aspect of the SIJ through
compression. This would be particularly important if there
were also an 'outflare' present. Additionally, the contralateral
external oblique may be important during intermittent and
high loading. There may also be a role for Psoas Major in
the prevention of excessive anterior ilial rotation?
Sacral Torsion
Sacral torsion around the oblique axis
The piriformis originates on the anterior aspect of the sacral
base and creates a posterior rotation relative to the ilium, whereas
the iliacus rotates the ilium anteriorly relative to the sacrum.
Either of these movements would create a wedging of the anteriorly
wider sacrum against the ilium and would under normal conditions
help stabilise the SIJ. However, excessive compression could result
in loss of SIJ movement. Inbalance or weakness or inco-ordination
in timing, could result in excessive movement.
Palpation in prone : the left sacral sulcus is anterior
whereas the right sacral apex is posterior resulting in forward
rotation
Shamberger (2002) described these
as 'backward rotations' where the base rotates back instead of
forwards. Whereas forward rotation accentuates a lumbar lordosis,
backward rotations reduce it and may even create a segmental low
lumbar kyphosis. In the Osteopathic literature, these presentations
have been linked to seemingly unrelated problems such as headaches,
disturbed function of the GIT (diarhoea alternating with constipation)
and genitourinal problems (frequency, nocturia and a disturbance
in menstrual function)
People with sacral torsions may have increased
force closure in one SIJ and reduced forced closure on the contralateral
side. Furthermore, they may present with poor form closure on
either side (more likely on the side of counternutation) resulting
in pain and load transfer dysfunction.
Since pelvic tilt plays an integral role in
the oblique torsions during weight bearing it would make sense
that the anterior, posterior and medial fibres of the gluteus
medius are activated to control the movement of the ilia on
the hip.
Bilateral
tightness of the piriformis may reduce sacral nutation,
whereas asymmetrical piriformis action can axially rotate the
sacrum resulting in excessive compression in the contralateral
SIJ. Is there piriformis insufficiency due to outflare created
by ischiococcygeus? Are they 'buttock clenchers'? Clinically,
improving SIJ stability by inhibiting
tonically active muscles and activating tonically inhibited
muscles (eg multifidus, transverse abdominis) usually
improves lateral hip rotator strength.
Check timing between the gluteus
maximus and hamstrings (hamies should not be dominant).
If the ilium is in anterior rotation it is very difficult for
the gluteus maximus to contract.
Can the hip stabilise on lateral
weight shift onto a stable ilium? If the
ilium goes into anterior rotation (counternutation) then the
acetablum may contact the superior-anterior surface of the head
of femur resulting in anterior hip pain. Additionally,
excessive uncontrolled lateral weight shift places greater strain
on the hip lateral stabilisers such as ITB/Tfl possibly resulting
in lateral hip pain such as trochanteric bursitis and tendonosis.
Do the opposite femoral nerve
(neural dynamics), external rotators (sacral torsion or ilial
outflare) and rectus femoris (anterior innominate rotation)
create excessive pressure on the opposite SIJ?
If there is an ipsilateral anterior
innominate rotation with jamming up of the SIJ concommitant
with contralateral hip internal rotation tightness with some
adverse neural dynamics of the femoral and sciatic nerves then
METs of the hamstrings and external rotators may reposition
the innominate and sacrum. In this position the lumbar and thoracic
spines can also be palpated. Thoracic rib tightness may be an
indication of sympathetic nervous system hypervigilence/dysfunction
which may lead increased mechanosensitivity in the muscles innervated
by these regions. It is important to do one step at a time before
arriving in this position.
Is the sacrum in too little
nutation due to lack of multifidus activation? Reflexogenic
inhibition and atrophy due to pain or is there excessive muscle
spasm?
is there a leg length discrepancy
or pubic symphysis instability?
due to poor hip/pelvic/trunk
control?
due to poor biomechanics
of the foot?
due to poor knee dynamics?
Osteitis Pubis may present as groin
pain. Inflammation of the the bone leads to softening of the
bone and cartilage leading to considerable disability. The time
frame for recovery is anywhere from 5 months to 2 years. Aetiology
is generally from excessive adductor action in activities such
as kicking, sitting too high in the saddle of a bike and/or
a poor saddle, forced abduction such as skiing, poor inner core
stability (transverse abdominis and horizontal fibres of internal
oblique) and poor outer sling co-ordination around the pelvis
and lumbar spine. However, don't ignore lower limb mechanics
such as excessive pronation of one foot and supination of the
other. Imbalances between the adductors and the contralateral
gluteus medius and the internal and external obliques can play
a significant role in poor recovery and may have been part of
the aetiology. Inferolateral abdominal wall hernias or weaknesses
may have also be the cause of osteitis pubis.
Upslips
and Downslips of the ilium are also possible, which maybe accompanied
by symphysis pubis shearing (osteitis pubis). Counternutation
of the ilium may be accompanied by an upslip or mistaken for
an upslip. What is the mechanism of injury?
Check quadratus lumborum, external oblique, adductor longus
and latissimus dorsi-thoracolumbar fascia for length, strength
and 'timing'.
Check stability in Stork test
and modified Trendelenburg's test
Palpate conjoint tendon, pubic
symphysis and the SIJ
Do the squeeze test at 30, 45
and 60degrees of knee flexion in supine crook lying
Do active SLR and check symphysis
pubis, then reassess with anterior or posterior ilia compression
to ascertain the affect of improved force closure. Reduced pain
or easier elevation with anterior compression may be indicative
of the need to train the transverse abdominis and horizontal
fibres of internal oblique (inner core). Conversely, improvements
with posterior compression may be indicative of the need to
train the multifidus which aids sacral nutation and/or train
the muscles and fascia of the posterior outer sling.
in clients with excessive force closure
this can be -ve
in clients with reduced force closure this
can be +ve
are they getting medial knee pain due to
adductor dysfunction?
Do active hip extension with or without anterior
or posterior compression of the ilia to ascertain 'force closure'.
Combinations of anterior and posterior compression on opposite
sides is also sometimes useful where a sacral torsion is involved.
Compressor Belts for the pelvis may also be useful
for these people.
The aim is the correction of pelvic mal-alignment
& asymmetry - both static and dynamic
note the very poor trunk posture
on hamstring stretching and the anterior pelvic tilting on quads
stretching!!! - he will never make the hurdling team
What is the influence of the global stabilisers? In particular,
external oblique and latissimus dorsi. As well as external
oblique and adductor longus. Remember that the gluteal
maximus works synergistically with the contralateral latissimus
dorsi/erector spinae/thoracolumbar fascia during gait.
Is the thoracic spine mobile
enough to allow localised movements without placing excessive
movement on the lumbar spine? Additionally, lack of
lateral chest expansion will affect the role of the diaphragm
in respiration and stabilisation. Suggestions have
been made that people who hyperventilate create respiratory
alkalosis which results in metabolic acidosis and therefore
creates excessive tension in the soft tissue through the
sympathetic innervation of the blood vessels. Finally,
lack of low thoracic spine mobility may affect the nutrition
to the nerves innervating the muscles and blood vessels
of the abdominal and pelvic region. Therefore, it
is imperative to assess the mobility of the thoracic spine.
Additionally, check the patency of the femoral artery
in the groin region. A discrepancy in pulse rate and pressure
may suggest that the iliopsoas is restricting blood flow.
An MET of the iliopsoas can confirm or negate this hypothesis.
Adhesion formations may be another reason. Moreover, reduced
lateral diaphragmatic movements and reduced inferior thoracic
spine mobility may be affecting sympathetic nervous system
blood vessel tone and hence the patency of the pulse. It
could be envisaged that reduced blood flow would affect
the deep endurance stabilising muscles of the leg.
What happens to the vertebrae and paraspinal
muscles when lifting the leg or arm or both?
does the spine remain
stable?
does the spine rotate
gently and segmentally during the Moggie?
What about 'the needle' exercise from yoga which may be used
to assess thoracic spine rotation
Connell AT (2008) Concepts
for assessment and treatment of anterior knee pain related
to altered spinal and pelvic biomechnics: a case report.
Manual Therapy, 13, 560-563
This author used 3 sessions
of treatment to the T10/11, T11/12, T12/L1 and L5/S1 to
improve the ROM and ability to squat in a patient with anterior
knee pain.
Grindstaff TL et al (2009) Effects of lumbopelvic
joint manipulation on quadriceps activation and strength in
healthy individuals. Manual Therapy, 14, 415-420.
These investigators
found a significant increase in the ability to produce
quadriceps force (+3%) and activation (+5%) immediatley
following lumbopelvic joint manipulation
Pelvic Floor
The pelvic floor can be considered as the
base of the cylinder which incorporates the pelvis, abdominal
muscles, back muscles, the thoracolumbar fascia and diaphragm.
Frequently, people presenting with low back and pelvic pain
also describe weakness of the bladder. Such weakness may involve
the urethra and effective force closure around the pelvis.
When a person coughs, the urethra usually contracts with the
abdominal muscles thereby avoiding embarrassment. However,
stess urinary incontinence occurs in 8.5 - 38% of women (Ashton-Miller
et al 2001, Scan J Urology & Nephrology Supp 207). It
affects 28% of elite female athletes (Bo & Borgen 2001,
Med Sc Sp Ex, 33, 11, 1797), one out of ten males and 4 of
every 10 females (Fantl et al 1996, Managing acute and chronic
urinary incontinence, clinical practice guidlelines, no2,
Rockville MD, US Dep't Health & Human Services). Cyclists
can also have pelvic floor dysfunction and neuropathies as
a result of direct presure on the pudendal nerves with an
incorrect saddle or saddle position. Urinary continence relies
on the support of the sphincter closure system and the urethral
support system. Essentially, the urethra sits inside a hammock
of muscular and fascial and liagmentous support.
The over contraction of the pubococcygeus
could result in sacral counternutation. It is likely that
the muscles are balanced in such a fashion that optimisation
of function occurs - 'not too much and not too little'
We routinely use transabdominal Real Time
Ultrasound as an assessment and biofeedback tool for training
the synergistic role of the pelvic floor and transverse abdominis
muscles. In particular during Active SLR we examine whether
there is pelvic floor descent and whether this changes with
manual pelvic compression and whether these people can be
trained to maintain or raise the pelvic floor during this
manouvre. Importantly, lumbar posture and spine neutral may
have a significant influence on results. Progression from
supine to side lying and to standing with weight shifting
are also carried out using R-T US. Coccygodynia can be the
result of excessive pubococcygeus activity.
Lee D, Lee L-J (2004) Stress Urinary Incontinence
- a consequence of failed load transfer through the pelvis?
5th World Interdisciplinary Congress on Low Back and Pelvic
Pain, Melbourne, November 2004
Smith et al (2006) Disorders of breathing
and continence have a stronger association with back pain
than obesity and physical activity. AJP, 52, 11-16
Sapsford RR et al (2000) Co-activation of
the abdominal and pelvic floor muscles during voluntary exercises.
Neurourology and Urodynamics, 20, 1, 31-42
Kelly M et al (2007) Healthy adults can more
easily elevate the pelvic floor in standing than in crook-lying:
an experimental study. AJP, 53, 187-191
Rahmani N & Mohseni-Bandpei MA (2009).
Application of perineometer in the assessment of pelvic floor
muscle strength and endurance: a reliability study. Journal
of Bodywork and Movement Therapies.
Stuge B et al (2006) To treat or not to treat
postpartum pelvic girdle pain with stabilizing exercises?
Manual Therapy, 11, 337-344.
These latter investigators
concluded that effective treatment of postpartum pelvic girdle
pain may be achieved when exercises for the entire spinal
musculature are included, individually guided and adpated
to each individual.
Hip - retroversion of the acetabulum
Reynolds, Lucas, Klaue (1999).
Retroversion of the acetabulum - a cause of hip pain. JBJS, 81B,
2, 281-8
Retroversion of the acetabulum can lead to increased
ROM of internal rotation with a conommittant loss of external
rotation which in turn affects pelvic rotation during activitis
such as ambulation.
Cam and Pincer Lesions can occur in association
with labral lesions. Excessive tension in the external hip rotators
can cause anterior acetabular impingement. Iliopsoas tendonosis
may be associated with anterior labral lesions. Excessive anterior
rotation of the innominate can cause anterior hip impingement.
Pfirrmann et al (Radiology, 240, 3, 2006 pp778-785)
used MRI measurements of alpha angles and the depth of the acetabulum
to determine the risk and incidence of CAM and Pincer lesions
in the hip. They concluded that a deep acetabulum and posteroinferior
acetabular cartilage lesions were a characteristic finding of
pincer impingement.
Trigger Points
and Fascia
Recent publications into trigger point therapy include
Biochemicals associated with
pain and inflammation are elevated in sites near to and remote
from active myofascial trigger points. Shah JP et al (2008)
Arch Phys Med Rehabil, 89, 16 -23.
Integrated Dry Needling with new concepts of
myofascial pain, muscle physiology and sensitization. Shah JP
In : Contemporary Pain Medicine, Integrative Pain Medicine, The
Science and Practice of Complementary nd Alternative Medicine
in Pain Management. Ed Audette & Bailey, Human Press, Totowa,
NJ
An explanation of Simons' integrated hypothesis
of trigger point formation. Gerwin RD, Doomerholt J, Shah JP (2004).
Current Pain and Headache reports, 8, 468-475
Uncovering the biochemical milieu of myofascial
trigger points using in vivo microdialysis: an application of
muscle pain concepts to myofascial pain syndrome. Shah JA &
Gilliams EA (2008). J of Bodywork and Movement Therapies, 12,
371-384
An in-vivo microanalytial technique for measuring
the local biochemical milieu of human skeletal muscle. Shah JP
et al (2005) J Appl Physiol, 99, 1977-1984
Comparison of normal, latent and active trigger
point physiology using microdialysis in the upper trapezius muscle
(Shah et al 2005). These researchers also found similar results
for Bradykinin, Calcitonin Gene Related Peptide (CGRP), Substance
P, Tumor Necrosis Factor alpha, and Interleukin 1beta. Additionally,
reduced pH levels were also seen in areas of active trigger points.
Trigger points have been classically
associated with plyometric type of exercise where muscles lengthen
during eccentric contraction which although it damages cytoskeletal
is considered adaptive in the formation of new sarcomeres.
Investigations into eccentric exercise revealed pain
8 hours after initial exercise which was maximal 48 hours later
(Newham, Mills, Q uigley, Edwards 1983). These
investigators found low frequency fatigue 10 minutes after a 20
minute period of stepping (Newham et al 1983). Additionally,
they demonstrated progressive increases in IEMG during the exercise
in the rectus femoris (160% increase) and vastus medialis (140%
increase) in the eccentric contracting leg (Newham et al 1983).
Mechanical damage to the sarcoplasmic reticulum resulting in less
calcium release for each excitatory action potential was suggested
as the cause of the low frequency fatigue (Newham et al 1983).
However, a number of sites in
the myofibrillar complex such as reduce binding sensitivity and
capacity of Troponin C for calcium, altered troponin-tropomysosin
interaction to impaired binding and force generation by actin
and myosin have been implicated in impaired force generation (Green
1990). Indeed, in the absence of any association between
relaxation rates and Calcium kinetics raises support for the notion
of a rate-limiting process controlling the relaxation of fatigued
muscles being located in the contractile proteins (Hill et al
2001). During fatigue the relaxation times can be prolonged
as much as 50% (Bigland-Ritchie et al 1986) thus resulting in
increased force generation during submaximal stimulation due to
tetanic fusion despite a substantial fall in the maximum tetanic
force (Bigland-Ritchie et al 1986).
The initial overall loss of force
production seen may be due to Desmin and Titan damage (Lieber
& Friden 2002). Desmin acts as an extra-sarcomeric mechanical
stabilizer between adjacent Z discs and the attachment to the
costomere at the sarcolemma (Lieber, Shah & Fridén
2002). The costomere complex contains Talin, Vinculin &
Dystrophin which attach to the trans-sarcolemmal proteins Integrin
and Dystrophin associated proteins. These proteins allow
the lateral transmission of force from actin to the basal lamina
containing type IV collagen which is contiguous with the endomysium
(Kovanen 2002). Desmin loss after eccentric exercise can
occur within 5 minutes, possibly as a result of increased intracellular
Calcium leading to Calpain activation and selective hydrolysis
of intermediate filament network (Lieber & Fridén 2002).
This may result in the ‘popping of sarcomeres' of different
length thereby potentially loosing their myofilament overlap of
actin and myosin (Lieber & Fridén 2002). Hence,
reduced force production would be expected. Additionally,
the release of matrix metalloproteinase (MMP) which may degrade
the extramyocellular type IV collagen (Korskinen, Kovanen, Komulainen
et al 1996). However, this effect occurs many days after
exercise (Korskinen et al 1996) and could even effect torque production
28 days after exercise (Lieber & Fridén 2002).
This has significant implications in exercise training prescription.
flash file created
by Martin Krause 2003
Titan molecules span
the gap between the ends of the thick filaments and Z-bands. At
the 2007 MPA conference in Cairns, Rob Herbert, provided the AJP
oration whereby he explained the significance of Titan as a major
determinant of extensibility in muscle fibres. Additionally, he
stated that Titan is differentially expressed in human skeletal
muscle as short stiff fibres and long compliant fibres
Costomeres are 15 different
proteins
Low oxidative muscles have a tendency to
tear during eccentric exercise
Loss of desmin proceeds loss of fibronectin
membrane
Fibre strain results in increased intracellular
and extracellular calcium which ?may lead to desmin hydrolysis
through calpaine?
Sarcomere shortening occurs to the detriment
of tendon lengthening
Excitation-contractile coupling may be the
area disrupted rather than pure sarcomere disruption
Structural changes of the disruption of the
cytoskeleton include dystrophin (sublaminal membrane protein),
sometimes desmin and titin, whereas alpha actin is always
OK ?suggesting that calpaine is not the enzyme responsible
for protein dysruption?
Creatine Kinase has no correlation with these
cytoskeletal changes
Inflammatory process important for tissue
cleaning and remodelling
Mechanism for muscle adaptation may be myosin
gene regulation - heavy chain myosin isoform upregulation
Oxygen into the Mitochondria and through
the electron transfer chain (ETC) results in ATP use of 20%
for power and 80% for heat, therefore people producing less
heat may be producing more power?
Slow twitch muscle fibre concentration varies
with the years of training
Cycling cadence velocity at peak efficiency
for slow twitch muscle fibres is 80rpm
Trigger Point palpation
Trigger point - gluteus medius
Trigger Points : piriformis, gluteus maximus,
quadratus lumborum, levator ani
Trigger Point - adductor magnus.
Note the anal referral which is common amongst cyclists who use
the adductors to power hip extension
Trigger Points : Obtrator Internus
and pelvic floor
Trigger point - iliopsoas
Fibroblasts and Loose
Connective Tissue
At the APA conference in Sydney during
October 2009, Dr Helene Longevin presented her research into the
effects of stretching subcutaneous tissue. Superficial and deep
fascia are composed of loose and dense connective tissue layers.
The loose layers allow dense layers to glide past one another.
This tissue contains abundant fibroblasts, immune cells and neurovascular
bundles. A 20% static stretch of loose connective tissue for 30minutes
significantly increases the size of fibroblasts in vivo and in
vitro. Although this mechanism remains unclear it is hypothesised
to be due to microtubule reorganisation (Beta-tubulin). Inhibition
of growth kinase and Roc prevents the cells from spreading out.
Actine polymerisation occurs at the leading edge. Fibro-attraction
occurs whereby fibroblasts push forward at it's front edge, whilst
retracting the rear (through Rho). Both Rac and Rho are activated
simultaneously. The fibroblasts microtubule assembly contributes
to connective tissue (C.T) relaxation, which means that tense
in connective tissue is actively regulated. Viscoelastic response
of loose connective tissue is influenced by specific cytoskeletal
inhibitors. Rac increases the equilibrium force. Active C.T tensioin
regulation may occur normally in response to sustained chnages
in tissue length (e.g. hift in body position). This role may be
to prevent sustained mechanical stimulation of other cells within
the C.T (immune cells, nerve fibres, blood vessels).
The dense C.T fibroblasts don't respond
to stretch due to the stiff matrix preventing the fibroblasts
from receiving any strain. Scarring due to injury causes an increase
in dense C.T which can be pevented by 10minutes, 2 times per day
for 1 week in a suspended tail animal model. The combination of
reduced movement and inflammation is a recipe for fibrosis. R-T
US can be used as feedback during dry needling to observe C.T
movement. In people suffering low back pain the fascial layers
are less fluid and less differentiated. Additionally, people with
LBP have hicker perivascular C.T. Involuntary muscle spasms may
decrease the relative C.T motion during passive movement. Conversely,
increased C.T thickness, stiffness and/or viscosity may affect
the passive stiffness and range of movement of adjacent muscles.
Intrinsic tension within C.T will
have profound effects in the cells within it such as blood vessel
precursors stimulating angiogenesis. Similarly, immune cells may
be affected by this tension. High amplitude or repetitive tissue
stretch may cause injury but can also increase C.T strength. Low
amplitude stretch within or slightly beyond the usual ROM may
help maintain appropriate mibility and dynamic tissue response.
Hence this may represent strong eveidence for STM, dry needling,
joint mobilisations, muscle energy technqiues, strain-counterstrain
techniques and training with Whole Body Vibration.
Exercise and Growth
Hormone
Bed rest can have deleterious effects
on muscle function. Researchers have recently described
a direct muscle afferent-pituitary axis whereby bio-assayable
growth hormone (BGH) regulation is tightly coupled with muscle
function rather than muscle fibre type. Unlike, exercise-induced
increases in plasma immuno-assayable growth hormone (IGH), whose
concentration peak occurs during or after longer duration aerobic
or resistance exercise involving larger muscle mass, BGH is released
after a brief series of isometric contraction (McCall et al 2001).
The BGH response is absent , despite the maintenance of normal
torque output and pre-exercise plasma BGH and IGH, when leg musculature
is chronically unloaded, as after 2 days bed rest or space flight.
They hypothesised that this was due to chronic alterations in
proprioceptive inputs (McCall et al 2001). These responses
normalised within approximately 8 days of ambulatory recovery.
Furthermore, they suggested that BGH stimulates bone growth and
that low threshold fibre activation through electrical stimulation,
exercise and /or vibration may ameliorate the effects of chronic
unloading (McCall et al 2001). Moreover, this
is direct evidence for the existence of a muscle-pituitary functional
pathway in the absence of inflammation. It also
highlights the need not to underestimate the effects of bed rest
when recommencing a training regime after a period of illness
or trauma. Furthermore, it would appear that low threshold
isometric contractions, as occur during the application of muscle
energy techniques, may stimulate this growth hormone.
Good exercise prescription (of power and endurance)
considers whether the person is functionally unstable due to
weakness, stiffness, atrophy or hypermobility
The force (and hence Power = Force
x velocity) produced by a muscle is directly proportional to it's
cross sectional area (as well as it's length when considering
power). Therefore, the presence of atrophy : hypertrophy across
the dynamic stabilising spectrum of Newton's third law of action-reaction
needs to be assessed and calculated into the clinical reasoning
process when considering left-right, anterior-posterior dysfunction.
Optimal torque becomes paramount as the linear forces create rotatory
inertia and momentum (see cycling
kinematics for torque dynamics).What about plyometrics and
energy absorption through eccentric-concentric muscle action?
When joints are accelerating, inverse dynamics
dictates that the 'two joint muscles' act as energy straps transducing
forces from one body segment to the next. Therefore,
it is important to ascertain whether the muscles are short and
weak. If this is the case, then excessive stretching may
result in inappropriate force transduction leading to injury in
the more mobile areas. Apart from predisposing to injury,
this uncontrolled energy reduces the efficiency
or economy of movement which normally can be captured with
the release of the potential energy during elastic recoil (for
more details refer to
endurance training for running )
Check out the 'tensegrity model'
as it applies to biomechanical integrety
- not for the faint hearted
and should only be attempted when the competency level has been
ascertained
Further Reading
Bermark (1989) Stability of the lumbar spine: a
study in mechanical engineering. Acta Orthopaedica Scandinavica,
230, 60, 20-24
Boyling & Jull (2004) Grieves Modern Manual
Therapy, The Vertebral Column, Churchill Livingston
Chaitow L (2001) Muscle Energy Techniques. Edinburgh
Chiarelli PE (1998) Womens waterworks ; curing incontinence.
Gore & Osment Publications Rushcutters Bay
Cholewicki & Silfies (2004) Clinical biomechanics
of the lumbar spine. In : Boyling & Jull (2004) Grieves Modern
Manual Therapy, The Vertebral Column, Churchill Livingston, ch7
Christensen et al (2004) Clinical reasoning in the
diagnosis and management of spinal pain. In : Boyling & Jull
(2004) Grieves Modern Manual Therapy, The Vertebral Column, Churchill
Livingston, ch27
Elvey & O'Sullivan (2004) A contemporary approach
to manual therapy. In Boyling & Jull (2004) Grieves Modern
Manual Therapy, The Vertebral Column, Churchill Livingston. Ch33
Gibbons & Tehen (2000) Manipulation of the spine,
thorax and pelvis. An osteopathic perspective. Churchill Livingstone,
Edinburgh
Hides et al (1994) Evidence of lumbar multifidus
muscle wasting ipsilateral to symptoms in patients with acute/subacute
low back pain. Spine, 19, 2, 165-177
Hides et al (1995) Multifidus recovery is not automatic
following resolution of acute first episode low back pain. Spine,
21, 23, 2763-2769
Hodges (1997) Feedforward contraction of transversus
abdominis is not influenced by the direction of arm movement.
Exp Brain Research, 114, 362-370
Hodges & Richardson (1997) Contraction of the
abdominal muscles associated with movement of the lower limb.
Physical Therapy, 77, 132-144
Hodges & Gandevia (2000) Changes in intra-abdominal
pressure during postural and respiratory activation of the human
diaphragm. J Appl Physiol, 89, 967-976
Hodges et al (2002) Feedforward activity of the
pelvic floor muscles precede rapid upper limb movements. Australian
Physiotherapy Association conference, Sydney, abstract 21
Holstege et al (1996) The emotional motor system.
Elsevier, Amsterdam
Kelly M et al (2007) Healthy adults can more easily
elevate the pelvic floor in standing than in crook-lying: an experimental
study. AJP, 53, 187-191
Lee D, Lee L-J (2004) Stress Urinary Incontinence
- a consequence of failed load transfer through the pelvis? 5th
World Interdisciplinary Congress on Low Back and Pelvic Pain,
Melbourne, November 2004
Lee D (2004) The Pelvic Girdle: an approach to the
examination and treatment of the lumbopelvic-hip region. Churchill
Livingstone, Edinburgh
Mercer (2004) Kinematics of the spine In : Boyling
& Jull (2004) Grieves Modern Manual Therapy, The Vertebral
Column, Churchill Livingston, ch4
O'Sullivan (2004) 'Clinical instability' of the
lumbar spine: its pathological basis, diagnosis and conservative
management. In : Boyling & Jull (2004) Grieves Modern Manual
Therapy, The Vertebral Column, Churchill Livingston Ch 22
O'Sullivan et al (2002) Altered motor control in
subjects with sacro-iliac joint pain during active straight leg
raise test. Spine 27, 1, E1-E8
O'Sullivan et al (2002) The effect of different
standing and sitting postures on trunk muscle activity in a pain
free population. Spine, 27, 1238-1244
O'Sullivan et al (2003) Lumbar repositioning deficit
in a specific low back pain population. Spine, 28, 10, 1074-1079
Panjabi (1992) The stabilizing system of the spine.
1: Function, dysfunction, adaptation, and enhancement. J of Spinal
Disorders, 5, 4, 383-389
Potter & Rothstein. Physical Therapy,1985, 65,
11, 1671-5
Rahmani N & Mohseni-Bandpei MA (2009). Application
of perineometer in the assessment of pelvic floor muscle strength
and endurance: a reliability study. Journal of Bodywork and Movement
Therapies.
Richardson et al (2002) The relationship between
the transversely oriented abdominal muscles, sacroiliac joint
mechanics, and low back pain. Spine, 27, 4, 399-405
Sapsford (2001) The pelvic floor: a clinical model
for function and rehabilitation. Physiotherapy, 87, 620-630
Sapsford et al (2001) Co-activation of the abdominal
and pelvic floor during voluntary exercises. Neurology and Urodynamics,
20, 31-42
Sapsford & Hodges (2001) Contraction of the
pelvic floor muscles during abdominal manouvers. Archives of Physical
Medicine and Rehabilitation, 82, 1081-1088
Sapsford & Kelley (2004) Pelvic Floor Dysfunction
in low back and sacroiliac dysfunction. In: Boyling & Jull
(2004) Grieves Modern Manual Therapy, The Vertebral Column, Churchill
Livingston, ch35
Schamberger W (2002) The malalignment syndrome ;
implication for medicine and sport. Churchill Livingstone, Edinburgh
Shumway-Cook & Woollacott (1995) Motor control:
theory and practical applications. Williams and Wilkins, Baltimore
Smith et al (2006) Disorders of breathing and continence
have a stronger association with back pain than obesity and physical
activity. AJP, 52, 11-16
Snijders et al (1993) Transfer of lumbosacral load
to iliac bones and legs. 1. Biomechanics of self bracing of the
sacroiliac joints and its significance for treatment and exercise.
Clinical Biomechnics, 8, 285-294
Snijders et al (1993) Transfer of lumbosacral load
to iliac bones and legs. 2. Loading of the sacroiliac joints when
lifting in a stooped posture. Clinical Biomechanics, 8, 295-301
Stuge B et al (2006) To treat or not to treat postpartum
pelvic girdle pain with stabilizing exercises? Manual Therapy,
11, 337-344.
Sturesson et al (2000). A radiostereometric analysis
of movements of the sacroiliac joints during standing hip flexion
test. Spine 25(3), 364-368
Van Wingerden et al (1993) A functional-anatomical
approach to the spine-pelvis mechanism: interaction between the
biceps femoris muscle and the sacrotuberous ligament. European
Spine Journal, 2, 140-144
Vleeming et al (1989). The sacrotuberous ligament:
a conceptual approach to its dynamic role in stabilizing the sacroiliac
joint. Clinical Biomechanics, 4, 201-203
Vleeming et al (1989). Load application to the sacrotuberous
ligament: influences on sacroiliac joint mechanics. Clinical Biomechanics,
4, 204-209
Vleeming et al (1990). Relation between form and
function in the sacroiliac joint. 1. Clinical anatomical aspects.
Spine, 15(2), 130-132
Vleeming et al (1990). Relation between form and
function in the sacroiliac joint. 2. Biomechnical aspects. Spine,
15(2), 133-136
Vleeming et al (1992). Mobility in the SI-joint
in old people: a kinematic and radiological study. Clinical Biomechanics,
7, 170-176
Vleeming et al (1995). The posterior layer of the
thoracolumbar fascia: its function in load transfer from spine
to legs. Spine, 20, 753-758
Vleeming et al (1996). The function of the long
dorsal sacroiliac ligament: its implication for understanding
low back pain. Spine, 21, 5, 556-562
External Links to Amazon.com
for book reviews and sales
Sahrmann S: Diagnosis & Treatment of Movement
Impairment Syndromes
also see
The Pelvic Girdle: An Approach to the Examination
and Treatment of the Lumbopelvic-Hip Region
Chaitow L: Muscle Energy Techniques
The thinking Body
Please note that Australian Law requires that visitors to this
site understand that by clicking to these book links, Pro Cure Physiotherapy
Pty Ltd t/a Back in Business Physiotherapy may receive a commission
from the generation of sales at the Amazon.com website. Never-the-less, these
books (by Vleeming, Lee, Chaitow and Sahrmann) have been read by the author
several times and are extremely highly recommended texts to physiotherapists
who treat low back pain and pelvic girdle dysfunction. 22 January 2005
Last update : 20 October 2009
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any injury and/or damage to persons or property as a matter of product
liability, negligence, or from any use of any methods, products, instruction,
or ideas contained in the material in this and it's related websites.
Because of rapid advances in the medical sciences, the author recommends
that there should be independent verification of diagnoses and exercise
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