POSTURE prepared by DR Aliaa Attiah Mohamed Diab

POSTURE prepared by: DR. Aliaa Attiah Mohamed Diab lecturer- basic science departement 1

DEFINITIONS OF POSTURE prepared by: Dr Aliaa Attiah Diab Posture is a “position or attitude of the body, the relative arrangement of body parts for a specific activity, or a characteristic manner of bearing one’s body. ” It is alignment of the body parts whether upright, sitting, or recumbent. It is described by the positions of the joints and body segments and also in terms of the balance between the muscles crossing the joints. 2

Impairments in the joints, muscles, or connective tissues prepared by: Dr Aliaa Attiah Diab may lead to faulty postures. Many musculoskeletal complaints can be attributed to stresses that occur from repetitive or sustained activities ( habitually faulty postural alignment). 3

CURVES OF THE SPINE The adult spine is divided into four curves: Two primary , or posterior, curves, so named because they are present in the infant and the convexity is posterior. Two compensatory, or anterior, curves, so named because they develop as the infant learns to lift the head and eventually stand, and the convexity is anterior. prepared by: Dr Aliaa Attiah Diab 4

prepared by: Dr Aliaa Attiah Diab 5

POSTURAL ALIGNMENT prepared by: Dr Aliaa Attiah Diab Gravity places stress on the structures responsible for maintaining the body upright and therefore provides a continual challenge to stability and efficient movement. For a weight-bearing joint to be stable, or in equilibrium, the gravity line of the mass must fall exactly through the axis of rotation, or there must be a force to counteract the moment caused by gravity. In the body, the counterforce is provided by either muscle or inert structures. In addition, the standing posture usually involves a slight anterior/posterior swaying of the body of about 4 centimeters (cm), so muscles are necessary to control the sway and maintain equilibrium. 6

Lateral view of standard postural alignment prepared by: Dr Aliaa Attiah Diab A plumb line is typically used for reference and represents the relationship of the body parts with the line of gravity. Surface landmarks are: • slightly anterior to the lateral malleolus, • slightly anterior to the axis of the knee joint, • through the greater trochanter (slightly posterior to the axis of the hip joint), • through the bodies of the lumbar and cervical vertebrae, • through the shoulder joint • through the lobe of the ear. 7

TYPES OF POSTURE: Static Posture: body segments aligned and maintained in certain positions (standing, lying, and sitting). No mechanical work performed. Muscle tension equal external load (isometric contraction). Dynamic posture: body segments are moving (walking, jumping, throwing, and lifting). The bones, joints, and ligaments provide major torque needed to counteract gravity. prepared by: Dr Aliaa Attiah Diab 8

POSTURAL STABILITY IN THE SPINE Spinal stability is described in terms of three subsystems: The three subsystems are interrelated and can be thought of as a three-legged stool; if any one of the legs is not providing support, it affects the stability of the whole. Instability of a spinal segment is often a combination of 1. tissue damage, 2. insufficient muscular strength or endurance, 3. poor neuromuscular control. prepared by: Dr Aliaa Attiah Diab 9

INERT STRUCTURES: INFLUENCE ON STABILITY ROM of any one segment is divided into neutral zone. When spinal segments are in the neutral zone (midrange/neutral range) prepared by: Dr Aliaa Attiah Diab an elastic zone the inert joint capsules and ligaments provide minimal passive resistance to motion and therefore minimal stability. 10

As a segment moves into the elastic zone, In addition to the inert tissues, the sensory receptors in the joint capsules and ligaments sense position and changes in position. Stimulation of these receptors provides feedback to the CNS, thus influencing the neural control system. prepared by: Dr Aliaa Attiah Diab the inert structures provide passive resistance to the motion occurs. When a structure limits movement in a specific direction, it provides stability in that direction. 11

MUSCLES: INFLUENCE ON STABILITY ROLE OF GLOBAL AND CORE MUSCLE ACTIVITY The muscles of the neck and trunk act as • • they are important stabilizers of the spine. Without the dynamic stabilizing activity from the trunk muscles, the spine would collapse in the upright position. Both superficial and deep muscles function to maintain the upright posture. The global muscles, being multisegmental, are the large guy wires that respond to external loads imposed on the trunk that shift the center of mass. Their reaction is direction-specific to control spinal orientation. prepared by: Dr Aliaa Attiah Diab prime movers or as antagonists to movement caused by gravity during dynamic activity, 12

The global muscles are unable to stabilize individual spinal segments except through compressive loading because they have little or no direct attachment to the vertebrae. If an individual segment is unstable, compressive loading from the global muscles may lead to or perpetuate a painful situation The deeper muscles, which have segmental attachments. They provide dynamic support to individual segments in the spine and help maintain each segment in a stable position so the inert tissues are not stressed at the limits of motion prepared by: Dr Aliaa Attiah Diab 13

NEUROLOGICAL CONTROL: INFLUENCE ON STABILITY influenced by • the nervous system, • peripheral and central mechanisms in response to fluctuating forces and activities. prepared by: Dr Aliaa Attiah Diab activated and controlled by • The muscles of the neck and trunk are 14

THE NERVOUS SYSTEM COORDINATES THE RESPONSE OF MUSCLES TO unexpected forces at the right time by the right amount prepared by: Dr Aliaa Attiah Diab expected forces by modulating stiffness and movement to match the various imposed forces. 15

MUSCLES OF THE SPINE LUMBAR SPINE Rectus abdominis (RA) Internal obliques (IO) and external obliques (EO) v Trunk flexion (sit-up and curl-up exercises). Bilateral contraction causes trunk flexion; v EO on one side with IO on contralateral side together cause diagonal trunk rotation with flexion; v EO and IO on same side cause side bending of trunk prepared by: Dr Aliaa Attiah Diab Transversus abdominis (Tr. A) Contributes to rotation 16

prepared by: Dr Aliaa Attiah Diab 17

prepared by: Dr Aliaa Attiah Diab 18

Quadratus lumborum (QL) Pelvic hiking and side bending of the spine Multifidus Intersegmental rotators and intertransversarii Spinal extension and contralateral rotation Superficial erector spinae (ES) muscles (iliocostalis, longissimus, spinalis) Primary trunk extensors; extend thorax on pelvis causing spinal backward bending; also side bending and posterior translation of the vertebrae prepared by: Dr Aliaa Attiah Diab Iliopsoas (iliacus and psoas major) Primary hip flexors and indirectly lumbar extensors; Iliopsoas creates an anterior shear on the lumbar vertebrae 19

CERVICAL SPINE Sternocleidomastoid and scalene group Bilateral contraction causes cervical flexion; unilateral contraction causes side bending with contralateral rotation and flexion . When the neck is stabilized, the scalenes elevate the upper ribs during inspiration, and the sternocleidomastoids (SCM) elevate the clavicles and sternum, which assists in inspiration Upper trapezius and cervical erector spinae Bilateral contraction causes cervical and capital extension; unilateral contraction causes side bending prepared by: Dr Aliaa Attiah Diab 20

prepared by: Dr Aliaa Attiah Diab 21

prepared by: Dr Aliaa Attiah Diab 22

prepared by: Dr Aliaa Attiah Diab 23

Levator scapulae The levator scapulae works with the upper trapezius to elevate the scapulae Longus colli; rectus capitis anterior and lateralis Craniocervical flexors; longus colli is the prime mover for cervical retraction (axial extension) prepared by: Dr Aliaa Attiah Diab 24

FACTORS AFFECT POSTURE prepared by: Dr Aliaa Attiah Diab 1 -Age Children: Elderly: have more flexed posture, and wider base of support. 2 - Pregnancy: Increase lordotic curve (cervical and lumbar), protraction of shoulder girdle, Hyperextension of knees. 3 Occupational changes 4 - Handedness: Low shoulder on the dominant hand side. 5 - Obesity 6 -Weak muscles 7 -High-heeled shoes 8 -Tight muscles; decreased flexibility 9 - Poor work environment 10 -Poor sitting and standing habits 25

IMPAIRED POSTURE ETIOLOGY OF PAIN 1. Effect of Mechanical Stress prepared by: Dr Aliaa Attiah Diab 26

Mechanical stress to pain-sensitive structures, such as sustained stretch to ligaments or joint capsules or compression of blood vessels prepared by: Dr Aliaa Attiah Diab causes distention or compression of the nerve endings leads to the experience of pain. 27

If the mechanical stresses exceed the supporting capabilities of the tissues relieves the pain stimulus, and the person no longer experiences pain breakdown musculoskeletal disorders or overuse syndromes with inflammation and pain affect function without an apparent injury. . prepared by: Dr Aliaa Attiah Diab Relieving the stress to the pain sensitive structure 28

2 -EFFECT OF IMPAIRED POSTURAL SUPPORT FROM TRUNK MUSCLES Little muscle activity is required to maintain upright posture ; but with total relaxation of muscles, prepared by: Dr Aliaa Attiah Diab the spinal curves become exaggerated passive structural support is called on to maintain the posture. 29

continued end-range loading, prepared by: Dr Aliaa Attiah Diab strain occurs with creep and fluid redistribution in the supporting tissues. making them vulnerable to injury 30

Continual exaggeration of the curves leads to 2 -muscle strength and flexibility imbalances 3 -other soft tissue restrictions or hypermobility Muscles that are habitually kept in a stretched position tend to test weaker. Muscles kept in a habitually shortened position tend to lose their elasticity. . prepared by: Dr Aliaa Attiah Diab 1 -postural impairment 31

3 -EFFECT OF IMPAIRED MUSCLE ENDURANCE prepared by: Dr Aliaa Attiah Diab 32

Endurance in muscles is necessary to maintain postural control. prepared by: Dr Aliaa Attiah Diab Sustained postures require continual, small adaptations in the stabilizing muscles to support the trunk against fluctuating forces. . 33

Large repetitive motions also as the muscles fatigue, prepared by: Dr Aliaa Attiah Diab require muscles to respond so as to control the activity. -the mechanics of performance change -the load is shifted to the inert tissues supporting the spine at the end ranges. . 34

with poor muscular support and a sustained load on the inert supporting tissues, prepared by: Dr Aliaa Attiah Diab creep and distention occur, causing mechanical stress injuries occur more frequently after a lot of repetitive activity or long periods of work when there is muscle fatigue. 35

prepared by: Dr Aliaa Attiah Diab PAIN SYNDROMES RELATED TO IMPAIRED POSTURE 36

1 --Postural 2 -Postural Dysfunction adaptive shortening of soft tissues and muscle weakness are involved The cause may be 1 -prolonged poor postural habits, 2 -it may be a result of contractures and adhesions formed during the healing of tissues after trauma or surgery. -Stress to the shortened structures causes pain. - strength and flexibility imbalances may predispose the area to injury or overuse syndromes prepared by: Dr Aliaa Attiah Diab Fault and the Postural pain Pain A postural Syndrome that fault is a results posture that from deviates mecha from normal nical alignment stress but has no -There when a structural are no person limitations abnormal maintai ities in ns a muscle faulty strength posture or for a flexibility; prolong -if ed the faulty period; posture the continue pain is s, usually strength relieve and d with flexibility activity. 37

POSTURAL HABITS Good postural habits in the adult are necessary to avoid postural pain syndromes and postural dysfunction. Also, careful follow-up in terms of flexibility and posture training exercises is important after trauma or surgery to prevent impairments from contractures and adhesions. In the child, good postural habits are important to avoid abnormal stresses on growing bones and adaptive changes in muscle and soft tissue. prepared by: Dr Aliaa Attiah Diab 38

POSTURE ASSESSMENT prepared by: Dr Aliaa Attiah Diab Posture analysis methods A wide range of methods has been used to objectively assess spinal posture. These can be broadly divided into five categories: 1 --roentenography, 2 --three-dimensional motion analysis, 3 --rastereography, 4 --photographic analysis 5 --manual measurement. consists of several different methods, such as manual goniometer, electrogoniometry , the use of a flexible ruler or ‘‘flexicurve’’, and the measurement of horizontal displacement of spinal landmarks from a vertical plumb line. 39

1 - Roentenography Because it allows clear visualization of bony landmarks, is the gold standard method and has been shown to be reliable. However, radiation hazards preclude its widespread use in research studies. prepared by: Dr Aliaa Attiah Diab 40

prepared by: Dr Aliaa Attiah Diab 2 - -Motion analysis systems v The motion analysis systems offer high resolution, accurate motion capture systems to acquire, analyze and display 3 D motion data on patients while walking. v In addition to quantify 3 D posture parameters adopted by persons during specific tasks or at static. v Methods of measurement include static, video and opto -electronic systems. To ensure accurate and reliable results, v technical concerns such as calibrated alignment of the camera image contrast, standardized postures for repeated measures and distortion effects must be addressed. 41

prepared by: Dr Aliaa Attiah Diab 42

3)- Rastereography (Formetric) is a special development for fast, contactless, and radiation-free static measurement of the back surface and spine. It offers a 3 D analysis of the back surface, spinal form and functions parameter, and visualizes a unique 3 D-reconstruction of the surface and spine. v analyses the back surface form in a sophisticated, automatic way, with no need for manual fixation of markers. Formetric System is a method based on photogrammetric principles that make threedimensional surface analysis possible prepared by: Dr Aliaa Attiah Diab v 43

v v v prepared by: Dr Aliaa Attiah Diab v It uses a system of horizontal parallel white light lines projected onto the back surface of the patient. Observing this light raster from a direction that is different from the projection reveals shape information from the distortion of the white lines. The synchronous projection and registration of all light lines in one instant reduces the measurement time of all the surfaces to typically 0. 25 sec. , . rastereography allows the automatic localization of anatomical landmarks on the back surface, like for example, the spinous processus of C 7 vertebra (vertebra prominens) or the right and left dimple points in the pelvic region (spinae iliacae posterior superior). On the basis of these landmarks the sagittal back profile is established automatically and a set of shape parameters characterizing the back profile is provided. 44

prepared by: Dr Aliaa Attiah Diab 45

v This is because it is relatively cheap, requiring only a camera, markers and adhesive tape; is highly portable; and permits the measurement of several posture angles simultaneously. It is thus frequently used in field and clinical studies. prepared by: Dr Aliaa Attiah Diab 4 -photographic analysis v Static photographic analysis with reflective markers placed on specified anatomical landmarks may be more suited to large-scale studies. 46

prepared by: Dr Aliaa Attiah Diab 47

v manual techniques may be useful for single angular measures, they may be time-consuming if several angles need to be measured. prepared by: Dr Aliaa Attiah Diab 5 - manual measurement v Some manual measurement techniques such as the pelvic goniometer and flexicurve have also been shown to be valid, and some have good reliability in adults. 48

prepared by: Dr Aliaa Attiah Diab 49

prepared by: Dr Aliaa Attiah Diab Plumb line analysis The most common method. The plumbline provides the clinician a visual frame of reference to evaluate various body landmarks and the alignment in relation to the verticality of the plumbline. The evaluation of the patient is done from the anterior, posterior and lateral stances. Standing posture is assessed in comparison to a standard reference line. The subject is positioned with a plumb-line passing just in front of the lateral malleolus. In an ideal posture this line should pass just anterior to the midline of the knee, and then through the greater trochanter, bodies of the lumbar vertebrae, shoulder joint, bodies of the cervical vertebrae, and the lobe of the ear. 50

prepared by: Dr Aliaa Attiah Diab 51

v v v prepared by: Dr Aliaa Attiah Diab v When viewed from the front, with the feet three inches apart, the line should bisect the body into two equal halves. The anterior superior iliac spines (ASIS) should be in the same horizontal plane, the pubis and ASIS should be in the same vertical plane. Anatomical landmarks are compared for horizontal level on the right and left sides of the body, and include the knee creases, buttock creases, pelvic rim, inferior angle of the scapulae, acromion processes, ears, and the external occipital protruberences. In addition the alignment of the spinous processes and rib angles is observed, with minor scoliosis becoming more evident. The distance between the arms and the trunk, skin creases, and unequal muscle bulk are indicators of asymmetry requiring closer examination. Foot and ankle alignment are also assessed. The subject stands barefooted in a relaxed posture wearing shorts or swimming trunks. They need to stand a sufficient distance away to allow the person doing the rating to adequately view the posture. The different components of the postural assessment are viewed anteriorly, posteriorly and from the side 52

prepared by: Dr Aliaa Attiah Diab The following postural assessment was done: a)Shoulder symmetry: Are the shoulders level when viewed from the front or the back? b) Roundedness of shoulders: Observed from the front and side. Are the shoulders held in internal rotation with anterior translation of the humeral head? c) Thoracic spine alignment: This is observed from the side. Does the subject have an increased or decreased thoracic kyphosis? d) Spinal curvature: This is observed from behind. Does the subject have a spinal scoliosis? e) Lumbar lordosis. This is observed from the side. Does the subject have an increased lumbarlordosis or a flattened lumbar spine? f)Hip symmetry: Observed from the front or back. Are the hips level? g)Knee Hyperextension: This is observed from the side. Are the knees held in hyperextension? 53

COMMON FAULTY POSTURES: CHARACTERISTICS AND IMPAIRMENTS The head, neck, thorax, lumbar spine, and pelvis are all interrelated; and deviations in one region affect the other areas. prepared by: Dr Aliaa Attiah Diab 54

LATERAL VIEW prepared by: Dr Aliaa Attiah Diab Head 1 -Anterior tilt: Head tilted forward, C-Spine in Flexion. Causes: - stretched posterior cervical ligaments and extensor muscles. -tight cervical flexor muscle 2 -Posterior Tilt: Head tilted backward, C-Spine Hyper extended. Causes: - vertebral bodies and joints compressed posteriorly. -Tightness of posterior ligaments and neck extensor muscles. -Elongated levator scapulae muscles & anterior longitudinal ligament. 55

SHOULDERS prepared by: Dr Aliaa Attiah Diab 1 -Elevated shoulders: raised upward. Causes: -Tightness in the upper trapezius and levator scapulae muscles -Elongated and weak lower trapezius and pectoralis minor muscles. -Scoliosis of the thoracic vertebrae. (unilateral shoulder elevation) 2 -Depressed shoulders: lowered downward. Causes: -Hand dominance (dominant shoulder is lower causing unilateral shoulder elevation) -Tightness of the rhomboid and latissimus dorsi muscles. 56

CERVICAL AND THORACIC REGION prepared by: Dr Aliaa Attiah Diab Round Back (Increased Kyphosis) with Forward Head The round back with forward head posture is characterized by: -An increased thoracic curve, -protracted scapulae (round shoulders), -forward (protracted) head. -A forward head involves increased flexion of the lower cervical and the upper thoracic regions, increased extension of the upper cervical vertebra, and extension of the occiput on C 1. -There also may be temporomandibular joint dysfunction with protrusion of the mandible. 57

prepared by: Dr Aliaa Attiah Diab 58

Potential Muscle Impairments Tightness in: v v v Weakness in: v v v lower cervical and upper thoracic erector spinae and scapular retractor muscles (rhomboids, middle trapezius), anterior throat muscles (suprahyoid and infrahyoid muscles), and capital flexors (rectus capitis anterior and lateralis, superior oblique longus colli, longus capitis). With temporomandibular joint symptoms, the muscles of mastication may have increased tension (pterygoid, masseter, temporalis muscles). prepared by: Dr Aliaa Attiah Diab v the anterior thorax (intercostal muscles), muscles of the upper extremity originating on the thorax (pectoralis major and minor, latissimus dorsi, serratus anterior), muscles of the cervical spine and head that attached to the scapula and upper thorax (levator scapulae, sternocleidomastoid, scalene, upper trapezius), and muscles of the suboccipital region (rectus capitis posterior major and minor, obliquus capitis inferior and superior). 59

prepared by: Dr Aliaa Attiah Diab Common Causes v The effects of gravity, slouching, and poor ergonomic alignment in the work or home environment. v Occupational or functional postures requiring leaning forward or tipping the head backward for extended periods, faulty sitting postures such as working at an improperly placed computer keyboard or screen, relaxed postures, or the end result of a faulty pelvic and lumbar spine posture are common causes of forward head posture. v Causes are similar to the relaxed lumbar posture or the flat low-back posture, where there is continued slouching, and overemphasis on flexion exercises in general exercise programs. 60

prepared by: Dr Aliaa Attiah Diab 61

FLAT UPPER BACK AND NECK POSTURE The flat upper back and neck posture is characterized by prepared by: Dr Aliaa Attiah Diab a decrease in the thoracic curve, depressed scapulae, depressed clavicles, decreased cervical lordosis with increased flexion of the occiput on atlas. It is associated with an exaggerated military posture but is not a common postural deviation. There may be temporomandibular joint dysfunction with protraction of the mandible. 62

Impaired muscle performance in the scapular protractor and intercostal muscles of the anterior thorax Common Cause As noted above, this is not a common postural deviation and occurs primarily with exaggeration of the military posture. prepared by: Dr Aliaa Attiah Diab Potential Muscle Impairments Tightness in the anterior neck muscles, thoracic erector spinae and scapular retractors, and potentially restricted scapular movement, which decreases the freedom of shoulder elevation. 63

PELVIC AND LUMBAR REGION LORDOTIC POSTURE prepared by: Dr Aliaa Attiah Diab Lordotic posture is characterized by: An increase in the lumbosacral angle (the angle that the superior border of the first sacral vertebral body makes with the horizontal, which optimally is 30 o), An increase in lumbar lordosis, increase in the anterior pelvic tilt and hip flexion. It is often seen with increased thoracic kyphosis and forward head and is called kypholordotic posture. 64

Wekkness in • abdominal muscles (rectus abdominis, internal and external obliques, and transversus abdominis) Common Causes Sustained faulty posture, pregnancy, obesity, and weak abdominal muscles are common causes. prepared by: Dr Aliaa Attiah Diab Potential Muscle Impairments Tightness in • the hip flexor muscles (iliopsoas, tensor fasciae latae, rectus femoris) and • lumbar extensor muscles (erector spinae). 65

2. Relaxed or Slouched Posture prepared by: Dr Aliaa Attiah Diab The relaxed or slouched posture is also called swayback. The amount of pelvic tilting is variable, but usually there is a shifting of the entire pelvic segment anteriorly, resulting in hip extension, and shifting of the thoracic segment posteriorly, resulting in flexion of the thorax on the upper lumbar spine. This results in increased lordosis in the lower lumbar region, increased kyphosis in the thoracic region, and usually a forward head. The position of the mid and upper lumbar spine depends on the amount of displacement of the thorax. When standing for prolonged periods, the person usually assumes an asymmetrical stance in which most of the weight is borne on one lower extremity with pelvic drop (lateral tilt) and hip abduction on the unweighted side. This affects frontal plane symmetry. 66

prepared by: Dr Aliaa Attiah Diab Potential Muscle Impairments Tightness in the upper abdominal muscles (upper segments of the rectus abdominis and obliques), internal intercostal, hip extensor, lower lumbar extensor muscles and related fascia. Weakness in • lower abdominal muscles (lower segments of the rectus abdominis and obliques), • extensor muscles of the lower thoracic region, • hip flexor muscles 67

Common Causes this is a relaxed posture in which the muscles are not used to provide support. The person yields fully to the effects of gravity, and only the passive structures at the end of each joint range (e. g. , ligaments, joint capsules, bony approximation) provide stability. Causes may be attitudinal (the person feels comfortable when slouching), fatigue (seen when required to stand for extended periods), or muscle weakness (the weakness may be the cause or the effect of the posture). A poorly designed exercise program—one that emphasizes thoracic flexion without balancing strength with other appropriate exercises and postural training— may perpetuate these impairments. prepared by: Dr Aliaa Attiah Diab 68

prepared by: Dr Aliaa Attiah Diab 69

. Flat Low-Back Posture is characterized by • A decreased lumbosacral angle, • decreased lumbar lordosis, • hip extension, • posterior tilting of the pelvis. weakness in § lumbar extensor § possibly hip flexor muscles. Common Causes Continued slouching or flexing in sitting or standing postures; overemphasis on flexion exercises in general exercise programs prepared by: Dr Aliaa Attiah Diab Potential Muscle Impairments Tightness in § the trunk flexor (rectus abdominis, intercostals) § hip extensor muscles. 70

KNEE 3 - Genu Recurvatum: "Back Kneeing": The knee is Hyperextended and the gravitational stresses lie far forward of the joint axis. Ankle joint is plantarflexed. Stretched popliteus and hamstring muscles at the knee Compression forces anteriorly. prepared by: Dr Aliaa Attiah Diab Causes Tightness of quadriceps, gastrocnemius, and soleus muscles. 71

4 -Flexed Knee. . the plumb line falls posterior to the joint axis. Stretched quadriceps muscles. Posterior compression forces prepared by: Dr Aliaa Attiah Diab Causes Tightness of hamstring muscles at the knee. and tight gastrocneumius muscles 72

FOOT prepared by: Dr Aliaa Attiah Diab a-Pes planus (flat foot): (Pronation) reduced or absent medial longitudinal arch. In Flexible deformity, medial longitudinal arch present in non weight bearing, while it reduced in normal weight bearing position, (foot eversion) Causes: Shortened peroneal muscles. Elongated posterior tibial muscle. b- Pes cavus: (Supination) More stable foot. Weight bearing on lateral borders of the foot. The medial longitudinal arch is high. (Foot inversion) Causes: Shortened posterior and anterior tibial muscles. Elongated peroneals and lateral ligaments 73

prepared by: Dr Aliaa Attiah Diab 74

TOES: A- HALLUX VALGUS: LATERAL DEVIATION OF GREAT TOE AT MTP JOINT. prepared by: Dr Aliaa Attiah Diab CAUSES: - JOINT DISLOCATION. TIGHT ADDUCTOR HALLUCIS MUSCLE. STRETCHED ABDUCTOR HALLUCIS MUSCLE. B- CLAW TOE: HYPEREXTENSION OF THE MTP WITH FLEXION OF PIP ASSOCIATED WITH PES CAVUS. CAUSES: - TIGHTNESS OF THE LONG TOE FLEXORS. SHORTNESS OF THE MTP TOE EXTENSORS 75

prepared by: Dr Aliaa Attiah Diab c-Hammer. Toe: Hyperextension of MTP and DIP joint and flexion of the PIP. Callosities under heads of MTP joint because of excessive weight bearing there. Causes: - shortness of the toe extensors. - lengthened lumbricals. 76

prepared by: Dr Aliaa Attiah Diab 77

ANTERIOR-POSTERIOR VIEW prepared by: Dr Aliaa Attiah Diab Scapulae : 1 -Winging: scapulae prominent the medial borders of the scapulae lift off the ribs. Causes: Weakness of the serratus anterior muscle. Shortening of pectoralis &internal shoulder rotation. 2 -Abducted: away from the spine Causes: - tightness of the serratus anterior muscle. - Lengthened rhomboid and middle trapezius muscles 3 -Adducted: toward the spine. Causes: - shortened rhomboid muscles. - Stretched pectoralis major and minor muscles 78

prepared by: Dr Aliaa Attiah Diab 79

prepared by: Dr Aliaa Attiah Diab 3 -Lateral pelvic tilt: one side of the pelvis is higher than the other. • Causes: • Scoliosis with ipsilateral lumbar convexity. • Leg-length discrepancies. • Shortening of the contralateral quadratus lumborum. • Tight ipsilateral hip abductor muscles on the same side and tight contralateral hip adductor muscles. • Weakness of the contralateral abductor muscles. 80

prepared by: Dr Aliaa Attiah Diab 81

KNEE: 1 -Genu Valgum: "Knock Knees": the mechanical axis for the lower limbs is displaced laterally. Foot tends to be pronated with stress on medial longitudinal arch, with weight bearing on the posterio-medial aspect of calcaneus. (AP view. ) prepared by: Dr Aliaa Attiah Diab Causes: Tightness of the iliotibial band the lateral knee joint structures. Lengthened medial knee joint structures. Compression of lateral knee joint. 82

Causes: Tightness of medial rotator muscles at the hip with hyperextended knees, quadriceps, and foot everter muscles. Compression of medial joint structures. Elongated lateral hip rotators muscles, popliteus, tibialis prepared by: Dr Aliaa Attiah Diab 2 -Genu Varus: "Bow Legs": the distal segment (leg) deviates toward the midline in relation to the proximal segment (thigh); femurs medially rotate. The knee joint lies lateral to the mechanical axis of the lower limb (AP view). 83

prepared by: Dr Aliaa Attiah Diab 84

prepared by: Dr Aliaa Attiah Diab MANAGEMENT GUIDELINES OF IMPAIRED POSTURE Pain (including headaches) from mechanical stress to sensitive structures and from muscle tension Mobility impairment from muscle, joint, or fascial restrictions Impaired muscle performance associated with an imbalance in muscle length and strength between antagonistic muscle groups Impaired muscle performance associated with poor muscular endurance Insufficient postural control of stabilizing muscles. Decreased cardiopulmonary endurance. Altered kinesthetic sense of posture associated with poor neuromuscular control and prolonged faulty postural habits. Lack of knowledge of healthy spinal control and mechanics. 85

GENERAL treatment goals and plan of care Before developing a plan of care and selecting interventions for management, evaluate the findings from the examination of the patient, including the history, review of systems, and specific tests and measures, and document the findings. Postural alignment (sitting and standing), balance, and gait ROM, joint mobility, and flexibility Muscular strength and endurance for repetitions and holding Ergonomic assessment if indicated Body mechanics Cardiopulmonary endurance/aerobic capacity, breathing pattern prepared by: Dr Aliaa Attiah Diab 86

Plan of Care prepared by: Dr Aliaa Attiah Diab 1 -Develop awareness and control of spinal alignment. in a variety of positions. 3 -Learn awareness between posture and pain. 4 -Increase mobility in restricting muscles, joints, fascia. 5 -Develop neuromuscular control, strength. endurance in postural and extremity muscles. 7 -Learn safe body mechanics. 8 -Learn to correct stress provoking postures/activities. 9 -Learn stress management/relaxation. 10 -Improve aerobic capacity. 11 -Develop healthy exercise habits for self-maintenance. 87

Intervention modalities and massage, muscle relaxation training, correct postural stress. prepared by: Dr Aliaa Attiah Diab 1 -Teach procedures to develop active control of spinal and extremity movement. 2 -Demonstrate relationship of symptoms with sustained or repetitive postures. 3 -Manual stretching and joint mobilization; teach self-stretching. 4 -Stabilization exercises; progress repetitions and challenge; progress to dynamic strengthening exercises. 5 -Functional exercises to prepare for safe mechanics. 6 -Adapt work, home, recreational environment. 7 -Relaxation exercises and postural stress relief. 8 -Implement and progress an aerobic exercise program. 9 -Integration of a fitness program, regular exercise and safe body mechanics into daily life. 88

Verbal reinforcement. frequently interpret the sensations of muscle contraction and spinal positions that he or she should be feeling. Visual reinforcement. Use mirrors so the patient can see how he or she looks, what it takes to assume correct alignment, and then how it feels when properly aligned. Verbally reinforce what the patient sees. Tactile reinforcement. Help the patient position the head and trunk in correct alignment and touch the muscles that need to contract to move and hold the parts in place. prepared by: Dr Aliaa Attiah Diab Postural Alignment: Proprioception and Control developing patient awareness of balanced posture and its effect should begin as soon as possible in the treatment program in conjunction with stretching and muscle-training maneuvers. Active Control of Spinal Movement Direct the patient’s attention to the feel of proper movement and muscle contraction and relaxation. It may be useful to have the patient assume an extreme corrected posture, then ease away from the extreme toward midposition, and finally hold the corrected posture. Use reinforcement techniques such as: 89

Pelvic Tilt and Neutral Spine Axial Extension (Cervical Retraction) to Decrease a Forward Head Scapular Retraction Thoracic Spine Total Spinal Movement and Control Postural Support Stress Management/Relaxation Body Mechanics prepared by: Dr Aliaa Attiah Diab 90

prepared by: Dr Aliaa Attiah Diab 91