EXERCISE AND QUALITY
OF LIFE
ISSN 1821-3480
Volume 6, Issue 1
UDC 796
June 2014
STAND CORRECTLY - GROW UP HEALTHY!
STOJ PRAVO - RASTI ZDRAVO!
СТОЈ ПРАВО - РАСТИ ЗДРАВО!
EQOL
JOURNAL OF SCIENCE IN SPORT
A project implemented by
This project is funded by
The European Union
Faculty of Sport and Physical Education, University of Novi Sad, Serbia
EXERCISE AND QUALITY OF LIFE
Journal of Science in Sport
Published by Faculty of Sport and Physical Education, University of Novi Sad, Serbia
For the Publisher:
Advisory Board:
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Faculty of Sport and Physical Education,
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University of Novi Sad, Serbia
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Wieslav Blach, Poland
Editor-in-Chief:
Tudor Bompa, Canada
Višnja Đorđić,
Julio Calleja, Spain
Faculty of Sport and Physical Education,
Igor Jukić, Croatia
University of Novi Sad, Serbia
Christos Kotzamanidis, Greece
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Guest editor:
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Dejan Madić,
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Faculty of Sport and Physical Education,
Izet Rađo, Bosnia and Herzegovina
University of Novi Sad, Serbia
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Špela Golubović,
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Faculty of Medicine, University of Novi Sad, Serbia
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Faculty of Medicine, University of Novi Sad, Serbia
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UDC 796
ISSN 1821-3480
EXERCISE AND QUALITY OF LIFE
Journal of Science in Sport
Volume 6, No. 1, 2014, 1-38
Contents
Branka Protić - Gava
The importance of postural status for the health of children and youth
1
Snežana Tomašević-Todorović
Physiotherapy aspect of diagnosis and treatment of postural disorders
7
Milan Kojić
Differences in indicators of postural status between boys and girls from srem
17
Nikola Jevtić
Scoliosis and treating scoliosis with schroth method
23
Dušica Marić, Mirela Erić, Bojana Krstonošić and Dragana Smiljenić
Fascia - the forgotten tissue
31
Guest Editor’s Foreword
Special issue of the Exercise and Quality of Life journal is dedicated to the IPA project
cross border programme Serbia and Bosnia and Herzegovina “Improving testing abilities on pos-
tural and spinal column status - SpinLab”, founded by the European Union, Directorate for Euro-
pean Integration.
Project leader is the Faculty of Sport and Physical Education of the University of Novi Sad,
with project partners being the Faculty of Sport and Physical Education of the University of Sa-
rajevo.
The project is the result of the need to improve the assessment of postural status among
children and to adopt it more widely. According to previous studies, the level of physical activities
is globally declining. Children and youth in transitional countries might be particularly vulnerable
groups in terms of physical inactivity. Huge economical and political changes in these countries
have led to significant changes in everyday living, affecting both parents and children. Research
conducted in Vojvodina and Bosnia and Herzegovina suggest that there are some negative trends
in children’s postural status as well as in their motor and functional abilities. At the same time,
evaluation of the postural status has been conducted, so far, mainly by using subjective methods,
which are time consuming and often lack accuracy.
The overall goal of the project is to improve the detection and prevention of postural disor-
ders, health problems of sensorimotor apparatus in children and adolescents between the two re-
gions, Srem (Serbia, Autonomous Province of Vojvodina) and Sarajevo (Bosnia and Herzegovi-
na). The project activities should develop one efficient, self-sustaining system that will, by using
advanced methods, provide early detection followed by programmed exercise for the correction of
the problem related to postural status. The first specific goal is to improve the assessment of pos-
tural status and the status of the spine as well as proper identification of the sensorimotor appara-
tus problem. The second specific goal is to raise awareness about the importance of early detection
and prevention of sensorimotor apparatus in children among target groups.
Authors of the contributions to the special issue are eminent scientist and professionals
within their field of expertise, who cooperate within the project network.
The papers present the state of art in the scientific areas relevant to the project, which pro-
vides stable framework for further project activities and interpreting the project findings.
Prof. Dejan Madić, PhD
Project Manager
EXERCISE AND QUALITY OF LIFE
Review article
Volume 6, No. 1, 2014, 1-6
UDC 616.711-007.5-053.5/.6:613.95
THE IMPORTANCE OF POSTURAL STATUS FOR THE
HEALTH OF CHILDREN AND YOUTH
Branka Protić - Gava*
Faculty of Sport and Physical Education - University of Novi Sad
Abstract
Postural disorders occur not just among school children but also among preschoolers, the
fact which coincides with critical periods of growth and development that are characteristic for
the occurrence of the mentioned disorders. They can be located on all the segments along the spi-
nal column, torso and lower limbs. Good body posture is of great importance for healthy growing
of the youngest while poor postural status harmfully influences locomotor system, circulation, as
well as respiratory and digestive system. Inadequate position while sitting, standing and walking
(as the result of muscular disbalance) causes pain in cervical, thoracic and lumbar part of the spi-
nal column, which later influences the overall quality of life. Surveys and numerous researches of
the locomotor system are all aimed at finding the most adequate system of preventive and correc-
tive activities with an emphasis on timely diagnostic of changes.
Keywords: postural status, body posture, health, importance, children and youth
Introduction
The occurrence of postural disorders as well as finding relationships among them and pos-
sible causes of their development raises interest of health workers and physical education teach-
ers. Older researches indicated more frequent occurrences of postural disorders among school
children. However, newer researches alarm us of more frequent occurrences of poor posture even
among preschoolers (Sabo, 2006).
Postural disorders of locomotor system among school children and preschoolers, which
have not been recognized and treated in a timely manner, can develop into body deformations that
are later difficult to treat (Protić - Gava et al., 2010). That is why it is highly recommended for
children to start practising well-designed and professionally-leaded physical activities at an ear-
ly age.
* Corresponding author. Faculty of Sport and Physical Education, University of Novi Sad, Lovćenska 16, 21000 Novi
Sad, Serbia, e-mail: brankapg@gmail.com
© 2014 Faculty of Sport and Physical Education, University of Novi Sad, Serbia
Branka Protić - Gava
The results of researches regarding the occurrence of postural disorders indicate more fre-
quent occurrence of multiple deviations in musculoskeletal system among young-school age chil-
dren (Protić - Gava et al., 2009a). However, the positive thing is that most of them are on the level
of functional stadium which has not yet reached the level of structural changes.
Postural status
The term posture refers to the position of body (Đorđić, 2007) which represents relative
position of body segments during rest or during some activity (Demeši-Drljan and Mikov, 2012).
Good postural status is conditioned by good muscular-skeleton balance that protects certain struc-
tures from injuries and occurrences of progressive deformations (Pavlović, 2009) reagrdless of the
position of body (Aleksić-Veljković and Stanković, 2010).
Muscles, which represent the active part of movement apparatus, have the most significant
role in the creation and preservation of regular posture. Together with ligament apparatus and ar-
ticulation system, they confront gravity both during movement and rest (Pavlović, 2009). If the
balance is dislocated (in these cases muscles suffer mostly), good body posture suffers as well
(Koturović and Jeričević, 1996).
Good and regular relations between all the segments in a body contribute to well-balanced
and uninterrupted functioning, and as such result in good body posture. Consequently, good body
posture causes muscles to function at their best (Aleksić-Veljković and Stanković, 2010), thus pro-
viding optimal position for abdominal and thoracic organs (Pavlović, 2009).
Upright and relaxed posture is characterized by body weight well-balanced on both legs
and adequate muscle tension to suppress gravity, while at the same time energy consumption is in-
significant. If vertical that goes from common centre of all the segments that burden the articula-
tion goes closer to the centre of that articulation, muscle strain is smaller (Đorđić, 2007).
Physiological curves of the spinal columns stabilize around the 18th month of age or even
later, while the curves range between 20º and 35º in thoracic and 15º and 30º in lumbar part
(Radisavljević, 2001). Spinal column is curveless in frontal plane (10º deviance is tolerable) and
should be without any rotation (Đorđić, 2007). Bone, ligament and muscle structures in a foot
play a significant role in the creation and preservation of foot arch (Đorđić, 2007; Radisavljević,
2001). The height of longitudinal arches is determined by the shape of bones and ligament strength
(Jovičić, 2007). Deterioration of this unique functional composition of active and passive tensors
causes changes in the shape, position and function of a foot (Radisavljević, 2001). Causes of de-
formations can be of different etiology, but what all of them have in common is disbalance of foot
muscles (Lee & Sucato, 2008).
Growth and development of any child follows the same rhythmic pattern which is marked
by certain so-called “growth crises” (Kosinac, 2006). The first and second year of life represent the
years when children experience intensive growth and as such these years are referred to as the first
critical period when rapid motor growth happens (upright position). In their seventh year of age
(second critical period) when they start school, children are exposed to more physical challeng-
es (carrying heavy school bag, sitting for longer period of time). Third critical period is the age of
puberty when children experience rapid growth. This period is followed by intensive secretion of
reproductive glands and closure of certain cartilago epiphysialis of long skeleton bones (Demeši-
Drljan and Mikov, 2012).
One of the primary preconditions for the occurrence of poor body posture, which is con-
sequently followed by disorders along the spinal column, is lack of movement. School environ-
2
The importance of postural status for the health of children and youth
ment represent a “fertile ground” for the occurence and development of certain postural disorders
(Medojević and Jakšić, 2007). In order to prove their claim that children who start school have
much less physical activity than younger children, these authors cite Vuković (1999) who claims
that children who start school have 50 % less physical activity than preschoolers. Đorđić (2007)
quotes Cardon (2004) who says that children spend 97 % of their school time sitting.
Weakness and inadequate development of musculoskeletal system are caused by lack or
smaller number of physical activities which than results in the development of poor postural hab-
its among the youngest (Demeši-Drljan and Mikov, 2012). Repeated and long-lasting activities ef-
fecting the spinal column in certain positions create poor habits regarding body posture. The re-
sult is the occurrence of many different forms of postural disorders. Tired muscular system finds
the best position to rest in the shortest time possible. However, due to disbalance it experiences,
it causes inadequate postural status (Medojević and Jakšić, 2007). What follows is the shortening
or weakening of a certain muscular system which then causes muscle disbalance that represents
the main cause of the occurrence and development of body deformations (Đokić and Stojanović,
2010). After primary changes on muscles, changes on ligament apparatus and then on skeleton also
occur, which means that poor body posture actually represents the first phase of certain deforma-
tions.
Obesity also represents a base for the development of certain deformations among chil-
dren, especially for the occurrence and development of lower limbs deformations - “X” shape legs
(Paušić, 2007) and flat feet (Protić-Gava, Krneta and Romanov, 2011).
Cooperation - parents, teachers, doctors - key to
success in the prevention of postural disorders
Cooperation between health facilities, preschool and school institutions, sport clubs and
family is of great importance in the school education system, where the main task is to teach youth
about the importance of good body posture for their health and overall quality of life. Physical ed-
ucation teachers in educational and sport institutions can contribute significantly when the recog-
nition of postural disorders, the prevention of poor body posture and mild forms of body deforma-
tions are in question. The role of family in raising consciousness regarding healthy life habits and
the importance of organized forms of physical activities is of great significance for the prevention
of any kind of disorder. Basic information and knowledge of the development of disorders and de-
formations can contribute to their prevention.
Continuous, adequately chosen, and controlled physical activity represents an efficient
tool that can influence growth and development of children as well as the creation and pres-
ervation of body status. In this sense, parents have great responsibility to motivate and encourage
their children to take part in different forms of physical activities. Adequate and precisely planned
physical activity positively influences the process of development, corrects postural disorders and
deformations and develops positive motor skills (Grabara & Hadzik, 2009a, prema Krneta, Protić-
Gava, Vuković and Šćepanović, 2012).
Since parents and physical education teachers are those who children spend most of their
time with and who follow children’s growth and development, they are the ones who, if they rec-
ognize any type of postural disorder, should react and initiate treatment.
3
Branka Protić - Gava
Instead of conclusion
The task of physical education teachers is to influence the adoption of good body posture as
well as to recognize functional changes of the postural status and foot status while medical facili-
ties should be in charge of diagnostics and treatment of structural changes (deformations).
The importance of timely recognition of postural disorders results in a smaller number of
children with poor body posture. Starting to teach children different forms of physical activities
at an early age has preventive and corrective effects on growth and development, especially in the
critical periods of growth.
Having in mind the etiology of the occurrences of postural disorders and basic principles
of preventive work, application of adequate techniques can prevent further progression of already
existing disorders and enable complete recovery. Adequate choice of physical activities can make
growth and development easier by improving the immunity, correcting postural disorders and
developing positive motor skills. Integration of compensative activities in everyday teaching of
physical education can greatly help and influence the creation of good body posture.
References
Aleksić-Veljković, A., & Stanković, M. (2010). Povrede kičmenog stuba u sportskoj gimnastici.
U: R. Stanković (ur.), Zbornik radova sa XIV međunarodnog naučnog skupa “Fis komuni-
kacije 2010” u sportu, fizičkom vaspitanju i rekreaciji (str. 363-369). Niš: Fakultet sporta i
fizičkog vaspitanja.
Demeši-Drljan, Č., i Mikov, A. (2012). Posturalni status dece predškolskog i ranog školskog uzras-
ta. U: M. Lazović (ur.), Zbornik radova sa 12. kongresa fizijatara Srbije sa međunarodnim
učešćem (str. 65-69). Vrnjačka Banja: Udruženje fizijatara Srbije.
Đokić, Z., i Stojanović, M. (2010). Morfološke karakteristike i posturalni status dece od 9 do 12
godina na području Sremske Mitrovice. Opšta medicina, 16(1-2), 41-49.
Đorđić, V. (2007). Posturalni status predškolske dece. Anthropological Characteristics and Abili-
ties of Preschool Children (ur. Gustav Bala), 155-202. Novi Sad: Fakultet sporta i fizičkog
vaspitanja.
Jovičić, M. (2007). Fleksibilno ravno stopalo kod dece: problem ili ne? Sportska medicina, 7(1),
9-14.
Kosinac, Z. (2006). Utjecaj nekih antropometrijskih i somatskih pokazatelja na dismorfične prom-
jene prsnog koša (pectus carinatum i pectus excavatum). Fizička kultura, 60(1), 39 - 49.
Koturović, Lj., Jeričević, D. (1996). Korektivna gimnastika. Beograd: IGP “MIS SPORT”.
Lee, M. C., & Sucato, D. J. (2008). Pediatric Issues with Cavovarus Foot Deformities. Foot Ankle
Clinics, 13(2), 199-219.
Madić, D. (2006). Relacije motoričkog i posturalnog statusa dece predškolskog uzrasta u Vojvo-
dini. Zbornik radova interdisciplinarne naučne konferencije sa međunarodnim učešćem
„Antropološki status i fizička aktivnost dece i omladine“, Novi Sad, 2006, (pp.185-191).
Novi Sad: Fakultet sporta i fizičkog vaspitanja.
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The importance of postural status for the health of children and youth
Medojević, S. & Jakšić, D. (2007). Razlike u posturalnim poremećajima između devojčica i dečaka
od 7 - 15 godina na teritoriji Vojvodine. Zbornik radova interdisciplinarne naučne konfer-
encije sa međunarodnim učešćem „Antropološki status i fizička aktivnost dece, omladine i
odraslih“, Novi Sad, 2007, (pp.49-54). Novi Sad: Fakultet sporta i fizičkog vaspitanja.
Paušić, J. (2007). Konstrukcija i vrednovanje mjernih postupaka za procjenu tjelesnog držanja u
dječaka dobi od 10 do 13 godina, doktorska disertacija. Kineziološki fakultet, Zagreb.
Pavlović, M. (2009). Odabrana poglavlja iz osnova kineziterapije, teorijske postavke sa uputst-
vima za vežbe (drugo dopunjeno izdanje). Beograd: Visoka zdravstvena škola strukovnih
studija.
Protić - Gava, B., Bošković, K., Krsmanović, T. & Romanov, R. (2009). The relationship between
pelvis posture and lower extremities in young schoolchildren. Proceedings of 1st Interna-
tional Scientific Conference ”Exercise and Quality of life”, Novi Sad, 2009, (pp. 447-452).
Novi Sad: Faculty of Sport and Physical Education, University of Novi Sad.
Protić - Gava, B., Krneta, Ž., Bošković, K. & Romanov, R. (2010). Efekti programiranog vežbanja
na status kičmenog stuba osmogodišnje dece Novog Sada. Glasnik antropološkog društva
Srbije sv.45, 365-374.
Protić-Gava, B., Krneta, Ž., i Romanov, R. (2011). Razlike u posturalnim poremećajima donjih
ekstremiteta kod adolescenata grupisanih prema morfološkim karakteristikama. Glasnik
Antropološkog društva Srbije, 46, 401-406.
Radisavljević, M. (2001). Korektivna gimnastika sa osnovama kineziterapije (prerađeno i dopun-
jeno izdanje). Beograd: Fakultet za sport i fizičko vaspitanje.
Sabo, E. (2006). Posturalni status dece predškolskog uzrasta na teritoriji AP Vojvodine. Zbornik ra-
dova interdisciplinarne naučne konferencije sa međunarodnim učešćem „Antropološki sta-
tus i fizička aktivnost dece i omladine“, Novi Sad, 2006, (pp. 97-100). Novi Sad: Fakultet
sporta i fizičkog vaspitanja.
5
EXERCISE AND QUALITY OF LIFE
Review article
Volume 6, No. 1, 2014, 7-15
UDC 616.711-007.5:615.8
Physiotherapy aspect of diagnosis and
treatment of postural disorders
Snežana Tomašević-Todorović*
Medical faculty, University of Novi Sad, Clinical Center of Vojvodina
Abstract
Postural disorders are common among preschool and school-age children. In regard to gen-
der and age distribution, children are characterized by different indicators of body posture. Posture
for different professionals has different importance, and from a standpoint of one physiatrist it rep-
resents a measure of the efficiency of muscular balance and neuromuscular coordination. Bad pos-
ture represents a functional deviation from normal posture status without structural changes to the
spine or lower extremities. Evaluation and treatment of postural disorders requires knowledge of
basic principles related to the conduct of individual body segments, joints and muscles. The com-
bined physical training programmes that include strength and muscle stretching exercises, particu-
larly with regard to the postural antigravity muscles, should help in the prevention of health prob-
lems that could occur later in life. Future research on the impact of early school-based back pos-
ture promotion in relation to the integration of back posture principles according to biomechanical
favourable lifestyle and back pain prevalence later in life is essential.
Keywords: posture, assessment, exercise, scoliosis
Introduction
Holding body is biological characteristics of human beings created through evolution. Pos-
ture includes static and dynamic behavior of the body in space relative to each other and the envi-
ronment.
It is difficult to define the legality and models “proper posture” of the body, because it is
very individual and specific. Proper posture depends on the structure of the skeleton, on correct ar-
rangement of muscles, muscle strength as well as the symmetry of the paired parts. Holding body
depends on the current emotional state of the personality as well as from a variety of influences.
Posture for different professionals has different importance, and from a standpoint of one physiat-
rist it represents a measure of the efficiency of muscular balance and neuromuscular coordination
* Corresponding author. Medical Faculty, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia, e-mail:
drtomasevic@gmail.com
© 2014 Faculty of Sport and Physical Education, University of Novi Sad, Serbia
Snežana Tomasevic-Todorovic
(Zec, 1984). Each individual will engage in many different postures every day. A good posture is
a posture that is stable, and produces minimal stress and strain on the spinal structures, such as
muscles, ligaments, intervertebral discs and nerves (Scannell & McGill, 2003; Callaghan & Mc-
Gill, 2001).
To put it simply, the posture of the body involves proper alignment of the body segments
and their balance, which is achieved by providing a minimal input of power with maximum me-
chanical efficiency (Garrison & Read, 1999; Zec, 1994). The malalignment of one body segments
will cause change to occur in adjacent segments, as well changes in other segments, as the body
seeks to adjust or compensate for the malalignment (closed-chain response to keep the head over
the sacrum) (Gelb et al., 1995).
Bad posture represents a functional deviation from normal posture status without structur-
al changes to the spine or lower extremities.
A bad posture is likely to subject the spine to abnormal and high levels of stress and strain
(Bullock-Saxton. 1993). Postures that represent an attempt to either improve function or normal
appearance are called compensatory postures ( Riegger-Krugh & Keysor, 1996). Bad posture has
also been linked to poor balance, as well as to decreases in gait and functional performance. In fact,
research shows that poor posture is even associated with increased mortality rates in older adults
(Page, 2005).
Current trends among domestic and foreign authors inidcate that poor posture among chil-
dren occurs in two forms: a neurological and kinesiology. Neurological is characterized by mus-
cular hypotonia, which is a consequence of immaturity of the central nervous system and usually
disappears by the age of five. In Kinesiology bad posture is described as an evident shortening of
the muscles, which needs to be timely noticed and treated. (Savic, 1994). “Typically, muscles over-
used in a certain direction will become tighter and shorter—an effect known as adaptive shorten-
ing. Opposing muscles to repetitive movements sustain stretches during prolonged postures. As a
result, these muscles tend to become longer and weaker—an effect known as stretch weakness”
(Kendall et. al., 2005).
The seated posture is a flexor-dominated posture that further shortens and tightens the mus-
culature on the ventral side of the body and lengthens while weakening the musculature on the
dorsal side of the body. “As a result of the muscle imbalances that develop in our musculoskele-
tal system, postural distortions occur that tend to correspond with the muscular findings” (Ham-
mer, 2007).
Monitoring of the growth and development of preschool and school-age children includes
continuous checking of their posture, especially during critical periods of growth and develop-
ment. There are periods during the growth of a child which are particularly important for the ap-
pearance of bad posture (Milosevic & Obradovic, 2008; Sabo, 2006). Therefore, it is highly im-
portant to detect the postural problems at an early stage and keep them under the strict kinesiolog-
ical control (Auxter et al., 1989). The first critical period - 1-2 years of life which is a marked as a
period of increasing in body weight and the development of locomotor function. Posture which is
accomplished in the first year of life is a complex function which is preceded by a series of chang-
es in the active and passive part of the locomotor apparatus, in particular musscle localized along
the spinal column. Of great importance is the state of mineral metabolism which is intensified in
this period often leads to various changes in the skeleton.
Second critical period
-
6-7 years of life when the child moves from preschool to
school age with a new physical load: more seating, as well as sitting in inadequate class-
rooms, writing often in incorrect position, carrying heavy school bags and so on. In the age be-
tween 5 and 10, when the growth becomes slower, the postural problems show somewhat low-
er rate of incidence, whereas with the onset of puberty, an increased emergence of postur-
8
Physiotherapy aspect of diagnosis and treatment of postural disorders
al abruptly deteriorating conditions and the detection of new cases can be widely anticipated.
The third critical period - from the age of 11 to the age of 14 is the period when it comes to of
work intensive sex glands, weight gain and increased physical activity, and thus to an increased
load of the skeleton. Bad posture can occur in adolescence when mainly conditioned by external
factors (bad seater, bad beds, inadequate clothing, professionally burden - particularly heavy pe-
riod of study crafts during the maturation of the skeleton, which is unable to resist the permanent
load, insufficient engagement sports activities). Some of these factors have an influence on the for-
mation of bad posture in the previous stages of the developmental period of the child. Due to the
long-term negative impact of gravity and retention of irregular posture while sitting, standing, aid-
ed by wearing (too) heavy school bag in one hand or on one shoulder posture over time takes on
the curve in the sagittal or frontal plane and thus incorrectly scoliotic posture (Kosinac 2006). A
prolonged flexed posture may also cause deconditioning of the spinal muscles thus inducing high-
er risk of injury (O ‘Sullivan et al., 2006).
Diagnosis of postural disorders
Postural status of children in preschool and school conditions is estimated by observation
or measurement. Visual methods are subjective, and measurement methods give somewhat more
accurate picture of body posture. The observation was performed in the sagittal plane from the
side, in the frontal plane with the front and rear. Analysis of each subject at a distance of 2 m with
the measures and evaluate individual body segments in the following order (Protic-Gava & Scep-
anovic, 2012).
1. Holding head and neck - holding your head includes raised brow parallel to the frontal
plane, and the direction of view is parallel with the horizontal plane. The shape of the neck is cy-
lindrical in posture lordosis formed with the distance from the vertical 3.5 cm. Head and neck pos-
ture describes when the patients sitting and standing and any differences should be notied. Janda
describes “upper crossed syndrome” to show the effect “poking chin” on the neck muscles, with
the weak neck deep flexors, as are rhomboids and serratus anterior (Page, 2005) .
2. Shoulders position: shoulders are normally placed in the frontal plane. Deviations may
be in the form of the curvature of the shoulders forward or asymmetry of the left and right shoul-
der. Inequality at shoulder height is usually associated with the dominant hand, raised his shoulder
tension of the upper trapezoid and levator scapula.
3. Appeatance of the chest - and the shape of the thorax, adjustedness front wall, the pres-
ence of deformities, half symmetry, regularity rebarnih arches, respiratory mobility of the ribs dur-
ing normal and deep inspiratory and muscle relief. Particular attention should be paid to the con-
figuration of the ribs of the posterior wall of the thorax, especially in front of the slope, which we
can indicate the presence of structural deformities of the spine.
4. Position the hull - look at whether the hull is set in the center line or dezaksiran.
5. Appearance of the abdomen - the anterior wall of the abdomen should be in the line of
the anterior chest wall or something behind.
6. Appearance Lorentz triangles stature - the space between the hull and the inner side of
limbs. We see their symmetry or asymmetry.
7. Pelvic position:- physiological pelvic tilt relative to the transverse plane is about 60 de-
grees.
9
Snežana Tomasevic-Todorovic
8. The appearance and position of scapula - are normally placed in the region of 4 -7 ribs.
Observe the asymmetry, distance and lift the inside edges relative to the spinal column. The asym-
metry of the position of the scapula (or attracting too much lapse of one or both scapulas or curved
fins) consequence is the weakening of serratus anterior muscle of the dominant hand (her shoul-
der is lower), the rhomboid muscle tension and lattisimus dorsi muscle. Drawn scapulas: shortened
rhomboid muscles, elongated pectoralis major and pectoralis minor muscle, spaced scapula: ser-
ratus anterior muscle tension, prolonged rhomboid and middle trapezoid muscle; curved fins: the
anterior serratus muscle weakness (Kosinac & Banovic, 2008).
9. Appearance of the spine - look at the position of the spine as a whole following the thorny
extensions, variations in the sagittal and frontal planes, the size of the physiological curve. Exces-
sive lumbar lordosis usually cause streching of anterior longitudinal ligament and shortening dor-
sal back extensors, posterior ligaments and scapular muscles as a result of excessive dorsal kypho-
sis (Adams & Hutton, 1985).
10. Appearance of the lower ekstremiteta- should pay attention to the direction of the lon-
gitudinal axis of the lower extremities, the presence of deformities (“x” or “o” leg), the length of
the limbs. Measuring with centimeter tape, starting from the anterior superior iliac spine to the in-
ternal malleolus or from the navel to the internal malleolus.Some extent of genu varum is normal
at birth and during infancy up to 3 or 4 years of age (Edgar, 2002).
11. The position and appearance of the feet - identification of the constitution of the foot,
an overview on all sides including plantar and spotting deformities. When one malleolus appears
more prominent or lower than the other and calcanear eversion is present, it is possible that the a
common foot problem known as pes planus, or flat foot, may be present.Calcaneal eversion of 5
to 10 is normal in toddlers, but by 7 years of age, no calcaneal eversion should be presents (Val-
massy, 1996).
Measurement methods
Assessment of posture is performed by measuring the physiological curvature of the spine
using the surplus with thinner ribbon, ruler. These methods give results, but not completely reli-
able. No matter what you have already overcome, this method is still applicable for pre-schools
and schools that are not able to purchase modern diagnostic equipment.
The most frequently used method of measurement is a method for assessing from Napele-
on Wolanski with measure 8 segments of body posture (pose, shoulders, keeping shoulder blades,
chest, thorax in the frontal plane, keeping the anterior abdominal wall, the shape of the leg and in-
step) (Protic-Gava , Scepanovic, 2012). By Wolanski there are three ratings: 0, 1 and 2 (Table 1).
The rating is 0 when all parameters are normal relations - normal status. Grade 1 represents some
deviation from the normal status posture. It is a functional deformity - give the active part of the
locomotor apparatus. Grade 2 is characterized by significant deviations from normal state, and cor-
responds to the structural changes of the locomotor apparatus. By calculating the score for each
segment, we get the total score based on which the posture estimates from very poor to excellent
(Table 1).
10
Physiotherapy aspect of diagnosis and treatment of postural disorders
Table 1. Grades by Wolanski
POSTURE
SCORE
EXCELLENT
0
VERY GOOD
1-4
GOOD
5-8
BAD
9-12
VERY POOR
13-16
Somathoscopic method according Radisavljević includes evaluation of the following seg-
mentSomathoscopic method according Radisavljević includes evaluation of the following seg-
ments body posture in the frontal plane, the back side: head, shoulders, shoulder blades, triangles
stature (Lorentz triangles), pelvis, knee, Achilles tendon. Observation in the sagittal plane (with
sides), includes posture: the neck (cervical), the chest (thoracic) and lumbar (lumbar) curve, the po-
sition of the knees and feet. From the front, in the frontal plane, watching the thorax (Radisavljević,
2001).
The mobility of the spine determine active and passive range of motion measurements of
flexion, extension, laterofleksije and rotation of the spine (Jandrić, 2009). Other tests that should
be part of the postural examination are measuring the length of the leg and straight-leg raising
test (Laseque test), as well as reviews of specific joints, length and muscle strength (Kendal et
al., 1993). The location of the joints indicates that the muscles in elongated or not (Magee, 1992).
Neurophysiological review covers motor skills, sensitivity and sensory function.There are many
methods and a range of equipment available for spinal posture and motion measurement. These
different measurement methods vary in size, cost, accuracy, dimensions of measurements, ease of
use and invasiveness, and each has its advantages and disadvantages. From the range of equip-
ment available, biplanar radiography, opto-electronic systems, electromagnetic tracking systems,
and inertial measurement systems are all capable of both 3 dimensional spinal posture and motion
measurements. Biplanar radiography, opto-electronic systems and electromagnetic tracking sys-
tems are the more established and common methods employed. Radiography or X-ray is one of
the popular methods used in posture and motion measurement, especially in spinal mobility mea-
surement; intersegmental vertebra kinematic analysis and postural tracking (Harrison et al., 2005).
It is necessary for lateral radiography of the whole spine in an upright position with scoli-
osis. The radiographic result is used for the determination of side (left or right, depending on the
convexity) and the degree of curvature (Cobb angles), the rotation of vertebral bodies and to deter-
mine the bone maturity to of the patient. To measure the angle of curvature by Cobb there is need
to choose the vertebrae above and below the apex of the curve, which are most inclined. Cobb an-
gle is the angle between the lines that intersect and are placed on top top and bottom of the low-
est vertebra.
Treatment of postural disorders
Individual approach to patients with postural disorders in the context of the history and
clinical evaluation is essential, and requires education of doctors and physiotherapists in specially
designed methods, focused on specific spinal deformity. Evaluation and treatment of postural dis-
orders requires knowledge of basic principles related to the conduct of individual body segments,
11
Snežana Tomasevic-Todorovic
joints and muscles. Improper handling resulting in uneven loads and stresses the bone, articular,
ligaments and muscles (Magee, 1992; Michele, & Moore, 2004). By understanding muscle imbal-
ances associated with functional impingement, specialist for physical medicine and rehabilitation
can prescribe appropriate exercises for both treatment and prevention.
Kinesiology treatment of scoliosis posture directed toward a specific type of problem caused
by poor posture is carried out in several stages (Tribastone, 1994). Cooperation with the doctor and
therapist is very important at the beginning of treatment, with the establishment of psychophysical
harmony with relaxation and acceptance exercises to develop awareness of poor posture. The most
important phase of Kinesiology treatment is correction of posture. Stretching with exercises in dif-
ferent positions and in motion, support the correction of the spine. In most cases, it is necessary to
complete the correction of posture breathing exercises, muscle relaxation, to eliminate certain mus-
cular tension and strengthening muscles to the functional findings, especially abdominal, in order
to give adequate support to the spine and to prepare for any sporting activities . They are extremely
important posture correction exercises with the mirror. Are the most effective exercises in the com-
pensation conditions, for example Klapp exercises creep. The ultimate goal of Kinesiology treat-
ment is the integration of postural adjustments that can be achieved in posture in everyday move-
ments, which allows a person with a scoliotic posture ability to resist negative impacts on standing
or when carrying schoolbags, improper seating, sports with monotonous motion (Tribastone, 1994) .
A very interesting approach to postural disorders represent Bowen therapy that includes a com-
plete relaxation of the body which activates the internal capabilities of the body and mind, return-
ing to balance and harmony.Bowen terapija dovodi do bolje usklađenosti tela, bez manipulacije
na zglobovima. Bowen moves stimulate several types of intrafascial mechanoreceptors that affect
muscle tonus and increase vagal tone. The type of move used in Bowen also assists the hydration
of fascia, which in turn encourages better vascular and nerve supply (Wilks, 2013).
Therapeutic exercise, alone or in combination with other forms of treatment, are a logi-
cal way to maintain and improve flexibility in patients with functional and structural changes in
the spinal cord, the risk for pain, pulmonary dysfunction, and progression (Jandrić, 2012). Liter-
ature data shows that exercises with the addition of (active release technique ) ART® will more
effectively correct postural distortion (Tacker et al., 2011). The combined physical training pro-
grammes that include strength and muscle stretching exercises, particularly with regard to the pos-
tural antigravity muscles, should help in the prevention of health problems that could occur later
in life, since incorrect or improper posture constitutes the basis for further deterioration of health.
The combined program of corrective gymnastics with games and exercises in water had signifi-
cant eff ects on improving the muscle tone in the respondents, which in turn had a direct impact
on improving their body posture, both in terms of all of the individually surveyed body parts and
in overall terms (Torlakovic et al., 2013). The more interventions studied are needed to allow the
formulation of evidence based guidelines for the prevention of back pain in schoolchildren (Car-
don et al., 2007). The intensive effective back posture education through elementary school curric-
ulum is effective til adolescence.
Therapeutic exercise can improve the angle of the curve Cobb angles in patients with id-
iopathic scoliosis, strength, mobility and balance, vital capacity (Fusco et al., 2011). International
Association of Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) in 2006
provided guidelines for conservative treatment of scoliosis (Weiss et al., 2006). The first of the
three methods of conservative treatment of spinal deformity are based on kinesiotherapeutic meth-
ods including Schroth, Lyonaiseovu, Side-Shiftovu and Dobosiewiczevui method, and other meth-
ods kinesiotherapeutical (Negrini et al., 2003). Scoliosis Intensive Rehabilitation (SIR), leads to a
subjective improvement and reduction of progression of the curve (Weiss et al., 2003). Treatment
of spinal orthosis has been shown effective in preventing the progression of curvature at the IS
12
Physiotherapy aspect of diagnosis and treatment of postural disorders
(Maruyama et al., 2011). It has been shown that treatment of spinal orthoses can reduce the preva-
lence of surgery, then restored sagittal profile and influence the rotation of the spine.
Future research on the impact of early school-based back posture promotion in relation to
the integration of back posture principles according to biomechanical favorable lifestyle and back
pain prevalence later in life is essential (Geldhof et al.,2007).
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Physiotherapy aspect of diagnosis and treatment of postural disorders
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15
EXERCISE AND QUALITY OF LIFE
Research article
Volume 6, No. 1, 2014, 17-22
UDC 616.711-007.5-053.5(497.113 Srem)
DIFFERENCES IN INDICATORS OF POSTURAL
STATUS BETWEEN BOYS AND GIRLS FROM SREM
Milan Kojić*
Faculty of Sport and Physical Education - University of Novi Sad
Abstract
Improper seating, various forms of activities as well as certain endogenous and exogenous
factors negatively affecting on postural status and does not lead to any body improvements. A
healthy and good posture is the basic form for properly constructed mechanics and the assumption
of good statics and dynamics of whole body. Postural status was evaluated on the sample of 833
children, aged 4-13, from the population of Preschool institution and Elementary School in Munic-
ipality of Ruma, Stara Pazova, Sremska Mitrovica and Indjija. Two anthropometric measures and
CONTEMPLAS 3D system for evaluation postural status were applied. Parameters of postural sta-
tus and trend were analysed wit basic descriptive statistics ANOVA and MANOVA. Result show
that almost 30% of all children have bad posture and there is a high number of those with weaker
body segments. Boys have better posture status than girls especially in legs deformity.
Keywords: Posture, Contemplas, Children, Gender differences
Introduction
Improper seating, various forms of activities as well as certain endogenous and exogenous
factors negatively affecting on postural status and does not lead to any body improvements. A
healthy and good posture represents a base for properly constructed mechanics and the assumption
of good statics and dynamics of the whole body. To adapt good posture in early childhood contrib-
utes to proper development, and as a result it affects overall health and quality of life. Creating a
proper posture status is of particular importance in pre-development period and the early years of
school period (Sabo, 2003). Most authors consider that the posture of the good status depends on
the health status of individuals. Disturbing the biomechanics and postural status leads to changes
in muscle, skeletal system, as well as in psychological and social status. Along with certain health
problems, aches and pains, causes of formation postural disorders among children are different:
obesity (Milosevic et al., 2007a, Milosevic et al., 2007b), malnutrition (Protic-Gava, 2008), insuf-
* Corresponding author. Bul. Arsenija Carnojevica 84 lok.4 - Novi Beograd, Serbia,
e-mail: pokretzaokret@yahoo.com
© 2014 Faculty of Sport and Physical Education, University of Novi Sad, Serbia
Milan Kojić
ficient physical activity (Sallis, 2000). Such a trend in the later development of the body and life
can be a serious problem. An extremely important factor and element in the process of growth and
development is certainly physical activity. Many previous studies have talked about it in the di-
rection of development of the entire musculoskeletal system of the body. Lack of movement leads
to a disorder and that is associated with the posture status. Modern way of life and living restric-
tions reduce movements witch reflected to some problem in postural status. Hypokinesis and lack
of exercise has consequences in terms of low activation of muscles, decreased activity of the whole
body and the occurrence of deformities.
These factors certainly accelerate process and condition for develop many problems with
postural status and body mechanics. One particular part of the deformity and disorder is definitely
determined by genetic but the trend of increasing the number of postural disorders which are as-
sociated with other factors. Thus, different endogenous and exogenous elements can act and cre-
ate an unfavourable presumption of continuing develop of deformity of different body segments.
However, active movement has the most important role in the formation and maintenance of prop-
er body posture. The weakness of certain muscle groups, and their excessive workloads, can cause
a variety of disorders of the spine, thorax, upper or lower extremities, especially the feet. Extreme-
ly bad habits and conditions lead to inactivity of different muscle group and inadequate behavior
segments in these conditions may in addition develop deformities and disorders. The prevalence
of these disorders occurs particularly among school age children. Researches show that occurrenc-
es of deformities and bad postural status have negative trends (Sabo, 2003; Slavnić et al., 2005).
Many studies showed that the flat-foot represents the most common disorder of the low-
er extremities especially in early childhood (Mihajlovic, Tončev and Hmjelovjec, 2008; Trajkov-
ic and Nikolic, 2008; Protic - Gava and Krneta, 2010). Such an occurrence is characterized by the
loosening and weakening of the arch of the foot, leading to the loss of its physiological and func-
tional properties. (Jovović, 1999, Jovovich and Čanjak, 2012). Zivkovic and Milenkovic (1994)
examined the state of postural disorders and the results show the highest percentage in spine and
feet deformity. Researches of postural status among preschool children in Novi Sad show that the
largest deviations occur in holding back, shoulders, abdomen, also boys had better posture of the
head and abdomen than girls (Sabo, 2003; Toth, 2001). From these studies it can be seen that the
disturbances is in really high percentage and that their appearance becomes increasingly wide-
spread, especially among children of pre-school age and also in early school period.
Method
The survey was conducted with a sample of 833 children, between the ages of 4 and 13.
All children attend either Kindergarten or Elementary School and come from the Municipality of
Ruma, Stara Pazova, Sremska Mitrovica and Indjija.
Measuring instruments used in this study were evaluating anthropometric and postural sta-
tus. Anthropometric measures were assessed according to the method of the International Biologi-
cal Program (IBP) (Lohman, Roche, & Martorell, 1988). The sample of anthropometric measures
included (Bala, 1981):
1. Body height (mm)
2. Body weight (0.1 kg)
18
Differences in indicators of postural status between boys and girls from Srem
Contemplas and
3D compact protocol analysis were used in assessing postural state.
1. Cervica spine (C7)
2. Sacrum
3. Acromion left
4. Trochanter major left
5. Acromion right
6. Trochanter major right
7. Thoracic spine (kyphosis)
8. Condylus left
9. Lumbar spine (lordosis)
10. Condylus right
11. ISG left
12. Maleolus lateralis left
13. ISG right
14. Maleolus lateralis right
Based on the marked points we get the value in:
1. Position of the shoulders in the frontal plan;
2. Position of the pelvic in the frontal plan:
3. Posture in the sagittal plane
4. Position of the legs
The collected data was analysed through basic descriptive statistics means, Standard Devi-
ation, Minimum, Maximum, Skewness and Kurtosis. The analysis was carried out separately ac-
cording to different gender. Manova and Anova were used to determinate differences between gen-
der in all system of variables and also separately by every variable. Statistical analysis was per-
formed using the SPSS 20.0 statistical package.
Results
In the table we can see values of most of the observed parameters of postural status. Ap-
proximately one third of respondents have a bad posture, and there id a high number of those with
weaker body segments.
Table 1. Descriptive statistics
N
Min
Max
AS
SD
Age
431
4,53
13,72
7,452
2,023
Boys
Body high
430
103,50
160,60
127,526
13,169
Body weight
430
14,70
59,70
28,220
9,273
Age
405
3,95
11,88
7,658
2,069
Girls
Body high
406
103,10
166,40
128,628
13,802
Body weight
406
14,80
58,80
28,664
9,063
Legend: N - Number of respondents; Min - Minimum; Max - Maximum; AS - Mean; SD -Stand-
ard Deviation.
The results presented in Table 1 show the parameters of anthropometric characteristics and
distribution in each group of respondents
19
Milan Kojić
Table 2. Manova and Anova according to a gender
Variable
Gender
N
AS
SD
f
Sig.
Boys
437
,1385
,913
Shoulder displacement
,001
,971
Girls
407
,1407
,850
Boys
437
,0264
,340
Pelvic obliquity
,093
,761
Girls
407
,0196
,306
Boys
437
-,2279
4,798
Shoulder obliquity
,563
,453
Girls
407
-,4715
4,620
Distance cervical spine -
Boys
437
1,8387
2,121
,134
,715
Girls
407
1,7862
2,041
sacrum
Distance thoracic spine -
Boys
437
-1,3736
1,614
6,971
,008
sacrum
Girls
407
-1,0767
1,651
Distance lumbar spine -
Boys
437
1,5118
1,019
60,034
,000
sacrum
Girls
407
2,0716
1,079
Boys
437
,4926
2,731
Varus/Valgus left
39,957
,000
Girls
407
1,6551
2,601
Boys
437
,8554
2,759
Varus/Valgus right
23,740
,000
Girls
407
1,7667
2,666
Boys
437
-,1947
,942
Cervical spine
,000
,991
Girls
407
-,1939
,861
Boys
437
-,3957
,717
Thoracic spine
,188
,665
Girls
407
-,4171
,712
Boys
437
-,1606
,318
Lumbar spine
,017
,898
Girls
407
-,1636
,349
F
Sig.
9,701
,000
Legend: N- Number of respondents; AS- Mean; SD- Standard Deviation; F- value of f test;
Sig- Statistical signification on level of p≤0, 05
By determining the difference between boys and girls on the whole sample variable, trying
to contribute to establishing the space in the relationship between gender and the characteristics of
postural status between them. Table 2 shows the results of multivariate analysis of variance, which
showed that there is a statistically significant difference between the two groups. When evaluat-
ing individual we can see that the differences do not occur in all variables. Specifically, the vari-
ables Distance thoracic spine - sacrum, lumbar spine Distance - sacrum, Varus / Valgus and Var-
us left / right Valgus show significant differences among each other. There is no significant differ-
ence between boys and girls when other variables are referred to. Univariate analysis of variance
and F-test value may indicate that the greatest difference noticed in the variables Distance lumbar
spine - sacrum and Varus / Valgus left. Moreover, it is evident that the distribution of the standard
deviation does not show large deviations from the normal distribution of values in both male and
20
Differences in indicators of postural status between boys and girls from Srem
female samples. Accordingly, it may be said that the sample belongs to the normal distribution in
the population.
Discussion
photometric method was applied in this research in order to assess postural status of sub-
jects of both genders aged 4 to 13 using the system for postural analysis of 3D body with the TEM-
PLO software. The great importance of this work lies in the fact that we are able to observe the de-
velopment of posture during this very important and tumultuous development period of children.
It gives us the ability to better identify their needs. We get the opportunity to make adequately and
efficiently programmed preventive system of physical exercise.
Research results that the boys and girls significantly distinguish in postural status. It is ev-
ident also that boys have a better segmental parameter and thus better postural status at a general
level. Individually, the difference is greatest in the area of leg deformities as well as in distance of
vertebrae in the frontal plane. Stronger muscles and better posture boys in this period may be the
reason for these results. The girls have a higher degree of deformity of the legs as varus and valgus
shape of legs. The bad status of spinal column in frontal plane show that scoliosis as a phenomenon
more common in girls, and that such deformities result of weak muscles, especially in lower back.
Modern diagnostic postural status with Contemplas equipment provides precise and effi-
cient detection of posture status. From result in the large number of respondents overall findings
suggest that proper growth and development of children and youth depend on many factors, but
primarily on the active involvement of parents. Therefore, it is necessary to let the kids run free,
jump, to climb, crawl, which can be achieved by involving children in active life, sport, gymnas-
tics but also in other forms of exercise. Children timely brought into the daily programming, and
strictly controlled physical activity aimed at improving posture status. With fining of this research
parents should pay more attention to the segments of the spine and legs as.
The lifestyle of parents and children causes a lack of movement so the children must spend
less time at the computer and more time in a variety of physical activities: cycling, swimming
training, training skating, roller skating, long walks. Along with that, with diagnostics of postur-
al status it is possible to prevent it, and encourage the proper growth and development. That form
should be created to help parents, physical education teachers, coaches, physicians and children.
References
Bala, G. (1981). Struktura i razvoj morfoloških i motoričkih dimenzija dece SAP Vojvodine. Novi
Sad: Fakultet fizičke kulture.
Jovović, V. & Čanjak, R. (2012). Frequency of angular deformities of the knee joint of school chil-
dren in relation to sex and ages. Glasnik Antropološkog društva Srbije, (47), 1-7
Jovović, V. (1999). Tjelesni deformiteti adolescenata. 3rd ed. Nikšić: Filozofski fakultet.
Lohman, T. G., Roche, A. F., &i Martorell, R. (1988). Anthropometric standardization reference
manual. Chicago: Human Kinetics Books.
Mihajlović, I., Tončev, I. & Hmjelovjec, I. (2008). Prevalence of flatfoot deformity in Boys de-
pending on their age. Acta Kinesiologica, 2(2), 103-106.
21
Milan Kojić
Milošević, Z., Obradović, B., Srdić, B. (2007a) Status uhranjenosti devojčica starijeg školskog uz-
rasta. U G. Bala (ur.) Antropološki status i fizička aktivnost dece, omladine i odraslih Novi
Sad. Fakultet sporta i fizičkog vaspitanja; 81-89.
Milošević, Z., Obradović, B., Srdić, B. (2007b) Status uhranjenosti dečaka starijeg školskog uz-
rasta. U G. Bala (ur.) Antropološki status i fizička aktivnost dece, omladine i odraslih. Novi
Sad. Fakultet sporta i fizičkog vaspitanja; 89-97.
Protić - Gava, B. i Krneta, Ž. (2010). Posturalni status dece mlađeg školskog uzrasta četiri okruga
Vojvodine; Glasnik antropološkog društva Srbije, 45, 375-383.
Protić-Gava, B. (2008). Frequenccy of impaired bodily posture in the BMI categories and its share
accord - ing to gender. U: Proceedings of the International Symposium Research and Edu-
cation in Innovation Era Arad: ”Aurel Vlaicu” University; 559-564.
Sabo, E (2003). Psihosomatski status dece predškolskog uzrasta pri upisu u osnovnu školu. Dok-
torska disertacija. Fakultet fizičke kulture. Novi Sad.
Sallis, J. F.(2000). Influences on physical activity of children, adolescents and adults. Peiden con-
cil on physical fitness and sports Research digest;1 (7).
Tot, J. (2001). Posturalni status dece predškolskog uzrasta u Novom Sadu. Diplomski rad. Fakultet
fizičke kulture. Novi Sad.
Trajković, S. i Nikolić, M. (2008). Komparativna analiza antropometrijskih mera i posturalnih
poremećaja školske dece generacija 1987. i 2002. godine. Glasnik Antropološkog društva
Srbije, 43(1), 386-391.
Živković, D. (2001). Teorija i metodika korektivne gimnastike. Niš: Fakultet sporta i fizičkog
vaspitanja.
Živković, D., Milenković, S. (1994). Stanje posturalnog poremećaja kod dece predškolskih ustano-
va. Fizička kultura, 40:2, str. 11. Beograd: Fakultet fizičke kulture.
22
EXERCISE AND QUALITY OF LIFE
Review article
Volume 6, No. 1, 2014, 23-30
UDC 616.711-007.5-085
SCOLIOSIS AND TREATING SCOLIOSIS WITH
SCHROTH METHOD
Nikola Jevtić*
Faculty of Sports and Physical Education - University of Novi Sad
Abstract
Idiopathic scoliosis is a deformity of the spinal column and is found among healthy chil-
dren. Etiology of idiopathic scoliosis is unknown. Spinal shift occurs in all three planes followed
by muscle disfunction and reduced vital capacity of the lungs. Asymmetric loading on the spine
can be listed as one of the factors of rapid progression of scoliosis, whereby large pressure is put on
the concave side of the scoliotic curvature due to the shift of standing balance of the body. Reha-
bilitation is based upon improvement of functionality, ability and capacity of the patient with sco-
liosis. The initial stage of rehabilitation rests on correct diagnosis and estimation of patient’s con-
dition in order to commence the treatment in the best possible manner. The Schroth method has a
long-standing tradition and is primarily applied in correction of scoliosis. It is based on three-di-
mensional breathing, proper pelvic correction and specific exercises and education of patients in
order to continue the treatment at home.
Keywords: the Schroth method, scoliosis, asymmetric loading, muscle disbalance
Introduction
Idiopathic scoliosis may be defined as a complex three-dimensional deformity of the spine
and trunk. It occurs in healthy persons and its etiology is unknown (Rigo, M., & Grivas, T. 2010).
With the aim to detect scoliosis easier, its specific name can be obtained according to the localiza-
tion of the principal curvatures (thoracic, lumbar, thoracolumbar, double major, double thoracic);
however, there are numerous classifications by means of which it is easier to recognize the type of
idiopathic scoliosis (Weiss, H.R. et al, 2013). In addition to idiopathic scoliosis, scoliosis can be
classified into two more groups according to the etiology: congenital and neuromuscular. Congen-
ital scoliosis is gained by nurture and the process of deformation can occur even in the embryonic
conception, while the other type of scoliosis comprises of neuromuscular scoliosis, whereby neu-
romuscular diseases occur as a result of deformity. Many authors dealt with etiology of idiopath-
ic scoliosis and did not wind up with a concrete answer. They suggest various causes as the rea-
* Corresponding author. Avgusta Cesarca 11/9, 21 000 Novi Sad, Serbia, e-mail: njevticns@gmail.com
© 2014 Faculty of Sport and Physical Education, University of Novi Sad, Serbia
Nikola Jevtić
sons of occurrence of this type of scoliosis; nevertheless, it is assumed that genetics and asymmet-
ric loading represent the greatest cause. The difference in rehabilitation from congenital and neuro-
muscular scoliosis in comparison to idiopathic scoliosis lies in the fact that the first two deal with
the causes of the deformity, while in idiopathic scoliosis consequences are ones that are addressed.
Biomechanical factors may have a significant role during the rapid progression of scolio-
sis in adolescence (Stokes, I. 2007). Asymmetric loading of the body, as well as the shift of stand-
ing balance of the body, may have serious consequences on the deformity of the lumbar spine.
Mechanical factor becomes predominant, as compared to the initial factor, in the period of rapid
growth during adolescence (Stokes, I. et al, 2006). Muscle disbalance occurs as a result of spinal
column shift, thus the muscles on one side of the spinal column are less active, whereby rotation
of the spinal column can be listed as the cause (Fidler, M.W. & Jowett, R.L. 1976). Patients who
suffer from this condition often have problems with reduced function of respiratory muscles, and
even reduced vital capacity of the lungs (Martinez-Liorens J. et al, 2010).
The Schroth method is a longstanding, traditional method applied in rehabilitation from
scoliosis and it is used around the globe. It originates from Germany and it rapidly spread to oth-
er countries in Europe and worldwide due to its results. The method was launched by Katharina
Schroth; later, her daughter Christa Lehnert Schroth joined her and gave a large contribution to the
development of this method (Weiss, H.R. 2010). The Schroth method corrects scoliosis in all three
planes, which is actually its advantage as compared to certain methods.
The history of Schroth method
The Schroth method is a non-operative treatment applied in the correction of scoliosis and
has a very long tradition. One may suggest that it is a conservative type of treatment that reminds
of Hippocrates’ original method. Although it has been more than 2,000 years since Hippocrates’
era, the conservative type of scoliotic correction retained the same approach to the problem. The
fact that three therapists used to work with one patient in order to prevent mistakes during the cor-
rection shows how seriously this problem used to be approached two centuries ago. Corrective
treatment based on the principles of the Schroth method is nowadays applied worldwide, precise-
ly because of its approach to the problem, primarily based on three-dimensional breathing, which
has the most significant role in treatment of scoliosis.
Development of the Schroth method rests upon professional work of three generations.
The first steps were recorded back in 1921, by Katharina Schroth, who suffered from scoliosis
herself. Dissatisfaction, caused by the treatment she had received in particular institutions, made
her to look for the solution to her problem by herself. She started to explore her body and apply a
new type of treatment. She was a teacher, so she did not know anything about anatomy, physiolo-
gy and biomechanics; however, her inspiring spirit contributed to the development of something
completely new, something that gave amazing results in the following years. She came to the con-
clusion that it is possible to achieve postural control exclusively by changing of postural percep-
tion. She was trying to make the correction of the rib cage by performing deep inhalations on the
concave side. She used to do that in front of a mirror in order to be able to control the movements
of the rib cage. Her primary inspiration was a balloon. While observing the balloon being inflat-
ed, she concluded that there is a possibility to make a correction of the deformity by following the
same principle. She started to develop the method in Meissen, Eastern Germany, where she had
her first small institute. During the 1930s and 1940s, Katharina received support in work and de-
velopment of the method from her daughter Christa, who was born in 1924. Katharina moved with
her daughter Christa to Bad Sobernhein in 1961. This is the town where they founded their insti-
24
Scoliosis and treating scoliosis with Schroth method
tute which gradually developed into a well-established clinic, officially opened in 1983 under the
name “Katharina Schroth Klinik”. After Katharina’s death in 1985, her daughter Christa Lehnert-
Schroth, therapist, continued with the development of the method. Later on, her son, Hans Ru-
dolf Weiss, orthopedic surgeon, joined her. Dr. Weiss was the director of the clinic during the peri-
od from 1995 to 2008. German health care provider, Asklepios, bought the clinic in 1995 with all
rights and liabilities to use the name “the Schroth Method”, thus today, the clinic bears the name
“Asklepios Katharina-Schroth-Klinik”.
In order to assess the influence of the Schroth method, the first research with patients was
conducted in the period 1989-1991, and it was published in German in 1995 and in English in
1997. The next research also included the division of patients according to their age and gender,
which brought about more valid results. Studies included the improvement of cardio-pulmonary
capacity, vital capacity, muscle function monitoring, electromyography and changes in pain dur-
ing the treatment. It was determined by EKG tests that there is a statistically significant reduction
of cardiac exertion during the intensive treatment of 6 weeks in 794 patients. The improvement of
vital capacity of the lungs and mobility of the ribs were recorded in more than 800 patients. Activ-
ity of the muscles was reduced in more than 300 patients after intensive treatment. The correction
of thoracolumbar curvature, including derotation by means of muscle psoas was improved during
the 1920s. The program of correction according to the principles of the Schroth method was de-
signed so that patients continue to practice at home after being provided with proper education su-
pervised by a Schroth therapist.
Etiology of scoliosis
Idiopathic scoliosis is a complex deformity of unknown etiology which includes morpho-
logical changes and transformation of the spinal column in all three planes. Scoliosis is a term that
describes lateral deviation of the vertebrae, axillar rotation of which stimulates three-dimension-
al deformity of the trunk. Therapists and doctors, who deal with this problem, understand what the
term “idiopathic scoliosis” is, but are speechless when etiology is concerned. Various studies who
deal with etiology of the idiopathic scoliosis have not come to a direct response, but they have
made certain conclusions. Thomas et al. (2008) listed several factors which cause the development
of scoliosis, the first of which is genetics.
Genetic or hereditary factors are widely accepted in the development of idiopathic scolio-
sis (Thomas et al., 2000). Harrington’s research with women who had scoliotic curvatures of more
than 15 degrees, ended with a result that showed that 27 percent of these women’s daughters have
scoliosis. It was determined that 11 percent of patients (first-degree relatives are affected), 2,4 per-
cent second-degree and 1,4 percent third-degree relatives suffer from scoliosis (Harrington, P.R.
1977). The research conducted with identical and fraternal twins who had scoliosis showed that
genetics has a large infuence on the developement of scoliosis. The group of autors obtained the
results which indicated that 73 percent of scoliosis developed in both identical twins when one of
them initially had scoliosis, while the percentage was slightly less in fraternal twins, so that scoli-
osis developed in both of them in 36 percent of cases (Kesling, K. L., i Reinker, K.A. 2009).
Other studies show that a hormon called melatonin also has a large influence on the de-
velopement of idiopathic scoliosis. In consequence, certain authors conducted numerous studies
in order to prove that fact. Dubousset et al. (1998) controlled the level of melatonin in thirty ad-
olescents in his study who had severe curvature, between 57 and 75 degrees. Patients who expe-
rienced the deterioration of the curvature of more than 10 degree had 35 percent- reduced secre-
tion of melatonin during the night, while in the group of patients with stable scoliosis, during the
25
Nikola Jevtić
same year, melatonin secreted without any problems. Lafortune et al. (2007) conducted an exper-
iment in which he did a research of the influence of melatonin on scoliosis in chickens. He divid-
ed the chickens into three groups. He removed the pineal gland, which secrets melatonin, from the
first group, made an incision on the second group in order to simulate the removal of the gland,
and the third group was the control group. All three groups had the same treatment during the ex-
periment, 12 hours of light, 12 hours of dark, 26 degree Celsius and 78% humidity. Scoliotic cur-
vature occurred in 55% of the chickens in the first group after two weeks and developed into a se-
vere condition during the third and fourth week. Cases of scoliosis were not recorded in the sec-
ond and third group.
Besides genetics and melatonin, some other factors, mentioned by various authors, can be
listed as the cause of idiopathic scoliosis. One of these factors can be effects of connective tissue.
Collagen and elastic fibers are crucial elements of the supporting structure of the spinal column
and have a significant role, according to many authors who deal with the pathophysiology of idio-
pathic scoliosis (Thomas, L. et al. 2000). Skeletal muscle abnormalities are also one of the factors
that can be claimed to have a significant role in the development of idiopathic scoliosis, as well as
the Role of Growth and Development.
Nevertheless, Manuel Rigo (2010) stated that there are two types of pathogenetic factors
for idiopathic scoliosis. The first group comprises the initial stage of scoliosis, where the main fac-
tors are biological, morphological, neuromuscular and biomechanical, while the main cause of
rapid progression of scoliosis lies in the biomechanical factors, i.e. asymmetric loading on the spi-
nal column.
Biomechanics of scoliosis
Understanding the etiology of scoliosis is a great challenge, but it is well known that me-
chanical factors have a significant role in the development of deformity. Geometry and anatomy
are fundamental for understanding mechanical part of deformity. It is mentioned that scoliosis is
a three-dimensional deformity; however, the entire process may include the fourth dimension as
well (Bagnall et al. 2009). Deformity shifts over time and, consequently, this is the time when the
fourth dimension is very important for patients because they can follow and control their own con-
dition.
The shifting process of deformity occurs due to the shifted standing balance of the body
which causes altered pressure on the spinal column (Rigo, M., Grivas, T. 2010). The concave side
of the spinal column suffers a lot more pressure than the convex side, which leads to certain conse-
quences. One of them is that vertebral body loses its natural geometry and becomes wedging ver-
tebrae over time (Stokes, I. 2007). Scoliosis progresses rapidly during the adolescent growth. That
period is considered the most critical for the development of scoliosis. Spinal column tissue and
trunk tissue also suffer from the loading during everyday activities, precisely because of the asym-
metric loading. In 2006, Professor Stokes introduced biomechanical modulation of spinal growth
and development of scoliosis in adolescents. In the illustrated scenario of loading, he explains to
what extent altered pressure actually affects the progress of scoliosis. He calculated that vertebral
body suffers the pressure of 1.3 MPa on the concave side on the verge of the curvature, whereas
the convex side suffers the loading of 0.7 MPa, with annual spinal growth of 3 percent (30 mm).
Growth of the vertebral body at the center of the curvature on the concave side amounts 0.5 mm
and 1.3 mm on the convex side, which would lead to the increase of the curvature of 6.7 degrees
and forming the wedging vertebrae. The influence of gravity can be listed as one of the crucial
factors in producing axial force that leads to asymmetry and torsion, because standing balance of
26
Scoliosis and treating scoliosis with Schroth method
the body is shifted to the side of convexity of the primary curvature. In that manner, the increase
of loading on the concave side, and consequently the increase of deformity, occurs (Stokes, I., et
al. 2006). Scoliosis research society explains that torsion of the spinal column may be defined in
two manners. The first is a mechanical torsion that influences the intervertebral disc in the verte-
bral body. The second type of torsion is explained as geometric and represents the movement of
the spinal column in space, i.e. the change in its physiological shape in all three planes (Rigo, M.,
Grivas, T., 2010).
Scoliosis also has significant influence on movement. Mahaudens et al. (2008) conducted a
research in which, besides muscle activation, he wanted to examine the difference in mobility of
certain parts of the body during movement. Between participants with formed scoliotic curvature
(exclusively lumbar and thoracolumbar) and healthy participants, those with scoliosis were divid-
ed into three groups in respect to the degree of the curvature. They concluded that statistically sig-
nificant reduced mobility of certain parts of the body, as well as length of a step, in comparison to
the control group, alterations mainly occurred during the movement of body segments in the fron-
tal plane. Participants with scoliosis had shorter steps as compared to the control group. Reduction
of pelvic and hip movement in the frontal plane, as well as hip movement reduction in the trans-
versal plane occurred. Differences between the experimental groups were not recorded, regardless
of the difference in the degree of the deformity.
Muscle disfunction
Besides the changes in bone structure, changes also occur in the muscles. In 1976, Fiddler
and Jowett conducted a research on corpses with large scoliotic curvatures in order to determine
the disbalance of the deep back muscles. They came to a conclusion that the muscle multifidus on
the verge of scoliotic curvature is shorter on the convex side. That was the consequence of the ro-
tation of the spinal column, while the erector spinae was longer on the convex side than on the con-
cave side, which is the cause of movement in the spinal column in the frontal plane.
Long-term use of braces may have a significant role in the change of muscle structure since,
due to muscular inactivity, transformation of muscle fibers may occur. In a research, during biop-
sy, Meier et al. (1997) discovered the transformation of muscle fibers in the muscle multifidus in
patients with scoliosis who had worn braces. Considering the fact that multifidus mainly compris-
es of slow muscle fibers, the other author came to the conclusion that, after long use of braces, the
muscles change their structure due to inactivity and slow muscle fibers become fast. The role of
braces is very significant in prevention of the progression of scoliosis; however, patients have to be
engaged in corrective activities in order to prevent transformation of the muscle fibers.
It can be noticed that numerous consequences occur on muscles in patients with scolio-
sis. Therefore, Dr. Weiss (1933) wanted to determine the effect of the Schroth treatment on mus-
cle activation. The study included 316 scoliotic persons who were tested before and after treat-
ment. Muscle activation was tested by electromyography having a patient extend the trunk from
the prone position. Overall results indicated significant improvement in postural capacity. Results
also showed significant reduction of muscle activation on the convex side of thoracic and lumbar
curvatures after the treatment. Major reduction in muscle activation was recorded on lumbar sco-
liotic curvature in comparison to thoracic scoliotic curvature.
27
Nikola Jevtić
Conclusion
Idiopathic scoliosis is a deformity that most often occurs among adolescents and its etiolo-
gy is unknown. However, rapid progression of scoliosis is assigned to biomechanical factors such
as asymmetric loading where the crucial role belongs to gravity. Due to this three-dimensional de-
formity, numerous side effects, such as disfunction of the respiratory system, muscle disbalance,
pelvic shift and shoulder girdle shift, come into play. All of them have an influence on the move-
ment disorder. The Schroth method is applied in correction of scoliosis and it influences the defor-
mity in all three planes. It impacts the improvement of vital capacity of the lungs and derotation of
the rib cage. This method appeared to be very effective in correction of scoliotic curvature by us-
ing gravity as an aid in rehabilitation. Therefore, it can be assumed that more rapid rehabilitation
from scoliosis would be achieved exactly with the increase of gravity.
References
Ake, I., Yazici, M. (2009). Growth modulation in the management of growing spine deformities.
Journal of child ortop, 3:1-9.
Bagnall, K., Grivas, T, Alos, N., Asher M., Aubin, C.E., Burwell, G., Dangerfield, P., Edouard, T.,
Hill, D., Lou, E., Moreau, A., O’Brein, J., Stokes, I., Weiss, H.R., Raso, J. (2009). The in-
ternational research society of spinal deformities (IRSSD) and its contribution to science.
Scoliosis J., 4:28.
Fidler, M.W., Jowett, R.L., (1976). Muscle imbalance in the aetiology of scoliosis. The journal of
bone and joint surgery, vol. 58-B, No. 2.
Lehnert-Schroth, C. (2007). Three-dimensional tretmant for scoliosis. Palo Alto, California, The
Martindale Press.
Lowe, T., Edgar, M., Chir, M, Margulies, J., Miller, N., Raso, J., Reinker, K. and Rivard, C-H.
(2000). Etiology of idiopathic scoliosis: Current trents in Research. The Journal of Bone
and Joint Surgery, 82-A, No 8.
Martinez-Liorens, J., Ramirez, M., Colomina, M.J., Bago, J., Molina, A., Caceres, E., Gea, J.
(2010). Muscle dysfunction and exercise limitation in adolescent idiopathic scoliosis. Eur
Respire J., 36, 393-400.
Rigo, M., and Grivas, T. (2010). “Rehabilitation schools for scoliosis” thematic series: describing
the methods and results. Scoliosis J., 5:27.
Stokes, I., Geoffrey, B., Dangerfield, P. (2006). Biomechanical spinal growth modulation and pro-
gressive adolescent scoliosis - a test of the “vicious cycle” pathogenetic hypothesis: Sum-
mary of an electronic focus group debate of the IBSE. Scoliosis J. 1:16.
Stokes, I. (2007). Analysis and simulation of progressive adolescent scoliosis by biomechanical
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Weiss, H.R. (1993). Imbalance of electromyographic activity and physical rehabilitation of pa-
tients with idiopathic scoliosis. Europen Spine Journal 1:240-243.
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Weiss, H.R. (2011). The method of Katharina Schroth - history, principles and current develop-
ment. Scoliosis J. 6:17.
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plication for treatment. OA Musculosceletal Medicine, 1(3):2
29
EXERCISE AND QUALITY OF LIFE
Review article
Volume 6, No. 1, 2014, 31-42
UDC 611.74/612.75/616.75
FASCIA - THE FORGOTTEN TISSUE
Dušica Marić*, Mirela Erić, Bojana Krstonošić and Dragana Smiljenić
Department of Anatomy, School of Medicine, University of Novi Sad, Serbia
Corresponding author: Department of Anatomy, Medical Faculty, University of Novi Sad
Abstract
Fascia is an important component of connective tissue that surrounds bones, muscles, blood
vessels, nerve and organs of the body. The fibrous fascia creates a web that wraps around struc-
tures of the body, providing a continuum that unites the entire human body from head to toe with-
out interruption. The term myofascial refers to the unit comprised of muscle and connective tis-
sue. A myofascial meridian can be defined as a linear series of muscles units interconnected with-
in the fascial webbing of the body. A myofascial meridian transfers tension sequentially from one
myofascial unit of the meridian to the next. Understanding the role of fascia in postural distortion
is of vital importance to movement therapists. Poor posture deforms the fascia and stress the mus-
cles, resulting in pain and weakness. Correction is possible, but both muscles and fascia need to
be taken into account.
Key words: Fascia; Myofascia; Connective tissue
Myofascial antomy
Fascia is a amazing event of bioengineering whose importance is now being realized. In re-
cent years fascia has accelerated to the leading position of rehabilitation science. Recommended
terminology generated after Ist International Fascia Research Congress in 2007 states that fascia is
a soft tissue component of connective tissue system, and it’s an uninterrupted, three-dimensional
web of tissue that extends from head to toe, from front to back, from interior to exterior, and sur-
rounds muscles, bones, organs, nerves, blood vessels and other structures.
The complexity of fascial tissue can be simplified into three parts: superficial, middle and
deep layers. The musculo-skeletal system is double bagged structure (Myers, 2009). The bones,
cartilage, periosteum and ligaments forming the inner bag, and the muscles are in the outer bag.
The outer bag makes the structures called fascia, intermuscular septa, and myofascia. Looking at
the body from this fascial perspective, we can see that fascia provides the context for all other tis-
* Corresponding author. Medical Faculty, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia, e-mail:
maricduska@gmail.com
© 2014 Faculty of Sport and Physical Education, University of Novi Sad, Serbia
Dušica Marić, Mirela Erić, Bojana Krstonošić and Dragana Smiljenić
sues to form. If bone cells lay down bone matrix within a fascial sleeve, a bone is formed within
fascial periosteum. If nerve cells are formed within fascial sleeving, the brain and spinal cord are
formed within meninges, and peripheral nerves are formed within sleeves of endoneurium, peri-
neurium, and epineurium (Myers, 2009).
The classic anatomical studies start with human dissection in the 17th century and explain-
ing the body as a series of isolated parts. The classic representation of muscles is that they have
discrete attachment on bones. By this model, each of the muscles is independent of one another
(a single muscle theory). We have convenient mechanical picture that a muscle ‘begins’ here and
‘ends’ there. According to new myofascial theory we have in body only one muscle; it just hangs
around in 600 or more fascial pockets (Myers, 2009). We need to remind ourselves that muscle
never attaches to bone. Muscle cells float within the fascial net like fish within fishing net (Myers,
2009). Their movement pulls on the fascia, the fascia is attached to the periosteum, and the peri-
osteum pulls on the bone. Far more often, even though some of the fascial tendinous fibers of the
muscle do attach into and end at the attachment bone, other fascial tendinous fibers go beyond the
bony attachment site and are continuous with the fascial tendinous fibers of the adjacent muscle.
These myofascial units are linked to each other. Examining the fascial connections between mus-
cles allows us to discern specific lines of linkage that travel throughout the body. These lines are
called myofascial meridians. Each myofascial meridian is a somewhat discrete aspect of the fas-
cial web that travels and connects far reaches of the body (Myers, 2009). In the single muscle the-
ory, the biceps gets defined as a radio-ulnar supinator, an elbow flexor, and a weak flexor of the
shoulder. In the Anatomy Trains view the biceps brachii is an element in a continous fascial plane
or myofascial meridian which runs from the outside of the thumb to the 4th rib and beyond. The
second fact does not negate the first, but adds a contex for understanding the biceps role in stabi-
lizing the thumb and keeping the chest open and breath full (Myers, 2009).
Myofascial meridians
The Anatomy Trains model identifies a set of myofascial meridians as the major continu-
al tension bands along which this tensile strain runs through the outer myofasciae from bone to
bone (Myers, 2009). Muscle attachments (stations in Anatomy Trains) are where the continuous
tensile net attaches to the relatively isolated, outwardly-pushing compressive struts. Thomas My-
ers describes myofascial meridians as a map of global lines of tension that traverse the entire mus-
cular surface of the human body acting to keep the skeleton in shape. Myofascial meridians in the
human body include: the superficial front line, the superficial back line, the lateral lines (2 sides),
the spiral line, the arm lines (2 front and 2 back), the functional lines (2 front and 2 back), and the
deep front line (Myers, 2009).
The superficial back line runs from the underside of the foot up the back of the leg to the sa-
crum, and up the back to the skull, and over the skull to the forehead. The superficial front line runs
from the toes up the front of the leg and up the torso to the top of the sternum, and passes along
the side of neck to the back of the skull. The lateral line runs from the underside of the foot up the
side of the leg and trunk, under the shoulder complex to the side of the neck and skull. Arms line:
deep front arm line runs from the ribs down the front of the arm to the thumb. The superficial front
arm line runs from the sternum and ribs down the inside of the arm to the palm of the hand. The
deep back arm line runs from the spinous processes through the scapula to the back of the arm and
little finger. The superficial back arm line runs from the spinous processes over the shoulder and
outside the arm to the back of the hand. The spiral line runs from the side of the skull across the
neck to the opposite shoulder and ribs, and back across the belly to the front of the hip, the outside
32
Fascia - the forgotten tissue
of the knee, the inside of the ankle, and under the arch of the foot and back up the leg and back to
the skull. The functional line: the back functional line runs from one shoulder across the back to
the opposite leg. The front functional line runs from one shoulder across the front of the belly to
the opposite leg. The deep front line is a core line that begins deep on the sole of the foot and runs
up of the leg to the front of the hip joint and across the pelvis to the front of the spine and on up
through the thoracic cavity to the jaw and the skull (Myers, 2009)..
Fascia takes responsibility for maintaining structural integrity, for providing support and
protection, and acts as shock absorber. Fascia has an essential role in hemodynamic and biochem-
ical process and provides the matrix that allows for intercellular communication (LeMoon, 2008).
Chaitow (Chaitow et al., 2006) adds that fascia extends to all dense fibrous connective tissues, in-
cluding aponeuroses, ligaments, tendons, retinaculae, joint capsules, organ and vessel tunics, the
epineurium, the meninges, the periostea, and all the endomysial and intermuscular fibers of the
myofasciae.
Fascia are controls the posture and regulate movements (Myers, 2009). The spinal mobili-
ty is limited by the lumbar fascia and the stability of foot is reachable thanks to the stiffness of the
plantar fascia (Grant & Riggs, 2008, Schleip, 2005), knee is supported by iliotibial tract along the
lateral thigh (Grant & Riggs, 2008). Retinacula are not static structures for joint stabilisation as
the ligaments, but specialized fasciae for local spatial proprioception of the foot and ankle move-
ments, and play integrative role of the fascial system in peripheral control of articular motility
(Stecco, 2010).
Fascial inerevation and response to tension
Fascia is densely innervated with mechanoreceptors and nociceptors (Langevin, 2006,
Schleip, 2003a, Schleip, 2003b). The mechanoreceptors, such as Pacini corpucles, Ruffini organs
and free-nerve endings, maintain muscular coordination via the constant feedback from ligaments.
Diversity in location of them suggest different functions, hence, retinaculum plays more percep-
tive function, while tendinous expansions are responsible for mechanical transmission of tension.
Various types of receptors capable of monitoring tension, elongation, pressure, velocity, pain are
located in fascial tissues and create a neurological feedback mechanism by which reflexive interac-
tion with muscles is provided to maintain joint stability and safety as well as coordination of move-
ment. Disruption of the fascia due to injury or overuse also results in corrupted feedback signals
and neurological disorders that are exposing the tissue to additional potential for injury or move-
ment disorders.
Bones, cartilage, ligaments, and tendons are built of varying degrees of the same substance
- collagen - so this unity is more than a structural connection. It is well known that all these things
are malleable, that is, they will transform and change shape and structure when stressed. Over time
the body becomes deformed, the legs bowed, the back bowed, the shoulders hunched, etc. Fascia
pulled continually out of alignment will eventually stay there. Poor posture and bad habits grad-
ually deform the fascia and stress the muscles, resulting in pain and weakness. Correction is pos-
sible, but both muscles and fascia need to be taken into account. The entire supporting structure
needs to be rebuilt.
33
Dušica Marić, Mirela Erić, Bojana Krstonošić and Dragana Smiljenić
Myofascial pain syndrome
Fascia is being recognized in etiology of pain and proprioception (Stecco et al., 2008).
Tightening of myofascia may occur as a response to trauma, overuse syndrome, repetitive stress
injuries, strain, stress, infection, poor posture, and chronic non-physiological tension in the fascia
or surgical scaring. Restricted fascia may compress and put extra stress on the linked soft tissue
structures, resulting in dysfunction and pain (LeBauer et al., 2008). According to Schleip, when
fascia increases its stiffness for a fairly short whereas constantly raised tension may consequently
have metabolic and physiological disadvantages leading to pathological contractures such as Du-
putryen disease, plantar fibromatosis, club foot or frozen shoulder. On the contrary, loss of fas-
cial tone may result in hypermobility of a joint, as in the example of sacroiliac pain (Schleip et al.,
2005). There is an accepted concept that unresolved trauma and/or frozen emotions can be ‘stored’
within the connective tissue in the form of pathology (Minasny, 2009).
The fascia of active people has more strength and springiness to it than that of inactive peo-
ple (Schleip, et al, 2005). Even strenuous activity has shown to strengthen and improve facial re-
sponse. In other words training can cause fascia to improve its function. This discovery can prove
why many players see increased velocity and arm strength after starting a long toss program. The
arms of those who long toss may have more ‘elastic’ storage capacity which can help with rapid
acceleration (Schleip, et al, 2005). By throwing longer and more often you can condition the fas-
cia in the arm. Training the myofascial system is one way that may be accomplished. Those who
adhere to a shorter throwing program or throw infrequently may never reach the level required to
train the myofascial system (Schleip, et al, 2005).
Myofascial pain syndrome is a chronic musculoskeletal pain disorder associated with lo-
cal or referred pain, decreased range of motion, autonomic phenomena, local twitch response in
the affected muscle and muscle weakness without an atrophy (LeMoon, 2008). The term “myofas-
cial pain syndrome” is used synonymously with “regional myofascial pain” and “myofascial trig-
ger point pain syndrome” (Cummings & Baldry, 2007). Myofascial trigger points can be located
in fascia, ligaments, muscles and tendons (Fernandez-de-las-Penas et al., 2005). Trauma, stress,
muscle wasting or ischaemia, visceral pain referral may aggravate the development of this criti-
cal point (Fernandez de las Penas et al., 2005, Fryer & Hodgson, 2005, Grieve, 2006). Myofas-
cial trigger points are considered to be one of the most common cause of musculoskeletal pain and
dysfunction (Cummings & Baldry 2007, Fernandez-de-las-Penas et al., 2005, Fryer & Hodgson,
2005, Simons, 2002). Trigger points are recognized as main cause of headache and neck pain (Fer-
nandez-de-las-Penas et al., 2005). They can be a reason to conditions like frozen shoulder, epicon-
dylitis, carpal tunnel syndrome, atypical angina pectoris or lower back pain (Simons, 2002).
References
Ist International Fascia Research Congress. 2007. (htpp://www.fasciacongress.org/2007/).
Myers, T. (2009). Anatomy trains, Myofascial meridians for manual and movement therapies. 2nd
edition, China: Churchill Livingstone.
LeMoon, K. (2008). Terminology used in Fascia Research. Journal of Bodywork and Movement
Therapies 12, 204-212
34
Fascia - the forgotten tissue
Chaitow L., Bradley D., & Gilbert C. (2002). Multidisciplinary Approaches to Breathing Pattern
Disorders. Churchill Livingstone, Edinburgh.
Grant, K. E., & Riggs, A. (2008). Chapter 9: Myofascial Release. 149-166 (Stillerman, E. 2008.
Modalities for Massage and Bodywork. USA: Elsevier Health Sciences).
Schleip, R., Klingier, W. & Lehmann-Horn, F. (2005). Active fascial contractility: Fascia may be
able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dy-
namics. Medical Hypothesis 65, 273-277.
Stecco C, Macchi V, Porzionato A, Morra A, Parenti A, Stecco A, Delmas V & De Caro R. (2010).
The ankle retinacula: morphological evidence of the proprioceptive role of the fascial sys-
tem. Cell Tissue Organs 192(3), 200-210.
Langevin, H.M. (2006). Connective tissue: a body-wide signaling network? Medical Hypotheses
66,1074-1077.
Schleip, R. (2003a). Fascial plasticity - a new neurobiological explanation: part 1. Journal of
Bodywork and Movement Therapies 7(1), 11-19.
Schleip, R. (2003b). Fascial plasticity - a new neurobiological explanation: part 2. Journal of
Bodywork and Movement Therapies 7(2), 104-116.
Stecco, C., Porzionato, A., Lancerotto, L., Stecco, A, Macchi, V., Ann Day, J. & De Caro, R. 2008.
Histological study of the deep fasciae of the limbs. Journal of Bodywork and Movement
Therapies 12, 225-230.
LeBauer, A., Brtalik, R. & Stowe, K. (2008). The effect of myofascial release (MFR) on an adult
with idiopathic scoliosis. Journal of Bodywork and Movement Therapies 12, 356-363.
Minasny, B. (2009). Understanding the Process of Fascial Unwinding. International Journal of
Therapeutic Massage and Bodywork 2 (3), 10-16.
LeMoon, K. (2008). Terminology used in Fascia Research. Journal of Bodywork and Movement
Therapies 12, 204-212.
Cummings, M. & Baldry, P. (2007). Regional myofascial pain: diagnosis and menagment. Best
Practice & Research Clinical Rheumatology 21(2), 367-387.
Fernandez de las Penas, C., Sohrbeck Campo, M., Carnero, J. & Page, J. (2005). Manual therapies
in the myofascial trigger point treatment: A systematic review Journal of Bodywork and
Movement Therapies 9, 27-34.
Fryer, G. & Hodgson, L. (2005). The effect of manual pressure release on myofascial trigger points
in the upper trapezius muscle. Journal of Bodywork and Movement Therapies 9, 248-255.
Grieve, R. (2006). Proximal hamstrings rupture, restoration of function without surgical interven-
tion: A case study of myofascial trigger point pressure release. Journal of Bodywork and
Movement Therapies 10, 99-104.
Simons, D. (2002). Understanding effective treatment of myofascial trigger points. Journal of
Bodywork and Movement Therapies 6(2), 81-88.
35
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EXERCISE and quality of life : journal of science in
sport / editor-in-chief Višnja Đorđić. - Vol. 6, no. 1 (2014)-.
Novi Sad : Faculty of Sport and Physical Education University
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Dva puta godišnje
ISSN 1821-3480
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EQOL
JOURNAL OF SCIENCE IN SPORT
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