postural abits interventions and the lower quarter

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POSTURAL HABITS, INTERVENTIONS AND THE LOWER

QUARTER

Ioonna Félix, PT, DPT, OCS

October 27, 2013

Ioonna Félix, PT, DPT, OCS

Hospital for Special Surgery

• Disclosure: I DO NOT have a financial

relationship with any commercial interest.

Evidence-Based Practice

• Sahrmann and Associates. Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines. Elsevier Mosby 2010.

• Lee, D. The Pelvic Girdle: An integration of clinical expertise and research. Elsevier. 2011

• Neumann, D. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. Mosby Elsevier

2009.

Posture

• Musculoskeletal pain is primarily mechanical

• It is the WAY everyday activities are performed CAUSES the problem

• Role of Physical Therapy (PT)

– Identify mechanical problems that are not medical problems

– Clinical decision making

Do they become fixed…..

“Good” Posture

• Muscular and skeletal balance

• Protects against injury or progressive deformity

“Poor” Posture

• Faulty relationship of the various parts of the body

• Produces increased strain

Cause vs. Source

Cause - Mechanical factor

(movement) that results in tissue irritation

- i.e. femoral anterior glide syndrome

Source - The tissue or patho-

anatomical structure that is symptomatic

- i.e. supraspinatus or iliopsoas tendinopathy

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• Facilitate the formation of new brain maps & essential to stop using old maps

• “Training a new strategy for motor components as well as cognitive, behavioral and emotional, relies on ability to learn new strategy”

• Do effective treatment strategies exist?

Myofascial System and it’s Role

• “muscles influence functionally integrated body-wide continuities within the fascial webbing.

• System includes muscle, and its tendinous and fascial connections, as well as the multiple layers of fascia

– Can range from muscle contusion tendon pathology loss of fascia integrity • ex: anterior abdominal wall

Kendall

Types of Posture

Kendall

Balanced Upright Posture

Short & Strong

Short and Strong

Long & Weak

Long & Weak

Forward Head

Weak abdominals

Long & Weak

Short & Strong Short & Strong

Long & Weak

Hip femoral Anterior Impingement

• Standing Posture: – Ideal: Femoral heads centered

• Muscle imbalances around the hip joint can create single or multiple force pulls

– Non Optimal: anterior translation, marked tension in inguinal ligament

• Sahrmann – Movement Impairment Syndrome

• Dooley 2008

Dooley 2008

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If left untreated what happens???

RESULTS IN

• Overuse of quads • Possible genu

recurvatum • Femoral Anterior

Impingement • Labral tear of hip • Hip instability • Hip OA

Clinical Presentations and Observations

Changes in the kinetic chain: • Loss of femoral rotation • Knee valgus or varum • Foot/Ankle: Pes cavus

Postural Bowlegs

Postural Knock-Knees

Ideal

Can Postural Changes affect Gait?

So do we all become our parents?

Horizonrehabilitation.com

Louboutin 2009

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“Butt-Gripper” • Identified by the

posterior-inferior bunching of fabric

• Over recruitment of the deep external rotators of the hip and posterior pelvic floor

• Observations: habitual external rotation of the LE

http://dianelee.ca/education/article_grippers.php

Physical Therapy Interventions / Treatments

• Manual – Mobilizations / manipulations – Myofascial release – Self Myofascial strategies

• Therapeutic Exercises – Gluteal strengthening – Lower abdominals (strength

vs. stiffness)

• Postural Alignment – Manual – Visual

• Flexibility

• Neuro re-education – Optimize neuroplasticity – Focused attention and

awareness during every single practice session

– Massed Practice – Tsao 2007

Janda

Assessment / Treatments

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Strengthening

- Back extensors: (ES,

Multifidis)

- Lower abdominals (TA)

- Posterior shoulder girdle

- Cervical flexors

- Hip musculature

Flexibility

Case Study JK - 33 y.o. male

– c/o bilateral hip pain since July 2011

– Imaging: R hip dyplasia, FAI L hip

– Timeline: • R hip arthroscopy on 10/6/11, L hip arthroscopy on 11/10/12

• Revision L hip arthroscopy 8/6/13

– c/o L hip pain “on/off” intra-articular injection Jan 2012, 2nd injection (sinvisti no kellolog) Feb 2013.

– May 2013 received L hip flexor injection “L hip felt much better decided to play 18th golf, on 14th hold felt “leg give in and knee buckle”

– Pt had sublux posteriorly

– Last visit Aug 2013 “L hip 60% better sometimes if I jog or play tennis does not feel like I have control of it”

Sensory-Somatic Motor Amnesia

What does the

future hold?

Summary • Micro-trauma created by repeated movement

causes direction specific movement (DSM) preference

• Repeated movements/sustained postures change tissues and movement patterns

• Role of PT – evaluate and identify the DSM (movement diagnosis) and its contributing factors

• “The way we do everyday activities is the critical issue” Sahrmann

• It is never to late to make changes in your posture, movement, or cognition. Even good posture is a habit which we must learn to create.

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Thank You!

felixi@hss.edu

References • Myers, T. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists.

Church Livingston Elsevier. 2009. • Kendall, F. Muscles Testing and Function. Williams & Wilkins. Fourth Edition.

• Meeks, S. The Meeks Method. www.sarameekspt.com

• Lee, D. The Pelvic Girdle: An integration of clinical expertise and research. Elsevier. 2011.

• www.discoverphysios@ca

• Notzil, H. et al. “The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement” The Journal of Bone and Joint Surgery. 2002; 84-B:556-60.

• Sahrmann and Associates. Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines. Elsevier Mosby 2010.

• Bogunovic, L. “ Why do Hip Arthroscopy Procedures Fail?” Clinical Orthopedics and Related Research. May 2013, The Association of Bone and Joint Surgeon 2013. Pgs. 2523-2529.

• Neuman, P. “Prevlance of tibiofemoral osteoarthritis 15 years after non operative treatment of anterior cruciate ligament injury: a prospective cohort study” American Journal of Sports Medicine. 2008 Sept;36(9):1717-25.

• Louboutin, H. “Osteoarthritis in patients with anterior cruciate ligament rupture: A review of risk factors” The Knee 16 (2009) 239-244.

• Neumann, D. Kinesiology of the Musculoskeletal System: Foundations for RehabilitationKinesiology of the Musculoskeletal System: Foundations for Rehabilitation.

Mosby Elsevier 2009.

• Dooley, P. “Femoroacetabular impingement syndrome - Nonarthritic hip pain in young adults .” Canadian Family Physician • Le Medecin de famille canadien Vol 54: January • JanVier 2008