Every patient must be examined and analysed individually, and educated for his own particular postural stress. Education is probably the most important part of the treatment for low back pain of postural origin. The patient must have a clear and unambiguous explanation of the mechanism that produces his pain. He must realise that, when he assumes the positions of stress causing pain, he is in fact pulling the ligaments apart; and all that is required to stop his postural pain, is to stop stressing the ligaments for about ten days. I also explain to the patient that once he commences the correction regime, he will and should develop some new pains which are commonly felt higher in the back. This is merely the consequence of adjustment to a new postural habit.
The more often pain is triggered, the more readily it will occur. And the less often pain is triggered, the more difficult it is to be produced. Thus, poor sitting positions maintained regularly will cause pain after the passage of less and less time. Conversely, good sitting postures will enable the patient to remain pain free for longer and longer periods, and when slouching next occurs it will take much more time for the pain to arise. After two weeks of correct sitting patients will be able to slouch for short periods without having pain. However, no one should be permitted to slouch for extended periods. For example, a patient who usually gets low back pain after ten minutes of slouched sitting, may after a couple of weeks of sitting correctly revert to the slouched position and only experience pain after twenty minutes in that position. This painfree slouched sitting period can be progressed up to a limit, so that at the end of ten weeks of correct sitting a patient may well be able to slouch for an hour or two. A possible explanation for this phenomenon is forthcoming from Professor P. D. Wall.
Correction of the sitting posture
All patients who have low back pain produced or enhanced by prolonged sitting, should receive an adequate explanation regarding the cause of pain and the need for maintenance of the correct sitting posture.
We must explain that when a person sits his spine will sooner or later take up a relaxed posture. Unless a special lumbar support is given or a conscious effort is made to maintain the lordosis, the lumbar spine will move into a fully flexed position placing various ligamentous structures on full stretch. The nucleus of the intervertebral discs is forced posteriorly, the intradiscal pressure rises, and the stresses on the posterior wall of the annulus are increased. At this stage there are many reasons for the spine to feel uncomfortable. If this position is maintained for a long period, the spine will become painful as well and in some cases derangement may occur. Few patients fail to comprehend our explanations, provided these are couched in terms understandable to the layman.
To convince the patient that our suspicions about his sitting posture are correct it is necessary to prove this to him. Pain of postural origin arising by sitting incorrectly will be abolished by sitting correctly. During the first treatment session we must reproduce the pain by positioning the patient and allowing enough time for postural stresses to build up. Once pain is felt the patient is easily convinced that it is posture-related, when on adopting the correct sitting posture the pain ceases. If we cannot reproduce the symptoms during the first treatment, we must instruct the patient to assess the relationship between posture and pain himself by correction of the sitting posture the next time pain is felt.
To achieve correction of the sitting posture the following is necessary:
- firstly the patient must be able to obtain the correct sitting posture;
- then he must know how to maintain it when sitting for prolonged periods.
To obtain the correct sitting posture
The patient must have a good understanding of the correct sitting posture, and his control of the muscles and joints involved in obtaining it must be restored. Therefore, it is necessary that he be acquainted with the extreme of the good and bad sitting positions before he is instructed regarding the correct sitting posture.
In order to achieve this we have to introduce the ‘slouch-overcorrect’ procedure. The patient must sit slouched on a backless chair or stool, allow the lumbar spine to rest on the ligaments in the fully flexed position, and permit head and chin to protrude. Then he must smoothly move into the erect sitting posture with the lordosis at its maximum and the head held directly over the spine with the chin pulled in. This sequence should be repeated in a flowing rhythmical manner, so that the patient moves from the extreme of the good to the extreme of the bad position.
Fig. a – Slouched sitting. b – Overcorrected sitting. c – Correct sitting. Figures a and b together form the ‘slouch-overcorrect’ procedure, and Figure c shows the ten percent release from the overcorrected position.
After some practise at this most patients are able to find the extreme of the good sitting position. They should become so good at it, that at the snap of the fingers they can assume the overcorrected sitting posture and hold it for a few minutes. Once this can be achieved patients are advised to follow this procedure whenever pain is felt and to maintain the extreme of the good sitting position for a few minutes. Pain induced by poor sitting is nearly always quickly abolished by this method. On discovering the relationship between sitting postures and pain by this simple exercise few patients fail to carry out our advice. Postural correction and exercises related to pain are easily understood and performed by most people.
Once the patient has a good understanding of the good and bad postures he can assume while sitting, he must be taught which position is the correct sitting posture. The extreme of the good position is of course closest to the desirable, but it is impossible to hold this position for any length of time because various structures are on full stretch and will become painful with time. Therefore, the patient is instructed to move into the extreme of lordosis and then release the last ten percent of the movement. After this release from fully strained erect sitting the position can easily be maintained if necessary. This is the position that must be adopted habitually in the future. It must be emphasised that in the correct sitting posture the lumbar spine always has a certain amount but not the maximum of lordosis. If postural pain arises in the sitting position, it is caused by an insufficient or lost lordosis and postural correction will abolish the pain. Thus, in order to leam how to assume the correct sitting posture with a lumbar lordosis patients must be instructed to carry out the ‘slouch-overcorrect’ procedure three times daily, fifteen to twenty times at each session. At the end of each session they must release the last ten percent of the extreme good sitting position. They have now found the correct sitting posture. This routine must be kept up for three to four days at least, longer if necessary, until the correct posture becomes automatic.
To maintain the correct sitting posture
When sitting for prolonged periods it is essential that a certain amount of lordosis be maintained at all times. From the very first day the patient must be shown how this can be achieved. The lumbar spine may be held in lordosis in two ways:
- (a) actively by conscious control of the lordosis, when sitting on a seat without backrest.
- (b) passively by the use of a lumbar support, when sitting on a seat with a backrest. The purpose of the lumbar supportive roll is to hold the lumbar spine in a good but not extreme lordosis in the sitting position while relaxing, working and driving the car. Without the support the lordosis will be lost as soon as a person leans back in a chair or concentrates on anything other than maintaining the lordosis.
The lumbar roll as sitting support:
A roll inserted in the small of the back provides adequate support for the lumbar spine in sitting, provided the apex of the support maintains the lordosis just short of its maximum. When placed at or just above the belt line, affecting approximately the area of the third and fourth lumbar vertebrae, it produces the optimum lordosis, provided one sits with the sacrum against the back of the chair. A cushion is not a suitable lumbar support because, when placed behind the low back, it merely pushes the whole spine a few centimeters away from the back of the chair without in any way influencing the angle of extension or degree of lordosis in the lumbar spine.
Fig. a – Use of lumbar roll in office chair. b – Use of lumbar roll in easy chair. This roll can also be used for support in a car seat.
Various rolls can be made for the different situations in which they may be required — for example, lounge chair, office chair and car seat. If a lounge chair or car seat is designed in such a way that the roll is absorbed by the upholstery, it may be necessary to place one or more cushions in the chair first and then add the lumbar roll.
Patients frequently complain about the effort they must expend to maintain the correct sitting posture, more so when this is done actively than with the help of a lumbar roll. In fact, many patients will describe a strain pain or say that the new position is a painful one. It is important that these pains are recognised as new postural stresses which should normally occur. If after a day or two of correct sitting a patient has not complained of ‘new pains’, it is likely that he has not maintained the corrected position often and long enough. Adjustment to a new posture results in shortlived transitional aching of a different quality and location than the pain which initially forced consultation. It should not last longer than five to six days.
It is reported that most people in North America sit with the lumbar lordosis accentuated. On several visits to the United States and Canada I have had the pleasure of treating some hundreds of patients, and I was relieved to notice that most of these, as well as most of the doctors and physiotherapists attending my courses, sat with the lumber spine held in flexion after about half an hour of sitting. I was relieved because I had been wondering whether patients in North America just might be different from those in Australasia and Europe, in which case the treatments I have developed would be most unsuitable in the North American continent. I mention this to draw attention to a fundamental error in the clinical observation of the basic mechanics of the sitting posture, which has led to the development of an inflexible concept of treatment for low back pain throughout North America based on the assumption that the lordosis is undesirable, extension harmful and flexion beneficial.
In that continent, the treatment of low back pain has been influenced by authors who argue that damage in the posterior compartment of the disc is the result of compressive forces exerted by the lordotic posture which they believe is a predominant feature of western cultures. The treatment recommended involves a combination of flexion exercises and postures all carefully calculated to reduce the lumbar lordosis. Supporters of the flexion philosophy argue that African and Asian cultures do not have as high an incidence of back pain as is found in western society and this is largely because of the flexed spinal postures adopted by these cultures. Other authorities, Armstrong, and more recently Hickey and Hukins, state that annular failure under compression is unlikely to be a significant cause of low back pain. White and Panjabi were not aware of any investigation in which cross cultural and racial comparisons had ever been satisfactorily studied and related to low back pain. They also state that Williams flexion exercises are based on the assumption that achieving and maintaining a flexed lumbar spine is preferable, but “this has not been proved and is contrary to evidence of studies in vivo of intradiscal pressure and electromyographic studies”.
Another widespread misconception, held by many doctors and therapists, suggests that postural correction can be achieved by strengthening the muscles of the spine. Strengthening of muscles has no effect on posture. No strengthening exercises will educate muscles to maintain the correct posture. Actively maintaining the correct posture is the only way to achieve postural correction. This has the added bonus that the muscles required to maintain this position are automatically strengthened merely by performing the task for which they were originally designed.
In postural retraining the problem does not lie in the inability to assume the correct posture, but in a loss of awareness of the correct posture, if indeed such an awareness existed. To restore this it is necessary to retrain postural concepts, which is essentially a matter of the will. Indeed, willpower motivated by pain must be our tool. We are able to show the patient what must be done to correct his posture, but only he himself can do it.
Correction of the standing posture
Prolonged standing is another position in which low back pain may be enhanced. Usually, the patient can be seen to stand with a protruding abdomen and the lordosis at its extreme, ‘hanging’ on the lumbo-sacral ligaments. To achieve postural correction in standing the patient must be shown how to move the lower part of the spine backwards by tightening the abdominal muscles and tilting the pelvis backwards, while at the same time moving the upper spine forwards and raising the chest.
Fig. a – Relaxed standing. b – Correct standing.
There are two common relaxed standing positions. One is achieved simply by folding one’s arms and allowing the chest to drop. Chest and thoracic spine move posteriorly and pelvis moves anteriorly. This places the lower lumbar and lumbo-sacral joints into full extension. You can try this for yourself and will find that, once having adopted this position further movement into extension is impossible. The best way to observe if this posture is the cause of the patient’s pain, is to talk with him for some time until he is standing relaxed. If pain is present due to this position, correction should reduce or abolish it.
To re-educate a patient with this stance, we must first place him in the relaxed standing position until pain is produced. Alteration of the angle of pelvic inclination will reduce the standing pain almost immediately. This is best achieved by lifting the chest and thoracic spine, simultaneously tilting the pelvis slightly backwards. The ability to control the pelvic inclination in standing must be mastered first; then the angle at which the pain is abolished must be established and maintained. If pain in standing can not be reproduced on the first examination the patient must be instructed to evaluate the relationship between posture and pain himself by postural correction the next time pain is felt.
The second relaxed standing position is obtained by taking all the body weight on one leg, while the knee of the other leg is allowed to bend causing the pelvis to droop at the same side. The lumbar spine moves into a full side gliding/rotation position. Again, you can try this for yourself and will find that having adopted this position no further movement into side gliding or extension is possible. If this position produces pain it is easily corrected and avoidance of the standing habit should suffice.
Correction of the lying posture
Pain in the lying position is common. It causes considerable distress when it interferes with sleep over a long enough period, and it requires attention when the patient regularly wakes up with pain in the morning, the pain abating as the day progresses. There are two factors to be investigated:
- The lying posture itself. This is different for each person and must be dealt with individually. The lying posture during sleep is difficult to influence.
- The surface on which one is lying. For the majority of people the mattress itself should not be too hard, whereas the base on which the mattress rests must be firm and unyielding. This allows adequate support for the contours of the body without placing stresses on the spine. Usually, the surface on which one is lying is easily corrected or modified.
When dealing with pain produced by lying in bed, I have three recommendations to make which may be worth considering:
Due to the natural contours of the body — that is, wider at shoulders and pelvis than at the waist — and due to the lordotic curvature of the lumbar spine, the lumbar area may be placed under stress in the prone, supine or side lying position. This is particularly so when a hard mattress is supported by a firm and unyielding base. If this is thought to be the cause of the problem, the patient should use a lumbar supportive roll. When lying prone the roll will prevent extreme extension in the lumbar spine. When lying supine with the legs outstretched the roll will fill the gap between the lumbar spine and the mattress and prevent sagging of the spine into flexion. When lying on the side it will fill the gap between pelvis and ribs and prevent sagging of the spine into side bending. This type of lumbar support in bed usually works quickly or not at all and should be tried for about three nights.
The lumbar roll as lying support
A beach towel folded end to end and then rolled cross-wise usually fits around the average middle. If this is too big a bath towel folded length-wise can be used instead. Each patient will have to experiment to find the correct size of lumbar roll required in his particular case. He should wrap the towel around the belt line and attach the two ends to each other. If left loose the roll will not remain in place and may, when positioned anywhere else than at the waist, further increase the stresses placed on the spine.
Fig. Use of lumbar roll in lying. The roll is not fastened in the picture in order to show the shape of the spine.
When the base of the mattress is not firm enough or the mattress itself is too soft, stresses may also be placed on the lumbar spine. Because of the costs involved in replacing a mattress or its base, I always recommend that the mattress be placed on the floor if it is felt that a firm flat base is required. If there is no improvement after sleeping three to four nights on a flat surface, it is unlikely that this is the answer to the patient’s problems.
There is a small number of people who require a sagging mattress. Usually these people fall under the flexion principle category. The sagging mattress can easily be created by placing pillows at both ends of the bed in between the mattress and its base to form a dish shape.
We should now have equipped the patient with sufficient information enabling him to sensibly control mechanical stresses and deal with symptoms himself. The essence of treatment of the postural syndrome is that, if it is possible for patients to stop their pain, it is also possible for them to prevent the onset of the pain. I feel that it is negligent of the medical and physiotherapy professions to continue giving relief for episodic pain without familiarising patients with the manner in which their pain arises and providing them with the means to prevent the onset of such pain. It is my experience that patients with postural pain, when properly instructed and advised, treat themselves ably and adequately. TTiey can well control their postural stresses, and only need assistance when excessive and sometimes unexpected external forces have been placed on their joints — for example, following lifting heavy weights, stepping unexpectedly from the pavement, being hit by a motor vehicle, a sudden bout of coughing or sneezing while sitting or bent forwards.
When treatment is completed successfully we must explain to the patient that, although the present pain has been relieved, recurrence of similar symptoms is possible whenever he forgets postural care for extended periods. The consequences of postural neglect should be discussed when appropriate.
Consequences of postural neglect
The effects of postural habits on the shape of man are obvious when we observe people around us. If head and chin are allowed to protrude long and often enough, the ability to glide the head dorsally will be lost which results in a permanently protruding head and a dowager’s hump. As age advances this once reversible situation will become irreversible. People with this type of posture have a flattened lumbar spine as well, and by the age of seventy the ability to stand erect is lost so that they walk with a slight stoop. Movement that was once easily obtained is lost forever. But this postural stoop is not the inevitable consequence of ageing. Loss of function can be prevented if movements in the desired direction are performed adequately and often enough.
Initially, poor postural habits will only produce pain without loss of function. If as a result of continuous slouched sitting, flexion is regularly performed but extension never, the anterior structures of the joints involved will shorten and the posterior structures will lengthen. In this way flexion remains readily obtainable, but extension becomes more and more difficult and will therefore be avoided. Thus, the consequences of postural neglect are adaptive shortening leading to dysfunction.
Adaptive shortening implies loss of function and movement. In addition to the production of pain whenever the shortened structures are placed on stress, this loss of movement and function must inevitably lead to impairment of nutrition in an avascular structure like the disc. This will become one of the contributing factors of disc degeneration.
We should point out to people engaged in sedentary occupations that adaptive shortening and dysfunction due to poor posture can be prevented by regular postural correction and adequate performance of the appropriate exercises before adaptive shortening is allowed to develop.