Postural Assessment in PT

Overview

This segment explores postural assessment in physical therapy, including the definition of posture, its effects, major historical contributors, categories of postural faults, informal assessment strategies, and intervention methods to address postural issues and support better patient outcomes.

Definition and Impact of Posture

• Posture is the alignment of each body segment in relation to adjoining segments.
• Posture both affects and is influenced by factors such as:
  • Joint range of motion
  • Muscle force production
  • Gait pattern and movement efficiency
  • Muscle length
  • Somatic awareness (awareness of body position)
  • Circulation
  • Respiration and breathing efficiency
• Ideal posture centers the body’s mass over its base of support, minimizing stress on joints and soft tissues and requiring relatively low muscular effort to maintain.
• Muscle fatigue leads to postural slump, causing ligaments to provide support. Over time, non-ideal posture results in:
  • Muscular weakness and tightness
  • Reduction in joint range of motion
  • Ligamentous and capsular tissue lengthening
  • Increased risk for joint degeneration
  • Pain and possible progression of underlying concerns
• Postural assessment helps predict impairments related to or causing patient problems, but it’s important not to make assumptions—always confirm with appropriate tests and measures.
• Not all non-ideal postures are abnormal, dysfunctional, or problematic.

Founders of Modern Postural Assessment

Florence Kendall

• Known as the mother of manual muscle testing in physical therapy.
• Contributed significantly to postural assessment theory.
• Developed the concepts of:
  • Stretch weakness: Weakness that results from muscles staying lengthened beyond their normal resting position.
  • Adaptive shortening: Tightness resulting from muscles remaining in a shortened position for prolonged periods.
• Defined three classic postural types:
  • Kyphotic lordotic
  • Flat back
  • Swayback posture
• Emphasized the pelvis’s role in determining postural type.

Vladimir Yanda

• Developed the terms upper crossed syndrome, lower crossed syndrome, and layer syndrome, widely used today.
• Observed that if an anterior muscle group is shortened and tight, the opposing posterior muscle group is lengthened and weak, creating imbalances that lead to functional difficulties and pain over time.
• Specific details:
  • Upper crossed syndrome:
    • Tightness: Pectorals (front); upper trapezius and levator scapula (back)
    • Weakness: Deep neck flexors (front); rhomboids, lower trapezius, and serratus anterior (back)
    • The muscle imbalances form a visible ‘cross’ when viewed from the side.
  • Lower crossed syndrome:
    • Tightness: Iliopsoas (front); erector spinae (back)
    • Weakness: Abdominals (front); gluteus maximus (back)
  • Layer syndrome: Combination of both upper and lower crossed syndromes, resulting in alternating layers of weak and tight muscles through the body.

Postural Faults: Structural vs Functional

• Functional faults can also be influenced by other medical issues:
  • Chronic shoulder injuries affecting scapular mechanics (impacting the neck, shoulder, or thoracic spine)
  • Stroke, which may cause one side to compensate and develop postural changes on the other
  • Chronic foot ulcers altering gait, potentially affecting mechanics up the entire kinetic chain (ankle, knee, hip, low back)

Informal Postural Assessment

• Informal assessment is vital and begins the moment the patient is observed, continuing throughout the visit.
• Patients often unconsciously correct posture if aware they are being watched, so observation outside of formal settings yields valuable information.

Outpatient Setting:

• Observe as patients exit their vehicle, walk into the building, and approach the clinic door.
• Note their posture while sitting in the waiting room, completing paperwork, and after finishing forms—do they remain slumped or sit up?
• Identify if they choose to stand (sometimes seen in patients with back pain who are unable to tolerate sitting).
• Watch their movement and posture as they walk into the exam room, are brought to the gym, and throughout the examination, especially when distracted.

Inpatient Setting:

• Begin observing immediately upon entering the patient’s room.
• Assess whether the patient is lying in bed, sitting in a chair, or standing; note the bed’s elevation and number of pillows used.
• Check if they sit up straight, are propped, lying flat, or elevated, and observe comfort level.
• Note whether the patient is awake, alert, drowsy, or asleep.
• Watch limb posture: is it guarded/protected, or relaxed in an open-packed position? (e.g., pillows under the knee after ACL surgery for comfort, mild hip external rotation)
• Assess mood and affect: are they guarded, stiff, loose, agitated, or relaxed? Are they rushing, disheveled, quiet, or sociable?

Nonverbal Behaviors:

• These behaviors offer additional insight into the patient’s comfort, attitude, and possible pain or distress.

Physical Therapy Interventions

• Not every postural fault is directly linked to the patient's current problem, but address posture if it may impede progress.
• In some cases, postural correction is central; in others, it is less critical.

Key Intervention Strategies:

• Educate patients on the long-term effects of postural faults and how to self-manage after discharge.
• Emphasize ergonomic changes, especially in work or daily environments—patients who return to poor setups (e.g., 8-10 hours of sitting) may negate therapy gains.
• General principle:
  • Stretch muscles that are tight and shortened
  • Strengthen muscles that are weak and elongated
• Predictions made during postural assessment must be confirmed (or ruled out) with formal tests and measures.

Other Medical Interventions:

• Use of orthotic devices or braces when needed.
• Botox injections for muscles with persistent abnormal tone.
• Surgical procedures for certain structural faults as warranted.
• Referrals to podiatrists if foot-related postural issues arise.
• Collaboration with orthopedic physicians, primary care physicians, or pediatricians based on the patient's needs.

Key Concepts

• Stretch Weakness: Weakness resulting from muscles remaining in a lengthened state beyond their normal position.
• Adaptive Shortening: Tightness resulting when muscles remain shortened for extended periods.
• Crossed Syndromes: Muscle imbalances where tightness in one group causes weakness in the opposing group, either anterior-posterior (upper/lower) or in alternating muscle layers (layer syndrome).
• Structural Faults: Originate from congenital, developmental, disease, or trauma-related changes; generally require surgical intervention for correction.
• Functional Faults: Caused by habits or daily activity patterns; usually managed effectively through physical therapy and behavioral change.

Important Reminders

• Posture significantly influences outcomes in physical therapy. Assessing posture and identifying contributing factors is crucial for effective treatment.
• Posture varies among individuals (“a continuum”) and is highly personalized—not every deviation is necessarily problematic.
• Avoid making assumptions based on appearance. Use observations to form hypotheses, and always employ appropriate tests and measures to confirm or rule out possible causes relating to posture.
• Patient education and engagement are key to long-term improvement and maintenance of optimal posture.

Postural assessment is a foundational skill in physical therapy—understanding its complexity, causes, and practical interventions leads to better patient results. Next, the formal assessment methods will be demonstrated.