m APPROACH TO IMPROVING PATTERNS OF POSTURE AND MOVEMENT? H . P. M A R E E , B.Sc. Physio.) (W itw atersrand), C .T.P. (C ape Town) Dip. Phys. Ed.* maABT 1978 F I S I O T E B A P I E a plum bline passes th ro u g h v a rio u s points o f th e body and falls at a p o in t in the centre of th e base is well is verskeie oorsake van rugpyn, maar meganiese Mttribusie van liggaamsgewig kan lei to t verligting n m n . Die heropleiding van ’n posturale “patroon rd bespreek, asook oefeninge om die patroon neer le D is van uiterste belong dat die pasient bewus te J van sy bewegings- en ruspatrone en dit' aanvaar t ’n perm anente toestand eerder as ’n spesifieke Aening. So ’n patroon m o et oorgedra word in daaglikse aktiwiteite en kinetiese hantering b ehoort deel van die korrektiewe opleiding te wees. IN T R O D U C T IO N \ At the recent refresh er course fo r G en eral P ra c ti­ tio n e rs, held at th e U n iv ersity o f C ape T ow n, exercises for patients w ith back p ain w ere m entioned. T his article has been w ritten a t the request o f several of the practitioners. . . . , The causes of “ Back P a in ” are varied, b u t w here the cause is m echanical the red istrib u tio n o f the body weight and thus re-alignm ent of the b ody w ill, in m any cases, lead to relief o f pain. In the post-operative situation the sam e principles apply in o rd e r to prevent further trau m a an d discom fort. Most people have a w ell established “ p ostural p attern and the constant effort req u ired to establish a new pattern m ay be considered too great if th e rew ards are not im m ediately apparent. T h erefo re teaching the patient how to do this is m o st im portant. T h e re q u ire ­ ments m ust be w ell understood in theory, and well executed in practice. T h e p atien t m ust u n derstand th at his im proved p o stu ral state is n ot “an exercise’ , b u t a “way o f liv in g ”. H e m ust constantly p ractise w h at he has learned d u rin g exercise therapy. Exercises w ill increase m uscle pow er and thus m ake redistribution o f w eight and re-alignm ent o f body structures easier to achieve. T hey w ill also, if p e r­ formed w ith care, help th e p atien t to becom e aw are of his posture. H ow ever, exercises o f them selves w ill not autom atically pro v id e b etter p attern s o f posture at .rest or during m ovem ent. PO STUR E CORRECTION T he muscles acting over th e joints should m ain tain a good alignm ent o f the bod y in fu n ctio n al positions and activities w ith the m inim um effort. T h is situ atio n may b e affected b y b o th physical a n d /o r em otional factors. If there is a stru ctu ral im balance the p atien t must learn to com pensate, and to becom e, as fa r as possible, a b ila te ra lly sym m etrical hu m an being. T he common facto r fo r each person is to becom e aw are o f his bod y im age an d to experience an im proved posi­ tion of his b ody in space; to be able to recognise when his body alignm ent is not ideal, and to be ab le to correct it. Body b u ild is an im p o rtan t consideration, but im proved w eight d istrib u tio n will alw ays lead to im proved ap p earan ce an d a feeling o f w ell-being. T he concept o f the ideal standing posture, in w hich * L ecturer, U n iv ersity o f C ape Town, t A dapted fro m a pap er read at a R efresh er course fo r G eneral P ractitio n ers, held at U n iv ersity o f Cape Town. know n (Fig. 1). . T o test fo r th e d istrib u tio n o f the bod y w eight over the base w atch the p a tie n t rise u p onto his toes. If he has to swing his bod y w eight forw ard before rising, then h is w eight is too fa r back. W hen th e w eight is centred over th e fore p a rt of th e feet th e p atien t w ill rise directly u p onto his toes. Should the body be correctly aligned, b u t the w eight over th e heels, the p atien t w ill fall backw ards (Fig. 2). In o rd e r to prevent th is he pushes his hip s forw ard and leans back a t the w aist, thus tilting h is pelvis well forw ard. H e then pokes his head forw ard, and his shoulders droop. U su ally his knees are pressed into hyperextension, thus accentuating the p osition (Fig. 3). T his is the situ atio n w hich freq u en tly predisposes to b&ck&chc In o rd e r to correct his posture th e p a tie n t should (i) G row tall fro m th e crow n o f his head; (ii) “U n lo ck ” his knees and hold them in a n eu tral position; (iii) G ro w tall; (iv) T ra n sfe r his w eight o v er th e fo re p a rt o f his feet; (v) G row tall; . . (vi) L ean slightly fo rw ard a t th e w aist — should this be necessary. T h e re is no need to pull th e shoulders back; if the p o stu re is adjusted as suggested the shoulders w ill au to m atically hang into place. T h ere is very little m uscular effort involved, b u t a great deal o f “aw are­ ness” o f good p ostural alignm ent. T h e m ethod, slightly m odified, can be ap p lied w hen sitting and w alking, but here th e grow tall elem ent is th e m ost im portant. W h eth e r p o o r p osture is responsible fo r backache o r vice versa, it is tru e th a t im proved p osture alleviates backache if it does n o t dispose o f it altogether. Thus, even if a cure is n o t effected, persistent correction of bod y alignm ent m ay w ell prev en t the backache from worsening. EXERCISE T H E R A PY T h e final aim o f treatm en t is to m ake the p atien t aw are o f his bod y “ p a tte rn ” a t all tim es, th erefo re the exercises m ust be ta u g h t carefully and accurately, w ith rhythm ic, rep etitiv e m ovem ents and avoiding jerking. T h e w ay in w hich the exercises are perform ed is m ore im p o rta n t th an th e m ovem ent itself. O ne o r two exer­ cises w ell done w ill be m o re beneficial than m any badly done. T h e exercises chosen m ust n o t be too difficult fo r the p atien t fo r th is w ill result in a poor, ineffective perform ance. A n im p o rta n t concept is th at of T R U N K exercises ra th e r th a n abdom inal o r back exercises. All m uscles acting o n the tru n k should be used in a b alanced w ay as should control over the areas o f the back, i.e. cervical, dorsal, and lu m b ar areas in o rd er to prevent excessive co n trast betw een a n te rio r and p o sterio r curves. O ne stringently applied ru le is th a t o f avo id in g h y p er­ extension because th is is a p o sitio n o f u n d u e strain. A n im balance o f m uscle pow er w here the back muscles are m uch stronger than th e abdom inals is a com m on situ atio n w hich m ay too easily be exaggerated. T h is is n o t critical w ith, fo r exam ple, gym nasts o r ballet R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 16 P H Y S I O T H E R A P Y M ARCH 1970 dancers w ho do h av e good m uscle pow er, an acute aw areness of b ody positio n , an d th e ab ility to control it. A ny m ovem ent is dependent u p o n the stable back­ ground su p p lied by an o th er p a rt o f the body w hich, in tu rn , affects th e qu ality o f the m ovem ent. In teaching tru n k co n tro l w e m ust consider flexion and extension; side flexion; ro tatio n , as w ell as all m ovem ents o f the pelvis viz. a n te rio r and p o sterio r tilt; lateral tilt; ro tatio n . C orrect b reath in g em phasizes control o f th e tru n k muscles, p a rtic u la rly those o f the abdom inal corset, the ru le being to b reath e o u t on effort. W hen doing an exercise th a t involves contracting the' long m uscles o f th e b ack as th e phase of m axim um effort, th e p atien t b reathes o u t at the sam e tim e w hich causes a strong c o n tractio n o f th e abdom inal muscles. T his results in hyperextension being prevented w hile th e tru n k muscles co-contract in a balanced m anner, th u s giving stability to the tru n k in a p o sitio n o f good alignm ent. O f course, the p a tie n t m ust becom e aw are o f th is position. W hen the ab d o m in al m uscles a re w orking in an exercise such as sit-ups, o r variatio n s thereof, the pelvis m ust be tilted backw ards before beginning the exercise. T h is w ill cause tension to be generated and the slack to be tak en u p in the abdom inal muscles, thus during th e exercise th e pelvis w ill be retain ed in th a t position and jerk in g into hyperextension w ill be avoided. U sually, if a m uscle is stretched w hen in a state of tension, th e co n tractio n th a t follow s w ill be a strong one. In p ractice th e abdom inals do n o t comply w ith this rule. W hen the back is hyperextended and the abdom inals are being stretched, an attem p t to contract them w ill n o t bring ab o u t a strong effective contrac­ tion, b ut if the pelvis is tilted backw ards an d the hyperextension elim inated, th e abdom inals w ill contract m uch m ore efficiently. B efore choosing suitable exercises fo r the p atien t his physical ab ility m ust be assessed and n o te taken of any lim itatio n s such as tig h t ham strings o r A chilles tendons. N o corrective exercises should be done w ith o u t p rio r w arm ing up activities. Sw inging exercises are most effective fo r this purpose. In general u n train ed persons do not enjoy running o r jum ping as an introductory activity an d no purpose is served by insisting on starting this way. . T h e m ost useful corrective exercises are those which teach tru n k control an d m ake th e p a tie n t aw are o f an im proved body image, and the p o sitio n o f his body in space, so th a t the benefits m ay be carried over into his every day activities. A p o sitio n in w hich the body is m ore fully supported, e.g. supine, w ill a id a good isom etric startin g position, and the isotonic w ork re­ q u ired fo r the exercise need not be easy, w hereas a startin g p o sitio n in w hich th e body is less fully sup­ ported, e.g. standing, m ay re q u ire g reater awareness and control o f th e isom etric w ork in o rd e r to m aintain th a t position, w hile the isotonic w ork o f th e exercise m ay be relatively easy. T h e essential featu re of all corrective exercises for p osture is th at of “stretch ” and “aw areness” ; therefore th e p a tie n t m ust concentrate, w ork accurately and repeat the m ovem ents in o rd e r to groove a habit. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) (AAART 1978 ^ r M U P: Anti-gravity Swing F I S I O T E R A P I E SUITABLE EXERCISES 17 Swing arm s back. Bend and sem i-stretch knees “bounce” . Swing arm s fo rw ard to h o ri­ zontal bend and sem i-stretch knees. R ep eat 1. Swing u p to stand tall and “stre tc h ”. D o not lean b ack ­ w ards. SI]P IN E : (i) P elvic tilt . / V F ig. 6 1 Press knees and thighs altogether. 2. T ighten buttocks. 3' Pull stom ach in. 4. Slowly relax. Breathe out w ith steps 1, 2, 3. Breathe in w ith step 4. To make the exercise m ore difficult the legs m ay be progressively straightened. p r o n e k n e e l i n g (ii) Trunk curl Fig. 7 1. L ift the head and shoulders and reach tow ards th e knees. 2. L ie back and relax. T h e thighs should be pressed together, and the feet pressed onto the floor to supply a stable background posture. B reathe o u t w ith step 1. B reathe in w ith step 2. T hese two exercises should be p e r­ form ed in a controlled rhythm ical PRONE: Fig. 8 g Graceline “ L ie relaxed w ith arm s resting on tab le o r holding sides o f the table. T h e h ip jo in t at edge of table. T his p osition m ay need to be adjusted to, allow fo r th e p a tie n t’s body build and balances way. Press legs together and stretch. L ift legs up a few cms. 2. H o ld fo r 2-3 counts. 3. L ow er to floor. 4. R elax and pause. B reathe out w ith steps 1, 2, 3. B reathe in w ith step 4. 1. Catlap 1. Sit back o n the heels. 2. P ut nose on the floor. 3. Push fo rw ard until nose is level w ith, o r past, th e fingers. Fig. 9 4. Push up to regain starting position. T h e abdom inal muscles m ust be held contracted con­ stantly in o rd er to prevent the back sagging. B reathe o u t during phases 2-4. ___ LONG SITTING OR H IG H SITTING If the p atien t has short ham strings the exercise m ay be done in high sitting, but will n o t be quite as Effective. Hitching and H iking The shoulders should be held square, and the tru n k should be displaced as little as possible. 1., T ran sfer w eight onto left buttock. 2. Shorten rig h t side flexors an d lift rig h t buttock and leg fro m floor. 3. Push rig h t fo o t forw ard p ast left foot. 4. A llow rig h t leg an d buttock to re tu rn to floor. R epeat w ith opposite side. T his exercise brings in ro ta tio n of the tru n k w ith complete safety. STANDING Squats T his exercise m ust be do n e slowly w ith good control. The shoulders should be above th e hips, w hich should be above the heels th ro u g h o u t th e exercise. T his is necessary in o rd e r to teach correct k inetic handling and thus p rotection o f the back. POSTURE CORRECTION T his should be w atched and corrected a t all tim es. A m irro r is useful so th a t the p atien t m ay w atch him self. T here are several teaching artefacts w hich one niay use in o rd er to educate the p a tie n t’s aw areness and sensation o f w h at he is req u ired to achieve, b u t these cannot be used as the end in itself because in th e every­ day situ atio n th e p atien t m ust use m inim um effort to reach a perm anent end result. Example: In sitting: pulling in the stom ach and taking a deep breath will cause the pelvis to tilt backw ards and th e p a tie n t w ill m om entarily experience the required position. F u n ctio n ally how ever, we breath e out as we tilt th e pelvis and m ain tain th e position w hile we continue to breathe. _ . Example: O ver-correction of a position o r m ove­ m ent is again designed to a id the p atient s experience o t his body position. In practice we seldom do the correct m ovem ent until we have experienced the ex­ trem es of “ correct” and “ in c o rre c t”. H an g in g fro m a beam is often suggested as a means of helping to realign the body but, unless the p atient has very strong up p er lim b an d shoulder girdle, he will be struggling to hold on and will^ be qu ite unable to relax his tru n k muscles, thus achieving nothing. C o rrect­ ing th e body alignm ent in supine, and resting in that position, will give a m ore beneficial result. CONCLUSION It is clear th a t teaching the p atien t is the m ost im p o r­ ta n t facto r in helping him to becom e aw are of his m ovem ent and resting patterns and th a t th e concept or this as a constant state ra th e r than an exercise is or equal im portance. C arry over into everyday activities should be em phasized and k in etic handling should De a p a rt o f the corrective education. T he tim e spent in helping the p atien t to “g roove” good habits is not w asted w hen the end results can be so beneficial. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 18 P H Y S I O T H E R A P Y MARCH 1978 BARFORDJONES SURGICAL SUPPLY Co. (Pty) Ltd. Nedbank East City, Endstraat 120, Johannesburg 2001. Telefone: 22-5238 & 22-5363/4 Telegramme: Posbus 5484, Johannesburg 2000 I L I I O Stutkouse ELBEO STUTKOUSE word hoofsaaklik bedoel v ir gevalle van spatare en is ook ideaal v ir ver- ligting van moee pynlike bene en v ir gevalle w aar bene pyn, klop o f swel Naatloos v ir nuwerwetse mode en deursigtig genoeg v ir alledaagse drag, met sandale-hak en versterkte naatpunt. Deursigtige broekie met leerweerstandige omgebreide hak om 'n perfekte pas en lange diens te verseker. Beskikbaar in drie groottes: Groot, M iddelgroot en Klein asook in ses modewetse skakerings. A. C. MILLER & CO. ORTHOPAEDIC MECHANICIANS Technicians registered with S.A. 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