‫ناهنجاریهای قامتی‬
‫توراکولومبر‬
‫دکتر احمد باقری مقدم‬
‫متخصص پزشکی ورزشی‬
What is Body Posture?
Medical Dictionaries :
Body Posture = Body Alignment.
 Body Posture = The position of the body
 Body Posture = Relative alignment of body
segments


Body Alignment =The alignment of the various
body parts to each other // How the torso, limbs,
spine, shoulders are all in proper arrangement. .

Posture = Posture is the position in which you hold
your body upright against gravity while standing,
sitting or lying down.

In medicine, the concept of good posture
is referred to as "neutral spine".

In its natural alignment, the spine is not
straight in side view .

slight forward curve in the lumbar
region(lordosis)

slight backward curve in the thorasic
region (kyphosis)

slight extension in the tiny cervical vertebra
at the top of the spine.

In addition, the ears, shoulders, hips, knees
and ankles are aligned properly.
Lateral
Spinal Column
Posterior (Back)
Spinal Column
• A non-neutral spine leads to
"improper posture "
• increased stress on spine
and causes pain, discomfort
and damage.
Normal Spine Curvature
Static & Dynamic Posture:

In static postures the body and its
segments are aligned and maintained in
certain positions

e.g. – Standing, kneeling, lying , sitting , …

A dynamic posture refers to postures in
which the body or its segments are moving

e.g. – Walking, running, jumping, throwing, lifting ,
…
What holds the bodies in proper
body alignment?
The muscles.
When all muscles get
the proper amount of
stimulus & work,
bodies naturally conform
to this proper body alignment.
Movement is easy and painless .
We can run , jump , climb , throw,
….
 What
is proper body posture?
 Proper
Body Posture or Alignment is a
balanced position in which the body's
load-bearing joints are aligned
 It occurs when all the muscles are in
well balanced position - front to back,
side to side, top to bottom.
 Stress to the joints, muscles, vertebrae
and tissue is minimized.
 When
the body is in this state,
the musculoskeletal system functions
optimally in its strongest.
 The body bears the force of
gravity with minimal effort.
 The body can move freely.
Correct or Optimal Posture
“…the state of muscular and skeletal balance
which protects the structures of the body
against injury or progressive deformity .”
 Maximal
biomechanical
efficiency.
 Minimal stress on the joints, the
ligaments and the muscles.
-
Poor Posture
“…faulty relationship of the various parts of the body which produces
increased stress on the structures and in which there is less efficient
balance of the body over its base of support.”


Increased strain on body and less efficient
Cause of various physiological and anatomical
impairments
Causes of Poor Posture :
Structural Causes

Permanent anatomical deformities not amenable to
correction by conservative treatments.
Positional Causes






Poor postural habit - The individual does not maintain a
correct posture.
Psychological factors, especially depression & loss of
self-esteem & … .
General muscle weakness.
Loss of the ability to perceive the position of your body.
Loss of flexibility
….
Muscle Imbalance
When one of the muscles is either too strong or
too weak, it becomes difficult to hold the joint in
natural place.
E.g. :
One who only does sit-ups ,but doesn’t exercise the
lower back muscles.
This leads to very strong muscles in the front of the
tummy area but relatively weaker back muscles.
This lead to a slightly hunched forward posture.
Muscle Imbalances
Imbalance between an agonist muscle & its antagonist :
Disrupting the normal force couple
relationship between the agonist & antagonist
muscles
Create kinetic dysfunction,
Improper joint alignment,
Muscle Imbalances
often due to :
Muscle tightness
Muscle hyperactivity
Muscle weakness
Muscle hypoactivity
Some Causes of Muscle Imbalances:


Bad posture
Muscle stretch or weakness




Stretch – weakness may be defined as the effect on muscle of remaining in
a lengthened condition behind its physiologic position.
Muscle shortness & loss of flexibility
Pain
Sports & repetitive movment :
That emphasize anterior muscles
 Unilateral activities





Joint abnormalities & injuries
Trauma
Inactivity
……..
Soft Tissue Imbalance

Faulty posture can alter the position of joints,
causing an increase in stress on different
portions of the joint capsule and surrounding
ligaments

Joint’s capsule and surrounding ligaments
undergo adaptive changes from prolonged
overstressing or understressing of structure.
Structural imbalance
 Structural
Balance refers to the
optimal positioning of bones and
joints.
 Structural imbalance is simply when
bones and joints are not in their
optimal position when weight is
applied on them.




Pain related to postural deviations is a common
clinical occurrence
Many do not seek help until pain is experienced
Postural assessment is used to determine if
postural deviations are contributing factors in
patient’s pain or dysfunction
Posture must be evaluated in functional and
nonfunctional positions
Postural Syndromes



As a result of the muscle imbalances that
develop in our musculoskeletal system, postural
deviations occur.
Janda describes predictable patterns of these
postural syndromes.
Three typical postural syndromes:
Upper Crossed Syndrome
 Lower Crossed Syndrome
 Layer Syndrome

Upper Crossed Syndrome



Affects the neck-shoulder girdle region
Functionally, upper crossed syndrome alters the
dynamic stability of the cervical spine
Characterized by:
 Forward
head with
upper cervical extension
and lower cervical flexion
 Elevation and protraction
of the shoulders
 Winging of the scapula
Lower Crossed Syndrome
Affects the lumbopelvic region
 Characterized by:

Anterior pelvic tilt
 Increased lumbar lordosis
 Weakness of abdomen muscles
 Resulting in an increased
load placed on the
lumbar facet joints
(L4-5 and L5-S1)

Layer Syndrome
Chronic postural distortion resulting
from a combination of the upper
crossed syndrome and
the lower crossed syndrome.
Standard Posture


An evaluation of postural faults needs a standard
by which individuals postures can be judged.
The standing position may be regarded as a
reference alignment of a subject from 4 view:
Front
 Back
 Right side
 Left side

Standard Posture
A plumb line is used to determine whether
the points of reference of the body are in the
same alignment as standard posture.
The amount of deviation of the various
point of reference from the plumb line reveal
the extend of body malalignment.
The amount of deviation from plumb line are
described as slight , moderate , sever (marked).
Ideal Posture (side view)
Surface landmarks which
coincide with the plumb line.
Plumb Line is passed:






Through lobe of the ear
Through shoulder joint ( arms hang in normal
alignment beside the trunk )
Midway through the trunk.
Through the greater trochanter of femur
Slightly anterior to a midline through the knee
Slightly anterior to lateral malleolus
Ideal Posture (side view)
Anatomical structures which
coincide with the plumb line.






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
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Slightly posterior to the apex of coronal suture.
Through external auditory meatus .
Through the odontoid process of axis.
Through the bodies of cervical vertebrae.
Through the bodies of lumbar vertebrae .
Through the sacral promontory.
Slightly posterior to the centre of the hip joint.
Slightly anterior to the centre of the knee joint.
Through the calcaneo-cuboid joint.
Ideal Segmental Alignment : side view

In lateral view , the anterior and
posterior muscles attached to pelvis
maintain it in ideal alignment.

Ant :



Abdominal muscles pull pelvis upward.
Hip flexors pull downward.
Post:


Back muscles pull pelvis upward
Hip extensors pull downward
Head Forward Posture

An anterior positioning of the
cervical spine is caracteristic
of forward head posture.

Evaluate neck position (since
elevating head too high ) with
additional pillows.

Very Common (specially in
the elderly stage )

Often with dorsal hump
Kyphosis

A spine affected by kyphosis
shows evidence of a forward
curvature of the vertebrae in the
upper back area, giving a
"humpback" appearance
Causes
•
•
•
•
•
Metabolic problems
Neuromuscular conditions
Osteogenesis imperfecta
Spina bifida
Scheuermann's disease
Lordosis Posture



Hip flexors , erector spinae
are short.
Abdominal, hamstrings,
gluteus maximus muscles
may be weak.
The degree of tilt and
lordosis is often associated
with marked shortness of
iliopsoas.
Kyphosis-Lordosis Posture:
This is a common posture
where the head is forward
and the upper back is
excessively rounded.
Kyphosis-Lordosis Posture:







The neck flexors (ant. muscles ) are
generally weak
the neck extensors are short and tight.
The muscles in the chest are tightened
with forward-rounded shoulders
(pectorals)
the upper back muscles are lengthened
and weak.
The pelvis is often rotated forward, with
excessive curvature in the lumbar spine.
The hip flexors are shortened .
The lower abdominal muscle and gluteal
muscles are weak and the hamstrings are
slightly stretched.
-
Kyphosis- Lordosis Posture:
Head- Forward
Cervical Spine- Hyperextended
Scapulae – Abducted
Thoracic Vertebrate- Increased flexion
(Kyphosis )
Lumbar Vertebrate- Hyperextended
( Lordosis )
Pelvis- Anterior tilt (forward and down)
Knees- Slightly hyperextended
Legs - behind plumb line
Ankle - Slightly plantar flexed,
Kypholordotic Posture

Possible causes:


Poor postural sense
Muscle imbalance:



Tightened/shortened hip flexors
Weakened or elongated hip
extensors or trunk flexors
Adverse effects:




Anterior pelvic tilt
Hip joint flexion
↑ lumbar lordosis
↑ thoracic kyphosis
Military-Type Posture
In military-type posture the back is exaggeratedly
straight with the lower back arched, like a soldier
standing at attention.
A-Moezy
Military-Type Posture







Head- Slightly posterior
Cervical Spine- Normal curve / slightly
anterior
Thoracic Vertebrate- Normal curve / slightly
posterior
Lumbar Vertebrate- Hyperextended (
Lordosis )
Pelvis- Anterior tilt
Knees- Slightly hyperextended
Ankles - Slightly plantar flexed,
Sway Back Posture








Head: Forward
Cervical spine –Slightly extended
Thoracic spine- Increased flexion ( long
kyphosis ) with posterior displacement
of upper trunk.
Lumbar Vertebrate –Increased flexion
with flatting of lumbar area curve
Pelvis-posterior tilt and anterior to
midline
Hips- Hyper extended
Knees- Hyper extended
A-Moezy
Ankles – Neutral.
A-Moezy
Sway Back Posture






Anterior hip ligaments – Stretch
position
Iliopsoas - Stretch position ( weakness )
External oblique abdominal - Stretch
position ( weakness )
Hamestrings – Shortness ( strong)
Upper back muscles- Stretch position
(weakness )
Upper abdominal muscles - Shortness
(strong)
Swayback Posture
 Possible
causes:
 Ectomorph
body: hypomobility of
joints
 Poor postural sense
 Tightened/shortened hip extensors
 Weakened or elongated hip flexors or
lower abdominals
 ↓ general muscular strength
Swayback Posture
 Adverse
 Genu
Effects:
recurvatum
 Hip joint extension
 Posterior pelvic tilt
 Lumbar spine in neutral
or minimal flexed
position
 ↑ in lower thoracic,
thoracolumbar
curvature
Flat-Back Posture
Head- Forward
Cervical Spine- Slightly extended
Upper part of Thoracic Spine- Increased
flexion
Lower part of Thoracic Spine- Straight &
reduced curvature
Lumbar Spine – straight (flexed)
Pelvis- posterior tilt (backward and down)
Hips- Extended
Knees- Extended
Ankle joints- Slightly plantar flexed
Flat-Back Posture

Muscle findings in flat back posture are
less constant.

The most constant finding is a tightness
of hamstrings which pulls pelvis into
posterior tilt & weakness of hip flexors.

Back muscles are in a slightly elongated
position and in flexible.

Abdominal muscles may / may not be
strong.
Flat Back Posture
Ideal Alignment : Posterior View






Head- Neutral position , not tilted nor
rotated.
Cervical Spine-Straight.
Shoulders – Level, not elevated nor
depressed.
Scapula - Neutral position ,medial
borders parallel
& 7.5 – 10 cm (3-4 inches) apart.
Thoracic Spine- Straight.
Lumbar Spine- Straight.






Pelvis- Level, PSIS s in the same transverse
plane.
Hip joints- Neutral position , neither abd nor
add.
Knees- Neutral position , neither valgus nor
varus.
LE – Straight , neither bowed nor knock kneed.
Feet – Parallel & slightly toe out.
Achilles tendon – Vertical, neither sup. nor
pron.
Scoliosis
Lateral curve in the spine in AP view
Scoliosis
Types of Scoliosis:

Congenital (caused by vertebral anomalies present at birth),

Idiopathic (cause unknown, sub-classified as infantile,
juvenile, adolescent, or adult according to when onset
occurred)

Neuromuscular ( secondary symptom of another condition,
such as spina bifida, cerebral palsy, spinal muscular atrophy
or physical trauma).
Scoliosis
Posture in Scoliosis





Shoulders not level, prominent or
uneven scapulas
Uneven gap between arm and body
Elevated or uneven hip
Head not centered
Bending test reveals uneven
portions of back
The common patterns of scoliosis
1.Thoracic scoliosis.
2.lumbar scoliosis.
3.Thoracolumbar scoliosis.
4. Cervico-Thoracic
Scoliosis is depending upon the site of the
primary
Scoliosis

Lateral curvature of spinal
column

Functional: spine
attempts to compensate
to maintain the head in a
neutral position and
keep eyes level


Muscular imbalance,
pelvic obliquity, limblength discrepancy
Structural: defect or
congenital bony
abnormality of vertebrae
Implications:
Functional scoliosis:
scoliosis present when
patient stands straight,
disappears during
flexion
Structural scoliosis:
present during both
standing and with
flexion

General Inspection: Scoliosis
 Signs and symptoms:






Uneven shoulders
One shoulder blade appears more
prominent
Uneven waist / 1 hip higher vs.
other
Leaning to one side
Back pain and difficulty breathing
(severe scoliosis)
Causes:



Idiopathic (85% of cases)
Underlying neuromuscular disease,
leg-length discrepancy, birth
defect, fetal development
(congenital)
Not caused by poor posture, diet,
exercise, or the use of backpacks

Diagnosis:

Angle: X-ray



Normal Spine (0
degrees)
Scoliosis: (> 10
degrees)
Complications:
(severe scoliosis)

Lung and heart
damage:
compression of rib
cage against heart,
lungs


> 70 degrees
Back problems
Measure spinal curvature using
Cobb method :
-
Choose the most tilted
verterbrae above & below
apex of the curve.
- Angle b/t intersecting lines
drawn perpendicular to the
top of the superior vertebrae
and bottom of the inferior
vertebrae is the Cobb angle.

General Inspection:
 Scoliosis
Test
Test: Adam’s Forward Bend
 Patient
Position: Standing with hands held in
front (arms straight)
 Evaluation Procedure: Patient bends
forward, sliding hands down the front of each
leg
 Positive Test:
Asymmetrical hump along lateral aspect of
thoracolumbar spine
 One shoulder blade appears more prominent
 Uneven hips

Treatment of scoliosis
•In mild cases: Physical Therapy Intervention
• In moderate cases: Brace treatment &
Physical Therapy Intervention
•In
severe cases:
(correction & fusion)
Surgical
treatment
Brace Treatment for Scoliosis




Most common is Boston brace
(aka Thoraco-lumbar-sacral
orthosis)
Braces have 74% success rate at
halting curve progression (while
worn)
Bracing does not correct scoliosis,
but may prevent serious
progression
Usually worn until patient reaches
Risser grade 4 or 5
Brace Treatment for Scoliosis


Of patients with 20 º - 29 º
curves, only 40% of those
wearing braces ultimately
required surgery, compared to
68% of those not wearing back
braces
Length of wearing time
correlates with outcome (At
least 16 hrs per day leads to
best chance of preventing
curve progression)
Pre/ Post Brace Comparison
Pre Brace X-Ray
In Brace X- Ray
TREATMENT GUIDELINES
Precautions:
Osteoporosis
• Post- Surgery
• Juvenile Hypermobility Syndrome (JHS)
• Osteogenesis Imperfecta
• Spondylolisthesis
•
Contraindications:
Reactive Scoliosis (tumor, disease, etc)
• Inflammatory diseases- during active phase
• Psychiatric Issues
•
Exercises



An effective regimen of exercises for scoliosis
must follow careful diagnosis of which muscle
groups in a patient's body are too weak, and
which are overdeveloped and tight.
Then the therapist designs a program to restore
normal balance.
Each person's scoliosis deformity is somewhat
unique, so a therapist tailors the scoliosis
exercises individually

They are shortened (blue), less
elastic and less freely movable
compared to the other side,
which are lengthened (red).

Deformation of the skeleton
causing nerves to become
trapped and eventually causing
pain



The regimen of muscle-strengthening and
stretching exercises aims to derotate and
elongate the spine back into its normal position.
The patient must do the scoliosis exercises for
about 1/2 hour daily. Patient compliance is
extremely important, and it's hard work
The Schroth method gives a patient the
knowledge and tools to control her or his own
postural health, lifelong
Schroth scoliosis exercises



The goal of Schroth scoliosis exercises is to
practice moving the body out of its unbalanced
state
past the longitudinal axis towards the opposite
side,
until the brain is correctly reprogrammed and
the patient is able to sit and stand straight
upright..
Schroth Exercises
Semi-Hanging Sagittal Plane
Prone on Knees-Transverse Plane
Anterior Gravity Assisted
Schroth Exercise
Supine Gravity Assisted- Transverse
Plane
Standing 3D Correction
Sagittal Plane Correction
Visit 1
Visit 3
Exercises Using Schroth
Principles
Exercises Using Schroth Principles
Visit 1 - Uncorrected
Visit 3 - Corrected Posture
Exercises – Sport Specific and InBrace
Sport Specific Training In Corrected
Posture
Visit 2
Sagittal Plane Correction
Sagittal Correction
Psoas Stretch
Stretching- Stabilization
Supine Hamstring Stretch
Scapular / Core Stability
Sagittal Correction
Visit 1
Visit 6 - 2 month follow up
Surgical Treatment for Scoliosis




Curves in growing children greater than 40 º
require a spinal fusion (Risser grade 0 to 1 in
girls and Risser 2 or 3 in boys)
Skeletally mature patients can be observed until
their curves reach 50 º
Posterior spinal fusion is best choice for thoracic
curves
Anterior spinal fusion is best treatment for
thoracolumbar and lumbar curves
Thank you
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