Lot's of doctors don't incorporate postural rehab (or any other type of rehab for that matter) into their care programs. Possibly because postural chiropractic methods have been associated almost entirely with a particular technique in the past, many doctors view the concepts as somehow contradictory to what they do in their offices. Strangely, many doctors resistant to embracing postural rehab concepts, are already familiar with the many ways in which postural imbalance impacts patients, but for some reason just never made the connection as to why structural rehab is really necessary. I thought I would take a stab at reviewing how some of the science is relevant to the importance of postural rehab in your practice.
We've got to start somewhere, so let's review what we already know about lumbar posture as it affects your patients. Due to the huge impact of low back pain on society, the lumbar spine has been studied more than any other area of the spine. Much research has been directed at trying to ascertain exactly how and why so many lower back (disc) injuries occur in the workplace. And consequently, we now know a lot about what is bad (and good) for lumbar discs. Here are a few things you might find of interest.
Flexion...It's A Bad Thing
In the upright (loaded) spine, forward bending of the thorax (lumbar flexion) is just about always a bad thing. When you add in the extra loading forces created by forward bending during lifting activities, you are making things that much worse.
Fact: Forward bending (flexion) puts more loading stress onto the discs and tends to force the nucleus backward toward the now taut posterior portion of the annulus fibrosus .1 (see fig. 1)
Fact: Combining forward flexed lumbar posture with additional loading (for example in lifting activities) creates even more pressure on the disc.2
But of course, our patients rarely just bend over and lift once during a typical work day do they? Instead, depending upon their occupation, they may well bend forward hundreds of times daily in the course of their days work. Or they may sit slumped in an office chair with their lower back in flexion. So it comes as no surprise that if a little flexion is bad, a whole lot more is considerably worse.
Fact: Repeated flexion motions and/or prolonged working in the flexed lumbar position subjects the lumbar discs to higher loading and the lower back to much greater risk of injury. The problems are exacerbated if the patient is lifting or holding any additional weight. 3,4,5
To complicate matters, when patients go about their daily activities, they typically move in multiple planes at once. In the real world, patients often bend, lean, and twist in any number of combinations and it is these "combination" movements which are extremely destructive to the spine. Combination movements involving forward flexion plus lateral bending and/or rotation are notorious for creating disc prolapse or protrusion.. Close questioning of many of your worst disc cases will reveal the truth of this fact.
Fact: Forward bending combined with lateral flexion or rotation subjects the posterior annulus to dangerous forces. Annular tearing and protrusion/prolapse of nuclear material is a common result of such movements. 6
Since we know so much about the destructive effect of flexion postures and motions in the lumbar spine, it's probably not surprisingly that there is also good evidence that lordotic postures (those with a healthy lumbar curve) are capable of providing a protective effect to the disc as well. When lifting, particularly from the floor, lumbar lordosis should be "the posture of choice." 7 Doctors should make every effort to both rehabilitate the patient's natural posture and to instruct patients as to how to lift properly.
Most doctors are well aware of the hazards of flexion postures. So it's surprising that most never make the connection that even mild flexion (flat back) postures actually pre position the lumbar spine toward more stressful flexion positions during work and play. Such postures predispose patients to injury, and chronic disc degeneration.. Keep that in mind next time you see a HYPOlordotic lumbar spine. Lumbar lordosis can be effectively rehabilitated using simple extension traction methods and exercise.8 But if you choose to just adjust or treat without rehabbing the underlying posture, you leave your patient potentially vulnerable to a life altering injury in the future.
Dr. Mark Payne is president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. A more detailed report on this subject is available for free, as well as a FREE SUBSCRIPTION to Postural Rehab...electronic newsletter on corrective chiropractic methods. CALL 334-448-1210 or email
- Beattie PF, et al. Effect of lordosis on the position of the nucleus pulposus in supine subjects. A study using magnetic resonance imaging. Spine. 1994 Sep 15;19(18): 2096-102.
- Andersson GB, et al. Intradiskal pressure, intra-abdominal pressure and myoelectric back muscle activity related to posture and loading. Clin Orthop Relat Res. 1977 Nov-Dec (129), 156-64.
- Kahrizi S, et al. Evalauation of spinal internal loads and lumbar curvature under holding static load at different trunk and knee positions. Pak J Biol Sci. 2007 Apr 1;10 (7): 1036-43.
- Gallagher S, et al. Torso flexion loads and the fatigue failure of human lumosacral motion segments. Spine. 2005 Oct 15:30 (20): 2265-73.
- Rohlmannt A, Comparison of intradiscal pressures and spinal fixator loads for different body positions and exercises.
- Gordon SJ, et al. Mechanism of disc rupture. A preliminary report. Spine 1991 Apr; 16(4) 450-6.
- Hart DL, et al. Effect of lumbar posture on lifting. Spine 1987; 12(2): 138-45.
- Harrison DE, et al. Changes in sagittal lumbar configuration with a new method of extension traction: nonrandomized clinical controlled trial. Arch Phys Med Rehabil. 2002 Nov;83(11):1585-91.