You are on page 1of 20



Gravitational Effects
Posture Analysis
Postural Changes During Growth
Gravitational Forces
Stabilization Mechanisms
The Alexander Technique
The Perry Technique
Stance and Motion Postures
Static Stance and Sitting Postures
Dynamic Postures
The Walking Function
Examination of Gait
Running and Jumping
Practical Fluid Mechanics
Typical Effects of Balance Defects
Effects of Bipedism
Body Type and Balance Defects
Etiology of Postural Faults
Basic Physiologic Reactions to Postural Faults

Gravitational Effects
Improper body alignment limits function, and thus it is a concern of
everyone regardless of occupation, activities, environment, body type,
sex, or age. To effectively overcome postural problems, therapy must
be based upon mechanical principles. In the absence of gross
pathology, postural alignment is a homeostatic mechanism that can be
voluntarily controlled to a significant extent by osseous adjustments,
direct and reflex muscle techniques, support when advisable,
therapeutic exercise, and kinesthetic training.
In the health sciences, body mechanics has often been separated from
the physical examination. Because physicians have been poorly

educated in biomechanics, most work that has been accomplished is

to the credit of physical educators and a few biophysicists. Prior to
recent decades, much of this had been met with indifference if not
opposition from the medical profession.

Posture Analysis
It has long been felt in chiropractic that spinal subluxations will be
reflected in the erect posture and that spinal distortions result in the
development of subluxation syndromes. Consequently, an array of
different methods and instrumentation has been developed for this
type of analytical approach such as plumb lines with foot positioning
plates to allow for visual evaluation relative to gravitational norms,
transparent grids, bubble levels, silhouettographs, posturometer
devices to measure specific degrees in attitude, multiple scale units to
measure weight of each vertical half or quadrant of the body, and
moire contourography.


The normal gait presents smoothness of function without any sign of
impairment or afflection of parts of the body. The normal walking cycle
is considered to have two phases:
(1) a stance phase, when the foot is in contact with theground; and
(2) a swing phase, when the foot is moving forward in the air (Fig.

During normal walking, one leg is in the stance phase while the other
isin the swing phase. Muscles must contract to counterbalance the
forces of gravity, to offer acceleration or deceleration to momentum
forces, and to overcomethe resistance of the walking surface.
The Stance Phase. About 60% of the walking cycle is used in the
stance phase. Because the stance phase is the weight-bearing phase
requiring the greatest stress, most problems will become apparent in
its analysis. The stance phase is subdivided into:
(1) heelstrike,
(2) footflat, and
(3) toe pushoff.
Midstance is that weight-bearing period between footflat to toeoff. The
duration of gait is usually measured from heelstrike to heelstrike, but
any two identical points can be taken.
The Swing Phase. This is subdivided into:

(1) initial acceleration,

(2) mid swing, and
(3) final deceleration --depending upon the intent.
The swing phase, about 40% of the gait cycle, begins with toeoff and
ends with heelstrike. Midswing represents the transition period
between acceleration and deceleration

Examination of Gait
Every person has a gait, or manner of progressive locomotion, which is
peculiar to that individual. However, there are also various modes of
walking peculiar to certain diseases which are important diagnostic
clues. The range of movements in the lower extremities assists in
recognizing specific diseases and helps the doctor of chiropractic
determine postural changes resulting from an unnatural gait. For
instance, a shortened leg gives a characteristic limp. A stiff knee
causes the affected limb to swing outward while walking. Intermittent
claudication or limping is observed in chronic peripheral vascular
diseases such as endarteritis because muscular activity requires more
blood than muscular inactivity.
As the walking gait is the most fundamental form of dynamic posture,
it should form the basis of holistic biomechanical analysis. In health,
most locomotive adjustments are conducted at an unconscious level.
This is not true with the patient suffering a neuromusculoskeletal
disability affecting gait. Every motion may require a frustrating
conscious effort such as that taken by a healthy person stepping into
a canoe where the support is unfamiliar.
Although children emulate adult gait in many respects, there are
differences that must be considered in analyzing a pathologic or
functionally impaired gait during childhood. Foley and associates,
utilizing a TV-computer system of data gathering and analysis, found
that joint-angle ranges were the same in children as those of
adults.5(155)4 However, accelerations, velocities, and linear
displacements were consistently larger for children aged from 6 to 13
years (mean value 10.2) than were adult values.


During examination, have the subject sit in a chair, arise, and then
walk across the room if you have not had an opportunity to witness
this previously. The chair should be one that gives firm sitting support
and provides for 90 flexion of the knees and hips.
While the patient is sitting, note from the front the patient's sitting
balance, levelness of ears, shoulders, and pelvis. From the side, note
head, shoulder, and pelvic carriage. Observe how the patient rises
from the chair to the standing position. Note the needed base of
support: how far the knees are apart and how far the forward foot is
from the back foot. If the chair has arms, note the degree the hands
are used from sitting to standing to assist weak knees, weak hip
extensors, or to maintain stability, balance, and coordination.
Noting a gait deformity and in what phase it occurs is most helpful to
diagnosis. Many subtle but significant points are frequently missed in
the fully clothed patient, thus the patient should be minimally clothed
and examined in a private environment. Immediately after analysis,
make a graphic or mental record of your impressions of the subject's
gait. Osler, the great diagnostician, warned that more can be learned
by observing the body in dynamic action than can be learned upon
the autopsy table when it is too late to help.
During normal ambulation, the normal range of motion at the ankle is
from 20 plantar flexion to 15 dorsiflexion. The knee moves 65 from
flexion to extension. At the hip, about 6 of adduction occurs and a

45 range is necessary from flexion to extension.

After the walking sequence has been initiated, the movements are
normally continued in a rhythmic manner solely by reflex actions. The
stretch reflex of the antagonistic extensor muscles is reflexly inhibited
as the flexors of the hip, knee, and ankle are stretched. Walking
actions are maintained by the reflexive interplay of muscles acting
around the joints in motion (Fig. 4.24).
During the stance phase, the heelstrike to footflat, footflat to
midstance, midstance to heeloff, heeloff to toeoff, toeoff to midswing,
and midswing to heelstrike actions should be analyzed. During the
swing phase, which is only about a third of the cycle, the acceleration
to midswing and midswing to deceleration actions should be analyzed.
Inspection. At heelstrike, the ankle is between dorsiflexion and
plantar flexion, the knee is fully extended, the hip flexes to about 25,
and the head and trunk are vertical. The right arm is posterior to the
midline of the body with the elbow extended, and the left arm is
anterior to the midline with the elbow partially flexed. The pelvis is
slightly rotated anteriorly, the knee is extended, and the leg is
vertically aligned with the pelvis. The foot is near a right angle to the
leg on the side of heelstrike, and the plantar surface of the forefoot is
visible from the front (Fig. 4.25).
Mechanisms. The reactive force of the ground tends to plantar flex
the foot so that a large surface contacts the ground, to flex the knee,
and to drive the hip into greater flexion. This reactive force is checked
by extensor action of the joints involved; ie, contraction of the ankle

dorsiflexors, eccentric quadricep contraction at the knee, and

contraction of the gluteus maximus and hamstrings at the hip. These
mechanisms prevent flexion collapse under body weight and absorb
the impact jar at heelstrike. There is also some contraction of the
posterior hamstrings at heelstrike, but this is considered only to
prevent hyperextension of the knee.
Joint Reaction. At heelstrike, it has been calculated that the
magnitude of the joint reaction at the foot is 5.8 times body weight for
a heavy, energetically walking male. It is 2.3 times body weight for an
average female walking slowly. For both male and female, the
maximum joint reaction at the knee during walking is about four
times body weight. The posterior cruciate ligaments carry more than
twice the shearing forces carried by the anterior cruciates.

Inspection. In weight bearing, the pelvis rotates on its vertical axis,
the femur rotates on the pelvis, and the tibia rotates laterally on the
Mechanisms. During footflat, maximum stabilization of the foot
occurs during stance when body weight is directly above the foot.
Forward momentum eliminates the need for active hip and ankle
flexion or extensor stabilization, but there is some knee flexion by
quadricep contraction. When body weight is placed on the stance side,
the plantar flexors of the foot contract to counterbalance the reactive
force of the walking surface which forces the foot into dorsiflexion up
to 15 at heeloff, and the adductors of the hip contract to
counterbalance the pelvic adduction resulting from pelvic tilt.

Inspection. At midstance, the head and trunk are vertical with the
arms near the midline of the body and at an equal distance from the
body. The elbows are partially flexed. On the weight-bearing side, the
pelvis is rotated slightly anterior, the knee is in slight flexion, the leg is
in slight lateral rotation at the hip, and the ankle is in slight
dorsiflexion. There is a downward pelvic tilt on the contralateral side
(Fig. 4.26).
Mechanisms. Following full vertical weight bearing, the line of
gravity moves forward on the stabilized plantar surface to produce a
reactive force which contributes to ankle, knee, and hip extension. Hip
extension reaches about 15 at the time of heeloff. This takes place
without any active extensor muscle action, but some stabilization
effect occurs by the iliopsoas. During this process, the gravity line
falls anterior to the knee so that quadriceps action is no longer
necessary. The ground reaction moves from the midfoot to the forefoot
as toeoff approaches which increases the moment of dorsiflexion. In
reaction, plantar flexion contraction peaks at heeloff to drive the body
forward. While this tends to extend the knee, full extension is
restricted by the gastrocnemius --an ankle and knee flexor.
Energy Absorption. During gait, peak activity of the joints of the
lower extremity is reached during the period of double support. At this
period, the knee muscles are absorbing energy while the other joints
are producing energy. As the hamstring group and gastrocnemius are
two-joint muscles, much of this energy can be transferred to produce
energy at other joints.

Compensation. When the power output of one segment exceeds the

power required, the surplus energy must be absorbed by other
segments. Likewise, when the power requirement of one segment
exceeds muscle output, the energy necessary must come from other
Effect of Shoe Lift. Although unsymmetrical lower extremity length
has long been known to have adverse effects in the spine, only recently
has its effects on contributing to depleting the body's energy stores
been measured. Delacerda and Wikoff have shown that the
equalization of leg length by a shoe lift equalized the time durations
for the four phases of gait and decreased the kinetic energy of the
lower extremity segments for both legs in spite of the difference in
segmental masses of the legs bilaterally. (158)

Inspection. On the side of pushoff, the arm is anterior to the
midline of the body and the elbow is partially flexed. On the
contralateral side, the arm is posterior, the elbow is slightly extended.
Both arms are equally distant from the body. On the side of pushoff,
the femur is slightly rotated laterally at the hip, the knee is slightly
flexed, the ankle is plantar flexed, and the toes are hyperextended at
the metatarsophalangeal joint. The plantar surface of the heel and
midfoot should become visible from the posterior during pushoff (Fig.
Mechanisms. The later part of stance occurs between heeloff and
toeoff and provides the major portion of forward and vertical
propulsion force. The hip adductors and iliopsoas begin to contract in

anticipation of the swing phase, but most action occurs at the ankle
and knee. The ankle changes from about 15 dorsiflexion at heeloff to
about 35 plantar flexion at toeoff, and the extended knee flexes to
about 40 as the quadriceps contract. At toeoff, the segments begin to
reverse the lateral rotation attained during footflat, and this medial
rotation of the pelvis, thigh, and leg continues to 2035, depending
on walking speed, until the next footflat is reached. Once the toes
leave the ground, hip and calf muscles relax.

Inspection. The period of acceleration of the advancing leg occurs
during the first part of the swing phase when the limb is between
toeoff and midswing. The swing phase involves almost simultaneous
hip flexion, knee flexion, ankle dorsiflexion, and usually a concomitant
forward swing of the hip that rotates the pelvis contralaterally to some
Mechanisms. The primary forces are generated by the hip flexors
and ankle dorsiflexors. Hip flexion is governed by the tensor fasciae
latae, the pectineus, and the sartorius. The most powerful hip flexor,
the iliopsoas, and the adductor magnus are not active during swing,
according to electromyographic evaluations. Knee flexion is aided by
sartorius contraction, gravity, and passive pull of the posterior
hamstrings. The flexion of the knee after toeoff is passive while the
thigh accelerates forward from action by the hip flexors. As the hip
and knee continue to flex and the ankle dorsiflexes, the leg "shortens"
so that it can clear the ground.


Inspection. The head and trunk are vertical, and both arms are near
the midline of the body and held an equal distance from the body. On
the weight-bearing side, the pelvis is rotated slightly anteriorly and
tilted downward, the hip and knee are flexed, the femur is rotated
slightly medial at the hip, the leg is vertically aligned with the pelvis,
and the foot is at a right angle to the leg and slightly everted (Fig.
Mechanisms. At heelstrike, the ankle is held in its neutral position
by its dorsiflexors, especially the anterior crural muscles, the knee
rapidly moves from flexion to full extension by hamstring contraction,
and this hamstring contraction also slows hip flexion. During the
swing phase, there is a ballistic movement of hip flexion where the
thigh is first accelerated by the hip flexors at the beginning of swing
and then decelerated by the hip extensors.

From the lateral note rhythm, symmetry, speed, and stride lengths of
cadence. Vertical excursion is best viewed from the side. Check if the
duration of the stance phase is the same bilaterally. As the patient
walks, note all deviations from normal gait. Normally, the head and
trunk are vertical, stride length is even, and the arms swing freely and
alternate with the leg swing.
Note the foot at heelstrike and pushoff. The foot is about at a right
angle to the leg and the knee is extended but not locked at heelstrike.

At pushoff, the foot is firmly flexed and the toes are hyperextended.
The foot easily clears the floor during the swing phase of the gait.
Displacement. The trunk should be vertical at stance. Observe the
degree of lurch during flexion, extension, and during the swing phase.
Note degree of hip, knee, and ankle flexion. If the head is carried far
forward, seek further evidence of atlanto-occipital fixation,
subluxation, costoclavicular or neurovascular syndrome, upper dorsal
lesion, or shoulder disorder. These malfunctions would also be suspect
if the head were titled to one side, but lateral carriage is found more
commonly in torticollis, in visual defects, and in primary or secondary
Pathologic Postures. If pain is present, determine where and when
it is greatest. Check for trunk fixation in flexion or extension. Fixed
lordotic and kyphotic spines will be evident during both stance and
swing, but posterior pelvic tilts are difficult to observe. Shoulders
drooping forward may be an indication of cardiac dysfunction, lung or
pleural pathology, depression, or a dorsal lesion. Diabetics and those
suffering from cardiorenal disorders often have pot bellies. Due to the
lack of tone in the abdominal musculature, the viscera sag downward
which results in organ malposition and disturbed function
contributing to the problem.

From the front and rear, note rhythm, symmetry, and speed of
cadence. Lateral motions are best viewed from the front or rear. As the
body advances, note smoothness of the body's vertical oscillation.
Pathology may express itself in increased vertical oscillation and

disrupt the normally smooth pattern. Normally, the pelvis is centrally

positioned over the line of progression at toeoff and begins its
movement toward the side of the weight-bearing limb.
Pelvic Displacement. Note the degree of pelvic tilt and drop on each
side. This is more easily noted by watching the top horizontal line of
the underwear. A lateral shift of the pelvis and hip of about one inch
to the weight-bearing side is normal to center the weight over the hip.
Maximum pelvic tilt is usually reached just after midstance. Its degree
is normally determined by stride width, which corresponds to the
lateral shear forces acting on the pelvis, and walking speed, which
determines how long these shear forces are acting on the body. Lateral
shifting is accentuated in gluteus medius weakness and should be
noted. A gait exhibiting bending to one side may be the result of a
pericardial or pleural friction rub, a sacroiliac lesion, shoulder
condition, affection of the brachial plexus, or lesion in the upper
dorsal section of the spine. On the other hand, a ram-rod gait is a sign
of a thoracic lesion, sacralization, or spasm of the lumbar
paravertebral musculature --all of which may or not be associated
with an abnormal lumbar curve. A fixed pelvic tilt or elevation will not
change from stance to swing. The pelvis is normally level at heel
contact, drops to its maximum on the side approaching toeoff during
double-support, then returns to a level position shortly after toeoff
and remains there until heel-strike. As speed increases, the degree of
drop increases on the side in the swing phase.
Base Width. Check the walking base width for broadness, stability,
and consistency (Fig. 4.21, right). From heel to heel, base width is
normally not more than from 2 to 4 inches. If wider, dizziness,
unsteadiness from a cerebellar problem, or numbness of a foot's
plantar surface may be a cause for the wider base. An abnormally

decreased base usually produces a crossover "scissor" action after

Limp. Any articular malfunction from the spine to the foot may
result in a limp. Muscular weakness or spasm, fascial contraction,
fracture, a torn ligament or tendon, bone disease, or a neurologic
affectation may be cause for a limp. Generally, an uncomplicated limp
can be traced to a knee, ankle, or foot dysfunction or deformity, a hip
disorder, or a sacroiliac or lumbar lesion. A female gait exhibiting rigid
buttocks is a sign of a uterus retroflexed or prolapsed, or of a
lumbosacral lesion.


Heelstrike. Inability of a foot to heelstrike is an indication of a heel
spur and associated bursitis or a blister. Failure of the knee to fully
extend during heelstrike is a sign of weak quadriceps or a flexion
fusion of the knee. A harsh heelstrike, usually associated with knee
hyperextension, is a frequent sign of weak hamstrings.
Footflat. When the foot slaps down sharply after heelstrike, weak
dorsiflexors should be suspect.
Midstance. Fused ankles will prevent a midstance flat foot. Weak
quadriceps display themselves in excessive flexion and poor knee
stability during mid-stance. A midstance forward lurch of the hip is a
typical indication of a weak gluteus medius, while a midstance
backward lurch is a sign of a weak gluteus maximus.
Pushoff and Swing. If the patient must rotate the pelvis severely

anterior to provide a thrust for the leg, the cause is most likely weak
quadriceps. If the hip is flexed excessively to bend the knee and thus
prevent the toe from scraping the floor as in a steppage gait, weak
ankle dorsiflexors are the usual cause. Failure to hyperextend the foot
during pushoff is a sign of arthrosis. Pushing off with the lateral side
of the front of the foot is usually seen in disorders involving the great
toe. A flat-footed calcaneal gait during pushoff is symptomatic of weak
gastrocnemius, soleus, and flexor hallucis longis muscles. The foot will
have trouble clearing the floor if the ankle dorsiflexors are weak or the
knee is unable to flex properly.

Guarded Limps. A limp may be a sign of disease, malfunction, or
both. It may also be in compensation to another condition such as a
sprained ankle, injured knee, old fracture malunion or hip surgery.
However, the majority of limps seen are those desribed as "guarded"
limps. Guarded limps frequently point to specific musculoskeletal
disorders. These limps are the result of the patient walking in a
manner that protects or relieves stress upon an area that would
otherwise be uncomfortable or painful. The term "antalgic position" is
that static posture assumed by the patient to produce the same pain
diminishing effect as does a guarded gait.
Midspinal and Bilateral Spinal Pain. When pain is in the midline of
the spine, the gait pattern is guarded, symmetrical, slow, with a short
stride and restricted trunk rotation and pelvic tilt. If paraspinal
muscle spasm is present, the patient will tend to lean backward
throughout the gait in compensation. However, if the irritation is
located at the posterior aspect of the spinal column (eg, articular

facets), the patient will tend to lean forward throughout gait in an

attempt to gain relief by reducing weight on the sensitive area. Walking
on the toes, as if walking on eggs, is often seen in cases of
lumbosacral or cervical lesions to reduce jar. To avoid jarring any
sensitive joint, the heel strike is usually eliminated and the length of
stride is shortened by reducing the swing phase.
Unilateral Spinal Pain. Walking in a stooped position with one hand
supporting the back is a frequent sign seen in a lumbar lesion. During
both stance and swing in mild or moderate irritations, the trunk
usually leans toward the affected side in compensation to muscle
splinting. However, in pronounced intervertebral disc or sacroiliac
lesions, the lean is usually away from the site of irritation to reduce
Hip Pain. While the hip joint of one extremity is in the stance phase
and acts as the fulcum for rotation, the other hip in the swing phase
rotates about 40 forward. This normal hip rotation is not seen in
patients suffering a stiff or painful hip. When a hip is painful, the gait
is asymmetrical, the base is widened during swing, the stance phase
is reduced on the affected side and made longer on the unaffected
side, the trunk is thrown forward during stance to shift the center of
mass, and the affected hip is lifted so the limb will clear the floor. The
affected hip is quite fixed in flexion, abduction, and rotated laterally to
reduce joint tension. As a consequence to the hip flexion, the knee and
ankle flex. Keep in mind the cyclic load on the hip during gait (Fig.
Knee Pain. If a knee joint is effused, with or without pain, 25
flexion offers the largest capsule volume, and thus the least tension.
This flexion is compensated by ankle plantar flexion and an absent

heelstrike, so that the patient will walk on the toes of the affected side.
This guarded gait minimizes quadriceps function and thus reduces
knee compression.
Ankle Pain. In any painful disorder of the ankle, ankle motion will be
guarded and the most comfortable position will be assumed. There is
little, if any, plantar flexion during footflat or heelstrike, or dorsiflexion
during heel-off. This will be compensated for by an exaggerated knee
flexion after heeloff and a restricted heel rise before toeoff. The patient
will reduce his base and shift his trunk so that more weight falls
directly over the joint during weight bearing.
Common Stance-Phase Problems. Most stance phase problems are
the result of pain and characterized by an antalgic gait wherein the
patient spends as little time on the affected extremity as possible. Gait
patterns vary according to the type and location of the disorder
present. A shoe problem should not be overlooked, as it is one of the
more common causes. Pain in a foot during midstance may be caused
by corns, calluses from a fallen transverse arch, rigid pes planus, a
plantar wart, bunion, subtalar arthritis, or poor-fitting shoes. Heelstrike will be eliminated, and toe walking will be seen, if a lesion is
present in the heel or posterior aspect of the foot. Lesions of the
forefoot such as metatarsal or phaangeal disorders are characterized
by heel walking, reduced pushoff, and an exaggerated forward hip
thrust and knee flexion in compensation. Sharp pain on pushoff is
often caused by corns between the toes or metatarsal callosities. In
longitudinal arch disorders, weight will be borne on the lateral plantar
surface during weight bearing. If chronic, excessive wear on the lateral
sole of the shoe will be noted.

Running and Jumping

The mechanics of running are similar to those of walking in several
respects. Both walking and running require that:
(1) weight be projected forward and the legs are carried alternately
under the body for brief periods of support, and
(2) the weight-bearing limb provides the propulsive action after the
center of body weight has passed over it. Walking becomes a running
gait at that point in acceleration when a period of nonsupport
appears. During the phase of nonsupport where there is no surface
friction, the body can be considered a missile.
Jumping is essentially the act of propelling the body into the air via
rapid leg extension. It is usually considered in three phases: takeoff,
flight, and landing. Jumping is governed by the same principles that
govern missiles. Thus, the motions made during flight have little
influence on direction, height, or distance. Their main purpose is to
prepare the body for

Impaired corrective responses to postural perturbations of the

arm in individuals with subacute stroke

Stroke is known to alter muscle stretch responses following a perturbation, but little is known
about the behavioural consequences of these altered feedback responses. Characterizing
impairments in people with stroke in their interactions with the external environment may lead to
better long term outcomes. This information can inform therapists about rehabilitation targets
and help subjects with stroke avoid injury when moving in the world.

In this study, we developed a postural perturbation task to quantity upper limb function of
subjects with subacute stroke (n=38) and non-disabled controls (n=74) to make rapid

corrective responses with the arm. Subjects were instructed to maintain their hand at a target
before and after a mechanical load was applied to the limb. Visual feedback of the hand was
removed for half of the trials at perturbation onset. A number of parameters quantified subject
performance, and impairment in performance was defined as outside the 95th percentile
performance of control subjects.

Individual subjects with stroke showed increased postural instability (44%), delayed motor
responses (79%), delayed returns towards the spatial target (79%), and greater endpoint errors
(74%). Several subjects also showed impairments in the temporal coordination of the elbow and
shoulder joints when responding to the perturbation (47%). Interestingly, impairments in task
parameters were often found for both arms of individual subjects with stroke (up to 58% for
return time). Visual feedback did not improve performance on task parameters except for
decreasing endpoint error for all subjects. Significant correlations between task performance and
clinical measures were dependent on the arm assessed.

This study used a simple postural perturbation task to highlight that subjects with stroke
commonly have difficulties responding to mechanical disturbances that may have important
implications for their ability to perform daily activities.
Keywords: Stroke, Proprioception, Assessment, Perturbation, Upper limb, Robotics