Development of low postural tone compensatory patterns predicted dysfunction patterns in lower part of the body

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1 382 Developmentl Period Medicine, 2014, XVIII, 3 IMiD, Wydwnictwo Alun Ann Gogol 1, Edwrd Sulicz 1,2, Michł Kuszewski 1, Młgorzt Mtyj 3, Andrzej Myśliwiec 1 Development of low posturl tone compenstory ptterns predicted dysfunction ptterns in lower prt of the ody Rozwój wzorców kompenscji oniżonego npięci posturlnego u dzieci przewidywne wzorce dysfunkcji w dolnej części cił 1 Chir of Kinesitherpy nd Specil Methods of Physiotherpy, Acdemy of Physicl Eduction, Ktowice 2 Acdemy of Buisiness, Dąrow Górnicz 3 Chir of Physiotherpy of the Nervous System nd Locomotory System, Acdemy of Physicl Eduction, Ktowice Astrct Lower posturl tone is not lwys ssocited with centrl nervous system structurl dmge. There is such kind of tone tht stys within the rodly defined norml rnge, ut is chrcterized y distinct decrese of tone of the deep muscles responsile for stiliztion. Externl syndromes re fetures of ctive or pssive compenstion oserved in the posturl nd motor ptterns. Active compenstion of the lower muscle tone is ssocited with excessive use of the superficil muscles for stiliztion tht leds to limittion of motion in the joints nd to functionl shortening of some muscles. Active compenstion mechnisms in the lower prt of the ody cuse decresed nterior pelvic tilt, functionl shortening of the hmstring muscles nd pes cvus (spstoidl type). Pssive compenstion is initited in cse of decresed tone of oth deep nd superficil muscles. Stiliztion is kept with considerle prticiption of the sptil shpe of ones, ligments, meniscus nd pssive properties of the muscles. Tendency to hypermoility of the perirthritis elements is oserved, which is mnifested y increse of the physiologicl rnge of motion in the joints. As result in the lower prt of the ody posturl fults develop, which re chrcterized y incresed lumr lordosis, nterior pelvic tilt, vlgus knee nd feet (tetoidl type). Oservtions indicte tht lower tone of the muscles responsile for stiliztion triggers off the sequence of compenstory mechnisms tht ultimtely led to specific posturl fults. Key words: posturl tone, ody stiliztion, low posturl tone, compenstory mechnism, posture fults Streszczenie Stn oniżonego npięci posturlnego nie zwsze związny jest z uszkodzeniem struktur ośrodkowego ukłdu nerwowego. Możn wskzć tki rodzj npięci, który zwrty jest w oszrze szeroko pojętej normy, le wyrźnie cechuje się oniżonym npięciem głęokich mięśni odpowiedzilnych z stilizcję. Zewnętrznym ojwem są cechy kompenscji czynnej lu iernej oserwowne we wzorcch posturlnych i motorycznych. Kompenscj czynn oniżonego npięci wiąże się z ndmiernym wykorzystniem do stilizcji mięśni powierzchownych, co doprowdz do zmniejszeni zkresu ruchomości w stwch orz do funkcjonlnego skróceni niektórych mięśni. Mechnizmy kompenscji czynnej w dolnej części cił

2 Development of low posturl tone compenstory ptterns predicted dysfunction ptterns in lower prt of the ody 383 prowdzą do zmniejszonego przodopochyleni miednicy, funkcjonlnego skróceni mięśni kulszowo- -goleniowych orz do wd stóp o chrkterze wydrążeni (typ spstoidlny). Kompenscj iern zostje uruchomion w sytucji oniżonego npięci zrówno mięśni głęokich, jk i powierzchownych. Stilizcj utrzymywn jest przy zncznym udzile przestrzennego ksztłtu kości, więzdeł, łąkotek i psywnych włściwości mięśni. Oserwuje się wówczs tendencję do hipermoilności elementów okołostwowych, co mnifestuje się zwiększeniem fizjologicznego zkresu ruchu w stwch. W efekcie w dolnej części cił dochodzi do powstni wd postwy chrkteryzujących się zwiększeniem lordozy lędźwiowej, przodopochyleniem miednicy, koślwością koln i stóp (typ tetoidlny). Oserwcje wskzują, że oniżone npięcie mięśni odpowiedzilnych z stilizcję wyzwl szereg mechnizmów kompenscji, które finlnie doprowdzją do powstni specyficznych wd postwy cił. Słow kluczowe: npięcie posturlne, stilizcj cił, oniżone npięcie posturlne, mechnizm kompenscji, wdy postwy DEV. period med., 2014, XvIiI, 3, Specificity of the pelvis nd lower lims control in children with spstoidl type Setting out to nlyze the qulity of the lumr segment nd pelvic control, it is worth exmining this issue from the ngle of Snijders nd Vleeming studies (1-3). The uthors descrie self-locking mechnism of the scroilic joints in prticiption of oth ctive (force closure mechnism) nd pssive susystem (form closure mechnism) (4-6). The force closure of the scroilic joints is eing ccomplished through ctivtion of the glol myofscil-ligmentous systems generting forces perpendiculr to the joint surfce nd hence incresing compression nd friction force. The muscles responsile for ccomplishment of the force closure crete few chrcteristic trins (longitudinl posterior trin, olique posterior nd nterior trin, lterl trin). Activtion of these trins to vrile extent cn influence scrotuerous ligment tension cusing excessive or too low compression of the scroilic joints (1, 2, 7, 8). Wheres the form closure mechnism is eing ccomplished y the proper sptil orienttion of the joint surfces nd wedged shpe of the scrum. The ltter rms etween the pelvic ones on the pttern of so-clled keystone in the rchitecturl rc (1-3). It seems tht in children with low posturl tone coopertion of these mechnisms in stiliztion is distured. Depending on the type of tone, excessive use of the force closure or form structure mechnism is oserved. In children with spstoidl type excessive ctivtion of the glol myofscil complexes generting compressive forces to the joint surfce re oserved. This hs direct impct on the pelvis nd lower lims lignment. Hip muscle dductors incresed ctivity constitutes the reson for lower lims lignment in the pttern of extension, dduction nd internl rottion (fig. 1, ). In this sitution, the femur heds to lower degree undergo the pressure to the cetulum. As consequence, the cetulum steepness nd vlgus femur necks my e dignosed in lter yers. Increse of the force closure prticiption limits the ility of posturl component involvement through the impct on the hip joints surfces sptil orienttion. Anlyzing the issue of excessive use of the force closure mechnism it is prticulrly worth noting the role of the hmstrings, which re included in the posterior longitudinl trin. Vn Wingerden J.P. nd co-uthors descrie the mentioned muscles s for oth internl nd externl stiliztion of the scroilic joint (9, 10). Internlly this influence is ssocited with strong ntomicl nd physiologicl reltions etween the iceps femoris muscle nd scrotuerous ligment. In the ontogenetic development, such movement ctivities re oserved which re ssocited with preprtion of the discussed muscles for future functions. The hmstrings of the neworn infnt demonstrte shortening due to the flexed fetus position, nd just five months old infnt is le to gr its feet y its hnds with knee joints extended (fig. 2). Children with spstoidl type on ccount of considerle hypertoni of the lower lims muscles omit the discussed ility which prevents from gining the full length of the hmstrings (fig. 2). It is difficult to stte unmiguously whether the stiffness of the hmstrings frequently oserved in dults is ssocited with the lck of formtion of the full length of these muscles in ontogenesis or whether it is cquired s result of the compenstory mechnisms involvement in lter yers. Nevertheless, incresed tension of these muscles in dults my e

3 384 Ann Gogol i wsp. Olique dominl muscle m. skośne rzuch erector spine muscle m. prostownik grzietu m. dwugłowy ud Fig. 1. Excessive ctivtion of the glol myofscil complexes in infnt with spstoidl type: ) in prone position strong ctivtion of posterior longitudinl trin; ) in stnding position strong ctivtion of nterior olique trin. Ryc. 1. Ndmiern ktywcj dużych zespołów mięśniowych u niemowlęci z typem spstoidlnym: ) w pozycji proncyjnej siln ktywcj tśmy podłużnej tylnej; ) w pozycji stojącej siln ktywcj tśmy ukośnej przedniej. Adductor muscle m. przywodziciele Fig. 2. Diversity of the hmstrings ctivities in infnts of similr developmentl ge: ) ility to extend the knee joint during feet gr in infnt with normotonic type; ) lck of the knee joint extension during feet gr in infnt with spstoidl type. Ryc. 2. Zróżnicownie ktywności mięśni kulszowo goleniowych u niemowląt w podonym okresie rozwojowym: ) zdolność wyprostu stwu kolnowego podczs chwytni z stopy u niemowlęci z typem normotonicznym; ) rk wyprostu stwu kolnowego podczs chwytni z stopy u niemowlęci z typem spstoidlnym. prt of the involuntry rthrokinemtic ody defense mechnism tht hs the tsk of reducing the spinl lod (11-13). If such sitution lsts long enough, the hmstrings (especilly iceps femoris) ecome shorter nd secondrily cuse dysfunction of the scroilic joint nd lumr segment (9). Tensed nd shorten hmstrings effectively limit nterior pelvic tilt, which cn e oserved from the infncy (fig. 3, ). The lignment of the muscle trins tht provide the most economic stiliztion in the lumr segment shows some diversity within this group. Oservtions indicte two possiilities: decrese of lumr lordosis (fig. 4) or its shortening with distinct deepening (short nd deep lordosis) (fig. 4). However, reduction of lumr lordosis occurs the most often, which is utomticlly connected with reduced nterior pelvic tilt. Shortening of the hmstrings hs direct effect on the muscles, which constitute their functionl continution, tht is, on gstrocnemius muscles. The heds of these muscles through the dhesion to the upper prts of the femor condyles rech up nd

4 Development of low posturl tone compenstory ptterns predicted dysfunction ptterns in lower prt of the ody 385 Fig. 3. Decresed nterior tilt of the pelvis oserved in the infnt with spstoidl type: ) in supine position; ) in prone position. Ryc. 3. Zmniejszone przodopochylenie miednicy oserwowne u niemowlęci w typie spstoidlnym: ) w pozycji supincyjnej; ) w pozycji procyjnej. surround the hmstrings tendons. The ltter descend, surround the gstrocnemius muscle nd dhere to the tii nd fiul ones. The sole prt of the foot constitutes the lst link of the functionl connections of the muscles plced on the posterior surfce of the lower lim nd specificlly plntr fsci, tendons nd venters of the short fingers flexors muscles (14). It cn e expected tht formtion of the foot would e the result of the functions of the muscles plced ove. It cn e conjecture tht in children with spstoidl type, development of the pes cvus occurs s result of the strong tension of the muscles of the lower lim posterior prt. Specificity of the pelvis nd lower lims control in children with tetoidl type Insufficiency of the ctive susystem oserved in children with tetoidl type imposes the oligtion to tke over the stiliztion function y the pssive susystem. Interprettion of this issue in the spect of Vleeming nd Snijders studies, llows to conclude tht distinct reduction of the force closure prticiption imposes increse of the form structure prticiption in the stiliztion of the lumr segment (1-3). By reson of the reduced tone of oth locl nd glol muscles in children with tetoidl type norml ctivtion of glol myofscil complexes producing perpendiculr compressive forces to the joint surfces re not oserved (fig. 5, 6, ). Insufficiency of the ctive susystem lredy in infnts ffects the pelvis lignment in the sustntil nterior tilt in oth supine nd prone positions (fig. 7, ). After otining the upright posture this condition ecome even more visile nd mintennce of the spinl xis flls primrily on the pssive susystem structures (fig. 8). Resulting system resemles lower crossed syndrome type descried y Jnd with considerle Fig. 4. Vrints of the pelvic lignment in spstoidl type: ) decresed lumr lordosis; ) deepened nd shortened lumr lordosis. Ryc. 4. Wrinty ustwieni miednicy w typie spstoidlnym: ) zmniejszon lordoz lędźwiow; )pogłęion i skrócon lordoz lędźwiow. nterior pelvic tilt nd wek stiliztion of the hip joints (15). It is necessry to emphsize tht in the form closure mechnism mintennce of the stility does not require energy input, ecuse it is ccomplished s result of the proper sptil orienttion of the joint surfces s well s the wedged shpe of the scrum. It is lso worth pying ttention to the hyperextension of the knee joints, which re used s the dditionl form of the stiliztion in the pssive compenstory mechnism (fig. 8). Such compenstory mechnism leds to insufficiency of the medius nd minimus gluteus muscles tht cn result in excessive internl rottion of the hip joint in

5 386 Ann Gogol i wsp. mm. skośne rzuch mm. przywodziciele Fig. 5. Lck of norml ctivtion of the myofscil complexes in infnt with tetoidl type (wek ctivity of the nterior olique trin). Ryc. 5. Brk włściwej ktywizcji zespołów mięśniowopowięziowych u niemowlęci z typem tetoidlnym (sł ktywność tśmy ukośnej przedniej). Furthermore, it is worth pying ttention to reltion etween the pssive compenstion mechnisms with occurrence of the scoliosis. Incresed nterior pelvic tilt oserved in the children with tetoidl type fvors self-olting of the scroilic joints. Sptil projection of the fcet joints in the lumr segment cuse their olting in the mximl spinl extension. A sitution, in which joint surfces of the two neighor segments re in the optiml contct cuse olishment of ny dditionl degrees of freedom of movement. In other words, ll lumr segment is olted in extension. The direct consequence of lumr lordosis lengthening is neutrliztion of the thorcic kyphosis nd development of the hollow ck in the sgittl plne (Fig. 8). Here is tht mny of the contemporry uthors oserve flttening of the thorcic kyphosis in sujects with idiopthic scoliosis (22, 23). Sommerville s erly s in 1952 hd stted the ppernce of decresed thorcic kyphosis in course of the thorcic scoliosis (24). A dozen yers lter Rof hd reveled tht in the idiopthic scoliosis nterior spinl column (including Adominl olique muscles mm. skośne rzuch Ltissimus dorsi musle m njszerszy grzietu Gluteus mximus musle m. pośldkowy wielki Adductors muscles mm. przywodziciele Fig. 6. Lck of norml ctivtion of myofscil complexes in the sme child s in fig. 5 t the ge of two: ) wek ctivity of the nterior nd posterior olique trins in the sgittl plne; ) wek ctivity of the posterior olique trin in the frontl plne. Ryc. 6. Brk włściwej ktywizcji zespołów mięśniowo powięziowych u tego smego dzieck (ryc. 5) w wieku dwóch lt: ) sł ktywność tśmy ukośnej przedniej i tylnej w płszczyźnie strzłkowej; ) sł ktywność tśmy ukośnej tylnej w płszczyźnie czołowej. the upright posture (fig. 9) (16). Such sitution increses compenstory forces in the lterl comprtment of the femorotiil nd femoroptellr rticultion joints, wheres shift of the ody weight on the medil side of the foot results in the longitudinl medil rch flttening nd pes plnus s well s vlgus nkle (17-21). verterl odies nd interverterl discs) is longer thn posterior spinl column (25). Longitudinl studies crried out within 3 yers on the group of 896 children show tht sujects with scoliosis ngle s vlue > 10 cc. to Co were tller nd hd reduced thorcic kyphosis in comprison with children without ny

6 Development of low posturl tone compenstory ptterns predicted dysfunction ptterns in lower prt of the ody 387 Fig. 7. Incresed nterior pelvic tilt oserved in infnts with tetoidl type: ) in supine position; ) in prone position. Ryc. 7. Zwiększone przodopochylenie miednicy oserwowne u niemowląt w typie tetoidlnym: ) w pozycji supincyjnej; ) w pozycji proncyjnej. Fig. 8. Stiliztion of the lumr segment sed on excessive use of the firm closure nd hyperextension of the knee joints. Ryc. 8. Stilizcj odcink lędźwiowego zując n ndmiernym wykorzystniu zmknięci strukturlnego orz przeprostch w stwch kolnowych. Fig. 9. Oserved muscles imlnce leding to vlgus knees nd feet in the child with tetoidl type. Ryc. 9. Oserwowny stn nierównowgi mięśniowej doprowdzjący do koślwego ustwieni koln i stóp u dzieck z typem tetoidlnym. deformtions of the spine (26). Tomschewski lso indictes the essentil role of the thorcic kyphosis flttening s well s multi-segmentl limittion of the ntireflexion in this spinl segment in the pthogenesis of idiopthic scoliosis (23). If we tke into considertion the fct tht in the thorcic segment verterl odies trnsfer verticl lod primry, then in cse of thorcic kyphosis flttening this force to the higher degree ecome trnsferred through the fcet joints. Wht is worse sed on the mthemtic scheme of the spine it hs een reveled tht some of the spinl segments inclined posteriorly generte dorslly directed sher forces (27). Sptil projection of the fcet joints in the thorcic segment predisposes them to performnce of the movement prticulrly in the crosswise section, therey not ensures full rottionl control of the vertere, especilly in the sitution of dorslly directed sher forces (28, 29). Studies of Cstelein nd Verrt show tht posterior inclintion of the vertere in the sgittl plne constitutes prediction of the progressive idiopthic scoliosis (30). Therefore, in cse of the thorcic kyphosis flttening sher forces re trnsferred through the fcet joints

7 388 Ann Gogol i wsp. then t their significnt freedom in crosswise plne little dditionl internl or externl impeding vrile is sufficient to throw the segment off its peculir lnce nd to cuse its grdul rottion to the one side. Becuse, s it is known, there is lwys link etween the rottionl movements of the spinl segment nd the lterl flexion movements, fvorle sitution occurs to initite the lterl scoliosis. Considering the ove, it cn e stted tht the primry source of mny idiopthic scoliosis my e the pssive compenstory mechnism, which leds to thorcic kyphosis flttening. Confirmtion of these hypothetic deliertions could e retrospective exmintion of the children with dignosed posturl hypotoni nd cyclic screening of the children with the tetoidl type. Perhps, detection of the pssive compenstion in infncy would llow to record erly symptoms of lterl scoliosis tht would e crucil for further tretment. REFERENCES 1. 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8 Development of low posturl tone compenstory ptterns predicted dysfunction ptterns in lower prt of the ody Od I., Aumi K., Cunninghm B.W., Kned K., McAfee P.C.: An in vitro humn cdveric study investigting the iomechnicl properties of the thorcic spine. Spine 2002, 27, E Tkeuchi T., Aumi K., Shono Y., Od I., Kned K.: Biomechnicl role of the interverterl disc nd costoverterl joint in stility of the thorcic spine. A cnine model study. Spine 1999, 24, Cstelein R.M., Verrt B.: Idiopthic scoliosis: prognostic vlue of the profile. Eur. Spine J. 1992, 1, Author s contriutions/wkłd Autorów According to the order of the Authorship/Według kolejności Conflicts of interest/konflikt interesu The Authors declre no conflict of interest. Autorzy prcy nie zgłszją konfliktu interesów. Received/Ndesłno: Accepted/Zkceptowno: Pulished online/dostępne online Address for correspondence: Ann Gogol Ktedr Kinezyterpii i Metod Specjlnych Fizjoterpii Akdemi Wychowni Fizycznego ul. Mikołowsk 72, Ktowice tel e-mil: nigogol@op.pl