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Chapter 6 Assessment of Posture Copyright © 2015. F.A. Davis Company Introduction Posture Position of the body at a given point in time Correct posture can Improve performance Decrease abnormal stresses Reduce development of pathological conditions ADLs Activities of daily living Copyright © 2015. F.A. Davis Company Clinical Anatomy Postural deviation or skeletal malalignment Cause other joints in the kinetic chain to compensate Copyright © 2015. F.A. Davis Company The Kinetic Chain “Chain reaction” Open chain Non–weight-bearing Closed chain Weight-bearing Distal segment is resisted or fixated. UE (e.g., push-up position) LE (e.g., standing) Copyright © 2015. F.A. Davis Company Forefoot Varus (A) Uncompensated (STJ Neutral) and (B) compensated forefoot varus. Copyright © 2015. F.A. Davis Company Examples of Compensatory Strategies of the Body Skeletal Subtalar Malalignment Joint Tibiofemoral Joint Hip Joint Pelvis and Lumbar Spine Forefoot or Rearfoot Varus Excessive or prolonged pronation Flexion Internal tibial rotation Flexion Internal femoral rotation Anterior rotation and excessive lumbar extension Forefoot Valgus Early supination Extension External tibial rotation Extension External femoral rotation Posterior rotation and excessive flexion Copyright © 2015. F.A. Davis Company The Kinetic Chain Adhesive capsulitis Arthrokinematic motions of the GH joint are decreased. Stenosis Narrowing of the vertebral foramen through which the spinal cord or spinal nerve root pass Lordosis Anterior curvature of the spine Copyright © 2015. F.A. Davis Company Muscular Function Joint stability Integrity of a joint when it is placed under a functional load Optimal length–tension relationship Muscles that are too long or too short can produce adverse stress on the joints Copyright © 2015. F.A. Davis Company Muscle Length and the Ability to Perform Function Muscle Length Ability to Provide Mobility Ability to Provide Stability Normal Efficient Efficient Shortened Inefficient Efficient Elongated Efficient Inefficient Copyright © 2015. F.A. Davis Company Muscular Length–Tension Relationships Effect of muscle length and the amount of tension (force) produced Tension-developing capacity Sarcomere unit Actin Myosin Optimal L–T relationship Position where the muscle can generate the most tension with the least effort Copyright © 2015. F.A. Davis Company Relationship of Actin and Myosin Cross-Bridges Copyright © 2015. F.A. Davis Company Agonist and Antagonist Relationships Agonist muscle Antagonist muscle Performs the opposite movement of the agonist Reciprocal inhibition Muscle that contracts to perform the primary movement Agonist reflexively relaxes to allow the agonist’s motion to occur Co-contraction Concurrent contraction of the agonist and antagonist muscles Copyright © 2015. F.A. Davis Company Muscle Imbalances Muscle 1 Copyright © 2015. F.A. Davis Company Causes of Muscle Imbalances Cause Result Nerve Pathology Paralysis, muscle weakness, or muscle spindle inhibition Pain Inhibition or muscle spasm Joint Effusion Reflexive inhibition of muscle Poor Posture Alteration in muscle length–tension relationship Repetitive Activity of One Muscle Group Adaptive shortening and increased recruitment Copyright © 2015. F.A. Davis Company Postural Versus Phasic Muscles Characteristic Postural Muscles Phasic Muscles Function Support body against forces of gravity Movement of the body Muscle Fiber Type Higher percentage of slow-twitch fibers Higher percentage of fast-twitch fibers Response to Dysfunction Become overactivated and tightened or shortened Become inhibited and weakened Common Soft Tissue Dysfunction Prone to tears and tendinopathies Prone to trigger points Trigger point: A pathological condition characterized by a small, hypersensitive area located within muscles and fasciae. Copyright © 2015. F.A. Davis Company Muscle Imbalances Muscle 1 Muscle 2 Copyright © 2015. F.A. Davis Company Clinical Examination of Posture Objective tools Radiographs Photographs Computer analysis Clinical tools Plumb lines String and pendulum that hangs perpendicular to surface Goniometers Flexible rulers Inclinometers Copyright © 2015. F.A. Davis Company Clinical Examination of Posture Described as Mild—25% deviation from normal Moderate—50% deviation Severe—75% deviation Use measurement to quantify malalignments whenever possible Copyright © 2015. F.A. Davis Company Assessed standing and sitting Orthoposition Normal or properly aligned posture Natural posture March in place 10x Roll shoulder forward and backward 3x Nod head forward and backward 5x Inhale and exhale deeply History Helps determine whether postural dysfunction is contributing to the patient’s pathology and symptoms Repetitive tasks can lead to overuse injuries. If the MOI is insidious and symptoms have increased over time Investigate the person’s day-to-day tasks Copyright © 2015. F.A. Davis Company Factors Influencing Posture Factor Example Neurological Pathology Winging of the scapula secondary to inhibition of the long thoracic nerve Muscle Imbalances Increased pelvic angles secondary to weak abdominal muscles Hypermobile Joints Genu recurvatum Hypomobile Joints Flexion contracture Decreased Muscle Extensibility Decreased pelvic angles secondary to tightness of the hamstring muscles Bony Abnormalities Toe in or toe out posture secondary to internal or external tibial torsion Leg-Length Discrepancies Functional scoliosis Pain Antalgic posture (e.g., side bending cervical spine to decrease compression on a nerve root) Lack of Postural Awareness Acquired bad habits (e.g., slouching in chair) Copyright © 2015. F.A. Davis Company Mechanism of Injury Indicates injury is poor posture Insidous onset with no specific cause of pain Nonspecific mechanism or time of injury Common responses Insidious onset of pain Pain worsening as the day progresses Description of posture-specific pain Complaints of intermittent pain Vague or generalized pain descriptions Initially starting as an ache that has progressively worsened over time Copyright © 2015. F.A. Davis Company Type, Location, and Severity of Symptoms Dysfunctions or pain are worse at night. Pain? Burning Sharp Aching Pulsating Paresthesia? Constant or intermittent? Does it radiate? Copyright © 2015. F.A. Davis Company Side of Dominance Right or left side dominant? If one side is used for most tasks, then bilateral imbalances are common. Copyright © 2015. F.A. Davis Company Activities of Daily Living (ADL) Which types of ADL? Duration Frequency Have patient demonstrate tasks See Table 6-6. Examples of Daily Stresses and Their Possible Resulting Pathologies Copyright © 2015. F.A. Davis Company Driving, Sitting, and Sleeping Postures Has anything changed in the person’s daily routine over the past few months? Changes provide insight about instigating factor. See Table 6-7. Driving, Sitting, and Sleeping Postures Copyright © 2015. F.A. Davis Company Level and Intensity of Exercise Exercise? Regular or sporadic? Routine change? Rapid change in exercise duration or intensity may make a previously benign postural fault problematic. Copyright © 2015. F.A. Davis Company Medical History Previous history? Medical attention sought Treatments General health questionnaire Copyright © 2015. F.A. Davis Company Inspection Examination area Private—protect modesty Comfortable temperature Clothing Male—only wear shorts Female–wear shorts and halter top (to expose back) Shoes should not be worn. Don’t tell them their posture is being assessed! Copyright © 2015. F.A. Davis Company Systematic approach Work inferior to superior or vice versa Comparing bilaterally Eyes at same level as body part Overall Impression Patient’s body type Ectomorph Mesomorph Endomorph Body mass index Relative mass based on height and weight Copyright © 2015. F.A. Davis Company Classifications of Body Types Ectomorph Copyright © 2015. F.A. Davis Company Mesomorph Endomorph Views of Postural Inspection Inspect from all planes with body in orthoposition Lateral (sagittal plane) Anterior (frontal plane) Posterior (frontal plane) Copyright © 2015. F.A. Davis Company Inspection of Ideal Posture Lateral Copyright © 2015. F.A. Davis Company Anterior Posterior Inspection of Leg-Length Discrepancy Contributes to LE and back pathology Longer limb Osteoarthritis and stress fractures Two categories Structural (true) Functional (apparent) Copyright © 2015. F.A. Davis Company Examination methods Radiograph Computed tomography Clinical methods Structural ASIS to medial malleolus Functional Navel to medial malleolus Leg-Length Differences Category Type Description Possible Causes Functional or Apparent Leg Length Leg-length difference that is attributed to something other than the length of the tibia or femur Tightness of muscle or joint structures or muscular weakness in the lower extremity or spine; examples include knee hyperextension, scoliosis, or pelvic muscle imbalances. Structural or True Leg Length An actual difference in the length of the femur or the tibia of one leg compared with the other Possibly from disruption in the growth plate of one of the long bones or a congenital anomaly Copyright © 2015. F.A. Davis Company Tape Measure Method of Detecting Leg-Length Discrepancies Copyright © 2015. F.A. Davis Company Measured Block Method of Determining Leg-Length Discrepancies Copyright © 2015. F.A. Davis Company Palpation Lateral aspect Pelvic position ASIS and PSIS on same side Copyright © 2015. F.A. Davis Company Palpation Anterior aspect Patellar position Iliac crest heights ASIS heights Lateral malleolus Fibula head heights Shoulder heights Copyright © 2015. F.A. Davis Company Anterior Aspect Finding the heights of the iliac crests Copyright © 2015. F.A. Davis Company Identifying the anterior superior iliac spine Identifying the level of the shoulders Palpation Posterior aspect PSIS positions Spinal alignment Scapular position Palpating the posterior superior iliac spines Copyright © 2015. F.A. Davis Company Reading Scapular Postures Copyright © 2015. F.A. Davis Company Reading Scapular Postures Copyright © 2015. F.A. Davis Company Muscle Length Assessment Standard and objective One-joint muscles Use normal ranges for PROM Goniometer Less likely to become shortened Two-joint muscles Specific measurable tests Greater tendency to become shortened See Table 6-12 and Table 6-13 for specific procedures to assess muscle length. Copyright © 2015. F.A. Davis Company Common Postural Deviations Not all postural deviations cause pathology. Distinguish between Normal posture Asymptomatic deviations Asymptomatic—without symptoms Postural deviations Copyright © 2015. F.A. Davis Company Foot and Ankle Pronated foot Flattened medial longitudinal arch Adduction and plantarflexion of the talus and eversion of the calcaneus when weight bearing Supinated foot Heightened medial longitudinal arch Abduction and dorsiflexion of the talus and inversion of the calcaneus Copyright © 2015. F.A. Davis Company Alignment of the Calcaneus (A) Calcaneal eversion (calcaneovalgus). (B) Calcaneal inversion (calcaneovarus). Copyright © 2015. F.A. Davis Company Foot Posture Index Designed to improve reliability and validity of foot posture classification 5-point Likert scale to assess six aspects 1. 2. 3. 4. 5. 6. Talar head palpation Curves above and below the lateral malleoli Inversion or eversion of the calcaneus Bulge in the region of the talonavicular joint Congruence of the medial longitudinal arch Abduction or adduction of the forefoot or the rearfoot Copyright © 2015. F.A. Davis Company Foot Posture Index Copyright © 2015. F.A. Davis Company Knee Genu recurvatum > 5° of knee hyperextension Congenital, or tear of ACL and PCL Genu valgum “Knock-kneed” Medial angulation of the femur and tibia Genu varum “Bowlegged” Lateral angulation of the femur and tibia Copyright © 2015. F.A. Davis Company Spinal Column Hyperlordotic posture Kypholordotic posture Swayback posture Flat back posture Scoliosis Copyright © 2015. F.A. Davis Company Hyperlordotic Posture Copyright © 2015. F.A. Davis Company Kypholordotic Posture Copyright © 2015. F.A. Davis Company Swayback Posture Copyright © 2015. F.A. Davis Company Flat Back Posture Copyright © 2015. F.A. Davis Company Scoliosis Copyright © 2015. F.A. Davis Company Shoulder and Scapula Forward shoulder posture Protraction and elevation of the scapulae Forward, rounded position of the shoulders Scapula winging Medial border projects posteriorly Weakness of the serratus anterior and middle and lower trapezius Secondary to trauma to the long thoracic nerve Copyright © 2015. F.A. Davis Company Forward Shoulder Posture Copyright © 2015. F.A. Davis Company Head and Cervical Spine Forward head posture Anterior displacement of the head relative to the thorax Copyright © 2015. F.A. Davis Company Combination of Forward Head Posture and Forward Shoulder Posture Muscles That Become Overactivated and Tightened Combination of Forward Head Posture and Forward Shoulder Posture Pectoralis minor Lower trapezius Upper trapezius Middle trapezius Upper rhomboids Serratus anterior Levator scapulae Copyright © 2015. F.A. Davis Company Interrelationship Between Regions Cause or Effect? Copyright © 2015. F.A. Davis Company Documentation of Postural Assessment Document the view that is being observed (e.g., anterior, posterior, right lateral, left lateral). Quantify each postural deficit using minimum (min), moderate (mod), or severe (sev) and, whenever possible, objectively measure the deficits. Note: Specific landmarks used Specific positions measured Specific techniques used Copyright © 2015. F.A. Davis Company Documentation of Postural Assessment Document the side of the body where the deficit occurs. If it involves unequal heights, choose whether to document the higher or lower side and then be consistent with your documentation. Use arrow symbols ( ) to represent increases or decreases regarding asymmetries in height. Use greater than (>) and less than (<) symbols to represent regions of muscle mass that are larger or smaller than the contralateral side. Copyright © 2015. F.A. Davis Company Documentation of Postural Assessment Document in an outline form. Document only postural deficits in the assessment. Identify normal regions WNL. Use standard, approved medical abbreviations. Use an asterisk (*) to emphasize a significant finding by placing the * beside the deficit. Copyright © 2015. F.A. Davis Company Documentation of Postural Assessment When evaluating an upper quarter condition, include the pelvis, lumbar spine, and all joints proximal to the injury. When evaluating a lower quarter condition, include the lumbar spine, pelvis, and all joints distal to the painful site in the postural assessment. Include the entire body in the postural assessment of a patient with a spinal injury. Copyright © 2015. F.A. Davis Company Documentation of Impairments Identified in a Full Postural Assessment View Characteristics Anterior • • • • • Minimal pes planus bilateral feet Moderate bilateral squinting patellae Moderate bilateral genu valgum Minimal increase in right ASIS height Minimal bilateral internal rotation shoulder, right greater than left Posterior • • • • Minimal bilateral calcaneal valgum Moderate bilateral genu valgum Minimal decrease in right PSIS height Minimal bilateral protraction scapulae, right greater than left Right Lateral • • • • Minimal genu recurvatum Moderate anterior pelvic tilt, 20° Minimal increase in lumbar lordosis Minimal FHP Left Lateral • • • • Moderate genu recurvatum Moderate anterior pelvic tilt, 20° Minimal increase in lumbar lordosis Minimal FHP Copyright © 2015. F.A. Davis Company