Michel PRADIER                                                               World congress of posturology 2005

Thèse pour le diplôme de "docteur en ostéopathie"à l'université de la L.U.de.S / Oradea en 2001                                                                                                

Résumé traduit par Gilles Dokerty  : OPTIMIZING ONE’S FUTURE INTEREST OF OSTEOPATHY AND POSTUROLOGY OR MUSICIANS  

           When I spoke to my friends about the project of my thesis, their answer was unanimous: « Something must be done for the poor violonists! ».Musicians are people listening to the others, demanding to themselves," hypersensitive" and reacting faster than the others to any disfunctioning. What is paradoxical is that they do not really have a body approach during their studies. Learning a personal posture is empirical, based on imitation and resourcefulness. This system has its own limits especially when the musician works too long or too much. Moreover he is a « high-level sportsman  who ignores he is one » and who does not apply the basic physical hygiene rules to himself. Either he needs full help or he does not ask for any help at all... (fate, resignation or fear of losing his job). Anyway, his request is often late. Interest of osteopathy: The painful disorder will be the reason for the consultation and there will often be a possibility of a fast and efficient solution if it is a functional and not an organic disorder. If the postural trouble is not modified, there is a risk of repetiton, hence the interest of posturology. Besides the curative aspect, prevention for learners is fundamental and must be integrated to teachers’training. One day, a patient came to my office with her eight-year-old girl who complained about her back after music classes. She had been learning the violin for three years. I asked her to show me how she used to play in order to examine the posture. While she was leaning forward to pick up her instrument, she immediately fixed it between her chin and her left shoulder then stood up ready to play which inevitably induces a lumbar hyperlordose. Even her mother, who was a neophyte, was surprised at her disgracious posture and  the fact that her teacher let her do such things...  At the dawn of the 21st century, it is unbelievable that a pupil should be injured by a musical activity. If, at the beginning a postural disorder only leads to functional disfunctioning (reversible), in the long run it will generate organic pathologies (not reversible with our therapies).  It is unconceivable for a music teacher to neglect the postural aspect in his teaching. Didier Lockwood,[1] a famous violonist used to say, I quote « From initiating pupils into playing the violin to teaching rigour, the distance for a teacher is too often underestimated and it is advisable to bring together, or even superimpose « learning and teaching ». Being a musician and teaching music do not call on the same qualities and require complementary skills. Teaching music is a complete job which is based on pedagogy. It is a « must » to fight  against the sclerosis of habits and to favor an individual approach which would make learning an encounter. » Before, this type of training did not enist. Nowadays, several possibilities are offered to professional musicians who often teach in music schools or conservatories:
         - first, they can attend evening classes organized by the CNFPT [2] and myself for 10 years now.
         - then, they can receive osteopathic and postural individual treatment.
At a national level, multidisciplinary medical groupings have been created with Dr Vincent Travers [3] in Lyon and Dr Raoul Tubiana [4] in PARIS.  Before, young people suffering from the spine were told to « stand up straight » or were accused of a « lack of motivation » and were prescribed by their doctors « Exercices for the back and abdominal muscles » as there was no anomaly visible on the X-ray.
The articular lesions are underestimated by the medical profession  because they are not mechanical but organic, and yet they cannot be ignored and enable us to understand what this local disfunctioning or this mechanical line are, (for example painful limbs) shown and codifed by Roland Solère [5].
By dealing with those troubles, we  focus our attention on a young, dynamic, enthusiastic and even « hypersensitive » population who is put ignored because of her non considered specificity and assimilated to other professions.
Do we still have to hear such hurtful sentenses: « Stand up straight » « Do not become flappy » or « Throw your shoulders back » or do we have to remember what our elders used to say « Relax, find your position, grow up, blossom out, breathe freely. » Since the seventies, numerous medical postural methods have flourished, such as Mézières, Stretching, Eutonie, McKenzie...Each one has its own advantages and its indications but the most efficient are the simplest to set up in the musicians' feeling and daily use. Needless to point out that such observation facts do not make it possible to conclude this diatribe without showing the solutions which are based on the osteopathic concept. The latter is a solution that we usually use, but the only difficulty is to be « medically » accepted as an intelligent help to better health. The musicians’ functional pathologies deserved to be studied through an osteopathic concept with the complementarity of posturology.The subject of my thesis, being very large, the posturology approach will be limited to how to position the spinal column the pelvic and scapular belts with the limbs and the breathing. The vestibular, masticator, eyepiece and podologic aspects will not be developed. In the same way the taking into account of energetic lesions described by Roland Solère [6] will be just mentioned in my statistics in chapter one in order to remain close to the mechanical aspect. It should be known that this energetic approach is described in 50% of clinical cases in connection with the frequent psychological tension among musicians and as Dr FredericSaurat [7] says for his therapic triptych : « modify the origin making the area instable » This concept will be the subject of another publication.Our study aims at putting forward a mechanical solution through a more adapted approach vis a vis the musicians' painful disorders.
We can now express our study hypotheses.
-These mechanical functional troubles would occur on a specific population among which organic pathology  absence would have been beforehand demonstrated.
-The study of  bio-mecanics should enable us to better apprehend the dynamic posture.
-The inspection of the patient’s posture through the osteopathic concept should permit to eliminate  muscular tensions and the articular blockings which disturb the necessary balance.
-The postural approach should enable us to understand the relevance of the muscular chain work to improve the functional experience and make it last.
-Pragmatism and scientific research should prove the complementarity of both osteopathy and posturology.

Very few scientific publications have been yet issued about what we are going to express.However the experiment based on a rigorous observation has enabled us to show in a logical way a real modification allowing us to come back to functional . This obviousness has been largely observed by our patients and that is the reason why we have been encouraged to plan our research.. We have built our thesis by selecting in our therapeutic file the consultations corresponding to mechanical functional troubles among musicians.Our goal is to materialize each element of our remarks by facts and to continue to collect data from our observations in order to contribute to the knowledge of the musicians’pathology. 

Each chapter deals with one of our proposals and this demonstration leads us to bring to the fore a therapeutic scheme, a kind of frame on which investigation and care choice can be built.This osteopathic and postural therapeutic program will be studied to show its information and limits. The demonstration of the osteopathic concept reasoning and application makes the « Rééquilibration Fonctionelle ®» method plausible apart from any organic pathologies.

This argumentation will seem to be objective to all those who look for in the body mechanism the logic of an order ( i.e. a good health ) in a disorder ( i.e. life ) and who accept that compensations (i.e. deviated physiology ) are necessary to adaptation ( i.e. general homeostasy ).[8]
-         The first chapter underlines that mechanical functional disorders occur on a specific population ( i.e. musicians ) among which the absence of organic pathology has first been proved.
-         The second chapter shows that the biomechanics study must enable us to better apprehend the « dynamic posture ».
-         The third chapter highlights that the investigation of the patient’s posture through the osteopathic concept must lead us to quickly suppress the muscular tension and the articular blockings which disturb the necessary balance.
-         The fourth chapter proposes the postural approach which enables us to understand the relevance of the work of the muscular chains to improve the functional experience and make it last.
-         The fifth chapter shows that scientific pragmatism and research must show the complementary of ostheopathy and poturology.
-         The sixth chapter describes the study of clinical cases allowing us to better apprehend what our daily job brings and what its limits are.
-          The seventh chapter refers to research on posturology in progress and to come: research on the diagnosis and its objectified effects on the postural
system must come out of its confidentiality and allow an optimized care of the identified pathologies  

«  Global thinking, local acting are the key of the systemic reasoning which enable our postural and osteopathic work to act where, when and as it is needed »
Pathologies met among musicians 
It is always striking to see  injured sportsmen (because of a lack of vigilance) whereas sport is meant to preserve a good heath. Musicians are sportsmen who ignore they are and professional musicians even are high-level sportsmen and yet they do not follow the « good behaviour rules ».

It is not logical for students to be injured because of music, hence the necessity of informing the people who teach them about the possible risks.  Going too far........    by Corinne Jamma  [9]   
Patient file study
We have been treating for the last three years 84 professionnal and amateur musicians for various disorders. 8 out of 84 were due to a traumatic origin (e.g. ankle or wrist sprain or public higway accident especially teenagers )
The majority of the other cases were linked to rachis and superior member disorders further to postural problems (including the breathing ones) overwork (overuse), tiredness and focal dystonia.
(see synoptic table n°1= statistical table of treated patients in cities).
In order to optimize your future you have to learn how to stand up quickly, to sit down without any constraint or effort so that the inferior and superior members should be freed from any movements.Gestures must be done with ease power and without any force?
How? By applying the basic biomechanics

BIOMECHANICAL APPROACH 
In our society, the common habit is to sag for a certain comfort (hyptony). Musicians on the contrary, are going to increase their muscular tensions because of
verwork or to overcome technical default.
The solution is to adopt a more efficient and energy-saving posture that is to say a « dynamic attitude » 

The « dynamic attitude » I would like to thank Dr Georges Siffrédi who allowed me to publish a summany of his conference: « The role of the third lumbar vertebra in the genesis of osteo-articular diseases of mechanical origin »  [10](authorization delivered 19/11/2001)
This Doctor, from the South of France, who has a passion for the « dynamic posture » told me the following words: « the pelvis fixing being done by a simple bascule and its maintaining during the selferecting, by the hips opening being done freely. My key words being « to retroversion, erection » or move with grace while keeping the coccyx between the thighs »... »  
ROLE OF THE THIRD LUMBAR VERTEBRA IN THE GENESIS OF OSTEO-ARTICULAR DISEASES OF MECHANICAL ORIGIN.   The non respect of the physiology for the reasons quoted in the former chapter will  lead to a deviated physiology (often a need) and create a functional lesion.  
OSTEOPATHIC APPROACH 

In body mechanics, general homeostasy requires the logic of a balance (i.e. health: the principle) in imbalance (i.e. life: the main point) by accepting compensations (i.e. deviated physiology). One of  Mankind's characteristic is to abuse of LIFE to the detriment of HEALTH. 

The functional osteopathic lesion

The mechanical ostheopathic lesion is an articular mobility restriction in one direction with a possibility of movement in the opposite direction: it is always called by the parameter inversed to the restriction
Ex: D4 in E.Rg.Sg the fourth dorsal is in a three-dimensional position of extension, of left rotation and left side angle. This loss of mobility is only partial and reversible: it can be corrected by osteopathic techniques by reversing the parameters responsible fpr this « blocking » in the physiological amplitudes.

In the Reequilibration Fonctionnelle® « the displaced vertebra is only a myth, only the movement is displaced ». Functional osteopathy does deal with ‘bad positions », it organizes the movement harmony according to « deviated physiology » (by reference to H.H. Fryette’s laws).[11] 

Reading table

The reading of the spinal column by palpated tests will clarify our mechanical diagnosis and will direct our treatment.
(Cf synoptic table n°IV : Reading table of the rachis) [12].
It will enable us to determine the primary lesion and the secondary lesion among the different possibilities:
         - Adaptation to constraints (vertebrae in opposite rotation)
         - Vertebra-vertebral compensation (group of 2 vertebrae)
         - Visceral compensation (group of 3 vertebrae)
         - Peripheral compensation (group of 4 vertebrae or more) 

Interlinking statistics

The oesteopathic approach for the musician shows, as seen before, that it is global and that pathologies are located topographically in certain « regions ».
This region complex study, such as the scapular belt is going to influence our suitable therapy. 
The musician’s scapular belt complex is one of the most sollicited. It consists of:

         - The cervico-dorsal vertebral central axis, with its  pivots D4, C7/D1, sometimes C2      with the superior ribs. The freedom of this area will also favour a good postural work (positioning)
         - The scapular belt itself with the collar bone (violin), the scapular with fixated muscles (stability)
         - The superior members must find their dexterity again (movement).
Although each element of  this complex has its particular function, the mechanical disorder analysis shows that there is not only one etiology (100 points) but several restrictions dispatched on the concerned complex that is to say a lesional sum (e.g. 30 pts on rhe elbow 25 pts on D4). 

The articular freedom will generate movement, therefore allow a better feeling in gestures and « the open-mindedness of the self » making the postural work easier. 
POSTURAL APPROACH 
Pains which justify an osteopathic consultation further to a postural problem or to a negative osteopathic checkup (on a direct postural trouble) will make the patient aware of the necessity of correcting his posture.
For the last years, many authors have worked on postural work:
           - On a reabilitation point of view (such as Mézieres, McKenzie, Siffredi…..)
-         But also on a research point of view (e.g. stabilometry...)

Example : During repeated movement testing of the lumbar spine as described by McKenzie, it is a frequent occurrence that one or more movement directions will decrease or centralize a patient’s symptoms.
These directional preferences can be used as a basis for the whole treatment plan. 

Biomechanics set up
When I spoke to musicians, looking for postural confort, they told me that they first thought about « how to position their hands », then why the superior members were recalcitrant, finally about the scapular which couldn’t be seen, felt and touched and moved a little. In fact they go from the distal (distance) to the proximal (proximity), I go the other way (because of my studies) from proximal (spiral column) to distal (superior members) which is more judicious and meaningful in terms of posturality.
Situation with the instrument
This moment is capital because it is when bad positions occur. You will have to be attentive and discreet to let the musician take his marks, to let him become confident in order to accept criticism. Choir members will be observed with stringed instuments. 

Waist and hips muscular strengthening
A few years ago, this technique was very fashionable. It is now old-fashioned with the emergence of modern machines.
It is a type of muscular reinforcement which could be similar to a kind of contraction mode of isometric type (without displacement).
It aims at, through various exercices, maintaining a certain posture enabling several groups of muscles to react in order to strengthen the anterior and superior chains responsible for balance. Posturology belongs to everyday life, but is quickly forgotten because « LIFE » gets over « HEALTH ».  

OSTEOPATHY AND POSTUROLOGY COMPLEMENTARITY 

Our pragmatism has led us to use both, because of our carreer and the needs when working.
But this obviousness is far from being approved unanimously. Our postural training (Mézières) was before our learning of the osteopathic concept. We have always managed with both approaches.
On the other hand, during the session I lead « The body and the instrument » musicians give me their complaints:
         - if they have seen an osteopath, they often come out a bit confused because they do not get practical advice except the osteopathic one.
         - if they consult a physiotherapist specialised in muscular chain or McKenzie technique, this interesting work seems to them to be long if it is not linked to anti -blocking technques and targeted on the musician’s gestures.
         - if they consult a therapist who has « more than one string to his bow , they will be interested but a bit confused by the amount of information they will have to learn. There is also a risk of  being puzzled compared to what they practise or have learnt before.
I always tell them that what they have learnt is not false. But things can be seen in another way without puzzling them. 

Mixing:
At the beginning the passion for research for my thesis made me « jump a few steps in scientific rigour, but taught me a lot in practice.
Instead of moving forward step by step, by hitching a carriage one by one, I took the following protocol: combine osteopathy and posturology in the same time and efficiency!
The protocol:
           1. When treating a patient According to the consultation purpose    - the daily posture is tested (the basic one), osteopathic lesions are then detected
         - the found lesions are normalized then the starting posture is tested again.
Results: the patient is all right and feels a new dynamic balance. But these results only last one day, it is often reactionnal and the advantages of the session are less efficient after a few days.

           2 In laboratories  [13]
For a non-treated patient by us, only carrying corrective proprioceptive soles for a pain situated on the left sacro-iliac. Pictures are taken at each stage of the protocol with the help of an Ortopodemetre (cf enclosed literature).

Results: They are negative! Why?
         Because too much information to learn in a short time
         Problem of rigour in the protocol Before-Meanwhile-After application of which the exact knowledge of the significant standard deviation in order to appreciate a valid result.
Priority:
Slipped disc: osteopathy limit, taken over by Mc Kenise.
Functional vertebral sprain: posturology limit. 

Discussion
Question-Answer at the osteopathic Academy of France:
Does Posturolory belong to Osteopathy? 
The clinical study with its results has the answer. 

CLINICAL CASES 
Most of the 84 clinical cases studied among professionnal and amateur musicians had rachis troubles at upper limbs, further to postural disorder; overwork and tiredness as well as breathing troubles.
(cf synoptic table n°1: statistic table of treated patients in city office). 

Three cases are going to be detailed:
         - A fourty four-year old guitarist showing « an overwork syndrome and a focal dystonia » of the third right finger with a deficit of extension.
         - A pianist operated for carpal canal abnormally remaining painful after healing.
         - A harpist with lumbar vertebra problem linked to a lesion said to be circulatory under diaphragram.
And eight other cases frequently met.  

RESEARCH PROPOSAL 
Research on the diagnosis and the objectived effects on the « fine postural system » must come out of its confidentiality and enable us to optimize better-identified phatology care.

What is existing
Research work in progress on stabilometry for singers.
What remains to be explored:
Posturology laboratories have sophisticated devices which can be at disposal. It should be interesting to integrate a pluridisciplinary team to ratify fast and efficient therapeutic schemes of care for musicians.
Prospects:
A specilisation in posturology can be carried out at the University of  LUDES after a doctorate in osteopathy. 

This systematic vision will become essential by the combined effect of theontical by obviousness, experimental control, social and economic needs, and alove all of procedure simplicity.It is urgent to widen the diagnosis concept in an investigation which would priviledge the patient study as an individual and not only as a patient being eventually ill.
With the help of simple observation means and non-iatrogenic standardizations, it has been possible to set up an effective therapeutic postural and osteopathi scheme which enables musicians to find the expression of their potential again in a few sessions.
So far, because the « disorder » substratum could not be detected thanks to the most recent knowledge of organic medecine these patients were too often forgotten and often sometimes sent to psychologists. Worse than that, they were often followed with long and unefficient treatments going from repetitive infiltrations to shiatsu massages by non specialists or to useless surgery. 

This work results from a training in articular standadization® and in visceral standardization®. Following these two modules, a third module of synthesis enabled us to understand that the necessary skills required for a D.O (Diploma in osteopathy) and the teachers’rigour of SC Formation Solère could enable us to support several proposals:
         - The importance of a good methodology to differentiate, in the multitude of clinical signs, the organic and functional disorders, and the postural, osteopathic etiology ones from the other specialities.
         - The necessity to take into account the functionnal problem of musician’s pathologies, apart from a therapeutic pragram in order to give a non iatrogenic solution and a quick answer, to this important population.
         - A perfect appropriateness between the legal competence, given to physiotherapist and the setting up of a care protocol of a therapeutic program, using the Rééquilibration Fonctionelle®.
         - The interest of prevention among young musicians thank to information given to teachers. The latter passing on to their students a  non- iatrogenic knowledge.
WARNING: That is what calls up the concerned doctors! Arlette Chabrol [14] says:
« Pr Tubiana thinks that teachers must be informed (or oven trained) about the dangers encountered by children. Prevention must start at the beginning, when chosing the instrument respecting the child’s mental and physical characteristics. Moreover; good postures and gestures must be learnt at the beginning... even if he agrees with the fact that playing some instruments, because of their shape and size, can generate important posture disorders, difficult to compensate.The famous retired professor, with lucidity, admits that doctors will change neither the shape, nor the practice of instuments. They will not change the system based on competition and parents’ pressure, source of anxiety and frustration for the children, what unable then to enjoy the pleasure of music. They hope, at least, that consultations gathering music teachers, doctors, physiotherapists and psychologists will be held systematically in every music schools  for children. And that in the long run, it will help take into account in a better way artists’health problems. 

Optimizing one’s future : it must become a reality for young musicians by optimizing the musical gesture which must be
« noble and magnificient ». 
To hold oneself erect!  

[1] Conférence Musique et pédagogie (la méthode) au 45^ème congrès de la FNAPEC mars 2001
[2] Centre National de Formation du Personnel Territorial (ce qui dépend des mairies)
[3] association Bio Amadéus, Médi Arts France
[4]association  Médecine des Arts  (siège à Montauban)
[5] Enseignant et concepteur de la méthode de Rééquilibration Fonctionnelle®.
[6] Cours d’énergétique en Rééquilibration Fonctionnelle®  1997
[7] exposé sur la dystonie de fonction  / Medart France 1994
[8] La Méthodologie pour  le mémoire et la thèse : Roland Solère.
[9] Corinne Jamma ( http://www.multimania.fr/tdincer/Bio-Article9.htm, L'article paru dans l'Impact médecin le 19.02.1993)
[10]  extrait de la conférence du Dr G. siffredi  ( http://www.chez.com/siffredi /role_l3 )
[11] FRYETTE H.H., - Principe des techniques ostéopathiques. OMC – Frison-Roche 1978.
[12]  Synthèse D.O : cours théoriques et pratiques : Roland Solère, Claude Altiéri, Arnaud Rey Lescure
[13]  Laboratoire Podo France : 18-20, rue Pierre Brossolette – 93160  Noisy-Le-Grand
[14] extrait de l’article Une discipline en attente de reconnaissance, tiré du Bulletin de l’ordre des médecin-Mars 1999