Identification and Treatment of Postural Dysfunction

Donald J Williams BSc, Mchiro, ICSSD

An Overview By: Julia Tyack

INTRODUCTION 

Within the basis of rehabilitation has always been the desire to treat the origin of mechanical disorders rather than simply provide temporary relief and pain control, which are the very factors that drive patients to seek care.  As a result, traditional assessment techniques (orthopaedic and neurological assessments, diagnostic imaging, etc) are designed to locate the specific anatomical origin of the symptoms.  Hence treatment is often aimed at these areas without second thought to finding and treating the underlying cause.   Karel Lewit once said, ‘He who treats at the site of pain is lost’. (1)

Injuries to the spine and body in general are the result of either a major injury (macro-trauma) or more commonly, repetitive micro-trauma (repetition of day-to-day activities), often at end range loading of the spine.   Much of this end range loading is the result of poor posture and excessive kyphosis inherent in our daily activities.  Unfortunately the majority of work and recreational activities enhances or encourages forward drawn postures which, if left unmanaged, often lead to ‘upper and lower crossed syndromes’ or patterns of dysfunction.

DISCUSSION

Characterizing and correcting the specific dysfunction causing the patient’s pain.  How this promotes a successful therapy, giving patients the opportunity to recover lost function and maintain comfort in their daily lives. (2)

THE GLOBAL APPROACH

  • Screen for key link
  • Restore key restricted muscle / joint function
  • Avoid perpetuating factors (posture, movements, activities
  • Facilitate movement which reinforces/ improves function
  • Use proprioceptive / reflex treatment to create central program
  • Broad concepts to keep in mind when developing Stabilization / Rehabilitation programs are:- exercise must target region intended
  • Minimize deleterious compensatory actions
  • Perform the exercise in the functional range
  • Exercise must be sufficiently challenging
  • Must not be so difficult as to frustrate patient
  • In treatment plan development, in the first acute phase emphasis is placed upon the Clinical symptom/ tissue injury complex, with relative rest, immobilization, adjustments, modalities, medication, remedial exercise and perhaps surgical intervention all being viable options.
  • Teach the patient to avoid what harms him (K. Lewit) (1).

The second Recovery Phase focuses on tissue overload and Functional Biomechanical Deficit.  In this phase, manual techniques and exercises are needed to restore mobility, flexibility and co-ordination.

The final Functional Restoration stage (often neglected), emphasizes Functional Biomechanical Deficits; subclinical adaptation complexes are targeted for training strength and sport or activity – specific skills.(3)

Generally muscles don’t work alone in producing movement.  Agonists, synergists and antagonists are terms we use to describe prime movers, their assistants and balancing/counteracting muscles.  These may be termed force couples, which describe two or more muscles working in a coordinated fashion to produce a net force.  Some upper body force couples that exist are; upper trapezius/levator scapulae with lower trapezius/serratus anterior, deltoid with rotator cuff, subscapularis with infraspinatous/teres minor.

It has been said that humans exhibit Four Fundamental Reflexes which have a tendency to exacerbate or exaggerate our postural tendencies (4

  • Extension, adduction, internal rotation in the lower extremity
  • prehension pattern flexion , adduction, internal rotation upper extremity
  • Adduction of the jaw (closing of the mouth)
  • Breathing

Janda generally categorize muscles as tonic (postural muscles), which tend to tightness and Phasic (stabilization) muscles which tend to inhibition (5, 6).  Phasic muscles are phylogenically younger than tonic muscles and functionally develop in the newborn through to four years of age as a result of increasing movement and postural changes.

Ideally the flexion, pronation or internal rotation of dominant chains of tonic muscles are balanced by the extension, supination, external rotation chain of phasic muscles.
Dysfunction in these opposing muscles can generally be grouped into upper and lower crossed syndromes (Facilitated or tight muscles in bold, weak muscles in normal print).  Generally speaking trigger points may develop in the facilitated muscle groups

Lower Crossed Syndrome

  1. g. maximus X iliopsoas, rectus femoris
  2. g abdominals X paraspinals
  3. g. medius X hip adductors, TFL, QL, Piriformis

Postural inspection should note anterior pelvic tilt, increased lordosis, hypertonicity of erector spinae and atrophy of gluteus maximus.  Usually hip extension and/or trunk flexion tests are positive.
Hyper-pronation syndrome may be a perpetuating factor.  This may also involve muscle imbalance with inhibition of the gluteus maximus and overactivity of the QL, TFL, piriformis and adductors (7).  Clinical consequence is increased facet and SIJ strain and altered hip mechanics.

Upper Crossed Syndrome

  1. Mid & lower trap X levator scap & upper trap.
  2. Serratus anterior X pectoralis minor
  3. Longus coli & longus capitus X suboccipitals, SCM.

Postural inspection shoulder – note chin jutting; forward head carriage; internally rotated shoulders and forearms, excessive upper thoracic kyphosis.  May perform poorly in; Jull test, dorsal extensor co-ordination test, respiration, scapulohumeral rhythm, orofacial screening tests (mouth opening, swallowing) push up.  Clinical consequences are headache, TMD, GH impingement, T4 costotransverse syndrome. (8)

Masticatory disorders and lower quarter influences must be considered when addressing upper crossed syndrome and sternosymphyseal disorders Head/neck.

Lewit; If there is forward head carriage, assess suboccipital tension, then have the patient sit down. If tension subsides the forward head carriage is secondary to forward drawn posture from the pelvis. (9)

The function of the masticatory system should be evaluated to rule out a possible involvement of the masticatory system in patients with neck pain or signs and symptoms of CSD (10)

Exhalation has a mobilizing effect on thoracic spine extension and is particularly important for those suffering from a forward drawn posture and kyphosis. The most important fault during breathing is lifting the thorax with the scalenes instead of widening it in the horizontal plane. This can lead to overstrain of the cervical spine.

MUSCULAR CHAINS

In 1994 Swiss neurologist showed that by treating distal muscles in the extremities we could influence proximal myofascial problems that were linked together in a ‘chain’.  This is described as being part of a linkage system related to upright posture.  As mentioned previously, sedentary postures may result in end range loading of the spine due to excessive kyphosis, called sterno-symphyseal syndrome. This may be thought of very basically as a combination of upper and lower crossed syndromes.  This kyphotic posture predisposes to disc injury, faulty respiration, T4 syndromes of headache, TMJ problemsand cervico-brachial syndromes. Muscle imbalance between agonist/antagonist muscle chains (+/-) (TRPs/inhibition) is the central feature of this syndrome.

Brugger developed a postural relief position to improve the function of the antagonist muscle chains and centrate key joints (Brugger relief position), and a facilitation method for the inhibited muscle chains (11).

In the upper extremity, the muscles which are inhibited include; 

  • finger, wrist, elbow and shoulder extensors
  • forearm supinators
  • shoulder external rotators and abductors

Therefore to facilitate these muscles an eccentric muscle energy technique can be use to bring about reciprocal inhibition of the hypertonic muscle chains associated with this increased kyphosis

Eccentrically resist

  • finger abduction
  • wrist and finger extension
  • forearm supination
  • shoulder external rotation
  • shoulder abduction

The lower quarter differs from the upper quarter in that the segments are more interdependent because of the closed chain nature of lower quarter function.  In the lower extremity the muscles which are inhibited include the

  • toe extensors
  • ankle dorsiflexors and pronators
  • hip abductors and external rotators

Therefore eccentrically resist;

  • toe extension, ankle dorsiflexion and eversion
  • hip abduction
  • hip external rotation

These techniques are somewhat general, however Kolar a PT from Prague trained in the Vojta methods of reflex stimulation has shown us that agonist-antagonist co-activation patterns evolve as neurodevelopment progresses to take the infant from a fetal position at birth to a stable upright posture at approximately 3 years of life.  As posture develops, the tonic contractions which are reflexly based begin to relax, facilitating co-activation patterns necessary for joint centration and load bearing.  Failure of co-activation results in faulty neurodevelopment of the motor system, best demonstrated by cerebral palsy sufferers.  Kolar utilises stimulation of reflex trigger zones at key areas of postural support such as the symphysis pubis, sternum or occiput to facilitate co-activation patterns (12).

FUNCTIONAL RANGE

It is inappropriate to load the spine when a basic level of active protective stability cannot be achieved (Richardson spine 1996).  Exercises should be performed in a function range that maintains quality of movement or proximal stability.- Progression should be from conscious perception to volitional control to automatization of co-ordination.  Spinal flexibility is shown to have little predictive value for future low back pain.  Large muscular forces are rarely required, rather low levels of activation are required for long periods of time (McGill LCCA 1999)

Patients must appreciate that the quality of movement is more important than the number of repetitions. This is very different from how most people view exercise and so time must be spent re-educating patients.

  1. Quality versus quantity.
  2. Always have the patient demonstrate the exercise on the next office visit to correct any errors they may have adopted.
  3. Whenever possible, have the patient work towards mimicking ADLs as part of exercise

Changing postural habits can be difficult, but can be assisted by;

  1. becoming more aware of the habit
  2. knowing how to correct it
  3. knowing when to correct it

The goal of exercise is to stabilize the osteo-ligamentous system, in other words, to reduce stress at key joints/ discs that is caused by abnormal movement patterns.  Movement patterns are important to assess because classic muscle tests evaluate strength but not quality of movement and do not take into account recruitment of other muscles.

To improve results

  1. longer contraction time
  2. harder contraction
  3. longer relaxation time w/ respiratory synkinesis
  4. wind-up – muscles to maximize isolation
  5. adjust restricted joints first

MANAGEMENT CONSIDERATIONS

There is still much to be learned and some suggest that we are only just starting to discover some of the complexities of the human locomotor and postural systems.  In design ing and implementing stabilization programs, there must be structure and order based on a logical thought process. Sherringtons law often applies here, which governs that if extreme tightness is present in a muscle group, strengthening in the antagonistic group is useless as the function of this group will continue to be neurologically inhibited by the tight group.  Attention should first be directed to lengthening the tight muscles.

Progress of Rehabilitation

  1. Adjust the manipulable lesion
  2. Peripheral joint dysfunction
  3. Stretch/inhibit tight muscles
  4. Facilitate weak/inhibited muscles
  5. Co-ordination training
  6. Propriosensory re-education
  7. Functional training/restoration
  8. Inhibition and Stretching Techniques

Muscle tightness may be neurologically mediated, referred to as muscle tone, or may be as a result of muscle length, inherent anatomical property of the tissues that make up the muscle and associated tendons.  Neuromuscular inhibition techniques (PIR, PNF, MET) take advantage of two unique neurological principles of muscle. Post-contraction inhibition is a temporary relaxation of contractile elements that follows a contraction. Reciprocal inhibition refers to using agonist contraction to drive a reflex relaxation of antagonistic.  Both these techniques cause an elastic change in muscle tone but do not affect muscle length (short lasting).

Unfortunately, muscle lengthening may only be achieved by using low force stretches held over a very long time frame (15-20 minutes).  This causes breaking of molecular bonds within the internal structure of the muscle and connective tissue. These changes are plastic (long lasting).

Muscle Facilitation

The activation of muscle contraction, which may be stimulated in a variety of ways; positioning, touch, vibration, verbal cues and exploitation of reflex pathways.  Always ensure when facilitating a muscle appropriate posture and direction of force is considered to try to achieve the desired effect, otherwise unwanted recruitment of synergistic and global muscle substitution may occur, inadvertently creating the opposite effect to that which is wanted.

Proprioceptive and Propriosensory Training

Incorporation of total limb and body movement should follow the development of proper movement co-ordination.  With open kinetic chain activities, there needs to be proximal stability before there can be distal mobility.  This rule holds true in closed kinetic chain, but the stable segment is not always proximal (For example, ankle stability before gait training).

As Early as 1965 Freeman, et al proposed the theory of impaired proprioception as a source of functional instability. Freeman treated his subjects using balance exercises on tilt and wobble-boards(13).  Proprioceptive loss is comparable to actual anatomical disruption in relation to dysfunction and disability.  In injury, ‘pain free’ does not always mean ‘cured’. (14)

Balance has been shown to increase 200% with just 2 weeks of daily balance training. (15)

Functional Training

Reintegration of activity relevant to the individuals demands of work and other activities.  The use of weight, tubing, wobble boards and other equipment is utilized, as long as the training is functionally relevant for providing a controlled return to sport/work/etc.

  1. Screening Tests
  2. ID pain generator
  3. ID overload mechanism
  4. ID kinetic linkage or faulty movement pattern

CONCLUSION

To effectively treat postural syndromes, the dysfunctional segment or region must be identified and treatment of the key link given. It is not enough to simply identify muscle imbalance and treat those muscles.  The muscle imbalance concept is supported by considering neurodevelopment of the upright posture.  Supraspinal control, which begins in the infant at 3 weeks, is the beginning of voluntary control. When dysfuncitonal muscle chains develop at a subcortical level, voluntary control must be initiated and practiced until correct function is adoped at the subcortical level.

REFERENCES

  1. Lewit K, “The functional Approach,” journal of Orthopaedic Medicine, 1994; 15: 73-74.
  2. The Physicaian and Sport Medicine, vol 25, 8 Aug 1997.
  3. Kibler WB, Herring SA, Press JM, Eds. Functional rehabilitation of Sports and Musculoskeletal Injuries. Rehabilitation institute of Chicago Publication Series. Aspen 1998.
  4. Janda V. Jorn of Prosth Dent 1986; 56:4.
  5. Janda V. On the concept of postural control muscles and posture in man. Aus J. Physiothe 1983; 29: 83-84.
  6. Jull G, Janda V. Muscles and motor control in low back pain. In: Twommey LT, Taylor JR (eds) Physical Therapy for the Low Back, Clinics in Physical Therapy, New York; Churchil Livingstine, 1987.
  7. Liebenson C. (ed), Rehabilitation of the Spine: A practitioners Manual. Baltimore: Williams & Wilkins, 1995.
  8. Lew K, Kolah P in Murphy D. Cervical Spine Rehabilitation. 1999
  9. Lewit K, Manipulative Therapy in Rehabilitation of the Motor System, 3rd ed, London: Butterworths, 1999
  10. spine 1996; 21:14. 1638-1646.
  11. Kolar P, The sensomotor nature of postural Functions, Its fundamental role in rehabilitation, J. Orthopaedic Medicine, 21, 2, 1999, 40-45.
  12. Lewit K. Chain reactions in the locomotor system in light or coactivation patterns base in developmental neurology, J. Orthopaedic Medicine, 21, 2 1999, 52-58.
  13. Laskowski, The physician and Sports medicine, vol 25, no. 10 Oct 1997.
  14. Freeman MAR. Instability of the foot after injuries to the lateral ligament of the ankle JBJS, 47-B; 669-677, 1965.
  15. Liebenson C, Journal of Bodywork & movement therapies 5:28 Jan. 2001

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