Tuesday, November 26, 2019

Part II- Posture, Pain and Clinical Reasoning

Continuing from Part I, the question remains…
How does clinical reasoning apply to postural assessment and treatment?
Let’s start with what posture is. (at least by several definitions)

Posture is:
-A summative visual reflection of how the body has adapted to intrinsic and extrinsic forces, gravity and its external forces in any particular position 1.
-The mobile anatomical history with an individual’s decisions, environmental adaptations, emotional expressions, all into one present moving picture.
- “Posture is the speech of the brain” - Dr. Vladimir Janda
-It is a snapshot and pre-requisite of ANY movement in ANY position. -“Posture follows movement like a shadow” - Sherrington 2
- An inherently dynamic concept
- A quick way of observing the status of the central nervous system and peripheral nervous system by reflection of the musculoskeletal system
Wikipedia Commons by Marchild

So then, what is “optimal” posture?
Per Kuchera and Kuchera, “optimal posture” is:
“a balanced configuration of the body with respect to gravity. It depends on normal arches of the feet, vertical alignment of the ankles, and horizontal orientation (in the coronal plane) of the sacral base. The presence of an optimum posture suggests that there is perfect distribution of the body mass around the center of gravity. . . Structural and functional stressors on the body, however, may prevent achievement of optimum posture. In this case, homeostatic mechanisms provide for ‘compensation’ in an effort to provide maximum postural function within the existing structure of the individual. Compensation is the counterbalancing of any defect of structure or function. “ 3
Basically, it is inferred that “optimal posture” is like “the perfect chocolate chip cookie”. Unrealistic! No such thing. The beauty is in the variations! (they are all perfect) Optimal posture is inherently functional adaptations with appropriately maintained homeostasis. Ideal posture must be held in context to that individual’s functional needs and environmental demands.
Subsequently, postural dysfunctions/deviations are identifiable observations that demonstrate the individual’s incapacity to adapt for maintenance of homeostasis for their functional needs and environmental demands which then may lead to pain, depending on its impact on the movement system. Per Karel Lewit and Pavel Kolar:
“The movement system is the most common source of pain in an organism and, in turn, pain is also the most common sign of a movement system dysfunction. The reason is obvious: the movement system is the largest system in the body, and moreover, it is the effector of our willpower. It does not possess any means of ‘defense’ other than to cause pain.” 2
The function of the movement system relies on a network of many structures that are controlled by various levels of the nervous system. 2 Since posture is simply a snapshot of the movement system at any given point, when attempting to identify pain, a systematic view must be taken into consideration.
While we are on the subject of defining things… I have used the term “clinical reasoning” pretty liberally throughout here. But let’s pause for a second here. If you are a clinician, ask yourself what the term “clinical reasoning” might mean to you. For many of us (myself included), it’s not so easy, because it’s much like trying to concisely define pain. It’s really hard to verbalize a succinct response but very easy to use as a catch-all term when specifics are not grasped. Without a specific definition in mind, talking about clinical reasoning is much like hugging a cloud. Beautiful to look at, impossible to capture. To avoid that and so we can be on the same page-
“Clinical reasoning is a reflective process of inquiry and analysis carried out by a health professional in collaboration with the patient with the aim of understanding the patient, their context, and their clinical problem(s) in order to guide evidence-based practice.” 4
by Ebrahim through Wikipedia Commons
Now I understand that even this definition still comes with complexity and nuance that could warrant its own post. But let’s put it into context of postural assessments or as I call it “the physical subjective”.
If we are to use clinical reasoning, we must first understand our patient to the best of our ability to understand their context. As quoted before: “Clinical reasoning is a reflective process of inquiry and analysis carried out by a health professional in collaboration with the patient with the aim of understanding the patient, their context, and their clinical problem(s) in order to guide evidence-based practice.” 4 So, contextually, let’s then consider postural factors leading to the people we have become in our own individual timelines. A few factors being-
Cultural and societal norms: sitting on floors, crossing legs, apparel and jewelry that could progressively change anatomy for appearances (lip plates, neck rings, foot binding, abdominal binders, high heels), sucking in our stomachs as a means for appearances (inverse diaphragm function), progressively sedentary work environments, etc
Postural ontogenesis: the infantile development of posture and movement and the development of our central nervous system, through the exploration of our environment. This occurs primarily through emotionally based motivation, development of the senses and positional development with appropriate development of joint centration via loading and repeated movements (take the Dynamic Neuromuscular Stabilization (DNS) courses after the Movement Links seminars for a thorough understanding of this)

Technological: Advances in technology have made physical labor less prominent (farming, factory work) and more towards efficiency and convenience. Phones and laptops have made us chronically get closer to our screens, rearview cameras in cars decrease our cervical rotations, a global decrease in outside play…Essentially- we have become an adaptation to our created environments

Sports, Music, Dance, Hobbies: functional adaptations which overtime create postural changes (however, if the anatomy from development is not necessarily optimal for certain sports, may lead to maladaptive functional adaptations leading to compensations) essentially, adaptations created to meet a conscious desire that requires physical actions

Psychological: Anxiety, depression, or other psychological states of being resulting in variance in normal breathing patterns and changes in resting positions of posture, fascia and the limbic system involvement 5, increase rise in mental illness prevalence 6
Neurological: Neurological considerations into posture is worthy of a post of its own… But do seek to learn more about this! DNS, Postural Restoration Institute or Integrated Kinetic Neurology are good starting places!

by Nick Youngson through Creative Commons

While patients often come in with common presentations and patterns, we must still include in these factors, because they are all individuals. That is why we use the verbal and physical subjective. The verbal subjective helps to contextually understand and hear the patient, while the physical subjective (postural exam) helps to see the history of that individual (ie: surgical scars, increased latissimus dorsi bulk from swimming, forward head positioning from vision deficits, etc). Then the clinical exam puts it together to test that information.
The next piece of clinical reasoning is understanding the patient’s clinical problem(s). The physical subjective will often show a lot of natural adaptations which make it difficult to identify which are clinically relevant to the patient’s clinical problem. This is because natural adaptations of the body to meet the conscious demands of the person are normal as the body is  constantly adjusting to what we choose to do and the things we experience.
As I have mentioned prior, the human systems are absolutely brilliant in that regard. We are so adaptable and have so much wiggle room. Which is great!...But also not so great! Because that also means we have so much room for maladaptive behaviors with no obvious signs of pathology. This leads to a lot of diagnostic images chasing pain and looking for the “tissue” that has the “issue” when the “issue” is a movement related problem. Because when done inappropriately, diagnostic imaging is costlier and may lead to fear-biased diagnoses,7-18 hence the urge for clinical reasoning! You have to be able to look beyond a “torn meniscus” or “degenerative disc”, and see the full picture of why the patient is sitting in front of you.
This is why postural assessments require a systematic understanding to understand the patient’s movement history. However, to utilize clinical reasoning to understand the patient’s clinical problem, in regards to posture, is understanding human behavior. Maladaptive behaviors (usually unknowingly) result in repetitive motions with repercussions, including tissue injuries, articular changes, and pain.
Now, caveat, there are technically no “bad movements” (or at least we should try to not label it that way to patients). Just movements without the appropriate buffers (capacity) or simply inefficient movements (energy cost is higher than it needs to be). Progressive or current load must be within the adaptable capacity limits, and when load is outside of capacity, something must give, and it usually leads to tissue pathology. In essence, our natural physiology is constantly in search of homeostasis, and our conscious decisions/external experiences drive an extrinsic influence on that balance.
This for the most part can be viewed via posture, seeing beyond just the site of injury, but perhaps going beyond to take note of postural markers (hypertrophy of the lumbar extensors or gluteal atrophy, etc, etc) and putting the pieces together.
When consciously driven actions, external actions of others/objects (physical injuries), or internal aberrancies in physiology lead to clinical problem(s), we must understand what has been done to drive the body out of homeostasis into a likely negative feedback loop. Furthermore, there must be an investigation as to why the nervous system has decided to signal for help or deem something as a threat via a painful response (correctly or erroneously).
Clinical reasoning and its integration into postural assessment (with whichever method you subscribe to) fit together much like chocolate chips on cookies. It comes in many various presentations (oatmeal, soft, crispy, chunky, flat, even in dough form) but no matter the shape or method, done well it’s always delicious. Much like pizza. (perhaps I am just hungry)
by Jon Sullivan through PIXNIO

Hopefully by now from Part I and II, I have made enough of an argument for that ‘posture and pain matters, but with clinical context and clinical reasoning. As you can see by the myriad of different factors lead by the consciously driven individual who has experienced life events that have either happened to them or are results of their actions, furthermore, combined with human system adaptability, it would make perfect sense that any postural deviation or dysfunction could be possibly related or unrelated to that individual’s pain.
So when does a postural deviation matter? How do we sieve out the clinically important details when sometimes our patients come in with SO many deviations from the norm?
So many questions…So many more questions to ask! Continued in part III!
Go forth and move well!

Blogpost by Josh Lee, PT, DPT, OCS
Josh is a physical therapist with Mercer University and Piedmont Hospital in Atlanta, GA. He is a Movement Links Specialist, board certified orthopedic clinical specialist (Mercer University Ortho Residency graduate), current Orthopedic Manual Physical Therapy fellow in training at Mercer University, and primary author of the Postural Considerations chapter in the 3rd edition of the Trigger Point Manual. Josh is an avid movement systems advocate, passionate about all things human movement related, and all things cookie related as well.

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