Posture

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Latest Edit: Iva Lloyd, ND 2013-6-03 (EDT)

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Posture is the “alignment of body parts in relation to one another at any given moment.[1] Posture requires the interaction between bones, muscles, connective tissue, joints and neurons. In addition to contributing to overall wellness, posture is a form of communication that reveals a person’s degree of confidence and self-esteem. Poor posture is a contributing factor to many symptoms and diseases. The most notable consequence is pain and discomfort, but it is also a factor in degenerative and chronic diseases.

Contents

Importance

Neutral Posture: In order to sustain good posture – referred to as neutral posture - the muscles of the body must be in balance to support an aligned spine. Neutral spine, does not equate to a flat spine, as there are many natural curvatures to the vertebral column. The neck, known as the cervical spine, has a natural anterior curve or lordosis which is necessary to balance the cranium. The thoracic spine, or trunk, has an opposite orientation. It curves posteriorly which is known as a kyphotic curve. The lumbar spine follows the same angle of the cervical spine, curving anteriorly, creating a second lordotic curve in the spine. These natural curves give the spine a slight ‘S’ shape when viewed from the side. In a neutral spine, there is balance between the musculature right-to-left and front-to-back. When in a neutral posture, the body is in its strongest and most balanced allowing for optimal efficiency and minimal stress on the joints and the rest of the body. Maintaining a neutral spine is a dynamic process that is meant to transition from position to position.

Neutral posture is essential for optimal wellbeing and functioning of the body.

Article Posture as a Key Health Determinant, Vital Link; 2011 Spring
  • Holding the weight of the body The most important function of a neutral posture is to maintain the body in an upright position, supporting the body against gravity.[2] If there is dysfunction in the alignment, excess stress and weight is put on muscles and joints which can lead to a significant amount of pain and discomfort.
  • Breathing The diaphragm, the primary muscle responsible for breathing, is attached to the ribs, spine and hip flexor muscle.[3] Weakness in the abdominal muscles causes a faulty posture, typically excessive lordosis, and inevitably impact the ability to perform maximal expiration.[4] Rounded shoulders interfere with the ability to straighten the upper back and prevent maximal thoracic expansion interfering with breathing capacity.
  • Musculoskeletal balance Good posture refers to a body in muscular and skeletal balance where each joint is bearing an appropriate load and each muscle is working at its appropriate capacity. As one muscle group fires there is always a counteracting muscle that works, these are known as agonist and antagonist muscles. Antagonist and agonist need to work synergistically to maintain balance and good posture. Poor posture leads to muscular imbalances where there is persistent use of certain muscles without adequate exercise of the opposing muscles. This leads to over stretching of one muscle and excessive tightening or shortening of another. Over time if posture is not corrected the muscles adapt and begin to take on their new length. This distorts the spine and joints and results in decreased range of motion, pain and discomfort.
  • Internal functions Posture contributes greatly to an individual’s shape. Each organ of the body has its natural position and place in the body that is, to a large degree, maintained by posture. Physiological and organ function depend greatly on a neutral posture. The tension and efficiency of the diaphragm’s movement is a good indication of overall posture. While in a neutral posture, the diaphragm is able to move optimally compressing the abdominal content during inspiration and recoiling during expiration. When the diaphragm is moving efficiently and the spine is neutral, the internal organs are in their optimal location, allowing for proper functioning. When posture is out of balance it creates distortions of the spine. These distortions can change the position of the internal organs, cramping the lungs, stomach and intestines which can lead to shallow breathing, faulty digestion, poor elimination and constipation.[5]
  • Concentration, memory and cognitive ability Many mental functions, including concentration, memory and cognitive ability depend on the flow of blood and energy from the body’s core to the brain. Any misalignment in posture, especially as it relates to the neck and head, can impact blood and energy flow and hence function.
  • Flow of energy throughout the body In traditional Chinese medicine (TCM), the body is viewed as unique systems and meridians which allow the free flow of Qi. Qi, is the body's life force that helps keep balance and movement within the body. When energy is free flowing through the meridians there is no pain and the body can function optimally.[6] Free flow of energy is best achieved when the body has a neutral spine. Blockages or stagnation as described in TCM, are a result of the obstruction of the flow of Qi and results in pain.

Influences

Due to the delicate balance that must occur between our skeletal and muscular system in order to maintain a neutral posture, there are inevitably many variables that trigger postural dysfunction. Below are some of the most common factors:

Sitting Good alignment is essential while sitting especially since most individuals spend a minimum of 8 hours a day sitting. Maintaining proper alignment can alleviate a significant amount of postural discomfort.[4]

  • Good seated posture begins with a proper chair. Chair height should allow the feet to be rested comfortably on the floor. Hips and knees should incline about 10 degrees and be at a 90 degree angle relative to the back of the chair. Arm rests should allow the arms to rest comfortable along the side of the body. Arm rests that are too high create extra strain in the neck regions.
  • Some of the most common faulty postures while sitting include: leaning too far forward in a chair creating excessive lordosis of the lumbar spine and sitting in a slumped position due to lack of lumbar support creating a faulty head and neck position.[4]
  • When sitting for a long period of time the knees and hips are in a flexed position. It is important to get up and walk around to allow extension of these joints on a frequent basis.

Standing Standing impacts posture to varying degrees.

  • In a neutral standing position, the chin is lifted and the head centred over the shoulder. Chest is lifted and hips neutral. The feet are slightly wider than hip width apart, knees slightly bent and feet stable on the floor with your body weight equallon both feet.
  • If a significant amount of time is spent standing, postural muscles can fatigue leading to faulty alignment. Lack of body awareness can also lead to improper posture while standing.
  • Commonly, the lumbar curve becomes exaggerated subsequently leading to changes in the thoracic spine. By being aware of standing position, one can alleviate a significant amount of postural dysfunctions.
  • If standing for long periods of time, it is ideal to shift your body weight from one leg to the other.

Carrying a Load Carrying a backpack, purse or briefcase puts additional stress on the spine and can alter posture and can increase postural sway. A carrying load should not exceed 10% of an individual’s body weight and needs to be carried in the right location.

  • In order to avoid stress on the spine, a backpack should be carried high in the thoracic region of the back. [7] When a backpack is carried near the low back, the upper spine is forced into flexion leading to postural dysfunction.[7]
  • Carrying a purse or single strap briefcase leads to a change in the body’s centre of pressure which affects neutral control of posture. Oversized bags and purses can also put a lot of stress in the neck, back and shoulders.[8]

Nutrition The structure and alignment of the body, especially in children, is dependent on proper nutrition.[4]

  • Diets high in acidic foods cause the body to leach calcium from the bones to help buffer the acidic environment in the body. This leads to decreased strength and mineralization of the bones over time leading to a weakened skeletal system. Peak bone mineral density is achieved in childhood and early adulthood and begins to decline in the mid to late twenties. Ensuring a diet high in alkalizing foods will help protect optimal bone development and ensure optimal bone density.
  • Diets low in alkalizing foods inhibits the body’s ability to neutralize an acidic environment. In order to balance an acid/alkaline environment the diet should be rich in alkalizing fruits and vegetables.
  • Nutrient deficiencies: a deficiency in vitamin D can cause adverse effects to our skeletal system. Vitamin D is essential to absorption of calcium in the body.

Clothes Clothing can have a big impact on postural alignment.

  • Large belts can hinder breathing capacity. Tight and restricting clothing alter posture by restricting the body’s normal movements.
  • Clothing influences body alignment and posture due to somatosensory feedback. The nervous system receives information from the skin and attempts to maintain posture based on this and other information received from various other systems in the body. Certain clothing, notably low rise jeans can cause a variation in somatosensory information resulting in subsequent postural adaptations.[9]

Shoes The feet are the body’s base of support and proper alignment of the spine begins with ensuring good shoes sizing and support.

  • High heels can cause a significant change in posture. Heels change the distribution of body weight shifting it forward.[4] The foot is forced into plantarflexion (toe down position) shifting body weight to the ball of the foot. The amount of weight directed to the forefoot is directly related to the height of the heel.[4] Changing the weight distrubtion over the feet causes the rest of the body to compensate in order to maintain balance. By changing the body’s weight distribution you alter the shock absorbing qualities of the S-curves in the spine. This alteration in shock absorption puts additional stress on the musclulature leading to pain and discomfort over time.
  • Proper shoe sizing is also essential to good posture. Shoes that are too large have been linked to a signifcant increase in ankle pain.[10]Shoes that are too small can cause foot pain, can impact alignment and development of the toes and the feet.

Accidents and Injuries Accidents and injuries can result in acute or chronic musculoskeletal pain and discomfort. This forces the body to find compensatory ways of functioning in order to avoid pain. Faulty posture and abnormal spinal curves and can increase your risk of suffering in an accident or injury.[11]

  • Whiplash, a common injury following a motor vehicle accident can greatly affect posture. Whiplash injuries usually occur following a hit from behind, but can occur in any car accident. In such an injury, the neck is forcefully thrown into hyperextension, followed immediately by hyperflexion of the neck, leading to mild to severe discomfort and pain.[4] The ‘hyper’ movements of the cervical spine cause the muscles and ligaments to stretch leading to faulty alignment. In addition to the direct musculoskeletal changes, researchers have found that whiplash injuries can cause distortion of the posture control system directly affecting posture.[12]
  • An injury to the ankle forces an individual to bear most of their weight on the good foot to avoid the discomfort associated with putting weight on the injured part. This prolonged change in position greatly impacts posture.

Sleeping: Individuals spend a third of their lives sleeping, yet do not practice good ergonomics during this time. Good sleep posture keeps the spine in its natural alignment and contributes to a neutral posture upon rising. In order to maintain a healthy sleep posture, it is important to

  • Have a firm mattress that does not allow the spine to deviate or the hips to sink into the mattress
  • The head should remain neutral in relation to the neck.
  • In a side lying position, it is helpful to place a pillow between the knees to avoid rotation at the lumbar spine.
  • When sleeping supine (on the back) it is helpful to keep a pillow under the knees to maintain the natural S-curve of the spine.

Computer work Most individuals spend a large portion of their day sitting at a computer. Improper position can lead to neck aches, headaches, frozen shoulder and frustration.[13]

  • Computer work puts a siginficant amount of stress in the neck and shoudler and contribute to a rounded shoulder position, collapsing the anterior chest.
  • While typing the wrists should be neutral or slightly flexed downard and the shoulders back in a neutral position.[14]

Psychological factors (i.e. self esteem) Several psychological factors affect posture. To maintain good posture it is essential to nourish the mind, as our mind, body and spirit all directly influence each other.

  • Self-esteem and confidence are typically portrayed in good posture with someone holding their head high.[15]
  • A common sight when observing children is the young child who grows quickly and develops rounded shoulders. This can be associated with low self-esteem or a lack of confidence about their size or stature.
  • Mood plays a role in posture, when feeling well and in good spirits, one typically maintains better posture; if feeling overwhelmed, sad or stressed the shoulders round forward creating a faulty posture.

Excess weight The spine is designed to absorb forces and distribute weight. When carrying excess weight, the spine is required to handle more load than it is designed for, resulting in compensatory actions.

  • Excess abdominal weight creates an exaggerated lordosis or curve in the lumbar spine which distorts its natural alignment.
  • If the abdominal muscles are weak and cannot compensate for this change in position, it leads to further postural dysfunction.
  • As proper alignment of the pelvis and lower spine are essential for proper alignment of the mid and upper back, this faulty positioning can lead to further complications in other segments of the spine. Keeping a healthy weight will not only allow one to live a long active life, it is essential for a neutral posture and balanced spine.

Age Postural changes occur as the body ages. It is also impacted throughout life due to the choices that we make and the situations that we encounter.

  • Children: The developing child has much greater mobility and flexibility than the adult leading to slightly different postural alignment including:[4]
    • Flat feet until the age of 6 or 7 when the bones of the foot, as well as ligaments and muscles are more mature.
    • Hyperextension of the knees is is typically due to the increased mobility and flexibility of the supporting ligamentous structures.
    • Knock knees is commonly seen as children begin to walk and should disappear with time.
    • In infancy, there is imbalance between the anterior and posterior muscles of the truck and back which allows the infant to lift their head.
    • Children tend to have a protruding abdomen. At around 10 to 12 years of age the waistline becomes relatively smaller and the abdomen no longer protrudes.
    • Young children often stand with their feet far apart to maintain balance and have a slight bend at the hips.
    • Early school aged children typically show a weakness in the upper back with the shoulder blades being quite prominent.
    • At around 9 years of age there is a tendency for an increased lumbar curve, or lordosis.
  • Older Adults: The factors that impact older adults include:[1]
    • Aging is a dynamic interaction between environmental factors and biological systems and with that are associated postural changes.
    • As aging occurs, one of the most noted postural transformations is an increase in thoracic kyphosis which forces the line of gravity to shift. This can cause changes in balance and create difficulties in shifting weight, such as when rising from a chair.
    • A more pronounced forward head position, accentuated thoracic curve and a loss of the normal lumbar lordosis.

Diseases Degenerative joint disease, osteoporosis, bone spurs, or osteophytes, can all cause postural changes.

Impact

Discomfort and pain are often one of the first signs of poor posture. Discomfort is a result of additional stress on muscle, ligaments, joints and cartilage. Pain is often the result of poor posture that eventually causes anatomical changes potentially causing constriction of blood vessels and nerves.[16]

  • Low back pain occurs when the spine and associated muscles can no longer support the postural misalignment. Herniation of a disc occurs when the gelatinous inner structure of the lumbar disc bulge out beyond its normal limit. If the herniation is significant enough it can lead to sciatica, an achy or shooting pain down the leg due to compression of the nerve root.
  • Neck pain Prolonged forward head position puts additional stress on the joints, ligaments and musculature of the neck.
  • Trigger point A trigger point, or knot in a muscle, develops when there is constant demand on a muscle causing the muscle to work harder, or if there has been an injury to the muscle.[17]
  • Headaches Improper alignment can cause impingements within the spine, compressing blood flow to the brain, resulting in pain. Headaches can also be a result of active trigger points in the neck muscles forward head position contributing to faulty neck alignment.[18]
  • TMJ One of the main causes and focus for treatment for TMJ (temporomandibular joint) is posture.
  • Plantar Fasciitis Improper foot posture (forefoot pronated), standing for long periods of time with incorrect arch support, or placing your weight on the balls of your feet when sitting all put stress on the ligamentous structure of the bottom of the foot eventually leading to pain.
  • Bone spurs cause pain and discomfort causing the elderly person to change their normal postural alignment or can physically prevent normal range of motion within a joint.
  • Degenerative joint disease occurs due to the excess strain on the joints. Improper wear on joints due to poor posture causing increased breakdown of cartilage and joint tissue. Ensuring a neutral posture puts minimal stress on the joints and in turn minimal breakdown.
  • Osteoporosis contributes to postural changes. Compression fractures are common with osteoporosis and typically result in a wedging of two of the thoracic vertebraes creating the excessive thoracic kyphosis. Osteoporosis also leads to collapsing of vertebral bodies. This results in a decrease in disc space and a decrease in height.
  • Respiratory problems are often associated with rounded shoulders and forward flexion of the upper body. Over time this leads to shortening and tightening of that anterior chest wall muscles and the diaphragm making breathing more difficult.

Assessing Posture

A thorough assessment of posture involves evaluating the alignment of the body, flexibility and muscle length and muscle strength.

1. Ideal alignment:

The following is an overview of ideal alignment:[4]

  • Head and neck the ideal position for the head and neck is one in which the head is well balanced and supported with a minimal amount of muscular effort. From the side view plumb line, the line should intersect through the ear canal and there should be a slight anterior curvature to the cervical spine. The head position should not be too far anterior or turned up or down.
  • Upper back alignment of the upper back is maintained by the lumbar spine and the pelvis and should have a minimal curve in the posterior direction. If there is excessive lordosis of the lumbar spine, the thoracic spine compensates and takes on a more flat back appearance straightening out the thoracic spine.
  • Chest the chest position should be up and slightly forward. This is somewhere between full inspiration and forced expiration.
  • Abdomen In adults the abdomen should be flat, however in children younger than 10 years old it is normal for the abdomen to protrude slightly.
  • Shoulders and arms In a neutral posture the scapulas should lie flat on the back between the 2nd and 7th thoracic vertebrae and the scapulas should sit approximately 4 inches apart. When examining from the side view plumb line, the line should intersect the middle of the shoulder joint, or glenohumeral joint. The arms should lie beside the trunk with a slight bend in the elbow and palms facing the body.
  • Pelvis and low back a neutral pelvis occurs when there is balance between each anterior superior iliac spine, which is the bony projections on the front of the hips. These two bony projections should be in the same horizontal plane and be pointing forward. When there is a neutral pelvis there is a natural lordotic curve and neutral lumbar spine. When looking at the side view plumb line, the line should intersect the centre of the acetabulum (hip socket). Using solely the side view does not give sufficient information about the position of the pelvis as it can shift side to side. Therefore it is important to note the level of the anterior superior iliac spine in a horizontal plane as well.
  • Hips and Knees When evaluating these joints from the side view the line should pass slightly posterior to the centre of the hip joint and slightly anterior to the centre of the patella. There should be even weight distribution between left and right side and knee caps should point anteriorly.
  • Ankles in side view, the plumb line should intersect slightly anterior to the lateral malleolus, the large bone at the side of the ankle. In a neutral position when the knee is straight, the ankle is held at 10 degrees of dorsiflexion (decreasing the angle between the top of the foot and the shin). This angle is greatly decreased when heel height is altered through footwear.
  • Feet and toes In a neutral position the feet should be separated approximately 3 inches and the feet turning outward about 8 degrees from each other and toes straight.
2. Flexibility and muscle length

There are several tests performed to determine flexibility and muscle length all of which provide indications of postural dysfunction.

  • Forward bending: is routinely used to evaluate the length and flexibility of the hamstrings, back and calf muscles. This can be done from a standing position or seating position. The number of inches reached past the toes or before the toes is noted.
  • Arm overhead elevation individuals are asked to extend their arms overhead to note if any muscular limitation exists. The results are noted bilaterally.
  • Hip Flexors Hip flexors length is measured by having an individual lie on their back on an examination table, hug one knee to their chest and extend the other leg off the table. Shortened hip flexors will not allow the extended knee to drop.
  • Trunk extension is the movement of backward bending and is done from a standing position. Knees should remain straight and extension should be from the lumbar spine. In muscular imbalances an individual will compensate and bend their knees to try to extend.
  • Trunk lateral flexion standing straight an individual is asked to extend as far to one side as possible (usually asked to keep arms at the side and extend one hand as far down the leg as possible). This test indicates limitations in trunk mobility.
3. Muscle strength

The third component of a postural assessment is testing muscle strength. Dysfunctions in posture can cause altered muscle strength. The abdominal muscles are integral to proper posture. A thorough evaluation of the upper, lower and oblique abdominals is essential. As well as, evaluation of the lateral trunk flexors, back extensors, middle and lower trapezius muscles, serratus anterior, gluteus medius, gluteus maximus, hamstrings, hip flexors, soleus and toe flexors is all part of a thorough postural assessment.[4]

Treatments

Always start by identifying and addressing the factors that are contributing to the postural misalignment. In general, there are several approaches used to help correct faulty posture. Awareness, behavioural changes and movement are fundamental to restore a neutral alignment.

  • Awareness it is essential to get a thorough postural assessment to determine your specific postural misalignments. Becoming aware of posture throughout the day is the first step in helping to correct misalignment. By understanding proper alignment and noting where you may be making deviations from such is fundamental to restoring a neutral spine.
  • Behavioural modifications once you are aware of your posture you can begin to make behavioural modifications to help optimize a neutral spine. Proper ergonomics should be practiced in all positions throughout the day. Some of the most common contributors to poor posture include poor ergonomics at a computer station, faulty sitting position and improper alignment while standing.
  • Movement and exercise a personalized exercise program is important to help rebalance postural muscles. Understanding your body’s own areas of weakness can help facilitate the re-development of a neutral spine. Stretching tight muscle and strengthening weak muscles is important for rebalancing the spine. Although, exercise is important to help retrain muscles, they are only preformed for a limited part of the day. Awareness of your posture is fundamental to establishing good posture and good health.

Please see your Naturopathic Doctor for a thorough health and postural assessment to help facilitate the body’s own healing and wellness.

References

  1. 1.0 1.1 Kauffman T (1987) Posture and Age. Top Geriatric Rehabilitation;13-28.
  2. Kisner CC (2007) Therapeutic Exercise. Philadephia: F.A. Davis Company.
  3. Asher A (2010) Muscles of breathing and posture. Retrieved June 28, 2010, from Bella Online: http://www.bellaonline.com/articles/art34572.asp
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Kendall FM (2005) Muscles: Testing and function with posture and pain (Vol. 5th edition) Baltimore: Lippincott Williams & Wilkins.
  5. Drury N (1984) The Bodywork Book California: Prism Alpha.
  6. Frank D (1995) Low Back Pain Care & prevention with traditional chinese medicine. Boulder: Blue Poppy Press.
  7. 7.0 7.1 Devroey CJ (2007) Evaluation of the effect of backpack load and position during standing and walking using biomechanical, physiological and subjective measures. Ergonomics;50(5):728-742.
  8. Weinman C (2008) Bag that oversize purse: this fashion trend can be tough on your neck, back and shoulders. Health & You.
  9. Beukes AC (2009) Hipster Fashion and Body Alignment. South African Journal of Occupational Therapy;39:2.
  10. de Castro AR (2010) The relationship between wearing incorrectly sized shoes and foot dimensions, foot pain and diabetes. Journal of Sport Rehabilitatoin;19(2):214-225.
  11. Stemper B (2005) Effects of Abnormal Posture on Capsular Ligament Elongations in a Computational Model Subjected to Whiplash Loading. Journal of Biomechanics;38(6):1313-1323.
  12. Gimse RT (1996) Disturbed Eye Movements after Whiplash Due to Injuries to the Posture Control System. Journal of Clinical and Experimental Neuropsychology;18(2):178-186.
  13. MacDonald G (1998) The Complete Illustrated Guide to the Alexander Technique. Boston: Element.
  14. Jones S (2010) Computer Work Postures and Injury: The Stress of Reaching for the Mouse, A Doctors' Perspective. Retrieved June 30, 2010, from buisness know how: http://www.businessknowhow.com/manage/computer-mouse-injuries.htm
  15. Weatherall V (2010) Correcting Faulty Posture. Retrieved June 23rd, 2010, from Advance Chiropractic: http://www.advancechiro.on.ca/posture_nf.htm
  16. Schubbe, J. (2004, May 17). Good posture helps reduce back pain. Retrieved July 6, 2010, from Spine Health: http://www.spine-health.com/wellness/ergonomics/good-posture-helps-reduce-back-pain
  17. http://www.pressurepointer.com/PressurePointerManual.pdf.
  18. Ferna¡ndez-de-Las-Peatas CM (2007) Myofascial Trigger Points, Neck Mobility, and Forward Head Posture in Episodic Tension-yype Headache. Medline;47(5):662-672.
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