Postural Examination

Dorn Spinal Therapy

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Instead of abandoning the use of exercises in the treatment of scoliosis, attention should be focused on a more scientific approach toward the evaluation and selection of appropriate exercises. Musculoskeletal evaluation should include alignment and muscle tests.

Postural alignment tests, both plumb line and segmental, in back, side, and front views should be included (see pp. 64-77).

Muscle length tests should include, but not be limited to, hip flexor (see pp. 376-380), hamstring (see pp. 383-389), forward bending for contour of the back and length of the posterior muscles (see pp. 174, 175), tensor fasciae Iatae and iliotibial band (see pp. 392-397), and teres and latissimus dorsi (see p. 309).

Muscle strength tests should include back extensors (see p. 181), upper and lower abdominals (see pp. 202 and 212), lateral trunk (see p. 185), oblique abdominal muscles (see p. 186), hip flexors (see pp. 422, 423), hip extensors (see p. 436), hip abductors and Gluteus medius (pp. 426, 427), hip adductors (pp. 432, 433), and in the upper back, the middle and lower trapezius (see pp. 329 and 330).

An essential part of examination is observation of the back during movement. The examiner stands behind the subject, and the subject bends forward and then returns slowly to the upright position. If there is a structural curve, some fullness (prominence) will be noted on the side of the convexity of the curve. The fullness will be on one side only if there is a single curve, (i.e. C-curve). In a double curve, (i.e. S-curve) as in a right thoracic, left lumbar, there will be fullness on the right in the upper back and on the left in the low back area. In a Junctional curve, however, there may be no evidence of rotation in forward bending. This is especially true if the functional curve is caused by lateral pelvic tilt that results from hip abductor or abdominal muscle imbalance.

Curve Convex Right
Mild right thoracic curve

Rotation of the spine or thorax, as seen in scoliosis cases, is observed with the patient bending forward.

For most people, the curves in the spine are "functional"; they do not become fixed or "structural." When curves do become fixed, they also tend to change and become "compensatory"—that is, change from a single C-curve to an S-curve. Usually, a single curve toward the left stays as a left curve in the low back and changes to a right curve in the upper back.

In an ordinary C-curve, the shoulder is low on the side of the high hip. If the shoulder is high on the same side as the high hip, there probably is an S-curve.

In some cases, faulty alignment appears to be limited to the spine. The accompanying figure shows a simple C-curve in which overall plumb alignment of the body is good. SegmentaUy, the right shoulder is low along with the C-curve.

Postural Exam

Mild left thoraco-lumbar curve (C-Curve)

For this patient, a shoe lift is not indicated because the pelvis is level. Exercise is indicated for the right internal oblique and left external oblique by shifting the upper trunk toward the right without any lateral movement of the pelvis.

110 POSTURAL EXAMINATION CHART

Name

Diagnosis Faulty posture, mild scoliosis

Onset

Occupation Student Handedness Right

Age 17

Doctor. Date of 1 st Ex Date of 2nd Ex Height Weight "

Leg length Left —r Right

Side view Back vtew

Devoted It

PLUMB ALIGNMENT

Deviated rt

SEGMENTAL ALIGNMENT

Feet

Knees

Pelvis

Low back

Up back

Thorax

Spine

Abdomen

Shoulder

Head

Hammer loes

Pronated

Med cotai

Hyperext

Leg in postural add

Lordosis marked

Kyphosis

Depressed chest

Total curve

Protruding slight

Forward

Hallm valgus

Supinated

Lat rotat e

Flexed L>R

Rotation

Flat

Flat

Elevated chest Lumbar-Thoracic

Scars

High_

Torticollis

TESTS FOR FLEXIBILITY AND MUSCLE LENGTH

Forward bending Limited 7" 8k Arm overhead elevation Lt 5/, limited Hip flexors Lt Tight Tensor (as lata Lt 5i tightness. Trunk extension Normal range Trunk lat flex To It slightly limited

HS N (2) G S^l.tlght Rt Normal length Rt Tight

Rt Normal length

Low ant arch

Flat long arch

Knock-kne^s slight

Tilt

Kyphosis

Scap 3bducted R>[,

Rotation

Dorsal

Forward

Ant toot varus

Ant.

Post. Deviation slight

Pigeon toes

Tibial torsion

Deviation

Operation

Scap elevated

Cervical-Thoracic

Med rotated

Rotation

TREATMENT

MUSCLE STRENGTH TESTS

G-

Mid trapezius

G+

F+

Low trapezius

F+

N

Back extensors

N

N

Glut medius

G-

N

Glut maximus

N

N

Hamstrings

N

N

Hip flexors

N

G

Tib posterior

N

Weak

Toe flexors

Left

SHOE CORRECTION

3/16r medium bar

(Wide Heell Inner wedge (Narrow heell

Level heel raise

Metatarsal support

Longitudinal support

NOTES 0) &ack flexibility limited slightly in lower thoracic area

(2) Hamstrings normal in forward bending (i.e., angle of sacrum with thigh.) Hs. appear tight in leg raising due to tight hip flexors keeping pelvis in anterior tilt.

HS N (2) G S^l.tlght Rt Normal length Rt Tight

Rt Normal length

SHOE CORRECTION

(Wide Heell Inner wedge (Narrow heell

Level heel raise

Metatarsal support

Longitudinal support

Exerases BK Lying

Knees tend to flex slightly, left>right (probably due to hip flexor shortness).

Exerases BK Lying

Pel tilt and breath X

Pel tilt and leg si X

Head and sh raising (omitj

Shoulder add stretch )(

Straight leg raise (omit)

Hip flex stretch X

Sd Lying Stretch left tensor X Sitting Forward bending

To stretch low bk

To stretch h s " Wall-sitting

Middle trapezius X

Lower trapezius X

Standing Foot and knee ex X

Wall-standing X

Other Exercises stretch toe extensors

In standing, with pelvis stabilized, shift upper trunk slightly toward the right (using left external oblique and right internal oblique abdominal muscles).

Support

Postural Exam

These photographs show faulty alignment, weakness of the lower abdominal muscles, error in testing for hamstring length and normal hamstring length. (See record of examination findings on the facing page.)

SCOLIOSIS AND LATERAL PELVIC TILT

If the pelvis tilts laterally, the lumbar spine moves with the pelvis into a position of lateral curve, convex toward the low side. An actual leg-length difference causes a lateral tilt in standing, low on the side of the shorter leg. A temporary position of lateral tilt can be demonstrated by standing with a lift under one foot.

An example of a muscle problem that was recognized as a contributing cause of scoliosis among patients with polio is unilateral tightness of the tensor fasciae latae and iliotibial band. The effect of such tightness is to produce a lateral tilt of the pelvis, low on the side of the tightness. The existence of unilateral tightness of these structures is not limited to persons with some known etiology; it is common among so-called "normal" individuals.

Less understood but equally important is the fact that unilateral weakness can result in a lateral pelvic tilt. Weakness of the right hip abductors as a group or, more specifically, of the right posterior gluteus medius will allow the pelvis to ride upward on the right side, tilting downward on the left side. Likewise, weakness of the left lateral trunk muscles will allow the left side of the pelvis to tilt downward. These weaknesses may be present separately or in combination, but they occur more often in combination (see p. 74).

In the sitting position, lateral pelvic tilt accompanied by a lateral curve in the spine will result from unilateral weakness and atrophy of the gluteus maximus muscle.

HANDEDNESS IN RELATION TO SCOLIOSIS

Seen frequently among right-handed individuals who also exhibit a functional left curve: pronation of the left foot, tightness of the left iliotibial band and weakness of the right gluteus medius, left hip adductors, and left lateral abdominals. Most people do not develop a scoliosis, but among those who do, there is a predominance of right thoracic, left lumbar curves. There is also a predominance of right-handed people in our society, and many activities and postural positions predispose these people to problems of muscle imbalance that are only discovered by precise and adequate manual muscle testing. Among left-handed individuals, the patterns tend to be the opposite. However, they occur with somewhat less frequency, probably because these people must conform to so many activities or positions that are designed for right-handed use. (Muscle imbalance as related to handedness is illustrated on pp. 74 and 76.)

FAULTY POSTURAL HABITS

It is important to be cognizant of the postural habits of a child in the various positions of the body in standing, sitting and lying. For a right-handed individual seated at a desk to write, the position is one in which the body (or upper body) is turned slightly counterclockwise, the paper is turned diagonally on the desk, and the right shoulder is slightly forward.

Children sometimes assume a side-lying position on the floor or bed to do their homework. A right-handed person will lie on the left side so that the right hand is free to write or turn pages in a book. Such a position places the spine in a left curve.

Sitting on one foot, such as the left foot, will cause the pelvis to tilt downward on the left and upward on the right because the right buttock is raised by resting on the left foot. The spine then curves to the left. __

If a back pack is carried by a strap over the left shoulder and the child keeps that shoulder raised to keep the strap from slipping off, there will be a tendency for the spine to curve toward the left.

Children who engage in repetitive, asymmetrical activities, whether vocational or recreational, are prone to develop muscle imbalance problems that can lead to lateral deviations of the spine.

When the spine habitually curves toward the same side in the various postural positions, it becomes a matter of concern with respect to correction or prevention of early scoliosis.

Not to be overlooked are problems associated with pronation of one foot with one knee slightly bent, if it is always the same knee that is bent. (See p. 448.) Logically, the imbalance in hip musculature and faulty fool or leg positions, which result in lateral pelvic tilts, are more closely related to primary lumbar or thoracolum-bar curves than to primary thoracic curves.

EXERCISES

Exercises should be carefully selected on the basis of examination findings. There must be adequate instruction to ensure that the exercises will be performed with precision. If possible, a parent or other individual in the home should monitor performance until the child becomes capable of doing the exercise without supervision. The object is to use asymmetrical exercises to bring about optimal symmetry.

In the subject below, it has been determined that the right iliopsoas is weak. The subject is a dancer. One of the stretching exercises she performs is a split in which one leg is forward and the other is back. Routinely, the left leg has been forward and the right leg back. There is a left lateral curve in the lumbar region and a right curve in the thoracic area.

Because the psoas muscle attaches to the lumbar vertebrae, transverse processes and the intervertebral disks, this muscle can pull directly on the spine. If the spine is flexible, it can be influenced by exercises, carefully performed, that help to correct the lateral deviation. The exercise is done sitting at the side of a table with the knees bent and the legs hanging down. (It is not done in a supine position.) A strong effort is made as if to lift the right thigh in flexion, but enough resistance is applied (by an assistant or the subject) to prevent movement of the thigh. By so doing, the force is not dissipated by movement of the thigh but is exerted on the spine, pulling it toward the right. (See Figure C below.)

The person who monitors this exercise should stand behind the subject while the exercise is being performed to ensure that both curves are being corrected simultaneously. Because curves vary greatly, close monitoring is necessary to avoid emphasis on the correction of one curve at the expense of the other.

In a right thoracic, left lumbar scoliosis, there is often weakness of the posterolateral part of the right external oblique muscle and shortness of the upper anterior part of the left external oblique. In the supine position, the subject places the right hand on the right lateral chest wall and the left hand on the left side of the pelvis. Keeping the hands in position, the object of the exercise is to bring the two hands closer by contracting the abdominal muscles, but without flexing the trunk. It is as if the upper part of the body shifts toward the left and the pelvis shifts toward the right. By not allowing trunk flexion and by contracting the posterolateral fibers of the external oblique, there will be a tendency toward some counterclockwise rotation of the thorax in the direction of correcting the thoracic rotation that accompanies a right thoracic curve.

It is of particular importance that girls between the ages of 10 and 14 years have periodic examination of the spine. More spinal curvatures occur in girls than in boys, and it usually appears between these ages.

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