Proceso de producción

Shortened muscles Lengthened muscles

Pectoralis major Pectoralis minor Rectus abdominis

Middle and lower fibres of trapezius Iliocostalis thoracis

80

KyPhoSiS

Figure 4.2 Therapist techniques for kyphotic posture include passively stretching pectoral muscles in (a) sitting or (b) supine positions, (c) passively stretching one side of the chest only, (d) massaging soft tissues of the chest and (e) applying soft tissue release to pectorals.

a c

d e

b

81 could be performed unilaterally. To do this, your client will need to be positioned diagonally across the treatment couch so that she can extend the shoulder on the side of the chest to be stretched. In this particular example the client has placed her hand behind her head, and you will discover that altering the position of the arm localizes the stretch to a different portion of the pectoral muscle (figure 4.2c).

■ Using the same positions that you use to stretch muscles passively, you could apply muscle energy technique.

■ Massage shortened tissues. Many clients feel comfortable with receiving massage to the clavicular portion of the pectoral muscle. The client can be supine, a position in which you have greatest leverage on this tissue. Where massage of the whole chest is acceptable, concentrate on stretching tissues from the sternum to the shoulder by using less of your massage medium than normal (figure 4.2d).

■ To enhance the stretch of chest tissues, you could use soft tissue release. Holding your client’s arm so that the shoulder is flexed at about 90 degrees, lock the chest tissue using your fingers or fist, gently pushing the tissues away from you. Maintaining your pressure, slowly abduct your client’s arm, passively stretching the tissues. See figure 4.2e, in which the therapist passively abducts the client’s arm. This technique works equally well if the client abducts her own arm, moving it in such a way as to localize the stretch to different parts of the pectoral muscle by varying the degree of abduction.

■ Address alterations to the position of other upper-body parts that are associated with kyphotic posture, in this case forward head posture (chapter 3), protracted scapulae and internal rotation of the humerus (chapter 9).

■ Tape the upper back. One method shown to produce a decrease in thoracic kypho-sis is that used by Lewis and colleagues (2005), described in the box that follows.

What Your Client Can Do

■ Identify any factors that may contribute to the maintenance of a kyphotic posture and avoid these where possible. Not all of the contributing factors may be avoid-able. For example, where there are degenerative changes to vertebrae. Pay particular attention to posture when watching TV, and avoid slouching. Avoid hunching over a steering wheel or desk. When using a laptop position this to avoid a slouched posture and wherever possible use a detachable keyboard. Follow the advice for the correct set up of electronic display screen equipment (see appendix).

■ Actively stretch shortened muscles, in this case the pectorals. Contraction of the rhomboids (figure 4.4a) is a simple method of stretching pectorals and has the advantage that it can be performed surreptitiously almost anywhere.

■ Where chest stretches prove to be uncomfortable, a client could rest supine with a bolster or pillow placed longitudinally along the length of the thorax (figure 4.4b), allowing the arms to relax. As the scapulae relax into a neutral or retracted posi-tion, tissues of the anterior chest wall stretch. Clients with pronounced kyphosis may struggle to adopt this resting position and might even find it uncomfortable because it encourages both extension of the spine (from the normal or exaggerated

KyPhoSiS

82

LeWiS TAPing TeChnique

1. Demonstrate to your client how to extend the thoracic spine, and let him practice this a few times.

2. With the spine in extension, apply a strip of tape bilaterally from T1 to T12 (figure 4.3). Lewis and col-leagues used Leukotape 1.5 inches (3.8 cm) wide.

3. Ask your client to fully retract and depress the scapulae and in this posi-tion apply the tape bilaterally from the centre of the spine of the scapulae to the spinous process of T12, thus forming a V shape (figure 4.3).

Lewis and colleagues made the important comment that whilst their taping protocol did extend the spine and retract, depress and posteriorly tilt the scapulae, in some

patients this had a detrimental effect on shoulder range, supporting one of their conclusions, which was that mechanically correcting posture does not necessarily produce an improvement in function or a decrease in pain.

Consider whether, in the long term, it is better to encourage your clients to facilitate postural correction through strengthening of their own muscles than to encourage reliance on tape, the effects of which may be short lived. Teach your client exercises to strengthen weakened muscles using exercises such as the dart and prone rhomboid retraction to strengthen the middle and lower fibres of tra-pezius and thus help retract the scapulae.

Figure 4.3 Thoracic taping. Tape strips applied bilaterally from T1 to T12 and from the centre of the spine of the scapula to T12 to form a V shape.

kyphotic curve) and retraction of the scapulae. In such cases, simply resting supine in the floor will encourage correction of the spine, unless this is anatomically fixed.

■ Some clients find it helpful to hold a small towel, thus stretching the anterior of the shoulder joint also (figure 4.4c).

■ A wall or doorframe can facilitate a chest stretch where a client has a shoulder problem and cannot stretch both shoulders and both sides of the chest simultane-ously. Try this for yourself. Notice that if you place your hand against a wall, elbow extended, and then turn your body away from the wall, the stretch can be localised to various regions of your chest when you raise your arm, sliding it up the wall before starting the stretch. Some clients find this too strong a stretch. Holding a vertical bar (rather than touching a wall) reduces the stretch because when holding a bar the

KyPhoSiS

83 Figure 4.4 Client techniques for kyphotic posture include (a) stretching pectorals by

con-tracting rhomboid muscles, (b) resting over a bolster, (c) using a towel, and (d) increasing thoracic extension by any means, including using a foam roller.

KyPhoSiS

c a

d b

84