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Lumbopelvic Hip Complex Dysfunction (LPHCD) Audio

Predictive Model of Lumbopelvic Hip Complex Dysfunction (LPHCD): Signs of lumbopelvic hip complex dysfunction, muscle, joint, fascia, nervous system, neuromuscular recruitment, subsystem, and core muscle contribution. Exercise selection related to lower cross syndrome, anterior pelvic tilt, posterior pelvic tilt, knee bow in, knee bow out, and forward lean.

Lumbopelvic Hip Complex Dysfunction (LPHCD)

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“Lumbopelvic Hip Complex Dysfunction (LPHCd)" 

is an edit and update of previous postural dysfunction models (e.g. lower body posture, lower-crossed syndrome, sway back posture, anterior pelvic tilt, etc.). It is important to recognize that in these models the term "posture" is being used as an analogy for "ideal alignment". Similarly, when movement professionals refer to pelvic posture, low back posture, good posture, poor posture, better posture, etc. they are referring to this analogy of ideal alignment; not the rigid positioning implied by the colloquial use of the term "posture."

Postural dysfunction and movement impairment syndromes are likely the beginning of "modeling". Modeling has significant potential to aid in refining clinical decision-making, intervention selection, and program design, and improve the reliability and effect size of outcomes. Models are especially conducive for assisting in interpreting multi-variant problems, which is how all clients and patients present. The 

 recommends that all sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, etc.) consider these models as an aid in refining decision-making in practice.

 Arthro- and osteo-kinematics alignment maintained by optimal myofascial activity and length, as a result of sensation, integration, and activation by the nervous system - both statically and dynamically.

 The absence of ideal posture as a result of maladaptation by one or multiple tissues within the human movement system.

Modeling patterns of movement impairment correlated with orthopedic dysfunction, based on all available evidence, with the intent of predicting best-practice assessments and techniques, to optimize measured outcomes.

Myofascial Synergies (Altered Recruitment)

Excessive lordosis (Anterior pelvic tilt)

Hip Internal Rotation at 90 Degrees of Hip Flexion

Hip External Rotation at 90 Degrees of Hip Flexion

Knee Extension with Hip Flexion (Hamstring Length

Correlated Injuries, Pathologies, and Pain

The Lumbo Pelvic Hip Complex Dysfunction (LPHCD) model 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 model, as the model itself could be defined as the expected maladaptive changes to arise from those impairments.

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)  

Instability/Hypermobility (146, 175, 426, 429-435, 462, 478)

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)

Peripartum Pelvic Pain (496-497, 511, 513-514, 532-534, 537-542)

Knee Pain and Medial Knee Displacement (59-64, 66-70, 82, 303, 305-308, 310-312, 381-385, 396-408, 518-520)

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Course Description: Lumbopelvic Hip Complex Dysfunction (LPHCD)

For an introduction to Postural Dysfunction and Movement Impairment please refer to:

Introduction to Postural Dysfunction and Movement Impairment

"Lumbo Pelvic Hip Complex Dysfunction" (LPHCD) has been previously described as "lower crossed syndrome" or an "anterior pelvic tilt"(1, 3), is likely similar to, or includes the dysfunctions described as kyphotic lordotic-posture, swayback posture (4), and is correlated with many low back and lumbosacral dysfunctions (4, 6-9). 

 will be addressed in a separate article, as a "variation" of the LPHCD model. To our knowledge, the first organization to refer to the integrated system of joints of the lumbar spine, sacrum, pelvis, and hips as the "lumbopelvic-hip complex" was the National Academy of Sports Medicine (3), with the intent of better defining the term "core." We have chosen to use the same segment-descriptive label for this model. Again, labeling by segment allows the model to evolve with ever-increasing detail and accuracy 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, muscle activity, fascial dysfunctions, changes in sensation, perception, motor unit recruitment, limit the tissues included, or limit the movement-related hypotheses used to construct the model.

LPHCD is limited to common impairments of the lumbar spine, sacroiliac joint, 

. This definition is not intended to exclude the possibility that more distal structures may impact motion of the LPHC; it is simply a border for the purposes of analysis. These borders were influenced by:

Practice - considering a minimum number of joints that should be assessed in those with complaints related to the LPHC.

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.

Karl Sterling, BI Presenter prepping to teach Gluteus Medius Activation

Introduction

Common Osteokinematic Dysfunction

Common Muscular Dysfunction

Fascial web 

Fascial Dysfunction

Illustration of the Posterior Oblique Subsystem with Muscles Labeled

Myofasical Synergies (Subsystems)

Common Arthrokinematic Dysfunctions

Summary of Model

 of muscle 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 model constructed in this article (see table above). The difference between the current BI model and the original Janda model is the amount of detail. This can be attributed in large part to a larger body of relevant research and advancements in research methods. Additional advancements are made via integration of muscular, articular, fascial, and motor control models, 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's work.

In the table above, note the reference to altered osteokinematic motion (anterior pelvic tilt and increased lordosis) and a list of tight and weak muscles. These considerations are a huge step beyond consideration of local "musculoskeletal lesion" or "neuromuscular lesion" being the sole contributor to a patient's complaints.

There are a few issues with the model above that should be considered:

First, the model 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 osteokinematic joint actions (like flexion, extension, abduction, etc.) Unfortunately, this results in ambiguity and a challenge when comparing this model to research studies. For example, an anterior pelvic tilt may imply a relatively "hip flexed" position during static standing, but the inclusion of hip flexion as a component of an anterior pelvic tilt is not agreed upon by all human movement professionals.

Second, this model does not consider the maladaptive changes of all tissues that cross all joints included in LCS. For example, how is the 

 affected by LCS? It has been noted that Janda assumed that "tightness" was the predominant dysfunction (weakness being secondary) (1), and several studies have noted over-activity of the 

 is not explicitly mentioned. This is just one example of the many excluded muscles that cross joints of the LPHC.

Third, the LCS model does not account for all of the combinations of relative changes in muscle 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 "synergistic dominance," "prime mover inhibition," "compensation pattern," and "altered recruitment patterns."

Fourth, this model misses analysis that would infer the use of techniques intended to address arthrokinematic dysfunction (mobilizations, manipulations, muscle energy techniques) and fascial dysfunction (pin and stretch, myofascial release, IASTM, etc). That is, the original model of LCS does not consider arthrokinematic or fascial dyskinesis. If the body is an adaptable, holistic system then all tissue systems should be accounted for. Further, a comprehensive model would include all effective modalities as demonstrated by 3rd party research.

Last, despite the intent of the model to describe a pattern of common impairments related to pain, the LCS does not attempt to list or define related diagnoses and pathologies.

Summary of Issues with the "Traditional" Model:

Joints included in the model are not clearly defined.

Many of the muscles crossing joints of the LPHC are not considered.

Categorization of muscles as either "tonic" and "phasic" is not sufficient for a comprehensive muscular model of impairment.

Fascial and arthrokinematic dysfunctions are not included in the LCS model.

No attempt is made to list the diagnoses and pathologies correlated with LCS.

Anterior Pelvic Tilt during Overhead Squat Assessment - Brookbush Institute

Why Do We Need a Better Model?

Lumbo Pelvic Hip Complex Dysfunction (LPHCD) model could be defined by related osteokinematic impairments that appear in the body of research, as well as their synonyms. This includes:

 (a.k.a. functional knee valgus, medial knee displacement, hip adduction, etc.)

 (a.k.a. functional varus, lateral knee displacement, hip abduction, etc.)

 (a.k.a. anterior pelvic tilt, sway back, etc.)

Assessment of LPHCD using the Overhead Squat Assessment (OHSA)

Anterior Pelvic Tilt

Osteokinematic Dysfunction

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

Signs of Lumbo Pelvic-Hip Complex Dysfunction

To create a detailed model 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 model. In this "level of analysis," an attempt is made to aggregate all relevant research on all muscles crossing the lumbopelvic hip complex.

Length Tension Relationship

Muscle Dysfunction

TFL and Iliotibial band (connecting fascia)

TFL, Adductors, Rectus Femoris and Lats

Quadratus Lumborum and Multifidus

Rotatores, Erector Spinae, and Psoas/Illiacus

Short/Overactive Muscles

Obliques

Bicep Femoris, Rectus Abdominis and External Obliques

Long/Overactive (Overactive Synergists)

Transverse Abdominis

Internal Obliques, Diaphragm, and Intercostals

Pelvic Floor

Gluteus Maximus

Gluteus Maximus, Gluteus Medius, Semitendinosus and Semimembranosus

Summary of Research Findings

Long/Underactive

Our understanding of fascia has benefited from an exponential increase in research over the past two decades. This includes more research on its traditional functions as a passive medium that supports, protects, and encapsulates tissues (323), and its capacity to store elastic energy for explosive activity (324, 325). This also includes exciting new research that implicates fascia as a medium of communication. Levangin hypothesized that this may occur via electrical, cellular, and/or mechanical signals (326). Histological studies have shown this tissue to be densely innervated by free 

 endings, as well as by Pacinian corpuscles and Ruffini endings (323, 324). This inspires consideration of fascia as a sensory organ with a strong link to motion and neuromuscular reflex. Further, Stecco et al. has demonstrated that deep fascia is arranged in layers that may 

 over one another (325). This finding is likely more responsible for inspiring various fascia-specific interventions and is most often referred to when describing fascia’s role in “interrupting” 

 motion. Carvalhais et al. demonstrated that tension may be transmitted through fascial sheaths to investing musculature, and Vleeming et al. has demonstrated the ability of fascia to transmit the force of multiple muscles to aid in joint stabilization (191, 201, 208, 327, 337 - 346, 376).

Research also suggests the existence of myofibroblasts within fascia, which may give fascia the ability to "contract" (151, 328, 329). This ability is limited when compared to skeletal 

, however, this "contraction" was found to be significant enough to alter mechanics (in the lumbar spine) (328). It should be noted that contraction in this study was very slow and was the result of response to antihistaminic substance, mepyramine, with some tissues also responding to histaminic substance, oxytocin (similar to smooth 

). These myofibroblasts do not respond to electric current, tension, epinephrine, acetylcholine, or adenosine. Although these findings are difficult to apply to practice, they do inspire more 

 regarding the importance and function of this previously ignored tissue. For example, Staubesand & Li (329) hypothesized that these fascial smooth muscle cells enable the autonomic nervous system to regulate fascial pre-tension independent of muscle tone.

Fascia as a Passive Tissue (Traditional Functions):

Fascia as an Active Medium of Communication

 endings, Pacinian corpuscles, and Ruffini endings

May transmit tension between invested musculature

May transmit the force of multiple muscles to aid in joint stabilization

Fibroblasts may play a role in increasing tension in fascia and altering mechanics

A growing body of research has started to investigate the effect 

 has on fascial tissue, and what role fascial dysfunction may play in contributing to 

. This statement by Schleip is a great example of this trend, “tonic muscles contain more perimysium and are therefore stiffer than phasic muscles” (151). The terms, tonic and phasic refer to a categorization of muscles based on their roles in maintaining 

 (1), whereas, Schleip is discussing how this categorization relates to the fascia enveloping fascicles of muscle.

Fascia does seem to follow a predictable set of responses to excessive stress. This includes thickening, histochemical changes, decrease in tensile strength (increased risk of rupture), the addition of disordered collagen fibers, and potentially a reduction of shear (motion) between layers (192, 358-359, 367, 380-383). These consistent changes may have important implications for how fascia should be addressed. In practice, fascial techniques have been biased toward increasing mobility using manual therapy, for example, myofascial release techniques, instrument-assisted soft-tissue mobilization (IASTM), and pin-and-stretch techniques. However, research does not paint a clear picture of how these techniques address dysfunction, and findings to date suggest that a more complex and nuanced description will likely replace current hypotheses.

Hypothesized Response to Therapeutic Intervention

Thoracolumbar Fascia

Thoracolumbar Fascia Anatomy, Stability and Contribution to Motion

Thoracolumbar Fascia Sensory Innervation and Practice

Abdominal Fascia

Sacrotuberous Ligament

IT Band

Iliotibial Band

Fascial Dysfunction: Summary of Research

Introduction to the Muscular and Fascial System

 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 

 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 

Single Leg Pulldown

Posterior Oblique Subsystem

Instrinsic Stabilization Subsystem

Muscles that attach to the pubis including Fascial Attachment between Rectus Abdominis and Adductor Tendons

Anterior Oblique Subsystem

Deep Longitudinal Subsystem

Myofascial Subsystems: Summary of Research

Myofascial Synergy a.k.a Subsystems

As mentioned earlier, if various approaches are effective for different reasons (as implied by their varied intents), then an integrated approach may have the potential to improve outcomes by addition of these benefits. Based on this premise, a weakness of the previous analyses (Traditional, Osteokinematic, 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 arthrokinematic motion 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 “level of analysis,” an attempt is made to aggregate all 

 research on altered arthrokinematics associated with impairments of the lower extremity (LED).

Knee

Lumbar Spine

Sacroiliac Joint (SIJ)

Arthrokinematic Dysfunction

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

I hope you have enjoyed this article. I believe it is the first attempt at integrating a postural dysfunction/movement impairment model with osteokinematic, muscular, fascial, myofascial synergy, motor control, and arthrokinematic based approaches. Further, I have attempted to be as thorough in my review of relevant research as possible in pursuit of a comprehensive 

 model. 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 optimal practice. Although this article represents a giant leap from my previous analysis, there is still a tremendous amount of work to be done.

Thank You

Phillip Page,Clare Frank, Robert Lander, 

Assessment and Treatment of Muscle Imbalance: The Janda Approach

Diagnoses and Treatment of Movement Impairment Syndromes,

NASM Essentials of Corrective Exercise Training

Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani

Manipulative Therapy: Musuloskeletal Medicine

Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability & Lumbopelvic Pain: 

Lumbopelvic Hip Complex Dysfunction (LPHCD)

Related Courses:

Course Description: Lumbopelvic Hip Complex Dysfunction (LPHCD)

Introduction

Summary of Model
5 Sub Sections

Why Do We Need a Better Model?

Signs of Lumbo Pelvic-Hip Complex Dysfunction
2 Sub Sections

Muscle Dysfunction

Short/Overactive Muscles
3 Sub Sections

Long/Overactive (Overactive Synergists)
1 Sub Section

Long/Underactive
5 Sub Sections

Introduction to the Muscular and Fascial System
7 Sub Sections

Myofascial Synergy a.k.a Subsystems
5 Sub Sections

Arthrokinematic Dysfunction
4 Sub Sections

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

Thank You

Bibliography

Related Courses:

Comments

Guest

Lumbopelvic Hip Complex Dysfunction (LPHCD)

Related Courses:

Course Description: Lumbopelvic Hip Complex Dysfunction (LPHCD)

Introduction

Summary of Model5 Sub Sections

Why Do We Need a Better Model?

Signs of Lumbo Pelvic-Hip Complex Dysfunction2 Sub Sections

Muscle Dysfunction

Short/Overactive Muscles3 Sub Sections

Long/Overactive (Overactive Synergists)1 Sub Section

Long/Underactive5 Sub Sections

Introduction to the Muscular and Fascial System7 Sub Sections

Myofascial Synergy a.k.a Subsystems5 Sub Sections

Arthrokinematic Dysfunction4 Sub Sections

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

Thank You

Bibliography

Related Courses:

Comments

Guest

Summary of Model
5 Sub Sections

Signs of Lumbo Pelvic-Hip Complex Dysfunction
2 Sub Sections

Short/Overactive Muscles
3 Sub Sections

Long/Overactive (Overactive Synergists)
1 Sub Section

Long/Underactive
5 Sub Sections

Introduction to the Muscular and Fascial System
7 Sub Sections

Myofascial Synergy a.k.a Subsystems
5 Sub Sections

Arthrokinematic Dysfunction
4 Sub Sections