Using the joint-by-joint approach can help you determine the proper therapeutic objective.
If you manipulate an area that is inherently supposed to be stable, it creates neurological confusion. The brain responds by tightening all the tissue around that area to provide artificial stability.
How many patients come in your practice and say, “I feel great after I get adjusted, but the tightness returns a day or so later”? When patients respond this way, think about what the brain is trying to accomplish by creating “tightness.” The brain is searching for joint stabilization and does so by recruiting mover muscles to tighten and provide artificial stability.
As manual therapists, the tendency for most DCs is to move the joint or muscle to make the area “loose” again, but this doesn’t get to the root of the problem. Uncovering the area that needs stabilization training is the key to relaxing the tightened mover muscles.
If you identify the areas that require stabilization training, you can then give motor-control exercises for that area. This will allow the superficial muscles to relax, because the brain is no longer recruiting additional muscles to assist the ones failing to adequately stabilize the joints.
A systematic approach
How do you know if an area of the body is supposed to be mobile or stable? Physical therapist Gray Cook and strength coach Mike Boyle came out with a joint-by-joint approach to the body. They determined the areas of the body that mostly need to be mobile and those that mostly need to be stable.
Stability can also be termed motor control because instead of increased muscle hypertrophy, what is often needed is better communication between the brain and the stabilizing system of the joint. Motor control is facilitated by the transmission of nerve impulses from the motor cortex, resulting in muscle contractions.
Table 2 shows areas that primarily need stability via motor control. The stabilizing system of joints is composed of active (muscle) and passive (joint), components as well as neurologic factors (brain and nerves). The joints aren’t inherently stable because they need to be both stable and readily mobile, thus requiring the coordinated contraction of muscles.
The first thing you should notice is the joints alternate between mobility and stability, e.g., the ankle needs increased mobility, and the knee needs increased stability. This allows for the efficient transmission of forces throughout the body so that not just one area accumulates stress.
A trend in musculoskeletal therapy is a move away from assessing joints and muscles in isolation to a more holistic approach of assessing movement patterns. For example: Instead of isolating the gluteus medius when training the hip, train the pattern of resisting internal rotation of the femur. There are more muscles than just the gluteus medius in the hip and they are all either movers or stabilizers.
By using a whole-body movement screen to identify dysfunction, you can then look at individual regions to treat accordingly. Using the joint-by-joint approach helps you understand if the area needs more mobility or more stability.
Doctors, therapists, and trainers are all moving toward a more regional approach to treat the area of complaint and then reintegrate that area with the rest of the body by grooving movement patterns. Some term this approach as “treating movements—not muscles.”
Injuries relate closely to joint dysfunction, which may or may not be the area of complaint. The back may be symptomatic but the problem could be a lack of hip mobility. Loss of function in the joint below—in the case of the lumbar spine, it’s the hips—seems to affect the joint or joints above.
In other words, if the hips can’t move, the lumbar spine will move in excess to compensate. The problem is that the hips are designed for mobility, and the lumbar spine for stability. When the intended mobile joint becomes immobile, the stable joint is forced to move as compensation, becoming less stable and subsequently painful.
The hips become tight because the core is not strong enough and the hip musculature is being recruited for artificial stability. Like a governor on a motor that controls its speed for safety, the brain can work the same way with the body. It might elect to make the hips (which are supposed to be mobile) tight to slow the system down.
A straightforward process
Given the above, it’s easy to see how this plays out in action:
- Lose ankle mobility—get knee, calf, or foot pain
- Lose hip mobility—get low-back pain
- Lose thoracic mobility—get neck, shoulder, or low-back pain
These processes are the results of movement dysfunction, which in turn fuels a vicious cycle. As the spine moves to compensate for the lack of strength and mobility of the hip, the hip loses more mobility. This leads to compensatory motion at the spine. The end result is a kind of conundrum, a joint that needs both strength and mobility in multiple planes.
The lumbar spine is a series of joints in need of stability, as evidenced by research in the area of core support. Some trainers mistakenly attempt to increase the static and active range of motion of an area that should be stable.
An open window
Most if not all of the rotary exercises designed for the lumbar spine have been misdirected. Shirley Sahrmann, PT, PhD,1 and James Porterfield, PT, and Carl DeRosa, PT, PhD,2 all indicate attempting to increase lumbar spine range of motion is not recommended and potentially dangerous.
If increased mobility is a mistake in areas like the lumbar spine, how do patients respond if you manipulate and artificially put more mobility into the segments? In the short term, the patient gets increased motor control, but that may only last between 30 minutes and 24 hours. That’s why you see improved range of motion that slowly diminishes over a day or so.
The way to keep this physiological window open is with some sort of neurosensory input to the area. Consider using kinesiology tape in conjunction with low-force exercises to allow the brain to adapt to the new range of motion.
Edward Le Cara, DC, PhD, ATC, CSCS, recently sold his practice of 14 years in California and relocated to Dallas. He is the director of athletic training at The KinetikChain and the director of trans global education at RockTape. He can be contacted at firstname.lastname@example.org, on Twitter and Instagram at @drlecara, or through rocktape.com.
1 Sahrmann S. (2001). Diagnosis and Treatment of Movement Impairment Syndromes. Maryland Heights, MO: Mosby.
2 Porterfield J, DeRosa C. (1995). Mechanical Low Back Pain: Perspectives in Functional Anatomy. Philadelphia: Saunders.