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10/27/2013
1
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
10/27/2013
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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
10/27/2013
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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.
10/27/2013
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Thank You!
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