The examination and assessment process is required to determine whether muscle imbalance is a causal factor of the patient’s symptoms. Recognition of postures that deviate from the expected normal (see Kendall et al. 2005and of physiological movement dysfunction patterns is essential to this.

It is also necessary to identify whether the abnormal postures and movement patterns are the primary or secondary source of the patient’s symptoms. Secondary stresses can give rise to symptomatology in any part of the kinetic chain affected by the alteration of posture and physiological movement further along the chain. The signs and symptoms of other anatomical regional areas will need to be addressed, but causal primary problems must always be recognised and addressed, as well as those that have developed secondarily. Treatment, intervention and management principles.As well as the theory described in this chapter, it must be noted that there are other factors to consider in order to determine the most effective and efficient intervention, such as psychosocial influences, age and comorbidities. Consideration also needs to be given to the patient’s expectations. Are the function and demands they expect to place upon themselves compatible with attaining/ maintaining ‘muscle balance’? The physiological parameters already discussed should inform your treatment decisions. In practice, there is an additional consideration and experiential, anecdotal phenomenon, which is important to consider for the life-busy (perceived or actual) patient who is at risk of non-compliance of rehabilitation if the programme is too time-consuming. Well-intended programmes have been known to be overloaded and discontinued if it becomes too much and so it may be prudent to withhold some lower priority rehabilitation for a later date and introduce as proven necessary.

The Lumbo-pelvic region

The lumbo-pelvic region has seen a significant amount of research and debate as to the role of the muscles in relation to lower back pain, which should not be surprising considering how common lower back pain is.  As transversus abdominis (TrA) has received considerable interest both in the literature and clinical environment, this will be the focus as a template approach for the physiotherapist to consider in practice.The concept of ‘core stability’ and muscular stabilization of the lumbar spine has derived from Panjabi’s (1992a, 1992b, 2003) model of the three subsystems described

previously. With reference to the passive subsystem, the lumbar spine appears to be at a disadvantage, ‘sandwiched’ between the inherently more stable thoracic spine (via the rib cage) and pelvis. Therefore, whilst the lumbar vertebrae and intervertebral discs are the largest and strongest in the spine, further support and control is required, but, TrA, along with the multifidus, diaphragm and pelvic floor, appear to form a ‘box’ (or more aptly, a corset). The diaphragm and pelvic floor appear to contribute mainly through increasing intra-abdominal pressure and restricting the movement

of the viscera (Richardson et al. 2004).

Transversus abdominis (TrA)

TrA is the deepest of the abdominal muscles. The direction of the muscle fibres runs horizontally medially from the lateral attachments of the internal surface of the six lowest ribs, the thoracolumbar fascia, internal surface of the iliac crest and the lateral third of the inguinal ligament to the sheath of rectus abdominis (Ombregt et al. 2003; Standring 2005). It can be seen from the attachments how contraction can mechanically increase intra-abdominal pressure and thus stabilise the lumbar spine, although it does not act alone, as co-contraction with multifidus is also thought to occur (Richardson et al. 2002, 2004). When considering this action, it is easy to

understand how dysfunction may lead to pathological signs and symptoms, and subjects with low back pain have been shown to demonstrate delay and inhibition of contraction compared with asymptomatic subjects (Richardson et al. 2002, 2004).

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