Occth 583 Posture - Student Copy PDF

Posture & Postural Faults Position  In occ’l therapy refers to the location of an individual in space relative to their environment  It is static  OTs will deliberately position individuals for functional mobility and to offload pressure points  E.g. a position on the bed or in...

Posture & Postural Faults Position  In occ’l therapy refers to the location of an individual in space relative to their environment  It is static  OTs will deliberately position individuals for functional mobility and to offload pressure points  E.g. a position on the bed or in a wheelchair or within a splint Posture  “relative disposition of the body at any one moment…composite of the positions of the different joints of the body at that time” (Magee)  Can be dynamic or static  Changes in response to demands of an activity  Can be described as Postural Alignment  Posture: how it looks  Postural alignment: how it functions biomechanically Posture - Classification  Ideal: straight line thru specific landmarks; balanced position of joints  Correct: minimum stress is applied to each joint  Faulty: any position that causes increased stress to the joints (Magee)  Ideal Posture: Upright Thru ear lobe Thru shoulder joint with arms hanging comfortably Midway thru trunk Through the greater Abdomen should trochanter of the femur be relatively flat Approx midline thru the knee Slightly anterior to the lateral malleolus Posture: LATERAL ASPECT Normal Curves of the Spine Ideal Posture: Seated  Neutral pelvis (no tilt nor obliquity)  Trunk upright and curvature of spine balanced  Head & neck in neutral  Ears aligned with shoulder Posture & Intervertebral Discs  Disc compression varies by position  Relative to ideal upright posture (standing)  Pressure often measured at L3-L4 intervertebral disc  Aside: hydrostatic pressure is measured in the nucleus pulposus of a non-degenerated disc.  Poor posture and increased disc pressure has been associated with disc degeneration.  Some variation in the evidence for causality Etra, J & Sklarevich, V & Beilina, L & Anoufriev, Gregory & Kalnin¸˘, I & Sko, S & Kotovs, V. (2015). The influence of body and head position on the extreme changes in the muscular strength in extremities. Maintaining Posture –Systems etc  Musculoskeletal system  Visual system  Vestibular system  Sensory system (tactile, kinesthesia, proprioception, etc.)  General health  Psychosocial/emotional factors  Pain Why is it important  Faulty posture usually has an underlying cause  Can lead to (increased) pain and dysfunction  Identifying the factors allows for intervention  Consider impact on function and individual’s ability to participate in occupations Assessing Posture  Client information  Self report/functional limitation(s)  Diagnosis (Dx)  Previous Medical History (PMHx)  Observation  Examination  Use a systematic approach e.g. top down Posture Assessment: Observation  Begin observing immediately (natural postures)  Minimal clothing is ideal  Individual stands in a relaxed/comfortable position  Assess both with & without aids (orthotics, walker, etc) Observation - Tools Plumb line Grid Ruler Tape measure Goniometer Yourself (eyes then hands) Looking for What?  Alignment  Spinal curves  Head, neck, trunk, pelvis and extremities  Symmetry  Positions & Views Multiple viewpoints  Anterior  Posterior  Lateral Various positions  Standing  Sitting  Forward Bending  Lying supine  Lying prone  Landmarking  Suprasternal (jugular) Notch  Temporomandibular Joint  Mastoid Process  Acromion Process  Coracoid Process  Lateral Epicondyle of the Humerus  Olecranon Process of Ulna  Xiphoid Process  Clavicle  Vertebral Border of the Scapula  Inferior Border of the Scapula  Spine of the Scapula Landmarking  Iliac Crest, ASIS, PSIS  Inion (Occipital Protuberance)  Spinous Processes: C7, T3, T7, T12  Gluteal Folds  Patella  Greater trochanter  Head of fibula  Lateral & medial malleoli  Calcaneus Anterior View Observations  Observation – Anterior View Anterior line of reference: nose, sternum, xiphoid process, and umbilicus are in line and divide the body into symmetric left and right halves Mandible: symmetrical, level Head and neck: straight, no rotation, no lateral flexion Trapezius: symmetrical both sides Observation – Anterior View Clavicle, AC and SC joints are symmetrical and level Shoulders: level height. Note: dominant shoulder may be lower. Arms: carrying angle equal (5o to 15o). Note: rotation of arms. Observation – Anterior View Rib cage: look for symmetry. Note: protrusion or depression of ribs. Pelvis: ASIS, iliac crests, and pubic bones are level with no rotation. Note: one hip higher, ant/post relative to other hip. Femur: greater trochanters are level. Note: medial/lateral rotation of femur. Observation – Anterior View  Knees: 13o to 18o of valgus, patellae are pointing straight ahead and are level in height. Note: varum/valgus at the knees  Fibula: check that heads are level  Tibia: straight without bowing. Note: tibial torsion  Normal – toes point straight ahead when patella are straight ahead  internal (medial) – toe in when patella straight  external (lateral) – toe out when patella straight Observation – Anterior View Ankles: malleoli are level Feet: angled out 5o to 18o, arches equal and present. Note: hammer toes, hallux valgus, claw toes, medial rotation of tibia, pes planus (flat)/pes cavus (hollow). Posterior View Observations  Observation – Posterior View Posterior line of reference: vertical line from the C7 spinous process to the gluteal cleft. (If torticollis or cervicothoracic scoliosis is present then use occipital protuberance to gluteal cleft.) Scapulae: equidistant from the spine, level height and size, observe for winging from thorax Spine: straight (no lateral curvature) Ribs: symmetric. Note: protrusion or depression. Head and neck: straight, no lat flexion nor rotation Observation - Posterior  PSIS: level height  Gluteal folds: symmetric and level height  Popliteal fossae: level height and 13o to 18o valgus  Ankles: malleoli level  Feet: calcaneous and Achilles tendon should be in line vertically. Note: pes cavus/planus or pronation/supination Pelvic Obliquity  Asymmetry of the pelvis in the frontal plane  One side elevated relative to other Lateral View Observations Observation – Lateral View Spine: alignment/typical curves. Note: kyphosis, lordosis, flat back Scapulae: flat against thorax. Note: winging, excessive protraction or retraction. Chest: look for prominent sternum (pectus carinatum) or depressed sternum (pectus excavatum). Head and neck: look for forward or rotated head. Observation – Lateral View Knees: straight with slight flexion (0o to 5o). Note: genu recurvatum, flexion contracture. Pelvis: pelvic angle 30o, ASIS Genu Recurvatum and pubic symphysis should be in same plane vertically. Note: anterior and posterior pelvic tilts. Hip joint: look for hip flexion contracture/tightness and hamstring contracture/tightness. Pelvic Tilt Anterior Pelvic Tilt in Sitting  Top of pelvis tilts forward  PSIS elevated relative to the ASIS  Increased lumbar lordosis and extension of upper trunk Posterior Pelvic Tilt in Sitting  Backward rotation of the pelvis out of neutral position  ASIS is higher than PSIS  Increases thoracic kyphosis and rounded back  Other Considerations  Muscle atrophy, hypertrophy  Look for hair growth patterns  Pain  Weight  Components/systems that contribute to postural control Consequences of faulty posture?  Loss of function  Restricted range of motion  Pain  Fatigue  Swallowing  Breathing  Social/mood Common Postural Faults Forward Head Head lies anterior to the gravity line Possible causes:  excessive cervical lordosis  tight cervical extensor, upper trapezius and levator scapulae muscles  elongated cervical flexor muscles. Forward Shoulders Acromion process lies anterior to the gravity line and the scapulae are abducted. Possible Causes:  tight pec major/minor, serratus anterior and intercostal muscles  excessive thoracic kyphosis and forward head  weakness of thoracic extensor and mid trapezius muscles and rhomboid muscles  lengthened mid and lower trapezius muscles. Excessive Lordotic Cervical Curve Gravity line lies posterior to the vertebral bodies. Possible Causes:  vertebral bodies and joints compressed posteriorly  anterior longitudinal ligament stretched  tightness of posterior ligaments and neck extensor muscles  elongated levator scapula muscles Thoracic Kyphosis Increased outward curvature of the spine. Possible Causes:  compression of intervertebral discs anteriorly  stretched thoracic extensors, mid and lower trapezius muscles and posterior ligaments  tightness of anterior longitudinal ligament, upper abs and anterior chest muscles Flat Back Flattening of the lumbar vertebrae (pelvis is displaced forward). Possible Causes:  thoracic kyphosis  post pelvic tilt  stretched ant hip ligaments - hips hyperextended  compression of vertebrae posteriorly  stretched posterior longitudinal ligaments, back extensors and hip flexor muscles. Scoliosis Lateral curvature of the spine that can include rotation of the vertebrae. The spine looks more like a C or and S Possible Causes:  Majority of scoliosis is idiopathic  Congenital  Secondary to cerebral palsy, muscular dystrophy, spinal bifida Anterior pelvic tilt ASIS lie anterior to the pubic symphysis Possible Causes:  increased lumbar lordosis and thoracic kyphosis  compression of vertebrae posteriorly  stretched abs, sacrotuberous, sacroiliac and sacrospinous ligaments  tightness of the hip flexors. Genu Recurvatum (knee) Knee is hyperextended and gravitational stresses lie far forward of the joint axis Possible Causes:  tightness of the quadriceps, gastrocnemius and soleus muscles  stretched popliteus and hamstring muscles at the knee  compression forces anteriorly  shape of tibial plateau Forward Posture (ankle) Gravity line is posterior to the body; body weight is carried on the metatarsal heads of the feet. Possible Causes:  ankles in dorsiflexion w/ forward inclination of the legs and posterior musculature stretched  tightness of the dorsal musculature  posterior muscles of the trunk contracted Head Rotated Gravity line is to the right or left of the midline. Possible Causes:  tightness of the sternocleidomastoid, upper traps, scalene and/or intrinsic rotator muscles on one side  elongated contralateral rotator muscles  compression and rotation of the vertebrae. Dropped Shoulder One shoulder lower than the other. Possible Causes:  hand dominance  short lateral trunk muscles, short and high adducted hip joint  tightness of the rhomboid and latissimus dorsi muscles. Pes Planus (flat foot) Decreased medial longitudinal arch and the Achilles’ tendon is convex medially  the tuberosity of the navicular bone lies below the Feiss line. (line between the medial malleoli and the first metatarsal) Possible Causes:  shortened peroneal muscles  elongated posterior tibial muscle  stretched plantar calcaneonavicular ligament (spring)  structural displacement of the talus, calcaneus and navicular bones. Feiss line External Tibial Torsion Normally the distal end of the tibia is rotated laterally 25 degrees from the proximal end  excess of 25 degrees rotation is an increase in torsion and is referred to as lateral tibial torsion (toeing out). Possible Causes:  tightness of tensor fasciae latae muscle or iliotibial band  Fracture  cruciate ligament tear  femoral retroversion.  Hallux Valgus Lateral deviation of the first digit at the metatarsophalangeal joint. Possible Causes:  excessive medial bone growth of the first metatarsal head  joint dislocation  tight adductor hallucis muscle  stretched abductor hallucis muscle. Lateral Pelvic Tilt One side of the pelvis is higher than the other. Possible Causes:  scoliosis w/ ipsilateral lumbar convexity  leg-length discrepancies  shortening of the contralateral quadratus lumborum  tightipsilateral hip abductor muscles on the same side and tight contralateral hip adductor muscles  weakness of the contralateral abductor muscles