Reading material on improving movement analysis and therapy

Norwegian psychomotor assessment  

  

Assessment of a patient allows us to decide whether or not psychomotor therapy is suitable for the individual 

  

Assessment consists parts:   

• Case history  
• An examination of the body: posture, respiration, physical function and reactions  
• The patient’s reaction to the examination itself  

It is preferred that the assessment is made in underwear but if the patient is uncomfortable the physiotherapist can also palpate through clothes. After that the physiotherapist start the assessment with the posture, movements, and body composition where the order might vary depending on the patient.  

The physiotherapist and the patient are making the findings in constant interaction. The emphasis of the assessment is on breathing and movement. The examination takes about a half hour and should not be prolonged.  

  

The physiotherapist is observing through the assessment the patient’s autonomic nervous system reactions, emotional reactions, body awareness and overall sensations arising from the assessment in order the patient becoming aware about them.  

  

  

CASE HISTORY AND EMPHASIS ON THE PATIENT’S LIFE HISTORY  

  

Natural functions  

What sort of physical problems has the patient experienced in life? There is interest in problems associated with musculoskeletal system but all bodily functions: stomach pain, digestive problems, difficulty in sleeping, hormonal disturbances etc. Questions about natural functions that include vegetative and hormonal conditions are important, as they rely useful information about the patient’s general state of health balance.  

  

Note! There is a close correlation between feelings and vegetative reactions. Stomachache or palpitations when we are worried or nervous. Autonomic disturbance and dysfunction are in general seen as an expression of emotional and mental stress.  

  

Previous injuries and illnesses  

No matter what the cause, pain results in reflex muscle tension. It can also result in a poor, ineffective movement pattern. Bad movement habits and ineffective use of the body may therefore be adopted due to negative reflex patterns. Asymmetrical tension and strain can arise because of an injury. Knowledge of a patient’s previous illnesses, injuries and surgery is of diagnostic value and being helpful in adjusting treatment dosage.   

  

Note! Especially important is to know what is happening in the respiratory organs.  

  

It is the physical problems that bring the patient to us. And they must come first. Other information, marital problems, difficulties within family etc. come in time, when contact and confidence are established. It is not only necessary to get information about the patient’s life but also how the patient experiences it.   

  

POSTURE  

  

Any posture which is asymmetrical in relation to the central line indicates that there is abnormal tension somewhere in the body. In the ideal posture the tension is balanced between front and back side of the body equally. The spine curves are adapted according to the position of the lower extremities and pelvis. The position of the upper extremities, shoulders and head has also effect on the overall posture. Everyone has personal posture which start to form itself from the childhood. The posture can be affected by physical factors like musculoskeletal injuries and psychological factors like emotions, unprocessed traumas and stress level. The posture can also give information about the patient’s overall attitude toward life.   

  

Bunkan has introduced 3 main types of posture according to the  

psychological stage. There is evidence that stress and uncertainty of life has effect on the body posture.  

  

1.  This type of posture is called flexor posture. Common factor is strong contraction of the flexor muscles especially abdominals, inversion of the upper limbs, flexion of the elbows, pronation of the arms, tying hands front, flexion of knees, spine and pelvis, weakness in the lower extremities and holding the breath.   

  

• Second type of the posture is collapsed posture. Sometimes it is hard to separate from the flexor position, the main separating factor is that in collapsed posture the muscles are hypotonic and in the flexor they are hypertonic. In collapsed posture the pelvis and head are front relative to the central axel.   

  

• The third type of posture what Bunkan is mentioning in her book is extension type. There the person is extending him/herself in order to cover the insecurity. This posture can be separated from the ideal posture with the muscle tension. As mentioned before in the ideal posture there is balanced muscle tone between the extensors and flexors but in extended posture there is increased muscle contraction in the extensor muscles.   

  

Note! The position of the legs can give information about the person resources to cope with the life from the body-mind point of view and how is the person facing the life. In addition, the leg position is affecting on the overall posture and that is why it gives to the physiotherapist information.   

  

The posture is assessed in the standing, sitting and laying down. It begins by asking the patient to stand in her/his typical standing posture. After that the physiotherapist asks the patient to take the standardized assessment posture where feet are hip width apart, the legs are parallel, knees are straightened and talocrural join is in 90 degrees. The weight should not be on the toes, in the posture patient is able to move their toes without changing the posture. The posture is assessed relative to the vertical axis. The vertical axis start from the atlanto occipital joint, goes trough cervix and thoracic junction, cut the lower part of sacrum, middle of the lower limbs until talocrural joint.   

  

The physiotherapist is assessing the symmetry and weight distribution of the body from the front, back and lateral direction. After that the physiotherapist is paying attention if there is deviations relation to the central and vertical axis, if there is findings she marks where and how much. Two other important marks are the spine and pelvis: how are the spinal curves (lumbar lordosis, thoracic kyphosis and cervical  

lordosis) and is the pelvis tilt forwards or backwards.   

  

After assessing the standing posture, the physiotherapist repeats the assessment in the sitting and laying down posture and pays attention if there are changes when the gravitation is eliminated. When the patient is laying down the physiotherapist is paying attention if the legs are separated or tied together and if the sacrum, shoulder blades  

and the knees are touching the mat. If the patient’s posture was tensed in the standing posture and the patient is able to relax when lying down, it shows that the patient has resources. In the sitting position the physiotherapist is observing how the patient is holding the posture, where the hands are situated and what happens to the spinal curves.   

  

  

RESPIRATION  

  

  

The respiration is assessed through the test battery during the posture, movement and muscular consistency assessment. The emphasis is on the movement what happens during the breathing in standing, sitting and laying down posture. The optimal breathing movement is happening in the lower ribs, stomach and sternum is moving slightly up and outwards. The main muscles moving during the inhalation are diaphragm and the outer intercostal muscles. In addition, there is some muscle activation in the upper respiratory muscles in the neck and shoulder but during the optimal breath it is barely seen from outside. During the exhalation the inspiration muscles relax, and the chest cavity goes down and the pressure moves from the chest cavity to the stomach cavity. From outside the abdomen goes slightly inwards during exhalation.   

  

When there is disturbance in the breathing pattern the inhalation happens more voluntarily. During the forced inhalation the muscles around nostrils and vocal cords, back extensors, sternocleidomastoid, scalene and pectoralis major and minor contract. That cause movement upwards in the shoulder and chest area. When exhale is done forced, we use abdominals and internal intercostals. This is causing tension and shortening in the abdominal muscles.   

   

Note! Give attention to the breathing posture, respiratory muscles used, flexibility of the thoracic area, respiratory rate and the natural breaks between inhalation and exhalation  

  

FUNCTION  

  

The movement tests give information about the range of motion, muscle function and self-movement. The tests are connected to the patient’s deeper resilience behind the  

muscular movement, and it shows the person’s ability to adapt to the situation and if one is feeling safe. The test pattern includes main joint movement tests, spinal mobility assessment and movements which show how the patient is able to relax during the passive movement. In addition to those the balance and flexibility is assessed because tensed muscle cause instability in the posture which can lead to musculoskeletal pain.  

  

Functional tests assess body’s flexibility and versatility. Functional tests are developed in such a way to give information about holistic qualities. Movement is considered good when it flows freely and is naturally accompanied by other movements throughout the body. If there is blocks to free movement and stretch impulses, there is less harmony between the various parts of the body demanding muscular effort in order to complete movements.   

  

Note! Find out what breaks are applied and what sort of blocks does the individual have.  

  

Relaxed stooped-standing position   

  

Patient stands with body bent forwards, the upper body hanging down as relaxed as possible.   

• The arms hang relaxed with the hands over the feet.  
• The back has an even curve and neck is relaxed  
• The knees are stretched with minimal quadriceps activity.  

  

In this position information is discussed and gathered:   

• Mobility  
• Elasticity in muscles and soft tissue  
• Ability to relax and allow the neck to become integrated part of the trunk  
• Ability to remain loose in the upper body while legs remain stretched, stable and active  

  

The long-sitting position  

The patient sits with legs parallel and stretched out in the front of the body. The muscles on the back of the body are stretched.  

  

How the person adapts to this position. In order to localize and differrenciate whether the brakes are in the legs, back or neck, these parts are independently flexed.   

  

Note! Activity in the extensors of the body are part of the “pull yourself together” pattern. Increased tension and static muscle work in the extensor apparatus results in less stretchability over a period of time.   

  

The two functional tests response in person’s with a more or less “pull yourself together” attitude. In people with reduced stretchinglength in the extensor system, we frequently find that the flexor muscles are also shortened. The individual is in other words more or less totally protected and stiff.   

  

Free movements between various parts of the body and isolated muscle contraction and the ability to relax  

  

The patient is standing still, and the physiotherapist is applying little bit force on the sacrum of the patient and then the physiotherapist is observing how is the movement of the whole body: is it stiff or is it wavelike movement. This can show how the patient is letting the movement flow through the body and the physiotherapist can see the body part where the movement is stopping. The patient is asked to let the movement flow through the body without stopping it. If the patient is losing the balance, it is a sign of a tension somewhere in the body.  

  

The assessment is continuing in the supine position by assessing the passive shoulder join movement in flexion position. Physiotherapist is assessing if the patient can let the hand move freely without assisting the movement or is the patient possibly resisting the movement. If the patient is assisting or resisting the movement, it shows that one is not able to be passive. The passive range of motion assessment continues with hip and knee joint flexion by observing the same principals as in the shoulder joint assessment. The last part of the assessment in supine position is the cervical spine passive flexion and rotation.  

  

The patient is in sitting position. First the patient is asked to lean forwards and curve the spine where the physiotherapist is assessing the position of the head, upper back and middle back. After that patient is asked to straighten the back slowly and the physiotherapist is observing is the movement happening in the whole spine or is there parts which stay stiff. In addition, the physiotherapist is assessing if the pelvis area is staying stable while straightening the spine. Last part in the sitting position is knee lift where the physiotherapist is paying attention on the movement control.  

  

Note! There is a psychological difference between individuals that resist passive movement and those that assist. People that resist have difficulty allowing others to control them. Such a person may have a deep sense of insecurity that emerges in uncontrollable resistance. Resistance seems to be a result of factors such a protest, reservation, anxiety, anger etc. Those that are assisting also express insecurity which would seem to be related to negative “ego feelings”.” I am not good enough”. “I have to help so as to be appreciated”.   

 PALPATION of MUSCULUATURE  

  

The assessment is made by palpating the certain muscle groups in laying down position where the gravity is eliminated, and the entire body is relaxed. when palpating the grip is firm in order to feel through the tissues. The main idea behind the muscle consistency  

assessment is that tensing the muscles is one of the most common defense mechanisms.  

  

During the palpation the physiotherapist is mainly paying attention on the size of the muscle if there is difference between sides, muscle tension and if the patient is feeling discomfort during the assessment. The physiotherapist is marking with colors on the assessment form is the muscular tension very high or is the tension below the normal  

muscle tone. From the picture the physiotherapist can see if the tension or lack of muscle tone is symmetric or affecting only certain muscle groups. When the physiotherapist is doing the palpation, she/he is asking if the patient is feeling the same.  

If the findings of the physiotherapist and the feeling of the patient is matching it tells that the patient has good body awareness. Emotional and autonomic nervous system reactions are also marked down.    

AUTONOMIC NERVOUS SYSTEM REACTIONS:  

  

The autonomic nervous system is divided into parasympathetic and sympathetic division. The autonomic nervous system is connected to our breathing, muscles, posture and movement. It is also regulating the function of many internal organs, the heartbeat for instance. The parasympathetic division is responsible for the “rest and digest” responses and the sympathetic for the “flight and fight” response. The internal organs have nerve branches from both divisions, depending on the nerve message, one of the divisions increase or decrease the activation of the organ in order to maintain the health.  

  

The autonomic nervous system reactions are assessed through all the four main parts of the assessment. Those reactions can tell important information about the alertness of the patient, and about how the person is sensing safety and danger. The reactions are assessed before, during and after the assessment. Those reactions can be for instance: changes in the color of the skin, temperature of the body, swelling, sweating or freezing, smell or changes in the breath. The goal is to create overall picture of the symptoms and make a conclusion regarding on that.   

  

  

BODYAWARENESS:   

  

Body awareness is very crucial part of our resources in life. The more we are aware of our body and the better the body image is the more we have resources. Body awareness means our ability to sense and be aware about our bodies. The awareness from the body parts is crucial for the overall situation, it tells if the patient has connection to the body parts and if they are part of their self-image. The body awareness is assessed through the whole assessment by comparing the findings of the physiotherapist and the patient.   

  

  

Contraindications for Norwegian psychomotor therapy:  

  

Since a person’s ability to adjust (physically and mentally) is central to psychomotor therapy, this does not imply that everyone is bale to profit from this therapy form. Should the examination show inability to adjust, one concludes that the individual is unsuitable for trearment. Physical, psychological and social factors may limit a patient’s potential to take advantage of this treatment.  

  

References:   

1. Thornquist, E. & Bunkan, H. 1991. What is Psychomotor therapy. Norwegian University Press  
2. Harjunen, E. 2020. ROBE – Resource oriented body examination – workshop for physiotherapy students. Bachelor thesis. Satakunta university of Applied Sciences