Application of special exercises in physical education. The Hungarian prevention programme

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Annamária Somhegyi MD, PhD, Director for Prevention, National Center for Spinal Disorders, Budapest, Hungary; National coordinator for WHO Schools for Health in Europe (SHE) Network, nominated by the Ministry of Human Capacities, Budapest, Hungary and Feszthammer, A., Darabosné Tim, I., Tóthné Steinhausz, V., Szilágyi, Á., Horváth, K. Z., Varga, P. P.

Summary

A sedentary lifestyle in children affects the development of their spine, its physiological curvature and the adoption of a biomechanically correct posture. This process tends to cause discopathy of the adult spine. To protect children, the Hungarian Spine Society (HSS) started its primary prevention programme in 1995 to achieve daily physical education (DPE) with special posture-correcting exercises for all students. Physical education (PE) teachers were given training and materials (booklet, videos, tests, website) throughout the whole country, effective posture correction became part of educational documents and regulations and DPE was built into the National Public Health Program. The prevention programme worked well and thus became part of the governmental plan for holistic health promotion (HHP) in schools with the goal of reaching all schoolchildren and giving them in school all that is needed to improve their physical and mental health. HHP has been prescribed for all educational institutions since 2012, and as part of it compulsory DPE was implemented gradually between 2012 and 2015; thus, all students and classes have taken part in DPE since 2015. As part of the ongoing revision of general practice (GP) in the Hungarian health care system there are also physiotherapists available to help patients and they will be able to help better the preventive work of PE teachers. This article is written in the framework of EU-OSHA’s 2020-2022 campaign — Healthy Workplaces Lighten the Load (on musculoskeletal disorders) — to show how health promotion programmes can contribute to enhancing the musculoskeletal health of children and young people (the future generation of workers).

Importance of biomechanically correct posture

Physical inactivity and the sedentary lifestyle that is unfortunately common among children and adolescents results in weakened and shortened postural muscles as a result of little or incorrect use. Thus, the proper balance among postural muscles is not achieved, and the gravitational load affects the small structural components of the spine, which are not able to endure the strain. Proper muscle balance ensures that the load falls upon components of the spine that are capable of enduring the strain. Muscle imbalance and overloading certain elements of the spine can cause degenerative spinal disorders. Degenerative changes in the overloaded intervertebral discs cause pathological hypermobility in facet joints, and then the two processes accelerate each other. Later spinal stenosis can occur because of the abovementioned degenerative changes in the discs and the facet joints.

Figure 1. The biomechanically correct posture. Reproduced from Somhegyi et al[1].

Dynamic balanced posture — i.e. alignment of body parts — is maintained by invisible, multidirectional functions of the postural muscles. Biomechanically correct posture[2] occurs when there is physiological tension on joint capsules and ligaments with a minimum amount of muscular effort because of the balanced interaction of the postural muscles. Thus, the pressure on the articular surface of the joints is evenly distributed. The biomechanically correct posture is based on the correct middle position of the pelvis and the physiological sagittal curves above it (Figure 1). In side view, the imaginary weight line of the body crosses the second to fifth cervical and the second to fifth lumbar vertebral bodies, which are relatively large bony components adapted for this, while the thoracic kyphosis assists flexibility[1].

There are several types of incorrect posture. One of them is anterior pelvic tilt (each anterior superior iliac spine will be in front of the pubic symphysis): this tends to increase the sagittal curves while the weight median of the body does not cross the abovementioned vertebral bodies (large components) but the facet joints or farther back (small components), thus increasing the load on the spine. The other typical poor posture is posterior pelvic tilt (each anterior superior iliac spine will be behind the pubic symphysis), which results in decreased lumbar and thoracic curves while significantly increasing the cervical curve; the weight median will be positioned behind the facet joints, thus considerably increasing the load on the spine. There is also a known posterior pelvic tilt that tends to increase the sagittal curves. Figure 2 illustrates the most common poor postures[1].

Figure 2: Correct (left) and several examples of poor (A-E) postures. Reproduced from Somhegyi et al[1].


Posture being automatically acquired, developing and maintaining a biomechanically correct posture is the basis for the primary prevention of discopathy.

The essence of the Hungarian Spine Society’s prevention programme (1995-2021)

To compensate for a sedentary lifestyle and the resulting harm to the spine and because numerous children suffer from poor posture[3][4][5][6][7], DPE, as well as developing and maintaining correct posture from childhood onwards, will prevent degenerative spinal disorders or delay their onset. Developing and maintaining correct posture may work best if special physical exercises are regularly applied from childhood. This is why DPE and, within that, regularly performed special posture correction exercises are needed for all schoolchildren.

To improve children’s chance of leading a healthy life, the HSS launched its prevention programme in 1995 with two goals: that schools offer DPE classes and that they teach special posture correction exercises to every student in DPE. The prevention programme was supported by the latest international medical literature and started in full agreement with all associated professions[3][4][7] and it is also supported by the current international medical literature[8][9][10][11][12][13][14][15][16][17].

Figure 3: The special HSS posture-correcting exercise programme is based on 12 goal- or test-exercises, as these show the strength and flexibility of postural muscles. There are three to five developing exercises belonging to all goal- or test-exercises. The PE teacher has to apply the exercise-blocks one after another, continuously throughout the whole school year — so it does not take too long but the regular and repetitive performance will develop the muscle balance. The performance of the exercises must be precise. Reproduced from Somhegyi et al[1].

The essence of the HSS’s prevention programme is to show PE teachers the special posture correction exercises that are to be taught to all schoolchildren (preferably also to children in kindergartens) as part of their DPE throughout their school years so that they develop and maintain a biomechanically correct posture, thereby contributing to the prevention of degenerative spinal disorders in adulthood. The special exercises were created by leading physiotherapists. The theoretical background and literature relating to these special posture correction exercises were reported in 2005 in Clinical Neuroscience[18]. The exercises were designed to develop and maintain muscle balance (i.e. appropriate flexibility and strength of the muscles responsible for posture) and the correct mid-position of the pelvis. Thus, the exercise programme targets all the postural muscles (stretching and strengthening), not only the well-known weak abdominal and back muscles. In order to develop and maintain the correct posture, exercises must be necessarily complex to affect several muscles and to improve global muscle balance. The special exercise programme is based on 12 goal-exercises that may function as test-exercises as well (Fig. 3). These 12 semi-objective muscle tests evaluate whether the subject is able to perform the exercises in the correct way or not. If a child is able to perform all of these 12 test-exercises perfectly, he or she has postural muscle balance: all postural muscles are appropriately flexible and strong. The construction and the proposed use of the exercise material is summarised in the box.

Construction of the whole exercise programme

The whole exercise programme consists of 52 exercises, which are to develop all muscle groups responsible for posture. The exercises are placed in 11 blocks, in which, after several developing exercises, the goal- or test-exercises are also located:

  1. conscious sensation of the correct posture in the standing position;
  2. strengthening (and stretching) certain parts of neck and shoulder girdle (with goal- or test-exercise no 2);
  3. common strengthening of the deep back muscles and hip extensors (with goal- or test-exercise no 3);
  4. strengthening certain parts of abdominal muscles (with goal- or test-exercises nos 4 and 5);
  5. strengthening the antigravity muscles of the lower limb (with goal- or test-exercises nos 1 and 6);
  6. stretching the deep back muscles (with goal- or test-exercise no 7);
  7. stretching abdominal muscles and hip flexors (with goal- or test-exercise no 8);
  8. increasing the rotation of the lower thoracic and lumbar spine: stretching pectoral muscles, muscle adductors, and muscle tensor fasciae latae, strengthening and stretching the oblique abdominal muscle (with goal- or test-exercise no 9);
  9. stretching the hamstring muscles (with the goal- or test-exercise no 10);
  10. increasing the mobility of the hip joint and stretching the hip flexors (with goal- or test-exercises nos 11 and 12);
  11. practising the awareness of correct posture.

Teachers of PE have to use the first block in every PE class and then one of the following blocks, so after 11 PE classes the blocks will be repeated. With this repetitive and regular method the exercises will develop, adopt and maintain the muscle balance and this can be detected, e.g. in improving results of tests of muscle balance. In 2014, according to the wish of leading PE teachers and with their contribution, a table form of the exercises to be applied in each physical education class was created: see on the website[19] and as an annex to this article[20].

Exercise material was given to teachers in a booklet and three DVDs: DVD 1 is an educational video, DVD 2 is a film suited to performing the exercises along with the instructions, and DVD 3 was produced for preschool and kindergarten teachers for younger children. Since 2014, the training films have been available on the website of the National Center for Spinal Disorders[19][20].

As a result of continued government support between 1995 and 2004, PE teachers could take part in training on the posture correction exercises throughout the whole country and were given the introductory exercise booklet and three DVDs — all free of charge. A total of 7 772 PE teachers teaching in 3 715 schools have become familiar with the special posture-correcting exercises; and a total of 51 475 functional muscle tests conducted by the PE teachers on 32 831 students revealed that only 11 % of the children had the muscle balance necessary for supporting correct posture. In the remainder of the children, some or more posture-supporting muscles were weakened and/or shortened[3]. Without governmental financing of the small secretariat of the programme, it cannot work, but the leadership of the programme is financed by the National Center for Spinal Diseases — the basis of the HSS — so the work is going on continuously. Now training of PE teachers is financed by the education system — which is really reasonable. The Ministry of Health financed this training for 9 years.

The exercise programme has been included in the national core curriculum since 2003 within the PE curriculum framework and made part of the qualification requirements for PE teachers, as well as part of the objectives and actions of the National Public Health Program in 2001 and 2003. The national core curriculum was revised in 2012 and in 2019, emphasising to an even much greater extent the necessity of posture correction (in addition to several other health promotion criteria). Professional review (subject monitoring and supervision of subject matter) was terminated in Hungary in 1985, but was reintroduced in 2012. However, PE supervision has not yet paid adequate attention to the effective application of the special posture-correcting exercises. That is why the health sector must also take further steps in this field, for which the renewed national core curriculum provides a basis in 2021.

The Hungarian School Sport Federation (HSSF) contributed to curricular developments in the field of PE within the framework of a huge project, entitled ‘Establishing a new strategy and physical performance evaluation system and enhancing complex physical activity programs in schools’. The Federation developed a project called TESI (i.e. Strategic Action for Health-Enhancing Physical Education, known by the Hungarian acronym TESI). There is a new focus in PE on the criterion of health promotion and as part of this also on spine and joint protection. Instead of the previously used fitness tests that often generated shear force in the lumbar spine, in 2015 HSSF developed a new fitness test battery (NETFIT), which does not operate on shear force or harm the joints and the spine. Some of the HSS’s muscle tests are also included in a measurable form. The use of NETFIT on all children in grades 5-12 has been prescribed by law for PE teachers since 2015, and it is supported by a good website[21].

The other objective of this preventive programme was to achieve compulsory DPE – as this is the only way to reach all children. After considerable work and some difficulties, it became part of the government programme in 2010 and it was prescribed in December 2011 in National Educational Law No CXC. After a reasonable 4-year long gradual implementation period between the school years 2012/2013 and 2015/2016, since September 2015 every student and every class has been taking part and so benefiting from it.

Short-term and medium-term efficacy studies of the special posture correction exercises

The effectiveness of applying the special posture correction programme integrated into formal PE has been tested several times.

A prospective controlled study was performed in the 2001/2002 school year on 6- to 14-year-old students in Békéscsaba. The results of this research were published in Clinical Neuroscience in 2005[22]. The controlled trial validated the efficacy of posture-correcting exercises integrated into PE classes.

A prospective study was performed to evaluate the effectiveness of applying special posture-correcting exercises in Pásztó and in Szentgotthárd over the 2009/2010 school year, involving 530 students, 7-12 years old, who performed the posture correction exercise programme for 6 months integrated into PE classes, conducted by their teachers. Meanwhile, the condition of their postural muscles — evaluated with the 12 muscle tests — significantly improved. According to the non-invasive ‘spinal mouse’ computer-analysed examination, the rate of bad posture among participating students decreased from 64 % (initial value) to 38.3 % among students from Pásztó and from Szentgotthárd. There was an inverse correlation between the students’ muscle balance and body mass — that is, there was lower rate of good postural balance among overweight students. Considering that obesity occurs more and more frequently among children and young people in Hungary, this is highly relevant[3].

Rosta et al.[23] applied HSS’s special posture-correcting exercises in kindergartens, and they evaluated children with the 12 muscle tests and a pressure sensor (pedograph) to measure and analyse pressure distribution on the feet. The condition of the children’s postural muscles and the body mass center projection distribution improved[23].

Several student physiotherapists have written theses on the short-term efficacy of HSS’s programme of special posture correction exercises, albeit usually studying a small sample size. As every thesis has supported the effectiveness of the programme, the results from these different studies need to be aggregated and analysed.

In 2013, a literature review of the primary prevention of symptoms of discopathy was published in the European Spine Journal[24]. The literature review shows that the HSS’s preventive programme is unique. Other preventive programmes evaluated the short-term effect of interventions focused upon giving theoretical knowledge or upon a limited exercise routine to be performed during classes. In accordance with this experience, an analysis of PE in the European countries provides an overview, in which it refers specifically to Hungary, where special posture-correcting exercises are integrated into DPE classes[25].

Help from school health services to achieve better performance of posture correction exercises in daily physical education

Posture correction in DPE could be monitored using the Matthiass test, which is a semi-objective clinical test to detect postural muscle weakness[26], and this could be administered by school health services. In this case every 2 years (in primary grades) the progress of postural muscle weakness could be monitored. These data could be presented to parents, PE teachers and school management, drawing their attention to the importance of good posture. The József Fodor School Health Society started a 3-year pilot project in 2012/2013 to examine the feasibility of applying the Matthiass test in practice. Based on that experience, the Matthiass test is suitable for making children aware of the importance of correct posture[27]. It is now planned to integrate the Matthiass test into regular school health screenings as a recommended method.

Further activities to be performed (2021)

Posture correction exercises that develop and maintain biomechanically correct posture were started by the HSS to be integrated into DPE in 1995, and there were remarkable results. Yet, there are further activities to be performed:

  1. Special posture-correcting exercises should be a mandatory topic in the graduate training of all PE teachers. For this purpose, the training requirements for PE teachers must be better specified as a part of recent legislative amendments.
  2. Posture correction programmes have to be part of the official postgraduate training of PE teachers.
  3. The posture correction programme’s should be comprehensively included in the training of subject monitoring and supervision specialists in relation to PE.
  4. According to Government Decree No 1722/2018 (XII.18), the National Musculoskeletal Program (author: Poór Gy), including the National Preventive Center of Musculoskeletal Disorders and its national network, has to be established. This means that, as part of enhancing primary care, physiotherapists would work in outpatient settings and they would help and oversee the work on prevention in schools, too: they would teach posture-correcting exercises to PE teachers, as well as assisting them with student examinations and follow-up work.
  5. School health services could help to improve the performance of posture correction exercises in DPE. Posture correction in DPE could be monitored by the school health service using the Matthiass test, which is a semi-objective clinical test to detect postural muscle weakness. Based on the József Fodor School Health Society’s 3-year pilot project examining the feasibility of the Matthiass test in practice, the test is now planned to be integrated into regular school health screenings as a recommended method.

References


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  3. 3.0 3.1 3.2 3.3 Somhegyi, A., Lazáry, Á., Feszthammer, A. et al., ‘Application of special exercises in physical education to develop, automatize and maintain the biomechanically correct posture’ (English abstract available), Népegészségügy 2014; 92:11-19.
  4. 4.0 4.1 Somhegyi, A., Varga, P. P., ‘A Gerincgyógyászati Nemzeti Központ országos primer prevenciós programja — Beszámoló a program indulásáról’, Népegészségügy 1999;80:23-33.
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Contributors

Palmer