The Janda Approach

The Janda Approach to Chronic

Musculoskeletal Pain

Phil Page, MS, PT, ATC, CSCS

Clare Frank, PT, MS, OCS

Dr. Vladimir Janda was a Czech neurologist and physiatrist. He retired as the director of

the physiotherapy school at the Charles University 3rd Faculty of Medicine in 2000. Janda has

done extensive clinical research on the pathogenesis and treatment of chronic musculoskeletal

pain. He is known around the world for his concepts

of muscle imbalance, and continued to be active in

clinical practice, research, and lecturing until his

death in November, 2002. The purpose of this paper

is to review Janda’s approach to the evaluation and

management of chronic musculoskeletal pain.

Janda became interested in physical medicine

after falling victim to polio in his teens. He spent 3

years in rehabilitation, after which he pursued his

medical degree specializing in neurology and physical medicine. He published his first book in

Copyright 2007 Philip Page 1

Vladimir Janda & Phil Page, 2002

Czechoslovakia on muscle testing at the age of 20. Noting the work of Hans Kraus, as well as

that of Henry and Florence Kendall, Janda became intrigued by the functional role of muscles.

He first observed that both polio and low back pain patients often had a dysfunctional gluteus

maximus. His observations led to testing his patients with surface electromyography where he

noted patterns of muscle contraction with particular limb movements, leading him to conclude

that the timing or recruitment pattern of synergists should be emphasized rather than traditional

manual muscle testing for strength. His thesis, “Postural and phasic muscles in the pathogenesis

of low back pain” was presented in 1968 (Janda, 1968). In 1979, he identified his specific

“crossed syndromes” of muscle imbalance (Janda, 1979) based on his clinical observations and

research and theorized that muscle imbalance was predictable and involved the entire motor

system.

Structure vs. Function

In musculoskeletal medicine, there are two main schools of thought, that is, a structural

or functional approach. In the structural approach, the pathology of specific static structures is

emphasized; this is the typical orthopaedic approach that emphasizes diagnosis based on

localized evaluation and special tests (X-Ray, MRI, CT Scan, etc). On the other hand, the

functional approach recognizes the function of all processes and systems within the body, rather

than focusing on a single site of pathology. While the structural approach is necessary and

valuable for acute injury or exacerbation, the functional approach is preferable when addressing

chronic musculoskeletal pain.


The Sensorimotor System

In chronic pain, special diagnostic tests of localized areas (for example, low back

radiographs) are often normal, although the patient complains of pain. The site of pain is often

not the cause of the pain. Recent evidence by supports the fact that chronic pain is centrally-

mediated (Staud et al. 2001). Similarly, research on the efficacy of different modes of exercise

management of chronic pain has shown a central effect of exercise in decreasing chronic low

back pain (Mannion et al. 1999). This research supports the basis of Janda’s approach: the

interdependence of the musculoskeletal and central nervous system. Janda states that these two

anatomical systems cannot be separated functionally. Therefore, the term “sensorimotor” system

is used to define the functional system of human movement. In addition, changes within one part

of the system will be reflected by compensations or adaptations elsewhere within the system

because of the body’s attempt at homeostasis (Panjabi, 1992).

The muscular system often reflects the status of the sensorimotor system, as it receives

information from both the musculoskeletal and central nervous systems. Changes in tone within

the muscle are the first responses to nociception by the sensorimotor system. This has been

supported by various studies demonstrating the effect of joint pathology on muscle tone. For

example, the presence of knee effusion causes reflex inhibition of the vastus medialis (Stokes &

Young, 1984). The multifidus has been shown to atrophy in patients with chronic low back pain

(Hides et al. 1994), and muscles demonstrate increased latency after ankle sprains (Konradsen &

Raven, 1990) and ACL tears (Ihara & Nakayama, 1986). The global effect of joint pathology on


the sensorimotor system was demonstrated by Bullock-Saxton (1994). She noted a delay in firing

patterns of the hip muscles and decreased vibratory sensation in patients with ankle sprains.

Because of the involvement of the CNS in muscle imbalance and pain, Janda emphasizes

the importance of the afferent proprioceptive system. A reflex loop from the joint capsular

mechanoreceptors and the muscles surrounding the joint is responsible for reflexive joint

stabilization (Guanche et al. 1995; Tsuda et al. 2001). In chronic instability, deafferentation (the

loss of proper afferent information from a joint) is often responsible for poor joint stabilization

(Freeman et al. 1965).

Tonic and Phasic Muscle Systems

Janda identified two groups of muscles based on their phylogenetic development (Janda,

1987). Functionally, muscles can be classified as “tonic” or “phasic”. The tonic system consists

of the “flexors”, and is phylogenetically older and dominant. These muscles are involved in

repetitive or rhythmic activity (Umphred, 2001), and are activated in flexor synergies. The

phasic system consists of the “extensors”, and emerges shortly after birth. These muscles work

eccentrically against the force of gravity and emerge in extensor synergies (Umphred, 2001).

Janda noted that the tonic system muscles are prone to tightness or shortness, and the

phasic system muscles are prone to weakness or inhibition (Table 1). Based on his clinical

observations of orthopedic and neurological patients, Janda found that this response is based on

the neurological response of nociception in the muscular system. For example, following

structural lesions in the central nervous systems (such cerebral palsy or cerebrovascular

accident), the tonic flexor muscles tend to be spastic and the phasic extensor muscles tend to be


flaccid. Therefore, patterns of muscle imbalance may be due to CNS influence, rather than

structural changes within the muscle itself.

It’s important to note that this classification is not rigid, in that some muscles may exhibit

both tonic and phasic characteristics. It should also be noted that in addition to neurological

predisposition to tightness or weakness, structural changes within the muscle also contribute to

muscle imbalance. However, in chronic pain that is centralized within the CNS, patterns of

muscle imbalance are often a result of neurological influence rather than structural changes.

Tonic Muscles

Prone to Tightness or Shortness

Phasic Muscles

Prone to Weakness or Inhibition

Gastroc-Soleus

Tibialis Posterior

Hip Adductors

Hamstrings

Rectus Femoris

Iliopsoas

Tensor Fascia Lata

Piriformis

Thoraco-lumbar extensors

Quadratus Lumborum

Pectoralis Major

Upper Trapezius

Levator Scapulae

Peroneus Longus, Brevis

Tibialis Anterior

Vastus Medialis, Lateralis

Gluteus Maximus, Medius, Minimus

Rectus Abdominus

Serratus Anterior

Rhomboids

Lower Trapezius

Deep neck flexors

Upper limb extensors


Scalenes

Sternocleidomastoid

Upper limb flexors

Table 1: Tonic & Phasic Muscles

Janda’s Crossed Syndromes

Over time, these imbalances will spread throughout the muscular system in a predictable

manner. Janda has classified these patterns as “Upper Crossed Syndrome” (UCS), “Lower

Crossed Syndrome” (LCS), and “Layer Syndrome” (LS) (Janda, 1987, 1988). [UCS is also

known as “cervical crossed syndrome”; LCS is also known as “pelvic crossed syndrome; and LS

is also known as “stratification syndrome.”] Crossed syndromes are characterized by alternating

sides of inhibition and facilitation in the upper quarter and lower quarter. Layer syndrome,

essentially a combination of UCS and LCS is characterized by alternating patterns of tightness

and weakness, indicating long-standing muscle imbalance pathology. Janda’s syndromes are

summarized in Figure 1.


Upper crossed syndrome is characterized by facilitation of the upper trapezius, levator,

sternocleidomastoid, and pectoralis muscles, as well as inhibition of the deep cervical flexors,

lower trapezius, and serratus anterior. Lower crossed syndrome is characterized by facilitation of

the thoraco-lumbar extensors, rectus femoris, and iliopsoas, as well as inhibition of the

abdominals (particularly transversus abdominus) and the gluteal muscles.


InhibitedDeep cervical flexors

FacilitatedUpper Trap / Levator Scapula

SuboccipitalsFacilitated

SCM / PectoralisInhibited

Lower Trap / Serratus Ant. Lower / Middle Trap.

InhibitedAbdominals

FacilitatedThoraco-lumbar extensors

Quadratus LumborumInhibited

Gluteus Min / Med/ MaxFacilitated

Rectus Femoris / Iliopsoas

Upp

er C

ross

ed

Synd

rom

eLo

wer

Cro

ssed

Sy

ndro

me

Lower C

rossed Syndrom

eU

pper Crossed

Syndrome

Figure 1 : Janda's Muscle Imbalance Syndromes

By using Janda’s classification, clinicians can begin to predict patterns of tightness and

weakness in the sensorimotor system’s attempt to reach homeostasis. Janda noted that these

changes in muscular tone create a muscle imbalance, which leads to movement dysfunction.

Muscles prone to tightness generally have a “lowered irritability threshold” and are readily

activated with any movement, thus creating abnormal movement patterns. These imbalances and

movement dysfunctions may have direct effect on joint surfaces, thus potentially leading to joint

degeneration. In some cases, joint degeneration may be a direct source of pain, but the actual

cause of pain is often secondary to muscle imbalance. Therefore, clinicians should find and treat

the cause of the pain rather than focus on the source of the pain.

Systematic evaluation of muscular imbalance begins with static postural assessment,

observing muscles for characteristic signs of hypertonicity or hypotonicity. This is followed by

observation of single leg stance and gait. Static posture, gait and balance often give the best

indication of the status of the sensorimotor system. Computerized force plate posturography is

often valuable in quantifying sensory and motor deficits. Next, characteristic movement patterns

are assessed, and specific muscles are tested for tightness or shortness. Surface

electromyography is useful in quantifying muscle activation patterns. All the above information

collected provides the clinician a system to determine or rule out the presence of muscle

imbalance syndromes. Furthermore, identification of specific patterns and syndromes of

imbalance also provides the clinician to choose appropriate interventions to address the cause of

the dysfunction.

Janda Approach to Treatment


1. Normalize the periphery. The Janda approach to treatment of musculoskeletal pain

follows several steps. Treatment of muscle imbalance and movement impairment begins with

normalizing afferent information entering the sensorimotor system. This includes providing an

optimal environment for healing (by reducing effusion and protection of healing tissues,

restoring proper postural alignment (through postural and ergonomic education), and correcting

the biomechanics of a peripheral joint (through manual therapy techniques).

2. Restore Muscle Balance. Once peripheral structures are normalized, muscle balance is

restored. Normal muscle tone surrounding joints must be restored. Sherrington’s law of

reciprocal inhibition (Sherrington, 1907) states that a hypertonic antagonist muscle may be

reflexively inhibiting their agonist. Therefore, in the presence of tight and/or short antagonistic

muscles, restoring normal muscle tone and/or length must first be addressed before attempting to

strengthen a weakened or inhibited muscle. Techniques to decrease tone must be specific to the

cause of the hypertonicity. These include post-isometric relaxation (PIR) (Lewit, 1994) and post-

facilitation stretch (PFS) (Janda, 1988).

Muscles that have been reflexively inhibited by tight antagonists often recover

spontaneously after addressing the tightness. In the Janda approach, the coordinated firing

patterns of muscle are more important than the absolute strength of muscles. The strongest

muscle is not functional if it cannot contract quickly and in coordination with other muscles;

therefore, isolated muscle strengthening is not emphasized in the Janda approach. Instead,

muscles are facilitated to contract at the proper time during coordinated movement patterns to

provide reflexive joint stabilization.


3. Increase afferent input to facilitate reflexive stabilization. Once muscle balance has

been addressed, Janda stresses increasing proprioceptive input into the CNS with a specific

exercise program, “Sensorimotor Training” (SMT) (Janda & Vavrova, 1996). This program

increases afferent information entering the subcortical pathways (including spinocerebellar,

spinothalamic, and vestibulocerebellar pathways) to facilitate automatic coordinated movements.

SMT involves progressive stimulation through specific exercises with increasing level of

challenge to the sensorimotor system. SMT has been proven to improve proprioception, strength,

and postural stability in ankle instability (Freeman et al. 1965), knee instability (Ihara &

Nakayam, 1996), and after ACL reconstruction (Pavlu & Novosadova, 2001).

4. Increase endurance in coordinated movement patterns. Finally, endurance is increased

through repetitive, coordinated movement patterns. Since fatigue is a predisposing factor to

compensated movement patterns, endurance is also more important than absolute strength.

Exercises are performed at low intensities and high volumes to simulate activities of daily living.

The Janda approach is valuable in today’s managed care environment. Once these

patterns and syndromes are identified, specific treatment can be implemented without expensive

equipment. Early detection of these causes of chronic pain allows the clinician to treat the

patient with fewer visits and less expensive equipment compared to traditional interventions that

emphasize modalities and passive treatments. The key to the Janda approach is in the home

exercise program. Inexpensive home exercise equipment such as wobble boards, elastic bands,


and foam pads are used with a specific progression of exercises as the patient improves in

function.

Summary

In summary, the Janda approach emphasizes the importance of the CNS in the

sensorimotor system, and its role in the pathogenesis in musculoskeletal pain. In particular: the

neurological pre-disposition of muscles to exhibit predictable changes in tone, and the

importance of proprioception and afferent information in the regulation of muscle tone and

movement. Therefore, assessment and treatment focus on the sensorimotor system, rather than

the musculoskeletal system itself. Using a functional, rather than a structural approach, the cause

of musculoskeletal pain can be quickly identified and addressed. The Janda approach can be a

valuable tool for the clinician in the evaluation and treatment of chronic musculoskeletal pain.


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The Janda Approach