The Perils of Poor Posture
By correcting faulty posture, your clients can improve their overall health.
Exercise professionals are committed to maintaining and improving the functional independence and physical performance of their clients. Most exercise professionals agree that good posture is essential for attaining these goals. It is often observed in the literature that a skeletal framework and/or spine that is misaligned may result in a cascade of bodily problems, most notably an impediment of the electrochemical messages of the nervous system (since the spine is the pathway for the nervous system to and from the brain) (Edmond et al. 2005). Healthwise this is of paramount concern, since the nervous system is involved in the control and regulation of most bodily system functions. This article reviews posture from a health perspective. Included are an overview of good and faulty posture; key points to be aware of in assessing lateral, frontal and posterior posture positions; and a discussion of posture as it affects health for different sectors of the population.
The word posture comes from the Latin verb ponere, which means “to put or place” (MedicineNet.com 1999). Posture refers to the position of the human body and its orientation in space.
Britnell et al. (2005) define posture as a state of skeletal and muscular balance and alignment that protects the supporting structures of the body from progressive deformity and injury. Whether a person is erect, lying, squatting or stooping, good posture allows the muscles of the body to function with maximum efficiency. In their research review, Kritz and Cronin (2008) add that with good standing posture the body’s joints are in a state of equilibrium (vertical and rotational forces balanced) with the least amount of physical energy being used to maintain this upright position.
Thus, as observed in the standing position, if a vertical line tracks from the neck to the tailbone and through the lower limbs, the body will not have to adjust to counter the forces of gravity (Kritz & Cronin 2008). Furthermore, Kritz and Cronin propose that a body in equilibrium theoretically is capable of doing the most efficient work.
In poor, or faulty, posture (aka postural dysfunction), there is an imperfect relationship among various skeletal structures of the body, and this may produce strain on the body’s supporting framework (Britnell et al. 2005). With faulty posture, the body is balanced less efficiently over its base of support. Therefore, any restriction, imbalance or misalignment of the musculoskeletal structures will have an adverse effect on the efficiency of movement.
Skilled personal trainers seek to assess their clients’ postural patterns and, more importantly, to target abnormal patterns such as lordosis (abnormal inward or forward curvature of the vertebral column) and kyphosis (abnormal curvature of the spine, causing a hunchback). A postural assessment provides an objective means of identifying a client’s postural concerns and establishing a direction for appropriate exercise program design. See Figure 1 for a comparison of common posture types and their resultant muscle imbalances.
Posture can be evaluated statically (stationary position) and dynamically (in motion) (Britnell et al. 2005). In both cases, joint positions and skeletal alignment can be assessed, as well as muscle length (i.e., stretch) and force production capabilities. Kritz and Cronin (2008) note that the relationship between static posture assessment and dynamic movement screening is unclear in the research. Although some fitness professionals use dynamic screening techniques with clients, the research supporting these techniques needs further validation through independent research.
Norris (1995) states that standing side posture should be assessed using the plumb line reference point. Have the client stand with the plumb line just in front of the lateral malleolus (lower end of the fibula that forms the prominent bulge on the outer side of the ankle). In optimal posture, this line passes through the midline of the knee, the lumbar vertebrae, the shoulder joint, the cervical vertebrae and the earlobe (see Figure 1).
Kritz and Cronin (2008) suggest assessing the following checkpoints in standing side posture (this list describes optimal posture):
- head: neutral, with no forward or backward tilt
- cervical spine: slight anterior curve
- scapulae: flat against upper back
- thoracic spine: slight posterior curve
- lumbar spine: modest anterior curve
- pelvis: anterior superior iliac spine in same vertical plane as symphysis pubis
- hip joints: neutral, neither flexed nor extended
- knee joints: neutral, neither flexed nor hyperextended
- ankle joints: neutral, with leg vertical to sole of foot
When standing posture is viewed from the front (with feet approximately 3 inches apart), a vertical line should divide the body into two similar halves. Norris (1995) suggests that the anatomical landmarks to compare for horizontal level on both sides of the body include the lateral malleolus (ankles), patella (knees), anterior superior iliac spine (hips), acromion process (highest point of shoulders) and ears. It is also important to look for muscular or structural differences in this frontal-view assessment. Kritz and Cronin (2008) add that the feet should be in a neutral position with no signs of pronation or supination. They suggest continuing the posture check from behind, observing the following (see Figure 2):
- head: neutral, with no tilt or rotation
- shoulders: level, with no depression or elevation
- scapulae: medial borders parallel and approximately 3–4 inches apart
- thoracic spine: straight with no lateral curve
- lumbar spine: no lateral curve
- pelvis: posterior superior iliac spines in the same plane
- lower extremities: straight, not bowed or knock-kneed
- feet: facing parallel or with toes slightly out; no pronation or supination
If the body segments are out of their optimal alignment for extended periods of time, the muscles eventually adapt by either shortening or lengthening (depending on the position) (Hrysomallis & Goodman 2001). Novak (2004) adds that prolonged misalignment adversely affects nerve tissue and function and that the adaptive changes in muscle tissue (whether lengthening or shortening) result in muscle imbalances, which can have a number of health consequences. The particular health issues caused by posture dysfunction tend to vary by population.
Posture Health for All Ages: Forward-Head PostureForward-head posture (FHP) is the most common form of poor posture in all age groups. People with FHP tend to develop a habitual head misalignment while sitting at a computer workstation, working on hobbies, playing video games or driving transport vehicles.
FHP is associated with neck and shoulder pain and temporomandibular joint dysfunction (incorrect alignment of the lower jaw to the skull) (Harman, Hubley-Kozey & Butler 2005). With FHP there is excessive anterior positioning of the head with increased curvature at the cervical spine and a rounding of the shoulders (see Figure 3). In addition to the musculoskeletal imbalance caused by FHP, this condition has also been linked to fatigue, restricted motion of the neck and chronic neck pain. Harman and colleagues demonstrated that an exercise program with strengthening exercises for the cervical flexors and shoulder retractors combined with stretching of the cervical extensor and pectoral muscles was most effective in helping to correct this posture problem.
Posture Concerns: Adolescents
Normally, as a child advances into adolescence (11–12 years) compressive forces on spinal intervertebral disks and facet joints are adequately balanced through ligamentous tension, allowing modest energy expenditure from postural muscles. However, structural or functional body stressors (e.g., tension, trauma, etc.) may prevent achievement of optimum posture.
Environmental factors that contribute to faulty posture include prolonged slouched sitting, ill-fitting school desks and overloaded bags and backpacks (Britnell et al. 2005). Growth spurts and discomfort with a changing body image may also predispose youth to body alignment disorders. According to Britnell, the most widespread posture deformity of adolescence is an idiopathic structural scoliosis (this is the most common type of scoliosis in adolescence, and it is much more common in females than males). Idiopathic structural scoliosis occurs in the thoracic region of the spine with convexity (or curvature) to the right side (when the body is viewed from behind). Given the complexity of the postural problems that can develop in adolescents, exercise professionals working to resolve these issues are well advised to collaborate with a physical therapist and/or primary health professional.
Posture Concerns: Adults (25–45 years)
Britnell et al. (2005) note that postural changes between ages 25 and 45 are no longer impacted by structural growth. However, sports activities and occupational behaviors (e.g., prolonged sitting, standing or stooping at work, heavy manual labor or repetitive movements) may contribute to posture adaptations, some of which may promote deviations from optimal posture. In addition, Britnell and colleagues note that high-risk social behaviors such as drug use and excessive drinking, as well as some fashion trends (e.g., high heels and restrictive clothing), may compromise muscle balance, movement patterns and joint positions. The authors state that these adult years are an ideal time to develop total-body and core-strengthening programs (as well as healthy lifestyle behaviors) that promote and maintain optimal posture.
Posture Concerns: Pregnancy and Postpartum
Britnell et al. (2005) state that numerous posture adaptations take place during pregnancy and postpartum. The changes are caused by retention of body fluid, an increase in body mass, and laxity in supporting joint structures (stemming from increased production of the hormone relaxin). Careful consideration must be taken in loading the spine. The authors add that pelvic pain and back pain are common problems during pregnancy. Some primary posture goals with this special population are core, pelvic-floor and balance-training exercises.
Posture Concerns: Older Individuals
Edmond et al. (2005), in a rather large study of 444 women (aged 72–96) who were part of the famous Framingham Study (a heart disease study originally composed of adults aged 30–62 from Framingham, Massachusetts), observed a number of limitations associated with (not caused by) poor posture. They included difficulty standing in one place for about 15 minutes; difficulty stooping, crouching and kneeling; difficulty getting in and out of a car; difficulty walking; difficulty putting on socks; difficulty reaching or extending arms above shoulder level; difficulty writing; and difficulty handling small objects. As observed by the authors, age-related musculoskeletal problems (e.g., osteoporosis) surely contributed to these findings. The two most notable limitations associated with declining posture, according to Edmond and colleagues, were difficulties pushing and pulling a large object, such as a living room chair.
Edmond et al. argue that this data is clear evidence that health professionals need to be proactive in developing interventions to minimize postural deviations and limitations. Britnell et al. (2005) propose that exercise programs need to focus on improving muscular fitness, balance, agility, range of motion and coordination for older clients. They specifically note that strength and agility training has been shown to meaningfully reduce the risk of falling in older women.
Enlighten clients that posture is an important consideration in all activities of daily living (e.g., walking, lifting objects, holding objects and driving) and that keeping good posture can make a considerable difference to the long-term health of the spine. Many postural problems are detectable at very early stages, regardless of age. If not corrected, these issues will become more pronounced.
Exercise professionals are in a leading position to correct spinal misalignments with a well-developed exercise program of flexibility, muscular strength, muscular endurance, agility and balance training. Educate your clients to adopt a new posture pleasure principle: planning and prevention precludes pain and promotes perfect posture.
A major factor in urinary incontinence in women is weak pelvic-floor muscles. Pelvic-floor exercises have proved successful for treating urinary incontinence (Britnell et al. 2005).
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The spine has three natural curvatures, which can become exaggerated in one direction or the other. Optimal (or neutral) posture is shown on the left, with exaggerated postures to the right.
Optimal Posture. In optimal posture, a vertical line passes through the midline of the knee, the lumbar vertebrae, the shoulder joint, the cervical vertebrae and the earlobe.
Kypholordotic Posture. An increased thoracic and lordotic curvature is observable. The head is held slightly forward, often becoming the most anterior segment of the body. The pelvis tends to tilt anteriorly with an increase in lumbar lordosis (inward curve).
Swayback Posture. The pelvis is gradually becoming the most anterior segment of the body, and there is an increase in lumbar lordosis. The knee joints tend to be hyperextended. Abdominal obesity worsens this posture.
Flat-Back Posture. The pelvis has a posterior tilt with very little normal inward curvature of the lumbar spine. The knee joints are often hyperextended. The head is sometimes tilted slightly forward. The thoracic spine may be flexed forward a bit.
Source: Adapted from Norris 1995.
1. What is a posture muscle?
Posture muscles help to fix or stabilize a joint; they prevent movement, while other muscles create movement. They are composed of muscle fibers that have a particular capacity for prolonged work. For instance, as a person leans forward slightly to walk up stairs (the movement), the posture muscles surrounding the spine help to prevent the upper body from falling too far forward.
2. Does poor posture affect a person’s psychological health?
Yes. It has been shown that individuals with poor posture are more likely to have poor self-image and less self-confidence (Watson & MacDonncha 2000).
3. What are the natural curves in a healthy spine?
There are three natural curves in a healthy vertebral spine. The low back (lumbar spine) curves inward (toward the anterior part of the body) and is referred to as a lordotic curve. The middle back (thoracic spine) is curved outward (posterior to the body). The neck (cervical spine) curves slightly forward and thus has a lordotic curve.
4. What is “neutral spine”?
Although the vertebral column has three natural curves, “neutral spine” usually refers to the lumbar region. Neutral spine is a pain-free position of the lumbar spine attained when the pressures in and around the pelvis joint structures are evenly distributed. The pelvis is balanced between its anterior and posterior positions.
5. What is a helpful way to explain the core to clients?
Akuthota and Nadler (2004) describe the core as an anatomical “box” in the mid-section of the body, with the abdominals in the front, the paraspinals next to the spine and the gluteals in the back. The diaphragm is the roof, while the pelvic floor and hip girdle musculature are at the bottom. The authors propose that the core functions as a muscular “corset,” working as a unit to stabilize the spine. It is the “foundation” of all limb movement.
6. Is it true that one should not do forward spinal exercises upon waking up?
Yes. Adams, Dolan and Hutton (1987) showed that pressure on the lumbar disks is 300% greater in the first hour after waking than it is later in the day. The authors concluded that the lumbar disks and ligaments are at greater risk of injury in that hour after waking.
7. A number of trainers are now doing neuromuscular control exercises for the spine. What does this mean?
Research shows that exercise programs that are designed for musculoskeletal injury prevention involve neuromuscular control components (Akuthota & Nadler 2004). These programs involve joint stability exercises (where agonist and antagonist muscles are co-contracting), balance training, proprioceptive training (e.g., wobble boards, roller boards, disks, physioballs), plyometric (jump and/or explosive reaction) exercises, and skill-specific training. These programs provide multiple stimuli to improve the body’s neuromuscular control mechanisms.
8. Is poor posture associated with increased falls in older adults?
Yes. Maki, Holliday and Topper (1994) compared the association of different postural positions and the risk of falling in 100 ambulatory elderly people (aged 62–96). The best predictor of future fall risk was deficiency in lateral posture stability. Although balance programs should be designed for all postural sway conditions, exercise professionals are encouraged to emphasize lateral stability exercises in older clients’ fall prevention programs.
9. What are the factors that cause people to lose control of their balance?
Freeman et al. (2009) suggest that the factors affecting balance include muscle weakness, diminished vision, vestibular disorders (referring to the inner ear, which helps regulate balance), bone integrity, spinal injury and somatosensory (pertaining to the processing of stimuli related to touch) deficit. Balance training and proper eyewear can markedly reduce many factors related to loss of balance control.
10. Do pelvic-floor exercises help manage and/or control urinary incontinence?
Although urinary incontinence is usually associated with elderly women, it is also seen in female athletes and in postpartum, perimenopausal and postmenopausal women (Britnell et al. 2005).
When they are sitting, many people slouch, relaxing the postural muscles of the back. This tends to transfer weight and stress to the body’s ligamentous tissues, which can become permanently lengthened if the stress persists for extended periods of time. This lengthening can lead to instability around the joints that the ligaments normally stabilize.
Proper sitting posture requires awareness and effort. Teach clients to keep the head up over the shoulders, with the back maintaining its three natural curves. Eyes should be level with the top portion of the monitor. Shoulders are back and relaxed, with elbows resting at the side. Thighs and forearms are perpendicular to the floor, with feet planted on the ground. The monitor should be 18–30 inches away and directly in front of the head. Remind clients to take regular breaks when sitting for prolonged periods.
1. Assess and identify the posture problem(s).
2. Make the client aware of the problem(s) and educate him or her about the potential ramifications. Explain the need for new, healthier posture habits and inspire the client to achieve this goal.
3. Develop and implement a restorative exercise approach designed to strengthen the weakened posture muscles and lengthen the shortened muscles (Harman, Hubley-Kozey & Butler 2005).
4. Coach the client to change the habit(s) that contributed to the poor posture. Proactive professional intervention plays a big part in the client’s success.
For more information on swayback posture, read “Designing a Program for Swayback Posture,” by Christine Romani-Ruby, PT, MPT, in the November–December 2010 issue of IDEA Fitness Journal, www.ideafit.com/fitness-library/designing-a-program-for-swayback-posture.
Akuthota, V., & Nadler, S.F. 2004. Core strengthening. Archives of Physical Medicine and Rehabilitation, 85 (3) (Supp. 1), S86–92.
Britnell, S.J., et al. 2005. Postural health in women: The role of physiotherapy. Journal of Obstetrics and Gynaecology Canada, 27 (5), 493–500.
Edmond, S.L., et al. 2005. Vertebral deformity, back symptoms, and functional limitations among older women: The Framingham Study. Osteoporosis, 16, 1086-95.
Freeman, S. et al. 2009. Olfactory stimuli and enhanced postural stability in older adults. Gait & Posture, 29, 658–60.
Harman, K., Hubley-Kozey, C.L., & Butler, H. 2005. Effectiveness of an exercise program to improve forward head posture in normal adults: A randomized, controlled 10-week trial. The Journal of Manual & Manipulative Therapy, 13 (3), 163–76.
Hrysomallis, C., & Goodman, C. 2001. A review of resistance exercise and posture realignment. Journal of Strength and Conditioning Research, 15 (3), 385–90.
Kritz, M.F., & Cronin, J. 2008. Static posture assessment screen of athletes: Benefits and considerations. Strength and Conditioning Journal, 30 (5), 18–27.
Maki, B.E., Holliday, P.J., & Topper, A.K. 1994. A prospective study of postural balance and risk of falling in an ambulatory and independent elderly population. Journal of Gerontology, 49 (2), M72–84.
MedicineNet.com. Definition of posture. 1999. www.medterms.com/script/main/art.asp?articlekey=9731; retrieved Dec. 5, 2010.
Norris, C.M. 1995. Spinal stabilization 4. Muscle imbalance and the low back. Physiotherapy, 81 (3), 127–38.
Novak, C.B. 2004. Upper extremity work-related musculoskeletal disorders: A treatment perspective. Journal of Orthopaedic & Sports Physical Therapy, 34 (10), 628–37.
Watson, A.W.S., & MacDonncha, C. 2000. A reliable technique for the assessment of posture: Assessment criteria for aspects of posture. The Journal of Sports Medicine and Physical Fitness, 40 (3), 260–70.
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