I cannot imagine treating any patient without assessing posture, or, more precisely, alignment. When the patient with low back pain has a flat back, the emphasis of my treatment is different than when the patient has an excessive lumbar lordosis. I will also expect that the contributing muscle impairments will be different in these two patients.
The ideal posture is reached by aligning the body through an imaginary vertical line passing from the center of the ear down through the neck (cervical vertebrae), the tip of the shoulder, then dividing the rib cage in half, down through the center of the lumbar vertebrae, then slightly behind the hip joint, slightly in front of the knee joint, to end slightly in front of the lateral malleolus (outside ankle bone). In this ideal posture, the head is in neutral position, not tilted forward nor backward, and the ribcage allows for efficiency breathing [1].
It can be evaluated in terms of muscle balance (the length and strength of the muscles working over a joint), joint position (alignment of the body), static posture (musculoskeletal positioning at any position of rest), dynamic posture (postural alignment maintained during movement). [2]
A comprehensive postural assessment consists of three essential components: examination of body alignment in standing (static and dynamic postures, assessment of bony architecture, and alignment of the upper and lower quadrants for deviations from ideal posture), tests for joint flexibility and muscle length, and tests for muscle strength.
Although there can be a combination of the three types of posture in one, the main postures are kyphosis-lordosis, swayback, and flatback. The first one is a common posture where the head is forward and the upper back is excessively round; the neck flexors are generally weak and the neck extensors are short and tight; the muscles in the chest are tightened with forward, rounded shoulders (pectorals) and the upper back muscles are lengthened and weak. The pelvis is often rotated forward, with excessive curvature in the lumbar (low) spine; the muscles in the low back and hip flexors are shortened; the abdominal and gluteal muscles are weak and the hamstrings are stretched.
The swayback posture is characterized by having the head rotated forward with weak neck flexors; the thorax is rounded forward and at the same time leaning backwards and the pelvis is swaying backwards; the curvature of the lower back is too little and almost flat. The knees are hyper-extended (locked) back; as a result, the lower abdominals and hip flexors are generally weak; the hamstrings are shortened and tight; the gluteals are weak, and the hip joints are over extended. In the flatback posture, the head is leaning forward; the curves of the spine are flattened and the pelvis tilted backwards; the knees are extended and locked; this results in weak neck flexors, short and tight hamstrings, and long and weak hip flexors. [1]
The swayback posture is characterized by having the head rotated forward with weak neck flexors; the thorax is rounded forward and at the same time leaning backwards and the pelvis is swaying backwards; the curvature of the lower back is too little and almost flat. The knees are hyper-extended (locked) back; as a result, the lower abdominals and hip flexors are generally weak; the hamstrings are shortened and tight; the gluteals are weak, and the hip joints are over extended. In the flatback posture, the head is leaning forward; the curves of the spine are flattened and the pelvis tilted backwards; the knees are extended and locked; this results in weak neck flexors, short and tight hamstrings, and long and weak hip flexors. [1]
In the upper quadrant we can detect for example, head forward posture and change in scapular and glenohumeral position. In the lower quadrant it can exist, for example, hip ante or retroversion, genu valgus or varus, tibial torsion, and foot malalignment. [2]
Treatment
To correct the imbalances in your body that are causing your discomforts or pain, you will begin a specific stretching plan to stretch the tight muscles only. Upon mastering this we would move along to stabilize the spine and the weak muscles throughout the body found in the assessment. This then moves into functional movement patterns that we do on a daily basis, to strengthen the body as a whole. This becomes the base of your strength and conditioning program to move to other goals, such as body fat loss, muscle shape/tone, strength for home, work or sports. [3]
Pilates and Physical Therapy both offer much insight into how to correct and improve upon one’s posture through therapeutic exercise, proper stretching, and strengthening of weak core muscles in order to create balance in the body. [1]
[1] Grifoni, Z. Recognizing your postural type. Synergy+ Physical Therapy & Pilates Studio
[2] Britnell, S.J et al (2005). Postural Health in Women: The Role of Physiotherapy. J Obstet Gynaecol Can; 27(5): 493-500
[3] Owen, M. Pain and Posture go Hand in Hand. Fitness Function. C.H.E.K. Institute
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