Self-Care for the Client/Patient with Slumped Spinal Posture
When working with a client/patient for the treatment of slumped spinal posture, the importance of client/patient self-care is critical. Most importantly, the client must be advised to avoid a slumped posture when sitting. Rather they should sit with anterior tilt of the pelvis and extension of the lumbar spine. Recommending a seat with firm lumbar support, or using a small pillow for lumbar support is essential. Given the initial weakness of the spinal extensor musculature, it is important to explain to them that improving their posture will take time and patience. Therefore, they should not expect to suddenly sit totally upright. Rather, it will be a gradual transition from their present posture to “ideal” posture as the tight muscle groups are gradually loosened and the weak muscle groups are gradually strengthened.
An excellent self-care exercise is to recommend that the client/patient lie supine on an exercise ball to help move the thoracolumbar spine into extension. A good anterior pelvic tilt exercise is to ask the client/patient lie supine on a mat (or carpeted floor), place a hand under the small of their back, and then gently anteriorly tilt their pelvis (“arch their low back”) to create space between their low back and the floor. Next, be sure to discuss with the client/patient all the scenarios in which they might be collapsing into a slumped spinal posture. These might include sitting posture at a computer, driving a car, or even standing.
Finally, self-care exercises for strengthening can greatly speed the client’s/patient’s recovery. The primary muscle group to strengthen is the spinal extensor musculature (perhaps by supine active exercises into extension [“McKenzie” exercises]). Strengthening exercises for retraction of the head and scapula, and lateral (external) rotation of the arm is also important.
Slumped spinal posture is a postural distortion pattern. As such, there really is no “medical” approach. Typically, if a medical doctor addresses this condition, it would be to refer the patient to physical therapy. Physical therapy would likely work with the patient with the same objectives of stretching and strengthening the musculature advocated here; moist heat and manual therapy might also be done. In addition, physical therapy modalities such as ultrasound and electrical muscle stimulation might also be performed for the tight musculature.
A brace that holds the upper trunk in extension and scapulae in retraction is sometimes recommended. This might help to alleviate an aspect of the poor posture while wearing it, but does nothing to help strengthen the back extensor and shoulder girdle retraction musculature, which ultimately is necessary to correct this condition. In fact, long-term use of a brace will actually take the job of the extensor/retraction musculature away from these muscles and they will further weaken. Therefore, a brace, if used, should only be used for short periods of time.
Manual Therapy Case Study for Slumped Spinal Posture
Desmond is a 38-year-old office manager whose job involves sitting at a desk and working at a computer all day. He is a self-described workaholic with a sedentary lifestyle who does not participate in any physical exercise. He has recently begun to feel pain in his neck and upper back. It was mild at first and he thought it would go away, but it has become fairly steady and is getting worse. He has also recently begun to experience headaches.
The therapist performed a static assessment of his posture and immediately noticed slumped spinal posture with the pelvis posteriorly tilted, a kyphotic lumbar spine, hyperkyphotic thoracic spine, hypolordotic lower cervical spine, and increased extension of the upper neck (hyperlordotic upper cervical spine) and head, with his head protracted anteriorly.
Palpation assessment revealed tight paraspinal (erector spinae and transversospinalis) extensors of the neck and upper back, with pressure into these muscles reproducing the pain that he has been experiencing. Further, pressure into trigger points located bilaterally in the semispinalis capitis referred into his head, reproducing his headache. Palpation also revealed tight anterior abdominal wall, scalenes, sternocleidomastoid, pectoralis, and hamstring muscles bilaterally.
Range of motion showed decreased extension of his entire thoracolumbar spine. Similarly, motion palpation of his thoracolumbar spine revealed decreased segmental extension (hypomobility) at numerous joint levels. Desmond also had decreased cervical spine flexion and rotation and lateral flexion bilaterally, with joint hypomobilities at multiple levels. All special orthopedic testing for sprains, strains, and space-occupying (nerve impingement) conditions were negative.
Given the assessment of slumped spinal posture, the therapist recommended two one-hour massages per week for four weeks and one one-hour massage per week for the following eight weeks. The therapist also referred Desmond out to a Pilates instructor with the request that the Pilates instructor pay specific focus on correcting the dysfunctional spinal flexion by stretching Desmond’s spine into extension and strengthening his spinal extensor musculature.
With the client/patient prone, soft tissue manipulation was performed for the cervicothoracic extensor musculature for approximately 10-20 minutes, gradually transitioning from mild to deeper pressure, while a moist heating pad was placed over the lumbar region. The moist heating pad was then moved to the thoracic region while the therapist worked Desmond’s hamstrings, gluteal, and lumbar regions, and then gently mobilized Desmond’s lumbar spine into extension. The therapist then removed the moist heating pad from the thoracic region and mobilized the thoracic spine into extension. Finally, the therapist stretched Desmond’s entire spine into extension. With whatever time was left, the therapist worked into Desmond’s pectoral, anterior neck, and glenohumeral joint muscles.
This approach was repeated at each session, with the intensity of all modalities increasing with each treatment as Desmond’s musculature and spine gradually loosened. Desmond was given self-care stretches into extension using an exercise ball; and he was told to perform these stretches two to three times per day after hot shower or other form of moist heat application. He was also given stretches for his neck and pectoral region. Finally, proper posture at work and home was discussed, including the recommendation to place a small pillow for lumbar support on his chair and to sit back against it. It was also recommended that Desmond get up every hour and walk around for a moment or two.
At the end of twelve weeks, Desmond’s pain was gone and his posture was beginning to show improvement. For proactive self-care with the goal of continuing to improve his slumped spinal postural distortion, Desmond continues to receive clinical orthopedic massage once or twice each month. He also continues to do Pilates once per week with an instructor and once per week at home on his own.