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U. S. DEPARTMENT OF LABOR JAMES J. DAVIS. Secretary CHILDREN’S BUREAU GRACE ABBOTT. Chie! POSTURE CLINICS O RG AN IZATIO N A N D EXERCISES By ARMIN KLEIN, M. D. 0 Bureau Publication N o . 164 WASHINGTON GOVERNMENT PRINTING OFFICE 1926 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SINGLE COPIES OF THIS PUBJUCATION MAY BE OBTAINED FREE UPON APPLICATION TO THE c h il d r e n ’ s b u r e a u , a d d it io n a l c o p ie s m a y BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS, GOVERNMENT PRINTING OFFICE, ■WASHINGTON, D . C. AT 15 C E N T S P E R C O P Y https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis S lo*. 1 I l Ç S cl I (o CONTENTS Letter o f transmittal--------------------------------------------- -------------------------------------------Importance of good body mechanics---------------------------------------------------------------Definitions of posture grades and body types------------------------------------------------Results of poor posture------------------------------------------------------------ 1------------_------- Purpose and scope of a posture clinic___ ;______________ I # ------------------1----------Organization of a posture clinic_________________ _-------------------------------------------Record taking and physical examination------------------------------------------------------Method of teaching posture to children______________________________________ Sum m ary_________________________________________________________________________ Page v 1 2 14 15 17 21 22 31 ILLUSTRATIONS Fio. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 3 Skeletal form of a person with good bodymechanics_______________ Skeletal form of a person with poor body mechanics_____________ 3 Posture standards— Stocky-type g ir ls_______________________________ 7 Posture standards— Stocky-type b oy s_______________________________ 8 Posture standards— Thin-type g ir ls_________________________________ 9 10 Posture standards— Thin-type boys__________________________________ Posture standards— Intermediate-type girls__________________________ 11 Posture standards— Intermediate-type boys___________________________ 12 Tracing o f the contour of the chest of a person with good posture13 Tracing o f the contour of the chest o f a person with poor posture13 Profile silhouette o f the body form at the beginning o f a school year ________________________________________________________ facing__ 18 Profile silhouette of the body form at the end of a school year with posture training_______________________________________facing_ 18 Passive pectoral stretching exercise_________________________ facing_ 18 Child in resting position_____________________________________ facing_ 18 18 Chest expansion with deep inspiration________ _____________ facing__ Manual “ coaching” to increase: chest expansion___________ facing_ 18 Tracing o f the body form by means of the schematograph_________ 21 Method o f correcting poor posture in the supine position__________ 23 Alternate arm raising while good posture is maintained in the supine position__________ _____ __________ 24 Straight-leg exercise with one thigh flexed on the abdomen_______ 24 Double leg exercise________________________________________________________ 25 Retraction o f the abdominal muscles and contraction of the but tock muscles to assume correct posture against the w all_______ 26 Method of correcting poor posture in the erect position____ _______ 27 Method o f walking away from the w all after correct posture has been attained there_________________________________________________ 28 Trunk forward-bending exercise_____________________________________ 29 Diaphragmatic-breathing exercise_____________________ - _____________ 30 Active pectoral stretching exercise__________________________________ 31 in https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis LETTER OF T R A N SM ITT A L U . S. D L abor, C h il d r e n ’s B u r e a u , epar tm en t of 'Washington, September 21, 1926. S i r : Transmitted, herewith is a report on Posture Clinics; organi zation and exercises, by Dr. Armin Klein, director o f the posture clinic o f the Massachusetts General Hospital. The exercises in this report are corrective, designed for children who are suffering from the effects o f poor posture, and.for use in clinics, just as the exercises in the bulletin entitled “ Posture Exercises ” are preventive, designed for the normal child and for use in schools. Acknowledgment is made to Drs. Joel E. Goldthwaite, Robert B. Osgood, and Lloyd T. Brown, and to Dr. Martha M. Eliot, director o f the child-hygiene division o f the Children’s Bureau, for helpful suggestions. Respectfully submitted. G r a c e A b b o t t , Chief. Hon. J a m e s J . D a v i s , Secretary of Labor. v https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis POSTURE CLINICS IM PORTANCE OF GOOD B O D Y M EC H AN ICS After infancy the child learns to stand and walk, and growth is then constituted more on a physiological than on an anatomical basis. Transition from the supine and prone positions to the up right position tends to strain the stabilizing and supporting frame work o f the body, and the result sooner or later is usually a com plete or partial exhaustion o f the postural muscles from the pull o f gravity. Descent o f the ribs and general ptosis follow. By early adult life this becomes more noticeable because o f its increase with growth. The posture o f the average man, because o f the force o f gravity and the influences o f growth and civilization, becomes drooped or ptotic. W ith the consequent derangement o f the elab orate mechanism maintaining the erect posture o f the body comes y derangement in position o f the viscera, which manifests itself fre quently in obscure but distressing ailments o f later life. Bacteria, foods, and poisons are important influences affecting the existence and functions o f the human organism that have been receiv ing due consideration, and the results are strikingly shown in the lengthened expectation o f life; but chronic ailments not due to infections, deficiency diseases, or toxins, but to continued habits o f wrong living and maladjustments o f the individual body to its environment should also be combated. Posture at present is not taught correctly in the family, at school, or by the medical profes sion as a whole, as is shown by the results o f physical examinations at schools and colleges and o f the Army examinations during the W orld War. Poor posture is far more prevalent than good posture, t— It is present in children o f lower school grades and is not outgrown in later life. In fact, defects o f posture noted in small children o f school age are duplicated in college students and vice versa. To relieve these children suffering from ailments due to their poor posture, posture clinics are definitely necessary, just as necessary as those relieving sufferers from chronic ailments due to other causes. The program o f the future is so to train the individual from early life as to prevent many o f the present ailments which are due to poor posture. His interest in his own maximum physical effi ciency should be aroused by education. He should realize that the freer and more economical use o f the body not only will prevent the chronic ailments that may be due directly to poor posture but by conserving energy will add to the body’s power to resist disease and thus prolong still further the period o f vigor for man. Thus the teaching o f good posture is a phase o f preventive medicine which should aid in combating at their outset not only diseases primarily <— due to poor body mechanics but also those functional conditions for l https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 POSTURE CLINICS which poor posture is responsible. Good posture by insuring effi cient use o f the body may increase the resistance o f the body to invasion by outside noxious agents. Since instruction in the intelligent care, nurture, and training o f the body will be most effective if given at an early age and to large groups, such instruction should be given in the schools. When this instruction has a recognized place in the curriculum, education will include in its aim the habitual correct use o f the body as well as o f the mind. Even when posture is generally taught in the schools, however, some posture clinics will be necessary to care for children requiring special attention, and until that time the posture clinic with its cor rective work fills an especially important role. It is the purpose o f this pamphlet to discuss the organization of such clinics for the purpose o f treating some o f the chronic ailments o f the individual. From the experience and insight gained from such corrective training o f individuals or small groups it has been possible to derive standards for the instruction of large groups so as to prevent incorrect body posture and its sequelae.1 POSTURE GRADES A N D BODY TYPES The body is in good mechanical position when the weight of it rests evenly on the heads o f the femurs; i. e., the hip joints. In this posi tion the head is balanced above the shoulders, the chest is elevated, and the breastbone is the part o f the body farthest forward. The lower abdomen is retracted and flat, and the back curves are within normal limits. In the standing position the hip joints in lateral view are directly in line with the Knees and ankle j oints. In this ideal standing posture a perpendicular dropped from the ear^ or just be hind it, would fall through the shoulder, hip, and ankle joints. The anterior groups o f muscles, in a state of tonus or o f postural or re flex contraction, are balanced 2 by similar action o f the posterior groups of muscles. This static or postural contraction used in sus taining the erect position may be continued indefinitely as it is main tained by the sympathetic nervous system. The normal individual therefore maintains his erect poise with ease, and the skeletal, muscu lar, and visceral systems are in proper relationship to function efficiently. In Figure 1 (p. 3) the head is held equipoised above the shoulders so that there is no undue strain on the muscles o f the neck and the blood will flow easily and freely to the brain. This makes for men tal alertness and vigor. . The chest is held up; “ costal” breathing will be unrestricted. The limits o f chest expansion will be reached freely and easily, and the lungs therefore will be well aerated. The heart also will not be handicapped in its action. The diaphragm will be elevated and dome shaped, in position for fullest activity and expansion; this will insure fullest aeration o f the lungs from the complementary diaphragmatic, or abdominal, breathing. i gee Posture Exercises; a handbook for schools and for teachers of physical educa tion (U. S. Children’s Bureau Publication No. 165, Washington, 192b). a Sherrington, C. H., M. D .: “ Posture.” The West London Medical Journal, Vol. XXV (1920), pp. 97-106. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ORGANIZATION AND EXERCISES Skeletal form of a person with good body mechanics (Mg. 1) and of a person with poor body mechanics (Fig. 2) 5795°— 26------2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 4 postu re cunncs The curves o f the spine are normal. The segments are balanced on one another, with minimum tension on the muscular and liga mentous stays o f the spine. This evenly distributed tension will prevent overstrain on certain parts and the pain that frequently* accompanies it. The lower abdominal muscles are retracted, and the abdominal wall furnishes the necessary support for the abdominal organs in their proper places in the upper abdominal cavity, thus preventing them from sagging. It has been shown that retraction ox the lower abdomen is sufficient to raise the stomach and the adjacent organs 1 to 5 inches into the upper abdominal cavity. Food can then pass readily through the stomach and small intestines. Because the head is held erect, because the chest is up, because the curves o f the spines are not exaggerated, and because the lower abdominal muscles are retracted the person whose posture is diagrammatically shown in skeleton form in Figure 1 will function with good balance and form, gracefully, smoothly, efficiently, alertly. A body with variations from the ideal pictured in Figure 1 (p. 3 )—that is, with forward head, drooping chest, hollow back, and protuberant abdomen—has poor posture, the degree depending on the amount o f variation. In Figure 2 (p. 3) the neck muscles from the upper back to the occiput are strained because o f the drooped head, and strained, aching, upper-neck muscles are conducive to weakness and list lessness. The chest has dropped and the antero-posterior diameter is thereby decreased. The ribs so slant from their attachments at the spine that they drop into the chest and so narrow its diameter. This means a definite handicap to the action o f the lungs and heart. Because the chest has dropped, the sides o f the thorax, originally well rounded (as in fig. 9, p. 13), often become more angular and flattened (as in fig. 10, p. 13). In this flattened chest the dia phragm has not the rounded contour at its origin that is necessary to give it the normal dome shape. It sags relaxed. Its tone de creases. Its excursion becomes shallow.3 Under these conditions the lungs can not be well aerated. The normal curves o f the spine are exaggerated, and the mus cular stays o f the spine must exert themselves unduly in order to support the body in the erect position. Energy must be expended to balance the slumped body—energy that otherwise might be utilized for ordinary daily needs or stored to increase resistance to disease. I f the strain becomes too great, the energy wasted consti tutes an absolute deficit, and pain finally appears in the support ing muscles, most commonly in the lower back and the base o f the skull. The chest is flattened and dropped and the abdominal mus cles become relaxed and lose their tone. Thus the vicious circle is completed, as these muscles “ take up slack” and tend to stabilize the parts in their faulty position. The pelvis is tilted forward, and this faulty position tends still further to relax the abdominal supports and to allow the abdominal organs to drop downward toward or into the pelvis. Constipation, 8 Brown, Lloyd T., M. D .: “ Bodily mechanics and medicine.” and Surgical Journal, Vol. CLXXXII (1920), pp. 649-655. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis The Boston Medical ORGANIZATION AND EXERCISES 5 painful menstruation, even the cyclic vomiting of children, it is believed, may be due to these malpositions. Because the head is dropped downward and forward; because the chest falls down and inward, becoming flat and angular at the sides; because the normal curves o f the spine are exaggerated; and because the abdominal muscles are relaxed, the person whose posture is diagrammatically shown in skeleton form in Figure 2 is forced to maintain his equilibrium by overexertion o f his spinal muscular supports and by flexed or overextended knees. He is a slouchy, un graceful, inefficient, uninspiring individual whose functioning is impaired as a result o f poor body mechanics. Posture grades. Some persons use their bodies like the ideal pictured in Figure 1, the alignment o f their body parts being perfect; others do fairly well but not so well as the first group; some stand poorly, and some very poorly. Thus individuals may be classified readily into four grades o f body carriage— excellent, good, poor, and bad; or A , B, C, and D (figs. 3, 4, 5, 6, 7, 8, pp. 7-12). ’ The indexes o f excellent posture (A ) are, first, head balanced above the shoulders, hips, and ankles; second, chest elevated with the breastbone the part o f the body farthest forward; third, abdomen flat and drawn in below but free and mobile above; and, finally, nor mal unexaggerated back curves. In good posture (B ) the head and chin are inclined slightly for ward. As a result the chest drops a little, and the upper part o f the back inclines somewhat backward. The abdomen, though perhaps rounded, does not protrude. The lower, or lumbar, spine follows, as it were, the abdomen, and the hollow back shows its first signs o f appearance. In poor posture (C ) the head is plainly forward, and the chin pro trudes. The curve from the back o f the head to the lower end o f the shoulder blades is elongated and accentuated. The chest has dropped until it is flat. The relaxed abdomen protrudes, and the lower back is hollow. In bad posture (D ) the head is allowed to drop forward. The chin is dropped. The chest is sunken. The upper truck has swayed backward. To maintain equilibrium the forward inclination o f the lower spine is markedly increased. The back curves are therefore extremely exaggerated. W ith the sinking o f the chest the abdomen drops, relaxed and protuberant. The knees are sometimes bent for ward, sometimes sprung backward. The. relaxation is complete: W ith classification according to grade of body carriage comes an appreciation o f the severity o f body defects that the subject must overcome to improve his posture. Obviously a child with a D rating has farther to go than the C child, who in turn has farther to go than the B child before they all acquire A posture. The examiner there fore can prognosticate which groups o f children, other things being equal, will take longer to learn to maintain a correct attitude. His findings can be passed on to the instructors to enable them to train their patients in body mechanics more sympathetically and intelli gently. The patients themselves are stimulated to correct their poor posture. Since the characteristics o f the posture grades are defined, the child when graded knows exactly what he must correct. I f he https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 6 POSTURE CLINICS has ordinary ambition he will be stimulated to correct his body de fects in order to advance his rating. Classification according to body type. It becomes apparent that gradations in body carriage vary with in dividuals. Generally speaking, the indexes o f bad posture are the same in two given persons, although they may appear to differ greatly. Basic differences in body structure determine the specific appearance o f individuals classified in the various.posture grades. Stocky individuals, as they assume the relaxed attitude, lean back ward from the middle o f the back, the dorsolumbar junction (figs. 3, 4 ). Thin individuals with poor use o f their bodies sway back ward from the lowest part o f the spine (figs. 5, 6). The pelvis at the same time is tipped forward. Individuals o f the intermediate type, as they deviate from good poise, bend backward not at the middle o f the back as do the broad, stocky persons, nor at the low est part o f the spine as do the thin persons, but midway in the lower back or lumbar spine (figs, 7, 8). These three types o f anatomical structure—broad, intermediate, and thin—are easily recognized if seen “ pure.” The thin type has a torso long and slender or delicate and narrow and a long, thin neck. The length in the lumbar region is striking. Frequently there may even be six lumbar vertebrae instead o f the usual five. The elongated spine gives more flexibility, and this ex plains the marked slump, or ptosis, possible in these persons. They sometimes look as i f some heavy force were pushing them down from above; so much so that they sway far backward in the upper back and protrude far forward in the lower back, the pelvis tipping for ward with the lower spine. The shoulders may become markedly rounded and forward and the shoulder blades scaphoid. The ex tremities and their muscles are usually long and slender. The broad type includes the heavy-looking, “ broad-backed ” per sons with large skeletons. The neck is short and “ chunky.” The torso is* broad and relatively short. The lumbar region is short, sometimes because there are only four lumbar vertebrae instead o f the usual five and sometimes because the sacrum is set well down between the hip bones. Because o f the very construction o f the spine the lumbar curve is less marked. Flexibility is lacking in this sturdily built spine. The extremities are large and broad. This is the type that tends to be obese. . . In the intermediate type the torso is a compromise in length and breadth between the othef two types. The normal rounded curves o f the spine, i f they become exaggerated, appear mild and gradual. The sharp “ corners ” o f the thin type and the large fatty deposits of the broad type are missing. The neck may be almost as long as that o f the thin type; or it may be short, though hardly so thick and “ chunky ” as in the broad type. The musculature is firm. Flexi bility or the spine, though not so marked as in the thin type, is much greater than in the broad type. This intermediate class is hetero geneous; it should include all individuals that do not fall readily into either o f the other groups. After study and experience the fun damental characteristics o f the thin and stocky types will ordinarily be seen to predominate sufficiently in the individuals examined to war rant classification in one o f these types. When, however, characteris https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 7 ORGANIZATION AND EXERCISES POSTURE STANDARDS StocKy-Type Girls Excellent Good A B Poor Bad C D Children's Bureau, United States Department of Labor, W ashington, p.ç,i9£S. F ig. 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 8 POSTURE CLINICS POSTURE STANDARDS StocKy-Type Boys Excellent Good Poor Bad if i f A B C D Children's Bureau, United States Department of Labor, W ashington, a c ,1925. F ig. 4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 9 ORGANIZATION AND EXERCISES POSTURE STANDARDS Thin-Type Girls Excellent Good A Poor B C Bad D Children's Bureau, United sta te s Department of Labor, Washington,o.C,l9£8. F ig . 5 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 10 POSTURE CLINICS POSTURE STANDARDS Thin-Type Boys Excellent Good A Poor c B Children's Bureau, United S tates Department of .Labor, W ashington,0.C, 1926. F ig . 6 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 11 ORGANIZATION AND EXERCISES POSTURE STANDARDS Intermediate-Type G irls Poor Excellent Good A c B Bad D PO O R POSTURE B A D P O STU R E 1. Head forward. l.Head marKedly forward. 2. Chest flat. a Chest depressed CSunken) 3. Abdomen relaxed ¿Part of body,far thest forward.) 4. BacK curves exag gerated. ° a Abdomen complete ly relaxed and pro tuberant. . 4 BacKcurves extreme ly exaggerated. Children's Bureau, United States Department of Labor, W ash in g ton ,0.0,1926. P ig . 7 5795°— 26----- 3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 12 POSTURE CLINICS POSTURE STANDARDS Intermediate-Type Boys Excellent Good Poor EXCELLENT POSTURE 1. Head up-chin in. (Head balanced above shoulders, hips,and ankles) S. Chest up (Breast bone the part of body far thest forward) 3. Lower abdomen in, and flat. 4 Back curves with in normal limits. Children1» Bureau, United sta te s Department of Labor, W ashington, ac,«M6. F ig . 8 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ORGANIZATION AND EXERCISES 13 tics peculiar to these types do not so stand out, classification in the intermediate type is .logical. In this group should fall those who might have a tendency toward thin or broad characteristics but do not actually possess them. Corrective needs of the different types. When classification as to body form has been completed it is clear what may be expected o f the individuals o f different types. The broad type usually are fitted anatomically for slow, heavy, “ labor ious ” work; the thin type for work requiring speed or agility; and the intermediate type for either kind of work according to whether their physical characteristics incline more to one group or the other. I f in the industrial world employees were selected according to the anatomical types best fitted for special kinds o f work, they would be more efficient individuals, more efficient employees, and more effi cient members o f society. It should also be remembered that with classification o f body type comes appreciation o f the effort necessary for any person to main tain good body carriage. The broad type leaning backward only in the upper spine has to be taught principally to mobilize the chest and to keep it raised in order to straighten the spine. Attention in Tracing o f the contour of the chest (at about the lower level of the shoulder blades) of a person with good posture (Fig. 9) and of a person with poor posture (Fig. 10) that case should be concentrated on exercise o f the upper thorax and head. A slight amount o f “ pelvic r o ll” is usually necessary to balance the lower back. Then the body mechanics is corrected. The problem with the thin type is greater. The long, thin, willowy bodies are easily contorted into almost grotesque shapes. As has been mentioned, some persons o f this type appear to be laboring under the effects o f a compressing load at the upper end o f the spine. First the pelvis must be rolled backward; usually it has tipped so far forward that it is rather difficult to get it back to its ideal inclina tion. Then the upper chest must be balanced over the pelvis and lower back. This again is often quite difficult. A t first in bringing the thorax and head into proper position the patient is likely to lose the correct position he has just learned for the pelvis and lower back. But with patience on the part o f the instructor and diligence and assiduity on the part o f the patient good body mechanics is finally learned. It is most difficult for the thin type, however, and this should be understood in training them. The persons o f the intermediate type are hardly so limber and willowy as the thin type but are more flexible than the broad type. Some individuals, perhaps, will find it hard to roll their pelvis and lower back into proper position; others will find it more difficult to https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 14 POSTURE CLINICS balance the chest and head on the fixed lower back and pelvis. In struction should be directed to the difficulty and concentrated there. The very fact that the patient can not easily correct the maladjust ment o f posture associated with his anatomical structure is a clear indication that individual instruction is essential. The examiner classifying individuals according to grades o f pos ture and physique can, from his knowledge o f the workings of the different types, direct the attention o f the instructor to the part o f the body where correction is most needed. RESULTS OF POOR POSTURE When the body is not in proper mechanical position it must func tion with some o f its vital parts out o f alignment. The human body may then compensate for this strain through its inherent reserve power. Once this ability to compensate is lost, however, symptoms o f deranged physiology may appear, and the parts affected will show signs o f strain, at first, perhaps, vague but nevertheless severe in their cumulative effect. When slight and merely annoying in char acter, the signs seem plausibly to indicate deranged physiology due to poor body mechanics. When severe, however, they may seem out o f all proportion to the defect in posture that is the apparent cause. Then only a most thorough and searching examination, to rule out other factors as possible causes o f the complaints, can determine their origin. I f such an examination by an internist or a pediatrist re veals no organic explanation, then and only then should these symp toms be attributed to poor posture. Backache may be due specifically to poor posture. Strain o f the supporting muscles and ligaments of the spine from maintaining the erect attitude in a position o f mechanical disadvantage eventually may result in pain. But other affections o f the spine—for instance, tuberculosis, the so-called arthritic processes, and other organic lesions, abdominal or pelvic—must first be ruled out as causative factors. Backache in the middorsal region between the shoulder blades or at the “ small of the back ” in the lumbosacral region, and many “ headaches ” at the base of the skull may be relieved by bal ancing the entire spine in its position of normal curvature. Constipation also may be due specifically to poor posture. With incorrect body mechanics the relaxed protuberant abdominal wall does not support the stomach and intestines adequately. Ptosis and then partial stasis in the gastrointestinal tract may follow. How ever, obstructions due to some chronic organic lesion, subacute in flammatory processes, atonic and congenital conditions o f the intes tines, and incorrect dietary and other habits must first be ruled out as causes. Correcting the posture can raise the abdominal viscera from 1 to 5 inches, to the highest position for these organs for the given individual. Abdominal muscle contraction, such as is neces sary for good posture, will generally accomplish this most effectively in subjects with lax abdominal walls. Abdominal pain, chest pain, and pain in the limbs may sometimes be due specifically to poor posture. The attitude with exaggerated spinal curves may produce signs of pressure on the dorsal roots o f the spinal nerves with segmental distribution of pain along the route https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ORGANIZATION AN D EXERCISES 15 o f the branch nerves.4 Here again, however, appendicitis, tabes mesenterica, herpes zoster, pleurisy, bursitis, varicose veins, tabes dorsalis, and many other organic conditions must first be eliminated as cti0logical factors. Correcting the posture will relieve pressure on the nerve roots as they emerge from the vertebral foramina, and will be followed by a cessation o f symptoms if there is no organic difficulty. In many cases where no active disease is present dysmenorrhea may be attributed directly to poor body mechanics with its asso ciated ptosis and displacement o f viscera. The uterus is crowded out o f position, and the free circulation o f blood through it is in terfered with. The supporting ligaments become lax. General body fatigue is present. The result may very well be a discomfort inten sified at the period of menstruation. I f by means o f posture tram-» ing the lower abdominal wall is retracted the abdominal viscera may be elevated, and the uterus and its adnexa, relieved o f pressure from superincumbent abdominal organs, may function normally. ^ Insomnia, poor or capricious appetite, and u general disability or neurasthenia may be due indirectly to poor posture with its waste o f the available energy of the individual and the consequent bodily fatigue. On extreme physical fatigue nervous or mental irritability may supervene and manifest itself in insomnia, poor appetite, or neurasthenia. But these symptoms also may be due to organic causes which should be eliminated as etiological possibilities before hope is extended to the sufferers from these complaints that they will be relieved by improving their body carriage. . . Malnutrition, the petit-mal form o f epilepsy, and cyclic vomiting are conditions often improved by correcting body posture. Here again posture training is the method o f relief only after all other factors have been eliminated or in connection with treatment for other causes. When the patient has learned to use his body economi cally he will suffer less from gastrointestinal stasis and fatigue, which are possible causes o f these complaints. _ .J ^ _ ■ In the physical conditions just discussed correction o f the body mechanics will afford relief so far as the symptoms may be directly or indirectly referable to disturbed physiology. It must be empha sized that good posture is not a panacea. Thus, it would be absurd for a patient vomiting periodically because o f a stomach lesion to hope for relief with postural training; just so with neurasthenia from goiter, constipation from megalocolon, or bachache from early Pott’s disease. Only when no organic cause can be found to explain the symptoms should poor posture be considered as the important etiological factor. Sometimes, however, even when other factors are known to be present, if poor posture is associated with them the gen eral condition o f the patient may be improved by improving the pos ture and so increasing the reserve energy with which to combat the other factors. PURPOSE A N D SCOPE OF A POSTURE CLINIC Persons with complaints deferable to disturbed physiology due to poor body mechanics may be relieved of their complaints by the 4 Danforth, Murray S.f M. D „ and Philip D.. Wilson M D .: “ The « t o m y of the lumbo-sacral region in relation to sciatica pain. The Journal of Bone and Joint Surgery [Boston], Vol. V, No. 1 (January, 1925), pp. 109 160. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 16 POSTURE CLINICS habitual assumption o f a good body carriage. For the purposes o f this report discussion o f methods o f treatment will be limited to treatment for children 5 to 15 years o f age, though older persons may profit by a similar routine. The logical site for a posture clinic is the out-patient department or dispensary o f a general hospital. Here patients with physical complaints naturally come for treatment. Since posture training should not be given in the hope o f relieving symptoms until all etiological factors other than poor body mechanics have been elimi nated, it is advantageous to have easily available the adequate hospital facilities for general physical examination and special study to eliminate such other factors. • Patients should be accepted in the posture clinic only when re ferred to it from other departments o f the dispensary. As a routine procedure consultations should be had with all other departments treating given symptoms. When these departments have ruled out the possibility o f organic cause for the trouble and are satisfied that disturbed function o f body parts is due to the poor position o f those parts, the patient should be enrolled in the posture clinic. This clinic will function as a correlating agency. Thus, i f a child is sent to the posture clinic from the orthopedic clinic because o f “ round shoulders and a forward head ” a consultation will first be held with the pediatrist, who will make a complete physical examination and advise with regard to further consultation as, for instance, with the opthalmologist to eliminate eye trouble as a cause for the forward head. WTiere a hospital location is not available a clinic will function well if established by a visiting-nurse association in conjunction with child-health centers. Patients will be referred from the neighbormg schools by the school nurses and from the district by local physicians. Many cases will be referred from the conferences o f the visiting nurse association personnel. Many cases will come directly from the home as a result o f cures reported fr o m parent to parent. But here again the child must first be examined by a pedia trician and an orthopedist. Before corrective posture training is begun the etiology o f the trouble must be diagnosed as poor body mechanics. To this end consultations should be held with medical men on the staff o f the nursing association or o f some near-bv hos pital. / When the child is accepted for training the regular organization o f the visiting-nurse association can be used very effectively. The nurses make admirable teachers o f good posture in the clinic. They also have the knowledge o f medical matters that is essential fo r productive home visiting in cases o f the type treated in the clinic. . Once the child is enrolled in the posture clinic and is started on its routine procedure he is best cared for i f an orthopedist and a pediatnst assume joint responsibility for his medical care. Tne following are among the kinds o f cases referred to the posture clime o f the Massachusetts General Hospital from various depart ments o f the institution: Cases o f malnutrition, cyclic vomiting, petit-mal epilepsy, enuresis, constipation, poor appetite, and ortho static albuminuria from the children’s clinic; cases o f backache and postural curvatures o f the spine from the orthopedic department; https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ORGANIZATION AND EXERCISES 17 and cases o f dysmenorrhea from the genitourinary department, of abdominal and chest pain from the medical and surgical depart ments, and o f general debility and neurasthenia from thie medical and neurological departments. ORGANIZATION OF A POSTURE CLINIC Location. The posture clinic, as has been stated, is logically situated in an out-patient or dispensary section o f a hospital, or at a child-health center, because it is then located at the source o f its greatest supply o f patients. The hospital clinic affords opportunity for treatment o f those with symptoms o f illness due to poor body mechanics. The health-unit clinic, on the other hand, furnishes its quota o f those who are usually not ill enough to go to a hospital for treatment. These patients may have in milder form the very same type o f symptoms as the patients who go to the hospital clinics for relief. The clinic should be on an upper floor i f possible. Since much o f the work is done with the children lying on the floor, it is advisable to move the clinic as far as possible away from drafts, especially o f cold air. Moreover, it is easier to keep the child quiet and restful when he is at a distance from the rest o f the busy hospital or healthunit activities. The clinic workers can then read to the children or entertain them otherwise while they are resting undisturbed. The maximum amounts o f sunlight and ventilation in the clinic room are o f course essential. Equipment. The equipment needed for the clinic should include a pad for each child to rest on. This should be a cylinder about 18 inches long and about 12 inches in circumference. It can be made of rolls o f news paper, excelsior, or some such material covered with cloth to make a little bolster. A camera or schematograph with which to make photographs or tracings o f the body form is also essential. Cameras taking pro file pictures directly on bromide paper are for sale. I f such a camera is not available a profile tracing can be made with a schematograph like the one sold by the American Posture League. The writer has used a schematograph made by salvaging an old square-cased camera, which cost about $6 and some spare moments. The lens was left as found. Directly back o f it, however, in the film chamber was put an ordinary mirror facing the aperture back o f the lens and fixed at an angle o f 45° to the bottom o f the case. The top o f the film chamber was removed and replaced by a piece o f glass. When an undressed patient was placed in front o f the camera, with the side o f his body toward the lens and with lights shining in back and in front o f him a piece o f tissue paper placed on the new glass top o f the camera would show the image o f the patient as reflected by the mirror below. The contour o f the image when traced on the paper would give a graphic record o f the body contour o f the indi vidual before the camera. A tracing o f this record as a pattern on black paper and then cut fom the black paper on the outline would give as a final result a black silhouette. An ordinary balance scale o f the type usually found in hospitals is adequate for weighing the children. For measuring their height https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 18 POSTURE CLINICS a wooden measuring rod attached securely and accurately to ,the wall should be used. When the child stands against it the base o f a “ right-angle” bracket on the top of the head and against the measuring rod will indicate the child’s height. I f the body measurements are to be kept the only equipment neces sary is an ordinary pelvimeter or calipers of the type used by ob stetricians, a tape measure preferably o f steel, and a device for measuring the angle formed by the lower ribs at their junction with the xyphoid cartilage. For this last instrument the writer used two pieces o f steel united at one end by a hinge joint and opening sidewise on a protractor. The protractor allows for a reading, in de grees, o f the size o f the angle formed by the sidewise opening of the two steel arms o f the instrument, and since these arms are placed against the angle formed by the lower rib borders the reading on the protractor is the angle o f the ribs— the intercostal angle. A mirror large enough to show the whole body o f the child is a great help in teaching the child correct posture. As is shown in the description o f exercises (see p. 28) posture is taught with the child standing up, first against a wall and later away from the wall. Then i f the child stands with the side o f his body toward the mirror he can see the defects in his body posture and can correct them more readily. Personnel. The personnel of the clinic should include an orthopedic surgeon in nominal charge, the examiner and consultant in all problems; one worker in actual charge o f the clinic; other workers to teach good posture (at least 1 worker for every 10 patients); and if possible a volunteer secretary. I f it is impossible to get secretarial service gratis, the work could be divided among the other members o f the staff. The best clinic workers are nurses with a background knowl edge o f orthopedic nursing and special training in posture work. O f course temperament and personality fitted for work with children are a fundamental requirement. Nurses seem to fit better into clinics than do graduate physical educators because of their knowledge of medical problems and procedure. Time spent by children in the clinic. The clinics should be held not less than twice a week and prefer ably three times. Each session should last generally from one to one and one-half hours. Each child after resting for 20 to 30 minutes should receive 10 to 15 minutes of intensive instruction. While the child is resting a volunteer or one of the staff may read to him or tell him a story. The child will then relax more completely. At the end of his rest period he should receive at first about 5 minutes of individual instruction. Then, with a knowledge o f how to do the fundamentals of postural training, he may be grouped with a few others for more or less advanced instruction, requiring about 10 minutes more. Thus, a child will spend only about 35 minutes twice or three times a week in the clinic in learning good body mechanics. He will therefore have to practice at home and repeat at least three times a day all that he has done in the clinic. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis F I G S . 11 A N D 12.— P R O F I L E S I L H O U E T T E S O F T H E B O D Y F O R M A T T H E B EG IN N IN G O F A S C H O O L Y E A R ' AND AT T H E EN D OF A S C H O O L Y E A R W IT H PO ST U R E TR A IN IN G F I G . 13.— P A S S I V E P E C T O R A L S T R E T C H I N G E X E R C I S E F I G . 14.— C H I L D IN R E S T I N G P O S I T I O N F I G . 15.— C H E S T E X P A N S I O N W I T H D E E P I N S P I R A T I O N F I G . 16.— M A N U A L " C O A C H I N G " T O I N C R E A S E C H E S T E X P A N S I O N https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ORGANIZATION AND EXERCISES 19 Children who will receive greatest benefit. Posture instruction in clinics may be expected to benefit most strikingly children, especially girls, between the ages o f 7 and 10. The child is then in his most receptive and pliable stage. He has what is very important in posture work—power to coordinate mind and body. His ability to coordinate, and a serious willingness to learn and to cooperate at an age when body defects have not yet be come fixed are the characteristics that warrant speedy benefits from postural training for children of 7 to 10. They will be relieved most readily from complaints due directly to poor body mechanics, espe cially backache and constipation. O f course, all children o f ages that can be taught good posture will be expected to derive some bene fit from the training in the correct use of the body, and this benefit will be in direct proportion to the children’s power to coordinate and willingness to cooperate. Attendance of mothers at clinic. Since most o f the time spent in learning to use the body well will have to be time out o f the clinic and under the parents’ supervision, the more the parents know about the subject the more they will stimu late the children to acquire and maintain good posture. Mothers should be urged to attend the clinic with the children once a month. When at the clinic the mothers should be close to the children to see just what they will have to repeat at home, and to receive explana tions. At the same time instruction and advice can be given them as to diet and other contributing causes of their children’s complaints. Home visits. To make sure , that the child does repeat at home what he has been taught, follow-up visits should be made to his home. A nurse trained in family-welfare work is ideal, and social-service workers are, o f course, also good for this kind o f work. During the home visits instructions can be repeated, difficulties that may have cropped out can be eliminated or minimized, and those who are concerned for the well-being o f the child can be kept inter ested in his work. The effect o f these visits will invariably be to increase cooperation and thus shorten the time necessary for correcting the child’s posture and forming the habit of good body mechanics. . . The workers at the clinic and the home visitors should be able to impress on the children and their parents what benefits may be expected if the children use their bodies correctly and what pen alties they may be called upon to pay if they do not. Workers should be familiar with the exercises, the manner o f doing them, and the reasons for doing them. The fundamentals especially should be clearly understood. In fact, only after much thought on the subject o f body mechanics will the workers’ ideas become crys tallized, but they must be crystallized and ready for logical and quick presentation to the children and their parents. The worker will create an unconscious feeling o f sympathy, the sine qua non in this sort o f work, if she will put herself in place o f the mother she is visiting. Before she makes her visits she should acquaint herself with the history o f the family and decide https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 POSTURE CLINICS what motive to concentrate on for appeal. Thus if the children are undernourished or pretubercular an appeal for regular attend ance or home cooperation should be based on the children’s needs in relation to these physical conditions. The parent may say that the poor child has too little time outside school, elocution, music, ¿Hid other lessons to devote time to posture training* The worker should then show why the clinic is important for the child, finally stressing the reason that seems to arouse the greatest interest. The gains o f some child in the neighborhood who attends the posture clinic and who is conscientious and cooperating may be described. Perhaps it is pride in the appearance of the child that appeals to the mother. I f so, she may be shown a picture o f Queen Louise, in which the points o f good body mechanics can easily be demonstrated. The fact that Queen Louise could not be beautiful if she stood poorly should be stressed. Perhaps the child is undernourished, and the visitor may appeal to the mother’s affection by expressing her own interest in improving the child’s condition and perhaps showing the mother some weight curves indicating the weight gained by children with malnutrition who have been taught body mechanics. Attention can be centered on changes in posture in children instructed for one season. The improvements can be noted and the values stressed on a physiological and health basis. This visual appeal by graphic curves and figures is usually most effective m transforming the interest o f the parents into a desire to see that their children avail themselves o f the privilege o f learning how the body should be used. I f the child is interested in athletics he may be shown the picture o f an athlete finishing a race. The child should be reminded that this posture was taken because the athlete had learned that if his body is thus used his speed and endurance are increased. Workers should show pictures o f Washington, Lincoln, and other men of achievement with strikingly good body mechanics. Posture, good or bad, seems to have a mental effect upon the individual which affects, favorably or unfavorably, his capacity to achieve. O f course, some children will have to be almost dragged to the clinic for instruction in posture. But if the workers are persistent in visiting the home and tactful in stressing the motives that make the strongest appeal to both parents and children they will influence the family toward complete cooperation. The necessity for regular attendance at classes and continuous cooperation in the intervals between classes should be emphasized. Workers, however, will foster the desire for the acquisition o f good body carriage only if they themselves believe in its importance. I f they are not interested they should not undertake family visits. They can not imbue others with a spirit that is lacking in themselves. Theirs is missionary work in preventive medicine, for correcting body mechanics is one important way to increase the body’s resist ance to disease. I f they are interested they will learn the subject matter o f body mechanics. Then, with thorough confidence in the value o f the subject, they will spread the gospel of health and grace from better mechanical use o f the body. Above all they must attain correct posture themselves. Their own example will gain as many converts as their words. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ORGANIZATION AND EXERCISES RECORD TA K IN G 21 A N D PHYSICAL E XA M IN A T IO N A ll children enrolled in posture clinics should first be questioned thoroughly by the nurse in charge as to their habit histories. The amount o f sleep, the time spent outdoors, dietary and other health habits (see the form at end o f report) should be investigated. It is the purpose o f the clinic to teach the child one o f the habits most effective for health— that o f good body carriage. It should also see that the child’s other habits upon which proper physiology greatly depends, are also good—fit company for good body mechanics. A f ter study has been made o f the child’s likes and dislikes for different foods and o f his habits as to times for eating, regularity o f meals is urged. A list o f proper foods is furnished from which his mother may choose sensible meals. Emphasis is placed on the child’s hav ing the amount o f sleep deemed sufficient for his age by most au thorities. Above all he is instructed— and this point is stressed— to take rest periods after each meal flat on his back on the floor with a pad under his shoulder blades. A t no time should he use pillows under his head. The effort is to straighten his spine; pillows would only serve to exaggerate the normal curves at one end. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 22 POSTURE CLINICS A history o f the child’s illnesses previous to entrance into the posture class, on comparison with a similar later history, will indi cate the effect o f posture on his resistance to infectious diseases. It is assumed that the child has no infectious disease nor organic cause for his trouble when admitted to the posture clinic. This will have been ascertained before his admittance by a routine pediatric ex amination by the pediatrician in attendance at the posture clinic or the consulting pediatrician in the children’s clinic. Once the child is enrolled, his standing and sitting height in his “ stocking feet ” are taken. Then his weight while wearing ordinary indoor clothing is recorded. These data furnish the clinic worker, with the help o f W ood’s table o f average weights for children o f given sexes, heights, and ages, with an idea o f the average weight for a child comparable with the patient. The weights are recorded weekly on plotting paper, and the points are joined to form a weight curve. These curves are always conspicuously displayed on the walls in the clinic. The children naturally vie with one another in fol lowing directions, hoping to increase their weight. The value o f stimulating such ambition, especially in undernourished children, need hardly be stressed when the importance o f good body nutrition is so generally recognized. A profile silhouette (figs. 11 and 12, facing p. 18) o f the body form may be made with a camera directly on bromide paper. I f such a camera5 is not available a profile tracing (fig. IT) is taken with a schematograph (see p. 21). These silhouettes are posted on a card hung on the wall, so that the children may note their own progress and thereby be stimulated to more energetic work. After this preliminary work the child should be examined by the orthopedist in attendance at the clinic. First he is classified with reference to his body form as thin, broad, or intermediate, and then he is graded A , B, C, or D on his posture, according to the standards o f classification and grading given on pages 5-13. Deformities o f the chest or spine and static deformities o f the lower limb are then recorded. The part o f the trunk where the movements o f respiration are featured is recorded; attention is drawn either to the abdomen where the excursion o f the diaphragm is the chief feature o f respiration or to the ribs when elevated in the costal type o f respir ation. Finally, with anthropometric measurements such as the girth o f the abdomen and chest at different levels and the angle formed by the lower borders of the ribs with the lower end o f the sternum the examination o f the child is completed. METHOD OF TEACHING POSTURE TO CHILDREN First the child lies supine on the floor, over a pad laid crosswise under the back, at the level o f the lower angle o f the shoulder blades (fig. 14, facing p. 18). He should draw his chin in as i f to “ make a double chin.” The arms should be extended above the head to open up the spaces between the ribs. This position is assumed beB Fradd, N. W .: “ A new method of recording posture.” Joint Surgery, Vol. V, No. 4 (October, 1923), pp. 757-758. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis The Journal of Bone and ORGANIZATION AND EXERCISES 23 cause it relaxes the muscles and ligaments usually contracted m maintaining the body in incorrect posture. The pad under the shoulder blades elevates the chest and tends to straighten the spine, forcing the trunk to the A position. Thus the child rests with ms body in its best position. Twenty to thirty minutes is usually neces sary to get complete relaxation before any attempt is made at cor rection o f the poor posture. Without this relaxation over a pad cor rection is much more difficult. The best time for the rest period is after each meal. Then the child benefits not only from getting the relaxation needed for the corrective exercises but also from getting rest during the period o f digestion. . After the rest period the pad is removed, and exercises are given to the child lying supine on the floor with knees slightly flexed. Corrective posture exercises. Exercise / . —Lying on the floor the child flattens the lower back by rolling the pelvis, i. e., contracts the buttock muscles and retracts the abdominal muscles and so rolls the hip about the hip joint as a pivot (fig. 18 A and B ). In doing this he may keep one hand A on the lower abdomen while he uses the other to feel the flattening o f the spine against the floor. In this way the child learns to roll the pelvis and to decrease the exaggerated curves o f the spine, with the help of gravity. „ _ . , n , ■, Exercise I I .—Lying with back flattened against floor (as de scribed in Exercise I ) the child does deep breathing. While expanding the ribs in inspiration (fig. 15,^facing p. 1?; the child may grasp the ribs (fig. 16, facing p. 18) where they form an angle with the lower end o f the sternum (breastbone) and may pull on them upward and outward to coach the thoracic muscles that cause the outward and upward movement o f the ribs in inspiration. Then, since expiration is fundamentally passm , let the child exhale without “ coaching manually. Let him keep on exhaling to the point o f complete expiration. This is aided by the contraction o f the abdominal muscles. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 24 POSTURE CLINICS This exercise increases the girth of the chest, enlarges the lungs through the thoracic movements, and tends to mobilize the dorsal spine and to render it more flexible for flattening. Exercise / / / . —Lying with back flattened against the floor (as described in Exercise I ) the child alternately raises the arms slowly F ig. 19. Alternate arm raising while good posture is maintained in the supine position over the head (fig. 19). This accustoms the child to using the arms without changing the position of the back—all with the help o f gravity. Exercise IV .—Lying with back flattened against floor (as described in Exercise I ) the child bends knees back over the abdomen. He then grasps one knee with both hands and holds that knee bent F ig . 20.— Straight leg exercise with one thigh flexed on the abdomen with the thigh on the abdomen. This keeps the back flat. He ex tends the other leg straight up from the abdomen and slowly and gradually lowers it to the floor (fig. 20). Then he returns both legs to the starting position and repeats the exercise, alternating the legs. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis # ORGANIZATION AND EXERCISES 25 Through this exercise the child gets the “ feel ” o f keeping the back flat while a leg is being used— and this with the help of gravity and one flexed thigii. The exercise also tends to loosen tightened muscles and ligaments which may prevent full range o f motion in the joints— as, for instance, tightened ham strings about the knee. Exercise V .—Lying with back flattened against the floor (as de scribed in Exercise I ) the child raises one leg to an extended posi tion at right angles to the torso and then slowly and gradually low ers it to the floor. Then after returning the legs to starting position he repeats the exercise, alternating them. This exercise develops the abdominal muscles and the ability to keep the back flattened while using the legs. Exercise V I.—Lying with back flattened against floor (as de scribed in Exercise I ) the child raises both legs to an extended po- the feet to the floor. This exercise accentuates the development o f the abdominal mus cles and the ability to keep the back flattened while using the legs. The foregoing exercises should be continued until the child can flatten his back against the floor fairly well. Then the following o-^up o f exercises should be taken in the standing position: */yExercise V II.— Standing with his heels 4 or 5 inches from the wall and with his buttocks, shoulders, and head against the wall the child flattens his back against the wall by contracting the buttock muscles and by pulling in the lower abdominal muscles 5 i. e.5 by rolling the hips on the hip joint as a pivot (fig. 22 A and B ). https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 26 POSTURE CLIN ICS F ig. 22.— Retraction of the abdominal muscles and contraction of the buttock muscles to assume correct posture against the wall https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ORGANIZATION AN D EXERCISES 27 I f the child will imagine that he has a tail on the end o f the spine and will try to touch the floor with the tail without bending the knees, he will grasp the idea o f rolling the pelvis and will get the “ feel ” o f flattening his lower back and o f standing erect without the help o f gravity. I f the child is taught to aim for a flat back he will attain the back desired, one with normal curves. Thus to get the proper position, as shown in Figure 23, A, B, C, the child first rests the upper back and buttocks against the wall, then flattens the lower back, and finally pulls the head back and the chin in, raising the chest into its proper position. Exercise V III.— Standing with back flattened against wall (as in Exercise V I I ) the child places his hands against wall and with flexion only at the ankle joints comes away from the wall with the body held in the same position as at the start o f the exercise. Then while holding this position he should walk forward (fig. 24, A ,B , C ). https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 28 POSTURE C LIN ICS When he can hold position while walking forward let him try to return and still maintain correct body alignment. I t is difficult at first to turn around and still keep the correct position. The abdomen, for instance, is held retracted consciously, and when some action like turning around is attempted the conscious control is lost while the mind is busy with the turning. Exercise I X .— Standing away from the wall with back flattened and chin in, the child bends the trunk forward at the hips (fig. 25 A and B ). This exercise may be made more difficult by clasping the hands on the top o f the head when starting the exercise. ' Either F ig. 24.— Method of walking away from the wall after correct posture has been attained there way it accustoms the child to maintain a good position and to keep the rib spaces open even while bending forward. Exercise X .— Standing awajr from the wall with back flattened and chin in, the child rises on his toes and stretches his arms upward and forward to form an angle o f 45° with the axis o f his head and neck, and at the same time inhales deeply. Then he lowers his arms and comes down on his heels again while exhaling. This exercise teaches flattening o f the spine while the mind is busy with: breathing and balancing the body. Exercise X I .— Standing away from the wall with back flattened and chin held in (the chin must be in so that the ribs will be held https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ORGANIZATION AND EXERCISES 29 elevated) the child breathes deeply. The hands may be kept clasped on the head or on the lower rib borders to offer resistance there. This resistance facilitates the acquisition o f control over the rib muscles. This exercise tends to strengthen the diaphragm and to teach the child diaphragmatic breathing (fig. 26, A , B, C ). Such breathing increases the circumference o f the lower thoracic cavity following the descent o f the normally dome-shaped diaphragm. The upper abdomen in this exercise is the part o f the trunk strikingly mobile with respiration. Exercise X I I .— Standing with as good posture as possible the child faces a corner o f the room and places one hand, palm flat and thumbs down, against each wall at shoulder height. W ith his arms F ig. 25.— Trunk forward bending exercise held at an angle o f about 90° at the elbows and wrists and with upper arms raised to shoulder level he rises on his toes and sways forward with flexion only at the elbows, maintaining at all times the good posture o f the start (fig. 27, p. 31). He should not “ hollow ” the back, drop the head and chin forward, nor drop the abdomen downward. The child returns to starting position and repeats. A marked strain should be felt on the pectoral group o f muscles, the degree depending on the amount o f tightening o f these muscles. I f this exercise does not stretch the tightened pectoral muscles where the shoulders are o f the exaggerated forward type (the very ro'und shoulders) the following exercise should be used: Exercise X I I I .— Sitting in good position, the child raises his arms to his shoulders and clasps his hands behind his neck. The assistant https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 30 POSTURE C LIN ICS then should put her knee against the child’s back at the region o f the apex o f the dorsal convexity, and when the child has reached deepest inspiration she levers the child’s arms back toward herself on her knee as a fulcrum (fig. 13, facing p. 18). W ays to interest the children. Through these exercises a child will first learn, with the help of gravity, to attain proper carriage o f the body while lying on the floor. Then standing against the wall he can get the feeling o f correct posture in the erect position. This is followed, after suffi cient practice and exercise, by ability to walk with good body me chanics. A ll this can be expedited, after a certain amount o f pre liminary instruction, by having the children put one another through A B c F ig. 26.— Diaphragmatic breathing exercise. A. Starting position. B. Inspiration. (Note how the lower ribs move outward at the sides.) C. Note excursion of the upper ab dominal wall with this type of breathing the exercises. They naturally learn much more quickly while teach ing and correcting the faults of others. The interest in and respon sibility for a “ neighbor’s ” and also one’s own posture under these conditions is remarkable and most encouraging. It is perhaps the pleasantest way o f practicing good body posture. Children who have learned the fundamentals may be grouped to do the foregoing exercises or any form o f “ setting-up drill.” They become extremely interested in the work if a different child each day gives the orders while another walks through the group and helps the “ instructor ” to see that his orders are obeyed accurately. In this way what the children know about posture becomes crystallized in their own minds. I f the children are given as much insight as possible into the fundamentals of good posture they will become more interested https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ORGANIZATION AND EXERCISES 31 in practicing at home what they learn in the clinic. Skeleton draw ings (figs. 1 and 2, p. 3), tracings, photographs, and illustrations of the exercises can be used as aids in teaching body mechanics to the child. He can learn what the indexes of good and bad posture are and analyze his body defects and the needs for correction in his own case and in that o f his neighbors in the clinic. Then he will want to correct his own posture and to do so before his neighbor does. This spirit o f competition can be stimulated through the use o f charts showing the tracings and grades for all the children. The more the child knows of posture the harder he will try to attain good posture. “ Natural ” body carriage the result of continuous practice. At this stage in the acquisition of good body mechanics the posture, though perhaps correct, will usually be stiff and awkward looking. Con tinuous practice until good body mechanics becomes habitual is the only means o f rendering it easy and graceful. Practice in maintaining good form while doing common everyday things, such as sitting, tying shoe strings, picking up ob jects from the floor, reaching for things, will also hasten the acquisi tion o f natural, graceful, and effi cient body mechanics and poise. Time required poise. to reestablish natural The time necessary to acquire habitual good body mechanics varies with different individuals. The de termining factor is the child’s abil ity to control the muscles o f his body F ig . 27.— Active pectoral stretching ex and to keep them in balance. With ercise initial conscious effort and with per severance one can learn to use his body subconsciously with mechani cal efficiency, grace, and rhythm and with the least waste o f energy, but first must come conscious control of groups of muscles essential to the maintenance o f perfect balance. Good habits must replace bad habits until the former become instinctive. The poise which has become essential to the perfect functioning o f the complicated ma chine, the human body, must be reestablished and maintained with out effort as it is in the normal young child. SUM M ARY The average man’s posture, because o f various influences, has become drooped or ptotic. This is often followed by conditions con sidered capable o f being explained as deranged physiology due to poor body mechanics. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32 POSTURE CLIN ICS When these manifestations can be interpreted as being due directly or indirectly to such poor posture they can be eliminated by teaching the child how to use his body correctly. In posture clinics children with symptoms apparently without organic cause and referable in some way to poor posture can be relieved by learning the funda mentals o f good body mechanics. The posture clinic is best located in connection with a hospital dispensary, where pediatric and orthopedic clinics may serve as referring agencies; or in conjunction with clinics maintained by visiting-nurse associations or by child-health centers. The posture clinic should cooperate with the various departments o f the hospital dispensary and also with health centers, conferences, and schools. The equipment necessary for the posture clinic is very unpre tentious and inexpensive. It consists o f a large room, a roll or pad for each child, a camera or schematograph, a weighing scale, an apparatus for measuring height, a pelvimeter, a tape measure, an anglemeter for measuring the angle between the lower rib borders, and a long mirror. The personnel o f the clinic should include an orthopedic surgeon and a pediatrist if no pediatric dispensary is available. There should be an instructor or worker for every 10 patients. The workers may be nurses or physiotherapists. The clinic should also have a worker who can do follow-up work judiciously and sympathetically. Clinics for instruction should be held at least twice a week. It is supposed that each child will first have had a physical examination by a pediatrist and then by an orthopedist. The latter will classify the child according to physique, grade him according to his posture, and then prescribe the instruction. First the child must be shown good posture. The indexes o f good and poor body mechanics are impressed on his mind. He is in structed in the conscious maintenance of good body carriage with the help o f gravity and then without it. Finally, with continuous practice, his carriage should become habitually graceful and easy without conscious effort. Good posture, however, will come only after continued effort and close cooperation on the part o f the child, the parents, and the clinic workers. The clinic staff must strive continuously to effect this cooperation by an attitude o f encouragement and approval toward the child and an attitude o f interest and understanding toward the parents. o https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis C . B. 83 Uà S. DEPARTMENT OF LABOR C h il d b e n ’s B ureau POSTURE STUDY Field No . S ex , M. F. Name Date of Birth Race, W . B . N . F . O . (S pec.) Clinic Address SYM . O ffice No . HISTORY. I. (6) Nap, N. .................................. II. .................................. III. SYM . (6) Nap, N. HISTORY. I. 14. Foods liked. ____________________ II. III. Bread, N., Cereal, IS Meat, N., Eggs, N., Pot., N -- Meat, N., Eggs, N., Pot., N ._ Meat, N., Eggs, N., Pot., N ._ Greens, N., oth. veg , N Milk, N., Butter, N Coffee, N . . . .................... 6. Infectious diseases (specify)________ Yes, N o _______________________ Yes, N o _______________________ Yes, N o . . . . . . . _______ Yes, N o ....................... .. Yes, N o ........................ Y ak , Nn Y p.s , Nn _ PHYSICAL EXAMINATION. I. II. III. Yes, N o ........................ Yes, N o .......................................... Yes, N o _______________________ Yes, No — ..................................... 17. Height_____________________________ 18. Weight_____________________________ lbs. ... % 19. Underweight_________________ _ AB C D 21. Color skin, memb . . Ih.K A B C D .............. lbs lbs. lbs. % ABCD % . — ............... 22. Eyes, normal (spec.)_________ (6) Noon, Hr_____________________ Food.. Y ak , Nil _ Prnh., Nn, Rem 26. Nasal discharge________________ Enl., N., Dis., N., Rem. N — Enl., N., Dis., N., Rem. N ____ Enl., N., Dis., N., Rem. N .._ 28. Other. .............................. (d) Other, Hr___________ Food.. 30. Teeth: (a) No. lost........ . (c) Clean___________ ______ Yes, Nn . 12. Appetite___________________ Yes, No.................. Y ak , N n (/) Malocclusion....... .............. Yes, N n _____________ 13. Digestive upsets....................... Y ak , N n (g) Other.... .................. ........ [Face] https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 5795— 26. (Follow J>. 32.) SYM. PHYSICAL EXAMINATION. Glands: 31. Occipital . ........ I. Palp. Enl. II. G. Enl. Palp. Enl. III. G; Enl. Palp. Enl. SYM. G. Enl. PHYSICAL EXAMINATION. I. II. hi. 50. Pronation........................ 51. Abduction_____________ 32. Submaxillary_______________ .34. Arill ary____________________ 52. Breathing..___ ________ Cos. Up. Abd., Low. Abd___ Cos. Up. Abd., Low. Abd___ 53. Retraction_____________ Costal, Abdominal_________ Cos. Up. Abd., Low. Abd___ Costal, Abdominal................ Costal, Abdominal_________ Circumference— 35. Epitrochlear___ ____ ________ 54. Abdomen at navel______ 36. Inguinal___________________ 37. Thyroid enlarged___ ______ ■Yes, N 0...................... Yes, N 0......................... Yes, N 38. Signs hyperthyroid (specify)__ Yes, N 0.....................— Yes, N 0..........-.............. Yes, N (c) Expiration____ ____ 56. Xyphoid: 39. Heart (spec. abn.)—— ! _____ (a) Neutral____ (b) Inspiration________ Nor., Abn...... .............. Nor., Abn...... ............. . Nor., Abn____ _______ (c) Expiration____ ____ Depth— 40. Lungs (spec, abn.)___________ Nor., Abn_______ __ Nor., Abn___________ Nor., Abn____ _______ (6) Inspiration________ (c) Expiration________ 58. Abdomen: (a) Normal___ 41. Abdomen (spec, abn.) _______ Nor., Abn................. . 42. Hernia (specify)_____________ Yes, No____________ Nor., Abn____________ Nor., Abn____________ (b) Retracted............ 61. Tracings_______________ 62. Examined by____ - - - - - - - Nor., Abn___________ Diagnosis, tions: 44. Type___ __________________ Thin, Nor., Broad____ 45'. Standing position____________ A B C D____________ ------------------------------------ in. 59. B readth of chest at xyphoid. 60. Vital capacity___ ____ Yes, No........................ Yes, No— ..................... ' 43. Reflexes (spec, abn.)_____ ____ Nor., Abn_______ ____ Nor., Abn____ _______ ........ ................................ in. recommenda Thin, Nor., Broad_____ Thin, Nor., Broad_____ A B C D____________ A B C D_____________ Nor., Abn..................... Nor., Abn___________ Nor., Abn...................... Nor., Abn..................... Nor., Abn___________ Nor., Abn...... ............... General:_______________________ 46. Shape chest..______ - _______ (spec, abn.)___ _____________ 47. Scapulae (spec, abn.)________ — —— ------------------------ 48. Spine (spec. abn.)--. ________ Nor., Abn___ ________ Nor., Abn..................... Nor., A bn......... ........... 49. Other abnormality (specify)___ Yes, Nc Yes, No Yes, No [Reverse] https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 5795— 26. (Follow p. 32.)