Movement Stability and Lumbopelvic Pain [PDF]

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Movement, Stability Lumbopelvic Pain



For Churchill Livingstone:



Senior Commissioning Editor: Sarena Wolfaard Associate Editor: Claire Wilson; Claire Bonnett Project Manager: David Fleming; Jane Dingwall Design: Stewart Larking Illustration Manager: Bruce Hogarth



2nd



Edition



Movement, Stabi ity & Lumbopelvic Pain Integration of Research and Therapy Edited by



Andry Vleeming



PhD



Clinical Anatomist and Founder Spine and Joint Center, Rotterdam, The Netherlands



Vert Mooney



MD



Measurement Driven Rehabilitation Systems, San Diego, CA, USA



Rob Stoeckart



PhD



Department of Neuroscience, Erasmus MC, Rotterdam, The Netherlands



Illustrations by Philip Wilson Chartwell CHURCHILL LIVINGSTONE



ELSEVIER Edinburgh



London



New York



Oxford



Philadelphia



St Louis



Sydney



Toronto



2007



CHURCHILL LIVINGSTO E ELSEVIER



CHURCHILL LtVI



GSTONE



An imprint of Elsevier Limited Pearson Professional Limited 1997 C Harcourt Publishers Limited



2007, Elsevier Limited. SV Paris 2007 h 26 Ch 35 SM McGill 2007



1999



All rights reserved.



The right of Andry V lceming, Vert Mooney and Rob StOl."'Ckart to be identified as editors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act



1988



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Reprinted 1999 Second edition 2007



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I



Contents viii



Contributors



x



Preface ...



SECTION 2 Evolution, biomechanics and kinematics 9



PART 1 Biomechanical, clinical-anatomical and



Evolution of the human lumbopelvic region and its relationship to some clinical deficits



evolutionary aspects of lumbopelvic pain and



of the spine and pelvis



dysfunction



. . . . . . . . . 141



CO Lovejoy



10



SECTION 1 Clinical-anatomical aspects



. 159



A Huson



The muscular, ligamentous, and neural 11



structure of the lumbosacrum and its relationship to low back pain . . . . .



Kinematic models and the human pelvis .............. .



How to use the spine, pelvis, and legs effectively in lifting. . . . . . . .



5



. 167



MA Adams, P Dolan



FHWiliard 2 Anatomical linkages and muscle slings of the



12



Is the sacroiliac joint an evolved



lumbopelvic region . . . . . . . . . . . .47



costovertebral joint?



C DeRosa, JA Porterfeld



S Gracovetsky



3 Anatomy and biomechanics of the lumbar



. . . . . . . . . . 185



13 The evolution of myths and facts



fasciae: implications for lumbopelvic control



regarding function and dysfunction of



and clinical practice . . . . . . . . . . . .63



the pelvic girdle . . . . . . . . . . . . . 191



PJ Barker, CA Br-iggs



o Lee



4 Clinical anatomy of the anterolateral abdominal



muscles. . .



. . . . . .75



PART 2 Insights in function and dysfunction of the



OM Urqullart. PW Hodges



lumbopelvic region



5 Clinical anatomy of the lumbar



multifidus . .



6



. . . . . .85



14 Anatomical, biomechanical, and clinical



L Danneels



perspectives on sacroiliac joints: an integrative



Clinical anatomy and function of psoas major



synthesis of biodynamic mechanisms



and deep sacral gluteus maximus . . . . .95



related to ankylosing spondylitis. . . . . 205



SGibbons



AT Masi, M Benjamin, A Vleeming



7 The sacroiliac joint: sensory-motor control



15 A suspensory system for the sacrum in pelvic



and pain. . . . . . . . . . . . . . . . . 103



mechanics: biotensegrity . . . . .



A Indahl, S Holm



SMLevin



8 The role of the pelvic girdle in coupling the



16 Why and how to optimize posture.



perspective on pelvic stability . . . . . . 113



. 239



RElrvin



spine and the legs: a clinical-anatomical AVleemrng, R S toeckart



. 229



17



Gait style as an etiology to lower back pain . . . . . . . . . . . . . . . . 253 HJ Dananberg



vi



Contents



18 A detailed and critical biomechanical analysis



of the sacroiliac joints and relevant kinesiology: the implications for lumbopelvic function and dysfunction . . . . . . . . . . .



. 265



PART 4 Guidelines



29



RL Don1igny



19



Stability or controlled instability?



European guidelines for prevention in low back pain . . . . . . . . . . . . . . 429 G Mullel on behalf of the COST 813



. 279



Working Group on European Guidelines foI



S Gracovetsky



Prevention in L ow 8ack Pain



30



PART 3 Diagnostic methods



Evidence-based medicine for acute and chronic low back pain: guidelines . . . . 447 M van Tulder, 8 Koes



SECTION 1 Visualization in relation to pelvic



31



dysfunction 20



AVleeming et al on behalf of the COST 813



Basic problems in the visualization of the sacroiliac joint . . . . . . . . . "



CT and MRI of the sacroiliac joints



Working Group on Pelvic Gildle Pain



. 299



PF Dijkstra



21



European guidelines on the diagnosis and treatment of pelvic girdle pain. . . . 465



.311



JMD O'Neill, E Jurriaans



PART 5 Effective training and treatment



SECTION 1 Psychological, social and motivational



22 Visualization of pelvic biomechanical



dysfunction . . . . . . . . . . . . . . . 327 TRavin



aspects 32



Behavioral analysis, fear of movement! (re)injury and cognitive-behavioral management



SECTION 2 The pelvic girdle



of chronic low back pain . . . . . . . .475 JWS Vlaeyen. LMGVancleef



23



Movement of the sacroiliac joint with special reference to the effect of load .



. 343



8Sturesson



24 What is pelvic girdle pain?



..



. 353



SECTION 2 Motor control 33



HCOstgaard



25



The pattern of intrapelvic motion and



34



lumbopelvic muscle recruitment alters in the presence of pelvic girdle pain .



Functional control of the spine. . . . . . 489 PW Hodges, J Cholewicki Motor control in chronic pain: new ideas for effective intervention .



. 361



. . 513



G Lorimer Moseley



8 Hungeliol-d, W Gilleard



SECTION 3 Different views on effective training SECTION 3 Low back 26



27



Differential diagnosis of low back pain . . 381



35



The painful and unstable lumbar spine:



SV Paris, J Viti



a foundation and approach for



Conditions of weight bearing: asymmetrical



restabilization . . . . . . . . . . . . . . 529



overload syndrome (AOS). . . . . . . . 391



SMMcGili



J A Porteliield, C DeRosa



28



and treatment



36



Important aspects for efficacy of treatment



Evidence-based clinical testing of the



with specific stabilizing exercises for



lumbar spine and pelvis . . . . . . . . . 405



postpartum pelvic girdle pain . . . . . . 547



M Laslett



8 Stuge, NKVollestad



Contents



37



Breathing pattern disorders and back pain . . . . . . . . . . . . . . . . 563 LChaitow



38



Effective rehabilitation of lumbar and pelvic



PART 6 Integrating different views and opinions when dealing with a complex system 39



An intregrated approach for the management



girdle pain. . . . . . . . . . . . . . . . 573



of low back and pelvic girdle pain: a case



V Moolley



report . .



.



.



.



.



.



.



.



. . . . . . . . . 593



o Lee 40 An integrated therapeutic approach to the



treatment of pelvic girdle pain .



.



.



. . 621



o Lee. AVleeming Index . . .



.



. . . . . . . . . . . . . . 639



vii



Contributors MA Adams BSe PhD



RL DonTigny PT



Senior Research Fellow, Department of Anatomy,



Physical Therapist, Havre, Montana, USA



University of Bristol, Bristol, UK



S Gibbons BSe (Hons) PT MSe MCPA



PJ Barker BAppSe(Physio) PhD



Stability Physiotherapy, Mt. Pearl, Newfoundland,



Senior Tutor, Department of Anatomy and Cell Biology,



Canada



The University of Melbourne, Victoria, Australia



W Gilieard PhD



M Benjamin PhD



Senior Lecturer in Biomechanics, School of Exercise



Professor of Musculoskeletal Biology and Sports



& Sports Management, Southern Cross University,



Medicine Research, School of Biosciences, Cardiff



Lismore, Australia



University, Cardiff, UK



CA Briggs BSe Dip Ed MSe PhD Associate Professor and Deputy Head, Department of Anatomy and Cell Biology, The University of Melbourne, Victoria, Australia



S Graeovetsky PhD Retired, Concordia University, Montreal, QC, Canada



PW Hodges BPhty (Hons) PhD MedDr Professor and NHMRC Principal Research Fellow, Division of Physiotherapy, The University of Queensland,



L Chaitow NO DO Honorary Fellow, School of Integrated Health, University



Brisbane, Australia



of Westminster, London, UK; Editor-in-Chief, Journal of



S Hoim



Bodywork & Movement Therapies



Professor, Department of Orthopaedics, Sahlgrenska University Hospital, Goteborg, Sweden



J Cholewieki Associate Professor, Department of Orthopaedics &



B Hungerford PhD



Rehabilitation, Yale University School of Medicine, New



Consultant Musculoskeletal Physiotherapist, Sydney



Haven, CT, USA



Spine & Pelvis Centre, Drummoyne, NSW, Australia



HJ Dananberg DPM



A Huson MD PhD



Podiatrist, private practice, Catholic Medical Centre,



Professor Emeritus, Maastricht University, The



Bedford, New Hampshire, USA; Contributing Editor,



Netherlands



Journal of the American Podiatric Medical Association



A Indahl MD PhD



L Danneels PT PhD



Consultant, Specialist in physical medicine and



Professor of Rehabilitation Sciences and Physiotherapy,



rehabilitation, Department of Physical Medicine and



Faculty of Medicine and Health Sciences, Ghent,



Rehabilitation, Hospital for Rehabilitation, Stavern,



Belgium



Norway



C DeRosa PT PhD



RE Irvin DO



Professor of Physical Therapy, Northern Arizona



Clinical Associate Professor, Dept of Osteopathic



University, Flagstaff, Arizona, USA



Manipulative Medicine, College of Osteopathic Medicine, Oklahoma State University Health Science Center, Tulsa,



PF Dijkstra MD DlC PhD Former Radiologist, Academic Medical Centre,



Oklahoma, USA



Amsterdam, The Netherlands; Former Head of



E Jurriaans BSe MBChB DTM&H FRCR(UK) FRCP(C)



Department of Radiology, Jan van Breemen Institute for



Associate Professor, McMaster University, Faculty of



Skeletal Disease, Amsterdam, The Netherlands



Health Sciences, Hamilton, Ontario, Canada; Staff Radiologist, St. Joseph's Healthcare, Hamilton, Ontario,



P Dolan PhD Reader in Biomechanics, Department of Anatomy, University of Bristol, Bristol, UK



Canada



ix Contributors B Koes PhD



JA Porterfield PT MA ATC



Professor of General Practice, Head of Research



Owner, Rehabilitation and Health Center, Inc., Akron,



Department, Department of General Practice, Erasmus



Ohio; CEO, Venture Practice Services Ltd., Akron, Ohio,



MC, University Medical Centre, Rotterdam, The



USA



Netherlands



T Ravin MD



M Laslett PhD NZRP Dip MT Dip MDT



Physician; President of the American Association of



Senior Clinician, Phy sioSouth @ Moorhouse Medical



Musculoskeletal Medicine, Denver, Colorado, USA



Clinic, Christchurch, New Zealand



R Stoeckart PhD



D Lee BSR FCAMT



Department of Neuroscience, Erasmus MC, Rotterdam,



Clinical and Education Consultant, Diane Lee &



The Netherlands



Associates, Canada



B Stuge PT PhD



SM Levin MD FACS



Senior Researcher, Institute of Nursing & Health



Director, Ezekiel Biomechanics Group, McLean, VA, USA



SCiences, University of Oslo, Norway



CO Lovejoy MA PhD



B Sturesson MD PhD



University Professor of Anthropology, Department of



Head of Spine Unit, Department of Orthopaedics,



Anthropology and Division of Biomedical Sciences, Kent



Angelholm Hospital, Angelholm, Sweden



State University and Northeast Ohio Universities College of Medicine, Ohio, USA



M van Tulder PhD Professor, Institute for Research in Extramural Medicine



AT Masi MD DR PH



(EM GO) and Institute for Health Sciences (HIS), V U



Professor of Medicine, University of Illinois College of



University Medical Centre, Amsterdam, The Netherlands



Medicine at Peoria ( UICOMP), Illinois, USA



DM Urquhart BPhysio(Hons) PhD



SM McGill



Dept of Epidemiology & Preventive Medicine, Monash



Professor, Faculty of Applied Health Sciences, Dept of



University, Victoria, Australia



Kinesiology, University of Waterloo, Ontario, Canada



LMG Vancleef MSc



V Mooney MD



Dept Medical, Clinical and Experimental Psychology,



Clinical Professor of Orthopaedics, USSD, Private



Maastricht University, The Netherlands



Practitioner, San Diego, California, USA



J Viti



G Lorimer Moseley PhD BAppSc(Phty)(Hons)



Assistant Professor, University of St. Augustine for



Nuffield Medical Research Fellow, Centre for fMRI of



Health Sciences, St. Augustine, Florida, USA



the Brain and Dept of Human Anatomy & Genetics, University of Oxford, UK



JWS Vlaeyen PhD



G Muller



Maastricht University, The Netherlands



Dept Medical, Clinical and Experimental Psychology, Orthopaedic Surgeon, Sports Medicine, Manual Therapy, Chairman of Rueckenzentrum Am Michel, Hamburg,



A Vleeming PhD



Germany



Clinical Anatomist and Founder, Spine and Joint Center, Rotterdam, The Netherlands



JMD O'Neill MB BAO BCh MRCPI MSc FRCR(UK) Assistant Professor, McMaster University, Faculty of



NK V"lIestad PhD



Health Sciences, Hamilton, Ontario, Canada; Staff



Professor, Head of Institute of Nursing & Health



Radiologist & Director - Musculoskeletal Imaging, St.



Sciences, University of Oslo, Norway



Joseph's Healthcare, Hamilton, Ontario, Canada



FH Willard PhD



HC Ostgaard MD PhD



Professor, College of Osteopathic Medicine, Family



Associate Professor, Chief of Dept of Orthopaedics,



Medicine, University of New England, Biddeford, Maine,



Sahlgren University Hospital, Molndal, Sweden



USA



SV Paris PT PhD FA PTA President, University of St. Augustine for Health Sciences, St. Augustine, Florida, USA



Preface There are a large number of books dealing with



and several others.



the lumbar spine and pelvis, so why this book



into the following parts:



on



1.



Movement, Stability and Lumbopelvic Pain?



This



Biomechanical, clinical-anatomical and evolutionary aspects of lumbopelvic pain and



question is pertinent as there are several excellent books available which cover these topics. Our



dy sfunction 2.



reasons are diverse.



In the book they are grouped



InSights in function and dysfunction of the lumbopelvic region



Firstly, several distinguished scientists, physicians and other specialists have lately provided evidence­



3.



Diagnostic methods



based, relevant new data on the lumbopelvic



4.



Guidelines



area. This forces us to look afresh at the adequacy



5.



Effective training and treatment



of current diagnostic and therapeutic methods.



6.



Integrating different views and opinions when



Secondly, most books deal either with the low back or with the pelvic girdle; our aim is to collect all



dealing with a complex system. The studies reviewed in this book reflect the



relevant material in one book. Thirdly, most books



specialties of the contributors, their backgrounds,



on the subject are written by one expert or by a small



sty les, approaches and specific ideas about how



team of experts. This makes it difficult to get a grip



lumbopelvic structures function and dy sfunction.



on the vast wealth of information available. Finally,



Several chapters were written by authors with a



and probably most importantly, notwithstanding all



unique concept about the origin of pain and dys­



efforts to treat patients adequately, large numbers



function of lumbopelvic structures and about the



of patients still suffer chronically from low back



therapy requested. In a way this is hazardous since



pain and/ or pelvic girdle pain. It is our hope and



certain authors were invited, not because of their



ambition to provide, together with all contributors,



evidence-based approach, but since in the opinion



an integrated book that can be of help to people



of the



involved in the diagnosis or treatment of patients



controversial ideas merit attention. Their concepts



with lumbopelvic pain.



should invite sound research that can confirm,



The contributors to this book include scientists



refute,



editors



their audacious and



or adapt



the



sometimes



ideas presented.



We are



of internationally renowned clinical groups and



convinced that the wealth of information presented



departments dealing with basic sciences. Their



by the contributors will help to create rational and



contributions



are



from



different



disciplines



embracing anthropology, orthopedic surgery, bio­ mechanical



engineering,



chiropractic



effective treatment programs for the management of lumbopelvic pain and dysfunction.



practice,



anatomy, osteopathy, physical therapy, podiatry,



Andry V leeming, Vert Mooney and



gynecology, rehabilitation medicine, epidemiology



Rob Stoeckart



Section One Biomechanical, c1inical­ anatomical and evolutionary aspects of lumbopelvic pain and dysfunction: Clinical­ anatomical aspects The muscular, ligamentous, and neural structure of the lumbosacrum and its relationship to low back pain FH Willard



2 Anatomical linkages and muscle slings of the



lumbopelvic region C DeRosa, JA Porterfield



3 Anatomy and biomechanics of the lumbar fasciae: implications for lumbopelvic control and clinical practice PJ Barker, CA Briggs



4 Clinical anatomy of the anterolateral abdominal



muscles OM Urquhart, PW Hodges 5 Clinical anatomy of the lumbar multifidus L Danneels



..__..__ 6



Clinical anatomy and function of psoas major and deep sacral gluteus maximus S Gibbons



7 The sacroiliac joint: sensory-motor control and



pain A Indahl, S Holm



8 The role of the pelvic girdle in coupling the spine and the legs: a clinical-anatomical perspective on pelvic stability A Vleeming, R Stoeckart



The muscular, ligamentous, and neural structure of the lumbosacrum and its relationship to low back pain FH Willard



INTRODUCTION The lumbosacral spinal column performs a key role in the transfer of weight from the torso and upper body into the lower extremities, both in static positions and during mobility. The primary bony structures involved in this force transduction are: five lumbar vertebrae, a sacrum, two innominate bones, and the two femoral heads. Critical to the stability of these bony components is a complex arrangement of dense corulective tissue. Although typically described as separate entities in most textbooks of anatomy, these fibrous, soft-tissue structures actually form a continuous ligamentous stocking in which the lumbar vertebrae and sacrum are positioned. The major muscles representing the prime movers in this region - such as the multifidus, gluteus maximus, and biceps femoris - have various attachments to this elongated, ligamentous stocking. The muscular and ligamentous relationships composing the lumbosacral connection are of extreme importance in stabilizing the lumbar vertebrae and sacrum during the transfer of energy from the upper body to the lower extremities. This arrangement has been termed a 'self-bracing mechanism' (Vleeming et a1 1995c) and, as such, its dysfunction is critical to the failure of the lower back. A critical relationship also exists between the neural components of the lumbosacral region and the surrounding ligamentous structures. Traumatic, inflammatory, and degenerative disease processes affect the structure of the lumbosacral region and impact on the surrounding nerves. Current research, using immunohistochemical techniques to identify specific types of axons, suggests that all of these connective tissue structures receive a supply of small-caliber, primary afferent fibers (Ab and C-fibers),



6



Movement, Stability and Lumbopelvic Pain



typical of those involved in nociception. Irritation of these primary afferent nociceptive axons initiates the release of neuropeptides that interact with fibroblasts, mast cells, and immune cells present in the surrounding connective tissue (Levine et al 1 993). The resultant cascade of events, referred to as a neurogenic inflammatory response, is thought to play a major role in degenerative diseases and the development of low back pain (Garrett et al 1992, Kidd et a1 1 990, Schaible et al 2005, Weidenbaum & Farcy 1 990, Weinstein 1992). Sensitization of these small-caliber, primary afferent fibers, along with sensitization of their central connections in the dorsal horn of the spinal cord, appears to play a crucial role in the evolution of chronic painful conditions (Coderre et al 1993, Ji et al 2003, Woolf & Chong 1 993). This chapter examines recent advances in our knowledge of the lumbosacral region structural architecture, pathology, and innervation.



Ligamentous structure of the lumbar region The various ligaments of the lumbar vertebral column form a continuous, dense, connective-tissue stocking surrounding the vertebrae and extending into the sacral area. For ease of description, the vertebral connective tissue sheath can be divided into three parts: (1) the neural arch sh'uctures; (2) the capsular structures; and (3) the ventral or vertebral body structures (Fig. 1 .1). However, it should be noted that the partitions between each of these three divisions are for convenience only, as the connective tissue of the dorsal and ventral components is essentially continuous across the pedicles of the vertebrae. Neural arch ligaments The neural arch of each I umbar vertebra is composed of the pedicles, laminae, transverse processes, and spine (Figs 1.1 and 1 .2). Two major ligaments participate in surrounding the neural arch: the ligamentum flavum and the interspi.nous ligament; two additional small ligaments are also described: the supraspinous ligament posteriorly and the intertransverse ligament laterally. To view the ligaments of the neural arch, the multifidus muscle must be completely removed from the lumbosacral region (Figs 1 .2 and 1 .3). Although most of these ligaments have a distinct biochemical make-up when analyzed in isolation (Ballard & Weinstein 1 992, Fujii & Hamada 1993, Fujii et al 1993, Yahia



Ventral



Capsular



Neural arch



ligaments



ligaments



ligaments Superior articular



--'--'\--- process ----- -( C , 1"...\"\ .. ) \ ') \ ( C ('



(



Transverse



-