Powered by Paolo Platania,best view at 1024 x 768, first issued gen 29 2007, contents editing in progress, last update of this page dec 16 2008

Posture, etiology of a syndrome

Paolo Platania
Posturology guidelines and
interdisciplinary case study

  
  
  
Posturology
  
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Abstract | Method | Status | Syndrome | Dossier | Evidences | Mechanics | Pathomechanics | Etiopathogenesis | Therapy | Discussion | Conclusion  

Evidences

Platania's syndrome relevant findings grouped by classes:
EVIDENCES: clinical evaluation findings
# Finding Images & details
Ecl01 Left ankle: slighty pronated No image
Ecl02 Left soleus (S): contracted, hypertrophic
Ecl03 Left hip adductor: contracted No image
Ecl04 Left tensor fascia lata (TFL) and rectus femoris (RF) : contracted, hypertrophic
Ecl05 Gluteus maximus (GM): inhibited
Inhibited with habitual pelvis pathologic tilt
gluteus inhibited
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Tonic with forced pelvis physiologic tilt
gluteus tonic
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Ecl06 Hamstring: inhibited No image, palpation evaluation
Ecl07 Left hip: medially rotated
Habitual unilateral left hip pathologic medial rotation, hands fall asymmetrically
left hip medial rotation
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Forced bilateral hip physiologic rotation, hands fall symmetrically
left hip forced normal rotation
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Ecl08 Pelvis: anterior tilted Courtesy of Carol Oatis "Kinesiology: the mechanics and pathomechanics of human movements": left physiologic pelvis tilt as opposed to right pathologic anterior tilt lamented by the patient, see also Ecl04, Ecl06.
Ecl09 Penis: right curved No image
Ecl10 Left internal oblique (IO): contracted
Ecl11 Right abdominal and chest hair: less thickness
Ecl12 Spine curves: increased lumbar lordosis, increased dorsal kyphosis Differential evaluation: red ordinary pathologic curves, blue more physiologic curves due to induced mandible slight protrusion by bite cotton thickness appliance
Ecl100 Left erector spinae (ES): inhibited No image, self evaluation
Ecl13 Left pectoralis major (PM) (clavicular portion): hypertonic
Courtesy of Henry Grey "Anatomy of the human body"
pectoralis major
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reduced scapular abducted lateral rotation ROM due to hypertonic PM
left pectoralis major hypertonic
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normal scapular abducted lateral rotation ROM
right pectoralis major
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Ecl14 Shoulder girdle: forwarded Differential evaluation: left pre orthodontic humeral convergence, right post orthodontic humeral divergence
Ecl15 Left shoulder: scapulohumeral joint (SHJ) further forwarded
forwarded SHJ increased adducted medial rotation range of movement (ROM)
left shoulder ROM
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less forwarded SHJ normal adducted medial rotation ROM
right shoulder ROM
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Ecl16 Left scalenes: contracted
scalenes
Courtesy of Carol Oatis "Kinesiology: the mechanics and pathomechanics of human movements"
Ecl101 Left splenius capiti (SC) and trapezius (T): contracted No image, palpation evaluation
Ecl17 Cervical spine: forwarded
Courtesy of Carol Oatis "Kinesiology: the mechanics and pathomechanics of human movements"
head forwarded 1
click to enlarge
Ecl18 Temporomandibular joint (TMJ): retruded
Ecl19 Bite occlusion: distocclusion II class II division, incisors crowding, deep bite, mandibular wisdom teeth extrusion over the bite plate, maxillary wisdom teeth extrusion under the bite plane, lack of canine and incisor guidance
Ecl20 left emitongue: weak Protruded tongue deviation is a neurological indicator of unilateral weakness effecting the side the tongue deviates to
Ecl21 Palate: velopharynx asymmetry
Ecl22 Left maxillary arch: insufficiently expanded After orthodontic therapy, the "before" situation doesn't allow reliable inter incisors line location to evaluate the arches asymmetry
Ecl23 Cheek and lips muscles: contracted Differential evaluation: red ordinary pathologic mimic expression, blue forced expressionless


EVIDENCES: Symptomatic and degenerative findings
# Finding Details
Esy01 Seasonal symptoms Include: pollen allergy with asthma, physical and athletic condition sudden drop in summer.
Esy02 Left hallux: ingrown big toe nail surgery Problematic big toe nail since the first childhood, surgical treatment at age 18.
Esy03 Anterior tibialis: compartment syndrome Onset only during jogging and cross country skiing, left pain arises before right, after 1h of pain the initial acute phase subsides and allows training completion, memories of it since age 15, almost subsided after orthodontic therapy.
Esy04 Knees: instability Knee injuries since childhood during athletic activity, first rupture of right anterior cruciate ligament (ACL) and surgical reconstruction at age 27, second right ACL rupture and surgical reconstruction at age 29. After recovering from ACL rupture, with a physiologic hamstring functionality, knee stability for ordinary functionality is restored making reconstruction an optional choice, whereas the patient's knee in this context revealed highly injury prone experiencing frequent subluxations confirming low hamstring involvement and main reliance on ACL for knee joint steadiness; this disabling instability required reconstruction for safety reasons.
Esy05 Left hip: instability Painful left hip after jogging training, no other contexts, arisen at age 33, resolved quitting jogging.
Esy06 Sacroiliac joint: acute pain events No episode before age 38 nor before orthodontic treatment.
Esy07 Lumbar spine: back pain Compressive but asymptomatic L3/L4 disc degeneration accidentally MRI diagnosed at age 35, no memory of traumatic events relatable, first back pain arise at age 38 during orthodontic therapy immediately after wisdom teeth extraction, acute right L3/L4 radiculopaty episode with motor involvement after 2 months, chronic presence so far.
Esy100 Left scapulae: painful back muscles Recurrent, after prolonged upright position
Esy08 Shoulders: instability First left shoulder subluxation at age 17, repeated and disabling subluxations since surgery at age 22, persistent instability but not disabling, first left shoulder subluxation at age 25, repeated not disabling subluxations so far; instability almost subsided after orthodontic therapy.
Esy101 Left neck muscles: torticollis Recurrent, mostly in summer and spring.
Esy09 Esophagus: slip Small and asymptomatic hiatal hernia accidentally EGCS diagnosed at age 37
Esy10 Intra oral: tonsillectomy surgery At age 3, reason unknown.
Esy11 Left ear: uneasiness and occasional pain Firstly onset at age 30 after swimming training, subsides after long swimming stops, chronic otherwise, resolved quitting swimming.
Esy12 Left naris: occasional epistaxis Only during flu, spontaneous.


EVIDENCES: self evaluation
Findings reported by the patient, assessed by means of self analysis and self designed test

generic co-contraction test: the co-contraction disorder is easily assessed by an operator rapidly and randomly flexing and extending the involved joint having the patient resisting the action, he will not find any resistance in the first degree of each direction change (lack of underlying co-contraction) but only after a slight delay (eliciting antagonist voluntary contraction);

ankle co-contraction test: the co-contraction disorder is easily assessed with the shoe wearing task where the patient attempts to wear a shoe without using hands, the foot has to sneak in the shoe using toe and ankle deformations by co-contraction of tibialis anterior (TA) / tibialis posterior (TP) as well as extensor hallucis longus (EHL) / flexor hallucis longus (FHL) and extensor digitorum longus (EDL) / flexor digitorum longus (FDL); difficulties in the task may underline co-contraction disorder;

genioglossus (GG) contraction test (Ese08): put a stick in the mouth having one end deep (as deep as possible) in the mandibular sub-lingual cavity and the other free outside the mouth, pulling vertically using pre molar teeth as fulcrum and having the patient exert as much tongue depressing torque as possible it is possible to manually test the GG force. Maximal torque left-to-right-side unbalance supports unilateral tongue weakness.
# Finding Images & details
Ese01 Left hallux: motor disorder Inhibited co-contraction of extrinsic foot muscles extensor EHL and FHL, resulting in impossibility to voluntarily flex the first phalangeal joint (PJ), furthermore, visibly low EHL basal contraction (EHL tendon not tight), slight improvement with specific exercises; the finding is further supported by generic co-contraction test applied to big toe first phalangeal joint.

Solid blu line in the image represent tendon activated by concentric muscle contraction, dashed blu line represents passive tendon due to muscle inhibition.

This condition is harmful because leads to ingrown big toe nail: inability to flex the big toe during swing phase of gait causes EHL to extend a straight big toe having its nail excessively pushing against the shoe.
Ese02 Left intrinsic foot muscles: muscular spasm Systematic intrinsic muscle spasm (cramp) during left foot unresisted toes flexing, supposed reason is the unresisted flexing torque (due to lack of extensors muscle basal tone) causing muscle to cotract close to minimum length excursion range, cramps subside with passive toes hyperextension.
Ese03 Left ankle: motor disorder Inhibited co-contraction of tibialis anterior (TA) and tibialis posterior (TP) to control and stabilize the foot resulting low plantar arch (slight pronation), unsteady motion and pathologic motor compensations (alternative muscular firing pattern) and ankle joint degeneration, the finding is further supported by ankle co-contraction test.
Ese04 Left hip: motor disorder Inhibited posterior thigh muscles semimembranosus (SM), semitendinosus (ST), biceps femoris (BF), GM due to overactive TFL and RF, resulting in poor coxofemoral joint stabilization, pathologic motor compensations (alternative firing muscular pattern) and joint degeneration; the finding is assessed by generic co-contraction test applied to left hip joint.
Ese05 Postural cycling analysis The chart, resulting from instrumental cycling evaluation, perfectly assists in describing the self evaluated motor unbalance during cycling activity and its harmful features: at high power demand (high and mid lines) corresponds great left/right load unbalance causing ipsilateral joint overload, at high neuromuscular coordination demand (low lines) corresponds great motor disorder causing uncontrolled motion.
Protocol: 6 pedalling modes with fixed power of 200 watt at changing frequencies and handlebar grip:
  1. 120 rpm high grip
  2. 120 rpm low grip
  3. 80 rpm high grip
  4. 80 rpm low grip
  5. 40 rpm high grip
  6. 40 rpm low grip
Chart: X axis = pedal cycle (degrees), Y axis = power outlet (N); Chart lines and quadrants:
  • lower lines couples display fast pedalling (high/low grip),
  • mid lines display normal pedalling,
  • high lines display slow pedalling,
  • left quadrant for left lower limb,
  • right quadrant display right lower limb.
Ese06 Postural gait analysis Inhibited posterior thigh muscles semimembranosus (SM), semitendinosus (ST), biceps Motor disorder in the left stride:

Left Ground contact: in this context left PM and PMI should be inhibited to facilitate left shoulder backward motion, their pathologic contraction results in visibly disharmonious shoulder motion;

Left Flat Foot: pathologically inhibited TP action resulting in unstable and pronated ankle;

Left Mid Stance: pathologically contracted TFL inhibits hamstring keeping pelvis in pathologic anterior tilt, resulting in low propulsion and poor balance;

Left Heel Off: pathologic hamstring elongation secondary to pelvis anterior tilt requires early knee flexion resulting in early heel off, in this phase GM that should be providing propulsion but pathologically contracted TFL inhibits it, supplementary motion is supplied by S;

Left Late Stance: early heel off and poor knee flexion due to pathologically inhibited hamstring result in vertical push off causing left hip adduction and poor propulsion;

Left swing: previous phase (late stance) fails in delivering limb inertial angular velocity to swing pahase, limb enhancement is then actively taken over by frontal muscles (TFL, RF) and clearance is optimised by quadratus lumborum (QL) providing hip adduction, it all results in poor foot clearance and easiness in stumbling. In this context EHL and FHL co-contraction (Ese01) should provide big toe clearance, but pathologically inhibited FHL is not able to flex phalangeal joint, as such, big toe is straight extended by EHL inducing harmful pressure of the nail against the shoe and threatening its ingrowing.
Ese07 Left thorax: motor disorder Inverted rib expansion during inspiration: chest expansion for inspiration is compromised by anterior scalenus and intracostalis contraction (as well al PM and suspect pectoralis minor (PMI)) and is compensated by posterior expansion and augmented kyphosis resulting in dorsal expansion respiration.
Ese08 Tongue: motor disorder Left unilateral tongue weakness (no apparent muscle loss): extraoral manifestation is a slight tongue deviation (Ecl20) assessable by GG contraction test as well, but the dramatic pharyngeal and intraoral consequences are upper airway patency loss (Ptd01), maxillary arch insufficiency (Ptd03) and swallowing disorder. Given the resulting functional limitation, tongue weakness is not confined to GG only but reasonably extend to hyoglossus (HG) and SG. Although GG contraction test may reliably assess genioglossus weakness, strength assessment on other extrinsic tongue muscles has to be otherwise performed.
Ese09 Mandible: motor disorder Mandibular left mastication pattern disorder (right is physiologic): lateral-retrusive jaw motion with maxillary canine distal guidance instead of the physiologic lateral-protrusive with maxillary canine mesial guidance; the evaluation is performed after orthodontic treatment because in the pre treatment teeth crowding kept from canine and incisors guidance employment, hence, from physiologic mastication.
Ese10 Facial expression: motor disorder Due to permanent cheeks activity in smile wise expression (Ecl23) impacting on mood and, according to context, resulting in social uneasiness, moreover, permanent orbicularis activity encourages upper incisors internal inclination;


EVIDENCES: regression events
Postural symptoms are chronic, continuous, no memory of arising, present at lease since age 22, nevertheless they are reversible, this confidence is provided by regression events. Regression events are periods of unilateral postural symptoms partial but simultaneous subsidence, complete understanding of these regression events is challenging, these events have been of great help for developing the mechanics-pathomechanics-etiopathogenesys hypothesis.
# Finding Details
Ere01 Regression extents Regression events extents:
  • index -2 (incidence 74%): ordinary condition;
  • index -1 (incidence 20%): suspect regression when preceding or following a superior index event occurrence, otherwise called suggestion when preceded and followed by 0 index;
  • index 0 (incidence 4%): small regression when preceded and followed by -1 index, part of a true regression when preceded or followed by 1 index;
  • index 1 (incidence 1%): true regression, not more than 2 times a year, never lasts more than 5 days;
  • index 2 (incidence 0,01%): full regression never actually experienced, the only occurrence was enthusiasm excess.
Ere02 Relationship During true regression events the patient experiments a true subsidence of all the unilateral postural disorder and some other symptom, physiologic motor behaviour is restored, in this context the patient has been able to notice that big efforts (eg. sport training) reduce the effect of the regression event, in other words fatigue seems to trigger back unilateral motor disorder. According to cause-effect relationship, regression events are subdivided into:
  • Spontaneous: for the majority of these events there is no apparent direct relationship with any action (eg. therapeutic attempt) or contextual element (eg. environmental), a kind of cyclical or seasonal occurrence is reported along with possible relationship with immune system activity local to the oral mucosa
  • Induced unrepeatable: appear to be a direct consequence of a therapeutic attempt or other action but do not always occur after repeating the same action, these index 1 and index 0 regression events are induced by auricolotherapy (Dra22) and chiropractical thrusts (Dra23)
  • Induced repeatable: appear to be a direct consequence of a therapeutic attempt or other action and occur after repeating the same action, these index 0 regression events are induced by interrupring pharyngeal airflow afferences either artificially (vagal reset procedure: Ddo10) and naturally (holding the breath)
Ere03 Sensations Sensations experienced during index 1 events:
  • sudden reversing of the weight bearing structures switching from the anterior to posterior myofascial chains (usually inhibited), occurring simultaneously in the whole body;
  • sudden subsidence of unilateral pathologic motor disorder resulting in harmonic coordination of motor tasks;
  • great enthusiasm due to confidence to have understood the correct postural strategy and to thereafter be able to voluntary replicate it;
  • frustration to ascertain that despite the voluntary effort, pathological motor control is always restored.
Ere04 Subsided symptoms Evidences experimenting subsidence during regression events: Ese01, Ese02, Ese03, Ese04, Ese05, Ese06, Ese07, Ese08, Ese09, Esy05, Esy07, Esy08.


EVIDENCES: orthodontic treatment, outcome and follow up
Evidences emerging from the initial kinesiologic diagnostic evaluation demonstrated dental occlusion disorder involvement in part of the patient postural deviation, unfortunately no direct evidence of relationship with the unilateral lamented symptoms emerged, despite this lack of confirm the orthodontic treatment has been decided to be worth undertaking.
# Phase Images & details
Eot01 Therapy Orthodontic treatment:
  • 1 year appliance of maxillary planas removable plate with tracks, arch expansion of 5mm;
  • 1 year appliance of mandibular planas removable plate with tracks, arch expansion of 1mm;
  • 4 wisdom teeth extraction.
planas on maxillary arch planas on mandibular arch planas bite occlusion planas bite occlusion
click on each item to enlarge
Eot02 Outcome Effects:
  • Resolved: distocclusion, teeth crowding, maxillary arch insufficiency, wisdom teeth conflicts, incisor and canine guidance;
  • Improved: deep byte;
  • Unchanged: maxillary arch asymmetry;
  • Worsen: palatal gums lesions.
planas on maxillary arch after planas on mandibular arch after maxillary arch after maxillary arch expansionbite collusion after
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Before/after::
maxillary arch pre/post planas bite occlusion pre/post planas arch expansion pre/post planas mandible retrusion pre/post planas
click on each item to enlarge
Eot03 Subsided postural symptoms Subsided symptoms per category:
  • unilateral postural symptom improvement: none;
  • symptoms wirth great improvement: Ecl03 (suddenly when wearing planas plate), Ecl05, Ecl06, Ecl08, Ecl12, Ecl14, Ecl19, Esy03, Esy04, Esy08;
  • symptoms wirth small improvement: Ecl17, Ecl18 (persisted in phonation and respiration), Ecl22, Ecl23;
  • other improvements: dorsal spine mobility, balance improvement in skiing, athletic tasks economy improvement (aerobic threshold power outlet).;
Eot04 Newly onset symptoms Esy06, Esy07.
Eot05 Follow up 2 months after orthotic removal:
  • Stable correction: right maxillary arch expansion, wisdom teeth conflicts;
  • Regression to initial: teeth crowding, deep byte, distocclusion, incisor and canine guidance, left maxillary arch collapse;
  • Regression to worse then initial: maxillary arch asymmetry;
  • Regression cause: left maxillary arch collapse.
Left maxillary arch collapse

unilateral incisors crowding
left maxillary arch collapse
click to enlarge
Right maxillary arch stability

canine diastema have been introduced by orthodontic treatment and witness right arch expansion stability
diastema witness arch stability diastema witness arch stability
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Eot06 Restored symptoms Ecl03, Ecl05, Ecl06, Ecl08, Ecl12, Ecl14, Ecl19, Esy03, Esy04, Esy08.
Eot07 Subsided symptoms Esy07 (improved but not subsided).


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Posture, etiology of a syndrome - 2008 Paolo Platania