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Enough Already: Upper/Lower Crossed Syndromes

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  • CT Enough Already: Upper/Lower Crossed Syndromes

    Enough already with the upper/lower crossed syndromes.

    These syndromes are very useful. Well, not in clinical or performance work, since there is almost no data to support these ideas and to my knowledge there never has been.

    They are useful because they help you see how these outdated ideas get popular in the first place and how that popularity continues despite changes in the science that should make you reject them.

    I don't blame Professor Janda, he was doing his best with what he had at the time and had what he probably felt was an important clinical insight, that improved his clinical process with patients.

    Now as practice went on, we found trends in the published literature that should have made us reject these ideas:

    1. Trend of poor reliability between clinicians in making these assessments

    2. Trend of no correlation between measures of muscle "tightness" to strength, pain, or any useful construct for treatment

    3. Trend of very little published data involving the use of this process to evaluate and manage patients/clients that lead to positive outcomes

    We also found trends in the foundational science that should have made us reject these ideas:

    1. The motor control literature grew toward an emphasis on CNS control and away from stretching or strengthening individual muscles

    2. The pain literature moved away from the importance of some of these findings as primary concerns in ongoing pain states

    3. The clinical literature has moved away from "tightness/weakness" of individual muscles as being critical to treatment (cf TrAbd and Multifidus).

    But this approach has strong memetic appeal. Why?

    1. It involves muscles. In our culture strength and fitness is a value, proper posture is a value, and alteration of muscles with stretching and strengthening is also a value. Some of these things are good and are healthy (like fitness) whereas some of these are unhealthiy or unimportant (posture).

    2. It's accessible to a wide variety of 'practitioners'. Since it involves muscular assessment, everyone from physicians to personal trainers to physical therapists, chiropractors, athletic trainers, massage therapists and strength coaches could use this approach with their patients or clients.

    Both clinicians (physicians, physical therapists, chiropractors, athletic trainers) and fitness and service professionals (personal trainers, strength coaches, massage therapists). Those with rigorous academic education at doctoral or postgraduate level (physicians, physical therapists), those with college education (athletic trainers, strength coaches, some trainers) and those with trade school or certification training (personal trainers, massage therapists).

    Huge numbers of different people in different people could use this. A marketing dream.

    3. It provides a simple solution to a complex problem that leverages deeply embedded cultural ideas that are far more powerful than scientific data.

    Why these crossed syndrome type things make no sense whatsoever but are not going away any time soon.People will be talking about this brilliant insight for another 50-odd years.

    I wonder if Janda would [facepalm] if he heard how people were unable to move beyond this idea, and had more fidelity to this particular product/idea than to the process he advocated.


    Sent from my iPhone using Tapatalk
    Jason Silvernail DPT, DSc, FAAOMPT
    Board-Certified in Orthopedic Physical Therapy
    Fellowship-Trained in Orthopedic Manual Therapy

    Certified Strength and Conditioning Specialist


    The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

  • #2
    Jason,

    I'm glad you don't blame Janda. Galileo and Newton we're shown to be wrong about a number of things too - but that was before advertising, social media, the rise of the New England Patriots, the fall of the Cleveland Browns (darn) and a few other things changed our view of things (I call it scattered).

    I found your view of the muscles interesting. Newton, after all, was an alchemist and probably thought lead could be turned into gold. He didn't know that one day science would find that chemistry wasn't the last word about the way things existed. Science is accumulative. It remains so.

    My own take on the situation is this: Therapy simply has gone along with the destruction or downgrading of the scientific method. It (the scientific method) has been overwhelmed. Now it has been handed over to those who don't know about it.
    Barrett L. Dorko

    Comment


    • #3
      Originally posted by Barrett Dorko View Post
      Jason,

      It (the scientific method) has been overwhelmed. Now it has been handed over to those who don't know about it.
      True...but they bug me far less than those that know the scientific method yet find a way around it.

      Recent unnamed online interaction in the past month or so at an unnamed site... by myself as exhibit #1.

      Cash being king and all...

      Comment


      • #4
        proud,

        Money certainly drives things.
        Barrett L. Dorko

        Comment


        • #5
          Jason,
          First of all, I'm amazed at your ability to write such a voluminous post on your cell phone with- as far as I can tell- only one typo.

          Secondly, though, what about Shirley Sahrmann? Has she not merely affixed some sciencey-sounding verbiage and unimpressive observational and reliability studies to what are essentially Janda's ideas? I don't see much face-palming going on at the prestigious Washington University School of Physical Therapy where the effort to attribute pain to a faulty instantaneous axis of joint rotation continues undaunted by the trends in the foundational science that you just referenced.
          John Ware, PT
          Fellow of the American Academy of Orthopedic Manual Physical Therapists
          "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
          “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
          be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

          Comment


          • #6
            John,

            As far as I can tell, Sahrmann expanded upon what Kendall taught. They're (many places) still teaching what Kendall came up with today.

            Now that the scientific method is not being taught, who are we to look at - the therapists who read nothing beyond school and/or the ones who taught them?

            Maybe both.
            Barrett L. Dorko

            Comment


            • #7
              In defense of Darth (Bill Belichick), Cleveland rejected him.

              Comment


              • #8
                In Janda's defense, at least he acknowledged the important role of the CNS in patients with persistent, mechanical pain:
                From Janda's viewpoint, chronic musculoskeletal pain and muscle imbalance are a functional pathology mediated by the CNS (see figure 1.3). He based his approach on his observations that patients with chronic low back pain exhibit the same patterns of muscle tightness and weakness that patients with upper motor neuron lesions such as cerebral palsy exhibit, albeit to a much smaller degree. Muscle imbalance often begins after injury or pathology leads to pain and inflammation. Imbalance may also develop insidiously from alterations in proprioceptive input resulting from abnormal joint position or motion. These two conditions lead muscles to either tighten (hypertoni- city) or weaken (inhibition), creating localized muscle imbalance. This imbalance is a characteristic response of the motor system to maintain homeostasis. Over time, this imbalance becomes centralized in the CNS as a new motor pattern, thus continuing a cycle of pain and dysfunction. Janda believed that muscle imbalance is an expression of impaired regulation of the neuromuscular system that is manifested as a systemic response often involving the whole body.
                (from ASSESSMENT AND TREATMENT OF MUSCLE IMBALANCE: The Janda Approach; Page P, Frank CC, and Lardner L, 2010, p9)

                What doesn't make sense is if Janda saw these patterns in patients with LBP as a "much smaller degree" of the imbalances that occur in individuals with CP, then why don't all people with [a certain type of?] CP have chronic LBP? In fact, several studies have shown that people with CP have similar rates of NO MSK pain as the general population. In this study, 18% of the CP group had no pain complaints compared with 15% in the reference group from the general population. The same study, though, found a higher prevalence of "chronic, disabling pain" among people with CP; although, there were significant confounders. It's obviously much harder to ferret out the cause of disability in someone with CP and someone who doesn't have a congenital neurological disorder. It's possible that the disability is misattributed to pain as opposed to other factors related to having chronic neurological impairments from CP. They acknowledge this to some extent in the study.

                Janda died 15 years ago, but Sahrmann and her colleagues at Washington University are still very much alive. Yet, their inability to shift their clinical focus away from the role of muscles in persistent mechanical pain is inexcusable. One of Janda's last acts was probably the performance of a face-palm when Sahrmann's book came out the very year he died.
                John Ware, PT
                Fellow of the American Academy of Orthopedic Manual Physical Therapists
                "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                Comment


                • #9
                  John,

                  Facepalming (is that a word?) is very effective. "You're not even wrong," seems to be something in the past, but it meant much the same. You're point is well-taken. I would pay to see you ask Janda about this. It's probably a little late.

                  I met Sahrmann one time and I asked her about her work (in relation to what Rothstein said in the APTA Journal).

                  She said nothing.

                  It was a few years ago. Maybe you could ask her again?
                  Barrett L. Dorko

                  Comment


                  • #10
                    Barrett,
                    I hear she's retired, but if I could, this is what I'd ask her:
                    "In a fairly recent textbook of his method, the authors state that Vladimir Janda thought 'muscle imbalance is an expression of impaired regulation of the neuromuscular system that is manifested as a systemic response often involving the whole body'." According to this statement, Janda thought the impairments in muscle length or strength and any resulting aberrant joint motion observed in patients with musculoskeletal pain were the consequence, or output if you will, of an impairment in the neuromuscular system. How does this view of aberrant muscular activity and associated impairments in joint alignment as essentially an output reconcile with your kinesiopathologically-based approach to explain the same phenomena?

                    After she looks at me quizzically for several seconds, I would give this shortened version:
                    "Janda thought muscle imbalances in patients with musculoskeletal pain represent a defense whereas your system proposes that they are defects per se. These are diametrically opposed explanations for the existence of the same clinical observations. Why is your explanation correct?

                    Jason,
                    Thanks for bringing this up. I didn't realize how relatively well-informed and circumspect Janda was about his approach to care. As you pointed out, certain groups, including PTs, co-opted his ideas in order to promote themselves rather than promote better care for patients and injured athletes.
                    John Ware, PT
                    Fellow of the American Academy of Orthopedic Manual Physical Therapists
                    "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                    “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                    be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                    Comment


                    • #11
                      While in Atlanta, were "trained" in Janda's approach by a therapist named Anna Signall.She had us put a tray high above our heads and march down the hall in order to "expose" dysfunction. The "treatment" was similar to contract-relax. Today I consider it quite indefensible.

                      John,

                      Your questions make sense. But to me.
                      Barrett L. Dorko

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