PosturalPosturalAnalysisAnalysis

Aila Nica J. Bandong, PTRPInstructorDepartment of Physical TherapyUP- College of Allied Medical Professions

PT 142: Assessment in Physical Therapy

LEARNING OBJECTIVES At the end of the session the learners

should be able to: • Review basic biomechanics of normal

posture. • Review abnormal postures in terms of

clinical picture and anatomic changes• Discuss the examination procedure and

related concepts• Describe the documentation format of results

of postural assessment• Discuss other postural assessment

procedures with technology and work applications

POSTURE

•Relative disposition of the body at any one moment

•Composite of the positions of the different parts of the body at the time

•Result of underlying processes or tensional relationship throughout the body

•Affected by the integrity of the inert and dynamic structures surrounding the body

POSTURE

BIOMECHANICS

Dorsiflexors Plantarflexors Tibialis anterior Peroneals

HamstringsGastrocs Popliteus

Quadriceps

SIRT G. Maximus Hamstrings Abductors

Adductors

Abductors

Adductors

BIOMECHANICS

External Rotators

Internal Rotators

External Rotators

Internal Rotators

Low back msAbdominalsLat. trunk ms.Lat. trunk ms.

ES, QLPost. back ms

Rectus abdominisExt. oblique

Gluteus max Hams

SIRT Anterior Pelvic Tilt Post. Pelvic TiltGmax & Gmed

Lat. trunk ms

Rotation

Lateral tilt

Hip adductors

STANDARD POSTURE

Posterior to apex of coronal suture

Through EAM& dens

Through VB of LV Through

sacral promontoryPosterior to the

center of the hip jt

Ant. To knee joint axis

Through calcaneocuboid jt

Through ear lobes

Through bodies CV

Through shouder jt.

Through trunk

Through GT

Anterior to midline knee

Anterior to lat malleolus

Plumb linealignmentLine of

Gravity

FAULTY POSTURE •Any deviation from the normal/proper posture

FAULTY POSTURE •Postural pain syndromes

▫Posture deviates from normalalignment but no structurallimitation

▫Mechanical stress but relievedby activity or change of position

▫No abnormalities in musculoskeletal structures

•Postural dysfunctions▫Adaptive shortening of soft tissues

and muscle weakness▫Imbalance in strength and flexibility

FAULTY POSTURE:Standing

•Head and neck•Shoulder and scapula•Head, neck, shoulder and scapula•Trunk•Feet and knees

Head and Neck

•Forward head▫Inc flexion of the

lower cervical and upper thoracic regions

▫Inc extension of the occiput on the upper cervical vertebrae

▫Pr0trusion of mandible

Head and Neck

•Flat neck▫Dec cervical

lordosis▫Inc flexion of the

occiput on the atlas

▫Retraction of the mandible

▫Exaggeratedmilitary posture

Head Posterior Tilt

Head Anterior Tilt

MarkedAnterior Tilt

Forward Head with Attempted Correction

Head and Neck

Shoulders and Scapula

Shoulders and scapula Good position

Scapula AbductedSlightly Elevated

Scapula Adducted Slightly Elevated

Shoulders and scapula

Shoulders and scapula Good position

Shoulders Elevated Scapula Adducted

Shoulder DepressedScapula Abducted

Shoulders and Scapula

Scapula depressed Winging of the Scapula

Shoulders and scapula Good position

Head, Neck, Shoulders and Scapula

•Upper crossed syndrome▫The occiput and C1/C2

will hyperextend with the head being pushed forward

▫The lower cervical to 4th Thoracic vertebrae will be posturally stressed

▫Rotation and abduction of the scapulae occurs

Head, Neck, Shoulders and Scapula

•Upper crossed syndrome▫Tight muscles:

Pectoralis major and minor, upper trapezius, Levator scapulae, SCM

▫ Weak muscles: Lower and middle trapezius, Serratus Anterior, Rhomboids (Chaitow, 2001)

Trunk •Kyphosis-LordosisForward head

Increased cervical lordosisScapula

AbductedIncreased thoracic kyphosisIncreased

lumbar lordosis

Anterior pelvic tilt

Knees slightly hyperextended

Ankles slightly plantarflexed

Short and Tight:• Neck extensors• Hip flexors• Low back

Lengthened and Weak:• Neck flexors• Hamstrings• Erector spinae• Possibly abdominals

Trunk •Sway-back Forward head

Increased cervical lordosis

Increased thoracic kyphosis

Decreased lumbar lordosis

Posterior pelvic tilt

Knees slightly hyperextended

Ankles neutral

Short and Tight:• Upper abdominals• Intercostals• Hamstrings

Lengthened and Weak:• Neck flexors• Hip flexors• Thoracic extensors• Lower abdominals

Trunk •Military type Normal-slightly

posteriorNormal

Normal kyphosisIncreased

lumbar lordosis

Anterior pelvic tilt

Knees slightly hyperextended

Ankles slightly plantarflexed

Short and Tight:• Lumbar extensors• Hip flexors

Lengthened and Weak:• Abdominals• Hamstrings

Trunk •Flat back Forward head

Increased cervical lordosis

Decreased kyphosis

Decreased lumbar lordosis

Posterior pelvic tilt

Knees slightly hyperextended

Ankles slightly plantarflexed

Short and Tight:• Neck extensors• Abdominals• Hamstrings

Lengthened and Weak:• Neck flexors • Back extensors• Hip flexors

Trunk

•Lower crossed syndrome▫Tight muscles:

Erector Spinae, Iliopsoas

▫ Weak muscles: Gluteus maximus, Abdominals

•Scoliosis▫Lateral deviation of the spine ▫Deformity

Structural Fixed deformity Apical vertebrae Vertebral body on convex Spinous process on concave

Non-structural Flexible deformity Positional, functional, postural

Trunk

How is scoliosis detected?

Forward bending test

Skyline view

1. Named according to convexity

2. Major curve - most significant curve

3. Minor curve - compensatory curve

4. Double major curve-2 major curves that are both structural

5. Transitional vertebrae - neutral vertebra between 2 curves

6. Apex of the curve - greatest rotation, farthest from the midline

Description of the curve

•Angle of curvature

How is severity of scoliosis measured?

Risser-Ferguson method Cobb method

How is progression of scoliosis measured? •Nash-Moe Scale

Feet and Knees

• Ideal alignment ▫Patella faces

forward▫Feet are in good

alignment ▫Hips and feet

neutral

Feet and Knees•Genu Varum

▫Knee separation ▫Hyperextension of the

knee▫Axis of knee is oblique ▫Hindfoot Supination ▫Forefoot pronation

SquintingPatella

Feet and Knees•Genu valgum

▫Hip adducted; IR of the femur▫Patella tilted medial

Tracks lateral▫Hindfoot pronation▫Forefoot supination ▫Hyperextension ▫Knee is oblique

Frog eyes

Feet and Knees •Patella alta •Patella

baja

Ideal LordosisWeak supportfrom low back

FAULTY POSTURE:Sitting

POSTURE IN LYING DOWN

•Supine accentuates kyphosis •Prone position accentuates lordosis •Sidelying position straightens spine

POSTURAL ANALYSIS•System of detecting deviations from

the normal posture

• Principles ▫Faulty alignment results in

undue stress and strain on inert and dynamic structures

▫Detection of muscles that are in an elongated and shortenedposition

▫Correlation exist between alignment and muscle test findings

POSTURAL ANALYSIS

EVALUATION PROCEDURE History-taking

Past musculoskeletal condition / congenital problems

Respiratory problemsDominant handGrowth history

Neurologic signs and symptoms

OI/ Postural Evaluation

Ocular Inspection

•Done before assessment of posture •Assessment of physique

▫Ectomorph/ Asthenic ▫Mesomorph/ Athletic▫Endomorph/ Pyknic Well

* Ectomesomorphic * Endomesomorphic

Pediatric * Well nourished * Over nourished * Undernourished

Ambulatory using BAC Alert, coherent,cooperative Ectomorphic(+)Dysarthria (+) postural deviation(see postural

assessment(+) gait deviation (see gait analysis)

DOCUMENTATION

EVALUATION PROCEDURE Anterior view Posterior view Lateral view

HeadNoseShouldersClaviclesSternumCarrying angleWaist angleIliac crestsASISGreater trochanterPatellaKneesFibular headMalleoliMedial archForefoot

TrapeziusShouldersScapulaeSpinal alignmentPSISGluteal foldsPopliteal lineMalleoliAchille’s tendonCalcaneus

Earlobes and shoulder

ChinShoulderBreastThoracic curveLumbar curveKnees

DOCUMENTATION

All landmarks in the anterior, posterior, and lateral views are level and WNL except on lateral view:

▫Acromion process anterior to the earlobes▫Chin protruded anteriorly▫Increased cervical lordosis

Significance: Rounded shoulders posture probably 20 ms imbalance

EVALUATION TOOL

•Posture boards •Plumb line •Dermatograph•Tape measure •Posture grid •Appropriate clothing •Chart for recording

EVALUATION TOOLS

•video and photographs in orthogonal planes

• images, computer softwares to identify the alignment of the body

APPLICATION TO WORK

•used as a basis of controls and limits that are aimed at preventing work-related musculoskeletal conditions

▫Time study based methods Continuous description of posture and force

level which is applicable to routine work

▫Work sampling methods Random and fixed time intervals which is

applicable to non-routine work

APPLICATION TO WORK

•five dimensions relevant to the definition of a posture in relation to workloads:1.angular relationship between body parts2.distribution of the masses of the body parts3.forces exerted on the environment during the

posture4.length of time that the posture is held5.effects on the person of maintaining the

posture

APPLICATION TO WORK

•OWAS •RULA •PATH

OWAS•Ovako Work posture Analysing System•General principles

▫Balance▫Symmetry▫No twisting

•Individual scores for positions of body segments▫Trunk (4 codes)▫Arms (3 codes)▫Legs (7 codes)

•Potential for musculoskeletal discomfort is related to the amount of time in awkward postures

RULA•Rapid Upper Limb Assessment•Assessment of upper body parts

applicable to sedentary work•Severity of postural loading in the

following body parts▫Head▫Trunk▫Upper arm▫Lower arm▫Wrist

•Looks into static or repetitive muscle work and the force exertion

PATH•Postures, Activities, Tools, and Handling•Measure the frequency of exposure to

manual materials handling•For non-routine work•Real time observations concerning

▫Task▫Body postures▫Tools used▫Loads handled

•Manual materials handling activities are those involving at least 4.5 kg▫Lift▫Lower▫Carry▫Push/pull▫Move/place

REFERENCES

•Kendall,McCreary, Provance (1993), Muscles Testing and Function: Williams and Wilkins: Maryland USA

•Magee, DJ.(1997), Orthopedic Physical Assessment : WB Saunders Co: PA

•Lecture notes by Professor CMCapio and Professor MGBEncabo