Movement, Stability & Lumbopelvic Pain: Integration of research and therapy, 2nd Edition, Edited by Andry Vleeming, Vert Mooney and Rob Stoekart
By Robert McWilliams, Certified Rolfer®, BFA, MFA Dance
Movement, Stability & Lumbopelvic Pain: Integration of Research and Therapy (2nd Edition; Churchill Livingston, Elsevier 2007) is a compendium of articles on lumbopelvic function and pathology from over fifty authors, including many hundreds of book and study source citations. As the editors state in the preface, one individual author could never put forward so many diverse aspects of the anatomy, epidemiology, clinical treatment experience and theory of this subject. All the material presented is “evidence based,” and as it doesn’t all agree yet, the editors seek to help clinicians develop an “evidence informed” approach to helping clients with lumbopelvic pain. For me, as a “non-scientist” and new Rolfer, it was hard to get through some of it, because of the density and depth of presentation. I have, however, found the sections I persisted with to have paid off. In practical terms, the work has given me a clearer sense of structures to free, connect and stabilize in order to achieve a particular effect. It is an opportunity for Rolfers who are not yet familiar with the vocabulary employed by physical therapists, osteopaths and orthopedists, to become more so. Concepts ranging from the lumbopelvic “self-bracing mechanisms” of form and force-closure, “moments of force” in joint kinesiology, and coupling motion concepts in the spine with alterations depending on the center of rotation are detailed and explained. For example, a different center of rotation will create either a counterclockwise, clockwise or fixed position of a vertebral problem given the same mix of lordosis and side-bend, a fact which has definite implications in “spinal mechanics” work with clients.
The opening chapter starts off describing the continuous ligamentous “stocking” in which the lumbar vertebrae and sacrum are positioned as being a key to its support, stability and function through the “self-bracing mechanism” of the area. It goes through a series of layer-by-layer dissections, with clear descriptions of the interconnections of the fascial layers and muscles affecting the whole region, ranging from the hamstrings to connections through to the mid-thoracics. Much discussion is devoted to potential stabilizing and de-stabilizing factors for the sacroiliac joint (SIJ), and lumbars. I think most Rolfers would find the images and discussion contained in the first chapter enlightening, as it includes clear imagery and concepts based on new information. The evidence in the work is often based on porcine and cadaver studies. Some of this information is hard to make out with the grayscale used, and some of the graphics were not always the easiest to follow, but definitely worth the effort.
This 2nd edition is significantly updated from the previous one, with new authors, and drawing on many studies as recent as 2006. Though it seeks to be based on hard science, it is not monolithic. Several points of view are represented, and some of them conflict. For example, questions about form closure versus force closure at the SI joint remain unresolved, in sum, by the array of varying ideas, dissections and kinematic studies presented. The work is full of amazing facts to ponder, such as “the degree of pain perceived from injury to the spinal ligaments is related to the speed of the injury and not to its extent” (Willard, referring to Olmarkrer et al., 1990). This would speak to the trauma and problems caused by car accidents, and some of the difficulty treating them.
In addition to sections on lumbar and sacral anatomy, the book focuses on function, clinical experience, kinematics, theory of SIJ stability, instability, form and/or force closure, diagnostic methods including CAT, MRI and x-ray, and demonstrates many manual tests for instability at the SIJ. In a photographed case study, Diane Lee shows the clinical benefits of specific motor control retraining of the multifidi and associated stabilizers to ease lumbar pain. Levin presents tensegrity theory, and theories on the possible evolution of the pelvis from costovertebral joints are gently disputed within various articles throughout the work. I was intrigued by Serge Gracevotsky’s wide-ranging discussion of “stability or controlled instability” that rolls through evolutionary subjects, gait, “creep”, spinal coupling, until concluding with the importance of a ridge structure at the tip of the transverse processes of S1 and S3 that locks into the innominates and “transfers the vertical loads” that he considers to be weight-bearing.
If there is a fault, it might be the decidedly mechanistic slant of most of the articles, as if “lack of stability in structure X here is remedied by exercising muscle Y there,” which is clearly limited as an approach. There is no real development of ideas anywhere on psychosomatic pain in the lumbopelvic region. Many passages on rehabilitative movement and exercise contain no discussion of quality of motion. Anticipatory reflex action mechanisms and their importance in setting muscle tone are discussed in a fascinating article, “Motor Control in Chronic Pain: new ideas for effective intervention” by G. Lorimer Mosely. Diane Lee and Andry Vleeming are given the last word in “An integrated therapeutic approach to the treatment of pelvic girdle pain.” This article focuses on combining the physical and emotional/cognitive factors involved in influencing joint motion, termed a “functional integration” approach to detrimental motor and patterns.
No Rolfers are quoted in the work, but some of the authors are probably already familiar to the Rolf community: Jean-Pierre Barral is cited; so are Serge Gracevotsky, author of The Spinal Engine, Diane Lee, an eminent clinician/author on pelvic pain, and Stephen M. Levin, MD, who writes here about the tensegral model. To me this begs the question: why no mention of Rolfing®? It would seem that Rolfing is completely off their radar. Because of the focus on fascial planes, functional “slings” and the interconnectedness and relatedness of structures in cases of dysfunction and pain, it would seem that the editors are looking for a general, holistic model. Perhaps some scientific minded Rolfer can present it to them in a way that is “evidence-based.”