POSTURAL RE-EDUCATION

rotation of the cervical spine and scapula abduction - the conse- quent sliding of the hand is a secondary movement.

As they continue the above movement they should be instructed to focus their awareness down the spine to how the thoracic and lumbar spine is also rotating towards the floor, and the uppermost thigh is gently sliding on the lower thigh to aid the overall move- ment of reaching forwards. Finally they should focus their atten- tion on the whole movement - the head turn, the scapula roll, the spine rotation and the leg slide. By now they should notice that the head turn has become more effortless and the hand should reach much further forward. By paying attention to the individual components of the movement, and how they move, the overall movement becomes more fluid. This exercise should be repeated on the other side. As the client comes to a standing position after the exercise they should notice more freedom of movement through the neck, shoulders and trunk, resulting in greater pos- tural control.

Body imaging Individuals with postural disturbances often have a distorted internal awareness of their posture (8). This is generally a chron- ic problem that results from compensation patterns developing post-injury or trauma - the kinetic chain compensates for injury by producing substitution movements or holding patterns to maintain a perception of normality. In this way chronic postural distortion feels normal as the sensory motor pathways become habituated. In spite of this internal feeling, external observation often presents a picture of dysfunction. Re-education of internal awareness using self-biofeedback can be an effective adjunct to traditional methods of postural correction.

Body image training addresses postural dysfunction through a process of sensory biofeedback and mirroring. Using a series of small movements performed with the eyes closed in front of a mir- ror, sensory feedback can be re-programmed to create a new body image. The standing body image exercise can be used to increase postural awareness and control in the sagittal, frontal and trans- verse planes, through activation of the labyrinthine and neck righting reflexes. Use of a mirror is crucial in creating new per- ceptions of body image.

Body imaging exercise - instruct the client to stand in front of a

mirror in a comfortable stance with eyes closed (Figure 4a). Ask them to notice the degree of postural sway and its direction. Keeping the eyes closed, they should begin the exercise by gen- tly tilting or swaying to one side (Figure 4b) and holding this position for a few seconds before returning to what feels like ver- tical. At this point they should open their eyes and check their posture in the mirror. If they are off balance, they should imme- diately close their eyes and correct the balance using their inter- nal sensory experience. As before, they should open their eyes, without moving. If still unbalanced, they should repeat this process until balance is achieved. This process should be contin- ued each side for a total of three repetitions. The exercise should be repeated in the sagittal plane (forward and backward tilting) and the transverse plane (tilting left and right) to restore postur- al image in all planes. With enough practice and sensory aware- ness, the internal image of posture and the external mirror image will begin to approximate.

Ideokinesis - all movement, including postural positioning involves co-ordination of muscle action at an unconscious level. Over time, posture can become so habitual and automatic that there may be no need for any conscious effort to maintain it. Visualisation can be used to help the nervous system coordinate the numerous and interrelated micro movements of muscle, that are too fine and complex to be controlled voluntarily (9). This approach has become known as ideokinesis and can be defined as the idea of movement occurring within one’s body in a specific place and direction, but not being voluntarily performed. Used as an integral part of postural re-education, the goal of

this

approach is to remove muscular holding patterns, enhance pos- tural alignment, and improve efficiency in movement. In at least one study, imagery has been found to have a more positive effect on posture than either flexibility training or abdominal strength- ening (10). Earlier research has also shown that imagined move- ment is an effective means of producing measurable changes in postural alignment (11). The ideokinetic approach relies on edu- cation and learning to improve posture. The client is generally guided through a series of images that allow the body to subtly reorganise its alignment. An explicit understanding of biome- chanical and kinesiological principles is an important prerequisite for successful use of this approach. The seated posture trainer is an example of an effective ideokinetic exercise that focuses on postural alignment in a seated position. It helps to increase awareness and co-ordination of the head, neck and opposing spinal curves to attain efficient and fluid alignment.

Seated posture trainer - this exercise is performed in a seated position, with the feet placed comfortably apart and the hands resting on the thighs (Figure 5a). With the eyes closed instruct the client to notice how they are sitting, in terms of muscular effort, spinal alignment and breathing pattern.

Figure 4a. Body imaging 20

Figure 4b. Gently tilt or sway to one side

Head/neck visualisation - they should begin by paying particu- lar attention to the position of their head. Instruct them to imag- ine that the head (when viewed from the side) represents a mechanical cog, with the top of the cog in line with the head, and the bottom of the cog in line with the base of the neck. Ask them to visualise a gentle turning of the cog in a forward direction, so that the chin tucks inwards and slightly downwards, and the top of the head turns upwards and slightly forwards (Figure 5b).

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