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Rehabilitation of the stability function of psoas major

ARTICLE · JANUARY 2002

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Sean Gibbons Neuromuscular Rehabilitation Institute

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Available from: Sean Gibbons Retrieved on: 27 July 2015 Rehabilitation of Psoas Major Rehabilitation of the Stability Function of Psoas Major

Sean GT Gibbons, Mark J Comerford and Peter L Emerson

Introduction attachments constitute individual supplied by branches of the femoral Psoas major is the largest muscle in fascicles. The fascicles of psoas are from L2, 3 and 4 (Gibbons, 1999, cross section at the lower levels of the about the same length within 2001, Gibbons et al, 2001). lumbar spine (McGill et al, 1988). A specimens and have a unipennate Literature Review Summary review of the literature reveals it has fibre orientation. The fibre length A tool was developed to been a poorly investigated muscle and within anterior fascicles range from 3 systematically evaluate literature on there is still controversy concerning its to 8cm and 3 to 5cm in the posterior muscle function, which consisted of true functional role (Gibbons, 1999). fascicles. The fascicles run infero- critical methodological criteria and This may be due to several reasons; its laterally to reach a central general methodological criteria. It was location within the body, which does where they descend over the pelvic divided into sections based on the type not permit routine access with brim and share a common insertion of research project and the methods myolectric electrodes or a clear visual with iliacus to the used. Each section was given a score with real-time imaging, it’s (Gibbons, 2001, Gibbons et al, 2001). based on the criteria within it. Very complex anatomy (Bogduk et al, Psoas also has significant fascial few studies passed the basic 1992), and finally, it is not always relations. The medial arcuate component of the critical considered separately from iliacus is a continuation of the superior psoas methodological criteria. In addition, (hence the name ‘’). A better . The right and left crus make up many studies did not consider psoas understanding of the implications of the spinal attachment of the separately from iliacus or the method the function of psoas major on the diaphragm. They attach to the antero- of assessment was very poor (Gibbons, stability of the lumbo-pelvic region lateral component of the upper three 1999; Gibbons, 2001). may improve clinical management of vertebrae and bodies. The crus and From the literature review, psoas related dysfunction. Research was their fascia overlap psoas and appear major is thought to function as a undertaken to gain an understanding continuous with psoas until they come stability muscle for the lumbar spine of the anatomy, physiology and more anterior and blend with the through axial compression and offers function of psoas major. This involved anterior longitudinal ligament little, or no contribution to range of a systematic review of the literature, (Gibbons, 1999). As psoas descends, spinal movement. (Bogduk et al, dissection studies of psoas major and its infero-medial fascia becomes thick 1992). Andersson et al (1995) state the deep myofascial system. From this, at its lower portion and is continuous that psoas major controls spinal lateral a biomechanical model was with the fascia. This also movement eccentrically and their developed. The purpose of this paper forms a link with the , results indicate that it also contributes is to briefly highlight this project and transversus abdominus, and the to stabilization of the joint and discuss specific strategies for training internal oblique. As psoas passes over assists iliacus with hip flexion. psoas major to contribute to lumbo- the pelvic brim, the fascia of the pelvic stability. posterior fascicles attaches firmly to Evidence of Muscle Dysfunction Based on motor control studies, Summary of Anatomy and the pelvic brim (McVay and Anson, 1940; Williams et al, 1989; Gibbons, Hodges and Richardson (1996, 1997; Physiology see Richardson et al, 1999a) Psoas major has fibrous 1999, 2001, Gibbons et al, 2001).). The nerve supply to psoas is not concluded transversus abdominus was attachments to the anterior aspect of important for spinal stabilization. They all lumbar transverse processes and to reported consistently as most anatomical texts list 3 different identified an anticipatory reaction in the antero-medial aspect of all the transversus abdominus in response to lumbar discs and adjoining bodies variations. These are listed under psoas major, the and spinal disturbance produced by with the exception of the L5-S1 disc movements. In subjects without low (Bogduk et al, 1992; Gibbons, 1999). the . Dissection has shown that the anterior and posterior back transversus abdominus was For their relative positions on the activated prior to limb movements and spine, the attachments on the fascicles have a separate nerve supply. The posterior fascicles are supplied by spinal disturbance, while activation of transverse processes were named transversus abdominus was posterior and those on the discs and the ventral rami of spinal T12 through L4. The anterior fascicles are significantly delayed in subjects with bodies called anterior. These low back pain independent of the www.orthodiv.org January/February 2002 - Orthopaedic Division Review 9 direction of limb movements and on the ipsilateral side. In a single case summated to the respiratory action of spinal disturbance. The delayed onset study, the width was decreased in the the diaphragm. This may occur, of contraction of transversus posterior fascicles at the level and however psoas is ideally located to abdominus indicates a deficit of motor ipsilateral to the site of symptoms in assist in a stability role here. Through control and as a result of this the acute low back pain (Whelan and its segmental attachments, axial authors hypothesize there would be Gibbons, submitted). More research is compression and links to the inefficient muscular stabilization of the currently in progress in this area. diaphragm and pelvic floor, psoas may spine. This is a similar pattern of inefficient play a role in spinal stability and There is evidence of lumbar normal low threshold recruitment should now be considered as an wasting ipsilateral to (previously referred to as inhibition) as important stabilizer of the lumbar symptoms in patients with acute / seen in the deep segmental fibres of spine. subacute low back pain (Hides et al, lumbar multifidus (Hides et al, 1994). Two previous classification systems 1994; Kader et al, 2001). Hides et al This implicates psoas as having a local of muscle function were combined to (1994) used real-time ultrasound to stabilizing role in the lumbar spine develop a new model (Mottram and assess the multifidus muscle. The (Gibbons, 1999; Gibbons et al, 2001; Comerford, 1998; Comerford and paraspinal muscles were scanned in Comerford and Mottram, 2000). Mottram, 2000; 2001). This divides normal subjects and in patients with Further motor control studies are in muscles into local stabilizers, global acute unilateral low back pain. progress to investigate a possible stabilizers and global mobilizers. Psoas Significant asymmetry of multifidus anticipatory timing pattern of psoas as major should be classified as a local cross sectional area (CSA) was noted seen in other local stability muscles. and global stabilizer. The posterior in subjects with low back pain. Model of Psoas Major Function fascicles are ideally suited to perform a This decrease in size of multifidus From dissection studies and a local stabilizer role while the anterior was seen on the side of the symptoms review of the literature, Gibbons fascicles are better suited to have a with the reduced CSA observed at a (1999) has presented a model of psoas global stabilizer role. single vertebral level suggesting pain major. A common model of lumbar Action: inhibition (now considered a decrease stability shows the musculature The local stability role of psoas is to in normal low threshold recruitment). forming a cylinder. The top of the produce axial compression along its However, while the pain may resolve cylinder is the diaphragm, the bottom line of pull. This has the effect of the dysfunction may persist. Hides et is the pelvic floor and the wall is compressing the vertebral bodies to fix al (1996) found that recovery of formed by the segmentally attaching the spine in neutral alignment while multifidus symmetry was not abdominal and posterior spinal longitudinally pulling the head of the spontaneous after painful symptoms musculature, specifically transversus into the acetabulum. This resolved. They observed that recovery abdominus and the segmental fibres of ‘pulling in’ or ‘shortening the leg’ of symmetry was more rapid and more lumbar multifidus (Morris, 1961; action should be localized to the hip complete in patients who received Bartlink, 1957; Richardson et al, and . There should not be any specific, localized multifidus retraining 1999a). Psoas major has intimate lateral tilt (‘hitching’), anterior or (Hides et al, 1996). Correction of this anatomical attachments to the posterior tilt, or rotation of the pelvis. asymmetry resulted in a decreased diaphragm and the pelvic floor. This Likewise, any spinal rotation, flexion incidence of recurrence after a three- unique anatomical disposition allows or extension should be discouraged. year follow up (Hides et al, 2001) psoas to act as a link between the Bogduk (1997) suggests that psoas Inamura et al (1983) examined diaphragm and the pelvic floor that has minimal ability to produce any psoas and sacrospinalis muscle CSA in may help maintain stability of the significant range of motion at the relation to sex and age. The results lumbar cylinder mechanism. This can lumbar spine. It has segmental suggest there is a decrease in psoas be conceptually visualized as a rod in attachments anteriorly to every lumbar CSA in increasing age for men and the middle of a cylinder. and disc (except L5/S1). He women. Cooper et al (1992) studied During inspiration, the diaphragm states that the primary role of psoas on sacrospinalis and psoas CSA in increases tension making the cylinder the lumbar spine is generating force subjects with recent and chronic low relatively more stable. During along a longitudinal moment to back pain. They found psoas atrophy expiration, the diaphragm relaxes enhance spinal stability via axial in both groups of subjects with a making the cylinder relatively less compression. Psoas contraction greater decrease in CSA in the chronic stable. The anticipatory timing pattern should increase stiffness segmentally group. This was of a similar degree to seen in transversus abdominus is in the lumbar spine and should resist that of the paraspinal muscle wasting. earlier in expiration (Hodges et al, motion segmentally rather than Dangaria and Naesh (1998) 1997), presumably to compensate for produce it (Comerford and Emerson, assessed the CSA of psoas major in this decrease in stability (Richardson 1998). unilateral sciatica caused by disc et al, 1999a). Richardson et al (1999a) Assessment and Rehabilitation herniation. There was significant feel that the motor control of the The assessment and retraining of reduction in the CSA of psoas major at stabilising action of transversus the stability role of psoas major is the level and the site of disc herniation abdominus may be superimposed and outlined in the diagram below.

10 January/February 2002 - Orthopaedic Division Review www.orthodiv.org 1. Instruct the specific action of axial compression +/- movement or load facilitators (low threshold recruitment / low load training)

2. Assessment of segmental stability role

3. Retraining of segmental stability role

4a. Specific local stability muscle retraining 4b. Assessment and specific global stability muscle retraining

5. Integration of local stability muscle recruitment into specific function

6. Integration of local & global co-activation into normal function

Figure 1: Summary of the six stages of psoas major stability rehabilitation.

Stage 1: Instruct Specific Action of lateral groin (5cm below the tibial band (ITB) to co-contract to Axial Compression ASIS)(Figure 3b). produce shortening of the hip. This Psoas should have the ability to The upper finger assesses for would be associated with noticeable activate in any position of the trunk control of movement of the pelvis and and significant and under any load situation. The first maintenance of the lumbo-pelvic resistance to passive rotation of the stage must be viewed as only neutral position while the lower finger femur. Rectus femoris and the instruction in the longitudinal action checks for excessive activity in rectus may also co-contract to of psoas. This is so the subject femoris and sartorius. As the client shorten the hip. This would be understands and is aware of the attempts to activate psoas, there associated with noticeable contraction contraction required. It is not part of should be no movement of the pelvis and significant resistance to passive the segmental assessment or (assessed by monitoring the ASIS). movement of the pelvis. rehabilitation, although information Any pelvic movement (monitored at Step 1 regarding sensation of effort, the ASIS) is discouraged. This is Describe the position of psoas and substitution considered a loss of the neutral lumbo- major on the lumbar spine and hip to strategies is gained. pelvic position and is thought to be the client. The action is vertical Monitoring technique associated with excessive activity of shortening so that the hip moves closer When assessment is performed in quadratus lumborum or . to the spine or it ‘shortens the hip into supine or inclined sitting, it is possible It is important that the client is the acetabulum’. The description that for the therapist to monitor these with aware of the sensation of shortening different individuals relate to will vary a simple palpation technique. The the leg. The therapist should not be so it is useful to become familiar with therapist uses the second and third able to palpate radial expansion of different verbal cues for this action. digits (‘peace sign’) to palpate the sartorius or rectus femoris under the When in the starting position, it may be anterior superior iliac spine (ASIS) and lower finger. It is possible for sartorius useful to passively distract the femur the below in the antero- and the tensor fascia latae (TFL)/ilio- and push it into the acetabulum www.orthodiv.org January/February 2002 - Orthopaedic Division Review 11 several times to give the sensation of displacement indicates a probable loss the action required. of segmental control of the local Step 2 stability role of psoas (Comerford and Starting position: Supine with the Emerson, 1998; Comerford and lumbar spine in a neutral position. A Mottram, 2000). This assessment may common substitution strategy is to also be performed in other positions hitch the hip using quadratus (prone or side lying) so long as lumborum or iliocostalis. In this distraction of the hip is controlled and situation, long sitting would be there is no over activation of the preferred instead of supine. paraspinal muscles. Alternatively, in long sitting a common Note: If the client is using facilitation substitution strategy is to rotate the techniques during the assessment to pelvis. In this situation supine would activate psoas, the palpation should be be preferred. The hip should be in performed with and without the neutral rotation (a guide is to position facilitators for comparison. It is the toes vertically) (Figure 3b). If the possible to facilitate other local hip is externally rotated at rest, it stability muscles, which may affect the should be placed in its mid position palpation component of the and actively controlled there. assessment. Stage 3: Retraining of the Step 3 Gently distract the femur and then Segmental (Local) Stability Role There are a variety of facilitation give an appropriate instruction. The strategies to aid in the rehabilitation of most common are “pull (or suck) your the segmental stability role of psoas. hip into the socket” or “shorten your hip without moving your back”. Facilitation Strategies: Maintain the distraction during the From the current research evidence activation to provide a sensory or to date, the local stability muscles have Figure 2: A: Starting position for the afferent stimulus for the longitudinal a motor control deficit in the presence assessment of the local stability role action of psoas. This is the action that of low back pain that is not related to for psoas major. B: Manual palpation Stage 2 will assess the segmental weakness or length change. These of the spine in the assessment efficiency of. deficits are better retrained with position. specific low effort exercises (Hides et Stage 2: Assessment of Segmental al, 1996; Richardson et al, 1999a; Stability Role or palpable co-contraction of the O’Sullivan, 1997). As with other local When the action of psoas has been erector spinae. If present, the therapist stability muscles, subjects respond correctly been taught the assessment should instruct the client to decrease differently to various facilitation of the segmental stabilizing role (local the effort until this is eliminated. Each strategies. The goal is to achieve stability) of psoas can start. lumbar vertebral level is re-palpated to consistent low threshold activation of The client is prone on the plinth assess the contracted joint play in the psoas major to provide segmental with one leg firmly extended to help transverse and anterior directions. stiffness when the assessment (Stage 2) maintain balance, and the other leg Ideally, there should be a significant is re-tested. When this can be hanging freely over the edge with the palpable increase in resistance to achieved, the facilitation techniques on the floor (Figure 2a). The side manual displacement (stiffness) at should be discarded and retraining with the leg hanging freely is the side each level with psoas activation. The should be progressed to a more to be assessed. Gravity will provide a client should be able to maintain the efficient specific contraction and slight distraction force. The pelvis and contraction (and increased stiffness) integration into function. spine are positioned in neutral with the for fifteen seconds with normal The following techniques can help trunk muscles relaxed. Each lumbar relaxed breathing and without fatigue facilitate psoas: vertebral level is manually palpated to or substitution. This response should assess the relaxed joint play be noted at all lumbar segmental 1 - Active hip external rotation displacement in the transverse and levels. This should be a slow, low effort, anterior directions (Figure 2b). Segmental psoas dysfunction is small range movement. When the Psoas is facilitated by instructing the identified at the vertebral level in client’s hip is normally positioned in patient to “pull the hip back into the which there is no increased resistance external rotation, it is useful to apply a socket”, against the minimal to manual displacement during psoas small amount of resistance to the distraction force of gravity, without activation when compared to adjacent external rotation so the movement is moving the spine or pelvis. This gentle levels (which do increase resistance to not passive (Figure 3). This facilitator contraction is sustained. Here, the translation when psoas is activated). serves three purposes. First, the therapist should check for observable This lack of resistance to manual external rotation may disadvantage or

12 January/February 2002 - Orthopaedic Division Review www.orthodiv.org inhibit the TFL/ITB, which is a femoral internal rotator. Second, the external rotation may recruit the deep hip intrinsic muscles. These fit the classification of local stabilizers as outlined by Comerford and Mottram (2001). Local stability muscles should functionally co-activate together (Richardson et al, 1999a), so activating the deep hip intrinsic muscles may facilitate the local stability role of psoas major. Thirdly, psoas and iliacus share a common tendon as they insert into the lesser trochanter and they may contribute to lateral rotation. In normal function the local and global muscles recruit synergistically. Low threshold activation of the global role of iliacus and the anterior fascicles of psoas through lateral rotation may Figure 4: Palpation of the lower facilitate the local function in the to monitor abdominal posterior fascicles of psoas. activation during a pelvic floor con- traction. (from the ASIS, palpate 2 - Normal (unforced) end range 2cm down along the inguinal liga- expiration ment then 1cm medial). During expiration the diaphragm ascends and because of the posterior fascicles attaches to the anatomical relationship that exists pelvic brim. As psoas generates force, between the diaphragm and psoas, this orientation creates a posterior expiration may create a mechanical rotation moment on the innominate pull on psoas via fascial connections. relative to the that can resist an However, it is possible that this anterior rotation action. The client is relationship may be more instructed to use minimal effort to neurophysiological rather than maintain a neutral spine and hold the biomechanical. Abdominal breathing pelvis steady during isometric in supine / crook lying provides the resistance to passive anterior rotation best excursion of the diaphragm and of the innominate. will have the best leverage for any Figure 3: A: Client positioned in hip fascial pull on psoas (Williams et al, external rotation at rest. B: Low 5 - Side-lying segmental lumbar 1989). effort resistance to active hip facilitation 3 - Pelvic floor contraction external rotation during psoas major The client is positioned in side lying There is a strong anatomical facilitation with the hip in neutral with the dysfunctional psoas relationship between the pelvic floor rotation. uppermost. The bottom leg is straight fascia and the inferior psoas fascia. and the top leg bent with the spine and The pelvic floor contraction should be and not a ‘bulge’ in the antero-lateral pelvis in neutral alignment in terms of a low effort (less than 25% maximum abdominal wall (Richardson et al, tilt and rotation. The top leg is voluntary contraction) contraction. If 1999b). It is understood that local supported horizontally with the spine, a proprioceptive / sensation of effort stability muscles should co-activate pelvis and upper trunk all neutral. deficit exists, a higher perceived effort (Richardson et al, 1999a). When a Psoas is facilitated by gently distracting is permissible (Comerford and ‘bulge’ is palpated, it is non-specific for the top leg longitudinally and the Mottram, 2001; Gibbons and transverses abdominus and may not patient is instructed to pull the hip Comerford, 2001) providing the be specific for posterior psoas major back into the socket without moving oblique abdominal muscles do not facilitation. the spine or pelvis. Facilitation may be dominate the contraction. The localized to the segmental level of oblique dominance is monitored via 4 - Resistance to passive anterior dysfunction by manually palpating the palpation of the antero-lateral rotation of the innominate dysfunctional spinal level (as abdominal wall (Figure 4). With a Psoas passes over the pelvic brim identified in Stage 2 testing). The slow, low effort pelvic floor where it becomes tendinous and therapist or client gently grips the contraction, a ‘tensioning’ (transversus continues to the lesser trochanter. spinous process and manually abdominus recruitment) should be felt While it does, the fascia of the oscillates that vertebrae with a side to www.orthodiv.org January/February 2002 - Orthopaedic Division Review 13 side, back and forth motion, while the threshold recruitment. Under higher bias shifts to multifidus and gluteals to psoas activation is sustained. This load situations psoas will be activated. eccentrically control the movement). provides afferent mechanical These can be used to facilitate psoas 3 - - knee diagonal push proprioception and feedback. As and then the client can return to the Lie in crook lying with the spine function improves with retraining, normal low load facilitators. supported in neutral. Slowly lift one there should be reassessment of Some techniques are listed below: knee towards the opposite hand and symmetry and segmental control with 1 - Side-lying rotation to neutral push them isometrically against each the assessment (Stage 2). other on a diagonal line (watch for Problem solving tips - watch for and (psoas co-activation with multifidus) substitution e.g. do not stabilise with eliminate substitution: the opposite foot or allow posterior 1 - Dominant or excessive (Adapted Grieve) pelvic tilt). Ensure that the neutral activation of rectus femoris The client is positioned in side lying spine position is maintained. Psoas Use less effort and a slower with the dysfunctional side of psoas strongly co-activates multifidus in this contraction. A pillow may be used to uppermost. The bottom leg is straight procedure. This technique uses put the knee in slight flexion to and the top leg bent with the spine and significant more global stabilizer co- disadvantage rectus femoris pelvis in neutral alignment in terms of contraction than many of the others. 2 - Dominant or excessive tilt and rotation. The uppermost leg is This may be appropriate when activation of TFL/ITB allowed to drop towards the plinth significant inhibition is present (e.g. Use less effort and a slower causing the trunk and pelvis to rotate post surgery or inflammatory trauma). contraction. Ensure the hip external forwards. Psoas is facilitated by gently Progression of Psoas Retraining rotation is active rather than passive distracting the top leg longitudinally Once the correct activation can be and slightly more effort may be used and the patient is instructed to pull the accomplished, psoas recruitment during the external rotation hip back into the socket until the trunk retraining is performed in a variety of contraction. The hip may be placed in and pelvis rotates back to the neutral different positions. Clinically, it may slight abduction to disadvantage position. The segmental or oblique be best to start in a position where the TFL/ITB. fibres of multifidus are co-activated by client is confident they can achieve a the direct rotational movement. The 3 - Dominant or excessive correct activation, rather than what the technique can be segmentally therapist feels is the best activation. of quadratus lumborum localized by manual fixation at the Ensure the spine is in neutral. Use For the majority of patients, recumbent level above the dysfunction. The same postures, such as supine lying, incline less effort and a slower contraction. facilitators as before may be used here. Change position to long sitting. sitting or side lying, are the positions Hip external rotation is achieved when where it is easiest to facilitate and 4 - Dominant or excessive the client gently pushes the top heel teach the correct activation of psoas. activation of iliocostalis downwards. The breathing, pelvic From this, other positions are trained. There is excessive anterior tilt and floor contraction or resistance anterior As a general guide, the psoas spinal extension. Ensure the spine is in rotation of the innominate can follow. contraction should be maintained for neutral. Use less effort and a slower 2 - Sitting - leaning back ten seconds and for ten repetitions, contraction. (eccentric hip flexors) during relaxed breathing. Two or 5 - Dominant or excessive The client sits with the spine and three sets a day are reasonable, activation of proximal trunk pelvis in neutral and the feet on the depending on the client. The muscles floor. Keeping the spine and pelvis segmental stability of psoas should be Significant resistance to passive neutral the patient is instructed to reassessed (Stage 2) regularly to rotation of the pelvis identifies this. slowly lean backwards by only moving ensure appropriate progression. Use less effort and a slower at the (rock from the ischium). contraction. Ensure low effort activity This requires that the deep hip flexors Stage 4 A and B by the facilitators. eccentrically lower the trunk Assessment of Global Stability backwards. Ensure that the lumbo- The global stability role of psoas 6 - Loss of neutral spine pelvic neutral alignment is maintained. (anterior fascicles) is functionally Ensure the spine is in neutral There should be no substitution combined with iliacus. This may be actively rather than passively after it is dominance from the hip flexor considered efficient when the achieved. Use less effort and a slower mobilisers (anterior tilt of the pelvis) or stabilizer can move the limb through contraction. the abdominals (palpable bulge in the the available passive range of 120° hip Movement and load facilitators antero-lateral abdominal wall; trunk flexion. In sitting with the lumbar In situations where psoas is flexion and posterior pelvic tilt), and spine in neutral, the hip is actively dysfunctional or there is a lack of there should be no fatigue. The client flexed through the full range of motion proprioception by the client, it can be can lean backwards as far as can be (ideally 120°). There should be no loss useful to use movement and load controlled and then leans forward to of lumbo-pelvic neutral or co- facilitators. A dysfunction identified in return to neutral (if the forward lean contraction of TFL / ITB and sartorius, psoas is a decrease in normal low continues beyond 90° hip flexion the or the hamstrings. This can be

14 January/February 2002 - Orthopaedic Division Review www.orthodiv.org identified as significant resistance to Global Spinal Stability Role - Conclusion passive rotation of the hip when it is Eccentric Control A review of the literature to date flexed. In optimum function, this Psoas also has an eccentric role in reveals that psoas major has been a position should be maintained for ten spinal stability. This can be started in poorly investigated muscle. It seconds and ten repetitions (it is sitting during a lean backwards and functions as a lumbar and hip recognized that there may be other then in standing. Standing and side stabilizer through axial compression reasons why there is a loss of a neutral bending of the trunk is also controlled and vertical shortening, respectively. spine during this test). by psoas and is best started supported Research suggests psoas may have a local stability role in the lumbar spine. Specific Retraining of the Local at a wall with the spine in neutral and then progressed to unsupported A model has been proposed in which and Global Muscle Role Through the posterior fascicles play a local Range standing. Rothstein has suggested that to stability role while the anterior Global Supported Hip Flexion integrate an activity or skill into fascicles are a global stability role. The global role is best started in normal, automatic or unconscious Specific exercises and facilitation supine or inclined sitting. Here, the function, many repetitions must be strategies have been developed for the local role of psoas is combined with performed under diverse functional rehabilitation of psoas major. the global role. ‘Shortening the hip’ situations. To do this, some form of Although not discussed here, this activates psoas, and then while reminder is needed. He has proposed model has implications for retraining of pelvic floor dysfunction. As well, maintaining this action, slow heel that small ‘red dots’ are placed so that psoas may be considered a local slides are started. The heel actively they are frequently seen and will act as stabilizer for the hip and components slides up beside the opposite leg a visual reminder (e.g. on wristwatch, of the above regime may be used in towards the buttock (as far as the clock, telephone, mirror etc.) for the contralateral knee). The heel should hip rehabilitation. Current research subject to perform a specific task each includes validation of the exercises slide only as far as the client time they are observed. This process confidently feels that the hip is still and monitoring technique with real- lends itself well to training of the local time ultrasound, and deep needle ‘shortened’. This position is held for stability system. ten seconds. The eccentric return . This will aid in the (straightening of the leg) should be Stage 5: Integration of Local further understanding of psoas, which may lead to improved assessment and controlled and performed at the same Stability Muscle Recruitment into rehabilitation strategies. slow pace as the concentric Specific Function component. The client should be When the psoas becomes efficient and is easily activated it can be readily taught to monitor tibial external References rotation, hip internal rotation and hip integrated into functional activities. It adduction (signs of TFL / ITB is easier to start with static activities Andersson E, Oddsson L, Grundstrom H, such as standing or sitting. When this Thorstensson A (1995) The role of the psoas dominating hip flexion) and lateral hip and iliacus muscles for stability and move- rotation (a sign of sartorius dominating becomes easier, it can be incorporated ment of the lumbar spine, pelvis and hip. hip flexion). The therapist should also into dynamic movements such as Scand J Med Sci Sports. 5: 10-16 check for co - contraction rigidity at bending and walking. Bartlink DL (1957) The role of intra-abdominal the point the hip is held. Once the heel pressure in relieving the pressure on the lum- Stage 6: Integration of Local and bar vertebral discs. Journal of and Joint slide can be coordinated and reach Surgery. 39B: 718-725 the opposite knee, the foot can be Global Co-Activation into Normal Function Bogduk N (1997) Clinical Anatomy of the lifted 2cm and held. The exercises can Lumbar Spine and Sacrum 3rd Ed. Churchill then be progressed to standing, and Since the local role of psoas is Livingstone, New York usually rehabilitated before the global sitting unsupported control exercises. Bogduk N, Pearcy M and Hadfield G (1992) role, integration of the local retraining Anatomy and biomechanics of psoas major. Global Unsupported Hip Flexion into function starts earlier. As the Clinical Biomechanics. 7: 109-119 Because the client often global role becomes more efficient, it Comerford M and Emerson P (1998) experiences difficulty performing this can also be incorporated into function. Unpublished Data without substitution, the global This can include the hip flexion Comerford M (2000) Dynamic Stability and retraining may start without the local component of the stairs, moving while Muscle Balance of the Sacro-iliac Joint. Kinetic Control Movement Dysfunction Course role. This can start in standing with sitting or driving, and standing. Publication. Kinetic Control, Southampton. some individuals. Others will have to It is important the client continue Comerford M and Mottram S (2000) start in supine or long sitting. In their functional activity when Movement Dysfunction: Focus on Dynamic standing, hip flexion can start at 70°, retraining psoas into function, and not Stability and Muscle Balance. Kinetic Control and progresses to 80° and 90°. This ‘stop’ and then activate. This may Movement Dysfunction Course Publication. can start supported on the wall with a hinder incorporation of psoas into Kinetic Control, Southampton. neutral spine and then unsupported function. The retraining is progressed Comerford MJ and Mottram SL (2001) Movement and stability dysfunction - contem- standing. This is progressed to sitting into activities of daily living, and then porary developments. Manual Therapy. 6 (1): hip flexion from 90° to 120°. work or sport related activities. 15-26 www.orthodiv.org January/February 2002 - Orthopaedic Division Review 15 Cooper RG, St. Clair Forbes W and Jayson Hides JA, Stokes MJ, Saide M, Jull GA and Reid JG, Livingson LA and Pearsall DJ (1994) MI (1992) Radiographic demonstration of Cooper DH (1994) Evidence of lumbar multi- The geometry of psoas muscle as determined paraspinal muscle wasting in patients with fidus muscle wasting ipsilateral to symptoms by MRI. Archives of Physical Medicine and chronic low back low back pain. British in patients with acute/subacute low back pain. Rehabilitation. 75: 703-708 Journal of Rheumatology. 31: 389-94 Spine. 19 (2): 165-172 Richardson C, Jull G, Hides J, Hodges P Dangaria TR and Naesh O (1998) Changes in Hodges PW and Richardson CA (1996) (1999a) Therapeutic Exercise for Spinal cross-sectional area of in Inefficient muscular stabilization of the lumbar Stabilisation: Scientific basis and practical unilateral sciatica caused by disc herniation. spine associated with low back pain. Spine. techniques. Churchill Livingstone, Edinburgh Spine. 23 (8): 928-931 21 (22): 2640-2650 Richardson C, Hides J and Roll S (1999b) Gibbons SGT (1999) A review of the anato- Hodges PW, Richardson CA, and Gandevia Advanced instruction in retraining motor con- my, physiology and function of psoas major: A SC (1997) Contractions of specific abdominal trol for segmental stabilization: Including real- new model of stability. Proceedings of: The muscles in postural tasks are affected by res- time ultrasound for feedback. London. Course Tragic Hip: Trouble in the Lower Quadrant. piratory manoeuvres. Journal of Applied Notes & Course Demonstration 11th Annual National Orthopaedic Physiology. 83 (3): 753-760 Symposium. Halifax, Canada. Nov 6-7 Romanes GJ (1987) The - Posterior Kader DF, Wardlaw D and Smith FW (2001) Abdominal Wall. In: Romanes GJ (Ed) Gibbons SGT (2001) The model of psoas Correlation between the MRI changes in the Cunningham’s Manual of Practical Anatomy, major stability function. Proceedings of: 1st lumbar multifidus muscles and leg pain. Vol II. 15th ed. Oxford University Press, International Conference on Movement Clinical Radiology. 55: 145-149 Oxford. p 174-85 Dysfunction. Edinburgh, Scotland. Sept 21-23 McGill SM, Patt N and Norman RW (1988) Rothstein JM (1982) Muscle biology. Clinical Gibbons SGT and Comerford MJ (2001) Measurement of the trunk musculature of Considerations. Physical Therapy. 62 (12): Strength versus stability. Part II; Limitations active males using CT scan radiography: 1823-30 and benefits. Orthopaedic Division Review. Implications for force and moment generating March / April. 28-33 capacity about the L4/L5 joint. Journal of Rothstein J, Roy S, Wolf S (1991) The Biomechanics. 21: 329-341 Rehabilitation Specialist’s Handbook. F.A. Gibbons SGT, Pelley B and Molgaard J Davis. (2001) Biomechanics and stability mecha- McVay CB and Anson BJ (1940) Aponeurotic nisms of psoas major. Proceedings of: 4th and fascial continuities in the abdomen, pelvis Whelan B and Gibbons SGT (2001) Interdisciplinary World Congress on Low Back and . The Anatomical Record. 76 (2): Computed tomography imaging of posterior Pain. Montreal, Canada. November 9-11 213-232 psoas major. Submitted Grieve GP Ed (1986) Modern Manual Morris JM, Lucas DB and Bresler B (1961) Williams PL, Warwick R, Dyson M and Therapy of the . 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