Download Chapter 6 - Assessment of Posture

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
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Clinical Anatomy
 Postural deviation or skeletal
malalignment
 Cause other joints in the kinetic chain to
compensate
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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)
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Forefoot Varus
(A) Uncompensated (STJ Neutral) and (B) compensated forefoot varus.
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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
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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
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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
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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
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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
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Relationship of Actin and Myosin
Cross-Bridges
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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
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Muscle Imbalances
Muscle
1
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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
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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.
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Muscle Imbalances
Muscle
1
Muscle
2
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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
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Clinical Examination of Posture
 Described as
 Mild—25% deviation from
normal
 Moderate—50% deviation
 Severe—75% deviation
 Use measurement to
quantify malalignments
whenever possible
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 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
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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)
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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
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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?
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Side of Dominance
 Right or left side dominant?
 If one side is used for most tasks, then
bilateral imbalances are common.
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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
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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
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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.
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Medical History
 Previous history?
 Medical attention sought
 Treatments
 General health questionnaire
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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!
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 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
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Classifications of Body Types
Ectomorph
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Mesomorph
Endomorph
Views of Postural Inspection
 Inspect from all planes with body in
orthoposition
 Lateral (sagittal plane)
 Anterior (frontal plane)
 Posterior (frontal plane)
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Inspection of Ideal Posture
Lateral
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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)
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 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
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Tape Measure Method of Detecting
Leg-Length Discrepancies
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Measured Block Method of Determining
Leg-Length Discrepancies
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Palpation
 Lateral aspect
 Pelvic position
 ASIS and PSIS on same side
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Palpation
 Anterior aspect






Patellar position
Iliac crest heights
ASIS heights
Lateral malleolus
Fibula head heights
Shoulder heights
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Anterior Aspect
Finding the heights of
the iliac crests
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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
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Reading Scapular Postures
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Reading Scapular Postures
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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.
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Common Postural Deviations
 Not all postural deviations cause
pathology.
 Distinguish between
 Normal posture
 Asymptomatic deviations
 Asymptomatic—without symptoms
 Postural deviations
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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
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Alignment of the Calcaneus
(A) Calcaneal eversion (calcaneovalgus). (B) Calcaneal inversion
(calcaneovarus).
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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
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Foot Posture Index
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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
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Spinal Column





Hyperlordotic posture
Kypholordotic posture
Swayback posture
Flat back posture
Scoliosis
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Hyperlordotic Posture
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Kypholordotic Posture
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Swayback Posture
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Flat Back Posture
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Scoliosis
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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
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Forward Shoulder Posture
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Head and Cervical Spine
 Forward head posture
 Anterior displacement of the head relative
to the thorax
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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
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Interrelationship Between Regions
Cause or Effect?
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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
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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.
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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.
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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.
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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
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