Chapter 11 Examining probable contributions towards dysfunctional posture and movement

Backs complain when their movement diet becomes limited and repetitive. By and large, compared with the liberated curious child, the modern adult tends to use less variety and less expressive movement. The possible contributions to depleted posturomovement control are many and varied. In any one patient, the blend of these various influences contribute towards the presenting picture of changed motor function. The seemingly most pertinent are explored.

Neurodevelopmental aspects

The quality of our motor development is reflected in the manner in which we posture and move ourselves. It is possible that one never had very good motor control.

Mature motor behavior: what is ‘normal’?

Sensorimotor development whilst progressing through common stages and patterns is nonetheless individual, adapting to various influences. Environment, opportunity, emotions, experience, cognitive and learning ability are some of the aspects that play a part in development. School and ‘mental learning’ mean we frequently sideline our sensorimotor learning. In some respects we ‘stop developing’ as our motor function deteriorates with the reduced demands and altered circumstances of sedentary lifestyles involved in education and work. For many of us, a certain untapped potential for developing more highly refined sensorimotor function remains. Some however, attempt to further develop their motor potential in exploring various experiential awareness and somatic learning practices such as Feldenkrais, The Alexander Principle, yoga, dance the martial arts and so on. Alexander ¹ drew attention to ‘The use of the self’ – how the person performs the ordinary movements involved during everyday activities can cause strain or otherwise on pain sensitive tissues.

More highly integrated sensorimotor development produces positive differences in the qualitative characteristics of the posture and movement responses. This begs the question – what is normal posture and movement? Just because a person does not have pain does not mean he moves ‘normally’ or well. Do ‘pain free’ and ‘healthy controls’ used in research design necessarily move in a well adapted way? Habitual behavior is common to us all – eating, drinking, smoking and the way we breathe and move. Changing any habit requires awareness of the problem, a desire to change it and application in doing so.

Abnormal early development: integrated versus more primitive control

Most of us develop the quantitative motor milestones – the ability to sit stand and walk and so on. However, we don’t all do it in the same way as the quality of our eventual neuromusculoskeletal organization can demonstrate. How we posture and move may be less than ideal. How to discern what factors underlie this picture of ‘soft dysfunction’?

Bartenieff ² was concerned to identify innate constitutional factors that could be traced through childhood to adulthood which affected and reflected how the person was able to cope with his environment. Observing a series of films of the movement behavior between two ‘normal’ children at birth through to age 12, she was able to discern six core qualities which were significant in identifying to a greater or lesser extent, the adaptability of the child. The first three were observable in the first few weeks of life; the last three became evident as sitting posture and locomotion developed. All six features operate through childhood and are discernable in the adult. To quote her:

1. Differentiated vs less differentiated use of the limbs and their segments, head/trunk, and constellations of trunk and limb.

2. Dominance of asymmetrical vs symmetrical use of limbs. Asymmetric use stimulates greater mobility and develops selectivity and range in pattern.

3. Use of areas of reach space (personal kinesphere) around the body before full uprightness vs limited use of reach space.

4. Flexible vs fixed use of verticality.

5. Development of verticality and full use of kinesphere into a territorial space (locomotor space) vs limited use. This becomes visible in the sitting stage.

6. Organization of activity patterns into phrases – ordering, combining, alternating, and elaborating – vs short monotone flexion and extension actions

The differences in response were evident from birth in the Moro or Startle response. One infant demonstrated multi use of all limbs; emphasis on horizontal use of limbs; shifting the body from side to side and varying symmetrical and asymmetrical limb movements. The other showed less limb movements in predominant flexion/extension ranges; a rigid and fixed constellation of the limbs at the end of the response which was actually a postural reflex, with upper limbs flexed and lower limbs extended; a definite emphasis on symmetrical limb use. The qualities of the core parameters were carried through the developmental stages so that at the age of four, the child with the less ideal motor behavior displayed a collapsed posture and protective attitude of the arms reminiscent of her early startle response with flexed upper limbs and high tension extension of the lower. She moved within a limited kinesphere, lacked variety in the movements she used and overall Bartenieff felt she showed a tendency towards rigid non-adaptability. Clearly some of us inherit a better neuromuscular apparatus than others. She believed that this small observational study revealed important insights for the movement therapist:

• the significance of core qualities which reflect interrelationships of movement behavior elements and

• the significance of pattern roots that appear in the early Startle behavior and are crystallized into later behavior patterns.

Inadequate integration during any stage of development creates the need for compensatory strategies which then become part of the person’s movement repertoire, as they become learned and habitual. In time they more than likely become a patient.

Aspects of more primitive motor behavior are clinically evident in subjects with spinal pain disorders (Chs 7& 8). Grieve³ noted the awkward movements, poorly developed kinesthetic appreciation and ‘physical illiteracy’ of many of his patients making it difficult to teach them exercises.

Janda ⁴ knew the relationship between the inability to work out good movement patterns and the development of vertebrogenic conditions. In a group of back pain patients who had been ‘therapeutic failures’ he found symptoms attributable to ‘minimal brain dysfunction’ (MBD; see Ch. 7). He considered that about 10–15% of the child population suffers from at least some signs of this syndrome and about 80% of subjects with chronic pain fit the MBD category.⁵

‘Acquired’ aspects contributing to posturomovement dysfunction

While we may have enjoyed an exemplary early motor development, the continual influence of numerous ongoing intrinsic and extrinsic factors serves to modify our motor presentation as we adaptively respond to the prevailing conditions. The most apparent are discussed in brief.

Lifestyle

Chairs have a lot to answer for! Western industrial societies have progressively evolved towards the adoption of more sustained static sitting postures for education, work and leisure. Our heads are occupied with intellectual pursuits or otherwise distracted, yet the CNS is disadvantaged by the relative lack of sensory intelligence as a result of more limited body movement. Many never get down onto the ground and as Beach ⁶ observes, floor to standing transitions use deeply embedded archetypal musculoskeletal patterns that young children and pre-modern adults would use constantly during daily life. Sensory deprivation makes the system become rusty and leads to what Hanna⁷ termed ‘sensorimotor amnesia’. The posturomotor control system suffers and we develop changed antigravity responses when sitting and standing (Ch. 8). Repeated often enough they become habituated responses that start to ‘feel normal’. Sitting with the spine flexed has been directly linked with back pain.^8,⁹ The desk worker then tries to become the ‘weekend warrior’ attempting the kinds of manual labor he is not well suited for, such as using the chain-saw. These activities inflict unreasonable kinematic demands upon an often struggling poorly organized posturomovement system.

The increasing incidence of obesity and associated inactivity is everywhere apparent within contemporary Western cultures and has been argued to predict back pain.¹⁰ Maintaining activity levels and back muscle endurance may prevent it.¹¹

In contrast, the subsistence farmer or hunter-gatherer ‘uses his body’ in a more physiological way as he walks daily for food and water, actively employing all his senses in hunting, manual work and possibly expressive dance and rituals. He is unlikely to have pain resulting from developing movement dysfunction.

Trauma

The influence of previous traumatic episodes is frequently overlooked yet can result in pernicious symptom development even many years later. If X-rays taken at the time were negative, the patient is usually told ‘it’s just soft tissue strain’ and ‘to rest’. Falls when skiing, off horses, out of trees etc. can be long forgotten, yet physical assessment can delineate the graveyards of old traumatic events. In particular, falls onto the bottom and knees and fractures of the coccyx can distort pelvic ring myomechanics and contribute to lumbopelvic symptoms.

Cultural trends

Volinn ¹² reviewed the epidemiological literature and found rates of low back pain were 2–4 times higher in European general populations than in Nigerian and Asian farmers. Within the low income countries, rates were higher among urban than among rural populations. He concluded that hard physical labor itself is not necessarily related to low back pain and that its prevalence may be on the rise as urbanization and rapid industrialization proceed.

Probably the most significant posturomovement differences between those observed in the West and other cultures is in the manner of sitting, carrying and in fashion.

Sitting

Sitting in a chair and ‘relaxing’ invariably means collapsing (see Ch. 8).

Many in the world have never seen a chair and rest in either a cross-legged sitting or squatting position. Janda ¹³ relates that Fahrni had noticed that Orientals spend a large part of the day thus, which maintained the lumbar curve. He said that they manifest no increased incidence of disc degeneration with advanced age and have a very low incidence of back pain. He apparently had radiological data showing that the incidence of disc narrowing was 80% by age 55 amongst Swedish heavy workers, 35% in office workers of the same age, while in a jungle population in India the incidence was 9%.

Squatting also maintains good opening in the hips and pelvis. The base of support is active through the feet (or ischia in sitting) which serves to fire up the SLMS. In some cultures birthing could happen in the fields but now, in the West, more often than not it entails an operation. Most of us in the West have lost the art of squatting and cross legged sitting. Attempts to do so invariably result in hyperflexion over the lumbosacral spine and axial collapse because of limited range in the hip. Note the pandemic of hip replacement surgery – if you don’t use them properly you need to replace them! As the saying goes – ‘use it or lose it’.

It has also been argued that chair designers and users have generally been distracted by concerns for representing social status rather than the physiological and kinesthetic aspects which might contribute to physical wellbeing.¹⁴

Carrying

A significantly large proportion of the world carry loads on their heads – biomechanically sound as it loads the axial column providing much proprioceptive input and firing up the SLMS. The poorest untouchable in India can look more regal than a queen, such is her beautiful carriage. The effectiveness of head loading is demonstrated by a physiotherapeutic ruse for helping severely ataxic children to walk. Putting a weighted helmet on their head would immediately improve the antigravity response and stabilize them enough to be able to walk unaided! Head loading entails getting the arms up to place or balance the load, maintaining their elevatory function including thoracoscapula mechanics and basal breathing. The arms are free and can swing inducing the shoulder–pelvis counterrotation, minimizing the energy load of walking. In the west it is usual to carry the load in front with the arms. The body becomes eccentrically loaded and stress is imposed on the system. This occurs around the neck-shoulders and low back as we are pulled forward into a more general pattern of flexion. For many, struggling with the weekly shopping becomes a repetitive act which compounds patterns of improper muscle use. Contrast the serenity and relaxed demeanor of the African women despite coping with mixed spinal loading (Figs 11.1 & 11.2).

Fig 11.1 • Despite carrying two loads and hurrying she is graceful and relaxed!

Fig 11.2 • Despite considerable vertical loading she is smiling!

Balancing the head load ensures that the column is well aligned while also activating balanced antigravity responses.

Fashion

It is difficult to know why the concept of a small waist came to be. Tight belts, constrictive clothing and holding in the stomach all contribute to the development of dysfunctional breathing patterns.^15,¹⁶ The recent fashion for skin tight and low slung jeans means that the wearer cannot flex the hips properly without her buttocks popping out of her pants, thus she is impelled to sit in posterior pelvic tilt and excessively flex the lumbar spine.¹⁷ Axial collapse of course ensues. Contemporary models frequently ‘tuck the tail’ and strike poses in lolling seductive, simpering postures which imply postural collapse is ‘cool’.

The fad for ‘trainers’ and orthotics has to be one of the biggest marketing cons. The person is so trussed up with ‘support’ that they don’t need and then can’t find their own intrinsic support through active feet with a dynamic lower kinetic chain. Collapsed feet are indicative of poor systemic posturomovement control. Walking barefoot would be much better! Stand in any shopping centre and observe the waddling, plodding, loping and disjointed steps of many of those using this type of footwear. They are generally also obese.

Cultural expression and customs

Movement serves both function and expression. The religious act of frequent daily prostration has the added side benefit of maintaining fitness! Cultural practices and rituals involving meditating, chanting singing and wailing, effectively tune the breathing mechanism. Gestural body movements including clapping, tapping, stamping, dancing and so on in solo or group performances provide a lot of sensory input to the system as well as group interaction and entertainment. Reaching for the heavens in exultation leaps and shrieks are empowering. Conversely we in the West have become to rely on passive entertainment – magazines, TV, DVDs, computers, movies etc. – all while collapsing in sitting (again!) and often solo. Sadly the trend is spreading afar.

Psychosocial and emotional factors

Modern living has become stressful living. Many of us are in a constant state of hyper arousal and tension as we cope with a multitude of demands – the kids and the ‘home front’ while meeting deadlines, performance reviews, escalating mortgage payments, sick relatives and so on, while at the end of the day worrying whether we look good in bed! Stress is a potent potentiator in musculoskeletal pain syndromes.

Psychological factors play a great role in faulty central motor patterns. Lewit ¹⁸ considers that ‘motor patterns are to a certain degree expressions of the state of mind: anxiety, depression and an inability to relax will greatly influence motor patterns. No less important is the subject’s psychological attitude to pain’. In general, one never sees a depressed or very shy person who is ‘up’ and ‘open’.

The ‘human consciousness or human potential movement’ evolved in the 1960s and 1970s and its many proponents included Ida Rolf, Alexander Lowen and Feldenkrais who variously explored disturbed somatic functioning and its relation to the psyche. Rolf ¹⁹ saw how each person’s shape and form constituted their personal history and suffering – genetics, trauma, habit and culture all contribute. Lowen²⁰ considered that neurosis and early psychologically traumatic events result in ‘body armoring’ where increased muscle tension limits motility and respiration. Feldenkrais²¹ considered that ‘to every emotional state corresponds a personal conditioned pattern of muscular contraction without which it has no existence’. He described ‘The body pattern of anxiety’ – a contraction of the flexor muscles especially in the abdominal region, and a halt in breathing soon followed by vasomotor changes as sweating and accelerated pulse and an increase in adrenalin. The head is lowered, we crouch and bend the knees and the arms come across the front of the body to protect the soft unprotected parts. He stressed that importantly ‘the sensation of fear and anxiety due to the disturbance of the diaphragmatic and cardiac region is actually abated by maintained general flexor contraction and in particular that of the abdominal region’. He observed that introverts have some habitual reduction of their extensor tonus thus either the head or the hip joints are forward. The extrovert on the other hand has a more erect standing posture and gait.

Influenced by Feldenkrais, Hanna ⁷ described ‘The reflexes of stress’. Fear avoidance behavior if repeated enough, becomes habitual (see Ch. 6., Part A and Ch 10). It is interesting to observe the very common postural habit of folding the arms in front of the chest in psychological protection and defense (see Fig. 3.3). Added to this, the adoption of further protective postures and splinting and guarding can ensue as a result of pain.

Breathing is the link between emotion and motion. Stress and anxiety alter the breathing patterns and hyperventilation syndromes ^22,²³ are common (Ch. 8.). Chaitow²⁴ remarks that breathing pattern disorders automatically increase levels of anxiety and apprehension which may be sufficient to alter motor control and to markedly influence balance control. A vicious pattern generating cycle is set in train.

Studies have certainly shown a clear relationship between low tolerance to stress and back pain.⁴ Marras et al.²⁵

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