Postural Balance

Posture is the result of musculoskeletal efforts to counteract the effects of gravity. Any deviation from the ideal posture coincides with heightened mechanical stress for the whole organism.

Kappler7^ defines perfect posture as a state in which the mass of the body is distributed in such a way that the muscles maintain their normal tone and that ligamentous tensions neutralize the effect of gravity.

In standing people, posture depends primarily on three factors:

• On the evenness or unevenness of the ground upon which the person is standing

• On the state of the feet, as point of contact with the ground

• On the sacral base as pedestal for the spinal column, which keeps the organs of equilibrium plumb

Note: In these three areas, the redistribution of weight takes place in different planes:

• OAA: In the sagittal plane: facets and vertebral bodies of C2

• LSJ: In the frontal plane: in the direction of the two hip joints

• Foot: In the horizontal plane: from the talus to the calcaneus and the cuboid and navicula

This once again demonstrates the adaptation of structure to function. During walking, a posteroanterior weight shift occurs in the spinal column, from right to left and vice versa in the pelvis, and from the calcaneus to the metatarsal heads V and I in the foot.

Dysfunctions or structural changes in these areas cause these force transferences to be misdirected, which leads to additional strain on the muscles. Consequently, changed muscle pulls develop, as a result of which the entire locomotor system adapts and forms a different postural pattern.

Fig. 9.3a, b Weight shift in the horizontal plane in the lower ankle joint.

Note: This holds true when we consider that a malposition of the OAA complex results in an adaptation of the sacrum. The OAA complex is bound to be balanced if the sacral base is horizontal. Nevertheless, we are inclined to add the OAA complex as a fourth factor because cranial dysfunctions can also be primary.

The three arches of the foot must be optimally balanced on both sides. The tibia should ideally stand perpendicular above the foot (in the frontal plane), so that the weight is distributed harmoniously onto the three arches. This guarantees an optimal transfer of force towards the pelvis. Here, we can already see the effects of uneven myofascial pulls on posture.

The iliolumbosacral junction is made up of the LSJ and the two iliosacral joints (ISJs). Stability is here ensured by the configuration of joints, by ligaments, and

muscles. With optimally oriented forces, the joints are compressed in such a way that no muscle effort is required to stabilize the pelvis.

The base tone of the muscles and ligaments guarantees that the joint surfaces are congruent. The three forces that meet at the LSJ neutralize each other. The gravity that affects the sacral base is neutralized by the two rising forces from the legs. This mechanism functions only when the sacral base is horizontal. Even a minor inclination of the promontory changes the line of force and leads to instability. Consequently, muscles are recruited to ensure stability. This by necessity has a detrimental effect on the entire locomotor system. The position of the pelvis is changed, and thereby also the position of the spinal column and the lower extremities.

Robert Irvin determined in a study [in155] that people with chronic back pain who had received traditional osteopathic treatment but without lasting effects, experienced a 70% improvement of general symptoms when the sacral base was leveled by shoe inserts in addition.The most commonly found malpositions are:

• Valgus of the back foot (pes valgus), pes abductus

• Lateral inclination of the sacral basis

All three of these deformities can be corrected with shoe inserts. Irvin found in a radiological study |in155] that 98% of all x-rayed persons had an average inclination of the sacral base of 1.2 mm in the frontal plane. A tilted sacral base (in the frontal plane) can have numerous causes:

• Sacral dysfunction: An anterior sacral base is also lower.

• Iliac dysfunction: The forward rotation of the ilium lifts the sacral base on the same side: a backward rotation lowers it on the same side.

• Leg length differences: Anatomical or acquired by traumas, surgeries, foot malpositions.

Adaptations of the spinal column to a tilted sacral base are always three-dimensional. The result can be a c-shaped (more rarely) or s-shaped scoliosis. Adaptation by an s-shaped curve is most economical. It facilitates the maintenance of equilibrium most easily. In newborns and toddlers, however, we only find c-shaped scolioses.

Rotation and sidebending are always opposite in cases with scoliosis and scoliotic posture (neutral po-sition-sidebending-rotation |NSR| according to Fry-ette-see Chapter 3). Functional scoliosis (scoliotic posture) can develop into structural scoliosis (adaptation of structure to function).

The organism tries to compensate for disturbed posture by allowing the sections of the body above and below the disturbed area to adapt in the opposite direction. This leads to alternating rotation-sidebend-ing. These changes develop in the transition zones.82 The Zink patterns are an example of this (see Chapter 7): Littlejohn's model of the biomechanics of the spinal column supplies the mechanical explanation (see Chapter 5). •

The treatment of scolioses or kypholordoses depends on whether the curves are functional or structural. In functional, not fixated curves, the goal is an improvement of posture. In the case of structural mal-posture, treatment aims primarily at alleviating pain and facilitating the optimal functioning of all structures and systems.

In each case, all possible causes of the malposition should be considered:

• Organs of equilibrium

• Cranium and OAA complex

• Temporomandibular joint

• Spinal column/pelvis

Fibroses, retractions, and adhesions must be treated specifically and over a longer time. Dynamic inserts are often very effective because they are able to stimulate those muscle chains specifically that are hypoac-tive. Furthermore, they are able to imitate a weight shift that influences the equilibrium via the vestibulospinal tracts.

It is often necessary, in structural changes of the feet to stabilize the foot arches with a postural shoe insert, in order to prevent nociceptive reflexes due to muscular overexertion. Leg length differences, whether anatomical or acquired, should be normalized when they are greater than 3 mm.81

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