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
Vladimir Janda & Phil Page, 2002
medical degree specializing in neurology and physical medicine. He published his first book in
Czechoslovakia on muscle testing at the age of 20. Noting the work of Hans Kraus, as well as
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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.
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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 centrallymediated (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.
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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.
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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
Phasic Muscles
Prone to Tightness or Shortness
Prone to Weakness or Inhibition
Gastroc-Soleus
Peroneus Longus, Brevis
Tibialis Posterior
Tibialis Anterior
Hip Adductors
Vastus Medialis, Lateralis
Hamstrings
Gluteus Maximus, Medius, Minimus
Rectus Femoris
Rectus Abdominus
Iliopsoas
Serratus Anterior
Tensor Fascia Lata
Rhomboids
Piriformis
Lower Trapezius
Thoraco-lumbar extensors
Deep neck flexors
Quadratus Lumborum
Upper limb extensors
Pectoralis Major
Upper Trapezius
Levator Scapulae
Scalenes
Sternocleidomastoid
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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.
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Upper Crossed
Syndrome
Lower Crossed
Syndrome
Facilitated
Rectus Femoris / Iliopsoas
Lower Crossed
Syndrome
Inhibited
Abdominals
Facilitated
SCM / Pectoralis
Facilitated
Upper Trap / Levator Scapula
Suboccipitals
Inhibited
Lower Trap / Serratus Ant.
Lower / Middle
Trap.
Facilitated
Thoraco-lumbar extensors
Quadratus
LumborumInhibited
Gluteus Min / Med/ Max
Upper Crossed
Syndrome
Inhibited
Deep cervical flexors
Figure 1 : Janda's Muscle Imbalance Syndromes
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.
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.
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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
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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 postfacilitation 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
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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.
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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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