All patients have 2 things in common.
They live in gravity and they have to breathe. These 2 truths are at the heart of most postural compensations.
Gravity influences posture and movement as the brain will seek stability over mechanical correctness by shifting a patient's center of gravity away from an instability to maximize base of support. Stability is gained but motion is lost as resting position is now shifted away from neutral. Nowhere is this more evident than in gait. As the center of gravity shifts to achieve stability, patients start to favor one of their legs and the entire body will shift in kind as seen in asymmetries. This leads to mechanical insult and with time, a pathology along the kinetic chain.
Respiration becomes compromised secondary to the systemic shift. A major part of favoring one leg for stability is the accompanying shift/rotation of the pelvis. In a rotated position at least half of the pelvic floor is compromised and therefore can not provide respiratory support for the diaphragm. With pelvic floor opposition lost respiration becomes dependent on extension and auxiliary muscle of respiration including the neck and back.
Patients that present with this shift will have asymmetric objective findings in range of motion, morphology, and strength.
The following treatment progression overview is a neuromechanical algorithm that we utilize to communicate to patients and their referring providers about initial deficits and progress.
1. Is the patient Neutral? Sagittal Plane.
Assessment: hip rotation symmetry, passive hip abduction symmetry, negative adduction drop test, lumbar rotation symmetry, infrasternal angle, shoulder rotation and horizontal abduction symmetry, cervical rotation, squat test, standing reach test
Patients with asymmetric findings are stuck in a neurologic pattern of unilateral stance and inhalation. This changes the positioning of the pelvis, spine, trunk, diaphragm, and costal cage (as represented by the square).
Treatment Goal: Neutrality through Reposition/Inhibit/Exhale
2. Is the patient Stable? Frontal Plane.
Assessment: joint range of motion, adductor lift frontal plane strength, abductor lift frontal plane strength, side plank integration,
Patients that exhibit too much joint range of motion are mechanically unstable.
Patients with frontal plane weakness are neurologically unstable. Both types of instability will result in compensation and postural shifting from C2 down (as represented by the arrow going from neck to the ground).
Treatment goal: Frontal plane integration. First on the table until adductor lift scores are >3/5, then in gravity with supported activities, and then integration with gait activities.
3. Can the patient reciprocate? Transverse Plane
Assessment: AF stability test, single leg balance, retro gait, alternating reciprocal test,
ability to maintain neutrality and stability with tri-planer activities.
Patients that have deficits in the transverse plane often present with poor balance. They are not able to hold positioning of the axis of rotation. Balance is triplaner strength. Patients need to be able to control pelvis on femurs to achieve alternating gait of right stance and left stance.
Treatment goal: Transverse plane integration.
Integration of gait activities without compensation.