Lower crossed syndrome (LCS) is a frequent muscular dysfunction syndrome, which may cause chronic low back pain due to muscular imbalance (Janda , 1987)

In Musculoskeletal medicine, these are two main schools of thought, that is a structural or functional approach. In the structural approach, the pathology of specific static structures is emphasized: This is the typical orthopedic approach that emphasizes diagnosis based on localized evaluation and special tests [X – ray, MRI, CT Scan etc.,].on the other hand, the functional approach recognizes the function of all processes and systems within the body, rather than focusing on a single site of pathology. So the functional approach is preferable when addressing chronic low back pain

Low back pain is one of the most frequent cases of disability. In Indian, the incidence of low back pain has been reported to be 23.09 % and has a lifetime prevalence of 60 -85 %.

 A simple and practical classification of low back pain, which has gained international acceptance is to divide low back pain into three categories – the so called “diagnostic triage’ [Wadell 1987]

Nonspecific low back pain is the one that is not attributable to a recognizable, Known Pathology [e.g infection, structural deformity, Osteoporosis, Fracture, Ankylosing spondylitis, cauda equina syndrome etc.]. There is no specific problem or disease   that can be identified as the cause of the pain. It is typically associated  with pain, soreness and stiffness in the lower back region and functional disability. It typically results due to poor posture, poorly designed seating, incorrect  bending and lifting motions as required in various occupations.

With regard to muscular influences on LBP, the hip musculature plays a significant role in transferring forces from the lower extremity up toward the spine during upright activities and thus theoretically may influence the development at low back pain.

Janda identified two groups of muscles based on their phylogenetic development. Functionally muscles can be classified as tonic or Flexors, and phasic or extensors. Janda noted that tonic system muscles are prone to tightness and  Phasic  system muscles are prone to weakness.

Based on his clinical observations of orthopedic and neurological patients, Janda found that this response is based on the neurological response of nociception in the muscular system.so lower crossed syndrome is characterized  by the imbalance between, tightened hip flexors and lumbar erector spinae and weakened gluteal abdominal muscles. This pattern of imbalance creates joint dysfunction, particularly at the L4-L5 and L5 – S1 segments, SI joint and hip joint. Specific postural joints   seen in lower crossed syndrome include anterior pelvic tilt, increases lumbar lordosis, lateral lumbar shift, lateral leg rotation and knee hyper extension. If the Lordosis is deep and short, then imbalance is predominantly in the pelvic muscles: If the Lordosis is shallow and extends into the thoracic area, then imbalance predominates in the trunk muscles.

Tonic Muscles Prone to TightnessPhasic Muscles Prone to Weakness
Gastroc – soleus Tibialis Posterior Hip AdductorsHamstringsRectus femorisIliopsoasTensor Fascia lataPiriformisThoraco –Lumbar extensors Quadratus LumboramPeroneus Longus,BrevisTibialis anteriorVastus  Medialis, LateralisGluteus MaximusGluteus Medius,MinimusRectus Abdominus

Janda Approach of Treatment

Janda Firmly believed that the CNS and motor system function as one unit, the sensory motor system. He suggested treatment be organized in to three stages.

  1. Normalization of peripheral structures
    • Treatment of muscle imbalance and movement impairment begins with normalizing afferent information entering the sensorimotor system. This includes providing an optimal environment for healing (by reducing effusion and protection of healing tissues, restoring proper postural alignment (through postural and ergonomic education) and correcting the biomechanics of a peripheral joint (Through manual therapy, IASTM, MFR, Neurodynamics , Trigger point  release etc.,)
  2. Restoration of Muscle Balance
    • Once peripheral structures are normalized muscle balance is restored. Thereafter stretching of the tight muscles must first be given, before attempting to strengthen a weakened muscles.[e.g., post isometric relaxation (PIR), massage relaxation]
  3. Facilitation of afferent system and sensory motor training;
    • Once muscle balance has been addresses, Janda stresses increasing proprioceptive input into the CNS with a specific exercise program” sensory motor training”. This involves, increase proprioceptive flow in three key areas: (The role of the foot, the cervical spine, the SJ joints), and balance training.

Summary:

The Janda approach is valuable in todays managed care environment. Once these lower crossed syndrome is identified, specific treatment can be implemented without expensive equipment. Early detection of these causes of chronic pain allows the clinician to treat the patient with fewer visits and less expensive equipment compared to traditional interventions. Therefore using a functional, rather than a structural approach the cause of musculoskeletal pain can be quickly identified and addresses. The Janda approach can be a valuable tool for the clinician in the evaluation and treatment of chronic low back pain.

References:

  1. Chiu T, Law E, Chiu T. Performance of the craniocervical flexion test in subjects with and without chronic neck pain. J Orthop Sports Phys Ther 2005;35:567-71.
  2. Fernandez-de-las-Penas C, Perez-de-Heredia M, Molero-Sanchez A, Miangolarra-Page JC. Performance of the craniocervical flexion test, forward head posture, and headache clinical parameters in patients with chronic tension-type headache: a pilot study. J Orthop Sports Phys Ther 2007;37:33-9.
  3. Guanche C, Knatt T, Solomonow M, Lu Y, Baratta R.1995. The synergistic action of the capsule and the shoulder muscles. Am J Sports Med. 23(3):301-6.
  4. Harman K, Hubley-Kozey C, Butler H, Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults: A Randomized, Controlled 10-Week Trial. The Journal of Manual & Manipulative Therapy 2005; 13 (3): 163- 176.
  5. Janda, V. 1988. Muscles and Cervicogenic Pain Syndromes. In Physical Therapy of the Cervical and Thoracic Spine, ed. R. Grand. New York: Churchill Livingstone.
  6. Daniele TatianeLizier Exercises for Treatment of Nonspecific Low Back Pain Rev Bras Anestesiol 2012; 62: 6: 838-846
  7. Shah S, Mahapatra R K. Effect of Mulligan Spinal Mobilization with Leg Movement and Shacklock Neural Tissue Mobilization in Lumbar Radiculopathy: A Randomised Controlled Trial. Journal Medical Thesis 2015 May-Aug ; 3(2):27-30.
  8. Airakson, O, Brox J, Cedrasch, C ; Hildebrandt, J ; Klaber-Moffet et al. Chap 4 European guidelines for the management of chronic nonspecific Low Back Pain. European Spine Journal, 2006; 15(S2, pp. s192-s300). Peeyoosha V Nitsure et al. Comparison of Elastic Resistance Band exercises and Yoga in Physiotherapy students with chronic Non-Specific Low Back Pain: A Randomised Clinical Trial, J Yoga PhysTher (2014) Vol 5 (1), 3-7.
  9. Baechle, T., Earle, R., 2000. Essentials of Strength Training and Conditioning, second ed. Human Kinetics. Barbosa, et al., 2014.
  10. Immediate improvements in activation amplitude levels of the deep abdominal muscle following a sacroiliac joint manipulation during rapid upper limb movement. J. Bodyw. Mov. Ther. 18, 626e632.
  11. Beach, P., 2010. Muscle & Meridians. Elsevier Edinburgh.
  12. Chek, P., 1998. Scientific Core Conditioning. Correspondence Course. CHEK Institute Publication.
  13. Fryer, G., Pearce, A.J., 2013. The effect of muscle energy technique on corticospinal and spinal reflex excitability in asymptomatic participants. J. Bodyw. Mov. Ther. 17, 440e447.
  14. Haywood, K., Getchell, N., 2005. Life Span Motor Development, fourth ed. Human Kinetics, p. 165e166.
  15. Hungerford, B., Gilleard, W., Hodges, P., 2003. Evidence of altered lumbopelvic muscles recruitment in the presence of sacroiliac joint pain. Spine 28 (14), 1593e1600.
  16. Bullock-Saxton JE. 1994. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther. 74(1):17-28.
  17. Bullock-Saxton J, Janda V, Bullock M. 1993. Reflex activation of gluteal muscles in walking with balance shoes: an approach to restoration of function for chronic low back pain patients. Spine. 18(6):704-708.
  18. Freeman MA, Dean MR, Hanham IW. 1965. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br 47(4):678-85.