While Vladimir Janda was the first to recognize Upper Crossed Syndrome (UCS) and Lower Crossed Syndrome (LCS), few studies have validated the specific pattern of muscle imbalance and postural abnormalities associated with these common muscle imbalance syndromes.

Janda's Upper Crossed Syndrome Janda’s Upper Crossed Syndrome

 

Matthias Treff, a Masters student in Engineering at Virginia Polytechnic recently wrote his thesis, “An investigation of musculoskeletal imbalances in the thoracic and cervical regions, with respect to an improved diagnostic approach for Upper Crossed Syndrome.” The purpose of his research was to determine if differences existed in cervical range of motion as well as cervical and shoulder muscle performance between a group of patients with UCS and subjects without symptoms. The study was a case-control design of 17 subjects with UCS (15 females and 2 males) and 17 matched healthy subjects. They were tested for range of motion and isometric strength and endurance of the neck and shoulder muscles using an isokinetic dynamometer. Compared to healthy subjects, statistically significant decreases in active neck range of motion in bending and rotation were found in the UCS patients, but there was no difference in flexion or extension range of motion. Significant weakness in isometric neck flexion and extension was found in the UCS patients compared to healthy subjects, as well as significant isometric weakness of shoulder external rotation and adduction. Strength ratios of shoulder internal/external rotation and abduction/adduction were also significantly lower in the UCS patients. There was no significant difference in muscular endurance between the UCS patients and healthy controls. The author correctly notes that the diagnosis of UCS is often made through observation of posture and movement patterns. Janda did not advocate manual muscle testing because of the limitations of pain and reliability. The subjects in this study were included based on postural observation and pain complaints, rather than an actual diagnosis of UCS from a set of diagnostic criteria:

“Inclusion criteria for this group were: presence of postural deficiencies such as forward head posture, increased cervical lordosis and thoracic kyphosis, elevated and protracted shoulders, and rotation or abduction and winging of the scapulae, and constant or frequently occurring neck- and shoulder pain for more than 6 months”

This thesis helped validate the patterns of muscle imbalance with objective measurements of strength and range of motion. Other studies on patients with upper quarter musculoskeletal pain such as chronic neck pain (Jull et al. 1999), cervicogenic headache (Page, 2011), and shoulder impingement (Cools et al. 2003) have identified muscular strength imbalances consistent with Janda’s classification. While this study helped support Janda’s classification of muscle imbalance patterns in patients with symptoms of UCS, further research can help strengthen evidence-led clinical management. Evaluation the strength of the scapular muscles (also included in Janda’s muscle classification of UCS) would be beneficial. Unfortunately, this research did not correlate the objective findings of muscle strength and range of motion with Janda’s movement patterns (cervical flexion, shoulder abduction), which are critical to an appropriate diagnosis of UCS. I’m hopeful that the author considers publication in a peer-reviewed journal to help strengthen its validity in the rehabilitation literature.

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Hip exercises beneficial for anterior knee pain

by Dr. Phil on September 24, 2012

Patellofemoral pain syndrome (also known as anterior knee pain) is characterized by pain around the kneecap that increases with prolonged activity or prolonged sitting. It is more common in females and is associated with weakness of the hip, particularly hip abductors, extensors and rotators (Prins et al. 2009) as Dr. Janda had proposed. This weakness is thought to lead to biomechanical deficits at the knee, most notably an increased knee abduction torque, which may alter patellar alignment over the distal femur at the knee. In addition, researchers (Leetun et al. 2004) have found that athletes with weak hip abductors and extensors in pre-participation screenings are more likely to be injured.

Therapeutic exercise programs strengthening the ‘proximal’ musculature (hip and core) have been successful in relieving symptoms of anterior knee pain. A research article in the American Journal of Sports Medicine reported on the outcomes of an exercise program in a series of young females with patellofemoral pain syndrome. After the 8-week exercise program, 17 out of 19 (89%) of the participants had successful outcomes. They had significant improvements in pain, functional ability, core endurance, and hip strength, as well as improvement in the knee abduction angle during gait. The main limitation of this study was the lack of a true control group, which would be able to identify if the exercise program was responsible for the improvements observed.

It would have been beneficial if the authors had identified specific muscle imbalance patterns within the individuals and prescribe an individualized program. In the current study, all participants performed the same exercises regardless of the presence of muscle imbalance. Such information would be helpful in determining if an individualized therapeutic exercise program can be more efficient and effective by targeting specific impairments.

Females with patellofemoral pain syndrome can benefit from a proximal strengthening program. A true control group and long-term follow-up would have been beneficial in further validating the efficacy of the program.

REFERENCE: Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011 Jan;39(1):154-63. Epub 2010 Oct 7.

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Prescribe appropriate instability levels during balance training exercises in low back pain patients

September 20, 2012

Dr. Janda often prescribed sensorimotor training exercises using unstable surfaces for patients with chronic low back pain. Dr. Janda considered unstable surfaces such as balance boards as important tools in rehabilitation of chronic musculoskeletal pain syndromes. His Sensorimotor Training program utilizes unstable surfaces can help facilitate automatic postural reactions, which are not possible through voluntary muscle […]

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Treating hamstring cramps: Functional or Structural Approach?

May 8, 2012

Imagine this case scenario: An elite triathlete is referred to your clinic for chronic hamstring cramps in his right leg. A traditional ‘structural’ approach would involve a stretching and strengthening program of the hamstrings. A more ‘functional’ approach would include an assessment of the entire lower kinetic chain, pelvis and trunk to look for biomechanical […]

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Groin strains related to hip muscle imbalance

May 2, 2012

                Fans of Dr. Janda’s work know it’s always important to evaluate more than just the area of pain, particularly the proximal segments of a more distal pathology. Recently, hip weakness was associated with anterior knee pain in several studies, as suggested by Janda. These proximal muscle imbalances are thought to lead to altered motor […]

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Can the scapula play a role in Thoracic Outlet Syndrome rehabilitation?

April 23, 2012

Thoracic Outlet Syndrome (TOS) is a complex and sometimes difficult condition to identify and treat. Thoracic outlet syndrome occurs with compromise of the nerves and blood vessels passing from the neck into the arm through a region known as the “thoracic outlet”. Entrapment of this neurovascular bundle can lead to both neurological symptoms (numbness and […]

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Evidence for DNS: Diaphragmatic dysfunction in low back pain patients

April 10, 2012

I’ve been a fan of Pavel Kolář’s work in merging the work of Vojta and Janda. Dr. Janda said Pavel was one of his best students, and often pointed to his emerging work with developmental kinesiology at the time and its implications in rehabilitation. I’ve attended several of the “pre-DNS” (Dynamic Neuromuscular Stabilization) courses including […]

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Lower Crossed Syndrome Type A vs. Type B: What’s the difference?

January 23, 2012

I recently received a question about the difference between Janda’s Type A Lower Crossed Syndrome and Type B Lower Crossed Syndrome. Janda talked about his Lower Crossed Syndrome have 2 different presentations in patients; one manifested in the lower back (Type B) and the other in the hip (Type A).  According to Assessment and Treatment of […]

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Isolated Hip Exercise Reduces Anterior Knee Pain

January 13, 2012

Anterior knee pain is often associated with hip muscle weakness of the abductors, extensors and external rotators. Dr. Vladimir Janda noted these muscles were particularly susceptible to inhibition and weakness. Patellofemoral pain is often associated with muscle imbalance. Hip weakness is particularly prevalent in females with anterior knee pain. This hip weakness is thought to […]

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FREE Webinar on Cervicogenic Headaches

December 15, 2011

About half the population suffers from headaches, and 15 to 20% of those headaches include head and neck pain. This type of headache is recognized as a ‘cervicogenic headache.’  It’s important to make an accurate diagnosis of cervicogenic headaches to initiate the proper treatment. Dr. Vladimir Janda discussed the presence of his Upper Crossed Syndrome […]

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