The pathogenesis of inflammatory bowel disease, or IBD, suggests that interrupted interactions between the gastrointestinal tract, or GI tract, and the gut microbiota can often be the cause behind the development of the disease. A damaged or unhealthy gastric mucosal barrier may result in increased intestinal permeability which can cause an immunological reaction and result in symptoms of inflammation. Individuals diagnosed with inflammatory bowel disease present several defects in the many specialized components of mucosal barrier function, from the mucous coating makeup to the adhesion molecules that regulate paracellular permeability. These alterations may represent a primary dysfunction in Crohn’s disease, but they may also cause chronic mucosal inflammation in ulcerative colitis.
How does inflammatory bowel disease affect intestinal permeability?
In clinical practice as well as experimental testings, many research studies have reported that changes in intestinal permeability can predict the development of inflammatory bowel disease, or IBD. Functional evaluations, such as the sugar absorption test or the novel imaging technique using confocal laser endomicroscopy, allow an in vivo assessment of intestinal barrier integrity. Antitumor necrosis factor-? (TNF-?) therapy reduces mucosal inflammation and soothes intestinal permeability from IBD patients. Butyrate, zinc, and some probiotics also ameliorate mucosal barrier dysfunction but their use is still limited and further research is required before suggesting permeability manipulation as a therapeutic goal in inflammatory bowel disease.
The gut plays a major role in food digestion and absorption of nutrients as well as in maintaining the overall homeostasis. It is estimated that the entire bacterial count in our entire body exceeds ten times the entire amount of individual cells in it, with more than one million species found in the gastrointestinal tract. The gut microbiota, whose genome includes 100 times more genes in relation to the entire human genome, also plays an important role in nutrition, energy metabolism, host defense, and immune system development. However, modified microbiota has been connected to, not just gastrointestinal disorders, but also to the pathogenesis of systemic conditions, such as obesity and metabolic syndrome. Therefore, the expression “mucosal barrier” seems to properly highlight the critical role of the gut and its interaction with microbiota: it is not a static shield but an active apparatus with specialized components. According to Bischoff et al. “permeability” is described as a functional feature of this barrier which allows the coexistence of bacteria required by our organism and prevents luminal penetration of macromolecules and pathogens. Altered intestinal permeability was documented during several diseases, including, acute pancreatitis, multiple organ failure, major surgery, and severe trauma, and may also explain the high incidence of Gram-negative sepsis and related mortality in critically ill patients. Furthermore, perturbation of the complex mechanism of permeability has been connected to the development of irritable bowel syndrome and steatohepatitis, or NASH.
The pathogenesis of inflammatory bowel disease, or IBD, remains unclear but it most likely is multifactorial and driven by an exaggerated immune response towards the gastrointestinal microbiome in a genetically susceptible host. Increasing evidence suggests that intestinal permeability may be critical and some authors even considered inflammatory bowel disease, or IBD, as a disease, primarily caused by intestinal barrier dysfunction.
Intestinal Barrier Dysfunction in Inflammatory Bowel Disease
The main component of the mucosal barrier is represented by the intestinal epithelium, which is made up of one layer of various subtypes of cells, including the enterocytes, goblet cells, Paneth cells, and enteroendocrine cells, as well as immune cells, such as intraepithelial lymphocytes and dendritic cells, as seen on Figure 1. The regulation of paracellular permeability of ions and tiny molecules is provided by three kinds of junctional complexes: the tight junctions, or TJs, adherence junctions, and desmosomes.
Individuals with IBD present enhanced paracellular permeability with TJ abnormalities, according to several research studies. These are complex multiprotein structures with an extracellular portion, a transmembrane domain and an intracellular association with the cytoskeleton, referenced from Figure 1. A decreased expression and redistribution of the components, such as occludins, claudins, and junctional adhesion molecules, abbreviated as JAM, have all been demonstrated in IBD, where a current experiment found that eliminating claudin-7 can cause colonic inflammation. In addition, tumour necrosis factor-? (TNF-?), one of the main factors behind IBD inflammation, may regulate the transcription of TJ proteins whereas its antagonists, anti-TNF-?, can ameliorate intestinal permeability. However, TNF-? may contribute to altered intestinal permeability as well, inducing apoptosis of enterocytes, increasing their rate of shedding and preventing the redistribution of TJs which should seal the remaining gaps.
Goblet cells are specialized in the secretion of mucus that covers the surface of the intestinal epithelium. Mucus is made up of carbohydrates, proteins, lipids, and a high amount of water while it also has antimicrobial properties because of antimicrobial peptides, mainly defensins produced by Paneth cells, and secretory IgA. Individuals with ulcerative colitis demonstrate a lesser variety of goblet cells, a reduced thickness of the mucus layer, and an altered mucus composition regarding mucins, phosphatidylcholine, and glycosylation. Moreover, modified Paneth cell distribution and function has been reported in IBD: these cells are typically limited to the small intestines, within the crypts of Lieberkühn, but in IBD, metaplastic Paneth cells may be found in colonic mucosa, together with subsequent secretion of defensins also from the large intestine. The role of Paneth cells may differ in the two disease phenotypes because the expression of defensins is caused by colonic inflammation in UC but is reduced in patients with colonic Crohn’s disease, or CD. The decreased Paneth cell antimicrobial function might be a main pathogenic component in Crohn’s disease, or CD, particularly ileal CD, although the greater secretion of defensins in UC could be a physiological response to mucosal damage.
Etiology of Intestinal Permeability in Inflammatory Bowel Disease
Whether mucosal barrier dysfunction is a result of the inflammatory response or a primary defect that prompts mucosal inflammation, still remains under debate. However, several research studies suggest that altered intestinal permeability may be an early event in Crohn’s disease pathogenesis. Increased paracellular permeability was found in patients with quiescent IBD and was connected to intestinal symptoms even when endoscopic activity was absent. Furthermore, an ex vivo study with Ussing chambers on colonic biopsies from CD patients revealed a spatially uniform increase in transepithelial conductivity regardless of the presence of minimal mucosal erosions. This finding was attributed to the downregulation of TJ proteins. Lastly, animal models of CD, particularly, IL-10 knockout mice and SAMP1/YitFc mice, also declared that increased permeability can be determined before the onset of mucosal inflammation.
Genes involved in intestinal barrier homeostasis have also been associated with IBD susceptibility, demonstrating a genetic predisposition that’s further supported by the observation that up to 40 percent of first-degree relatives of CD patients have altered small intestinal permeability, with a significant connection to familial CD and NOD2/CARD15 variations. This gene, which is involved in bacterial recognition, regulates both innate and adaptive immune responses and is the main susceptibility locus for the development of Crohn’s disease. Other research studies have not found a correlation between permeability and hereditary polymorphisms but it’s noteworthy they’ve mostly involved sporadic CD instances. However, environmental factors are also principal contributors in determining mucosal permeability because permeability is raised even in a percentage of CD spouses. Additionally, a recent research highlighted the value of age and smoking status rather than genotype in family. There is only one reported instance of CD development predicted by an abnormal permeability test in a healthy relative.
Independently from being genetically determined or caused by environmental factors, intestinal permeability leads to the disruption of the physiological equilibrium between mucosal barrier and luminal challenge which cannot be properly counteracted by inherent resistance of IBD patients, which on the opposite reacts with an underactive immune trigger. As a matter of fact, many defects in bacterial recognition and processing have been documented in CD patients taking certain genetic polymorphisms, mainly of pattern-recognition receptors, such as NOD2/CARD15 and genes involved in autophagy, like ATG16L1 and IRGM. In intestinal mucosa, the absence of feedback between mutated NOD2/CARD15 expression and gut luminal microbiota may result in the breakdown of tolerance. Interestingly, a recent research study by Nighot et al. revealed that autophagy is also involved with the regulation of the TJs by degradation of a pore-forming claudin, connecting autophagy with permeability.
Finally, intestinal microbiota may become altered in IBD, especially in its relative diversity and composition. This could represent a consequence of chronic mucosal inflammation however, the influence of host genotype in shaping microbial community cannot be missed in CD and NOD2/CARD15 genotype has been shown to influence the composition of gut microbiota in humans. This dysbiosis can further exacerbate permeability dysfunction from the reduction of the symbiotic connection between the microbiota and the mucosal barrier integrity. Information referenced from the National Center for Biotechnology Information (NCBI) and the National University of Health Sciences. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Clinical Application of Neuromuscular Techniques: Assessment and Treatment of Hip Flexors – Rectus Femoris, Iliopsoas
Patient lies supine with buttocks (coccyx) as close to end of table as possible, non-tested leg in flexion at hip and knee, held by patient or by having sole of foot of non-tested side placed against the lateral chest wall of the practitioner. Full flexion of the hip helps to maintain the pelvis in full rotation with the lumbar spine flat, which is essential if the test is to be meaningful and stress on the spine is to be avoided.
Notes on Psoas
- Lewit (1985b) mentions that in many ways the psoas behaves as if it were an internal organ. Tension in the psoas may be secondary to kidney disease, and one of its frequent clinical manifestations, when in spasm, is that it reproduces the pain of gall-bladder disease (often after the organ has been removed).
- The definitive signs of psoas problems are not difficult to note, according to Harrison Fryette (1954). He maintains that the distortions produced in inflammation and/or spasm in the psoas are characteristic and cannot be produced by other dysfunction. The origin of the psoas is from 12th thoracic to (and including) the 4th lumbar, but not the 5th lumbar. The insertion is into the lesser trochanter of the femur, and thus, when psoas spasm exists unilaterally, the patient is drawn forwards and sidebent to the involved side. The ilium on the side will rotate backwards on the sacrum, and the thigh will be everted. When both muscles are involved the patient is drawn forward, with the lumbar curve locked in flexion. This is the characteristic reversed lumbar spine. Chronic bilateral psoas contraction creates either a reversed lumbar curve if the erector spinae of the low back are weak, or an increased lordosis if they are hypertonic.
- Lewit says, ‘Psoas spasm causes abdominal pain, flexion of the hip and typical antalgesic (stooped) posture. Problems in psoas can profoundly influence thoraco-lumbar stability.’
- The 5th lumbar is not involved directly with psoas, but great mechanical stress is placed upon it when the other lumbar vertebrae are fixed in either a kyphotic or an increased lordotic state. In unilateral psoas spasms, a rotary stress is noted at the level of 5th lumbar. The main mechanical involvement is, however, usually at the lumbodorsal junction. Attempts to treat the resulting pain (frequently located in the region of the 5th lumbar and sacroiliac) by attention to these areas will be of little use. Attention to the muscular component should be a primary focus, ideally using MET.
- Bogduk (Bogduk et al 1992, Bogduk 1997) provides evidence that psoas plays only a small role in the action of the spine, and states that it ‘uses the lumbar spine as a base from which to act on the hip’. He goes on to discuss just how much pressure derives from psoas compression on discs: ‘Psoas potentially exerts massive compression loads on the lower lumbar discs … upon maximum contraction, in an activity such as sit-ups, the two psoas muscles can be expected to exert a compression on the L5–S1 disc equal to about 100 kg of weight.’
- There exists in all muscles a vital reciprocal agonist–antagonist relationship which is of primary importance in determining their tone and healthy function. Psoas–rectus abdominis have such a relationship and this has important postural implications (see notes on lower crossed syndrome in Ch. 2).
- Observation of the abdomen ‘falling back’ rather than mounding when the patient flexes indicates normal psoas function. Similarly, if the patient, when lying supine, flexes knees and ‘drags’ the heels towards the buttocks (keeping them together), the abdomen should remain flat or fall back. If the abdomen mounds or the small of the back arches, psoas is incompetent.
- If the supine patient raises both legs into the air and the belly mounds it shows that the recti and psoas are out of balance. Psoas should be able to raise the legs to at least 30° without any help from the abdominal muscles.
- Psoas fibres merge with (become ‘consolidated’ with) the diaphragm and it therefore influences respiratory function directly (as does quadratus lumborum).
- Basmajian (1974) informs us that the psoas is the most important of all postural muscles. If it is hypertonic and the abdominals are weak and exercise is prescribed to tone these weak abdominals (such as curl-ups with the dorsum of the foot stabilised), then a disastrous negative effect will ensue in which, far from toning the abdominals, increase of tone in psoas will result, due to the sequence created by the dorsum of the foot being used as a point of support. When this occurs (dorsiflexion), the gait cycle is mimicked and there is a sequence of activation of tibialis anticus, rectus femoris and psoas. If, on the other hand, the feet could be plantarflexed during curl-up exercises, then the opposite chain is activated (triceps surae, hamstrings and gluteals) inhibiting psoas and allowing toning of the abdominals.
- When treating, it is sometimes useful to assess changes in psoas length by periodic comparison of apparent arm length. Patient lies supine, arms extended above head, palms together so that length can be compared. A shortness will commonly be observed in the arm on the side of the shortened psoas, and this should normalise after successful treatment (there may of course be other reasons for apparent difference in arm length, and this method provides an indication only of changes in psoas length).
If the thigh of the tested leg fails to lie in a horizontal position in which it is parallel to the floor/table, then the indication is that iliopsoas is short. If the lower leg of the tested side fails to achieve an almost 90° angle with the thigh, vertical to the floor, then shortness of the rectus femoris muscle is indicated (Fig. 4.6B). If this is not clearly noted, application of light pressure towards the floor on the lower third of the thigh will produce a compensatory extension of the lower leg only when rectus femoris is short. A slight degree (10–15°) of hip extension should be possible in this position, by pushing downwards on the thigh, without knee extension occurring. This can subsequently be checked by seeing whether or not the heel on that side can easily flex to touch the buttock of the prone patient (if rectus is short heel will not easily reach the buttock). If effort is required to achieve 10° of hip extension, this confirms iliopsoas shortening on that side. If both psoas and rectus are short, rectus should be treated first. If the thigh hangs down below a parallel position, this indicates a degree of laxity in iliopsoas (Fig. 4.6C). A further cause of failure of the thigh to rest parallel to the floor can be due to shortness of tensor fascia lata. If this structure is short (a further test proves it, see later in this chapter) then there should be an obvious groove apparent on the lateral thigh and the patella, and sometimes the whole lower leg will deviate laterally. A further indication of short psoas is seen if the prone patient’s hip is observed to remain in flexion. In this position passive flexion of the knee will result in compensatory lumbar lordosis and increased hip flexion if rectus femoris is also short. (See also functional assessment method for psoas in Ch. 5 and notes on psoas in Box 4.4.)
Figure 4.6A Test position for shortness of hip flexors. Note that the hip on the non-tested side must be fully flexed to produce full pelvic rotation. The position shown is normal.
Figure 4.6B In the test position, if the thigh is elevated (i.e. not parallel with the table) probable psoas shortness is indicated. The inability of the lower leg to hang more or less vertically towards the floor indicates probable rectus femoris shortness (TFL shortness can produce a similar effect).
Figure 4.6C The fall of the thigh below the horizontal indicates hypotonic psoas status. Rectus femoris is once again seen to be short, while the relative external rotation of the lower leg (see angle of foot) hints at probable shortened TFL involvement.
Mitchell’s Strength Test
Before using MET methods to normalise a short psoas, Mitchell recommends that you have the patient at the end of the table, both legs hanging down and feet turned in so that they can rest on your lateral calf areas as you stand facing the patient. The patient should press firmly against your calves with her feet as you rest your hands on her thighs and she attempts to lift you from the floor. In this way you assess the relative strength of one leg’s effort, as against the other. Judge which psoas is weaker or stronger than the other. If a psoas has tested short (as in the test described earlier in this chapter) and also tests strong in this test, then it is suitable for MET treatment, according to Mitchell. If it tests short and weak, then other factors such as tight erector spinae muscles should be treated first until psoas tests strong and short, at which time MET should be applied to start the lengthening process. It is worth recalling Norris’s (1999) advice that a slowly performed isotonic eccentric exercise will normally strengthen a weak postural muscle. (Psoas is classified as postural, and a mobiliser, depending on the model being used. Richardson et al (1999) describe psoas as ‘an exception’ to their deep/superficial rule since, ‘it is designed to act exclusively on the hip’. There is therefore universal agreement that psoas will shorten in response to stress.) NOTE: It has been found to be clinically useful to suggest that before treating a shortened psoas, any shortness in rectus femoris on that side should first be treated.
MET Treatment for Shortness of Rectus Femoris
Patient lies prone, ideally with a cushion under the abdomen to help avoid hyperlordosis. The practitioner stands on the side of the table of the affected leg so that he can stabilise the patient’s pelvis (hand covering sacral area) during the treatment, using the cephalad hand. The affected leg is flexed at hip and knee. The practitioner can either hold the lower leg at the ankle (as in Fig. 4.7), or the upper leg can be cradled so that the hand curls under the lower thigh and is able to palpate for bind, just above the knee, with the practitioner’s upper arm offering resistance to the lower leg. Either of these holds allows flexion of the knee to the barrier, perceived either as increasing effort, or as palpated bind. If rectus femoris is short, then the patient’s heel will not easily be able to touch the buttock (Fig. 4.7).
Figure 4.7 MET treatment of left rectus femoris muscle. Note the practitioner’s right hand stabilises the sacrum and pelvis to prevent undue stress during the stretching phase of the treatment. Once the restriction barrier has been established (how close can the heel get to the buttock before the barrier is noted?) the decision will have been made as to whether to treat this as an acute problem (from the barrier), or as a chronic problem (short of the barrier). Appropriate degrees of resisted isometric effort are then introduced. For an acute problem a mild 15% of MVC (maximum voluntary contraction), or a longer, stronger (up to 25% of MVC) effort for a chronic problem, is used as the patient tries to both straighten the leg and take the thigh towards the table (this activates both ends of rectus). Appropriate breathing instructions should be given (see notes on breathing earlier in this chapter, Box 4.2).
The contraction is followed, on an exhalation, by taking of the muscle to, or stretching through, the new barrier, by taking the heel towards the buttock with the patient’s help. Remember to increase slight hip extension before the next contraction (using a cushion to support the thigh) as this removes slack from the cephalad end of rectus femoris. Repeat once or twice using agonists or antagonists. Once a reasonable degree of increased range has been gained in rectus femoris it is appropriate to treat psoas, if this has tested as short.
MET Treatment of Psoas
Method (a) (Fig. 4.8) Psoas can be treated in the prone position described for rectus above, in which case the stretch following the patient’s isometric effort to bring the thigh to the table against resistance would be concentrated on extension of the thigh, either to the new barrier of resistance if acute or past the barrier, placing stretch on psoas, if chronic.
Figure 4.8 MET treatment of psoas with stabilising contact on ischial tuberosity as described by Greenman (1996). The patient is prone with a pillow under the abdomen to reduce the lumbar curve. The practitioner stands on the side opposite the side of psoas to be treated, with the table-side hand supporting the thigh. The non-table-side hand is placed so that the heel of that hand is on the sacrum, applying pressure towards the floor, to maintain pelvic stability (see also Fig. 4.11A). The fingers of that hand are placed so that the middle, ring and small fingers are on one side of L2/3 segment and the index finger on the other. This allows these fingers to sense a forwards (anteriorly directed) ‘tug’ of the vertebrae when psoas is stretched past its barrier. (An alternative hand position is offered by Greenman (1996) who suggests that the stabilising contact on the pelvis should apply pressure towards the table, on the ischial tuberosity, as thigh extension is introduced.
The author agrees that this is a more comfortable contact than the sacrum. However, it fails to allow access to palpation of the lumbar spine during the procedure.) The practitioner eases the thigh (knee is flexed) off the table surface and senses for ease of movement into extension of the hip. If there is a strong sense of resistance there should be an almost simultaneous awareness of the palpated vertebral segment moving anteriorly. It should – if psoas is normal – be possible to achieve approximately 10° of hip extension before that barrier is reached, without force. Greenman (1996) suggests that ‘Normally the knee can be lifted 6 inches [15 cm] off the table. If less, tightness and shortness of psoas is present.’ Having identified the barrier, the practitioner either works from this (in an acute setting) or short of it (in a chronic setting) as the patient is asked to bring the thigh towards the table against resistance, using 15–25% of their maximal voluntary contraction potential, for 7–10 seconds. Following release of the effort (with appropriate breathing assistance if warranted), the thigh is eased to its new barrier if acute, or past that barrier, into stretch (with patient’s assistance, ‘gently push your foot towards the ceiling’). If stretch is introduced, this is held for not less than 10 seconds and ideally up to 30 seconds. It is important that as stretch is introduced no hyperextension occurs of the lumbar spine. Pressure from the heel of hand on the sacrum can usually ensure that spinal stability is maintained. The process is then repeated.
Method (b) (Fig. 4.9A) Grieve’s method involves using the supine test position, in which the patient lies with the buttocks at the very end of the table, non-treated leg fully flexed at hip and knee and either held in that state by the patient, or by placement of the patient’s foot against the practitioner’s lateral chest wall. The leg on the affected side is allowed to hang freely with the medioplantar aspect resting on the practitioner’s far knee or shin.
Figure 4.9A MET treatment of psoas using Grieve’s method, in which there is placement of the patient’s foot, inverted, against the practitioner’s thigh. This allows a more precise focus of contraction into psoas when the hip is flexed against resistance.
Figure 4.9B Psoas treatment variation, with the leg held straight and the pelvis stabilised. The practitioner stands sideways on to the patient, at the foot of the table, with both hands holding the thigh of the extended leg. The practitioner’s far leg should be flexed slightly at the knee so that the patient’s foot can rest as described. This is used as a contact which, with the hands, resists the attempt of the patient to externally rotate the leg and, at the same time, flex the hip. The practitioner resists both efforts, and an isometric contraction of the psoas and associated muscles therefore takes place. This combination of forces focuses the contraction effort into psoas very precisely. Appropriate breathing instructions should be given (see notes on breathing, Box 4.2). If the condition is acute, the treatment of the patient’s leg commences from the restriction barrier, whereas if the condition is chronic, the leg is elevated into a somewhat more flexed position. After the isometric contraction, using an appropriate degree of effort (i.e. is this acute or chronic?), the thigh should, on an exhalation, either be taken to the new restriction barrier, without force (acute), or through that barrier with slight, painless pressure towards the floor on the anterior aspect of the thigh (chronic), and held there for 10–30 seconds (see Fig 4.10B; see also variation Fig. 4.9B). Repeat until no further gain is achieved.
Method (c) (Figs. 4.10A, B) This method is appropriate for chronic psoas problems only. The supine test position is used in which the patient lies with the buttocks at the very end of the table, nontreated leg fully flexed at hip and knee and either held in that state by the patient (Fig 4.10A), or by the practitioner’s hand (Fig 4.7B), or by placement of the patient’s foot against the practitioner’s lateral chest wall. The leg on the affected side is allowed to hang freely. The practitioner resists (for 7–10 seconds) a light attempt of the patient to flex the hip. Appropriate breathing instructions should be given (see notes on breathing, Box 4.2). After the isometric contraction, using an appropriate degree of effort, the thigh should, on an exhalation, be taken very slightly beyond the restriction barrier, with a light degree of painless pressure towards the floor, and held there for 10–30 seconds (Fig. 4.10B). Repeat until no further gain is achieved.
Figure 4.10A MET treatment involves the patient’s effort to flex the hip against resistance.
Figure 4.10B Stretch of psoas, which follows the isometric contraction (Fig. 4.10A) and is achieved by means of gravity plus additional practitioner effort.
Self-Treatment of Psoas
Method (a) Lewit suggests self-treatment in a position as above in which the patient lies close to the end of a bed (Fig 4.10A without the practitioner) with one leg fully flexed at the hip and knee and held in this position throughout, while the other leg is allowed to reach the limit of its stretch, as gravity pulls it towards the floor. The patient then lifts this leg slightly (say 2 cm) to contract psoas, holding this for 7–10 seconds, before slowly allowing the leg to ease towards the floor. This stretch position is held for a further 30 seconds, and the process is repeated three to five times. The counterpressure in this effort is achieved by gravity.
Method (b) Patient kneels on leg on side to be self-stretched so that the knee is behind the trunk, which remains vertical throughout. The non-treated side leg is placed anteriorly, knee flexed to 90°, foot flat on floor. The patient maintains a slight lumbar lordosis throughout the procedure as she lightly contracts psoas by drawing the treated side knee anteriorly (i.e. flexing the hip) without actually moving it. Resistance to this isometric movement is provided by the knee contact with the (carpeted) floor. After 7–10 seconds the patient releases this effort, and while maintaining a lumbar lordosis and vertical trunk, eases her pelvis and trunk anteriorly to initiate a sense of stretch on the anterior thigh and hip area. This is maintained for not less than 30 seconds before a further movement anteriorly of the pelvis and trunk introduces additional psoas stretch (see also Fig. 4.11B).
Figure 4.11A Alternative prone treatment position, not described in text (see also Fig. 4.8). B Psoas self-stretch, not described in text.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany.
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