WHAT IS BRGGER'S SITTING POSTURE?

(Contribution to the correct understanding of posture according to Brgger)

INTRODUCTION The concept of the Swiss neurologist, Dr. med. Alois Brgger (1920) is an integrated and extensive concept comprising the diagnosis and therapy of the motor system malfunctions. Brgger's name is associated with good posture and particularly the so-called "Brgger's sitting posture". Unfortunately, this concept is frequently understood, described and interpreted incorrectly, even by renowned authors involved in failures of the motor system. This often leads to incorrect therapies. The objective of this paper is to present basic characteristics of a sitting posture, as it is described, defined and taught by Brgger. Similarly to other therapeutic concepts, Brgger understands working hypothesis to be the most critical step within the diagnostic approach, from which further specific therapeutic procedures are derived. The main objective of these therapeutic methods is to alter postural and motion patterns which are understood as a protection of the organism. These patterns need to be changed into physiological motion patterns, particularly based on the reduction of the so-called intruding factors which were identified and evaluated during the process of diagnosis, together with the specification of their stratification; Brgger talks about the socalled Staffelung (stratification) of intruding factors. Except for the specification of the intruding factors, and their stratification, it is necessary to define the current significance of the method of treatment, both at the beginning and during the course of the therapy, or the method of initiation, i.e. either oriented at functions or the global aspects. As regards both approaches, the basic objective of the therapy according to the Brgger's concept may be expressed as follows in authors words: "pathoneurophysiological initial position (non-oriented and oriented stand-by position) and motion programmes should be modified or returned into neurphysiological positions and motion programmes". Whether the therapy is initiated with a function-oriented or a global approach, the first step in each patient is the so-called posture correction. This can be done either in a standing or sitting position, naturally depending on the current situation of the patient. In case that the correction is carried out in a sitting position, we can talk about a training of "Brgger's sitting posture". GEAR WHEEL MODEL The key image for the understanding of the socalled motion global character, i.e. mutual functional relations related to global motion programmes, is the gear wheel model (Figure 1). This model, which is just a model scheme (in fact gear wheels move in the space, not around biomechanically defined axes), was developed by Brgger in the 1950s, and it serves particularly as a visual aid for patients. The model of gear wheels demonstrates mutual interconnection of three primary movements: 1. pelvis moving forward, 2. chest moving upwards and 3. stretching of the neck, with the projecting and reversing motion impulses for the limbs, or from the limbs. It is therefore necessary to underline that the "gear wheel model" does not comprise only the concept of "Brgger's sitting posture with pelvis tilting motion", it is a much more complex understanding which is a proof of mutual interconnection and possible influencing within the entire backbone and all limbs. The gear wheel model thus creates a basis for the diagnosis and therapy of motor system malfunctions. UPRIGHT POSTURE ACCORDING TO BRGGER As we said above, Brgger claims that upright posture (both sitting and standing) is a global motion pattern. It is therefore impossible to train correct sitting posture just by moving your pelvis forward, which is unfortunately a frequent method of treatment (for the posture correction procedures, see below). Reaching an upright posture is among the highlights of Brgger's concept. In 1965, Brgger developed a "construction of upright posture", which is contrary to the so-called "sterno-symphysal load posture. The general characteristics or incorrect and physiological posture according to Brgger is generally known (see Figure 2). What has to be pointed out is the form, i.e. the curve of the backbone which is the target during the correction of one's posture. Brgger characterizes upright posture as a posture in which the backbone forms two lordotic sections: 1. torsco-lumbar lordosis (or throraco-lumbar stretch), running from the sacrum to Th5, and 2. cervicocranial stretch, running from Th5 in the cranial direction. With respect to the correction of one's posture, the object is not to ensure increased lordosis in the lumbar section of the backbone (even despite frequent misinterpretations), but to ensure harmonic stretch in the area of backbone, together with the elimination of the so-called compensating sections. Optimally, this curve should reach to the Th5 area. However, it is possible to reach this optimum posture only providing that the patient is able to move the pelvis forwards. Moving the pelvis forward is just a minor movement around the sitting corpora which are in contact with the sitting surface. The quality of this movement is much more important that its quantity. In no case can this be understood as an

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anteversion of pelvis, to which patients usually tend when incorrectly instructed (together with loosening of one's muscles), the subsequent bending in the lumbar area and arching of the abdominal wall. Such a situation, which could be characterised as lumbar hyperlordosis has absolutely nothing in common with "Brgger's teaching" (Figure 3). According to what has been said above, it is obvious that in order to reach a correct and upright posture, it is necessary to ensure mutual coordination of muscles within muscle loops or the so-called functional groups of muscles. Concerning the global character of motion, mutual coordination of individual functions can be demonstrated on the basis of a large diagonal muscle loop. Such a loop comprises functional muscle groups in series, i.e. six elements (Figure 4): 1. Muscles lifting the chest; 2. External rotator of shoulder joint; 3. Shoulder blade retainer; 4. Functional group of abdominal muscles; 5. Muscles moving pelvis forward; 6. Functional leg support. Within a single muscle function or an element, there exists the so-called parallel connection of muscles (e.g. for external rotation in the shoulder joint, m. teres minor, m. infraspinatus, m. deltoideus pars spinalis, etc.). This diagonal loop and the method of its functioning should among other factors be considered during the process of posture correction, and it is therefore necessary to distinguish between a single function of a muscle and its function in a functional group. Also, it is necessary to take into account the fact that the same muscles may contribute to the so-called incorrect or load posture under certain circumstances and otherwise they may contribute to an upright posture. In this context, Brgger talks about the so-called system change. In connection with the construction of the upright posture according to Brgger, it is necessary to underline the importance of the chest position, activity of the trunk muscles, including the most important issues associated with this question. Let's define two concepts which are specific for Brgger: thorax extension (Thoraxaufsatz), formed by the upper thoracic vertebrae, sternum and the corresponding ribs, is based on the second part, the so-called thorax support (Thoraxuntersatz), formed by caudal thoracic vertebrae and lumbar backbone. This classification or definition of a thorax extension and support is based on the functional approach. The border of the thorax extension and support is a point where muscles "meet", following the principle of synergy, i.e. from both the cranial and caudal direction, m. rectus abdominis, m. obligus abdominis externus and m. transverses abdominis. These muscles, together with m. erector spinae in the thoracic area, lift the thorax support. M. pectoralis maior, which helps you reach upright posture through cranial tension, moves towards the

5th rib. Thanks to the connection of the thorax extension and support, the upright posture is directly dependent on sufficient lordotic intensity in the thoracolumbar area (Figure 5). We may therefore claim that an upright posture according to Brgger is the outcome of a synergic function of an entire complex of trunk muscles, i.e. both ventral and dorsal musculature, in "cooperation" with m. transverses abdominis. Brgger believes that a significant role is also attributed to diaphragm. On the other hand, we cannot agree with the description of Lewit (1996) and other authors who interpret Brgger's sitting posture as follows: "The patient is sitting on the edge of a chair, with knees and legs apart and with abdominal and gluteal muscles completely loosened. The pelvis thus moves forward, the lumbo-sacral area is in hyper-lordosis position and the abdomen arches forwards." This description of a sitting posture is in sharp contracts with the sitting posture defined and applied by Brgger. CORRECTION OF SITTING POSTURE ACCORDING TO BRGGER Correction of the sitting posture is the basis step taken by a therapist working according to Brgger's concept during the patient's first visit. Correction is carried out within the diagnostic phase and it accompanies the entire therapy. It is divided into two stages: 1. Gross correction or verbal: - Instruction concerning the correct height of the sitting surface (i.e. enabling the forward movement of pelvis); - Instruction concerning the correct position of lower limbs (it is necessary to avoid full adduction in hip joints, so that it is possible to move pelvis forward; as regards the adduction angle in the hip joint, this should be adjusted to the current situation, it is therefore incorrect to insists on 45, however frequent this mistake can be; the position of the crura and legs must correspond to the functional adjustment of the lower limb axes, with the correct three-point load on legs). - Instruction concerning the position of upper limbs (it is recommended to leave hands hang freely or place them on one's thighs). - The patient is instructed to "straighten up" (after this command, the therapist informs the patient about his/her abilities to hold an upright posture). Note: Before this correction phase, the patient should be informed - with the use of a gear wheel model and other visual aids - about the targets of the posture correction and the global characteristics of body movements. 2. Fine or tactile correction: during this correction phase, the therapist manually helps the patient reach an upright posture, again with respect to the current situation. There are three possible manual contacts, of which the most frequently used one is the contact

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through which the therapist ensures an optimum correction of the patient's posture (the so-called optimum thoracolumbar stretch). There are the following three manual contacts: - On spinae anteriores superiores, - One hand behind shoulder blades and one hand on the caudal part of sternum. - One hand in the area of chin and one hand in the area of protuberantia occipitalis externa. No matter if the correction of the tactile phase is carried out with the use of a manual contact in any area, the patient is instructed to "straighten up" and the therapist leads the movement (according to the gear wheel model movements). Patients should not carry out an isolated movement of the pelvis, chest or head, as straightening up is a global movement. The outcome of each correction must the "an increase in the body height". During the course of correction, it is necessary to avoid the so-called over-correction, which may lead to the patient's feelings of hard breathing, swallowing or even feelings of pain. We can usually observe increased or enormous muscle stretch on the ventral side of the neck. Corrected posture, or upright posture ("Brgger's sitting posture") must be acceptable for the patient and it must not be associated with any feelings of discomfort or pain. This means that "we correct only as far as it is convenient for the patient at the moment". Along with further therapy, the intensity of correction changes, always according to the current situation and feelings of the patient. Brgger's sitting posture is not and cannot be the only therapeutic element. The objective the therapy in Brgger's concept is to reduce disturbing factors. The procedures used for this purposes are always applied within corrected posture, as regards any position (sitting, standing or lying), the objective is always to ensure an optimum position with harmonic thoracolumbar lordosis. STATIC OR DYNAMIC SITTING POSTURE? "Brgger's sitting posture" is frequently criticised as a position which patient's are instructed to hold for long periods. This is once again a misunderstanding of Brgger's theory. Brgger's approach considers "dynamics" to be the principal task for patients, during the course of the whole day. This concerns not only standing but also sitting postures. Brgger does not recommend you to hold a certain posture for a long time, but to change positions as frequently as possible, because "our bodies are not designed for statics but for dynamics". Naturally, upright postures are preferred. However, it is not necessary to avoid certain "flexion postures" either, in order to ensure variety of movements (Brgger has developed a method of exercising, which includes a number of trunk-flexion positions). Nevertheless, all movements carried out by patients should be within his/her "movement sector".

CONCLUSION The purpose of this paper was to point out the most significant mistakes associated with the socalled "Brgger's sitting posture". In order to understand this posture (i.e. construction of an upright posture) correctly, only the basic facts and notes were included, particularly with respect to the practical aspects. Our intention was not to focus on deeper theoretic details associated with this topic, which shall be presented elsewhere.

Popisky k obrzkm: Figure 1: Gear wheel model: upright posture (left), incorrect (load) posture (right) (Brgger, 1999). Figure 2. Posture: a upright (correct) posture: straight thorax, pelvis tilted forwards, harmonic thoracolumbar lordosis from Th5 to os sacrum, cervical spine stretched, inclination posture of upper spine C, retroposition of arm girdle, physiological position of lower limbs (not part of the picture); b - sterno-symphysal (incorrect, load) posture: lowered thorax, pelvis tilted backwards, distinctive kyphosis, L. Th and lower spine C, compensation lordosis of central spine C, reclination position of upper spice C, anterposition of arm girdle, non-physiological position of lower limbs (not part of the picture) (Brgger, 1980). Figure 3: Incorrect sitting position with anteversion of pelvis and lumbar hyperlordosis. Figure 4: Large diagonal loop (Brgger, 1999). Figure 5: Schematic illustration of muscles between the caudal and cranial "chest lifters" (Brgger, 1980).

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