posture

Prof.Dr. Mahmoud Ewidea

Professor of physical therapy
Chairman of basic science department
 Course Description
(Therapeutic exercise ǁ) (2019 – 2020)

1
Introduction To posture
analysis
2
Clinical analysis of posture

3 Clinical analysis of posture

quiz Case study
4
Spinal mobilization 1
5
Spinal mobilization 2
 Course Description
(Therapeutic exercise ǁ) (2019 – 2020)

6 Proprioceptive training (quiz 2)

7
Piriformis Muscle Syndrome

8
Neural mobilization 1

9
Neural Mobilization 2 (Quiz 3)
10
11 Muscle energy techniques,Revision,
Proplem solving
Posture

 Posture is a “position or attitude of the body

either with support during muscular
inactivity, or by the means of the co-
ordinated action of many muscles working to
maintain stability or to form an essential
basis which is being adapted constantly to
the movement which is supper-imposed
upon it.
POSTURE
 POSTURE acronym for
east reference:
 P:- Pelvis is neutral,
with weight distributed.
 O:- On the whole foot
 S:- Stable joints.
 T:- Tight abdominals.
 U:- Upright ribs.
 R:- Retracted midway
shoulders
 E:- Ear same level over
shoulder
Types of Postures

There are two types of postures:

1. Inactive postures 2. Active postures

Static postures

Dynamic postures
Inactive Posture

 Attitude adopted for resting or sleeping.

 All essential muscular activity reduces to

minimum.
 Used for training general relaxation.
Active Postures

Integrated activity or action of many muscles

is required to maintain active posture.
 It may be

Static posture Dynamic posture

Static and dynamic posture
Static posture Dynamic posture

 The body and its  The body and its

segments are aligned
and maintained in
certain position.
 Constant pattern of
posture.
 E.g.: Standing, lying  E.g.: Walking, running,
and sitting.

segments are constantly
modified and adjusted to
meet the changing
circumstances which
arise as the result of
movement.
jumping, throwing and
lifting.
Posture Assessment
 The examiner must be able to
separate the parts of the body from
the whole and in turn assess the sum
of these parts, in reference to their
interaction in the entire anatomical
structure.
 In correct posture, the gravity line

passes through the axes of all joints,

.Cont
 Therefore, the closer a person’s
postural alignment lies to the
center of all joint axes; the less
gravitational stress is placed on
the soft tissue components of the
supporting system.
Principle of assessment
 principleamong muscles involved in
the three cardinal planes of motion.
When a force couple is out of balance,
the segment moves off its axis of
rotation and there is faulty joint
motion.
 The head, trunk, shoulders and pelvic

girdle serve as the foundations, from

which forces are directed to the limbs.
 Postural faults can be used as
guidelines for identifying alterations in
muscle and ligament length.
 This may occur when one muscle

groups becomes tight and the

antagonist elongated. Synergistic
muscles around a joint may be
unbalanced as well as the agonists.
The Postural Mechanism

The Nervous
Muscles Control

Interaction
between muscles
and nervous
system
muscles
 The intensity and distribution of the muscle
work which is required for both static and
dynamic postures varies with the pattern of
the posture and the physical characteristics of
the individuals.
 The group of muscle are used to maintain the

erect position of the body, by working to

counteract the effects of gravity. They are
known as anti-gravity muscles.
 These anti-gravity muscles present certain
structural characteristics to perform function
with efficiency and the minimum of effort.
 Posture maintaining muscles contain more of

red muscle fibers, which are slowly

contracting and not easily fatigued.
 Nervous Control
 Postures are maintained or adapted as a
result of neuromuscular co-ordination, the
appropriate muscles being innervated bye
means of a very complex reflex mechanism.

The Postural Reflex

O An efferent response to an afferent stimulus.

O The afferent response in this instance is a motor one, the
anti-gravity muscles being the principal effector organs.
Cont. nervous control
 Afferent stimuli arise from a variety of
sources all over the body, the most important
receptors being situated in the muscles
themselves, the eyes and the ears.
 The Muscles
 The Eyes
 The Ears
 Joint Structures
.Cont
 The Muscles: Neuromuscular and
neurotendinous spindles within the muscles
record changing tension.
 The Eyes: Visual sensation records any

alternation in the position of the body with

regard to its surroundings.
 The Ears: Stimulation of the receptors of the

vestibular nerve results from the movement

of fluid contained in the semicircular canals
of the internal ear.
Lower crossed
syndrom
Upper crossed syndrome
Upper and lower crossed syndrome
X ray of bad posture
stretch weakness

stretch weakness
 A form of positional weakness in which the 

apparent weakness of a muscle results from 
prolonged  positioning in alengthened position,
 thus  shifting 
the muscle lengthtension curve to the  right.
 
 This phenomenon is observed when the force

production of the lengthened muscle is limited 
when it is tested in a relatively short position. 
Patient care
 Care must be taken in positioning when testing for

 muscle force production. To assess strength 
accurately, 
 muscles should be tested in their actual or

functional positions or through their range of

motion.
muscle that is chronically elongated
 A muscle that is
chronically elongated
adds sarcomeres.
Over time, its resting
length increases
(from l0 to l1) and its
length-tension curve
shifts rightward.
muscles that is chronically shortened
 A muscles that is
chronically shortened
loses sarcomeres. Over
time, its resting length
decreases (from l0 to l1)
and its length-tension
curve shifts leftward.
:stretch weakness condition
 Minor alignment faults in posture limit
motion and lead to tightness of
muscles and other soft tissues.

 Muscles that are elongated often

develop their maximal force in the
stretched position and are weak in the
normal physiological position. Kendall
calls this condition stretch weakness.
systematic approach to postural
analysis
1. Postural assessment must be performed
with the subject minimally clothed.
2. The examiner should instruct the subject to
assume a comfortable and relaxed posture.
3. Subjects who use orthotic or assistive
devices should be assessed with and
without them to determine their
effectiveness in correcting posture.
4. The examiner should note relevant medical
history.
Cont. protocol of assessment
5. complete description of present symptoms.
6. All previous treatments for the presenting
postural complaints, including orthopedic
and neurological therapy.
7. The upper limb dominance of the subject.
Posture Analysis and
clinical implication
 EYE DOMINANCE
 It is important to realize that the examiner's
peripheral vision is used for judging the body
bilaterally. This is true in posture analysis as
well as in the physical examination.

 for instance, bilateral motion of the rib cage

is assessed. If the examiner has a dominant
eye, the reclining patient should be observed
with the dominant eye over the midline of the
patient's body. 
Shoulder girdle
1. note the prominence, rotation, or tilting of
the inferior angles of the scapulae.
2. The cervicobrachial spine is always scoliotic
toward the side of the high shoulder.
3. Note the distance of the scapulae vertebral
borders from the spine.
4. If the shoulder is high on the right and the
scapula flares on the right, the entire
cervicobrachial and thoracic spine is
scoliotic toward the right.
Cont. shoulder
 If the shoulder is high on the right ,the left
scapula flares, the cervicobrachial spine is
scoliotic to the right and the midthoracic
spine is scoliotic to the left. 
Cervical scoliosis
Comment on this
photo
Find Proplem and
give treatment
Thoracic
1. From the front, observe any signs of hollow
chest, sternal or rib depression, or pathologic
signs such as funnel chest, barrel chest, or
pigeon chest.
2. note the contours of the trapezius muscles
for normal development or for abnormal
tightness or tenderness.
3. Note the angles of the ribs.
4. A difference in the height of the scapulae and
the iliac crests usually indicates a scoliosis.
Cont. thoracic
5. Lateral positions of the spinous processes
and anterior or posterior positions of the
transverse processes together with an
elevation of the angles of the ribs indicates
a rotation of vertebrae.
Rotation of vertebrae in scoliosis
Rotation of spinal vertebrae
Funnel chest
 Pectus excavatum, also known as sunken
or funnel chest, is a congenital chest wall
deformity in which several ribs and the
sternum grow abnormally, producing a
concave, or caved-in, appearance in the
anterior chest wall.
Funnel chest
Pigeon chest
 Pectus carinatum is a rare chest wall
deformity that causes the strnum to push
outward instead of being flush against
the chest. It is also known as pigeon chest or
keel chest. When the chest wall develops, the
cartilage that connects the ribs usually grows
flat along the chest.
Pigeon chest
Barrel chest
 Arthritis can stiffen the chest causing the ribs
to become fixed in their most expanded
position, giving the appearance of a barrel
chest. Barrel chest also refers to an increase
in the anterior posterior diameter of
the chest wall resembling the shape of
a barrel, most often associated with
emphysema.
  .Abdomen
 From the side, check the degree of
abdominal muscle relaxation.

 Keep in mind that children normally

have a prominent abdomen and adult
women have a deposit of superficial
fat lying transversely below the
umbilicus. 
spine
1. From the side, check the curvatures of the
spine. Evaluate as normal or abnormal;
lordotic or kyphotic.
2. Note the degree of sacral tilt and
lumbosacral angle.
3. compare the line of the spinous processes.
Bear in mind the possibility of a spinous
process being asymmetrical, deviated to the
right or left, without the body of the vertebra
being involved. Evaluate any degree of
scoliosis. 
.lumbosacral angle
pelvise
1. A low and less prominent iliac crest will be
best observed from the front.
2. Note the comparative height of the iliac
crests and greater trochanters. Check the
comparative height and depth of the sacral
dimples, the position of the gluteal cleft,
and the bilateral buttock height.
comparative height of the iliac crests
.and greater trochanters
How can differentiate between
degenerative disc and
?sacroiliities
.Cont
 If chronic sciatic neuralgia is on the high iliac
crest side, degenerative disc weakening with
posterolateral protrusion should be
suspected.
 If it occurs on the side of the low iliac crest,

one must consider the possibility of a

sacroiliac slip and lumbosacral torsion as
being the causative factor. 
Clinical implication of iliac crest
position
Clinical implication of iliac crest
position
BODY BALANCE AND EQUILIBRIUM

 Active and Passive States. 

   Positions of the body that require muscular
forces to maintain balance are said to be in
active equilibrium, while those that do not
require muscular effort are in passive
equilibrium.
 In passive equilibrium, all segmental centres
of gravity and the centres of all joints fall
within the gravity line of the body which must
fall within the base of support.
When the forces of gravity on a body are in
a balanced position,
the pull is equal on all sides about the
centre of gravity.
Static and dynamic
posture
INDIVIDUAL DIFFERENCES IN STANCE
POSTURE
1. Racial Differences. 
2. Weight.
3. Height
4. Military Postures
5. Pelvic Tilt
6. Effects of Pregnancy
7. Effects of High Heels
8. Occupational Effects
9. Shoes.
 Faulty and
good sitting
Relaxed sitting position
 In the relaxed sitting position, the head is
held erect, balanced over the neck, with the
head's centre of gravity situated slightly
anterior to the atlanto-occipital joint.

 Body weight should be supported upon the

ischial tuberosities and the adjacent soft
tissues
Faulty sitting
 Disc Pressure.   Lumbar IVD pressure is
increased during sitting as compared to
the erect posture. The reason for this is
that disc pressure increases with the
tendency toward lumbar kyphosis.
 This increased pressure while sitting

can be diminished by arm rests on the

chair, back support to maintain:
lumbar lordosis, and reclining the back
of the chair from 90°–100°.
Faulty sitting

COG move increase

posterior to Muscle fatigue lumbar
ischium kyphosis

Strain on Minor stress

Increase IVD
posterior pressure
which lead to
ligament Disk prolapse
DIAGNOSTIC STANCE AND
SWING CLUES
Heel strike
Inability of a foot to heelstrike is an indication
of a heel spur and associated bursitis or a
blister.
 Failure of the knee to fully extend during

heelstrike is a sign of weak quadriceps or

a flexion fusion of the knee.
 A painfull heelstrike, that usually associated

with knee hyperextension, is a frequent sign

of weak hamstrings.
Pain and its effects
on Gait
ANTALGIC GAITS
A limping may be a sign of disease,
malfunction, or both. It may also be in
compensation to another condition
such as a sprained ankle, injured knee,
old fracture malunion or hip surgery.
 However, the majority of limps seen

are those described as "guarded"

limps.
Guarded limps
 frequently point to specific
musculoskeletal disorders. These
limps are the result of the patient
walking in a manner that protects or
relieves stress upon an area that
would otherwise be uncomfortable or
painful.
 .Mid spinal and Bilateral Spinal Pain
 When pain is in the midline of the
spine, the gait pattern is guarded,
symmetrical, slow, with a short
stride and restricted trunk
rotation and pelvic tilt.
 Unilateral Spinal Pain. Walking in a stooped
position with one hand supporting the back is
a frequent sign seen in a lumbar lesion. During
both stance and swing in mild or moderate
irritations, the trunk usually leans toward the
affected side in compensation to muscle
splinting.
 However, in pronounced intervertebral
disc or sacroiliac lesions, the lean is
usually away from the site of irritation
to reduce pressure.
 Aetiology of Postural Faults
 (1)   gravity; 
 (2)   environment, eg, occupation, weather; 
 (3)   architecture of the vertebral column,

upper and lower appendages, organs and

tissues that attach to or are suspended from
the spinal column; 
 (4)   pathology, 
 (5)   emotional states, 
 (6)   pain.
Basic Physiologic Reactions to Postural
Faults 
 Poor posture from habit, disease, or
abnormal reflexes results in constant
structural malalignment which allows a
disproportionate amount of weight and
muscle pull to fall upon some parts.

 This alters the normal locomotion

apparatus and functions of the internal
organs as well.
 Strength
and
endurance

Bad habit
Posture
and
fault
stress

strain Exhaustion
Musculoskeletal Disorders may result
.from posture fault
Increase IVD • Respirator •
pressure y disorders

Generalized
neuralgia weakness
and fatigue

Intrafascuilar Trigger
adhesions points
Fatigue and strain • Circulatory •
disorders
VISCERAL IMPLICATIONS

 It is unwise to consider the various

parts of the body as separate entities.
All parts share responsibility in the
orthograde posture.
 Any disturbance in one part causes an

immediate and definite functional

change in other parts.
 Extreme curvature and malalignment produce
physiologic changes and are considered to be
pathologic.
 but how much deviation is possible without

causing severe impairment of health?

poor body mechanics & viscera
poor body mechanics predisposes to
certain visceral disorders; ie, the viscera
are held in their optimum position for
function in good body mechanics.
 If mechanics are good, the abdominal

cavity is shaped like an inverted pear

with adequate space above L4 for the
abdominal viscera of an intermediate
body type.
  .The Stomach
 With the stomach lying mainly to the
left of the spine and supported by a
diaphragmatic attachment behind the
transverse sagittal plane, there is little
tendency for downward displacement
if there is rib cage deformity or
abdominal muscle weakness.
.The Liver
    The liver is generally posterior to the
transverse sagittal plane. It is partly
supported by the surrounding organs and its
attachments to the diaphragm, but most of
its weight is borne by the concave space at
the side of the spine and by the curves of the
lower ribs.
.The Kidneys
    The kidneys normally rest in definite
depressions which begin around the
level of L4 and are supported by the
psoas muscle, quadratus lumborum,
and retroperitoneal fat.
Posture fault and kidney position
  .The Colon
The attachments of the hepatic and splenic
flexures of the colon are external to the
kidney and attached to the posterior surface
of the abdominal cavity.
 About 87% of the weight of the abdominal

organs is borne by the psoas shelf and the

muscles of the abdominal wall.
Digestive Disturbances
Mild digestive symptoms may be present in
the apparently healthy person.
 This is sometimes traced to a degree of

visceroptosis which results from dysfunction

of the displaced organs.
 This is most likely the outcome of stretching

of the sympathetic nerves. that stretched

nerves within involuntary or voluntary
muscles.
Digestive Disturbances
 when the abdominal cavity becomes
shortened longitudinally, the viscera
become crowded as do the glands of
internal secretion and the nerve
ganglia as well.
 Thus, orthostatic albuminuria,
dysmenorrhea, and constipation may
sometimes be associated.
 .The Diaphragm
 The Diaphragm.   the chest held high is important
because the anterior mediastinal ligaments attached
to the diaphragm originate in the deep cervical fascia
and are attached to the lower cervical vertebrae.
 When mechanics are poor, proper coordination of the
muscles of respiration is lost. This abnormal position
may decrease vital capacity by more than half.
 Venous and lymphatic return is greatly assisted by the
rhythmic contractions of the diaphragm. When the
diaphragm has been lowered, it has a much shorter
range of excursion and is thus much less effective as
a circulatory aid.
Diaphragm
Scoliosis
 Lateral curvature of the spine.
 Scoliosis usually involves the thoracic and

lumbar regions.
 C curve or S curve.
 Structural or non structural
 There may be asymmetry in the hips, pelvis,

and lower extremities.

Scoliosis
Structural Nonstructural
scoliosis Scoliosis
 involves an irreversible  involves an reversible
lateral curvature with lateral curvature
fixed rotation of the without rotation of
vertebrae. the vertebrae.
 Rotation of the  No rotation of
vertebral bodies is vertebral bodies.
toward the convexity of  A posterior rib hump
the curve.
is not always
 A posterior rib hump is
detected on forward
detected on forward
bending test
bending in structural
scoliosis
sciliosis
Diagnosis of sciliosis
 1. Subjective evaluation of patient in a
standing position. Physical asymmetry is
examined in the following areas:
 a. Shoulder height
 b. Scapular position
 c. Chest area, pelvic and hip joint position
 d. Lateral deviation of the spinal column
 2.Forward
bending test
The forward bend
test is a test used
most often in
schools and
doctor's offices to
screen for
scoliosis. During
the test, the child
bends forward
with the feet
together and
knees straight
while dangling the
arms. Any
imbalances in the
Plump line test
Lateral bending
test
Scoliometer
1. Between 15 and 20
degrees: Some studies
say that the patient
does not require any
specific treatment
2. Between 20 and 40
degrees: An
orthopedic doctor will
generally prescribe a
back brace to keep the
spine from developing
more of a curve.
3. 40 – 50 degrees or
more: Surgery may be
required

X-rays (COBB angle)

Scoliosis treatment
 Positioning
 Strengthening
 Stretching
 Abdominal and back exercises
 Static exercises which also make use of body

weight (various “hanging” and traction

exercises) for releasing tension along the
spine.
 Electrical stimulation
 Bracing Milwaukie or Boston brace
 Milwaukie  Boston
Kyphosis
 Kyphosis is the name given to a postural
disorder in which the curve of the
thoracic vertebrae is exaggerated and the
shoulders and head assume a forward tilt
 shortening of the thoracic muscles and

weakness of the upper back muscles and

scapular adductors. Exaggerated curves
are also likely to develop in the cervical
and lumbar spine areas as compensatory
processes.
Functional disturbances
 1. Diminished optimal functioning of internal
organs, mainly in the chest area
 2. Difficulties in motor functioning (as a

result of movement limitations)

 3. Tension and discomfort in the neck and

shoulder girdle because of excessive muscle

tone.
Possible causes of kyphosis
 Pathologies of the spinal vertebrae (e.g.,
kyphosis during adolescence caused by
Scheuermann’s Disease, which affects the
secondary growth center of vertebral bodies)
 Imbalance between antagonist muscle

groups.
 Psychological factors, such as emotional

stress and low self esteem.

 Low body awareness and faulty movement

habits in daily activities.

Main areas of treatment of kyphosis
1.Exercises to maintain normal pelvic position –
to create a basis for correct alignment of the
spine.
2.Exercises to stretch and lengthen the chest
muscles (pectoralis major/pectoralis minor) the
chest muscles are essential for good range
3.Strengthening the upper back muscles, the
deep erector spinae and the shoulder extensors
4.Breathing exercises for increasing range of
respiration