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ACADEMY
REVIEW ARTICLE Open Access

A Novel Approach to Treating Musculo-skeletal Disorders and Injuries:

Global Posture Systems Therapeutic Pathways Approach
Stef Harley, Alice Zelco, Bogdan Ambrožič, Nedda Pellegrini, Valeria Leoni

ABSTRACT Global posture is a good indicator of general musculoskeletal health. Prevalence and incidence
of musculoskeletal disorders and injuries, and in particular low back pain, is rapidly rising on a global scale. The
tightness or spasm Quadratus Lumborum muscle is a common cause for non-specific low back pain and is also closely
connected to postural deviations and faulty movement patterns. Having a more complete, holistic and encompassing
view of postural deviations will give the clinician more information to put into the clinical reasoning process. A more
efficient and effective treatment plan with long-term results is usually the result. We propose Global Posture Systems
Therapeutic Pathways as possible solution to more effectively and efficiently treat musculoskeletal disorders and
injuries. In this paper we explain the concept in more detail using a case of a chronically tight Quadratus Lumborum
muscle that causes low back pain and functional issues. It is also the cause of important postural deviations. At the
centre of the GPS Therapeutic Pathways concept lies a thorough static posture assessment. This provides the clinician
information on which systems affect posture and how this affects an injury or injury risk. It forms the basis for
choosing the right GPS Therapeutic Pathway. A first pathway focusses on autogenic relaxation, breathing techniques,
myofascial release and stretching using the innovative therapeutic couch, Mi.TO/Sinthesi. In a second phase we
stimulate pain modulation and cellular regeneration with a capacitive and resistive energy transfer technology, TCare.
A third pathway assists the clinician in being able to suit each type of therapeutic exercise exactly to the patient’s needs
using various configurations of suspension slings and pulleys; the Archimedes Pulley System with BlueCord Exercise
System. Lastly new and healthy movement and posture patterns are integrated in every day living activities using a
variety of proprioceptive and integrative exercise tools.

Conclusion: When comparing the before and after digital images recorded with the GPS Postural Lab we can clearly
see improvement in the patient’s posture indicating that the chronically tight Quadratus Lumborum muscle has been
effectively released and lengthened. We conclude that GPS Therapeutic Pathways is a very interesting concept that is
cost-effective, able to be applied to many different types of neuromusculoskeletal disorders and can be integrated in
modern rehabilitation and physical therapy centres.

Keywords: global posture, musculoskeletal injuries and disorders, poor posture, posture assessment, clinical
reasoning, therapeutic pathways.

Author details:
1. Department of physiotherapy, Higher Education Institute Fizioterapevtika, Laško, Slovenia
2. Private physiotherapy practice, Synovia Fizioterapija, Grosuplje, Slovenia
3. Scientific coordinator, Global Posture Systems Academy, Udine, Italy

Correspondence: stefharley@yahoo.com

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Background

There is a general consensus within the medical community that
global posture is a good indicator of musculoskeletal health (1).
Global posture is the composition of the positioning of all body
segments at a given point in time (2,3). Good posture provides
muscular and skeletal balance which protects the supporting
structures of the body against injury or progressive deformity,
irrespective of the attitude in which these structures are working or
resting (4,5). Poor posture is a faulty relationship of various parts
of the body which produces increased strain on the supporting
structures and in which there is less efficient balance of the body
over its support base (4,6). It is therefore acceptable to assume
that poor posture can be linked to the aetiology of the majority of
musculoskeletal disorders.
It is a grave concern that the prevalence and incidence of
musculoskeletal disorders continue to rise on a global level (7).
The World Health Organisation (WHO) reports in the 2013 Global
Burden of Disease Study that musculoskeletal disorders have
increased disability with 60.7% globally. Low back pain (LBP)
was the most common disorder in this category. It is well known
that 80% of the world population will suffer from low back pain
at least once during their lifetime. And at any given point in time,
eventually leading to a large number of secondary issues. In his
seminal works, Vladimir Janda refers to a cycle of deconditioning
which results in changes in function and physiology of postural
and phasic (locomotor) muscle groups. This eventually leads
to the upper and lower crossed postural syndromes (29-33).
Effectively and efficiently treating postural syndromes or any
posture-related injuries and disorders, including non-specific
low back pain, requires advanced clinical reasoning skills and a
multifaceted approach in developing and managing the treatment
plan (34).
In this paper we will discuss treatment principles of non-specific
low back pain due to QL MTrPs using a global posture systems
approach. We propose a diagnostic and therapeutic approach
- Global Posture Systems (GPS) Therapeutic Pathways - to
effectively and efficiently treat and prevent posture-related injuries
and disorders. GPS Therapeutic Pathways is a multifaceted
approach in which a detailed posture assessment and analysis
plays a pivotal role.
MITO™ Postural table ARCHIMEDE™ Pulley therapy system

up to 33% of the population is affected by it (17-18). Neck pain

is also among the top 10 musculoskeletal disorders according to
the WHO.

Clinicians have always intuitively connected posture and spinal

pain although there is relatively little concrete evidence to GPS 600™ Postural lab

prove a relationship (8,15). However with the introduction of

cost-effective, more advanced and accurate methods to make
quantitative global posture assessments, the body of evidence
to support a definite link between poor posture and spinal pain
is growing (5,9-15). Myofascial pain syndromes, generalised
and regional musculoskeletal disorders, respiratory dysfunction
as well as increased risk of falling in the elderly have all been
linked to poor posture (16). Myofascial trigger points (MTrP)
are a common cause and important subdivision of non-specific
LBP. The quadratus lumborum (QL) muscle often develops active
and latent MTrPs (17). The QL is an important stabiliser of the
lumbar spine and trunk, causes lateral flexion, aids extension Proprioceptive exercises TCARE™ for Tecar therapy
and fixates the 12th rib during inspiration. We rely on QL activity
during spine movements, walking, sitting, and transferring from
lying to sitting to standing. It is thus easy to understand that the Figure 1. GPS Therapeutic Pathways is based on a detailed and accurate GPS
QL can be relatively quickly injured during everyday activities, Postural Labs assessment of the patient’s static posture to investigate which
including the development of active and latent MTrPs (17-23). potential underlying postural deviations are contributing to the current condition.
MTrPs cause a myriad of signs and symptoms, which are often Based on this knowledge the therapist can make a more encompassing therapeutic
considered to be part of myofascial pain syndromes, non-specific plan that can include any of the therapeutic pathways; postural myofascial release
low back pain and fibromyalgia. Signs and symptoms may be using the Mi.TO/Sinthesi therapeutic table, muscle activation and strengthening
and joint mobilization using the Archimede pulley therapy system, pain and
widespread musculoskeletal discomfort and pain, local muscle
inflammation modulation using TCare CRET technology, and finally offering a
tenderness with or without a local twitch response and, tightness range of proprioceptive and postural integrative exercises.
and shortening of the muscle. This leads to muscle dysfunction
with muscle weakness, loss of coordination, eventually changes Based on the outcome of the global posture assessment and
in joint range of motion and alterations of muscle function on clinical reasoning of the clinician, different therapeutic pathways
cellular level which will affect normal physiological processes can be engaged to ensure the best possible therapeutic results
(24-27). The final result will be subtle changes in static posture, for the patient. In acute clinical situations, the first pathway to

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 GlobalPostureSystems ACADEMY

employ is modulating pain and inflammation, and stimulating
cellular regeneration, using electrophysiological modalities. To
then further ensure that tissue healing is naturally stimulated and
adverse loads in tissues are avoided, the clinician can choose
between the pathways of muscle activation and strengthening,
and myofascial release and muscle relaxation. Finally healthy
posture habits need to be integrated into movement patterns for
everyday living activities for which the clinician can engage the
therapeutic pathway of integrative proprioceptive and balance
exercises.
recently several studies have reported on the negative effects of
using modern technologies such as the smartphone, on global
posture (72-77). Biopsychosocial factors have also been proven
to affect global posture; researchers have found connections with
emotion, perceived fatigue, signs of depression and even familial
associations (78-81). Other studies have found that physical and
mental impairments, disabilities and handicaps (82-84) have a
particular effect on global posture.

Global posture systems assessment and analysis

Global posture is the combination of positions of all body

segments at a given point in time (1-6). It can be positively or
negatively affected by many different subsystems (33,34). For
this reason we prefer to use the term “global posture systems”
because a thorough assessment and analysis should take as
many of these subsystems into consideration.

Global posture is in the first place strongly affected by muscle

balance around the joints. Acute and chronic muscle fatigue,
strength, length and tone influence the balance in passive
tensions between agonist and antagonist muscles around a joint
(28-32, 35-37). Muscle injury, musculoskeletal and myofascial
pain, including latent MTrPs, will also affect posture (38,39)
either directly through tissue dysfunction or through adaptive
posture adaption strategies in order to avoid pain and discomfort.
Postural sway and the somatosensory systems including vision,
proprioception and the vestibular organs affect the alignment
of the various body segments over the body’s support base
(40-44). and therefore play an important role in maintaining
healthy posture throughout daily activities. Posture also
changes throughout the different phases of child and adolescent
development as well as during the ageing, particularly in the later Figure 2. Collection of data that is typically taken during a GPS Postural
stages of life (45-52). For example, Poussa et al reported that Labs global posture assessment. The combination and interaction of data from
the tendency towards increasing thoracic kyphosis continues for photographic evidence and measurements with stabilometric data provides
men between the ages of 11 to 22, while it decreased for women. important insights into how the various subsystems of global posture can interact
with each other.
Schultz et al observed a change in lower limb alignment during
maturation from greater knee valgus, recurvatum and fore foot
It is thus clear that in order to be of any clinical value a global
pronation to straightening and external rotation of the knee, and
posture assessment must encompass information from many
supination of the foot. Many of the aforementioned studies (1,
different subsystems. Data from these different subsystems must
49-55) confirm that there are also important gender differences in
then be combined the clinical reasoning process to then develop
posture. For example, women demonstrate larger Qangles, more
an effective and efficient treatment program. A good global
genu recurvatum, greater anterior pelvic tilt and more femoral
posture assessment requires a degree of clinical experience and
anteversion. However, some studies (55,56) regarding lumbo-
some particular know how of global posture assessments that is
pelvic alignment did not find any significant differences between
often readily available from continued professional education and
sexes. Researchers have also shown relationships between
training providers and global posture systems assessment device
body posture and mandibular position, temporomandibular joint
manufacturers.
function, masticatory muscle activity and occlusion (57-64,85).
Our interactions with our environment; particularly repetitive
There are many different methods and technologies to assess
movements and exposure to maintained strained and awkward
global posture systems; each have their inherent advantages and
postures in the workplace (65,75) or in sports, and interactions
disadvantages. The cheapest and most simple way to assess
with sports equipment (66), and footwear (67-71) can lead to
global posture in a clinical practice setting is using a plumb line
long term, mostly adverse changes in our global posture. More

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 GlobalPostureSystems ACADEMY
and posture grids. However, without recording the patient’s global
posture with either photography or video much of the information
may not be observed or simply lost because of our limited ability
to remember and record information.
Using photography or video with in addition a quantitive
measurements of certain global posture parameters through
special ised sof tware al ready of fer s considerable benefits.
Figure 3. Global posture assessment using plumb line and posture grids on a
mirror. It is a cheap and simple way to assess global posture. However much clinically
useful information will be lost because it is not observed or remembered in the
short time a patient is assessed. Photographic data allows the clinician to observe
and analyse global posture information in a more structured and tranquil way.
Nevertheless lighting conditions, photo angles and other
parameters in the environment can easily change which makes
it difficult to optimally stndardize photogrpahs. This can be
solved by using dedicated devices that assist in standardizing
photograph taking. To take linear or angle measurements
of certain body segments, some rely on using a set of bubble
levels, goniometers, accelerometers, tape measures etc. They are
commonly place on the patient to make these measurements. It
is clear that simply placing these instruments on the patient can
disturb natural standing posture and therefore make the global
posture assessment less accurate and relevant. The state of the
art today in global posture assessments are “postural labs” that
combine data from different subsystems of posture and that
ensure that data is recorded in an accurate, repeatable and reliable
way.
GPS Postural Labs generally consist of different parts. At the heart
of the device is the software that needs to be reliable and allow for
accurate and repeatable measurements of relevant global posture
parameters. A good software package will also include a patient
management system with easy and simple interface to record
patient data and history. To record photographic evidence they
have a fixed camera and platform for the patient to stand on in a
standardized position. In this way repeatability of photographic
evidence is increased so that comparisons can be made in order to
more accurately gain insights into how therapeutic interventions
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are affecting global posture. A good software package will also have
a photo comparison function that enables the clinician and patient
to easily see changes in posture. GPS Postural Labs also include
a stabilometric, bipedal footboard with incorporated podoscope.
This allows the clinician to investigate and analyse postural sway
parameters and how they are affected by different systems in the
body, e.g. sight, vestibular function, mechanoreceptors in the
cervical spine and more. Through the podoscope with load cells,
clinicians can determine weight distribution over both lower limbs
and within each foot separately.
Figure 4. State-of-the-art global posture labs now incorporate different
technologies and use advanced software packages to allow clinicians to make
more complete and accurate assessments of global posture. GPS600 Postural Lab
(Chinesport, Udine - Italy).
In this paper we present a case of acute and latent MtrPs in the
quadratus lumborum (QL) muscle. Patients will typically present
(86-88) with a dull, diffuse aching pain in one or both sides of
the low back, particularly when sitting for prolonged periods of
time or during transitions from sitting to standing. There will be
stiffness and pain in the morning when getting out of bed. In more
severe cases pain may even radiate down the lateral aspect of the
hip and thigh, towards the front along the quadriceps.
In a global posture assessment we typically will see a lateral
pelvic tilt in which the affected side is higher than the unaffected
side (3). In persistent cases the patient will often also be tilted
towards the unaffected side due to abduction of the contralateral
hip and associated tightening of the gluteus medius, while the
ipsilateral hip is posturally adducted due to adductor tightness. A
careful and precise global posture assessment is quite necessary
in such cases because a lateral pelvic tilt can also be caused by
either an anatomical or functional leg length discrepancy. Indeed
both postural deviations may even co-exist making the clinical
presentation even more complex and a detailed posture analysis
using a GPS Postural Lab even more valuable.
 GlobalPostureSystems ACADEMY

In our case the patient presented with the typical, aforementioned

signs and symptoms of non-specific low back pain due to
myofascial tightness. As a recreational runner he also found that
his normal running patterns had changed and started recently
feeling discomfort in knees and hips. The pain and associated
discomfort had now become serious enough to disturb normal
daily activities and for him to consequently seek medical advice.

Our global posture assessment indicated that the right pelvis

was higher than the left pelvis; lines between the PSIS and ASIS
respectively formed and angle of 3° with the horizontal. Further
investigation showed that there was no functional or anatomical
leg length difference, the sagittal knee position was near
symmetrical, medial footarches were of equal height, with normal
range navicular drop, anterior pelvic tilt was within normal range
and there was no additional pelvic rotation, shift or torsion. The
lateral pelvic tilt did not affect spinal or shoulder girdle alignment.

The outcome of our global posture assessment helped us create

a comprehensive treatment plan and assisted us in assuring
ourselves that we did not miss any other potential underlying
mechanisms that could be the cause of MTrPs in the quadratus
lumborum. For our treatment plan we choose to incorporate
different Global Posture Systems Therapeutic Pathways.

Figures 5 and 6. Using GPS Postural Labs for a detailed analysis of human
static posture aids the clinicians in building a detailed and comprehensive image
of possible underlying causes for the patient’s current complaints. In this case
we can see that other than a hip hike on the right, caused by a tight QL muscle,
that there is relatively good postural symmetry throughout the body. From this we
concluded that the tight QL was probably an isolated issue and developed out GPS
Therapeutic Pathways approach accordingly.

Muscle release and lengthening techniques using the Mi.TO/

Sinthesi therapeutic couches

Patients can experience an acute spasm in the QL as very debilitating

3° and extremely painful. Guidelines for acute non-specific low back
pain are rather sparse. Current recommendations include patient
education and information, advising staying active instead of bed
rest, prescribing analgesics and muscle relaxants if necessary,
considering spinal manipulation and a multidisciplinary approach
in occupational settings (89).

Within the GPS Therapeutic Pathways concept it is therefore

common practice to choose the Mi.TO/ Sinthesi pathway as a first
therapeutic intervention in cases of acute, intense low back pain.
In a first step we recommend placing the patient in a semi-traction
position (90). This position (Figure 7) can also be referred to as
the “psoas position”, “active rest”, “semisupine” or “Alexander
lying-down position”. It is generally known that this position
allows the iliopsoas to release and relax which can provide much
comfort to the patient.

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 GlobalPostureSystems ACADEMY
Figure 7. Taking advantage of the Mi.TO/Sinthesi couch’s virtually unlimited
range of patient position options. In cases of acute lumbar spine pain, patients will
benefit from constructive rest in this position.
Because the Mi.TO/Sinthesi couch can be moved and adjusted by
the clinician from a sitting position to the reclined lying position
at the simple touch of a few buttons, the patient does not need to
actively move to get into this psoas release position. Two electric
motors and a series of individual moveable segments allow the
clinician to move the patient into position in a smooth and quick
fashion. In our opinion this is very advantageous to the general
well-being of the patient.
In this position we can assist the patient in constructive rest which
is well known to those who are familiar with Alexander technique. In
the first phase of constructive rest we cultivate an integrated body
awareness. The patient is made aware of all tactile, kinaesthetic
and emotional sensations they are feeling at that precise moment.
They are then made aware of any pain sensations they experience
and how they experience these sensations in context of tactile,
kinaesthetic and emotional awareness. In the second phase the
patient should use integrated body awareness to explore muscle
tensions. By placing muscle tensions in context the patient can
start becoming aware of release of tension in specific muscles.
An important, third phase is restoring healthy, normal breathing
patterns using the patient’s regained body awareness and
increasing freedom from muscle tension.
A particular advantage of the Mi.TO/Sinthesi couch is that if offers
an extensive range of positional release positions. In the case
of an acute QL spasm, we can place the patient in a side-lying
position (Figure 8) on the unaffected and gently increase tensile
pressure on the QL and associated myofascia by increasing side
bending using the couch’s moveable leg and upper body parts.
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Figure 8. The Mi.TO/Sinthesi couch can be used to place patients in a
gentle, passive stretching position that is very tolerable for patients for a
longer period of time. Using gravity and own body as the main stretching
load, longer periods of stretching can be administered. This frees the
clinician to focus on other therapeutic interventions, e.g. assisting the
patient with proper breathing technique.
If this is uncomfortable for the patient it is also possible to
have the patient lie on affected side. By increasing side bending
towards the affected side the length and tension of the affected
QL decreases, which may help release the spasm. It is important
to note that none of the above manoeuvres require any work from
the patient, nor clinician. We are able to let gravity influence all the
body segments, which is generally assists in releasing tension in
muscle and helps the patient relax.
During the breathing awareness phase of constructive rest the
clinician can draw the patient’s attention to rib, abdominal wall
and pelvic floor movement. It often helps if the clinician manually
assists rib movement. The QL muscle stabilises the 12th rib during
breathing. In the case of acute spasm, these type of therapeutic
interventions can be particularly useful to release the QL.
Once the patient has found comfort through the process of
constructive rest, possibly in different postures on the Mi.TO/
Sinthesi couch, than we can close this phase of therapy by
cultivating an accurate and comprehensive body map and
working with the patient on their relationship in space and time.
We first take the patient through introspection and extrospection
to conclude with inclusive awareness in which the patient is aware
of himself and the environment around them.
Following constructive rest we recommend stretching and
lengthening the QL muscle. We suggest to first administer passive
 GlobalPostureSystems ACADEMY

Figure 10. Example of a CRET, capacitive and resisted energy transfer device,
TCare by Chinesport, Udine, IT. The device includes 3 capacitive and 3 resistive
mode hand pieces. Unique to this system are the roll-on applicators in the hand
pieces which promotes introduction of pharmaceuticals, cosmeceuticals and other
active ingredients through the skin.

overused QL muscle we would at this point in therapy primarily

seek to continue increasing muscle flexibility and surrounding
Figure 9. Passive, passive/active or active stretching techniques are made soft tissue extensibility, because we know that these probably lie
efficient and simple on the Mi.TO/Sinthesi couch with the patient placed in a at the source of our patient’s complaints (17-23).
posture that already emphasizes stretching of a particular muscle or muscle group,
It is easier for both clinician and patient to focus on proper technique and feedback. CRET is a form of thermotherapy. It is well known that
The forces of gravity are left to do most of the work, while the patient can relax or thermotherapy increases tissue temperature which in turn
activate specific muscle groups depending on the therapeutic goal.
contributes to an increase in soft tissue extensibility, which can
lead to increased muscle flexibility. Moreover, vasodilatation in
stretching, before progressing to passive/active, active/passive
response to a tissue temperature increase will improve blood
and active stretching. By placing the patient in increasing degrees
circulation, which in turn promotes tissue repair and healing by
of side flexion on the Mi.TO/Sinthesi couch (Figure 9), passive
supplying nutrients to the site of injury. These processes will
stretching and lengthening can be very easily administered in in
reverse the hypoxic conditions in tissues, production and release
varying degrees by the clinician. In this way it is possible to apply
of algesic substances, tissue fibrosis, pain, spasm and joint
a constant, physiological and consistent stretch to the contracted
contracture that insufficient blood circulation causes (91,92).
muscle and surrounding myofascial structures. The tensile
stresses can thus be transmitted along the entire myofascial
CRET is a diathermy electrophysiological modality (92). Deep
chain and throughout all depths. Because we can place the patient
heat is generated in tissues by movement of ions and electrolytes
in an ideal stretching posture on the Mi.TO/ Sinthesi without
as radio frequency waves in a range of approx. 0.5 to 1.2 MHz
any additional effort, we can focus on instructing the patient on
oscillate between an active and passive electrode. The TCare
relaxation, breathing or active participation in stretching. In this
device (Chinesport, Italy) that has been incorporated in the GPS
way we can administer contract-relax PNF techniques by providing
Therapeutic Pathways concept allows capacitive and resistive
resistance with both hands cupped over the crista iliaca. In this
energy transfer through two different sets of handpieces. During
particular position we ask the patient to lift the top arm overhead
capacitive energy transfer energy accumulates in the proximity
and slide the top heel down the couch and pull the toes and foot
and mostly directly under the moving, active handpiece (92).
cranially. In our practical experience good results are achieved in
Tissue temperature increase and decay are more intense and
terms of tissue lengthening when holding this position for 40-60
faster than in resistive mode (93). Capacitive mode acts on soft
seconds in 3-4 repetitions, 4 times per day on a daily basis.
tissue; muscle, blood and lymphatic vessels and adipose tissue.
Resistive mode on the other hand acts on tissues with greater
Capacitive and Resistive Energy Transfer for cellular
resistance; bone, cartilage, tendon and fascia (92). Furthermore,
regeneration and pain modulation
by providing the option to select different radio wave frequencies
within the 0.5 to 1.2 MHz range, the TCare device allows clinicians
The second GPS Therapeutic Pathway we rely on in our proposed
to determine the depth and intensity at which the energy is
therapeutic model is using capacitive and resistive energy transfer
delivered. Lower frequencies are recommended for more acute
(CRET) in order to reduce pain intensity and stimulate cellular
injuries, higher frequencies for more chronic conditions. In
regeneration. In our case of a tight or shortened, and strained or
addition, TCare handpieces include a roll-on, cream delivery

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 GlobalPostureSystems ACADEMY
system through which pharmaceuticals, essential oils and other
active ingredients can be easily and efficiently delivered to the
treated area. By adjusting the CRET intensity, the therapeutic
responses can be adjusted (92) from a cellular biostimulation and
activation of arteriovenous and lymphatic microcirculation during
low-level, athermal application, to intense tissue heating and
muscle relaxation effects during high-level, thermal application.
Figure 11. It is recommended to always first administer a short, athermal,
capacitive mode application in order to prepare the to-be-treated structures for the
more therapeutic CRET intervention. Here we also make use of the unique Mi.TO/
Sinthesi postural release positions to ensure the patient is comfortable.
In our case of tight and shortened QL muscle we propose to first
administer a short, 4-6 minute, application of capacitive mode
with very low intensity and lower RF frequency setting to ensure
athermal work. The aim of this phase is to stimulate cellular
regeneration and microcirculation, which will remove harmful
metabolites from the affected area, increase lymphatic drainage
to reduce any potential swelling, and through increased arterial
microcirculation bring valuable nutrients to the area. To ensure
we are working in an athermal mode, we ask feedback from the
patient on a regular basis. We should lower the treatment intensity
when the patient feels a heating sensation on the skin. We can also
use the Energy Transfer Indicator on the TCare display; the led
indicators should not increase above the set treatment intensity
indicator and should stay as low as possible. If the patient is in
great pain, we recommend using the unique advantage of the
Mi.TO/Sinthesi couch, and placing the patient in a mild flexed
position by lowering the leg and/or upper body segments (Figure
11). The Mi.TO/Sinthesi couch allows you to adjust the segments’
position exactly according to the posture the patient prefers the
most for a pain-relieving effect. For example, during the treatment
the leg segments can be lowered and elevated so that a gentle
pelvic rotation is obtained. This affects the QL length and allows
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Figure 12. We demonstrate a unique advantage of the GPS Therapeutic Pathways
concept. At the same time as administering capacitive, thermal, resistive mode
CRET aimed at lengthening myofascial structures around the QL, we also use the
Mi.TO/Sinthesi positional release positions to add a lengthening element to the
therapeutic configuration.
the clinician and patient to explore the boundaries of signs and
symptoms.
After the short, athermal capacitive mode application, we
recommend a longer, thermal, resistive mode application. The
aim of this phase is to now introduce a heating effect in the
deeper structures, namely the QL muscle. Tissue temperature
increases of 2-3°C will reduce pain and muscle spasm, 3-4°C will
increase tissue extensibility (92,94-95). Because of “the nature
of resistive” mode interaction with tissue we can also expect
more energy to be absorbed in more inert structures, among
which myofascia and tendon. In cases of chronic issues with
QL tightness this is very beneficial to the overall treatment. In
these situations we recommend to also use the Mi.TO/Sinthesi
to the patient’s advantage by placing the patient in side flexion. In
this situation we can make use of the tensile forces to lengthen
myofascial structures. Patients will often report, and clinicians
can often notice, a sudden increase is soft tissue extensibility
as a critical temperature level is reached in the right structures
for some time; the pelvis will start dropping on the affected side
during the treatment. The parameters of the TCare treatment
depend on hydration level of the patient, treatment area and depth,
presence of inflammation or not, tolerance levels of the patient
to the treatment. For these reasons it is not possible to provide
exact parameters; they should be determined for each individual
patient and each individual treatment session. We recommend a
treatment session of 8-12 minutes and a treatment intensity set to
a level with which the patient reports a feeling of deep heating but
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us, it makes economical sense to have an exercise system that

is highly adaptable and customisable. This is why we prefer to
include suspension and, sling and pulley exercise devices in our
GPS Therapeutic Pathways concept.

In the case of a tight QL muscle, one possible therapeutic

construction is placing the patient in side bending towards the
unaffected side (see figure 13) in a Mi.TO/Sinthesi positional
release posture, combined with TCare CRET therapy. The lower
extremity of the affected side is suspended in a sling, with
suspension point directly above the hip. While we apply TCare
CRET, the patient moves the hip into flexion and extension. We
ask the patient to actively stabilise the pelvis which includes QL
work; this over time increases blood flow to the area and the
penetration of RF energy to the area. The patients repeats these
movements for as long as possible during this third and longer,
thermal, capacitive mode session.

The envisioned therapeutic outcomes of this phase in the GPS

Figure 13. Hip flexion and extension with stabilisation of the pelvis
activates the QL increasing blood perfusion in the area. TCare CRET,
capacitive mode more readily affects the area. The GPS Therapeutic
Pathways concept provides a unique opportunity to combine 3 therapeutic
modalities in one treatment to gain more effective and efficient results.
Therapeutic Pathways concept are (1) decrease in pain intensity
or the patient is pain-free and (2) release and lengthening of the
QL muscle.
Suspension and, sling and pulley therapy to restore normal
muscle function and joint mobility.

Since the early 1900s mechanotherapy has been used to

not intense heating on the skin surface. The active and passive
stimulate joint movement, muscle activation and strengthening.
plates need to be placed in such a configuration that the to-be-
This therapeutic intervention a wide variety of pulley and sling
treated areas lies geometrically in the middle between the two
configurations to suspend body segments (96).
plates.

In a third phase we propose a longer, 6-8 minute session in

thermal, capacitive mode. This will increase circulation in the
more superficial soft tissue layers and assist in removing harmful
metabolites and bringing nutrients to the area. We propose
treating the entire dermatome of the affected structures during
this phase reasoning that by doing so we also make use of the
gate-control phenomena to decrease pain intensity.

In this phase we also make perfect use of the unique advantage

of the GPS Therapeutic Pathways concept in that we combine
three different treatment modalities to increase overall treatment
efficiency and efficacy. In the previous passage we already
explained the benefits of combining both the TCare CRET and
Mi.TO/Sinthesi myofascial release treatments. At this point we are
using capacitive mode CRET which we know more readily affects
soft tissue that contain more blood (92). It is also generally
accepted that capacitive does not penetrate as deep in the body Figure 14. Gurthrie Smith conducted much of the fundamental research
as resistive mode (93). However to increase the penetration depth in suspension and mechanotherapy to improve the rehabilitation of
of the capacitive mode and ensure better delivery of RF energy soldiers from the frontlines during WWI.
there where necessary, we propose to increase blood perfusion
in the target area. We propose to do this using activation and The knowledge base of therapeutic exercises and the equipment
sustained contractions of the target muscles. Because there is has greatly evolved since these early days. We now know that
such a extensive variety of therapeutic exercises available to mechanotherapy, through the process of mechanotransduction,

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 GlobalPostureSystems ACADEMY

is essential in initiating tissue repair processes. We now know

that therapeutic exercises need to be specifically designed to
physically stimulate specific cells in specific tissues. Movement is
a repair method (97). This is the reason why the Archimede Pulley
System with BlueCord Exercise System (Chinesport, Udine, IT)
is an essential component of the GPS Therapeutic Pathways
concept.

The Archimede Pulley System with BlueCord Exercise System

provides the clinician with several therapeutic exercise options:
(1) suspension of one or multiple segments to stimulate
movement in a weightless environment, (2) assisted movement
by increasing the effects of gravity on the suspended segment,
(3) resisted movement with can require eccentric or concentric
contractions, (4) traction therapy and (5) it allows for functional
assessments, ROM testing and other diagnostic procedures. The
therapeutic goals of the BlueCord Exercise System are restoring
healthy muscle length-tension relationships within individual
muscles or entire kinetic chains, restoring ROM and myotensive
balance, creating improved kinaesthesia, and finally increasing
joint stability and muscle strength. Key advantages over other
exercise modalities are that the Archimede Pulley System with
BlueCord Exercise System allows the clinician to individualise
each exercise exactly according to the current abilities of patient;
very careful progressions can be made by slight adjustment to the
configurations.

In our case of an acute or chronic QL muscle spasm, we integrate

movement and Archimede mechanotherapy while treading the
second pathway when we work on cellular regeneration and pain
modulation. Therapeutic work on the Mi.TO/Sinthesi couch will
also already have released and lengthened the tight QL muscle at
this point. At this point we recommend using mechanotherapy to
reintroduce muscle work at normal length-tension relationships
and to reeducate the patient in healthy posture and movements
patterns.

One of the main functions of the QL muscle is stabilizing the

pelvis when walking. In a first series of exercises (figure 15) we
thus propose to focus on the stabilizing function of the QL muscle
during hip flexion and extension, as in walking. In order to do so,
we place the patient in side lying position with a neutral spine and
pelvis. The lower leg is usually flexed to add stability, but we can
also ask the patient to extend the leg thus reducing the base of
support and progressing the exercise in difficulty level. The higher
leg is suspended in an ankle sling. To make the exercise easier we
can also add a sling just above the knee. This then aids the patient
in relaxing the tight musculature better during the movements
because the knee joint does not need to be stabilized as much.

Figure 15, 16, 17. The Archimede Pulley System with BlueCord Exercise
System offers the clinician a limitless variety to therapeutic exercises options. By
changing the suspension point from centrally (15) above the hip joint to distal (16)
we change the configuration to a strengthening exercise. Moving the suspension
point proximally to the hip joint creates a joint mobilisation exercise.

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 GlobalPostureSystems ACADEMY

In this way we can avoid for example overactivation of the tensor

fascia latae muscle which is a common problem in patients with
compromised pelvic stability. The suspension point is placed
directly above the hip joint, which creates a horizontal movement
plane; the same force is needed to move the hip into extension as
in flexion. We instruct the patient on properly stabilizing the pelvis
during hip flexion and extension. The aim of the exercise is that
the patient actively stabilizes the pelvis during these movements,
thereby properly activating the QL muscle . Over time this should
correct the length-tension relationships and improve muscle
coordination thereby reducing future injury risk.

The previous therapeutic exercise (figure 15) can also function

as a functional test. The clinician may notice that during the hip
flexion or extension movements muscle power is insufficient to
stabilize the pelvis. By simply moving the sling suspension point
caudally from the hip joint (figure 16). By doing so the movement
plane becomes concave; i.e. at the end of the hip flexion and
extension range the leg needs to be lifted against gravity, the
hip flexors and extensors respectively need to increase their
muscle work. This thus becomes a very targeted activation and
strengthening exercise. Similarly to the above, the clinician may
find that mobility in hip flexion or extension is lacking. This could
be due to joint restrictions or due to soft tissue restrictions. By
moving the sling suspension point cranially from the hip joint, the
movement plane becomes convex. This means that the muscle
work needed at the end of hip flexion and extension ranges is less
than require to return to the mid point of the range of movement.
Gravity at the end of the range of movement pulls the limb further.
This can be used to stretch the soft tissue structures or with the
right fixation the clinician can mobilise the hip joint to improve
joint restrictions. Alternatively this exercise could also be used to
stimulate and create better joint stability and muscle activation.

The Archimede Pulley System with BlueCord Exercise System can

also be used to administer therapeutic suspension exercises. In
our QL case we use the suspension exercises in a similar way
to the previously discussed pelvic stabilization and strengthening Figures 18, 19. A wide range of suspension exercises - often know as S.E.T. - is
exercises. In this therapeutic exercise set up (figures 18 and 19) also possible using the Archimede Pulley System with BlueCord Exercise System.
the patient lies supine. The Mi.TO/Sinthesi couch is set up so that These figures demonstrate an example of QL muscle strengthening exercises or if
the legs slope downwards, allowing the legs to be suspended administered in the opposite way stretching exercises.
and move in a horizontal plane without hinderance from the
couch surface. We suspend the patient’s pelvis slightly. This now
allows the patient to side bend actively or with assistance from
the clinician. In this way the QL muscle can be either stretched
or on the contralateral side the patient can be stimulated to
contract the QL muscle properly; it is a targeted activation and
strengthening exercise. The clinician can choose to elicit an
isometric, concentric and even eccentric contraction. By altering
the suspension point, number of slings, position of slings and
cord type (elastic or regular), these exercises can be accurately
fine-tuned and progressed.

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 GlobalPostureSystems ACADEMY
Integrative proprioceptive exercises to improve normal daily
activities and prevent future injury.
Figures 20, 21, 22, 23, 24. Examples of how the Archimede Pulley System
with BlueCord Exercise System is used to deconstruct a wide variety of every day
movement patterns so that the patient can relearn, new and healthy movement
patterns to avoid reinjury.
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In a final GPS Therapeutic Pathway we include integrative,
proprioceptive exercises for which we can use a variety of
proprioceptive exercise tools and aids. The aim of the integrative
exercises is to integrate normal muscle function, in the normal
length-tension relationship, into the entire muscle chain. The
Archimede Pulley System with BlueCord Exercise System is an
excellent tool to do this. We can deconstruct every-day movement
patterns into manageable exercises for the patient with our sling
and pulley constructions so that the patient can relearn healthy
movement patterns in order to avoid future injuries.
Conclusion
In this paper we have presented our proposed Global Posture
Systems Therapeutic Pathways concept. This treatment concept
aims to assist in treating a very wide range of neuromusculoskeletal
disorders and injuries. A thorough global posture analysis is
a central part of the GPS Therapeutic Pathways concept and
complements other conventional assessment and diagnostic
methods to provide a deeper, more detailed holistic view of the
neuromusculoskeletal disorder or injury at hand. Using the GPS
Therapeutic Pathways should lead to more efficient, effective and
Figure 25. GPS Postural Lab comparison photo; red outlines before GPS
Therapeutic Pathways treatment, white after treatment. The careful observer will
see that the line connecting the SIPS is oblique before the treatment and horizontal
after. This indicates the pelvis has become horizontal during the treatment,
indicating the quadratus lumborum muscle has lengthened.

long term results in the rehabilitation and treatment of disorders.
A core principle is healthy posture for healthy movement.
Throughout this paper we have demonstrated the core concepts
of the GPS Therapeutic Pathways using a case of a chronically
tight quadratus lumborum muscles which caused low back pain
and changes in posture. We proposed a variety of therapeutic
interventions that can be used to treat such cases.
In our opinion the GPS Therapeutic Pathways concept consisting
of the GPS Postural Labs for extended diagnostics, the Mi.TO/
Sinthesi therapeutic couches for myofascial release, the TCare for
cellular regeneration and pain modulation and the The Archimede
Pulley System with BlueCord Exercise System for therapeutic and
integrative exercise, is a cost effective and simple starting point
for any modern rehabilitation and physical therapy practice.
Finally the GPS Postural Labs software (figure 25) allows direct
comparison of before and after digital imaging in different ways.
One of those is overlapping the digital imaging outlines. This
allows us to show and demonstrate that the proposed GPS
Therapeutic Pathways concept is indeed effective and efficient in
treating posture deviations cause by a chronically tight Quadratus
Lumborum muscle.
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15
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