The Chasm between Posture
Chiropractic Education and Treatment
Dr. David Seaman
Abnormalities of posture are common cause of pain and disability often
overlooked by practitioners who treat patients suffering from acute and chronic
musculoskeletal complaints.1-5 Kendall states: "Postural faults that
persist can give rise to discomfort, pain, or disability. The range of effect from
discomfort to incapacitating disability is related to the severity and persistence of the
Believe it or not, in 1947, the American Academy of Orthopaedic Surgeons
(AAOS) had a posture committee. According to Kendall, the AAOS definition of poor posture
is ". . . a faulty relationship of the various parts of the body which produces
increased strain on the supporting structures and in which there is less efficient balance
of the body over its base of support."6
Addressing poor posture is an important issue, and it is typically
neglected in chiropractic education and clinical practice. Do you remember the class you
had in chiropractic college that was exclusively devoted to assessing and restoring normal
posture? We don't.
Despite this lack of formal education, most DCs still acknowledge the
importance of good posture, as did the AAOS in 1949 with this definition: "Good
posture is that state of muscular and skeletal balance which protects the supporting
structures of the body against injury or progressive deformity irrespective of the
attitude (erect, lying, squatting, stooping) in which these structures are working or
resting. Under such conditions the muscles will function most efficiently and the optimum
positions are afforded for the thoracic and abdominal organs."
What Constitutes Good Posture?
To be able to recognize the attributes of bad posture, one must first
have some standard of what constitutes good or normal posture. Fortunately, many authors
have discussed the importance of normal posture.1,4,5,7,8 In the lateral
view, normal postural alignment is defined as balance about a coronal line of reference or
gravity line that passes through the external auditory meatus, acromioclavicular joints,
greater trochanters and lateral malleoli. In the anteroposterior view, approximate
skeletal symmetry allows division of the body into symmetrical halves with bisection of
the following points: glabella; frenulum; episternal notch; xiphoid process; symphysis
pubis; and a point midway between the medial malleoli of the ankle joints.
Of course, radiographic examination may also be helpful in evaluating a
patient's posture since the x-ray passes through the patient's three-dimensional posture
and is captured as a two-dimensional artifact on the x-ray film. The focus of this article
is introductory and general in nature. The complexities of correlating a patient's 3-D
posture with their projected 2-D image is a topic of much importance that will be
discussed in a later article. For now, let it suffice to say that deviation away from the
general guidelines described here could be considered as alterations away from normal
posture, the outcome of which can ultimately lead to the development of pain and
Some of the Physiological Effects of Altered Posture
Bad posture is a lifetime scenario for most people.
World-renowned physiatrist Rene Cailliet,MD, has demonstrated that if
the head weighs 10 pounds and is aligned with the external auditory meatus directly above
the acromioclavicular joint, the effective load on the spinal tissues is 10 pounds.
However, if the head is translated anterior, the weight exerted by the head is effectively
increased by a factor of 10 with each additional inch of forward translation. That is to
say, if the abnormal posture presented demonstrates two inches of forward head posture,
the effective weight of the head to the supporting tissues is not 10 pounds, but 20
pounds; three inches of forward head posture results in an effective weight of 30 pounds,
and so on. It is known that bone and soft tissue can suffer from such postural
Research has demonstrated that when loads are altered, bone remodels to
accommodate the imposed demands.9 Imagine for a moment the shape of the
cervical spine of the woman in Figure II. It is likely that her lower cervical spine would
be hypolordotic; a situation that could lead to the development of osteophyte formation.
Indeed, it has been shown that subjects with hypolordotic cervical spines have a greater
incidence of osteophyte formation10 that is probably due to the imposed demands
placed on the hard tissue.
The consequences of bad posture are potentially damaging for the soft
tissues as well. Evidence exists that some postural positions can compromise neural tissue
by changing blood flow to the spinal cord itself.11 Flexed postures have also
been associated with intervertabral disc damage.12 Clinically, we have all
observed changes in muscle tension and function in patients who sit for long periods in
front of computer screens that have not been set up for maximum postural ergonomics.
Sustained abnormal postures cause the muscles to contract isometrically, which leads to
hypoxia and tissue damage. Remember that connective tissue also adapts to sustained
changes in posture.
It is well-known that tendons, ligaments and discs display time- and
history-dependent viscoelastic properties that reflect the complex interaction of collagen
and the surrounding ground substances and proteins.13-18 When a significant
load is applied to spinal tissues and sustained over time, the tissue experiences creep
(deformation) and stress relaxation (a decline in internal stress over a period of time).
In other words, connective tissues undergo plastic changes that can become permanent. This
is probably why many individuals who exhibit postural abnormalities cannot be placed into
proper postural alignment with either short-term active or passive methods.
Patients with uncorrected abnormal postures are left to potentially
suffer a wide variety of unpleasant conditions: neurovascular entrapment syndromes,
myofascial pain syndromes, chronic strains, and a wide variety of other nonspecific
musculoskeletal pain syndromes.1-5,7,19-20 Brendon Reilly, MD, states: " .
. . chronic postural disorders are probably the most common initiating or contributory
cause of chronic back pain."5
What Should We Do about Bad Posture?
We should acknowledge that PTs, MDs and DCs all appreciate that poor
posture is bad and good posture is, well, good. However, this observation by PTs, MDs and
DCs is not really surprising, as parents untrained in spinal function also know that poor
posture is detrimental. Moms and grandmothers are known for telling their slouching kids
to "stand up straight."
What is our standard chiropractic approach for addressing poor posture?
Unfortunately, there isn't one that is universally taught in our chiropractic educational
institutions. For the most part, we do what grandmothers do, i.e., admonish patients to
"stand up straight." Such awareness training is an important first step, but an
inadequate approach by itself.
Can standard diversified adjusting, Activator adjusting, SOT adjusting,
or similar adjustments correct longstanding postural imbalances? Unfortunately, there is
little evidence to suggest that adjustments of any kind will substantially influence a
patient's postural alignment. This leaves the chiropractic profession between the
proverbial rock and a hard place. We know posture is an important factor in health, but we
have no real effective tools in our standard chiropractic arsenal to address the problem.
In our next column, we will further discuss the attributes of normal
upright resting posture and how to assess whether or not the subject under investigation
has normal posture, and how to classify their abnormalities of posture. In future columns,
we will investigate the works of chiropractic and medical innovators and their specific
approaches to postural rehabilitation.
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