The Postural Syndrome

DEFINITION

I would define the postural syndrome as mechanical deformation of postural origin causing pain of a strictly intermittent nature, which appears when the soft tissues surrounding the lumbar segments are placed under prolonged stress. This occurs when a person performs activities which keep the lumbar spine in a relatively static position (as in vacuuming, gardening) or when they maintain end positions for any length of time (as in prolonged sitting).

History

Patients with postural pain are usually aged thirty or under. Frequently they have a sedentary occupation and in general they lack physical fitness. In addition to low back pain they often describe pains in the mid-thoracic and cervical areas. They state that the pain is produced by positions and not by movement, is intermittent and may sometimes disappear for two to three days at a time. It is often found that, when patients are more active at weekends — playing tennis and dancing — they have relatively little or no trouble. The reason is that, although activity places more stress on the lumbar spine than does the adoption of static postures, with movement the stresses are continually changing and pain does not occur. The stresses arising from static postures, although less than those occuring during activity, are sustained and will, if maintained, eventually cause pain.

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Examination

On examination no deformity is evident, no loss of movement will be detected and the test movements prove to be painfree. X-rays are normal and laboratory tests are negative. The patient’s sitting and often the standing posture will be poor, and usually this is the only objective finding.

Clinical example

Let us look at the clinical example of a typical patient with the postural syndrome. The patient has a bad posture indeed, and the pain cannot be reproduced by the test movements. To reproduce the appropriate postural stress, the patient must assume and maintain the position that is stated to cause pain — that is, the sitting posture. Only after the passage of sufficient time will the symptoms appear in this position, and up to half an hour may be required before pain is felt. Once pain has been produced by adoption of a certain posture, it will be abolished by correction of that posture. Now our suspicions are confirmed and a diagnosis can be made. In short, the patient with the postural syndrome has no clinical or laboratory findings indicating a particular pathology and all functions appear perfectly normal.

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Thousands of people are seeking treatment for pain resulting from bad postures; they consult doctors who often are unsuited to deal with the problem and, taking the easiest way out, prescribe pain relieving drugs instead of recommending postural correction; disillusioned with drug therapy patients attend a chiropractor, osteopath, physiotherapist or some fringe manipulator who, mainly out of ignorance, proceeds to manipulate joints in which there is no pathology and certainly nothing ‘out of place’.

I must emphasise that in many patients presenting with postural pain no pathology needs to exist. All patients with low back pain have an increase in pain when postural stresses are added. In derangement and dysfunction there is a pathological cause for the pain, and postural stresses may enhance the pathological state. But in the postural syndrome no pathology is present, and the only treatment that is required is postural correction and re-education and instruction in prophylaxis.

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Postures involved

Every patient with pain of postural origin has a different description for the circumstances leading to the production of pain. Sitting, by no means the only postural situation causing and prolonging low back pain, is the most frequent cause of postural pain. Some patients will name the sitting position purely and simply as causative, and they complain that pain is produced as soon as they spend more than a certain amount of time, say ten minutes, in any sort of chair or car seat. Others will describe sitting at the typewriter as the only time that pain is felt. Bus, taxi, and car drivers all complain of being worse while seated for long periods in their vehicles; both pilots and passengers complain about the seating in airplanes.

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Fig. Clinical example of a typical patient with the postural syndrome.

Fig. Sitting postures.

Working in prolonged standing positions also may cause postural pain, but the opportunity to move and change position is greater in standing than in sitting and the avenues for relief are more numerous. Consequently, there are less complaints of pain arising from the standing position than from sitting. People who work in cramped positions, be it standing or sitting, are also likely to complain of low back pain. The incidence of low back pain is very high in people who work in continuously stooped positions.

Fig. Standing postures.

The lying position may be an additional source of stress enhancing low back pain, and if pain predominantly occurs while lying it requires thorough investigation.

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Fig. Lying posture.

Spine Health. PROCEDURE 3 — EXTENSION IN LYING The patient, already lying prone, places the hands (palms down) near the shoulders as for the traditional press-up exercise. He now presses the top half of his body up by straightening the arms, while the bottom half, from the pelvis down is allowed to sag with gravity. The top half of the body is then lowered and the exercise is repeated about ten times. The first two or three movements should be carried out with some caution, but once these are found to be safe the remaining extension stresses may become successively stronger until the last movement is made to the maximum possible extension range. If the first series of exercises appears beneficial, then a second series may be indicated. More vigour can be applied and a better effect will be obtained if the last two or three extension stresses are sustained for a few seconds. It is essential to obtain the maximum elevation by the tenth excursion and once obtained the lumbar spine should be permitted to relax into the most extreme ...
Spine Health. PROCEDURE 5 — SUSTAINED EXTENSION To apply a sustained extension stress to the lumbar spine an adjustable couch, one end of which may be raised, is a necessary piece of equipment. The patient lies prone with his head at the adjustable end of the couch which is gradually raised, about one to two inches at the time over a five to ten minute period. Once the maximum possible degree of extension is reached, the position may be held for two to ten minutes, according to the patient’s tolerance. When lowering the patient the adjustable end of the couch should slowly be returned to the horizontal over a period of two to three minutes. This must not be done rapidly, for acute low back pain may result. Fig. Sustained extension. Effects: The procedure is predominantly used in the treatment of derangement. The effect is similar to that of the third procedure, but a time factor is added with the graduated increase and the sustained nature of the extension. In certain circumstances a sustained extension stress is preferable...
Spine Health. PROCEDURE 12 — ROTATION MANIPULATION IN FLEXION The sequence of procedure 11 must be followed completely to perform the required pre-manipulative testing. If the manipulation is indicated a sudden thrust of high velocity and small amplitude is performed, moving the spine into extreme side bending and rotation. Fig. Rotation manipulation in flexion. Effects: There are many techniques devised for rotation manipulation of the lumbar spine. When rotation of the lumbar spine is achieved by using the legs of the patient as a lever or fulcrum of movement, confusion arises as to the direction in which the lumbar spine rotates. This is judged by the movement of the upper vertebrae in relation to the lower — for example, if the patient is lying supine and the legs are taken to the right, then the lumbar spine rotates to the left. It has become widely accepted that rotation manipulation of the spine should be performed by rotation away from the painful side. This has applied to derangement as well as dysfunction, because hitherto n...
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