Posturology-a pluridisciplinar approach. Treatment principles

SUMMARY The Treatment principles of posture and gait disturbances first need a general assesment of child’s posture,following the motor development stages from 0-14 months and from 14 months to 6 years. Once walking developed,we need to asses the posture disturbances,taking into account the general development stage and that some postures are temporary physiological and they do not require intervention. We need to spotlight that the mature gait is to Be considered only afeter 6 years of age. It is important to educate the parents about the wrong postures of the child, like the „ W” posture,and the child will go barefoot inside,for working the plantar muscles and the plantar torsion between the forefoot and the ankle. The ortopedic check up of the child is required for every gait disturbance noticed,to asses the normal or pathological aspect,that could Be corrected by using an orthesis or other apropriate rehabilitation. Keywords: posturology, treatment, orthesis

Postural assesment-ontogenetic stage I (0-14 months) – Exam of archaic reflexes – Exam of muscular tonus (the scarf manoeuver, the poplitheal angle measurement) – Motor aquisition assesment-ontogenetic We must note down the strabism, torticolis, plagiocephaly. From 0-14 months, the postural system builds up on the main cephalic system (ear, mandible, vestibulary system). Acording to the law of cephalic-caudal development, the head movement control is the first develomental stage of postural control [1]. Motor development stages: – Head movement control – 3 months – The sitting posture – 6-7 months – Walking (assisted) – 10 months – Independent walking -12-15 months. Warning sign – lack of head movement control at 4 months, or sitting pose unaquired at 9 months. În the first ontogenic stage, postural training manouvers (between 8 weeks – 3 months), regard cervical extension stimulation to improve cervicodorsal muscle tonus. The exercises regard pronation lifts or placing the baby on the therapist’s forearm. At 4 ½ months we can start lateral and visual stimulation (placing objects into the visual field, starting from the median line to the periphery). At 9 months-initialising the crossed corporal scheme (rolling, sitting, walking on all fours, verticalisation). Walking on all fours is very important, ensuring eye-hand and visual field coordination, s trenghtening the lateral and posterior muscle chains and the skull moulding by the posterior cervical muscle traction. It also stimulates head lifting and cervical lordosis wich will improve tongue movement and nasal ventilation [2]. Postural assesment-ontogenetic stage II (14 months – 6 years) starts with walking-the postural system builds on the podal element, propriceptive, joints and cutaneous element. The organisation of postural control is now ascendant (feet-head). It is very important the stability of the hips, of side walking equilibrium [1]. At this time, is necessary for the child to aquire: – walking, between 12-15months
– running, at 24 months – climbing stairs altenating the legs, at 30 months – tricycle riding at 3 years – jumping on one foot at 4-5years. Warning – the child doesn’t walking independently at 1, 6 years. POSTURAL DISTURBANCED OF GAIT – Walking with one or both feet în acentuated rotation, frequent falling; – Walking with asymetrical rotation of the feet; – Tiptoe walking (digitigrade); – Genu varum/valgum acentuated/asymetrical; – Dorso-lumbar joint rigidity, disfuntions în hip joints. Unaquired walking at 18 months requires special recomandation for psycho-motor assesment [3]. Plantar Neurosensitive exteroceptive informations play their role în ortostatism’s control [4]. Child’s gait is different from adult’s gait because: – Immaturity of equilibrium [5]. – Insuficiency of muscular force [6]. – Immaturity of neuronal network [7]. A mature gait is considered after 5-6 years of independent walking or after 7 years of age. After 2 years of age, the hip Goes înto the suport stage, in internal rotation and adduction.The pelvis is less antevert and so the hip flexion decreases. Some children keep the pelvis anteversion, wich generates an internal rotation gait and a postural desequilibration [3]. Starting walking generates an internal tibial torsion, wich determines a physiological internal rotation of the forefoot. During growing period are noticed an external femural torsion and an external tibial torsion. There is an physiological oscilation between -genu varum/ valgum. The lower limbs are în their own axe around 7 years of age. Genu varum is physiological before 2 years, then it is genu valgum, wich disminishes until 12 years. It is considered physiological genu valgum în children between 3-10 years, if it is symetrical. At birth there is a normal tibio- tarseal valgum, wich will normally settle until 12 years [8]. Children between 1 and 5 are prone to have flat valgue foot, by insufficient development of the plantar curve [9].

The child walks with everted feet, with sole valgusit dissapears when shoes are talent off [10]. Most of the times, the flat valgue foot spontaneously regresses. The benign caracter of this posture can be checked by asking the child to walk on tiptoes, looking for the Jack sign (the toe extension) [9]. Tiptoe posture anihilates the eversion. This is why we indicate walking barefoot inside, for training the sole muscles. The internal arcade needs to be shaped by the physiological torsion between the forefoot and the backfoot, and rigid wich presents normal when standing on toes or barefoot. It is not necessary to wear orthopedic shoes or undergo kinetotherapy, but to go barefoot inside and wear flexibile sole shoes outside. WALKING ANALYSING We should observe the front barefoot walking, then the back and side walking. Walking analyse criteria: – Legs distancing for a bigger sustaining area; – Syncronisation between upper/lower limbs; – Anterior or posterior postural desequilibrium; – Ankle attack în support phase; – Foot rotation during the support phase; – Tiptoe walking; – Genu recurvatum; – Arms balance, girdle dissociation; – Checking the shoes’soles for abnormal support or vicious postures. PATHOLOGICAL GAIT I. Walking în internal rotation of the feet [12]. a) Internal rotation is normal until 3 years. b) Exagerate femoral antetorsion is frequent before 6 years and it is often familial. We need an X Ray – exam to exclude hip displasia. Internal rotation walking, with knees and feet inside orientated can lead to frequent falling, especially when running [3]. This abnormality is frequently isolated, but it can be seen în cerebral palsy, congenital malformations or secondary to congenital hip luxation or a vicious calous after hip epiphysiolisis or Legg – Perthes- Calve disease [14]. The favourite W pose (kneeling with the bottom between ankles, calves în external rotation) generates exagerate femoral antetorsion, and should be forbidden [15].
c) Excess internal tibial torsion [10]. It is rare. The child preferes to sit with the legs în internal rotation and stuck under the bottom. Metstarsus adductus-it is a rarer cause of internal rotation walking. d) Pelvic persistent anteversion – is the most frequent cause of internal rotation walking, especially în girls. II. External rotation walking – the it is rarer. a) Torsion al abnormalities: – Reduced femoral antetorsion [15] – External calf rotation – Femoral epiphysitis – Neuromuscular abnormalities. b) Pelvic retroversion – it is rarer than the snteversion. It is characterised by smaller lombar lordosis and compensating dorsal cyphosis. III. Genu valgum – is frequent between 2-7 years and it is not pathological if it’ s symetrical. From 2 years of age therek is an femuro-tibial valgum, wich lowers progresively to 5 grades at 8-9 years, stabilising at puberty. În case of asymetrical valgum is required an
X Ray-exam [16]. One sided valgum is pathological – posibile epiphysiolisis. IV. Genu varum-there is an external knee angulation wich is physiological before 2 years. Idiopatic genu varum represents an accentuation of this phenomenon after 2 years. We must search a familial history, with good prognosis. Walking is a little balanced but not painful [16]. În obese children, the fatty tissue from inside the knees can lead to a genu varum like appearence. Genu varum can be accentuated în case of femoral torsion and genu recurvatum [12]. V. Digitigrade walking There must be excluded non-postural origins: congenital shortening of Achilles’ tendon, cerebral palsy, miopathies. Digitigrade walking-clinical findings – When standing still the child stands on the whole sole, when walking he lifts himself on toes – No previous history – No achillean retraction. Until 5, tiptoe walking is due to – immaturity of postural control. If it persists after that, we should test the sural triceps (with extended knee).
We should take podoscopic prints for carved -foot, neurologic -exam (MRI, Babinsky). TREATMENT OF POSTURAL GAIT DISTURBANCES Growing steps are not symetrical, do there are postural asymetries, and we shouldn’t correct one leg’s shortening during growing period. Correction is necessary only when the shortening is post traumatic or there is a serious malformation. If the lenght asimetry is corrected, it has to be checked regularly [13]. Proprioceptive orthosis Exteroceptive plantar sensors have a precision of few milligrams. By contrary, upper sensitivity limits for mecanoreceptors is about 150g [17]. A bove this limits, they won’t give any informations. So, a postural adjustment trough proprioceptive sole supports can be done only with very fine elements, about 3 mm [18]. Proprioceptive stimulation can interact with postural control depending on their localisation, and they have neurosensitive action. Mechanic orthesis Sole orthesis will be recomended to soothe the pain în flat valgue feet, bilateral [19]. They will be recomended only in asymetrical pronation, associated with a pelvic anteversion on pronation’s side [20]. Indications of proprioceptive and mechanical orthesis – Proprioceptive orthesis are inefficient if child’s mielinisation is not complete (before 4-5 years). – Before mielinisation is complete, the cutaneous plantar test leads to toe’s extension-in this case mechanical orthesis can be prescribed. – After mielinisation is complete, the cutaneous plantar test is in flexion, so proprioceptive orthesis can be prescribed. TREATMENT OF INTERNAL ROTATION GAIT A.Treatment of a torsion abnormality Antetorsion/anteversion of femoral neck is mantained by the „W” pose, with external rotation of the legs, pose wich should be forbidden. Sitting pose with legs undergo bottom, in internal rotation, shoud also be forbidden [21]. There 2 poses are frequent seen before 6 years and the abnormality disminishes with age, by lowering the femoral antetorsion. Under 5-6 years, if internal rotation is accentuated and the cutaneous plantar test is in
extension, mechanical orthesis is recomended. If the test is in flexion, proprioceptive orthesis can be recomended, as well as postural and proprioceptive training. B.Treatment of internal rotation gait due to pelvic anteversion Pelvic anteversion leads to an internal rotation of hips, wich can be hidden in case of ligament laxity. Treatment becomes necessary after 5-6 years. Pelvic anteversion required postural treatment if they lead to a sagital desequilibrium. În torsional asymetrical abnormality with gait disturbances, we must check for an pelvic anteversion associated with traumatic anteriorised ileon (falling on buttocks). TREATMENT OF EXTERNAL ROTATION GAIT A. Related to a tensional abnormality – very rare cases, can be fixed spontaneously or short term use of mechanical orthesis. B. Related to Pelvic retroversion – they require treatment only if there is a sagital desequilibrium.
We can use proprioceptive orthesis and postural training [21]. TREATMENT OF DIGITIGRADE GAIT Generally we recomend postural treatment after 5-6 years (if there is no-neuromuscular pathology involved) training and proprioceptive orthesis can be recommended. TREATMENT OF GAIT DISTURBANCES BECAUSE OF GENU VARUM AND GENU VALGUM An accentuated genu varum/valgum leads to gait disturbances and recurent falling. Treatment alternatives depending on cutaneous plantar test. Mechanical orthesis can be prescribed after 3 years of age, with postural training. PROPRIOCEPTIVE TRAINING OF SOLE AREA În case of hipotone feet with postural disturbances, pelvic retroversion or flat back, proprioceptive sole supports won’t give adequate relief. Training can be done by stimulation of sole interactions (irregular surfaces and objects) and muscle stimulation.

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