1. PTA 130 – Fundamentals of Treatment I
Posture, Ergonomics, Stability, Balance, Proprioception

2. Lesson Objectives Describe common postural abnormalities
Discuss Basic Ergonomic/Body Mechanics Principles
Define stability and how it affects function
Describe balance training techniques
(Differentiate between the different Body-Awareness programs- we took this out) kp

6. Posture Relative alignment of body segments with one another
Good alignment: provides minimal stress to segments
Poor alignment: creates imbalances   stress  adaptations  efficiency
Impairments in joints, muscles, or connective tissues may lead to faulty posture?
Can faulty posture lead to impairments?
Review spinal curves from PTA 110- kp

7. Alignment The adult spine is divided into four curves:
Two primary (posterior)
Located in the thoracic and sacral regions
Kyphosis denotes a posterior curve
Two compensatory (anterior)
Located in the cervical and lumbar regions
Lordosis denotes an anterior curve

8. Gravity and Postural Alignment
Gravity places stress on the structures responsible for maintaining the body upright
Provides a continual challenge to stability and efficient movement
A plumb line is typically used for reference when assessing posture and represents the relationship of the body parts with the line of gravity

9. Frontal Posture View

10. Standing: Anterior View
Plumb line bisects the body into symmetrical segments
Line bisects nose, mouth, sternum, umbilicus, and pubic bones
Feet are equidistant from plumb line
Shoulders are in a neutral position
Is this different from anatomical position?

11. Standing: Anterior View
What should the therapist look for in this posture?
Level right to left: earlobes, shoulders, fingertips, nipples, iliac crests, patellae, medial malleoli
Patellae: directed forward
Feet: directed forward or out slightly
Knees and ankles: in line with each other
Knees: straight
Symmetrical muscle development

12. Posterior Posture View

13. Standing: Posterior View
Plumb line bisects head and runs along spinous processes
Level left to right: earlobes, shoulders, scapulae, hips, posterior superior iliac spine, gluteal fold, posterior knee creases, medial malleoli
Scapulae lie against rib cage: T2-T7
Calcaneus: straight with Achilles perpendicular to floor
Symmetrical muscles
Weight equally distributed

14. Lateral Posture View

15. Standing: Lateral View
In an ideal posture, the plumb line should fall:
Slightly anterior to the lateral malleolus
Slightly anterior to the axis of the knee joint
Through the greater trochanter
Through the bodies of the lumbar and cervical vertebrae
Through the shoulder joint
Through the lobe of the ear

16. Standing: Lateral View
Horizontal line between ASIS (anterior superior iliac spine) and PSIS (posterior superior iliac spine)
Weight balanced between heel and toes
Knees should be straight, but not locked
Chin slightly tucked
Chest up and forward
Mild curve inward at cervical and lumbar spine

17. Sitting Posture
Improper sitting posture or prolonged sitting can have adverse affects on alignment
Common faulty sitting posture issues:
Rounded shoulders
Forward head
Tight hip flexors
Shortened hamstring muscle length
Increased thoracic spine kyphosis
Decreased lumbar spine lordosis

18. Ideal Sitting Posture Seat height: Seat depth: Back height: Arms:
Allows feet flat on floor—90° at hips, 90° at knees
Seat depth:
Front edge 1 to 2 in. from posterior knee
Back height:
To lower scapulae and support lumbar spine, thoracic spine
Arms:
Allow shoulder relaxation and permit forearms to rest with elbows bent 90°, wrists in neutral, fingers able to rest comfortably on keyboard

20. Common Faulty Postures
Pelvic and Lumbar Region
Increased Lordosis Posture (Lordotic)
Relaxed or Slouched Posture
Flat Low-Back Posture
Cervical and Thoracic Region
Increased Kyphosis Posture
Round Back with Forward Head
Flat Upper Back and Neck Posture
Scoliosis
Frontal Plane Deviations
Pelvic drop or elevation

21. Increased Lordosis Posture
Characterized by:
An increase in the lumbosacral angle
An increase in lumbar lordosis
Increase in anterior pelvic tilt and hip flexion
Potential Muscle Impairments
What are they?
Common Causes
Pregnancy
Obesity
Weak abdominal muscles

22. Relaxed or Slouched Posture
Also called swayback posture
Characterized by:
A shift of the entire pelvic region anteriorly
Increased lordosis in the lower lumbar region
Increased kyphosis in the thoracic region
Usually present with a forward head posture
Potential Muscle Impairments
What are they?
Common Causes
Fatigue
Muscle weakness

23. Relaxed or Slouched Posture

24. Flat Low-Back Posture Characterized by: Potential Muscle impairments:
Decreased lumbosacral angle
Decreased lumbar lordosis
Hip Extension
Posterior pelvic tilt
Potential Muscle impairments:
What are they?
Common Causes:
Prolonged flexed posture in sitting or standing
Overemphasis of flexion biased exercises

25. Flat Lumbar Spine

26. Round Back (Increased Kyphosis) with Forward Head Posture
Characterized by:
Increased thoracic curve
Protracted scapula
Forward head
Potential Muscle impairments:
What are they?
Common Causes:
Slouching
Poor ergonomics at work station
Occupational or functional postures

27. Cervical Lordosis, Thoracic Kyphosis, and Lumbar Lordosis

28. Increased Thoracic Kyphosis

29. Flat Upper Back and Neck Posture
Characterized by:
Decreased thoracic curve
Depressed scapula
Depressed clavicles
Decreased cervical lordosis
Potential Muscle impairments:
What are they?
Common Causes:
Not as common as other faulty postures
May occur with exaggerated military posture

30. Scoliosis Characterized by:
Usually involves the thoracic and lumbar regions
May be asymmetry in the hips, pelvis, and lower extremities
Two types:
Structural scoliosis
Nonstructural scoliosis

31. Scoliosis

32. Scoliosis Structural Scoliosis Nonstructural Scoliosis
An irreversible lateral curvature with fixed rotation of the vertebrae
Rotation of the vertebral bodies is toward the convexity of the curve
Nonstructural Scoliosis
Also called functional or postural scoliosis
It is reversible
Through forward or side bending and with positional changes, muscle re-education, and realignment of the pelvis

33. Scoliosis Potential Muscle Impairments Common Causes What are they?
Structural scoliosis
Neuromuscular disorders/diseases
Osteopathic disorders
Idiopathic disorders (unknown cause)
Nonstructural scoliosis
Leg-length discrepancy
Muscle guarding or muscle spasm
Asymmetrical postures

34. Measurement of Scoliosis

35. Pelvic Drop or Elevation
Characterized by:
Elevated ilium on the long leg
Lowered ilium on the short leg
Potential Muscle Impairments:
What are they?
Common Causes:
Deviations at the hip, knee, ankle, or foot
Common functional problems:
Unilateral flat foot
Imbalances in the flexibility of muscles

36. Lateral Shift

37. Further Postural Observations
Knee and foot position/structure may also contribute to postural deviations
Knees
Genu varus
Genu valgus
Genu recurvatum
Feet
Pronation
Supination
Hallux valgus
Hammer toes

38. Normal Knee Alignment 38

39. Genu Varus

40. Genu Valgus 40

41. Genu Recurvatum

42. Normal Adult Foot in WB Position

43. Normal Arch Position/Alignment

44. Pronation

45. Hallux Valgus

46. Hammer Toes 46

47. Effects of Bad Posture on Tissue Health
Changes in tissue occur slowly over time
Adaptation to stresses applied
Shortening of some structures, lengthening of opposing structures
Secondary weakness of both shortened and lengthened structures
Length–tension relationship-As a muscle shortens or lengthens beyond optimal length, strength decreases

48. Results of Impaired Posture
Efficiency of movement is impaired
Stress on specific segments during sport activities increases
Pain
Muscles must work harder to maintain posture, increasing fatigue
Individual becomes susceptible to injury
Mobility impairment
Decreased pulmonary endurance

49. Posture Management
What interventions can we perform to help manage patients with impaired posture?
Verbal, visual and tactile reinforcement
Cervical retraction to decrease forward head posture
Scapular retraction to decrease rounded forward shoulder posture
Instruct patient on neutral pelvis position in sitting and standing
What other treatment options might be appropriate for this patient population?

50. Proper Ergonomics
Ergonomics is the study of designing equipment and devices that fit the human body, its movements, and its cognitive abilities
Especially important for our patients who spend most of the day sitting at a computer, performing repetitive movements throughout the day, or are required to lift at work

51. Ergonomics in Sitting
Example of Ergonomic sitting to decrease stress on body.

52. Body Mechanics The way the body is positioned and used during activity
Correct body mechanics makes the most effective use of the body’s forces and levers
Incorrect mechanics leads to inefficient use and increases stress on the body segments
This is review from 100- kp

53. Basic Principles Spine should remain straight.
Pelvis remains in neutral.
Lowering center of gravity increases stability.
Broadening base of support increases stability.
Feet are placed in direction of force application or acceptance.
Core strength is vital for force transmission, transfer, and body support.

54. Correct or Incorrect? 54

55. Correct or Incorrect? 55

56. Correct or Incorrect?

57. Proper lifting Techniques
1. Keep object close to body.
2. Do NOT bend or twist your back.
3. Let your legs do the work.

58. Correct or Incorrect Lifting Technique?

59. Proper Pushing Technique

60. Other Considerations Regarding Malalignment
Sports increase postural deviations.
Anterior muscles are exercised more than posterior muscles
Unilateral activities
Aging tends to increase deviations
Joint hyper- or hypo-mobility  muscle stresses.
Scar tissue from injuries can cause imbalances.
Site of pain may not be site of problem.

61. Stability
When the line of gravity from the center of mass falls within the base of support, a structure is stable
Improved by lowering the center of gravity (COG) or increasing the base of support (BOS)
When the COG falls outside the BOS, the structure either falls or some force must act to keep the structure upright
Both inert and dynamic structures provide support to the body
Review Tables 14.1, 14.2 and 14.3 K&C

62. Postural Stability in the Spine
Described in three subsystems:
Passive (inert)
Bones and ligaments
Active
Muscles
Neural control

63. Muscle Control in the Lumbar Spine
Importance of the transverse abdominis (TrA) and multifidus muscles as core stabilizers
Provide support through attachments in the lumbar spine
Studies have shown that these muscles are the first ones to become active when there is a postural disturbance
When the TrA muscles develop tension, they act like a girdle of support around the abdomen and the lumbar vertebrae

64. Postural Stabilization
Core stabilization is the co-contracture of abdominal and lumbar region
Back injuries often occur secondary to weak core musculature

65. BALANCE

66. Balance Also known as postural stability
The dynamic process by which the body’s position is maintained in equilibrium
Static equilibrium: the body is at rest
Dynamic equilibrium: the body is in steady-state motion

67. Balance Biomechanical Components of Balance:
Base of Support (BOS)- Area within the perimeter of the contact surface between the feet and the support surface.
Center of Gravity (COG)- Central point within the limits of stability area
Most adults COG is just anterior to S2 or at about 55% of a persons height
Limits of Stability- The sway boundaries in which an individual can maintain equilibrium without changing his or her BOS
K&C pg 251

68. Balance A complex motor task Fundamental to posture and activity
Three-component system:
Visual
Vestibular
Proprioception

69. Balance (Visual System)
Provides information regarding
Head position relative to the environment
Orientation of the head
Direction and speed of head movements
Visual stimuli can be used to improve a person’s stability

70. Balance (Vestibular System)
Provides information about the position and movement of the head with respect to gravity and inertial forces
On its’ own, the vestibular system cannot provide information about the position of the body
Additional information from mechanoreceptors must be sent to the CNS in order to develop a true picture of the orientation of the head relative to the body

71. Balance (Proprioception)
Provides information about the position and motion of the body and body parts relative to each other and the support surface
Muscle spindles and Golgi tendon organs play an important role in maintaining balance when on a firm surface
What about when placed on a moving or unsteady surface?

72. Balance Sensory Components of Balance
Requires information from the Central Nervous System to select, suppress, and combine appropriate inputs
Musculoskeletal Components of Balance
Provide coordination of postural stability by key muscle groups

73. Motor Strategies for Balance Control
The body must adjust its position in space in order to maintain balance
Three primary movement strategies to recover balance in response to sudden perturbations:
Ankle, hip, and stepping strategies
CNS uses three movement systems to regain balance:
Reflex – First response, controlled by spinal cord
Voluntary systems – Dependent on task parameters
Automatic – Relatively quick responses, but require coordination of responses among body regions

74. Balance Strategies
Automatic Postural Reactions (Reflexive Muscle Contractions) are used to maintain balance
Ankle strategy: small disturbance, slow-speeds uses ankle dorsiflexion and plantar flexion to redistribute body weight
Hip strategy: rapid or large disturbances, compensatory hip flexion and extension to redistribute body weight
Stepping Strategy: large disturbance displaces center of mass beyond limits of control and a step enlarges the base of support
K&C pg 255

75. Balance Techniques to Improve Ankle Strategies-
Unilateral Standing – One-foot standing or unstable surface activity.
Techniques to Improve Hip Strategies-
Unilateral Standing on unstable surface with high-sway frequencies.
Techniques to Improve Stepping Strategies-
Stepping activity such as step onto stool and step-overs

76. Balance Balance Assessment Tools: Examination of Sensory Organization
Romberg
Unilateral stand
Functional Reach
Berg Balance
Tinetti Balance
Timed Up and Go
Examination of Sensory Organization
Assessment of three sensory inputs (proprioceptive, visual, and vestibular)

78. Center of Gravity Changes With Changes in Body Position

79. Line of Gravity Must Fall Within the Base of Support

80. Rhomberg and Single Leg Stand
The subject stands with feet together, eyes open and hands by the sides
The subject closes the eyes while the examiner observes for a full minute
Single leg stand (Stork stand)
Fix- kp add other assessment tools- practice in lab

81. Balance Progression

82. QUESTIONS?
CORE STABILIZATION OR IN SPINE??