Posture assessment cpd

This presentation is about Posture assessment

1. Posture Assessment

2. Assessment of posture HIPS H istory I nspection (Observation) P alpation S pecial (Functional) Tests

3. History Was there any history of injury? if so what was the mechanism of injury? If there is h/o had the patient experienced any back injury previously? if so what caused the pain? Is there any posture that relieves pain or increase symptoms? Does the family have any h/o back or anr special problems(congenital abnormalities)?

4. Any Previous illness ,surgery, injury? Any h/o other conditions(connective tissue disorder? Does the foot wear make any difference to the patients posture or symptoms? Age of patient(degeneration changes)? In child ,if growth spurt-when it began?

5. For females, when menarche begin? any back pain during menses? If deformity present-progressive or stationary? Any neurological symptoms? Nature ,extent,type,duration of pain? In children is there any difficulty in fitting clothes?(scoliosis)

6. Any difficulty in breathing? Dominant hand? Any previous treatment? what ?was it successful? Driving, sitting, and sleeping postures Level and intensity of exercise

7. OBSERVATION Considerations Area being used is private, comfortable Patient preparedness Do not inform patient you are assessing posture Use systematic approach Start at feet and work superiorly or vice versa Compare bilaterally for symmetry Your eyes should be at level of region you are observing Note any use of assisstive device Habitual relaxed posture must be examined

8. Asymmetry 1.standing 2.sitting 3.lying( supine,prone ) Presence of muscle wastings Soft tissue/bony swelling /enlargement Scars and skin changes

9. Observation Use of a plumb line Anatomical reference 3 views Lateral ( sagittal plane movements) Anterior (frontal/ transverse plane movements) Posterior (frontal/ transverse plane movements)

10. STANDING Determine patient’s general body type Ectomorph , mesomorph , endomorph Inherited Can indicate a person’s natural abilities and disabilities

11. Plumb line

12. Plumb line test(lateral view) The plumb line is placed just in front of lateral malleolus or through greater trochanter . The individual to be tested is asked to take a few steps in place and then stand still with the feet at approximately the width of the hip joints, the arms relaxed at the side of the body, and the eyes looking forward

13. Plumbline test (anterior view) The feet are equidistant from the plumb line parallelity of the feet standard posture： 3" apart + 10-15°ofabduction of each foot level stance (at 0° of dorsiflexion )： 9° of abduction of the feet wearing shoes (about 15° of plantarflexion )： 3° of abduction of the feet through the midline of the body

14. Plumbline (anterior view)

15. Plumbline (posterior view)

16. Observation and documentation of plumbline measurement

17. Lateral view Head and neck: • Plumb line: The line falls through the ear lobe to the acromion process. • Common faults include: • Forward head: • Flattened lordotic cervical curve • Excessive Lordotic curve

18. Lateral view-Shoulder   Shoulder: • Plumb line: It falls through the acromion process. • Common faults include: • Forward shoulders • Lumbar Lordosis

19. Lateral view Thoracic vertebrae Plumb line: The line bisects the chest symmetrically. Common faults Kyphosis Pectus excavatum (Funnel chest) Barrel chest Pectus cavinatum (Pigeon chest

20. Lateral view Lumbar vertebrae: Plumb Line: The line falls midway between the abdomen and back and slightly anterior to the sacroiliac Joint. Common faults include: Lordosis Sway back Flat back

21. Lateral view Ankle: Plumb line: The line lies slightly anterior to the lateral malleolus , aligned with tuberosity of 5th metatarsal. Common faults include: Forward posture

22. Posterior view Head and neck: Plumb line: The midline bisects the head through the external occipital protuberance; head is usually positioned squarely over the shoulders so that eyes remain level. Common faults include: Head tilt Head rotated Adducted scapulae Abducted scapulae Winging of the scapulae:

23. Posterior view Trunk Plumb Line: The line bisects the spinous process of the thoracic and lumbar vertebrae. Common faults include: Lateral deviation (Scoliosis)

24. Posterior view Pelvis and Hip: Plumb line: The line bisects the gluteal cleft and the posterior superior iliac spines are on the same horizontal plane; the iliac crests, gluteal folds and greater trochanters are level. Common faults include: Lateral pelvic tilt Pelvic rotation Abducted hip

25. Posterior view Knee Plumb Line: The plumb line lies, equidistant between the knees. Common faults include: Genu varum Genu Valgum

26. Posterior view Ankle and Foot Plumb line: The line is equidistant from the malleoli , a line is drawn from the medial malleolus to the first metatarsal bone and the tuberosity of the navicular bone lies on the line. Common faults include: Pes planus ( Pronated ) Pes Cavus ( supinated

27. Anterior view Shoulders: Plumb Line: A vertical line bisects the sternum and xiphoid process. It may be due to: Dropped or elevated shoulder Clavicle and joint asymmetry

28. Anterior view Elbows: Common faults include: Cubitus valgus : The forearm deviates laterally from the arm at angle greater than 15° (female) and 10° (male). It may be due to: Elbow hyperextension. Distal displacement of trochlea in relation to capitulum of humerus . Stretched ulnar collateral ligament. Cubitus varus

29. Anterior view Hip Plumb line: Common faults include: Lateral rotation Medial rotation

30. Anterior view Knee: Plumb Line: The legs are equidistant from a vertical line through the body. Common Faults include: External tibial torsion Internal tibial torsion

31. Anterior view Ankle and Foot: Plumb line: Common Faults include: Hallux valgus Hammer toes

32. OBSERVATION IN SITTING Sitting on a stool without back support Anterior view Lateral view

33. Sitting-Anterior view

34. Sitting lateral view

35. Sitting-Anterior view Note for the knees whether it it at same distance from floor

36. Observation -Lying Supine lying Prone lying

37. SUPINE LYING Position of head,cervical spine and shoulder girdle Chest observed for protrusion( pectus carinatum )or sunken( pectus excavatum )

38. Supine lying Abdomen muscles noted(flabby) Waist angle noted ASIS level Any extension in lumbar spine

39. Prone lying Note position of head neck and shoulder girdle PSIS level Note for the muscles of gluteals,posterior thigh and calf

40. PALPATION In assessment position (i.e., standing), palpate: Laterally ASIS vs. PSIS Anteriorly Patellae Iliac Crests ASIS heights Lateral Malleolar heights Fibular Head heights Shoulder heights - Posteriorly PSIS positions Spinal alignment Scapular positions

41. Functional testing Slump Test Leg length measurement Romberg Tandem walking Others designed to: Rule out bony restrictions Rule out soft tissue restrictions Assess muscular length ROM Resting muscle length

42. Other examination Video Analysis 3D Motion Analysis Sway Measurement Tools Force Plate Biodex Stability System

43. Postural deviations

44. Commonly seen postural deviations Foot & Ankle Hyperpronation Supination Knee Genu Recurvatum Genu Valgum Genu Varum

45. Commonly seen postural deviations Spine Lordosis Sway back deformity Kyphosis Round back humpback/ gibbus Flat back Dowagers hump Scoliosis Non –structural scoliosis Structural scoloisis Idiopathic scoliosis

46. Lordosis Lordosis is an excessive anterior curvature of spine Pathologically it is exaggeration of the normal curves found in the cervical and lumbar spines

47. Lordosis Lordosis causes: Postural deformity Lax muscles (esp. abs) Heavy abdomen Compensatory mechanisms Hip flexion contracture Spondylolisthesis Congential problems Fashion (high heels)

48. Lordosis Observe sagging shoulder Medial rotation of leg Head poking forward The normal pelvic angle(30degree) is increased with lordosis

49. Postural correction exercises- Lordosis Lengthening the muscles that create anterior pelvic tilt and making them more flexible Strengthening and shortening the muscles that create posterior pelvic tilt Learning to control normal pelvic position

50. Swayback deformity Increased pelvic inclination (40) Typically includes kyphosis

51. Kyphosis It is excessive posterior curvature of spine Pathologically it is exaggeration of the normal curve found in the thoracic spine

52. kyphosis Kyphosis Excessive posterior curvature of the spine Round back Humpback/ gibbus Flat back Dowager’s Hump

53. Kyphosis -Round back Long rounded curve with ed pelvic inclination and thoraco lumbar kyphosis O/E Tight (hip ext & trunk flexors) Weak(hip flexors &lumbar extensors)

54. Kyphosis –Hump back/ Gibbus Localised sharp posterior angulation of thoracic spine

55. Kyphosis –Flat back Decreased pelvic inclination (20 degrees) Mobile lumbar spine

56. Kyphosis -Dowagers Hump Older patient Causes-osteoporosis Where thorocic vertebral bodies degenerates and wedge in anterior direction

57. Corrective exercises for kyphosis Exercises to maintain normal pelvic position – to create a basis for correct alignment of the spine. Exercises to stretch and lengthen the chest muscles ( pectoralis major/ pectoralis minor) Strengthening the upper back muscles, the deep erector spinae and the shoulder extensors

58. Corrective exercises for kyphosis Breathing exercises for increasing range of respiration (especially inhalation). In addition to the chest muscles mentioned above, movement of the joints connecting thorax and ribs (the sterno -costal joints) and those linking ribs and vertebrae (the costo -vertebral joints)is of great importance for maintaining chest fl exibility and optimal respiratory functioning

59. Mobility exercises for the thoracic vertebrae (T1–12) on all movement planes, from a variety of starting positions Exercises to increase hamstring fl exibility and thus improve functional pelvic mobility on the sagittal plane (in anterior and posterior pelvic tilt). Awareness and relaxation exercises.

60. Corrective exercises-Flat back Exercise to maintain normal pelvic position – for optimal alignment of the spine and for encouraging anterior pelvic tilt on the sagittal plane • Hamstring fl exibility and lengthening exercises, to improve anterior pelvic tilt • Strengthening hip flexors • Exercise to improve general lower back vertebral mobility

61. scoliosis Scoliosis Nonstructural Structural idiopathic

62. Non-Structural and structural scoliosis Non structural FUNCTIONAL RELATED TO LIMB LENGTH DISCREPANCY NO BONY DEFORMITY SIDEBENDIG IS USUALLY SYMMETRIC FORWARD FLEXION –SCOLIOTIC CURVE DISAPPEARS NON PROGRESSIVE Structural CONGENITAL/ACQUIRED MAY BE IDIOPATHIC BONY DEFORMITY SIDE BENDING –ASYMMETRIC FORWARD FLEXION-SCOLIOTIC CURVE DOES NOT DISAPPEAR PROGRESSIVE

63. IDIOPATHIC SCOLIOSIS 70-85% of all structural scoliosis Fixed rotational prominence on convex side RAZOR BACK SPINE

64. Objective measurement Demographic data, Anthropometric tests Height of acromia Scapula–spine distance S1–acromia distance Biacromial diameter Height of the anterior superior iliac spine (ASIS) Lower limb length

65. Functional tests LATERAL BENDING TEST FLEXIBILITY TEST OF SHOULDER GIRDLE X-rays (COBB angle).

66. Corrective exercies for scoliosis 1.Symmetrical exercises aimed to strengthen back and abdominal muscles and for functional improvement in ranges of joint motion. 2. Breathing exercises to increase lung volume and thorax mobility and flexibility. 3. Asymmetrical exercises for lengthening muscles on the concave (shortened) side, and for contracting muscles on the convex (lengthened) side. Asymmetrical exercises are also designed to encourage specific movement of spinal column vertebrae in desired directions (mainly for moderating or balancing rotation in cases of structural scoliosis). 4. Static exercises which also make use of body weight (various “hanging” and traction exercises) for releasing tension along the spine

67. POSTURAL DEVIATIONS-KNEE Knee Genu Recurvatum Genu Valgum Genu Varum

68. GENU VALGUM Genu valgum , commonly called "knock-knees", is a condition where the knees angle in and touch one another when the legs are straightened.

69. CAUSES OF GENU VALGUM(KNOCK KNEE) Rickets Osteomalacia Rheumatoid Arthritis Muscular paralysis of semimembranosus or semitendinosus Fracture May be secondary to flat foot,  osteoarthritis

70. MEASUREMENT OF GENU VALGUM The degree of knock knee is measured by the distance between the medial malleoli at the ankle when the child lies down with the knees touching each other

71. TREATMENT FOR GENU VALGUM In mild cases of Genu Valgum in young  children , wearing of boots with the inner side of heel raised by 3/8" inch and elongated forward heel (Robert Jones heels) corrects the deformity.

72. TREATMENT FOR GENU VALGUM In more complicated cases, the child requires a supracondyles closed wedge osteotomy . Post operative Physiotherapy Gradual  knee mobilization  is the main part of the treatment.   heat modalities  may be given for  relief of pain . Strengthening exercises  for  quadriceps , hamstrings and  gluteus muscles  are given. When the patient is able to walk, he is given correct training for standing,  balancing , weight transferring and walking

73. GENU VARUM Genu varum (also called bow- leggedness or bandiness ), is a deformity marked by medial angulation of the leg in relation to the thigh, an outward bowing of the legs, giving the appearance of a bow.

74. Due to defective growth of the medial side of the epiphyseal plate. It is commonly seen unilaterally and Seen in conditions such as Rickets, Paget's disease and severe degree osteoarthritis of the knee

75. The degree of deformity is measured by the distance between the two medial femoral condyles when the patient is lying.

76. TREATMENT OF BOW LEGS Generally, no treatment is required for idiopathic presentation as it is a normal anatomical variant in young children. Treatment is indicated when its persists beyond 3 and half years old, Unilateral presentation, or progressive worsening of the curvature. During childhood, assure the proper intake of vitamin D to prevent rickets.

77. TREATMENT OF BOW LEGS Mild degree of deformity can be treated by wearing surgical shoes with 3/8" outer raised and with a long inner rod extending to the groin and leather straps across the tibia and the knee. Corrective operations can also be performed, if necessary. The person would need to wear casts or braces following the operation Post op management same as genu valgum

78. GENU RECURVATUM HYPER EXTENDED KNEE

79. GENU RECURVATUM A defined disorder of the connective tissue • Laxity of the knee ligaments • Instability of the knee joint due to ligaments and joint capsule injuries • Irregular alignment of the femur and tibia • A deficit in the joints • A discrepancy in lower limb length • Certain diseases: Cerebral Palsy,  Multiple Sclerosis , Muscular Dystrophy • Birth defect/congenital defect

80. measure the patient's heel heights. If there is a normal contralateral (opposite) knee to compare to, an increase in heel height can be diagnostic for genu recurvatum .

81. TREATMENT FOR GENU RECURVATUM QUADRICEPS STRENGTHENING EXERCISES IF SEVERE TIBIAL OSTEOTOMY POST OP BRACES LIMITING HYPEREXTENSION

82. POSTURAL DEVIATIONS OF ANKLE Ankle Hyperpronation Supination

83. SUPINATED FOOT High arched foot May at birth

84. HYPER PRONATED FOOT Causes. Bunion deformity Hammer toe Plantar fascitis Tarsal tunnel syndrome Posterio tibial tendon dysfunction