K Class 8 Postural Assessment 2013B

8/10/2019 K Class 8 Postural Assessment 2013B

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Kinesiology

FES Chapter 10 p. 468



Posture:

◦ Upright position in gravity

◦ Involves a complex set of closed chain activities

◦ Reflects the strength, balance, equilibrium and

stability of multiple structural and functionalparts of the body.

Postural Assessment: observing the client‟sgravitation line, balance and symmetry in various

positions



Good posture is important because itdecreases the amount of stress places onligaments, muscles, and tendons

Good posture improves function anddecreases the amount of muscle energyneeded to keep the body upright.

If posture is not balanced, postural muscles

must function more like ligaments andbones.





◦Tight muscles =

shortened

◦ Taut muscles =

stretched

◦

The body works like a

pulley system. If

muscles on anterior

side are shortened and

tight, the muscles

opposite side must be

lengthened and taut.

The lengthened and

taut muscles still

need work for

possible trigger

points,

herapist‟s focus

needs to be to loosen

the shortened

muscles and to

reeducate them for

proper position and

function.



◦ Some clients with

upper back and neck

pain will want nothing

but upper back and neck

work

◦

In doing a postural

analysis, the therapist

may find that the client

is internally rotated

(rounded shoulders)

which means that pecs,

lats, and other anterior

muscles must be

worked.

◦Trigger points may

exist in the lengthened

muscles (trapezius,

rhomboids, and serratus

posterior superior) that

need to be released.

◦ The focus of the work

would be on the muscles

of the rounded shoulder

posture.



Most postural problems are functional andnot structural.

For ex: a person who sits or stands for long

periods of time tend to slouch, resulting inmuscle imbalances which cause positionalstrain.

Other influences include: age, traumas,

birth defects, systemic disease, ergonomics,postural habits, lifestyle, habits, hydration,and nutritional status.



Spinal Curvatures



Curves are developed as we grow

Curves are present during rest and activityand function as shock absorbers.

Concave anteriorly & convex posteriorly:thoracic and sacral

Convex anteriorly & concave posteriorly:cervical and lumbar

Pelvis should be level







Lordosis or Hyperlordosis – increasedanterior curve or swayback

Kyphosis or Hyperkyphosis

–

increased

thoracic curve - hunchback

Flat back – decreased thoracic curve,decreased lumbar curve

Scoliosis

–

lateral curve of vertebral

column







If a person has a

habitual posture that

increases a spinal

curve, the following

will result

◦The muscles on the

concave side tend to

shorten and tighten

◦

The muscles on the

convex side tend to

become long , taut

and weak.





Standing Posture



When we stand for

long periods of time

we shift between 2

stances.

◦

A: Symmetric stance is

with weight distributed

equally on both feet

◦ B: Asymmetric stance is

weight nearly all on

one foot

Asymmetric is the

most common

standing position



Muscles that contractto resist the pull ofgravity and assist inmaintaining posture.

Examples include

muscles of the jaw thatkeep the mouth closed.

Muscles most involved: ◦

hip & knee extensors (including the quads)

◦trunk & neck extensors.



Ankle plantar flexors &

dorsiflexors control

postural sway (back and

forth movements at the

ankle)

Other postural muscles

involved in the upright

position:

◦ Trunk & neck flexors

◦ Hip abductors &

adductors

◦Ankle evertors

(pronators) & invertors

(supinators).



Upper trapezius Piriformis Levator scapula Oblique abdominals

SCM Adductor longus &magnus

Upper pectoralis major Tensor fascia latae

Latissimus dorsi Rectus femoris

Erector Spinae Medial hamstrings

Iliopsoas Soleus Gastrocnemius Tibialis posterior



Head moves forward

The hips bend

The torso moves forward

Legs lift the body from a semi-squat

position to a standing position









To perform a

complete

postural analysis,

the client needs

to be observed

from 3 views:

◦ Lateral view

◦Anterior view

◦ Posterior view



Client needs to be in symmetric stance with feet

about a shoulders-width apart.

Best done with the eyes closed so client is unable tobalance the body visually.

Often the client will tip the head or rotate it slightly to

feel balanced; this indicates muscular imbalance &internal postural imbalance information relayed bypositional receptors.

Look for:◦ Bilaterally symmetry◦ Head forward posture◦ Locking of the knees

A full assessment will include evaluation of the major joints.



Begin either from the head down or the feet up. The client should be without shoes or socks. Things to look for:

◦ Alignment of the Achilles tendon – Is the footpronated, supinated or neutral?

◦

Arches of the feet: You should be able to fit the tip ofyour index finger under the arch. If you are unable to get that much under the arch, the

client may have flat feet (pes planus); If more than that can go under the arch, the client may

have high arches (pes cavas).◦

Position of the feet: Are the hips medially or laterallyrotated?◦ Calf area: Is one larger than the other? Are they even?



Popliteal fold: Is it level? If it is higher on thelateral side of the knee, it could indicate a tight ITBand/or anterior pelvic tilt.

Hips: Are they level?◦ If the hips are not level when he is standing but

are level when he is are sitting, the problem ismost likely below the hips.◦ Is there an anterior or posterior tilt? Check the

level of the right ASIS compared to the right PSIS.Also compare the left ASIS & left PSIS.

◦

If the ASIS is 5-10 degrees lower than the PSIS,she has an anterior pelvic tilt.◦ If the PSIS is lower than the ASIS at all, she has a

posterior pelvic tilt.





Achieve the most

accurate assessments

by using a plumb line

suspended from the

ceiling and/or with a

postural grid behind

the person

The plumb line is a

string or cord with a

weight attached to the

lower end. Because of

its weight, it hangs

perfectly straight in a

vertical line.







An integrated functional unit Kinetic = force; chain = linked together

Composed of 3 systems:◦ Myofascial system (muscle, ligament, tendon and fascia)

◦

Joint system

◦ Nervous system

Each of these 3 systems work independently toallow movement in all planes.

If 1 or more do not work efficiently,

compensations & adaptations occur in the othersystems, leading to stress in the body &eventually to dysfunctional patterns.



• All movements require:• Acceleration from concentric muscle action• Stabilization provided by isometric contractions• Decelerations provided by eccentric contractions

All 3 actions are occurring at every joint in the

kinetic chain & in all 3 planes with eachmovement. Muscles must react to gravity, momentum,

external forces, & forces produced by othermuscle actions.

Muscles cooperate in integrated groups duringmovement & can be categorized into:◦ Inner unit (stabilizers/postural muscles)

◦ Outer unit (movers/phasic muscles).









Muscles that have their

proximal attachment

on the spine & include:

Deep erector spinae

Deep cervical muscles

Transverse abdominus

Abdominal obliques

Diaphragm

Lumbar multifidus

Muscles of pelvic floor



There are also inner

units of muscles in the

joints of the shoulder,

pelvic girdle and limbs.

EX: Rotator cuff

muscles stabilizes the

glenohumeral joint by

keeping the head of

humerus in the glenoid

fossa.





Muscles that are

primarily

responsible for

movement of trunk

& limbs

Superficial muscles

that attach from the

limbs, shoulder

girdle, & pelvic

girdle to the trunk

or core.

Muscles include:

◦Rectus abdominus

◦External obliques

◦Erector spinae

◦Latissimus dorsi

◦Hamstrings

◦Gluteus maximus

◦Thigh adductors

◦Quadriceps



Muscle Groups With Dysfunctions



Include:◦ Erector spinae

◦ Thoracolumbar fascia

◦ Sacrotuberous ligament◦ Biceps femoris (a hamstring muscle)

Dysfunction can lead to SI pain





Includes:

Erector spinae

Psoas

Abdominals

Diaphragm

Lumbar multifidus

Pelvic floor muscles

Dysfunction can

lead to SI instability

and low back pain



Allow rotation of pelvis

& contribute to walking

by swinging the leg

forward

Include:

◦

Internal oblique◦ Adductors

◦ External hip rotators

◦ Contralateral gluteus

maximus

◦ Latissimus dorsi

◦

Anterior & posterior

tibialis

◦ Soleus

◦ Gastrocnemius

◦ Peroneal group



Dysfunction can lead

to SI joint problems

plus rotation strain in

lumbar region, pelvic

area, knee & ankle.

May also cause

increased tension in

hamstrings that can

cause hamstrings

strains



Include:

Gluteus medius

Tensor fascia latae

Adductors

Quadratus lumborum

During single leg

movements, the same

side gluteus medius,

TFL & adductors work

with the opposite side

quadratus lumborum

to control the pelvis &

femur

Dysfunction can cause

instability and strain

during walking,

running and jumping.



Two segments provide postural stability in adiagonal counterbalancing function:◦ Muscles located between base of skull & top of

shoulders

◦ Muscles located between the last thoracicvertebra & the top of the hips

Compensation & dysfunction can occur hereas well.



If right hip is elevated from tense back

muscles, there is usually a compensationpattern in the anterior muscles on the left

between C7 & T12.

Pain in the quadriceps on the left show acompensation pattern in:◦ The calf on the right side

◦ Between the hips & SI on the right

◦ There could also be tension on the top of the left

foot.



Postural Dysfunctions



Standing and walking are closed kinetic chain

activities and because of the tensegretic nature of the

body, the position or motion of one joint affects the

positions or motions of other joints.

Tensegrity refers to structures that maintain theirintegrity primarily because of a balance of continuous

tensile forces through the structure. Tension forces naturally transmit the shortest

distance between 2 points, so components oftensegretic structures are positioned to withstandstress best.

The bones, muscles and fascia create a tensegreticstructure. The bones are the compression membersand the myofascial is the surrounding tensionmember. Muscles are required to hold the skeletonupright.









Figure 10-32 Upper & Lower Crossed Syndrome

Flow Chart

Figure 10-33 Upper & Lower Syndrome





Predictable neuromuscular chain reactions 2 of the most common dysfunction postural

patterns. The muscular response occurs inconsistent and predictable patterns.

Causes can include: poor posture, excessivephysical demands, joint blockage, habitualmovement patterns, painful or noxiousstimuli, CNS malregulation, and psychological(emotional) stressors.



Some upper crossed muscles when stressedtighten and become neurologicallyfacilitated. These muscles are postural.

Other upper crossed muscles actually

weaken when exposed to the samestressors. These muscles are phasic ordynamic.

There is shoulder elevation and scapulaprotraction and inhibition in the deep neckflexors and lower shoulder stabilizers.



Forward head is most common postural fault in US.The tight line travels thru pectorals, levator scapulaand upper trapezius. The sustainedhypercontraction in these typically tonic muscleselevate and protract scapula. The weak line travelsthrough the deep neck flexors and lower shoulderstabilizers.

Stretching pectoralis major and minor, levatorscapula, upper trapezius, teres major, SCM,

scalenes, and rectus capitis is beneficial.





Our population has moved from being movers to asedentary group of sitters. Davis‟s Law emphasizes that if muscles are lax for

extended periods of time, reciprocal inhibition willtake up the slack.

This is true for the hip flexors. As the psoas andrectus femoris neurologically shorten from prolongedsitting, the ilia are pulled in an anterior/inferiordirection which results in excessive lumbar lordosiswhen standing.

Compensations from this swayback posture often

lead to thoracic hyperkyphosis, forward headpostures, and upper crossed syndrome. It is estimated that 75 of neck/back pain clients

have 1 or both of these patterns.









Compensation: process of counterbalancing a defect in bodystructure or function;

Compensation patterns are the result of a person adjusting tosome sort of dysfunction. Most compensation patternsdevelop to maintain a balanced posture & even though the

posture becomes distorted, the overall result is a balancedbody in the pull of gravity.

Resourceful compensation:

◦ common action of the body

◦ adjustments the body makes to manage a permanent or

chronic dysfunction Ex: A protective muscle spasm (guarding) around a

compromised disk. The splinting action of the spasmsprotects the nerves & provides additional stability in the area.



When resourceful compensation is present, themassage needs to support the altered posture andprevent any increase in postural change than isnecessary to support the body‟s compensation.

Compensation can also be set up for temporarysituations.◦ Ex. Having a leg in a cast and walking on crutches

for a time.◦ Ex. The body catching itself in an „almost‟ fall.

Unfortunately the body often habituates thesepatterns and maintains them beyond theirusefulness. Overtime the body begins to showsymptoms of pain or inefficient movement or both.





A client experienced a car accident 4 years ago thatresulted in a bulging disk at L4. The injury hashealed with minimal difficulties.

During assessment, palpation indicated a moderatedegree of pliability of the lumbar dorsal fascia and

mild shortening in lumbar muscles. Forward flexionand rotation of the lumbar area are mildly impaired.

Massage was focused to reduce the muscleshortening in the lumbar area and increaseconnective tissue pliability.

Immediately after the massage, the client reportedincreased mobility but within 15 min began tocomplain of lower back pain. Explanation?



When standing barefoot, the perpendicularline of the erect standing body creates a 90degree angle with the floor.

On a 2-inch heel, were the body a rigid

column and forced to tilt forward, the anglewould be reduced to 70 degrees and a 3-inchheel would result in a 55 degree angle.

For the body to maintain an erect posture, awhole series of joint adjustments (ankle,knee, hip, spine and head) are required tomaintain an erect stance and equilibrium.







The slope or slant from the heel, rear to front, iscalled the heel wedge angle. With bare feet, there is no wedge angle. With a heeled shoe, the wedge angle shifts the body

forward. With a low heel, body weight is shared 40% heel, 60%

ball, and with a high heel, it is 90% ball and 10% heel. High-heeled shoes throw the entire weight of the

body forward, demanding additional effort tomaintain an upright balance.

Women wearing high heeled shoes must use extra

muscular effort to keep from falling forward. A great deal of this effort is concentrated in the low

back, producing an exaggerated arch, which caneasily lead to back pain.



Specific Postural Dysfunctions



Also called hyperlordosis Pelvis is positioned forward and downward

(anterior pelvic tilt). Hips are slightly flexed andlumbar spine is excessively hyperextended.

Increased risk of low back injury during standingor lying, weighted overhead activities, and inactivities involving hip flexion and extension.

Short and tight/strong: erector spinae, hip

flexors

Long and weak: may include abdominals,hamstrings, gluteus maximus





Also called hyperkyphosis

Exaggerated anterior-posterior curvature of the

vertebral column, most often involves an excessive

forward bending in the thoracic region.

Occurs in older adults, particularly in women with

osteoporosis and osteoarthritis. Sometimesaccompanied by other posterior problems includingposterior pelvic tilt and protracted shoulder girdle.

Kyphosis makes it difficult to do overhead activitiesparticularly when combined with winged scapula or

inflexible lateral rotators of the shoulder. Short and tight/strong: neck extensors, pectorals

Long and weak: Upper back erector spinae, neckflexors, external obliques







Excessive lateral curve

Which muscles are short or elongated willdepend on curvature pattern



An anterior pelvic tilt is normal postural position withthe tilt being between 0-5 degrees in men & 7-10degrees in women.

Excessive anterior pelvic tilt causes the thigh bonesto rotate inward, causing increased stress of themedial portion of the knee.

Along with the internal rotation of the thigh, there isincreased weight bearing on the inside of the footwhich puts strain on the muscles that supinate(invert) the foot.

Fallen arches are a common result of excessive

anterior pelvic tilt. However, flat feet can contributeto anterior pelvic tilt. Body weight tends to be on balls of foot & therefore

may be tender.





Anterior pelvic tilt also causes a postural distortion. Thepelvis controls the amount of curve in the lumbar region.If the pelvis tilts too far anteriorly, the arch in the back

increases significantly (swayback).

We have found that what happens in the low back will alsohappen in the neck.

This shared dysfunction is a result of our reflexes to keepour eyes, ears and jaw level with the horizon. As the neckextends, it will tend to jut forward creating the forwardhead position. (Sitting for long hours at a desk can

contribute to an anterior pelvic tilt.)

Short and tight/strong: iliopsoas, sartorius, quadriceps,

quadratus lumborum, tensor fascia latae and Iliotibialtract, tibialis anterior, Long and weak: may include abdominals, hamstrings,

gluteus maximus



Inferior angle of

scapula protrudes

slightly from the

body; may be

accompanied by a

protracted shoulder

girdle.

Short and

tight/strong:

pectoralis minor

Long and weak:

serratus anterior,rhomboids



Facet joints are paired synovial joints that joinone vertebra to another. Facet joints are highly innervated including the

presence of pain receptors. During normal movements, the facet joint are

exposed to numerous forces. These forces candamage the joint capsule or the surroundingmuscle tissue.

Compression from faulty posture can generate apain response.

With disk narrowing from compression, as muchas 70% of the force can be spread across thefacets. The force may be strong enough tostretch the capsule and trigger a pain stimulus.





Another possible irritation to the facet joints is „locking‟ ofthe joint. This frequently occurs when a personstraightens up after a deep flexion and isn‟t fully able toachieve a full upright position.

When deep movement is made in any direction, a smallgap is created between the facet joints. The gap canentrap soft tissue when the person is returning to anormal position. The entrapped tissue can be the jointcapsule or other soft tissue structures.

Pain is usually unilateral and very sharp and localized,causing significant muscle spasms that reinforce thelocking.

Massage and mobilization of the joints can help with facet joint irritation and especially joint locking.

Stretching of the low back, hip, and anterior trunk can beof benefit. Avoid stretches that cause hyperextension ofthe spine.



“The sacroiliac joint continues to be one of mostmisunderstood joints in the body” (Cibulka, 2002).

It is classified as synchrondrosis which is animmoveable joint but it is subjected to the sameinflammatory and infectious conditions that affect

synovial joints. “There are 35 muscles that attach directly to the

sacrum and/or innominate bones” (Thompson, 2001).

The SI joint functions primarily as a shock absorber.It also completes the pelvic ring and spreads the load

from the upper body to the legs. It is estimated that 15 -30 of people with low back

pain have a SI dysfunction.



Mechanoreceptors in the ligaments of thearea are important for their role in activity themuscles for postural control. The restrictionof movement by these ligaments plays an

important role in stability. Sustained isometric contractions for stability

can produce muscular weakness and lead tooverstretching of these ligaments and

inflammation as well as a pain-spasm-paincycle.



The only 2 possible movements of these joints are◦ A nodding movement of the sacrum

◦ An anterior or posterior pelvic tilt

Decreased mobility of the SI due to aging, overuse, orunderuse, results in an increased movement of

lumbar spine. This also works in reverse, decreasedmovement in the lumbar spine leads to increasedmovement of the SI joints.

Ipsilateral gluteal pain, typically around the PSIS, isthe most common complaint and is often

accompanied by a palpable soft tissue nodule overthe PSIS.



The pain and discomfort can radiate into thegroin and legs and cause numbness, clicking,or popping in the posterior pelvis.

In the early stages of a SI pain episode, a

protective muscles spasm develops as thesacrum gets stuck in a side-bent and rotatedposition usually from an incident thatinvolved a forward-bending and rotatingmovement.

Using stretches for the iliopsoas, hip flexorsand gluteals can benefit this condition.



Anterior positioning of the cervical spine Can be aggravated by a too high pillow at

neck.

Can be caused by hours of a flexed head

position such as using a sewing machine.

Short and tight/strong: neck extensors

(including trapezius)

Long and weak: anterior neck flexors

Neck rotators are long





The shoulders are pulled forward. The medialborders of the scapula may protrude slightlyfrom the body in winged scapula.

Increased risk of shoulder injury duringhorizontal adduction/abduction especially when

elbow travels behind shoulder. Can be aggravated by side sleeping with the arm

down.

Short and tight/strong: subscapularis, pectoralis

minor, pectoralis major, serratus anterior, SCM,and scalenes

Long and weak: upper trapezius and rhomboids







Greek. Ergon “work” and nomo “by natural laws”; theapplication of scientific information to the needs ofpeople in the design of objects, systems andenvironments for human use.

Incorporates information from anatomy, physiology,

kinesiology, psychology and design to maximizehuman performance while recognizing limitations andsafety concerns.

Ergonomic concerns for a workspace are the height ofthe items, adequate lighting, sharp corners sticking

out, and things placed where they are the mostaccessible without you having to twist or bend.

Massage therapists generally see clients whenincorrect ergonomics are used and problems occur.



All work activities should allow the workerto assume several different, but equallyhealthy and safe postures

When muscular force has to be exerted, it

should be exerted by the largestappropriate muscle group available

Work activities should be performed withthe joints at about the midpoint of theirROM. This applies particularly to the head,neck, & upper limbs.



Good computer

workstation

◦ Monitor at or below

eye level

◦Phone headset

◦Chair has armrests

Incorrect computer

workstation

◦ Computer in a corner

on a platform

◦Phone on shoulder

◦Feet propped up on

chair legs



Good sitting posture which requires the leastexpenditure of muscle energy

◦ 90 degree angle for hips and knees

◦ 10 degree of incline for the back of the chair

◦ Armrests at proper height Too high and shoulders are pushed upward

Too low and arms won‟t have propersupport



Avoid working at a table at the incorrect height,bending at the waist and applying all our pressurewith our thumbs

When working at a desk, get up and take frequentstretch breaks.

Optimally you should alternate between sitting andstanding postures

Consider sitting when working head and feet andstanding for the rest of the massage

You could also do some personal stretches whenthe client is prone

Have thick carpet or a rubber mat under your table



Workspace can have a

separate keypad and

gel pads for wrist

support.

Other good tools are

an adjustable footrest

and adjustable monitor

stand.

Positioning keyboard

and mouse so that

wrists are straight in a

neutral position can

help prevent carpal

tunnel syndrome.



Good chair is adjustable

chair with lumbar

support, has clearance

between the back of the

knees and the edge of

the chair to avoid putting

pressure on sciatic nerve,

armrests at correct

height to loosely support

arms near the torso.

Chair height should place

hips at about same

height as knees to avoid

putting undue pressure

on legs and gluteals.



Good mechanics improves the strength andeffectiveness of massage, keeps the therapistfrom getting tired, and enhances the client‟sexperience.

Work from center of your pelvis and let your

legs to do most of the work. Keep elbows closeto the body and wrists relaxed. Use elbowsand forearms for pressure work or deep glidingstrokes.

If a particular movement is causing you pain,make the necessary adjustments to yourposture or technique.



Check the massage table height Wear comfortable attire so you can easily move Warm up and stretch before and after giving

massages

Use a variety of strokes Position your pressure so that you are behind

your work Maintain proper body mechanics Breathe Move smoothly Get in tune with your body



Tell male clients to not carry wallet in backpocket since this can cause sciatic pain.

Children with heavy backpack can havebiomechanical problems.

Women who always carry heavy purses ortheir toddlers on the same hip arecontinually out of balance.

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