Continuing our discussion from part 1 of this article [March 2018] on assessing more challenging causes of forward head posture, check the pelvis for asymmetrical quadratus lumborum (QL) and lats. The lats connect to the pelvis and the shoulder. Tight lats can cause forward shoulder syndrome and decrease shoulder motion just to keep the pelvis in check. Breathing by using the accessory muscles can cause the QL and other muscles that depress the rib cage to be overactive.2 A tight QL and tight lats can prevent the right or left mediastinum from expanding during normal respiration, causing the accessory muscles to be overactive.
Continue to reduce bad input (levator scapula with associated contralateral inferior oblique capitis) via restoration of right apical expansion. You know you are on the right track if nerve tension reduces significantly with each session. In some particularly difficult, unresponsive UCS cases, you may need to rule out a dental and/or vision issue.
The repetitive inefficient diaphragm breathing mechanics, with resultant recruitment of the accessory muscles, can perpetuate the UCS postural distortions. Review the polyarticular chain: diaphragm, iliacus, psoas, tensor fascia lata, vastus lateralis and biceps femoris. The SCM and scalenes can become overactive and hypertonic when accessory muscle recruitment for breathing is used, rather than diaphragmatic breathing mechanics.2
Overactivity of the scalenes and SCM leads to elevation of the clavicle and the first rib (potential causes for thoracic outlet syndrome), as well as forward head posture, forward and internally rotated shoulder position, and changes in the upper extremity kinetic chain.2
How to Break the Cycle
On day one of my examination, I may teach patients postural re-education, kinesthetic awareness and mental visualization in combination with diaphragmatic breathing to re-establish proper movement mechanics.2 The first exercise Patel and Patel2 describe is a simple visualization exercise while performing diaphragmatic breathing.
Visualization During Diaphragmatic Breathing
Ask the patient to lie supine on a treatment table or the floor, either with knees straight or in a hook-lying position (knees bent with the soles of the feet flat on the surface), and place one hand on their abdomen just below the umbilicus. Then instruct them to continue breathing through their nose while you determine whether the movement (rise and fall) originates from the abdomen or the chest.
Next, ask the patient to visualize filling up a balloon in their abdomen during inspiration, causing the hand to rise; and then to visualize the diaphragm flattening as they exhale in a slow and controlled manner, allowing the hand to fall.
The recommended progression for this exercise is for the patient to lie supine on a stability ball to create gentle traction on the abdominal muscles. It is believed that the gentle traction will provide a degree of kinesthetic awareness to the proper movement of the rib cage during breathing.2
Body Imaging for Posture Awareness
Giving patients a posture lesson to re-educate proper static posture is time well-spent. It is believed that many individuals who exhibit postural distortions have a distorted view of both their own posture and internal awareness of their body's positioning.2 These occurrences happen over time as a result of movement compensation following a traumatic incident or injury. Substitute postural patterns give the individual a sense of normality when posture is affected by injury or trauma.
My static posture evaluation becomes an awareness lesson for patients whose sensory input has changed to allowing them to think their abnormal posture deviation is normal. Proper body alignment imaging or "auto-correction" exercises can be used to re-educate postural control in all planes (sagittal, transverse and frontal).
The body imaging exercise is performed by having the patient stand in front of a mirror with their eyes closed. Ask them to sense the degree of postural sway and the direction of the sway. Still keeping their eyes closed, the patient should begin the exercise by gently swaying to one side and holding that position for several seconds before returning to what they feel is vertical posture.2
It is at this point that the individual should open their eyes and check their posture in the mirror. If they are still off vertical, they should immediately close their eyes and correct their balance and posture using their internal sensory mechanisms.
Patel and Patel2 recommend that this exercise be repeated for a total of three repetitions on each side, as well as repeated with movements in the sagittal plane (forward and backward tilting), and the frontal plane (left and right orientation). Through the practice of sensory awareness over a period of time, the patient's internal sense of proper posture and the external presentation of the mirror image will begin to match.2
Editor's Note: The complete reference for citation #2 appears in part 1 of this article.
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