Is there a universal rehabilitation plan that works?
No – not really. An effective rehabilitation for chronic musculoskeletal problems is not simply focused on a few muscles or a single joint, it must take into consideration your overall health and fitness. A rehabilitation plan for chronic pain that does not also improve health and fitness will not achieve the intended goal – improving function and decreasing pain.
Having said that, I believe there is a sound strategy for addressing chronic musculoskeletal pain that would be helpful for the patient to know: the crossed syndromes . . . Upper Crossed Syndrome and Lower Crossed Syndrome. Vladimir Janda, MD (yonda) was a Czech neurologist who observed that the nervous system had a predictable pattern for using our muscles – a neuro-motor strategy – for daily activities.
Janda’s observations are not about how each muscle works in isolation but rather how groups of muscles work together to allow balanced movement, such as walking, running, throwing, and even posture.
In general, Dr. Janda observed:
three ways our nervous system recruits our muscles,
each muscle is used primarily in one of these three groups: spinal stabilizers, peripheral mobilizers, or a mix of the two, and
certain muscles, when dysfunctional, tend towards being shortened, tight; other muscles tend toward being elongated, weak; neither are as efficient as a result.
Basic muscle physiology has shown that when a muscle is contracted - such as flexing the bicep - the opposite muscle(s) – in this case, the triceps – is inhibited. This allows the bicep to continue to contract and curl the arm, without having to fight against a tight tricep.
It can appear as though the inhibited tricep muscle is weak. It is not necessarily weak but a low-grade nerve signal is preventing the tricep from contracting, which allows the bicep to continue bending the elbow. If this relationship between opposite muscles did not exist, we would have a hard time moving, as many opposing muscles would contract at the same time.
Janda applied this physiology clinically by explaining that muscles that tend toward tightness when dysfunctional cause a persistent inhibition of particular opposite muscles, leading to various imbalances across joints of the hip, spine, and shoulders. This can contribute to posture problems and result in muscle fatigue. Persistent muscle fatigue can lead to pain as I explained in yesterday’s blog post.
Janda theorized that the rehabilitation plan should address tight muscles prior to strengthening weak muscles – weakened due to prolonged inhibition. He called this tight-inhibited dysfunction: crossed syndrome. For the low back-hip region, he called it the Lower Crossed Syndrome. For the neck-shoulder region, he called it the Upper Crossed Syndrome. He used the term crossed because the weak-inhibited muscles criss-crossed from front to back.
The Lower Crossed Syndrome has this basic combination of muscles:
Tight: Iliopsoas, Quadricep, Quadratus Lumborum, Erector Spinae
Inhibited: Gluteus Maximus, Transversus Abdominus, Posterior Deep Spinal Muscles, Hamstring
The Upper Crossed Syndrome has this basic combination of muscles:
Tight: Pectoralis Major/Minor, Upper Trapezius, Levator Scapula
Inhibited: Anterior Deep Cervical Muscles, Middle and Lower Trapezius, Rhomboids
The Janda rehabilitation plan stretches the tight muscles – decreasing the inhibition signals to the opposite muscles – and then strengthens weak muscles that have had, at least temporarily, their inhibition decreased by stretching tight muscles. The consequence is improvement in the spinal stabilizer muscle groups (core muscles) allowing for a more efficient transfer of energy to the peripheral mobilizing muscles, which allow us to move our shoulders for reaching and move our legs for squatting, walking, and running.
The longer the crossed syndrome has been present, the longer it can take to re-establish balance between the tight-weak muscles. But, as the tightness of the muscle lessens and the inhibited muscles get stronger, there should be less muscle fatigue, and, eventually less pain.
This plan can also be useful for rehabilitation of acute injuries such as sprained ankles, rotator cuff injuries, or after surgeries such as for Anterior Cruciate Ligament repairs or spine surgery. After the early phases of rehabilitation, working on Lower Crossed muscles for low back and lower extremity injuries or Upper Crossed muscles for neck or upper extremity injuries can speed up full recovery.
Vladimir Janda, MD, applied his findings to mainly developmentally disabled patients. Phillip Greenman, DO, from Michigan State University College of Osteopathic Medicine, worked closely with Dr. Janda and incorporated his findings in his manual therapy.
Because there are so many modern situations where we are forward leaning, these syndromes are common. This is a stretch that I recommend to all my patients. I call it the doorway stretch. This should be done throughout the day and right before exercising. It stretches the muscles that are typically shortened while contracting the muscles that are typically lengthened. Copy this stance, ensuring that the same side that the arm is up, the leg is forward. Then, contract the muscles in between the scapulas and contract the glute on the side where the leg is backward. Contracting these opposing muscles helps deepen the stretch. Lean further into the stretch. Then, do the other side.
If you have a job where you sit a lot, try doing this stretch at the top of every hour and see if it makes a difference in how your body feels and moves. I would love to know if you did in the comment section.