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Movement, Stability Lumbopelvic Pain

For Churchill Livingstone:

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

2nd

Edition

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

Andry Vleeming

PhD

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

Vert Mooney

MD

Measurement Driven Rehabilitation Systems, San Diego, CA, USA

Rob Stoeckart

PhD

Department of Neuroscience, Erasmus MC, Rotterdam, The Netherlands

Illustrations by Philip Wilson Chartwell CHURCHILL LIVINGSTONE

ELSEVIER Edinburgh

London

New York

Oxford

Philadelphia

St Louis

Sydney

Toronto

2007

CHURCHILL LIVINGSTO E ELSEVIER

CHURCHILL LtVI

GSTONE

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

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

1999

All rights reserved.

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

1988

o part of this publication may be reproduced. slored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical. photocopying. recording or otherwise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Totlenham Court Road, London W,T 4LP. Permissions may be sought directly from Elsevier's Health Sciences Rights Department in Philadelphia, USA: phone:

(+1) 215 238 7869, fax: (+1) 215238 2239,

e-mail: healthpcrmission!laelsevier.com. You may also complete your request on­ line via the Elsevier Science homepage (http://www.elsevier.com). by selecting 'Customer Support' and then 'Obtaining Permissions'. First edition

1997

Reprinted 1999 Second edition 2007

ISS

9780443101786

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is

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Printed in China

I

Contents viii

Contributors

x

Preface ...

SECTION 2 Evolution, biomechanics and kinematics 9

PART 1 Biomechanical, clinical-anatomical and

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

evolutionary aspects of lumbopelvic pain and

of the spine and pelvis

dysfunction

. . . . . . . . . 141

CO Lovejoy

10

SECTION 1 Clinical-anatomical aspects

. 159

A Huson

The muscular, ligamentous, and neural 11

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

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

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

5

. 167

MA Adams, P Dolan

FHWiliard 2 Anatomical linkages and muscle slings of the

12

Is the sacroiliac joint an evolved

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

costovertebral joint?

C DeRosa, JA Porterfeld

S Gracovetsky

3 Anatomy and biomechanics of the lumbar

. . . . . . . . . . 185

13 The evolution of myths and facts

fasciae: implications for lumbopelvic control

regarding function and dysfunction of

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

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

PJ Barker, CA Br-iggs

o Lee

4 Clinical anatomy of the anterolateral abdominal

muscles. . .

. . . . . .75

PART 2 Insights in function and dysfunction of the

OM Urqullart. PW Hodges

lumbopelvic region

5 Clinical anatomy of the lumbar

multifidus . .

6

. . . . . .85

14 Anatomical, biomechanical, and clinical

L Danneels

perspectives on sacroiliac joints: an integrative

Clinical anatomy and function of psoas major

synthesis of biodynamic mechanisms

and deep sacral gluteus maximus . . . . .95

related to ankylosing spondylitis. . . . . 205

SGibbons

AT Masi, M Benjamin, A Vleeming

7 The sacroiliac joint: sensory-motor control

15 A suspensory system for the sacrum in pelvic

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

mechanics: biotensegrity . . . . .

A Indahl, S Holm

SMLevin

8 The role of the pelvic girdle in coupling the

16 Why and how to optimize posture.

perspective on pelvic stability . . . . . . 113

. 239

RElrvin

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

. 229

17

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

vi

Contents

18 A detailed and critical biomechanical analysis

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

. 265

PART 4 Guidelines

29

RL Don1igny

19

Stability or controlled instability?

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

. 279

Working Group on European Guidelines foI

S Gracovetsky

Prevention in L ow 8ack Pain

30

PART 3 Diagnostic methods

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

SECTION 1 Visualization in relation to pelvic

31

dysfunction 20

AVleeming et al on behalf of the COST 813

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

CT and MRI of the sacroiliac joints

Working Group on Pelvic Gildle Pain

. 299

PF Dijkstra

21

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

.311

JMD O'Neill, E Jurriaans

PART 5 Effective training and treatment

SECTION 1 Psychological, social and motivational

22 Visualization of pelvic biomechanical

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

aspects 32

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

SECTION 2 The pelvic girdle

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

23

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

. 343

8Sturesson

24 What is pelvic girdle pain?

..

. 353

SECTION 2 Motor control 33

HCOstgaard

25

The pattern of intrapelvic motion and

34

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

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

. 361

. . 513

G Lorimer Moseley

8 Hungeliol-d, W Gilleard

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

27

Differential diagnosis of low back pain . . 381

35

The painful and unstable lumbar spine:

SV Paris, J Viti

a foundation and approach for

Conditions of weight bearing: asymmetrical

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

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

SMMcGili

J A Porteliield, C DeRosa

28

and treatment

36

Important aspects for efficacy of treatment

Evidence-based clinical testing of the

with specific stabilizing exercises for

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

postpartum pelvic girdle pain . . . . . . 547

M Laslett

8 Stuge, NKVollestad

Contents

37

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

38

Effective rehabilitation of lumbar and pelvic

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

An intregrated approach for the management

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

of low back and pelvic girdle pain: a case

V Moolley

report . .

.

.

.

.

.

.

.

. . . . . . . . . 593

o Lee 40 An integrated therapeutic approach to the

treatment of pelvic girdle pain .

.

.

. . 621

o Lee. AVleeming Index . . .

.

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

vii

Contributors MA Adams BSe PhD

RL DonTigny PT

Senior Research Fellow, Department of Anatomy,

Physical Therapist, Havre, Montana, USA

University of Bristol, Bristol, UK

S Gibbons BSe (Hons) PT MSe MCPA

PJ Barker BAppSe(Physio) PhD

Stability Physiotherapy, Mt. Pearl, Newfoundland,

Senior Tutor, Department of Anatomy and Cell Biology,

Canada

The University of Melbourne, Victoria, Australia

W Gilieard PhD

M Benjamin PhD

Senior Lecturer in Biomechanics, School of Exercise

Professor of Musculoskeletal Biology and Sports

& Sports Management, Southern Cross University,

Medicine Research, School of Biosciences, Cardiff

Lismore, Australia

University, Cardiff, UK

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

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

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

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

Brisbane, Australia

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

S Hoim

Bodywork & Movement Therapies

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

J Cholewieki Associate Professor, Department of Orthopaedics &

B Hungerford PhD

Rehabilitation, Yale University School of Medicine, New

Consultant Musculoskeletal Physiotherapist, Sydney

Haven, CT, USA

Spine & Pelvis Centre, Drummoyne, NSW, Australia

HJ Dananberg DPM

A Huson MD PhD

Podiatrist, private practice, Catholic Medical Centre,

Professor Emeritus, Maastricht University, The

Bedford, New Hampshire, USA; Contributing Editor,

Netherlands

Journal of the American Podiatric Medical Association

A Indahl MD PhD

L Danneels PT PhD

Consultant, Specialist in physical medicine and

Professor of Rehabilitation Sciences and Physiotherapy,

rehabilitation, Department of Physical Medicine and

Faculty of Medicine and Health Sciences, Ghent,

Rehabilitation, Hospital for Rehabilitation, Stavern,

Belgium

Norway

C DeRosa PT PhD

RE Irvin DO

Professor of Physical Therapy, Northern Arizona

Clinical Associate Professor, Dept of Osteopathic

University, Flagstaff, Arizona, USA

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

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

Oklahoma, USA

Amsterdam, The Netherlands; Former Head of

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

Department of Radiology, Jan van Breemen Institute for

Associate Professor, McMaster University, Faculty of

Skeletal Disease, Amsterdam, The Netherlands

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

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

Canada

ix Contributors B Koes PhD

JA Porterfield PT MA ATC

Professor of General Practice, Head of Research

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

Department, Department of General Practice, Erasmus

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

MC, University Medical Centre, Rotterdam, The

USA

Netherlands

T Ravin MD

M Laslett PhD NZRP Dip MT Dip MDT

Physician; President of the American Association of

Senior Clinician, Phy sioSouth @ Moorhouse Medical

Musculoskeletal Medicine, Denver, Colorado, USA

Clinic, Christchurch, New Zealand

R Stoeckart PhD

D Lee BSR FCAMT

Department of Neuroscience, Erasmus MC, Rotterdam,

Clinical and Education Consultant, Diane Lee &

The Netherlands

Associates, Canada

B Stuge PT PhD

SM Levin MD FACS

Senior Researcher, Institute of Nursing & Health

Director, Ezekiel Biomechanics Group, McLean, VA, USA

SCiences, University of Oslo, Norway

CO Lovejoy MA PhD

B Sturesson MD PhD

University Professor of Anthropology, Department of

Head of Spine Unit, Department of Orthopaedics,

Anthropology and Division of Biomedical Sciences, Kent

Angelholm Hospital, Angelholm, Sweden

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

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

AT Masi MD DR PH

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

Professor of Medicine, University of Illinois College of

University Medical Centre, Amsterdam, The Netherlands

Medicine at Peoria ( UICOMP), Illinois, USA

DM Urquhart BPhysio(Hons) PhD

SM McGill

Dept of Epidemiology & Preventive Medicine, Monash

Professor, Faculty of Applied Health Sciences, Dept of

University, Victoria, Australia

Kinesiology, University of Waterloo, Ontario, Canada

LMG Vancleef MSc

V Mooney MD

Dept Medical, Clinical and Experimental Psychology,

Clinical Professor of Orthopaedics, USSD, Private

Maastricht University, The Netherlands

Practitioner, San Diego, California, USA

J Viti

G Lorimer Moseley PhD BAppSc(Phty)(Hons)

Assistant Professor, University of St. Augustine for

Nuffield Medical Research Fellow, Centre for fMRI of

Health Sciences, St. Augustine, Florida, USA

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

JWS Vlaeyen PhD

G Muller

Maastricht University, The Netherlands

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

A Vleeming PhD

Germany

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

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

NK V"lIestad PhD

Health Sciences, Hamilton, Ontario, Canada; Staff

Professor, Head of Institute of Nursing & Health

Radiologist & Director - Musculoskeletal Imaging, St.

Sciences, University of Oslo, Norway

Joseph's Healthcare, Hamilton, Ontario, Canada

FH Willard PhD

HC Ostgaard MD PhD

Professor, College of Osteopathic Medicine, Family

Associate Professor, Chief of Dept of Orthopaedics,

Medicine, University of New England, Biddeford, Maine,

Sahlgren University Hospital, Molndal, Sweden

USA

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

Preface There are a large number of books dealing with

and several others.

the lumbar spine and pelvis, so why this book

into the following parts:

on

1.

Movement, Stability and Lumbopelvic Pain?

This

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

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

dy sfunction 2.

reasons are diverse.

In the book they are grouped

InSights in function and dysfunction of the lumbopelvic region

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

3.

Diagnostic methods

based, relevant new data on the lumbopelvic

4.

Guidelines

area. This forces us to look afresh at the adequacy

5.

Effective training and treatment

of current diagnostic and therapeutic methods.

6.

Integrating different views and opinions when

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

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

relevant material in one book. Thirdly, most books

specialties of the contributors, their backgrounds,

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

sty les, approaches and specific ideas about how

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

lumbopelvic structures function and dy sfunction.

on the vast wealth of information available. Finally,

Several chapters were written by authors with a

and probably most importantly, notwithstanding all

unique concept about the origin of pain and dys­

efforts to treat patients adequately, large numbers

function of lumbopelvic structures and about the

of patients still suffer chronically from low back

therapy requested. In a way this is hazardous since

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

certain authors were invited, not because of their

ambition to provide, together with all contributors,

evidence-based approach, but since in the opinion

an integrated book that can be of help to people

of the

involved in the diagnosis or treatment of patients

controversial ideas merit attention. Their concepts

with lumbopelvic pain.

should invite sound research that can confirm,

The contributors to this book include scientists

refute,

editors

their audacious and

or adapt

the

sometimes

ideas presented.

We are

of internationally renowned clinical groups and

convinced that the wealth of information presented

departments dealing with basic sciences. Their

by the contributors will help to create rational and

contributions

are

from

different

disciplines

embracing anthropology, orthopedic surgery, bio­ mechanical

engineering,

chiropractic

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

practice,

anatomy, osteopathy, physical therapy, podiatry,

Andry V leeming, Vert Mooney and

gynecology, rehabilitation medicine, epidemiology

Rob Stoeckart

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

2 Anatomical linkages and muscle slings of the

lumbopelvic region C DeRosa, JA Porterfield

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

4 Clinical anatomy of the anterolateral abdominal

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

..__..__ 6

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

7 The sacroiliac joint: sensory-motor control and

pain A Indahl, S Holm

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

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

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

6

Movement, Stability and Lumbopelvic Pain

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

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

Ventral

Capsular

Neural arch

ligaments

ligaments

ligaments Superior articular

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

(

Transverse

-