Lower back and hip pain - Professor Shirley Sahrmann

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I was privileged to be able to hear Professor Shirley Sahrmann speak in Manchester on Sunday 6^th November 2011. For those who don't know her, she is a highly regarded expert on muscle and movement imbalances. Her book, Diagnosis and Treatment of Movement Impairment Syndromes, is an absolute must read for any therapist working with the body, regardless of modality.

Prof. Sahrmann is based at Washington University, USA, so to catch her on a flying visit to the UK was an opportunity not to be missed.

So what was I there to learn? The official title of the course was Differentiation and Effective Management of Lumbar Spine and Hip Pain using the Movement System Syndromes Approach. A bit of a mouthful I think you'll agree.

Issues covered:

• Kinesiology of the lumbar spine, pelvis and hip.
• The concept of relative flexibility and it's presentation in the lumbar spine and hip
• Current knowledge of the structural variations in the hip including cam and pincer.
• Movement systems syndromes of the lumbar spine and hip joint, and contributing factors.
• Clinical and research evidence of the interactions between the lumbar spine and hip.
• Practical application of the movement system syndromes including screening and clinical reasoning.
• Rehab exercises to correct movement faults.

The objectives of the day were to enhance our treatment strategy when a client presents with back and hip pain, learn how to effectively manage those conditions and have a more systematical way to examine those clients.

What have I learnt?
There were some big issues that have resounded with me since the course last weekend.

• All Systems in the body involve Movement, be it muscle fibres contracting to produce movement via the joints and bones, gases being exchanged in the respiratory system and the circulatory system transporting those gases and nutrients to where they are needed. Any abnormality in any one of the systems affects the others, and all structures in the body. Something works less efficiently, becomes dysfunctional and pain is felt. 

• Repeated Movements and Prolonged Postures cause deviations at joints, making them less efficient, dysfunctional and in some cases painful. The tissue changes that occur with Repeated Movements and Prolonged Postures includes neuromuscular changes. The progression of dysfunction and its associated degenerative changes is not only affected by physiological factors, but also biomechanical interactions and through an individuals lifestyle and personal movement patterns - the way that everyday activities are performed is the critical issue.

• The body will always chose to move along the path of least resistance. With the resulting tissue changes from Repeated Movements and Prolonged Postures, relative flexibility or weakness can develop. For example, long distance runners typically have strong and dominant hamstrings, rectus femoris (one of your quadriceps) and tensor fascia lata (involved in hip flexion, medial rotation and abduction) - bending the hip, turning it in, and pushing it out whereas weakness tends to develop in the iliopsoas (hip flexors) and gluteus maximus (external hip rotation and hip extension). The joint movements can then become disrupted from the optimal, and in this case, where the hamstrings are dominant and gluteus maximus weak, the end result can be a hamstring strain. Sahrmann attributes this to the joint movement being altered because the muscles which should be working to control the precise, pain free movement of hip extension, are not doing so. I'll write more about this soon because it really is fascinating, and definitely a topic for all runners to know more about.

• You get what you train. Quite simply, if you train a muscle to be strong, it will hypertrophy and develop more fibres, and hence be stronger. But, and this is the important point, following on from the previous point about the path of least resistance, those muscles not trained (or not as much) will be comparatively weaker.  Why is this important? Well, if you have strong quadriceps (thigh muscles) but weaker abdominals (stomach muscles) your pelvis will be pulled down at the front and this can lead to lower back pain because of an increased lumbar curve.

• The presence of a muscle doesn't not mean it is being used appropriately. Sahrmann calls this "missing in action"- meaning that although there is physically a muscle being "worn" does not automatically mean it's working the way is should. This also contributes to the path of least resistance in movement.

• The final message which is still ringing in my ears is this, You will continue to do what is familiar, not necessarily what is right.  It's worth reading that again to really get it in your head.

Having a good therapist (and Sahrmann is a very, very good one) test muscles for movement impairments and weaknesses is essential. It is the first step to correcting any imbalances you may have. You have, of course, got to want to make the change, as different ways of moving will need to become habit. They have to become part of your daily activities. Comfortingly, this is one message which we at Global Therapies already advise our clients. We show clients where they have movement patterns or imbalances which are sub-optimal, and then educate them on how to modify movements and strengthen specific areas to improve symptoms.

I have to say that I'm quite overwhelmed by the amount of knowledge passed on by Prof. Sahrmann. She is quite incredible, and to see her working with a client, demonstrating the tests she carries out was truly humbling. I'll be ordering her second book, there's a whole lot more for us to learn yet.