Violencia de género, contra la mujer y el grupo familiar

This is a position in which a degree of asymme- try between the two sides of the body is invari- ably present. Figure 3.7 illustrates one posture which may be adopted by an individual when asked to assume this position.

Certain characteristics may be noted. The weight-bearing side of the body is more extended and elongated than the non-weight-bearing side which is side flexed. This position is influenced by the anatomical structure of the individual; the greater the pelvic girth, the greater is the side flexion of the non-weight-bearing side.

There are many variations of the side-lying position. One such variation is bilateral flexion of the legs where the individual takes up a modi- fied foetal position.

The position of the shoulder is determined by the tendency to lie towards prone or supine. Only those with bilateral leg flexion will lie with one side of the body virtually in alignment with the other. People who lie towards supine tend to protract the supporting shoulder, whereas those who lie towards prone tend to lie with the

Figure 3.7 Side-lying.

supporting shoulder retracted. Accordingly, the degree of trunk rotation varies in respect of the position of the shoulders and their relationship with the pelvis.

The weight-bearing side provides stability, through its acceptance of and interaction with the base of support, to allow for selective move- ment of the non-weight-bearing side. Impair- ment resulting in inactivity or inappropriate activity of the weight-bearing side may disrupt or prevent functional movement of the non- weight-bearing side.

This is a position widely used and recom- mended in the positioning of patients with neu- rological disability (Bobath 1990, Davies 1994). The relative asymmetry of this position enables 'the break up' of either predominant flexor or extensor hypertonus. It is also recommended as a

position whereby coordination, postural control and sensory reintegration of the weight-bearing side may be facilitated through functional move- ment of the non-weight-bearing side.

Sitting

Analysis of this position is complex due to the varying amount and type of support offered. This posture is described in terms of unsupported and supported sitting.

Unsupported sitting with the hips and knees at 90 degrees

Anti-gravity control in unsupported sitting (Fig. 3.8) is recruited primarily through extensor

Figure 3.8 Unsupported sitting.

activity at the pelvis and lumbar spine. In the absence of full support this anti-gravity, extensor activity is essential for dynamic maintenance of an upright posture. Consideration of the base of support in relation to the feet is discussed when analysing moving from sitting to standing.

The shoulder girdles are protracted with medial rotation and adduction of the shoulders. This reflects the relative lack of activity required by the upper limbs to maintain this posture.

The position of the pelvis depends upon the degree of upright or slumped sitting assumed by the individual. There is an element of extensor activity observed primarily at the lumbar spine and reflected in the degree of anterior pelvic tilt.

The degree of pelvic tilt influences the posi- tion of the lower limbs and vice versa. It is observed that the starting position affects associ- ated limb movements. With the hips and knees at 90 degrees or more flexion, the greater the anterior tilt, the more pronounced will be the degree of lateral rotation and abduction. How- ever, if the subject is seated on a higher chair with the hips and knees at an angle of less than 90 degrees, an increase in the anterior pelvic tilt tends to produce medial rotation and adduction. Conversely, if a patient has limited hip flexion, this is combined with posterior pelvic tilt and flexion of the lumbar spine.

Unsupported sitting is a position of predomi- nant flexion with recruitment of extensor activity arising primarily at the lumbar spine, pelvis and hips.

Supported sitting

The amount and type of support offered varies considerably between, for example, a dining chair and a lounge chair. The dining chair is a more rigid structure and therefore most individ- uals are less likely to relax and depend on it for full support. In many respects, the posture taken up by an individual sitting on a dining chair is no different from that of unsupported sitting.

Conversely, the lounge chair, depending upon the degree of comfort, the angle of recline and the provision or otherwise of a head support, affords more support to the individual (Fig. 3.9). The

Figure 3.9 Supported sitting.

body conforms to the chair with a posterior pelvic tilt and the shoulder girdles protracted. The arms and legs rest in various and diverse positions. Movement away from this position of full sup- port initially requires flexor activity closely fol- lowed by extension to provide the proximal stability essential for the achievement of function such as reaching for a cup or preparing to stand.

Supported sitting in a lounge chair is a posi- tion of predominant flexion, there being no necessity to recruit anti-gravity activity, given the extended base of support offered by the chair back and arms.

In contrast, the amount of activity when sitting on a dining chair depends upon the position of the pelvis: the degree of anterior or posterior tilt and whether it is forwards on the edge of the chair or positioned at the back of the chair.

The distribution of tone is also dependent on the extent of support. This support is substantially increased if the individual leans forward, resting the arms on a table such as when writing. In this posture there is a marked reduction in the anti- gravity activity within the trunk and pelvis. The size and distribution of the base of support are changed significantly with more weight being taken through the upper limbs, and hence the requirement for dynamic postural stability within the trunk and pelvis is reduced.

Clinical application

This analysis of sitting assists with the planning of treatment interventions. For example, for pa- tients with hypertonus, it may be more effective to provide an increased base of support in sitting to facilitate tone reduction. Conversely, for those with hypotonus, where the aim of treatment is to increase tone, less support should be provided by the therapist, thereby facilitating activity within the trunk. This analysis is also relevant to the provision of wheelchairs and the correct posi- tioning of the patient in the chair. The position of the pelvis will have a direct influence on the posture of the lower limbs. Equally, the use of upper limb support, such as a tray attached to a wheelchair, will have a direct effect on trunk and pelvic activity.

Standing

Standing requires extensive anti-gravity activity to sustain the upright position over a relatively small base of support.

Muscle relaxation tends to accentuate the lumbar, thoracic and cervical curvatures and the pelvis tilts anteriorly. This posture may be seen in particularly lethargic individuals and in women in the later stages of pregnancy (Kapandji 1980).

Normal subjects may demonstrate flattening of spinal curvatures commensurate with their level of tonus (Fig. 3.10). This is initiated at the level of the pelvis. The anterior tilt of the pelvis is counterbalanced by the activity, primarily of gluteus maximus and the hamstrings, restoring the horizontal alignment of the interspinous line

Figure 3.10 Standing.

between the anterior superior iliac spine and the posterior superior iliac spine. The abdominal muscles contract in conjunction with the gluteus maximus to flatten the lumbar curvature. From this position the paravertebral muscles can act effectively to pull back the upper lumbar verte- brae and extend the vertebral column (Kapandji 1980).

In standing, the upper limbs adopt a position of medial rotation with the shoulder girdles pro- tracted. Providing the centre of gravity remains within the base of support, the upper limbs are not essential for the maintenance of balance. This state of relative inactivity enables freedom of movement of the arms for the performance of functional tasks.

It may be postulated that the position of the pelvis determines the extent of activity at the shoulder girdles and upper limbs. An anterior pelvic tilt introduces an element of flexion at the hips counteracted by increased extensor activity in the trunk, shoulder girdles and upper limbs. A neutral position of the pelvis or a slight posterior tilt produces a more mechanically efficient position as the iliofemoral ligament pro- vides anterior stability which complements the extensor activity at the hips and pelvis.

Activity within the foot musculature varies according to the size of the base of support. There is less activity in stride standing than when standing with a smaller base of support when the feet are closer together. The constant adjustments by the lower limbs and feet in response to any change in weight distribution serve to maintain the centre of gravity within the supporting surface. For this activity to be effective, adequate mobility within the feet and in the muscles acting over the ankle joint is essential.

In clinical practice it is observed that the major- ity of patients with abnormal tone affecting the feet lose some and, in severe cases, all of this mobility and as a result their balance in standing is impaired. Unless the problem of immobility of the feet is first addressed, rehabilitation of standing balance will be compromised.

ANALYSIS OF MOVEMENT