Syndrome de Déficience posturale
Agressologie, 28, 941-943, 1987.
The postural deficiency syndrome ( PDS)
H. MARTINS DA CUNHA
Hôpital Santa Maria, Lisbonne.
In our physical medicine and rehabilitation department, we were able to observe and study from a postural point of view, about thousand patients sent by various departments of Santa Maria's hospital, in Lisbon.
A big part of these patients, having normal conventional examinations, present the same various functional and physical signs, which seem to group them.
Indeed, this complex symptomatology is dominated by functional cardinal signs as pain (headache, back pain, joints pain, thoracic or abdominal pain), imbalance (dizziness, sickness, inexplicable falls), some suggestive visual symptoms (diplopia, scotom, dim vision) and some proprioceptive like troubles (asomatognosie, dysmetria). These patients can present not cardinal functional signs also, sometimes as important as the precedents, as articular signs (temporo-mandibular joint syndrome, recurrent sprains), neuromuscular and neurovascular signs (paresia, paresthesia) (See Tables 1 and II in annexe).
We verified that, on the other hand, they present in common a stereotypical physical attitude, scoliotic, with an asymmetrical paraspinal muscular hypertonia and asymmetrical feet support also, dominated by a gaze deviation, rightwards or leftwards.
All these patients, indeed, present a tone disorder of their eye and postural muscles and part of their symptoms is connected to a deficit, which seems to affect both the proprioceptive information system and the visual information system.
Thats why we have been isolating and defining a new postural syndrome, the "Postural Deficiency Syndrome" ( PDS).
It is important, from a diagnostic and prognostic point of view for this disorder, to look for certain signs as an important asymmetry of the face leading to some difficulties for movements of the temporo-mandibular joint, a change of spinal muscles tone at one side of the neck, the trunk and the members root and, especially, the presence of muscular or periarticular painful points different from those of Valleix that can be discovered easily by digital compression.
Chest and spinal X-rays can reveal either a net asymmetry of the intercostal spaces, or a vertebral slope different from the classic orthopaedic scoliosis, these images being very legible, especially when X-rays are studied upside down. The use of clinical stereometry, easy and not invasive exam, helped us, by a relief perception, to understand X-rays exams and to follow up these patients posture after treatment, which we finalized.
Thermography of the face allows us to show, for example, that the change of the foot support, at once can modify the blood circulation in the field of external carotid, this modification demonstrating itself at once by a reheating in the area of the ophthalmic artery and in particular the angular artery. Even among healthy individuals, the blood pressure and the heart frequency can change after small postural modifications, changing, for instance, the type of foot support or of rest, either by modifying the relative position of both feet in orthostatic posture, or by modifying the height of the chair, or, in clinostatism, by removing or putting a simple pillow under the head.
Our interdisciplinary studies especially came to investigating ophtalmological phenomena of PDS, being given the importance of visual symptomatology of these patients and the presence of some disorders of the ocumomotor system that we found "ab initio" and that moreover, were not confirmed by ophtalmological conventional examinations.
The results of our first investigations were far from being encouraging. Then, with 0. A1ves Da Silva, ophthalmologist in our hospital, we began a new method of ophtalmological investigation, "the directional scotometry". For years and among thousands of patients suffering from PDS, this method put in evidence various visual disorders and in particular the functional pseudo-scotoma (directional scotoma) connected to functional defects of the proprioceptive and visual information. It allowed, on the other hand, better understanding some phenomena, as monocular diplopia, triplopia or even certain dyslexia that can be found in many of these patients. The study of tonic convergence has a particular interest, not only for the diagnosis, but especially because, in a very high number of cases, it is indispensable to introduce an eye correction by prismatic glasses of weak power, which play on this parameter.
The treatment of the PDS begins with "the somatanalyse", during which the patient is led to interpret his functional signs by trying to establish a relation between his symptoms, his postural disorders and his proprioceptive information. Then he discovers some defect of his body image maturation, with a false localization in the space of his various body segments and a false image of his limits, which it is absolutely necessary to correct.
For some patients, this somatanalyse is harder than a psychoanalysis, because "one sees oneself through ones own eyes and not through the eyes of the psychoanalyst".
Just after starting this awareness of his body in front of a mirror, the patient is introduced to a rehabilitation technique "The postural reprogrammation" that is made by provoking very simple modifications of proprioceptive information by small and brief .postural corrections.
These corrections, executed at rest or in activity, aim at teaching patients to modify their postures in a trend to a more stable and symmetric balance. To this awareness are added elementary respiratory exercises that intend to force physiological thoracic ventilation, simple movements of spine rotation, flexion and extension of members and active mobilization of the scapulo-thoracic and members joints.
The new proprioceptive sensations highlighted by this technique of treatment will be remembered at once, by a cybernetic mechanism, and will lead quickly to a more exact notion of the body schema. When it has been learnt, postural reprogrammation should be continued at home as at work.
In orthostatic posture, a new type of support will be tried with a perfect parallelism of both feet; the right foot put parallel and a little behind the left one, this posture gives a bigger stability and, in spite of a false and strange sensation of feet convergence, this position determines a well being sensation and a favorable modification of many physiological parameters. One will note the immediate improvement of binocular vision and the disappearance of PDS painful points, especially if, simultaneously, a pelvis retroversion is executed, and a shoulders antepulsion and a discreet mandibular protrusion with occlusion on incisors.
In cathedrostatic posture, the position should be obtained on a low chair with stiff seat, by avoiding dorsal support and by heightening left foot, firmly supported, the head will be maintained in better position if patient looks at the horizon.
In clinostatic posture, dorsal decubitus will always be tried without pillow. One can also try the lateroventral, right or left, rest with a rotation of the head and a position of members in contradiction with the neck reflex.
Beyond the somatanalyse and beyond the postural reprogrammation, frequently, for treating a PDS, it is necessary to add prismatic glasses of weak power, chosen by an ophthalmologist aware of this particular domain of posturology. Indeed, prisms are prescribed not only on results of the directional scotometry, but often also in agreement with not ophtalmological parameters that it is necessary to know how to look for and consider. In these conditions, the prismatic correction will play a very important role in the field of proprioceptive information, under all its .aspects: reception, transmission or "treatment". With prisms, one can note a more correct appreciation of the localization of the various body segments and a disappearance of imbalance and of PDS painful points.
Physiotherapy and\or drugs can be necessary especially in acute phases, but we always envisage them as extra therapeutic: it is necessary to fight against all the forms of dependence of the patients.
According to our opinion, the postural reprogrammation facilitated by the somatanalyse and the introduction of prisms of weak power, leads to a correction of the proprioceptive information received by the centers of balance and consequently to a correction of the orders that they send to all the effector organs. It brings about recovery of a physiological postural balance disturbed by a sedentary and anxious civilization.
The study of the PDS should establish an important field of interdisciplinary investigation, interesting particularly the social medicine and its implications in a great number of industrial or road accidents, in ergonomics and in the prevention of the decompensations of many chronic diseases.
Off-prints: MARTINS DA CUNHA
Pinheiro Chagas 68 2-nd lashed out
1000 Lisboa. Portugal.
Functional signs of the syndrome of postural deficiency ( PDS)
[Martins Da Cunha H. (1979) Syndrome de déficience posturale, Actualités en rééducation fonctionnelle et réadaptation, 4e série (Ed. L. Simon), Masson, Paris.]
Functional signs of the postural deficiency syndrome ( PDS).
|Pain||Headache, retro-eye, thoracic or abdominal pain, arthralgies, rachialgies|
|Imbalance||Sickness, nausea, dizziness, inexplicable falls|
|Ophtalmological signs||Asthenopia, dim vision, diplopia, directional scotoma, metatopsia.|
|proprioceptive like signs||Dysmetria, somatoagnosia, errors of appreciation of the body image.|
Not cardinal signs.
|Articular||TMJ Syndrome, stiff neck, lumbago, periarthrities, sprains|
|Neuromuscular||Paresia, defect of driving control of the extremities.|
|Neuro-vascular||Paresthesia of the extremities, Raynaud's phenomenon.
|Psychic||Dyslexia, dysgraphia, agoraphobia, defect of orientation, defect of spatial localization right and left. Defect of concentration, loss of memory, asthenia, anxiety, depression.|