I hope the future chiropractor will be recognized for slowing down the degenerative process. I think we can all agree that joint hypermobility can lead to degeneration in the joints. If we recognize this, then one of our treatment goals should be addressing hypermobility in the joints. Improving or restoring optimal muscle length via motor control strategies will help slow the path to degeneration.
Over the years, I have progressed from only utilizing motion palpation to determine hypomobile and hypermobile segments to incorporating functional movement analysis, then to prescribing treatment that can not only decrease pain, but also increase overall movement ease and efficiency. About 50-60 percent of my patient time is spent teaching corrective exercise. But it all starts with basic postural analysis and then transitions to movement analysis.
The Consequences of Posture (Both Good and Bad)
Any abnormal posture or movement pattern causes forces to be dissipated improperly. Muscle imbalances and joint dysfunctions associated with poor posture can create areas of excessive motion in certain spinal segments, causing instability. These areas may then wear out prematurely, while other areas may have too little motion in the spine, causing range-of-motion / mobility dysfunctions. Either way, the nerves will have abnormal tension placed on them, which can cause inefficiencies within the neuromusculoskeletal system.
Overactive muscles and underactive muscles can cause asymmetry, and anytime we have an asymmetry in the body, we are more susceptible to injury. Poor posture can cause incoordination of muscles and balance systems of the body. On the other hand, good posture provides less muscle and soft-tissue tension stress on joints, facilitates proper neural messages, promotes normal growth, and prevents injury and overuse trauma. Good posture allows us to look our age, whereas poor posture makes us look older. I think one of the reasons actors and actresses have "presence" when they walk into a room is because many of them have been trained in proper posture – they have mastered the art of appearance.
After the static postural analysis, I think we should transition into functional movement assessments. I think chiropractors are really good at evaluating motion at each region of the body (cervical, thoracic, lumbar, etc.), and at individual joints and segments. Functional movement assessments allow the practitioner to prescribe corrective exercises designed to improve motor control strategies.
Faulty Movements Leading to More Faulty Movements
Pain is a poor correlate of tissue damage, yet most people still believe there is a linear relationship between the two. Using a functional movement system analysis helps me understand when rehab should begin, as well as when treatment is complete. For my practice, some of the criteria I use to guide my treatment decisions are: 1) What stage is the physiological process of healing at? Is it complete or not? (This may be based on time.) 2) Have functional movement patterns improved? Movement is the language of the body and good range of motion is a correlate to good function. 3) Have physical performance or activities of daily living been reinstated?
The brain keeps tabs on faulty movements within the body. When we sustain an injury, the brain focuses increased attention on the harmed area. If the body is not completely healed and you still feel something "isn't right," maybe the brain is looking after us because it perceives that the threat of further injury (or re-injury) is still high.
If the patient comes in and says, "It doesn't hurt anymore, but it feels different" or "I'm aware of it," the brain (neuromatrix) is not satisfied that threat levels have reduced and it has not "turned off" its surveillance. To an athlete, this kind of body surveillance can lead to game-time anxiety – poor skill execution or poor movement patterns. If your patient is a runner, this could cause hesitation in going "full out." If the patient is a golfer, this could lead to tentativeness (or unwillingness) to perform swings to full range of motion, and they may adopt sloppy form. You can see how this could lead patients to frustration. Feeling whole in your own skin (emotionally and physically) is the proper foundation for good posture.
How do we help our patients go from "surveillance" to the "end" of active care/rehab without any feelings of surveillance? When I went to Los Angeles College of Chiropractic, I used Gray's Anatomy as "the book" in anatomy lab. I learned that each muscle had an origin, insertion and usually a single action. What a huge disappointment from the way I view the body now. Here's an example of a treatment plan for a patient with kyphotic-lordotic posture who just never seemed to feel "right."
A Sample Treatment Plan
Evaluation: A 35-year-old male presents with chronic low-grade neck-shoulder pain and interscapular region pain/ache. Static postural evaluation revealed a forward head posture, increased cervical lordosis, increased thoracic kyphosis, elevated and protracted shoulders, and abduction and "pseudo-winging" (the inferior border of the scapula had slight winging, not the entire medial border) of the scapulae. The lumbar spine had slightly increased lordosis and there was anterior pelvic tilt. The hip joints were slightly flexed, the knee joints slightly hyperextended and the ankle joints slightly plantar flexed.
Muscle evaluation revealed overactive mobilizers: scalenes, SCM, splenius, pectorals (major/minor), levator scapulae, upper trapezius, rhomboids, hyoids, hip flexors and quadriceps. Inefficient stabilizers: deep neck flexors, semispinalis/multifidus, suboccipitals, rotator cuff, upper/mid/lower trapezius, serratus anterior, external obliques and hamstrings.
I used many functional assessments on this patient, but one (a favorite for many patients) involved having him perform the overhead deep squat. I can find out if this causes pain or no pain and easily assesses the ankles, knees, lumbopelvic-hip complex and shoulders. The deep squat creates a filter for movement dysfunction, and demonstrates movement compensations and asymmetries. The squat allows me to focus on the most limited area of movement and determine if the patient has mobility and/or stability problems.
Treatment: The treatment approach for this patient was strengthening the weak muscles, especially the deep neck flexors, the transverse abdominals and multifidus, and the middle/lower trapezius. The hamstrings were long and weak and needed strengthening. Stretching of the tight global muscles – the hip flexors, quads, neck extensors, and lumbar extensors – was required on a daily basis.
The patient was taught how to establish neutral pelvic tilt and thoracic extension postural positions. He was instructed to avoid slouch of the thoracic spine, and I cued him to maintain a "tall spine" and maintain a chin-in / head-up posture. For gait, he was instructed to bend the knee as part of the leg-swing movement and increase his stride length.
Specific exercises:
- Foam rolling the thoracic spine for two minutes daily.
- Stretching the cervical extensors: chin drops progressing to hand-assisted stretches.
- Stretching the pectoralis muscles: switching weekly from unilateral to bilateral stretches.
- Strengthening the shoulder retractors: standing shoulder pullbacks with a band, progressing to heavier free-weights and kettlebells.
- Strengthening deep cervical flexors: lying chin tucks progressing to lying chin tucks with a head piece raised for prolonged periods of time.
- Cervical extension dynamic isometric (sitting) exercise. I instructed the patient to begin by sitting with a loop of band securely attached on one end, and the loop around his head; then (while keeping his back and neck straight) to slightly lean forward from his hips, moving his head about 10 cm forward. He was instructed to hold that position and then slowly return to the starting position, keeping his neck straight and moving with his shoulders.
- Y-T-V-L drills were performed for mobility and strengthening of the thoracic extensors.
- I introduced him to yoga poses and I recommended a yoga DVD so he could perform the poses on an every-other-day basis.
Strengthening exercises were performed for three sets of 12 and stretches were held for three sets of 30 seconds. The program was repeated four times a week at home.
Because this patient was sitting slouched in front of his computer for hours every day at work, he was also instructed to use a specific device at home to improve thoracic extension. This device employs the force of gravity to gently stretch the spine. It opens, stretches and relaxes the upper back, shoulder and neck area. He was told to relax and breathe into the rib cage for chest expansion as deeply as possible for 5-10 minutes at a time, twice a day.
Prioritize Function
We were not taught integrated muscle action in anatomy class. Rarely do muscles act in isolation; they work together in an integrated or chain action. Muscles are an accident of dissection – the brain doesn't think in terms of isolated muscles. It's too bad I wasn't learning yoga back in chiropractic college in the early '80s; my first patients could have practiced yoga like those I treat today. Now, my patients learn that yoga can create a softening of poor postural habits and movement patterns. It's taken me years to figure out how to coach patients on how to let go of old movement patterns, damaging postural habits and stressful dietary addictions. (By the way, these are the topics I feel I need to address in future articles.)
In my attempts at helping patients learn new patterns of movement, restore normal range of motion, and correct skeletal malpositions (or whatever you want to call it), muscular balance around the joints, and the motor behavior of the muscles involved, I want to make it absolutely clear that the goal is to improve function, not just appearance.
This is part 9 of an ongoing series on posture evaluation / correction that began in the March 12, 2010 issue. Search for parts 1-8 using the search phrase "Tucker posture evaluation."
