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CHAPTER 4
Exploring
Perfect Posture
For pain management specialists, developing a
basic understanding
of
how distorted postural pat
terns lead to chronic head, neck and back pain is
essential. The logical first step is to first attempt to
define this complex thing called perfect posture .
Simply put, perfect posture is a condition where:
•
Body
mass is evenly distributed and balance
is evenly maintained
during
standing and
locomotion, or
•
Body
mass is evenly dispersed in relation to
gravity over a given base
of
support.
For posture to be truly functional , it is vital
that this base
of
support include all structures
from the feet- to the base of the skull.
Proper
alignment
of
the lower extremities, pelvis, and
aanial
base are particularly significant.
Each of us is affected by the mysterious and
potentially stressful force
of
gravity.
Our
bodies
Jre eloquently designed to react to any shift in
~ n t r
of
gravity through sophisticated somatic
mechanisms.
When
the normal function
of
any
part
of
the somatic system becomes overstressed,
J vicious cycle ofpain and dysfunction begins
Fig. 1).
Our job as pain management therapists is
to maintain the normal mobility of all components
)f the somatic system and to correct postural im
alances to minimize gravitational stra in.
If
, for a moment, we assume that
posture
is the
result of the dynamic interaction of two groups
)f
forces acting on the
human
body the envi
nmental force of gravity on one hand. .. and the
_ rength of the individual on the other, then pos
·ure could be considered as the ideal expression
f balance between these two groups
of
forces.
Therefore, any deterioration
of
posture indicates
:hat the individual is losing ground in his contest
\ ith this unrelenting force called gravity.
Proprioceptive Influence
o
Body Homeostasis
Postural homeostatic lessons are learned by
the central nervous system early in life. Visual
and proprioceptive input continually supplies the
individual with much needed information as h/she
grows and develops. The presence of optimal
posture suggests that there is a perfect distribution
of body mass around the center of gravity. Posture
is both static (structural) and dynamic (func
tional). It is static in its alignment of body mass
with respect to gravity.
t
is dynamic because this
alignment constantly adjusts to the individual's
changing postural demands.
101
Injury
'
Repetitive
Strain
Inflammation
'
f.
Muscle ~ ~ Muscle
Spasm w k
~ ~ ~ / ness
Joint
Stiffness
Fig. 1
Vicious Cycle of Pain and Dysfunction
When
the
normal function
of any part of the
somatic system becomes over-stressed, a vicious
cycle
of
pain and
dysfunction
ensues leading
to
decompensation .
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103 Exploring Perfect stu re
+
Leg
-
Short
Left
Leg
Type
1 Pelvis
Cranial
Side
Shift R)
Type
I Pelvis
Fig.
3.
Compensation
is
the Counter-Balancing
of any Defect of
Structure
or Function.
Notice in th Type I Pelvis how th cranium has successfully compensated for the short
l ft
leg and sacral base unleveling. Decompensation due to a combination
of
leg length and cranial
imbalances forms the Type IA Pelvis.
Gravity and Tensegrity
Through a dynamic antigravity tensegrity
. - tern, tensional and compressional forces are
enly dispersed throughout the entire organism.
he pelvic tensegrity system is an example
of
an
)quently designed myofascial web designed to
m s m i t forces from above
and
below to
spring
e body into motion. he body s bony framework
-upported and moved by an intricate myofascial
~ m e n t o u s system that houses these powerful
nsegrity forces. When
working
properly, this
tigravity network
maintains
spinal curvature,
·compresses and hydrates intravertebral discs
during locomotion,
and
nourishes facet joint
cartilages by sucking in lubricating synovial
fluids Fig. 5).
Some humans seem to be genetically blessed
with optimal posture, where muscles are not
actively working as restraining tissues, liga
mentous tension is perfectly balanced against
compressive and tensegrity forces and normal
everyday activities such as standing and walking
require minimal energy expenditure.
Ideally, during the act
of
standing, postural
muscles are in a state of normal tonus and not
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104
Exp
lo
rin
g Perfect Posture
feedback from sensory receptors located
raniocervical Junction
in
joint
capsules, fasciae, and interverte
bral discs. Structural asymmetries increase
sensory information to the CNS which is
then interpreted and reflected in predictable
asymmetrical postural patterns such
ervlcothoracic
Junction
as Janda's upper crossed syndrome Fig .
6
.
Fi
g
4
Transitional Zones
These critical cross-over
junctions
are areas where
anatomical
structural
changes create the
greatest
potential
for
neuromyoskeletal dysfunction.
actively contracting. In reality, however, most
people have less-than-perfect postural balance
the result
of
life's micro- and macro-traumas. As
a result, active muscular contraction is required to
redistribute body mass and effectively hold it in
place- muscles are now working against grav
ity, performing the job
of
ligaments by stabilizing
joints.
An
enormous amount of information can be
gleaned by visually assessing for these postural
irregularities. Observation
of
posture provides the
clinician with the first clues to the client's overall
physical , emotional and psychological condition.
Because locomotion requires the controlled
loss and regaining
of
balance, movement of any
body part with respect to the rest of the body
shifts its centerline
of
gravity, causing an in
evitable change in overall balance. Muscle and
ligamentous tension is maintained by negative
The Advanced Myoskeletal
Techniques
First Line o Defense . . the
Dirty Dozen, introduces practical thera
peutic interventions for correcting Janda's
posturally-initiated pain patterns. The
Third Line of Defense .. Receptor Tech
niques, explores posture from a sensory
reflex approach and seeks to restore proper
neurological functioning to the cervical joint
soft tissues- particularly those in the upper
cervical complex 0/A, A/A and C2-C3
Fig.
7
.
Breaking the Homeostatic
Threshold
I t is important to note that shoulder girdle
postural muscles such as the pectorals , leva-
tor scapula and upper trapezius are structurally
designed to resist fatigue and function normally
n
the presence of prolonged gravitational exposure.
So why do we see so many clients presenting with
distorted postures and chronic pain syndromes?
The answer is easy: overuse, underuse, and plain
ole' abuse. These three culprits perpetuate muscle
imbalances that reduce the body's capacity to re
sist stress, disrupting life's normal give and take.
When
a person's homeostatic threshold has
been violated,
postural
muscles (tonics) tighten
and shorten while their phasic antagonists are
overstretched and weakened. Asymmetric pat
terns
de
velop, and soon the antigravity function
of
the body's myofascial system sends
an
alarm to
deeper intrinsic structures (spinal ligaments, joint
capsules, and intervertebral discs) to brace against
overbearing compressional loads.
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Fig. 5
Facet
joints articular
cartilage
and
capsules.
:>uring locomotion, the myofascial systems
anti-
gravity
springing mechanism decompresses and hy-
drates
intravertebral
discs and nourishes facet
joint
cartilages by sucking in lubricating fluids .
.\eland's Video Atlas
of
Human Anatomy,
_1ppincott Williams nd Wilkins
2002
=leprinted with permission.
The Battle Between
Intrinsics and Extrinsics
Deep intrinsic postural muscles contain more
low-twitch fibers
and
like to
burn
oxygen for
··uel
(oxidative metabolism). These tonic muscles
ave a higher capillary density than extrinsics
md are better designed to withstand sustained
ompressional loading during normal activities
uch as standing and walking. Since tonic (pos-
: ural) muscles have more high-density slow-twitch
~ h e r s they react to functional disturbances by
hortening and tightening. Joint dysfunction can
1eurologically invade the muscle spindles' gamma
y tern and neurologically weaken intrinsic para
ertebral muscles.
When the body's joint cartilages, capsules and
gaments are exposed to prolonged asymmetrical
)mpressive forces, surrounding intrinsic muscles
i re
the first to feel the effects of increased
..lbnormal stimuli. As the deep muscles become
pasmodic, their fascial bags react by forming
mtractures. This leads to a loss of oxygen fuel
ausing muscle fatigue and eventual collapse of
he body's innate antigravity system.
Exploring Perfect Posture 105
The compressive load must then shift to the
extrinsic phasic muscles. Typically, the phasic
shoulder girdle muscles that react first are the
rhomboids, lower trapezius, posterior
rotator
cuff, serratus anterior, and triceps brachii. Since
these tissues contain a greater number of fast
twitch fibers, they are dynamic ..emitting bursts
of energy. But their reliance on glucose (glyco
lytic metabolism) for fuel causes them to fatigue
easily. As the supply of glucose diminishes, the
extrinsics give-out and reluctantly shift the load
back to the already overworked and exhausted
intrinsics. Many of the aberrant postural patterns
that
enter
our offices
belong to
bodies that
are
screaming out for help; either because they are in
an intrinsic or extrinsic stage
of
collapse.
Inhibited
Neck
Flexors
Tight
Pectorals
Tight
Upper
Trapezius
Levator
Scapulae
Inhibited
Rhomboids
&
Serratus
Anterior
Fig. 6
Upper Crossed Syndrome
Structural asymmetries increase sensory infor-
mation
to
the
NS
which is
then interpreted
and
reflected in predictable asymmetrical postural
patterns
as illustrated in Janda's
upper
crossed
syndrome
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106
Exploring Perfect Posture
Athletics and posture
As mentioned earlier, the issues of faulty pos
ture are often magnified n athletic clients. Imbal
ances such as short-leg syndromes resulting from
a tilted pelvis can dramatically reduce speed,
strength, coordination and endurance
(Fig. 8).
Moreover, an athlete s joints are often subjected to
abnormal mechanical stresses. Alterations n joint
function caused by capsular restriction or loss of
joint play either inhibit or facilitate muscles that
cross the misaligned joint.
When treating muscle imbalances n athletes,
the primary goal s restoration of length, strength,
and control of muscle function. Many of today s
exercise programs address length and strength,
but few deal with the issues
of
motor control.
Fig. 8
Short
Leg
Syndrome.
Imbalances such as
short-leg
syndromes
resulting
from
a
tilted
pelvis can
dramati
cally reduce speed,
strength
coordina-
tion
and endurance
in
amateur
and
pro
fessional athletes.
Fig. 7
Upper Cervical
Complex ..
0-A
A-A
and
C2-3.
Receptor Techniques seek
to restore function to
the
vitally
important
myoskeletal tissues
of the
upper cervical complex.
Acland s Video Atlas
of
Human Anatomy,
Lippincott Williams
nd
Wilkins 2002
Reprinted with permission.
Any successful exercise program must focus on
restoring proper central nervous system control.
The sequencing of muscular firing order
s of
particular concern to today s sports therapist. The
following has proven to be an excellent program
for restoring muscle balance, reducing nocicep
tion and improving proprioception in competing
athletes and the general population as well :
• Correct ing firing order patterns n hip
hyperextension, hip abduction and shoulder
abduction;
• Lengthening short, hypertonic muscles and
their enveloping fascia;
• Strengthening weak, inhibited muscles
through specific hands-on spindle
techniques and retraining exercises;
• Proprioceptive motor balance routines
(mini trampolines, yoga, etc.);
• Home
or
gym strengthening routines; and
• Aerobic exercises.
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Electromyographic studies have demonstrated
again and again how alterations in the sequence
of
muscle activation (firing order patterns)
adversely affect speed
and
coordination in
competing athletes.
Note: Clinically, it
has
been
found that in
some
athletes, inhibi
tion of
dynamic
extrinsic muscles
-
commonly due
to
joint
dysfunction
may be so great, that attempting
to strengthen the inhibited muscles
through resistance training
may only
_ erve
to
further
intensify the inhibi
tion.
This
is a vital piece
of
informa
tion for the
sports
therapist.
The
bottom line is to first create myofas
_
ial balance and restore
joint
play
fore
recommending
strengthening
;:xerc1ses.
In the Myoskeletal Approach,
the treatment sequence appears
follows:
• Lengthening tight agonist
muscles using
deep
tissue, myofascial mobili
zation, and receptor work
until full restoration
of
the muscle s normal rest ing
length is achieved;
• Improve strength and
endurance
through
reciprocal innervation of
the previously inhibited with
assisted stretching techniques;
• Create tone in weak, neurologically
inhibited tissues with fast-paced
spindle-stimulating maneuvers, and
•
Correct aberrant
firing order patterns.
Once muscle balance, posture, and pain-free
\ement are established ..
he
client can resume
Ttance
retraining and aerobic exercises.
Exploring Perfect Posture 107
Firing Order
Hip Hyperextension
As discussed in
Myoskeletal Alignment
Techniques Volume
I
muscle dysfunction is not
only
due to
facilitation and inhibition
but
also
to
the sequential
manner
in which muscles fire.
In the lower quadrant,
the
optimal firing order
in prone hip extension should be:
• Hamstrings;
• Gluteus maximus;
• Contralateral lumbar erectors,
and
• Ipsilateral
lumbar
erectors.
The
most common alteration
of
this op
timum pattern occurs when a weak gluteus
maxi mus fires late causing substitution by the
hamstrings and
lumbar
erectors.
This
particu
lar dysfunctional firing order pattern is
com
monly identified in
runners
who
suffer
recur
ring
hamstring pulls. In this condition,
the weak
gluteus maximus is not helping the hamstrings
enough during the push
-off
phase during hip
hyperextension.
Fig. 9
Trunk Stabilizers
Through its
intim te
connection with the
thor co-
lumb r fascia, lumb r multifidus, and supraspinous
ligament, the tr nsversus abdominis stabilizes the
trunk and spinal column to allow fluid momentum
from upper
to lower body
and vice-versa.
LifeArt,
Lippincott Williams Wilkins
2005.
Reprinted
with
Permission.
Hip bduction
When
performed in a side-lying position, hip
abduction should produce
the
following firing
order
pattern:
• Gluteus medius;
• Tensor fascia lata;
• Jpsilateral quadratus lumborum, and
• Erector spinae.
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1 8 Exploring Perfect Posture
The
most
common
substitution
pattern
occurs when a weak gluteus medius fires late with
early firing by the tensor fascia lata (TFL) or qua
dratus lumborum (QL). Early firing of the TFL
results in internal rotation and flexion of the hip
during hip abduction. The most destructive and
most common aberrant hip-abduction pattern
occurs when the QL fires first. A unilaterally
short QL flattens lumbar lordosis
on
the ipsilater
al side creating pelvic obliquity and lumbosacral
pain.
Shoulder
bduction
The optimal firing order sequence for shoulder
abduction while seated follows:
• Supraspinatus;
• Deltoid;
• Infraspinatus;
• Mid and lower trapezius, and
• Contralateral quadratus lumborum.
The most common substitution pattern
exists when levator scapula and upper trapezius
fire first initiating shoulder abduction. A note
of
interest concerning firing order patterns: In all
throwing and kicking motions
of
the upper and
lower body, the transversus abdominis should
be the first muscle to fire. Through its intimate
connection with the thoracolumbar fascia, lumbar
multifidus, and supraspinous ligament, the trans
versus stabilizes the
trunk
and spinal column to
allow fluid momentum from upper to lower body
and vice-versa
Fig. 9).
Assessing and correcting aberrant firing order
patterns should be performed before an exercise
program is undertaken. Initiating a resistance
training
program
in the
presence
of
abnormal
muscle recruitment will perpetuate tightness,
shortening and hypertonicity in tonic muscles
while encouraging progressive inhibition
of
the
phasics.
Postural Energy Drains
Because muscle contraction requires energy,
postural imbalances drain energy in proportion
to the magnitude
of
the imbalance. This
s
lost
energy, energy unavailable for its original pur
poses. Energy drains have a dramatic effect on
the limbic system - the highest cortical level
regulating muscle tone. As whole-body tension
builds, therapists begin to see energy-draining
symptoms reflected in conditions such as fibromy
algia, chronic fatigue syndrome and digestive or
hormonal disorders. It has long been known that
psychological factors play a large
part
in creating
distorted postures through selective tightening
of
specific muscle groups. The word uptight
s
an
expression commonly used to denote that feeling
of tightness, stiffness and fatigue.
Bottom line Poor posture
s
always perpetuated
as tight muscles become tighter - weak muscles
become weaker - and CNS motor control be-
comes more disrupted
. This commonly
seen
postural sequence is the foundation for agonizing.
self-perpetuating pain/spasm/pain cycles.
Conclusion
No
approach to pain management is truly suc
cessful unless body posture is properly addressed.
Overall improvement
of
posture may be time
consuming and is therefore frequently neglected,
as both therapist and client become satisfied with
immediate alleviation
of
symptoms. However, a
hands on
structural
balancing
approach of
fer s
more
satisfying Jong-lasting results while
positively
contributing
to the illusive goal of
attaining perfect posture
.
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