Introduction

Summary of Issues with the "Evidence-Based Osteokinematic Analysis"

Intro to Muscle Dysfunction

Short/Over-active Muscles TFL, Adductor and Rectus Femoris

Short and Overactive QL and Multifidus

Short/Overactive Rotatores, Erector Spinae, and Psoas/Illiacus

Long/Over-active (Over-active Synergists)

TVA 

Internal Obliques, Diaphram, and Intercostals

Pelvic Floor

Gluteus Maximus, Gluteus Medius, Semitendinosus and Semimembranosus

Common Osteokinematic Dysfunction

Summary of Research Findings

Introduction to the Muscular and Fascial System

Hypothesized Response to Therapeutic Intervention

Thoracolumbar Fascia Anatomy, Stability and Contribution to Motion

Thoracolumbar Fascia Sensory Innervation and Practice

Abdominal Fascia

Sacrotuberous Ligament

Iliotibial Band

Fascial Dysfunction: Summary of Research

Myofascial Synergy a.k.a Subsystems

Common Muscular Dysfunction

Posterior Oblique Subsystem

Instrinsic Stabilization Subsystem

Anterior Oblique Subsystem

Deep Longitudinal Subsystem

Myofascial Subsystems: Summary of Research

Arthrokinematic Dysfunction

Knee

Lumbar Spine

Sacroiliac Joint (SIJ)

Fascial Dysfunction

Symptoms, Injuries and Diagnoses Associated with Lumbo Pelvic Hip Complex Dysfunction (LPHCD)

Thank You

Myofasical Synergies (Subsystems)

Common Arthrokinematic Dysfunctions

Why Do We Need a Better Model?

Signs of Lumbo Pelvic-Hip Complex Dysfunction

Osteokinematic Dysfunction

Lumbopelvic Hip Complex Dysfunction (LPHCD)

PACE

TPTA

YOGA

NCBTMB

REPSI

NASM

CIMSPA

AUSPHYSIO

REPS

NYPT

ISSA

CanFitPro

AFAA

ProCert

ACSM

PTAGlobal

WITS

AOTA

Predictive Model of Lumbo Pelvic Hip Complex Dysfunction

Course Description: Lumbopelvic Hip Complex Dysfunction (LPHCd)

For an introduction to <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">Postural</a> Dysfunction and <a id="movement-impairment" data-tip="1575" target="_blank" href="/glossary-term/movement-impairment" class="glossary">Movement Impairment</a> please refer to:
<span style="background-color: transparent; font-family: inherit; font-size: inherit; font-style: inherit; font-variant-ligatures: inherit; font-variant-caps: inherit; font-weight: inherit; letter-spacing: 0px;"><a href="https://brookbushinstitute.com/article/introduction-to-postural-dysfunction-and-movement-impairment" style="letter-spacing: 0px;" target="_blank" rel="noopener">Introduction to </a><a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">Postural</a> Dysfunction and Movement Impairment
Lumbo Pelvic-Hip Complex Dysfunction:
&quot;Lumbo Pelvic Hip Complex Dysfunction&quot; (LPHCD) has been previously described as &quot;lower crossed syndrome&quot; or an &quot;anterior pelvic tilt&quot;(1, 3), is likely similar to, or includes the <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> described as kyphotic lordotic-posture, swayback <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> (4), and is correlated with many low back and lumbosacral <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> (4, 6-9). <a href="https://brookbushinstitute.com/article/sacroiliac-joint-motion-and-predictive-model-of-dysfunction" target="_blank" rel="noopener">Lumbosacral Dysfunction (LSD)</a> will be addressed in a separate article, as a &quot;variation&quot; of the LPHCD <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>. To our knowledge, the first organization to refer to the <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> system of joints of the lumbar spine, sacrum, pelvis, and hips as the &quot;lumbopelvic-hip complex&quot; was the National Academy of Sports Medicine (3), with the intent of better defining the term &quot;core.&quot; We have chosen to use the same segment-descriptive label for this <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>. Again, labeling by segment allows the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> to evolve with ever-increasing detail and <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> as new theories, research, techniques, and outcome measures increase our knowledge of impairment. Further, the risk is reduced that the title itself will imply a certain set of altered motions, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity, fascial <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a>, changes in sensation, perception, <a id="motor-unit" data-tip="1303" target="_blank" href="/glossary-term/motor-unit" class="glossary">motor unit</a> recruitment, limit the tissues included, or limit the movement-related <a id="hypothesis" data-tip="1447" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypotheses</a> used to construct the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>.
LPHCD is limited to common impairments of the lumbar spine, sacroiliac joint, <a href="https://brookbushinstitute.com/article/hip-joint" target="_blank" rel="noopener">hip</a>, and <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a>. This definition is not intended to exclude the possibility that more <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> structures may impact motion of the LPHC; it is simply a border for the purposes of analysis. These borders were influenced by:
<ul>
 <li>Practice - considering a minimum number of joints that should be assessed in those with complaints related to the LPHC.</li>
 <li>Education - considering the minimum number of joints that would be included in describing all of the muscles and fascial structures with attachments to the pelvis.</li>
</ul>
<img src="https://www.datocms-assets.com/25800/1649271781-brookbush-gluteus-medius-1.jpeg" alt=" Karl Sterling, BI Presenter prepping to teach Gluteus Medius Activation"> Karl Sterling, BI Presenter prepping to teach Gluteus Medius Activation

Summary of Model

<table border="1" height="515" style="border-collapse: collapse;">
 <tbody>
 <tr>
 <td>Commonly observed/studied impairments:
 <ul>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">Excessive Lordosis</a> (a.k.a. <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt, sway back, etc.)</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">Knees Bow In</a> (a.k.a. functional knee valgus, <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> knee displacement, hip adduction, etc.)</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-7-knees-bow-out" target="_blank" rel="noopener">Knees bow out</a> (a.k.a. functional varus, <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> knee displacement, hip abduction, etc.)</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-10-arms-fall" target="_blank" rel="noopener">Arms Fall</a> (loss of shoulder flexion)</li>
 <li>
 <h4><a href="https://brookbushinstitute.com/article/introduction-to-goniometry" target="_blank" rel="noopener">Goniometry:</a></h4>
 <ul>
 <li>More hip <a href="https://brookbushinstitute.com/video/goniometry-hip-external-rotation-at-90-degrees-of-hip-flexion-9090-hip-er" target="_blank" rel="noopener">external rotation</a> than <a href="https://brookbushinstitute.com/video/goniometry-hip-internal-rotation-at-90-degree-of-hip-flexion-9090-hip-ir" target="_blank" rel="noopener">internal rotation</a></li>
 <li>Loss of <a href="https://brookbushinstitute.com/video/knee-extension-with-hip-flexion-goniometry-hamstring-length-test" target="_blank" rel="noopener">hip flexion/knee extension</a> (biceps femoris <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a>)</li>
 <li>Loss of <a href="https://brookbushinstitute.com/video/hip-extension-goniometry" target="_blank" rel="noopener">hip extension</a></li>
 </ul>
 </li>
 </ul>
 </td>
 <td>Recommended Assessment:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/sign-clusters-compensation-patterns-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat </a><a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> (OHSA):
 <ul>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">Knees bow in</a></li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-7-knees-bow-out" target="_blank" rel="noopener">Knees bow out</a></li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">Excessive lordosis (</a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> pelvic tilt)</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-10-arms-fall" target="_blank" rel="noopener">Arms Fall</a></li>
 </ul>
 </li>
 <li>
 <h4><a href="https://brookbushinstitute.com/article/introduction-to-goniometry" target="_blank" rel="noopener">Goniometry</a></h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/video/shoulder-flexion-goniometry" target="_blank" rel="noopener">Shoulder Flexion Goniometry</a></li>
 <li><a href="https://brookbushinstitute.com/article/lower-body-goniometry" target="_blank" rel="noopener">Lower Body Goniometry</a></li>
 </ul>
 </li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>

<table border="1" height="682" style="border-collapse: collapse;">
 <tbody>
 <tr>
 <td>
 <h4>Short/Over-active (<a href="https://brookbushinstitute.com/articles?category=flexibility" target="_blank" rel="noopener">Release and Lengthen</a>)</h4>
 <ul>
 <li>Lumbar Extensors
 <ul>
 <li><a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">Erector Spinae</a></li>
 <li><a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">Multifidus</a></li>
 <li><a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus Dorsi</a></li>
 <li><a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">Quadratus Lumborum</a> (not a true lumbar extensor)</li>
 </ul>
 </li>
 <li>
 <h4>Hip Flexors</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a></li>
 <li><a href="https://brookbushinstitute.com/article/iliacus" target="_blank" rel="noopener">Iliacus</a></li>
 <li><a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">Rectus Femoris</a></li>
 <li><a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">Tensor Fasciae Latae (TFL)</a> (and <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">Vastus Lateralis)</a></li>
 </ul>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">Gluteus Minimus</a></li>
 <li><a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">Anterior Adductors</a></li>
 <li><a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">Sartorius</a></li>
 </ul>
 </li>
 </ul>
 </td>
 <td>Recommended Assessments:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/lower-body-goniometry" target="_blank" rel="noopener">Goniometry: Lower Body</a></li>
 <li><a href="https://brookbushinstitute.com/article/muscle-length-tests" target="_blank" rel="noopener">Muscles Length Tests</a></li>
 </ul>
 <h4>Recommended Techniques:</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/lumbar-extensor-flexibility" target="_blank" rel="noopener">Lumbar Extensor: </a><a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">Release</a> and Lengthening</li>
 <li><a href="https://brookbushinstitute.com/article/hip-flexor-flexibility" target="_blank" rel="noopener">Hip Flexor: </a><a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">Release</a> and Lengthening</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>
 <h4>Short/Under-active (Prime Mover Inhibition - Integrate)</h4>
 <ul>
 <li>Lumbar Stabilizers
 <ul>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a></li>
 </ul>
 </li>
 </ul>
 </td>
 <td>Recommended Assessment:
 <ul>
 <li>Palpation</li>
 </ul>
 <h4>Recommended Techniques:</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/video/psoas-activation-positional-isometric" target="_blank" rel="noopener">Psoas Activation</a> and <a href="https://brookbushinstitute.com/video/psoas-integration-reverse-lunge-resisted-triple-flexion" target="_blank" rel="noopener">Psoas Integration</a></li>
 <li><a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic Stabilization Subsystem Integration</a></li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>
 <h4>Long/Under-active (<a href="https://brookbushinstitute.com/article/introduction-to-activation-exercise" target="_blank" rel="noopener">Activate</a>)</h4>
 <ul>
 <li>Lumbar Flexors
 <ul>
 <li><a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">Transverse Abdominis</a> (not a true lumber flexor)</li>
 <li><a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">Internal Obliques</a></li>
 <li>Diaphragm</li>
 <li>Pelvic Floor</li>
 <li>Intercostals</li>
 </ul>
 </li>
 <li>Hip Extensors
 <ul>
 <li><a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">Gluteus Medius</a></li>
 <li><a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">Gluteus Maximus</a></li>
 <li><a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semitendinosus and Semimembranosus</a></li>
 </ul>
 </li>
 </ul>
 </td>
 <td>Recommended Assessments
 <ul>
 <li><a href="https://brookbushinstitute.com/article/lower-body-manual-muscle-testing" target="_blank" rel="noopener">Manual </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing: Lower Body</li>
 </ul>
 <h4>Recommended Techniques</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/gluteus-medius-activation-progression" target="_blank" rel="noopener">Gluteus Medius Activation</a></li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">Gluteus Maximus Activation</a></li>
 <li><a href="https://brookbushinstitute.com/article/transverse-abdominis-activation-quadrupeds-progressions" target="_blank" rel="noopener">Transverse Abdominis Activation</a></li>
 <li><a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic Stabilization Subsystem Integration</a></li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Long/Over-active (Synergistically Dominant &#x2013; <a href="https://brookbushinstitute.com/articles?category=flexibility" target="_blank" rel="noopener">Release Only</a>)
 <ul>
 <li><a id="synergists" data-tip="1650" target="_blank" href="/glossary-term/synergists" class="glossary">Synergists</a> of hip External Rotation
 <ul>
 <li><a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">Piriformis</a> and <a href="https://brookbushinstitute.com/article/deep-rotators-of-the-hip" target="_blank" rel="noopener">Deep Rotators</a></li>
 <li><a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">Adductor Magnus</a></li>
 <li><a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">Biceps Femoris</a></li>
 </ul>
 </li>
 <li>Lumbar Flexors
 <ul>
 <li><a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">Rectus Abdominis</a></li>
 <li><a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">External Obliques</a></li>
 </ul>
 </li>
 </ul>
 </td>
 <td>Recommended Assessments:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/lower-body-goniometry" target="_blank" rel="noopener">Goniometry: Lower Body</a></li>
 <li><a href="https://brookbushinstitute.com/article/muscle-length-tests" target="_blank" rel="noopener">Muscles Length Tests</a></li>
 </ul>
 <h4>Recommended Techniques (Release Only)</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/hip-external-rotator-flexibility" target="_blank" rel="noopener">Hip External Rotator: Release</a></li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>

<table border="1" height="242" style="border-collapse: collapse;">
 <tbody>
 <tr>
 <td>Restricted Mobility (Thickening, histochemical changes, decrease in tensile strength, addition of disordered collagen fibers)
 <ul>
 <li>Abdominal Fascia</li>
 <li>Thoracolumbar Fascia</li>
 <li>Sacrotuberous ligament</li>
 <li>Iliotibial Band</li>
 </ul>
 </td>
 <td>Recommended Techniques
 <ul>
 <li><a href="https://brookbushinstitute.com/video/vastus-lateralis-self-administered-dynamic-release-a-k-a-pin-stretch" target="_blank" rel="noopener">Vastus Lateralis (ITB) Dynamic Release</a></li>
 </ul>
 <h4>Additional manual techniques:</h4>
 <ul>
 <li>Instrument Assisted Soft Tissue Mobilization</li>
 <li>Pin and Stretch</li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>
<img title="Fascial web " src="https://www.datocms-assets.com/25800/1649100927-fascia-web-in-body.jpg">

<table border="1" height="402" style="border-collapse: collapse;">
 <tbody>
 <tr>
 <td>Under-active (Integrate)
 <ul>
 <li><a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic Stabilization Subsystem</a></li>
 <li><a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">Posterior Oblique Subsystem</a></li>
 </ul>
 <h4>Over-active (Release and Avoid)</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">Anterior Oblique Subsystem</a></li>
 <li><a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">Deep Longitudinal Subsystem</a></li>
 </ul>
 </td>
 <td>Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">Quadrupeds</a></li>
 <li><a href="https://brookbushinstitute.com/article/bridge-progression" target="_blank" rel="noopener">Bridges</a></li>
 <li><a href="https://brookbushinstitute.com/article/axe-chop-progression" target="_blank" rel="noopener">Chops</a></li>
 <li><a href="https://brookbushinstitute.com/article/stability-progression-for-integrated-exercise" target="_blank" rel="noopener">Legs with Pull or Push</a></li>
 </ul>
 <h4>Release</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/hip-external-rotator-flexibility" target="_blank" rel="noopener">Hip External Rotator: </a><a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">Release</a> and Lengthening</li>
 </ul>
 <h4>Avoid</h4>
 <ul>
 <li>Leg Raises</li>
 <li>Hyperextensions</li>
 <li>Hamstring Curls</li>
 <li>Potentially Planks and Crunches</li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>
<img alt="Illustration of the Posterior Oblique Subsystem with Muscles Labeled" title="Illustration of the Posterior Oblique Subsystem with Muscles Labeled" src="https://www.datocms-assets.com/25800/1649099506-posterior-oblique-subsystem.png">

<table border="1" height="281" style="border-collapse: collapse;">
 <tbody>
 <tr>
 <td>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a>: Inadequate <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> of the tibia on the femur (the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> compartment may be more restricted)</li>
 <li><a href="https://brookbushinstitute.com/article/hip-joint" target="_blank" rel="noopener">Hip</a>: Inadequate posterior/inferior <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> of the femur in the acetabulum</li>
 <li>Lumbar Spine: Combination of <a id="hypermobility" data-tip="1679" target="_blank" href="/glossary-term/hypermobility" class="glossary">Hypermobile</a> and <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">Hypomobile</a> segments</li>
 <li>Sacroiliac Joint: Asymmetric laxity/stiffness</li>
 </ul>
 </td>
 <td>Recommended Assessments:
 <ul>
 <li>Passive <a id="arthrokinematics" data-tip="1860" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">Accessory Motion</a> Assessment</li>
 </ul>
 <h4>Recommended Techniques:</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/joint-mobilization-lower-body-self-administered" target="_blank" rel="noopener">Self-administered Joint Mobilization: Lower Body</a></li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>

The recognition of a pattern of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> dysfunction related to common impairments is likely the most well-known contribution Vladimir Janda made to practice. The description of lower crossed syndrome was the first pattern described by Janda, and closely resembles the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> constructed in this article (see table above). The difference between the current BI <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> and the original Janda <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> is the amount of detail. This can be attributed in large part to a larger body of <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> research and advancements in research methods. Additional advancements are made via <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> of muscular, articular, fascial, and motor control <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a>, and a concerted effort to innovate solutions for gaps in the current body of research/knowledge. Janda built a strong foundation; the BI continues to build on that foundation. The table below was constructed using the wording used by Paige (1) in reference to Janda&apos;s work.
<table>
 <tbody>
 <tr>
 <td colspan="4" width="779">
 <h3>Lower-crossed Syndrome (LCS)</h3>
 </td>
 </tr>
 <tr>
 <td colspan="2" width="390">Tonic</td>
 <td colspan="2" width="390">Phasic</td>
 </tr>
 <tr>
 <td width="195">Lordosis</td>
 <td width="195">
 <ul>
 <li><a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">Erector Spinae</a></li>
 </ul>
 </td>
 <td width="195">Anterior trunk muscles</td>
 <td width="195">
 <ul>
 <li><a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">Transverse Abdominis</a><a href="https://brookbushinstitute.com/article/tibialis-anterior" target="_blank" rel="noopener"></a>
 <a href="https://brookbushinstitute.com/article/tibialis-anterior" target="_blank" rel="noopener"></a>
 </li>
 </ul>
 </td>
 </tr>
 <tr>
 <td width="195">Anterior pelvic tilt</td>
 <td width="195">
 <ul>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a></li>
 <li><a href="https://brookbushinstitute.com/article/iliacus" target="_blank" rel="noopener">Iliacus</a></li>
 <li><a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">Rectus Femoris</a></li>
 </ul>
 </td>
 <td width="195"></td>
 <td width="195">
 <ul>
 <li><a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">Gluteus Medius</a></li>
 <li><a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">Gluteus Maximus</a><a href="https://brookbushinstitute.com/article/tibialis-anterior" target="_blank" rel="noopener"></a>
 <a href="https://brookbushinstitute.com/article/tibialis-anterior" target="_blank" rel="noopener"></a>
 </li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>
In the table above, note the reference to altered <a id="osteokinematic-motion" data-tip="1518" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic motion</a> (<a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt and increased lordosis) and a list of tight and weak muscles. These considerations are a huge step beyond consideration of local &quot;musculoskeletal lesion&quot; or &quot;neuromuscular lesion&quot; being the sole contributor to a patient&apos;s complaints.
There are a few issues with the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> above that should be considered:
<ul>
 <li>First, the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> does not clearly define all the joints involved in Lower-crossed Syndrome (LCS), and it does not discuss the excessive or inadequate motions of each joint in terms of <a id="osteokinematic-motion" data-tip="1881" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic</a> joint actions (like flexion, extension, abduction, etc.) Unfortunately, this results in ambiguity and a challenge when comparing this <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> to research studies. For example, an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt may imply a relatively &quot;hip flexed&quot; position during static standing, but the inclusion of hip flexion as a component of an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt is not agreed upon by all human movement professionals.</li>
 <li>Second, this <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> does not consider the maladaptive changes of all tissues that cross all joints included in LCS. For example, how is the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">tensor fasciae latae (TFL)</a> affected by LCS? It has been noted that Janda assumed that &quot;tightness&quot; was the predominant dysfunction (weakness being secondary) (1), and several studies have noted over-activity of the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, but the inclusion of the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> is not explicitly mentioned. This is just one example of the many excluded muscles that cross joints of the LPHC.</li>
 <li>Third, the LCS <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> does not account for all of the combinations of relative changes in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and length that are implied by research. Janda used the terms Tonic and Phasic, which loosely approximate the terms short/over-active and long/under-active, but research implies that dysfunction may also result in muscles that are short/under-active and long/over-active. Some of the terms used to describe these additional dysfunctional behaviors include &quot;synergistic dominance,&quot; &quot;prime mover inhibition,&quot; &quot;compensation pattern,&quot; and &quot;altered recruitment patterns.&quot;</li>
 <li>Fourth, this <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> misses analysis that would infer the use of techniques intended to address <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> dysfunction (mobilizations, manipulations, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy techniques) and fascial dysfunction (pin and stretch, myofascial <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a>, IASTM, etc). That is, the original <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of LCS does not consider <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> or fascial <a id="dyskinesis" data-tip="1693" target="_blank" href="/glossary-term/dyskinesis" class="glossary">dyskinesis</a>. If the body is an adaptable, <a id="holism" data-tip="1463" target="_blank" href="/glossary-term/holism" class="glossary">holistic</a> system then all tissue systems should be accounted for. Further, a comprehensive <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> would include all effective modalities as demonstrated by 3rd party research.</li>
 <li>Last, despite the intent of the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> to describe a pattern of common impairments related to pain, the LCS does not attempt to list or define related diagnoses and pathologies.</li>
</ul>
Summary of Issues with the &quot;Traditional&quot; Model:
<ul>
 <li>Joints included in the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> are not clearly defined.</li>
 <li>Many of the muscles crossing joints of the LPHC are not considered.</li>
 <li>Categorization of muscles as either &quot;tonic&quot; and &quot;phasic&quot; is not sufficient for a comprehensive muscular <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of impairment.</li>
 <li>Fascial and <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> are not included in the LCS <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>.</li>
 <li>No attempt is made to list the diagnoses and pathologies correlated with LCS.</li>
</ul>
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/09/Anterior-Pelvic-Tilt-2.jpg" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/09/Anterior-Pelvic-Tilt-2.jpg" alt="Anterior Pelvic Tilt during Overhead Squat Assessment"></a>
<a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Pelvic Tilt during Overhead Squat <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> - Brookbush Institute

Lumbo Pelvic Hip Complex Dysfunction (LPHCD) <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> could be defined by related <a id="osteokinematic-motion" data-tip="1881" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic</a> impairments that appear in the body of research, as well as their synonyms. This includes:
<ul>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">Knees Bow In</a> (a.k.a. functional knee valgus, <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> knee displacement, hip adduction, etc.)</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-7-knees-bow-out" target="_blank" rel="noopener">Knees bow out</a> (a.k.a. functional varus, <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> knee displacement, hip abduction, etc.)</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">Excessive Lordosis</a> (a.k.a. <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt, sway back, etc.)</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-10-arms-fall" target="_blank" rel="noopener">Arms fall</a> (a.k.a loss of shoulder flexion)</li>
 <li>Goniometry:
 <ul>
 <li>More <a href="https://brookbushinstitute.com/video/goniometry-hip-external-rotation-at-90-degrees-of-hip-flexion-9090-hip-er" target="_blank" rel="noopener">hip external rotation</a> than <a href="https://brookbushinstitute.com/video/goniometry-hip-internal-rotation-at-90-degree-of-hip-flexion-9090-hip-ir" target="_blank" rel="noopener">hip internal rotation</a></li>
 <li>Loss of straight leg hip flexion (<a href="https://brookbushinstitute.com/video/knee-extension-with-hip-flexion-goniometry-hamstring-length-test" target="_blank" rel="noopener">biceps femoris extensibility</a>)</li>
 <li>Loss of <a href="https://brookbushinstitute.com/video/hip-extension-goniometry" target="_blank" rel="noopener">hip extension</a></li>
 </ul>
 </li>
</ul>
Assessment of LPHCD using the Overhead Squat <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> (OHSA)
<iframe src="https://player.vimeo.com/video/109548485" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

The <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> <a id="osteokinematic-motion" data-tip="1881" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic</a> analysis solves many of the issues that exist in the &quot;traditional <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>.&quot; This includes a more accurate account of which joints should be included in the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> and their excessive joint actions. Further, using this analysis allows for a better account of altered <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> lengths. It is notable that, unlike other <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a>, the <a id="osteokinematic-motion" data-tip="1881" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of LPHCD only suffers from one <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> appearing on both sides of the graph, the <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">psoas</a>. Based on this table it is tempting to end our construction of this <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>, list short muscles as over-active and long muscles as under-active, and dismiss the categorization of the <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">psoas</a> as anomalous. However, in the next section, many muscles will need to be re-categorized based on current EMG studies. The relationship between LPHCD and some diagnoses, pathologies, and symptoms (e.g. low back pain) was identified in the above analysis; however, this analysis is far from comprehensive. Last, this <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> still ignores fascial, myofascial synergy, and <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> contributions.
Remaining issues:
<ul>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a> appears in both the long and short sides of the table without a clear reason (muscles cannot be long and short at the same time).</li>
 <li>Analysis of altered <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity is incomplete.</li>
 <li>Fascial structures have been excluded from this analysis.</li>
 <li>Arthorkinematic dysfunction has been excluded from this analysis.</li>
 <li>A list of diagnoses and pathologies related to LPHCD is incomplete.</li>
</ul>
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/09/Straight-leg-test.gif" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2017/09/Straight-leg-test.gif" alt="Illustration of bilateral straight leg raise test. Lumbar stability test."></a>
By Davidjr74 - http://www.herniateddiscrecovery.info/diagnosing-a-herniated-disc/lumbar-disc-herniation/, CC0, https://commons.wikimedia.org/w/index.php?curid=15289227

To create a detailed <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of practice that will help to refine exercise selection, further analysis is required to determine the relative changes in activity of all muscles included in the LPHCD <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>. In this &quot;level of analysis,&quot; an attempt is made to aggregate all <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> research on all muscles crossing the lumbopelvic hip complex.
<img title="Length Tension Relationship" src="https://www.datocms-assets.com/25800/1649100835-length-tension.jpeg">

Muscle Dysfunction

Short/Overactive Muscles

<a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">Tensor Fasciae Latae (TFL)</a> and <a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">Gluteus Minimus</a> - First, attention should be brought to a study that was well ahead of its time by Dr. Ober (creator of the &quot;Ober&apos;s Test&quot;), which discusses the relationship between the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>/ITB and Low Back Pain/Sciatica (71). The <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> and <a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">gluteus minimus</a> contribute to the same joint actions at the <a href="https://brookbushinstitute.com/article/hip-joint" target="_blank" rel="noopener">hip</a>, including flexion, abduction, internal rotation, and the ability to contribute to an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt. Further, these muscles seem to become <a id="synergistic-dominance" data-tip="1649" target="_blank" href="/glossary-term/synergistic-dominance" class="glossary">synergistically dominant</a> for an inhibited <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a>; that is, over-activity of the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> and <a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">gluteus minimus</a> may result from, or contribute to a decrease in <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> activity. We may presume this is a commonly observed phenomenon, as a study was published by Selkowitz et al. in 2013 comparing various <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> exercises with the intent of reducing <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> activity (316). Several studies have noted over-activity of the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> and inhibition of the <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> in those exhibiting a <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">functional knee valgus</a> (62, 63, 66 - 69). <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">Support</a> may also be found in a study by Sutter et al. demonstrating that abductor tendon tears (<a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">gluteus minimus</a> tendon) are correlated with <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> hypertrophy; which may imply prolonged <a id="synergistic-dominance" data-tip="1643" target="_blank" href="/glossary-term/synergistic-dominance" class="glossary">synergistic dominance</a> and dysfunction is a precursor to this type of injury (70). This relationship becomes more pertinent to the LPHCD <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> when we look at several studies demonstrating a reduction in <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> activity with low back pain (61, 302). This may also partially explain the relationship between knee pathology and LPHC dysfunction noted earlier (58-61) - a reduction in <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> activity will result in an increase in <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> activity, which may be correlated with low back pain or <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">functional knee valgus</a>, and may result in one pathology contributing to the other.
Unfortunately, no studies exist (to our knowledge) that investigate the activity of the <a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">gluteus minimus</a>. This is likely due to its location deep to the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a>, and iliotibial band. Functionally, the <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> acts much like the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, contributing to hip flexion, abduction, and internal rotation, and the <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> is innervated by the same <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> (<a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> gluteal <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a>)(72). One notable difference is the investment of the <a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">gluteus minimus</a> into the hip joint capsule, which may have implications relative to complaints of hip pain (73). BI recommends treating the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> and <a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">gluteus minimus</a> similarly relative to <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>, LPHCD, or <a href="https://brookbushinstitute.com/article/sacroiliac-joint-motion-and-predictive-model-of-dysfunction" target="_blank" rel="noopener">Lumbosacral Dysfunction (LSD)</a>.
<img title="TFL and Iliotibial band (connecting fascia)" src="https://www.datocms-assets.com/25800/1649100748-treeposetflgluteusminimus.jpg" width="139" height="257">
<a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">Anterior Adductors</a> - Over-activity of the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductors</a> has been correlated with <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">functional knee valgus</a> (62, 63, 67), hinting at this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> group&apos;s common maladaptive behavior. In individuals with sacroiliac joint (SIJ) pain, <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a> activity remained unchanged (along with the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>) while <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal oblique</a>, <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">lumbar multifidus</a>, and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> activity decreased or fired later (74). This change in recruitment could be viewed as a relative increase in the synergistic activity of the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductors</a>. Although it may not be a direct indicator of relative changes in length, the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductors</a> (and adductor tendons) are commonly associated with tendonitis and groin pain (75-77), of these muscles the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a> longus seems to be the most often affected (78). As will be discussed later in &quot;myofascial synergies,&quot; the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a> longus and <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> tendons exhibit fascial continuity and synergistic activity, implying a role in core function.
<a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">Rectus Femoris</a>, <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">Sartorius</a> and <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">Vastus Lateralis</a> - The <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> and <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a> are categorized as short/over-active due to their ability to contribute to hip flexion and an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt; however, to our knowledge, EMG studies do not exist comparing the activity of the <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> and <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a> in asymptomatic controls to those exhibiting dysfunction. The <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a> is included due to its investment in the iliotibial band and research implying a relationship with the <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> and <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, both hip flexors. Like the <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a>, no studies could be located correlating <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a> activity with low back pain. We do have a few studies that may provide vague indicators of their common maladaptive behavior. The <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> and <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a> play a similar role in gait, being most active during late stance to swing transition, and early swing phase during running (deceleration of hip extension/knee flexion, and initial impulse of hip flexion) (79 - 81). These studies highlight that hip flexion may be their primary role (eccentric deceleration of hip extension being the same). Further, the impact of over-activity of these muscles can be hypothesized as early push-off (limited extension); increasing reliance on lumbar extension to <a id="compensation-pattern" data-tip="1697" target="_blank" href="/glossary-term/compensation-pattern" class="glossary">compensate</a> for lost hip extension. Studies have shown that the quadriceps may be inhibited by knee joint <a id="effusion" data-tip="1459" target="_blank" href="/glossary-term/effusion" class="glossary">effusion</a> (82); however, based on this study by Spencer et al. the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus medialis obliquus</a> has been shown to be affected by much lower volumes of fluid (less swelling) than the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a> and <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> - these two muscles seem to be affected similarly. Another study by Vaz et al. demonstrated similar recruitment patterns between the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a> and the <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> during a fatiguing protocol (83). An odd clinical finding during <a href="https://brookbushinstitute.com/video/elys-test-rectus-femoris-flexibility-assessment" target="_blank" rel="noopener">Ely&apos;s Test</a>, <a href="https://brookbushinstitute.com/video/obers-test-tfl-flexibility-assessment" target="_blank" rel="noopener">Ober&apos;s test</a>, and the &quot;back leg&quot; of a <a href="https://brookbushinstitute.com/video/sagittal-plane-lunge" target="_blank" rel="noopener">lunge</a>&#xA0;is the ability of a short/over-active <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> to contribute to or deflect the thigh into abduction during extension. To our knowledge, the <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> contributing to abduction is only mentioned in one text (Muscles Alive, 1985)(79). The <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a> is most often compared to the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, contributing to hip flexion and abduction of the <a href="https://brookbushinstitute.com/article/hip-joint" target="_blank" rel="noopener">hip</a>, and although these muscles contribute to opposing directions of rotation at the <a href="https://brookbushinstitute.com/article/hip-joint" target="_blank" rel="noopener">hip</a> and <a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">knee</a>, these opposing actions do not seem to interfere with both muscles contributing similarly to various motions (84, 85). Although direct evidence of maladaptive changes in length and activity of the <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> and <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a> are not documented in the body of research, relationships between the <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a> and <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, as well as the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a> and <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> may suggest a synergistic relationship. It is the BIs recommendation that these muscles are considered a &quot;flexion/abduction synergy&quot; and treated similarly.
<a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus Dorsi</a> - The <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> has been implicated as a lumbar extensor via the thoracolumbar fascia; however, studies show that the potential contribution is relatively small (161 - 164). Strangely, the <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> behaves like a global mover of the spine, demonstrating a marked increase in activity during the initiation of squat and stoop lifts and asymmetrical activation during trunk rotation (126, 165). A correlation between a loss of <a href="https://brookbushinstitute.com/video/shoulder-flexion-goniometry" target="_blank" rel="noopener">shoulder flexion</a> and LPHCD has been noted clinically, leading to the <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> that the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> is reflexively over-activity in conjunction with other global lumbar extensors (<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>). The BI recommends <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> and lengthening techniques for this muscle; however, further research is needed to correlate changes in <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> activity with LPHCD.

TFL, Adductors, Rectus Femoris and Lats

<a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">Quadratus Lumborum</a> - There is not much research on the <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">quadratus lumborum (QL)</a>, likely due to its location deep to other paraspinal muscles. Studies have demonstrated a moment arm too small to contribute to large amounts of force, and motion of the lumbar spine results in little change to <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> length (111, 112). Lying <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> flexion and the <a href="https://brookbushinstitute.com/video/side-plank" target="_blank" rel="noopener">side plank</a> result in significant recruitment of the <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> (114, 115); however, the muscle&apos;s size and short moment arm suggests its acting as a &quot;stabilizer&quot;, and not a <a id="prime-mover" data-tip="1662" target="_blank" href="/glossary-term/prime-mover" class="glossary">prime mover</a> (9). An interesting finding by McGill et al. demonstrated an increase in EMG activity with the increased load during <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> carrying (9), and two studies have shown that the <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> is still active during the &quot;flexion-relaxation phenomenon&quot; (113, 114). The <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> carrying results in comprehensive forces, which may imply the increase in <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> activity is similar to that of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> and <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> in response to <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> of the lumbar spine. Further, activity during the flexion-relaxation phenomenon is another trait of intrinsic stabilizing muscles (ISS).
To our knowledge no studies exist comparing the EMG activity of the <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> in symptomatic low back pain patients to asymptomatic controls; however, two MRI studies have shown a decrease in <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> cross-sectional area in those with chronic low back pain (97, 110). A study by Hua et al. demonstrated good <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for locating myofascial <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> when matched to tenderness upon palpation and replication to patient symptoms (116), and a case study by Graber reported targeted inhibition/relaxation of the <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> to resolved low back pain symptoms (551). Activity similar to other stabilizers, development of <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a>, and atrophy in those with low back pain is similar to the behavior noted in the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a>. It is the recommendation of the BI that the <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> and <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> are addressed as short/overactive muscles, with <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> techniques, lengthening techniques when necessary, and ISS (stabilization) exercises.
<img src="https://www.datocms-assets.com/25800/1648090199-1642105597-ql.png" alt="Quadratus Lumborum">
<a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">Multifidus</a> - There is a significant amount of research on the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a>, including the relationship between the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> and low back pain. In fact, there is so much research on the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> it highlights a potential over-simplification inherent in the terms &quot;under-active&quot; and &quot;over-active&quot;, and may aid in the development of more nuanced definitions. Regarding the LPHCD <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> and categorization of this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> relative to activity and length, this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> does not cleanly fall into one category. Similar to the <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a> this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> may be short/over-active or short/under-active; however, it is BI&apos;s assertion that short/over-active is more likely. Starting with biomechanics: the lumbar <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> forms five distinct bands that are innervated segmentally by the <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> root corresponding to the vertebrae they attach to (117). The primary forces they contribute to are extension and <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> and have some potential to contribute to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> shear; however, fiber arrangement suggests a larger role in frontal plane stabilization (118 - 121). In a resting position, the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> is in a relatively shortened position, reaching <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> <a id="lengthtension-relationship" data-tip="1685" target="_blank" href="/glossary-term/lengthtension-relationship" class="glossary">length/tension</a> as the spine flexes (121). Although these muscles are often considered important to proprioception, studies have demonstrated that these muscles have very low <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> spindle density (122, 123).
The <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> seems to function primarily as stabilizers. Although these muscles contract ipsilaterally during weighted trunk rotation, they contract bilaterally during unweighted rotation (124). They also co-contract with spinal flexors during flexion and their activity increases with increases in load (125). Further, during asymmetric lifting tasks, these muscles contract bilaterally (126). During isometric activities (holding a load in one hand) the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> contract first and fatigue faster when compared to the iliocostalis (127). Some distinctions may need to be made between deep and superficial fibers. Several studies have shown that the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> is only active during active <a id="posture" data-tip="1661" target="_blank" href="/glossary-term/posture" class="glossary">postures</a> (upright sitting, walking, swinging both arms forward) (127 - 129). However, a study by Moseley et al. demonstrated the deep fibers behaved more like the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdomonis</a> and were active during static standing and during <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> and <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> arm swings in both directions (130). In summary, like other stabilizing muscles of the trunk, the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> contract bilaterally regardless of the direction of motion, the deep fibers are active during low-intensity tasks (static <a id="posture" data-tip="1661" target="_blank" href="/glossary-term/posture" class="glossary">postures</a>), activity increases during active <a id="posture" data-tip="1661" target="_blank" href="/glossary-term/posture" class="glossary">postures</a>, and loading, and these muscles may fire before larger movers of the spine.
The case for categorizing the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> as under-active relative to low back pain and <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction (LPHCD)</a> starts with a group of studies showing atrophy, histochemical and <a id="connective-tissue-cell" data-tip="1368" target="_blank" href="/glossary-term/connective-tissue-cell" class="glossary">connective tissue</a> changes. Several studies have shown that cross-sectional area of these muscles decreases in those with chronic low back pain. The atrophy is often segment-specific and is likely to occur unilaterally in those with sided pain (95 - 100, 131-136, 143). Although preferential atrophy of type II fibers has been observed in some studies, it is not clear whether this is correlated with low back pain or a byproduct of surgery and/or age-related changes (136 - 140). <a id="connective-tissue-cell" data-tip="1368" target="_blank" href="/glossary-term/connective-tissue-cell" class="glossary">connective tissue</a> changes are worthy of further investigation, as a study by Lehto et al, found fibrosis correlated with impaired ability to recover (141). Last, although not clinically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> for human movement professionals, core-targetoid (moth-eaten) changes to type I fibers may have <a id="relevance" data-tip="1504" target="_blank" href="/glossary-term/relevance" class="glossary">relevance</a> to diagnosis and prognosis if lab tests can be made easily implantable (142). It is important that we do not confuse atrophy with under-activity, relative to our categorization for use during exercise selection. Although it may be more difficult to hypothesize a process that results in atrophy from over-activity; research and clinical findings on activity relative to dysfunction must be considered in addition to findings of atrophy.
As mentioned above, the activity of the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> is complex. There are a couple of studies that imply denervation is a cause of <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> dysfunction (138, 144); however, this does not appear to be a consistent finding (137, 142). It seems more likely that denervation is <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to surgical intervention and retrolisthesis (138, 144). In those individuals exhibiting chronic low back pain the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> are less active, especially in lumbar extended positions (145, 146), are weaker and fatigue faster (147, 148), are more active during static standing and stabilization (149-151), peak higher during flexion, spontaneously discharge around <a id="hypermobility" data-tip="1679" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobile</a> segments (146, 149, 151), and remain active for longer after a lift (152). Changes in motor behavior are also demonstrated by a &quot;decoupling&quot; of the <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> contraction normally seen during lifting tasks (126, 153). <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a> development may also be common (16, 154). To summarize, <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> function of the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> is replaced with continuous low force output, <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> and asymmetrical recruitment in response to stress, spasm, or high-activity with any high-intensity task or task requiring significant <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>, and increased activity for a longer period post recruitment. This change in behavior would seem to replace an appropriately low-intensity stabilization function, with bracing and over-activity. Even the loss of force output, quicker time to fatigue, and inactivity in extended positions can be explained by adaptive shortening and altered <a id="lengthtension-relationship" data-tip="1685" target="_blank" href="/glossary-term/lengthtension-relationship" class="glossary">length/tension</a>, resulting in less efficient force output and active insufficiency in extended positions.
<h4>Hypothesized compensation pattern of the Multifidus:</h4>
<ol>
 <li>Low activity at all times (not quite during static <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>)</li>
 <li>Weaker and fatigue faster</li>
 <li><a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">Bilateral</a> activation replaced by directions <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> activation</li>
 <li>Spasm/increased activity in response to load and instability</li>
 <li>Increased activity for longer post response to stress</li>
 <li><a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger point</a> development</li>
</ol>
Exercise has been shown to be effective for increasing <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> cross-sectional area, although it would seem that stabilization exercises are generally more effective than loaded extension (155, 156). Research by Hides et al. has shown that recovery of the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> is not automatic post low back pain; however, stabilization exercises are effective for both a short-term reduction of symptoms and reduction of low back pain recurrence long term (157 - 159). Last, it may be prudent to not &quot;wait for injury&quot;, as a study by Lee et al (1999) demonstrated that imbalance between spine flexors and extensors was a risk factor for a low back injury in a 5-year <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> (160). Based on the <a id="compensation-pattern" data-tip="1696" target="_blank" href="/glossary-term/compensation-pattern" class="glossary">compensation pattern</a> adopted, and the stabilization exercise being more effective than <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> strengthening, the Brookbush Institute recommends treating these muscles as short/overactive (<a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> and lengthening). However, careful attention during core <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> exercise is also recommended; specifically using cueing to enhance <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> activation of the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> during <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic Stabilization Subsystem Integration</a>.

Quadratus Lumborum and Multifidus

Rotatores, Erector Spinae, and Psoas/Illiacus

Long/Overactive (Overactive Synergists)

Bicep Femoris, Rectus Abdominis and External Obliques

Long/Underactive

<a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">Transverse Abdominis</a> - The <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis (TVA)</a> has been thoroughly researched due to the popularity of ground-breaking studies published by Hodges, Richardson, and Hides in the late 1990s through early 2000s (184-186, 195-196, 201-208, 215). This work would lead to the publication of a textbook in 1999 -Therapeutic Exercise for Lumbo Pelvic Stabilization &#x2013; A Motor Control Approach for the Treatment and Prevention of Low Back Pain, which had a dramatic impact on the treatment and prevention of low back pain, as well as our understanding of human movement. The function of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> is relatively well understood and may serve as a <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> for understanding the behavior of a <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> whose primary role is stabilization and is <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> to inhibition in those exhibiting dysfunction. The <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> contracts prior to planned activity, bilaterally, regardless of the direction of limb motion, and activity increases with changes in <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> including increased <a id="center-of-mass-gravity" data-tip="1187" target="_blank" href="/glossary-term/center-of-mass-gravity" class="glossary">center of gravity</a> height, increased respiration, and speed of locomotion (184-187, 213). The stabilizing function of the transverse abdominis appears to occur by two primary mechanisms. First, increased <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in the <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> results in increased <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> of the thoracolumbar fascia (TLF) resulting in increased stiffness of the lumbar spine and <a id="force-closure" data-tip="1448" target="_blank" href="/glossary-term/force-closure" class="glossary">force closure</a> of the sacroiliac joint (188-194). Contraction of this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> also results in a decrease in intra-abdominal volume and an increase in intra-abdominal pressure. Intra-abdominal pressure has been shown to increase the rigidity of the spine, decompress the spine, and resist flexion <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> (195 - 197). Recent studies have attempted to rebuke the initial findings of the late 1990s, but only add nuance to our understanding of the behavior of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a>. In studies by Morris et al., the asymmetrical firing of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> was demonstrated with greater resistance and speed, and synergy was demonstrated between the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">obliques</a>, and <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">lumbar multifidus</a> muscles (198, 199); note these same findings were demonstrated by Hodges et al. more than a decade earlier (201, 202). Although this may seem to contradict the <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> contraction noted above, it simply implies that the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> contracts bilaterally and relatively equally at lower intensities, and as larger forces are generated by the limbs (either due to increased weight or velocity) activity of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> on the more stressed side increases to match. Because the Brookbush Institute recommends &quot;Quadrupeds and Progressions&quot; for <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">TVA Activation</a>, which includes both the purposeful recruitment of the synergy of muscles mentioned above (<a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic Stabilization Subsystem</a>) and <a id="exercise-progression" data-tip="1184" target="_blank" href="/glossary-term/exercise-progression" class="glossary">progression</a> toward higher velocity movement patterns, BI&apos;s approach is supported by these findings. In another study by Masse-Alarie et al. (200), the <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> activation mentioned earlier only occurred for certain patterns at higher speeds, again, this does not change recommendations but may explain why some movement patterns or speeds are more problematic than others, especially relative to low back pain.
In 1996, Hodges et al. published a pivotal study that demonstrated the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> fired prior to the initiation of arm swing in asymptomatic individuals but fired after the initiation of arm swing in individuals with low back pain (203). Hodges et al. would follow up this study with research demonstrating the same pattern also occurred during leg movement, various speeds of arm movement, and demonstrated the same recruitment pattern could be acutely created with injection-induced low back pain (204-207). Further, they would show that low back pain results in not only decreased recruitment of intrinsic muscles (<a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">obliques</a>, and <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">lumbar multifidus</a> muscles) but increased reliance on &quot;global muscles&quot; (208). More recent research has demonstrated that altered recruitment patterns increased the likelihood of low back pain/injury in the following year, that unresolved altered recruitment patterns resulted in worse outcomes a year post-physical therapy, changes in <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> recruitment patterns correlate strongly with a disability index, and that even adductor/groin injury/pain may result in altered <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> recruitment strategies (209 - 212). In one study, an increase in <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">lumbar multifidus</a> activity, but not <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> activity, was correlated with better clinical success (228). Although the findings relative to the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">lumbar multifidus</a> are not surprising, the findings relative to the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> are surprising. These findings differ from so many studies that the <a id="power" data-tip="1399" target="_blank" href="/glossary-term/power" class="glossary">power</a> of the study and <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> of the equipment should be considered, and the study repeated.
The practical application of <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> research is the inclusion of exercise that challenges or cues the &quot;abdominal <a id="drawing-in" data-tip="1580" target="_blank" href="/glossary-term/drawing-in" class="glossary">drawing-in</a> maneuver&quot; (<a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a>) (during Quadrupeds may be best).
<ul>
 <li>Abdominal <a id="drawing-in" data-tip="1580" target="_blank" href="/glossary-term/drawing-in" class="glossary">Drawing-in</a> Maneuver (<a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a>) - A light contraction of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abominis</a> (and potentially the entire <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">intrinsic stabilization subsystem</a>) is achieved by gently pulling the lower abdominal region away from one&apos;s waistband. This should have minimal effect on breathing, and should not be confused with a maximal contraction of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> resulting in a &quot;vacuum pose&quot;.</li>
</ul>
Low back pain has been shown to reduce the ability to perform the <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> (214), and <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of the <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> has been shown to be a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> for decreased <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> function (215). <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> preferentially recruits the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a>, to the exclusion of more superficial muscles (<a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> and <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a>) (216), and cueing the <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> increases <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> contraction during more functional tasks (217). <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">Specific</a> training of deep muscles results in an immediate change to recruitment strategies, neutral spine has been demonstrated to result in greater <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> thickness, and somewhat strangely, adding ankle dorsiflexion to <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> exercises increases <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> activity (218-221). Quadrupeds <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">(TVA Activation)</a> with cueing of the <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> resulted in similar <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> activity in asymptomatic individuals and those with low back pain, which may suggest this exercise is ideal for normalizing recruitment patterns (222). Leg raises resulted in greater <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> activity; however, this exercise also sharply increased <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> activity (223), a <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> to over-activity. Although interventions should be <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">Specific</a> to low back pain patients assessed issues, generally, stabilization exercise results in better outcomes than stretching, and a &quot;segmental stabilization <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">(TVA Activation)</a>&quot; approach results in better outcomes than global <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> training (224, 225). Correlations have been made between <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> thickness, lumbar <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>, and <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>, which may have implications for injury prevention and sports performance (226). Using the <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> during Pilates resulted in increased <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> thickness, but only during Pilates exercises (no carry-over) (227). This does not suggest that the <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> should not be used by Pilates instructors, but rather that Pilates may not be an ideal exercise methodology for low back pain patients and those with goals other than Pilates performance (227). In summary, the Brookbush Institute categorizes this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> as commonly under-active in those exhibiting LPHCD, recommends &quot;Quadrupeds and Progressions&quot; for <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">TVA Activation</a>, and <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> should be cued during all functional activities in a clinical or performance setting.
<img src="https://www.datocms-assets.com/25800/1649273500-tva.png" title="Transverse Abdominis" alt="Transverse Abdominis">

Transverse Abdominis 

<a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">Internal Obliques</a> - The <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> can perform the same actions as the <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a>, but function and behave like the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> relative to stabilization and altered recruitment in those exhibiting low back pain. Studies have demonstrated these muscles are active during rotation (112, 232), have the potential to contribute to side bending (233), and may contribute to flexion via transmission of force through the semilunar lines (234). However, the activity of these muscles increases with increased respiration and gait speed (similar to the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>) (187), and are active bilaterally when lifting asymmetric loads (unlike the <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a>) (126). Studies have also demonstrated that the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> are active when the spine is compressed, perhaps contributing to the &quot;unloading&quot; force generated when intra-abdominal pressure increases (89, 197). The <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> invest in the thoracolumbar fascia contributing to <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> force on the spinous process (primarily below L3), <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> (<a id="force-closure" data-tip="1448" target="_blank" href="/glossary-term/force-closure" class="glossary">force closure</a>) of the sacroiliac joint (SIJ), and as mentioned above, increased intra-abdominal pressure via the abdominal tourniquet (188, 189, 192). Interestingly, despite behavior/activity that resembles &quot;stabilizing&quot; muscles that are generally smaller, the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> are the thickest <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> wall <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> in adolescents when observed using ultrasound in <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> (235).
It is common to see reference to &quot;intrinsic stabilizers&quot; and &quot;global muscles&quot; when discussing the function of trunk musculature (2, 8, 9, 14); this visual <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> aids in understanding the change in recruitment patterns noted in those with low back pain. Based on the research above, the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> behave like the &quot;intrinsic stabilizers&quot; often implicated as under-active by research. In two studies by Ng et al., increased <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a> activity and decreased <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> activity was noted during static and dynamic <a id="axial-skeleton" data-tip="1292" target="_blank" href="/glossary-term/axial-skeleton" class="glossary">axial</a> rotation in those exhibiting symptoms of low back pain (229, 230). Further, decreased <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> activity has been noted in those with &quot;swayback&quot; <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, and those exhibiting SIJ pain (128, 174). Although not always mentioned, the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> are commonly studied in conjunction with <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>. For example, Hodges et al. demonstrated that the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> and the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> fired before lower extremity activity in asymptomatic individuals, but both muscles demonstrated latent firing patterns in those with low back pain (185). Further, in the study by Chon et al., adding dorsiflexion to exercises using the abdominal <a id="drawing-in" data-tip="1580" target="_blank" href="/glossary-term/drawing-in" class="glossary">drawing-in</a> maneuver (<a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a>) increased <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> as well as the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> (221). In summary, the Brookbush Institute (BI) categorizes this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> as commonly under-active in those exhibiting LPHCD and considers this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> part of the <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic stabilization Subsystem (ISS)</a>, which the BI commonly addresses with &quot;<a href="https://brookbushinstitute.com/video/transverse-abdominis-tva-isolated-activation-quadruped" target="_blank" rel="noopener">Quadrupeds and Progressions</a>&quot; and <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">TVA Activation</a>. Further, the <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a> should also be cued during all functional activities in clinical, and/or performance settings.
Diaphragm &#x2013; Hodges et al. (271) describes the relationship between breathing, diaphragm activity, and <a href="https://brookbushinstitute.com/glossary/posture/" target="_blank" rel="noopener">postural</a> change as &#x201C;time-locked&#x201D; and potentially linked via reflex. Two studies by Hodges et al. demonstrated that stimulus of the diaphragm resulted in increased stiffness of the spine (196, 267), and various studies have noted a change in diaphragm activity during lifting, changes in position and <a href="https://brookbushinstitute.com/glossary/posture/" target="_blank" rel="noopener">posture</a>, movement of the limbs, and changes in gait speed (268 - 272, 276, 279). A study by Hodges et al. (270), may give inference of how the diaphragm accomplishes respiration and stabilization concurrently. In this study, repetitive upper body motion (arm swings) resulted in an increase in average diaphragm activity (EMG) (270). Further, a study by Kolar et al. demonstrated lower average activity and a higher relative position in those exhibiting low back pain (273). Based on these findings we may be able to assume that <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> with respiration is accomplished by higher average activity and a lower relative position, decreasing intra-abdominal space and increasing intra-abdominal pressure. This pattern is disrupted in those exhibiting signs of pain and dysfunction.
Lower activity/higher relative position may be part of the compensatory pattern associated with low back pain. The studies by Kolar et al. and Hodges et al. (270, 273) mentioned above are supported with additional studies on diaphragm activity and impairment (274 &#x2013; 278). Hodges et. al, demonstrated less diaphragmatic motion and activity in low back pain patients (278). Further, Vastatek et al. demonstrated that those with sacroiliac joint (SIJ) pain exhibited altered diaphragm activity during isometric lifting of the limbs; activity returned to normal when the SIJ was stabilized via manual <a href="https://brookbushinstitute.com/glossary/compression/" target="_blank" rel="noopener">compression</a> of the pelvis (274). Several studies have noted increases in respiratory demand, and/or diaphragm fatigue results in a loss of lumbar <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> (276-278). The studies by Jansen et al. demonstrate that low back patients are quicker to diaphragm fatigue, and that diaphragm fatigue resulted in a more rigid stabilization pattern during lifting (276, 277). Last, a study by McGill et al. demonstrated that <a href="https://brookbushinstitute.com/glossary/compression/" target="_blank" rel="noopener">compression</a> and <a href="https://brookbushinstitute.com/glossary/glide/" target="_blank" rel="noopener">shear</a> forces on the spine increase when ventilatory demand increases (279), which may imply that research is needed to determine the correlation between diaphragm activity and injury. Considering these studies together, the compensatory pattern adopted by the diaphragm in those exhibiting pain and dysfunction may be lower average activity, a higher relative position, with smaller excursion during respiration, which results in a more rigid (and likely weaker) stabilization strategy resulting in quicker fatigue, which in turn results in larger <a href="https://brookbushinstitute.com/glossary/glide/" target="_blank" rel="noopener">shear</a> and <a href="https://brookbushinstitute.com/glossary/compression/" target="_blank" rel="noopener">compressive forces</a> on the spine during motion and <a href="https://brookbushinstitute.com/glossary/posture/" target="_blank" rel="noopener">postural</a> change. To date, no <a href="https://brookbushinstitute.com/glossary/prospective-study/" target="_blank" rel="noopener">prospective</a> studies are available to determine whether altered diaphragm activity and motion may increase the risk of injury; however, studies have demonstrated that altered core control and an increased risk of injury (58, 59).
Hypothesized <a id="compensation-pattern" data-tip="1696" target="_blank" href="/glossary-term/compensation-pattern" class="glossary">compensation pattern</a> of the diaphragm:
<ol>
 <li>Lower average activity</li>
 <li>Higher relative position</li>
 <li>Decrease in excursion with respiration</li>
 <li>More rigid stabilization strategy (less change in response to changing stimulus)</li>
 <li>Quicker fatigue</li>
 <li>Larger <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">shear</a> and <a id="compression" data-tip="1596" target="_blank" href="/glossary-term/compression" class="glossary">compressive forces</a> on the lumbar spine</li>
</ol>
The study mentioned above by Vastatek et al. (274) implies that stabilization exercise may aid in both low back pain and diaphragm function. Further, a <a href="https://brookbushinstitute.com/glossary/randomized-control-trial/" target="_blank" rel="noopener">randomized control trial</a> by Mehling et al. demonstrated that &#x201C;controlled-breath therapy&#x201D; was effective for the treatment of low back pain patients (280). Although core stabilization exercises are recommended by the Brookbush Institute (BI), &#x201C;controlled-breathe therapy&#x201D; admittedly deserves more attention. Based on the research and compensatory pattern above, it may be worth testing breathing from a higher activity/lower position. Not just deep breathing in and out, but breathing in deeper and trying to maintain normal tidal volume from a &#x201C;deeper place&#x201D;. This could be added to tasks that challenge <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> (e.g. <a href="https://brookbushinstitute.com/video/static-standing-chop-pattern" target="_blank" rel="noopener">standing chops</a>).
The increase in activity with changes in <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, and the decrease in activity with increased length exhibited in those with signs of dysfunction is similar to the behavior of the <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">TVA</a> and <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a>.
Intercostals - A study by Rimmer et al. seems to demonstrate that intercostal <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity is similar to the activity of the diaphragm. That is to say, during rotation of the trunk intercostal <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity increased overall - this is in conjunction with the normal increase in external intercostal activity and decrease in internal intercostal activity noted during inspiration (287). Further consideration of the role of the intercostals in <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> and motion may be inspired by their relatively high <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> spindle density (288). There is not enough research to determine maladaptive changes in length and activity relative to dysfunction; however, the potential role these muscles play in <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> and proprioception should inspire further research. To date the Brookbush Institute does not recommend <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> exercise or interventions for the intercostals; however, consideration is given to the ribs role in thoracic <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> in the <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper Body Dysfunction (UBD)</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>.

Internal Obliques, Diaphragm, and Intercostals

Pelvic Floor - Research concerning symptoms and pathology <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to pelvic floor dysfunction (stress urinary incontinence, female pelvic organ prolapse, pelvic floor pain, etc.) will not be covered in this section. This decision was made for 3 reasons: these topics deserve more consideration than should be covered in this article, these <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> may be separate from a <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of LPHCD, and to date, little research has correlated <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> pelvic floor pathology to LPHCD. The research discussed here is <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to pelvic floor function as it relates to LPHC function and dysfunction.
Several studies indicate that the pelvic floor muscles (PFM) behave like, and in conjunction with, the diaphragm and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a>. A study by Hodges et al. that mirrors their pivotal 1996 study on <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> activity (203), demonstrated the PFM is active prior to deltoid activation during arm swing, and activity is not direction-specific (281). Sapsford et al. demonstrated that the voluntary activation of core muscles during various common exercises also recruited PFM (282). Madill and colleagues showed the reverse relationship - voluntary contractions of the PFM resulted in an initial increase in lower vaginal pressure, along with an increase in PFM, <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominus</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a>, and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> activity, with later increases in pressure (last 30% maximum pressure) being associated with primarily increases in <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominus</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a>, and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> activity (283).
One study was located that demonstrated individuals with chronic pelvic pain also had a higher incidence of signs that are commonly associated with <a href="https://brookbushinstitute.com/article/sacroiliac-joint-motion-and-predictive-model-of-dysfunction" target="_blank" rel="noopener">Sacroiliac Joint Dysfunction (LSD)</a> (284). A relationship between the pelvic floor and the sacroiliac joint seems very plausible, if for no other reason than the potential of a change in PFM <a id="lengthtension-relationship" data-tip="1685" target="_blank" href="/glossary-term/lengthtension-relationship" class="glossary">length/tension</a> with sacral motion. A study examining whether PFM activity continues to mimic the diaphragm and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> in those experiencing low back pain should also be explored as a continuation of the work by Hodges et al. mentioned above (203).
<a href="https://brookbushinstitute.com/glossary/relevance/" target="_blank" rel="noopener">Relevant</a> to exercise, a study by Critchley demonstrated that cueing PFM contraction during the <a href="https://brookbushinstitute.com/video/transverse-abdominis-tva-isolated-activation-quadruped" target="_blank" rel="noopener">quadruped</a> exercise increased <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> contraction strength (285). This may suggest that although the PFM fires with the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> reflexively, the addition of a voluntary PFM contraction may stimulate further recruitment of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a>. Pilates exercises have also shown evidence of being effective for increasing PFM <a href="https://brookbushinstitute.com/glossary/muscle-cell/" target="_blank" rel="noopener">muscle</a> strength, demonstrating similar results when compared to a <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> PFM program (286). Based on the function and behavior of the PFM the Brookbush Institute considers these muscles part of the <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic Stabilization Subsystem (ISS)</a>, behaving like the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">TVA</a> and diaphragm. Based on the function of the PFM and the results of the study by Critchley and Culligan (285, 286) it is unlikely that <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> exercise is necessarily relative to LPHCD, but cueing a PFM contraction while doing <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">ISS</a> exercise may be beneficial.

<a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">Gluteus Maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">Gluteus Medius</a> - A reduction in <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> activity has been correlated with pain and dysfunction of the low back, sacroiliac joint (SIJ), and all lower extremity joints, including the hip, knee, and ankle (174 - 175, 180, 294 - 305). Even in the absence of pain, <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> weakness has been noted in those with <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">functional knee valgus</a>, a loss of hip extension, an <a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">anterior</a> pelvic tilt, and a lack of <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-8-excessive-forward-lean" target="_blank" rel="noopener">forward lean</a> during running (62-63, 66, 173, 304 - 306). <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">Gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> weakness are such common findings in research concerning both <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">LED</a> and <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">LPHCD</a>, it may be hypothesized as the &quot;bridge&quot; which spreads dysfunction from one to another. Consider just a few of the studies cited in this article, Cooper et al. demonstrated the prevalence of <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> weakness in those experiencing low back pain (302), Bolga et al. demonstrated <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> weakness in those with patellofemoral pain (305), Cholewicki et al. demonstrated altered core <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment as a predictor of low back pain (58), Zazulak et al. demonstrated core recruitment deficits are correlated with future ACL injury (59), and another <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> by Nadler et al. demonstrated a correlation between lower extremity injury and a higher prevalence of low back pain during the season (61). Pertinent to rehabilitation and sports performance, greater <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> strength has been correlated with better squatting, stair climbing, running, and landing mechanics (305-310).
Several studies have shown that targeted exercise for these muscles can have a positive impact on lower extremity biomechanics and pain (308-311). In a study by Bell et al., a corrective intervention similar to that recommended in this article, improved movement quality (reduced <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">functional knee valgus</a>) (312), and based on two studies by Bolga et al. the intervention may not have to make measurable change in mechanics to reduce pain and dysfunction (306, 307). The notable weakness of this group of studies is the lack of research demonstrating that targeted intervention for the <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> has a positive or negative effect on low back pain and LPHCD. This is not to say that the targeted intervention will not have an impact on low back pain, but that there is no research testing the <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a>. Several studies have demonstrated altered <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> recruitment patterns during extension, abduction, and standing - including latent firing and reduced strength/endurance in those with chronic low back pain (298-300, 313 - 315). However, unlike research on the lower extremity, it appears no researcher has tested the efficacy of targeted exercise for the <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> to correct the pattern in low back pain patients. It is important to note, that based on personal accounts and discussion with other professionals targeted intervention is common in clinical practice with great benefit to low back pain patients.
Research has compared various <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> exercises, and to what extent over-active <a href="https://brookbushinstitute.com/glossary/synergists/" target="_blank" rel="noopener">synergists</a> are recruited &#x2013; including <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">tensor fasciae latae</a>, <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>, and <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> (316 - 325). These studies suggest that hip abduction along with hip extension results in a relative increase in <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> activity and/or a reduction in <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">tensor fasciae latae</a> and <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> activity. Additionally, <a href="https://brookbushinstitute.com/article/gluteus-medius-activation-progression" target="_blank" rel="noopener">clams</a> and <a href="https://brookbushinstitute.com/video/gluteus-medius-activation-progressions-activation-circuit" target="_blank" rel="noopener">side-lying leg raises</a> may be effective for targeting the <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and incorporate the <a href="https://brookbushinstitute.com/glossary/superior/" target="_blank" rel="noopener">superior</a> fibers of the <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> (319). Three studies suggest cues may improve <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> activity during exercise - a study by Lewis et al. suggests cueing <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> contraction (squeeze the glutes) (313), a study by Oh et al. suggests cueing the abdominal <a id="drawing-in" data-tip="1580" target="_blank" href="/glossary-term/drawing-in" class="glossary">drawing-in</a> maneuver (<a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a>) (318), and a study on several Pilates exercises suggested cueing &#x201C;<a href="https://brookbushinstitute.com/glossary/posterior/" target="_blank" rel="noopener">posterior</a> pelvic tilt&#x201D;(321). Finally, a study by Berry et al. demonstrated more forward lean during <a href="https://brookbushinstitute.com/video/side-stepping-progressions-gluteus-medius-reactive-activation" target="_blank" rel="noopener">resisted side-stepping</a> may also increase <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> activation (322). The Brookbush Institute uses mild hip abduction, <a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a>, <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> tilting, and &quot;squeezing the glutes&quot; as cues during <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">gluteus maximus activation</a> exercises, and forward bending during <a href="https://brookbushinstitute.com/video/side-stepping-progressions-gluteus-medius-reactive-activation" target="_blank" rel="noopener">resisted side-stepping</a>.
<a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semitendinosus and Semimembranosus (Semi&apos;s)</a> - Unfortunately, there is very little research to suggest the common compensatory pattern adopted by the <a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semi&apos;s</a> in those exhibiting signs of LPHCD. Most studies examining hamstring activity use <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> EMG as an indicator of overall hamstring activity (169, 173 - 175). No studies could be located that directly compared <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> and <a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semi&apos;s</a> activity. Considering these muscles have opposing actions in the transverse plane, measuring one or the other is likely insufficient for determining the behavior of the hamstrings as a group. Several studies (mentioned above) demonstrate a decrease in hamstring <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a> during forward bending and the active straight leg raise <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> in those exhibiting low back pain (43, 44, 49, 50); however, this reduction in hamstring <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a> cannot be attributed to an increase in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> stiffness (289 - 292). This may be an indicator that changes in <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a> are due to changes in relative activity/tone, reinforcing a <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> that over-activity is the cause of <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a> loss. One study by Guimar&#xE3;es et al. used the <a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semi&apos;s</a> as an indicator of hamstring activity while testing the hip extension recruitment pattern, demonstrating that the <a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semi&apos;s</a> fired first, then the <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>, and last the <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> (293). This recruitment pattern is similar to studies using the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> as an indicator of hamstring activity (173, 174). Although the loss of hamstring <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a> and similarity to the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> during extension patterns seems to indicate this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> is long and over-active, these muscles are also tibial internal rotators. Tibial internal rotators were found to be long and under-active in the <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>. More research comparing the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> and <a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semi&apos;s</a> is needed.
<img src="https://www.datocms-assets.com/25800/1649273641-glute-max.png" width="220" height="315" title="Gluteus Maximus" alt="Gluteus Maximus">

<ul>
 <li>The <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> muscular <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of LPHCD benefits from more research than the other predictive <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of dysfunction.</li>
 <li><a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">Transverse abdominis</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a>, diaphragm, pelvic floor, and potentially the <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a> behave similarly. Dysfunction leads to under-activity and perhaps an increase in length, despite the increase in length not contributing to any joint action.</li>
 <li>The <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> are <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> to under-activity and an increase in length in both <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a> and LPHCD. These muscles may be &quot;the bridge&quot; that propagates dysfunction from one to the other. Note: the <a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">semitendinosus and semimembranosus (semi&#x2019;s)</a> may behave similarly to the <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a></li>
 <li>The <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">tensor fascia latae</a>, <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a>, <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a>, and <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> appear to behave similarly. Although <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a> and <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a> activity in those exhibiting dysfunction should be researched further, research does hint at similar changes in activity to the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">tensor fascia latae</a> and <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a>.</li>
 <li>The <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>, <a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">piriformis</a>, <a href="https://brookbushinstitute.com/article/deep-rotators-of-the-hip" target="_blank" rel="noopener">deep rotators of the hip</a>, and <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor magnus</a> are over-active despite being lengthened by <a href="https://brookbushinstitute.com/article/hip-joint" target="_blank" rel="noopener">hip</a> flexion, and the <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> and <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a> are also over-active despite being lengthened by lumbar extension. This behavior is categorized as long/over-active and is believed to imply these muscles are acting as &quot;over-active&quot; <a id="synergists" data-tip="1650" target="_blank" href="/glossary-term/synergists" class="glossary">synergists</a>.</li>
</ul>
In this graph &quot;red muscles&quot; are over-active, note that muscles no longer appear on both sides of the table.
<table>
 <tbody>
 <tr>
 <td colspan="4">
 <h3>Lumbo Pelvic Hip Complex Dysfunction based on Muscle Research</h3>
 </td>
 </tr>
 <tr>
 <td colspan="2">Short</td>
 <td colspan="2">Long</td>
 </tr>
 <tr>
 <td>Lumbar Stabilizer</td>
 <td>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a></li>
 </ul>
 </td>
 <td>Lumbar Stabilizer</td>
 <td>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">Transverse Abdominis</a> (not a true lumber flexor)</li>
 <li><a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener" style="letter-spacing: 0px;">Internal Obliques</a></li>
 <li>Diaphragm</li>
 <li>Pelvic Floor</li>
 <li>Intercostals?</li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Hip Flexors</td>
 <td>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a></li>
 <li><a href="https://brookbushinstitute.com/article/iliacus" target="_blank" rel="noopener">Iliacus</a></li>
 <li><a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">Rectus Femoris</a></li>
 <li><a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">Tensor Fasciae Latae (TFL)</a> (and <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">Vastus Lateralis)</a></li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">Gluteus Minimus</a></li>
 <li><a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">Anterior Adductors</a></li>
 <li><a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">Sartorius</a></li>
 </ul>
 </td>
 <td>
 <ul>
 <li>Hip Extensors</li>
 </ul>
 </td>
 <td>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">Gluteus Medius</a></li>
 <li><a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">Gluteus Maximus</a></li>
 <li><a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semitendinosus</a></li>
 <li><a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semimembranosus</a></li>
 <li><a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">Piriformis</a> (not a true extensor)</li>
 <li><a href="https://brookbushinstitute.com/article/deep-rotators-of-the-hip" target="_blank" rel="noopener">Deep Rotators</a> (not a true extensor)</li>
 <li><a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">Adductor Magnus</a></li>
 <li><a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">Biceps Femoris</a></li>
 </ul>
 </td>
 </tr>
 <tr>
 <td>Lumbar Extensors</td>
 <td>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">Erector Spinae</a></li>
 <li><a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">Multifidus</a></li>
 <li><a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus Dorsi</a></li>
 <li><a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">Quadratus Lumborum</a> (not a true lumbar extensor)</li>
 </ul>
 </td>
 <td>Lumbar Flexors</td>
 <td>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">Rectus Abdominis</a></li>
 <li><a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">External Obliques</a></li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>
Summary of Issues with the &quot;Evidence-based Muscular Analysis&quot;:
The research used to construct an &quot;evidence-based muscular analysis,&quot; when used to refine the <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> <a id="osteokinematic-motion" data-tip="1881" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic</a> analysis, offers a more refined account of changes in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and length. This offers several advantages when creating a corrective intervention; however, more research and further analysis is needed.
Remaining issues:
<ul>
 <li>As evidenced by the following two points, more consideration should be given to lower extremity muscles and LPHCD and the link between LPHCD and <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>.</li>
 <li>Several muscles are categorized with muscles of similar functions because insufficient research exists to <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> the muscle&apos;s behavior (<a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">gluteus minimus</a>, <a href="https://brookbushinstitute.com/article/rectus-femoris" target="_blank" rel="noopener">rectus femoris</a>, <a href="https://brookbushinstitute.com/article/sartorius" target="_blank" rel="noopener">sartorius</a>, <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">gracilis</a>, <a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">semitendinosus &amp; semimembranosus,</a> intercostals, <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor magnus</a>).</li>
 <li>Further research is needed for a few muscles that compare activity and recruitment in asymptomatic individuals and individuals exhibiting LPHC symptoms (<a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> and <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">anterior adductors</a>).</li>
</ul>

Strain Hardening - In two studies, it was shown that fascia stiffens when repetitively stretched or put under static <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a>, and this process was termed &quot;strain hardening&quot; (365, 366). This process seems to be achieved (or is heavily influenced) by an increase in tissue hydration that starts returning to normal levels about 1 hour after the strain is removed. Further, repetitive strain/rest periods result in adaptation, which included a higher <a id="base-of-support" data-tip="1196" target="_blank" href="/glossary-term/base-of-support" class="glossary">base</a> level of hydration even after a recovery period (366). Note, strain hardening is likely a different process than the increase in <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> hypothesized from contraction of myofibroblasts (151, 328, 329), as strain hardening was achieved in previously frozen tissues (freezing often destroys cells) (366). Evidence of &quot;strain hardening in response to repeated lengthening&quot; does seem to contradict the increase in <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a> reported by manual therapists using fascia intended techniques.
Improve <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">Shear</a> Between Layers - In a study by Levangin et al. comparing <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">Shear</a> strain (movement between fascial planes) of the thoracolumbar fascia (TLF), a chronic low back pain group showed approximately 20% less <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">Shear</a> strain than asymptotic controls (367). Although the TLF tissues were not directly tested for chemical, cellular or structural changes between layers, it was hypothesized that mal-adaptive cross-bridging by collagen fibers between layers may be a response to damage and inflammation and limit normal fascial motion and <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a>. Note, the application of &quot;shearing forces&quot; to disrupt mal-adaptive cross-bridging has been proposed as a primary mechanism and benefit of many myofascial <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">Shear</a> (myofascial <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a>), IASTM, and pin-and-stretch techniques.
Altered Sympathetic <a id="tone" data-tip="1639" target="_blank" href="/glossary-term/tone" class="glossary">Tone</a> and Local Circulation - In trying to explain the palpable change noted by manual therapists (especially during slow, deep pressure), Schleip hypothesized an &quot;integrated systems&quot; <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of connective tissue&apos;s response to pressure - &quot;stimulation of intrafascial sympathetic afferents (e.g. via manual medicine therapy) may trigger modifications in global autonomic <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> <a id="tone" data-tip="1639" target="_blank" href="/glossary-term/tone" class="glossary">Tone</a>, as well as in local circulation and matrix hydration&quot;(358, 359). This <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> includes not only the hydration processes mentioned in relation to strain hardening, but stimulation of fibroblasts discussed above via sympathetic reflex arcs stimulated by receptors embedded in the fascia (358, 359, 374), and the alterations in <a id="tone" data-tip="1639" target="_blank" href="/glossary-term/tone" class="glossary">Tone</a> may include a reduction in electromyography (EMG) activity of related muscles (373). This <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> system&apos;s explanation of tissue response to manual pressure is likely the most complete; however, Schleip may need to add the role strain hardening plays on the &quot;palpable tissue response.&quot;
<img src="https://www.datocms-assets.com/25800/1649274268-schleip.png" width="485" height="328" alt="Schleip">
Tissue Manipulation <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">Model</a> - Schleip, R. (2003). Fascial plasticity&#x2013;a new neurobiological explanation Part 2. Journal of Bodywork and movement therapies, 7(2), 104-116.
Increased <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">Stability</a> - Several studies have demonstrated the ability of fascia to transmit the force of multiple muscles to aid in joint stabilization (191, 201, 208, 327, 337 - 346, 376). This may have interesting implications relative to manual therapy - the mediation of fibroblast activity via sympathetic reflex arcs and strain hardening may increase fascial stiffness, improving force transmission from invested musculature, joint <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">Stability</a>, and <a id="arthrokinematics" data-tip="1701" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic motion</a>. However, a further explanation would be needed to explain the &quot;palpable&quot; feelings of <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> and increased <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>. Further implications of fascia&apos;s role in stabilization is hypothesized &quot;myofascial synergies&quot; that incorporate multiple muscles, transmitting force through fascial sheaths, to aid in stabilization and motion. This has a profound impact on exercise that is discussed below under &quot;Myofascial Synergies&quot;.
In summary, the role of fascia and its response to intervention are complex. This includes strain hardening by repetitive or constant <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a>, decreased <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">shear</a> and the potential of cross-bridging between fascial layers, changes in both <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="tone" data-tip="1639" target="_blank" href="/glossary-term/tone" class="glossary">tone</a> and fibroblast mediated pre-tension via deep sustained pressure, and fascias role in transmitting the force of multiple muscles to stabilize a joint. These roles are used as the rationale for techniques that include static <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> techniques, IASTM techniques, pin-and-stretch, and stabilization/activation exercises. Below the facial structures that have the largest impact on the lumbopelvic hip complex (LPHC) are discussed.
<h4>Fascia&apos;s Response to Fascia Directed Intervention:</h4>
<ul>
 <li>Strain hardening</li>
 <li>Improve <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">Shear</a> Between Layers</li>
 <li>Altered Sympathetic <a id="tone" data-tip="1639" target="_blank" href="/glossary-term/tone" class="glossary">Tone</a> and Local Circulation</li>
 <li>Enhanced Joint Stability</li>
</ul>

The thoracolumbar fascia (TLF) is likely the most well-researched fascial structure. Much of the research cited on the potential of fascial tissue to contribute to movement, dysfunction, and/or pain seems to be based on research performed on the TLF (6, 326-328, 335, 352, 354, 357-360, 366-367). The TLF can be described as a 3 layer system, with the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer having deep and superficial laminae (layers), and the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> layer often being omitted from movement analysis because it is thought to be too thin to contribute to lumbar <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> (192, 337). (The <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> layer may be continuous with the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> abdominal fascia). The division of the TLF into 3 layers (or 4 if counting the two layers of the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer separately), is often described as a 2 layer system in research, combining the two laminae of the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer and omitting the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> layer altogether. The 3 layer system is used in this article.
Anatomy - The superficial laminae of the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer is continuous with the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a>, serratus <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a>, <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a>, as well as part of the <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a> and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">lower trapezius</a> (6, 192, 330 - 334). Medially, the majority of the superficial layer is bordered by the supraspinous ligament and spinous process <a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a> to L4, but fibers do cross to attach to the <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> sacrum, PSIS, and iliac crest (6). Some fibers of the TLF, arising from the <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a>, also cross the mid-line attaching to the opposite sacrum, PSIS, or <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> raphe (6, 192, 333). The deep laminae of the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer runs continuous from the splenius capitis and cervicis, superficial <a href="https://brookbushinstitute.com/article/rhomboids" target="_blank" rel="noopener">rhomboids</a>, envelops the <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> (acting as a retinaculum), and is continuous with the sacrotuberous ligament and potentially the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> (192, 334, 337). The middle layer of the TLF extends from the transverse processes, between the <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">quadratus lumborum</a> and <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>, and runs continuous with the aponeurosis of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> and <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> (192, 330-334). The deep laminae of the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer and middle layer fuse to <a id="posture" data-tip="1660" target="_blank" href="/glossary-term/posture" class="glossary">form</a> the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> raphe, which may be thought of as a thickening of the middle layer to reinforce the attachment of the abdominal tourniquet muscles (192, 337). As mentioned above, the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> layer is generally given little attention; the thinnest of the 3 layers likely does not contribute much to lumbar <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> or force transmission between muscles (192, 337), but may be continuous with the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> abdominal fascia, abutting the transverse fascia and peritoneum.
<h4>Summary</h4>
<ul>
 <li><a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> layer (Superficial laminae derived from the aponeurosis of the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> and serratus <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a>) investing muscles:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">Lower Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus Dorsi</a></li>
 <li>Serratus <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> Inferior</li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">Gluteus Maximus</a></li>
 <li>Gluteal Fascia (<a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">Gluteus Medius</a>)</li>
 </ul>
 </li>
 <li><a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> layer (Deep laminae - retinacular sheath of the erectors) investing muscles:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">Erector Spinae</a></li>
 <li>Splenii</li>
 <li><a href="https://brookbushinstitute.com/article/rhomboids" target="_blank" rel="noopener">Rhomboids</a></li>
 <li>Sacrotuberous Ligament</li>
 <li><a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">Biceps Femoris</a></li>
 </ul>
 </li>
 <li>The middle layer (Combines with Deep Laminae of <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> Layer at LIFT to <a id="posture" data-tip="1660" target="_blank" href="/glossary-term/posture" class="glossary">form</a> <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">Lateral</a> Raphe) investing muscles:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">Transverse Abdominis</a></li>
 <li><a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">Internal Obliques</a></li>
 </ul>
 </li>
 <li><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> layer (Thin) investing muscles (May be continuous with <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer of abdominal fascia):
 <ul>
 <li><a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">Quadratus Lumborum</a></li>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a></li>
 </ul>
 </li>
</ul>
<img title="Thoracolumbar Fascia" src="https://www.datocms-assets.com/25800/1647306269-1642021632-thoracolumbar-fascia.jpeg" alt="Thoracolumbar Fascia">
By Anatomist90 &#x2013; Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17900177; Thoracolumbar fascia. Notice the lighter-colored band of tissue. This is the fascia.
Stability - Several studies have implicated the TLF as instrumental to lumbar spine and sacroiliac joint (SIJ) <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">Stability</a> (191, 201, 208, 337 - 346). Some of these studies imply the significance of the role of the TLF indirectly; that is, via the attachment of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> and <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> and their contribution to lumbar and SIJ <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">Stability</a> (191, 201, 208, 338). Other studies have directly tested increased <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in the TLF and its impact on lumbar rigidity using cadavers (334, 339 - 340). A <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> proposed by Vleeming et al. further supports the importance of the TLF (and investing musculature) to SIJ <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">Stability</a>, suggesting that the bumps, ridges, and friction coefficient of the intra-articular surfaces of the SIJ (<a id="form-closure" data-tip="1452" target="_blank" href="/glossary-term/form-closure" class="glossary">form closure</a>) are insufficient to stabilize the joint without additional <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> from muscles and <a id="connective-tissue-cell" data-tip="1368" target="_blank" href="/glossary-term/connective-tissue-cell" class="glossary">connective tissue</a> (<a id="force-closure" data-tip="1448" target="_blank" href="/glossary-term/force-closure" class="glossary">force closure</a>) (340, 341). Studies by Cisco et al., Vleeming et al. and Richardson et al. reinforced this assertion, demonstrating increased SIJ <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">Stability</a> with <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and <a id="form-closure" data-tip="1452" target="_blank" href="/glossary-term/form-closure" class="glossary">form closure</a> (191, 194, 342). Additional evidence for the importance of the TLF&apos;s role in the <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">Stability</a> of the LPHC is the review of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> behavior discussed in this article, and how many of these muscles would not directly impact the lumbar spine, SIJ or pelvis if not for their investment in the TLF (including the sacrum and sacrotuberous ligament).
Contribution to motion - The TLF was originally thought to aid in lumbar extension, but further research refuted this <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> (343 - 347). However, several studies have noted that the TLF may aid in resisting lumbar flexion (aid in eccentric deceleration) by increasing in length while decreasing in width (192, 334, 347). &quot;Traction studies&quot; (studies in which force is applied to the TLF in a similar way to a particular set of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> fibers would pull on the TLF), aids in understanding the ability of the TLF to communicate or transfer force. The amount of displacement of fascial tissue and the distance displacement of fascial tissue occurs away from the site of <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> are indicators of the ability of fascia to communicate force from one <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> to another structure. Several studies have demonstrated displacement, especially when replicating the force from the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a>, <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> (superficial <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer of TLF), <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>, and <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> (middle layer of TLF) (162, 327, 335, 348).
<h4>Results from Vleeming et al. (348):</h4>
<ul>
 <li><a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">Traction</a> of <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius muscle</a> - <a id="ipsilateral" data-tip="1550" target="_blank" href="/glossary-term/ipsilateral" class="glossary">ipsilateral</a> displacement up to 2 cm</li>
 <li><a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">Traction</a> to the <a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> fibers of the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> - <a id="ipsilateral" data-tip="1550" target="_blank" href="/glossary-term/ipsilateral" class="glossary">ipsilateral</a> displacement up to 2&#x2013;4 cm</li>
 <li><a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">Traction</a> to the <a id="caudal" data-tip="1557" target="_blank" href="/glossary-term/caudal" class="glossary">caudal</a> part of the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> - <a id="ipsilateral" data-tip="1550" target="_blank" href="/glossary-term/ipsilateral" class="glossary">ipsilateral</a> displacement 8 - 10 cm up to the midline
 <ul>
 <li>Between L4&#x2013;L5 and S1&#x2013;S2 levels, the displacement spread to the <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> side.</li>
 </ul>
 </li>
 <li><a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">Traction</a> to the <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> - ipsilateral and <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> displacement up to 4 to 7 cm.</li>
</ul>
Additionally, studies have demonstrated similar recruitment between muscles linked by the TLF. Kim et al. demonstrated <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity of the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> during gait, which increased when speed increased or weights were held (348). Hodges et al. demonstrated a relationship between increased arm speed and recruitment of <a id="ipsilateral" data-tip="1550" target="_blank" href="/glossary-term/ipsilateral" class="glossary">ipsilateral</a> and <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> trunk musculature (tourniquet/middle layer TLF) (201). Stevens et al. demonstrated the co-contraction of various muscles investing in the TLF during a &quot;quadruped&quot; exercise (349). Last, DeRiddler et al. demonstrated the recruitment of muscles investing in the deep <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer of the TLF during an extension exercise (350). An interesting study by Schuenke et al. demonstrates the complexity and necessity for <a id="intramuscular-coordination" data-tip="1667" target="_blank" href="/glossary-term/intramuscular-coordination" class="glossary">intramuscular coordination</a> of muscles investing in the TLF (356). In this study, inflation of the deep <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer by extensor muscles altered the moment arm and load angle of muscles investing in the superficial <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer and middle layer of the TLF (356). This could imply that the force, action, and function of individual muscles could be altered when the order of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment is altered (as seen in those with low back pain). Further, Huskins et al. proposed a <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> that demonstrated that the deep laminae (extensor retinaculum) could aid in increasing the force output of the <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> by up to about 30%, by restricting its radial expansion (364).

Sensory Innervation - Various studies and texts have implicated fascia, and the TLF specifically, as a sensory organ closely tied to neuromuscular reflex, motion, dysfunction, and pain. The presence of corpuscular receptors in the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer of the TLF is commonly described by the older studies - such as Golgi, Pacini, and Ruffini endings which imply a role in proprioception (352-354). Interestingly, the most recent study (using modern methods) by Tesarz et al. failed to find such corpuscular endings, with the exception of possible Ruffini endings (354). If the TLF does play a role in proprioception it would likely be indirect through forces imparted on the supraspinous, interspinous, and iliolumbar ligaments, which are abundantly innervated by Pacinian receptors and Ruffini endings (352, 361). However, additional studies show that these receptors may only be stimulated at end range as limit detectors which implies they have less of a role in mid-range (362-363).
The study by Tesarz et al. did find that the TLF was especially dense in free <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> endings, presumably nociceptors, in the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer (354). These findings are supported by several studies as research in this area has increased in recent years (355, 557 - 559). Although these findings do not <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> the notion of the TLF as a proprioceptive organ, they do <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> the <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> that micro-trauma and inflammation of the TLF may contribute to low back pain. There is additional evidence to suggest that an increase in sympathetic activity, and/or inflammation may &quot;sensitize&quot; the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer of the TLF contributing to an increase in nociception (357-359). The role of the TLF in low back pain was originally discussed by Hirsh in 1963 (352), revisited as a potential mechanism for chronic low back pain by Punjabi in 2oo6 (356), and beautifully summarized in the quote below by Vleeming (192):
Quote from Vleeming et al. (192):
<ul>
 <li>To summarize, the sensory innervation of the TLF suggests (may imply) at least three different mechanisms for fascia-based low back pain sensation: (1) micro-injuries and resulting irritation of nociceptive <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> endings in the TLF may lead directly to back pain; (2) tissue deformations due to injury, immobility or excessive loading could also impair proprioceptive signaling, which by itself could lead to an increase in pain <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> via an activity-dependent sensitization of wide dynamic range neurons; and finally, (3) irritation in other tissues innervated by the same spinal segment could lead to increased <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> of the TLF, which would then respond with nociceptive signaling, even to gentle stimulation.</li>
</ul>
Fascial <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">Mobility</a>, SIJ <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">Stability</a>, and Practice - As mentioned above a study by Levangin et al. compares <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">shear</a> strain (movement between fascial planes) of the TLF in those with and without a history of low back pain (367). It was proposed that maladaptive cross-bridging in response to tissue damage and inflammation may have reduced movement between layers. The Brookbush Institute does recommend IASTM techniques with the intent of disrupting these cross-bridges; however, careful consideration must be given to the irritability of the patient and the receptor density of the TLF.
Perhaps the most obvious application of TLF research is a focus on activation and strengthening of investing musculature with the goal of increased <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> of the lumbar spine and SIJ. Mooney et al. showed the effectiveness of <a id="pivot-joint" data-tip="1838" target="_blank" href="/glossary-term/pivot-joint" class="glossary">rotary</a> exercises for the treatment of SIJ dysfunction (368), and many of the previously mentioned studies by Richardson et al., Hides et al, Hodges et. al., and Morris et al. have demonstrated the efficacy of <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> and <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal oblique</a> activation/strengthening for stabilization of the lumbar spine and SIJ, and treatment of low back pain (157-159, 194-196).
In conclusion, <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and/or <a id="activation-technique" data-tip="1531" target="_blank" href="/glossary-term/activation-technique" class="glossary">activation techniques</a> may result in positive changes. Current studies suggest that manual therapy and other myofascial modalities may increase TLF stiffness while increasing <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">shear</a> (movement) between layers, affect <a id="tone" data-tip="1639" target="_blank" href="/glossary-term/tone" class="glossary">tone</a> of fibroblasts, and investing musculature, while activation and strengthening of investing musculature may improve <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> of the lumbar spine and SIJ. Care should be taken in addressing these tissues directly, as there is evidence to suggest that the TLF could be a source of nociceptive input for those suffering from chronic low back pain. The Brookbush Institute does recommend IASTM techniques and <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">Posterior Oblique Subsystem </a><a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">Integration</a> (POS) (discussed below) based on these findings.

Anatomy - The rectus sheath envelopes the <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> anteriorly and posteriorly. From the costal cartilage to the arcuate line (the level of the umbilicus), the <a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">anterior</a> sheath is comprised of a continuation of the <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external oblique</a> fascia while the <a href="https://brookbushinstitute.com/glossary/posterior/" target="_blank" rel="noopener">posterior</a> sheath is comprised of a continuation of the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal oblique</a> and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> fascia. Note, some texts suggest the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal oblique</a> fascia splits, contributing to both <a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">anterior</a> and <a href="https://brookbushinstitute.com/glossary/posterior/" target="_blank" rel="noopener">posterior</a> rectus sheaths (6). Below the level of the arcuate line, the <a href="https://brookbushinstitute.com/glossary/posterior/" target="_blank" rel="noopener">posterior</a> sheath does not continue, and the fascia of the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a>, <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a>, and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> continue <a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">anteriorly</a> to the <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a>. <a href="https://brookbushinstitute.com/glossary/posterior/" target="_blank" rel="noopener">Posteriorly</a>, deep to the fascia of the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal oblique</a> and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>, the transverse fascia (not to be confused with the fascia of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>) lines the abdominal muscles, <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">quadratus lumborum</a>, <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">psoas</a>, <a href="https://brookbushinstitute.com/glossary/inferior/" target="_blank" rel="noopener">inferior</a> surface of the diaphragm, and blends with the fascia of the <a href="https://brookbushinstitute.com/article/iliacus" target="_blank" rel="noopener">iliacus</a>; lying between the deep (investing) fascia and the peritoneum (18). Based on texts and current research, it is difficult to determine if there is continuity between the deep fascia of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>, the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> layer of the TLF, and the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> layer of fascia lining of the diaphragm, in addition to, or perhaps in conjunction with transverse fascia, although it seems likely. The <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">pyramidalis</a> actually lies within the <a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">anterior</a> rectus sheath, from the pubis to approximately half the distance to the umbilicus. The fascial layers of the abdomen converge at the linea alba, where they continue into identical fascial sheaths on the opposite side. The linea alba, running down between the two <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> muscles, is itself a thickening created by the crossing of transverse oriented fibers of the fascial sheaths (14). The transverse inscriptions that run through the <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> are also continuations of the oblique fascia (192). In addition, the <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a> invests in the abdominal fascia, and the <a href="https://brookbushinstitute.com/article/serratus-anterior" target="_blank" rel="noopener">serratus anterior</a> invests in the <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external oblique</a> fascia (6, 16, 370, 371), which invites ideas of an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> myofascial synergy extending from shoulder to femur.
<ul>
 <li>Envelops
 <ul>
 <li><a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">Rectus abdominis</a></li>
 </ul>
 </li>
 <li><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> layer (Combines with deep laminae of the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer of the TLF at LIFT to <a id="posture" data-tip="1660" target="_blank" href="/glossary-term/posture" class="glossary">form</a> the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> raphe) investing muscles:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">Pyramidalis</a></li>
 <li><a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">External Obliques</a></li>
 <li><a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">Internal Obliques</a>
 <ul>
 <li>Potentially
 <ul>
 <li><a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">Pectoralis Major</a></li>
 <li><a href="https://brookbushinstitute.com/article/serratus-anterior" target="_blank" rel="noopener">Serratus Anterior</a></li>
 </ul>
 </li>
 </ul>
 </li>
 </ul>
 </li>
 <li><a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> layer (Does not exist below the arcuate line and may be continuous with the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> layer of TLF) investing muscles:
 <ul>
 <li><a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">Internal Obliques</a></li>
 <li><a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">Transverse Abdominis</a>
 <ul>
 <li>Potentially
 <ul>
 <li><a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">Quadratus Lumborum</a></li>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a></li>
 </ul>
 </li>
 </ul>
 </li>
 </ul>
 </li>
</ul>
Function - Any <a href="https://brookbushinstitute.com/glossary/lateral/" target="_blank" rel="noopener">lateral</a>, <a href="https://brookbushinstitute.com/glossary/posterior/" target="_blank" rel="noopener">posterior</a>, or rotational force imparted on the trunk will result in an increase in <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a>, <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">pyramidalis</a>, <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a>, and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> activity (14), and potentially an increase in <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">quadratus lumborum</a> and <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">psoas</a> activity (89, 93, 115). This increase in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity will also result in an increased <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> of the abdominal fascia, transverse inscriptions, and linea alba, and any force imparted by one <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> will be transmitted between layers of the abdominal fascial network (372, 373). The corset-like effect of this myofascial synergy has been discussed by several researchers/authors, contributing to <a href="https://brookbushinstitute.com/glossary/force-closure/" target="_blank" rel="noopener">force closure</a> of the sacroiliac joints and pubic symphysis, an increase in intra-abdominal pressure, <a href="https://brookbushinstitute.com/glossary/posterior/" target="_blank" rel="noopener">posterior</a> shift of the abdominal <a id="viscera" data-tip="1278" target="_blank" href="/glossary-term/viscera" class="glossary">viscera</a> into the lumbar vertebrae, and enhanced force transmission from the lower to upper extremities (6, 14, 18, 192, 219, 264, 348). Vleeming makes the following analogy (6) - like the thoracolumbar fascia (TLF), the abdominal fascia features muscles encased in a fascial network. The paired <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> muscles are encased in the fascia of investing muscles (<a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a>, and <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a>). <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in these muscles increases <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in the abdominal fascia like the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> increases <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in the TLF.
The relationship between <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> with the abdominal fascia and the middle layer of the TLF completes the loop necessary to create a tourniquet or belt that may aid in the lumbar spine and SIJ <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> via increased <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> and intra-abdominal pressure. The selection of exercises with the intent of targeting these muscles has been discussed above and will be discussed further under the heading <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic Stabilization Subsystem (ISS)</a>. Further, the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> layer of the fascia along with the fascia of the <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> and <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a> may imply a synergy of muscles known as the <a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">Anterior Oblique Subsystem (AOS)</a> which also has implications for exercise selection.
To our knowledge only one study could be located that may imply the efficacy of a technique directed at the abdominal fascia. In this study deep, slow pressure resulted in a decrease in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity (370). Admittedly, this is not a common or comfortable technique to apply to the abdomen. If manual pressure is applied a tangential force is recommended to reduce discomfort. No studies could be located that investigated IASTM on the abdominal region, but based on the idea that <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">shear</a> between layers may be reduced as a result of dysfunction, careful application in practice may be warranted, especially where the layers converge at the semilunar lines and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> raphe of the TLF.
<img src="https://www.datocms-assets.com/25800/1644872641-abdominal-fascia.png" width="427" height="535" title="Abdominal Fascia" alt="Abdominal Fascia">

Several of the muscles discussed above, invest in and may increase <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in the sacrotuberous ligament. The <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> seem particularly adept at increasing <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in this structure (191, 377); however, the <a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">piriformis</a>, <a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">semitendinosus, semimembranosus</a>, <a href="https://brookbushinstitute.com/article/deep-rotators-of-the-hip" target="_blank" rel="noopener">obturator internus</a>, and <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> have also been implicated due to their attachments (378). The Brookbush Institute considers the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor magnus</a> part of this group due to the attachment of fibers from the ichiocondylar (<a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a>) head to the sacrotuberous ligament; however, there is a void in the literature regarding this <a href="https://brookbushinstitute.com/glossary/muscle-cell/" target="_blank" rel="noopener">muscle</a>. Of importance to the development of the <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a> and LPHCD <a href="https://brookbushinstitute.com/glossary/model/" target="_blank" rel="noopener">models</a> is the role these muscles have on stabilization and/or dysfunction of the sacroiliac joint (SIJ). Studies by Vleeming et al. have shown that contraction of the muscles mentioned can increase <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> of the sacrotuberous ligament, and contribute to <a href="https://brookbushinstitute.com/glossary/force-closure/" target="_blank" rel="noopener">force closure</a> of the SIJ (191, 375-376). Further, increased <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> of the sacrotuberous ligament via muscular contraction can resist <a id="nutation" data-tip="1213" target="_blank" href="/glossary-term/nutation" class="glossary">nutation</a> (376, 377), and potentially contribute to altered movement patterns and <a href="https://brookbushinstitute.com/glossary/arthrokinematics/" target="_blank" rel="noopener">arthrokinematic</a> <a href="https://brookbushinstitute.com/glossary/dyskinesis/" target="_blank" rel="noopener">dyskinesis</a> of the SIJ, lumbar spine, pelvis, and potentially the hip via muscles crossing from femur to sacrum.
As mentioned above, the <a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">piriformis</a>, <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>, and <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor magnus</a> are <a href="https://brookbushinstitute.com/glossary/prone/" target="_blank" rel="noopener">prone</a> to over-activity. This over-activity may result in increased <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> of the sacrotuberous ligament and limit sacral <a id="nutation" data-tip="1213" target="_blank" href="/glossary-term/nutation" class="glossary">nutation</a> during functional activities. Although further research is needed, a limit to sacral <a id="nutation" data-tip="1213" target="_blank" href="/glossary-term/nutation" class="glossary">nutation</a> would be congruent with various components of the LPHCD (as well as <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">LED</a>) <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>. It is the Brookbush Institute&apos;s recommendation that the sacrotuberous ligament is treated indirectly via the <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> of the investing muscles and mobilization of the SIJ. Although deep pressure to the sacrotuberous ligament is likely possible, no benefit has been seen in practice, and no research to date has investigated efficacy. The sacrotuberous ligament and research cited above also play a role in exercise selection as part of the <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">Deep Longitudinal Subsystem (DLS)</a> discussed below.
<h4>Muscles investing in the sacrotuberous ligament:</h4>
<ul>
 <li><a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">Multifidus</a></li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">Gluteus maximus</a></li>
 <li><a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">Piriformis</a></li>
 <li><a href="https://brookbushinstitute.com/article/deep-rotators-of-the-hip" target="_blank" rel="noopener">Obturator internus</a></li>
 <li><a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">Biceps femoris</a></li>
 <li><a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semitendinosus</a></li>
 <li><a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">Semimembranosus</a></li>
</ul>

The iliotibial band is a thickening of the fascia lata of the leg, creating a complex network of investing structures. Based on studies by Faircough et al. and Stecco et al. the ITB invests in the following (379, 380):
<ul>
 <li>Iliac Spine</li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">Gluteus Maximus</a></li>
 <li><a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">Tensor Fasciae Latae (TFL)</a></li>
 <li><a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">Vastus Lateralis</a></li>
 <li><a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">Biceps Femoris</a></li>
 <li>Patellar tendon</li>
 <li><a href="https://brookbushinstitute.com/glossary/lateral/" target="_blank" rel="noopener">Lateral</a> collateral ligament (LCL)</li>
 <li><a href="https://brookbushinstitute.com/glossary/lateral/" target="_blank" rel="noopener">Lateral</a> intermuscular septum with a strong attachment to the <a href="https://brookbushinstitute.com/glossary/lateral/" target="_blank" rel="noopener">lateral</a> femoral condyle</li>
 <li><a href="https://brookbushinstitute.com/glossary/lateral/" target="_blank" rel="noopener">Lateral</a> patellar retinaculum</li>
 <li>Fascial slips to Gerdy&#x2019;s tubercle (just <a href="https://brookbushinstitute.com/glossary/inferior/" target="_blank" rel="noopener">inferior</a> to the <a href="https://brookbushinstitute.com/glossary/lateral/" target="_blank" rel="noopener">lateral</a> tibial plateau)</li>
 <li>Fibular head</li>
 <li><a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">Anterior</a> tibiofibular ligament</li>
</ul>
These research studies by Faircough et al. and Stecco et al. are what inspired consideration of the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a>, and ITB as a synergy involved in resisting hip extension and adduction, and the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a> being treated in conjunction with the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> in those exhibiting LPHCD. That is, although the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a> is not a hip flexor or abductor, it may contribute to LPHCD by increasing <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in the ITB. Further, the ITB creates a bridge for the propagation of dysfunction from LPHCD to the knee and <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>. As mentioned above, the ITB also invests in the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">biceps femoris</a> adding another powerful tibial external rotator to the synergy. Over-activity of this synergy may contribute to tibial external rotation noted in <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-5-feet-turn-out-breakdown" target="_blank" rel="noopener">feet turn out</a>, as well as <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">knees bow in</a> (combination of tibial external rotation and femoral internal rotation in a closed chain), and inadequate <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> glide&#xA0;of the fibular head. Although a relationship between the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> and <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">biceps femoris</a> can be deduced from their common action as external rotators of the tibia, the synergy establishes a rationale for why the <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> of <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a> (commonly and mistakenly referred to as &#x201C;foam rolling the iliotibial band&#x201D;) is often effective in alleviating knee pain. The relationship between the ITB and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> is harder to explain. This <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> is <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> to under-activity, and therefore, cannot be a contributor to dysfunction/diagnoses that are related to increased stress. The <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> should likely be viewed as a <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> that pulls the entire lower extremity/ITB synergy as a unit. That is, the <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> acts as an <a id="antagonists" data-tip="1705" target="_blank" href="/glossary-term/antagonists" class="glossary">antagonist</a>, providing an opposing force to the synergy as a whole. The <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> is also the bridge between the ITB with the TLF (6), linking two of the largest fascial systems in the body.
The ITB is often considered a source of dysfunction and pain. Several studies investigating knee pathology have noted the same histochemical changes seen in dysfunction of other fascial structures (379 - 383). Although a couple of case reports have been published on myofascial <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> and instrument-assisted soft-tissue mobilization (IASTM) applied directly to the ITB, these publications did not demonstrate better outcomes or additional benefit when compared with <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a>, stretching, or activation of the muscles investing in the ITB (384-385). In practice, the Brookbush Institute has noted that interventions that address the ITB directly (myofascial <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a>, pin-and-stretch, IASTM) tend to be very uncomfortable, and offer little benefit relative to objective outcomes. Addressing the investing musculature, and considering the ITB as the fascial component of a synergy that includes the <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a>, and <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">biceps femoris</a> has proven an effective addition to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach to treatment, and <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to ITB directed techniques.
<img src="https://www.datocms-assets.com/25800/1649274859-myers-it-band-proximal-1.jpeg" width="318" height="327" title="IT Band" alt="IT Band">

<ul>
 <li>Fascial dysfunction results in a predictable set of changes to the tissue including thickening, histochemical changes (which may stimulate nociceptors and pain), decrease in tensile strength, the addition of disordered collagen fibers, and a reduction in <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">shear</a>.
 <ul>
 <li>The TLF, abdominal fascia, ITB, and sacrotuberous ligament are invested by multiple muscles and may play an important role in the synergistic function of those muscles.</li>
 <li>The TLF, abdominal fascia, and iliotibial band are layered, and may be a site of restriction due to an interruption of &#x201C;sliding layers&#x201D;.</li>
 <li>Research on techniques directed at these fascial structures is lacking; however, the evidence does <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> treating investing musculature. (This is not to imply that fascial techniques do not work, only that they have not been well researched.)</li>
 </ul>
 </li>
</ul>

Research leading to the development of <a href="https://brookbushinstitute.com/glossary/hypothesis/" target="_blank">hypotheses</a> on myofascial synergies (also known as slings or subsystems, and similar to the serape effect) (6, 367, 386) has influenced how the Brookbush Institute selects core exercises and <a href="https://brookbushinstitute.com/glossary/integration/" target="_blank">integrated</a> movement patterns. It is our belief that research on these myofascial synergies is an important step toward investigating movement patterns as they are recruited; as opposed to looking at isolated structures without perspective of their role in an <a href="https://brookbushinstitute.com/glossary/integration/" target="_blank">integrated</a> system.

<h4>Under-active <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">Posterior Oblique Subsystem (POS)</a>:</h4>
<ul>
 <li><a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">Lower Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">Latissimus Dorsi</a></li>
 <li>Thoracolumbar Fascia (Superficial <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> Layer)</li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">Contralateral Gluteus Maximus</a></li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">Gluteus Medius</a> (via the gluteal fascia)</li>
</ul>
The muscles that comprise the <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a> are the largest in the body. This subsystem plays a significant role in transferring force between lower and upper extremities, is involved in all pulling and rotational movement patterns (especially turning out), multi-segmental extension, and eccentrically decelerates spinal flexion and rotation, as well as hip flexion, adduction, and internal rotation (<a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">knees bow in</a> and <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-8-excessive-forward-lean" target="_blank" rel="noopener">excessive forward lean</a>).
Several studies have demonstrated the synergistic function of these muscles, force transfer between the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> via the thoracolumbar fascia, and the contribution of the <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a> to lumbar and sacroiliac joint stabilization (6, 191-192, 201, 208, 330 &#x2013; 334, 337 &#x2013; 346). These are larger muscles, and seemingly in congruence with the &#x201C;law of parsimony,&#x201D; appear to be recruited at higher intensities, but may not act as <a id="prime-mover" data-tip="1663" target="_blank" href="/glossary-term/prime-mover" class="glossary">prime movers</a> during low-intensity tasks (such as walking) (387). At all intensities, the <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a> must work in conjunction with the <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic Stabilization Subsystem (ISS)</a> and <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">Deep Longitudinal Subsystems (DLS)</a> (specifically the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">erector spinae</a>, <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>, and <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> (350, 387).
As mentioned above, a reduction in <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> activity has been correlated with pain and dysfunction of the low back, sacroiliac joint (SIJ), and all lower extremity joints, including the hip, knee, and ankle (74, 180, 297, 302, 303, 310). Even in the absence of pain, <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> weakness has been noted in those with <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">functional knee valgus</a>, a loss of hip extension, an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt, and a lack of <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-8-excessive-forward-lean" target="_blank" rel="noopener">forward lean</a> during running (62, 63, 173, 303, 304, 310, 317). Most pertinent to practice, greater <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> strength has been correlated with better landing mechanics, running mechanics, and squat mechanics (66, 303, 304, 308, 309, 317).
In asymptomatic individuals, the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi </a>muscle behaves like a global mover of the spine, demonstrating a marked increase in activity during the initiation of squat and stoop lifts and asymmetrical activation during trunk rotation (126, 165). A correlation between a loss of <a href="https://brookbushinstitute.com/video/shoulder-flexion-goniometry" target="_blank" rel="noopener">shoulder flexion</a> and LPHCD has been noted clinically, which has led to the <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> that the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> is reflexively over-active, which would also match similar behavior of the lumbar extensors (<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>). However, based on the inclusion of the <a href="https://brookbushinstitute.com/article/latissimus-dorsi" target="_blank" rel="noopener">latissimus dorsi</a> in the <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a>, research is desperately needed to determine if perhaps this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> is under-active and should be considered like a <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> of the shoulder.
The <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">lower trapezius</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> will be considered in the predictive <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper Body Dysfunction (UBD)</a>, as this <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> has no relationship to the LPHC, other than its relationship to the <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a>.
Based on research, the function of the <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a>, and the impairments noted (<a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> weakness) in the LPHCD <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>, it is our <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> that the system is <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> to under-activity. The Brookbush Institute addresses this issue by making the <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a> a focus during the selection of core exercise and <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> (whole-body) movement patterns - using exercise as a means of increasing the activity and strength of the <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a>. For example, an individual exhibiting LPHCD may be progressed to a routine that includes <a href="https://brookbushinstitute.com/article/bridge-progression" target="_blank" rel="noopener">bridge</a> <a id="exercise-progression" data-tip="1182" target="_blank" href="/glossary-term/exercise-progression" class="glossary">progressions</a> and <a href="https://brookbushinstitute.com/article/stability-progression-for-integrated-exercise" target="_blank" rel="noopener">legs with pull</a> <a id="exercise-progression" data-tip="1182" target="_blank" href="/glossary-term/exercise-progression" class="glossary">progressions</a>.
<img src="https://www.datocms-assets.com/25800/1649275037-sl-squat.png" width="579" height="617" title="Single Leg Pulldown" alt="Single Leg Pulldown ">
Single-Leg Squat to <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">Bilateral</a> Cable Pull Down

<h4>Under-active <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">Intrinsic Stabilization Subsystem (ISS)</a>:</h4>
<ul>
 <li><a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> layer of abdominal fascia</li>
 <li><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> layer of thoracolumbar fascia
 <ul>
 <li>Continuous with investing fascia of Diaphragm and Pelvic Floor</li>
 </ul>
 </li>
 <li>Transverse Fascia
 <ul>
 <li><a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">Internal Obliques</a></li>
 <li><a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">Transverse Abdominis</a></li>
 <li>Diaphragm</li>
 <li>Pelvic Floor</li>
 <li><a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">Multifidus</a></li>
 <li><a href="https://brookbushinstitute.com/article/rotatores-interspinales-and-intertransversarii" target="_blank" rel="noopener">Rotatores, Intertransversarii, and Interspinalis</a>
 <ul>
 <li>Potentially
 <ul>
 <li><a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">Quadratus Lumborum</a></li>
 <li><a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">Psoas</a></li>
 </ul>
 </li>
 </ul>
 </li>
 </ul>
 </li>
</ul>
The muscles that comprise the <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">ISS</a> are the same muscles that have been referred to as intrinsic stabilizers, <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> stabilizers, and segmental stabilizers of the lumbar spine (1-3, 6-9, 14). Their categorization as stabilizers is the result of research demonstrating an ability to increase <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in the thoracolumbar fascia (TLF), increase <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in the abdominal fascia, resist rotation and extension torques, increase stiffness of the lumbar spine, and contribute to <a id="force-closure" data-tip="1448" target="_blank" href="/glossary-term/force-closure" class="glossary">force closure</a> of the sacroiliac joint (188 - 194). Further, these muscles are responsible for increasing intra-abdominal pressure, which may also increase rigidity of the spine, as well as contribute to decompression forces and resist flexion <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> (195 - 197, 267). By integrating fascial research and research on motor control with the concept of &quot;subsystems&quot;, it is the Brookbush Institute&apos;s intent to develop a single <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of core <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> behavior that may aid in exercise/intervention selection.
The activity of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a>, diaphragm, and pelvic floor are incredibly similar relative to function and dysfunction. These muscles show an increase in activity with increases in respiration, gait speed, increases in intra-abdominal pressure, compressive loads on the spine, increase in <a id="center-of-mass-gravity" data-tip="1187" target="_blank" href="/glossary-term/center-of-mass-gravity" class="glossary">center of gravity</a> and changes in <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, are active bilaterally even with asymmetric loads, and fire prior to movement of the upper or lower extremities in asymptomatic individuals (89, 126, 128. 174, 184-189, 192, 197, 213, 268-272, 276, 279). Further, decreased activity (and/or latent firing) has been demonstrated in those exhibiting &quot;swayback&quot; <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, low back pain, and SIJ pain, (128, 174, 266-267, 274-278, 284), resulting in altered recruitment patterns that more heavily rely on &quot;global muscles&quot; (<a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">AOS</a> and <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">DLS</a>) (208).
Similarities in function and behavior also exist between the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a>, <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">psoas</a>, and <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">quadratus lumborum (QL)</a>. All 3 muscles seemingly play a larger role in frontal plane stabilization than sagittal plane stabilization or motion, as evidenced by EMG studies (93, 114, 115, 118-121). For example, <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> carries may result in larger increases in activity than activities that resist traditionally assigned joint actions. Further, all 3 muscles are <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> to atrophy in those exhibiting low back pain; often atrophy is sided and <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to the affected segment (94-100, 110, 131-136, 143). Unlike the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>, <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a>, diaphragm, and pelvic floor - the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a>, <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">psoas</a>, and <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a> seem to be more <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> to over-activity and may respond well to <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> techniques (16, 146, 149-151, 154, 551).
The link between these muscles may be several layers of continuous fascia. Deep to the fascia of the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal oblique</a> and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>, the transverse fascia (not to be confused with the fascia of the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>) lines the abdominal muscles, <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">quadratus lumborum</a>, <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">psoas</a>, <a href="https://brookbushinstitute.com/glossary/inferior/" target="_blank" rel="noopener">inferior</a> surface of the diaphragm, and blends with the fascia of the <a href="https://brookbushinstitute.com/article/iliacus" target="_blank" rel="noopener">iliacus</a>. This layer is between the deep (investing) fascia and the peritoneum (18). The fascia of the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> and <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> completes a loop, investing in the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> layer of the abdominal fascia, and the middle layer of the TLF (192, 330 - 334, 337). The middle layer of the TLF also would be continuous with the laminae enveloping the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a>. The published research that is missing is the layer between the transverse fascia and the &quot;middle layer&quot; fascia. That is, does the internal layer of <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> fascia run continuously with the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> layer of the TLF (which envelopes the <a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">psoas</a> and <a href="https://brookbushinstitute.com/article/quadratus-lumborum" target="_blank" rel="noopener">QL</a>) and with the fascia of the pelvic floor and diaphragm. The continuity of these fascial linings seems likely but more research is needed.
All of the muscles of the <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">ISS</a> are <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> to either under-activity or atrophy, resulting in the categorization of the <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">ISS</a> as under-active as a system. Studies <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> the use of the abdominal <a id="drawing-in" data-tip="1580" target="_blank" href="/glossary-term/drawing-in" class="glossary">drawing-in</a> maneuver (<a id="drawing-in" data-tip="1588" target="_blank" href="/glossary-term/drawing-in" class="glossary">ADIM</a>), <a href="https://brookbushinstitute.com/video/transverse-abdominis-tva-isolated-activation-quadruped" target="_blank" rel="noopener">Quadrupeds</a>, stabilization type exercise, perhaps with the addition of dorsiflexion, pelvic floor activation, and controlled breathing for addressing <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">ISS</a> under-activity (214 - 216, 218-222, 224-225, 280, 285-286). The Brookbush Institute includes these cues in the <a id="exercise-progression" data-tip="1184" target="_blank" href="/glossary-term/exercise-progression" class="glossary">progression</a> recommended for <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">TVA Activation</a>. However, it would be more accurate to title these exercises, as well as all exercises targeting the <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a>, &quot;<a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">ISS</a>&quot; activation.
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2013/06/b38_thoraco-lumbar_section.jpg" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2013/06/b38_thoraco-lumbar_section.jpg" alt="Muscular Layers of the Core - You can infer from this picture that the external oblique fascia runs continuous with the superficial abdominal fascia, and does not invest in the thoracolumbar fascia posteriorly. http://www.bandhayoga.com/online-courses/online-courses/shaktitest/images/Blog/b38_thoraco-lumbar_section.jpg"></a> Consider how <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> contraction of the TVA would increase <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> on the thoracolumbar fascia, pulling laterally on both sides simultaneously increasing rigidity. Further, consider how an increase in pressure <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to the lumbar vertebrae would resist and <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> translation and <a id="glide" data-tip="1817" target="_blank" href="/glossary-term/glide" class="glossary">shear</a>. - http://www.bandhayoga.com/online-courses/online-courses/shaktitest/images/Blog/b38_thoraco-lumbar_section.jpg

<h4>Over-active <a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">Anterior Oblique Subsystem (AOS)</a></h4>
<ul>
 <li><a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">External Obliques</a></li>
 <li><a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">Rectus Abdominis and Pyramidalis</a></li>
 <li>Abdominal Fascia (<a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Layer)/Linea Alba</li>
 <li><a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">Contralateral </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Adductors
 <ul>
 <li>Potentially
 <ul>
 <li><a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">Pectoralis Major</a></li>
 <li><a href="https://brookbushinstitute.com/article/serratus-anterior" target="_blank" rel="noopener">Serratus Anterior</a></li>
 </ul>
 </li>
 </ul>
 </li>
</ul>
The muscles that comprise the <a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">AOS</a> are also large but have less mass than the muscles of the <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a>. This subsystem plays a significant role in transferring force between lower and upper extremities, is involved in all pushing and rotational movement patterns (especially turning in), multi-segmental flexion, and eccentrically decelerates spinal extension and rotation, as well as hip extension, abduction, and external rotation. Although a bit over-simplified, it may be worth considering this to be the anti-rotation/anti-extension subsystem, and a primary mechanism of defense against acute lumbar injuries. When this subsystem is over-active it may also contribute to hip flexion, adduction, and internal rotation (<a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">knees bow in</a> and <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-8-excessive-forward-lean" target="_blank" rel="noopener">excessive forward lean</a>).
A few publications indicate that there may be a relationship between the sacroiliac joint, pubic symphysis, <a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">anterior</a> abdominal activity, and <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a> activity (6, 174, 388-390). Discussing this relationship with the addition of abdominal <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> motor control studies can be complicated, but if considered from the perspective of how the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductors</a> are involved and how facial continuity may play a role, the relationship can be presented with more clarity. In a study by Snijders et al., it was found that crossing the legs decreased the activity of the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> (390). It is hypothesized that crossing the legs altered <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a> activity and force imparted on the pubis, resulting in a reduction in activity by the <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal obliques</a> to equalize the force on the pubis. In another study on individuals with sacroiliac joint pain, <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a> activity remained unchanged (along with <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>) while <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal oblique</a>, <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">lumbar multifidus</a>, and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> activity decreased or fired later (174). This could be viewed as a relative increase in <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a> activity (along with <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a> and <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>) when SIJ kinematics are affected. Linking the abdominal musculature to SIJ kinematics, several studies have demonstrated that <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> abdominal <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity increases <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> on the thoracolumbar fascia (TLF) resulting in increased stiffness of the lumbar spine and <a id="force-closure" data-tip="1448" target="_blank" href="/glossary-term/force-closure" class="glossary">force closure</a> of the sacroiliac joint (188-194). Although these studies do not directly <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> the relationship between the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> abdominal muscles and the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductors</a>, it may be evidence of the importance of the fascia&apos;s role in transmitting the force of multiple muscles to stabilize joints, and an intricate relationship between the SIJ, pelvis, and abdominal muscles. Relative to the &quot;abdominal fascia&quot;, any increase (or decrease) in abdominal <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity will also result in a change in <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> of the abdominal fascia, transverse inscriptions, and linea alba, and any force imparted by one <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> will be transmitted between layers of the abdominal fascial network (372, 373). The strongest continuity between the abominal fascia and <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductors</a> may exist between the <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> and <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor longus</a> tendons (see image below).
Note: The relationship of the <a href="https://brookbushinstitute.com/article/serratus-anterior" target="_blank" rel="noopener">serratus anterior</a> and <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a> muscles will be considered in the predictive <a href="https://brookbushinstitute.com/glossary/model/" target="_blank" rel="noopener">model</a> of <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper Body Dysfunction (UBD)</a>, as these muscles have no other relationship to the LPHC.
As mentioned above, over-activity of the <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductors</a> has been correlated with <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">knees bow in</a> (62-63, 66), and it may be presumed based on function (and research on dysfunction and over-activity of the <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a> and <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a>) that an over-active <a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">AOS</a> may contribute to an <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-8-excessive-forward-lean" target="_blank" rel="noopener">excessive forward lean</a>. Based on this, our <a href="https://brookbushinstitute.com/glossary/hypothesis/" target="_blank" rel="noopener">hypothesis</a> is that this system is more <a href="https://brookbushinstitute.com/glossary/prone/" target="_blank" rel="noopener">prone</a> to over-activity. The Brookbush Institute addresses this issue with &#x201C;release and avoid.&#x201D; That is, the <a href="https://brookbushinstitute.com/glossary/muscle-cell/" target="_blank" rel="noopener">muscle</a> and fascial structures that can be <a id="release" data-tip="1253" target="_blank" href="/glossary-term/release" class="glossary">released</a> are addressed, and exercises that place emphasis on the <a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">AOS</a> are avoided until movement quality improves (for example, avoid <a href="https://brookbushinstitute.com/article/plank-progression" target="_blank" rel="noopener">planks</a>, <a href="https://brookbushinstitute.com/article/crunch-progression" target="_blank" rel="noopener">crunches</a>, leg raises, etc.). However, in an <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">anterior pelvic tilt</a>, the <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external obliques</a> and <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> are long, which creates a puzzling combination of both short and long muscles in the <a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">AOS</a> and over-activity throughout. In this case, the Brookbush Institute has found <a href="https://brookbushinstitute.com/article/axe-chop-progression" target="_blank" rel="noopener">chop patterns</a> (integrating <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">anterior abdominal muscles</a> and <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">glute complex</a> activity), and <a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">AOS</a> <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> followed immediately by <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a> <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> was very helpful. Generally, the result of this <a id="exercise-progression" data-tip="1184" target="_blank" href="/glossary-term/exercise-progression" class="glossary">progression</a> is from an <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">anterior pelvic tilt</a> to an <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-8-excessive-forward-lean" target="_blank" rel="noopener">excessive forward lean</a>, followed by improvement of the <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-8-excessive-forward-lean" target="_blank" rel="noopener">excessive forward lean</a> with <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a> <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a>.
<img alt="Muscles that attach to the pubis including Fascial Attachment between Rectus Abdominis and Adductor Tendons" title="Muscles that attach to the pubis including Fascial Attachment between Rectus Abdominis and Adductor Tendons" src="https://www.datocms-assets.com/25800/1649099601-aos.jpg">
Fascial Attachment between Rectus Abdominis and Adductor Tendons

<h4>Over-active <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">Deep Longitudinal Subsystem (DLS)</a></h4>
<ul>
 <li><a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">Erector Spinae</a></li>
 <li><a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> Layer of the thoracolumbar fascia (deep laminae)</li>
 <li>Sacrotuberous Ligament</li>
 <li><a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">Biceps Femoris</a></li>
 <li>Head of Fibula</li>
 <li><a href="https://brookbushinstitute.com/article/fibularis-muscles" target="_blank" rel="noopener">Fibularis Longus</a> (aka Peroneals)
 <ul>
 <li>Potentially
 <ul>
 <li><a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">Multifidus</a></li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">Gluteus maximus</a></li>
 <li><a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">Piriformis</a></li>
 <li><a href="https://brookbushinstitute.com/article/deep-rotators-of-the-hip" target="_blank" rel="noopener">Obturator internus</a></li>
 <li><a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">Biceps femoris</a></li>
 </ul>
 </li>
 </ul>
 </li>
</ul>
It is likely easiest to consider the function of the <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">DLS</a> relative to gait. <a id="optimal" data-tip="1573" target="_blank" href="/glossary-term/optimal" class="glossary">Optimally</a>, the <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">DLS</a> would eccentrically decelerate hip flexion, knee extension, and supination during late-phase swing, stabilize the sacroiliac joint (SIJ) and arch of the foot during heel strike, and aid in propulsion during early stance and push-off phases. Further, this myofascial synergy may act as a proprioceptive mechanism to relay information about <a id="ground-reaction-force" data-tip="1397" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">ground reaction forces</a> upon heel strike, ensure adequate but not excessive pronation, and as a product of the proprioceptive information relayed to the CNS &#x2013; resulting in <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> recruitment of <a id="prime-mover" data-tip="1663" target="_blank" href="/glossary-term/prime-mover" class="glossary">prime movers</a> during mid-stance and push-off.
The synergistic relationship or at least a similar recruitment pattern noted between the <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> and <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> has been well documented during the push-off phase of gait. It may be important to note that this synergy also plays a role in other extension-type exercises, for example, a <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">quadruped with opposite arm/leg raise</a> and reverse-hypers (350, 391). Pertinent to LPHCD, several studies show a trend toward earlier onset and increased activity of <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> and <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> in those with low back pain (392-393). As mentioned earlier, the increased activity of <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> and <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> is often paired with a reduction in <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> activity (<a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a> activity) (173-175). Leinonen et al, demonstrated this relationship precisely, showing earlier and increased activity of the <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> and <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> and a reduction in <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> activity during gait in those with low back pain (392). If the synergy does arise from fascial <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a>, it is likely through the complex network of fascia and ligaments of the lumbosacral region. Specifically, Vleeming et al. showed that the <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> and <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> contribute to <a id="force-closure" data-tip="1448" target="_blank" href="/glossary-term/force-closure" class="glossary">force closure</a> of the SIJ via the thoracolumbar fascia and sacrotuberous ligaments (190), and van Wingerden et al. demonstrated that &#x201C;Tension in the long <a href="https://brookbushinstitute.com/glossary/dorsal/" target="_blank" rel="noopener">dorsal</a> sacroiliac ligament increased during loading of the <a id="ipsilateral" data-tip="1550" target="_blank" href="/glossary-term/ipsilateral" class="glossary">ipsilateral</a> sacrotuberous ligament and <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae </a><a href="https://brookbushinstitute.com/glossary/muscle-cell/" target="_blank" rel="noopener">muscle</a> (191).&#x201D;
As mentioned earlier, several studies by Vleeming et al. have shown that contraction of the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> can increase <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> of the sacrotuberous ligament, contribute to <a href="https://brookbushinstitute.com/glossary/force-closure/" target="_blank" rel="noopener">force closure</a> of the SIJ, and this increased <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> may resist <a id="nutation" data-tip="1213" target="_blank" href="/glossary-term/nutation" class="glossary">nutation</a> (181, 191, 375, 377). One of the primary functions of this myofascial synergy may be to stabilize the SIJ during heel strike to ensure a stable &#x201C;platform&#x201D; from which the <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> may generate force. It is our <a href="https://brookbushinstitute.com/glossary/hypothesis/" target="_blank" rel="noopener">hypothesis</a> that over-activity of the <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">DLS</a> (<a href="https://brookbushinstitute.com/glossary/synergistic-dominance/" target="_blank" rel="noopener">synergistic dominance</a> for an inhibited <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a>) may explain the relationship between <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a>, SIJ stiffness, LPHCD, and <a href="https://brookbushinstitute.com/article/sacroiliac-joint-motion-and-predictive-model-of-dysfunction" target="_blank" rel="noopener">Lumbosacral Dysfunction (LSD)</a>, noted clinically.
Note: The <a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">piriformis</a>, <a href="https://brookbushinstitute.com/article/semitendinosus-and-semimembranosus" target="_blank" rel="noopener">semitendinosus, semimembranosus</a>, <a href="https://brookbushinstitute.com/article/deep-rotators-of-the-hip" target="_blank" rel="noopener">obturator internus</a>, and <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> may also be implicated in this synergy due to their attachments and ability to increase <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> in the sacrotuberous ligament (378).
The last connection to be made in this synergy is between the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> and the <a href="https://brookbushinstitute.com/article/fibularis-muscles" target="_blank" rel="noopener">fibularis</a> muscles. The most obvious connections are anatomical connections, as both the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> and the <a href="https://brookbushinstitute.com/article/fibularis-muscles" target="_blank" rel="noopener">fibularis</a> muscles insert on the fibular head. Further, the iliotibial band (ITB) invests in the fibular head, invest in the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> via the <a href="https://brookbushinstitute.com/glossary/lateral/" target="_blank" rel="noopener">lateral</a> intermuscular septum, and continues into and over the <a href="https://brookbushinstitute.com/article/fibularis-muscles" target="_blank" rel="noopener">fibularis</a> muscles with a more expansive attachment into the <a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">anterior</a> tibiofibular ligament (often continuous with the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> tendon) and crural fascia (379, 380, 394). Note, consideration of the iliotibial band may implicate a relationship between the DLS and a myofascial synergy noted earlier that includes the ITB, <a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, and <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a>. Although no further research examining <a href="https://brookbushinstitute.com/glossary/muscle-cell/" target="_blank" rel="noopener">muscle</a> activity between the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> and the <a href="https://brookbushinstitute.com/article/fibularis-muscles" target="_blank" rel="noopener">fibularis</a> muscles could be located, an <a href="https://brookbushinstitute.com/glossary/arthrokinematics/" target="_blank" rel="noopener">arthrokinematic</a> relationship may also exist. Over-activity of the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> (along with muscles investing in the ITB) would result in an excessive <a href="https://brookbushinstitute.com/glossary/posterior/" target="_blank" rel="noopener">posterior </a><a href="https://brookbushinstitute.com/glossary/glide/" target="_blank" rel="noopener">glide</a> of the <a href="https://brookbushinstitute.com/glossary/proximal/" target="_blank" rel="noopener">proximal </a><a href="https://brookbushinstitute.com/article/ankle-joint-talocrural-subtalor-tibiofibular-joints" target="_blank" rel="noopener">tibiofibular joint</a>. The tendons of the <a href="https://brookbushinstitute.com/article/fibularis-muscles" target="_blank" rel="noopener">fibularis</a> muscles pass behind the <a href="https://brookbushinstitute.com/glossary/lateral/" target="_blank" rel="noopener">lateral</a> malleolus in a groove and may be able to <a href="https://brookbushinstitute.com/glossary/glide/" target="_blank" rel="noopener">glide</a> the <a href="https://brookbushinstitute.com/glossary/distal/" target="_blank" rel="noopener">distal </a><a href="https://brookbushinstitute.com/article/ankle-joint-talocrural-subtalor-tibiofibular-joints" target="_blank" rel="noopener">tibiofibular joint </a><a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">anteriorly</a>. It has been hypothesized that the <a href="https://brookbushinstitute.com/article/ankle-joint-talocrural-subtalor-tibiofibular-joints" target="_blank" rel="noopener">tibiofibular joints</a> (<a href="https://brookbushinstitute.com/glossary/distal/" target="_blank" rel="noopener">distal</a> and <a href="https://brookbushinstitute.com/glossary/proximal/" target="_blank" rel="noopener">proximal</a>) move in opposition to one another due to the fiber arrangement of the interosseous membrane. That is, the <a href="https://brookbushinstitute.com/glossary/posterior/" target="_blank" rel="noopener">posterior </a><a href="https://brookbushinstitute.com/glossary/glide/" target="_blank" rel="noopener">glide</a> of one will result in an <a href="https://brookbushinstitute.com/glossary/anterior/" target="_blank" rel="noopener">anterior </a><a href="https://brookbushinstitute.com/glossary/glide/" target="_blank" rel="noopener">glide</a> of the other. As both the <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> and the <a href="https://brookbushinstitute.com/article/fibularis-muscles" target="_blank" rel="noopener">fibularis</a> muscles are <a href="https://brookbushinstitute.com/glossary/prone/" target="_blank" rel="noopener">prone</a> to over-activity, the motion of the <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> and <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> <a href="https://brookbushinstitute.com/article/ankle-joint-talocrural-subtalor-tibiofibular-joints" target="_blank" rel="noopener">tibiofibular joints</a> may add a biomechanical link to this synergistic relationship.
Based on this research, the function of the <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">DLS</a>, and the impairments noted in the LPHCD <a href="https://brookbushinstitute.com/glossary/model/" target="_blank" rel="noopener">model</a>, it is our <a href="https://brookbushinstitute.com/glossary/hypothesis/" target="_blank" rel="noopener">hypothesis</a> that this synergy is <a href="https://brookbushinstitute.com/glossary/prone/" target="_blank" rel="noopener">prone</a> to over-activity. The Brookbush Institute addresses this issue with &#x201C;release and avoid.&#x201D; That is, the <a href="https://brookbushinstitute.com/glossary/muscle-cell/" target="_blank" rel="noopener">muscle</a> and fascial structures that can be <a id="release" data-tip="1253" target="_blank" href="/glossary-term/release" class="glossary">released</a> are addressed, and exercise that places emphasis on the <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">DLS</a> are avoided until movement quality improves, for example, leg curls, back extensions, etc...
<a href="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2012/02/Screen-Shot-2016-10-18-at-7.10.39-PM.png" target="_blank" rel="noopener"><img src="https://brookbush.s3.us-east-2.amazonaws.com/wordpress/wp-content/uploads/2012/02/Screen-Shot-2016-10-18-at-7.10.39-PM.png" alt></a> Deep Longitudinal Subsystem

<ul>
 <li>Research <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to myofascial synergy adds to our understanding of how groups of muscles (synergies) may be recruited, and how the force they generate may be summated to aid in the stabilization of a joint and/or multi-joint motion.</li>
 <li>The categorization implied in the <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> muscular and fascial <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> above can be applied to myofascial synergies.</li>
 <li>The <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a> has a propensity toward under-activity.</li>
 <li>The addition of an <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">ISS</a> unites motor control and myofascial synergy research, for a more comprehensive <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> of core behavior. Note: the <a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">ISS</a> is typically under-active in those exhibiting dysfunction.</li>
 <li>The <a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">AOS</a>, although important for stabilizing the pelvic girdle, has a propensity toward over-activity. In instances of an assessed <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">anterior pelvic tilt</a>, some activation may be necessary initially.</li>
 <li>The <a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">DLS</a> has a propensity to become over-active and <a href="https://brookbushinstitute.com/glossary/synergistic-dominance/" target="_blank" rel="noopener">synergistically dominant</a> for an inhibited/under-active <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a>.</li>
</ul>
Note: The use of an AOS <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> exercise with an individual who has an APT will usually correct lumbopelvic hip alignment, but in some cases results in an excessive forward lean. In this case, it is appropriate to follow an AOS <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> exercise with a <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">Posterior Oblique Subsystem (POS)</a> <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> exercise.
Summary of the <a href="https://brookbushinstitute.com/articles?category=core-subsystems" target="_blank" rel="noopener">Subsystem</a> involvement in LPHCD:
<table>
 <tbody>
 <tr>
 <td>Dysfunction</td>
 <td>Inhibit/Avoid</td>
 <td>Activate</td>
 <td>Integrate</td>
 </tr>
 <tr>
 <td>LPHCD</td>
 <td><a href="https://brookbushinstitute.com/article/deep-longitudinal-subsystem" target="_blank" rel="noopener">DLS</a></td>
 <td><a href="https://brookbushinstitute.com/article/intrinsic-stabilization-subsystem" target="_blank" rel="noopener">ISS</a> --&gt; <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a></td>
 <td><a href="https://brookbushinstitute.com/article/anterior-oblique-subsystem-aos" target="_blank" rel="noopener">AOS</a> &#x2013;&gt; <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">POS</a></td>
 </tr>
 </tbody>
</table>

As mentioned earlier, if various approaches are effective for different reasons (as implied by their varied intents), then an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach may have the potential to improve outcomes by addition of these benefits. Based on this premise, a weakness of the previous analyses (Traditional, <a id="osteokinematic-motion" data-tip="1881" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">Osteokinematic</a>, Muscular, Fascial and Myofascial Synergies) is a failure to consider the effectiveness of well-established joint-based approaches. For example, osteopathic medicine, chiropractic, Cyriax/Maitland, Mulligan, Paris, etc... Although measuring small amounts of <a id="arthrokinematics" data-tip="1701" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic motion</a> poses a considerable challenge for researchers, the body of research is growing. Further, several studies have noted a change in muscular activity as a result of joint mobilizations (401, 413, 414), implying some interdependence between the muscular and articular systems. In this &#x201C;level of analysis,&#x201D; an attempt is made to aggregate all <a href="https://brookbushinstitute.com/glossary/relevance/" target="_blank" rel="noopener">relevant</a> research on altered <a id="arthrokinematics" data-tip="1859" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematics</a> associated with impairments of the lower extremity (LED).

<h4><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a>: Inadequate anterior glide of the tibia on the femur (the lateral compartment may be more restricted)</h4>
<ul>
 <li>It is hypothesized that <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> dysfunction of the tibiofemoral joint results from inadequate <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> of the tibia on the femur during terminal extension. This <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> is congruent with the over-activity of the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">biceps femoris</a> noted in the &quot;Evidence-based Muscular Analysis&quot;. Further, it may be hypothesized that the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> compartment may be more restricted as evidenced by the over-activity of all external rotators of the tibia (<a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">TFL</a>, <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus lateralis</a>, <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">biceps femoris</a> via the ITB) and the common occurrence of <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">functional valgus (knees Bow In)</a> (femoral internal rotation, tibial external rotation) noted in the &quot;evidence-based <a id="osteokinematic-motion" data-tip="1881" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic</a> <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>.&quot; Unfortunately, direct evidence of these altered <a id="arthrokinematics" data-tip="1859" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematics</a> is not available. One study showed that rotation played a larger <a id="roll" data-tip="1602" target="_blank" href="/glossary-term/roll" class="glossary">roll</a> than <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> in terminal knee extension during weight-bearing activities (395), which may partially explain the clinical observation of passive accessory stiffness of the knee being less common than stiffness in other joints of the lower extremity (<a href="https://brookbushinstitute.com/article/ankle-joint-talocrural-subtalor-tibiofibular-joints" target="_blank" rel="noopener">ankle</a>, <a href="https://brookbushinstitute.com/article/ankle-joint-talocrural-subtalor-tibiofibular-joints" target="_blank" rel="noopener">tibiofibular joints</a>, <a href="https://brookbushinstitute.com/article/hip-joint" target="_blank" rel="noopener">hip</a>). That is, <a id="osteokinematic-motion" data-tip="1518" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic motion</a> plays a larger role than <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> restriction. An exception to this observation would be the stiffness noted post knee surgery. Indirect evidence of the direction of <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> dysfunction exists, as the majority of studies on knee joint mobilization use either <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> to <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> tibia on femur mobilizations, or <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> femur on tibia mobilizations. Knee mobilizations have proven very effective for reducing pain (396, 398-399, 404-405), increasing range of motion (ROM) in those exhibiting limitation, improving function (although not in all cases, additional strengthening may be necessary) (396, 400, 403), quality of motion (397), and may result in an immediate increase in <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> strength and activity (401).</li>
</ul>
<h4><a href="https://brookbushinstitute.com/article/knee" target="_blank" rel="noopener">Knee</a>: Excessive lateral glide of the patella on the femur is the result of forces related to <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">Knees Bow In</a></h4>
<ul>
 <li>Although excessive <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> of the patella is an often-cited dysfunction, in recent years it has been widely accepted that this is due to forces related to a <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">functional valgus (knees bow in)</a>. These forces may include altered <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> angle (Q-angle), tibial external rotation, femoral internal rotation, increased <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> on the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> retinaculum via the iliotibial band (ITB), and potentially a decrease in <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">VMO</a> activity. A way to visualize the relationship is to imagine <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-6-knees-bow-in-breakdown" target="_blank" rel="noopener">knees bow in</a> underneath a patella that stays in place, ending up on the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> side of the femoral condyles. A wonderful review of this relationship can be found in a paper published in <a href="https://www.jospt.org/doi/pdf/10.2519/jospt.2003.33.11.639?code=jospt-site" target="_blank" rel="noopener">2003 by Christopher M. Powers, Ph.D.</a> (406). Not surprisingly, no recent studies could be located that investigated the use of patellofemoral mobilizations alone, although some evidence exists that patellofemoral mobilizations may be effective when used in conjunction with other therapeutic modalities (403, 404). It is the stance of the Brookbush Institute that correcting <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction (LED)</a> or LPHCD is a better treatment option for patellofemoral pain and that mobilization of the patellofemoral joint is rarely necessary or effective, and should only be considered an adjunct therapeutic modality.</li>
</ul>
<h4>Knee Mobilization:</h4>
<iframe src="https://player.vimeo.com/video/228854751" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

<h4><a href="https://brookbushinstitute.com/article/hip-joint" target="_blank" rel="noopener">Hip</a>: Inadequate posterior and inferior glide of the femur in the acetabulum</h4>
<ul>
 <li>There is a surprisingly scarce amount of research on hip <a id="arthrokinematics" data-tip="1859" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematics</a> and the effects of hip mobilization. Research has called for a better understanding of <a id="arthrokinematics" data-tip="1859" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematics</a> and femur-labrum contact, asserting that bone-on-bone <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> are insufficient (405). Another study on osteoarthritic patients demonstrated that pain during the FABER and FADIR tests could be explained by fibrotic shortening of the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> capsule, resulting in an increase in capsule stretching, stretching of the investing sensory nerves, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> spasm, and a reduction in <a id="arthrokinematics" data-tip="1701" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic motion</a> increasing <a id="compression" data-tip="1596" target="_blank" href="/glossary-term/compression" class="glossary">compressive forces</a> (407). Although this is a great study, it can only lead to more <a id="hypothesis" data-tip="1447" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypotheses</a> to be tested. Research has demonstrated that the femur may <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> in the acetabulum (405, 406, 408). <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a>, <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a>, and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> mobilizations of the hip have shown promising results for improving range of motion, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength, and reducing pain (408 - 410). <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">Superior</a> to <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> Grade IV mobilizations increased range of motion and <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> strength, and Grade IV <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> to <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> mobilizations increased <a href="https://brookbushinstitute.com/article/gluteus-maximus" target="_blank" rel="noopener">gluteus maximus</a> strength (409, 410). In the study by Loubert et al, it was shown that end range <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> mobilizations were necessary to improve hip flexion ROM and that mobilizations performed in a more neutral hip position resulted in little if any change (408). Examining the methods used in the 3 studies on mobilizations cited in this section, all mobilizations were performed in or near end range (408 - 410). Based on the current research the Brookbush Institute (BI) recommends end range, Grade III and IV hip mobilizations, done prior to <a id="activation-technique" data-tip="1531" target="_blank" href="/glossary-term/activation-technique" class="glossary">activation techniques</a>. Further, BI hypothesizes that the femur has a propensity to excessively <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> and <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">Superior</a> in the capsule. This is based on the increase in activity noted in <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> hip muscles (<a href="https://brookbushinstitute.com/article/piriformis" target="_blank" rel="noopener">piriformis</a>, <a href="https://brookbushinstitute.com/article/deep-rotators-of-the-hip" target="_blank" rel="noopener">deep rotators</a>) and femoral internal rotators (<a href="https://brookbushinstitute.com/article/tensor-fascia-latae-tfl" target="_blank" rel="noopener">tensor fasciae latae (TFL)</a>, <a href="https://brookbushinstitute.com/article/gluteus-minimus" target="_blank" rel="noopener">gluteus minimus</a>) and a hypothesized fibrotic shortening of the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> capsules. The direction of mobilization most often performed by the Brookbush Institute is <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> <a id="distraction" data-tip="1591" target="_blank" href="/glossary-term/distraction" class="glossary">distractions</a> at end-range hip flexion and internal rotation.</li>
</ul>
<h4>Hip Mobilization</h4>
<iframe src="https://player.vimeo.com/video/228843901" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

<h4>Lumbar Spine: Combination of Hypermobile and Hypomobile Segments</h4>
<ul>
 <li><a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">Arthrokinematic</a> dysfunction in the lumbar spine cannot be described by direction (i.e. <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a>, closed, extended, etc...) with currently published research; however, there is some evidence to describe patterns of stiffness and altered translation (timing) of vertebrae during flexion and extension. These patterns are complicated by the alterations being noted while in motion, primarily in mid-range, rendering studies using end-range radiographs less <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a>, and studies using lumbar range of motion as an outcome measure less significant (415 - 431). A study by Teyhen et al. may provide the best data relative to motion of the lumbar spine in those exhibiting dysfunction (432). Using digital fluoroscopy, the study attempted to identify a sub-group of individuals suffering from low back pain (LBP) who would benefit from a <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> exercise program (<a id="hypermobility" data-tip="1680" target="_blank" href="/glossary-term/hypermobility" class="glossary">hyper-mobile</a> participants). The findings suggest a mixture of excessive motion at L3 and L5/S1 segments and lag from L4, L5 segments during the first 15&#xB0; of flexion and during 65&#xB0; - 75&#xB0; of extension, with little difference in imaging, noted between groups at end range (Note: the study was limited to L3 - S1 segments). (432). The motion described here supports a <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> about the &quot;neutral zone&quot; and altered motion originally published by Panjabi in 1992 (neutral zone = the zone in which <a id="connective-tissue-cell" data-tip="1368" target="_blank" href="/glossary-term/connective-tissue-cell" class="glossary">connective tissue</a> does not provide <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a>)(433, 434), and adds detail to studies describing step wise motion of vertebral segments with inter-segmental lag in those exhibiting dysfunction (420, 421, 435). The contribution of lag to dysfunction may also explain why some studies show a stronger correlation between LBP and a reduction in movement velocity than LBP and a loss of ROM (57).</li>
 <li>The relationship between lag and stiffness is not clear due to the effects of muscular activity, but a relationship likely exists. In two studies, PA mobilization reduced bending stiffness (436-437); in one of these studies, it was demonstrated that stiffness returned to near the levels of asymptomatic individuals with a significant decrease in pain (437). Although direct reference is not mentioned in the body of research, PA mobilizations with the intent of reducing stiffness seem to correspond well with PA mobilizations decreasing inter-segmental lag and <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a> (420, 421, 432 - 435). Further, PA mobilizations have been shown to be effective for reducing pain, increasing range of motion, and increasing function in those with LBP (438 - 446). Note, studies have shown mobilizations do not decrease stiffness, alter lumbar intervertebral motion or increase ROM in asymptomatic individuals (447 - 449). Further, some of the reduction in stiffness post PA mobilization may be a result of increased water diffusion in the intervertebral disk (456-457).</li>
 <li>PA mobilizations result in extension of lumbar segments (except L5/S1 which flexes) (450 - 454). It may be important to note the subtle variations in the direction of force applied during a PA (i.e. more <a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a> or <a id="caudal" data-tip="1557" target="_blank" href="/glossary-term/caudal" class="glossary">caudal</a>) may affect the stiffness noted by the therapist; however, this may be more important in research settings (452-452). It should also be noted that force applied to one segment affects adjacent segments (450-451).</li>
 <li>Studies have also demonstrated that <a id="hypermobility" data-tip="1677" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobility</a> may be more associated with LBP symptoms (455. 458). Rather than consider this evidence in contradiction to research on PA mobilizations and stiffness, the research on aberrant motion in mid-range may indicate both <a id="hypomobility" data-tip="1675" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypo-mobile</a> segments resulting in lag, and <a id="hypermobility" data-tip="1680" target="_blank" href="/glossary-term/hypermobility" class="glossary">hyper-mobile</a> segments that move early and excessively, exist in the same individual. It may also be possible that those segments that lag are <a id="hypermobility" data-tip="1680" target="_blank" href="/glossary-term/hypermobility" class="glossary">hyper-mobile</a>, but restrained by altered <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity. Several studies have noted altered <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity immediately following lumbar mobilizations (459 - 468). Note: returning to the &quot;Evidence-based Myofascial Model&quot; will highlight the relationships between altered <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and low back pain.</li>
 <li>There are those who have proposed that the impact mobilizations/manipulations have on a patient&apos;s perceived pain and function are purely neural, and several studies have noted significant neural phenomena including increased cutaneous pain tolerance (469), altered motorneuron <a id="excitability" data-tip="1310" target="_blank" href="/glossary-term/excitability" class="glossary">excitability</a> (as measured by H-reflex) (470, 471), change in pain and skin conductance without objective changes in movement (motion not tested under fluoroscopy) (472, 473), and improved joint position sense (474). However, based on the effectiveness of mobilizations, the mechanical changes noted in stiffness and aberrant motion under dynamic fluoroscopy, and several studies that successfully demonstrated changes in ROM, it seems far more likely that mobilizations result in neural, mechanical, and muscular changes.</li>
 <li>In summary, dysfunction of the lumbar spine may be described as aberrant motion in mid-range. This aberrant motion may be due to a combination of segments that move early and excessively (<a id="hypermobility" data-tip="1680" target="_blank" href="/glossary-term/hypermobility" class="glossary">hyper-mobile</a>) and those that lag behind (<a id="hypomobility" data-tip="1675" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypo-mobile</a>). The research trends toward &quot;inter-segmental lag&quot;; that is, <a id="hypermobility" data-tip="1678" target="_blank" href="/glossary-term/hypermobility" class="glossary">hyper-mobility</a> of the L5/S1 and upper lumbar segments, with stiffness noted in L2 - L4 segments (420, 421, 432, 435, 478) (note: individual differences likely occur, for example, <a id="hypermobility" data-tip="1678" target="_blank" href="/glossary-term/hypermobility" class="glossary">hyper-mobility</a> at L3/L4 or stiffness as high as T12). Mobilizations may be effective for decreasing joint stiffness (<a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>), as well as reducing pain, increasing function, altering motor <a id="nerve-cell" data-tip="1360" target="_blank" href="/glossary-term/nerve-cell" class="glossary">neuron</a> <a id="excitability" data-tip="1310" target="_blank" href="/glossary-term/excitability" class="glossary">excitability</a>, and improving <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity. Further, it is recommended that mobilizations are followed by activation/stabilization exercises to address <a id="hypomobility" data-tip="1675" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypo-mobile</a> segments. The effectiveness of stabilization exercise for LBP is discussed in the &quot;Evidence-based Muscular Model&quot; above, especially in the section titled &quot;Transverse Abdominis&quot;. It is recommended by the Brookbush Institute and supported by several studies that a combination of mobilizations and <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> stabilization exercise are likely the best approach to addressing lumbar spine dysfunction (475-477).</li>
</ul>
<h4>Lumbar Spine Mobilization</h4>
<iframe src="https://player.vimeo.com/video/245396646" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

The Lumbo Pelvic Hip Complex Dysfunction (LPHCD) <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> is constructed based on research demonstrating the maladaptive alterations of tissues and motion associated with common impairments of the human movement system. If we create a list of these impairments, this adds to the definition of the LPHCD <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>, as the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> itself could be defined as the expected maladaptive changes to arise from those impairments.
<ul>
 <li>Low Back Pain (24, 26-27, 30-31, 33-35, 37, 39-58, 65, 71, 95, 97-100, 110, 116, 131-132, 134, 144, 147-160, 166-170, 172, 203-206, 208-210, 212, 214, 218-219, 221-222, 224-225, 228, 229-231, 249-250, 256, 264, 276-277, 280, 290-293, 298-302, 314-315, 339-353, 357, 360, 388, 392-393, 418, 421, 422, 437, 438, 440-441, 445-446, 455-456, 458, 460, 465-466, 475-477, 485-487, 494, 499, 500-505)
 <ul>
 <li>Disk Herniation (133, 136-143, 444)</li>
 <li>Spondylolisthesis (29, 32, 428)</li>
 <li>Instability/Hypermobility (146, 175, 426, 429-435, 462, 478)</li>
 <li>Sacroiliac Joint Pain (36, 38, 74, 174, 194, 275, 368-369, 389, 488-493, 500, 507, 515, 525-527, 529-530, 535, 544-546, 549)</li>
 <li>Sciatica (94, 96, 135)</li>
 <li>Peripartum Pelvic Pain (496-497, 511, 513-514, 532-534, 537-542)</li>
 </ul>
 </li>
 <li>Knee Pain and <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">Medial</a> Knee Displacement (59-64, 66-70, 82, 303, 305-308, 310-312, 381-385, 396-408, 518-520)</li>
 <li>Hamstring Strain (521)</li>
 <li>Hip Pathology (180, 410-411)
 <ul>
 <li>Snapping Iliopsoas Tendon (102-109)</li>
 <li>Adductor and Groin (77, 78, 211)</li>
 <li>Piriformis <a id="trigger-point" data-tip="1638" target="_blank" href="/glossary-term/trigger-point" class="glossary">Trigger-point</a> (182)</li>
 <li>Chronic Pelvic Pain (284)</li>
 </ul>
 </li>
</ul>

I hope you have enjoyed this article. I believe it is the first attempt at integrating a <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> dysfunction/movement impairment <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> with <a id="osteokinematic-motion" data-tip="1881" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic</a>, muscular, fascial, myofascial synergy, motor control, and <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> based approaches. Further, I have attempted to be as thorough in my review of <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> research as possible in pursuit of a comprehensive evidence-based <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>. If you take a moment to review the bibliography you will also notice it is sub-divided into categories for easy review on any topic addressed in this article. It is my sincere hope that readers will have suggestions for additions to the bibliography, or alternate interpretations of the research cited as we continue to pursue <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> practice. Although this article represents a giant leap from my previous analysis, there is still a tremendous amount of work to be done.

Bibliography

<html><head></head><body>(C) 2018 Brent Brookbush
Comments, questions, and critiques are welcome and encouraged.</body></html>

Copyright

A-Band - Refers to the part of the muscle cell that looks darker under a microscope.  This area of the cell is darker due to parallel arrangement of thicker filaments (myosin) and overlap with the thinner filaments (actin).
<ul>
 	<li>As a muscle contracts, the A-band is where actin and myosin interact.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Accuracy - the proportion of individuals correctly identified by the test results.
<ul>
 	<li>For example, a special test with perfect accuracy would imply a test has 100% specificity, 100% sensitivity, 100% positive predictive value and 100% negative predictive values.</li>
</ul>

Action Potential - A rapid change in voltage, resulting in a wave of excitation, that may result in stimulation of a nerve or muscle cell.
<ul>
 	<li>In order for an action potential to be initiated, the resting membrane voltage must exceed the excitation threshold, which then results in a cascade of depolarization and the "wave of excitation." Any stimulus below that threshold will not result in an action potential, and a stimulus greater than the threshold will not increase a single action potential, but may result in additional action potentials.  In this way, the action potential functions more like an on/off switch (all or none), and less like a dimmer switch.</li>
</ul>

A single-joint movement pattern (most often) designed to load a specific under-active muscle(s), while minimizing the contribution of over-active synergists via specific cues/joint motions.
<ul>
 	<li style="text-align: left;">Activation techniques/exercises are performed with the intent of addressing a muscle exhibiting a reduction in activity (tone) as a result of, or contributing to postural dysfunction.</li>
 	<li style="text-align: left;">Activation techniques/exercises cannot be multi-joint movement patterns due to relative flexibility, altered reciprocal inhibition, and synergistic dominance resulting in compensation patterns.</li>
</ul>
Example, <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/activation/gluteus-medius-activation-progression/" target="_blank">gluteus medius activation</a> involves resisted hip abduction while minimizing the contribution of the TFL via hip extension.

Active stretching is a term used to describe a stretch that involves an active contraction of opposing musculature to lengthen a muscle to its end range. Generally these stretches are held for 2-5 seconds and repeated for 8-15 repetitions.

Adenosine triphosphatase (ATPase): is the enzyme responsible for catalyzing (initiating and accelerating) the decomposition of ATP to ADP.
<ul>
 	<li>This dephosphorylation (breakdown) reaction releases energy for processes like muscular contraction.</li>
</ul>

Adenosine triphosphate (ATP): The molecule that functions as a universal energy-transfer molecule, providing most of the energy associated with muscular contraction and human movement. ATP is composed of an adenine group, a ribose group, and three molecules of inorganic phosphates.
<ul>
 	<li>Energy is provided when hydrolysis results in the cleaving of a phophate group; resulting in adenosine diphosphate, an inorganigic phosphate group, and energy.</li>
</ul>

Algometry - measuring the amount of pressure to result in sensitivity or pain, using an algometer.
<ul>
 	<li>Generally, research uses algometry to establish a minimum pain pressure threshold (PPT), in which a lower PPT implies more sensitivity and pain, and a higher PPT implies less sensitivity and pain. PPT is a common outcome measure in trigger point research.</li>
</ul>
<a href="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg"><img class="aligncenter wp-image-140177" src="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg" alt="Image of an Algometer" width="500" height="333" /></a>

All-or-none principle - a nerve or muscle cell's response to a stimulus is independent of the strength of the stimulus. If that stimulus exceeds the threshold potential (threshold of an action potential), the nerve or muscle fiber will respond completely; otherwise, there is no response.

Example, when a motor unit in the biceps brachii is stimulated it contracts the same way whether a 10 lb or 50 lb dumbbell is lifted.  It is actually the number of muscle cells and the size of the motor unit that determines force output.

&nbsp;

The transition period between eccentric load and concentric contraction during a repetition of an exercise.  This term is most often used in reference to power/plyometric exercises, in which a shorter amortization phase is believed to be beneficial.  The shorter amortization phase may better use the stored energy from the elastic deformation of connective tissue and enhance synchronization of myotatic (stretch) reflex with maximum voluntary contraction.

Example, the athlete was cued to spend as little time as possible in the bottom of their squat stance (the amortization phase) during a set of box jumps.

Muscles that oppose the prime mover and synergists for a given joint action.

That is, all the muscles that can perform the opposing joint action.

Example: The triceps and anconeus are antagonists during elbow flexion.

An anatomical direction; toward the front

Example, the face is on the anterior aspect of the head

Appendicular Skeleton - referring to the bones the bones of the arms and legs, as well as the bones that support them. This includes the pelvis, clavicle and scapula. There are approximately 126 bones in the appendicular skeleton.
<ul>
 	<li>Etymology - Appendicular, as in appendage, "that which is appended to something as a proper part," 1640s, from <a class="crossreference" href="https://www.etymonline.com/word/append?ref=etymonline_crossreference">append</a> + <a class="crossreference" href="https://www.etymonline.com/word/-age?ref=etymonline_crossreference">-age</a>. - <a href="https://www.etymonline.com/word/appendage" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Appendicular skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/axial-skeleton/" target="_blank" rel="noopener">axial skeleton</a>".

A reflexive decrease in muscle activity due to joint dyskinesis.
For example, a reduction in deep cervical flexor activity as a result of cervical spine dyskinesis.

Arthrokinematic Motion - Small amplitude motions between bone surfaces at a joint.  The arthrokinematic motions are roll, glide (slide or translation), spin, compression and distraction (traction). Arthrokinematic motions accompany osteokinematic motions to maintain joint congruence.
<ul>
 	<li>Example, arthrokinematic motion of the talus includes posterior glide on the tibia during ankle dorsiflexion.</li>
</ul>
Synonyms include: arthrokinematics, passive accessory motion, joint play and component motion

&nbsp;

Assessment - is the act of assessing, i.e. determining the importance, size, or value of -

In most cases, the results of an assessment are compared to normative data. If the individual exhibits values that are within normal parameters, it may be assumed that the aspect of health or motion assessed is not contributing to the patient's complaint, symptoms or movement impairment. If the results fall outside of normal parameters, it may indicate that the aspect of health or motion assessed is contributing to, or being affected by the patient/client's complaint, symptoms, or movement impairment. In some cases, the results of an assessment are compared to an "ideal model." In this case, deviations from the ideal are noted as potential issues. For example, deviations noted in the <a title="Introduction to the Overhead Squat Assessment" href="https://brentbrookbush.com/online-courses/articles/assessment/introduction-overhead-squat-assessment/" target="_blank">Overhead Squat Assessment</a> are compared to an "ideal model" of posture and motion.

Assessments used by human movement professionals can be divided into three broad categories:
<ul>
 	<li>"Clear" the Patient/Client for Intervention - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.
<ul>
 	<li>For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A Calf Squeeze (Thompson) Test is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.</li>
</ul>
</li>
 	<li>Highlight Contraindications - Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.
<ul>
 	<li>For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.</li>
</ul>
</li>
 	<li>Refine Exercise/Intervention Selection: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.
<ul>
 	<li>Most movement assessments fall into this category. For example, a positive <a href="https://brentbrookbush.com/vimeo_videos/elys-test-rectus-femoris-flexibility-assessment/" target="_blank">Ely's Test</a> may indicate a need to release and/or lengthen the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/rectus-femoris/" target="_blank">rectus femoris</a>.</li>
</ul>
</li>
</ul>
Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to Refine Exercise/Intervention Selection, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"

Axial Skeleton - referring to the bones of the head, neck, trunk and spinal column (does not include pelvis). There are approximately 80 bones in the axial skeleton.
<ul>
 	<li>Etymology - Axial, as in "axis", referring to "imaginary motionless straight line around which a body (such as the Earth) rotates," from Latin axis "axle, pivot, axis of the earth or sky" - <a href="https://www.etymonline.com/word/axis" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Axial skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/appendicular-skeleton/" target="_blank" rel="noopener">appendicular skeleton</a>".

Balance - The ability to maintain a body’s center of mass over its base of support. Balance can be static or dynamic.
<ul>
 	<li>For example, maintaining balance is harder on one leg because the center of mass must stay over a much smaller base of support.</li>
</ul>

A ball and socket joint (also called a spheroid joint or spheroidal joint) is a synovial joint in which the rounded or spherical end of one bone fits into a cup-like depression of another bone. The distal bone is capable of motion around an indefinite number of axes, which have one common center. Examples include the hip and shoulder (glenohumeral joint)

Base of support (BoS) - refers to the area beneath an object or person, and the area within the perimeter created by every point of contact that the object or person makes with the supporting surface. This may include the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/gluteus-maximus/" target="_blank" rel="noopener">glutes</a> of someone sitting on a chair, or the back of someone leaning against a wall.
<ul>
 	<li>For example, during a single leg balance the BoS is the area of the foot in contact with the surface; however, when a person is standing on two feet, the BoS is the area of both feet and the surface between them.</li>
</ul>

Pertaining to both sides

Example, bilateral rows are performed with both arms at the same time.

Case-control Study - a particular form of retrospective study that samples a matched group of people who have, and do not have the outcome being studied. A case-control study is a quasi-experimental design, often used in medicine to aid in determining potential contributing factors (cannot determine causality). In this study type exposure is the dependent variable and outcome is independent.
<ul>
 	<li>Example, in this retrospective case-control, medical records were investigated for trends correlated with cervical pain (1).
<ol>
 	<li>Mäkela, M., Heliövaara, M., Sievers, K., Impivaara, O., Knekt, P., &amp; Aromaa, A. (1991). Prevalence, determinants, and consequences of chronic neck pain in Finland. American journal of epidemiology, 134(11), 1356-1367.</li>
</ol>
</li>
</ul>

An anatomical direction; toward the tail, relative to humans this term is often used to refer to "in the direction of the tale (toward the feet)".

Example, to release the trapezius muscle the therapist used a force directed caudally.

Center of mass (CoM) - an object's mean position of mass; that is, a point that is perfectly surrounded by an equal amount mass in all directions.

Center of gravity (CoG) - point where gravity appears to act. Since the human body is so small compared to the earth, we can assume gravity acts uniformly on the body, and that CoG and CoM are the same.
<ul>
 	<li>Example, the CoM of the human body while lying down or standing straight up is close to our navel. However, it is possible that during a resistance exercise, the combination of the body's weight and the weight of the resistance will place the combined CoM outside the body. For example, during the mid-portion of a <a href="https://brentbrookbush.com/vimeo_videos/back-squat/" target="_blank" rel="noopener">back squat</a> the CoM would be several anterior to the naval.</li>
</ul>

An anatomical direction; toward the head (synonym: cranial)

Example, hip pain was felt with any force directed cephalad.

Cohort Study - a particular form of longitudinal study that samples a cohort (a group of people who share a defining characteristic), performing a cross-section at intervals through-out a period of time. A cohort study is a quasi-experimental design often used in medicine to aid in determining etiology or a cause-and-effect relationship. In this study type exposure is the independent variable and outcome is dependent.
<ul>
 	<li>Example, the study by Cholewicki et al. (1) investigated Yale Varsity Athletes (the cohort) with 2 and 3 year follow up (longitudinal design) and found that trunk muscle response time to off-loading was predictive of future low back injury.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/core/increased-trunk-muscle-latency-may-cause-rather-than-result-from-low-back-pain/" target="_blank" rel="noopener noreferrer">Cholewicki, J., Silfies, S., Shah, R., Greene, H., Reeves, N. Alvi, K., Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23), 2614-2620</a></li>
</ol>

Comparable Sign: A combination of pain, stiffness and/or spasm during examination that is comparable to the patients symptoms.
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

An alternative movement pattern that has been adopted to compensate for dysfunction/impairment in the human movement system.
Example: A lack of calf extensibility may limit dorsiflexion, leading to the knees bowing inward (functional valgus) and excessive forward lean of the torso during a squat.

An arthrokinematic motion - the approximation of joint surfaces; that is, a force that directs one bone surface into another resulting in a reduction in intra-articular volume. Although widely thought of as a "destructive force", it is likely best to consider compression as a naturally occurring, stabilizing force. Any arthrokinematic force in excess (spin, glide, roll, traction) may be viewed as potentially deleterious.

For example, during a squat the femoral head is compressed into the acetabulum by muscular forces, bodyweight and any additional external load.

Concave (Concavity) - Having an outline or surface curved like the interior surface of a bowl or sphere - to cave-in or curve inward.
<ul>
 	<li>Example, the internal surfaces of the pelvis is concave, holding some of the bodies viscera.</li>
</ul>

Concordant Sign - The patient's specific pain, symptom or complaint. 
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

Conductivity: Stimulation results in more than a local effect (1).
<ul>
 	<li>For example, in a muscle cell the stimulation of a motor endplate results in a change in cell membrane polarity that rapidly propagates (is conducted) along the entire length of the muscle cell, stimulating all sacromere.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

A condyloid joint (also called condylar, bicondylar, ellipsoid, or ellipsoidal) is an ovoid articular surface, or condyle, that is received into an elliptical cavity.  These joints permit movement in two planes.  Examples include the knee, metacarpophalangeal joints and metatarsophalangeal joints.

Connective Tissue Cell - One of the four basic types of animal tissue, consisting mostly fibers and ground substance.  These cells are specialized to binds organs together, holds them in place, protect them from external forces, and may fill space in the body's cavities.

Example, the body's muscles are enclosed in durable connective tissue sheets known as the "epimysium", "perimysium", and "endomysium," which and in support and transmitting force.
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Contractility: The ability to shorten (1).
<ul>
 	<li>Contractility: Muscle cells are unique in the amount they can shorten when stimulated; this is this largerly due to the highly organized and unique arrangement of myofilaments (actin and myosin).</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Pertaining to the opposite side

Example, the external oblique muscle performs contralateral rotation; rotation to the opposite side.

Convex (Convexity) - Having an outline or surface curved like the exterior of a circle or sphere - to bulge or curve outward.
<ul>
 	<li>Example, the top of your head is shaped by the convex exterior surface of your skull.</li>
</ul>

Correlational Research - Non-experimental <a href="https://www.questionpro.com/blog/what-is-research/">research</a> method in which the statistical relationship between two variables is investigated.
<ul>
 	<li>In this research by Kwon et al., a correlation was noted between a decrease in extensibility during a hamstring length test (goniometry) and current knee pain (1).</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/correlation-patellofemoral-pain-syndrome-pfps-hamstring-activity/" target="_blank" rel="noopener">Kwon O, Yun M, and Lee W. (2014). Correlation between intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. J. Phys. Ther. Sci. 26: 961-964</a></li>
</ol>

Counter-nutation - posterior rotation of sacrum relative to ilium, and/or anterior rotation of ilium relative to sacrum.
<ul>
 	<li>The pelvic floor muscles are examples of muscle that may counter-nutate the sacrum.</li>
</ul>
[caption id="attachment_126335" align="aligncenter" width="400"]<a href="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png"><img class=" wp-image-126335" src="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png" alt="Nutation and Counter-nutation of the Sacroiliac Joint" width="400" height="967" /></a> Nutation and Counter-nutation of the Sacroiliac Joint[/caption]

&nbsp;

Crossover (Study) Design - A type of longitudinal, repeated measures quasi-experimental design in which each group receives both treatments, but at different times. It is named "crossover" due to the patients "crossing-over" to the other treatment or sham group after a specified period of time.
<ul>
 	<li>This type of study has the advantage of every individual serving as their own control, which may reduce the influence of confounding variables.</li>
 	<li>Unfortunately, the design itself introduces the chances that anyone receiving the experimental variable in the first period will continue to be effected in the second period.</li>
</ul>
In a study by Senna et al., a cross-over design was used to investigate the difference load made on inter-set rest intervals (1).
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/strength-training-research-corner/heavy-vs-light-load-single-joint-exercise-performance-with-different-rest-periods/" target="_blank" rel="noopener">Senna, G.W., Rodrigues, B.M., Sandy, Scudese, Bianco, A, &amp; Dantas, E.H.M. (2017). Heavy vs light load single-joint exercise performance with different intervals. Journal of Human Kinetics, 58, 197-206. </a></li>
</ol>

Cross-sectional Study - a research design that involves gathering data from a population or representative subset at a specific point in time.
<ul>
 	<li>Example, the study by Karimi-Mobarake et al.(1) investigated the prevalence of genu varum and genu valgum among school children 7-11 years old in Iran.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/low-prevalence-of-genu-varum-and-valgum-among-elementary-school-children/" target="_blank" rel="noopener noreferrer">Karimi-Mobarake, M., Kashefipour, A., Yousfnejad, Z. The prevalence of genu varum and genu valgum in primary school children in Iran 2003-2004. (2005) Journal of Medical Science 5(1). 52-54</a></li>
</ol>

Cytokine - A broad and loose category of small proteins that act through receptors, and are especially important to immune function (inflammation).
<ul>
 	<li>Cytokines include substances such as interferon, interleukin, and growth factors, which are secreted by certain cells of the immune system and have an effect on other cells. Their definite distinction from hormones is a topic of continued research.</li>
</ul>
&nbsp;

Dependent variable - in research, this is the variable that is changed by the independent variable, most often this is the "outcome" of the study.
<ul>
 	<li>Example, in the study by Cleland et al. (1), the independent variable is "thoracic manipulation," and the dependent variable is "lower trapezius muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/short-term-effects-lower-thoracic-manipulation-lower-trapezius-muscle-strength/" target="_blank" rel="noopener noreferrer">Cleland J, Selleck B, Stowell T, Brown L, Alberini S, St. Cyr H, Caron T. Short-term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength.  Journal of Manual &amp; Manipulative Therapy. 2004; 12(2): 82-90</a></li>
</ol>

An anatomical direction; further from the trunk or center of the body

Example, the foot is at the distal end of the leg.

An arthrokinematic motion - a force applied to a body part that may result in the separation of joint surfaces, a reduction in intra-articular pressure, and/or an increase in intra-articlar space.

For example, to hang from one's hands (i.g. in preparation for a pull-up) results in a traction force on the glenohumeral joint (shoulder).

An anatomical term of location; back or upper surface

Example, shoe laces may compress tissues on the dorsal surface of the foot

The "drawing-in" maneuver is a common cue used during exercise and rehabilitation programs. A light contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abominis</a> (and potentially the entire <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/core-subsystems/intrinsic-stabilization-subsystem/" target="_blank" rel="noopener">intrinsic stabilization subsystem</a>) achieved by gently pulling the lower abdominal region away from one's waist band. This should have minimal effect on breathing, and should not be confused with a maximal contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abdominis</a> resulting in a "vacuum pose".
<ul>
 	<li>Research often refers to this maneuver as the "abdominal drawing-in maneuver"; abbreviated ADIM.</li>
</ul>
Development and introduction of this cue into practice is based on the pivotal research and resulting text:
<ol>
 	<li>Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004</li>
</ol>

Faulty or abnormal movement; an alteration of normal kinematics.

For example, joint stiffness or a reduction in arthrokinematics motion that results in limited osteokinematic range of motion - inadequate inferior glide of the femoral head resulting in limited abduction of the hip.

The seeping into, or abnormal collection of fluid in a body cavity.

For example, knee effusion describes swelling within the knee joint.

Note: the word "effusion" is used differently in medicine than it is used in reference to the movement (seeping out) of liquids and gases, for example in chemistry.

&nbsp;

A trait of body tissues that allows a tissue to return to its resting length or state after deformation or stretch.
Example:  Muscle is elastic tissue; many muscles will return to their resting length after being stretched to 150% of that length without any appreciable change in tissue quality.

Elasticity: Elasticity refers to the ability of a cell to return to its resting length after being stretched/lengthened.
<ul>
 	<li>Note: this term is often confused with extensibility. Elasticity is not the ability to stretch; it is the ability to return to normal length after being stretched. Muscle tissue, connective tissue and even nerve tissue have varying levels of elasticity.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Epithelial cell - One of the four basic cell types, found lining the body's cavities, blood vessels, organs and constitutes most gland tissue.  These cells are specialized to aid with absorption, secretion, or act as a barrier from foreign objects.
<ol>
 	<li>Saladin, K. S., &amp; Miller, L. (1998). Anatomy &amp; physiology. New York (NY): WCB/McGraw-Hill.</li>
</ol>

Equilibrium - a state in which opposing forces or influences are balanced.
<ul>
 	<li>For example, to maintain a neutral trunk while pushing or pulling a weight in one hand, your core musculature must balance the force by creating an equal amount of force in the opposite direction.</li>
</ul>

The study of causation, or origination. The word is commonly used in the medical professions, where it may refer to the study of why things occur, or the reason behind why things act a certain way.

For example, the etiology of low back pain is a complex subject, with multiple contributing factors and various structures implicated.

<div class="gs_citr" tabindex="0">Evidence-based medicine (practice) is the integration of best research evidence with clinical expertise and patient(client) values (2)."</div>
<ul>
 	<li class="gs_citr" tabindex="0">...the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (clients).  It involves the integration of at least (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve (1).</li>
</ul>
&nbsp;
<ol>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., &amp; Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. Bmj, 312(7023), 71-72.</li>
 	<li class="gs_citr" tabindex="0">Sackett D et al. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1</li>
</ol>

Excitability: The ability of a cell to change in membrane conductance as a response to stimulation.

<ul>
 	<li>For example, muscle cells are specialized to react to a change in membrane potential with contraction, where as nerve cells are specialized to propagate a change in membrane potential along there axons and communicate that message to other tissues via neurotransmitters.
</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Excitation threshold: The level that a depolarization must reach for an action potential to occur.
<ul>
 	<li>The excitation threshold is a contributing factor to the "all-or-none" response of muscle and nerves cells to a stimulus.</li>
</ul>

Exercise Progression - Modification of an exercise with the intent of promoting adaptation by increasing demand. This can be accomplished by increasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise progression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise, or series of exercises that make it harder to maintain stability with good form.
<ul>
 	<li>Sample Exercise Progression: <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a></li>
</ul>
</li>
</ul>

Exercise regression - The opposite of progression; that is, modification of an exercise with the intent of reducing demand. This can be accomplished by decreasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability. Generally, regressions are used to modify an exercise to the client's current level of ability, with the intent of improving form, motor learning and retention.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise regression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise or series of exercises that make it easier to maintain stability with good form.
<ul>
 	<li>Sample Exercise Regression: <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a></li>
</ul>
</li>
</ul>

Experimental Research - Studies in which the researchers introduce the variable to be studied, with the intent of observing the outcome. This is different than observational research which observes the effect of a variable already present. Many texts also assert that experimental research should include randomization and ideally a control group, as is seen in Randomized Control Trials. Studies in which the variable is introduced by the researchers, but participants are not randomized may be considered Quasi-experimental research.
<ul>
 	<li>In this study by Esformes, the experimental variable was squat depth and the outcome measures observed were various performance measures related to power (1).</li>
</ul>
<ol>
 	<li><a href="https://brookbushinstitute.com/article/back-squat-depth-lower-body-post-activation-potentiation/" target="_blank" rel="noopener">Esformes, J., &amp; Bampouras, T. (2013). Effect of back squat depth on lower-body postactivation potentiation. Journal of Strength and Conditioning Research, 27(11), 2997-3000.</a></li>
</ol>
&nbsp;

Extensibility: The ability of a cell to be stretched or lengthened without damage (1).
<ul>
 	<li>For example, most cells would rupture with even a modest stretch, but muscles can stretch up to 3 times their contracted length.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

False Negative - the proportion of negatives in a group that were assessed incorrectly (assessed as negative when the patient was actually positive)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

False Positive - the proportion of positives in a group that were assessed incorrectly (assessed as positive when the patient was actually negative)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

The function of fascia is to transmit force, provide support, and protect tissues. Fascia can effect motion by:
Transmitting force from one or more muscles (example: the thoracolumbar fascia)
Restricting motion in cases of adaptive shortening and/or adhesion to proximal structures (example: iliotibial band in cases of lower-leg dysfunction)
Elastic recoil after stretching can contribute to force production (example: plyometric exercise)

Note: There is evidence that fascia may house more receptors related to human movement than other tissues. In this way fascia may act as a motherboard for the nervous system

The fascial system does not contract or develop trigger points, and its capacity to adapt to stretching and or strengthening exercise is limited, especially when compared to the adaptive capacity of muscle tissue.

Fibromyalgia - A loosely defined diagnosis that is associated with a combination of widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. Consideration may also be given to the presence of psychosocial stressors and inflammatory disease in the patients history. Newer research suggests that fibromyalgia may be at least in part due to central sensitization of myofascial pain, often associated with trigger points (1 - 4).
<ol>
 	<li>Wolfe, F. (2018). Fibromyalgia Syndrome and Fibromyalgia Syndrome Criteria: Problems in Definition and Validity. Fibromyalgia Syndrome and Widespread Pain: From Construction to Relevant Recognition.</li>
 	<li>Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., ... &amp; Fam, A. G. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis &amp; Rheumatism: Official Journal of the American College of Rheumatology, 33(2), 160-172.</li>
 	<li>Alonso-Blanco, C., Fernandez-de-las-Penas, C., Morales-Cabezas, M., Zarco-Moreno, P., Ge, H. Y., &amp; Florez-García, M. (2011). Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. The Clinical journal of pain, 27(5), 405-413.</li>
 	<li>Staud, R., Nagel, S., Robinson, M. E., &amp; Price, D. D. (2009). Enhanced central pain processing of fibromyalgia patients is maintained by muscle afferent input: a randomized, double-blind, placebo-controlled study. PAIN®, 145(1-2), 96-104.</li>
</ol>
&nbsp;

Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.
Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.

An increase in joint stability via compressive forces resulting from muscular contraction and increased tension in fascial structures (1,2).
<ul>
 	<li>This term is most often used in reference to core intrinsic stabilizers, the thoracolumbar fascia and the sacroiliac joint; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Form closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

The relative contribution of joint shape and structure to the stability of a joint (1,2).
<ul>
 	<li>This term is most often used in reference to the "rough" articulating surfaces of the sacroiliac joint and the wedge shape of the sacrum; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Force closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

An arthrokinematic motion - linear motion across a joint surface parallel to the plane of the adjacent joint surface, just as your posterior moves relative to a "slide" in a park.

For example, the glide of facet joint in the spine during spinal flexion and extension, or the posterior glide of the humeral head that must accompany anterior roll to maintain congruence with glenoid fossa during shoulder horizontal adduction.

A plane joint (also called an arthrodial joint, gliding joint or plane articulation) is a synovial joint which allows only gliding movement in the plane of the articular surfaces. The opposed surfaces of the bones are flat or almost flat, with movement generally limited by tight capsules and ligaments. Plane joints are numerous, are most often small, and allow very little motion.  Examples include the carpal joints of the wrist, the tarsal joints of the ankle, and the facet joints of the spine.

"...refers to the measurement of angles, in particular the measurement of angles created at human joints by the bones of the body (1).

&nbsp;
<ol>
 	<li>Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company</li>
</ol>

Ground reaction force (GRF) - The force exerted by the ground on the body in contact with it.

For example, when a runner's foot strikes the ground with a force equal to the mass of the individual times their acceleration due to gravity, momentum and muscular exertion, the ground exerts an equal and opposite force on the runner's foot.
<ul>
 	<li>GRF is often measured in research studies using force plates as a means of quantitatively measuring the force generated by an individual.</li>
</ul>

H-Band - Refers to the central zone of a sarcomere that looks lighter under a microscope.  This area of the sarcomere is a lighter portion of the A-band where there is no overlap between the thinner filaments (actin), and the thicker filaments (myosin).
<ul>
 	<li>Example, when a muscle contracts, actin and myosin cross-bridging occurs in the region of the A-band until the H-band is reached where no overlap occurs.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

A hinge joint (also called a ginglymus) is a synovial joint in which the articular surfaces fit one another in a way that only permits motion in one plane. Examples include the elbow, the knee (unless considered a condyloid joint) and the interphalangeal joints.

Holism (holistic) (biological holism) - (from Greek holos "all, whole, entire") is the idea that systems and their properties should be viewed as wholes, not just as a collection of parts.
<ul>
 	<li>Summarized by Aristotle in his "Metaphysics": "The whole is more than the sum of its parts". However, the term "holism" was introduced into language by the South African statesman Jan Smuts as recently as 1926. (Smuts J. C. 1987 [1926]. Holism and evolution. Cape Town: N &amp; S Press.)</li>
</ul>
Example: The Brookbush Institute promotes a holistic approach to human movement science, in which the muscular, fascial, articular and neural systems are not viewed as separable and all proximal segments are considered.

Hormone: Chemical messengers produced by the endocrine system, transported via tissue fluids such as blood, to stimulate cells to "act."
<ul>
 	<li>Example: Growth hormone is secreted by the pituitary gland in the brain; stimulating growth, cell reproduction and cell regeneration in certain types of cells</li>
</ul>
The English physician E. H. Starling discovered in collaboration with the physiologist W. M. Bayliss secretin, the first hormone, in 1902. (1).
<ol>
 	<li>Henriksen, J. H., &amp; de Muckadell, O. S. (2000). Secretin, its discovery, and the introduction of the hormone concept. Scandinavian journal of clinical and laboratory investigation, 60(6), 463-472.</li>
</ol>

A range of motion achieved by the patient/client that is more than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If an individual can place their forehead on their knees they are likely hypermobile at one, if not several joints

Example 2: 110° of shoulder external rotation would be considered hyper-mobile.

Hyperplasia is an increase in organic tissue size due to an adaptive increase in the number of cells per organ.
<ul>
 	<li>Although muscle hyperplasia has been noted in some animals, human muscle tissue does not seem to have this adaptive ability.</li>
</ul>

A condition of excessive tone of the skeletal muscles; increased resistance of muscle to passive stretching.  May be related to increased neural drive, synergistic dominance, trigger points, reflexive over-activity, and/or muscle length.
Example:  Individuals who exhibit ankle eversion and abduction during an overhead squat assessment likely have hypertonic fibularis (peroneal) muscles.

Muscular hypertrophy is an increase in muscle mass/size due to increase in the volume and cross-sectional area (CSA) of individual muscle cells. The increase in cross-sectional area can be attributed to an an increase in contractile proteins and structural elements (myofibrillar hypertophy), as well as an increase in glycogen storage and elements related to metabolism (sarcoplasmic hypertophy). Hypertrophy is an adaptation of both cardiac and skeletal muscle fibers in response to progressive increases in workload.
<ul>
 	<li>Note: Hypertrophy is not hyperplasia. Hyperplasia is an increase in muscle size due to an adaptive increase in the number of muscle fibers/cells per muscle. This type of adaptation does not occur in human muscle tissue.</li>
</ul>

A range of motion achieved by a patient/client that is less than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If the end range of shoulder external rotation is reached and measured as 75° during goniometric assessment, the client/patient is exhibiting hypomobility of the glenohumeral joint (shoulder).

Hypothesis - a proposed explanation for a phenomenon; "scientific hypotheses" are generally constructed in a way that is testable or falsifiable.
<ul>
 	<li>Example: The hypothesis, "excessive knee valgus may be correlated with future knee pain and injury," has been the subject of several studies published over the last decade.</li>
</ul>

Diminished tone of skeletal muscles; diminished resistance of muscles to passive stretching.   May be related to inhibition, reciprocal inhibition, arthrokinematics inhibition and/or  increased resting length of muscle.
Example:  If your knees cave (hip adduction) during a squat or leg-press it is likely that your gluteus medius is hypotonic.

I-Band - Refers to the part of the muscle cell that looks lighter under a microscope.  This area of the cell is lighter due to parallel arrangement of thinner filaments (actin), and no overlap with the thicker filaments (myosin).
<ul>
 	<li>As a muscle contracts, the I-bands will decrease in width and move closer to one another.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Independent variable - in research, this is the variable or phenomenon being manipulated in the study.
<ul>
 	<li>Example, in the study by Ghanbari et al. (1), the independent variable is "knee joint mobilization", the dependent variable is "quadriceps muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/effect-knee-joint-mobilization-quadriceps-muscle-strength/" target="_blank" rel="noopener noreferrer">Ghanbari A. and Kamalgharibi S. (2013). Effect of knee joint mobilization on quadriceps muscle strength. International Journal of Health and Rehabilitation Sciences. 2(4): 186-191</a></li>
</ol>

An anatomical direction; toward the bottom (below)

Example, the mouth is inferior to the eyes

A reduction in neural drive, muscular activity, and or force output due to altered neuromuscular reflex.  Alterations in neuromuscular reflex may occur due to increases in muscle length (hypothesis: increased excitation threshold), altered reciprocal inhibition in response to increased antagonist tone, and or alterations in joint motion (arthrokinematics inhibition).

Making a whole of parts.

Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.

Intermuscular Coordination - Optimal timing and motor unit recruitment of agonists, antagonists, synergists, neutralizers, stabilizers and fixators.

Example: Role of Muscles during Hip Extension
<ul>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Prime Mover" href="https://brentbrookbush.com/glossary/prime-mover/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Prime Mover&lt;/div&gt;The muscle most responsible for a joint action under load -&lt;br /&gt;&lt;br /&gt;That is, the muscle that can produce the most force for a given joint action. Often this term is used synonymously with the term agonist. The prime mover as defined above, may or may not be the most active muscle for a joint action during activities of daily living.&lt;br /&gt;&lt;br /&gt;Example: the gluteus maximus is the most powerful hip extensor and therefore the prime mover; however, the hamstrings are likely the most active hip extensors during low level activities like walking or standing.">Prime Mover</a>:  <a href="https://player.vimeo.com/external/82855344.hd.mp4?s=54c3e7d98fb9d4e0af8d282c85ba9b3e">Gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Synergists" href="https://brentbrookbush.com/glossary/synergists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Synergists&lt;/div&gt;Muscles that assist the prime mover in performing a joint action.&lt;br /&gt;&lt;br /&gt;That is, all muscles that can perform a joint action that are not the prime mover, are termed synergists.&lt;br /&gt;Example: The rectus abdominis is the prime mover of spinal flexion. All other muscles that can perform spinal flexion are synergists including – external obliques, internal obliques and psoas.">Synergists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/biceps-femoris/">Biceps femoris (long head)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/semitendinosus-and-semimembranosus/">semitendinosus, semimembranosus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">posterior head of adductor magnus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Antagonist" href="https://brentbrookbush.com/glossary/antagonists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Antagonist&lt;/div&gt;Muscles that oppose the prime mover and synergists for a given joint action.&lt;br /&gt;&lt;br /&gt;That is, all the muscles that can perform the opposing joint action.&lt;br /&gt;&lt;br /&gt;Example: The triceps and anconeus are antagonists during elbow flexion.">Antagonists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/psoas/">Psoas</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/iliacus/">iliacus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/tensor-fascia-latae-tfl/">tensor fascia latae</a> (TFL),<a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-femoris/"> rectus femoris</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">anterior adductors (especially pectineus)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/sartorius/">sartorius</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Neutralizer" href="https://brentbrookbush.com/glossary/neutralizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Neutralizer&lt;/div&gt;Muscles that oppose unwanted joint motions created by the prime mover and/or synergists, and/or muscles that prevent unwanted ancillary motion.&lt;br /&gt;Example: The teres minor and infraspinatus neutralize the internal rotation force created by the pectoralis major during horizontal adduction of the shoulder.">Neutralizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-minimus/">Gluteus minimus</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-medius/">anterior fibers of gluteus medius</a> neutralize external rotation force of <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-maximus/">gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Stabilizer" href="https://brentbrookbush.com/glossary/stabilizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Stabilizer&lt;/div&gt;Muscles whose primary role is to improve arthrokinematics by maintaining optimal alignment of joint surfaces.&lt;br /&gt;&lt;br /&gt;Most often these muscles are the most intrinsic muscles of a joint, have a larger percentage of Type I muscle fibers and are rich in proprioceptors.&lt;br /&gt;Example: The muscles of the rotator cuff act as stabilizers for most shoulder motions.">Stabilizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/deep-rotators-of-the-hip/">Deep rotators of hip</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Fixator" href="https://brentbrookbush.com/glossary/fixators/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Fixator&lt;/div&gt;Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.&lt;br /&gt;Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.">Fixators</a>: <a href="https://brentbrookbush.com/articles/core-subsystems/intrinsic-stabilization-subsystem/">Intrinsic stabilization subsystem</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-abdominis/">rectus abdominis</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/internal-obliques/">internal</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/external-obliques/">external obliques</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/quadratus-lumborum/">quadratus lumborum</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/erector-spinae/">erector spinae</a></li>
</ul>
&nbsp;

Example from: <a href="https://brentbrookbush.com/articles/anatomy-articles/introduction-to-functional-anatomy/kinesiology-of-the-hip/" target="_blank" rel="noopener">Introduction to Functional Anatomy: Kinesiology of the Hip</a>

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