Download Assessing Posture

What is Posture?
Assessing Posture
Paul Taylor & Oliver Scott
z Position of the body, or relative alignment of body parts; in
particular the musculo-skeletal system; but has an effect
on every system of the body
z COG over base of support
z Posture should fulfill 3 functions (Martin, 2002):
z Maintain the alignment of body segments in all
positions; standing, sitting, quadruped, prone & supine
z Anticipate change to facilitate engagement in goaldirected movements such as reaching & stepping
z React to unexpected disturbances in balance
z Not just a static state – it is important during movement
and has an impact on balance
z Sitting
z Standing
z Moving
What is Posture?
Good And Poor Posture
z Understanding the principles of posture Æ better
exercise prescription
z Optimal posture Æ body requires minimal energy to
maintain its position and movement is more efficient
z We use multiple sensing references
z Visual
z Somatosensory
z Vestibular
z Neural component cannot be understated
z Basis of motor control
z Connective tissue is active in posture
z Fascia & Ligaments
z Good posture is the state of muscular and skeletal
balance that protects the supporting structures of
the body against injury or progressive deformity
irrespective of the attitude (eg erect, lying,
squatting, stooping) in which these structures are
working
Implications of Poor Posture
Implications of Poor Posture
z Impaired movement
z Body will compensate if one or more segment/s of
the kinetic chain is not in proper alignment
z Repeated movements and sustained postures
associated with daily work and recreation activities
are the main culprit (Sahrmann, 2002)
z Computer analyst / office worker
z Supermarket checkout assistant
z Golfer / Soccer player
z Inappropriate exercise prescription can exacerbate
faulty movement patterns
z Pattern overload – machine VS free weights
z Poor posture is a faulty relationship of the various
parts of the body, which produces increased strain on
the supporting structures and in which there is less
efficient balance over its base of support
z Posture Committee of the American Academy of
Orthopaedic Surgeons
z Pain
z In poor posture, the postural muscles are more
active, with greater energy expended
z Muscle ischaemia – the level of contraction of a
muscle is inversely proportional to blood flow through
it: at 50-60% peak contraction, blood flow is almost
zero (Sjogaard, 1988)
z Can lead to pain, dysfunction and breakdown in
numerous systems of the body (compensatory
effects)
Importance of Posture
z Forward head posture:
z Average head weighs around 7% of BW
z Activity of neck extensors increase dramatically
z Reduced blood flow and build-up of waste products
z Leads to reflex muscle contraction & trigger points
z For every inch the COG of the head moves forward, lower
cervical spine is subjected to compressive forces equivalent to
an additional single head weight (Zohn, 1988)
z Chronic pain develops
Muscle Fibre Types & Actions
z Fibre type
z Fast-twitch: for powerful, gross movements
z Slow-twitch: low-level endurance activities (posture)
z Tonic, phasic and mixed musculature
z Tonic: resist gravity, so are strongly involved in
posture. Slow-twitch dominant and react to faulty
loading by shortening
z Phasic: main function is movement. Predominantly
fast-twitch and react to faulty loading by lengthening
z Mixed: majority of muscles are mixed. React to faulty
loading by either shortening or lengthening
z Muscle imbalance is identified where there is a lack of
balance between tonic and phasic muscles (Spring et al,
1991)
Implications of Muscle Lengthening
z Stretch weakness (Kendall et al, 1993)
z Result of altered length-tension relationship
z Reduced contractile force as actin and myosin
filaments are pulled apart
z Increase in Serial Sarcomere Number
z Stretched muscle adds more sarcomeres in an attempt
to move actin & myosin filaments closer together
(Norris, 2000)
Muscle imbalance
z Traditional viewpoint:
z Occurs when a muscle shortens and its antagonist
is stretched and lengthens
z Both disadvantaged biomechanically
z Length-tension relationship not optimal
z Can displace the bones where they attach
z Kinetic chain response
Implications of Muscle Shortening
z Pseudoparesis (Janda, 1986):
z Tight or overactive muscles may hinder or inhibit the
opposing muscle (antagonist)
z Reciprocal inhibition
z The hypertonic muscles become active in movements
they are not normally associated with
z Tonic muscles are innervated by smaller type 2 motor
neuron
z Lower excitability threshold than phasic muscles
z Can inhibit antagonist
z Direct affect on movement patterns, range of motion
and posture
Muscle Classifications
Shoulder
Girdle
Trunk
Predominantly Tonic
(shortening)
Predominantly Phasic
(lengthening)
Pectoralis major
Rhomboids
Levator scapulae
Upper trapezius
Lower trapezius
Mid trapezius
Biceps brachii
Triceps brachii
Neck extensors
Neck flexors
Lumbar & cervical
erectors
Quadratus lumborum
Thoracic extensors
Adapted from Spring et al, 1991
Abdominals
Muscle Classifications
Pelvic
Girdle
Tensegrity
Predominantly Tonic
(shortening)
Predominantly Phasic
(lengthening)
Biceps femoris
Semitendinosus
Semimembranosus
Vastus medialis
Vastus Lateralis
Iliopsoas
Rectus femoris
Gluteus maximus
Gluteus mimimus
Gluteus medius
Adductors
Piriformis
TFL
Lower
Leg
Gastrocnemius
Soleus
Tibialis anterior
Peroneals
z Spine not stabilised by compression forces alone
z Vertebral bodies do not bear all forces transmitted to
the spine
z Neural arch assists in transmitting force
z Spinal erectors form guide-wires for stabilising spine
z Help resists flexion & reduce forces on vertebral
body & discs
z Spinous & transverse processes provide framework
for guide-wires
z Pain & forces can refer throughout kinetic chain
z Beauty & complexity of Human design
z Need to view dysfunction globally
Adapted from Spring et al, 1991
Development of the Muscle and
Fascia
Correcting Faulty Posture
z Myofibril
z Endomysium
z Fibre bundle
z Perimysium
z Muscle
z Epimysium
z Consider main myofascial line(s) involved
z Tonic/phasic components within a line
z Other lines that assist/oppose to achieve balance
z Stimulate NS & blood flow – mobilisers
z Myofascial release – foam roller or therapist
z Facilitate - mobilisers
z Effective movement – exercises
Postural Assessments
Static Postural Assessment
z Static
z Useful in identifying overt abnormalities
z Critical for effective exercise prescription
z Dynamic
z ‘3 big rocks’
z Targeted movement screens
z Intervention flow chart
z Assessment of posture in “relaxed” position
z Begin with a general observation to get an idea of
global alignment
z Head / Cervical Spine
z Shoulder / thoracic spine / scapulae / arms
z Lumbar spine / pelvis
z Knees
z Ankles & feet
z Observe client’s posture sequentially: inferior to
superior or vice versa
z Observe from anterior, posterior & lateral viewpoints
z Move focus to specific screening points
Muscle Imbalances
Postural Screening – Back View
z Weight shift
z Ankle alignment
z Relative knee alignment
z Varus/valgus
z PSIS levels
z Oblique folds
z Gluteal folds
z Spinal alignment
z Scapulae
z Flat against upper back
z Shoulder height
z Head carriage
z PT Academy view:
z Take a global look
z Tonic & phasic still
has relevance
z View as part of
myofascial line
disturbance
z Prolonged sitting
Video Link
Static Postural Assessment – Anterior
View
z Feet & ankle
z Relative knee position
z Pelvis - Iliac crest height
z ASIS
z Shoulder height – level?
z Hand position
z Head carriage
z Laterally flexed /
rotated?
z Weight shift?
z Nose & umbilicus
Video Link
Lateral View
Scoliosis
z Structural & functional
z Compensatory lateral
displacement of spinal
column
z Often notice imbalances
in tone/mass of spinal
erectors
z Beyond scope of PT Refer!
Video Link
Anterior Pelvic Tilt
z Slightly anterior to ankle bone
z Leg vertical and at right angle to sole of foot
z Through or slightly anterior to centre of knee
z Knees neither flexed or hyperextended
z Through or slightly posterior to hip bone
z Pelvis - neutral position, not tilted
z Hips - neither flexed or extended
z Through the shoulder
z Thoracic Spine - slightly convex posteriorly
z Lumbar Spine - slightly convex anteriorly
z Through lobe of the ear
z Head not tilted forward or back
Video Link
z Short/tight erector spinae?
z Short/tight quadratus lumborum?
z Short/tight iliopsoas?
z Short/tight rectus femoris?
z Long/weak hamstrings and gluteus
maximus?
z The interactions are complicated
z Kinetic chain!!
Upper & Lower Crossed Back
Posture
Posterior Pelvic Tilt
z Head: Forward, cervical spine hyperextended
z Short upper traps & SCM
z Long neck flexors
z Thoracic Spine: kyphosis
z Long mid traps & rhomboids
z Short pecs & lats
z Pelvis: Anterior tilt
z Short erector spinae
z Long abdominals
z Short hip flexors
z Long hamstrings & gluteus maximus
z Knee Joints: Hyperextended
z Ankle Joints: slightly plantar flexed
z Short plantar flexors
z Short/tight rectus abdominus?
z Short/tight external obliques?
z Short/tight gluteus maximus?
z Short/tight hamstrings?
z Long/weak hip flexors?
Lower Crossed (Lumbar Lordosis) –
Pertinent Myofascial Lines
DFL
Lordosis – Management Plan
SBL
SFL
Video Link
Upper Crossed (Thoracic Kyphosis) –
Pertinent Myofascial Lines
SFAL
DFAL
SFL
Foam Roller
ITB
Adductors
Calves
TLF
Mobilisers
Sag hip mobiliser
Tri-plane adductor
Anterior knee driver
Basic Exercises
Cable rev woodchop
Squat w/ diagonal cable row
Alt arm bent knee shoulder
press w/ hip driver
Advanced Exercises
2-arm DB uppercut
High cable saggital jacks
Rev step DB scaption (extra
load)
Kyphosis – Management Plan
DBAL
Foam Roller
Mobilisers
Video Link
Thoracic
Lats
Incline crawl
Segmented gait with lateral
reach
Tri-plane shoulder press w/ hip
driver
Basic Exercises
Reverse step scaption
YTWL
T-push-up
Advanced Exercises
1-arm hip extension swings
1-leg backhander
Multi-directional punching
Flat Back – Pertinent Myofascial
Lines
Flat Back Posture
DFL
z Head: Forward, cervical spine slightly
extended
z Short upper traps & SCM
z Long neck flexors
z Thoracic Spine: Upper part increased flexion,
lower part straight
z Long mid traps & rhomboids
z Short pecs & lats
z Straight (flexed) Lumbar Spine & Posterior
tilt of pelvis, with hip extended
z Long erector spinae
z Short abdominals
z Long hip flexors (iliopsoas)
z Short hamstrings (& gluteus maximus)
z Knee Joints: Extended (or flexed)
z Ankle Joints: Slightly plantar flexed
z Short plantar flexors
Flat Back – Management Plan
Hamstrings
Lower leg
Mobilisers
Prone dynamic knee drive
Rev woodchop w/ forward/reverse
step
Functional chest mobiliser
Basic Exercises
2-arm cable row with knee driver
Cable lawnmower
Reverse step dumbell scaption
Advanced Exercises
2-D uppercut
Cable trunk rotation w/ knee
driver
Barbell kayak
Sway Back – Pertinent Myofascial
Lines
SFAL
Video Link
Sway Back Posture
Foam Roller
SBL
SBL
z Head: Forward, cervical spine slightly extended
z Short upper traps & SCM
z Long & weak neck flexors
z Thoracic Spine: Increased flexion (long kyphosis
with posterior displacement of upper trunk)
z Long mid traps & rhomboids
z Short pecs, lats
z Short upper abdominals
z Lumbar Spine: Flattening of lower lumbar spine
z Strong (but not short) erector spinae
z Long lower abdominals & obliques
z Pelvis: Posterior tilt with hip extended & forward
z Long & weak iliopsoas
z Short & tight hamstrings (& gluteus maximus)
z Knee Joints: Hyperextended
z Ankle Joints: Neutral Position (pelvis deviation) or
plantar flexed
z Short plantar flexors??
Pronation
DBAL
DFL
SBL
Spiral
Lateral
Video Link
DFL
Pronation Distortion– Management
Plan
Winging Scapula
DFAL
Foam Roller
Medial calf
Glutes
Adductors
ITB
Mobilisers
Hip swings
Pigeon-toed walking
Forward/rev step w/foot adaptors
Basic Exercises
Dynamic squat w/ toe-in
Cable toe-in step
Alt arm bent-knee shoulder press
w/ knee driver
Advanced Exercises
Bent-over leg swings
Cable x-over posterior toe-in step
2-arm cable ward w/ frontal bound
Winging Scapula – Management
Plan
SFAL
DBAL
Video Link
Summary
Foam Roller
Thoracic serratus pulse
Thoracic
Mobilisers
Multi-planar wall scap mobiliser
Squat diagonal reach w/ foot
adaptors
Wall fixed arm step around
Basic Exercises
Reverse step scaption
T-push up
YTWL
Advanced Exercises
Barbell kayak
Low cable pull w/ DB press
Multi-directional punching
z Know your limits
z Refer where appropriate
z Do good, do no harm
z Remember the Kinetic Chain
z Compensations
z Augment with movement screen
z Observation, observation, observation
THE BIG “3”
z THE ANKLE (TALOCRURAL) COMPLEX
z ILIO-FEMORAL (HIP) JOINT
DYNAMIC POSTURAL
ASSESSMENTS
Michol Dalcourt
z THORACIC SPINE
Lateral
THE ANKLE (TALOCRURAL) JOINT
THE ANKLE (TALOCRURAL) JOINT
z Made up of:
z Tibiotalar Joint
z Normal Motions available:
z
Fibulotalar Joint
z
Tibiofibular Joint
z
20° Inversion
z
10° Eversion
z
20° Dorsiflexion
z
50° Plantarflexion
z
19° Rotation
THE Ilio-Femoral (Hip) JOINT
THE Ilio-Femoral (Hip) JOINT
z Normal Motions available:
z Normal Motions available:
z
z
z
z
z
z
110 - 120° Flexion
10 - 15° Extension
30 - 50° Abduction
30° Adduction
30 - 40° Internal
Rotation
40 - 60° External
Rotation
z
z
z
z
z
z
110 - 120° Flexion
10 - 15° Extension
30 - 50° Abduction
30° Adduction
30 - 40° Internal
Rotation
40 - 60° External
Rotation
THE THORACIC SPINE
Movement Assessments –
Video Links
z Normal Motions available:
• Assessment 1 – Ankle complex
z
30 - 40° Flexion
z
20 - 30° Extension
z
20 - 25° Lateral Flexion
(from neutral)
z
35° Rotation (from
neutral)
• Assessment 2 – Hip complex
• Assessment 3 – Thoracic spine complex
Movement Screen Examples
More Movement Screen Examples
• Initial Movement Screen
• Mobilisers linked to the previous
Movement Screen
• Latissimus Dorsi Foam Roller linked to
Movement Screen
• Movement Screen Re-testing
• Thorax Foam Roller linked to Movement
Screen
• Mobilisers linked to Movement Screen and
Re-test