Posture - Client Assessment Ideas

Client Assessment: Going Beyond the Medical Questionnaire

 By this we mean that the first training session for any new client will be an assessment of their posture and overall muscular balance, only when you have this information can you prescribe a safe and effective training programme. For instance, if a client is presenting no serious risk factors but has told you they get backache or headaches it would be foolish to embark on a programme of exercise before you have made an attempt to discover the root cause of the problem. Equally if a client revealed during the consultation that they get chronic knee pain you would not immediately introduce them to a training programme containing high levels of lunges and squats

One of the most important procedures you can carry out is the client assessment, this will give you invaluable information about your client and will reveal muscular imbalances and can often lead to uncovering the root causes of joint pain, backache and recurring headaches. 

What do we mean by muscle balance?

When we refer to muscle balance we are primarily concerned with muscle length and strength. For the purpose of this course we will be concentrating mainly on the basics of testing for muscle length. When the body is in balance we can expect to find neutral postural alignment, full range of motion through Sagittal, Frontal and Traverse planes and a full range of motion through the joints of the limbs.

When a body is subject to continual faulty loading through, poor postural alignment, driving, sedentary occupation or trauma the body will respond by shortening or tightening some muscles (Tonic) and lengthening others (Phasic). This intern will interfere with the neurological information that they receive and can result in, pain, faulty muscle action and poor biomechanics. As we adjust to these imbalances we make mechanical compensation for poor function that will ultimately compound any problem we may have and in most cases lead to new ones.

Once we have identified an area of imbalance through correct assessment we can begin to correct the problem and start to bring about a return to correct function and then on to correct exercise with a solid foundation.

Starting at the head and working down in sequence

This group of tests are essentially stretches to establish your client’s range of motion (ROM) through various planes. All corrective stretches are listed in the next article in the series " Assessment & Corrective Stretches" 

Neck Flexion 

Neck Rotation

Appley Scratch

Pecs Major & Minor

Spinal Rotation

Latissimus Test

Side Bend

McKenzie Press Up

Groin

Hips

Hamstrings

Quads

Iliopsoas

Calves

Neck Flexion.

Standing or sitting drop you head to one side as if you were trying to touch your ear to your shoulder. Maintain good posture throughout and be sure not to let the head drop forwards/backwards or rotate. Normal range of motion is between 25-40°. If it is obvious that the neck has greater flexion on one side, include the side flexor stretch in your programme for the short side.

Neck Rotation

Standing or sitting with good posture making sure that the head is in correct alignment. Slowly turn the head as far as is comfortable to the left and then the right with the intention of looking over the shoulder. Normal range of motion is between 70-90°. Be aware that the normal range of motion for older populations is reduced to around 70°. 

Apley Scratch

With the client standing get them to place their right hand behind their back and ask them to reach up as high as possible. They should be able to comfortably reach T7/8. This is testing Adduction and Internal Rotation of the shoulder joint.

Next with the client standing ask them to put their hand behind their head and reach down as far as possible. They should be able to comfortably reach C7-T12. This is testing Abduction and External Rotation of the shoulder joint.   

The shoulder is an area (second only to the spine) where you will come across a lot of either injuries or general discomfort. It is the most mobile joint we have but is also highly unstable. Holding the whole joint together are the four rotator cuff muscles, Supraspinatus, Infraspinatus, Subscapularis and Teres Minor, together they form a single tendon unit that creates a capsule around the shoulder. Rotator cuff muscles act primarily as stabilizers while Deltoids, Trapezius and Teres Major are the prime movers.   

Pecs Major & Minor

With the client lying on their back get them to put their hands behind the head and relax the arms. Normal range of motion will allow the forearms to touch the floor. If they are tight on either side or perhaps both you will see the elbows are off the floor and drawn in to the center line of the body.

Spinal Rotation (Lumbar)

With the client still lying on the floor get them to stretch their arms out to the side level with the shoulder. Get them to raise and bend the knees so they have a 90° angle at the hip and the knee. No slowly get them to lower the knees to the floor keeping the legs together and maintaining the angles. Do not allow the opposite shoulder to lift off the floor. Once they have gone as far as they comfortably can, return to center and repeat on the other side. Normal lumbar spinal mobility will allow for the knees to reach the floor while keeping the shoulders flat.

Latissimus Test

Stand the client against a wall with the heels about one foot away from the skirting and feet slightly apart. The head, shoulders and buttocks should all be in contact with the wall. Place your hand in the small of the back and gauge the amount of lordosis. With palms together and straight arms get the client to raise their arms up and towards the wall. If you feel the lordosis increase they have short lats. If they can raise their arms up over the head and touch the wall without an increase in lordosis they have normal lat length. If you detect a reduction in lordosis and see the head lifting away from the wall and forward, coupled with the inability to touch the wall this would be an indication of poor thoracic mobility.

Side Bend

With the client standing as with the lat test only this time with the heels touching the skirting and the feet together, get the client to slide the left hand down the side of the body as far as they can without any forward flexion. Return to the start position and repeat on the opposite side. Normal spinal flexion would allow the hand to reach the knee.

McKenzie Press Up.

Test to establish mobility of lumbar spine and also a mobilization exercise in its own right. With the client lying face down with hands slightly forward of the shoulders. Inhale and begin to push the upper body off the floor by straightening the arms exhaling as they go keep the pelvis in contact with the floor. It is vital that they keep the thighs and buttocks relaxed and breathe out as they push up. If they have normal mobility they should be able to straighten the arms and keep the pelvis on the floor.

Groin

Very easy this one. With the client lying flat on their back with arms by their side get them to open their legs as wide as possible. Normal range of motion will be between 45-50° from the mid line. Less than this will likely be due to tight adductors.

Hips 

Hip rotators are easy to assess and can provide you with valuable information. With the client lying down on their back ask them to relax the legs and feet completely. Now look at the feet and gauge the turnout . Anything over 45° would be an indicator of shortened hip rotators on that side, arguably the most important of which is the Piriformis. This muscle will laterally rotate the hip and when it becomes tight it will contribute to the toe out gait often seen in dancers and will also cause increased pressure on the sciatic nerve. The primary function of the Piriformis however is not as a rotator but as a postural muscle acting to stabalise the spine via it’s attatchment to the sacrum, and working with the psoas to stabilize the pelvis. 

Hamstrings

Hamstring length can be assessed quite well by conducting a simple leg lift test. With the client lying supine get them to lift a leg as high as possible keeping the leg straight. Optimal ROM is 90° of flexion.

Quads

Tight quads are again very common and can result in poor knee alignment and joint pain. Get the client to perform a standing quad stretch be grasping the left ankle with the left hand and pulling in towards the buttock. Take care to keep the hips forward and the knees together. Note where the client feels the stress, is it in the quads only or is the tension in the left side of the groin/lower abdominal when the hips are pressed forward? Normal range of motion will allow for the foot to reach the buttocks will a little help.

Iliopsoas

If you conduct a quad test and find that the client feels tension in the abdomen or pelvic area it is possible that they have tight Iliopsoas muscles. Tight Iliopsoas can result in poor motor function, anterior tilting of the pelvis, low back pain, knee torque and restricted diaphragmatic breathing to name just a few. To test for tight psoas lay the client face down and get them to lift one leg as far as possible without lifting or twisting the pelvis. Normal range of motion would allow for an elevation of about 30°. 

Calves

Again here is a muscle group that in most cases will be short.  Chronic tightness can result in knee pain, shin splints and plantar fasciitis amongst other conditions. Get the client to stand on a step with their weight on the ball of one foot. Allow the heel to drop down keeping the supporting leg straight but without stressing the knee joint. This will stretch the Gastrocnemius, to move the stretch to the Soleus slowly bent the supporting leg until they feel the tension moving down the calve towards the heel. Do not let the stretch progress to the Achilles tendon. 

As you move through the assessment you will be recording the results and noting the degree of flexibility in each of the stretches. This will not only show which areas need work but will ultimately dictate the initial training and stretching programme that you will develop for your client. Recording the results on a table such as the one bellow will make reference easier.

TEST	TIGHT	NORMAL	NOTES
Neck Flexion
Neck Rotation
Apley Scratch
Pecs Major/Minor
Spinal Rotation
Latissimus Test
Side Bend
McKenzie Press Up
Groin
Hips
Hamstrings
Quads
Iliopsoas
Calves

It is important to remember that while we are primarily looking for imbalance due to muscular shortening, some clients may present with hyper flexibility. This is obviously the other extreme of muscular imbalance and although not nearly as common needs to be addressed through a well thought out training programme that seeks to bring a return to muscular balance.

With the assessment now complete we can begin to build a picture of the clients needs in terms of their muscular balance. You now have all the information you need to put together a daily stretching routine that will target the shortest muscle groups, and have some understanding of their training requirements as far as resistance training is concerned.