POSTURAL RE-EDUCATION

(not a kick through). Heel strike is with the lateral border of the calcaneum , fol- lowed by eccentric lowering of the outer border of the foot and then the first ray, into the stance phase.

The trailing leg is then preparing to go into toe off and the sequence is repeated on the other side. While at stance phase, the hips are kept parallel, spine length- ened and the head is directed forwards and up (no chin poke).

This is then practiced at intervals throughout the day eg. walking around the house, office, to and from the station etc, until the motor engram becomes established. At this point you should see a decrease in pain in walking.

mental cues given are very important as they engage the CNS (26,27). Alexander recognised that we all have a frame of ref- erence and this needs to be accessed if the re-education of movement is to be effective. For an instruction to be most effective it needs to engage the clients preferred learning style at an appropriate point in the learning cycle. For example, instructing the lordotic patient to ‘tuck their belly button in’ would not change the posture but would instead create the feeling of tension and rigidity.

Successful repetition of this optimal pos- ture may be necessary for the new pattern to be consolidated and embedded in the nervous system (28,5). With regards to motor learning, perhaps the axiom ‘prac- tice makes perfect’ should be changed to ‘practice makes permanent’.

Once standing posture has been addressed the programme could be progressed as follows:

Gait re-education - from standing the first step forwards should be initiated by the simultaneous action of knee flexion and ankle plantar flexion, into the toe-off stage. At toe-off the talocrural joint should not invert, so momentum is through the entire length of the first, not the fifth digit. This allows enough plantar flexion to carry the knee through into flexion, activating the stretch reflex in the quads. Now the anterior tibials can be activated to DF the ankle, giving the foot clearance for the swing through phase

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Sit - stand - akin to squatting, this involves instructing client to keep feet and knees parallel as they rise from sitting into a standing position. Most will auto- matically externally rotate their feet as they go to stand up. This procedure acti- vates VMO and can be practiced every time they stand up or sit down from their chair or toilet. It encourages the thought that semi-squatting is done through par- allel feet, knees and hips. As mentioned earlier, engaging the primary control will automatically activate the stabiliser mus- cles.

Stairs - akin to one leg standing squat. Client is instructed to keep the feet paral- lel when going down stairs (they usually turn their feet out) so that deep stabilis- ers are activated eccentrically. Feet should also be placed parallel on the stairs for ascent. On ascent the heel should remain down as climbing stairs on the toes loads the PF joint (Fig.9). They then do this every time they attempt stairs, and should note a decrease in symptoms.

Running - increase the velocity with the gait re-education. Think of the gait pat- tern described above whilst running. The client may want to concentrate on one thing at a time, this may be a more later- al heel strike, a more open ankle at toe off, allowing the knees to soften, or sim- ply running taller and relaxing their shoulders, and thinking the occiput for- wards and upwards.

Introduce change in incline, terrain - single legged dips, lunges, hop, skip and

jump depending on their sport eg netball, cricket, basketball, high jump etc. Emphasis is on the awareness of their alignment and incorporating that aware- ness into various sport specific skills.

CONCLUSION The postural solution challenges the cur- rent popular notion of teaching isolated muscular activity in the management of PFPS (29). The key to permanent resolu- tion is in changing the sensory apprecia- tion of how the body is used in everyday functional settings, such as sitting to standing, standing, and walking.

It draws

on current research, which demonstrates that stabiliser/postural muscles are auto- matically strengthened by the repetition of aligned and controlled functional move- ment. It advocates the immediate re-edu- cation of postures and movement patterns which may positively alter the patients muscle imbalance and pain.

Whilst postural re-education may not be a new concept to many practitioners, this article hopefully presents a clearer under- standing and insight into the concept. This article also calls for a revitalisation of this under-emphasized and under-utilised skill that has endured all the developments the profession has undergone.

In a health-care environment that demands evidence-based effectiveness and efficiency, we need to question and justify our choice of approach to client manage- ment. Change can occur anywhere in the cycle (Fig. 1), so other physiotherapeutic modalities are not challenged, however to be most effective, we need to address the cause of movement dysfunction.

The scope of the paper limited the authors from fully expanding on the Alexander Technique. The references will provide fur- ther information.

The authors would welcome comment and discussion regarding the approach out- lined in this article. Please email tor@sportex.net with feedback.

Acknowledgments Carmen Tarnowski MCSP MSTAT, Veronica Warbuton MCSP, colleagues and patients.

THE AUTHORS ■ Sudhir Daya graduated from the University of Cape Town, South Africa. He worked at the Sport Science Institute of

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