ASSESSMENT AND TREATMENT OF MUSCLE IMBALANCE The J a n da Approach Phil Page, PT, ATC Baton Rouge, LA Clare C. Frank, DPT Movement Links, Inc. and Kaiser Permanente Movement Science Fellowship, Los Angeles, CA Robert Lardner, PT Chicago, IL Human Kinetics Library of Congress Cataloging-in-Publication Data Page, Phillip, 1967- Assessment and treatment of muscle imbalance : the Janda approach / Phil Page, Clare Frank, Robert Lardner. p. cm. Includes bibliographical references and index. ISBN-13: 978-0-7360-7400-1 (hardcover) ISBN-10: 0-7360-7400-7 (hard cover) 1. Janda, Vladimir, Doc. MUDr. 2. Myalgia-Patients-Rehabilitation. 3. Musculoskeletal system- Diseases-Patients-Rehabilitation. I. Frank, Clare, 1962- II. Lardner, Robert. III. Title. [DNLM: 1. Musculoskeletal Diseases—diagnosis. 2. Muscles—physiopathology. 3. Musculoskeletal Diseases—rehabilitation. 4. Neuromuscular Manifestations. WE 141 P142a2010] RC935.M77P34 2010 616.7'42-dc22 2009026864 ISBN-10: 0-7360-7400-7 (print) ISBN-13: 978-0-7360-7400-1 (print) Copyright © 2010 by Benchmark Physical Therapy Inc., Clare C. Frank, and Robert Lardner All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including xerography, photocopying, and recording, and in any information storage and retrieval system, is forbidden without the written permission of the publisher. Acquisitions Editor: Loam D. Robertson, PhD; Developmental Editor: Maggie Schwarzentraub; Managing Editor: Melissa J. Zavala; Assistant Editors: Nicole Gleeson, Casey A. Gentis, and Joanna Hatzopoulos Portman; Copyeditor: Jocelyn Engman; Indexer: Craig Brown; Permission Manager: Dalene Reeder; Graphic Designer: Fred Starbird; Cover Designer: Keith Blomberg; Photographer (cover): Neil Bernstein; Photographers (interior): Phil Page, Clare C. Frank, and Robert Lardner unless otherwise noted. Photos on pages 161 (Figure 11.2), 168 (Figure 11.12), 170 (Figure 11.15), 181 -184, 201 -202, 203 (Figures 13.9 & 13.10), 204 (Figures 13.12, 13.13, & 13.14), and 205 © Performance Health/Hygenic Corporation; Photo Asset Manager: Laura Fitch; Visual Production Assistant: Joyce Brumfield; Photo Production Manager: Jason Allen; Art Manager: Kelly Hendren; Associate Art Manager: Alan L. Wilborn; Illustrator: Jason M. McAlexander, MFA; Printer: Sheridan Books Printed in the United States of America 10 9 8 7 6 5 4 3 21 The paper in this book is certified under a sustainable forestry program. Human Kinetics Web site: www.HumanKinetics.com United States: Human Kinetics Australia: Human Kinetics P.O. Box 5076 57A Price Avenue Champaign, IL 61825-5076 Lower Mitcham, South Australia 5062 800-747-4457 08 8372 0999 e-mail: [email protected] e-mail: [email protected] Canada: Human Kinetics New Zealand: Human Kinetics 475 Devonshire Road Unit 100 P.O. Box 80 Windsor, ON N8Y 2L5 Torrens Park, South Australia 5062 800-465-7301 (in Canada only) 0800 222 062 e-mail: [email protected] e-mail: [email protected] Europe: Human Kinetics 107 Bradford Road Stanningley Leeds LS28 6AT, United Kingdom +44(0) 113 255 5665 e-mail: [email protected] E4423 W e dedicate this book to the memory of Vladimir Janda and to all those who have striven to learn more about his wonderful approach to helping patients. His knowl edge and passion helped transform our own clinical practice and gave us the ability to share his teachings with others. This book is also dedicated to the researchers who have yet to prove many of Janda's theories. We also would like to dedicate this book to promoting better understanding and coopera tion among different disciplines, hoping to bridge the gaps among physiotherapy, chiropractic, and medicine. Most importantly, we dedicate this book to our families, who endured our countless hours of research, writing, and revisions. To Angela, Madison, Caitlin, Hannah, and Andrew Page, thank you for your understand ing and support. I couldn't have done anything without the best wife in the world, my best friend Ange. Phil Page To Kirsten and Lauren Frank, thank you for your constant loving reminders to persevere. You are the best daughters any mother can ask for. Clare Frank I very humbly dedicate this book to Professor Karel Lewit, who has inspired me ever since I knew of him and his wonderful work. Robert Lardner III CONTENTS Preface ix A Tribute xi Acknowledgments xiii 1 Structural and Functional Approaches CHAPTER to Muscle Imbalance 3 Intrinsic Versus Extrinsic Function 4 Muscle Balance in Function and Pathology 5 Muscle Imbalance Paradigms 7 Summary 11 2 The Sensorimotor System 13 CHAPTER Sensorimotor Hardware and Software 13 Neuromuscular Aspects of Postural Stability and Joint Stabilization 19 Pathology in Proprioception 22 Summary 25 3 Chain Reactions 27 CHAPTER Articular Chains 28 Muscular Chains 30 Neurological Chains 37 Summary 42 4 Pathomechanics of Musculoskeletal Pain CHAPTER and Muscle Imbalance 43 Pathology of Musculoskeletal Pain 43 Pathomechanics of Muscle Imbalance 46 Causes of Muscle Tightness and Weakness 49 Janda's Classification of Muscle Imbalance Patterns 52 Summary 55 V VI CONTENTS 5 Posture, Balance, and Gait Analysis 59 CHAPTER Muscle Analysis of Standing Posture 59 Evaluation of Balance 71 Evaluation of Gait 72 Summary 75 6 Evaluation of Movement Patterns 77 CHAPTER Janda's Basic Movement Patterns 77 Additional Movement Tests Complementary to Janda's Tests 86 Selected Manual Muscle Tests 89 Summary 91 7 Muscle Length Testing 93 CHAPTER Muscle Length Assessment Technique 94 Lower-Quarter Muscles 95 Upper-Quarter Muscles 105 Hypermobility 109 Summary 110 8 Soft-Tissue Assessment 111 CHAPTER Characteristics of Trigger Points 112 Assessment of Trigger Point or Tender Point Chains 116 Scars 123 Myofascia 123 Summary 123 9 Normalization of Peripheral Structures 127 CHAPTER Central Indirect Techniques 128 Local Direct Techniques 130 Summary 136 10 Restoration of Muscle Balance 137 CHAPTER Factors Contributing to Muscle Weakness 138 Additional Treatment Techniques for Muscle Weakness 139 Factors Contributing to Muscle Tightness 146 Additional Treatment Techniques for Muscle Tightness 147 Summary 155 CONTENTS VII 11 Sensorimotor Training 157 CHAPTER Role of Sensorimotor Training in Janda's Treatment 158 Sensorimotor Training Components 160 Sensorimotor Training Progression 163 Summary 172 12 Cervical Pain Syndromes 175 CHAPTER Regional Considerations 175 Common Pathologies 176 Case Study 189 Summary 190 13 Upper-Extremity Pain Syndromes 191 CHAPTER Regional Considerations 191 Assessment 195 Common Pathologies 199 Case Study 210 Summary 211 14 Lumbar Pain Syndromes 213 CHAPTER Regional Considerations 213 Common Pathologies 216 Assessment 218 Management of Low Back Pain Syndromes 221 Case Study 223 Summary 226 15 Lower-Extremity Pain Syndromes 227 CHAPTER Regional Considerations 227 Assessment 229 Common Pathologies 232 Case Study 241 Summary 245 References 247 Index 289 About the Authors 297 PREFACE V ladimir Janda was a clinician, researcher, and educator well known not only in his native Prague but also around the world. His theories of muscle imbal ance served as the basis for evaluation and treatment of patients throughout Europe, giving him the title Father of Rehabilitation. As he lectured in the United States and other parts of the world, he developed an interdisciplinary following of physio therapists, chiropractors, and physicians. Janda's approach provided a unique perspective on rehabilitation to many Western practitioners. In contrast to the traditional structural view of rehabilitation, Janda sug gested a more functional approach by emphasizing the importance of the sensorimotor system in controlling movement and in chronic musculoskeletal pain syndromes. His theories were so revolutionary that he was often years ahead of science. Janda once compared his approach to musculoskeletal pain to Mendeleev and the periodic table. Mendeleev created a system for classifying elements because he knew there was a systematic way of predicting their properties. At the time Mendeleev devel oped the table, he left blank spaces for elements that he knew must exist because they fit the pattern but that were not yet discovered by science. Using a similar philosophy, Janda created a systematic and predictable approach to chronic musculoskeletal pain that has yet to be fully discovered by science. We were fortunate enough to spend time with Janda both in the United States and in Prague many times before his death in 2002. His philosophies were revolutionary and often contrasted the traditional theories taught in school and practiced daily in the United States. After implementing his approach in our clinical practice, we saw its practicality and results. His ideas revolutionized our approach to treating many patients with chronic pain, often the most difficult patients to treat. We knew we had to continue his legacy and protect his approach by teaching workshops to clinicians in the United States. Janda's approach has been discussed in many textbooks, often in chapters that he authored. Despite his popularity around the world, there was no text to integrate his approach into evidence-based practice. It was likely difficult for the humble Janda to write a textbook devoted to himself and his methods; he always gave credit to others in framing his approach. Many years ago he published a muscle testing book in English but it is now out of print. His last text on muscle testing is not available in English. There are several collections of his articles in English, but they are often difficult to draw from in clinical application. We were frustrated by a lack of any definitive resources to guide clinicians, so we wrote this textbook to preserve and share Janda's teachings with a practical, evidence-based approach. This book was written for health care providers treating patients with musculo skeletal complaints. Exercise experts may also find Janda's theory of muscle imbal ance valuable in developing exercise programs. Our goal in writing this text was to provide a practical, systematic approach to implementing his theories in everyday clini cal practice. We have provided a scientific basis for many of his theories, which often preceded the available evidence. Chapters are divided into four parts filled with illustrations, photos, and step-by-step instructions. Part 1 provides the scientific IX X PREFACE basis for Janda's approach to muscle imbalance. The four chapters review the differ ent paradigms of muscle imbalance, describe the role of the sensorimotor system in function and dysfunction, explain different chain reactions throughout the body, and introduce Janda's classification of muscle imbalance. Part II describes the functional evaluation of muscle imbalance, outlining Janda's step-by-step system of evaluation. These chapters include analysis of posture, bal ance, and gait; evaluation of Janda's movement patterns; muscle length testing; and soft-tissue assessment. Part III outlines Janda's approach to the treatment of musculoskeletal syndromes. Chapters include details on normalizing peripheral structures, restoring muscle bal ance, and sensorimotor training. Each chapter has many photographs and detailed descriptions of evaluation and treatment techniques. Finally, part IV brings the theory, evidence, and practical applications together to apply Janda's approach to specific body regions. This helps clinicians easily implement Janda's approach in everyday practice when evaluating and treating cervical, upper- extremity, lumbar, and lower-extremity pain syndromes. Each chapter describes the practical implementation of Janda's system of evaluation and treatment outlined in parts II and III. Specific musculoskeletal conditions commonly seen in the clinic, such as chronic neck pain, chronic back pain, shoulder impingement, and anterior knee pain, are also discussed with emphasis on applying Janda's approach. Each chapter concludes with a case study that compares Janda's approach with the traditional approach to treatment. In conclusion, we wanted to write a text that both preserves and supports Janda's teachings. This book is only a tool for everyday practitioners; it is not meant to address all chronic pain syndromes or even all muscle imbalance syndromes. Instead, it pro vides practical, relevant, and evidence-based information arranged into a systematic approach that can be implemented immediately and used along with other clinical techniques.